The Indian Journal of Pediatrics

, Volume 86, Issue 2, pp 140–147 | Cite as

Predicting Complicated Parapneumonic Effusion in Community Acquired Pneumonia: Hospital Based Case-Control Study

  • Meganathan P
  • Shally AwasthiEmail author
Original Article



To identify predictors of complicated parapneumonic effusion (CPE)/empyema in patients of community acquired pneumonia (CAP) by using clinical and simple laboratory variables like hemoglobin (Hb), serum C-reactive protein (CRP), serum albumin (SA) levels and total leukocyte counts (TLC).


This prospective case-control study was conducted after institutional ethical approval. Subjects between ages of 2–59 mo with World Health Organization (WHO) defined CAP with written, informed parental consent were included. Cases had CAP with CPE/empyema diagnosed by pleurocentesis. Controls had severe CAP without significant pleural collection on chest X-ray (CXR). Patients with congenital and chronic diseases/infections and possible immune deficiency were excluded. Variables with univariate association with case-control status were considered as potential predictors. Final prediction model was developed by Forward Stepwise Logistic Regression (FSLR). Adjusted odd’s ratios (Adj OR) were smoothened into nearest whole numbers to develop KGMU-CPE score.


From 2016 to 17, 30 cases (66.6% males, age 38.7 + 14.9 mo) and 118 controls (78% males, age 17.8 + 16.9 mo) were included. In FSLR, predictors of CPE/empyema were ibuprofen intake (adj OR 6.8; 95%CI: 1.07–43.6), infective focus elsewhere (adj OR 28.2; 95%CI: 1.4–563.1), hypoalbuminemia <3.1 g/dL (adj OR 6.9; 95%CI: 1.22–39.3), serum CRP >20 mg/dL (adj OR 59; 95%CI: 1.86–1874.7), Hb <10 g/dL (adj OR 21.1; 95%CI: 2.8–158.1) and TLC >10,000 (adj OR 37; 95%CI: 5.7–239.8) and these six variables formed KGMU-CPE Score with a minimum score of 0 and maximum of 25. KGMU-CPE score area under the ROC curve was 0.97 and cut- off 15.55 had sensitivity of 80% and specificity of 94% for predicting CPE/empyema.


Using simple clinical and laboratory parameters it is possible to predict CAP with CPE/empyema. Use of ibuprofen is to be avoided in CAP as it associated with CPE. KGMU-CPE score had good diagnostic accuracy and needs external validation.


Community acquired pneumonia Children Complicated parapneumonic effusion Empyema Predictors KGMP-CPE score 


Authors' Contributions

SA: Conceptualization. Both authors are responsible for data collection, analysis and writing the manuscript. This was MD thesis work of Meganathan P. SA will act as guarantor for this paper.

Compliance with Ethical Standards

Conflict of Interest



  1. 1.
    World Health Organization (WHO) Pneumonia Fact Sheet. Updated September 2016, Available at: Accessed on 26th June 2018.
  2. 2.
    Krenke K, Krawiec M, Kraj G, Peradzynska J, Krauze A, Kulus M. Risk factors for local complications in children with community-acquired pneumonia. Clin Respir J. 2018;12:253–61.CrossRefGoogle Scholar
  3. 3.
    Maziah W, Choo KE, Ray JG, Ariffin WW. Empyema thoracis in hospitalized children in Kelantan, Malaysia. J Trop Pediatr. 1995;41:185–8.Google Scholar
  4. 4.
    Mishra OP, Das BK, Jain AK, Lahiri TK, Sen PC, Bhargara V. Clinico-bacteriological study of empyema thoracis in children. J Trop Pediatr. 1993;39:380–1.CrossRefGoogle Scholar
  5. 5.
    Deiros Bronte L, Baquero-Artigao F, García-Miguel MJ, Hernández González N, Peña García P, del Castillo Martín F. Parapneumonic pleural effusion: an 11-year review. An Pediatr (Barc). 2006;64:40–5.CrossRefGoogle Scholar
  6. 6.
    Anstadt MP, Guill CK, Ferguson ER, et al. Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis. Am J Med Sci. 2003;326:9–14.Google Scholar
  7. 7.
    Dass R, Deka NM, Barman H, et al. Empyema thoracis: analysis of 150 cases from a tertiary care Centre in north East India. Indian J Pediatr. 2011;78:1371–7.Google Scholar
  8. 8.
    Strange C, Tomlinson JR, Wilson C, Harley R, Miller KS, Sahn SA. The histology of experimental pleural injury with tetracycline, empyema, and carrageenan. Exp Mol Pathol. 1989;51:205–19.CrossRefGoogle Scholar
  9. 9.
    Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med. 1998;19:363–71.CrossRefGoogle Scholar
  10. 10.
    World Health Organization. Revised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries. Available at: Accessed on 26th June 2018.
  11. 11.
    Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax. 2005;60:i1–21.CrossRefGoogle Scholar
  12. 12.
    FAO, WHO. World Declaration and Plan of Action for Nutrition. International Conference on Nutrition. Rome, Food and Agriculture Organization of the United Nations, December 1992. Available at: Accessed on 26th June 2018.
  13. 13.
    Prais D, Kuzmenko E, Amir J, Harel L. Association of hypoalbuminemia with the presence and size of pleural effusion in children with pneumonia. Pediatrics. 2008;121:e533–8.CrossRefGoogle Scholar
  14. 14.
    Niemi E, Korppi M. Parapneumonic empyema in children before the era of pneumococcal vaccination. Acta Paediatr. 2011;100:1230–3.CrossRefGoogle Scholar
  15. 15.
    World Health Organization. Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. Available at: Accessed on 26th June 2018.
  16. 16.
    WHO Multicentre Growth Reference Study Group. WHO child growth standards: length/ height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva: World Health Organization; 2006.Google Scholar
  17. 17.
    Prober CG, Srinivas NS, Mathew R. Central nervous system infections. In: Kleigman, Staton, St Geme, et al editors. Nelson Text book of Pediatrics, 20th ed. Philadelphia: Elsevier; 2016. p. 2936–46.Google Scholar
  18. 18.
    Raosoft Sample size Calculator. Available at: Accessed on 2nd August 2016.
  19. 19.
    Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest. 2000;118:1158–71.Google Scholar
  20. 20.
    François P, Desrumaux A, Cans C, Pin I, Pavese P, Labarère J. Prevalence and risk factors of suppurative complications in children with pneumonia. Acta Paediatr. 2010;99:861–6.CrossRefGoogle Scholar
  21. 21.
    Le Bourgeois M, Ferroni A, Leruez-Ville M, et al. Nonsteroidal anti-inflammatory drug without antibiotics for acute viral infection increases the empyema risk in children: a matched case-control study. J Pediatr. 2016;175:47–53.CrossRefGoogle Scholar
  22. 22.
    Mazaleuskaya LL, Theken KN, Gong L, et al. PharmGKB summary: ibuprofen pathways. Pharmacogenet Genomics. 2015;25:96–106.Google Scholar
  23. 23.
    Stevens DL. Could nonsteroidal anti-inflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock syndrome? Clin Infect Dis. 1995;21:977–80.CrossRefGoogle Scholar
  24. 24.
    Solberg CO. Influence of phenylbutazone on the phagocytic and bactericidal activities of neutrophil granulocytes. Acta Pathol Microbiol Scand B: Microbiol Immunol. 1974;82:258–62.Google Scholar
  25. 25.
    Factor SH, Levine OS, Harrison LH, et al. Risk factors for pediatric invasive group a streptococcal disease. Emerg Infect Dis. 2005;11:1062–6.Google Scholar
  26. 26.
    Dilber E, Cakir M, Kalyoncu M, Okten A. C-reactive protein: a sensitive marker in the management of treatment response in parapneumonic empyema of children. Turkish J Pediatr. 2003;45:311–4.Google Scholar
  27. 27.
    Hsieh YC, Hsueh PR, Chun-Yi L, Lee PI, Lee CY, Huang LM. Clinical manifestations and molecular epidemiology of necrotizing pneumonia and empyema caused by Streptococcus pneumoniae in children in Taiwan. Clin Infect Dis. 2004;38:830–5.CrossRefGoogle Scholar
  28. 28.
    Izhakian S, Wasser WG, Fox BD, Vainshelboim B, Kramer MR. The diagnostic value of the pleural fluid C-reactive protein in parapneumonic effusions. Dis Markers. 2016;2016:7539780.CrossRefGoogle Scholar
  29. 29.
    Wexler ID, Knoll S, Picard E, et al. Clinical characteristics and outcome of complicated pneumococcal pneumonia in a pediatric population. Pediatr Pulmonol. 2006;41:726–34.Google Scholar
  30. 30.
    Kopec JA, Esdaile JM. Bias in case-control studies. A review. J Epidemiol Community Health. 1990;44:179–86.Google Scholar
  31. 31.
    Laupacis A, Sekar M, Stiell IG. Clinical prediction rules: a review and suggested modifications of methodological standards. JAMA. 1997;277:488–94.CrossRefGoogle Scholar
  32. 32.
    Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision-making in physical therapist practice. Phys Ther. 2006;86:122–31.CrossRefGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2018

Authors and Affiliations

  1. 1.Department of PediatricsKing George’s Medical UniversityLucknowIndia

Personalised recommendations