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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 47-53

Assessment of bacteriological profile and outcome of empyema thoracis of hospitalized children: A single center experience


Department of Pediatrics, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Submission21-Aug-2022
Date of Decision24-Dec-2022
Date of Acceptance27-Dec-2022
Date of Web Publication09-Mar-2023

Correspondence Address:
Dr. Sweta Sadani
Department of Pediatrics, Gauhati Medical College and Hospital, Guwahati 781006, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/prcm.prcm_12_22

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  Abstract 

Background: Empyema is often associated with the consequence of infection including pneumonia, tuberculosis, or lung abscess. This study was conducted to assess the clinico-etiological profile and outcomes of empyema thoracis cases. Materials and Methods: This was a prospective hospital-based observational study conducted from July 2019 to June 2020 which included patients of either sex, aged between 2 months to ≤12 years, with empyema thoracis confirmed by radiological evidence of pleural fluid. Clinico-etiological details were collected and presented using appropriate statistics. Results: A total of 42 patients were included in the study, of which 35.7% were aged between 4 and 7.99 years and 27 patients (64.3%) were male. Twenty (47.6%) patients had a history of cough for 7–14 days while eight had cough for >14 days; however, a total of 29 (87.9%) patients had breathing difficulty for ≤7 days. Chest pain was observed in 16.7% of patients. Chest X-ray showed that right side pleural effusion was more commonly affected than the left pleural effusion (69.0% vs. 31.0%). The most common micro-organism pleural fluid culture was Staphylococcus aureus (n = 8; 20.5%). The majority of patients with empyema thoracis had elevated levels of leukocytes (>11,000 cumm) and CRP levels (>10 mg/dL) [92.9% and 97.6%, respectively]. Conclusion: The present study showed that most of the children presented at the age of 4–7.99 years with a male predominance. S. aureus was the major organism associated with pediatric empyema in this region.

Keywords: Empyema thoracis, pediatric, single center, Staphylococcus aureus


How to cite this article:
Sadani S, Das M. Assessment of bacteriological profile and outcome of empyema thoracis of hospitalized children: A single center experience. Pediatr Respirol Crit Care Med 2022;6:47-53

How to cite this URL:
Sadani S, Das M. Assessment of bacteriological profile and outcome of empyema thoracis of hospitalized children: A single center experience. Pediatr Respirol Crit Care Med [serial online] 2022 [cited 2023 Mar 26];6:47-53. Available from: https://www.prccm.org/text.asp?2022/6/3/47/371404




  Introduction Top


Thoracis empyema is usually caused by a lung infection and it is a pus accumulation within the pleural space in the thorax. Empyema is often associated with the consequence of infection including pneumonia, tuberculosis, or lung abscess.[1]

A wide range of microbes have been implicated in pleural infection in children. Common bacterial pathogens include Staphylococcus aureus (S. aureus), Streptococcus milleri, Streptococcus pneumoniae (S. pneumoniae),  Escherichia More Details coli (E. coli), Pseudomonas, Haemophilus influenza, Klebsiella pneumoniae, Enterobacteriaceae species.[2],[3] Previous literature suggests that S. pneumoniae is the most common etiologic agent in empyema which has an important role in disease progression. However, in developing countries, S. aureus is one of the most important causes of thoracis empyema.[4],[5]

Major risk factors associated with thoracis empyema are male sex, parapneumonic PE, longer duration of illness, incomplete antibiotic course, leukocytosis, or neutrophilia.[6],[7] In developing countries, malnutrition, history of measles, are infection with antibiotic-resistant organisms increase the risk of developing thoracis empyema.[8] These risk factors predominantly affect children which could lead to longer disease exposure and increase chronic complications. Hence the early identification of risk factors is necessary to avoid further complications related to the disease.

Chest tube drainage, intrapleural fibrinolytics, VATS (video-assisted thoracoscopic surgery), and open decortications alone or in combination with antibiotics are being explored in various studies for their efficacy and safety in alleviating infection, thereby improving the survival outcomes.[4],[5],[9]

Radiological investigation of pleural effusion is a key element in diagnosing and determining the management. Conventional chest radiograph (CXR) remains as the initial investigation of suspected pleural disease. Computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and thoracis ultrasound (US) can each play important roles in further investigation.[10]

With the above background, the present study was conducted to assess the clinico-etiological profile and outcome of empyema thoracis cases.


  Methods and Materials Top


This was a prospective hospital-based observational study conducted in patients with empyema thoracis admitted in the Department of Pediatrics in Gauhati Medical College and Hospital, Bhangagarh, Guwahati, India from1st July 2019 to 30th June 2020.

Ethical consideration

The study was conducted in accordance with ethical principles that are consistent with the Declaration of Helsinki, ICH GCPs, and the applicable legislation on non-interventional studies. The study protocol was approved by the Institutional Ethics committees.

Inclusion and exclusion criteria

The inclusion criteria were patients of either sex, aged within the range of 2 months to ≤12 years, with empyema thoracis, radiological evidence of pleural fluid. Patients aged >12 years were excluded.

Treatment

Initially, intravenous antibiotics such as amoxicillin-clavulanic acid were started empirically in the dose of 100 mg/kg/day in three divided doses. Vancomycin was started as an infusion in the dose of 40 mg/kg/day in four divided doses if staphylococcal pneumonia was suspected. Later on, suitable antibiotics were further started according to culture sensitivity reports. After ICD insertion—a chest X-ray was done to confirm the exact place of the tube, also to document lung expansion and residual collection subsequently. Bedsides, an examination was done daily to look for vital signs, air entry, and the patency of the ICD tube. Whenever blockage was suspected, the intercostal tube was readjusted. Every day, the amount of pus draining each day via chest tube was noted. If drainage is nil, tube patency was checked by flushing the tube with normal saline. For those with persistent symptoms and no signs of recovery, an ultrasound of chest was done to look for any loculations following tube thoracostomy. Diet advice was given to all patients to maintain good nutritional status.

Chest physiotherapy was started at an earliest. Older children were advised to use a respirometer for good lung expansion. Younger children were encouraged to blow balloons. ICD was removed when the drainage was less than 50 mL/day with radiological and clinical improvement. Proper antibiotics were started and were continued depending on the clinical condition of the patient and the organism isolated. After verifying good lung expansion and absence of fever, patients were discharged. However, children with continual clinical symptoms, not showing improvement with medications, incomplete lung expansion after ICD insertion and antibiotics, ultrasound chest suggestive of multiple locations, and thick pleural peel were planned for surgery. The criteria for discharge for all patients were absence of fever for at least 5 days, good oral acceptance, chest tube removal, absence of respiratory distress, and clinical well-being.

Data collection

After detailed clinical examination, all children were subjected to baseline investigations such as age, month of admission, duration of fever, cough, breathing difficulty, chest pain, history of contact with TB patient, type of infection, predisposing factor, immunization status, history of prior antibiotic use, symptoms, nutritional status [Table 6], incidence of anemia [Table 7], socio-economic status [Table 8], side of chest involvement, Mantoux test, blood culture, pleural fluid culture, leukocyte count, CRP, pleural fluid protein, pleural fluid glucose, LDH, duration of chest tube in situ, complications, lung expansion, outcome, and hospital stay. The patients suspected of pleural effusion were subjected to a chest X-ray.
Table 6: Nutritional status

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Table 7: Hemoglobin levels for anemia

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Table 8: Modified Kuppuswamy scale for socio-economic status

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Follow up

On discharge, advice was given to all children for follow-up at regular interval in pediatrics OPD, GMCH for check-up. The clinical examination was done to assess for lung expansion and deformities of the chest wall and chest X-ray was performed if required.

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL). Categorical variables were presented as frequency and percentages. A comparison of quantitative variables between the groups was done using the χ2 test and Fisher’s exact test. A P < 0.05 was considered statistically significant.


  Results Top


Demographic characteristics

Out of 42 patients studied, at admission majority of patients belonged to age group of 4 to 7.99 years (35.7%) followed by the age group 1 to 3.99 years (31.0%), age group <1 year (19.0%), and age group 8 to 12 years (14.3%). In total, 27 patients (64.3%) were male and 15 patients (35.7%) were female. Twenty children (47.6%) with empyema had a history of cough for 7–14 days while eight children had a cough for more than 14 days and the remaining 14 children had a cough history of less than 7 days. Total 29 (87.9%) patients had breathing difficulty for ≤7 days and the remaining 4 patients had breathing difficulty for 8–14 days. Chest pain was observed in 16.7% of patients. Pneumonia was majorly observed in 90.5% of patients while pulmonary tuberculosis and the hepatic abscess were observed in 7.1% and 2.4% of patients, respectively. A number of children with complete, partial, and no immunization were 41.4%, 44.8%, and 13.8%, respectively. The most common presenting symptoms were tachypnea (95.2%; n = 40), nasal flaring (33.3%; n = 14), followed by grunting (21.4%; n = 9). Signs of respiratory discomfort such as subcostal retractions (45.2%) were common in patients with empyema thoracis. In the overall study population, 57.1% of children were underweight, 38.1% were stunted, and the remaining 14.3% were wasted [Table 1].
Table 1: Demographic characteristics

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Biochemical and radiological parameters and outcome

Chest X-ray showed that right side pleural effusion was more commonly affected than the left pleural effusion (69.0% vs. 31.0%). Only two (5.1%) patients showed induration for the Mantoux test. The most common micro-organism isolated on the culture of pleural fluid was S. aureus which was present in eight cases (20.5%) followed by E. coli in two cases (5.1%). The majority of patients with empyema thoracis had elevated levels of leukocytes (>11,000 cumm) and CRP levels (>10 mg/dL) [92.9% and 97.6%, respectively]. Six patients (14.3%) had chest tube indwelling for more than 8 days while 33 patients (78.6%) had chest tube indwelling for 5–8 days. Incidence of bronchopleural fistula (n = 1) and pneumothorax (n = 4) was developed among patients with empyema thoracis. Out of 38 patients, 36 (94.7%) had complete lung expansion, while two patients (30%) had only partial expansion. Total of 90.5% (n = 38) of patients improved; while 7.1% (n = 3) of patients died [Table 2].
Table 2: Biochemical parameters and outcome

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Culture and clinicopathological parameters

The majority of children with empyema without any growth in blood culture had a fever for 7–14 days [Table 3].
Table 3: Association between culture and clinicopathological parameters

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Clinical parameters and outcome

Three patients with empyema who died lie between 1 to 3.99 years of age. Majority of patients who improved (39.5%) were of less than 1 year of age. It was noted that the patients who expired had pneumonia as the foci of infection. A total of 35 (92.1%) patients who improved had pneumonia as the foci of infection, 19 patients who improved were completely immunized, and only 10.5% of children who improved were not at all immunized [Table 4].
Table 4: Association between clinical parameters and outcome

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  Discussion Top


The present study prospectively determined the prevalence of thoracis empyema and bacteriological profile and outcome including pediatric patients diagnosed with thoracis empyema. The salient observations were: (i) majority of population were presenting age group of 4–7.99 years; (ii) male preponderance in the overall study population; (iii) the most common micro-organism isolated was Staphylococcus aureus; (iv) majority of patients with empyema thoracis had elevated level of leukocytes and CRP levels; (v) incidence of improved status in 90.5% of patients; (vi) incidence of bronchopleural fistula and pneumothorax was developed among patients with empyema thoracis [Table 5].
Table 5: Association between foci and complication

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In this study, the common age of presentation of empyema thoracis was 4–7.99 years followed by age group 1–3.99 years, age group <1 year, and age group 8–12 years. This result was in concordance with a prospective study carried out by Kumar et al. which showed a median age of presentation of 3 years.[11] It is more common in younger patients, higher incidence of empyema has been reported in 52% of children younger than 5 years.[11] Another evidence-based study reported the prevalence of thoracis empyema and 37.5%of patients were below 2 years of age. Similarly previous longitudinal study showed that the mean age of patients with thoracis empyema was 3.89 years with a male predominance.

The present study also shows that thoracis empyema occurs in both sexes with a male predominance. The study correlated well with the studies done by Narayanappa et al. and Borade et al.[12],[13]

Among the culture positive cases, S. aureus was the most common organism isolated among 20.5% of patients. Similarly, other studies also reported corroborating findings indicating S. aureus as the most common organism to be observed in patients with thoracis empyema.[14] Toppo et al. evaluated the bacteriological profile of children with empyema thoracis. The authors concluded that S. aureus was the most common causative.

Organism present in 70.0% of children.[15] Similar outcome was also seen in several other studies carried out by Kumar et al. and Barnawal et al. where S. aureus was the most common organism isolated from pleural fluid culture, and the percentage being 83% and 77%, respectively.[11],[16] Therefore, all these evidences along with the present study allude that the predominance of S. aureus in patients with thoracis empyema. In contrast to studies previous noteworthy study from Malaysia, Ho et al., showed S. pneumoniae as the most common isolated pathogen.[17] This wide variation in different countries might be due to the mandatory vaccination policy, or presence of malnutrition and low social-economic status.

The evaluation of a single CRP measurement is a useful prognostic marker in the diagnosis of thoracis empyema. Recently, CRP has become more widely used to evaluate the activity of inflammatory diseases and following its evolution over the duration of a hospital stay can be more helpful in the monitoring of the response to therapy.[18] The higher incidence of elevated levels of leukocytes and CRP among the present study patients with thoracis empyema is in accordance with the previous studies.[19] Dielbar et al. and Watanabe reported high incidence of elevated CRP levels in patients with thoracis empyema.[20] Therefore, all these evidences along with the present study allude that the predominance of leucocytes and CRP in patients of thoracis empyema.

In the present study, all patients with thoracis empyema were managed by chest tube drainage. The present study reported incidence of improved status in 90.5% of patients. It is interesting to note that a study by Akanksha et al. that included 52 patients with thoracis empyema, showed 94% survival.[14] Seema et al. showed that the incidence of the clinical improvement was 100%.[21] In a previous study by Baranwal et al., two patients died due to tension pneumothorax, one more expired with uncontrolled septicemia and one child due to postoperative shock.[16] In concordance with the Baranwal et al. study, the present study also reported incidence of bronchopleural fistula and pneumothorax among patients with empyema thoracis.[16]

Authors acknowledge few limitations of this study. This study did not record the type of socio-economic status of the patients which could have added valuable data while inferring the observations. This has considerably limited the result interpretation and indicates a need of well-designed prospective studies to validate these results.

Also, in this setup, antigen test was not available. So, authors could not use pleural fluid antigen test, urine pneumococcus antigen test, and pleural fluid PCR to exclude the possibility of Streptococcus pneumoniae co-infection. Streptococcus pneumoniae is the most common cause of pneumonia in children which can lead to pleural effusion and later empyema. And lastly, small sample size has restricted its applicability to a general population.


  Conclusion Top


The present study showed that most of the children presented at the age of 4–7.99 years with a male predominance. S. aureus was the major organism associated with pediatric empyema in this region. All the patients were treated chest tube drain. Majority them (90.5%) responded well to the treatment. While the incidence of bronchopleural fistula and pneumothorax complications was developed among patients with thoracis empyema. Early diagnosis and management are crucial in reducing the mortality, morbidity, and associated complications in pediatric empyema thoracis cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Falguera M, Carratalà J, Bielsa S, García-Vidal C, Ruiz-González A, Chica I, et al. Predictive factors, microbiology and outcome of patients with parapneumonic effusion. Eur Respir J 2011;38:1173-9.  Back to cited text no. 7
    
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Tumwine JK. Lung abscess in children in Harare, Zimbabwe. East Afr Med J 1992;69:547-9.  Back to cited text no. 8
    
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Chambers A, Routledge T, Dunning J, Scarci M. Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema? Interact Cardiovasc Thorac Surg 2010;11:171-7.  Back to cited text no. 9
    
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Kumar A, Sethi GR, Mantan M, Aggarwal SK, Garg A. Empyema thoracis in children: A short term outcome study. Indian Pediatr 2013;50:879-82.  Back to cited text no. 11
    
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Narayanappa D, Rasmi N, Prasad NA, Kumar A. Clinico-bacterial profile andoutcome of empyema. Indian Paediatrics 2013;50: 783-5.  Back to cited text no. 12
    
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Borade A, Badbade K, Gulawani S, Agarkhedkar S, Dhongade R. Empyema thoracus in children: Experience fromtertiary care hospital in Pune, India. Asian J Clin Ped Neonatol 2014;2:19-22.  Back to cited text no. 13
    
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Akanksha S, Dutta A, Guha A. Clinico-bacteriological profile and outcome of empyema thoracis in children below 12 years of age. J Med Sci Clin Res 2018;6:106-12.  Back to cited text no. 14
    
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Toppo A, Yadu S. Assessment of bacteriological profile and outcome of empyema thoracis in hospitalized children in a tertiary care hospital of Raipur city, Chhattisgarh, India. Int Surg J 2018;5:1914-8.  Back to cited text no. 15
    
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Baranwal AK, Singh M, Marwaha RK, Kumar L. Empyema thoracis: A 10-year comparative review of hospitalised children from south Asia. Arch Dis Child 2003;88:1009-14.  Back to cited text no. 16
    
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Ho YL, Jamaluddin MF, Krishinan S, Salleh A, Khamis AY, Abdul Kareem BA. Pediatric empyema thoracis: Roles and outcomes of surgery in advanced disease. Asian Cardiovasc Thorac Ann 2020;28:152-7.  Back to cited text no. 17
    
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Dilber E, Cakir M, Kalyoncu M, Okten A. C-reactive protein: A sensitive marker in the management of treatment response in parapneumonic empyema of children. Turk J Pediatr 2003;45: 311-4.  Back to cited text no. 20
    
21.
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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