Comparative Efficacy, Safety, and Cost of Different Intrapleural Fibrinolytic Agents for the Management of Empyema Thoracis in Children: A Systematic Review.

CONTEXT: Pediatric empyema thoracis is a serious complication of bacterial pneumonia, and poses management challenges due to the absence of evidence-based guidelines on optimal treatment approaches. Intrapleural fibrinolytic agents are frequently used to enhance pleural drainage and avoid surgical intervention in pediatric empyema thoracis; however, the comparative efficacy, safety, and cost-effectiveness of different fibrinolytic agents remain uncertain.

OBJECTIVE

To systematically evaluate and compare the efficacy, safety, and cost of different intrapleural fibrinolytic agents in children with empyema thoracis, to develop evidence-based recommendations for informing clinical decision-making.

EVIDENCE ACQUISITION: A systematic search of PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, ProQuest, OpenGrey, and four clinical trial registries was done, from their inception. Studies were eligible for inclusion in the systematic review if they were randomized controlled trials (RCT) including children under 18 years old with empyema thoracis (defined by any standard definition), comparing different fibrinolytic agents such as streptokinase, urokinase, and tissue plasminogen activator. The main outcomes included treatment failure, need for surgery, serious adverse events, and short-term clinical outcomes. Other outcomes were length of hospital stay, symptom duration, and cost.

RESULTS

A total of 3110 records was identified; after de-duplication, 2022 unique citations were screened. A three-step screening process identified no RCT meeting the eligibility criteria. The available studies had other study designs, or lacked pediatric data.

CONCLUSIONS

Current evidence is insufficient to determine the most effective and safe fibrinolytic agent for pediatric empyema thoracis. There is an urgent need for well-designed, comparative pediatric trials to support evidence-based treatment guidelines.