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Preprints.org
By Tarditi G, Pisa CM, Ricci I and 4 others.
Pediatric pleural empyema remains a major complication of community-acquired pneumonia despite vaccination and advances in minimally invasive treatment. This narrative review summarizes current evidence on etiology, diagnosis, antimicrobial therapy, pleural drainage, fibrinolysis, and surgery.
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PubMed was searched from inception through July 2026 for English-language studies involving patients aged 0–18 years. Pediatric trials, observational studies, surveillance reports, guidelines, reviews, and relevant case series were considered. Of 42 publications assessed in full, 38 were included in the narrative synthesis.
Streptococcus pneumoniae, particularly serotype 3, Staphylococcus aureus, and Streptococcus pyogenes remain the principal pathogens. Chest ultrasound is preferred for characterizing pleural collections and guiding intervention, whereas computed tomography is reserved for atypical disease or suspected complications. Small, uncomplicated effusions may respond to antibiotics alone; large, purulent, or clinically significant collections generally require source control. Image-guided small-bore catheter drainage with protocol-based urokinase or tissue plasminogen activator is effective for many loculated effusions. Pediatric evidence does not support routine addition of DNase. Comparative trials show broadly similar clinical outcomes for fibrinolysis and video-assisted thoracoscopic surgery, although heterogeneous protocols and limited sample sizes preclude identification of a universally superior strategy. Thoracotomy is rarely required.
Management should integrate respiratory and septic severity, pleural anatomy, microbiology, adequacy of drainage, clinical trajectory, and local expertise rather than rely on rigid staging. Long-term recovery is excellent in most previously healthy children receiving timely treatment. Standardized definitions, pediatric outcome sets, multicenter comparative trials, validated predictors of treatment failure, and studies of antimicrobial duration remain important research priorities.
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Published in Preprints.org (preprint). The abstract is shown as published and remains the work of its authors; read the full article at the source.
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