“You will miss a case of meningitis at some point, everyone does.”
As a first-year paediatric trainee, I was told that it was inevitable that I, and most of my colleagues, would eventually ‘miss’ a case of meningitis or sepsis in our careers. Those words never left me. I remember thinking that I didn’t ever want to miss a life-threatening infection. Surely there was a way I could do better? Was it really that hard to spot the sick child?
Unfortunately, it can be that hard… and the realities of this hit home for me when I cared for Ryan* during my paediatric intensive care training. Ryan was a similar age to my own son at the time he became unwell. His life-changing illness started with a cough, then a rash, and then he was admitted to the intensive care unit with invasive meningococcal disease. Ryan had attended a doctor the day before he came to hospital, but his serious infection had been ‘missed‘.
Typically, if I’m not sure about a diagnosis I might request some tests. Unfortunately, the tests used for detecting serious infection haven’t been changed in over 20 years.
So why can we sometimes miss serious infections in children? The first thing is that they aren’t missed due to negligence, poor training or laziness. The problem is that serious infections often do not look serious initially. The child who is obviously unwell is easy to spot. How do I spot those ones that haven’t deteriorated…yet? Typically, if I’m not sure about a diagnosis I might request some tests. Unfortunately, the tests used for detecting serious infection haven’t been changed in over 20 years. They are unreliable and relatively slow. I could also look at measurements of vital signs and record the history and clinical exam but interpreting these findings can be really difficult. So, if it’s so difficult to diagnose and if I do not have a magic crystal ball, what do I do?
"Give ceftriaxone and ask questions later" is a common strategy that was, and is, still widely used across paediatrics in the UK. On the face of it, this approach makes sense - if we can’t spot the sick child then just treat them all! The issue is that this isn’t safe or feasible. Fever is the commonest reason for a child to be brought to the Emergency Department or to their General Practitioner. I couldn’t attempt to treat every child, I would be run off my feet. Also, "give antibiotics just in case" actually means give broad-spectrum intravenous antibiotics. These are the antibiotics that I need for my sickest patients. What will happen when there are resistant bacteria that we can no longer treat?
We need to reduce the number of children with serious infections in the first place, and improve the approach to diagnosing serious infections.
So, what can I do? How can I improve the care of these children with fever in ways that are balanced and safe? I can see two approaches to go about it to go about it: firstly, we need to reduce the number of children with serious infections in the first place, and secondly, we need to improve the approach to diagnosing serious infections.
I’d consider the meningococcal vaccination programme as an example of how the number of children with serious infections can be reduced. In 1999-2000 there were 203 cases of meningococcal meningitis/sepsis in Northern Ireland where I’m based. The introduction of the Meningococcal C vaccine in 1999 and the Meningococcal B vaccine in 2015 has brought this number down to just 16 in 2019-2020! The same pattern is found with other life-threatening paediatric infections such as Pneumococcal and Haemophilus. If I know a child is vaccinated, I know the likelihood that the child has a serious infection is reduced even before I assess them.
I can then combine this lower likelihood with better diagnostic approaches. We are learning to use big data and artificial intelligence to better understand the signs and symptoms of disease. We are researching new blood markers of infection using novel techniques such as proteomics and transcriptomics and we have new rapid molecular tests that can deliver results within minutes.
We still do not have a crystal ball, but we are definitely beginning to find the middle ground between "everyone misses a case" and "give ceftriaxone and ask questions later".
Tom is a Clinical Lecturer at Queen's University Belfast, and a Consultant in Paediatric Emergency Medicine. He was recently awarded the 2021 Donald Paterson prize.
- *Names and other information that could identify someone have been changed.