Use of antimicrobials during the COVID-19 pandemic: a qualitative study among stakeholders in Nepal

The COVID-19 pandemic was a major public health threat and the pressure to find curative therapies was tremendous. Particularly in the early critical phase of the pandemic, a lot of empirical treatments, including antimicrobials, were recommended. Drawing on interviews with patients, clinicians and drug dispensers, this article explores the use of antimicrobials for the management of COVID-19 in Nepal. A total of 30 stakeholders (10 clinicians, 10 dispensers and 10 COVID-19 patients) were identified purposively and were approached for an interview. Clinicians and dispensers in three tertiary hospitals in Kathmandu assisted in the recruitment of COVID-19 patients who were undergoing follow-up at an out-patient department. Interviews were audio recorded, translated and transcribed into English, and were analyzed thematically. The respondents report that over-the-counter (OTC) use of antibiotics was widespread during the COVID-19 pandemic in Nepal. This was mostly rooted in patients' attempts to mitigate the potential severity of respiratory illnesses, and the fear of the stigmatization and social isolation linked to being identified as a COVID-19 patient. Patients who visited drug shops and physicians reportedly requested specific medicines including antibiotics. Clinicians reported uncertainty when treating COVID-19 cases that added pressure to prescribe antimicrobials. Respondents from all stakeholder groups recognized the dangers of excessive use of antimicrobials, with some referring to the development of resistance. The COVID-19 pandemic added pressure to prescribe, dispense and overuse antimicrobials, accentuating the pre-existing OTC use of antimicrobials. Infectious disease outbreaks and epidemics warrant special caution regarding the use of antimicrobials and specific policy response

Global, regional, and national burden of headache disorders, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 estimates health loss from migraine, tension-type headache, and medication-overuse headache. This study presents updated results on headache-attributed burden from 1990 to 2023, along with clinical and public health implications. Methods: Data on the prevalence, incidence, or remission of migraine, tension-type headache, and medication-overuse headache were extracted from published population-based studies. We used hierarchical Bayesian meta-regression modelling to estimate global, regional, and country-level prevalence of headache disorders. For the first time in GBD 2023, age-specific and sex-specific estimates of time in symptomatic state were applied by meta-analysing individual participant data from 41 653 individuals from the general populations of 18 countries from all parts of the world. Disability weights were applied to calculate years lived with disability (YLDs). Since medication-overuse headache is a sequela of a mistreated primary headache (due to medication overuse), its burden was reattributed to migraine or tension-type headache, informed by a meta-analysis of three longitudinal studies. Findings: In 2023, 2·9 billion individuals (95% uncertainty interval 2·6–3·1) were affected by headache disorders, with a global age-standardised prevalence of 34·6% (31·6–37·5) and a YLD rate of 541·9 (373·4–739·9) per 100 000 population, with 487·5 (323·0–678·8) per 100 000 population attributed to migraine. The prevalence rates of these headache disorders have remained stable over the past three decades. YLD rates due to headache disorders were more than twice as high in females (739·9 [511·2–1011·5] per 100 000) as in males (346·1 [240·4–481·8] per 100 000). Medication-overuse headache contributed 58·9% of the YLD estimates for tension-type headache in males and 56·1% in females, as well as 22·6% of the YLD estimates for migraines in males and 14·1% in females. Interpretation: Headache disorders, in particular migraine, continue to be a major global health challenge, emphasising the need for effective management and prevention strategies. Much headache-attributed burden could be averted or eliminated by avoiding overuse of medication (including over-the-counter medication), underscoring the importance of public education

Global, regional, and national prevalence of adult overweight and obesity, 1990–2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021

Background: Overweight and obesity is a global epidemic. Forecasting future trajectories of the epidemic is crucial for providing an evidence base for policy change. In this study, we examine the historical trends of the global, regional, and national prevalence of adult overweight and obesity from 1990 to 2021 and forecast the future trajectories to 2050. Methods: Leveraging established methodology from the Global Burden of Diseases, Injuries, and Risk Factors Study, we estimated the prevalence of overweight and obesity among individuals aged 25 years and older by age and sex for 204 countries and territories from 1990 to 2050. Retrospective and current prevalence trends were derived based on both self-reported and measured anthropometric data extracted from 1350 unique sources, which include survey microdata and reports, as well as published literature. Specific adjustment was applied to correct for self-report bias. Spatiotemporal Gaussian process regression models were used to synthesise data, leveraging both spatial and temporal correlation in epidemiological trends, to optimise the comparability of results across time and geographies. To generate forecast estimates, we used forecasts of the Socio-demographic Index and temporal correlation patterns presented as annualised rate of change to inform future trajectories. We considered a reference scenario assuming the continuation of historical trends. Findings: Rates of overweight and obesity increased at the global and regional levels, and in all nations, between 1990 and 2021. In 2021, an estimated 1·00 billion (95% uncertainty interval [UI] 0·989–1·01) adult males and 1·11 billion (1·10–1·12) adult females had overweight and obesity. China had the largest population of adults with overweight and obesity (402 million [397–407] individuals), followed by India (180 million [167–194]) and the USA (172 million [169–174]). The highest age-standardised prevalence of overweight and obesity was observed in countries in Oceania and north Africa and the Middle East, with many of these countries reporting prevalence of more than 80% in adults. Compared with 1990, the global prevalence of obesity had increased by 155·1% (149·8–160·3) in males and 104·9% (95% UI 100·9–108·8) in females. The most rapid rise in obesity prevalence was observed in the north Africa and the Middle East super-region, where age-standardised prevalence rates in males more than tripled and in females more than doubled. Assuming the continuation of historical trends, by 2050, we forecast that the total number of adults living with overweight and obesity will reach 3·80 billion (95% UI 3·39–4·04), over half of the likely global adult population at that time. While China, India, and the USA will continue to constitute a large proportion of the global population with overweight and obesity, the number in the sub-Saharan Africa super-region is forecasted to increase by 254·8% (234·4–269·5). In Nigeria specifically, the number of adults with overweight and obesity is forecasted to rise to 141 million (121–162) by 2050, making it the country with the fourth-largest population with overweight and obesity. Interpretation: No country to date has successfully curbed the rising rates of adult overweight and obesity. Without immediate and effective intervention, overweight and obesity will continue to increase globally. Particularly in Asia and Africa, driven by growing populations, the number of individuals with overweight and obesity is forecast to rise substantially. These regions will face a considerable increase in obesity-related disease burden. Merely acknowledging obesity as a global health issue would be negligent on the part of global health and public health practitioners; more aggressive and targeted measures are required to address this crisis, as obesity is one of the foremost avertible risks to health now and in the future and poses an unparalleled threat of premature disease and death at local, national, and global levels. Funding: Bill & Melinda Gates Foundation

Life style factors associated with overweight and obesity in Nepalese women of reproductive age

Background and Objectives: Overweight and Obesity is a highly prevalent global epidemic. South Asians are more vulnerable to obesity-related diseases with rising co-morbidities when compared to developed countries. It is linked with several health complications. Globally more women are found overweight or obese compared to men. So this study is planned to examine the life-style related determinants of overweight and obesity in reproductive aged females (15-49 years) in Nepal. Material and Methods: Analytical cross-sectional study was carried out among reproductive aged females (15-49 years) of Kathmandu Metropolitan city, Nepal. Stratified random as well as population proportionate sampling technique was used to determine number of respondents from each selected ward. A structured questionnaire for nutrition intake and various demographic and lifestyle factors reviewed by the panel of experts was administered for data collection. Overweight or obesity was considered as per BMI international cut-off points for adults. Results: Overweight or obesity (BMI≥25) in reproductive aged females was found to be 26%. Women who were working, married, and had family history of overweight and obesity and those who took fast foods moderately were found significantly more likely of becoming overweight or obese (p &lt; 0.05). Moderate physical activity, daily breakfast intake, were found to be significantly less likely of becoming overweight or obese in reproductive aged women (p &lt; 0.05). Conclusions: Moderate physical activities as well as daily breakfast consumption is more likely to reduce overweight and obesity. The findings can be used as a guideline for overweight and obesity prevention in reproductive aged women. Some larger prospective studies are needed.</jats:p

Methicillin-Resistant <i>Staphylococcus aureus</i> (MRSA): Prevalence, Antimicrobial Susceptibility Pattern, and Detection of <i>mec</i>A Gene among Cardiac Patients from a Tertiary Care Heart Center in Kathmandu, Nepal

Background: Methicillin Resistant Staphylococcus aureus (MRSA) is a significant human pathogen associated with nosocomial infections. mecA in the S. aureus is a marker of MRSA. The main objective of this study was to detect mecA and vanA genes conferring resistance in S. aureus among cardiac patients attending Sahid Gangalal National Heart Centre (SGNHC), Kathmandu, Nepal between May and November 2019. Methods: A total of 524 clinical samples (blood, urine, sputum) were collected and processed. Bacterial isolates were tested for antimicrobial susceptibility test (AST) and screening for MRSA was carried out by cefoxitin disc diffusion method. Minimum inhibitory concentration (MIC) of vancomycin for MRSA was established by agar dilution method and chromosomal DNA was extracted and used in polymerase chain reaction targeting the mecA and vanA genes. Results: Out of 524 specimens, 27.5% (144/524) showed bacterial growth. Among 144 culture positive isolates, S. aureus (27.1%; 39/144) was the predominant bacteria. Among 39 S. aureus isolates, all isolates were found resistant to penicillin followed by erythromycin (94.9%; 37/39), gentamicin (94.9%; 37/39) and cefoxitin (87.2%; 34/39). Out of 39 S. aureus, 87.2% (34/39) were MRSA. Among 34 MRSA, 8.8% (3/34) were vancomycin intermediate S. aureus (VISA). None of the MRSA was resistant to vancomycin. All of the 3 VISA isolates were obtained from inpatients. Of 39 S. aureus, 82.1% (32/39) harbored mecA gene. Similarly, the entire VISA isolates and 94.1% (32/34) of the MRSA isolates were tested positive for mecA gene. Conclusions: High prevalence of MRSA among the cardiac patients indicates the increasing burden of drug resistance among bacterial isolates. Since infection control is the crucial step in coping with the burgeoning antimicrobial resistance in the country, augmentation of diagnostic facilities with routine monitoring of drug resistance is recommended. </jats:sec

Extended Spectrum Beta-lactamase Producing Gram Negative Bacterial Isolates from Urine of Patients Visiting Everest Hospital, Kathmandu, Nepal

Objectives: The study was aimed to determine the prevalence of Extended Spectrum Beta Lactamase (ESBL) producing Gram negative pathogens from urine samples along with their antimicrobial resistance.&#x0D; Methods: This cross-sectional study was conducted from December 2015 to May 2016 at Everest Hospital, Kathmandu. Mid-stream urine samples were collected and processed for culture by standard loop streak method. Identified bacterial isolates were tested for Antibiotic Susceptibility by modified Kirby Bauer disc diffusion method and, were subjected to ESBL screening by using 30µg cefotaxime and ceftazidime. ESBL production was confirmed by combination disc method.&#x0D; Results: Of the three hundred urine samples, 22.7% (67/300) showed significant growth. Four different bacterial species were identified. Among the isolates, E. coli was the most common pathogen (71.64%) followed by Klebsiella pneumoniae (14.92%), Pseudomonas spp (8.95%) and Acinetobacter spp (4.48%). Altogether 92.54% (n=62) isolates were sensitive to gentamicin, 89.55% (n=60) to amikacin, and 79.10% (n=53) to nitrofurantoin. 70.10% (n=47) isolates were resistant to antibiotic ampicillin while 62.68% (n=42) were found as Multi-Drug Resistant (MDR) and 29.8% (n=20) were ESBL producers.&#x0D; Conclusions: The overall prevalence of MDR and ESBL among uropathogens is low in comparison to other studies though it is essential to have a regular monitoring of ESBL producing clinical isolates in laboratory practice.</jats:p

Methicillin Resistant Staphylococcus aureus in Health Care Workers of a Tertiary Care Infectious Disease Hospital in Nepal

Objectives: Acquisition of mecA gene in infectious strains of Methicillin resistant Staphylococcus aureus (MRSA) are considered as one of the potential virulence factors that enables the host bacteria to carry out several nosocomial and community-acquired infections. The main aim of this study was to determine the prevalence of MRSA, their antibiogram and mecA gene in the bacterial isolates obtained from the asymptomatic healthcare workers (HCWs) working in Sukraraj Tropical and Infectious Disease Hospital (STIDH), Kathmandu Nepal.&#x0D; Methods: This prospective cross-sectional study involved the collection of nasal and hands swab of 125 randomly selected HCWs from December 2019 to February 2020. Conventional microbiological methods were used to isolate and identify S. aureus. Antimicrobial susceptibility testing was done by modified Kirby Bauer disc diffusion method. MRSA was confirmed by using cefoxitin disc. Detection of mecA gene in the chromosome which was extracted by Phenol: Chloroform: isoamyl alcohol DNA extraction method, amplified by using PCR and visualized by running agarose gel electrophoresis.&#x0D; Results: The overall and MRSA carriage rate among the HCWs was found to be 28% (35/125) and 10.4% (13/125) respectively. S. aureus carriage rate was highest among sanitation staffs (34.2%) followed by pharmacy staffs (33.3%), laboratory personnel (18.8%), doctors (9.1%) and nurses (7.5%). Similarly, 34.2% (13/38) of the S. aureus isolates were resistant to methicillin, 31.6% (12/38) were inducible-clindamycin resistant and 63.2% (24/38) of them were multi-drug resistant (MDR). All the 13 MRSA isolates harbored the mecA gene.&#x0D; Conclusions: Carriage rate of MRSA among HCWs was high and alarming, indicating the prompt need of intervention measures to curb the growth and spread of resistant isolates in the hospital settings. Effective surveillance (of infectious diseases) and establishment of advanced diagnostic facilities can assist in estimating the actual burden of the MRSA which in turn helps to formulate and implement the appropriate policies and infection-control programs to address the increasing antimicrobial resistance in the country.  </jats:p

Toxoplasma, Rubella, Cytomegalo and Herpes Viral Antibody Level in Patients at National Public Health Laboratory (NPHL), Kathmandu

The primary infection of Toxoplasma gondii, Rubella virus, Cytomegalovirus (CMV) and Herpes simplex virus (HSV) abbreviated as TORCH has remained a major problem in the women of childbearing age in Nepal. The main objective of this study was to determine the seroprevalence of TORCH infections among the women of childbearing age visiting the National Public Health laboratory (NPHL), Teku, Kathmandu. A total of 314 blood samples were collected and tested for TORCH infections by Chemiluminescent Immunoassay (CLIA). Of the total 314 patients, different patterns were observed in the requested test series. Highest number of patients (243) requested for CMV IgM test while only 195 requested for the same for Rubella. The IgM seroprevalence rates were 4.20% (9/214) for Toxoplasma gondii, 5.12% (10/195) for Rubella, 4.91% (12/244) for Cytomegalovirus and 5.56% (13/234) for Herpes Simplex virus. Significant portion of the test exhibited the equivocal result making this latest technology further complicated. Equivocal results were 2.33 % (5/214) for Toxoplasma gondii, 3.58% (7/195) for Rubella, 3.27% (8/244) for Cytomegalovirus and 4.27% (10/234) for Herpes Simplex Virus. The seropositivity rate in pregnant women was 11.97 % (17/142), in which the seropositivity in pregnant women with Bad Obstetric History (BOH) was found to be 12.5% (13/104) and women without BOH was found to be 10.52% (4/38). The statistical association of any one of the TORCH infections with previous obstetric history was significant (p&lt;0.05). The seropositivity rate was the highest for HSV infection followed by Rubella, CMV and T. gondii.</jats:p

Extended Spectrum Beta-Lactamase (ESBL) producing Escherichia coli and Klebsiella species in pediatric patients visiting International Friendship Children's Hospital, Kathmandu, Nepal

Abstract Background Emergence of antibiotic resistance among pathogenic strains has spread due to production of β-lactamases, which can lead to failure of empirical therapy in clinical settings. Inappropriate use of antibiotics, particularly third generation cephalosporins has contributed to the development of antimicrobial resistance (AMR). This study aims to determine the prevalence of Extended Spectrum β-Lactamase (ESBL) production in E. coli and Klebsiella species isolated from various clinical samples. Methods This cross-sectional study was conducted at International Friendship Children's Hospital, Kathmandu, Nepal from August 2017 to January 2018. Various clinical samples that included urine, pus, Cerebro-Spinal Fluid (CSF), body fluids, wound swab, endotracheal tip, catheter tip and blood were processed for culture. Following sufficient incubation, isolates were identified by colony morphology, gram staining and necessary biochemical tests. Identified bacterial isolates were then tested for antibiotic susceptibility test by modified Kirby Bauer disc diffusion method, and were subjected to Extended Spectrum Beta Lactamase (ESBL) screening by using 30µg cefotaxime and ceftazidime. ESBL production was confirmed by combination disc method. Results From a total of 103 non-duplicated clinical isolates, E. coli (n=79), Klebsiella pneumoniae (n=18) and K. oxytoca (n=6) were isolated from different clinical specimens. Majority (62.1%; 64/103) exhibited Multi-Drug Resistance (MDR) and 28.2% (29/103) were ESBL producers. All of ESBL producing isolates were resistant towards ampicillin, cefotaxime, ceftriaxone, ceftazidime. Most ESBL producers were found to be susceptible towards imipenem (89.7%; 26/29), nitrofurantoin (82.8%; 24/29), piperacillin/tazobactam (79.3%; 23/29), and Amikacin (72.4%; 21/29). Conclusions High prevalence of multi-drug resistant ESBL organisms found in this study warrants restricting empirical treatment of the bacterial infection. Identification of ESBL producers in routine treatment of infectious diseases can reduce unnecessary and inappropriate antimicrobial use and can reduce the preventable morbidity and mortality.</jats:p