Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation.

Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.

Initial posaconazole dosing to achieve therapeutic serum posaconazole concentrations among children, adolescents, and young adults receiving delayed-release tablet and intravenous posaconazole.

Posaconazole is a broad-spectrum antifungal used for prophylaxis and treatment of invasive fungal diseases. There are limited data on the optimal dosing, safety, and efficacy of the DRT and IV formulations in immunocompromised pediatric and adolescent patients. We describe our experience including dosing, plasma trough concentrations, safety, and tolerability. Plasma concentrations ≥.7 µg/mL were considered therapeutic for prophylaxis and ≥1.0 µg/mL for treatment. Fifty-four patients (median age of 16 years) received DRT or IV formulations of posaconazole. Thirty-one (57%) patients received posaconazole for treatment and 23 (43%) for prophylaxis. Overall, 36 (67%) patients achieved targeted initial plasma trough concentrations (median 1.3 µg/mL) (Figure 1). The median daily dose among patients <13 years of age who achieved the targeted initial concentrations was 7.3 mg/kg/day for the DRT formulation and 9.8 mg/kg/day for the IV formulation. The median daily dose among patients ≥13 years of age who achieved the targeted initial concentrations was 4.9 mg/kg/day for the DRT formulation and 5.6 mg/kg/day for the IV formulation. Thirty-six patients (67%) developed transaminitis, mostly grade 1. Our observations show that DRT and IV formulations are safe and effective in immunocompromised children, adolescents, and young adults. Higher dosing per body weight of DRT and IV posaconazole may be required in patients <13 years of age compared with patients 13 years of age and older to achieve therapeutic plasma concentrations. [Figure: see text].

Vitamin D deficiency and hypocalcemia in an infant with newly diagnosed AML.

We report a 4-month-old male presenting with hypocalcemia, hyperleukocytosis, and newly diagnosed acute myeloid leukemia. He received chemical leukoreduction through low-dosed cytarabine, with appropriate decrease in his white blood cell count and development of subsequent symptomatic hypocalcemia, which did not normalize until the underlying vitamin D deficiency was addressed. A single dose of cholecalciferol raised the serum calcium concentration to an appropriate level within 48 hours. For infants with newly diagnosed leukemia and prolonged hypocalcemia, vitamin D deficiency should be considered in the differential diagnosis and managed appropriately.

Biossegurança em fonoaudiologia / Biosafety in Speech, Language and Hearing Sciences

OBJETIVO: pesquisar, entre um grupo de fonoaudiólogos, o grau de conhecimento e utilização das normas de biossegurança na rotina clínica. MÉTODO: foi realizada pesquisa por meio de um questionário respondido por cem profissionais de diferentes áreas de atuação (Audiologia Clínica, Audiologia Ocupacional, Voz, Neonatologia, Linguagem, Motricidade Orofacial e que atuam em mais de uma área). Cada item, respondido de forma positiva, correspondia a 1 ou 2 pontos, sendo a máxima pontuação (100%) correspondendo a 80 pontos. As respostas obtidas foram analisadas e as pontuações encontradas, padronizadas, ou seja, transformadas em índices percentuais indicando seu desempenho. O valor da percentagem de cada questionário poderia variar de 0 a 100%, sendo que quanto maior a percentagem obtida, maior o conhecimento e aplicabilidade das normas de biossegurança pelo profissional na rotina clínica. Foram adotadas as faixas de (0-25%), (26-50%), (51-75%) e (76-100%) para distinguir o nível de conhecimento e aplicação das medidas de precaução pelos participantes. RESULTADOS: dos cem fonoaudiólogos avaliados por meio dos questionários (100%), 1% obteve a percentagem na faixa de (0 a 25%), 45% em (26 a 50%), 50% entre (51 a 75%) e 4% (76 a 100%). CONCLUSÃO: a maioria dos profissionais que participaram conhece e aplica as medidas de biossegurança.

PURPOSE: research, among a group of speech pathologists, the degree of knowledge and use of standards of biosafety in clinical routine. METHOD: a survey was conducted through a questionnaire answered by one hundred professionals from different areas (Clinical Audiology, Occupational Audiology, Voice, Neonatology, Language, Orofacial Motricity and more than one performing area). Each item, responded in a positive way, corresponding to 1 or 2 points and the maximum score (100%) corresponding to 80 points. The responses were analyzed and the found scores were standardized, or converted into percentage index indicating its performance. The percentage value of each questionnaire could vary from 0 to 100%, and the greater the percentage obtained, the more knowledge and applicability of standards of biosafety professionals in the clinical routine. Tracks were taken (0-25%), (26-50%), (51-75%) and (76-100%) to distinguish the level of knowledge and application of precautionary measures by the participants. RESULTS: of one hundred speech therapists assessed by the questionnaires (100%), 1% obtained the percentage in the range (0 to 25%), 45% (26 to 50%), between 50% (51 to 75%) and 4% (76 to 100%). CONCLUSION: the most of the professionals who participated knows and applies biosafety measures.

Posaconazole therapeutic drug monitoring in pediatric patients and young adults with cancer.

BACKGROUND: Limited information exists regarding the use of posaconazole for treating systemic fungal infections in children, adolescents, and young adults with cancer. At St. Jude Children's Research Hospital, the recommended posaconazole dose in patients weighing less than 34 kg is 18-24 mg/kg daily, given in 4 divided doses. For patients aged 13 years or older or those weighing 34 kg or more, the recommended dose is 800 mg daily, given orally in 4 divided doses. OBJECTIVE: To determine whether the current posaconazole dosing guidelines achieve target posaconazole plasma concentrations of 0.7 µg/mL or greater. METHODS: This retrospective clinical study examined data from patients who received treatment-dose posaconazole and had at least 1 posaconazole plasma concentration measurement. RESULTS: Data from 33 patients who received posaconazole for the treatment of fungal infections were analyzed. The median age of patients was 11.5 years (range 0.5-23.2). Twenty-one of 33 patients (63.6%) had posaconazole concentrations of 0.7 µg/mL or greater (median 1.4; range 0.7-2.98) at the first measurement. The median posaconazole dosage referenced to total body weight in these patients was 20 mg/kg/day. Patients with concentrations less than 0.7 µg/mL (median 0.4; range 0.025-0.69) received lower posaconazole dosages when referenced to body weight (median 12.9 mg/kg/day; p = 0.02). Of the 12 patients with concentrations less than 0.7 µg/mL, 7 (58.3%) were aged 13 years or older. CONCLUSIONS: The current dosing approach for posaconazole yielded therapeutic plasma concentrations more frequently in patients younger than 13 years than in those 13 years or older. This difference may be related to the practice of capping adolescent and young adult doses at the suggested maximum adult daily dose. Therefore, we recommend weight-based dosing in all pediatric, adolescent, and young adult patients with cancer, with routine therapeutic drug monitoring to ensure adequate concentrations.

A experiência de estudantes de enfermagem em um grupo de educação em saúde: uma abordagem dialógica / Nursing students? experience in a health education group: a dialogic approach

Objetivo: Fazer uma reflexão teórica sobre a experiência de estudantes de Enfermagem em um grupo de educação em saúde, no município de Campinas-SP, tendo como referencial teórico-metodológico o Modelo Dialógico. Síntese dos Dados: Tratou-se de um relato de experiência, realizado em um Centro de Saúde do Distrito de Saúde Sudoeste, no município de Campinas-SP, no período de agosto a dezembro de 2009. Este Grupo foi dividido em 04 subgrupos de, em média, 60 usuários cada, sendo realizadas avaliação diagnóstica; identificação de temáticas a serem trabalhadas com os usuários e planejamento e execução de dinâmicas de grupo. A metodologia desenvolvida nas atividades educativas baseava-se no referencial teórico do Modelo Dialógico de Educação em Saúde. Por meio das dinâmicas de grupo, promoveram-se três mudanças na forma de pensar e fazer educação em saúde: i) do enfoque biologicista à apreensão multidimensional do indivíduo; ii) ao compartilhar, nós aprendemos: o princípio da bidirecionalidade; e iii) saber, não-saber ou sabemos? O princípio da simetria. Conclusão: Demonstra-se a viabilidade e operacionalidade do Modelo Dialógico para intervenções educativas em saúde.

Objective: To conduct a theoretical reflection on the experience of nursing students in a group of health education, in Campinas-SP, having as theoretical and methodological referential the Dialogical Model. Data Synthesis: This was an experience report, conducted in a Health Center of Southwest Health District, located in Campinas-SP, in the period from August to December 2009. This group was divided into 04 subgroups of on average 60 users each, being held diagnostic evaluation, identification of issues to be worked with users and planning and execution of group dynamics. The methodology developed in the educational activities was based on the theoretical Dialogical Model of Health Education. By means of group dynamics three changes were promoted in the way in which health education is thought and conducted: i) from a biologicist focus to the multidimensional apprehension of the individual; ii) through sharing, we learn: the principle of bidirectionality; iii) to know, not to know or do we know? The principle of symmetry. Conclusions: The viability and operability of the Dialogic Model for health education interventions is demonstrated.

Use of Plerixafor with Granulocyte Colony-Stimulating Factor for Stem Cell Mobilization in a Pediatric Patient.

OBJECTIVE: To present a case where plerixafor was successfully used in combination with granulocyte colony-stimulating factor (G-CSF) for mobilization of hematopoietic stem cells in a pediatric patient. CASE SUMMARY: An 11-year-old boy with recurrent anaplastic large-cell lymphoma failed to yield an adequate number of CD34+ cells with G-CSF for mobilization. After a single subcutaneous dose of plerixafor 240 µg/kg was administered in addition to filgrastim, sufficient CD34+ cells were harvested for transplantation. A local injection site reaction was the only adverse reaction reported. DISCUSSION: Several studies in adults have shown plerixafor to be effective for the mobilization of hematopoietic stem cells when used in combination with G-CSF in adults with non-Hodgkin's lymphoma and multiple myeloma who failed to mobilize sufficient CD34+ cells with G-CSF alone. There is limited information regarding the safety and efficacy of plerixafor in pediatric patients. CONCLUSIONS: Plerixafor was effective in increasing the number of hematopoietic stem cells in the peripheral blood of an 11-year-old patient; studies are needed to evaluate the safety and effectiveness of plerixafor in pediatric patients.