The Efficacy of Intrapleural Fibrinolytic Agents Following Surgical Intervention for Empyema Thoracis: A Prospective Cross-Sectional Study in a Pediatric Population

Background: Intrapleural instillation of fibrinolytic agents is novel in treating empyema. Although the efficacy of this method for treating empyema remains a topic of debate among experts, several studies have shown that the results of this technique are almost equivalent to surgical operations in the lower stages of the disease. However, in more advanced stages of empyema, surgery may be required. Despite the worldwide use of fibrinolytic agents instead of surgical procedures, the benefits of using these agents postoperatively still need to be defined. Objectives: In this prospective study, we aimed to compare the effects of streptokinase and alteplase in managing empyema in patients who underwent any surgical operations. Methods: We prospectively compared the outcomes of using alteplase and streptokinase in children who underwent surgical operations for empyema between 2015 and 2022. Following the surgery, fibrinolytic agents were instilled through thoracostomy tubes according to a specific protocol. The length of stay, frequency of complications, need for another surgery, and mortality were measured in each group. Results: Among 53 patients who met the inclusion criteria, 31 (58.5%) patients received streptokinase postoperatively, while the others were treated using alteplase. The length of stay after the surgery, wound infection, and mortality rate did not differ significantly between the groups (P-value = 0.394, 0.080, 0.767, respectively). However, the need for another surgery due to unexpanded lungs was significantly lower in the alteplase group (0% vs. 19.4%, P = 0.028). Conclusions: Alteplase as an intrapleural fibrinolytic is more effective than streptokinase in patients who underwent surgical operations due to empyema. The need for another surgery following the instillation of alteplase through chest tubes postoperatively may be decreased.