CPS Hospital pediatrics

Question 1

What are the 3 most common causative organisms in empyema?

Answer 1

1. Strep pneumo
2. Staph aureus
3. GAS

Question 2

What are the stages of empyema development?

Answer 2

1. Stage 1: moderate-large exudative parapneumonic effusion
2. Loculation
3. Fibrinous peel

Question 3

What are 3 findings on exam of a pleural effusion?

Answer 3

1. Decreased breath sounds
2. Decreased chest expansion
3. Dullness to percussion

Question 4

What is the utility of repeating CXRs on a daily basis to evaluate the status of a pleural effusion or empyema?

Answer 4

Not necessary unless clinical deterioation is evident

Question 5

In what percentage of empyema cases will the blood culture be positive?

Answer 5

10%
-but should still collect before abx to potentially guide choice of abx for children who are ill enough to be hospitalized for pneumonia

Question 6

When should you consider early procedural intervention for a patient with a pleural effusion?

Answer 6

If the patient is in moderate to severe resp distress

Question 7

What is the usual empiric antibiotic choice for a child with empyema?

• what about for severe suspected MRSA pneumonia?
• duration of treatment?

Answer 7

Ceftriaxone or cefotaxime +/- clindamycin to cover anaerobic infection or community acquired MRSA –> when improved, can switch to PO amoxi-clav

• severe MRSA: consider adding vancomycin or linezolid
• duration of treatment: no evidence exists for the recommended duration but usually requires total of 3-4 wks (IV, then switch to PO when afebrile, drainage of effusion is complete, clinically improved and off O2)

Question 8

What is the management of a child with empyema on appropriate IV abx who continues to have fevers past 72 hrs of abx despite clinical improvement?

Answer 8

No change = common for children with empyemas to have fevers > 72 hrs
-only worry if there is no clinical improvement otherwise

Question 9

What are the options of procedural interventions for empyema and which is the most cost-effective?
-what is the dose of fibrinolytic agent used?

Answer 9

1. VATS
2. Early thoractomy
3. Chest tube placement with instillation of fibrinolytics (CTWF) = most cost effective
   - dose of TPA (tissue plasminogen activator): 4 mg in 50 ml NS daily x 3 d)

Question 10

In a patient who has been treated for empyema, does a repeat CXR need to be done?

Answer 10

Yes - child should be followed as outpt until they have clinically recovered and their CXR has returned to near normal (may take several months)
-repeat CXR at 2-3 months