Amoxicillin renal toxicity: how often does it occur?

OBJECTIVES: To determine the incidence of renal symptoms associated with amoxicillin, a retrospective review of exposures to amoxicillin in children younger than 6 years as reported to the National Poison Data System was done. METHODS: All ingestions of amoxicillin without coingestants in humans younger than 6 years reported to the National Poison Data System from 2004 through 2008 were analyzed. Data included age, sex, management site, outcome, symptoms, amount ingested, certainty of amount, chronicity, weight, and therapy. The study was approved by the institutional review board. Descriptive statistics were used to characterize the data. RESULTS: A total of 14,717 cases were identified. Related renal symptoms occurred in 5 patients (0.03%). In 1687 patients (9.6%), the total amount (in milligrams) was documented, and the median amount ingested was 1000 mg. In patients with a known amount (in milligrams) along with the child's weight (n = 1356), the median amount was 82.6 mg/kg. In this group, 213 ingested greater than 250 mg/kg (range, 251.4-1531.1 mg/kg; median, 366.5 mg/kg). Treatment sites for this group included the following: treated in the home, 129 (60.6%); treated and released from an health care facility, 63 (29.6%); treated while admitted, 2 (0.9%); refused a referral, 7 (3.3%); lost to follow-up, 9 (4.2%); and managed at other sites, 3 (1.4%). Within this group, 94 patients (44.1%) were followed up to a definitive outcome: 77 (81.9%) had no effect, 15 (16.0%) had minor symptoms, and 2 (2.1%) had moderate symptoms. CONCLUSIONS: Although renal toxicity may occur with amoxicillin ingestions, it is rare and does not seem to be dose related.

Whole fentanyl patch ingestion: a multi-center case series.

BACKGROUND: Fentanyl is a potent synthetic opioid with large abuse potential. A common preparation of fentanyl is a sustained-release transdermal patch. To our knowledge, there are only two published case reports of whole patch ingestion. A case series of 76 patients with a history of whole patch ingestion is reported. STUDY OBJECTIVES: To characterize whole fentanyl patch ingestion to develop a clinical guideline for management. METHODS: This was a retrospective review of all patients who ingested intact fentanyl patches as reported to three regional poison information centers (RPIC) from 2000 to 2008. The three RPIC medical record databases were queried for all exposures with a substance code matching the Micromedex® (Thomson Reuters, New York, NY) fentanyl product codes. Collected data included: age, gender, reason for the exposure, number of patches ingested, dose (µg/h), symptoms, symptom onset and duration, treatment hospital flow (level of care), and outcome. RESULTS: A total of 76 patients met the inclusion criteria. Two patients had both time of onset and symptom duration documented. In both patients, the signs and symptoms developed within 2 h of the exposure, and the patients were asymptomatic at 6½ and 9 h, respectively. Fifty-eight (78.3%) patients were admitted. Of those patients who were admitted, 56 (96.5%) were admitted to a critical care unit. Fourteen patients required intubation, and naloxone infusions were documented in eight cases. CONCLUSION: Ingestion of whole fentanyl patches may lead to prolonged and significant toxicity based on these poison center data.

A regional poison information center IVR medication identification system: does it accomplish its goal?

BACKGROUND: The 2009 AAPCC NPDS report identified 1,057,632 medication identification requests to poison information centers. This represents 24.7% of all calls to US poison information centers. To reduce the impact of medication identification requests on a poison information center, a regional poison information center developed and implemented an automated medication identification system that utilized an interactive voice response (IVR) system. The objective of this project was to describe how the IVR affected the regional poison information center medication identification request call volume and workload of the staff. METHODS: All documented medication identification request inquiries from January 1, 2007 through June 30, 2011 were extracted from the RPIC Visual Dotlab electronic medical record system. Descriptive statistics, presented as means, were used to characterize the monthly call volume inquiries. RESULTS: Over the 18 months (January, 2007 to June, 2008) preceding the implementation of the IVR medication identification request system, a mean of 4,389.6 medication identification requests per month required manual electronic documentation by SPI. In the immediate 12 months (August, 2008 to July, 2009) following the IVR medication identification request system implementation, a mean of 2132.6 inquiries per month (54% reduction) were managed by the IVR. During the 12 month period of July, 2010 through June, 2011, the combined monthly mean of medication identification requests documented by SPI and the IVR decreased to a total of 686.7 compared to the mean pre-implementation monthly total of 4,389.6. CONCLUSIONS: The IVR medication identification request system was successful in reducing the number of medication identification requests that required manual electronic documentation by SPI and freed up a substantial amount of time for SPI to perform other critical patient care-related responsibilities. The enhanced technology that was implemented to improve efficiency came with the unintended consequence of discouraging the public from using the RPIC medication identification service as extensively.

Friends and foes in the plant world: a profile of plant ingestions and fatalities.

INTRODUCTION: Plants are beneficial as foodstuffs and many have medicinal properties. However, some plants also have the potential to produce toxicity. The objective of this study was to characterize plant exposures that involve humans and to discuss those that are associated with morbidity and mortality, as well as some that have undeserved bad reputations. MATERIALS AND METHODS: The American Association of Poison Control Centers (AAPCC) 1983-2009 annual reports were reviewed to identify all plant-related fatalities. The 2000-2009 AAPCC Toxic Exposure Surveillance System and the National Poison Data System databases were queried to identify all plant ingestions. The data were analyzed to identify the specific plants, the age and gender of those who were exposed, the reason for the exposures and patient outcome. RESULTS: During the decade of 2000-2009, 668 111 plant ingestion exposures were reported, 621 109 were single substance exposures with no co-ingestants, and the age was known in 611 708 of the exposures. There has been a steady decline in the number of plant exposures reflected as a percentage of all exposures reported to US poison centers. A total of 8.9% of all exposures involved plants in 1983, 6.0% in 1990, 4.9% in 2000, and 2.4% in 2009. Males accounted for 52.2% of the ingestions and over 60% of the moderate and major outcomes occurred in males. Morbidity was related directly to the reason for the exposure with the most severe outcomes occurring in those who ingested plants intentionally for self-harm or substance abuse. Children ≤5 years of age accounted for 81.2% of plant ingestion exposures. Within this age category, there were 497 002 ingestions over the 10-year period where a known age was recorded and 57.8% occurred in children less than 1 year of age. Only 45 fatalities were recorded between 1983 and 2009. Datura and Cicuta species were responsible for 35.5% of the fatal outcomes. CONCLUSIONS: Plant ingestion exposures remain a common call to poison information centers. However, the volume of those calls has decreased steadily over the last three decades. Most plant ingestion exposures occur in children, specifically children ≤5 years of age. Within this age group, there were an inordinate number of exposures in children <1 year of age, a previously unidentified finding with an unknown epidemiological basis. Morbidity and mortality associated with plant ingestion exposures were very low relative to the total number of reported exposures.

The use of an automated interactive voice response system to manage medication identification calls to a poison center.

INTRODUCTION: In 2007, medication identification requests (MIRs) accounted for 26.2% of all calls to U.S. poison centers. MIRs are documented with minimal information, but they still require an inordinate amount of work by specialists in poison information (SPI). An analysis was undertaken to identify options to reduce the impact of MIRs on both human and financial resources. METHODS: All MIRs (2003-2007) to a certified regional poison information center were analyzed to determine call patterns and staffing. The data were used to justify an efficient and cost-effective solution. RESULTS: MIRs represented 42.3% of the 2007 call volume. Optimal staffing would require hiring an additional four full-time equivalent SPI. An interactive voice response (IVR) system was developed to respond to the MIRs. DISCUSSION: The IVR was used to develop the Medication Identification System that allowed the diversion of up to 50% of the MIRs, enhancing surge capacity and allowing specialists to address the more emergent poison exposure calls. This technology is an entirely voice-activated response call management system that collects zip code, age, gender and drug data and stores all responses as .csv files for reporting purposes. The query bank includes the 200 most common MIRs, and the system features text-to-voice synthesis that allows easy modification of the drug identification menu. Callers always have the option of engaging a SPI at any time during the IVR call flow. CONCLUSIONS: The IVR is an efficient and effective alternative that creates better staff utilization.

Profile of medication identification requests managed by a U.S.-certified regional poison information center.

INTRODUCTION: According to the American Association of Poison Control Centers, the number of medication identification requests (MIR) to poison centers has increased dramatically. In 2003, there were 617,414 calls compared to 1,070,537 in 2007. The purpose of this investigation was to characterize the nature of the most common requests to a poison center for medication identification. METHODS: To profile the MIR to a poison information center, the data from 2003 to 2007 were analyzed to identify all requests for medication identification. The subset of MIR data was extracted and analyzed to profile the requests by the specific medication and category. Descriptive statistics were used to characterize the data. RESULTS: MIR were responsible for 193,006 calls: 24,643 in 2003, increasing to 55,473 in 2007. In 2003, there were inquiries about 1,261 different medications and in 2007 that increased to 3,165. During all but two of the five years, substances with known substance abuse potential accounted for 24 of the 25 most common MIR. Acetaminophen in combination with either hydrocodone or oxycodone dominated the requests. The most common identification request each year was for the brand-specific product Mallinckrodt 512 (acetaminophen/oxycodone). DISCUSSION: The most frequent MIR involved medications with substance abuse potential, primarily opioids. CONCLUSIONS: Poison center MIR data can provide important information to officials about substance abuse trends.

Pediatric ingestions of hand sanitizers: debunking the myth.

OBJECTIVE: Poison centers frequently receive calls concerning children who are exposed to hand sanitizers. These exposures can occur while the product is being used correctly or when a child has unsupervised access to the container. In 2007, the use of ethanol-containing hand sanitizers in the pediatric population came under media scrutiny owing to an Internet urban legend that resulted in a greater awareness of the potential toxicity of these sanitizers based on their high ethanol content. METHODS: A retrospective review of all exposures to hand sanitizers in children younger than 6 years reported to a regional poison information center from January 1, 2000 to March 30, 2007 was performed. Data reviewed included substance, age, sex, and outcome. Data were analyzed using descriptive statistics. RESULTS: Six hundred forty-seven cases were identified including 324 females and 323 males. Ages ranged from 1 month to 5 years with a mean of 1.89 years and a median of 2 years. Outcome data included 31 patients (4.8%) with no effect, 26 (4%) with a minor effect, 372 cases (57.5%) coded as nontoxic Y expect no effect, 208 cases (32.1%) with minimal clinical effects possible, and 10 cases (1.6%) where the symptoms were judged to be unrelated to the exposure. There were no moderate or major outcomes and no fatalities. CONCLUSIONS: Children in this age group have frequent hand-to-mouth activity and environmental curiosity making the application or availability of a hand sanitizer the perfect situation for an exposure to occur. Although ethanol-based hand sanitizers have the potential to cause toxicity, the benefits of prevention of illness outweigh the hazards when used in a supervised situation.

Disease surveillance and nonprescription medication sales can predict increases in poison exposure.

INTRODUCTION: Real-time Outbreak and Disease Surveillance (RODS) is a national real-time syndromic surveillance system that classifies hospital registration chief complaints into one of seven syndromic categories. The National Retail Data Monitor (NRDM) is a public health surveillance tool that is designed to collect and analyze the daily sales of 18 categories of nonprescription medications. The goal of RODS and NRDM is to provide early warning of disease outbreaks, such as biological terrorism. The purpose of this study was to determine whether peak syndromic activity and the consequential purchase of nonprescription medications could predict an increase in poisoning exposures involving NRDM-monitored medications. METHODS: Data from the RODS and NRDM databases were plotted graphically to portray activity that occurred during 2003. Data from a regional poison information center electronic medical record system that involved all human exposure calls related to NRDM monitored medications in 2003 were extracted and graphed. Analysis included comparisons between the data sets. RESULTS: Poison center exposure volume correlated predictably and simultaneously with the peak activity in both the RODS and NRDM databases. DISCUSSION: There was no delay between the onset of an influenza outbreak in December 2003, the sale of nonprescription palliative mediations, and the increase in poison center exposure call volume. Increased availability of and access to nonprescription medications resulted in more poisoning exposure calls. CONCLUSIONS: Real-time surveillance using other databases can help to forecast poison center activity. This knowledge allows the poison center to provide anticipatory guidance to the residents of its region.

Combining primary and secondary poison prevention in one initiative.

OBJECTIVE: Contrary to the recommendations of the Institute of Medicine (IOM) report on Forging a Poison Prevention and Control System, a certified regional poison information center combined both primary and secondary education with another public health initiative to determine if there was an impact on poison center awareness. METHODS: Poison Help stickers that contained the national toll-free poison center number were inserted into a quarterly publication from a children's hospital and mailed to 136,741 residents of a poison center service region. Benchmark data from a six-month period were used to compare call volume both before and after the initiative. RESULTS: Call volume increased by a mean of 8.8% from the counties where at least 5% of residents received the mailing. CONCLUSIONS: A single passive mass-mailing education program that combined primary and secondary poison prevention education may have had a small, but positive impact on poison center call volume when a threshold of 5% of the residents received the information.

Child-resistant closures for mouthwash: do they make a difference?

OBJECTIVES: The Poison Prevention and Packaging Act of 1970 mandated that certain potentially hazardous drugs and other products be sold in child-resistant containers (CRCs). The Consumer Product Safety Commission estimates that CRCs for aspirin and oral prescription medicine saved the lives of about 700 children since the requirements went into effect in the 1970s. Under this Act, the Consumer Product Safety Commission issued a rule requiring child-resistant packaging for mouthwashes containing 3 g or more of ethanol per package. The effective date was July 24, 1995, and applied to all applicable products packaged on or after that date. METHODS: To determine the effectiveness of this 1995 ruling, all American Association of Poison Control Center Toxic Exposure Surveillance System data involving children younger than 6 years who ingested ethanol-containing mouthwash 10 years before the implementation of this ruling, the transition year, and 10 years after were reviewed. Only single-substance exposures were included. Data reviewed included the total number of exposures per pre and post years and the outcome. RESULTS: A total of 61,185 cases met the criteria. There were 18,275 exposures from 1985 through 1994 prerequirement (0.12% of all exposures); 39,376 from 1996 to 2005 postrequirement years (AR) (0.17% of all exposures); and 3,534 cases reported in 1995 (0.17% of all exposures). Definitive outcomes were coded in 62.6% of the prerequirement group and 42.2% of the AR group. CONCLUSIONS: Numerous factors affect these results. However, in those cases where definitive outcomes were coded, the AR group has better outcomes.

Backyard mushroom ingestions: no gastrointestinal decontamination--no effect.

Treating the unintentional "backyard" mushroom ingestion continues to be controversial. A review of pediatric "backyard" mushroom ingestions was conducted. A Regional Poison Information Center (RPIC) conducted a retrospective review of all mushroom ingestions in children younger than 6 years of age. Data were extracted from the RPIC electronic record system for the years 2000-2003. All exposures that involved "backyard" mushroom ingestions with no gastrointestinal decontamination were included. There were 322 mushroom exposures in children younger than 6 years of age reviewed. The mean age reported was 2.1 years (SD +/- 1.18). All exposures with a definitive outcome had a 24-h follow-up post-exposure to make this determination. There was no effect in 256 cases (79.5%); minor effect in 6 (1.9%); judged as nontoxic, expect no effect in 20 (6.2%); minimal clinical effects possible in 31 (9.6%); and unrelated effect in 9 (2.8%). It was concluded that "backyard" mushrooms do not present a toxicity hazard in unintentional pediatric exposures and require no gastrointestinal decontamination.

Capitalizing on a current fad to promote poison help: (1-800-222-1222).

INTRODUCTION: The distinctive yellow Lance Armstrong 'Live Strong' silicon wristbands, which support cancer research, have reached iconic status and spawned substantial interest from other organizations seeking to capitalize on the same awareness opportunity. To promote the national toll-free Poison Help telephone number, a regional poison information center developed and introduced a Poison Help wristband. METHODS: The RPIC worked with a marketing firm to design the Poison Help wristband, conduct a feasibility analysis to determine the financial viability of the project and develop a plan to market and sell the wristbands. The wristbands were a unique color, contained the words Poison Help and the national toll-free telephone number. RESULTS: Approximately 50,000 wristbands were distributed in the first four months. CONCLUSIONS: By developing a practical application for a popular item, the RPIC increased poison center awareness and, as a secondary benefit, generated revenue to support other poison prevention education endeavors.

The epidemiology of poisonings in infants <6 months of age.

Contrary to popular belief, children that are less than six months of age are the common victims of unintentional poisoning. The purpose of this study was to examine the profile of poisoning exposures of children as they matriculate through their first six months of life by examining actual exposure data from a certified regional poison information center. Data analysis revealed that adult caregivers were responsible for the majority of exposures in children 0-3 months of age as a consequence of medication administration errors. Due to enhanced motor skills, children from 4-6 months of age frequently exposed themselves to potential poisons that were within their grasp. Parents and caregivers need to be educated proactively by health care professionals to prevent unintentional poisoning exposures in children less than six months of age.

Accidental exposure to oral rabies vaccine.

BACKGROUND: To combat raccoon rabies, various government agencies have implemented a plan to distribute oral rabies vaccine (ORV) in wooded areas. The bait blocks containing ORV are available for its intended population but also for humans and domestic animals. METHODS: A regional poison information center (RPIC) identified all exposures to ORV from 2002-2004 reported to the center. RESULTS: Twenty-two accidental exposures to the ORV were reported. Eight (36%) of the exposures were human and 14 (64%) were domestic animals. The animal exposures were oral while the human contaminations were oral (1), dermal (6), inhalation (1), and ocular (1). Eight of the cases involved multiple victims. No symptoms were reported in the humans or canines although the feline died (unsubstantiated if related). Treatment consisted of irrigation/dilution and in one instance emesis was induced. CONCLUSION: In this case series, accidental exposure to ORV posed no hazard to domestic animals or humans.

Is mass-mailing an effective form of passive poison center awareness enhancement?

This project determined whether the massive distribution of poison center telephone number (Poison Help 800-222-1222) awareness stickers via a direct mail campaign, as a passive education technique, enhanced poison center awareness and was cost-effective. A regional ambulance service conducts an annual membership renewal/solicitation drive via mail to all residents within its service area. A sheet of Poison Help stickers was inserted in each ambulance service recruitment envelope and mass-mailed in 3 separate mailings over 4 w to 51% of households in a single county (population 368,983) at a direct expense of 4,477 dollars. Call volumes from zip codes that received the mailing were compared to an identical benchmark time period from the previous year. Analysis of call volume data over the study period revealed that call volume decreased by 1.3% during the study period. A mass-mail campaign to enhance poison center awareness failed to increase poison center call volume from the targeted county and, cannot be construed as cost-effective.

Beware of canine Gorilla Glue ingestions.

Household adhesive ingestions are considered relatively non-toxic. Gorilla Glue is a household glue containing a urethane polymer and a polymeric isocyanate liquid compound available in container sizes of 2 to 36 oz, and when applied will expand to 3-4 times its original volume. We report the ingestion of Gorilla Glue by 2 dogs that caused obstructive masses requiring surgical intervention. Dogs with a history of Gorilla Glue ingestion should be monitored closely by their owners and a veterinary referral made if signs of gastrointestinal distress develop.

A profile of calls to a poison information center regarding older adults.

OBJECTIVES: The authors sought to examine the nature of calls to poison information centers by adults ages 50 and over. METHODS: The authors used data from the national Toxic Exposure Surveillance System and conducted a retrospective review of all cases reported to an American Association of Poison Control Centers Certified Regional Poison Information Center in 1998 and 1999 (N = 6,365). RESULTS: The results indicated that females' poison experiences were more likely the result of therapeutic error, adverse drug reactions, ingestions, and the acute-on-chronic class. The authors found that older age was inversely associated with acute class, suspected suicide, food poisoning, and inhalation and dermal exposures. DISCUSSION: Older adults are the greatest consumers of over-the-counter drugs, take multiple medications for various medical conditions, and are experiencing biological changes that affect drug metabolism. Older women may be at especially high risk because of high drug use. Poison prevention education should target older adults.

Stability of atropine sulfate prepared for mass chemical terrorism.

BACKGROUND: Preparedness for chemical terrorism includes the procurement of the appropriate pharmacological antagonists. A large emphasis has been placed on having a sufficient quantity of atropine available to treat patients exposed to acetylcholinesterase inhibitors such as sarin. Severe exposures may necessitate the administration of large amounts of atropine and dictate the need to prepare significant quantities of extemporaneously compounded atropine solution to respond to mass numbers of casualties over the first 24-48 hours postexposure. OBJECTIVE: The objective of this project was to determine the stability of a 1 mg/mL atropine solution prepared in multidose IV solutions of 0.9% sodium chloride over a 72-hr period stored at varying temperatures. METHODS: Atropine sulfate solution 1 mg/mL in 0.9% sodium chloride was prepared from sterile pharmaceutical-grade atropine sulfate powder. Multidose bags of atropine sulfate (100 mL) were stored at controlled temperatures of 4 degrees C to 8 degrees C, 20 degrees C to 25 degrees C, and 32 degrees C to 36 degrees C for 3 days and covered with an amber occlusive cover to minimize exposure to light. Six samples from each bag were drawn at 6, 12, 24, 48, and 72 h after preparation and compared with a time zero control sample. The samples were assayed using United States Pharmacopeia/National Formulary (USP/NF) high-performance liquid chromatography (HPLC) methods for atropine sulfate injection. The USP standard of 95% for atropine sulfate stability was used as the primary endpoint. RESULTS: Atropine sulfate 1 mg/mL in 0.9% sodium chloride was stable for at least 72hr at 4 degrees C to 8 degrees C (percent initial concentration ranging from 96.5% to 103.4%), 20 degrees C to 25 degrees C (percent initial concentration ranging from 98.7% to 100.2%), and 32 degrees C to 36 degrees C (percent initial concentration ranging from 98.3% to 102.8%). Because the IV bags were protected from light during this study, we recommend this practice after preparing the atropine solution. CONCLUSIONS: The amount of atropine necessary to treat hundreds to thousands of victims of a chemical attack is immense. The extemporaneous preparation of atropine solution from pharmaceutical-grade powder eliminates concerns about the storage of excessive quantities of atropine. A 1 mg/mL solution is stable for at least 3 days, allowing for use during the most critical treatment periods after exposure.

Initial impact of toll-free access on poison center call volume.

Prior to the implementation of the nationwide toll-free telephone number, most poison centers already provided toll-free service; therefore, the impact of toll-free access to a poison center on call volume is difficult to assess in the majority of poison centers. This analysis examined the effect that the new nationwide toll-free telephone number had on total call volume (exposures and information calls) in a poison center without previous toll-free access and serving a large urban and rural population. All calls received by a Regional Poison Information Center (RPIC) over a consecutive 27-mo period (2000, 2001, Jan-Jun 2002) were analyzed. April 2001 was the first full month of toll-free service. Data from January-March and January-June for 2000, 2001 and 2002 served as 3 and 6-mo benchmark and study periods. The 3 and 6-mo periods for each of the 3 years were used to conduct comparative trend analysis. Over 1.1 million pieces of literature and sheets of stickers that contained the toll-free number were distributed throughout the region over the study period. Use of the toll-free number increased from 590 calls in July 2001 to 2,157 in June 2002. Total call volume increased by 11.2%. Trend analysis revealed a 9.9% increase in exposure volume when comparing 2001 and 2002 data. There was a significant increase in utilization of the toll-free number for information purposes from people residing in rural counties. Toll-free access to the RPIC increased the volume of information calls dramatically. Initial trend analysis indicated that the availability of toll-free access has reversed the erosion of exposure-related calls.