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BACKGROUND: Improving the diagnosis of serious bacterial infections (SBIs) in the children’s emergency department is a clinical priority. Early recognition reduces morbidity and mortality, and supporting clinicians in ruling out SBIs may limit unnecessary admissions and antibiotic use. METHODS: A prospective, diagnostic accuracy study of clinical and biomarker variables in the diagnosis of SBIs (pneumonia or other SBI) in febrile children <16 years old. A diagnostic model was derived by using multinomial logistic regression and internally validated. External validation of a published model was undertaken, followed by model updating and extension by the inclusion of procalcitonin and resistin. RESULTS: There were 1101 children studied, of whom 264 had an SBI. A diagnostic model discriminated well between pneumonia and no SBI (concordance statistic 0.84, 95% confidence interval 0.78–0.90) and between other SBIs and no SBI (0.77, 95% confidence interval 0.71–0.83) on internal validation. A published model discriminated well on external validation. Model updating yielded good calibration with good performance at both high-risk (positive likelihood ratios: 6.46 and 5.13 for pneumonia and other SBI, respectively) and low-risk (negative likelihood ratios: 0.16 and 0.13, respectively) thresholds. Extending the model with procalcitonin and resistin yielded improvements in discrimination. CONCLUSIONS: Diagnostic models discriminated well between pneumonia, other SBIs, and no SBI in febrile children in the emergency department. Improvements in the classification of nonevents have the potential to reduce unnecessary hospital admissions and improve antibiotic prescribing. The benefits of this improved risk prediction should be further evaluated in robust impact studies.

Aims-To determine long term neurodevelopmental outcome following the spectrum of meningococcal infection. Methods-Between 1988 and 1990, 152 cases of meningococcal disease were recruited; 139 survived. Between 1998 and 1999, 115 survivors (83%) were evaluated, together with 115 sex and age matched controls. Standard measures of neurological function, coordination, cognition, behaviour, and hearing were used to assess neurodevelopmental status. Results-One case has spastic quadriplegia. Gross neurological examination was normal in all other cases and all controls. Five cases and no controls have significant hearing loss. Cases performed at a lower level than controls on measures of coordination, cognition, and behaviour. Four cases and no controls had major impairments. The adjusted odds ratios for moderate and minor impairments were 3.6 (95% CI 1.3 to 10.3) and 1.6 (95% CI 0.8 to 3.4) respectively. Conclusion-The majority of survivors from this cohort do not have gross neurological deficits. However, when objective measures of motor function, cognitive ability, and behaviour were applied significant detriments were found in meningococcal survivors. (Arch Dis Child 2001;85:6-11)

Sixty nine patients with meningococcal disease some of whom presented with a maculopapular rash were entered in a prospective multicentre study. The clinical and laboratory features of children presenting with maculopapular rashes were compared with those of children presenting with typical haemorrhagic rashes. Of the 69 children 26 (38%) developed maculopapular rashes; nine (13%) had a maculopapular rash only, and the remaining 17 had a mixed maculopapular-purpuric rash. Twelve of the 17 (7%) had less than 12 petechiae. Children with maculopapular rashes had significantly higher platelet counts (median 294 compared with 243x 10I), and plasma total haemolytic complement activity (80.5 compared with 65-0 U/mi) and significantly lower Glasgow meningococcal septicaemia prognostic scores (2.5 compared with 5.5) than those with purpuric rashes on admission. There were no significant differences between the groups in mortality, white celi count or absolute neutrophil count on admission, or C reactive protein concentration.Meningococcal disease can present with a maculopapular rash alone but this does not necessarily mean that the disease is less severe.

Objective: To examine the outcomes of calls to NHS Direct (NHS-D) in relation to attendance at the accident and emergency (A&E) department. Design: A prospective collection of data about consecutive calls to NHS-D North West Coast was matched with attendances at the A&E department over a period of 3 months. Setting: NHS-D Regional Trust and a large urban paediatric A&E department. Patients: Children and young adults aged ,16 years living in local postal code areas. Main outcome measures: To examine (1) whether advice given by NHS-D was followed and (2) the differences in disease severity and necessity of attendance of patients referred by NHS-D and those referred by general practitioners and self-presenters. Results: The relationship between the advice given and subsequent action is complex. Only 70% of calls advised to attend the A&E department did so. A further 1% (176) were advised not to attend the A&E department did in fact attend the department. Patients referred by NHS-D represented only 3.2% of department attendances. There was little difference in the triage categories of the presenting groups, but there were significantly less admissions (p,0.01) in the NHS-D group. Conclusions: Delivering telephone advice about illness severity in children is difficult as visual clues are so important. More collaborative prospective studies are needed, including with primary care, to understand families' choices, and to refine and assess NHS-D's ability to discriminate those requiring further clinical assessment.