Medicine and Health Sciences Commons^™

Success With Extended-Infusion Meropenem After Recurrence Of Baclofen Pump-Related Achromobacter Xylosoxidans Meningitis In An Adolescent, Kristen R. Nichols, Chad A. Knoderer, Nicholas G. Jackson, John J. Manaloor, John C. Christenson

Kristen R. Nichols

A 13-year-old female experienced a recurrence of baclofen pump-related central nervous system (CNS) infection caused by Achromobacter, despite absence of retained foreign material. Due to the failure of meropenem (120 mg/kg/d in divided doses every 8 hours and infused over 30 minutes) in the initial infection, the dose was infused over 4 hours during the recurrence. Meropenem is an antibiotic for which efficacy is time dependent, and 4-hour versus 30-minute infusions have been shown to prolong the time the concentration of the antibiotic exceeds the minimum inhibitory concentration (MIC) of the organism at the site of infection (T>MIC). Meropenem …

Late-Occurring Vancomycin-Associated Acute Kidney Injury In Children Receiving Prolonged Therapy, Chad A. Knoderer, Allison L. Gritzman, Kristen R. Nichols, Amy C. Wilson

Kristen R. Nichols

Background: Acute kidney injury (AKI) in patients receiving vancomycin has been associated with trough concentrations ≥15 mg/L and longer therapy duration. The objective of this study was to determine the incidence and factors associated with late AKI in children receiving ≥8 days of vancomycin therapy. Methods: Children aged 30 days to 17 years who were admitted to our institution and received intravenous vancomycin for at least 8 days during January to December of 2007 and 2010 and had a suspected or proven gram-positive infection were included. Late AKI was categorized as AKI occurring after the first 7 days of therapy …

Compatibility Of Vancomycin And Oxacillin During Simulated Y-Site Delivery, Hilary Teibel, Chad Knoderer, Kristen Nichols

Kristen R. Nichols

Background: Vancomycin and oxacillin may be used together as empiric coverage in patients with proven or suspected Staphylococcus aureus infections. Though vancomycin hydrochloride 20 mg/mL and oxacillin sodium 160 mg/mL are reported to be compatible via Y-site delivery, Y-site compatibility of commonly used concentrations, vancomycin 10 mg/mL and oxacillin 20 mg/mL, has not yet been reported. Objective: To determine the Y-site compatibility of vancomycin 10 mg/mL and oxacillin 20 mg/mL. Methods: One vancomycin hydrochloride 1 g vial was reconstituted with 10 mL sterile water for injection (SWFI) and diluted with 90 mL 5% dextrose in water (D5W) in an evacuated …

Optimized Antimicrobial Dosing Strategies: A Survey Of Pediatric Hospitals, Chad A. Knoderer, Kristen R. Nichols, Elaine G. Cox

Kristen R. Nichols

Background Extended-interval aminoglycoside (EIAG) and extended- and continuous-infusion β-lactam (EIBL and CIBL) dosing strategies are increasingly used in adults, but pediatric literature is limited. Objective The objective of this study was to describe the use of EIAG, EIBL, and CIBL dosing in pediatric hospitals in the USA. Study Design, Setting, and Participants A national survey of children’s hospitals was conducted. A single practitioner from each target hospital was identified through the Children’s Hospital Association. Practice-based survey questions identified whether hospitals utilize EIAG, EIBL, and CIBL dosing. Main Outcome Measure The main outcome measure was the percentage utilization of the dosing …

Implementing Extended-Infusion Cefepime As Standard Of Care In A Children’S Hospital: A Prospective Descriptive Study, Kristen R. Nichols, Lauren C. Karmire, Elaine G. Cox, Michael B. Kays, Chad A. Knoderer

Kristen R. Nichols

Background: Extended-infusion cefepime (EIC) has been associated with decreased mortality in adults, but to our knowledge, there are no studies in children. Objective: The objective of this study was to determine the feasibility of implementing EIC as the standard dosing strategy in a pediatric population. Methods: This was a descriptive study of children aged 1 month to 17 years, including patients in the intensive care unit, who received cefepime after admission to a freestanding, tertiary care children’s hospital. Patients were excluded if they were admitted to the neonatal intensive care unit or received cefepime in the outpatient, operating, or emergency …

Acid-Suppressing Agents And Risk For Clostridium Difficile Infection In Pediatric Patients, Katelyn E. Brown, Chad A. Knoderer, Kristen R. Nichols, Ashley S. Crumby

Kristen R. Nichols

Background. Acid-suppressing agents have been associated with increased Clostridium difficile infection (CDI) in adults. The objective of this study was to evaluate the association of acid-suppressing therapy with the development of CDI in the pediatric population. Methods. This was a retrospective case-control study. Children aged 1 through 17 years with a positive C difficile polymerase chain reaction (PCR) result obtained between June 1, 2008, and June 1, 2012, were randomly matched to a control population selected from patients with negative PCR. Results. A total of 458 children were included. No difference was observed in acid-suppressive therapy prior to PCR in …

Linezolid-Associated Thrombocytopenia In Children With Renal Impairment, Sara Jones, Kristen Nichols, Heather Deyoung, Elaine Cox, Chad Knoderer

Kristen R. Nichols

Impaired renal function has been associated with an increased risk of thrombocytopenia in adults receiving linezolid. Findings from this retrospective cohort demonstrate an association between thrombocytopenia and lower creatinine clearance in children receiving linezolid.

Y-Site Compatibility Of Vancomycin And Piperacillin/ Tazobactam At Commonly Utilized Pediatric Concentrations, Kristen Nichols, Michael Demarco, Michael Vertin, Chad Knoderer

Kristen R. Nichols

Background: Vancomycin and piperacillin/tazobactam are common empiric antibiotics in hospitalized pediatric patients. Studies evaluating intravenous (IV) compatibility at various concentrations show inconsistent results. Objective: The objective of this study was to determine the Y-site compatibility of vancomycin 10 mg/mL and piperacillin/tazobactam 112.5 mg/mL. Methods: Vancomycin (10 g vial) was reconstituted using sterile water for injection (SWFI) and diluted with 5% dextrose in water (D5W) to a final concentration of 10 mg/mL in an evacuated IV bag. Piperacillin/tazobactam (40.5 g vial) was reconstituted and diluted with SWFI to a final concentration of 112.5 mg/mL (100 mg/mL piperacillin) in an evacuated IV …

Are Elevated Vancomycin Serum Trough Concentrations Achieved Within The First 7 Days Of Therapy Associated With Acute Kidney Injury In Children?, Chad A. Knoderer, Kristen R. Nichols, Kelsey C. Lyon, Megan M. Veverka, Amy C. Wilson

Kristen R. Nichols

Background In 2008, the empiric vancomycin dosing recommendation in children at our institution was changed from 40 to 60 mg/kg per day. Subsequently, an increased incidence of acute kidney injury (AKI) in patients receiving vancomycin was suspected. The objective of this study was to evaluate AKI in children receiving vancomycin and to determine risk factors for AKI development. Methods Medical records of patients aged 30 days through 17 years who received vancomycin for at least 72 hours between January and December 2007 (40 mg/kg per day) and January and December 2010 (60 mg/kg per day) were reviewed. Patients with cystic …

Conversion Of A Single-Facility Pediatric Antimicrobial Stewardship Program To Multi-Facility Application With Computerized Provider Order Entry And Clinical Decision Support, E. Webber, H. Warhurst, S. Smith, E. Cox, A. Crumby, Kristen Nichols

Kristen R. Nichols

Objective: Antimicrobial stewardship programs (ASPs) help meet quality and safety goals with regard to antimicrobial use. Prior to CPOE implementation, the ASP at our pediatric tertiary hospital developed a paper-based order set containing recommendations for optimization of dosing. In adapting our ASP for CPOE, we aimed to preserve consistency in our ASP recommendations and expand ASP expertise to other hospitals in our health system.

Methods: Nine hospitals in our health system adopted pediatric CPOE and share a common domain (Cerner Millenium™). ASP clinicians developed sixty individual electronic order sets (vendor reference PowerPlans™) to be used independently or as …

Outcomes Of Extended-Infusion Piperacillin/Tazobactam In Pediatric Patients., Kristen R. Nichols, Katie Andricopulos, Ashley S. Crumby, Elaine G. Cox, Chad A. Knoderer

Kristen R. Nichols

Poster presented at: ID Week 2013, October 2013, San Francisco, California.

System-Wide Implementation Of The Use Of An Extended-Infusion Piperacillin/Tazobactam Dosing Strategy: Feasibility Of Utilization From A Children's Hospital Perspective, Kristen R. Nichols, Chad A. Knoderer, Elaine G. Cox

Kristen R. Nichols

Background Use of extended infusions of piperacillin/tazobactam (PT) in adult patients has been described, but data in children are limited. Objective The goal of this study was to determine the feasibility of using an extended-infusion PT dosing strategy as the standard of care in a children's hospital. Methods This was a prospective observational study of patients aged >30 days who received PT after admission to a freestanding, tertiary care children's hospital. After institution of an extended-infusion PT dosing protocol as the standard dosing option, patients receiving PT were prospectively assessed for presence of and reasons for changes in dosing regimen. …

Vancomycin And Gentamicin Pharmacokinetic Alterations In An Adolescent Amputee, Kristen R. Nichols, Kari M. Edison, Michelle D. Rosenbaum, Chad A. Knoderer

Kristen R. Nichols

A 14-year-old male with bilateral above-the-knee amputations presented to our hospital for treatment of a skin and soft-tissue infection. We report the experience of vancomycin and gentamicin therapy in this patient. Because these medications require weight-based dosages and pharmacokinetic monitoring of serum levels, it was necessary to obtain peak and trough levels of the two drugs in order to determine the pharmacokinetic differences in this patient compared to those in an adolescent male without amputations. To our knowledge, this is the first report describing pharmacokinetic differences in an adolescent amputee.

Linezolid-Associated Thrombocytopenia In Children With Renal Impairment, Chad A. Knoderer, Kristen R. Nichols, Heather L. Deyoung, Sara J. Jones, Elaine G. Cox

Kristen R. Nichols

Poster presented at ID Week, October 2013, San Francisco, California.

Cefepime Neurotoxicity In An Adolescent Cystic Fibrosis Patient With Aminoglycoside-Induced Acute Kidney Injury, Kristen R. Nichols, Danielle M. Brown, Chad A. Knoderer, Sharon P. Andreoli

Kristen R. Nichols

Objective: To describe a case of cefepime neurotoxicity in an adolescent with cystic fibrosis and aminoglycoside-associated acute kidney injury (AKI).

Case Summary: A 15-year-old, 46-kg male with cystic fibrosis (CF) and chronic sinusitis was admitted to the hospital for CF exacerbation. The patient was subsequently discharged to complete home antibiotic therapy with intravenous gentamicin and cefepime. Thirteen days after discharge, while still receiving intravenous antibiotics, the patient presented to an outside hospital complaining of vomiting, fatigue, decreased appetite, and decreased urine output. The patient was diagnosed with AKI and was transferred to our institution, where he displayed signs and symptoms …

Cinacalcet Administration By Gastrostomy Tube In A Child Receiving Peritoneal Dialysis, Kristen Nichols, Chad Knoderer, Bethanne Johnston, Amy Wilson

Kristen R. Nichols

A 2-year-old male with chronic kidney disease with secondary hyperparathyroidism developed hypercalcemia while receiving calcitriol, without achieving a serum parathyroid hormone concentration within the goal range. Cinacalcet 15 mg (1.2 mg/kg), crushed and administered via gastrostomy tube, was added to the patient’s therapy. This therapy was effective in achieving targeted laboratory parameters in our patient despite instructions in the prescribing information that cinacalcet should always be taken whole.