Antibiotic utilization based on primary treatment of pediatric empyema

Abstract

Background

Chemical fibrinolysis has been shown to be as effective as surgical debridement for the treatment of pediatric empyema. However, no studies effectively evaluate antibiotic treatment. We evaluated antibiotic utilization among different treatments of pediatric empyema.

Methods

This is a retrospective review of 169 empyema patients who underwent chemical and/or mechanical fibrinolysis at a dedicated children's hospital from 2005–2013. Data points included duration of therapy, cultures, presence of necrosis or abscess, and adverse drug reactions. Immunocompromised patients and those with additional foci of infection were excluded.

Results

Twenty-seven patients underwent video-assisted thoracoscopic surgery (VATS), 123 had chemical fibrinolysis via tube thoracostomy with tissue plasminogen activator (tPA), and 19 had tPA followed by VATS. The mean (±standard deviation) duration of total antibiotic therapy was 25.7 ± 6.5 d; following a 24 h afebrile period of 19.4 ± 6.3 d. Patients who had tPA had a significantly shorter duration of parenteral antibiotic therapy when compared with primary VATS (9.2 ± 3.6 d versus 11.6 ± 5.5 d, P = 0.04) and VATS following tPA (9.2 ± 3.6 d versus 14.3 ± 8.1 d, P < 0.01). Patients with necrosis or abscess (n = 26) had an increased total duration of antibiotics (29.3 ± 5.7 d versus 25.1 ± 6.4 d, P < 0.01). Seventy patients (41%) had an adverse reaction related to antibiotic use.

Conclusions

Patients with empyema currently receive a protracted variable course of antibiotic therapy influenced by primary treatment and the presence of necrosis or abscess. With a high incidence of adverse reactions, a standardized protocol with truncated treatment duration should be considered.

Introduction

The treatment of pediatric empyema has undergone a significant transformation over the course of the past decade. Mechanical debridement was originally performed by thoracotomy, progressing to a minimally invasive approach via video-assisted thoracoscopic surgery (VATS). When compared to a thoracostomy tube, VATS resulted in a more timely and thorough resolution of the pleural space disease [1]. However, practitioners have begun injecting tissue plasminogen activator (tPA) via the thoracostomy tube, which results in disruption of the tissue loculations leading to adequate drainage. Two randomized studies comparing mechanical debridement (VATS) and chemical debridement (tPA or urokinase) found no difference in the length of hospitalization or other outcome parameters except surgical debridement was more expensive [2], [3].

No studies have been completed evaluating the appropriate length of antibiotic therapy for empyema. The current recommendation is a 10-d course once afebrile [1]. However, this is a grade D recommendation and traditionally, patients have continued antimicrobial therapy much longer. One study found an average parenteral antibiotic duration of 24 d although fever abated by 9 d raising the concern that increased duration of therapy could contribute to bacterial resistance [4]. A recent survey of infectious disease experts failed to reach a consensus on antibiotic selection or duration for empyema. Thirty-five percent recommended 11–14-d treatment, 41% advised 15–21 d, and 17% recommended >21 d [5]. We sought to assess the current medical treatment of empyema in our institution to help establish an evidence-based treatment protocol.