Extended Interval Tobramycin Pharmacokinetics in a Pediatric Patient With Primary Ciliary Dyskinesia Presenting With an Acute Respiratory Exacerbation

Extended Interval Aminoglycoside Treatment for Klebsiella Pneumoniae Endocarditis in an Extremely Low Birth Weight Neonate

Infective endocarditis (IE) in neonates is associated with high mortality and incidence has been increasing over the past two decades. The majority of very low birth weight infants will be treated with at least one nephrotoxic medication during their hospital course. Over one-quarter of very low birth weight neonates exposed to gentamicin may develop acute kidney injury (AKI); this is particularly worrisome as AKI is an independent factor associated with increased neonatal mortality and increased length of stay. AKI during periods of neonatal nephrogenesis, which continues until 34-36 weeks postmenstrual age, may also have serious effects on the long-term nephron development which subsequently puts infants at risk of chronic kidney disease. Extended interval (EI) aminoglycoside (AMG) dosing has been used for decades in adult populations and has proven to reduce AKI while being at least as effective as traditional dosing, although there is limited published research for using an EI AMG in endocarditis in adults or pediatric patients. We describe an extremely low birth weight neonate, born preterm at 24 weeks gestation treated for Klebsiella pneumoniae IE that required AMG therapy who also had concurrent AKI. We utilized EI AMG combination therapy for treatment of Klebsiella pneumoniae endocarditis with good outcome and encourage others to report their experiences to improve our knowledge of EI AMG in this population.

Access to medicines for rare diseases: beating the drum for primary ciliary dyskinesia

Rare diseases are collectively common, affecting an estimated 6.2% of the world's population [1], but each rare disease affects fewer than 4 to 5 in 10 000 individuals in Europe or less than 200 000 individuals in the USA [2]. Patients with rare diseases are often disadvantaged by late diagnosis and off-label prescribing of medicines [3]. Primary ciliary dyskinesia (PCD) is a genetic disease of impaired motile ciliary function that does not have a unique International Classification of Diseases (ICD)-10 code or licensed treatments, although Q34.8 denoting “other specified malformations of the respiratory tract” including nasopharyngeal atresia has also been applicable to PCD since 2017. The disease is characterised by mucus stagnation leading to chronic airway infection, bronchiectasis, chronic rhinosinusitis, reduced fertility and abnormalities of organ laterality with an associated increased risk of complex congenital heart disease [4]. The estimated prevalence of PCD in Europe is around 1 in 10 000 to 1 in 20 000 [5]. The international PCD cohort (iPCD) includes over 3800 PCD patients ranging in age from under 12 months to over 80 years, from Europe, Northern and Southern America, Australia and Western Asia [6]. Under-diagnosis of PCD is due to a lack of awareness among the general public and physicians in general, as well as a lack of diagnostic expertise in some countries [7]. Tools to help physicians identify patients needing testing (e.g. PICADAR) [8] and the European Respiratory Society (ERS) guidelines for diagnostic testing [9] aim to improve this. In contrast to cystic fibrosis (CF), a monogenic disease, PCD is caused by mutations in one of at least 45 identified genes for which there is no effective mutation-specific therapy; this is likely to be a long way off for most patients [10]. Thus, treatment aims to prevent and manage disease complications. Even then, the lack of an evidence base for supportive treatment in PCD means that treatment recommendations are based on expert opinion and extrapolated from CF despite differing pathophysiology [11].

Primary ciliary dyskinesia, a rare disease causing bronchiectasis, lacks a sound evidence base for treatment. @beatpcd proposes 1) forming a PCD European clinical trial network to address this situation and 2) conducting n-of-1 trials to access medication.https://bit.ly/3j5blfM