Presurgical Antibiotic Prophylaxis Pattern In An Indian Tertiary Care Teaching Hospital

Authors: Rupinder Kaur, Mohd Tariq Salman, Narendra K. Gupta, Uma Gupta, Ali Ahmad, Vinod K. Verma

The present study was performed to study the antibiotic prophylaxis pattern in patients admitted in Surgery and Obstetrics and Gynaecology wards of a Tertiary Care Teaching hospital in North India. It was an observational, non interventional and analytical study used to evaluate the patients undergoing surgery through period of one and half years. Information concerning demographic data, type of surgery, and parameters of antibiotic therapy (selection of antibiotic, dose, route and duration of therapy as well as cost) was collected from case records of 400 patients. Third generation cephalosporins were the most commonly prescribed class of antibiotics. No consistency was noted in the timing of administration of prophylactic antimicrobials agents which were prescribed 30 minutes to 6 hours before surgery. The dose was not repeated during surgery. Majority of antibiotics were prescribed from Essential Medicines List. Surgical prophylaxis was inappropriate in terms of choice of antimicrobial agent, timing of administration as well as the total duration of prescription, in majority of the cases. Interventions are warranted to promote the development, dissemination and adoption of evidence based guidelines for antimicrobial prophylaxis.

JK Science Vol. 17 No. 2, April - June 2015

Top Ten Health Stories of the Year 2010

The year 2010 saw a lot of ‘hustle and bustle’ in the medical circle. Here are the Top 10 stories as viewed by eMedinewS.

1. Overhauling of Medical Council of India: The major story of the year was the arrest of MCI President Dr. Ketan Desai, dissolution of the MCI; appointment of six out of seven Board of Governors; subsequent release of Dr. Ketan Desai on bail, common entrance exam for MBBS; reduction in forensic faculty requirement; increase in retirement age to seventy and the suspense behind 7th seat of Board of Governors etc.
2. Medical Council of India action against Indian Medical Association: MCI took action against the IMA President and Secretary for violation of MCI Ethics on the ground that IMA should not have endorsed Pepsi products. The IMA had to approach High Court to take a stay. The matter is now in the High Court. Is that a start of MCI actions against ethics violations? Will it act against the cut system?
3. Delhi Bug: A huge controversy arose when British Medical Journal broke a story about NDM1 bug being named after New Delhi. The medical circle in India said that it was unfair and was an attempt to sabotage the medical tourism in India. The new bug is a gram negative bacteria showing resistance to all present antibiotics. New Delhi metallo–beta–lactamase (NDM–1) is an enzyme that makes bacteria resistant to a broad range of beta–lactam antibiotics. These include the antibiotics of the carbapenem family, which are a mainstay for the treatment of antibiotic–resistant bacterial infections. The gene for NDM–1 is one member of a large gene family that encodes beta–lactamase enzymes called carbapenemases. Bacteria that produce carbapenemases are often referred to in the news media as “superbugs” because infections caused by them are difficult to treat. Such bacteria are usually only susceptible to polymyxins and tigecycline. NDM–1 was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008. It was later detected in bacteria in India, Pakistan, the United Kingdom, the United States, Canada, Japan and Brazil. The most common bacteria that make this enzyme are Gram negative such as Escherichia coli and K. pneumoniae, but the gene for NDM–1 can spread from one strain of bacteria to another by horizontal gene transfer.
4. H1N1 havoc: H1N1 created great havoc, but ultimately, proved to be a ‘much hyped’ virus with mortality even lower than the regular human flu virus. Most of the hospitals who had started special H1N1 virus wards, now do not have these wards.
5. Chikungunya epidemic: The latest epidemic in the North India was that of Chikungunya with patients presenting with fever, rash and joint pains. It complicated the pre–existing dengue epidemic in the society.
6. Dengue with a difference: This year dengue was different than other years, came with more GI symptoms, pancreas involvement, dengue hepatopathy and lot of skin reactions. The platelet count dropped to less than 10000 but most required no platelet transfusion.
7. Diabetes diagnosis: The year saw a new advancement where A1C is to be used for diagnosis of diabetes and not fasting sugar. An A1C >6.5% means diabetes.
8. New pill for HIV prevention: A new pill is now available for HIV prevention along with condoms. It is to be used before the act and continues for seven days. In a trial involving nearly 2,500 HIV–negative, but high risk, gay men in six countries, researchers found that a combination antiretroviral pill (tenofovir and emtricitabine) reduced the risk of HIV infection by 44%, compared with placebo. When scientists looked more carefully at the study volunteers who took the medication most faithfully, on a daily basis, they found that the risk of contracting HIV was even lower — 73% lower than the placebo group. More studies will need to confirm the benefit of antiretrovirals in the prevention of HIV, and public health experts warn that even if the results hold up, it would not replace the best method of prophylaxis: safe sex and consistent use of condoms. That’s because the way so–called pre–exposure prophylaxis, or PrEP, works is to load up high–risk people with HIV–disabling antiretroviral drugs before exposure to the virus, which allows the medication to hit HIV as early as possible. But the drugs do not work as a vaccine would, by priming the immune system to actually prevent infection.
9. National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) started in the country:At last, Govt. of India, Ministry of Health and Family Welfare has started the above program.
10. New drug for premature ejaculation: The year ended with the launch of an SOS drug for premature ejaculation. This will be breakthrough for the community. Premature ejaculation, the most common sexual problem apart from erectile dysfunction, has been often found to put marriages under strain. While the existing drugs, which are not specific to treat premature ejaculation, need to be taken regularly, the new pill can be popped just a few hours before intercourse. It works by altering levels of serotonin, a chemical in the brain. The drug, dapoxetine, comes from a family of drugs called selective serotonin reuptake inhibitors, which block the reabsorption of the neurotransmitter serotonin.

Treatment of Swine flu Influenza

Antiviral Treatment:

• Should be considered for confirmed, probable, or suspected cases of swine flu virus infection.
• Oseltamivir and zanamivir should be initiated as soon as possible after the onset of symptoms.
• Recommended duration of treatment is five days.
• Doses recommended for treatment are the same as those recommended for seasonal influenza.
• Oseltamivir use in children <1 year old was recently approved by the FDA under an Emergency Use Authorization (EUA).
  

Antiviral Chemoprophylaxis:

• Chemoprophylaxis is recommended for:
  • Household close contacts who are at high-risk for complications of influenza (eg, certain medical conditions, persons ≥65 years old, children <5>
  • School children who are at high-risk for complications of influenza and who had close contact with a confirmed, probable, or suspected case.
  • Travelers to Mexico who are at high-risk for complications of influenza.
  • Healthcare workers and public health workers who were not using appropriate protective equipment during close contact with an ill confirmed, probable, or suspected case during the infectious period.
• Chemoprophylaxis (pre-exposure) may be considered for:
  • Healthcare workers at high-risk for complications of influenza and who are working in areas that contain patients with confirmed illness or who are caring for patients with acute febrile respiratory illness.
  • Non-high risk persons who are travelers to Mexico, first responders, or border workers who are in areas with confirmed cases.
• Oseltamivir or zanamivir may be used.
• Post-exposure: duration of chemoprophylaxis is 10 days after last known exposure to ill confirmed case.
• Pre-exposure: chemoprophylaxis should be given during potential exposure period and for 10 days after last known exposure.
• Oseltamivir may be used for chemoprophylaxis in children <1>

level of swine influenza pandemic alert raised from phase 3 to phase 4

Human cases of swine influenza A/H1N1 virus infection also have been confirmed internationally: US has reported 40, Canada has reported 6 confirmed human cases of infection; Spain has reported 1 case; Scotland has reported 2 cases. Mexico has reported 26 cases of infection, including 7 deaths.

On the advice of the Emergency Committee of the World Health Organization, the Director-General has raised the level of influenza pandemic alert from phase 3 to phase 4. The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable.

The Emergency Committee's recommendation is based on the available data on confirmed outbreaks of A/H1N1 swine influenza in the United States, Mexico, and Canada. The Committee also considered reports of possible spread to additional countries.

The decision was based primarily on epidemiological data demonstrating human-to-human transmission and the ability of the virus to cause community-level outbreaks.

Given the widespread presence of the virus, the Director-General considered that containment of the outbreak is not feasible. The current focus should be on mitigation measures.

In Mexico, the suspected number of cases is reportedly as high as 1,600, and the suspected number of deaths in Mexico is up to 80. Potential new cases also have been reported in France, Hong Kong, and New Zealand. These numbers and reports are not yet confirmed.

Laboratory testing has found the swine influenza A/H1N1 virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir.

New subtype of influenza virus - Swine influenza

The Centers for Disease Control and Prevention (CDC) report laboratory-confirmed human cases of swine influenza A/H1N1. Human cases of swine influenza A/H1N1 virus infection also have been identified internationally.

Based on preliminary testing, the virus is being described as a new subtype of A/H1N1 not previously detected in swine or humans.

Laboratory testing has found the swine influenza A/H1N1 virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir. According to Anne Schuchat, MD, the CDC's Interim Deputy Director for Science and Public Health Program, treatment should begin within 48 hours of onset. Vaccine development is in process, but it will take several months to prepare a vaccine.

CDC has issued interim recommendations for diagnostic testing and antiviral use, but local and state circumstances may vary and individual protocols may be put in place.

The CDC also has prepared interim guidance on how to care for people who are sick and interim guidance on the use of face masks in a community setting where spread of this swine flu virus has been detected. This is a rapidly evolving situation and CDC will provide new information as it becomes available.

The World Health Organization (WHO) reports that the government of Mexico also has reported several laboratory-confirmed cases of swine influenza A/H1N1. In a media briefing today, the CDC confirmed several swine influenza-related deaths as well. Investigation is continuing to clarify the spread and severity of the disease in Mexico. Suspect clinical cases have been reported in 19 of the country's 32 states.

Investigations are ongoing to determine the source of the infection and whether additional people have been infected with swine influenza viruses.

CDC is working very closely with officials in states where human cases of swine influenza A/H1N1 have been identified, as well as with health officials in Mexico, Canada, and WHO. This includes deploying staff domestically and internationally to provide guidance and technical support. CDC has activated its Emergency Operations Center to coordinate this investigation.

WHO and the Global Alert and Response Network (GOARN) are sending experts to Mexico to work with health authorities. WHO and its partners are actively investigating reports of suspect cases in other Member States as they occur and are supporting field epidemiology activities, laboratory diagnosis and clinical management.

Circumcision reduced the incidence of human immunodeficiency virus (HIV), HSV 2, HPV infections

Male circumcision significantly reduced the incidence of HIV and herpes simplex virus type 2 (HSV-2) infection and the prevalence of human papillomavirus (HPV) infection, suggesting potential public health benefits, according to the results of a randomized controlled trial reported in the March 26 issue of the New England Journal of Medicine.

"Male circumcision significantly reduced the incidence of...HIV infection among men in three clinical trials," write Aaron A.R. Tobian, MD, PhD, from Bloomberg School of Public Health, Johns Hopkins University in Baltimore, Maryland, and colleagues. "We assessed the efficacy of male circumcision for the prevention of...HSV-2 and...HPV infections and syphilis in HIV-negative adolescent boys and men."

Two trials of male circumcision to prevent HIV and other sexually transmitted infections in a rural Ugandan population enrolled a total of 5534 HIV-negative, uncircumcised male subjects aged 15 to 49 years. Of 3393 subjects (61.3%) who were HSV-2 seronegative at enrollment, 1684 had been randomly assigned to undergo immediate circumcision (intervention group) and 1709 to undergo circumcision after 24 months (control group). Subjects were tested for HSV-2 and HIV infection and syphilis and underwent physical examinations and interviews at baseline and at 6, 12, and 24 months. A subgroup of subjects was also evaluated for HPV infection at baseline and at 24 months.

The cumulative probability of HSV-2 seroconversion by 24 months was 7.8% in the intervention group vs 10.3% in the control group. High-risk HPV genotypes were present at 24 months in 18.0% of the intervention group vs 27.9% of the control group.

"In addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure," the study authors write. "These findings, in conjunction with those of previous trials, indicate that circumcision should now be accepted as an efficacious intervention for reducing heterosexually acquired infections with HSV-2, HPV, and HIV in adolescent boys and men. However, it must be emphasized that protection was only partial, and it is critical to promote the practice of safe sex."

Points to remember

• Uncircumcised men may be at higher risk for sexually transmitted infection because of greater exposure of the lightly keratinized inner preputial mucosa during intercourse, a higher risk for microtears, and a favorable environment in the subpreputial cavity for incubation of infection.
• In the current study, circumcision reduced the risk for infection with HSV-2 and HPV

(ClinicalTrials.gov numbers, NCT00425984 [ClinicalTrials.gov] and NCT00124878 [ClinicalTrials.gov] .)

Aaron A.R. Tobian et al. Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis. New England Journal of Medicine. 360 (13) :1298-1309, March 26, 2009