A prospective observational study of pediatric opioid prescribing at postoperative discharge: how much is actually used?

PURPOSE: Research describing opioid misuse in children after surgery currently describes single specialties, short follow-up, and heterogeneous data not conducive to comparative discussion. Our primary objective was to quantify opioids prescribed to pediatric surgical patients on discharge from hospital. Secondary objectives were quantifying opioids remaining unused at four-week follow-up, and family attitudes to safe storage and disposal. METHODS: We conducted a prospective observational study under counterfactual consent with telephone follow-up at four weeks of children who had undergone a surgical procedure and filled an opioid prescription at The Hospital for Sick Children, Toronto, ON, Canada. Exclusion criteria included opioid use within the previous six months, history of chronic pain, or discharge to a rehabilitation facility. Pre- and post-discharge prescribing, dispensing, and consumption data were collected prospectively in addition to parental reports of home opioid use. Opioid-dosing was converted to oral morphine milligram equivalents (MME). RESULTS: There were 8,672 MMEs prescribed to 110 patients. Twenty-one patients were lost to follow-up, accounting for 1,416 MME. Of the remaining 7,256 MME, 67% went unused. At follow-up, 78% of unused opioid remained in the home. Most opioids were stored in an easily accessible location in the home. CONCLUSION: These findings confirm overprescribing of opioids to pediatric surgical patients. Families tend not to return opioids that exceed post-discharge analgesic requirements at home and many of the reported disposal methods are unsafe. We recommend future studies focus on optimizing opioid prescriptions to meet, but not excessively surpass, home pain management requirements, and to encourage safe opioid disposal/return methods. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03562013); registered 7 June, 2018.

RéSUMé: OBJECTIF : La recherche s'intéressant à la mauvaise utilisation des opioïdes après une chirurgie chez des enfants décrit actuellement des spécialités uniques, un suivi de courte durée et des données hétérogènes ne permettant pas de déboucher sur un débat comparatif. Notre objectif principal était de quantifier les opioïdes prescrits à des patients chirurgicaux pédiatriques au moment de leur congé de l'hôpital. Les objectifs secondaires étaient de quantifier les opioïdes inutilisés restant après quatre semaines de suivi et l'attitude des familles envers un stockage et une élimination sécuritaires. MéTHODES : Nous avons réalisé une étude observationnelle prospective sous consentement contre-factuel avec suivi téléphonique à quatre semaines d'enfants qui avaient subi une procédure chirurgicale et avaient reçu une prescription honorée d'opioïdes au Hospital for Sick Children de Toronto (ON, Canada). Les critères d'exclusion étaient l'utilisation d'opioïdes dans les six mois précédents, des antécédents de douleur chronique et un congé vers un établissement de réadaptation. Les prescriptions avant et après le congé, les données de remise et de consommation des médicaments ont été collectées de manière prospective en plus des rapports parentaux sur l'utilisation des opioïdes au domicile. Les doses d'opioïdes ont été converties en milligrammes équivalents de morphine (MEM) orale. RéSULTATS : Il y a eu 8 672 MEM prescrits à 110 patients. Vingt et un patients représentant 1 416 MEM ont été perdus au suivi. Sur les 7 256 MEM restants, 67 % n'ont pas été utilisés. Au suivi, 78 % des opioïdes non utilisés étaient encore au domicile. La majorité d'entre eux étaient conservés dans un endroit facile d'accès au domicile. CONCLUSION : Ces constatations confirment la prescription excessive d'opioïdes aux patients chirurgicaux pédiatriques. Les familles ont tendance à ne pas rapporter les opioïdes qui dépassent les besoins analgésiques après le congé et un grand nombre des méthodes d'élimination indiquées ne sont pas sécuritaires. Nous recommandons de concentrer les études futures sur l'optimisation des prescriptions d'opioïdes afin de satisfaire, mais sans dépasser de façon excessive, les besoins pour la gestion de la douleur au domicile et d'encourager des méthodes de retour/élimination sécuritaire des opioïdes. ENREGISTREMENT DE L'ESSAI CLINIQUE : www.ClinicalTrials.gov (NCT03562013); Enregistré le 7 juin 2018.

Antimicrobial Resistance in Typhoidal Salmonella in Nepal: Surveillance for Enteric Fever, 2016-2019.

BACKGROUND: Enteric fever (caused by Salmonella enterica) has been associated with poor hygiene and is endemic in the South-Asian countries. The increase in resistance to first line antimicrobials has been observed, while the emergence of multi/extremely drug resistance cases have been identified in several countries. The objective of this study is to analyze the current trend of antimicrobial resistance in Salmonella isolates in Nepal, and to identify the status of multi- and extremely- drug resistant isolates. METHODS: We recruited individuals at study hospitals with suspected enteric fever between September 2016 and August 2019 and performed blood cultures. The Salmonella isolates were tested for antimicrobial susceptibility and the antimicrobial resistance trend was evaluated. RESULTS: 1438 positive blood culture isolates were studied for antimicrobial resistance. 88% were culture positive for Salmonella Typhi and 12% for Salmonella Paratyphi. Multidrug resistant S. Typhi cases appeared mostly in December 2018 and January 2019, while there were no multidrug resistant S. Paratyphi cases. Also, extremely drug resistant S. Typhi cases were not observed during the study period. CONCLUSIONS: The Salmonella isolates were mostly susceptible to first-line antimicrobials, cephalosporins and others. Many fluoroquinolones non-susceptible Salmonella were obtained, nevertheless their overall trend seems to be declining. In addition, the S. Paratyphi total cases are reducing since September 2017. Among S. Typhi isolates, only few were multidrug resistant and there were no extremely drug resistant isolates.

Opioid-related harm in a quaternary pediatric hospital: A 5-year review.

BACKGROUND: Opioid therapy in pediatrics may be particularly prone to error, yet the incidence of opioid-related medication error and harm has not yet been described in the pediatric inpatient setting. METHODS: We reviewed a prospectively compiled medication safety database from November 1, 2012 to October 31, 2017. Reports originated from voluntary reporting, hospital code events, naloxone administrations, and reports of unexpected experiences of patient pain. Time, location, error characteristics, drug, route, prescription, error phase, mechanisms, harm, and outcome were collected for all reports. Error and harm were classified by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) system. RESULTS: Over 697 opioid medication safety reports were included during the study period. Opioids were administered at a rate of 79.26 administrations per 100 patient bed days, with morphine and hydromorphone administered at 62 versus 15 administrations per 100 bed days, respectively. Overall error rate was 0.94 errors per 103 patient days. Although the absolute rate of error reporting was greater for morphine (0.65 errors reported per 103 opioid administrations) than for hydromorphone, the adjusted incidence of harm was 0.211 per 103 hydromorphone administrations compared to 0.086 per 103 morphine administrations. 47 opioid errors resulted in harm, and administration errors (29) were almost twice as common as prescribing errors (15). CONCLUSIONS: We report and aim to establish a comparative reference point for incidence of opioid-related error and harm adjusted for both hospital bed days and total opioid administrations within the pediatric hospital inpatient setting based on the above findings.