Today we are outlining the key recommendation updates from the Infectious Diseases Society of America (IDSA) and Pediatric Infectious Diseases Society (PIDS) guideline Management of Community-Acquired Pneumonia (CAP) in Infants and Children Older Than 3 Months of Age. Pneumonia associated with parapneumonic effusion and/or empyema, also known as complicated pneumonia, occurs in a small portion of cases, but is associated with increased morbidity and mortality. 

This 2026 IDSA/PIDS guideline update builds on the prior 2011 guideline and incorporates new evidence to guide the diagnosis and management of children with pneumonia with parapneumonic effusion. Five of the six recommendations received an update, with a single recommendation remaining the same as the 2011 recommendation, indicated below.  

View the full-text version of the 2026 guideline update for the most thorough explanation of these recommendations. 

Recommendations from the 2026 Guideline

The Use of Chest Ultrasound in Children with Parapneumonic Effusion

  • In children with radiographic evidence of a moderate to large parapneumonic effusion, the panel suggests obtaining a chest ultrasound over CT or MRI to characterize the size and complexity of the effusion.

The Use of Pleural Fluid Drainage versus Observation

  • In children with small, uncomplicated parapneumonic effusions, the IDSA panel suggests observation over pleural drainage.
  • No update: In children with moderate parapneumonic effusions associated with respiratory distress, large parapneumonic effusions, or documented purulent effusions, the panel recommends pleural drainage. 

The Use of Pleural Fluid Drainage compared to Surgical Debridement

  • In children and adolescents (3 months to 18 years) with pneumonia-associated empyema in whom pleural drainage is indicated, the panel suggests using chest tube drainage and intrapleural fibrinolytics rather than surgical debridement as first-line therapy in most cases.

The Choice of Chest Tube Size

  • In children (3 months to 18 years) with parapneumonic effusion or empyema that necessitates drainage, the panel members suggest the use of small-bore (≤12Fr) chest tubes over large-bore (≥14FR) tubes.

The Use of tPa and DNase or tPa Alone for Fibrinolysis

  • In children (3 months to 18 years of age) with pneumonia-associated empyema, the panel suggests administering tPA alone over tPA and DNase.

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