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.

HIV-exposed infants with acute respiratory failure secondary to acute lower respiratory infections managed with and without mechanical ventilation.

OBJECTIVES: The decision to provide mechanical ventilation (intermittent positive pressure ventilation (IPPV)) to HIV-exposed infants in resource-poor settings has remained difficult owing to problems in confirming HIV infection and the lack of data on outcome. We evaluated the predictive value of the HIV antibody test in confirming infection in infants requiring mechanical ventilation for acute lower respiratory infections (ALRIs), and compared the outcome for children denied access with the outcome for similar subjects who were ventilated. SETTING AND DESIGN: This investigative study was conducted over a 12-month period at the paediatric intensive care unit (PICU) at King Edward VIII Hospital (KEH) in Durban, and at Ngwelezana Hospital in northern KwaZulu-Natal. SUBJECTS: HIV-exposed patients with acute respiratory failure (ARF) secondary to ALRI entering the PICU at KEH were enrolled into the IPPV arm, while similar children who were refused such care at Ngwelezana Hospital were admitted into the non-IPPV arm. Standardised protocols for entry and management of enrolled subjects were utilised. OUTCOME MEASURES: HIV DNA polymerase chain reaction (PCR) testing was performed to establish HIV status. Clinical and laboratory parameters were correlated with HIV status to determine predictors of infection and outcome (survival to discharge). RESULTS: One hundred and sixteen HIV-exposed infants were enrolled, 49 into the IPPV arm and 67 into the non-IPPV arm. The median age of both groups was 3.0 months (0.5-11 months), and the male/female ratio and proportion of infants under 3 months of age were similar in both groups. The predictive values of the HIV antibody test in determining HIV infection in the IPPV and non-IPPV arms were 87.8% and 85.0% respectively. Splenomegaly and a serum globulin of > 35 g/l increased the likelihood of being HIV PCR-positive (p = 0.006 and p = 0.04 respectively). Survival to discharge rates for HIV-infected children in the IPPV and non-IPPV arms were 41.9% and 24.6% respectively (p = 0.08). Age less than 3 months (p = 0.04) and very severe pneumonia (p = 0.007) were the only indicators of poor outcome. CONCLUSION: Mechanical ventilation provided little benefit in HIV-infected children with ARF from ALRI. An HIV antibody test in infants with ALRI and ARF is highly suggestive of HIV infection. Splenomegaly and a serum globulin of greater than 35 g/l were the only useful markers in identifying HIV infection.

Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm.

OBJECTIVE: To determine the validity of an algorithm used by primary care health workers to identify children with symptomatic human immunodeficiency virus (HIV) infection. This HIV algorithm is being implemented in South Africa as part of the Integrated Management of Childhood Illness (IMCI), a strategy that aims to improve childhood morbidity and mortality by improving care at the primary care level. As AIDS is a leading cause of death in children in southern Africa, diagnosis and management of symptomatic HIV infection was added to the existing IMCI algorithm. METHODS: In total, 690 children who attended the outpatients department in a district hospital in South Africa were assessed with the HIV algorithm and by a paediatrician. All children were then tested for HIV viral load. The validity of the algorithm in detecting symptomatic HIV was compared with clinical diagnosis by a paediatrician and the result of an HIV test. Detailed clinical data were used to improve the algorithm. FINDINGS: Overall, 198 (28.7%) enrolled children were infected with HIV. The paediatrician correctly identified 142 (71.7%) children infected with HIV, whereas the IMCI/HIV algorithm identified 111 (56.1%). Odds ratios were calculated to identify predictors of HIV infection and used to develop an improved HIV algorithm that is 67.2% sensitive and 81.5% specific in clinically detecting HIV infection. CONCLUSIONS: Children with symptomatic HIV infection can be identified effectively by primary level health workers through the use of an algorithm. The improved HIV algorithm developed in this study could be used by countries with high prevalences of HIV to enable IMCI practitioners to identify and care for HIV-infected children.