Epidemiology and Surgical Outcomes of Pediatric Empyema Thoracis In Baghdad: A Retrospective Cohort Analysis
Iranian Journal of Pediatric Surgery,
Vol. 11 No. 2 (2025),
26 Aban 2025
,
Page 252 - 276
https://doi.org/10.22037/irjps.v11i2.48745
Abstract
Abstract:
Background: Empyema thoracis, the accumulation of purulent fluid in the pleural cavity, remains a significant cause of pediatric morbidity in developing regions despite global advancements in treatment. This study examines the epidemiology, clinical presentation, microbiological profile, and therapeutic outcomes of pediatric empyema in Baghdad, Iraq, providing comparative insights with regional and international data.
Methods: A retrospective cohort analysis was conducted across three tertiary care centers in Baghdad—Ghazi Al-Hariri Surgical Specialties Hospital/Medical City, Ibn al-Nafees Hospital, and Al-Imamain Al-Kadhmian Medical City—from January 2022 to December 2023. Patients were stratified into uncomplicated and complicated empyema groups based on clinical and radiological criteria.
Results: Among 50 pediatric cases (62% male, 38% female; ratio 1.6:1), the predominant age group was 1–5 years (46%). Universal fever (100%), dyspnea (84%), and cough (76%) were the most frequent symptoms, with bronchopneumonia as the leading predisposing factor (32%). Microbiological analysis identified pleural fluid pathogens in 38% of cases, predominantly Streptococcus pneumoniae (16%) and Staphylococcus aureus (14%). Complications included pyopneumothorax (26%) and pneumothorax (8%). Tube thoracostomy with antibiotics achieved treatment success in 90% of patients, while 10% required surgical decortication. Seventy percent of cases had hospital stays under 14 days.
Conclusion:
Pediatric empyema in Baghdad exhibits distinct characteristics, including delayed presentation, high complication rates, and a unique microbiological profile. The 90% efficacy of tube thoracostomy supports its role as a first-line, resource-adapted therapy in comparable settings. These findings underscore the need for tailored management protocols in high-burden regions.
- Pediatric
- Empyema thoracis
- Surgery
How to Cite
References
1. Le Roux BT, Mohlala ML, Odell JA, Whitton ID. Suppurative disease of the lung and pleural space. Part 1: Empyema thoracis and lung abscess. Curr Probl Surg 1986; 23:1-89.
2. Hippocrates: The Book of Prognostics. In Adams F, editor: The Genuine works of Hippocrates, Baltimore, MD, 1939, Williams & Wilkins.
3. Myer JA: Gotthard Bülau and closed water-seal drainage for empyema, 1875-1891. Ann Thorac Surg 48:597–599, 1989.
4. . Graham EA, Bell RD: Open pneumothorax: its relation to the treatment of empyema. Am J Med Sci 156:839–871, 1918.
5. Peters RM: Empyema thoracis: historical perspective. Ann Thorac Surg 48:306–308, 1989.
6. Bartlett JG: Bacterial infections of the pleural space. Semin Respir Infect 3:308–321, 1988.
7. Forty J, Yeatman M, Wells FC: Empyema thoracic: a review of a four-and-a-half-year experience of cases requiring surgical treatment. Respir Med 84:147–153, 1990.
8. Empyema in Children: Epidemiology,Diagnosis, and Management Arthur DeLuca, MD, and GeoffreyKurland, MD
9. Light RW: Parapneumonic effusions and empyema. Proc Am Thorac Soc 3:75–80, 2006.
10. Mandal AK, Thadepalli H, Mandal AK, et al: Outcome of primary empyema thoracis: therapeutic and microbiologic aspects. Ann Thorac Surg 66:1782–1786, 1998.
11. Maskell NA, Davies CW, Nunn AJ, et al: UK controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 352:865–874, 2005.
12. Carlos GG, Yuwei Z, Pekka JN, et al: Emergence of parapneumonic empyema in the USA. Thorax 66:663–668, 2011
13. Schultz KD, Fan LL, Pinsky J, et al: The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 113:1735–1740, 2004.
14. Buckingham SC, King MD, Miller ML: Incidence and etiologies of complicated parapneumonic effusions in children, 1996 to 2001. Pediatr Infect Dis J 22:499–504, 2003.
15. Pilishvili T, Lexau C, Farley MM, et al: Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis 201:32–41, 2010.
16. Whitney CG, Farley MM, Hadler J, et al: Decline in invasive pneumococcal disease after the introduction of proteinpolysaccharide conjugate vaccine. N Engl J Med 348:1737–1746, 2003.
17. Grijalva CG, Nuorti JP, Zhu Y, et al: Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis 50:805–813, 2010.
18. Grijalva CG, Nuorti JP, Arbogast PG, et al: Decline in pneumonia admissions after routine childhood immunisation with pneumococcal conjugate vaccine in the USA: a time-series analysis. Lancet 369:1179–1186, 2007.
19. Ampofo K, Herbener A, Blaschke AJ, et al: Association of 2009 pandemic influenza A (H1N1) infection and increased hospitalization with parapneumonic empyema in children in Utah. Pediatr Infect Dis J 29:905–909, 2010.
20. Byington CL, Hulten KG, Ampofo K, et al: Molecular epidemiology of pediatric pneumococcal empyema from 2001 to 2007 in Utah. J Clin Microbiol 48:520–525, 2010.
21. Obando I, Munoz-Almagro C, Arroyo LA, et al: Pediatric parapneumonic empyema, Spain. Emerg Infect Dis 14:1390–1397, 2008.
22. Eltringham G, Kearns A, Freeman R, et al: Culture-negative childhood empyema is usually due to penicillin-sensitive Streptococcus pneumoniae capsular serotype 1. J Clin Microbiol 41:521–522, 2003.
23. Tarrago D, Fenoll A, Sanchez-Tatay D, et al: Identification of pneumococcal serotypes from culture-negative clinical specimens by novel real-time PCR. Clin Microbiol Infect 14:828–834, 2008.
24. Ploton C, Freydiere AM, Benito Y, et al: Streptococcus pneumoniae thoracic empyema in children: rapid diagnosis by using the Binax NOW immunochromatographic membrane test in pleural fluids. Pathol Biol (Paris) 54:498–501, 2006
25. Le Monnier A, Carbonnelle E, Zahar JR, et al: Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids. Clin Infect Dis 42:1135–1140, 2006.
26. Ahmed RA, Marrie TJ, Huang JQ: Thoracic empyema in patients with community-acquired pneumonia. Am J Med 119:877–883, 2006.
27. Maskell NA, Davies CW, Nunn AJ, et al: UK controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 352:865–874, 2005.
28. Maskell NA, Batt S, Hedley EL, et al: The bacteriology of pleural infection by genetic and standard methods and its mortality significance. Am J Respir Crit Care Med 174:817–823, 2006
29. Finley C, Clifton J, Fitzgerald JM, et al: Empyema: an increasing concern in Canada. Can Respir J 15:85–89, 2008.
30. Spellberg B, Guidos R, Gilbert D, et al: The epidemic of antibioticresistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis 46:155– 164, 2008.
31. Kyaw MH, Lynfield R, Schaffner W, et al: Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumoniae. N Engl J Med 354:1455–1463, 2006
32. Hankins JR, Miller JE, Alter S, et al. Bronchopleural fistula: thirteen-year experience with 77 cases. J Thorac Cardiovasc Surg 1978; 76:755.
33. Varkey B, Rose HD, Kesavan-Kurry CP, Politis J. Empyema thoracis during a ten-year period: Analysis of 72 cases and comparison to a previous study (1952 to 1967). Arch Intern Med 1981; 141:1771
34. Stark DD, Federle MP, Goodman PC, et al. Differentiating lung abscess and empyema: radiography and computed tomography. AJR Am J Roentgenol 1983; 141:163
35. . Hanna JW, Read JC, Choplin RH. Pleural infections: a clinical radiological review. J Thorac Imaging 1991; 6:68-79
36. Orringer MB. Thoracic empyema: Back to basics. Chest 1988; 93:901
37. Sullivan KM, O’Toole RD, Fisher RH, Sullivan KN. Anaerobic empyema thoracis: the role of anaerobes in 226 cases of culture proven empyemas. Arch Intern Med 1973; 131:521.
38. Cohen RG, DeMeester TR, Lafontaine E. The pleura. In: Sabiston DC, Spencer FC, editors. Surgery of the chest. 6th ed. Philadelphia: WB Saunders; 1995.
39. Moran JF. Surgical management of pleural space infections. Semin Respir Infect 1988; 3:383
40. Personne C. Role of early thoracotomy in the treatment of empyema. In: Deslauriers J, Lacquet LK, editors. International trends in general thoracic surgery. St. Louis: Mosby–Year Book; 1990, Vol 6
41. Ferguson MK. The healing hands. Chest 1990; 97:4
42. Deslauriers J, Invited commentary to Cassina PC, et al. Video-assisted thoracoscopy in the treatment of pleural empyema: Stage-based management and outcome. J Thorac Cardiovasc Surg 1999; 117:238
43. Silen ML, Naunheim KS. Thoracoscopic approach to the management of empyema thoracis: indications and results. Chest Surg Clin North Am 1996; 6:491
44. Fishman NH, Ellertson DG. Early pleural decortication for thoracic empyema in immunosuppressed patients. J Thorac Cardiovas Surg 1977; 74:537.
45. Miller JI. Empyema thoracis. Ann Thorac Surg 1990; 50:343
46. Bergeron MG. The changing bacterial spectrum and antibiotic choice in thoracic surgery: Surgical management of pleural diseases. In: Deslauriers J, Lacquet LK, editors. International trends in general thoracic surgery. St. Louis: Mosby–Year Book; 1990, Vol 6. p. 197-207
47. Tillett WS, Sherry S. The effect in patients of streptococcal fibrinolysin (streptokinase) and streptococcal desoxyribonuclease on fibrinous, purulent and sanguineous pleural exudations. J Clin Invest 1949; 28:173
48. Delarue NC. Empyema: Principles of management: an old problem revisited. In: Deslauriers Lacquet LK, editor. International trends in general thoracic surgery. St. Louis: Mosby–Year Book; 1990, Vol 6.
49. Samson PE. Empyema thoracis: essentials of present-day management. Ann Thorac Surg 1971; 11:210.
50. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935; 60:1096.
51. Virkkula L, Eerola S. Treatment of postpneumonectomy empyema and large fistula. Les Bronches 1973;23:230.
52. Blasco E, Paris F, Padilla J. Acute postpneumonic empyema treated by intercostal tube drainage with suction and pleural washing but without rib resection. In: Deslauriers J, Lacquet LK, editors. International trends in general thoracic surgery. St. Louis: Mosby–Year Book; 1990, Vol 6
53. Morin JE, Munro DD, MacLean LD. Early thoracotomy for empyema. J Thorac Cardiovasc Surg 1972; 64:530.
54. Moir R, Telander RL. Complications of lower respiratory tract infection, empyema complicating pneumonia, pneumatoceles, and respiratory embarrassment. In: Fallis JC, Piller RM, Lemoine G, editors. Current topics in general thoracic surgery. New York: Elsevier; 1991, Vol 1
55. Sensenig DM, Rossi NP, Ehrenhaft JL. Decortication for chronic non-tuberculous empyema. Surg Gynecol Obstet 1963; 1117:443.
56. Kumar, Akshay, and Sachit Anand. "Lung Decortication." (2020).
57. The Modern Use of Thoracoplasty Richard A. Hopkins, M.D., Ross M. Ungerleider, M.D., E. Wilson Staub, M.D., and W. Glenn Young, Jr., M.D.
58. Goyal, V., Kumar, A., Gupta, M., Sandhu, H. P. S., & Dhir, S. (2014). Empyema thoracis in children: Still a challenge in developing countries. African Journal of Paediatric Surgery, 11(3), 206-210.
59. Acharya, P. R., & Shah, K. V. (2007). Empyema thoracis: A clinical study. Annals of thoracic medicine, 2(1), 14-17.
60. Sharma, S., Dutta, R., & Singh, T. (2010). Pediatric empyema thoracis: A 5-year study from a tertiary care center in North East India. Indian Journal of Pediatrics, 77(9), 967–970. https://doi.org/10.1007/s12098-010-0123-6
61. The Survey of Pediatric Pleural Empyema in North of Iran (From 2014 to 2016) International Journal of Pediatrics pages:7421-7432
62. Maffey, A., Colom, A., Venialgo, C., Acastello, E., Garrido, P., Cozzani, H., ... & Teper, A. (2019). Clinical, functional, and radiological outcome in children with pleural empyema. Pediatric pulmonology, 54(5), 525-530.
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