Pediatric Empyema in the Post-Pandemic Period: Evaluating Changing Trends in Microbiology, Investigations, Fibrinolysis, and Surgical Outcomes

We present a retrospective analysis of our experience managing pediatric empyema, focusing on clinical, microbiological, radiological aspects, surgical and fibrinolytic outcomes over an 8-year period, encompassing the 2022-2023 United Kingdom invasive group A <i>Streptococcus</i> (iGAS) surge. This observational study aimed to test the hypothesis that the post-pandemic period has revealed a new pattern of microbes, disease patterns, and treatment effectiveness.Case notes of children (<16 years) with thoracic empyema who had an intercostal drain between 2014 and 2023 were reviewed for demographic, imaging, microbiological, and operative findings. Periods were categorized as pre-pandemic (2015-2020), pandemic (2020-2021), and post-pandemic (2022-2023).From 86 cases, median ages fell from 9.9 years (pre-pandemic), 6.2 years (pandemic), to 4.4 years (post-pandemic). Pleural culture detected organisms in 27% while 16S PCR increased the yield to 90.7%. <i>Streptococcus pyogenes</i> (43.4%) and <i>Streptococcus pneumoniae</i> (30.2%) predominated. Viral coinfection was associated with necrosis (45% vs. 24% without coinfection). Intrapleural fibrinolysis effectiveness fell from 81% pre-pandemic to 60% post-pandemic, with a concomitant rise in need for further surgery from 19% to 48%. Alongside these changes, the length of stay increased from 8 to 11 days (pre- vs. post-pandemic). There were no empyema-related deaths at our center over this study period.Post-pandemic empyema was characterized by younger age, a higher proportion of <i>S. pyogenes</i>, and increased intrapleural fibrinolytics failure and surgery. These data support earlier surgical consultation for younger patients or those with viral coinfections, prospective evaluation of dual-agent fibrinolysis in children, and integration of 16S PCR into pleural workflows. Ongoing surveillance of empyema epidemiology is needed to optimize future management.