Aminoglycoside use in a pediatric hospital: there is room for improvement-a before/after study.

UNLABELLED: Aminoglycoside prescriptions were rarely evaluated in children care facilities. Because of risk of toxicity, these narrow spectrum antibiotics are commonly misused. In this study, we evaluate aminoglycoside prescription and assess the impact of an information campaign on modalities of prescription and monitoring practices in a pediatric hospital. This prospective study, before/after diffusion of local recommendations, has been conducted over 6 months. All computerized prescriptions were analyzed. A semi-passive diffusion of local recommendations to prescribers allowed researchers to differentiate between a pre-intervention (P1) and post-intervention period (P2). Endpoints were the improvement of administered doses (mg/kg), modalities of administration, treatment duration, indications, and the presence of pharmacological monitoring. Three hundred and ten prescriptions were analyzed (P1 = 163, P2 = 147). Most common sites of infection treated were as follows: joint-bone (33 %), urinary tract (17 %) and intra-abdominal (15 %). Among all prescriptions, respectively, 12 and 13 % were avoidable. Short-duration treatment and single daily dosing seem to be widely achieved, but despite an improvement between the two periods, 45 % of prescribed doses in P2 were still below our recommendations (77 % in P1). CONCLUSION: The semi-passive diffusion of recommendations has not improved significantly medical practices. Active diffusion with a regular monitoring could be useful to improve the use of aminoglycosides. WHAT IS KNOWN: • Misuse of aminoglycosides has been frequently described and evaluated in adult hospitals. • This misuse could be explained by their nephrotoxicity and their low therapeutic index. What is New: • Through this study, conducted in a pediatric hospital, we highlighted that practitioners misunderstand the aminoglycoside pharmacokinetic and pharmacodynamic targets and 12.3 % of aminoglycoside prescriptions could be avoided. • Finally, we showed that a semi-passive diffusion of local recommendations is not enough to improve aminoglycoside prescriptions.

Serum phosphate level and its kinetic as an early marker of acute kidney injury in tumor lysis syndrome.

INTRODUCTION: Acute kidney injury (AKI) is a major cause of mortality in tumor lysis syndrome. The biochemical parameters and kinetics of tumor lysis syndrome remain poorly described. Particularly, whether blood serum phosphate variations may help in the identification and management of patients who will eventually develop AKI remains to be studied. METHODS: In this retrospective study, we included patients with tumor lysis syndrome episodes without AKI at diagnosis, and analyzed serum phosphate kinetic, clinical and tumor lysis syndrome biochemical variables to identify factors associated with AKI onset, and determine threshold values of phosphatemia associated with AKI development. RESULTS: One hundred thirty tumor lysis syndrome episodes occurred in 120 patients during an 11-year period at the University Hospital of Angers. AKI developed in 56 tumor lysis syndrome episodes. In multivariable analysis, among the analyzed factors, only an increase in serum phosphate levels (before AKI diagnosis), exposure to platinum salts and an increase in LDH levels were associated with AKI development. Before AKI onset, a serum phosphate cut-off of 2.1 mmol/L was not effective in predicting AKI development (sensitivity 48%, specificity 84%, area under the receiver operating characteristic curve (AUC) 0.63 [0.52-0.74]). No other biochemical parameters were effective to better predict AKI occurrence. CONCLUSION: This work suggests that increases in serum phosphate and LDH appear to be early and reliable biomarkers of AKI in tumor lysis syndrome. No valuable threshold value of serum phosphate was found to effectively predict AKI. This work is the basis for further prospective controlled studies on phosphate monitoring and phosphate lowering therapies to prevent AKI during tumor lysis syndrome.

High flow nasal cannula improves breathing efficiency and ventilatory ratio in COPD patients recovering from an exacerbation.

BACKGROUND AND STUDY PURPOSE: High flow nasal cannula (HFNC) may improve CO2 elimination by washing out CO2 from the upper airways. This study aimed at assessing the effect of HFNC on minute ventilation and ventilatory ratio (VR), a surrogate of dead space, in patients hospitalized for acute hypercapnic COPD exacerbation. METHODS: Physiological study comparing HFNC at 40 L/min to low flow oxygen. Variations of tidal volume (VT) and minute ventilation between the two treatments were estimated from chest plethysmography. Respiratory rate (RR) and arterial blood gases were measured. Variations in VR were calculated. Data were compared using Wilcoxon tests. RESULTS: Recordings performed in 10 patients. Minute ventilation was reduced with HFNC by -16.2 [-30.9-0.4] % (p = 0.049). VT was not different but RR was lower during HFNC. PaCO2 was lower with HFNC compared to standard oxygen: 48.7 [46.4-58.1] vs 50.7 [48.4-57.5] mmHg (p = 0.020). VR decreased by -18.0 [-34.7 - -4.0] % (p = 0.020) with HFNC. CONCLUSIONS: In patients recovering from acute COPD exacerbation, the use of HFNC reduced RR, minute ventilation, PaCO2 and VR compared to standard oxygen. These changes are consistent with a decrease in physiologic dead space with HFNC.

A Retrospective Study on Infusion-Related Reactions to Rituximab in a Heterogeneous Pediatric Population.

OBJECTIVES: To assess risks and outcomes of infusion-related reactions to rituximab in a heterogeneous pediatric population. METHODS: All patients who received rituximab between July 2010 and July 2012 were retrieved from the pharmacy software and included for analysis. Data were collected according to 4 categories: demographic data, infusion data, infusion-related reactions, and biological data considered as risk factors (i.e., absolute lymphocyte count, lactate dehydrogenase levels). RESULTS: Sixty-seven patients treated for a total of 17 different indications were included. A total of 282 rituximab infusions were administered. Forty-three, mostly grade 1 or 2, infusion-related reactions occurred in 30 patients. Reactions occurred in 39.2% "first-dose" infusions, but this rate dropped drastically to 2.7% in subsequent doses. In multivariate analysis, high absolute lymphocyte count was the only risk factor for infusion-related reaction (OR = 1.03; 95% CI: 1.01-1.06; p = 0.014). CONCLUSIONS: Rituximab infusion-related reactions in a heterogeneous pediatric population were frequent on first infusion, but rare in subsequent ones. Overall, these reactions were mild and manageable through pharmacological treatment. Patients with an elevated absolute lymphocyte count before infusion were at greater risk for an infusion-related reaction.