An audit of bilious vomiting in term neonates referred for pediatric surgical assessment: can we reduce unnecessary transfers?

BACKGROUND: Between 20% and 50% neonates with bilious vomiting are diagnosed with surgical pathology. Distinguishing neonates requiring surgery remains challenging. Our aim was to conduct an audit of term neonates with bilious vomiting referred for assessment to identify characteristics of this cohort and management. Secondary aims were to identify factors predictive of surgical pathology. METHODS: Infants <28 days referred for bilious vomiting from 2011 to 2015 were identified through cross-referencing multiple patient databases. Data obtained included clinical features, laboratory, radiological investigations and management. The sensitivity and specificity of tests were calculated and regression analyses were conducted to identify predictors of surgical pathology. RESULTS: 351 eligible neonates were referred [46% female; mean gestation 39 + 6 weeks (SD 9.2 days); mean birthweight 3469 g (SD 558 g)]. Laboratory results were available for 68.7% patients, 88.9% underwent X-ray and 96.6% contrast studies. 11.7% had a surgical diagnosis [malrotation 4.6% (1.7% with volvulus)]. No single test available in peripheral centers could exclude a surgical diagnosis. In regression analyses, age > 72 h, presence of abdominal distension, raised CRP and abnormal X-ray were statistically significant predictors of surgical pathology, while only the former two were predictive of time-critical surgical pathology. CONCLUSION: 11.7% neonates had surgical pathology, fewer than in previous studies. Only contrast fluoroscopy could exclude surgical pathology and therefore prevent transfer. A more sensitive, widely available test would be required to reduce unnecessary neonatal transfers. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level III.

Audit of ventriculoperitoneal shunt infections in paediatric patients, 2006-2013.

BACKGROUND: Infection following ventriculoperitoneal shunt placement remains a significant complication with an incidence of 3-27% cited in literature. Infections cause significant morbidity, and it is important that empirical antibiotic therapy for management is guided by accurate knowledge of prevailing aetiologies and local antibiotic sensitivity patterns. AIMS: To establish the incidence of shunt infections in our paediatric population, to identify the causative micro-organisms, and to determine the antibiotic resistance patterns of the responsible micro-organisms. METHODS: Retrospective data collection utilising existing databases in the Royal Hospital for Sick Children, Yorkhill, between 1 January 2006 and 30 September 2013. RESULTS: Total number of shunt operations was 308 with 28 episodes of infection involving 27 patients (male = 12, female = 15). The incidence of infection was 9%. In all, 79% of the episodes involved a single pathogen with 21% being mixed pathogens. Coagulase-negative staphylococci were the most common cause of infection (44%). Gram-positive sensitivity to flucloxacillin and gentamicin was noticeably low at 22% and 14%, respectively with 87% of coagulase-negative staphylococci resistant to gentamicin and 81% resistant to flucloxacillin. CONCLUSIONS: The changing spectrum of Gram-positive organisms has impacted on antibiotic sensitivity patterns, and our local prescribing policy has been adapted in order to manage shunt infections most effectively.