Background: The most effective treatment for community-acquired childhood pneumonia complicated by empyema remains uncertain.

Aim and objectives: This review aims to systematically compare treatment options reported in pediatric literature, examining whether hospital length of stay (LOS), complication rates, and cost differ based on the treatment modality employed.

Study Design and Methods: We conducted a living systematic review of pediatric randomized controlled trials. Studies were included if they targeted empyema and compared at least two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis (NMA) was performed to evaluate treatment effects on LOS.

Results: Our NMA included eleven trials with a total of 590 patients. When compared to chest tube alone, chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with mean differences of 5.05, 6.33, and 5.86 days, respectively. Fibrinolytics demonstrated healthcare-associated cost advantages compared to VATS. Short- and long-term morbidity and mortality were low, regardless of the chosen treatment modality.

Conclusion: This NMA revealed that chest tube alone was associated with a longer LOS compared to other treatment modalities. The lower cost associated with chest tube insertion combined with fibrinolytics warrants consideration when choosing between treatment options.