The paper by Wright et al1 in this issue of the NZMJ should serve as another serious wake-up call for the serious and distressing health problems faced by New Zealand's children, especially Māori and Pacific. The study has clearly shown for the first time a much higher rate of empyema disease in Māori and Pacific children compared to other ethnic groups.

The high incidence of empyema, with long inpatient stays, places not only a severe and distressing burden on the child and its family but will often be associated with significant financial cost for the treating institution. The high incidence sits on an enormous background admission rate for pneumonia for New Zealand children.2

The entry of video-assisted thoroscopic techniques (VATS) for treating empyema in children is well established and provides a treatment modality with less postoperative pain or discomfort compared to open thoracotomy. The latter, as the authors point out, is required in only a few cases where it is felt that adequate removal of organised collections within the pleural cannot be achieved by VATS.

Safety and visibility of the operative fields in VATS has improved greatly in recent years with the introduction of high-definition digital technology. Another recent advance is the development of periscopic cameras that allow the surgeon to look well past an angle of 90 degrees. This will prove particularly useful in the thorax. Malleable instruments have also been developed to allow access to areas without the need of extra incisional ports.

Open thoracotomy can also be associated with late development of scoliosis which VATS alone can avoid.

Wright et al do not demonstrate the use of fibrinoltyic infusion into the chest cavity (urokinase) but reference the point that some studies demonstrate excellent outcomes with this modality alone combined with a chest tube.

The placing of a chest tube in a child almost always requires a general anaesthetic and as these children are often very sick a skilled paediatric anaesthetist is required as well as intensive care backup. This means transfer to a paediatric surgical centre is important. It is true however that intensive care post surgery is seldom required.

Factors most associated with poor response are failure to use a sensitive antibiotic in the first instance with MRSA increasing in incidence and secondarily a missed intrapulmonary abscess. It is surprising that only two children in the study isolated MRSA strains for those with proven staphyloccal infection.

ESR NZ 2007 figures for DHB wide notifications showed a marked geographic variation for MRSA annualised incidence rates across New Zealand. In 2007, for example, the Counties Manukau region recorded 441.6 notifications per 100,000 persons by far the highest in the country at the time. The Auckland central region being close behind.3

In our own study of subcutaneous abscess admissions competed in 2001 at Wellington Children's Hospital we recorded an incidence of 7% isolates positive for methicillin resistance . Recent and mounting concerns of antibiotic resistance for many bacterial infections will no doubt place a serious block to treatment success in future.

Early and aggressive treatment of pneumonia is crucial to prevent empyema in children and access to free primary care 24 hours is essential to achieve this. There are still many areas in New Zealand where such access is limited, especially in the afterhours setting.

I believe high rates of incidence of empyema seen in Māori and Pacific children will not reduce until this problem is remedied . Parent education to present children for assessment early is also crucial.

Author information: Brendon Bowkett, Paediatric Surgeon, Wellington Hospital, Wellington South

Correspondence: Brendon Bowkett, Paediatric Surgeon, Wellington Hospital, Private Bag 7902, Wellington South, New Zealand. Email: Brendon.Bowkett@ccdhb.org.nz