Community acquired pneumonia with effusion: One approach

By Matthew Gray, MD, and Patricia Lye, MD

Community acquired pneumonia is a common pediatric infection with increased severity and mortality when complicated by parapneumonic effusion or empyema. An estimated 0.6 percent of pneumonias will progress to empyema¹, and the overall incidence of empyema is increasing^2,3. In a study of children who presented to Primary Children's Medical Center in Utah from 1996-2004, there were 478 cases of pediatric empyema⁴. During the course of the study, the incidence of empyema increased from 38 cases per year to 71.5 cases per year. At Children's Hospital of Wisconsin, there were 35 patients with community acquired pneumonia complicated by effusion or empyema from July 2007 through June 2008.

Since the establishment of routine PCV7 vaccinations in children younger than 2, the epidemiology of pneumonia is changing. While pneumococcal pneumonia remains the most common cause of bacterial pneumonia, recent studies have suggested that there is a decrease in the proportion of complicated pneumonia caused by S. pneumoniae and an increase in the proportion caused by S. aureus^2,3. In addition, surveillance studies suggest there has been a selection of nonvaccine serotypes among those cases caused by S. pneumoniae.⁵ In the same study at Primary Children's Medical Center, 78 percent of pneumococcal isolates identified in patients with empyema were nonvaccine serotypes⁴.

Despite the common nature of pediatric community acquired pneumonia with effusion, there are widely varying treatment practices. Due to a lack of quality evidence, most existing treatment guidelines are based primarily on expert opinion6. Of the current multiple treatment modalities, recent focus has been on placing a chest tube with the instillation of fibrinolytics as well as video-assisted thorascopic surgery. Two prospective randomized trials comparing video-assisted thorascopic surgery to chest tube placement with instillation of fibrinolytics found that there was no difference in treatment outcome based on length of hospital stay, analgesic requirement and days until afebrile^7,8.

In light of the changing epidemiology of pneumonia, equivocal evidence and conflicting recommendations from the literature, and concern about lack of standardized care, a group of interested Children's Hospital of Wisconsin clinicians convened to investigate this common therapeutic dilemma. Care providers from critical care, general surgery, hospitalist medicine, infectious diseases, pulmonology and radiology participated. An extensive review of the medical and surgical literature was performed, with a goal of developing a clinical practice guideline and order set. Guiding principles included:

• Using existing guidelines with highest level of evidence available.
• Minimizing invasive procedures, radiation exposure and frequency of sedation.
• Using local expertise and providing an accessible source of information for Children's Hospital of Wisconsin providers.

See Figure 1 for the Community Acquired Pneumonia with Pleural Effusion Clinical Practice Guideline that was developed. Key points include:

• Combining PICC placement and chest tube placement.
• Forgoing a staged approach with thoracentesis and then chest tube placement.
• Initial considerations of when to place a chest tube with fibrinolytics versus a primary video-assisted thorascopic surgery.
• Restriction of initial use of vancomycin to critically ill children.
• Guidance on considerations for consultation.
• Guidance on daily treatment decisions and monitoring.

Clinicians need easily accessible resources to help them make decisions about common diseases. Although several guidelines exist for complicated pneumonia, the evidence behind them is not clearly outlined. The acceptance and use of treatment guidelines improves when there is agreement and guidance from local experts. This guideline aims to provide some of that perspective.

While Children's Hospital of Wisconsin providers believe this treatment guideline will help standardize the care of children with complicated community acquired pneumonia in an evidence-based manner, several questions remain, including:

• What size effusion requires drainage?
• When should a primary video-assisted thorascopic surgery be used?
• Does standardized care positively influence patient care? 

Future studies are needed to address these important clinical questions.

Acknowledgements

Members of the Children's Hospital of Wisconsin Community Acquired Pneumonia with Pleural Effusion Work Group are Marjorie Arca, MD, Casey Calkins, MD, Lynne D'Andrea, MD, Sheila Hanson, MD, Peter Havens, MD, Patricia Lye, MD, Kim Somers, PA-C, and Robert Wells, MD. Matthew Gray, MD, developed the order set.

References

1. Hardie W, Bokulic R, Garcia VF, Reising SF, Christie CD. "Pneumococcal pleural empyemas in children." Clin Infect Dis. 1996; 22(6):1057-63.

2. Alfaro C, Fergie J, Purcell K. "Emergence of community-acquired methicillin-resistant staphylococcus aureus in complicated parapneumonic effusions." Pediatr Infect Dis J. 2005; 24(3):274-6.

3. Schultz KD, Fan LL, Pinsky J, Ochoa L, Smith EO, Kaplan SL, Brandt ML. "The changing face of pleural empyemas in children: Epidemiology and management." Pediatrics. 2004; 113(6):1735-40.

4.  Byington C, Korgenski K, Daly J, Ampofo K, Pavia A, Mason E. "Impact of the Pneumococcal Vaccine on Pneumococcal Parapneumonia Empyema." Pediatr Infect Dis J. 2006; 25:250-254.

5. Farrell DJ, Klugman KP, Pichichero M. "Increased antimicrobial resistance among nonvaccine serotypes of streptococcus pneumoniae in the pediatric population after the introduction of 7-valent pneumococcal vaccine in the United States." Pediatr Infect Dis J. 2007; 26(2):123-8.

6. Jaffe A, Balfour-Lynn IM. "Management of empyema in children." Pediatr Pulmonol. 2005; 40(2):148-56.

7. Sonnappa S, Cohen G, Owens CM, van Doorn C, Cairns J, Stanojevic S, Elliott MJ, Jaffe A. "Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema." Am J Respir Crit Care Med. 2006; 174(2):221-

8. St Peter SD, Tsao K, Harrison C, Jackson MA, Spilde TL, Keckler SJ, Sharp SW, Andrews WS, Holcomb GW, 3rd, Ostlie DJ. "Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: A prospective, randomized trial." J Pediatr Surg. 2009; 44(1):106-11.

Matthew Gray, MD, is a resident in Pediatrics at Children's Hospital of Wisconsin.

Patricia Lye, MD, is medical director of the Hospitalist Program and a pediatric hospitalist at Children's Hospital of Wisconsin, an associate professor of Pediatrics (Hospital Medicine) at The Medical College of Wisconsin and a member of Children's Specialty Group.

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