50 Years Ago in The Journal of Pediatrics:

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Lionakis BL, Gray SW, Skandalakis JE, and Hopkins WA. J Pediatr 1958;53:719-25

“…this study covers the period of practical extinction of empyema” and “1947 should mark the essential closing of this chapter of the history of thoracic surgery” are 2 ill-fated prophesies made by these authors based on their observation that the incidence of childhood empyema had fallen dramatically after the introduction of antibiotics in the late 1940s. Contrary to their predictions, however, the worldwide incidence of childhood empyema continues to increase, the reason for which remains unknown. The most common causative organisms remain pneumococcus and staphylococcus; however, there is evidence that pneumococcal serotype 1 is becoming more dominant. This shift in serotype has been speculated to be due to the introduction of a 7-valent pneumococcal vaccine that does not cover serotype 1; however, to date an association, but not a causation, has been shown.

Despite the increase in cases, the outcomes for children with empyema have improved greatly since the time of this report. In the authors' observation period from 1932 to 1957, the average length of hospital stay was 7 weeks, and death occurred in approximately 50% of children under age 2 years. Today, death rarely occurs, and the average hospital stay is less than 1 week after intervention.

Although it has been recognized since Hippocrates' time that drainage of empyema is essential, the best method to do so remains controversial. Rib section, the treatment of choice 50 years ago, has been replaced by primary video-assisted thoracoscopic surgery (VATS), and chest drainage has been refined by the use of small percutaneous drains with instillation of fibrinolytics, which is cheaper than and as effective as VATS. The past 5 decades also have seen the development of imaging techniques to aid diagnosis. Although ultrasound is a useful tool, some children may be receiving unnecessary exposure to radiation from routine computed tomography scans, which may not affect management.¹ We need to be mindful not to do unnecessary harm as we strive to perfect the prevention and treatment of empyema in children over the next 50 years.

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1. Jaffé A, Calder AD, Owens CM, Stanojevic S, Sonnappa S. The role of routine computed tomography in paediatric pleural empyema. Thorax. 2008;63:897–902
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