Risk factors for adverse drug reactions in pediatric inpatients: a systematic review

Risk Factors Associated With Drug-Related Side Effects in Children: A Scoping Review

Objective. Children's vulnerability to drug-related side effects has been highlighted in several studies. However, there is no consensus on the risk factors associated with these side effects. This study aimed to investigate risk factors associated with drug-related side effects in children. Methods. This scoping review was conducted across multiple databases. The search strategy was created with a focus on drug-related side effects, as they are more predictable based on the pre-determined risk factors. Data were collected, and reported narratively. Results. The demographic, health, hospital, and drug-related risk factors may cause drug-related side effects in children. Among them, low age, sex, polypharmacy, length of hospitalization, and medications used for comorbidities may increase the risk. Conclusion. While most of the risk factors might be similar in adults and children, their impact might be different in these 2 groups. Therefore, future studies should identify more details about the impact of the risk factors in children.

The epidemiology of drug-related hospital admissions in paediatrics - a systematic review

BACKGROUND

Despite previous efforts, medication safety in paediatrics remains a major concern. To inform improvement strategies and further research especially in outpatient care, we systematically reviewed the literature on the frequency and nature of drug-related hospital admissions in children.

METHODS

Searches covered Embase, Medline, Web of Science, grey literature sources and relevant article citations. Studies reporting epidemiological data on paediatric drug-related hospital admissions published between 01/2000 and 01/2024 were eligible. Study identification, data extraction, and critical appraisal were conducted independently in duplicate using templates based on the 'Joanna Briggs Institute' recommendations.

RESULTS

The review included data from 45 studies reporting > 24,000 hospitalisations for adverse drug events (ADEs) or adverse drug reactions (ADRs). Due to different reference groups, a total of 52 relative frequency values were provided. We stratified these results by study characteristics. As a percentage of inpatients, the highest frequency of drug-related hospitalisation was found with 'intensive ADE monitoring', ranging from 3.1% to 5.8% (5 values), whereas with 'routine ADE monitoring', it ranged from 0.2% to 1.0% (3 values). The relative frequencies of 'ADR-related hospitalisations' ranged from 0.2% to 6.9% for 'intensive monitoring' (23 values) and from 0.04% to 3.8% for 'routine monitoring' (8 values). Per emergency department visits, five relative frequency values ranged from 0.1% to 3.8% in studies with 'intensive ADE monitoring', while all other eight values were ≤ 0.1%. Heterogeneity prevented pooled estimates. Studies rarely reported on the nature of the problems, or studies with broader objectives lacked disaggregated data. Limited data indicated that one in three (median) drug-related admissions could have been prevented, especially by more attentive prescribing. Besides polypharmacy and oncological therapy, no other risk factors could be clearly identified. Insufficient information and a high risk of bias, especially in retrospective and routine observational studies, hampered the assessment.

CONCLUSION

Given the high frequency of drug-related hospitalisations, medication safety in paediatrics needs to be further improved. As routine identification appears unreliable, clinical awareness needs to be raised. To gain more profound insights especially for generating improvement strategies, we have to address under-reporting and methodological issues in future research.

TRIAL REGISTRATION

PROSPERO (CRD42021296986).

Immunological Mechanisms in Cutaneous Adverse Drug Reactions

Adverse drug reactions (ADRs) are an inherent aspect of drug use. While approximately 80% of ADRs are predictable, immune system-mediated ADRs, often unpredictable, are a noteworthy subset. Skin-related ADRs, in particular, are frequently unpredictable. However, the wide spectrum of skin manifestations poses a formidable diagnostic challenge. Comprehending the pathomechanisms underlying ADRs is essential for accurate diagnosis and effective management. The skin, being an active immune organ, plays a pivotal role in ADRs, although the precise cutaneous immunological mechanisms remain elusive. Fortunately, clinical manifestations of skin-related ADRs, irrespective of their severity, are frequently rooted in immunological processes. A comprehensive grasp of ADR morphology can aid in diagnosis. With the continuous development of new pharmaceuticals, it is noteworthy that certain drugs including immune checkpoint inhibitors have gained notoriety for their association with ADRs. This paper offers an overview of immunological mechanisms involved in cutaneous ADRs with a focus on clinical features and frequently implicated drugs.

Adverse reactions to antimicrobials in pediatric patients admitted to a tertiary hospital: a cohort study

BACKGROUND

Antimicrobials are widely used in hospitals and are often associated with adverse drug reactions (ADRs). The objective of this study was to determine the incidence of ADRs caused by antimicrobials and classify them according to the type of reaction, the class of antimicrobials used, causality, severity and avoidability.

METHODS

A prospective cohort study was carried out with paediatric patients for 6 months. Causality was verified using the Naranjo and Liverpool algorithms, the severity was verified with the adapted scale of Hartwig and the avoidability was verified with the Liverpool Avoidability Assessment Tool.

RESULTS

A total of 303 patients were followed, and 18.2% (55/303) of them had one or more ADRs during the hospital stay. Just over half of the patients (28/55) had diarrhea. The most used antimicrobials were beta-lactams and second-generation cephalosporins. Suspicions were classified mainly as possible 78.6% (55/70) according to the Naranjo algorithm, and as probable 48.6% (34/70) according to the Liverpool algorithm. The antimicrobial most involved with ADRs was cefepime. The risk of manifesting ADR was greater with the use of some antimicrobials such as clindamycin (relative risk (RR) 3.0, CI 1.67 to 5.4), as well as with the increase in hospitalisation days (OR 1.022, CI 1.008 to 1.036) and in the number of antimicrobials prescribed (OR 1.649, CI 1.360 to 2.001).

CONCLUSION

ADRs were observed in approximately one-fifth of patients and were mostly gastrointestinal, moderate, unavoidable and with variable causality, depending on the algorithm used.

Adverse Drug Reactions to Anti-infectives in Hospitalized Children: A Multicenter Study in Brazil

INTRODUCTION

Adverse drug reactions (ADRs) to anti-infectives affect especially hospitalized children and contribute to increased morbidity, mortality, length of stay, and costs in healthcare systems.

OBJECTIVE

To assess ADRs associated with anti-infective use in Brazilian hospitalized children.

METHODS

A prospective cohort study was conducted in 5 public hospitals over 6 months. Children aged 0-11 years and 11 months who were hospitalized for more than 48 h and prescribed anti-infectives for over 24 h were included.

RESULTS

A total of 1020 patients met the inclusion criteria. Of these, 152 patients experienced 183 suspected ADRs. Most reactions were related to the gastrointestinal system (65.6%), followed by skin reactions (18.6%). Most reactions were classified as probable causality (58.5%), moderate severity (61.1%), and unavoidable (56.2%). Our findings showed that ADRs were associated with increased length of stay (P < .001), increased length of therapy (P < .015), increased days of therapy (P = .038), and increased number of anti-infectives prescribed per patient (P < .001).

CONCLUSION

Almost 15% of hospitalized children exposed to anti-infectives presented suspected ADRs. Their occurrence was classified as probable, of moderate severity, and unavoidable. ADRs were significantly influenced by the length of hospital stay and the number of anti-infectives prescribed per patient.

An Audit on Pharmacists' Knowledge and Experience in Pediatric Care

OBJECTIVE

The aim of this study was to determine pharmacists' perceived knowledge and expertise required to deliver pharmaceutical care services to pediatric patients.

METHODS

Once ethical approval was obtained, a questionnaire was posted on local pharmacy groups. The questionnaire is composed of 4 domains: 1) Demographics, 2) Perceived knowledge of pediatric treatment and dosing, 3) Real-life pediatric cases, and 4) Future aspirations to enhance pediatric pharmacy.

RESULTS

A total of 200 questionnaires were completed and submitted online. Most participants (62.5%) practiced in a community setting. Most respondents (40%) reported that 41% to 60% of their patients were pediatrics. In general, respondents had a good perception of their knowledge and expertise to deliver pharmaceutical care services to pediatric patients. However, most respondents had a low knowledge score when faced with real-life pediatric cases. On a scale of 7 most respondents obtained the score of 2 (32%).

CONCLUSIONS

The present study sheds light on an alarming lack of knowledge in pediatric pharmaceutics among pharmacies in Jordan. Further training and educational programs should be put in place to address this gap in knowledge.

Trends in Length of Stay and Readmissions in Children's Hospitals

BACKGROUND AND OBJECTIVES

Patient complexity at US children's hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children's hospitals.

METHODS

Retrospective cohort study of hospitalized patients from 42 children's hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix.

RESULTS

Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased (P < .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, P < .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; P = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; P < .001).

CONCLUSIONS

Across US children's hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children's hospitals are providing more efficient care for an increasingly complex patient population.

Predicting Adverse Drug Events in Chinese Pediatric Inpatients With the Associated Risk Factors: A Machine Learning Study

The aim of this study was to apply machine learning methods to deeply explore the risk factors associated with adverse drug events (ADEs) and predict the occurrence of ADEs in Chinese pediatric inpatients. Data of 1,746 patients aged between 28 days and 18 years (mean age = 3.84 years) were included in the study from January 1, 2013, to December 31, 2015, in the Children’s Hospital of Chongqing Medical University. There were 247 cases of ADE occurrence, of which the most common drugs inducing ADEs were antibacterials. Seven algorithms, including eXtreme Gradient Boosting (XGBoost), CatBoost, AdaBoost, LightGBM, Random Forest (RF), Gradient Boosting Decision Tree (GBDT), and TPOT, were used to select the important risk factors, and GBDT was chosen to establish the prediction model with the best predicting abilities (precision = 44%, recall = 25%, F1 = 31.88%). The GBDT model has better performance than Global Trigger Tools (GTTs) for ADE prediction (precision 44 vs. 13.3%). In addition, multiple risk factors were identified via GBDT, such as the number of trigger true (TT) (+), number of doses, BMI, number of drugs, number of admission, height, length of hospital stay, weight, age, and number of diagnoses. The influencing directions of the risk factors on ADEs were displayed through Shapley Additive exPlanations (SHAP). This study provides a novel method to accurately predict adverse drug events in Chinese pediatric inpatients with the associated risk factors, which may be applicable in clinical practice in the future.

Causality and avoidability of adverse drug reactions of antibiotics in hospitalized children: a cohort study

BACKGROUND

Adverse drug reactions are a problem in healthcare systems worldwide. Children are more susceptible than adults, especially when exposed to specific drug classes, such as antibiotics.

OBJECTIVE

To assess the incidence, causality, severity, and avoidability of antibiotic-associated adverse drug reactions in hospitalized pediatric patients.

SETTING

Pediatric ward of a high-complexity public hospital in northeast Brazil.

METHODS

A prospective cohort study was conducted over six months, including children aged between 28 days and 12 years, hospitalized for more than 48 h, and receiving antibiotics. Liverpool's causality and avoidability assessment tools were used. Primary outcome measures: Incidence of adverse drug reactions, causality, severity, and avoidability, major antibiotics implicated, risk factors.

RESULTS

A total of 183 patients were followed, and 35 suspected adverse drug reactions were recorded overall incidence equal to 14.7%. Most adverse drug reactions were classified as moderate severity (76.7%), probable (57.1%) and defined (28.6%) causality, and unavoidable (66.7%). The affected organs were the gastrointestinal system (74.1%) and skin (25.9%). Major antibiotics implicated were ceftriaxone (40.7%), azithromycin (25.9%), and crystalline penicillin (11.1%). The number of antibiotics prescribed per patient during hospitalization and the length of stay were the risk factors identified.

CONCLUSION

Causality and severity assessment indicated that most adverse drug reactions were probable and moderate. Possibly avoidable reactions occurred due to inappropriate prescribing when preventive measures were not implemented. Monitoring the use of antibiotics in children is essential to ensure the safety of these patients.

A 7-Years Active Pharmacovigilance Study of Adverse Drug Reactions Causing Children Admission to a Pediatric Emergency Department in Sicily

Children represent one of the most susceptible groups to adverse drug reactions (ADRs), as a consequence of physiological growth and maturation of different organ systems. The aim of this study was to characterize the frequency, preventability and seriousness of ADRs recorded in the Pediatric Emergency Department (ED) of the University hospital of Messina, in Sicily. All the suspected adverse reactions to drugs and vaccines collected from 2012 to 2018 were selected and then analyzed. Only adverse drug reactions (ADRs) with a probable or possible causality assessment were included, according to the Naranjo Algorithm and the World Health Organization criteria; the preventability assessment using Schumock and Thornton criteria was also carried out. The Medical Dictionary for Regulatory Activities (MedDRA) was used to group ADRs. Of 75,935 admissions to the Pediatric ED, 120 were due to suspected ADRs. The rate of hospital admission due to ADRs (75.8%) was significantly greater than that of patients without ADRs (11.9%). Among pediatric patients with ADRs the median (Q1–Q3) age was 29.5 (12–73.25) months. Most of ADRs were observed in infants and children (43.3% and 41.7%, respectively vs adolescents, 15%). In addition, in children with ADRs, females [41 (14–105)] were older than males [23 (11–45)] (p=0.044). Most adverse reactions were serious (75.8%) and 20.8% were preventable or probably preventable; however, the majority of serious ADRs (93.4%) resulted without sequelae. The reactions were found to be as probable (54.2%) or possible (45.8%). Vaccines (n=63), antibacterials (n=31) and anti-inflammatory medicines (n=14) were the most frequently drugs involved. Organ toxicity mapping due to vaccines was general disorders and administration site conditions (65.1%), nervous disorders (50.2%), cutaneous disorders (35%), followed by gastrointestinal disorders (20.6%). Cutaneous disorders (76%) gastrointestinal (20.7%), general (15.5%), and nervous disorders (8.6%) were the organ toxicity mapping due to drugs. Active pharmacovigilance has an essential role in supporting the development of strategies aimed at intervention to reduce admissions due to ADRs. Our data suggest that ADRs represent the first cause of hospitalization to the Pediatric Emergency Department. Furthermore, according to the literature, vaccines and antibiotics are the most frequent cause of adverse drug reactions in children.

Evaluation of potential drug-drug interactions in a pediatric population

Aim:

A large number of medications are prescribed in pediatric clinics and this leads to the development of drug–drug interactions (DDI) that may complicate the course of the disease. The aim of the study was to identify the prevalence of potential drug–drug interactions, to categorize main drug classes involved in severe drug–drug interactions and to highlight clinically relevant DDIs in a pediatric population.

Material and Methods:

A total of 1500 prescriptions during the 12-month study period were retrospectively reviewed; 510 prescriptions that comprised two or more drugs were included in study. The presence of potential drug–drug interactions was identified by using the Lexi-Interact database and categorized according to severity A (unknown), B (minor), C (moderate), D (major), and X (contraindicated).

Results:

There were 1498 drugs in 510 prescriptions; 253 of these (49.6%) included 2 drugs, 228 (44.7%) included 3–4 drugs, and 29 (5.6%) included ≥5 drugs. A total of 634 (42%) potential drug–drug interactions were idenfied. Among those, 271 (42.7%) were categorized as A, 284 (44.8%) as B, 53 (8.4%) as C, and 26 (4.1%) as D. There was no potential risk for X interaction. Anti-infectives (36%) were the most commonly prescribed drug classes involved in C and/or D categories. Clarithromycin was the most commonly interacting agent that interfered with budesonide.

Conclusion:

It is noteworthy that a significant number of drugs causing potential drug–drug interactions are prescribed together in pediatric clinics. Increasing the awareness of physicians on this issue will prevent potential complications and ensure patient safety.

Development and validation of a questionnaire for the assessment of the knowledge, management and reporting ADR in paediatrics by healthcare teams (QUESA-P)

OBJECTIVE

We aimed to develop and validate a new instrument called Questionnaire for the assessment of the knowledge, management and reporting ADR in Paediatrics by Healthcare teams (QUESA-P).

DESIGN

This is a cross-sectional study.

SETTINGS AND PARTICIPANTS

Teams of healthcare professionals (HCP) that lead with pharmacological therapy in Paediatrician's sector (Paediatric-HCP) in seven public hospitals in Brazil.

OUTCOME

An assessment of the knowledge and current management of ADR in Paediatric-HCP.

METHODS

We developed and validated QUESA-P, using a standardised procedure which included item development and psychometric prevalidation using Cronbach's Alpha, item-total correlation and test-retest validity for internal consistency and reliability. External criterion was used as criterion validation (the instrument was applied to the focus group expert vs focus group team of Paediatric-HCP in hospitals). The focus group of experts who participated in psychometrics was asked to respond to the QUESA-P twice in order to assess test-retest reliability. The content validity of the initial questionnaire was assessed by the Delphi method and pilot test. Subsequently, we made minor revisions and finalized the QUESA-P RESULTS: Selection of domains and facets were based on literature review made in duplicate by authors. Content validity was done by trial of different examiners (panellists, n=16), conducting analysis through Delphi method (three rounds). The QUESA-P was constructed with three domains. The intraclass correlations (0.80) and the Cronbach's alpha coefficient (0.82), indicated adequate test-retest reliability and internal consistency for each domain. The application of the QUESA to 61 Paediatric-HCP in hospital resulted in lower mean score of 42.1 ± 3.4 in all domains when compared with expert teams (n= 46) 48.2 ± 3.7 (p <0.001) indicating that the instrument is valid to discriminate QUESA experts and Paediatric-HCP.

CONCLUSION

The selected domains can be used to check weaknesses in the identification, management and reporting of suspected ADR by Paediatric-HCP in Brazil.

Adverse drug events in Chinese pediatric inpatients and associated risk factors: a retrospective review using the Global Trigger Tool

Understanding the epidemiology and risk factors of adverse drug events (ADEs) in pediatric inpatient is essential if we are to prevent, reduce or ameliorate the harm experienced. The Global Trigger Tool (GTT) is a method of retrospective medical record review that measures harm in hospitalized children. We employed a three-stage retrospective chart review of random samples of 1800 pediatric inpatients discharged from January 2013 to December 2015. 31 kinds of pediatric-specific triggers were made based on the previous trigger tool studies developed for use in adult or pediatric. Positive predictive value (PPV) of individual triggers, as well as ADEs detection rates were calculated. Stepwise logistic regression was performed to investigate risk factors associated with ADEs. Of 1746 patients, detected in 221 patients (12.7%) with 247 ADEs. The PPV of the trigger tool was 13.3%. Of the 247 ADEs, 82.6% were identified as category E, 11.7% category F and 5.7% category H. The pediatric-focused trigger tool is a feasible and useful tool for detecting pediatric ADEs. Especially for patients who have had more drugs, more doses or more admissions which needs to be closely monitored as triggers to improve the safety.

Risk factors for postoperative infection in Chinese lung cancer patients: A meta-analysis

OBJECTIVE

The objective of this study was to identify risk factors for postoperative infection in Chinese lung cancer patients.

METHODS

A comprehensive search was performed in PubMed, EMbase, CNKI, and WanFang Data databases to identify studies investigating risk factors for postoperative infection in Chinese lung cancer patients. Meta-analysis was performed by using Revman 5.2 software.

RESULTS

A total of 12 studies were included. The results of meta-analysis showed that old age, male gender, diabetes, cigarette smoking, squamous cell carcinoma, pulmonary diseases, longer of mechanical ventilation, and longer time of surgery procedure were associated with increased risk of postoperative infection. In addition, prophylactic antibiotic was associated with decreased risk of postoperative infection.

CONCLUSION

The current meta-analysis suggests that the old age, male gender, diabetes mellitus, cigarette smoking, squamous cell carcinoma, pulmonary diseases, longer of mechanical ventilation, and longer of surgery time are risk factors for postoperative infection in Chinese lung cancer patients. Due to the limited quality and quantity of included studies, more high-quality studies are needed to verify the above results.

Risk factors for adverse drug reactions in pediatric inpatients: A cohort study

Purpose

The present study aims to identify the risk factors for adverse drug reactions (ADR) in pediatric inpatients.

Methods

A prospective cohort study in one general pediatric ward in a hospital in Northeast Brazil was conducted in two stages: the first stage was conducted between August 17^th and November 6^th, 2015, and the second one between March 1^st and August 25^th, 2016. We included children aged 0–14 years 11 months hospitalized with a minimum stay of 48 hours. Observed outcomes were the ADR occurrence and the time until the first ADR observed. In the univariate analysis, the time to the first ADR was compared among groups using a log-rank test. For the multivariate analysis, the Cox regression model was used.

Results

A total of 173 children (208 admissions) and 66 ADR classified as “definite” and “probable” were identified. The incidence rate was 3/100 patient days. The gastro-intestinal system disorders were the main ADR observed (28.8%). In addition, 22.7% of the ADR were related to antibacterials for systemic use and 15.2% to general anesthesia. Prior history of ADR of the child [hazard ratio (HR) 2.44; 95% confidence interval (CI) 1.19–5.00], the use of meglumine antimonate (HR 4.98; 95% CI 1.21–20.54), antibacterial for systemic use (HR 2.75; 95% CI 1.08–6.98) and antiepileptic drugs (HR 3.84; 95% CI 1.40–10.56) were identified risk factors for ADR.

Conclusions

We identified as risk factors the prior history of ADR of the child and the use of meglumine antimonate, antibacterial for systemic use and antiepileptic drugs.