Conservative Management of Complicated Pneumonias in Children

Background: BTS guidelines for treatment of empyema recommend drainage, fibrinolysis and antibiotics, which has a similar efficacy to surgical intervention. Both strategies reduce the duration of illness but complications such as bronchopulmonary fistula are being increasingly described¹

Objectives: To consider the role for treatment limited to antibiotics with outpatient assessment in those children who are stable, with complicated pneumonia demonstrated on CXR, even with large empyema or effusion.

Methods: We retrospectively reviewed all cases of paediatric empyema between December 2015 and August 2016 at a tertiary respiratory centre. We included only patients not treated in a high dependency unit.

Results: We identified 8 patients between 12m and 10y old. All 8 had moderate to large pleural effusion with no substantial co-morbidity. 5 had a long history of illness. 3 had antibiotics in the community. 3 had a septated effusion. 4 patients were treated with IV antibiotics alone for 2-14 days. This was followed by oral antibiotic treatment of 2–4 weeks. 4 patients underwent insertion of an 8Fr pigtail chest drain.1 patient was lost to follow up. In the remaining 3 patients treated with a chest drain, there was some degree of re-accumulation of the effusion after drain removal. No patients had surgical decortication. After re-accumulation, these patients had IV antibiotics for 2-4 weeks. All 7 patients had complete resolution of effusion on imaging performed as an outpatient.

Conclusion: In moderate pleural effusion, even after failure of initial treatment or with loculation, conservative management with antibiotics alone can be considered as a viable alternative to progression to further invasive treatment.

References:

1. Sawicki GS et al. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur. Respir. J. 31, 1285–1291 (2008).