Lithium Use in Pregnancy and the Risk of Cardiac Malformations

There has been concern that exposure to lithium early in pregnancy may be associated with a marked increase in the risk of Ebstein’s anomaly (a right ventricular outflow tract obstruction defect) in infants and overall congenital cardiac defects, but data are conflicting and limited | NEJM

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Image source: Erin – Flickr // CC BY-NC-ND 2.0

Methods: We conducted a cohort study involving 1,325,563 pregnancies in women who were enrolled in Medicaid and who delivered a live-born infant between 2000 and 2010. We examined the risk of cardiac malformations among infants exposed to lithium during the first trimester as compared with unexposed infants and, in secondary analyses, with infants exposed to another commonly used mood stabilizer, lamotrigine. Risk ratios and 95% confidence intervals were estimated with control for psychiatric and medical conditions, medications, and other potential confounders.

Conclusions: Maternal use of lithium during the first trimester was associated with an increased risk of cardiac malformations, including Ebstein’s anomaly; the magnitude of this effect was smaller than had been previously postulated

Full reference: Patorno, E. et al. (2017) Lithium Use in Pregnancy and the Risk of Cardiac Malformations. New England Journal of Medicine. 376 pp. 2245-2254

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Using a simple point-prevalence survey to define appropriate antibiotic prescribing in hospitalised children across the UK

Gharbi, M. et al. BMJ Open. 6:e012675

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Background: The National Health Service England, Commissioning for Quality and Innovation for Antimicrobial Resistance (CQUIN AMR) aims to reduce the total antibiotic consumption and the use of certain broad-spectrum antibiotics in secondary care. However, robust baseline antibiotic use data are lacking for hospitalised children. In this study, we aim to describe, compare and explain the prescription patterns of antibiotics within and between paediatric units in the UK and to provide a baseline for antibiotic prescribing for future improvement using CQUIN AMR guidance.

Methods: We conducted a cross-sectional study using a point prevalence survey (PPS) in 61 paediatric units across the UK. The standardised study protocol from the Antibiotic Resistance and Prescribing in European Children (ARPEC) project was used. All inpatients under 18 years of age present in the participating hospital on the day of the study were included except neonates.

Results: A total of 1247 (40.9%) of 3047 children hospitalised on the day of the PPS were on antibiotics. The proportion of children receiving antibiotics showed a wide variation between both district general and tertiary hospitals, with 36.4% ( 95% CI 33.4% to 39.4%) and 43.0% (95% CI 40.9% to 45.1%) of children prescribed antibiotics, respectively. About a quarter of children on antibiotic therapy received either a medical or surgical prophylaxis with parenteral administration being the main prescribed route for antibiotics (>60% of the prescriptions for both types of hospitals). General paediatrics units were surprisingly high prescribers of critical broad-spectrum antibiotics, that is, carbapenems and piperacillin-tazobactam.

Conclusions: We provide a robust baseline for antibiotic prescribing in hospitalised children in relation to current national stewardship efforts in the UK. Repeated PPS with further linkage to resistance data needs to be part of the antibiotic stewardship strategy to tackle the issue of suboptimal antibiotic use in hospitalised children.

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Decision-making tool may help doctors cut unnecessary antibiotic prescribing

ScienceDaily | Published online: 1 September 2016

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Respiratory tract infections (RTI) with cough are the most common reason children are prescribed antibiotics by their doctors, but up to a third of prescriptions may be unnecessary. A new study of over 8000 children has identified seven key predictors which could help general practitioners (GPs) and nurses in primary care identify low risk children who are less likely to need antibiotics, according to new research published in The Lancet Respiratory Medicine.

The authors estimate that if antibiotic prescribing in this low risk group was halved, and even if it increased to 90% in high risk patients, the new tool could reduce antibiotic prescribing to children with RTI and coughs by 10% overall, similar to other interventions used to combat antibiotic resistance.

The proposed tool called STARWAVe uses seven predictors of future hospitalization that can be easily identified by doctors and nurses during a patient visit — short illness (less than 3 days), high temperature (?37.8°C on examination or parent reported severe fever in the previous 24 hours), aged under 2 years, respiratory distress, wheeze, asthma, and moderate/severe vomiting in the previous 24 hours. Children presenting with no more than one of these items are deemed at very low risk of future complications. The authors say that the rule now needs externally validating in a randomised trial, but could be a useful tool to improve the targeting of antibiotics to reduce the growing threat of antibiotic resistance.

View the original research articles here and here.

Read the full commentary here

Compliance with the current recommendations for prescribing antibiotics for paediatric community-acquired pneumonia is improving

Launay, E. at al. BMC Pediatrics | Published online: 12 August 2016

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Image shows electron micrograph of klebsiella pneumoniae bacteria 

Background: Lower respiratory tract infection is a common cause of consultation and antibiotic prescription in paediatric practice. The misuse of antibiotics is a major cause of the emergence of multidrug-resistant bacteria. The aim of this study was to evaluate the frequency, changes over time, and determinants of non-compliance with antibiotic prescription recommendations for children admitted in paediatric emergency department (PED) with community-acquired pneumonia (CAP).

Methods: We conducted a prospective two-period study using data from the French pneumonia network that included all children with CAP, aged one month to 15 years old, admitted to one of the ten participating paediatric emergency departments. In the first period, data from children included in all ten centres were analysed. In the second period, we analysed children in three centers for which we collected additional data. Two experts assessed compliance with the current French recommendations. Independent determinants of non-compliance were evaluated using a logistic regression model. The frequency of non-compliance was compared between the two periods for the same centres in univariate analysis, after adjustment for confounding factors.

Results: A total of 3034 children were included during the first period (from May 2009 to May 2011) and 293 in the second period (from January to July 2012). Median ages were 3.0 years [1.4–5] in the first period and 3.6 years in the second period. The main reasons for non-compliance were the improper use of broad-spectrum antibiotics or combinations of antibiotics. Factors that were independently associated with non-compliance with recommendations were younger age, presence of risk factors for pneumococcal infection, and hospitalization. We also observed significant differences in compliance between the treatment centres during the first period. The frequency of non-compliance significantly decreased from 48 to 18.8 % between 2009 and 2012. The association between period and non-compliance remained statistically significant after adjustment for confounding factors. Amoxicillin was prescribed as the sole therapy significantly more frequently in the second period (71 % vs. 54.2 %, p < 0.001).

Conclusions: We observed a significant increase in the compliance with recommendations, with a reduction in the prescription of broad-spectrum antibiotics, efforts to improve antibiotic prescriptions must continue.

Read the full article here