Intrapleural administration of streptokinase in complicated purulent pleural effusion: A CT-guided strategy

Objective: To determine the usefulness and the results of a strategy using intrapleural streptokinase (SK) instillation guided by repeated computed tomography (CT) scan examinations in pleural empyemas unresponsive to chest tube drainage. Design: A retrospective chart review. Setting: The medical Intensive Care Unit and Department of Radiology, in a university hospital. Patients: Sixteen patients with empyema who had a persistent pleural effusion despite drainage, among 37 patients with infectious pleural effusion. Interventions: In the 16 patients, CT examination was performed before and at least once after SK. Intrapleural SK was instilled, either through the chest tube or via a needle puncture, according to the CT scan results. Results: The first CT scan confirmed a persistent effusion in all, showing a multiloculated effusion in 13 patients, and an ectopic loculus in one. The first SK instillation resulted in a dramatic increase of fluid drained per day (from 68 +/- 28 mi to 567 +/- 262 mi, p < 0.001), leading to complete resolution in 11 patients, while the others required a second CT scan-guided procedure. In one, the chest tube was misplaced, while in two, transparietal injection was needed. Finally, a complete resolution was observed in 14 (87.5%) of the patients. Two patients had a poor initial response to SK and were eventually scheduled for video-thoracoscopy. A single episode of chills and fever was observed among 32 SK instillations. Conclusion: CT-guided SK instillation in pleural empyema appears to be safe, and allowed complete resolution in 87.5% of our patients.