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Predictors of Failure of Medical Management in Children with Empyema Thoracis: A Systematic Review
Meenakshi Sachdeva1,2, Kanchankumar Bhagyawant3, Pawan Kalyan4
1Advanced Centre for Evidence Based Child Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
Insights
Predicting treatment failure in pediatric empyema thoracis remains challenging. Current evidence is insufficient to identify reliable clinical, radiological, or laboratory predictors for guiding medical or surgical management.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Infectious Diseases
Background:
- Empyema thoracis in children often requires surgical intervention when medical management fails.
- Identifying predictors of medical management failure is crucial for timely surgical planning.
Purpose of the Study:
- To systematically review existing literature for predictors of medical management failure or surgical necessity in pediatric empyema thoracis.
- To identify clinical, radiological, laboratory, or microbiological factors associated with treatment outcomes.
Main Methods:
- A comprehensive systematic search of seven major databases and four trial registries was performed.
- Included studies were observational, focusing on predictors of treatment failure in pediatric empyema thoracis.
- Data extraction and risk of bias assessment were conducted independently by two reviewers.
Main Results:
- Seven studies were included from over 12,000 citations.
- One study suggested immediate ICU admission, absence of complex septations on ultrasound, and positive blood cultures as predictors.
- Other potential indicators included persistent pus discharge and loculations on imaging despite treatment, though evidence certainty was very low.
Conclusions:
- Current evidence is limited and lacks clinically meaningful predictors for medical management failure or surgical need in pediatric empyema thoracis.
- The heterogeneity and low quality of existing studies restrict generalizability and reliable prediction.
Context:
Children with empyema thoracis often respond to medical management, but some do not, and require surgical intervention. Prediction of failure of medical management will help to guide further management and plan surgical intervention.
Objective:
To systematically review literature for clinical, radiological, laboratory, or microbiological predictors, associated with failure of medical management or the need for surgery in children with empyema thoracis.
Evidence Acquisition:
A systematic search was conducted in seven databases (PubMed, Embase, Cochrane Library, Scopus, Web of Science, ProQuest, and Open Grey) and four trial registries. Observational studies exploring predictors of treatment failure in empyema thoracis were eligible. Two reviewers independently screened the studies, extracted the data, and assessed the risk of bias. Data were analyzed in accordance with the review protocol.
Results:
Amongst 12,311 citations identified, seven studies were included. One study identified three statistically significant predictors of medical treatment failure, viz. immediate ICU admission: OR (95%CI) 1.95 (1.18, 3.22); absence of complex septations on ultrasonography: 1.72 (1.21, 2.47); and positive blood culture: 2.8 (1.54, 5.07). Another study reported that "continuing pus discharge for ≥ 10 days after chest tube insertion" and "persistence of loculations on ultrasonography or CT scan despite fibrinolytic therapy" prompted surgical intervention. The presence of fever was identified as a significant predictor, although its duration and grade were not reported. The evidence had very low overall certainty, being limited by small, single-center, retrospective studies with heterogeneous designs, population, and outcome definitions, limiting generalizability.
Conclusions:
Current evidence did not identify any clinically meaningful predictors of the failure of medical management (or need for surgery) in children with empyema thoracis.
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