Summaryobjectives To assess over-the-counter antimicrobial dispensing by drug retailers in Kathmandu, Nepal, for rationality, safety, and compliance with existing government regulations.methods Standardized cases of dysuria in a young adult male and acute watery diarrhoea in a child were presented by a mock patient to retailers at 100 randomly selected pharmacies. Questions asked by retailers and advice and medications given at their initiative were recorded.results All retailers engaged in diagnostic and therapeutic behaviour beyond their scope of training or legal mandate. Historical information obtained by retailers was inadequate to determine the nature or severity of disease or appropriateness of antimicrobial therapy. 97% (95% CI ϭ 91.5-99.4%) of retailers dispensed unnecessary antimicrobials in diarrhoea, while only 44% (95% CI ϭ 34.1-54.3%) recommended oral rehydration therapy and only 3% (95% CI ϭ 0.6-8.5%) suggested evaluation by a physician. 38% (95% CI ϭ 28.5-48.2%) gave antimicrobials in dysuria, yet only 4% (95% CI ϭ 1.1-9.9%) adequately covered cystitis. None covered upper urinary tract or sexually transmitted infections, conditions which could not be ruled out based on the interviews, and only 7% (95% CI ϭ 2.9-13.9%) referred for a medical history and physical examination necessary to guide therapy.conclusions Although legislation in Nepal mandates a medical prescription for purchase of antibiotics, unauthorized dispensing is clearly problematic. Drug retailers in our study did not demonstrate adequate understanding of the disease processes in question to justify their use of these drugs. Risks of such indiscretion include harm to individual patients as well as spread of antimicrobial resistance. More intensive efforts to educate drug retailers on their role in dispensing, along with increased enforcement of existing regulations, must be pursued.

Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.

ObjectiveBacterial meningitis is a medical emergency associated with high mortality rates. Cerebrospinal fluid (CSF) culture is the “gold standard” for diagnosis of meningitis and it is important to establish the susceptibility of the causative microorganism to rationalize treatment. The Namibia Standard Treatment Guidelines (STGs) recommends initiation of empirical antibiotic treatment in patients with signs and symptoms of meningitis after taking a CSF sample for culture and sensitivity. The objective of this study was to assess the antimicrobial sensitivity patterns of microorganisms isolated from CSF to antibiotics commonly used in the empirical treatment of suspected bacterial meningitis in Namibia.MethodsThis was a cross-sectional descriptive study of routinely collected antibiotic susceptibility data from the Namibia Institute of Pathology (NIP) database. Results of CSF culture and sensitivity from January 1, 2009 to May 31, 2012, from 33 state hospitals throughout Namibia were analysed.ResultsThe most common pathogens isolated were Streptococcus species, Neisseria meningitidis, Haemophilus influenzae, Staphylococcus, and Escherichia coli. The common isolates from CSF showed high resistance (34.3% –73.5%) to penicillin. Over one third (34.3%) of Streptococcus were resistance to penicillin which was higher than 24.8% resistance in the United States. Meningococci were susceptible to several antimicrobial agents including penicillin. The sensitivity to cephalosporins remained high for Streptococcus, Neisseria, E. coli and Haemophilus. The highest percentage of resistance to cephalosporins was seen among ESBL K. pneumoniae (n = 7, 71%–100%), other Klebsiella species (n = 7, 28%–80%), and Staphylococcus (n = 36, 25%–40%).ConclusionsThe common organisms isolated from CSF were Streptococcus Pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Staphylococcus, and E. coli. All common organisms isolated from CSF showed high sensitivity to cephalosporins used in the empirical treatment of meningitis. The resistance of the common isolates to penicillin is high. Most ESBL K. pneumoniae were isolated from CSF samples drawn from neonates and were found to be resistant to the antibiotics recommended in the Namibia STGs. Based on the above findings, it is recommended to use a combination of aminoglycoside and third-generation cephalosporin to treat non–ESBL Klebsiella isolates. Carbapenems (e.g., meropenem) and piperacillin/tazobactam should be considered for treating severely ill patients with suspected ESBL Klebsiella infection. Namibia should have a national antimicrobial resistance surveillance system for early detection of antibiotics that may no longer be effective in treating meningitis and other life-threatening infections due to resistance.

Although some hospital-based data are available, there are no large scale or nationwidedata available on the problem of pesticide poisoning in Nepal. This study wasdone to fill up this gap to some extent and was carried out at five major hospitals ofNepal - Bir Hospital, Patan Hospital and Tribhuvan University Teaching Hospital(TUTH) in Kathmandu, Western Regional Hospital (WRH) in Pokhara, and B. P.Koirala Institute of Health Sciences (BPKIHS) in Dharan. A harmonized PesticideExposure Record (PER), which was finalized during the "WHO Regional Workshopon Pesticide Poisoning Database in SEAR Countries" held in 1999 in Delhi,1 was usedin the study. Data collection was done for a period of six months in each of the fivehospitals.Altogether there were 256 patients in the present study. There were 98 patients fromBir hospital, 48 from Patan hospital, 45 from TUTH, 36 from BPKIHS, and 29 fromWRH. Of the 256 patients, 112 were males and 144 females. The most common agegroup involved in pesticide poisoning was 15-24 years. In most of the cases patient'sarrival to hospital was within three hours after pesticide exposure. In the majority ofcases the nature of exposure was intentional and the route of exposure oral. Mostpoisonings occurred in urban set-up and at home.Organophosphorous compounds were found to be the most common pesticides involved(in >50% cases), followed by zinc phosphide and aluminium phosphide. All caseswere given first aid treatment in the Emergency Room of the study hospitals, followingwhich most of the cases (n=197) were admitted; the rest were discharged or referredto other hospitals. Systemic effects of poisoning were recorded to have been present in95% of cases. For nearly two-third (65.6%) of the cases the poisoning severity scorewas recorded in the PER as "moderate" or "severe." More than 16% of patients hadfatal outcome.Improved regulation on availability of pesticides, strict registration of vendors,modification in packaging of pesticides, adequate provision of information to thepublic, further research on pesticide poisoning (including community-based studies),creation and regular revision of national/local standard treatment guidelines (STGs),regular training of health care providers based on such STGs, better availability ofdrugs/antidotes, establishment of poison information centers, and enhanced regionallinkages are some of the measures that will help reduce the problem of pesticidepoisoning in Nepal.Key Words: Pesticide poisoning, Organophosphates, Zinc phosphide, Aluminiumphosphide, Pesticide exposure record, Hospital, Nepal.

The multi-faceted complexities of antimicrobial resistance (AMR) require consistent action, a multidisciplinary approach, and long-term political commitment. Building coalitions can amplify stakeholder efforts to carry out effective AMR prevention and control strategies. We have developed and implemented an approach to help local stakeholders kick-start the coalition-building process. The five-step process is to (1) mobilise support, (2) understand the local situation, (3) develop an action plan, (4) implement the plan, and (5) monitor and evaluate. We first piloted the approach in Zambia in 2004, then used the lessons learned to expand it for use in Ethiopia and Namibia and to the regional level through the Ecumenical Pharmaceutical Network [EPN]. Call-to-action declarations and workshops helped promote a shared vision, resulting in the development of national AMR action plans, revision of university curricula to incorporate relevant topics, infection control activities, engagement with journalists from various mass media outlets, and strengthening of drug quality assurance systems. Our experience with the coalition-building approach in Ethiopia, Namibia, Zambia, and with the EPN shows that coalitions can form in a variety of ways with many different stakeholders, including government, academia, and faith-based organisations, to organise actions to preserve the effectiveness of existing antimicrobials and contain AMR.

In 1994, a clinically oriented drug information unit was established at the Tribhuvan University Teaching hospital in Nepal, with a view to providing objective and independent information through a question-answer service and bulletin production. During the first 2 years of its service, the unit received a total of 674 encounters, with an average of 28 inquiries a month (range 13-42): about three-quarters (74.5%) of all the inquiries were from prescribing doctors, including 38.0% from specialist clinicians: about a quarter (24.6%) were related to patient problems. Most (86.8%) of the responses were provided within 24 h of the inquiry. Frequently encountered queries related to: pharmacotherapy of a disease or drug indication(s), adverse drug reactions, drug doses, availability, drug use in pregnancy, ingredient(s) of a proprietary product, precautions for use and drug interactions. Details of the inquiries received and the responses provided by the unit are documented in a standard question-answer form. The unit also carries out proactive dissemination of information through the publication and free distribution of a bimonthly bulletin which includes brief referenced reviews on drug- and therapeutics-related topics. Nepal- or the local situation-related write-ups are now being increasingly included in the bulletin. A users' survey carried out at the end of 1-year service indicated that the question-answer and bulletin production activities of the unit were well-perceived by its target audiences, i.e. the prescribing doctors and postgraduate medical students. Although Medline on CD-ROM and original journal articles available in the hospital library were consulted for answering a few of the questions, the vast majority of them could be adequately handled by consulting a limited number of well-known drug information books. Our experience indicates that in developing countries such as Nepal, where funds are often severely limited, a small-scale drug information centre, serving a local area, can be usefully initiated by a few motivated staff with a modest collection of about a dozen key reference books.

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ObjectivesA public-private partnership in Tanzania launched the accredited drug dispensing outlet (ADDO) program to improve access to quality medicines and pharmaceutical services in rural areas. ADDO dispensers play a potentially important role in promoting the rational use of antimicrobials, which helps control antimicrobial resistance (AMR). The study objectives were to 1) improve dispensing practices of antimicrobials, 2) build ADDO dispensers’ awareness of the consequences of misusing antimicrobials, and 3) educate consumers on the correct use of antimicrobials through the use of printed materials and counseling.MethodsOur intervention targeted ADDO dispensers and community members in Kilosa district. We promoted AMR awareness using posters hung in public places, health facilities, and ADDOs; sensitizing 84 health care providers on AMR issues; and providing training and on-site support for 124 ADDO dispensers to increase their AMR knowledge and dispensing skills. Baseline and endline assessments included direct observation of dispensers’ practices; interviews with ADDO dispensers (71 at baseline and 68 at endline) regarding dispensing experiences; 230 exit interviews with ADDO customers regarding use of antimicrobials during monitoring visits; and review of ADDO records. Indicators were based on product availability, dispensing practices, customers’ knowledge of how to take their medicines, and dispenser and public awareness of the AMR threat.ResultsAvailability of tracer antimicrobials increased by 26% (p = 0.0088), and the proportion of ADDOs with unauthorized items decreased from 53% to 13% (p = 0.0001). The percentage of ADDO dispensers following good dispensing practices increased from an average of 67% in the first monitoring visit to an average of 91% during the last visit (p = 0.0001). After the intervention, more dispensers could name more factors contributing to AMR and negative consequences of inappropriate antimicrobial use, and over 95% of ADDO customers knew important information about the medicines they were dispensed.ConclusionsProviding educational materials and equipping ADDO dispensers with knowledge and tools helps significantly improve community medicine use and possibly reduces AMR. The number of community members who learned about AMR from ADDO dispensers indicates that they are an important source of information on medicine use.