Protocol-driven Antibiotic Treatment of Pediatric Empyema After Fibrinolysis

BACKGROUND

The duration of antibiotic treatment after resolution of empyema in children is variable. We evaluated the efficacy and safety of a protocol-driven antibiotic regimen aimed to decrease antibiotic duration following treatment with fibrinolysis.

METHODS

Our institutional protocol consisted of 7 further days of antibiotics upon removal of the thoracostomy tube, with the patient being afebrile, off supplemental oxygen, and having negative cultures. A prospective observational study was then performed between September 2014 and March 2019. Empyema recurrence and antibiotic-related complications were recorded. Results were compared with previously published data from the preprotocol era.

RESULTS

A total of 37 patients were included. Mean total duration of antibiotics decreased from 26 ± 6.5 days in the preprotocol group to 22 ± 9.7 days in the postprotocol group (P = 0.004). This resulted in a significant decrease in hospital stay from the preprotocol cohort to the postprotocol cohort, respectively (9.3 ± 4.8 d versus 6.8 ± 3.1 d, P = 0.003). Sixty-two percentage of the patients were intended to treat according to the protocol, with a 50% adherence rate. Patients in which the protocol was followed had an average of 2.8 fewer days of antibiotics after discharge (P = 0.004), although overall duration was not statistically different. Significantly fewer antibiotic-related complications were noted after protocol initiation. There was no difference in empyema recurrence or readmissions.

CONCLUSIONS

Institution of a protocol-driven approach to antibiotic duration following resolution of pleural space disease may reduce antibiotic duration and complications without reducing efficacy.

Inpatient Observation After Transition From Intravenous to Oral Antibiotics

OBJECTIVES

Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs).

METHODS

We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation.

RESULTS

Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed.

CONCLUSIONS

Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.

Single Trocar Thoracoscopic Surgery for Pleural Empyema in Children

Aim: To present outcomes of single trocar thoracoscopic surgery in the treatment of pleural empyema (PE) in children. Patients and Methods: The thoracoscopic surgery was performed using a single trocar inserted through the fifth intercostal space. A conventional rigid scope with a working channel was used. Pleural fluid was aspirated, followed by debridement and ablation of all septa using one instrument through the working channel. Results: Sixty patients from 1 month to 14 years of age underwent surgery without any intraoperative complications or death. The mean operative time was 67 ± 21 minutes. There was no conversion to open thoracotomy. Postoperative complications occurred in 4 patients. Reoperation was required in 1 patient. Mean duration of postoperative hospitalization was 15 ± 9 days. Follow-up was obtained in 57 patients and resulted in normal clinical and chest X-ray findings in all patients. Conclusion: Single trocar thoracoscopic operation is safe, feasible, and effective in the treatment of PE in children. A future study with control group is required to draw accurate conclusions.

Factors Affecting Outcome Following Video-Assisted Thoracoscopic Surgery for Empyema in Children: Experience from a Large Tertiary Referring Centre

Introduction: We report the results of video-assisted thoracoscopic surgery (VATS) in a large population of children with empyema, focusing on the factors affecting the postoperative length of stay (LOS). Materials and Methods: After ethical approval (RES-18-0000-071Q), a retrospective review was performed (2013-2018). Results are reported as number of cases (%) and median (range) and analyzed by Mann-Whitney U and Kruskal-Wallis tests. Correlation analysis was conducted. Results: We identified 159 children with empyema; 75 [42 (56%) males] underwent VATS. Median age was 3.6 (0.4-14.5) years. Presentation was: autumn 15 (20%), winter 26 (35%), spring 18 (24%), summer 16 (21%) with no difference in LOS (P = .6). Preoperative symptoms duration was 7 (2-28) days. Postoperatively, chest drain was on suction in 30 (40%) patients, in situ for 3 (2-13) days. Six (8%) children required further procedures. LOS was 8 (3-47) days. Pleural fluid revealed: Streptococcus species. 41 (55%), other species 8 (11%), no bacteria 26 (34%); LOS was longer with positive pleural fluid: 9 (4-47) versus 6.5 (3-16) days (P = .02). There was no correlation between the LOS and preoperative symptoms duration (r = -0.03 [95% CI -0.3 to 0.2]; P = .7), empyema size (r = 0.2 [95% CI -0.07 to 0.5]; P = .1) and chest drain size (r = 0.09 [95% CI -0.14 to 0.3]; P = .4). Discussion: In our experience, >90% of children with empyema will be treated with a single VATS with an average LOS of 8 days. Positive microbiology culture significantly affects the LOS.

[Evolution of complex treatment of patients with non-specific pleural empyema]

AIM

To analyze long-term own experience of NPE treatment in view of evolution of surgical sanitation of pleural cavity.

MATERIAL AND METHODS

The analysis included 5115 patients with NPE for the last 39 years (1977-2015). Morbidity, features of microflora of purulent exudate, changes in the structure of surgical methods were assessed. The role of computed tomography in the diagnostic algorithm and treatment of NPE was studied.

RESULTS

The evolution of NPE surgical management includes introduction of video technologies, thermal surgical instruments and widespread use of computed tomography in the diagnosis of pleural empyema. So, significant reduction of patients who were discharged with residual cavities was observed. Postoperative mortality was 19.5% for the period 1977-1996 when traumatic open surgery was used. At the same time there were no deaths within 1997-2015 due to introduction of VATS pleural drainage. Overall mortality decreased from 4.9% to 3.2% for the same period due to reduced postoperative complications.

CONCLUSION

The introduction of minimally invasive technologies, new thermal surgical instruments changed management of NPE patients, reduced the number of traumatic open procedures. So, improved outcomes were achieved.