IntroductionOver-the-counter (OTC) use of antibiotics contributes to the burgeoning rise in antimicrobial resistance (AMR). Drawing on qualitative research methods, this article explores the characteristics of OTC sales of antibiotic in Nepal, its drivers and implications for policy.MethodsData were collected in and around three tertiary hospitals in eastern, western and central Nepal. Using pre-defined guides, a mix of semi-structured interviews and focus group discussions were conducted with dispensers at drug stores, patients attending a hospital and clinicians. Interviews were audio-recorded, translated and transcribed into English and coded using a combination of an inductive and deductive approach.ResultsDrug shops were the primary location where patients engaged with health services. Interactions were brief and transactional: symptoms were described or explicit requests for specific medicine made, and money was exchanged. There were economic incentives for clients and drug stores: patients were able to save money by bypassing the formal healthcare services. Clinicians described antibiotics as easily available OTC at drug shops. Dispensing included the empirical use of broad-spectrum antibiotics, often combining multiple antibiotics, without laboratory diagnostic and drug susceptibility testing. Inappropriately short regimens (2–3 days) were also offered without follow-up. Respondents viewed OTC antibiotic as a convenient alternative to formal healthcare, the access to which was influenced by distance, time and money. Respondents also described the complexities of navigating various departments in hospitals and little confidence in the quality of formal healthcare. Clinicians and a few dispensers expressed concerns about AMR and referred to evadable policies around antibiotics use and poor enforcement of regulation.ConclusionsThe findings point to the need for clear policy guidance and rigorous implementation of prescription-only antibiotics.

Background: Acinetobacter baumannii is one of the major organisms causing nosocomial infections and is intrinsically resistant to multiple classes of antibiotics. The main objective of this study was to investigate the trend and characteristics of A. baumannii infections including its resistance pattern among patients attending Universal College of Medical Sciences, Teaching Hospital (UCMSTH) in Western Nepal, between January and December 2018. Patients and Methods: A total of 4862 clinical samples received at the microbiology laboratory of UCMSTH over a period of a year were analyzed. Following bacterial culture on the samples, culture-positive isolates were tested for antibiotic susceptibility using a modified Kirby-Bauer method. The demographic profile of the patient, information about samples, and the antibiotic profile of the A. baumannii isolated from different samples were recorded and analyzed. Results: A total of 1180 (24.2%; 1180/4862) organisms were isolated from the total samples. Acinetobacter baumannii (12.4%; 147/1180) was the third most common organism. Prevalence of A. baumannii was found to be high in late summer/early winter (July: 15.9%; 18/113 and December: 18.8%; 13/69). The majority 71.4% (n=105) of A. baumannii isolates were multidrug resistant (MDR). None of the isolate was pan-drug resistant. Colistin, polymyxin B, and tigecycline were 100% sensitive to A. baumannii. MDR bacteria were significantly associated with the gender of the patients [female: 51.4% (54/105) versus male: 48.6% (51/105); p=0.05], clinical specimens [swab: 40% (42/105) sputum: 21.9% (23/105) and urine: 10.5% (11/105); p=0.02] and different wards of the hospital [surgery: 30.5% (32/ 105); ICU: 21.9% (23/105) and medicine: 19.0% (20/105); p< 0.03]. Conclusion: The high burden of MDR Acinetobacter isolates in clinical specimens shows an alarming presence of antimicrobial resistance. Two-thirds of the specimens showed MDR and were associated with demographic and clinical characteristics of the patients. In the management of infectious diseases at UCMSTH, there should be a high suspicion of Acinetobacter infection, and isolation and treatment should be carried out based on an antibiotic susceptibility test.

Earthquakes are a major natural calamity with pervasive effects on human life and nature. Similar effects are mimicked by man-made disasters such as fuel crises and power outages in developing countries. Natural and man-made disasters can cause intangible human suffering and often leave scars of lifelong psychosocial damage. Lessons from these disasters are frequently not implemented. The main objective of this study was to review the effects of the 2015 earthquakes, fuel crisis, and power outages on the health services of Nepal and formulate recommendations for the future. The impacts of earthquakes on health can be divided into immediate, intermediate, and long-term effects. Power outages and fuel crises have health hazards at all stages. It is imperative to understand the temporal effects of earthquakes, because the major needs soon after the earthquake (emergency care) are vastly different from long-term needs such as rehabilitation and psychosocial support. In Nepal, the inadequate and nearly nonexistent specialized health care at the peripheral level claimed many lives during the earthquakes and left many people disproportionately injured. Preemptive strategies such as mobile critical care units at primary health centers, intensive care training for health workers, and alternative plans for emergency care must be prioritized. Similarly, infrastructural damage led to poor sanitation, and alternative plans for temporary settlements (water supply, food, settlements logistics, space for temporary settlements) must be in place where the danger of disease outbreak is imminent. While much of these strategies are implementable and are often set as priorities, long-term effects of earthquakes such as physical and psychosocial supports are often overlooked. The burden of psychosocial stresses, including depression and physical disabilities, needs to be prioritized by facilitating human resources for mental health care and rehabilitation. In addition, inclusion of mental health and rehabilitation facilities in government health care services of Nepal needs to be prioritized. Similarly, power outages and fuel crises affect health care disproportionately. In the current context where permanent solutions may not be possible, mitigating health hazards, especially cold chain maintenance for essential medicines and continuation of life-saving procedures, are mandatory and policies to regulate all health care services must be undertaken. (Disaster Med Public Health Preparedness. 2017;11:625-632).

BackgroundMultidrug resistant Staphylococcus aureus is common in both tertiary and primary health care settings. Emergence of methicillin resistance in S. aureus (MRSA) along with macrolide, lincosamide, streptogramin B (MLSB) has made treatment of Staphylococcal infection more challenging. The main objective of this study was to detect MRSA, MLSB (inducible; MLSBi and constitutive; MLSBc) resistant S. aureus using phenotypic methods and to determine their antibiogram.MethodsVarious samples were collected from 1981 patients who attended Lumbini Medical College and Teaching Hospital (LMCTH) during the period of 6 months from September 2015 to February 2016. Out of a total of 1981 samples, 133 S. aureus were isolated. Cefoxitin was used to detect MRSA by the disk diffusion test. Inducible clindamycin resistance (MLSBi) was detected by the D-zone test. The antibiotic profile of all isolates was tested by a modified Kirby Bauer disk diffusion method.ResultsAmong 133 S. aureus, there were 58 (43.6%) MRSA, 34 (25.6%) MLSBi and 30 (22.6%) MLSBc. Of a total of 64 MLSB, a significant proportion (62.5%) was MRSA (p < 0.001). Among 11 different antibiotics that were tested for S. aureus, MRSA showed significant resistance to 9 (p < 0.05) with the exception of vancomycin and linezolid. All the isolates were 100% sensitive to linezolid. MLSBi organisms were 100% sensitive to vancomycin and linezolid. Both MLSBi and MLSBc showed a higher degree of resistance to multiple antibiotics (p < 0.05).ConclusionsIsolation of MRSA, MLSBi and MLSBc were remarkably high. Routine use of simple and cost effective methods such as the disk diffusion test by cefoxitin for MRSA and the D-zone test for MLSBi organisms can easily identify these isolates. Antibiotic resistance profiles from this study can optimize the treatment of multi-drug resistant S. aureus.

The risk of secondary solid malignancies is increased after allogeneic hematopoietic stem cell transplantation (HSCT). The risk starts at about 10 years after HSCT and continues even 20 years later. The most common secondary malignancies include squamous cell carcinoma of skin, genitourinary tract and oral cavity; lung and breast cancers. The use of total body irradiation or conditioning chemotherapy, chronic graft-versus-host disease and duration since HSCT can influence the risk of secondary solid malignancies. Secondary solid malignancies are common causes of nonrelapse mortality in long-term survivors and may account for up to 10% of late deaths. Avoiding smoking, alcohol use and excess sun exposure may reduce the risk. Cancer prevention guidelines are largely consensus-driven and follow the recommendations for general population.