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of tracheitis should not rest on culture results alone. Rather, clinicians should obtain a Gram stain and viral testing
in addition to bacterial culture. Standard precautions should be used.
Empyema
Empyemas are purulent pleural effusions that can complicate pneumonia. Empyemas are most commonly seen
with S. aureus and pneumococcal pneumonia and increasing incidence rates of staphylococcal pneumonia have
been seen in the post-Prevnar era. Gram-negative pathogens should be suspected in immunocompromised hosts,
neonates, and patients with indwelling chest tubes. The most common symptoms are fever, shortness of breath, and
pleuritic chest pain. The most common examination finding is tachypnea; auscultation can reveal rales or
decreased breath sound. Pleural friction rubs are rarely heard in young children. Chest radiography demonstrates
blunting of the costophrenic angle. A decubitus or cross-table lateral radiograph can be performed to see if the
fluid is free-flowing. Ultrasonography can be very useful to determine if sufficient fluid is present for
thoracentesis; for older children, a decubitus fluid layer at least 1 cm thick is considered sufficient to attempt
thoracentesis. CT allows for better differentiation between an empyema and lung abscess. Thoracentesis for pleural
fluid can be sent for cell count and differential, lactate dehydrogenase (LDH), protein, glucose, and pH in addition
to Gram stain and cultures. Cultures that should be obtained include aerobic, anaerobic, and acid-fast cultures.
Adenosine deaminase (ADA) should be sent from the pleural fluid if tuberculosis is suspected. The pleural fluid
parameters that help differentiate causes of pleural effusion are reviewed in
e-Table 94.9 . Some children with
empyema will need video-assisted thoracoscopic surgery with debridement; this has been shown to decrease
hospital length of stay and fever duration. Empiric antibiotic therapy should target pneumococcus, S. aureus, and
GAS. For mildly ill patients, ampicillin and azithromycin treatment for community-acquired pneumonia may be
appropriate. For children with risk for staphylococcal disease (e.g., history of staphylococcal disease, presence of
pneumatocele), combination therapy with clindamycin and a third-generation cephalosporin is reasonable.
Critically ill children should be treated with vancomycin and a third-generation cephalosporin. Anaerobic coverage
should be considered for neonates, immunocompromised hosts, associated neck infections (especially with jugular
thrombophlebitis), and patients with indwelling chest tubes. Standard precautions are recommended for children
with empyema unless tuberculosis is suspected (in which case, airborne precautions should be used) or unless the
child has draining skin lesions (in which case contact precautions should be utilized).