Introduction
Pediatric community-acquired pneumonia (CAP) is a significant health
problem and a leading infectious cause of childhood morbidity and
mortality worldwide 1. Even though the once
significant mortality rates associated with CAP have decreased in the
industrialized world thanks to vaccines, accessible antibiotics and
advances in diagnostics and monitoring, some complications are still a
matter of concern, most commonly parapneumonic effusions that have been
increasing in Europe and the United States during the last decades2.
Parapneumonic effusion complicates
up to 13% of cases of hospitalized pneumonia among children3. It can be divided into three stages: inflammatory
exudate, clear in appearance, sterile (stage I); purulent exudate
resulting from translocation of white blood cells into the fluid with
deposition of fibrin in the pleural space (stage II); organized empyema
with formation of a thick membrane covering the visceral pleura (stage
III) 4,5. The management of parapneumonic effusions
remains an area of controversy, and various therapeutic options are
described 6,7. If conservative treatment with
antibiotics alone is a reasonable option for small parapneumonic
effusions, guidelines recommend evacuation of effusions which are
enlarging, compromising respiratory function and/or associated with
loculations; intrapleural fibrinolysis is usually suggested for
effusions of thick fluid with loculations or empyema; and surgery
(either thoracotomy with decortication or video-assisted thoracoscopic
surgery (VATS)) is recommended in case of failure of antibiotics, chest
tube drainage and fibrinolytics 8,9. However, surgery
is invasive and not without risks, requires general anesthesia as well
as a highly skilled pediatric surgical team, and is more expensive than
conservative management 10. Therefore, alternative
non-surgical strategies would be appealing in children failing
antibiotics, drainage and intrapleural fibrinolysis.
Inflammation plays a key role in the genesis of parapneumonic effusion11. Corticosteroids have well-known anti-inflammatory
properties, based on which they have been successfully studied in
several infectious diseases including bacterial meningitis and
community-acquired pneumonia of the adult 12,13.
However, even though their use may be attractive, corticosteroids are
not included in the recommendations for the management of complicated
parapneumonic effusion, probably because evidence to support this
approach is still lacking. Despite this, aiming to favor a less invasive
approach than surgery, we have introduced corticosteroids in the
therapeutic armamentarium used in managing children with complicated
parapneumonic effusion admitted to our hospital. We prescribe
corticosteroids to children with persisting fever despite pleural
drainage and fibrinolysis, or to febrile children with effusions that
are organized and loculated to such an extent that chest drainage is not
an option. We report here our 15-year experience with this strategy.