Treatment
ÎA chest tube can be removed in the absence of an intrathoracic air leak and when pleural fluid drainage is less than 1 mL/kg/24 hours, usually calculated over the last 12 hours. (SR-VL)
Antibiotic Therapy for Parapneumonic Effusion/Empyema
ÎWhen the blood or pleural fluid bacterial culture identifies a pathogenic isolate, antibiotic susceptibility should be used to determine the antibiotic regimen. (SR-H)
ÎIn the case of culture-negative parapneumonic effusions, antibiotic selection should be based on the treatment recommendations for patients hospitalized with CAP. (SR-M)
ÎThe duration of antibiotic treatment depends on the adequacy of drainage and on the clinical response demonstrated for each patient. (SR-L)
Note: In most children, antibiotic treatment for 2-4 weeks is adequate. Nonresponse
ÎChildren who are not responding to initial therapy after 48-72 hours should be managed by one or more of the following:
• Clinical and laboratory assessment to determine the current severity of their illnesses and anticipated progression in order to determine whether higher levels of care or support are required. (SR-L)
• Imaging evaluation to assess the extent and progression of the pneumonic or parapneumonic process. (WR-L)
• Further investigation to identify whether the original pathogen persists, the original pathogen has developed resistance to the agent used, or whether there is a new secondary infecting agent. (WR-L)
ÎA BAL specimen should be obtained for Gram stain and culture from the mechanically ventilated child. (SR-M)
ÎA percutaneous lung aspirate should be obtained for Gram stain and culture from the persistently and seriously ill child for whom previous investigations have not yielded a microbiologic diagnosis. (WR-L)
ÎAn open lung biopsy for Gram stain and culture should be obtained from the persistently and critically ill, mechanically ventilated child for whom previous investigations have not yielded a microbiologic diagnosis. (WR-L)
ÎA pulmonary abscess or necrotizing pneumonia identified in a nonresponding patient can be initially treated with IV antibiotics. Well-defined peripheral abscesses without connection to the bronchial tree may be drained under image-guided procedures by either aspiration or with a drainage catheter that remains in place, but most will drain through the bronchial tree and heal without surgical/ invasive intervention. (WR-VL)
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