— The following is a summary of the above discussion regarding the clinical presentation and evaluation of children with parapneumonic effusion and is consistent with the guidelines published by the Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic Society [2,22].
●The incidence of parapneumonic effusions appears to be increasing in the United States and the United Kingdom. Empyema in children occurs primarily in association with underlying pneumonia. The causative organisms have changed over time. S. pneumoniae is the predominant organism, and antibiotic resistant strains are particularly important. In addition, community-acquired S. aureus is becoming more common. (See 'Epidemiology'above and 'Etiology' above.)
●The most common presenting symptoms in children with empyema are fever, cough, malaise, anorexia, chest pain, and dyspnea. Failure to improve after 48 hours of appropriate therapy for pneumonia is another important presenting scenario. (See 'Clinical presentation' above.)
●Children with the above clinical findings should be evaluated with chest radiograph. If a large or non-free-flowing (loculated) effusion is suspected, ultrasonography is the preferred imaging modality to confirm the presence of fluid in the pleural space and to evaluate for early loculations and septations. Cultures of blood and sputum (if the patient is able to expectorate) should be obtained. (See 'Radiologic evaluation' above and 'Blood and sputum cultures' above.)
●If thoracocentesis or drainage of pleural fluid is indicated or if a noninfectious etiology is suspected, pleural fluid should be sent for analysis (see "Management and prognosis of parapneumonic effusion and empyema in children", section on 'Thoracentesis'). The pleural fluid should be sent for the following studies:
•Gram stain and culture (aerobic and anaerobic). (See 'Microbial analysis' above.)
•Cell count and differential. (See 'Other studies' above.)
•pH, glucose, and lactate dehydrogenase (LDH) may not affect clinical management decision; therefore, they are not routinely indicated unless the diagnosis is questionable. (See 'Other studies' above.)
●Additional pleural fluid studies that may improve the yield of identifying the etiology, and are particularly useful if the child received antibiotics before pleural fluid was obtained, include:
•Pneumococcal antigen detection (latex agglutination studies). (See 'Microbial analysis' above.)
•Specific or broad range polymerase change reaction (PCR) studies.
•Cytology if malignancy is suspected (eg, because of lymphocytic predominance on cell count, mediastinal mass, or lymphadenopathy). (See 'Other studies' above.)
●Other tests that may be helpful in identifying the causative organism, assessment of severity, presence of complications, and monitoring progress include (see 'Other tests' above):
•Tuberculin skin testing (TST) and sputum (or gastric aspirates) for acid fast bacilli in patients with risk factors for tuberculosis
•Complete blood count with differential
•C-reactive protein may be useful in monitoring progress
•Serum electrolytes (to detect inappropriate antidiuretic hormone [ADH] syndrome)
•Serum LDH, used to calculate the pleural to serum LDH ratio
●Children with parapneumonic effusion who have a history of recurrent bacterial infections, poor growth, or had S. aureus or P. aeruginosa as the infecting organism, should be evaluated for cystic fibrosis and immunodeficiency. (See "Cystic fibrosis: Clinical manifestations and diagnosis" and "Approach to the child with recurrent infections", section on 'Laboratory evaluation'.)
Comparison of serotypes in pneumococcal vaccines
| Conjugate vaccines | Polysaccharide vaccine | ||||
PCV7
(Prevnar 7)
|
PCV10*
(Synflorix)
|
PCV13
(Prevnar 13)
| PCV15¶ |
PPSV23
(Pneumovax 23)
| |
| 4 | 4 | 4 | 4 | 4 | 2 |
| 6B | 6B | 6B | 6B | 6B | 8 |
| 9V | 9V | 9V | 9V | 9V | 9N |
| 14 | 14 | 14 | 14 | 14 | 10A |
| 18C | 18C | 18C | 18C | 18C | 11A |
| 19F | 19F | 19F | 19F | 19F | 12F |
| 23F | 23F | 23F | 23F | 23F | 15B |
| 17F | |||||
| 1 | 1 | 1 | 1 | 20 | |
| 5 | 5 | 5 | 5 | 22F | |
| 3 | 3 | 3 | 33F | ||
| 7F | 7F | 7F | 7F | ||
| 19A | 19A | 19A | |||
| 6A | 6A | ||||
| 22F | |||||
| 33F | |||||
PCV7: 7-valent pneumococcal conjugate vaccine; PCV10: 10-valent pneumococcal conjugate vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine.
* Not available in the United States.
¶ In development.
* Not available in the United States.
¶ In development.
Graphic 77274 Version 5.0
Free layering pleural effusion
Panel A shows blunting of the right costophrenic sulcus (arrow) on an upright chest radiograph due to the presence of a pleural effusion. Panel B shows a right lateral decubitus radiograph from the same patient, and reveals layering of pleural effusion (arrowhead). Effusions thicker than 1 cm on decubitus views are usually large enough for sampling with thoracentesis.
Courtesy of Steven E Weinberger, MD.
Graphic 51660 Version 3.0
Management and prognosis of parapneumonic effusion and empyema in children
General overview
●Although approaches vary, there is a growing consensus that simple parapneumonic effusions should be treated with drainage and antibiotics, and complicated effusions with either fibrinolysis and chest tube drainage, or early surgical drainage (video-assisted thoracoscopic surgery [VATS]) (algorithm 2). (See 'Overview' above.)
●The majority of patients with pneumonia complicated by parapneumonic effusions will require hospitalization for further management. Transfer to a facility with specialists in pediatric pulmonology, pediatric surgery, and pediatric anesthesia should be considered early in the care of children with large or effusions because they may require VATS or fibrinolytic therapy. (See 'Hospitalization' above.)
Antibiotics
●All children with parapneumonic effusion should be treated with antibiotic therapy. The choice of antibiotic initially is based upon the suspected causative organism based on characteristics of the patient and local population and subsequently tailored according to the results of microbiologic testing. (See 'Choice of agent' above.)
●The duration of antibiotic therapy should be individualized, depending on the adequacy of drainage and clinical response of the patient. A common approach is to continue intravenous (IV) antibiotics for two to five days after resolution of fever, followed by oral therapy to complete total antibiotic course of two to four weeks. (See 'Duration' above.)
Free-flowing fluid — Management of parapneumonic effusion with free-flowing fluid depends on the size of the collection and clinical course of the patient.
●Children with small pleural effusions (eg, occupying <1 cm on lateral decubitus radiograph or opacifying less than one-fourth of the hemithorax) who are in no respiratory distress usually can be managed as outpatients, with broad-spectrum oral antibiotics and close observation with chest radiographs (algorithm 1). (See 'Small parapneumonic effusion' above.)
●We suggest that children who present with moderate or large amounts of free fluid documented by chest radiograph and ultrasonography undergo pleural drainage via small bore chest tube (pigtail catheter) in addition to intravenous antibiotics, rather than antibiotic therapy alone (Grade 2C). A 24 to 48 hour trial of antibiotic therapy without chest tube placement is an acceptable alternative for hospitalized stable patients who are not in respiratory distress, and are closely monitored. Patients who respond clinically are continued on antibiotic therapy as described above. (See 'Chest tubes' above and 'Antibiotic therapy' above.)
●For patients who do not have a good clinical and radiologic response within 24 to 48 hours to management with antibiotics with chest tube drainage, we suggest advancing to the therapies used for loculated fluid or empyema (ie, either fibrinolytic therapy or video-assisted thoracoscopic surgery [VATS]) (Grade 2C). At some institutions, a repeat ultrasound is performed to evaluate for loculation before proceeding to fibrinolytic therapy or VATS. At other institutions, therapy is advanced empirically. (See 'Failure to respond' above.)
Loculated fluid or empyema — Patients who have loculated pleural fluid documented by ultrasonography can be treated with either antibiotics alone, pleural catheter placement with fibrinolytics, or surgical therapy (VATS) (algorithm 2).
●We suggest pleural drainage via small-bore chest tube (pigtail catheter) with fibrinolysis and antibiotics as the initial treatment of choice for children with loculated effusions (Grade 2C). However early VATS is an acceptable alternative, and may be the first-line option in centers with surgeons experienced with VATS. The choice may be influenced by available expertise, cost considerations, and patient preferences. Pleural drainage with fibrinolysis is successful in approximately 80 percent of children; the remainder who fail medical therapy will require VATS. (See 'Intrapleural fibrinolytics versus surgical treatment' above and 'Fibrinolytic therapy'above.)
●Long-term outcomes are excellent for either primary medical or surgical therapy, but surgical therapy is associated with higher treatment costs and possibly greater short-term complications. (See 'Intrapleural fibrinolytics versus surgical treatment' above and 'Video-assisted thoracoscopic surgery (VATS)' above.)
Chest tube removal
●Chest tube removal is indicated once there is clinical resolution and minimal chest tube drainage. Clinical resolution is indicated by resolution of fever, with decreased white blood cell count, respiratory rate, and heart rate, and improved air entry and sense of well-being. (See 'Removal' above.)
Follow-up
●Children who have been treated for parapneumonic effusion should continue to be followed until they have recovered completely. Follow-up chest radiographs are appropriate for patients with residual symptoms or those who had particularly severe disease at presentation. (See 'Outpatient follow-up' above.)
Initial oral empiric antibiotics for outpatient treatment of pediatric community-acquired pneumonia
| Age group | Empiric regimen |
| 1 to 6 months | |
| Bacterial (not Chlamydia trachomatis) | Infants <3 to 6 months of age with suspected bacterial pneumonia should be hospitalized |
| Chlamydia trachomatis | Refer to UpToDate topic on Chlamydia trachomatis infections in the newborn |
| 6 months to 5 years | |
| Typical bacterial* | Amoxicillin¶ 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), OR |
| Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component in 2 or 3 divided doses (MAX 4 g/day amoxicillin component), OR | |
| For patients with non type 1 hypersensitivity to penicillins: | |
| - Cefdinir 14 mg/kg per day in 2 divided doses (MAX 600 mg/day), OR | |
| For patients with type 1 hypersensitivity to penicillins: | |
| - LevofloxacinΔ16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), OR | |
| - Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), OR | |
| - Erythromycin 30 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as ethylsuccinate), OR | |
| - Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on day 1 and 250 mg thereafter), OR | |
| - Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), OR | |
| In communities with a high rate of pneumococcal resistance to penicillin: | |
| - LevofloxacinΔ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), OR | |
| - Linezolid 30 mg/kg per day in 3 divided doses (MAX 1800 mg/day) | |
| ≥5 years | |
| Mycoplasma pneumoniae or Chlamydophila pneumoniae | Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as ethylsuccinate), OR |
| Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on day 1 and 250 mg thereafter), OR | |
| Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), OR | |
| Doxycycline◊ 4 mg/kg per day in 2 divided doses (MAX 200 mg/day), OR | |
| For patients ≥18 years: | |
| - LevofloxacinΔ§ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 500 mg/day); 500 mg once per day for children for children ≥16 years, OR | |
| - Moxifloxacinħ 400 mg once per day | |
| Typical bacterial* | Amoxicillin¶ 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), OR |
| For patients with non type 1 hypersensitivity to penicillins: | |
| - Cefdinir 14 mg/kg per day in 2 divided doses (MAX 600 mg/day), OR | |
| - Cefpodoxime 10 mg/kg per day in 2 divided doses (MAX 400 mg/day), OR | |
| For patients with type 1 hypersensitivity to penicillins: | |
| - LevofloxacinΔ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg once daily for children ≥16 years | |
| - Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), OR | |
| - Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as ethyl succinate), OR | |
| - Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on day 1 and 250 mg thereafter), OR | |
| - Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), OR | |
| In communities with a high rate of pneumococcal resistance to penicillin: | |
| - LevofloxacinΔ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg once daily for children ≥16 years, OR | |
| - Linezolid 30 mg/kg per day divided in 3 doses (MAX 1800 mg/day) for children <12 years; 20 mg/kg per day divided in 2 doses (MAX 1200 mg/day) for children ≥12 years | |
| Aspiration pneumonia | |
| Community-acquired | Amoxicillin-clavulanate 40 to 50 mg/kg per day in 2 or 3 divided doses (MAX 1750 mg/day amoxicillin component), OR |
| For patients with type 1 hypersensitivity to beta-lactam antibiotics: | |
| - Clindamycin 30 to 40 mg/kg per day, divided in 3 or 4 doses (MAX 1.8 g/day) | |
CAP: community-acquired pneumonia; MAX: maximum.
* For the infant or child who is suspected to have bacterial CAP and is unable to tolerate liquids at the time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered intramuscularly or intravenously before starting oral antibiotics.
¶ Preferred agent.
Δ In the United States, fluoroquinolones (eg, levofloxacin and moxifloxacin) are approved by the Food and Drug Administration for community acquired pneumonia for patients ≥18 years of age. However, they may be used in younger children if other antibiotics are inappropriate (eg, due to hypersensitivity or local antimicrobial resistance patterns).
◊ Should be used with caution in patients under the age of eight years.
§ Also covers typical bacterial pathogens.
* For the infant or child who is suspected to have bacterial CAP and is unable to tolerate liquids at the time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered intramuscularly or intravenously before starting oral antibiotics.
¶ Preferred agent.
Δ In the United States, fluoroquinolones (eg, levofloxacin and moxifloxacin) are approved by the Food and Drug Administration for community acquired pneumonia for patients ≥18 years of age. However, they may be used in younger children if other antibiotics are inappropriate (eg, due to hypersensitivity or local antimicrobial resistance patterns).
◊ Should be used with caution in patients under the age of eight years.
§ Also covers typical bacterial pathogens.
Data from:
- McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
- Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
- American Academy of Pediatrics. Antibacterial drugs for pediatric patients beyond the newborn period. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015 p.884.
Graphic 80561 Version 20.0
Parenteral empiric antibiotics for inpatient treatment of pediatric pneumonia
| Age group and suspected pathogens | Suggested empiric regimens* |
| 1 to 6 months¶ | |
| Bacterial (not Chlamydia trachomatis or Staphylococcus aureus) |
Ceftriaxone 50 to 100Δ mg/kg per day in 1 or 2 divided doses (2 doses should be used for severe infection or substantial local penicillin resistance), OR
Cefotaxime 150 mg/kg per day in 3 or 4 divided doses (4 doses should be used for severe infection or substantial local penicillin resistance) |
| Chlamydia trachomatis | Azithromycin 10 mg/kg on days one and two of therapy; transition to oral therapy if possible |
| >6 months¶ | |
| Uncomplicated bacterial (not Mycoplasma pneumoniae,Chlamydophila pneumoniae, or S. aureus) |
Ampicillin◊ 150 to 200 mg/kg per day in 4 divided doses (MAX 12 g/day), OR
Penicillin G◊ 200,000 to 250,000 units/kg per day in 4 or 6 divided doses, OR
Cefotaxime§ 150 mg/kg per day in 3 divided doses (MAX 8 g/day or 10 g/day divided in 4 doses for severe infection or substantial local penicillin resistance), OR
Ceftriaxone§ 50 to 100Δ mg/kg per day in 1 or 2 divided doses (MAX 2 g/day or 4 g/day divided in 2 doses for severe infection or substantial local penicillin resistance) |
| M. pneumoniae or C. pneumoniae |
Azithromycin 10 mg/kg once per day for two days (MAX 500 mg/day); transition to oral therapy at 5 mg/kg per day as soon as clinically appropriate, OR
Erythromycin¥ 20 mg/kg per day in 4 divided doses (MAX 4 g/day), OR
Levofloxacin 16 to 20 mg/kg per day in 2 divided doses for children 6 months to 5 years; 8 to 10 mg/kg per day for children 5 to 16 years (MAX 750 mg) |
| Syndrome | Suggested empiric regimens‡ |
| Severe pneumonia† (Refer to UpToDate topic on inpatient treatment of pneumonia in children for clinical features) |
Either ceftriaxone 100 mg/kg per day in 2 divided doses (MAX 4 g/day), OR cefotaxime 150 mg/kg per day in 4 divided doses (MAX 10 g/day)
PLUS one of the following:
|
| Severe pneumonia requiring ICU admission¶¶ (refer to UpToDate topic on inpatient treatment of pneumonia in children for details) |
Vancomycin 60 mg/kg per day in 4 divided doses (MAX 4 g/day) PLUS either
Ceftriaxone 100 mg/kg per day in 2 divided doses (MAX 4 g/day) OR cefotaxime 150 mg/kg per day in 4 divided doses (MAX 10 g/day)
PLUS
Azithromycin 10 mg/kg once per day for two days (MAX 500 mg/day); transition to oral therapy at 5 mg/kg per day as soon as clinically appropriate
PLUS (if necessary)
NafcillinΔΔ 150 mg/kg per day in 4 or 6 divided doses (MAX 12 g/day)
PLUS (if indicated)
Antiviral treatment for influenza |
| Complicated pneumonia/abscess◊◊ |
Either ceftriaxone 100 mg/kg per day in 2 divided doses (MAX 4 g/day) OR cefotaxime 150 mg/kg per day in 4 divided doses (MAX 10 g/day)
PLUS (if necessary)§§
Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 3.6 g/day) OR, for patients allergic to clindamycin or if clindamycin-resistant S. aureus is prevalent¥¥ in the community,
Vancomycin 40 to 60 mg/kg per day in 3 or 4 divided doses (MAX 4 g/day) |
| Nosocomial (hospital-acquired) pneumonia‡‡ | Either gentamicin†† 7.5 mg/kg per day divided in 3 doses for children <5 years; 6 to 7.5 mg/kg per day divided in 3 doses for children ≥5 years OR amikacin 15 to 22.5 mg/kg per day divided in 3 doses, PLUS one of the following:
|
| Community-acquired aspiration pneumonia*** |
Ampicillin-sulbactam 150 to 200 mg/kg per day in 4 divided doses (MAX 8 g/day of ampicillin component)
OR, if MRSA is a consideration,
Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 3.6 g/day)
|
| Hospital-acquired aspiration pneumonia in patients colonized with unusual gram-negative pathogens***,¶¶¶ |
Piperacillin-tazobactam 300 mg/kg per day in 4 divided doses (MAX 16 g/day), OR
Meropenem 60 mg/kg per day in 3 divided doses (MAX 3 g/day) |
MAX: maximum dose; ICU: intensive care unit; MRSA: methicillin-resistant Staphylococcus aureus.
* Consultation with a specialist in infectious diseases for children is suggested for children with severe hypersensitivity to beta-lactam antibiotics (eg, penicillins and cephalosporins).
¶ Add vancomycin 40 to 60 mg/kg per day in 3 or 4 divided doses or clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses for suspected community-associated methicillin resistant S. aureus pneumonia.
Δ The 100 mg/kg per day dose of ceftriaxone should be used only if local rates of penicillin resistance to Streptococcus pneumoniae are substantial (≥25 percent).
◊ Fully immunized with conjugate vaccines for Haemophilus influenzae type b (Hib) and S. pneumoniae in communities where penicillin resistance in invasive strains of pneumococcus is insignificant.
§ Not fully immunized with conjugate vaccines for Hib and S. pneumoniae or in communities where penicillin resistance in invasive strains of pneumococcus is significant.
¥ Parenteral erythromycin is associated with phlebitis, prokinetic and, rarely, cardiotoxic effects.
‡ Dosages recommended are for patients with normal renal function.
† Children of any age with severe infection may benefit from broad-spectrum therapy that addresses both atypical and typical pathogens.
** Should be used with caution under the age of 8 years.
¶¶ These recommendations are for children of any age.
ΔΔ If S. aureus is likely, since methicillin-sensitive S. aureus is more rapidly killed by nafcillin than by vancomycin.
◊◊ Pneumonia complicated by significant parapneumonic effusion or necrotizing process (S. pneumoniae, S. aureus, and Streptococcus pyogenes are possible pathogens).
§§ If MRSA is a consideration.
¥¥ The threshold prevalence of clindamycin-resistant MRSA (constitutive plus inducible) for choosing vancomycin varies from center to center, usually ranging from 10 to 25 percent, trying to balance the benefit of definitive therapy for the patient with the risk of increasing vancomycin resistance in the community.
Additional considerations in the decision to choose vancomycin include the prevalence of MRSA in the community, the severity of illness, and the turn-around time for susceptibilities.
‡‡ The aminoglycoside/meropenem combination should be used if extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are possible etiologies. The aminoglycoside/cephalosporin combination should not be used if aspiration pneumonia is a possibility. Vancomycin should be added to the empiric regimen if MRSA is a consideration.
†† Gentamicin dosage is adjusted for peak concentration of 7 to 9 mcg/mL and trough of <2 mcg/mL.
*** Patients with severe hypersensitivity reaction to beta-lactam antibiotics can be treated with a combination of clindamycin plus an aminoglycoside.
¶¶¶ Vancomycin should be added to the empiric regimen if MRSA is a consideration.
* Consultation with a specialist in infectious diseases for children is suggested for children with severe hypersensitivity to beta-lactam antibiotics (eg, penicillins and cephalosporins).
¶ Add vancomycin 40 to 60 mg/kg per day in 3 or 4 divided doses or clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses for suspected community-associated methicillin resistant S. aureus pneumonia.
Δ The 100 mg/kg per day dose of ceftriaxone should be used only if local rates of penicillin resistance to Streptococcus pneumoniae are substantial (≥25 percent).
◊ Fully immunized with conjugate vaccines for Haemophilus influenzae type b (Hib) and S. pneumoniae in communities where penicillin resistance in invasive strains of pneumococcus is insignificant.
§ Not fully immunized with conjugate vaccines for Hib and S. pneumoniae or in communities where penicillin resistance in invasive strains of pneumococcus is significant.
¥ Parenteral erythromycin is associated with phlebitis, prokinetic and, rarely, cardiotoxic effects.
‡ Dosages recommended are for patients with normal renal function.
† Children of any age with severe infection may benefit from broad-spectrum therapy that addresses both atypical and typical pathogens.
** Should be used with caution under the age of 8 years.
¶¶ These recommendations are for children of any age.
ΔΔ If S. aureus is likely, since methicillin-sensitive S. aureus is more rapidly killed by nafcillin than by vancomycin.
◊◊ Pneumonia complicated by significant parapneumonic effusion or necrotizing process (S. pneumoniae, S. aureus, and Streptococcus pyogenes are possible pathogens).
§§ If MRSA is a consideration.
¥¥ The threshold prevalence of clindamycin-resistant MRSA (constitutive plus inducible) for choosing vancomycin varies from center to center, usually ranging from 10 to 25 percent, trying to balance the benefit of definitive therapy for the patient with the risk of increasing vancomycin resistance in the community.
Additional considerations in the decision to choose vancomycin include the prevalence of MRSA in the community, the severity of illness, and the turn-around time for susceptibilities.
‡‡ The aminoglycoside/meropenem combination should be used if extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are possible etiologies. The aminoglycoside/cephalosporin combination should not be used if aspiration pneumonia is a possibility. Vancomycin should be added to the empiric regimen if MRSA is a consideration.
†† Gentamicin dosage is adjusted for peak concentration of 7 to 9 mcg/mL and trough of <2 mcg/mL.
*** Patients with severe hypersensitivity reaction to beta-lactam antibiotics can be treated with a combination of clindamycin plus an aminoglycoside.
¶¶¶ Vancomycin should be added to the empiric regimen if MRSA is a consideration.
Data from:
- McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
- Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
- American Academy of Pediatrics. Antimicrobial agents and related therapy. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS. (Eds), American Academy of Pediatrics, 2015. p.871.
Graphic 56260 Version 25.0
Management of a small parapneumonic effusion in children
* A small effusion is defined as <10 mm on a lateral decubitus radiograph, or one that opacifies less than one-fourth of the hemithorax.[1]
Courtesy of Khoulood Fakhoury.
- Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
Graphic 78748 Version 2.0
Approach to the management of pneumonia with a moderate or large parapneumonic effusion in children
CT: computerized tomography; IV: intravenous; VATS: video-assisted thoracoscopic surgery.
* A small effusion is defined as <1 cm on a lateral decubitus radiograph, or one that opacifies less than one-fourth of the hemithorax[1].
¶ Ultrasonography is generally preferred over CT for evaluation and monitoring of pleural effusions. CT should be reserved for complicated cases in which further characterization of parenchymal disease is needed, or ultrasonography is inadequate[2].
Δ An alternative to chest tube placement for patients who are clinically stable is a trial of empirically selected intravenous antibiotics for 24 to 72 hours.
◊ Whenever thoracentesis or drainage is performed, the fluid should be cultured and IV antibiotics started; the choice of antibiotics should be reevaluated depending on culture results.
§ If a chest tube is placed, small-bore tubes (<14F) should be used when possible, even for loculated effusions. Small-bore chest tubes are effective with fibrinolytics and cause less discomfort to the patient[2].
¥ For initial treatment of a complicated effusion, most experts agree that either pleural drainage with fibrinolytics or VATS is a reasonable first step. The choice may be influenced by available expertise, cost considerations, and patient preferences.
‡ Patients who fail to improve after VATS may require open thoracotomy to remove the pleural rind and evacuate pyogenic material ("decortication").
† Antibiotics may be changed from IV to oral route when the child has been afebrile for two to five days.
* A small effusion is defined as <1 cm on a lateral decubitus radiograph, or one that opacifies less than one-fourth of the hemithorax[1].
¶ Ultrasonography is generally preferred over CT for evaluation and monitoring of pleural effusions. CT should be reserved for complicated cases in which further characterization of parenchymal disease is needed, or ultrasonography is inadequate[2].
Δ An alternative to chest tube placement for patients who are clinically stable is a trial of empirically selected intravenous antibiotics for 24 to 72 hours.
◊ Whenever thoracentesis or drainage is performed, the fluid should be cultured and IV antibiotics started; the choice of antibiotics should be reevaluated depending on culture results.
§ If a chest tube is placed, small-bore tubes (<14F) should be used when possible, even for loculated effusions. Small-bore chest tubes are effective with fibrinolytics and cause less discomfort to the patient[2].
¥ For initial treatment of a complicated effusion, most experts agree that either pleural drainage with fibrinolytics or VATS is a reasonable first step. The choice may be influenced by available expertise, cost considerations, and patient preferences.
‡ Patients who fail to improve after VATS may require open thoracotomy to remove the pleural rind and evacuate pyogenic material ("decortication").
† Antibiotics may be changed from IV to oral route when the child has been afebrile for two to five days.
References:
- Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
- Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg 2012; 47:2101.
Graphic 76277 Version 7.0
British thoracic guidelines for management of pleural infection in children
| Supportive care |
| Antipyretics should be given. |
| Analgesia is important to keep the child comfortable, particularly if he or she has a chest drain. |
| Chest physiotherapy is not beneficial. |
| Early mobilization is recommended. |
| Antibiotics |
| All cases should be treated with intravenous antibiotics. |
| Coverage for Streptococcus pneumoniae should be included. Broader spectrum coverage is necessary for children with hospital acquired infections, and effusions secondary to surgery, trauma, or aspiration. |
| Antibiotic therapy should be tailored to microbiology results. |
| Oral antibiotics should be continued at discharge for one to four weeks or longer if there is residual disease. |
| Chest drains |
| Chest drains should be inserted by adequately trained personnel. |
| Ultrasonography should be used to guide thoracentesis or drain placement. |
| Adequate analgesia and/or sedation, with appropriate monitoring, should be used during the procedure. |
| Small drains (including pigtail catheters) should be used whenever possible to minimize discomfort; there is no evidence that large bore chest drains confer any advantage over small drains. |
| A chest radiograph should be performed after insertion of the chest drain. |
| A bubbling chest drain should never be clamped. |
| A clamped chest drain should be immediately unclamped if the patient complains of chest pain or breathlessness. |
| The drain should be removed once there is clinical resolution. |
| A drain that cannot be unblocked should be removed and replaced if significant pleural fluid remains. |
| Intrapleural fibrinolytics |
| Intrapleural fibrinolytics may shorten hospital stay and are recommended for any complicated parapneumonic effusion or empyema. |
| Surgery |
| Failure of chest tube drainage, antibiotics, and fibrinolysis should prompt early discussion with a thoracic surgeon. |
| Patients should be considered for surgical treatment if they have persisting sepsis in association with persistent pleural fluid, despite chest tube drainage and antibiotics. |
| Organized empyema in a symptomatic child may require formal thoracotomy and decortication. |
| Follow-up |
| Children should be followed until they have recovered completely and their chest radiograph has returned to near normal. |
Adapted from Balfour-Lynn, IM, Abrahamson, E, Cohen, G, et al. BTS guidelines for the management of pleural infection in children. Thorax 2005; 60 Suppl 1:i1.
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Summary of the data from a systematic review of primary operative versus nonoperative therapy for pediatric empyema
| Outcome | Antibiotics and chest tube (N = 3183) | Fibrinolytic therapy* (N = 64) | VATS¶ (N = 176) | Thoracotomy (N = 175) |
| Mortality rate (range) | 3.3 percent (0 to 35 percent) | 0 percent | 0 percent | 0 percent |
| Failure rateΔ (range) | 23.6 percent (0 to 67 percent) | 9.4 percent (6.7 to 14.2 percent) | 2.8 percent | 3.1 percent |
| Length of stay | 20 ± 8.3 days | 10.7 ± 5.1 days | 11.2 days | 10.6 days |
| Duration of chest tube | 10.6 ± 3.4 days | 4 days | 4 days | 6.2 days |
| Duration of antibiotics | 21.3 ± 7.9 days | Not specified | 13.2 days | Not specified |
| Complication rate◊ (range) | 5.6 percent (0 to 45 percent) | 12.5 percent (0 to 16.6 percent) | 5.4 percent | 5.2 percent |
* Fibrinolytic therapy: Treatment with fibrinolytics either at the time of or within 24 hours of tube thoracostomy.
¶ VATS: Video-assisted thoracoscopy.
Δ Failure: Failure of primary intervention necessitating subsequent operative intervention.
◊ Complications typically included pneumothorax, bronchopleural fistula, persistent or recurrent empyema, bleeding, and wound infection.
¶ VATS: Video-assisted thoracoscopy.
Δ Failure: Failure of primary intervention necessitating subsequent operative intervention.
◊ Complications typically included pneumothorax, bronchopleural fistula, persistent or recurrent empyema, bleeding, and wound infection.
Adapted from Avansino, JR, Goldman, B, Sawin, RS, Flum, DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics 2005; 115:1652.
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