Improving the Documentation of Penicillin Allergy Labels Among Pediatric Inpatients.

BACKGROUND AND OBJECTIVES: Penicillin allergy is the most common medication allergy, and the penicillin allergy label is commonly over-applied without adequate reaction history inquiry or documentation. Because penicillin allergy labels are often applied in childhood and carried into adulthood, we sought to increase the completeness of reaction history documentation from 20% to 70% for pediatric hospital medicine patients and from 20% to 50% for all other pediatric inpatients within 12 months. As a secondary outcome, we also aimed to increase the proportion of delabeling unnecessary penicillin labels to 20% for all pediatric inpatients. METHODS: To address our aims, our quality improvement initiative included education for pediatric faculty and staff, development and implementation of a clinical pathway for allergy risk stratification, and electronic health record optimizations. Statistical process control charts were used to track the impact of the interventions facilitated by an automated dashboard. RESULTS: Within 12 months of interventions, the completeness of allergy labels improved from 20% to 64% among patients admitted to the pediatric hospital medicine service and improved from 20% to 45% for all other pediatric inpatients. The frequency of penicillin allergy delabeling remained unchanged; however, 98 patients were risk stratified and 34 received outpatient allergy referrals for further testing. The number of adverse drug reactions to penicillin, a balancing measure, did not change during the study period. CONCLUSIONS: We increased the completeness of penicillin allergy documentation using a standardized workflow facilitated by a multidisciplinary clinical pathway. With ongoing efforts, more penicillin delabeling in low-risk patients is anticipated.

Treatment of Aspergillus fumigatus infection with posaconazole delayed-release tablets.

PURPOSE: A pediatric patient with cystic fibrosis (CF) was successfully treated for Aspergillus fumigatus infection with posaconazole delayed-release tablets. SUMMARY: A 13-year-old, 29-kg, Caucasian boy with CF was admitted to the hospital for a pulmonary exacerbation. The patient had a history of multiple hospital admissions and was colonized with methicillin-sensitive Staphylococcus aureus, Stenotrophomonas maltophilia, and A. fumigatus. The patient was started on piperacillin-tazobactam 2.8 g (piperacillin 2 g and tazobactam 0.8 g) i.v. every 6 hours (400 mg/kg/day) and tobramycin 400 mg i.v. every 24 hours (13.7 mg/kg/day). After 2 weeks of therapy and therapeutic tobramycin concentrations, doxycycline 75 mg given orally twice daily was continued due to lack of clinical improvement. After 2 additional weeks of therapy, the patient was started on posaconazole delayed-release tablets 300 mg given orally daily with the evening meal due to concern about A. fumigatus colonization and a further decline in forced expiratory volume in 1 second to 37%. The posaconazole trough concentration was 1,500 ng/mL after 5 days of therapy. As this level was within the goal range, posaconazole was continued, with a plan to periodically check the trough level, pulmonary function, and liver function. The patient's liver function values remained stable throughout therapy. The patient's appetite improved and weight increased. Once the patient's weight exceeded 35 kg, his dosage of posaconazole delayed-release tablets was increased to 400 mg daily. His pulmonary function improved during posaconazole therapy, and A. fumigatus was eradicated. Posaconazole was discontinued after 9 months of therapy. CONCLUSION: A 13-year old patient with CF was successfully treated for an A. fumigatus infection with posaconazole delayed-release tablets.

Resolution of a posttraumatic pancreatic pseudocyst with octreotide acetate in a pediatric patient.

A pancreatic pseudocyst is a complication of abdominal trauma in pediatric patients. Octreotide acetate is an effective adjunct therapy used in combination with traditional surgical approaches. We describe a 19-month-old boy with a pancreatic pseudocyst secondary to blunt abdominal trauma who was successfully managed with octreotide acetate in combination with percutaneous drainage and the placement of a pancreatic stent. Octreotide acetate 1 µg/kg/hour was administered as a continuous intravenous infusion for 24 hours, followed by 2.5 µg/kg/dose every 12 hours subcutaneously for 11 days. The patient was discharged after the pseudocyst had resolved and oral feeding was restored. He had no recurrence of the pseudocyst. The published literature regarding octreotide acetate therapy for pediatric pancreatic pseudocysts is limited. Previously reported cases demonstrated successful resolution of pancreatic pseudocysts with varying doses of intravenous and subcutaneous octreotide acetate within 23-30 days; however, with our patient's regimen, along with surgical interventions, the pseudocyst resolved within 11 days. In addition, our patient's regimen involved higher doses of octreotide acetate given more frequently than those reported in the literature. This case report illustrates that use of higher octreotide acetate dosages may be a potential adjunct therapy to surgical interventions for the management of pancreatic pseudocysts in children.

Trimethoprim-sulfamethoxazole-induced hepatotoxicity in a pediatric patient.

Due to the escalating rates of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection, trimethoprim-sulfamethoxazole (TMP-SMX) is being used increasingly in the pediatric population for skin and soft tissue infections. Although this combination agent has been associated with a hypersensitivity syndrome involving cutaneous skin eruptions, pediatric cases of TMP-SMX-induced hepatotoxicity are rare. We describe a relatively healthy, 9-year-old boy who developed a CA-MRSA skin and soft tissue infection and was treated with TMP-SMX. After 14 days of therapy, he was taken to the emergency department with a 3-day history of fever, headache, and neck pain. He was diagnosed with a viral syndrome, acetaminophen was prescribed, and he was sent home. Three days later, the patient returned to the emergency department with fever, vomiting, decreased energy and appetitie, and suprapubic abdominal pain, and he was hospitalized. Laboratory test results revealed elevated liver function test values. After other potential causes of liver toxicity were excluded, TMP-SMX was determined to be the cause of his acute liver toxicity. The drug was discontinued, his symptoms resolved, and his liver function tests returned to normal. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between the patient's development of hepatotoxicity and the TMP-SMX therapy. This rare adverse reaction to TMP-SMX has been reported in adults; however, to our knowledge, it has been reported in only five other children. Due to the increasing use of TMP-SMX in children, clinicians should be aware of this potentially life-threatening, immunemediated hypersensitivity reaction. Fortunately, however, the hepatotoxicity appears to resolve after discontinuation of the TMP-SMX therapy in most reported cases. This case report illustrates the importance of early detection of drug-induced hepatotoxicity and timely drug discontinuation to prevent the need for liver transplantation.