Five years of outpatient parenteral antibiotic therapy with ceftriaxone in the paediatric emergency department: what clinical features are associated with need for admission?

BACKGROUND: More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission. METHODS: We conducted a service evaluation over a 5-year period (12 September 2015-12 September 2020) at a single UK tertiary centre paediatric ED formally known as the Royal Hospital for Sick Children Edinburgh. All children referred from the ED for OPAT with ceftriaxone were included. OPAT failure was defined as a decision by a senior clinician of need for admission. Univariate statistical testing and multivariate logistic regression modelling were performed. RESULTS: 754 children received OPAT in the ED over a 5-year period. 95 children (13%) required admission for inpatient management. Need for admission was independently associated with having a positive blood culture (adjusted OR (aOR) 8.9; 95% CI 1.49 to 47; p=0.01) or an ultrasound performed (aOR 6.8; 95% CI 3.74 to 12.7; p<0.001). We observed no significant association between age and systemic features (fever, white cell count or C reactive protein) with need for admission in our multivariate analysis. CONCLUSION: In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.

Are you tuned in? The challenges of seizure identification in children with intellectual disability - A potential for video-based care-pathway.

This qualitative study explores the challenges parents/carers face in seizure identification in children with coexisting epilepsy and intellectual disability (ID). Semi-structured interviews with parents/carers provided ten hours of data, transcribed verbatim for data analysis. Themes and subthemes were identified and grouped to reflect the findings. The importance of knowing the child's usual behavior and recognizing changes to this was a consistent theme. All participants reported that being 'in tune' with their child helped in seizure recognition. Participants felt that the healthcare professionals (HCP) were poor at recognizing seizures in their children at times. They had mixed thoughts on the difficulty the presence of an ID contributes to seizure recognition. The severity of ID and the seizure type were the two main variables discussed. The study concludes that knowing the child well and understanding the usual behavior of the child is crucial to seizure recognition. A video-based care pathway with videos of both usual behavior and seizure activity available to the HCP to classify the events correctly may be potentially beneficial to improve patient care.

Human T cell responses to Japanese encephalitis virus in health and disease.

Japanese encephalitis (JE) virus (JEV) is an important cause of encephalitis in children of South and Southeast Asia. However, the majority of individuals exposed to JEV only develop mild symptoms associated with long-lasting adaptive immunity. The related flavivirus dengue virus (DENV) cocirculates in many JEV-endemic areas, and clinical data suggest cross-protection between DENV and JEV. To address the role of T cell responses in protection against JEV, we conducted the first full-breadth analysis of the human memory T cell response using a synthetic peptide library. Ex vivo interferon-γ (IFN-γ) responses to JEV in healthy JEV-exposed donors were mostly CD8(+) and targeted nonstructural (NS) proteins, whereas IFN-γ responses in recovered JE patients were mostly CD4(+) and targeted structural proteins and the secreted protein NS1. Among patients, a high quality, polyfunctional CD4(+) T cell response was associated with complete recovery from JE. T cell responses from healthy donors showed a high degree of cross-reactivity to DENV that was less apparent in recovered JE patients despite equal exposure. These data reveal divergent functional CD4(+) and CD8(+) T cell responses linked to different clinical outcomes of JEV infection, associated with distinct targeting and broad flavivirus cross-reactivity including epitopes from DENV, West Nile, and Zika virus.