SummaryBackgroundBecause treatment with third-generation cephalosporins is associated with slow clinical improvement and high relapse burden for enteric fever, whereas the fluoroquinolone gatifloxacin is associated with rapid fever clearance and low relapse burden, we postulated that gatifloxacin would be superior to the cephalosporin ceftriaxone in treating enteric fever.MethodsWe did an open-label, randomised, controlled, superiority trial at two hospitals in the Kathmandu valley, Nepal. Eligible participants were children (aged 2–13 years) and adult (aged 14–45 years) with criteria for suspected enteric fever (body temperature ≥38·0°C for ≥4 days without a focus of infection). We randomly assigned eligible patients (1:1) without stratification to 7 days of either oral gatifloxacin (10 mg/kg per day) or intravenous ceftriaxone (60 mg/kg up to 2 g per day for patients aged 2–13 years, or 2 g per day for patients aged ≥14 years). The randomisation list was computer-generated using blocks of four and six. The primary outcome was a composite of treatment failure, defined as the occurrence of at least one of the following: fever clearance time of more than 7 days after treatment initiation; the need for rescue treatment on day 8; microbiological failure (ie, blood cultures positive for Salmonella enterica serotype Typhi, or Paratyphi A, B, or C) on day 8; or relapse or disease-related complications within 28 days of treatment initiation. We did the analyses in the modified intention-to-treat population, and subpopulations with either confirmed blood-culture positivity, or blood-culture negativity. The trial was powered to detect an increase of 20% in the risk of failure. This trial was registered at ClinicalTrials.gov, number NCT01421693, and is now closed.FindingsBetween Sept 18, 2011, and July 14, 2014, we screened 725 patients for eligibility. On July 14, 2014, the trial was stopped early by the data safety and monitoring board because S Typhi strains with high-level resistance to ciprofloxacin and gatifloxacin had emerged. At this point, 239 were in the modified intention-to-treat population (120 assigned to gatifloxacin, 119 to ceftriaxone). 18 (15%) patients who received gatifloxacin had treatment failure, compared with 19 (16%) who received ceftriaxone (hazard ratio [HR] 1·04 [95% CI 0·55–1·98]; p=0·91). In the culture-confirmed population, 16 (26%) of 62 patients who received gatifloxacin failed treatment, compared with four (7%) of 54 who received ceftriaxone (HR 0·24 [95% CI 0·08–0·73]; p=0·01). Treatment failure was associated with the emergence of S Typhi exhibiting resistance against fluoroquinolones, requiring the trial to be stopped. By contrast, in patients with a negative blood culture, only two (3%) of 58 who received gatifloxacin failed treatment versus 15 (23%) of 65 who received ceftriaxone (HR 7·50 [95% CI 1·71–32·80]; p=0·01). A similar number of non-serious adverse events occurred in each treatment group, and no serious events were reported.InterpretationOur results suggest that fluoroquinolo...

INTRODUCTION: Drug resistant Salmonella spp. is endemic in several Asian countries. Nalidixic acid-resistant Salmonella enterica serovar Typhi and Salmonella enterica serovar Paratyphi A show reduced susceptibility to fluoroquinolones and have resulted in a rise in treatment failures. Over the past few decades, nalidixic acid-resistant Salmonella spp have emerged in Nepal as well.MATERIAL & METHODS: This is a retrospective study that aims to provide a more recent antibiogram of S. Typhi and S. Paratyphi A isolates in Kathmandu. Between Poush, 2071 and Ashwin, 2072 (December 16, 2014 to October 17, 2015), 186 culture positive cases of enteric fever were diagnosed at the Civil Service Hospital. Upon isolation of S. Typhi or S. Paratyphi A, antimicrobial susceptibility testing was performed with amoxicillin, azithromycin, ceftriaxone, chloramphenicol, ciprofloxacin, cotrimoxazole, nalidixic acid, ofloxacin and tetracyciline.RESULTS: This study shows a much higher frequency of nalidixic acid-resistance in Kathmandu than previously reported; 95.7% in Salmonella enterica serovar Paratyphi A and 86.5% in Salmonella enterica serovar Typhi.The rates of ciprofloxacinand ofloxacin-resistance were over 50% in both serovar.CONCLUSION: In Nepal, it is necessary to reevaluate the use of fluoroquinolone therapy and introduce feasible alternatives so as to curb treatment failures.Journal of Universal College of Medical Sciences (2017) Vol. 5, No, 2, Page: 22-25

Background: Hypertension is leading cause of deaths in the world. It is a modifiable and major risk factor for cardiovascular, renal and brain diseases. This study was done to see the current trend of prescription patterns of antihypertensive drugs in a tertiary care hospital in Nepal. Materials and Methods: Observational cross sectional study was done in the patients with hypertension from September 2018 to September 2019 in the department of Medicine of Civil Service Hospital, a tertiary care hospital in Kathmandu, Nepal. A total of 242 Patients who were undergoing antihypertensive treatment were included. All calculations and statistical analyses are processed by the SPSS 25.0. Results: Out of 242 prescriptions, 135(55.8%) were males, and 107(44.2%) were females. Among them, 49 (20.2%) patients had controlled Blood Pressure, 63(26%) patients had hypertension stage I and the remaining 130 patients (53.7%) patients had stage II hypertension. In the present study, 133 (54.96%) were treated with monotherapy while, 71 (29.33%) patients were prescribed with dual therapy. The most frequently prescribed drug as monotherapy was Calcium Channel Blocker in 71(53.3%) patients followed by Angiotensin Receptor Blockers in 38 (28.6%) and thiazide diuretics in 21 (15.7%) patients. Calcium Channel Blockers with Angiotensin Receptor Blockers was the most prescribed combination in 44 (62.1%) patients followed by Angiotensin Receptor Blockers and Thiazide Diuretics in 19 (26.8%) patients. Conclusion: Calcium channel blockers are the highest among the drugs that are used as monotherapy. In combination therapy, Calcium channel blockers with angiotensin receptor blocker and angiotensin receptor blockers with thiazide diuretics are the frequently prescribed drugs.

Background Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are non-inferior to each other for culture-confirmed enteric fever treatment. Methods We conducted a double blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day + sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients (aged 3-64 years) presenting to two Kathmandu hospitals with temperature ≥ 38.0°C for ≥4 days without localising signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. ClinicalTrials.gov number: NCT02773407. Results From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture-confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% CI 2.6-3.3) in the SXT arm and 2.1 days (95% CI 1.6-3.2) in the azithromycin arm 1.25 (95% CI 0.99-1.58, P=0.059). The hazard ratio of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI 0.37-1.05, p=0.073). Planned sub-group analysis showed azithromycin resulted in faster FCT in those with sterile blood cultures and less relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions Despite similar FCT and treatment failure in the two arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal.

Introduction Diabetes mellitus (DM) and lipid disorders (LD) in hypertensive patients are associated with increased risk of cardiovascular complications requiring close follow-up and more aggressive treatment. Hence, the present study was done to study the prevalence of diabetes and dyslipidemia in young hypertensive patients i.e. <40 years in a tertiary care hospital, Nepal. MethodsThis is a hospital based cross-sectional study carried out in Civil Service Hospital, Kathmandu. Study included 165 patients of <40 years who had hypertension, either newly diagnosed or undergoing antihypertensive treatment from September 2018 to September 2019. Blood pressure was measured two times on right upper arm in sitting position at interval of 30 minutes and the aver­age was taken. Fasting Lipid Profile and Fasting Blood Glucose was measured after 12 hours of fasting and the prevalence of dyslipidemia and diabetes were analyzed from the data collected. All calculations and statistical analyses are processed by the SPSS 25.0. ResultsAmong 165 patients included, majority of patients, 107 (64.8%) were among 31-39 years, followed by 53 (32.1%) patients among 21-30 years. In total, 98 (59.4%) were male and 67 (40.6%) female. The prevalence of diabetes was 24 (14.5%) and pre-diabetes was 49 (29.7%). The prevalence of dyslipidemia was 125 (75.6%), high triglyceride being the most common disorder followed by low HDL in 87 (52.1%). Elevated total cholesterol was found in 53 (32.1%) patients and 48 (29%) had high LDL cholesterol level. ConclusionA high prevalence of diabetes, pre-diabetes and dyslipidemia was observed in the hypertensive patients <40 years of age.