Antimicrobial dispensing practices and determinants of antimicrobial resistance: a qualitative study among community pharmacists in Pakistan

BackgroundThere are concerns with the extent of dispensing of antibiotics among community pharmacists in Pakistan often without a prescription adding to antimicrobial resistance (AMR) rates.ObjectiveTo explore the determinants of AMR and the pattern of antimicrobial dispensing among community pharmacists.DesignIn this qualitative study design, a semistructured interview guide was developed based on an in-depth review of published papers. Audio-recorded interviews with transcripts were analysed by thematic content analysis.SettingInterviews were conducted among community pharmacists in Lahore, Pakistan.ParticipantsIn order to obtain individual points of view, in-depth face-to-face interviews with purposively selected pharmacists were conducted.ResultsA total of 12 pharmacists were interviewed for the study. After analysis, four major themes emerged: (1) knowledge and perception of community pharmacists about antimicrobials, (2) antimicrobial dispensing practices of community pharmacists, (3) determinants of AMR, (4) potential interventions to control AMR. Most of the pharmacists have limited knowledge about AMR, antimicrobial stewardship programmes and related guidelines. However, all the pharmacists strongly agreed that different appropriate actions should be taken in order to rationalise future antimicrobial use.ConclusionThe results indicated that irrational antimicrobial dispensing and use is common among community pharmacists in Pakistan owing to lack of knowledge. The community pharmacists perceived that behaviour of patients and the societal environment contributed to irrational antimicrobial use and subsequent development of AMR. They suggested a need for a multidisciplinary framework in order to improve future antimicrobial use and reduce AMR in Pakistan.</jats:sec

Impact of duration of therapy on side effect profile of anti-HCV protocol: A retrospective cohort study from two tertiary health facilities in Pakistan

Purpose: To evaluate the plausible risks and adverse effects related to the duration of therapy in hepatitis C (HCV) patients in Lahore, Pakistan.Method: A retrospective observational study involving 250 HCV patients who received combination therapy with ribavirin and interferon was conducted. The patients were segregated into two groups on the basis of duration of therapy (≤ 6 months and &gt; 6 months). Adverse effect profiles of patients under treatment were collected using a pre-validated questionnaire and compared using Pearson’s Chi- Square Test/Chi-Square Goodness-of-Fit tests and unpaired t-test.Results: Patients who underwent treatment for ≤ 6 months frequently encountered side-effects such as GIT disturbance (23.77 %) and joint pains (29.63 %). Additionally, diabetes mellitus (27.86 %) and frequent injections (74.59 %) were the most commonly observed co-morbid condition and disease risk, respectively. On the other hand, in patients who underwent therapy for &gt; 6 months, skin disorders (30.46 %) and gastric acidity (10.15 %) were the most frequently observed side-effects with less frequent reporting on co-morbid conditions and disease risk factors. Moreover, there was a significant reduction in body weight (p = 0.03), serum bilirubin (p = 0.0005), albumin (p = 0.003) and triglycerides (p = 0.006) levels due to longer duration of treatment.Conclusion: The data suggest that treatment-related risks are higher among HCV patients on shorter treatment duration whereas adverse events subside in patients on longer duration of therapy (&gt;6 months). Changes in biochemical profile were also more evident in those receiving treatment for periods &gt;6 months.Keywords: Interferon, Ribavirin, Side effects, Duration of therapy, Outcomes of therap

Impact of diabetes-related knowledge and medication adherence on quality of life among type 2 diabetes patients in a tertiary health facility in Multan, Pakistan

Purpose: To assess the impact of drug adherence and diabetes-related knowledge on the quality of life (QoL) of type 2 diabetes patients in a hospital in Pakistan.Methods: A cross-sectional study was conducted in City Hospital, Multan, Pakistan between March and September 2020. A total of 151 patients diagnosed with type 2 diabetes mellitus (T2DM) were recruited. Medication adherence, diabetes-related knowledge, and QoL were assessed by Drug attitude inventory-10 (DAI-10), the Michigan Diabetes Knowledge Test (MDKT), and EQ-5D-3L tools, respectively. The association between sociodemographic data and study variables was assessed by independent t-test and one-way ANOVA.Results: Among the 151 patients, 53 % were males. The mean MDKT score was 0.33 ± 0.18, indicating poor knowledge of diabetes. An overall moderate level of adherence was observed among the participants (mean adherence score, 6.14 ± 1.39). Mean QoL score was 1.31 ± 0.28, and the Visual Analog Scale score (VAS) was 59.6 ± 12.21, indicating a good to moderate QoL among the study participants. Study participants with a longer duration of diabetes and poor adherence to their medications showed poor QoL (p = 0.01, p = 0.004 respectively).Conclusion: Overall, the patients reported poor knowledge, moderate adherence, and good to moderate QoL. Moreover, patients with poor adherence to medication, longer duration of diabetes, and poorly controlled HbA1c showed poor QoL

Snapshot of antimicrobial stewardship programs in the hospitals of Pakistan: findings and implications

Objective: We are unaware of the extent of antimicrobial stewardship programs (ASPs) among hospitals in Pakistan, which is a concern given the population size, high use of antibiotics across sectors and increasing antimicrobial resistance (AMR) rates. Consequently, we sought to address this by undertaking a comprehensive survey. Method: In this cross-sectional observational study in Punjab, an instrument of the measure was developed based on health care facility characteristics and ASPs after an extensive literature review. The questionnaire was circulated by mail or through drop off surveys to medical superintendents or directors/heads of pharmacy departments of hospitals. Results: Out of 254, a total of 137 hospitals fully completed the questionnaire - 11 primary, 65 secondary, 46 tertiary and 15 specialized hospitals. The use of antimicrobial prescribing guidelines (68.7%), provision of infectious diseases consultation services (66.4%), clinical pharmacy service (65.7%), use of drug and therapeutics committees to approve antimicrobial prescribing (65.5%), regular audit by doctors on antimicrobial prescribing (54.1%) and use of a restricted formulary for antimicrobial (50.4%) were the most common ASPs. However, most of these activities were only somewhat or moderately successful. Whereas, electronic antimicrobial prescribing approval systems (15.3%), using a sticker to notify prescribers regarding the need to obtain approval for the antimicrobial prescribed (16.1%) and participation in the national antimicrobial utilization surveillance program (19.7%) were only seen in a few hospitals. Conclusion: Study inferred that there are inadequate ASPs in the hospitals of Pakistan. A multidisciplinary approach, clinical leadership and availability of motivated and trained individuals are essential elements for the success of future ASPs

Association of hypertension and dyslipidaemia with increasing obesity in patients with Type 2 Diabetes Mellitus

The study was performed to estimate the association of hypertension and dyslipidaemia with increasing body weight and obesity in Type II diabetics of Lahore, Pakistan. An observational study was conducted by enrolling 2708 obese diabetics from four diabetes care centres of Lahore, Pakistan. Data was collected for a period of 7 months. Associations were estimated using chi-square, binary and multinomial logistic regression. Data suggested that blood pressure, systolic and diastolic, exhibited continual increase with increasing body weight and obesity class in diabetes patients with 41.8% increase in the prevalence of hypertension in obesity class III subjects (OR; 1.91, p=0.02). Likewise, triglycerides and total cholesterol exhibited continual increase in their mean values with increasing obesity, i-e., an overall increase in the prevalence of dyslipidaemia of 27.2% in obesity class 3 subjects (OR; 1.94, p=0.29). Taken together, this data suggested that hypertension is potentially associated with increasing obesity in diabetics, while dyslipidaemia demonstrated plausible association only with obesity class 3

Predictors of Outcome of Bronchiolitis in Children Using Children Hospital of Wisconsin Respiratory Score: An Experience of a Tertiary Care Hospital

Objective: To study the correlation of CHWR score and its various clinical markers with the length of stay in hospital bronchiolitis. Study Design: Cross-sectional analytical study. Place and Duration of Study: Department of Pediatrics Combined Military Hospital, Lahore Pakistan, from Nov 2018 to Apr 2019. Methodology: This study included children aged 2 to 24 months, clinically diagnosed with bronchiolitis. The Receiver Operator Characteristic (ROC) was used to determine the discriminative validity of the CHWR score in predicting the length of stay. Results: One hundred thirty-eight children of either gender were enrolled in the study. The median age of the study population was 10.8 (9) months. ROC curve showed significant discriminate validity of CHWR score and its component criterion on admission. CHWR score of >10.5 predicted a longer stay (>24 hours) in ICU. Pearson correlation showed a statistically significant positive correlation between CHWR score at admission and length of stay (r=0.831, p=<0.001). Conclusion: CHWR scoring system on admission is an easy, safe and effective way to classify bronchiolitis severity and thus help predict the length of stay

Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan.

Introduction:Our aim was to study the outcomes and predictors of in-hospital cardiopulmonary resuscitation (CPR) among adult Patients at a tertiary care centre in Pakistan.Methods:We conducted a retrospective chart review of all adult Patients (age \u3e or =14 years), who underwent CPR following cardiac arrest, in a tertiary care hospital during a 5-year study period (June 1998 to June 2003). We excluded Patients aged 14 years or less, those who were declared dead on arrival and Patients with a do not resuscitate order. The 1- and 6-month follow-ups of discharged Patients were also recorded.Results:We found 383 cases of adult in-hospital cardiac arrest that underwent CPR. Pulseless electrical activity was the most common initial rhythm (50%), followed by asystole (30%) and ventricular tachycardia/fibrillation (19%). Return of spontaneous circulation was achieved in 72% of Patients with 42% surviving more than 24 h, and 19% survived to discharge from hospital. On follow-up, 14% and 12% were found to be alive at 1 and 6 months, respectively. Multivariable logistic regression identified three independent predictors of better outcome (survival \u3e24 h): non-intubated status [adjusted odds ratio (aOR): 3.1, 95% confidence interval (CI): 1.6-6.0], location of cardiac arrest in emergency department (aOR: 18.9, 95% CI: 7.0-51.0) and shorter duration of CPR (aOR: 3.3, 95% CI: 1.9-5.5).Conclusion:Outcome of CPR following in-hospital cardiac arrest in our setting is better than described in other series. Non-intubated status before arrest, cardiac arrest in the emergency department and shorter duration of CPR were independent predictors of good outcome

Genotoxic and cytotoxic potential of whole plant extracts of Kalanchoe laciniata by Ames and MTT assay

Lack of data on safety of herbal medicines have endangered human health and life. The present study evaluated the genotoxic and mutagenic effect of Kalanchoe laciniata to access the safety and usefulness of the medicinal plant. Aqua-methanolic and n-hexane extracts of K. laciniata were evaluated for the genotoxic potential using Ames assay and cytotoxicity was evaluated using MTT assay. Ames assay was conducted using two strains of Salmonella typhimurium TA-100 and TA-102 whereas MTT assay was performed on baby hamster kidney cell line BHK-21. Aqua-methanolic extract of K. laciniata exhibited significant mutagenicity when exposed to TA- 102 strain with a mutagenic index of 50.66 and 54.74 at maximum dose 150 mg/plate. The extract was also muta- genic to TA-100 strain but to a lesser extent. M.I of n-hexane extract was 12.15 and 15.51 for TA-100 and TA- 102 respectively. n-hexane extract was mutagenic but little difference was observed between results of two strains. Both extracts were found to be cytotoxic with an IC50 of 321.9 and 638.5 µg/mL for aqua-methanolic and n-hexane extracts respectively. On the basis of results it was concluded that aqua-methanolic and n-hexane extracts of K. mutagenic and cytotoxic potential. It is suggested to explore the plant further to evaluate its safety in rodents and other species

ASSESSMENT OF RISK FACTORS AND COMPLICATIONS OF DIABETES MELLITUS IN DIFFERENT STAGES OF HYPERTENSION: A RETROSPECTIVE COHORT STUDY FROM A MAJOR METROPOLITAN CITY OF PAKISTAN

Diabetes mellitus is a group of metabolic disorders clinically manifested by hyperglycemia. Diabetic patient having hypertension has more chances of heart diseases, peripheral vascular disease, nephropathy and retinopathy. The aim of the study was to evaluate the prevalence of risk factors and related complications in diabetic patients having hypertension. This retrospective observational study was conducted by enrolling 250 patients for study. Results have indicated that there was higher percentage of female diabetics (60.16%) as compared to males due to more prevalence of obesity in females. Patients in pre-hypertensive stage were having more risk factors; salt intake (66.42%), fat intake (67.8%), aerobic exercise &lt;30 minutes (70.2%) and even 50% were not exercising. They were experiencing more symptoms and complications such as thirst (63.1%), dryness of mouth (60.33%), loss of appetite (59.2%), abdominal pain (67.1%), nausea and vomiting (56.3%), frequent urination (56.7%) and high blood sugar level (56.33%). About 92.30% patients were satisfied with the treatment and were following the instructions by the doctors. The study inferred that the risk factors and complications related to diabetes were more prevalent in pre-hypertensive stage which could progress the disease to advanced stages