British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England

Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.

Impact analysis of rotavirus vaccination in various geographic regions in Western Europe

BACKGROUND

Universal mass vaccination (UMV) against rotavirus has been implemented in many but not all European countries. This study investigated the impact of UMV on rotavirus incidence trends by comparing European countries with UMV: Belgium, England/Wales and Germany versus countries without UMV: Denmark and the Netherlands.

METHODS

For this observational retrospective cohort study, time series data (2001-2016) on rotavirus detections, meteorological factors and population demographics were collected. For each country, several meteorological and population factors were investigated as possible predictors of rotavirus incidence. The final set of predictors were incorporated in negative binomial models accounting for seasonality and serial autocorrelation, and time-varying incidence rate ratios (IRR) were calculated for each age group and country separately. The overall vaccination impact two years after vaccine implementation was estimated by pooling the results using a random effects meta-analyses. Independent t-tests were used to compare annual epidemics in the pre-vaccination and post-vaccination era to explore any changes in the timing of rotavirus epidemics.

RESULTS

The population size and several meteorological factors were predictors for the rotavirus epidemiology. Overall, we estimated a 42% (95%-CI 23;56%) reduction in rotavirus incidence attributable to UMV. Strongest reductions were observed for age-groups 0-, 1- and 2-years (IRR 0.47, 0.48 and 0.63, respectively). No herd effect induced by UMV in neighbouring countries was observed. In all UMV countries, the start and/or stop and corresponding peak of the rotavirus season was delayed by 4-7 weeks.

CONCLUSIONS

The introduction of rotavirus UMV resulted in an overall reduction of 42% in rotavirus incidence in Western European countries two years after vaccine introduction and caused a change in seasonal pattern. No herd effect induced by UMV neighbouring countries was observed for Denmark and the Netherlands.

Pneumococcal vaccine and serotype replacement in England: the bias of increased reporting

Background

Increased incidence of invasive pneumococcal disease (IPD) attributable to non-vaccine serotypes (NVT) has been reported in several countries following introduction of PCV7 and PCV13 vaccines, concurrently with a reduction in vaccine-type IPD. Such serotype replacement has, importantly, emerged in England, offsetting the benefit of PCV introduction. We scrutinise most recent findings to assess if the estimated increase in NVT disease might result from surveillance artefacts.

Methods

Using IPD surveillance for 2000-2018, we estimate the impact of PCV7 and PCV13 introduction on age-serotype-specific incidence rates through a synthetic control regression model, building counterfactuals by combining age-specific incidences reported for pathogens unaffected by PCVs.

Results

Following the introduction of PCV7 and PCV13 (pre-2006 vs post-2011), total IPD incidence declined by 57% and by 76% in children younger than 5. PCV7-IPD decreased by 93% in all age groups, whereas PCV13-IPD declined by 68% since PCV13 was introduced. Importantly, NVT-IPD increased by 43% after PCV7, with non-significant statistical increases in most age groups.

Conclusions

Through appropriate statistical modelling, we disentangled the impact of vaccine and improved surveillance on the changes in IPD incidence rates. By controlling for the confounding effects of improved surveillance, we are able to estimate a lower serotype replacement.

Key messages

Pneumococcal vaccine has been beneficial despite serotype replacement. Adequate statistical methods are needed to disentangle the two phenomena.

SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

OBJECTIVES

To understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents.

METHODS

An outbreak investigation involving 394 residents and 70 staff, was carried out in 4 nursing homes affected by COVID-19 outbreaks in central London. Two point-prevalence surveys were performed one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing.

RESULTS

Overall, 26% (95% CI 22-31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70-336) compared with previous years. Systematic testing identified 40% (95% CI 35-46) of residents as positive for SARS-CoV-2, and of these 43% (95% CI 34-52) were asymptomatic and 18% (95% CI 11-24) had only atypical symptoms; 4% (95% CI -1 to 9) of asymptomatic staff also tested positive.

CONCLUSIONS

The SARS-CoV-2 outbreak in four UK nursing homes was associated with very high infection and mortality rates. Many residents developed either atypical or had no discernible symptoms. A number of asymptomatic staff members also tested positive, suggesting a role for regular screening of both residents and staff in mitigating future outbreaks.

Overweight, obesity and adiposity in survivors of childhood brain tumours: a systematic review and meta-analysis

Survivors of childhood brain tumours (SCBT) have increased cardiometabolic risks, but the determinants of these risks are unclear. This systematic review aims to compare the prevalence of overweight and obesity as well as adiposity measures between SCBT and non-cancer controls. The PubMed, EMBASE, MEDLINE, CINAHL and the Cochrane Library databases were searched. The primary outcomes were the prevalence of overweight and obesity based on body mass index. The secondary outcomes were adiposity measures including percent fat mass, waist-to-hip and waist-to-height ratios. Forty-one studies were included in the meta-analysis. The prevalence of overweight and obesity combined was similar between overall SCBT, SCBT excluding craniopharyngioma and non-cancer controls (42.6%, 95% CI 30.1-55.1 vs. 31.7%, 95% CI 20.4-43.0 vs. 40.4%, 95% CI 34.0-46.8). We also found that SCBT have higher percent fat mass (mean difference 4.1%, 95% CI 2.0-6.1), waist-to-hip ratio (mean difference 0.07, 95% CI 0.02-0.13) and waist-to-height ratio (mean difference 0.06, 95% CI 0.01-0.10) than non-cancer controls. We conclude that SCBT have similar overweight and obesity distribution but higher adiposity than non-cancer controls. More studies were needed to explore the determinants of adiposity and its contribution to cardiometabolic outcomes in SCBT.

Supporting decisions to increase the safe discharge of children with febrile illness from the emergency department: a systematic review and meta-analysis

BACKGROUND

Despite fewer serious infections presenting to the children's emergency department (ED), hospital admissions of children with febrile illness have increased. We review evidence for the use of decision rules to increase the safe discharge of these children from the ED.

METHODS

A systematic review of prospective studies of decision rules for the discharge of children with febrile illness, and prediction rules for the diagnosis of serious infections in children presenting to ED. We reviewed the MEDLINE database, Cochrane Library and hand searched the bibliographies of related studies. The search was limited to the English language.

RESULTS

Thirty-three studies were identified. Fourteen reported low-risk criteria to rule out serious bacterial infection (SBI) in infants less than 3 months of age. In this group, clinical tools such as the Rochester and Philadelphia criteria support the safe discharge of low-risk infants without empirical antibiotics. Seventeen studies reported prediction rules in older children, though only four included children over 3 years. Two impact studies based upon multivariable prediction models failed to demonstrate any impact on rates of discharge from ED.

CONCLUSIONS

The use of clinical prediction models can improve discrimination between serious and self-limiting infections in children. The application of low-risk thresholds may help to rule out serious infections and discharge children from the ED without empirical antibiotics. A growing evidence base for prediction rules has so far failed to translate into validated rules to aid decision-making. Future work should evaluate decision rules in well designed impact studies, focusing on the need for hospital admission and antibiotic therapy.

An unusual transmission event of Neisseria meningitidis serogroup W135 type 2a in a healthcare setting, England, 2012

We report an outbreak of Neisseria meningitidis serogroup W135, associated with a transient transmission event between asymptomatic individuals in a healthcare setting. Two elderly persons subsequently developed invasive meningococcal disease. The duration and type of close contact for those directly involved in the probable transmission incident would not have warranted chemoprophylaxis according to current guidelines. Meningococcal infection in older persons usually presents with pneumonia rather than meningitis or septicaemia with purpura.

Open-label, randomised, parallel-group, multicentre study to evaluate the safety, tolerability and immunogenicity of an AS03(B)/oil-in-water emulsion-adjuvanted (AS03(B)) split-virion versus non-adjuvanted whole-virion H1N1 influenza vaccine in UK children 6 months to 12 years of age

OBJECTIVE

To evaluate the safety, tolerability and immunogenicity of an AS03(B)/oil-in-water emulsion-adjuvanted (AS03(B)) split-virion versus non-adjuvanted whole-virion H1N1 influenza vaccine in UK children aged 6 months to 12 years.

DESIGN

Multicentre, randomised, head-to-head, open-label trial.

SETTING

Five UK sites (Oxford, Bristol, Southampton, Exeter and London).

PARTICIPANTS

Children aged 6 months to < 13 years, for whom a parent or guardian had provided written informed consent and who were able to comply with study procedures, were eligible for inclusion.

INTERVENTIONS

A tocopherol/oil-in-water emulsion-adjuvanted (AS03(B)) egg culture-derived split-virion H1N1 vaccine and a non-adjuvanted cell culture-derived whole-virion vaccine, given as a two-dose schedule, 21 days apart, were compared. Participants were grouped into those aged 6 months to < 3 years (younger group) and 3 years to < 13 years of age (older group) and were randomised by study investigators (1 : 1 ratio) to receive one of the two vaccines. Vaccines were administered by intramuscular injection (deltoid or anterior-lateral thigh, depending on age and muscle bulk). Local reactions and systemic symptoms were collected for 1 week post immunisation, and serum was collected at baseline and after the second dose. To assess safety and tolerability, parents or guardians recorded the following information in diary cards from days 0-7 post vaccination: axillary temperature, injection site reactions, solicited and unsolicited systemic symptoms, and medications.

MAIN OUTCOME MEASURE

Comparison between vaccines of the percentage of participants demonstrating seroconversion by microneutralisation assay.

RESULTS

Among 937 children receiving vaccine, per-protocol seroconversion rates were higher after the AS03(B)-adjuvanted vaccine than after the whole-virion vaccine (98.2% vs 80.1% in children < 3 years, 99.1% vs 95.9% among those aged 3-12 years), as were severe local reactions (3.6% vs 0.0% in those under 5 years, 7.8% vs 1.1% in those aged 5-12 years), irritability in children < 5 years (46.7% vs 32.0%), and muscle pain in older children (28.9% vs 13.2%). The second dose of the adjuvanted vaccine was more reactogenic than the first, especially for fever > 38.0°C in those under 5 years of age (8.9% vs 22.4%).

CONCLUSION

The adjuvanted vaccine, although reactogenic, was more immunogenic, especially in younger children, indicating the potential for improved immunogenicity of influenza vaccines in this age group.

TRIAL REGISTRATION NUMBER

ISRCTN89141709.

Safety and immunogenicity of AS03B adjuvanted split virion versus non-adjuvanted whole virion H1N1 influenza vaccine in UK children aged 6 months-12 years: open label, randomised, parallel group, multicentre study

OBJECTIVES

To compare the safety, reactogenicity, and immunogenicity of an adjuvanted split virion H1N1 vaccine and a non-adjuvanted whole virion vaccine used in the pandemic immunisation programme in the United Kingdom.

DESIGN

Open label, randomised, parallel group, phase II study.

SETTING

Five UK centres (Oxford, Southampton, Bristol, Exeter, and London).

PARTICIPANTS

Children aged 6 months to less than 13 years for whom a parent or guardian had provided written informed consent and who were able to comply with study procedures were eligible. Those with laboratory confirmed pandemic H1N1 influenza or clinically diagnosed disease meriting antiviral treatment, allergy to egg or any other vaccine components, or coagulation defects, or who were severely immunocompromised or had recently received blood products were excluded. Children were grouped by age: 6 months-<3 years (younger group) and 3-<13 years (older group). Recruitment was by media advertising and direct mailing. Recruitment visits were attended by 949 participants, of whom 943 were enrolled and 937 included in the per protocol analysis.

INTERVENTIONS

Participants were randomised 1:1 to receive AS03(B) (tocopherol based oil in water emulsion) adjuvanted split virion vaccine derived from egg culture or non-adjuvanted whole virion vaccine derived from cell culture. Both were given as two doses 21 days apart. Reactogenicity data were collected for one week after immunisation by diary card. Serum samples were collected at baseline and after the second dose.

MAIN OUTCOME MEASURES

Primary reactogenicity end points were frequency and severity of fever, tenderness, swelling, and erythema after vaccination. Immunogenicity was measured by microneutralisation and haemagglutination inhibition assays. The primary immunogenicity objective was a comparison between vaccines of the percentage of participants showing seroconversion by the microneutralisation assay (fourfold rise to a titre of >or=1:40 from before vaccination to three weeks after the second dose).

RESULTS

Seroconversion rates were higher after the adjuvanted split virion vaccine than after the whole virion vaccine, most notably in the youngest children (163 of 166 participants with paired serum samples (98.2%, 95% confidence interval 94.8% to 99.6%) v 157 of 196 (80.1%, 73.8% to 85.5%), P<0.001) in children under 3 years and 226 of 228 (99.1%, 96.9% to 99.9%) v 95.9%, 92.4% to 98.1%, P=0.03) in those over 3 years). The adjuvanted split virion vaccine was more reactogenic than the whole virion vaccine, with more frequent systemic reactions and severe local reactions in children aged over 5 years after dose one (13 (7.2%, 3.9% to 12%) v 2 (1.1%, 0.1% to 3.9%), P<0.001) and dose two (15 (8.5%, 4.8% to 13.7%) v 2 (1.1%, 0.1% to 4.1%), P<0.002) and after dose two in those under 5 years (15 (5.9%, 3.3% to 9.6%) v 0 (0.0%, 0% to 1.4%), P<0.001). Dose two of the adjuvanted split virion vaccine was more reactogenic than dose one, especially for fever >or=38 masculineC in those aged under 5 (24 (8.9%, 5.8% to 12.9%) v 57 (22.4%, 17.5% to 28.1%), P<0.001).

CONCLUSIONS

In this first direct comparison of an AS03(B) adjuvanted split virion versus whole virion non-adjuvanted H1N1 vaccine, the adjuvanted vaccine, while more reactogenic, was more immunogenic and, importantly, achieved high seroconversion rates in children aged less than 3 years. This indicates the potential for improved immunogenicity of influenza vaccines in this age group.

TRIAL REGISTRATION

Clinical trials.gov NCT00980850; ISRCTN89141709.

Haemophilus influenzae serotype b conjugate vaccine failure in twelve countries with established national childhood immunization programmes

The present study describes the clinical and immunological features of children with Hib vaccine failure, who were identified through national surveillance between 1996 and 2001 in Europe, Israel and Australia. True vaccine failure was defined as invasive Hib disease occurring ≥2 weeks after one dose, given after the first birthday, or ≥1 week after ≥2 doses, given at <1 year of age. Of the 423 cases (representing 0.2 cases per 100,000 child-years at risk) reported, 330 (78%) had received three doses in the first year of life and developed disease at a median age of 28 months. Of the remaining 93, 48 had received two doses in infancy, 34 had received four doses including a booster, and 11 had received a single dose after 12 months of age. These children developed disease at a median age of 12, 33 and 71 months, respectively. In total, 47 out of 258 children (18%) with available information had an underlying medical problem (including prematurity) and 53 out of 161 (33%) had immunoglobulin deficiency. Convalescent Hib antibody concentrations were above the putative protective concentration of 1.0 mg/L in 147/194 (76%) children; low concentrations were associated with both the presence of an underlying medical problem and young age at the time of Hib disease. Almost all children who received an additional vaccine dose developed antibodies at protective concentrations. Thus, Hib vaccine failure is rare, but can occur with any immunization schedule. Children with Hib vaccine failure should have immunoglobulin and convalescent Hib antibody concentrations measured after infection and receive additional vaccination, if required.

Fall in Haemophilus influenzae serotype b (Hib) disease following implementation of a booster campaign

OBJECTIVE

To assess the impact of a Hib vaccination booster campaign targeting children aged 6 months to 4 years between May and September 2003, following a nationwide increase in the number of invasive Haemophilus influenzae serotype b (Hib) cases in all age groups after 1999.

DESIGN

The Health Protection Agency Centre for Infections prospectively monitors all cases of H influenzae disease in England and Wales and collects data from primary care trusts (PCTs) on coverage for vaccines in the childhood programme.

POPULATION

Adults and children in England and Wales (January 1991 to December 2006) RESULTS: Data on vaccine coverage during the Hib booster campaign were available for 288/303 (95%) PCTs in England and revealed coverage of 71.8% for the 6-12-month age group and 63.2% for the 13-48-month age group. The Hib booster campaign resulted in a dramatic reduction in cases within 12 months in the age groups targeted for the booster. This decline was followed by a reduction in the number of cases reported among older children and adults. Since the campaign, however, there has been an increase in the number of cases reported among 1-3-year-old children (13 cases in 2004, 26 cases in 2005 and 32 cases in 2006), primarily in children who were too young to be vaccinated in the booster campaign. This group of children will be targeted in the pre-school catch-up programme that began in September 2007.

CONCLUSIONS

The Hib booster campaign has helped to re-establish herd immunity in the UK. The increase in Hib disease among toddlers after 2004 supports the decision to introduce routine boosting for Hib at 12 months of age.

Changes in ascertainment of Hib and its influence on the estimation of disease incidence in the United Kingdom

Enhanced surveillance for Hib infection, initially covering Wales and five English regions, began in 1990 and in 1995 was extended to the whole of England and Wales. To determine whether changes in the ascertainment of Haemophilus influenzae may have affected estimates of Hib disease incidence, data from January 1990 to December 2003 were analysed. A total of 8887 and 4020 (45%) cases of H. influenzae and Hib respectively were reported. The proportion of isolates that were serotyped increased over time, and therefore reported incidence may have underestimated the true incidence in the early years of the study. Adjusting for this under-ascertainment, the incidence in children aged <5 years declined from a peak of 28.3/100,000 in 1991 to 0.97/100,000 in 1998 and increased to 3.8/100,000 in 2003. Following the implementation of universal vaccination a dramatic decline in the true incidence of invasive Hib disease occurred. The observation of the subsequent resurgence was real but the highest incidence reached was 85% below the corrected incidence in the pre-vaccine era. Continued high-quality surveillance is needed in order to accurately monitor and detect changes in disease incidence.

Trends in imported childhood malaria in the UK: 1999-2003

OBJECTIVE

To describe the epidemiology of imported malaria in children in the UK.

METHODS

Surveillance data on children with imported malaria, collected through an enhanced surveillance network set up by the Malaria Reference Laboratory (London, UK), diagnosed between January 1999 and December 2003 were analysed.

RESULTS

Over the 5-year study period, 9238 cases were reported to the Malaria Reference Laboratory, and children accounted for 1456 (14.8%) cases. The number of imported paediatric malaria cases fell from 326 in 1999 to 241 in 2003. Malarial infection occurred in children of all ages and the number of patients increased gradually with age. Visiting family and relatives was the most common reason for travel (59.5%), with only 7.2% travelling to an area endemic to malaria on holiday. Most infections (88.4%) were acquired in Africa, and mainly in Nigeria (49.7%). Plasmodium falciparum was responsible for 81.7% of all cases, followed by P. vivax (11.1%). The number of both P. falciparum and P. vivax cases fell gradually from 262 and 45 cases in 1999 to 196 and 20 cases in 2003, respectively. Malaria prophylaxis was taken by 39% of 500 children with malaria who had travelled to a country endemic to malaria. The proportion of children with malaria who had taken malaria prophylaxis decreased steadily from 53% in 1999 to 29% in 2003. Two (0.14%) children died compared with 62 (0.76%) adults over the 5-year study period (p = 0.007).

CONCLUSIONS

Although the incidence of malaria has started to decline, a considerable number of children are still diagnosed with malaria in the UK. In addition, the proportion of children with malaria who had taken malaria prophylaxis is falling. Although it is reassuring to note the low mortality, there is an urgent need to improve preventive measures among families travelling to high-risk countries.

Presentation of vitamin D deficiency

AIMS

To describe the various ways in which vitamin D deficiency presents in children in selected districts of London and to identify which factors, if any, determine the mode of presentation.

METHODS

Retrospective review of patients presenting to Newham General, Royal London, Great Ormond Street, and King's College Hospitals between 1996 and 2001 with either hypocalcaemia or rickets caused by vitamin D deficiency. Children with plasma 25-hydroxyvitamin D levels <25 nmol/l (10 ng/ml) were considered to have vitamin D deficiency.

RESULTS

Sixty five children, mostly from Black or Asian ethnic minority groups, were identified, 29 of whom had hypocalcaemic symptoms. Seventeen of these had no radiological evidence of rickets. The remainder (48 children) had radiological evidence of rickets with or without clinical signs. Symptoms and signs reverted to normal in all cases with vitamin D supplementation. All children who presented with symptomatic hypocalcaemia were aged either <3 or >10 years. There was a strong correlation between age at presentation and population growth velocity reference data.

CONCLUSIONS

Rickets remains a problem in the UK especially in "at risk" ethnic minority groups. Symptomatic hypocalcaemia is an important, but under-recognised presenting feature. Growth rate is likely to be an important factor in determining the mode of presentation. Unexplained hypocalcaemia should be attributed to vitamin D deficiency in "at risk" ethnic minority groups until proved otherwise.

Bacteraemia due to Staphylococcus aureus

AIMS

To describe the clinical features and outcome of bacteraemia due to Staphylococcus aureus in children admitted to a rural Kenyan hospital.

METHODS

Retrospective case review of all children with a positive blood culture for S aureus admitted to Kilifi District Hospital, Kenya, between January 1996 and December 2001.

RESULTS

Ninety seven children (median age 17 months, range 1 day to 12 years; 46 male) with bacteraemia due to S aureus were identified, accounting for 5% of all positive blood cultures; 10 were considered to be nosocomially acquired. A focus that was clinically consistent with staphylococcal infection was identified in 52 cases; of these, 88% had multiple foci. Children with a focus were likely to be older, present later, and have a longer duration of hospital stay. Most children in this group (90%) received intravenous cloxacillin on admission in contrast to none of those without a focus. In the former group, mortality was only 6% compared to 47% among those without a focus; 10/13 neonates without an apparent staphylococcal focus died compared to none of the 11 with a focus. Eight of the 10 neonates in the former group died within 48 hours of admission, before empirical antibiotics could be changed to include cloxacillin.

CONCLUSIONS

Children most at risk of death associated with bacteraemia due to S aureus are least likely to have clinical features traditionally associated with this infection.

Increasing antibiotic resistance among urinary tract isolates

A five year retrospective study was performed to identify organisms isolated from the urinary tract of 2815 children in the community and 1314 children with underlying renal problems and their antimicrobial susceptibilities. Isolates from children in the latter group were generally more resistant to commonly used antibiotics. In particular, up to a third of E coli isolates from children in the community and almost two thirds of E coli isolates from children with underlying renal disease may be resistant to trimethoprim.

Low back pain at presentation in a newly diagnosed diabetic

Insulin dependent diabetes mellitus predisposes to a range of different and unusual infections, including epidural and psoas abscesses. However, they occur mainly in adults with longstanding diabetes. We report the case of a 12 year old boy who presented with diabetic ketoacidosis and low back pain, and was subsequently diagnosed with both a left psoas abscess and an extensive thoracolumbar spinal epidural abscess measuring 20 cm in length. This case report highlights the need to maintain a high index of suspicion for epidural abscesses in children presenting with fever and localised back pain. Early diagnosis with appropriate imaging and aggressive management can prevent development of permanent neurological damage as was the case in our patient.

Septicaemia due to glucose non-fermenting, gram-negative bacilli other than Pseudomonas aeruginosa in children

Bloodstream infections due to non-fermenting Gram-negative bacilli other than Pseudomonas aeruginosa (NF-GNB) are uncommon in children but their incidence is reported to be increasing. The aim of this study was to determine the characteristics of such infections in children in a London teaching hospital. All paediatric patients with positive NF-GNB blood cultures and clinical evidence of sepsis between July 1995 and June 2000 were included in the study. A total of 10278 blood cultures was performed, of which 356 (3.5%) represented clinically significant episodes of bacteraemia. Of these, 12 (0.1%) were due to NF-GNB. Nine of the 12 (75%) patients were receiving haemodialysis for end-stage renal failure (ESRF). Only one patient was receiving immunosuppressive therapy and none was neutropenic or had any malignancy. An intravascular catheter was identified as the focus of infection in all 12 cases. Stenotrophomonas maltophilia was the most common organism isolated (67%). Six patients were successfully treated with antibiotics alone. Four others received antibiotics, but also required line removal, and two patients responded to line removal without the need for antibiotics.

CONCLUSION

An association was found between ESRF and NF-GNB infections, possibly related to the requirement for long-term catheters for dialysis. Antibiotic treatment alone was only successful in half the cases of catheter-related NF-GNB septicaemia, while removal of the infected catheter ensured complete cure in the cases where antibiotic treatment alone did not suffice.

Measuring plasma paracetamol concentrations in all patients with drug overdose or altered consciousness: does it change outcome?

OBJECTIVE

To assess whether measuring plasma paracetamol concentrations in all patients with drug overdose or collapse (altered consciousness) changes outcome.

METHOD

A retrospective survey was performed of all patients attending the Accident and Emergency Department at Guy's Hospital, London over a 12 month period who had plasma paracetamol concentrations measured (it is hospital policy that patients presenting after any drug overdose, or with a collapse/altered consciousness have a plasma paracetamol concentration).

RESULTS

A total of 440 patients were identified who had plasma paracetamol concentrations measured, of whom 411 were eligible for the study. Altogether 115 patients presented after a collapse and paracetamol was detected in four of these. A total of 296 patients presented after a drug overdose-136 denied overdose with a paracetamol containing product and paracetamol was not detected in any of these 136 cases. Of the remaining 160 patients who gave a positive history for overdose with paracetamol, 122 presented within 24 hours and 94 had detectable paracetamol values with 16 cases above the treatment line, 12 presented more than 24 hours after ingestion, and 26 presented with a staggered overdose. One patient died as a result of paracetamol overdose.

CONCLUSIONS

This is the first study in the United Kingdom to evaluate the clinical value of routine paracetamol levels in patients presenting to the emergency department after any overdose or a collapse. Taking blood samples for plasma paracetamol estimation in patients who deny taking paracetamol is of little clinical value. However, there is the potential for missing significant paracetamol poisoning in patients presenting with collapse and so screening with a plasma paracetamol concentration is clinically justified in these patients. Such an approach can only be justified in a country in which paracetamol poisoning is prevalent, such as the United Kingdom.

Recent developments in staphylococcal scalded skin syndrome

Staphylococcal scalded skin syndrome describes a spectrum of superficial blistering skin disorders caused by the exfoliative toxins of Staphylococcus aureus. In its severe form, the exfoliation can spread to cover the entire body surface area. Two S. aureus exfoliative toxin serotypes affecting humans have been identified, but their purpose and mechanism of action have remained elusive. Based on their interaction with human and mouse epidermis, their three-dimensional structure and site-directed mutagenesis studies, it is speculated that they act as atypical serine proteases, and desmoglein-1 has now been identified as the specific epidermal substrate. Recent studies also suggest that the toxins may have a unique superantigenic activity. Clinically, new rapid diagnostic tests have been developed, including one that is able to detect the toxins directly from serum. With early diagnosis and appropriate management, mortality in children remains low and long-term complications are rare because the lesions are superficial and heal rapidly without scarring. In adults, however, the condition carries a mortality of almost 60% despite aggressive treatment, usually because of serious underlying illness. The recent developments in our understanding of the exfoliative toxins should lead to new and improved diagnostic and therapeutic strategies, including the use of specific antixoxins to prevent exfoliation.

Development and evaluation of detection systems for staphylococcal exfoliative toxin A responsible for scalded-skin syndrome

Staphylococcal scalded-skin syndrome is usually diagnosed clinically by its characteristic exfoliating rash. Isolation of Staphylococcus aureus from the patient further supports the diagnosis. Several detection systems have been developed to determine whether the isolated strain produces exfoliative toxin, but none are routinely available in hospital laboratories. In a novel approach, we used computer models to predict the structure of the exfoliative toxins based on other serine proteases and to identify surface epitopes for the production of antibodies that specifically bound the exfoliative toxin A (ETA) serotype. Several rapid immunologically based diagnostic tests for ETA were developed with these antibodies and compared with existing systems. Our results showed that Western blot analysis using these antibodies was in complete correlation with PCR, which has been validated against the "gold standard" mouse model. On the other hand, the double-antibody enzyme-linked immunosorbent assay (ELISA) and Ouchterlony immunodiffusion assay gave unacceptably high false-positive results due to interference by staphylococcal protein A. This problem was successfully overcome by the development of a F(ab')(2) fragment ELISA, which was rapid and reproducible and was as sensitive and specific as PCR and Western blot analysis. The F(ab')(2) fragment ELISA is superior to existing diagnostic systems because it is quantitative, which may be related to the severity of the condition, and can detect amounts of exfoliative toxin in the picogram range directly from serum. This is the first detection system with the potential to confirm the diagnosis of staphylococcal scalded-skin syndrome from a routine blood test within 3 h of presentation.

Pulmonary echinococcosis with chest wall involvement in a patient with no apparent risk factors

Pulmonary hydatid disease is rare in the U.K., and chest wall involvement has to our knowledge not previously been described in this country. We report the case of a 72-year-old man who was found to have a left upper lobe opacity on his chest radiograph. He declined further investigation at the time, but 2 years later developed a palpable mass over his left lateral chest wall. Fine-needle aspiration-biopsy of this mass revealed the diagnosis of pulmonary hydatid disease. Despite thorough questioning, no risk factor could be identified for the development of the disease. Hydatid disease should be remembered as a rare cause of mass lesions identified on chest radiographs even in non-endemic regions. Spread to the chest wall may mimic malignancy.

Non responding pneumonia with skin lesions

Sweet's syndrome (acute febrile neutrophilic dermatitis) is characterised by classical skin lesions accompanied by fever and malaise. Systemic involvement may be present and lung involvement in Sweet's syndrome has been reported in the form of bilateral pulmonary infiltrates, bronchiolitis obliterans organising pneumonia and pleural effusion. There are dense papillary neutrophilic infiltrates on histopathology. We present a case of Sweets' syndrome with left lower lobe consolidation and persistent fever which was non-responsive to antibiotics but showed clinical improvement with clearing of radiological opacities on oral steroid therapy.

Takayasu disease masquarading as interruption of the aortic arch in a 2-year-old child

Takayasu disease is a chronic, progressive inflammatory vasculitis of large and medium-sized vessels, which commonly presents in adulthood. This case report describes a 2 year old girl who presented with acute heart failure and complete occlusion of the aortic arch and was subsequently diagnosed with Takayasu disease. As far as we can determine, this is the first report of such an acute and atypical presentation of Takayasu disease at such a young age.

Female genital mutilation: analysis of the first twelve months of a Southeast London specialist clinic

OBJECTIVES

To analyse the sources and reasons for referral of women who have undergone genital mutilation to a recently established specialist clinic, and to determine the consequences of the genital mutilation procedure.

DESIGN

Retrospective descriptive case series.

SETTING

The maternity units of Guy's and St. Thomas's Hospital, London.

POPULATION

One hundred and sixteen women attending the clinic over a one-year period.

MAIN OUTCOME MEASURES

(1) sources and reasons for referral to the specialist clinic; (2) characteristics of the women attending the clinic; (3) acute and chronic complications of the genital mutilation procedure; (4) attitudes towards female genital mutilation.

RESULTS

Complete case records were available for 108 women. Of the 86 women who could remember the procedure, 78% were performed by a medically unqualified person, usually at home (71%), at a median age of seven years. Acute and chronic complications were each present in 86% of women with Type III genital mutilation. Most women (82%) were referred by their midwife because they were pregnant, of whom 48% were primigravid. Eighteen non-pregnant women also attended the clinic to request either defibulation or for advice. None of the 89 pregnant women requested re-infibulation after delivery, but almost 6% were seriously considering having their daughter undergo genital mutilation outside the United Kingdom. In addition, fewer than 10% of the women refused to continue the tradition of female genital mutilation.

CONCLUSIONS

During its first year, the recently established African Well Woman Clinic has provided specialist care for 116 women with genital mutilation. Such women may attend with a variety of common medical or psychiatric conditions and often do not volunteer that they have undergone the procedure. Doctors and midwives in particular, should enquire specifically about genital mutilation when caring for women from high risk countries, and offer the services of specialist clinics for female genital mutilation.

Staphylococcal scalded skin syndrome: exfoliative toxin A (ETA) induces serine protease activity when combined with A431 cells

Staphylococcal scalded skin syndrome is the term used for a spectrum of primarily neonatal blistering skin diseases caused by the exfoliative toxins, ETA and ETB, of Staphylococcus aureus. Despite 25 y of research, the toxins' mechanism of action is still poorly understood, although evidence suggests that they may act as serine proteases. In this study, 0.1 mg purified ETA isolated from a baby with pemphigus neonatorum was incubated with A431 cells (a human squamous cell line) at 37 degrees C for 8, 24 and 48 h and the supernatant tested for protease activity using azocasein as a non-specific substrate. Phosphate-buffered saline was also incubated as negative control. Incubation of ETA with A431 cells for 48 h resulted in a four-fold increase in supernatant azocaseinolytic activity compared with buffer and cells, ETA alone and buffer alone (p < 0.001). Furthermore, this proteolytic activity was inhibited by PMSF (p < 0.001), a specific serine protease inhibitor. These results provide further evidence for the role of the exfoliative toxins as serine proteases. Furthermore, the A431 cell assay provides a simpler, quicker, cheaper and more acceptable alternative to neonatal mouse epidermis to study the mechanism of action of the exfoliative toxins.

Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staphylococcal scalded-skin syndrome

The exfoliative (epidermolytic) toxins of Staphylococcus aureus are the causative agents of the staphylococcal scalded-skin syndrome (SSSS), a blistering skin disorder that predominantly affects children. Clinical features of SSSS vary along a spectrum, ranging from a few localized blisters to generalized exfoliation covering almost the entire body. The toxins act specifically at the zona granulosa of the epidermis to produce the characteristic exfoliation, although the mechanism by which this is achieved is still poorly understood. Despite the availability of antibiotics, SSSS carries a significant mortality rate, particularly among neonates with secondary complications of epidermal loss and among adults with underlying diseases. The aim of this article is to provide a comprehensive review of the literature spanning more than a century and to cover all aspects of the disease. The epidemiology, clinical features, potential complications, risk factors, susceptibility, diagnosis, differential diagnoses, investigations currently available, treatment options, and preventive measures are all discussed in detail. Recent crystallographic data on the toxins has provided us with a clearer and more defined approach to studying the disease. Understanding their mode of action has important implications in future treatment and prevention of SSSS and other diseases, and knowledge of their specific site of action may provide a useful tool for physiologists, dermatologists, and pharmacologists.

Neonatal Pseudomonas putida infection presenting as staphylococcal scalded skin syndrome

A case of neonatal Pseudomonas putida sepsis presenting as staphylococcal scalded skin syndrome is described. Staphylococcal scalded skin syndrome is a clinical term used for a spectrum of primarily neonatal blistering skin disorders caused by the exfoliative toxins of Staphylococcus aureus. The disease typically begins with general erythema and fever, followed by the formation of large fluid-filled bullae that coalesce and rupture on slightest pressure to leave extensive areas of denuded skin. The 9-day-old male infant described presented with a generalised non-tender, macular, erythematous rash that later developed into large, flaccid, clear fluid-filled bullae to leave extensive erythematous, weeping, and denuded areas covering over 90% of the total body surface. Despite aggressive antibiotic and symptomatic treatment, he died 11 days after admission. While Pseudomonas infections may present with vesico-bullous eruptions, this is believed to be the first case of neonatal Pseudomonas putida sepsis presenting as staphylococcal scalded skin syndrome.

The management of established postherpetic neuralgia: a comparison of the quality and content of traditional vs. systematic reviews

In the face of an exponential increase in published biomedical studies, dermatologists frequently turn to review articles in order to keep abreast of important developments in the treatment of skin diseases. Traditional review articles have recently been criticized on the basis of their incompleteness and susceptibility to bias. Such biases can be minimized by employing a systematic approach to gathering, combining and interpreting the evidence of treatment efficacy. Using eight predetermined quality criteria, we compared the quality of 10 traditional review with one systematic review of treatments for postherpetic neuralgia, which were identified from the Medline database for 1992-96. None of the 10 traditional review articles satisfied all eight criteria: one satisfied five, two satisfied four and the rest satisfied two or fewer criteria. There was a wide variation in the recommendations of the authors for the treatment of postherpetic neuralgia, often based on anecdotal evidence and clinical experience. On the other hand, the systematic review fulfilled seven of the eight quality criteria, failing only to discuss future directives. Furthermore, treatment recommendations were made solely on the basis of randomized controlled trials, which are considered to be the gold standard for measuring the benefits of any intervention. The variation in quality and treatment recommendations of traditional reviews is worrying. Systematic reviews should be encouraged in dermatology because they provide a summary of evidence of the effects of dermatological treatments, which has been derived using explicit methods widely accepted within science.

Leprosy in Pakistan: LEPRA elective study

As part of the curriculum, medical students at the United Medical and Dental Schools of Guy's and St Thomas's Hospitals (UMDS), London, are encouraged to spend an elective period of 8 weeks in their final year anywhere in the world, studying any field of medicine they are interested in. Having lived in Tanzania for 10 years, I have had contact with people suffering from leprosy and my interest in leprosy continued after I moved to Europe to continue my education. I therefore decided to use my elective to gain hands-on experience with the disease so that I could understand and appreciate the impact of leprosy in developing countries such as Pakistan.