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The changing face of pleural empyemas in children: epidemiology and management
Karen D Schultz1, Leland L Fan, Jay Pinsky
1Department of Pediatrics, Pulmonology Section, Baylor College of Medicine Houston, Texas, USA.
Insights
Pediatric empyema has shifted towards Staphylococcus aureus, including MRSA, following the pneumococcal conjugate vaccine. Early video-assisted thoracoscopy (VATS) significantly shortens hospital stays for children with empyema.
Area of Science:
- Pediatric infectious diseases
- Thoracic surgery
- Microbiology
Background:
- Empyema in children presents a significant public health challenge, contributing to substantial morbidity.
- Evolving microbial resistance patterns and widespread vaccination campaigns necessitate re-evaluation of empyema management strategies.
- The role of minimally invasive surgical techniques like video-assisted thoracoscopy (VATS) in pediatric empyema outcomes requires ongoing assessment.
Purpose of the Study:
- To analyze temporal changes in pediatric empyema epidemiology and microbiology.
- To evaluate the impact of the pneumococcal conjugate vaccine (PCV) on causative pathogens.
- To assess the effectiveness of early video-assisted thoracoscopy (VATS) in improving patient outcomes.
Main Methods:
- Retrospective chart review of pediatric patients diagnosed with empyema and community-acquired pneumonia from 1993-2002.
- Data collection included demographics, clinical presentation, radiographic and laboratory findings (including cultures), and hospital course.
- Analysis compared outcomes before and after the widespread adoption of the pneumococcal conjugate vaccine and evaluated early versus late VATS.
Main Results:
- A decrease in pediatric empyema admissions was observed post-PCV introduction (23 to 12.6 per 10,000 admissions).
- Streptococcus pneumoniae prevalence declined, while Staphylococcus aureus, particularly methicillin-resistant S aureus (MRSA), became the predominant pathogen.
- Early VATS (<48 hours) significantly reduced hospitalization duration compared to late VATS (>48 hours).
Conclusions:
- The microbial landscape of pediatric empyema has shifted, with a notable increase in S aureus, including MRSA.
- The pneumococcal conjugate vaccine has altered the epidemiology of bacterial pneumonia leading to empyema.
- Implementing early VATS as initial therapy for pediatric empyema is associated with improved clinical outcomes, including shorter hospital stays.
Objective:
Empyema remains a significant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-assisted thoracoscopy (VATS).
Methods:
A retrospective chart review was performed on all patients who were discharged with a diagnosis of empyema and community-acquired pneumonia over a 10-year period (1993-2002) at Texas Children's Hospital in Houston, Texas. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course.
Results:
A total of 230 charts were available for review. The mean age of the patients was 4.0 +/- 3.6 years. Of the pleural fluid cultures performed, 32% (69 of 219) were positive. An additional 27 patients had a cause identified by blood culture. The first penicillin-nonsusceptible Streptococcus pneumoniae was identified in 1995, and the first methicillin-resistant Staphylococcus aureus was identified in 1998. After the universal use of the pneumococcal conjugate vaccine, 3 major changes have occurred (1999-2000 vs 2001-2002): 1) the number of patients admitted with empyema (per 10 000 admissions) has decreased from 23 to 12.6; 2) the prevalence of S pneumoniae has decreased from 66% (29 of 44) to 27% (4 of 15); and 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization (11.49 +/- 6.56 days vs 15.18 +/- 8.62 days).
Conclusions:
The microbiologic cause of empyema has changed with an increasing incidence of S aureus, particularly methicillin-resistant S aureus. The use of VATS for initial therapy of empyema results in decreased duration of fever and length of hospitalization.
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