Recommended Initial Treatment Approach for Phlegmon Formation in Children
Non-operative management with antibiotics and percutaneous drainage (if available) is the recommended initial treatment approach for phlegmon formation in children, particularly in settings where advanced laparoscopic expertise is not available. 1
Initial Management Algorithm
Step 1: Assessment and Diagnosis
- Confirm the presence of phlegmon using appropriate imaging (ultrasound is recommended for initial assessment) 1
- All children with suspected phlegmon should be admitted to hospital for treatment 1
- Blood cultures should be performed in all patients before starting antibiotics 1
Step 2: Initial Treatment
- Begin broad-spectrum intravenous antibiotics immediately 1
- For appendiceal phlegmon:
Step 3: Antibiotic Selection
- Empirical treatment must cover common pathogens including Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus 1
- Recommended antibiotic options include:
- For hospital-acquired infections or those secondary to surgery, trauma, or aspiration, broader spectrum coverage is required 1
Special Considerations by Type of Phlegmon
Appendiceal Phlegmon
- Non-operative management with antibiotics and percutaneous drainage (if available) is recommended as first-line treatment 1
- Laparoscopic approach may be considered where advanced laparoscopic expertise is available 1
- Routine interval appendectomy after successful non-operative management is not recommended for children 1
- Interval appendectomy should only be performed for those with recurrent symptoms 1
Pleural Phlegmon
- Intrapleural fibrinolytics are recommended for any complicated parapneumonic effusion with loculations or empyema 1
- Urokinase should be given twice daily for 3 days (6 doses total) using appropriate weight-based dosing 1
- Chest tube drainage with fibrinolytics is recommended; if not responding (approximately 15% of patients), proceed to video-assisted thoracoscopic surgery (VATS) 1
Duration of Treatment
- Continue intravenous antibiotics until the child is afebrile or at least until any drainage device is removed 1
- Oral antibiotics should be given at discharge for 1-4 weeks, but longer if there is residual disease 1
- Where possible, antibiotic choice should be guided by microbiology results 1
Monitoring Response to Treatment
- Children who are not responding to initial therapy after 48-72 hours should be reassessed 1
- Consider imaging evaluation to assess the extent and progression of the phlegmon 1
- Further investigation may be needed to identify whether the original pathogen persists or has developed resistance 1
Indications for Surgical Intervention
- Failure of conservative management (antibiotics and drainage) should prompt early discussion with a surgeon 1
- Consider surgical treatment if there is persisting sepsis in association with a persistent collection despite drainage and antibiotics 1
- In the case of appendiceal phlegmon, laparoscopic surgery in experienced hands is a safe and feasible alternative to non-operative management 1
- Surgical approach may be associated with shorter length of hospital stay and fewer additional interventions than conservative treatment 1
Pitfalls and Caveats
- Avoid routine interval appendectomy after successful non-operative management of appendiceal phlegmon in children 1
- Never use substantial force or a trocar when inserting a drain for drainage of phlegmon 1
- A bubbling chest drain should never be clamped 1
- Chest physiotherapy is not beneficial and should not be performed in children with empyema 1
- For appendiceal phlegmon in adults ≥40 years old, consider both colonic screening with colonoscopy and interval full-dose contrast-enhanced CT scan due to higher incidence of appendicular neoplasms (3-17%) 1