An international survey on the use of intrapleural tPA/DNase therapy for pleural infection

Introduction Intrapleural tissue plasminogen activator (tPA) combined with human recombinant DNase (DNase) could be an effective alternative to surgery in managing pleural infection as demonstrated in the Multi-centre Intrapleural Sepsis Trial (MIST)-2. However, the optimal delivery regime is still unknown. The aim of this survey is to identify the current practice of tPA/DNase use by physicians with published interests in pleural infection, and their opinions on dose de-escalation of tPA/DNase therapy. Methods Potential participants were identified using four search strategies. Only practicing physicians who are managing patients with pleural infections and are either actively involved in pleural research and publications, or members of relevant pleural disease guideline panels at the time of survey were included. Results An invitation email with the questionnaire was sent to 102 participants of which 49 (48%) responded. Most respondents (90%, n=44) have used tPA/DNase to manage pleural infection but the dosing and delivery regimens employed varied. Many (86%, n=38/44) respondents have used 10 mg tPA, while 73% (n=32), 16%, (n=7) and 9% (n=4) have used 5 mg, 2.5 mg and 1 mg doses respectively. Most respondents instilled tPA/DNase concurrently (61%, n=27) and routinely administered 6 doses of tPA/DNase (52%, n=23) twice daily (82%, n=36). Respondents would consider using a lower starting dose of tPA (with the possibility of escalation if clinically needed) if 80% [IQR 50–80] of patients could be successfully treated at that dose. Conclusion This survey observed a large variation in the current treatment protocol of intrapleural tPA/DNase therapy worldwide and the need for more data on this subject.