Chest infection showdown: drugs or surgery for empyema?

Copied word for word from the study's registry entry, so the wording is the study team's rather than ours.

Inclusion Criteria: * 18 years or more on the day of hospitalization * Must be able to provide informed consent * Acute hospitalization within the last 48 hours * Meeting diagnostic criteria for community acquired pleural infection using the following criteria: 1. A clinical presentation compatible with pleural infection AND 2. Has pleural fluid which is either: 1. purulent pleural fluid or 2. gram stain positive or 3. culture positive or 4. acidic with pH \< 7.2 or 5. low pleural fluid glucose (\< 2 mmol/L) in the absence of accurate pH measurement or 6. septated pleural fluid on ultrasound Exclusion Criteria: * • Pregnancy. Prior to inclusion of fertile women (defined as the period from menarche to postmenopause) a negative pregnancy test must be available * Breastfeeding * Declared terminally ill or a predicted survival of less than 3 months * Previous intrathoracic surgery (within \<1 year on the same side of the thorax as where the parapneumonic effusion/pleural empyema is located * Previously (within \<1 year) hospitalized with with complex parapneumonic effusion (stage II) or pleural empyema (stage III) * Drainage during the current admission on the same side of the thorax (excluding diagnostic pleural puncture) * Hospitalization within 7 days prior to current hospitalization * Previous allergic reaction to alteplase or DNase * Use of alteplase therapy contraindicated: * Ongoing treatment with oral anticoagulant incl. new oral anticoagulants (e.g. warfarin (Marevan), Dabigatranetexilat (Pradaxa), Rivaroxaban (Xarelto), Apixaban (Eliquis), Endoxaban (Lixiana)) * Significant ongoing bleeding or within last six months * Known haemorrhagic diathesis * Previous or suspected intracranial hemorrhage * Suspected subarachnoidal hemorrhage or condition following subarachnoidal hemorrhage from aneurysm * All forms of damage to the central nervous system (e.g. cerebral tumors, aneurysm, intracranial / spinal surgery) * Recent (within 10 days) cardiac resuscitation, birth, or perforation of non-compressible blood vessel (e.g. puncture of v. subclavia, v. jugularis) * Severe, uncontrolled arterial hypertension * Bacterial endocarditis, pericarditis * Acute pancreatitis * Documented ulcerative gastrointestinal disease within last 3 months, esophagal varices, arterial aneurysm, arterio-venous malformations * Tumor / malignancy with an increased risk of hemorrhage * Severe liver disease, including liver failure cirrhosis, portal hypertension (esophagal varices), and active hepatitis * Large operation or significant trauma within previous 3 months