A Systematic Critical Review of Clinical Pharmacokinetics of Torasemide.

PURPOSE: Torasemide is a potassium-sparing loop diuretic used to treat fluid retention associated with congestive heart failure and kidney and hepatic diseases. This systematic review was conducted to combine all accessible data on the pharmacokinetics (PK) of torasemide in healthy and diseased populations, which may help clinicians avert adverse drug reactions and determine the correct dosage regimen. METHODS: Four databases were systematically searched to screen for studies associated with the PK of torasemide, and 21 studies met the eligibility criteria. The review protocol was registered in the PROSPERO database (CRD42023390178). RESULTS: A decrease in maximum plasma concentration (C max ) was observed for torasemide after administration of the prolonged-release formulation in comparison to that after administration of the immediate-release formulation, that is, 1.12 ± 0.17 versus 1.6 ± 0.2 mcg/mL. After administering an oral dose of torasemide, a 2-fold increase in the area under the concentration-time curve (AUC) was reported in patients with congestive heart failure compared with the healthy population. Moreover, the patients with renal failure (clearance < 30 mL/min) showed an increase in value of AUC 0-∞ that is, 42.9 versus 8.091 mcg.h -1 .mL -1 compared with healthy subjects. In addition, some studies have reported interactions with different drugs, in which irbesartan showed a slight increase in the AUC 0-∞ of torasemide, whereas losartan and empagliflozin did not. CONCLUSIONS: The current review summarizes all available PK parameters of torasemide that may be beneficial for avoiding drug-drug interactions in subjects with renal and hepatic dysfunction and for predicting doses in patients with different diseases.

Using Culture Sensitivity Reports to Optimize Antimicrobial Therapy: Findings and Implications of Antimicrobial Stewardship Activity in a Hospital in Pakistan.

Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient's medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization's Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics.

Point Prevalence Survey of Antimicrobial Use in Selected Tertiary Care Hospitals of Pakistan Using WHO Methodology: Results and Inferences.

Background and objectives: The inappropriate use of antibiotics in hospitals can potentially lead to the development and spread of antibiotic resistance, increased mortality, and high economic burden. The objective of the study was to assess current patterns of antibiotic use in leading hospitals of Pakistan. Moreover, the information collected can support in policy-making and hospital interventions aiming to improve antibiotic prescription and use. Methodology and materials: A point prevalence survey was carried out with data abstracted principally from patient medical records from 14 tertiary care hospitals. Data were collected through the standardized online tool KOBO application for smart phones and laptops. For data analysis, SPSS Software was used. The association of risk factors with antimicrobial use was calculated using inferential statistics. Results: Among the surveyed patients, the prevalence of antibiotic use was 75% on average in the selected hospitals. The most common classes of antibiotics prescribed were third-generation cephalosporin (38.5%). Furthermore, 59% of the patients were prescribed one while 32% of the patients were prescribed two antibiotics. Whereas the most common indication for antibiotic use was surgical prophylaxis (33%). There is no antimicrobial guideline or policy for 61.9% of antimicrobials in the respected hospitals. Conclusions: It was observed in the survey that there is an urgent need to review the excessive use of empiric antimicrobials and surgical prophylaxis. Programs should be initiated to address this issue, which includes developing antibiotic guidelines and formularies especially for empiric use as well as implementing antimicrobial stewardship activities.

Antibiotic Susceptibility Surveillance in the Punjab Province of Pakistan: Findings and Implications.

Background and Objectives: The increase in antimicrobial resistance (AMR) across countries has seriously impacted the effective management of infectious diseases, with subsequent impact on morbidity, mortality and costs. This includes Pakistan. Antimicrobial surveillance activities should be mandatory to continually assess the extent of multidrug-resistant bacteria and the implications for future empiric prescribing. The objective of this retrospective observational study was to monitor the susceptibility pattern of microbes in Pakistan. Materials and Methods: Clinical samples from seven laboratories in Punjab, Pakistan were collected between January 2018 and April 2019, with Punjab being the most populous province in Pakistan. The isolates were identified and their antimicrobial susceptibility was tested using the Kirby-Bauer disc diffusion assay and micro broth dilution methods. The antibiotics assessed were those typically prescribed in Pakistan. Results: In total, 2523 bacterial cultural reports were studied. The most frequently isolated pathogens were Staphylococcus aureus (866, 34.3%), followed by Escherichia coli (814, 32.2%), Pseudomonas aeruginosa (454, 18.0%) and Klebsiella pneumoniae (269, 10.7%). Most pathogens were isolated from pus (1464, 58.0%), followed by urine (718, 28.5%), blood (164, 6.5%) and sputum (81, 3.2%). Conclusions: The findings suggest that current antimicrobial options are severally restricted in Pakistan due to the emergence of multidrug-resistant pathogens. This calls for urgent actions including initiating antimicrobial stewardship programs to enhance prudent prescribing of antibiotics. This includes agreeing on appropriate empiric therapy as part of agreed guidelines, in line with the WHO EML and AWaRe book, whilst awaiting culture reports. This is alongside other measures to reduce inappropriate antimicrobial prescribing and reverse the threat of rising AMR.

Retrospective drug utilization review of meropenem and role of infectious disease pharmacist in specialized cancer care hospital.

OBJECTIVES: Carbapenem antimicrobials are considered for the treatment of serious bacterial infections. The objective of this study was to review the use of meropenem in cancer patients and to evaluate the impact of clinical pharmacist's intervention in this practice to reduce possible risks associated with use of meropenem. METHODS: This retrospective study was conducted among 100 patients who received meropenem at hospital. A structured questionnaire was used to collect data. Descriptive statistics was used to analyze the collected data. RESULTS: A total of 100 patients were included in this retrospective study with aim to review rationality and possible side effects associated with meropenem use in our study population. It was revealed that meropenem used was associated with rise in bilirubin in many of our study patients. Pharmacist were found to be instrumental in placing timely interventions for either de-escalation or switch of meropenem to imipenem/cilastatin to reduce that risk. Interventions were accepted by physicians in most of the cases. CONCLUSION: De-escalation and switching were performed in accordance with pharmacist recommendations in more than half of study population with empirically started/ study population in which meropenem was used.

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

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.

Knowledge, attitude, and perception of community pharmacists towards antimicrobial stewardship in Saudi Arabia: A descriptive cross-sectional study.

Background: Antimicrobial resistance is of paramount concern globally. Community pharmacists (CPs) play a vital role in supporting judicious antimicrobial use in the community as they are the key healthcare providers at a public level. This study aimed to assess the knowledge, attitude, and perception of CPs towards antimicrobial stewardship at the community level in Saudi Arabia. Methods: A self-administered questionnaire was distributed to all community pharmacies in four major cities of Saudi Arabia. A simple random sampling approach was used to select pharmacies in each chain. Results: A total of 520 CPs responded to the survey with a response rate of 98.6 %. Most of the pharmacists (n = 479, 92.1 %) accepted that antimicrobial stewardship programs are essential tools to limit injudicious usage of antimicrobials at the community level. Interestingly, very few (n = 105, 21 %) agreed to recommend antibiotics for common illnesses, including upper respiratory tract infections, cold, and flu without a valid prescription. Further, we found a significant role of Saudi health authorities, e.g., Saudi food & drug authorities and the Ministry of Health, in restricting antimicrobials sale in community pharmacies without a valid prescription. Conclusion: Our study findings revealed that CPs had good knowledge about antimicrobial stewardship in Saudi Arabia. The CPs play an active role in the optimization of antimicrobial therapy and infections caused by different microbes. Strict policies by the Saudi health care authority regarding the restricted dispensing of antimicrobials are welcomed by the CPs and thus may contribute toward lowering of antimicrobial resistance burden on the patients and Saudi health care authorities.

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

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.

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

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.

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

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 (ß;0.383, p = 0.0001) and MA (ß; - 0.133, p = 0.018) were significantly associated with PCS-12, and MCS-12 with MA (ß; - 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.

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

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.

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

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.

Xeroderma Pigmentosum Associated with Squamous and Basal Cell Carcinoma in Pakistan: A Case Series.

ABSTRACT: Xeroderma pigmentosum (XP) is an autosomal recessive condition characterized by an extreme sensitivity to UV rays from sunlight. It presents clinically with progressive pigmentary abnormalities and an increased incidence of skin and mucous membrane cancers at sun-exposed sites. Parental consanguinity is a significant risk factor. Previously, cases of XP have been reported from various regions of Pakistan including Larkana, Sibbi, Karachi, Lahore, and District Dir in 1993, 2009, and 2010. Genetic studies have been conducted on seven consanguineous families with XP belonging to the Khosa tribe of Baloch ethnicity. In May 2018, XP was reported in four siblings in a family from a small village in Sindh Province, Pakistan. Current surveillance has been carried out in the tribal village of Lundi Khosa, District Kachhi at Baluchistan, Pakistan. The disease has been endemic in the tribe since 1986, although it was brought under control in the last few years. This case report describes five patients (aged 3-12 years) with XP who have developed nonmelanoma skin malignancies.

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

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.

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

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.

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

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

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.

Cross verification of prescribing trends through loop evaluation of physicians, patients and medical store personnel.

BACKGROUND: Prescription connects physician, patient and community pharmacy personnel who can help in understanding prescribing pattern. The present study was aimed to get an insight of viewpoints of all members involved in progression of events from prescription to drug purchase, i.e., physician, patient and medical-store personals regarding the prescription pattern in Pakistan. METHODS: Therefore, a cross-sectional study was conducted in four provinces and capital territory (Islamabad) of Pakistan to evaluate the perception of physicians, patients and medical stores/pharmacy personnel of the prescribing trends in Pakistan. RESULTS: Response rate was higher from Punjab and lower in Sindh. Responses of 981 walk-in patients with 393 physicians and 618 medical stores/pharmacies were received and statistically evaluated. The majority of physicians, patients and pharmacists/medical store personnel considered the medicines of multinational manufacturers as more effective. Physicians considered their prescribing cost-effective. However, majority of patients as well as pharmacists/medical store personnel strongly disagreed or disagreed with this notion that physicians prescribe cheap medicines. Furthermore, physicians and patients reported that medicines of local companies were not as effective as the medicines of multinational manufacturers, which were contrary to what pharmacists thought. Majority of physicians disagreed that their prescribing was under the influence of medical stores in their vicinity. The response of most of the patients (40.5%) was in line with that of physicians whereas 32% pharmacist/medical store personnel agreed. Nearly half of the physicians strongly agreed or agreed that patients demand medicines of multinational companies. Contrarily, a majority of patients and medical store personnel denied that patients demand for the medicines of multinational manufacturers. CONCLUSION: The study highlighted that there was a need to develop policy guidelines at the level of Federal Government and Drug Regulatory Authority of Pakistan in connection with prescribing practices to reduce the variation in perception of key stakholders involved in drug use process.

A randomized control trial of primary care-based management of type 2 diabetes by a pharmacist in Pakistan.

BACKGROUND: The role of a pharmacist in primary health care settings of Pakistan is still obscure. Thus, we aimed to demonstrate the pharmacist-led improvements in glycemic, blood pressure and lipid controls in type 2 diabetes mellitus (T2DM) patients of Lahore, Pakistan. METHODS: The first open label, randomized control trial conducted at a primary health care facility of Lahore, Pakistan by enrolling 244 uncontrolled type 2 diabetes (hemoglobin A1 c, (HbA1c); 10.85 ± 1.74) patients. The pharmacological intervention included identification of drug related problems, drug interactions, change in dose, frequency and therapy switches in collaboration with physician, while non-pharmacological intervention consisted of diet, lifestyle and behavior counseling. Outcome measures were glycemic (HbA1c), blood pressure and lipid controls. RESULTS: In intra-group comparison, compared to control arm (C, n = 52), subjects in the intervention arm (I, n = 83) demonstrated significant differences in process outcome measures; baseline vs final, such as HbA1c (C; 10.3 ± 1.3 vs 9.7 ± 1.3, p <  0.001, I; 10.9 ± 1.7 vs 7.7 ± 0.9, p <  0.0001), systolic blood pressure (SBP) (C; 129.9 ± 13.9 vs 136 ± 7.1, p = 0.0001, I; 145 ± 20.4 vs 123.9 ± 9.9 mmHg, p <  0.0001), diastolic blood pressure (DBP) (C; + 4, p = 0.03, I; - 7 mmHg, p <  0.0001), cholesterol (C; 235.8 ± 57.7 vs 220.9 ± 53.2, p = 0.15, I; 224 ± 55.2 vs 153 ± 25.9 mg/dL, p < 0.0001), triglycerides (C; 213.2 ± 86.6 vs 172.4 ± 48.7, p = 0.001, I; 273 ± 119.4 vs 143 ± 31.6 mg/dL, p < 0.0001) and estimated glomerular filtration rate (eGFR) (C; 77.5 ± 18.6 vs 76 ± 14.2, p = 0.5, I; 69.4 ± 21.3 vs 93.8 ± 15.2 ml/min/1.73m2, p < 0.0001). Likewise, inter-group improvements were more significant in the subjects of intervention group at final follow up in comparison to control for various process outcome measures; HbA1c (p < 0.001), SBP (p < 0.0001), DBP (p = 0.02), cholesterol (p < 0.0001), triglycerides (p < 0.0001), SCr (p < 0.001), eGFR (p < 0.001). Moreover, both male and female subjects exhibited similar responses towards intervention with similar improvements in outcome measures. CONCLUSION: These data suggested that pharmacist intervention in collaboration with physician in primary health care settings may result in significant improvements in glycemic, blood pressure and lipid controls in Pakistani population. TRIAL REGISTRATION: The trial was registered retrospectively with International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry on July 26, 2017 under nutritional, metabolic, endocrine category with assigned registration # ISRCTN22657497 and can be assessed at https://doi.org/10.1186/ISRCTN22657497.

A cross-sectional assessment of knowledge, attitudes and self-perceived effectiveness of complementary and alternative medicine among pharmacy and non-pharmacy university students.

BACKGROUND: Traditional medicine has always been Pakistan's cultural heritage, providing health care to a large part of its population. Thus, we aimed to assess and compare the knowledge, attitude, and perception about complementary and alternative medicine (CAM) between pharmacy and non-pharmacy students, the results of which may be helpful in devising national health-education policy. METHODS: A cross-sectional study was conducted by enrolling 937 students, pharmacy (437) and non-pharmacy (500), of Punjab University, Lahore. A self-administered questionnaire was used for data collection. Data were analyzed using SPSS. (IBM v22). RESULTS: Data suggested that majority of students knew about the use of traditional herbs and considered massage (P: 84.4%, NP: 82%, p = 0.099), homeopathy, herbs (P: 86.5%, NP: 81%, p = 0.064], yoga [P: 357 (81.7%), NP: 84%), p = 0.42] and spiritual healing (P: 85.6%, NP: 86.2%, p = 0.55) as effective and least harmful CAM modalities. The pharmacy students had better knowledge about CAM modalities compared to non-pharmacy students. Despite utilizing non-reliable sources of CAM information and their belief that CAM is practiced by quacks, the majority of students had positive attitudes and perceptions about CAM usage. Students also believed that CAM had a positive impact on health outcomes [P: 3.19 ± 1.04, NP: 3.02 ± 1.09, p = 0.008] and acceded to include CAM in the pharmacy curriculum. However, non-pharmacy students scored higher in their beliefs that CAM usage should be discouraged due to the non-scientific basis of CAM (P: 3.04 ± 0.97, NP: 3.17 ± 1.02, p = 0.028) and a possible threat to public health (P: 3.81 ± 1.74, NP: 4.06 ± 1.56, p = 0.02). On the other hand, pharmacy students believed that patients might get benefits from CAM modalities (P: 4.31 ± 1.48, NP: 4.12 ± 1.45, p = 0.02). Majority of students perceived that spiritual healing is the most useful and safer CAM modality, while acupuncture (P: 25.4%, NP: 21.8%, p = 0.0005), hypnosis (P: 26.8%, NP: 19.6%, p = 0.001) and chiropractic (P: 18.8%, NP: 11.6%, p = 0.0005) were among the harmful ones. CONCLUSION: In conclusion, despite poor knowledge about CAM, students demonstrated positive attitudes and beliefs regarding CAM. They exhibited better awareness about yoga, spiritual healing/prayer, herbs, and massage. Students also showed willingness to advance their knowledge about CAM and favored its inclusion in the curriculum.