Short-term effects of antimicrobial stewardship programs on antibiotics usage, clinical outcomes, and multidrug resistant organisms in the post COVID-19 era

BACKGROUND

Antimicrobial resistance is associated with increasing mortality rates and the emergence of multidrug-resistant (MDR) organisms. There is scarcity of data on the short-term impact of Antimicrobial Stewardship Programs (ASP) on antibiotic usage, clinical outcome and MDR organisms' pattern following the COVID-19 pandemic. This study evaluated the short-term effects of ASP on antibiotic usage, clinical outcomes and MDR organisms' pattern in the post COVID-19 era.

METHODS

Conducted at a tertiary academic health center, this observational study involved adult patients (≥18 years) in the general medical unit, treated with oral or intravenous antibiotics from May 1, 2021, to April 30, 2022. The applied ASP strategy was a prospective audit and feedback where a weekly meeting was held to discuss the antimicrobial therapy of admitted patient, after which recommendations were made regarding antimicrobial use.

RESULTS

The study included 301 patients with 166 (55.1%) pre-ASP and 135 (44.9%) post-ASP. The median (IQR) age was 69 (55-77) years with 56.1% were female. Antibiotic usage dropped by 25.2% post-ASP. The length of hospital stay (LOS) was longer post-ASP (7 days vs. 7.9 days, p = 0.001), with MDR infections being a significant predictor (OR: 0.486, p < 0.001). There were no significant differences in 28-day readmission, recurrence of infections and all-cause mortality. Post-ASP, MDR pathogens increased (17.0% vs. 6.6%, p = 0.013), however, after separating post-ASP into two three-months periods, MDROs numbers decreased slightly (13 vs. 10).

CONCLUSION

Short-term ASP implementation post COVID-19 reduced antibiotic usage while other clinical outcomes remained unchanged. Nonetheless an increase in MDR pathogens and LOS was observed. Further research is required to assess ASP's long-term impact on MDR infections rates and specific patient group outcomes.

The Prevalence and Impact of Evidence-Based Medications on Cardiovascular and Cerebrovascular Outcomes in Patients with Acute Coronary Syndrome Post-Revascularization in Oman

OBJECTIVES

International cardiovascular guidelines recommend prescribing a combination of five evidence-based medications (EBM) for acute coronary syndrome (ACS) patients post-revascularization. This study aims to assess the prevalence and impact of prescribing the full (five medications) versus partial (four medications or fewer) EBM combination on major adverse cardiovascular and cerebrovascular events (MACCE) in patients with ACS post-revascularization.

METHODS

Data from patients with ACS who had revascularization between January 2016 and September 2021 were collected retrospectively. Patients were then followed up until March 2022 for MACCE.

RESULTS

The full EBM combination was prescribed to 70% of the patients. However, after taking into account the presence of contraindications and clinical factors, the actual adherence to the guidelines was 95%. Patients who received the full EBM combination were younger (58 versus 62 years; p = 0.0 and 3) and had lower rates of chronic kidney disease (11% versus 41%; p < 0.001) and heart failure (9% versus 20%; p = 0.012) when compared to patients who received the partial EBM. Compared to the partial EBM group, the full EBM group was associated with lower MACCE rates (54% versus 37%, p = 0.012). After employing the propensity score technique utilizing the 1:1 nearest neighbor matching method without replacement, the univariate findings were further re-affirmed with those on full EBMs (compared to those on partial EBMs) associated with a significant reduction in the MACCE rate (average treatment effect of -25%; 95% confidence interval: -10--40%; p = 0.001).

CONCLUSIONS

The full EBM utilization was significantly high in our setting and in line with international guidelines. The full EBM combination was predominantly prescribed in younger and less comorbid patients and was associated with lower MACCE rates. The findings were further reaffirmed by the propensity score matching method.

A snapshot on the usage pattern of gabapentinoids in Oman

Background

Since their introduction as adjunct anticonvulsants, the use of gabapentinoids (gabapentin and pregabalin) has increased substantially worldwide to include a wide range of clinical conditions. Various reports have demonstrated that they possess addiction liability and can produce effects similar to traditional recreational drugs, such as significant euphoric effects, enhanced sociability, and relaxation. However, there is limited information on the use of these agents in the Middle East.

Objectives

Here, we describe the usage pattern of gabapentinoids at Sultan Qaboos University Hospital, a tertiary care medical institution in Oman.

Methods

Adult patients (≥18 years) who were prescribed gabapentinoids for six months (March-August 2019) were included in this retrospective cross-sectional study. Indications and dosing regimens were reviewed according to the Food and Drug Administration labeling. Controlled and restricted drugs were reviewed using Oman National Formulary. Institutional ethical approval was obtained before conducting the study.

Results

We analyzed 291 prescriptions. The mean (standard deviation, SD) age was 60.5 years (SD = 13.0) with the age group of ≥60 years being the most common (190, 65.3%). Most of patients were females (178, 61.2%). The majority of prescriptions were for outpatients (85.8%). Drugs were prescribed as refill and follow-up in 116 (40.0%) and 97 (33.4%) of prescriptions, respectively. Diabetic peripheral neuropathy (50, 79.4%) was the most labeled indication for both. Off-label use was 128 (51.8%) and 31 (70.5%) for pregabalin and gabapentin, respectively, with lower back pain as being the most common indication for both drugs. A total of 54 (19.0%) patients were using at least one of the psychotropic drugs.

Conclusions

Our findings indicate that gabapentinoids are frequently prescribed for off-label use. Awareness programs and the establishment of policy for the use of these drugs are required to ensure their rational use and prevent misuse and/or abuse.

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Oman: utilization, reasons behind non-prescribing, and dose optimization

Background: Objective:

To determine the reasons behind guideline-directed medical therapy (GDMT) non-prescribing, drug utilization before and after excluding those intolerable to GDMT, as well as dose optimization in heart failure (HF) patients with reduced ejection fraction (<40%) (HFrEF) in Oman.

Methods:

The study included HF patients seen at the medical outpatient clinics at Sultan Qaboos University Hospital, Muscat, Oman, between January 2016 and December 2019 and followed up until the end of June 2021. The use of renin-angiotensin-system (RAS) blockers (angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNIs)), beta blockers and mineralocorticoid receptor antagonists (MRAs) were evaluated as per the European, American, and Canadian HF guidelines. Analyses were performed using univariate statistics.

Results:

A total of 171 HFrEF patients were enrolled for this study, the overall mean age of the cohort was 63 ± 15 years old and 59% were male. Over 65% of the patients had chronic kidney disease. Almost 55% of the patients were intolerable to GDMT. The proportion of patients on beta blockers, RAS blockers/ hydralazine-isosorbide dinitrate combination, and MRAs, before and after excluding those intolerable to GDMT, were 89%, 97%, and 77%, and, 94%, 47% and 85%, respectively, while the proportion of patients on the GDMT combination concomitantly was 41% and 83%, respectively. A total of 61%, 44% and 100% of the patients were prescribed ≥50% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively, while 19%, 8.2% and 94% of the patients attained 100% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively.

Conclusions:

Reasons behind GDMT non-prescribing were frequent and not clearly obvious in patients’ medical notes. The majority of the patients were prescribed GDMT. However, dose optimization, specifically for beta blockers and RAS blockers/ HYD-ISDN combination, was still suboptimal. The findings should be interpreted in the context of low study power and that future studies, with larger sample sizes, are warranted to minimize this limitation.

Appropriateness of antifungal prescribing in Oman

Background:

The inappropriate use of antimicrobials has substantially contributed to the development of antimicrobial drug resistance. Appropriate antibacterial prescribing has been emphasised, with minimal focus on appropriate prescribing of antifungals. Evaluation of antifungal use in the clinical setting is essential to prevent unnecessary drug exposure, development of resistance, adverse effects, and high hospitalisation costs.

Objective:

The purpose of this study was to assess the appropriateness of antifungal prescribing among adult patients at the Sultan Qaboos University Hospital (SQUH) in Oman.

Methods:

In this retrospective, observational study, the study population comprised adult patients treated with oral or intravenous antifungals between July 2018 and December 2019. The appropriateness of treatment was assessed using guidelines from the Infectious Diseases Society of America (IDSA) and the National Comprehensive Cancer Network (NCCN), as well as a set of literature-based criteria that were modified by SQUH infectious diseases team to suit local practices. These criteria included indication, dosage, and potential drug interactions. The primary outcome was the frequency of adherence to the treatment guidelines for fungal infections. Descriptive statistics were used for data analysis.

Results:

A total of 400 prescriptions were collected, of which 158 (39.5%) were for empirical therapy, 135 (33.8%) for targeted therapy, 69 (17.3%) for prophylactic therapy, and 38 (9.5%) for pre-emptive therapy. The overall appropriateness was 74.8%. The indication, dosage, and potential for antifungal-drug interactions were considered appropriate in 391 (97.8%), 314 (78.5%), and 381 (95.3%) prescriptions, respectively. Anidulafungin was the most prescribed antifungal agent, with 210 prescriptions (52.5%), followed by fluconazole with 102 prescriptions (25.5%), and voriconazole with 48 prescriptions (12%).

Conclusion:

In comparison with publised literature, our study revealed appropriate antifungal drug prescribing practices. However, studies with larger sample size in various hospital settings are necessary to confirm our findings on a national scale, and to obtain better statistical inferences and generalisability.

The Effects of Furosemide on Behavioral and Hormonal Parameters in Male and Female Mice Subjected to Immobilization and Cold-Water Stress

Introduction

The diuretic agent furosemide (FUR, 25 and 50 mg/kg) has been shown in a single report to act as an anti-stressor agent in two models of acute stress in mice, viz. electric foot-shock stress and immobilization (IMS). The present work aimed to investigate the possible anti-stressor action of FUR on two models of acute stress in mice, cold-water stress (CWS) and IMS, and tried to determine whether gender has any impact on the effect of FUR.

Methods

FUR (40 mg/kg) was injected intraperitoneally, and after 30 minutes, mice were subjected to CWS (4°C for three minutes) or IMS (fixing movement for two and a half hrs using adhesive tape). Motor and exploratory activities, neuromuscular coordination, and thermal nociception were then tested. Blood was collected from the mice and used to measure the concentrations of three stress hormones (corticosterone, epinephrine and prolactin).

Results

Mice subjected to CWS and IMS had significantly reduced motor and exploratory activities, neuromuscular coordination, and increased nociception. CWS and IMS also significantly increased the plasma concentrations of the three hormones. FUR pretreatment significantly mitigated these stress-induced hormonal changes. There was no significant sex difference when CWS or IMS was applied.

Discussion

IMS and CWS stimuli in male and female mice caused significant elevations in the plasma concentrations of corticosterone, epinephrine, and prolactin, accompanied by a significant reduction of motor and exploratory activities, neuromuscular coordination, and thermal nociception. There were no sex differences when IMS was applied. In stressed mice, prior administration of FUR (40 mg/kg) significantly decreased the concentrations of stress hormones, and this effect significantly mitigated the stress-induced behavioural and motor changes.

The salutary action of melatonin and betaine, given singly or concomitantly, on cisplatin-induced nephrotoxicity in mice

Cisplatin (CP) is commonly used in the treatment of various solid tumors. Its use, however, is hampered by nephrotoxicity. In this study, we compared the effect of betaine and melatonin given singly, with that of a combination of these two agents on CP-induced nephrotoxicity in mice. CP (20 mg/kg, given intraperitoneally on the 8th day of 12 days of the experiment) showed the typical physiological, biochemical, and histologic features of nephrotoxicity. CP-treated mice showed a significant reduction in food intake, body weight, and urine and fecal output. It also induced significant increases in the plasma concentrations of urea, creatinine, uric acid, phosphorous, adiponectin, interleukin-1β, interleukin-6, transforming growth factor -β1, tumor necrosis factor-α, and cystatin C. All these effects were significantly reduced by daily administration of betaine or melatonin at oral doses of 200 mg/kg and 10 mg/kg, respectively. Furthermore, using the two agents in combination caused further significant reductions in the above parameters. These findings suggest that betaine and melatonin concomitant use is likely to provide greater protection against CP-induced nephrotoxicity than when they are given singly, rendering them potentially suitable and safe agents to use in clinical trials to assess their possible beneficial actions in cancer patients receiving CP.

Effects of repeated increasing doses of cisplatin as models of acute kidney injury and chronic kidney disease in rats

Cisplatin (CP) is nephrotoxic, and this side effect is used as an animal model for acute kidney injury (AKI). Earlier research has been focused on CP-induced AKI, with relatively little attention being paid to its ability to progress to chronic kidney disease (CKD) on repeated administration. We aimed here to test the dose dependency of its nephrotoxic actions by comparing various physiological, biochemical, molecular, and histopathological indices using repeated increasing doses of CP in rats. Furthermore, we investigated whether these doses of CP would result in the development of CKD. Biochemical, molecular, and histopathological measurements were conducted in plasma, urine, and/or kidneys of rats treated with increasing doses of CP at 1.6, 3.2, and 4.8 mg kg-1 weekly for four consecutive weeks. These doses induced significant and dose-dependent elevations in most of the measured renal indices. These included increased renal fibrosis, as suggested histopathologically and biochemically by the significant increase in transforming growth factor-β1, significant decrease in actin alpha 2, and variable actions of collagen I and IV. CP also dose-dependently increased nuclear factor (erythroid-derived 2)-like 2 and caspase-3. Multiple repeated doses of CP (1.6 to 4.8 mg kg-1) induced multiple episodes of AKI, leading to CKD after the 4th weekly dose and confirmed that this dosage regimen could be used as an experimental animal model of AKI progressing to CKD. These actions were driven by inflammation, oxidative, and nitrosative stress.

The influence of the prebiotic gum acacia on the intestinal microbiome composition in rats with experimental chronic kidney disease

Chronic kidney disease (CKD) is a globally common and important disease and there are evidence for a bidirectional relationship between microbiota and CKD. The aim of the study was to examine the influence of prebiotic - gum acacia (GA) on the intestinal microbiota in rats with adenine-induced CKD. Animals were randomly distributed into four equal groups (n = 6): control, adenine, GA and adenine + GA groups. CKD was induced by adenine (0.75% w/w) given in the diet daily for four weeks, and GA was administered in drinking water at a concentration of 15% w/v. The 16s rRNA analysis was performed on Illumina Miseq targeting V3-V4 region to characterize microbial composition. The abundance of Actinobacteria, Proteobacteria, Tenericutes and Verrucomicrobia bacteria was increased in adenine-induced CKD, and GA treatment successfully reversed those levels. Interestingly, alpha and beta diversity index were both reduced with GA treatment in rats with CKD. Short chain fatty acids (SCFAs) measurement and PICRUSt analysis have shown that GA treatment completely restored the depleted butyrate level and various perturbated functional pathways, respectively, in CKD rats. Taking together, our results suggest that GA supplementation has a beneficial role in treating CKD, through an increased production of butyrate, as well as its anti-inflammatory, antioxidant capacity and anti-nitrosative properties.

Evaluation of guideline-based cardiovascular medications and their respective doses in heart failure patients in Oman

Background Significant gaps exist between guidelines and practice in the management of heart failure, not only in Oman but the Arabian Gulf region in general. Currently, only limited research exists on the use of these guideline-based cardiovascular medications and their corresponding target doses in the region. Objective To evaluate the use of guideline-based cardiovascular medications and their corresponding target doses in heart failure patients with reduced (< 40%) and mid-range (40-49%) ejection fraction in Oman. Setting Cardiology clinics at Sultan Qaboos University Hospital, Muscat, Oman. Methods The study included heart failure patients seen at the clinics between January 2016 and December 2019. The use of angiotensin-converting-enzyme inhibitors (captopril, lisinopril) or angiotensin II receptor blockers (irbesartan, valsartan), β-blockers (bisoprolol, carvedilol) and spironolactone along with their respective target doses were evaluated as per the European, American, and Canadian heart failure guidelines. Analyses were performed using univariate statistics. Main outcome measure The proportion of patients that was prescribed guideline-based heart failure medications along with their target doses as per guidelines. Results The overall mean age of the cohort (N = 249) was 63 ± 15 years and 61% (n = 151) were males. Seventy-one percent (n = 177) of the patients had heart failure with reduced ejection fraction while 29% (n = 72) had heart failure with mid-range ejection fraction. A total of 87% (n = 216), 62% (n = 154) and 39% (n = 96) of the patients were on β-blockers, angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers and spironolactone, respectively. Only 33% (n = 81) of the patients were on the triple guideline-based cardiovascular medication classes concurrently. Patients with reduced ejection fraction were more likely to be prescribed the triple guideline-based cardiovascular medication classes concurrently than those that had heart failure with mid-range ejection fraction (37% vs 22%; p = 0.027). A total of 100% (96/96), 56% (121/216) and 42% (64/153) of the patients were prescribed ≥ 50% of target dose for spironolactone, β-blockers and angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers, respectively. Conclusions The use of guideline-based cardiovascular medications in heart failure patients with reduced and mid-range ejection fraction is low in Oman. They were also largely not optimally dosed at target levels.

Effect of concomitant treatment of curcumin and melatonin on cisplatin-induced nephrotoxicity in rats

Cisplatin (CP) is a potent anticancer drug used to treat solid tumors. Its use, however, is dose-limited by its nephrotoxicity. We aimed to compare the effect of melatonin and curcumin given singly, with that of a combination of these two agents on CP-induced nephrotoxicity in rats. CP (6 mg/kg, given once intraperitoneally) induced nephrotoxicity as evidenced by several significant adverse physiological, biochemical and histopathological actions that included a reduction in body weight, increased urine production, and significant alterations in some conventional and novel renal damage indices in plasma, urine and kidneys. CP also elevated several pro-inflammatory cytokines and caused renal oxidative/nitrosative stress. Supplementation with either curcumin (200 mg/kg) or melatonin (10 mg /kg) given singly by oral gavage for eight consecutive days prior to CP injection and four days thereafter, significantly mitigated the adverse renal effects of CP, by attenuating the pro-inflammatory and apoptotic mediators and improving antioxidant competence in renal tissues of CP- treated rats. When curcumin and melatonin were given together, the ameliorative effect was augmented in some of the measured indices e.g. tumor necrosis factor alpha, cystatin C, uric acid, phosphorus in plasma and, urine creatinine and creatinine clearance. Renal platinum concertation was reduced more with curcumin than that with melatonin, while the reduction was maximized when both melatonin and curcumin were given. Pending further pharmacological and toxicological studies, a combination of these two agents is likely to be mor effective in mitigating the adverse renal effects of CP administered to cancer patients.

The Effect of Single or Multiple Doses of Grapefruit Juice on the Analgesic Effect of Ibuprofen in Mice

Grapefruit juice (GFJ) is a rich source of nutritional compounds but has been shown to alter the concentrations of several clinically useful drugs. Ibuprofen is a commonly used over-the counter-drug. Aim: This study aims to examine the effect of a single or multiple dose of GFJ on the analgesic effect of ibuprofen. Methodology: CD1 male mice were randomly distributed into four equal groups (n=9, each). The first group served as a control, the second group was given ibuprofen (100 mg/Kg) by oral gavage, the third group was given a single dose of GFJ (10 mg/Kg) by oral gavage followed by ibuprofen, and the fourth group was given a single dose of GFJ for five days and on the fifth day was given ibuprofen. The analgesic effect was tested using two methods with different mechanisms: thermal (hot plate) and chemical (acetic acid-induced abdominal constriction) pharmacologic stimuli models. Results: Both GFJ dosing regimen significantly increased the duration of abdominal constriction test when compared with ibuprofen group and did not exert any significant effect on the hot plate effect. This suggest that GFJ may affect the peripherally modulated analgesic effect of ibuprofen. Conclusion: The observed effect of GFJ on ibuprofen analgesic effect warrants further studies on their impact and clinical significance on humans.

Bacterial diversity, biogenic amines and lipids oxidation in traditional dried anchovy (Encrasicholina punctifer) during ambient storage

This study aimed to elucidate the effect of ambient storage (23±2°C, 68% RH) on the bacterial load and diversity, biogenic amines and lipids oxidation in traditional dried anchovy (E. punctifer) in order to evaluate its safety, quality and stability during 12 weeks of storage. Total aerobic bacteria (TAB), Staphylococcus aureus, Enterobacteriaceae (ENT), histidine decarboxylating bacteria (HDB), lysine decarboxylating bacteria (LDB) and ornithine decarboxylating bacteria (ODB) were enumerated and identified by conventional, VITEK 2 compact and sequencing of 16S rRNA gene methods. Histamine, cadaverine and putrescine contents were determined by high performance liquid chromatography. Lipid oxidation was evaluated by peroxide value (PV). Total aerobic bacteria, S. aureus, ENT, HDB, LDB and ODB initial counts of log10 4.9 ± 0.85, 3.7 ± 0.57, 4.2 ± 0.05, 3.7 ± 0.72, 3.9 ± 0.40 and 4.1 ± 0.24 CFU/g respectively did not significantly change (p > 0.05) during 12 weeks of storage. A high bacterial diversity of 27 species belonging to 20 genera was found, with the dominance of S. aureus, Acinetobacter lwoffii and S. warneri and the first incidence of Psychrobacter celer, Desemzia incerta, Granulicatella elegans and Bhargavaea indica in dried fish.  Initial histamine, cadaverine and putrescine contents and PV of 5.2 ± 4.3, 8.5 ± 1.9 and 5.8 ± 0.6 mg/100g and 0.19 ± 0.02 meq/kg respectively did not significantly change (p > 0.05) during 12 weeks of storage. This study found that ambient storage at 23±2°C, 68% RH for 12 weeks did not affect the bacterial load,  biogenic amines and lipids, and that the dried anchovy remained microbiologically safe and of good quality.

Gum arabic reduces inflammation, oxidative, and nitrosative stress in the gastrointestinal tract of mice with chronic kidney disease

The aim of this study was to investigate some biochemical indices of inflammation and oxidative and nitrosative stresses in the gastrointestinal tract of mice with experimental chronic kidney disease (CKD) and treated with gum arabic (GA). Male CD1 mice (n = 28) were randomly distributed into four groups and treated for four consecutive weeks: group 1: Control: received the same diet without treatment until the end of the study; group 2: Adenine: switched to a powder diet containing adenine (0.2% w/w in feed); group 3: Gum acacia (GA): given normal feed and GA in drinking water at a concentration of 15% w/v; and group 4: Adenine + GA: given adenine in the feed as in the second group plus GA in the drinking water at concentration of 15% w/v. CKD was induced to mice by adenine feeding and concomitantly treated with the prebiotic dietary fiber gum acacia, GA (15% in drinking water). Duodenal mucosa from CKD mice had significantly higher concentrations of TNF-alfa, IL- 6, and TGF-beta-1 and lipid peroxidation. Moreover, low concentrations of IL-10, some antioxidants (catalase, glutathione reductase, total antioxidant capacity, and superoxide dismutase), and nuclear factor erythroid 2-related factor 2 were found in the duodenum. The levels of nitrosative stress (nitrite, nitrate, and total nitrate) were significantly increased by CKD, as well as the concentrations of ammonia and urea creatinine in the cecal content. Concomitant GA treatment significantly mitigated these harmful effects. Taken together, GA reduces inflammation and duodenal oxidative and nitrosative stress in the gastrointestinal tract of mice with CKD.

The effect of sildenafil on rats with adenine-Induced chronic kidney disease

The erectile dysfunction drug sildenafil has cardiopulmonary protective actions, and a nephroprotective action in cisplatin and ischemia-reperfusion-induced acute kidney injury. Here, we assessed its possible ameliorative action in a model of chronic kidney disease (CKD) using adenine feeding. Eight groups of rats were treated with saline (controls), adenine (0.25% w/w in feed daily for 5 weeks), and oral sildenafil (0.1, 0.5 or 2.5 mg/kg), either alone, or concomitantly with adenine. Urine was collected 24 h after the end of the treatments from all rats and blood pressure measured, followed by collection of blood and kidneys for the measurement of several functional, biochemical and histopathological parameters. Adenine treatment reduced body weight, creatinine renal clearance, and increased water intake and urine output, as well as the plasma concentrations of urea and creatinine, neutrophil gelatinase-associated lipocalin, and N-acetyl-β-D-glucosaminidase activity, and albumin in urine. Adenine also increased the concentrations of the uremic toxins indoxyl sulfate, uric acid and phosphate, and a number of proteins and inflammatory cytokines, and decreased that of several anti - oxidant indices. Renal histopathological markers of damage (inflammation and fibrosis) were significantly increased by adenine. Sildenafil, given simultaneously with adenine, induced a dose - dependent improvements in most of the above parameters, suggesting its possible use as adjunct treatment for CKD in humans.

Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use

Background Adverse drug events from preventable medication errors can result in patient morbidity and mortality, and in cost to the healthcare system. Medication reconciliation can improve communication and reduce medication errors at transitions in care. Objective Evaluate the impact of medication reconciliation and counselling intervention delivered by a pharmacist for medical patients on clinical outcomes 30 days after discharge. Setting Sultan Qaboos University Hospital, Muscat, Oman. Methods A randomized controlled study comparing standard care with an intervention delivered by a pharmacist and comprising medication reconciliation on admission and discharge, a medication review, a bedside medication counselling, and a take-home medication list. Medication discrepancies during hospitalization were identified and reconciled. Clinical outcomes were evaluated by reviewing electronic health records and telephone interviews. Main outcome measures Rates of preventable adverse drug events as primary outcome and healthcare resource utilization as secondary outcome at 30 days post discharge. Results A total of 587 patients were recruited (56 ± 17 years, 57% female); 286 randomized to intervention; 301 in the standard care group. In intervention arm, 74 (26%) patients had at least one discrepancy on admission and 100 (35%) on discharge. Rates of preventable adverse drug events were significantly lower in intervention arm compared to standard care arm (9.1 vs. 16%, p = 0.009). No significant difference was found in healthcare resource use. Conclusion The implementation of an intervention comprising medication reconciliation and counselling by a pharmacist has significantly reduced the rate of preventable ADEs 30 days post discharge, compared to the standard care. The effect of the intervention on healthcare resource use was insignificant. Pharmacists should be included in decentralized, patient-centred roles. The findings should be interpreted in the context of the study's limitations.

Gum Acacia Improves Renal Function and Ameliorates Systemic Inflammation, Oxidative and Nitrosative Stress in Streptozotocin-Induced Diabetes in Rats with Adenine-Induced Chronic Kidney Disease

BACKGROUND/AIMS

The effect of treatment with gum acacia (GA), a prebiotic shown previously to ameliorate chronic kidney disease (CKD), in diabetic and non - diabetic rats with adenine - induced CKD has been investigated using several conventional and novel physiological, biochemical, and histopathological parameters.

METHODS

Diabetes mellitus was induced in rats by a single injection of streptozotocin (STZ). Diabetic and non - diabetic rats were randomly divided into several groups, and given either normal food or food mixed with adenine (0.25% w/w, for five weeks) to induce CKD. Some of these groups were also concomitantly treated orally with GA in the drinking water (15% w/w).

RESULTS

Rats fed adenine alone exhibited physiological (decreased body weight, increased food and water intake and urine output), biochemical (increase in urinary albumin/creatinine ratio, plasma urea and, creatinine, indoxyl sulfate and phosphorus), inflammatory biomarkers (increased in neutrophil gelatinase-associated lipocalin, transforming growth factor beta -1, tumor necrosis factor alpha, adiponectin, cystatin C and interleukin-1β), oxidative biomarkers (8-isoprostane, 8 -hydroxy -2-deoxy guanosine), nitrosative stress biomarkers (nitrite and nitrate) and histopathological (increase in tubular necrosis and fibrosis) signs of CKD. STZ - induced diabetes alone worsened most of the renal function tests measured. Administration of adenine in STZ - diabetic rats further worsened the renal damage induced by adenine alone. GA significantly ameliorated the renal actions of adenine and STZ, given either singly or in combination, especially with regards to the histopathological damage.

CONCLUSION

GA is a useful dietary agent in attenuating the progression of CKD in rats with streptozotocin-induced diabetes.

Effect of aqueous extract and anthocyanins of calyces of Hibiscus sabdariffa (Malvaceae) in rats with adenine-induced chronic kidney disease

OBJECTIVES

The aim of this work was to assess the possible beneficial effects of aqueous extracts of Hibiscus sabdariffa L. calyces and anthocyanins isolated therefrom in an adenine-induced chronic kidney disease (CKD) model.

METHODS

Rats were orally given, for 28 consecutive days, either adenine alone or together with either aqueous extract of H. sabdariffa calyces (5 and 10%) or anthocyanins (50, 100 and 200 mg/kg of anthocyanin concentrate). For comparative purposes, two groups of rats were given lisinopril (10 mg/kg).

KEY FINDINGS

When either H. sabdariffa aqueous extract or the anthocyanins isolated from it was administered along with adenine, the adverse effects of adenine-induced CKD were significantly lessened, mostly in a dose-dependent manner. The positive effects were similar to those obtained by administration of lisinopril.

CONCLUSIONS

The results obtained show that both H. sabdariffa and its anthocyanins could be considered as possible promising safe dietary agents that could be used to attenuate the progression of human CKD. This could have added significance as H. sabdariffa tea is widely consumed in many parts of Africa and Asia and is thus readily available.

Preparation and Validated Analysis of Anthocyanin Concentrate from the Calyces of Hibiscus sabdariffa

Extracts of Hibiscus sabdarnffa calyces have been shown to have various medicinal properties, some of which have been reported to be due to anthocyanins present in the calyces. To study whether these claims are valid, it is necessary to produce an extract with a high anthocyanin content and to have available a method to identify and quantify the individual compounds in the product. A method of extraction and purification has been developed based on a polyamide column chromatographic purification step. Using this method, anthocyanin concentrates were produced containing from 57 to 64% of delphinidin-3- sambubioside plus cyanidin-3-sambubioside. A rapid, efficient and validated HPLC analytical method was developed and used for the analysis of the anthocyanin concentrate.

Preparation and Validated Analysis of Anthocyanin Concentrate from the Calyces of Hibiscus sabdariffa

Extracts of Hibiscus sabdariffa calyces have been shown to have various medicinal properties, some of which have been reported to be due to anthocyanins present in the calyces. To study whether these claims are valid, it is necessary to produce an extract with a high anthocyanin content and to have available a method to identify and quantify the individual compounds in the product. A method of extraction and purification has been developed based on a polyamide column chromatographic purification step. Using this method, anthocyanin concentrates were produced containing from 57 to 64% of delphinidin-3-sambubioside plus cyanidin-3-sambubioside. A rapid, efficient and validated HPLC analytical method was developed and used for the analysis of the anthocyanin concentrate.

Therapeutic Effect of Chrysin on Adenine-Induced Chronic Kidney Disease in Rats

BACKGROUND/AIMS

To study the therapeutic effect of chrysin, a flavonoid with strong antioxidant and anti-inflammatory activities, on adenine-induced chronic kidney diseases (CKD) in rats.

METHODS

Chrysin, in three graded oral doses (10, 50 and 250 mg/kg), was given for 10 consecutive days to rats after the induction of CKD by feeding them adenine (0.25%(w/w) for 35 days). Several plasma and urine biomarkers and tissues morphology were used the investigate chrysin effect on kidney structure and function.

RESULTS

Adenine lowered creatinine clearance and elevated the concentrations of urea, creatinine, plasma neutrophil gelatinase-associated lipocalin and urinary N-Acetyl-beta-D-glucosaminidase activity, and increased the concentrations of the uremic toxin indoxyl sulfate, in addition to some inflammatory cytokines. Renal histopathological markers of inflammation and fibrosis were significantly increased. Renal catalase and superoxide dismutase activities, total antioxidant capacity and reduced glutathione were all adversely affected. Most of these adenine - induced actions were moderately mitigated by chrysin, especially at the highest dose. Compared to control, chrysin did not cause any overt adverse effects on the treated rats.

CONCLUSION

Different doses of chrysin produce variable therapeutic salutary effects in rats with CKD, and that, pending further studies, its usability as a possible therapeutic agent in human CKD should be considered.

The effect of thymoquinone treatment on the combined renal and pulmonary toxicity of cisplatin and diesel exhaust particles

Particulate air pollution (PAP) exposure is associated with increased morbidity and mortality, particularly in patients with renal disease. However, there are only a few studies on the interaction between PAP and renal injury, and none on agents that may ameliorate it. We studied the interaction between cisplatin (CP) nephrotoxicity and a single exposure to diesel exhaust particle (DEP) in rats 24 h before sacrifice, and assessed the effect of co-treatment with the active ingredient in Nigella Sativa seed oil, thymoquinone (TQ) thereon. Rats were injected intraperitoneally with CP (6 mg/kg) and four days later, they were exposed intratracheally to DEP (0.5 mg/kg), and were sacrificed 24 h later. Oral TQ (20 mg/kg) was given daily throughout the experimental period. CP alone caused several physiological, biochemical, and histopathological changes that included reduced growth and creatinine clearance, and raised plasma neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL-6) and C-reactive protein (CRP), creatinine and urea concentrations, and urinary N-acetyl-b-D-glucosaminidase (NAG) activities. It adversely affected several indices of oxidative damage in the kidneys, and induced renal tubular necrosis. Most of these actions were significantly potentiated in rats given both CP and DEP. TQ significantly abrogated many of the effects of CP and DEP, given alone and in combination. These results provide experimental evidence that subjects with renal diseases can be at higher risk from PAP, and that TQ, pending further pharmacological and toxicological studies, can be considered a useful agent in patients with renal diseases and exposed to PAP.

Sampling time and indications appropriateness for therapeutically monitored drugs at a teaching university hospital in Oman

Objective: To evaluate prospectively the appropriateness of indications, sampling time and outcome of TDM requests at a teaching university hospital in Oman. Methods: A prospective cross-sectional study was conducted over a four months period; October 2013–January 2014 at the Sultan Qaboos University Hospital (SQUH), an 855 bed university teaching hospital. Appropriateness criteria for indications and sampling time were defined a priori. The evaluated drug’s requests were for carbamazepine, phenytoin, phenobarbital, valproic acid, digoxin, gentamicin, amikacin, vancomycin, tobramycin, theophylline, lithium, and cyclosporine. Results: Of 733 evaluated TDM requisitions, the majority were for antibiotics (75.0%) followed by antiepileptics (10.5%) and cyclosporine (8.9%). Most of the requests had appropriate indication (78.2%), however, only 28.5% had appropriate sampling time. Results were applied by dosage adjustments in 65.8% of requests and some of the inappropriately sampled requests (15.3%) were used as a basis for modifying the dosage regimen. Of all the reported plasma concentrations 42.3%, 41.2%, and 16.5% were within, below and above the reference range, respectively. Conclusion: TDM service is much less than optimal in SQUH. A lot of effort needs to be carried out to improve TDM use in the developing countries as adjusting the doses on results that are based on wrong sampling time might expose patients to toxicity or therapeutic failure.

Glycemic control among patients with type 2 diabetes at a primary health care center in Oman

AIMS

To determine the status of blood sugar control by using fasting blood sugar (FBS) of ≤6.1 mmol/l and glycosyted hemoglobin A1c (HbAc1) of <7% as indictors of glycemic control and to assess the influence of demographic, blood pressure (BP) and lipid characteristics on glycemic control.

METHODS

This retrospective study included all Omani patients with type 2 diabetes (N=177) attended a primary health care center in Al-Dakhiliya region, Oman.

RESULTS

The overall mean age of the cohort was 53±12 years (range: 24-91) with females representing 60% (n=106) of the study sample. The study found that only 9.6% (n=17) and 35% (n=62) of the patients attained optimal FBS and HbAc1 levels, respectively. Higher HbA1c was significantly associated with higher diastolic BP (84 versus 80 mm Hg; p=0.006), higher total cholesterol (5.2 versus 4.7 mmol/l; p=0.002) and higher low-density lipoprotein cholesterol (3.8 versus 3.0 mmol/l; p=0.034).

CONCLUSIONS

The results demonstrated poor glycemic control in Oman type 2 diabetic patients comparable to local and global studies especially in those hypertensive and dyslipidemic patients. Implementation of early and aggressive management of diabetes mellitus at the primary care setting is warranted.

Renoprotective effects of gamma-aminobutyric acid on cisplatin-induced acute renal injury in rats

To investigate the effect of gamma-aminobutyric acid (GABA) on acute renal injury (ARI), we used here a rat model of acute tubular necrosis induced by the anticancer drug cisplatin (CP). GABA was given orally (100 or 500 mg/kg/day for ten consecutive days), and on the 6th day, some of the treated rats were also injected intraperitoneally with either saline or CP (6 mg/kg). Four days after CP treatment, urine was collected from all rats, which were then anaesthetized for blood pressure and renal blood flow monitoring. This was followed by intravenous injection of norepinephrine for the assessment of renal vasoconstrictor responses. Thereafter, blood and kidneys were collected for measurement of several functional, biochemical and structural parameters. GABA treatment (at 500 but not 100 mg/kg) significantly mitigated all the measured physiological and biochemical indices. Sections from saline- and GABA-treated rats showed apparently normal proximal tubules. However, kidneys of CP-treated rats had a moderate degree of necrosis. This was markedly lessened when CP was given simultaneously with GABA (500 mg/kg). The concentration of platinum in the cortical tissues was not significantly altered by GABA treatment. The results suggested that GABA can ameliorate CP nephrotoxicity in rats. Pending further pharmacological and toxicological studies, GABA may be considered a potentially useful nephroprotective agent in CP-induced ARI.

Epidemiology of chemotherapy-induced neutropenia at a tertiary university hospital in Oman

BACKGROUND

Little is known about the incidence and burden of chemotherapy-induced neutropenia (CIN) in Oman or the Arabian Gulf.

OBJECTIVES

To determine the epidemiology of CIN at Sultan Qaboos University Hospital in Oman.

METHODS

A retrospective observational study of all eligible CIN episodes in adult (>18 years) patients with solid tumors and hematological malignancies at Sultan Qaboos University Hospital (SQUH) from January to December 2010. Analyses were performed using univariate statistics.

RESULTS

A total of 1,357 episodes in 159 patients with a mean age of 50 ± 15 years (19-91) were evaluated. Fifty-four percent (n = 86) of the patients were female. A total of 46 % (73/159) of the patients developed CIN accounting for 15 % (210/1,357) of all episodes. Twelve percent (25/210) of these CIN episodes were associated with fever in 26 % (19/73) patients. There was significant association between CIN and chemotherapy regimen (P < 0.001), younger age (P < 0.001), low hemoglobin (Hb) levels (P < 0.001) and advanced cancer stage (P = 0.006).

CONCLUSIONS

This study suggests a high incidence of CIN in SQUH patients which resulted in chemotherapy delays, longer hospital stays, and inpatient mortality. CIN was significantly correlated with chemotherapy regimen, younger age, low Hb levels and cancer stage.

Utilization patterns of antiepileptic drugs among adult epileptic patients at a tertiary hospital in Oman

Objectives

To describe utilization patterns of antiepileptic drugs (AEDs) among adult epileptic patients at a tertiary hospital in Oman.

Methods

Data were collected retrospectively from January 2006 to December 2009. The study included all adult (&gt;18 years) epileptic patients on AEDs and followed up at a neurology clinic at Sultan Qaboos University Hospital in Oman. All reported therapeutic drug monitoring (TDM) requests for serum AED concentrations were also collected. Institutional ethical approval was sought and obtained.

Key findings

The study included a total of 372 patients with a mean age of 34 ± 15 years. Monotherapy AEDs accounted for 53% of the prescriptions, whereas polytherapy with two or three AED combinations accounted for 27% and 20% respectively. The most frequently prescribed AED was sodium valproate (27%) followed by carbamazepine (23%). The commonly prescribed AED combinations were sodium valproate with clonazepam (12%) followed by sodium valproate with lamotrigine (12%). Evaluation of 574 TDM requests for three AEDs showed that 57% of carbamazepine, 78% of phenytoin and 54% of valproic acid requests were either above or below the recommended therapeutic threshold. Most of these requests were ordered from the hospital's emergency department for suspected insufficient serum concentrations.

Conclusions

Antiepileptic drug monotherapy is still the most frequently employed therapeutic strategy in adult patients with epilepsy in keeping with the standard therapeutic guidelines. Sodium valproate is commonly used for different types of seizures reflecting its wide spectrum of anticonvulsant potential. Newer AED utilizations are becoming increasingly popular in our subjects particularly as add-on with other standard AEDs.

HPLC-fluorescence method for measurement of the uremic toxin indoxyl sulfate in plasma

A sensitive and reproducible high-performance liquid chromatography-fluorescence method was developed and validated for quantitative determination of indoxyl sulfate in plasma using methyl paraben as an internal standard. The separation was carried out on an OSD-2 C18 Spherisorb column by isocratic elusion with sodium acetate buffer (pH 4.5) and acetonitrile (10:90, v/v) as the mobile phase. The method was validated and found to be linear in the range of 2.5 to 50 µM. The limit of quantification was 2.0 µM. The variations for intra-day and inter-day precision were less than 10.1%, and the accuracy values were between 93.4 and 102.5%. The extraction recoveries were more than 89%.

Application of Routine Monitoring Data for Determination of the Population Pharmacokinetics and Enteral Bioavailability of Phenytoin in Neonates and Infants With Seizures

This study investigated the population pharmacokinetics and the enteral bioavailability of phenytoin (PTN) in neonates and infants with seizures. Data from 83 patients were obtained retrospectively from medical records. A 1-compartment model was fitted to the log-transformed concentration data using NONMEM. Between-subject variability and interoccasion variability were modelled exponentially together with a log transform, both-sides exponential residual unexplained variance model. Covariates in nested models were screened for significance. Model robustness was assessed by bootstrapping with replacement (n = 500) from the study data. The parameters of the final pharmacokinetic model were clearance (L/h) = 0.826.[weight (WT, kg) / 70].[1 + 0.0692.(postnatal age (d) - 11)]; volume of distribution (L) = 74.2.[WT (kg) / 70]; absolute enteral bioavailability = 0.76; absorption rate constant (h) = 0.167. The between-subject variability for clearance and volume of distribution was 74.2% and 65.6%, respectively. The interoccasion variability for clearance was 54.4%. The unexplained variability was 51.1%. Final model parameter values deviated from median bootstrap estimates by less than 9%. Phenytoin disposition in neonates and infants can be described satisfactorily by linear pharmacokinetics. The values of allometrically scaled clearance and volume were similar to adult values, suggesting no major kinetic differences between adults and infants on the basis of size alone. Postnatal age independently influenced clearance. Switching from enteral to intravenous routes may require a dosage adjustment. The results of this study provide a basis for more rational prescribing of phenytoin in infants and neonates.