Transitioning paediatric empyema management: Comparative efficacy analysis of tPA and DNase versus surgical interventions.

INTRODUCTION: Empyema significantly impacts paediatric morbidity and imposes a financial burden on healthcare systems. This study evaluates the efficacy of tissue plasminogen activator (tPA) and dornase alpha (DNase) combination in fibrinolytic therapy compared with surgical interventions (VATS/thoracotomy) in children with empyema.

MATERIALS AND METHODS: A retrospective cohort consisted of 87 consecutive patients from January 2018 to December 2024, of whom 43 underwent surgical treatment and 44 received tPA + DNase therapy. The fibrinolytics group was divided into two subgroups to assess the learning curve: initial period (n = 22) and latest period (n = 22). The primary outcome was the hospitalisation duration. The secondary outcome measures included intensive care unit (ICU) admission rate, reintervention rate, costs of treatment, and empyema relapse within 30 days.

RESULTS: The median age was 3.9 years (range 0.7-17.3). The median duration of hospitalisation was 11 [9-14] days in VATS/thoracotomy group and 10 [7-13] days in fibrinolytics group (p = 0.086). The ICU admission rate was significantly lower in the fibrinolytics group (34.8 % vs. 13.6 %, p = 0.019), as were the costs of treatment (€32,628 [€25,386 - €44,504] vs €27,523 [€19,264 - €34,662], p = 0.011). Two empyema relapses were observed in each group. No readmissions occurred. The fibrinolytics group demonstrated higher reintervention rate compared to VATS/thoracotomy group (22.7 % vs. 7.0 %, p = 0.038) but significantly decreased in the latest period compared to the initial period (9.1 % vs. 36.0 %, p = 0.034), indicating a clear learning curve.

CONCLUSION: tPA + DNase therapy is a safe and effective management option for paediatric empyema.