Anthrax: safe treatment for children

Outcome of Injection Sclerotherapy With Doxycycline in Lymphatic, and Veno-lymphatic Malformation in Children: A Single Centre Experience

AIM

Lymphatic malformations (LMs) and Veno-lymphatic malformations (VLMs) are congenital slow flow vascular malformations. Intralesional sclerotherapy is a good alternate option for treatment of LMs and VLMs. Our aim was to evaluate the outcome of doxycycline sclerotherapy for lymphatic and veno-lymphatic malformation in children in our institute.

METHODS

Retrospectively review of children with LMs or VLMs, primarily treated with doxycycline sclerotherapy in our hospital from January 2012 to December 2023. Patient's demographics, type and location of lesion, number of sclerotherapy sessions, final outcome and complications were recorded and data was analyzed. The clinical response was deemed excellent if lesion resolved completely (>90 % resolution) and satisfactory if there was >50 % resolution of lesion based on visual estimate. The response was considered as poor if <50 % resolution of lesion.

RESULTS

Out of 70 patients, 34 (48 %) patients had lesion located in cervicofacial region. 164 sessions were required (range 1-7/patient). 47/70 (68 %) patients showed excellent response, 9/70 (12 %) patients showed satisfactory response and remaining 14/70 (20 %) patients showed poor response. 8 patients (11 %) required subsequent surgery after sclerotherapy. Sclerotherapy with doxycycline was successful in 80 % of patients. No major complication was noted in any patient.

CONCLUSION

Doxycycline sclerotherapy resulted in excellent clinical outcome and complete resolution of lesions in majority of cases without increased need for subsequent surgical resection. Doxycycline is a readily available and cost effective treatment option with minimum side effects. It should be considered as a primary treatment for LM and VLM in children.

A retrospective analysis of Q fever osteomyelitis in children, with recommendations

Osteomyelitis in children due to Q fever is a rare occurrence. In this study, we review 25 pediatric cases of this disease entity. The mean age of these 25 patients was 3.7years (range, 2-7 years). The risk factor for infection was history of contact with animals, such as cattle and sheep (23/25, 92.0%). The most common sites of infection were foot and ankle (12/25, 48.0%). The diagnosis of Q fever was confirmed by serologic testing in 25 children. On PCR, Coxiella burnetii was detected in 17 cases and it was not detected in the remaining five cases. A total of 22 children were treated with antibiotics, of which 15 received surgical treatment. The composition and duration of treatment varied greatly. Only 18 patients achieved significant recovery of joint mobility after drug and/or surgical treatment. Our current literature review show that the clinical manifestations of Q fever osteomyelitis in children are atypical. In the absence of serological test results, mNGS identification may be a good option. Compared with the guidelines that recommend doxycycline combined with hydroxychloroquine, we recommend that ciprofloxacin-based treatment combined with rifampicin or sulfamethoxazole/trimethoprim should be preferred in children under the age of 8 years, and the need for performing combined surgical debridement and determining the treatment duration should be evaluated according to their actual clinical situation.

Off-label drug use evaluation in paediatrics--applied to ciprofloxacin when used as treatment of cholangitis

PURPOSE

To evaluate drug and indication specific off-label use in paediatrics, applied to ciprofloxacin (CPFX) in cholangitis.

METHODS

We collected four different sets of data for an off-label drug use evaluation. (1) Literature review from medical journals, (2) the use and safety profile from the whole Swedish paediatric population by extracting data from national registers, (3) locally performed retrospective drug chart reviews, and (4) interviews regarding paediatric patients with CPFX treated cholangitis.

RESULTS

The literature reviews show a lack of information for paediatric use of CPFX in cholangitis. The prescribing of CPFX to Swedish children has grown over the last decade and generated a small number of reports for adverse drug reactions. In our local biliary atresia population 32 patients had suffered from at least one episode of cholangitis and 13 patients had been prescribed CPFX. The dosing strategy had an empirical prescribing approach, since monitoring of bacterial resistance and efficacy is difficult in the biliary ducts. No clear relationship was seen between dosing and age/weight. Reports of suspected side effects could not be found in the retrospective chart reviews. The interviews show that the existing dosage forms are well accepted.

CONCLUSIONS

This drug use evaluation creates awareness of the off-label situation. The international and national data are sparse for the paediatric use of CPFX in cholangitis. Locally we have highlighted a heterogeneous dosing strategy of CPFX, drug/drug interactions, and the need to monitor and report the risk of short- and long-term adverse drug reactions.

Bioterrorism: Evaluating the preparedness of pediatricians in Michigan

OBJECTIVE

There is a paucity of literature in the United States regarding preparedness for a bioterrorist attack on children. The main objective of this study was to assess the self-reported level of bioterrorism preparedness of pediatricians practicing in Michigan.

METHODS

We conducted a survey that was mailed to 1000 pediatricians practicing in Michigan from July through December 2006. Survey questions were designed to evaluate the overall level of preparedness, as defined by the American Academy of Pediatrics, in dealing with a possible biological event and to describe key demographic variables.

RESULTS

Of the 590 pediatricians who responded (59%), a majority (80%) were general pediatricians, whereas 20% were pediatric subspecialists. Sixty percent of responders believe terrorism is a threat, with biological agents (52%; 95% confidence interval (CI), 48.00-56.12) as the most likely cause of an event. Half of the pediatricians who responded had a workplace disaster plan, but only 12% feel their preparedness for a biological attack/event was good. Sixty-six percent (392/590) were not currently Pediatric Advanced Life Support certified, 38% (95% CI,34.63-42.51) have never attended a lecture based on bioterrorism, 85% (95% CI, 82.00-87.78) have never participated in a bioterrorism training exercise, and 89% (95% CI, 87.00-91.95) do not provide disaster-oriented anticipatory guidance to their patients. Seventy-six percent (95% CI, 73.10-79.98) of all responders indicated their desire for more bioterrorism training, with 42% preferring diagnostic algorithms and 37% (95% CI, 32.79-40.59) preferring a prepared lecture on video format.

CONCLUSIONS

Surveyed pediatricians in Michigan consider bioterrorism a significant threat but are overwhelmingly underprepared to deal with an event. There is a perceived need for a coordinated educational program to improve level of preparedness.

Comparison of clarithromycin and ciprofloxacin therapy for Bacillus anthracis Sterne infection in mice with or without 60Co gamma-photon irradiation

Biological agents and ionizing radiation lead to more severe clinical outcomes than either insult alone. This study investigated the survival of non-irradiated and (60)Co-gamma-irradiated mice given therapy for inhalation anthrax with ciprofloxacin (CIP) or a clinically relevant mixture of clarithromycin (CLR) and its major human microbiologically important metabolite 14-hydroxy clarithromycin (14-OH CLR). All B6D2F1/J 10-week-old female mice were inoculated intratracheally with 3 x 10(8) c.f.u. of Bacillus anthracis Sterne spores 4 days after the non-lethal 7 Gy dose of (60)Co gamma radiation. Twenty-one days of treatment with CLR/14-OH CLR, 150 mg kg(-1) twice daily, or CIP, 16.5 mg kg(-1) twice daily, began 24 h after inoculation. Pharmacokinetics indicate that the area under the curve (AUC) for 14-OH CLR on the concentration-versus-time graph was slightly higher in gamma-irradiated than non-irradiated animals. Neither drug was able to increase survival in gamma-irradiated animals. CIP and CLR/14-OH CLR therapies in non-irradiated animals increased survival from 49 % (17/35 mice) in buffer-treated animals to 94 % (33/35) and 100 %, respectively (P < 0.001). B. anthracis Sterne only was isolated from 25-50 % of treated mice with or without irradiation. Mixed infections with B. anthracis Sterne were present in 50-71 % of gamma-irradiated mice but only in 5-10 % of mice without irradiation.

Doxycycline-induced staining of permanent adult dentition

BACKGROUND

Doxycycline is the most effective antibiotic for managing brucellosis. Although it is relatively free from side effects, complications involving the skin, nails and teeth may rarely be encountered.

METHODS

Four patients with brucellosis developed yellow-brown discolouration of teeth following a 30-45 day course of doxycycline therapy during summer at a dose of 200mg/day.

RESULTS

All four patients were diagnosed as having doxycycline-induced staining of the permanent dentition. In all cases, the staining completely resolved and the teeth recovered their original colour following abrasive dental cleaning.

CONCLUSIONS

These observations indicate that the incidence of staining of the permanent dentition, as a complication of doxycycline, may be much higher than the literature indicates, especially if treatment is administered during summer months. Fortunately, this complication is reversible and does not require termination of doxycycline therapy. Complete resolution following abrasive cleaning may suggest that an extrinsic mechanism within the dental milieu may be involved in its pathogenesis. Strict avoidance of sunlight exposure during high-dose, long-term doxycycline therapy might prevent the development of this complication.

Bioterrorism: pivotal clinical issues. Consensus review of the Society of Infectious Diseases Pharmacists

OBJECTIVES

To discuss specific facts regarding use as a bioweapon, epidemiology, microbiology, clinical manifestations, diagnosis, antimicrobial therapy, immunization, and isolation precautions for five most likely agents of bioterrorism; to review and provide recommendations for health care clinicians on the management of these bioterrorism agents; and to share information on the pharmacist's role in preparedness and response.

PARTICIPANTS

The manuscript was drafted by the three authors, reviewed by a group of selected members of the Society of Infectious Diseases Pharmacists, and approved by its Board of Directors.

EVIDENCE

The primary focus was to review and summarize recent and key articles on bioterrorism. Preference was given to peer-reviewed journal information and government-sponsored journals, such as the MMWR, Morbidity and Mortality Weekly Report.

CONSENSUS PROCESS

Written comments were requested from each reviewer. Comments were incorporated into the final draft.

CONCLUSION

Pharmacists play an integral role in disaster preparedness and response and should be involved in planning committees. As drug information specialists, pharmacists can assist other health care providers and emergency personnel, as well as provide counseling to calm, comfort, and empower the public.