Therapeutic drug monitoring of vancomycin in a morbidly obese patient.

The authors describe the therapeutic drug monitoring of vancomycin in a man who is morbidly obese. Because serum vancomycin concentration (SVC) monitoring continues to be deemphasized, nomogram use will likely increase. However, vancomycin dosing nomograms have not been studied in patients who are morbidly obese. Furthermore, in nomograms that incorporate body weight, it is unclear whether ideal or total body weight (IBW and TBW, respectively) should be used to dose the morbidly obese. Therefore, the authors retrospectively evaluated four nomograms (Moellering, Matzke, Lake-Peterson, and Rodvold) and an individualized method in the simulated vancomycin dosing of their patient. Total body weight was more accurate than IBW in selecting a vancomycin dose when using the individualized method and in all nomograms except the Matzke nomogram. The Rodvold nomogram and the individualized method yielded the most appropriate doses. All nomograms suggested dosing intervals that were unacceptably short; the individualized method suggested an appropriately longer interval. Thus, if nomograms or the individualized method are used to empirically dose vancomycin, TBW--not IBW--should be used. Because these nomograms yielded inappropriately short dosing intervals in the patient, it is likely that patients who are morbidly obese represent a unique population in which at least one set of SVCs are necessary to select an appropriate dosing regimen.

Epiglottitis: a 9-year case review.

A retrospective chart review of all cases of suspected epiglottitis from 1985 to 1993 at Arkansas Children's Hospital identified 29 patients treated for epiglottitis during this 9-year period. Review of the immunization status of these patients showed 72% without Hib vaccination, 11% who had initiated the Hib series, and 17% with unknown immunization status. The incidence of epiglottitis declined over the duration of the study with 0.61/1,000 admissions in 1985, 0.27 in 1986, 1.42 in 1987, 0.9 in 1988, 0.39 in 1989, 0.0 in 1990, 0.35 in 1991, 0.0 in 1992, and 0.0 in 1993. Comparing the years before available conjugate vaccine--1985 to 1988--with the years after conjugate vaccine--1989 to 1993--shows a significant change in the incidence of epiglottitis. With increasing populations of susceptible children receiving Hib immunization, Hib epiglottitis may become a vanishing entity.

Blastomycosis in children.

Infections due to Blastomyces dermatitidis are not commonly encountered in children and adolescents. Knowledge of the diagnosis and treatment of this disease is largely based upon experience with adult patients. We recently reviewed our experience with blastomycosis to evaluate the difficulties in diagnosis and treatment of this disease in the pediatric population. Ten patients with blastomycosis were identified during our review, and five had pulmonary disease alone. Of these five patients, four required open-lung biopsy for diagnosis, even though three had previously undergone bronchoalveolar lavage. The response to treatment with the oral azole antifungal agents (ketoconazole, fluconazole, and itraconazole) was limited, and the agent with the greatest success remains amphotericin B. Until more data are available, amphotericin B should be used for complicated and life-threatening cases of blastomycosis. If oral azole agents are used for non-life-threatening cases, patients should be followed closely, and if clinical deterioration occurs or serum levels of medications are not adequate, then amphotericin B should be substituted for the oral azole agent.