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Eldredge JA, Pittet LF, Gwee A. Incidence of amoxycillin-clavulanic acid associated hepatotoxicity in an Australian children's hospital. J Antimicrob Chemother 2024; 79:589-594. [PMID: 38297994 DOI: 10.1093/jac/dkae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVES Amoxycillin/clavulanic acid is the most common antimicrobial cause of drug-induced liver injury in adults. It is a less common cause of severe drug-related hepatotoxicity in children despite its frequent use. We studied the incidence, characteristics and predictive factors for amoxycillin/clavulanic acid hepatoxicity in children. DESIGN Retrospective cohort study of children who received oral or intravenous amoxycillin/clavulanic acid at a quaternary children's hospital over a 5-year period. Children were included if they had liver function tests (LFTs) determined at baseline, during and within 3 months after the treatment course. Causality was assessed using the Naranjo criteria for adverse drug reactions and Roussel Uclaf Causality Assessment Method. RESULTS Of 3271 children prescribed amoxycillin/clavulanic acid, 374 were included. Forty-nine (13%) had LFT abnormalities related to amoxycillin/clavulanic acid. Fourteen (3.6%) fulfilled Common Terminology Criteria for Adverse Events (CTCAE) grade 2 criteria with clinically significant hepatotoxicity. Age <2 years, sepsis, post-gastrointestinal surgical indications, prolonged treatment course of >7 days and higher cumulative amoxycillin (>10 g) and clavulanic acid dose (>1 g) were predictive of hepatotoxicity. The median time to resolution of LFT abnormalities was 4 weeks (range 3-7). CONCLUSIONS The incidence of amoxycillin/clavulanic acid related LFT abnormalities (CTCAE Grade 2 or above) in children was 3.6%. A prolonged treatment course >7 days, high cumulative amoxycillin (10 g) and clavulanic acid (>1 g) doses, those aged <2 years, and patients with sepsis or post-gastrointestinal surgery were predictive of a higher likelihood of abnormal LFTs. LFT monitoring should be considered in children receiving ≥7 days of treatment, particularly in those with other predisposing factors.
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Affiliation(s)
- Jessica A Eldredge
- Department of General Medicine, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Laure F Pittet
- Department of Paediatrics, Faculty of Medicine, Infectious Diseases Unit, Gynaecology and Obstetrics, University of Geneva and University Hospitals of Geneva, Geneva, Switzerland
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital Melbourne, Reception Level 2, West Building, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Amanda Gwee
- Department of General Medicine, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital Melbourne, Reception Level 2, West Building, 50 Flemington Road, Parkville, Victoria 3052, Australia
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Pérez Solís D, Gómez de Oña C, Nicieza García ML, Suárez Gil P, Pérez Solís P, Suárez Mier B, Rolle Sóñora V. Use of antibiotics in Paediatric Primary Health Care before and during the COVID-19 pandemic. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:529-534. [PMID: 36624035 PMCID: PMC9792423 DOI: 10.1016/j.eimce.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Consumption of antibiotics is high in Spain, primarily in children. Excessive use of then contributes to the development of antimicrobial resistance. The aim of our study is to analyse the evolution of antibiotic consumption at the Primary Health Care in the paediatric population of Asturias, Spain, from 2014 to 2021, and to evaluate the impact of COVID-19 pandemic on it. METHODS Retrospective and observational study using data about antibacterial agents for systemic use dispensed for official prescriptions to children under 14 years in Primary Care. Antibiotic consumption is expressed as defined daily dose (DDD) per 1000 inhabitants per day (DID). RESULTS The antibiotic consumption rate dropped from 13.9 DID in 2014 to 4.0 in 2021 (β=-1,42, p=0,002), with and inflection point in 2019. From 2019 to 2020 antibiotic use dropped by 47.1%. Antibiotic consumption remained very low from April 2020 to September 2021, and then moderately increased from October 2021. Prevalence of antibiotic use dropped from 39.9% in 2014 to 17.5% in 2021 (β=-3,64, p=0,006). Relative consumption of amoxicillin/clavulanic acid decreased, while those of amoxiciline and third-generation cephalosporins increased. CONCLUSIONS Paediatric antibiotic consumption collapsed in Asturias in 2020, coinciding with COVID-19 pandemic. Monitoring of antimicrobial usage indicators will allow to check if these changes are sustained over time.
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Affiliation(s)
- David Pérez Solís
- Servicio de Pediatría, Hospital Universitario San Agustín, Avilés, Spain.
| | - Constanza Gómez de Oña
- Servicio de Farmacia de Atención Primaria, Área Sanitaria V del Servicio de Salud del Principado de Asturias, Gijón, Asturias, Spain
| | - María Luisa Nicieza García
- Servicio de Farmacia, Dirección General de Política y Planificación Sanitarias, Consejería de Salud, Asturias, Spain
| | - Patricio Suárez Gil
- Plataforma de Bioestadística y Epidemiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
| | - Pablo Pérez Solís
- Medicina Familiar y Comunitaria, Centro de Salud Laviada, Gijón, Asturias, Spain
| | - Belén Suárez Mier
- Estrategia de Seguridad del Paciente, Dirección General de Calidad, Transformación y Gestión del Conocimiento, Consejería de Salud, Asturias, Spain
| | - Valeria Rolle Sóñora
- Plataforma de Bioestadística y Epidemiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
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Solís DP, de Oña CG, García MLN, Gil PS, Solís PP, Mier BS, Sóñora VR. [Use of antibiotics in Paediatric Primary Health Care before and during the COVID-19 pandemic]. Enferm Infecc Microbiol Clin 2022; 41:S0213-005X(22)00159-8. [PMID: 35911852 PMCID: PMC9318689 DOI: 10.1016/j.eimc.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/30/2022] [Indexed: 11/16/2022]
Abstract
Introduction Consumption of antibiotics is high in Spain, primarily in children. Excessive use of then contributes to the development of antimicrobial resistance. The aim of our study is to analyse the evolution of antibiotic consumption at the Primary Health Care in the paediatric population of Asturias, Spain, from 2014 to 2021, and to evaluate the impact of COVID-19 pandemic on it.Methods Retrospective and observational study using data about antibacterial agents for systemic use dispensed for official prescriptions to children under 14 years in Primary Care. Antibiotic consumption is expressed as defined daily dose (DDD) per 1000 inhabitants per day (DID).Results The antibiotic consumption rate dropped from 13.9 DID in 2014 to 4.0 in 2021 (β = -1,42, p=0,002), with and inflection point in 2019. From 2019 to 2020 antibiotic use dropped by 47.1%. Antibiotic consumption remained very low from April 2020 to September 2021, and then moderately increased from October 2021. Prevalence of antibiotic use dropped from 39.9% in 2014 to 17.5% in 2021 (β = -3,64, p=0,006). Relative consumption of amoxicillin/clavulanic acid decreased, while those of amoxiciline and third-generation cephalosporins increased.Conclusions Paediatric antibiotic consumption collapsed in Asturias in 2020, coinciding with COVID-19 pandemic. Monitoring of antimicrobial usage indicators will allow to check if these changes are sustained over time.
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Affiliation(s)
- David Pérez Solís
- Servicio de Pediatría, Hospital Universitario San Agustín, Avilés, España
| | - Constanza Gómez de Oña
- Servicio de Farmacia de Atención Primaria. Área Sanitaria V del Servicio de Salud del Principado de Asturias, Gijón, España
| | - María Luisa Nicieza García
- Servicio de Farmacia, Dirección General de Política y Planificación Sanitarias, Consejería de Salud, Asturias, España
| | - Patricio Suárez Gil
- Plataforma de Bioestadística y Epidemiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Pablo Pérez Solís
- Medicina Familiar y Comunitaria. Centro de Salud Laviada, Gijón, España
| | - Belén Suárez Mier
- Estrategia de Seguridad del Paciente, Dirección General de Calidad, Transformación y Gestión del Conocimiento, Consejería de Salud, Asturias, España
| | - Valeria Rolle Sóñora
- Plataforma de Bioestadística y Epidemiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
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Analysis of Immunogenetic Factors in Idiosyncratic Drug-induced Liver Injury in the Pediatric Population. J Pediatr Gastroenterol Nutr 2017; 64:742-747. [PMID: 28005582 DOI: 10.1097/mpg.0000000000001502] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Idiosyncratic drug-induced liver injury is a multifactorial complex disease, in which the toxic potential of the drug, together with genetic and acquired factors and deficiencies in adaptive processes, which limit the extent of damage, can determine susceptibility, and make individuals unique in their development of hepatotoxicity. The aim of the present study is to analyse the genetic factors (human leukocyte antigen [HLA], cytokine polymorphisms, and killer cell immunoglobulin-like receptor [KIR] genotype) of children who experience an episode of drug-induced liver injury. PATIENTS AND METHODS Prospective multicentre case-control study. The subjects included in the study were 30 paediatric patients-infants and children ages between 0 and 15 years and who presented possible liver disease associated with the intake of medicines, herbal products, drugs, or toxins. As a control group, 62 subjects were selected. RESULTS Although HLAC0401 and HLADQB0603 may provide a hepatoprotective mechanism in the paediatric population, HLADQA0102 and HLA-DR12 are more commonly found in sick children and their presence may be related to liver damage. The KIR inhibitor KIR3DL1 was not present in any child in the control group. CONCLUSIONS Polymorphisms that are low producers of interleukin-10 occur more frequently in children who have experienced hepatotoxicity.
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Schaaf HS, Thee S, van der Laan L, Hesseling AC, Garcia-Prats AJ. Adverse effects of oral second-line antituberculosis drugs in children. Expert Opin Drug Saf 2016; 15:1369-81. [PMID: 27458876 DOI: 10.1080/14740338.2016.1216544] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Increasing numbers of children with drug-resistant tuberculosis are accessing second-line antituberculosis drugs; these are more toxic than first-line drugs. Little is known about the safety of new antituberculosis drugs in children. Knowledge of adverse effects, and how to assess and manage these, is important to ensure good adherence and treatment outcomes. AREAS COVERED A Pubmed search was performed to identify articles addressing adverse effects of second-line antituberculosis drugs; a general search was done for the new drugs delamanid and bedaquiline. This review discusses adverse effects associated with oral second-line antituberculosis drugs. The spectrum of adverse effects caused by antituberculosis drugs is wide; the majority are mild or moderate, but these are important to manage as it could lead to non-adherence to treatment. Adverse effects may be more common in HIV-infected than in HIV-uninfected children. EXPERT OPINION Although children may experience fewer adverse effects from oral second-line antituberculosis drugs than adults, evidence from prospective studies of the incidence of adverse events in children is limited. Higher doses of second-line drugs, new antituberculosis drugs, and new drug regimens are being evaluated in children: these call for strict pharmacovigilance in children treated in the near future, as adverse effect profiles may change.
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Affiliation(s)
- H Simon Schaaf
- a Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - Stephanie Thee
- b Department of Paediatric Pneumology and Immunology , Charité, Universitätsmedizin Berlin , Berlin , Germany
| | - Louvina van der Laan
- a Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - Anneke C Hesseling
- a Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - Anthony J Garcia-Prats
- a Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
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Zhu Y, Li YG, Wang JB, Liu SH, Wang LF, Zhao YL, Bai YF, Wang ZX, Li JY, Xiao XH. Causes, Features, and Outcomes of Drug-Induced Liver Injury in 69 Children from China. Gut Liver 2016; 9:525-33. [PMID: 25717050 PMCID: PMC4477997 DOI: 10.5009/gnl14184] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Drug-induced liver injury (DILI) is a frequent cause of pediatric liver disease; however, the data on DILI are remarkably limited. Methods All 69 children hospitalized with DILI between January 2009 and December 2011 were retrospectively studied. Results A total of 37.7% of the children had medical histories of respiratory infection. The clinical injury patterns were as follows: hepatocellular 89.9%, cholestatic 2.9%, and mixed 7.2%. Liver biopsies from 55 children most frequently demonstrated chronic (47.3%) and acute (27.3%) hepatitis. Hypersensitivity features, namely, fever (31.9%), rash (21.7%), and eosinophilia (1.4%), were found. Twenty-four children (34.8%) developed chronic DILI. Antibiotics (26.1%) were the most common Western medicines (WMs) causing DILI, and the major implicated herbs were Ephedra sinica and Polygonum multiflorum. Compared with WM, the children whose injuries were caused by Chinese herbal medicine (CHM) showed a higher level of total bilirubin (1.4 mg/dL vs 16.6 mg/dL, p=0.004) and a longer prothrombin time (11.8 seconds vs 17.3 seconds, p=0.012), but they exhibited less chronic DILI (2/15 vs 18/39, p=0.031). Conclusions Most cases of DILI in children are caused by antibiotics or CHM used to treat respiratory infection and present with hepatocellular injury. Compared with WM, CHM is more likely to cause severe liver injury, but liver injury caused by CHM is curable.
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Affiliation(s)
- Yun Zhu
- Integrative Medicine Center, 302 Military Hospital, China.,Medical School of Chinese PLA, China
| | - Yong-Gang Li
- Integrative Medicine Center, 302 Military Hospital, China
| | - Jia-Bo Wang
- China Military Institute of Chinese Medicine, Beijing, China
| | - Shu-Hong Liu
- Department of Pathology, 302 Military Hospital, Beijing, China
| | - Li-Fu Wang
- Integrative Medicine Center, 302 Military Hospital, China
| | - Yan-Ling Zhao
- China Military Institute of Chinese Medicine, Beijing, China
| | - Yun-Feng Bai
- Integrative Medicine Center, 302 Military Hospital, China
| | - Zhong-Xia Wang
- Integrative Medicine Center, 302 Military Hospital, China
| | - Jian-Yu Li
- Integrative Medicine Center, 302 Military Hospital, China
| | - Xiao-He Xiao
- China Military Institute of Chinese Medicine, Beijing, China
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Effects of Amoxicillin and Clavulanic Acid on the Spontaneous Mechanical Activity of Juvenile Rat Duodenum. J Pediatr Gastroenterol Nutr 2015; 61:340-5. [PMID: 25844706 DOI: 10.1097/mpg.0000000000000804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES There are a limited number of medications for the treatment of foregut dysmotility. Enteral amoxicillin/clavulanic acid induces phase III duodenal contractions in a fasting pediatric patient. The mechanism by which this occurs is unknown. We examined the individual contributions of amoxicillin and clavulanic acid on the spontaneous mechanical activity of juvenile rat duodenum to better understand this phenomenon. METHODS Duodenal segments from juvenile rats were longitudinally attached to force transducers in organ baths. Samples were cumulatively exposed to amoxicillin or clavulanic acid. Separate samples were exposed to carbachol alone to assess response in both the presence and absence of amoxicillin or clavulanic acid. Basal tone, frequency, and amplitude of contractions were digitized and recorded. RESULTS The amplitude of the spontaneous contractions increased with amoxicillin. Inhibition of neuronal activity prevented this effect. Clavulanic acid did not affect the spontaneous contractions. Basal tone and the rate of contractions did not differ with either drug. Stimulation with carbachol in the presence of amoxicillin caused a statistically significant increase in the contractility compared with carbachol alone. CONCLUSIONS Amoxicillin alters the spontaneous longitudinal mechanical activity of juvenile rat duodenum. Our results suggest that amoxicillin modulates the spontaneous pattern of cyclic mechanical activity of duodenal smooth muscle through noncholinergic, neurally mediated mechanisms. Our work provides an initial physiologic basis for the therapeutic use of amoxicillin in patients with gastrointestinal dysmotility.
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Yazici C, Mutlu E, Bonkovsky HL, Russo MW. Risk factors for severe or fatal drug-induced liver injury from amoxicillin-clavulanic acid. Hepatol Res 2015; 45:676-82. [PMID: 25163514 DOI: 10.1111/hepr.12410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/01/2014] [Accepted: 08/19/2014] [Indexed: 12/21/2022]
Abstract
AIM To identify risk factors for severe liver injury or mortality from drug-induced liver injury (DILI) from amoxicillin-clavulanic acid. To determine if co-administration of potentially hepatotoxic drugs was associated with an increased risk of DILI from amoxicillin-clavulanic acid. METHODS We conducted a systematic review of the published work and data extraction of articles on DILI injury from amoxicillin-clavulanic acid. Potentially hepatotoxic drugs were defined as medications with DILI listed in the package insert or reported in the published work. Individual patient data were entered into an SPSS (version 17.0; Chicago, IL, USA) database and were analyzed using the χ(2) -test or Fisher's exact test; Student's t-test; and non-parametric tests such as Mann-Whitney U-test as appropriate. RESULTS We identified 3932 articles of which 41 publications with 255 reported cases met inclusion criteria. Mortality from DILI from amoxicillin-clavulanic acid was increased among patients receiving concomitant potentially hepatotoxic drugs compared with patients not on concomitant potential hepatotoxic drugs (21.4% [3/14] vs 2.3% [2/89], P = 0.017]. The most common classes of concomitant drugs were: antimicrobials, analgesics and hormonal therapy. Female patients were more likely to receive a concomitant potentially hepatotoxic medication (25% vs 9.1% for men, P = 0.05). CONCLUSION Patients who developed severe or fatal DILI from amoxicillin-clavulanic acid were more likely to be on concomitant hepatotoxic medications. Female patients were more likely to receive concomitant hepatotoxic drugs. Further studies are needed to investigate drug interaction between amoxicillin-clavulanic acid and concomitant potentially hepatotoxic drugs.
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Affiliation(s)
- Cemal Yazici
- Department of Medicine, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Ece Mutlu
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Herbert L Bonkovsky
- Department of Medicine, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Mark W Russo
- Department of Medicine, Carolinas HealthCare System, Charlotte, North Carolina, USA
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