# Drainage of bacterial pleuropneumonia in children: A 13-year retrospective monocentric study

Apolline Furgier, Marion Caseris, Remadji Fiona Kossadoum, Audrey Baron, Arnaud Bonnard, Jérôme Naudin, Nina Martz, Jessy Zenon, Hosam Dawoud, Chrystele Madre, et al.

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## To cite this version:

Apolline Furgier, Marion Caseris, Remadji Fiona Kossadoum, Audrey Baron, Arnaud Bonnard, et al. Drainage of bacterial pleuropneumonia in children: A 13-year retrospective monocentric study. Archives de Pédiatrie, 2026, 33 (1), pp.8-15. 10.1016/j.arcped.2025.10.002. hal-05503463

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Research paper

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# Drainage of bacterial pleuropneumonia in children: A 13-year retrospective monocentric study

Apolline Furgier<sup>a,∗</sup><sup>ID</sup>, Marion Caseris<sup>a</sup>, Remadji Fiona Kossadoum<sup>b</sup>, Audrey Baron<sup>c</sup>, Arnaud Bonnard<sup>d,e</sup>, Jérôme Naudin<sup>f,g</sup>, Nina Martz<sup>d</sup>, Jessy Zenon<sup>c</sup>, Hosam Dawoud<sup>c</sup>, Chrystele Madre<sup>g</sup>, Maya Husain<sup>h</sup>, Elise Mallart<sup>a</sup>, Naïm Ouldali<sup>a</sup>, Michael Levy<sup>g, ID</sup>, Jeanne Truong<sup>a, ID</sup>

## ARTICLE INFO

### Keywords:

- Pleurisy

- Pleural drainage

- Pediatric

- Chest-tube insertion

- Drain insertion

## ABSTRACT

**Introduction:** There is no consensus on indications and modalities of drainage procedures for bacterial pleuropneumonia in children. This study aimed to analyze the clinical course following drainage procedures and the different techniques used.

**Method:** This retrospective single-center study included children with drained bacterial pleuropneumonia at a French University Hospital, from January 1, 2011, to December 31, 2023.

**Results:** Thirty-three children were included, with a median age of 3.3 years. The most frequently identified pathogens were *Staphylococcus aureus* (n = 13; 39 %), *Streptococcus pyogenes* (GAS) (n = 9; 27 %), and *Streptococcus pneumoniae* (n = 5; 15 %). Indications for pleural drainage included respiratory distress (n = 16; 48 %) and persistent/abundant pleural effusion (n = 7; 21 %). 73 % of cases presented mediastinal deviation. Percutaneous drainage was performed for 23 patients (70 %) and surgical drainage for 10 patients (30 %). Drainage cultures were positive in 14/27 cases (52 %) after a median of 3 days (IQR: 1.2–5.5) of antibiotics. After drainage, the median durations of fever, intravenous antibiotics, and hospitalization were 8 (IQR: 4.2–14), 11 (IQR: 8.5–15), and 15.5 days (IQR: 8.7–18.5), respectively. Univariate analysis showed that children with percutaneous drainage had longer post drainage fever (12 vs. 5.3 days, *p* = 0.01) and ventilation durations (7 vs. 2.25 days, *p* = 0.02) than those with surgical drainage.

**Conclusion:** The cohort had severe cases, with percutaneous drainage more commonly used. Positive drainage cultures highlighted the challenges of antibiotic penetration and supported the role of drainage in selected cases. Despite favorable medium-term outcomes, post-drainage recovery was prolonged, with extended durations of hospitalization, persistent fever, and prolonged antibiotic treatment.

## 1. Introduction

Bacterial pleuropneumonia in children has been increasing since the early 2000s [1–3] with an estimated incidence of 43 cases per 100,000 children under five years old [4]. Often arising as a complication of

pneumonia or parapneumonic effusion due to bacterial spread, it is associated with considerable morbidity, including prolonged hospitalizations (median duration of 14 days [3]) and the need for ventilatory support in approximately 12 % of cases [5]. Across the world, the main bacteria commonly identified are *Staphylococcus aureus* (SA),

<footnote><sup>a</sup> Department of General Pediatrics, Pediatric Internal Medicine, Rheumatology and Infectious Diseases, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France</footnote>

<footnote><sup>b</sup> Department of Emergency Pediatrics, University Hospital Bordeaux, France</footnote>

<footnote><sup>c</sup> Department of Microbiology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France</footnote>

<footnote><sup>d</sup> Department of Pediatric Surgery, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France</footnote>

<footnote><sup>e</sup> Inserm UMR 1141, Paris Cite University, France</footnote>

<footnote><sup>f</sup> Pediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France</footnote>

<footnote><sup>g</sup> Department of Surgical Intermediate Care, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France</footnote>

<footnote><sup>h</sup> Necker Hospital for Sick Children, General Pediatrics and Pediatric Infectious Diseases, Paris Cite University, Paris, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: apolline.furgier@aphp.fr (A. Furgier).</footnote>
Streptococcus pyogenes (GAS) and Streptococcus pneumoniae (Sp) [6–8].

The management of pleuropneumonia involves two main components. The first is antibiotic therapy, which is widely standardized in France [9]. The second component is the potential drainage of pleural effusion, either through repeated punctures or the placement of a drain (chest tube alone, video-assisted thoracoscopy (VATS), or thoracotomy, with or without fibrinolysis). Currently, there are no international guidelines regarding the indications and methods for draining bacterial pleuropneumonia in children, leading to great heterogeneity in practices [10,11]. Decisions are generally made on a case-by-case basis by a multidisciplinary team (including infectious disease specialists, pediatricians, pulmonologists, surgeons, intensivists...), taking into account factors such as effusion size and clinical tolerance [12]. Thoracic drains are mainly characterized by their intrathoracic end (pigtail, right) and external diameter (French/Charrière). Chest tubes can be inserted by dissection (clamp/fingers), Seldinger (wire) or via a trocar. Medical drainage can be performed by qualified physicians, using Seldinger or trocar techniques under local anaesthetic at the patient's bedside. Surgical drainage is performed in the operating theatre, under general anaesthetic, sometimes combined with VATS [13]. VATS allows for simultaneous debridement, adhesiolysis, and septal flattening, and is less invasive than traditional thoracotomy [14]. Ultimately, each medical center selects its techniques based on its own expertise.

The primary objective of this study was to analyze the clinical course of children following a drainage procedure for bacterial pleuropneumonia. The secondary objective was to analyze the indications and modalities of pleural drainage.

## 2. Method

**STUDY DESIGN** - We conducted a single center retrospective observational study.

**INCLUSION CRITERIA** - We included all children aged between one month and 18 years (exclusive) hospitalized for an infectious pleuropneumonia and treated with a chest tube at the Robert-Debré University Hospital, in Paris, France, between January 1, 2011, and December 31, 2023. Patients were identified by crossing two databases: the Microbiology Laboratory and the French Program for the Medicalization of Information Systems. We used the following ICD-10 codes: J85 (Lung and Mediastinum Abscess), J86 (Pyothorax), J90 (Pleural Effusion, not elsewhere classified), J91 (Pleural Effusion in Diseases Elsewhere Classified), and GGJB001 (Pleural Drainage). Patients with: abscessed lung disease without pleural involvement, nosocomial pleuropneumonia, tuberculous pleurisy, and non-infectious pleurisy were excluded.

**DEFINITIONS** - Bacterial pleuropneumonia was defined using clinical, biological, and imaging criteria. Clinical criteria included fever, dyspnea, and/or chest or abdominal pain. Comorbidities were defined by the presence of associated chronic diseases. Biological criteria involved the presence of an inflammatory syndrome, which was either microbiologically confirmed by pleural fluid or indicated by exudative pleural fluid combined with a positive blood culture. Imaging criteria, such as chest X-ray, ultrasound, or computed tomography (CT), identified lung parenchymal involvement with a puncturable pleural effusion (measuring >10 mm on ultrasound or chest CT).

Indications for pleural drainage were categorized into five groups based on our interpretation of the medical records, as no standardized protocol was followed at the hospital. Patients could have several drainage criteria. The categories included: respiratory distress; effusion (recurrent and/or high-volume > 5 cm on pleural ultrasound); spontaneous or post-intubation pneumothoraces; persistent or recurrent fever; and hemodynamic compromise and/or mediastinal shift. The Pediatric Intensive Care Unit (PICU) at Robert-Debré University Hospital accepts children according to criteria of severity, but is also primarily responsible for placing and monitoring pleural drains.

"Short-term evolution" was defined as events occurring up until hospital discharge, while "medium-term evolution" referred to follow-

up consultations at 3, 6, and/or 9 months or any late complications if available.

**DATA COLLECTION** - Data related to demographics, clinical aspects, biology, radiology, short-term and medium-term evolutions were collected. The PELOD-2 score, that assessed organ dysfunction and mortality risk in the first 24 h, was reported for each patient transferred to PICU [15].

**OUTCOMES** - The primary outcome was a composite measure, including post-drainage durations of hospitalization, fever, invasive/ non-invasive ventilation, intravenous antibiotic therapy, and third-level analgesic use. The secondary outcomes included the indications and modalities of pleural drainage (percutaneous or surgical).

**STATISTICAL ANALYSIS** - Continuous variables were summarized as medians with interquartile ranges (IQR, 25th-75th percentiles), and categorical variables were presented as frequencies and percentages. Comparisons were made using Student's t-test for continuous variables and Chi² or Fisher's tests for categorical variables. A significance level of *p* < 0.05 was considered, with analyses conducted using STATA® 12.1 (College Station, Texas).

**ETHICS** - This study was approved by the Robert-Debré Ethics Committee (No. 2024-720bis).

## 3. Results

### 3.1. General characteristics of the population

Thirty-three cases of infectious pleuropneumonia with chest drainage were recorded between 2011 and 2023 at the Robert-Debre University Hospital (Fig. 1). The median age was 3.3 years (IQR: 0.6–6.0) with ages ranging from 2 months to 16 years, and a male-to-female ratio of 0.9. Comorbidities were rare (18 %) and included extreme prematurity (*n* = 1), post-neonatal anoxia encephalopathy (*n* = 1), Sanfilippo disease (*n* = 1), polymalformative syndrome (*n* = 2), and Bartter syndrome (*n* = 1). None of the patients had a known immune deficiency at diagnosis. Most cases (57 %) occurred during winter (Table 1).

### 3.2. Clinical, biological and radiological characteristics

The clinical signs of pleuropneumonia were fever (97 %), polypnea (91 %), cough (75 %) and signs of struggle (76 %). The median total duration of fever was 16 days (IQR: 13–22).

Biological data on admission are summarized in Table 1.

All patients underwent a chest X-ray, 31 (93 %) underwent pleural ultrasound and 23 (70 %) had chest CT scans. The 2 patients who did not have pleural ultrasounds benefited from a chest CT scan. The extent of pleural effusion and findings such as septa, bubbles, and mediastinal deviation are detailed in Table 1.

### 3.3. Microbiological data

All pleuropneumonia were microbiologically documented from analyses carried out on pleural fluid before (needle puncture *n* = 23/33) or after placement of the chest tube (Table 2). A pleural puncture before the placement of a chest tube allowed for the identification of one or more microorganisms in 82.6 % of cases (*n* = 19/23). The main pathogens were SA (*n* = 13; 39 %), GAS (*n* = 9; 27 %), Sp (*n* = 5; 15 %), and Fusobacterium (*n* = 3; 9 %). In three cases, documentation revealed a polymicrobial infection involving oropharyngeal flora. All SA isolates were methicillin-sensitive, and 12 (92 %) carried Panton-Valentine leucocidin (PVL). The PVL subgroup was young (median age 0.5 years old). The single positive Sp culture showed no reduced sensitivity to penicillin. (Table 2).
<figure><img src="image_5.png" /><figcaption>Fig. 1. Flow chart of patients hospitalized and drained for a pleuropneumonia at Robert-Debre hospital between 2011 and 2023.</figcaption></figure>

### 3.4. Medical care

Median hospital length of stay was 21 days (IQR: 16–28), with 94 % of patients (n = 31) transferred to PICU for a median of 9.5 days (IQR: 5–15). Median PELOD-2 score for patients transferred to PICU is reported in Table 1.

A bi-antibiotic therapy was initiated in 45 % of cases, mainly with penicillin and clindamycin. The median duration of IV treatment was 16 days (IQR: 14–24) with a total duration of antibiotic therapy of 29.5 days (IQR: 23.2–47.7). Additional management details, including ventilatory support, vascular fluid bolus, vasopressor use, and third-level analgesic administration, are presented in Table 3.

### 3.5. Pleural drainage

a) **Indications for pleural drainage:** The main indications for pleural drainage are reported in Table 4. Among 11 patients drained for persistent/high-volume effusion and/or recurrent fever, 9 also had mediastinal deviation. Some patients underwent multiple pleural punctures prior to drainage (2 for nine patients and at least 3 for two patients).

b) **Drainage technique**

Initial pleural effusion drainage was performed percutaneously for 23 patients (70 %) and surgically via VATS for 10 patients (30 %) (Table 4). The selection of a drainage method was determined by practitioners following a discussion between doctors and surgeons. The fluid volume drained could not be reported due to missing data.

From 2015 onwards, the majority of drains were placed percutaneously. Fibrinolysis was applied in 8/23 patients (35 %) undergoing percutaneous drainage, using alteplase (n = 5) or urokinase (n = 3).

c) **Time to drain**

Drainage was performed at a median of 7 days after hospitalization (IQR: 3–10) and 6 days (IQR: 2–10) after intravenous therapy. Two patient groups were identified based on PICU transfer timing. The first group included 26 patients (79 %) who were transferred early to PICU, within the first 5 days of hospitalization. Their median PELOD score was 3 (IQR: 1–5, n = 20). Mainly of these patients (14/26; 54 %) was drained for respiratory distress. Forty - two % of them (11/ 26) underwent drainage within the first 48 h following PICU admission. The second group consisted of 5 patients (15 %) who were transferred to PICU after the seventh day of hospitalization, with the latest transfer occurring on day 33. Their median PELOD score was 0 (n = 2). All five patients underwent chest tube drainage on the day of PICU transfer.

d) **Microbiological cultures of drainage**

During the procedure, 27 pleural fluid samples were sent for microbiological analysis, with 14 (52 %) yielding positive cultures. In percutaneous drainage patients, 12 of 23 bacterial identifications were achieved via the drain, compared with 1 of 10 in surgical drainage patients. These patients with positive drainage culture had been on antibiotics for a median of 3 days (IQR: 1.2–5.5) prior to sampling.

e) **Drainage-related complications**

Drainage-related complications occurred in 3 cases (9 %): two
<table><caption>**Table 1**
Clinical and biological features of the children drained for bacterial pleuropneumonia.</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td><strong>Demographics:</strong></td><td></td></tr><tr><td>Age, in year, median (IQR)</td><td>3.3 (0.6–6)</td></tr><tr><td>Gender: ratio M/F</td><td>0.9</td></tr><tr><td>Season: winter / spring / summer / autumn, n (%)</td><td>19 (57 %) / 6 (18 %) / 3 (9 %) / 6 (18 %)</td></tr><tr><td>Comorbidities, n (%)</td><td>6 (18 %)</td></tr><tr><td>Prior antibiotic therapy, n (%)</td><td>7 (21 %)</td></tr><tr><td>Prior NSAIDs, n (%)</td><td>4 (12 %)</td></tr><tr><td><strong>Symptoms on arrival at the health facility</strong></td><td></td></tr><tr><td>Fever, n (%)</td><td>32 (97 %)</td></tr><tr><td>Cough, n (%)</td><td>25 (75 %)</td></tr><tr><td>Polypnea / Signs of struggle, n (%)</td><td>30 (91 %) / 25 (76 %)</td></tr><tr><td>Chest pain / Abdominal pain, n (%)</td><td>6 (19 %) / 9 (27 %)</td></tr><tr><td>Diarrhea/Vomiting, n (%)</td><td>7 (21 %) / 7 (21 %)</td></tr><tr><td>Astenha, n (%)</td><td>26 (79 %)</td></tr><tr><td>Rash, n (%)</td><td>7 (21 %)</td></tr><tr><td><strong>Initial severity in ICU:</strong></td><td></td></tr><tr><td>PELOD-2 score, median (IQR), (N = 24)</td><td>2.5 (1–5)</td></tr><tr><td>Predictive mortality rate according to PELOD-2 score, median (IQR), (N = 19)</td><td>0.55 % (0.1 %–1.22 %)</td></tr><tr><td><strong>Biology: median (IQR)</strong></td><td></td></tr><tr><td>Baseline CRP in mg/L, (N = 33)</td><td>255 (195–311)</td></tr><tr><td>Baseline PCT in µg/L (N = 9)</td><td>15 (4–73)</td></tr><tr><td>Baseline White cells count per mm3, (N = 31)</td><td>16 110 (8915–28 410)</td></tr><tr><td>Baseline Neutrophils count per mm3, (N = 24)</td><td>12 165 (6725–18 262)</td></tr><tr><td><strong>Imaging performed: n (%)</strong></td><td></td></tr><tr><td>Chest X-ray</td><td>33 (100 %)</td></tr><tr><td>Lung ultrasound</td><td>31 (93 %)</td></tr><tr><td>Chest CT scan</td><td>23 (70 %)</td></tr><tr><td><strong>Imaging details *: n (%)</strong></td><td></td></tr><tr><td>Partitions (N = 31)</td><td>23 (74 %)</td></tr><tr><td>Bubbles, (N = 28)</td><td>5 (18 %)</td></tr><tr><td>Mediastinal deviation</td><td>24 (73 %)</td></tr><tr><td>Effusion of high abundance, >5 cm</td><td>14/29 (48 %)</td></tr><tr><td>Effusion of mean abundance, 2–5 cm (N = 29)</td><td>14/29 (48 %)</td></tr><tr><td>Effusion of low abundance, 1–2 cm (N = 29)</td><td>1/29 (3 %)</td></tr></tbody></table>

$M/F$ = male / female - NSAIDs = non-steroidal anti-inflammatory drugs - ICU = intensive care unit - IQR = interquartile with first and third quartile, CRP = C-reactive protein - PCT = procalcitonin.

*Ultrasound or thoracic computed tomography scan if not available.

<table><caption>**Table 2**
Microbiological characteristics of children drained for bacterial pleuropneumonia.</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td><strong>Pleural puncture:</strong></td><td></td></tr><tr><td>Patient with at least 1 pleural puncture, n (%)</td><td>23 (70 %)</td></tr><tr><td>Total volume collected (mL), median (IQR) (N = 9)</td><td>700 (290–850)</td></tr><tr><td>Reconstitution after puncture, n (%) (N = 31)</td><td>21 (64 %)</td></tr><tr><td><strong>Bacterial identification: n (%)</strong></td><td></td></tr><tr><td><strong>On pleural puncture / On pleural drainage</strong></td><td></td></tr><tr><td><strong>Staphylococcus aureus</strong></td><td><strong>13 (39 %)</strong></td></tr><tr><td>Positive pleural effusion culture</td><td>12 (92 %)</td></tr><tr><td>Positive pleural specific PCR</td><td>3 (23 %)</td></tr><tr><td>Positive ARN 16S on pleural effusion</td><td>1 (7 %)</td></tr><tr><td>Positive blood culture</td><td>6 (46 %)</td></tr><tr><td>Methicillin Resistant</td><td>0</td></tr><tr><td>Penicillinase</td><td>8 (61 %)</td></tr><tr><td>Positive PLV</td><td>12 (92 %)</td></tr><tr><td><strong>Streptococcus pyogenes (SGA)</strong></td><td><strong>9 (27 %)</strong></td></tr><tr><td>Positive pleural effusion culture</td><td>7 (78 %)</td></tr><tr><td>Positive ARN 16S on pleural effusion</td><td>2 (22 %)</td></tr><tr><td>Positive respiratory infection PCR</td><td>1 (11 %)</td></tr><tr><td>Positive blood culture</td><td>2 (22 %)</td></tr><tr><td><strong>Streptococcus pneumoniae</strong></td><td><strong>5 (15 %)</strong></td></tr><tr><td>Positive pleural effusion culture</td><td>1 (20 %)</td></tr><tr><td>Positive binax ® pneumococcal antigen</td><td>4 (80 %)</td></tr><tr><td>Positive pleural specific PCR</td><td>1 (20 %)</td></tr><tr><td>Positive respiratory infection panel</td><td>2 (40 %)</td></tr><tr><td>Positive blood culture</td><td>0</td></tr><tr><td><strong>Fusobacterium nucleatum / necrophorum (ARN16S)</strong></td><td><strong>3 (9 %)</strong></td></tr><tr><td><strong>Polymicrobial</strong></td><td><strong>3 (9 %)</strong></td></tr></tbody></table>

IQR = interquartile with first and third quartile; PLV = Panton valentine leukocidin.

pneumothoraces (from percutaneous drainage) and one diaphragmatic hernia identified 4 years after surgical drainage (Table 4).

### f) Evolution

The first drain remained in place for a median of 5 days (IQR: 4–7). Post-drainage, patients stayed in the hospital for a median of 15.5 days (IQR: 8.7–18.5), including 7 days in the PICU (IQR: 5–11). They experienced fever for 8 days (IQR: 4.2–14), used third-level analgesic for 5 days (IQR: 4–10), and received IV antibiotics for 11 days (IQR: 8.5–15) after drainage.

Four patients required rehospitalization. Among them, one underwent pleural drainage during the 1st hospitalization, and the 2nd hospitalization led to a continuation of intravenous antibiotics. The other 3 patients benefited from pleural drainage only during the 2nd hospitalization.

A 7-month-old infant died from SA septic shock (PVL+), complicated by Lemierre's syndrome and severe cerebrovascular events. At 6–9 months, 10 out of 12 patients (83 %) (21 missing data) had a normal X-ray. Only one patient had a prolonged follow-up by a paediatric pulmonologist for the early development of asthma.

### g) Multiple pleural drainages

Three patients initially treated with percutaneous drainage (2 with GAS infections and one with a polymicrobial infection) required a second procedure (2 VATS, 1 percutaneous), none of whom had received fibrinolysis.

## 3.6. Percutaneous (medical) versus surgical pleural drainage

In univariate analyses, patients who underwent percutaneous drainage were compared with those who received surgical drainage (Table 5). Surgical drainage was associated with significantly shorter durations of total PICU stay, post-drainage fever, and post-drainage mechanical ventilation (Table 5). SA infections were predominantly managed with percutaneous drainage (n = 12 versus 1 surgical, p = 0.05), while GAS infections were more frequently treated with surgical drainage (n = 6 versus 3 percutaneous, p = 0.01).

## 4. Discussion

This study reviewed 33 pediatric cases of bacterial pleuropneumonia requiring pleural drainage between 2011 and 2023 at a tertiary pediatric center in France. The cohort primarily consisted of severe cases, with 42 % requiring invasive ventilation and 67 % requiring non-invasive support, and a median PELOD score of 2.5, which indicated a predicted mortality rate of 0.55 %. Following drainage, the median durations of fever (8 days), intravenous antibiotics (11 days), and hospitalization (15.5 days) were relatively prolonged. These durations were longer in patients with percutaneous drainage compared to surgical drainage, though not all significantly so. No drainage-related deaths or severe sequelae occurred.

In our cohort, the most common pathogen was SA (39 %), followed by GAS (27 %) and Sp (15 %). This differs from typical European studies, where Sp is the leading pathogen, particularly before widespread pneumococcal vaccination [6,16,17]. Sp, which is harder to culture, was often diagnosed via soluble pneumococcal antigen detection (4/5 cases).

In our study, regarding SA pleuropneumonia, pleural cultures were positive in 13 cases, and blood cultures in 6/14. Among the 13 SA isolates, all were methicillin-sensitive, with 12 producing PVL toxin, primarily in very young patients (<1 year), consistent with findings from the French study by Gillet et al. [18].

SA pleuropneumonia cases were more frequently managed with percutaneous drainage (12 vs. 1, p = 0.05), while GAS cases were more often treated surgically (6 vs. 3, p = 0.01). This may reflect the different pathogenicity of GAS, which involves hyper-adhesion, invasion, immune evasion, and lymphocyte-activating superantigen production, as described by Bidet et al. [19].

During the SARS-CoV-2 pandemic, particularly in 2021, no
<table><caption>**Table 3**
Medical care of children drained for bacterial pleuropneumonia.</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td><strong>Probabilistic antibiotic therapy:</strong></td><td></td></tr><tr><td>Monotherapy / double therapy / triple therapy, n (%)</td><td>13 (39 %) / 15 (45 %) / 5 (15 %)</td></tr><tr><td>Amoxicillin / Amox - Acid clavulanique n (%)</td><td>5 (15 %) / 15 (45 %)</td></tr><tr><td>3rd generation cephalosporin, n (%)</td><td>13 (40 %)</td></tr><tr><td>Piperacillin - Tazobactam, n (%)</td><td>2 (6 %)</td></tr><tr><td>Vancomycin, n (%)</td><td>5 (15 %)</td></tr><tr><td>Clindamycin, n (%)</td><td>12 (36 %)</td></tr><tr><td>Rifampicin, n (%)</td><td>3 (9 %)</td></tr><tr><td>Aminosid, n (%)</td><td>4 (33 %)</td></tr><tr><td>Adaptation time by pathogen in days, median (IQR) (N = 25)</td><td>2 (1-6)</td></tr><tr><td>Antibiotic treatment duration before drainage, median (IQR) (N = 33)</td><td>6 (2-10)</td></tr><tr><td>Total duration of IV antibiotics in days, median (IQR) (N = 31)</td><td>16 (14-24)</td></tr><tr><td>Total duration of antibiotic therapy in days, median (IQR) (N = 26)</td><td>29.5 (23.2-47.7)</td></tr><tr><td><strong>Ventilatory and oxygen therapy support:</strong></td><td></td></tr><tr><td>Invasive ventilation, n (%)</td><td>14 (42 %)</td></tr><tr><td>Invasive ventilation duration in days, median (IQR) (N = 16)</td><td>4.5 (2.7-9)</td></tr><tr><td>Non Invasive Ventilation, n (%)</td><td>22 (67 %)</td></tr><tr><td>NIV duration in days, median (IQR) (N = 20)</td><td>5.5 (1-10.5)</td></tr><tr><td>Oxygen therapy, n (%)</td><td>26 (79 %)</td></tr><tr><td>Oxygen therapy duration (days), median (IQR) (N = 20)</td><td>6 (3-9.5)</td></tr><tr><td><strong>Fluid resuscitation / Vasopressive drugs: n (%)</strong></td><td>13(39 %)/5(15 %)</td></tr><tr><td><strong>Total duration of fever in days, median (IQR)</strong></td><td>16 (13-22)</td></tr><tr><td><strong>Third-level analgesic: n (%)</strong></td><td>23 (70 %)</td></tr><tr><td>Total duration in days, median (IQR) (N = 18)</td><td>7.5 (4.2-13.5)</td></tr><tr><td><strong>Hospitalization:</strong></td><td></td></tr><tr><td>Hospital stay, total duration (days), median (IQR) (N = 29)</td><td>21 (16-28)</td></tr><tr><td>ICU stay, duration (days), median (IQR) (N = 30)</td><td>9.5 (5-15)</td></tr><tr><td>Hospital stay with rehospitalization, total duration (days), median (IQR) (N = 29)</td><td>23 (17-32)</td></tr><tr><td>Rehospitalization (%)</td><td>3 (9 %)</td></tr></tbody></table>

IQR = interquartile with first and third quartile, IV = intravenous - NIV = Non-invasive ventilation - ICU = intensive care unit.

<table><caption>**Table 4**
Characteristics of drainage for children drained for bacterial pleuropneumonia.</caption><thead><tr><th></th><th></th></tr></thead><tbody><tr><td><strong>Dominant Drainage Criterion: n (%)</strong></td><td></td></tr><tr><td>Respiratory distress</td><td>16 (48 %)</td></tr><tr><td>Effusion (recurring/high volume)</td><td>7 (21 %)</td></tr><tr><td>Spontaneous or post-intubation pneumothorax</td><td>4 (12 %)</td></tr><tr><td>Fever (recurrence/persistence)</td><td>4 (12 %)</td></tr><tr><td>Hemodynamic impact/mediastinal deviation</td><td>2 (6 %)</td></tr><tr><td><strong>Drainage Features:</strong></td><td></td></tr><tr><td>Medical: percutaneous, n (%)</td><td>23 (70 %)</td></tr><tr><td>Chirurgical: VATS, n (%)</td><td>10 (30 %)</td></tr><tr><td>Fibrinolytic use, n (%) (N = 23)</td><td>8 (35 %)</td></tr><tr><td>Time to pleural drain placement (days since admission), median (IQR) (N = 31)</td><td>7 (3-10)</td></tr><tr><td>Pleural drainage duration, days, median (IQR)</td><td>5 (4-7)</td></tr><tr><td><strong>Bacteriology of drainage</strong></td><td></td></tr><tr><td>Macroscopic aspect: purulent / citrine / serohematic / NS, n (%)</td><td>13 (40 %) / 5 (15 %) / 3 (9 %) / 12 (36 %)</td></tr><tr><td>Positive culture / Negative culture/ No pleural sampling, n (%)</td><td>14 (42 %) / 13 (40 %) / 6 (18 %)</td></tr><tr><td>Germ different from pleural puncture, n (%)</td><td>3 (9 %)</td></tr><tr><td><strong>Biology:</strong></td><td></td></tr><tr><td>Pre-drainage CRP in mg/L, (N = 29)</td><td>206 (147 - 269)</td></tr><tr><td>Post-drainage CRP in mg/L, (N = 25)</td><td>85 (54-222)</td></tr><tr><td><strong>Post-drainage evolution:</strong></td><td></td></tr><tr><td>ICU hospitalization duration after drain insertion, days, median (IQR) (N = 28)</td><td>7 (5-11)</td></tr><tr><td>Total hospitalization duration after drain insertion, days, median (IQR) (N = 26)</td><td>15.5 (8.7-18.5)</td></tr><tr><td>Third-level analgesic duration after drain insertion, days, median (IQR) (N = 18)</td><td>5 (4-10)</td></tr><tr><td>Fever duration after drain insertion, days, median (IQR) (N = 22)</td><td>8 (4.2-14)</td></tr><tr><td>Invasive ventilation duration after drain insertion, days, median (IQR) (N = 14)</td><td>5.5 (3-8)</td></tr><tr><td>Non-invasive ventilation duration after drain insertion, days, median (IQR) (N = 16)</td><td>2 (0-6)</td></tr><tr><td>Oxygen therapy duration after drain insertion, days, median (IQR) (N = 17)</td><td>4 (2-5)</td></tr><tr><td>Intravenous antibiotics duration after drain insertion, days, median (IQR) (N = 27)</td><td>11 (8.5-15)</td></tr><tr><td>Post drainage complication, n (%)</td><td>3 (9 %)</td></tr></tbody></table>

IQR = interquartile with first and third quartile, VATS = video-assisted thoracoscopic surgery - IQR = interquartile range - NS = not specified - CRP = C-reactive protein - ICU = intensive care unit.

pleuropneumonia cases required drainage in our cohort, likely due to reduced bacterial circulation from barrier measures [20]. However, in 2022, post-pandemic, a higher prevalence of pleuropneumonia requiring drainage was observed.

Amoxicillin ± clavulanic acid was the most commonly used probabilistic antibiotic (45 %). The median IV antibiotic duration was 16 days, with a total median duration of 29.5 days, consistent with French (2-6 weeks) [9] and American (2-4 weeks) guidelines [21].

There are currently no international guidelines on the indications and methods for draining bacterial pleuropneumonia in children, resulting in varying practices [10,11,22]. Several studies have attempted to answer the question of the indications for pleural drainage. In our cohort, the primary criteria reported for drainage were respiratory distress (48 %) and the presence of persistent/ significant pleural effusion >5 cm (21 %), often accompanied by mediastinal shift and/or persistent fever.

American pediatric guidelines recommend pleural drainage for moderate para-pneumonic effusions with respiratory distress, large effusions, or purulent effusions, emphasizing the importance of assessing respiratory distress and effusion size, particularly with opacification of more than half of a pulmonary hemifield [21]. The British Thoracic Society recommends pleural drainage for children if the pleural effusion increases under antibiotic therapy and/or compromises respiratory function in a febrile child. These recommendations rule out the performance of iterative punctures and recommend the installation of a chest tube when a 2nd pleural puncture is considered [23]. To date, there are no national recommendations in France regarding the precise indications for drainage in bacterial pleuropneumonia. The French Group of Pediatric Infectious Disease proposes to consider pleural drainage in two situations: before bacterial identification when there are signs of severity (hemoptysis, leukopenia, toxin signs and septic shock) after multidisciplinary evaluation, and in cases of severe pleuropneumonia caused by methicillin-resistant SA LPV secretors [9]. Epaud et al. (2006) compared two groups of children with pleuropneumonia who underwent VATS: one with "classic" drainage criteria (effusion >1/3 of the lung, purulent fluid with pleural white blood cell counts >1000/mm³, or pleural LDH >1000 IU/L), and another with more restrictive criteria
<table><caption>**Table 5**
Percutaneous (medical) drainage versus Surgical drainage for children drained for bacterial pleuropneumonia, univariate analysis.</caption><thead><tr><th></th><th>Percutaneous (medical) drainage<br>(N = 23)</th><th>Surgical drainage (N = 10)</th><th>p</th></tr></thead><tbody><tr><td><strong>Overall characteristics:</strong></td><td></td><td></td><td></td></tr><tr><td>Age (years), mean (SD)</td><td>3,9 (4,6)</td><td>4.34 (3.2)</td><td>0.61</td></tr><tr><td>Gender (male), n (%)</td><td>11 (52 %)</td><td>4 (40 %)</td><td>0.71</td></tr><tr><td>Comorbidity, n (%)</td><td>6 (26 %)</td><td>0</td><td>0.15</td></tr><tr><td>Pre-hospital antibiotic therapy, n (%)</td><td>6 (26 %)</td><td>1 (10 %)</td><td>0.4</td></tr><tr><td>Pre-hospitalization NSAIDs, n (%)</td><td>2 (9 %)</td><td>2 (20 %)</td><td>0.57</td></tr><tr><td>PELOD-2 score, men (SD), (N = 24)</td><td>3,5 (3,9)</td><td>3.8 (4.2)</td><td>0.91</td></tr><tr><td><strong>Imaging:</strong></td><td></td><td></td><td></td></tr><tr><td>Chest CT scan, n (%)</td><td>17 (74 %)</td><td>6 (60 %)</td><td>0.44</td></tr><tr><td>Mediastinal deviation, n (%)</td><td>16 (69 %)</td><td>8 (80 %)</td><td>0.69</td></tr><tr><td>Partitions, n (%) (N = 31)</td><td>14 (67 %)</td><td>9 (90 %)</td><td>0.22</td></tr><tr><td>Bubbles, n (%) (N = 28)</td><td>5 (28 %)</td><td>0</td><td>0.128</td></tr><tr><td><strong>Microbiology, n (%)</strong></td><td></td><td></td><td></td></tr><tr><td><i>S. pneumoniae</i></td><td>4 (17 %)</td><td>2 (20 %)</td><td>1</td></tr><tr><td><i>GAS</i></td><td>3 (13 %)</td><td>6 (60 %)</td><td><strong>0.01</strong></td></tr><tr><td><i>SA</i></td><td>12 (52 %)</td><td>1 (10 %)</td><td>0.05</td></tr><tr><td><i>Fusobacterium spp</i></td><td>2 (9 %)</td><td>1 (10 %)</td><td>1</td></tr><tr><td>Polymicrobial</td><td>3 (13 %)</td><td>0</td><td>0.54</td></tr><tr><td><strong>Biology:</strong></td><td></td><td></td><td></td></tr><tr><td>Baseline CRP in mg/L, mean (SD) (N = 33)</td><td>239.5 (106.8)</td><td>246.2 (87.23)</td><td>0.57</td></tr><tr><td>Baseline White cells count per mm3, (N = 31)</td><td>17,412 (10,968)</td><td>20,128 (15,999)</td><td>0.71</td></tr><tr><td><strong>Hospital care:</strong></td><td></td><td></td><td></td></tr><tr><td>Vasopressor drugs, n (%)</td><td>4 (17 %)</td><td>1 (10 %)</td><td>1</td></tr><tr><td>Drain duration, days, mean (SD)</td><td>8.4 (13.9)</td><td>5.5 (1.2)</td><td>0.26</td></tr><tr><td>Hospital stay duration before drain insertion, days, mean (SD) (N = 31)</td><td>7.0 (8.5)</td><td>10.6 (6.5)</td><td>0.86</td></tr><tr><td>Hospital stay duration after drain insertion, days, mean (SD) (N = 26)</td><td>10.0 (7.9)</td><td>5.2 (4.0)</td><td>0.10</td></tr><tr><td>Total hospital stay duration *, days, mean (SD) (N = 29)</td><td>30.1 (18.5)</td><td>22.5 (7)</td><td>0.13</td></tr><tr><td>ICU stay duration after drain insertion, days, mean (SD) (N = 28)</td><td>20.6 (16.9)</td><td>10.3 (7.9)</td><td>0.06</td></tr><tr><td>Total ICU stay duration, days, mean (SD) (N = 30)</td><td>13.3 (8.7)</td><td>6.2 (8.1)</td><td><strong>0.03</strong></td></tr><tr><td>Fever duration after drain insertion, mean (SD) (N = 22)</td><td>12 (7.1)</td><td>5.3 (3.2)</td><td><strong>0.01</strong></td></tr><tr><td>Oxygen therapy duration after drain insertion, days, mean (SD) (N = 19)</td><td>9.6 (8.8)</td><td>4.3 (2.6)</td><td>0.09</td></tr><tr><td>Non-invasive ventilation duration after drain insertion, days, mean (SD) (N = 16)</td><td>6.1 (8.9)</td><td>1.7 (1.5)</td><td>0.2</td></tr><tr><td>Invasive ventilation duration after drain insertion, days, mean (SD) (N = 14)</td><td>7 (1.2)</td><td>2.25 (1)</td><td><strong>0.02</strong></td></tr><tr><td>Antibiotic therapy duration before drain insertion, days, mean (SD) (N = 33)</td><td>6.7 (7.8)</td><td>10.7 (6.1)</td><td>0.91</td></tr><tr><td>IV therapy duration after drain insertion, days, mean (SD) (N = 27)</td><td>26.6 (20.2)</td><td>21.7 (9.1)</td><td>0.3</td></tr><tr><td>Antibiotic total duration, days, mean (SD) (N = 26)</td><td>37.3 (22.4)</td><td>33.5 (9.4)</td><td>0.32</td></tr><tr><td>Duration of third-level analgesic post-drainage in days, mean (SD) (N = 18)</td><td>9.9 (7.6)</td><td>4.7 (3.3)</td><td>0.10</td></tr><tr><td>Total third-level analgesic duration, days, mean (SD) (N = 18)</td><td>11.7 (8.4)</td><td>6.2 (3.9)</td><td>0.12</td></tr><tr><td>Recurrence, n (%)</td><td>3 (13 %)</td><td>1 (10 %)</td><td>1</td></tr><tr><td>2nd drainage, n (%)</td><td>3 (13 %)</td><td>0</td><td>0.54</td></tr><tr><td>Death, n (%)</td><td>1 (4 %)</td><td>0</td><td>–</td></tr></tbody></table>

SD = standard deviation - NSAIDs = non-steroidal anti-inflammatory drug - Sp = Streptococcus pneumoniae - GAS = Group A Streptococcus SA = Staphylococcus aureus - ICU = intensive care unit - IV = intravenous - * total even if recurrence - CRP = C-reactive protein.

(mediastinal deviation or uncontrolled sepsis). In the restrictive group, fever duration and CRP normalization were significantly shorter, with no differences in hospital stay, intravenous antibiotic duration, or chest X-ray normalization. Based on these findings, Epaud et al. recommended reserving chest tube insertion for severe cases involving mediastinal deviation, significant respiratory distress, or uncontrolled sepsis [24]. Thus, our study confirms the lack of protocol with defined indications for pleural drainage.

Culture of pleural drainage was positive for 14/27 patients (52 %). Patients with positive cultures had a median of three days of intravenous antibiotics beforehand, underscoring the difficulty of antibiotic penetration into septate pleural fluid. Boselli et al. noted that plasma antibiotic concentrations do not reliably reflect drug activity in pulmonary tissue and are even less predictive in pleural fluid [25]. Moreover, three patients required rehospitalization for drainage after both IV and oral antibiotics. Antibiotics alone were probably insufficient for these cases.

Our study found that percutaneous drainage was used in 70 % of cases, reflecting current practices to favor less invasive approaches and reserve surgical intervention for those unresponsive to antibiotics or to percutaneous drainage with fibrinolytics [26]. The British Thoracic Society similarly advises starting with a small-bore medical drain in adults, with escalation to VATS or thoracotomy if needed [23]. In a German series of 645 pediatric pleural empyemas, Segerer et al. reported that 31 % underwent drainage, 24 % of which were percutaneous [27].

Concerning surgical drainage, meta-analysis from experts supports VATS as the first-line surgical drainage method, with a 80 % success rate for adults [28]. A randomized Korean study involving 80 children showed that VATS, compared to thoracotomy, was associated with a shorter hospital stay, a lower rate of postoperative complications, less intraoperative bleeding, fewer surgical wound infections, and a shorter duration of analgesic consumption (univariate analysis) [29]. In our cohort, all surgical drainages were performed via VATS, with no thoracotomy conducted.

In 2017, Redden synthesized through a systematic review in the Cochrane, the various randomized controlled trials evaluating percutaneous pleural drainage versus surgical drainage (VATS or thoracotomy). Among six retrospective pediatric randomized studies [30–35], no deaths were reported, and no significant differences were found in hospital stay length or procedural complications between VATS and percutaneous drainage. In our cohort, in univariate analysis, the length of PICU hospitalization, post-drainage fever, and mechanical ventilation durations were significantly longer in the percutaneous drainage group compared to the surgical group. However, we did not perform a multivariate analysis, as the number of patients was quite small. A multicenter study on a larger cohort, comparing percutaneous and surgical drainage, would be useful.

In our study, the use of fibrinolytics associated with percutaneous drainage was not systematic (37 %) and not protocolized. Three patients
required a second drainage, none of whom had received fibrinolysis. According to American recommendations, percutaneous drainage combined with fibrinolytic agents and VATS are considered effective treatment methods for bacterial pleuropneumonia. However, in cases with moderate to large effusions that are freely flowing, the placement of a chest tube without fibrinolytics is considered a reasonable first-line solution [21]. A 2019 Cochrane meta-analysis by Altmann et al. found fibrinolysis reduced surgery needs and treatment failure in adult pleuropulmonary disease but did not affect mortality [36]. More recently, a 2023 pediatric meta-analysis by Fernandez Elviro et al. showed chest tubes alone resulted in longer hospital stays compared to tubes with fibrinolysis, VATS, or thoracotomy [37].

This study enabled to distinguish 2 groups of patients. The first group consisted with patients transferred to PICU within the first few days and not necessarily drained immediately after transfer. The second group comprised patients transferred to PICU after the seventh day of hospitalization and drained on the same day, suggesting that the transfer was potentially prompted by the need for pleural drainage. It would be interesting to study these two populations in a larger-scale study.

Our study reported few post-drainage complications: two pneumothoraxes and one diaphragmatic hernia requiring surgical management after VATS. Typical complications of these procedures include pain, bleeding (e.g., internal mammary artery injury), drain malposition, pulmonary re-expansion edema, insertion site or pleural infection, and persistent pneumothorax [38–40]. Specific to VATS are risks from general anesthesia and potential lung parenchymal damage during pachypleuritis resection [12].

In the medium term, chest imaging in our study mostly improved at 3 months and normalized by 6–9 months. Similarly, in Marhuenda et al.'s study [31], chest X-rays at 3 months were deemed normal or nearly normal in 67.9 % of VATS cases and 84 % of simple drainage with fibrinolysis cases.

## 4.1. Limitations

The main limitations of this study include its retrospective, single-center design, which resulted in substantial missing data and may limit the generalizability of our findings. The cohort predominantly included severe and very severe cases, reflecting both the tertiary nature of our hospital and the restrictive indications for pleural drainage, which may limit the generalizability of our findings to less severe or more typical populations of pediatric pleuropneumonia.

Then the absence of standardized protocols and predefined indications. No forced us to infer drainage criteria retrospectively from medical records. Likewise, the high rate of PICU admissions reflects not only patient severity but also the fact that this unit is primarily responsible for placing and monitoring pleural drains, potentially biasing our assessment of clinical severity. Finally, the relatively small sample size reduced statistical power, and comparisons between drainage techniques were confined to univariate analyses, which constrains the robustness and wider applicability of our conclusions.

## 5. Conclusion

This study analyzed the clinical evolution of drained pleuropneumonia, as well as the methods of pleural drainage at a French tertiary pediatric center over 13 years. Consistently with available recommendations and literature, percutaneous drainage was more common than surgery. While medium-term outcomes were favorable, post-drainage recovery was prolonged, with lengthy hospitalization, fever, and antibiotic therapy durations. Univariate analysis showed that children with percutaneous drainage had longer post-drainage fever and ventilation durations than those with surgical drainage. Antibiotic diffusion in pleural effusion is challenging, and could support drainage in some cases, as shown by positive drainage cultures despite adequate antibiotic therapy and cases of medical treatment failure. This work justifies

conducting a multicenter retrospective case-control study to compare drained and undrained bacterial pleuropneumonia. A larger, more diverse population could address initial severity bias in drained cases, evaluate drainage effectiveness, and guide prognosis scoring and therapeutic strategies.

## Funding

This study did not receive any funding.

## Declaration of competing interest

Naïm Ouldali declares receiving travel grants from MSD, Pfizer, Sanofi, and GSK. All other authors have no conflict of interest to disclose.

## References

[1] Nayak R, Brogly SB, Lajkosz K, Lougheed MD, Petsikas D. Two decades of thoracic empyema in Ontario, Canada. Chest 2020;157:1114–6. https://doi.org/10.1016/j.chest.2019.11.040.

[2] Blanc P, Dubus JC, Bosdure E, Minodier P. Community-acquired purulent pleurisy in children: where do we stand? Arch. Pediatr. 2007;14:64–72. https://doi.org/10.1016/j.arcped.2006.10.001.

[3] Finley C, Clifton J, Fitzgerald JM, Yee J. Empyema: an increasing concern in Canada. Can. Respir. J. 2008;15:85–9. https://doi.org/10.1155/2008/975312.

[4] Perisson C. [Pleuropneumopathy in children] Pleuropneumopathie de l'enfant. Réalités Pédiatriques 2013;176:1–3.

[5] Gross CJ, Porter JJ, Lipsett SC, Monuteaux MC, Hirsch AW, Neuman MI. Variation in management and outcomes of children with complicated pneumonia. Hosp. Pediatr. 2021;11:207–14. https://doi.org/10.1542/hpedis.2020-001800.

[6] Madhi F, Levy C, Morin L, Minodier P, Dubos F, Zenkhri F, et al. Change in bacterial causes of community-acquired parapneumonic effusion and pleural empyema in children 6 years after 13-valent pneumococcal conjugate vaccine implementation. J. Pediatr. Infect Dis. Soc. 2019;8:474–7. https://doi.org/10.1093/jpids/piy103.

[7] Gautam A, Wiseman GG, Goodman ML, Ahmedpour S, Lindsay D, Heyer A, et al. Paediatric thoracic empyema in tropical North Queensland, Australia: epidemiological trends over a decade. J. Paediatr. Child Health 2018;54:735–40. https://doi.org/10.1111/jpc.13853.

[8] Grijalva CG, Nuorti JP, Zhu Y, Griffin MR. Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin. Infect. Dis. 2010;50:805–13. https://doi.org/10.1086/650573.

[9] Madhi F, Panetta L, De Pontual L, Biscardi S, Remus N, Gillet Y, et al. Antimicrobial treatment of lower respiratory tract infections in children. Infect. Dis. Now. 2023; 53:104782. https://doi.org/10.1016/j.idnow.2023.104782.

[10] Gillet PY. [Pneumoniae and pleuropneumoniae] Pneumonie et pleuropneumonie [Internet] Journées Nationales d'infectiologies Nantes 13 juin 2018. Available at: https://www.infectiologie.com/UserFiles/File/jni/2018/com/jni2018-pleur-o-pneumo-gillet.pdf.

[11] Andréjak P.C. Recommendations on the management of infectious pleurisy 2018. [Internet]. Available at: https://www.sfm-microbiologie.org/recommandations-prise-en-charge-pleurésie-infectieuse/ (accessed May 20, 2025).

[12] Le Pimpec-Barthes F, Legras A, Arame A. [Surgical issues posed by purulent pleurisy] Problèmes chirurgicaux posés par les pleurésies purulentes. EMEC-Techniques chirurgicales - Thorax, 33; 2016. p. 1–19. https://doi.org/10.1016/S1241-8226(16)64615-7.

[13] Braggio C, Todesco A, Arbelot C, Fourdrain A, D'Journo XB. [Principles of thoracic drainage] principes du drainage thoracique. EMC-Techniques chirurgicales - Thorax, 40; 2023. p. 1–9. https://doi.org/10.1016/S1241-8226(23)43418-4.

[14] Etienne H, Assouad J. Minimally invasive video- and robot-assisted approaches in thoracic surgery: voies d'abords mini-invasives vidéo- et robot-assistées en chirurgie thoracique. EMC-Techniques chirurgicales - Thorax, 39; 2022. p. 1–13. https://doi.org/10.1016/S1241-8226(22)45410-7.

[15] Paediatric logistic organ dysfunction 2 score calculator. European Society of Paediatric Neonatal Intensive Care - ESPNIC. [Internet] Available at: https://www.espnec.eu/calcolatori/Paediatric%20Logistic%20Organ%20Dysfunction%20Score%20%20Calculator%20%20Professional%20Resources%20%20Education%20%20European%20Society%20of%20Paediatric%20Neonatal%20Intensive%20Care%20%20ESPNIC_files.htm (accessed March 17, 2025).

[16] Kossadoum R, Husain M, Stephane B, Caseris M. Epidemiology of bacterial pleuropneumopathies in children. Med. Mal. Infect Form. 2023;2:S128. https://doi.org/10.1016/j.mmifmc.2023.03.000.

[17] Ouldali N, Levy C, Minodier P, Morin L, Biscardi S, Aurel M, et al. Long-term association of 13-valent pneumococcal conjugate vaccine implementation with rates of community-acquired pneumonia in children. JAMA Pediatr. 2019;173: 362–70. https://doi.org/10.1001/jamapediatrics.2018.5273.

[18] Gillet Y, Tristan A, Rasigade JP, Saadatian-Elahi M, Bouchiat C, Bes M, et al. Prognostic factors of severe community-acquired staphylococcal pneumonia in France. Eur. Respir. J. 2021;58:200445. https://doi.org/10.1183/13993003.04445-2020.
[19] Bidet P, Bonacorsi S. Pathogenicity factors of Streptococcus pyogenes. Arch. Pediatr. 2014;21:S54–61. https://doi.org/10.1016/S0929-693X(14)72261-4.

[20] Rybak A, Ouldali N, Angoulvant F, Minodier P, Biscardi S, Madhi F, et al. Shift in clinical profile of hospitalized pneumonia in children during the COVID-19 pandemic non-pharmaceutical interventions period: a prospective multicenter study. Front. Pediatr. 2022;10:782894. https://doi.org/10.3389/fped.2022.782894.

[21] Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The management of community-acquired pneumonia in infants and children older than 3 months: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin. Infect. Dis. 2011;53:e25–76. https://doi.org/10.1093/cid/cir531.

[22] Hafen GM, Grenzbach AC, Moeller A, Rochat MK. Lack of concordance in parapneumonic effusion management in children in Central Europe. Pediatr. Pulmonol. 2016;51:411–7. https://doi.org/10.1002/ppul.23263.

[23] Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, et al. BTS guidelines for management of pleural infection in children. Thorax 2005;60(1): i1–21. https://doi.org/10.1136/thx.2004.030676. Suppl.

[24] Epaud R, Aubertin G, Larroquet M, Pointe HD, Helardot P, Clement A, et al. Conservative use of chest-tube insertion in children with pleural effusion. Pediatr. Surg. Int. 2006;22:357–62. https://doi.org/10.1007/s00383-006-1645-4.

[25] Boselli E, Allaouchiche B. Pulmonary diffusion of antibiotics: critical literature analysis. Ann. Fr. Anesth. Reanim. 2001;20:612–30. https://doi.org/10.1016/S0750-7658(01)00439-7.

[26] Lui JK, Billatos E, Schembri F. Evaluation and management of pleural sepsis. Respir. Med. 2021;187:106553. https://doi.org/10.1016/j.rmed.2021.106553.

[27] Segerer FJ, Seeger K, Maier A, Hagemann C, Schoen C, van der Linden M, et al. Therapy of 645 children with parapneumonic effusion and empyema—A German nationwide surveillance study. Pediatr. Pulmonol. 2017;52:540–7. https://doi.org/10.1002/ppul.23562.

[28] Scarci M, Abah U, Solli P, Page A, Waller D, van Schil P, et al. EACTS expert consensus statement for surgical management of pleural empyema. Eur. J. Cardiothorac. Surg. 2015;48:642–53. https://doi.org/10.1093/ejcts/ezv272.

[29] Mohajerzadeh L, Lotfollahzadeh S, Vosoughi A, Harirforoosh I, Parsay S, Amirifar H, et al. Thoracotomy versus video-assisted thoracoscopy in pediatric empyema. Korean J. Thorac. Cardiovasc. Surg. 2019;52:125–30. https://doi.org/10.5090/kjtcs.2019.52.3.125.

[30] Cobanoglu U, Sayir F, Bilici S, Melek M. Comparison of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III

empyema: a prospective randomized study. Pediatr. Rep. 2011;3:e29. https://doi.org/10.4081/pr.2011.e29.

[31] Marhuenda C, Barceló C, Fuentes I, Guillén G, Cano I, López M, et al. Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial. Pediatrics 2014;134:e1301–7. https://doi.org/10.1542/peds.2013-3935.

[32] Karaman I, Erdoğan D, Karaman A, Cakmak O. Comparison of closed-tube thoracostomy and open thoracotomy in thoracic empyema management in children. Eur. J. Pediatr. Surg. 2004;14:250–4. https://doi.org/10.1055/s-2004-817840.

[33] Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics 2006;118:e547–53. https://doi.org/10.1542/peds.2005-2719.

[34] St Peter SD, Tsao K, Spilde TL, Keckler SJ, Harrison C, Jackson MA, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J. Pediatr. Surg. 2009;44:106–11. https://doi.org/10.1016/j.jpedsurg.2008.10.018. discussion 111.

[35] Sonnappa S, Cohen G, Owens CM, van Doorn C, Cairns J, Stanojevic S, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am. J. Respir. Crit. Care Med. 2006;174:221–7. https://doi.org/10.1164/rccm.200601-027OC.

[36] Altmann ES, Crossingham I, Wilson S, Davies HR. Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst. Rev. 2019;2019: CD002312. https://doi.org/10.1002/14651858.CD002312.pub4.

[37] Fernandez Elviro C, Longcroft-Harris B, Allin E, Leache L, Woo K, Bone JN, et al. Conservative and surgical modalities in the management of pediatric parapneumonic effusion and empyema: a living systematic review and network meta-analysis. Chest 2023;164:1125–38. https://doi.org/10.1016/j.chest.2023.06.010.

[38] Redden MD, Chin TY, van Driel ML. Surgical versus non-surgical management for pleural empyema. Cochrane Database Syst. Rev. 2017;3:CD010651. https://doi.org/10.1002/14651858.CD010651.pub2.

[39] Bawazir OA. Thoracoscopy in pediatrics: surgical perspectives. Ann. Thorac. Med. 2019;14:239–47. https://doi.org/10.4103/atm.ATM_114_19.

[40] Moritz F, Dominique S, Lenoir F, Veber B. Thoracic drainage in emergency settings. EMC Médecine 2004;1:165–75. https://doi.org/10.1016/j.emcmed.2004.01.002.