A 4-year-old with right lower lobe pneumonia has remained febrile despite 48 hours of appropriate intravenous antibiotics. He has worsening respiratory distress, decreased breath sounds and dullness at the right base, and the chest X-ray shows a large pleural collection with shift of the mediastinum to the left. Ultrasound shows multiple septations. What is the next step in management?

• A Change to a broader spectrum cephalosporin and continue observation
• B Start oral antipyretics and discharge on antibiotics
• C Insert a chest tube and instill intrapleural fibrinolytics ✓
• D Perform diagnostic thoracentesis only and await culture results

Explanation

Persistent fever with a large, mediastinum-shifting, septated pleural collection indicates complicated parapneumonic effusion or empyema requiring drainage. Chest tube insertion with intrapleural fibrinolytics (or VATS where available) is standard, because fibrin strands cause loculations that prevent simple aspiration. Continuing antibiotics alone fails once pus is organized, and diagnostic tap alone delays definitive source control.

Reference: Ghai Essential Pediatrics, 9th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.