Medical management of parapneumonic pleural disease

From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema

Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.

Targeting plasminogen activator inhibitor-1 in tetracycline-induced pleural injury in rabbits

Elevated active plasminogen activator inhibitor-1 (PAI-1) has an adverse effect on the outcomes of intrapleural fibrinolytic therapy (IPFT) in tetracycline-induced pleural injury in rabbits. To enhance IPFT with prourokinase (scuPA), two mechanistically distinct approaches to targeting PAI-1 were tested: slowing its reaction with urokinase (uPA) and monoclonal antibody (mAb)-mediated PAI-1 inactivation. Removing positively charged residues at the "PAI-1 docking site" (¹⁷⁹RHRGGS¹⁸⁴→¹⁷⁹AAAAAA¹⁸⁴) of uPA results in a 60-fold decrease in the rate of inhibition by PAI-1. Mutant prourokinase (0.0625-0.5 mg/kg; n = 12) showed efficacy comparable to wild-type scuPA and did not change IPFT outcomes ( P > 0.05). Notably, the rate of PAI-1-independent intrapleural inactivation of mutant uPA was 2 times higher ( P < 0.05) than that of the wild-type enzyme. Trapping PAI-1 in a "molecular sandwich"-type complex with catalytically inactive two-chain urokinase with Ser¹⁹⁵Ala substitution (S195A-tcuPA; 0.1 and 0.5 mg/kg) did not improve the efficacy of IPFT with scuPA (0.0625-0.5 mg/kg; n = 11). IPFT failed in the presence of MA-56A7C10 (0.5 mg/kg; n = 2), which forms a stable intrapleural molecular sandwich complex, allowing active PAI-1 to accumulate by blocking its transition to a latent form. In contrast, inactivation of PAI-1 by accelerating the active-to-latent transition mediated by mAb MA-33B8 (0.5 mg/kg; n = 2) improved the efficacy of IPFT with scuPA (0.25 mg/kg). Thus, under conditions of slow (4-8 h) fibrinolysis in tetracycline-induced pleural injury in rabbits, only the inactivation of PAI-1, but not a decrease in the rate of its reaction with uPA, enhances IPFT. Therefore the rate of fibrinolysis, which varies in different pathologic states, could affect the selection of PAI-1 inhibitors to enhance fibrinolytic therapy.

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n = 10) and scuPA (0.5 mg/kg; n = 12) was monitored by serial ultrasonography alone (n = 12) or alongside CT scanning (n = 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0-240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, α-macroglobulin/fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group (kobs = 0.016 and 0.042 min(-1)). Significant amounts of bioactive uPA/α-macroglobulin (but not tPA; P < 0.05) complexes accumulated at 0-40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS ≤ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS (r(2) = 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4-8 h. CT scanning was associated with less effective (GLIS > 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4-8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes.

Retrospective analysis of large-dose intrapleural alteplase for complicated pediatric parapneumonic effusion and empyema

OBJECTIVES

Medical treatment of complicated parapneumonic effusion or empyema in pediatric patients includes antibiotics and pleural space drainage. Intrapleural fibrinolysis may facilitate pleural drainage; however, there is a lack of consensus regarding the optimal dosing regimen. The primary purpose of this study was to evaluate the efficacy and safety of a large-dose intrapleural alteplase regimen in pediatric patients. Secondarily, this investigation sought to differentiate the clinical characteristics of responders and non-responders to intrapleural alteplase therapy.

METHODS

All patients with parapneumonic effusions treated with intrapleural alteplase between June 2003 and December 2011 were reviewed retrospectively. Efficacy was assessed by comparing chest tube output, in mL/hr and mL/kg/hr, for 24 hours before and after the first dose of alteplase. Additional efficacy outcomes included duration of in situ chest tubes, a need for surgical intervention for pleural effusion, and length of hospital stay. Safety was assessed by frequency and severity of adverse events. Non-responders and responders were compared based on demographic and disease characteristics. Responders were defined as patients who did not require surgical intervention after intrapleural alteplase therapy.

RESULTS

Seventy-three patients, aged 0.5 to 22.5 years, received intrapleural alteplase to facilitate pleural drainage. Median alteplase dose was 7 mg (range, 3 to 10 mg; median 0.38 mg/kg). Chest tube output increased from 10.7 to 24.2 mL/hr (p = 0.006), and median length of hospital stay was 9 days. Eighty-four percent of patients were responders. The most common adverse events were pain (20.5%) and oxygen desaturation greater than 10% from baseline (16.4%). High-flow nasal cannula was the most common intervention for oxygen desaturation to 80% to 90%. Nine patients (12%) required a blood transfusion during the study.

CONCLUSION

Large-dose intrapleural alteplase is effective in facilitating pleural drainage in pediatric patients with complicated parapneumonic effusion or empyema. Common adverse effects include pain and oxygen desaturation. The potential for bleeding warrants clinical monitoring.

Survey of hospital procedures for parapneumonic effusion in children highlights need for standardised management

AIM

This study sought to evaluate the initial management of children with parapneumonic effusion admitted to all French university hospitals.

METHODS

A nationwide survey of all 35 university hospitals took place in 2011 to assess practices for children with parapneumonic effusion, using a hypothetical clinical vignette and a standardised questionnaire. Two to four paediatricians per hospital were interviewed and asked about their initial management, probabilistic antibiotic therapy and its adaptation to microbiological results and subsequent course. Answers from paediatricians working in emergency departments, intensive care units and conventional paediatric units were compared.

RESULTS

Of the 100 paediatricians contacted, 95 responded. Of these, 98% would order an initial blood test, 70% would order diagnostic thoracentesis, and all would start immediate antibiotic therapy: 31% with a single drug, 67% with two drugs and 2% with three drugs. The most frequent initial choices were third-generation cephalosporin alone (17%) or combined with rifampicin (34%) or vancomycin (24%). Adaptation varied according to drug used, dose and duration, especially when the microorganism was not Streptococcus pneumoniae. Practices did not differ significantly among the different groups of paediatricians.

CONCLUSION

Standardised management of parapneumonic effusion, including routine thoracentesis and more consistent prescription of antibiotics, is needed.

Seventeen-year study shows rise in parapneumonic effusion and empyema with higher treatment failure after chest tube drainage

AIM

To evaluate epidemiology, pre-admission characteristics and management of paediatric parapneumonic effusions (PPEs) and empyema in a tertiary paediatric pulmonary centre between 1993 and 2010.

METHODS

Retrospective chart review study using paediatric and thoracic database searches, with particular emphasis on pre-admission characteristics, disease stage (simple or complex effusion or empyema), general management and surgical procedures.

RESULTS

One hundred children were eligible, exhibiting a significant increase in incidence from 0.5 to 2.6 per 100 000 across the study period. Baseline characteristics were similar across disease stages. Streptococcus pneumoniae was the most common pathogen. Surgical intervention beyond chest tube drainage (CTD) was required in 50%; this rate showed a particular increase in children aged 0-5 years (OR, 3.1), but was otherwise not influenced by baseline characteristics, disease stage or use of intrapleural fibrinolytics. Length of hospitalisation did not differ across disease stages or primary interventional procedures.

CONCLUSION

This study confirmed an increasing incidence of PPEs and empyema in a Scandinavian tertiary paediatric pulmonary centre. Young children exhibited higher treatment failure after CTD. Length of hospitalisation was similar across disease stages and was comparable to previous reports according to primary interventional procedure.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Pleural infection: changing bacteriology and its implications

The incidence of pleural infection continues to rise worldwide. Identifying the causative organism(s) is important to guide antimicrobial therapy. The bacteriology of pleural infection is complex and has changed over time. Recent data suggest that the bacterial causes of empyema are significantly different between adult and paediatric patients, between community-acquired and nosocomial empyemas and can vary among geographical regions of the world. Since the introduction of pneumococcal vaccines, a change has been observed in the distribution of the serotypes of Streptococcus pneumoniae in empyema. These observations have implications on therapy and vaccine strategies. Clinicians need to be aware of the local bacteriology of empyema in order to guide antibiotic treatment.

Impact of an evidence-based algorithm on quality of care in pediatric parapneumonic effusion and empyema

OBJECTIVE

To determine whether implementation of a collaborative, evidence-based algorithm for care of pediatric parapneumonic effusion and empyema (PPE) can improve the quality of care delivered.

STUDY DESIGN

Prospective cohort with retrospective control comparison of children aged 1 month to 18 years admitted with a clinical diagnosis of PPE. Quality improvement techniques were used to develop an algorithm, which was implemented September 2008. Primary outcome measures were decreased median and variability in length of stay (LOS), reduction in the use of chest computed tomography (CT), reduction in the total number of painful procedures, and increased initial use of effective drainage procedures when drainage was indicated.

RESULTS

Compared with controls, algorithm implementation substantially reduced use of chest CT (0% vs. 41% of patients, P = 0.01) with no observed negative impact on LOS. Reductions in median LOS were not significant, but variability in LOS was reduced (P < 0.01 by F-test). Changes in number of procedures and use of effective drainage when indicated were in the predicted direction but not statistically significant.

CONCLUSIONS

Quality improvement techniques are an effective means for incorporating evidence-based medicine into pediatric care. PPE can be managed safely without the use of chest CT.

Predictive factors of morbidity in childhood parapneumonic effusion-associated pneumonia: a retrospective study

STUDY OBJECTIVE

To find the clinical and laboratory criteria that best predict a prolonged fever in children with parapneumonic effusion-associated pneumonia treated conservatively.

DESIGN

Retrospective, cohort study.

PATIENTS

Children admitted to the Shaare Zedek Medical Center between January 1, 1997, and December 31, 2006, and who had been discharged with a diagnosis of empyema and pleurisy.

MEASUREMENTS AND RESULTS

One hundred-twenty children were included, all of whom were treated with antibiotics; in 80 patients, a thoracic drain was introduced; in 23, pleural tap was performed; and in 17 patients, no special procedure was performed. In no case was video-assisted thoracic surgery performed. The mean total days of fever was 12.8 +/- 5.9 (2-29 days), and the mean length of stay at the hospital was 11.5 +/- 4.9 (3-25) days. In 44 patients (37%), a bacterial culture was positive either in blood or in pleural fluid or both. A positive blood or a positive pleural fluid culture was significantly associated with a prolonged fever as was a history of an underlying disease. Platelet counts, serum Na, serum protein, pleural lactate dehydrogenase (LDH), pleural glucose, pleural/serum LDH ratio, pleural/serum glucose ratio, and pleural fluid pH were the only factors significantly but weakly correlated with the total duration of fever or duration of fever after admission. A "fever duration" score using platelet count, pleural fluid pH, pleural/serum LDH ratio, and pleural/serum glucose ratio predicted a prolonged course of fever (>7 days) with a sensitivity of 91% (95% confidence interval: 60%-100%) and a specificity of 47% (95% confidence interval: 25%-71%).

CONCLUSIONS

In children with parapneumonic effusion-associated pneumonia, a positive bacterial culture and an underlying disease are associated with prolonged fever. A low score based on platelet count, pH pleural fluid and glucose, and LDH pleural/serum ratio is associated with a prolonged fever. We speculate that children with the risk factors mentioned earlier may be the best candidates for an early aggressive approach.

Management of children with empyema: Pleural drainage is not always necessary

BACKGROUND

There is considerable variation in the management of pediatric empyema, and there are no clear criteria for when to perform pleural drainage. Our study aims were: (1) to retrospectively review our experience with an empyema treatment strategy that started with intravenously administered (IV) antibiotics alone in medically stable patients with procession to pleural drainage only if there was no clinical improvement after 48 hr, and (2) to identify predictors for undergoing pleural drainage.

METHODS

We performed a retrospective review of 182 previously healthy children, 1-18 years old, hospitalized with empyema from December 1996 through December 2008. The primary outcome measures were the proportion of patients requiring pleural drainage procedures and hospital length of stay (LOS).

RESULTS

Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and 8 chest tube followed by VATS/thoracotomy); only 4 received fibrinolytics. Mean (standard deviation) LOS was significantly shorter in the antibiotics alone group, 7.0 (3.5) versus 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>(1/2) thorax filled).

CONCLUSIONS

Some children with empyema can be treated with IV antibiotics alone and have reasonably short LOS. At our institution, those that required intensive care or had large effusions with mediastinal shift were more likely to require pleural drainage.

Imaging of Chest Infections in Children

■ Imaging studies have limited value in the differentiation between viral and bacterial lower respiratory tract infections (moderate evidence).

■ CT provides more information than plain radiographs for complicated pulmonary infections with empyema, pleural effusion, or bronchopleural fistula (moderate evidence).

■ In immunocompromised patients, CT has been shown to characterize the type of infection better than plain radiographs (moderate evidence).

■ Ultrasound has an advantage over CT in the identification and characterization of complicated effusions (moderate evidence).

■ Early detection and therefore intervention for pleural complications of pneumonia are critical and can result in better outcomes (moderate evidence).

■ Early surgery (VATS) is more cost-effective than thoracotomy (without or with image guidance) in the treatment of empyemas in children (strong evidence).

The relationship between chest tube size and clinical outcome in pleural infection

BACKGROUND

The optimal choice of chest tube size for the treatment of pleural infection is unknown, with only small cohort studies reported describing the efficacy and adverse events of different tube sizes.

METHODS

A total of 405 patients with pleural infection were prospectively enrolled into a multicenter study investigating the utility of fibrinolytic therapy. The combined frequency of death and surgery, and secondary outcomes (hospital stay, change in chest radiograph, and lung function at 3 months) were compared in patients receiving chest tubes of differing size (chi(2), t test, and logistic regression analyses as appropriate). Pain was studied in detail in 128 patients.

RESULTS

There was no significant difference in the frequency with which patients either died or required thoracic surgery in patients receiving chest tubes of varying sizes ( < 10F, number dying or needing surgery 21/58 [36%]; size 10-14F, 75/208 [36%]; size 15-20F, 28/70 [40%]; size > 20F, 30/69 [44%]; chi(2)trend, 1 degrees of freedom [df] = 1.21, P = .27), nor any difference in any secondary outcome. Pain scores were substantially higher in patients receiving (mainly blunt dissection inserted) larger tubes ( < 10F, median pain score 6 [range 4-7]; 10-14F, 5 [4-6]; 15-20F, 6 [5-7]; > 20F, 6 [6-8]; chi(2), 3 df = 10.80, P = .013, Kruskal-Wallis; chi(2)trend, 1 df = 6.3, P = .014).

CONCLUSIONS

Smaller, guide-wire-inserted chest tubes cause substantially less pain than blunt-dissection-inserted larger tubes, without any impairment in clinical outcome in the treatment of pleural infection. These results suggest that smaller size tubes may be the initial treatment of choice for pleural infection, and randomized studies are now required.

TRIAL REGISTRATION

MIST1 trial ISRCTN number: 39138989.

Intrapleural streptokinase treatment in children with empyema

Our aim was to compare intrapleural streptokinase (SK) treatment and simple tube drainage in the treatment of children with complicated parapneumonic pleural effusion. A retrospective review of medical records included patient demographics, clinical presentation, biochemical and microbial studies of pleural effusion, radiographic evaluation of chest tube drainage, use of fibrinolytic agents and type of surgical intervention. During the 2.5-year period (1999-2002), 53 children (29 M, 24 F) with complicated parapneumonic effusions or empyema were identified. Closed tube drainage and antibiotic treatment were administered to patients with a diagnosis of complicated parapneumonic effusion (n = 24) until October 2000; after that time point, intrapleural streptokinase was added to this regimen (n = 29). The median age at the time of presentation was 2.5 years (range: 5 months-14.6 years). There were no significant differences in terms of clinical outcomes between the two groups. The average length of hospital stay was 19.1 +/- 5.5 and 21.9 +/- 11.2 days for the drainage and streptokinase groups, respectively; the time to afebrile state after admission was 5.8 +/- 4.1 and 7.6 +/- 7.5 days. The percentage of patients who eventually required surgical intervention was 8.3% for the drainage group and 20.6% for the streptokinase group. In conclusion, in the treatment of complicated parapneumonic effusions or empyema, the adjunctive treatment with intrapleural SK does not significantly reduce durations of fever, chest tube drainage and hospital stay, and the need for surgery, regardless of the stage of the disease, compared to simple closed tube drainage.

Interventional radiology treatment of empyema and lung abscesses

Pneumonias in children can be complicated by pleural effusions, empyema and abscesses. The incidence of these complications is increasing, correlated to an increased virulence of the pneumococcal bacterium. These complications may prolong morbidity and lead to decreased pulmonary function. Traditionally, patients were treated medically with antibiotics, and refractory complications were treated surgically with large bore chest tube placement and thoracotomy. Improvements included instilling fibrinolytics into the chest tubes and video-assisted thoracoscopic surgery, which expedited recovery and improved outcomes. Image guided techniques from interventional radiology have been developed as an alternative to treat these patients with minimal invasiveness. These therapies have achieved high success and low complication rates, and are the preferred first-line procedures when available.

Management of parapneumonic effusions in pediatrics: current practice

Pneumonia with associated complex pleural disease is a cause of significant morbidity among hospitalized children. The management of this patient population continues to be a challenge and varies even among single institutions. The article presented here reviews the management goals for pediatric patients hospitalized with complex parapneumonic effusions and provides updated summaries of both medical and surgical therapies.

Management of community-acquired pneumonia in children

Community-acquired pneumonia (CAP) is a significant cause of childhood morbidity and mortality worldwide. Viral etiology is most common in young children and decreases with age. Streptococcus pneumoniae is the single most common bacterial cause across all age groups. Atypical organisms present similarly across all age groups and may be more common than previously recognized.A bacterial pneumonia should be considered in children presenting with fever >38.5 degrees C, tachypnea, and chest recession. Oxygen therapy is life saving and should be given when oxygen saturation is <92%. For non-severe pneumonia, oral amoxicillin is the antibacterial of choice with low failure rates reported. Severely ill children are traditionally treated with parenteral antibacterials. Penicillin non-susceptible S. pneumoniae prevalence rates are increasing and have been linked to community antibacterial prescribing. Most pneumococci remain sensitive to high-dose penicillin-based antibacterials but macrolide resistance is also a problem in some communities. However, primary combination treatment with macrolides is indicated in areas where there is a high prevalence of atypical organisms. The most common complications in CAP are parapneumonic effusions and empyema. The use of ultrasonography combined with intercostal drainage augmented with the use of fibrinolytic therapy has significantly reduced the morbidity associated with these complications. There is increasing evidence that a preventative strategy with the 7-valent pneumococcal conjugate vaccine (PCV-7) results in a significant fall in CAP in early childhood.

Ultrasound of the chest in children (mediastinum excluded)

Ultrasound (US) of the paediatric chest has become an established imaging tool that may supplement plain film findings helping to reduce or tailor other ionizing (sectional) imaging in a variety of paediatric conditions such as sequestration or pneumonia. US has been shown to offer valuable imaging alternatives, both reliably enabling diagnosis without need for ionising imaging such as in diaphragmatic palsy (traditionally diagnosed by fluoroscopy) and revealing additional information in patients with equivocal findings on radiographs or replacing follow-up examinations (for example, in pleural effusion). This review outlines the technical requisites for paediatric chest US applications and will discuss its diagnostic potential. Furthermore, it will consider US restrictions, mention some rare applications, and discuss the potential role of chest US in imaging algorithms of certain conditions.

[Epidemiology and clinical characteristics of childhood parapneumonic empyemas]

Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries.

AIM OF THE STUDY

The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications.

POPULATION AND METHODS

We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003.

RESULTS

During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003.

CONCLUSION

The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.

Parapneumonic effusion and empyema in children: retrospective review of the duPont experience

Management of pediatric parapneumonic effusions and empyema remains controversial. Treatment includes antibiotics, chest tube, fibrinolytic therapy, video-assisted thoracoscopy and debridement, and open thoracotomy and decortication. A retrospective 10-year study was done to identify patient selection variables for specific therapies. Charts (n = 101) with diagnoses of empyema without comorbidity were reviewed, a database was developed, and variables between patients who did and did not receive thoracoscopic debridement were compared at admission and during hospitalization. The difference in positive culture reports with video-assisted thoracoscopy compared with medical management was significant (P < .018). Postsurgical patients used the intensive care unit and had 2 or more chest tubes with greater frequency than medically managed patients (P < .014, P < .002). Antibiotics, video-assisted thoracoscopy, and chest tube within 48 hours of admission shortened hospitalization by 4 days (P < .001) compared with delayed video-assisted thoracoscopy done after 48 hours of admission.

Bacteriology of complicated parapneumonic effusions

PURPOSE OF REVIEW

The bacteriology of complicated parapneumonic effusions has changed in recent decades, but the causative organisms often remain obscure in up to 40% of cases. Recently, new molecular methods have become available which might help clinical management and improve our understanding of this condition. In this review, we will consider the current bacteriological spectrum of pleural infection and look at some of the new molecular methods.

RECENT FINDINGS

Hospital-acquired pleural infection exhibits a different bacteriology than pleural infection originating in the community. It carries a significantly higher mortality and requires different antibiotics at presentation. Streptococcal and anaerobic infections have low associated mortalities whereas staphylococcal, enterobacterial and mixed aerobic infections carry a worse prognosis. The yield of causative organisms can be significantly increased by the use of bacterial nucleic acid amplification and this may have a role in routine clinical practice in the near future.

SUMMARY

The bacteriology of pleural infection has changed markedly in recent years. Mortality is highest with hospital-acquired pleural infection and infections caused by staphylococci, Enterobacteriacae and mixed aerobes. New molecular microbiological methods substantially increase bacterial yield in pleural fluid.

[Intrapleural streptokinase in the treatment of complicated parapneumonic empyema]

INTRODUCTION

Parapneumonic empyema is a frequent cause of admission in the Pediatric Hospital of the Pereira Rossell Hospital Center. In January 2005, we implemented a treatment protocol that included intrapleural streptokinase (STK) for children with complicated parapneumonic empyema as an alternative to surgery.

OBJECTIVES

To describe the results of intrapleural STK in the treatment of hospitalized children with complicated parapneumonic empyema and to compare these results with those of early thoracotomy.

PATIENTS AND METHODS

Children with complicated parapneumonic empyema admitted between January 1st 2004 and October 1st 2005 were included. The children were divided into two groups: a historical group, composed of children hospitalized between January 1st and December 31st 2004, treated with conventional thoracotomy before day 8 of chest drain placement and a prospective group, composed of children hospitalized between January 1st and October 1st 2005, treated with intrapleural STK before day 8 of chest drain placement. The variables used to compare outcome and treatment complications were duration of chest tube drainage after the treatment procedure, complications, re-admission, length of hospital stay, and death.

RESULTS

The results in both groups were similar. Length of hospital stay showed no significant differences. Duration of chest tube drainage after intrapleural STK was significantly shorter than after thoracotomy (p < 0.001). In the thoracotomy group a significantly higher proportion of patients required partial atypical pneumonectomy (p = 0.051). There were no deaths.

CONCLUSIONS

Intrapleural STK is a valid alternative for the treatment of children with complicated parapneumonic empyema.

Pleural effusions

The ability to recognize, understand, and treat pleural effusions in the pediatric population is important for pediatric health care providers. The topic of pleural effusions has been extensively studied in the adult population. In recent years, these studies have extended into the pediatric population. This review describes pleural effusions in detail, including the different types and underlying pathophysiology. We then go on to provide a comprehensive review of the recent literature regarding the diagnosis and treatment of pleural effusions in the pediatric population.

Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema

BACKGROUND

Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema.

AIM

To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema.

METHODS

Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs.

RESULTS

Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001).

CONCLUSIONS

There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.

Management of empyema in children

The incidence of empyema complicating community-acquired pneumonia is increasing and causes significant childhood morbidity. Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. Newer molecular techniques utilizing the polymerase chain reaction have led to an increase in identification of causative bacteria, previously not isolated by conventional culture techniques. This remains an important epidemiological tool, and may help in guiding correct antibiotic use in the future. There are many treatment options, however, and the care a child currently receives is dependent on local practice, which is largely determined by availability of medical personnel and their preferences. Although there are many reported case series comparing treatment options, only two randomized controlled studies exist to guide treatment in children. There is an urgent need for this to be addressed, particularly with the introduction of relatively new surgical techniques such as video-assisted thorascopic surgery.