Predictors of Surgical Outcome for Complicated Pneumonia in Children: Impact of Bacterial Virulence

The charts of 110 children with community acquired bacterial pneumonia were reviewed. A subset of children who required surgical intervention for empyema or parapneumonic effusion was identified. Patients were divided into two treatment groups: antibiotics/tube thoracostomy alone (group 1) versus operative intervention (group 2). Overall, 33 (30%) of the children required surgical intervention for complications. Seventeen (15%, group 1) were successfully treated with antibiotics/tube thoracostomy alone, while 16 (15%) in group 2 were treatment crossovers, failing this initial therapy. Of group 2 children, 4 (25%) underwent thoracotomy and lobectomy, while 12 (75%) underwent video‐assisted thoracoscopic surgery (VATS). Although group 2 children were younger than those in group 1 (4.4 ± 3.6 versus 6.3 ± 4.1 years, p < 0.05) and had longer hospitalizations (20.1 ± 10.1 versus 8.2 ± 3.9 days, p < 0.05), symptom duration, preoperative antibiotics, fibrinolytic use, and leukocytosis were similar (p > 0.05). Group 1 children had 13 (76%) positive cultures, 92% with pan‐sensitivities, in contrast to group 2, which had 12 (75%) positive cultures, but only 33% were sensitive to first‐line antibiotics (p < 0.01). Group 2 patients were also more likely to have complex multi‐loculated empyemas, pneumatoceles, or pulmonary necrosis identified on imaging studies (100% versus 24%, p < 0.01). These data suggest that the natural history of pneumonia in children is heavily influenced by bacterial virulence. Tube thoracostomy and appropriate antibiotics remain effective for pan‐sensitive, simple parapneumonic effusions and empyema. Complex parapneumonic effusions and empyema, however, which occur more frequently in the setting of first‐line antibiotic resistance, often fail more conservative managements and may be best treated by earlier operative debridement.