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Antibiotic Stewardship

General paediatrics, Infectious disease, Microbiology

Given that it’s hard, slow and expensive to develop antibiotics, and it is virtually inevitable that genetic diversity will generate antibiotic resistance, trying to maintain the usefulness of the antibiotics and reduce the prevalence of resistance is a global health priority.

This principle is called antibiotic stewardship and involves:

  • Appropriate use of antibiotics
  • Selecting the most appropriate antibiotic for a given infection (narrow spectrum where possible)
  • Not relying excessively on in vitro measures of antibiotic effectiveness (MIC etc) if a narrow spectrum antibiotic clinically effective – or maximising the effectiveness of a narrow spectrum antibiotic by choosing a particular dosing regimen or route
  • Surveillance for resistance

The UK has set (2025) primary care targets (90% of amoxicillin prescriptions will be for 5 day course rather than longer, less than 3% of all antibiotics will be for co-amoxiclav and cipro combined, for example), and secondary care targets:

  • IV antibiotic prescribing will be 10% lower by 2029 than 10 years previously
  • 95% of antimicrobial prescriptions will have an indication recorded by 2029

Sublingual immunotherapy

Allergy, General paediatrics, Immunology

Used for grass (GRAZAX) and house dust mite (ACARIZAX) allergies.

But also offered for food immunotherapy.

Hugh Windom, Sarasota (Florida) 2024– 50 patients. None needed adrenaline.

Initial doses diluted 50% in glycerine saline. Liquid egg white used. With glycerin, can be stored at room temperature for 12 months. Else freeze (No change in SPT reactivity with freezing)

Peanut, sesame (flour), wheat (Vital) diluted with glycerine to 30-40mg/ml.

(Initial dosing 1:1000 (cohort 1) abandoned as being excessively cautious)

[From FAST OIT 2025]

So maintenance is 6mg for peanut. For milk/egg, 10/11mg.

Syringe preferred to dropper.

2 minute hold in mouth before swallowing (no evidence yet for shorter holds or spitting). Wait five to 15 minutes before eating or drinking (no evidence yet for shorter).

No rest (sloth) period required – exercise challenges all negative. Only skip dose if asthma flare or vomiting.
Annual OFC, +/- labs to assess response – baked for milk/egg (!), 10/30/100mg for year 1, 100/300mg year 2.

Skip 3-4 months with little loss of protection!

87% pass 140mg at 1 yr. In Canadian study (Soller 2024?) switched to OIT if passed 340mg (obviously)

Tree nut immunotherapy

Allergy, General paediatrics

Multi-food OIT

Many people allergic to one nut are allergic to other nuts, and/or other foods.

Doing simultaneous OIT for multiple nuts makes sense in terms of the time/cost saving. Outcomes are pretty similar. The more foods, the more complicated – it also means a higher amount of maintenance

Obviously makes sense if younger age, lower IgE, higher reaction thresholds.

You need to think about what you are going to choose to treat, and what/if you need to challenge. Often some of the nut allergies come up on testing only and have never been eaten, so probably less important to challenge. You can always adjust the regimen to pause one food and continue another, if things are not going to plan. Most clinics just reduce both/all foods if there is a reaction, for simplicity.

Cyclical Vomiting Syndrome

Gastro, OPD

A type of functional GI disorder. Thought to be similar to migraine – periodic, sudden onset repeated vomiting, but without headache. Then fine for weeks/months.

Can be severe enough to require admission for IV fluids. Even if not, child can be wiped out for days.

Try hot baths or showers.

Ondansetron is the mainstay of treatment. Melts make sense. Sumitriptan spray/tablets. The sedating antihistamine Promethazine is helpful in some cases and has a lower wide effect profile than perhaps some other anti-sickness medicines.

Electrolyte solutions rather than just water, ideally containing some sugar for energy. These come in gel, bottle or powdered form.

Adults with this condition often use cannabis!

Else Amitriptyline or Topiramate.

Tetanus

General paediatrics, Infectious disease

UK schedule is for 3 tetanus containing vaccines in first year of life, followed by extra dose of 6 in 1 at 18 months (new from July 2025). First real booster is pre-school (3 years 4 months). Second booster is at 10 years after 1st course, routine is for Td/IPV at 14.

Incubation period is 4-21 days.

Tetanus prone wounds

  • Puncture in soil contaminated environment
  • Wounds containing foreign bodies
  • Compound fractures
  • Wounds/burns with systemic sepsis
  • Some animal bites/scratches

Not exclusive. Animal bites/scratches depends on whether there would have been soil in the mouth/claw…

High risk wounds on the other hand include heavy contamination with soil/manure, wounds/burns with extensive devitalised tissue, delayed surgical intervention beyond 6 hours even if not high risk initially.

Management of Wounds

If within 5 years of last vaccine (and complete primary course) – so up to 8 years old, likely good antibody levels so no booster required. If more than 5 years since immunisation, then giving booster vaccine is as effective as giving Tetanus immunoglobulin (TIG) so save it for high risk wounds only.

Avian influenza

General paediatrics, Infectious disease, Respiratory

UK-PAS meeting (David Goldfarb from University of British Columbia – PID and micro.)

H5N1 first appeared in 1997 in China but no more cases until early 2000s.

2017 report lots of young children, high mortality (53%). Unrecognised cases never admitted?

New clade 2.3.4.4b in 2021 – crossing over to mammals in Americas. Last year some mild cases related to cows.

Death in Louisiana H5N1 2025 (not the clade in dairy farms), related to poultry (underlying health issues and over 65 years). H5N1 circulating in wild and farmed birds in Scotland, H5N5 back in wild birds.

HPS guidance here.

Case

2024 – 13yr old mild asthma, obesity (117kg), presented with conjunctivitis and fever. Then vomiting and dyspnoea, quickly transferred to PICU. LLL pneumonia. No risk factors.

Biofire resp panel used for PICU – includes pan influenza A antigens, so positive but H1/3 negative. Then did reflexive Xpert assay, which is quantitative.  Relatively strong so referred to reference lab.

Genomics done within 4 days. Showed close to “cackling goose” strains. Also identified mutations associated with increased binding (not seen before in H5) so infectivity increased.

At same time Louisana case with same gene type and mutations.

Infection control tricky – new genes! Other studies have suggested incubation up to 13 days. Maintained airborne precautions until 2 negative samples (lower resp samples continued to be positive for 15 days, tracheal just 2 days…)

Note potential exposure to lab staff – discuss!

Ashraf Znait (PICU fellow) – intubated for hypoxia despite BipAP. Echo showed good function on intoropes. Started ECMO at 6 hours after intubation. Double cannulas (IJ and femoral) required to achieve sats of 80%. Dual lumen cannula. Required CRRT for fluid overload and anuria but high pressure with combination so switched to separate femoral dialysis catheter.

SIRS and haemodynamic instability persisted, decided against steroids (higher mortality in influenza cases 2019 – Recovery trial in UK currently?) so plasmapheresis.

D10 off inotropes. D15 before decannulated. D21 extubated.

Mode of acquisition never explained! No immunological problem found.

Ellie MacBain (PID fellow)  – case series from 2012 found 75% increased risk of death with delayed oseltamivir treatment. IL6 and IFNgamma, resp sample viral load higher in fatal cases.

Oseltamivir resistance has been described in avian cases of this clade. WHO suggests higher doses (eg 150mg BD), combination therapy, or prolonged treatment.

This case had PCR positive serum with cycle threshold (CT) suggestive of true viraemia. Added amantadine, baloxavir, unable to procure IV zanamavir. From different classes of antiviral in any case.

Never positive bacterial cultures! On/off antibiotics throughout.

Ashley Roberts (Prof PID) – treatment doses used for oseltamivir prophylaxis, for 7-10 days.

Topical Steroid Withdrawal

Dermatology, General paediatrics

Social media storm in 2023 onwards, although already talked about prior to 2021.

No medical definition, of course. So hard to research or talk about. Concerns are around skin inflammation in previously unaffected areas, flares when you stop using topical steroids, and chronic red, inflamed skin (potentially thickened/lichenified).

Social media talks about “Sleeve sign” (palms less affected than other areas of arm), “headlight sign” (mid-face less affected than rest).

There are a range of different issues:

  • Erythroderma – widespread inflammation (more than 90% of body surface area), with accompanying problems with sleep, temperature control, blood pressure, fluid balance. Serious, often needs hospital treatment.
  • Papulopustular lesions – can be side effect of topical steroids, esp on face. Can obviously get worse on stopping steroids. Steroids can cause acne/rosacea, so you might be better with antibiotics etc. Or could be infection eg herpes, hand/food/mouth.
  • Tachyphylaxis – where previously effective medicine stops working. Seen with other medicines too.
  • Other physical symptoms eg lethargy, dizziness. Beware adrenal suppression!
  • Natural progression of eczema – steroids work, so when you stop giving them, the eczema often comes back.
  • Contact dermatitis related to preservative in creams.

Try to be supportive of concerns! Agree practical plans, offering alternatives to topical steroids if people would otherwise stop using them.

[Joint statement from National Eczema Society and BAD 2024 – https://eczema.org/blog/topical-steroid-withdrawal-updated-joint-statement/]

Fetal alcohol syndrome

Cardiology, Clinical, Community

Salford study in 2021 found 1.8% rate in school (3.6% including possible cases) when actively sought – none of whom had previously diagnosed developmental problem. Estimated 2-4% in population.

Cognitive impairment, ADHD/impulsivity, visual/hearing impairments, physical complications.

SIGN guideline 156 (and now NICE).

Assess –

  • Alcohol exposure
  • Facial features (3 “sentinel” – small eyes, smooth philtrum, thin upper lip) – computer based tools available.
  • Brain pathology (growth ie OFC else scan)

Confirming alcohol exposure can be tricky – ED attendances? Blood alcohol levels? Police involvement? Using self completed form perhaps more reliable than saying face to face. Diagnosis can be made without good history if all 3 facial features present.

No safe limit for alcohol exposure in pregnancy. “When did you find out you were pregnant?”

Assess facial photo when NOT smiling! Other features are hirsutism, epicanthic folds, clown eyebrows, ptosis, flat nasal bridge.

Brain domains – need 3 or more. Neurodevelopmental and speech/language and sensory integration (occupational therapy) assessment. Only valid in school age children. So diagnosis in preschool only possible if microcephaly or similar.

Diagnosis is FASD +/- sentinel facial features, or “at risk” indeterminate (because too young to do proper assessment, for example).

Management

SPECIFIC parenting course developed in Salford.

National organisation for FASD has algorithms etc.

Congenital cataracts

Clinical, Congenital, General paediatrics, Genetics, Neonatology

Differential:

  • Varicella
  • Rubella
  • CMV
  • Toxoplasmosis
  • HSV
  • Syphilis, HIV
  • Genetic non syndromic – various
  • Syndromes – Downs/Patau
  • X-linked Lowe syndrome (LD and proximal tubular dysfunction)
  • Autosomal dominant myotonic dystrophy (various eye problems), Neurofibromatosis type 2
  • Zellweger (includes neonatal adrenoleukodystrophy and infantile Refsum) – peroxisomal
  • Galactosaemia, Cockayne syndrome

GLP-1 receptor agonists

Endocrinology, Gastro, General paediatrics, Nutrition, OPD

=Glucagon-like peptide receptor agonists eg semaglutide.

Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial BMI ≥30 kg/m² (or ≥27 kg/m² with at least one weight-related comorbidity).

NICE recommends as an adjunct to lifestyle measures only when:

  • it is used for a maximum of 2 years, 
  • within a specialist weight management service, and
  • in patients who have at least 1 weight-related comorbidity and have BMI ≥35 kg/m² (or a BMI between 30 kg/m² to <35 kg/m² who “meet the criteria for referral to specialist weight management services”).

NICE recommends using lower BMI thresholds (eg 2.5 kg/m² less) for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family backgrounds.

RCT data showed that patients receiving semaglutide lost an average of 6% to 16% of their total body weight compared with controls, when combined with other behavioural modifications. It has also demonstrated cardiovascular benefits: in adults aged 45 and older who have concurrent cardiovascular disease (but no history of diabetes), semaglutide reduces the overall risk of major cardiac events (heart attack, stroke, or cardiovascular death) by 20% at a mean follow-up of 40 months.

Common adverse effects include explosive diarrhoea, nausea, eggy burps, headache, fatigue, and hypoglycaemia in diabetic patients. Contraindicated in history of thyroid medullary cancer or MEN2.

Liraglutide is similar but was inferior in 1 head to head trial. Daily SC injections.

Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist. Weekly SC injections. RCTs showed weight loss of 18-20%. Similar indications and contra-indications.