Use of intrapleural streptokinase in the treatment of thoracic empyema

The incidence of pleural effusions in bacterial pneumonia may exceed 40%, a factor that may be related to increased morbidity and mortality. Options in the treatment of complicated pleural effusions or empyema, when unresponsive to closed tube drainage, include repositioning of the indwelling tube thoracostomy or insertion of additional chest tubes, instillation of intrapleural streptokinase, and surgical intervention. The authors describe the course of three patients wherein the use of intrapleural streptokinase was efficacious in effecting prompt drainage of previously inadequately evacuated empyema, thus eliminating the necessity for further invasive intervention.     

A comparative study of community- and nursing home-acquired empyema thoracis

OBJECTIVES: To compare the clinical presentation, microbiological features, and outcomes of patients with community-acquired empyema (CAE) with those of patients with nursing home-acquired empyema (NHAE).
DESIGN: A retrospective observational study.
SETTING: Three tertiary care centers.
PARTICIPANTS: One hundred fourteen patients admitted from the community and 55 patients transferred from nursing homes.
MEASUREMENTS: Baseline sociodemographic information, activities of daily living, Charlson Comorbidity Index score, and clinica, and microbiologic data were obtained. Outcome was assessed at hospital discharge and 6 months postdischarge.
RESULTS: Patients admitted from nursing homes had a delayed presentation, with dyspnea, weight loss, and anemia as the predominant manifestation. Patients with CAE presented more acutely, with fever, cough, and chest pain. Anaerobic organisms were more commonly isolated from patients with NHAE. The success rate of nonsurgical intervention was significantly lower for the NHAE patients than for the CAE group (39% vs 63; P =.01). In-hospital mortality was not significantly different between the two groups (NHAE, 18%; CAE, 8%; P =.09). In a Cox regression analysis, preadmission functional status (hazard ratio (HR)=1.26, 95% confidence interval (CI)=1.19–1.4; P <.001) and surgical intervention (HR=0.47, 95% CI=0.24–0.92; P =.03) were the only variables highly correlated with long-term outcome.
CONCLUSION: Patients admitted with NHAE have distinctly different clinical and microbiological presentation from that of patients with CAE. Because of the delayed presentation in patients with NHAE, medical treatment alone may be associated with higher rate of failure. Surgical therapy should be considered for selected cases, with the aim of improving long-term survival.     

Recent trends in empyema thoracis

One hundred and twenty-three patients with empyema thoracis presenting between 1968 and 1978 were studied. The predominant cause was pneumonia, with thoracic and gastrooesophageal surgery as the other important predisposing factors. 99 patients had received antibiotics before hospital admission and organisms were isolated from the empyema of 62 of these (63%). Of the 62 patients with organisms 39 (63%) had previously received an antibiotic appropriate to the sensitivity of the pathogen. Staph. aureus, Str. pneumoniae and anaerobes were the organisms most frequently found in empyemata following pneumonia, whilst Gram-negative enteric bacilli, the most frequently isolated organisms, were the predominant pathogens in postoperative cases.Following treatment with antibiotics alone or with closed chest drainage 29% of empyemata resolved but another 64% required subsequent surgery. The former group had a mean duration of symptoms of 2.8 (se ± 0.8) weeks before hospital treatment whereas the surgically treated group had symptoms for a mean period of 8.3 (se ± 1.5) weeks. 83% of patients who required thoracotomy had a history of more than four weeks at the time of admission.Thirty-six deaths were recorded, 11 of which were attributable to the empyema, giving an empyema mortality-rate of 9%.We conclude that with widespread use of antibiotics the nature of empyemata has changed and that those now seen are more often refractory to closed chest drainage, particularly if the history prior to hospital admission is longer than four weeks.     

Treatment of post-pneumonic empyema thoracis

OBJECTIVE: The present study evaluates the management of 65 consecutive patients with post-pneumonic empyema thoracis (PET) treated in our department during the last ten years. MATERIALS: There were 51 male (78.5 %) and 14 female (21.5 %) aged 23 - 82 years. The initial cause of PET was pneumonia (postoperative and posttraumatic empyemas were excluded). In 2 cases, a bronchopleural fistula coexisted. Diagnosis was based on clinical, radiological and pleural fluid culture findings. Pneumonococci and staphylococci were the predominant bacterial isolates in our series. RESULTS: Tube thoracostomy drainage (TS) was performed in all our patients. Forty-nine patients (75.4 %) were successfully treated with TS alone. The other 16 patients were submitted to thoracotomy: lung decortication (n = 14) along with segmentectomy in two cases and the Eloesser procedure, also in two cases. The mortality rate reached 9.2 % (n = 6). Septic shock, multiple organ failure, cardiac insufficiency, and end-stage renal failure were the causes. CONCLUSIONS: 1. Complete drainage and full lung expansion by tube thoracostomy with suction are essential in the management of post-pneumonic empyema thoracis. Surgery should only be carried out right away if these conditions are not achieved. 2. Despite clinical experience and the major strategies and procedures available, the mortality remains high.     

Clinico-radiological profile of the patients with empyema thoracis: A prospective analytical study

BackgroundEmpyema thoracis is defined as the presence of pus in the pleural cavity and carries significant morbidity and mortality. This study aimed to explore the demographic and clinico-radiological characteristics of patients with empyema thoracis.Material and methodsThe present study was conducted in a tertiary care teaching hospital in North India. The patients diagnosed with empyema thoracis were included in the study. Demographic, etiologic, clinical, radiographic, and outcome data were prospectively collected and analyzed.ResultsThe study included 48 patients. The median age of empyema thoracis patients was 37(IQR 26–45) years. Common presenting symptoms were breathlessness (n = 37,77%) and chest pain (n = 34,70%). Contrast-enhanced computed tomography (CECT) of the chest showed type III empyema in 52% (21) patients followed by type 1 and type II in 25% and 22%, respectively. CECT thorax showed the collapse of lung and consolidation in (n = 28, 70%) and (n = 24, 60%) patients, respectively. All the patients, except for one, were managed with underwater seal intercostal tube drainage (ICD) procedure for the management of empyema. The median time to remove the ICD tube among 35 patients was 14 (IQR 9–21) days. Forty patients (83.3%) responded to the treatment and were discharged. Eight patients (16.7%) deteriorated and succumbed to the disease.ConclusionPatients of empyema thoracis required a prolonged period of chest tube drainage and carried significant morbidity and mortality.     

Significance of microbiological and biochemical analyses in empyema thoracis

Following the indifferent results of a retrospective analysis, a prospective study was undertaken to analyse the causative organisms in 51 cases of empyema. Cultures were positive in 44/51 (= 86.3%) cases. 2 bacterial species were recovered for each empyema. The aerobic gram-positive cocci represented the largest group (57%), followed by aerobic gram-negative bacteria (18.6%), anaerobic bacteria (18.6%), and fungi (5.8%). Polymicrobial empyema accounted for 59.1% of the cases. Anaerobic bacteria were cultured from 36.4% of empyema. Anaerobic bacteria were more frequently isolated from pleural effusions than from other specimens. Swabs were found to be of minor value for anaerobics. Analyses of glucose and pH value in pleural effusions have been reported to be useful in differentiating complicated from uncomplicated effusions in cases where the aspirated fluid is not purulent and is negative on gram stain, but clinical as well as radiological findings point to an empyema. Our results have shown that pH-values less than 7.30 and Glucose less than 60 mg/dl were not absolutely specific for empyema. In contrast, PMN-elastase in pleural effusion and HI-30 in urine showed a statistically significant differentiation of empyema from exudates of other origin.     

Major hemorrhage following administration of intrapleural streptokinase

Severe spontaneous bleeding has not been reported to complicate therapy with intrapleural streptokinase (SK). Recent data have demonstrated intrapleural SK to be devoid of systemic fibrinolytic effect. This report presents a patient who suffered major hemorrhage following the administration of 500,000 units of SK intrapleurally.     

Review of one hundred cases of empyema thoracis

One hundred cases of empyema thoracic have been reviewed. Aetiology of empyema was tubercular in 21 per cent cases and non-tubercular in 79 per cent cases. Gram negative organisms were cultured in 84.6% cases, whereas gram positive organisms were cultured only in 15.4% cases. It was observed that management of cases of empyema differed considerably with the presence or absence of BPF, thick or thin pus and size of empyema. It was concluded that all cases of simple empyema with thin pus and only those cases of simple empyema with thick pus where size of empyema is small should be managed by aspiration/s. Cases failed by above method, all cases of simple empyema with thick pus and with moderate to large size of empyema and all cases of empyema with BPF should be straightway managed by intercostal drainage tube connected to water seal. On the whole, cases of empyema with BPF were difficult to manage and needed major surgery in 45.8 per cent cases in comparison to only 2.9 per cent cases of simple empyema.     

Pleural penetration of ciprofloxacin in patients with empyema thoracis

We evaluated the pharmacokinetics of a single 200-mg dose of ciprofloxacin, administered as a 30-minute infusion, into pleural exudate in five elderly patients with empyema thoracis. Ciprofloxacin was measured by HPLC and the pharmacokinetic parameters were determined by noncompartmental methods. Mean peak serum levels 30 minutes after administration were 1.98 +/- 0.07 mg/L. Terminal serum half-lives ranged from 3.9 to 5.1 h. Mean concentrations of ciprofloxacin in pleural exudate were 1.44 +/- 0.42 mg/L at a mean time of 4.5 +/- 2.5 h. After this time, the pleural exudate level exceeded the corresponding serum twofold to tenfold. The mean percentage penetration into the inflammatory compartment was approximately 210 percent. Our data suggested that ciprofloxacin penetrates well into the pleural fluid of patients with empyema thoracis. The concentrations achieved were well above the MIC90 of most pathogens normally found in patients with empyema thoracis for a period of approximately 12 h.     

Intrapleural streptokinase in complicated parapneumonic effusions and empyema

BACKGROUND: The management of complicated parapneumonic effusions (CPE) and empyema by chest tube drainage usually fails because of thick viscous fluid and multiple pleural space loculations. The use of intrapleural fibrinolytic agents facilitates pleural drainage and can obviate the need for more invasive surgical interventions in these types of effusions. OBJECTIVE: To evaluate the role of intrapleural fibrinolytic therapy with streptokinase (STK) as an adjunctive therapy in the management of CPE and empyema. MATERIAL AND METHODS: Thirty patients of CPE and empyema were considered for intrapleural fibrinolytic therapy when the chest tubes/catheter drainage became insignificant (i.e., less than 50 ml a day) and the tube was adequately positioned and patent. Intrapleural STK was administered eight hourly in the dosage of 2,50,000 IU in 50 ml of saline. The end points were volume of fluid drained and radiological resolution. RRESULTS:There were 24 (80%) patients with CPE and six (20%) with empyema, with a mean age of 35 years. The median of STK doses used were three in 26 (87%) cases and two in four (13%) cases. There was significant drainage (mean +/- SD) 1094 ml +/- 116 and radiological resolution in 26 (87%) cases. The only complication observed was transient chest pain in one and fever in two patients. CCONCLUSION:Intrapleural fibrinolytic therapy with STK is a safe and effective adjunctive therapy in the management of CPE and empyema.     

Etiologic diagnosis of intrapleural empyema by counterimmunoelectrophoresis.

Cultural methods failed to identify the infecting organism in 4 patients with intrapleural empyema. Antimicrobial drugs had been administered to 3 of the patients before their admssion to the hospital. In each case, soluble polysaccharides believed to be those of pneumococcus or hemophilus were detected in the empyema fluid by counterimmunoelectrophoresis. These findings provided a rational basis for management of antimicrobial therapy for 3 of the patients and useful information on the origins of the empyema in the fourth patient. Counterimmunoelectrophoresis is a useful additional method for presumptively identifying the infecting organism in patients with intrapleural empyema.     

Outcome of pediatric empyema thoracis managed by tube thoracostomy

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.     

Video-assisted thoracoscopic sterilization for exacerbation of chronic empyema thoracis

STUDY OBJECTIVE: To investigate the efficacy of video-assisted thoracoscopic sterilization to treat patients with exacerbation of chronic empyema thoracis. DESIGN: Case reports and literature review. SETTING: Academic department of surgery. PATIENTS: Two elderly, debilitated patients with worsening, chronic empyema thoracis as diagnosed by radiographs, CT, and thoracentesis. Both patients had a history of therapeutic pneumothorax for tuberculosis without bronchopleural fistulas. INTERVENTIONS: Video-assisted thoracoscopic sterilization of the thoracic cavity. Measurements and results: There was no recurrence of empyema during a 6-year follow-up period for one patient and a 2.5-year follow-up period for the other patient. CONCLUSIONS: Video-assisted thoracoscopic sterilization is a minimally invasive useful treatment for elderly or debilitated patients with exacerbation of chronic empyema thoracis.     

Intrapleural streptokinase for empyema and complicated parapneumonic effusions

We conducted a single-center, randomized, placebo-controlled trial to determine whether streptokinase instillations adjunctive to chest tube drainage reduce the need for surgery and improve outcome in patients with pleural empyema. Fifty-three patients (frank pus aspirated, 81%; microbiological agent cultured, 62%; mean effusion pH, 6.6 +/- 0.4) received antibiotic treatment, chest tube drainage, and once-daily pleural rinses with either normal saline or normal saline with streptokinase (250,000 IU). Nine patients were excluded for various reasons before pleural rinses were started. Streptokinase (n = 22) was instilled over 4.5 +/- 2 days and saline (n = 22) was instilled over 3 +/- 1.3 days. One patient in each group died during treatment. Clinical treatment success and need for referral to surgery were the main outcome measures. No difference was observed after 3 days. After 7 days, streptokinase-treated patients had a higher clinical success rate (82 vs. 48%, p = 0.01) and fewer referrals for surgery (45 vs. 9%, p = 0.02). No significant radiologic or functional differences were observed between groups during follow-up over 6 months. We conclude that intrapleural streptokinase adjunctive to chest tube drainage reduces the need for surgery and improves the clinical treatment success in patients with pleural empyema.     

Complicated parapneumonic effusion and empyema thoracis: microbiologic and therapeutic aspects

Patients with pleural infections have a high risk of morbidity and mortality with prolonged hospitalization. The best methods for treating pleural infections remain debatable. Although the increasing drainage volume effect of streptokinase adjunctive to chest-tube, is well known, its effect on clinical outcomes like duration of hospitalization and need for further surgery, remains controversial. The aim of this study was to analyze the etiological and microbiological factors for pleural infections, and assess the effect of streptokinase adjunctive to chest tube for clinical outcomes. Charts of patients with a chest disease department discharge diagnosis of complicated parapneumonic effusion or empyema were retrospectively reviewed. Of the 107 patients (85 male), the mean age was 47.9+/-17.1 years. The most frequently shown bacteriological agent was Staphylococcus aureus. Drainage with thoracentesis was used in 44 patients (group 1); chest tube was performed in 44 patients (group 2) and intrapleural streptokinase was given after chest tube insertion in 19 patients (group 3). Mean hospitalization time in group 1 was shorter than the other two groups (P<0.05), but there was no significant difference between group 2 and 3. Our mortality rate was 8.4%. Success rates were 95.4%, 65.9% and 78.5% in groups 1, 2, and 3, respectively (P>0.05). Intrapleural streptokinase is a safe procedure but it did not effect the duration of hospitalization, mortality and success rate. Mortality remains especially high in patients with concomitant disease.     

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.