Murphy’s article on the management of bloody diarrhoea in children in primary care (and indeed his interests, judging from his reference 1) seems to be orientated towards the early diagnosis and treatment of inflammatory bowel disease.1 Some of his recommendations, however, particularly figure 1, should therefore be expanded so as not to be problematic for the management of infection, in general, and verotoxin producing Escherichia coli O157, in particular.
Surveillance based on a GP sentinel scheme in Wales showed an incidence of bloody diarrhoea of 30/100 000 in under 15 year olds, 80% of which was caused by either salmonella or campylobacter infection,2 in line with Murphy’s estimates. Recognised infection with verotoxin producing E coli O157 is rare (1-2/100 000 per year in Wales), but early diagnosis—which, contrary to table 2, can usually be achieved by stool culture—is important:
Spread occurs readily in household3 and similar settings (such as children’s nurseries4) and affects primarily young children who are at high risk of developing life threatening haemolytic uraemic syndrome (HUS.)5
Diagnosis is a contraindication for antibiotic therapy and antimotility therapy
Outbreak detection is facilitated and thereby, hopefully, further cases are prevented.
The risk of household spread of verotoxin producing E coli O157 and its serious complications may be sufficient in certain circumstances (such as a young child in nappies with a similarly young sibling) to merit promptly admitting a child to hospital (or in some other way separating them from their siblings5) even if they are passing less than six bloody stools a day. Suspicion of the diagnosis, on clinical grounds such as severe abdominal pain or epidemiological grounds such as a history of contact with farm animals, even with no bloody stools (which may occur in less than 50% of cases), should lead to urgent steps to establish the diagnosis and communication with public health services, to ensure that urgent action is taken to prevent further cases.
Competing interests: None declared.
References
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