For complicated parapneumonic effusions, which adjunct therapy has been shown to improve clinical outcomes?

• A. Intrapleural fibrinolytics (e.g., tPA) and DNase
• B. Systemic corticosteroids
• C. High-dose IV antibiotics alone
• D. Watchful waiting

Answer: (A)

Loculated pleural fluid from a complicated pneumonia won’t drain well with antibiotics alone because fibrinous septations trap the infected fluid. Delivering intrapleural fibrinolytics (tPA) with DNase directly into the pleural space breaks down these septations and lowers fluid viscosity, making drainage much more effective. This combination has been shown to improve clinical outcomes—more complete drainage, fewer required surgeries for decortication, shorter hospital stays, and better radiographic resolution—compared with antibiotics and drainage by themselves. The benefit arises because tPA dissolves fibrin barriers, allowing DNase to access and degrade the DNA-rich pus, further reducing viscosity and promoting drainage. While systemic corticosteroids aren’t consistently proven to help in this scenario, and high-dose IV antibiotics alone or watchful waiting don’t address the loculated, poorly draining fluid, the intrapleural combination therapy directly tackles the physical barriers to cure.