Pleural effusion: infection: streptokinase and urokinase were probably equally as effective.

Clinical bottom line (level 1b)

  1. Streptokinase and urokinase were probably equally effective in treating parapneumonic effusions. Both increased the fluid drained from the chest.
  2. Around a tenth of patients with parapneumonic effusions required surgery to clear them.
Bouros et al: American Journal of Respiratory Critical Care Medicine 1997; 155: 291-295
Expires April 2003

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: university hospital, Greece

50 patients (aged range 15 to 92 years; median 48, 76% male) complicated parapneumonic effusions (multiloculated pleural effusion with concomitant pneumonia, bronchiectasis or lung abscess confirmed by CT or ultrasound scan) or loculated pleural empyema which failed to drain via thoracostomy (<70 ml in 24 hours)

Excluded if
  • presence of empyema or florid sepsis
  • bronchopleural fistula
  • history of previous streptokinase thrombolysis
  • contraindication to thrombolysis: history of haemorrhagic stroke, intracranial neoplasm, cranial surgery or head trauma within 14 days, or major surgery within 10 days


    • Control Group: (n = 25, 25 analysed): streptokinase 250 000 units in 100 ml saline instilled; chest tube clamped for 3 hours
    Experimental Group: (n = 25, 25 analysed): urokinase 100 000 units in 100 ml saline instilled; chest tube clamped for 3 hours
    The agent was reinstalled if persistent effusion on CT or ultrasound scan, or drainage was <50 ml in 24 hours. All patients were on antibiotics, commonly ceftazidime, amikacin and clindamycin.
    100% followed for 12 months

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    reduction in volume of67% or less 12 months 8
    (32.0%)    		 6
    (24.0%)    		 25%
    (-85% to 70%)    		 8.00%
    (-16.8% to 32.8%)    		 13
    (NNT = 3 to infinity;
    NNH = 6 to infinity)
    required surgery 12 months 2
    (8.00%)    		 2
    (8.00%)    		 0%
    (-555% to 85%)    		 0.00%
    (-15.0% to 15.0%)    		 inf
    (NNT = 7 to infinity;
    NNH = 7 to infinity)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    increase in volume of fluid drained/ ml 380
    (99)     		421
    (110)     		40
    (-19 to 100)

  • Patients on average had six installations of streptokinase or urokinase.

    • Comments

    1. This study is too small to show any clear differences between streptokinase and urokinase.
    2. Additionally, the use of urokinase in uncontrolled trials and clinical practice suggest this is likely a safe alternative to streptokinase

    Citation

    1. Bouros D, Schiza S, Patsourakis G, et al: Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study. American Journal of Respiratory Critical Care Medicine 1997; 155: 291-295
    Search Terms: pleural effusion in Cochrane
    Contributor: Chris Ball and Clare Wotton, April 2000
    Reviewer: Niteesh K Choudhry

    Clinical Question.
    Patient parapneumonic effusions
    Intervention or Exposure streptokinase
    Comparison urokinase
    Outcome fluid drained