ABSTRACT
OBJECTIVE: The aim was to carry out a retrospective review of the efficacy and safety of anakinra in paediatric patients with undifferentiated autoinflammatory disease (uAID). METHODS: We carried out a retrospective study of children with uAID at a single quaternary centre. The clinical efficacy of anakinra was evaluated using physician global assessment (PGA) and serological response assessed by levels of serum amyloid A and CRP. Safety was assessed by exploring adverse events, including infection and drug reactions. RESULTS: This study included 22 patients, 64% females and 36% males of median age 7.1 years (range 0.13-14.11 years), with uAID. The median starting dose of anakinra was 2 mg/kg (range 2-6 mg/kg) and the median duration of treatment 19.6 months (range 0.8-100 months). Before anakinra treatment, the median PGA, on a three-point Likert scale, was 2 (range 1-2), which fell to 1 (range 0-2) within 3 months of treatment. Eight of 22 (36%) patients achieved complete clinical and serological remission; 8/22 (36%) achieved a partial response; and 6/22 (28%) had no response to anakinra. Adverse events included death (3/22, 14%) and allogeneic haematopoietic stem cell transplantation (1/22, 5%). There were no new safety signals, and anakinra was well tolerated overall. CONCLUSION: Retrospectively, 72% of children with uAID responded well to anakinra, with 36% achieving full clinical and serological remission within 3 months. This suggests that empirical trials of IL-1 blockade might be warranted in children with uAID. Clear stopping criteria based on predefined parameters should be considered, because non-responders required alternative therapies, facilitated by a definitive molecular diagnosis where possible.
ABSTRACT
BACKGROUND:: Antibiotic prophylaxis is crucial in head and neck surgery to prevent infection from clean contaminated wounds. Scottish Intercollegiate Guidelines Network (SIGN) guidance, the gold standard of practice, recommends that administration of broad spectrum antibiotics is discontinued after 24 hours post-operation. A three-audit cycle quality improvement project was conducted to assess clinical practice against SIGN guidance at a large London teaching hospital. METHODS:: Three change initiatives were implemented to improve antibiotic stewardship. First, an update of Trust guidelines with an associated poster campaign to educate staff and improve awareness. Second, introduction of a specific 'prophylactic antibiotics in head and neck surgery' bundle on the electronic hospital-wide prescribing system. Third, an update to an antibiotic prescribing guide (Microguide). RESULTS:: Over a 3-year study period the number of patients receiving antibiotics beyond 24 hours declined significantly (88% in 2015, 76% in 2016, 25% in 2018), demonstrating improved compliance with SIGN guidelines overall. Despite this, staff documentation of indications for extended antibiotic use remains suboptimal (58% in 2016 and 44% in 2018) as does the number of specimens sent for microbiological analysis (52% in 2016 and 0% in 2018). CONCLUSIONS:: Appropriate prophylactic antibiotic prescribing can improve morbidity and mortality rates in head and neck cancer patients. Three change initiatives have been demonstrated which can help to improve prescribing compliance in line with SIGN guidance. Ongoing auditing is required to maintain the longevity of improvements made and encourage staff documentation of indications for extended antibiotic use and microbiology specimen analysis.