Pleural effusion: infection: streptokinase helped drainage.

Clinical bottom line (level 1b)

  1. Patients with pleural effusions from pneumonia who had streptokinase instilled daily into their chest drain, passed more fluid (~1.5 L more) and more had >50% reduction in the effusion at discharge (NNT = 2 at unknown) , compared with patients who just had saline.
  2. Patients were also less likely to require surgery (NNT = 4 at unknown) .
Davies et al: Thorax 1997; 52: 416-421
Expires April 2003

The study

Double-blinded concealed randomised trial without intention-to-treat
Setting: university hospital, UK

24 patients (aged ?, 71% male) community-acquired pneumonia associated with systemic sepsis (fever, raised white cell count and CRP) and a pleural effusion requiring drainage (purulent fluid, culture-positive for bacteria, LDH-effusion >100, glucose effusion:serum ratio <0.25, or loculation/septation of pleural fluid on CT or ultrasound scan)

Excluded if
  • aged <18 or >90
  • treatment with streptokinase by any route within two years
  • bleeding diathesis, stroke or significant haemorrhage within six months
  • known sensitivity to streptokinase
  • life expectancy <2 months


    • Control Group: (n = 12, 12 analysed): saline flush
    Experimental Group: (n = 12, 12 analysed): streptokinase 250 000 units in 20 ml once daily (in place of a saline flush)
    All patients had a 14-French van Sonnenberg catheter inserted under ultrasound-guidance into the most dependent portion of the collection or the largest locule, which was kept on continuous suction drainage for three days. All catheters were flushed every six hours with 20 ml saline. Catheters were removed after five days of drainage was <150 ml/day for two days.
    100% followed for weeks
    Outcome notes:
    • reduction in volume <75% : based blinded on CXR reports

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    reduction in volume <75% weeks 8
    (66.7%)    		 2
    (16.7%)    		 75%
    (6% to 93%)    		 50.0%
    (16.0% to 84.0%)    		 2
    (1 to 6)
    surgery required weeks 3
    (25.0%)    		 0
    (0.00%)    		 100%
    (% to %)    		 25.0%
    (0.50% to 49.5%)    		 4
    (2 to 200)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    volume of fluid drained 1059
    (502)     		2564
    (1663)     		1500
    (470 to 2500)

  • No patients had local pleural or systemic haemorrhagic problems during the study.

    • Comments

    1. Intrapleural streptokinase may improve pleural drainage , but duration of hospital stay is an important clinical outcome which appears not to have been shortened.

    Citation

    1. Davies RJ, et al: Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997; 52: 416-421
    Search Terms: pleural effusion in Cochrane
    Contributor: Chris Ball and Bob Phillips, April 2000
    Reviewer: Mitsuhiro Kamei

    Clinical Question.
    Patient pleural effusion
    Intervention or Exposure streptokinase in chest drain
    Comparison placebo
    Outcome effusion discharge, need for surgery