Change in Bacterial Causes of Community-Acquired Parapneumonic Effusion and Pleural Empyema in Children 6 Years After 13-Valent Pneumococcal Conjugate Vaccine Implementation

Antimicrobial treatment of lower respiratory tract infections in children

Lower respiratory tract infections (LRTI) encompass a wide range of clinical syndromes, prominently including bronchiolitis, bronchitis and pneumonia. LRTIs are the second leading cause of antibiotic prescriptions. The vast majority of these infections are due to (or triggered by) viruses and are self-limited diseases. Pneumonia in children is responsible for significant morbidity and mortality worldwide. For clinicians, one of the main difficulties consists in diagnosing pneumonia in febrile children with (or without) cough. The diagnosis is given on the basis of anamnesis, clinical examination and (if necessary) complementary examinations, with chest X-ray or thoracic ultrasound; biological markers are particularly important. Over recent years, since the implementation of PCV13, the bacterial epidemiology of pneumonia and empyema has evolved; involvement in these diseases of pneumococcus has been reduced, and resistance to penicillin has lessened - and remained extremely low. In 2021, according to the National Pneumococcal Reference Center, only 6% of the strains isolated from blood cultures in children are resistant to amoxicillin. The therapeutic choices proposed in this article are in full compliance with the previously published official French recommendations.

Evaluation of the efficiency of the systemic immune-inflammation index in differentiating parapneumonic effusion from empyema

AIM

To evaluate the effectiveness of the systemic immune-inflammation index (SII) and other biomarkers in distinguishing parapneumonic effusion (PPE) and empyema.

METHODS

Patients who were thought to have pleural effusion secondary to pneumonia in the pediatric emergency department (PED) between 2004 and 2021 were retrospectively evaluated. The patients were divided into two groups as empyema and PPE. The efficacy of infection markers in predicting empyema was compared.

RESULTS

Fifty-nine patients (59.3% male) were included in the study. Forty-three (72.9%) patients were in the PPE and 16 (27.1%) were in the empyema group. Length of hospital stay and pleural fluid thickness measured with thoracic ultrasonography were significantly higher in the empyema group (p = 0.018 and p = 0.002, respectively). The mean SII was 1902.73 ± 1588.87 in PPE patients, while it was 6899.98 ± 6678 in empyema patients (p = 0.009). C-reactive protein (CRP), white blood cell (WBC) count, absolute neutrophil count (ANC), and neutrophil-lymphocyte ratio (NLR) ​​were significantly higher in the empyema group; absolute lymphocyte count (ALC) and lymphocyte-monocytes ratio (LMR) were significantly lower than the PPE group. When the best cut-off values of inflammation markers are determined according to the area under the curve, the highest odds ratios suggesting empyema were found in SII, LMR, CRP, and ANC, respectively.

CONCLUSION

Inflammation markers can be useful in predicting empyema. The best markers were found to be SII, LMR, CRP, and ANC. High SII is one of the practical diagnostic markers that can be used differentiate empyema from PPE in PED.

Staphylococcus aureus Community-acquired Pneumonia in Children After 13-Valent Pneumococcal Vaccination (2008-2018): Epidemiology, Clinical Characteristics and Outcomes

BACKGROUND

The epidemiology of community-acquired pneumonia (CAP) has changed, influenced by sociosanitary conditions and vaccination status. We aimed to analyze the recent epidemiology of bacterial CAP in hospitalized children in a setting with high pneumococcal vaccination coverage and to describe the clinical characteristics of pediatric Staphylococcus aureus CAP.

METHODS

Children <17 years old hospitalized from 2008 to 2018 with bacterial CAP in 5 tertiary hospitals in Spain were included. Cases with pneumococcal CAP were randomly selected as comparative group following a case-control ratio of 2:1 with S. aureus CAP.

RESULTS

A total of 313 bacterial CAP were diagnosed: Streptococcus pneumoniae CAP (n = 236, 75.4%), Streptococcus pyogenes CAP (n = 43, 13.7%) and S. aureus CAP (n = 34, 10.9%). Throughout the study period, the prevalence of S. pyogenes increased (annual percentage change: +16.1% [95% CI: 1.7-32.4], P = 0.031), S. pneumoniae decreased (annual percentage change: -4.4% [95 CI: -8.8 to 0.2], P = 0.057) and S. aureus remained stable. Nine isolates of S. aureus (26.5%) were methicillin-resistant. Seventeen cases (50%) with S. aureus CAP had some pulmonary complication and 21 (61.7%) required intensive care. S. pneumoniae CAP showed a trend toward higher prevalence of pulmonary complications compared with S. aureus CAP (69.1% vs. 50.0%, P = 0.060), including higher frequency of pulmonary necrosis (32.4% vs. 5.9%, P = 0.003).

CONCLUSIONS

The incidence of S. aureus CAP in children remained stable, whereas the prevalence of pneumococcal CAP decreased and S. pyogenes CAP increased. Patients with S. aureus presented a high frequency of severe outcomes, but a lower risk of pulmonary complications than patients with S. pneumoniae.

Pediatric Parapneumonic Effusion/Pleural Empyema in Japan: A Nationwide Survey

BACKGROUND

Pediatric parapneumonic effusion/ pleural empyema (PPE/PE) is a severe infectious condition, and its management should be guided by local epidemiology and the patient's medical history. This survey aimed to determine the clinical and bacteriologic features of PPE/PE in Japan.

METHODS

A nationwide retrospective questionnaire survey was conducted, targeting 159 pediatric specialist training medical facilities for inpatients ≤18 years of age who were admitted for PPE/PE between January 2007 and December 2016.

RESULTS

Valid responses were obtained from 122 facilities, and 96 patients were identified from 38 facilities. The median age (interquartile range) was 2.7 (0.8-7.8) years. Overall, 60 (63 %) patients were men and 49 (51%) had comorbidities. The causative bacteria were identified in 59% of patients by culture except in one case identified using PCR. Streptococcus pyogenes (16%), Staphylococcus aureus (14%) and Streptococcus pneumoniae (13%) were the major pathogens. Carbapenems were administered to 34% of patients without comorbidities. Chest tube drainage was performed in 71%, intrapleural fibrinolytic therapy in 9.4%, surgery in 25% and mechanical ventilation in 29% of the patients. Five patients (5.2%) had complications and one (1.1%) had sequelae, but all patients (100%) survived.

CONCLUSIONS

This is first report of a nationwide survey pertaining to pediatric PPE/PE in Japan. We found that the etiology showed a different trend from that reported in other countries. It is worrisome that molecular methods were rarely used for pathogenic diagnosis and carbapenems were overused. Thus, it is imperative to establish clinical guidelines for PPE/PE in Japan.

Inpatient outcomes for children receiving empiric methicillin-resistant Staphylococcus aureus coverage for complicated pneumonia

Rigorous evidence for antibiotic management of pediatric complicated pneumonia is lacking, likely contributing to variation in empiric antibiotic(s). Using the Pediatric Health Information System database, we sought to describe use and clinical outcomes of children hospitalized with complicated pneumonia who received empiric antibiotic regimens with and without methicillin-resistant Staphylococcus aureus (MRSA) coverage. We evaluated empiric antibiotic selection on Day 0-1, grouping based on use of an antibiotic with or without MRSA coverage. We used generalized linear mixed effects models to examine the association of MRSA coverage and outcomes. Across 46 children's hospitals, 71.5% of children (N = 1279) received an empiric antibiotic regimen with MRSA coverage. In adjusted analyses, length of stay, need for repeat pleural drainage procedures, 7-day emergency department revisits and 7-day readmissions were similar between groups. Future prospective studies examining the need for MRSA coverage may assist in refining national treatment guidelines for complicated pneumonia in children.

The Evolution and Distribution of Pneumococcal Serotypes in Adults Hospitalized With Community-Acquired Pneumonia in Spain Using a Serotype-Specific Urinary Antigen Detection Test: The CAPA Study, 2011-2018

Background

Spain introduced the 13-valent pneumococcal conjugate vaccine (PCV13) in the childhood National Immunization Program in 2015–2016 with coverage of 3 doses of 94.8% in 2018. We assessed the evolution of all pneumococcal, PCV13 vaccine type (VT), and experimental PCV20-VT (PCV13 + serotypes 8, 10A, 11A, 12F, 15B, 22F, 33F) hospitalized community-acquired pneumonia (CAP) in adults in Spain from 2011–2018.

Methods

A prospective observational study of immunocompetent adults (≥18 years) admitted to 4 Spanish hospitals with chest X-ray–confirmed CAP between November 2011 and November 2018. Microbiological confirmation was obtained using the Pfizer serotype-specific urinary antigen detection tests (UAD1/UAD2), BinaxNow test for urine, and conventional cultures of blood, pleural fluid, and high-quality sputum.

Results

Of 3107 adults hospitalized with CAP, 1943 were ≥65 years. Underlying conditions were present in 87% (n = 2704) of the participants. Among all patients, 895 (28.8%) had pneumococcal CAP and 439 (14.1%) had PCV13-VT CAP, decreasing from 17.9% (n = 77) to 13.2% (n = 68) from 2011–2012 to 2017–2018 (P = .049). PCV20-VT CAP occurred in 243 (23.8%) of those included in 2016–2018. The most identified serotypes were 3 and 8. Serotype 3 accounted for 6.9% (n = 215) of CAP cases, remaining stable during the study period, and was associated with disease severity.

Conclusions

PCV13-VT caused a substantial proportion of CAP in Spanish immunocompetent adults 8 years after introduction of childhood PCV13 immunization. Improving direct PCV13 coverage of targeted adult populations could further reduce PCV13-VT burden, a benefit that could be increased further if PCV20 is licensed and implemented.

Complications in community acquired pneumonia: magnitude of problem, risk factors, and management in pediatric age

Introduction: In the last decades, the large use of several effective vaccines has dramatically reduced the incidence of community acquired pneumonia (CAP) in infants and children. Moreover, the availability of new antibiotics effective against emerging resistant strains of bacteria has greatly improved the early and long-term prognosis of this disease.Areas covered: The aim of this manuscript is to evaluate the burden of complicated CAP in pediatric age and to discuss its appropriate management.Expert opinion: Complicated CAP remains a problem for children in industrialized and developing countries. A larger use of lung ultrasonography (US) as first diagnostic approach could significantly improve early identification of cases at higher risk of complications. Difficult to solve, is the problem of the use of an antibiotic therapy able to assure adequate control in all the CAP cases, including those at high risk of or with already established complications. All these findings reveal that control of the incidence of complicated CAP remains difficult and will not be significantly changed in the next few years. Any attempt to improve complicated CAP management must be made. Consensus documents on better definition of the use of corticosteroids, fibrinolytic agents, and interventional procedures (including surgery) can allow us to reach this goal.

Necrotizing pneumonia among Italian children in the pneumococcal conjugate vaccine era

BACKGROUND

Necrotizing pneumonia (NP) is a severe complication of community-acquired pneumonia. The impact of 13-valent pneumococcal conjugate vaccine (PCV13) on the epidemiology of NP in children has not been assessed.

PATIENTS AND METHODS

Medical records of children less than 18 years admitted with NP to two pediatric hospitals in Italy between 2005 and 2019 were reviewed. The following four periods were defined: 2005-2010 (pre-PCV13), 2011-2013 (early post-PCV13), 2014-2016 (intermediate post-PCV13), and 2017-2019 (late post-PCV13).

RESULTS

Forty-three children (median age, 44 months) were included. Most of them (93%) were previously healthy. No differences in age, sex, season of admission, comorbidity, clinical presentation, or hospital course were identified between pre-PCV13 and post-PCV13 periods. A significant decrease in the rate of NP-associated hospitalizations was found between the early (1.5/1000 admissions/year) and the intermediate (0.35/1000 admissions/year) post-PCV13 period (p = .001). An increased trend in admissions was found thereafter. Streptococcus pneumoniae was the most common agent detected in both periods (pre-PCV13: 11/18, 61%; post-PCV13: 13/25, 52%). Serotype 3 was the most common strain in both periods (pre-PCV13: 3/11, 27%; post-PCV13; 4/13, 31%). There were no changes in the etiology over time, but most patients with Streptococcus pyogenes or Staphylococcus aureus infection were admitted during the post-PCV13 period.

CONCLUSIONS

The hospitalization rate for NP in children decreased a few years after the implementation of PCV13 immunization in Italy. However, an increased trend in admissions was found thereafter. S. pneumoniae was the most frequent causal agent in both pre- and post-PCV13 periods. Pneumococcal serotypes were mainly represented by Strain 3.

Assessing the impact of the 13 valent pneumococcal vaccine on childhood empyema in Australia

BACKGROUND

Empyema is a serious complication of pneumonia frequently caused by Streptococcus pneumoniae (SP). We assessed the impact of the 13-valent pneumococcal conjugate vaccine (13vPCV) on childhood pneumonia and empyema after inclusion in the Australian National Immunisation Program.

METHODS

For bacterial pneumonia and empyema hospitalisations, we ascertained incidence rates (IRs) using the National Hospital Morbidity Database International Statistical Classification of Disease discharge codes and relevant population denominators, and calculated incidence rate ratios (IRR) comparing the 13vPCV period (June 2012-May 2017) with the 7vPCV period (June 2007-May 2011). Blood and pleural fluid (PF) cultures and PF PCR of 401 children with empyema from 11 Australian hospitals during the 13vPCV period were compared with our previous study in the 7vPCV period.

FINDINGS

Across 7vPCV and 13vPCV periods, IRs per million children (95% CIs) were 1605 (1588 to 1621) and 1272 (1259 to 1285) for bacterial pneumonia, and 14.23 (12.67 to 15.79) and 17.89 (16.37 to 19.42) for empyema hospitalisations. IRRs were 0.79 (0.78 to 0.80) for bacterial pneumonia and 1.25 (1.09 to 1.44) for empyema. Of 161 empyema cases with SP serotypes, 147 (91.3%) were vaccine types. ST3 accounted for 76.4% of identified serotypes in the 13vPCV period, more than double than the 7vPCV period (p<0.001); ST19A decreased from 36.4% to 12.4%. No cases of ST1 empyema were identified in the 13vPCV period versus 14.5% in the 7vPCV period.

INTERPRETATION

13vPCV resulted in a significant reduction in all-cause hospitalisations for bacterial pneumonia but empyema hospitalisations significantly increased, with emergence of pneumococcal ST3 as the dominant serotype in empyema.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trial Registry ACTRN 12614000354684.

Diagnostic Accuracy of Routinely Available Biomarkers to Predict Bacteremia in Children With Community-Acquired Pneumonia: A Secondary Analysis of the GPIP/ACTIV Pneumonia Study in France, 2009-2018

Objective(s): Blood cultures (BC), when performed in children seen in the emergency department with community-acquired pneumonia (CAP), are most of the time sterile. We described the diagnostic accuracy of white blood cells (WBC), absolute neutrophils count (ANC), C-reactive protein (CRP), and procalcitonin (PCT) to predict blood culture (BC) result in childhood CAP. Study Design: Secondary analysis of a prospective study carried out in eight pediatric emergency departments (France, 2009-2018), including children (≤15 years) with CAP. Analyses involved univariate comparisons and ROC curves. Results: We included 13,752 children with CAP. BC was positive in 137 (3.6%) of the 3,829 children (mean age 3.7 years) in whom it was performed, mostly with Streptococcus pneumoniae (n = 107). In children with bacteremia, ANC, CRP and PCT levels were higher (median 12,256 vs. 9,251/mm³, 223 vs. 72 mg/L and 8.6 vs. 1.0 ng/mL, respectively; p ≤ 0.002), but WBC levels were not. The area under the ROC curve of PCT (0.73 [95%CI 0.64-0.82]) was significantly higher (p ≤ 0.01) than that of WBC (0.51 [0.43-0.60]) and of ANC (0.55 [0.46-0.64]), but not than that of CRP (0.66 [0.56-0.76]; p = 0.21). CRP and PCT thresholds that provided a sensitivity of at least 90% were 30 mg/L and 0.25 ng/mL, respectively, for a specificity of 25.4 and 23.4%, respectively. CRP and PCT thresholds that provided a specificity of at least 90% were 300 mg/L and 20 ng/mL, respectively, for a sensitivity of 31.3 and 28.9%, respectively. Conclusions: PCT and CRP are the best routinely available predictive biomarkers of bacteremia in childhood CAP.

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

Complicated pneumonia in children

Complicated community-acquired pneumonia in a previously well child is a severe illness characterised by combinations of local complications (eg, parapneumonic effusion, empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated community-acquired pneumonia should be suspected in any child with pneumonia not responding to appropriate antibiotic treatment within 48-72 h. Common causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging with chest radiography and ultrasound, which can also be used to assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local microbiological knowledge and by subsequent positive cultures and molecular testing, including on pleural fluid if a drainage procedure is done. Information from pleural space imaging and drainage should guide the decision on whether to administer intrapleural fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely needed; in any event, in low-income and middle-income countries, resources for extensive surgeries are scarce. The clinical course of complicated community-acquired pneumonia can be prolonged, especially when patients have necrotising pneumonia, but complete recovery is the usual outcome.

Pediatric parapneumonic effusion before and after national pneumococcal vaccination programs in Taiwan

BACKGROUND

Reports on the effectiveness of pneumococcal conjugate vaccines (PCVs) on pediatric parapneumonic effusion are limited. We report the changes in cases and etiologies of pediatric parapneumonic effusion in a children's hospital before and after national PCV13 vaccination programs.

METHODS

We screened medical records of children 0-18 years admitted to the National Taiwan University Hospital with diagnoses of lobar pneumonia and parapneumonic effusion between 2008 and 2017. Patients with effusion analyses were included. Results of blood, pleural fluid, and respiratory specimens surveyed as standard care were analyzed.

RESULTS

Diagnostic testing revealed at least a pathogen in 85% of 202 children with lobar pneumonia and parapneumonic effusion. After national PCV13 immunization, pneumococcal empyema decreased by 72% among 2- to 5-year olds. Mycoplasma pneumoniae was the second most common etiology. There were marked differences in effusion characteristics, metabolic, and respiratory parameters between children infected with pneumococcus and M. pneumoniae.

CONCLUSION

The effectiveness of the national PCV13 immunization programs on pneumococcal empyema was evident and remained substantial after 4 years in Taiwan. Continuous surveillance is important to monitor the emergence of other pathogens including non-PCV serotypes and M. pneumoniae.

Combined influence of practice guidelines and prospective audit and feedback stewardship on antimicrobial treatment of community-acquired pneumonia and empyema in children: 2012 to 2016

Background

Aminopenicillins are recommended empiric therapy for community-acquired pneumonia (CAP). The aim of the study was to assess treatment over a 5-year period after CAP guideline publication and introduction of an antimicrobial stewardship program (ASP).

Methods

Using ICD-10 discharge codes for pneumonia, children less than 18 years admitted to the Children's Hospital of Eastern Ontario January 1, 2012 and December 31, 2016 were identified. Children ≥ 2 months with consolidation were included. One day of therapy (DOT) was one or more doses of an antimicrobial given for 1 day.

Results

Of 1,707 patients identified, 713 met inclusion criteria. Eighteen (2.5%) had bacteria identified by culture and 79 of 265 (29.8%) had Mycoplasma pneumoniae detected. Mean DOT/1,000 patient days of aminopenicillins/penicillin (AAP) increased by 18.1% per year (95% confidence interval [CI] -0.2, 39.9%) and decreased by 37.6% per year (95% CI -56.1, -11.3%) for second- and third-generation cephalosporins in the post-ASP period. The duration of discharge antimicrobials decreased. Of 74 (10.4%) patients who had pleural fluid drained, 35 (47.3%) received more than 5 days of AAP and ≤ 5 days of second-/third-generation cephalosporins with no difference in median length of stay nor mean duration of antimicrobials.

Conclusions

Implementation of CAP management guidelines followed by prospective audit and feedback stewardship was associated with a sustained decrease in the use of broad-spectrum antibiotics in childhood CAP. Use of AAP should also be strongly considered in patients with effusions (even if no pathogen is identified), as clinical outcome appears similar to patients treated with broad-spectrum antimicrobials.

[Antibiotic strategy in pleural empyema in children: Consensus by the DELPHI method]

INTRODUCTION

The evolution of the microbial epidemiology of pleuropulmonary infections complicating community-acquired pneumonia has resulted in a change in empirical or targeted antibiotic therapy in children in the post Prevenar 13 era. The three main pathogens involved in pleural empyema in children are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus.

METHODS

A questionnaire according to the DELPHI method was sent to experts in the field (paediatric pulmonologists and infectious disease specialists) in France with the purpose of reaching a consensus on the conservative antibiotic treatment of pleural empyema in children. Two rounds were completed as part of this DELPHI process.

RESULTS

Our work has shown that in the absence of clinical signs of severity, the prescription of an intravenous monotherapy is consensual but there is no agreement on the choice of drug to use. A consensus was also reached on treatment adjustment based on the results of blood cultures, the non-systematic use of a combination therapy, the need for continued oral therapy and the lack of impact of pleural drainage on infection control. On the other hand, after the second round of DELPHI, there was no consensus on the duration of intravenous antibiotic therapy and on the treatment of severe pleural empyema, especially when caused by Staphylococci.

CONCLUSIONS

The result of this work highlights the needed for new French recommendations based on the evolution of microbial epidemiology in the post PCV13 era.

Outcome of Severe Bacterial Pneumonia in the Era of Pneumococcal Vaccination

Introduction: After the introduction of pneumococcal conjugate vaccines, community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae has decreased whereas Staphylococcus aureus and Streptococcus pyogenes could be increasing. These bacteria have been associated with high rates of complications. Aims: (1) To describe the characteristics of pediatric bacterial CAP requiring hospitalization. (2) To compare outcomes according to causative microorganisms. (3) To analyze changes in bacterial CAP rate and etiology over time. Patients and Methods: Retrospective single-center study of inpatients aged 1 month-16 years with culture-confirmed bacterial CAP in 2010-2018 in Madrid, Spain. Results: We included 64 cases (42 S. pneumoniae, 13 S. pyogenes and 9 S. aureus). Culture-confirmed CAP represented 1.48-2.33/1,000 all-cause pediatric hospital admissions, and its rate did not vary over time. However, there was a significant decrease in pneumococcal CAP in the last 3 years of the study (78% of CAP in 2010-2015 vs. 48% in 2016-18, p = 0.017). Median hospital stay was 10.5 days (interquartile range 5-19.5), 38 patients (59%) developed complications and 28 (44%) were admitted to the intensive care unit. Outcomes were similar among children with S. pneumoniae and S. aureus CAP, whereas S. pyogenes was associated with a higher risk for complications (OR 8 [95%CI 1.1-57.2]) and ICU admission (OR 7.1 [95%CI 1.7-29.1]) compared with pneumococcal CAP. Conclusion: In a setting with high PCV coverage, culture-confirmed bacterial CAP did not decrease over time and there was a relative increase of S. pyogenes and S. aureus. Children with CAP caused by S. pyogenes were more likely to develop complications.

Impact of the 13-Valent Pneumococcal Conjugate Vaccine on Severe Invasive Disease Caused by Serotype 3 Streptococcus Pneumoniae in Italian Children

The effectiveness and impact of the 13-valent pneumococcal conjugate vaccine (PCV13) against invasive pneumococcal diseases (IPD) due to serotype 3 (ser3) has been questioned. However, the impact of PCV13 on different clinical presentations of ser3-IPD has not been studied so far. The impact of PCV13 on different clinical presentations of ser3-IPD in a population of Italian children aged 0–8 years was evaluated, comparing pre- and post-PCV13 introduction period. Real-time polymerase chain reaction (PCR) was used for the diagnosis and serotyping of IPD. During the observation period (1 January 2006–1 August 2018), ser3 was detected in 60/284 (21.1%) children under 8 with serotyped IPD. The incidence of sepsis and meningitis was 0.24 per 1,000,000 person-years (p-y) in pre-PCV13 and 0.02 per 1,000,000 p-y in post-PCV13. No cases occurred in vaccinated children. In the post-PCV13 period, case reduction was 13% for all ser3 IPD and 92% for sepsis and meningitis. Vaccination impact may be underestimated due to significant improvement in pneumococcal surveillance in post-PCVC13. Our data suggest a significant impact of PCV13 on meningitis and sepsis due to ser3 and a lower impact against pneumonia. While waiting for increasingly effective anti-pneumococcal vaccines, PCV13, which guarantees protection against the most severe clinical presentations of ser3-IPD, is currently the most effective prevention option available.

Pleural Tap-Guided Antimicrobial Treatment for Pneumonia with Parapneumonic Effusion or Pleural Empyema in Children: A Single-Center Cohort Study

Parapneumonic effusion or pleural empyema (PPE/PE) is a frequent complication of community-acquired pneumonia (CAP) in children. Different management approaches exist for this condition. We evaluated a 14-day treatment with amoxicillin (AMX) with/without clavulanic acid (AMC) confirmed or modified by microbiological findings from pleural tap. Children ≤16 years of age with radiologically diagnosed PPE/PE and initial diagnostic pleural tap were included at University Children’s Hospital Zurich from 2001–2015. AMX/AMC was given for 14 days and rationalized according to microbiological pleural tap results. Clinical and radiological follow-up was scheduled until six months or full recovery. In 114 of 147 (78%) children with PPE/PE a pathogen was identified by culture, polymerase chain reaction (PCR), and/or antigen testing. Streptococcus pneumoniae was detected in 90 (79%), S. pyogenes in 13 (11%), and Staphylococcus aureus in seven cases (6%), all but two cultured pathogens (96%) were sensitive to AMX/AMC. One-hundred two of 147 (69%) patients received treatment with AMX/AMC for 14 days. They recovered more rapidly than patients with a different management (p = 0.026). Of 139 children with follow-up, 134 (96%) patients fully recovered. In conclusion, 14-day AMX/AMC treatment confirmed and rarely modified by microbiological findings from pleural tap resulted in full recovery in >95% of children with PPE/PE.