Comparing Initial Surgery versus Fibrinolytics for Pleural Space Infections: A Retrospective Multicenter Cohort Study

Wilshire, Candice L.; Jackson, Anee Sophia; Meggyesy, Austin M; Buehler, Kerrie E.; Chang, Shu Ching; Horslen, L.C.; Rayburn, J.R.; Fuller, Carson C; Farivar, Alexander S.; Bograd, Adam J.; Louie, Brian E.; Vallières, Eric; Aye, Ralph W.; Gilbert, Christopher R.; Gorden, Jed A.

doi:10.1513/annalsats.202108-964oc

Cited by 6 publications

(17 citation statements)

References 19 publications

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“…More recently, Wilshire et al compared initial surgery vs. fibrinolytics through retrospective cohort analysis and did not find a mortality benefit of either management strategy. However, the results were in line with prior studies showing initial surgery to be associated with a shorter overall hospital length of stay, shorter duration of chest tube, lower rates of additional treatments and treatment failures, and lower risk of readmission, all of which met statistical significance [ 59 ].…”

Section: Procedural Managementsupporting

confidence: 87%

“…Similarly, dose reduction to 5 mg of alteplase (as opposed to 10 mg) has been studied due to concerns about bleeding and in an effort to reduce costs and has been shown to be effective as well [ 58 ]. In line with this, a recent retrospective cohort study found that intrapleural fibrinolytic therapy, as prescribed by the original MIST2 study, was only utilized in 52% of cases for which intrapleural therapy was used, suggesting substantial physician variability in practice patterns [ 59 ]. Contraindications to intrapleural fibrinolytic therapy include coagulopathy, concurrent anticoagulation therapy, allergy, or hypersensitivity to the medications.…”

Section: Intrapleural Medical Therapiesmentioning

confidence: 97%

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Pleural Space Infections

Foley

Parrish

2023

Life

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Pleural space infections have been a well-recognized clinical syndrome for over 4000 years and continue to cause significant morbidity and mortality worldwide. However, our collective understanding of the causative pathophysiology has greatly expanded over the last few decades, as have our treatment options. The aim of this paper is to review recent updates in our understanding of this troublesome disease and to provide updates on established and emerging treatment modalities for patients suffering from pleural space infections. With that, we present a review and discussion synthesizing the recent pertinent literature surrounding the history, epidemiology, pathophysiology, diagnosis, and management of these challenging infections.

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Section: Procedural Managementsupporting

confidence: 87%

Section: Intrapleural Medical Therapiesmentioning

confidence: 97%

Pleural Space Infections

Foley

Parrish

2023

Life

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“…There are, however, significant limitations to these studies, including underpowered statistics and inadequate or heterogenous categorization of the nonoperative management group. 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 .…”

Section: Discussionmentioning

confidence: 99%

“…Complicated pleural infections (CPIs), including complicated parapneumonic effusions and empyemas, are common, affecting approximately 80 000 patients each year in the US and United Kingdom combined . Management is challenging, as these infections are associated with significant morbidity and an all-cause mortality rate that may approach 18% . Hospital stays are prolonged at a mean of 14 days, and medical costs approach $40 000 per episode …”

Section: Introductionmentioning

confidence: 99%

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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“…It is, therefore, timely that in this issue of Annals ATS , Wilshire and colleagues (pp. 1827–1833 ) report their data comparing outcomes of initial surgical versus initial IET (tPA and DNase) management ( 16 ). This was a large retrospective multicenter cohort study conducted in 18 hospitals over 5 states and comprising 566 patients with pleural infection (complicated parapneumonic effusion or frank empyema).…”

mentioning

confidence: 99%