RANDOMIZED CONTROLLED TRIAL OF INTRAPLEURAL STREPTOKINASE IN COMMUNITY-ACQUIRED PLEURAL INFECTION

Background - Standard treatment for pleural infection includes cathete r drainage and antibiotics. Tube drainage often fails if the fluid is loculated by fibrinous adhesions when surgical drainage is needed. Str eptokinase may aid the process of pleural drainage, but there have bee n no controlled trials to assess its efficacy. Methods - Twenty four p atients with infected community acquired parapneumonic effusions were studied. All had either frankly purulent/culture or Gram stain positiv e pleural fluid (13 cases; 54%) or fluid which fulfilled the biochemic al criteria for pleural infection. Fluid was drained with a 14F cathet er. The antibiotics used were cefuroxime and metronidazole or were gui ded by culture. Subjects were randomly assigned to receive intrapleura l streptokinase, 250 000 IU daily, or control saline flushes for three days. The primary end points related to the efficacy of pleural drain age - namely, the volume of pleural fluid drained and the chest radiog raphic response to treatment. Other end points were the number of pleu ral procedures needed and blood indices of inflammation. Results - The streptokinase group drained more pleural fluid both during the days o f streptokinase/control treatment (mean (SD) 391 (200)ml versus 124 (4 4)ml; difference 267 mi, 95% confidence interval (CI) 144 to 390; p<0. 001) and overall (2564 (1663) mi versus 1059 (502) mi; difference 1505 mi, 95% CI 465 to 2545; p<0.01). They showed greater improvement on t he chest radiograph at discharge, measured as the fall in the maximum dimension of the pleural collection (6.0 (2.7) cm versus 3.4 (2.7) cm; difference 2.9 cm, 95% CI 0.3 to 4.4; p<0.05) and the overall reducti on in pleural fluid collection size (p<0.05, two-tailed Fisher's exact test). Systemic fibrinolysis and bleeding complications did not occur . Surgery was required by three control patients but none in the strep tokinase group. Conclusions - Intrapleural streptokinase probably aids the treatment of pleural infections by improving pleural drainage wit hout causing systemic fibrinolysis or local haemorrhage.