Pleural Empyema In Children Research Articles

Clinical presentations and complications of parapneumonic effusion and pleural empyema in children presenting in a tertiary care setup.

Objective: To evaluate the clinical presentations and complications of parapneumonic effusion (PPE) and pleural empyema (PE) in children presenting in a tertiary care setup in Karachi. Study Design: Cross-sectional study. Setting: Medical Units of National Institute of Child Health, Karachi, Pakistan. Period: July 2022 to June 2023. Material & Methods: Hospitalized children of either gender, aged between 1 month and 12 years diagnosed with PPE or PE on the basis of radiological findings were analyzed. Baseline laboratory investigations were done. Complications of PPE/PE were noted. Outcome was observed in the form of discharged, referred or mortality. Results: In a total of 86 with PPE/PE, 61.6% were boys while the overall mean age was 4.35±3.17 years. Common clinical symptoms included fever (100%), decreased air entry (86%), cough (75.6%), and respiratory difficulty (74.4%). Blood cultures revealed bacterial infections in 10.5% of cases, while most common isolates were Staphylococcus aureus and Pseudomonas. Positive pleural fluid cultures noted in 39.5% of cases while pseudomonas and staphylococcus aureus were the most common bacterial isolates. Most commonly used antimicrobials were Vancomycin, Ceftriaxone, Tazobactum+Piperacillin, and Linezolid. Tube thoracostomy was performed in 96.5% of patients. Most frequent complications of PPE/PE included residual organized empyema (36%), pneumothorax (9.3%), and sepsis (9.1%). Overall, the mortality was noted in 5.8% cases. Conclusion: Most frequent clinical presentations of PPE/PE include fever, cough, respiratory difficulty, and abdominal pain, with fever being universal. Staphylococcus aureus and Pseudomonas were the most common bacterial isolates. The most common complications were residual organized empyema, pneumothorax, and sepsis.

Pleural drainage vs video-assisted thoracoscopic debridement in children affected by pleural empyema

BackgroundBoth thoracic drainage and video-assisted thoracic surgery (VATS) are available treatment for pleural empyema in pediatric patients.Materials and methodsThis retrospective multicenter study includes pediatric patients affected by pleural empyema treated from 2004 to 2021 at two Italian centers. Patients were divided in G1 (traditional approach) and G2 (VATS). Demographic and recovery data, laboratory tests, imaging, surgical findings, post-operative management and follow-up were analyzed.Results70 patients with a mean age of 4.8 years were included; 12 (17.1%) in G1 and 58 (82.9%) in G2. Median surgical time was 45 min in G1, 90 in G2 (p < 0.05). Mean duration of thoracic drainage was 7.3 days in G1, 6.2 in G2 (p > 0.05). Patients became afebrile after a mean of 6.4 days G1, 3.9 in G2 (p < 0.05). Mean duration of antibiotic therapy was 27.8 days in G1, 25 in G2 (p < 0.05). Mean duration of postoperative hospital stay was 16 days in G1, 12.1 in G2 (p < 0.05). There were 4 cases (33.3%) of postoperative complications in G1, 17 (29.3%) in G2 (p > 0.05). 2 (16.7%) patients of G1 needed a redosurgery with VATS, 1 (1.7%) in G2.ConclusionsVATS is an effective and safe procedure in treatment of Pleural Empyema in children: it is associated to reduction of chest tube drainage, duration of fever, hospital stay, time of antibiotic therapy and recurrence rate.

Çocuklarda Plevral Ampiyemde Video Yardımlı Torakoskopik Dekortikasyonun Sonuçları

Objectives: The aim of this study is to determine efficacy, safety, and feasibility of video-assisted thoracoscopic surgery (VATS) in childhood empyema with two port technique. Materials and Methods: 34 patients under 17 years of age were included to the study. Demographic and clinical data of the patients were recorded retrospectively. Results: 34 patients under 17 years of age were included in the study. The first time the complaints started was 12 days. VATS was performed on mean 12 (2-46) days after the complaints of the patients started. The empyemas were in right hemithorax in 21 children and left in 11. Two patients underwent bilateral decortication Mean of chest tube removal time was 9.70 (2-26) days. While the postoperative stay was 23.50 (4-120) days, the total hospital stay was 32.50 (7-142) days. Emphysema developed in 7 patients in the following period. Chest tube revision was performed in a patient. Emphysema spontaneously regressed at follow-up in 6 patients. Two children had died due to 1- arrest and 2 – after liver transplant. Conclusion: VATS is a feasible method with good results pleural empyema in children. The results are satisfactory in the early or late period of disease.

Changes in Etiology and Clinical Outcomes of Pleural empyema during the COVID-19 Pandemic.

Healthcare-seeking behavior changed during the COVID-19 pandemic and might alter the epidemiology of pleural empyema. In this study, the incidence, etiology and outcomes of patients admitted for pleural empyema in Hong Kong in the pre-COVID-19 (January 2015-December 2019) and post-COVID-19 (January 2020-June 2022) periods were compared. Overall, Streptococcus pneumoniae was the predominant organism in <18-year-old patients, while Streptococcus anginosus, anaerobes and polymicrobial infections were more frequent in adults. In the post-COVID-19 period, a marked decline in the incidence of pleural empyema in children was observed (pre-COVID-19, 18.4 ± 4.8 vs. post-COVID-19, 2.0 ± 2.9 cases per year, p = 0.036), while the incidence in adults remained similar (pre-COVID-19, 189.0 ± 17.2 vs. post-COVID-19, 198.4 ± 5.0 cases per year; p = 0.23). In the post-COVID-19 period, polymicrobial etiology increased (OR 11.37, p < 0.0001), while S. pneumoniae etiology decreased (OR 0.073, p < 0.001). In multivariate analysis, clinical outcomes (length of stay, ICU admission, use of intrapleural fibrinolytic therapy, surgical intervention, death) were not significantly different in pre- and post-COVID-19 periods. In conclusion, an increase in polymicrobial pleural empyema was observed during the pandemic. We postulate that this is related to the delayed presentation of pneumonia to hospitals.

Is there any role for medical thoracoscopy in the treatment of empyema in children?

It is still controversial whether surgical or nonsurgical treatment approaches are most appropriate for empyema in children, and there are no data regarding the role of medical thoracoscopy in this population. The aim of this study was to describe our experience with medical thoracosocpy in children with multiloculated and organizing pneumonia. We retrospectively reviewed children admitted to our hospital with a diagnosis of empyema from 2011 to 2021 and treated with medical thoracoscopy. A total of six patients with empyema were treated by medical thoracoscopy; empyema was multiloculated in five cases and organized in one case; all children in the study recovered completely with full lung expansion after chest X-rays, and no disease sequelae were reported after clinical follow-up. Our small case series suggests that in selected cases, medical thoracoscopy could safely and effectively treat pleural empyema in children, with less invasiveness and reduced psychological consequences.

Pleural empyema in children - benefits of primary thoracoscopic treatment.

IntroductionPleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage.AimTo assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3rd phase of pleural empyema.Material and methodsThe clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication.ResultsThe results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3rd stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases.ConclusionsThe thoracoscopic approach is safely feasible in the 3rd stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.

Stratégie antibiotique dans les pleurésies en pédiatrie : consensus par méthode DELPHI

The evolution of the microbial epidemiology of pleuropulmonary infections complicating community-acquired pneumonia has resulted in a change in empirical or targeted antibiotic therapy in children in the post Prevenar 13 era. The three main pathogens involved in pleural empyema in children are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus. A questionnaire according to the DELPHI method was sent to experts in the field (paediatric pulmonologists and infectious disease specialists) in France with the purpose of reaching a consensus on the conservative antibiotic treatment of pleural empyema in children. Two rounds were completed as part of this DELPHI process. Our work has shown that in the absence of clinical signs of severity, the prescription of an intravenous monotherapy is consensual but there is no agreement on the choice of drug to use. A consensus was also reached on treatment adjustment based on the results of blood cultures, the non-systematic use of a combination therapy, the need for continued oral therapy and the lack of impact of pleural drainage on infection control. On the other hand, after the second round of DELPHI, there was no consensus on the duration of intravenous antibiotic therapy and on the treatment of severe pleural empyema, especially when caused by Staphylococci. The result of this work highlights the needed for new French recommendations based on the evolution of microbial epidemiology in the post PCV13 era.

Surgical treatment of tuberculous empyema in children

To analyze surgical treatment of tuberculous pleural empyema in children depending on the stage of the process. There were 82 patients aged 4-17 years with tuberculous pleural empyema. Clinical and X-ray features of different stages of disease are described. Certain types of surgical interventions at each stage of the process are analyzed. In 72 children with empyema stage III 76 surgeries were performed. Postoperative complications occurred in 2 (2.6%) cases (delayed lung inflation) that required thoracocentesis with pleural drainage. There was no postoperative mortality. Complex treatment of tuberculous pleural empyema in children and adolescents with the use of modern surgical methods is followed by satisfactory outcomes in all patients. However, surgical technique, postoperative morbidity and hospital-stay depend on the stage of the process. Unfortunately, almost 90% of patients had empyema stage III. Therefore, minimally invasive surgery was not advisable and extensive, traumatic surgeries were required.

Methods of treatment of pleural empyema in children

Methods of treatment of pleural empyema in children

Change in Bacterial Causes of Community-Acquired Parapneumonic Effusion and Pleural Empyema in Children 6 Years After 13-Valent Pneumococcal Conjugate Vaccine Implementation.

We describe here changes in the bacterial causes of pleural empyema before and after implementation of the 13-valent pneumococcal conjugate vaccine (PCV13) program in France (2009-2017). For 220 (39.3%) of 560 children, a bacterial cause was found. The frequency of pneumococcal infection decreased during the study from 79.1% in 2009 to 36.4% in 2017 (P < .001). Group A streptococcus is now the leading cause of documented empyema (45.5%).

СОФІЯ ПАРФАНОВИЧ – УКРАЇНСЬКИЙ ЛІКАР ТА ПРОСВІТНИК (до 120-РІЧЧЯ З ДНЯ народження)

The life and work of Sofia Parfanovych (1898-1968), one of the prominent ascetics of Ukrainian medicine, first female Ukrainian student of medical faculty of Lviv University, active public figure and writer is described. Together with Sofia Okunevska they belong to the first female doctors in Western Ukraine that woke Ukrainian womenfolk to education, struggle for gender equality and social progress. Sofia Parfanovych finished her study at Lviv University in 1926 and got the diploma of a doctor. She began her professional career as obstetrician and gynecologist at General hospital in Lviv, then started private medical practice and work on a voluntary basis at “Narodna lichnytsya”. In 1929 doctor Parfanovych became the head of anti-alcohol section of Ukrainian Hygiene Society as well as the chief of anti-alcohol and anti-nicotine society “Vidrodzhennya”. The members of these societies worked actively publishing about half a million educational postcards, posters and magazines. The slogan printed on each paper motivated for a healthy lifestyle, eradication of bad habits such as smoking and alcohol drinking. It was one of the ways of hygienic education of population. As a scientist Sofia Parfanovych wrote a plenty of articles dedicated to the diagnostics and treatment of pleural empyema in children, mycosis as a women’s disease, vaginal endometriosis, protein therapy of certain women’s diseases, trichomonas infection, the relation between youth’s villainy and mental retardation and acute alcoholism. Moreover, doctor Parfanovych published works for hygienic education of families. The most famous of them are: “Women’s hygiene”, “Proper nutrition”, “Husband and wife”. At the end of 1939 Sofia Parfanovych became the director of paramedic and obstetric school in Lviv. Two years later she wrote a dissertation “Metastases of malignant tumors of ovaries to the central nervous system” and became a docent at Lviv Medical University. In 1944 due to the strained situation in Ukraine associated with the World War II the family of Sofia Parfanovych and her husband Pylyp Volchuk together with his son emigrated to Austria, firstly to Wienna and later to the small Austrian city of Telfs. A year later they continued travelling and settled in Bayern, Germany. Unfortunately, in 1946 Pylyp Volchuk after years of fighting against stomach cancer died. In 1949 Sofia Parfanovych emigrated to the USA where seven years later affirmed her doctor’s diploma and got the permission for a private medical practice. Due to the disease of retinal detachment of the left eye doctor Parfanovych stopped her work at the hospital and dedicated herself to the literary work. In December 1968 Sofia Parfanovych died and was buried at Mount Olivet Cemetery in Detroit. The life of a doctor and enlightener Sofia Parfanovych demonstrates the sacrifice and mercy, professionalism and patriotism, love to the people and Ukraine. All this contributed to the development of the Ukrainian culture and nation.

Pleural Empyema in Children: Diagnosis and Management in a Pediatric Department in Development Country

Pleural empyema is a serious complication of pneumonia, its morbidity and mortality is important in developing country where hospital resources are limited. Different treatment strategies continue to generate controversy. We reported our experience in diagnosis and management of pleural empyema in children in a pediatric department in a development country.The early adequate surgical treatment in children with pleural empyema results in low morbidity, shorter hospital stay and good long-term outcome.

Etiology of parapneumonic effusion and pleural empyema in children. The role of conventional and molecular microbiological tests.

BackgroundAn increasing incidence of parapneumonic effusion and pleural empyema (PPE/PE) has been reported in recent studies. As only few data on etiology of PPE/PE in Central Europe have been reported, we undertook a study on the etiology of PPE/PE in children, using both standard culture and molecular techniques. MethodsThis prospective study was conducted between June 2011 and December 2013. Consecutive children with PPE/PE complicating community acquired pneumonia, who required diagnostic/therapeutic thoracentesis were included. Blood and pleural fluid samples for microbiological cultures were collected. Molecular methods were applied to identify Streptococcus pneumonia, Haemophilus influenzae, Staphylococcus aureus, Streptococcus pyogenes, Mycoplasma pneumoniae, Chlamydophila pneumoniae, and respiratory viruses in pleural fluid. ResultsThe study group included 64 children, median age 4 (1–15). Seven of 64 (10.9%) blood cultures and 11 of 64 (17.2%) pleural fluid cultures revealed bacterial growth. The most common bacteria detected was S. pneumoniae (13 blood and pleural fluid samples from 11/64 (17.2%) children). DNA sequences of typical bacteria were found in 29/64 (45.3%) pleural fluid samples. S. pneumoniae was identified in 90% of these samples. The most common serotypes were: serotype 6B in 9/26 (36.6%), 19A in 6/26 (23%), serotype 3 in 3/26 (11.5%), 6A and 23F (both in 2/26 i.e. 7.7%) patients. Molecular methods identified atypical bacteria in 8/58 (13.8%) and respiratory viruses in 12/58 (20.7%) pleural fluid samples. ConclusionsS. pneumoniae, in particular serotype 6B and 19A, is the most common etiologic agent of PPE/PE in Polish children. The use of PCR significantly improves pathogen identification in pleural fluid.

When should clinicians suspect group A streptococcus empyema in children? A multicentre case–control study in French tertiary care centres

BackgroundThe incidence of invasive group A streptococcus (GAS) infections is increasing worldwide, whereas there has been a dramatic decrease in pneumococcal invasive diseases. Few data describing GAS pleural empyema in...

Para- and Postpneumonic Pleural Empyema: Current Treatment Strategies in Children and Adults

Parapneumonic pleural effusions arise from pneumonia and may develop into pleural empyema (PE). PE is defined as collection of pus in the pleural space with secondary inflammation of the visceral and parietal pleura. This review article describes the current treatment strategies for para- and postpneumonic PE both in children and adults. Selective literature research via Medline (key words: pleural empyema, pleural empyema in children, thoracic empyema) and presentation of our own clinical experience with therapy recommendations. The incidence of postpneumonic PE is increasing in both children and adults. PE is associated with a high morbidity and mortality if it is not treated early and adequate. Progression of PE follows a characteristic morphological course, which is classified in three stages: the exsudative, fibrinopurulent, and organizing phase. Treatment should be adapted to these three phases including systemic antibiotic therapy and drainage of the pleural space. Intrapleural fibrinolysis can be performed with good success independent of age in the transition of stage 1 and 2. In persistent PE (stage 2), thoracoscopic decortication is recommended to avoid progression into the organizing phase (stage 3) with the need of an open decortication. In debilitated elderly patients the increasing use of intrathoracic vacuum therapy (Mini-VAC/Mini-VAC-instill) offers an effective and less invasive therapy option. Para- and postpneumonic PE requires an individualized and stage adapted therapy using a combination of medical and surgical treatment strategies with the aims of removing the source of infection and ensuring re-establishment of lung expansion.

An integrated care pathway for optimizing the investigation and management of pediatric pleural empyema

There are no reports of the use of an integrated care pathway (ICP) to facilitate the management of pleural empyema in children. Our aim is to assess pleural empyema management in our institute, to establish an ICP and to review the impact of this on the patient journey. Data were collected about management strategies, pain control and length of hospital stay from children admitted in 2000 with a diagnosis of pleural empyema. An integrated care pathway was developed to facilitate change in practice and provide greater consistency in management. This incorporated the use of intrapleural urokinase and guidelines on pain control. This was followed by data collection in 2004 to review the impact of the integrated care pathway. The 2000 review revealed that the majority of children (eight of 13) underwent a primary surgical intervention. Urokinase was not used. The median length of stay was 11.5 days (range 4–49 days). Implementation of the pathway led to a reduction in the number of children who underwent surgery (one of 18) with no adverse impact on clinical outcome. Median length of stay was 9 days (range 2–28 days). Children had a smoother patient journey, with prompter investigation and intervention. Children on the pathway had smaller chest drains inserted, received urokinase and had a clearly recorded analgesia strategy. Pleural empyema in childhood requires multi-disciplinary management. The implementation of an integrated care pathway is a valuable tool for managing a condition that requires multi-disciplinary input.

Risk factors for the development of pleural empyema in children

Pediatric pleural empyema has increased substantially over the past 20 years and reasons for this rise remain not fully explained. We investigated potential risk factors for the development of empyema in children by examining a cohort of patients with community-acquired pneumonia. Demographic, clinical, and socioeconomic characteristics, use of Ibuprofen prior to presentation and selected potential epidemiological risk factors were analyzed. Data were collected from a prospective etiological study of radiologically confirmed pneumonia in hospitalized children aged ≤16 years. One hundred sixty children were enrolled; 56% were male and 69% aged <5 years. Empyema complication developed in 40 (25%) children. Children with empyema were more frequently prescribed Ibuprofen prior to admission to hospital than those without (82% vs. 46.2%; OR 1.94, 97.5% credible interval 0.80-3.18). Bacterial infection was strongly associated with the development of empyema (OR 3.34, 97.5% credible interval 1.70-5.14). In contrast age, sex, maternal age, parental smoking, level of socioeconomic status, nursery attendance, asthma, household characteristics (bedrooms and number of occupants) were not significantly different between groups. In conclusion, children with pneumonia who developed empyema had more often received Ibuprofen prior to hospitalization and confirmed bacterial infection. We suggest a population-based study involving both primary and secondary care settings would help to investigate the role of Ibuprofen use in modulating the course of disease in children with pneumonia.

Pleural Empyema in Children: A Review of 85 Cases

We concluded that appropriate antibiotics with early closed-chest tube drainage are adequate to achieve clinical and physiologic resolution. Patients referred late to the hospital may require further surgical intervention. The long term prognosis is excellent.

Comparison of the Methods of Fibrinolysis by Tube Thoracostomy and Thoracoscopic Decortication in Children with Stage II and III EmpyemA: A Prospective Randomized Study

Today, in spite of the developments in imaging methods and antibiotherapy, childhood pleural empyema is a prominent cause of morbidity and mortality. In recent years, it has been shown that there has been an increase in the frequency of pleural empyema in children, and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult. Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease, there is are not enough studies comparing these two treatments. The aim of this study was to prospectively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options.We excluded from the study cases with: i) thoracoscopic intervention and fibrinolytic agent were contraindicated; ii) immunosuppression or additional infection focus; iii) concomitant diseases, those with bronchopleural fistula diagnosed radiologically, and Stage I cases. This gave a total of 54 cases: 23 (42.6%) in stage II, and 31 (57.4%) cases in stage III. These patients were randomized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication (VATS). The continuity of symptoms after the operation, duration of thoracic tube in situ, and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications (P=0.0001). In 19 of 27 cases (70.37%) in which fibrinolytic treatment was applied and in 21 cases of 27 (77.77%) in which VATS was applied, the lung was fully expanded and the procedure was considered successful. There was no significant difference with respect to success rates between the two groups (P=0.533). The complication rate in our cases was 12.96% and no mortality was observed. Similar success rates in thoracoscopic drainage and enzymatic debridement, and the low cost of enzymatic drainage both served to highlight intrapleural streptokinase treatment as a reliable method in reducing the need for surgery in complicated empyema.

Video-Assisted Thorascopic Surgery vs Chest Drain With Fibrinolytics for the Treatment of Pleural Empyema in Children: A Systematic Review of Randomized Controlled Trials

Video-Assisted Thorascopic Surgery vs Chest Drain With Fibrinolytics for the Treatment of Pleural Empyema in Children: A Systematic Review of Randomized Controlled Trials