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.