Objective: To evaluate the knowledge of community pharmacists about antibiotics, and their perceptions and practices toward antimicrobial stewardship (AMS) in Punjab, Pakistan. Materials and methods: A descriptive cross-sectional study was conducted among community pharmacists in Punjab, Pakistan from April 1, 2017 to May 31, 2017. A self-administered and pretested questionnaire was used for data collection. A simple random-sampling method was used to select community pharmacies. Independent-sample Mann–Whitney U tests, independent sample Kruskal–Wallis tests, and logistic regression analysis were performed with SPSS version 21.0. Results: Of the 414 pharmacists, 400 responded to the survey (response rate 96.6%). The participants had good knowledge about antibiotics. They showed positive perceptions, but poor practices regarding AMS. All of the participants were of the view that AMS program could be beneficial for health care professionals for improvement of patient care, and 78% (n=312) of participants gave their opinion about incorporation of AMS programs in community pharmacies. Collaboration was never/rarely undertaken by pharmacists with other health care professionals over the use of antibiotics (n=311, 77.8%), and a significant proportion of participants (n=351, 87.8%) never/rarely participated in AMS-awareness campaigns. Logistic regression analysis revealed that male sex (OR 0.204, 95% CI 0.104−0.4; P<0.001), age 20–29 years (OR 0.172, 95% CI 0.05−0.595; P=0.005), and <1 year of experience (OR 0.197, 95% CI 0.083−0.468; P<0.001) were the factors associated with poor practices regarding AMS. Conclusion: Pharmacists had good knowledge about antibiotics. There were some gaps in perceptions and practices of community pharmacists regarding AMS. In the current scenario, it will be critical to fill these gaps and improve perceptions and practices of community pharmacists regarding AMS by developing customized interventions.

Availability and affordability of anticancer medicines is a matter of great concern especially for low and middle income countries e.g., Pakistan. Prime focus of this study was to evaluate the availability of anticancer medicines in public and private sectors, and their affordability among patients with different income levels. A descriptive, cross-sectional survey was conducted in 22 cancer care hospitals (18 public hospitals and 04 private hospitals) and 44 private pharmacies in Punjab, Pakistan. All (n = 4400) participants were ≥18 years of age. Data were collected at different intervals and analyzed by using Statistical Packages for Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) A total of 4913 patients were approached, and 4400 responded to the survey (response rate = 89.6%). Non-hodgkin lymphoma (12.3%), breast cancer (8.6%), and leukemia (7.6%) were the most prevailing cancers. Conventional medicines like cisplatin, cyclophosphamide, and etoposide were the most prescribed medicines. Oncologists were reluctant to prescribe newer anticancer medicines due to high prices. Originator brands (OBs) were more readily available (52.5%) but less affordable (53.4%); whereas, lowest price generics (LPGs) were less available (28.1%) but more affordable (67.9%). Anticancer medicines were more affordable by the high income class patients than the low income class patients. The availability of both OBs and LPGs was greater at private hospitals and pharmacies as compared to public hospitals. The high income class had more affordability of both OBs and LPGs; however, LPGs were more affordable for all income classes.

To investigate the antimicrobial (AM) use and prescribing patterns at primary health care centers (PHCCs) in Punjab, Pakistan. A cross-sectional study was designed according to the World Health Organization (WHO) methodology for AM usage from January, 2017 to June, 2017. Standard data collection forms designed by the WHO were used to collect the data from 32 PHCCs (16 rural healthcare centers (RHCs) and 16 basic health units (BHUs)) in Punjab province of Pakistan. PHCCs were randomly selected from 8 main cities. The study sample consisted of prescription records of 6400 outpatients (200 prescriptions records from each PHCC) and 800 inpatients (25 inpatient records from each PHCC). Data of the year 2016 were collected retrospectively by using systematic random sampling technique and analyzed through SPSS. Among the hospital indicators, standard treatment guidelines (STGs) regarding the infectious diseases were not available in PHCCs. Number of days during which key AMs were out of stock was 12.1 days per month (range = 3.1–19.2). Out of total PHCC medicines costs, expenditures on AMs were 26.2% (range = 17.1–39.0). In case of prescribing indicators, the average number of AMs per prescription was 1.4 (range = 1.1–1.7), percentage of prescriptions prescribed with AMs was 81.5% (range = 68.9–89.1) and duration of AM treatment on average was 5.1 days per patient (range = 3.3–6.4). Average cost of prescribed AMs per patient was 1.3 USD (range = 0.6–4.3). The PHCCs prescribed a median of 5 (range = 3–9) types of AMs, including 10 (range = 5–15) individual agents. Out of 79.3% prescriptions of outpatients prescribed with AMs, only 16.4% were properly prescribed. Out of 100% prescriptions of inpatients prescribed with AMs, 12.1% were properly prescribed. Out of all the AM prescriptions 23.6% contained penicillins, 20.1% contained cephalosporins and 19.4% contained fluoroquinolones Metronidazole (18.0%), ciprofloxacin (16.5%) and co-amoxiclav (14.3%) were most commonly prescribed AMs. In PHCCs, AMs were prescribed more frequently. However large proportions of these prescriptions were inappropriate. Continuous education and training of medical staff and cost effective policies could play an important role in promotion of rational use of AMs.

Background and objective: The noncompliance of treatment guidelines by healthcare professionals, along with physiological variations, makes the pediatric population more prone to antibiotic prescribing errors. The present study aims to evaluate the prescribing practices and errors of the most frequently prescribed antibiotics among pediatric patients suffering from acute respiratory tract infections who had different lengths of stay (LOS) in public hospitals. Methods: A retrospective, cross-sectional study was conducted in five tertiary-care public hospitals of Lahore, Pakistan, between 1 January 2017 and 30 June 2017. The study population consisted of pediatric inpatients aged 0 to 9 years. Results: Among the 11,892 pediatric inpatients, 82.8% were suffering from lower acute respiratory tract infections and had long LOS (53.1%) in hospital. Penicillins (52.4%), cephalosporins (16.8%), and macrolides (8.9%) were the most frequently prescribed antibiotics. Overall, 40.8% of the cases had antibiotic prescribing errors related to wrong dose (19.9%), wrong frequency (18.9%), and duplicate therapy (18.1%). Most of these errors were found in the records of patients who had long LOS in hospital (53.1%). Logistic regression analysis revealed that the odds of prescribing errors were lower in female patients (OR = 0.6, 95% CI = 0.1–0.9, p-value = 0.012). Patients who were prescribed with ≥3 antibiotics per prescription (OR = 1.724, 95% CI = 1.1–2.1, p-value = 0.020), had long LOS (OR = 12.5, 95% CI = 10.1–17.6, p-value < 0.001), and were suffering from upper respiratory tract infections (URTI) (OR = 2.8, 95% CI = 1.7–3.9, p-value < 0.001) were more likely to experience prescribing errors. Conclusion: Antibiotics were commonly prescribed to patients who had long LOS. Prescribing errors (wrong dose, wrong frequency, and duplicate therapy) were commonly found in cases of lower respiratory tract infections (LRTIs), especially among those who had prolonged stay in hospital.

Objective: To evaluate influence of education level of older patients on polypharmacy, potentially inappropriate medications (PIMs) listed in Beer’s Criteria, and unplanned hospitalization. Methods: A cross-sectional study was conducted among older people aged ≥65 years between 1 December 2017 and 28 February 2018. For data analysis, descriptive statistics and logistic regression analysis were employed. Results: Among 385 older patients, 88.8% were prescribed PIMs and 56.4% underwent PIMs associated unplanned hospitalization. Older people were less exposed to polypharmacy or excessive polypharmacy as their education levels increased (no formal education vs. primary vs. secondary vs. tertiary, 74% vs. 69.8% vs. 60.5% vs. 58.1%). Patients having higher education were also accompanied by significantly lower prescription of PIMs (no formal education vs. primary vs. secondary vs. tertiary, 96% vs. 87.3% vs. 84.5% vs. 79.1%) as well as unplanned hospitalization (no formal education vs. primary vs. secondary vs. tertiary, 64.7% vs. 76.2% vs. 40.3% vs. 46.5%). Results of regression analysis revealed that no formal education (OR = 1.202, 95% CI = 1.032–2.146, p-value = 0.003) and primary education level (OR = 1.175, 95% CI = 1.014–1.538, p-value = 0.039) were significantly associated with the use of polypharmacy among older people. On the other hand, no formal education was significantly associated with the prescription of PIMs (OR = 1.898, 95% CI = 1.151–2.786, p-value = 0.007). Furthermore, older people with no formal education (OR = 1.402, 95% CI = 1.123–1.994, p-value = 0.010) and primary education level (OR = 1.775, 95% CI = 1.281–3.018, p-value = <0.001) were significantly more likely to undergo unplanned hospitalization. Conclusions: Patients having low literacy level are more likely to receive PIMs, polypharmacy, and undergo unplanned hospitalization in comparison to highly educated patients. Hence, promotion of health literacy for patients is crucial to overcome these problems.

Background and objectives: Due to physiological and pharmacological variations, geriatrics are at high risk of experiencing life-threatening outcomes related to the use of potentially inappropriate medications (PIMs). Thus, the present study aims to evaluate prescribing practices of PIMs among elderly patients who may lead to unplanned hospitalization and associated risk factors. Methods: A cross-sectional study was conducted in different hospitals of Lahore, Pakistan. The study population consisted of geriatric patients aged ≥65 years. Data were collected from the medical records of geriatric patients, who attended these selected hospitals between December 1, 2017, and February 28, 2018. Data were analyzed using SPSS (IBM SPSS Statistics for Windows, Version 21.0) and Microsoft Excel (MS Office 2010). Results: The records of 385 geriatric patients were investigated. More than half (60.8%) of the patients were subjected to polypharmacy, which can be defined as the utilization of 5–9 drugs by the patient at the same time, whereas 36.4% were prescribed with one PIM and 56.4% were hospitalized due to PIMs. Majority of them were prescribed with PIMs including N02BA01 (aspirin, 32.4%), A02BC01 (omeprazole, 23.6%), A10AB02 (insulin, 17.4%), A02BC05 (esomeprazole, 8.5%), C08CA01 (amlodipine, 8.3%), and R06AA02 (diphenhydramine, 5.9%). Results of regression analysis revealed that patients exposed to polypharmacy (OR=2.556, 95% CI=1.579–4.135, P-value≤0.001) and excessive polypharmacy (OR=37.828, 95% CI=4.754–300.9, P-value≤0.001) were significantly associated with unplanned hospitalization, whereas factors such as age 75–84 years (OR=0.343, 95% CI=0.156–0.756, P-value=0.008) and polypharmacy (OR=2.480, 95% CI=1.219–5.048, P-value=0.012) were significantly correlated with PIMs. Conclusion: The utilization of PIMs listed in Beers criteria among geriatric population can cause unplanned hospitalization. As the patients receiving polypharmacy are at high risk of unplanned hospitalization, so caution must be exercised in prescribing PIMs for elderly people.