Urokinase as effective as surgery for empyema in children

By Will Boggs MD

NEW YORK (Reuters Health) - Drainage followed by urokinase instillation is as effective as video-assisted thoracoscopic surgery (VATS) for treating septated parapneumonic empyema in children, researchers from Spain report.

"We have two equally effective treatments for septated empyema in children," Dr. Claudia Marhuenda from Hospital Universitari Son Espases, Palma de Mallorca, Spain told Reuters Health. "One is surgical, the other is nonsurgical. Let's try the less invasive first: fibrinolytics."

As many as 2% of pediatric pneumonia cases are complicated by empyema, including up to 53% of patients hospitalized for pneumonia, Dr. Marhuenda and colleagues write in Pediatrics, online October 27. But the optimal treatment remains controversial, with some authorities favoring VATS and others favoring intrapleural fibrinolytic agents like urokinase.

Dr. Marhuenda's team compared outcomes of 103 children with parapneumonic empyema, including 53 randomized to VATS and 50 randomized to urokinase.

The median length of postintervention hospitalization did not differ significantly between the VATS group (10 days) and the urokinase group (9 days). The groups did not differ significantly either in how long stayed at the hospital overall, in the duration of fever after treatment or in the number of patients who required another procedure to resolve their empyema.

Children in the urokinase group retained their chest tube one day longer, on average, than did children in the VATS group (p<0.001).

Most children in both groups (81.1% of VATS patients, 82% of urokinase patients) had no treatment- or pneumonia-related complications.

By the three-month follow-up visit, radiologists interpreted chest radiographs as normal or showing only small changes in 66.7% of VATS-treated patients and 59.5% of urokinase-treated patients (p=0.40).

"This multicenter study adds strength to current recommendations to use chemical debridement as first-line therapy in these patients," the researchers conclude.

"With the evidence we have at this point, my first choice would be fibrinolytic treatment, and more so the sicker the patient is," Dr. Marhuenda said. "I would use thoracoscopy when fibrinolytics are contraindicated, especially when there is a pulmonary fistula at diagnosis, and, also, when fibrinolysis fails."

She added, "There are still many aspects of the treatment of empyema in children that need to be researched. One of those is the identification of the clinical and biological characteristics of the patients that fail the fibrinolytics treatment. Another one would be if there are long-term differences in the pulmonary function depending on the treatment. These two points would help clinicians to decide the best first-line treatment for a particular patient."

SOURCE: http://bit.ly/1rW3UFD

Pediatrics 2014.

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