Tag Archives: infectious disease

June 2012 PDF

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June’s PDF digest is ready for consumption.  Both APLS and NICE have lost paraldehyde from their status epilepticus algorithms, a link to Working Together and an article on sticky eyes v. conjunctivitis.  Blood pressure centile charts and a plug for the London Deanery’s communication skills courses.  Do leave comments below.

Whooping cough outbreak 2012

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More background to pertussis with thanks to Dr Rupa Vora

  • whooping cough is caused by Bordetella pertussis, a gram negative pleomorphic bacillus. It is spread by aerosol transmission and the bacteria cause damage by attaching to the respiratory cilia
  • it occurs in clusters every 2-5 years during the summer months. We currently have an outbreak with the HPA provisionally reporting 665 cases in the first quarter of 2012 (cf. 1040 cases in 2011, 421 in 2010)
  • cases have dropped dramatically since pertussis vaccinations have been introduced. Acellular pertussis vaccination is given at 2 and 3 months, followed by a pre-school booster.  However, protection wanes quickly and has virtually disappeared by 12 years old
  • incubation period is 3-12 days and children are most infectious in the first 2-3 weeks. They are most likely to present in the second phase of illness at 3-4 weeks
  • can present with coryza (1st stage which lasts a couple of weeks), paroxysms of cough, difficulty feeding and pneumonia. Younger infants (<6months) may not present with the characteristic ‘whoop’. Older children and adults often present with a persistent cough
  • complications include chronic cough (“100 day cough”), hypoglycaemia, seizures, encephalopathy and intracranial haemorrhage
  • any infant is vulnerable and up to 50% may need hospitalisation.  Especially vulnerable are ex-prems and those with underlying cardiology, respiratory or neurological problems.  
  • In England and Wales, whooping cough is statutorily notifiable.  The diagnosis is usually made on clinical grounds without the requirement for laboratory confirmation
  • The UK Health Protection Agency advises a 7 day course of erythromycin or clarithromycin (or azithromycin for 3-5 days if under 4 weeks) to reduce spread.  A pernasal swab to confirm or refute B. pertussis as the causative organism can be carried out.  If the cough has been present for more than two weeks and the child is in the community, serum serology can be sent to Colindale.  See table below:

 

Appropriate laboratory tests for a sporadic case of pertussis reported to HPA on clinical suspicion (with thanks to Dr Maria O’Callaghan): 

Age Clinical symptoms
≤ 2 weeks cough > 2 weeks cough
≤ 1 yr

Hospitalised

 NPA/PNS for PCR (RSIL)

PNS for culture (local laboratory)

 NPA/PNS for PCR (RSIL)

PNS for culture (local laboratory)

Serum for serology (RSIL)
≤ 1 yr

community

 PNS for culture (local laboratory) Serum for serology (RSIL)
> 1 yr to 6 yr
6 to 15 yr Serum for serology (RSIL)
> 15 yr

 NPA – nasopharyngeal aspirate; PNS – pernasal swab;

RSIL – Respiratory and Systemic Infections Laboratory, Colindale

Useful websites:

HPA: www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/WhoopingCough/

NHS Choices: www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx

Antipyretics – single or dual therapy?

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Managing Fever in Children with thanks to Dr Ranjev Kainth

Fever, both in primary and secondary care is a frequent presentation. Often, it is a sign of an illness and in the first instance, it is important to establish the most likely underlying causative factor. Once this has been determined, focus often turns to the management of the fever.  Two recent articles in Archives highlight the varying practice amongst clinicians both in primary and secondary care.

In accordance with NICE guidelines1, the authors2-3 suggest anti-pyretics should not be used for the sole purpose of controlling fever.  Agents such as paracetamol and ibuprofen are often administered to promote comfort in the child when there is  fever.  In such situations, children may be prescribed single or dual therapy.

In a systematic review, E.Purssell3 examines the evidence for combined anti-pyretic therapy with either paracetamol or ibuprofen alone. He concluded that ‘only marginal benefit was shown for the combined treatment compared with each drug individually which, taken alongside the risk of overdose and further increasing the fear of fever, suggests there is little to recommend this practice’.

With the real risk of parents being unable to accurately measure medication4, it is important clear guidance is given on when and what type of drug therapy is appropriate in clinical situations.

References:

  1. NICE Guideline: Feverish Illness in Children:  Quick reference guideline http://guidance.nice.org.uk/CG47/QuickRefGuide/pdf/English
  2. McLyntyre, J. Management of fever in Children. Arch Dis Child Dec 2011 V 96;12 P.1173
  3. Purssell, E. Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child Dec 2011 V 96;12 P.1175
  4. Beckett, V.L. et al. Accurately administering oral medication to children isn’t child’s play. Arch Dis Child 2011;96:A7 doi:10.1136/adc.2011.212563.14  

November’s Paediatric Pearls available now!

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This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month!  NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below).  Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.

Meningococcus

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Had another fatal Meningococcal B case a few weeks ago.  Always upsetting.  Text book management by the night team, excellent support and fast action by CATS retrieval team, the full services of one of the top PICUs in the country – but that horrible little diplococcus won the battle.  Of course it didn’t really, our antibiotics would have killed it off pretty quickly, but the cascade it had set in motion was irreversible.  2 of the juniors involved with the case have separately presented it and looked into aspects of it further – a mark of how deaths like this have an effect on every member of the team.   Dr Keir Shiels looked at prophylaxis and secondary prevention:

Neisseria meningitidis is found in the throats of around 15% of the population and is the cause of the much-feared meningococcal septicaemia. The incidence of meningococcaemia has fallen significantly since the advent of vaccines against some strains; and public awareness of the danger of non-blanching rashes is high.

Despite the relatively high prevalence of N. meningitidis as a commensal organism in the population and the relatively low incidence of meningococcaemia, meningococcal sepsis is still a notifiable disease. This stems from the pre-vaccine days when Men A was able to spread epidemically. The HPA still recommends prophylactic antibiotics for contacts of a patient with meningococcaemia.
 
A recent Cochrane review has been published regarding the effectiveness of different antibiotic regimens in obliterating N. meningitidis from the throats of inoculated hosts. The study has compared the effectiveness of Rifampicin, cefalosporin and Ciproflaxacin and comes to several conclusions which have altered UK HPA Guidelines.
 
The increasing risk of rifampicin-resistant N. meningitidis, plus the reduced likelihood of compliance with a twice daily prophylaxis for two days, means that for adults and older children, rifampicin is no longer the antibiotic of choice. The HPA now recommend ciproflaxacin to be given as a single one-off dose instead. It is believed that this is at least equally effective, but with far better compliance. 
 
People who require prophylaxis remain as: first degree relatives, people sleeping in the same house, classmates and teacher at school.
 
Given the risks of using fluoroquinolones in children, the Cochrane review is circumspect in advising the administration of ciprofloxacin to children. However, the HPA leave it to a paediatrician’s discretion to consider the risks of a single one-off dose and still suggest ciprofloxacin as first line consideration. Rifampicin (2 doses daily for 2 days) is now considered second line.

October’s Paediatric Pearls

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October’s edition is joint again this month on account of my right radius being fractured and its being too difficult to type and format text boxes with just my left hand…  I am obviously not quite as good at ice-skating as I thought I was.  All the topics this month should be of interest to both the ED and primary care teams anyway:  a paper on paediatric early warning scores, the start of our neurodevelopment series, an update on services for bereaved children and their families and some useful links on the subject of head-lice.

GP’s September 2011 issue now available

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It’s the last day of September today so I’ve just got in by the skin of my teeth…  In this month’s edition I have done a bit on BCG vaccination from the recently updated NICE guideline on TB, reminded you of where to get the new growth charts from and how to plot ex-prem babies on them and featured a somewhat depressing paper from Archives of Disease in Childhood this month on the effects of maternal obesity on the baby.  Do leave comments and questions below.

GP May 2011!

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May 2011 GP version available here!  Can you tell the difference between septic arthritis and transient synovitis?  We have a new algorithm to help you.  Also a reminder about measles, information on inguinal hernias, NICE on otitis media with effusion and a link to an important discussion on the website about what one can and can not do / take while breastfeeding.  Do leave comments below.