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Covid-19 is no worse in immunocompromised children, says NICE

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1802 (Published 01 May 2020) Cite this as: BMJ 2020;369:m1802
  1. Jacqui Wise
  1. London

Doctors should reassure parents and carers of children who are immunocompromised that immunosuppression does not seem to increase the risk of severe covid-19, the UK National Institute for Health and Care Excellence advises in a rapid guideline.1

“Covid-19 usually causes a mild, self-limiting illness in children and young people, even in those who are immunocompromised,” NICE says.

Children and teenagers who are immunocompromised and their carers may be feeling particularly anxious and fearful about covid-19, so it is important they are involved in decision making as much as possible, NICE advises. Doctors should also support patients’ and carers’ mental wellbeing through communication and by signposting to charities and support groups.

The guideline says that patients should not avoid their usual appointments unless they have been told to and should continue with their usual treatment. However, face-to-face contact should be reduced where safely possible and alternative approaches such as telephone, video, or email consultations used instead.

When deciding whether to start treatments that affect the immune system, doctors should discuss the risks and benefits with the patient and their carers. If it is safe to delay treatment then watchful waiting should be undertaken.

If covid-19 is suspected, patients and their carers are advised to contact their specialist team as soon as possible to ensure that any symptoms and underlying conditions are appropriately assessed. Doctors should advise patients and their carers to keep a list of the drugs they take and the conditions they have, and a copy of a recent clinic letter, to give to the healthcare staff if they need treatment for covid-19.

For children and teenagers with complex needs, carers should have a plan in place in case they themselves become ill.

The guideline points out that patients taking drugs that affect the immune response might have atypical presentations of covid-19; for example, patients taking prednisolone may not develop a fever.

NICE has also published a rapid guideline on the antibiotic management of pneumonia in adults in hospitals, to replace its existing guidance on pneumonia during the pandemic.2

“When a patient first presents with suspected pneumonia, it is difficult to differentiate between covid-19 pneumonia and bacterial pneumonia on clinical features alone,” the guideline says. It points out that during the covid-19 pandemic most cases of pneumonia have been viral and therefore antibiotics are ineffective unless there is a bacterial co-infection. Inappropriate antibiotic use may reduce their availability, and indiscriminate use may lead to Clostridioides difficile infection and antimicrobial resistance.

The guideline says the evidence so far is that bacterial co-infection occurs in less than 10% of patients with covid-19. However, likelihood of bacterial infection is higher among patients in critical care than among patients in other hospital wards or settings.

NICE says if there is confidence that the clinical features are typical for covid-19, it is reasonable not to start antibiotic treatment. However, empirical antibiotics should be started if there is clinical suspicion of bacterial infection. Treatment should be started within one hour if the patient has suspected sepsis.

Tests to inform decision making about antibiotic use include upper and lower respiratory tract specimens, chest imaging techniques, and a full blood count. The guideline says that evidence is insufficient to recommend routine procalcitonin testing to guide decisions on antibiotic use. NICE also warns, “Be aware that high C-reactive protein levels do not necessarily indicate that the pneumonia is due to bacteria rather than covid-19.”

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