Tratamento cirúrgico de pneumonia necrosante em crianças em um período de 10 anos / Surgical treatment of necrotizing pneumonia in children: a 10-year assessment

RESUMO Objetivo: A pneumonia necrosante (PNS) é uma grave e rara complicação da pneumonia adquirida na comunidade, acometendo principalmente crianças, sendo assim, objetivamos analisar prontuários de crianças submetidas ao tratamento cirúrgico de PNS e comparação dos resultados obtidos com os presentes na literatura médica. Métodos: Análise retrospectiva dos prontuários de crianças submetidas ao tratamento cirúrgico por PNS entre julho de 2006 a julho de 2016 em dois hospitais do sul de Santa Catarina, Brasil. Resultados: Do total de 26 crianças, com mediana de idade 2,70 anos, maioria mulheres (61,5%). Os principais sintomas foram febre (88,5%) e tosse (65,4%). Houve média de 4,31 antibióticos utilizados por paciente. O principal agente etiológico foi o Staphylococcus aureus (23,1%) mas as culturas foram negativas em 69% dos pacientes. Em 23 pacientes realizou-se decorticação e desbridamento das áreas necróticas (88,5%). A média de drenagem pleural pós-operatória foi 8,12 dias. Fístula broncopleural ocorreu em 50,0% no pré-operatório e 46,2% após a cirurgia. O tempo total de internação hospitalar foi, em média, de 27,52 dias e tempo pós-operatório com média de 12,60 dias. Complicações pós-operatórias ocorreram em 13 crianças e não houve mortalidade. Conclusões: Propõe-se abordagem cirúrgica nos pacientes sem resposta ao tratamento clínico, pois o atraso na intervenção cirúrgica associa-se a infecção progressiva no parênquima pulmonar e taxas maiores de complicações. A cirurgia pode conduzir a melhor evolução clínica e recuperação mais precoce.

ABSTRACT Objective: Necrotizing pneumonia (PNZ) is a severe and rare complication of a community-acquired pneumonia, affecting mainly children. We aimed to analyze medical records of children undergoing surgical treatment for PNZ and compare our results with those found in the medical literature. Methods: Retrospective analysis of children's medical charts who underwent an operation for PNZ, between July 2006 and July 2016, in two hospitals in southern Santa Catarina, Brazil. Results: A total of 26 children with a median age of 2.70 years and mostly females (61.5%) were included in the current study. The main symptoms were fever (88.5%) and cough (65.4%). There was an average use of 4.31 antibiotics per patient. The primary etiological agent was Staphylococcus aureus (23.1%), but cultures were negative in 69% of the patients. Decortication and debridement of necrotic areas were performed in 23 patients (88.5%). The mean postoperative pleural drainage was 8.12 days. The presence of bronchopleural fistula occurred in 50.0% in the preoperative period and 46.2% in the postoperative. The total length of hospital stay was, on average, 27.52 days and the postoperative length of stay was 12.60 days (mean). Postoperative complications occurred in 13 children and there was no mortality. Conclusion: The surgical approach is indicated to patients with no response to clinical treatment. Late surgical intervention is associated with progressive parenchyma infection and higher rates of complications. Surgery can lead to better clinical outcomes and earlier recovery.

Neumonías necrosantes graves con empiema asociado / Severe necrotizing pneumonias with secondary empyemas

Introducción: Las neumonías necrosantes (NN) con empiema son una enfermedad grave y un desafío multidisciplinario. El objetivo de este estudio es realizar una caracterización epidemiológica y, en forma secundaria, analizar su tratamiento y evolución. Presentación de casos: Se realizó un estudio retrospectivo de una serie de casos consecutivos con NN con empiema que se presentaron en el Hospital Padre Hurtado. Siete (77,8%) eran de sexo masculino. La mediana de edad fue de 53 (rango 21-73) años. El 44% presentaban comorbilidades (diabetes, HTA o enfermedades neurológicas). El 44% presentaban abuso de drogas y 3 estaban en un estado de desnutrición severa. Manejo y evolución: La mediana de tiempo de hospitalización fue de 41 (rango 16-129) días. En 4 pacientes el germen aislado fue un Enterococcus faecalis. Complicaciones torácicas ocurrieron en el 33,3% de los pacientes. Un paciente requirió una lobectomía, un paciente una fenestración y otro paciente falleció. Discusión: Las NN con empiemas son raras. Sin embargo, frente a la asociación de diabetes, desnutrición y abuso de drogas continuaremos viendo estos casos de difícil manejo con elevada morbimortalidad.

Introduction: Necrotizing pneumonia complicated with empyema is a life-threatening condition that challenges multidisciplinary teams. The aim of this study is to perform an epidemiological characterization of these patients, and secondly, analyse their treatment and outcomes. Case presentation: A retrospective analysis of a series of consecutive patients experiencing necrotizing pneumonia with empyema who presented at Hospital Padre Hurtado. Seven (77.8%) were male. The median age was 53 (range 21-73) years. 44% presented with comorbidities (diabetes, high blood pressure, and neurological diseases). 44% presented drug abuse consumption and three (33.3%) were in a state of severe malnutrition. Management and outcome: The median time of hospitalization was 41 (range 16-129) days. Thoracotomies were performed in eight (83.2%) of the patients. In four patients, the isolated bacteria's were Enterococcus faecalis. Thoracic complications occurred in three (33.3%) patients. One patient required a lobectomy, one patient a fenestration and one (11.1%) patient died. Discussion: Necrotizing pneumonias complicated with empyema are rare, however, if there is an association with drug abuse, diabetes and malnutrition, we will continue to see such challenging cases with high morbidity and mortality.