Therapy

• Instill streptokinase ^a or urokinase ^d (e.g. 250 000 units streptokinase in 20 ml daily) 

Why?

• Patients who have streptokinase compared with saline instilled daily into their chest drain pass more fluid (~1.5 l more) and more have at least a 50% reduction in the effusion at discharge ^a
• Patients are less likely to require surgery. ^a
• Streptokinase and urokinase are probably equally effective in treating parapneumonic effusions. Both increase the fluid drained from the chest. ^d

Streptokinase reduces need for surgery

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
parapneumonic effusion a	streptokinase	saline	surgery at at discharge	32%	0.22 (0.06 to 0.82)	4 (3 to 24)

Streptokinase increases drainage 

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
parapneumonic effusion a	streptokinase	saline	reduction in volume > 50% at at discharge	58%	71% (6% to 177%)	2 (1 to 7)