Tag Archives: viral infections

April 2016 PDF digest

April 2016′s offering ripe for reading over the bank holiday weekend.  Last text box from the 2014 BTS asthma guideline – this time on acute management, FGM and the importance of reporting colleagues who may be involved in the practice, Group A strep infection as a complication of chicken pox and some links to some good CPD sites for you and your patients.

We also welcome Dr Kat Smith this month, paediatric registrar and education fellow at King’s College Hospital, who has kindly volunteered to write monthly articles for the newsletter.  It’s nice to have a fresh pair of eyes on paediatric topics and a fresh nose to the ground so to speak.  Thanks, Kat, for your help.

Do leave comments below.

Invasive Group A Strep (GAS) and chicken pox

With thanks to Dr Kat Smith, education fellow and paediatric registrar at King’s College Hospital who answered my call last month for more writers to help me put together the monthly Paediatric Pearls newsletters.

 

Group A Streptococcal Infection in Chickenpox

 

Chickenpox in children is common and usually follows a mild and self-limiting (if somewhat itchy) course. After an incubation period of 10-21 days the first signs of illness are viral prodrome, mild pyrexia, and the classic cropping vesicular rash; the pyrexia is typically mild (38-39oC) and lasts 3-4 days.

 

In otherwise healthy children the most common complication of chickenpox is secondary bacterial skin infection, typically caused by scratching lesions. Whilst most of these are mild impetigo or localised cellulitis, the increased incidence of group A streptococcal (GAS) colonisation in children (around 10% are asymptomatic carriers in the throat or on skin) makes invasive GAS infection a real concern.

 

Secondary bacterial skin infection

This is characterised by erythema +/- tenderness around lesions. Children may be well in themselves if the infection is superficial; if they become more unwell this raises the suspicion of a more serious or invasive bacterial infection.

 

Serious bacterial superinfection / Invasive GAS infection

Around a third of children admitted to hospital with chickenpox have secondary skin infection, some of whom develop invasive infections such as pneumonia, osteomyelitis and septicaemia. GAS in particular can be associated with more fulminant infectious processes such as necrotising fasciitis and toxic shock syndrome (TSS); both are associated with high mortality and morbidity in children.

Features that should prompt consideration of a serious bacterial superinfection are:

  • A lethargic or unwell-looking child; remember, children with chickenpox are typically uncomfortable but well.
  • Spiking, high-grade pyrexia
  • Pyrexia for longer than 4 days, particularly after initial improvement
  • Diarrhoea or vomiting
  • Soft tissue pain which seems disproportionate to other examination findings (an early sign of necrotising fasciitis)

 

How to prevent bacterial superinfection

Because scratching lesions is the most likely way to allow bacteria to breach the body’s normal defences, the primary aim of prevention is to limit scratching:

  • Keep skin moisturised. Many parents still use calamine lotion but it is worth noting that it becomes ineffective once dry, and traditional emollients (e.g. 50:50) may be more effective.
  • There is evidence that sedating antihistamines offer some benefit; chlorphenamine is licensed for this use.
  • Dress children in smooth, loose, cotton clothing.
  • Keep fingernails trimmed short.
  • There are rare reports of NSAIDs potentially worsening skin infections in chickenpox, so ibuprofen should be used with caution. In practice, it would be unusual for a child to need ibuprofen if receiving regular paracetamol; pain or pyrexia necessitating its use in addition to paracetamol should prompt consideration of serious bacterial superinfection.
  • There is no evidence to support the use of acyclovir in young, immunocompetent children with self-limiting, uncomplicated chickenpox; it does not decrease the incidence of complications.

 

What to do if you suspect bacterial superinfection

  • Otherwise well children with evidence of few, small areas of bacterial superinfection can be managed in the community with oral antibiotics and safety-netting advice.
  • Children with evidence of collection, extensive areas of bacterial superinfection, who are unwell, or have other features consistent with possible serious bacterial superinfection, need urgent referral to secondary care.
  • In secondary care, unwell children with evidence of shock / sepsis need urgent resuscitation and intravenous antibiotic administration; if possible this should include clindamycin, due to its vital role in inhibiting toxin production by GAS.
  • Invasive GAS infection has high mortality, and if suspected there should be a low threshold to involve senior staff, regional PICU services, and in the case of necrotising fasciitis, surgical teams (for early debridement); early use of inotropes and IVIG may also be required.

 

Bibliography

Chickenpox NICE Clinical Knowledge Summary (which I found to be the best resource by far): http://cks.nice.org.uk/chickenpox

Cohen J, Breuer J. Chickenpox treatment. Systematic review 912. BMJ Clinical Evidence.

Papadopoulos, AJ. Chickenpox. emedicineWebMD. www.emedicine.com

 

 References

 Re: “the increased incidence of group A streptococcal (GAS) colonisation in children (around 10% are asymptomatic carriers in the throat or on skin)”

Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics. 2010 Sep;126(3):e557-64

 

Re. “Around a third of children admitted to hospital with chickenpox have secondary skin infection”:

Bovill B, Bannister B. Review of 26 years/ hospital admission for chickenpox in North London. Journal of Infection. 1998;36(suppl1);17-23.

 

Re: “necrotising fasciitis and toxic shock syndrome (TSS); both are associated with high mortality and morbidity in children.” AND “IVIG may also be required.”

Chuang YY, Huang YC, Lin TY. Toxic shock syndrome in children: epidemiology, pathogenesis, and management. Paediatr Drugs. 2005;7(1):11-25.

Re. “There is evidence that sedating antihistamines offer some benefit”

Tebruegge M, Kuruvilla M, Margarson I. Does the use of calamine or antihistamine provide symptomatic relief from pruritus in children with varicella zoster infection? Archives of Disease in Childhood. 2006:91(12);1035-1036.

 

Re: (continued from above) “chlorphenamine is licensed for this use.”

BNFC, available at: https://www.medicinescomplete.com/mc/bnfc/current/PHP1934-chlorphenamine-maleate.htm?q=chlorphenamine&t=search&ss=text&tot=40&p=1#_hit

 

Re: “if possible this should include clindamycin, due to its vital role in inhibiting toxin production by GAS.” (as well as having it drilled in to us by the microbiologists at St Thomas’):

http://emedicine.medscape.com/article/228936-medication#2

March 2016 uploaded

March 2016: a few odds and ends on asthma this month and assessing a child in an acute exacerbation, Childline survey, Meningococcus W and paediatric neck lumps.  Do leave comments below:

September 2015 uploaded

September 2015: ENT feature this month – quinsy, Part 2 of the NICE guideline summary on bronchiolitis, information about a domestic violence campaign, self help books for children and a round up of topics to get you started if you are new to paediatric practice.  Do leave comments below.

August 2015

August 2015: ENT feature this month – acute mastoiditis, PVL producing staph from the dermatology team, Henoch Schonlein purpura – long term management and follow up and Part 1 of the NICE guideline summary on bronchiolitis.  Just in time for the RSV season….

Do leave comments below:

June 2015 published

Gianotti Crosti this month, updated “Working Together” safeguarding document, epistaxis and malaria.  Also links to a few other useful documents recently uploaded to the Primary Care Guidelines part of the website, with thanks to Redbridge and West Suffolk.  All comments welcome.

March 2015 published

March 2015: the first post of the new ENT feature this month – glue ear, more help with viral exanthems, important safeguarding information on the UK government’s Prevent Strategy, breastfeeding for mums and research in the paediatric ED. 

February 2015 (just)

Have just uploaded February 2015 newsletter – with 4.5 hours of February to go….

NICE on gastro-oesophageal reflux disease, how to recognise speech delay, more viral exanthems, resus cards and information on forthcoming allergy courses.  Do leave comments below:

January 2015, late but useful!

January 2015 newsletter is being published late with apologies.  The newsletter is circulated prior to publication to be checked by my 8 paediatric consultant colleagues and any guest authors.  I neglected to attach the newsletter to my initial email, a fact pointed out to me on the 31st January…..  Now checked and ready to go.

Andrew Lock has put together a really helpful guide to viral exanthems with trustworthy links to proper images, Vicky Agunloye is back this month with an invaluable guide to the healthcare professional’s assessment of a crying baby (and his/her mother).  Tom Waterfield has looked at the usefulness of saline nebs in bronchiolitis, there are some more “do not do” recommendations from NICE and a link to Suffolk’s guideline on managing anaphylaxis and its follow up from primary care.  Do leave comments below:

December 2014 – in time for Christmas

December 2014 : ‘flu vaccination for children, calprotectin, paintballing bruises, eczema and some useful links to atopy downloads.   Do leave comments: