Paediatric Acute care Guidelines PMH Emergency Department

Background

  • Returned travellers commonly suffer from health problems related to travel, which can present as minor self-limited illnesses or potentially life threatening infections.1
  • Non-specific viral illness, diarrhoeal diseases and respiratory illnesses are the most common clinical syndromes.3,4 The most common specific diagnoses among returned travellers with fever are malaria, dengue and salmonella infections including typhoid.3,4
  • Clinicians who are evaluating returned travellers who are ill must maintain a broad differential diagnosis that includes routine infections, as well as exotic infections and illness that may be non-infectious in nature.2
  • Returned travellers from Bali will still need investigation for Malaria, even if they have not travelled to rural/remote or the Lombok area

Assessment

Travel history checklist
Where did you travel?

Information regarding country specific risks can be found at:

When did you travel?
  • Include travel dates and duration of travel to establish possible incubation period 
Vaccination status including routine vaccines and travel vaccines? 
  • Vaccines such as typhoid, provide incomplete protection and travellers are still at risk.2,6
  • Travellers unimmunised to standard vaccines, such as measles, are at increased risk of exposure abroad.6
Malaria prevention strategies
  • Malaria prophylaxis is never 100 percent effective and the use of bed nets is the most effective strategy
  • Type of medication and dosing regimen
  • Adherence to medication and duration of therapy prior to and after leaving an endemic area

Differential Diagnosis

Infection  Incubation Period  
Malaria Variable P.Falciparum: 7 days-12 weeks
Other malarial species: weeks to several years
Typhoid (Salmonella)  Variable 3 days – 3 months (usually 8-14 days)
Rickettsial infection  Variable 3-21 days (depending on type) 
Dengue Short 3-14 days (usually 5 days)
Chikungunya Short 1-12 days (usually 3-7 days) 
Influenza Short 1-5 days (usually 2 days) 
Campylobacter  Short 1-10 days (usually 3 days)
Shigella Short 12 hours-7 days (usually 2 days)
Measles Intermediate 7-18 days (usually 10 days)
Viral haemorrhagic fever (Ebola)  Intermediate 2-21 days (usually 8 days)
Hepatitis A Long 2-7 weeks (usually 30 days)
Rabies Long 3-8 weeks (sometimes years)

Management 

Children are unlikely to present as severely unwell, if indicated please refer to the management for the severely unwell patient.  

Non Severely Unwell Patient 
Always consider infection control precautions – refer to Rash Management
Take a travel history  

 Perform a thorough examination including:

  • Rashes / skin lesions (dengue, typhoid, rickettsia, measles, leptospirosis)
  • Hepatomegaly (malaria, typhoid, dengue, viral hepatitis)
  • Splenomegaly (malaria, typhoid, mononucleosis)
  • Acute abdomen or GI haemorrhage (typhoid)
  • Cough, coryza, conjunctivitis (respiratory viruses, measles)
  • Jaundice (viral hepatitis, malaria)
  • Lymphadenopathy (rickettsia, toxoplasmosis, brucellosis, HIV, infectious mononucleosis)
  • Petechiae (meningococcal disease, viral haemorrhagic fever, rickettsia)
  • Neurologic findings: confusion, lethargy, meningism (malaria, meningitis)
  • Insect bites and eschars (malaria, dengue, rickettsia)

 Investigations (to be performed on all returned travellers with a history of fever):

  • Blood culture
  • Thick and thin blood film for malaria (purple top) – this must be performed on 2-3 separate occasions, 12-24 hours apart, to be reliably negative
  • Rapid diagnostic test for malarial Ag (purple top) (only positive in P. falciparum: call Hematology lab for urgent results available 24hr/day)
  • FBC
  • LFT, EUC

 Other tests to consider: 

  • Serology for dengue/arboviruses (+/- the dengue NS1 Ag in the 1st week of illness) (red/gold top)
  • Measles PCR on PNA/urine/blood and IgM + IgG for Measles in suspected cases (most frequently identified in unimmunised cases) 
  • CXR +/- NPA for respiratory viruses
  • Stool bacterial cultures and enteric viruses
  • Urine microscopy and culture

 Management

  • Depends on the patient’s clinical presentation and specific diagnosis.
  • If the patient is suitable for outpatient management, consult Infectious Diseases (in hours) prior to discharge. If urgent advice is required after hours contact Clinical microbiology on call.
  • If the patient requires admission, the primary admitting team will be General Paediatrics with consideration for obtaining an Infectious Diseases Consultation

 

Severely Unwell Patient
  • Haemodynamic compromise
  • Altered conscious state
  • Seizures
  • Bleeding

Refer to the Serious Illness guideline 
Always consider infection control precautions – refer to Rash Management

Initial Investigations

  • Blood cultures
  • FBC and thick and thin blood film for malaria (purple top) 
  • Rapid diagnostic test for Malaria Ag (purple top) – label urgent and call Haematology Lab for result (available 24hrs/day)
  • Microscopy and culture of urine, CSF and stool (including rectal swab for ESBL)
  • LFT  and EUC (green top)
  • Coagulation profile (blue top)
  • PCR (meningococcal, malaria) (purple top)
  • Serum tube (dengue and other serology) (red/gold top)

Treatment 

  • Malaria positive – refer to Malaria guideline
  • Otherwise treat with empirical antibiotics
    • First: IV Meropenem 40mg/kg (maximum 2 grams) 8 hourly
      then
    • IV Vancomycin 15mg/kg (maximum 750mg) 6 hourly
For Further advice contact the Infectious Diseases Fellow or Clinical Microbiologist (after hours) 

References

  1. Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med 2002; 347:505-16.
  2. Looke DF, Robson JM. Infections in the returned traveller. MJA 2002; 177:212-219.
  3. Wilson ME, Weld LH, Boggild A, Keyston JS, Kain KC, Sonnenburg FV,
  4. West NS, Riordan FA. Fever in returned travellers: a prospective review of hospital admissions for a two and a half year period. Arch Dis Child 2003 88:432-434.
  5. Phillips-Howard PA, Radalowicz A, Mitchell J, Bradley DJ. Risk of malaria in British residents returning from malarious areas. BMJ. 1990;300(6723):499.
  6. Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO et al. The practice of travel medicine: Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1499-1539.
  7. Dorsey G, Gandhi M, Oyugi JH, Rosenthal PJ. Difficulties in the prevention, diagnosis, and treatment of imported malaria. Arch Intern Med. 2000;160(16):2505.
  8. Traveller’s diarrhoea. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
  9. Simmons CP, Farrar JJ, Nguyen VV, Wills BS. Dengue. N Engl J Med. 2012 Apr;366(15):1423-32
  10. Kumar N, Lewis DJ. Fever and rash in a returning traveller. BMJ. 2012;344:e2400
  11. WHO Dengue. Guidelines for diagnosis, treatment, prevention and control. New Edition, 2009 http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf
  12. Sanchez-vargas FM, Abu-el-haija MA, Gomez-duarte OG. Salmonella infections: An update on epidemiology, management, and prevention. Travel Medicine and Infectious Disease (2011) 9, 263-277. 
  13. Typhoid In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar
  14. Princess Margaret Hospital CHAMP guidelines. Presumed Bacteraemia, Sepsis. Last revised 4th November 2013
  15. Malaria In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2015 Mar

Guideline Developed by: Anita Campbell (Infectious Diseases Fellow) July 2015
External Review: PMH Infectious Diseases Team August 2015
External Review: Zoy Goff (PMH Pharmacy Department) August 2015

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