Israel Medical Association Journal

Background: Many medications used for children have not undergone evaluation to assure acceptable standards for optimal dose, safety and efficacy. As a result, the majority of children admitted to hospital wards receive medications outside the terms of their license (off-label) or medications that are not specifically licensed for use in children (unlicensed). The extent of unlicensed and off-label medication use in ambulatory children is unknown.

Objective: To determine the extent of unlicensed and off-label medication use in a general pediatrics ambulatory hospital unit in Israel.

Patients and Methods: We conducted a retrospective analysis of the medical records of 132 outpatient children treated in the General Pediatrics Ambulatory Unit of the Soroka Medical Center, Beer Sheva, in November–December 1998.

Results: The children’s ages ranged from 1 month to 18 years (mean ± SD 50±58 months). Of the 222 prescriptions given to these children, one-third were unlicensed (8%) or unlabeled (26%). Different dose and age were the most common categories of off-label medication use. All 18 cases of unlicensed use were due to modifica-tion of licensed drugs (tablets were crushed to prepare suspensions). Altogether, 42% of children received medicines that were off-label and/or unlicensed.

Conclusions: More off-label than unlicensed medications were used. Further investigations are required to establish the extent of unproved drug use in both hospitalized and ambulatory pediatric patients in Israel. Recommendations recently issued by the Ministry of Health’s National Council for Child Health and Pediatrics constitute a first step in the Israeli contribution to the international effort demanding testing of medications for children.

Background: Urinary tract infection is one of the most common bacterial infections. Since antibiotics are given empirically, it is necessary to assess the distribution and susceptibility of the microorganisms in each case.

Objectives: To evaluate the demographic characteristics of ambulatory patients with UTI, the distribution and susceptibility of uropathogens, and the risk factors associated with trimethoprim-sulfamethoxazole resistant bacteria in women.

Methods: During 12 days in August 1997 all the urine cultures sent to the Tel-Hanan Laboratory (Haifa) were evaluated. Demographic characteristics of the patients, their underlying diseases and the previous use of antibiotics were obtained.

Results: During the 12 day survey 6,495 cultures were sent for evaluation. Of the 1,075 (17%) that were positive 950 were included in the study; 83.7% were from females, of whom 57% were ≥50 years old. Escherichia coli was the most common pathogen, with 74.7% in the female and 55% in the male population; 86.2% of the E. coli were resistant to amoxicillin, 38.8% to cephalexin and 46.8% to TMP-SMX. Cefuroxime (4.2%), ofloxacin (4.8%), ciprofloxacin (4.8%) and nitrofurantoin (0.4%) showed the lowest rates of resistance. By a multivariant analysis, post-menopause and recurrent UTI were found to be independent factors related to TMP-SMX resistance in women.

Conclusion: In northern Israel, ampicillin, cephalexin and TMP-SMX cannot be used empirically in the treatment of community-acquired UTI. Post-menopause and recurrent UTI are independent factors associated with TMP-SMX resistant pathogens in women.

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UTI= urinary tract infection

TMP-SMX= trimethoprim-sulfamethoxazole

Background: In Israel the pediatric emergency room functions as an urgent primary care clinic in addition to dealing with life-threatening situations. Due to health insurance stipulations, most patients come to the PER with a referral from the community clinic. The relationship between the referring physician’s expectations and the subsequent management of the referred patient in the PER is not well defined.

Objectives: To evaluate the relationship between the expectations of the primary care physician and the management of referred patients in the PER, assess the type of information provided by the referring physician, and examine the effect of additional information obtained from the referring physician on patient management in the PER.

Methods: We reviewed the records of patients presenting at the PER with referrals from primary care physicians as well as additional information obtained by telephone interviews with the referring physicians.     

Results: The expectations of the referring physicians were not fully documented in the referral form. The PER responded to the patient as if the PER was the initial contact. There was no significant difference in the response of PER physicians with or without additional information from the referring physicians.

Conclusions: The PER acts as an independent unit with no obligation to satisfy the expectations of the referring physicians. The relationship between the PER and the referring physicians needs to be clarified. Guidelines and structured PER referral forms should be implemented in all primary care clinics to improve patient management and communication between health providers. 

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PER= Pediatric Emergency Room

Background: Cefuroxime is a second-generation cephalosporin antibiotic used widely for the treatment of various infections.

Objectives: To assess the appropriateness of cefuroxime usage as well as the long-term impact of re-feeding the results to prescribing physicians.

Methods: Drug utilization evaluation involved three data-collecting periods, each comprising 6 weeks, during which all patients receiving cefuroxime were evaluated. Results of phase I were distributed to all physicians in a newsletter and departmental lectures; phase II was announced and conducted 6 months later. An identical phase III was unannounced and conducted one year after phase II. The study included all patients receiving cefuroxime during the three phases. The main outcome measure was appropriateness of initiation, and continuation beyond 3 days, of empirical treatment. Appropriateness was determined according to a prepared list of indications based on the literature and the hospital's protocols.

Results: Cefuroxime was initiated appropriately in 104 of 134 patients (78%) in phase I, in 85 of 100 (85%) in phase II, and in 93 of 100 (93%) in phase III (P<0.001). Cefuroxime was continued appropriately after 3 days in 58/134 (43%), 57/100 (57%) and 70/100 (70%) respectively (P<0.001). The total number of appropriate treatment days out of all treatment days increased from 516 of 635 (81%) in phase I, to 450 of 510 (88%) in phase II, to 485 of 509 (95%) in phase III (P<0.001). The principal reason for cefuroxime usage was community-acquired respiratory tract infection.

Conclusion: Drug utilization evaluation may provide valuable data on the usage of a particular drug. This information, once re-fed to physicians, may improve utilization of the particular drug. This positive effect may be prolonged beyond the immediate period of observation.

Background: Bronchiolitis caused by respiratory syncytial virus is one of the major causes of hospitalization in young children, especially during the winter.  Recent evidence has shown that pharmacological treatment, especially nebulized epinephrine, in addition to the traditional supportive treatment, can alleviate symptoms and shorten hospitalization, but this approach is not yet widespread.

Objectives: To determine whether the management of bronchiolitis in Israel is moving toward a stronger emphasis on pharmacological care.

Methods: A questionnaire on the diagnosis and management of bronchiolitis was completed by 27 heads of pediatric departments throughout Israel.  The questionnaire dealt with the frequency of usage of diagnostic and selected therapeutic procedures.

Results: Chest X-ray and arterial blood gases are commonly used as a diagnostic aid in more than 75% of the departments, and antibiotics are prescribed routinely in 24%.  Corticosteroids are still in use: 48% use systemic steroids, and 19% nebulized steroids.  Nebulized epinephrine is used in 22% of the departments, while nebulized beta-agonists are used frequently in two-thirds of the departments.

Conclusions: Despite convincing data that beta-agonists and steroids have no positive effect on the outcome of bronchiolitis on the one hand, and that nebulized epinephrine has advantages in children on the other, we found significant use of the former two agents and sparse use of the latter.  Greater awareness is needed among pediatricians, and measures should be introduced to incorporate the new recommendations, with further study of the effect of the old and new drugs on bronchiolitis.

 

Objective: To describe the clinical and epidemiological features of hepatitis B virus infection in Israeli children, and to evaluate their response and compliance to therapy.

Methods: We retrospectively studied 51 patients (34 males, 17 females), aged 2–18 years, from several medical centers in Israel.

Results: Of the 51 patients, 38 with elevated transaminase, positive hepatitis B e antigen and/or HBV DNA, and histologic evidence of liver inflammation were treated. Interferon was administered by subcutaneous injections three times a week for 3-12 months (dosage range 3–6 MU/m²). Only 16% were native Israelis, while 78% of the children were of USSR origin. A family history of HBV infection was recorded in 25 of the 51 patients (9 mothers, 16 fathers or siblings). Five children had a history of blood transfusion. The histological findings were normal in 3 patients, 24 had chronic persistent hepatitis, 14 had chronic active hepatitis and 2 had chronic lobular hepatitis. Five children also had anti-hepatitis D virus antibodies. Twelve of the 38 treated patients (31.5%) responded to IFN completely, with normalization of the transaminase levels and disappearance of HBeAg and HBV DNA. In no patient was there a loss of hepatitis B surface antigen. The main side effects of IFN were fever in 20 children, weakness in 10, headaches in 9, and anorexia in 6; nausea, abdominal pain, and leukopenia were present in 3 cases each. The response rate was not affected by age, country of origin, alanine/aspartate aminotransferase levels, or histological findings. However, a history of blood transfusion was a predictor of good response, 60% vs 27% (P<0.05).

Conclusions: We found IFN to be a safe and adequate mode of treatment in children with chronic HBV infection, regardless of their liver histology and transaminase levels. Therefore, in view of the transient side effects associated with this drug, we recommend considering its use in all children with chronic hepatitis B. 

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HBV = hepatitis B virus

IFN = interferon

HBeAg = hepatitis B e antigen

Background: Hallway medicine is an integral part of physicians' medical culture, but little is known about it.

Objective: To characterize the practice of hallway medicine among hospital physicians, both as providers and consumers.

Methods: We conducted a survey of 112 randomly chosen hospital physicians at the Soroka Medical Center in Beer Sheva, Israel between November 1997 and May 1998. A self-administered 39-item questionnaire was used that included sociodemographic data, the extent to which hallway medicine is practiced, and satisfaction from and attitudes to it.

Results: Of the 112 selected physicians, 111 responded (99.1%). Of these, 91 (82%) had been asked by their colleagues to provide hallway medicine. Most of them (91%) agreed because of "willingness to help," because "it's unpleasant to refuse," or "it's the acceptable thing to do." Most of the requests (72%) were unscheduled and time consuming (41% up to 10 minutes and 21% more than 20 minutes). Records were kept in only 36% of the cases and follow-up in 62%. Physicians who provided hallway medicine were also consumers of it (P<0.001), based on personal acquaintance, time saved and easy accessibility. In general, the attitude to hallway medicine was negative (54%) or ambiguous (37%). Most requests for hallway medicine were made to Israeli-trained physicians, surgeons or gynecologists, and senior physicians.

Conclusions: Hallway medicine is practiced frequently among hospital physicians. A formal organization of health care service within medical centers might provide physicians with better medical care and reduce potential ethical, medical, legal, psychosocial and economic problems.

Background: Acute respiratory distress syndrome is a well-recognized condition resulting in high permeability pulmonary edema associated with a high morbidity.

Objectives: To examine a 10 year experience of predisposing factors, describe the clinical course, and assess predictors of mortality in children with this syndrome.

Methods: The medical records of all admissions to the pediatric intensive care unit over a 10 year period were evaluated to identify children with ARDS¹. Patients were considered to have ARDS if they met all of the following criteria: acute onset of diffuse bilateral pulmonary infiltrates of non-cardiac origin and severe hypoxemia defined by <200 partial pressure of oxygen during ³6 cm H2O positive end-expiratory pressure for a minimum of 24 hours. The medical records were reviewed for demographic, clinical, and physiologic information including PaO2² /forced expiratory O2, alveolar–arterial O2 difference, and ventilation index.

Results: We identified 39 children with the adult respiratory distress syndrome. Mean age was 7.4 years (range 50 days to 16 years) and the male:female ratio was 24:15. Predisposing insults included sepsis, pneumonias, malignancy, major trauma, shock, aspiration, near drowning, burns, and envenomation. The mortality rate was 61.5%. Predictors of death included the PaO2/FIO2, ventilation index and A-aDO2³ on the second day after diagnosis. Non-survivors had significantly lower PaO2/FIO2 (116±12 vs. 175±8.3, P<0.001), and higher A-aDO2 (368±28.9 vs. 228.0±15.5, P<0.001) and ventilation index (43.3±2.9 vs. 53.1±18.0, P<0.001) than survivors.

Conclusions: Local mortality outcome for ARDS is comparable to those in tertiary referral institutions in the United States and Western Europe. The PaO2/FIO2, A-aDO2 and ventilation index are valuable for predicting outcome in ARDS by the second day of conventional therapy. The development of a local risk profile may allow early application of innovative therapies in this population. 

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¹ARDS = acute respiratory distress syndrome

² PaO2 = partial pressure of oxygen

³A-aDO2 = alveolar–arterial O2 difference

Background: Although the onset of fever in children often prompts parents to seek immediate treatment, the general level of parental knowledge on pediatric fever and administration of antipyretic medications is unknown. Parents without a basic understanding of treatment principles may give their children incorrect doses of medication. Overdosing may cause drug toxicity, while underdosing may lead to unnecessary, repeated clinic and/or emergency room visits.

Objectives: To assess parental decision-making with regard to treating fever in children, and its effectiveness, and to suggest methods for improving the level of treatment.

Methods: In this cross-sectional self-reported survey, questionnaires were completed by 650 parents who sought medical assistance for a child under the age of 10 years. Parents represented various socioeconomic levels, educational backgrounds and religious affiliations.

Results: Ninety-six percent of parents treated fevers that reached 38.5°C, and 77.6% treated fevers of only 38°C. Acetaminophen was the treatment of choice for 96% and dipyrone for 4%. Parental sources of information for managing and administering antipyretic drugs were medical personnel (40.7%), mother's or grandmother's experience (30%), and the enclosed leaflet or instructions on the bottle (29.3%). Forty-three percent of the parents administered the recommended dosage (10–20 mg/kg), whereas 24.3% used less and 32.7% used more; 11% exceeded a daily dosage of 120 mg/kg. 

Conclusions: A total of 57% of parents treated children with incorrect doses of antipyretic drugs. In 11% of the children treated, the daily dose was at a level that could cause severe toxicity. Parental knowledge of the treatment of fever must be improved.

Objectives: To determine the number of incidents of trauma encountered by medics in the Israel Defense Forces during peacetime, and to ascertain the role of these medics in providing primary trauma care to the victims.

Methods: A retrospective questionnaire, reviewing the activities of medics in treating injured trauma victims, was distributed to medics who were in service for at least 2 years after their professional training.

Results: Of the 128 responding medics, 87 (68%) had actively participated in the treatment of trauma victims under various circumstances. The average number of trauma events was 1.2 events over a period of 2 years per combat medic, and 0.7 for medics stationed in rear units. Their activities included insertion of numerous intravenous fluid lines (57% of medics), assistance in intubations (37%), tube thoracostomies (23%), insertions of central catheters (14%) or orogastric tubes (28%), and manual ventilations (41%).

Conclusion: Since it is difficult to increase the level of practical experience in dealing with trauma within the military framework, new techniques should be applied to improve the trauma training.