Management of pleural infection remains heterogeneous worldwide. This review highlights current controversies in therapeutic strategies for pleural infection, focusing particularly on recent studies and their implications.

The introduction of intrapleural therapy combining alteplase [a tissue plasminogen activator (tPA)] and deoxyribonuclease (DNase) has revolutionized treatment practices, though the optimal delivery and dosing regimen is an area of active investigation. Variations to simplify administration protocols and/or to lower the required drug doses have been published. Most were exploratory studies, but the variations showed maintained therapeutic efficacy.Whether intrapleural alteplase/DNase or video-assisted thoracoscopic surgery (VATS) is superior is a topic of debate. Retrospective comparative analyses between the two revealed no clear benefits on all-cause mortality from either approach. Pilot randomized trials have been published and further full-scale, head-to-head trials are underway.

Effective management of pleural infection involves adequate pleural drainage and appropriate antibiotic use. This review outlines the current evidence (and its limitations) and highlights knowledge gaps in optimizing the therapeutic strategies.

When chest tube drainage does not adequately resolve thoracic empyema, video assisted thoracoscopic surgery (VATS) is often needed. However, the proper duration of antibiotics after VATS is poorly defined. Consequently, the objective of this study was to evaluate if short antibiotic durations post-VATS was equally effective compared to longer durations.

Patients with thoracic empyema treated with VATS were identified retrospectively by a query of the hospital billing database. The bacterial causes of the empyema were divided into 8 different categories while the antibiotic duration after VATS was divided into two groups which included antibiotics ˂ 14 days and antibiotics >14 days. The primary outcome measured was rates of empyema recurrence. Statistical comparisons were conducted between the antibiotic duration groups overall and when stratified based on the different bacterial causes.

137 patients were included in this study with the main cause of empyema being culture negative empyema (37.2%) while alpha haemolytic Streptococcus spp. was the most cultured bacteria (26.3%). There was no statistical difference (p = 0.5168), in the rates of empyema recurrence, when short antibiotic durations (median 11.6 days)were compared to longer antibiotic durations (median 29.1 days)post-VATS. Nor was there a statistical difference in recurrence rates when stratifying based on bacterial cause.

This study reinforces that antibiotic durations less than 14 days post-VATS are equally effective as prolonged antibiotic durations. However, to determine the proper duration of antibiotic therapy post-VATS, a prospective clinical trial is needed to reduce complications of prolonged antibiotic therapies for these patients.

Intrapleural fibrinolytic therapy (IPFT), also known as intrapleural enzymatic therapy (IET), has been utilized for decades to treat pleural infections by expediting drainage in patients with pleural organization. The successful MIST2 trial demonstrated that IPFT improves pleural opacification, reduces hospital stays, and decreases short-term surgical referrals. Despite significant progress, gaps remain in identification of the optimal fibrinolytic agents, dosing, and safety improvements. IPFT is generally recommended for patients with loculation and failed pleural drainage, with a consensus panel advocating for combined tissue plasminogen activator (tPA) and DNase therapy. How each agent may affect the activity or function of the other in the combination remains unclear. While IPFT can reduce the need for surgical intervention, there are relatively few comparative clinical trials to guide initial therapy. Emerging low-dose IPFT treatment approaches may benefit patients who are poor surgical candidates. Personalized IPFT candidate approaches, such as the Fibrinolytic Potential Assay (FPA), could refine dosing and improve outcomes. Additionally, biomarkers like pleural fluid PAI-1 and suPAR concentrations may predict clinical outcomes and guide treatment. New therapeutic agents, including PAI-1 inhibiting peptides and mesothelial profibrogenic targets, are under investigation to enhance IPFT efficacy. These advances hold promise for improving the management of pleural infections and other forms of pleural organization.

Lung ultrasonography is an essential tool in the management of pleural infection. We report the usage of lung point-of-care ultrasound (POCUS) using a handheld ultrasound system (HHUS), which changed the immediate management of a complex pleural effusion.A middle-aged diabetic patient presented with fever, dyspnoea and left-sided pleuritic chest pain, suggestive of left pleural infection. Lung POCUS using a HHUS showed a multiloculated pleural effusion with no connections between the locules, and this was confirmed later with CT, along with left empyema necessitans. An upfront video-assisted thoracoscopy was done instead of catheter drainage and intrapleural enzyme therapy. Methicillin-sensitive Staphylococcus aureus was grown from the drained pus. The patient was subsequently discharged with prolonged antibiotic treatment.Lung POCUS by a trained physician is useful in deciding the immediate management of pleural infection. Modern HHUS provides a practical and reliable method for identifying and characterising pleural effusion.

Pleural infection represents a significant and ongoing challenge for patients, clinicians, and healthcare providers given the morbidity and mortality associated with this condition. Whilst our understanding of how pleural infection develops and how it should be treated has improved considerably over the past couple of decades, this has yet to translate into a meaningful positive impact on key outcomes. Making the diagnosis of pleural infection is not always straightforward, and the long-standing belief that it always occurs as a complication of lung parenchymal infection is being increasingly recognised as incorrect. Identifying the causative organism(s) is equally uncertain, with almost half of cases of pleural infection proving to be culture negative using traditional methods. Whilst we are now able to determine which patients are more likely to have a poor outcome from their pleural infection at the time of diagnosis, how this should affect their treatment pathway-including the role of more invasive strategies such as surgery or intrapleural enzyme therapy-is not yet known. This review article aims to summarise the existing evidence base and best clinical practice for the non-specialist, whilst highlighting recent research which has or will change the way we manage pleural infection, as well as those areas where further studies are still needed.

Sepsis, a life-threatening condition characterized by systemic inflammation and multiorgan dysfunction, is closely associated with the excessive formation of neutrophil extracellular traps (NETs) and the release of cell-free DNA. Both play a central role in sepsis progression, acting as major contributors to immunothrombosis and associated complications. Endogenous DNases play a pivotal role in degrading NETs and cell-free DNA, yet their activity is often dysregulated during thrombotic disease. Although exogenous DNase1 administration has shown potential in reducing NET burden and mitigating the detrimental effects of immunothrombosis, its therapeutic efficacy upon intravenous administration remains uncertain. The development of engineered DNase formulations and combination therapies may further enhance its therapeutic effectiveness by modifying its pharmacodynamic properties and avoiding the adverse effects associated with NET degradation, respectively. Although NETs are well-established targets of DNase1, it remains uncertain whether the positive effects of DNase1 on immunothrombosis are exclusively related to it's targeting of NETs or if other components contributing to immunothrombosis are also affected. This review examines the endogenous regulation of NETs in circulation and the therapeutic potential of DNases in immunothrombosis, underscoring the necessity for further investigation to optimize their clinical application.

Fibrinopurulent thorax is a rare condition that can lead to respiratory failure. Fibroblastic decortication surgery has been shown to be an effective treatment for chronic empyema in previous studies. However, there is limited evidence supporting surgical intervention for fibrinopurulent thorax in cases of respiratory failure.

We report a case of a male patient with a fibrinopurulent thorax and acute respiratory failure. The patient required invasive mechanical ventilation but showed no improvement, necessitating surgical intervention for empyema drainage. DNA gene sequencing technology was employed to diagnose the infection etiology, which facilitated the adjustment of antibiotics. This approach ultimately led to the patient's improvement and liberation from the ventilator.

This case demonstrates the efficacy of surgical treatment for fibrinopurulent thorax with respiratory failure, a scenario not previously documented in literature. Successful treatments for pneumonia and chronic empyema in the context of respiratory failure have provided both inspiration and validation for this approach. The findings of this case highlight the potential of surgical intervention as a new treatment option for clinical practice. However, as this is a single case report, further research is necessary to validate the efficacy and safety of this treatment method.

In this study we evaluated the utility of RAPID score in Parapneumonic effusion and empyema. Both of which are most common causes of exudative pleural effusion and this score was developed by Rahman et al by using multicentre intrapleural trial 1[MIST1 and MIST2]. Most of the patients with parapneumonic effusion usually recovers but mortality rate still around 10% along with long hospital stay, surgical interventions requirement, morbidity (3-month follow up) despite of advances in treatment specially in empyema cases. For this reason, this study was done as there is no such study have done by anyone in our knowledge specially in India. After calculating RAPID score in pleural infection then patients were stratified in the different risk categories and association was compared with these risk categories with different variables.

This is a prospective study at tertiary in which clinical utility of RAPID score in pleural infection in INDIAN population where tuberculosis infection is predominant. Baseline RAPID score was calculated on admission and stratified into risk category according to RAPID score. Primary outcome both mortality and morbidity, secondary outcome need of surgical interventions, length of hospital at 3-months in different risk category.

Overall, 120 patients were included in this study. Mortality was 7 (5.83%) in our study. Total 17 (14.17%) patients needed surgery and length of hospital study was compared in all three categories of RAPID score. Total 26 (21.67%) patients had <7 days and 94 (78.33%) >7 days hospital stays. Most common organism isolate was mycobacterium tuberculosis. RAPID score was compared in Tubercular And non-tubercular organisms.

Prognostic utility of RAPID score is well established especially in non-tubercular organisms. Here, in our study management utility of RAPID score also found useful. It performs good some aspects in tubercular aetiology.

Despite medical advancements, the rise in pleural empyemas persists in the United States. Surgical decortication for pleural empyema subjects patients to the potential complication of a prolonged air leak (PAL). This study aims to uncover the incidence, predictors, and outcomes of PAL following surgical decortication for pleural empyemas within a single tertiary institution.

Patients who underwent surgical decortication for plural empyema between 2011 and 2021 were identified in our single tertiary institution and divided into two groups: PAL and no PAL. Preoperative characteristics and postoperative outcomes were compared, and the results of the descriptive univariate analyses were reported.

Among the 228 patients who met inclusion criteria, 7.5% undergoing surgical decortication for pleural empyema were diagnosed with PAL. While demographic differences were not significant between PAL and no PAL groups, PAL patients showed higher chronic obstructive pulmonary disease prevalence (82.4% versus 34.1%, P < 0.001) and lifetime tobacco use. PAL cases had increased rates of reoperation (29.4% versus 8.1%, P = 0.015) and remained intubated at the conclusion of the case.

Patients with chronic obstructive pulmonary disease were significantly more likely to develop PAL, which is associated with higher rates of reoperation and extended hospital stays. These findings underscore the importance of preoperative identification of high-risk patients and the implementation of targeted preventive measures to improve surgical and postoperative outcomes, thereby reducing morbidity and healthcare costs.

This article translates the guidelines for the treatment of empyema established by the Japanese Association of Chest Surgery in 2023 from Japanese to English. These guidelines were developed by the Working Group on Guidelines for the Treatment of Empyema of our society, involving the establishment of clinical questions, conducting systematic reviews in accordance with the MINDS (Medical Information Distribution Service) Manual for Guideline Development 2020 version 3.0 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system, and determining the levels of recommendations. Furthermore, external evaluators provided assessments. Subsequently, the guidelines were finalized after receiving public comments from the members of the society. Even in the current era of advanced antibiotic therapy, empyema remains difficult to treat. However, the specific guideline for the treatment of empyema lacks in our country. Each institution is conducting clinical practices in its own way. Therefore, aiming to standardize the treatment of empyema, we have developed a practice guideline of empyema treatment. The pathophysiology of empyema is diverse, so empyema is classified into acute, chronic, and postoperative empyema. The recommended surgical treatment for each type of empyema is described, being categorized by the strength of recommendation, strength of evidence, and consensus rate.

This study aimed to evaluate the clinical efficacy, safety, and feasibility of medical thoracoscopy combined with fibrinolytic therapy for the treatment of complicated parapneumonic effusions and empyema, with a focus on therapeutic outcomes and recovery duration.

A retrospective cohort study was conducted involving 108 patients treated at Zhongshan Hospital, Xiamen University, between January 2015 and May 2024. Patients were categorized into two groups: the medical thoracoscopy group (n = 33) and the traditional treatment group (n = 75). The thoracoscopy group underwent thoracoscopic adhesiolysis and loculation breakdown, followed by intrapleural urokinase administration. The traditional treatment group received pleural catheter drainage combined with urokinase therapy. Primary outcomes included changes in inflammatory markers (white blood cell count, C-reactive protein, and procalcitonin), imaging outcomes (resolution of pleural effusion, pulmonary inflammation, and the incidence of pleural thickening at three months), pulmonary function assessed by forced vital capacity (FVC), and in-hospital mortality. Secondary outcomes encompassed the duration of postoperative fever, drainage time, intravenous antibiotic use, complication rates, initial treatment failure, length of hospital stay, and hospitalization costs.

Both groups demonstrated significant reductions in inflammatory markers post-treatment (P < 0.05). Pleural effusion resolution, pulmonary inflammation reduction, and the incidence of pleural thickening at three months were comparable between the groups (P > 0.05). Improvements in FVC were observed in both groups, with significantly greater gains in the thoracoscopy group (P < 0.05). No in-hospital mortality was reported. Compared to the traditional treatment group, the thoracoscopy group exhibited significantly lower postoperative inflammatory marker levels (P < 0.05), alongside shorter durations of postoperative fever, pleural drainage, intravenous antibiotic use, and hospital stay (all P < 0.05). The thoracoscopy group also had a significantly lower initial treatment failure rate (P < 0.05). Complication rates and hospitalization costs were comparable between the groups (P > 0.05).

Medical thoracoscopy combined with fibrinolytic therapy offers significant advantages in the management of complicated parapneumonic effusions and empyema. This approach effectively enhances inflammation control, improves pulmonary function, and accelerates recovery time without compromising safety or increasing costs, underscoring its potential for broader clinical application.

Pleural infections are common and associated with substantial healthcare costs, morbidity, and mortality. Accurate diagnosis remains challenging due to low culture positivity rates, frequent polymicrobial involvement, and non-specific diagnostic biomarkers. Here, we undertook a prospective study examining the feasibility and performance of molecular methods for diagnosing suspected pleural infection. We prospectively characterized 26 consecutive clinically suspected pleural infections, and 10 consecutive patients with suspected non-infective pleural effusions, using shotgun metagenomics, bacterial metataxonomics, quantitative PCR, and conventional culture. Molecular methods exhibited excellent diagnostic performance, with each method identifying 54% (14 out of 26) positive cases among the pleural infection cohort, versus 38% (10 out of 26) with culture. Metagenomics and bacterial metataxonomics unveiled complex polymicrobial infections that were not captured by culture. Dominant microbes included streptococci (Streptococcus intermedius, Streptococcus pyogenes, and Streptococcus mitis), Prevotella spp. (Prevotella oris and Prevotella pleuritidis), staphylococci (S. aureus and S. saprophyticus), and Klebsiella pneumoniae. However, we encountered challenges that complicated pleural infection interpretation, including: (i) uncertainties regarding microbial pathogenicity and the impact of prior antibiotic therapy on diagnostic performance; (ii) lack of a clinical diagnostic gold-standard for molecular performance comparisons; (iii) potential microbial contamination during specimen collection or processing; and (iv) difficulties distinguishing background microbial noise from true microbial signal in low-biomass specimens. This pilot study demonstrates the potential utility and value of molecular methods in diagnosing pleural infection and highlights key concepts and challenges that should be addressed when designing larger prospective trials.IMPORTANCEConfident pleural infection diagnosis is often challenging due to low culture positivity rates, frequent polymicrobial involvement, and non-specific diagnostic biomarkers. Limitations of conventional diagnostic tests result in prolonged and inappropriately broad-spectrum antimicrobial use, encouraging antimicrobial resistance and leading to avoidable adverse effects. Here, we demonstrate the feasibility, utility, and challenges associated with the use of culture-independent molecular techniques for accurate pleural infection diagnosis in a real-world clinical setting. These data will help to inform the design of larger prospective clinical trials and identify potential obstacles to be overcome before next-generation sequencing technologies can be integrated into routine clinical practice.

Biofilms are bacterial communities encapsulated in a self-produced extracellular polymeric matrix comprising carbohydrates, proteins, lipids, and DNA. This matrix provides structural integrity while significantly enhancing bacterial antibiotic resistance, presenting substantial disinfection challenges. The persistence of biofilm-associated infections and foodborne outbreaks underscores the need for more effective disinfection strategies. Conventional antibacterial agents often are less effective against biofilm-protected cells compared to their efficacy against planktonic (non-attached) bacteria. Integrating hydrolytic enzymes, such as cellulases, proteases, and DNases, into disinfection protocols offers a promising approach by breaking down the biofilm matrix to expose the bacteria. However, the follow-up use of antibacterial agents is important, as enzymes alone do not possess bactericidal properties. Unlike traditional disinfectants, natural antibacterial agents work synergistically with enzymes, enhancing biofilm disruption without compromising the enzymatic activity through oxidation. This review offers a comprehensive analysis of the current knowledge and potential of combining hydrolytic enzymes with disinfectants to disrupt biofilms and eradicate the released bacterial cells, emphasizing applications for clinical and foodborne pathogens.

A man in his 60s with advanced COPD and lung adenocarcinoma presented with sepsis and acute hypoxaemic respiratory failure. Imaging revealed bilateral pleural effusions, and he was found to have a polymicrobial empyema which included Capnocytophaga sputigena Despite appropriate treatment, he continued to deteriorate and ultimately died of sepsis. Capnocytophaga species, typically benign constituents of the oral microbiota, rarely can instigate pleuropulmonary infections, especially in immunocompromised individuals. We highlight the difficulty in the identification and the optimal antimicrobial treatment of Capnocytophaga in the setting of growing antibiotic resistance.

Pleural diseases is a common respiratory disorder, mainly characterized as pleural effusion and patients with pleural effusion caused by pneumonia and empyema constituted 29% of the cohort, which suggests pleural infection as the predominant etiology of pleural effusion in China. Medical thoracoscopy (MT) combined with intrapleural injection of Urokinase holds significant therapeutic value for patients with early to moderate-stage empyema. However, there remains a lack of high-quality evidence regarding the efficacy and safety of combining MT with intrapleural injection of Urokinase administration in patients with pleural infections.

This study is a prospective, multicenter, randomized controlled clinical trial involving patients with pleural infections. The intervention involves medical thoracoscopy. The control group receives conventional treatment involving intrapleural urokinase injection followed by chest tube placement for drainage. The study outcomes include efficacy and health economic benefits. The estimated minimum sample size for each group is 64 cases, totaling 128 cases. The study groups are delineated as follows: patients in group A receives intrapleural urokinase injection followed by chest tube placement for drainage, while patients in group B undergoes MT to remove multiple septa and necrotic tissue followed by chest tube placement for drainage, and then intrapleural urokinase injection the day after MT. It is recommended that the diameter of the chest tube be 12-14 F, with three daily flushes of 30 ml normal saline to ensure optimal drainage. Subsequently, comprehensive statistical analyses will be conducted to compare treatment effects and complications across all groups, ultimately leading to conclusive findings.

The study is the first prospective, multicenter clinical trial on the efficacy and safety of medical thoracoscopy combined with intrapleural urokinase injection for the treatment of pleural infection. This study aims to offer clinical guidance for the management of pleural infection.

ChiCTR2300078352 (Registration Date: 2023/12/06).

Empyema, defined as a purulent pleural effusion within the pleural cavity, typically results from severe infections and presents significant diagnostic and therapeutic challenges. This case report details the intricate clinical journey of a 44-year-old male with a complex medical history, including chronic substance abuse, significant tobacco use, and untreated hepatitis C, who presented with acute respiratory failure, hypoxia, and right-sided chest pain. Despite initial management with antibiotics and chest tube drainage, the patient's condition necessitated advanced surgical intervention due to persistent sanguineous output. A right thoracoscopy converted to open thoracotomy with decortication was performed due to dense adhesions. Intraoperatively, bronchoscopy revealed a hidden fentanyl patch in the right lower lobe, which was removed, leading to a significant release of purulent material and marked improvement in the patient's condition. Postoperatively, the patient steadily recovered with decreased oxygen requirements and improved ambulation. However, he developed acute tubular necrosis, likely due to nephrotoxic medications, which was managed appropriately. The patient was discharged with instructions for pulmonary function tests and lifestyle modifications, including cessation of tobacco use. This case emphasizes the importance of considering foreign body aspiration in patients with persistent or unexplained pulmonary symptoms, especially those with a history of substance abuse or unexplained recurrent respiratory infections. The multidisciplinary approach, comprehensive diagnostics, and collaborative care were pivotal in achieving a successful outcome, offering valuable insights for similar future cases.

The use of medical thoracoscopy (MT) has gained widespread acceptance for the diagnosis and management of pleural disease. It is less invasive compared to video-assisted thoracoscopic surgery (VATS), can be performed in the endoscopy suite and in patients who are unfit to undergo general anaesthesia. It is safe, with high diagnostic yield, and enables pulmonologists to intervene therapeutically.

There have been several developments in this field, particularly for malignant pleural effusions (MPE). Specifically, we discuss further techniques that can be employed during MT to distinguish between benign and malignant pleural disease. There is also potential for combined thoracoscopic talc poudrage (TTP) and indwelling pleural catheter (IPC) insertion to shorten hospital stay.

Beyond MPE, we discuss the role of MT in patients with pneumothorax and pleural infection. We discuss the advantages and disadvantages of MT over traditional practices in a variety of conditions - diagnosis of exudative pleural effusions, prevention of recurrent MPE and pneumothoraces as well as treatment of pleural infections, so as to better aid physicians in selecting the optimum procedure for patients.

Translational research in Interventional Pulmonology has made significant advances in recent years, ranging from novel biomarkers and imaging to practice-changing clinical trials in lung cancer and pleural disease. This review article aims to summarize key research studies in the field to understand the latest published evidence and to highlight areas of growing academic interest.

In lung cancer, the role of novel imaging and biomarkers and their potential utility in early lung cancer diagnosis will be highlighted. In pleural disease, less invasive/conservative treatment in pneumothorax, early aggressive treatment in pleural infection along with novel biomarkers, and the shift beyond drainage strategies in malignant pleural effusion and mesothelioma will be discussed.

This overview of translational research in the field of interventional pulmonology will ultimately help to highlight the gaps in current evidence to promote research in areas of clinical significance.

Complex pleural space infections often require treatment with multiple doses of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease, with treatment failure frequently necessitating surgery. Pleural infections are rich in neutrophils, and neutrophil elastase degrades plasminogen, the target substrate of tPA, that is required to generate fibrinolysis. We hypothesized that pleural fluid from patients with pleural space infection would show high elastase activity, evidence of inflammatory plasminogen degradation, and low fibrinolytic potential in response to tPA that could be rescued with plasminogen supplementation.

Does neutrophil elastase degradation of plasminogen contribute to intrapleural fibrinolytic failure?

We obtained infected pleural fluid and circulating plasma from hospitalized adults (n = 10) with institutional review board approval from a randomized trial evaluating intrapleural fibrinolytics vs surgery for initial management of pleural space infection. Samples were collected before the intervention and on days 1, 2, and 3 after the intervention. Activity assays, enzyme-linked immunosorbent assays, and Western blot analysis were performed, and turbidimetric measurements of fibrinolysis were obtained from pleural fluid with and without exogenous plasminogen supplementation. Results are reported as median (interquartile range) or number (percentage) as appropriate, with an α value of .05.

Pleural fluid elastase activity was more than fourfold higher (P = .02) and plasminogen antigen levels were more than threefold lower (P = .04) than their corresponding plasma values. Pleural fluid Western blot analysis demonstrated abundant plasminogen degradation fragments consistent with elastase degradation patterns. We found that plasminogen activator inhibitor 1 (PAI-1), the native tPA inhibitor, showed high antigen levels before the intervention, but the overwhelming majority of this PAI-1 (82%) was not active (P = .003), and all PAI-1 activity was lost by day 2 after the intervention in patients receiving intrapleural tPA and deoxyribonuclease. Finally, using turbidity clot lysis assays, we found that the pleural fluid of 9 of 10 patients was unable to generate a significant fibrinolytic response when challenged with tPA and that plasminogen supplementation rescued fibrinolysis in all patients.

Our findings suggest that inflammatory plasminogen deficiency, not high PAI-1 activity, is a significant contributor to intrapleural fibrinolytic failure.

ClinicalTrials.gov; No.: NCT03583931; URL: www.

gov.

To compare the efficacy and safety of administering six doses of intrapleural streptokinase (SK) versus the conventional three doses, in children with empyema.

In this open label, placebo-controlled, randomized trial, we enrolled 53 children with empyema, who received three doses of intrapleural SK. Thereafter, those without clinical improvement (n = 34) and those showing clinical improvement but having persistent pleural fluid width > 10 mm on chest ultrasonography (n = 13), were randomized to receive three additional doses of SK, or three doses of placebo (normal saline). The remaining 6 children improved clinically and radiologically, hence were not randomized. The outcomes recorded were cumulative volume of pleural fluid drained, total duration of intercostal drainage, time taken for clinical improvement, duration of hospitalization, proportion of children with treatment failure requiring surgery, and adverse events. Spirometry, 6-min walk test, chest X-ray and ultrasonography were done 3 months following discharge. We analyzed by intention-to-treat.

The baseline characteristics of children who received six versus three doses SK were comparable. There was no statistically significant difference in the cumulative volume of fluid drained; median (IQR): 810.0 (330.0, 1630.0) [95% CI: 505, 1463] mL versus 530.0 (255.2, 1325.0) [95% CI: 325, 1131] mL, p 0.46. There were no significant inter-group differences in the total duration of intercostal drainage, time taken for clinical improvement, duration of hospitalization, treatment failure, surgical decortication and adverse events.

In children with empyema, intrapleural therapy with six doses of SK is not superior to three doses, although it is safe.

Pleural infections are a significant cause of mortality. Intrapleural fibrinolytic therapy (IPFT) utilising alteplase and dornase is a treatment option for patients unsuitable for surgery. The optimal dose of alteplase is unknown, and factors affecting treatment success in an Asian population are unclear. We sought to determine the factors affecting treatment success in Tan Tock Seng Hospital, Singapore and evaluate the efficacy of lower doses of IPFT.

A retrospective analysis of patients with pleural infections treated with IPFT between July 2016 and November 2023 was performed. Treatment success was defined as survival without surgery at 3 months. Data, including patient demographics; comorbidities; RAPID (renal, age, purulence, infection source and dietary factor) scores; and radiological characteristics, were extracted from medical records and analysed. Linear mixed effects model and logistic regression were performed to determine factors affecting treatment success.

A total of 131 cases were analysed. Of these, 51 (38.9%) reported positive pleural fluid culture, and the most common organism was Streptoccocus anginosus. Mean age was 65 years (standard deviation [SD] 15.5). Mean time from chest tube insertion to first dose of IPFT was 10.2 days (SD 11.5). Median starting dose of alteplase was 5 mg. Treatment success was reported in 112 cases (85.5%). There were no significant differences between the alteplase dose and radiological clearance. Patient age (odds ratio [OR] 0.94, confidence interval [CI] 0.89-0.98) and interval between chest tube insertion to first dose (OR 0.95, CI 0.91-0.99) were statistically significant variables for the treatment success.

Lower starting doses of alteplase remain effective in the treatment of pleural infection. Early IPFT may result in better outcomes.

Fibrinolytic agents (FA) activate the fibrinolytic system, converting plasminogen into plasmin to break down fibrin. Their use for irrigation of abdominal abscesses is debated, and this meta-analysis evaluates their efficacy.

We searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing FA and saline in percutaneous drainage of abdominal abscesses. Outcomes included length of hospitalization, duration of drainage, and drainage volume. We pooled mean differences (MD) and 95% confidence intervals (CI) using a random-effects model. We also performed a trial sequential analysis (TSA).

We included six RCTs encompassing 299 patients. In the overall analysis, FA increased drainage volume (MD 104.25 mL; 95% CI 35.72-172.77 mL; p = 0.003; I2 = 0%). In children, saline reduced hospitalization duration (MD -1.26 days; 95% CI -1.98 to -0.55 days; p = 0.0006; I2 = 0%), whereas FA increased drainage volume (MD 84.66 mL; 95% CI 5.77-153.54 mL; p = 0.04; I2 = 0%). In adults, FA significantly reduced hospitalization duration (MD -11.12 days; 95% CI -15.16 to -7.08 days; p < 0.00001; I2 = 0%) and duration of drainage (MD -6.53 days; 95% CI -9.25 to -3.81 days; p < 0.00001; I2 = 0%) while increasing drainage volume (MD 164.47 mL; 95% CI 26.16-302.78 mL; p = 0.02; I2 = 0%). On TSA, the required information size was achieved only for the adult subgroup's hospitalization and drainage duration.

In adults, FA reduce hospitalization and drainage duration and increase drainage volume. In children, saline seems more effective in reducing hospitalization duration, while FA increase drainage volume. These findings underscore the need for age-specific treatments and further research, especially in the pediatric population.

Hemothorax is a serious complication following thoracic surgery, often resulting from vessel injury or rib fractures, and is typically managed with chest tube drainage. Persistent or loculated hemothorax, referred to as retained hemothorax, may require more invasive interventions, such as thoracotomy. Although the intrapleural administration of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) has shown promise in managing pleural infections, its use for hemothorax remains controversial due to bleeding risks. We present a case of a 74-year-old female who developed a retained hemothorax following a robotic left upper lobectomy for lung cancer. Initial chest tube drainage was insufficient, and her high-risk status rendered her unsuitable for further surgery. After a thorough evaluation and obtaining informed consent, intrapleural tPA and DNase were administered, resulting in significant clinical and radiographic improvement without complications. This case suggests that intrapleural tPA and DNase may be a potential alternative to surgery for managing retained hemothorax. Further studies are needed to establish treatment guidelines.

Thoracostomy and chest tube placement are key procedures in treating pleural diseases involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air (pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the centuries, chest drainage achieved a historical milestone in the 19th century with the creation of closed drainage systems to prevent the entry of air into the pleural space and reduce infection risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest tube design and function. Technological advancements led to the availability of various chest tube designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes with radiopaque stripes for better radiological visualization. Modern chest drainage units can incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices enhances drainage efficacy, although careful regulation is needed to avoid complications such as re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable lung, maintaining a long-term chest drain may be the most appropriate approach and procedures such as the placement of an indwelling pleural catheter can significantly improve quality of life. Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone of effective pleural disease management. This review provides a comprehensive overview of the historical evolution and modern advancements in pleural drainage. By addressing both current technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals aiming to optimize pleural disease management and patient care.

Since the advent of the MIST2 trial, the combined instillation of dornase and alteplase has become an effective nonsurgical treatment option for empyema and pleural fluid collection. Percutaneous drainage of abdominal abscesses and fluid collections, rather than open surgical treatment, also has become commonplace. The are several case reports and studies on the use of fibrinolytics to drain abdominal fluid collections but no literature reporting use of both alteplase and dornase for abdominal administration.

We present a case series from an academic medical center where dornase therapy was added to fibrinolytic therapy to treat intra-abdominal fluid collections, hematoma, and abdominal drainage catheters with low output.

This is an institutional review board-approved retrospective case series of 13 patients who underwent combination use of alteplase and dornase via intra-abdominal route. The primary objective was to assess for increased drain output, reduction in size of the fluid collection, and adverse events.

Many patients had improved drain output after dornase-alteplase therapy. One patient had significant bleeding complications.

All patients were discharged alive from the hospital. Clinical success was difficult to define due to variable goals of therapy. Further data are needed to establish the safety and efficacy of this practice, especially compared with intra-abdominal alteplase alone. Patients in our series generally received larger doses of alteplase than in prior studies due to use of dosing modeled on the MIST2 trial. Based on the limited experience of our study, we recommend holding therapeutic anticoagulation during the administration of intra-abdominal dornase-alteplase.

We present a patient with a post-pneumonectomy empyema refractory to surgical debridement and systemic antibiotics. The patient initially presented with a bronchopleural fistula and pneumothorax secondary to tuberculosis (TB) destroyed lung, which required a pneumonectomy with Eloesser flap. Ongoing pleural infection delayed the closure of the Eloesser flap, and thoracoscopic inspection of his chest cavity revealed a green, mucous biofilm-like structure lining the postpneumonectomy pleural cavity. Cultures identified pan-susceptible Pseudomonas aeruginosa. Despite debriding this biofilm-like structure and administering systemic antibiotics, the patient continued to show persistent signs of infection and regrowth of the film. We employed a novel approach to dissolve the biofilm-like structure using intrapleural dornase alfa followed by intrapleural antibiotic washes. After 3 weeks of daily washes, repeat inspection demonstrated the biofilm-like structure had completely resolved. Resolving the pseudomonas biofilm-like structure allowed permanent closure of his chest without further need for systemic antibiotics. At follow up 3 months later, he showed no sequalae. This treatment option can be an important adjunct to improve likelihood of chest closure in patients with post-pneumonectomy empyema that resists standard treatment options due to biofilm formation.

Pleural infections present significant clinical challenges, particularly in elderly or immunosuppressed patients, leading to prolonged hospital stay, high morbidity and high mortality. While CT and X-ray are standard imaging modalities, MRI's potential remain unexplored due to historical limitations in scan duration and patient discomfort. Advances in MRI technology, however, may enable its broader use in thoracic imaging. The study aimed to explore the feasibility of thoracic MRI from the radiographers' and patients' perspectives.

A prospective feasibility study was conducted involving thirteen patients with pleural infections who underwent thoracic MRI as an add-on within 48 h of the conventional contrast-enhanced chest CT. Feasibility was assessed on technical success, and scan duration. Patients and radiographers experiences were evaluated through questionnaires and qualitative comments.

Technical success was high as all thirteen patients completed the scans. The mean in-room time was 30.7±5.5 minutes and the mean scan time was 23 ± 5.4 minutes. Radiographers reported the MRI scans as feasible with few patients requiring breaks or assistance. Most patients found the MRI experience manageable though two reported difficulties with breath-hold instructions. No patients were challenged by lying in supine position and no patients felt very anxious. No significant movement- or breathing artefacts were identified on MRI.

Thoracic MRI is feasible with high technical success, acceptable scan time, and good patient experience in patients with pleural infections offering potential as a radiation-free imaging modality. Furthermore, compared to CT, the use of MRI showed potential advantages in identifying pleural effusion septations.

The state of healthcare is consistently being driven towards evidence-based practices to establish both optimal and consistent healthcare for all patients. From this evidence, treatment guidelines arise to meet these goals. As new data, diseases, and treatments develop, these guidelines that influence evidence-based practice are refined and redefined. However, while we have come far to understand the human body, there remain gaps in our knowledge and in the guidelines we rely on to treat our patients. We present a case of a patient with a common presentation but a rare finding where the guidelines have not yet been defined due to a lack of data. We describe a case of spontaneous bacterial peritonitis complicated by loculated ascites leading to hospital readmission. Of the patient's two loculated collections, only one of the two nearly resolved with clearance of loculations. That collection was treated with drain placement and alteplase dwells. There has been no analysis into whether this potential treatment may improve outcomes, but there are limited cases suggesting its possible benefit.

Management of complicated pleural infections (CPIs) had historically been surgical; however, following the publication of the second multicenter intrapleural sepsis trial (MIST-2), combination tissue plasminogen (tPA) and dornase (DNase) offers a less invasive and effective treatment. Our aim was to assess the quality of life (QOL) and functional ability of patients' recovery from a CPI managed with either intrapleural fibrinolytic therapy (IPFT) or surgery.

We identified 565 patients managed for a CPI between January 1, 2013 and March 31, 2018. There were 460 patients eligible for contact, attempted through 2 phone calls and one mailer. Two questionnaires were administered: the Short Form 36-Item Health Survey (SF-36) and a functional ability questionnaire.

Contact was made in 35% (159/460) of patients, and 57% (90/159) completed the survey. Patients had lower QOL scores compared to average US citizens; those managed with surgery had higher scores in physical functioning (surgery: 80, IPFT: 70, P=0.040) but lower pain scores (surgery: 58, IPFT: 68, P=0.045). Of 52 patients who returned to work, 48% (25) reported an impact on their work effectiveness during recovery, similarly between management strategies (IPFT: 50%, 13/26 vs. surgery: 46%, 12/26; P=0.781).

Patients with a CPI had a lower QOL compared with average US citizens. Surgically managed patients reported improved physical functioning but worse pain compared with patients managed with IPFT. Patients returned to work within 4 weeks of discharge, and nearly half reported their ability to work effectively was impacted by their recovery. With further research into recovery timelines, patients may be appropriately counselled for expectations.

This case report explores the intricate challenges of diagnosing and managing empyema caused by Streptococcus constellatus, particularly in patients with predisposing factors such as alcohol abuse and underlying respiratory conditions. We present a 34-year-old male patient with a medical history of hypertension, peripheral neuropathy, and alcohol abuse who developed empyema. Despite an initial presentation at another facility with symptoms mimicking a myocardial infarction and unremarkable chest X-ray results, his condition worsened, leading to a subsequent emergency department visit. The patient's persistent pleuritic chest pain and fever were initially managed with ibuprofen and steroids, which proved ineffective. Upon re-evaluation, he exhibited hemodynamic instability, and imaging revealed a moderate pleural effusion. An urgent chest tube placement drained over 1600 ml of purulent fluid, with cultures confirming S. constellatus. The patient was treated with broad-spectrum antibiotics and intrapleural administration of tissue plasminogen activator and dornase alfa; however, unresolved effusion necessitated video-assisted thoracoscopic surgery (VATS). This intervention successfully eradicated the infection. The case underscores the importance of considering less common pathogens like S. constellatus in atypical empyema cases and emphasizes the critical role of VATS in resolving complex pleural infections. Early recognition, comprehensive management strategies, and a high index of clinical suspicion are vital to reducing morbidity and mortality associated with such infections.

Spontaneous bacterial peritonitis (SBP) complicated by loculated ascites presents a therapeutic challenge, particularly when standard of care or surgical intervention is not feasible. This case report documents the successful use of intraperitoneal tissue plasminogen activator (tPA) as adjunctive salvage therapy in an adult female with decompensated liver cirrhosis and loculated infected ascites. After no improvement in the patient's clinical condition following 14 days of intravenous antibiotics, catheter-directed intraperitoneal tPA was administered for three days, resulting in the improvement of her abdominal pain and resolution of the loculations. This case provides additional support for the potential efficacy of tPA as salvage therapy in managing loculated infected ascites in cirrhotic patients who have failed standard treatments.

Purpose The study aimed to evaluate the effectiveness of different initial interventions, including thoracostomy drain tubes, open thoracotomy with decortication, and video-assisted thoracoscopic surgery (VATS) thoracoscopy in the management of empyema. Methods This prospective cohort study was conducted at two teaching hospitals in Sana'a, Yemen, over a two-year period from 2022 to 2024. The study included 40 patients diagnosed with empyema, categorized according to the type of initial intervention received. Demographic data, clinical presentation, imaging findings, intervention details, and outcomes were systematically collected and analyzed. Statistical analyses were performed to identify associations between demographic characteristics, empyema stage, intervention type, and treatment success. Results The study included 40 patients with a higher proportion of males (67.5%) than females (32.5%). The mean age was 47.1 years (standard deviation (SD): 12.85). The overall success rate of the initial interventions was 55%, with significant variation based on empyema stage, comorbidities, and intervention type. Stage I empyema had the highest success rate (80%), followed by Stage II (50%) and Stage III (27.3%), with a statistically significant difference (p = 0.034). Smoking history was identified as a significant negative predictor of success (p = 0.001). Higher pleural fluid pH was associated with better outcomes (p = 0.015). The most common complications were chest infections (20%) and bronchopleural fistulas (10%), with a mortality rate of 7.5%. Conclusion The empyema stage significantly affects the success rate, with early stages showing better outcomes. Early and appropriate intervention, particularly in later stages, is crucial for better outcomes. Effective management of postoperative complications is vital. This study highlights the need for early diagnosis and tailored interventions based on the empyema stage to improve patient outcomes. Future research should focus on larger multicenter studies to validate these findings and develop standardized treatment protocols.

The risk of early recurrent events after stroke remains high despite currently established secondary prevention strategies1. Risk is particularly high in patients with atherosclerosis, with more than 10% of patients experiencing early recurrent events1,2. However, despite the enormous medical burden of this clinical phenomenon, the underlying mechanisms leading to increased vascular risk and recurrent stroke are largely unknown. Here, using a novel mouse model of stroke-induced recurrent ischaemia, we show that stroke leads to activation of the AIM2 inflammasome in vulnerable atherosclerotic plaques via an increase of circulating cell-free DNA. Enhanced plaque inflammation post-stroke results in plaque destabilization and atherothrombosis, finally leading to arterioarterial embolism and recurrent stroke within days after the index stroke. We confirm key steps of plaque destabilization also after experimental myocardial infarction and in carotid artery plaque samples from patients with acute stroke. Rapid neutrophil NETosis was identified as the main source of cell-free DNA after stroke and NET-DNA as the causative agent leading to AIM2 inflammasome activation. Neutralization of cell-free DNA by DNase treatment or inhibition of inflammasome activation reduced the rate of stroke recurrence after experimental stroke. Our findings present an explanation for the high recurrence rate after incident ischaemic events in patients with atherosclerosis. The detailed mechanisms uncovered here provide clinically uncharted therapeutic targets for which we show high efficacy to prevent recurrent events. Targeting DNA-mediated inflammasome activation after remote tissue injury represents a promising avenue for further clinical development in the prevention of early recurrent events.

Pleural empyema is significant cause of morbidity and mortality. Debate in the literature exists regarding the best initial and definitive therapy, with recent research demonstrating superior short-term outcomes with initial surgical intervention. Despite this, the impact of surgical intervention on long-term outcomes has been incompletely described. A systematic review was undertaken to assess the current evidence evaluating the long-term impact of surgical intervention.

A systematic review was undertaken according to PRISMA guidelines utilizing three databases. Articles included all papers where patients received surgical intervention for empyema with outcomes evaluated beyond 90 days. Two reviewers extracted and reviewed the articles. Grey literature was included.

Eleven studies and two abstracts were extracted. One study and two abstracts evaluated the quality of life outcomes, two studies evaluated dyspnoea outcomes, seven studies evaluated long-term lung function and two studies evaluated mortality and re-admissions. 60-65% of patients had no dyspnoea between 2 and 7 years follow-up. In six of seven studies, normal lung function was achieved in patients with chronic fibrothorax with FEV1% and FVC% improvements between 14-30% and 13-50%, respectively. The results from such biased cohorts could not be extrapolated to conclude that surgical intervention results in better outcomes than ICC drainage. Risk of bias was severe for all 11 studies.

Surgical intervention potentially improves post-operative lung function, long-term dyspnoea, and mortality. The impact this has on quality of life remains unknown. Future prospective trials with homogenous comparative groups are required to better define the role of surgery and its impact on long-term outcomes.

Complicated pleural infection comprises of complex effusions and empyema. When tube thoracostomy is ineffective, treatment options include surgical drainage, deloculation and decortication or intrapleural fibrinolysis. We performed a systematic review and meta-analysis to examine which technique is superior in treating complicated pleural infections.

PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to July 2023 comparing surgery and intrapleural fibrinolysis for treatment of complicated pleural infection. The primary outcome was treatment success. Secondary outcomes included hospital length of stay, chest drain duration and in-hospital mortality.

Surgical management of complicated pleural infections was more likely to be successful than intrapleural fibrinolysis (RR 1.18; 95% CI 1.02, 1.38). Surgical intervention group benefited from statistically significant shorter hospital length of stay (MD: 3.85; 95% CI 1.09, 6.62) and chest drain duration (MD: 3.42; 95% CI 1.36, 5.48). There was no observed difference between in-hospital mortality (RR: 1.00; 95% CI 0.99, 1.02).

Surgical management of complicated pleural infections results in increased likelihood of treatment success, shorter chest drain duration and hospital length of stay in the adult population compared with intrapleural fibrinolysis. In-hospital mortality did not differ. Large cohort and randomized research need to be conducted to confirm these findings.

Bleeding within the pleural space may result in persistent clot formation called retained hemothorax (RH). RH is prone to organization, which compromises effective drainage, leading to lung restriction and dyspnea. Intrapleural fibrinolytic therapy is used to clear the persistent organizing clot in lieu of surgery, but fibrinolysin selection, delivery strategies, and dosing have yet to be identified. We used a recently established rabbit model of RH to test whether intrapleural delivery of single-chain urokinase (scuPA) can most effectively clear RH. scuPA, or single-chain tissue plasminogen activator (sctPA), was delivered via thoracostomy tube on day 7 as either one or two doses 8 h apart. Pleural clot dissolution was assessed using transthoracic ultrasonography, chest computed tomography, two-dimensional and clot displacement measurements, and gross analysis. Two doses of scuPA (1 mg/kg) were more effective than a bolus dose of 2 mg/kg in resolving RH and facilitating drainage of pleural fluids (PF). Red blood cell counts in the PF of scuPA, or sctPA-treated rabbits were comparable, and no gross intrapleural hemorrhage was observed. Both fibrinolysins were equally effective in clearing clots and promoting pleural drainage. Biomarkers of inflammation and organization were likewise comparable in PF from both groups. The findings suggest that single-agent therapy may be effective in clearing RH; however, the clinical advantage of intrapleural scuPA remains to be established by future clinical trials.

The treatment for empyema thoracis has been evolving over the years, including the usage of intrapleural fibrinolytic therapy (IPFT), for example, alteplase with intrapleural deoxyribonuclease (DNase) to enhance the drainage of pleural effusion. Here, we report two cases of thoracic empyema that were successfully treated with intrapleural saline irrigation and intrapleural tyloxapol apart from parenteral antibiotics as the pillar of the treatment. Both patients averted surgical procedure (decortication) and were discharged well. Upon follow-up, both cases showed clinical cure, biochemical recovery, and radiological improvement, indicating a good treatment outcome. This is the first reported cases on combination of saline irrigation with tyloxapol as alternative treatment for pleural infection.

Pleural effusion is the most common manifestation of pleural disease, and chest ultrasound is crucial for diagnostic workup and post-treatment monitoring. Ultrasound helps distinguish the various types of pleural effusion and enables the detection of typical manifestations of empyema, which presents as a complicated, septated effusion. This may benefit from drainage and the use of intrapleural enzyme therapy or may require more invasive approaches, such as medical or surgical thoracoscopy. The mechanism of action of intrapleural enzymatic therapy (IPET) is the activation of plasminogen to plasmin, which breaks down fibrin clots that form septa or the loculation of effusions and promotes their removal. In addition, IPET has anti-inflammatory properties and can modulate the immune response in the pleural space, resulting in reduced pleural inflammation and improved fluid reabsorption. In this article, we briefly review the literature on the efficacy of IPET and describe a case series in which most practical applications of IPET are demonstrated, i.e., as a curative treatment but also as an alternative, propaedeutic, or subsequent treatment to surgery.

Background: Bacterial aggregation has been well described to occur in synovial fluid, but it is unknown if bacteria form aggregates in body fluids beyond the synovial fluid. Consequently, this translational study evaluated the ability to form bacterial aggregates in different pleural fluids. Methods: Four of the most common causes of thoracic empyema-Streptococcus mitis, Streptococcus pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa-were used here. The different pleural fluids included one transudative and two exudative pleural fluids. Twenty-four-well microwell plates were used to form the aggregates with the aid of an incubating shaker at different dynamic conditions (120 RPM, 30 RPM, and static). The aggregates were then visualized with SEM and evaluated for antibiotic resistance and the ability of tissue plasminogen activator (TPA) to dissolve the aggregates. Statistical comparisons were made between the different groups. Results: Bacterial aggregates formed at high shaking speeds in all pleural fluid types, but no aggregates were seen in TSB. When a low shaking speed (30 RPM) was used, only exudative pleural fluid with a high protein content formed aggregates. No aggregates formed under static conditions. Furthermore, there was a statistical difference in the CFU/mL of bacteria present after antibiotics were administered compared to bacteria with no antibiotics (p < 0.005) and when TPA plus antibiotics were administered compared to antibiotics alone (p < 0.005). Conclusions: This study shows that bacteria can form aggregates in pleural fluid and at dynamic conditions similar to those seen in vivo with thoracic empyema. Importantly, this study provides a pathophysiological underpinning for the reason why antibiotics alone have a limited utility in treating empyema.

Although intrapleural administration of fibrinolytics is an important treatment option for the management of empyema, the addition of fibrinolytics failed to reduce the need for surgery and mortality in previous randomized controlled trials. This study aimed to investigate the effects of administrating fibrinolytics in the early phase (within 3 days of chest tube insertion) of empyema compared with late administration or no administration.

We used the Japanese Diagnosis Procedure Combination Inpatient Database to identify patients aged ≥16 years who were hospitalized and underwent chest tube drainage for empyema. A 1:2 propensity score matching and stabilized inverse probability of treatment weighting were conducted.

Among the 16 265 eligible patients, 3082 and 13 183 patients were categorized into the early and control group, respectively. The proportion of patients who underwent surgery was significantly lower in the early fibrinolytics group than in the control group; the odds ratio (95% confidence interval) was 0.69 (0.54-0.88) in the propensity score matching (P = 0.003) and 0.64 (0.50-0.80) in the stabilized inverse probability of treatment weighting analysis (P < 0.001). All-cause 30-day in-hospital mortality, length of hospital stay, duration of chest tube drainage, and total hospitalization costs were also more favourable in the early fibrinolytics group.

The early administration of fibrinolytics may reduce the need for surgery and death in adult patients with empyema.