Pharmacological management of acute bronchiolitis

This article reviews the current knowledge base related to the pharmacological treatments for acute bronchiolitis. Bronchiolitis is a common lower respiratory illness affecting infants worldwide. The mainstays of therapy include airway support, supplemental oxygen, and support of fluids and nutrition. Frequently tried pharmacological interventions, such as ribavirin, nebulized bronchodilators, and systemic corticosteroids, have not been proven to benefit patients with bronchiolitis. Antibiotics do not improve the clinical course of patients with bronchiolitis, and should be used only in those patients with proven concurrent bacterial infection. Exogenous surfactant and heliox therapy also cannot be recommended for routine use, but surfactant replacement holds promise and should be further studied

Impact of a Multimodal Antimicrobial Stewardship Program on Pseudomonas aeruginosa Susceptibility and Antimicrobial Use in the Intensive Care Unit Setting

Objective. To study the impact of our multimodal antibiotic stewardship program on Pseudomonas aeruginosa susceptibility and antibiotic use in the intensive care unit (ICU) setting. Methods. Our stewardship program employed the key tenants of published antimicrobial stewardship guidelines. These included prospective audits with intervention and feedback, formulary restriction with preauthorization, educational conferences, guidelines for use, antimicrobial cycling, and de-escalation of therapy. ICU antibiotic use was measured and expressed as defined daily doses (DDD) per 1,000 patient-days. Results. Certain temporal relationships between antibiotic use and ICU resistance patterns appeared to be affected by our antibiotic stewardship program. In particular, the ICU use of intravenous ciprofloxacin and ceftazidime declined from 148 and 62.5 DDD/1,000 patient-days to 40.0 and 24.5, respectively, during 2004 to 2007. An increase in the use of these agents and resistance to these agents was witnessed during 2008–2010. Despite variability in antibiotic usage from the stewardship efforts, we were overall unable to show statistical relationships with P. aeruginosa resistance rate. Conclusion. Antibiotic resistance in the ICU setting is complex. Multimodal stewardship efforts attempt to prevent resistance, but such programs clearly have their limits

Population ecology of the sea lamprey (Petromyzon marinus) as an invasive species in the Laurentian Great Lakes and an imperiled species in Europe

The sea lamprey Petromyzon marinus (Linnaeus) is both an invasive non-native species in the Laurentian Great Lakes of North America and an imperiled species in much of its native range in North America and Europe. To compare and contrast how understanding of population ecology is useful for control programs in the Great Lakes and restoration programs in Europe, we review current understanding of the population ecology of the sea lamprey in its native and introduced range. Some attributes of sea lamprey population ecology are particularly useful for both control programs in the Great Lakes and restoration programs in the native range. First, traps within fish ladders are beneficial for removing sea lampreys in Great Lakes streams and passing sea lampreys in the native range. Second, attractants and repellants are suitable for luring sea lampreys into traps for control in the Great Lakes and guiding sea lamprey passage for conservation in the native range. Third, assessment methods used for targeting sea lamprey control in the Great Lakes are useful for targeting habitat protection in the native range. Last, assessment methods used to quantify numbers of all life stages of sea lampreys would be appropriate for measuring success of control in the Great Lakes and success of conservation in the native range

PhD

dissertationComputerized medical decision support tools have been shown to improve the quality of care and have been cited as one method to reduce pharmaceutical errors by the Institute of Medicine. An existing adult antiinfective decision support tool was enhanced by adding medical logic to make it appropriate for pediatric patients. Pediatric modifications to the medical logic and new antiinfective and dosage recommendations were implemented into the decision support tool. Measurements of appropriate antiinfective use, antiinfective costs, the rate of adverse drug events secondary to antiinfectives, antimicrobial-bacterial susceptibility mismatches, and pharmacy staff interventions for antiinfective agents were prospectively monitored during a six-month control and a six-month intervention period. Mandatory use of the decision support tool was initiated for all antiinfective orders in a 26-bed pediatric intensive (PICU) during the intervention period. Clinician opinions of the decision support tool were surveyed at the end of the intervention period. The patient populations during both the control period (n = 809) and the intervention period (n = 949) were similar with respect to their PICU and hospital lengths of stay, severity of illness, risk of mortality, and total hospital costs. The intervention group was significantly younger (5.5 years vs. 6.2 years, p < 0.05), and a greater percentage were treated with antibiotics (66.5 percent vs. 60.2 percent, p < 0.01). There was not a significant difference in type of antiinfectives ordered, or the number of antiinfectives, or antiinfective doses. Neither was there a difference in the rate of adverse drug events, or antibiotic-bacterial susceptibility mismatches. However, the rate of pharmacy interventions on erroneous drug doses declined by 59 percent from 35.5 to 14.5 interventions per 1000 patient-antiinfective courses (p < 0.01). The rate of antiinfective subtherapeutic patient days decreased by 36 percent from 7.4 to 4.7 subtherapeutic days per 100 patient days (p< 0.0001), and the rate of excessive-dose days declined by 28 percent from 8.5 to 6.1 excessive-dose days per 100 patient days (p < 0.0001). Additionally, the number of orders placed per antibiotic course decreased 11.5 percent from an average of 1.56 to 1.38 orders/pt-antiinfective (p < 0.01), and the robust estimate of the antiinfective costs per patient decreased 9 percent from $86.60 to$78.43 (p < 0.05). These data are supported by the surveyed clinicians who cited the dosage calculation assistance to be most helpful, and reported the program improved their antiinfective agent choices, increased their awareness of impairments in renal function, and reduced the likelihood of adverse drug events. Use of the pediatric antiinfective decision support tool in a PICU was considered beneficial to patient care by the clinicians, and positively impacted the rates of erroneous drug orders and antiinfective sub- and supratherapeutic risk-days

Foreign Body Aspiration Presenting as Pneumothorax in a Child.

A typical presentation of a foreign body aspiration (FBA) in a child includes witnessed choking, respiratory distress, cyanosis, coughing, wheezing, diminished breath sounds, and/or altered mental status. Following an extensive literature review, we found pneumothorax occurring secondary to FBA is a rare occurrence and should elicit prompt treatment. This 17-month-old female was admitted for respiratory syncytial virus (RSV) bronchiolitis and developed a subsequent pneumothorax during her hospital stay, consequent to aspiration of a cashew fragment two weeks before presentation. In light of the National Institute of Allergy and Infectious Diseases (NIAID)-sponsored expert panel\u27s addended guidelines, published and endorsed by the American Academy of Pediatrics (AAP) in 2017, we highlight a potential complication of increasing encouragement of peanut consumption in children as young as four months