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The Changing Face of Empyemas in Children

Texas Children’s Hospital/Baylor College of Medicine, Houston, TX

PURPOSE: Empyema remains a significant cause of morbidity in children. This study was undertaken to evaluate the changes that have affected the outcome in children including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video assisted thoracoscopy (VATS).

METHODS: A retrospective chart review was performed on all patients discharged with a diagnosis of empyema and community-acquired pneumonia over a ten-year period (1993-2002) at Texas Children’s Hospital in Houston, TX. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course.

RESULTS: Two hundred thirty charts were available for review. The mean age was 4.0±3.6 years. Of the pleural fluid cultures performed, 32% (69/219) were positive. An additional 27 patients had an etiology identified by blood culture. The first penicillin non-susceptible S. pneumoniae was identified in 1995, and the first methicillin-resistant S aureus (MRSA) was identified in 1998. Following the universal use of the pneumococcal conjugate vaccine three major changes have occurred (1999-2000 vs 2001-2002): (1) the number of patients admitted with empyema (per 10,000 admissions) has decreased from 23 to 11 (p=0.04); (2) the prevalence of S pneumoniae has decreased from 32% (28/87) to 9% (5/53) (p=0.001); and (3) S aureus has become the most common pathogen isolated (8% vs. 19%, p=0.05) with 70% of those being methicillin-resistant. The use of early VATS (<48 hours after admission) has significantly decreased the length of hospitalization (11.5±6.6d vs 15.4±8.8d, p=0.005) as well as length of fever (7.1±5.6d vs 9.4±5.5d, p=0.046)

CONCLUSIONS: The microbiologic etiology of empyema has changed with an increasing incidence of S aureus and particularly of MRSA. The use of VATS for initial therapy of empyema results in decreased length of stay and length of fever.

CLINICAL IMPLICATIONS: Initial antibiotic therapy in these patients should empirically cover MRSA. Early VATS is beneficial to patients and is now part of the standard therapy for patients with empyema admitted to our institution.

DISCLOSURE: K.D. Schultz, None.