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The objectives of this study were to: 1) evaluate the prevalence of augmented renal clearance in critically ill pediatric patients using vancomycin clearance; 2) derive the pharmacokinetic model that best describes vancomycin clearance in critically ill pediatric patients; and 3) correlate vancomycin clearance with creatinine clearance estimated by modified Schwartz or Cockcroft-Gault.Retrospective, two-center, cohort study from 2003 to 2016.Clinical drug monitoring services in the PICUs at two tertiary care, teaching hospitals.Children from 1 to 21 years old.None.Identify patients with augmented renal clearance (vancomycin clearance ≥ 130 mL/min/1.73 m used as definition of augmented renal clearance). Derive final population-based pharmacokinetic model and estimate individual patient pharmacokinetic parameters. Compare estimated glomerular filtration rate (modified Schwartz or Cockcroft-Gault depending on ageor ≥ 17 yr) with vancomycin clearance. Augmented renal clearance was identified in 12% of 250 total subjects. The final population-based pharmacokinetic model for vancomycin clearance (L/hr) was 0.118 × weight (e). Median vancomycin clearance in those with versus without augmented renal clearance were 141.3 and 91.7 mL/min/1.73 m, respectively (p0.001). By classification and regression tree analysis, patients who were more than 7.9 years old were significantly more likely to experience augmented renal clearance (17% vs 4.6% in those ≤ 7.9 yr old; p = 0.002). In patients with augmented renal clearance, 79% of 29 had vancomycin trough concentrations less than 10 µg/mL, compared with 52% of 221 in those without augmented renal clearance (p0.001). Vancomycin clearance was weakly correlated to the glomerular filtration rate estimated by the modified Schwartz or Cockcroft-Gault method (Spearman R = 0.083).Augmented renal clearance was identified in one of 10 critically ill pediatric patients using vancomycin clearance, with an increase of approximately 50 mL/min/1.73 m in those with augmented renal clearance. As augmented renal clearance results in subtherapeutic antibiotic concentrations, optimal dosing is essential in those exhibiting augmented renal clearance.

Purpose The study objective was to compare different body size descriptors that best estimate vancomycin V d and clearance (CL). Methods Patients between 3 months and 21 years old who received vancomycin for ≥48 hours from 2003 to 2011 were evaluated in this matched case-control study. Cases had body mass index in the ≥85th percentile; controls were nonobese individuals who were matched by age and baseline serum creatinine (SCr). Using a 1-compartment model with first-order kinetics, Bayesian post hoc individual V d and CL were estimated. Findings Analysis included 87 matched pairs with 389 vancomycin serum concentrations. Median ages were 10.0 (interquartile range [IQR], 4.8–15.2) years for cases (overweight and obese children) and 10.2 (IQR, 4.5–14.8) years for controls (normal-weight children). Median weights were 44.0 (IQR, 23.4–78.1) kg for cases and 31.3 (IQR, 16.8-47.1) kg for controls. Mean (SD) for the baseline SCr values were also similar between the groups: 0.51 (0.22) (IQR, 0.34–0.67) mg/dL and 0.48 (0.20) (IQR, 0.30–0.60) mg/dL for the cases and controls, respectively. Actual weight and allometric weight (ie, weight 0.75 ) were used in the final model to estimate V d and CL, respectively. The mean V d and CL, based on weight, for cases were lower than controls by 0.012 L/kg and 0.014 L/kg/h, respectively. Implications In obese children, actual weight and allometric weight are reasonable, convenient estimations of body fat to use for estimating vancomycin V d and CL, respectively. However, these pharmacokinetic differences between obese children and those with normal weights are small and may not likely to be clinically relevant in dose variation.

Introduction: Orthogeriatric care models have been introduced within many health-care facilities to improve outcomes for hip fracture patients. This study aims to evaluate differences in care between 3 models, an orthopedic model, a geriatric model, and a comanaged model. Materials and Methods: A retrospective analysis was conducted for hip fracture patients treated at Western Health between November 2012 and March 2014. All patients aged 65 years or older were included in the analysis. Results: There were 183 patients in the orthopedic model, 137 in the geriatric model, and 126 in the comanaged model. Demographics and clinical characteristics were similar across the 3 models. Length of stay, mortality, and discharge destination were also consistent across the 3 groups. However, groups involving geriatricians were more likely to receive preoperative medical assessments, have greater recognition of postoperative medical problems, and have implementation of long-term osteoporosis management. Conclusion: The involvement of geriatricians in perioperative care models resulted in more comprehensive medical care without impacting length of stay, mortality, or discharge destination.

Optimal monitoring of vancomycin in children needs evaluation using the exposure target with area under the curve (AUC) of the serum concentrations versus time over 24 hours. Our study objectives were to: (1) compare the accuracy and precision of vancomycin AUC estimations using 2 sampling strategies-1 serum concentration sample (1S, near trough) versus 2 samples (2S, near peak and trough) against the rich sample (RS) method; and (2) determine the performance of these strategies in predicting future AUC against an internal validation sample (VS).This was a retrospective cohort study using population-based pharmacokinetic modeling with Bayesian post hoc individual estimations in nonlinear mixed effects modeling (version 7.2). Pediatric subjects 3 months-21 years of age who received vancomycin ≥48 hours and had more than 3 drug samples within the first ≤96 hours of therapy were enrolled. Outcome measures were the accuracy, precision, and internal predictive performance of AUC estimations using 2 monitoring strategies (ie, 1S versus 2S) against the RS (which was derived from modeling all serum vancomycin concentrations obtained anytime during therapy) and VS (from serum concentrations obtained after 96 hours of therapy).Analysis included 138 subjects with 712 vancomycin serum concentrations. Median age was 6.1 (interquartile range, 2.2-12.2) years, weight 22 (13-38) kg, and baseline serum creatinine 0.37 (0.30-0.50) mg/dL. Both accuracy and precision were improved with the 2S, compared with 1S, for AUC estimations (-2.0% versus -7.6% and 10.3% versus 12.8%, respectively) against the RS. Improved accuracy and precision were also observed for 2S when evaluated against VS in predicting future AUC.Compared with 1S, the 2S sampling strategy for vancomycin monitoring improved accuracy and precision in estimating and predicting future AUC. Evaluating 2 drug concentrations in children may be prudent to ensure adequate drug exposure.

Background: The pharmacy profession continues to evolve and shape itself with increasing complexity. With this escalating complexity, pharmacist clinical competency needs to be addressed within each healthcare practice setting. The objectives of this study were to describe a unique pharmacist competency program and evaluate its satisfaction at two community hospitals. Methods: Long Beach Memorial and Miller Children’s Hospital of Long Beach are tertiary community hospitals with 308 total beds for Millers Children’s Hospital and 462 total beds for Long Beach Memorial. A unique and intensive pharmacist competency program has been established at these hospitals for over 20 years. The content of this program was assessed and a survey was conducted in March 2011 to ascertain pharmacist satisfaction. Results: The unique pharmacist competency program was structured in the form of age-related, hospital-wide and unit specific modules, pharmacy-regulated therapies (PRT), and a Pharmacy Skills Day that provide updates on PRT and other pharmacy-related topics. Forty-two of 61 (69%) pharmacists responded to the survey. Mean age of pharmacists was 38.8 ± 11.5 years, 36% were male, 86% completed residency training, and 12% were board-certified pharmacotherapy specialists. Over 80% of pharmacists agreed that the program was informative and supportive of their daily patient care activities. Although the program was well-received by the pharmacists, there were facets of the program that needed improvement, including resources for continuing education opportunities and additional modules for competency. Conclusion: A unique pharmacist competency program at two community hospitals was described. The program was well-received by the pharmacists, and, more importantly, ensured continuous professional development in pharmacy practice.