What is the recommended treatment for a gross empyema in a child?

Treatment of Gross Empyema in Children

Start broad-spectrum intravenous antibiotics immediately, insert a small-bore chest drain under ultrasound guidance, and administer intrapleural urokinase twice daily for 3 days; if the child remains febrile with persistent pleural collection after 7 days, refer urgently for video-assisted thoracoscopic surgery (VATS). 1, 2

Initial Medical Management

Immediate Antibiotic Therapy

• Begin broad-spectrum IV antibiotics targeting Streptococcus pneumoniae, Staphylococcus aureus, and group A Streptococcus without waiting for culture results 2, 3
• Ensure anaerobic coverage is included in all cases, as anaerobes frequently co-exist 4
• Never use aminoglycosides (gentamicin, tobramycin, amikacin) because they have poor pleural penetration and are inactivated by acidic pleural fluid 4
• Adjust antibiotics based on culture results when available 2

Chest Drain Insertion

• Insert a small-bore chest drain (8-14 French) under ultrasound guidance to minimize discomfort and improve success rates 1, 2
• Connect the drain to a unidirectional flow drainage system kept below the patient's chest level at all times 2
• Clamp the drain for 1 hour after initially removing 10 ml/kg to prevent re-expansion pulmonary edema 1, 2
• Check drain patency daily by flushing if drainage suddenly stops 1

Intrapleural Fibrinolytic Therapy

Administer intrapleural urokinase for any gross empyema or complicated parapneumonic effusion with loculations, as this shortens hospital stay and improves drainage. 1, 2

Dosing Protocol

• For children ≥10 kg: 40,000 units urokinase in 40 ml 0.9% saline 1, 2
• For children <10 kg: 10,000 units urokinase in 10 ml 0.9% saline 1, 2
• Administer twice daily for 3 days (total of 6 doses) 1, 2
• Recent data from Dubai showed median hospital stay of 11 days with fibrinolysis versus 27 days without, with marked reduction in surgical need 5

Surgical Intervention

Timing of Surgical Referral

• Initiate early discussion with a thoracic surgeon if the child fails to respond within 7 days of chest tube drainage, antibiotics, and fibrinolytics 1, 2
• Consider earlier referral (within 3-5 days) if persistent sepsis continues despite optimal medical management 4

Specific Surgical Indications

• Persisting sepsis with persistent pleural collection despite antibiotics, chest tube drainage, and fibrinolytics 1, 2
• Complex empyema with significant lung pathology (delayed presentation with thick peel and trapped lung) 1, 2
• Bronchopleural fistula with pyopneumothorax 2
• Multiple loculations not responding to fibrinolytic therapy 2
• Large effusion occupying >40% of the hemithorax 4

Choice of Surgical Approach

• VATS is the preferred surgical approach for early-stage empyema, offering less postoperative pain, shorter hospital stay (7.4 vs 15.4 days), and better cosmetic results compared to open thoracotomy 2, 6
• VATS is most effective when performed early in the fibrinopurulent stage; failure rates increase in advanced organized empyema 1, 2
• Reserve formal thoracotomy with decortication for late-presenting, chronic, or organized empyema with thick fibrous peel causing trapped lung 1, 2
• Contraindications to VATS include inability to create a pleural window, thick purulent material, or dense fibrotic pleural rind 1

Supportive Care

• Provide antipyretics for fever control 1
• Ensure adequate analgesia, particularly with a chest drain in place 1
• Do not perform chest physiotherapy, as it is not beneficial in children with empyema 1
• Encourage early mobilization and exercise 1

Monitoring Clinical Response

• Expect clinical improvement within 48-72 hours, including fever resolution, improved respiratory status, and decreased inflammatory markers 4
• Obtain repeat ultrasound or CT if clinical improvement does not occur to identify residual loculations or suboptimal catheter position 4
• Secondary thrombocytosis (platelets >500) and scoliosis on chest radiograph are common but benign; no specific treatment is required 1

Critical Pitfalls to Avoid

• A persistent radiological abnormality in a symptom-free, clinically well child is NOT an indication for surgery 1, 2
• Never delay surgical referral beyond 7 days of failed medical management, as delays increase morbidity, prolong hospitalization, and worsen mortality 4
• Never omit anaerobic coverage, as anaerobes are present in the majority of empyema cases 4
• Avoid blind chest tube placement; always use ultrasound or CT guidance 4

Follow-Up

• Follow children after discharge until complete recovery and chest radiograph returns to near normal 1
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis in appropriate cases 1