DIARY OF EVENTS

Month of September
Department: ARV Pharmacy
Tuesday, 01 September

Today was my first day of internship at Windhoek Central Hospital. All the interns were
warmly welcomed by the chief pharmacist and the pharmaceutical staff. Afterwards, we
were divided into different groups and received a monthly rotation schedule that, with
time, allows us to work at each department in the hospital. The 8 pharmaceutical
departments are: In-patient, Out-patient, Manufacturing, Store, the ARV pharmacy,
Psychiatric, Maternity and the Oncology pharmacy.
My first rotation is the ARV Pharmacy. Here, I will be given the opportunity to meet the
pharmacist in charge of this department.

Wednesday, 02 September

The ARV pharmacy is one that deals with the dispensing of Anti-retroviral medication to
patients who are diagnosed as HIV positive and those who require Hepatitis B, PEP or
PREP medication. Patients also provided with counseling and are also given TB
preventative therapy, co-trimoxazole as well as the necessary vitamins needed for ART
therapy. I became familiarised with the organisation and the regular routines that occur
in the pharmacy, those which including taking and recording temperature, it should not
exceed 25oC, disinfecting the pharmacy, arranging medication and collecting patient
cards for counting and distributing the amount of pills necessary for their treatment. I
learnt that the pill count is very important as it measures patient compliance by
comparing the number of doses remaining in a container with the number of doses that
should remain. It also helps to determine the patient’s adherence percentage and indicates
whether the patient is administering their medication correctly.
Once the pill count is completed we proceed to dispensing the patient’s medication using
the EDT system. I gladly observed and learnt how to use this system.

Thursday, 03 September

Today I learnt how to view the number of appointments there are in a day as well as the
amount of patients that are booked. When dispensing medication, we give enough to last
until the next doctors follow up either on the same day or the following day when the
patient has to comes back for blood count. Also, when booking patients, we avoid
booking them on the first wednesday of each month as it clashes with when we dispense
medicine to prisoners. When printing out labels there are two types:
 one which shows the patients ART number, name, regimen, dispense date, the
next follow up date and the patient’s adherence in percentage which should be in
the range of 95%-105%
 The other is a label that contains a full regimen, the doses and instructions of how
to take the different medications.
In addition, I also learnt how to calculate the appropriate number of tablets to give a
patient. First we count the number of days up to the next follow up date, then we subtract
the pill count and then lastly add 2 extra tablets.
Friday, 04 September

I learnt how to enter a in-transit patient to the EDT system. An in-transit patient is one
that does not appear on the WCH EDT system. These patients either arrive from an
external clinic or are admitted into the hospital. In each case, we only dispense medicine
that is sufficient for 1 month.
Tutor Comments:

Monday, 07 September

I learnt how to switch and substitute patient regimens on the EDT system. Most patients
are being switched from the TLE (Tenofovir +Lamivudine+Efavirenz) to the TLD
(Tenofocvir+Lamivudine+Dolutegravir) regimen in order to make DTG (Dolutegravir)
the standard first line treatment.
Dolutegravir is more competent than efavirenz and other ARVs as it has a more
developed barrier to combat drug resistance, lower potential for drug interactions, and a
shorter median time to viral suppression (within 4-6 weeks).
Due to the fact that most patients are being switched from EFV to DTG, which are both
1st line, we were instructed to only dispense TLD for one month to monitor the patient’s
response to the medication and the adverse effect profile of patients that take DTG for the
first time.
When counselling the patients, I must reassure them that the medication works the same
way as the previous regimen (also taken at night) does, inform them that DTG is a newer
drug on the market and that potential side effects include headache, skin irritation,
insomnia, nausea, vomiting. I must inform them to return to the pharmacy if these side
effects persist beyond 14 days.

Tuesday, 08 September

I read and revised through the ART treatment guidelines, specifically went through the 1st
line and 2nd line treatments, alternative therapies, mechanism of action of ART
medication as well as the classes.

Wednesday, 09 September

I read about the difference between gravida and para as instructed by our supervisor.
Gravida refers to the number of times that a female has been pregnant regardless of the
outcome.
Para is the number of pregnancies that have been carried at a viable gestational age (20-
28 weeks).
Thursday, 10 September

Today I learnt about the requirements needed to switch patients from Avonza (TLE) to
Acriptega (TLD). In order for patient to switch, there should be 2 consecutive viral load
tests should be done. The results of these tests should be TND (To Non Detectable levels)
which is less than 40copies/ml.

Friday, 11 September

Today we had a discussion about switching regimen from 1st line to 2nd line treatment.
We change patients as a result of treatment failure on first line. Treatment failure can be
observed either clinically, from a patient’s medication history, a physical examination or
virologically by means of viral load or immunologically from CD4 count.
Clinical failure is defined as the occurrence of new opportunistic infections (OI) or other
clinical evidence according to the WHO staging of HIV disease progression during
therapy.
Virological failure is defined as a viral load above 1000copies/ml based on two
consecutive viral load measurements that are take within 3-6 months of each other, with
enhanced adherence support following last visit. (???????)
Immunologic failure is the failure of CD4 count to rise by 25-50 microliter or 50% fall
from the on-treatment peak value or persistent CD4 levels below 200-350 copies/ml 6
months after initiation of therapy. (?????????)
Tutor comments:

Monday, 14 September

Today I did a presentation on the factors that one should consider when determining
whether it appropriate to initiate ART therapy on a patient
All patients who are tested HIV positive, regardless of CD4 count and WHO stage, are
eligible for the initiation of ART therapy (test and treat). Treatment must start as soon as
possible within 1 week. If, at the time of initiation, the patient presents opportunistic
infections (OI’s):
 Diagnosis of cryptococcal meningitis: defer ART until after 4-6weeks of starting
antifungal treatment.
 Diagnosis of TB: start ART therapy after 2-8 weeks of TB treatment.
When a patient presents with OI’s one must, treat the infection first. Only the can ART
therapy commence.
If ART therapy is initiated at the same time as other OI (opportunistic Infection)
therapies, the patient is at risk of acquiring Immune Reconstitution Inflammatory
Syndrome (IRIS).
This illness results from a dramatic increase in the inflammatory response to antigens
from previous , partially treated or latent infections of HIV patients shortly after initiating
ART. IRIS usually occurs in the first few weeks after a patient starts therapy.
Risk factors of IRIS include:a rapid decline in viral load, initiation of ART soon after
initiation of treatment for OI and a low baseline CDS count.
Tuesday, 15 September

Today we were told to look up the treatment of syphilis. Syphilis is a sexually transmitted
infection caused by bacteria Treponema pallidum. Syphilis is classified into different
stages based on signs and symptoms:
Primary stage: presents with ulcers at the infection site, which usually occur around the
genitals, rectum, in or around the mouth.
Secondary stage: presents with skin rush, mucocutaneous lesions and lymphadenopathy
Tertiary stage: terminal stage of the disease, affects many organs and can result to death.
Latent stage: the disease is not active, shows no symptoms but can be spread from one
person to another.
Treatment:
Penicillin G administered intramuscularly (IM) or intravenously (IV) is the standard drug
of choice in the treatment of syphilis.
Primary and secondary syphilis treatment: administer benzathine penicillin G 2.4 million
units IM as a single dose, in penicillin allergic patient’s doxycycline 100mg PO BD for
14 days.
In latent syphilis: administer benzathine penicillin G 7.2 million units total, administered
as 2.4 million units IM each at one week intervals, for penicillin allergic patient’s
doxycycline 100mg PO BD for 28 days is administered.

Wednesday, 16 September

I dispensed a prescription to a patient for Pre Exposure Prophylaxis (PEP). PEP is

defined as the use of antiretroviral (Anti-retroviral) drugs by HIV negative people to
prevent the acquisition of HIV after exposure.
Patients on PEP are given Tenofovir+Lamivudine+Dolutegravir (TLD) once daily for a
duration of 28 days. PEP should be initiated promptly preferably within 1-2 hours post
exposure and is not offered at more than 72 hours, the longer it takes to initiate PEP the
higher the risk of contracting HIV following exposure.
I counselled the patient about why they are taking PEP and that during the first 7 days
they should use a condom if sexually active.

Thursday, 17 September

I learnt about the backbone of ART being tenofovir+Lamivudine (TDF/3TC) and why we
maintain the even though resistance has occurred. The rationale is that they act as
boosters to help reduce mutations from occurring in other ARV medications and
resistance when added to a regimen.

Friday, 18 September

Today I counselled a patient who refused to adhere to her TB prophylaxis treatment and
co-trimoxazole treatment. I assessed her adherence to her ART therapy which was not
consistent. When I asked her why she refuses to take her TB prophylaxis medication, she
complained of the side effects which caused her to stop taking them. I instructed her on
the correct way to take her tablets, she should take isoniazid 300mg once daily together
with pyridoxine 25mg tablets in order to counteract her peripheral neuropathy side effects
that she has been experiencing, she did not fully understand why she had to administer
them together. I reassured her that the side effects would subside once administered
correctly. In addition I emphasized on the importance of adhering to her ARVs and why
she takes co-trimoxazole tablets in order to prevent OI’s.
Tutor comments:

Monday, 21 September

I learnt about patients who are defaulter and loss to follow up. When a patient returns
after loss to follow who has not been n therapy for at least six months the following steps
should be followed:
 Carry out baseline tests that is CD4, viral load, HBsAG (test for hep B), CrAg
(test for cryptococcal meningitis), Hb (hemoglobin) and CrCl (Creatinine
Clearance).
 Many any co-infections if patient presents with any
 Provide appropriate prophylaxis
 Re-start with the same regimen that the patient was on unless contraindicated.

Tuesday, 22 September

Today I read on the baseline tests and routine bio-clinical monitoring of patients on ART.
Baseline tests include viral load, CD4, HbsAG (test for hep B), CrAg (plasma
cryptococcal antigen), Hb (hemoglobin) and CrCl (renal function test). The plasma
cryptococcal test is carried out once the CD4 count is less than 200 copies/ml.
For children and adolescents less than 19 years of age routine viral load should be done
every 6 months. During pregnancy routine viral load is carried out every 3 months until
delivery and in breastfeeding women 6 weeks after delivery then 3 months until end of
breastfeeding period.

Wednesday, 23 September

I reviewed how to interpret viral load (VL) results:

When VL is more than 1000 copies/ml treatment failure is present, between 40-1000
copies/ml indicates low level viremia and when less than 40 copies/ml or target non-
detected (TND) = viral suppression.

Thursday, 24 September

Today I explained to a patient who enquired about why CD4 count is so relevant. CD4
count is essential for the assessment of immunological status and to assess the risk of
possible OI. In addition, CD4 count can help determine when to stop prophylaxis
treatment (e.g. fluconazole in Cryptococcal meningitis therapy) as to when immune
reconstitution has occurred.

Friday, 25 September

We had a discussion about Co-trimoxazole Preventative Therapy (CPT). CPT is useful

for the potential to prevent opportunistic infections such as cryptococcal meningitis,
Tuberculosis, pneumocystis pneumonia, toxoplasmosis, malaria episodes, and bacterial
infections including bacterial pneumonia, diarrhea and bacteremia.
We initiate CPT in adults and adolescents with severe or advanced HIV (stage 3 or 4),
and/or a CD4 count less than 350 cell/mm3. In infants and children with HIV irrespective
of clinical stage or CD4 count. Initiate in all HIV-exposed infants at 6 weeks of age. In
TB/HIV co-infected patients CPT is initiated regardless of CD4 count.
In patients who are allergic to Co-trimoxazole we give Dapsone 100mg daily.
Tutor Comments:

Monday, 28 September

Today I revised the management of cryptococcal meningitis. In the initiation phase we

give Amphotericin B IV 0.7mg/kg/day which is given with pre-emptive hydration and
electrolytes plus high dose fluconazole 1200mg daily for 2 weeks. Followed by
continuation phase Fluconazole 800mg for two months then maintenance phase with
fluconazole 200mg daily for minimum 1 year in total and discontinue when patient has 2
CD4 counts more than 200 cells/mm3 at least 6 months apart.

Tuesday, 29 September

Counselled a patient who was initiated on PrEP (Pre-exposure Prophylaxis) today. I

advised the patient that it is only effective when taken daily and she should use a condom
for 21 days because it takes 7-21 days for PrEP to achieve protective levels. I also
explained to her about the possible side effects such as nausea, vomiting, dizziness,
headache, abdominal pain and fatigue may arise within the first 2 weeks of therapy and
are self-limiting.

Wednesday, 30 September

I learnt that we use Darunavir in third line treatment of HIV and only when resistance
(genotype and phenotype) test are done.
Tutor comments:
 MONTH OF OCTOBER
Department: In Patient Pharmacy

Thursday, 01 October

Today was my first day in the in-patient pharmacy department and I will be here for two
months (October and November). This day mostly comprised of orientation and learning
how things are done in this department.
The day starts by first recording the temperature, disinfecting the pharmacy work station,
checking the pre-packs if there is any that require a refill.
In patient department involves dispensing medication to patients that are admitted in the
hospital. We dispense to 16 wards in total, the prescriptions are brought to the pharmacy
by the nurses and they register the number of cards brought to the pharmacy and are
carried in a dispensing box from each ward.
Most common prescriptions dispensed involve injectable, antibiotics, eye drops, cold
chain fridge items and some oral medications.
When dispensing IV medication, we only dispense enough for 1 day except on weekends
we dispense enough for the entire weekend, this helps to control medication use in the
wards avoid wasting and track proper administration of medication. For oral medication
we issue for 7 days only.

Friday, 02 October

I spent most of my day familiarizing myself with the most commonly dispensed
medication in this department, as well as taking note of the brand names and noting down
the abbreviations used by doctors when prescribing medication.
For example occ=ointment; os=left eye; R/L=both eyes are few to mention. I also
refreshed my memory on antibiotics as they bare the most frequent medication prescribed
in this department.
Monday, 05 October

Ordering of stock in the in-patient department is carried out on Mondays, which is what I
did today. I also researched about the drug Albendazole, a broad-spectrum anthelmintic
used in the treatment of parasitic worm infections such as giardiasis, trichuriasis,
filariasis, neurocysticercosis, and hydatid disease.
After oral administration, its absorption is enhanced by fatty foods, metabolized in the
liver with a half 8-12 hours. Side effects include: epigastric pain, diarrhea, headache,
nausea, dizziness, insomnia common in long term therapy. Safety profile in pregnancy
has not been established.
Tuesday, 06 October

Today we discussed paracetamol toxicity also known as acetaminophen poisoning, which

is caused by an overdose of paracetamol above the maximum daily dose per body weight
which is 150mg/kg or more than 4g per day.
Paracetamol toxicity mainly causes liver injury and is known to be the most common
type of poisoning worldwide.
Clinical features present in different phases:
Phase 1: within 24hours, patient maybe asymptomatic or presents with GI upset.
Phase 2: 24-48hrs, nausea + vomiting, RUG pain and tenderness, progressive elevation of
transaminases, bilirubin.
Phase 3: 48hrs+ hepatic failure (jaundice, coagulopathy, encephalopathy).
Phase 4: severe hepatic failure and death
In rare cases, an overdose may initially present with coma and metabolic acidosis.
Hepatoxicity may be prevented if an antidote acetylcysteine is administered within the
first 8 hours of an acute overdose.
Wednesday, October 7

Today we discussed about the drug aspirin and indications of low dose and high dose
aspirin.
At low doses (75-100mg), it is used to prevent cardiovascular risk events and for its anti-
platelet activity.
At 150mg, it is indicated in thromboembolic prophylaxis.
At high doses (300mg +), its used for its analgesic and anti-inflammatory effect.
Aspirin overdose occurs at doses more than 4g in 24 hours, the classic symptoms include
ringing in the ears, nausea, abdominal pain, and tachycardia. Antidote for aspirin
poisoning: activated charcoal to reduce further absorption of aspirin and sodium
bicarbonate with IV fluids and electrolytes due to dehydration.
In addition, aspirin is not recommended in children as it causes Reye’s syndrome. A
condition defined by brain and liver damage. Aspirin is also contraindicated in
pregnancy, however low dose aspirin is considered safe to use for the delayed onset of
preeclampsia, clotting disorders and recurrent miscarriages.

Thursday, October 8

Today I intervened in a prescription where doctor prescribed Pen V 250mg QID for 1
month for Rheumatic heart disease. The correct dosage is 250mg BD for 1 month.
My supervisor instructed me to do more research and come and present about
pathogenesis and treatment rheumatic heart disease.

Pen V is also indicated in tonsillitis as 500mg QID for 10 days (adults) and 250mg QID
for 10 days (children).
Friday, October 9
As instructed by my supervisor I did a presentation on rheumatic heart disease and its
treatment.
Rheumatic fever is an autoimmune inflammatory reaction to throat infection caused by
group-A-hemolytic streptococci. The autoimmune response to one or more episodes of
rheumatic fever causes an inflammatory condition in the body, resulting in an ongoing,
chronic and permanent heart valve damage known as rheumatic heart disease (RHD).
Streptococcal throat infections are common in children, hence rheumatic fever mostly
affects children and adolescents.

Treatment of choice for Rheumatic fever is Penicillin (oral Pen V or Injectable

benzathine penicillin).
Alternative treatment for patients allergic to penicillin include narrow spectrum
cephalosporin, clindamycin or macrolide.
Patients who have had an episode of Rheumatic fever need to be given prophylactic
treatment as they are prone to recurrences. Hence the recommended duration of
prophylaxis is dependent on the number of previous attacks, age of patient, presence of
absence of cardiac involvement.
Tutor comments:

Monday, October 12

Today I received a prescription with amplicox 1g PO TDS a combination of Ampicillin

and Cloxacillin. Since we do not have a fixed dose combination I learnt that in practice
we have to divide the dose by 2, given as: Ampicillin 500mg tds PO and Cloxacillin
500mg QID PO for 5 days.

TREATMENT?

Tuesday ,October 13

Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an

important cause of peptic ulcer disease and gastric cancer. There are two therapeutic
goals in h.pylori eradication therapy: to heal the ulcers and to eradicate the organism.
The most effective regimen is the triple therapy comprising of two antibiotics and a
proton pump inhibitor (PPI): Omeprazole 20mg BD + clarithromycin 500mg BD +
Amoxycillin 1g BD or Metronidazole 400mg BD for 7-14 days. After completion of
the triple therapy the PPI should be continued for 4-6weeks to ensure complete ulcer
healing.
The rational of the PPI is that it has minor antimicrobial properties and it raises
intragastric pH which lowers the minimal inhibitory concentration of antibiotics
against H.pylori.

Alternative regimen is called the “sequential treatment” consisting of a PPI twice daily
+ amoxicillin 1g BD on days 1-5 then days 6-10 of PPI twice daily + Clarythromycin
500mg BD + Metronidazole 400mg BD, for duration of 10 days.
OR
Quadruple therapy includes 2 antibiotics + PPI + Bismuth subscylicate for 10-14 days.

Today I received a prescription where clarithromycin 500mg BD + Amoxicillin 500mg

TDS + Omeprazole 20mg OD, I called the doctor to intervene with the dosing
frequency for amoxicillin and omeprazole and changed it accordingly.
Wednesday, October 14

Today I researched about the rationale of zinc in cardiac disease, as it is mostly added
to cardiac based regimens in IPD.
Zinc supplements reduces risks of atherosclerosis and protects the heart from
myocardial infarction, ischemic injury, by regulating calcium movement in the heart,
improving cardiac function and prevents further damage. In addition, there is a strong
association between heart failure and oxidative stress in the body, which results due to
an imbalance between free radicals and protective anti-oxidants. Free radicals attack
essential cholesterol that circulates in blood. Cholesterol becomes harmful when
oxidized by free radicals, oxidized cholesterol is embedded in the vessel wall and leads
to atherosclerosis.
Zinc has anti-oxidant properties and is able to fight these free radicals and hence helps
improve cardiac function.
Thursday, October 15

Today I received a prescription for a 2 year old male pediatric patient, with a suspected
upper respiratory tract infection who was prescribed:
Azithromycin 5ml p.o OD for 3days
Amoxycillin 5ml p.o OD for 3 days
Friday, October 16

We had a tutorial with the Chief Pharmacist about antibiotics where I learnt more about
the classifications, mechanism of actions, indications and the use of antibiotics in
practice as well as the most frequently prescribed antibiotics at central hospital.
We also discussed the choice of antibiotics is based on the spectrum of the
antimicrobial, nature of causative organisms, resistance, multiple drug resistance and
mixed infections, severity of infection, patient medical case (renal/liver function),
pregnancy and safety/side effect profile.
Tutor Comments:

Monday, 19 October
Today we received a prescription of a 44 year old female with a complicated UTI, and
was prescribed ciprofloxacin 500mg BD for 14 days plus nitrofurantoin 100mg TDS. I
called the doctor and enquired as to why nitrofurantoin was prescribed in this case and to
verify if they wanted to use it for prophylaxis treatment for UTI, doctor said no. I then
advised the doctor that there was no need to combine both antibiotics for complicated
UTI, and ciprofloxacin alone was enough to clear the UTI, as her culture and sensitivity
test results showed that she was sensitive to ciprofloxacin.
Tuesday, 20 October

Today we received a prescription of a 27 year old female with known hyperemesis

gravidarum of which prochlorperazine 10mg po tds was prescribed for 5 days. We did
not have this drug in stock, so I went to enquire with my supervisor on the alternative
medication which can be given to the patient and we discussed and agreed on the drug
ondansetron.
Prochlorperazine is a category C drug even though it is reserved for hyperemesis in
pregnancy, this means that studies that were done in animals showed potential harm to
the fetus and there are no studies done in humans, and used when benefits outways the
risk.
Ondansetron is effective as well and is safer as it is a Category B, this means that studies
were done in animals and no potential risk to the fetus was found and no studies were
done in humans.
We then opted for ondansetron and called the doctor to inform him that there was no
stock for prochlorperazine and advised that he changes the prescription to ondansetron
4mg BD PO for 5days.

Wednesday, 21 October

Today we received a prescription of a 36 year old with dysmenorrhea:

1. Tranexamic acid 1g BD PO for 7 days
2. Paracetamol 1g TDS Po for 7 days
3. Betacod (Paracetamol 500mg, codeine 8 mg) 2 tablets TDS PO for 7 days
4. Ibuprofen 400mg TDS PO for 7 days
Were prescribed, I raised concern to the doctor about prescribing all 3 analgesic drugs
together and advised him to remove paracetamol as Betacod also contains paracetamol if
administered together there would be a daily overdose of 6g which is not recommended
(recommended daily dose is 4g/day) and that he should only prescribe Betacod with
ibuprofen alone.
Thursday, 22 October

A prescription for a 30 year old female with h.pylori induced peptic ulcers was brought to
the pharmacy:
Omeprazole 20mg PO OD for 7 days
Amoxicillin 1g PO BD for 7 days
Metronidazole 400mg PO BD for 14 days
Clindamycin 150mg QID for 14 days
I called the doctor to enquire about the rationale of using clindamycin and raised concern
about the duration of the antibiotics and advised that h.pylori treatment is prescribed as 2
antibiotics plus proton pump inhibitor for 7-14 days, the duration should be the same,
followed by 4-6 weeks of Omeprazole 20mg OD to ensure complete ulcer healing.

Friday, 23 October

Today we had a tutorial with the chief pharmacist about anxiety. I learnt that anxiety is
caused by an imbalance in serotonin levels. Benzodiazepines are preferred over
barbiturates because they are safer, and have a longer therapeutic index. Benzodiazepines
are used short term to prevent dependence and tolerance. If dependence occurs we switch
to longer acting benzodiazepines and tapper the dose in order to prevent withdrawal
effects and convulsions. I also learnt about the other classes of drugs used such as
selective serotonin reuptake inhibitors (SSRI), Monoamine oxidase type A inhibitors and
Tricyclic antidepressants. SSRI are the agents of choice for long term treatment. I learnt
about other types such obsessive compulsive disorder (OCD), Post-Traumatic Stress
Syndrome. Additional therapy such as propranolol can be given for tremors.

Monday, 26 October

Today I learnt about the management of Epididymo-orchitis, which is an inflammatory

process of the epididymis and testes. It most often presents with acute onset of pain and
swelling, caused by either sexually transmitted pathogens ascending from the urethra or
non-sexually transmitted uropathogens spreading from the urinary tract. Sexually
transmitted infections: chlamydia trachomatis and Neisseria gonorrhoeae especially in
young men under age 35. Non-sexually transmitted infections: E.coli, and other risk
factors include obstructive urinary disease and urinary tract surgery.
Management :
Ceftriaxone 250mg IM plus Doxycycline 100mg BD for 14 days, if likely to be a
sexually transmitted pathogen.
OR
Ciprofloxacin 500mg BD PO or Levofloxacin 500mg BD PO for 14 days, if likely to be
enteric pathogen.

Tuesday, 27 October

Today I learnt that in pediatrics the dose of Augmentin 120mg/5ml (Amoxicillin +

Clavulanic acid) can be reduced or halved in order to reduce the dose of clavulanic acid,
then add an additional dose of amoxicillin to get the desired effects of amoxicillin. The
rationale is to prevent Gastro intestinal side effects
For example today we received a prescription for a 8months female infant:
Amoxicillin/Clavulanic acid syrup 90mg (3.75ml) PO TDS plus Amoxicillin 90mg PO
TDS.

Wednesday, 28 October

We came across a prescription of a patient who is RVD-R on ART with crptococcal

meningitis in request for Amphotericin B, and a CD4 count of 10 copies/ml. Today we
went to the wards to follow up on this patient and we found that he passed on.
Cryptococcal meningitis is a potentially fatal fungal infection that presents in HIV
positive patients who are severely immunocompromised with a CD4 count less than 200
copies/ml. Treatment is divided into 3 phases:
Initiation phase: Amphotericin B 0.7mg/kg/day IV for 2 weeks
Consolidation phase: Fluconazole 400-800mg PO OD for 6-8 weeks
Maintenance phase: Fluconazole 200mg PO OD for 2 weeks until immune reconstitution
that is CD4 count reaches above 350copies/ml.

Thursday, 29 October

I reviewed a prescription of 56 year old male with epididymorchitis who was prescribed:
Ceftriaxone 250mg IM STAT; Doxycycline 100mg BD PO for 14 days plus
ciprofloxacin 500mg BD for 14 days.
The urine culture showed no presence of chlamydia or gonohhrea species and that the
cause of the infection was due to enteric pathogens in this case E.coli.
I then called the doctor and advised that there was no need for prescribing all 3 antibiotics
and that either ciprofloxacin or levofloxacin alone was enough to clear the infection
considering the causative pathogen, we then agreed on ciprofloxacin 500mg BD for 14
days alone and it was dispensed.

Friday, 30 October

A prescription for a 5 year old patient was brought to the pharmacy for paracetamol syrup
5ml PO OD. I called the doctor to change the dosing frequency to TDS to achieve the
desired effect of the medication, it has a short half-life of approximately 1-4 hours.
Tutor comments:
 MONTH OF NOVEMBER
Department: In-Patient Department
Monday. 02 November

Today I ordered weekly stock for the department and labelled all the drugs expiring
within the next 5 months on the shelves. I also removed all the expired drugs and
prepacks from the shelves and noted them down on the expiry item form which is then
handed over to the store pharmacy who prepare the medication for disposal.

Tuesday, 03 November

A prescription was brought to the pharmacy for Co-Amoxyclav (Amoxicillin +

Clavulanic acid) 1.2g IV TDS for 5 days plus Ceftriaxone 750mg IV TDS. I called the
doctor to enquire on the rationale of prescribing both drugs as they are from the same
class with similar mechanism of action and I explained that only one should be given as
there is high risk of cross resistance between both drugs. Both drugs cannot be taken
together hence only Co-Amoxiclav 1.2g IV TDS was given.

Wednesday, 04 November

A few prescriptions were brought to the pharmacy with dosing errors which I reviewed
and intervened.
Co-Amoxiclav 1.2g IV BD for 7 days; ceftriaxone PO BD for 5 days; Metronidazole
500mg PO TDS for 5 days
I called the doctor and advised the following:
Co-Amoxiclav 1.2g iv is taken three times daily and not twice daily, the twice daily
regimen is administered orally.
Ceftriaxone is only taken IV and not orally, and I advised to give cefuroxime 500mg PO
BD for 5 days.
Metronidazole 500mg is only found in IV form and the correct oral dose is 400mg BD for
5 days.

Thursday, 05 November

Today I attended a presentation for Nestle NAN, an infant formula milk specially
recommended for infants who are lactose intolerant and to prevent allergies in infants that
are high risks of acquiring them with known family history.
It has the ability to reduce risk of allergic rhinitis by 33% and atopic dermatitis by 42%.

Friday, 06 November

A doctor came to the pharmacy and enquired on how to calculate the dose for
methotrexate for an ectopic pregnancy. The dose is calculated according to total body
surface area at 50mg/m2. I verified with my supervisor and I dispensed the medication.
Tutor comments:

Monday, 09 November

Today I had to calculate the correct quantity for mist morphine 15mg/10ml for the
desired duration for a couple of prescriptions. I also prepared a mixture for chlorhexidine
mouthwash.

Tuesday, 10 November

I was instructed by supervisor to give a presentation on different indications for

antifungals.
Antifungals are classified into:
Antibiotics: Polyenes( Amphotericin B, Nystatin) and Heterocyclic benzofuran
( Griseofulvin)
Antimetabolite: Flucytosine
Azoles are further classified into:
 Imidazoles: Ketoconazole, clotrimazole, miconazole
 Triazoles: Fluconazole, itraconazole,voriconazole

Indications:
Amphotericin B: drug of choice for most severe and life threatening systemic mycoses
such as disseminated candidiasis, cryptococcosis, mucormycosis, histoplasmosis, and
blastomycosis.
Nystatin: oral cutaneous, mucocutaneous candida infections.
Ketoconazole: an alternative to amphotericin B in mild yeast infections such as chronic
and recurrent vaginal candidiasis, chronic infections of the skin, nails, and hair
unresponsive to topical therapy,oesophangeal candida.
Miconazole and clotrimazole; mostly used for topical vulvovaginal candida, tinea,
cutaneous candida infections
Fluconazole: vaginal ad oropharyngeal candida not responding to topical therapy,
esophageal and systemic candida, cryptococcal meningitis.
Itraconazole: vulvovaginal, oropharyngeal or esophageal candidiasis not responding to
other therapies.
Wednesday, 11 November

Today the doctor called the pharmacy to confirm if we have fluconazole in stock and
what alternative drug we can give to a patient with vaginal candidiasis, since fluconazole
is out of stock I advised the doctor to prescribe itraconazole as they are both from the
same class and have the same mechanism of action administered orally 100mg once daily
for 7 days.

Thursday, 12 November

A prescription with a diagnosis of epididyorchitis was brought to the pharmacy:

Metronidazole 400mg BD PO + Azithromycin 2g STAT+ Doxycycline 100mg po BD for
14 days was prescribed.
I called the doctor and advised that there is no need to give metronidazole as the
suspected causative organisms for this infection is chlamydia and N.gonorrhea of which
metronidazole only covers anaerobes.
Instead of giving azithromycin and doxycycline together which both covers chlamydia , I
advised to rather give a STAT dose of ceftriaxone 250mg IM which covers N.gonorrhea
plus Doxycycline 100mg BD PO for 14 days which covers chlamydia.

Friday, 13 November

Today I learnt that in practice gliclazide is preferred over glibenclamide in the treatment
of type 2 diabetes, because glibenclamide has more hypoglycemic effects especially in
elderly patients. In addition, we received a prescription for Nitrofurantoin 100mg BD PO
in a prescription for a patient with an uncomplicated UTI. Nitrofurantoin is administered
three-four times daily and not twice, after consulting the doctor I dispensed accordingly.
Tutor comments:
Monday, 16 November

Today I received a prescription of a patient with known otitis media and has been on
treatment for 6 months with Gentamycin ear drops. I raised this concern to my supervisor
and after discussing we saw the need to intervene into this case. The gentamycin ear
drops were withheld and I called the doctor to raise this concern, the doctor refused to
switch to an alternative. I counselled the patient as to why we withheld the gentamycin
eardrops and advised him to go and see a nose-ear-throat specialist for examination and a
new prescription.

Tuesday, 17 November

A prescription was brought to the pharmacy with ceftriaxone 750mg IV TDS plus
cefuroxime 500mg BD PO for 5 days.
I called the doctor and advised that ceftriaxone and cefuroxime cannot be used together.
We stopped the IV ceftriaxone as patient was able to take oral cefuroxime 500BD for 5
days.

Wednesday, 18 November

Today I learnt about VVM (Vaccine Vial Monitors), which a thermochromics label put
on vials containing vaccines which gives a visual indication of whether the vaccine has
been kept at a temperature which preserves its potency. It is sensitive to temperature
change consisting of a white square which is surrounded by a circle purple in color. The
inner square should always remain white and when exposed to excessive heat it changes
color. When the inner square matches the outer circle the vaccine should not be used and
should be discarded.

Thursday, 19 November

Today I received a prescription where I had to calculate the require dose and dispense
Promethazine syrup (5mg/5ml) and methadone (2mg/1ml) scheduled drug under the
supervision of my supervisor. These two drugs are used to sedate patients prior to
surgery.

Friday, 20 November

Today I received a scheduled form in request for mist morphine 20mg/15ml without a
doctor’s prescription, I called the doctor to ask for a full complete prescription and
handed over the scheduled form to my supervisor.
Tutor comments:
Monday, 23 November

Today I read on the rationale of using allopurinol in cancer patients. Chemotherapy

causes an elevation of serum uric acid levels by causing an increased turnover rate of cell
death. Chemotherapy is usually followed by a rapid amount of cellular destruction and
tumor lysis which is normally seen in leukemia, lymphomas or multiple myeloma.
Allopurinol 150mg is normally prescribed together with chemotherapy agents in the
treatment of leukemia to prevent hyperuricemia.

Tuesday, 24 November

Today I intervened a schedule 4 prescription under the supervision of my supervisor:

Methylphenidate 45 tablets, 10mg mane and 5mg midday. The doctor made it repeatable
for 3 months, and by law it cannot be made repeatable. Secondly the “45 tablets” was not
written in full words next to it, the full prescription should be written as follows:
Rx Methylphenidate, fourty five tablets (45 tablets), 10mg mane and 5mg midday for one
month.

Methylphenidate is used in the treatment of Attention Deficit Hyperactivity Disorder, and

should not be taken at night it causes insomnia. It should be taken after food not before
meals as absorption may be rapid enough to cause anorexia.

Wednesday, 25 November

Today I observed how scheduled drugs are handed over to the nurses for the wards.
The scheduled drug is handed over to the registered nurse by the registered pharmacist.
The order book is brought to the pharmacy a day prior to handing over.
On the day of handing over, the pharmacist double checks the remaining balance and
then hands over the ordered medication to the registered nurse who then double checks if
the medication is correct and intact, not damaged.
The quantity issued, balance, date issued and signature should always be filled in the
order book in duplicate, with a reference number. Once filled in and signed by the
registered nurse, the original copy remains with the pharmacist.

Thursday, 26 November

A nurse brought in a complaint to the pharmacy about metoclopramide IV ampoule, from

cospharm, she complained that it is difficult to break as there no dot or indicator on the
ampoule. I advised her to fill in Product Quality Form which will be submitted to NMRC.
The NMRC (Namibia Medicines Regulatory Council) is a statutory body established in
terms of Medicines and Related Substances Act of 3003 to regulate the use of medicines
in Namibia.
Friday,27 November

Today I learnt that when initiating a patient on Entresto (Valsartan + Sacubitril ), the
patient should first stop their current ACEI(Angiotensin Converting Receptor
Inhibitors)/ARB (Angiotensin Receptor Blockers) treatment regimen they are on and wait
for 36 hours then start Entresto, in order to avoid severe hypotension.

Monday, 30 November

Today I learnt about the support indications for the presence of bacterial infections using
clinical and laboratory data, the inflammatory markers to look out for is C-reactive
protein (CRP) and procalcitonin (PTC) levels. PTC are more precise than CRP.
Tutor comments:
 MONTH OF DECEMBER
Department: ARV- Pharmacy

01 December

Today marked my second rotation in the ARV department.

I came across a case of a 45 year old female, RVD-R on TLD (Tenofovir, Lamivudine,
Dolutagravir) diagnosed with Lupus nephritis class 1.
The co-existence of HIV with Lupus nephritis is a rare condition, hence I was told to research
about the condition, implication of lupus nephritis co-administration with a
nephrotoxic drug (Tenofovir).
Lupus nephritis is a condition characterized by the inflammation of the kidneys caused by
systemic lupus erythematosus an autoimmune disease.
Despite having Lupus nephritis the patients CrCl C was 120ml/min, which is a major indicator
for kidney function and is within normal range (88-128ml/min). Hence, there was no
need to have her switched from tenofovir to a less nephrotoxic drug such as Abacavir
(ABC) or Tenofovir Alafenamide (TAF).
According to the Namibian ARV guidelines a patient is eligible for change from TDF to ABC
or TAF when their CrCl < 50 ml/min.

02 December

Every first Wednesday of the month is prisoner’s day, in the ARV pharmacy department.
Usually we are required to go to prison and dispense but due to COVID all
prescriptions are brought to the pharmacy by the correctional services and we attend to
them in the pharmacy.

03 December

Today I analyzed the prescription of a patient on second line treatment AZT/TDF/3TC/ATV-r,

who was experiencing protease inhibitor induced hyperlipidemia. Her BMI was also
high, with a value of 30 which indicates she is obese.
The patient was initiated on Simvastatin 10mg at night, to help control her cholesterol levels.

I then had to counsel the patient on lifestyle modifications in order to watch her diet closely
due to her BMI and her hyperlipidemia. This includes exercising at least 3 times a
 week for 30-90 min, cutting down on fatty foods, meat, and eating lots of vegetables
and fruits as well as unsaturated fats. I explained to her the dangers of a high BMI, and
increased cholesterol and how important it is to keep healthy. In addition I reminded
her of the hyperlipidemic side effects of protease inhibitor Atazanavir/ritonavir (ATV-
r), and emphasized on the importance of adehering to her medication.

04 December

Today my supervisor gave me the task of preparing a monthly report.

The report mainly comprises of:
 All patients to date which is a cumulative number of active, in-transit, loss to follow
up, transferred-out, transferred-in, deceased, stopped and re-started.
 new patients,
 number of pick up by patients this includes routine refills, in-transit, re-started and
transferred-in
 number of regimens switched,
 number of patients whose status changed,
 number of patients late for appointments,
 Patient adherence which is based on pill counts for patients who came for routine fills
in a given month.
 a list of the number of patients on each regimen
 Monthly stock status for the ARV pharmacy.

Tutor comments:

07-18 December: SICK leave due to COVID-19

21 December

Today I consulted the Doctor concerning a 47 year old, male patient who came to the
pharmacy with end stage Chronic Kidney Disease (CKD), with CrCl=5 ml/min and
GFR 6ml/min/1.73m^2, his current regimen was as follows:
ABC 300mg , BD PO
3TC 150mg, OD PO
EFV 400mg, NOCTE, PO
CTX (cotrimoxazole) 480mg OD

I brought to the doctors attention to modify the patients 3TC (lamivudine) dose to be 150mg as
STAT dose then 50mg OD, because his CrCl <10ml/min
And
Stop his Cotrimoxazole as his CrCl<15ml/min.
As referenced in the Namibian ARV Treatment Guidelines.
22 December
We received a complaint from a patient concerning Dolutagravir associated side effects one of
them being skin reactions, who was switched from TLE (Tenofovir, Lamivudine, Efavirenz) to
TLD (Tenofovir, Lamivudine, Dolutagravir) regimen 2 weeks ago.
The patient complained of itching of all over body since the initiation of this regimen.
We then reassured the patient, about the medication and advised the patient to go back and see
the doctor to prescribe a systemic anti-histamine to help relieve the side effects and advised
the patient that if the side effects still persist or worsen, they should come back to change their
medication.
23 December

Today I read about Pneumocystis pneumonia (PJP) which is caused by Pneumocystis jirovecii.
It is an AIDS defining illness that occurs at WGO clinical stage 4. Risk factors include
severely immunocompromised patients who have a CD4 count less than 200cells/mm3 who
either unaware of their HIV status or defaulted.
Treatment of PJP:
1. Co-trimoxazole (CTX) 20mg/kg IV for 21 days or PO divided in 3-4 doses daily
2. Steroids are given in patients with severe hypoxia that is prednisolone 40mg twice
daily PO for 5 days then 40mg once daily PO for 5 days then 20mg once daily for 5
days.
In patients allergic to CTX: trimethoprim (TMP) + Dapsone or clindamycin + primaquine.
Prophylaxis: CTX 2 tablets (960mg)/day lifelong

24 December

A patient came to the pharmacy, who is non-adherent, has a viral load of 1180 copies/ml and
CD4 count of 98 cells/mm^3. In addition, the patient was put on TB preventative therapy and
did not take the medication either.

I counselled the patient and explained that increase in viral load and decreased CD4 count
simply indicates that she is not adhering to her medication. I re-emphasized the importance of
taking her medication and the goals of ART which is to suppress viral load to non-detectable
levels, prevention of opportunistic infections, restore the immune system and improve the
quality of life.
Her low CD4 count implies that she is at high risk of acquiring opportunistic infections, and
was thus initiated on TB preventative therapy which she wasn’t taking. Therefore, I explained
the importance of taking her medication and showed her how to take it. Isoniazid 300mg is
taken once daily together with Pyridoxine 25mg to counteract the peripheral neuropathy side
effect of isoniazid. In addition, I also handed over her co-trmoxazole antibiotics re-emphasized
the importance of her taking them for the prevention of further opportunistic infections that
she is at high risk of acquiring, as she is severely immunocompromised.
25 December

Public holiday: Christmas day

Tutor comment:
December 28-31: Vacation leave
 MONTH OF JANUARY
Department: Out-Patient Department (OPD)

Monday, 04 January

Today marked my first day in the out-patient department where I was oriented on the
organization of the pharmacy. There are 3 different processes when dispensing in OPD namely
collecting of medication, writing labels and dispensing to the patient which is carried by
different people reason being to reduce errors as this is one of the most busy pharmacy
departments in the hospital.

Tuesday, 05 January

A patient came to the pharmacy with a prescription: lorazepam 1 mg for 2 weeks and
fluoxetine 20mg for 1 month and was prescribed in the previous month (December). I
explained to her that I could not dispense her medication as her prescription is no longer valid
as it was not made repeatedable. I advised her to go and see the doctor to the doctor for a new
prescription.

Wednesday, 06 January

Today I learnt how to calculate the dose for insulin when dispensing in order to know the
quantity to be dispensed that is: total units X frequency X duration. I reviewed a prescription
for Actraphane (Intermediate acting) 16 IU mane and 9 IU nocte for 30 days. When calculated
her total units for the month are 1500 IU (25 X 2 X 30), and each injection carries a total of
1000 IU hence I dispensed two injections to the patient.