Final Project R2
Final Project R2
Final Project R2
Group members
2
Signature Page
Head of Department
Faculty of Pharmacy
Pogram Coordinator
Faculty of Pharmacy
Supervisor
Mam Anum Hnif
Faculty of Pharmacy
3
Approval Certificate
We the under signed clarify that we have carefully read and recommended to the faculty of
Pharmacy. The Hajvery University Lahore, for the acceptance of this project entitiled
This project is prepared by Rizwan Ahmed Khan,Talha Zulfiqar , Majid Munir, Aniqa Fiyaz,
Zain Farrukh, under my guidance for the fulfillment of clinical pharmacy practical, is hereby
Signature:
Assistant Professor
Faculty of Pharmacy,
4
Acknowledgment:
All praises for Almighty Allah, the most Beneficent and the most Merciful, for giving us strength
to complete this project. And then we express our special gratitude to our supervisor Assistant
Professor (Pharmacy Practice) Faculty of Pharmacy for his valuable advice and help
The group would like to express their deep appreciation indebtedness to the following;
We would like to thank HAJVERY UNIVERSITY for giving us permission to accomplish our
Pharm-D degree.
We are thankful to our parents and friends for their prayers, encouragement and support,
otherwise it was not possible to complete our project within the specified time duration.
5
Dedication
Almighty Allah, beloved Prophet Muhammad (P.B.U.H), and to all the people who inspired
6
Abbreviations/ Medical terms
ALT: Alanine -amino transferase ALP: Alkaline phosphatase
APTT (Activated Partial Thromboplastin Time) PT (Prothrombin Time)
½ St D/Saline: ½ Strength Dextrose saline ADR: Adverse Drug Reaction
BP: Blood Pressure BD: Twice a Day
BF: Before Feeding C.I: Contra-Indication
BA: *Birth Asphyxiation DS susp: Double Strength suspension
D.I: Drug Interaction DWI: Drug without indication
Del: Delayed Dx: Clinical Diagnosis
E.D: Excessive Dose F: Female (♀)
FTP: Full Turn Pregnancy GNS: General Nervous System
GPE: General Physical Examination HOPI: History of Present Illness
Hx: History I.D.F: Inappropriate Dosage Form
I.D.S: Inappropriate Drug Selection LM: Loose Motions
M.P.R: Monitoring Parameter Required M: Male (♂)
N/G: Naso-Gastric Feeding NAD: No abnormality detected
U.C: Untreated Condition NNJ: Neonatal jaundice
NVD: Normal vaginal Delivery OD: Once A day
P/O: Per Oral P/R: Per Rectal
PMC: Patient Medication Chart QID: Four Times a Day
ROA: Route Of Administration S.D: Subtherapeutic Dose
SE: Systemic Examination Sept MG: Septic Meningitis
SUMMARY
Meningitis is the inflammation of the meninges, the protective tissues surrounding the
brain and spinal cord. Although meningitis is most commonly caused by a viral infection,
it may also occur as a result of a bacterial or fungal infection, an adverse reaction to
certain drugs, or physical injury.
A three-month study was conducted at the HMC Peads-A and Paeds-B Wards. The study
was focused predominantly on patients of meningitis. The aim and objective of the study
was to study the various drug related problems in the prescription, also any cost related
problems, with management of actual or potential drug interactions included.
A total of 10 cases of meningitis were collected with the help of a pre-designed pro forma
containing all the relevant information about patient demographics, chief complaints,
laboratory tests, hospital treatment and management of drug related problems. Finally,
these medication histories were analyzed and interpreted.
7
The drug related problems in patients of meningitis: A total of 48 drug related problems
were found, out of which Untreated Conditions were 10, Improper Drug Selection were
10, Drug Interactions were 10, Drug Without Indications were 1, Dose Adjustment in
Renal Impairment were 7 and Cost Related Problems were again 10.
TABLE OF CONTENTS
8
Chapter no. 4 Medication Histories……………………………………..
(Medication histories of patients of Meningitis) 26
Chapter no. 5 Results and Findings……………………………………..
(analysis of collected data via charts and tables) 97
Chapter 1
Introduction
9
INTRODUCTION
History: Pediatric microorganism infectious disease may be a grievous unhealthiness that results
from microorganism infection of the tissue layer. as a result of microorganism infectious disease
within the time of life has its own distinctive epidemiological and etiologic options, it'll be
mentioned one by one during this article as necessary. (Martha L Muller. et al.,2019).
Beyond the time of life, the three commonest organisms that cause acute microorganism
infectious disease streptococcus pneumonia , Neisseria meningitidis, and Hemophilia influenza
group B (Hib). Since the routine use of Hib, conjugate diplococcus, and conjugate
meningococcal vaccines within the u. s., the incidence of infectious disease has dramatically
faded.(Martha L Muller. et al., 2019)
10
Predisposing factors embrace respiratory tract infection, otitis, rubor, head trauma, blood disease,
human immunological disorder virus (HIV) infection, and different immune deficiency states.
(DebjitBhowmik et al Arch.et al.,2010 )
Causes Of Meningitis is the is the inflammation of the meninges associated with the presence of
bacteria, viruses or other micro-organisms in the CSF, i.e. cerebrospinal fluid.CSF is present in
the subarachnoid space, i.e. the space between pia mater and arachnoid membrane.The
inflammation of the meninges may be less commonly caused by certain drugs.
(David Santamarta. et al., 2018).
Classification Of Meningitis
Broadly there are 2 categories of infectious disease supported the supply of infection;
Septic Meningitis: Septic infectious disease is largely caused by a microorganism supply. the
kinds of bacterium that cause microorganism infectious disease vary by cohort, as shown within
the following table. Tubercular infectious disease is infectious disease because of infection with
mycobacterium, thus it's additionally septic infectious disease.(G. A. Pankey. et al., 2004).
Aseptic Meningitis :The term sterile infectious disease refers loosely to all or any cases of
infectious disease within which no microorganism infection is incontestable . this can be
sometimes because of viruses, however it's going to result to microorganism infection that has
already been part treated, with disappearance of the bacterium from the meninx, or by infection
in an exceedingly house adjacent to the meninx (e.g. sinusitis). carditis (infection of the center
valves with unfold of tiny clusters of bacterium through the bloodstream) might cause sterile
infectious disease. infectious disease is also encountered in cerebral protozoal infection (malaria
infecting the brain). flora infectious disease, e.g. because of Cryptococcus neoformans, is often
seen in folks with immune deficiency like AIDS. rhizopodan infectious disease, infectious
disease because of infection with amoebae is contracted from fresh sources.(Nitin Butala. et al.,
2015).
Etiology:It refers to the causative agents of meningitis. The important causative agents worth
mentioning here are bacterial, viral and fungal.
Most cases ar caused by bacterium or viruses, however some may be thanks to sure medicines or
diseases.Many of the bacterium and viruses that cause infectious disease ar fairly common and
cause alternative routine diseases. each varieties of infectious disease unfold like most alternative
common infections do somebody who's infected touches, kisses, or coughs or sneezes on
somebody UN agency is not infected.(Elana Pearl Ben-Joseph. et al., 2020)
11
Diagnosis : Bacterial infectious disease are often terribly serious. therefore if you see
symptoms or assume that your kid may have infectious disease, it is vital to visualize the
doctor quickly.If infectious disease is suspected, the doctor can order tests, in all probability
together with a spinal tap (spinal tap) to gather a sample of humour. This check can show any
signs of inflammation and whether or not the infection is because of a pestilence or
bacterium.(Kim Jackson. et al., 2020)
Treatment :
Most cases of microorganism infectious disease finish inside seven to ten days. Some folks
would possibly have to be compelled to be treated within the hospital, though youngsters
sometimes will recover reception if they don't seem to be too unwell. Treatment to ease
symptoms includes rest, fluids, and over-the-counter pain medication.If microorganism
infectious disease is diagnosed or maybe suspected doctors can begin endovenous (IV)
antibiotics as before long as attainable. Fluids could also be given to exchange those lost to
fever, sweating, vomiting, and poor appetence.(Kim Jackson, et al., 2020).
Risk factors: While most healthy kids will fight the infection with their natural defences,
kids whose immune systems ar compromised ar at higher risk of developing respiratory
disease. A child's system could also be weakened by deficiency disease or hunger,
particularly in infants United Nations agency aren't solely breastfed.Pre-existing diseases,
like symptomatic HIV infections and contagious disease, additionally increase a child's risk
of acquiring respiratory disease.The following environmental factors additionally increase a
child's susceptibleness to pneumonia:indoor pollution caused by change of state and heating
with biomass fuels (such as wood or dung)living in crowded homes and parental smoking.
(Muhammad Waseem. et al., 2020).
12
Chapter 2
Aims and Objectives,
Literature Review
13
AIMS AND OBJECTIVES
Taking histories of the patients with special emphasis on medication histories and based
on this conducting drug utilization review.
The identification of actual and potential drug related problems.
Monitoring patient compliance status and adherence to drug therapy and to identify the
factors responsible for non-compliance.
Reviewing patient medication therapy in wards in order to diagnose, detect, identify and
manage the various medication related problems.
14
LiteratureReview:
Meningitis is an inflammation (swelling) of the protective membranes covering the brain and
spinal cord. A bacterial or viral infection of the fluid surrounding the brain and spinal cord
usually causes the swelling. However, injuries, cancer, certain drugs, and other types of
infections also can cause meningitis. (Thomas EK. et al., 2002 ).
Owing to multiple factors, like depleted laboratory capability, poor news systems thanks to
restricted access to health care facilities and restricted illness police investigation programmes,
the particular illness burden of infectious disease is unknown and will be mostly under-
reported.A systematic literature review was performed to describe: (a) the prevalence of
meningitis; and (b) its etiological infective agent across completely different regions, age teams
and patients with comorbidities.( Canna J. et al., 2021).
Such meningitis may not respond to high dose penicillin therapy and those resistant to
cephalosporin may not respond to the standard dose.47 The resistance of S pneumoniae to
penicillin and other β lactam antibiotics is caused by either alteration in the penicillin binding
proteins involved in the synthesis of bacterial cell wall or the production of β lactamase.48 In
view of the increasing reports of resistant strains of S pneumoniae in the United States, the
American Academy of Pediatrics recommended combination therapy, initially with vancomycin
and either cefotaxime or ceftriaxone for all children 1 month of age or older with definite or
15
probable bacterial meningitis. Studies in adults have shown that vancomycin should not be used
alone in resistant cases as there are doubts about its penetration into the CSF, especially in those
given dexamethasone concurrently.49,50 A recent study in children showed that vancomycin
need not be given if LP is done early and Gram positive diplococci are not seen on Gram stain.51
We suggest that in the majority of UK centres where cephalosporin resistance remains at very
low levels, empirical use of vancomycin is not necessary. Where vancomycin is used
empirically, it should be discontinued if the organism is later shown to be susceptible to
penicillin, or to cefotaxime or ceftriaxone. (Irebu KC. et al., 2015).
Acute bacterial meningitis (ABM) is a severe illness mostly affecting children under the age of
five years but people of any age can develop ABM. Despite advances in medical treatment ABM
remains an important cause of childhood morbidity and mortality throughout the world.1
Neurological sequelae are common in children who suffered from ABM.2 Fever, vomiting, poor
feeding, convulsions, headache, neck stiffness and altered consciousness are common
presentations of meningitis in children.3 The diagnosis of central nervous system (CNS)
infection is made on examination of cerebrospinal fluid (CSF) and CNS infections can be
categorized according to pathogen involved into bacterial, viral, fungal or protozoal.4 The exact
etiological diagnosis is often not possible, because prior antibiotic therapy, low bacterial load
and delay in plating for culture. (Margo Kl.et al., 1986).
Miller and Shahab studied the cost effectiveness of immunisation strategies for the control of
epidemic meningococcal meningitis. The research work in gives a detailed description of the use
of antibiotics for the prevention and treatment of meningitis infection. Irving et al. [14] used
deterministic compartmental models to investigate how well simple model structures with
seasonal forcing were able to qualitatively capture the patterns of meningitis infection. They
demonstrated that the complex and irregular timing of epidemics could be caused by the
interaction of temporary immunity conferred by carriage of the bacteria together with seasonal
changes in the transmissibility of infection. Actually, there have been a significant number of
studies of various types of Meningitis in Africa and Europe without the use of optimal control
analysis Over 1.2 million cases of bacterial meningitis are estimated to occur worldwide each
year . The incidence and case-fatality rates for bacterial meningitis vary by region, country,
pathogen, and age group. (LeD Acute bacterial.et al., 2018).
Children, the best way to prevent the most common etiological agents for bacterial meningitis
(H. Influenzae, S. Pneumoniae, N. Meningitidis) continues to be compliance with timely
childhood vaccination against these organisms, which will also aid in providing herd immunity
in neonates and infants who are either not or under vaccinated.Premature infants, neonates and
infants less than 2 months of age represent the highest risk groups for bacterial meningitis in
children. The predisposition to develop bacterial meningitis is similar to the risk of developing
sepsis and can be due to the lack of maternal immunoglobulins that cross the placenta after 32-
week gestation11 and secondary to the immature immune system with impaired phagocytic
16
ability of neutrophils and monocytes. (Harrison LH Mohan. et al., 2010).
Meningococcal meningitis (MM) is known to be responsible of high cost for the Public Health
Administration. Aim of the work is to calculate the costs for the hospitalization of pediatric
patients affected by MM. Pediatric bacterial meningitis is a life-threatening illness that results
from bacterial infection of the meninges and leaves some survivors with significant sequelae.
Therefore, meticulous attention must be paid to appropriate treatment and monitoring of patients
with this disease. (Nigrovic LE.et al.,2012).
Children, serum inflammatory markers can also be of help in differentiating viral and bacterial
meningitis. Multiple studies have been conducted to identify biomarkers that can help clinicians
in their assessment of patients. Normal C-reactive protein (CRP) and procalcitonin values have
good diagnostic accuracy in excluding all bacterial infections including those causing meningitis
but they are not widely used in clinical practice.46–48 Serum concentration of CRP greater than
80 mg/dl41 and elevated serum procalcitonin level (0.5-ng/mL) can be helpful in identifying
patients with ABM. One study showed that a procalcitonin level >0.5 ng/mL was 99% sensitive
and 83% specific for ABM,47 while another study showing a value of >2 ng/mL was 100%
sensitive and 63% specific.48 This latter study also showed that the procalcitonin level could
also be used to follow the response to antibiotic therapy. (Nigrovic LE.et al.,2012).
Since the diagnostic value of clinical features in children with meningitis is limited, a low
threshold for the use of diagnostic tools such as lumbar puncture (LP) for suspected meningitis in
infants and young children is recommended. Typical CSF findings for bacterial meningitis are an
elevated white blood cell count (WCC), with polymorph predominance, decreased glucose and
increased protein. TBM is associated with elevated lymphocytes and protein; glucose may be
decreased. The profile of meningitis in a tertiary paediatric hospital in South Africa. (L
JanszHeloise.et al.,2018).
Initial treatment approach to the patient with suspected acute bacterial meningitis depends on
early recognition of the meningitis syndrome, rapid diagnostic evaluation, and emergent
antimicrobial and adjunctive therapy . Our management algorithm for infants and children is
shown in figure 1, and that for adults is shown in figure 2. Once there is suspicion of acute
bacterial meningitis, blood samples must be obtained for culture and a lumbar puncture
performed immediately to determine whether the CSF formula is consistent with the clinical
diagnosis. In some patients, the clinician may not emergently perform the diagnostic lumbar
puncture (e.g., secondary to the inability to obtain CSF), even when the diagnosis of bacterial
meningitis is considered to be likely, or the clinician may be concerned that the clinical
presentation is consistent with a CNS mass lesion or another cause of increased intracranial
pressure and will thus order a CT scan of the head prior to lumbar puncture.(Miller. et al., 2014).
The ‘comprehensive strategy’ mimicked the diagnostic algorithm utilized in the Cryptococcal
17
Optimal ART Timing (COAT) trial which was a randomized strategy trial to determine if early
or deferred ART was optimal for 6-month survival. (HumanT. Et al., 2017 ).
Hyponatremia has frequently been described as a common complication associated with bacterial
meningitis, though its frequency and clinical course in children with bacterial meningitis are
unclear. The present study aimed to investigate the frequency, clinical characteristics, and
prognosis associated with pediatric hyponatremia due to bacterial meningitis.
Previous study show that hyponatremia occurred in 66.4% of the assessed pediatric bacterial
meningitis patients. Moderate and severe hyponatremia affected the severity of pediatric
bacterial meningitis. Only severe hyponatremia affected the short-term prognosis of patients with
pediatric bacterial meningitis. We recommend that patients with pediatric bacterial meningitis
who exhibit convulsions and increased blood glucose levels should be checked for severe
hyponatremia. Further studies are needed to evaluate the effectiveness of treatment of
hyponatremia. (Human T. et al., 2017).
Tuberculous infectious disease could be a terribly serious variety of T.B.. within the absence of
irregular controlled trials of different treatment regimens, its management depends on using
potent medication that penetrate well into the body fluid (CSF). The penetration of INH,
rifampin, and antibiotic drug into the CSF of twenty seven Chinese patients was studied
victimisation fluorimetric and microbiologie procedures. INH apace subtle into the CSF, peak
concentrations in more than three mg/L, or over thirty times its lowest repressing concentration
(MIC) against Mycobacterium tuberculosis being earned among four 60 minutes. In distinction,
antibacterial drug and antibiotic drug penetrated terribly slowly across the tissue layer, and CSF
levels solely slightly in more than their MICs against M. T.B. were achieved. The penetration of
the medication into the CSF correlate poorly with variations in their partitioning between
octanol/water and cyclohexane/water however can be foretold employing a easy model
supported their urinary organ clearance rates and protein binding. it's counseled that patients with
sick infectious disease ought to be treated for a minimum of nine months with a mix of INH,
rifampin, and pyrazinamide, which can be supplemented within the initial a pair of mo with
antibiotic drug. (Gordon A. Ellard. et al., 1994).
Neurologists ar typically the primary medical suppliers to judge patients with doable infectious
infectious disease. data of the clinical displays and bodily fluid, microbiologic, and
neuroimaging findings for various etiologies is important to create a prompt designation and
initiate applicable treatment. T.B. may be a common explanation for infectious disease in
developing countries with a high prevalence of T.B.. However, T.B. affects populations in each
country and every one neurologists got to be argus-eyed for doable cases of tubercular infectious
disease presenting to their medical facilities. this text discusses the challenges of designation and
treating tubercular infectious disease and highlights recent advances in diagnostic technology.
(Jerome H. et al., 2014).
Acute bacterial meningitis has a relatively rapid onset of symptoms, and routine laboratory
techniques can usually identify the pathogen. The most common causes have been Streptococcus
19
pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B
Streptococcus (GBS), and Listeria monocytogenes. These organisms caused more than 80% of
acute bacterial meningitis in children during the 1970s and 1980s. In 1990, conjugate Hib
vaccine was introduced. It has almost eliminated Hib meningitis in countries where it has been
implemented and decreased the overall incidence of acute bacterial meningitis by 55%.
Implementation of the heptavalent pneumococcal conjugate vaccine (PCV7) in 2000 resulted in a
59% reduction in rates of pneumococcal meningitis in children younger than 2 years of age.
(Whitney CG. et al., 2003).
Etiology was printed in ninety 5 of 1 hundred forty four (66%) patients with antiseptic
communicable disease. Enteroviruses were the foremost vital causative agents (26%), followed
by HS2 (17% of all, twenty fifth of females) and VZV (8%). Etiology was proverbial in fifteen
of forty 2 (36%) patients with inflammation, VZV (12%), HSV-1 (9%), and tick-borne
inflammation virus (9%) being the foremost usually involved pathogens. Etiologic designation
was achieved by PCR in forty third of the patients with communicable disease and in terrorist
organization of those with inflammation.Enteroviruses and HS2 ar the leading causes of adult
antiseptic communicable disease, and PCR is of diagnostic price. However, in most cases of
inflammation, the etiology remains vague . (L. Kupila. et al., 2006).
Meningitis were collected in the French national survey for bacterial meningitis in children, and
analysis was carried on 439 of Proven meningitis cases, the 5 remaining cases were considered
as“possible meningitis.” This is currently the largest described seriesOf neonatal bacterial
meningitis. Despite this high number of Reported cases, it is likely that the incidence of bacterial
20
neonatal Meningitis remains underestimated. Several studies have highlighted this
underestimation, both for early- and late-onset meningitis. Nearly 30% of bacterial meningitis
cases in infants are not Diagnosed when only one blood culture is performed to confirm Neonatal
infection.10,11 Additionally, lumbar puncture is not systematically performed when infection is
suspected clinically inNeonatal intensive care units, and shock at diagnosis or very lowBirth
weight may limit its performance. In 38 cases, the lumbarPuncture was performed more than 48
hours after admission andTherefore they were nosocomial. Nevertheless, E. Coli which accounts
for two-third of these cases is not usually associated with a Horizontal contamination. (Georget-
Bonquit E et al ., 2015- 18).
The Management of central nervous system (CNS) infections is difficult across all settings due to
the high mortality and morbidity rates if proper treatment is not initiated promptly. Common
CNS infections include bacterial meningitis, cryptococcal meningitis (CM), tuberculosis
meningitis (TBM), viral meningitis (VM), and various types of encephalitis and cerebral
abscesses.1 In resource-limited settings, case management of CNS infections is extremely
difficult with in-hospital mortality rates of 17–67% for bacterial meningitis, 40–69% for TBM,
and 19–50% for CM in Sub-Saharan Africa.2,3 Of clinical importance is the prevalence of
HIV/AIDS, and how AIDS influences disease prevalence rates and outcomes. With an estimated
9.7 to 11.5 million children and adults in Sub-Saharan Africa requiring antiretroviral therapy
(ART) in 2010,4 opportunistic infections are expected to continue for the foreseeable future
requiring clinical tools to enhance diagnosis and treatment of CNS infections.( Rajasingham R.
et al., 2012).
21
Chapter 3
Methodology
22
METHODOLOGY
This study is based on Clinical Pharmacy Clerkship that was completed during a 3-month period
from April 2014 to June 2014. In this study, we collected and considered 10 cases of patients
having pediatric infectious disease, Meningitis at Pediatrics Wards (A and B), Hayat Abad
Medical Complex Peshawar, Pakistan.
Study Protocol
The data of patients were collected with the help of a pre-defined standard pro forma, which was
comprised of the following sections.
23
Daily progress report (DPR)
Drug related problems (DRPs)
Chapter 4
Medication History
24
CASE NO. 01
Patient’s Information:
BedNo: 01
Gender: Male
Weight: 23kg
Chief Complaints:
Fever…………………….7 days
Vomiting………………...7 days
Fits………………………5 days
Drowsiness…………….. 3 days
Headache………………..7 days
25
History of present illness:According to mother, the patient was alright before but since the last
17 days has suffered from high grade fever, associated with severe headache and vomiting followed by
fits (with no previous history of fits).
Impression:The patient condition is deterioratedwith mild hydrocephalus (buildup of too much CSF
in the brain)
CLINICAL TESTS:
CT Scan Brain (with contrast):
Conclusion: Appearances are suggestive of meningitis and that too pyogenic i.e.
involving or relating to the production of pus.
Systemic Review:
CNS:
Drowsy
Neck stiffness
Febrile
26
Exaggerated reflexes
CVS:
S1 + S2 + 0
Eosinophils 0-6% 2%
CSF EXAMINATION:
Physical Examination:
Colour: colorless……….white
Volume: 1ml……………2ml
Clotting: nil……………..nil
Turbidity: nil……………nil
Chemical Examination:
Proteins: 105mg/dl…………85mg/dl
Glucose: 23mg/dl…………..17mg/dl
Microscopic Examination:
Neutrophils: 60 %
27
Lymphocytes: 40 %
WBC count: 120/cmm……………150/cmm
RBC count: 20/cmm………………nil
Staining:
Gram staining: no microorganism seen ??
Z.N staining: no AFB seen ??
GENERAL ASSESMENT:
HOSPITAL TREATMENT:
Date Brand, Dosage-Form, Generic & Strength DOSE Frequency
28
Inj; Meronem (meropenemtrihydrate) 1g I/V 1gm Three times daily
2/5/20 INF; Meronem 1g IV TDS (in 100ml fluids) 1gm Three times daily
Inj; Gravinate[Dimenhydrinate] ½ IM
1g and
Inj; Streptomycin 1gm, 700mg IM/state (add 3cc 700mg and
d/w) then on alternate day give 2cc then 2cc On alternate days
CASE ANALYSIS:
The patient is diagnosed with meningitis (pyogenic). His stay at hospital is elongated
since the condition of the patient is deteriorating and he is not responding properly to
medications.
There is history of headache since 1 ½ month
There is also history of fever since 1 ½ month
29
He is also vomiting since 10 days
The patient is not responding to antibiotics
Admitted in HMC for the past 28 days
Epival: Valproic acid (its sodium salt) is indicated in the treatment of patients with complex
partial seizures.
Brufen:Brufen syrup is indicated for its analgesic, anti-pyretic and anti-inflammatory effects.
Vancomycin(brand: Vancocin): This medicine is used for severe infections caused by bacteria
which can resist other antibiotics. It is used in patients who have not responded to treatment with,
or have had a bad reaction to, other antibiotics.
Rocephin(generic: Ceftriaxone): It is an antibiotic given to adults and children (including
newborn babies). It works by killing bacteria that cause infections. It belongs to a group of
medicines called cephalosporins. Rocephin is used to treat infections of the brain (meningitis).
Plabolyte-M: (5% Dextrose and Electrolytes Injection) It is a maintenance solution and provides
electrolytes along with calories for some metabolic needs and supplies daily requirements of
water and electrolytes.
Provas: It is a brand drug for the generic Paracetamol which is used as analgesic and antipyretic
agent.
Meronem: Generically it is meropenemtrihydrate. Meronem is indicated for the treatment of
acute bacterial meningitis. Meronem may be used in the management of neutropenic patients with
fever that is suspected to be due to a bacterial infection.
Mannitol: It is an osmotic diuretic. It works by increasing the amount of fluid excreted by the
kidneys and helps the body to decrease pressure in the brain and eyes.
Rimactal:Rimactal is a bacteriostateic antibiotic based on the main ingredient Rifampicin. Also
used for meningococcal meningitis prophylaxis.
30
Vermox: It is an "antihelmintic" or anti-worm, medication. It prevents worms from growing or
multiplying in the body. Vermox is used to treat infections caused by worms such as whipworm,
pinworm, roundworm, and hookworm.
Gravinate injection [Dimenhydrinate]: It is prescribed for the prevention and treatment of
motion sickness, dizziness, nausea, vomiting.
N/G tube feeding: It is a method of artificial feeding which can provide patients with essential
nutrients and hydration through a tube when they cannot eat or drink by natural means. In Naso-
gastric (NG) feeding, a tube is inserted through the nose into the stomach.
Syrup PZQ (Praziquantel): This medication is used to treat infections of certain parasites (e.g.,
Schistosoma and liver flukes). Praziquantel belongs to a class of drugs known as antihelmintics.
It works by killing the parasites. It also paralyzes the parasites, causing them to release their hold
on the blood vessel walls so the body can remove them naturally.
Tab; INH: Isoniazid is an antibiotic, which is used as an antibacterial, for tubercular meningitis.
Streptomycin: Streptomycin injection is used to treat moderate to severe bacterial infections in
many different parts of the body. Streptomycin belongs to the class of medicines known as
aminoglycoside antibiotics. It works by killing bacteria or preventing their growth.
Decadron (Dexamethasone): It is prescribed as an anti-inflammatory agent. This drug works on
the immune system to help reduce itching, swelling, and inflammation. Dexamethasone is a
corticosteroid, a class of steroid hormone.
31
Recommendations (Management Plan For Each DRP):
1. Drugs without Indications:Isoniazid (INH) tablets and streptomycin may have been prescribed
without indications. Also the anthelmintic medications may belong to this category of DRPs.
2. Untreated Conditions:Cough for which cough suppressant may be prescribed. In case of
hydrocephalus (buildup of too much CSF in subarachnoid space) and other edematous conditions,
diuretics may be prescribed. Similarly for drowsiness, some relevant agent may be prescribed.
3. Drug Interactions:Cortico-steroids (Decadron) enhance the GI ulceration caused by
NSAIDs. The various antibiotics prescribed may interact with each other and reduce their
effectiveness. Ceftriaxone increases CSF proteins level. STREPTOMYCIN—
CEFTRIXONE causes Nephrotoxcity. Streptomycin may be replaced if it is not
necessary. Corticosteroids reduces plasma concentration of INH, so the dose must be
adjusted accordingly. Corticosteroid with Rifampicin and Isoniazid should be avoided if
possible.
4. Improper Drug Selection:It may be the case that an antibiotic to which the pathogens
are resistant is prescribed and hence needs revision. Also it may happen that an expensive
brand is being prescribed, in place of which a more economic brand is available.
Ceftriaxone is prscribed while the drug of choice is Cefotoxime and Penicllin.
5. Requiring Dose Adjustment in Renal Impairment: The dose of Ceftriaxone may need
to be adjusted in a renally-impaired patient whose serum creatinine level goes above
normal.
6. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available, which can generally be afforded by financially challenged population.
32
Prescribed Drugs Alternative Brands Retail Price
Zeftrox Rs. 88
Epival Rs. 63
33
Sodium Valpro Rs. 41
Valproate
Decadron Rs. 56
Dexamethasone
Dexamex Rs. 35
Provas Rs. 15
Paratol Rs. 14
CASE NO. 02
Patient’s Information:
Gender: Male
Weight: 9.5kg
Chief Complaints:
Fever …...…………. 4 days
Fits ………………... 2 days
Rash ………………. on face
34
History of present illness:According to the attendant, the patient had fever for 4 days now. This
fever was high grade and associated with chills. Fits come every 1hr and come for 5 minutes. It is
associated with up-rolling of eyes, not associated with unconsciousness. Also patient has rash on face. On
examination, he is ill-looking and febrile.
GENERAL ASSESMENT:
Vital signs tests Results
Temperature 98 – 104oF
CSF EXAMINATION:
Physical Examination:
Colour: colorless
Volume: 1.5ml
Clotting: nil
Turbidity: nil
Chemical Examination:
Proteins: 80 mg/dl
Glucose: 48 mg/dl
35
Microscopic Examination:
Neutrophils: 10 %
Lymphocytes: 90 %
WBC count: 55/cmm
RBC count: 0.5/cmm
Staining:-ve
Three times
5/5/20 Inj; Aclova 100mg I/V infusion 30ml daily (TDS)
Twice daily
Inj; Quinine 0.33cc in D/W 100ml I/V 0.33cc (BD)
Inj: Phenobarb 1cc I/V, then 0.2cc I/V 1.2cc Twice daily
Three times
INF; Provas 10ml I/V 10ml daily (TDS)
Three times
7/5/20 Inj; Vancomycin 150mg I/V in 100ml IV fluids 150mg daily (TDS)
CASE ANALYSIS:
36
Aclova (generic: Acyclovir): It belongs to DNA polymerase inhibitor pharmacological group on
the basis of mechanism of action and also classified in Antiviral Agents pharmacological group.
It is indicated for Herpes simplex infections, Varicella zoster infections, Herpes simplex infection
in neonates, prophylaxis of CMV (CytoMegaloVirus) infection in bone marrow transplant
recipient and Herpes simplex (in immuno-compromised patients). Acyclovir Injection is a
formulation for intravenous administration.
Quinine: It have antipyretic (fever-reducing), anti-malarial, analgesic (painkilling) and anti-
inflammatory properties and so is used for these purposes.
Phenobarb: Phenobarbital is often referred to as simply 'pheno' or 'phenobarb' and abbreviated as
PB.It is along-acting barbiturate and the most widely used anti-seizure medication globally. It has
also sedative properties.
Rocephin: (generic: Ceftriaxone): It is an antibiotic given to adults and children (including
newborn babies). It works by killing bacteria that cause infections. It belongs to a group of
medicines called cephalosporins. Rocephin is used to treat infections of the brain (meningitis).
Provas: It is a brand drug for the generic Paracetamol which is used as analgesic and antipyretic
agent.
Vancomycin: (brand: Vancocin): This medicine is used for severe infections caused by bacteria
which can resist other antibiotics. It is used in patients who have not responded to treatment with,
or have had a bad reaction to, other antibiotics.
Phenobarbitone: It is along-acting barbiturate and the most widely used anti-seizure
medication globally. It has also sedative properties. It reduces the agitation and calms the patient
down.
37
Requiring Dose Adjustment in Renal Impairment Yes
Excessive Dose No
Improper Duration No
Therapeutic Duplication No
38
Rocephin Rs. 477
Zeftrox Rs. 88
Provas Rs. 15
Paratol Rs. 14
CASE NO. 03
Patient’s Information:
39
Age: 1½ months Peads-A Narowal
DOD: 8/5/20
Bed No: 05
Gender: Male
Weight: 4kg
Chief Complaints:
Fever…………………2 days (high grade)
Fits…………………..1 day (frequent attacks)
History Of Present Illness:According to the attendant, the patient had fits since 1 day. It came
after every hour for 10-15 minutes. It is associated with up-rolling of eyes. It is also associated with post-
ictal unconsciousness for ten minutes. Fits were continuous after every hour.
GENERAL ASSESMENT:
40
Vital signs tests Results
Temperature 98 – 100oF
PR (pulse rate) -
Respiration rate -
Physical Examination:
Colour: clear
Volume: 1ml
Clotting: nil
Turbidity: nil
Chemical Examination:
Proteins: 88mg/dl
Glucose: 30mg/dl
Microscopic Examination:
Neutrophils: 00 %
Lymphocytes: 100 %
WBC count: 35/cmm
RBC count: 55/cmm
Staining:
Gram staining: no microorganism seen
Z.N staining: no AFB seen
Hospital Treatment:
Date Brand, Dosage-Form, Generic &Strength DOSE Frequency
41
7/5/20 Inj; Vitamin D3 ½ IM 2 units Once daily
CASE ANALYSIS:
42
Valium (generic - Diazepam): It is prescribed as an anticonvulsant. Valium is a benzodiazepine
that is used to treat anxiety disorders or muscle spasms. Valium is sometimes used with other
medications to treat seizures.
Excessive Dose No
Improper Duration No
Therapeutic Duplication No
43
4. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available, which can generally be afforded by financially challenged population.
Zeftrox Rs. 88
44
CASE NO. 04
Patient’s Information:
Gender: Male
Weight: 10kg
Chief Complaints:
Fever…………………7 days
Loss of appetite……...7 days
History Of Present Illness:According to the mother of the patient, he was alright 7 days before,
but since then suffered from continuous high grade fever that was also associated with the loss of
appetite.
45
Glucose: 35mg/dl
Microscopic Examination:
Polymorphs: 40 %
Lymphocytes: 60 %
Atypical cells: ---
WBC count: 220/cmm
RBC count: 72/cmm
Staining:
Gram staining: no microorganism seen
Z.N staining: no AFB seen
Monocytes 2-10% 2%
Eosinophils 0-6% 2%
46
HOSPITAL TREATMENT CHART:
General Assessment:
Parameters Results
Temp 96-102OF
Anemia -ve
Jaundice -ve
Cyanosis -ve
CASE ANALYSIS:
47
Plabolyte-M: (5% Dextrose and Electrolytes Injection) It is a maintenance solution and provides
electrolytes along with calories for some metabolic needs and supplies daily requirements of
water and electrolytes.
Aclova (generic - Acyclovir): It belongs to DNA polymerase inhibitor pharmacological group on
the basis of mechanism of action and also classified in Antiviral Agents pharmacological group.
It is indicated for Herpes simplex infections, Varicella zoster infections, Herpes simplex infection
in neonates, prophylaxis of CMV (CytoMegaloVirus) infection in bone marrow transplant
recipient and Herpes simplex (in immuno-compromised patients). Acyclovir Injection is a
formulation for intravenous administration.
Vancomycin: (brand: Vancocin): This medicine is used for severe infections caused by bacteria
which can resist other antibiotics. It is used in patients who have not responded to treatment with,
or have had a bad reaction to, other antibiotics.
Oxidil (generic - Ceftriaxone): It is prescribed for the treatment of meningitis and is much
cheaper than Rocephin. It is an antibiotic given to adults and children (including newborn
babies). It works by killing bacteria that cause infections. It belongs to a group of medicines
called cephalosporins.
Rocephin (generic - Ceftriaxone): It is prescribed for the treatment of meningitis. It is an
antibiotic given to adults and children (including newborn babies). It works by killing bacteria
that cause infections. It belongs to a group of medicines called cephalosporins. Rocephin is used
to treat infections of the brain (meningitis).
Excessive Dose No
Improper Duration No
Therapeutic Duplication No
48
Recommendations (Management Plan For Each DRP):
Zeftrox Rs. 88
49
CASE NO. 05
Final Diagnosis:Meningitis
Patient’s Information:
Gender: Female
Weight: 08kg
Chief Complaints:
The one year old Kashmala presented us with the following symptoms;
Fever………………..1 week
Fits (GTC)………….3 days back, 2nd today at 11:00 am
Cough……………….on / off
History Of Present Illness:According to the attendant, the patient has high-grade fever for the
last 1 week which is intermittent. It is not associated with chills. Also patient has cough on/off which is
50
dry (non-productive; doesn’t produce sputum). Also had fits 3 days back and again today which was
associated with up-rolling of eyes.
Birth History:
FTP (full-term pregnancy), NVD (normal vaginal delivery) at hospital
Past Medical History:The patient had measles 3 months back. Also febrile fit at the time of
measles.
Developmental History:Normal
Feeding History:
Breast fed
Weaning started at the age of nine months
On Examination (O/E):
Febrile
Respiration rate: 35/min
Abdomen: soft, non-tender
CVS: S1 + S2 + 0
Hospital Treatment:
51
9/5/20 INJ: Rocephin 500mg IV 500mg two times daily
As
Nebulin Nebulization necessary 6 hourly
CASE ANALYSIS:
52
Drug Interactions Yes
Excessive Dose No
Therapeutic Duplication No
53
5. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available, which can generally be afforded by financially challenged population.
Zeftrox Rs. 88
54
CASE NO. 06
Final Diagnosis:Meningitis
Patient’s Information:
Gender: Female
Weight: 5.3kg
Chief Complaints:
History Of Present Illness:According to mother, the patient has fever since 3 days. This fever
was high grade and continuous. Patient also has fits since 2 days which came every 1 hr and lasted for 10-
15 minutes. It is associated with up-rolling of eyes and close eyes for 30 minutes. Also patient cries a lot
throughout the day continuously.
Birth History:
FTP (full-term pregnancy), NVD (normal vaginal delivery) at hospital
55
Past Medical History:Not significant.
Developmental History:Normal
On Examination (O/E):
Febrile
Ill-looking
Irritable child with high-pitched excessive crying
Respiration rate: 30/min
Pulse rate: 120/min…………………..108/min
Abdomen (GIT): soft, non-tender, no visceromegaly
CVS: S1 + S2 + 0
56
Tests Monocytes 2-10% 3%
Eosinophils 0-6% 2%
GENERAL ASSESSMENT:
Edema -ve
Cyanosis -ve
CSF EXAMINATION:
Physical Examination:
Colour: colorless
Volume: 1.5ml
Clotting: nil
Turbidity: nil
Chemical Examination:
Proteins: 80 mg/dl
Glucose: 48 mg/dl
Microscopic Examination:
Neutrophils: 10 %
Lymphocytes: 90 %
WBC count: 55/cmm
RBC count: 0.5/cmm
Staining: -ve
57
Date Brand, Dosage-Form, Generic &Strength DOSE Frequency
Twice daily
9/5/20 Inj; Rocephin 250ml through IV canula 250ml (BD)
Twice daily
Inj; Plabolyte-M 250ml IV 250ml (BD)
½
dropper
Inj: Panadol drops through ½ dropper size Once daily
Thrice daily
10/5/20 Inj; Aclova 75mg IV (in 30ml infusion) 75mg (TDS)
CASE ANALYSIS:
58
Panadol Drops: It is a suspension of Paracetamol. Children’s Panadol Suspension 1 – 6 years
provides effective relief of fever and pain in younger children.
Excessive Dose No
Therapeutic Duplication No
59
brand is being prescribed, in place of which a more economic brand is available.
Ceftriaxone is prscribed while the drug of choice is Cefotoxime and Penicllin.
4. Requiring Dose Adjustment in Renal Impairment: The dose of Ceftriaxone may need
to be adjusted in a renally-impaired patient whose serum creatinine level goes above
normal.
5. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available, which can generally be afforded by financially challenged population.
Zeftrox Rs. 88
CASE NO. 07
Final Diagnosis:Meningitis
60
Patient’s Information:
Gender: Male
Weight: 9.2kg
Chief Complaints:
Loose motions……… 1 day
Vomiting…………….1 day
High grade fever …... 1 day
Fits ……………….....1 day
History Of Present Illness:According to the mother of the baby, he was in his usual state of
health since yesterday evening when suddenly he started loose motions (diarrhea) which is watery and has
foul smell. There is no blood or mucous in the stool. He is also suffering from high grade fever since 1
day, which is associated with vomiting. He has suffered from fits since this morning.
Birth History:
FTP, NVD, with immediate cry
Developmental History:Normal
61
Feeding History:Exclusively breast-fed
On Examination (O/E):8 months old male child with average build presented to us with
unconscious state having;
Temperature: 990F
Pulse rate: 129/min
Respiration rate: 47/min
Dehydration: ++
Abdomen (GIT): soft, non-tender
Heart sounds: S1 + S2 + 0
Eosinophils 0-6% 2%
62
GENERAL ASSESSMENT:
CVS S1 + S2 + 0 S1 + S2 + 0 S1 + S2 + 0
Physical Examination:
Colour: Watery
Volume: 1.5ml
Clotting: nil
Turbidity: nil
Microscopic Examination:
Neutrophils: 10 %
Lymphocytes: 90 % (mostly)
WBC count: 04/cmm
RBC count: +
Staining:
63
Gram staining: no microorganism seen
Z.N staining: no AFB seen
8/5/20 Inj; Ceftriaxone 250mg through IV line BD 250mg Twice daily (BD)
INF; Provas (Paracetamol) 13ml I/V TDS 13ml Three times daily
9/5/20
(morning) Inj; Ceftriaxone 500mg IV OD 500mg Once daily
NBM
1ml (start),
9/5/20 Inj; Phenobarb 1ml IV at start, then 0.2cc IV 0.2cc
(evening) OD (then) Once a day
64
Inj; Vancomycin 150mg IV, QID (in 50ml
12/5/20 fluids) 150mg Four times daily
INF; Provas (Paracetamol) 13ml I/V TDS 13ml Three times daily
INF; Provas (Paracetamol) 13ml I/V TDS 13ml Three times daily
CASE ANALYSIS:
65
Phenobarb: Phenobarbital is often referred to as simply 'pheno' or 'phenobarb' and abbreviated as
PB.It is along-acting barbiturate and the most widely used anti-seizure medication globally. It has
also sedative properties.
Vancomycin: (brand: Vancocin): This medicine is used for severe infections caused by bacteria
which can resist other antibiotics. It is used in patients who have not responded to treatment with,
or have had a bad reaction to, other antibiotics.
Provas: It is a brand drug for the generic Paracetamol which is used as analgesic and antipyretic
agent.
Valium (generic - Diazepam): It is prescribed as an anticonvulsant. Valium is a benzodiazepine
that is used to treat anxiety disorders or muscle spasms. Valium is sometimes used with other
medications to treat seizures.
Ciprofloxacin is an antibiotic that can treat a number of bacterial infections. It is a second-
generation fluoroquinolone. Special attention should be paid to available information on
resistance to ciprofloxacin before commencing therapy. Consideration should be given to official
guidance on the appropriate use of antibacterial agents.
Excessive Dose No
Therapeutic Duplication No
66
by a certain anti-emetic agent. Loose motions may be symptomatically treated by prescribing any
anti-diarrheal agent e.g., Lomotil. Otherwise it is non-significant.
2. Drug Interactions: The various antibiotics prescribed may interact with each other and
reduce their effectiveness. Ceftriaxone increases CSF proteins level. Ciprofloxacin is
associated with an increased risk of tendinitis and tendon rupture in all ages.
Ciprofloxacin may exacerbate muscle weakness in persons with myasthenia gravis, so it
must be avoided in patients with known history of myasthenia gravis. Otherwise drug
interactions in this treatment schedule are not significant.
3. Improper Drug Selection:It may be the case that an antibiotic to which the pathogens
are resistant is prescribed and hence needs revision. Also it may happen that an expensive
brand is being prescribed, in place of which a more economic brand is available.
Ceftriaxone is prscribed while the drug of choice is Cefotoxime and Penicllin.
4. Requiring Dose Adjustment in Renal Impairment: The dose of Ceftriaxone may need
to be adjusted in a renally-impaired patient whose serum creatinine level goes above
normal. Quinolones (including Ciprofloxacin) and their metabolites are eliminated by the
kidney. Patients with renal impairment may be at greater risk for adverse effects from
quinolones, including nephrotoxicity, due to decreased drug clearance, so dosage
adjustments may be necessary.
5. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available, which can generally be afforded by financially challenged population.
Provas Rs. 15
Paratol Rs. 14
CASE NO. 08
67
Final Diagnosis:Meningitis
Patient’s Information:
Gender: Male
Weight: 10kg
Chief Complaints:
History Of Present Illness:The patient was presented to the ward in a state of shock with fits.
The patient has generalized tonic-clonic fits for the last 2 days. The patient has high grade fever for 1 day.
The patient has bleeding from mouth and nose for one day. Also hemato-emesis i.e. blood in vomiting for
one day. The patient also has reported chest infection since birth.
68
Pulse rate: 130/min
Heart sounds: S1 + S2 + 0
Heart murmur: Nil
Family History:There is history of fits in family. One elder brother died of fits.
TB contact: -ve
Socio-economic history:Satisfactory
Birth History:
FTP, NVD at hospital, NNJ0, BA0
Developmental History:Normal
Vaccination History:done
On Examination (O/E):
Temperature: 980F
Pulse rate: 132/min
Respiration rate: 36/min
GIT: soft, non-tender abdomen and hepatomegaly
Heart sounds (CVS): S1 + S2 + 0
Respiratory system: B/L wheezing chest
CNS: unconscious
69
CT Brain (with or without contrast):
Enhancing sylvian cisterns and tentorium seen bilaterally with generalized hypodensity of
brain.
Normal ventricular system.
Conclusion: Appearances are in keeping with meningitis associated with brain edema.
Eosinophils 0-6% 5%
70
Thromboplastin Time) Patient 76 sec
PT (Prothrombin Time) 11-15 sec Control 14 sec
Patient 16 sec
INR 1.1 sec
GENERAL ASSESSMENT:
Temperature 98oF
Three times a
13/5/20 Inj; Vancomycin IV 200mg/50ml 200mg day (TDS)
Inj; Quinine 100mg IV TDS (in 100ml Pladex 5%) Thrice daily
Three times a
14/5/20 INF; Vancomycin 200mg/50ml 200mg day
71
Inj: Daypime (Cefepime) 500mg 500mg
Inj; Merocon 500mg IV TDS (in 50ml N/S) 500mg Thrice daily
CASE ANALYSIS:
72
symptomatology. Phenytoin exerts its anticonvulsant effect mainly by limiting the spread of
seizure activity and reducing seizure propagation.
Daypime (generic - Cefepime) is a fourth generation cephalosporin antibiotic. Cefepime is
effective in a large variety of bacterial infections. It belongs to peptidoglycan synthesis inhibitor
pharmacological group on the basis of mechanism of action.
Merocon (generic – Meropenem) is an intravenous broad spectrum antibiotic. It has a slightly
greater activity against gram-negative aerobes and slightly less activity against gram positive
anaerobes.
FFP (Fresh Frozen Plasma): It is the liquid portion of human blood that has been frozen and
preserved after a blood donation and will be used for blood transfusion. It is prescribed here to
make up for the bleeding. It is important in the management of bleeding. Also indicated for
replacement of multiple coagulation factors in patients with deficiencies.
Platelets: 1 unit slow IV is prescribed here to help the blood coagulate, so that excessive bleeding
can be halted.
Excessive Dose No
Therapeutic Duplication No
73
1. Untreated Conditions:In case of hydrocephalus (buildup of too much CSF in subarachnoid
space) and other edematous conditions, diuretics may be prescribed. Vomiting may be controlled
by a certain anti-emetic agent. Similarly, something can be done about the chest infection of the
patient. Otherwise it is non-significant.
2. Drug Interactions: It is possible that Epigran (Phenytoin) and Phenobarb (Phenobarbital
Sodium) may interact each other. Phenytoin causes rise in plasma concentration of
phenobarbital sodium, so it is important to monitor the serum level of Phenobarb and
adjust the dosages accordingly. Also there is minor interaction between Phenobarb and
Ulcerex, but that does not cause harm or require change in therapy. There is a major
interaction between phenytoin and cimetidine. Using phenytoin with cimetidine may
increase the effects of phenytoin, so dose adjustment is strictly needed to safely use both
the medications. Phenytoin also has a moderate interaction with food. Phenytoin levels
may decrease when the suspension is given with enteral feedings i.e. Phenytoin
absorption is altered (decreased) with food, so at least 2 hrs gap must be there between
the meal and phenytoin dose for it to absorb easily. Apart from this, the various
antibiotics prescribed may interact with each other and reduce their effectiveness.
3. Improper Drug Selection:It may be the case that an antibiotic to which the pathogens
are resistant is prescribed and hence needs revision. Also it may happen that an expensive
brand is being prescribed, in place of which a more economic brand is available.
Ceftriaxone is prscribed while the drug of choice is Cefotoxime and Penicllin.
4. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available which can generally be afforded by financially challenged population.
74
CASE NO. 09
Final Diagnosis:Meningitis
Patient’s Information:
Gender: Female
Weight: 9.3kg
Chief Complaints:
History of present illness:According to the attendant, the patient has history of loose motion;
yesterday stool color was black but today yellow color stool passed with scanty quantity of mucous and
blood. There is also history of vomiting and yesterday there were streaks of blood with vomiting.
Developmental History:Normal
Vaccination History:notdone
On Examination (O/E):
Afebrile
CNS: Drowsy
Mild anemic
GIT: no distension
Respiratory system: chest is clear
Pulse: 100/min
Temperature: A/F
RR: 20/min
BP: 70/40 mm Hg
CVS: S1 + S2 + 0
Physical Examination:
Colour: colorless
Volume: 1.5ml
Clotting: nil
Turbidity: nil
Chemical Examination:
Proteins: 66 mg/dl
Glucose: 60 mg/dl
76
Microscopic Examination:
Neutrophils: 70 %
Lymphocytes: 28 %
WBC count: 12/cmm
RBC count: 02/cmm
Staining:
Gram staining: no microorganism seen
Z.N staining: no AFB seen
Monocytes 2-10% 1%
Eosinophils 0-6% 1%
GENERAL ASSESSMENT:
Temperature 98 – 104oF
77
HOSPITAL TREATMENT:(medications given)
Date Brand, Dosage-Form, Generic &Strength DOSE Frequency
Twice daily
13/5/20 Inj; Ceftriaxone 500mg IV BD 500mg (BD)
Three times
INF; Flagyl 14ml IV TDS 14ml daily (TDS)
Three times
Inj; Decadron 0.5ml IV TDS 0.5ml daily
CASE ANALYSIS:
78
Rimactal:Rimactal is a bacteriostateic antibiotic based on the main ingredient Rifampicin. Also
used for meningococcal meningitis prophylaxis
Vitamin A (Retinol) is a fat-soluble vitamin. Vitamin A is essential for normal visual function,
for healthy skin and for growth. It plays an important role as an antioxidant as it scavenges free
radicals, thus protects the body from the harm that may be caused by free radicals. Here it is
prescribed as a nutritional supplement against meningitis, which helps in its prevention.
Rifampicin-H: It is prescribed to fight bacterial infections. Here it is precisely prescribed to treat
meningitis. Rifampicin works by killing the bacteria that cause certain infections.
PZA-CIBA (Pyrazinamide) is antituberculosis agent. It may be bacteriostatic or bacteriocidal
against Mycobacterium tuberculosis depending on the concentration of drug attained at the site of
infection. The recent incident in patient life of vomiting with streaks of blood hints towards
tuberculosis infection, which is why this agent is prescribed.
N/G tube feeding: It is a method of artificial feeding which can provide patients with essential
nutrients and hydration through a tube when they cannot eat or drink by natural means. In Naso-
gastric (NG) feeding, a tube is inserted through the nose into the stomach.
Plabolyte-M: (5% Dextrose and Electrolytes Injection) It is a maintenance solution and provides
electrolytes along with calories for some metabolic needs and supplies daily requirements of
water and electrolytes.
Vancomycin(brand: Vancocin): This medicine is used for severe infections caused by bacteria
which can resist other antibiotics. It is used in patients who have not responded to treatment with,
or have had a bad reaction to, other antibiotics.
Decadron (Dexamethasone): It is prescribed as an anti-inflammatory agent. This drug works on
the immune system to help reduce itching, swelling, and inflammation. Dexamethasone is a
corticosteroid, a class of steroid hormone.
Oxidil (generic - Ceftriaxone): It is prescribed for the treatment of meningitis and is much
cheaper than Rocephin. It is an antibiotic given to adults and children (including newborn
babies). It works by killing bacteria that cause infections. It belongs to a group of medicines
called cephalosporins.
79
Cost related problems Yes
Excessive Dose No
Therapeutic Duplication No
80
4. Requiring Dose Adjustment in Renal Impairment: The dose of Ceftriaxone may need
to be adjusted in a renally-impaired patient whose serum creatinine level goes above
normal.
5. Cost Related Problems: There are brands of drugs available that are too costly for some
patients to afford, so more economical and equally safe and effective brands are also
available, which can generally be afforded by financially challenged population.
Diagnosis:Meningitis
Patient’s Information:
Gender: Female
Weight: 4.5kg
81
Chief Complaints:
Fever …................…………. 12 days
Loose motion………………. 1 ½ month
Vomiting ……………………. 1 ½ month
History of present illness:According to the mother, the patient developed loose motion and
vomiting for last 1 month. Then patient developed fever for last 12 days. With these, there is no history of
fits.
Family History:
TB………………..+ve
Asthma…………..+ve
Birth History:
FTP/NVD at hospital, NNJ0, BA0
Developmental History:Normal
Feeding History:
Mother-fed ……………………. 4 days only
Systemic Review:
Baby is pale, anemic and semi-comatose
Abdomen is soft
No neck rigidity
On Examination (O/E):
Afebrile
CNS: active
82
Abdomen: distension is there
Respiratory system: chest is clear (B/L)
Heart rate: 122/min
Heart sounds: S1 + S2 + 0
Respiration Rate: 50/min
Monocytes 2-10% 3%
Eosinophils 0-6% 2%
GENERAL ASSESSMENT:
Temperature 98 – 101oF
83
Ultrasound abdomen Normal
CSF EXAMINATION:
Physical Examination:
Colour: colorless
Volume: 1.5ml
Clotting: nil
Turbidity: nil
Chemical Examination:
Proteins: 73 mg/dl
Glucose: 41 mg/dl
Microscopic Examination:
Polymorphs: 10 %
Lymphocytes: 90 %
WBC count: 24/cmm
RBC count: 30/cmm
Staining:
Gram staining: no microorganism seen
Z.N staining: no AFB seen
Twice daily
Inj; Ceftriaxone 250mg IV BD 250mg (BD)
Three times
INF; Flagyl 7ml IV TDS 7ml daily (TDS)
84
INF; Plabolyte-M 100ml IV BD 100ml Twice daily
Three times
Inj; Aclova 50mg IV TDS (in 30ml fluids) 50mg daily
Three times
Ventolin nebulization TDS daily
Four times
Panadol drops Q.D daily
Three times
Syrup QPlex ½ TSF TDS ½ TSF daily
Three times
INF; Merocon 200mg IV TDS (in 30ml IV fluids) 200mg daily
CASE ANALYSIS:
N/G tube feeding: It is a method of artificial feeding which can provide patients with essential
nutrients and hydration through a tube when they cannot eat or drink by natural means. In Naso-
gastric (NG) feeding, a tube is inserted through the nose into the stomach.
Plabolyte-M: (5% Dextrose and Electrolytes Injection) It is a maintenance solution and provides
electrolytes along with calories for some metabolic needs and supplies daily requirements of
water and electrolytes.
Vancomycin(brand: Vancocin): This medicine is used for severe infections caused by bacteria
which can resist other antibiotics. It is used in patients who have not responded to treatment with,
or have had a bad reaction to, other antibiotics.
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Oxidil (generic - Ceftriaxone): It is prescribed for the treatment of meningitis and is much
cheaper than Rocephin. It is an antibiotic given to adults and children (including newborn
babies). It works by killing bacteria that cause infections. It belongs to a group of medicines
called cephalosporins.
Flagyl (generic – Metronidazole) is a synthetic antibacterial and antiprotozoal agent that
belongs to the nitroimidazole class. Metronidazole is effective therapy against protozoa such as
Trichomonasvaginalis, amebiasis, and giardiasis. In addition, Metronidazole is one of the most
effective drugs available against anaerobic bacterial infections. Metronidazole is also useful in
treating Crohn's disease, antibiotic-associated diarrhea, and rosacea. Here it is prescribed to treat
loose motions.
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Drugs without Indications No
Excessive Dose No
Therapeutic Duplication No
87
Prescribed Drugs Alternative Brands Retail Price
Provas Rs. 15
Paratol Rs. 14
88
Chapter 5
Results and findings
This chapter comprises of analysis of data collected in Peads ward Childern Hospital Lahore,with the
help of Tables and Charts. These tables and charts aids tremendously in understanding this study.
89
S.No Patient Ward Bed Address Gender Age Stay at
Name No.
Hospital
Table 4.2: All the medications prescribed to patients of Meningitis, along with
their Generic names, Brand names and their specific Indication(s)
(Generic)
90
caused by worms
91
26. Meropenem Meronem®, Merocon® Antibiotic for bacterial meningitis
1 29 Days 1 10
2 7 Days 1 10
3 5 Days 1 10
4 4 Days 2 20
5 3 Days 2 20
6 2 Days 3 30
92
Chart: Distribution of Patients on the basis of stay at hospital
1 Male 6 60%
2 Female 4 40%
93
Chart: Gender-wise Distribution of Patients of Meningitis
1 Neonates 00 00%
(1day-1month)
2 Infants 05 50%
(1month-1yr)
3 Child 05 50%
(1yr-12yrs)
4 Adolescent 00 00%
(12yrs-18yrs)
94
Charts: Age-wise Distribution of Patients of Meningitis
1 Shahdara, Lahore 2 20
2 Lahore 1 10
3 Narowal 1 10
4 Gajumata,Lahore 1 10
95
5 Sahiwal 3 30
6 Peshawar 2 20
1 Ceftriaxone 9 13.04
2 Diazepam 2 2.90
96
3 Sodium valproate 1 1.45
4 Ibuprofen 1 1.45
5 Mebendazole 1 1.45
6 Paracetamol 5 7.25
7 Dexamethasone 2 2.90
8 Dimenhydrinate 1 1.45
9 Metronidazole 2 2.90
11 Phenobarbital 4 5.80
12 Cimetidine 1 1.45
13 Mannitol 2 2.90
14 Streptomycin 1 1.45
15 Salbutamol 1 1.45
16 INH+Rifampicin 2 2.90
17 Pyrazinamide 1 1.45
18 Phenytoin Na 1 1.45
19 Cefepime 1 1.45
20 Vitamin A 1 1.45
21 Vitamin D3 1 1.45
22 Plabolyte-M 7 10.14
23 Nebulin 1 1.45
24 Vancomycin 7 10.14
25 Acyclovir 5 7.25
26 Meropenem 3 4.35
28 Smecta 1 1.45
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29 Quinine 2 2.90
30 Ciprofloxacin 1 1.45
Table 4.7: Frequency and percentage of drugs used by the patients of Meningitis
98
Chart: Frequency and percentage of drugs used by the patients of Meningitis
99
S.NO. DRUG RELATED PROBLEMS FREQUENCY %AGE
[DRPs]
100
Chart: Frequency of Drug Related Problem(s) in patients of Meningitis
101
Zeftrox Rs. 88 Zeftrox
102
Chapter 6
Discussion
DISCUSSION
103
During the 3 months project study carried out at Peads-A and Peads-B wards of Hayat Abad
Medical Complex Peshawar, the infectious disease i.e. Meningitis was studied for which 10
cases were analyzed in detail.
During the said duration, we encountered as many as 10 patients that were diagnosed as having
meningitis. These 10 cases of meningitis were meticulously monitored for the assessment of their
condition on quarterly a week basis.
These 10 patients of meningitis were followed for their stay in hospital (as long it was, in these
cases minimum hospital stay of these patients was 2 days while maximum stay was 29 days) and
treatment protocol, their past histories were collected and recorded, their treatment regimens
were monitored and analyzed for any discrepancies, the clinical laboratory tests were checked
and probed into to get a complete understanding of the patient’s condition and to properly
interpret it, the treatment chart was revised where any chance of adverse drug reaction was
detected.
Demographically among these patients 6 were males and 4 females, while age-wise 5 were
infants (1month-1yr) and 5 were in child category (1yr-12yrs).
Area-wise all the patients were belonging to different areas, majority of patients were belonging
to lahore, areas other than lahore to whom the patients were belonging were sahiwal, Peshawar,
narowal, vehari and Gujranwala.
The total (approx. 30) drugs prescribed were of strictly 18 different classes of which Antibiotics
(to fight bacterial infections) were in high ratio; classes of drugs other than Antibiotics were
104
Analgesic and Antipyretic agents (for body aches and hyperthermia),
Anti-Viral drugs (as co-medications in treatment of viral meningitis),
Anti-Histamines (to combat allergy),
Vitamins and Supplements (to make up for essentials),
H2-Receptor Antagonists (against ulcer and bleeding),
Blood-components transfusion products (to make up for blood components),
Anti-Diarrheals (to treat loose motions),
Anti-Tussives (to treat cough) and
Broncho-Dilators (to bring relief of shortness of breath).
Total 48 Drug Related Problems were found, out of which Untreated Conditions were 10,
Improper Drug Selection were 10, Drug Interactions were 10, Drug Without Indications were 1,
Dose Adjustment in Renal Impairment were 7 and Cost Related Problems were again 10.
The most often occurred problems were that related to drug interactions, untreated conditions,
cost related problems, improper drug selection, dose adjustments in various co-morbidities,
required special precautions, adverse drug reactions, monitoring parameters required, and the
improper dosage schedule.
The therapy should be rationalized as much as it is humanly possible, in order to avoid any
mishap that can lead to morbidity, mortality, prolong hospitalization and cost maximization.
105
Chapter 7
Conclusion
CONCLUSION
106
In order to provide safe, effective and cost-effective therapy to the individual patients and whole
community, it can be concluded that positive mutual interaction between physicians, patients,
surgeons, clinical pharmacists and other health-care professionals is necessary which will ensure
rational medication therapy and the desired outcomes.
107
Chapter 8
References
108
REFERENCES
Books Consulted:
For normal laboratory reference values of various tests, the following sources were accessed at
different times,
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The charts presented in this thesis report are originally designed using Microsoft Excel software.
For general information about meningitis, its types, diagnosis, prevention, management and
various other aspects, Wikipedia was accessed at times,http://en.wikipedia.org/wiki/Meningitis
o And also another website,
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The possibility of any interaction among the drugs (and between drugs and food) prescribed to
the patients of meningitis was checked through Drug Interactions Checker at the website,
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The different drugs prescribed to the patients of meningitis, information regarding these drugs
were collected from the following websites,
http://www.medindia.net/doctors/drug_information/home.asp
o http://www.medicines.org.uk/emc/
o http://www.drugs.com/drug_information.html
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For Nutrition's Role in Meningitis i.e. the importance of vitamins and their supplements in the
control and mitigation of meningitis, the following website was accessed at times,
http://www.lef.org/Protocols/Infections/Meningitis/Page-06
110
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111
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