Group A Streptococccal Infections in Children - What Has Changed?

At the time of publication, the UK is experienced the effects of an increase in cases of group A streptococcal (GAS) infections in children.  Scarlet Fever cases are more prevalent and there are more cases of invasive infection than in an average year.  Most importantly the number of deaths in children related to GAS infection is high and the associated news coverage has been significant.

When our clinical landscape changes, the question should always be: What has changed and what should I be doing differently?  Let's look at each element of practice around GAS infections and see what has or should have changed.

Recognising the seriously unwell child

The clinical task of recognising the unwell child is actually business as usual.  It remains the case that the vast majority of children who are unwell have uncomplicated upper respiratory tract infections with very low likelihood of developing complications or invasive infection.

The UKHSA has stated that the GAS infections are of normal pathogenicity which in the UK means very low risk of complications or invasive infection.  The number of viral infections circulating has also risen substantially which means that the probability of any one febrile child having GAS is likely to be similar to normal times.

In any case our task of recognising the seriously unwell child remains the same as at any other time.  It is and always has been a complex business which cannot be reduced to a formula.  It is also the case that any febrile child, no matter how well, can go on to develop a serious illness such as sepsis or meningitis.  That has always been true and all the information we are getting suggests that the risk of that happening to a child without signs of invasive infection at the time of assessment remains very small.

Diagnosing Uncomplicated Group A Streptococcal Infection

This remains as problematic as ever.  GAS infection has always been a reasonably common cause of URTI including tonsillitis.  Scarlet fever aside, there is no one clinicial feature with a high predictive value for GAS infection.  Decision tools such as FeverPAIN are misleadingly named because they only moderately separate children into groups with different risks of having GAS.  As the score goes up the likelihood of GAS also goes up but a significant number of children will have GAS infection with a low score.  

Tools such as CENTOR and FeverPAIN were never introduced to help clinicians to treat GAS more often.  Quite the opposite - these tools were developed to reduce antibiotic prescribing in a culture of default antibiotic use for all sore throats.

Throat swabs are often used as a means of identifying who definitely has GAS.  There are two big problems with bacterial throat swabbing though.  The first is that GAS is a normal commensal in throats and can be found even in asymptomatic cases.  The second is that the result takes time.  Due to pressures on microbiology services that time is likely to be longer at the moment.  The usefulness of a swab result two to three days into an illness is therefore questionable.

The current recommendation from the UKHSA is to prescribe antibiotics to children with a FeverPAIN score of 3 or more.  Throat swabs are only recommended for cases of invasive infection, scarlet fever or diagnostic uncertainty.  I have assumed that diagnostic uncertainty cannot refer to being unsure as to whether an URTI/ tonsillitis is viral or bacterial as we can never be certain in any case, regardless of FeverPAIN score.

Antibiotic Choice

This has been very interesting.  The UKHSA continues to recommend Penicillin V as the first choice antibiotic both for uncomplicated URTI/ tonsillitis and for scarlet fever despite the known very low compliance rate.  Pen V tastes very unpleasant and as a result less than half of children will complete a course.  This recommendation to use Pen V has always been based on the low risk posed by GAS infection, balanced against the risk to the population of liberal use of broad spectrum antibiotics.  The continued recommendation to use Pen V as first line implies a continuation of where we were before.  The effect of antibiotics is too small to change to antibiotics with better compliance rates as the harm from using broad spectrum antibiotics is believed to be greater than the benefits.

The element that has changed the most is probably the numbers seeking a medical assessment of their child, anxieties about the dangers of GAS and an increased expectation of antibiotics.  If you're already good at managing all of those things then you are equipped for this moment in time.  If you're still learning how to manage anxieties then this situation will be a great learning opportunity!

What parents often worry about - fever and rashes, are some of the least important factors in recognising serious illness in children.  Fever is not a predictor of serious illness and even a sandpaper rash indicates Scarlet Fever which is still low risk for invasive GAS.

This brings us back to the issue of recognising the unwell child.  That is still the most important task in each assessment, even if the chance of finding a child with invasive infection is small.  Here's a very condensed guide to separating the unwell children into groups.  Note that neither fever nor rash make the shortlist of key features.

The key things that have changed are volume of children presenting and  the level of anxiety in the accompanying adults.  The features of serious illness and the effectiveness of decision tools and antibiotics remain the same as always.

Stay safe.  Hopefully this post becomes redundant soon for all of the right reasons!

Edward Snelson

@sailordoctor

Swabbing decks not throats

COVID Questions No 3 - Should I stop examining children's throats?

As increasing evidence comes out of the countries hit worst by the COVID-19 pandemic, there is growing concern about the number of healthcare workers being affected.  A large number of COVID-19 positive tests in Italy (currently about 10%) have been healthcare workers.

It is important to emphasise that these statistics will inevitably have at least some bias.  Healthcare workers are much more likely to be tested for COVID-19.  It is a concerning figure nevertheless and it is well known that healthcare environments are inherently risky when it comes to acquiring infection.

There are three main ways to avoid getting infection as a healthcare worker.  The first is to avoid patient contact where possible.  The second is to use appropriate personal protective equipment as per guidance.  The third is to minimise the risk of the clinical encounter.

Over the past few days, there has been a growing discussion amongst frontline clinicians about a radical cultural change in clinical practice.  We have been asking his question:

Should I stop examining children's throats?

Like any such suggestion, the first time the question was asked out loud was probably in a one-to-one conversation in a closed room after checking that the GMC hadn't bugged the place.  Then, as the question was asked more and more, it became quickly apparent that there was a large proportion of frontline clinicians who felt that this was a sensible move in the current situation.

On 25th March 2020 the RCPCH published guidance stating that in the current situation "the oropharynx of children should only be examined if essential."  Never before in my career have I seen such a change in practice go from whispers between colleagues to official college guidance in such a short period of time.  Well done RCPCH!  For the first time since the introduction of FAOMed, you're ahead of us!

While this move is entirely intended to reduce the risk of clinical contact during the COVID-19 pandemic, clinicians will at the very least have questions.  When something is part of our routine and then taken away from us it will cause anxieties.  As acute clinicians, our intuitive thinking relies on a reasonably consistent approach and in most paediatric encounters, we are used to looking in the throat.  So the question is, is it OK to stop doing that routinely?

Here are a few common questions in response to this radical change.

What if I need to know what the focus of infection is?
Good question.  This has always been a hugely subjective issue.  Even before this pandemic, the majority of clinicians and organisations have been trying to encourage self-care for uncomplicated febrile illness in children.  If a clinical confirmation of infection focus was essential, health care organisations would be getting the message out.  "Never give your child fever medicines without seeing a doctor to check what the problem is."  That's not a thing.
A snotty febrile child has an URTI.  URTI does not exclude other infections nor does it exclude sepsis so the redness of the throat should not reassure us if we think a child has another probable diagnosis such as UTI, LRTI or sepsis.
The important question has always been, "does this child have signs of serious bacterial infection or sepsis?"  If the answer is no then the throat exam won't really change things (see below).  If the answer is yes, you're looking for a source and it probably isn't in the throat.

When might I need to examine the throat?
The necessity for this is probably going to be mainly to look for evidence of a significant pathology such as peri-tonsillar abscess.  I would suggest that such a possibility can be all but excluded clinically if a child is well analgesed and is able to eat or drink.
If you do feel that examining the throat is important to do, you must wear eye protection.

Don’t I need to determine if the child has tonsillitis?
Tonsillitis in children can always be treated symptomatically.  The NICE guidance for treating sore throats attempts to direct the clinician toward cases where a symptom benefit from antibiotics is more likely but does not mandate the use of antibiotic in any uncomplicated URTI/ tonsillitis.  The reason there is no mandate is that there is no evidence that in this era in the UK, antibiotics prevent the rare complications of URTI/tonsillitis.
Regardless of clinical findings, the symptom benefit from antibiotics is poor.  The lack of evidence for significant benefit has led the Children's Hospital Melbourne to recommend no prescription of antibiotics in any case apart from high risk children or signs of complicated URTI.
So if the child is low risk (99.9% of children) and has no signs of complications from the infection, the visualisation of the tonsils is non-essential.

Should I therefore prescribe antibiotics empirically?
In the interests of openness and honesty, I need to say first that the RCPCH does advocate this.  There is a reminder that under the age of three years old, FeverPAIN should not be used.  Over the age of three, it is proposed that in the current climate we prescribe antibiotics as follows.
"If using the feverpain scoring system to decide if antibiotics are indicated (validated in children 3 years and older), we suggest that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an examination seems reasonable. 
Children with a total feverpain score or 4 or 5 should be prescribed antibiotics (we suggest children with a score of 3 or less receive safety netting advice alone)"

I'm going to stick my neck out and suggest that this approach is wrong, for the following reasons:

1. First and foremost, it contradicts the public health approach to containing the COVID-19 pandemic.  People are being told that if they have a fever without signs of something that looks like a serious illness (difficulty breathing, poorly responsive etc.) they should stay at home, self-medicate and not seek a face to face clinical contact.  This is for their benefit, to protect the health service and to reduce the spread of COVID-19.  Lowering a threshold for prescribing antibiotics for sore throat at this time goes against that move.
2. Secondly, the RCPCH has misquoted the NICE guidance.  In their speediness to protect clinicians from unnecessary risk, they have missed a word.  Just the one but it the word from the guidance that frequently goes unnoticed.  That word is consider.  It doesn't say give antibiotics for a FeverPAIN score above 4.  It says consider.  I consider that question every time and in most cases the answer is "The likelihood of benefit from antibiotics does not justify the risks."  

I feel (personal opinion) that since there is no mandate to treat low risk children who have no signs of complications of their URTI/tonsillitis, we should default to not prescribing antibiotics in these cases.  To lower our threshold for prescribing instead of raising it at this time of such a high risk clinical environment feels wrong.  It seems contrary to the need to protect children and their carers from the risks of a visit to a GP or hospital and it feels contrary to the drive to reduce the number of people bringing COVID-19 with them to those places.

Again, huge respect to the RCPCH for cutting through the red tape and rapidly producing guidance to protect healthcare workers.  Whenever something is done in that sort of timeframe, it is likely that detail gets missed.  That's where we come in.  We notice the typos and consider the implications.  We ask questions that deserve answers after the fact in lieu of the consultation period that couldn't happen due to the timescale needed.

Edward Snelosn
@sailordoctor

Should I prescribe antibiotics for a child with otitis media and discharge from eardrum rupture?

The answer to that question is much more complicated than most guidelines will lead you to believe.

The headline statement recommending the use of antibiotics in this scenario has buried the evidence in multiple layers of interpretation.  To get to the truth, we have to look at the lierature ferred to in the decision to make that recommendation.

Guideline writers put in huge amounts of work looking at all the available evidence and then turning that into simple statements.  When these recommendations are truly simple and make sense in clinical practice, we tend to just follow them.  In a recent Twitter poll of over 600 people, this was far from the case.

If over half of clincians would avoid treatment, that suggests that there is something about the recommendation that is misaligned with our front-line work.  When you deconstruct the recommendation, it becomes clear why that is.

First of all though, let’s look at simple otitis media without rupture of the eardrum (tympanic membrane).

Otitis media is a common childhood infection.  It starts off with a cold and then progresses to an infected middle ear.  It is important to be aware that neither ear pain nor a red tympanic membrane is diagnostic of otitis media.

• An inflamed tympanic membrane is a common finding in uncomplicated viral upper respiratory tract infections (URTI).  In such cases the tympanic membrane is red but not bulging.
• Ear pain (otalgia) may be caused by eustachian tube blockage even when there is no middle ear infection.  In these cases the tympanic membrane is typically retracted.
• A painful ear with a red bulging tympanic membrane is the usual presentation of otitis media.

The evidence for antibiotics being effective in the treatment of otitis media is pretty poor.  In a Cochrane review of this subject (1) it is reported that antibiotics have no effect on pain at 24 hrs and that you need to treat 16 children in order to see one of those children having less pain at 2-3 days.  In line with previous discussions re antibiotics, the same review noted that antibiotics had no effect on the rate of complications.  With a similar number of children being made unwell by the antibiotics, it is questionable what their role is at all in uncomplicated otitis media.

Many guidelines list exceptions to this rule.  One that often confuses clinicians is the scenario of the child who presents with a sudden onset of purulent discharge from the ear.  In these circumstances, there is often a recommendation to treat with antibiotics.

So where does this recommendation come from?  Peeling back the layers is quite interesting and what lies beneath the recommendation shows that it is far from a straightforward "must do" for antibiotics in children when the otitis media bursts the tympanic membrane.

Starting with a commonly cited recommendation, the NICE CKS for acute otitis media (2) states "...immediate antibiotic prescription could be considered in children... ...of any age with both AOM and ear discharge..."  The basis for this recommendation is cited as the aforementioned Cochrane Review (1).  This Review states "Antibiotics are most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease in high-income countries, an expectant observational approach seems justified."

The Cochrane Review conclusion itself is based on a paper (3) that looked at the features that made it more likely that antibiotics would have an effect.  In the case of otitis media with otorrhoea, it found that the NNT improved to 3.  That sounds good, so why would most people avoid treating?

The answe is simple.  In the published evidence, the effect of antibiotics was still to do with symptom (mainly pain) improvement.  That is clinicaly important because in many cases pain is resolved when the discharge occurs.  Presumably this is because the pain was due to the stretching of the tympanic membrane rather than due to the inflammation of soft tissues.

If the pain is resolved, the NNT to treat becomes irrelevant.  How can you improve pain that has gone away? Even if there is still some discomfort, if this is controlled by analgesia, isn't that a better option than antibiotics?

Therefore, when a child presents with otorrhoea due to otitis media, rather than faithfully following a recommendation to give antibiotics, we consider the applicability to the child in front of us.  If the pain has gone or is easily controlled with analgesia, we can hold off.  The appearance of the discharge may be alarming but it is often the beginning of the end of the illness.

What about topical antibiotics?  These are also frequently recommended.  In answer to these recommendations I would point out that neither the NICE CKS nor the Cochrane review have recommended antibiotic ear drops for this clinical scenario.  In addition, there is BMJ paper (4) that states "Topical antibiotics are associated with fewer systemic side effects and a lower risk of antibiotic resistance than oral antibiotics, but there is no strong direct evidence to support their use in this condition."

So there you have it - the bottom line:

Once the recommendation to treat is deconstucted, it all makes sense.  In this case, it seems that taking it apart and looking inside reveals why most of us still don't give antibiotics when nasty green stuff starts pouring out of a child's ear.

Edward Snelson
Guideline Deconstrucivist
@sailordoctor

Disclaimer - One time I took a guideline apart and couldn't work out how to put it back together. It's still in my cellar.

References

1. Cochrane Database of Systematic Reviews Antibiotics for acute otitis media in children
2. Acute Otitis Media Clinical Knowledge Summary, NICE
3. Rovers M at al, Antibiotics for acute otitis media: a meta-analysis with individual patient data, The Lancet, Vol 368, Issue 9545, 21–27 October 2006, Pages 1429-1435
4. P Venekamp et al, Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge?, BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i308

I'm On Your Side - How to stop the URTI-antibiotic discussion becoming an ordeal

The antibiotic debate is a big one for several good reasons.  One of those reasons is that times have changed and change can be challenging.  Antibiotics were used liberally by previous generations of clinicians.  We and our patients now find ourselves in a world where antibiotics are being used less often.  This culture change is a major contributor to the conflict that arises due to expectation of antibiotics as a treatment for sore throats and painful ears in young children.

The good news is that if you are prescribing fewer antibiotics then you are part of a growing trend.  In the UK and many other countries, antibiotics prescribing rates have fallen over the past few years.  This means a lot more children are benefiting from symptomatic treatment without the added side effects of antibiotics.  So far the evidence is that this reduction has not been the cause of a rise in bacterial complications such as peritonsillar abscess and rheumatic fever.(1)

If you work in a country with a low incidence of complications of streptococcal infections, that tells you more about the pathogenicity of your local bacteria than about your prescribing rates.  We therefore greatly rely on our Public Health team to facilitate the safety of the no-antibiotic approach to managing URTI/AOM/tonsillitis.  The Public Health team monitors the rates of complications of streptococcal infection and alerts you when there is a more pathological strain of strep and will make recommendations regarding temporary changes in prescribing practices.

It's great to know that Public Health have our backs, but it's a little complicated to explain to patients and parents in the time restrictions of a consultation.  Explaining the rationale for avoiding antibiotics for sore throats and ears can be tricky.  While many of of us are finding that it is problematic less often than it used to be, it is still one of the most important skills that we should have.  The question is, what can we do to make it likely that this discussion goes well and goes quickly?

The first thing to do is make sure that we're coming at this from the point of view of the best interests of the child.  I understand the need for antibiotic guardianship but quite frankly when it comes to each clinical encounter, I'm always going to choose what will be best for my patient.  If this is what is driving our avoidance of antibiotics then the parents will hopefully sense that we want what they want -their child to be as well as possible as soon as possible.  What this child centred approach achieves is that we then have the right attitude towards the subject of antibiotics.  We don't come across as having a hidden agenda.  It's all about the child and wee hope that parents will respond well to that.

When we have the discussion it is important to be considered when choosing our words.  If we talk about "not needing" antibiotics, it might come across as them not having fulfilled the criteria for what they see as the ultimate treatment.  Instead, talk in terms of antibiotics not helping.

It is fairly standard at this point to mention the side effects of antibiotics.  I don't tend to mention allergic reactions, partly because they are not that common and partly because we are trying to get away from parents thinking that everything that happens while taking antibiotics is an allergic reaction.  What I do emphasise is that common side effects are abdominal pain, vomiting and diarrhoea.  I make sure that the parents know that the main reason for wanting to avoid antibiotics is that I don't want to do that to the child and I don't want to make life harder for the parents.

Because most people don't seek a medical opinion about what not to do, this is the ideal time to discuss what does work.  Analgesia is key and parents will sometimes need encouragement in this regard.  One thing that causes much confusion is the issue of what the medicine is for.  There has been an unhealthy emphasis on controlling temperature which sometimes means that paracetamol (acetominophen) and ibuprofen are not used as analgesia when the child is afebrile but refusing to drink.

This is all important information and yet at the same time it is way too much information for a parent.  In many ways, the complexity of the information is part of what perpetuates the overuse of antibiotics.  It is far simpler for the parents and the clinician to simply say, "Your child needs antibiotics."  Unfortunately this is the illusion of simplicity.

So what we need are strategies to simplify the complicated. A leaflet is a very good way to achieve this.  We know what the questions that most people tend to ask, so why not give them some answers?  Here is a simple leaflet, in a question and answer format:

You could even start the process in the waiting room.  A poster that gives a bit of context might soften the ground for the discussion to be allowed to focus on more important things.

If you would like access to either the leaflet or the poster then please let me know and I can give you a fully editable copy.  You will need to register a free account at canva.com  When you have done that, either send me a direct message via social media or post a comment at the end of this blog.  (You don't need to worry about anyone seeing the comment.  I get to review all comments before they are published and if you start your comment with "not for publishing" I will keep it for my eyes only.)  Give me your email address that you used to register the canva.com account and I will share the templates of the leaflets or poster if that is of use to you.  You can then use these to edit and personalise.  

There are lots of leaflets, posters and websites available.  You should use them both to inform and to simplify.  My view is that they should be basic but contain the important information.

Finally, make sure that the parents know that they need to be looking out for signs of secondary infection and sepsis.  Complications of URTI are thankfully low where I practice but we should all be thinking of URTI as pre-sepsis.  I think that this safety-netting discussion can actually be used to support  the no-antibiotic element of the consultation.  Parents need to know that the clinician realises that their child is genuinely ill.  For that reason, we should avoid the phrase "just a virus".  It may be meant as reassurance but is often perceived as dismissive.  By completing the consultation with and explanation of signs of complicated URTI and when to re-attend we are helping the parent to see that we have taken the child's illness seriously.

Edward Snelson
Very Serious Doctor
@sailordoctor

Disclaimer:  The online content of this blog may have been corrupted by pixies and as such the responsibility for anything that turns out to be wrong sits with the Fairy King.

Reference

1. Sharland M, et al, Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis, BMJ 2005;331:328

Decision Fatigue and What to Do About It - When to Use Antibiotics for URTI, AOM and Tonsillitis in Children

Recently I was speaking to a GP colleague about the ways to protect oneself from decision fatigue.  Decision fatigue is a serious issue for anyone in a high volume, high turnover medical job.  He had some great insights into the problem and the solutions.

What are the effects of decision fatigue?  In the short term, your decision making ability gradually declines.  In the long term there is a risk of burnout.  From your patient’s point of view, your fatigue could mean that because you have already made too many decisions, you will not make the right decision when it really matters.  It is possible that this could lead to harm to a  patient.  Decision fatigue affects our ability to show compassion or provide patient centred care.  Subconsciously we protect ourselves from too many decisions by caring less and being more directive.

My GP friend’s solution to all of this was elegantly simple: make fewer decisions.  His rationale was this: there is only so much that we can give and we need to choose when to use our decision making energy.  If decision making is a finite resource then to use it indiscriminately is could even be seen as irresponsible.

So, how do you choose what to stop deciding?  Well, I would start with a commonly occurring dilemma that creates a great deal of uncertainty.  How about antibiotics for sore throats and ears in children?

You will notice I don’t talk about tonsillitis, URTI or otitis media.  These terms all imply an aetiology.  That is a presumption that is completely misleading.  Tonsillitis may be viral and red throat without exudate may be streptococcal.  The truth is that we don’t have a reliable way of discriminating between viral and bacterial aetiology when we examine throats and ears.  So we can't know who to give antibiotics to.  Rather than exhausting ourselves trying to get it right, perhaps we should just stop, but is that safe and justifiable? I am not the first person to ask that question. (1)

The decision that we are all faced with, to antibiotic or not-antibiotic, has to have a valid goal.  So the next question has to be, “What is the benefit in giving antibiotics?”

Do we give antibiotics to prevent complications?  In the UK this is not the case.  The evidence is very much against a need to give antibiotics as a way of preventing complications of URTI.  Antibiotic prescribing rates are falling and yet there is no crisis caused by increased numbers of invasive infection or the sequelae of streptococcal infection.(2)  Logically, if there was a quantifiable risk of complications related to reduced antibiotic prescribing, we would all have to justify each decision not to prescribe.  As previously mentioned, there is no reliable discriminator, so shouldn’t we be hearing from the public health authorities that we need to be more proactive in our antibiotic prescribing.  That’s not the message we are getting at all.  Why?  Because prescribing antibiotics for sore throats and sore ears in children (in a country with a low prevalence of complications such as rheumatic fever) is not part of a strategy for prevention of secondary infection, invasive infection, sepsis or any other complication.(3)

Should we be giving antibiotics to control symptoms?  Let’s look at that as a reason to prescribe antibiotics.  What are the facts?

• The odds of antibiotics helping the symptoms of any one child are low.  The actual number varies by age, study and whether we are talking about ear or throat symptoms but they are all in the same region.  The odds of benefit are in the region of 10-20%.  
• Decision tools such as Centor and FeverPain are designed to improve the odds that antibiotics will help symptoms but there are  major problems with these aids.  Firstly, they are not validated in the younger children who account most of the presentations of sore ears and sore throats.  Secondly, these tools imply a binary outcome.  If you score above a certain number, antibiotics will help right?  Wrong.  A high score means slightly less awful odds that antibiotics will help.  Again, that is only validated if your patient is an older child. (4,5)
• Rapid antigen testing has been validated as a way of reducing antibiotic prescribing but has not been shown to have a high sensitivity from the point of view of directing treatment to where it is effective.  These two things are very different. (6)
• There is a significant harm done by antibiotics in children.  Depending on the antibiotic and the study, the odds of making a child unwell (vomiting, abdominal pain, diarrhoea) with an antibiotic is 5-10%.  

So where have we heard 10% before.  Wasn’t it something to do with odds of benefit?  What would a statistician say if they looked at the odds of benefit and the odds of harm and saw that they overlapped.  In all truthfulness I couldn’t stay awake for the full answer but the gist was that there’s not a lot of point in such a treatment being used as a way to manage symptoms.

Finally, here are two things that make a nonsense of the whole question.

1. Children often refuse the antibiotics we give them.  Phenoxymethyl penicillin in particular is disgusting and children tend to be quite discerning in their medicine preferences.  Often the outcome of a difficult decision over whether to give antibiotics is later made meaningless as the child decides for all involved that the antibiotics are not going to happen.  The parent, remembering that it was a choice rather than a must-do usually gives up the fight.
2. The issue of antibiotics for tonsillitis and otitis media fails an important test: Snelson's Safeguarding Test.  It goes like this:  A parent brings a 2 year old to you with a fever and a cough.  You see exudate on the tonsils and are about to prescribe penicillin.  The parent says that they prefer not to treat their child with antibiotics.  You have confidently ruled out sepsis, meningitis and pneumonia.  What are you going to do? Get a court order to force the parent to give the antibiotics?  Refer the child to social services?  I don't think so.

So if the parents and the child are allowed to refuse antibiotics for sore throats and ears, how important can they be?  We wouldn't allow these barriers to get in the way if the child's life was at risk or even if the child was going to suffer as a result of non-treatment.  This way of looking at it is a good way of identifying the children who should be having antibiotics:

• Children with severe symptoms despite maximal analgesia
• Children with complications of URTI (such as infected lymph nodes)
• Scarlet fever (typical rash and oral inflammation alongside pharyngitis/tonsillitis and febrile illness) implies a more pathological strain of steptococcal infection
• Children with prolonged symptoms e.g. no signs of improvement after five days of illness

So next time you see a child with URTI, ask yourself, could I insist that this child should have antibiotics?  If not, save yourself a decision.  You know it makes sense.  All we have to do is convince the parents that this is the right thing to do.  (more on that very soon)

Edward Snelson
Vacilatologist
@sailordoctor

Disclaimer: I was replaced by a robot three years ago.

References

1. Morton P. Should we treat strep throat with antibiotics? Canadian Family Physician. 2007;53(8):1299.
2. Kvaerner KJ, Bentdal Y, Karevold G., Acute mastoiditis in Norway: no evidence for an increase, Int J Pediatr Otorhinolaryngol. 2007 Oct;71(10):1579-83. Epub 2007 Aug 20.
3. NICE, Sore Throat (acute): Antimicrobial Prescribing, NG84, January 2018
4. Little Paul, Hobbs F D Richard, Moore Michael, Mant David, Williamson Ian, McNulty Cliodna et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management) BMJ 2013; 347 :f5806
5. Roggen I, van Berlaer G, Gordts F, et al Centor criteria in children in a paediatric emergency department: for what it is worth BMJ Open 2013;3:e002712. doi: 10.1136/bmjopen-2013-002712
6. Little Paul, Hobbs F D Richard, Moore Michael, Mant David, Williamson Ian, McNulty Cliodna et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management) BMJ 2013; 347 :f5806

Hunting the focus of infection

Finding a focus for infection in a child is one of those things that we all know we ‘must do’.  That can be more difficult than it sounds.  Often, no focus is easily found and then the questions are, “Where do I look?  What if I can't find a focus?  I don’t know when to stop looking!”

How many children are seen with significant temperatures, where the eardrum is not easily seen?   On probability alone, the focus is more likely to be a hidden upper respiratory tract infection rather than something else.  Is probability enough to go on? 

Then there are the things that could be called a focus, but are rather soft signs.  Is a runny nose a focus?  If so, how high is the temperature allowed to be?  What about vomiting and diarrhoea?  Is that a focus in its own right?  You could throw that question out to an audience of primary and secondary care clinicians and I could guarantee that the conversation (if it continued in a way that could be called that) would go on for quite some time.  The outcome would almost certainly be that many would agree to disagree.

If you ask me, the answer depends entirely on the circumstances because the focus of infection is not nearly so important as the global assessment and the specifics of the presentation.  If a child presents early in an illness, is relatively well and has just got a runny nose, then that might be enough to go on.  Good symptom management and careful safety netting are probably the most important things in these cases.

Example 1

A 3 year old has a temperature of 38.2 at home.  They have a runny nose and a cough but no other symptoms.  They have no convincing focus of infection in their throat or ears.  Chest is clear and there is no respiratory distress.  Heart and respiratory rate are normal.  During the consultation, they are running around and playing with the toys.

Example 2

A 3 year old has had a temperature of 38 to 39 on and off for three days.  They have a runny nose and a cough but no other symptoms.  They have no convincing focus of infection in their throat or ears.  Chest is clear and there is no respiratory distress.  Heart and respiratory rate are normal.  They are alert but neither cheerful nor very active.  They have just returned from a three week trip to an area where malaria is endemic.

Who would like to accept the runny nose and cough as a focus in child 2?

So when do I need to find a focus?  Here are a few examples of circumstances in which I would want to have something that is fairly definitive:

My two top tips for finding a focus are:

1. Repeat the ENT examination unless you have already had really good views of tympanic membranes and pharynx
2. Check a clean catch urine sample

When deciding about how hard to look and how invasive the search should be, don't start at the beginning, start at the end.  The child in front of you and the clinical scenario determine what the hunt will involve.

Edward Snelson

Variable Venator

@sailordoctor

The Best Medicine

We all want to give the best medicine. If you are not part of that ideology, please stop reading. This is not for you.

Prescribing for children is tricky.  Sometimes dosing is about weight, sometimes age and sometimes it's not that simple such as when giving bronchodilators.  The choice of treatment is also difficult. I try to practice evidence based medicine but there is often a lack of good quality research on which to base my decisions.

In the brave new world of guideline driven medicine, there is one factor that I don't often consider and that's a shame because it can make all the difference.  That factor is the acceptability of the treatment to the child.

In our desire to make a child better (or at least feel better) it may be wise to consider what the child wants. I know, that's crazy talk.  But the best medicine may just be the one that the child will take.

Let's talk about a few examples.

What is the best corticosteroid for treating croup?

I recently ran through the management of croup.  In that I addressed a question that I am often asked by my GP colleagues: "Should we be giving dexamethasone or prednisolone?"  The evidence comes down gently in the favour of dexamethasone. However,  prednisolone is often cheaper and more readily available.  

But what would the child choose?  I have prescribed each of these steroids enough times that I've got a strong suspicion that a consumer survey would say dexamethasone is the customer's favourite.  This is based on the number of pens I have worn out writing that prednisolone can be re-administered since the first dose is now fluorescent decoration on a parent's clothes.  This is a lot easier to sort out while the child is sat near me in the ED.  It's less easy to resolve if they've picked up their medicine from a pharmacy and are at home when they vomit back their steroid.

I don't have the facts on how many children spit out or vomit back prednisolone versus dexamethasone.  It would be good to know so that I could offer more than a belief when someone asks the dex/ pred question.  In the absence of hard facts, I will continue to point to the dex bottle and mouth, "This one!" in a way that allows plausible deniability.

What is the best oral antibiotic for bacterial tonsillitis in children?

I recently read with interest an article in the Archives of Disease in Childhood about another treatment choice that would affect even more children.  This article had the bravery to question the well established practice of giving ten days of phenoxymethylpenicillin  to children with suspected or proven streptococcal tonsillitis.  Apparently the old thing about a high proportion of cases of Epstein-Barr virus (EBV) infection having florid rashes when prescribed amoxicillin is a myth.  Well, technically it is a misunderstanding (or mythunderstanding perhaps?) since the reaction described originally was to ampicillin.  The latest evidence is that there is no increased occurrence of rash when amoxicillin is given and EBV is present.  Can I trust no one?

The article goes on to mention (casually, as if to avoid hate mail) that since amoxicillin is better tolerated by children, perhaps we should prescribe this instead of phenoxymethylpenicillin.  Bonkers.

Now before anyone changes their practice, there is another consideration: antibiotic guardianship.  Amoxicillin has a broader spectrum of antimicrobial activity and with rising bacterial resistance we should be using broad spectrum antibiotics as infrequently as possible.  What is exciting to me is that someone has questioned our long-continued routine.  Better still, they have as good as involved the child in the discussion that should rightly follow.

Is phenoxymethypenicillin that bad?  Parents frequently tell me that the phenoxymethylpenicillin prescribed to their child has transformed them from a nice child with a febrile illness into some sort of rabid beast undergoing an exorcism.  It seems entirely reasonable therefore to ask that the writers of guidelines consider whether the evidence and stewardship of phenoxymethylpenicillin outweighs the acceptability of amoxicillin.  How many additional completed completed antibiotic courses would it take to allow amoxicillin to win in a straight fight?

I would not be me if I didn't mention the other option for the child who has a deep loathing for their antibiotic.  There are ten good reasons to make stopping the antibiotic the best way forward. There is only really one reason to change to something like amoxicillin: the child needs the antibiotic.

Edward Snelson
@sailordoctor
Medical mythologist

Disclaimer: Trust no one

References

1. Christine Chew, Anu Goenka "Does amoxicillin exposure increase the risk of rash in children with acute Epstein–Barr virus infection?" Arch Dis Child doi:10.1136/archdischild-2015-310364
2. johnathanlaird.com "The Ten Real Reasons Not to Prescribe Antibiotics"