Pleural Empyema Research Articles

Application of thoracoscopic surgery in patients with pleural empyema

Application of thoracoscopic surgery in patients with pleural empyema

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema.

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema.

Diagnostic value of imaging examinations in pleural empyema

Diagnostic value of imaging examinations in pleural empyema

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.

Minimally invasive intrathoracic negative-pressure therapy and flexible thoracoscopy (FlexVATS) for patients with pleural empyema

To determine whether a new surgical method using a flexible endoscope (FlexVATS) to perform sparing debridement and apply negative-pressure therapy without extensive decortication may be an alternative treatment option for empyema. Surgical treatment of pleural empyema is associated with considerable postoperative complications and mortality rates, and alternative treatment options are being explored to improve patient outcomes. This was a prospective case series. Seventeen consecutive patients treated with FlexVATS between February 2021 and August 2022 were included in the study. Only patients for whom FlexVATS was the first therapeutic intervention for pleural empyema were included. Treatment success, defined as infection resolution, was the primary endpoint of the study. The secondary endpoints were length of hospital stay, 90-day mortality, and empyema cavity volume reduction. Patients who had previously been treated for pleural empyema by either drainage or surgery were excluded. The trial was performed as a single-centre study at a tertiary medical centre in Germany. In total, 17 patients with pleural empyema were included in the study. The median (IQR) duration of vacuum treatment was 15 days (8–35 days). Twelve of the 17 (71%) patients were successfully treated, and a significant reduction in the empyema cavity volume was observed. 41% of the dressing changes were performed outside the operating room. Compared with a historic cohort of conventionally treated patients (decortication via VATS or thoracotomy), the 90-day mortality rates tended to be lower without reaching statistical significance. Three patients (18%) died in hospital during treatment. No negative pressure-therapy-related complications were observed. FlexVATS therapy is a promising alternative therapy for both healthy and debilitated patients with pleural empyema. Larger randomised trials are required to validate this treatment option.

Outcome of Emergency Pulmonary Lobectomy under ECMO Support in Patients with COVID-19.

Not much is known about the results of nonelective anatomical lung resections in coronavirus disease 2019 (COVID-19) patients put on extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyze the outcome of lobectomy under ECMO support in patients with acute respiratory failure due to severe COVID-19. All COVID-19 patients undergoing anatomical lung resection with ECMO support at a German university hospital were included into a prospective database. Study period was April 1, 2020, to April 30, 2021 (first, second, and third waves in Germany). A total of nine patients (median age 61 years, interquartile range 10 years) were included. There was virtually no preexisting comorbidity (median Charlson score of comorbidity 0.2). The mean interval between first positive COVID-19 test and surgery was 21.9 days. Clinical symptoms at the time of surgery were sepsis (nine of nine), respiratory failure (nine of nine), acute renal failure (five of nine), pleural empyema (five of nine), lung artery embolism (four of nine), and pneumothorax (two of nine). Mean intensive care unit (ICU) and ECMO days before surgery were 15.4 and 6, respectively. Indications for surgery were bacterial superinfection with lung abscess formation and progressive septic shock (seven of nine) and abscess formation with massive pulmonary hemorrhage into the abscess cavity (two of nine). All patients were under venovenous ECMO with femoral-jugular configuration. Operative procedures were lobectomy (eight) and pneumonectomy (one). Weaning from ECMO was successful in four of nine. In-hospital mortality was five of nine. Mean total ECMO days were 10.3 ± 6.2 and mean total ICU days were 27.7 ± 9.9. Mean length of stay was 28.7 ± 8.8 days. Emergency surgery under ECMO support seems to open up a perspective for surgical source control in COVID-19 patients with bacterial superinfection and localized pulmonary abscess.

Are Extensive Open Lung Resections for Elderly Patients with Lung Cancer Justified?

Older patients with malignancies are more comorbid than younger ones and are usually undertreated only because of their age. The aim of this study is to investigate the safety of open anatomical lung resections for lung cancer in elderly patients. We retrospectively analyzed all patients who underwent lung resection for lung cancer in our institution and categorized them into two groups: the elderly group (≥70 years old) and the control (<70). In total, 135 patients were included in the elderly group and 375 in the control. Elderly patients were more frequently diagnosed with squamous cell carcinoma (59.3% vs. 51.5%, p = 0.037), higher differentiated tumors (12.6% vs. 6.4%, p = 0.014), and at an earlier stage (stage I: 55.6% for elderly vs. 36.6%, p = 0.002). Elderly patients were more vulnerable to postoperative pneumonia (3.7% vs. 0.8%, p = 0.034), lung atelectasis (7.4% vs. 2.9%, p = 0.040), and pleural empyema (3.2% vs. 0%, p = 0.042), however, with no increased 30-day-mortality (5.2% for elderly vs. 2.7%, p = 0.168). Survival was comparable in both groups (43.4 vs. 45.3 months, p = 0.579). Elderly patients should not be excluded from open major lung resections as the survival benefit is not reduced in selected patients.

Organotypic 3D Co-Culture of Human Pleura as a Novel In Vitro Model of Staphylococcus aureus Infection and Biofilm Development.

Bacterial pleural infections are associated with high mortality. Treatment is complicated due to biofilm formation. A common causative pathogen is Staphylococcus aureus (S. aureus). Since it is distinctly human-specific, rodent models do not provide adequate conditions for research. The purpose of this study was to examine the effects of S. aureus infection on human pleural mesothelial cells using a recently established 3D organotypic co-culture model of pleura derived from human specimens. After infection of our model with S. aureus, samples were harvested at defined time points. Histological analysis and immunostaining for tight junction proteins (c-Jun, VE-cadherin, and ZO-1) were performed, demonstrating changes comparable to in vivo empyema. The measurement of secreted cytokine levels (TNF-α, MCP-1, and IL-1β) proved host-pathogen interactions in our model. Similarly, mesothelial cells produced VEGF on in vivo levels. These findings were contrasted by vital, unimpaired cells in a sterile control model. We were able to establish a 3D organotypic in vitro co-culture model of human pleura infected with S. aureus resulting in the formation of biofilm, including host-pathogen interactions. This novel model could be a useful microenvironment tool for in vitro studies on biofilm in pleural empyema.

Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema.

Pleural infection is life-threatening and increasingly prevalent. In addition to usual care, twice-daily, separate administration of tissue plasminogen activator and deoxyribonuclease (tPA-DNase) reduces radiological pleural opacity with lower surgical referral rates. This retrospective cohort study examines the use of once-daily, concurrent administration of tPA-DNase for complex parapneumonic pleural effusion and empyema. Patients with pleural infection who received intrapleural tPA-DNase between October 2014 and July 2020 at Logan Hospital, where it is given concurrently and once-daily as salvage therapy, were retrospectively identified. Radiographic opacification, inflammatory markers, clinical response and complications were examined. Thirty-one patients were identified. Mean age was 48.8 years (standard deviation [SD], 17.2). Median tPA-DNase administration was 3 (interquartile range [IQR], 2-3). Chest x-ray pleural opacity decreased significantly (P = 0.047) from a median of 39.6% (IQR, 28.8-65.7%) to 9.7% (IQR, 2.5-23.2%), a median relative reduction of 75.5% (IQR, 47.7-93.9%). White cell count and C-reactive protein improved significantly (P = 0.002 and P = 0.032, respectively) from a median of 16.3 × 109 /L (IQR, 11.8-20.6 × 109 /L) to 9.9 × 109 /L (IQR, 8.0-12.3 × 109 /L) and 311.0 mg/L (IQR, 218.8-374.0 mg/L) to 69.0 mg/L (IQR, 36.0-118.0 mg/L), respectively. No patients experienced significant bleeding or died. Five patients (16.1%) were referred for surgery. This is pilot evidence that a practical regimen of concurrent, once-daily intrapleural tPA-DNase improved pleural opacification and inflammatory markers without bleeding or mortality. The surgical referral rate was higher than in studies assessing twice-daily administration, though the validity of this outcome as a measure of treatment success is limited, and further studies are needed to assess the optimal dose and frequency of intrapleural therapy and indications for surgical referral.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased Morbidity and Mortality in Patients Undergoing Thoracic Surgery for Pleural Empyema

Surgery for pleural empyema carries a high burden of morbidity and mortality. The authors investigated the incidence of postoperative pulmonary complications (PPCs) and their effects on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs were analyzed. Retrospective observational study. A single, large university hospital. A total of 250 adult patients were included who underwent thoracic surgery for pleural empyema between January 2017 and December 2021. None. A total of 250 patients with pleural empyema underwent thoracic surgery by video-assisted thoracoscopic surgery (49%; n = 122) or open thoracotomy (51%; n = 128). A proportion (42% [105]) of patients had ≥1 PPCs; 28% (n = 70) had to undergo resurgery; and 10% (n = 25) were re-admitted unexpectedly to the ICU. Preoperative respiratory failure (odds ratio [OR]: 5.8, 95% CI: 2.4-13.1), general anesthesia without regional analgesia techniques (OR: 2.9, 95% CI: 1.4-5.8), open thoracotomy and subsequent resurgery (OR: 3.9, 95% CI 1.5-9.9), surgery outside the regular working hours (OR: 3.1, 95% CI 1.2-8.2), and postoperative sepsis (OR: 2.6, 95% CI 1.1-6.8) were identified as independent risk factors for PPCs. Postoperative pulmonary complications were independent factors for unplanned intensive care unit admission (OR: 10.5, 95% CI 2.1-51 for >1 PPC), death within 360 days (OR: 4.5, 95% CI 2.2-12.3 for ≥2 PPCs), and death within 30 days for ≥1 PPCs (OR: 1.2, 95% CI 1.1-1.3). The incidence of PPCs is a significant risk factor for morbidity and mortality after surgery for pleural empyema. Targeting the risk factors identified in this study could improve patient outcomes.

Unexpected Increase in Invasive Group A Streptococcal Infections in Children After Respiratory Viruses Outbreak in France: A 15-Year Time-Series Analysis.

In a 15-year pediatric time-series analysis, we showed a rise of invasive Group A streptococcal (iGAS) infections since October 2022, mainly involving pleural empyema, simultaneously to a respiratory virus outbreak. Physicians should be aware of this increased risk of pediatric iGAS infections, especially in settings with intense respiratory viruses' circulation.

An independent prognostic factor in surgical cases of pleural empyema caused by common bacteria is the presence of a fistula.

Some surgical cases of pleural empyema lead to death despite multidisciplinary treatment. The purpose of this study was to identify prognostic factors in cases treated surgically for pneumonia-associated pleural effusions and empyema caused by common bacteria. We conducted a retrospective cohort study of 108 surgical patients of empyema who encountered at our hospital between 2011 and 2021. Patients were divided into surviving and non-surviving cases. Factors on admission (age, sex, body mass index, presence of fistula, performance status, pleural fluid culture results, HbA1c, albumin, leukocytes, hemoglobin, body temperature, heart rate, respiratory rate, systolic blood pressure, prognostic nutritional index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and RAPID score) were compared between the two groups. There were 87 cases of pleural empyema caused by pneumonia due to common bacteria. Variables that differed significantly in univariate analysis between the surviving and non-surviving cases in patients' characteristics on admission were fistula (p value < 0.001, odds ratio 20.000, 95% confidence interval 3.478-115.022), positive pleural fluid culture (0.016, 6.591, 1.190-36.502), body mass index < 18.5 (0.001, 16.857, 1.915-148.349), performance status 0-1 (0.007, 11.778, 1.349-102.858), and hemoglobin (0.024, 1.768, 1.077-2.904). Multivariate analysis showed significant differences in the presence of fistula (p = 0.036, CI 1.174-125.825). The odds ratio was 12.154. The mortality rate was 3.8% for non-fistulous empyema and 44.4% for fistulous empyema. In 6 of 9 cases of fistulous empyema, the fistula could be closed. Fistula was a significant independent prognostic factor for pneumonia-associated pleural effusions and empyema caused by common bacteria.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Aggregatibacter actinomycetemcomitans infection in a 15-year-old boy with pulmonary empyema: a case report and review of literature

BackgroundAggregatibacter actinomycetemcomitans (Aa), previously known as Actinobacillus actinomycetemcomitans, is a slow-growing Gram-negative coccobacillus, member of the HACEK group of bacteria colonizing oral flora. Besides causing infectious diseases in the oral cavity such as dental caries and periodontitis, it is responsible for severe extra-oral infections secondary to hematogenous spread or aspiration, such as endocarditis, soft tissue abscesses and osteomyelitis. The diagnosis depends on prolonged bacterial culture of biological material obtained through biopsy. Aa is susceptible to most antibiotics but complete eradication often requires a long term treatment.Case presentationWe report the case of a 15-year-old previously healthy boy diagnosed with both pulmonary empyema and subphrenic chest wall abscess caused by Aa. He was admitted to our Pediatric Emergency department for evaluation of a right mass associated with marked asthenia and dry cough. After radiological findings etiological diagnosis was made by culture of fluid drainage of pleural empyema. He started empirical antibiotic therapy with intravenous piperacillin/tazobactam, whose sensibility was confirmed by the antibiogram, then, for occurrance of hepatopathy it was switched to ciprofloxacin: the patient almost completely recovered after 6-month therapy.ConclusionsExtra-oral infections caused by Aa are extremely rare, especially in children, and not well described yet. To our knowledge, there is only another similar case described in literature. However, the case described in our manuscript represents the only one presenting with pulmonary empyema without involvement of lung parenchyma in children. We also conducted a brief review of published cases of Aa infection in the pediatric population. This case report reminds us the importance of an accurate inspection of the oral cavity during the examination of pediatric patients.

Intrathoracic negative pressure therapy for pleural empyema using an open-pore drainage film.

We report our initial experience with intrathoracic negative pressure therapy (ITNPT) in the stage-adjusted treatment of pleural empyema (PE) based on acase series. ITNPT represents afurther development for intrathoracic use. After thoracic surgical open debridement, an intrathoracic negative pressure dressing was inserted. The drainage elements were athin open-pore double-layer drainage film (OF) with open-pore polyurethane foams (PUF). Only the OF was placed in direct contact with the lung parenchyma. Negative pressure was generated using an electronic pump (continuous suction, -75 mm Hg). In revision thoracotomies, ITNPT was stopped or continued depending on local findings. In total, 31patients with stageII andIII pleural empyema underwent ITNPT, which was administered during the primary procedure (n = 17) or at revision (n = 14). Treatment duration was amean of 10days (2-18days) with amean change interval of 4days (2-6days). Intrathoracic negative pressure dressings were applied amean of 3.5 (1-6) times. The empyema cavity continuously reduced in size and was cleansed by the suction. The OF has aminimum intrinsic volume with maximum absorption surface. Once negative pressure is established, there is no intrathoracic dead volume and the parenchyma can expand. The protective material properties of OF make ITNPT suitable for the treatment of pleural empyema. Targeted local intrathoracic drainage of the septic focus is apossible adjunct to surgery. The surgical dressings must be changed repeatedly. The method is suitable for the treatment of complex stageII andIII pleural empyemas. The OF can be used as an intrathoracic drainage element for ITNPT in pleural empyema. This new application option expands the range of indications for negative pressure therapy.

A contemporary view of the problem of destructive pneumonia in children

The problem of community-acquired pneumonia in children remains relevant at the present time. Complicated forms, which include pleural empyema, abscess, necrotizing pneumonia, bronchopleural fistulas and acute respiratory distress syndrome do not decrease, despite modern antibacterial therapy and the availability of vaccination against pneumococcus. The main pathogens associated with lung destruction in children are S. pneumoniae and S. aureus, often MRSA. The role of other pathogens in necrotizing pneumonia is much less frequently reported: Streptococcus pyogenes, Haemophilus influenzae, Pseudomonas aeruginosa, Fusobacterium nucleatum, Legionella pneumophila, Klebsiella pneumoniae, anaerobes. However not only pathogenic factors of the pathogen are important for necrotizing pneumonia development. Often, a viral prodrome, often associated with the influenza A (H1N1) virus, precedes complicated pneumonia. During the epidemic of COVID-19, endothelial damage with a high degree of probability was a predisposing factor for the development of a secondary bacterial infection with lung tissue necrosis. Significant destruction and liquefaction of the lung tissue may develop despite adequate antibiotic therapy. Great importance in the development of necrosis is attached to the activation of hemostasis and thrombus formation in the vessels of the lungs. Timely diagnosis often is difficult due to the predominance of general symptoms over local ones, especially in young children. Chest x-ray is the standard for diagnosing. However, the diagnostic capabilities of this method in necrotizing pneumonia are limited. To assess a number of parameters of the state of the pleural cavity and lung tissue, ultrasound is preferred. It is necessary to analyze the current features of the course of necrotizing pneumonia in children and develop clinical guidelines for the management of patients in the acute period and rehabilitation.

Successful Multimodal Therapy with Intracerebral Liposomal Amphotericin B and Systemic High-Dose Isavuconazole in Proven Disseminated Aspergillosis

We report the case of a 32-year-old man receiving chemotherapeutics for an acute B-lymphoblastic leukemia who developed proven cerebral and pulmonary aspergillosis with Aspergillus flavus. Because of progressive fungal disease with neurological deterioration despite adequate systemic antifungal therapy and surgical debridement, intracerebral administration of liposomal amphotericin B was initiated at 5 mg twice weekly. This led to improvement of the cerebral infection. Surgical debridement of a pleural Aspergillus empyema was necessary, and pleural trough level of isavuconazole was found to be subtherapeutic despite adequate blood trough levels, which led us to increase the dose of isavuconazole. We conclude that intralesional amphotericin B might be beneficial at 5 mg twice weekly in cerebral aspergillosis if systemic antifungals and surgical debridement fail. In Aspergillus empyema, measurement of pleural isavuconazole trough levels should be considered.

Impact of Multiple Drug Resistant Tuberculous Mycobacteria on the Outcomes of Lung Resection for Fibrous Cavernous Tuberculosis

The objective: to study the impact of multiple drug resistant tuberculosis (MDR TB) on the outcomes of comprehensive treatment with surgical resection of fibrous cavernous pulmonary tuberculosis.Subjects and Methods. A prospective retrospective cohort study was performed; 526 HIV negative patients with unilateral fibrous cavernous tuberculosis who underwent lung resection were enrolled in the study. Patients were divided into two groups: multiple drug resistant tuberculosis - 216 subjects, drug susceptible tuberculosis - 310 subjects. Each group was divided into three subgroups: with the low (MDR TB - 105 subjects; DS TB 221 subjects), moderate (MDR TB - 67 subjects; DS TB - 68 subjects) and high activity (MDR TB - 44 subjects; DS TB - 21 subjects) of tuberculous inflammation.Results. The chances of adverse outcomes of comprehensive treatment with surgical resections of fibrous cavernous pulmonary tuberculosis are 2.5 times higher in MDR TB Group versus DS TB Group (p &lt; 0.001; χ2, OR = 2.5; 95% CI 1.6-3.9). At the time of the surgery, among patients with MDR TB, there were significantly more patients with moderate and high activity of tuberculous inflammation versus DS TB Group (p &lt; 0.001; χ2). When comparing the groups of patients with a homogeneous degree of tuberculous inflammation activity, no significant impact of MDR TB on the outcomes of comprehensive treatment with resections was found. However, the course of the postoperative period differed, in MDR TB Group, pleural cavity empyema (OR = 3.1; 95% CI 1.7-5.5) and tuberculosis exacerbations (OR = 4.7; 95% - CI 2.1-10.7) were significantly more frequent compared to DS TB Group.

The role of the RAPID score in surgical planning for empyema.

The RAPID [Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)] score is a validated scoring system which allows risk stratification in patients with pleural infection at presentation. Surgical intervention plays a key role in managing pleural empyema. A retrospective study of patients with complicated pleural effusions and/or empyema undergoing thoracoscopic or open decortication admitted to multiple affiliated Texas hospitals from September 1, 2014 to September 30, 2018. The primary outcome was all-cause 90-day mortality. The secondary outcomes were organ failure, length of stay and 30-day readmission rate. The outcomes were compared between early surgery (≤3 days from diagnosis) and late surgery (>3 days from diagnosis) and low [0-3] vs. high [4-7] RAPID scores. We enrolled 182 patients. Late surgery was associated with increased organ failure (64.0% vs. 45.6%, P=0.0197) and longer length of stay (16 vs. 10 days, P<0.0001). High RAPID scores were associated with a higher 90-day mortality (16.3% vs. 2.3%, P=0.0014), and organ failure (81.6% vs. 49.6%, P=0.0001). High RAPID scores with early surgery were associated with higher 90-day mortality (21.4% vs. 0%, P=0.0124), organ failure (78.6% vs. 34.9%, P=0.0044), 30-day readmission (50.0% vs. 16.3%, P=0.027) and length of stay (16 vs. 9 days, P=0.0064). High vs. low RAPID scores with late surgery was associated with a higher rate of organ failure (82.9% vs. 56.7%, P=0.0062), but there was not a significant association with mortality. We found a significant association between RAPID scores and surgical timing with new organ failure. Patients with complicated pleural effusions who had early surgery and low RAPID scores experienced better outcomes including decreased length of stay and organ failure compared with those who had late surgery and low RAPID scores. This suggests that using the RAPID score may help identify those who would benefit from early surgery.

Consecutive Seven Serious Cases with Invasive Group A Streptococcal Infections at December 2022-January 2023.

To the Editors: During the second and third year of the COVID pandemic, an increased number of serious cases due to different microorganisms have been reported. In the second half of 2022, it has been reported that there has been an increase in invasive group A streptococcal (iGAS) infections in many countries including England, the Netherlands and others.1–3 iGAS is defined as a life-threatening invasive infection characterized by the isolation of Streptococcus pyogenes from normally sterile body fluids with culture or by pathogen-specific polymerase chain reaction (PCR). If GAS has grown from a probable carrier location, such as the throat, and the clinical course is compatible with GAS disease and no other causing organism has been found, these patients need to be handled as iGAS.4 Before the pandemic, GAS was the most common pathogen among children in Europe who had to be hospitalized for a community-acquired bacterial infection. Patients with GAS infection had a 12% impairment at discharge and a 2% fatality rate. Increases in toxic shock syndrome, necrotizing fasciitis and pleural empyema have all been linked to increased mortality.4 In UK, during the last couple of months, the rate per 100,000 population of iGAS is higher among children.1 Between December 2022 and January 2023, in our tertiary care facility, we followed up 7 consecutive cases of iGAS infection—3 boys and 4 girls, ages 37–96 months—without any relation to one another (Table 1). All children were previously healthy. Five children were admitted to the pediatric intensive care unit, including 1 with toxic shock syndrome and 4 with pleural effusion/empyema. In 6 out of 7 children, the diagnosis of iGAS infection was made based on a positive culture and/or PCR from a typically sterile place, with the pleural fluid being the most frequent site. iGAS infection was defined in a child with toxic shock syndrome based on positive throat culture. In Table 1, antibiotic therapy is displayed. Each patient received clindamycin and 1 patient received intravenous immunoglobulin (IVIG). Due to empyema, thoracic tubes had to be inserted in 5 patients. In 2 of the pleural empyema cases, tube thoracostomy was carried out; in the third video assisted thoracostomy and in the fourth, thoracotomy and decortication were carried out. One child with GAS bacteremia required surgery for mastoiditis, and throughout the course of the investigation, sinus venous thrombosis was detected. Five children required pediatric intensive care unit stay. The length of hospital stay ranged from 7 to 21 days. TABLE 1. - Clinical Characteristics of 7 Children with Invasive Group A Streptococcal Infection Patient Age (month) Gender Diagnosis Culture Multiplex PCR Treatment PICU Stay Length of hospital stay (day) 1 37 Girl Pleural Empyema - Pleural fluid Streptococcus pyogenes Meropenem + vancomycin + clindamycin IVIG Thoracotomy and decortication + 14 2 40 Girl Pleural Empyema Throat Streptococcus pyogenes Pleural fluid Streptococcus pyogenes Tube thoracostomy Ceftriaxone + clindamycin + 9 3 96 Girl Pleural Empyema - Pleural fluid Streptococcus pyogenes Meropenem + vancomycin + clindamycin Tube thoracostomy Video assisted thoracostomy + 15 4 62 Boy Bacteremia, Mastoiditis, Sinus vein thrombosis Blood Streptococcus pyogenes - Meropenem + vancomycin + clindamycin Mastoidectomy - 21 5 48 Boy Pleural Empyema - Pleural fluid Streptococcus pyogenes Ceftriaxone + vancomycin + clindamycin Tube thoracostomy + 10 6 59 Boy Toxic Shock Syndrome Throat Streptococcus pyogenes - Ceftriaxone + vancomycin + clindamycin + 7 7 42 Girl Bacteremia, Pleural Empyema Blood Streptococcus pyogenes - Ceftriaxone + clindamycin - 10 IVIG, intravenous immune globulin; PICU, pediatric intensive care unit. Both the frequency and morbidity of iGAS infections increased after the COVID-19 pandemic as before. While there was only one iGAS case during the previous 3 years, 7 patients in a row were hospitalized during a 2-month period in our setting. Clindamycin would be efficient to deactivate M-protein and these exotoxins because S. pyogenes has the cell wall M-protein that prevents complement activation and reduces phagocytosis. This would produce a positive outcome similar to our case series.4,5 Although culture is the gold standard method for diagnosis, molecular methods such as multiplex PCR are important in identifying the causative agent. Despite treatment, we have seen serious complications in our case series, such as pleural decortication, mastoiditis, sinus venous thrombosis and toxic shock syndrome. Early diagnosis of patients (using molecular techniques included) and the initiation of appropriate treatment including clindamycin, are crucial. To comprehend the postpandemic condition, it is essential to monitor the clinical findings and prognosis of iGAS cases from various countries.