For empyema, tPA plus DNAse in the pleural space improved outcomes (RCT, NEJM) - PulmCCM
Dec 262011

More than 65,000 people develop empyema each year, and 25% of them are in the hospital a month or longer. Past randomized trials and a meta-analysis showed streptokinase didn't help, but case series suggested tissue plasminogen activator might.

Rahman et al randomized 210 people to a 2 x 2 table: double-placebo, DNAse and t-PA, DNAse alone, or t-PA alone. The combination of DNAse and t-PA improved radiographic clearance of the pleural space (primary endpoint). Combination therapy also reduced the rate of surgery consultation by an absolute 8% (4% vs. 16%). Mean hospital stay was 5 days shorter in the combination therapy group (12 vs. 17 days); these were all prespecified secondary endpoints. There was no difference in mortality. N Engl J Med 2011;365:518-526.

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  2 Responses to “For empyema, tPA plus DNAse in the pleural space improved outcomes (RCT, NEJM)”

  1. You might add that tPA by itself was no better than control. So, the data from 2 RCT (MIST1 and MIST2) show that neither streptokinase nor tPA alone is effective. I would suggest that most programs rely on tPA as a sole agent for empyema. It will require emphatic repetition before programs understand that tPA is doing nothing.

    Another point is the giving the combination per this study is tricky – 2 separate injections, each dwelling for one hour, with one hour between. This will not be so easy to replicate in clinical practice.

  2. Excellent points Dr Broaddus. Per our telephone discussion, it sounds as if leading academic centers are exploring using this therapeutic modality more or less routinely for empyema, but it will probably require a written clinical protocol (with an order set) to ensure the injections are given at the proper times.

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