Implications of Using a Clinical Practice Guideline on Outcomes in Pediatric Empyema

Introduction: Various randomized control trials in the pediatric population have shown no therapeutic advantage of video-assisted thoracoscopic surgery over fibrinolytic therapy (tissue plasminogen activator [tPA]) for empyema management. However, literature detailing changes in practice management and protocol implementation is limited. In 2018, we instituted clinical practice guidelines (CPGs) for empyema management utilizing tissue plasminogen activatorinstillation via a small bore chest tube as initial therapy. Before standardization, surgeon preference drove management. Our aim was to determine differences in management and outcomes following institutional CPG implementation. Methods: A single-institution retrospective study (2002-2022) examined patients 0-18 y of age diagnosed with pneumonia and associated empyema (loculated pleural fluid on ultrasound or computed-tomographic scan). The comparison groups were pre- and post-CPG implementation groups. Comparative statistics were performed, and the significance level was set at P < 0.05. Results: Sixty-one patients met the inclusion criteria: 33 (54%) preimplementation and 28 (46%) postimplementation. The demographics and diagnostic imaging modalities were similar between groups. There were no significant differences in time to initiate antibiotics, antibiotic duration, intensive care unit length of stay (LOS), or total hospital LOS. The utilization of video-assisted thoracoscopic surgery as initial intervention significantly decreased from 66% to 10% after protocol implementation (P < 0.01); the failure rates of initial therapy choice were similar (12% versus 10%, P = 0.87). Marked reduction in total patients undergoing operative intervention at any point during the course of therapy was observed, 76% preimplementation versus 21% postimplementation (P < 0.01). Conclusions: In children treated for empyema, the overall incidence of operative intervention significantly decreased following CPG implementation. The changes in antibiotic usage, intensive care unit/total LOS, and initial therapy failure rates did not differ. In our experience, the implementation of a CPG was instrumental in adherence to national guidelines.