Which symptoms and clinical features correctly identify serious respiratory infection in children attending a paediatric assessment unit?

OBJECTIVE: Parent-reported symptoms are frequently used to triage children, but little is known about which symptoms identify children with serious respiratory infections. The authors aimed to identify symptoms and triage findings predictive of serious respiratory infection, and to quantify agreement between parent and nurse assessment. DESIGN: Prospective diagnostic cohort study. SETTING: Paediatric Assessment Unit, University Hospitals Coventry and Warwickshire NHS Trust. PATIENTS: 535 children aged between 3 months and 12 years with suspected acute infection. METHODS: Parents completed a symptom questionnaire on arrival. Children were triaged by a nurse, who measured routine vital signs. The final diagnosis at discharge was used as the outcome. Symptoms and triage findings were analysed to identify features diagnostic of serious respiratory infection. Agreement between parent and triage nurse assessment was measured and kappa values calculated. RESULTS: Parent-reported symptoms were poor indicators of serious respiratory infection (positive likelihood ratio (LR+) 0.56-1.93) and agreed poorly with nurse assessment (kappa 0.22-0.56). The best predictor was clinical assessment of respiratory distress (LR+ 5.04). Oxygen saturations <94% were highly specific (specificity 95.1%) but had poor sensitivity (35.6%). Tachypnoea (defined by current Advanced Paediatric Life Support standards) offered little discriminatory value. CONCLUSION: Parent-reported symptoms were unreliable discriminators of serious respiratory infection in children with suspected acute infection, and did not correlate well with nurse assessment. Using symptoms to identify higher risk children in this setting is unreliable. Nurse triage assessment of respiratory distress and some vital signs are important predictors.

How well do vital signs identify children with serious infections in paediatric emergency care?

OBJECTIVES: To determine whether vital signs identify children with serious infections, and to compare their diagnostic value with that of the Manchester triage score (MTS) and National Institute for Health and Clinical Excellence (NICE) traffic light system of clinical risk factors. DESIGN: Prospective cohort of children presenting with suspected acute infection. We recorded vital signs, level of consciousness, activity level, respiratory distress, hydration and MTS category. SETTING: Paediatric assessment unit at a teaching hospital in England. PARTICIPANTS: 700 children (median age 3 years), of whom 357 (51.0%) were referred from primary care, 198 (28.3%) self-referrals and 116 (16.6%) emergency ambulance transfers. Just over half (383 or 54.7%) were admitted. MAIN OUTCOME MEASURES: Severity of infection categorised as serious, intermediate, minor or not infection. RESULTS: Children with serious or intermediate infections (n = 313) were significantly more likely than those with minor or no infection (n = 387) to have a temperature >or=39 degrees C, tachycardia, saturations 2 seconds. Having one or more of temperature >or=39 degrees C, saturations

Deriving temperature and age appropriate heart rate centiles for children with acute infections.

OBJECTIVES: To describe the reference range for heart rate in children aged 3 months-10 years presenting to primary care with self-limiting infections. DESIGN: Cross-sectional study of children presenting to primary care with suspected acute infection. Heart rate was measured using a pulse oximeter and axillary temperature using an electronic thermometer. Centile charts of heart rates expected at given temperatures for children with self-limiting infections were calculated. SETTING: Ten general practice surgeries and two out-of-hours centres in England. PARTICIPANTS: 1933 children presenting with suspected acute infections were recruited from in-hours general practice surgeries (1050 or 54.3%) or out-of-hours centres (883 or 45.7%). After excluding children who subsequently attended hospital and those without a final diagnosis of acute infection, 1589 children were used to create the centile charts of whom (859 or 54.1%) had upper respiratory tract infections and (215 or 13.5%) non-specific viral illness. MAIN OUTCOME MEASURES: Median, 75th, 90th and 97th centiles of heart rate at each temperature level. RESULTS: Heart rate increased by 9.9-14.1 bpm with each 1 degrees C increment in temperature. The 50th, 75th, 90th and 97th centiles of heart rate at each temperature level are presented graphically. CONCLUSIONS: Age-specific centile charts of heart rates expected at different temperatures should be used by clinicians in the initial assessment of children with acute infections. The charts will identify children who have a heart rate higher than expected for a given temperature and facilitate the interpretation of changes in heart rate on reassessment. Further research on the predictive value of the centile charts is needed to optimise their diagnostic utility.

Challenges faced by health workers in implementing the prevention of mother-to-child HIV transmission (PMTCT) programme in Uganda.

BACKGROUND: To report the experience of health workers who had played key roles in the early stages of implementing the prevention of mother-to-child HIV transmission services (PMTCT) in Uganda. METHODS: Interviews were conducted with 15 key informants including counsellors, obstetricians and PMTCT coordinators at the five PMTCT test sites in Uganda to investigate the benefits, challenges and sustainability of the PMTCT programme. Audio-taped interviews were held with each informant between January and June 2003. These were transcribed verbatim and manually analysed using the framework approach. RESULTS: The perceived benefits reported by informants were improvement of general obstetric care, provision of antiretroviral prophylaxis for HIV-positive mothers, staff training and community awareness. The main challenges lay in the reluctance of women to be tested for HIV, incomplete follow-up of participants, non-disclosure of HIV status and difficulties with infant feeding for HIV-positive mothers. Key informants thought that the programme's sustainability depended on maintaining staff morale and numbers, on improving services and providing more resources, particularly antiretroviral therapy for the HIV-positive women and their families. CONCLUSION: Uganda's experience in piloting the PMTCT programme reflected the many challenges faced by health workers. Potentially resource-sparing strategies such as the 'opt-out' approach to HIV testing required further evaluation.

The impact of HIV on maternal quality of life in Uganda.

To study the effect of HIV infection on quality of life (QOL) during pregnancy and puerperium, QOL was measured in a cohort study at St. Francis Hospital Nsambya, Kampala, Uganda. Dartmouth COOP charts were administered to 132 HIV-positive and 399 HIV-negative women at 36 weeks of pregnancy and six weeks post-partum. Responses were coded from 0 = best health-status to 4 = worst health-status and scores of 3-4 defined as poor. Odds ratios (OR) (95% confidence intervals(CI)) for poor scores were calculated and independent predictors of poor QOL examined using logistic regression. In pregnancy, HIV-positive women were more likely to have poor scores in feelings: OR = 3.2(1.9-5.3), daily activities: OR = 2.8(1.4-5.5), pain: OR = 2.1(1.3-3.5), overall health: OR = 1.7(1.1-2.7) and QOL: OR = 7.2(3.6-14.7), all p= 0.2). HIV infection was independently associated with poor QOL: OR = 8.5(3.8-19). Findings in puerperium were similar to those in pregnancy except more HIV-positive women had poor scores in social activities: OR = 2.5(1.4-4.7) and change in health: OR = 5.4(2-14.5) and infant death also predicted poor QOL: OR = 6.7(2.4-18.5). The findings reflect HIV's adverse impact on maternal QOL and the need for interventions to alleviate this infection's social and emotional effects.

Audit of antibiotic policies in the South East of England, 2004.

OBJECTIVES: The antibiotic policies of hospitals and primary care trusts (PCTs) in South East England were audited in the summer of 2004, to see how they had improved since 2000. METHODS: Antibiotic policies were obtained from pharmacists in NHS hospitals and PCTs, and examined for dates, formats, evidence base for policies, the type of guidance given on dosage, length of treatment, choice of antibiotics, coverage of common infections and reasons for prophylaxis. RESULTS: Twenty-three hospital and 25 primary care policies were examined. The average age of policies was 12 months, but 13 were more than 2 years old. The commonest format was an A4-sized document available in an electronic version. Primary care policies were more uniform than hospital policies. More primary care than hospitals' policies gave evidence to support their guidance. Ten policies used plain English for dosages, and 38 (79%) policies made few or no cautionary points about the drugs recommended. Respiratory and urinary infections were covered in most policies, but guidance on gastroenteritis and antibiotic prophylaxis was less frequent. There was little advice in the policies on the management of methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Primary care policies have improved since 2000, using a national model for evidence and a consistent style. Hospitals could benefit from similar national guidance, especially in the evidence to support the contents of antibiotic policies.

A survey of hepatitis C prevalence amongst the homeless community of Oxford.

Hepatitis C (HCV) is an emerging health concern across the world, with 170 million people chronically infected and at risk of liver cancer, cirrhosis or liver failure. There is no vaccination and so it is important to learn as much as possible about how to prevent future infection. Modes of transmission include intravenous drug use (IDU), blood products, tattooing and, to a lesser extent, sexual intercourse. Homelessness is a risk factor of HCV because of the environments and behaviours associated with homeless communities such as poor hygiene, poor nutrition and high levels of IDU. The aim of this project was to determine the prevalence of HCV and its risk factors amongst the homeless community of Oxford, which is the second largest in the country. Ninety-eight individuals of the Oxford homeless community were interviewed and tested for HCV. The results gave an estimated HCV prevalence of 26.5 percent. The major risk factors in this population were IDU (past and present), age (over 20 years old) and sharing the paraphernalia used by i.v. drug users (e.g. spoons, foil and filters). With the exception of age, these risk factors could all be targeted in an attempt to reduce this prevalence and combat the major public health concern that HCV poses to the homeless community of Oxford.

Enhancing surveillance of cryptosporidiosis: test all faecal specimens from children.

The heightened risk of waterborne cryptosporidiosis, associated with heavy rainfall in autumn 2000, prompted us to survey laboratory practice in the South East Region of England in testing faecal specimens for Cryptosporidium spp. oocysts and reporting to the Public Health Laboratory Service Communicable Disease Surveillance Centre (PHLS CDSC). Varied practices were found. Ideally, all faecal specimens should be tested, but where laboratories are unable to do so, screening all faecal specimens from children age 15 years or younger would improve surveillance and could probably be accomplished with minimal additional resources.

Encouraging good antimicrobial prescribing practice: a review of antibiotic prescribing policies used in the South East Region of England.

BACKGROUND: Good prescribing practice has an important part to play in the fight against antimicrobial resistance. Whilst it was perceived that most hospitals and Health Authorities possessed an antibiotic policy, a review of antibiotic policies was conducted to gain an understanding of the extent, quality and usefulness of these policies. METHODS: Letters were sent to pharmacists in hospitals and health authorities in across the South East region of the National Health Service Executive (NHSE) requesting antibiotic policies. data were extracted from the policies to assess four areas; antibiotic specific, condition specific, patient specific issues and underpinning evidence. RESULTS: Of a possible 41 hospital trusts and 14 health authorities, 33 trusts and 9 health authorities (HAs) provided policies. Both trust and HA policies had a median publication date of 1998 (trust range 1993-99, HA 1994-99). Eleven policies were undated. The majority of policies had no supporting references for the statements made. All policies provided some details on specific antibiotics. Gentamicin and ciprofloxacin were the preferred aminoglycoside and quinolone respectively with cephalosporins being represented by cefuroxime or cefotaxime in trusts and cephradine or cephalexin in HAs. 26 trusts provided advice on surgical prophylaxis, 17 had meningococcal prophylaxis policies and 11 covered methicillin resistant Staphylococcus aureus (MRSA). There was little information for certain groups such as neonates or children, the pregnant or the elderly. CONCLUSION: There was considerable variation in content and quality across policies, a clear lack of an evidence base and a need to revise policies in line with current recommendations.

Invasive pneumococcal disease in England and Wales: vaccination implications.

Knowledge of the epidemiology of invasive pneumococcal disease (IPD) will aid in planning the use of pneumococcal vaccines. A United Kingdom (UK)-based surveillance in England and Wales (1995-1997) of 11,528 individuals with IPD and a local enhanced surveillance in the Oxford (UK) area (1995-1999) have been analyzed. IPD has a high attack rate in children, with 37.1-48.1 cases per 100,000 infants <1 year old per year, and in older persons, with 21.2-36.2 cases per 100,000 persons >65 years old per year, for England, Wales, and Oxford. The 7-valent conjugate vaccine includes serotypes causing < or =79% of IPD in children <5 years old, but only 66% in adults >65 years old. The data also indicate that IPD varies by serotype, age, and country, emphasizing that the epidemiology of IPD is heterogeneous and requires continued surveillance.

Outcome of invasive pneumococcal disease: a UK based study. Oxford Pneumococcal Surveillance Group.

METHODS: The records of 106 children aged less than 5 years with invasive disease caused by Streptococcus pneumoniae were reviewed. RESULTS: The clinical manifestations were meningitis (37%), upper respiratory tract infection (24%), pneumonia (19%), and occult bacteraemia (18%). One child died and seven had persisting neurological impairment. Five serotypes caused 83% of disease and 92% of the serotypes are included in the seven valent conjugate vaccines which are undergoing trials. CONCLUSIONS: These data suggest that S pneumoniae infection is associated with a low case fatality rate but substantial morbidity in the UK.

Public health physicians who contribute to on-call communicable disease control duties: national comparative clinical audit by questionnaire survey.

BACKGROUND: In most health authorities in the UK, general public health physicians provide out-of-hours cover for specialists in communicable disease control. Although communicable disease control was part of their specialist training, there is no current formal mechanism to enable these doctors to keep up to date. The Faculty of Public Health Medicine has an active Continuing Professional Development Programme. A new initiative aimed to assess the knowledge of general public health physicians who take part in on-call communicable disease control rotas, or may do so in the future, by means of an educational clinical audit exercise. METHODS: Experts in communicable disease control developed a questionnaire containing a selection of scenarios, covering six different situations that might arise on-call. This was circulated to all members of the Faculty, but participation was voluntary. Answers were marked against model answers agreed by the experts. Results were analysed by positions held by participants. RESULTS: Response was unacceptably low. Overall scores ranged from 15 per cent to 89 per cent with a mean of 63 per cent. There was a trend of improvement in marks from those not normally involved in on-call (mean score 56.1 per cent (95 per cent confidence interval 51.6-60.7 per cent)) through Directors of Public Health (58.4 (54.9-62.0) per cent), Consultants (62.8 (60-65.6) per cent), and specialist registrars (67.9 (65.2-70.6) per cent), to Consultants in Communicable Disease Control (70.9 (68.1-73.6) per cent). CONCLUSION: The public health physicians who took part in this audit appear to be competent in their knowledge of communicable disease control, and particularly good at dealing with meningitis and salmonella, which are frequently encountered out of hours.

Diagnosis of viral infections of the central nervous system: clinical interpretation of PCR results.

BACKGROUND: Standard laboratory techniques, such as viral culture and serology, provide only circumstantial or retrospective evidence of viral infections of the central nervous system (CNS). We assessed the diagnostic accuracy of PCR of cerebrospinal fluid (CSF) in the diagnosis of viral infections of the CNS. METHODS: We examined all the CSF samples that were received at our diagnostic virology laboratory between May, 1994, and May, 1996, by nested PCR for viruses associated with CNS infections in the UK. We collected clinical and laboratory data for 410 patients from Oxford city hospitals (the Oxford cohort) whose CSF was examined between May, 1994, and May, 1995. These patients were classified according to the likelihood of a viral infection of the CNS. We used stratified logistic regression analysis to identify the clinical factors independently associated with a positive PCR result. We calculated likelihood ratios to estimate the clinical usefulness of PCR amplification of CSF. FINDINGS: We tested 2233 consecutive CSF samples from 2162 patients. A positive PCR result was obtained in 143 patients, including 22 from the Oxford cohort. Logistic regression analysis of the Oxford cohort showed that fever, a virus-specific rash, and a CSF white-cell count of 5/microL or more were independent predictors of a positive PCR result. The likelihood ratio for a definite diagnosis of viral infection of the CNS in a patient with a positive PCR result, relative to a negative PCR result, was 88.2 (95% CI 20.6-378). The likelihood ratio for a possible diagnosis of viral infection of the CNS in a patient with a negative PCR result, relative to a positive PCR result, was 0.10 (0.03-0.39). INTERPRETATION: A patient with a positive PCR result was 88 times as likely to have a definite diagnosis of viral infection of the CNS as a patient with a negative PCR result. A negative PCR result can be used with moderate confidence to rule out a diagnosis of viral infection of the CNS. We believe that PCR will become the first-line diagnostic test for viral meningitis and encephalitis.

A study of 42 episodes of overwhelming post-splenectomy infection: is current guidance for asplenic individuals being followed?

Individuals without a spleen have an increased risk of overwhelming post-splenectomy infection (OPSI). Improved awareness in recent years has stimulated increased efforts to prevent OPSI. Published guidelines have described policies for immunization, chemoprophylaxis and other measures considered beneficial to asplenic patients, yet OPSI episodes continue to occur. In an attempt to investigate why serious infections are still being seen, we have conducted a nationally based survey of recent OPSI episodes, using mainly a network of medical microbiologists. Data including clinical background to both splenectomy and OPSI episode, immunization and chemoprophylaxis history have been collated. Forty-two cases of overwhelming infection were reported by June 1996. Patients of all ages were affected with OPSI occurring up to 59 years after splenectomy. A mortality rate of 45% was seen. Pneumococcal infection caused at least 37 of 42 episodes, but only 12 patients had received pneumococcal vaccine. Four cases were possible vaccine failures. Only 22% of individuals had taken any chemoprophylaxis since splenectomy, and only one carried a medical alert card. Much more needs to be done to ensure that asplenic patients are warned of the risks of infection, and given at least pneumococcal vaccine. The role of antibiotics for either continual prophylaxis or as a reserve supply for self-prescription at appropriate times also needs greater discussion. Further work on improving pneumococcal vaccine response together with suitable programmes for revaccination are required. Surveillance should continue until the incidence of OPSI reaches an irreducible minimum.

Meningococcal vaccines for the United Kingdom.

New meningococcal vaccines are needed in the United Kingdom with some urgency. Almost all Neisseria meningitidis disease in this country is caused by serogroups B and C. Infants have the highest attack rates, but also make the poorest immunological responses to potential vaccines. The development of vaccines that protect infants is a significant challenge. A capsule-based serogroup B vaccine is unlikely to be successful in infants because the capsule is poorly immunogenic and the polysaccharide molecule mimics a human epitope. Without completely discounting capsule as an immunogen, alternate antigens are being considered for immunisation: outer membrane proteins (OMP), iron regulating proteins, and lipopolysaccharide. Vaccines based on OMP have been used in several phase 3 trials in South Africa, Cuba, Brazil, Norway, and Chile, in which two doses of vaccine were given. The Cuban and Norwegian vaccines have been compared in phase 2 trials in Iceland and Chile. Potential limitations are epitope heterogeneity and the theoretical ability of N. meningitidis to adapt even to hosts who have received polyvalent vaccines. A phase 2 trial of a hexavalent class 1 OMP vaccine is under way in Gloucester, with 100 babies receiving injections at 2, 3, and 4 months. Serogroup C vaccines have been developed from capsular polysaccharide but, unconjugated, these vaccines do not protect those under 2 years of age. Conjugate vaccines with C and AC polysaccharides are immunogenic in infants, but antibody titres may wane quickly.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of conjugate vaccine on carriage of Haemophilus influenzae type b.

Conjugate vaccines against Haemophilus influenzae type b (Hib) may modify Hib pharyngeal colonization. Hib colonization was compared in 371 infants and their families. In Oxfordshire, infants received PRP-T (polyribosylribitol phosphate conjugated to tetanus toxoid) and in Buckinghamshire they did not (controls). Infants were followed at 6, 9, and 12 months of age. Also, 6 unvaccinated Hib carriers were vaccinated and followed for 6 weeks. Hib acquisition was lower in vaccinees than controls (P < .01). During surveillance, 1.5% of vaccinees and 6.3% of controls carried Hib (P = .04). Among those with family Hib exposure, the carriage rates were 8.7% and 38.5% (P = .07), respectively. Hiv carriage rates were lower among vaccinees' unvaccinated siblings. Giving conjugate vaccine to a child carrying Hib did not rapidly terminate carriage. Thus, a primary means by which herd immunity to Hib is induced in a vaccinated population may be through reduction or delay in the initial acquisition of Hib.