Canadian Immunization Guide: "Anaphylaxis and other acute reactions following vaccination" chapter update.

BACKGROUND: The Canadian Immunization Guide (CIG) is a comprehensive resource on immunization for health professionals and vaccine program decision-makers. It is developed based on the evidence-based recommendations of the National Advisory Committee on Immunization (NACI). The NACI Vaccine Safety Working Group (VSWG) is comprised of NACI members, liaison members and external experts. The World Allergy Organization now recommends that antihistamines should not be used in the initial treatment of anaphylaxis. The update of the chapter was also used to provide further information and clarity to several tables in the chapter. METHODS: In updating the CIG anaphylaxis guidance, VSWG conducted an environmental scan, a review of relevant literature and consulted international and Canadian experts and professional societies. RESULTS: The use of diphenhydramine hydrochloride as adjunctive treatment in the management of anaphylaxis in a community setting is no longer recommended. Other notable changes made to the chapter include the following: 1) retitled: "Anaphylaxis and other acute reactions following vaccination"; 2) inclusion of new tables: "Key distinguishing features of anaphylaxis and vasovagal syncope" and "Signs and symptoms of anaphylaxis"; and 3) updated tables: "Anaphylaxis management kit: recommended items" and "Dosage of intramuscular EPINEPHrine 1:1000 (1 mg/mL) solution, by age or weight". CONCLUSION: The updated CIG chapter provides healthcare providers with further clarity in recognizing and managing anaphylaxis in community settings. The updated intramuscular epinephrine dosage table will aid in optimal epinephrine administration, while the revised guidance against the use of diphenhydramine hydrochloride will prevent its unnecessary stockpiling in preparation for potential mass vaccination clinics related to the coronavirus disease 2019 pandemic.

Therapeutic drug monitoring guided raltegravir dosing for prevention of vertical transmission in a premature neonate born to a woman living with perinatally acquired HIV.

We report a case of therapeutic drug monitoring guided raltegravir use for the prevention of vertical HIV transmission in a premature neonate born to a woman living with perinatally acquired HIV and documented resistance to multiple HIV drugs. Maternal viral load was above 1,000 copies/ml at delivery. This case demonstrates delayed raltegravir elimination in a neonate born at 33 weeks gestational age and a need for less frequent raltegravir dosing than is used in older infants and children.

Administration of the adjuvanted pH1N1 vaccine in egg-allergic children at high risk for influenza A/H1N1 disease.

BACKGROUND: In Canada, the pH1N1 influenza vaccine is recommended for children, particularly those less than 5 years of age or with chronic underlying disease. The pH1N1 vaccine, which contains residual allergenic egg white proteins, may pose a risk for vaccination of egg-allergic children. OBJECTIVE: To describe the outcome of pH1N1 influenza vaccine administration to egg-allergic children at risk for severe H1N1 disease. DESIGN/METHOD: Prospective observational cohort study. Children identified as at high risk for egg allergy and H1N1 influenza were vaccinated using a two-dose split protocol in a controlled medical setting. Children were given an initial test dose; if no reaction was noted, the remainder of the dose was administered and the children were followed for allergic reactions. Those who tolerated the split dose and required a second dose of vaccine were offered vaccination four weeks later as one injection. RESULTS: Sixty-two egg-allergic children considered at high risk for H1N1 disease received the adjuvanted pH1N1 vaccine. Egg allergy was diagnosed both clinically by an allergist and using skin and/or serum IgE testing. Within one hour of immunization, 2 children developed hives, 1 had a vasovagal response and 1 had a hypo-responsive episode. Fourteen children received the second H1N1 dose and 1 developed erythema and itching. There were no anaphylactic reactions. CONCLUSION: Administration of the adjuvanted pH1N1 vaccine in egg-allergic children at risk for severe H1N1 influenza was safe when performed in a two-dose split protocol in a controlled medical setting.

Protocol for management of imported pediatric malaria decreases time to medication administration.

BACKGROUND: A malaria management protocol was developed and implemented at a tertiary care children's hospital in September 1999. We retrospectively evaluated children admitted with malaria 10-years preimplementation and 7-years postimplementation to determine the impact the protocol had on management and time delay to appropriate antimalarial therapy. METHODS: This before and after study compared all admissions with the discharge diagnosis of malaria in the study period. Retrospective chart review was used to determine the time from emergency department (ED) registration to administration of antimalarial treatment. Other outcomes measured included mortality, length of hospital stay, and intensive care unit admission. RESULTS: Fifty-eight admissions were identified during the defined period, most of which were due to Plasmodium falciparum[r] malaria. Thirty-one (53.4%) cases were before implementation of the protocol. Children were more likely to receive appropriate investigations to assess for possible severe malaria before transfer from the ED to the ward after protocol implementation (18% vs. 63%, P = 0.005). Analysis of index cases of malaria, excluding patients diagnosed after the diagnosis of a sibling, showed there was a significant reduction in time to medication administration (8 vs. 5.5 hours, P = 0.036). CONCLUSION: After broad-based implementation of a malaria treatment protocol in a pediatric hospital, children received more thorough investigations, were more likely to receive therapy before leaving the ED and had a shorter delay before receiving appropriate antimalarial therapy.

Rectal fluconazole for tinea capitis.

The present report describes a case of tinea capitis in a boy with autistic spectrum disorder and an aversion to oral medications. He refused weekly oral fluconazole and there was a poor response to daily rectal griseofulvin. He tolerated once-weekly rectal fluconazole (10 mg/kg) well and there was an excellent clinical outcome.

A comparison of Canadian general pediatric dosing publications.

A comparison of the general pediatric dosing guidelines published in Canada was conducted. Institutions that publish pediatric dosing guidelines as a separate publication or as part of the hospital formulary were mailed a survey of questions to describe their publication. Publications that met the inclusion criteria were evaluated using 12 assessment criteria: approval or submissions by medical specialty groups, drug inclusion, dosing guidelines, dosing in organ failure, pharmacokinetic/pharmacodynamic parameters, therapeutic guidelines, intravenous and oral administration guidelines, adverse drug reactions/drug interactions, referencing, drug acquisition costs, organization and readability. Four Canadian pediatric centres satisfied the criteria for publishing general pediatric dosing guidelines. These were reviewed by the process of formulary selection (in alphabetical order by city): Formulary of Drugs and Dosing Manual (Halifax), Formulary of Drugs (Toronto), Drug Dosage Guidelines and Formulary (Vancouver), and Pediatric Drug Dosage Handbook (Winnipeg). Dosing guidelines from published pediatric drug trials have been collated with institutional experience and historical practice to produce a practical source of pediatric dosing information.