We previously reported that approximately half of children hospitalized with empyema recovered uneventfully with antibiotics alone, e.g. without pleural drainage (Chest 2006;130(4):139S). In 2005 we implemented a guideline that recommended initial treatment with antibiotics alone in medically stable patients, and we have now collected data through year 2008. Our purpose is to report our 12-year experience with the management of pediatric empyema and to propose predictors for undergoing pleural drainage.
This is a retrospective review of 182 previously healthy children, 1–18 years old, hospitalized with moderate - large empyemas from 1996–2008. An effusion was moderate if it filled between ¼ - ½ of the hemi-thorax and large if it occupied > ½ of the hemi-thorax. Medically stable patients, e.g. not in the intensive care unit and no whiteout of the hemi-thorax with mediastinal shift, were treated with antibiotics alone. If the patient's clinical condition did not improve within 48–72 hours, either a chest tube was placed or VATS was done. Primary outcome measures were the proportion of patients requiring pleural drainage procedures and hospital length of stay (LOS).
Ninety-five children (55%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS, and 8 chest tube followed by VATS). Mean(SD) LOS was significantly shorter in the antibiotics alone group, 7.0(3.5) vs. 11(4.0) days. Logistic regression analysis identified the strongest predictors of undergoing pleural drainage to be admission to the intensive care unit, large effusion size, and mediastinal shift noted on radiograph.
We found that many children with empyema, especially those with moderate-sized effusions and stable clinical conditions, could be successfully treated with antibiotics alone but that those who required intensive care and/or had large effusions with mediastinal shift were likely to require pleural drainage.
Pleural effusion size, the presence/absence of mediastinal shift, and a patient's clinical condition can be used to help determine which children with empyema can be treated with antibiotics alone and avoid pleural drainage.
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