scholarly journals Vancomycin Prescribing Practices and Therapeutic Drug Monitoring for Critically Ill Neonatal and Pediatric Patients: A Survey of Physicians and Pharmacists in Hong Kong

2020 ◽  
Vol 8 ◽  
Author(s):  
Twinny Cheuk Hin Chow ◽  
Janice Yuen Shun Li ◽  
Jasper Chak Ling Wong ◽  
Freddie Man Hong Poon ◽  
Hugh Simon Lam ◽  
...  
Keyword(s):  
Hong Kong ◽  
Critically Ill ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Therapeutic Monitoring ◽  
Therapeutic Drug ◽  
Prescribing Practices ◽  
Cross Sectional ◽  
The Impact ◽  
Trough Levels

Background: Deviations from the optimal vancomycin dosing may occur in the neonatal and pediatric population due to inconsistencies in the recommended dosing algorithms. This study aims to collect the expert opinions of clinicians who practice in the neonatal or pediatric intensive care units (NICU/PICUs) of 12 major medical centers in Hong Kong.Methods: This was a multicenter, cross-sectional study. Eligible physicians and pharmacists completed a structured questionnaire to identify the challenges they encountered when selecting the initial intermittent vancomycin dosing. They also answered questions concerning therapeutic monitoring services (TDM) for vancomycin, including the targeted trough levels for empirical vancomycin regimens administered for complicated and uncomplicated infections.Results: A total of 23 physicians and 43 pharmacists completed the survey. The top clinical parameters reported as most important for determining the initial vancomycin dosing were renal function (90.9%), post-menstrual/postnatal age (81.8%), body weight (66.7%), and suspected/documented pathogen (53.0%). Respondents reported challenges such as difficulties in determining the optimal initial dose for a targeted level (53.0%), inconsistencies between dosing references (43.9%) and a lack of clear hospital guidelines (27.3%). Half of the pharmacists (48.8%) reported that they had helped to interpret the TDM results and recommend vancomycin dose adjustments in >75% of cases. For methicillin-resistant Staphylococcus aureus infection, physicians, and pharmacists reported target trough levels of ~10–15 and 15–20 mg/L, respectively. For suspected moderate/uncomplicated Gram-positive infections physicians tended to prefer a lower trough range of 5–10 mg/L, while pharmacists preferred a range of 10–15 mg/L.Conclusions: Our results demonstrate that clinicians used varying vancomycin dosing guidelines in their practices. The multidisciplinary TDM service in Hong Kong can be improved further by establishing a standardized dosing guideline and implementing a well-structured, evidence-based service protocol. Future work includes conducting drug utilization studies to evaluate real-world antimicrobial usage patterns and the impact on tangible clinical outcomes, and developing pharmacokinetic-guided dose calculator for antimicrobials in critically ill neonates and pediatric patients.

scholarly journals 1346. Implementation of a Multidisciplinary 48 Hour Antibiotic Timeout in a Pediatric Population

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S684-S684
Author(s):  
Victoria Konold ◽  
Palak Bhagat ◽  
Jennifer Pisano ◽  
Natasha N Pettit ◽  
Anish Choksi ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Pediatric Population ◽  
Intervention Group ◽  
Post Intervention ◽  
Days Of Therapy ◽  
New Antibiotics ◽  
Core Elements ◽  
Quasi Experimental ◽  
Empirical Antibiotics ◽  
The Impact

Abstract Background To meet the core elements required for antimicrobial stewardship programs, our institution implemented a pharmacy-led antibiotic timeout (ATO) process in 2017 and a multidisciplinary ATO process in 2019. An antibiotic timeout is a discussion and review of the need for ongoing empirical antibiotics 2-4 days after initiation. This study sought to evaluate both the multidisciplinary ATO and the pharmacy-led ATO in a pediatric population, compare the impact of each intervention on antibiotic days of therapy (DOT) to a pre-intervention group without an ATO, and to then compare the impact of the pharmacy-led ATO versus multidisciplinary ATO on antibiotic days of therapy (DOT). Methods This was a retrospective, pre-post, quasi-experimental study of pediatric patients comparing antibiotic DOT prior to ATO implementation (pre-ATO), during the pharmacy-led ATO (pharm-ATO), and during the multidisciplinary ATO (multi-ATO). The pre-ATO group was a patient sample from February-September 2016, prior to the initiation of a formal ATO. The pharmacy-led ATO was implemented from February-September 2018. This was followed by a multidisciplinary ATO led by pediatric residents and nurses from February-September 2019. Both the pharm-ATO and the multi-ATO were implemented as an active non-interruptive alert added to the electronic health record patient list. This alert triggered when new antibiotics had been administered to the patient for 48 hours, at which time, the responsible clinician would discuss the antibiotic and document their decision via the alert workspace. Pediatric patients receiving IV or PO antibiotics administered for at least 48 hours were included. The primary outcome was DOT. Secondary outcomes included length of stay (LOS) and mortality. Results 1284 unique antibiotic orders (n= 572 patients) were reviewed in the pre-ATO group, 868 (n= 323 patients) in the pharm-ATO and 949 (n= 305 patients) in the multi-ATO groups. Average DOT was not significantly different pre vs post intervention for either methodology (Table 1). Mortality was similar between groups, but LOS was longer for both intervention groups (Table 1). Impact of an ATO on DOT, Mortality and LOS Conclusion An ATO had no impact on average antibiotic DOT in a pediatric population, regardless of the ATO methodology. Disclosures All Authors: No reported disclosures

scholarly journals Standards of laboratory practice: cardiac drug monitoring

1998 ◽  
Vol 44 (5) ◽  
pp. 1096-1109 ◽  
Author(s):  
Roland Valdes ◽  
Saeed A Jortani ◽  
Mihai Gheorghiade
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Drug Monitoring ◽  
Free Fraction ◽  
Therapeutic Index ◽  
Therapeutic Monitoring ◽  
Therapeutic Drug ◽  
Laboratory Practice ◽  
Clinical Complications ◽  
The Impact

Abstract In this Standard of Laboratory Practice we recommend guidelines for therapeutic monitoring of cardiac drugs. Cardiac drugs are primarily used for treatment of angina, arrhythmias, and congestive heart failure. Digoxin, used in congestive heart failure, is widely prescribed and therapeutically monitored. Monitoring and use of antiarrhythmics such as disopyramide and lidocaine have been steadily declining. Immunoassay techniques are currently the most popular methods for measuring cardiac drugs. Several reasons make measurement of cardiac drugs in serum important: their narrow therapeutic index, similarity in clinical complications and presentation of under- and overmedicated patients, need for dosage adjustments, and confirmation of patient compliance. Monitoring may also be necessary in other circumstances, such as assessment of acetylator phenotypes. We present recommendations for measuring digoxin, quinidine, procainamide (and N-acetylprocainamide), lidocaine, and flecainide. We discuss guidelines for measuring unbound digoxin in the presence of an antidote (Fab fragments), for characterizing the impact of digoxin-like immunoreactive factor (DLIF) and other cross-reactants on immunoassays, and for monitoring the unbound (free fraction) of drugs that bind to α1-acid glycoprotein. We also discuss logistic, clinical, hospital, and laboratory practice guidelines needed for implementation of a successful therapeutic drug monitoring service for cardiac drugs.

Resilience, pessimism, and depression in undergraduates in Hong Kong during Covid-19: A cross-sectional online survey study (Preprint)

2021 ◽  
Author(s):  
Min Yi Sum ◽  
Sherry Kit Wa Chan ◽  
Gloria Hoi Yan Wong
Keyword(s):  
Hong Kong ◽  
Depressive Symptoms ◽  
Undergraduate Students ◽  
Family Conflict ◽  
Online Survey ◽  
Mental Wellbeing ◽  
Survey Study ◽  
Cross Sectional ◽  
Mediation Analyses ◽  
The Impact

BACKGROUND Adolescence and young adulthood is a period of heightened risk of mental disorders onset. The Covid-19 pandemic may have impacted the daily lives and learning of students, exposing them to risks of emotional distress. Understanding factors associated with individual differences in distress can inform remedial strategies for schools. OBJECTIVE To investigate the impact of Covid-19 on undergraduate students’ lifestyle and learning, and explore relationship between depressive symptoms, resilience, and optimism/pessimism bias in undergraduate students in Hong Kong. METHODS Cross-sectional online survey of undergraduate students in a university (n=1020) before and during the third wave of Covid-19 outbreak in Hong Kong between May and August 2020. Changes in habits and family conflicts, depressive symptoms (measured using Patient Health Questionnaire-9), resilience (measured using Connor-Davidson Resilience Scale), optimism/pessimism towards Covid-19 risks, and knowledge about Covid-19 were recorded. Multivariable linear regression and mediation analyses were used to explore relationships with depressive symptoms. RESULTS 61.7% of respondents have mild to severe depressive symptoms. The regression model found that 18.5% of the variance in depressive symptoms was explained by resilience, pessimism bias, changes in sleep, decrease in study at home, and increase in family conflict. Mediation analysis showed that resilience is indirectly related to depressive symptoms through its relationship with pessimism (ab = -0.042, CI = -0.057 to -0.013). Higher resilience was associated with lower depressive symptoms even after accounting for resilience’s indirect effect through pessimism (c’ = 0.311, P < .001). CONCLUSIONS The findings highlight the mental health vulnerability of undergraduate students. Measures to reduce family conflict, maintain healthy daily habits, adjust optimism/pessimism bias, and enhance resilience may be useful for improving the mental wellbeing of undergraduate students during the pandemic.

TO WHAT EXTENT DOES THE VANCOMYCIN ASSAY CONTRIBUTE TO THE VARIABILITY IN VANCOMYCIN CONCENTRATION ESTIMATES IN NEONATES?

2015 ◽  
Vol 101 (1) ◽  
pp. e1.10-e1 ◽  
Author(s):  
J. Samardžić ◽  
A. Smits ◽  
V. Cossey ◽  
I. Soldatović ◽  
M. Bajčetić ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Therapeutic Drug ◽  
P Value ◽  
Congenital Diseases ◽  
Vancomycin Concentration ◽  
Young Infants ◽  
Significant Difference ◽  
Postmenstrual Age ◽  
The Impact ◽  
Trough Levels

*presenting author, supported by ERAWEB II scholarship for postdoctoral program at the KU Leuven, Belgium (2014–2015)IntroductionVancomycin, a glycopeptide antibiotic, is frequently used for late onset sepsis (LOS) and catheter-related infection. Larger inter- and intra-patient variability, combined with a narrow therapeutic index, warrants therapeutic drug monitoring (TDM). However, large inter-individual variability in PK parameters in neonates is documented, only partly explained by covariates such as weight, age or serum creatinine (1,2). In the current study, we focus on the potential impact of between assay differences for vancomycin (3) on the variability in its concentration in a single neonatal intensive care unit (NICU).MethodsVancomycin TDM observations of neonates and young infants treated with intravenous vancomycin, mainly for (suspected) LOS (ie, >72 hours after birth), in the Leuven NICU, Belgium, between June 2011 and December 2014. Our patient population, consists of (pre)term neonates, inborn or transferred, in need of specialized care related to prematurity, infections, perinatal asphyxia, congenital diseases (eg, surgery for cardiopathy, congenital diaphragmatic hernia, or esophageal atresia), or other diseases. Clinical characteristics at birth, as well as characteristics at the moment of TDM were extracted from the patient files. We aimed to document early vancomycin exposure, therefore only first trough levels were included. Serum vancomycin assay was performed either with a particle-enhanced turbidimetric inhibitionimmunoassay method (Siemens Dimension; Dade Behring, Deerfield, Illinois–PETINIA) or with an enzyme multiplied immunoassay technique (Cobas c702; Roche Diagnostics, Basel, Germany–COBAS). The data were analyzed by Chi-square test, t test and Mann-Whitney U test. Linear Mix Model was used to assess significant differences between groups, when adjusting for confounding factors. Data were analyzed in SPSS 20.0 (IBM corp.), p-value <0.05 was significant.ResultsIn total, 564 vancomycin TDM observations, 311 assayed with PETINIA and 253 with COBAS, were included. Both cohorts had comparable clinical characteristics (median [min-max] current weight 2150 [420–5000] grams for PETINIA vs. 2120 [500–5840] grams for COBAS, and median postmenstrual age 35 [25–58] weeks for PETINIA vs. 35 [25–51] weeks for COBAS). We determined the significant difference between the vancomycin concentrations using two different immunoassays: PETINIA vs. COBAS (F=17.971; p<0.001). When adjusting for current body weight and postmenstrual age, the major covariates associated with vancomycin serum trough levels in neonates, the difference in vancomycin concentration between cohorts was statistically significant (F=17.076, p<0.001, F=18.951, p<0.001, respectively). Overall, immunoassays PETINIA and COBAS significantly differed by vancomycin concentrations when adjusting for covariates, and the mean difference for vancomycin concentration was 2.167 mg/l.ConclusionThe present study confirms the impact of assays on the variability in vancomycin concentration in neonates in a single NICU. Comparison between these two immunoassays showed a mean proportional differences >20%. Therefore, it is important to know how the vancomycin is measured when interpreting results, and particularly the transferability of vancomycin results between the laboratories has to be interpreted with caution.

Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery

2011 ◽  
Vol 31 (5) ◽  
pp. E5 ◽  
Author(s):  
Geoffrey Appelboom ◽  
Stephen D. Zoller ◽  
Matthew A. Piazza ◽  
Caroline Szpalski ◽  
Samuel S. Bruce ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Adult Population ◽  
Pediatric Trauma ◽  
Anatomical Variations ◽  
Decompressive Surgery ◽  
Pediatric Populations ◽  
The Impact

Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population. In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma. The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.

Evaluation of Intravenous Phenobarbital Pharmacokinetics in Critically Ill Patients With Brain Injury

2022 ◽  
Author(s):  
Seyedeh Sana Khezrnia ◽  
Bita Shahrami ◽  
Mohammad Reza Rouini ◽  
Atabak Najafi ◽  
Hamid Reza Sharifnia ◽  
...  
Keyword(s):  
Brain Injury ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Normal Population ◽  
Volume Of Distribution ◽  
Pharmacokinetic Parameters ◽  
Therapeutic Drug ◽  
Uv Detector ◽  
Therapeutic Goals ◽  
The Impact

Phenobarbital is still one of the drugs of choice in managing patients with brain injury in the intensive care unit (ICU). However, the impact of acute physiological changes on phenobarbital pharmacokinetic parameters is not well studied. This study aimed to evaluate the pharmacokinetic parameters of parenteral phenobarbital in critically ill patients with brain injury. Patients with severe traumatic or non-traumatic brain injury at high risk of seizure were included and followed for seven days. All patients initially received phenobarbital as a loading dose of 15 mg/kg over 30-minutes infusion, followed by 2 mg/kg/day divided into three doses. Blood samples were obtained on the first and fourth day of study at 1, 2, 5, 8, and 10 hours after the end of the infusion. Serum concentrations of phenobarbital were measured by high-pressure liquid chromatography (HPLC) with an ultraviolet (UV) detector. Pharmacokinetic parameters, including the volume of distribution (Vd), half-life (t1/2), and the drug clearance (CL), were provided by MonolixSuite 2019R1 software using stochastic approximation expectation-maximization (SAEM) algorithm and compared with previously reported parameters in healthy volunteers. Data from seventeen patients were analyzed. The mean value±standard deviation of pharmacokinetic parameters was calculated as follows: Vd: 0.81±0.15 L/kg; t1/2: 6.16±2.66 days; CL: 4.23±1.51 ml/kg/h. CL and Vd were significantly lower and higher than the normal population with the value of 5.6 ml/kg/h (P=0.002) and 0.7 L/kg (P=0.01), respectively. Pharmacokinetic behavior of phenobarbital may change significantly in critically ill brain-injured patients. This study affirms the value of early phenobarbital therapeutic drug monitoring (TDM) to achieve therapeutic goals.

scholarly journals Are Further Interventions Needed to Prevent and Manage Hospital-Acquired Hyponatraemia? A Nationwide Cross-Sectional Survey of IV Fluid Prescribing Practices

2020 ◽  
Vol 9 (9) ◽  
pp. 2790
Author(s):  
Per Sindahl ◽  
Christian Overgaard-Steensen ◽  
Helle Wallach-Kildemoes ◽  
Marie Louise De Bruin ◽  
Hubert GM Leufkens ◽  
...  
Keyword(s):  
Emergency Department ◽  
Inappropriate Prescribing ◽  
Plasma Sodium ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Clinical Scenarios ◽  
Hypotonic Fluids ◽  
Hospital Acquired ◽  
The Impact

Background: Hyponatraemia is associated with increased morbidity, increased mortality and is frequently hospital-acquired due to inappropriate administration of hypotonic fluids. Despite several attempts to minimise the risk, knowledge is lacking as to whether inappropriate prescribing practice continues to be a concern. Methods: A cross-sectional survey was performed in Danish emergency department physicians in spring 2019. Prescribing practices were assessed by means of four clinical scenarios commonly encountered in the emergency department. Thirteen multiple-choice questions were used to measure knowledge. Results: 201 physicians responded corresponding to 55.4% of the total population of physicians working at emergency departments in Denmark. About a quarter reported that they would use hypotonic fluids in patients with increased intracranial pressure and 29.4% would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. Also, 29.4% selected the correct fluid, a 3% hypertonic saline solution, for a patient with hyponatraemia and severe neurological symptoms, which is a medical emergency. Most physicians were unaware of the impact of hypotonic fluids on plasma sodium in acutely ill patients. Conclusion: Inappropriate prescribing practices and limited knowledge of a large number of physicians calls for further interventions to minimise the risk of hospital-acquired hyponatraemia.

scholarly journals 2 Systemic glucocorticoids and bradycardia in critically ill children: a retrospective study

2020 ◽  
Vol 25 (Supplement_2) ◽  
pp. e1-e1
Author(s):  
Camille Maltais-Bilodeau ◽  
Maryse Frenette ◽  
Geneviève Morissette ◽  
Dennis Bailey ◽  
Karine Cloutier ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Heart Rate ◽  
Intensive Care ◽  
Retrospective Study ◽  
Critically Ill ◽  
Medical Staff ◽  
Pediatric Population ◽  
Critically Ill Children ◽  
Rate Variation ◽  
The Impact

Abstract Background Glucocorticoids are widely used in the pediatric population. They are associated with numerous side effects including repercussions on the cardiovascular system. The impact on heart rate is not well known, but bradycardia has been reported, mostly with high doses. Objectives We described the occurrence of bradycardias and the variation of heart rate in critically ill children receiving glucocorticoids. Design/Methods We conducted a retrospective study including 1 month old to 18 year old children admitted to the Pediatric Intensive Care Unit between 2014 and 2017, who received a glucocorticoid dose equivalent to 1 to 15 mg/kg/day of prednisone. We collected data on exposition to glucocorticoids, heart rate before, during and after the exposition, and interventions from the medical staff in response to bradycardia. The primary outcome was the occurrence of bradycardia and the secondary outcomes were the magnitude of heart rate variation and the clinical management of bradycardias. Results We included 92 admissions (85 patients). The median dose of glucocorticoid used was 2.80 mg/kg/day of prednisone (2.08—3.80). We found 70 cases (76%) with at least one bradycardia. Before treatment, all patients had a mean heart rate higher than the 5th percentile for age. During exposition to glucocorticoids, 8 patients (10%, n = 83) had a median heart rate ≤ 5th percentile. We noted 46 cases of bradycardia (50%) that led to an intervention from the medical staff, but no patient had a major event associated to bradycardia. We found a significant association between bradycardia and age (estimate -0.136, 95% CI -0.207—-0.065, p &lt; 0.001), glucocorticoid dose (estimate 4.820, 95% CI 2.048—7.592, p &lt; 0.001) and intravenous administration (estimate 8.709, 95% CI 1.893—15.524, p = 0.012). Conclusion In our study, most children hospitalized at the intensive care unit receiving standard doses of glucocorticoid experienced bradycardia. The majority of episodes led to an intervention from the medical staff. Presence of bradycardia was associated with younger age, higher dose and IV administration of glucocorticoids.

scholarly journals Cefepime Pharmacokinetics in Critically Ill Pediatric Patients Receiving Continuous Renal Replacement Therapy

2019 ◽  
Vol 63 (4) ◽  
Author(s):  
Gideon Stitt ◽  
Jennifer Morris ◽  
Lindsay Schmees ◽  
Joseph Angelo ◽  
Ayse Akcan Arikan
Keyword(s):  
Intensive Care Unit ◽  
Body Weight ◽  
Intensive Care ◽  
Retrospective Study ◽  
Critically Ill ◽  
Pediatric Patients ◽  
Pediatric Intensive Care ◽  
Free Drug ◽  
Therapeutic Drug ◽  
Free Drug Concentration

ABSTRACT This retrospective study included pediatric intensive care unit patients receiving continuous veno-venous hemodiafiltration (CVVHDF) being treated with cefepime. The free drug concentration above one time the MIC (fT>1×MIC) and four times a presumed MIC (fT>4×MIC) of 8 μg/ml were calculated. Four patients received doses ranging from 48 to 64 mg/kg of body weight every 6 to 12 h. Three patients achieved 100% fT>1×MIC, with the fourth patient achieving 98% fT>1×MIC. Therapeutic drug monitoring should be considered for critically ill patients receiving cefepime on CVVHDF.

scholarly journals Pharmacokinetics of Daptomycin in Critically Ill Pediatric Patients

2018 ◽  
Vol 62 (6) ◽  
Author(s):  
Charalampos Antachopoulos ◽  
Stavroula Ilia ◽  
Paschalis Kadiltzoglou ◽  
Eirini Baira ◽  
Aristides Dokoumetzidis ◽  
...  
Keyword(s):  
Critically Ill ◽  
Drug Exposure ◽  
Pediatric Patients ◽  
Plasma Concentrations ◽  
Therapeutic Drug ◽  
Burn Patients ◽  
Time Curve ◽  
Once Daily ◽  
Concentration Time ◽  
Optimal Drug

ABSTRACT The pharmacokinetics of daptomycin (10 mg/kg once daily) was studied in 4 critically ill pediatric patients aged 8 to 14 yrs. The area under the concentration-time curve from time zero to infinity (AUC 0–∞ ) of plasma concentrations on day 1 ranged between 123.8 to 663.9 μg · h/ml, with lower values observed in septic and burn patients; clearance ranged from 15.1 to 80.7 ml/h/kg. Higher-than-recommended doses of daptomycin may be needed in septic children to ensure optimal drug exposure. Interpatient variability may suggest a role for therapeutic drug monitoring.

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