Management of paediatric tuberculosis in leading UK centres: unveiling consensus and discrepancies

SETTING

Large specialist paediatric TB clinics in the UK.

OBJECTIVE

To evaluate clinical practice and compare with national and international guidelines.

DESIGN

A survey based on an electronic questionnaire on the management of latent tuberculous infection (LTBI) and tuberculosis (TB) disease was conducted in 13 specialist paediatric TB clinics. The consensus and discrepancies were evaluated by descriptive analysis.

RESULTS

Practice was reportedly different when choosing age limits for preventive treatment for TB contacts with initially negative tuberculin skin tests (TSTs), interpretation of TST results and use of interferon-gamma release assays (IGRAs) in the context of LTBI. In relation to management of children with TB disease, practices varied for duration of treatment of osteoarticular TB, monitoring for ethambutol ocular toxicity and use of pyridoxine. There was limited experience with multidrug-resistant TB (MDR-TB), and over half of the clinics monitored MDR-TB contacts without giving preventive treatment.

CONCLUSIONS

The survey showed heterogeneity in several aspects of clinical care for children with TB. Available paediatric TB guidelines differ substantially, explaining the wide variations in management of childhood TB. Prospective paediatric studies are urgently required to inform and standardise clinical practice, especially in the context of evolving drug resistance.

Mortality and morbidity of nosocomial respiratory syncytial virus (RSV) infection in ventilated children--a ten year perspective

BACKGROUND

Respiratory syncytial virus (RSV) is one of the most common pathogens involved in nosocomial infection in children. The aim of the study was to determine the impact of nosocomial RSV infection on mortality and pediatric intensive care unit (PICU) morbidity of ventilated children.

METHODS

This is a prospective observational cohort study of all children ventilated with RSV infection in a tertiary-referral PICU over a 10-year period. Determinants of the relationship of nosocomial (PICU-acquired and hospital ward-acquired) RSV infection to mortality and PICU morbidity were adjusted for by performing multiple regression analysis.

RESULTS

Of 525 RSV-positive children ventilated on PICU during the ten-year study period, 38 (7.2%) acquired their RSV infection following PICU admission and 38 (7.2%) had acquired RSV in hospital. Ten (26%) children that acquired RSV on PICU died (RR 6.4, 95%CI 3.2-12.9) and 11 (29%) with hospital ward-acquired infection died (RR 9.8, 95%CI 5.1-18.9), compared to 18 (4%) with community-acquired RSV infection. Nosocomial RSV infection was significantly and independently associated with death which was more strongly predicted by immunodeficiency and congenital heart disease (P<0.01). Nosocomial RSV infection was the strongest predictor for morbidity as reflected in duration of ventilation and length of stay on PICU (P<0.01).

CONCLUSION

Nosocomial RSV infection was independently associated with increased mortality and was the strongest predictor of duration of ventilation and length of stay in children on PICU. Decreasing nosocomial RSV infection would reduce deaths in ventilated children.

How to use: C-reactive protein

C-reactive protein (CRP) is an acute-phase protein that increases 4-6 h after an inflammatory trigger and peaks at 36-50 h. Levels decrease rapidly with the resolution of inflammation. CRP is generally highly elevated in invasive bacterial infections and is often used as a marker of inflammation. A single CRP level is neither sensitive nor specific enough to identify all children with serious bacterial infection. However, a raised CRP does suggest serious bacterial infection and should suggest further assessment is needed. CRP levels that fail to decrease, or continue to rise, after 48 h of antibiotic therapy suggest treatment failure. In infants with suspected neonatal sepsis, two CRP measurements 24 h apart that are <10 mg/l are useful in excluding sepsis.

Tuberculosis in the United Kingdom and Republic of Ireland

AIMS

To describe the clinical features, diagnosis and management of children with tuberculosis in the United Kingdom and Republic of Ireland.

METHODS

Cases of culture-confirmed and clinically diagnosed tuberculosis were reported to the British Paediatric Surveillance Unit from December 2003 to January 2005.

RESULTS

385 eligible cases were reported. Pulmonary disease was present in 154 (40%) children. Just over half (197, 51%) of children presented clinically and most of the remainder (166, 43%) at contact tracing. A probable source case was identified for 73/197 (36%) of the children presenting clinically. The majority (253, 66%) of children had a microbiological and/or histological investigation, and culture results were available for 240 (62%), of whom 102 (26%) were culture positive. Drug resistance was reported in 15 (0.4%) cases. 44% (128/292) of non-white children did not receive the recommended quadruple drug therapy. Seven children died. Only 57% (217) of children were managed by a paediatric subspecialist in respiratory or infectious diseases or a general paediatrician with a special interest in one of these areas. Fewer than five cases were reported from 119/143 (83%) respondents and 72 of 96 (75%) centres.

CONCLUSIONS

Many paediatricians and centres see few children with tuberculosis. This may affect adherence to national guidelines. Managed clinical networks for children with tuberculosis may improve management and should be the standard of care.

An evaluation of the completeness of reporting of childhood tuberculosis

The sensitivity of the Enhanced Tuberculosis Surveillance (ETS) scheme for monitoring tuberculosis in children is unknown. We used the British Paediatric Surveillance Unit (BPSU) reporting scheme to conduct a prospective observational study of tuberculosis in children aged <16 yrs in the UK. Reported cases were then matched with records from the ETS database. A total of 320 cases were reported to the BPSU between January and December 2004. We estimated that there were 557 paediatric cases in England, Wales and Northern Ireland in 2004: 222 (40%) cases reported to both BPSU and ETS, 98 (18%) reported to BPSU but not ETS and 237 (42%) reported to ETS but not BPSU. Children aged <5 yrs were significantly less likely to be reported to ETS compared with older children (p<0.01). There is substantial under-reporting of childhood tuberculosis, especially of children aged <5 yrs. ETS provides a representative picture of the demographics but may miss approximately 20% of cases. This should be taken into account when planning training and resource requirements for tuberculosis. Increased efforts are needed to ensure that all paediatric cases are reported to ETS.

Update on antiretroviral therapy

Combination antiretroviral treatment (cART) has been highly successful in preventing mother to child transmission of human immunodeficiency virus (HIV) and in reducing mortality and morbidity in HIV infected children. cART is now recommended for all HIV infected infants and selected older children. As these children will need to take cART until adulthood, the aim is to use cART with low risks of virological failure, resistance and toxicity. Since increasing numbers of antiretroviral drugs are becoming available for children, ongoing studies are needed to determine the correct doses for children, to improve adherence and to assess potential toxicity and drug interactions (such as between ritonavir and inhaled fluticasone).

Hyponatraemia and hypokalaemia during intravenous fluid administration

BACKGROUND

Hospital-acquired hyponatraemia is associated with excessive volumes of hypotonic intravenous fluids and can cause death or permanent neurological deficit.

METHODS

A cross-sectional survey was carried out in 17 hospitals on all children receiving intravenous fluids during 1 day of a specified week in December 2004.

RESULTS

77 of 99 children receiving intravenous fluids received hypotonic solutions and 38% received >105% of fluid requirements. 21 of 86 children were hyponatraemic, but the electrolytes of only 79% had been checked in the preceding 48 h.

CONCLUSIONS

Intravenous fluids should be used with caution as regards the tonicity and volume administered, and with appropriate monitoring of serum electrolytes.

Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland

OBJECTIVE

To describe changes in demographic factors, disease progression, hospital admissions, and use of antiretroviral therapy in children with HIV.

DESIGN

Active surveillance through the national study of HIV in pregnancy and childhood (NSHPC) and additional data from a subset of children in the collaborative HIV paediatric study (CHIPS).

SETTING

United Kingdom and Ireland.

PARTICIPANTS

944 children with perinatally acquired HIV-1 under clinical care.

MAIN OUTCOME MEASURES

Changes over time in progression to AIDS and death, hospital admission rates, and use of antiretroviral therapy.

RESULTS

944 children with perinatally acquired HIV were reported in the United Kingdom and Ireland by October 2002; 628 (67%) were black African, 205 (22%) were aged > or = 10 years at last follow up, 193 (20%) are known to have died. The proportion of children presenting who were born abroad increased from 20% in 1994-5 to 60% during 2000-2. Mortality was stable before 1997 at 9.3 per 100 child years at risk but fell to 2.0 in 2001-2 (trend P < 0.001). Progression to AIDS also declined (P < 0.001). From 1997 onwards the proportion of children on three or four drug antiretroviral therapy increased. Hospital admission rates declined by 80%, but with more children in follow up the absolute number of admissions fell by only 26%.

CONCLUSION

In children with HIV infection, mortality, AIDS, and hospital admission rates have declined substantially since the introduction of three or four drug antiretroviral therapy in 1997. As infected children in the United Kingdom and Ireland are living longer, there is an increasing need to address their medical, social, and psychological needs as they enter adolescence and adult life.

Diagnosis of primary human herpesvirus 6 and 7 infections in febrile infants by polymerase chain reaction

Primary human herpesvirus 6 (HHV-6) and 7 (HHV-7) infections were identified in febrile children by qualitative and quantitative polymerase chain reaction (PCR) assays. Diagnosis was based on the differential detection of viral DNA in peripheral blood mononuclear cells (PBMC), but not in saliva. Six of 41 febrile infants, but none of seven non-febrile controls, were identified with primary infections (three HHV-6, three HHV-7). These children had significantly higher viral loads in PBMC (HHV-6, median 24213 genomes/10(6) PBMC; HHV-7, median 6,040,000 genomes/10(6) PBMC) than DNA-aemic, saliva PCR positive children (HHV-6, median 1606 genomes/10(6) PBMC, p < 0.01; HHV-7, median 7089 genomes/ 10(6) PBMC, p < 0.05). Viral DNA was detected in serum by PCR in only 50% of primary infections. All three children with primary HHV-7 infection had febrile convulsions. Thus PCR, including quantitative assays, may identify primary HHV-6 and HHV-7 infections when an appropriate combination of clinical specimens is used.

Pets and diseases

Pet ownership is very common. Pets contribute to the physical and mental wellbeing of their owners but do have the potential to cause disease. These diseases are uncommon but recognition that disease could be because of a family pet will lead to correct management for both the patient and the pet and may prevent further disease.

Hearing assessment after meningitis and meningococcal disease

A method to increase audiology referral after meningitis or meningococcal disease was audited in 89 children. A standardised proforma increased referrals from 78% to 96% over a two year period. However, only 73% of children had a hearing test. The major reason for hearing not being tested changed from non-referral to non-attendance.

Primary cutaneous infection by Aspergillus ustus in a 62-year-old liver transplant recipient

We report the first case of primary cutaneous aspergillosis caused by Aspergillus ustus, a species that seldom infects human beings. The patient, a 62-year-old liver transplant recipient with end-stage hepatitis C-induced cirrhosis, was receiving the experimental immunosuppressive drug FK-506. Trauma to the skin of the right arm from tape and from an arm board holding intravenous and intraarterial catheters in place and to the left leg from an occlusive knee brace may have contributed to this unusual mycosis. The patient's cutaneous aspergillosis responded to a combination of intravenous amphotericin B and topical terbinafine cream. Although the patient died shortly thereafter from hepatic failure, there was no evidence of systemic aspergillosis.

Congenital peripheral neuropathy presenting as apnoea and respiratory insufficiency

A seven-week-old girl presented with recurrent apnoeic episodes and respiratory insufficiency. The child was hypotonic, weak, areflexic and had a paradoxical movement of the right hemidiaphragm. Cranial nerve and sphincter function was normal; there was no fasciculation. Nerve conduction studies showed a severe axonal sensory and motor peripheral neuropathy. Biopsy of the sural nerve revealed marked axonal atrophy. The infant is now over two years of age, is ventilator-dependent and has clinical and electrophysiological evidence of further progression of one of the earliest reported presentations of a congenital peripheral neuropathy.

Children who are seen but not referred: hearing assessment after bacterial meningitis

Bacterial meningitis is an important cause of hearing loss in children. Previous studies have shown that a proportion of survivors of childhood bacterial meningitis do not have a formal hearing assessment. To confirm this finding amongst children treated for bacterial meningitis in our hospital, a retrospective audit was performed. The hospital case notes and community audiological records were examined to see how many children were referred for hearing assessment after their illness, and how many actually attended. Between 1984 and 1991, 194 children were directly admitted to our hospital with bacterial meningitis. Thirteen children died, and hearing assessment was carried out on 135 of the 181 survivors (75%), 15 of whom had evidence of sensorineural hearing loss. The major reason for hearing not being assessed was non-referral (31 out of 46 cases), 12 children did not attend for assessment despite referral, and three moved shortly after discharge. Thirty of the children remaining in the area who had no assessment (69.7%) were however seen in hospital out-patients. Routine referral for hearing testing at discharge, with re-referral at out-patient attendance, could help increase the number of children assessed after bacterial meningitis.