Fungal Empyema Thoracis

NCT ID: NCT07337993

Last Updated: 2026-01-13

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 50 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2025-07-01
• Study Completion Date: 2027-03-31

Brief Summary

Background:

Fungal empyema thoracis is a rare but life-threatening pleural infection caused by fungal organisms such as Aspergillus and Candida species. It typically occurs in immunocompromised or debilitated patients and carries a high mortality rate. Conventional management involves systemic antifungal therapy and surgical decortication; however, many patients are unfit for surgery due to poor clinical status or multiple comorbidities. The use of local intrapleural antifungal therapy remains poorly studied.

Objective:

This study aims to evaluate the efficacy and safety of pleural lavage with voriconazole in patients with fungal empyema thoracis, both as a pre-surgical adjunct and as a palliative measure for patients who cannot undergo surgery.

Methods:

A prospective cohort study will be conducted at the Department of Thoracic Surgery, Services Hospital, Lahore. Patients diagnosed with fungal empyema confirmed by pleural fluid culture or cytology will be included. Through an indwelling chest tube, voriconazole (200 mg in 100 mL normal saline) will be instilled into the pleural cavity once daily for three consecutive days. Patients will be assessed for improvement in clinical symptoms, radiological clearance, reduction in fungal load, and the need for surgical intervention. Data will be statistically analyzed to determine treatment response and safety outcomes.

Conclusion:

Pleural lavage with voriconazole offers a promising, minimally invasive approach for managing fungal empyema thoracis. If proven effective, this method could serve as a valuable addition to current antifungal strategies, improving outcomes for critically ill patients who are not candidates for surgery.

Detailed Description

Empyema thoracis remains an important cause of morbidity and mortality worldwide. While the vast majority of pleural space infections are bacterial, fungal empyema is a distinct and increasingly recognized clinical entity that carries substantially higher mortality and a more complex therapeutic course than typical bacterial empyema. Fungal empyema most commonly occurs in patients with significant comorbidities or healthcare exposures (e.g., recent thoracic surgery, prolonged antibiotics, gastrointestinal perforation, or immunosuppression) and is frequently due to Candida or Aspergillus species. Reported crude mortality rates range between 40-70%, which are considerably higher than for bacterial empyema [1, 2].

Standard management of fungal empyema combines prompt pleural drainage with systemic antifungal therapy and, when indicated, surgical intervention (decortication or debridement) in the presence of loculation, trapped lung, or persistent sepsis [3]. However, surgical treatment is often high-risk because many patients are elderly, immunocompromised, or poor surgical candidates. Even when surgery is performed, fungal empyema is associated with increased intra- and postoperative complications and prolonged hospitalization compared with bacterial empyema [4]. These challenges underscore the need for adjunctive or alternative strategies that can enhance pleural sterilization, control sepsis, and either avert or optimize the timing of definitive surgery.

Voriconazole, a second-generation triazole antifungal, demonstrates excellent activity against Aspergillus and Candida species and has favorable pleural space penetration when administered systemically [5]. Local administration of antifungal agents directly into the pleural cavity has been described in isolated reports, with encouraging outcomes using agents such as amphotericin B and voriconazole [6-8]. Pleural lavage (intrapleural irrigation) allows high local drug concentrations at the infected pleural surface, improving fungal clearance while minimizing systemic toxicity. Case reports have demonstrated successful outcomes using intrapleural antifungal lavage as adjunct therapy or as a palliative measure in patients who could not undergo surgical decortication [7-9].

Despite these encouraging findings, there remains a paucity of prospective evidence evaluating the efficacy and safety of pleural lavage with voriconazole in fungal empyema. To address this gap, we designed a prospective cohort study to assess the outcomes of pleural lavage with voriconazole in patients with confirmed fungal empyema. The primary objectives are to evaluate (1) the effectiveness of intrapleural voriconazole lavage as an adjunct prior to surgical decortication and (2) its potential as a palliative option for patients unfit for surgery. Secondary outcomes include pleural sterilization rates, clinical improvement, conversion to surgery, length of hospital stay, and treatment-related adverse effects. This study aims to provide clinical evidence supporting the role of local antifungal therapy in optimizing the management of fungal empyema, particularly in high-risk and resource-limited settings.

Conditions

Pyothorax; Fungal Infection Lungs; Pleural Empyema

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: SINGLE

Study Groups

pleural lavage group

participants of this group are diagnosed as having fungal empyema on investigations of pleural fluid before any kind of surgical intervention is carried out.

Group Type: EXPERIMENTAL

pleural lavage followed by surgery

Intervention Type: PROCEDURE

participants of this group are managed with pleural lavage with anti-fungals and than decortication is performed.

Surgical group

Participants of this group are misdiagnosed as having bacterial empyema before surgery, but diagnosed as having fungal empyema intra-operatively or after surgery on post-operative culture results.

Group Type: ACTIVE_COMPARATOR

Decortication

Intervention Type: PROCEDURE

patient underwent direct surgery for fungal empyema

Non-surgical group

participants of this group are diagnosed as having fungal empyema and they are unfit for any kind of surgical intervention and are only managed with pleural lavage with anti-fungal drugs.

Group Type: ACTIVE_COMPARATOR

Conservative Arm

Intervention Type: OTHER

patients are only managed with pleural lavage

Interventions

pleural lavage followed by surgery

participants of this group are managed with pleural lavage with anti-fungals and than decortication is performed.

Intervention Type: PROCEDURE

Decortication

patient underwent direct surgery for fungal empyema

Intervention Type: PROCEDURE

Conservative Arm

patients are only managed with pleural lavage

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• All age patients with confirmed fungal empyema thoracis.
• Patients with adequate pleural drainage through an intercostal chest tube.
• Patients receiving systemic antifungal therapy.
• Patients either:

1. scheduled for surgical decortication but undergoing lavage as a preoperative adjunct, or

2. considered unfit for surgery and managed conservatively.

Exclusion Criteria

• Bacterial empyema without fungal growth.
• Known hypersensitivity to anti-fungals.
• Severe hepatic impairment (Child-Pugh class C) contraindicating voriconazole.
• Pregnancy or lactation.
• Refusal to participate.

• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

University of Health Sciences Lahore

OTHER

Sponsor Role: lead

Responsible Party

Zeeshan Sarwar

Dr

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Muhammad Shoaib Nabi, FCPS

Role: STUDY_CHAIR

Saglik Bilimleri Universitesi

Locations

Services Hospital Lahore

Lahore, Punjab Province, Pakistan

Site Status: RECRUITING

Countries

Pakistan

Central Contacts

Zeeshan Sarwar, MBBS

Role: CONTACT

zeeshan.sarwar195@gmail.com

+923214347410

Facility Contacts

Muhammad Shoaib Nabi, FCPS

Role: primary

one111@gmail.com

+923009403511

Other Identifiers

IRB/2025/1720/SIMS

Identifier Type: -

Identifier Source: org_study_id