Differences between AKURIT and conventional TB drugs.

AKURIT is one of the fixed dose combinations for anti TB medications. The 2 FDCs available in MOH Drug formulary for adult are: 4drugs combination : INH 75mg, RIF 150mg, PZA 400mg and EMB 275mg 3 drug combination : INH 75mg, RIF 150mg, PZA 400mg The recommended dosage for the 2 FDC are 30 - 37 kg body weight: 2 tablets daily 38 - 54 kg body weight: 3 tablets daily 55 - 70 kg body weight: 4 tablets daily More than 70 kg body weight: 5 tablets daily FDC help reducing the emergence of drug resistance TB and reduce pill burdens for patient and increase patient adherence to medication. The conventional TB drugs is the separation of anti TB drugs and its normally used if patients developed drug toxicity, intolerance or contraindications to its component.

Treatment and prophylaxis for PCP

PCP prophylaxis One double strength of cotrimoxazole daily or dapsone 100mg daily if cotrimoxazole is contraindicated. The duration of prophylaxis is until the CD4 count > 200 for 3 months PCP treatment Trimetoprim 15-20mg/kg /day plus sulfamethoxazaole 75-100mg/kg/day in QID or TDS Treatment duration is 21 days.

National antibiotic guideline 2008 & the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.

Treatment duration for syphilis

Treatment of primary and secondary syphilis among HIV infected patients in benzathine penicilline G, 2.4 mu intramuscular in a single dose. Most HIV positive pateints who have early syphilis might be at risk for neurologic complications. Based on the national antibiotic guideline 2008, patients infected with HIV with syphilis should be treated as neurospiphylis. Benzylpenicillin 3-4 mu 4 hourly for 14 days.

Clinical Case Presentation

HIV-TB co-infection
By Khairuzzaman

Patient Details
Name: Mr S RN: HTJ 476731 Age: years old Race: Malay Gender: male DOA: 21/11/13 Weight: 95 kg

Chief complaint
Fever and referred from private clinic

History of Presenting Illness

Fever for 2 days Arthralgia for 1 day Vomiting 2 times per day Low of apatite for 2 days Lives at dengue area Exposed to rat at home

Social History
Chronic smoker History of alleged MVA in 1997, claimed laser done for blood clot

Review of System
BP PR Temp Spo2 89/28 110 39.8 100

Provisional Diagnosis
1. Septic shock secondary pneumonia 2. TRO dengue fever

Diagnosis
1. leptospirosis

Leptospirosis
Causal agent: leptospira genus (long corkscrew-shaped bacteria). It is too thin to be visible under ordinary microscope. Mode of transmission: domestic animal are the reservoir of the agent and transmitted through contact with the urine membranous or broken skin with water or food contaminated with urine of the infected animals.

Laboratory results:
FBC Reference range 21/11 22/11

TWBC HB Platelet

4-11x10/L 11.5-16.5 g/100mL 150-400 g/100mL

9.4 14.1 198

5.7 13.6 166

Renal profile

Reference range

21/11

22/11

25/11

Urea
Na+

1.7-8.3 mmol/L
135-145 mmol/L

3.7
132

2.1
134

5.6
126

K+
SCr CrCl

3.5-5.0 mmol/L
64 122 mmol/L 105-150 ml/min 0.8-1.45 mmol/L 2.1 2.6 mmol/L

3.9
104

2.8
101

4.0
112

PO4-

0.5
2.07

Ca2+

Liver profile Albumin T. Bilirubin T. Protein ALP ALT

Reference range 35-50g/L <20 umol/L 66 87 g/L 53-141 u/l < 37 u/l

21/11 31 7 66 80 160

22/11 32 5 68 81 163

25/11 32 9 75 80 186

Ward medication
Drug IV CEFTRIAXONE 1G BD IV CEFTRIAXONE 2G OD T AZITHROMYCIN 500MG OD T. PARACETAMOL 1G STAT IV TRAMADOL 50MG STAT TDS IV METOCHLORPRAMIDE 10MG STAT IV OMEPRAZOLE 20MG BD Date start 21/11 21/11 22/11 22/11 23/11 23/11 25/11 Date stop 21/11 Indication Empirical therapy for CAP Empirical therapy for CAP Empirical therapy for CAP Antipyretic Analgesic Antiemetic Gastritis

Pharmaceutical Care Issue

 Inappropriate drug management

Patient was provisionally diagnosed with sepsis secondary to pneumonia and treated with IV ceftriaxone 2g od and T. azithromycin 500mg od. On 22/11 patient was confirmed with leptosirosis based on the leptospirosis antibody test. Prescriber still continue the treatment with 2g of ceftriaxone Recommendation Suggest to reduce the dose of ceftriaxone to 1g od. Outcome and monitoring parameters. Prescriber still continued the ceftriaxone 2g od.