Thoracic empyema in children: Clinical presentation, microbiology analysis and therapeutic options

doi:10.1016/j.jiac.2013.12.006

Journal of Infection and Chemotherapy

Volume 20, Issue 4, April 2014, Pages 262-265

https://doi.org/10.1016/j.jiac.2013.12.006 Get rights and content

Abstract

Thoracic empyema is an accumulation of purulent fluid in the pleural space presenting as a complication of bacterial pneumonia. The aims of the study were to present the incidence, demographic results, clinical presentation, laboratory and microbiology results, imaging and the therapeutic options. From January 1992 until December 2009 we collected data of children hospitalized with empyema in our medical center in north of Israel. Empyema was found in 53 pediatric patients. The median age of the patients was 3 years and 31 (58%) were male. Forty one (77%) of the cases were diagnosed in the last nine years. Fever, cough and respiratory distress were the most frequent clinical signs. In 29 (55%) patients pleural effusion was found at admission. Chest ultrasound was performed in 44 (83%) of the patients. Causative organisms were confirmed by culture in 35 patients. Positive culture was found in 17 (32%) patients in the pleural fluid. Streptococcus pneumoniae was the leading pathogen. The drugs the patients received at admission were penicillin in 21 cases, cefuroxime in19 cases and ceftriaxone in 11 cases. During hospitalization a change of antibiotic therapy was required, using mainly ceftriaxone and clindamycin. The pleural purulent fluid was drained by video assisted thoracoscopy surgery in 34 (64%) patients. All the children recovered. The incidence of empyema as a complication of community acquired pneumonia had increased in the last decade in our region. Streptococcus pneumoniae is the most common pathogen. Third generation cephalosprins and clindamycin can be suggested as a good empiric treatment.

Introduction

Thoracic empyema is an accumulation of purulent fluid in the pleural space as a result of a complicated pneumonia. The pus contains leukocytes, bacteria and cellular debris. In the fibrinopurulent stage usually low pH, below 7.20, and high LDH above 1000 IU can be found. The most frequent pathogens that cause thoracic empyema include Streptococcus pneumoniae, Staphylococcus aureus, Group A Streptococcus and rarely Haemophilus influenzae type b [1], [2], [3], [4]. Several reports have shown an increase in the incidence of thoracic empyema in children worldwide [5], [6], [7]. This increased incidence of empyema occurred despite the decrease in the incidence of pneumonia following the introduction of conjugate pneumococcal vaccine [5].

The treatment of thoracic empyema depends on the clinical presentation and the stage of the disease. The initial treatment of empyema is to begin empiric antibiotic therapy for prompt eradication of the causative organism; the second step is directed to drain the purulent fluid in order to restore pleural fluid circulation, allow lung re-expansion and improve lung function [8].

Several options of interventional treatment are suggested beside the antibiotic therapy. The first option of invasive treatment is thoracocentesis or chest tube insertion with or without performing pleural rinsing with a fibrinolytic agent. An alternative option is the performance of video assisted thoracoscopy surgery (VATS) or even open decortication [8], [9], [10], [11].

The goals of the present study are to describe the incidence, clinical symptoms and results of blood and pleural fluid cultures in a cohort of children hospitalized in a regional medical center, in the last 18 years, with the diagnosis of thoracic empyema, as a complication of community acquired pneumonia. The invasive therapeutic procedures performed were also reported.

Section snippets

Patients and methods

From January 1992 until December 2009 we collected data of all the hospitalized children with the diagnosis of thoracic empyema. The patients were admitted to our medical center, which is a regional hospital who serves the population in north-east Israel. The increase of new patients admitted from the initiation of the study till year 2009 is only 7%.

Patient's age was till age 18 years, according to the department admission policy. The diagnosis of thoracic empyema was based on three criteria:

Results

Data of 53 patients was summarized, 34 (64%) were of Jewish origin and 19 (36%) of Arabic origin. The median patients age was 3 years (Mean 4.9 ± 4.1 ys, range 1–16 ys) and 31 (58%) were male. None of the patients included in the study was previously vaccinated with conjugated pneumococcal vaccine before being admitted with empyema. Forty one cases (77%), were diagnosed in the last nine years; this increase of incidence is shown in Fig. 1. The most frequent clinical signs on admission included

Discussion

In the last decade we have observed an increase in the incidence of empyema in children compared to the relatively low frequence in the past. Several reports have also shown increased incidence of empyema in the US and Europe. Two reports have found similar increment in children despite conjugated pneumococcal vaccination [5], [7] while another report published by Van Ackere et al. [12] showed increased incidence of empyema in children before the implementation of the pneumococcal vaccine.

Conclusions

We found an increase in the incidence of empyema in our region during the last decade. S. pneumoniae, S. aureus and Group A Streptococcus were the most frequent isolated pathogens. Empyema is a severe complication of pneumonia and there is a need to initiate treatment with broad spectrum antibiotics as ceftriaxone alone or plus clindamycin in order to give adequate empiric cover against these pathogens. In the presence of treatment failure or in cases with moderate or large pleural effusion

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Community acquired pneumonia (CAP) is a leading cause of childhood morbidity worldwide. Because of the rising antimicrobial resistance rates and adverse effects of childhood antibiotic use on the developing microbiome, rational prescribing of antibiotics for CAP is important. This review summarizes and critically reflects on the available evidence for the epidemiology, etiology and antimicrobial management of childhood CAP. Larger prospective studies on antimicrobial management derive mostly from low- or middle-income countries as they have the highest burden of CAP. Optimal antimicrobial management depends on the etiology, age, local vaccination policies and resistance patterns. As long as non-rapid surrogate markers are used to distinguish viral- from bacterial pneumonia, the management is probably suboptimal. For a young child with signs of non-severe pneumonia (with or without wheezing), watchful waiting is recommended because of probable viral etiology. For children with more severe CAP with fever, a five-day oral amoxicillin course would be the first choice therapy and dosage will depend on local resistance rates. There is no clear evidence yet for superiority of a macrolide-based regimen for all ages. For cases with CAP requiring hospitalization, several studies have shown that narrow-spectrum IV beta-lactam therapy is as effective as a broad-spectrum cephalosporin therapy. For most severe disease, broad-spectrum therapy with or without a macrolide is suggested. In case of empyema, rapid IV-to-oral switch seems to be equivalent to prolonged IV treatment.
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A significant increase in the incidence of PPE/PE in children with CAP treated in our institution in the last twelve years was found. S. pneumoniae was the most common causative microorganism. Antibiotic therapy with chest drain insertion ± intrapleural fibrinolysis is an effective treatment of PPE/PE and surgical intervention is seldom necessary. With proper management, the overall prognosis in children with CAP related PPE/PE is good.
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Original articleThoracic empyema in children: Clinical presentation, microbiology analysis and therapeutic options

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

J Pediatr Surg

Paediatr Respir Rev

J Pediatr Surg

Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids

Clin Infect Dis

Incidence and etiologies of complicated parapneumonic effusions in children, 1996 to 2001

Pediatr Infect Dis J

Complicated community acquired pneumonia in children prior to the introduction of the pneumococcal conjugated vaccine

Scand J Infect Dis

Management of parapneumonic effusion and empyema

Arch Dis Child

Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine

Pediatrics

Increasing pediatric empyema admissions

Thorax

Increasing incidence of empyema complicating childhood community – acquired pneumonia in the United States

Clin Infect Dis

Management of empyema in children

Pediatr Pulmonol

Update on the causes, investigation and management of empyema in childhood

Arch Dis Child

BTS guidelines for the management of pleural infection in children

Thorax

Original article
Thoracic empyema in children: Clinical presentation, microbiology analysis and therapeutic options