[Antibiotic treatment of child empyema: lessons from published studies and therapeutic options]

Children empyema pose therapeutic problems for reasons that are not clearly established. The pneumococcus is by far the bacteria most often responsible. There is no clinical study demonstrating the superiority of an antibiotic regimen over another. Even though these studies exist, they would be challenged by the evolution of bacterial resistance that may vary depending on different parameters: antibiotic pressure, vaccination etc. Therefore, it is on the microorganism suspected, the data of bacterial resistance and pharmacokinetics-pharmacodynamic (Pk / Pd) parameters that lead to antibiotic choice. An analysis of these elements can lead to the following proposals. For pneumococcal empyema, intravenous 3rd generation cephalosporin at dose of 100mg/kg/day divided 4 injections IV for cefotaxime or 50mg/kg/day in once a day for ceftriaxone. These doses are likely to be doubled in case of pneumococcus resistant to penicillin. Neither fosfomycine or aminoglycosides have a sufficient activity against pneumococcus to be offered in combination. If an association seems useful, the two best candidates are vancomycin and rifampin. For group A streptococcus empyema, clindamycin in association with is certainly the best choice. The recent evolution of resistance to macrolides should lead to check the susceptibility of the bacteria implicated. If S. aureus is susceptible to meticilline (most often), a M penicillin by parenteral route associated with an aminoglycoside is proposed. Fosfomycine can be an alternative to the aminoglycoside. If S. aureus is meticilline resistant, the association vancomycin and rifampicin seems best suited. When no bacteria has been isolated, the choice against pneumococcus resistant seems most appropriate.