Intrapleural streptokinase: the answer to community acquired pleural infection?

Approximately 40% of patients with community acquired prevent surgery it must be initiated before the fibrino-purulent stage is advanced and organisation occurs. pneumonia develop a parapneumonic effusion, despite the Placement of the catheter under ultrasound guidance availability of appropriate antibiotics. 1 This effusion may allows better positioning, particularly in multiloculated become secondarily infected, denoted by changes in fluid effusions where it can be placed in the largest loculation. chemistry (fall in pH and glucose, rise in LDH), organisms The catheters used by radiologists are frequently much on gram staining or culture, and extensive fibrin deposition. smaller than chest drains traditionally used at the bedside, Untreated it can result in an empyema with frank pus with improved patient comfort and a more controlled and fibrous organisation in the pleural space. 2 Effective rate of fluid drainage. However, even with the use of treatment requires adequate and early drainage of the fluid. radiologically guided placement, suction and saline flushes, Options include simple aspiration or tube drainage, but the addition of intrapleural streptokinase significantly en-these may be hindered by loculation, the formation of hances drainage and reduces the need for surgery. 12 fibrinous clots blocking chest drains, and progressive The findings of Davies et al 11 allow us to re-evaluate the pleural thickening. Thoracotomy with rib resection or management of patients with parapneumonic effusions. decortication achieves the best drainage but carries an All patients with suspected pneumonia should be examined associated morbidity and mortality. 2 3 clinically and radiologically for the presence of an effusion. Prompt treatment of infected effusions is essential since Prompt diagnostic thoracocentesis should be performed fibrin deposition can occur within the space of a few days. 4 where fluid is detected. If frankly purulent fluid is obtained, However, delays often occur in diagnosis, both in primary there is direct or indirect laboratory evidence of an infected care and following admission to hospital. 5 Thus, patients effusion, or there is loculation on imaging, then a drain may present with complicated multiloculated effusions, should be inserted, preferably under ultrasound guidance. not amenable to tube drainage alone. Furthermore, the Streptokinase should be administered daily (250 000 IU), lack of prospective randomised trials has led to controversy even if the effusion is not multiloculated, and continued over the optimum treatment of infected effusions. 1 6 7 until the volume drained is <100 ml/24 hours. Patients One approach is enzymatic debridement of the pleural …