Paediatric Empyema: New Insights into Treatment and Management

Abstract

Introduction/Aim: Prevalence and severity of empyema in children is increasing in Australia with changes in aetiology (increasing rates of S.pyogenes(GAS) internationally). Interventional options include chest drain with fibrinolytics (CDF) or Video Assisted Thoracoscopic Surgery (VATS), with variations across countries. We audited our local approach at Queensland Children's Hospital (QCH), a tertiary paediatric institution to describe the local experience. Methods: A retrospective analysis of three consistent time points (May-July) in years unaffected by COVID (2019, 2022, 2023) were examined. Treatment modality was clinically determined. Data was extracted from the electronic medical records for variables including prevalence, causative organisms, type of procedure (TOP), length of admission (LOA), LOA post procedure, chest drain duration, and (as a surrogate for associated pain) the duration of acute pain team service involvement (APS). Values were compared across the specified time periods using Mann Whitney U and chi-squared analysis as appropriate. Results: 62 children were treated: 13 in 2019, 15 in 2022, 34 in 2023. Similar age was observed [Median (range) 5 (2mo-15), 5 (1-11) and 5 (10mo-13) respectively].Organisms isolated were S.pneumoniae (48.3%), GAS (16.1%), Mycoplasma spp. (4.8%), S.aureus (3.2%), H.influenzae (1.6%), and no organism (25.8%). GAS was only detected in 2023 (29.4% of cases in 2023). Viruses were detected in 51.7% of cases: Influenza A/B was most common (20.9%) with increased prevalence in 2023 [33% vs 7.1% in other years]. VATS was the initial intervention in 51.6% vs. 35.4% CDF, with 13% IV antibiotics alone. CDF use increased in 2023 (46%) vs. other years (18%, p=0.043), with a consistent proportion of interventions performed by surgeons (p=1.00). The proportion of cases where surgeons performed the intervention did not change across periods (p=1.00). LOA was numerically greater for CDF but did not reach statistical significance (p=0.09). CDF was associated with a significant increase in chest drain duration and duration of APS involvement vs. VATS (both p<0.01). Only 1 (5.3%) CDF subjects had VATS as a 2nd intervention procedure.Conclusion: Empyema rates increased in 2023 with increased rates of GAS. Recent shift in practice led to more CDF as initial intervention. CDF was associated with greater chest drain duration and pain service involvement vs. VATS. Future work will confirm these patterns in an expanded dataset and explore factors underlying this change in practice.