Toward Optimal Outpatient Therapy for Pediatric Parapneumonic Empyema.

Parapneumonic empyema (PPE) is an important complication of pediatric pneumonia and leads to prolonged hospitalization and substantial short-term morbidity. Over the past decade, there has been vigorous debate into the optimal management of such patients leading to marked variation in care. Most of the debate has focused on the optimal drainage procedure, focusing on clinical trials that have assessed the relative merits of chest tubes with instillation of fibrinolytic agents compared with surgical approaches, such as video-assisted thorascopic surgery. Relatively less attention has been paid to important questions related to the medical management of these patients, especially those that address the route and duration of antimicrobial therapy. In terms of outpatient therapy duration, current national guidelines recommend 2 to 4 weeks of outpatient therapy (Pediatric Infectious Diseases Society [PIDS] and Infectious Diseases Society of America [IDSA]). Other reputable guidelines are fairly similar; for instance, the British Thoracic Society recommends 1 to 4 weeks of outpatient therapy, or longer, if residual disease. Little research to date has specifically explored the question of the comparative effectiveness of outpatient parenteral antibiotic therapy (OPAT) with oral antibiotic therapy in the posthospitalization therapy of PPE. The PIDS/IDSA guidelines (for children .3 months of age) recommend conversion to oral outpatient stepdown therapy rather than parenteral outpatient therapy as a strong recommendation, but acknowledge that this recommendation is based on low-quality evidence.