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Lees EA, Williams TC, Marlow R, Fitzgerald F, Jones C, Lyall H, Bamford A, Pollock L, Smith A, Lamagni T, Kent A, Whittaker E. Epidemiology and Management of Pediatric Group A Streptococcal Pneumonia With Parapneumonic Effusion: An Observational Study. Pediatr Infect Dis J 2024; 43:841-850. [PMID: 38900036 PMCID: PMC11319078 DOI: 10.1097/inf.0000000000004418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND During autumn/winter 2022, UK pediatricians reported an unseasonal increase in invasive group A streptococcal infections; a striking proportion presenting with pneumonia with parapneumonic effusion. METHODS Clinicians across the United Kingdom were requested to submit pseudonymized clinical data using a standardized report form for children (<16 years) admitted between September 30, 2022 and February 17, 2023, with microbiologically confirmed group A streptococcal pneumonia with parapneumonic effusion. RESULTS From 185 cases submitted, the median patient age was 4.4 years, and 163 (88.1%) were previously healthy. Respiratory viral coinfection was detected on admission for 101/153 (66.0%) children using extended respiratory pathogen polymerase chain reaction panel. Molecular testing was the primary method of detecting group A streptococcus on pleural fluid (86/171; 50.3% samples). Primary surgical management was undertaken in 171 (92.4%) children; 153/171 (89.4%) had pleural drain inserted (96 with fibrinolytic agent), 14/171 (8.2%) had video-assisted thoracoscopic surgery. Fever duration after admission was prolonged (median, 12 days; interquartile range, 9-16). Intravenous antibiotic courses varied in length (median, 14 days; interquartile range, 12-21), with many children receiving multiple broad-spectrum antibiotics, although evidence for additional bacterial infection was limited. CONCLUSIONS Most cases occurred with viral coinfection, a previously well-recognized risk with influenza and varicella zoster, highlighting the need to ensure routine vaccination coverage and progress on vaccines for other common viruses (eg, respiratory syncytial virus, human metapneumovirus) and for group A streptococcus. Molecular testing is valuable to detect viral coinfection and confirm invasive group A streptococcal diagnosis, expediting the incorporation of cases into national reporting systems. Range and duration of intravenous antibiotics administered demonstrated the need for research on the optimal duration of antimicrobials and improved stewardship.
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Affiliation(s)
- Emily A. Lees
- From the Department of Paediatrics, University of Oxford, Children’s Hospital Oxford, Oxford, United Kingdom
- Fitzwilliam College, University of Cambridge, Cambridge, United Kingdom
| | - Thomas C. Williams
- Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Robin Marlow
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
- Bristol Vaccine Centre, Schools of Population Health Sciences and of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Felicity Fitzgerald
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK United Kingdom
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Christine Jones
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Hermione Lyall
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK United Kingdom
| | - Alasdair Bamford
- Department of Infectious Diseases, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
- Infection, Immunity, and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London
| | - Louisa Pollock
- Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Andrew Smith
- College of Medical, Veterinary and Life Sciences, Glasgow Dental School, University of Glasgow, Glasgow, United Kingdom
| | - Theresa Lamagni
- Healthcare-Associated Infection & Antimicrobial Resistance Division, UK Health Security Agency, London, United Kingdom
| | - Alison Kent
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK United Kingdom
| | - Elizabeth Whittaker
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK United Kingdom
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, United Kingdom
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Turan Ciftci T, Akinci D, Unal E, Tanır G, Artas H, Akhan O. Percutaneous management of complicated parapneumonic effusion and empyema after surgical tube thoracostomy failure in children: a retrospective study. ACTA ACUST UNITED AC 2021; 27:401-407. [PMID: 34003128 DOI: 10.5152/dir.2021.20331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the results of percutaneous management of complicated parapneumonic effusions (PPE) and empyema after surgical tube thoracostomy failure in children. METHODS A total of 84 children treated percutaneously after surgical tube thoracostomy failure between 2004 and 2019 were included to this retrospective study. Technical success was defined as appropriate placement of the drainage catheter. Clinical success was defined as complete resolution of infection both clinically and radiologically. Management protocol included imaging-guided pigtail catheter insertion, fibrinolytic therapy, serial ultrasonographic evaluation, catheter manipulations as necessary (revision, exchange, or upsizing), and appropriate antibiotherapy. All patients were followed up at least 6 months. RESULTS Technical success rate was 100%. Unilateral single, unilateral double, and bilateral catheter insertions were performed in 73, 9, and 2 patients, respectively. Inserted catheter sizes ranged from 8 F to 16 F. Streptokinase, urokinase, and tissue plasminogen activator were used as fibrinolytic agent in 29 (34%), 14 (17%), and 41 (49%) patients, respectively. In order to maintain effective drainage, 42 additional procedures (catheter exchange, revision, reposition, or additional catheter placement) were performed in 20 patients (24%). Clinical success was achieved in 83 of 84 patients (99%). Median catheter duration was 8 days (4-32 days). Median hospital stay during percutaneous management was 11.5 days (7-45 days). Factors affecting the median catheter duration were the presence of necrotizing pneumonia (p < 0.001) and bronchopleural fistulae (p < 0.001). CONCLUSION Percutaneous imaging-guided catheterization with fibrinolytic therapy should be the method of choice in pediatric complicated PPE and empyema patients with surgical tube thoracostomy failure. Percutaneous treatment is useful in avoiding more aggressive surgical options.
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Affiliation(s)
- Turkmen Turan Ciftci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Emre Unal
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Gonul Tanır
- Department of Pediatric Infectious Disease, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Hakan Artas
- Department of Radiology, Firat University School of Medicine, Elazig, Turkey
| | - Okan Akhan
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
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Baram A, Yaldo F. Pediatric Thoracic Empyema-Outcomes of Intrapleural Thrombolytics: Ten Years of Experience. Glob Pediatr Health 2020; 7:2333794X20928200. [PMID: 32551331 PMCID: PMC7281637 DOI: 10.1177/2333794x20928200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 04/13/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction. Pediatric thoracic empyema is a special entity with increasing frequency. Consensus regarding the best management strategy is still evolving. We describe our single-center 10-year experience adopting intrapleural thrombolytics using tissue plasminogen activator as first-line treatment following failure of simple thoracostomy drainage techniques. Methods. Observational prospective study included all children from 1 day to 18 years admitted for parapneumonic effusion and treated with intrapleural thrombolytics. Results. From January 2008 to December 2018, 95 patients were treated by intrapleural thrombolytics for different stages of empyema thoracis. Number of thrombolytic doses required is 2.1 (range = 1-3), and mean amount of drainage is 1050 mL (range = 400-2500 mL). Mean total days of hospitalization is 7.3 days. Complete re-expansion was the primary outcome in 94 patients (98.9%). Conclusion. Intrapleural thrombolytics in complicated pediatric thoracic empyema results in excellent outcome and should be encouraged particularly in limited resource countries.
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Affiliation(s)
- Aram Baram
- University of Sulaimani, Sulaymaniyah, Kurdistan, Iraq
| | - Fitoon Yaldo
- Kurdistan Board for Medical Specialties, Erbil, Kurdistan Region, Iraq
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Bueno Fischer G, Teresinha Mocelin H, Feijó Andrade C, Sarria EE. When should parapneumonic pleural effusions be drained in children? Paediatr Respir Rev 2018; 26:27-30. [PMID: 28673835 DOI: 10.1016/j.prrv.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
Pneumonia is an important health problem in children, and parapneumonic pleural effusion (PPE) is a frequent complication. There is no standard strategy for treating PPE, reflected in the few international guidelines that have been published on the issue. Compared to adults, there is no consensus on the utility of pleural fluid analysis in paediatric PPE. This is because of the lack of good evidence either in favour or against it and the risks of procedural sedation for acquiring pleural fluid for analysis to guide management. In this paper we provide a succinct review of the different approaches to the management of PPE, including diagnosis, pleural fluid analysis (Light's criteria) and treatment, both medical and surgical.
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Affiliation(s)
| | | | - Cistiano Feijó Andrade
- Department of Paediatric Thoracic Surgery, Hospital da Criança Santo Antônio, Porto Alegre and Post-Graduate Program in Pulmonology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Edgar E Sarria
- Department of Biology and Pharmacy, School of Medicine, Universidade de Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil
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Lewis MR, Micic TA, Doull IJM, Evans A. Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children - 16-year, single-centre experience of radiologically placed drains. Pediatr Radiol 2018; 48:1410-1416. [PMID: 29951836 PMCID: PMC6105150 DOI: 10.1007/s00247-018-4171-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/29/2018] [Accepted: 04/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion. OBJECTIVE To evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital. MATERIALS AND METHODS This was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre. RESULTS Three hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery. CONCLUSION Our technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.
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Affiliation(s)
- Megan R. Lewis
- Department of Postgraduate Medical and Dental Education at Cardiff University, Heath Park Way, Cardiff, UK CF14 4YU
| | - Thomas A. Micic
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
| | - Iolo J. M. Doull
- Department of Paediatric Respiratory Medicine, Children’s Hospital for Wales, Cardiff, UK CF14 4XW
| | - Alison Evans
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
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