Fifty-three profoundly granulocytopenic patients with relapsed acute leukemia who were undergoing reinduction chemotherapy were prospectively randomized to receive either trimethoprim-sulfamethoxazole plus nystatin or gentamicin plus nystatin for prevention of infections. The acquisition of new organisms per patient during the total study period was similar in both groups. Thirty-five symptomatic infections (five of which were bacteremias) occurred in patients receiving trimethoprim-sulfamethoxazole plus nystatin, whereas 31 infections (eight bacteremias) occurred in patients receiving gentamicin plus nystatin. Four deaths related to infection occurred in patients taking trimethoprim-sulfamethoxazole, and eight occurred in patients taking gentamicin. We conclude that trimethoprim-sulfamethoxazole plus nystatin was approximately as effective as gentamicin plus nystatin for prophylaxis against infection in relapsed acute leukemia. Furthermore, side effects were fewer and compliance was better with trimethoprim-sulfamethoxazole plus nystatin.
Piperacillin sodium is a beta lactam antibiotic with a broad range of antibacterial activity that includes gram-negative bacilli, gram-positive cocci (except penicillinase-producing S. aureus) and anaerobic pathogens such as Clostridium difficile, and Bacteroides fragilis. Piperacillin inhibits many of the members of the Enterobacteriaceae, including Klebsiella sp and Pseudomonas, at lower concentrations than required for carbenicillin and ticarcillin. Piperacillin sodium is administered by intramuscular and intravenous injection and is widely distributed throughout body fluids and tissues. Like other newer penicillins, piperacillin is excreted by both renal and biliary mechanisms. The primary route of elimination is by glomerular filtration, which results in high urinary concentrations of the unchanged compound. Piperacillin has been approved for patients with serious infection caused by susceptible strains of specific organisms in intra-abdominal, urinary tract, gynecologic, lower respiratory tract, skin and skin structure, bone and joint, and gonococcal infections and septicemia. As with other penicillins, piperacillin has a low frequency of toxicity. The usual dose of piperacillin in adults with serious infections with normal renal function is 3-4 g every 4-6 hr as a 20-30 min infusion, with a maximum dose of 24 g per day. It is stable in most large volume parenteral solutions. Less serious infectins (requiring smaller dosages) may be treated by intramuscular injection; however, no more than 2 g should be given at any one injection site. Overall, piperacillin has a greater degree of activity than other penicillins. Evidence from prospective studies indicates that piperacillin is a highly effective agent for the treatment of patients with infections caused by susceptible organisms.
Ticarcillin was used in combination with either cephalothin or gentamicin as initial empiric antibiotic therapy for 127 patient trials of suspected infection in granulocytopenic cancer patients. Bacteremia was present in 20%, nonbacteremic microbiologically documented infections in 21%, clinically documented infections in 23%, and possible infections in 5%; infection was doubtful in 31%. Although Staphylococcus aureus was the most common single organism isolated (23%), gram-negative bacilli accounted for 54% of all pathogens. Both antibiotic regimens were highly efficacious, with complete resolution in 46% of bacteremias, 88% of nonbacteremic microbiologically documented infections, and 95% of clinically documented infections. Among bacteremias, 8 of 9 caused by S. aureus but only 4 of 15 (27%) caused by gram-negative bacilli were completely resolved with these antibiotic combinations. Reasons for nonresponse in bacteremias were persistent granulocytopenia, mixed infection and, in two patients, antibiotic-resistant organisms. Toxicities other than hypokalemia were minimal. Although the rate of further infections was high overall (18/127), only one occurred among the 39 patients with <4 days of antibiotic therapy. Ticarcillin in combination with either cephalothin or gentamicin was effective as initial empiric therapy of suspected infection in granulocytopenic cancer patients.
Nephrotoxicity is usually the dose-limiting toxicity associated with cisplatin therapy. Frequently the nephrotoxicity is mild and reversible. However, it is both dose-related and cumulative and may become life-threatening and irreversible at higher dosages. Many interventions such as vigorous hydration, osmotic or loop diuretics, and alterations of infusion times have been evaluated in the hope of ameliorating this serious toxicity, and are summarized. More recently, hypertonic NaCl 0.9% has been reported to decrease the incidence of cisplatin nephrotoxicity. In addition, newer platinum analogs are currently undergoing clinical trials to ascertain if they retain the antitumor properties of cisplatin but produce less toxicity.
An analysis of hypersensitivity reactions to teniposide was approached using three methods: investigator survey, adverse drug reaction analysis, and literature search. By the survey method, hypersensitivity incidence was 6.5% with the majority of the reactions (82%) occurring in brain tumor or neuroblastoma patients. By the second method, 43 cases of hypersensitivity that were reported to the National Cancer Institute (NCI) between January 1983 and October 1985 were analyzed in detail. Reaction onset was unpredictable according to the number of drug doses. The majority of the patients (65%) experiencing the reaction had neuroblastoma or brain tumors, and these patients also tended to react earlier in the course of drug administration than those with hematologic malignancies. Clinical presentation was not correlated with the patient's diagnosis. All patients recovered. However, only six of 13 were successfully rechallenged with the drug. The third approach, the literature search, provided information on 82 hypersensitivity reactions among 2,250 patients (3.6% incidence). Forty-five percent of these reactions were linked to neuroblastoma or brain tumor patients. The analysis of hypersensitivity to teniposide by these three methods provides insight into the true incidence of hypersensitivity reactions in the general patient population. The frequency of the reactions is substantially higher in patients with neuroblastoma and brain tumors. This population should be considered for future trials of aggressive prophylactic therapy.
Objectives: To identify and characterize areas for improvement in the clinical performance of nurses in relation to medication administration. Method: Nurses participated in a simulated pediatric stabilization event which was videotaped. Their clinical performance was evaluated at each of the following steps: (1) communicating and confirming the dose of medication; (2) converting the dose; (3) selecting the correct medications; (4) properly preparing the medication formulation; and (5) measuring medication doses. The time required to convert and draw up the medications was also evaluated. Results: A total of 150 medication orders for five medications were given by the physician. Only 55% of the orders were verbally repeated back by the nurses. Of the 120 orders in which the doses were converted from milligrams to milliliters by nurses, 17 (14.2%) were converted incorrectly and the maximum dose deviation reached 400%. Selection of the wrong medication occurred in 11 of the 150 orders. Dextrose (which requires dilution before being administered to children) was not diluted in 17% of the medication orders and in 12% it was diluted improperly. About 40% of the orders for ceftriaxone (which requires reconstitution) were not properly reconstituted. In 49 (32.7%) of the 150 medication orders that were drawn up in a syringe, the amount measured was not consistent with the stated dose. For some medications, a prolonged time was required by nurses to convert the doses and draw up the medications. Conclusions: By observing the clinical performance of nurses in a simulated videotaped pediatric stabilization event, we have identified some important areas in need of improvement in each step of the medication administration process. These findings indicate a need for improved education, training, and use of clinical aids or adjuncts for pediatric emergency nurses. M edication errors are among the most frequently reported errors in the pediatric emergency setting. Kozer et al 1 found that approximately 10% of children treated in the emergency department were subject to medication error. The risk of medication error is even more profound when children require resuscitation and emergency stabilization. This is because stabilization events are stressful and highly variable situations during which healthcare providers must make rapid decisions and react promptly to patients' needs, often with only limited information.1 Over the past few years, several safety initiatives and clinical tools have been developed and implemented to help decrease medication errors during pediatric stabilization events. One of the most widely used tools is the Broselow-Luten Emergency Tape (Vital Signs Inc, NJ, USA). Studies have shown that this tape, which provides pre-calculated medication doses based on children's weight, is effective in reducing medication error during simulated pediatric stabilization scenarios. Nurses play a very important role during pediatric stabilization events and delivery of medications is one of many important tasks required...
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