Final Project R2

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“Treatment strategies of meningitis in pediatric”
Group members
Rizwan Ahmad khan 1151
Talha Zulfiqar 1137
Aniqa Fiaz 1111
Majid Munir 1135
Zain Farrukh 1157
FACULTY OF PHARMACY HAJVERY UNIVERSITY EURO CAMPUS

LAHORE
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Signature Page
Head of Department
Dr. Lubna Shakir
Faculty of Pharmacy
Hajvery University, Lahore
Pogram Coordinator
Mam Hina Khalid
Faculty of Pharmacy
Supervisor
Mam Anum Hnif
Faculty of Pharmacy
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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
“Treatment strategies of meningitis in pediatric”
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
approved for submission.
Signature:
Assistant Professor
Mam Anum Hanif
Faculty of Pharmacy,
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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
throughout the project.
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.
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Dedication
This research project is dedicated to:
Almighty Allah, beloved Prophet Muhammad (P.B.U.H), and to all the people who inspired
us and encouraged us throughout this journey.
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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.
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 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.
 The therapy needs to be rationalized as much as it is possible, to reduce this incidence of

drug related problems in order to minimize the related danger and harm.
TABLE OF CONTENTS
S. No. Chapter Title Page No.

Acknowledgement …………………………… 5
Abbreviations ………………………………… 7
Summary ……………………………………… 8
Introduction to Meningitis………………………….... 10
i. History……………………………………... 11
ii. Classification…………………………………. 12
iii. Etiology……………………………………….... 12
Chapter no. 1 iv. Diagnosis………………………………………. 12
v. Treatment……………………………………… 13
vi. Risk Factor………………………………………. 13
Chapter no. 2 Aims and Objectives……………………………………. 14

Literature Review
Chapter no. 3 Methodology……………………………………………. 23
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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 no. 6 Discussion………………………………………………… 112

Chapter no. 7 Conclusion ……………………………………………….. 115
Chapter no. 8 References………………………………………………… 117
Chapter 1
Introduction
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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)
Although S pneumoniae is currently the leading explanation for community-acquired

microorganism infectious disease within the u. s. (1.1 cases per 100,000 population overall), the
speed of diplococcus infectious disease is fifty nine under it absolutely was before the
introduction of the conjugate vaccine in 2000. The incidence of malady caused by S pneumoniae
is highest in youngsters aged 1-23 months and in adults older than sixty years.(Elena Prina. et
al., 2010)
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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)
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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).
(last accessed 29.6.2020)
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).
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Chapter 2
Aims and Objectives,
Literature Review
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AIMS AND OBJECTIVES
The cardinal aims and objectives of this clerkship were:
 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.
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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
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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
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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
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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).
Neonatal Bacterial meningitis:
Neonatal bacterial meningitis continues to be an important cause of mortality and morbidity.

Contributing factors to such mortality and morbidity include our incomplete knowledge on the
pathogenesis of how meningitis-causing bacteria penetrate the blood brain barrier, emergence of
antimicrobial resistance, and difficulty in early diagnosis of meningitis. An early empiric
antibiotic treatment is critical for the management of neonates with bacterial meningitis, but
early recognition of neonatal meningitis continues to be a challenge. Bacterial nucleic acid–
based detection of pathogens and cerebrospinal fluid biomarkers will help in the development of
early diagnosis of neonatal bacterial meningitis. Bacterial penetration of the blood brain barrier is
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essential for the development of meningitis, and the continued elucidation of microbial
penetration of the blood brain barrier is likely to bring a new approach for prevention and
therapy of neonatal bacterial meningitis .(NeoReviews. et al , 2015).
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).
The pathogenesis of pediatric bacterial meningitis is unclear.5 Meningitis-causing pathogens

typically cross the blood-brain barrier (BBB) after colonization of the nasopharynx. The
mechanism of penetration depends on the organism involved. The BBB also exhibits increased
permeability during a meningeal infection.Certain factors increase a person’s risk of bacterial
meningitis, including exposure to the infection (i.e., meningococcal) or Kaplan SL. Bacterial
meningitis in children older than one month: clinical features and diagnosisPediatric bacterial
meningitis is often fatal if treatment is delayed. Pharmacists should be aware of the signs and
symptoms to assist in the timely diagnosis of meningitis in pediatric patients. If meningitis is
suspected, an examination of the CSF via LP should be performed in eligible patients to
determine the organism involved. Immediate initiation of antibiotics and supportive care is
essential for reducing the morbidity and mortality of meningitis. Even with treatment, patients
may have long-term neurologic sequelae. Pharmacists should recommend the discussed
vaccinations knowing that they may reduce the risk of meningitis. (Kaplan SL. et al., 2016).
Kaplan SL. Bacterial meningitis in children: neurologic complications.Dexamethasone medical

aid has been enforced on an oversized scale as connected treatment of adults with diplococcus
infectious disease within the Netherlands. The prognosis of diplococcus infectious disease on a
national level has considerably improved once the introduction of connected Decadron medical
aid. This study provides category III evidence that Decadron (10 mg IV, given each six hours for
four days started before or with the primary dose of channel antibiotics) reduced the proportion
of patients with unfavorable outcomes (Glasgow Outcome Scale score of one to 4) within the
2006–2009 cohort, as compared to the 1998–2002 cohort (39% vs 50%; OR zero.63; ninety fifth
CI zero.46–0.86; p = 0.002). death rate (20% vs 30%; absolute risk distinction 10%; ninety fifth
CI 4%–17%; p = zero.001) was additionally lower in 2006–2009. (M.C. Brouwer. et al., 2010).
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
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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).
CSF sterilization as a result of antibiotic pretreatment may result in unwarranted or unnecessarily

Prolonged treatment if the clinical presentation and Other laboratory investigations cannot
exclude the possibility of bacterial meningitis. Of the 12 cases With culture-negative pleocytosis
that failed to meet Our study criteria, at least 7 were pretreated patients Who received :7 days of
parenteral antibiotics for This reason, including 1 whose LP was completed Within 5 minutes
after antibiotics. Previous lactam Administration is unlikely to prevent recognition of Organisms
with reduced susceptibility. However, Pretreatment with multiple antibiotics that target resistant
organisms may preclude the use of simpler And less toxic regimens, if cultures subsequently fail
To yield a bacterial pathogen. (Klugman KP. et al ., 1995).
In conclusion, the presence of eosinopenia at the admission Of children presenting meningitis is

a simple diagnostic andPrognostic tool to differentiate quickly bacterial from asepticMeningitis.
Although its sensitivity remains lower than thePCT, eosinopenia has not competitor when such
biomarkersAre unavailable or doable in routine. We believe its costeffectiveness makes it
particularly attractive in low- and Middle-income countries. A larger study is necessary
toconfirm those findings that are only applicable to meningitis and pediatrics.
(Recommandations. Paris et al., 2008).
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
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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).
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Chapter 3
Methodology
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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.
 Demographic information of patients

 Chief complaints (C/C)
 History of present illness
 Past medical and surgical history
 Family/ social/ personal/ medication history
 Clinical Laboratory tests
 Treatment at hospital
 Discharge medications
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 Daily progress report (DPR)
 Drug related problems (DRPs)
Chapter 4
Medication History
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CASE NO. 01
Final Diagnosis: Pyogenic Meningitis
Patient’s Information:
Name: Umar Ward: Address:Shahdaralahore DOA: 19/04/20

Ali
Peads-B
Age: 08 years DOD: 18/05/20
BedNo: 01
Gender: Male
Weight: 23kg
Chief Complaints:
 Fever…………………….7 days
 Vomiting………………...7 days
 Fits………………………5 days
 Drowsiness…………….. 3 days
 Headache………………..7 days
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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):
 Meningial enhancement is seen in basal region, tentorium and bilateral parietal

regions
 There is no evidence of mass/ mass effect
 Normal ventricular system
 Mild dilatation of lateral, 3rd and 4th ventricles
 The gray white matter differential is normal
 Basal cistern and cortical sulci are normal
 No evidence of midline shift
 No evidence of hemorrhagic / infarct
 Brainstem and cerebellum appear normal
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
CLINICAL LABORATORY TESTS:

Test Reference range Results
Serum Na+ 135-145mmol/L 123 mmol/L
electrolytes K+ 3.5-5mmol/L 4.0 mmol/L
Blood urea (BUN) 8-18mg/dl 22 mg/dl
RFTs Serum creatinine M 0.6-1.2mg/dl 0.7 mg/dl
(Crs) F 0.5-1.1mg/dl
Blood Sugar RBS (glucose random) 65-155mg/dl 117mg/dl
Hb test M 12-18gm/dl 11.4 gm/dl

F 12-16gm/dl
WBC/TLC 4000-11000/cmm 9200/cmm
Neutrophils 40-70% 85%

Hematological
Lymphocytes 20-25% 12%
Tests
Monocytes 2-10% 1%
Eosinophils 0-6% 2%
PLT (Thrombocyte/Platelet count) 150-450x103/cmm 459x103/cmm
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:
General vital signs Readings at different time points
Temp 98OF 99OF 100OF 101OF 102OF
BP(mmHg) 100/60 110/70
HOSPITAL TREATMENT:
Date Brand, Dosage-Form, Generic & Strength DOSE Frequency
Syp; Epival (Sodium Valproate) 250mg/5ml

19/4/20 1TSF 250mg Twice daily
Syp; Brufen (Ibuprofen) DS 1TSF QID
20/04/20 Inj: Vancomycin 350mg with infusion 350mg
21/4/20 Inj: Vancomycin 500mg in infusion 500mg
Inj: Epival 250mg with infusion 250mg
Inj; Rocephin (Ceftriaxone) 1gm
23/04/20 Inj; Vancomycin 500mg 500mg
INF; Plabolyte-M 500ml 500ml
Inj; Rocephin (antibiotic) 1gm
INF; Provas (Paracetamol) 20ml 20ml
28
Inj; Meronem (meropenemtrihydrate) 1g I/V 1gm Three times daily
INF; Mannitol 100ml 100ml
2/5/20 INF; Meronem 1g IV TDS (in 100ml fluids) 1gm Three times daily
INF; Manitol 100ml IV OD 100ml Once daily
6/5/20 Tab; Rimactal (Rifampicin) 300mg Twice daily
Tab; Vermox (Mebendazole) 100mg Twice daily
Inj; Gravinate[Dimenhydrinate] ½ IM
Inj; Rocephin (Ceftriaxone) 1gm
7/5/20 NG tube feeding
Syp; PZQ (Praziquantel)11cc p/o 11cc Once daily
Tab; INH 100mg 2 ½ tab 100mg Once daily
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
Inj; Decadron 1cc IV 1cc Three times daily
8/5/20 INF; Meronem 1gm in 100ml infusion 1g Three times daily
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
Indications Of Prescribed Medications (Case Specific):
 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.
Drug Related Problems (DRPs):
Drugs without Indications Yes
Untreated Conditions Yes
Cost related problems. Yes
Drug Interactions Yes
Requiring Dose Adjustment in Renal Yes

Impairment
Improper Drug Selection Yes
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
Rocephin Rs. 477
Ceftriaxone Bestrix Rs. 220
Sporcef Rs. 321
Oxidil Rs. 200
Zeftrox Rs. 88
Mercefex Rs. 196
Gravinate Rs. 150
Dimenhydrinate Grinit Rs. 90
Devom Rs. 106
Vancocin Rs. 743
Vancomycin Maparax Rs. 350
Vancorin Rs. 666
Epival Rs. 63
33
Sodium Valpro Rs. 41
Valproate
Decadron Rs. 56
Dexamethasone
Dexamex Rs. 35
Paracetamol Panadol Rs. 25
Provas Rs. 15
Paratol Rs. 14
CASE NO. 02
Final Diagnosis:Viral Meningitis
Name:Faizan Afzal Ward: Address: DOA: 05/05/20

Lahore
Age: 7 months Peads-B
DOD: 08/05/20
BedNo: 04
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.
Family History:There is history of fits in family.

electrolytes Cl- 95-105mmol/L 102 mmol/L
K+ 3.5-5mmol/L 4.4 mmol/L
GENERAL ASSESMENT:
Vital signs tests Results
Temperature 98 – 104oF
PR (pulse rate) 120/min
Respiration rate 22/min
CSF EXAMINATION:
 Colour: colorless
 Volume: 1.5ml
 Clotting: nil
 Turbidity: nil
 Proteins: 80 mg/dl
 Glucose: 48 mg/dl
35
 WBC count: 55/cmm
 RBC count: 0.5/cmm
 Staining:-ve
HOSPITAL TREATMENT:(medications given)
Date Brand, Dosage-Form, Generic &Strength DOSE Frequency
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
6/5/20 Inj: Rocephin 500mg I/V 500mg 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)
Tab; Phenobarbitone 1tablet OD at night 1 unit Once daily
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).
agent.
 Vancomycin: (brand: Vancocin): This medicine is used for severe infections caused by bacteria
 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.
Drugs without Indications No
37
Requiring Dose Adjustment in Renal Impairment Yes
Excessive Dose No
Improper Duration No
Therapeutic Duplication No

diuretics may be prescribed. Similarly for rash, some relevant agent may be prescribed.
2. Drug Interactions: The various antibiotics prescribed may interact with each other and
reduce their effectiveness. Ceftriaxone increases CSF proteins level. Drug Interactions in
this treatment schedule are not significant. Though there is chance of minor interaction
between Aclova and Rocephin but that is unlikely and non-significant.
4. 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.
38
Rocephin Rs. 477
Sporcef Rs. 321
Oxidil Rs. 200
Zeftrox Rs. 88
Mercefex Rs. 196
Vancocin Rs. 743
Vancorin Rs. 666
Provas Rs. 15
Paratol Rs. 14
CASE NO. 03
Final Diagnosis:Viral Meningitis
Name: Sameer Ward: Address: DOA: 5/5/20
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.
[The post-ictal state is the altered state of consciousness after an epileptic seizure. It usually lasts

between 5 and 30 minutes, but sometimes longer in the case of more severe seizures and is characterized
by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms]
On Examination (O/E):The patient is semi-conscious and ill-looking.

GENERAL ASSESMENT:
40
PR (pulse rate) -
Respiration rate -
CSF EXAMINATION (tests required):
 Colour: clear
 Volume: 1ml
 Clotting: nil
 Turbidity: nil
 Proteins: 88mg/dl
 Glucose: 30mg/dl
 RBC count: 55/cmm
 Staining:
 Gram staining: no microorganism seen
 Z.N staining: no AFB seen
Hospital Treatment:
5/5/20 Inj: Rocephin 500gm IV (Ceftriaxone) 500 mg Once daily
Inj; Aclova 50mg IV 50mg Thrice daily
Inj: Plabolyte 100ml IV 100ml TDS
Inj: Phenobarbitone IV 80mg at start, then 20mg 80mg and

Phenobarbitone IV 20mg Once daily
41
7/5/20 Inj; Vitamin D3 ½ IM 2 units Once daily
INF; 10% Dextrose/Saline 20ml IV slowly 20ml
Inj; Valium 0.3cc 0.3cc
CASE ANALYSIS:
 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).
 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.
 Plabolyte: (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.
 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.
 Vitamin D3 or Cholecalciferol (generic - Calciferol): This is important for the absorption of
calcium from the stomach and for the functioning of calcium in the body. Cholecalciferol is used to
treat or prevent many conditions caused by a lack of vitamin D, especially conditions of the skin or
bones. It is generally prescribed for weak bones.
 10% Dextrose/Saline: This solution contains dextrose and sodium chloride.It is used to replenish
fluids and electrolytes in the body. Also it serves as a source of instant calories.
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.
Cost related problems Yes
Excessive Dose No

diuretics may be prescribed.
2. Drug Interactions: Ceftriaxone increases CSF proteins level. There is safety concern
when Calciferol and seizure medications like Valium and Phenobarbitone are
administered concurrently.
43
Rocephin Rs. 477
Sporcef Rs. 321
Oxidil Rs. 200
Zeftrox Rs. 88
Mercefex Rs. 196
44
CASE NO. 04
Final Diagnosis:Septic or Pyogenic Meningitis (TBM)
Name:AmanUllah Ward: Address: DOA: 2/5/20
Age: 7 years Peads-B Gajumatalahore

DOD: 6/5/20
Bed No: 05
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.
CSF EXAMINATION (test required):
 Physical Examination (fluid report):

 Volume: 1ml
 Clotting: nil
 Turbidity: nil
 Proteins: 113mg/dl
45
 Glucose: 35mg/dl
 Polymorphs: 40 %
 Atypical cells: ---
 Staining:

RBC (Erythrocytes/ Red blood cells) M 4-6x 106/µl 4.56 x 106/µl

F 3.5-5x106/µl
F 12-16gm/dl
PCV (packed cell volume or M: 40-52% 36.7%
hematocrit) F: 36-47%
MCV (mean cell volume) 27-33pg (picogram) 80.2pg (increased)
Hematological Tests MCH (mean cell hemoglobin) 76-96fl 25.2 fl (decreased)
MCHC (mean corpuscular hemoglobin 33-35g/dl 31.3 g/dl

concentration)
WBC/TLC 4000-11000/µl 6400/µl
Lymphocytes 20-25% 45% (increased)
Monocytes 2-10% 2%
Eosinophils 0-6% 2%
PLT (Thrombocyte/Platelet count) 150-450x103/µl 252x103/µl
46
HOSPITAL TREATMENT CHART:
2/5/20 Inj; Plabolyte-M 500ml IV 500 ml Twice daily
Inj: Aclova 200mg IV (in 30ml infusion) 200mg Thrice daily
Inj: Vancomycin 300mg IV 300mg Thrice daily
4/05/20 Inj: Oxidil 1gm IV 1gm Twice daily
5/5/20 Inj; Rocephin IV 1gm BD 1gm Twice daily
General Assessment:
Parameters Results
Temp 96-102OF
BP(mmHg) 120/80 mm Hg (normal)
PR /mint 60-100/min (normal)
Anemia -ve
Jaundice -ve
Cyanosis -ve
CASE ANALYSIS:
47
 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.
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
48
1. Untreated Conditions:Cough; for which mypramine maleate can be given. In case of

diuretics may be prescribed. Also to stimulate appetite, Cyproheptadine (CYPRODIN) 1 mg TDS
can be given.
reduce their effectiveness. Ceftriaxone increases CSF proteins level. Drug Interactions in
this treatment schedule are not significant. Though there is chance of minor interaction
Rocephin Rs. 477
Sporcef Rs. 321
Oxidil Rs. 200
Zeftrox Rs. 88
Mercefex Rs. 196
49
CASE NO. 05
Final Diagnosis:Meningitis
Name:Kashmala Ward: Address:sahiwal DOA: 9/05/20
Age: 01 year Peads-A

DOD: 11/05/20
Bed No: 09
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
BA (birth asphyxiation) –ve, NNJ (neo-natal jaundice) +ve, physiological
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
Vaccination History:Not done
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:

 Nebulin: It is prescribed to treat neuro-muscular diseases. It restores the strength back to the
muscles.
[ Nebulin is an actin-binding protein which is localized to the thin filament of the sarcomeres in
skeletal muscle. It is a very large protein and binds as many as 200 actin monomers. Because its
length is proportional to thin filament length, it is believed that nebulin acts as a thin filament
"ruler" and regulates thin filament length during sarcomere assembly. Other functions of nebulin,
such as a role in cell signaling, remain uncertain. Mutations in nebulin cause some cases of
the autosomal recessive disorder, nemaline myopathy ].
52
Excessive Dose No

Impairment

diuretics may be prescribed. Also to control fits and the up-rolling of eyes, a relevant agent may
be prescribed.
2. Drug Interactions: Ceftriaxone increases CSF proteins level. Otherwise Drug
Interactions in this treatment schedule are not significant.
normal.
53
Rocephin Rs. 477
Sporcef Rs. 321
Oxidil Rs. 200
Zeftrox Rs. 88
Mercefex Rs. 196
54
CASE NO. 06
Name:Javeria Ward: Address:peshawar DOA: 09/05/20
Age: 3 months Peads-B

DOD: 11/05/20
Bed No: 12
Gender: Female
Weight: 5.3kg
Chief Complaints:
 Fever …...…………. 3 days

 Fits ………………... 2 days
 Excessive crying ……. 3 days
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.
Family History:Not significant.
Birth History:
FTP (full-term pregnancy), NVD (normal vaginal delivery) at hospital
BA (birth asphyxiation) –ve, NNJ (neo-natal jaundice) +ve, physiological
55
Past Medical History:Not significant.
Feeding History:Exclusively breast-fed
Vaccination History:Given till now (up-to-date)
 Febrile
 Ill-looking
 Irritable child with high-pitched excessive crying
 Pulse rate: 120/min…………………..108/min
 Abdomen (GIT): soft, non-tender, no visceromegaly
 CVS: S1 + S2 + 0


F 12-16gm/dl
WBC/TLC 4000-11000/cmm 18900/cmm

Hematological
56
Tests Monocytes 2-10% 3%
Eosinophils 0-6% 2%
GENERAL ASSESSMENT:
PR (pulse rate) 108-120/min
Edema -ve
Cyanosis -ve
CSF EXAMINATION:
 Volume: 1.5ml
 Clotting: nil
 Turbidity: nil
 RBC count: 0.5/cmm
 Staining: -ve
57
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

Impairment
1. Untreated Conditions:In case of hydrocephalus (buildup of too much CSF in subarachnoid

space) and other edematous conditions, diuretics may be prescribed. Also to control fits and the
up-rolling of eyes, a relevant agent may be prescribed. Otherwise it is non-significant.
2. Drug Interactions: Ceftriaxone increases CSF proteins level. Drug Interactions in this
treatment schedule are not significant. Though there is chance of minor interaction
59
normal.
Rocephin Rs. 477
Sporcef Rs. 321
Oxidil Rs. 200
Zeftrox Rs. 88
Mercefex Rs. 196
CASE NO. 07
60
Name:AyanShafiq Ward: Address: DOA: 08/05/20
Age: 8 months Peads-B vehari

DOD: 15/05/20
Bed No: 09
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
Remained admitted in nursery due to sepsis
No history of NNJ, no history of TB contact
Past Medical History:Previous hospitalization +ve in nursery, rest is -ve
61
Vaccination History:not done
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
 Dehydration: ++
 Abdomen (GIT): soft, non-tender
 Heart sounds: S1 + S2 + 0

Hb test M 12-18gm/dl 10 gm/dl

F 12-16gm/dl
WBC/TLC 4000-11000/cmm 20,000/cmm

Hematological
Tests
Monocytes 2-10% 3%
Eosinophils 0-6% 2%
62
GENERAL ASSESSMENT:
Vital signs tests Results date-wise
9/5/14 12/5/14 15/5/14
Temperature 370C 380C 39.50C
PR (pulse rate) 110/min 90/min 85/min
Respiration rate afebrile 35/min 30/min 30/min
CVS S1 + S2 + 0 S1 + S2 + 0 S1 + S2 + 0
CNS Intact drowsiness drowsiness
GIT Soft, non-tender abdomen Soft, non-tender Soft, non-tender

abdomen abdomen
BP (Blood Pressure) - - 80/60
CSF EXAMINATION: (dated: 9/5/20) --- Fluid Report
 Colour: Watery
 Volume: 1.5ml
 Clotting: nil
 Turbidity: nil
 Lymphocytes: 90 % (mostly)
 RBC count: +
 Staining:
63

Date Brand, Dosage-Form, Generic & Strength DOSE Frequency
8/5/20 Inj; Ceftriaxone 250mg through IV line BD 250mg Twice daily (BD)
INF; Plabolyte-M 500cc IV TDS 500cc Three times daily
INF; Ciprofloxacin 25cc IV BD 25cc Twice daily
INF; Provas (Paracetamol) 13ml I/V TDS 13ml Three times daily
Inj; Valium ½ cc IV SOS (dilute in 5cc and

give slowly) ½ cc SOS (when needed)
9/5/20
(morning) Inj; Ceftriaxone 500mg IV OD 500mg Once daily
Inj; Vancomycin 150mg IV, QID (in 50ml

fluids) 150mg Four times daily
Plabolyte-M 250ml IV TDS 250ml Thrice 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
10/5/20 INF; Plabolyte 150ml IV TDS 150ml Thrice daily
11/5/20 Inj; Vancomycin 150mg/50 ml 150ml QID
64
Inj; Vancomycin 150mg IV, QID (in 50ml
12/5/20 fluids) 150mg Four times daily
INF; Plabolyte-M 150ml IV 150ml
INF; Vancomycin 150mg, QID (in 50ml

14/5/20 fluids) 150mg Four times daily
INF; Plabolyte-M 150ml 150ml
Inj; Phenobarb 0.2cc IV OD 0.2cc Once a day
Inj; Ceftriaxone 500mg IV OD 500mg Once daily
CASE ANALYSIS:

water and electrolytes. It is helpful in case of loose motions since it restores all necessary
electrolytes and water level in the body that is lost during diarrhea.
65
also sedative properties.
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

Impairment

space) and other edematous conditions, diuretics may be prescribed. Vomiting may be controlled
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.
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.
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.
Provas Rs. 15
Paratol Rs. 14
CASE NO. 08
67
Name:Khamisullah Ward: Address: DOA: 13/05/20

Lahore
Age: 2 years Peads-B
DOD: 15/05/20
BedNo: 11
Gender: Male
Weight: 10kg
Chief Complaints:
 Fever …...……………………………. 1 day

 Fits …………………………………... 2 days
 Chest infection ………………………. Since birth
 Bleeding from mouth & nose ……….. 1 day
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.
General Physical Exam:Temperature 990F
Cardio Vascular System:
68
 Heart murmur: Nil
Family History:There is history of fits in family. One elder brother died of fits.
TB contact: -ve
HCV contact: -ve
Socio-economic history:Satisfactory
Birth History:
FTP, NVD at hospital, NNJ0, BA0
Vaccination History:done
 Temperature: 980F
 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.
Blood Bank Section Result
 Blood group: O+ve

 Rh factor: +ve

Serum Calcium 8-10.5mg/dl 8mg/dl
electrolytes
Total bilirubin <1 mg /dl 0.8mg/dl

LFTs ALT (alanine aminotransferase) M: 10-50U/L 63 U/L
F: 10-35U/L
ALP (alkaline phosphatase) 41-133U/L 37 U/L
F 12-16gm/dl
WBC/TLC 4000-11000/cmm 20,000/cmm

Hematological
Tests
Monocytes 2-10% 5%
Eosinophils 0-6% 5%
APTT (Activated Partial 17-27sec Control  32 sec
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
Blood Pressure (BP) 90/60 mm Hg
Three times a
13/5/20 Inj; Vancomycin IV 200mg/50ml 200mg day (TDS)
Inj; Ulcerex (Cimetidine) 0.5ml IV BD 0.5ml Twice daily
INF; Mannitol 50ml IV TDS 50ml Thrice daily
Inj; Quinine 100mg IV TDS (in 100ml Pladex 5%) Thrice daily
Inj; Phenobarb 50mg IV OD 50mg Once daily
Inj; Epigran (Phenytoin Na) 0.5ml IV BD (in 50ml

N/S) 0.5ml Twice 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
1 unit of FFP (fresh frozen plasma) IV slowly 1 unit Slowly
1 unit of Platelets IV slowly 1 unit Slowly
CASE ANALYSIS:

also sedative properties. It exerts its anticonvulsant effect mainly by elevating the seizure
threshold.
 Ulcerex (generic - Cimetidine) is a histamine H2-receptor blocking agent. It is considered the
prototype drug for ulcer therapy and is used to control the stomach ulcer and the bleeding
associated therewith, which comes out during vomiting.
 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. Overall it normalizes the
blood pressure in the body.
 Quinine: It has antipyretic (fever-reducing), anti-malarial, analgesic (painkilling) and anti-
inflammatory properties and so is used for these purposes.
 Epigran (generic - Phenytoin Na) is prescribed for its anticonvulsant action. Specifically, it is
used for the prophylactic management of tonic-clonic seizures and partial seizures with complex
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
Requiring Dose Adjustment in Renal No

Impairment
73
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.
available which can generally be afforded by financially challenged population.
Cefepime Daypime Rs. 275
Cefipar Rs. 175
Meropenem Merocon Rs. 800
Merocin Rs. 600
74
CASE NO. 09
Name:Feroza Ward: Address:muridke DOA: 13/05/20
Age: 2 years Peads-B

DOD: 17/05/20
BedNo: 10
Gender: Female
Weight: 9.3kg
Chief Complaints:
 Fever …................…………. 3 days

 Loose motion………………. 3 days
 Vomiting (3-4 times) ……….. 3 days
 Drowsy………………………. 1 day
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.
Family History:Not Significant (there is suspicion for contact TB)
Past Medical History:Not Significant

75
Birth History:
FTP and NVD at home, NNJ0, BA0
Feeding History:home-made foods
Vaccination History:notdone
 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
CSF EXAMINATION (Fluid Report):
 Volume: 1.5ml
 Clotting: nil
 Turbidity: nil
76
 Staining:

Total bilirubin <1 mg /dl 0.5mg/dl

LFTs ALT M: 10-50U/L 130 U/L
F: 10-35U/L
ALP 41-133U/L 108 U/L
F 12-16gm/dl
WBC/TLC 4000-11000/cmm 10,400/cmm

Hematological
Tests
Monocytes 2-10% 1%
Eosinophils 0-6% 1%
GENERAL ASSESSMENT:
77
Twice daily
13/5/20 Inj; Ceftriaxone 500mg IV BD 500mg (BD)
Three times
INF; Flagyl 14ml IV TDS 14ml daily (TDS)
INF; Plabolyte-M 150ml IV BD 150ml Twice daily
INF; Rimactal 500ml IV state 500ml state
Vitamin A 2 units state given 2 units state
15/5/20 Syrup Rifampicin-H 7ml p/o – OD 7ml Once daily
Syrup PZA-CIBA (Pyrazinamide)5ml p/o -- OD 5ml Once daily
Three times
Inj; Decadron 0.5ml IV TDS 0.5ml daily
Inj; Vancomycin 150mg IV TDS (in 50ml IV Three times

fluids) 150mg daily
NG feed 30ml/ 2 hrly 30ml Every 2 hrs
CASE ANALYSIS:
 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.
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.
 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.
79
Excessive Dose No

Impairment

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: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. Corticosteroid with Rifampicin
should be avoided if possible (moderate interaction). There is a possibility of major
interaction between Rifampicin and Pyrazinamide. This can cause damage to the liver.
Liver function and drug levels in the blood may be monitored with blood tests during
treatment. A dose adjustment or special tests may be needed to safely take both
medications. Also Rifampicin and Flagyl can have a moderate interaction with each
other. Using Rifampicin together with Flagyl may decrease the effects of Flagyl, so care
must be taken.
80
normal.
Vancocin Rs. 743
CASE Vancomycin Maparax Rs. 350 NO. 10

Vancorin Rs. 666
Final
Diagnosis:Meningitis
Name:Manahil Ward: Address DOA: 15/05/20
Age: 2 ½ years Peads-B gujranwala

DOD: 20/05/20
BedNo: 17
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
Past Medical History:Not Significant
Birth History:
FTP/NVD at hospital, NNJ0, BA0
Feeding History:
Mother-fed ……………………. 4 days only
Bottle-fed ………………………with Lactogen formula
Systemic Review:
 Baby is pale, anemic and semi-comatose
 Abdomen is soft
 No neck rigidity
Vaccination History:only one vaccine, polio drops given
 Afebrile
 CNS: active
82
 Abdomen: distension is there
 Respiratory system: chest is clear (B/L)
 Heart rate: 122/min
 Respiration Rate: 50/min

RBC (Erythrocytes/ Red blood cells) M 4-6x 106/µl 3.28 x 106/µl

F 3.5-5x106/µl
F 12-16gm/dl
PCV M: 40-52% 27.2%
F: 36-47%
MCV (mean cell volume) 27-33pg (picogram) 82.9pg (increased)
Hematological Tests MCH (mean cell hemoglobin) 76-96fl 29.9 fl (decreased)
MCHC (mean corpuscular hemoglobin 33-35g/dl 36 g/dl

concentration)
WBC/TLC 4000-11000/cmm 12300/cmm
Lymphocytes 20-25% 35% (increased)
Monocytes 2-10% 3%
Eosinophils 0-6% 2%
GENERAL ASSESSMENT:
83
Ultrasound abdomen Normal
CSF EXAMINATION:
 Volume: 1.5ml
 Clotting: nil
 Turbidity: nil
 Polymorphs: 10 %
 Staining:
15/5/20 Inj; Oxidil 250mg IV 250mg
Twice daily
Inj; Ceftriaxone 250mg IV BD 250mg (BD)
Three times
INF; Flagyl 7ml IV TDS 7ml daily (TDS)
N/G feeding 15ml 2 hrly 15ml Every 2 hrs
84
INF; Plabolyte-M 100ml IV BD 100ml Twice daily
Inj; Vancomycin 100mg IV TDS (in 30ml IV Three times

fluids) 100mg 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
Smecta sachet 1 p/o BD Twice daily
Three times
Syrup QPlex ½ TSF TDS ½ TSF daily
NBM------ nothing by mouth
Three times
INF; Merocon 200mg IV TDS (in 30ml IV fluids) 200mg daily
CASE ANALYSIS:
85
 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.

 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.
 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.
 Ventolin (generic – Albuterol/ Salbutamol) is a beta receptor agonist. Albuterol is a short acting
agent and is used only in the managment of acute episode of asthma. It relaxes the smooth muscle
in the lungs and dilates or expands the bronchi (air ways) in lungs and makes breathing easy.
 SMECTA: Smecta is an antidiarrheal gastrointestinal protectant. Smecta is indicated in the
treatment of diarrhea.
 Syrup Qplex: It is indicated for the treatment of cough. It is an Ayurvedic cough syrup.
86
Excessive Dose No

Impairment

by a certain anti-emetic agent. Otherwise it is non-significant.
reduce their effectiveness. Ceftriaxone increases CSF proteins level. Otherwise it is non-
significant.
normal.
87
Meropenem Merocon Rs. 800
Merocin Rs. 600
Vancocin Rs. 743
Vancorin Rs. 666
Provas Rs. 15
Paratol Rs. 14
88
Chapter 5
Results and findings
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.
Table 4.1: Overall 10 cases of Meningitis: Cursory Introduction
89
S.No Patient Ward Bed Address Gender Age Stay at
Name No.
Hospital
1 Umar Ali Peads-B 1 Shahdaralahor M♂ 8 years 29 days

e
2 Faizan Afzal Peads-B 4 Lahore M♂ 7 months 3 days
3 Sameer Peads-A 5 Narowal M♂ 1 ½ month 3 days
4 AmanUllah Peads-B 5 Gajumata, M♂ 7 years 4 days

Lahore
5 Kashmala Peads-A 9 Sahiwal F♀ 1 year 2 days
6 Javeria Peads-B 12 Peshawar F♀ 3 months 2 days
7 Ayanshafiq Peads-B 9 Vehari M♂ 8 months 7 days
8 Khamisullah Peads-B 11 Lahore M♂ 2 years 2 days
9 Feroza Peads-B 10 muridke F♀ 2 years 4 days
10 Manahil Peads-B 17 Gujranwala F♀ 2 ½ years 5 days
Table 4.2: All the medications prescribed to patients of Meningitis, along with
their Generic names, Brand names and their specific Indication(s)
S.No. Drug Names Brand Name(s) Indication(s)
(Generic)
1. Ceftriaxone Rocephin®, Oxidil® For treatment of bacterial meningitis
2. Diazepam VALIUM® As a sedative to relieve fits
3. Sodium valproate EPIVAL® For treatment of seizures
4. Ibuprofen BRUFEN® For treatment of pain, fever and

inflammation
5. Mebendazole VERMOX® As an anti-helmintic, treat infections
90
caused by worms
6. Paracetamol Panadol®, Provas® As an anti-pyretic
7. Dexamethasone DECADRON® As an anti-inflammatory
8. Dimenhydrinate GRAVINATE® For prevention and treatment of nausea

and vomiting
9. Metronidazole Flagyl® To treat loose motions
10. Praziquantel syrup PZQ® As an anti-helmintic, treat infections of

certain parasites
11. Phenobarbital PHENOBARB® As anti-seizure
12. Cimetidine ULCEREX® To control bleeding associated with

stomach ulcer
13. Mannitol MANNITOL® For the reduction of CSF pressure and

intra-cranial pressure (osmotic diuretic)
14. Streptomycin STREPTOMYCIN® In combination with ATT for tubercular

meningitis
15. Salbutamol VENTOLIN® SOB (shortness of breath)
16. INH+Rifampicin Rimactal INH® For tubercular meningitis
17. Pyrazinamide PZA-CIBA® In combination with ATT for tubercular

meningitis
18. Phenytoin Na EPIGRAN® prescribed for its anticonvulsant action
19. Cefepime DAYPIME® effective in a large variety of bacterial

infections
20. Vitamin A RETINOL® as a nutritional supplement against

meningitis, which helps in the
prevention of meningitis
21. Vitamin D3 Calciferol® for weak bones
22. Plabolyte PLABOLYTE-M® dextrose and electrolytes maintenance

solution
23. Nebulin NEBULIN® For muscle weakness
24. Vancomycin Vancocin® to fight antibiotics-resistant bacteria
25. Acyclovir Aclova® for control of viral meningitis
91
26. Meropenem Meronem®, Merocon® Antibiotic for bacterial meningitis
27. Syrup Qplex QPLEX® for the treatment of cough
28. Smecta SMECTA® for the treatment of diarrhea
29. Quinine QUININE® As anti-pyretic and anti-malarial
30. Ciprofloxacin CIPRO® Treatment of a number of bacterial

infections
Stay-at-hospital wise distribution of patients
S.NO. STAY AT HOSPITAL FREQUENCY %AGE
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
Table 4.3: Distribution of Patients on the basis of Stay at Hospital
92
Chart: Distribution of Patients on the basis of stay at hospital
Gender-wise distribution of patients
S.No. GENDER FREQUENCY %AGE
1 Male 6 60%
2 Female 4 40%
Table 4.4: Gender-wise Distribution of Patients of Meningitis
93
Chart: Gender-wise Distribution of Patients of Meningitis
Age-wise distribution of patients
S.NO. AGE GROUPS FREQUENCY %AGE
1 Neonates 00 00%
(1day-1month)
2 Infants 05 50%
(1month-1yr)
3 Child 05 50%
(1yr-12yrs)
4 Adolescent 00 00%
(12yrs-18yrs)
Table 4.5: Age-wise Distribution of Patients of Meningitis
94
Charts: Age-wise Distribution of Patients of Meningitis
Area-wise distribution of patients
S.No. Area (address) Frequency %age
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
Table 4.6: Geographical (area-wise) distribution of Patients of Meningitis
Chart: Geographical (area-wise) distribution of Patients of Meningitis
Drug-wise distribution of patients of Meningitis
S.No. Drugs Frequency %age
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
10 Praziquantel syrup 1 1.45
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
27 Syrup Qplex 1 1.45
28 Smecta 1 1.45
97
29 Quinine 2 2.90
30 Ciprofloxacin 1 1.45
Table 4.7: Frequency and percentage of drugs used by the patients of Meningitis
Drug-wise distribution of patients of Meningitis
98
Chart: Frequency and percentage of drugs used by the patients of Meningitis
DRP-wise distribution of patients of Meningitis
99
S.NO. DRUG RELATED PROBLEMS FREQUENCY %AGE
[DRPs]
1 Drugs without Indications 01 2.1
2 Untreated Conditions 10 20.8
3 Cost related problems 10 20.8
4 Sub-therapeutic Dose 00 0.0
5 Drug Interactions 10 20.8
6 Excessive Dose 00 0.0
7 Requiring Dose Adjustment in Renal 07 14.6

Impairment
8 Therapeutic Duplication 00 0.0
9 Improper Drug Selection 10 20.8
Table 4.8: Frequency of Drug Related Problem(s) in patients of Meningitis
100
Chart: Frequency of Drug Related Problem(s) in patients of Meningitis
Management of Cost-related problems (CRPs)
Prescribed Drugs Alternative Retail Price Suggested Best alternative

Brands (expensive) (economical)
(generics)

Rocephin Rs. 477 Rocephin
Sporcef Rs. 321
Oxidil Rs. 200
101
Zeftrox Rs. 88 Zeftrox
Mercefex Rs. 196
Gravinate Rs. 150 Gravinate
Grinit Rs. 90 Grinit
Dimenhydrinate Devom Rs. 106 Devom (2nd best)
Vancocin Rs. 743 Vancocin
Maparax Rs. 350 Maparax
Vancomycin Vancorin Rs. 666 Vancorin (2nd best)
Sodium Valproate Epival Rs. 63 Epival
Valpro Rs. 41 Valpro
Dexamethasone Decadron Rs. 56 Decadron
Dexamex Rs. 35 Dexamex
Panadol Rs. 25 Panadol
Paracetamol Provas Rs. 15
Paratol Rs. 14 Paratol
Cefepime Daypime Rs. 275 Daypime
Cefipar Rs. 175 Cefipar
Meropenem Merocon Rs. 800 Merocon
Merocin Rs. 600 Merocin
Table 4.9: List of Alternative Cost Effective Brands for Meningitis
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
 NSAIDs, (for pain, fever, inflammation)

 Anti-Convulsants (for seizure treatment),
 Nutrients and Electrolytes (replenishment and maintenance solutions),
 Diuretics (to decrease intra-cranial pressure and to relieve edema),
 Anti-Helmintics (to fight worms),
 Anti-Emetics (to treat vomiting),
 Anti-TB drugs (as co-medications in treatment of tubercular meningitis),
 Anti-Inflammatory agents (to treat meningitis),
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:
 Pharmacotherapy Handbook (The McGraw-Hill Companies, 2009) authored by B.G.

Wells, J.T. DiPiro, T.L. Schwinghammer and C.V. DiPiro, 7th edition, Section 08;
Infectious diseases, Chapter 36; Central nervous system infections, page no. 387-398.
 (BNF-C) BNF for children 2011-2012 by Royal Pharmaceutical Society of Great Britain
and Royal College of Pediatrics and Child Health and others, Section 05; CNS Infections,
Chapter 5.1; Empirical therapy of Meningitis with anti-bacterial drugs, page no. 248
 Lab Notes: Guide to Lab & Diagnostic Tests (F. A. Davis Company, Philadelphia, 2005)
authored by Tracey Hopkins, Cerebrospinal Fluid Analysis (CSF Analysis) at page no.
15
Internet Used:
 For normal laboratory reference values of various tests, the following sources were accessed at
different times,
o http://en.wikipedia.org/wiki/Reference_ranges_for_blood_tests
o http://www.merckmanuals.com/professional/appendixes/normal_laboratory_values/n
ormal_laboratory_values.html
o http://www.globalrph.com/labs.htm
 https://www.medscape.com/answers/961497-179173/what-is-pediatric-bacterial-
meningitis
 http://misc.medscape.com/pi/android/medscapeapp/html/A961497-business.html
 https://www.scribd.com/document/330902863/Meningitis-3
 https://www.scholarsresearchlibrary.com/articles/role-of-community-pharmacist-care-of-
meningitis-patients.pdf
 https://www.news-medical.net/health/Meningitis-Mechanism.aspx
109
 https://www.sciencedirect.com/topics/neuroscience/subarachnoid-space
 Gottschalk M, Higgins R, Boudreau M. Use of polyvalent coagglutination reagents for
serotyping of Streptococcus suis. J ClinMicrobiol. 1993;31:2192–4. [PMC free
article] [PubMed] [Google Scholar]
 https://www.lancet.co.za/wp-content/uploads/2015/07/South-Africa-MENINGITIS-G
%C3%87%C3%B4-THE-BASICS-MARCH2015.pdf
 https://www.who.int/news-room/fact-sheets/detail/pneumonia
 https://www.webmd.com/lung/covid-and-pneumonia#1
 https://www.webmd.com/lung/covid-and-pneumonia#1
 https://www.unicef.org/reports/every-childs-right-survive-pneumonia-2020
 Information about the popular Anti-inflammatory, Decadron was accessed at the following
website address,
o http://www.medicinenet.com/dexamethasone-injectable/article.htm
 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,
o http://www.symptomfind.com/diseases-conditions/meningitis/
 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,
o http://www.drugs.com/drug_interactions.php
 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
 For cost-related problems, price comparisons and to select an economical brand against an
expensive one, the following website was accessed at times, http://www.druginfosys.com/
 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
 https://doi.org/10.1177/20499361211046453
 https://www.cdc.gov
 Harrison, L., Mohan, N. & Kirkpatrick, P. Meningococcal group A, C, Y and W-135

conjugate vaccine. Nat Rev Drug Discov 9, 429–430 (2010).
https://doi.org/10.1038/nrd3194
 https://adc.bmj.com.
 https://doi.org/10.3389/fneur.2019.00421
 CookAM,AngerB,BledsoeK,CastleA,DeenD,etal.Treatmentofhyponatremiainpatientswith
acuteneurologicalinjury.NeurocritCare.(2017)27:242–8.Doi:10.1007/s12028-016-0343-x
PubMedAbstract|CrossRefFullText|GoogleScholar
 https://doi.org/10.1164/ajrccm/148.3.650 PubMed: 8368635
 https://doi.org/10.1212/CPJ.0000000000000023
 https://doi.org/10.1542/neo.16-9-e535
 . www.uptodate.com/contents/bacterial-meningitis-in-children-older-than-one-month-
clinical-features-and-diagnosis. Accessed February 28, 2016. a recent upper respiratory
tractinfection.4
 www.uptodate.com/contents/bacterial-meningitis-in-children-neurologic-
complications. Updated September8,2015.Accessed January23,2016.
 https://doi.org/10.1212/WNL.0b013e3181f96297
 Whitney CG, Farley MM, Hadler J, et al; Active BacterialCore Surveillance of the
Emerging Infections ProgramNetwork. Decline in invasive pneumococcal disease
afterthe introduction of protein-polysaccharide conjugatevaccine. N Engl J Med.
2003;348(18):1737–1746CrossRefPubMedGoogle
 https://doi.org/10.1212/01.wnl.0000191407.81333.00
 Disponiblehttp:/www.infectiologie.com/UserFiles/File/medias/_documents/consensus/
Meningites_consensus-long.pdf.Accessed Apr 2018 Between2001 and2007,444
casesof neonatalbacterial
 Rajasingham R, Rolfes MA, Birkenkamp KE, Meya DB,Boulware DR.

Cryptococcal meningitis treatmentstrategies in resource-limited settings: a cost-
effectiveness analysis. PLoS Med. 2012;9(9):e1001316.[PMCfreearticle][PubMed]
[GoogleScholar].
 Dagan R, The Meropenem MeningitisStudy Group. Randomized comparison of

meropenemwithcefotaximefortreatmentOfbacterialmeningitis.AntimicrobAgentsC
hemother.1995;39:1140–1146
111
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“Treatment strategies of meningitis in pediatric”

Rizwan Ahmad khan 1151

Talha Zulfiqar 1137

Aniqa Fiaz 1111

Majid Munir 1135

Zain Farrukh 1157

FACULTY OF PHARMACY HAJVERY UNIVERSITY EURO CAMPUS

Dr. Lubna Shakir

Hajvery University, Lahore

Mam Hina Khalid

Hajvery University, Lahore

Hajvery University, Lahore

“Treatment strategies of meningitis in pediatric”

approved for submission.

Mam Anum Hanif

Hajvery University, Lahore

throughout the project.

This research project is dedicated to:

us and encouraged us throughout this journey.

 The therapy needs to be rationalized as much as it is possible, to reduce this incidence of

S. No. Chapter Title Page No.

Chapter no. 2 Aims and Objectives……………………………………. 14

Chapter no. 6 Discussion………………………………………………… 112

Although S pneumoniae is currently the leading explanation for community-acquired

(last accessed 29.6.2020)

The cardinal aims and objectives of this clerkship were:

Neonatal Bacterial meningitis:

Neonatal bacterial meningitis continues to be an important cause of mortality and morbidity.

The pathogenesis of pediatric bacterial meningitis is unclear.5 Meningitis-causing pathogens

Kaplan SL. Bacterial meningitis in children: neurologic complications.Dexamethasone medical

CSF sterilization as a result of antibiotic pretreatment may result in unwarranted or unnecessarily

In conclusion, the presence of eosinopenia at the admission Of children presenting meningitis is

 Demographic information of patients

Final Diagnosis: Pyogenic Meningitis

Name: Umar Ward: Address:Shahdaralahore DOA: 19/04/20

 Meningial enhancement is seen in basal region, tentorium and bilateral parietal

CLINICAL LABORATORY TESTS:

Hb test M 12-18gm/dl 11.4 gm/dl

Neutrophils 40-70% 85%

PLT (Thrombocyte/Platelet count) 150-450x103/cmm 459x103/cmm

General vital signs Readings at different time points

Temp 98OF 99OF 100OF 101OF 102OF

BP(mmHg) 100/60 110/70

Syp; Epival (Sodium Valproate) 250mg/5ml

Syp; Brufen (Ibuprofen) DS 1TSF QID

20/04/20 Inj: Vancomycin 350mg with infusion 350mg

21/4/20 Inj: Vancomycin 500mg in infusion 500mg

Inj: Epival 250mg with infusion 250mg

Inj; Rocephin (Ceftriaxone) 1gm

23/04/20 Inj; Vancomycin 500mg 500mg

INF; Plabolyte-M 500ml 500ml

Inj; Rocephin (antibiotic) 1gm

INF; Provas (Paracetamol) 20ml 20ml

INF; Mannitol 100ml 100ml

INF; Manitol 100ml IV OD 100ml Once daily

6/5/20 Tab; Rimactal (Rifampicin) 300mg Twice daily

Tab; Vermox (Mebendazole) 100mg Twice daily

Inj; Rocephin (Ceftriaxone) 1gm

7/5/20 NG tube feeding

Syp; PZQ (Praziquantel)11cc p/o 11cc Once daily

Tab; INH 100mg 2 ½ tab 100mg Once daily

Inj; Decadron 1cc IV 1cc Three times daily

8/5/20 INF; Meronem 1gm in 100ml infusion 1g Three times daily