AimEffective treatment of neonatal infection can be life-saving, but is increasingly limited by the development of resistant organisms. Antimicrobial stewardship is therefore important, to optimally ...select antimicrobial treatments that have a targeted spectrum, and suitable duration. This should result in the best clinical outcome and minimise impact on subsequent resistance. We audited the use of antibiotics for episodes of suspected Early (<72 h) and Late onset sepsis (> 72 h) on a local neonatal unit.MethodData was collected prospectively for 68 episodes (66 patients) of antibiotic prescribing in our NICU over a one month period in June 2015. We looked at indications to initiate/change antibiotics, and also choice and duration of antibiotic treatment. We examined the results of blood cultures, and whether cultures were taken before initiating/changing antibiotics.Results61 episodes of suspected Early onset sepsis were noted. All were treated with Benzylpenicillin and Gentamicin (as per local guidelines and national recommendation1) 46/61 (67%) episodes received less than 5 days of antibiotics. 7 episodes of suspected Late onset sepsis were noted. 6/7 (86%) episodes were treated with Flucloxacillin/Gentamicin or Tazocin/Vancomycin as per local guidelines. The most common indications for antibiotics were respiratory distress and temperature instability. 4/7 (57%) episodes had positive growth on blood culture, with antibiotics changed based on the results. 4/7 (57%) episodes received less than 5 days antibiotics. Blood cultures were repeated when antibiotics were changed in all but one episode.ConclusionIndications and choices of antibiotics were almost always in keeping with local guidelines, with appropriate optimisation of antibiotics following review of blood cultures. However, there were several delays in stopping antibiotics, contrary to national guidance.2 Clear documentation of daily antibiotic review should be implemented in order to further improve antibiotic stewardship.ReferencesVergnano S, Menson E, Kennea N, et al. Neonatal infections in England: the NeonIN surveillance network. Arch Dis Child Fetal Neonatal Ed. 2011;96:F9–14National Institute for Health and Clinical Excellence: Antibiotics for early-onset neonatal infection. CG149. London: National Institute for Health and Clinical Excellence, 2012
BackgroundNICE Tuberculosis (TB) guideline 2015 recommends all children, regardless of BCG status, with Mantoux ≥ 5mm induration receive treatment for latent TB once active TB has been excluded. The ...2011 version defines a positive Mantoux as ≥ 6mm (no prior BCG) and ≥ 15mm (prior BCG). NICE 2011 recommends screening of household contacts of all cases of TB compared with the 2015 guideline which recommends screening of contacts of pulmonary TB only.ObjectivesTo establish the impact of the change in NICE recommendations on the number of children assessed and treated for latent TB infection (LTBI) or TB disease in our department.MethodsWe performed a retrospective analysis of all children < 16 years referred for contact tracing, new entrant screening or medical assessment who had a Mantoux between January and December 2014. Nurse assessment was followed by specialist consultant review in all infants ≤ 2 years and children with symptoms or Mantoux ≥ 10mm. Medical notes, Mantoux and BCG status categorised those who would have been treated according to the 2011 and 2015 NICE TB guidelines.Results445 patients were referred, 75 with symptoms, 138 new entrants, 63 non-pulmonary contacts and 169 pulmonary contacts.Of those with symptoms, 5 had positive Mantoux (NICE 2011) compared with 18 (NICE 2015). In this group 0/75 were treated for LTBI and 7/75 for TB disease.Results of patients referred for contact tracing/new entrant screening are shown in Table 1. Two contacts with LTBI and 1 with TB disease (all IGRA positive) would have been missed by the 2011 guideline but identified in 2015.Following NICE 2015 63 non-pulmonary contacts would not have been seen. None of these had LTBI or TB disease. Of the remaining 307 contacts/new entrants 47(15%) had a positive Mantoux of whom 11(4%) had LTBI and 4(1%) TB disease.Abstract G523(P) Table 1Results of Mantoux testing and TB disease status in patients referred for contract tracing or new entrant screening Conclusion37% more children will be investigated and treated for TB infection/disease under the new NICE TB guideline. In a 12 month period in our clinic this represents 33 additional children with 1 extra case of TB disease and 2 cases of LTBI identified.
G254(P) BP measurement in children’s A&E Chakraborty, S; Mohan, P; Hajiyani, N ...
Archives of disease in childhood,
04/2016, Letnik:
101, Številka:
Suppl 1
Journal Article
Recenzirano
AimBlood pressure (BP) is not measured routinely in children at triage, but should be done in a selective group of children. In our busy Children’s ED we have developed a local guideline in response ...to critical incidents where BP was not found to have been measured. We report a retrospective audit on how successfully we followed our local policy and performed BP measurement in population of children.MethodsWe performed a retrospective audit looking at the ED notes over the month of March, 2015 of all children fulfilling the criteria of our guideline who should have had a BP measurement performed at triage. We reviewed the following data: adherence to the guideline compared to the age of the child and indication for the BP measurement.A literature search was also performed to look at data from other hospitals and for any guideline available.Results107 records were reviewed where the patient qualified for a BP measurement according to the guideline. Only 46% had a BP measured. 5% of the children were <1 year old, 42% were 1–5 years old, (in total 47% were children under five where BP measurement can be difficult). A detailed breakdown of the patients according to the clinical indication is shown in Figure 1.Abstract G254(P) Figure 1ConclusionBlood pressure is not performed as a screening tool in the Children’s ED as measuring blood pressure in children can be problematic. An appropriately sized cuff may not be available, the child could be non co-operative and the readings could be falsely high. In most EDs, clear guidance is unavailable for absolute indication of measuring BP in children.We have shown that despite the development of clear guidance on whom to measure BP we only achieve this in less than 50% of cases. This is in a busy children’s ED with fully trained children’s nurses.Measurement of BP is essential in a group of children either as a baseline or as a guide to their care. We therefore recommend that BP should be measured whenever possible in children’s A&E particularly with the presentations mentioned in our guideline.
AimsDKA management is standardised by BSPED. Studying current practice helps identify problems in guideline interpretation enabling education and simplification of updates.MethodsThe Children’s Acute ...Transport Service gets complicated DKA referrals for advice/retrieval from North Thames region, recorded on standard admission forms. Retrospective analysis was done 1st January – 31st December 2014. Population characteristics, current DGH practice (following BSPED 2009) and significance of risk factors for cerebral oedema (Fischer exact test) were studied.ResultsTotal 44 referrals. 37 included as >75% data documented. (Table 1) 12 transferred for cerebral oedema (7), age < 2 years (3), renal failure (2). 2 intubated. No deaths. 18 suspected cerebral oedema- all with low GCS, 6 with headache and 1 bradycardia. 11 improved at DGH : 3 received osmotherapy, 2 decreasing fluids, 4 both, 3 neither. CT Head done in 8 (1 mild cerebral oedema). Practice deviated from guideline in fluid bolus management, delay in start of insulin, hypokalemia management without central access and decreasing fluids for cerebral oedema. (Table 2) 88% received a fluid bolus. 94% with moderate dehydration received 10 ml/kg bolus. 50% received >10 ml/kg for prolonged CRT and tachycardia only. 19% received >10 ml/kg bolus despite estimating <8% dehydration. 11% received >30 ml/kg. 19% delayed start of insulin >2 hrs. Refractory hypokalemia (despite 40 mmol/L delivery) inadequately treated in 3/4. 1 received bicarbonate. 39% decreased fluids for cerebral oedema. Risk factors for cerebral oedema were analysed (Table 3). Admission GCS <=12 has significant association (p = 0.00015).Abstract G446 Table 1Population characteristicsAbstract G446 Table 2Current DGH clinical practiceAbstract G446 Table 3Significance of risk factors for cerebral edemaConclusionPopulation characteristics identified that complicated DKA patients (pH <7.1, age <2years) are at risk of cerebral oedema, electrolyte disturbances, renal failure. Outreach education and guidelines should clarify that fluid boluses should not be guided by delayed CRT (confounded by severe hypocarbia), delays in start of insulin beyond 1 hr should be avoided, emphasise advice on reducing fluid delivery alongwith osmotherapy for cerebral oedema and evaluate options for refractory hypokalemia. Future studies should evaluate evidence justifying risk of CT head in cerebral oedema and whether a 10 ml/kg fluid bolus in the first hour in all severe DKA is a safe standardisation to match clinical practice.
AimsTo measure the outcomes of offering structured aetiological investigation of PCHI in children in line with recommendations from the BAAP/BAPA Guidelines.MethodWe retrospectively applied ...standards, set by the British Association of Audiovestbular Physicians on the aetiological investigation of children with permanent hearing impairment1. Children aged 0–19 were identified from the Audiology department database of a Foundation Trust serving a population of 0.5 million. 152(92%) were invited to attend for assessment, 89(54%) responded and 76(46%) agreed to proceed. The medical records of non-responders were reviewed and 21(26%) had already been investigated or had an established diagnosis/syndrome known to be associated with PHI. All responders were investigated to BAAP standards.Results27(36%) had bilateral mild to moderate HL, 27(36%) severe-profound HL, and 22 (28%) unilateral mild – severe. In 32(42%) children the aetiology was undetermined or investigations were on-going at the time of writing. PCHI was attributable to perinatal events in 20(26%) children. In 7(9%) children PCHI was familial and in a further 7(9%) a mutation of the connexin gene was found. CMV or other infections accounted for 7(9%) and among the remaining children 1 had a deletion of chromosome 22q, 1 PCHI was secondary to chemotherapy and 1 child had a hind-brain abnormality (Figure 1, aetiology of PCHI).Abstract G593(P) Figure 1Aetiology of PCHIConclusionThe structured aetiological investigation of PCHI in children has many benefits not least to answer parent’s question “why is my child deaf”. In addition we have identified previously unsuspected diagnoses such as Connexin 26 mutations and 22q deletion, which is important as these children and their families can receive genetic counselling, and appropriate onward referral.We have also developed local pathways following diagnosis of PCHI.
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide ...evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.
The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups.
There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
‘Covert’ cerebral small vessel disease (ccSVD) is common on neuroimaging in persons without overt neurological manifestations, and increases the risk of future stroke, cognitive impairment, ...dependency, and death. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist with clinical decisions about management of ccSVD, specifically white matter hyperintensities and lacunes, to prevent adverse clinical outcomes. The guidelines were developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We prioritised the clinical outcomes of stroke, cognitive decline or dementia, dependency, death, mobility and mood disorders, and interventions of blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, glucose lowering and conventional treatments for dementia. We systematically reviewed the literature, assessed the evidence, formulated evidence-based recommendations where feasible, and expert consensus statements. We found little direct evidence, mostly of low quality. We recommend patients with ccSVD and hypertension to have their blood pressure well controlled; lower blood pressure targets may reduce ccSVD progression. We do not recommend antiplatelet drugs such as aspirin in ccSVD. We found little evidence on lipid lowering in ccSVD. Smoking cessation is a health priority. We recommend regular exercise which may benefit cognition, and a healthy diet, good sleep habits, avoiding obesity and stress for general health reasons. In ccSVD, we found no evidence for glucose control in the absence of diabetes or for conventional Alzheimer dementia treatments. Randomised controlled trials with clinical endpoints are a priority for ccSVD.
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