Less treatment failure, crossovers with initial surgery for pleural space infections
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Surgery for managing complicated pleural space infections had better outcomes than fibrinolytic therapy, according to study results published in Annals of the American Thoracic Society.
“We identified surgery as the initial management strategy for complicated pleural space infections (CPSIs), which may be associated with superior outcomes and treatment success compared with initial intrapleural fibrinolytic therapy (and initial second Multicenter Intrapleural Sepsis Trial [MIST II] intrapleural fibrinolytic therapy) management in patients with similar age and RAPID score,” Candice L. Wilshire, MBBCh, research program director of the center for lung research at the Swedish Medical Center and Cancer Institute, and colleagues wrote.
In a retrospective multicenter cohort study, Wilshire and colleagues evaluated 566 adults (median age, 58 years; interquartile range, 46-68 years; 66% men) with CPSI to find out if the most favorable management strategy for these patients is surgery or dual agent intrapleural fibrinolytic therapy.
Researchers identified fibrinolytic as any dose of dual-agent fibrinolytic therapy, while five to six doses of 10 mg alteplase (Activase, Genentech) and 5 mg dornase (Pulmozyme, Genentech) twice daily (MIST II dosing) was further classified as standard fibrinolytics.
Researchers assessed adults who received either management strategy between January 2015 and March 2018, primarily looking at their rates of additional treatments, treatment failure (persistent infection with a pleural collection that needs intervention) and crossover (any fibrinolytics following surgery or vice versa).
To consider the selection bias effect in the outcomes of treatment failure and crossover, researchers used logistic regression with inverse probability of treatment weighting.
Of the total cohort, 311 (55%) patients had initial surgery while 255 (45%) had initial fibrinolytic therapy.
Adults who received surgery had shorter median hospital stays (10 days vs. 12 days; P < .001) and median chest tube duration (5 days vs. 7 days; P < .001) than those on fibrinolytic therapy but 1 day longer in terms of time to initiation of management (P = .002).
Compared with patients on fibrinolytic therapy, researchers found fewer patients who received surgery had additional treatments (10% vs. 39%; P < .001), treatment failures (7% vs. 29%; P < .001), crossovers (6% vs. 19%; P < .001) and readmissions (5% vs. 12%; P = .004).
Further, the 147 (58%) patients who received MIST II dosing within the fibrinolytic therapy group also had more instances of additional treatments and treatment failures than those who received surgery, but researchers found no difference in crossovers between both groups.
Researchers also observed that surgery was related to a decreased chance for treatment failure and crossover than any fibrinolytics (treatment failure OR = 0.2; 95% CI, 0.1-0.3; crossover OR = 0.13; 95% CI, 0.07-0.23) and standard fibrinolytic MIST II dosing (treatment failure OR = 0.2; 95% CI, 0.11-0.35; crossover OR = 0.27; 95% CI, 0.14-0.52) in the logistic regression analysis.
Mortality at 30 days and 90 days did not differ between both management strategies.
“While there is a lack of consensus as to the optimal management strategy for patients with a CPSI, in surgical candidates, operative management may offer more benefits and could be considered early in the management course,” Wilshire and colleagues wrote. “However, prospective trials are needed to explore this further. While this is real-world experience, there are limitations to retrospective data, and this should serve to emphasize the importance of a future randomized trial.”
This study by Wilshire and colleagues adds important data to the literature on what treatment is the best for adults with CPSIs, but more efforts, especially randomized trials, are needed to confirm their findings before they can be implemented, according to an accompanying editorial by Eihab O. Bedawi, MD, clinical research fellow in the Oxford Centre for Respiratory Medicine at Oxford University Hospitals NHS Foundation Trust, and colleagues.
“The results from Wilshire and colleagues highlight some of the challenges in evaluating these two treatment strategies in pleural infection,” Bedawi and colleagues wrote. “If early surgery is indeed associated with improved patient outcomes, then health care systems should be universally restructured to allow earlier surgical evaluation as the treatment of choice, particularly for those with high RAPID scores who are at risk of the worst outcomes. However, as the data from Wilshire and colleagues suggest and as they conclude, further prospective randomized controlled trials are urgently needed in this area before firm conclusions on optimal initial treatment can be made.”