Comparison of Early Intrapleural Fibrinolytic Therapy, Versus Administration After Failure of Intercostal Drainage in Children with Empyema Thoracis: A Systematic Review

Context: Intrapleural fibrinolytic therapy (IPFT) is widely used in pediatric empyema thoracis. Some physicians administer it early (when empyema is confirmed) whereas others try it after intercostal drainage (ICD) has failed. The optimal timing of IPFT administration is unclear. Objective: To compare early IPFT (i.e. as an initial therapy when empyema is diagnosed), versus IPFT administered after failure of ICD, in children with empyema thoracis. Evidence Acquisition: Literature search was conducted through PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, and two grey literature databases. Additional searches in four clinical trials registries, and hand-searching were conducted. The goal was to identify randomized controlled trials (RCT) comparing early IPFT (as an initial therapy, upon the diagnosis of empyema), versus delayed IPFT (i.e. administered after failure of ICD), in children with empyema thoracis (diagnosed by standard criteria). The outcomes recorded were clinical recovery, need for surgery, hospital stay, and safety. Results: The literature search yielded 2907 citations across the 11 databases examined. However, there were no RCTs directly addressing the review question. Indirect evidence from pediatric trials suggested that early IPFT may reduce pleural thickening and hospital stay, although decrease in surgery was not demonstrated consistently. In contrast, some observational studies reported high success rates with IPFT administered after failure of ICD, with avoidance of surgery in many cases. Conclusion: There is no RCT evidence comparing the initial administration of IPFT versus administration after failure of ICD. Well-designed RCTs are urgently needed. © The Author(s), under exclusive licence to Indian Academy of Pediatrics 2026.