Topics

Toxicology

Emergency medicine Research Letter 28 January 2019 Free

Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016

The popularity of e‐cigarettes has increased in Australia since they first became available as smoking cessation tools; an estimated 1.3% of the New South Wales population used them in 2015, and as many as 8.4% had experimented with them.1 E‐cigarettes have been recommended by Public Health England and the Royal College of Physicians as safe smoking cessation tools.2,3 In Australia, a prescription is required for legally importing nicotine‐containing e‐cigarettes.4 The safety of these products for users and the risks for members of their households have not been established. Imported products may not conform to Australian standards, including having child‐resistant closures and appropriate labelling, and refill bottles containing highly concentrated nicotine solutions — one millilitre of which can be lethal if ingested by a child — can be purchased online. Podcast with Ms Carol Wylie We undertook a retrospective analysis of calls to Australian Poisons Information Centres (PICs) during 2009–2016. PICs play a valuable role as health care sentinels when new products such as e‐cigarettes are introduced. Our study was exempted from formal ethics approval by the Children's Health Queensland Hospital and Health Service Human Research Ethics Committee. The numbers of calls about e‐cigarette exposures increased considerably across the study period (Box), although the overall PIC call volume was stable at about 164 000 cases per year. Of 202 sequential e‐cigarette‐related cases, 38% were from relatives of children worried about their exposure to the liquid component of an e‐cigarette after children were found with uncapped vials, sucking the mouthpiece, drinking from separated liquid containers, inhaling the liquid, eating the cartridge, or having splashed liquid in their eyes. Adults and adolescents were the subjects of calls in 126 cases (62%), including calls about the potential side effects of routine use or accidental ingestion, or about skin or eye splash exposures. Twelve calls followed deliberate administration for self‐harm, ten by oral ingestion and two by injection. The reported median concentration of the 43 commercial nicotine solutions involved was 20.2 mg/mL, (range, 0.06–200 mg/mL), but confirmatory testing was not performed and actual concentrations may be higher than labelled, as noted recently.5 Most patients had only mild symptoms at the time of the call to the PIC, mainly gastrointestinal disturbances; twelve had moderate symptoms, usually a gastrointestinal disturbance combined with sedation. The potential risks, however, should not be underestimated; we are aware that an infant recently died in Australia after ingesting a concentrated nicotine solution. Almost all exposures of children to nicotine‐containing e‐cigarette liquid require their hospitalisation for monitoring of possible toxic effects. Australian PIC data refer to calls about exposures to e‐cigarette liquid but may not reflect the prevalence of such exposures. These data nevertheless provide insights into patterns of exposure, usage, and the side effects of e‐cigarettes. Our study can assist health care practitioners when advising patients about the use of e‐cigarettes, and our findings indicate that nicotine‐containing products should be stored where children cannot access them. We would welcome any move to improve the safety of electronic cigarettes, including changes to their labelling, storage, and packaging. Box – Numbers of cases related to e‐cigarette exposures reported to Australian Poisons Information Centres, by calendar year and state* No calls were received about cases in the Northern Territory.

Carol Wylie · Aaron Heffernan · Jared A Brown · Rose Cairns · Ann‐Maree Lynch · Jeff Robinson

Mja2 12032
Toxicology Letters 16 July 2018 Free

Azithromycin for Salmonella infection: don’t presume it works

To the Editor:Salmonella infection manifests as enteritis and enteric fever, predominantly acquired overseas. When required, therapy with azithromycin, ciprofloxacin or ceftriaxone is recommended by the Therapeutic guidelines: antibiotic;1 however, reduced susceptibility to fluoroquinolones in Asia limits the use of ciprofloxacin unless susceptibility is confirmed.2 The Australian Bureau of Statistics recorded a 546% increase in short term departures to Indonesia over 10 years, with 1.2 million nationally in 2016.3 A 31-year-old man was taking long term azithromycin 250 mg daily to prevent bronchiolitis obliterans syndrome after a bilateral lung transplant several years earlier for cystic fibrosis. Three weeks after returning from Bali, he was admitted with fatigue, fever, diarrhoea and abdominal pain. He had acute kidney injury. His C-reactive protein level was 190 mg/L (reference interval [RI], < 5 mg/L) and procalcitonin concentration was 3.5 μg/L (RI, < 0.05 μg/L). A single set of blood cultures was negative. Stool culture isolated Salmonella enterica serovar Paratyphi B var Java, sensitive to ceftriaxone and ciprofloxacin, with a raised azithromycin minimum inhibitory concentration (MIC) of 64 mg/L by ETEST (bioMérieux); an MIC > 16 mg/L indicates non-wild-type4 and is associated with treatment failures. Owing to his immunocompromised state, the patient received a 14-day course of ciprofloxacin (MIC, 0.016 mg/L). Our review of 2015–2017 data from the Western Australian public pathology provider revealed that two of 31 typhoidal Salmonella isolates (Salmonella Paratyphi A and Salmonella Typhi bacteraemia, each acquired in India) and one of 15 non-typhoidal Salmonella isolates (S. typhimurium, no clinical details provided) had an azithromycin MIC > 16 mg/L. Ceftriaxone resistance was low at 0% (0/117) of typhoidal Salmonella and 0.4% (7/1648) of non-typhoidal Salmonella; ciprofloxacin resistance was higher at 48.0% (47/98) of typhoidal Salmonella and 6.8% (94/1384) of non-typhoidal Salmonella. By comparison, azithromycin MIC > 16 mg/L was found in 16.1% of typhoidal Salmonella from travellers returning to the Netherlands,5 and in 1.3% of non-typhoidal Salmonella in the United States.4 Azithromycin use while travelling probably selected for resistant Salmonella infection in this case. However, our data show that azithromycin susceptibility cannot be assumed in Salmonella infections; testing should therefore occur in serious cases, along with ongoing surveillance for evolving resistance.

Alan J Rogers · Gar-hing A Lee · Peter Boan

Toxicology Research 6 June 2016 Free

A decade of Australian methotrexate dosing errors

Potentially fatal dosing errors continue to occur despite a number of safety initiatives — new strategies are required

Rose Cairns PhD, BPharm(Hons) · Jared A Brown BPharm(Hons), MPH, FSHP · Ann-Maree Lynch BSc(Hons), PhD · Jeff Robinson BPharm, FSHP, GradDipHospPharm · Carol Wylie BPharm, PGDClinPharm · Nicholas A Buckley BMed, FRACP, MD

15 01242

Subscribe to MJA email alerts

No spam, you can unsubscribe anytime you want.

By providing your information, you agree to our Terms of Use and our Privacy Policy.

Thanks for Subscribing! Tell us more

Your email updates will use your name.

Good one! Your updates are coming

Thank you for subscribing to the MJA email alerts. Receive the latest content in your inbox.