Intrapleural Fibrinolytics and Deoxyribonuclease for Treatment of Indwelling Pleural Catheter-Related Pleural Infection: A Multi-Center Observational Study.

Abstract

BACKGROUND:

Indwelling pleural catheters (IPC) are increasingly used for management of recurrent (especially malignant) effusions. Pleural infection associated with IPC use remains a concern. Intrapleural therapy with tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) significantly reduces surgical referrals in non-IPC pleural infection, but data on its use in IPC-related pleural infection are scarce.

OBJECTIVE:

To assess the safety and efficacy of intrapleural tPA and DNase in IPC-related pleural infection.

METHODS:

Patients with IPC-related pleural infection who received intrapleural tPA/DNase in five Australian and UK centers were identified from prospective databases. Outcomes on feasibility of intrapleural tPA/DNase delivery, its efficacy and safety were recorded.

RESULTS:

Thirty-nine IPC-related pleural infections (predominantly Staphylococcus aureus and gram-negative organisms) were treated in 38 patients; 87% had malignant effusions. In total, 195 doses (median 6 [IQR = 3-6]/patient) of tPA (2.5 mg-10 mg) and DNase (5 mg) were instilled. Most (94%) doses were delivered via IPCs using local protocols for non-IPC pleural infections. The mean volume of pleural fluid drained during the first 72 h of treatment was 3,073 (SD = 1,685) mL. Most (82%) patients were successfully treated and survived to hospital discharge without surgery; 7 required additional chest tubes or therapeutic aspiration. Three patients required thoracoscopic surgery. Pleurodesis developed post-infection in 23/32 of successfully treated patients. No major morbidity/mortality was associated with tPA/DNase. Four patients received blood transfusions; none had systemic or significant pleural bleeding.

CONCLUSION:

Treatment of IPC-related pleural infection with intrapleural tPA/DNase instillations via the IPC appears feasible and safe, usually without additional drainage procedures or surgery. Pleurodesis post-infection is common.

• Authors: Deirdre B Fitzgerald, Sanjeevan Muruganandan, Selina Tsim, Hugh Ip, Rachelle Asciak, Steven Walker, Juan-Pablo Uribe Becerra, Adnan Majid, Liju Ahmed, Najib M Rahman, Nick A Maskell, Kevin G Blyth, Y C Gary Lee
• Journal: Respiration; international review of thoracic diseases (Respiration) 2021 Vol. 100 Issue 5 Pg. 452-460 ISSN: 1423-0356 [Electronic] Switzerland
• PMID: 33784710 (Publication Type: Journal Article, Multicenter Study, Observational Study)
• Copyright: © 2021 S. Karger AG, Basel.

Chemical References

• Fibrinolytic Agents
• Deoxyribonucleases
• Tissue Plasminogen Activator

Topics

• Aged
• Catheters, Indwelling (adverse effects)
• Deoxyribonucleases (administration & dosage, adverse effects)
• Drug Therapy, Combination
• Empyema, Pleural (microbiology)
• Female
• Fibrinolytic Agents (administration & dosage, adverse effects)
• Humans
• Leukocyte Count
• Male
• Middle Aged
• Pleural Diseases (drug therapy)
• Pleural Effusion (microbiology, therapy)
• Respiratory Tract Infections (drug therapy)
• Tissue Plasminogen Activator (administration & dosage, adverse effects)