Research Letter
3.
4. 5.
6. 7. Figure 2: Rodent model of Iowa gambling task
8.
As shown in Figure 2, the mice in the control group chose the disadvantageous arms of the IGT at a frequency of 67.16 ± 6.85 over a period of 9 days and 135 trials to each mouse. The mice in the naltrexone (45.33 ± 6.62), potassium clavulanate (51.16 ± 6.73) and combination group (46.33 ± 5.92) were observed to choose the disadvantageous arm at much lower frequency. The observations of the mice in the naltrexone group were comparable statistically to those mice in potassium clavulanate group. Furthermore, the combination group showed statistically comparable results to the naltrexone and the clavulanate groups. One can hypothesize that potassium clavulanate increases serotonin levels in the CNS, which improves decision taking abilities of alcohol dependent mice. Zeeb et al. have shown that 5‑hydroxytryptamine 1A receptor agonist, 8-hydroxy‑N, N‑dipropyl‑2‑aminotetralin, which decreases presynaptic serotonin release impaired decision taking on IGT.[8] Increased serotonergic transmission by potassium clavulanate in the CNS might be responsible for improvement in decision‑making in our experiment.
Kshitij S. Jadhav, Padmaja A. Marathe
et al. Beta‑lactam antibiotics offer neuroprotection by increasing glutamate transporter expression. Nature 2005;433:73‑7. Cordovil De Sousa Uva M, Luminet O, Cortesi M, Constant E, Derely M, De Timary P. Distinct effects of protracted withdrawal on affect, craving, selective attention and executive functions among alcohol‑dependent patients. Alcohol Alcohol 2010;45:241‑6. Rawls SM, Karaca F, Madhani I, Bhojani V, Martinez RL, Abou‑Gharbia M, et al. ß‑lactamase inhibitors display anti‑seizure properties in an invertebrate assay. Neuroscience 2010;169:1800‑4. Kim DJ, King JA, Zuccarelli L, Ferris CF, Koppel GA, Snowdon CT, et al. Clavulanic acid: A competitive inhibitor of beta‑lactamases with novel anxiolytic‑like activity and minimal side effects. Pharmacol Biochem Behav 2009;93:112‑20. Hwa LS, Chu A, Levinson SA, Kayyali TM, DeBold JF, Miczek KA. Persistent escalation of alcohol drinking in C57BL/6J mice with intermittent access to 20% ethanol. Alcohol Clin Exp Res 2011;35:1938‑47. van den Bos R, Lasthuis W, den Heijer E, van der Harst J, Spruijt B. Toward a rodent model of the Iowa gambling task. Behav Res Methods 2006;38:470‑8. Zeeb FD, Robbins TW, Winstanley CA. Serotonergic and dopaminergic modulation of gambling behavior as assessed using a novel rat gambling task. Neuropsychopharmacology 2009;34:2329‑43. Access this article online Quick Response Code:
Website: www.jpharmacol.com
DOI: 10.4103/0976-500X.142439
Antimicrobial utilization in multidisciplinary intensive care units of a public tertiary care hospital
Department of Pharmacology and Therapeutics, Seth GS Medical College, KEM Hospital, Parel, Mumbai, Maharashtra, India Address for correspondence: Kshitij S Jadhav, Department of Pharmacology and Therapeutics, Seth GS Medical College, KEM Hospital, Parel, Mumbai ‑ 400 012, Maharashtra, India. E‑mail: [email protected] Received: 20-01-2014 Revised: 24-03-2014 Accepted: 28-04-2014
REFERENCES 1. 2.
252
Sari Y, Sakai M, Weedman JM, Rebec GV, Bell RL. Ceftriaxone, a beta‑lactam antibiotic, reduces ethanol consumption in alcohol‑preferring rats. Alcohol Alcohol 2011;46:239‑46. Rothstein JD, Patel S, Regan MR, Haenggeli C, Huang YH, Bergles DE,
Sir, Antimicrobials are one of the most common class of drugs prescribed to patients in the intensive care units (ICUs). The total antimicrobial consumption is approximately tenfold greater in ICUs than in a general hospital wards. This high density of antimicrobial use favours the development of multi‑drug resistant pathogens.[1] Rice, in 2008, reported that “Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa and Enterobacter species” pathogens are responsible for causing two‑thirds of hospital infections and effectively “escape” the effects of antibacterial drugs.[2] The increase in the prevalence of drug resistant
Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4
Research Letter
pathogens is occurring at a time when the discovery of new antimicrobial agents is slowing down dramatically.[3] In order to minimize the antimicrobial resistance, it is essential that the pattern of antimicrobial utilization is known well. The aim of this study was to understand the antimicrobial utilization pattern in the ICUs of a public tertiary care hospital. This 3‑month observational study was carried out at the ICUs of a public tertiary care hospital. ICUs with 14 bed capacity handle all patients who require ICU level care. Only patients with >24 h of ICU stay and who were prescribed at least one antimicrobial were included in this study. Patient records with incomplete documentation were excluded. The age and sex of patient, disease and treatment regimen were recorded in a predesigned standardized proforma. The patients were followed for the first 7 days of ICU stay and any changes made in the treatment regimen were carefully analyzed. Antimicrobial utilization was assessed using Rational Pharmaceutical Management plus indicators. The prescriptions were also studied for the use of similar spectrum of antimicrobials, frequent switching of antimicrobials (without considering any sensitivity report within 72 h of its administration) and antimicrobial cocktail (use of more than two broad spectrum antimicrobials, excluding metronidazole and antifungals). Results are expressed in percentages and average ± standard error of the mean, as applicable. A total of 87 patients’ data was collected; and two patients’ were excluded. One patient had ICU stay of less than 1 day, while the other had incomplete documentation. Of these 85 patients, 48 underwent a surgery and remaining 37 patients were nonsurgical patients. The average age of patients was found to be 39.27 ± 1.93 years. Over 75% patients were in the age group of 18-60 years. And the mortality rate was found to be 28%. The average number of medications prescribed was found to be 13.88 ± 0.48. And, the average number of antimicrobials was found to be 2.96 ± 0.16. Adhikari et al. have shown that 45.1% of prescribed antimicrobials are consistent with National List of Essential Medicines (NLEM) 2011.[4] In this study, it was 56%, reflecting a better level of adherence to prescribing from NLEM. The common antimicrobials prescribed consistent with NLEM, were metronidazole, ceftriaxone, amikacin, amoxicillin + clavulanic acid, gentamicin and vancomycin. Approximately, 96% were administered by parenteral route. 37% of antimicrobials were prescribed by the generic name. [Table 1] These findings, however, are not in concurrence with findings from a private setting. It was shown that a total of 71.1% antimicrobial drugs were prescribed by generic name.[5] This difference is most likely due to the difference in the hospital setting (government vs private).
Table 1: RPM plus indicators RPM plus indicator
Value
Average number of medications
13.88
Average number of antimicrobials
2.96
Percentage of antimicrobials prescribed consistent with NLEM Percentage of antimicrobials administered by parenteral route Percentage of antimicrobials prescribed by generic name
56 96 37
Number of antimicrobial sensitivity tests reported
72
Percentage of hospitalization with one or more antimicrobials prescribed
100
RPM=Rational pharmaceutical management, NLEM=National list of essential medicines
Of 72 culture sensitivity tests performed, 43 were found to be positive. Acinetobacter sp. was the most common microorganism observed (15/43). All the patients were prescribed at least one antimicrobial agent. 30% of the patients were prescribed three antimicrobials, 28% with 2, 14% with 1, and the remaining 28% with more than three antimicrobials. Antimicrobial prescriptions were studied for their relative use in the ICU patients. It was found that Metronidazole was the most frequently prescribed antimicrobial (61% patients) followed by piperacillin + tazobactam (32%). Imipenem + cilastatin, cefoperazone + sulbactam and ciprofloxacin were used for 25%, 22% and 20% of patients, respectively. Metronidazole is the drug of choice for the treatment of anaerobic infections, which are usually treated empirically, without susceptibility testing. In terms of the relative contribution to the prescribed antimicrobials, β‑lactams were ranked first, contributing 41%. The second and third most commonly used antimicrobials were metronidazole and aminoglycosides in 21% and 12%, respectively. Fluoroquinolones, macrolides, oxazolidinones, antifungals and glycopeptides were used in 9%, 3%, 3%, 2%, and 1% patients, respectively. To understand the nature of antimicrobial prescribing further, use of antimicrobials with a similar spectrum of activity, frequent switching of antimicrobials and use of antimicrobial cocktail were studied. Low values of any of these parameters indicate the careful prescribing. Use of antimicrobials with a similar spectrum of activity and frequent switching of antimicrobials was observed in only 6% of patients. Imipenem and piperacillin, amoxicillin + clavulanic acid and cefoperazone + sulbactam were the most common antimicrobial combinations with a similar spectrum prescribed. Use of more than two broad spectrum antimicrobials was seen in only 9% of patients.
Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4
253
Research Letter
Badar and Navale have reported that 77% patients were prescribed between one and three antimicrobials.[6] In this study, 72% patients were prescribed one to three antimicrobials which is similar to above mentioned study. This will have a bearing on the outcome of treatment. However, it is premature to comment on this conclusively on the basis of data on a limited number of patients. Based on the findings of this study on 85 patients in the ICU, it appears logical that the use of antimicrobials in the ICUs should be studied over a longer period of time. The findings of prescription pattern reflect a very encouraging trend. Only 6% of patients witnessed prescription of similar spectrum antimicrobials and frequent switching. This ongoing study has provided initial evidence on antimicrobial utilization in an Indian public setting ICU.
Gudapati Bhanu Naga Sireesha, Pramil Tiwari, Satinder Gombar1, Sanjay D’Cruz2, Atul Sachdev2 Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, SAS Nagar, Punjab, Departments of 1Anaesthesia and Intensive Care and 2General Medicine, GMCH, Chandigarh, India Address for correspondence: Pramil Tiwari, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, SAS Nagar ‑ 160 062, Punjab, India. E‑mail: [email protected] Received: 30-01-2014 Revised: 01-04-2014 Accepted: 08-08-2014
REFERENCES 1.
Kavar KS, Jha RK, Gaikwad NR, Jarande SS, Ranpura AM. Antibiotic use density in medicine ICU in a tertiary care rural hospital of central India. Res J Pharm Biol Chem Sci 2012;3:133‑42. 2. Rice LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: No ESKAPE. J Infect Dis 2008;197:1079‑81. 3. Mulvey MR, Simor AE. Antimicrobial resistance in hospitals: How concerned should we be? CMAJ 2009;180:408‑15. 4. Adhikari A, Singh S, Bhowal T, Biswas S, Banerjee S, Ray M, et al. Study of prescribing pattern of antimicrobial agents in selected patients attending tertiary care hospital in India. Explor Anim Med Res 2013;3:29‑35. 5. Tiwari P, Singhal R, Malhotra S. Antimicrobial utilization in ICUs of a private tertiary care hospital. In: Lawrence R, Ebenezer J, Thomas G, editors. Antimicrobial Resistance: A Cause for Global Concern. New Delhi: Narosa Publishing House; 2013. 6. Badar VA, Navale SB. Study of prescribing pattern of antimicrobial agents in medicine intensive care unit of a teaching hospital in central India. J Assoc Physicians India 2012;60:20‑3. Access this article online Quick Response Code:
Website: www.jpharmacol.com
DOI: 10.4103/0976-500X.142441
254
Pediatric dosing errors due to variable drug formulations Sir, Dosing errors are not uncommon in day-to-day clinical practice in children. Pediatric patients are more vulnerable to adverse drug events because of small body size and need for weight based dosing.[1‑3] Among various reasons, one of the reasons for dosing errors in pediatric patients is, availability of different formulations with variable concentration of drugs.[4] We present three cases where errors had occurred due to this in order to highlight such dosing errors and to raise awareness among clinicians. A 6-year-old male child presented with complaints of giddiness and frequent falls since 2 days. The symptoms started after the patient had started using a different brand of prescribed antiepileptic drug (phenytoin). The patient was previously using the prescribed medicine with a concentration of 30 mg/5 ml; but this had been replaced with another brand with a concentration of 125 mg/5 ml. Thus, instead of receiving 7.5 ml twice a day (or a total dose of 90 mg at the rate of 5 mg/kg/day), the patient ended up receiving a total dose of 375 mg at the rate of 20.8 mg/k/d. The investigations revealed high levels of serum phenytoin. In another case, a 4-year-old female child (weight: 15 kgs) was referred for kidney biopsy and management after being diagnosed with steroid resistant nephrotic syndrome. She was advised treatment with prednisolone (10 mg thrice daily). She underwent extensive investigations to rule out secondary causes, but all were inconclusive. It was found that inadvertently prednisolone 5 mg thrice daily was being administered instead of 10 mg thrice daily, as prescribed. This aspect had been overlooked by all clinicians prior to referral to our hospital. Another 2-year-old male child presented with recurrent vomiting after intake of medication prescribed during a course of acute gastroenteritis. The medications were checked and it revealed the patient was receiving a zinc formulation with a concentration of 20 mg elemental zinc/ml as drops instead of 5 ml syrup with a concentration of 20 mg/5ml. Thus, the dose given was 5 times the prescribed dose. Clinicians may have come across similar cases in their practice. Various studies are available citing multiple reasons and possible preventive aspects for the reduction of such errors.[2,3] The chances of similar errors are greater with drugs available in different formulations and fixed dose combinations with different components and variable concentrations.[4] Fortunately, none of our patients had serious
Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4
Copyright of Journal of Pharmacology & Pharmacotherapeutics is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
3.
4. 5.
6. 7. Figure 2: Rodent model of Iowa gambling task
8.
As shown in Figure 2, the mice in the control group chose the disadvantageous arms of the IGT at a frequency of 67.16 ± 6.85 over a period of 9 days and 135 trials to each mouse. The mice in the naltrexone (45.33 ± 6.62), potassium clavulanate (51.16 ± 6.73) and combination group (46.33 ± 5.92) were observed to choose the disadvantageous arm at much lower frequency. The observations of the mice in the naltrexone group were comparable statistically to those mice in potassium clavulanate group. Furthermore, the combination group showed statistically comparable results to the naltrexone and the clavulanate groups. One can hypothesize that potassium clavulanate increases serotonin levels in the CNS, which improves decision taking abilities of alcohol dependent mice. Zeeb et al. have shown that 5‑hydroxytryptamine 1A receptor agonist, 8-hydroxy‑N, N‑dipropyl‑2‑aminotetralin, which decreases presynaptic serotonin release impaired decision taking on IGT.[8] Increased serotonergic transmission by potassium clavulanate in the CNS might be responsible for improvement in decision‑making in our experiment.
Kshitij S. Jadhav, Padmaja A. Marathe
et al. Beta‑lactam antibiotics offer neuroprotection by increasing glutamate transporter expression. Nature 2005;433:73‑7. Cordovil De Sousa Uva M, Luminet O, Cortesi M, Constant E, Derely M, De Timary P. Distinct effects of protracted withdrawal on affect, craving, selective attention and executive functions among alcohol‑dependent patients. Alcohol Alcohol 2010;45:241‑6. Rawls SM, Karaca F, Madhani I, Bhojani V, Martinez RL, Abou‑Gharbia M, et al. ß‑lactamase inhibitors display anti‑seizure properties in an invertebrate assay. Neuroscience 2010;169:1800‑4. Kim DJ, King JA, Zuccarelli L, Ferris CF, Koppel GA, Snowdon CT, et al. Clavulanic acid: A competitive inhibitor of beta‑lactamases with novel anxiolytic‑like activity and minimal side effects. Pharmacol Biochem Behav 2009;93:112‑20. Hwa LS, Chu A, Levinson SA, Kayyali TM, DeBold JF, Miczek KA. Persistent escalation of alcohol drinking in C57BL/6J mice with intermittent access to 20% ethanol. Alcohol Clin Exp Res 2011;35:1938‑47. van den Bos R, Lasthuis W, den Heijer E, van der Harst J, Spruijt B. Toward a rodent model of the Iowa gambling task. Behav Res Methods 2006;38:470‑8. Zeeb FD, Robbins TW, Winstanley CA. Serotonergic and dopaminergic modulation of gambling behavior as assessed using a novel rat gambling task. Neuropsychopharmacology 2009;34:2329‑43. Access this article online Quick Response Code:
Website: www.jpharmacol.com
DOI: 10.4103/0976-500X.142439
Antimicrobial utilization in multidisciplinary intensive care units of a public tertiary care hospital
Department of Pharmacology and Therapeutics, Seth GS Medical College, KEM Hospital, Parel, Mumbai, Maharashtra, India Address for correspondence: Kshitij S Jadhav, Department of Pharmacology and Therapeutics, Seth GS Medical College, KEM Hospital, Parel, Mumbai ‑ 400 012, Maharashtra, India. E‑mail: [email protected] Received: 20-01-2014 Revised: 24-03-2014 Accepted: 28-04-2014
REFERENCES 1. 2.
252
Sari Y, Sakai M, Weedman JM, Rebec GV, Bell RL. Ceftriaxone, a beta‑lactam antibiotic, reduces ethanol consumption in alcohol‑preferring rats. Alcohol Alcohol 2011;46:239‑46. Rothstein JD, Patel S, Regan MR, Haenggeli C, Huang YH, Bergles DE,
Sir, Antimicrobials are one of the most common class of drugs prescribed to patients in the intensive care units (ICUs). The total antimicrobial consumption is approximately tenfold greater in ICUs than in a general hospital wards. This high density of antimicrobial use favours the development of multi‑drug resistant pathogens.[1] Rice, in 2008, reported that “Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa and Enterobacter species” pathogens are responsible for causing two‑thirds of hospital infections and effectively “escape” the effects of antibacterial drugs.[2] The increase in the prevalence of drug resistant
Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4
Research Letter
pathogens is occurring at a time when the discovery of new antimicrobial agents is slowing down dramatically.[3] In order to minimize the antimicrobial resistance, it is essential that the pattern of antimicrobial utilization is known well. The aim of this study was to understand the antimicrobial utilization pattern in the ICUs of a public tertiary care hospital. This 3‑month observational study was carried out at the ICUs of a public tertiary care hospital. ICUs with 14 bed capacity handle all patients who require ICU level care. Only patients with >24 h of ICU stay and who were prescribed at least one antimicrobial were included in this study. Patient records with incomplete documentation were excluded. The age and sex of patient, disease and treatment regimen were recorded in a predesigned standardized proforma. The patients were followed for the first 7 days of ICU stay and any changes made in the treatment regimen were carefully analyzed. Antimicrobial utilization was assessed using Rational Pharmaceutical Management plus indicators. The prescriptions were also studied for the use of similar spectrum of antimicrobials, frequent switching of antimicrobials (without considering any sensitivity report within 72 h of its administration) and antimicrobial cocktail (use of more than two broad spectrum antimicrobials, excluding metronidazole and antifungals). Results are expressed in percentages and average ± standard error of the mean, as applicable. A total of 87 patients’ data was collected; and two patients’ were excluded. One patient had ICU stay of less than 1 day, while the other had incomplete documentation. Of these 85 patients, 48 underwent a surgery and remaining 37 patients were nonsurgical patients. The average age of patients was found to be 39.27 ± 1.93 years. Over 75% patients were in the age group of 18-60 years. And the mortality rate was found to be 28%. The average number of medications prescribed was found to be 13.88 ± 0.48. And, the average number of antimicrobials was found to be 2.96 ± 0.16. Adhikari et al. have shown that 45.1% of prescribed antimicrobials are consistent with National List of Essential Medicines (NLEM) 2011.[4] In this study, it was 56%, reflecting a better level of adherence to prescribing from NLEM. The common antimicrobials prescribed consistent with NLEM, were metronidazole, ceftriaxone, amikacin, amoxicillin + clavulanic acid, gentamicin and vancomycin. Approximately, 96% were administered by parenteral route. 37% of antimicrobials were prescribed by the generic name. [Table 1] These findings, however, are not in concurrence with findings from a private setting. It was shown that a total of 71.1% antimicrobial drugs were prescribed by generic name.[5] This difference is most likely due to the difference in the hospital setting (government vs private).
Table 1: RPM plus indicators RPM plus indicator
Value
Average number of medications
13.88
Average number of antimicrobials
2.96
Percentage of antimicrobials prescribed consistent with NLEM Percentage of antimicrobials administered by parenteral route Percentage of antimicrobials prescribed by generic name
56 96 37
Number of antimicrobial sensitivity tests reported
72
Percentage of hospitalization with one or more antimicrobials prescribed
100
RPM=Rational pharmaceutical management, NLEM=National list of essential medicines
Of 72 culture sensitivity tests performed, 43 were found to be positive. Acinetobacter sp. was the most common microorganism observed (15/43). All the patients were prescribed at least one antimicrobial agent. 30% of the patients were prescribed three antimicrobials, 28% with 2, 14% with 1, and the remaining 28% with more than three antimicrobials. Antimicrobial prescriptions were studied for their relative use in the ICU patients. It was found that Metronidazole was the most frequently prescribed antimicrobial (61% patients) followed by piperacillin + tazobactam (32%). Imipenem + cilastatin, cefoperazone + sulbactam and ciprofloxacin were used for 25%, 22% and 20% of patients, respectively. Metronidazole is the drug of choice for the treatment of anaerobic infections, which are usually treated empirically, without susceptibility testing. In terms of the relative contribution to the prescribed antimicrobials, β‑lactams were ranked first, contributing 41%. The second and third most commonly used antimicrobials were metronidazole and aminoglycosides in 21% and 12%, respectively. Fluoroquinolones, macrolides, oxazolidinones, antifungals and glycopeptides were used in 9%, 3%, 3%, 2%, and 1% patients, respectively. To understand the nature of antimicrobial prescribing further, use of antimicrobials with a similar spectrum of activity, frequent switching of antimicrobials and use of antimicrobial cocktail were studied. Low values of any of these parameters indicate the careful prescribing. Use of antimicrobials with a similar spectrum of activity and frequent switching of antimicrobials was observed in only 6% of patients. Imipenem and piperacillin, amoxicillin + clavulanic acid and cefoperazone + sulbactam were the most common antimicrobial combinations with a similar spectrum prescribed. Use of more than two broad spectrum antimicrobials was seen in only 9% of patients.
Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4
253
Research Letter
Badar and Navale have reported that 77% patients were prescribed between one and three antimicrobials.[6] In this study, 72% patients were prescribed one to three antimicrobials which is similar to above mentioned study. This will have a bearing on the outcome of treatment. However, it is premature to comment on this conclusively on the basis of data on a limited number of patients. Based on the findings of this study on 85 patients in the ICU, it appears logical that the use of antimicrobials in the ICUs should be studied over a longer period of time. The findings of prescription pattern reflect a very encouraging trend. Only 6% of patients witnessed prescription of similar spectrum antimicrobials and frequent switching. This ongoing study has provided initial evidence on antimicrobial utilization in an Indian public setting ICU.
Gudapati Bhanu Naga Sireesha, Pramil Tiwari, Satinder Gombar1, Sanjay D’Cruz2, Atul Sachdev2 Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, SAS Nagar, Punjab, Departments of 1Anaesthesia and Intensive Care and 2General Medicine, GMCH, Chandigarh, India Address for correspondence: Pramil Tiwari, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, SAS Nagar ‑ 160 062, Punjab, India. E‑mail: [email protected] Received: 30-01-2014 Revised: 01-04-2014 Accepted: 08-08-2014
REFERENCES 1.
Kavar KS, Jha RK, Gaikwad NR, Jarande SS, Ranpura AM. Antibiotic use density in medicine ICU in a tertiary care rural hospital of central India. Res J Pharm Biol Chem Sci 2012;3:133‑42. 2. Rice LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: No ESKAPE. J Infect Dis 2008;197:1079‑81. 3. Mulvey MR, Simor AE. Antimicrobial resistance in hospitals: How concerned should we be? CMAJ 2009;180:408‑15. 4. Adhikari A, Singh S, Bhowal T, Biswas S, Banerjee S, Ray M, et al. Study of prescribing pattern of antimicrobial agents in selected patients attending tertiary care hospital in India. Explor Anim Med Res 2013;3:29‑35. 5. Tiwari P, Singhal R, Malhotra S. Antimicrobial utilization in ICUs of a private tertiary care hospital. In: Lawrence R, Ebenezer J, Thomas G, editors. Antimicrobial Resistance: A Cause for Global Concern. New Delhi: Narosa Publishing House; 2013. 6. Badar VA, Navale SB. Study of prescribing pattern of antimicrobial agents in medicine intensive care unit of a teaching hospital in central India. J Assoc Physicians India 2012;60:20‑3. Access this article online Quick Response Code:
Website: www.jpharmacol.com
DOI: 10.4103/0976-500X.142441
254
Pediatric dosing errors due to variable drug formulations Sir, Dosing errors are not uncommon in day-to-day clinical practice in children. Pediatric patients are more vulnerable to adverse drug events because of small body size and need for weight based dosing.[1‑3] Among various reasons, one of the reasons for dosing errors in pediatric patients is, availability of different formulations with variable concentration of drugs.[4] We present three cases where errors had occurred due to this in order to highlight such dosing errors and to raise awareness among clinicians. A 6-year-old male child presented with complaints of giddiness and frequent falls since 2 days. The symptoms started after the patient had started using a different brand of prescribed antiepileptic drug (phenytoin). The patient was previously using the prescribed medicine with a concentration of 30 mg/5 ml; but this had been replaced with another brand with a concentration of 125 mg/5 ml. Thus, instead of receiving 7.5 ml twice a day (or a total dose of 90 mg at the rate of 5 mg/kg/day), the patient ended up receiving a total dose of 375 mg at the rate of 20.8 mg/k/d. The investigations revealed high levels of serum phenytoin. In another case, a 4-year-old female child (weight: 15 kgs) was referred for kidney biopsy and management after being diagnosed with steroid resistant nephrotic syndrome. She was advised treatment with prednisolone (10 mg thrice daily). She underwent extensive investigations to rule out secondary causes, but all were inconclusive. It was found that inadvertently prednisolone 5 mg thrice daily was being administered instead of 10 mg thrice daily, as prescribed. This aspect had been overlooked by all clinicians prior to referral to our hospital. Another 2-year-old male child presented with recurrent vomiting after intake of medication prescribed during a course of acute gastroenteritis. The medications were checked and it revealed the patient was receiving a zinc formulation with a concentration of 20 mg elemental zinc/ml as drops instead of 5 ml syrup with a concentration of 20 mg/5ml. Thus, the dose given was 5 times the prescribed dose. Clinicians may have come across similar cases in their practice. Various studies are available citing multiple reasons and possible preventive aspects for the reduction of such errors.[2,3] The chances of similar errors are greater with drugs available in different formulations and fixed dose combinations with different components and variable concentrations.[4] Fortunately, none of our patients had serious
Journal of Pharmacology and Pharmacotherapeutics | October-December 2014 | Vol 5 | Issue 4
Copyright of Journal of Pharmacology & Pharmacotherapeutics is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
