Efficacy, Safety, and Long-Term Outcomes of Shorter (≤ 4 Weeks) Versus Longer (> 4 Weeks) Antibiotic Therapy in Pediatric Empyema Thoracis: A Systematic Review

CONTEXT: Although antibiotics remain the cornerstone of empyema thoracis management, the optimal duration of therapy in children remains uncertain. Prolonged antibiotic courses are frequently used despite limited evidence supporting their necessity; potentially increasing healthcare costs, medication-related adverse effects, and the risk of antimicrobial resistance. OBJECTIVE: To evaluate the available evidence on the efficacy, safety, and clinical outcomes of shorter (≤ 4 weeks) versus longer (> 4 weeks) total antibiotic treatment durations (from initiation to cessation) in children with empyema, with the aim of informing evidence-based guidance. EVIDENCE ACQUISITION: A systematic search of PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, ProQuest, OpenGrey, and four major clinical trial registries was conducted. Randomized controlled trials enrolling children (< 18 years) with empyema defined by standard criteria, and comparing different durations of antibiotic therapy were eligible. Outcomes of interest included resolution of disease, relapse, need for additional interventions, re-hospitalization, adverse events, long-term clinical outcomes, and cost. All key steps of the review were undertaken by two reviewers working independently. RESULTS: The search yielded 20,353 records. After excluding 5497 duplicate citations, 14,856 unique citations were screened using a three-step process. A total of 18 citations were short-listed for full-text examination. However, there were no randomized controlled trials fulfilling the eligibility criteria. Although several observational studies were identified, these were ineligible for inclusion. CONCLUSION: The optimal duration of antibiotic therapy for children with empyema thoracis remains uncertain, due to paucity of randomized controlled trials comparing shorter versus longer treatment courses.