When should clinicians suspect group A streptococcus empyema in children? A multicentre case-control study in French tertiary care centres

Inflammatory rebound and postinfectious inflammatory response in children with pleural infection: A single-center retrospective study

INTRODUCTION

As pleural inflammation plays a central role in pleural infection (PI), corticosteroids are increasingly being considered as a potential therapy. However, the timing of treatment and the identification of patients who might benefit most remain unresolved. The aim of this study was therefore to investigate the inflammatory trajectories of children with PI.

METHODS

This retrospective single-center study included children aged 3 months to 17 years and 11 months hospitalized for PI due to Streptococcus pyogenes, Streptococcus pneumonia, and Staphylococcus aureus over 10 years. An inflammatory rebound was defined biologically as a reincrease in C-reactive protein (CRP) of at least 50 mg/L after an initial decrease in CRP of at least 50 mg/L.

RESULTS

We included 53 cases of PI, including 16 due to S. pyogenes, 27 due to S. pneumonia, and 10 due to S. aureus. An inflammatory rebound occurred in 20 patients (38%) after a median of 4.5 (3-6) days. This inflammatory rebound occurred in 9 (56%) children with S. pyogenes, 8 (30%) children with S. pneumonia, and 3 (30%) children with S. aureus. Children with an inflammatory rebound also had a higher rate of persistent fever after Day 7 and a longer length of stay (p = .01 for both).

CONCLUSION

We postulate that the inflammatory rebound identified in nearly 40% of our patients corresponds to an early postinfectious inflammatory response, and thus that corticosteroids may be most beneficial for children with PI if administered early (between Days 2 and 5).

Paediatric pneumonia in high-income countries: Defining and recognising cases at increased risk of severe disease

World Health Organisation definitions of pneumonia severity are routinely used in research. In high income health care settings with high rates of pneumococcal vaccination and low rates of mortality, malnutrition and HIV infection, these definitions are less applicable. National guidelines from leading thoracic and infectious disease societies describe 'severe pneumonia' according to criteria derived from expert consensus rather than a robust evidence base. Contemporary cohort studies have used clinical outcomes such as intensive care therapy or invasive procedures for complicated pneumonia, to define severe disease. Describing severe pneumonia in such clinically relevant terms facilitates the identification of risk factors associated with worsened disease and the subsequently increased morbidity, and need for tertiary level care. The early recognition of children at higher risk of severe pneumonia informs site of care decisions, antibiotic treatment decisions as well as guiding appropriate investigations. Younger age, malnutrition, comorbidities, tachypnoea, and hypoxia have been identified as important associations with 'severe pneumonia' by WHO definition. Most studies have been performed in low-middle income countries and whilst they provide some insight into those at risk of mortality or treatment failure, their generalisability to the high-income setting is limited. There is a need to determine more precise definitions and criteria for severe disease in well-resourced settings and to validate factors associated with intensive care admission or invasive procedures to enhance the early recognition of those at risk.

Paediatric empyema: worsening disease severity and challenges identifying patients at increased risk of repeat intervention

OBJECTIVE

Empyema is the most common complication of pneumonia. Primary interventions include chest drainage and fibrinolytic therapy (CDF) or video-assisted thoracoscopic surgery (VATS). We describe disease trends, clinical outcomes and factors associated with reintervention.

DESIGN/SETTING/PATIENTS

Retrospective cohort of paediatric empyema cases requiring drainage or surgical intervention, 2011-2018, admitted to a large Australian tertiary children's hospital.

RESULTS

During the study, the incidence of empyema increased from 1.7/1000 to 7.1/1000 admissions (p<0.001). We describe 192 cases (174 CDF and 18 VATS), median age 3.0 years (IQR 1-5), mean fever duration prior to intervention 6.2 days (SD ±3.3 days) and 50 (26%) cases admitted to PICU. PICU admission increased during the study from 18% to 34% (p<0.001). Bacteraemia occurred in 23/192 (12%) cases. A pathogen was detected in 131/192 (68%); Streptococcus pneumoniae 75/192 (39%), S. aureus 25/192 (13%) and group A streptococcus 13/192 (7%). Reintervention occurred in 49/174 (28%) and 1/18 (6%) following primary CDF and VATS. Comparing repeat intervention with single intervention cases, a continued fever postintervention increased the likelihood for a repeat intervention (OR 1.3 per day febrile; 95% CI 1.2 to 1.4, p<0.0001). Younger age, prolonged fever preintervention and previous antibiotic treatment were not associated with initial treatment failure (all p>0.05).

CONCLUSION

We report increasing incidence and severity of empyema in a large tertiary hospital. One in four patients required a repeat intervention after CDF. Neither clinical variables at presentation nor early investigations were able to predict initial treatment failure.

Outcome of Severe Bacterial Pneumonia in the Era of Pneumococcal Vaccination

Introduction: After the introduction of pneumococcal conjugate vaccines, community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae has decreased whereas Staphylococcus aureus and Streptococcus pyogenes could be increasing. These bacteria have been associated with high rates of complications. Aims: (1) To describe the characteristics of pediatric bacterial CAP requiring hospitalization. (2) To compare outcomes according to causative microorganisms. (3) To analyze changes in bacterial CAP rate and etiology over time. Patients and Methods: Retrospective single-center study of inpatients aged 1 month-16 years with culture-confirmed bacterial CAP in 2010-2018 in Madrid, Spain. Results: We included 64 cases (42 S. pneumoniae, 13 S. pyogenes and 9 S. aureus). Culture-confirmed CAP represented 1.48-2.33/1,000 all-cause pediatric hospital admissions, and its rate did not vary over time. However, there was a significant decrease in pneumococcal CAP in the last 3 years of the study (78% of CAP in 2010-2015 vs. 48% in 2016-18, p = 0.017). Median hospital stay was 10.5 days (interquartile range 5-19.5), 38 patients (59%) developed complications and 28 (44%) were admitted to the intensive care unit. Outcomes were similar among children with S. pneumoniae and S. aureus CAP, whereas S. pyogenes was associated with a higher risk for complications (OR 8 [95%CI 1.1-57.2]) and ICU admission (OR 7.1 [95%CI 1.7-29.1]) compared with pneumococcal CAP. Conclusion: In a setting with high PCV coverage, culture-confirmed bacterial CAP did not decrease over time and there was a relative increase of S. pyogenes and S. aureus. Children with CAP caused by S. pyogenes were more likely to develop complications.

Clinical observation of bronchoscopy alveolar lavage combined with thoracoscopy in the treatment of empyema in children

The objective of this study was to investigate the therapeutic effects of bronchoscopy alveolar lavage (BAL) combined with thoracoscopy in the treatment of empyema in children.Retrospectively analyzed 174 cases of pediatric empyema treated with thoracoscopy combined with BAL from January 2010 to December 2016 in our hospital. All the cases, according to admission order, were randomly divided into 2 groups, the control group (group A), which contained 89 cases, was treated with thoracoscopy; and the experimental group (group B), which contained 85 cases, was treated with BAL combined with thoracoscopy. The results of BAL treatment, the inflammatory indexes including body temperature, total leukocyte count in peripheral blood and CRP, and the therapeutic effect and prognosis including the days of antibiotic use, hospital stay, the incidence of thoracotomy and lobectomy were compared between the 2 groups.There was statistical difference in all the therapeutic indexes (P < .05).Bronchoscopy alveolar lavage combined with thoracoscopy has a higher success rate in the treatment of pediatric empyema, and is more comprehensive, safe and effective in controlling inflammation.

Increasing Rates of Pediatric Empyema and Disease Severity With Predominance of Serotype 3 S. pneumonia: An Australian Single-center, Retrospective Cohort 2011 to 2018

BACKGROUND

The impact of universal 13-valent pneumococcal conjugate vaccine immunization on pediatric empyema rates and pathogens in Australia is not known. We aimed to describe empyema epidemiology, clinical characteristics and treatment during an 8-year period.

METHODS

A retrospective study between 2011 and 2018 of empyema cases admitted to a large pediatric referral hospital, for management with either pleural drainage and fibrinolytics or surgical intervention.

RESULTS

There were 195 cases in 8 years. Empyema incidence and ICU admission rates significantly increased during the study with a peak incidence of 7.1/1000 medical admissions in 2016 (χ for trend of incidence 37.8, P < 0.001 and for ICU admissions 15.3, P < 0.001). S. pneumoniae was the most common pathogen (75/195, 39%) with serotype 3 the most detected (27/75: 27%). S. pyogenes compared with S. pneumoniae had significantly fewer days of fever before admission (3.9 vs. 6.4, mean difference 2.4, 95% CI: 0.84-4.08, P = 0.003) and higher proportion requiring direct ICU admission (6/75; 8% vs. 7/15; 47%, P < 0.001). Compared with S. pneumoniae, cases with no pathogen detected by culture or PCR had fewer days of fever post intervention (4.4 vs. 7.4 days, mean difference 2.7 days, P = 0.002). S. aureus occurred more commonly in infants (10/25; 40% vs. 1/75; 1%, P < 0.001) and children of indigenous background (5/25; 20% vs. 1/75; 1%, P < 0.001) compared with S. pneumoniae.

CONCLUSIONS

We report increasing rates of pediatric empyema with higher proportions requiring ICU treatment. The most common pathogens detected were S. pneumoniae, S. aureus and S. pyogenes. Despite high 13-valent pneumococcal conjugate vaccine coverage, serotype 3 was the most common S. pneumoniae serotype identified.