When water is thicker than blood: recognising a systemic cause of haemoptysis.

The case of an 11-year-old child presenting with acute haemoptysis and breathlessness is described. The girl was Malaysian and had recently arrived in the UK. She subsequently deteriorated, developing respiratory failure. The course of the illness is described, with reference to the diagnostic process at each stage. The case demonstrates the importance of having a broad investigatory approach in acute haemoptysis.

Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement.

There is compelling evidence to support the rationale for managing children on intravenous antimicrobial therapy at home whenever possible, including parent and patient satisfaction, psychological well-being, return to school/employment, reductions in healthcare-associated infection and cost savings. As a joint collaboration between the BSAC and the British Paediatric Allergy, Immunity and Infection Group, we have developed good practice recommendations to highlight good clinical practice and governance within paediatric outpatient parenteral antibiotic therapy (p-OPAT) services across the UK. These guidelines provide a practical approach for safely delivering a p-OPAT service in both secondary care and tertiary care settings, in terms of the roles and responsibilities of members of the p-OPAT team, the structure required to deliver the service, identifying patients and pathologies that are suitable for p-OPAT, ensuring appropriate vascular access, antimicrobial choice and delivery and the clinical governance aspects of delivering a p-OPAT service. The process of writing a business case to support the introduction of a p-OPAT service is also addressed.

Ambulatory intravenous antibiotic therapy for children with preseptal cellulitis.

OBJECTIVE: This study aimed to compare the use of outpatient ambulatory care versus admission for intravenous antibiotics in the management of preseptal cellulitis. METHODS: This is a retrospective consecutive cohort study of children younger than 16 years presenting to an Inner London Paediatric Emergency Department with signs and symptoms of preseptal cellulitis. RESULTS: A total of 94 cases were identified during a 17-month period. Of them, 30 children were prescribed oral antibiotics. One child did not receive treatment. Of the 63 children prescribed with intravenous antibiotics, 42 were managed on an ambulatory basis and 21 were admitted. There was no significant difference in duration of treatment in days between those on ambulatory management and those admitted (2.79 ± 0.8 vs 2.76 ± 1.9, P = 0.94) or in the rate of complications. The net cost saving was $205,924 (£131,065; &OV0556;147,578) overall, equal to $4900 (£3120; &OV0556;3513) per patient. CONCLUSIONS: Ambulatory intravenous antibiotics with daily review are a safe and cost-effective alternative to inpatient admission in simple preseptal cellulitis for children in our population who require parenteral antibiotics.

Clinical predictors of nasal continuous positive airway pressure requirement in acute bronchiolitis.

INTRODUCTION: There is growing use of nasal continuous positive airway pressure ventilation (nCPAP) for infants with bronchiolitis, based on clinical assessment of severity. Despite this there have been no studies which identify clinical predictors for the requirement of nCPAP. OBJECTIVE: To identify clinical factors in infants with acute bronchiolitis in the emergency department (ED), which might predict a requirement for nCPAP following admission. MATERIALS AND METHODS: Retrospective review of pediatric ED case notes was conducted on bronchiolitis admissions to one dedicated Paediatric ED over a 12-month period. Potential predictors were identified through literature review. Data extraction of predictors was carried out and recorded for each case. Logistic regression was conducted for each variable to identify statistically significant predictors of nCPAP requirement. RESULTS: Twenty-eight (17%) of the 163 admitted infants received nCPAP. The strongest predictors of nCPAP requirement in were as follows: oxygen requirement within the ED (P < 0.001), lower oxygen saturation (P < 0.001), younger age at presentation (P = 0.002), higher respiratory rate (P = 0.002), higher heart rate (P = 0.003), lower Glasgow Coma Scale score (0.006), and younger gestational age (P = 0.024). CONCLUSION: We have identified clinical variables that were predictive of nCPAP requirement in infants admitted to our unit with bronchiolitis, oxygen requirement in the ED being the strongest single predictor. This is the first such study in the UK, and we hope it may be a starting point for further work that may provide an evidence base to aid clinicians in predicting the use of nCPAP in infants with bronchiolitis.

Ambulatory intravenous ceftriaxone in paediatric A&E: a useful alternative to hospital admission?

BACKGROUND: Treatment of children with intravenous ceftriaxone on an ambulatory basis is described. This allows a child to remain at home, but also be reviewed regularly when attending the Emergency Department for antibiotics. METHODS: Indications for, and length of, treatment and laboratory parameters were recorded. Also, a survey of children's parents was undertaken to ascertain opinions regarding ambulatory treatment. RESULTS: 36 patients were treated with ambulatory ceftriaxone over 4 months. Indications included fever without focus, tonsillitis, periorbital cellulitis, urinary tract infection, petechial rash and lymphadenitis. Median duration of treatment was 2.3 days. There was no occult bacteraemia but five positive urine cultures. There was one failure of treatment with subsequent admission for alternative intravenous antibiotics. CONCLUSIONS: Parental opinion favours ambulatory treatment, with 94% of parents acknowledging they would choose it again in similar circumstances. Cost analysis favours ambulatory treatment based on predicted costs of a similar length of inpatient stay.