Clinical impact of rapid viral respiratory panel testing on pediatric critical care of patients with acute lower respiratory infection.

BACKGROUND: We aimed to determine the impact of utilizing a rapid panel test of respiratory viral and atypical bacteria (FilmArray® Respiratory Panel, FA RP) on etiological diagnosis of acute lower respiratory infection (ALRI) and antimicrobial stewardship in critical care pediatric patients. METHODS: Prospective cohort study of patients aged<18 years with clinical diagnosis of ALRI that were admitted to the Pediatric Intensive Care Unit (PICU) of Hospital Sant Joan de Deu (Barcelona, Spain) during December 2015-February 2017. Patients were diagnosed by FA RP and by a bundle of routine microbiological assays. RESULTS: ALRI viral and bacterial etiology was confirmed by a composite reference standard of routine microbiological assays in 72 (55.4%) and 15 (11.5%) respiratory samples, respectively, that were collected from 130 children (median age, 3.5 months, IQR 1.1-14.8 months; 54.6% male). Comparatively, FA RP use increased etiological confirmation of ALRI in up to 123 (94.6%) samples (p<0.001) but only determined a bacterial origin in 2 (1.5%). Availability of diagnostic results before patient discharge from the PICU rose from 65.4 to 38.5% (p<0.001). Use of the new panel test directly influenced antimicrobial stewardship in 11 (8.4%) episodes, leading to discontinuation of antiviral drugs (n=5), administration of targeted antibiotics (n=3), antiviral therapy start (n=2) and both targeted antibiotic administration and discontinuation of antiviral drugs (n=1). CONCLUSION: FA RP contributed to improve etiological diagnosis of ALRI in a timely manner while enhancing a more rational use of antimicrobial drugs in critical care pediatric patients.

Clinical impact of rapid viral respiratory panel testing on pediatric critical care of patients with acute lower respiratory infection / Impacto clínico de una prueba rápida de detección múltiple de virus respiratorios en pacientes pediátricos críticos con infección respiratoria aguda de vías bajas

BackgroundWe aimed to determine the impact of utilizing a rapid panel test of respiratory viral and atypical bacteria (FilmArray® Respiratory Panel, FA RP) on etiological diagnosis of acute lower respiratory infection (ALRI) and antimicrobial stewardship in critical care pediatric patients.MethodsProspective cohort study of patients aged<18 years with clinical diagnosis of ALRI that were admitted to the Pediatric Intensive Care Unit (PICU) of Hospital Sant Joan de Deu (Barcelona, Spain) during December 2015–February 2017. Patients were diagnosed by FA RP and by a bundle of routine microbiological assays.ResultsALRI viral and bacterial etiology was confirmed by a composite reference standard of routine microbiological assays in 72 (55.4%) and 15 (11.5%) respiratory samples, respectively, that were collected from 130 children (median age, 3.5 months, IQR 1.1–14.8 months; 54.6% male). Comparatively, FA RP use increased etiological confirmation of ALRI in up to 123 (94.6%) samples (p<0.001) but only determined a bacterial origin in 2 (1.5%). Availability of diagnostic results before patient discharge from the PICU rose from 65.4 to 38.5% (p<0.001). Use of the new panel test directly influenced antimicrobial stewardship in 11 (8.4%) episodes, leading to discontinuation of antiviral drugs (n=5), administration of targeted antibiotics (n=3), antiviral therapy start (n=2) and both targeted antibiotic administration and discontinuation of antiviral drugs (n=1).ConclusionFA RP contributed to improve etiological diagnosis of ALRI in a timely manner while enhancing a more rational use of antimicrobial drugs in critical care pediatric patients.

AntecedentesNuestro objetivo fue determinar el impacto de la utilización de una prueba rápida de detección múltiple de virus y bacterias atípicas respiratorias (FilmArray® Respiratory Panel [FA RP]) en el diagnóstico etiológico de la infección respiratoria aguda de vías bajas (IRAVB) y en la administración de antimicrobianos en pacientes críticos pediátricos.MétodosEstudio de una cohorte prospectiva de pacientes <18 años con diagnóstico clínico de IRAVB que ingresaron en la Unidad de Cuidados Intensivos Pediátricos (UCIP) del Hospital Sant Joan de Deu, Barcelona, España, durante diciembre de 2015-febrero de 2017. Los pacientes fueron diagnosticados por FA RP y por un grupo de pruebas microbiológicas de rutina.ResultadosLas pruebas microbiológicas de rutina confirmaron la etiología viral y bacteriana de la IRAVB en 72 (55,4%) y 15 (11,5%) muestras respiratorias, respectivamente, obtenidas de 130 niños (edad mediana: 3,5 meses; rango intercuartil: 1,1-14,8 meses; 54,6% varones). Comparativamente, el uso de FA RP aumentó la confirmación etiológica de la IRAVB en hasta 123 (94,6%) muestras (p<0,001), pero solo determinó un origen bacteriano en 2 (1,5%). La disponibilidad de resultados diagnósticos antes del alta del paciente de la UCIP aumentó del 38,5 al 65,4% (p<0,001). El uso de la nueva prueba de detección múltiple influyó directamente en la administración de antimicrobianos en 11 (8,4%) episodios, orientando la interrupción de tratamientos antivirales (n=5), la administración de antibióticos dirigidos (n=3), el inicio de terapias antivirales (n=2) y la administración dirigida de antibióticos e interrupción simultánea de tratamiento antiviral (n=1).

Clinical impact of rapid viral respiratory panel testing on pediatric critical care of patients with acute lower respiratory infection.

BACKGROUND: We aimed to determine the impact of utilizing a rapid panel test of respiratory viral and atypical bacteria (FilmArray® Respiratory Panel, FA RP) on etiological diagnosis of acute lower respiratory infection (ALRI) and antimicrobial stewardship in critical care pediatric patients. METHODS: Prospective cohort study of patients aged<18 years with clinical diagnosis of ALRI that were admitted to the Pediatric Intensive Care Unit (PICU) of Hospital Sant Joan de Deu (Barcelona, Spain) during December 2015-February 2017. Patients were diagnosed by FA RP and by a bundle of routine microbiological assays. RESULTS: ALRI viral and bacterial etiology was confirmed by a composite reference standard of routine microbiological assays in 72 (55.4%) and 15 (11.5%) respiratory samples, respectively, that were collected from 130 children (median age, 3.5 months, IQR 1.1-14.8 months; 54.6% male). Comparatively, FA RP use increased etiological confirmation of ALRI in up to 123 (94.6%) samples (p<0.001) but only determined a bacterial origin in 2 (1.5%). Availability of diagnostic results before patient discharge from the PICU rose from 65.4 to 38.5% (p<0.001). Use of the new panel test directly influenced antimicrobial stewardship in 11 (8.4%) episodes, leading to discontinuation of antiviral drugs (n=5), administration of targeted antibiotics (n=3), antiviral therapy start (n=2) and both targeted antibiotic administration and discontinuation of antiviral drugs (n=1). CONCLUSION: FA RP contributed to improve etiological diagnosis of ALRI in a timely manner while enhancing a more rational use of antimicrobial drugs in critical care pediatric patients.

Micafungin in the treatment of invasive fungal infection in an infant with extracorporeal / Micafungina como tratamiento de la infección fúngica invasiva en un paciente con oxigenación por membrana extracorpórea

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Glutamine effects on heat shock protein 70 and interleukines 6 and 10: Randomized trial of glutamine supplementation versus standard parenteral nutrition in critically ill children.

BACKGROUND & AIMS: To determine whether glutamine (Gln) supplementation would have a role modifying both the oxidative stress and the inflammatory response of critically ill children. METHODS: Prospective, randomized, double-blind, interventional clinical trial. Selection criteria were children requiring parenteral nutrition for at least 5 days diagnosed with severe sepsis or post major surgery. Patients were randomly assigned to standard parenteral nutrition (SPN, 49 subjects) or standard parenteral nutrition with glutamine supplementation (SPN + Gln, 49 subjects). RESULTS: Glutamine levels failed to show statistical differences between groups. At day 5, patients in the SPN + Gln group had significantly higher levels of HSP-70 (heat shock protein 70) as compared with the SPN group (68.6 vs 5.4, p = 0.014). In both groups, IL-6 (interleukine 6) levels showed a remarkable descent from baseline and day 2 (SPN: 42.24 vs 9.39, p < 0.001; SPN + Gln: 35.20 vs 13.80, p < 0.001) but only the treatment group showed a statistically significant decrease between day 2 and day 5 (13.80 vs 10.55, p = 0.013). Levels of IL-10 (interleukine 10) did not vary among visits except in the SPN between baseline and day 2 (9.55 vs 5.356, p < 0.001). At the end of the study, no significant differences between groups for PICU and hospital stay were observed. No adverse events were detected in any group. CONCLUSIONS: Glutamine supplementation in critically-ill children contributed to maintain high HSP-70 levels for longer. Glutamine supplementation had no influence on IL-10 and failed to show a significant reduction of IL-6 levels.

Diseño de un modelo de atención farmacéutica infantil para la validación de órdenes médicas en hospitales españoles / Development of a Paediatric Pharmaceutical Care Model for validating prescriptions orders in Spanish Hospitals

El presente proyecto desarrolla un modelo de Atención Farmacéutica Infantil para la validación de órdenes médicas de pacientes pediátricos. Para su desarrollo, se realizó un estudio del perfil de seguridad en la prescripción en 8 hospitales españoles pediátricos. Se registraron 667 intervenciones (49,3%-error dosis; 15,1%-forma farmacéutica errónea; 10,7%-medicamento incorrecto 9,3%-frecuencia errónea, entre otros). Posteriormente se desarrolló dicho modelo siguiendo la metodología Delphi con un panel de 50 expertos. Como resultado se obtiene un modelo con 39 cuestiones dividido en 3 niveles de complejidad: básico, intermedio y avanzado, con sus respectivas herramientas para el chequeo y perfectamente exportable a otros hospitales (AU)

This project develops a model for Pharmaceutical Care Child validation of pediatric medical orders. For its development, a study of the safety profile in prescribing Spanish in 8 pediatric hospitals. There were 667 interventions (49.3%-error dose, 15.1%, wrong dosage form, 10.7%, 9.3% wrong medicine-often erroneous, among others). Subsequently that model was developed by the Delphi methodology with a panel of 50 experts. The result is a model with 39 questions divided into three levels of complexity: basic, intermediate and advanced, with their respective tools for checking and perfectly exportable to other hospitals (AU)

Profile of prescribing errors detected by clinical pharmacists in paediatric hospitals in Spain.

BACKGROUND: Pharmaceutical care involves three essential functions: identifying potential and real medication-related problems, solving real medication-related problems and preventing potential medication related problems. OBJECTIVE: To describe the profile of prescribing errors detected and prevented by paediatric clinical pharmacists in medical orders for inpatients in Spain. SETTINGS AND METHODS: A prospective, descriptive, multicentre epidemiological study on medical orders for inpatients aged 1 day to 18 years, conducted between July and October 2011 at eight hospitals treating paediatric patients. MAIN OUTCOME MEASURE: primary variables were most common errors, including clinical severity (according to a previously validated instrument), pharmacotherapeutic groups and drugs most commonly involved, the impact of pharmaceutical interventions, as well as the population receiving most interventions, and type of prescription (manual of electronic) and dispensation system (ward stock, unit-dose or automated dispensing cabinets) that are most involved in Spain. RESULTS: A total of 667 interventions related to quality of the prescription were recorded at eight sites. 21 were excluded. 41.2 % concerned manual prescribing systems, and 58.8 % electronic prescribing systems. The interventions were performed on patients with a mean age of 5 years (standard deviation 5.43). In interventions concerning prescribing errors, 212 different drugs were involved, mainly belonging to the group of anti-infectives. The main factor triggering pharmacist's recommendations was dose errors of 1.5-10 times the recommended dose. Therefore, the main prescription errors are dosing errors (49.3 %). With regard to the clinical severity of these prescribing errors, 51.9 % (306 cases) were considered significant, 26.3 % (155 cases) of minor significance, 19.8 (117 cases) were clinically serious and 2.0 % (12 cases) were potentially fatal. There was a 95.4 % global acceptance rate for recommendations. The impact of accepted interventions showed that 64.7 % had a significant impact on patient health outcome, highlighting 1.1 % with a highly significant impact. The activity level of the paediatric clinical pharmacists was highly variable, with a median of 0.014 interventions/bed-day during the data collection period. CONCLUSION: In view of the importance of the dosing errors in the prescription phase, and the clinical relevance of the errors detected, it seems to be necessary to implement measures as the development of decision support systems for paediatric dosing and strengthen the presence of pharmacists as a key element in preventing prescribing errors from reaching patients, thus ensuring that children receive effective, safe and efficient drug therapy.

Two-round Delphi technique for the consensual design of a paediatric pharmaceutical care model.

The main goal of clinical pharmacists is to improve patient care quality by providing individualised care. This is achieved by validating prescriptions and performing pharmacotherapeutic follow-up, leading to effective, safe and efficient drug therapy. However, there is no specific model for medication order validation in paediatrics addressing the distinct issues of paediatric drug use or the greater susceptibility of medication errors occurring in this patient group. For this reason we intended to design and reach consensus on a paediatric pharmaceutical care model by applying a two-round Delphi technique. In order to define the levels of complexity in reaching consensus for the model, three variables were taken into account: level of access to patient medical and drug records (partial vs. total), access to medical and nursing staff attending the patient (on-site vs. off-site) and the pharmacist available time (limited vs. adequate). In order to describe the minimum items to be included in the validation process at each of the three levels of complexity, we analysed the safety profile in the medication order prescription previously defined in an epidemiological study in eight hospitals with a total capacity of 1565 paediatric beds. A panel of experts was recruited (50 experts from 20 different hospitals) and the questionnaire was completed. Consensus was established at 70% of agreement by experts for an item. Following debate on the items that did not obtain consensus, a second round was performed, after which the final consensus model was defined. After two rounds of consultation, consensus was obtained for 39 out of the 41 items that were surveyed. Of these, 17 were then used for the basic validation model (e.g. weight/age check, dose/weight check), 13 were implemented in the intermediate level (e.g. identification of adverse effects from excipients) and 9 were incorporated at advanced level (e.g. reconciliation at discharge for patients at risk). By applying the model, based on homogenous criteria for action, the clinical pharmacist's role will improve, and in turn, this will doubtlessly reduce drug errors through medication order validation.

Hormonal environment in the induction of breast cancer in castrated rats using dimethylbenzanthracene: influence of the presence or absence of ovarian activity and of treatment with estradiol, tibolone, and raloxifene.

OBJECTIVE: The influence of hormone therapy on the induction or the promotion of breast cancer has yet to be determined. Recent studies establish a cause-effect relation between hormones and cancer, although epidemiological data and studies of tumor behavior give rise to doubts. The aim of the study was to observe and evaluate the influence of different hormonal environments on the induction of breast cancer in a well-established experimental model. DESIGN: In this experimental animal study, breast cancer was induced by using a single intragastric dose of 20 mg of dimethylbenzanthracene in prepubertal Sprague-Dawley rats randomized into five groups: group 1 (control); group 2 (castrated prepubertal animals); and groups 3, 4, and 5 (castration of prepubertal animals followed by hormonal treatment starting at puberty [11 weeks] with tibolone, raloxifene, and estradiol, respectively). Follicle-stimulating hormone and estradiol levels were measured at 6, 11, 16, and 31 weeks. RESULTS: Absence of ovarian activity was observed in groups 2, 3, 4, and 5, as well as the expected variations in hormone levels in all groups. Breast cancers were obtained in 100% of the animals in the control group, with an average of four (two to seven) tumors per animal in this group. Only one cancer appeared in groups 2, 3, and 4, and none appeared in group 5. CONCLUSIONS: In this experimental model and using the hormone treatments chosen, neither the treatments nor the absence of ovarian activity induced breast cancer.