Antibiotic management of complicated parapneumonic effusion or empyema complicating community-acquired pneumonia in children

Children with community-acquired pneumonia (CAP) who develop a complicated pleural effusion (parapneumonic effusion) or empyema require:

  • admission to hospital
  • pleural fluid sampling and drainage
  • intravenous antibiotics.

For the definitions of complicated parapneumonic effusion or empyema, and a summary of management, see Definitions and management of parapneumonic effusion and thoracic empyema.

In children, Streptococcus pneumoniae is the most common pathogen, followed by Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA])Feris-Iglesias, 2014Golden, 2021Krenke, 2016Strachan, 2021von Mollendorf, 2022. Therefore, empirical therapy with activity against both S. pneumoniae and S. aureus is recommended. Streptococcus pyogenes (group A streptococcus) is an uncommon cause, but is important to consider because of the increasing incidence of invasive group A streptococcal (iGAS) infection. Anaerobes are an uncommon cause of parapneumonic effusion and empyema in children, so empirical anaerobic therapy is not required.

Note: Collect pleural fluid samples for culture to identify the pathogen.

Collect pleural fluid samples for culture. Culturing pleural fluid in blood culture bottles, in addition to standard culture, can increase microbial yieldMenzies, 2011. Other investigations, such as nucleic acid amplification tests (NAAT) (eg polymerase chain reaction [PCR]), are sometimes performed on pleural fluid samples.

If available, use the results of microbiological investigations to guide antibiotic therapy.

Culture results are often negative because of preceding antimicrobial therapy for pneumonia. If microbiological results are not available or are negative, use the empirical therapy regimens below.

Seek expert advice for managing children younger than 2 months with complicated parapneumonic effusion or empyema complicating CAP.