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Comparison of intrapleural use of urokinase and tissue plasminogen activator/DNAse in pleural infection

Benoît Bédat, Jérôme Plojoux, Jade Noel, Anna Morel, Jonathan Worley, Frédéric Triponez, Wolfram Karenovics
ERJ Open Research 2019 5: 00084-2019; DOI: 10.1183/23120541.00084-2019
Benoît Bédat
1Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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  • For correspondence: benoit.bedat@hcuge.ch
Jérôme Plojoux
2Division of Pneumology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Jade Noel
1Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Anna Morel
1Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Jonathan Worley
1Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Frédéric Triponez
1Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Wolfram Karenovics
1Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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  • ORCID record for Wolfram Karenovics
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  • FIGURE 1
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    FIGURE 1

    Change in a) pleural opacity, b) serum C-reactive protein and c) serum leukocyte counts over time according to the type of fibrinolysis. There were no differences in these variables between groups (p>0.05). t-PA: tissue plasminogen activator.

Tables

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  • TABLE 1

    Patient characteristics

    CharacteristicsOverallUrokinaset-PA/DNAsep-value
    Patients935241
    Age years61.5±17.261.4±17.661.6±170.95
    Males63 (68%)39 (75%)24 (59%)0.09
    Right-sided effusion55 (59%)28 (54%)27 (66%)0.24
    Presence of lung cancer16 (17%)7 (13%)9 (22%)0.28
    Pleural fluid analyses93 (100%)
     Positive bacterial culture33 (35%)16 (31%)17 (41%)0.28
     pH7±0.47±0.26.9±0.40.63
     Glucose mmol·L−13.5±8.13.9±9.92.8±4.40.59
     Lactate dehydrogenase IU·L−12217±26762447±31711912±18310.38
    Radiological findings
     Area occupied by effusion at baseline %39.4±19.638.8±2040.1±19.40.76
     CT scan86 (92%)47 (90%)39 (95%)0.39
     Number of collections2.5±1.42.4±1.42.6±1.50.46
     Isolated if ≥2 collections39 (64%)22 (71%)17 (57%)0.24
    Drainage
     Image-guided procedure76 (82%)38 (73%)38 (93%)0.02
     Tube size French13.7±414.5±4.812.6±2.40.02
     Hospitalisation-to-drainage duration days3 (1–8)2 (0–7)3 (2–9)0.31
     Drainage-to-lysis duration days1 (0–2)1 (0–2)1 (0–2)0.23

    Data are presented as mean±sd or median (interquartile range), unless otherwise stated. t-PA: tissue plasminogen activator; CT: computed tomography.

    • TABLE 2

      Clinical outcomes

      Clinical outcomesOverallUrokinaset-PA/DNAsep-value
      Additional procedure32 (34%)20 (38%)12 (29%)0.35
       Surgical referral12 (13%)8 (15%)4 (10%)0.42
       Additional chest tube20 (21%)12 (23%)8 (19%)0.68
      Duration of fibrinolysis days3 (3–5)5 (4–7)3 (3–3)<0.001
      Duration of drainage days6 (4–9)7 (4–10)6 (5–8)0.05
      Change in area occupied by effusion from baseline %
       On day 3−19.3±17.9−19.4±16−19.1±20.20.94
       On day 7−28.7±18−26.9±19.2−30.8±16.70.38
      Change in serum CRP level from baseline mg·dL−1
       On day 3−82.3±86.2−70.4±76.1−96.8±960.15
       On day 7−131±109.2−104.6±99.7−163.7±112.40.01
      Change in blood leukocyte count from baseline ×109 L−1
       On day 3−2.2±4.2−1.6±4.3−2.9±40.15
       On day 7−3.8±5.8−2.1±5.4−5.9±5.50.002
      Complications of fibrinolysis7 (8%)0 (0%)7 (17%)0.002
      Length of stay days18 (11–26)18 (11–25)18 (11–32)0.12
      Death at 30 days6 (6%)4 (8%)2 (5%)0.58

      Data are presented as median (interquartile range) or mean±sd unless otherwise stated. t-PA: tissue plasminogen activator; CRP: C-reactive protein.

      • TABLE 3

        Odds ratios for failure of fibrinolysis and subgroup surgical referral, determined using a univariate logistic regression model

        CovariateAdditional procedureSurgical referral
        OR (95% CI)p-valueOR (95% CI)p-value
        Urokinase versus t-PA/DNAse0.66 (0.28–1.59)0.360.59 (0.17–2.13)0.43
        Age1 (0.97–1.02)0.950.99 (0.95–1.02)0.45
        Positive bacterial culture1.71 (0.71–4.16)0.232 (0.59–6.79)0.27
        Hospitalisation-to-drainage duration0.93 (0.85–1.01)0.070.87 (0.72–1.05)0.14
        Drainage-to-lysis duration1.13 (0.93–1.36)0.221.19 (0.96–1.47)0.12
        Non-image-guided versus image-guided procedure2.59 (0.89–7.56)0.080.88 (0.17–4.44)0.88
        Tube size (ref. 8–12 French)
         14–18 French1.06 (0.4–2.78)0.911.54 (0.41–5.79)0.53
         20–24 French4.86 (1.26–18.77)0.021.72 (0.29–10.18)0.55
        Duration of fibrinolysis1.18 (0.98–1.41)0.081.05 (0.83–1.33)0.66
        Duration of drainage (ref. 1–3 days)
         4–10 days1.25 (0.31–5.1)0.760.57 (0.1–3.16)0.52
         >10 days6.75 (1.16–39.2)0.031.5 (0.2–11)0.69
        Baseline area occupied by effusion (ref. ≤1/3)
         1/3 to 2/3 of the hemithorax2.94 (1.02–8.5)0.041.69 (0.4–7.1)0.47
         >2/3 of the hemithorax4.33 (1.1–17.1)0.041.61 (0.24–10.9)0.49
        One versus multiple collections4.81 (1.48–15.66)0.0092.53 (0.49–11.82)0.31
        Isolated versus grouped collections1.27 (0.43–3.69)0.672.45 (0.47–12.78)0.29

        t-PA: tissue plasminogen activator.

        • TABLE 4

          Odds ratios for failure of fibrinolysis and subgroup surgical referral, determined using a multivariate logistic regression model

          CovariateAdditional procedureSurgical referral
          OR (95% CI)p-valueOR (95% CI)p-value
          Urokinase versus t-PA/DNase0.69 (0.25–1.91)0.480.52 (0.14–2.02)0.35
          Tube size (ref. 8–12 French)
           14–18 French1.1 (0.39–3.14)0.851.71 (0.44–6.69)0.44
           20–24 French11.19 (1.7–73.9)0.011.67 (0.26–10.78)0.59
          One versus multiple collections6.58 (1.68–25.73)0.0072.44 (0.48–12.26)0.28

          t-PA: tissue plasminogen activator.

          • TABLE 5

            Cost of injections

            CostUrokinaset-PA/DNAsep-value
            Cost per injection CHF144.45229.17NA
            Cost per patient CHF mean±sd1550.06±101.921263.23±530.370.04

            t-PA: tissue plasminogen activator; NA: not applicable.

            Supplementary Materials

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              Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

              FIGURE S1 Measurement of percentage of opacity using chest radiography in posteroanterior view: the area of effusion (right) was divided by the area of the chest (left). The landmarks were the spine, lateral edge of the chest wall and diaphragm. Area measurements (in mm2) were performed using the Weasis software v2.6.3 (HUG, Geneva, Switzerland). 00084-2019

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            Comparison of intrapleural use of urokinase and tissue plasminogen activator/DNAse in pleural infection
            Benoît Bédat, Jérôme Plojoux, Jade Noel, Anna Morel, Jonathan Worley, Frédéric Triponez, Wolfram Karenovics
            ERJ Open Research Jul 2019, 5 (3) 00084-2019; DOI: 10.1183/23120541.00084-2019

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            Comparison of intrapleural use of urokinase and tissue plasminogen activator/DNAse in pleural infection
            Benoît Bédat, Jérôme Plojoux, Jade Noel, Anna Morel, Jonathan Worley, Frédéric Triponez, Wolfram Karenovics
            ERJ Open Research Jul 2019, 5 (3) 00084-2019; DOI: 10.1183/23120541.00084-2019
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