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Purpose To compare the effects of video-assisted thoracoscopic surgery (VATS) and fibrinolytic injection into the pleural space in children with empyema. Methods This randomized clinical trial included 51 children with empyema, who were divided into two groups. In the first group (25 patients), VATS was performed, while in the second group (26 patients), 0.1 mg/kg of Reteplase was injected into the pleural space for 3 days. The length of hospitalization, pediatric intensive care unit (PICU) stay, duration of fever and dyspnea, duration of antibiotic administration, duration of chest tube presence, and the need for reoperation were compared between the groups. Results In the Reteplase injection and VATS groups, the mean duration of hospitalization was 21.1 ± 7.5 and 12.3 ± 6 days ( P  < 0.001), respectively, and the length of PICU stay was 7.8 ± 3.8 and 1.9 ± 2.3 days ( P  < 0.001), respectively. The duration of antibiotic administration was significantly longer in the Reteplase group. The chest tubes were present for a longer duration in the Reteplase group, and the duration of fever was also significantly longer. Conclusion VATS surgery in children with empyema is associated with more favorable clinical outcomes compared to fibrinolytic therapy with Reteplase.

Abstract 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.

Corynebacterium jeikeium is an uncommon but increasingly recognized cause of invasive infection, usually affecting immunocompromised patients. Empyema due to C. jeikeium has not been previously reported in an immunocompetent adult. We describe the first case and review the existing literature on non-diphtherial Corynebacterium -related empyema to highlight diagnostic and therapeutic challenges. A 26-year-old previously healthy man presented with 5 days of pleuritic chest pain, fever, and productive cough. Chest computed tomography revealed a large, loculated left pleural effusion with an air–fluid level. Initial thoracentesis yielded frank pus, confirming empyema, but the patient declined immediate drainage and was started on intravenous cefoperazone/sulbactam and moxifloxacin. His condition worsened, prompting repeat thoracentesis and catheter drainage. Culture of pleural fluid grew C. jeikeium , leading to a switch to intravenous vancomycin and meropenem. The patient improved rapidly, with defervescence, normalization of inflammatory markers, and complete radiographic resolution. He remained well at the 3-month follow-up. A literature review identified only four previous cases of non-diphtherial Corynebacterium-related empyema, all in patients with significant comorbidities. This case demonstrates that C. jeikeium can cause empyema even in immunocompetent hosts. Early microbiological diagnosis, timely pleural drainage, and appropriate antimicrobial therapy, particularly vancomycin, are critical for successful outcomes. Increased awareness and case reporting will help refine management strategies for this rare but clinically relevant pathogen.

In this randomized trial involving 454 patients with pleural infections that required antibiotic therapy and chest-tube drainage, there was no benefit from the use of intrapleural streptokinase in terms of survival, the need for surgery, the length of the hospital stay, or the resolution of radiographic abnormalities. In this trial involving 454 patients with pleural infections, there was no benefit from the use of intrapleural streptokinase in terms of survival, the need for surgery, the length of the hospital stay, or the resolution of radiographic abnormalities. Pleural infection develops in about 65,000 patients each year in the United States and the United Kingdom. 1 Approximately 15 percent of patients die, 2 which is similar to the death rate among patients hospitalized with pneumonia, 3 , 4 and 15 to 40 percent require surgical drainage of the infected pleural space. 2 , 5 The median duration of inpatient care is 15 days, with 20 percent of patients remaining in the hospital for a month or longer. 2 Apart from antibiotic therapy, treatment in patients with pleural infection consists mainly of drainage of the infected pleural fluid, and the intrapleural administration of fibrinolytic drugs is . . .

Abstract Rationale Intrapleural tissue plasminogen activator (tPA)/deoxyribonuclease (DNase) therapy for pleural infection given at the time of diagnosis has been shown to significantly improve radiological outcomes. Published cases are limited to only a single randomized controlled trial and a few case reports. Objectives Multinational observation series to evaluate the pragmatic “real-life” application of tPA/DNase treatment for pleural infection in a large cohort of unselected patients. Methods All patients from eight centers who received intrapleural tPA/DNase for pleural infection between January 2010 and September 2013 were included. Measured outcomes included treatment success at 30 days, volume of pleural fluid drained, improvement in radiographic pleural opacity and inflammatory markers, need for surgery, and adverse events. Measurements and Main Results Of 107 patients treated, the majority (92.3%) were successfully managed without the need for surgical intervention. No patients died as a result of pleural infection. Most patients (84%) received tPA/DNase more than 24 hours after failing to respond to initial conservative management with antibiotics and thoracostomy. tPA/DNase increased fluid drained from a median of 250 ml (interquartile range [IQR], 100–654) in the 24 hours preceding commencement of intrapleural therapy to 2,475 ml (IQR 1,800–3,585) in the 72 hours following treatment initiation (P < 0.05). We observed a corresponding clearance of pleural opacity on chest radiographs from a median of 35% (IQR 25–31) to 14% (7–28) of the hemithorax (P < 0.001), as well as significant reduction in C-reactive protein (P < 0.05). Pain necessitating escalation of analgesia occurred in 19.6% patients, and nonfatal bleeding occurred in 1.8%. Conclusions This large series of patients who received intrapleural tPA/DNase therapy provides important evidence that the treatment is effective and safe, especially as a “rescue therapy” in patients who do not initially respond to antibiotics and thoracostomy drainage.

To compare the efficacy of adjunctive intrapleural streptokinase (SK) with simple closed chest tube drainage (Drain) in the treatment of empyemas and complicated parapneumonic effusions. This was a controlled study of 52 patients (mean age, 57 years; 41 men) with pleura space sepsis. Forty patients (77%) had empyema and 12 had complicated parapneumonic effusions. Twenty-nine patients were treated with Drain only while 23 received, in addition, repeated daily SK, 250,000 U in saline solution (mean, 5.3 days). The two groups of patients had comparable degrees of peripheral blood leukocytosis, frequency of loculated effusions, pleural fluid pH, and lactate dehydrogenase levels. Infective organisms were isolated in 54% of which 32% were anaerobic and 21% were polymicrobial infections. The incidence of surgical decortication was 17% and mortality was 15%. A significantly larger volume of pleural fluid was drained from patients in the SK treatment group (2.0 [1.5] L) than those in the Drain treatment group (1.0 [1.01] L). There were no significant differences, however, between the two treatment groups in terms of duration before defervescence, duration of hospital stay, the need for surgical intervention, or mortality rates. We conclude that thrombolytic therapy increased the volume of fluid drained from pleural empyemas but did not markedly reduce morbidity and mortality.

IntroductionPleural empyema is a frequent disease with a high morbidity and mortality. Current standard treatment includes antibiotics and thoracic ultrasound (TUS)-guided pigtail drainage. Simultaneously with drainage, an intrapleural fibrinolyticum can be given. A potential better alternative is surgery in terms of video-assisted thoracoscopic surgery (VATS) as first-line treatment. The aim of this study is to determine the difference in outcome in patients diagnosed with complex parapneumonic effusion (stage II) and pleural empyema (stage III) who are treated with either VATS surgery or TUS-guided drainage and intrapleural therapy (fibrinolytic (Alteplase) with DNase (Pulmozyme)) as first-line treatment.Methods and analysisA national, multicentre randomised, controlled study. Totally, 184 patients with a newly diagnosed community acquired complicated parapneumonic effusion or pleural empyema are randomised to either (1) VATS procedure with drainage or (2) TUS-guided pigtail catheter placement and intrapleural therapy with Actilyse and DNase. The total follow-up period is 12 months. The primary endpoint is length of hospital stay and secondary endpoints include for example, mortality, need for additional interventions, consumption of analgesia and quality of life.Ethics and disseminationAll patients provide informed consent before randomisation. The research project is carried out in accordance with the Helsinki II Declaration, European regulations and Good Clinical Practice Guidelines. The Scientific Ethics Committees for Denmark and the Danish Data Protection Agency have provided permission. Information about the subjects is protected under the Personal Data Processing Act and the Health Act. The trial is registered at www.clinicaltrials.gov, and monitored by the regional Good clinical practice monitoring unit. The results of this study will be published in peer-reviewed journals and presented at various national and international conferences.Trial registration numberNCT04095676.

This review discusses the substantial advances that have been made in our understanding of pleural biology and related pathophysiology, as well as in the epidemiology and treatment of parapneumonic effusions, empyema, and malignant pleural effusions.

Abstract 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 $9,127 ($6,914) were significantly lower than those for the VATS arm $11,379 ($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.

Our study aimed to assess the benefit of intrapleural fibrinolysis before resorting to surgery to treat complicated parapneumonic effusion and empyema. We conducted a retrospective and descriptive study, including all patients hospitalized in the intensive care unit (ICU) of the Abderhaman Mami hospital, Tunisia for empyema treated with instillation of intrapleural fibrinolytic therapy between the 1 January 2000 and 31 December 2016. In all patients, empyema was diagnosed on clinical features, imaging findings (chest X-ray, thoracic echography and/or computed tomography (CT), and microbiological data. The fibrinolytic agent used was streptokinase. The efficiency of intrapleural fibrinolytic therapy was judged on clinical and paraclinical results. Among 103 cases of complicated parapneumonic effusion and empyema, 34 patients were included. The mean age was 34 years [15-81] with a male predominance (sex ratio at 2.77). Median APACH II score was 9. Fifty (50%) of the patients (n=17) had no past medical history; addictive behavior was described in 17 patients (50%). All patients were admitted for acute respiratory failure and one patient for septic shock. Pleural effusion was bilateral in 7 patients. Bacteria isolated were Streptococcus pneumonia (6 cases), Staphylococcus aureus (3 cases, including one which methicillin-resistant), Staphylococcus epidermidis (1 case), anaerobes (5 cases), and Klebsiella pneumoniae (1 case). First-line antimicrobial drug therapy was amoxicillin-clavulanate in 20 patients. A chest drain was placed in all cases in the first 38 hours of ICU admission. The median number of fibrinolysis sessions was 4 [2-9] and the median term of drainage was 7 days [3-16]. No side effects were observed. Video-assisted thoracoscopic surgery was proposed in 5 patients. The median length of hospitalization stay was 15 days [6-31]. One patient died due to multi-organ failure.