title: 'Less may be best'-Pediatric parapneumonic effusion and empyema management: Lessons from a UK center.
abstract: BACKGROUND
  Children with empyema are managed at our center using a protocol-driven clinical care pathway. Chemical fibrinolysis is deployed as first-line management for significant pleural disease. We therefore examined clinical outcome(s) to benchmark standards of care while analyzing disease severity with introduction of the pneumococcal conjugate vaccine.
  
  
  METHODS
  Medical case-records of children managed at a UK pediatric center were surveyed from Jan 2006 to Dec 2012. Binary logistic regression was utilized to study failure of fibrinolytic therapy. The effects of age, comorbidity, number of days of intravenous antibiotics prior to drainage and whether initial imaging showed evidence of necrotizing disease were also studied.
  
  
  RESULTS
  A total of 239 children were treated [age range 4months-19years; median 4years]. A decreasing number of patients presenting year-on-year since 2006 with complicated pleural infections was observed. The majority of children were successfully managed without surgery using antibiotics alone (27%) or a fine-bore chest-drain and urokinase (71%). Only 2% of cases required primary thoracotomy. 14.7% cases failed fibrinolysis and required a second intervention. The only factor predictive of failure and need for surgery was suspicion of necrotizing disease on initial imaging (P=0.002, OR 8.69).
  
  
  CONCLUSIONS
  Pediatric patients with pleural empyema have good outcomes when clinical care is led by a multidisciplinary team and protocol driven care pathway. Using a 'less is best' approach few children require surgery.
authors.affiliation: Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
authors.forename: Anna-May
authors.initials: AM
authors.lastname: Long
authors.affiliation: Medical School University of Liverpool, Liverpool, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Smith-Williams
authors.affiliation: Department of Respiratory Medicine, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Mayell
authors.affiliation: Department of Respiratory Medicine, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
authors.forename: Jon
authors.initials: J
authors.lastname: Couriel
authors.affiliation: Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
authors.forename: Matthew O
authors.initials: MO
authors.lastname: Jones
authors.affiliation: Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK; Academic Department of Paediatric Surgery, University of Liverpool, Liverpool, UK. Electronic address: paul.losty@liv.ac.uk.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Losty
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D000072700:Conservative Treatment / Q000379:methods*; D019468:Disease Management; D016724:Empyema, Pleural / Q000628:therapy*; D005260:Female; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D010996:Pleural Effusion / Q000628:therapy*; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Antibiotics; Clinical trials; Empyema; Parapneumonic effusion; Thoracic surgery; Urokinase