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Clinical practice: treatment of childhood empyema

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Abstract

Introduction

The incidence of empyema in children is increasing. Adequate knowledge of treatment modalities is therefore essential for every pediatrician. At the university hospital of Leuven, the incidence per 100,000 admissions increased from 40 in 1993 to 120 in 2005. The treatment of choice, however, is still a matter of debate. This is mainly due to the scarcity of prospective randomized trials in children but is further complicated by the absence of uniform terminology. This review starts with clarifying definitions of empyema and complicated versus noncomplicated parapneumonic effusion. The place of different imaging techniques—ultrasound, chest X-ray, computerized tomography and magnetic resonance imaging—is illustrated. All treatment steps are evaluated starting with antibiotic choices, duration of i.v. and oral antibiotics, pleural fluid analysis, indications for chest drain placement, and fibrinolysis. As to the surgical interventions, there is at present insufficient evidence that early surgery is superior to noninvasive medical treatment. Therefore, video-assisted thoracoscopy cannot be advised as general first-line therapy.

Conclusion

Since the pathogenicity of empyema is a dynamic process, therapeutic strategy must be decided based on empyema stage and clinical experience. Each referral center should agree on a diagnostic and therapeutic flowchart based on current evidence and local expertise. The flow chart outlined for our center is presented.

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Abbreviations

PE:

parapneumonic effusion

CPE:

complicated parapneumonic effusion

UPE:

uncomplicated parapneumonic effusion

VATS:

video-assisted thoracoscopic surgery

BTS:

British Thoracic Society

References

  1. Avansino JR, Goldman B, Sawin RS et al (2005) Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics 115:1652–1659

    Article  PubMed  Google Scholar 

  2. Balfour-Lynn IM, Abrahamson E, Cohen G et al (2005) BTS guidelines for the management of pleural infection in children. Thorax 60(Supll I):i1–i21

    Article  PubMed  Google Scholar 

  3. Bekri H, Cohen R, Varon E et al (2007) Streptococcus pneumoniae serotypes involved in children with pleural empyemas in France. Arch Pediatr 14:239–504

    Article  PubMed  CAS  Google Scholar 

  4. Buckingham SC, King MD, Miller ML (2003) Incidence and etiologies of complicated parapneumonic effusions in children, 1996 to 2001. Pediatr Infect Dis J 22(6):499–504

    Article  PubMed  Google Scholar 

  5. Byington CL, Korgenski K, Daly J et al (2006) Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 25(3):250–254

    Article  PubMed  Google Scholar 

  6. Byington C, Spencer LY, Johnson TA et al (2002) An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Inf Dis 34:434–440

    Article  Google Scholar 

  7. Chiu C-Y, Wong K-S, Huang J-L et al (2006) Echo-guided management of complicated parapneumonic effusion in children. Pediatr Pulmonol 41:1226–1232

    Article  PubMed  Google Scholar 

  8. Chiu C-Y, Wong K-S, Huang J-L et al (2008) Proinflammatory cytokines, fibrinolytic system enzymes and biochemical indices in children with infectious para-pneumonic effusions. Pediatr Infect Dis J 27:699–703

    Article  PubMed  Google Scholar 

  9. De Boeck K, Vermeulen F, Vreys M et al (2008) Airway clearance techniques to treat acute respiratory disorders in previously healthy children: where is the evidence? Eur J Pediatr 167(6):607–612

    Article  PubMed  Google Scholar 

  10. Eastham KM, Freeman R, Kearns AM et al (2004) Clinical features, aetiology and outcome of empyema in children in the north east of England. Thorax 59:522–525

    Article  PubMed  CAS  Google Scholar 

  11. Epaud R, Aubertin G, Larroquet M et al (2006) Conservative use of chest-tube insertion in children with pleural effusions. Pediatr Surg Int 22:357–362

    Article  PubMed  CAS  Google Scholar 

  12. Gates R, Canioano DA, Hayes JR et al (2004) Does VATS provide optimal treatment of empyema in children: a systematic review. J Pediatr Surg 39:381–386

    Article  PubMed  Google Scholar 

  13. Hamm H, Light RW (1997) Parapneumonic effusion and empyema. Eur Resp J 10:1150–1156

    Article  CAS  Google Scholar 

  14. Hardie W, Bolulic R, Garcia VF et al (1996) Pneumococcal pleural empyemas in children. Clin Infect Dis 22:1057–1063

    PubMed  CAS  Google Scholar 

  15. Jaffe A, Calder AD, Owens CM et al (2008) The role of computed tomography in paediatric pleural empyema. Thorax 63:897–902

    Article  PubMed  CAS  Google Scholar 

  16. Karaman I, Erdoğan D, Karaman A et al (2004) Comparison of closed-tube thoracostomy and open thoracotomy procedures in the management of thoracic empyema in childhood. Eur J Pediatr Surg 14(4):250–254

    Article  PubMed  CAS  Google Scholar 

  17. Kearny SE, Davies CWH, Davies RJO et al (2000) Computed tomgraphy and ultrasound in parapneumonic effusions and empyema. CLin Radiol 55:542–545

    Article  Google Scholar 

  18. Light RW (1997) Diagnostic principles in pleural disease. Eur Respir J 10(2):476–481

    Article  PubMed  CAS  Google Scholar 

  19. Mitri RK, Brown SD, Zurakowski D et al (2002) Outcomes of primary image-guided drainage of parapneumonic effusion in children. Pediatrics 110:37–43

    Article  Google Scholar 

  20. Obando I, Munoz-ALmagro C, Arroyo LA et al (2008) Pediatric parapneumonic empyema. Emerg Infect Dis 14:1390–1397

    Article  PubMed  Google Scholar 

  21. Peltola V, Ruuskanen O, Svedström E (2008) Magnetic resonance imaging of lung infections in children. Pediatr Radiol 38:1225–1231

    Article  PubMed  Google Scholar 

  22. Playfor SD, Smyth AR, Stewart RJ (1997) Increase in incidence of childhood empyema. Thorax 52(10):932

    PubMed  CAS  Google Scholar 

  23. Poe RH, Marin MG, Israel RH et al (1991) Utility of pleural fluid analysis in predicting tube thoracostomy/decortication in parapneumonic effusions. Chest 100:963–967

    Article  PubMed  CAS  Google Scholar 

  24. Rahman NM, Mishra E, Davies H et al (2008) Clinically important factors influencing the diagnostic measurement of pleural fluid pH and glucose. Am J Resp Crit Care Med 178:483–490

    Article  PubMed  CAS  Google Scholar 

  25. Ramnath RR, Heller RM, Ben Ami T et al (1998) Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia. Pediatrics 101:68–71

    Article  PubMed  CAS  Google Scholar 

  26. Rees JH, Spencer DA, Parikh D et al (1997) Increase in incidence of childhood empyema in West Midlands, UK. Lancet 349(9049):402

    Article  PubMed  CAS  Google Scholar 

  27. Roberts JE, Bezack DO, Winger DI et al (2008) Association between pericardial effusion in a pediatric cohort. Pediatrics 122:1231–1235

    Article  Google Scholar 

  28. Satish B, Bunker M, Seddon P (2003) Management of thoracic empyema in childhood: does the pleural thickening matter? Arch Dis Child 88(10):918–921

    Article  PubMed  CAS  Google Scholar 

  29. Schultz KD, Fan LL, Pinsky J et al (2004) The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 113(6):1735–1740

    Article  PubMed  Google Scholar 

  30. Shoseyov D, Bibi H, Shatzberg G et al (2002) Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. (2002) 121(3):836–840

    Google Scholar 

  31. Sonnappa S, Cohen G, Owens CM et al (2006) Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 174(2):221–227

    Article  PubMed  Google Scholar 

  32. Tan TQ, Mason EO Jr, Wald ER et al (2002) Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumonia. Pediatrics 110(1Pt1):1–6

    Article  PubMed  Google Scholar 

  33. Tarago D, Fenoll A, Sanchez-Tatay D et al (2008) Identification of pneumococcal serotypes from culture-negative clinical specimens by novel real-time PCR. Clin Microbiol and Infection 14:828–834

    Article  Google Scholar 

  34. Thomson AH, Hull J, Kumar MR et al (2002) Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 57(4):343–347

    Article  PubMed  CAS  Google Scholar 

  35. Utine GE, Ozcelik U, Yalcin E et al (2005) Childhood parapneumonic effusions: biochemical and inflammatory markers. Chest 128(3):1436–1441

    Article  PubMed  CAS  Google Scholar 

  36. Utine GE, Pinar A, Özçelik U et al (2008) Pleural fluid PCR method for detection of Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae in pediatric parapneumonic effusion. Respiration 75:437–442

    Article  PubMed  CAS  Google Scholar 

  37. Van Ackere T, Proesmans M, Vermeulen F et al (2009) Complicated parapneumonic effusion in Belgian children: increased occurrence before routine pneumococcal vaccine implementation. Eur J Pediatr 168:51–58

    Article  PubMed  Google Scholar 

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The authors deny any conflict of interest

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Authors and Affiliations

  1. Department of Pediatric Pulmonology, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium

    Marijke Proesmans & Kris De Boeck

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  1. Marijke Proesmans
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  2. Kris De Boeck
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Correspondence to Marijke Proesmans.

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Proesmans, M., De Boeck, K. Clinical practice: treatment of childhood empyema. Eur J Pediatr 168, 639–645 (2009). https://doi.org/10.1007/s00431-009-0929-9

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  • DOI: https://doi.org/10.1007/s00431-009-0929-9

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