Empyema thoracis in a tertiary care centre: Analysing clinical trends and outcomes

INTRODUCTION

Empyema, characterised by the presence of pus within the pleural cavity, is the most frequent complication arising from bacterial pneumonia in children. Its incidence is estimated at approximately 3.3/100,000 children,^[1] with the highest occurrence noted in the 4–6-year age group. Acute respiratory infections, particularly those affecting the upper respiratory tract, are widespread during childhood; however, bacterial pneumonia remains a major contributor to severe lower respiratory tract infections. Pleural effusion is reported in at least 40% of bacterial pneumonia cases,^[2,3] with around 60% of these progressing to empyema.^[2,3] Despite advancements in antibiotic therapies, empyema is still associated with a significant mortality rate ranging between 10% and 16%.^[4]

In community-acquired pneumonia, the leading causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. S. pneumoniae is more frequently isolated in developed nations, while S. aureus, including methicillin-resistant S. aureus strains (MRSA), is more common in developing countries and hospital-acquired infections.^[5-7]

Despite the availability of newer antimicrobial agents, empyema continues to pose a significant burden due to its high prevalence and associated morbidity and mortality in children. It remains a therapeutic challenge, particularly in the context of evolving bacterial resistance and limited recent data on its epidemiology. Given the scarcity of studies addressing the prevalence, risk factors, changing microbiological trends, antibiotic sensitivity patterns, treatment responses and long-term pulmonary outcomes, the present study was undertaken.

MATERIAL AND METHODS

This retrospective observational study was conducted in the Department of Paediatrics at Karnataka Medical College and Research Institute, Hubballi, from January to June 2024. The study enrolled all children aged 0–12 years diagnosed with pyogenic empyema. Inclusion criteria comprised the presence of pus in the pleural cavity and/or positive bacterial culture from pleural fluid. Patients with tuberculous pleural effusion, prior chest tube insertion before hospital admission, significant thoracic deformities or empyema secondary to trauma were excluded from the study.

A detailed clinical and demographic data, nutritional status, immunisation history, presenting symptoms, investigations, treatment details and outcomes were recorded using a structured case report form. Diagnostic workup included routine haematological tests, chest X-ray, pleural fluid analysis (including culture and sensitivity) and blood cultures. All patients underwent chest ultrasonography, while computed tomography (CT) scans were reserved for cases with suspected multiloculated effusions or lack of clinical improvement with initial therapy.

During thoracocentesis or intercostal chest drain (ICD) placement, 10 mL of pleural fluid was collected aseptically for analysis, including total and differential cell counts, glucose, lactate dehydrogenase, Gram staining, acid-fast Bacillus staining and microbial culture with sensitivity testing.

Initial management included intravenous antibiotics tailored to hospital protocols targeting common pathogens. ICD insertion was performed in cases of fibrinopurulent or loculated effusions and in exudative effusions not resolving with antibiotics alone. Supportive care involved antipyretics, analgesics and nutritional support. Treatment response was evaluated based on clinical improvement (reduced respiratory distress and improved air entry) and radiological resolution. In cases of persistent fever, ongoing drainage, poor oral intake or elevated inflammatory markers, antibiotic therapy was escalated to include coverage for MRSA, Pseudomonas and anaerobic organisms. Antibiotics were modified based on culture results or continued empirically in culture-negative cases. Once afebrile and clinically stable, patients were transitioned to oral antibiotics, with total therapy duration extending to at least 3 weeks.

For patients with loculated effusions, intrapleural thrombolytics (streptokinase) were administered at a dose of 10,000 units/kg for children under 1 year and 20,000 units/kg for older children, typically for 3 consecutive days. However, 4–6 doses demonstrated superior outcomes compared to three doses. ICDs were clamped and removed once lung re-expansion was confirmed on radiographs and drainage remained minimal (<20 mL/day for 3 consecutive days). CT scans were reserved for non-resolving cases or those with complications such as persistent sepsis or poor lung expansion with thickened pleura. These patients were referred for video-assisted thoracoscopic surgery (VATS) by a paediatric surgeon for pleural debridement and decortication.

Long-term pulmonary outcomes were evaluated using pulmonary function tests (PFTs) conducted 6 months post-discharge.

RESULTS

In the present study [Figure 1], out of 2,171 paediatric inpatient admissions, 164 children were diagnosed with pneumonia, and 32 cases were identified as empyema, yielding an incidence of 7.5% for pneumonia and 19.5% for empyema among pneumonia cases.

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Figure 1:

Study flow chart. ICD: Intercostal chest drain, VATS: Video-assisted thoracoscopic surgery

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The majority of empyema cases (68.7%) occurred in children aged 5–12 years, with a male predominance of 62.5%. Fever and cough were universally present, reported in 100% of cases. Notably, 75% of the children were found to be undernourished at the time of admission.

Prior antibiotic use was reported in 62.5% (20 out of 32) of the patients before hospitalisation. Microbiological analysis revealed that only one blood culture was positive, growing MRSA with multidrug resistance. All other cultures, including pleural fluid samples, were sterile.

Table 1 shows baseline characteristics of study cases.

In the present study, treatment modalities varied based on the clinical condition and response to therapy. Of the 32 children diagnosed with empyema, 4 cases (12.5%) were managed with intravenous antibiotics alone. Thirteen children (40.2%) responded favourably to a combination of antibiotics and ICD. In 10 cases (31.2%), intrapleural thrombolytics were administered alongside antibiotics and ICD to manage loculated effusions and promote drainage. Five children (15.6%) underwent VATS due to inadequate response to conservative management, allowing for pleural debridement, adhesiolysis and decortication.

Regarding treatment outcomes, 22 patients (68.7%) showed a favourable response to first-line antibiotics, specifically ceftriaxone and vancomycin. Clinical improvement, defined by resolution of fever, was noted in 23 cases (71.2%) within the first 7 days of treatment initiation. The mean duration of hospital stay was 21 days for children managed with ICD and 17 days for those who underwent VATS. The average duration of ICD insertion was 6 days in cases treated with tube thoracostomy and 3 days in those who received VATS [Table 2]. Follow-up PFTs were performed in 12 out of 22 eligible cases (including two children aged 1–5 years and 10 aged over 5 years) [Table 3]. Among these, 4 children (33.3%) demonstrated restrictive lung disease, while the remaining 8 (66.6%) had normal pulmonary function 6 months post-discharge.

DISCUSSION

Empyema thoracis continues to pose a major health challenge in developing countries, often attributed to delayed diagnosis of pneumonia, inadequate healthcare access, malnutrition and delayed referral to tertiary care centres. Successful management depends on early initiation of appropriate antibiotics, timely drainage of infected pleural fluid and measures to facilitate optimal lung re-expansion.

In the present study, a male predominance was observed (male-to-female ratio of 1.6:1), which is consistent with findings reported in similar paediatric cohorts.^[8,9] Interestingly, the age distribution differed from previous studies. While earlier reports by Sharma et al.,^[8] Rao et al.,^[10] Langley et al.^[11] and Thakkar et al.^[12] Our study identified children aged 1–5 years as the most commonly affected group; however, it noted a higher incidence (68.7%) in children aged 5–12 years.

Malnutrition was noted in 75% of cases based on the Indian Academy of Paediatrics classification,^[13] underscoring its role as a key risk factor. Similar trends have been highlighted in other studies, suggesting that undernutrition compromises immunity, thereby increasing vulnerability to severe infections and complications such as empyema thoracis.^[12]

Fever and cough were universal symptoms across all patients, with breathlessness and tachypnoea also frequently observed. These findings are aligned with clinical presentations described in other paediatric studies.^[14] In terms of microbiology, pleural fluid cultures were sterile in all but one case, where MRSA was isolated from blood culture. This low culture yield may be attributed to prior antibiotic administration and the inability to isolate fastidious organisms, particularly anaerobes. Although several studies have cited S. aureus as the most common pathogen and followed by S. pneumoniae, Pseudomonas and Klebsiella pneumoniae as leading pathogens in paediatric empyema,^[14] culture positivity rates are variable and often limited in resource-constrained settings.

First-line antibiotic therapy with ceftriaxone and vancomycin was effective in 68.7% of cases. However, in patients showing poor response, escalation to broader-spectrum agents such as piperacillin-tazobactam or meropenem was required. A total of 71.2% of patients became afebrile within 7 days of initiating treatment, reflecting good early response rates. Regarding treatment modalities, 40.5% of cases were managed with antibiotics and intercostal chest tube drainage, 31.4% required adjunctive thrombolytics and 15.6% underwent VATS. A smaller group (12.5%) received antibiotics alone due to minimal pleural pus accumulation.

The average duration of hospitalisation was 21 days in the ICD group and 19 days in the VATS group. Although the difference was not statistically significant (P = 0.142), the mean duration of ICD placement was significantly shorter in the VATS group (3 days) compared to conventional management (6 days), with a highly significant P-value (P = 0.0002) [p < 0.05 statistically significant]. Among the 32 cases, 31 achieved complete pleural evacuation and lung re-expansion, and all were discharged with clinical improvement and no mortality.

VATS was particularly beneficial in patients unresponsive to conservative therapy. Procedures such as pleural adhesiolysis, debridement and decortication facilitated faster recovery, reduced ICD duration and potentially shortened hospital stay. These findings support growing evidence that VATS, when performed early, may enhance clinical outcomes in paediatric empyema.^[15,16]

Long-term follow-up revealed favourable pulmonary outcomes in most cases, with the majority demonstrating normal lung function at 6 months. Only a few cases showed restrictive deficits, consistent with the recovery trajectory noted in similar studies 15. However, given the limited sample size, caution should be exercised in generalising these results. Further multicentric studies with larger cohorts are warranted to validate these findings and establish evidence-based treatment algorithms.

CONCLUSION

Empyema thoracis continues to be a significant cause of acute paediatric emergencies. This study reinforces existing evidence regarding demographic patterns, clinical features and treatment outcomes. Early diagnosis, coupled with prompt and appropriate management—including empirical antibiotic therapy and timely surgical intervention- leads to favorable clinical outcomes. A combination of antibiotics and ICD remains the cornerstone of treatment, while VATS demonstrates superior outcomes in selected cases, including shorter hospital stays and faster recovery. Follow-up PFT suggests that most children recover well, although a subset may develop mild restrictive lung disease. These findings highlight the importance of early intervention, adequate nutritional support and structured long-term follow-up to ensure optimal recovery and lung function preservation in affected children.

This study contributes data that are region-specific, treatment-focused and outcome-oriented. It is particularly relevant to comparable low-resource healthcare settings. It offers valuable insights by comparing outcomes of ICD versus VATS, supporting early surgical intervention in select cases. The study also highlights the high success of empirical antibiotic therapy despite largely sterile cultures and emphasises the strong association between undernutrition and empyema. Importantly, it includes 6-month PFT data-seldom reported in Indian paediatric literature-demonstrating largely favourable long-term respiratory outcomes.