1
|
Willis ZI, Oliveira CR, Abzug MJ, Anosike BI, Ardura MI, Bio LL, Boguniewicz J, Chiotos K, Downes K, Grapentine SP, Hersh AL, Heston SM, Hijano DR, Huskins WC, James SH, Jones S, Lockowitz CR, Lloyd EC, MacBrayne C, Maron GM, Hayes McDonough M, Miller CM, Morton TH, Olivero RM, Orscheln RC, Schwenk HT, Singh P, Soma VL, Sue PK, Vora SB, Nakamura MM, Wolf J. Guidance for prevention and management of COVID-19 in children and adolescents: A consensus statement from the Pediatric Infectious Diseases Society Pediatric COVID-19 Therapies Taskforce. J Pediatric Infect Dis Soc 2024; 13:159-185. [PMID: 38339996 DOI: 10.1093/jpids/piad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 12/27/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Since November 2019, the SARS-CoV-2 pandemic has created challenges for preventing and managing COVID-19 in children and adolescents. Most research to develop new therapeutic interventions or to repurpose existing ones has been undertaken in adults, and although most cases of infection in pediatric populations are mild, there have been many cases of critical and fatal infection. Understanding the risk factors for severe illness and the evidence for safety, efficacy, and effectiveness of therapies for COVID-19 in children is necessary to optimize therapy. METHODS A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacology, and pediatric intensive care medicine from 21 geographically diverse North American institutions was re-convened. Through a series of teleconferences and web-based surveys and a systematic review with meta-analysis of data for risk factors, a guidance statement comprising a series of recommendations for risk stratification, treatment, and prevention of COVID-19 was developed and refined based on expert consensus. RESULTS There are identifiable clinical characteristics that enable risk stratification for patients at risk for severe COVID-19. These risk factors can be used to guide the treatment of hospitalized and non-hospitalized children and adolescents with COVID-19 and to guide preventative therapy where options remain available.
Collapse
Affiliation(s)
- Zachary I Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carlos R Oliveira
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Mark J Abzug
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Brenda I Anosike
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Monica I Ardura
- Department of Pediatrics, ID Host Defense Program, Nationwide Children's Hospital & The Ohio State University, Columbus, OH, USA
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Juri Boguniewicz
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kathleen Chiotos
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Divisions of Critical Care Medicine and Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Downes
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Steven P Grapentine
- Department of Pharmacy, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Adam L Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Sarah M Heston
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Diego R Hijano
- Department of Infectious Diseases, St. Jude Children's Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - W Charles Huskins
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Scott H James
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah Jones
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA
| | | | - Elizabeth C Lloyd
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Molly Hayes McDonough
- Center for Healthcare Quality & Analytics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christine M Miller
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Theodore H Morton
- Department of Pharmacy, St Jude's Children's Research Hospital, Memphis, Tennessee, USA
| | - Rosemary M Olivero
- Department of Pediatrics and Human Development, Michigan State College of Human Medicine and Helen DeVos Children's Hospital of Corewell Health, Grand Rapids, MI, USA
| | | | - Hayden T Schwenk
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - Prachi Singh
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Vijaya L Soma
- Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA
| | - Paul K Sue
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington School of Medicine, and Division of Infectious Diseases, Seattle Children's Hospital, Seattle, WA, USA
| | - Mari M Nakamura
- Antimicrobial Stewardship Program and Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
2
|
Bio LL, Hiroshima L, Schwenk HT, Green S. Successful enteral administration of crushed posaconazole delayed-release tablets in children. Pediatr Blood Cancer 2024; 71:e30782. [PMID: 37990039 DOI: 10.1002/pbc.30782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 11/23/2023]
Abstract
Erratic absorption of posaconazole oral suspension necessitates frequent dosing and administration with meals or supplements. Alternative enteral formulations are desirable for patients intolerant to enteral nutrition. Crushed posaconazole delayed-release tablets (POS-DRT) show promise in adults; limited evidence exists in children. We used crushed POS-DRT in 10 encounters with nine pediatric patients, achieving target POS concentrations in 90% of encounters. This highlights crushed POS-DRT as a potential enteral option for pediatric antifungal prophylaxis and treatment.
Collapse
Affiliation(s)
- Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Lyndsie Hiroshima
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Hayden T Schwenk
- Division of Pediatric Infectious Diseases, Stanford School of Medicine, Stanford, California, USA
| | - Sean Green
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| |
Collapse
|
3
|
Aparicio C, Willis ZI, Nakamura MM, Wolf J, Little C, Maron GM, Sue PK, Anosike BI, Miller C, Bio LL, Singh P, James SH, Oliveira CR. Risk Factors for Pediatric Critical COVID-19: A Systematic Review and Meta-Analysis. medRxiv 2024:2024.01.17.24301452. [PMID: 38293040 PMCID: PMC10827273 DOI: 10.1101/2024.01.17.24301452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Background Risk stratification is a cornerstone of the Pediatric Infectious Diseases Society COVID-19 treatment guidance. This systematic review and meta-analysis aimed to define the clinical characteristics and comorbidities associated with critical COVID-19 in children and adolescents. Methods Two independent reviewers screened the literature (Medline and EMBASE) for studies published through August 2023 that reported outcome data on patients aged ≤21 years with COVID-19. Critical disease was defined as an invasive mechanical ventilation requirement, intensive care unit admission, or death. Random effects models were used to estimate pooled odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was explored through subgroup analyses. Results Among 10,178 articles, 136 studies met the inclusion criteria for review. Data from 70 studies, which collectively examined 172,165 children and adolescents with COVID-19, were pooled for meta-analysis. In previously healthy children, the absolute risk of critical disease from COVID-19 was 4% (95% CI, 1%-10%). Compared with no comorbidities, the pooled OR for critical disease was 3.95 (95% CI, 2.78-5.63) for presence of one comorbidity and 9.51 (95% CI, 5.62-16.06) for ≥2 comorbidities. Key risk factors included cardiovascular and neurological disorders, chronic pulmonary conditions (excluding asthma), diabetes, obesity, and immunocompromise, all with statistically significant ORs >2.00. Conclusions While the absolute risk for critical COVID-19 in children and adolescents without underlying health conditions is relatively low, the presence of one or more comorbidities was associated with markedly increased risk. These findings support the importance of risk stratification in tailoring pediatric COVID-19 management.
Collapse
Affiliation(s)
- Camila Aparicio
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Zachary I. Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mari M. Nakamura
- Antimicrobial Stewardship Program and Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children’s Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Cordell Little
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Gabriela M. Maron
- Department of Infectious Diseases, St. Jude Children’s Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Paul K. Sue
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Brenda I. Anosike
- Department of Pediatrics, The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY
| | - Christine Miller
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Laura L. Bio
- Department of Pharmacy, Lucile Packard Children’s Hospital, Stanford, CA
| | - Prachi Singh
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Scott H. James
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Carlos R. Oliveira
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
4
|
Nishiguchi JL, Bio LL, Cornell ST, Schwenk HT. Indication-driven order entry decreases stewardship and pharmacist interventions. Infect Control Hosp Epidemiol 2024; 45:120-122. [PMID: 37529840 DOI: 10.1017/ice.2023.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Indication-driven order entry (IDOE) was implemented at our pediatric institution for cefazolin, piperacillin-tazobactam, and meropenem; the 3 most intervened upon antibiotics during prospective audit and feedback (PAF) by the antimicrobial stewardship program (ASP). IDOE was associated with a significant reduction in both ASP PAF recommendations and clinical pharmacist interventions.
Collapse
Affiliation(s)
- Jacey L Nishiguchi
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Sean T Cornell
- Center for Pediatric & Maternal Value, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford School of Medicine, Stanford, California
| |
Collapse
|
5
|
Bio LL, Weng Y, Schwenk HT. Antifungal stewardship in practice: Insights from a prospective audit and feedback program. Infect Control Hosp Epidemiol 2023; 44:2017-2021. [PMID: 37381887 PMCID: PMC10755142 DOI: 10.1017/ice.2023.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To identify characteristics of antifungal prospective audit and feedback (PAF) and to compare rates of PAF recommendation and acceptance between antifungal and antibiotic agents. DESIGN Retrospective cohort study of antifungal and antibiotic audits by a children's hospital antimicrobial stewardship program (ASP) from November 1, 2020, to October 31, 2022. METHODS Antimicrobial audit data were retrieved from the ASP data warehouse. We characterized antifungal PAF using descriptive statistics. We then compared the overall rates of PAF recommendation and recommendation acceptance between antifungals and antibiotics. We also compared the differences in antifungal and antibiotic PAF recommendation and acceptance rates across various factors, including infectious problem, medical service, and recommendation type. RESULTS Of 10,402 antimicrobial audits identified during the study period, 8,599 (83%) were for antibiotics and 1,803 (17%) were for antifungals. The highest antifungal recommendation rates were for liposomal amphotericin B, antifungals used for sepsis or respiratory tract infection, and antifungals prescribed in the cardiovascular intensive care unit. The rate of PAF recommendation was higher for antibiotics than for antifungals (29% vs 21%; P < .001); however, the rates of recommendation acceptance were similar. Recommendations to discontinue or for medication monitoring were more common for antifungals. CONCLUSIONS Our analysis of antifungal PAF identified key opportunities to improve antifungal use, including the optimized use of specific agents and targeted use by certain medical services. Moreover, antifungal PAF, despite identifying fewer recommendations compared to antibiotic PAF, were associated with similarly high rates of acceptance, highlighting a promising opportunity for antifungal stewardship.
Collapse
Affiliation(s)
- Laura L. Bio
- Department of Pharmacy, Lucile Packard Children’s Hospital Stanford, Stanford, California
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Hayden T. Schwenk
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
6
|
Yu D, Bio LL. Shedding Light on Amoxicillin, Amoxicillin-clavulanate, and Cephalexin Dosing in Children from a Pharmacist's Perspective. J Pediatric Infect Dis Soc 2022; 11:594-602. [PMID: 36112500 DOI: 10.1093/jpids/piac105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/15/2022] [Indexed: 12/30/2022]
Abstract
Selection of an antibiotic and dosing regimen requires consideration of multiple factors including microbiological data, site of infection, pharmacokinetics, and how it relates to the pharmacodynamic target. Given the multiple dosage regimens of amoxicillin with/without clavulanate and cephalexin, we review the principles of dose selection from a pharmacist's perspective.
Collapse
Affiliation(s)
- Diana Yu
- Department of Pharmacy, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| |
Collapse
|
7
|
Wolf J, Abzug MJ, Anosike BI, Vora SB, Waghmare A, Sue PK, Olivero RM, Oliveira CR, James SH, Morton TH, Maron GM, Young JL, Orscheln RC, Schwenk HT, Bio LL, Willis ZI, Lloyd EC, Hersh AL, Huskins CW, Soma VL, Ratner AJ, Hayes M, Downes K, Chiotos K, Grapentine SP, Wattier RL, Lamb GS, Zachariah P, Nakamura MM. Updated Guidance on Use and Prioritization of Monoclonal Antibody Therapy for Treatment of COVID-19 in Adolescents. J Pediatric Infect Dis Soc 2022; 11:177-185. [PMID: 35107571 PMCID: PMC8903349 DOI: 10.1093/jpids/piab124] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Starting in November 2020, the US Food and Drug Administration (FDA) has issued Emergency Use Authorizations (EUAs) for multiple novel virus-neutralizing monoclonal antibody therapies, including bamlanivimab monotherapy (now revoked), bamlanivimab and etesivimab, casirivimab and imdevimab (REGEN-COV), and sotrovimab, for treatment or postexposure prophylaxis of Coronavirus disease 2019 (COVID-19) in adolescents (≥12 years of age) and adults with certain high-risk conditions. Previous guidance is now updated based on new evidence and clinical experience. METHODS A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacotherapy, and pediatric critical care medicine from 18 geographically diverse US institutions was convened. Through a series of teleconferences and web-based surveys, a guidance statement was developed and refined based on a review of the best available evidence and expert opinion. RESULTS The course of COVID-19 in children and adolescents is typically mild, though more severe disease is occasionally observed. Evidence supporting risk stratification is incomplete. Randomized controlled trials have demonstrated the benefit of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-specific monoclonal antibody therapies in adults, but data on safety and efficacy in children or adolescents are limited. Potential harms associated with infusion reactions or anaphylaxis are reportedly low in adults. CONCLUSIONS Based on evidence available as of August 31, 2021, the panel suggests a risk-based approach to administration of SARS-CoV-2 monoclonal antibody therapy. Therapy is suggested for the treatment of mild to moderate COVID-19 in adolescents (≥12 years of age) at the highest risk of progression to hospitalization or severe disease. Therapeutic decision-making about those at moderate risk of severe disease should be individualized. Use as postexposure prophylaxis could be considered for those at the highest risk who have a high-risk exposure but are not yet diagnosed with COVID-19. Clinicians and health systems should ensure safe and timely implementation of these therapeutics that does not exacerbate existing healthcare disparities.
Collapse
Affiliation(s)
- Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Mark J Abzug
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Brenda I Anosike
- Department of Pediatrics, Children's Hospital at Montefiore, New York, New York, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Alpana Waghmare
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Paul K Sue
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rosemary M Olivero
- Department of Pediatrics and Human Development, Helen DeVos Children's Hospital of Spectrum Health, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
| | - Carlos R Oliveira
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Scott H James
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Theodore H Morton
- Department of Pharmacy, St Jude's Children's Research Hospital, Memphis, Tennessee, USA
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer L Young
- Department of Pharmacy, Washington University and St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Rachel C Orscheln
- Department of Pediatrics, Washington University and St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Laura L Bio
- Department of Pharmacy, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Zachary I Willis
- Department of Pediatrics, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Elizabeth C Lloyd
- Department of Pediatrics, University of Michigan and CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Charles W Huskins
- Department of Pediatrics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Vijaya L Soma
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, New York, USA
| | - Adam J Ratner
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, New York, USA
| | - Molly Hayes
- Center for Healthcare Quality & Analytics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin Downes
- Department of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathleen Chiotos
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Steven P Grapentine
- Department of Pharmacy, University of California-San Francisco, San Francisco, California, USA
| | - Rachel L Wattier
- Department of Pediatrics, University of California-San Francisco, San Francisco, California, USA
| | - Gabriella S Lamb
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Philip Zachariah
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Mari M Nakamura
- Antimicrobial Stewardship Program and Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Schwenk HT, Bio LL. Hidden No More: Capturing the Full Picture of Prolonged Perioperative Antibiotic Prophylaxis. Hosp Pediatr 2022; 12:e83-e85. [PMID: 35039820 DOI: 10.1542/hpeds.2021-006409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Hayden T Schwenk
- Stanford University School of Medicine, Stanford, California.,Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Laura L Bio
- Lucile Packard Children's Hospital Stanford, Palo Alto, California
| |
Collapse
|
9
|
Wolf J, Abzug MJ, Wattier RL, Sue PK, Vora SB, Zachariah P, Dulek DE, Waghmare A, Olivero R, Downes KJ, James SH, Pinninti SG, Yarbrough A, Aldrich ML, MacBrayne CE, Soma VL, Grapentine SP, Oliveira CR, Hayes M, Kimberlin DW, Jones SB, Bio LL, Morton TH, Hankins JS, Marόn-Alfaro GM, Timberlake K, Young JL, Orscheln RC, Schwenk HT, Goldman DL, Groves HE, Huskins WC, Rajapakse NS, Lamb GS, Tribble AC, Lloyd EE, Hersh AL, Thorell EA, Ratner AJ, Chiotos K, Nakamura MM. Initial Guidance on Use of Monoclonal Antibody Therapy for Treatment of Coronavirus Disease 2019 in Children and Adolescents. J Pediatric Infect Dis Soc 2021; 10:629-634. [PMID: 33388760 PMCID: PMC7799019 DOI: 10.1093/jpids/piaa175] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND In November 2020, the US Food and Drug Administration (FDA) provided Emergency Use Authorizations (EUA) for 2 novel virus-neutralizing monoclonal antibody therapies, bamlanivimab and REGN-COV2 (casirivimab plus imdevimab), for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adolescents and adults in specified high-risk groups. This has challenged clinicians to determine the best approach to use of these products. METHODS A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacy, pediatric intensive care medicine, and pediatric hematology from 29 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a guidance statement was developed and refined based on review of the best available evidence and expert opinion. RESULTS The course of COVID-19 in children and adolescents is typically mild and there is no high-quality evidence supporting any high-risk groups. There is no evidence for safety and efficacy of monoclonal antibody therapy for treatment of COVID-19 in children or adolescents, limited evidence of modest benefit in adults, and evidence for potential harm associated with infusion reactions or anaphylaxis. CONCLUSIONS Based on evidence available as of December 20, 2020, the panel suggests against routine administration of monoclonal antibody therapy (bamlanivimab, or casirivimab and imdevimab), for treatment of COVID-19 in children or adolescents, including those designated by the FDA as at high risk of progression to hospitalization or severe disease. Clinicians and health systems choosing to use these agents on an individualized basis should consider risk factors supported by pediatric-specific evidence and ensure the implementation of a system for safe and timely administration that does not exacerbate existing healthcare disparities.
Collapse
Affiliation(s)
- Joshua Wolf
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA,Corresponding author: Dr. Joshua Wolf MBBS, PhD, FRACP, Department of Infectious Diseases, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS 320, Memphis, TN 38105, USA, Tel: 901 595 3300; Fax: 901 595 3099,
| | - Mark J Abzug
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Rachel L Wattier
- Division of Infectious Diseases and Global Health, Department of Pediatrics, University of California–San Francisco, San Francisco, California, USA
| | - Paul K Sue
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Surabhi B Vora
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Washington, Seattle; Children’s Hospital, Seattle, Washington, USA
| | - Philip Zachariah
- Division of Infectious Diseases, Department of Pediatrics, Columbia University, New York, New York, USA
| | - Daniel E Dulek
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University and Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee, USA
| | - Alpana Waghmare
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Washington, Seattle; Children’s Hospital, Seattle, Washington, USA,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Rosemary Olivero
- Section of Infectious Diseases, Department of Pediatrics and Human Development, Helen DeVos Children’s Hospital of Spectrum Health, Michigan State College of Human Medicine, Grand Rapids, Michigan, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott H James
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Swetha G Pinninti
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - April Yarbrough
- Department of Pharmacy, Children’s of Alabama, Birmingham, Alabama, USA
| | - Margaret L Aldrich
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital at Montefiore, New York, New York, USA
| | | | - Vijaya L Soma
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, United States
| | - Steven P Grapentine
- Department of Pharmacy, University of California–San Francisco Benioff Children’s Hospital, San Francisco, California, USA
| | - Carlos R Oliveira
- Division of Infectious Diseases and Global Health, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States
| | - Molly Hayes
- Antimicrobial Stewardship Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David W Kimberlin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah B Jones
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children’s Hospital Stanford, Palo Alto, California, USA
| | - Theodore H Morton
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Gabriella M Marόn-Alfaro
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kathryn Timberlake
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L Young
- Department of Pharmacy, St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Rachel C Orscheln
- Division of Infectious Diseases, Department of Pediatrics, Washington University and St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Hayden T Schwenk
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital Stanford, Stanford, California, USA
| | - David L Goldman
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital at Montefiore, New York, New York, USA
| | - Helen E Groves
- Division of Infectious Diseases, Department of Pediatrics,; Hospital for Sick Children, Toronto, Ontario, Canada
| | - W Charles Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nipunie S Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gabriella S Lamb
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Alison C Tribble
- Department of Pediatrics, Division of Infectious Diseases, University of Michigan and CS Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Elizabeth E Lloyd
- Department of Pediatrics, Division of Infectious Diseases, University of Michigan and CS Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Emily A Thorell
- Division of Infectious Diseases, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Adam J Ratner
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, United States,Department of Microbiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Kathleen Chiotos
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mari M Nakamura
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA,Antimicrobial Stewardship Program, Boston Children’s Hospital, Boston, Massachusetts, USA,Co-Corresponding author: Mari M. Nakamura, MD, MPH, Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Avenue, Mailstop BCH 3052, Boston, MA 02115, Tel: 617 355 1561,
| |
Collapse
|
10
|
Seddik TB, Rabsatt LA, Mueller C, Bassett HK, Contopoulos-Ioannidis D, Bio LL, Anderson VD, Schwenk HT. Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis. J Surg Res 2020; 260:141-148. [PMID: 33340867 DOI: 10.1016/j.jss.2020.11.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/05/2020] [Accepted: 11/15/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis. METHODS This is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared. RESULTS Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively. CONCLUSIONS Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.
Collapse
Affiliation(s)
- Talal B Seddik
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California.
| | - Lauren A Rabsatt
- Analytics and Clinical Effectiveness Specialist, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Claudia Mueller
- Pediatric Surgery, Stanford University School of Medicine, Stanford, California
| | - Hannah K Bassett
- Pediatric Hospitalist Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Victor D Anderson
- Infection Prevention and Control Specialist, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Hayden T Schwenk
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
11
|
Bio LL, Schwenk HT, Chen SF, Conlon S, Gallo A, Bonham CA, Gans HA. Standardization of post-operative antimicrobials reduced exposure while maintaining good outcomes in pediatric liver transplant recipients. Transpl Infect Dis 2020; 23:e13538. [PMID: 33252820 DOI: 10.1111/tid.13538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/15/2020] [Indexed: 12/17/2022]
Abstract
Infections following orthotopic liver transplant (OLT) result in significant morbidity and mortality, warranting careful consideration of risks associated with antibiotic overuse and benefits of infection prevention. In the absence of specific guidelines for antimicrobial prophylaxis in pediatric OLT, we developed a standardized approach to post-operative (post-op) antimicrobial therapy including 48 hours of antibiotics, no vancomycin for post-op fever within the first 48 hours, and caspofungin only for certain situations. The goal was to reduce antimicrobial utilization and adverse outcomes associated with longer duration of and broader treatment while maintaining good outcomes. The impact of this standardization on antimicrobial utilization and clinical outcomes at the largest pediatric liver transplant center in the United States is described. All individuals receiving an OLT from 1/1/17-9/30/17 (N = 38) and 3/14/18-12/13/18 (N = 27) were included in the pre-intervention (PreI) and post-intervention (PostI) groups, respectively. The intervention resulted in a significant reduction in individuals receiving post-op broad-spectrum gram-negative antibiotics for >48 hours (76% PreI vs 44% PostI OLT recipients, P = .01) and post-op vancomycin use (50% PreI, vs 7.4% PostI, P < .001). There were no statistically significant differences between groups for post-op fever, positive pre-/post-operative cultures, receipt of massive transfusion, or hospital length of stay. In conclusion, following the implementation of a standardized approach to post-op prophylaxis, antimicrobial exposure was significantly reduced without affecting OLT recipient outcomes.
Collapse
Affiliation(s)
- Laura L Bio
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
| | - Hayden T Schwenk
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sharon F Chen
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Conlon
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
| | - Amy Gallo
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.,Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Clark Andy Bonham
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.,Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Hayley A Gans
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
12
|
Schwenk HT, Bio LL, Kruger JF, Banaei N. Clinical Impact of Clostridium difficile PCR Cycle Threshold-Predicted Toxin Reporting in Pediatric Patients. J Pediatric Infect Dis Soc 2020; 9:44-50. [PMID: 30476169 DOI: 10.1093/jpids/piy117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reliance on tests that detect only the presence of toxigenic Clostridium difficile can result in overdiagnosis and overtreatment of C difficile infection (CDI). The C difficile polymerase chain reaction (PCR) cycle threshold (CT) can sensitively predict the presence of free C difficile toxins; however, the clinical application for this testing strategy remains unexplored. We evaluated the impact of dual PCR and toxin result reporting, as predicted by the CT, on CDI management and outcomes in children. METHODS Before the intervention, results for C difficile testing at Lucile Packard Children's Hospital Stanford were reported as PCR positive (PCR+) or negative (PCR-) according to the GeneXpert C diff Epi tcdB PCR assay (Cepheid, Sunnyvale, California). Beginning October 5, 2016, the presence of free toxins, as predicted by the CT, was reported also. The CDI treatment rates 1 year before and 18 months after implementation of toxin reporting were compared. Demographic and treatment-related data were collected, and patient outcomes were followed up 8 weeks later. RESULTS CDI treatment decreased 22% after the intervention (96% [preintervention] vs 74% [postintervention]; P < .001). During the postintervention period, there were 152 PCR+C difficile results, and 94 (62%) of them were toxin positive (toxin+) according to the CT. Of the 58 PCR+/toxin-negative (toxin-) results, 38 (66%) did not result in CDI treatment. Seven (18%) of the untreated PCR+/toxin- patients underwent repeat testing within 8 weeks, and 5 (13%) of them were subsequently PCR+/toxin+ and treated. No CDI-related complications were identified. CONCLUSIONS Addition of the CT-predicted C difficile toxin result to PCR reporting reduces the proportion of PCR+ children treated for CDI.
Collapse
Affiliation(s)
- Hayden T Schwenk
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Jenna F Kruger
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, California.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, California
| |
Collapse
|
13
|
Bio LL, Patterson BJ, Sen S, Bingham AL, Bowen JF, Ereshefsky B, Siemianowski LA. Variables Affecting Pharmacy Students' Patient Care Interventions during Advanced Pharmacy Practice Experiences. Am J Pharm Educ 2016; 80:116. [PMID: 27756924 PMCID: PMC5066919 DOI: 10.5688/ajpe807116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/09/2015] [Indexed: 06/06/2023]
Abstract
Objective. To identify the temporal effect and factors associated with student pharmacist self-initiation of interventions during acute patient care advanced pharmacy practice experiences (APPE). Methods. During the APPE, student pharmacists at an academic medical center recorded their therapeutic interventions and who initiated the intervention throughout clinical rotations. At the end of the APPE student pharmacists completed a demographic survey. Results. Sixty-two student pharmacists were included. Factors associated with lower rates of self-initiated interventions were infectious diseases and pediatrics APPEs and an intention to pursue a postgraduate residency. Timing of the APPE, previous specialty elective course completion, and previous hospital experience did not result in any significant difference in self-initiated recommendations. Conclusion. Preceptors should not base practice experience expectations for self-initiated interventions on previous student experience or future intentions. Additionally, factors leading to lower rates of self-initiated interventions on infectious diseases or pediatrics APPEs should be explored.
Collapse
Affiliation(s)
- Laura L Bio
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | - Brandon J Patterson
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | - Sanchita Sen
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | - Angela L Bingham
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | - Jane F Bowen
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | - Benjamin Ereshefsky
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | - Laura A Siemianowski
- University of the Sciences Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| |
Collapse
|
14
|
Mathew JT, Bio LL. Injectable ammonium chloride used enterally for the treatment of persistent metabolic alkalosis in three pediatric patients. J Pediatr Pharmacol Ther 2012; 17:98-103. [PMID: 23118664 DOI: 10.5863/1551-6776-17.1.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Enteral administration of injectable ammonium chloride may offer an effective method for the treatment of persistent metabolic alkalosis, without the adverse effects associated with the intravenous route. This case series describes 3 pediatric patients who received ammonium chloride enterally for the treatment of persistent metabolic alkalosis. The patients were a 2-month-old female infant, a 6-week-old male infant, and a 3-year-old male toddler. Four to 18 doses of ammonium chloride were administered enterally (range, 3-144 mEq/dose). Two of the 3 patients achieved resolution of metabolic alkalosis with ammonium chloride, while 1 patient's condition was refractory to treatment. Resolution of metabolic alkalosis occurred at 4 and 8 days, which required a total weight-based dose of 10.7 mEq/kg and 18 mEq/kg, respectively. No adverse effects were recorded. The use of ammonium chloride injection administered enterally was a safe and effective option in 2 of the 3 pediatric patients with persistent metabolic alkalosis.
Collapse
Affiliation(s)
- Jennie T Mathew
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, Philadelphia, Pennsylvania
| | | |
Collapse
|
15
|
Abstract
OBJECTIVE To compare the cardiac effects of levalbuterol with those of racemic albuterol based on changes in heart rate (HR) in pediatric patients. METHODS The medical records of hospitalized children ages 1 month to 12 years, who received either levalbuterol or racemic albuterol via nebulizer for 3 consecutive doses between January 2006 and December 2008 were reviewed. The documented HR was collected prior to and after each administered dose of bronchodilator. The primary outcome was the largest percentage of change in HR between groups. Secondary outcomes of comparisons of the number of patients who had more than a 10% change in HR and incidence of tachycardia were included. RESULTS A total of 50 patients, 25 in each group, was included in the study. All patients in the racemic albuterol group received 2.5 mg per dose, while most of the patients in the levalbuterol group received 0.63 mg per dose (19 patients, 76%). Only 6 levalbuterol patients received a dose of 1.25 mg. Nineteen of 25 patients (76%) in the levalbuterol group were tachycardic prior to the first recorded dose compared to 15 patients (60%) in the racemic albuterol group (p = 0.36). The median of the largest percentage of change in HR was 4.1% (interquartile range [IQR], 1.8-8.7) in the levalbuterol group compared to 5% (IQR, 1.9-7.8) in the racemic albuterol group (p = 0.763). Four patients in the levalbuterol group experienced an HR increase of more than 10% compared to 5 patients in the racemic albuterol group (p = 1.0). CONCLUSION Levalbuterol and racemic albuterol bronchodilator therapies produced similar effects on HR. No clinically significant differences were detected in HR changes between the two treatment groups, despite administration of a larger equipotent albuterol dose in the racemic albuterol group than in the levalbuterol group.
Collapse
|