In the late 1990s there was a progressive increase in the number of complicated cases of community-acquired pneumonia (CAP), and particularly of cases complicated by pleural effusion.1,2 The trend continued over the following decade, with striking incidences of pleural empyema and necrotising forms of disease, especially of pneumococcal aetiology, in children older than 2 years.3–5 This epidemiological change was probably due to multiple factors, including the serotype shift in the nasopharyngeal carriage of pneumococcal strains due to the pressure of the 7-valent pneumococcal conjugate vaccine, although the trend was already apparent before the vaccine was introduced.1,2 This new situation mostly involved the emergence of several pneumococcal serogroups, such as 1, 3, 5 and 19A.3 However, it seems that the increasing trend has been partially curbed since the introduction in 2010 of new pneumococcal vaccines that cover the emerging serotypes, especially the 13-valent vaccine.6,7

Meanwhile, disease caused by Staphylococcus aureus (S. aureus) has been increasing at a slow pace, including disease by methicillin-resistant strains (MRSA) and strains that produce specific virulence factors, such as Panton-Valentine leukocidin (PVL), that can increase clinical severity, while the prevalence of other causative agents, such as Streptococcus pyogenes (S. pyogenes), continues to be low.8

This consensus document has been developed by the Sociedad Española de Infectología Pediátrica (Spanish Society of Paediatric Infectious Medicine [SEIP]) and the Sociedad Española de Neumología Pediátrica (Spanish Society of Paediatric Chest Diseases [SENP]), and it proposes guidelines for the treatment of complicated CAP and for the management of special circumstances, concluding the documents previously published in this journal on the diagnosis,8 treatment of uncomplicated cases, and prevention of CAP.9

The criteria for admitting children with CAP to the hospital may vary from one facility to another. This consensus offers recommendations approved by the authors of this document and supported by international guidelines, 10,11 which can be consulted in Table 1.

While there is broader consensus on first-line antibiotic treatment, its choice should be determined on a case-by-case basis in a certain group of at-risk patients. There is greater controversy surrounding the best approach to the management of complicated cases with pleural effusion, both from a medical and a technical–surgical standpoint, which we will therefore analyse here.

In addition to antibiotic treatment, children admitted with CAP require supportive care, a subject that was partly addressed in the previous consensus document9 and that we proceed to complete in this one.

It is defined as the development of respiratory failure or the persistence of tachypnoea 72h after the onset of disease, or as persistence of fever or of poor general health status 48–72h following admission.10 However, in the latter case, if the patient shows improvement and the levels of acute phase reactants (especially of C reactive protein) decrease, antibiotic treatment has probably not failed.

If treatment is considered to have failed 48–72h after initiation, a clinical, radiological and laboratory re-evaluation should be performed, assessing for the most frequent causes of failure (Table 7).10,29

Approximately 20–40% of children admitted with CAP will have pleural effusion, and up to 0.6% will progress to empyema.30

About half of the cases of parapneumonic pleural effusion resolve with antibiotic treatment and do not require invasive interventions.30 The patient's clinical condition (especially breathing difficulty) and the extent of the effusion are key in decision-making. Fig. 1 presents the recommended care protocol for parapneumonic pleural effusion.

Figure 1.

Algorithm for the management of significant parapneumonic pleural effusion. (a) Subclinical pleural effusion (costophrenic angle blunting, minimal volume) will be managed as an uncomplicated pneumonia. (b) In selected cases, a diagnostic thoracocentesis may be performed in cases of small effusion. (c) These findings, which are available quickly, are an indication for immediate pleural drainage during the same procedure. Other findings in the pleural fluid that become available at a later time, such as visualisation of bacteria by Gram staining, positive culture, LDH>1000IU/mL, glucose<40–60mg/dL, may be indications for pleural drainage a posteriori. The use of these biochemical data for the purposes of decision-making is outdated. A positive PCR result for a bacterium or a positive S. pneumoniae antigen test (BinaxNow) in pleural fluid will not be used as the sole criteria for chest tube placement. (d) In the absence of empyema, under certain circumstances and in certain patients, if staff trained in the placement and maintenance of a chest drain were not available promptly, a therapeutic thoracocentesis could be performed. (e) Consider other causes for poor outcome: necrotising pneumonia, pulmonary abscess.

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Whenever there is a moderate to large pleural effusion or there is doubt as to the presence or extent of a small effusion in the radiograph, a thoracic ultrasound should be performed. The extent and sonographic characteristics of the effusion should be determined, along with the optimal puncture site or sites for a potential chest drain, searching for the thickest area that can be accessed most easily, which is usually found between the fifth and the seventh intercostal spaces at the level of the mid-posterior axillary line. Drainage should not be performed in cases of subpulmonic effusion. Effusions smaller than 10mm should not be performed routinely.11

Thoracocentesis is to be performed in a properly equipped room (anaesthesia, PICU, or operating room), although there may be other equally fitted areas in the emergency department or inpatient wards. We recommend that chest tube insertion be performed in an intensive care unit or operating room.

A chest tube should be placed if the effusion meets one or more of the criteria for pleural empyema or if it causes moderate to severe breathing difficulty. A complicated effusion with septations requires not only tube drainage but also administration of fibrinolytics, and if the patient does not respond favourably, performance of video-assisted thoracoscopic surgery (VATS).

Catheters of variable size may be used. The American Pediatric Surgical Association recommends using 12F catheters.31 A recent multicentric study in Spain used 12F–14F catheters,32 although other studies have used 8F–10F tubes.33 Small-bore catheters (8F–14F) are as effective as large-bore catheters, cause less pain, and shorten the length of stay.34 The use of trocars is discouraged, and it is recommended that soft tubes are used for insertion with the Seldinger technique. Radiography should be used to confirm proper placement of the tube and rule out pneumothorax. The tube has to be connected to a unidirectional flow drainage system that must be kept at a level lower than the patient's chest. The indications for using a drainage system remain unclear, but it seems to improve fluid removal. When these systems are used, a water seal must be used at a pressure of 5–10cm H2O.

The drain should be clamped for 1h once 10mL/kg have been removed. In older children and adolescents, it is recommended that no more than 1.5L of fluid are removed at one time, or that larger amounts are drained slowly at a rate of approximately 500mL per hour.

The drain is usually removed when there is minimal drainage (<40–60mL/24h).32,33 Some authors recommend keeping the drain until serous fluid drainage amounts to less than 1mL/kg/day for the previous 12h. The absence of a significant amount of fluid in ultrasound examination may guide this decision.11 Drain removal does not require previous clamping.

We propose the use of fibrinolytics for the first-line treatment of pleural effusion with septations, either with floating septa or forming loculations (Fig. 1).31,32 Their use has proven to be cost-effective compared to placement of chest drains without fibrinolytics.35 In cases with no sonographic septations but with a lower than expected drainage volume, and especially if the fluid is thick, treatment with fibrinolytics should be considered once other possible causes have been ruled out.

Out of all the available fibrinolytic agents, this panel recommends the use of urokinase because it is the one for which there is the most data for the paediatric age group.

Clinical trials comparing intrapleural urokinase with VATS in children32,33 found no differences between these two interventions. A recent multicentre clinical trial conducted in Spain compared the usefulness of urokinase and VATS in 103 children with fibrinopurulent pleural effusion.32 The results showed that urokinase is as effective as VATS in the treatment of septated pleural empyema, while no differences were found in the length of stay from the time treatment was initiated.32

These results support the current recommendation of the American Pediatric Surgical Association of using fibrinolytics as the first-line treatment of these patients, given its lower cost and easier implementation, as it does not require surgical intervention.31–33,36

The urokinase doses used in different studies range between 10000 and 100000IU.37 The recommendation in this consensus is the following:32

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  Infants age<1 year: 10000IU in 10mL of 0.9% saline solution.

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  Children age≥1 year: 40000IU in 40mL of 0.9% saline solution.

It is administered through the intrapleural catheter (which is subsequently clamped for 4h), twice a day for 3 days.32,33 Additional doses can be used if the patient has not fully responded after the initial six.37

The administration of fibrinolytics through a chest tube may cause discomfort, so it must be accompanied by appropriate analgesia. It may also cause light bleeding and, on rare occasions, immediate hypersensitivity reactions.

Fibrinolytic therapy should be discontinued if it is ineffective, which can happen in highly organised effusions, and should not be considered in patients with bronchopleural fistula when bubbling is observed in the chest tube, as it is suggestive of an air leak. In the latter case, clamping the tube could cause tension pneumothorax. Chest drains should be unclamped immediately if the child develops signs of clinical worsening, such as increased breathing difficulty or chest pain.

Video-assisted thoracoscopic surgery can be used to determine the stage of the effusion, break the septations, drain the fibrinopurulent material, reduce the bacterial load in the initial stages, and place the chest drain correctly. Furthermore, it allows the visualisation of the underlying lung, its expansion capacity, and the location of bronchopleural fistulae.

At present, there are two accepted indications for VATS:

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  Persistent moderate to massive effusion with respiratory compromise despite treatment with drainage and fibrinolytics for 2–3 days,11 which usually happens in 15% of cases.33,36

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  Complications such as bronchopleural fistula.33

It is also an option for the initial treatment of highly fibrinopurulent and organised effusions in which a thick fibrous peel has developed, or when treatment with fibrinolytics cannot be implemented.31,38 Its use as initial treatment must be considered on a case-to-case basis, taking into account the duration and characteristics of the effusion, as well as the availability and surgical experience of the centre for performing VATS. Decortication is not usually necessary in children.

The efficacy of VATS for the treatment of empyema is quite high. Compared to plain drainage without fibrinolysis, VATS significantly reduces the duration of symptoms (fever usually resolves in 24–72h), the length of stay (reduced to 6–7 days) and the cost of healthcare.31,39 On the other hand, its efficacy seems to be similar to that of treatment with drainage and fibrinolytics.32,33,36,40 It is estimated that the cost of VATS is higher than that of fibrinolytic treatment,33,35,36 although some authors believe that performing VATS early on could be more efficacious and reduce healthcare costs.38

The rate of complications is low (6–7%), including air leaks of persistent pneumothorax, pneumatocele, or bleeding.38

Conflicts of interest of the authors in relation to this document (past five years):

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  DMP has collaborated in educational activities funded by GlaxoSmithKline, Pfizer and Sanofi Pasteur MSD, as a researcher in a clinical trial for Novartis, and as a consultant in the Advisory Boards of Astra-Zeneca and Pfizer.

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  AAM has no conflicts of interest to declare.

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  ATG has collaborated in research activities funded by Pfizer.

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  AEM has collaborated in educational activities funded by Novartis, as a researcher in a multicentre study promoted by GlaxoSmithKline and as a consultant in an Advisory Board for Gilead.

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  JFM has collaborated in educational activities funded by Gilead and Abbvie.

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  JGG has collaborated in educational activities funded by Pfizer and Sanofi Pasteur MSD.

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  AMG has participated as a consultant in the Advisory Boards of Abbvie and Gilead, has received institutional research grants from Abbvie and grants for attending scientific conferences from Abbvie, Actelion, Ferrer, GlaxoSmithKline and Novartis.

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  CRGL has collaborated in educational activities funded by GlaxoSmithKline, Novartis, Pfizer and Sanofi Pasteur MSD, as a researcher for clinical trials for GlaxoSmithKline and a consultant in the Advisory Boards of Astra-Zeneca, Novartis, GlaxoSmithKline and Pfizer.

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  JSL has collaborated as a researcher in clinical trials for GlaxoSmithKline and Roche.