Safety and Efficacy of Intrapleural Tissue Plasminogen Activator and DNase during Extended Use in Complicated Pleural Space Infections

Abstract

The use of intrapleural therapy with tissue plasminogen activator and DNase improves outcomes in patients with complicated pleural space infections. However, little data exists for the use of combination intrapleural therapy after the initial dosing period of six doses. We sought to describe the safety profile and outcomes of intrapleural therapy beyond this standard dosing. A retrospective review of patients receiving intrapleural therapy with tissue plasminogen activator and DNase was performed at two institutions. We identified 101 patients from January 2013 to August 2015 receiving intrapleural therapy for complicated pleural space infection. The extended use of intrapleural tissue plasminogen activator and DNase therapy beyond six doses was utilized in 20% (20/101) of patients. The mean number of doses in those undergoing extended dosing was 9.8 (range of 7–16). Within the population studied there appears to be no statistically significant increased risk of complications, need for surgical referral, or outcome differences when comparing those receiving standard or extended dosing intrapleural therapy. Future prospective study of intrapleural therapy as an alternative option for patients who fail initial pleural drainage and are unable to tolerate/accept a surgical intervention appears a potential area of study.

Clinical efficacy and bleeding outcomes of tissue plasminogen activator and dornase alfa in pleural space infection with once daily concurrent administration: a retrospective cohort study

“…There is conflicting data as to whether reducing the dose of tPA will lead to a reduction in pleural bleeding [14,15]. Conversely, a study utilizing extended tPA/DNase dosing (mean 9.8 doses) in patients who were not surgical candidates, demonstrated a similar efficacy rate as six doses but a higher pleural bleeding rate at 10% [16]. Two studies investigated the effect of concurrent administration of tPA and DNase.…”

Clinical Response-Guided tPA and DNase Administration as Rescue Treatment for Postoperative Empyema

“…8 Kheir corroborated this concurrent administration of tPA and DNase as a safe and effective option. 9 A study by McClune et al 10 showed that extended use of this intrapleural therapy was safe and effective for pleural space infections. A series of multinational observational studies 11,12 evaluated the combination of tPA and DNase as a "rescue" intervention for community acquired pneumonia if there was no improvement after 24 hours of treatment with antibiotics and tube thoracostomy.…”

Medical and Surgical Management of Empyema

“…A retrospective comparison of extended tPA and DNase (mean 9.8 doses, range 7-16) versus conventional (<6) doses found similar rates of needing surgery (15 vs. 16%), but nonsignificant trends toward more bleeding (10 vs. 3%), additional tube placement (35 vs. 15%), longer LOS (17 vs. 13 days), and greater need to escalate narcotics (80 vs. 57%). 119 Presumably extended dose patients were less fit for or refused surgery, but it appears that patients unsuccessfully drained after a short course of IPFT benefit more from additional image-guided tubes or surgery than prolonged IPFT dosing.…”