• VATS
• decortication
• empyema
• fibrinolysis

The incidence of empyema has increased dramatically in children over the past decade. A sevenfold increase in cases was first recorded in the UK in 1997,¹ and a similar increase has recently been reported in the USA.² Routine bacterial culture is usually negative in the UK as the great majority of patients have received antibiotics prior to referral, and this has impeded research into the cause of the phenomenon. Fortunately, new techniques have recently confirmed that the majority of our cases are due to pneumococcal infection,³ and fascinatingly that most of these cases are due to infection with organisms of serotype 1.⁴ This serotype is also now dominant in culture positive cases in the USA,² and is associated with an increase of invasive pneumococcal disease in Scandinavia.⁵ In recent years serotype 14 has been the dominant cause of invasive disease in the UK,⁶ and until now infection with serotype 1 has been principally a problem in developing countries. The reason for this serotype shift and the mechanism of increased virulence of serotype 1 have yet to be determined. However, these findings have major implications for preventative strategies as the response to the polysaccharide vaccine is inconsistent in children under 5 years of age,⁷ and the new conjugate pneumococcal vaccine does not protect against this serotype.⁸

This recent increase in incidence has highlighted the need to …