Parenteral Beta-Lactam/Beta-Lactamase Inhibitor Ordering in Hospitals That Provide Care for Pediatric Patients.

OBJECTIVES: The purpose of this study was to define current practices related to beta-lactam/beta-lactamase inhibitor (BL/BLI) dose descriptions in hospitals that provide care for pediatric patients and to identify perceived implications of standardizing BL/BLI dose communication and ordering to a total drug-based strategy. METHODS: A 27-item electronic survey was distributed via 4 pediatric pharmacy and infectious diseases listservs. Survey questions pertained to hospital demographics, dosing communication practices, BL/BLI ordering and labeling practices, obstacles to safe BL/BLI use, and the effects of potential standardization to a total drug communication strategy. SPSS was used for quantitative analysis and MAXQDA was used for qualitative analysis. RESULTS: A total of 140 unique survey responses were analyzed after exclusion of incomplete responses and reconciliation of multiple responses from the same institution. Overall, 56.2% of institutions order BL/BLIs by BL component for pediatric patients, and 22% of institutions order by BL component for adult patients. Approximately half (51.8%) of respondents felt that standardizing to total drug would have a negative effect at their institution; perception of potential effect varied based on the institution's ordering strategy. CONCLUSION: Communication and ordering of BL/BLIs is inconsistent across institutions and between pediatric and adult patients. In the short term, the perception is that standardization would compound institutional challenges.

Unusual presentation of disseminated cryptococcal infection complicated by myocarditis in a heart transplant recipient.

BACKGROUND: Cryptococcus neoformans is the third most common cause of invasive fungal infection in solid organ transplant (SOT) recipients. While cryptococcal infection can involve any organ, cases of myocarditis are exceedingly rare. METHODS: A retrospective chart review was completed for this case report. RESULTS: We present the case of a 21-year-old heart transplant recipient who developed disseminated cryptococcal infection with biopsy-proven cryptococcal myocarditis. CONCLUSIONS: Cryptococcal disease in SOT recipients poses diagnostic and therapeutic challenges. There are no current guidelines for the duration of cryptococcal myocarditis treatment. Repeat myocardial biopsy may play a role in guiding length of therapy.

Implementation of a Shared Pediatric Pharmacy Elective During the COVID-19 Pandemic.

During the COVID-19 pandemic, educators were forced to identify innovative teaching strategies to deliver high-quality learning experiences to students. In spring 2021, faculty at Butler College of Pharmacy and Health Sciences and Purdue University College of Pharmacy collaborated to successfully implement a shared pediatric pharmacy elective at both institutions.

Five-Year Review of a Pediatric Pharmacy Internship Program.

Pharmacy internship programs improve job readiness for pharmacy learners. Pediatric-focused programs are not well described in the literature and represent only a small subset of pharmacy internships; furthermore, they offer unique experiences for learners with a strong interest in pediatrics. To better meet this need, a paid pediatric pharmacy internship was implemented in 2017 for rising second- and third-year professional pharmacy students. The program provides high-quality inpatient experience to pharmacy students with a strong interest in pediatrics via a 10-week, full-time summer program and ongoing weekend shifts throughout the academic year. Key focus areas of the internship include clinical shadowing and topic discussions, completing medication histories, research activities, and inpatient pharmacy triage. This program offers a multifaceted approach to providing interns with health-system experience and prepares learners for future careers in clinical and health-system pharmacy. To date, 100% of the 6 former interns who have graduated from pharmacy school have obtained residency positions. Furthermore, a permanent medication history technician role was created secondary to the positive response to interns providing this service.

Risk of Inappropriately Timed Live Vaccination After Pediatric Cardiovascular Surgery.

OBJECTIVE: The American Academy of Pediatrics (AAP), Advisory Committee on Immunization Practices (ACIP), and Centers for Disease Control and Prevention (CDC) recommend delaying live vaccinations up to 11 months after transfusions of certain blood products due to the risk of immunoglobulins decreasing immunization efficacy. Because vaccination schedules recommend live immunizations at 12 months, infants aged 5 to 12 months who undergo cardiac surgery requiring blood products are potentially at risk for improper vaccination. The objective of this study was to identify the risk of inappropriately timed live vaccination in pediatric patients after cardiovascular surgery. METHODS: This single-center, retrospective chart review included 345 patients 5 to 12 months of age who underwent cardiovascular surgery between January 1, 2010, and December 31, 2016. Included patients received packed red blood cells (PRBCs) and/or platelets during the surgical admission and a live vaccine within the first 18 months of life. The primary endpoint was the incidence of live vaccine administration within 7 months of receiving PRBCs and/or platelets. RESULTS: Of the 345 included patients, 67% (n = 230) were inappropriately vaccinated after receiving platelets and/or PRBCs during cardiac surgery. CONCLUSIONS: Infants who undergo cardiac surgery between the ages of 5 and 12 months are at risk for inappropriate live vaccination timing. A clinically significant percentage of pediatric patients who received blood products during a cardiac surgical admission later received live vaccines at times that were inconsistent with AAP, ACIP, and CDC recommendations. Future interventions aimed at educating providers and patients may be warranted.

Safety of enteral sildenafil in hemodynamically unstable children.

BACKGROUND: Enteral sildenafil may be used in the intensive care unit for treatment of pulmonary arterial hypertension. We aimed to determine if initial enteral sildenafil dosing is safe in children receiving concurrent vasoactive infusions. METHODS: We performed a single-centre retrospective chart review that included patients less than 2 years of age in paediatric and cardiovascular intensive care units at an academic medical centre from 1 January, 2010 to 30 November, 2016. Included patients received concomitant enteral sildenafil and a continuously infused vasoactive agent. Exclusion criteria consisted of mechanical circulatory support, any form of dialysis, or a suspicion of septic shock at the time of sildenafil initiation. We sought to identify patients who developed worsening hemodynamic instability after initiation of enteral sildenafil defined as one or more of the following observations within 24 hours of sildenafil initiation: sildenafil discontinuation, total fluid bolus receipt >10 ml/kg, increased vasoactive support, epinephrine intravenous push administration, and/or the initiation of mechanical circulatory support. RESULTS: Worsening hemodynamic instability was identified in 35% of the 130-patient cohort. Patients younger than 4 months were at increased risk of further hemodynamic instability compared with older patients (56% versus 44%, p = 0.0003) despite receiving lower median doses (1.28 mg/kg/day versus 1.78 mg/kg/day, p = 0.01). CONCLUSIONS: Critically ill children receiving vasoactive infusions may be at increased risk for further hemodynamic instability after initiation of enteral sildenafil, particularly in younger patients. This population may benefit from lower starting enteral sildenafil doses of 0.25 mg/kg/dose or less every 8 hours to avoid further hemodynamic compromise.

Establishment of prophylactic enoxaparin dosing recommendations to achieve targeted anti-factor Xa concentrations in children with CHD.

BACKGROUND: Enoxaparin may be used to prevent central venous catheter-related thrombosis in patients with CHD. We aimed to determine whether current enoxaparin dosing regimens effectively achieve anti-factor Xa concentrations within prophylactic goal ranges in this patient population. METHODS: We implemented a formal protocol aimed at reducing central venous catheter-related thrombosis in children with CHD in January, 2016. Standard empiric prophylactic enoxaparin dosing regimens were used - for example, 0.75 mg/kg/dose every 12 hours for patients <2 months of age and 0.5 mg/kg/dose every 12 hours for patients ⩾2 months of age - with anti-factor Xa goal range of 0.25-0.49 IU/ml. Patients <2 years of age who received enoxaparin and had at least one valid steady-state anti-factor Xa measurement between 25 January, 2016 and 31 August, 2016 were retrospectively reviewed. RESULTS: During the study period, 47 patients had 186 anti-factor Xa concentrations measured, of which 20 (11%) were above and 112 (60%) were below the prophylactic goal range. Anti-factor Xa concentrations within the goal range were ultimately achieved in 31 patients. Median dose required to achieve anti-factor Xa concentrations within the prophylactic range was 0.89 mg/kg/dose (25, 75%: 0.75, 1.11) for patients <2 months (n=23 patients) and 0.79 mg/kg/dose (25, 75%: 0.62, 1.11) for patients ⩾2 months (n=8 patients). CONCLUSIONS: Enoxaparin doses required to achieve prophylactic anti-factor Xa concentrations in young children with CHD were consistently higher than the currently recommended prophylactic dosing regimens. Further study is needed to determine whether dose titration to achieve prophylactic anti-factor Xa concentrations is effective in preventing central venous catheter-related thrombosis.

Optimizing Guideline-Recommended Antibiotic Doses for Pediatric Infective Endocarditis.

The American Heart Association recently published an updated scientific statement on the management of infective endocarditis in childhood. The recommendations included for vancomycin, aminoglycoside, and ß-lactam dosing and monitoring are based primarily on expert opinion and do not consider available evidence for dose optimization based on pharmacokinetic and pharmacodynamic principles in pediatric patients. This is concerning because even when clinically necessary, some practitioners may be hesitant to deviate from guideline-recommended doses. In this perspective, we highlight potential areas for improvement in the statement-recommended doses and summarize evidence supporting antibiotic dosing optimization. The addition of a pediatric clinical pharmacist with expertise in antibiotic dosing to the panel would be beneficial for future updates.

Tissue plasminogen activator for the treatment of parapneumonic effusions in pediatric patients.

Intrapleural fibrinolysis has been investigated for the treatment of pleural effusion for several decades. Fibrinolytics have the ability to break up fibrin and loculations that characterize complicated pleural effusions, facilitating drainage. Older fibrinolytics such as urokinase and streptokinase have been replaced by tissue plasminogen activator (tPA) for this indication due to product availability and a more favorable safety profile. The literature supports tPA as a treatment approach for this indication in adult patients, and the use of tPA has become a standard management approach in this population. Over the past decade, data on the efficacy of intrapleural fibrinolytic therapy in children have also been generated, which now support the use of fibrinolysis as a treatment alternative to more invasive therapeutic options such as surgical intervention. In this review, we discuss the pathophysiology, diagnosis, and treatment of parapneumonic effusion and empyema, with a focus on intrapleural fibrinolysis, specifically tissue plasminogen activator, in the pediatric population. Recent articles provide sufficient evidence to support the use of this drug in pediatric patients for the management of pleural effusions; however, due to study heterogeneity, questions remain that may be addressed in future studies.

Underutilization of cardiovascular medications: effect of a continuity-of-care program.

PURPOSE: The effect of hospital pharmacists' enhanced communication with patients and community providers on the underutilization of key cardiovascular medications was studied. METHODS: Patients enrolled in the Iowa Continuity of Care study were eligible for inclusion in this study if they had a diagnosis of hypertension, hyperlipidemia, heart failure, coronary artery disease, or a combination of these diagnoses. Eligible patients also had to be admitted to the internal medicine, family medicine, cardiology, or orthopedics services and receive their usual medical care in the community and their prescriptions from a community pharmacy. Patients were randomized to receive minimal intervention, enhanced intervention, or usual care. For the minimal- and enhanced-intervention groups, pharmacy case managers (PCMs) performed comprehensive medication reconciliations and identified drug-related problems within 24 hours of admission. The PCMs made recommendations to the inpatient care team and to patients' community physicians. For patients in the enhanced-intervention group, the PCM developed a discharge care plan containing the patient's discharge medication list. PCMs made specific recommendations to optimize regimens that did not meet current guidelines or medications that were underutilized. Medication underutilization was assessed at admission, discharge, 30 days after discharge, and 90 days after discharge. RESULTS: A total of 732 patients were enrolled in this study. There were no significant differences among the three study groups. Overall, the rate of underutilization remained constant among all three groups, despite enhanced pharmacist involvement in both intervention groups. CONCLUSION: Enhanced interventions by PCMs had no effect on the underutilization of key cardiovascular drugs during hospitalization or after hospital discharge.