Starting 2.5-mg tPA/5-mg DNase dose effective in patients with pleural infection

Use of 2.5-mg tissue plasminogen activator (tPA) and 5-mg deoxyribonuclease (DNase) therapy as a starting intrapleural dose, with up-titration if needed, appears effective in patients with pleural infection, suggests a study, noting that this treatment warrants further research.

The researchers enrolled consecutive patients with pleural infection treated with a starting regime of 2.5-mg tPA/5-mg DNase from two centres in Australia and UK. Escalation of tPA was allowed if clinical response was inadequate.

Of the 69 patients (mean age 61.0 years) who received intrapleural 2.5-mg tPA/5-mg DNase, 88.4 percent achieved treatment success and were discharged from hospital without surgery by 90 days.

Patients received a median of five doses of tPA/DNase, and the total amount of tPA used for each was 12.5 mg. Dose escalation of tPA was required in 17 patients, most (n=12) of which for attempted drainage of distant noncommunicating locule(s).

Clearance of pleural opacities on radiographs (from median 27.0 percent to 11.0 percent of hemithorax; p<0.0001), along with increased pleural fluid drainage (1.98 L over 72 h following commencement of tPA/DNase), and reduction of serum C-reactive protein level (by 45 percent from baseline at day 5; p<0.0001), confirmed the success of treatment.

Of note, two patients needed to undergo surgery, while six patients with significant comorbidities (eg, advanced cancer) had an ongoing infection when palliated and then died. In addition, two patients had self-limiting pleural bleeding and received blood transfusion.

“Intrapleural tPA/DNase therapy is increasingly used in pleural infection,” the researchers said. “Bleeding risks and costs associated with tPA remain the clinical concerns.”