Management of catheter-related infections in pediatric patients

Broviac catheters are commonly used to provide parenteral nutrition and access for infusion of blood products and drugs to pediatric patients. Sepsis is the most common serious complication of continued catheter use. Although removal of the catheter is generally recommended when it becomes contaminated, it may not be feasible to do so without compromising patient care. We evaluated the management of catheter-related infections in pediatric patients with and without removal of catheter. Seventy-seven episodes of catheter sepsis were evaluated in 61 pediatric patients; 24 were neonates and 37 were older children. The catheters were used for multiple purposes in 75% of cases. The most common microorganisms isolated were Staphylococcus epidermidis in 26%, Klebsiella pneumoniae in 9%, and Streptococcus viridans in 8% of cases; other pathogens included group D Enterococcus, Staphylococcus aureus, and Escherichia coli. Pseudomonas aeruginosa was isolated in four older children. Thirty-five patients were treated with antibiotics without catheter removal. Thirty patients received appropriate antibiotic therapy based on the susceptibility data. Twenty-six of these 30 patients responded within 5 days of therapy whereas the others required 15-39 days of treatment. Lack of response was mainly associated with the presence of abscess, immunocompromised status, and organisms P. aeruginosa and Candida albicans. Based on the sensitivity and minimum inhibitory concentration data, a combined regimen of gentamicin and vancomycin would be an effective initial therapy. These findings suggest that (1) catheter sepsis can be managed with appropriate antibiotics, and (2) when continued use of Broviac catheter is desired, a trial of antibiotic therapy should be attempted before catheter removal.     

Status of child health worldwide.

OBJECTIVE: The objective of this article is to summarize some of the facts about child health and goals of international health organizations. DATA SOURCES: The sources included the publications of World Health Organization's (WHO), United Nations Children Fund, and United Nations Educational, Scientific, and Cultural Organizations; and journal articles. DATA EXTRACTION: Data on areas related to child health were obtained from various publications. DATA SYNTHESIS: Although childhood mortality continues to fall worldwide, nearly 14 million children under five years of age still die annually in developing countries. Diarrhea, measles, tetanus, pertussis, pneumonia, and malnutrition are preventable and treatable and yet account for the majority of deaths. AIDS has begun to substantially affect the pediatric population. It is encouraging that the WHO's goal to immunize 80 percent of all children in the developing world has been met. The World Summit for Children, in consultation with governments of 159 countries, and the agencies of the United Nations, has adopted new goals to be attained by the year 2000. CONCLUSIONS: It is hoped that governmental and nongovernmental agencies will embrace these goals and formulate plans to markedly reduce childhood morbidity and mortality.     

Cefotaxime and metabolite disposition in two pediatric continuous ambulatory peritoneal dialysis patients.

OBJECTIVE: To characterize the pharmacokinetics of cefotaxime and desacetylcefotaxime in pediatric patients undergoing continuous ambulatory peritoneal dialysis (CAPD) after intraperitoneal administration of cefotaxime. DESIGN: Case series. SETTING: Ambulatory children from Children's Hospital nephrology clinic, Columbus, Ohio. PATIENT POPULATION: Two adolescents without peritonitis. METHODS: A single intraperitoneal dose of cefotaxime 500 mg per 1 L dianeal was given during CAPD. Cefotaxime and desacetyl-cefotaxime were measured in plasma, urine, and dialysate by HPLC. RESULTS: Maximum plasma concentration (Cmax) of cefotaxime was 11.94 and 13.08 mg/L and that of desacetylcefotaxime 5.73 and 5.33 mg/L. Time to reach maximum concentration (Tmax) of cefotaxime was 2.22 and 4.08 h, and that of desacetylcefotaxime was 5.33 and 5.73 h after instillation of the intraperitoneal cefotaxime dose. Systemic absorption of cefotaxime was 56.6 and 64.8 percent. Total clearance of cefotaxime was 62 and 79 mL/min/1.73 m2. Nonrenal clearance accounted for nearly 95 percent; renal and CAPD clearance contributed approximately 5 percent of the total clearance. Renal and CAPD clearance measurements of desacetylcefotaxime were similar to those for cefotaxime. Cefotaxime half-life was 1.83 and 2.49 h and desacetylcefotaxime half-life was 8.14 and 11.0 h. CONCLUSIONS: Cefotaxime was well absorbed and therapeutic serum concentrations were achieved after intraperitoneal administration. Renal and CAPD clearances for cefotaxime and desacetylcefotaxime were low. Cefotaxime nonrenal clearance was unaffected. Further studies are needed to establish appropriate intraperitoneal dosing guidelines of cefotaxime in pediatric CAPD patients.     

Guidelines for antimicrobial prophylaxis

Antimicrobials are frequently used to prevent infections. Principles of prophylaxis, and antimicrobial prophylaxis in surgery, tuberculosis, acquired immunodeficiency syndrome, influenza A, traveller's diarrhoea, malaria, recurrent otitis media, Haemophilus influenzae type b infection, pertussis, rheumatic fever, and urinary tract infection are described. Various strategies to improve the prophylactic use of antibiotics are discussed. Collaborative efforts among health care disciplines are needed to assure optimal antimicrobial prophylaxis. This should maximize efficacy and minimize adverse effects, the development of bacterial resistance and associated costs.     

Dopamine pharmacokinetics in critically ill newborn infants

Summary Dopamine is frequently used in critically ill newborn infants for treatment of shock and cardiac failure, but its pharmacokinetics has not been evaluated using a specific analytical method. Steady-state arterial plasma concentrations of dopamine were measured in 11 seriously ill infants receiving dopamine infusion, 5–20 g · kg^–1 · min^–1, for presumed or proven sepsis and hypotensive shock.Steady-state concentrations of dopamine ranged from 0.013–0.3 g/ml. Total body clearance averaged 115 ml · kg^–1 · min^–1. The apparent volume of distribution and elimination half life averaged 1.8 1 · kg^–1 and 6.9 min, respectively.No relationship was observed between dopamine pharmacokinetics and gestational age, postnatal age or birthweight. Substantial interindividual variation was seen in dopamine pharmacokinetics in seriously ill infants, and plasma concentrations could not be predicted accurately from its infusion rate.Marked variation in clearance explains in part, the wide dose requirements of dopamine needed to elicit clinical response in critically ill newborn infants.VBM was a Fellow at Ohio State University and Children's Hospital at the time of study and is now at the Department of Pharmacy Services and College of Pharmacy, University of Michigan, Ann Arbor, MI, USA     

Effectiveness of antibiotic therapy in pediatric patients with cat scratch disease

Background Appropriate antibiotic treatment of cat scratch disease (CSD) in pediatrics is not well established. Objective The purpose of this study was to evaluate the response rates of antibiotic therapy in pediatrics with CSD. Methods The electronic medical records of a cohort of pediatric patients with confirmed diagnosis of CSD (2006–2016) were reviewed, retrospectively. Data collection included patient demographics, clinical and laboratory results, antibiotic treatment and follow-up evaluations. Results One hundred and seventy-five patients (aged 7.4?±?4.4 years) had confirmed CSD. Azithromycin and trimethoprim/sulfamethoxazole (TMP/SMX) were the largest groups with documented effectiveness at follow-up visits. Resolution and improvement of CSD was observed in 51.4% and 61.5% of patients with azithromycin and TMP/SMX, respectively among those with follow-up assessment. The effectiveness of azithromycin and TMP/SMX was comparable (p?=?0.56). Conclusion Azithromycin and TMP/SMX were most frequently prescribed antibiotics. Azithromycin appeared to be an appropriate option for the treatment of CSD. TMP/SMX may be considered as an alternative antibiotic when azithromycin cannot be used.     

Impact of a novel family-centered values clarification tool on adolescent sperm banking attempts at the time of a new cancer diagnosis

Purpose

Over half of males experience fertility impairment after childhood cancer therapy, which often causes psychosocial distress. Yet, fertility preservation (FP) remains underutilized. The goals of this study were to determine the feasibility and impact of implementing a family-centered FP values clarification tool on sperm banking attempts among adolescent males newly diagnosed with cancer, and identify key determinants of banking attempts.

Methods

A prospective pilot study was conducted among families of males (12–25 years old), prior to cancer therapy. Thirty-nine of 41 families agreed to participate (95%); 98 participants (32 adolescents, 37 mothers, 29 fathers) completed the Family-centered Adolescent Sperm banking values clarification Tool (FAST). Analyses assessed the impact of the FAST on banking attempts and examined associations between demographic/medical characteristics, FAST subscales (perceived threat, benefits, barriers), and banking attempts.

Results

Twenty-three (59%) adolescents attempted to bank, compared to 8 adolescents (33%) during baseline assessment (p=.04). Significant associations were identified between banking attempts and adolescents’ report of perceived threat (r_pb=.45, p=.01) and benefits (r_pb=.57, p=.01). Only mothers’ proxy reports of adolescent perceived threat (r_pb=.42, p=.01) and benefits (r_pb=.47, p=.003) were associated with banking attempts, while fathers’ self-reported perceived benefits (r_pb=.43, p=.03), self-reported barriers (r_pb=.49, p=.01), and proxy reports of adolescent perceived threat (r_pb=.38, p=.04) and benefits (r_pb=.59, p=.02) were associated with banking attempts.

Conclusion

Adolescent sperm banking attempt rates significantly increased after implementation of a family-centered FP values clarification tool prior to cancer treatment. Findings underscore the importance of targeting both adolescents and their parents, particularly fathers, in FP efforts.