BackgroundEmerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region.MethodsAn open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia.Results105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups.ConclusionsCombined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia.Trial registrationTrial registration number: NCT02224040.

IntroductionTyphoid fever (TF) continues to cause considerable morbidity and mortality in Nepal, but only limited epidemiologic data is available about TF outside Kathmandu.MethodsAs part of an interventional trial, we performed a prospective cohort study of bacteremic TF patients in Dhulikhel Hospital between October 2012 and October 2014. Demographic, epidemiological, clinical, and microbiologic data were recorded.Results116 bacteremic typhoid patients were included in the study. Most were young, healthy, adults (mean age 27.9±12 years), 41.4% of whom were female. More than 70% of patients were employed in non-manual services or were university students. Salmonella Typhi accounted for 64/115 (55.7%) of all isolates, while Salmonella Paratyphi accounted for 51/115 (44.3%), of which 42 were Paratyphi A and 9 Paratyphi B. A significant proportion of TF cases occurred also during the dry season (48/116, 41.6%). The clinical presentation of Salmonella Typhi and Paratyphi infections was similar, except for a greater proportion of arthralgia in patients with Salmonella Typhi. Most Salmonella Typhi and Paratyphi isolates were resistant to nalidixic acid and susceptible to older antibiotics. One Salmonella Paratyphi isolate was resistant to ceftriaxone.ConclusionsTF remains common in the Dhulikhel area, even among those with a high level of education. Public health measures aimed at reducing the incidence of TF in the Dhulikhel area are warranted. The relative burden of TF caused by Salmonella Paratyphi is rising; a vaccine with activity against Salmonella Paratyphi is needed. Since Salmonella Paratyphi B was more prevalent in this cohort than in large cohorts of patients from Kathmandu, it is likely that there are significant regional variations in the epidemiology of TF outside Kathmandu.

Background: Management of Type 2 Diabetes Mellitus includes nonpharmacological and pharmacological interventions of which insulin remains one of the most effective methods for achieving glycemic control, either alone or in combination with oral anti-diabetic medications. Effective usage of insulin in the management of glycaemia remains a challenge in developing countries like Nepal. To best of our knowledge, there is not any study regarding insulin prescription pattern on Type 2 Diabetes Mellitus patients using insulin from Nepal, so we studied the prescription pattern of insulin on insulin using Type 2 Diabetes Mellitus patients.Methods: Patients aged 30 years or above who present in Dhulikhel Hospital outpatient clinic during the period from January 2015 to June 2015 with diagnosis of Type 2 Diabetes Mellitus diagnosed at least for 6 months and were taking injection insulin at least since last 3 months were enrolled in this cross sectional, observational study.Results: Forty-five study participants had a mean age of 56.6 ±10.95 year, body mass index of 23.97 4.72 kg/m2, Diabetic duration of 10.33 6.41 years and HbA1c of 8.53 ±1.53%. Fifty-three percent were female and almost all study participants (96%) were taking Oral Antidiabetic Drugs along with Insulin. Sixty-three percent of participants were using Premix insulin whereas 33% were using basal insulin alone. Mean Insulin dose was 28.96 11.75 units per day. Among them, 80% were “self” injecting insulin and 53% were using Glucometer.Conclusion: Our data showed that premixed insulin being most commonly used insulin. All patients used Insulin Pen as delivery device and larger proportions of them were self injecting insulin. All patients felt mild hypoglycemia which can be improved by increased utilization of glucometer.Jour of Diab and Endo Assoc of Nepal 2017; 1(1): 3-7

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