Safety and Efficacy of Intrapleural Instillation of Streptokinase for Complex Empyema in Pediatric Population

Background: Complex parapneumonic (stage II – III) empyema poses a major surgical challenge in Egyptian hospitals, especially for children. Initial treatment typically involves tube drainage and antibiotics, which may control the infection but do not free the lung from thickened pleura and chest wall adhesions. Aim of study: This study aimed to determine whether intrapleural dose-adjusted streptokinase (SK) instillation was safe and effective in treating complex empyema in children without requiring pleural decortication (PD) surgery. Methods: From March 2021 to May 2025, 79 children who met the inclusion criteria were enrolled in this study. They were divided into two groups: Group A (control) consisted of 43 individuals treated conventionally without streptokinase treatment and group B (the SK group) had 36 patients who got streptokinase therapy (15,000 IU/kg) in addition to conventional treatments. Data regarding the amount of fluid drained following SK instillation, the time needed to achieve the afebrile state and a notable radiological improvement, the need for PD, and the in-hospital stay were collected and statistically analyzed. Results: The amount of fluid drained increased significantly after starting SK therapy, from 148.56 ± 90.06 to 598.27 ± 110.50 ml (p < 0.0001). The time to reach an afebrile state was shorter in the SK group (5.31 ± 3.62 days vs. 7.83 ± 5.21 days, p = 0.0166), as was the time for radiological improvement (6.24 ± 4.21 days vs. 8.82 ± 6.34 days, p = 0.0403). Only 3 patients (8.33%) in the SK group needed PD surgery, compared to 13 (30.23%) in the other group (p = 0.0165). Additionally, SK patients had shorter hospital stays (16.78 ± 9.81 days vs. 23.67 ± 11.32 days, p = 0.0054). Chest drains brought minimal bloody discharge in three patients from the SK group, with no significant drop in hemoglobin levels. Any patient who experienced an allergic reaction to SK was excluded from the study. Conclusion: Intrapleural instillation of SK is a safe and effective adjuvant therapy for children with complex empyema, provided that an allergic reaction to SK does not hinder its completion. This method results in a reduced need for surgical evacuation compared to conventional methods alone.