Ceftriaxone-Induced Immune Hemolytic Anemia: In Vitro Reversal with Peptide Inhibitor of Complement C1 (PIC1).

We report a case of ceftriaxone-induced immune hemolytic anemia in a 10-year-old with chronic active Epstein-Barr virus disease and hemophagocytic lymphohistiocytosis. After chemotherapy, she became febrile and received ceftriaxone. She rapidly developed respiratory failure and anemia. Her direct antiglobulin test was positive for IgG and C3. To confirm this was ceftriaxone-induced complement-mediated hemolysis, we adapted the complement hemolysis using human erythrocytes (CHUHE) assay by adding exogenous ceftriaxone to the patient's serum which enhanced lysis of her erythrocytes. We confirmed that ceftriaxone initiated a classical complement pathway-mediated hemolysis by in vitro reversal with peptide inhibitor of complement C1 (PIC1).

Improving Palivizumab Compliance rough a Pharmacist-Managed RSV Prevention Clinic.

OBJECTIVES: Palivizumab is a monoclonal antibody approved for the prevention of serious lower respiratory tract infections caused by respiratory syncytial virus (RSV) in high-risk pediatric patients. While palivizumab is more effective if used correctly, compliance with the monthly dosing is suboptimal. We established a pharmacist-managed RSV prevention clinic in an effort to improve compliance. The primary objective of this study was to determine the impact of a pharmacist-managed RSV prevention clinic on palivizumab compliance. METHODS: A chart review was performed. Patients who received palivizumab between September 2009 and April 2012 were identified. Compliance was determined as the number of patients who received eligible doses at 28- to 30-day intervals, consecutively. RESULTS: One hundred seventy-two patients received at least 1 dose of palivizumab. An average of 92% of patients who received at least 1 dose subsequently received all doses of palivizumab during the RSV season. Of those, 88% received all eligible doses in consecutive 28-to 30-day intervals. CONCLUSION: A pharmacist-managed RSV prevention clinic can assist physicians in the prevention of RSV by increasing compliance with palivizumab dosing.

A review of Candida prophylaxis in the neonatal intensive care population.

OBJECTIVE: To review the efficacy and safety of antifungal prophylaxis in the neonatal intensive care setting. DATA SOURCES: English-language literature was accessed using MEDLINE (January 1988- December 2010). The following Medical Subject Heading (MeSH) search terms were used: "amphotericin B," "fluconazole," "nystatin," "itraconazole," "caspofungin," "voriconazole," "Candida," "prevention and control," and "critically ill." Literature was further limited to studies focusing on patient birth to 6 months of age. Abstracts and original research articles were included. Preference was given to published controlled trials. Articles providing descriptions of the safety and effectiveness of antifungal prophylaxis in neonatal intensive care patients were also used in this review. RESULTS: Twenty-two studies have evaluated the impact of antifungal prophylaxis on Candida colonization or invasive infections in the Neonatal Intensive Care Unit (NICU). The two antifungal agents most commonly studied were nystatin and fluconazole. All of the nystatin studies demonstrated that nystatin is effective at reducing fungal colonization and invasive fungal infections. All of the studies designed to evaluate the impact of fluconazole prophylaxis on fungal colonization demonstrated a reduction in the incidence of fungal colonization with fluconazole prophylaxis. A total of 12 of 16 studies that evaluated the impact of fluconazole prophylaxis on the incidence of invasive fungal infections demonstrated a reduction in invasive fungal infections with fluconazole prophylaxis. Two studies found no difference between fluconazole and nystatin when used for prophylaxis. CONCLUSION: Antifungal prophylaxis appears to be effective in reducing the incidence of Candida colonization and invasive Candida infections in the NICU. Antifungal prophylaxis also appears to be safe in the NICU population. The impact of antifungal prophylaxis on resistance patterns could be significant and needs to be evaluated long term before widespread prophylaxis can be recommended.

Sevelamer therapy for pediatric end-stage renal disease.

Sevelamer, a non-calcium-containing, non-aluminum-containing phosphate binder, is frequently prescribed for treatment in adults with hyperphosphatemia secondary to end-stage renal disease (ESRD). However, published information regarding sevelamer use in children younger than 11 years is lacking. We report the use of sevelamer as a phosphate binder in a 19-month-old girl with ESRD who was receiving calcium carbonate 1250 mg 3 times/day for hyperphosphatemia. The patient's initial serum phosphorus concentration was 8.6 mg/dl, and the calcium-phosphorus product was 75 mg(2)/dl(2). This was well above the level that places patients at risk for complications such as joint, vessel, and soft-tissue calcification. An aluminum-containing phosphate binder was not an option given the patient's renal disease and the concern for neurotoxicity. Sevelamer was considered, but a MEDLINE search revealed no pediatric dosing information. An initial dosage of 100 mg/kg/day divided every 8 hours was administered, as extrapolated from adult data, and then titrated to 130 mg/kg/day divided every 8 hours based on the patient's response. The child's dietary phosphorus intake remained constant throughout her hospital stay. During sevelamer therapy, her serum phosphorus concentration dropped as low as 5.2 mg/dl; at discharge it was 6.5 mg/dl, with a corresponding calcium-phosphorus product in the upper 50s. No adverse effects associated with sevelamer were observed. In the dosages we used, sevelamer resulted in an acceptable calcium-phosphorus product and returned the patient's serum phosphorus concentration to near normal. Sevelamer appears to be a viable option as a phosphate binder in children with ESRD.

Prospective randomized double-blind placebo controlled trial of recombinant human erythropoietin administration to reduce blood transfusions in anemic pediatric intensive care patients.

OBJECTIVE: The purpose of this study was to determine if the number of red blood cell (RBC) transfusions anemic pediatric intensive care unit patients receive could be reduced by the prophylactic administration of recombinant human erythropoietin (rHuEPO). METHODS: This was a randomized, double-blind placebo controlled trial. Patients were randomized to receive either intravenous rHuEPO 300 units/kg/day or placebo. Both groups received elemental iron 6 mg/kg/day. RESULTS: Twenty-seven patients, ages 1 month to 13 years, were enrolled. Baseline hematocrit (Hct), reticulocyte count, and erythropoietin concentration were similar between the two groups. Three patients randomized to rHuEPO received 1 RBC transfusion each, and 4 patients randomized to placebo received 9 transfusions total (P = .68). The end-of-study Hct was not significantly different between the rHuEPO and placebo groups, 30.3 ± 3.6 and 26.8 ± 4.8, respectively (P = .06). Additionally, neither the % Hct change (baseline to final), nor the % reticulocyte change (baseline to final), was statistically different between the two groups. CONCLUSION: In this small group of anemic pediatric intensive care unit patients, prophylactic rHuEPO administration did not reduce the number of patients who received RBC transfusions. Furthermore, it did not significantly increase Hct or reticulocyte count when compared to placebo.

Prokinetic drug therapy in children: a review of current options.

OBJECTIVE: To review the pharmacology, safety, and efficacy of the prokinetic agents metoclopramide and erythromycin in children. DATA SOURCES: English-language literature was accessed using MEDLINE (1970-June 2004) with metoclopramide, erythromycin, macrolides, gastroesophageal reflux, and gastrointestinal motility as the search terms. STUDY SELECTION AND DATA EXTRACTION: Abstracts and original research articles were included. Preference was given to published controlled trials. Articles providing descriptions of pharmacology, safety, and effectiveness of metoclopramide and erythromycin for the treatment of gastroesophageal reflux (GER) were also used in this review. DATA SYNTHESIS: Some authors advocate using a prokinetic agent along with acid suppression for treatment of GER in children. The 2 prokinetic agents most commonly used are erythromycin and metoclopramide. Erythromycin has numerous observational reports and controlled trials demonstrating its efficacy in improving feeding tolerance in children. Adverse drug reactions associated with its use were uncommon in prospective controlled trials. Few data support the use of metoclopramide for management of GER, and the potential adverse effects associated with its use need to be considered before prescribing. CONCLUSIONS: The literature supports the use of erythromycin as a prokinetic agent. Many children with GER are adequately controlled with acid suppression alone; however, if use of a prokinetic agent is warranted, erythromycin in combination with acid suppression should be considered. Given the lack of prospective controlled studies demonstrating metoclopramide's efficacy and safety in the treatment of GER in children, metoclopramide should not be considered a treatment option.

An assessment of vancomycin pharmacokinetic variability in pediatric cardiology patients.

OBJECTIVES: To establish the steady-state pharmacokinetic profile of vancomycin in pediatric cardiology patients; determine an empiric vancomycin dose; and evaluate the correlation between fluid balance and volume of distribution (Vd), serum creatinine and clearance (CL), and daily dose of furosemide and Vd. METHODS: Retrospective pharmacokinetic evaluation in 36 pediatric cardiology, cardiac surgery, or cardiac transplant patients treated with vancomycin. The pharmacokinetic profile for vancomycin including elimination half-life (t1/2), elimination rate constant (ke), volume of distribution (Vd), and clearance (CL) was calculated for each patient. The relationship between fluid balance and Vd, serum creatinine and CL, and the total daily dose of furosemide and Vd was evaluated. RESULTS: The patient population had an average half-life of 5.9±1.2 hr and a Vd of 0.4±0.12 L/kg. A statistically significant correlation was noted between serum creatinine and CL (r(2)=0.19, P<0.01). Additionally, a statistically significant correlation exists between the total daily furosemide dose and the Vd (r(2)=0.31, P<0.01). A dose of 10 mg/kg/dose every 12 hrs was predicted to result in the greatest number of serum vancomycin concentrations within the reference range. CONCLUSIONS: Routine monitoring of serum vancomycin concentrations is prudent for this population, and special consideration should be given to those with elevated serum creatinine and to those receiving large doses of furosemide.

Treatment of sickle cell pain.

Sickle cell disease affects 70,000 Americans who experience an average of 0.8 painful episodes each year. The pathophysiology of sickle cell pain is not completely understood. The disease is characterized by both acute and chronic pain syndromes. Patients with sickle cell pain often encounter barriers to receiving appropriate care, including lack of continuity of care and perceived opiate addiction. Studies describing pharmacotherapy for sickle cell pain have been primarily retrospective and uncontrolled. In analyzing the available literature regarding pathophysiology, assessment, and treatment of sickle cell pain, we found a need for increased practitioner education and intervention to improve the level of care provided to patients with this disease.