Point-prevalence survey of antimicrobial use in intensive care units in Nepal.

Objective: This study aimed to investigate the prevalence and practices of antibiotic use in intensive care units (ICUs) in Nepal and to identify potential areas for implementing antimicrobial stewardship programs. Design: A point prevalence survey was conducted to characterize and quantify the antimicrobial utilization in level III ICUs of Nepal. Methods: Data on antibiotic prescription rates, reasons for prescribing antibiotics, and prescribing practices were collected and analyzed. The prevalence of antimicrobial resistance was also assessed. Results: The antibiotic prescribing rate was found to be very high, with 92.85% of patients in ICU on antibiotics. Prolonged surgical prophylaxis was the most common reason for prescribing antibiotics. Empirical therapy accounted for 67.5% of all antibiotic prescriptions. Prescribing practices were poor, with low adherence to guidelines and best practices. Broad-spectrum antibiotics were commonly used even for surgical prophylaxis or community-acquired infections. High resistance was observed against commonly used antibiotics. Conclusions: The study underscores the urgent need for effective antimicrobial stewardship programs in ICUs of Nepal. Implementing robust stewardship programs could help optimize antibiotic utilization, improve patient outcomes, and combat the global threat of antimicrobial resistance. The findings serve as a stepping stone toward understanding and improving antibiotic prescribing practices in ICUs of Nepal.

Attempted suicidal poisoning with pretilachlor: case series of a herbicide simulating organophosphorus toxicity.

Pretilachlor is a herbicide that can cause clinical symptoms in people that are comparable to those of organophosphate poisoning when ingested. Given how closely it mimics the toxicity of organophosphate compounds, it presents a significant challenge to clinicians during management. The following cases were presented to the Emergency Department at Nepalgunj Medical College Teaching Hospital, Kohalpur, Banke, Nepal.

Severe recurrent hyponatremia in a 72-year-old patient with undiagnosed partially empty Sella syndrome-a case report.

Hyponatremia is one of the most common electrolyte abnormalities encountered in medical practice and is caused by multiple conditions. SIADH is the most common cause of hyponatremia, however, careful workup must be performed on all patients as mere supplementation may cause recurrent hyponatremia and serious side effects. Adrenal insufficiency is a principal culprit that mimics the clinical picture of SIADH and tends to worsen when treated in the line of SIADH. In addition, individuals may have various comorbidities, such as hypothyroidism in our case, which can also cause hyponatremia, making it difficult to determine precise etiology. We present a case of a 72-year-old man with recurrent hyponatremia, who was subsequently diagnosed as partially empty sella syndrome. Given the temporal relationship between the use of corticosteroids and the improvement of his symptoms, low cortisol and ACTH levels, adrenal insufficiency was most likely the cause of the hyponatremia in our patient.

Best and worst performing health facilities: A positive deviance analysis of perceived drivers of primary care performance in Nepal.

Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst performing primary health care centers in Nepal and investigated perceived drivers of best performance. We selected eight primary health care centers in Province 1, Nepal, using an index of basic clinical and operational activities to identify four best and four worst performing primary health care centers. We conducted semi-structured, in-depth interviews with managers and clinical staff from each of the eight primary health care centers for a total of 32 interviews. We identified the following factors that distinguished best from worst performers: 1) Managing the facility effectively, 2) engaging local leadership, 3) building active community accountability, 4) assessing and responding to facility performance, 5) developing sources of funding, 6) compensating staff fairly, 7) managing clinical staff performance, and 8) promoting uninterrupted availability of supplies and equipment. These findings can be used to inform quality improvement efforts and health system reforms in Nepal and other similarly under-resourced health systems.

Loss of Consciousness and Cardiac Arrest as an Atypical Presentation of Tubercular Meningitis: A Case Report.

Tubercular meningitis is a devastating presentation of extra pulmonary tuberculosis, with fatality in each case without treatment. A 39 years male, a regular consumer of alcohol and a known case of major depressive disorder, presented with the alleged history of using an electric heater in a closed room, and presented to emergency with unconsciousness and cardiac arrest. As his neurological status didn't improve over 72 hrs, a magnetic resonance imaging brain was done which was non-conclusive. Electroencephalogram revealed diffuse right fronto-parietal seizure activity ceasing with midazolam injection, hence levetiracetam was started. Lumbar puncture revealed increased adenosine deaminase and nil white blood cells. Repeat lumbar puncture showed lymphocytic-predominant pleocytosis, elevated protein and low glucose. The patient was started on anti-tubercular therapy and an injection of dexamethasone was added. Repeat electroencephalogram didn't show any seizure-like activity. It is important to be aware of variety of presentations of tubercular meningitis. Delay in treatment leads to irreversible neurological damage and even death. Keywords: cardiac arrest; case report; tubercular meningitis; unconsciousness.

Anxiety and depressive symptoms among home isolated patients with COVID-19: A cross-sectional study from Province One, Nepal.

Home isolated patients infected with COVID-19 might be at increased risk of developing mental health problems. The study aimed to identify the prevalence and factors associated with anxiety and depression among COVID-19 home isolated patients in Province One, Nepal. This was a cross-sectional study conducted between February 17, 2021, to April 9, 2021. A total of 372 home isolated patients from Province One were phone interviewed in the study. Anxiety and depression were measured using a 14-items Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression analysis was done to determine the risk factors of anxiety and depression. Among home isolated COVID-19 infected participants, 74.2% and 79% had symptoms of anxiety (borderline: 48.7% and abnormal: 25.5%) and depression (borderline: 52.7% and abnormal: 26.3%), respectively. Watching television was significantly associated with lower odds of experiencing symptoms of anxiety and depression. Females had significantly higher odds of having depression symptoms compared to males while ever married, those with COVID-19 related complications, and those taking medicine for the treatment of COVID-19 symptoms had a higher likelihood of exhibiting symptoms of anxiety. A focus on improving the mental health well-being of COVID-19 infected patients in home settings with connection to the health services is warranted with timely psychological interventions.

Adverse events with ayurvedic medicines- possible adulteration and some inherent toxicities.

Ayurvedic medicine, a traditional system of medicine practiced in the Indian subcontinent is considered to be devoid of adverse events. We report three cases which highlight the possibility of adverse events related with the use of ayurvedic products. A 35 year old woman with hepatitis took ayurvedic powder medicine and swarnabhasma (gold salt) and had her liver injury worsened, possibly due to alkaloids, and developed nephrotic syndrome, possibly due to gold salt. A 57 year old hypertensive man was taking ayurvedic medicine containing reserpine which had long been withdrawn from the allopathic system of medicine due to wide range of side effects. A 47 year old woman with rheumatoid arthritis was taking an unknown tablet containing steroid as an adulterant for 2 years and developed side effects typical of steroid excess. We would like to highlight the fact that ayurvedic medicines do have propensity to cause adverse events due to adulteration or inherent constituents like alkaloids, and hence may not always be completely safe.