Introduction Intrapleural infection remains a significant cause of morbidity and mortality. In many patients medical management with chest tube drainage and antibiotics fails and surgical intervention is required. The MIST2 trial reported improved resolution following intrapleural treatment with combined tissue plasminogen activator and DNase (tPA/DNase).

Aims To study the outcomes in patients with pleural infection treated with tPA/DNase over a one year period in a 1,109 bed city centre hospital.

Methods A prospective audit was undertaken of all patients with pleural infection treated with intrapleural tPA/DNase. The decision to initiate therapy was at the discretion of the treating team. The main outcomes were changes in chest drain output and CXR opacification, complications, and surgical intervention. The area of pleural opacity was calculated using the method described by the MIST2 group.

Results Ten patients were treated over a one year period, all of whom had clinical features of infection and yielded frank pus or pleural fluid with a pH below 7.2.

Treatment with tPA/DNase was not initiated as a first line therapy in any patient. All were initially managed with chest tube drainage and antibiotics and the decision to initiate tPA/DNase was due to subsequent poor or absent drain output combined with evidence of persistent pleural fluid.

Changes in pleural fluid output and pleural opacification on CXR following treatment are shown in Table 1.

In one patient treatment was discontinued after 1 dose due to a non-functioning drain and in one patient treatment was discontinued after the fifth dose due to heavy blood staining of the pleural fluid. There were no other treatment related complications. Only one patient required cardiothoracic intervention and all patients were discharged home.

Conclusions In keeping with the MIST2 trial, these data suggest that intrapleural tPA/DNase can safely be used to treat pleural infection. In this selected group of patients that failed to respond to conventional medical management tPA/DNase treatment led to further fluid drainage with an associated reduction in pleural opacification and a low requirement for cardiothoracic intervention.