Acute Kidney Injury During Treatment with Intravenous Acyclovir for Suspected or Confirmed Neonatal Herpes Simplex Virus Infection

OBJECTIVE

To describe the epidemiology of and risk factors associated with acute kidney injury (AKI) during acyclovir treatment in neonates and infants.

STUDY DESIGN

We conducted a multicenter (n = 4), retrospective cohort study of all hospitalized infants age <60 days treated with intravenous acyclovir (≥1 dose) for suspected or confirmed neonatal herpes simplex virus disease from January 2011 to December 2015. Infants with serum creatinine measured both before acyclovir (baseline) and during treatment were included. We classified AKI based on changes in creatinine according to published neonatal AKI criteria and performed Cox regression analysis to evaluate risk factors for AKI during acyclovir treatment.

RESULTS

We included 1017 infants. The majority received short courses of acyclovir (median, 5 doses). Fifty-seven infants (5.6%) developed AKI during acyclovir treatment, with an incidence rate of AKI at 11.6 per 1000 acyclovir days. Cox regression analysis identified having confirmed herpes simplex virus disease (OR, 4.35; P = .002), receipt of ≥2 concomitant nephrotoxic medications (OR, 3.07; P = .004), receipt of mechanical ventilation (OR, 5.97; P = .001), and admission to an intensive care unit (OR, 6.02; P = .006) as risk factors for AKI during acyclovir treatment.

CONCLUSIONS

Among our cohort of infants exposed to acyclovir, the rate of AKI was low. Sicker infants and those exposed to additional nephrotoxic medications seem to be at greater risk for acyclovir-induced toxicity and warrant closer monitoring.

Structural approaches to knowledge exchange: comparing practices across five centres of excellence in public health

Background

In 2008, five UKCRC Public Health Research Centres of Excellence were created to develop a coordinated approach to policy and practice engagement and knowledge exchange. The five Centres have developed their own models and practices for achieving these aims, which have not been compared in detail to date.

Methods

We applied an extended version of Saner's model for the interface between science and policy to compare five case studies of knowledge exchanges, one from each centre. We compared these practices on three dimensions within our model (focus, function and type/scale) to identify barriers and facilitators for knowledge exchange.

Results

The case studies shared commonalities in their range of activities (type) but illustrated different ways of linking these activities (function). The Centres' approaches ranged from structural to more organic, and varied in the extent that they engaged internal audiences (focus). Each centre addressed policymakers at different geographical levels and scale.

Conclusions

This article emphasizes the importance of linking a range of activities that engage policymakers at different levels, intensities and points in their decision-making processes to build relationships. Developing a structural approach to knowledge exchange activities in different contexts presents challenges of resource, implementation and evaluation.

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.

609. Acute Kidney Injury During Treatment with Intravenous Acyclovir (AKITA) for Suspected Neonatal Herpes Simplex Virus Infection

Background

Intravenous (IV) acyclovir is often administered empirically in neonates with suspected herpes simplex virus (HSV) disease. Acute kidney injury (AKI) can occur within 1–2 days after starting acyclovir due to crystal nephropathy, but the epidemiology of acyclovir-associated AKI in infants is not well-described. Our objective was to detail the incidence and timing of AKI among acyclovir-exposed infants.

Methods

We identified all hospitalized infants age <60 days treated with ≥1 dose of IV acyclovir for suspected or confirmed neonatal HSV disease from January 2011 to December 2015 at four US hospitals. Subjects were included if they had both a baseline (lowest value obtained before initiation of acyclovir) and follow-up serum creatinine (SCr; obtained after at least one dose of acyclovir [Day 0] through 48 hours after completion) recorded. Infants with congenital kidney disease were excluded. We defined AKI using Kidney Disease: Improving Global Outcomes SCr criteria: ≥50% increase from baseline, or ≥0.3 mg/dL change within any 48-hour period.

Results

We identified 3,374 infants who received IV acyclovir, 1,535 of whom (45.5%) had SCr as defined for inclusion in our analyses (range 52–898 infants per hospital); 50% were white, 44% were female, and the median gestational age was 37 weeks (IQR 35 – 39). On acyclovir Day 0, the median age was 6 days (IQR 2–18), and 50.0% (n = 768) were admitted to the NICU. The median acyclovir dose was 59.5 mg/kg/day (IQR: 55.8–61.2) and the median duration of treatment was 3 days (IQR: 3–6). Thirty-two infants had confirmed HSV disease (10 CNS, 14 disseminated, and eight skin, eye, and mucous membrane disease). In all, 96 infants (6.3%) had AKI detected after acyclovir initiation including 62 (64.5%) on Day 0, 20 (20.8%) on Day 1 or 2, and 14 (14.6%) on/after Day 3. Of those with AKI on Day 1 or later, 41% (n = 14) had Stage 2 AKI (doubling of SCr or more from baseline). Seven of 32 (21.8%) infants with confirmed HSV had AKI including 4 on Day 0, 2 on Days 1–2, and 1 on Day 12.

Conclusion

The incidence of AKI among infants treated with IV acyclovir in our study was low. Most AKI was detected soon after acyclovir initiation, potentially owing to more severe illness at the start of treatment and/or drug toxicity, but AKI also developed later. SCr monitoring should be considered throughout acyclovir treatment in infants.

Disclosures

B. L. Haltzman, Pfizer, Inc.: Study Coordinator, Salary. K. J. Downes, Pfizer, Inc.: Investigator, Research support. Merck, Inc.: Investigator, Research support. S. E. Coffin, Merck, Inc.: Investigator, Research support.