case presentation

1. R.Anusha
Pharm D V Year
Roll No:07

2.  Patient Name:Mr.AN
 Gender:Male
 Age:37 years
 IP No:IP291834
 DOA:29/1/19
 DOD:31/1/19

3. SUBJECTIVE
 Chief complaints: Complaint of fever associated with loose
stools and also Oozing from surgical site infection since 2
days.
 Past medical history: K/c/o Hypertension, and CKD stage 5
(status post B/L renal transplant on 13th December 2018)

4. OBJECTIVE
 Vitals
Pulse rate:85/min
Respiratory rate:20/min
Blood pressure:120/80 mm
Hg
Temperature:99.60F
 Physical Appearance
Height : 167 cms
Weight : 107 kgs
BMI : 38.4 kg/m2

5. FINAL DIAGNOSIS:
 Patient post renal transplant status having acute febrile
illness
 Surgical site infection
 K/c/o Hypertension

6. DRUG CHART
Drug Generic Dose Freq. ROA Category Indication
Inj.Meropenam Meropenam 1 gm BD IV Carbepenam Infection
IV Fluids NS Normal
saline
50 ml/hr STAT IV Electrolyte Hydration
Inj.Pan Pantoprazole 40 mg OD PO PPI APD
T.Mycofit Mycophenolate
Sodium
360 mg(
2tab)
BD PO Immuno
suppressant
Renal
transplant
T.Pangraf Tacrolimus 2.5 mg BD PO Immuno
suppressant
Renal
transplant
T.Wysolone Prednisolone 20 mg OD PO steriod Renal
transplant

7. T.Valren Valganciclovir 450
mg
OD PO Antiviral CMV
T.Bact
Oinment
Mupirocin BD L/A Topical
Antibiotic
Surgical site
infection
(Bacteria)
T.Syscan
-DT
Fluconazole
Dispersable
Tablet
100
mg
OD PO Antifungal Surgical site
infection
(Fungal)
T.Betaloc Metoprolol 12.5
mg
BD PO Beta
blocker
HTN

8. ASSESSMENT
 Patient a known case of renal transplantation came with
complaint of fever associated with loose stools and oozing
from surgical site wound.
 Swab culture was sent and urology referral was taken and
dressing was changed.
 IV Fluids NS 50 ml/hr IV STAT was given for fluid
management.
 Inj.Meropenam 1 gm BD IV given as an antibiotic for
infection prophylaxis
 Inj.Pantoprazole 40 mg OD PO was given for APD

9.  Patients who undergo solid organ transplant require lifelong
immunosuppression to prevent organ rejection.
 T.Mycophenolate Sodium 360 mg( 2tab) BD PO given as
Immuno suppressant.
 The initial adult post-transplant dose of mycophenolate
sodium is 720 mg PO bid
 Mycophenolic acids are used in combination post-transplant
immunosuppressive regimens to prevent solid organ
transplant rejection.
 It selectively suppresses proliferation of T- and B-
lymphocytes.

10.  T. Tacrolimus 2.5 mg BD PO given as Immunosuppressant.
 Tacrolimus is an immunosuppressant used in combination
with other immunosuppressants to prevent transplant
rejection.
 Tacrolimus inhibits T-lymphocyte activation.
 The post-transplant initial adult oral dose of tacrolimus
IMMEDIATE release is 0.12 to 0.15 mg/kg/day divided
every 12 hours.
 Valganciclovir is a prodrug of ganciclovir,used for the
prevention and treatment of cytomegalovirus (CMV)
infections in immuno-compromised or immunosuppressed
patients.450 mg PO is the daily dose.

11. MONITORING PARAMETERS
 When mycophenolic acids are administered with acyclovir, ganciclovir,
and valganciclovir, increased plasma concentrations of acyclovir,
ganciclovir, and valganciclovir may occur due to competition for tubular
secretion in the presence of renal failure.Monitor carefully.
 Many of the common side effects are dose dependent and can be
ameliorated by reducing or discontinuing the immunosuppresants dose
temporarily.However, this may leave the transplant recipient at increased
risk of allograft acute rejection as a result of suboptimal
immunosuppression.

12.  Patient was afebrile during hospital stay and general
condition improved.

13.  BMI as a risk factor for the development of SSI following renal
transplantation.
 Median time from transplant to incisional surgical site infections
was 20 days
 Surgical site infections (SSI) have remained a common and major
complication in solid organ transplant (solid organ transplant)
recipients and are reported to occur in 5-40% of these patients
(2,9,17,19,74). The frequency of surgical site infections after
solid organ transplant is similar to other surgical procedures of
comparable complexity. The incidences of surgical site infections
are highest following intestinal (102) transplantation followed by
liver (33,75) and pancreas (68,78) transplantation; after renal
(52,66) and heart (77,82) transplantation low rates of surgical site
infections can be expected

14.  Surgical site infections (SSI) have remained a common and major
complication in solid organ transplant (solid organ transplant)
recipients and are reported to occur in 5-40% of these patients
 predominant pathogen:Coagulase negative staphylococci, Gram-
negative bacteria
 additional pathogen:Candida albicans

15. PLAN
 Monitor vitals
 Twice daily wound dressing

16. PATIENT COUNSELLING
 Surgical site infections (SSIs) are defined as infections
occurring up to 30 days after surgery

17. DISCHARGE MEDICATION
 Inj.Meropenem 1 gm to be taken twice daily intravenously
for 6 days.
 T.Mycofit 360 mg to be taken orally twice daily for 6 days.
 T.Wysolone 20 mg to be taken orally once daily till review.
 T.Pangraf 2.5 mg to be taken orally twice daily till review.
 T.Valren 450 mg to be taken orally once daily till review.
 T.Syscan-DT 100 mg to be taken orally once daily for 3
months.
 T.Bact oinment for L/A twice daily
 T.Betaloc 12.5 mg to be taken orally twice daily till review.
To review after 1 week with RP II and CBC reports.

18.  Tacrolimus on empty stomach
 Vancyclovir with food
 Valganciclovir is a prodrug of Ganciclovir, which is rapidly
converted to ganciclovir after oral administration
 Valganciclovir is approved for the prevention of cytomegalovirus
(CMV) disease in solid organ transplant recipients who are at risk.
 Co-administration with other myelosuppressive agents
(mycophenolic acids, azathioprine) increases the risk of toxicity