Empirical Antibiotic Therapy for the Management of Empyema Thoracis in Children: A Systematic Review.

CONTEXT: Empyema thoracis necessitates timely empirical antibiotic therapy while awaiting confirmation of microbial etiology. However, there is no evidence-based guidance on this applicable to the Indian context. OBJECTIVE: To systematically review existing literature on empirical antibiotic therapy in empyema and to contribute to an evidence-based guideline for managing childhood empyema in India. EVIDENCE ACQUISITION: A comprehensive search was conducted across PubMed, Embase, Cochrane Library, Scopus, Web of Science, ProQuest, OpenGrey and four clinical trial registries. Studies (any design) describing empirical antibiotic therapy in pediatric empyema were examined to determine the appropriateness of the choice(s) on the basis of the organisms identified subsequently. Clinical outcomes based on antibiotic choices were also evaluated, as was the need to change the empirical choice(s). RESULTS: The literature search retrieved 15,887 citations. Following de-duplication and a three-step screening process, 17 studies were included. Cloxacillin was the empirical antibiotic in 10/17 studies (638 children) and was deemed an appropriate choice in six studies (419 children) as Staphylococcus aureus was the dominant pathogen identified. Third-generation cephalosporins were used in 9/17 studies (444 children) and deemed appropriate empirical therapy in four studies (283 children). There was insufficient and inconsistently reported data on clinical outcomes, need to change empirical antibiotics and the overall impact of the empirical therapy on patient-centric outcomes. CONCLUSION: There is considerable variability in empirical antibiotic selection, but cloxacillin and ceftriaxone were appropriate choices in six and four studies, respectively.