Comparative effectiveness of treatment strategies for pediatric empyema thoracis: a systematic review with pairwise and network meta-analyses
- 1College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health, Dubai, United Arab Emirates
- 2Department of Pediatric Surgery, Mediclinic Parkview Hospital, Dubai, United Arab Emirates
Abstract
BackgroundEmpyema thoracis is a complication of bacterial pneumonia in children with substantial morbidity. Multiple treatment options are available, but the optimal strategy remains uncertain. This systematic review compared major treatment strategies for pediatric empyema thoracis across clinically relevant outcomes.MethodsThe protocol was prospectively registered with PROSPERO (CRD420251274193). PubMed, Embase, Scopus, Web of Science, and CENTRAL were searched for studies published from January 2000 through January 2026 evaluating empyema thoracis in children aged <18 years. Random-effects pairwise and frequentist network meta-analyses compared chest tube (CT) alone, CT + fibrinolytics, video-assisted thoracoscopic surgery (VATS), and thoracotomy. The primary outcome was hospital length of stay (LOS); secondary outcomes included treatment escalation, treatment success, complications, mortality, and treatment-related durations. Treatments were ranked using P-scores; a sensitivity analysis restricted the network to primary-line arms. Risk of bias was assessed using ROBINS-I, RoB 2, or the JBI critical appraisal checklist, as appropriate to study design, and certainty of evidence was evaluated using GRADE.ResultsSeventy-seven studies (7,378 children) were included. Compared with CT, treatment escalation was lower with VATS (RR 0.17, 95% CI 0.07–0.37), thoracotomy (RR 0.13, 95% CI 0.04–0.36), and CT + fibrinolytics (RR 0.48, 95% CI 0.26–0.89); certainty was moderate for three of six escalation comparisons and low or very low elsewhere. VATS was associated with shorter pleural drainage (MD −2.54 days, 95% CI −4.64 to −0.44), antibiotic duration (−4.95, −9.36 to −0.54), and fever duration (−2.00, −3.97 to −0.04) but not with LOS (−2.06, −4.57 to 0.45). In pairwise analysis, escalation was higher with CT + fibrinolytics than with VATS (RR 3.18, 95% CI 1.45–6.96). Restricting the network to primary-line arms preserved these associations; the higher network mortality with thoracotomy lost significance. Exploratory mean P-scores were 0.74 (VATS), 0.50 (thoracotomy), 0.47 (CT + fibrinolytics), and 0.29 (CT alone).ConclusionsCT alone was associated with more treatment escalation than each alternative, while VATS was associated with shorter treatment-related durations. However, the evidence is predominantly observational, of low to very low certainty for most comparisons, while estimates involving thoracotomy were sensitive to treatment line. These associations are hypothesis-generating and do not establish a treatment hierarchy. Trials with explicit staging and standardized escalation definitions are needed.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251274193, PROSPERO CRD420251274193.
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BibTeX
@article{alhusami2026comparative,
title = {{Comparative effectiveness of treatment strategies for pediatric empyema thoracis: a systematic review with pairwise and network meta-analyses}},
author = {Minat Allah Alhusami and Khaled Senjab and Maryam Alabdullah and Momina Malik and Sarah Kanj and Lana Kanj and Hussein Naji and Hussein Naji},
journal = {Frontiers in Pediatrics},
year = {2026},
month = oct,
doi = {10.3389/fped.2026.1980275},
url = {https://doi.org/10.3389/fped.2026.1980275},
note = {CC BY},
}
RIS
TY - JOUR
TI - Comparative effectiveness of treatment strategies for pediatric empyema thoracis: a systematic review with pairwise and network meta-analyses
AU - Minat Allah Alhusami
AU - Khaled Senjab
AU - Maryam Alabdullah
AU - Momina Malik
AU - Sarah Kanj
AU - Lana Kanj
AU - Hussein Naji
AU - Hussein Naji
PY - 2026
DA - 2026/10/26
JO - Frontiers in Pediatrics
DO - 10.3389/fped.2026.1980275
UR - https://doi.org/10.3389/fped.2026.1980275
AB - BackgroundEmpyema thoracis is a complication of bacterial pneumonia in children with substantial morbidity. Multiple treatment options are available, but the optimal strategy remains uncertain. This systematic review compared major treatment strategies for pediatric empyema thoracis across clinically relevant outcomes.MethodsThe protocol was prospectively registered with PROSPERO (CRD420251274193). PubMed, Embase, Scopus, Web of Science, and CENTRAL were searched for studies published from January 2000 through January 2026 evaluating empyema thoracis in children aged <18 years. Random-effects pairwise and frequentist network meta-analyses compared chest tube (CT) alone, CT + fibrinolytics, video-assisted thoracoscopic surgery (VATS), and thoracotomy. The primary outcome was hospital length of stay (LOS); secondary outcomes included treatment escalation, treatment success, complications, mortality, and treatment-related durations. Treatments were ranked using P-scores; a sensitivity analysis restricted the network to primary-line arms. Risk of bias was assessed using ROBINS-I, RoB 2, or the JBI critical appraisal checklist, as appropriate to study design, and certainty of evidence was evaluated using GRADE.ResultsSeventy-seven studies (7,378 children) were included. Compared with CT, treatment escalation was lower with VATS (RR 0.17, 95% CI 0.07–0.37), thoracotomy (RR 0.13, 95% CI 0.04–0.36), and CT + fibrinolytics (RR 0.48, 95% CI 0.26–0.89); certainty was moderate for three of six escalation comparisons and low or very low elsewhere. VATS was associated with shorter pleural drainage (MD −2.54 days, 95% CI −4.64 to −0.44), antibiotic duration (−4.95, −9.36 to −0.54), and fever duration (−2.00, −3.97 to −0.04) but not with LOS (−2.06, −4.57 to 0.45). In pairwise analysis, escalation was higher with CT + fibrinolytics than with VATS (RR 3.18, 95% CI 1.45–6.96). Restricting the network to primary-line arms preserved these associations; the higher network mortality with thoracotomy lost significance. Exploratory mean P-scores were 0.74 (VATS), 0.50 (thoracotomy), 0.47 (CT + fibrinolytics), and 0.29 (CT alone).ConclusionsCT alone was associated with more treatment escalation than each alternative, while VATS was associated with shorter treatment-related durations. However, the evidence is predominantly observational, of low to very low certainty for most comparisons, while estimates involving thoracotomy were sensitive to treatment line. These associations are hypothesis-generating and do not establish a treatment hierarchy. Trials with explicit staging and standardized escalation definitions are needed.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251274193, PROSPERO CRD420251274193.
SN - 2296-2360
ER -