CME Review
Treatment approaches for empyema in children

https://doi.org/10.1016/j.prrv.2007.05.002Get rights and content

Summary

Empyema is an important cause of childhood morbidity with an increasing worldwide incidence. Despite many treatment options being available, there is no general consensus on the optimal management approach due to conflicting reports and lack of properly conducted studies to challenge the personal bias of a physician or surgeon. The reason for this is likely to be the fact that, irrespective of the treatment children receive, they ultimately make an excellent clinical recovery. This review summarises the current evidence and evaluates the clinical efficacy of various treatment modalities in the context of relevant outcome measures in an attempt to demonstrate the differences in treatment options for the child with empyema.

Section snippets

Potential prognostic factors and outcome measures

Prognostic factors that may determine the course of the disease include: initial white cell counts; C-reactive protein levels; the radiological appearance, including ultrasonographic changes, which are useful in staging the disease; identification of the causative organism; and pleural fluid biochemistry including lactate dehydrogenase, pH, glucose and protein.5 However, although factors such as the biochemical composition of the pleural fluid are used to guide management in adults, there are

Antibiotics alone

Several studies have suggested that chest tube drainage may not be necessary in children if appropriate antibiotic therapy and supportive care are provided, particularly in those with smaller (less than 10 mm thickness) pleural collections.6, 7 Data from these studies indicate that patients who present with smaller pleural collections will have a similar length of hospital stay if treated by either antibiotics alone or operative interventions. However, these studies were retrospective and had

Discussion

The limited prospective studies reviewed above demonstrate that all the treatment options currently available are effective and safe in the treatment of childhood empyema. The controversy surrounding optimal treatment is increased by the lack of uniformity in outcome variables and the heterogeneity of the study population. The most consistently reported outcome measure is hospital stay after intervention. Hospital stay in the studies using intrapleural urokinase13, 15 compare favourably with

Pneumococcal prevention

Pneumococcus is the primary cause of community-acquired pneumonia and empyema in the developed world. The UK has recently introduced routine childhood immunisation with the heptavalent pneumococcal conjugate vaccine, but this vaccine does not contain the antigen for serotype 1. Although the introduction of this vaccine in the USA in 2001 has significantly reduced invasive pneumococcal disease in children, an increase in the number of cases of empyema has been reported.21 The disease in the

Conclusion

It is clear that, irrespective of the intervention a child receives, the clinical outcome is excellent. In order to refine our choices of treatment and our inherent biases, there is a need for prospective studies to be conducted to directly compare available treatment options with additional long-term outcome measures such lung function. In an era of health rationalisation, cost analysis becomes increasingly important and should be included in these studies.

Educational Aims

  • To emphasise that childhood empyema has a different clinical course from adult empyema.

  • To discuss the various treatment modalities in childhood empyema.

  • To assess which treatment is better in the context of available outcome measures.

Key points

  • Limited evidence is available for the optimal management approach in childhood empyema.

  • Intrapleural urokinase has a similar outcome to video-assisted thoracoscopic surgery and is 25% cheaper.

  • Streptococcus pneumoniae is the most common pathogen in developed countries, and Staphylococcus aureus the most common in the developing world

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