A study of empyema thoracis and role of intrapleural streptokinase in its management

Abstract

Background: Clinical spectrum, microbiology and outcome of empyema thoracis are changing. Intrapleural instillation of fibrinolytic agents is being increasingly used for management of empyema thoracis. The present study was carried out to describe the clinical profile and outcome of patients with empyema thoracis including those with chronic empyema and to study the efficacy and safety of intrapleural streptokinase in its management.

Methods: Clinical profile, etiological agents, hospital course and outcome of 31 patients (mean age 40 +/- 16 years, M: F 25: 6) with empyema thoracis treated from 1998 to 2003 was analyzed. All patients were diagnosed on the basis of aspiration of frank pus from pleural cavity. Clinical profile, response to therapy and outcome were compared between the patients who received intrapleural streptokinase (n = 12) and those who did not (n = 19).

Results: Etiology was tubercular in 42% of the patients (n = 13) whereas the rest were bacterial. Amongst the patients in which organisms could be isolated (n = 13, 42%) Staphylococcus aureus was the commonest (n = 5). Intrapleural streptokinase was instilled in 12 patients. This procedure resulted in increase of drainage of pleural fluid in all patients. Mean daily pleural fluid drainage after streptokinase instillation was significantly higher for patients who received intrapleural streptokinase than those who did not (213 ml vs 57 ml, p = 0.006). Only one patient who was instilled streptokinase eventually required decortication, which had to be done in five patients (16.1%). Mean hospital stay was 30.2 +/- 17.6 days whereas two patients died.

Conclusions: Tubercular empyema is common in Indian patients. Intrapleural streptokinase appears to be a useful strategy to preserve lung function and reduce need for surgery in patients with late stage of empyema thoracis.

Figure 1

Mean pleural fluid drainage 5 days before and 5 days after intrapleural streptokinase (IPSTK) instillation for the two groups, ↓ :time of starting streptokinase instillation

Figure 2

(A) CT chest of patient with loculated empyema thoracis (arrow) and (B) marked resolution following intrapleural streptokinase therapy. (C) Empyema thoracis and (D) significant improvement after intrapleural streptokinase therapy in another patient.