PURPOSE: We wished to identify factors predisposing to pleural fluid drainage in children hospitalized with pneumonia/parapneumonic effusion (empyema). We also analyzed differences in outcomes of patients treated with drainage procedures vs. antibiotics alone.
METHODS: A retrospective review identified 88 previously healthy children, 1-18 years-old, treated for empyema between 1997-2004. The standard management was IV antibiotics first and then if there was no improvement over several days to place a chest tube (CT) or perform video-assisted thoracoscopic surgery (VATS). Thoracentesis and fibrinolytics were used sparingly. We evaluated potential risk factors for requiring intervention (CT or VATS), including mediastinal shift, effusion size, and fluid loculations. We analyzed differences in outcomes, e.g. length of hospital stay (LOS), based on the intervention received.
RESULTS: Of the 88 children (mean age 6.4 yrs), 48 (55%) were treated with antibiotics alone, and 40 (45%) underwent CT and/or VATS (14 CT alone, 20 VATS alone, and 6 CT followed by VATS). A higher percentage of children undergoing CT and/or VATS had large pleural effusions than did those who were treated with IV antibiotics alone, but there were no significant differences in the proportion with loculations or mediastinal shift. Compared to children receiving CT and/or VATS, those treated with antibiotics alone had shorter LOS, 7.5(SD,3.5) vs. 10.4(3.9) days, shorter duration of IV abx treatment, 9.1(5.2) vs. 12.0(3.8) days, and fewer hospital days with fever, 4.2(3.0) vs. 6.8(2.9); p < 0.005 for all comparisons.
CONCLUSION: Many children with empyema can be treated with antibiotics alone. Those with large effusions are more likely to undergo drainage procedures. Chest tube placement may not prevent the need for VATS. We were unable to assess the use of early intervention with fibrinolytics.
CLINICAL IMPLICATIONS: In medical centers that are comfortable performing VATS, most children with empyema can initially be treated with IV antibiotics alone and then proceed directly to VATS if they do not clinically improve. We are in the process of formally implementing and evaluating this strategy at our institution.
DISCLOSURE: Edward Carter, None.