Intrapleural fibrinolytic therapy for pleural infection: a multicentre real-world comparison of dosing regimens

Advances in the non-surgical management of pleural infection using intrapleural alteplase and DNase have reshaped treatment strategies. While twice-daily intrapleural fibrinolytic therapy (IPFT) is commonly used, evidence supporting once-daily regimens remains limited. We aimed to describe real-world outcomes associated with once- and twice-daily IPFT regimens and to compare their efficacy and safety, including outcomes among patients receiving modified alteplase doses.

We conducted a retrospective study of patients diagnosed with pleural infection across three tertiary referral hospitals in Singapore. Clinical, radiological, and biochemical data were analysed. Logistic regression models were used to evaluate the association between dosing frequency, dose modification, and treatment outcomes.

A total of 266 patients were included. The mean age was 64 years, with a median Charlson Comorbidity Index of 3 and median RAPID (renal, age, purulence, infection source, dietary factors) score of 3. Twice-daily dosing was used in 238 patients (89.5%), while 28 patients (10.5%) received once-daily dosing. Alteplase dosing was 10 mg in 132 patients and modified (<10 mg) in 131 patients. Overall treatment success was 83.1%, with no significant difference between twice-daily and once-daily regimens (81.9% vs. 92.9%, P=0.19). On logistic regression analysis, dosing frequency was not significantly associated with treatment success or 30-day mortality. There were also no significant differences in treatment success or bleeding complications between modified and standard-dose alteplase regimens.

In this multicentre retrospective cohort, once-daily IPFT achieved clinical outcomes comparable to twice-daily regimens. Modified alteplase dosing (<10 mg) was similarly effective, and earlier initiation of therapy appeared to be associated with improved treatment success. Prospective studies are needed to define optimal dosing strategies, particularly in Asian populations where data remain limited.