Antibiotics Use

History	Dx	Antibiotic Used	Comment (if any)
50 y/M/Chinese Stage 4 Lung Cancer with discharge 6 days prior p/w SOB for 2 days with crepitation over lungs and new pneumonic changes seen in X-ray	Hospital Acquired Pneumonia w/ u/l stage 4 lung carcinoma	IV Cefepime 2g BD	With the patient’s immnocompromised status and also the history of hospital admission the patient should be started on a broad spectrum antibiotic with the choices being piptazo, cefepime and meropenam with vancomycin added if the patient is suspected to have MRSA
30 y/M/Malay with u/l ESRF on dialysis was referred from the dialysis centre of culture was positive for E. coli sensitive to gentamicin and imipenem	UTI due to E. Coli infection with u/l ESRF	Imipenem 125mg BD	The although the organism was found to be sensitive to gentamicin the patient was not started due to the u/l ESRF and toxicity that aminoglycosides present in these cases. The patient also must have the dose adjusted to the patient’s bodyweight and also the Creatinine clearance
17 y/M/Malay with previous mastoidectomy and previous sub-occipital cranioectomy referred for continuation of care and antibiotics	Cerebellar abscess with mastoidectomy and previous sub-occipital cranioectomy	Ceftriaxone 1g BD	Ceftriaxone has good cover for anerobic gram negative and aerobic streptococci and is also the first choice treatment for patients who have mastoiditis
70 y/M/Male NKMI Fever for 3 days with productive cough and crepitation heard on the L lower zone with pneumonic changes on X-ray	Community acquire pneumonia	IV Augmentin 1.2g TDS T. EES 800mg BD	The common regime used in the hospital for community acquired pneumonia in HSNI
62 y/M/Chinese with u/l DM and COPD p/w SOB on the day of admission with cough 2 days prior to admission	AECOAD secondary to CAP	IV Augmentin 1.2g TDS T. Azithromycin 500mg OD	Another common regime used in HSNI for the treatment of CAP
19 year old M/Malay u/l Hodgkins Lymphoma p/w shortness of breath	CAP and UTI with u/l hodgkins lymphoma	Completed IV Cefepime 2g BD IV Ceftriaxone 2g BD	Again the patient in an immunecompromised state was started on cefepime for the lung infection and the ceftriaxone for the UTI
72y/M/Malay u/l COPD with SOB for the past 2 days with fever and cough for the same duration	AECOAD with CAP	IV Augmentin 1.2g TDS T. EES 800mg BD
45y/F/Chinese with u/l Down Syndrome p/w 2 episodes of generalized tonic-clonic seizures with one episode in the past 1 year with UFEME showing a UTI picture	UTI with u/l Down Syndrome	IV Cefuroxime 750 mg TDS.
52 y/M/Malay with u/l Bronchial Asthma presented with worsening SOB for 2 days not relieved by the inhaler associated with non-productive cough for the past 2 days.	AEBA with CAP	IV Augmentin 1.2g TDS T. Azithromycin 500mg OD

            In my opinion almost all of the cases where I have seen antibiotics used in the ward are warranted and the clinicians are sensitive to the indications and also the correct dosages that are to be used in each patient.

The use of antibiotics in the wards-Dharishini

No.	Antibiotics Details	Diagnosis	Antibiotics Prescribed	Discussion
1	17 y.o.Malay Boy, NKMI	Post Right Suboccipital Craniotomy for Right Cerebral Abscess	IV Ceftriaxone 2g Twice Daily	Ceftriaxone is a third generation cephalosporin.  it has broad-spectrum activity against Gram positive and Gram Negative bacteria
2	79 y.o Malay male u/l DM, HPT,COPD,  IHD, Gastritis, BPH	Acute Exacerbation of Chronic Obstructive Pulmonary disease secondary to CAP	IV Augmentin 1.2g TDS T. Azithromycin 500mg OD	Augmentin is usually used for B-Lactamase producing bacteria such as Strep pneu., H. influenza, Moraxella c. Azithromycin is used for CAP.
3	76 y.o Malay male U/L HPT, Dyslipidemia, COPD	Acute Exacerbation of Chronic Obstructive Pulmonary Disease secondary to CAP	T. Erythromycin 800mg BD IV Augmentin 1.2g TDS	Augmentin is usually used for B-Lactamase producing bacteria such as Strep pneu., H. influenza, Moraxella c. Erythromycin is  prescribed to treat acute bacterial infections
4	78 y.o. Malay male NKMI	CAP	T. Erythromycin 800mg BD IV Augmentin 1.2g TDS
5	52 y.o Malay Female U/L: DM and HPT	Sepsis secondary to Urinary tract Infection	IV Augmentin 1.2g TDS	Augmentin is used to treat B-lactamase producing bacteria such as in Urinary tract infections.
6	66 y.o Malay Female U/L: DM, ESRF, IHD, CVA	1.Acute Pulmonary Oedema secondary to Hypertensive Emergency 2. Hospital Acquired Pneumonia	IV Cefepime 1g BD	Cefepime is a fourth generation cephalosporin. It is used as a broad spectrum antibiotic targeting moderate to severe hospital acquired infections caused by multi-resistant bacteria such as pseudomonas aeruginosa.
7	54 y.o Malay Female U/L COPD, DM, HPT	AECOAD secondary to CAP	IV Augmentin 1.2g TDS T. Azithromycin 500mg OD
8	63 y.o Malay Female U/L: DM,HPT, Dyslipidemia	1.      Urosepsis secondary to urinary tract infection 2.      Acute coronary syndrome	T. Erythromycin 800mg BD IV Augmentin 1.2g TDS Changed to 1.IV Ceftriaxone 2g OD 2. T.Doxycycline 100mg BD	Patient’s antibiotic was changed because patient was not responding and her fever had not reduced. Doxycycline is a tetracycline. Susceptible organisms include Moraxella catarhalis, Brucella melitensis, Chlamydia pneumoniae, and Mycoplasma pneumoniae . Some H. influenza strains have acquired resistance.
9	48 y.o. Chinese female U/L Bronchial asthma, HPT	AEBA secondary to CAP	IV Augmentin 1.2g TDS T. Azithromycin 500mg OD
10	64 y.o Indian Male U/L COPD, HPT, DM	AECOAD secondary to CAP	IV Augmentin 1.2g TDS T. Azithromycin 500mg OD

Most of the patients above who were prescribed antibiotics were apropiate to the provisional diagnosis made and the presenting complaints of the patients. However in patient no. 8, I disagree with the prescription of Erythromycin in that patient as for sepsis, erythromycin is not suitable since it is a bacteriostatic antibiotic. Fortunately, it was changed to Ceftriaxone and doxycycline and patient recovered well. In this hospital, community acquired pneumonia the drug of choice is Augmentin and Erythromycin. Augmentin is prescribed because Augmentin contains B-lactam antibiotic with B-lactamase inhibitor. Hence it has a increased spectrum of action and is also efective against bacteria which produce B-lactamase. Erythromycin is a macrolide and is a bacteriostatic antibiotic. As such both drugs are prescribed together as one antibiotic is bacteriocidal and one is bacteriostatic. 

-Dharishini-

Hepatosplenomegaly

1. Personal Details: Name: Achmad Khoerudin

I.D: 2194220

Gender: Male

Age: 40 years old

Race: Indonesian

Date of Admission: 15/3/2014

Date of Discharge:

Occupation: Works in a farm

Marital Status: Married with a 7 year old child

Address:

Housing:

2. Chief Complaint:

A previously well non-smoker non-alcoholic patient presented with worsening right hypochondriac pain which started 3 months ago associated with an on and off fever for the same duration and passing blood stained stools for the past 2 days with loss of appetite and weight.

3. History of Presenting Illness:

Previously the abdominal pain was bearable however in the past 1 week the patient notes that the pain is worsening and help in the hospital. The pain is described as colicky in nature and is aggravated when the patient takes food. However the pain does not radiate to any other place on the body.

The fever is an on and off low grade fever that lasts for 2-3 days before the patient and subsides. The patient denies any high risk behaviour, tattoos and also previous blood transfusions. The patient does not note any recent travel, jungle trekking or swimming in rivers. The last time that the patient returned to Indonesia was 2 years ago. The patient denies high risk behaviour and there are no one the patient knows that is suffering from the same condition. There are no localising symptoms other than one episode of passing blood stained stool on the day of admission and is not associated with any altered bowel habits or change in stool colour.

The patient has not been passing any tea coloured urine.

The patient works as a farmer and denies walking barefooted in the past.  

4. Medical History:

The patient has no known medical illness and this is the first admission to the hospital

The patient does not have any known drug allergies

5. Family History:

The patient does not not any one in the family with malignancy

6. Social History:
7. Physical Examination:

The patient is comfortable and communicative

There is no clubbing, pallor, jaundice, enlarged neck nodes and pitting edema

Hydration is fair

No rashes noted on the patient's body and also no tatoos present.

Vitals:

BP: 130/86 mmHg

HR: 78 beats per minute regular rhythm good volume

RR: 18 breaths per minute

C: 37C

Weight: 55 KG

CVS:

DRNM

Lungs:

Clear

Abdominal:

On examination the patient does not have any signs of liver stigmata

On inspection there abdomen is not distended with no visible scars, striae, masses, visible peristalsis and umbilical veins

On palpation the liver is enlarged 8 FB, firm, tender, non-pulsatile with regular edges

The spleen is also enlarged at 2 FB.

On percussion the patient does not have shifting dullness or fluid thrill

On auscultation the patient does not have any liver bruit.

Day to day progression:

NB that the patient was admitted for 6 days in the ward however no treatment was initiated for the patient and the patient was subsequently discharged because of his status as a foreigner with the hospital not wanting to incur any additional charges on him and also because of his wish to start treatment in Indonesia.

Day 1:

The patient remained comfortable. Abdominal pain noted to be less than on the day of admission.

BP: 124/84 mmHg

T: 37.1 C

HR: 71 beats per minute

RR: 20 breaths per minute

Provisional Diagnosis: Hepatosplenomegaly TRO cause

Patient was planned for U/S HBS but in view of the weekend the patient had to wait for a working day.

Day 2:

Patient was comfortable. No passing of bloody stool.

BP: 126/90 mmHg

T: 37.0C

HR: 80 beats per minute

RR: 19 breaths per minute

Provisional Diagnosis: Hepatosplenomegaly TRO cause

Investigations:

HB: 16.2 / WBC: 7.6 / Plt: 232

RP: 3.8/134/4.0/84

INR: 1.25

BFMP: -ve

Blood C+S: no growth

Stool FEME: no ova and cyst seen

Urine C+S: no growth

stool occult blood: negative

RF: negative

RPR: negative

ALP 136/ GGT 330/ LDH 412/ AST 114

Day 3:

Patient was comfortable. No passing of bloody stool.

BP: 135/86 mmHg
T: 37.0 C

HR: 76 beats per minute

RR: 20 breaths per minute

Provisional Diagnosis: Hepatosplenomegaly TRO cause

Day 4:

Patient was comfortable: No passing of bloody stool

BP: 130/90 mmHg

T: 37.0C

HR: 72 beats per minute

RR: 20 breaths per minute

U/S HBS done. Scan revealed hepatosplenomegaly with multiple liver lesions and portal vein thrombosis.

Provisional Diagnosis: Hepatocellular Carcinoma with portal venous thrombosis

Patient KIV to start antithrombolytics

Day 5:

Patient was comfortable. No passing of bloody stool

BP: 128/96 mmHg

T: 37.0C

HR: 75 beats per minute

RR: 20 breaths

Provisional Diagnosis: Hepatocellular Carcinoma with portal venous thrombosis

The patient was started on S/C Clexane

Patient was planned for a 3 phase CT scan

Day 6:

CT reporting came back and the patient’s diagnosis was confirmed as Hepatocellular Carcinoma with lung metastasis. The patient’s condition and further treatment was explained to the patient. The patient opted to be discharged and as he wanted to seek treatment back in Indonesia. The patient was discharged with a referral letter to the hospital of his choice and was told if he was still in Batu Pahat and anything should happen that he should come back to the hospital for treatment.  

The CT reporting came back showing a liver enlarged at 21.8 cm with an irregular liver margin. There are multiple enhancing liver lesions of varying sizes in both lobes of the liver. The largest lesion noted at segment VI, VII and VIII measuring 13.8x13.0x12.3 cm (APxWxCC). The lesion shows inhomogenous in appearance (hypo to iso-dense) to the liver parenchyma in non contrast images, demonstrates early arterial enhancement and heterogeneously enhancing protalhase. There is irregular hypodense area in the center of this lesion in keeping with central necrosis. THere is no speck of calcifications within. There is a mild left intrahepatic duct dilatation.

There is a filling defect seen within the main portal vein and extends to involve the righ portal vein. LEft portal vein is well opacified. There is a small focal filling defect within the inferior vena cava measuring 0.8x0.8.0.8cm. There is also long segment filling defect within the superior mesentric vein (SMV). However, there is till contrast opacification within the SMV lumen.

Large porta hepatic node measuring 1.4x1.4cm

Subcentimeter paraaortic and paracaval lymphadenopathy.

Spleen is enlarged measuring 17.9cm. There is an upper pole splenic lesion measuring 2.2x1.8x2.2 cm. THis lesions shows enhancement in arterial and portovenuos phases with attenuation value of 106HU and 161 HU respectively.

Gall Bladder is normal. No gallstone and CBD is not dilated.

Pancreas and adrenals are homogenous with no focal lesion

Both kidneys are perfused and excreting well. No hydronephrosis bilaterally.

No obvious bowel related mass een. No dilated bowel loops.

Free fluid seen in the abdomen and pelvis.
Urinary bladder i well distended.

MUltiple scattered lung nodules seen in the visualised lun bases

No suspicious bony lesion seen.