Impact of Intravenous Fat Emulsion Choice on Candida Biofilm, Hyphal Growth, and Catheter-Related Bloodstream Infections in Pediatric Patients.

BACKGROUND: Use of mixed-oil (MO) intravenous fat emulsion (IFE) was shown to inhibit Candida albicans biofilm formation and overall rate of catheter-related bloodstream infections (CR-BSIs) compared with soybean-oil (SO) IFE). We aimed to delineate this inhibitory mechanism and impact of IFE choice on distribution of fungal CR-BSIs. METHODS: Transcriptional profiling was conducted on C. albicans grown in SO-IFE, MO-IFE, or SO-IFE with capric acid. Overexpression strains of shared down-regulated genes were constructed using a tetracycline-off system to assess hypha and biofilm formation in IFEs. A 5-year retrospective multicenter cohort study was performed to assess differences in CR-BSIs caused by Candida species based on the IFE formulation received in pediatric patients. RESULTS: Genes significantly down-regulated in MO-IFE and SO-IFE with capric acid included CDC11, HGC1, and UME6. Overexpression of HGC1 or UME6 enabled filamentation in capric acid and MO-IFE. Interestingly, only overexpression of UME6 was sufficient to rescue biofilm growth in MO-IFE. MO-IFE administration was associated with a higher proportion of non-albicans Candida versus C. albicans CR-BSIs (42% vs 33%; odds ratio, 1.22 [95% confidence interval, .46-3.26]). CONCLUSIONS: MO-IFE affects C. albicans biofilm formation and hyphal growth via a UME6-dependent mechanism. A numerical but not statistically significant difference in distribution of Candida spp. among CR-BSIs was observed.

Delivery of carbohydrates, amino acids, and lipids via intravenous catheters is necessary for some patients to supply daily caloric needs. These nutrient-dense parenteral solutions can promote microbial biofilm growth on the catheter surface, which may seed subsequent catheter-related bloodstream infection (CR-BSI). In fact, receipt of parenteral nutrition is an established risk factor for CR-BSI caused by the polymorphic fungal pathogen Candida albicans. New intravenous fat emulsions (IFEs) have gained market share and IFEs containing capric acid (mixed-oil [MO] IFE) compared with those without (soybean-oil [SO] IFE) impair the C. albicans yeast-to-hypha switch­a trait strongly associated with pathogenicity and biofilm formation. In this study, we found that MO-IFE and capric acid reduced expression of a transcriptional regulator involved in hyphal extension (UME6) and down-regulated genes involved in cell partitioning (HGC1). Overexpression of these genes enabled hyphal growth in MO-IFE. Secondly, we sought to determine whether the type of IFE administered was associated with the clinical incidence of CR-BSIs caused by C. albicans or other common non-albicans Candida species. There was a nonsignificant numerical reduction in C. albicans infections in patients administered MO-IFE compared with SO-IFE. Collectively, this work shows that IFEs differentially affect Candida biology with potential infectious consequences for the patient.

Codeine prescribing practices before and after the 2017 FDA warning at an academic health system.

BACKGROUND: In April of 2017, the U.S. Food and Drug Administration (FDA) issued a boxed warning contraindicating codeine use in all patients younger than 12 years of age. OBJECTIVES: The purpose of this study was to describe changes in codeine prescribing practices across a broad range of professions and specialties before and after the boxed warning and identify opportunities for optimization of a health system-wide response to changes in evidence-based practice recommendations. METHODS: Patients younger than 12 years of age with codeine-containing products prescribed between February 2017 and April 2018 at a single health system were included. Patient demographics, provider specialty, and prescription indication were collected by retrospective chart review. For categorical variables, frequency and percentage were calculated; for continuous variables, means with standard deviations or medians with interquartile ranges were calculated. RESULTS: Codeine prescriptions for patients younger than 12 years of age declined after the boxed warning issued by the FDA. Some provider specialties reacted promptly whereas others took longer to change their practice. Temporally, the largest decreases in prescribing centered around the month after the FDA communication release in April 2017 and the later implementation of electronic health record (EHR) alerts in June 2017. CONCLUSION: Given the persistence of codeine prescribing even after EHR soft-stop alerts were implemented, future pharmacy informatic responses to changes in evidence-based practice recommendations could be optimized using hard-stop alerts for high-impact recommendations. Studies comparing combination codeine products and other opioid medications for chronic pain in pediatric patients would be helpful to characterize the true level of risk in this population.

Call to expand access to vaccines for children through pharmacist education, collaboration, and advocacy.

Vaccines are a daycare and school requirement for children. The Public Readiness and Emergency Preparedness (PREP) Act 3rd amendment grants pharmacists and pharmacy interns the capability to vaccinate children at ages 3-18 years according to the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices schedule of recommended vaccines. Before this, only some state boards of pharmacy allowed pharmacists to administer pediatric vaccines. Despite these opportunities, immunization training programs lack the comprehensive training of pediatric vaccines and administration for pharmacists and pharmacy interns without additional financial cost. All pharmacists should be adequately trained and pharmacies be reimbursed to provide vaccines to all ages of pediatric patients. Advocacy is necessary to ensure children have reliable, affordable, and convenient access to lifesaving vaccines today and after the PREP Act expires.

Twice weekly prophylaxis with trimethoprim/sulfamethoxazole for Pneumocystis jirovecii pneumonia in pediatric oncology patients.

Current recommendations for prophylaxis of Pneumocystis jirovecii pneumonia in oncology patients include administration of trimethoprim/sulfamethoxazole (TMP/SMX) three times weekly or the same total weekly dose given daily. The primary objective of this study was to evaluate the efficacy of two consecutive days per week of TMP/SMX for prevention of Pneumocystis jirovecii pneumonia (PJP) in pediatric oncology patients. A retrospective cohort, single-center analysis was conducted in oncology patients 21 years and younger who received TMP/SMX for PJP prophylaxis between February 1, 2013 and July 31, 2017. Changes to the prophylaxis regimen were documented and analyzed. A total of 322 patients received TMP/SMX on two consecutive days per week for PJP prevention, of whom four had confirmed PJP (1.3%). Neutropenia was the most common reason for switching to alternative prophylaxis therapy (11.5%). Two consecutive prophylaxis days with TMP/SMX may be insufficient to prevent PJP in children with hematologic malignancies. Neutropenia remains a barrier for TMP/SMX use for PJP prophylaxis. Further studies to compare PJP incidence in children receiving alternative prophylaxis regimens should be considered.

Calcineurin inhibitor- and corticosteroid-free immunosuppression in pediatric heart transplant patients.

Pediatric heart transplant patients at our institution are immunosuppressed with a CNI and another immune-modulating agent without utilizing corticosteroids. Patients whose renal function worsened and who did not respond to CNI minimization had their CNI discontinued. The clinical history of 35 pediatric heart transplant patients with significant renal insufficiency whose CNI was discontinued was retrospectively analyzed. Data including serum creatinine and weight were collected before, at time of, and every 3-6 months after CNI discontinuation. This was used to calculate an eGFR. Cardiac allograft rejection and mortality data were also collected. CNI discontinuation occurred 39 times in 35 patients. The median eGFR significantly increased by 14 mL/min 3 months after CNI discontinuation and the increase continued to be significant (P≤.05) at 5 years. Freedom from rejection analysis showed no difference between graft rejection 2 years before versus after CNI discontinuation (P=.437). No mortality was associated with CNI discontinuation. Immunosuppression free of CNIs and corticosteroids appears to be a safe alternative in pediatric heart transplant patients with significant renal insufficiency. Furthermore, this strategy can significantly reverse renal insufficiency, even late after transplantation.

URINARY TRACT INFECTIONS IN PATIENTS YOUNGER THAN 60 DAYS OLD.

The safety and efficacy of transitioning from parenteral to oral antibiotics in patients aged less than 60 days with urinary tract infections were assessed. Patients who transitioned to oral therapy had a lower mean length of stay with no significant difference in medically attended urinary tract infection symptoms within 30 days of treatment.

Use of dornase alfa in pediatric patients without cystic fibrosis.

OBJECTIVES: Literature regarding clinical benefits of dornase alfa (DNase) in pediatric patients without cystic fibrosis is lacking. In December 2020, the study institution implemented restrictions to limit DNase use in this patient population. The primary objective was adherence to DNase ordering restrictions. Secondary objectives included length of stay, respiratory function, and use of inhaled mucolytic agents. METHODS: This single-center retrospective chart review included patients less than 18 years of age who received DNase one year prior to through one year after order restriction implementation. Data collected included patient demographics and respiratory clinical parameters. Dosing regimens for DNase, n-acetylcysteine, and hypertonic saline were collected, as well as changes in length of stay (LOS) and adherence to ordering restrictions. RESULTS: Of 101 total DNase orders, 45 were placed after implementation of ordering restrictions and 16 (36%) met all ordering criteria. Hospital and intensive care unit (ICU) LOS after implementation of restrictions were not significantly different (p = 0.767 and p = 0.219, respectively). There was no significant change in patients' mean oxygenation index (p = 0.252) or FiO2% (p = 0.113) 24 hours after DA administration. CONCLUSION: Respiratory function did not significantly change after DNase administration. Implementing restrictions on DNase did not impact intensive care unit or hospital LOS. Adherence to DNase ordering restrictions could be improved.

Ethanol Lock for Prevention of CVC-Related Bloodstream Infection in Pediatric Patients: A Systematic Review and Meta-Analysis.

Ethanol lock therapy (ELT) can be used in patients with an indwelling central line to assist in the prevention of central venous catheter (CVC)-associated infections. However, its efficacy has not been consistently demonstrated in the pediatric population. The primary objective of this review and meta-analysis was to determine the efficacy and safety of ELT in prevention of central line-associated bloodstream infection (CLABSI) in the pediatric population. A search was conducted with the PubMed, CINAHL, PSCYInfo, Cochrane Library, and Academic Search Premier databases from inception through January 21, 2022. Studies were included if they reported incidence of CVC-related infections with ELT in pediatric patients. Meta-analyses used random-effects models according to the heterogeneity of all included studies. Of 736 studies, 25 met inclusion criteria for review and 10 for inclusion in the meta-analysis. Meta-analysis with pre- and post-ELT treatment showed that use of ELT significantly decreased mean CVC-related infections when compared with pre-treatment with no ELT with a mean difference of -5.79 (95% CI, -9.08 to -2.51; p < 0.001). The number of CVC infections also significantly decreased (OR, 0.42; 95% CI, 0.23-0.75; p = 0.004). Increased risk of thrombosis and increased frequency of catheter breakage, repair, and replacement were noted in several studies. Ethanol lock therapy is effective in preventing infection related to central venous catheter use in pediatric patients. Further study is warranted to determine the optimal protocol for, and incidence of, adverse events related to use of ELT.

The use of vitamin K for coagulopathy in critically ill children.

OBJECTIVES: Coagulopathy is associated with increased mortality in children in the intensive care unit (ICU). Recommended management of vitamin K-deficient coagulopathy is vitamin K administration. The goal of this study was to evaluate vitamin K administration for coagulopathy in critically ill children and determine a relationship between vitamin K dose and change in prothrombin time (PT) and international normalized ratio (INR). METHODS: This retrospective cohort study reviewed electronic medical records of patients ≤17 years who received vitamin K for acute coagulopathy in the pediatric ICU from January 2013 to January 2021. Patients receiving vitamin K antagonists were excluded. Effectiveness data included change in PT/INR after vitamin K administration. Safety data included incidence of hypersensitivity or anaphylaxis. RESULTS: A total of 310 patients (median age 6.8 years, range 22 days-17.7 years) received vitamin K. A median of three doses (range 1-8) and 0.14 mg/kg per dose (range 0.09-0.22 mg/kg) were given, most frequently intravenously (892/949, 94%). Most patients (304/310, 98%) had at least one risk factor for vitamin K deficiency. Mean PT/INR was 21.5/2.1 prior to vitamin K administration, which decreased by 4.4 (SD = 9.0, 95% CI 16.011 to 18.015, p < 0.001) and 0.5 (SD = 1.0, 95% CI 1.490 to 1.705, p < 0.001) to means of 17.0 and 1.6, respectively, after the first vitamin K dose. No linear relationship was found between vitamin K dose and change in PT/INR. No hypersensitivity or anaphylaxis occurred following vitamin K administration; 27% (84/310) of patients died. CONCLUSIONS: Administration of vitamin K is effective and safe for the management of vitamin K-deficient coagulopathy in critically ill pediatric patients. Further study is needed to determine a relationship between vitamin K dose and change in PT/INR.

Methylnaltrexone for Opioid-Induced Dysmotility in Critically Ill Infants and Children: A Pilot Study.

OBJECTIVE: Critically ill pediatric patients commonly experience opioid-induced dysmotility. Methylnaltrexone, a subcutaneously administered, peripherally acting mu-opioid receptor antagonist, is a compelling adjunct to enteral laxatives in patients with opioid-induced dysmotility. Data for methylnaltrexone use in critically ill pediatric patients are limited. The purpose of this study was to determine the effectiveness and safety of methylnaltrexone for opioid-induced dysmotility in critically ill infants and children. METHODS: Patients younger than 18 years who received subcutaneous methylnaltrexone from January 1, 2013, through September 15, 2020, in the pediatric intensive care units at an academic institution were included in this retrospective analysis. Outcomes included incidence of bowel movement, enteral nutrition feeding volume, and adverse drug events. RESULTS: Twenty-four patients, median age 3.5 years (IQR, 0.58-11.1), received 72 methylnaltrexone doses. The median dose was 0.15 mg/kg (IQR, 0.15-0.15). Patients were receiving a mean ± SD of 7.5 ± 4.5 mg/kg/day of oral morphine milligram equivalents (MMEs) at methylnaltrexone administration and received opioids for median 13 days (IQR, 8.8-21) prior to methylnaltrexone administration. A bowel movement occurred within 4 hours following 43 (60%) administrations and within 24 hours following 58 (81%) administrations. Enteral nutrition volume increased by 81% (p = 0.002) following administration. Three patients had emesis and 2 received anti-nausea medication. No significant changes in sedation or pain scores were observed. Withdrawal scores and daily oral MMEs decreased following administration (p = 0.008 and p = 0.002, respectively). CONCLUSIONS: Methylnaltrexone may be an effective treatment for opioid-induced dysmotility in critically ill pediatric patients with low risk of adverse effects.

Just DOAC: Use of direct-acting oral anticoagulants in pediatrics.

PURPOSE: The aim of this article is to provide an overview of the current literature for direct-acting oral anticoagulant (DOAC) use in pediatric patients and summarize ongoing trials. SUMMARY: In treatment of venous thromboembolism (VTE) in pediatric patients, evidence supports use of both dabigatran and rivaroxaban. Dabigatran has been shown to be noninferior to standard of care (SOC) in terms of efficacy, with similar bleeding rates. Similarly, treatment with rivaroxaban in children with acute VTE resulted in a low recurrence risk and reduced thrombotic burden, without increased risk of bleeding, compared to SOC. Treatment of pediatric cerebral venous thrombosis as well as central venous catheter-related VTE with rivaroxaban appeared to be both safe and efficacious and similar to that with SOC. Dabigatran also has a favorable safety profile for prevention of VTE, and rivaroxaban has a favorable safety profile for VTE prevention in children with congenital heart disease. Many studies with several different DOACs are ongoing to evaluate both safety and efficacy in unique patient populations, as well as VTE prevention. CONCLUSION: The literature regarding pediatric VTE treatment and prophylaxis is growing, but the need for evidence-based pediatric guidelines remains. Additional long-term, postauthorization studies are warranted to further elucidate safety and efficacy in clinical scenarios excluded in clinical trials. Additional data on safety, efficacy, and dosing strategies for reversal agents are also necessary, especially as the use of DOACs becomes more common in the pediatric population.

Student perception of academic advising in a school of pharmacy.

OBJECTIVES: Literature assessing the optimal means of providing academic advisement in pharmacy education is limited. The objective of this study was to describe students' perception of advising within a school of pharmacy. METHODS: A 27-question survey was developed utilizing Qualtrics and sent to all students at one school of pharmacy. Baseline descriptive data regarding frequency and format of meeting with the assigned advisor were collected, as well as students' opinions of these meetings. KEY FINDINGS: Of 282 students who were sent the survey, 90 responded (31.9%). The majority of students preferred to meet with their faculty advisor in a group as compared with one-on-one (59 versus 29, 67%). Most students found the advisor/advisee relationship beneficial (n = 77, 85%). CONCLUSIONS: There was no statistically significant difference in student perception of the quality or value of advisor/advisee meetings between students who met in a group or one-on-one with their advisors.

Prophylaxis for Pneumocystis jirovecii pneumonia in patients with inflammatory bowel disease: A systematic review.

Patients with inflammatory bowel disease (IBD) are at increased risk of developing Pneumocystis jirovecii pneumonia (PJP) than the general population. Many medications utilized for the treatment of IBD affect the immune system, potentially further increasing the risk of PJP. Recommendations for prophylaxis against PJP in this patient population are based upon limited evidence, and risk factors for PJP development are not well-agreed upon. The purpose of this systematic review was to consolidate and evaluate the evidence for PJP prophylaxis in patients with IBD. An electronic literature search was performed, and 29 studies were included in the review, of which 24 were case reports or case series. Combined data from five cohort studies showed an absolute risk of developing PJP to be 0.07%. The majority of patients who developed PJP were receiving corticosteroids at the time of diagnosis (76%). The number of concomitant immunosuppressants received at time of PJP diagnosis varied from one to four. All studies reporting treatment of PJP utilized sulfamethoxazole-trimethoprim. Of the 27 studies reporting mortality data, 19% of patients died. Given the lack of conclusive data regarding risk factors for PJP development and the overall low incidence of PJP in patients with IBD, it is recommended to assess the patient's risk on a case-by-case basis to determine whether PJP prophylaxis is warranted.

Renal Impairment Associated With Trimethoprim-Sulfamethoxazole Use in the Pediatric Population.

OBJECTIVE: Limited studies describe acute kidney injury (AKI) in children receiving trimethoprimsulfamethoxazole (SXT). The primary objective of this study was to describe AKI with SXT use in pediatric patients. Secondary objectives included describing the incidence of hyperkalemia and blood dyscrasias with SXT use. METHODS: In this retrospective, single-center observational study, inpatient electronic medical records were reviewed for patients younger than 18 years of age who received at least 5 days of SXT for treatment of a bacterial infection. Patients were excluded if serum creatinine data prior to and after initiation of SXT were unavailable, they had AKI or were on hemodialysis prior to SXT initiation, or they were admitted to an oncology unit. RESULTS: Of 98 patients who met inclusion criteria, 24 (24.5%) experienced stage I AKI and 16 (16.3%) experienced stage II or III AKI. The mean treatment duration with SXT at time of AKI development was 5.9 days. Coadministration of SXT with other nephrotoxic medications increased the risk of development of AKI (OR, 1.7; 95% CI, 1.2-2.4). Hyperkalemia was noted in 29 patients (29.6%), anemia in 39 patients (39.8%), thrombocytopenia in 30 (30.6%), and neutropenia in 39 (39.8%). CONCLUSIONS: Changes in renal function suggestive of AKI occur frequently in pediatric patients receiving at least 5 days of treatment with SXT, particularly when using serum creatinine as a marker of AKI. In contrast, when using urine output rather than serum creatinine, the incidence is much lower and may be more reflective of a true change in renal function. Coadministration of nephrotoxic agents increases the risk of development of AKI. Anemia and hyperkalemia are common in patients receiving SXT and not associated with development of AKI. Further prospective study is warranted to validate these results.

Myelosuppression Rates with Administration of Nafcillin with and without Rifampin in Pediatric Patients.

Myelosuppression, a potential adverse reaction of nafcillin and rifampin, is rarely documented in pediatric populations. The objective of this study is to describe the incidence of myelosuppression in pediatric patients receiving nafcillin or a combination of nafcillin and rifampin therapy. This retrospective chart review identified patients who received nafcillin alone or in combination with rifampin. The primary endpoint was the incidence of myelosuppression as a composite outcome. The secondary endpoints were the incidence of thrombocytopenia, anemia, and neutropenia individually. Of 199 patients in this study, 98 received nafcillin alone. There was no difference in the rates of myelosuppression between patients receiving nafcillin alone or in combination with rifampin (p = 0.0763), and the use of combination therapy did not affect the development of neutropenia (p = 0.2764) or thrombocytopenia (p = 0.1672). Patients receiving combination therapy were more likely to be anemic at the end of therapy (odds ratio [OR] = 2.333, 95% confidence interval [CI] 0.999, 5.446). Similarly, patients receiving longer durations of nafcillin were more likely to experience anemia (OR 1.774, 95% CI 1.382, 2.370) and neutropenia (OR 1.256, 95% CI 1.024, 1.540). The use of nafcillin does not significantly affect myelosuppression in pediatric patients, although longer durations of therapy may result in increased rates of neutropenia and anemia. Combination therapy with rifampin may result in increased rates of neutropenia.

Enteral antipseudomonal fluoroquinolones for ventilator-associated tracheobronchitis in children with pre-existing tracheostomy.

INTRODUCTION: Pseudomonas aeruginosa is the most commonly isolated organism in tracheostomy-dependent children with ventilator-associated tracheobronchitis (VAT). Enteral treatment with an antipseudomonal fluoroquinolone such as ciprofloxacin or levofloxacin is sometimes employed, but supportive data are limited. The purpose of this study was to evaluate the effectiveness and safety of enteral antipseudomonal fluoroquinolones for VAT in children with pre-existing tracheostomy. METHODS: This was a retrospective review of electronic medical records for tracheostomy-dependent children <18 years of age who received an enteral antipseduomonal fluoroquinolone for the treatment of presumed VAT from January 2013 through January 2020 at an academic children's hospital. RESULTS: Seventy-six treatment courses representing 60 children (median age: 9.5, interquartile range [IQR]: 3.6-13.1 years) received an antipseudomonal fluoroquinolone for VAT treatment during the study period. Median treatment duration was 8 (range: 7-10) days. Most tracheostomy cultures (n = 70/82, 85%) were polymicrobial, with P. aeruginosa most commonly isolated (n = 67/224 organisms, 30%). Sixty-five courses (86%) were successfully treated with an enteral fluoroquinolone. Antibiotics were changed or extended for two (3%) children. Antibiotics were prescribed for 10 (13%) courses and eight (11%) required hospitalization for a respiratory infection within 30 days of fluoroquinolone completion. Six (8%) courses received a seizure rescue medication, seven (9%) experienced emesis, and one (1%) had elevated transaminases. Tendonitis and tendon rupture were not observed. CONCLUSIONS: The results of this study suggest enteral antipseudomonal fluoroquinolones may be effective for the treatment of VAT in children with tracheostomy. Further study is warranted to clarify the role of these agents in pediatric VAT.

Key articles and guidelines for the pediatric clinical pharmacist from 2019 and 2020.

PURPOSE: To summarize recently published research reports and practice guidelines deemed to be significantly impactful for pediatric pharmacy practice. SUMMARY: Our author group was composed of 8 board-certified pediatric pharmacists. Eight major themes were identified: critical care, hematology/oncology, medication safety, general pediatrics, infectious diseases, neurology/psychiatry, gastrointestinal/nutrition, and neonatology. The author group was assigned a specific theme(s) based on their practice expertise and were asked to identify articles using MEDLINE and/or searches of relevant journal articles pertaining to each theme that were published from January 2019 through December 2020 that they felt were "significant" for pediatric pharmacy practice. A final list of compiled articles was distributed to the authors, and an article was considered significant if it received a vote from 5 of the 8 authors. Thirty-two articles, including 16 clinical practice guidelines or position statements and 16 review or primary literature articles, were included in this review. For each of these articles, a narrative regarding its implications for pediatric pharmacy practice is provided. CONCLUSION: Given the heterogeneity of pediatric patients, it is difficult for pediatric pharmacists to stay up to date with the most recent literature, especially in practice areas outside their main expertise. Over the last few years, there has been a significant number of publications impacting the practice of pediatric pharmacists. This review of articles that have significantly affected pediatric pharmacy practice may be helpful in staying up to date on key articles in the literature.

Adherence to the 2014 American Academy of Pediatrics palivizumab prophylaxis recommendations.

INTRODUCTION: This study aims to describe adherence rates to the 2014 American Academy of Pediatrics (AAP) Committee on Infectious Disease guidance document recommending which patients should receive palivizumab for prophylaxis against respiratory syncytial virus (RSV). METHODS: A retrospective, single-center analysis of patients who received at least one dose of palivizumab between October 1, 2012, and March 1, 2017 was conducted. Data collected included demographics, medical history, palivizumab administration regimens, and incidence of RSV infection. RESULTS: Data were collected on 457 patients who received palivizumab over five RSV seasons. Approximately half of the patients (45% and 55%, respectively) received palivizumab according to the AAP recommendations in place at the time (2012 or 2014 recommendations, respectively). One percent of patients had a breakthrough RSV infection after receiving at least one dose of palivizumab. There was no significant difference in the number of breakthrough infections before and after the 2014 recommendations were released (3 vs. 2). CONCLUSIONS: Approximately half of the patients received prophylaxis in accordance with the 2014 AAP recommendations and infrequently suffered from a breakthrough RSV infection.

Comparison of the Efficacy of Posaconazole Delayed Release Tablets and Suspension in Pediatric Hematology/Oncology Patients.

OBJECTIVES: Posaconazole is effective in preventing invasive fungal infections in neutropenic pediatric patients. The oral suspension has challenges in administration and absorption that are theorized to be minimized with delayed release tablets. However, this has not been validated in the pediatric population. This study was conducted to compare the efficacy and safety of posaconazole suspension and delayed release tablets in pediatric hematology/oncology patients. METHODS: A retrospective chart review in pediatric hematology/oncology patients was conducted from February 2013 to February 2017. Data collected include patient demographic data; posaconazole formulation, dose, and serum concentrations; and adverse events. RESULTS: Sixty-five patients with 353 serum posaconazole concentrations were included; 51.6% of concentrations drawn while patients were receiving posaconazole suspension were therapeutic, whereas 62.5% of concentrations drawn while patients were receiving posaconazole delayed release tablets were therapeutic (p = 0.035). Serum concentrations drawn while taking acid suppression (histamine receptor antagonists or proton pump inhibitors) and posaconazole suspension were less likely to be therapeutic (p < 0.0001) compared with those taken while receiving delayed release tablets. Adverse event profiles were similar between both formulations. CONCLUSIONS: Delayed release tablets proved more effective in achieving therapeutic serum posaconazole concentrations than posaconazole suspension, with minimal difference in adverse events, in pediatric hematology/oncology patients.

Hyperosmolar Therapy for Severe Traumatic Brain Injury in Pediatrics: A Review of the Literature.

Traumatic brain injury remains a leading cause of morbidity and mortality in children. The use of hyperosmolar therapy to offset increased intracranial pressure (ICP) is described in pediatric guidelines, yet some controversy remains regarding which option to select. A search was conducted using the PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health, Academic Search Premier, PsycInfo, and Cochrane Library databases. Studies were included if they described the hyperosmolar therapy use, involved severe traumatic brain injury (TBI), and patient age was 0 to 18 years. A total of 331 studies published between 1987 and 2017 were retrieved; of these, 9 met the inclusion criteria. Included studies were evaluated for the type and concentration of hyperosmolar therapy, associated mortality outcomes, ICP and coronary perfusion pressure (CPP) measurements, concurrent medications, and reported serum sodium and serum osmolarity or osmolality values. Hypertonic saline was the most commonly reported hyperosmolar therapy. Mannitol was less studied, but collectively demonstrated a higher incidence of mortality than hypertonic saline. There were several studies that did not report monitoring outcomes associated with serum sodium and/or serum osmolarity, despite the use of hyperosmolar therapies. Inconsistencies were noted between the studies in the overall study design as well as reported monitoring parameters and length of stay. Hypertonic saline appears to be safe and efficacious at several concentrations for treatment of increased ICP associated with severe TBI in pediatric patients. The limited available data regarding the use of mannitol do not allow a strong conclusion to be made regarding its use.