One hundred and forty-six children, for whom a total of 194 pairs of gentamicin results were available, were included in this study: 72 children (with 94 pairs of results) before discontinuation of the pharmacist- initiated TDM consult service and 74 children (with 100 pairs of results) after discontinuation of the TDM consult service (Table 1).

The actions taken in response to exceptional serum concentrations of gentamicin were appropriate in 93 (99%) of 94 instances with the TDM service in place and in 64 (64%) of 100 instances after the TDM service was terminated (p < 0.001) (relative risk 21.92, 95% confidence interval 3.16-152.23). Of the 93 instances in which the clinician’s action was appropriate while the TDM service was in place, 72 (77%) required no dose adjustment, and 21 (23%) required an adjustment. Of the 64 instances in which the clinician’s action was appropriate after discontinuation of the TDM service, 56 (88%) required no dose adjustment, and 8 (12%) required an adjustment. Of the 36 instances in which the clinician’s action was inappropriate after discontinuation of the TDM service, 20 (56%) involved a dose adjustment that was necessary but not made or made incorrectly, and 16 (44%) involved modification of the drug regimen when no dose adjustment was necessary. Of instances when a dose adjustment was required, the adjustment was made before the next scheduled dose in all 21 cases when the TDM service was in place but in only 1 of 8 cases after the TDM service was discontinued (p < 0.001). sildenafil 50mg

Table 1. Characteristics of Children Receiving Gentamicin Before and After Discontinuation of a Therapeutic Drug Monitoring (TDM) Service




No.

(%)
of
Patients*




Characteristic




With TDM Service




Without TDM Service



(n


=




72)



(n


= 74)


Median age (years)


8


.5


5.8


Age range


110
days-17.5 years


7
days-15.6 years


Male


46


(64)


47 (64)


Female


26


(36)


27 (36)


No. of gentamicin concentration pairs


94


100


Median length of gentamicin treatment and range (days)


5


(1-30)


6 (1-20)


No. of positive culture results


15


16




Underlying condition


Appendicitis


29


(40)


32 (43)


Malignancy


9


(12)


11 (15)


Pelvic abscess


5


(7)


2 (3)


Bowel obstruction


2


(3)


5 (7)


Othert


27


(38)


24 (32)




Indication for gentamicin


Surgical prophylaxis


61


(85)


63 (85)


Febrile neutropenia


5


(7)


6 (8)


Documented infection


2


(3)


4 (5)


Urinary tract infection


2


(3)


0


Other


2


(3)


1 (1)


*Except where indicated otherwise.


tIncludes esophageal obstruction, Crohn’s disease, ulcerative colitis,
gastroesophageal reflux, gastroenteritis, abdominal


abscess, pelvic abscess, perianal abscess, peritonitis, jejunal
perforation, biliary atresia, splenic laceration, cholangitis,


lung resection, pancreatic transection, spina bifida, necrotizing
fasciitis, chronic osteomyelitis, and


Hirshsprung’s disease.

The sample sizes for assessment of the secondary outcome were smaller because no dose adjustment was required in most cases (Table 2). Before discontinuation of the TDM service, repeat determination of serum gentamicin concentration was ordered appropriately in all 21 cases after dose adjustment. After discontinuation of the service, repeat determination of serum gentamicin concentration was ordered appropriately in only 5 of 8 cases after dose adjustment (p = 0.006). canadian antibiotics

Table 2. Results for Secondary Outcome (Appropriateness of Response)


Question and Response


With TDM Service


Without TDM Service




p value


Were gentamicin concentrations ordered appropriately after dose
adjustments?


Yes No


(n


= 21)
21


0


(n


= 8)
5
3


0.006


Was the gentamicin dose adjusted before the scheduled next dose?


Yes No


(n


= 21)
21


0



(n
= 8) 1

7


<0.001


For therapy
> 7
days, was a weekly determination of trough concentration ordered?


Yes No


(n


= 14)
14


0


(n


= 28)
4
24


<0.001


For therapy > 7 days, was a weekly sample drawn for determination of
trough concentration?


Yes No


(n


= 14) 5 9


(n


= 28)
4
24


<0.001


For therapy > 7 days, was a weekly determination of serum creatinine
ordered?


Yes No


(n


= 14)
14


0


(n


= 28)
9
19


<0.001


For therapy > 7 days, was a weekly sample drawn for serum creatinine
determination?


Yes No


(n


= 14)
11


3


(n


= 28)
9
19


0.005



TDM

=

therapeutic drug monitoring.

For 42 patients, 14 in the period before discontinua­tion of the TDM service and 28 after discontinuation, gentamicin therapy continued beyond 7 days. A weekly trough gentamicin concentration was appropriately requested for all 14 patients before discontinuation and for 4 of the 28 patients after (p < 0.001). Interestingly, the requested trough concentration was actually drawn for only 5 of the 14 patients before discontinuation and for 4 of the 28 patients (i.e., all of those for whom it was requested) after discontinuation (p < 0.001). Similar patterns of ordering and drawing of samples emerged for serum creatinine (Table 2). generic cialis 20mg

There were 15 positive blood culture results before and 16 positive results after discontinuation of the TDM service. The appropriateness of adjustment of antibiotics on the basis of culture results could not be compared because there were no requirements for changes in antibiotic therapy.

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