- Background Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided. Objectives A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients. Study design One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment. Results No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (± SD) duration of a temperature ≥ 39°C, 6.2 ± 2.4 vs 6.5 ± 1.8 days, respectively; mean duration of a temperature ≥ 38°C, 9 ± 3.9 vs 8.2 ± 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 ± 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 ± 13.2 vs 30.2 ± 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 ± 7.6 vs 24.2 ± 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation. Conclusion The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.