The Changing Face of Pleural Empyemas in Children: Epidemiology and Management

Objective. Empyema remains a signifi- cant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resis- tant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-as- sisted 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 re- view. 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 pneu- mococcal conjugate vaccine, 3 major changes have oc- curred (1999 -2000 vs 2001-2002): 1) the number of pa- tients 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 ad- mission) significantly decreased the length of hospital- ization (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 de- creased duration of fever and length of hospitalization. Pediatrics 2004;113:1735-1740; empyema, community-ac- quired pneumonia, video-assisted thoracic surgery, chil- dren, microbiology. ABBREVIATIONS. CTD, chest tube drainage; VATS, video-as- sisted thoracic surgery; PCN-NS, penicillin nonsusceptible; MIC, minimum inhibitory concentration; LOS, length of stay; MRSA, methicillin-resistant Staphylococcus aureus; PCN-S, penicillin sus- ceptible; MSSA, methicillin-susceptible Staphylococcus aureus.