ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

VICTORIANO LUNA MEDICAL CENTER

WHAOC / OCLUB
Camp Colonel Victoriano Luna Avenue, Quezon City

DIM 03 August 2023

Subject: Justification Letter

To: CHIEF, VLMC

Post
(Attn: Chief, Pharmacy)

1. Reference: List of Medicine not listed in the Philippine National Formulary 6 th

Edition of the Department of Health.

2. Doripenem for injection is indicated for the treatment of infections caused by

susceptible microorganisms in the following conditions: nosocomial pneumonia,
complicated intra-abdominal infection, and complicated urinary tract infection.
Doripenem is one of the four carbapenems commonly used for management of
infection, namely pneumonia. The patient has already been through Ertapenem
and Meropenem, which are both available in the hospital, but only minimal or no
improvement was noted while ongoing therapy. (Include the Drug and Study)

3. C. The medicine is more effective and/or less toxic than a medicine listed for the
same indication
Or
D. The medicine is least as effective and safe and of lower cost than a medicine
listed for the same indication

4. For info and reference

P2LT ARIELLE R VIDAL MC

Resident-in-Charge

CPT CERNAN C OLIVEROS MC

WARD OFFICER, MICU

Or Chief ng Service
 ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND
VICTORIANO LUNA MEDICAL CENTER
WHAOC / OCLUB
Camp Colonel Victoriano Luna Avenue, Quezon City

TREATMENT PROTOCOL

Name: BGEN IGNACIO MAXIMA Age: 56 y/o Sex: FEMALE

Diagnosis: FEBRILE NEUTROPENIA SECONDARY TO HOSPITAL ACQUIRED

PNEUMONIA, SEVERE SEPSIS SECONDARY; MYELODYSPLASTIC SYNDROME
WITH MULTILINEAGE DYSPLASI HIGH RISK; ACUTE TONSILLOPHARYNGITIS
EXUDATIVE; ORAL CANDIDIASIS; TYPE 2 DIABETES MELLITUS; ALLERGIC
RHINITIS, MILD; INTERMITTENT VOCAL CORD CYST, RIGHT; GOUTY ARTHRITIS
NOT IN FLARE.

DRUGS # OF DAYS DRUG PRICE PER # OF PRICE PER SUPPLIER

ADMIN PREPARATION UNIT(PESOS) ITEMS CYCLE
DORIPENEM 21 DAYS 500MG / VIAL PHP 3,500.00 3 VIALS PHP 220,500.00 OPTION ONE
SOLUTION FOR PER DAY ENTERPRISE,
IV INFUSION MARIAN
MEDICAL ARTS
BUILDING,
DAHLIA,
NOVALICHES,
QUEZON CITY

TOTAL: PHP 220,500.00 FOR 21 DAYS

P2LT ARIELLE R VIDAL MC

Resident-in-Charge

CPT CERNAN C OLIVEROS MC

Ward Officer, MICU