Treatment and disposal practices of pharmaceutical effluent containing potential antibiotic residues in two states in India and perceptions of various stakeholders on contribution of pharmaceutical effluent to antimicrobial resistance: a qualitative study.

BACKGROUND: Antimicrobial resistance (AMR) is a looming pandemic, demanding prompt actions to avert catastrophic consequences. Effluents from pharmaceutical industries containing antimicrobial residues could serve as one of the entry points of these drugs to the environment. This qualitative study explores the treatment and disposal practices of pharmaceutical effluent (PE) containing potential antibiotic residues (ARs) by interviewing major stakeholders. In addition, we assessed their knowledge and perception on contribution of PE to AMR. METHODS: The study was conducted in the two Indian states, Haryana and Telangana and at the federal level. Data was collected by semi-structured in-depth interviews of 29 participants from 17 stakeholders/organizations viz. Central Pollution Control Board (CPCB), State Pollution Control Boards (SPCBs) of Telangana and Haryana, civic body, pharmaceutical manufacturers, pharmaceutical associations and civil society. Data was analyzed using thematic analysis. RESULTS: The effluent treatment and disposal practices varied with the multinational companies (MNCs) having advanced technologies whereas the small and medium-scale pharmaceutical companies (SMPCs) having effluent treatment plants as per the regulations but often under-utilized. The presence of ARs in the PE was considered inconsequential by SPCBs and SMPCs and majority of stakeholders imputed other causes as major contributors to AMR. However, the MNCs were well aware of the contribution of PE to AMR and CPCB also considered ARs as direct source of AMR. The central regulators as well as MNCs expressed concerns regarding the current regulations lacking maximum ARs in the PE. CONCLUSION: Setting up regulatory standards for maximum ARs in PE, their implementation and monitoring is an urgent need to curb environmental contribution of ARs to AMR. The findings of our study will help in systematic approach in policy making, awareness programs and capacity-building in dealing with the ARs in PE to combat AMR.

Therapeutic potential of N-acetyl cysteine during COVID-19 epoch.

N-acetyl cysteine (NAC) is a promising drug for prophylaxis and treatment of coronavirus disease 2019 (COVID-19) based on antioxidant and anti-inflammatory mechanisms. Further studies with cautious approach are needed to establish the benefits and risks before considering NAC as an adjuvant treatment for COVID-19.

Valproate Induced Acute Pancreatitis - A Unique Case Report.

BACKGROUND: Valproate is a widely prescribed medication for the control of seizures in the pediatric population. It has been reported to be an important implication for drug induced pancreatitis. A case of valproate induced acute pancreatitis operated as surgical abdomen has been reported here. CASE REPORT: A 13-year-old child presented to the emergency department with severe pain and abdominal distension associated with vomiting and constipation for four days. The patient's caregivers did not disclose any medication history. Based on clinical examination and ultrasonography that revealed mild free fluid, a provisional diagnosis of pyoperitoneum with peritonitis was made. An emergency exploratory laparotomy was undertaken during which acute pancreatitis was diagnosed intra-operatively. On further enquiry, the caregiver revealed the history of valproate intake for the last six months for generalized tonic-clonic seizures. Valproate was discontinued and there was complete resolution of symptoms. CONCLUSION: Both clinicians, as well as caregivers of paediatric patients receiving valproate, should be watchful regarding this possible life-threatening complication to avoid delay in diagnosis and appropriate management.

Is the education of human and animal healthcare professionals about antimicrobial resistance and stewardship adequate during their pre-service training?

PURPOSE: This paper explores inclusion of topics on antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) in pre-service human and animal healthcare professional curricula as mandated in the first strategic objective of National Action Plan on Antimicrobial Resistance. METHODS: Online versions of pre-service medical [Bachelor of Medicine, Bachelor of Surgery (MBBS)], dental [Bachelor of dental sciences (BDS)], pharmacy [Bachelor of Pharmacy (B Pharm)], veterinary [Bachelor of veterinary science and animal husbandry (B.V.Sc. & A.H.)] and post graduate medical [Doctor of medicine (MD), Master of surgery (MS) and post graduate (PG) medical diploma courses] curricula and hardcopy of nursing (Bachelor of science (BSc) Nursing-Basic) curricula were assessed. Validated search terms were used for identifying individual learning topics, domains of learning and number of hours of learning related to AMS and AMR. Recent edition of commonly referred medical textbooks were manually checked for inclusion of chapters or separate sections on AMR and AMS. RESULTS: Low coverage and poor depth with no mention of required duration of learning for AMR and AMS was observed across the majority of curricula. MS, BDS, B Pharm and BSc nursing curricula did not include AMR and AMS. Out of twenty-three textbooks assessed, only six textbooks included AMS. Gynecology, Obstetrics, Orthopedic and Surgery textbooks did not include separate section on AMR or AMS. CONCLUSIONS: Our study documented inadequate inclusion of AMR and AMS in pre-service medical, dental, nursing, pharmacy and veterinary curricula and post graduate medical curriculum. Standardized education regarding AMR and AMS in multi-professional curricula by educational councils across sectors and updating of medical textbooks of all the subjects by authors/publishers for adequate emphasis on these topics is urgently needed for success of 'One health' in combating AMR.

Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome Associated with Ethambutol use: A Case Report.

BACKGROUND: Among the first line Anti-Tubercular Drugs (ATDs), ethambutol has been rarely associated to cause drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. CASE REPORT: A 34-year-old woman presented in an out-patient department of Dermatology with fever, skin eruptions, eosino- philia, hyperinflated lung fields and deranged liver enzymes after 35 days of the initiation of ATDs. The patient recovered completely after stopping ethambutol and administration of topical and sys- temic corticosteroids. RESULTS AND CONCLUSION: Based on the available evidences of de-challenge and re-challenge of suspected drugs, ethambutol was certainly implicated to cause DRESS syndrome.