Publications by authors named "Zikria Saleem"

49 Publications

Patterns of Antimicrobial Use in Hospitalized Children: A Repeated Point Prevalence Survey From Pakistan.

J Pediatric Infect Dis Soc 2021 Jul 22. Epub 2021 Jul 22.

Department of Pharmacy, The University of Lahore, Lahore, Pakistan.

Three repeated point prevalence surveys (PPSs) were conducted in pediatric wards of 5 hospitals using the methodology developed by Global-PPS to identify key targets for interventions and antibiotic stewardship programs. Out of the 916 hospitalized patients, 865 (94.6%) were treated with at least 1 antibiotic.
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http://dx.doi.org/10.1093/jpids/piab026DOI Listing
July 2021

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future.

Front Public Health 2021 24;9:671961. Epub 2021 Jun 24.

Pharmacy Department, Eswatini Medical Christian University, Mbabane, Eswatini.

Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.
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http://dx.doi.org/10.3389/fpubh.2021.671961DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264781PMC
August 2021

Evidence-based public policy making for medicines across countries: findings and implications for the future.

J Comp Eff Res 2021 08 9;10(12):1019-1052. Epub 2021 Jul 9.

School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa.

Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Extensive narrative review of published papers and contextualizing the findings to provide future guidance. New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Multiple measures will be needed to attain and retain universal healthcare.
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http://dx.doi.org/10.2217/cer-2020-0273DOI Listing
August 2021

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries.

Life (Basel) 2021 Jun 7;11(6). Epub 2021 Jun 7.

Department of Pharmacy, School of Health Sciences, University of Zambia, P.O. Box 32379, Lusaka 10101, Zambia.

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.
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http://dx.doi.org/10.3390/life11060528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8229985PMC
June 2021

Current utilization patterns for long-acting insulin analogues including biosimilars among selected Asian countries and the implications for the future.

Curr Med Res Opin 2021 09 14;37(9):1529-1545. Epub 2021 Jul 14.

National Institute of Health, Islamabad, Pakistan.

Introduction: Prevalence rates for diabetes mellitus continue to rise, which, coupled with increasing costs of complications, has appreciably increased expenditure in recent years. Poor glycaemic control including hypoglycaemia enhances complication rates and associated morbidity, mortality and costs. Consequently, this needs to be addressed. Whilst the majority of patients with diabetes have type-2 diabetes, a considerable number of patients with diabetes require insulin to help control their diabetes. Long-acting insulin analogues were developed to reduce hypoglycaemia associated with insulin and help improve adherence, which can be a concern. However, their considerably higher costs have impacted on their funding and use, especially in countries with affordability issues. Biosimilars can help reduce the costs of long-acting insulin analogues thereby increasing available choices. However, the availability and use of long-acting insulin analogues can be affected by limited price reductions versus originators and limited demand-side initiatives to encourage their use. Consequently, we wanted to assess current utilisation rates for long-acting insulin analogues, especially biosimilars, and the rationale for patterns seen, across multiple Asian countries ranging from Japan (high-income) to Pakistan (lower-income) to inform future strategies.

Methodology: Multiple approaches including assessing utilization and prices of insulins including biosimilars among six Asian countries and comparing the findings especially with other middle-income countries.

Results: Typically, there was increasing use of long-acting insulin analogues among the selected Asian countries. This was especially the case enhanced by biosimilars in Bangladesh, India, and Malaysia reflecting their perceived benefits. However, there was limited use in Pakistan due to issues of affordability similar to a number of African countries. The high use of biosimilars in Bangladesh, India and Malaysia was helped by issues of affordability and local production. The limited use of biosimilars in Japan and Korea reflects limited price reductions and demand-side initiatives similar to a number of European countries.

Conclusions: Increasing use of long-acting insulin analogues across countries is welcomed, adding to the range of insulins available, which increasingly includes biosimilars. A number of activities are needed to enhance the use of long-acting insulin analogue biosimilars in Japan, Korea and Pakistan.
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http://dx.doi.org/10.1080/03007995.2021.1946024DOI Listing
September 2021

Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications.

Expert Rev Anti Infect Ther 2021 Jul 26:1-23. Epub 2021 Jul 26.

School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town Malaysia.

: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.
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http://dx.doi.org/10.1080/14787210.2021.1935238DOI Listing
July 2021

Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices.

BMC Infect Dis 2021 Apr 21;21(1):374. Epub 2021 Apr 21.

Department of Pharmacy, University of Huddersfield, Huddersfield, UK.

Background: The emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices.

Methods: In this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data.

Results: The analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics.

Conclusion: This study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.
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http://dx.doi.org/10.1186/s12879-021-06043-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059254PMC
April 2021

Association of health literacy and medication adherence with health-related quality of life (HRQoL) in patients with ischemic heart disease.

Health Qual Life Outcomes 2021 Apr 13;19(1):118. Epub 2021 Apr 13.

Department of Pharmacology, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan.

Background: Medication Adherence (MA) and Health Related Quality of Life (HRQoL) are two inter-connected concepts, co-influenced by Health Literacy (HL), with significant impact on patient management and care. Thus, we aimed to estimate the association of HL and MA with HRQoL in IHD patients.

Methods: Cross-sectional study of 251 IHD patients recruited from Lahore over 6 months period. HL, MA and HRQoL was assessed using validated questionnaires; 16-items of HL, Morisky Green Levine Scale (MGLS) and SF-12, respectively. Chi-square for significance, logistic-regression for association and linear regression for predictions were used.

Results: IHD patients; males (p = 0.0001), having secondary-higher education (p = 0.0001), middle/upper class (p = 0.0001) and employed (p = 0.005) had adequate HL, and were more likely to be adherent (OR; 4.3, p = 0.014). Both physical (PCS-12) and mental (MCS-12) component scores of HRQoL for age, gender, education, area of residence, employment and MA were significantly higher in patients with adequate HL. In multinomial regression, improved PCS-12 scores tend to be higher in subjects having secondary-higher education (OR; 3.5, p = 0.067), employed (OR; 6.1, p = 0.002) and adherent (OR; 2.95, p = 0.218), while MCS-12 scores tend to be higher in patients < 65 years (OR; 2.2, p = 0.032), employed (OR; 3, p = 0.002) and adherent (OR; 4, p = 0.004). In adjusted model, HL (β;0.383, p = 0.0001) and MA (β; - 0.133, p = 0.018) were significantly associated with PCS-12, and MCS-12 with MA (β; - 0.161, p = 0.009) only.

Conclusion: Data suggested that adequate HL was significantly associated with adherence and both physical and mental dimensions of HRQoL were higher in IHD patients with adequate HL. Besides, HL and MA are independent predictors of HRQoL in IHD patients.
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http://dx.doi.org/10.1186/s12955-021-01761-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045399PMC
April 2021

Comparative safety and efficacy of conventional interferon versus pegylated-interferon based therapy for HCV: A retrospective cohort study from Gujranwala, Pakistan.

Pak J Pharm Sci 2020 Sep;33(5):2037-2045

Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan/ Faculty of Pharmacy, The University of Lahore, Pakistan.

Numerous studies on risk factors, clinical presentation and treatment of hepatitis C are known to the world. However, no data is available about the safety and efficacy of anti-hepatitis C therapy among the patients of Gujranwala, Pakistan. This retrospective study compared two dosage forms of interferon; conventional interferon (IR) and Pegylated interferon (PIR) in 370 Hepatitis C patients selected through non probability convenient sampling technique. Clinical data were collected related to therapy outcomes at the start of therapy, after each follow up and at the end of therapy. The study indicated that HCV 3 was the most prevalent genotype of hepatitis C. Main side effects associated with therapies were pain at injection site (PIR; 49%, IR; 48%), inflammation at injection site (PIR; 34%, IR; 48%), fever (PIR; 56.12%, IR; 61.5%), myalgia (PIR; 24.5%,IR; 22.99%), malaise (PIR; 7.14%, IR; 5.75%), anorexia (PIR; 46%, IR; 39%), vomiting (PIR; 43%, IR; 41%), irritability (PIR; 4%, IR; 11.5%) and impaired concentration (PIR; 13%, IR; 21). The sustained viral response rate was significantly better in PIR group as compared to IR group (PIR; 80.61%, IR; 66.67%). In conclusion Pegylated interferon based therapy showed better clinical response with less adverse events as compared to conventional interferon based therapy. However, there is dire need to shift from these intravenous dosage forms to relatively new oral dosage forms for the treatment of hepatitis C to further improve clinical outcome and minimize the risks of adverse events.
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September 2020

Perception and practices of community pharmacists towards antimicrobial stewardship in Lahore, Pakistan.

J Glob Antimicrob Resist 2021 06 28;25:157-161. Epub 2021 Mar 28.

Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia.

Objectives: Antimicrobial resistance is a major health concern worldwide. Community pharmacists can play an important role in rational antibiotic use. This study aimed to evaluate the perception and practices of community pharmacists regarding antimicrobial stewardship (AMS) in Lahore, Pakistan.

Methods: A descriptive cross-sectional study was conducted among community pharmacists in Lahore from 1 November 2017 to 31 December 2017. A self-administered questionnaire was used for data collection. Non-probability convenience sampling was performed to select community pharmacists. Descriptive statistics were applied and Mann-Whitney U-tests and Kruskal-Wallis tests were performed to compare independent groups using SPSS v.20.0. A P-value of <0.05 was considered statistically significant. Perception and practice scores were determined to access community pharmacist knowledge regarding AMS. A score of 0.5-1 was considered to be very good.

Results: The overall response rate was 70.9%. Sex, age, work experience and education level did not significantly influence the perception and practices of community pharmacists. Experienced pharmacists showed a better response to AMS. The majority of pharmacists strongly agreed that they educate patients on the use of antimicrobials and resistance-related issues.

Conclusion: It was concluded that community pharmacists in Lahore have good perception regarding AMS and they are practicing it well. But there are several gaps in their practices that must be filled, such as dispensing without a prescription and dispensing for a longer duration than prescribed. Additionally, there should be strict implementation of guidelines for dispensing antibiotics in order to rationalise antibiotic use and decrease antimicrobial resistance.
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http://dx.doi.org/10.1016/j.jgar.2021.03.013DOI Listing
June 2021

Evaluation of a Multidisciplinary Antimicrobial Stewardship Program in a Saudi Critical Care Unit: A Quasi-Experimental Study.

Front Pharmacol 2020 10;11:570238. Epub 2021 Mar 10.

Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.

Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. With regard to critically ill patients, appropriate antimicrobial usage is of significance, and any delay in therapy increases their risk of mortality. Therefore, the implementation of structured multidisciplinary ASPs in critical care settings is of the utmost importance to promote the judicious use of antimicrobials. This quasi-experimental study evaluating a multidisciplinary ASP in a 20-bed critical care setting was conducted from January 1, 2016 to July 31, 2017. Outcomes were compared nine months before and after ASP implementation. The national antimicrobial stewardship toolkit by Ministry of health was reviewed and the hospital antibiotic prescribing policy was accordingly modified. The antimicrobial stewardship algorithm (Start Smart and Then Focus) and an ASP toolkit were distributed to all intensive care unit staff. Prospective audit and feedback, in addition to prescribing forms for common infectious diseases and education, were the primary antimicrobial strategies. We found that the mean total monthly antimicrobial consumption measured as defined daily dose per 100 bed days was reduced by 25% (742.86 vs. 555.33; = 0.110) compared to 7% in the control condition (tracer medications) (35.35 vs. 38.10; = 0.735). Interestingly, there was a negative impact on cost in the post-intervention phase. Interestingly, the use of intravenous ceftriaxone measured as defined daily dose per 100 bed days was decreased by 82% (94.32 vs. 16.68; = 0.008), whereas oral levofloxacin use was increased by 84% (26.75 vs. 172.29; = 0.008) in the intensive care unit. Overall, involvement of higher administration in multidisciplinary ASP committees, daily audit and feedback by clinical pharmacists and physicians with infectious disease training, continuous educational activities about antimicrobial use and resistance, use of local antimicrobial prescribing guidelines based on up-to-date antibiogram, and support from the intensive care team can optimize antibiotic use in Saudi healthcare institutions.
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http://dx.doi.org/10.3389/fphar.2020.570238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988078PMC
March 2021

Access to Essential Cardiovascular Medicines in Pakistan: A National Survey on the Availability, Price, and Affordability, Using WHO/HAI Methodology.

Front Pharmacol 2020 25;11:595008. Epub 2021 Jan 25.

Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, United Kingdom.

This national survey was aimed at measuring the access to cardiovascular disease (CVD) medicines in terms of their availability, price, and affordability in Pakistan. This was done by using the standard WHO/Health Action International (HAI) methodology. The price and availability data for 18 CVD medicines were collected from public sector hospitals (n = 40) and private sector retail pharmacies (n = 40) in eight cities of Pakistan. The outcome measures were availability (calculated as percentage of health facilities stocked with listed medicines), medicine price to the international reference price ratio (i.e., median price ratio (MPR)), and affordability (calculated as number of days' wages (NDWs) of the lowest paid unskilled government worker required to afford one-month treatment of a chronic disease). The affordability of standard treatment in Pakistan with four CVD drugs was compared with data from six other low and middle income countries (LMICs) using HAI database. The mean percent availability of CVD medicines was significantly low ( < 0.001) in the public sector as compared to the private sector, that is, 25.5% vs. 54.6% for originator brands (OBs) and 30.4% vs. 34.9% for lowest price generics (LPGs), respectively. For all OBs and LPGs, the inflation-adjusted mean MPR was 2.72 and 1, respectively. CVD medicines were found to be unaffordable with average NDWs of 6.4 and 2.2 for OBs and LPGs, respectively, that is, NDWs of more than 1. In international comparison with countries such as Sudan, Lebanon, Egypt, India, Afghanistan, and China, the affordability of standard treatment with selected CVD medicines (atenolol, amlodipine, captopril, and simvastatin) in Pakistan was found to be low. Overall, all four OBs and three out of four LPGs of selected CVD drugs were found unaffordable in Pakistan. This data indicated that the availability of selected CVD medicines was low in both public and private sector medicine outlets. Both OBs and LPGs were found unaffordable in the private sector, necessitating the redressal of pricing policies, structuring, and their implementation.
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http://dx.doi.org/10.3389/fphar.2020.595008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941209PMC
January 2021

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications.

Int J Gen Med 2021 18;14:515-530. Epub 2021 Feb 18.

Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.

Background: There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.

Methods: Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.

Results: There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.

Conclusion: There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.
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http://dx.doi.org/10.2147/IJGM.S253216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901404PMC
February 2021

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications.

Int J Gen Med 2021 18;14:515-530. Epub 2021 Feb 18.

Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.

Background: There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.

Methods: Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.

Results: There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.

Conclusion: There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.
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http://dx.doi.org/10.2147/IJGM.S253216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901404PMC
February 2021

Comparative study of oral and IV dexamethasone premedication in the prevention of docetaxel induced allergic reactions.

J Oncol Pharm Pract 2021 Feb 24:1078155220984369. Epub 2021 Feb 24.

Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan.

Background: The hypersensitivity reactions after docetaxel administration is a main concern in this study. The aim of this study is to check the incidence of hypersensitivity reactions (HSRs) after receiving a single dose of intravenous dexamethasone before docetaxel administration.

Method: In this retrospective study, 1 year data from Jan 1st 2018 to Dec 31st 2018 was retrieved from hospital information system (HIS). We examined 210 patients who visited hospital during the last 12 months during their cancer treatment and took dexamethasone orally 3 days prior to docetaxel administration or 20 mg intravenously before 15 minutes of docetaxel.

Results: Out of 210 patients, only 50 patients were taking IV dexamethasone injection prior to docetaxel constitutes only 23.5% while patients who were taking oral dexamethasone were found to be 160 which constitutes 75%. There was no hypersensitivity reaction with oral and IV dexamethasone before docetaxel administration. Majority of the patients were without taking oral dexamethasone before docetaxel administration which not only saved time but also improve patient compliance.

Conclusion: No hypersensitivity reaction had been found either in oral or intravenous dexamethasone prior to docetaxel administration by using patient data from Hospital Information System (HIS). However, intravenous dexamethasone not only improve patient compliance but also reduce the risk of hypersensitivity reactions but the cost of intravenous dexamethasone is higher than the cost of oral dexamethasone. In conclusion, single dose of intravenous IV dexamethasone is preferred treatment option.
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http://dx.doi.org/10.1177/1078155220984369DOI Listing
February 2021

WHO key access antibiotics price, availability and affordability in private sector pharmacies in Pakistan.

Cost Eff Resour Alloc 2021 Feb 16;19(1):10. Epub 2021 Feb 16.

Department of Pharmacy, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK.

Background: Poor availability and unaffordability of key access antibiotics may increase antimicrobial resistance in the community by promoting inappropriate antibiotic selection and abridged therapy compliance.

Objective: To check the prices, availability, and affordability of the World Health Organization (WHO) key access antibiotics in private sector pharmacies of Lahore, Pakistan.

Methodology: A survey of WHO key access antibiotics from WHO essential medicine list 2017 was conducted in private sector pharmacies of 4 different regions of Lahore employing adapted WHO/HAI methodology. The comparison of prices and availability between originator brands (OB) and lowest price generics (LPG) were conducted followed by the effect of medicine price differences on patient's affordability. The data were analyzed using a preprogrammed WHO Microsoft excel workbook.

Results: The mean availability of OB products was 45.20% and the availability of LPGs was 40.40%. The OBs of co-amoxiclav, clarithromycin and metronidazole and LPGs of azithromycin and ciprofloxacin were easily available (100%) in all private sector pharmacies. Whereas, antibiotics like chloramphenicol, cloxacillin, nitrofurantoin, spectinomycin, and cefazolin were totally unavailable in all the surveyed pharmacies. The OBs and LPGs with high MPRs were ceftriaxone (OB; 15.31, LPG; 6.38) and ciprofloxacin (OB; 12.42, LPG; 5.77). The median of brand premium obtained was 38.7%, which varied between the lowest brand premium of 3.97% for metronidazole and highest for ceftriaxone i.e. 140%. The cost of standard treatment was 0.5 day's wage (median) if using OB and 0.4 day's wage (median) for LPG, for a lowest paid unskilled government worker. Treatment with OB and LPG was unaffordable for ciprofloxacin (OB; 2.4, LPG; 1.1) & cefotaxime (OB; 12.7, LPG; 8.1).

Conclusion: There is dire need to properly implement price control policies to better regulate fragile antibiotic supply system so that the availability of both OB and LPG of key access antibiotics should be increased. The prices could be reduced by improving purchasing efficiency, excluding taxes and regulating mark-ups. This could increase the affordability of patients to complete their antibiotic therapy with subsequent reduction in antimicrobial resistance.
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http://dx.doi.org/10.1186/s12962-021-00263-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885400PMC
February 2021

Perceptions of and barriers to ethical promotion of pharmaceuticals in Pakistan: perspectives of medical representatives and doctors.

BMC Med Ethics 2021 01 4;22(1). Epub 2021 Jan 4.

College of Pharmacy, Universality of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan.

Background: In Pakistan, drug promotion practices, ethical or unethical, have rarely been in the spotlight. We aimed to assess the perception and barriers of medical representatives (MRs) and doctors (MDs) regarding ethical promotion of pharmaceuticals in Pakistan.

Methods: A cross sectional survey was conducted in seven major cities of Pakistan for 6-months period. Self-administered questionnaire was used for data collection. Logistic regression and five-point Likert scale scoring was used to estimate the perceptions and barriers.

Results: Compared to national companies (NCs), the medical representatives (MRs) of multinational companies (MNCs) strongly believed that their companies follow World Health Organization (WHO) (OR; 5.31, p = 0.0005), International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) (OR; 6.45, p = 0.0005) and national codes of ethics (OR; 5.84, p = 0.0005). MNCs trained their MRs (OR; 6.68, p = 0.0005), provide accurate and valid scientific data (OR; 4.01, p = 0.007) with adequate system of accountability and controls on product samples (OR; 1.96, p = 0.047), while, NCs sponsor social or entertainment activities, seminars and conferences, and all sort of facilitation in form of gifts of their choice and clinic renovation for medical doctors (MDs). MDs perceptions were similar to MRs mentioned above, yet strongly agreed that companies offer cash payments or equivalents to MDs. The MRs of NCs/MNCs and MDs agreed/strongly agreed that no external accountability, profiteering, pressure on sale targets, job insecurity, condoning unethical promotion by high-ups' and business promotion by junior MDs were the predominant barriers.

Conclusion: In conclusion, MRs of MNCs and MDs believed that MNCs follow certain codes of ethics in the promotion of pharmaceuticals, while NCs tend to be more profit oriented and even condone unethical promotion. All stakeholders, MRs, MDs and companies, might pose certain barriers, intentionally or unintentionally, in ethical promotion.
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http://dx.doi.org/10.1186/s12910-020-00569-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783997PMC
January 2021

Perceptions of and barriers to ethical promotion of pharmaceuticals in Pakistan: perspectives of medical representatives and doctors.

BMC Med Ethics 2021 01 4;22(1). Epub 2021 Jan 4.

College of Pharmacy, Universality of the Punjab, Allama Iqbal Campus, Lahore, 54000, Pakistan.

Background: In Pakistan, drug promotion practices, ethical or unethical, have rarely been in the spotlight. We aimed to assess the perception and barriers of medical representatives (MRs) and doctors (MDs) regarding ethical promotion of pharmaceuticals in Pakistan.

Methods: A cross sectional survey was conducted in seven major cities of Pakistan for 6-months period. Self-administered questionnaire was used for data collection. Logistic regression and five-point Likert scale scoring was used to estimate the perceptions and barriers.

Results: Compared to national companies (NCs), the medical representatives (MRs) of multinational companies (MNCs) strongly believed that their companies follow World Health Organization (WHO) (OR; 5.31, p = 0.0005), International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) (OR; 6.45, p = 0.0005) and national codes of ethics (OR; 5.84, p = 0.0005). MNCs trained their MRs (OR; 6.68, p = 0.0005), provide accurate and valid scientific data (OR; 4.01, p = 0.007) with adequate system of accountability and controls on product samples (OR; 1.96, p = 0.047), while, NCs sponsor social or entertainment activities, seminars and conferences, and all sort of facilitation in form of gifts of their choice and clinic renovation for medical doctors (MDs). MDs perceptions were similar to MRs mentioned above, yet strongly agreed that companies offer cash payments or equivalents to MDs. The MRs of NCs/MNCs and MDs agreed/strongly agreed that no external accountability, profiteering, pressure on sale targets, job insecurity, condoning unethical promotion by high-ups' and business promotion by junior MDs were the predominant barriers.

Conclusion: In conclusion, MRs of MNCs and MDs believed that MNCs follow certain codes of ethics in the promotion of pharmaceuticals, while NCs tend to be more profit oriented and even condone unethical promotion. All stakeholders, MRs, MDs and companies, might pose certain barriers, intentionally or unintentionally, in ethical promotion.
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http://dx.doi.org/10.1186/s12910-020-00569-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783997PMC
January 2021

Evaluation of Antimicrobial Stewardship Programs (ASPs) and their perceived level of success at Makkah region hospitals, Kingdom of Saudi Arabia.

Saudi Pharm J 2020 Oct 14;28(10):1166-1171. Epub 2020 Aug 14.

Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti of Sains Malaysia, Penang, Malaysia.

Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. The general administration of pharmaceutical care in the Saudi ministry of health (MOH) is putting outstanding efforts in implementing antimicrobial stewardship in Saudi health care settings. Several surveys have been conducted globally and reported many types of antimicrobial stewardship strategies in health institutions and their effectiveness. This study aims to identify ASPs in Makkah region hospitals and their perceived level of success. We administered a regional survey to explore current progress and issues related to the implementation of ASPs in Makkah region hospitals at the pharmacy level (n = 25). Among responding hospitals, 19 (76%) hospitals, the most commonly reported ASP were as following: formulary restrictions (90%) for broad-spectrum antimicrobials and use of prospective feedback on antimicrobial prescribing (68%), use of clinical guidelines and pathways (100%), and use of automatic stop orders (68%) to limit inappropriate antimicrobial therapy. The study outcomes will also be of pivotal importance to devise policies and strategies for antimicrobial stewardship implementation in other non-MOH settings in the Makkah region. Based on our results, all reported institutions have at least one antimicrobial stewardship program in a process with a high success rate. A multidisciplinary ASP approach, active involvement of drug & therapeutic committee, formulary restrictions, and availability of education & training of pharmacists and physicians on ASP are the primary elements for perceived successful antimicrobial stewardship programs in the Makkah region hospitals.
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http://dx.doi.org/10.1016/j.jsps.2020.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7584782PMC
October 2020

Impact of National Drug Pricing Policy 2018 on access to medicines in Lahore division, Pakistan: a pre-post survey study using WHO/HAI methodology.

BMJ Open 2020 10 8;10(10):e034720. Epub 2020 Oct 8.

Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, West Yorkshire, UK.

Objective: To evaluate the impact of new National Drug Pricing Policy (NDPP) 2018 on access to medicines in terms of prices, availability and affordability.

Design: Two cross-sectional surveys were undertaken before and after the launch of NDPP 2018, using a modified WHO/Health Action International (WHO/HAI) methodology.

Setting: Four districts of Lahore division, Pakistan.

Participants: 16 public sector hospitals and 16 private sector retail pharmacies.

Measures: The pre and post survey data on prices and availability of lowest price generics (LPGs) and originator brands (OBs) of 50 medicines were obtained by visiting the same public and private sector health facilities (n=32). Out of 50, 46 surveyed medicines were from the National Essential Medicines List. Inflation-adjusted median unit prices (MUPs) and median price ratios (MPRs) from 2019 were used for price comparison. Affordability was calculated in terms of number of days' wages required to get a standard treatment by the lowest paid unskilled government worker.

Results: The overall mean percent availabilities remained poor in both years, that is, far less than 80%. In the public sector, the mean percent availability of OBs improved from 6.8% to 33.1%, whereas, in the case of LPGs, it was reduced from 35.1% to 9%. In the private sector, the mean percent availability of both OBs and LPGs demonstrated slight improvements in 2019, that is, 55.0%-58.3% and 20.3%-32.3%. The adjusted MUPs and MPRs of OBs significantly increased by a median of 4.29% (Wilcoxon test p=0.001, p=0.0001), whereas the adjusted MUPs and MPRs of LPGs increased by a median of 15.7% (p=0.002, p=0.0002). Overall, the affordability of many medicines for common ailments was reduced significantly in 2019.

Conclusions: The availability of medicines slightly improved, except in the case of LPGs, which was reduced in the public sector. The implementation of NDPP 2018 led to increase in drug prices, making the standard treatment for some of the most prevalent ailments unaffordable. So verily, the drug pricing policy must be reviewed to ensure access to essential medicines.
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http://dx.doi.org/10.1136/bmjopen-2019-034720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545625PMC
October 2020

The burden of healthcare-associated infections among pediatrics: a repeated point prevalence survey from Pakistan.

Hosp Pract (1995) 2021 Feb 26;49(1):34-40. Epub 2020 Oct 26.

Department of Paediatric Surgery, King Edward Medical University , Lahore, Pakistan.

Background: Healthcare-associated infections (HAIs) are considered a major threat to public health resulting in significant morbidity, mortality, and additional costs. The present study aimed to assess the current patterns and risk factors of HAIs among hospitalized children.

Materials And Methods: Three repeated point prevalence surveys were conducted in the pediatric inpatients of four hospitals by using the methodology developed by the European Center for Disease Prevention and Control. All patients present in the ward at 8:00 AM on the survey day and not discharged from the hospital on the same day were included. A standardized data collection form containing information on the presence of HAIs and the associated risk factors was completed for the patients.

Findings: Out of 888 hospitalized patients, 116 (13.1%) had the symptoms of HAIs. Most common infections were bloodstream infections (BSIs) (32.8%), pneumonia (21.0%), ear, eyes, nose and throat infections (11.8%), and skin and soft tissue infections (SSTs) (19.0%). Factors significantly associated with infections were the length of hospital stay (p = 0.000), admission to the medicine ward (p = 0.034), and male gender (p = 0.010). BSIs were most common in children belonging to the age group of less than one month (78.9%), who were admitted to intensive care units (73.7%). SSTs including surgical site infections were more prevalent in surgery wards (78.3%).

Conclusions: A high rate of HAIs among pediatrics was found in Pakistan. Infection control and prevention strategies are needed with a major focus on interventions to prevent the spread of most prevalent HAIs.
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http://dx.doi.org/10.1080/21548331.2020.1826783DOI Listing
February 2021

Knowledge, attitude and preventive practices related to COVID-19 among health professionals of Punjab province of Pakistan.

J Infect Dev Ctries 2020 Jul 31;14(7):707-712. Epub 2020 Jul 31.

Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan.

Introduction: Considering health professionals among high-risk individuals, we aimed to evaluate their knowledge, attitude and practices (KAP) regarding COVID-19.

Methodology: This cross-sectional study was conducted among the health professionals (medical doctors, nurses, pharmacists, physiotherapists, hospital technicians and technologists) providing services at seven hospitals of Punjab province of Pakistan. A self-administered questionnaire was used to evaluate knowledge, attitude and practices regarding COVID-19.

Results: All of the participants (N = 429) reported that they were aware of COVID-19 and social media was the major source (65%) of this information. Mean knowledge score was 12 ± 2.1, with 75.5% of participants having satisfactory knowledge. Doctors were found to have significantly better knowledge scores than the other health professionals (p = 0.001). Mean attitude score was 8.0 ± 1.2, with a wide majority of health professionals (86.5%) having positive attitudes. Regarding preventive practices, around 64% reported of always covering nose and mouth with a tissue paper during sneezing or coughing and nearly 65% disposed of the dirty tissue paper in trash bin. Only 40% of the participants reported that 'if they do not have tissue, they cough or sneeze into upper sleeves'. Around 45% reported that they used face mask during their working hours in hospitals nowadays. Mean practice score was 23.3 ± 3.6, with 73.4% of health professionals having satisfactory practices.

Conclusions: The overall COVID-19 related KAP of Pakistani health professionals are satisfactory, however some misperceptions and malpractices uncovered in the present study must be addressed to effectively combat COVID-19.
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http://dx.doi.org/10.3855/jidc.12878DOI Listing
July 2020

Sale of WHO AWaRe groups antibiotics without a prescription in Pakistan: a simulated client study.

J Pharm Policy Pract 2020 3;13:26. Epub 2020 Aug 3.

Hamdard Institute of Pharmaceutical Sciences, Hamdard University, Islamabad, Pakistan.

Introduction: Resistant strains of bacteria are rapidly emerging with increasing inappropriate use of antibiotics rendering them less efficacious. Self-purchasing of antibiotics particularly for viral infections is a key driver of inappropriate use, especially in lower- and middle-income countries. There is a particular issue in countries such as Pakistan. Consequently, there is a need to assess current rates of self-purchasing especially for reserve antibiotics to guide future policies.

Aims: Assess the extent of current antibiotic sales without a prescription in urban areas of Pakistan.

Methodology: A multicenter cross-sectional study was conducted in different areas of Punjab, Pakistan using Simulated Client technique. The investigators demanded different predefined antibiotics from WHO AWaRe groups without prescription. Three levels of demand were used to convince the pharmacy staff in order to dispense the antibiotic without a prescription. A data collection form was completed by simulated clients within 15 min of each visit.

Results: Overall 353 pharmacies and medical stores were visited out of which 96.9% pharmacies and medical stores dispensed antibiotics without demanding a prescription (82.7% at demand level 1 and 14.2% at demand level 2), with only 3.1% of pharmacies refusing to dispense antibiotics. The most frequently dispensed antibiotic was ciprofloxacin (22.1%). Surprisingly, even the reserve group antibiotics were also dispensed without a prescription. In only 25.2% visits, pharmacy staff guided patients about the use of antibiotics, and in only 11.0% pharmacists enquired about other medication history.

Conclusion: Currently, antibiotics are easily acquired without a legitimate prescription in Pakistan. There is a need for strict adherence to regulations combined with a multi-dimensional approach to enhance appropriate dispensing of antibiotics and limit any dispensing of WHO restricted antibiotics without a prescription.
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http://dx.doi.org/10.1186/s40545-020-00233-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397594PMC
August 2020

Clinical efficacy of various anti-hypertensive regimens in hypertensive women of Punjab; a longitudinal cohort study.

BMC Womens Health 2020 08 1;20(1):161. Epub 2020 Aug 1.

Institute of Health and Society, Department of Medicine, University of Oslo, Oslo, Norway.

Background: Gender wise differences exist in anti-hypertensive treatment outcomes, yet still un-explored in Pakistan. Thus, we aimed to estimate the clinical efficacy of four different anti-hypertensive regimens in hypertensive women of Punjab, Pakistan.

Methods: A longitudinal cohort study of 12 months duration was conducted by enrolling 300 hypertensive women on four anti-hypertensive regimens. Chi-square for significance, logistic regression for association and multilevel regression for changes in outcomes were used.

Results: Majority of subjects were < 60 years of age, weighing > 65 Kg, having family history, married and hailing from urban areas, with diabetes as the most common comorbidity. Hypertension, adjusted for covariates, was significantly associated with salt intake (OR:2.27, p <  0.01) and physical activity (OR;2.16, p <  0.01). High-risk subjects, compared to low-risk, were consuming more fat (OR;1.54), meat (OR; 2), salt (OR; 2.48) and even vegetables/fruits (OR;3.43). Compared to baseline, the maximum reduction in BP was observed with combination therapy, N-GITS+LTN + HCT (SBP; - 50.17, p <  0.01, DBP; - 16.55, p <  0.01), followed by N-GITS alone (SBP; - 28.89, p <  0.01, DBP; - 12.21, p <  0.01). Compared to baseline, adjusted for treatment effects, significant reductions in SBP (low-risk; - 17.92, p <  0.01 high-risk; - 19.48, p <  0.01) and DBP (low-risk; - 17.92, p <  0.01, high-risk; - 19.48, p <  0.01) were observed in low and high risk patients. Among all four cohorts, orthostatic hypotension and edema were common in N-GITS+LTN + HCT only, but variable effects were observed on biochemical values; urea, BSR and creatinine.

Conclusion: In conclusion, compared to a single agent, combination therapy conferred improved BP controls followed by N-GITS alone in low and high risk women with manageable side effects.
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http://dx.doi.org/10.1186/s12905-020-01033-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395419PMC
August 2020

Off-label antibiotic use in a specialized children care hospital in Punjab, Pakistan: Findings and implications.

J Infect Dev Ctries 2020 05 31;14(5):540-544. Epub 2020 May 31.

University College of Pharmacy, University of the Punjab, Pakistan.

Introduction: Most of the antibiotics currently used in pediatrics are either unlicensed or being prescribed outside the specifications of product label (off-label prescribing). The aim of this study was to assess the extent of off-label antibiotic use in pediatrics.

Methodology: A six month longitudinal off-label antibiotic utilization survey was carried out from January to June, 2018. A structured questionnaire was designed to collect detailed information for each pediatric patient admitted to participating health center. The data included basic demographic and clinical diagnosis with details of prescribed antibiotics (formulation, dose, dosage, route of administration and indication for use). Data were analyzed using Social packages for Statistical Sciences (SPSS) version 21.0.

Results: Of 1,810 admissions, 1,795 (99.2%) patients received antibiotics. Out of these, a total of 451 (25.1%) patients (326 patients admitted in the medical ward and 125 patients in ICUs) received at least one unlicensed/off-label antibiotic. Antibiotics were predominantly prescribed for the treatment of infections (n = 311, 69.0%). The majority of the pediatric patients who received off-label antibiotic suffered from respiratory tract infections (n = 223, 49.4%), skin and soft tissue infections (n = 53, 11.8%), gastrointestinal tract infections (n = 56, 12.4%) and other infections (n = 46, 10.2%). Co-amoxiclav (n = 190, 42.1%) was the most frequently off-label prescribed antibiotic to pediatric patients. An inappropriate dose for patients (n = 430, 95.3%) was the most frequent cause of prescribing off-label antibiotics.

Conclusions: Further evaluation of health and economic outcomes of off-label prescribing and determinants influencing the drug choice is required.
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http://dx.doi.org/10.3855/jidc.12058DOI Listing
May 2020

Dosing errors in total parenteral nutrition prescriptions at a specialized cancer care hospital of Lahore: The role of clinical pharmacist.

J Oncol Pharm Pract 2021 Apr 13;27(3):531-540. Epub 2020 May 13.

ShaukatKhanum Cancer Memorial and Research Center, Lahore, Pakistan.

Study Objective: To determine the role of pharmacist in identifying the frequency of errors in total parenteral nutrition prescriptions in cancer patients for the years 2015 and 2016. Total parenteral nutrition has a high potential for medical errors because of its complex composition, thus leading to severe complications. Pharmacist review of the prescriptions reduces the risk of inappropriate prescribing, preparation, and administration of parenteral nutrition.

Methodology: An observational study was performed by collecting data of total parenteral nutrition prescriptions of 71 patients for the last two years from Pharmacy Department of specialized cancer care hospital.

Results: It was found that the frequency of dosing errors and incomplete prescriptions was higher in 2015 compared to 2016. Additionally, the frequency of macro and micronutrients dosing errors were higher in adults (23.4% and 66.2%) compared to pediatrics (14.6% and 46.6%). Furthermore, the frequency of illegible prescriptions was higher (5.03%) in year 2016 as compared to year 2015 (1.64%). Nevertheless, such dose interventions improved patient's weight (20%) and promoted enteral feeding (42.3%). Major complication was hypophosphatemia (39.4%) followed by hyperglycemia (10%) and catheter-induced infection, i.e. sepsis (4.2%).

Conclusion: In conclusion, data suggested that pharmacist played instrumental role in identifying and rectifying total parenteral nutrition dosing errors for both micronutrients and macronutrients-with higher frequency in 2015 compared to 2016, leading to improvements in total parenteral nutrition-related complications and switches to enteral feeding.
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http://dx.doi.org/10.1177/1078155220923014DOI Listing
April 2021

Knowledge, attitude and preventive practices related to COVID-19: a cross-sectional study in two Pakistani university populations.

Drugs Ther Perspect 2020 May 9:1-7. Epub 2020 May 9.

1Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, 1-Km Defense Road, Lahore, Pakistan.

Objective: The aim of this study was to assess COVID-19-related knowledge, attitudes, and preventive practices of two Pakistani university populations.

Methods: A cross-sectional study was conducted among students and employees of two higher education institutions in Lahore, Pakistan, namely the University of Lahore and the Gulab Devi Educational Complex. Participants were recruited using a convenient sampling method. A validated 45-item, self-administered questionnaire was used to collect data. Total possible scores were 0-14 for knowledge (scores < 7, 7-10 and > 10 were considered to indicate poor, moderate and good knowledge, respectively); 0-7 for attitude (scores > 5 were considered to indicate a good attitude); and 0-18 for COVID-19 preventative practices (scores > 12 were considered to indicate good preventative practices).

Results: Of the 417 enrolled participants, 416 reported that they were aware of COVID-19 and social media was the major source of their information. Mean scores were 10.12 ± 2.20 for knowledge (good, moderate and poor knowledge in 50.2%, 42.8% and 7.0% of participants, respectively); 5.74 ± 1.28 for attitude (65.4% of individuals had a positive attitude); and 11.04 ± 3.34 for COVID-19 preventative practices (only 36.5% of participants had good preventive practices).

Conclusion: Pakistani university students and employees have good knowledge and attitudes regarding COVID-19, but unsatisfactory preventive practices. Therefore, health regulators should use multiple communication approaches, such as electronic, print and social media, phone messages, etc., to increase awareness and improve practices related to COVID-19.
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http://dx.doi.org/10.1007/s40267-020-00737-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210795PMC
May 2020

Point prevalence surveys of antimicrobial use: a systematic review and the implications.

Expert Rev Anti Infect Ther 2020 09 20;18(9):897-910. Epub 2020 May 20.

Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences , Lahore, Pakistan.

: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. : One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. : This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.
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http://dx.doi.org/10.1080/14787210.2020.1767593DOI Listing
September 2020

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

Fam Med Community Health 2019 12;7(3):e000138. Epub 2019 Jul 12.

Faculty of Pharmacy and Health sciences, University of Balochistan, Quetta, Pakistan.

Background: There are concerns with the extent of dispensing of antibiotics among community pharmacists in Pakistan often without a prescription adding to antimicrobial resistance (AMR) rates.

Objective: To explore the determinants of AMR and the pattern of antimicrobial dispensing among community pharmacists.

Design: In 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.

Setting: Interviews were conducted among community pharmacists in Lahore, Pakistan.

Participants: In order to obtain individual points of view, in-depth face-to-face interviews with purposively selected pharmacists were conducted.

Results: A 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.

Conclusion: The 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.
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http://dx.doi.org/10.1136/fmch-2019-000138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910752PMC
July 2019

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future.

Curr Med Res Opin 2020 02 30;36(2):301-327. Epub 2019 Dec 30.

Raleigh Fitkin Memorial Hospital, Manzini, Swaziland.

Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use. Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known. Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals. Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.
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http://dx.doi.org/10.1080/03007995.2019.1700947DOI Listing
February 2020
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