K. W. Gonzalez1, B. G. Dalton1, A. L. Myers1, J. G. Newland1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA
Introduction:
Chemical fibrinolysis has been shown in prospective randomized trials to be as effective as surgical debridement for the treatment of empyema in children, and both therapies are widely used today. However, no studies have effectively evaluated antibiotic treatment. We wanted to evaluate how different treatment strategies for pediatric empyema impacted antibiotic utilization.
Methods:
A retrospective chart review of patients with empyema who underwent chemical and/or mechanical fibrinolysis at a single, dedicated children’s hospital from 2005-2013. Data points included duration of antibiotic therapy, culture results, presence of necrosis or abscess, and adverse reactions associated with antibiotic therapy. Immunocompromised patients and those with additional foci of infection were excluded. Comparative analysis was performed utilizing 2-tailed Student t-tests and Pearson correlation. Tukey HSD was used to analyze differences between chemical and mechanical fibrinolysis.
Results:
There were 169 patients identified of which 27 underwent primary video assisted thoracoscopic debridement (VATS), 123 patients had chemical fibrinolysis via tube thoracostomy with tissue plasminogen activator (tPA), and 19 had tPA followed by VATS. The mean (±STD) duration of total antibiotic was 25.7 ± 6.5 days (d), and following a 24 hour afebrile period was 19.4 ± 6.3d. Patients who underwent chemical fibrinolysis had a significantly shorter mean duration of parenteral antibiotic therapy when compared to primary VATS (9.2 ± 3.6d versus 11.6 ± 5.5d, p 0.04) and VATS following tPA (9.2 ± 3.6d versus 14.3 ± 8.1d, p <0.01). There was no correlation between the length of antibiotic therapy following discharge and last recorded white blood cell count (Figure 1). The presence of positive blood or pleural cultures also did not correlate with duration of antibiotic therapy. Patients with necrosis or abscess (n=26) had an increased total mean duration of antibiotics (29.3 ± 5.7d versus 25.1 ± 6.4d, p <0.01). Seventy patients (41%) had an adverse reaction related to antibiotic use (rash, nausea/vomiting, diarrhea, antifungal, other). There was no correlation between duration of antibiotics and complication. There were no recurrences of empyema after discontinuing antibiotics.
Conclusion:
Patients diagnosed with empyema are currently placed on a protracted and variable time course of antibiotic therapy, which seems to be influenced by primary treatment and the presence of necrosis or abscess. Since nearly half of our population experienced side effects from antimicrobial therapy, a standardized protocol with truncated duration of treatment should be considered.
