Clinical outcomes of intrapleural alteplase in pediatric empyema: real-world data from a tertiary center

Pediatric empyema remains an important complication of pneumonia and is associated with considerable morbidity. Although intrapleural fibrinolytic therapy is increasingly used, the optimal management approach remains controversial. To evaluate the clinical outcomes and treatment success of intrapleural alteplase in children with empyema in a real-world clinical setting. We retrospectively analyzed 84 children diagnosed with empyema between November 2022 and December 2024. Demographic, clinical, laboratory, microbiological, and radiological data were collected. Patients were managed either conservatively with antibiotics alone or with invasive interventions, including pleural drainage with or without intrapleural fibrinolytic therapy. The median age was 5.6 years (IQR: 3.85–9.39 years), and 58.3% of patients were male. Fever (86.9%), cough (78.6%), and dyspnea (50%) were the most common presenting symptoms. Intrapleural alteplase was administered to 61 patients (92.4% of those requiring drainage), with a clinical success rate of 95% [61/64 invasive patients]. Surgical intervention was required in only three patients. No major complications were observed. The median hospital stay was 15 days (IQR: 12.25–20; range: 5–33 days), and 15.4% of patients required pediatric intensive care. Chest drainage combined with intrapleural alteplase appeared to be a safe and feasible treatment approach for pediatric empyema in our real-world cohort. However, prospective multicenter studies are needed to further clarify its role in relation to alternative treatment strategies.