Intrapleural Fibrinolytic Therapy as the Initial Modality, Compared to no Intrapleural Fibrinolytic Therapy, in Children With Empyema: A Systematic Review and Meta-analysis.

CONTEXT: There is a wide variation in the use of intrapleural fibrinolytic therapy (IPFT) in children with empyema. This necessitates an up-to-date evaluation of the evidence, to develop an evidence-based guideline recommendation.

OBJECTIVE

To evaluate the efficacy and safety of IPFT versus no IPFT in children with empyema.

EVIDENCE ACQUISITION: A systematic search for randomized controlled trials (RCTs) comparing IPFT versus no IPFT in children with empyema, was conducted in databases of published literature (PubMed, Embase, Cochrane Library, Scopus, Web of Science), grey literature, and four clinical trial registries. Multiple a priori outcomes reflecting efficacy and safety were evaluated. The Cochrane Risk-of-Bias 2 tool was used for quality assessment, and the certainty of evidence was evaluated using the GRADE approach.

RESULTS

The literature search identified 3,113 citations, and their step-wise screening identified three relevant RCTs. The pooled odds ratio for the critical outcome 'failure of therapy' was 0.15 (95% CI 0.04 - 0.50, I2 = 50%) with fixed-effect model, and 0.14 (95% CI 0.02 - 1.12, I2 = 50%) with the random-effects model. Serious adverse events were rare but comparable between the groups. Length of hospitalization was reported variably, but one RCT reported a shorter stay with IPFT. There were no data on long-term clinical outcomes, pulmonary function tests, or cost of therapy. The evidence certainty was 'very low'.

CONCLUSION

The available evidence on IPFT as an initial modality for pediatric empyema is limited and of very low certainty. Although pooled estimates suggested a potential reduction in treatment failure with IPFT, the results were sensitive to the statistical model used.