Pediatric Pleural Empyema: Disease Complexity, Contemporary Management, and Future Research Priorities

Background: Pediatric pleural empyema remains a major complication of community-acquired pneumonia despite vaccination and advances in minimally invasive treatment. This narrative review summarizes current evidence on etiology and microbiology, diagnosis and imaging, antimicrobial therapy, supportive care, pleural drainage, fibrinolysis, surgery, complications, and short- and long-term outcomes. Methods: This structured narrative review searched PubMed from inception through 30 July 2026. No formal risk-of-bias assessment was performed. Of 42 publications assessed in full, 38 were included in the narrative synthesis. Results: Streptococcus pneumoniae, particularly serotype 3, Staphylococcus aureus, and Streptococcus pyogenes remain the principal pathogens. Chest ultrasound is preferred for characterizing pleural collections and guiding intervention, whereas computed tomography is reserved for atypical disease or suspected complications. Small pediatric comparative trials report broadly similar outcomes for catheter drainage with fibrinolysis and video-assisted thoracoscopic surgery (VATS), but differences in sample size, eligibility, treatment protocols, and outcome definitions limit conclusions about comparative effectiveness. Image-guided small-bore catheter drainage with protocol-based urokinase or tissue plasminogen activator is effective for many loculated effusions. Pediatric evidence does not support routine addition of DNase. Comparative trials show broadly similar clinical outcomes for fibrinolysis and video-assisted thoracoscopic surgery, although heterogeneous protocols and limited sample sizes preclude identification of a universally superior strategy. Thoracotomy is rarely required. Conclusions: Management should integrate respiratory and septic severity, pleural anatomy, microbiology, adequacy of drainage, clinical trajectory, and local expertise rather than rely on rigid staging. Long-term recovery is excellent in most previously healthy children receiving timely treatment. Standardized definitions, pediatric outcome sets, multicenter comparative trials, validated predictors of treatment failure, and studies of antimicrobial duration remain important research priorities.