Complicated Community-Acquired Pneumonia in Children: An Updated Systematic Review of Literature and Meta-Analysis

Background: A recent significant increase in the incidence of complicated community-acquired pneumonia (CCAP) was reported in children. However, there is a complete lack of consensus on the indications for invasive surgical procedures in these cases. Previously published reviews were inconclusive due to limited quality and analysis of the evidence. This study aimed to systematically evaluate the management of patients admitted for CCAP, comparing conservative and surgical approaches. Methods: PubMed, Scopus, and Web of Science databases were explored to select all studies evaluating conservative treatment versus surgery in the management of children and adolescents < 18 years old with CCAP. A meta-analysis was also performed to compare the different approaches in relation to: length of hospital stay (LOS), treatment failure, perioperative complications, and mortality. Results: Twenty-eight studies were included in the systematic review. Children conservatively treated (including antibiotics alone and chest drainage) had longer LOS (mean difference in days 1.82 [0.80, 2.84]), and a higher rate of treatment failure (RR 2.03 [1.22−3.40]) than those who underwent surgery. No difference was found in the complication rate (RR 0.92 [0.54−1.56], p = 0.76). Overall, the mortality rate was low. Substantial heterogeneity emerged. Conclusions: This systematic review offers an updated, comprehensive overview of the management of complicated pneumonia in children. Conservative treatment in children with CCAP is associated with longer LOS and a higher need for reintervention compared to patients treated with surgery. However, the indication of early surgery remains unclear.