Children’s and Women’s Health Centre of BC, Department of Pharmacy Fall 2017

The C&W PT&N Committee serves as the Pediatric subcommitteeto the Provincial Pharmacy and Therapeutics Committee.We continue to have representation from other HealthAuthorities, in addition to our membership from C&W.

Policies & Procedures

The following new or updated policies & procedures have beenapproved and are posted on the C&W Intranet on ePOPS:

The Procedural Sedation: Non Critical Care Areas policy(formerly Procedural Sedation and Analgesia Standardsand Guidelines) have been updated. Monitoring respiratoryrate is no longer required for oral or intranasal sedation.The Sedation Record has also been updated.

The updated Empiric Antimicrobial Guidelines were approved.

The following PT&N Policies have been updated: DoseAdministration by a Nurse or Prescriber, Medication Handlingin the Procedure Suites, Nutrition Orders by Dietitians

Drug Dosage Handbook Updates

Epinephrine – The ratios were removed and replaced by thestrength in mg/mL, as recommended by ISMP Canada. Thereis a reference to the ratio conversion to mg/mL, as some productsmay have both listed until manufacturers switch their labelling.

Gentamicin and Tobramycin (neonatal) monographs wereupdated with the new extended interval dosing and monitoringguidelines. See the article in this edition for further information.

Levothyroxine – The tablet strengths are now expressed inmicrograms (mcg) instead of milligrams, to align withISMP Canada’s recommendation.

Backorders and Product ChangesNaproxen suppositories have been discontinued by the onlymanufacturer in Canada. Diclofenac suppositories are thepreferred alternate rectal NSAID at C&W. There is a therapeuticinterchange in place at Women’s Hospital and order sets arebeing updated accordingly. Pediatric dosing is available in theDrug Dosage Handbook (intranet).

Parenteral Drug ManualThe following monographs have been updated:Ampicillin – may be administered IV directCefotaxime – may be administered IV directCosyntropin – clarification of different brands and routesDextrose – may be administered IV directEphedrine – may be administered IV direct (critical care)Glucarpidase (SAP) – may be administered IV intermittentGlycopyrrolate – new monographInfliximab – removal of requirement for physician presenceIron sucrose – additional monitoring guidance providedKetamine – may be administered IM (critical care) and IVcontinuous infusion (critical care and APS)Magnesium sulfate – additional monitoring guidance providedfor doses administered over 20 minutesPotassium chloride – maximum rates for patients on the DKAprotocol were addedSodium acetate – new monograph

Pre-printed OrdersThe following C&W pre-printed orders have been approved since September 2016 and are posted on the C&W Intranet on ePOPS:Blood Product AdministrationRed Blood CellsPlateletsPlasma and Cryoprecipitate

Emergency DepartmentOutpatient IV AntibioticsStatus EpilepticusTrauma Team Activation

PainAnalgesic, Antiemetic, Antipruritic Agents for patients greater than 3 monthsAPS, PICU and Oncology Hydromorphone Infusion (2): regular and overweightFentanyl Infusion – Acute Pain Service (APS) and PICU OnlyHydromorphone PCA For Acute Pain Service (APS) Only (2): regular and overweightIntermittent Morphine for patients greater than 3 monthsMorphine Infusion (2): Greater than 3 months and overweightMorphine Infusion WeaningMorphine PCA for APS: regular and overweightOncology Peripheral Blood Progenitor Cell Collection (2): weight less than 25 kg and weight greater than or equal to 25 kg)

PICUPICU Admission (Neonate)PICU ECLS Circuit PrimingOncologyPlasma Exchange Standard Apheresis Orders (2):TTP and Coagulation Disorders and OtherRed Blood Cell ExchangeWhite Blood Cell DepletionOtherHigh Flow Humidified Nasal Prong Oxygen TherapyIntranasal Medication for Procedural SedationPre-Op Surgical DaycareSpinal Surgery Postoperative

NICUNICU Inborn AdmissionNICU DischargeNICU Pre-Operative/Pre Interventional RadiologyNICU Post-Operative/Post Interventional Radiology

Women’s HospitalWH Adult IVIGWH Newborn Admission

Updates from C&W Pharmacy,Therapeutics and Nutrition

(PT&N) CommitteeJennifer Kendrick, BScPharm, PharmD

In This Issue:PT&N Committee Update…1Extended Interval Gentamicin in Neonates…2Long Acting Injectable Antipsychotics…3Empiric Antimicrobial Guidelines Update…4Research & Awards…5Pharmacy Informer Editorial Board…5

http://policyandorders.cw.bc.ca/http://bit.ly/2vXMQsRhttp://bit.ly/2x6TEVrhttp://bit.ly/2x6TEVrhttp://bit.ly/2wi5ePLhttp://policyandorders.cw.bc.ca/http://policyandorders.cw.bc.ca/

Extended Interval Aminoglycosides in NeonatesVanessa Paquette, BSc(Pharm), PharmDReviewed by Sonia Jeffries, BSc(Pharm)

Aminoglycosides are commonly used in the treatment of neonatal sepsis.[1] Traditional dosing (TD) of aminoglycosides involvessmaller doses given more frequently while extended interval dosing (EID) involves larger doses given less frequently. EID ofaminoglycosides is based upon certain pharmacokinetic (PK) and pharmacodynamic (PD) drug properties including concentrationdependent bactericidal activity and an extended post-antibiotic effect.[2,3] Achieving early high peak concentrations has beenassociated with improved clinical outcomes and lower trough concentrations may be associated with reduced nephrotoxicity.[4,5]Other proposed advantages of EID include convenience with administration of fewer daily doses and the potential fordecreased therapeutic drug monitoring resulting in reduced blood loss.

EID of aminoglycosides has been used extensively in the adult and older pediatric population. Overall, TD and EID ofaminoglycosides in these populations have comparable efficacy.[6-8] Decreased nephrotoxicity reported with EID mostlycomes from animal model data as meta-analyses of human data show no significant difference. Also, to date, there is noevidence to suggest any differences in ototoxicity between the two dosing schemes.[6-9]

Neonates, until more recently, had largely been excluded from EID protocols due to variability in pharmacokinetics ofaminoglycosides in this population and limited published literature.

The pharmacokinetics of drugs in neonates are variable and influenced by gestational age, postnatal age, and weight.The neonatal population has a higher volume of distribution (Vd) due to an increased extracellular fluid compartment anddecreased renal clearance compared to adults.[10-12] As a result, larger milligram per kilogram doses are often required toovercome the larger Vd and extended dosing intervals are often required to accommodate the reduced glomerular filtrationrate.[13] These pharmacokinetic differences make EID of aminoglycosides a viable and potentially favorable option in thispopulation.[14]

There is an increasing amount of published literature surrounding the use of extended interval gentamicin, particularly in thelate preterm and term neonatal population and EID dosing protocols are now being used in neonatal intensive care units(NICU) worldwide.[13,15-26]

Two meta-analyses have been published reviewing EID of aminoglycosides in neonates.[15,17] Overall, EID of gentamicinresults in a higher percentage of neonates within target peak and trough concentrations compared to TD. In neonates,target peak concentrations are most commonly defined as 5 to 12 mg/L and target trough concentrations are definedas < 2 mg/L for both TD and EID regimens. Both studies concluded that there was no difference in nephrotoxicity orototoxicity between the two regimens. There have also been no reported differences in treatment failures; however,there were a low number of neonates with culture proven sepsis in the included studies.[15,17]

Based on the above summarized literature and proposed advantages of EID of aminoglycosides in neonates, the NICU atBC Women’s Hospital developed and implemented EID protocols in May 2017 in place of the previous TD protocols. The variationsin EID protocols for neonates published in tertiary references (including NeoFax and the Redbook) reflect the variability ofEID protocols used in the literature. Development of the new dosing protocols at our center was undertaken as a joint effortbetween the NICU, antimicrobial stewardship, infectious diseases, and pharmacy. They can be found online at Pedmed inthe neonatal dosing section under gentamicin or tobramycin, or via the Neonatal Drug Dosing Guidelines. (BCCH intranet)

At this time, EID of aminoglycosides can be used in neonates at BC Children’s Hospital and at BC Women’s Hospital inthe Intermediate Nursery and NICU only. For those neonates admitted to any of the postpartum units at BC Women’sHospital the TD aminoglycoside protocol will continue to be used. Aminoglycosides on the postpartum units are currentlygiven IV push. The larger doses used in the EID protocol cannot currently be given safely by this method and need to begiven via IV intermittent infusion over 30 minutes. Please refer to the BC Women’s Hospital policy and procedure onantibiotic administration in the newborn which can be found on ePOPS.

References1. Shane A, Sanchez P, Stoll B. Neonatal sepsis. Lancet 2017; pii: S0140-6736(17)31002-4. [Epub ahead of print]. Accessed 7 Aug 2017. Full Text2. Spivey J. The postantibiotic effect. Clin Pharm 1992;11:865-75. Abstract3. Levison M, Levison J. Pharmacokinetic and pharmacodynamics of antibacterial agents. Infect Dis Clin North Am 2009;23:791-815, vii. Full Text4. Moore R, Smith C, Lietman P. The association of aminoglycosides plasma levels with mortality in patients with gram negative bacteremia. J Infect Dis 1984;149: 443-8. Abstract5. Rybak M, Abate B, Kang S, et al. Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity. AntimicrobAgents Chemother 1999;43:1549-55. Full Text6. Hatala R, Dinh T, Cook D. Once-daily aminoglycoside dosing in immunocompetent adults: a meta-analysis. Ann Intern Med 1996;124:717-25. Abstract7. Barza M, Ioannidis J, Cappelleri J, et al Single or multiple daily doses of aminoglycosides: a meta-analysis. BMJ 1996;312:338–45. Full Text8. Contopoulos-Ioannidis D, Giotis N, Baliatsa D, et al. Extended-interval aminoglycoside administration for children: a meta-analysis. Pediatrics 2004;114:e111-8. Full Text9. Giuliano R, Verpooten G, De Broe M. The effect of dosing strategy on kidney cortical accumulation of aminoglycosides in rats. Am J Kidney Dis 1986;8:297-303. Abstract10. Murphy J, Austin M, Frye R. Evaluation of gentamicin pharmacokinetics and dosing protocols in 195 neonates. Am J Health Syst Pharm 1998;55:2280-8. Abstract11. Su SW, Stonestreet BS. Core concepts: neonatal glomerular filtration rate. NeoReviews 2010;11:c714–21. Abstract12. Garcia B, Barcia E, Perez F, et al. Population pharmacokinetics of gentamicin in premature newborns. J Antimicrob Chemother 2006;58:372–9. Abstract13. Sundaram A, Alshaikh B, Dersch-Mills D, et al. Extended-interval dosing of gentamicin in premature neonates born at 7 days of age.Clin Ther 2017;39:1233–41. Abstract14. Lanao JM, Calvo MV, Mesa JA, et al. Pharmacokinetic basis for the use of extended interval dosage regimens of gentamicin in neonates. J Antimicrob Chemother 2004;54:193–8. Abstract15. Rao SC, Srinivasjois R, Hagan R, et al. One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates.Cochrane Database Syst Rev 2011:CD005091. Abstract16. Alshaikh B, Dersch-Mills D, Taylor R, et al. Extended interval dosing of gentamicin in premature neonates < 28-week gestation. Acta Paediatr 2012;101:1134–9. Abstract17. Nestaas E, Bangstad H-J, Sandvik L, et al. Aminoglycoside extended interval dosing in neonates is safe and effective: a meta- analysis. Arch Dis Child Fetal Neonatal Ed 2005;90:F294–300. Full Text18. Thingvoll ES, Guillat R, Caserta M, et al. Observational trial of a 48-hour gentamicin dosing regimen derived from Monte Carlo simulations in infants born at lessthan 28 weeks gestation. J Pediatr 2008;153:530–4. Abstract19. Hossain MM, Chowdhury NA, Shirin M, et al. Simplified dosing of gentamicin for treatment of sepsis in Bangladeshi neonates. J Health Popul Nutr 2009;27:640-5. Full Text20. Avent ML, Kinney JS, Istre GR, et al. Gentamicin and tobramycin in neonates: comparison of a new extended dosing interval regimen with a traditional multipledaily dosing regimen. Am J Perinatol 2002;19:413–20. Abstract21. Rastogi R, Agarwal G, Pyati S, et al. Comparison of two gentamicin dosing schedules in very low birth weight infants. Pediatr Infect Dis J 2002;21:234–40. Abstract22. El-Chaar GM, Supaswud-Franks T, Venugopalan L, et al. Extended interval gentamicin administration in neonates: a simplified approach. J Perinatol 2016;36:660–5. Abstract23. Stickland MD, Kirkpatrick CM, Begg EJ, et al. An extended interval dosing method for gentamicin in neonates. J Antimicrob Chemother 2001;48:887-93. Abstract24. Bajaj M, Palmer K. Gentamicin usage in newborn a simple and practical regimen. Pharm World Sci. 2004;26:242–4. Abstract25. Mercado M, Brodsky N, McGuire M, Hurt H. Extended interval dosing of gentamicin in preterm infants. Am J Perinatol 2004;21:73–7. Abstract26. Hanses A, Forbes P, Arnold A, et al. Once daily gentamicin dosing for the preterm and term newborn: proposal for a simple regimen that achieves target levels.J Perinatol 2003;23:635-9. Full Text

http://bit.ly/189ovmZhttp://bit.ly/189ovmZhttp://bit.ly/2eIKLtnhttp://policyandorders.cw.bc.ca/http://bit.ly/2xBiD3fhttp://bit.ly/2etpA1Ehttp://bit.ly/2xBzHpRhttp://bit.ly/2iLPmQchttp://bit.ly/2iLPmQchttp://bit.ly/2vNqqZVhttp://bit.ly/2wqZPUrhttp://bit.ly/2eITAn1http://bit.ly/2eIR7ZJhttp://bit.ly/2etolPUhttp://bit.ly/2etolPUhttp://bit.ly/2gubn5ghttp://bit.ly/2gubn5ghttp://bit.ly/2wmpEpXhttp://bit.ly/2xEy8rihttp://bit.ly/2wW1PqMhttp://bit.ly/2wYT0MOhttp://bit.ly/2emU29Shttp://bit.ly/2xBqqhDhttp://bit.ly/2xBhn07http://bit.ly/2vNsFfNhttp://bit.ly/2iLQqUhhttp://bit.ly/2gmJs3ohttp://bit.ly/2xBrKkBhttp://bit.ly/2xBrKkBhttp://bit.ly/2xBrKkBhttp://bit.ly/2xBrKkBhttp://bit.ly/2eIUVu3http://bit.ly/2eIUVu3http://bit.ly/2wW3ZH0http://bit.ly/2eti1YHhttp://go.nature.com/2eIK5Ev

Long-Acting Injectable Antipsychotic Use in AdolescentsDean Elbe, BScPharm, PharmD, BCPP

Reviewed by Ric Procyshyn, BScPharm, MSc, PharmD, PhDBCCH Research Institute

Prescription of long-acting injectable antipsychotics (LAIA) in adolescents appears to be increasing, despite a lack of publishedrandomized controlled trials demonstrating efficacy and safety in adolescents.[1-5] Among contemporary antipsychotics withavailable LAIA formulations, only oral aripiprazole currently has Health Canada approval for use in adolescents (age 13 and upin bipolar disorder, and age 15 and up in schizophrenia).[6]

Potential benefits of LAIAsAdherence to a medication regimen can be challenging for adolescents, particularly in those with severe mental illness anda lack of insight. LAIAs virtually guarantee medication adherence if they are administered at appropriate intervals. Child andadolescent psychiatrists may be leaning towards LAIA prescribing as they become aware of literature showing improvedsymptom control and significantly reduced relapse rates in adults receiving LAIAs.[7]

for overlap with oral risperidone for three weeks after the first injection, the need for product refrigeration if dispensed morethan seven days before the scheduled injection date, and administration delays due to reconstitution procedures.[9] Whenpossible, arranging for scheduled ordering, prescription processing and direct delivery of the Consta formulation by the communitypharmacy to the administering provider reduces the risk of treatment delay and drug wastage due to improper storage.For all LAIAs, this also reduces the chance of late or missed doses.

LAIA formulations of paliperidone monthly (Sustenna) and every three months (Trinza) offer several advantages overrisperidone (Consta), including no required oral paliperidone overlap after the first loading dose, and availability as a pre-loadedsyringe that does not require reconstitution or refrigeration.[8,10] Longer intervals between injections and leeway in dosetiming (up to 7 days (Sustenna) or 14 days (Trinza) earlier or later than the scheduled date is allowed for maintenance doses)offer flexibility for scheduling appointments.[8,10] However, a reduced frequency of office visits for injections means feweropportunities for providers to meet with adolescents to observe and discuss their functioning and provide psychosocial support.

Aripiprazole (Maintena) is administered monthly and a 2-week overlap with oral aripiprazole is recommended after the firstinjection. It does not require refrigeration, but must be reconstituted before administration.[11] The recommended monthlydose of Maintena is 400 mg daily for adults, except in patients taking strong CYP2D6 or CYP3A4 inhibitors concurrently formore than two weeks, who require a reduced dose.[11] The 400 mg monthly dosage is potentially problematic in adolescents,since this dose was designed to achieve serum levels comparable to oral aripiprazole 20 mg daily, which is higher than theapproved adolescent oral aripiprazole dose of 10 mg daily.[6,11]

Prescribers and pharmacists should verify patient tolerance of the corresponding oral antipsychotic formulation beforedispensing/administering the first dose of a LAIA. Following administration, LAIA effects may persist for several months andcan’t be “taken back” if severe adverse effects develop. At present there are no LAIA dosing guidelines for children & adolescents.Cautious dosing is particularly warranted in adolescents with low deltoid or gluteal muscle mass, and in those who vigorouslyexercise injection-site muscle groups, since exercise can lead to faster drug absorption, increased adverse effects, and shorterduration of action or symptom relapse before the next scheduled injection.[12]

Drug absorption rate from the injection site is the main determinant of LAIA duration of action, not elimination half-life.[13,14]When initiating treatment, many prescribers follow the manufacturer’s adult dosage guidelines and may ‘overshoot’ therequired dosage, or underestimate the time required to reach steady-state levels. This can result in higher than anticipatedserum levels and delayed adverse effects, including severe extrapyramidal symptoms (EPS), akathisia and dystonia.[14-17]If an oral anticholinergic such as benztropine is not prescribed concurrently with the LAIA, prescribers and pharmacists shouldeducate patients that oral (nonprescription) diphenhydramine is available over the counter and 25 mg taken as needed cantreat mild to moderate EPS symptoms.[18] For more severe EPS, such as dystonia or oculogyric crisis, oral diphenhydramineis likely to be inadequate, and patients should be educated regarding when to contact emergency health services.

As with use of oral antipsychotics, appropriate Canadian monitoring guidelines for antipsychotic treatment, includingperiodic blood testing for monitoring metabolic complications should be followed.[19] (see http://camesaguideline.org/)At a cost of up to $5000/year, most families cannot afford to pay for LAIA treatment. BC Pharmacare specialauthority coverage for LAIAs is available when special authority criteria (usually, when the treatment is for apsychotic disorder, and there is evidence of repeated hospitalizations due to non-adherence to oral medication) aremet. A special authority approval application should be completed before LAIA treatment starts. Prescribers can alsoassist families to apply for coverage via the BC Pharmacare Plan G no-charge psychiatric medication program if thenet annual family income is below $30,000/year, plus an additional $3,000 per dependent. Continued on page 5…

Potential barriers to LAIA usePotential barriers to LAIA use include patient fear of injection-related pain, highacquisition cost and restricted drug benefit plan coverage. There are also logisticalchallenges since many adolescents do not have a consistent primary care providerto administer the injections. Unfortunately, despite extensive uptake of injectiontraining certification programs, pharmacists in British Columbia are currently notpermitted to administer LAIAs.

Specific LAIA formulationsLAIAs may be administered via deltoid or gluteal injections (exception: loadingdoses of paliperidone (Sustenna)) must be given into the deltoid.[8] CurrentBCCH policy limits deltoid site injection volume in children to 1 mL, whichmay influence LAIA usage.

Risperidone (Consta) was the first LAIA available in Canada. Challenges with usingthis product in adolescents include an every-two-week injection frequency, the need

image: istock.com

Empiric Antimicrobial Guidelines – 2017 UpdateKaren Ng (BScPharm, PharmD, BCPS)

Reviewed by Dr. Ashley Roberts, Infectious Diseases and Antimicrobial Stewardship

After an annual review of available evidence and guidelines, theAntimicrobial Stewardship Program has updated the BC Children’sHospital Empiric Antimicrobial Guidelines. Please refer to thefull version posted onto ePOPS for details. Therapeutic updatesin this version include:

○ Aspiration pneumonitis: Aspiration can lead to acutelung injury with rapid respiratory distress within hoursof the event, and fast clinical recovery within 24 to 48hours.[12] Distinguishing non-infectious aspirationpneumonitis from aspiration pneumonia is importantas pneumonitis does not require antibiotic treatment.

○ Mild-moderate community-acquired aspiration pneumonia:Unlike in aspiration pneumonitis, the aspiration eventis rarely witnessed, and the course is more indolent.[12]Distinguishing aspiration pneumonia from CAP is oftenchallenging, therefore empiric regimens chosen for theBCCH guidelines provide coverage for pneumonia fromboth etiologies. Amoxicillin for mild pneumonia providescoverage for the most likely pathogens including oralanaerobes. Broadening to amoxicillin-clavulanate foradditional anaerobic coverage may improve cure rates ifanaerobic pathogens are likely. If parenteral antibioticsare required, ampicillin may be used with optionalmetronidazole. Clindamycin monotherapy is analternative[13] where the diagnosis is clearly aspirationpneumonia as it provides activity against oralstreptococci, S. aureus, and anaerobic bacteria, butlacks coverage for important CAP pathogens ofHaemophilus influenzae and Moraxella catarrhalis.

○ Severe/Hospital-acquired aspiration pneumonia:Aspiration pneumonia occurring during hospitalizationmay include mixed bacterial pathogens similar to thoseimplicated in nosocomial infections, and thereforerequires broader antimicrobial coverage with theempiric regimen of cefotaxime + metronidazole.Although beta-lactams provide some anaerobiccoverage, addition of clindamycin or metronidazolemay be necessary for beta-lactamase producinganaerobes as failures have been reported withbeta-lactam monotherapy.[14]

● Mastoiditis: Empiric therapy has been changed fromcefotaxime* + vancomycin to cefotaxime* ± vancomycin± metronidazole. The most common pathogens implicatedare Streptococcus pneumoniae, Streptococcus pyogenes,and Staphylococcus aureus.[1] Although no publishedguidelines for the treatment of mastoiditis exist, theconsensus from a meeting involving ENT, ID, CTU and AMSis that MRSA is an uncommon etiologic pathogen, thusvancomycin should be reserved for patients with colonizationor a history of MRSA infection.[2] Empiric anaerobiccoverage should be considered in severe cases withevidence/suspicion of abscess. An antipseudomonalagent may be added if P. aeruginosa infection is suspectedbased on a patient history of recurrent mastoiditis or aftertympanostomy tube insertion.[3,4]

● Orbital Cellulitis: Distinguishing signs may includeblurred vision, ophthalmoplegia, proptosis, and chemosis.[5,6]Published treatment guidelines are not available, butENT, ID, CTU and AMS reviewed available literature andchanged recommended empiric therapy from cefotaxime +vancomycin to cefotaxime ± vancomycin ± metronidazole.The most commonly implicated pathogens are similar tothose in rhinosinusitis, including S. pneumoniae, S. aureus,Streptococcus anginosis, Staphylococcus epidermidis,S. pyogenes, and Haemophilus influenzae.[7-9] The infectionis often polymicrobial, with anaerobic bacteria generallyassociated with chronic or inflamed sinuses. Empiric MRSAcoverage can be added in cases with evidence of abscessor bone involvement, orbital trauma, recent ophthalmicsurgery or severe infection. Empiric anaerobic coverageshould be considered in severe cases with evidence/suspicion of abscess. Antibiotics which provide adequateCNS penetration should be used for intra-orbital and/orintracranial complications.

● Community-acquired pneumonia (CAP) (3 monthof age): S. pyogenes was added to the list of most likelyorganisms. Empiric treatment for patients allergic to penicillinwas changed to allow optional vancomycin. Cefotaximeprovides coverage for the most likely organisms of MSSA,S. pneumoniae, H. influenzae, and S. pyogenes. Vancomycinshould be reserved for patients with suspected MRSAinfection, as the incidence of resistant S. pneumoniaerequiring vancomycin for pneumonia has dropped to verylow rates approaching 0%.[11]

● Aspiration Pneumonia: Aspiration can cause a spectrumof pulmonary syndromes depending on a number of factorsincluding the nature, amount and frequency of aspirationand the patient’s response.[12] Rather than one empiricregimen, treatment has been separated into:

● Pelvic inflammatory disease: As per the most recentBCCDC guidelines[15], azithromycin has been added asan alternative to doxycycline. Treatment regimens coverfor both gonorrhea and Chlamydia infections, butdoxycycline may provide increased effectiveness for theco-treatment of Chlamydia over azithromycin.[16]

● Severe cellulitis: when MRSA risk factors are present,vancomycin has replaced clindamycin in this update totarget MRSA. With increasing MRSA clindamycin resistanceof ~28%,[17] vancomycin is more reliable. For patientswithout MRSA risk factors, cefazolin remains the first-lineempiric option.

● Documented Group A Streptococcal (GAS)necrotizing fasciitis: for penicillin-allergic patients,rather than using cefotaxime as the alternative for penicillin,this has been changed to cefazolin. GAS is generallysusceptible to cefazolin, with an MIC90 of 0.12.[18]

* As noted in previous updates, ceftriaxone may be substituted for cefotaxime forchildren over 30 days-old and not on calcium-containing parenteral products (e.g. TPN).

New lanyard cards with the 2017 updates are available free of charge. If youwould like a card for you and/or for your division, please contact Karen Ng(Karen.Ng2@cw.bc.ca) with your location and number of cards desired.

http://bit.ly/2iOpfrVmailto:Karen.Ng2@cw.bc.ca

LAIA Antipsychotics …continued from page 3References1. Pope S, Zaraa SG. Efficacy of long-acting injectable antipsychotics in adolescents.J Child Adolesc Psychopharmacol 2016;26:391-4. Abstract2. Fàbrega M, Sugranyes G, Baeza I. Two cases of long-acting paliperidone inadolescence. Ther Adv Psychopharmacol 2015;5:304-6. Full Text3. Fu-I L, Boarati MA, Stravogiannis A, et al. Use of risperidone long-acting injectionto support treatment adherence and mood stabilization in pediatric bipolar patients:a case series. J Clin Psychiatry 2009;70:604-6. Abstract4. Tutkunkardas MD, Abali O. Long-acting risperidone in an adolescent with conductdisorder: a case report. Psychopharmacol Bull 2011;44:69-72. Full Text5. Umehara H, Iga J, Ohmori T. Successful treatment of anorexia nervosa in a10-year old boy with risperidone long-acting injection. Clin PsychopharmacolNeurosci 2014;12:65-6. Full Text6. Bristol-Myers Squibb Canada. Abilify (aripiprazole) product monograph.Montreal, QC; June 22, 2015. Link7. Kishimoto T, Nitta M, Borenstein M, et al. Long-acting injectable versus oralantipsychotics in schizophrenia: a systematic review and meta-analysis ofmirror-image studies. J Clin Psychiatry 2013;74:957-65. Abstract8. Janssen Inc. Invega Sustenna (paliperidone palmitate prolonged-releaseinjectable suspension) product monograph. Toronto, ON; November 25, 2015. Link9. Janssen Inc. Risperdal Consta (risperidone powder for injectable prolonged-release suspension) product monograph. Toronto, ON; May 4, 2015. Link10. Janssen Inc. Invega Trinza (paliperidone palmitate prolonged-release injectablesuspension) product monograph. Toronto, ON; June 22, 2016. Link11. Bristol-Myers Squibb Canada. Abilify Maintena (aripiprazole for prolongedrelease injectable suspension) product monograph. Montreal, QC; October 4, 2016. Link12. Seeman MV. Exercise and antipsychotic drugs. J Patient Care 2016;2:114. Full Text13. Spanarello S, La Ferla T. The pharmacokinetics of long-acting antipsychoticmedications. Curr Clin Pharmacol 2014;9: 310-7. Abstract14. Lee LHN, Choi C, Collier AC, et al. The pharmacokinetics of second-generationlong-acting injectable antipsychotics: limitation of monograph values. CNS Drugs2015;29:975-83. Abstract15. Gopal S, Liu Y, Alphs L, et al. Incidence and time course of extrapyramidalsymptoms with oral and long-acting injectable paliperidone: a post-hoc pooledanalysis of seven randomized controlled studies. Neuropsych Dis Treat 2013;9:1381-92. Full Text16. Greenaway M, Elbe D. Focus on aripiprazole: a review of its use in child andadolescent psychiatry. J Can Acad Child Adolesc Psychiatry 2009;18:250-60. Full Text17. Boarati Ma, Wang Y-P, Ferreira-Maia AP, et al. Six-month open-label follow-upof risperidone long-acting injections use in pediatric bipolar disorder. Prim CareCompanion CNS Disord 2013;15, pii:PCC.12m01368. Full Text18. Lexicomp Online®, Lexi-Drugs® [Diphenhydramine], Hudson, Ohio: Lexi-Comp,Inc.; January 29, 2015. (accessed February 17, 2017).19. Ho J, Panagiotopoulos C, McCrindle B, et al. Management recommendationsfor metabolic complications associated with second generation antipsychotic use inchildren and youth. J Can Acad Child Adolesc Psychiatry 2011;20:234-41. Full Text

Empiric Antibiotic Guidelines Update …continued from page 4References1. Bunik M. Mastoiditis. Pediatr Rev 2014;35:94-95. Abstract2. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acutebacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72-112. Abstract3. Laulajainen-Hongisto A, Saat R, Lempinen L, et al. Bacteriology in relation to clinicalfindings and treatment of acute mastoiditis in children. Int J Pediatr Otorhinolaryngol2014;78:2072-8. Full Text4. Lin HW, Shargorodsky J, Gopen Q. Clinical strategies for the management of acutemastoiditis in the pediatric population. Clin Pediatr (Phila) 2010;49:110-5. Abstract5. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev 2010;31:242-9. Abstract6. Kinis V et al. Management of orbital complications of sinusitis in pediatric patients.J Craniofac Surg 2013;24:1706-10. Abstract7. Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management oforbital cellulitis. Pediatrics 2011;127:e566-72. Abstract8. Bedwell J, Bauman NM. Management of pediatric orbital cellulitis and abscess.Curr Opin Otolaryng Head Neck Surg 2011;19:467-73. Abstract9. Brook I. Microbiology and antimicrobial treatment of orbital and intracranialcomplications of sinusitis in children and their management. Int J PediatrOtorhinolaryngol 2009;73:1183-6. Full Text10. Temple ME, Nahata MC. Treatment of listeriosis. Ann Pharmacother 2000;34:656-61. Abstract11. Canadian Antimicrobial Resistance Alliance. CANWARD Susceptibility. Winnipeg:CANWARD; 2015 [cited 2017 Aug 15]. Link12. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001;344:665-71. Abstract13. DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends.J Crit Care 2015;30:40-8. Full Text14. Bartlett JG. How important are anaerobic bacteria in aspiration pneumonia?Infect Dis Clin N Am 2013;27:149-55. Full Text15. British Columbia Centre for Disease Control. British Columbia treatment guidelines.Sexually transmitted infections in adolescents and adults 2014. B.C. Centre forDisease Control. Link16. Kong FY, Tabrizi SN, Law M et al. Azithromycin versus doxycycline for thetreatment of genital chlamydia infection: a meta-analysis of randomized controlledtrials. Clin Infect Dis 2014;59:193-205. Abstract17. Division of Medical Microbiology. BC Children’s and Women’s Health CentreCumulative Antibiogram. 2015 Vancouver; Dec 2016. Link (intranet)18. Bennett JE, Dolin R, Blaser MJ, editors. Mandell, Douglas, and Bennett’s Principlesand Practice of Infectious Diseases. 8th ed. Philadelphia: content Repository Only!; 2015.

Research & AwardsKaren Ng, BScPharm, PharmD, BCPS

ResearchTan J, Paquette V, Levine M, Ensom MHH. Levetiracetamclinical monitoring in pediatric patients with epilepsy. ClinPharmacokinet 2017 Mar 28. [Epub ahead of print] Abstract

Beach J, Perrott J, Turgeon R, Ensom MHH. Penetration ofvancomycin into the cerebrospinal fluid: A systematic review.Clin Pharmacokinet 2017 20 May. [Epub ahead of print] Abstract

Tang JY, Kiang TKL, Ensom MHH. Pharmacokinetic interactionsbetween valproic acid and lorazepam (PIVOtAL Study): A review ofsite-specific practices. Can J Hosp Pharm 2017;70:171-8. Full Text

Smith AD, Rempel G, Szeitz A, Klassen TL, Ensom MHH.Vancomycin 50 mg/ml suspension in oral syrup: stability inplastic bottles and syringes at 2 temperatures. Can J HospPharm 2017;70:247-9. Full Text

Peterson S, Lau TTY, Ensom MHH. Combination ofceftriaxone and ampicillin for the treatment of Enterococcalendocarditis: A qualitative systematic review. Ann Pharmacother2017;51:496-503. Abstract

Dagenais R, Barry AR, Ensom MHH. ‘The bus analogy’: A newanalogy to help pharmacy students conceptualize the Well-Stirred Model. Currents in Pharmacy Teaching and Learning2017;9:639-43. Full Text

Wilby KJ, Johnson EG, Johnson HE, Ensom MHH. Evidence-based review of pharmacotherapy used for Parkinson’sDisease psychosis. Ann Pharmacother 2017;51:682-95. Abstract

Dagenais R, Wilby KJ, Elewa H, Ensom MHH. The impact ofgenetic polymorphisms on phenytoin pharmacokinetics andclinical outcomes in the Middle East and North Africa region:A systematic review. Drugs in R&D 2017 26 July. Full Text

Saunders S, Tulloch K, Maan EJ, van Schalkwyk J, Money D.An evaluation of introduction of rapid HIV testing in a perinatalprogram. J Obstet Gynaecol Can 2017;39:668-75. Abstract

Elbe D. Pediatric Mental Health: Long-acting InjectableAntipsychotic Use in Adolescents. Pharmacy Practice PlusMay 2017. Full Text (requires CanadianHealthcareNetwork.ca login)

Book chapterKiang TKL, Ensom MHH. Anti-rejection Agents. In: ClinicalPharmacokinetics. J Murphy (ed); Sixth Ed. Bethesda, MD:American Society of Health-System Pharmacists. 2017.

AwardsDr. Mary Ensom received the Class of 2017 Master TeacherAward, UBC Faculty of Pharmaceutical Sciences (June, 2017).

Dr. Jennifer Kendrick was awarded the Lower MainlandPharmacy Services Residency Program Veteran Preceptorof the Year for 2016-17, recognizing her excellence inteaching, precepting, and mentoring residents.

Dr. Katie Haubrich was awarded the Lower MainlandPharmacy Services Residency Program New Preceptorof the Year for 2016-17, recognizing her excellence inteaching, precepting, and mentoring residents.

Pharmacy Informer Editorial Board

Dean Elbe, BScPharm, PharmD, BCPP (Editor)delbe@cw.bc.caKaren Ng, BScPharm, PharmD, BCPS (Editor)Karen.Ng2@cw.bc.caSharon Ho, BScPhm, ACPRJennifer Kendrick, BScPharm, PharmD(PT&N Liaison)Roxane Carr, BScPharm, PharmD, BCPS, FCSHP(Clinical Coordinator)

image: istock.com

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