Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema

Altmann, Emile S; Crossingham, Iain; Wilson, Stephen; Davies, Huw Richard H R

doi:10.1002/14651858.cd002312.pub4

Cited by 50 publications

(56 citation statements)

References 54 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Our results (Figure 7) clearly indicate that local, low‐dose PAI‐1‐TFT in two models of rabbit pleural injury does not statistically affect the number of RBCs in pleural fluids and, thus, does not increase the risk of intrapleural bleeding complications. Current trends in pharmacological treatment of empyema in humans include (i) de‐escalation of sctPA dose to use in combination with deoxyribonuclease (Hart et al, 2019; Popowicz et al, 2017), (ii) evaluation of need of deoxyribonuclease and dose timing when combined with sctPA (Innabi et al, 2018; Majid et al, 2016, 2017; Mehta et al, 2016; Thommi et al, ,2012, 2014) and (iii) comparison of the efficacy of tPA and uPA (Aleman et al, 2015; Altmann et al, 2019; Beckert et al, 2019; Bedat et al, 2019; Nie et al, 2014). Our studies demonstrate that the level of PAI‐1 and fibrinolytic potential in pleural fluids (Beckert et al, 2019; Florova et al, 2015; Komissarov et al, 2016) are significant contributors to the outcome of fibrinolytic therapy following pleural injury in two rabbit models.…”

Section: Discussionmentioning

confidence: 99%

Precision targeting of the plasminogen activator inhibitor‐1 mechanism increases efficacy of fibrinolytic therapy in empyema

et al. 2021

View full text Add to dashboard Cite

Section: Discussionmentioning

confidence: 99%

Precision targeting of the plasminogen activator inhibitor‐1 mechanism increases efficacy of fibrinolytic therapy in empyema

et al. 2021

View full text Add to dashboard Cite

“…However, in sensitivity analysis, removing studies at high risk of bias eliminated these benefits. Importantly, the largest study (MIST-1: streptokinase vs placebo, 427 participants), also deemed to be at low risk of bias, was discordant with these findings [67]. It is important to note that the studies analysed in this latest systematic review represent both a heterogeneous population (MIST-1 recruited all patients with a diagnosis of pleural infection, whilst others specified patients with radiological evidence of loculation or failure to progress with tube drainage) and heterogeneous measured outcomes [57,58,62,63,[68][69][70][71][72][73][74][75].…”

Section: Intrapleural Enzyme Therapy (Iet)mentioning

confidence: 87%

Management of Pleural Infection

2020

View full text Add to dashboard Cite

Pleural infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Gram-positive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16–27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multi-centre Intrapleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient’s specific ‘fibrinolytic potential’, in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of pleural infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling pleural catheters, intrapleural antibiotics, pleural irrigation and steroid therapy.

show abstract

“…Notably, a more recent randomized clinical trial (i.e. MIST2 trial) and a meta-analysis showed that intrapleural fibrinolytic therapy, administered through chest tube, was associated with a reduced frequency of surgical interventions and treatment failure; however, mortality rate did not significantly change [ 21 , 22 ].…”

Section: Discussionmentioning

confidence: 99%

Medical thoracoscopy treatment for pleural infections: a systematic review and meta-analysis

et al. 2021

View full text Add to dashboard Cite

Background Complicated parapneumonic effusions and empyema represent advanced stages of pleural infections and are characterized by a high mortality. Medical thoracoscopy is a safe and minimally invasive endoscopic technique prescribed to treat severe pleural infections. However, only a few studies evaluated its success rate. A systematic review of observational studies was performed to assess the efficacy of medical thoracoscopy in patients with complicated parapneumonic effusions and empyema, as well as its predictive factors. Methods A search of the scientific evidence was carried out using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials. Articles describing observational studies on medical thoracoscopy in patients with parapneumonic effusions and empyema were selected. Results Eight studies met the inclusion criteria. The pooled treatment success rate of thoracoscopy was 85% (95% CI 80.0–90.0%; I2: 61.8%) when used as first-line intervention or after failure of chest tube. The pooled complication rate was 9.0% (95% CI 6.0–14.0%; I2: 58.8%). A pooled difference of treatment success of 9.0% (95% CI 1.0–18.0%) was found when post-thoracoscopy intra-pleural fibrinolysis was prescribed. Pooled success rate was higher in cases with pleural fluid culture negativity (pooled difference: 14.0%; 95% CI 4.0–24.0%). Conclusions Medical thoracoscopy is effective and safe when prescribed for complicated parapneumonic effusions and empyema. Bacteriological negativity of pleural effusion specimens and administration of adjuvant intra-pleural fibrinolysis after the procedure are associated with a higher success rate.

show abstract

Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema

Cited by 50 publications

References 54 publications

Precision targeting of the plasminogen activator inhibitor‐1 mechanism increases efficacy of fibrinolytic therapy in empyema

Precision targeting of the plasminogen activator inhibitor‐1 mechanism increases efficacy of fibrinolytic therapy in empyema

Management of Pleural Infection

Medical thoracoscopy treatment for pleural infections: a systematic review and meta-analysis

Contact Info

Product

Resources

About