|
|
|
Indian Pediatr 2017;54: 539-540 |
 |
Point-of-Care Diagnosis in Pediatric Practice
|
|
Anupam Sachdeva
National President – 2017, Indian Academy of
Pediatrics.
Email: [email protected]
|
|
I
nfectious diseases contribute to high morbidity
and mortality of humans since times immemorial. Their potential to
spread has resulted in epidemics and even pandemics of cholera,
influenza, tuberculosis and plague. Their spread within the hospitals
causing hospital-acquired infections in the growing population of
susceptible hosts (e.g., those with cancer, autoimmune diseases
and organ transplants) is another major concern for medical
professionals. Apart from well-recognized bacterial diseases, we also
have viral diseases (dengue, chikungunya, viral encephalitis), fungal
infections (candidiasis), parasitic infections (malaria, echino-coccosis,
trypanosomiasis, taeniasis, schistosomiasis), and now emerging and
re-emerging diseases. The exact burden of these diseases in the
developing countries, including India, is unknown due to
under-diagnosis, under-reporting and the lack of appropriate diagnostic
facilities. Two major landmarks in the history of communicable diseases
have been ‘hygiene revolution’ in the western world in early 19th
century (‘Swachh Bharat’ in India 200 years later), and the discovery of
antibiotics in the 20th century. However, the development of
antimicrobial resistance (natural and induced) and lack of development
of new molecules (discovery void) have led us to a post-antibiotic era
of antimicrobial resistance in microbes – a matter of great public
health concern leading to increased morbidity, mortality and increased
healthcare costs. This has caught the attention of world community of
medical professionals, economists, social scientists and various
political bodies, including United Nations.
Antimicrobial resistance (AMR) is linked to excessive
and inappropriate use of antimicrobials, self-medication, and excessive
use of antibiotics in agriculture and live-stock. This issue needs a
multipronged approach, which includes:
• improved specimen collection and transport from
bedside to laboratories
• improved diagnostic facilities using rapid
point-of-care testing, and development of immunodiagnostics,
biomarkers and genomic technology
• surveillance for infectious diseases and AMR
• health education regarding hygiene, antibiotic
prescription/consumption, AMR and adverse events associated with
antibiotic use among medical professional and public
• restricting agriculture and veterinary use of
antimicrobials
• development of new drug molecules
• promote use of vaccines and development of new
vaccines
• mandatory implementation of hospital infection
control practices, including hand hygiene
Recently, Ministry of Health, Government of India has
started an Initiative ‘National Program for AMR Containment’ [1], and
published National Treatment Guidelines for Antimicrobial Use in
Infectious Diseases [2]. All professional bodies/organizations in India
must discuss these at appropriate forums for early implementation. This
coupled with internationally recommended stewardship program is the
approach that requires implementation and urgent attention [3]. We
should develop our guidelines for common pediatric infections (diarrhea,
acute respiratory infections, skin and soft tissue infections, urinary
tract infections, enteric fever and meningoencephalitis), and also
prepare a document on appropriate dosages and adverse events.
Point-of-care diagnostic methods can make a
difference in rationalizing antibiotic therapy. Full blood count is one
of the commonly used blood test in practice. White cell count with
differential count is used widely by clinicians for risk assessment and
to decide the need for immediate treatment or for follow-up. It
constitutes an important tool in predicting the risk for bacterial
infection and deciding initiation of antibiotics in office-practice.
Point-of-care white cell counters (e.g., Hemocue) are currently
available, which can be used in outpatient departments, and white cell
counts with differential count can be made available instantly with a
simple finger prick method [4]. Thus, a decision to start antibiotics
can be made instantly in children presenting with fever and respiratory
illnesses. Studies have shown a significant reduction in antibiotic
usage with the use of point-of-care devices for white cell count,
without any influence on recovery and complications. Definitely, such
devices should be utilized in an optimal fashion to making instant
treatment decisions like withholding antibiotics in a stable child and
the need for urgent management in children with sick child with
leukocytosis and neutrophilia, especially if the fever has lasted for
more than three to four days.
Point-of-care echocardiography and ultrasonography
have greatly improved the management of critically ill children in
emergency departments and intensive care units. In a child presenting
with hypotension, apart from traditional physical examination, use of
point-of-care echocardiography provides valuable information that may
not be clinically evident. It discloses valuable information regarding
left ventricular function, child’s volume status, and evidence of
pericardial effusion and tamponade. Measurements of inferior vena caval
size and respiratory variation using point-of-care ultrasonography have
shown good correlation with central venous pressure and volume
responsiveness of the patient. More than a single assessment, serial
measurements after every intervention (like administration of fluid
boluses or inotropes) provide important feedback regarding the response
to these interventions and directs regarding the next appropriate step
of management. Point-of-care lung ultrasound is also gaining popularity
among intensivists. It allows fast, accurate, bedside evaluation of most
acute respiratory disorders. It also enables a pathophysiological
approach to circulatory failure. The versatility of ultrasound heralds a
kind of visual medicine, a priority in intensive care as well as many
other disciplines and settings [5].
References
1. Directorate General of Health Services, Ministry
of Health & Family Welfare, Government of India. National Programme on
Containment of Anti-Microbial Resistance. Available from:
http://dghs.gov.in/WriteReadData/user files/file/National_Programme_on_Containment_of_Anti
_Microbial_Resistance.pdf. Accessed June 24, 2017.
2. National Centre for Disease Control, Directorate
General of Health Services, Ministry of Health & Family Welfare,
Government of India. National Treatment Guidelines for Antimicrobial Use
in Infectious Diseases. Version 1.0 (2016). Available from:
http://pbhealth.gov.in/AMR_ guideline7001495889.pdf. Accessed June
24, 2017.
3. Bedi N, Gupta P. Antimicrobial stewardship in
pediatrics: An Indian perspective. Indian Pediatr. 2016;53:293-8.
4. Ivaska L, Niemelä J, Leino P, Mertsola J, Peltola
V. Accuracy and feasibility of point-of-care white blood cell count and
C-reactive protein measurements at the pediatric emergency department.
PLoS One. 2015;10:e0129920.
5. Rath C, Suryawanshi P. Point of care neonatal ultrasound - head,
lung, gut and line localization. Indian Pediatr. 2016;53:889-99.
|
|
|
 |
|
