Pleural infection (parapneumonic effusion and empyema) has an annual incidence of 3.3 per 100 000 children. The incidence of childhood empyema may be increasing in the UK. If so, it is not clear whether this is related to different referral patterns, changes of antibiotic usage in primary care, or whether there is a genuine increase in disease incidence. Parapneumonic effusions and empyema are more common in boys, in infants and young children, and in winter and spring, presumably because of their infective origin. Streptococcus pneumoniae is currently the most common pathogen in the UK, but a number of other pathogens can also be implicated.

Empyema is a significant cause of morbidity, but fortunately not mortality, in children, and at times can be a therapeutic challenge. It is rare for children to have an underlying lung disease, and the final outcome is almost always excellent. There are important differences between adult and paediatric pleural infections. In adults empyema is a cause of significant morbidity with 40% of patients requiring pleural surgery because of failed catheter drainage, and a mortality rate of 20%, which is related to co-morbidity (for example, malignancy, immunodeficiency). Evidence from paediatric therapeutic trials is lacking, and it is inappropriate simply to extrapolate adult data to children. There is little consensus over management among respiratory paediatricians and thoracic surgeons in the UK.

An evidence based guideline has been developed under the auspices of the British Thoracic Society.¹ This covers the recognition, diagnosis, investigation, and alternative treatment options, including intrapleural fibrinolytics. Detailed guidance on chest drain management is included. Audit criteria and research priorities are suggested.

KEY PRACTICE RECOMMENDATIONS

• All children with parapneumonic effusion or empyema should be admitted to hospital [grade D]

• If a child remains pyrexial or unwell 48 hours after admission for pneumonia, parapneumonic effusion/empyema must be excluded [grade …