On management of empyma thoracis

The administration of intrapleural streptokinase is common in the management of loculated empyema thoracis. Due to its immunogenicity and its inability to reduce pus viscosity, tissue plasminogen activator (tPA) has been sugggested as better alternative to facilitate drainage of empyema thoracis. tPA induces fibrinolysis by preferentially activating plasminogen bound to fibrin and is less immunogenic.

Another alternative is to use recombinant human deoxyribonuclease (DNase) which is known to reduce pus viscosity by fragmenting free uncoiled deoxyribonucleic acid found in pus. 

Interestingly, atleast one randomized trial has shown that combination of tPA and DNase is superior but DNase or tPA alone are ineffective. Moreover, DNase alone appears to be associated with an increased frequency of surgery or death. 

Rahman NM, Maskell N, Davies CW, West A, Teoh R, Arnold A, et al. Primary result of the second multicentre intrapleural sepsis (MIST2) trial; randomized trial of intrapleural tPA and DNase in pleural infection. Thorax 2009;64:A1

Link: http://thorax.bmj.com/content/64/Suppl_4/A1.full