BACKGROUND

Appropriate use of medication is an important indicator of quality healthcare delivery among children. Previously published studies on drug utilization involved Filipino households in general and were conducted in the 1990s. No recent Philippine studies have been conducted that focus on drug utilization in children.

To describe the current prescribing patterns in one primary care service in a rural site in the Philippines using the World Health Organization (WHO) prescribing indicators.

A cross-sectional study was conducted by review of electronic medical records of patients seen at the primary care facility under the Philippine Primary Care Studies (PPCS) rural site from April 2019 to March 2020. Out of 9,930 total encounters, 623 patient encounters with prescriptions for pediatric patients were included in the study through systematic sampling. The average number of drugs per encounter, percentage of drugs prescribed by their generic names, percentage of encounters with prescribed antibiotics, percentage of encounters with prescribed injections, and percentage of drugs prescribed from the Philippine Drug Formulary were calculated. Values were compared to the cut-offs considered “good practice” for outpatient care in the WHO manual: (1) an average number of less than two drugs per encounter; (2) less than 30% of encounters are prescribed with antibiotics; (3) less than 20% of encounters are prescribed with injections; (4) 100% of drugs are prescribed by generic name; and (5) 100% of drugs are from the formulary.

On the average, three drugs were prescribed per encounter. Most patient encounters (80.9%) involved antibiotics prescription — higher than the WHO standard value of 30%. All drugs were prescribed by generic name and were prescribed from the formulary. Only 0.5% of encounters were prescribed injections, all of which were administered through the intramuscular route. Of the 1,962 prescriptions generated, antibiotics was the most prescribed medication (25.7%). The most common diagnosis was infectious in nature (88.8%).

The primary care service achieved the WHO standard values in terms of prescribing by injections and by generic names. There was a high rate of antibiotic prescriptions at 83%, and a high average number of drugs prescribed per encounter, exceeding the WHO standard value.

Executive Summary Leptospirosis is a disease prevalent mostly in tropical and subtropical countries. Its potential to be a concerning problem emerges with the onset of the rainy season, as flooding and heavy rainfall facilitate disease epidemics. Among those at risk of contracting the disease are field workers, veterinarians, sewer workers, military personnel and those who swim or wade in contaminated waters. In the absence of an existing evidence-based guideline for the pediatric age group, this first edition hopes to standardize approach to diagnosis, antibiotic management, and prevention of leptospirosis. The intended users are primary care physicians, family medicine physicians, pediatricians, and other healthcare workers involved in the management of leptospirosis in children. Ten priority questions were identified by a group of experts composed of an oversight committee, a guideline writing panel, and a technical review committee. The GRADE methodology was used to determine the quality of evidence of each recommendation. The draft recommendations (summarized below) were finalized after these were presented to and voted on by a panel of stakeholders.

Background and Objective: The University of the Philippines Manila (UPM) subcommittee on students in distress was convened during the COVID-19 pandemic to develop “plans, programs and mechanisms” to deal with students experiencing distress and mental health concerns. This study was conducted as one of the activities of the Subcommittee to inform policy to address the following research objective: to describe the experiences, perceptions, and knowledge of both students and faculty members of UP Manila regarding distress. Methods: An online survey tool was created using the results from seven online focus group discussions among 20 faculty of UP Manila. The survey was conducted for one month among faculty and students sampled from the seven colleges of UP Manila and the three extension campuses of the Schools of Health Sciences. The different categories which were consistently perceived as important by both faculty and students as well as those with disparity in the perceptions between faculty and students were described and discussed. Results: A total of 136 faculty (F) and 290 students (S) participated in the study, representing 39% vs 98% (F vs S) of the target sample, respectively. Results showed that among the effects of stressors for students, avoidance of schoolwork (F79 vs S70.3%) and sleep disturbance (F79.4 vs S72.4%), were perceived by both faculty and students as the most frequently perceived response of students to stress.Among the causes of stress, unclear boundaries between school and home (F73.5 vs S63.1%), family duties (F76.5 vs S50.7%), lack of socialization (F89 vs S57.6%), limited recreational activity (F76.5 vs S64.8%), adapting to new ways of socialization (F67.6 vs S53.8%), and internet signal (F99.3 vs S88.3%) were perceived by both faculty and students as the most frequently perceived causes of stress. Among the coping mechanisms, connecting with friends online (F86.8 vs S69.7%), listening to music (F72.8 vs S78.3%), browsing social media (F82.4 vs S81%), viewing movies (F84.6 vs S74.5%), and sleeping or resting (F67.6 vs S84.1%) were perceived by both faculty and students as the most employed by students to cope with stress.Results also show that there were marked disparities in the perceptions of faculty and students. Among the effects of stressors, the largest disparities were in non-performance in academics (F86 vs S51.7%) and academic failure (F76.5 vs S53.8%). Of the causative factors, the largest disparities were in the areas of death (F94.1 vs S14.5%) or sickness in the family (F66.9 vs S0%), family issues (F82.4 vs S24.5%), financial concerns (F89 vs S36.9%), absence of physical connectedness and interaction, (F94.9 vs S23.8%) lack of socialization (F89 vs S57.6%), owning a gadget (F73.5 vs S22.1%), and lack of funds for the internet (F79.4 vs S22.4%).Among the support systems available in the university (psychosocial, academic and wellness activities of the colleges), 70% of the faculty perceived that the students were aware of the support process offered by the university. In contrast, 28% of students were aware of the support services offered to them. Conclusion This study shows that UP Manila faculty and students perceived stress due to the effects of COVID-19 on teaching, learning, and everyday living. Distress among student respondents was commonly perceived to be caused by family concerns, environmental restrictions, connectivity issues, and experiencing a sense of lack. While support services and mental health programs have been in place within the university, only 28% of students perceive that students in distress were aware of the process in receiving support.
Adaptation, Psychological ; Mental Health ; COVID-19 ; Education

Background: Pulmonary TB in children remains to be a burden in the Philippines. Diagnosis remains to be a challenge for pediatricians due to its paucibacillary nature, difficulty in obtaining specimens, cost of test as well as the varied sensitivity of the different tests available. Gastric aspirate (GA), commonly used for bacteriological diagnosis of pulmonary tuberculosis (PTB) in children, involves an invasive procedure that may cause discomfort and sometimes require admission. Nasopharyngeal aspirate (NPA), on the other hand, can be easily and non-invasively obtained but is currently not a recommended specimen for testing for PTB. Objectives: This study aims to determine the accuracy of NPA GeneXpert in diagnosing PTB among pediatric patients 0-18 years old with presumptive TB using GA GeneXpert as the initial screening test and GA TB culture as gold standard. Methodology: This prospective, cross-sectional diagnostic study involved collection of single NPA and GA specimens for GeneXpert and TB culture in 100 patients with presumptive PTB seen at a tertiary government hospital in the Philippines. Results: Of the one hundred pediatric patients (mean age 6 ± 5.63 years) enrolled, 50 were clinically diagnosed PTB, 16 bacteriologically-confirmed and 34 were not PTB disease. Sensitivity, specificity and predictive values with 95% confidence intervals of the NPA GeneXpert were determined compared to GA GeneXpert and GA culture. Sensitivity, specificity, positive and negative predictive values of the NPA GeneXpert compared to GA GeneXpert were 70%, 96.67%, 70% and 96.67%, respectively. While NPA GeneXpert compared to GA TB culture were 40%,91.58%, 20% and 96.67%, respectively. Conclusion GeneXpert testing on a single NPA specimen is a highly specific and rapid test that can be used to diagnose PTB in pediatric patients, particularly where gastric aspiration or mycobacterial culture is not feasible.
Tuberculosis, Pulmonary

Background: The features and outcome of hepatobiliary tuberculosis (HBTB) have not been extensively reported in children. Objective: To describe the clinical, biochemical, radiologic, microbiologic and histologic features and outcome of children diagnosed with HBTB. Methods: Data of HBTB patients aged 0-18 years were collected by review of medical records and as they were admitted. Cases were classified as bacteriologically-confirmed (positive AFB smear, TB culture or PCR of bile/liver tissue) or clinically-diagnosed (clinical, histologic and/or radiologic evidence). Results: A total of 36 patients were included (mean age: 13yrs; 64% males): three bacteriologically-confirmed and 33 clinically-diagnosed. Most common signs/symptoms were weight loss (69%), fever (67%), hepatomegaly (61%) and jaundice (53%). Of the total, 68% had hypoalbuminemia, 50% increased transaminases and 47% prolonged prothrombin time. Fifteen (42%) patients were AFB positive on various microbiologic specimens. Most common imaging finding was hepatic calcification (64%). Of 11 patients with liver biopsy, seven (64%) had chronic/ granulomatous inflammation. All 36 were managed medically. Eight were lost to follow up, six died, and 22 (61%) are alive, nine with complete resolution of liver disease. Conclusion Hepatobiliary tuberculosis presents with non-specific clinical and biochemical findings. Several investigations are necessary to confirm the diagnosis. Overall response to anti-TB treatment is satisfactory with possible resolution of liver disease.
Polymerase Chain Reaction ; Granuloma

Background: Antimicrobials are drugs that are often misused and inappropriate antimicrobial prescribing often results in poor clinical outcome and drug resistance. Monitoring and regulation of antimicrobial use is currently being done by the Department of Health through the Antimicrobial Stewardship (AMS) Program. There is a need to determine the factors that affect successful implementation of an AMS program in private hospitals in the Philippines. This study was conducted to identify the enablers and potential barriers in implementing an AMS program in nine (9) private hospitals. Methodology: A concurrent mixed methods design was used to assess various stakeholders’ (physicians, administrators, other AMS members) perceptions of existing or proposed AMS programs, and to identify barriers and enablers in their implementation. Quantitative data were collected using self-administered survey questionnaire to assess clinician’s acceptance of AMS programs. Qualitative data were collected through semi-structured one-on-one interviews of clinicians and other AMS personnel and focus group discussions (FGD) of selected clinician groups. Data were gathered from October 2018 to October 2019. Results: 409 clinicians were surveyed, 52 were interviewed and 46 sat for 13 sessions of FGDs. Overall, the survey established that physicians were well aware of antimicrobial resistance problem. Majority of the clinicians indicated general agreement with the currently practiced antimicrobial protocols in their hospitals and with the AMS program. However, there were disagreements in perceptions with how antimicrobial restrictions impair prescribing practices and overuse of the same. These responses were strong points of discussion during the Key Informant Interviews (KII) and FGDs. All respondents were amenable with the institutionalization of an AMS program in their hospitals. The hospital leadership’s commitment was determined to be the key enabler of a successful AMS program’s implementation. Barriers identified for hospitals with existing AMS programs were: lack of dedicated staff, resistance and/or non-cooperation of physicians, lack of support from non-medical departments, and inadequate cooperation between hospital personnel. Barriers identified, regardless of the status of the AMS programs were: deficiency in knowledge with developing and implementing an AMS program, inadequate information dissemination, unavailability of an IT-based monitoring for antibiotic use, and the influence of pharmaceutical companies on stakeholders with regards to antimicrobial use. Conclusion Similar enablers and barriers to a successful implementation of an AMS program were seen in the different hospitals. A hospital leadership’s commitment was determined to be the key enabler. The success or failure of any AMS program appears to depend on physician understanding, commitment and support for such a program. By involving the main players in an AMS program- the hospital administrators, clinicians and other key members, perceived barriers will be better identified and overcome, and enablers will help allow a successful implementation of an AMS program. This multi-center study was funded by Philippine Council on Health Research and Development ( PCHRD) and Pediatric Infectious Disease Society of the Philippines ( PIDSP) and was conducted by the PIDSP Research Committee.
Physicians ; Multicenter Studies as Topic

Objective: To describe the clinical, biochemical, microbiologic, radiologic and histological features and outcome of intestinal TB. Methods: Medical records of patients diagnosed with intestinal TB were reviewed. Cases were considered bacteriologically-confirmed if intestinal tissue was positive on smear culture or polymerase chain reaction (PCR); and clinically-diagnosed if with clinical, histologic, and radiologic evidence of extra-pulmonary TB. Results: Fifteen patients [Mean (SD) age: 13 (4) years; 53% females] were included. One was bacteriologically-confirmed; and fourteen were clinically-diagnosed. Fever (87%) and abdominal pain (73%) were commonly seen. Seven (47%) had anemia, 5 (33%) leukocytosis and 10 (71%) hypoalbuminemia. Eleven (73%) were positive on smear or TB PCR of various specimens. Nine of 10 (90%) patients with an abdominal CT scan had thickening of bowel loops. Three with intestinal biopsy demonstrated caseation granuloma. Fourteen patients were given quadruple anti-TB medications. Six had surgery, 8 had no disease-related complications, 4 died of sepsis and 3 were lost to follow up. Conclusion Intestinal TB presents with non-specific clinical and laboratory features. Radiologic findings may provide a clue to the diagnosis. Histologic confirmation in intestinal tissue was only seen in a few cases. The prognosis was favorable for patients who completed the anti-TB treatment.
Tuberculosis, Extrapulmonary ; Mycobacterium tuberculosis

Introduction: Healthcare-associated infections (HCAIs) are a common complication of prolonged hospital stay, leading to increased morbidity and mortality. This study aims to determine the effectiveness of daily chlorhexidine bathing in reducing HCAIs in the pediatric intensive care unit (PICU). Methodology: This is a randomized controlled, observer-blinded study conducted over a 6-month period. Included were 2 months to 18-year-old patients admitted to the PICU, randomly assigned to daily bathing with 2% chlorhexidine or to the standard practice of bathing with plain soap and water. Primary outcome was the incidence of HCAI in each group. Results: A total of 50 patients were enrolled in the study. Overall incidence of HCAI was lower in the chlorhexidine group compared to the control group (12% versus 36%, RR=0.33, 95% CI 0.10 – 1.09, p=0.047). Incidence density rate was lower in the chlorhexidine group (5.91 versus 21.03 infections per 1000 person-days, p=0.049). Ventilator-associated pneumonia and bloodstream infections were lower in the chlorhexidine group, but results were not statistically significant. There were no significant differences in mortality rates and length of hospital stay. One adverse event of transient rash occurred in the chlorhexidine group. Conclusion Daily chlorhexidine bathing may be more effective in reducing HCAIs in the PICU compared to standard care.
Chlorhexidine ; Intensive Care Units, Pediatric

Objective: The clinical presentation, outcome, and risk factors for mortality in children with Fever of Unknown Origin (FUO) were determined. Methods: Medical records of pediatric patients admitted for FUO from January 2009 to December 2013 were reviewed. Clinical manifestations, physical exam findings, diagnostic work-ups and final diagnosis were determined, as well as the relationship between final diagnosis and risk for mortality. Results: Fifty-seven patients with FUO were included. Weight loss, cough, colds, and rashes were common symptoms while pallor, lymphadenopathies, and hepatomegaly were common physical exam findings. All patients underwent Phase I evaluation for FUO, while 73.7% underwent further diagnostic tests. A specific etiology was established in 96.5% of cases: infectious, 43.9%, connective tissue disease, 38.6%, and hematologic/oncologic, 14%. Two cases remained to have no specific diagnosis. Majority of patients had a benign course and were discharged improved (84.2%). The mortality rate is 15.8% and was not associated with any disease category (p-value 0.204). Conclusion FUO in children occurs across all age groups. Its clinical presentations are varied and non-specific and common signs and symptoms are pallor, lymphadenopathies, weight loss, cough, colds. and joints pains. Infection is the most common cause of FUO in children, followed by connective tissue diseases and hematologic and oncologic diseases. The mortality rate from FUO is 15.8%.
Fever of Unknown Origin

Objective: This study aimed to determine the clinical profile and outcome of pediatric patients with acute viral encephalitis syndrome admitted at a single tertiary government hospital. Methods: All pediatric patients admitted at the Philippine General Hospital from January 2011 to December 2014 and discharged with a final diagnosis of acute viral encephalitis were included. After demographic data, clinical manifestations, and laboratory findings were collected, the outcome was determined using the Modified Rankin Scale for children. The data were summarized using descriptive statistics. The median test was used to compare the outcomes while the chi-square test was used to analyze the comparison between study groups. Results: Sixty-four patients diagnosed with acute viral encephalitis syndrome were included in the study. The highest number of cases was reported in ages 1- 4 years (32.81%) and among the male population (68.75%). The most common symptoms were seizure (46.87%), abnormal behavior (21.88%), and altered sensorium (20.31%). Forty-four patients had CSF viral studies done, and among them, the 11 (25%) were positive for Japanese encephalitis. The modified Rankin scale showed that 41 (64.08 %) subjects showed good outcomes, while 23 (35.23%) exhibited poor outcomes. There was no significant difference in the modified Rankin scale for Japanese encephalitis compared to the other etiologic agents of acute viral encephalitis (p value= 0.717). Conclusion In patients with acute viral encephalitis, the most common symptoms were seizures, abnormal behavior, and altered sensorium. Majority of the subjects did not show any significant symptoms and disability. No difference was seen in the clinical outcome of patients infected with Japanese encephalitis compared to other etiologic agents, but these results need to be verified by larger studies.<
Acute Febrile Encephalopathy ; Encephalitis, Japanese