Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema

Exogenous intrapleural injection of interleukin-27 may improves outcome and prognosis in patients with tuberculous pleural effusion

We hypothesize that exogenous intrapleural injection of interleukin-27 may improve outcome and prognosis in patients with tuberculous pleural effusion (TPE). Studies have found that the balance of Th1/Th2 determines the development trend of TPE. High concentrations of IFN-γ and TNF-α in pleural effusion are associated with pleural adhesion in patients with TPE. Interleukin-27 is a member of the IL-12 family, and IL-27 has a dual regulatory effect on Th1 immunity. On one hand, IL-27 can promote the initial CD4+ T cell proliferation by inducing the expression of T-bet, IL-12Rβ2 and ICAM-1 in the initial CD4+ T cells, and also promote its differentiation into Th1 cells and IFN-γ production in the early infection. On the other hand, in the case of high Th1 polarization, IL-27 induced STAT3 phosphorylation and inhibited TNF and IL-12 production in activated peritoneal macrophages, indicating a novel feedback mechanism by which IL-27 can modulate excessive inflammation, thereby preventing damage to the body caused by excessive immune response. Studies haves confirmed that after stimulation of antigen by mononuclear cells in TPE, the Th1 and Th2 cell subsets and Th1/Th2 ratio markedly increase, and the increase of Th1 is more obvious than that of Th2. Therefore, compared to patients with TPE in the high-level IL-27 group, we hypothesized that pleural effusion is absorbed more slowly, pleural thickening is more obvious, pleural adhesions are more extensive, and the incidence of thoracic collapse is higher in the low-level IL-27 group under the same conditions of anti-tuberculosis treatment. However, exogenous intrapleural injection of IL-27 may induce Stat3 phosphorylation and inhibit TNF and IL-12 production, finally reduces the secretion of IFN-γ and TNF-α. This negative regulation inhibits the excessive inflammatory reaction caused by tuberculosis infection, reduces pleural adhesion, pleural thickening and local pleural tissue damage, thereby improving the prognosis of patients.

Retrospective analysis of large-dose intrapleural alteplase for complicated pediatric parapneumonic effusion and empyema

OBJECTIVES

Medical treatment of complicated parapneumonic effusion or empyema in pediatric patients includes antibiotics and pleural space drainage. Intrapleural fibrinolysis may facilitate pleural drainage; however, there is a lack of consensus regarding the optimal dosing regimen. The primary purpose of this study was to evaluate the efficacy and safety of a large-dose intrapleural alteplase regimen in pediatric patients. Secondarily, this investigation sought to differentiate the clinical characteristics of responders and non-responders to intrapleural alteplase therapy.

METHODS

All patients with parapneumonic effusions treated with intrapleural alteplase between June 2003 and December 2011 were reviewed retrospectively. Efficacy was assessed by comparing chest tube output, in mL/hr and mL/kg/hr, for 24 hours before and after the first dose of alteplase. Additional efficacy outcomes included duration of in situ chest tubes, a need for surgical intervention for pleural effusion, and length of hospital stay. Safety was assessed by frequency and severity of adverse events. Non-responders and responders were compared based on demographic and disease characteristics. Responders were defined as patients who did not require surgical intervention after intrapleural alteplase therapy.

RESULTS

Seventy-three patients, aged 0.5 to 22.5 years, received intrapleural alteplase to facilitate pleural drainage. Median alteplase dose was 7 mg (range, 3 to 10 mg; median 0.38 mg/kg). Chest tube output increased from 10.7 to 24.2 mL/hr (p = 0.006), and median length of hospital stay was 9 days. Eighty-four percent of patients were responders. The most common adverse events were pain (20.5%) and oxygen desaturation greater than 10% from baseline (16.4%). High-flow nasal cannula was the most common intervention for oxygen desaturation to 80% to 90%. Nine patients (12%) required a blood transfusion during the study.

CONCLUSION

Large-dose intrapleural alteplase is effective in facilitating pleural drainage in pediatric patients with complicated parapneumonic effusion or empyema. Common adverse effects include pain and oxygen desaturation. The potential for bleeding warrants clinical monitoring.

Experience with an evidence-based protocol using fibrinolysis as first line treatment for empyema in children

INTRODUCTION

We previously reported a prospective, randomized trial comparing video-assisted thoracoscopic decortication (VATS) to fibrinolysis for the treatment of empyema. In that study no advantages to VATS were identified, although VATS resulted in significantly higher hospital charges. We subsequently implemented the algorithm from the trial utilizing primary fibrinolytic therapy in all children diagnosed with empyema. In this study, we reviewed our experience to examine the clinical efficacy of this protocol.

METHODS

After IRB approval, we conducted a retrospective review of all children diagnosed with empyema as all were treated with the fibrinolysis protocol utilized in the prospective trial since the completion of the trial.

RESULTS

In 102 consecutive patients treated with fibrinolysis, 16 patients (15.7%) required subsequent VATS. No patients were treated with initial VATS. No major side effects were seen from fibrinolytic therapy. Mean operative time for VATS after fibrinolysis was 62 minutes. The length of stay after VATS was 5.9 days.

CONCLUSIONS

The results of an evidence-based protocol using fibrinolysis to treat empyema have replicated the results of the trial that led to the implementation of the protocol. The pediatric empyema population can be successfully treated without an operation in the majority of cases.

New therapy of pleural empyema by deoxyribonuclease

Empyema is a severe complication of different diseases and traumas. Management of this complication is difficult and should comprise general and local procedures. The general procedure is mainly based on administering wide-spectrum antibiotics. Local management depends on patient general condition, but in all cases the essential procedure is to insert a drain into the pleural cavity and to evacuate the pus. Sometimes pus is very thick and its evacuation and following re-expansion of the lung is rather impossible. In these patients surgical intervention is needed. The use of intrapleural enzymes to support the drainage was first described in 1949 by Tillett and Sherry using a mixture of streptokinase and streptococcal deoxyribonuclease. Nowadays, purified streptokinase has come into widespread use, but recent studies reported no streptokinase effect on pus viscosity. On the other side, deoxyribonuclease reduces pus viscosity and may be more useful in treatment. We report two cases of intrapleural administration of Pulmozyme (alfa dornase – deoxyribonuclease (HOFFMANN-LA ROCHE AG) in dosage 2 × 2.5 mg with a significant improvement caused by changes in pus viscosity.

The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee

The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Intrapleural hemorrhage after administration of tPA: a case report and review of the literature

OBJECTIVE

Intrapleural fibrinolytic enzymes have been used for over 60 years in the treatment of complicated pleural effusions to lyse loculations and promote resolution. Despite this extensive history of use, however, little is known about complications that may arise with the use of this therapy. Here we discuss a patient with chronic renal failure on hemodialysis who developed an intrapleural hemorrhage after the administration of intrapleural tPA to treat a complicated parapneumonic effusion. A review of the literature examines the efficacy and safety of this therapy, focusing on bleeding complications. Specific attention is paid to patients who have underlying coagulopathies or who are receiving anticoagulation.

DATA SOURCES

A review of the literature, as indexed in PubMed, was undertaken using the following search terms in combination: tPA, pleural effusion, complications of thrombolytics, and intrapleural hemorrhage. The search was inclusive of patients under the age of 18, but was limited by English language and human subjects.

STUDY SELECTION/DATA EXTRACTION

All relevant articles identified during the search were reviewed. Those studies that reported on bleeding complications, or lack thereof, were included in this review. Limitations of each article are noted in the text.

CONCLUSIONS

Multiple studies, including a 2000 ACP consensus statement and a 2008 Cochrane review, indicate the need for further investigations to evaluate the safety and efficacy of intrapleural thrombolytics for the treatment of complicated pleural effusions and empyemas. Limited studies specifically address bleeding complications, especially in subpopulations of patients receiving concurrent anticoagulant therapy.

Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial

PURPOSE

Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema.

METHODS

After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/microL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an alpha of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart.

RESULTS

At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy.

CONCLUSIONS

There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.

Interventional radiology treatment of empyema and lung abscesses

Pneumonias in children can be complicated by pleural effusions, empyema and abscesses. The incidence of these complications is increasing, correlated to an increased virulence of the pneumococcal bacterium. These complications may prolong morbidity and lead to decreased pulmonary function. Traditionally, patients were treated medically with antibiotics, and refractory complications were treated surgically with large bore chest tube placement and thoracotomy. Improvements included instilling fibrinolytics into the chest tubes and video-assisted thoracoscopic surgery, which expedited recovery and improved outcomes. Image guided techniques from interventional radiology have been developed as an alternative to treat these patients with minimal invasiveness. These therapies have achieved high success and low complication rates, and are the preferred first-line procedures when available.

[Intrapleural streptokinase in the treatment of complicated parapneumonic empyema]

INTRODUCTION

Parapneumonic empyema is a frequent cause of admission in the Pediatric Hospital of the Pereira Rossell Hospital Center. In January 2005, we implemented a treatment protocol that included intrapleural streptokinase (STK) for children with complicated parapneumonic empyema as an alternative to surgery.

OBJECTIVES

To describe the results of intrapleural STK in the treatment of hospitalized children with complicated parapneumonic empyema and to compare these results with those of early thoracotomy.

PATIENTS AND METHODS

Children with complicated parapneumonic empyema admitted between January 1st 2004 and October 1st 2005 were included. The children were divided into two groups: a historical group, composed of children hospitalized between January 1st and December 31st 2004, treated with conventional thoracotomy before day 8 of chest drain placement and a prospective group, composed of children hospitalized between January 1st and October 1st 2005, treated with intrapleural STK before day 8 of chest drain placement. The variables used to compare outcome and treatment complications were duration of chest tube drainage after the treatment procedure, complications, re-admission, length of hospital stay, and death.

RESULTS

The results in both groups were similar. Length of hospital stay showed no significant differences. Duration of chest tube drainage after intrapleural STK was significantly shorter than after thoracotomy (p < 0.001). In the thoracotomy group a significantly higher proportion of patients required partial atypical pneumonectomy (p = 0.051). There were no deaths.

CONCLUSIONS

Intrapleural STK is a valid alternative for the treatment of children with complicated parapneumonic empyema.

Once-daily vs. twice-daily intrapleural urokinase treatment of complicated parapneumonic effusion in paediatric patients: A randomised, prospective study

To evaluate the effective dose frequency (once daily vs. twice daily) of intrapleural urokinase treatment in children who required tube thoracostomy for drainage of a complicated parapneumonic effusion, we designed a randomised prospective study in a tertiary medical centre in Taiwan. From June 2002 to January 2005, 30 paediatric patients with complicated parapneumonic effusion who had received chest tube drainage were randomised 1 : 1 to the once-daily (urokinase 5000-6000 IU/kg/dose) or twice-daily (urokinase 2500-3000 IU/kg/dose) treatment. We compared clinical manifestations and outcomes in both groups. There were no differences in pleural effusion characteristics between the groups. Six patients had Streptococcus pneumoniae, one had Staphylococcus aureus, one had Group A Streptococcus, and 22 had unknown pathogens. There were no significant differences between the once- vs. twice-daily group in the amount of drained pleural fluid (564.9 +/- 422.1 ml vs. 560.5 +/- 198.6 ml, respectively), fever duration after chest tube insertion (4.3 +/- 3.2 days vs. 5.3 +/- 2.7 days), or total admission days (14.3 +/- 3.9 days vs. 14.6 +/- 3.0 days) (p > 0.05 for all). Only two patients (one in each group) required the surgery. Thus, we found that both once- and twice-daily administration of urokinase were similarly efficacious, and resulted in good clinical outcomes. Both obviated the need for surgery in most (93%) cases of pneumonia with complicated parapneumonic effusion in this series. A larger, multicentre study is necessary to verify our findings.

Percutaneous Thoracic Drainage in Neonates: Catheter Drainage versus Treatment with Aspiration Alone

PURPOSE

To retrospectively compare thoracic drainage in neonates by using catheter and aspiration techniques.

MATERIALS AND METHODS

Approval was obtained from the institutional research ethics board; informed consent from parents was waived. Retrospective review of 21 neonates (19 boys, two girls; mean gestational age, 39.3 weeks) who underwent percutaneous thoracic drainage during a 9-year period was performed. Data such as indication for drainage, type of drainage, age and weight at birth, corrected age and weight at the time of drainage, use of mechanical ventilation at the time of drainage, and outcomes were collected. Drainage was considered successful if the collection was treated without additional surgical or radiologic intervention. Fisher exact test and two-tailed unpaired student t test with a confidence level of 95% (unequal variances assumed) were used to compare neonates treated with a catheter and those treated with aspiration.

RESULTS

Image-guided therapy was used to treat pleural effusion (29%, n = 6), chylothorax (24%, n = 5), empyema (19%, n = 4), pneumothorax (14%, n = 3), mediastinal seroma (10%, n = 3), and congenital cystic adenomatoid malformation (5%, n = 1). Sixteen (76%) infants were treated with catheter placement, with a success rate of 81% (13 of 16). Five (24%) infants were treated with simple aspiration with no success. The difference in success rates was significant (P = .003). There was no significant difference between the catheter placement and aspiration groups in terms of average age, average weight, and percentage dependent on mechanical ventilation. One complication (cellulitis) was directly related to catheter drainage. In cases where treatment was successful, the mean length of the chest tube placement was 13.5 days, and there were no deaths at follow-up. In cases where treatment failed, the long-term mortality rate was 50% (four of eight).

CONCLUSION

Image-guided percutaneous thoracic drainage success rates are improved if drainage catheters are placed rather than if aspiration alone is performed.

Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema

BACKGROUND

Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema.

AIM

To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema.

METHODS

Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs.

RESULTS

Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001).

CONCLUSIONS

There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.

Management of empyema in children

The incidence of empyema complicating community-acquired pneumonia is increasing and causes significant childhood morbidity. Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. Newer molecular techniques utilizing the polymerase chain reaction have led to an increase in identification of causative bacteria, previously not isolated by conventional culture techniques. This remains an important epidemiological tool, and may help in guiding correct antibiotic use in the future. There are many treatment options, however, and the care a child currently receives is dependent on local practice, which is largely determined by availability of medical personnel and their preferences. Although there are many reported case series comparing treatment options, only two randomized controlled studies exist to guide treatment in children. There is an urgent need for this to be addressed, particularly with the introduction of relatively new surgical techniques such as video-assisted thorascopic surgery.

Utilidad de la urocinasa intrapleural en el tratamiento del derrame pleural paraneumónico

INTRODUCTION

Intrapleural fibrinolytic instillation has been used in the treatment of loculated pleural effusions and empyemas and has reduced the need for surgical intervention. Currently, the most commonly used fibrinolytic is urokinase, although the doses have not yet been standardized in children. The aim of the present study was to evaluate the utility of urokinase in the treatment of infectious pleural effusions in children.

MATERIAL AND METHODS

A retrospective study was performed of children with infectious pleural effusions admitted to the pediatric intensive care unit (PICU) between January 2000 and December 2003. Age, sex, clinical features, laboratory tests, response to urokinase treatment and clinical course during hospital stay were analyzed.

RESULTS

Thirty-one children were treated. The mean age was 38.1 months (SD: 22). There were 18 boys and 13 girls. The most frequent month of diagnosis was November and the number of admission significantly increased from 2002 onwards. The most frequent antibiotic therapy used before admission to the PICU was cefotaxime associated with vancomycin (41 %), followed by cefotaxime alone (16 %). Positive cultures for Streptococcus pneumoniae were found in 11 patients (35 %). Pleural loculation was found in 14 patients (45 %). Treatment with intrapleural urokinase was used in 23 patients (74 %). The mean chest tube drainage was 140 ml (SD: 175) in the 24 hours before urokinase instillation and was 406 ml (SD: 289) in the 48 hours after fibrinolytic therapy (p < 0.05). Twenty-one patients (91 %) who received urokinase treatment had a good response. There were no complications during the treatment. The mean length of stay in the PICU was 5.8 days (SD: 2.6).

CONCLUSIONS

The incidence of complicated pleural effusions due to S. pneumoniae has increased in the last few years, despite antibiotic therapy. Intrapleural urokinase is an effective treatment, including in empyemas without loculation. None of our patients required thoracotomy and there were few adverse effects.

Source control in the management of severe sepsis and septic shock: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.

Drainage, fibrinolytics, or surgery: a comparison of treatment options in pediatric empyema

BACKGROUND

The current treatments of pediatric empyemas include tube thoracostomy with or without the instillation of fibrinolytics, video-assisted thoracoscopic surgery (VATS), and open thoracotomy with decortication. Whereas success has been reported for all of these techniques, VATS has been suggested as the best method because of decreased length of stay.

METHODS

A chart review of children who presented with parapneumonic effusions from February 2000 to June 2002 was conducted. The patients were divided into 4 groups depending on the treatment received: group I, chest tube alone (n = 18); group II, chest tube and fibrinolytics (n = 24); group III, chest tube, fibrinolytic, and surgery (n = 5); and group IV, surgery alone (n = 6). Preadmission, in-hospital, and outcome variables for the groups were recorded and compared using the Kruskall-Wallis test, with a P value less than .05 considered significant. All the patients who received fibrinolytics (group II and III) were grouped into subjects who received immediate transpleural fibrinolytics versus those who received fibrinolytics 48 hours after chest tube insertion. Length of stay (LOS), need for surgery, and hospital costs were compared between the early and late fibrinolytic groups using the Wilcoxon rank-sum test, with a P value less than .05 considered significant.

RESULTS

Comparison of duration of symptoms, duration of preadmit antibiotics, initial white blood cell count, total lymphocyte count, and antibiotics showed no significance among the 4 groups. When comparing outcome variables, the "nonsurgery groups" (groups I and II) had shorter LOS, intensive care unit stay, and hospital charges when compared with the "surgery groups" (groups III and IV). The timing of fibrinolytic instillation (immediate versus later) did not significantly affect in the LOS, hospital charges, or the tendency to need surgery eventually in the patients who received intrapleural fibrinolytics (group II and III combined). LOS was predicted by preadmit duration of symptoms (P = .025) and overall duration of fever (P < .01). The level of pleural glucose seemed to be predictive of need for surgery (P = .015). Overall, 11 of 54 children (20.2%) eventually needed surgery.

CONCLUSIONS

Tube drainage with intrapleural instillation of fibrinolytics can be performed successfully in a large number of children with empyemas. Ultrasound characterization of the fluid and, perhaps, glucose levels may guide surgical versus nonsurgical therapy. In centers in which percutaneous drainage and tissue plasminogen activator are available, this option may be a safe and less costly alternative to surgery.

Treatment of Complicated Parapneumonic Pleural Effusion With Intrapleural Streptokinase in Children

OBJECTIVE

To evaluate the role of intrapleural streptokinase in the management of complicated parapneumonic effusions in children.

DESIGN

Prospective comparative study.

SETTING

Cheng Kung University Hospital, a tertiary medical center in Tainan, Taiwan.

PATIENTS AND METHODS

We enrolled as our prospective study group 20 consecutive children with complicated parapneumonic effusions who received intrapleural streptokinase treatment between August 2000 and July 2002. We also retrospectively analyzed a comparison group of 22 consecutive children with complicated parapneumonic effusions who received chest tube drainage without streptokinase treatment from January 1992 to July 2000. We then compared the clinical manifestations and outcome of these two patient groups. The patient population (21 boys and 21 girls) ranged in age from 9 to 130 months (mean age, 41.5 +/- 26.3 months [mean +/- SD]). The characters of pleural effusion showed no difference between the two groups. Nineteen patients had positive findings for Streptococcus pneumoniae, 2 patients had positive findings for Staphylococcus aureus, 2 patients had positive findings for Pseudomonas aeruginosa, and 19 patients had undetermined pathogens. All patients were treated with appropriate antibiotics.

RESULTS

More pleural fluid was drained from the streptokinase group than from the comparison group during streptokinase treatment (816 +/- 481 mL vs 279 +/- 238 mL, p < 0.01). The duration of fever after chest tube insertion was also significantly lower in the study group (5.3 +/- 3.1 days vs 7.9 +/- 4.6 days, p < 0.05). Only two patients in the streptokinase group required surgical intervention compared with nine patients in the comparison group (p < 0.05). No major side effects were noticed after streptokinase instillation.

CONCLUSION

Intrapleural fibrinolytic treatment with streptokinase is safe and effective, and it can obviate the need for surgery in most cases. The combination treatment should be attempted early on, when complicated parapneumonic effusion is first diagnosed.