Favipiravir does not improve viral clearance in mild to moderate COVID-19 - A systematic review and meta-analysis of randomized controlled trials

Purpose

Favipiravir has been used in the therapy of COVID-19, including patients with mild to moderate symptoms in certain countries. The aim of our systematic review and meta-analysis was to investigate its efficacy and safety in mild-to-moderate COVID-19 infections.

Methods

The PubMed, Embase, Web of Science, and Cochrane databases were systematically reviewed for articles reporting the results of randomized controlled trials published until January 6, 2023, resulting in the identification of 20 eligible studies.

Results

There were no significant differences in viral clearance time (HR = 1.20, p = 0.09) compared to those without favipiravir therapy. However, in the subgroup analyses, favipiravir treatment significantly increased viral clearance by 59 % (HR = 1.59, p < 0.01) and 42 % (HR = 1.42, p < 0.01], I2 = 20 %) compared to the comparator group in patients with moderate severity of COVID-19 and in the inpatient care setting, respectively. Favipiravir had no beneficial effects in the case of patients with mild symptoms and treated in ambulatory care.

Conclusions

The use of favipiravir is questionable in the treatment of outpatients with COVID-19 with mild symptoms. Moderate beneficial effects in the case of patients with moderate symptoms and inpatients should be treated with care due to the limitations of the analysed trials.

Hungarian general practice paediatricians' antibiotic prescribing behaviour for suspected respiratory tract infections: a qualitative study

OBJECTIVES

Inappropriate antibiotic prescribing is a major cause of antimicrobial resistance (AMR). The aim of this study was to explore paediatric general practitioners' (GP Peds) antibiotic prescription practice in suspected respiratory tract infections (RTIs), using the capability-opportunity-motivation-behaviour framework.

DESIGN

The design is a qualitative study based on individual, semistructured telephone or virtual interviews.

SETTING

Paediatric general practice in Hungary. We applied stratified maximum variation sampling to cover the categories of age, sex and geographical location of participants.

PARTICIPANTS

We interviewed 22 GP Peds. Nine were male and 13 were female: 2 of them were less than 40 years old, 14 were between 40 and 60 years, and 6 were above 60 years. 10 worked in low-antibiotic prescription areas, 5 in areas with medium levels of antibiotic prescription, 3 in high-antibiotic prescription areas, and 4 in and around the capital city.

RESULTS

Study participants had varying antibiotic prescription preferences. Personal experience and physical examination play a central role in GP Peds' diagnostic and treatment practice. Participants emphasised the need to treat children in their entirety, taking their personal medical record, social background and sometimes parents' preferences into account, besides the acute clinical manifestation of RTI. Most respondents were confident they apply the most effective therapy even if, in some cases, this meant prescribing medicines with a higher chance of contributing to the development of AMR. Some participants felt antibiotic prescription frequency has decreased in recent years.

CONCLUSIONS

Our findings suggest that a more prudent attitude toward antibiotic prescribing may have become more common but also highlight relevant gaps in both physicians' and public knowledge of antibiotics and AMR. To reinforce awareness and close remaining gaps, Hungary should adopt its national AMR National Action Plan and further increase its efforts towards active professional communication and feedback for primary care physicians.

Trends and regional differences in antidiabetic medication use: a nationwide retrospective observational study

BACKGROUND

The prevalence of diabetes is increasing, and several new drug groups have been authorized and used successfully in the treatment of diabetes, while older drug groups are still in use. Our aim was to assess the utilization tendencies and regional differences in antidiabetic medication consumption in Hungary between 2015 and 2021 and to identify the possible determinants of regional differences in antidiabetic medication use.

METHODS

For this retrospective drug utilization study, yearly wholesale database was used, which provides total coverage for ambulatory antidiabetic drug sales in Hungary, including both reimbursed and non-reimbursed medications. Data were expressed as Defined Daily Dose per 1000 inhabitants per day (DDD/TID), percentage of total use and the ratio of the highest and lowest utilization values among the counties (max/min ratio). To assess the potential reasons for regional differences in antidiabetic drug use, we analyzed the associations between regional drug utilization data and possible determinants.

RESULTS

The total national antidiabetic medication use has increased by 7.6% and reached 94.8 DDD/TID in 2021. Regarding antidiabetic subgroups, the use of metformin and novel antidiabetics (DPP4Is, GLP1As and SGLT2Is) and their combinations increased in all counties, while sulfonylurea consumption decreased, and insulin use was stable. In 2021, 19.2-24.1% of the total antidiabetic medication consumption was novel antidiabetics, 39.1-47.2% metformin, 14.8-25.8% sulfonylureas and 23.6-30.5% were insulins. Regional differences in antidiabetic medication consumption were considerable mainly in the case of GLP1As (max/min ratio:3.00), sulfonylureas (2.03) and SGLT2Is (1.92) in 2021. The association between antidiabetic medication use and possible determinants was confirmed in the case of unemployment rate and sulfonylurea use, the number of public medical card holders per ten thousand inhabitants and human insulin and sulfonylurea use. GLP1As were the only antidiabetic drug group that did not correlate with any of the investigated factors.

CONCLUSIONS

Although novel antidiabetic drug use was growing dynamically in Hungary, sulfonylurea use is still considerable. Differences in antidiabetic drug consumption were substantial between the regions.

Storage Conditions Influence the Quality of Ginger - A Stability Study Inspired by Clinical Trials

Ginger has traditionally been used to treat and prevent nausea and vomiting; however, the results of clinical trials are ambiguous. The efficacy of ginger is attributed to gingerols and their metabolites, shogaols. Since these compounds have different pharmacological profiles, the clinical efficacy of ginger products is largely dependent on their chemical composition. The goal of our study was to examine the stability of ginger, determining the 6-gingerol contents in order to assess the effects of different storage conditions. We have performed a 6-month stability test with dry ginger rhizome samples stored in a constant climate chamber in three different storage containers (uncovered glass container, glass container sealed with rubber stopper, and plastic container). The 6-gingerol contents were measured by HPLC method. The concentration of 6-gingerol decreased in all samples. In the sealed glass container, the decrease in 6-gingerol content was significantly lower than in the unsealed glass container and in the plastic container. These results demonstrate that storage conditions have a significant impact on the quality of ginger, which may also affect efficacy.

Hospital Antibiotic Consumption before and during the COVID-19 Pandemic in Hungary

The aim of this study was to assess antibiotic use in the Hungarian hospital care sector during and before the pandemic. Aggregated systemic antibiotic (ATC: J01) utilisation data were obtained for the 2010-2021 period. Classifications and calculations were performed according to the WHO ATC/DDD index and expressed as DDD per 1000 inhabitants and per day (DID), DDD per 100 patient-days (DHPD) and DDD/discharge. A linear regression (trend analysis) was performed for the pre-COVID years (2010-2019) and a prediction interval was set up to assess whether the pandemic years' observed utilisation fit in. Antibiotic utilisation was constant in DID before and during the pandemic (2019: 1.16; 2020: 1.21), while we observed a substantial increase in antibiotic use when expressed in DDD per 100 patient-days (2019: 23.3, 2020: 32.2) or DDD/discharge (2019: 1.83, 2020: 2.45). The observed utilisation level of penicillin combinations; first-, third- and fourth-generation cephalosporins; carbapenems; glycopeptides; nitroimidazoles and macrolides exceeded the predicted utilisation values in both pandemic years. Before the pandemic, co-amoxiclav headed the top list of antibiotic use, while during the pandemic, ceftriaxone became the most widely used antibiotic. Azithromycin moved up substantially on the top list of antibiotic use, with a 397% increase (2019: 0.45; 2020: 2.24 DHPD) in use. In summary, the pandemic had a major impact on the scale and pattern of hospital antibiotic use in Hungary.

Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital

UTIs (urinary tract infections) are common bacterial infections with a non-negligible hospitalization rate. The diagnosis of UTIs remains a challenge for prescribers and a common source of misdiagnosis. This retrospective observational study aimed to evaluate whether recorded diagnosis by clinicians and empirical antibiotic therapy met the EAU (European Association of Urology) guideline in patients hospitalized with UTI. The study was conducted at an internal medicine unit of a tertiary care medical center in Hungary. The diagnosis was assessed based on clinical presentation, physical examination, and laboratory (including microbiological) results, considering all the potential risk factors. Diagnosis was considered misdiagnosis when not confirmed by clinical presentation or clinical signs and symptoms. Evaluation of empirical antibiotic therapy was performed only for confirmed UTIs. Empirical treatment was considered guideline-adherent when complying with the relevant recommendations. Out of 185 patients, 41.6% failed to meet EAU-based UTI diagnosis criteria, of which 27.6% were misdiagnosed and 14.1% were ABU (asymptomatic bacteriuria). The diagnosis of urosepsis recorded at admission (9.7%, 18/185) was not confirmed either by clinical or microbiological tests in five (5/18) cases. The initial empirical therapies for UTI showed a relatively low rate (45.4%) of guideline adherence regarding agent selection. The most common guideline-non-adherent therapies were combinations with metronidazole (16.7%). Dosage appropriateness assessments showed a guideline adherence rate of 36.1%, and underdosing due to high body weight was common (9.3%). Overall (agent, route of administration, dose, duration) guideline adherence was found to be substantially low (10.2%). We found a relatively high rate of misdiagnosed UTIs. Written protocols on the ward may be crucial in reducing misdiagnosis and in optimizing antibiotic use.

Multidisciplinary management of acute cholecystitis during the COVID-19 pandemic

The coronavirus disease 2019 pandemic had a major impact on most medical services. Our aim was to assess the outcome of acute cholecystitis during the nationwide lockdown period. All patients admitted to our emergency department for AC were analysed. Patient characteristics, performance status, AC severity, treatment modality and outcome of AC were assessed during the lockdown period (Period II: 1 April 2020-30 November 2021) and compared to a historical control period (Period I: 1 May 2017-31 December 2018). AC admissions increased by 72.8% in Period II. Patients were younger (70 vs. 74 years, p = 0.017) and greater in number in the CCI 1 group (20.4% vs. 11.2%, p = 0.043) in Period II. The unplanned readmission rate (6.3 vs. 0%, p = 0.004) and the gallbladder perforation (GP) rate was higher (18.0 vs. 7.3%, p = 0.006) in Period II. Percutaneous transhepatic gallbladder drainage (PTGBD) was more frequent (24.1 vs. 12.8%, p = 0.012) in Period II. In addition to a drop in patient age and CCI, a significant rise in the prevalence of acute cholecystitis, GP and unplanned readmissions was observed during the nationwide lockdown due to the COVID-19 pandemic. PTGBD was more frequent during this period, whereas successful conservative treatment was less frequent.

Results of a systematic review and meta-analysis of early studies on ivermectin in SARS-CoV-2 infection

Ivermectin, an antiparasitic drug, has been repurposed for COVID-19 treatment during the SARS-CoV-2 pandemic. Although its antiviral efficacy was confirmed early in vitro and in preclinical studies, its clinical efficacy remained ambiguous. Our purpose was to assess the efficacy of ivermectin in terms of time to viral clearance based on the meta-analysis of available clinical trials at the closing date of the data search period, one year after the start of the pandemic. This meta-analysis was reported by following the PRISMA guidelines and by using the PICO format for formulating the question. The study protocol was registered on PROSPERO. Embase, MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), bioRvix, and medRvix were searched for human studies of patients receiving ivermectin therapy with control groups. No language or publication status restrictions were applied. The search ended on 1/31/2021 exactly one year after WHO declared the public health emergency on novel coronavirus. The meta-analysis of three trials involving 382 patients revealed that the mean time to viral clearance was 5.74 days shorter in case of ivermectin treatment compared to the control groups [WMD = -5.74, 95% CI (-11.1, -0.39), p = 0.036]. Ivermectin has significantly reduced the time to viral clearance in mild to moderate COVID-19 diseases compared to control groups. However, more eligible studies are needed for analysis to increase the quality of evidence of ivermectin use in COVID-19.

[Deprescribing: an essential part of rational pharmacotherapy]

Deprescribing is a planned, systematic process supervised by a healthcare professional. It is considered to be a fundamental part of good prescribing. Deprescribing can be defined as the complete withdrawal of medications as well as dose reduction. The patient's health status, life expectancy, values, preferences and the therapeutic goals should be given serious consideration while planning the deprescribing process. The main objective of deprescribing may vary but reaching the patients' goals and improving their quality of life remain constant priorities. In our article, based on the international literature, we review potential deprescribing targets such as the characteristics of high-risk patients, medications that should prompt a therapy review and the ideal settings for deprescribing. We also cover the steps, risks and benefits of the process, and discuss the existing specific guidelines and algorithms. We provide information on the enablers and barriers of deprescribing among both patients and healthcare professionals, and discuss international initiatives as well as the future of deprescribing. Orv Hetil. 2023; 164(24): 931-941.

Impact of the COVID-19 Pandemic on Ambulatory Care Antibiotic Use in Hungary: A Population-Based Observational Study

The COVID-19 pandemic and related restrictions have potentially impacted the use of antibiotics. We aimed to analyze the use of systemic antibiotics (J01) in ambulatory care in Hungary during two pandemic years, to compare it with pre-COVID levels (January 2015-December 2019), and to describe trends based on monthly utilization. Our main findings were that during the studied COVID-19 pandemic period, compared to the pre-COVID level, an impressive 23.22% decrease in the use of systemic antibiotics was detected in ambulatory care. A significant reduction was shown in the use of several antibacterial subgroups, such as beta-lactam antibacterials, penicillins (J01C, -26.3%), and quinolones (J01M, -36.5%). The trends of antibiotic use moved in parallel with the introduction or revoking of restriction measures with a nadir in May 2020, which corresponded to a 55.46% decrease in use compared to the previous (pre-COVID) year's monthly means. In general, the systemic antibiotic use (J01) was lower compared to the pre-COVID periods' monthly means in almost every studied pandemic month, except for three months from September to November in 2021. The seasonal variation of antibiotic use also diminished. Active agent level analysis revealed an excessive use of azithromycin, even after evidence of ineffectiveness for COVID-19 emerged.

Conception and reality: Outcome of SARS-CoV-2 infection and vaccination among Hungarian IBD patients on biologic treatments

Introduction

Inflammatory bowel disease potentially elevates the risk of infections, independently from age, while the disease activity and medical treatment(s) can also increase the risks. Nevertheless, it is necessary to clarify these preconceptions as well during the COVID-19 pandemic.

Methods

An observational, questionnaire based study was conducted in Hungary between February and August 2021. 2 questionnaires were completed. The first questionnaire surveyed the impact of the pandemic on patients with biologic treatments and assessed the severity and outcome of the infection, whereas the second one assessed vaccination rate and adverse events.

Results

472 patients participated in the study. 16.9 % of them acquired the infection and 6.3 % needed hospitalization. None of them required ICU care. Male sex elevated the risk of infection (p = 0.008), while glove (p = 0.02) and mask wearing (p = 0.005) was the most effective prevention strategy. Nevertheless, abstaining from community visits or workplace did not have an impact on the infection rate. Smoking, age, and disease type did not elevate the risk. UC patients had poorer condition during the infection (p = 0.003); furthermore, the disease activity could potentially worsen the course of infection (p = 0.072). The different biological treatments were equally safe; no difference was observed in the infection rate, course of COVID-19. Azathioprine and corticosteroids did not elevate the infection rate. 28 patients (35.0 %) suspended the ongoing biologic treatment, but it had no impact on the disease course. However, it resulted in changing the current treatment (p = 0.004). 9.8 % of the respondents were sceptic about being vaccinated, and 90 % got vaccinated. In one case, a serious flare-up occurred.

Discussion

Most patients acquired the infection at workplace. Biologic therapies had no effect on the COVID-19 infection, whereas male sex, an active disease, and UC could be larger threat than treatments. Vaccination was proved to be safe, and patient education is important to achieve mass vaccination of the population.

Ustekinumab is associated with superior treatment persistence but not with higher remission rates versus vedolizumab in patients with refractory Crohn's disease: results from a multicentre cohort study

BACKGROUND

Treatment with antitumor necrosis factor alpha (anti-TNF-α) is safe and effective as first-line therapy; however, its efficacy is limited due to primary nonresponse (PNR) and secondary loss of response (LOR), resulting in treatment discontinuation in approximately 40%-50% of cases. Vedolizumab (VDZ) and ustekinumab (UST) therapies could be good alternatives in patient with anti-TNF failure; however, no head-to-head randomized comparison of these drugs as second- or third-line treatments has been made.

OBJECTIVES

This study aimed to assess the treatment persistence and comparative effectiveness of UST and VDZ in patients with refractory Crohn's disease (CD).

DESIGN

In this nationwide retrospective study, patients with CD on UST or VDZ maintenance therapy were enrolled. Clinical data at baseline, after induction, and at week 52 were obtained.

METHODS

Clinical and biochemical activities as well as corticosteroid-free remission (SFR) rates were assessed, while concomitant medications, comorbidities, hospitalizations, and surgeries were recorded during the follow-up to detect any predictors.

RESULTS

A total of 161 UST- and 65 VDZ-treated patients completed the follow-up. No significant difference in clinical or biochemical remission rates was observed after induction between the two treatment groups; however, clinical remission rate at week 52 was higher in UST group. UST showed superior drug persistence than VDZ (86.5%, 57.9%, p < 0.0001). The drug type was predictive of clinical SFR at week 52 [p = 0.011, odds ratio (OR) = 2.39 with UST]. Drug failure rates were higher for VDZ than those for UST (PNR rates: 21.54% and 4.97%, respectively, p < 0.001, OR = 8.267, p = 0.001). LOR and escalations were more common during UST treatment (61.5% versus 36.9%, p < 0.001; 64.2% versus 23.1%, p < 0.001). Hospital and surgical admission rates did not differ significantly. Only one adverse event occurred with VDZ at week 20, which led to drug cessation.

CONCLUSIONS

VDZ and UST were safe and effective for treating patients with CD in whom anti-TNF therapy failed. UST showed superior drug persistence than VDZ, but dose escalation was more frequent. Biologicals used in lower treatment lines resulted in better drug persistence.

Trends in the hospital-sector consumption of the WHO AWaRe Reserve group antibiotics in EU/EEA countries and the United Kingdom, 2010 to 2018

BackgroundIn 2019, the World Health Organization published the 21st Model list of Essential Medicines and updated the Access, Watch Reserve (AWaRe) antibiotics classification to improve metrics and indicators for antibiotic stewardship activities. Reserve antibiotics are regarded as last-resort treatment options.AimWe investigated hospital-sector consumption quantities and trends of Reserve group antibiotics in European Union/European Economic Area countries and the United Kingdom (EU/EEA/UK).MethodsHospital-sector antimicrobial consumption data for 2010-2018 were obtained from the European Centre for Disease Prevention and Control. Antibacterials' consumption for systemic use (Anatomical Therapeutic Chemical classification (ATC) group J01) were included in the analysis and expressed as defined daily doses (DDD) per 1,000 inhabitants per day. We defined reserve antibiotics as per AWaRe classification and applied linear regression to analyse trends in consumption of reserve antibiotics throughout the study period.ResultsEU/EEA/UK average hospital-sector reserve-antibiotic consumption increased from 0.017 to 0.050 DDD per 1,000 inhabitants per day over the study period (p = 0.002). This significant increase concerned 15 countries. In 2018, four antibiotics (tigecycline, colistin, linezolid and daptomycin) constituted 91% of the consumption. Both absolute and relative (% of total hospital sector) consumption of reserve antibiotics varied considerably (up to 42-fold) between countries (from 0.004 to 0.155 DDD per 1,000 inhabitants per day and from 0.2% to 9.3%, respectively).ConclusionAn increasing trend in reserve antibiotic consumption was found in Europe. The substantial variation between countries may reflect the burden of infection with multidrug-resistant bacteria. Our results could guide national actions or optimisation of reserve antibiotic use.

Trends in Opioid Utilisation in Hungary, 2006-2020: A Nationwide Retrospective Study with Multiple Metrics

BACKGROUND

Opioid use is well-documented in several countries: some countries struggle with overuse while others have almost no access to opioids. For Europe, limited data are available. This study analysed Hungarian opioid utilisation in ambulatory care between 2006 and 2020.

METHODS

We obtained national drug utilization data on reimbursed opioid analgesics (ATC code: N02A) from a national health insurance database for a 15-year period. We investigated utilisation trends, using three volume-based metrics (defined daily dose per 1000 inhabitants per day (DID), oral morphine equivalent per 1000 inhabitants per day, packages dispensed per 1000 inhabitants per year). We stratified data based on administration routes, analgesic potency and reimbursement categories.

RESULTS

Total opioid utilisation increased during the study period according to all three metrics (74% in DID) and reached 5.31 DID by 2020. Upward trends were driven by an increase both in weak and strong opioid use (79% vs. 53%). The most commonly used opioids were fentanyl (in the strong category; 0.76 DID in 2020) and tramadol (in the weak category; 2.62 DID in 2020). Overall, tramadol was also the most commonly used opioid throughout the study period. Oral administration of opioid medications was dominant. Based on reimbursement categories, musculoskeletal pain was becoming a more frequent indication for opioid use (1552% increase in DID), while opioid use for cancer pain declined significantly during the study period (-33% in DID).

CONCLUSIONS

Our low utilisation numbers might indicate underuse of opioid analgesia, especially for cancer pain.

Impact of Guideline Adherence on Outcomes in Patients Hospitalized with Community-Acquired Pneumonia (CAP) in Hungary: A Retrospective Observational Study

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. This retrospective observational study evaluated the antibiotic prescription patterns and associations between guideline adherence and outcomes in patients hospitalized with CAP in Hungary. Main outcome measures were adherence to national and international CAP guidelines (agent choice, dose) when using empirical antibiotics, antibiotic exposure, and clinical outcomes. Demographic and clinical characteristics of patients with CAP in the 30-day mortality and 30-day survival groups were compared. Fisher’s exact test and t-test were applied to compare categorical and continuous variables, respectively. Adherence to the national CAP guideline for initial empirical therapies was 30.61% (45/147) for agent choice and 88.89% (40/45) for dose. Average duration of antibiotic therapy for CAP was 7.13 ± 4.37 (mean ± SD) days, while average antibiotic consumption was 11.41 ± 8.59 DDD/patient (range 1−44.5). Adherence to national guideline led to a slightly lower 30-day mortality rate than guideline non-adherence (15.56% vs. 16.67%, p > 0.05). In patients aged ≥ 85 years, 30-day mortality was 3 times higher than in those aged 65−84 years (30.43% vs. 11.11%). A significant difference was found between 30-day non-survivors and 30-day survivors regarding the average CRP values on admission (177.28 ± 118.94 vs. 112.88 ± 93.47 mg/L, respectively, p = 0.006) and CCI score (5.71 ± 1.85 and 4.67 ± 1.83, p = 0.012). We found poor adherence to the national and international CAP guidelines in terms of agent choice. In addition, high CRP values on admission were markedly associated with higher mortality in CAP.

Az antibiotikum ambuláns alkalmazásának jellemzői és tendenciái Magyarországon (2010–2019)

Összefoglaló. Bevezetés: Az antibiotikumok észszerű alkalmazása kulcsfontosságú a hatékonyságuk megőrzésében és a néhol kritikus méreteket öltő antibiotikumrezisztencia visszaszorításában. Célkitűzés: A hazai ambuláns antibiotikumfelhasználás jellemzőinek, trendjeinek bemutatása. Módszer: A 2010 és 2019 közötti időszakra vonatkozó, dobozszámban kifejezett ambuláns szisztémás antibiotikumfelhasználási adatokat – a WHO 2019. évi indexe alapján – „defined daily dose” (DDD – napi átlagdózis) egységbe konvertáltuk. Standardizált technikai egységünk a DDD/1000 fő/nap volt (DID). Az antibiotikumfelhasználás értékelésére nemzetközileg elfogadott minőségi indikátorokat alkalmaztunk. Eredmények: Az antibiotikumfelhasználás mértéke kismértékű ingadozást mutatott (min.: 12,9 DID, max.: 14,7 DID), viszont a szezonális ingadozás a teljes megfigyelt időszakban jelentős mértékű volt. A széles versus szűk spektrumú béta-laktámok és makrolidek felhasználási hányadosa évről évre tovább emelkedett (2010: 13,3 vs. 2019: 71,6), a fluorokinolonok alkalmazási aránya továbbra is meghatározó (2010: 14,3%, 2019: 14,5%). A vizsgált 12 minőségi indikátor közül a tanulmány nyitó évében 4, a tanulmány záró évében 6 indikátor esetében a legkedvezőtlenebbül teljesítő európai országok közé tartoztunk. Megbeszélés: A hazai antibiotikumalkalmazás mértéke európai mérce szerint nem magas, de csökkentésére látszik lehetőség; mintázata szuboptimális, és az évek során kedvezőtlen irányba változott. Következtetés: A kapott antibiotikumfelhasználási adatok s azok értelmezése alapján rendkívül sürgető morális kötelesség a szakmai és hatósági intervenciókra épülő hazai antibiotikumstratégia és -akcióterv mielőbbi kidolgozása, implementálása. Orv Hetil. 2022; 163(4): 140–149.

Summary. Introduction: Prudent antibiotic use is an important tool to preserve their effectiveness as well as reverse and confine antibiotic resistance. Objective: To evaluate the trends and characteristics of Hungarian outpatient antibiotic use. Methods: Crude, package level antibiotic sales data for the period 2010–2019 were converted into DDD (defined daily dose) and were standardized for 1000 inhabitants and per year (ATC-DDD index, version 2019). Internationally validated drug-specific quality indicators were used to evaluate antibiotic use. Results: The scale of antibiotic use was stagnating with minimal fluctuation (min.: 12.9 DID, max.: 14.7 DID), and with high intra-year seasonality index. The ratio of the consumption of broad to narrow spectrum beta-lactams and macrolides increased gradually from year to year (2010: 13.3 vs. 2019: 71.6) and the relative consumption of fluoroquinolones is still remarkable (2010: 14.3%, 2019: 14.5%). Out of the twelve surveyed drug-specific quality indicators in the first and last year of analysis, we were ranked among the weakest European countries in the case of four and six indicators, respectively. Discussion: The scale of Hungarian outpatient antibiotic use is not high, in European comperison, but has some reserve capacity for reduction. The pattern of Hungarian antibiotic use is suboptimal and had further decreased quality through the years. Conclusion: Based on the recorded data of antibiotic use and their interpretation, the development of national antibiotic strategy (including both professional and authority interventions) is a pressing moral obligation. Orv Hetil. 2021; 163(4): 140–149.

The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit

Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.

A comparison of the antimicrobial resistance of fecal Bacteroides isolates and assessment of the composition of the intestinal microbiotas of carbapenem-treated and non-treated persons from Belgium and Hungary

The antimicrobial susceptibilities of Bacteroides strains isolated from the feces of imipenem-treated patients from Belgium and Hungary were compared with those isolated from the normal microbiota from these two and five other European countries and assessed. Of the 10 antibiotics tested, highly significant differences were found with cefoxitin (decrease for Belgium and for this two and the five countries from the previous study), clindamycin (decrease for Belgium and for this two and the five countries from the previous study) and moxifloxacin (increase for Belgium and for this two and the five countries from the previous study) relative to normal microbiota strains reported earlier. Imipenem treatment brought about modest, but notable differences in the compositions of the microbiomes where there was less diversity in the treated group relative to the non-treated group.

Surgical outcome of percutaneous transhepatic gallbladder drainage in acute cholecystitis: Ten years' experience at a tertiary care centre

Background

Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies.

Patients and Methods

We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male–female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient’s performance status and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD were analysed.

Results

PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR 6.07; CI 1.79–20.56), clinical progression (OR 7.62; CI 2.64–22.05) and the need for emergency CCY (OR 14.75; CI 3.07–70.81) were mostly determined by AC severity grade.

Conclusion

PTGBD is an easy-to-perform intervention with promising clinical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality.

Evaluation of the conversion rate as it relates to preoperative risk factors and surgeon experience: a retrospective study of 4013 patients undergoing elective laparoscopic cholecystectomy

Background

Our aim is to determine the relationships among patient demographics, patient history, surgical experience, and conversion rate (CR) during elective laparoscopic cholecystectomies (LCs).

Methods

We analyzed data from patients who underwent LC surgery between 2005 and 2014 based on patient charts and electronic documentation. CR (%) was evaluated in 4013 patients who underwent elective LC surgery. The relationships between certain predictive factors (patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), acute cholecystitis (AC), abdominal surgery in the patient history, as well as surgical experience) and CR were examined by univariate analysis and logistic regression.

Results

In our sample (N = 4013), the CR was 4.2%. The CR was twice as frequent among males than among females (6.8 vs. 3.2%, p < 0.001), and the chance of conversion increased from 3.4 to 5.9% in patients older than 65 years. The detected CR was 8.8% in a group of patients who underwent previous ERCP (8.8 vs. 3.5%, p < 0.001). From the ERCP indications, most often, conversion was performed because of severe biliary tract obstruction (CR: 9.3%). LC had to be converted to open surgery after upper and lower abdominal surgeries in 18.8 and 4.8% cases, respectively. Both AC and ERCP in the patient history raised the CR (12.3%, p < 0.001 and 8.8%, p < 0.001). More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Conclusions

Patient demographics (male gender and age > 65 years), previous ERCP, and upper abdominal surgery or history of AC affected the likelihood of conversion. More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Determinants of influenza vaccine uptake and willingness to be vaccinated by pharmacists among the active adult population in Hungary: a cross-sectional exploratory study

Background

Many studies have addressed influenza vaccine uptake in risk-group populations (e.g. the elderly). However, it is also necessary to assess influenza vaccine uptake in the active adult population, since they are considered to be a high-transmitter group. In several countries pharmacists are involved in adult vaccination in order to increase uptake. This study therefore aimed to investigate the determinants of influenza vaccination uptake and examine the willingness to be vaccinated by pharmacists.

Methods

A cross-sectional study was conducted among Hungarian adults using a self-administered online questionnaire distributed via social media (Facebook). The questionnaire included five domains: demographics, vaccine uptake, factors that motivated or discouraged vaccination, knowledge and willingness of participants to accept pharmacists as influenza vaccine administrators. Descriptive statistics were applied and logistic regression was conducted to assess the possible determinants of vaccination uptake.

Results

Data from 1631 participants who completed the questionnaires were analysed. Almost 58% of respondents (944/1631) had occupational and/or health risk factors for influenza. Just over one-tenth (12.3%;200/1631) of participants were vaccinated during the 2017/18 influenza season, 15.4% (145/944) of whom had a risk factor for influenza. Approximately half of the participants (47.4%) believed that influenza vaccination can cause flu, and just over half of them (51.6%), were not knowledgeable about the safety of influenza vaccine ingredients. Logistic regression found that age, sex, health risk factor and knowledge on influenza/influenza vaccination were associated with influenza vaccination uptake (p < 0.05). The most frequently cited reason for having an influenza vaccination was self-protection (95.0%). The most common reason given for refusing the influenza vaccine was that the respondent stated they rarely had an infectious disease (67.7%). The number of participants who were willing to be vaccinated by pharmacists was two-times higher than the number of participants who were actually vaccinated during the 2017/18 influenza season.

Conclusion

Influenza vaccine uptake in the active adult population is low in Hungary. Public awareness and knowledge about influenza vaccination and influenza disease should be increased. The results also suggest a need to extend the role played by pharmacists in Hungary.

Efficacy, tolerability and safety of a split-dose bowel cleansing regimen of magnesium citrate with sodium picosulfate - a phase IV clinical observational study

BACKGROUND

There are contradictory results about the effect of magnesium citrate plus sodium picosulfate bowel cleansing agents on the fluid and electrolyte balance. Therefore, this study aimed to determine the efficacy, tolerability and safety of this medication in colonoscopy preparation.

METHODS

233 patients were enrolled in this phase IV prospective observational study. The effectiveness of bowel cleansing was assessed using the Boston Bowel Preparation Scale (BBPS). Adequate cleansing was defined as BBPS ≥ 6 and excellent cleansing as BBPS > 7. Tolerability was examined using a standardized questionnaire. In the safety analysis, the change of serum electrolytes levels and renal function during bowel cleansing was assessed.

RESULTS

Adequate and excellent bowel cleansing were achieved 94.85% and 72.96% of cases, respectively. None or very mild symptoms were reported in 47.21% of cases. Statistically significant changes occurred in serum potassium (4.38±0.43 vs. 4.25±0.43 mmol/L, p<0.0001), urea (4.86±1.37 vs. 3.84±1.43 mmol/L, p<0.0001) and creatinine (male: 81.07±16.02 vs. 84.54±15.11 μmol/L; female: 69.32±12.22 vs. 72.96±12.11 μmol/L, p<0.0001) levels during the colonoscopy preparation. However, the number of patients with values outside of the normal range increased significantly only in the case of serum urea (3.95% vs. 26.97%, p<0.0001).

CONCLUSION

Magnesium citrate with sodium picosulfate is outstandingly effective, well tolerated and a safe agent in colonoscopy preparation. It caused significant, but non-clinically relevant changes in serum electrolytes levels and renal function.

Prevalence and Antibiotic Resistance of ESKAPE Pathogens Isolated in the Emergency Department of a Tertiary Care Teaching Hospital in Hungary: A 5-Year Retrospective Survey

Antibiotic treatments initiated on Emergency Departments (ED) are empirical. Therefore, knowledge of local susceptibility patterns is important. Despite this, data on expected pathogens and their resistance profile are scarce from EDs internationally. The study aim was to assess the epidemiology and resistance patterns of bacterial isolates from a tertiary-care ED over 5 years, focusing on ESKAPE bacteria (including the Enterobacterales group). After removal of duplicates, n = 6887 individual bacterial isolates were recovered, out of which n = 4974 (72.22%) were ESKAPE isolates. E. coli was the most frequent isolate (2193, 44.1%), followed by the Klebsiella genus (664; 13.4%). The third most frequent isolate was S. aureus (561, 11.3%). In total, multi-drug resistance (MDR) was present in 23.8% and was most prevalent in A. baumanii (65.5%), P. mirabilis (42.7%), and K. pneumoniae (32.6%). MRSA was isolated in 19.6%, while ESBL-producing Enterobacterales in 17.7%, and these were associated with remarkably higher resistance to other antibacterials as well. Difficult-to-treat resistance (DTR) was detected in 0.5%. The frequent isolation of some ESKAPE bacteria and the detected considerable acquired resistance among ED patients raise concern. The revealed data identified problematic pathogens and will guide us to set up the optimal empiric antibiotic protocol for clinicians.

Use of Proton Pump Inhibitors in Hungary: Mixed-Method Study to Reveal Scale and Characteristics

Background

Due to their efficacy and tolerability, utilization of proton pump inhibitors (PPI) has significantly increased worldwide. Parallel to the clinical benefits, potential long-term side effects have been observed, which, along with increasing medical expenses and potential drug interactions, justifies the analysis of the trends of utilization.

Objective

The aim of the present study was to show the level, pattern, and characteristics of PPI use.

Methods

We assessed the nationwide use of proton pump inhibitors in ambulatory care based on aggregated utilization data from the National Health Insurance database. The annual PPI utilization was expressed as the number of packages and as number of DDDs per 1,000 inhabitants and per year. For 2018, we estimated PPI exposure as the number of packages and as the number of DDDs per user per year. The annual reimbursement costs of proton pump inhibitors were also calculated. Moreover, three patient-level surveys were carried out in non-gastroenterological inpatient hospital departments to reveal characteristics of proton pump inhibitor use, namely dose, duration, and indication.

Results

The PPI utilisation increased from 5867.8 thousand to 7124.9 thousand packages and from 41.9 to 50.4 DDD per 1,000 inhabitants and per day between 2014 and 2018. Nationwide data showed that 14% of the adult population was exposed to proton pump inhibitors in 2018, while among hospitalized patients, the prevalence of proton pump inhibitor use was between 44.5% and 54.1%. Pantoprazole was the most frequently used active ingredient, both in the nationwide data and in the patient-level surveys. In the patient-level survey in majority of patients (71.5%-80.0%) proton pump inhibitors were prescribed for prophylaxis. Many inpatients (29.4%-36.9%) used 80 mg pantoprazole per day. The average number of PPI packages per user was 6.5 in 2018 in the nationwide data. The duration of PPI therapy was typically between 1 and 5 years in the patient-level surveys and nearly 20% of the inpatients had been taking proton pump inhibitors for more than 5 years.

Conclusions

Our data suggests that Hungarian patients receive proton pump inhibitors in high doses and for a long time. Use of proton pump inhibitors beyond their recommended indications was also found.

Evaluating the distribution of the locations of colorectal cancer after appendectomy and cholecystectomy

Backgrounds

The number of appendectomies and cholecystectomies performed is gradually increasing worldwide. An increasing incidence of colorectal cancer (CRC) after appendectomy and cholecystectomy has been reported, but the location of tumors in certain segments of the colon and rectum after appendectomy and cholecystectomy is still uncertain. We aimed to evaluate the distribution of the locations of colorectal cancer after appendectomy and/or cholecystectomy in patients who underwent CRC surgery.

Methods

We reviewed the medical records of patients who had undergone CRC surgery between 2015 and 2017 for the presence of previous appendectomy/cholecystectomy. Data were collected from the Colorectal Data Base of the University of Szeged, Department of Surgery.

Results

Surgery for CRC was performed in 640 patients during the study period. Data of 604 patients were analyzed. Appendectomy was performed in 100 patients (16.6%), cholecystectomy in 65 (10.8%), and both interventions in 18 (3%) before the CRC surgery. Out of those patients who underwent appendectomy alone, 92 (92%) had undergone appendectomy more than 10 years before the CRC surgery. Also in these 100 patients, the prevalence of right-sided colon cancer (CC) was 35% (n = 35), in comparison with the prevalence among the 504 other patients (20.4%, n = 103). The prevalence of right-sided CC among patients who underwent cholecystectomy alone was 36.9% (n = 24), in comparison with 21.2% (n = 114) of the 539 other patients.

Conclusions

A significant left to right side shift in CRC was noted among patients who had previously undergone appendectomy/cholecystectomy. Because right-sided CC has a worse prognosis, the role of incidental appendectomy and routine cholecystectomy seems that need re-evaluation.

A Europe-wide assessment of antibiotic resistance rates in Bacteroides and Parabacteroides isolates from intestinal microbiota of healthy subjects

Here, we sought to assess the levels of antibiotic resistance among intestinal Bacteroides and Parabacteroides strains collected between 2014 and 2016 in Europe and also attempted to compare resistance levels between clinical and commensal isolates. Bacteroides and Parabacteroides isolates were recovered from faecal samples via the novel Bacteroides Chromogenic Agar (BCA) method. Antibiotic susceptibilities were determined by agar dilution for ten antibiotics. The values obtained were then statistically evaluated. Altogether 202 Bacteroides/Parabacteroides isolates (of which 24, 11.9%, were B. fragilis) were isolated from the faecal specimens of individuals taken from five European countries. The percentage values of isolates resistant to ampicillin, amoxicillin/clavulanate, cefoxitin, imipenem, clindamycin, moxifloxacin, metronidazole, tetracycline, tigecycline and chloramphenicol were 96.6, 4.5, 14.9, 2.0, 47.3, 11.4, 0, 66.2, 1.5 and 0%, respectively. These values are close to those reported in the previous European clinical Bacteroides antibiotic susceptibility survey except for amoxicillin/clavulanate and clindamycin, where the former was lower and the latter was higher in normal microbiota isolates. To account for these latter findings and to assess temporal effects we compared the data specific for Hungary for the same period (2014-2016), and we found differences in the resistance rates for cefoxitin, moxifloxacin and tetracycline.

The Role of Gram-Negative Bacteria in Urinary Tract Infections: Current Concepts and Therapeutic Options

Urinary tract infections (UTIs) are some of the most common infections in human medicine worldwide, recognized as an important public health concern to healthcare systems around the globe. In addition, urine specimens are one of the most frequently submitted samples for culture to the clinical microbiology laboratory, exceeding the number of most of the other sample types. The epidemiology, species-distribution and susceptibility-patterns of uropathogens vary greatly in a geographical and time-dependent manner and it also strongly correlated with the reported patient population studied. Nevertheless, many studies highlight the fact that the etiological agents in UTIs have changed considerably, both in nosocomial and community settings, with a shift towards "less common" microorganisms having more pronounced roles. There is increasing demand for further research to advance diagnostics and treatment options, and to improve care of the patients. The aim of this review paper was to summarize current developments in the global burden of UTI, the diagnostic aspects of these infectious pathologies, the possible etiological agents and their virulence determinants (with a special focus on the members of the Enterobacterales order), current guidelines and quality indicators in the therapy of UTIs and the emergence of multidrug resistance in urinary pathogens.

Use of glucose-lowering drugs in Hungary between 2008 and 2017: the increasing use of novel glucose-lowering drug groups

AIMS

To analyse glucose-lowering drug utilization, focusing on the novel glucose-lowering drug groups dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors, and the financial burden they entail.

METHODS

Crude reimbursed national drug utilization and expenditure data for the entire population of Hungary were obtained from the National Health Insurance Fund for the study period: 2008 to 2017. Data were analysed using the WHO's Anatomical Therapeutic Chemical Classification/defined daily dose system and were expressed in defined daily dose per 1000 inhabitants per day.

RESULTS

Total glucose-lowering drug consumption in Hungary showed an 18% increase over the study period, reaching 74.7 defined daily doses per 1000 inhabitants per day, while novel glucose-lowering drug use increased to 11.7 defined daily doses per 1000 inhabitants per day (16% of total glucose-lowering drug use) by 2017. Dipeptidyl-peptidase 4 inhibitor consumption grew to 7.4 defined daily doses per 1000 inhabitants per day by 2017. The most widely used dipeptidyl-peptidase 4 inhibitor was sitagliptin. Glucagon-like peptide-1 receptor agonists were used the least, but by 2017 rose to 1.5 defined daily doses per 1000 inhabitants per day, led by liraglutide. Sodium-glucose co-transporter-2 inhibitors appeared in the utilization data in 2014 and their consumption, mainly empagliflozin, reached 2.8 defined daily doses per 1000 inhabitants per day by 2017. The total expenditure on glucose-lowering drugs increased 94% between 2008 and 2017, and the total cost of novel glucose-lowering drug utilization comprised 44% of the total glucose-lowering drug expenditure in 2017.

CONCLUSIONS

Both the use of and the financial burden posed by novel glucose-lowering drugs in Hungary increased steadily between 2008 and 2017. This increase is expected to continue.

Vitex agnus-castus in premenstrual syndrome: A meta-analysis of double-blind randomised controlled trials

Although chasteberry (Vitex agnus-castus, VAC) has been studied in several clinical trials and available as medicine for the alleviation of premenstrual syndrome (PMS) symptoms, the efficacy of properly characterised preparations has not been assessed in meta-analyses. The aim of our work was to evaluate the efficacy of VAC in PMS. The meta-analysis was performed following the PRISMA guidelines using the PICOS format, taking into account the CONSORT recommendations. PubMed, Embase, the Cochrane Central Register of Controlled Trials and Web of Science were searched for studies on VAC. The analysis assessed the efficacy of properly characterised products VAC compared to a placebo for the alleviation of PMS symptoms in terms of responder rate, considering the decrease of Total Symptom Score or PMS Diary score. The random effects model was used to calculate summary relative risk (RR) and 95% confidence interval (CI). Only those randomised, double-blind, placebo-controlled trials were included that fulfilled the criteria of the CONSORT recommendations aiming at the proper characterization of herbal products. Out of the 21 clinical trials, three studies (520 females) fulfilled the inclusion criteria, comparing the efficacy of special extracts Ze 440 and BNO 1095 to a placebo for the treatment of PMS. VAC preparations were confirmed to be effective in the reduction of PMS symptoms: women taking VAC were 2.57 (95% CI 1.52-4.35) times more likely to experience a remission in their symptoms compared to those taking the placebo. Although several clinical trials have been carried out with VAC, the majority of the studies cannot be used as evidence for efficacy due to incomplete reporting, especially concerning the description of the used medication. More trials following the CONSORT recommendations are needed to assess the efficacy of VAC extracts.

Physical compatibility of MCT/LCT propofol emulsions with crystalloids during simulated Y-site administration

Objective

In intensive care units numerous drugs have to be infused simultaneously, resulting inline incompatibility. Propofol is formulated as a lipid emulsion and it is well known that electrolytes can affect the stability of an emulsion system. Our goal was to evaluate and to compare the physical compatibility of three commercial propofol lipid emulsions of different manufacturers, mixing them with the most commonly used crystalloids in intensive care units.

Methods

Simulated Y-site administration was accomplished by mixing the 2% MCT/LCT propofol emulsions with the commonly used crystalloids in the intensive care unit in a 1:1 ratio in a polypropylene syringe. The aliquot samples were evaluated immediately and at 15, 30, 60 and 120 min after preparation by visual observation, pH and droplet size measurement.

Results

There was no emulsion breakdown or any visible change during the study period. Mixing the propofols with crystalloids, 10% magnesium sulphate or 10% potassium chloride there was no significant change in the droplet size compared with the original propofol emulsions. A slight alteration in droplet size was noticed in a few of the propofol samples, when magnesium, potassium or both were the secondary additives to the crystalloids, but this is not considered clinically relevant.

Conclusion

The physical properties of emulsions are determined by component, therefore the compatibility data in literature has to be evaluated prudently. All three commercially available MCT/LCT propofol emulsions are considered physically compatible with the tested crystalloids.

Ginger (Zingiber officinale): An alternative for the prevention of postoperative nausea and vomiting. A meta-analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a distressing outcome related to surgeries. Traditionally, ginger has been used in the treatment of nausea and vomiting for thousands of years. Recently, several randomized, placebo-controlled clinical trials (RCTs) have been conducted to evaluate the efficacy of ginger in PONV.

PURPOSE

To systematically evaluate the efficacy of ginger on postoperative nausea and vomiting (PONV) compared to placebo, based on RCTs.

STUDY DESIGN

The meta-analysis was reported following the PRISMA guidelines using the PICO format, and it was registered with the PROSPERO register.

METHODS

PubMed, Embase, the Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant studies. Human, placebo-controlled clinical studies of patients undergoing any types of surgery, receiving pharmacological doses of ginger per os were included. Only clinical trials with explicit description of the ginger preparation used were analysed. No language or publication year restrictions was applied.

RESULTS

Ten randomized trials including a total of 918 patients were pooled for the statistical analysis. The present meta-analysis supports that ginger has a significant effect on the severity of PONV based on visual analogue scale (VAS) results: in a fixed effects model the pooled standardized mean difference (SMD) was -0.247 (favouring ginger; [LL]: -0.455, [UL]: -0.040, p-value: 0.019). Moreover, our results suggest that ginger reduces the incidence of postoperative nausea and vomiting, as well antiemetic drug demand; however, these effects are not statistically significant compared to placebo, which may be explained by underdosing.

CONCLUSIONS

According to our thorough meta-analysis ginger is safe and well tolerated, and decreases the severity of PONV, and may lower the incidence of postoperative nausea and vomiting, which in turn may reduce antiemetic drug demand, suggesting that ginger may be a useful alternative to antiemetic medications to alleviate PONV.

[Antibiotic use in the Hungarian hospitals in the last two decades (1996-2015)]

INTRODUCTION

Growing bacterial resistance threatens public health, which can be tempered by prudent antibiotic use.

AIM

To quantify systemic antibacterial use in Hungarian hospitals.

METHOD

Consumption data were analysed using the Anatomical-Therapeutic-Chemical - Defined Daily Dose (ATC/DDD) methodology. Data were standardized for patient turnover and also for population to enable international benchmarking.

RESULTS

Hospital antibiotic use was quite constant (22.4 ± 1.5 DDD/100 patient-days), but its composition changed substantially. The use of parenteral products rose gradually (in 1996 26.4% and in 2015 41.6%). The pattern of use was homogenised due to the headway of co-amoxiclav use. A substantial increase of fluoroquinolone (2.3 vs. 4.2 DDD/100 patient-days) and third generation cephalosporin (1.0 vs. 2.9 DDD/100 patient-days) use was detected. In parallel the use of narrow spectra penicillins diminished.

CONCLUSION

Hungarian hospital antibiotic use is low. The causes and the justification of this low use together with the internationally outstanding use of certain antibacterials should be addressed in future studies. Orv. Hetil., 2016, 157(46), 1839-1846.

Medication use and risk of falls among nursing home residents: a retrospective cohort study

Background Geriatric falls are leading causes of hospital trauma admissions and injury-related deaths. Medication use is a crucial element among extrinsic risk factors for falls. To reduce fall risk and the prevalence of adverse drug reactions, potentially inappropriate medication (PIM) lists are widely used. Objective Our aim was to investigate the possible predictors of geriatric falls annualized over a 5-year-long period, as well as to evaluate the medication use of nursing home residents. Setting Nursing home residents were recruited from the same institution between 2010 and 2015 in Szeged, Hungary. Method A retrospective epidemiological study was performed. Patient data were analysed for the first 12 months of residency. Chi-squared test and Fisher's-test were applied to compare the categorical variables, Student's t test to compare the continuous variables between groups. Binary logistic regression analysis was carried out to determine the association of falls with other variables found significant in univariate analysis. Microsoft Excel, IBM SPSS Statistics (version 23) and R (3.2.2) programs were used for data analysis. Main outcome measure Falls affected by age, gender, number of chronic medications, polypharmacy, PIM meds. Results A total of 197 nursing home residents were included, 150 (76.2%) women and 47 (23.8%) men, 55 fallers (annual fall prevalence rate was 27.9%) and 142 non-fallers. Gender was not a predisposing factor for falls (prevalence in males: 23.4 vs 29.3% in females, p > 0.05). Fallers were older (mean years ± SD; 84.0 ± 7.0) than non-fallers (80.1 ± 9.3, p < 0.01). The age ≥80 years was a significant risk factor for falls (p < 0.001). The number of chronic medications was higher in male fallers (12.4 ± 4.0) than in non-fallers (6.9 ± 4.2, p < 0.001). Polypharmacy (taking four or more chronic medications) was a significant risk factor of falls (p < 0.01). Those PIMs carrying fall risk were taken by 70.9% of fallers and 75.3% of non-fallers (p > 0.05). Taking pantoprazole, vinpocetine or trimetazidine was a significant risk factor for falls. Conclusion Older age, polypharmacy and the independent use of pantoprazole, vinpocetine, and trimetazidine were found to be major risk factors for falls. Further real-life epidemiological studies are necessary to confirm the role of particular active agents, and to help professionals prescribe, evaluate and review geriatric medication use.

Gender inequalities in the treatment of osteoporosis

INTRODUCTION

Our aim was to perform both gender- and age-specific analysis regarding the utilisation of anti-osteoporotic drugs in Hungary, between 2007 and 2011, and to compare our results with other European countries.

METHODS

The database of the Hungarian National Health Insurance Fund was screened for anti-osteoporotic medications, covering 100% of the Hungarian population (10 million people). ICD coding system (International Classification of Diseases) and WHO ATC/DDD methodology were used for medication screening and analysis.

RESULTS

In Hungary, the total bisphosphonate use was 6.66 DDD/TID (Defined Daily Dose/1000 inhabitants/day) in 2007, and 6.22 DDD/TID in 2011; the rate of bisphosphonate combinations slightly increased from 1.60 to 2.81 DDD/TID. The total vitamin D use almost doubled (13.73 DDD/TID in 2011), while the calcium supplementation tripled (4.47 DDD/TID in 2011), and so did the strontium ranelate utilisation (0.70 DDD/TID in 2011) within the investigated time period. Denosumab consumption was marginal. Male patients were disproportionately, 10-20 times undertreated in all age groups, and treatment choice was restricted among men. Several differences were seen in our results compared to those in Baltic countries, Finland and in Norway.

CONCLUSIONS

Men were significantly undertreated in all age groups, compared to women. The 10 to 20-fold difference calls attention to this unrecognised problem.

[Treatment practice of acute cystitis on the basis of national prescription data]

INTRODUCTION

Urinary tract infections are one of the common diseases in the primary health care.

AIM

To analyse patterns of ambulatory antibiotic use in acute cystitis.

METHOD

Antibiotic use data was based on national-level prescription turnovers. Patterns of antibiotic use were evaluated by prescribing quality indicators. The content of different national guidelines for treatment of acute cystitis and adherence to these guidelines were also evaluated.

RESULTS

For the treatment of acute cystitis quinolones were used predominantly. Norfloxacin (26%) and ciprofloxacin (19%) were prescribed most commonly. The use of internationally recommended agents such as sulphonamides, nitrofurans and fosfomycin shared 15%, 7% and 2%, respectively. The average adherence rate to national guidelines was 66% and certain weak points (e.g. controversial content) of the national guidelines were also identified.

CONCLUSIONS

Antibiotic use in acute cystitis seems to be suboptimal in Hungary. Considering actual local antibiotic resistance patterns, a new national guideline should be worked out for acute cystitis treatment.

[Evaluation of ambulatory antibiotic use in Hungary using drug-specific quality indicators]

INTRODUCTION

Rational use of antibiotics is an important tool in combating antibiotic resistance.

AIM

The aim of the authors was to evaluate the quality of ambulatory antibiotic use in Hungary.

METHOD

Crude antibiotic sales data for the period between 1996 and 2010 were converted into DDD (Defined Daily Dose) per 1000 inhabitants and per year. The recently developed and validated drug-specific quality indicators were used to evaluate antibiotic use.

RESULTS

Beside constant quantity (18.0±1.8 DDD/1000 inhabitants/day), the authors detected major changes in the composition of antibiotic use. Ratios of the consumption of broad to narrow spectrum beta-lactams and macrolides increased eight-fold (1996: 2.2 vs. 2010: 15.8) and consumption of fluoroquinolones tripled. Out of the ten surveyed drug-specific quality indicators, Hungary belonged to the European elite in case of three, while considering the remaining seven, Hungary ranked among the weak or weakest European countries.

CONCLUSION

In quantity Hungary an ambulatory antibiotic use resembles to Scandinavian countries while it mimics antibiotic consumption patterns of southern countries.

The First Steps Towards Fluoroquinolone Resistance in Hungarian Pneumococci

The incidence of fluoroquinolone resistance among Hungarian routine laboratory Streptococcus pneumoniae isolates, collected in 2000-2002, in common with other European countries, was very low; only 5/304 strains (1.64%) were resistant to ciprofloxacin (MIC = 4 microg/ml), and the other fluoroquinolones showed full efficacy. However, we could identify the Lys-137-Asp amino acid change, caused by a point mutation in the QRDR of the parC gene, in five strains. Additionally, we observed a definite shift in the minimum inhibitory concentrations (MICs) of all fluoroquinolones towards higher values throughout the study period. These two findings, coupled with the increasing consumption figures of fluoroquinolones, suggest that pneumococcal resistance looks poised to develop in Hungary.

Drug-related problems in the elderly

The aging population in developed countries is a growing problem nowadays. The burden on healthcare is particularly high, since the prevalence of the diseases, especially chronic diseases increases with age. Prevalence of polypharmacy is common among elderly patients. While comorbidities require usage of several active agents with evidence based indication, polypharmacy increases the likelihood of interactions and adverse drug reactions, reduces patient compliance, affects quality of life and puts a significant financial burden on the patient and society. In order to reduce drug-related problems among the elderly, different lists of potentially inappropriate drugs and doses were created. One of the earliest known lists is the “Beers criteria”. The use of listed drugs is risky and not recommended for elderly patients. Following foreign examples, a list was compiled and adapted to the Hungarian drug spectrum based on the main concerns and alternative therapeutic suggestions. Orv. Hetil., 2012, 153, 1926–1936.

Variations and determinants of antibiotic consumption in Hungarian adult intensive care units

PURPOSE

The aim of this work was to study the use of systemic antibacterials and its possible determinants in Hungarian intensive care units (ICUs).

METHODS

Hospital pharmacy. departments provided package level dispensing data for their corresponding ICU (2006). Data were converted into defined daily doses (DDDs) and expressed as DDD per 100 patient-days and DDD per 100 admissions. Antibiotics were ranked by volume of DDDs, and the agents responsible for 90% of total use (DU90%) were noted. To explore differences and relationships between antibiotic use and antibiotic policy elements/ICU characteristics, the analysis of variances or the Pearson correlation analysis was performed.

RESULTS

Valid data were obtained for 44 ICUs. Antibiotic use varied widely (from 27.9 to 167.8 DDD per 100 patient-days and from 104.7 to 1784.6 DDD per 100 admissions). In total, 11-34 different antibacterials per ICUs were used, of which, 5-15 were in the DU90% segment. The proportional use of parenteral agents ranged from 46.2 to 98.3%. The mean of overall antibiotic use was highest for penicillins with beta-lactamase inhibitors, followed by quinolones and third-generation cephalosporins. Of the studied factors, only the ICU category (i.e., level of care) showed significant association with total antibacterial use.

CONCLUSIONS

The striking differences in total antibiotic use and the extensive use of the oral agents in some ICUs may indicate room for improvement. As none of the antibiotic policy elements were accompanied by lower antibiotic use in the pooled analysis, it suggests that--beside the ICU category--other unrevealed factors determine antibiotic use.

Microbiological service for intensive care units in Hungary

Az intenzív osztályon az infekciók hatékony kezeléséhez elengedhetetlen a megbízható mikrobiológiai háttér, a mikrobiológiai leletek értékeléséhez infektológus vagy mikrobiológus szakember. A hazai felnőtt intenzív osztályok antibiotikum-politikájáról, mikrobiológiai hátteréről, infektológiai/mikrobiológiai konzultációs lehetőségeiről 97 kérdést tartalmazó kérdőív alapján készült felmérés. Az intenzív osztályok 62%-a (60/96) küldte vissza a kitöltött kérdőívet. A kérdésekre válaszoló osztályok 55%-ában működik az anyaintézetben mikrobiológiai laboratórium. Az antibiotikum-választáshoz a mikrobiológiai lelet szolgáltat elsősorban információt, míg a gyakori nosocomialis pneumoniák kórokozójának kimutatására szolgáló pozitív tenyésztésű alsó légúti minta eredménye hét közben 50%-ban, hétvégén <20%-ban érkezik optimális időben vissza az osztályokra. Az eredmények értelmezését segítő infektológus-mikrobiológus konzíliumra munkaidőben >90%-ban, munkaidőn kívül infektológus 70%-ban, mikrobiológus 55%-ban érhető el. Az osztályok közel fele veszi igénybe az infektológus, kevesebb mint egyharmada a mikrobiológus segítségét. A mikrobiológiai laboratóriumi diagnosztikai háttér messze nem optimális a magyarországi intenzív osztályok esetében, ezt a működési minimumfeltételek sem írják elő. Nagyon kevés a személyes szakmai konzultáció lehetősége is.

[The participation of pharmacist in antibiotic related activities of Hungarian hospitals and intensive care units]

The present paper describes the antibiotic related activities of Hungarian adult intensive care units (ICUs) and their parent hospitals, specially focusing on the role of hospital pharmacists. Information was gathered by a structured questionnaire, which was sent to the head of ICU departments by post and by email. The multidisciplinary team of authors developed and validated the questions. Results were compared to recommendations set up by the Antibiotic Resistance Prevention And Control (ARPAC) project. Minimal requirements appointed by the ARPAC have not been fulfilled by many aspects: multidisciplinary hospital commitees were not realized and the activity of these committees in antibiotic guideline developments was not satisfactory. Continuous education and calculation of standardized antibiotic use was rarely performed at ICUs. The role of pharmacist remained marginal in every field. All these findings suggest the need for appointment of a responsible, multidisciplinary antibiotic manamement team including also a pharmacist.

[Analysis and interpretation of non-reimbursed antibiotic use data in Hungary]

The present paper describes one special field of the Hungarian ambulatory care antibiotic consumption: it focuses on the non-reimbursed antibiotic use and interprets it by using different measurement units, including the WHO recommended DDD per 1000 inhabitants and per day. The most commonly dispensed active agents belonged to the penicillin, tetracycline or sulfonamide antibacterial groups. Although the non-reimbursed antibiotic use increased during the study period, it was still low in 2004, representing approximately 2% of total Hungarian ambulatory care antibiotic use. Our study also revealed interregional differences in the non-reimbursed antibiotic use, which was outstanding in some western Hungarian counties.