A retrospective review was conducted at Primary Children’s Hospital of patients younger than 18 years of age hospitalized from 2005 to 2014 with a diagnosis of pediatric parapneumonic empyema and who were discharged with either oral therapy or outpatient parenteral (intravenous) antibiotic therapy (OPAT). The primary outcome was any complication, including both pneumonia-related complications (e.g., any unplanned hospital readmission or emergency department/urgent care visits within 30 days of discharge from the index hospitalization where the primary reason was related to pneumonia) and treatment-related complications (e.g., adverse drug effects or catheter-related complications).

A total of 391 children were hospitalized with parapneumonic empyema, of which 337 children (86%) received OPAT. The median age was 3.8 years (IQR 2.2–7.5 years) and the median length of stay during the initial hospitalization was 8.8 days (IQR 6.9–11.3 days). The most common etiology in the cohort was Streptococcus pneumoniae.

Antibiotics commonly used for OPAT were ceftriaxone or cefotaxime (299 children, 89%) and clindamycin (23 children, 7%). Antibiotics commonly used for oral therapy included amoxicillin alone (27 children, 50%), clindamycin (13 children, 24%), amoxicillin/clavulanate (7 children, 13%), and levofloxacin (4 children, 7%). Children discharged with oral antibiotics were more likely to be admitted to the ICU (57% vs 32%, P < 0.001) and have longer length of stay (median 10.0 days vs 8.7 days, P = 0.01). Other demographic and baseline characteristics were comparable between the two treatment groups.

A total of 35 children (9%) experienced a complication, including 30 children (8.9%) who received OPAT, and five children (9.3%) who received oral therapy. The annual proportion of patients who experienced a complication did not change over time (P = 0.53). Two patients (0.6%) treated with OPAT had treatment failure. Catheter-related complications occurred in 5% of patients who received OPAT. After adjusting using propensity score weighting, the frequency of complications was similar between oral therapy and intravenous therapy (adjusted odds ratio 0.97; 95% confidence interval, 0.23–4.65).

COMMENTARY

Parapneumonic empyema is an uncommon though serious complication of pneumonia in children and young adults, usually requiring prolonged antibiotic therapy for 2–4 weeks after hospitalization. Evidence suggests that the incidence of parapneumonic empyema in children is increasing nationally over the last decade. Partly because of the lack of controlled clinical trials, there is considerable practice variability in the management of these patients.

This is the first study comparing outcomes between oral and intravenous therapy following hospitalization for parapneumonic empyema in children. Oral therapy has been successfully used for prolonged therapy of children with bone and joint infections. In general, children tolerate well the high doses of antibiotics that are most often used in these circumstances — amoxicillin, amoxicillin/clavulanate, and clindamycin. This study shows that the frequency of complications following hospital discharge for children with parapneumonic effusion was similar for oral therapy and intravenous therapy.

Oral antibiotics appear to be safe and effective for children with parapneumonic effusion who will complete antibiotic therapy in an outpatient setting. This finding is consistent with recent guidelines from the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, both of which recommend oral therapy instead of OPAT for completing therapy for parapneumonic empyema.