Evaluation of prescribing patterns for pediatric community-acquired pneumonia in the outpatient department of a tertiary-care medical center in the Philippines

OBJECTIVES@#This study evaluated the antibiotic prescribing patterns in pediatric patients in the Out Patient Department (OPD) of the Philippine Children’s Medical Center (PCMC) where it may encourage drug monitoring and improvement in the utilization of antibiotics in the department.@*MATERIALS AND METHODS@#A descriptive, cross-sectional study involving patient encounters selected using convenience sampling was conducted at the outpatient department of PCMC. All previously healthy pediatric patients aged 3 months to 18 years diagnosed with pediatric community- acquired pneumonia (PCAP) with no known acute and chronic comorbidities were included. The observed values of the antibiotic prescribing indicators were compared with the optimal values recommended by the World Health Organization (WHO), and the Index of Rational Drug Prescribing (IRDP) was calculated.@*RESULTS@#A total of 600 patients diagnosed with PCAP were included in the study seen at the PCMC OPD from January 2020 to July 2022. Ninety-six percent of the patient encounters had at least one antibiotic prescribed (SD + 0.20). The average number of medicines prescribed per patient encounter was 2.05 (SD + 0.85). Of these, 100% were prescribed by generic name and were prescribed from the essential drug list. The most commonly prescribed medications were antibiotics (43.17%) with coamoxiclav (42.93%), amoxicillin (37.76%), and cefuroxime (7.59%) being the top three commonly prescribed antibiotics.@*CONCLUSION@#With respect to the IRDP, PCMC scores well with 3.16 where the most rational score is 4. However, this study highlights the high occurrence of prescribing antibiotics in the institution.

Philippine guidelines on periodic health examination: Pediatric immunization

Executive Summary@#This Clinical Practice Guideline for the Periodic Health Examination (Pediatric Immunization) is an output from the joint undertaking of the Department of Health and National Institutes of Health-Institute of Clinical Epidemiology. This clinical practice guideline is a systematic synthesis of scientific evidence on immunization for the prevention of human papilloma virus (HPV) infection, influenza, typhoid fever, Japanese encephalitis, poliomyelitis, meningococcal infection, and Hepatitis A in the pediatric population. The CPG provides nine (9) recommendations on prioritized questions regarding the relevant vaccines for preventing these seven (7) diseases. Recommendations are based on the appraisal of the best available evidence on each of the eight identified clinical questions. The CPG is intended to be used by general practitioners and specialists in the primary care setting, policy makers, employers and administrators, allied health practitioners and even patients. The guideline development process followed the widely accepted Grading of Recommendations, Assessment, Development, and Evaluation or the GRADE approach including GRADE Adolopment, a systematic process of adapting evidence summaries and the GRADE Evidence to Decision (EtD) framework. 1,2 It includes 1) identification of critical questions and critical outcomes, 2) retrieval of current evidence, 3) assessment and synthesis of the evidence base for these critical questions, 4) formulation of draft recommendations, 5) convening of a multi-sectoral stakeholder panel to discuss values and preferences and assess the strength of the recommendations, and 6) planning for dissemination, implementation, impact evaluation and updating. The recommendations in this CPG shall hold and will be updated after 3 years or when new evidence arise.

Clinical practice guidelines on leptospirosis in children 2019

Executive Summary@#Leptospirosis is a disease prevalent mostly in tropical and subtropical countries. Its potential to be a concerning problem emerges with the onset of the rainy season, as flooding and heavy rainfall facilitate disease epidemics. Among those at risk of contracting the disease are field workers, veterinarians, sewer workers, military personnel and those who swim or wade in contaminated waters. In the absence of an existing evidence-based guideline for the pediatric age group, this first edition hopes to standardize approach to diagnosis, antibiotic management, and prevention of leptospirosis. The intended users are primary care physicians, family medicine physicians, pediatricians, and other healthcare workers involved in the management of leptospirosis in children. Ten priority questions were identified by a group of experts composed of an oversight committee, a guideline writing panel, and a technical review committee. The GRADE methodology was used to determine the quality of evidence of each recommendation. The draft recommendations (summarized below) were finalized after these were presented to and voted on by a panel of stakeholders.

Fulminant Hepatic Failure in a SARS-CoV-2 positive pediatric patient: A case report

@#Respiratory symptoms are the most common manifestation of COVID-19 across all age groups and it is most often associated with radiographical findings consistent with pneumonia.2 A recent systematic review estimated that 16% of children with SARS-CoV-2 infection are asymptomatic,3 or others may present with seizures, gastrointestinal bleeding or jaundice. This reports a 2-year old boy with no known co-morbidity who had a 2-week history of abdominal pain and jaundice then had a rapidly progressive course of neurological deterioration and eventual demise. He had markedly elevated liver enzymes and deranged bleeding parameters with elevated ammonia and ferritin levels. Hepatitis B and hepatitis A titers were non-reactive. He was managed as a case of hepatic encephalopathy secondary to cholestatic jaundice. His chest x-ray was normal but his SARS-CoV-2 RT PCR result was positive with a low cycle threshold. Locally, this is the first reported case of SARS-CoV-2 RT-PCR positive pediatric patient presenting as fulminant hepatic failure with no associated respiratory manifestations. Clinicians should be mindful that such presentation, however uncommon, is possible and a high index of suspicion should be maintained.

Utility of Urine KOH in Detecting Candiduria in Infants

Background@#Candida species are common cause of urinary tract infection in infants requiring medical care. Candida fungal elements may be demonstrated in urine using microscopic examination with potassium hydroxide (KOH). However, detection of these elements does not always correlate with candiduria. @*Objectives@#To establish the utility of urine KOH in identifying candiduria and to determine the risk factors, as well as urinalysis and CBC parameters associated with candiduria. @*Methods@#This prospective cross-sectional study included admitted infants 1 year and below with urine culture and with any risk factor/s for candiduria. Additional urine KOH testing was done using clean catch or catheter method. Urine culture was used as the gold standard. @*Results@#Among the 90 study participants with both urine culture and urine KOH, 13 (14%) had candiduria. The use of indwelling catheter, presence of urinary tract anomalies, positive leukocyte esterase in urinalysis, and increased monocyte counts in CBC are all associated with candiduria. Urine KOH has sensitivity of 100%, (CI 75.2-100%), specificity 59.7%, (CI 47.9-70.7%), PPV 29.5%, (CI 17.7-45.2%), and NPV 100%, (CI 92.2-100%) in detecting candiduria.@*Conclusions@#Negative urine KOH has excellent negative predictive value, while positive urine KOH result may warrant further investigation. Urine KOH results should be interpreted with caution depending on patient’s risk factors, clinical status, and other laboratory results prior to initiation of empiric antifungal therapy. Positive urine KOH may not always require treatment.

Utility of urine KOH in detecting candiduria in infants

BACKGROUND@#Candida species are common cause of urinary tract infection in infants requiring medical care. Candida fungal elements may be demonstrated in urine using microscopic examination with 10-20% KOH. However, detection of these elements does not always correlate with candiduria. @*OBJECTIVES@#The main objective of this study was to establish the utility of urine KOH in identifying candiduria in terms of sensitivity, specificity, PPV, and NPV. The study also aims to determine the risk factors, as well as urinalysis and CBC parameters associated with candiduria.@*METHODS@#This prospective study included admitted infants 1 year and below with urine culture request and with any risk factor for candiduria. Additional urine KOH testing was done using clean catch or catheter method (for those with indwelling catheter). @*RESULTS@#Among the 90 study participants, 13 had candiduria (14%). The use of indwelling catheter, presence of urinary tract anomalies, leukocyte esterase in urinalysis, and increased monocyte counts in CBC are all associated with development of candiduria. Urine KOH had a sensitivity of (100%; CI 75.2- 100%), specificity (59.7%; CI 47.9-70.7%), PPV (29.5%; CI 17.7-45.2%), and NPV (100%; CI 92.2- 100%) in detecting candiduria. @*CONCLUSIONS@#A negative urine KOH has excellent negative predictive value, while a positive result does not always mean true infection.@*RECOMMENDATIONS@#This study recommends that urine KOH results be interpreted with caution depending on patient‘s risk factors clinical status and other laboratory tests such as urine culture and that a positive urine KOH result will not always require prompt treatment.

Microbiologic profile and predictors of severe outcome of pediatric cancer with Febrile Neutropenia admitted at a tertiary medical center

Background@#The treatment of pediatric cancer has advanced dramatically. With the discovery of newer, more potent chemotherapeutic agents, patients are confronted with severe and prolonged degrees of neutropenia, which has inherent consequences. @*Objective@#The study aimed to determine common microbial isolates and predictors of severe outcome of pediatric cancer patients with febrile neutropenia aged 0-18 years old admitted at a tertiary hospital. @*Methods@#This was a cross-sectional study on pediatric cancer patients with febrile neutropenia admitted at the Philippine Children’s Medical Center from March 1,2017 to September 30,2017.The clinical presentations of subjects were noted. Patients were categorized as to the presence or absence of severe outcomes. Common microbial isolates were noted. Predictors of severe outcome were identified using stepwise logistic regression analysis. @*Results@#Out of 105 enrolled patients, 32 developed severe outcomes. The most common isolates were Klebsiella pneumoniae followed by Escherichia coli and Candida species. Univariate analysis showed that acute myelogenous leukemia (p-value: 0.0195), treatment relapse (p-value: 0.0131), ANC on admission 7 days during admission (p-value: 0.0001), non-response to empiric antibiotics (pvalue:0.0001), microbiologically-defined infection (MDI, p-value: 0.0001), fever without a focus p-value:0.001), bloodstream infection (p-value: 0.0192), unknown focus of infection (p-value: 0.0058), and a positive culture (p-value: 0.0001) were related to a severe outcome. None of these predictive variables, however, were statistically significant on multivariate logistic regression analysis. @*Conclusion@#K. pneumoniae, E. coli and Candida were the predominant organisms identified in febrile neutropenic cancer patients in our institution. Although AML, treatment relapse, profound neutropenia, fever of >7 days during admission, nonresponse to empiric antibiotics, MDI, fever without a focus, bloodstream infection, unknown focus of infection and a positive culture were related to a severe outcome, multivariate regression analysis did not show these to be significant.

Comparison of total aerobic count before and after application of different antiseptic solutions prior to venipuncture and its correlation to developing phlebitis, in children admitted at a tertiary hospital in Quezon City

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To compare the effect on Total Aerobic Count (TAC) of application of Isopropyl alcohol, Chlorhexidine, and povidone iodine plus alcohol prior to venipuncture and development of phlebitis in children admitted at a tertiary hospital.</p><p style="text-align: justify;"><strong>METHODS</strong>: A prospective randomized clinical trial in a tertiary hospital in Quezon City. A total of 129 patients one-year old and above with physician orders for IV insertion and extractions. Pre and post swabbing of the venipuncture site was done and placed on a blood agar plate. The three antiseptic solutions were applied over the venipuncture site and swabbed and placed on the agar plate. The primary outcome measure was the TAC in each blood agar of the tested antiseptic solution and correlation to developing phlebitis.</p><p style="text-align: justify;"><strong>RESULTS</strong>: The CFU/mL after disinfection was significantly different between groups, with the lowest CFU/mL observed among patients disinfected with Chlorohexidine. Phlebitis was only noted in the alcohol group. No reactions were observed from patients who were disinfected with povidone iodine and chlorohexidine.</p><p style="text-align: justify;"><strong>CONCLUSIONS</strong>: Single application of Chlorhexidine is the optimal method to be used as antisepsis prior to procedures like venipuncture. However, the use of povidone iodine plus 70% isopropyl alcohol also has comparable effect to Chlorhexidine.</p>