This case presentation discusses two pediatric patients treated at Sultan-ul-Uloom College of Pharmacy in Hyderabad. The first case involves a 7-year-old boy diagnosed with osteomyelitis and treated with flucloxacillin and later clindamycin due to an allergic reaction, while the second case concerns an 18-month-old girl who underwent appendectomy for a perforated appendix and received a multimodal analgesic approach with careful monitoring of medication dosages. Both cases emphasize the importance of accurate dosing and drug therapy monitoring in pediatric patients.

1. CASE PRESENTATION ON
PAEDIATRICS
Presented By
Meraj Fatima, PharmD 4th Year.
Sultan-ul-Uloom College of Pharmacy
Hyderabad, India.
Guided by
Dr. S P Srinivas Nayak, Assistant Professor
Dept. of Pharmacy Practice, SUCP

2. Case:
A 7year old male patient weighting 16kg Presented in the
emergency department with a 2-day history of worsening groin
and hip pain. Could not bear weight. Patient was febrile with a
temperature of 39.2°C, vomiting and dehydrated. There was
no history of injury. There is no previous medical history, No
known drug allergies, no drug history
Differential diagnosis :
Septic arthritis, Osteomyelitis
Dept. of pharmacy practice, SUCP, HYDERABAD 2

3. Test results :
Bone scan revealed right pubic osteomyelitis
CRP = 56mg/L (normal range 0–10mg/L)
ESR = 34mm/h (normal range 1–10mm/h)
Blood culture revealed - Staphylococcus
aureus sensitive to flucloxacillin
Dept. of pharmacy practice, SUCP, HYDERABAD 3

4. Medication prescribed :
■ Flucloxacillin i.v. 800mg four times a day for 2 weeks.
■ To be followed by oral flucloxacillin 800mg four times a
day for 4 weeks.
Progress :
■ Temperature settled and ESR/CRP decreased following
initiation of antibiotic therapy.
Dept. of pharmacy practice, SUCP, HYDERABAD 4

5. On the third day of treatment the patient
developed a raised red rash which was
suspected of being an allergic reaction to
flucloxacillin.
Treatment was changed to i.v. Clindamycin
160mg three times a day (10mg/kg/dose) for 2
weeks followed by oral clindamycin 160mg
three times a day for a further 4 weeks.
Dept. of pharmacy practice, SUCP, HYDERABAD 5

6. Comments on drug therapy and
monitoring required:
•Body weight appears low for age; therefore, need to check if the
weight is correct (expected weight for a 7-year old to be approx. 23kg). If
incorrect, doses of medication will need to be recalculated.
•Recommended i.v. Dose of flucloxacillin of 50mg/kg/dose is correct.
However, usual maximum oral dose of flucloxacillin is 25mg/kg/dose.
This is because of the increased risk of gastric side effects with high
oral doses of flucloxacillin.
• There is a need to consider compliance with oral flucloxacillin therapy
due to poor palatability of the suspension formulation (if the child would
not take capsules) and the frequent dosingregimen.
Dept. of pharmacy practice, SUCP, HYDERABAD 6

7. • Whilst the risk of flucloxacillin-induced hepatotoxicity is low in children, there
is a need to consider measuring baseline and repeat liver function tests
because of the prolonged course (more than 2 weeks) of flucloxacillin therapy.
• Clindamycin has good oral bioavailability, so i.v. Therapy may be
unnecessary.
• The recommended dose of clindamycin by i.v. Infusion is up to 10mg/kg
dose 6 hourly in severe infection. The infusion should be diluted to 6mg/mL
with sodium chloride 0.9% or dextrose 5% (or a combination) and administered
over 30–60min at a maximum rate of 20mg/kg/h. Consider 160mg in 27mL
sodium chloride 0.9% over 30min.
• The recommended standard oral dose of clindamycin is 3–6mg/ kg/dose
four times a day. This may contribute to problems with adherence to long-term
therapy. A three times daily dosing regimen is to be preferred, particularly as
this child may return to school, and four times daily dosing would require a
dose to be administered at school which may be problematic.
Dept. of pharmacy practice, SUCP, HYDERABAD 7

8. • Consideration should be given to how to administer clindamycin. Clindamycin
palmitate suspension, which was palatable, is no longer available as a licensed
preparation in the UK. Whilstextemporaneous formulations are available that
use clindamycin - hydrochloride capsules, the palatability of the resultan
suspension is a major concern, particularly given the prolonged course of
therapy. A 75mg/5mL suspension, licensed in Belgium, can be imported. From
a safety and efficacy perspective it is preferable to use such a product, which
has been through a regulatory process similar to that of the UK, than to
compound an extemporaneous preparation, which has not undergone
appropriate pharmaceutical/pharmacokinetic evaluation.
Dept. of pharmacy practice, SUCP, HYDERABAD 8

9. •Consideration could be given to decreasing the
dose of clindamycin to 150mg three times a day to
accommodate capsules, although the child may
have difficulty taking these.
•The most serious adverse effect of clindamycin is
antibiotic associated colitis. Therefore, it is
important to monitor for diarrhoea. If this arises
treatment should be discontinued.
Dept. of pharmacy practice, SUCP, HYDERABAD 9

10. 18 months old female patient, weighting 10 kg is
presented with Severe right-sided abdominal pain,
Vomiting and loss of appetite, Increased temperature
38.2°C
No previous medical history, no known drug allergies.
Test : ultrasound
Provisional diagnosis : Appendicitis
■ Appendicectomy was performed.
■ The appendix was noted to be perforated.
Dept. of pharmacy practice, SUCP, HYDERABAD 10

11. Medications :
Morphine 50mg in 50mL to run at 1–4mL/h (10–40mcg/kg/h)
Paracetamol 200mg four times a day as required orally or per rectum
Diclofenac 12.5mg twice a day as required per rectum.
or
Ibuprofen 100mg four times a day as required orally when tolerating milk
Five days of i.v. Antibiotic therapy with:
Gentamicin 70mg daily
Ampicillin 250mg four times a day
Metronidazole 75mg three times a day
Dept. of pharmacy practice, SUCP, HYDERABAD 11

12. Comments on the patient’s drug
therapy :
• The morphine dose is incorrect. If the infusion is prepared as directed, 1mL/h will
actually provide 100μcg/kg/h. This is a 10-fold overdose which is a medication error
frequently seen in children.
• There is a need to consider how to administer the appropriate rectal dose of
paracetamol to this child. Often post appendicectomy patients will need to be nil by
mouth for several days. Rectal bioavailability is lower than oral bioavailability and
there may be a need to consider giving a larger rather than smaller paracetamol dose,
that is, possibly 250mg/rectum 8 hourly rather than 125mg 6 hourly, for up to 48h,
but not exceeding 90mg/kg/day.
Dept. of pharmacy practice, SUCP, HYDERABAD 12

13. • Suggest that paracetamol and NSAID are administered regularly in addition to the morphine
for at least the first few days post-surgery. Multimodal analgesic therapy is recommended.
• There will be a need to monitor CS for side effects. Nausea, vomiting and pruritus all occur
frequently with morphine but can be treated/prevented.
• Young children are particularly susceptible to developing myoclonic jerks with morphine.
These are often worrying for parents but resolve on withdrawal of the morphine.
Dept. of pharmacy practice, SUCP, HYDERABAD 13

14. • NSAIDs are well tolerated by children and the risk of adverse
events is much lower in children than the adult population.
However, it is important to ensure adequate hydration status
postoperatively, particularly when using NSAIDs. Acute renal failure
has been reported in children who have been treated with NSAIDs
and not adequately hydrated.
• The choice of antibiotics for CS is appropriate. High-dose (7
mg/kg) once-daily aminoglycoside (gentamicin/tobramycin)
therapy is now routinely used in children. It is administered by short
infusion over 20 min. Plasma drug levels should be monitored to
achieve a 18–24 h trough level of <1 mg/L. Monitor urea and
electrolytes and serum creatinine. Ampicillin can be given as a
bolus injection over 3–5 min. Metronidazole should be given as a
short infusion over 20 min.
Dept. of pharmacy practice, SUCP, HYDERABAD 14

15. Thank you
Dept. of pharmacy practice, SUCP, HYDERABAD 15