Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage

Conservative Treatment of Parapneumonic Effusion in Children: Experience From a 10-Year Consecutive Case Series

BACKGROUND

In children with parapneumonic effusion (PPE), it remains unclear when conservative treatment with antibiotics suffixes or when pleural drainage is needed. In this study we evaluate clinical features and outcomes of children with PPE.

METHODS

A retrospective, multicentre cohort study at 4 Dutch pediatric departments was performed, including patients 1-18 years treated for PPE between January 2010 and June 2020.

RESULTS

One hundred thirty-six patients were included (mean age 8.3 years, SD 4.8). 117 patients (86%) were treated conservatively and 19 (14%) underwent pleural drainage. Patients undergoing pleural drainage had mediastinal shift more frequently compared with conservatively treated patients (58 vs. 3%, difference 55%; 95% CI: 32%-77%). The same accounted for pleural septations/pockets (58 vs. 11%, difference 47%; 95% CI: 24%-70%), pleural thickening (47 vs. 4%, difference 43%; 95% CI: 20%-66%) and effusion size (median 5.9 vs. 2.7 cm; P = 0.032). Conservative management was successful in 27% of patients (4 of 15) with mediastinal shift, 54% of patients (13 of 24) with septations/pockets, 36% of patients (5 of 14) with pleural thickening, and 9% of patients (3 of 32) with effusions >3 cm, all radiological signs generally warranting pleural drainage. In patients treated conservatively, median duration of hospitalization was 5 days (IQR 4-112) compared with 19 days (IQR 15-24) in the drainage group ( P < 0.001), without significant difference in readmission rate (11 vs. 4%, difference 6%; 95% CI: -8%-21%).

CONCLUSION

This study suggests that the greater amount of children with PPE could be treated conservatively with antibiotics only, especially in absence of mediastinal shift, pleural septations/pockets, pleural thickening or extensive effusions.

Is there any role for medical thoracoscopy in the treatment of empyema in children?

It is still controversial whether surgical or nonsurgical treatment approaches are most appropriate for empyema in children, and there are no data regarding the role of medical thoracoscopy in this population. The aim of this study was to describe our experience with medical thoracosocpy in children with multiloculated and organizing pneumonia. We retrospectively reviewed children admitted to our hospital with a diagnosis of empyema from 2011 to 2021 and treated with medical thoracoscopy. A total of six patients with empyema were treated by medical thoracoscopy; empyema was multiloculated in five cases and organized in one case; all children in the study recovered completely with full lung expansion after chest X-rays, and no disease sequelae were reported after clinical follow-up. Our small case series suggests that in selected cases, medical thoracoscopy could safely and effectively treat pleural empyema in children, with less invasiveness and reduced psychological consequences.

A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial

BACKGROUND

Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection.

AIMS AND OBJECTIVES

To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients.

METHODS

Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation.

RESULTS

From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection.

CONCLUSIONS

The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further.

TRIAL REGISTRATION

ISRCTN: 84674413.

Entzündliche und infektiöse Erkrankungen der Lunge und Pleura bei Kindern und Jugendlichen

Entzündliche Erkrankungen der Lunge und Pleura bei Kindern und Jugendlichen umfassen ein weites Spektrum von der komplizierten Pneumonie, der Tuberkulose, Mykosen bis hin zur Echinokokkose. Die Häufigkeit hängt stark von der geografischen Herkunft ab. Diese Übersichtsarbeit gibt einen Überblick von der Diagnostik bis hin zur chirurgischen Therapie dieser Erkrankungen beim pädiatrischen Kollektiv.

Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement

Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.

Pediatric empyema thoracis: What has changed over a decade?

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.

Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax: which is better?

Background

Needle aspiration and chest tube drainages are two main treatments for primary spontaneous pneumothorax (PSP). However, the application of needle aspiration or chest tube drainages has not reached a consensus. The aim of this study is to compare the needle aspiration with chest tube drainages in patients suffering with PSP and therefore help offer suggestions for clinical practice.

Methods

We searched literatures from PubMed, OVID and Web of Science from their inception to June 30, 2017. Continuous and dichotomous outcomes were expressed by weight mean difference (WMD) and risk ratio (RR) respectively, and each with 95% confidence intervals (CIs). We used the fixed effect or random effect model to perform quantitative synthesis.

Results

A total of 6 RCTs recruiting 458 participants were included in our analysis. On the basis of the six studies, our results indicated that compared with chest tube drainage applying needle aspiration shortened the hospital stay (WMD: ‒1.67 days; 95% CI: ‒2.25 to 1.08; P<0.001) and decreased hospitalization rate (RR: 0.40; 95% CI: 0.22-0.75; P=0.004). However, there was no difference regarding immediate success rate (RR: 1.01; 95% CI: 0.70-1.46; P=0.96) and one-year recurrence rate (RR: 0.89; 95% CI: 0.58-1.38; P=0.61).

Conclusions

In the light of this present research, it is necessary to apply needle aspiration into treating PSP to reduce hospitalization rate and shorten hospital stay. However, the two treatments have no significant difference with respect to immediate success rate, one-year recurrence rate, one-week success rate, three-month recurrence rate or complication rate.

Repeated therapeutic thoracentesis to manage complicated parapneumonic effusions

PURPOSE OF REVIEW

In complicated parapneumonic effusion (CPPE), antibiotics and evacuation of the infected pleural fluid are mandatory. The first-line evacuation treatment is still controversial. The aim of this article is to highlight the usefulness of repeated therapeutic thoracentesis (RTT) as a first-line treatment.

RECENT FINDINGS

In the most recent study on RTT in CPPE, disposable pleural needles were used and the median number of thoracentesis was 3. The success rate was 81%, and only 4% of the patients were referred for thoracic surgery. The 1-year survival rate was 88%. On multivariate analysis, the observation of microorganisms in the pleural fluid after Gram staining and first thoracentesis volume at least 450 ml was associated with a higher risk of RTT failure. RTT is less invasive and can target different loculated pleural collections. Patients are less confined to beds between each procedure, and could even be ambulatory managed. The use of intrapleural fibrinolytics in association with DNase could most likely enhance the efficacy of RTT.

SUMMARY

RTT is efficient and well tolerated in the management of CPPE, including pleural empyema, and could be proposed as a first-line therapy for CPPE. This technique could be used in association with intrapleural fibrinolytics and DNase.

Indicators for surgical intervention in thoracic empyema in children

OBJECTIVES

To determine predictors for surgical intervention of thoracic empyema in children, and its associated morbidity.

METHODS

We conducted a retrospective review of medical records of children with empyema thoracis admitted in the Maternity and Children Hospital, Al Madinah Al Munawwarah, Saudi Arabia between January 2007 and January 2012. The data extracted included: socio-demographic data, clinical data, method of treatment, and follow up data. According to the introduced therapeutic methods, a total of 62 patients were divided into 2 groups; patients treated with chest tube (CT) insertion (51 cases), and 11 cases that required thoracotomy (TH); groups were compared to determine predictors for thoracotomy.

RESULTS

Of 62 patients, 37 were females and 25 were males. In terms of age, side of lesion, presence of cough, or dyspnea, both groups were homogenous. Both groups had significant differences for duration of complaint (TH and CT) (13.5±6.5 days versus 10±3.6, p=0.005), presence of fever (90.2% versus 36.4%, p less than 0.001), history of recurrent chest infections (90.9% versus 37.3%, p=0.001), and radiological findings. However, it was not evident that any of these variables influenced treatment decision except absence of fever, which was significantly less in patients treated with thoracotomy.

CONCLUSION

No specific indicator was found to increase expectancy for surgical intervention as a treatment choice, except the absence of fever, which may reflect the delayed referral and prolonged use of antibiotics and cannot be interpreted truly without caution as an indicator for surgical intervention.

[The management of complicated parapneumonic effusions in France]

INTRODUCTION

There are no French guidelines for the management of complicated parapneumonic effusions. A national observational study was carried out to assess the main features of current clinical practice for this condition.

MATERIAL AND METHODS

A questionnaire was sent by email to the 1500 members of the Société de Pneumologie de Langue Française (SPLF) between 15th November and 15th December 2012.

RESULTS

There were 92 responders, i.e. a response rate of 6%. Of these, 87 physicians mentioned that they were involved in the management of patients with complicated parapneumonic effusions with a median number of cases of 10 per year (IQR: 5-20). Chest tube drainage was the main approach used for pleural fluid aspiration (n=51/87), followed by repeated thoracentesis (n=29/87) and early surgery (1/87). Five physicians answered both chest tube drainage or repeated thoracentesis and one physician either chest tube drainage or early surgery. Pleural fibrinolytics were never used by 20% of physicians, only in case of loculations by 70% and by 10% of respondents in all cases. Only 3 physicians combined fibrinolytics with DNAse. A double antibiotic dose was used by one third of physicians. All the physicians used respiratory physiotherapy during hospitalization and to aid recovery. Follow-up practices were heterogeneous.

CONCLUSIONS

The management of complicated parapneumonic effusions varies significantly in France. National guidelines may be helpful to define best practice and aid in its implementation.

A clinical review of the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats

OBJECTIVE

To review the current literature in reference to the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats.

ETIOLOGY

Pyothorax, also known as thoracic empyema, is characterized by the accumulation of septic purulent fluid within the pleural space. While the actual route of pleural infection often remains unknown, the oral cavity and upper respiratory tract appear to be the most common source of microorganisms causing pyothorax in dogs and cats. In human medicine, pyothorax is a common clinical entity associated with bacterial pneumonia and progressive parapneumonic effusion.

DIAGNOSIS

Thoracic imaging can be used to support a diagnosis of pleural effusion, but cytologic examination or bacterial culture of pleural fluid are necessary for a definitive diagnosis of pyothorax.

THERAPY

The approach to treatment for pyothorax varies greatly in both human and veterinary medicine and remains controversial. Treatment of pyothorax has classically been divided into medical or surgical therapy and may include administration of antimicrobials, intermittent or continuous thoracic drainage, thoracic lavage, intrapleural fibrinolytic therapy, video-assisted thoracic surgery, and traditional thoracostomy. Despite all of the available options, the optimal treatment to ensure successful short- and long-term outcome, including the avoidance of recurrence, remains unknown.

PROGNOSIS

The prognosis for canine and feline pyothorax is variable but can be good with appropriate treatment. A review of the current veterinary literature revealed an overall reported survival rate of 83% in dogs and 62% in cats. As the clinical presentation of pyothorax in small animals is often delayed and nonspecific, rapid diagnosis and treatment are required to ensure successful outcome.

[Parapneumonic pleural effusions: Epidemiology, diagnosis, classification and management]

Parapneumonic pleural effusions represent the main cause of pleural infections. Their incidence is constantly increasing. Although by definition they are considered to be a "parapneumonic" phenomenon, the microbial epidemiology of these effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated parapneumonic effusions. Only complicated parapneumonic effusions need to be drained. Therapeutic evacuation modalities include repeated therapeutic thoracentesis, chest tube drainage or thoracic surgery. The choice of the first-line evacuation treatment is still controversial and there are few prospective controlled studies. The effectiveness of fibrinolytic agents is not established except when they are combined with DNase. Antibiotics are mandatory; they should be initiated as quickly as possible and should be active against anaerobic bacteria except for in the context of pneumococcal infections. There are few data on the use of chest physiotherapy, which remains widely used. Mortality is still high and is influenced by underlying comorbidities.

The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee

The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.

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.

Effects of blood conservation on the incidence of anemia and transfusions in pediatric parapneumonic effusion: a hospitalist perspective

BACKGROUND

Children with pneumonia may develop parapneumonic effusion (PNE). The associated inflammatory process and nutritional compromise can blunt erythropoesis. Traditional treatment for these children with PNE includes repeated phlebotomy and surgical intervention, resulting in ongoing blood losses. Blood transfusions used to treat acquired anemia are associated with multiple complications.

OBJECTIVES

This study evaluated the effect of hospitalists' implementation of blood conservation guidelines (BCG) on the incidence of anemia and transfusion requirements in children with PNE.

DESIGN

Retrospective cohort study of hospitalized children with PNE.

SETTINGS

University affiliated Children's Hospital.

PATIENTS

Children who were admitted to the hospital with PNE and managed using BCG (Group I) were compared to simultaneous no intervention group (S) and historical no intervention group (H). Group (I) and (S) were admitted from year 2000 to 2004 and the Group (H) were admitted from year 1997 to 1999.

MEASUREMENTS

Phlebotomy frequency and volume, measured hemoglobin (Hgb) levels, and the need for red blood transfusions.

RESULTS

Children in the BCG group (n = 24) compared to simultaneous no intervention group (n = 28) and historical no intervention group (n = 29) had lesser phlebotomy volumes (14 ± 8, 18 ± 14 and 69 ± 66 mL; P = 0.001), trend toward lesser Hgb drop (1.7 ± 1.4, 2.1 ± 1.2 and 2 ± 1.4 gm%; P ≤ 0.37), and lesser incidence of transfusion (8%, 18% and 31%; P = 0.11). Transfused children were younger (3.5 ± vs. 6.4 ± 4 years; P = 0.001) and had lower initial Hgb (9.9 ± 1 vs. 11.4 ± 1 gm%; P = 0.001), more phlebotomy (5.9 ± 7 vs. 1.1 ± 1 mL/kg., P = 0.001), longer hospitalization (18.7 ± 5 vs. 11.1 ± days; P = 0.001), and slightly higher (pediatric risk of mortality [PRISM]) scores (3.4 ± 5.7 vs. 1.6 ± 2.7; P = 0.25).

CONCLUSION

Implementing BCG lowers phlebotomy losses and the need for transfusion.

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).

WITHDRAWN: Surgical versus non-surgical management of pleural empyema

BACKGROUND

Pleural empyema is a collection of pus between the lungs and the chest wall. There is debate about treatment options with the advent of both fibrinolytic enzymes to facilitate tube drainage and less invasive video-assisted thoracoscopic surgery (VATS).

OBJECTIVES

To determine which was more effective: surgical (using thoracoscopy or thoracotomy) or non-surgical techniques (thoracocentesis, chest tube drainage); and to establish whether there was an optimum time for intervention.

SEARCH STRATEGY

In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, issue 3) which contains the Acute Respiratory Infections Group's specialized register; MEDLINE (January 2002 to July Week 4, 2005); and EMBASE (January 2001 to 3rd Quarter 2005). Bibliographies, reference lists of identified studies and review articles were handsearched. Personal communication with authors is ongoing. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed using Jadad criteria (Jadad 1996). Authors were contacted for missing information. The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed the length of time chest tubes were required, pain, hospital stay and any complications.

MAIN RESULTS

Only one small randomised study was identified. Some methodological quality considerations cast doubt on the validity of the study with regard to patient selection, unclear allocation concealment and outcome assessor blinding and it scored 'B' overall (Jadad score 3). When compared with chest tube drainage combined with streptokinase, video-assisted thoracoscopic surgery (VATS) had a significantly higher primary treatment success and patients spent less time in hospital. Each treatment group suffered one mortality. The latest search revealed no further published randomised studies but communication with authors revealed two ongoing studies comparing conventional chest tube drainage plus antibiotics with and without fibrinolytics with video-assisted thorascopic surgery (VATS). A small unpublished study is awaiting assessment that compared chest tube drainage and antibiotics with thoracoscopy or thoracotomy plus antibiotics.

AUTHORS' CONCLUSIONS

It seems that for large, loculated pleural empyemas VATS is superior to chest tube drainage in terms of duration of chest tubes in situ and length of hospital stay. However, there are questions about validity in the one study which met the inclusion criteria and the study has too few participants to draw conclusions. There are risks of complications (associated with all treatments) which may not be apparent with small numbers. Larger studies are needed.

Cost-effectiveness of competing strategies for the treatment of pediatric empyema

BACKGROUND

The optimal management of pediatric empyema is controversial. The purpose of this decision analysis was to assess the relative merits in terms of costs and clinical outcomes associated with competing treatment strategies.

METHODS

A cost-effectiveness analysis was conducted using a Bayesian tree approach. Probability and outcome estimates were derived from the published literature, with preference given to data derived from randomized trials. Costing was based on published estimates from Great Ormond Street Hospital (London, United Kingdom), supplemented by American and Canadian data. Five strategies were evaluated: (1) nonoperative; (2) chest tube insertion; (3) repeated thoracentesis; (4) chest tube insertion with instillation of fibrinolytics; or (5) video-assisted thorascopic surgery. The model was used to project overall costs, survival in life-years, and incremental cost-effectiveness ratios for competing strategies.

RESULTS

In the base-case analysis, chest tube with instillation of fibrinolytics was the least expensive therapy, at $7787 per episode. This strategy was projected to cost less but provide equivalent health benefit when compared with all of the competing strategies except repeated thoracentesis, which had an incremental cost-effectiveness ratio of approximately $6,422,699 per life-year gained relative to chest tube with instillation of fibrinolytics. In univariable and multivariable sensitivity analyses, thorascopic surgery was preferred only when the length of stay associated with chest tube with instillation of fibrinolytics exceeded 10.3 days or when the probability of dying as a result of this strategy exceeded 0.2%, assuming a threshold willingness to pay of $75,000 per life-year gained. Chest tube with instillation of fibrinolytics was preferred in >58% of Monte Carlo simulations.

CONCLUSIONS

On the basis of the best available data, chest tube with instillation of fibrinolytics is the most cost-effective strategy for treating pediatric empyema. Video-assisted thorascopic surgery would be preferred to chest tube with instillation of fibrinolytics if the differential in length of stay between these 2 strategies were proven to be greater than that suggested by currently available data.

Treatment approaches for empyema in children

Empyema is an important cause of childhood morbidity with an increasing worldwide incidence. Despite many treatment options being available, there is no general consensus on the optimal management approach due to conflicting reports and lack of properly conducted studies to challenge the personal bias of a physician or surgeon. The reason for this is likely to be the fact that, irrespective of the treatment children receive, they ultimately make an excellent clinical recovery. This review summarises the current evidence and evaluates the clinical efficacy of various treatment modalities in the context of relevant outcome measures in an attempt to demonstrate the differences in treatment options for the child with 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.

Minimal access thoracic surgery in the pediatric population

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

Pleurésies purulentes communautaires de l'enfant. Où en sommes-nous?

Community-acquired pleural infection is a life-threatening complication of pneumonia in children. It seems to be more prevalent actually. This pathology is associated with an high morbidity and frequently requires prolonged hospitalization and invasives procedures. However, there is no consensus on its management in pediatrics, especially because of the lack of trials. To improve the quality of the future studies and to compare the series, a child-adapted classification is required. To date, in attempt of evidence, chest drainage or thoracocentesis-thoracoscopy are questionable. For treatment, high regimens of synergic and intravenously-delivered antibiotics seem to be the better choice.

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

PURPOSE

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.

METHODS

From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.

RESULTS

The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.

CONCLUSION

The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage

OBJECTIVE

Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage.

DESIGN

A prospective, randomized trial was conducted at DeVos Children's Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol.

RESULTS

Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group.

CONCLUSIONS

The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.

Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standard of Care for Advanced Pneumonia with Empyema?

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of <0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

The Approach to the Patient with a Parapneumonic Effusion

Parapneumonic effusion is a common clinical problem, and those that go on to develop pleural infection have high morbidity and mortality. The process of pleural infection evolution involves changes in pleural physiology that are increasingly being elucidated and understood. The microbiology of pleural infection has changed over recent years, with clear differences emerging between hospital- and community-acquired infections. Using biochemical surrogates of infection, chest drainage can be undertaken rationally for those who do not respond to antibiotics alone. Recent data suggest that fibrinolytics do not influence outcomes in pleural infection. The optimal type and timing of surgery remain controversial.

Conservative use of chest-tube insertion in children with pleural effusion

The aim of this work was to evaluate the effect of a more conservative use of chest-tube insertion on the short-term and long-term outcome of pleural infection. Sixty-five patients with pleural infection, aged 1 month to 16 years were each treated according to one of the two protocols: classical management with chest-tube insertion (classical group, n = 33), or conservative use of chest-tube insertion (conservative group, n = 32), with drainage indicated only in the case of voluminous pleural effusion defined by a mediastinal shift and respiratory distress and/or an uncontrolled septic situation. The two groups were comparable with regard to age, baseline C-reactive protein (CRP) value and white blood cell counts, pleural thickness, identified bacteria, and antibiotic treatment. Chest-tube insertion was performed in 17 patients (52%) of the classical group compared to eight patients (25%) of the conservative group (P = 0.03). Duration of temperature above 39 degrees C was shorter in the conservative group (10 +/- 1 vs. 14 +/- 1 days, P = 0.01), as was the normalization of CRP (13 +/- 1 vs. 17 +/- 1 days, P = 0.03). Duration of hospitalization and intravenous (IV) antibiotherapy as well as the delay of chest-radiograph normalization was not significantly different between the two groups. A more conservative use of chest-tube insertion did not change short- and long-term outcome of the pleural infection in children. Drainage could be restricted to the most severely affected patients with pleural empyema causing a mediastinal shift and respiratory distress and/or presenting with an uncontrolled septic situation.

Surgical versus non-surgical management of pleural empyema

BACKGROUND

Pleural empyema is a collection of pus between the lungs and the chest wall. There is debate about treatment options with the advent of both fibrinolytic enzymes to facilitate tube drainage and less invasive video-assisted thoracoscopic surgery (VATS).

OBJECTIVES

To determine which was more effective: surgical (using thoracoscopy or thoracotomy) or non-surgical techniques (thoracocentesis, chest tube drainage); and to establish whether there was an optimum time for intervention.

SEARCH STRATEGY

In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005) MEDLINE (January 2002 to July Week 4, 2005) and EMBASE (January 2001 to 3rd Quarter 2005). Bibliographies, reference lists of identified studies and review articles were handsearched. Personal communication with authors is ongoing. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed using Jadad criteria (Jadad 1996). Authors were contacted for missing information. The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed the length of time chest tubes were required, pain, hospital stay and any complications.

MAIN RESULTS

Only one small randomised study was identified. Some methodological quality considerations cast doubt on the validity of the study with regard to patient selection, unclear allocation concealment and outcome assessor blinding and it scored 'B' overall (Jadad score 3). When compared with chest tube drainage combined with streptokinase, video-assisted thoracoscopic surgery (VATS) had a significantly higher primary treatment success and patients spent less time in hospital. Each treatment group suffered one mortality. The latest search revealed no further published randomised studies but communication with authors revealed two ongoing studies comparing conventional chest tube drainage plus antibiotics with and without fibrinolytics with video-assisted thorascopic surgery (VATS). A small unpublished study is awaiting assessment that compared chest tube drainage and antibiotics with thoracoscopy or thoracotomy plus antibiotics.

AUTHORS' CONCLUSIONS

It seems that for large, loculated pleural empyemas VATS is superior to chest tube drainage in terms of duration of chest tubes in situ and length of hospital stay. However, there are questions about validity in the one study which met the inclusion criteria and the study has too few participants to draw conclusions. There are risks of complications (associated with all treatments) which may not be apparent with small numbers. Larger studies are needed.

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.

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.

Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis

OBJECTIVE

The optimal treatment of children with empyema remains controversial. The purpose of this review was to compare reported results of nonoperative and primary operative therapy for the treatment of pediatric empyema.

METHODS

A systematic comprehensive review of the scientific literature was conducted with the PubMed (National Library of Medicine) database for the period from 1981 to 2004. This reproducible search identified all publications dealing with treatment of empyema in the pediatric population (<18 years of age). A meta-analysis was performed with studies with adequate data summaries for > or =1 of the outcomes of interest for both treatment groups.

RESULTS

Sixty-seven studies were reviewed. Data were aggregated from reports of children initially treated nonoperatively (3418 cases from 54 studies) and of children treated with a primary operative approach (363 cases from 25 studies). The populations were similar in age. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs 3.3%), reintervention rate (2.5% vs 23.5%), length of stay (10.8 vs 20.0 days), duration of tube thoracostomy (4.4 vs 10.6 days), and duration of antibiotic therapy (12.8 vs 21.3 days), compared with patients who underwent nonoperative therapy. In 8 studies for which meta-analysis was possible, patients who received primary operative therapy were found to have a pooled relative risk of failure of 0.09, compared with those who did not. Meta-analysis could not be performed for any of the other outcome measures investigated in this review. Similar complication rates were observed for the 2 groups (5% vs 5.6%).

CONCLUSIONS

These aggregate results suggest that primary operative therapy is associated with a lower in-hospital mortality rate, reintervention rate, length of stay, time with tube thoracostomy, and time of antibiotic therapy, compared with nonoperative treatment. The meta-analysis demonstrates a significantly reduced relative risk of failure among patients treated operatively.

Medical management of parapneumonic pleural disease

Considerable heterogeneity exists in the management of parapneumonic pleural disease. A randomized controlled trial (RCT) demonstrated the effectiveness of small-catheter drainage with fibrinolysis, but surgical devotees suggest this may only be applicable to "early" cases. We examined evidence-based medical management in "all-comers." We performed a retrospective database analysis of the management of all children with complex pleural effusion admitted to the John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten children were admitted. Ten were excluded as they were part of a multicenter RCT and had received intrapleural saline instead of urokinase. Of the remaining 100, 51 were female and 49 male. Median age on admission was 5.8 years (range, 0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common month for presentation. Ninety-six underwent chest ultrasound, confirming an effusion in all, described as loculated/septated (68) or echogenic (11). In 17 cases, no specific comment was made regarding the nature of the fluid seen on ultrasound. Ninety-five had subsequent chest tube drainage and then received intrapleural fibrinolysis with urokinase. An etiological organism was identified in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5, Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid microscopy, but did not grow on culture. Two (2%) required surgery due to the persistence of symptoms and an inadequate response to medical management. Median duration of admission was 7 days (range, 2-21 days); median duration of stay from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks (range, 3-20 weeks), all children were symptom-free, with minimal pleural thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain insertion and intrapleural urokinase is effective in treating complex parapneumonic effusion and is associated with a good long-term outcome.

The changing face of pleural empyemas in children: epidemiology and management

OBJECTIVE

Empyema remains a significant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-assisted thoracoscopy (VATS).

METHODS

A retrospective chart review was performed on all patients who were discharged with a diagnosis of empyema and community-acquired pneumonia over a 10-year period (1993-2002) at Texas Children's Hospital in Houston, Texas. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course.

RESULTS

A total of 230 charts were available for review. The mean age of the patients was 4.0 +/- 3.6 years. Of the pleural fluid cultures performed, 32% (69 of 219) were positive. An additional 27 patients had a cause identified by blood culture. The first penicillin-nonsusceptible Streptococcus pneumoniae was identified in 1995, and the first methicillin-resistant Staphylococcus aureus was identified in 1998. After the universal use of the pneumococcal conjugate vaccine, 3 major changes have occurred (1999-2000 vs 2001-2002): 1) the number of patients admitted with empyema (per 10 000 admissions) has decreased from 23 to 12.6; 2) the prevalence of S pneumoniae has decreased from 66% (29 of 44) to 27% (4 of 15); and 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization (11.49 +/- 6.56 days vs 15.18 +/- 8.62 days).

CONCLUSIONS

The microbiologic cause of empyema has changed with an increasing incidence of S aureus, particularly methicillin-resistant S aureus. The use of VATS for initial therapy of empyema results in decreased duration of fever and length of hospitalization.

Toracocentese esvaziadora com irrigação e uso de antimicrobiano intrapleural no tratamento do empiema

INTRODUÇÃO: O empiema é uma doença grave caracterizada classicamente pela presença de pus na cavidade pleural. Seu reconhecimento precoce exige tratamento imediato, porém ainda existe grande controvérsia em relação à melhor terapêutica. OBJETIVO: Analisar o tratamento do empiema através de toracocentese, irrigação do espaço pleural, e uso de antimicrobiano intrapleural. MÉTODO: Foram avaliados dezessete pacientes com diagnóstico de empiema pleural livre ou septado, no período de janeiro de 1999 a maio de 2000, nos quais foi realizada toracocentese esvaziadora, seguida de lavagem exaustiva da cavidade pleural com solução isotônica e administração intrapleural de agente antimicrobiano não irritante à pleura. RESULTADOS: Foram analisados 15 homens e 2 mulheres com idade média de 44 anos. Os sinais clínicos mais freqüentes foram febre, tosse produtiva, dor torácica e dispnéia. A causa mais comum foi pneumonia. Macroscopicamente, 12 pacientes apresentavam líquido pleural francamente purulento. O agente etiológico foi identificado em quatro casos (26,67%), sendo o mais frequente o Staphylococcus sp. Dois pacientes foram encaminhados para decorticação pulmonar e foram excluídos do estudo. O tempo médio de internação foi de 15,1 dias, sendo que três pacientes realizaram o protocolo ambulatorialmente. Não observamos recidiva com o método e todos os pacientes sobreviveram. CONCLUSÃO: Essa abordagem diminuiu a necessidade de outros procedimentos invasivos. Mostrou-se eficaz, segura e com baixa morbi-mortalidade em comparação com as demais modalidades terapêuticas.

Technique de drainage à thorax fermé d'une pleurésie purulente

In purulent pleuresia, thoracenthesis is the gold standard treatment. Fiblinolytics should be infused through the drain at an early stage in order to prevent or treat fibrotic encystement. The cause of the pleuresia should be treated parallely to the drainage.

Does VATS provide optimal treatment of empyema in children? A systematic review

PURPOSE

The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children.

METHODS

The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies.

RESULTS

Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P =.003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P =.055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement.

CONCLUSIONS

Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.

Treatment of Complicated Parapneumonic Pleural Effusion With Intrapleural Streptokinase in Children

OBJECTIVE

To evaluate the role of intrapleural streptokinase in the management of complicated parapneumonic effusions in children.

DESIGN

Prospective comparative study.

SETTING

Cheng Kung University Hospital, a tertiary medical center in Tainan, Taiwan.

PATIENTS AND METHODS

We enrolled as our prospective study group 20 consecutive children with complicated parapneumonic effusions who received intrapleural streptokinase treatment between August 2000 and July 2002. We also retrospectively analyzed a comparison group of 22 consecutive children with complicated parapneumonic effusions who received chest tube drainage without streptokinase treatment from January 1992 to July 2000. We then compared the clinical manifestations and outcome of these two patient groups. The patient population (21 boys and 21 girls) ranged in age from 9 to 130 months (mean age, 41.5 +/- 26.3 months [mean +/- SD]). The characters of pleural effusion showed no difference between the two groups. Nineteen patients had positive findings for Streptococcus pneumoniae, 2 patients had positive findings for Staphylococcus aureus, 2 patients had positive findings for Pseudomonas aeruginosa, and 19 patients had undetermined pathogens. All patients were treated with appropriate antibiotics.

RESULTS

More pleural fluid was drained from the streptokinase group than from the comparison group during streptokinase treatment (816 +/- 481 mL vs 279 +/- 238 mL, p < 0.01). The duration of fever after chest tube insertion was also significantly lower in the study group (5.3 +/- 3.1 days vs 7.9 +/- 4.6 days, p < 0.05). Only two patients in the streptokinase group required surgical intervention compared with nine patients in the comparison group (p < 0.05). No major side effects were noticed after streptokinase instillation.

CONCLUSION

Intrapleural fibrinolytic treatment with streptokinase is safe and effective, and it can obviate the need for surgery in most cases. The combination treatment should be attempted early on, when complicated parapneumonic effusion is first diagnosed.

Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia

AIMS

To study the clinical and microbial profile of childhood empyema in South Asia and to identify the changes over the past three decades.

METHODS

A total of 265 children (aged 1 month to 12 years) with empyema admitted to the Advanced Pediatric Center, PGIMER, Chandigarh, India in 1989-98, were reviewed retrospectively.

RESULTS AND CONCLUSIONS

One third of children were under 5. Culture positivity had decreased significantly (48% v 75%) over the years. Staphylococcus aureus continues to be the commonest (77%) aetiological agent; clustering was seen during hot and humid months (46%). Culture positive Streptococcus pneumoniae cases also decreased (9% v 27%); all were seen during the winter and spring season. Gram negative rods grew in more patients (11% v 7%). Community acquired methicillin resistant S aureus (MRSA) was isolated in three patients. Most children (93%) were treated with parenteral cloxacillin and an aminoglycoside. Tube drainage (TD) was used in 92% of fibropurulent cases, and was successful in 79%. Of 48 patients with failed TD, 12 needed decortication; limited thoracotomy was sufficient in the remaining 36. Surgery was mainly required by children with persistent pleural sepsis after 10 days of TD. Delaying surgery until 14 days had a significantly higher potential of requiring decortication. Early change to oral antibiotics (after 1-2 weeks of parenteral therapy) reduced the hospital stay significantly (17+7 v 23+7 days) without compromising long term outcome. Twenty two patients presenting late in the chronic stage underwent decortication at admission.