'Prospective audit with intervention and feedback' as a core antimicrobial stewardship strategy in the paediatrics department of a Nigerian tertiary hospital.

Introduction: Inappropriate use of antibiotics for childhood illnesses, especially for non-bacterial infections, contributes to the development of antimicrobial resistance (AMR). Globally, implementation of antimicrobial stewardship programme (ASP) in all healthcare institutions is a strategic intervention to improve the appropriate use of antibiotics, reduce antimicrobial consumption and tackle AMR. The aim of this study was to evaluate the effect of prospective audit with intervention and feedback as an antimicrobial stewardship strategy on antimicrobial use, evaluate prescribers' response to recommendations and determine the rate of AMR in the Paediatrics Department of the Lagos University Teaching Hospital, Nigeria. Materials and Methods: This was an implementation study of the paediatrics Antimicrobial Stewardship Programme (ASP) over a period of 6 months. It was initiated with a point prevalence survey (PPS) to describe the antimicrobial prescribing patterns and followed by prospective audit with interventions and feedback using an antimicrobial checklist and the existing antimicrobial guidelines in the Paediatrics Department. Results: The antibiotic prescribing prevalence was high (79.9%) at baseline PPS with 139 patients on admission, of which 111 (79.9%) were treated with 202 antibiotic therapies. Over the 6 months of study, 582 patients on 1146 antimicrobial therapies were audited. Compliance with departmental guidelines was 58.1% of the total 1146 prescriptions audited (n = 666), making the antimicrobial prescription inappropriate in 41.9% (n = 480) of therapies. The most recommended intervention for inappropriateness was 'change antibiotics' 48.8% (n = 234), followed by 'stop antibiotics' 26% (n = 125), 'reduce the number of antibiotics' 19.6% (n = 194) and 'de-escalate' 2.4% (n = 11). Agreement with ASP interventions occurred in 193 (40.2%) cases, and the least agreed intervention was 'stop antibiotics' (n = 40, 32%). However, there was a steady increase in compliance rates with ASP interventions over the 6 months of period study, which was statically significant (χ2: 30.005; P = 0.001). Conclusion: ASP prospective audit with intervention and feedback was of significant benefit in improving compliance with antimicrobial guidelines, thereby improving antimicrobial therapy in the Paediatrics Department of LUTH, Nigeria.

Low prevalence of isoniazid preventive therapy uptake among HIV-infected patients attending tertiary health facility in Lagos, Southwest Nigeria.

INTRODUCTION: the burden of HIV and tuberculosis co-infection is a global public health challenge. Despite the benefit of isoniazid preventive therapy (IPT) in reducing the rate of co-infection, the uptake is generally limited in developing countries. This study aimed to determine the prevalence of IPT use and the factors affecting the uptake among HIV-infected patients attending our Teaching Hospital. METHODS: this cross-sectional survey involved 300 HIV-infected individuals attending the AIDS prevention initiatives in Nigeria clinic of the Lagos University Teaching Hospital. A self-designed and well-structured questionnaire was used to document the demographic data, patients' exposure to tuberculosis, and IPT uptake. Clinical data of eligible patients were also extracted from their case notes. The main outcome measure was the prevalence of IPT use and non-use. RESULTS: out of the respondents evaluated, (72.7%, n = 218) were females. Tuberculosis was the predominant comorbidity (15.7%, n = 47) and majority (53.0%, n = 159) had a CD4 count of < 500 cells/ml. Overall prevalence of IPT uptake was very low (7.1%, n = 18) among HIV-infected patients. Major factors affecting uptake were lack of awareness of benefit (44.4%, n = 8) and lack of fear of contracting tuberculosis (22.2%, n = 4). However, lack of awareness of IPT benefit was the only independent factor associated with poor IPT uptake (adjusted odds 1168.75, 95% confidence interval: 85.05-16060.33; p = 0.001). CONCLUSION: isoniazid preventive therapy uptake was found to be very low in this study. Increased awareness and policy implementation of IPT by the healthcare provider is necessary.

Evaluation of the effects of atazanavir-ritonavir on the pharmacokinetics of lumefantrine in patients living with HIV in Lagos University Teaching Hospital, South-Western Nigeria.

PURPOSE: Atazanavir-ritonavir (ATVr)-based antiretroviral therapy and artemether-lumefantrine (AL) are commonly used drugs for the treatment of human immune deficiency virus (HIV) infection and malaria respectively. However, interaction of both drugs, with Cytochrome P 3A4 (CYP 3A4) isoenzyme, may spawn clinically significant pharmacokinetic interactions. This study evaluated the effects of atazanavir-ritonavir on the pharmacokinetics of lumefantrine. METHOD: In a case-control study, twenty participants having Plasmodium falciparum malaria were recruited and divided into two groups (ATVr-arm, n=10; and control-arm, n= 10). All the participants were administered six oral doses of AL 80-480 mg (Coartem). Thereafter, their blood samples were collected at different time intervals over seven days. The concentration of lumefantrine in each sample was quantified with high-performance liquid chromatography (HPLC) and used to determine its pharmacokinetic parameters which were compared between the test and control groups. RESULTS: ATVr increased the mean day 7 concentration of lumefantrine (ATVr 3847.09 ± 893.35 ng/mL, control 1374.53 ± 265.55 ng/mL, p = 0.016) and the area under its plasma concentration-time curve (ATVr 670529.57 ± 157172.93 ng.h/mL, control 447976.28 ± 80886.99 ng.h/mL, p = 0.224) by 179.88 % and 49.68 %, respectively, but decreased its mean maximum plasma drug concentration (Cmax) (ATVr 13725.70 ± 2658.44 ng/mL, control 15380.48 ± 2332.62 ng/mL, p = 0.645) by 10.76 %. CONCLUSION: ATVr increased drug exposure and day 7 plasma concentration of lumefantrine. AL is therefore considered effective for the treatment of malaria in patients taking ATVr-based regimen. However, the safety associated with the interaction requires further elucidation. TRIAL REGISTRATION: Clin ClinicalTrials.gov Identifier: NCT04531072, August 27, 2020. "Retrospectively registered".

High Risk of Drug-drug interactions among Hospitalized Patients with kidney Diseases at a Nigerian Teaching Hospital: A Call for Action.

BACKGROUND: Potential drug-drug interactions (DDIs) are increasingly common in clinical practice, especially among individuals with chronic conditions, such as chronic kidney dysfunction. However, data relating to DDIs among chronically ill patients are limited in Nigeria. We, therefore, investigated the prevalence and pattern of DDIs among patients with kidney diseases on admission at a tertiary hospital in Lagos, Nigeria. MATERIALS AND METHODS: This was a prospective observational study involving 61 adults with kidney diseases and on admission in medical wards of the study center, over a 3-month period. Data extractions were with a purposefully designed pro forma to extract relevant data on demographic, clinical, and dosing regimens of the prescribed drugs for individual patients. Potential DDIs were identified, and their severity was rated using the MICROMEDEX® software database (IBM® Watson-Truven Health Analytics), which is available online with limited access. RESULTS: Of the 61 patients evaluated, majority were males (34; 55.7%), were elderly (26; 42.6%), and had chronic kidney disease Stage 3 (40; 65.5%). The most common cause of kidney disease was hypertension (20; 32.8%). Out of the 542 prescriptions received by the patients, potential DDI was observed in 508 (93.7%) prescriptions. Clinically significant drug interactions (CSDIs) were detected in 486 (85.7%) prescriptions. Pharmacodynamic DDIs (466; 91.7%) were the most common. Pill burden exceeding 25 pills/day was present in nine (14.8%) patients. The severities of the potential DDIs were major (135; 24.9%), moderate (333; 61.4%), and minor (38; 7.1%). Only two different potential DDIs were rated X (contraindicated). CONCLUSION: Exposure to drugs with potential DDIs was very common among patients with kidney diseases. Most of the CSDIs observed were of major severity. The use of DDI checker before prescribing drugs for individuals with kidney diseases could avert clinically significant interactions.