Clinical Evolution of Practice Patterns in the Management of Pleural Space Infections: A Community-based Healthcare Network Review

Wilshire, Candice L.; Jackson, Anee Sophia; Horslen, L.C.; Rayburn, J.R.; Fuller, Carson C; Gilbert, Christopher R.; Rahman, Najib M.; Bedawi, Eihab; Bograd, Adam J.; Vallières, Eric; Gorden, Jed A.

doi:10.1513/annalsats.202010-1232rl

Cited by 3 publications

(4 citation statements)

References 6 publications

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“…A previous publication, although retrospective, identified surgical intervention to have advantages over IPFT. Additionally, surgical management of CPI was identified as declining as IPFT becomes more prevalent, and there is large variation in IPFT dosing regimens . Current guidelines, both medical and surgical, lack comparative trials on which to base recommendations …”

Section: Discussionmentioning

confidence: 99%

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Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections

et al. 2023

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ImportanceThere is a paucity of high-quality prospective randomized clinical trials comparing intrapleural fibrinolytic therapy (IPFT) with surgical decortication in patients with complicated pleural infections.ObjectiveTo assess the feasibility, safety, and efficacy of an algorithm comparing tissue plasminogen activator plus deoxyribonuclease therapy with surgical decortication in patients with complicated pleural infections.Design, Setting, and ParticipantsThis parallel pilot randomized clinical trial was performed at a single urban community-based center from March 1, 2019, to December 31, 2021, with follow-up for 90 days. Seventy-four individuals were screened and 48 were excluded. Twenty-six patients 18 years or older with clinical pleural infection and positive findings of pleural fluid analysis were included. Of these, 20 patients underwent randomized selection (10 in each group), and 6 were observed.InterventionsIntrapleural tissue plasminogen activator plus deoxyribonuclease therapy vs surgical decortication.Main Outcomes and MeasuresPrimary outcomes were the percentage of patients enrolled to study completion and multidisciplinary adherence. Secondary outcomes included the number of patients with and the reason for inadequate screening, screening to enrollment failures, time to accrual of 20 patients or the number accrued at 1 year, and clinical data.ResultsTwenty-six patients were enrolled, 10 were randomized to each group, and 6 were observed. There was 100% enrollment to study completion in each treatment group, no protocol deviations, 2 minor protocol amendments, and no screening to enrollment failures. It took 32 months to enroll 26 patients. The 20 randomized patients had a median age of 57 (IQR, 46-65) years, were predominantly men (15 [75%]), and had a median RAPID (Renal, Age, Purulence, Infection Source, and Dietary Factors) score of 2 (IQR, 1-3). Treatment failure occurred in 1 patient and 2 crossover treatments occurred, all of which were in the IPFT group. Intraprocedure and postprocedure complications were similar between the groups. There were no reoperations or in-hospital deaths. Median duration of chest tube use was comparable in the IPFT (5 [IQR, 4-8] days) and surgery (4 [IQR, 3-5] days) groups (P = .21). Median hospital stay tended to be longer in the IPFT (11 [IQR, 4-18] days) vs surgery (5 [IQR, 4-6] days) groups, although the difference as not significantly different (P = .08). There were no 30-day readmissions or 30- or 90-day deaths.Conclusions and RelevanceIn this pilot randomized clinical trial, the study algorithm was feasible, safe, and efficacious. This provides evidence to move forward with a multicenter randomized clinical trial.Trial RegistrationClinicalTrials.gov Identifier: NCT03873766

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Section: Discussionmentioning

confidence: 99%

“…Additionally, surgical management of CPI was identified as declining as IPFT becomes more prevalent, and there is large variation in IPFT dosing regimens. 11 , 26 , 27 , 28 , 29 Current guidelines, both medical and surgical, lack comparative trials on which to base recommendations. 1 , 16 , 17 …”

Section: Discussionmentioning

confidence: 99%

Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections

et al. 2023

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“…What is clear is that more patients with pleural infections undergo surgery when the admitting service is surgical. 59…”

Section: Surgerymentioning

confidence: 99%

Nonmalignant Pleural Effusions

Porcel

2022

Semin Respir Crit Care Med

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Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14–16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure–related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

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“…34 In oncology patients, there is good evidence that there is no increased risk of IPC-related infection by chemotherapy or an immunosuppressed state. 35,36 The pleural biopsies revealed malignant epithelioid mesothelioma. Following discussion in the lung multidisciplinary team meeting, the patient was referred to oncology for systemic treatment.…”

Section: What Is the Role Of Indwelling Pleural Catheters?mentioning

confidence: 99%

Modern day management of a unilateral pleural effusion

Ajmal

Tufail

et al. 2021

Clinical Medicine

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Over 50 systemic conditions may affect the pleura and, thus, unilateral pleural effusions may present for a variety of reasons. Investigating the cause is essential to providing appropriate management. Various pleural interventions are available in current practice, but have varying diagnostic sensitivity. It is, therefore, vital to consider the intervention with the highest diagnostic yield appropriate to the particular clinical situation. The diagnostic pathway in unilateral pleural effusion is increasingly outpatient based, avoiding hospitalisation, which is particularly relevant with the recent COVID-19 pandemic.

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Clinical Evolution of Practice Patterns in the Management of Pleural Space Infections: A Community-based Healthcare Network Review

Cited by 3 publications

References 6 publications

Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections

Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections

Nonmalignant Pleural Effusions

Modern day management of a unilateral pleural effusion

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