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Nandan D, Agarwal S, Bidhuri N, Shrivastava K, Nanda P, Lata S. Role of Intrapleural Urokinase in Empyema Thoracis. Indian J Pediatr 2019; 86:1099-1104. [PMID: 31628638 DOI: 10.1007/s12098-019-03060-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/06/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the role of fibrinolytic therapy in pediatric empyema in relation to duration of hospital stay, need for surgical intervention and survival to discharge. METHODS Retrospective analysis of case records of children <16 y of age admitted in a tertiary care hospital during January 2013 - December 2017 with diagnosis as empyema thoracis was done. Clinico-laboratory characteristics and the primary and secondary outcomes between the group which received intrapleural urokinase (IPU) and the group which did not (non IPU), were compared. RESULTS Of the 84 cases, 40 children received IPU. Mean duration of hospital stay in IPU group (17.51 + 4.57 d) was significantly less than non IPU group (24.32 + 10.18 d, CI -10.19 to -3.64, p < 0.001), so was the duration of intercostal drain (ICD) insertion (9.08 + 3.12 d - IPU group vs. 11.20 + 3.95 d - non IPU group, CI -3.68 to -0.50, p < 0.01). No statistically significant difference was found between the groups with regard to need for surgical intervention [IPU - 4 (10%), non IPU - 9 (20.4%), p = 0.23]. There was no mortality or adverse reaction to urokinase in either group. CONCLUSIONS IPU holds promising results in terms of reduction of hospital stay and duration of ICD insertion. It may be the initial choice of treatment in septated empyema where surgical options are not easily available or cost-effective especially in resource limited settings.
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Affiliation(s)
- Devki Nandan
- Department of Pediatrics, PGIMER and Dr. RML Hospital, Delhi, India
| | - Sheetal Agarwal
- Department of Pediatrics, PGIMER and Dr. RML Hospital, Delhi, India.
| | - Neha Bidhuri
- Department of Pediatrics, PGIMER and Dr. RML Hospital, Delhi, India
| | | | - Pamali Nanda
- Department of Pediatrics, PGIMER and Dr. RML Hospital, Delhi, India
| | - Sandhya Lata
- Department of Pediatrics, PGIMER and Dr. RML Hospital, Delhi, India
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Mandal KC, Mandal G, Halder P, Mitra D, Debnath B, Bhattacharya M. Empyema Thoracis in Children: A 5-Year Experience in a Tertiary Care Institute. J Indian Assoc Pediatr Surg 2019; 24:197-202. [PMID: 31258270 PMCID: PMC6568155 DOI: 10.4103/jiaps.jiaps_112_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: Empyema thoracis (ET) in children is a disease of significant morbidity and mortality. In the event of failure to resolute following intercostal chest tube drainage (ICD), thoracotomy decortication (TDC) remains the treatment of choice. We have reviewed the outcome of management of 96 cases of ET with the intent to establish the scope of ICD as primary form of the management. Materials and Methods: This is a retrospective study of 96 patients of ET who were managed in pediatric surgery department over a period of 5 years (April 2013 – March 2018). Ninety-six patients at a single center met inclusion criteria for having ET and underwent ICD. We excluded the cases where video-assisted thoracoscopic surgery was provided as primary treatment. The patients were categorized into complicated and uncomplicated groups. Those with pyopneumothorax, encysted empyema, multiloculated empyema, and bilateral ET were assigned as complicated group. There were two treatment groups: (I) those responded with ICD alone (II) those with ICD followed by TDC. Results: All 96 cases received ICD as primary management. There were 54 uncomplicated cases and 42 complicated cases. Out of 42 complicated cases, 26 patients recovered with ICD alone and 16 patients needed TDC. A total of 80 (83.33%) patients (54 uncomplicated ± 26 complicated) recovered with ICD alone. Significant complications were encountered in follow-up of patients who underwent delayed thoracotomy in the form of overriding of the ribs (n = 3) and postoperative air leak (n = 4). There was no mortality in our series. Conclusion: Early initiation of management of ET with intercostal tube drainage is simple, safe, effective even in complicated cases, and has less complications. Thoracotomy with decortication should be reserved for ICD failure cases.
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Affiliation(s)
- Kartik Chandra Mandal
- Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Gobinda Mandal
- Department of Pediatric Medicine, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Pankaj Halder
- Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Dipanwita Mitra
- Department of Anesthesiology, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Bidyut Debnath
- Department of Pediatric Surgery, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Mala Bhattacharya
- Department of Pediatric Medicine, Dr. B. C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
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Angurana SK, Kumar R, Singh M, Verma S, Samujh R, Singhi S. Pediatric empyema thoracis: What has changed over a decade? J Trop Pediatr 2019; 65:231-239. [PMID: 30053189 DOI: 10.1093/tropej/fmy040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The purposes of this paper are to study clinicobacteriological profile, treatment modalities and outcome of pediatric empyema thoracis and to identify changes over a decade. DESIGN This is a retrospective study. SETTING Department of Pediatrics of a tertiary care hospital in North India. PATIENTS We enrolled 205 patients (1 month-12 years) of empyema thoracis admitted over 5 years (2007-11) and compared the profile with that of a previous study from our institute (1989-98). RESULTS Pleural fluid cultures were positive in 40% (n = 82) cases from whom 87 isolates were obtained. Staphylococcus aureus was the most common isolate (66.7%). Methicillin-sensitive S. aureus accounted for 56%, Methicillin-resistant S. aureus (MRSA) 10% and gram-negative organisms 18.3% of isolates. Intercostal drainage tube (ICDT) was inserted in 97.5%, intrapleural streptokinase was administered in 33.6%, and decortication performed in 27.8% cases. Duration of hospital stay was 17.2 (±6.3) days, duration of antibiotic (intravenous and oral) administration was 23.8 (±7.2) days and mortality rate was 4%. In the index study (compared with a previous study), higher proportion of cases received parenteral antibiotics (51.7% vs. 23.4%) and ICDT insertion (20.5% vs. 7%) before referral and had disseminated disease (20.5% vs. 14%) and septic shock (11.2% vs. 1.6%), less culture positivity (40% vs. 48%), more MRSA (10.3% vs. 2.5%) and gram-negative organisms (18.4% vs. 11.6%), increased use of intrapleural streptokinase and surgical interventions (27.8% vs. 19.7%), shorter hospital stay (17 vs. 25 days) and higher mortality (3.9% vs. 1.6%). CONCLUSIONS Over a decade, an increase in the incidence of empyema caused by MRSA has been noticed, with increased use of intrapleural streptokinase and higher number of surgical interventions.
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Affiliation(s)
- Suresh Kumar Angurana
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Meenu Singh
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Verma
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Pediatric Surgery, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunit Singhi
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mathew JL, Soni V, Singh M, Mittal P, Singhi S, Gautam V, Sodhi KS, Jayashree M, Vaidya P. Intrapleural streptokinase is effective and safe for children with multi-loculated empyema regardless of the time from disease onset. Acta Paediatr 2018; 107:2165-2171. [PMID: 29782063 DOI: 10.1111/apa.14408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/24/2018] [Accepted: 05/16/2018] [Indexed: 11/30/2022]
Abstract
AIM This study compared the efficacy of administering intrapleural streptokinase to children with multi-loculated empyema within 14 days or at any time after disease onset. METHODS We studied children under 12 years with multi-loculated empyema who were admitted to a teaching hospital in Chandigarh, India, from July 2013 to June 2017. They received antibiotics, pleural drainage and intrapleural streptokinase. The first group received three doses within 14 days of disease onset, the second received three doses regardless of time after onset and the third group received four to six doses regardless of time after onset. The three phases lasted 18, 18 and 12 months, respectively. RESULTS Of 195 children, 133 (68%) received streptokinase within 14 days, 46 (24%) beyond 14 days and 16 (8%) did not receive it. There was no difference in surgical decortication (14/133 versus 7/46, p > 0.05) and median hospitalisation duration (15 versus 14 days, p > 0.05) between administration before versus after 14 days. Median hospitalisation was shorter with four to six doses than three doses (11 versus 16 days, p < 0.01). CONCLUSION Intrapleural streptokinase was effective for multi-loculated empyema even when it was administered more than 14 days after disease onset and four to six doses were superior to three doses.
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Affiliation(s)
- Joseph L. Mathew
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Vimlesh Soni
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Meenu Singh
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Piyush Mittal
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Sunit Singhi
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
- Department of Paediatrics; Medanta, The Medicity; Gurgaon India
| | - Vikas Gautam
- Department of Medical Microbiology; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Kushaljit S. Sodhi
- Department of Radiodiagnosis and Imaging; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Muralidharan Jayashree
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Pankaj Vaidya
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
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Mathew JL, Singhi S, Ray P, Hagel E, Saghafian-Hedengren S, Bansal A, Ygberg S, Sodhi KS, Kumar BVR, Nilsson A. Etiology of community acquired pneumonia among children in India: prospective, cohort study. J Glob Health 2015; 5:050418. [PMID: 26528392 PMCID: PMC4623579 DOI: 10.7189/jogh.05.020418] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Childhood community acquired pneumonia (CAP) is a significant problem in developing countries, and confirmation of microbial etiology is important for individual, as well as public health. However, there is paucity of data from a large cohort, examining multiple biological specimens for diverse pathogens (bacteria and viruses). The Community Acquired Pneumonia Etiology Study (CAPES) was designed to address this knowledge gap. Methods We enrolled children with CAP (based on WHO IMCI criteria of tachypnea with cough or breathing difficulty) over 24 consecutive months, and recorded presenting symptoms, risk factors, clinical signs, and chest radiography. We performed blood and nasopharyngeal aspirate (NPA) bacterial cultures, and serology (Mycoplasma pneumoniae, Chlamydophila pneumoniae). We also performed multiplex PCR for 25 bacterial/viral species in a subgroup representing 20% of the cohort. Children requiring endotracheal intubation underwent culture and PCR of bronchoalveolar lavage (BAL) specimens. Findings We enrolled 2345 children. NPA and blood cultures yielded bacteria in only 322 (13.7%) and 49 (2.1%) children respectively. In NPA, Streptococcus pneumoniae (79.1%) predominated, followed by Haemophilus influenzae (9.6%) and Staphylococcus aureus (6.8%). In blood, S. aureus (30.6%) dominated, followed by S. pneumoniae (20.4%) and Klebsiella pneumoniae (12.2%). M. pneumoniae and C. pneumoniae serology were positive in 4.3% and 1.1% respectively. Multiplex PCR in 428 NPA specimens identified organisms in 422 (98.6%); of these 352 (82.2%) had multiple organisms and only 70 (16.4%) had a single organism viz. S. pneumoniae: 35 (50%), Cytomegalovirus (CMV): 13 (18.6%), Respiratory Syncytial Virus (RSV): 9 (12.9%), other viruses: 6 (8.7%), S. aureus: 5 (7.1%), and H. influenzae: 2 (2.9%). BAL PCR (n = 30) identified single pathogens in 10 (S. pneumoniae–3, CMV–3, S. aureus–2, H. influenzae–2) and multiple pathogens in 18 children. There were 108 (4.6%) deaths. The pattern of pathogens identified did not correlate with pneumonia severity or mortality. Conclusions The majority of children with CAP have multiple pathogens (bacteria and viruses). S. pneumoniae and S. aureus predominate in NPA and blood respectively. CMV and RSV were the dominant respiratory viruses in NPA and BAL. The presence of multiple pathogens, especially organisms associated with nasopharyngeal carriage, precludes confirmation of a causal relationship in most cases.
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Affiliation(s)
| | - Sunit Singhi
- Department of Pediatrics, PGIMER, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Eva Hagel
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | | | - Arun Bansal
- Department of Pediatrics, PGIMER, Chandigarh, India
| | - Sofia Ygberg
- Dept of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Anna Nilsson
- Dept of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Chaudhry LA, Mousa AAB, Zamzami M, Robert AA. Contemporary empyema thoracis necessitans in an adult male caused by Staphylococcus aureus: decortication is superior to traditional under water seal intercostal tube in chronic empyema. Pan Afr Med J 2015; 20:115. [PMID: 26090063 PMCID: PMC4458315 DOI: 10.11604/pamj.2015.20.115.5865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/18/2015] [Indexed: 11/17/2022] Open
Abstract
Empyema thoracis necessitans is a rare clinical finding nowadays. We report 55 years old Saudi male with past history of road traffic accident, poly trauma, chest surgery and paraplegia admitted for rehabilitation in Sultan Bin Abduaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia and diagnosed with empyema thoracis necessitans due to Staphylococcus aureus, treated initially with traditional thoracostomy under water seal intercostal intubation and antibiotics but subsequently required decortication.
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Affiliation(s)
- Liaqat Ali Chaudhry
- Department of Internal Medicine, Pulmonary Division, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
| | - Ahmed A Ba Mousa
- Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Marwan Zamzami
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Asirvatham Alwin Robert
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Pediatric empyema thoracis--role of conservative management. Indian Pediatr 2014; 51:239. [PMID: 24736926 DOI: 10.1007/s13312-014-0365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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