A study of adverse drug reactions in pediatric patients

Antibiotic prophylaxis in pediatric dog bite injuries: Infection rates and prescribing practices

Objective

Pediatric dog bite injuries are a major public health concern and antibiotic prophylaxis is often prescribed due to concern about the development of infection. The Infectious Diseases Society of America recommends 3‒5 days of antibiotic prophylaxis for high-risk dog bites. The purpose of our study was to compare infection rates among patients receiving antibiotic prophylaxis and those who did not receive antibiotic prophylaxis.

Methods

We conducted a retrospective cohort study of children aged 3 months to 17 years enrolled in the healthcare systems' affiliated accountable care organization (ACO). Eligible children with a dog bite injury presented at an urgent care center or emergency department between 2016 and 2019. We excluded children who were immunosuppressed or had bites that required closure by a surgeon. An electronic health record review was completed and ACO claims data were used to determine if a prescription was filled. Patients with an International Classification of Diseases (ICD)-10 code concerning for infection within 7 days of injury were recorded as having a bite infection.

Results

A total of 2653 non-immunosuppressed children presented for care of dog bite injuries and 672 children met eligibility criteria. Thirty-five children developed an infection of their injury. Of the 539 children who received antibiotic prophylaxis, 5.8% developed an infection and 3.0% of the 133 children who did not receive antibiotic prophylaxis developed an infection (p = 0.28).

Conclusion

The overall infection rate for pediatric dog bite injuries was 5.2%. In our single-center study, no difference in infection rates was found between those receiving and not receiving antibiotic prophylaxis.

Safety of deer antler extract in children: A 12-week randomized controlled clinical trial

BACKGROUND

Deer antlers have been used as strong tonifying medicine in Asian countries, especially for the growth and development of children in pediatrics of Korean medicine. The safety of deer antler in adults cannot be applied directly to children because of their physiological characteristics. To accumulate reliable data on the safety of deer antler in pediatric populations, well-designed clinical studies are required.

METHODS

This research is a 12-week, randomized, double-blind, placebo-controlled clinical trial evaluating the safety of deer antler extract (DAE) in children. The DAE group received an intervention containing 1586 mg of DAE, whereas the control group received a placebo for 12 weeks. The safety was assessed by monitoring adverse drug reactions (ADRs) and laboratory test results.

RESULTS

One hundred participants were included in the safety analysis. Three and 2 participants in the DAE and control groups, respectively, reported ADRs. There was no significant difference in incidence between the 2 groups. ADRs are categorized into gastrointestinal and skin-related symptoms. No serious ADR was observed throughout the study. The laboratory test results were within or outside the normal range at clinically insignificant levels.

CONCLUSION

The research discovered that the DAE is safe in terms of ADRs and laboratory parameters under the conditions studied. Further studies are required to accumulate safety data about DAE dosage adjustment and potential interactions with other medicines.

Exploration and Evaluation of Adverse Drug Reactions Documented in a Tertiary-Care Hospital in Chennai: An In-Depth Retrospective Observational Study

INTRODUCTION

 While drugs are intended to benefit patients, adverse drug reactions (ADRs) represent a significant negative outcome of drug consumption. They rank as the sixth leading cause of death among hospitalized patients. Many harmful effects are preventable and can reduce morbidity, mortality, and hospitalization duration. This study is a valuable resource for physicians, aiding in the safe and optimal use of medications.

METHODOLOGY

 This retrospective observational study, conducted at the Pharmacovigilance Center of Saveetha Medical College and Hospital, Chennai, India, received approval from the Institutional Ethics Committee. All adverse drug interactions reported in our hospital from January 2019 to February 2024 were included after screening for inclusion and exclusion criteria. The collected reactions were analyzed, assessed, and evaluated between February 2024 and April 2024. Data on the drugs causing adverse reactions, the types of reactions, and the treatments administered were collected and documented. The reactions were categorized using the Rawlins and Thompson classification, while causality and severity were assessed using the standard Naranjo causality and modified Hartwig and Siegel severity assessment scales.

RESULTS

 During the study, 252 ADRs were documented by the Central Drugs Standard Control Organization. The gender distribution showed 123 cases (48.8%) in males and 129 cases (51.2%) in females, with a higher prevalence in the 20-40 age group. The departmentwise distribution revealed the highest number of ADRs in Obstetrics and Gynecology (60 cases, 24%), followed by General Surgery (52 cases, 21%), General Medicine (44 cases, 17%), Pediatrics (22 cases, 9%), and Emergency Medicine (20 cases, 8%). Antimicrobial drugs constituted the majority of ADRs (149 cases, 59.1%), followed by vitamins and mineral supplements (21 cases, 13.8%), contrast dye (15 cases, 6%), antituberculosis drugs (15 cases, 6%), analgesics (13 cases, 5.2%), and gastrointestinal (GIT) drugs (8 cases, 3.2%). Cefotaxime was the most commonly reported antibiotic (42 cases, 28.2%), followed by Ciprofloxacin (41 cases, 27.5%). Among vitamins and mineral supplements, iron sucrose was implicated in the highest number of ADRs (15 cases, 71.4%). The parenteral route of drug administration showed the highest incidence of ADRs (229 cases, 91%), followed by oral (20 cases, 8%) and topical routes (3 cases, 1%). Dermatological manifestations were most frequently reported (196 cases, 77.8%), followed by GIT symptoms (27 cases, 10.7%), and other manifestations such as shivering, fever, seizures, and dyspnea (29 cases, 11.5%). Based on the Naranjo causality assessment scale, 179 ADRs (71%) were categorized as probable, 55 (22%) as possible, 10 (4%) as certain, and 8 (3%) as doubtful. Approximately 47.2% of ADRs were self-limiting, while 44.1% required symptomatic treatment and 8.7% necessitated aggressive treatment, leading to a prolonged hospital stay or admission to the intensive care unit.

CONCLUSION

 The pattern of ADRs in our hospital aligns with findings from other studies. While many of these reactions are unpredictable and mild, they underscore the importance of raising awareness among clinicians and regulatory authorities to promote safe medication use and prevent potentially serious outcomes.

Should secondary pharmacogenomic variants be actively screened and reported when diagnostic genome-wide sequencing is performed in a child?

This white paper was prepared by the Global Alliance for Genomics and Health Regulatory and Ethics Work Stream's Pediatric Task Team to review and provide perspective with respect to ethical, legal, and social issues regarding the return of secondary pharmacogenomic variants in children who have a serious disease or developmental disorder and are undergoing exome or genome sequencing to identify a genetic cause of their condition. We discuss actively searching for and reporting pharmacogenetic/genomic variants in pediatric patients, different methods of returning secondary pharmacogenomic findings to the patient/parents and/or treating clinicians, maintaining these data in the patient's health record over time, decision supports to assist using pharmacogenetic results in future treatment decisions, and sharing information in public databases to improve the clinical interpretation of pharmacogenetic variants identified in other children. We conclude by presenting a series of points to consider for clinicians and policymakers regarding whether, and under what circumstances, routine screening and return of pharmacogenomic variants unrelated to the indications for testing is appropriate in children who are undergoing genome-wide sequencing to assist in the diagnosis of a suspected genetic disease.

Analysis of Adverse Drug Reactions in Pediatric Patients with Epilepsy: An Intensive Pharmacovigilance Study

Epilepsy is a chronic neurological disease characterized by the presence of spontaneous seizures, with a higher incidence in the pediatric population. Anti-seizure medication (ASM) may produce adverse drug reactions (ADRs) with an elevated frequency and a high severity. Thus, the objective of the present study was to analyze, through intensive pharmacovigilance over 112 months, the ADRs produced by valproic acid (VPA), oxcarbazepine (OXC), phenytoin (PHT), and levetiracetam (LEV), among others, administered to monotherapy or polytherapy for Mexican hospitalized pediatric epilepsy patients. A total of 1034 patients were interviewed; 315 met the inclusion criteria, 211 patients presented ADRs, and 104 did not. A total of 548 ASM-ADRs were identified, and VPA, LEV, and PHT were the main culprit drugs. The most frequent ADRs were drowsiness, irritability, and thrombocytopenia, and the main systems affected were hematologic, nervous, and dermatologic. LEV and OXC caused more nonsevere ADRs, and PHT caused more severe ADRs. The risk analysis showed an association between belonging to the younger groups and polytherapy with ADR presence and between polytherapy and malnutrition with severe ADRs. In addition, most of the severe ADRs were preventable, and most of the nonsevere ADRs were nonpreventable.

Pharmacovigilance in low- and middle-income countries: A review with particular focus on Africa

Low- and middle-income countries (LMIC) face unique challenges with regard to the establishment of robust pharmacovigilance systems capable of generating data to inform healthcare policy and practice. These include the limited integration and reliability of pharmacovigilance systems across LMIC despite recent efforts to harmonize pharmacovigilance rules and regulations in several regional economic communities. There are particular challenges relating to the need to translate reporting tools into numerous local languages and the low numbers of healthcare providers relative to number of patients, with very short consultation times. Additional factors frequent in LMIC include high uptake of herbal and traditional medication, mostly by self-medication; disruptive political conflicts jeopardizing fragile systems; and little or no access to drug utilization data, which makes it difficult to reliably estimate the true risks of medicines use. Pharmacovigilance activities are hindered by the scarcity of well-trained personnel with little or no budgetary support from national governments; high turnover of pharmacovigilance staff whose training involves a substantial amount of resources; and little awareness of pharmacovigilance among healthcare workers, decision makers and consumers. Furthermore, little collaboration between public health programmes and national medicines regulatory authorities coupled with limited investment in pharmacovigilance activities, especially during mass drug administration for neglected tropical diseases and mass vaccinations, produces major challenges in establishing a culture where pharmacovigilance is systematically embedded. Very low spontaneous reporting rates with poor quality reports hinders robust signal detection analyses. This review summarises the specific challenges and areas of progress in pharmacovigilance in LMIC with special focus on the situation in Africa.

Neonatal medium-sized vessel vasculitis: A rare case report

Vasculitis is a rare disorder during the neonatal period. We present a term male neonate of consanguineous parents and birthweight of 4 030 g who presented at 11 days of life with an evolving skin rash. There was no history of drug exposure in the neonate except for routine care. On day 7 of life, multiple erythematous plaques with necrotic or pustular centres appeared. There were no signs of mucosal involvement or sepsis and laboratory findings were normal. Skin biopsy revealed small and intermediate vessel vasculitis. At follow-up 2 weeks after discharge from the hospital, the skin lesions persisted, and at age 2 months, the patient presented with features of severe pneumonia and subsequently died. Vasculitis was reported as the cause of death on postmortem biopsy.

Information for children and young people about reporting suspected adverse drug reactions

BACKGROUND

When children and young people (CYP) report their own suspected adverse drug reactions (ADRs), different patterns of drugs and symptoms are noted. A new guide to reporting suspected ADRs using the Medicines and Healthcare Products Regulatory Agency (MHRA) Yellow Card scheme was developed by CYP, paediatric clinical pharmacology, Yellow Card Centres and the MHRA.

METHODS

An anonymous quality improvement project to assess the guide for CYP was undertaken (September 2020-February 2021).

RESULTS

The survey was completed by 234 CYP age 13-18 years. Within respondents, 68/226 (30.1%) were using medicines, 209/225 (92.9%) had used medicines previously, and 211/225 (93.8%) had heard of side effects. 79/225 (35.1%) believed they had experienced a side effect, with some requiring hospitalisation. Only 8/221 (3.6%) respondents were aware of the MHRA Yellow Card scheme.Overall, 182/196 (92.9%) of CYP both understood the guide and felt more knowledgeable about how to report suspected side effects. CYP comfortable to report their own suspected ADR increased from 179/222 (80.6%) before reading guide, to 189/196 (96.4%) after reading the new CYP guide. In addition, 156/196 (79.6%) believed they would report a side effect from a medicine used in future. Over 360 free-text comments were also received, providing comments about what was good about the new guide and areas for improvement that could be made.

CONCLUSION

The new guide for CYP to inform them about how to report a suspected ADR to the MHRA was well received and increased the knowledge, and confidence to report, in those who responded.

Pediatric Adverse Drug Reactions: An Observational Cohort Study After Health Care Workers' Training

OBJECTIVE

Adverse drug reactions (ADRs) in children are an important but underestimated public health issue. This study describes ADRs in a registered pediatric population of Bologna and demonstrates that ADRs might be better detected after health care personnel training.

METHODS

A prospective cohort was recruited from July 1, 2016, to June 30, 2019, after health care worker sensitization, and compared to a retrospective cohort enrolled from 2013 to 2016. The ADRs are classified by system organ classes and drugs are categorized according to the Anatomical Therapeutic Chemical classification system.

RESULTS

We retrospectively recruited 78 pediatric patients with ADRs in the 2013 to 2016 period, and we prospectively enrolled 127 children in the 2016 to 2019 period. In both periods, most of the ADRs reported were classified as non-serious reactions (68.8%). The most frequent ADRs were general and administration site disorders. During 2013 to 2016 vaccines were the most frequent cause of ADRs (83.3%;) and the main reporters were health care workers other than physicians (84.6%), whereas during the second period, medical doctors become the main signalers (65.4%) and ADRs related to vaccines significantly decreased (55.1%). During the 2016 to 2019 period the number of drug categories was higher than in the 2013 to 2016 period (24 vs 8). Patients with ADRs due to vaccinations present more frequently a favourable outcome (63%).

CONCLUSIONS

This study demonstrates that active pharmacovigilance and health care personnel sensitization are associated with improved ADR detection, providing valuable information about drugs' safety profile in pediatric patients.

Adverse Drug Reactions of Acetaminophen and Ibuprofen in the Paediatric Population: Analysis of the Italian Spontaneous Reporting Database

BACKGROUND

Acetaminophen and ibuprofen are the only antipyretics drugs approved in children, and are considered safe and well tolerated. However, data regarding the adverse drug reaction (ADR) profile of these drugs in children are scattered.

AIM

The aim of our study is to evaluate the ADRs of acetaminophen and ibuprofen through an observational study over a period of 15 years (January 2005-April 2020). Reports of suspected ADRs to the active substances 'acetaminophen' and 'ibuprofen' are listed and accessible through the Italian spontaneous reporting database (RAM system) by AIFA (Pharmacovigilance of the Italian Drug Agency).

METHODS

Acetaminophen ADRs in paediatric populations were 15% of cases, with more frequent involvement of skin and soft tissue (54.36%) and gastrointestinal apparatus (44.09%); liver dysfunction accounts for 5.67%.

RESULTS

Ibuprofen paediatric ADRs were 26%: skin and soft tissues in 63.16% of cases, gastrointestinal tract in 47.75%, hematemesis and melena in 6.38%; kidney injury in 2.25% of cases.

CONCLUSION

Children aged 2 to 11 are more frequently affected by ADRs than infants and adolescents. The risk of gastrointestinal and renal side effects is significantly higher with ibuprofen. Hepatobiliary side effects are more frequently linked to acetaminophen. Potentially fatal ADRs have been reported sporadically for both drugs.

Adverse Drug Reactions in the Pediatric Population: Findings From the Adverse Drug Reaction Monitoring Center of a Teaching Hospital in Odisha (2015-2020)

Background and objective

The incidence of adverse drug reactions (ADRs) in hospitalized children varies from 0.6-16.8%. There is a lack of uniformity and an absence of quality reporting with respect to the collection of data on ADRs worldwide, resulting in a scarcity of data regarding ADRs in children. In light of this, we aimed to analyze various factors related to ADRs in the pediatric population in the ADR Monitoring Center (AMC) of a teaching hospital in Odisha, India.

Methods

This was a record-based study conducted by the department of pharmacology in collaboration with the department of pediatrics. Detailed information regarding all ADR cases in children (<14 years of age) was collected in a format designed by the Indian Pharmacopoeia Commission (IPC). A total of 105 ADRs reported during a five-year period (2015-20) were subjected to analysis.

Results

The largest number of ADRs were reported in the age group zero to five years (41%). Males were affected more compared to females (1.7:1). Cutaneous ADRs were the most common type (86.5%) followed by the involvement of the gastrointestinal system (10%); 21% of cases were serious in nature, i.e., they required either hospitalization or led to a prolonged hospital stay. Antibiotics were the major drug category involved in causing drug reactions (66%) and among them, ceftriaxone (24.6%) was the most common causative agent.

Conclusions

One-fifth of the pediatric cases of ADRs were serious in nature. The most common causative agent was antibiotics, especially beta-lactams. There is an urgent need to raise awareness among healthcare professionals by conducting training programs to encourage the spontaneous reporting of ADRs, which will help to ensure drug safety in the pediatric population.

Evaluation of Adverse Drug Reactions in Paediatric Patients: A Retrospective Study in Turkish Hospital

Drug safety in paediatric patients is a serious public health concern around the world. The paediatric patients are more prone to adverse drug reactions (ADRs) than adults. Moreover, there is a scarcity of information about ADRs in paediatric patients. This study was conducted to determine the frequency, causality, severity, preventability of paediatric patients’ ADRs reported in a tertiary care hospital in Adana, Turkey. A retrospective study was conducted on all spontaneously reported ADRs between January 01, 2020, to July 30, 2021, in paediatric patients. The ADRs reports were evaluated in terms of gender, age, ADR characteristics, suspected drugs and reporting source. All included ADRs reports were characterized according to the Naranjo Algorithm/World Health Organization (WHO) causality scales, Hartwig/Siegel and Common Terminology Criteria for Adverse Events (CTCAE) severity scales, the modified Schoumock and Thornton preventability scale and hospital pharmacovigilance center criteria for seriousness. Therapeutic groups were also coded using the WHO-Anatomical Therapeutic and Chemical (ATC) classification. During the study period, 8,912 paediatric patients who were admitted had 16 ADRs with 1.7 ADRs/1,000 admissions. The majority of ADRs were found in infants (31.2%) and children (56.2%) as compared to adolescents (12.5%). ADRs were observed more in females (81.2%) than males. Skin (62.5%) was the most affected organ due to the ADRs, and maculopapular rash and erythema multiforme were the most commonly reported symptoms. Most ADRs were probable/likely (93.7%), severe (50%), preventable or probably preventable (43.7%) and serious (37.5%). Antibiotics (93.7%) were found to be the most common cause of ADRs in paediatric patients. The majority of ADRs were associated with vancomycin (68.7%). Most of the ADRs were reported by a medical doctor in this study. This small sample size study highlights significant problems of ADRs in paediatric patients, mainly caused by antibiotics and with a majority of ADRs manifest as skin reactions. Furthermore, a high proportion of the identified ADRs were found to be preventable. More focused efforts are needed at the national level to avoid preventable ADRs in hospitals. Monitoring and management of ADRs and future studies would be beneficial for better patient care and safety.

Methods for the detection of adverse drug reactions in hospitalized children: a systematic review

Introduction: Adverse drug reactions (ADR) are a problem for healthcare systems worldwide. Pediatric patients constitute a vulnerable group with regard to ADRs. However, although pediatric patients are at increased risk for these reactions, there is little progress on ADR detection methods in this group.Areas covered: In this systematic search, performed according to PRISMA statements, we selected studies, published in PubMed/Medline databases; Scopus; LILACS; Web of Science; Embase and Cochrane Library until April, 2020, on ADRs in hospitalized pediatric patients.Expert opinion: The increase of pediatric drug safety data is essential to the improvement of childcare. Health services must continuously stimulate educational programs focused on ADR detection tools to minimize the barriers and raise awareness among professionals. Therefore, it is necessary to consider that each method has advantages and disadvantages and must be analyzed in detail to be implemented according to the peculiarities of each practice scenario. Triggers tools (active method) correlated with electronic medical notes seems a good strategy for ADR identification, whether pediatric parameters are well checked and adapted with each age group. In any event, combined methods will add data to identification and clearer ADR assessment.

The Burden of Preventable Adverse Drug Events on Hospital Stay and Healthcare Costs in Japanese Pediatric Inpatients: The JADE Study

Background:

Adverse drug events (ADEs) are a burden to the healthcare system. Preventable ADEs, which was ADEs due to medication errors, could be reduced if medication errors can be prevent or ameliorate.

Objective:

We investigated the burden of preventable ADEs on the length of hospital stay (LOS) and costs, and estimated the national burden of preventable ADEs in pediatric inpatients in Japan.

Methods:

We analyzed data from the Japan Adverse Drug Events (JADE) study on pediatric patients and estimated the incidence of preventable ADEs and associated extended LOS. Costs attributable to extended LOS by preventable ADEs were calculated using a national statistics database and we calculated the effect of preventable ADEs on national cost excess.

Results:

We included 907 patients with 7377 patient-days. Among them, 31 patients (3.4%) experienced preventable ADEs during hospitalization. Preventable ADEs significantly increased the LOS by 14.1 days, adjusting for gender, age, ward, resident physician, surgery during hospitalization, cancer, and severe malformation at birth. The individual cost due to the extended LOS of 14.1 days was estimated as USD 8258. We calculated the annual extra expense for preventable ADEs in Japan as USD 329 676 760. Sensitivity analyses, considering the incidence of preventable ADEs and the length of hospital stay, showed that the expected range of annual extra expense for preventable ADEs in Japan is between USD 141 468 968 and 588 450 708.

Conclusion:

Preventable ADEs caused longer hospitalization and considerable extra healthcare costs in pediatric inpatients. Our results would encourage further efforts to prevent and ameliorate preventable ADEs.

Relationship between adverse drug reactions and unlicensed/off-label drug use in hospitalized children (EREMI): A study protocol

INTRODUCTION

To date, few studies have shown a significant association between off-label drug use and adverse drug reactions (ADRs). The main aims of this study is to evaluate the relationship between adverse drug reactions and unlicensed or off-label drugs in hospitalized children and to provide more information on prescribing practice, the amplitude, consequences of unlicensed or off-label drug use in pediatric inpatients.

METHODS

In this multicenter prospective study started from 2013, we use the French summaries of product characteristics in Theriaque (a prescription products guide) as a primary reference source for determining pediatric drug labeling. The detection of ADRs is carried out spontaneously by health professionals and actively by research groups using a trigger tool and patients' electronic health records. The causality between suspected ADRs and medication is evaluated using the Naranjo and the French methods of imputability independently by pharmacovigilance center. All suspected ADRs are submitted for a second evaluation by an independent pharmacovigilance experts.

STRENGTH AND LIMITATIONS OF THIS STUDY

For our best knowledge, EREMI is the first large multicenter prospective and objective study in France with an active ADRs monitoring and independent ADRs validation. This study identifies the risk factors that could be used to adjust preventive actions in children's care, guides future research in the field and increases the awareness of physicians in off-label drug use and in detecting and declaring ADRs. As data are obtained through extraction of information from hospital database and medical records, there is likely to be some under-reporting of items or missing data. In this study the field specialists detect all adverse events, experts in pharmacovigilance centers assess them and finally only the ADRs assessed by the independent committee are confirmed. Although we recruit a high number of patients, this observational study is subject to different confounders.

No population left behind: Improving paediatric drug safety using informatics and systems biology

Adverse drugs effects (ADEs) in children are common and may result in disability and death. The current paediatric drug safety landscape, including clinical trials, is limited as it rarely includes children and relies on extrapolation from adults. Children are not small adults but go through an evolutionarily conserved and physiologically dynamic process of growth and maturation. Novel quantitative approaches, integrating observations from clinical trials and drug safety databases with dynamic mechanisms, can be used to systematically identify ADEs unique to childhood. In this perspective, we discuss three critical research directions using systems biology methodologies and novel informatics to improve paediatric drug safety, namely child versus adult drug safety profiles, age-dependent drug toxicities and genetic susceptibility of ADEs across childhood. We argue that a data-driven framework that leverages observational data, biomedical knowledge and systems biology modelling will reveal previously unknown mechanisms of pediatric adverse drug events and lead to improved paediatric drug safety.

Suspected Overlap Between Serotonin Syndrome and Neuroleptic Malignant Syndrome in a Child Treated With Metoclopramide?

A 19-month-old child presented with fever and acute neurological deterioration with hypertonia, tremors, and clonus 1 day after starting metoclopramide. The clinical course of the patient was suggestive of neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS), which can both be triggered by metoclopramide. This first pediatric report of an overlap between NMS and SS associated to metoclopramide highlights the importance of considering this new entity and its consequences on treatment.

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.

Improvement in the Analysis of Vaccine Adverse Event Reporting System Database

As a national public health surveillance resource, Vaccine Adverse Event Reporting System (VAERS) is a key component in ensuring the safety of vaccines. Numerous methods have been used to conduct safety studies with the VAERS database. These efforts focus on the downstream statistical analysis of the vaccine and adverse event associations. In this paper, we primarily focus on processing the raw data in VAERS before the analysis step, which is also an important part of the signal detection process. Due to the semi-annual update in the Medical Dictionary for Regulatory Activities (MedDRA) coding system, adverse event terms that describe the same symptom might change in VAERS; therefore, we identify these terms and combine them to increase the signal detection power. We also consider the uncertainty of the vaccine and adverse event pairs that arise from reports with multiple vaccines. Finally, we discuss four commonly used statistics in assessing the vaccine and adverse event associations, and propose to use the statistics that are robust to the reporting bias in VAERS and adjust for potential confounders of the vaccine and adverse event association to increase signal detection accuracy.

Pharmacovigilance Reports Received from Children and Young People, and Development of Information to Aid Future Reporting from this Age Group

OBJECTIVES

This study aimed to determine the contribution of children and young people (CYP) to the Medicines and Healthcare Products Regulatory Agency (MHRA) Yellow Card Scheme (YCS), and to develop age appropriate information with CYP through focus groups to help aid future reporting by this cohort.

METHODS

Reports for suspected adverse drug reactions (ADRs) in patients < 19 years of age received by the MHRA YCS from 1 January 2008 to 29 November 2018 were collated and analysed. Consultation activities with CYP from regional, national and international groups were undertaken from November 2017 to July 2018 to develop CYP-appropriate information from current available literature about reporting ADRs to the YCS.

RESULTS

CYP contributed 2.3% of YCS reports for patients < 19 years (948 self-reports from a total of 41,630 YCS reports). Patients from 10 years of age contributed YCS reports, and the number of CYP reports represented in the total YCS reports rose by 3% in October 2018 compared with the previous year. Self-reported YCS from the CYP contain different suspected medications and reactions compared with YCS reported on behalf of patients aged < 19 years. The most reported medicines by self-reported YCS from CYP were adolescent vaccinations (such as the human papilloma virus [HPV] vaccine, n = 69), oral contraceptives, acne medication, anti-infectives, and antidepressants. The most commonly reported suspected ADRs submitted by CYP to the YCS were headache (n = 107), nausea and fatigue. CYP-generated reports included alternative suspected ADRs compared with adult reports about ADRs in CYP; these included depression, anxiety and suicidal ideation. The second part of the study used focus groups involving CYP from various backgrounds to develop two information leaflets regarding reporting suspected ADRs in the YCS; this was highlighted in phase I by CYP who identified divergent information needs dependent on age. Phase II-VI updated and improved the relevant information required for both age groups in a succinct and satisfactory manner. Overall, more than 300 CYP contributed to the development of the information.

CONCLUSIONS

CYP's contribution to the YCS is limited, but increasing, and demonstrates distinct patterns of suspected medications and reactions. Age-appropriate information for CYP to aid reporting of suspected ADRs has been developed.

Induced pluripotent stem cells for therapy personalization in pediatric patients: Focus on drug-induced adverse events

Adverse drug reactions (ADRs) are major clinical problems, particularly in special populations such as pediatric patients. Indeed, ADRs may be caused by a plethora of different drugs leading, in some cases, to hospitalization, disability or even death. In addition, pediatric patients may respond differently to drugs with respect to adults and may be prone to developing different kinds of ADRs, leading, in some cases, to more severe consequences. To improve the comprehension, and thus the prevention, of ADRs, the set-up of sensitive and personalized assays is urgently needed. Important progress is represented by the possibility of setting up groundbreaking patient-specific assays. This goal has been powerfully achieved using induced pluripotent stem cells (iPSCs). Due to their genetic and physiological species-specific differences and their ability to be differentiated ideally into all tissues of the human body, this model may be accurate in predicting drug toxicity, especially when this toxicity is related to individual genetic differences. This review is an up-to-date summary of the employment of iPSCs as a model to study ADRs, with particular attention to drugs used in the pediatric field. We especially focused on the intestinal, hepatic, pancreatic, renal, cardiac, and neuronal levels, also discussing progress in organoids creation. The latter are three-dimensional in vitro culture systems derived from pluripotent or adult stem cells simulating the architecture and functionality of native organs such as the intestine, liver, pancreas, kidney, heart, and brain. Based on the existing knowledge, these models are powerful and promising tools in multiple clinical applications including toxicity screening, disease modeling, personalized and regenerative medicine.

Naranjo Question Answering using End-to-End Multi-task Learning Model

In the clinical domain, it is important to understand whether an adverse drug reaction (ADR) is caused by a particular medication. Clinical judgement studies help judge the causal relation between a medication and its ADRs. In this study, we present the first attempt to automatically infer the causality between a drug and an ADR from electronic health records (EHRs) by answering the Naranjo questionnaire, the validated clinical question answering set used by domain experts for ADR causality assessment. Using physicians' annotation as the gold standard, our proposed joint model, which uses multi-task learning to predict the answers of a subset of the Naranjo questionnaire, significantly outperforms the baseline pipeline model with a good margin, achieving a macro-weighted f-score between 0.3652 - 0.5271 and micro-weighted f-score between 0.9523 - 0.9918.

Adverse Drug Events and Reactions Managed by Medical Toxicologists: an Analysis of the Toxicology Investigators Consortium (ToxIC) Registry, 2010-2016

INTRODUCTION

Adverse drug events/reactions (ADE/ADRs) cost more than $30 billion annually and are among the leading causes of death in the USA. Little is known about patients treated at the bedside for ADE/ADR by medical toxicologists.

METHODS

We conducted a retrospective study of ADE/ADR cases reported to the Toxicology Investigators Consortium (ToxIC) registry between January 1, 2010, and December 31, 2016. Clinical and demographic data were collected including age, sex, circumstances surrounding exposure, suspected offending substance, clinical manifestations, treatment, disposition, and outcome.

RESULTS

Among 51,440 ToxIC cases during this time period, 673 ADE/ADR cases were reported (337 females). By age, ADE/ADRs were seen most commonly among adults age 19-65 years (442/673, 65.7% of ADE/ADR) and older adults age 65-89 years (134/673, 19.9% of ADE/ADR). 222/673 (33%) of consults for ADE/ADR were seen in the emergency department (ED); 181/673 (26.9%) were seen in the hospital ward; and 160/673 (23.8%) were seen in the intensive care unit (ICU). The most commonly reported sign for ADE/ADR was tachycardia: 51/673 (7.6%), followed by bradycardia: 49/673 (7.3%). Most commonly reported agents associated with ADE/ADR were as follows: 97/673 (14.4%) due to cardiovascular medications; 76/673 (11.3%) due to antipsychotic medications; and 61/673 (9.1%) due to antidepressants. 429/673 (63.7%) of ADE/ADR were reported as due to a single agent, and 212/673 (31.5%) were reported as due to multiple agents.

CONCLUSIONS

4.2% of cases managed at the bedside by a consulting toxicologist and reported to the ToxIC registry between 2010 and 2016 had ADE/ADR as the reason for consultation. Agents most commonly involved in ADE/ADRs included cardiovascular medications, antipsychotic medications, and antidepressants.

Clinical Judgement Study using Question Answering from Electronic Health Records

Clinical judgement studies are essential for recognising the causal relation of a medication with adverse drug reactions (ADRs). Traditionally, these studies are conducted via expert manual chart review. By contrast, we propose an end-to-end deep learning question answering model to automatically infer such causal relations. Our proposed model identifies the causal relation by answering a subset of Naranjo questionnaire Naranjo et al. (1981) from electronic health records. It employs multi-level attention layers along with local and global context while answering these questions. Our proposed model achieves a macroweighted F-score of 0.4598 - 0.5142 across the selected questions and an overall F-score of 0.5011. We also did an ablation study to validate the importance of local and global context for the model.

The practice of off label prescribing and associated adverse drug reactions in pediatric inpatients in a tertiary care hospital in India

Objectives

To assess the extent of use, patterns, variables and Adverse Drug Reactions associated with off label prescribing in Pediatrics.

Methods

A prospective observational study was conducted for a period of 6 months for children of the age group 0-17 years in a tertiary care Hospital in Maharashtra, India. Off label drug use was assessed using Micromedex and British National Formulary for Children (BNFC 2016–2017). Adverse Drug Reactions (ADRs) were assessed according to the physicians' notes, recorded during the patient's hospital stay. Pearson correlation coefficient was computed to assess the relationship between age and the number of off-label drugs. Odds ratio was calculated for the occurrence of ADRs in on-label prescriptions Vs off label-prescriptions. A P value of &lt;0.05 was considered as significant.

Key findings

A total of 1514 prescriptions were evaluated in 300 patients. Out of which 542 (35.79%) and 423 (27.9%) were off label according to Micromedex and BNFC respectively. The number of patients who received at least one off label was found to be 225 (75%) – Micromedex and 223 (74.3%) – BNFC Unspecified indication and use of drugs outside the specified age limit were identified as the main variables associated with off label prescribing. Highest proportion of off-label drugs was found in Alimentary system. A total of 35 ADRs (OR 6.92 CI 95%(OR 6.92, 95% CI, 3.13-15.27)) were identified in 31 patients.

Conclusions

Off-label drug use is prevalent in the pediatric population and warrants an evidence-based approach to improve prescribing practices in pediatrics.

Serious Adverse Events Associated with Off-Label Use of Azithromycin or Fentanyl in Children in Intensive Care Units: A Retrospective Chart Review

OBJECTIVES

Half of prescription drugs commonly given to children lack product labeling on pediatric safety, efficacy, and dosing. Two drugs most widely used off-label in pediatrics are azithromycin and fentanyl. We sought to determine the risk of serious adverse events (SAEs) when oral azithromycin or intravenous/intramuscular fentanyl are used off-label compared to on-label in pediatric intensive care units (ICUs).

STUDY DESIGN

Six pediatric hospitals participated in a retrospective chart review of patients administered oral azithromycin (n = 241) or intravenous/intramuscular fentanyl (n = 367) between January 5, 2013 and December 26, 2014. Outcomes were SAEs by drug and labeling status: off-label compared to on-label by Food and Drug Administration (FDA)-approved age and/or indication. Statistical analysis was performed using logistic regression to estimate odds ratios (ORs) and Cox regression to estimate hazard ratios (HRs).

RESULTS

Twenty-one (9%) children receiving azithromycin experienced SAEs. Off-label use of azithromycin was not associated with a higher risk of SAE (OR 0.87, 95% CI 0.27-2.71, p = 0.81). Ninety-five (26%) children receiving fentanyl experienced SAEs. Fentanyl off-label use by both age and indication was not associated with a higher risk of overall SAEs compared to on-label use (OR 1.99, 95% CI 0.94-4.19, p = 0.07). However, the risk of the SAE respiratory depression was significantly greater when fentanyl was used off-label by both age and indication (OR 5.05, 95% CI 1.08-23.56, p = 0.044). Results based on HRs were similar.

CONCLUSIONS

Azithromycin off-label use in pediatric ICUs does not appear to be associated with an increased risk of SAEs. Off-label use of fentanyl appears to be more frequently associated with respiratory depression when used off-label by both age and indication in pediatric ICUs. Prospective studies should be undertaken to assess the safety and efficacy of fentanyl in the pediatric population so that data can be added to the FDA labeling.

Evaluation of Reported Adverse Drug Reactions in Antibiotic Usage: A Retrospective Study From a Tertiary Care Hospital, Malaysia

Adverse drug reaction (ADR) primarily caused by many drugs including antibiotics. At present, the incidence and pattern of ADR caused by antibiotics have remained as neglected area in Malaysia. This study was conducted to determine the incidence and analyze the pattern of ADR caused by antibiotics among patients in a tertiary care hospital. It is a 2-year retrospective observational study conducted at Hospital Pulau Pinang, Malaysia. All eligible patients who had antibiotic prescribed belonging to any age group either from outpatient or inpatient that had experienced ADR was included in this study. The outcomes were measured with the aid of Naranjo’s and Hartwig’s scales. The incidence of the ADRs among patients prescribed with antibiotics in Hospital Pulau Pinang is about 1.1%. Vancomycin and Trimethoprim/Sulfamethoxazole both are considered to be the major contributors to ADR incidences. The skin was the most affected organ by ADRs followed by gastrointestinal system. Most of the severe ADRs were caused by Penicillin. The causality relationship of all the severe reactions was mostly probable. General Medicine unit had reported the highest number of ADRs caused by antibiotics. The common manifestations of ADRs are acute kidney injury and exanthem. In addition, majority of the ADRs caused by antibiotics were reversible. A large multicenter study is suggested to confirm the present findings.

Surveillance study on the tolerability and safety of Flebogamma® DIF (10% and 5% intravenous immunoglobulin) in adult and pediatric patients

Direct comparisons of tolerability and safety of concentrated intravenous immunoglobulin (IVIG) versus less concentrated products are scarce. In this postauthorization, prospective, observational, multicenter study, a systematic comparison of 10% and 5% concentrations of Flebogamma® DIF IVIG was performed in both adult and pediatric patients treated with the studied IVIG products according to the approved indications under routine conditions. Dose of product administered, adverse events (AEs), physical assessments, laboratory tests, and concomitant therapy were analyzed. Patient recruitment in the 10% and 5% product groups was, respectively, 34 (32 analyzed, 13 of them children, receiving 130 IVIG infusions) and 35 (34 analyzed, receiving 135 IVIG infusions). Twenty‐four infusions (18.5%; 95% CI: 11.8, 25.1) with the 10% product and 3 (2.2%; 95% CI: −0.3, 4.7) with the 5% product were associated with potentially treatment‐related AEs (P < 0.0001). Nine patients (28.1%) infused with the 10% product and 3 (8.8%) infused with the 5% product presented, respectively, 33 and 8 treatment‐related AEs (of which 7 and 6, respectively, were serious AEs, experienced by only three hypersensitive patients). The profile of AEs occurring with the infusion of 10% and 5% products were comparable. The most frequent treatment‐related AEs were headache (n = 17, 3 patients; 15 episodes, 1 patient) and pyrexia (n = 6, 4 patients). In conclusion, no unpredictable risk was detected for both Flebogamma DIF 10% and 5% concentrations, which were therefore deemed as safe and well‐tolerated IVIG in the studied population. The frequency of infusions associated with treatment‐related AEs was lower with the 5% concentration.

Characterization of serious adverse drug reactions as cause of emergency department visit in children: a 5-years active pharmacovigilance study

Background

To describe frequency, preventability and seriousness of adverse drug reactions (ADRs) in children as cause of emergency department (ED) admission and to evaluate the association between specific factors and the reporting of ADRs.

Methods

A retrospective analysis based on reports of suspected ADRs collected between January 1st, 2012 and December 31st, 2016 in the ED of Meyer Children’s Hospital (Italy). Demographics, clinical status, suspected drugs, ADR description, and its degree of seriousness were collected. Logistic regression was used to estimate the reporting odds ratios (RORs) with 95% confidence intervals (CIs) of potential predictors of ADR seriousness.

Results

Within 5 years, we observed 834 ADRs (1100 drug-ADR pairs), of whom 239 were serious; of them, 224 led to hospitalization. Patients were mostly treated with one drug. Among patients treated with more than one drug, 78 ADRs presented a potential interaction. The most frequently reported ADRs involved gastrointestinal system. The most frequently reported medication class was antinfectives. Risk of serious ADR was significantly lower in children and infants compared to adolescents (ROR 0.41 [95% CI: 0.27–0.61] and 0.47 [0.32–0.71], respectively), and it was significantly increased in subjects exposed to more than one drug (ROR 1.87 [1.33–2.62] and 3.01 [2.07–4.37] for subjects exposed to 2 and 3 or more drugs, respectively). Gender, interactions and off-label drug use did not influence the risk of serious ADRs.

Conclusion

Active surveillance in pharmacovigilance might represent the best strategy to estimate and characterize the clinical burden of ADRs in children.

Electronic supplementary material

The online version of this article (10.1186/s40360-018-0207-4) contains supplementary material, which is available to authorized users.

An analysis of adverse drug reactions in extremes of age group at tertiary care teaching hospital

Objectives:

To analyze clinical spectrum, seriousness, outcome, causality, severity and preventability of ADRs in geriatrics and pediatric patients.

Materials and Methods:

All ADRs reported in geriatrics (≥ 65 years) and pediatrics (≤ 12 years) indoor as well outdoor patients from January, 2010 to April, 2016 at ADR monitoring centre, Department of Pharmacology, B. J. Medical College and Civil Hospital were identified. A retrospective analysis was carried out for clinical presentation, causality (as per WHO-UMC scale and Naranjo's algorithm), severity (Hatwig and Seigel scale) and preventability (Schaumock and Thornton criteria).

Results:

Out of 3690 ADRs, 160 were in geriatric patients (4.33%) while 231 in pediatric patients (6.26%). The most commonly affected body system was gastrointestinal (53, 33.13%) followed by neurological disorders (26, 16.25%) in geriatric patients. While in pediatric patients, the most commonly affected body system was skin and appendages (73, 31.60 %) followed by gastrointestinal disorders (58, 25.11%). The most common causal drugs in geriatric patients was cardiovascular (38, 23.75%) followed by antimicrobials (28, 13.25%). While in pediatric patients, the most common causal drug group was antimicrobials (85, 33.46%) followed by blood products (36, 14.12%). Total 17 ADRs reported following vaccination, 7 (41.17%) were injection site abscess and 11 (64.70%) were due to pentavalent vaccine. Polypharmacy was common in geriatrics (31, 19.37%). Causality assessment for majority of ADRs in geriatrics (83, 52.5%) and pediatrics (171, 67.32%) were probable.

Conclusion:

ADRs are common in geriatric and pediatric patients usually within four weeks of oral therapy. Active surveillance of drug safety monitoring in these vulnerable population is recommended.

Improved drug safety through intensive pharmacovigilance in hospitalized pediatric patients

BACKGROUND

The aim of this study was to detect and analyze Adverse Drug Reactions (ADRs) through Intensive Pharmacovigilance (IPV) in hospitalized pediatric patients to improve drug safety.

METHODS

A prospective 6-month cross-sectional study was performed in the pediatric service of a regional hospital in Mexico in order to assess hospitalized children from 1 day to 18 years old. The inclusion criteria were: both genders, all hospitalization causes, and at least one prescribed medication (indistinct drug group). Notifications were performed through medical visits, phone calls, or spontaneous reports. ADR suspicions were assessed with severity scales: Naranjo algorithm, Schumock & Thornton and Hartwig and Siegel.

RESULTS

From a total of 1083 hospital admissions, 19 ADRs were recorded. The average age of patients in years was 7.2 (±5.9). The causality assessment in this study showed that most of the ADRs were probable (68.4%) and 4 certain (8.2%); causality was mainly attributed to antibiotics (AB) and an antiepileptic drug. We found a relationship of AB with ADRs (p < 0.05) with an increased risk at the third day of prescription (p < 0.05). The average severity was level 2 and 21% were classified as "preventable". Lastly, an increase in hospital stay associated with ADRs (p < 0.05) and with concomitant medications (p < 0.05), was also found. The most severe ADRs were hemolysis and toxic epidermal necrolysis.

CONCLUSIONS

IPV was an effective tool for ADR prevention, detection, and treatment in hospitalized patients. The intensive monitoring approach in pharmacovigilance amplifies ADR detection and this translates into the improvement of drug safety in children.

Health-related quality of life in children with cutaneous adverse drug reactions

Adverse drug reactions (ADRs) are a common problem in children. Health-related quality of life in patients with such conditions has not been well studied. In this study we found that health-related quality of life is adversely affected in children who developed ADRs with cutaneous manifestations.

Mobile App Design, Development, and Publication for Adverse Drug Reaction Assessments of Causality, Severity, and Preventability

BACKGROUND

Adverse drug reactions (ADRs) cause significant morbidity and mortality. Improved assessment of ADRs to identify the causal relationship, the severity, and the preventability will aid ADRs prevention or reduce patient burden.

OBJECTIVE

The aim of this study was to develop mobile apps in assisting clinical decision in ADR assessments of causality, severity, and preventability using validated tools. The usability of the apps was assessed.

METHODS

We designed mobile apps using validated assessment tools for ADRs. They are the Liverpool ADRs Causality Assessment Tool, Hartwig's Severity Assessment Scale, and the Modified Schumock and Thronton Preventability Scale. The apps were named "Adverse Drug ReactionCausality," "Adverse Drug ReactionSeverity," and "Adverse Drug RxnPreventability." A survey was conducted using the System Usability Scale (SUS) to assess the usability of the developed apps among health care professionals.

RESULTS

These apps are available for download through Google Play Store for free since January 2015. From the survey, the mean SUS score was 70.9 based on 26 responses from the pediatric ward of Hospital Ampang, Malaysia.

CONCLUSIONS

The developed apps received an overall acceptable usability among health care professionals. The usage of these apps will improve detection, assessment, and avoidance of future ADRs. They will also contribute to future research on ADRs, thus increasing drug safety.

Reported Adverse Drug Reactions in Infants: A Nationwide Analysis in Malaysia

Spontaneous adverse drug reactions (ADRs) reporting is a useful source of drug safety information in infants as only adult patients are routinely tested in clinical trials. This study was aimed to evaluate the spontaneously reported ADRs using WHO Adverse Reaction Terminology and to identify the common drugs associated with ADRs in children under 2 years of age. A retrospective analysis of ADR data for children below 2 years old from 2000 to 2013 was conducted using the data extracted from Malaysia’s national pharmacovigilance database, QUEST2 System. From 2000 to 2013, Malaysia’s National Pharmaceutical Control Bureau received a total of 11,932 reports for children from various healthcare facilities in Malaysia. 14.0% (n = 1667) of the ADRs reported for those children were related to children under 2 years old. The data retrieved was analyzed in terms of age, gender, source of reporting, type of reporters, suspected medicines and characteristics of ADRs (category, onset, severity, and outcomes). A total of 1312 ADRs reported in 907 ADR reports were analyzed. The most common ADRs reported were skin appendage disorders (60.1%), and the most frequently reported symptoms were rash (n = 215), maculopapular rash (n = 206), urticaria (n = 169), erythematous rash (n = 76), and pruritus (n = 58). In general, drugs from antibacterials for systemic use (58.8%) appeared to be the most common contributors to ADRs in children below 2 years old. Penicillins and other β-Lactam Antibacterials accounted for more than 40% of all drugs implicated in ADRs. The majority of ADRs were subacute reactions that occurred within 24 h of exposure to the drug. A high proportion of ADRs was classified as mild, and most victims had no sequela. Only one fatality was seen. There were 10 cases for each symptom, namely erythema multiforme and Stevens–Johnson Syndrome, observed in this study. A large proportion of ADRs in children under 2 years old were mainly caused by drugs from antibacterial for systemic use, with most of the ADRs manifesting in skin reactions. This study also reveals rare cutaneous ADRs experienced by Malaysian children under the age of 2, which constitutes a crucial cause of harm among children.

A study of antimicrobial use in children admitted to pediatric medicine ward of a tertiary care hospital

OBJECTIVES

Antimicrobials are frequently used in tertiary care hospitals. We conducted an observational study on children admitted to a teaching hospital in Eastern India, to generate a profile of antimicrobial use and suspected adverse drug reactions (ADRs) attributable to them.

MATERIALS AND METHODS

Hospitalized children of either sex, aged between 1 month and 12 years, were studied. Baseline demographic and clinical features, duration of hospital stay, antimicrobials received in hospital along with dosing and indications and details of suspected ADRs attributable to their use were recorded. Every patient was followed up till discharge, admission to the Pediatric Intensive Care Unit, or death.

RESULTS

Over the 1 year study period, 332 admissions were screened. The prevalence of antimicrobial use was 79.82%. The majority of the 265 children who received antimicrobials were males (61.10%) and hailed from rural and low socioeconomic background. Median age was 36 months. Six children died, 43 were transferred out, and the rest discharged. In most instances, either 2 (40%) or a single antibiotic (39.6%) was used. Ceftriaxone, co-amoxiclav, amikacin, vancomycin, and ampicillin were predominantly used. Antivirals, antimalarials, and antiprotozoals were used occasionally. Average number of antimicrobials per patient was 2.0 ± 1.27; the majority (84.1%) were by parenteral route and initial choice was usually empirical. Prescriptions were usually in generic name. The antimicrobial treatment ranged between 1 and 34 days, with a median of 7 days. Six ADRs were noted of which half were skin rash and the rest loose stools.

CONCLUSIONS

The profile of antimicrobial use is broadly similar to earlier Indian studies. Apparent overuse of multiple antimicrobials per prescription and the parenteral route requires exploration. Antimicrobials are being used empirically in the absence of policy. ADRs to antimicrobials are occasional and usually mild. The baseline data can serve in situation analysis for antibiotic prescribing guidelines.

Adverse drug reaction profile of microtubule-damaging antineoplastic drugs: A focused pharmacovigilance study in India

OBJECTIVES

The aim of the study was to analyze the adverse drug reaction (ADR) profile of microtubule-damaging antineoplastic drugs (taxanes and vinca alkaloids) and to look for unexpected ADRs among the local population. Focused study on these drugs, rampantly used in oncology department for a wide variety of tumors including early and advanced malignancies, would enable better treatment care by physicians.

MATERIALS AND METHODS

Data on ADRs were collected from the cancer patients belonging to both gender and of all ages, on taxanes- or vinca-based cancer chemotherapy and reported in the Indian Pharmacopoeia Commission form. Causality was assessed using the WHO criteria and Naranjo's Algorithm. Preventability and severity of ADRs were also assessed.

RESULTS

A total of 97 ADRs were reported among 488 patients on microtubule-damaging anticancer drugs admitted over a period of 1 year. The incidence rate was 19.87%. Gastrointestinal system (40.2%) was the most affected followed by bone marrow (33%) and skin (8.2%). The highest incidence of ADRs was reported among paclitaxel (54.6%), and vincristine (39.2%). Most of the reported ADRs were of milder nature and preventable. The WHO causality assessment scale indicated 71.1% possible reactions.

CONCLUSIONS

This study showed that most ADRs are preventable with effective ADR monitoring. There is a great need to create awareness among healthcare professionals regarding the importance of the pharmacovigilance system. Judicious use of the preventive measures will lead to a reduction in the incidence of ADRs due to the drug armamentarium, thereby enabling additional economic benefit to the patient and society.

Adverse Drug Reactions in Hospitalized Pediatric Patients: A Prospective Observational Study

OBJECTIVES

To determine the incidence, pattern, causality, preventability, severity and predictors of adverse drug reactions (ADRs) in pediatric population.

METHODS

It was a prospective, observational study that included patients of either sex, of any age treated in the pediatric wards of a tertiary care hospital. Study patients were followed throughout their hospital stay. Whenever an ADR was detected, all the required data was collected and analyzed. Data was analyzed for incidence, causality (by using WHO Probability scale and Naranjo's algorithm), preventability (by using Modified Shumock and Thornton scale), severity (by using Modified Hartwig and Siegel scale) and predictors of ADRs.

RESULTS

Of the 1775 children admitted in the pediatrics ward, 1082 patients met study criteria and were enrolled into the study. A total of 64 ADRs were identified from 54 patients. The incidence of ADRs was 4.99 %. Male patients experienced majority (68.52 %) of ADRs. Drugs most commonly implicated in ADRs were amoxicillin + clavulanate (21.87 %) followed by ceftriaxone (20.31 %). Most (51.56 %) of the ADRs reported belonged to the system organ class, gastrointestinal system disorders. Among the ADRs reported, 82.85 % of ADRs were mild. Majority (87.5 %) of the ADRs were of 'probable' causality category and 96.9 % were not preventable. There was a significant association between occurrence of ADRs and the use of ≥4 number of medications, age (infants) and gender (male).

CONCLUSIONS

Among the pediatric population, infants, male gender and those receiving ≥4 number of medications are at risk of developing ADRs. Constant monitoring is required to address the safety issue in pediatric population especially in infants and patients receiving ≥4 drugs.

Evidence for neurotoxicity associated with amoxicillin in juvenile rats

Amoxicillin (AMX) is one of the most commonly prescribed antibiotics for children, and childhood is the period to have the highest risk for toxicity cases including drug-induced adverse reactions. Some neurological adverse effects (anxiety, hyperactivity, confusion, convulsions, and behavioral changes) have been reported related to AMX treatment. In the present study, we aimed to determine the neurotoxic effects of AMX administration at clinically relevant doses in female juvenile rats. AMX was administered in single oral daily doses of 25 and 50 mg/kg for 14 days. According to our results, while AMX administration caused a significant increase in the immobility time of animals, swimming time of these animals significantly decreased. AMX administration significantly reduced the onset of pentylenetetrazole-induced convulsions. The serotonin levels of brain tissues in the AMX-administered groups were decreased significantly, which is thought to be related to depression. The glutamate levels in brain tissues increased significantly in AMX-administered groups, which is thought to be related to convulsion. Otherwise, superoxide dismutase and catalase activities were significantly decreased in brain tissues of AMX-administered groups. In conclusion, AMX administration triggered depression and shortened the time of the appearance of first seizure in juvenile rats. Also, altered brain neurotransmitter levels and increased oxidative stress observed in our study were thought to be the possible underlying mechanisms of AMX-induced neurotoxicity.

Pattern of Adverse Drug Reactions in Children Attending the Department of Pediatrics in a Tertiary Care Center: A Prospective Observational Study

AIM

To study the pattern of various adverse drug reactions (ADRs) occurring in children attending the Department of Pediatrics, SMGS Hospital, Jammu over 1 year.

SUBJECTS AND METHODS

This was a prospective study, with study population of patients attending Department of Pediatrics over a period of 1 year. A structured format was used to enroll the participants. A pilot study was conducted to test the suitability of the format and feasibility of the study. The study was carried out to review various pattern of ADRs by using the Naranjo probability scale, and severity was assessed by using the Hartwig severity scale. ADRs were classified according to the classification used by the Adverse Drug Reaction Monitoring Center, Central Drugs Standard Control Organization, New Delhi, India.

RESULTS

In the present study, 104 patients were found to have developed acute drug reactions. Among these, 83.6% were type B, 14.42% type A, and 1.92% were type U. Furthermore, 25.96% ADRs were due to anticonvulsants, followed by antibiotics (22.11%), antipyretics (11.53%), vaccination (8.65%), steroids (6.73%), decongestants (5.67%), snake antivenom and antiemetics (3.84%), and fluids, insulin, and antacids (1.92%). The patients’ dermatological system was involved in 67.30%, followed by the central nervous system (CNS) in 11.53% patients. Renal system was involved in 6.73% patients. Cardiac, musculoskeletal, metabolic, and other systems were involved in 4.80%, 3.84%, 2.88%, and 0.96%, respectively. According to the Hartwig severity scale of ADRs, 64.4% patients had moderate ADRs, 29.8% patients had severe ADRs, and 5.76% had mild ADRs. In the present study, 64.4% patients expressed moderate severity, whereas 29.8% expressed high severity and 5.76% expressed mild ADRs.

CONCLUSION

ADRs were seen in 71% of the patients between 1 and 5 years of age, 26% in the age group of 5–10 years, and 3% were more than 10 years old. Anticonvulsants (25.96%) and antibiotics (22.11%) were responsible for majority of ADRs. Rash (55.76%) was the most common presentation of ADR. Owing to the high number of ADRs, the present study points to the need for rigid adverse drug monitoring among pediatric patients to ensure the safety of drug therapy.

A retrospective study on the incidences of adverse drug events and analysis of the contributing trigger factors

Objectives:

To retrospectively determine the extent and types of adverse drug events (ADEs) from the patient cases sheets and identify the contributing factors of medication errors. To assess causality and severity using the World Health Organization (WHO) probability scale and Hartwig's scale, respectively.

Methods:

Hundred patient case sheets were randomly selected, modified version of the Institute for Healthcare Improvement (IHI) Global Trigger Tool was utilized to identify the ADEs; causality and severity were calculated utilizing the WHO probability scale and Hartwig's severity assessment scale, respectively.

Results:

In total, 153 adverse events (AEs) were identified using the IHI Global Trigger Tool. Majority of the AEs are due to medication errors (46.41%) followed by 60 adverse drug reactions (ADRs), 15 therapeutic failure incidents, and 7 over-dose cases. Out of the 153 AEs, 60 are due to ADRs such as rashes, nausea, and vomiting. Therapeutic failure contributes 9.80% of the AEs, while overdose contributes to 4.58% of the total 153 AEs. Using the trigger tools, we were able to detect 45 positive triggers in 36 patient records. Among it, 19 AEs were identified in 15 patient records. The percentage of AE/100 patients is 17%. The average ADEs/1000 doses is 2.03% (calculated).

Conclusion:

The IHI Global Trigger Tool is an effective method to aid provisionally-registered pharmacists to identify ADEs quicker.

A prospective study on Adverse Drug Reactions of antibiotics in a tertiary care hospital

Adverse reactions are the recognized hazards of drug therapy and they can occur with any class of drugs and many studies revealed that the incidence is more in case of antibiotics. The main aim of this study was to detect and analyze Adverse Drug Reactions of antibiotics in inpatients of a tertiary care hospital. A prospective spontaneous reporting study by active and passive methods was carried out for a period of six months. A total of 49 ADRs were reported during the study period with male predominance (53.06%) and geriatric age group. More number of ADRs was from General Medicine and Pediatric departments in which the most affected organ systems were the GIT (38.77%) and the skin (30.61%). The antibiotic classes mostly accounted were cephalosporins (34.69%) followed by fluoroquinolones and others in which type A reactions were more compared to type B and 59.18% of them were predictable. The severity assessment revealed that most of them were moderate (63.26%) followed by mild and severe reactions. Of the reported reactions, 55.10% were definitely preventable and causality assessment was done which showed that 71.42% of the reactions were probable, possible (18.36%), definite (10.20%) and no reactions were unlikely. The study concluded that Adverse Drug Reactions to antibiotics are common and some of them resulted in increased healthcare cost due to the need of some interventions and increased length of hospital stay. The health system should promote the spontaneous reporting of Adverse Drug Reactions to antibiotics, proper documentation and periodic reporting to regional pharmacovigilance centers to ensure drug safety.

Comparative epidemiology of hospital-acquired adverse drug reactions in adults and children and their impact on cost and hospital stay--a systematic review

PURPOSE

To study and analyze the comparative impact of hospital-acquired adverse drug reactions (ADRs) in adult and pediatric patients in terms of the economic implications, (length of) hospital stay, and salient features in relation to the incidence rate, severity, morbidity, mortality, and preventability of the ADRs.

METHODS

A systematic search to identify and retrieve relevant articles/studies in the PubMed, Medline, Scopus, MEDPAR, and Cochrane databases and by the Google search engine was performed for the study period 2000 to April 2013. In total, 51 studies were identified on patients hospitalized for ADRs, and these were included in the study. The incidence rate of ADRs, their severity, mortality, morbidity, preventability, cost, and association with extended hospital stay due to ADRs were extracted and scrutinized.

RESULTS

Hospital-acquired ADRs are more widely studied in adults than in children, and the incidence rate is higher in the former. However, a wide variation in the incidence rate worldwide is observed in both groups. Irrespective of the ages of patients, ADRs are among the most frequent causes of morbidity and mortality. Interestingly, preventable ADRs are more frequently observed in patients at the younger and older ends of the age spectrum. Hospital-acquired ADRs place an immense economic burden on healthcare systems, with the overall cost for a hospitalized patient with an ADR reported to be $2,401 per patient, which is equivalent to a 19.86 % additional increase in the total cost of care and an increase in average length of hospital stay of 8.25 %.

CONCLUSION

Based on the findings of this review, we suggest that excellent assertive measures of pharmacovigilance with the aim to diminish the incidence rate of hospital-acquired ADRs and support the development of interventions are needed to promote vital facets of drug safety with an overall objective to avert potential ADRs.

Adverse drug reactions in hospitalized pediatric patients of Saudi Arabian University Hospital and impact of pharmacovigilance in reporting ADR

OBJECTIVES

Children are more vulnerable to ADRs, and this susceptibility is compounded due to hospitalization. There is a lack of local data regarding the potential risk of ADRs in hospitalized pediatric patients. Therefore, this study is designed to identify the frequent nature, severity of adverse drug reactions, drugs implicated and factors influencing ADRs.

METHODS

Intensive monitoring study of ADRs was done in hospitalized pediatric patients of King Abdulaziz University Hospital, Jeddah from January to December 2011, with an analogous retrospective study for the preceding year to determine incidence rate, demographic aspects, causality appraisal, polypharmacy, body organs/systems involved and drugs implicated in ADR. Comparison of the two data was done to determine the impact of pharmacovigilance.

RESULTS

Incidence rate of ADRs in retrospective study was (4.50%) and (8.2%) in prospective study. ADR was more in patients who received 5-6 drugs, which was (15.5%) in retrospective study and (22.1%) in prospective study. Regarding age, it was the highest in patients of 0-1 year of age which was (40.7%) in retrospective study and (38.8%) in prospective study. Anti-infective agents were the most frequently involved in ADR (40.8%) in prospective study and (48.2%) and retrospective study. This study also demonstrated that, there was high susceptibility of the skin to the ADR which was (37%) in retrospective study and (42.9%) in prospective study. None of the ADRs proved to be fatal.

CONCLUSION

Well premeditated intensive monitoring approach in pharmacovigilance amplifies the ADR detection, which can persuade healthcare providers into more drug safety.