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DEFINITIONS AND EPIDEMIOLOGY

The term complicated pneumonia in this chapter will refer to pneumonia complicated by the accumulation of fluid or purulent material in the pleural space; this term includes parapneumonic effusions and empyema. The frequency of complicated pneumonia among all children with community-acquired pneumonia (CAP) is not known. Complicated pneumonia has been reported to occur in 6–8% of children hospitalized with CAP.1,2 In the Centers for Disease Control and Prevention (CDC) Etiology of Pneumonia in the Community study, complicated pneumonia was reported in 4% of children hospitalized with CAP from 2010 through 2012.3

Streptococcus pneumoniae and Staphylococcus aureus remain the most common bacterial causes of complicated pneumonia (Table 37-1), although the epidemiology of complicated pneumonia appears to be changing. In February 2000, the Food and Drug Administration licensed a heptavalent pneumococcal conjugate vaccine (PCV7), which was subsequently recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics for use in children aged ≤2 years as well as in older, high-risk children in the United States.4 PCV7 uptake was rapid, and substantial declines in rates of invasive pneumococcal disease (IPD) including CAP were documented in children.1,5,6 Post-PCV7 licensure studies revealed increases in nasopharyngeal carriage and IPD caused by non-PCV7 serotypes.7–9 However, in the United States and other regions of the world where PCV7 was used, hospital admissions of children with complicated pneumonia increased.10–15 Pneumococcal serotypes associated with the increase in parapneumonic effusion and empyema with PCV7 were serotypes 1, 3, 7F, and 19A.16–19

TABLE 37-1Causes of Empyema

In February 2010, a 13-valent pneumococcal conjugate vaccine [PCV13 (Prevnar 13, Wyeth Pharmaceuticals Inc., a subsidiary of Pfizer Inc.)] replaced PCV7 in the United States. PCV13 was recommended for children 5 years and younger, and for children younger than 6 years who have underlying medical conditions that increase the risk of pneumococcal disease or complications.20 Similar to observations noted with PCV7, nasopharyngeal carriage by non-PCV13 serotypes increased with the transition to PCV13.21–24 The incidence of IPD in children and adults decreased with PCV13.25,26 Moore et al, using laboratory- and population-based data from the CDC’s Active Bacterial Core surveillance, reported a 64% decline in IPD in children younger than 5 years, primarily from a 93% decline in serotypes added to PCV13 by 2012/3 when compared with the period 2004–2010.26 Overall, there were declines in bacteremia, meningitis, and pneumonia in both children and adults with PCV13 in the United States....

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