Comparing the safety and efficacy of sequential vs concurrent intrapleural fibrinolytic and enzyme therapy (iet) for pleural infection: a retrospective review

SESSION TITLE: Complicated Pleural Effusions SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/10/2023 12:55 pm - 01:44 pm PURPOSE: There is insufficient data to support the routine use of concurrent vs sequential administration of IET with tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) for pleural infection despite an increasing trend of physician preference for concurrent administration. METHODS: A retrospective review of patients in two tertiary institutions who received IET for pleural infection from 2017-2022 was conducted. Pleural infection was defined as a compatible clinical history with at least one of the following pleural fluid characteristics: i) purulent macroscopically, ii) positive gram stain or culture, iii) pH ≤ 7.20, glucose ≤ 3.0 mmol/L or lactate dehydrogenase (LDH) > 1,000 IU/L, iv) complex pleural effusion defined by ultrasonographic (or radiographic) evidence of loculations or septations. RESULTS: 135 patients (77.8% male, median age 64 years) were recruited. 84 (62.2%) patients received sequential, and 51 (37.8%) patients received concurrent IET. Median RAPID score was 3 (IQR 2-4). IET initiation occurred at a median of 2 (IQR 1-4) days after chest tube insertion. There were no significant differences in demographic and RAPID scores between both groups. 29.6% of patients received 1-2 doses, 39.3% received 3-4 doses, and 31.1% received 5-6 doses of IET. 20.7% of patients received once daily IET dosing and 11.1% received reduced dose tPA (5mg). Compared to sequential IET, the concurrent IET group received fewer doses (3 (IQR 2-3) vs 4 (IQR 3-6), p<0.001), but fewer received a reduced tPA (5mg) dose (3.9% vs 15.5%, p=0.038). Following the first dose, length of stay was 6 (IQR 4-11) days and duration of chest tube drainage was 4 (IQR 3-6) days. Treatment success was 93.3%. Treatment failure, defined by in-hospital mortality attributed to pleural infection, or the need for surgical intervention within 30 days following the initial dose of tPA/DNase, occurred in 9 (6.7%) patients – 3 (surgery for empyema), 6 (in-hospital mortality from pleural infection). Adverse events occurred in 34 (25.2%) patients – 5.9% had pleural bleeding (bloody pleural fluid with acute drop in haemoglobin, requiring blood transfusion or surgery), 11.9% had chest pain requiring escalation in analgesia, and 2.2% had 30-day readmission related to unresolved pleural infection. There were no significant differences in treatment failure (8.3% vs 3.9%, p=0.482) and adverse event rates (26.2% vs 25.5%, p=0.928) for sequential vs concurrent IET. No significant differences in pleural bleeding (4.8% vs 9.8%, p=0.298) and significant chest pain (13.1% vs 9.8%, p=0.566) were observed. CONCLUSIONS: Our study demonstrates the feasibility of concurrent IET, with similar efficacy and safety compared to sequential IET. CLINICAL IMPLICATIONS: Further studies to validate the benefits of concurrent IET and optimal dosing should be performed, including the impact on overall cost. DISCLOSURES: No relevant relationships by Devanand Anantham No relevant relationships by Imran Bin Mohamed Noor No relevant relationships by Wui Mei Chew No relevant relationships by Eugene Gan No relevant relationships by Ken Junyang Goh No relevant relationships by Marnie Tamayo Gutierrez No relevant relationships by Sandra Hui No relevant relationships by Carrie Leong No relevant relationships by Wen Ting Lim No relevant relationships by Jasmine Ong No relevant relationships by Ivana Phua No relevant relationships by Aza Taha No relevant relationships by Qiao Li Tan No relevant relationships by Kah Yee Tham No relevant relationships by Jane Wong