AIM:The North Queensland region of Australia has a high incidence of pediatric thoracic empyema (pTE). We describe the management of empyema at the Townsville University Hospital which is the regional referral center for these children. The impact of a newly developed institutional guideline is also discussed.METHODS:This retrospective audit included children under the age of 16 years treated for empyema between 1 Jan 2007 and 31 December 2018. Demographic and management-related variables were correlated to outcomes. A local guideline was introduced at the beginning of 2017 and patient outcomes characteristics pre, and post introduction of this guideline are compared.RESULTS:There were 153 children with pTE (123 before and 30 after the introduction of a local guideline). Nonsurgical management was associated with a higher treatment failure rate. Median length of stay (LOS) was 11.8 (IQR 9.3-16) days. Longer hospital LOS was associated with younger age (r2 -0.16, P = 0.04), Aboriginal and/or Torres Strait (ATSI) ancestry (13.8 vs. 10.5 days, P = 0.002) and concomitant respiratory viral infections (14.4 vs. 10.9 days, P = 0.003). The introduction of local guideline was associated with significant decrease in the use of empirical chest CT scans (54.4% before vs. 6.7% after, P < 0.001) and duration of intravenous antibiotics (14 days before vs. 10 days after, P = 0.02). There was no significant change in the hospital LOS (12.1 days pre and 11.7 post, P = 0.8).CONCLUSIONS:Younger age, concomitant viral respiratory infections and ATSI ancestry were identified as potential risk factors for increase LOS. Hospital LOS following the adoption of an institutional guideline was unchanged. However, such a guideline may identify populations at risk for an unfavorable course and avoid unnecessary antibiotic treatment and radiation exposure.

Aims & Objectives: North Queensland (NQ) region witnesses one of the highest published incidence rates of pTE (8.5 per 100,000) in the world. We aimed to review the local management practices of pTE to help guide an evidence based but locally adaptable treatment protocol. Methods Design: Retrospective chart review Setting and participants The Townsville Hospital (TTH) provides paediatric surgical as well as paediatric ICU services in NQ. All children between 1 month to 16 years presenting /referred with pTE between January 2007 to December 2016 were evaluated. Patient/organism related variables and management strategies (CT Vs Ultrasound, Medical (antibiotics or chest drain +/_ fibrinolytics) Vs Surgical (thoracotomy or VATS) were analysed in relation to outcomes (LOS, Length of PICU stay, Ventilation hours) Results 123 patient (median age 2.7 yrs) were included. Risk factors for adverse outcomes were Indigenous ancestry, younger age, concomitant viral co-infection and MRSA infection. 45% patients underwent CT scan pre-intervention after an initial chest X ray. The choice of imaging prior to intervention (CT, US or both) had no impact on any outcome parameter. Of the 91 (74%) patients managed surgically, three quarters underwent thoracotomy. In the last few years, this trend has switched towards VATS. Surgically managed patients had shorter LOS and less likelihood of a 2nd drainage procedure (6% vs 57%, p<0.001) Conclusions A pre-intervention Ultrasound was not inferior to CT. Surgical management was more effective in our cohort. Our local protocol (Fig.1)has incorporated ultrasound as imaging modality and VATs as an intervention modality of choice.

Aim: The Townsville Hospital and Health Service is the regional referral centre for children in the north of Queensland. Aboriginal and Torres Strait Islander (ATSI) people make up 7-10% of the population. Increasing numbers of children with paediatric thoracic empyema (pTE) are being referred to Townsville Hospital and Health Service for management. This study aims to describe the incidence rates, epidemiology, microbiology and trends of this disease in North Queensland over a 10-year period. Methods: A retrospective chart review of all children (1 month to 16 years), admitted in the years 2007-2016, with community-acquired pTE was conducted. International Classification of Diseases codes were used to identify the patients. Epidemiological and microbiological data were extracted from records. Results: Of the 123 cases identified, incidence rates per 100 000 were 8.5 (95% confidence interval (CI) 8.4-8.6) in all children and much higher at 19.8 (95% CI: 19.5-21.9) in ATSI children. The under 5 years age group had the highest rate (24.5; 95% CI: 24.4-24.6). There was a progressive rise in incidence during the 10-year period, with the highest incidence of 15.2 (95% CI: 15.1-15.2) occurring in 2016. A pathogen was isolated in 76% of cases. Non-multi-resistant methicillin-resistant Staphylococcus aureus was the most common pathogen isolated in 22 of 64 ATSI children (34%), while Streptococcus pneumoniae was the most common pathogen isolated in 27 of 59 non-ATSI children (46%). Conclusions: A high and increasing incidence of pTE in North Queensland is being observed. ATSI children have higher incidence rates and are more likely to have non-multi-resistant methicillin-resistant Staphylococcus aureus as a causative agent.

With prompt administration of appropriate antimicrobial therapy and access to modern intensive care support, fatal pediatric melioidosis is very unusual. We describe cases of two children in whom the possibility of melioidosis was recognized relatively early, but who died of the disease, despite receiving optimal supportive care. We discuss the resulting implications for bacterial virulence factors in disease pathogenesis.

Primary amoebic meningoencephalitis (PAM) is a fulminant, diffuse haemorrhagic meningoencephalitis caused by Naegleria fowleri, with an almost invariably fatal outcome. In Australia and the developed world, PAM remains a rare disease, although it is very likely that large numbers of cases go undetected in developing countries. N. fowleri is a thermophilic, free-living amoeba with a worldwide distribution. It is acquired when contaminated fresh water is flushed into the nose and penetrates the central nervous system via the cribriform plate. Clinical features are similar to those of bacterial meningitis, but it does not respond to standard therapy and rapid progression to death occurs in most cases. Some survivors have been reported; these patients received early treatment with amphotericin B in combination with a variety of other medications. Our review describes the local and worldwide experience of this disease and its clinical features, and discusses the associated diagnostic challenges. We hope that by detailing the local response to a recent case, and the outcomes of our public health campaign, we can improve the knowledge of this rare disease for doctors working in rural and remote Australia.

Primary amoebic meningoencephalitis (PAM) is a fulminant, diffuse haemorrhagic meningoencephalitis caused by Naegleria fowleri, with an almost invariably fatal outcome. In Australia and the developed world, PAM remains a rare disease, although it is very likely that large numbers of cases go undetected in developing countries. N. fowleri is a thermophilic, free-living amoeba with a worldwide distribution. It is acquired when contaminated fresh water is flushed into the nose and penetrates the central nervous system via the cribriform plate. Clinical features are similar to those of bacterial meningitis, but it does not respond to standard therapy and rapid progression to death occurs in most cases. Some survivors have been reported; these patients received early treatment with amphotericin B in combination with a variety of other medications. Our review describes the local and worldwide experience of this disease and its clinical features, and discusses the associated diagnostic challenges. We hope that by detailing the local response to a recent case, and the outcomes of our public health campaign, we can improve the knowledge of this rare disease for doctors working in rural and remote Australia.