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Complicated Pneumonia/Parapneumonic

Effusion Pathway

Diagnosis of pneumonia and parapneumonic
effusion on chest x-ray Note: These guidelines apply to immunocompetent with
community acquired pneumonia with effusion.

Small effusion: <1/4 thorax opacified LABS: Moderate to large Laboratory testing on
on upright chest x-ray CBC, CRP and blood culture effusion: pleural fluid:
> 1/4 thorax opacified on Gram stain and bacterial culture.
upright chest x-ray; and/or WBC with differential. pH, LDH,
respiratory compromise. glucose and protein. If patient
produces sputum, also send sputum
for bacterial culture.
Antibiotics only:
First line: ampicillin
Beta-lactam allergy: clindamycin Chest Ultrasound
or Levofloxacin. Consider azithromycin
if at risk for complicated atypical
pneumonia.

Not loculated, “simple” Loculated, “complicated”
Antibiotic recommendations: Antibiotic recommendations:
First line: ceftriaxone +/- clindamycin Beta-lactam allergy: First line: ceftriaxone and clindamycin
Good Clinical Response? clindamycin and levofloxacin. Beta-lactam allergy: clindamycin and levofloxacin.
Consider ceftriaxone and vancomycin OR ceftriaxone and
linezolid if critically ill or in the presence of cavitary or
necrotizing pneumonia.
YES NO <1/2 thorax opacified >1/2 thorax opacified
on upright on upright
chest x-ray chest x-ray
If not responding within 24-48 Consult pediatric surgery and PICU for chest tube insertion
Continue fibrinolytic therapy (vs VATS) Consult ID and pulmonary
Antibiotics hours or worsening (fever,
hypoxemia, respiratory distress,
ill-appearing): reassess effusion Call PICU for chest tube insertion and drainage.
with ultrasound. Consult ID and Pulmonary
Go to moderate to large 10.5 Fr chest tube with 3 doses of tPA 4mg tPA/40mL
effusion pathway. saline x 3 with 1 hour dwell 24 hours apart
first dose in PICU.
10.5 Fr chest tube

Management of chest tube on Inpatient Transfer to floor after first dose
Transfer to floor if clinically stable
Floor- pediatric surgery of TPA if clinically stable

YES YES
Good Clinical Good response, draining well. Monitor with chest x-ray at Good Clinical
Response? 48 hrs. Chest tube can be removed if no air leak Response?
and drainage <1ml/kg/48hrs
NO NO
Authors
Chhavi Katyal, MD Persistent or progressive symptoms (hypoxemia, Not draining well. Persistence of moderate to large effusion
Medical Director worsening respiratory distress, ill-appearing): Repeat and ongoing respiratory compromise after 48 hours.
Steven H. Borenstein, MD US. If reaccumulation of fluid or loculation, go to
Pediatric Surgeon complicated effusion pathway.
Dominique M. Jan, MD Ultrasound/Chest CT
Chief, Pediatric Surgery
Director, Pediatric Transplantation Surgery
Raanan Arens, MD
Chief, Respiratory and Sleep Medicine
Betsy Herold, MD George Ofori-Amanfo, MBChB, FACC
Chief, Infectious Disease Division Chief, Critical Care Medicine Persistent loculated effusion: VATS with debridement or open Parenchymal disease
Harold and Muriel Block Chair, Pediatrics Katherine M. O’Connor, MD chest debridement with decortication. only: continue IV antibiotics.
Vice Chair, Research Pediatric Hospital Medicine