What can you tell parents to reasonably expect after their child with empyema gets discharged from the hospital?
Clinically important sequelae commonly persist in the first month after discharge but resolve in almost all cases by 6 months. And the rare patient who has lingering significant abnormalities on chest x-ray or spirometry 6 months after leaving the hospital can expect them to normalize by 1 year, according to a prospective Canadian study.
"Long-term [sequelae] are uncommon. This information may aid decision making for clinicians and families balancing the risks and benefits of interventions," Dr. Eyal Cohen observed.
The findings in this observational study take on added clinical relevance because the incidence of complicated pneumonia, or empyema, is increasing throughout the world, particularly in younger children. Proposed explanations for this phenomenon include pneumococcal serotype replacement and/or evolving antimicrobial resistance patterns, said Dr. Cohen of the Hospital for Sick Children, Toronto.
He recently reported on 82 children with empyema – as defined by ultrasound evidence of pleural effusions with loculations – at the annual meeting of the Pediatric Academic Societies. The children were seen at 1 and 6 months post discharge, where they underwent clinical examination, a chest x-ray, quality-of-life assessment using the Peds-QL instrument, and spirometry if they were at least 5 years old.
The median age of the subjects was 3.6 years; 27% of them had an organism isolated, most commonly Streptococcus pneumoniae. Of note, methicillin-resistant Staphylococcus aureus was the causative organism in only one child. A chest drain was used in 51 children, and 40 of those also received fibrinolytics. The remaining patients were treated only with antibiotics. Video-assisted thorascopic surgery was not employed.
The average length of hospital stay was 10 days. Eight children went to the pediatric ICU.
At discharge, 21% of patients still had fever, which lasted up to 1 further week; 7% of children were readmitted within 1 month.
At the 1-month follow-up, 18% of the patients had fever, 23% cough, and 2% failure to thrive; 59% of the school-age children had missed a median of 5 classroom days. By 6 months, however, only 16% of children were still coughing, and 30% of school-age children had missed an average of 2 days of school since the 1-month evaluation. None of the children were experiencing fever or failure to thrive at late follow-up.
At 1 month post discharge, 7 of 20 children had abnormal spirometry, defined as a forced expiratory volume in 1 second that is 80% or less of predicted. Of the 82 children, 24 had persistent abnormalities on chest x-ray, mostly effusion, pneumatocele, or abscess. Twelve of 68 parents rated their child’s health-related quality of life as abnormal based on a Peds-QL score more than 1 standard deviation below the normal population.
By 6 months, only one child had abnormal spirometry and three had persistent chest x-ray abnormalities. At 1 year, these abnormalities had resolved in three patients, while the fourth was lost to follow-up.
Moreover, at 6 months, parents rated their child’s quality of life on the Peds-QL as similar to that in 8,430 healthy historical controls and significantly better than were the scores for 157 children with asthma, according to Dr. Cohen.
He declared having no financial conflicts of interest.