Background We performed a retrospective review of the management of clinically well children presenting to our PED with a petechial rash. Our management follows the NICE petechial pathway, however we feel that many children with a low risk of meningococcal sepsis receive intravenous (IV) antibiotics unnecessarily. In this study we used the Systemic Inflammatory Response Syndrome (SIRS) criteria to review the management of children with a petechial rash.
Methods We used SAP® Business Objects to search the hospital database for patients presenting with a petechial rash, September 2012–13. Cases were divided into those with or without evidence of SIRS (defined as core temperature <36oC or > 38.5oC, an elevated or depressed leukocyte count, tachypnoea and an abnormal heart rate). The management of the non-SIRS group was reviewed, including laboratory results, use of IV antibiotics and final outcome.
Results 69 cases of petechiae were identified, of which 55 (80%) did not meet the SIRS criteria. 22 (40%) of this group were given IV antibiotics of which 9 (41%) were admitted and 13 (59%) were ambulated. Of these, 18 were pyrexial, mean 38.5oC (range 37.5–40.2oC), 18 had a raised C-reactive protein (CRP), mean 32 mg/L (13–106 mg/L) and 6 had abnormal leukocyte counts, mean 14.9 × 109/L (2.5–20.6 × 109/L). There were no cases of proven sepsis. All 22 children had an uneventful recovery after a mean of 2 doses (1 to 3) of IV ceftriaxone. The remaining 14 children who had SIRS all received IV antibiotics but none had proven sepsis.
Conclusions In our study, 40% of children with a petechial rash but no evidence of SIRS received IV antibiotics. 59% were sent home with a line in-situ for ambulatory care, confirming the clinician view of a low risk of sepsis. No child proved to have sepsis. We believe the NICE petechiae pathway is over-cautious and we suggest that observation only is a valid strategy within a tight safety netting protocol. We recognise a larger scale study is needed to further assess our conclusion given the low prevalence yet significance of a case of meningococcal sepsis.