June 2014 issue no 8 by sjrum

June 2014 - Issue No.8

Sudan Journal of Rational Use of Medicine

Federal Ministry of Health

Antibiotic Resistance

Directorate General of Pharmacy

â&#x20AC;˘

Publication team Editor in chief Sarah A. Kareem Hassan B. Pharm, M. Pharm, MBA Editors Prof. Ali Mohamed Arabi MBBS. MD . Randa Alsadig Alsaddig BSC. MSc. Clinical Phamacy Elkhatim Elyas Mohamed MBBS. MCOMH. Diploma Thoracic Med. Habab Khalid El Kheir B. Pharm., M. Pharm., Ph.D Nuha Mohamed A. Agabna B. Pharm, M. Pharm, Ph.D Ghada Omar Shouna B. Pharm., MSc Clinical Phamacy Duria Hassan Merghani B. Sc. N, M.Sc. N., Ph.D Padreldin Said Hagnour B. Pharm, FPSM Yasir Mirghani Abdalrahman B. Pharm. Sawsan Eltaher Ahmed B. Pharm. Graphic Design Mahmoud Gahalla Ahmed Advisory board Prof. Sami Ahmed Khalid B. Pharm., M. Pharm., Ph.D Prof. Abdalla O. Elkhawad B. Pharm., M. Pharm., Ph.D Mohamed A. Zeinelabdin B. Pharm., M. Pharm. udan Journal for Rational Use of Medicine (SJRUM) is a quarterly publication produced by the National Medicine Information Center and Reference Library (NMICRL); Directorate General of Pharmacy; Federal Ministry of Health; Sudan. SJRUM is funded by Global Fund and technically supported by the World Health Organization. The first issue was published in September 2012. SJRUM aims to promote Rational Use of Medicines (RUM) through disseminating principles, views, news, and educating health providers about rational use of medicines. SJRUM targets health professionals; prescribers, pharmacists, and nurses. Each issue is centered on a theme; which usually is an important subject in RUM. SJRUM highlights in each issue the current situation in Sudan relevant to the theme, presented either by evidence from local research or with reliable anecdotal evidence. SJRUM includes research studies which aim to encourage young researchers to publish their work at national and international levels. SJRUM also includes a section for educational materials relevant to RUM relying mostly on the WHO educational materials and other reliable sources. The section of news reflects some important published news that may affect RUM practice. SJRUM includes some selected case studies, reflecting current practice at different health facilities in Sudan, so as to highlight the irrational aspects in order to overcome them. As part of NMICRL activities, medical students and the public are endowed with leaflets and fliers on selected topics of SJRUM. Readers have the freedom to use and reproduce any part of this journal. For participation please contact: sjrum@khmic.org For more information â&#x20AC;ŚYou can access SJRUM online on www.sjrum.sd

Acknowledgement

The Directorate General of Pharmacy gratefully acknowledges the financial support of the Global Fund to fight against HIV/AIDS, Tuberculosis and Malaria. This work would not have been possible without technical support of World Health Organization. Sudan Journal of Rational Use of Medicine

Contents

Contents Editorial

Where Are We?

Current Topic

•

The Issue of Antibiotic Resistance

Practice Issues • Antibiotic Misuse • Community Associated- Methicillin-resistant Staph. aureaus (CA-MRSA) • Antibacterial Resistance (AMR): Urgent Actions Needed ! • Irrational Use of Antibiotics for Upper Respiratory Tract Infection (URTI)

Standard Treatment Guidelines • Standard Treatment Guidelines for Lower Urinary Tract Infection

Articles • Antibiotics Resistance: An Overview of the Situation in Sudan

Research Article • Prevalence of Co-amoxiclav Resistance in Urinary Tract Infections in Khartoum State News

Focus • Antimicrobial Resistance (AMR): 2014 Global Situation

Useful Tips • General Guidance on Preparation of Injectable Medicines

Questions and Answers

Success Stories • Pharmacists' Union, South Darfur State

Continuous Medical Education • How to Combact Anti Microbial Resistance( AMR) • Anti Biograms • Antibiotic Policy for Hospitals • Multi-Drug-Resistant Tuberculosis

Pharmacovigilance Awareness • Pharmacovigilance and Drug Safety

Sudan Journal of Rational Use of Medicine

Editorial

Dear fellows and readers

Antibiotics: The Double-Edged Sword!

Welcome to the 8th issue of SJRUM.

hat a coincidence that we are publishing the 8th issue of SJRUM addressing antibiotics resistance almost concurrently with the first World Health

Organization (WHO) Global Report on Antimicrobial Resistance. The WHO report categorically stated that a ‘post-antibiotic era’ could soon become a reality, which I’m

afraid, it already has! Medicines that were once life savers are no longer effective and resistant bacteria are currently threatening public health and wreaking havoc across the globe.

Multidrug resistance is becoming an eminent public threat due to the growing microbial

resistance which affecting almost all classes of antibiotics including mainly multidrugresistant Klebsiella pneumonia and Escherichia coli. These resistant pathogens have spread to all parts the world causing hospital-acquired infections such as pneumonia

and urinary tract infections. Strains of extensively drug-resistant tuberculosis (TB), methicillin-resistant Staphylococcus aurous (MRSA) are now considered serious threats to both humans and animals health. Resistant mutant strains are

overgrowing in an alarming rate replacing almost all susceptible bacterial populations especially when compared with resistance to antibiotics which was virtually zero 30 years ago.

The main topic covered in this issue which is entitled: “Antibiotics Resistance in Sudan” has revealed

that the situation in

Sudan is very grim even when compared with some neighbouring countries. The evidence provided by the author warrants immediate action due to the excessive use of antibiotics especially the third generation cephalosporins and quinolones. It is strikingly alarming that 60 to 80% of E.coli and K. pneumonia isolates encountered in two teaching hospitals in Khartoum are active producers of extended-spectrum beta-lactamase (ESBL) and the prevalence of Methicillin-resistant Staphylococcus

aureus (MRSA) infections in Sudan is ranging between 30 to 80%, whiles 2 to 25% of Staphylococcus aureus strains are emerging as vancomycin-resistant. The situation is further aggravated by the emergence of 3 to 5% of resistance among Pseudomonas spp even to carbapenems which are uniquely resistant to hydrolysis by most β-lactamases.

This issue of SJRUM is a snapshot of a complex problem. However, it intends to explicitly conveying an important message to

its readers which in essence underlines that the indiscriminate use of these medicines has contributed substantially to the persistence of infections, as a major cause of morbidity and mortality. Irrational use of antimicrobial agents has dramatically

accelerated this process and selected substantial number of resistant sub-populations which soon become the dominating member of the species. Antibiotics irrational use comprises inappropriate prescribing which is mainly due to the absence

of standard treatment guidelines and/or physicians do not adhering to them when they are available. It is estimated that

50 per cent of prescriptions by qualified physicians are inappropriate. Pharmacists have contributed significantly to this chaotic situation by dispensing of antibiotics and other prescription-only medicines to the public based on patient demand and not clinician’s assessment or prescription. Moreover, huge quantities of antimicrobials are used in veterinary sector for therapeutic as well as non-therapeutic purposes.

Undoubtedly there is a complex socioeconomic and behavioural factors associated with antibiotics resistance including the misuse of antibiotics by health professionals, unskilled practitioners and public in general. Poor drug quality, inadequate surveillance and stewardship also contributed significantly to the emergence and spread of antibiotic-resistant bacteria.

Implementation of a stringent antimicrobial stewardship policy across all health care settings seems to be indispensable to salvage the current situation.

Professor Sami A. Khalid

Sudan Journal of Rational Use of Medicine

here are we from:

Badereldin S. Hagnour

Underlying factors for AMRs

Ina ive qu dequ Wea s n e ality ate ant ko preh and syst com response surv imicrob r absen a f o d ial r uni ems k eilla t e c t a a L n esis n i nce d r o f m terrup to ens tanc and d coo n e e a d m syst icin ted s ure ems onitorin upp es g ly Ins Inap pre uffic pr ien ven t me opriate tion dia dici Poor infecti and gno nes use o on preventi stic , inc f an t o h n too era , and control ls hus luding timicro practices peu b ban in tic dry anim ial al sing Lack o nd dispen a f supe g in b ri c rvision Poor pres servic practices e train and in ing

Antibiotic

AMR can lead to: • • • •

Prolonged illness and greater risk of death Poor control of infectious disease Increase in the cost of health care Health insecurity and damage economies

Resistance prevalence

Amoxicillin

97.7%

Cefuroxime

92.5%

Trimethoprim-sulfamethoxazole

88.3%

Tetracycline

77.1%

Nalidixic Acid

72.0%

Ceftriaxone

64.0%

Ciprofloxacin

58.4%

Ofloxacin

55.1%

Amoxicillin-clavulanate

50.4%

Ceftazidime

35.0%

Gentamicin

35.0%

AMR Examples in Khartoum State Hospitals1 References 1. ME Ibrahm, NE Bilal, and ME Hamid ,Increased multi-drug resistant Escherichia coli from hospitals in Khartoum state, Sudan. African Health Sciences, Afr Health Sci. Sep 2012; 12(3): 368–375. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557680 . 2. WHO Rational use of medicines Fact sheet N°338 May 2010, available from: http://www.who.int/mediacentre/factsheets/fs338/en. 3. WHO Global Strategy for Containment of Antimicrobial www.who.int/drugresistance WHO_Global_strategy_English.pdf-896k 4. Mohamel L.S, Abd Rahim R.A. Assessment of self-medication in patient in Khartoum state. Ahfad University for Women, 2009. Unpublished Dissertation for partial fulfillment of BSc pharmacy.

Sudan Journal of Rational Use of Medicine

Current Topic

The Issue of Antibiotic Resistance

T Kamal M. Elhag1

he explosion of antibiotic usage worldwide was always followed by the appearance of clinical infection with organisms resistant to commonly used antibiotics.The global antibiotic resistance is rising, while development of new antimicrobials is lagging behind. We must value and conserve whatever antibiotics we have and should use them wisely and judiciously.

organisms and drug adverse effects associated with antibiotic use like pseudomembraneous colitis caused by Clostridium difficle. Collateral damage can be avoided by good selection of empiric antibiotics 5.

Effective antibiotic polices and rational uses in some societies have resulted in better outcomes.

At the Cleveland Department of Veteran Affairs Medical Centre, the addition of piperacillintazobactam to the hospital formulary Microorganisms are several and minimization of the administration of ceftazidime, were associated with steps ahead of us. marked decrease in ceftazidime-resistant Some of the causes of these rising bacterial isolates 6 . Furthermore, Paterson has resistance have been recognized to be due shown that fluoroquinolones resistance was to the unjustified overuse of antibiotics. significantly higher among ESBL producing Implicated practices have included; Enterobacteriaceae than non-producers 7. The the excessive use of third generation association between ESBL production and cephalosporins, which promote ESBL fluoroquinolones resistance was found to be production by Gram negative bacteria. Several due to co-transfer of qnr determinant that code reports have provided sufficient evidence that for reduced susceptibility to fluoroquinolones 8. overuse of third generation cephalosporins Another problem of Gram negative bacteria is associated with increase in the prevalence is the emergence of carbapenem-resistant of extended spectrum β-lactamase (ESBL) strains with increasing frequency. Meropenem producing bacteria as well as methicillinresistance may be due the notorious metallo-βresistant Staphylococcus aureus (MRSA)1,2. lactamases that inactivate all β-lactams except Cephalosporins use also was correlated aztreonam. Recently strains of Escherichia with the prevalence of ESBL-producing K. coli and Klebsiella spp. carrying genes for pneumoniae and multi-resistant A. baumannii 3. this resistance (blaNDM1) originated from The increasing prevalence of ESBL producers the Indian Subcontinent and have spread among Enterobacteriaceae worldwide worldwide 9. Infections with carbapenemhas prompted many centres to reduce the resistant organisms are treated with colistin consumption of oxyimino cephalosporins (colistimethate sodium) or tigecycline. and replace them with β-lactam-β-lactamase inhibitors. The latter are more effective In these series of articles the modes of and least associated with what is known as antimicrobial resistance, the current collateral damage1,2,4. Collateral damage is a therapeutic problems with resistance and finally term that describes adverse ecological effects the situation with antibiotics and antimicrobial of antibiotic therapy, like selection of resistant resistance in Sudan will be described. 1. Consultant Microbiologist, Soba University Hospital, Khartoum, kamal.elhag4@gmail.com

Sudan Journal of Rational Use of Medicine

Current Topic

References 1. Landman D, Chockalingam M, Quale JM. Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime resistant Klebsiella pneumoniae following changes in Antibiotic Hospital Formulary. Clin Infect Dis 1999; 28:1062-6. 2. Fukatsu K, Saito H, Matsuda T, Ikeda S, Furukawa S, Muto T. Influence of type and duration of antimicrobial prophylaxis on an outbreak of methicillin-resistant Staphylococcus aureus and on the incidence of wound infection Arch Surg 1997;132(12):1320. 3. Landman D, Quale JM, Mayorga D, et al. Citywide clonal outbreak of multiresistant Acinetobacter baumannii and Pseudomonas aeruginosa in Brooklyn, NY: the preantibiotic era has returned. Arch Intern Med 2002; 162:1515â&#x20AC;&#x201C;20. 4. Al-Lawati A, Crouch N, Elhag KM. Antibiotic consumption and development of resistance among Gram-negative bacilli in ICU in Oman. Annals of Saudi Medicine 2000; 20:324-7. 5. Weber D J. Collarateral damage and what the future might hold. The need to balance prudent antibiotic utilization and stewardship with effective patient management. International J of infectious diseases 2006; 10: S1- S14. 6. Denis O, Rodriguez-Villalobos H, Struelens J. The problem of resistance. In: Finch RG, Greenwood D, Norrby SR, Whitley RJ eds. Antibiotics and chemotherapy 9th ed. Edinburgh: Elsevier; 2010:24-48. 7. Paterson DL, Bonomo RA. Extended spectrum Î˛-lactamases: a clinical update. Clin Microbiol Rev 2005; 18:657-86. 8. Landman D, Chockalingam M, Quale JM. Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime resistant Klebsiella pneumoniae following changes in Antibiotic Hospital Formulary. Clin Infect Dis 1999; 28:1062-6. 9. Fukatsu K, Saito H, Matsuda T, Ikeda S, Furukawa S, Muto T. Influence of type and duration of antimicrobial prophylaxis on an outbreak of methicillin-resistant Staphylococcus aureus and on the incidence of wound infection Arch Surg 1997;132(12):1320.

Sudan Journal of Rational Use of Medicine

Practice Issues

Antibiotic Misuse Nuha M. Agabna

H Scene one

ala, a pharmacist working in a community pharmacy was suffering symptoms of cold, her throat is sore, had headache, stuffy nose and a troublesome cough. She used analgesic/ antihistamine tablets three times the day before and tried to survive the symptoms. She was tired, her symptoms had worsened and her chest was heavy, putting in mind that she has no way to rest, she decided to start an antibiotic. She choosed azithromycin because she usually forgets her tablets and a once-a-day regiment can help.

Scene two Khalid a medical officer was on his way out of the hospital after a long and exhausting shift, made worse by cold and cough that had been going for some days. He was thinking of what to do to get over the cold quickly because he has to prepare for tomorrow’s presentation. He meets Husam - a medical doctor- who showed concern over his health. After a short discussion over possible treatments; Husam gave his friend a strip of a free promotional sample of a third generation cephalosporin. Khalid accepted the drug thankfully and harried to start using it.

Scene three Mohamed a medical doctor received a telephone call from his sister; she was in the pharmacy requesting some therapy for her school aged boy who had some respiratory symptoms. After inquiring about the boy’s health, he spoke with the pharmacist to dispense an antibiotic and antipyretic.

Sudan Journal of Rational Use of Medicine

Two days later the boy became better, and resumed his school. The mother stopped giving the medicines as there was no need.

Problems

• The use of antibiotics to treat common • •

cold, cough and upper respiratory tract symptoms when viral infections are the likely cause. Use of strong antibiotics when first line antibiotics could be used. This exposes second and third line antibiotics to resistance with serious consequences. Health professionals using strong second line and third line antibiotics to treat themselves or family and friends without proper diagnosis or justified causes.

Solutions

• Raised community awareness about

• •

treatment of common cold, cough and the inappropriate use of antibiotics in their management is essential to limit the inadvertent use of antibiotics and reduces the pressure on health care professionals to prescribe/dispense unsuitable medication. Access to antibiotics should be restricted, and acquired only by prescriptions. Health care professionals should be encouraged and prompted to abide with standard treatment guidelines and protocols when treating family, friends and themselves. They should act professionally all the time even at out-ofthe-job situations.

Solutions: • RAISE AWARENESS • APPLY RESTRICTIONS • ACT PROFFESIONALLY

Practice Issues

Community Associated- Methicillin-resistant Staph. aureaus (CA-MRSA)

Randa A. Almahdi

Problems

Scenario

hmed was 5 years old boy. While he was playing on the gymnasium, he fell on his face and cut his lip, which has immediately swollen up. One day later, he developed fever. The mother took him to the hospital, where the pediatrician thought that the cut was infected and gave him oral cefpodoxime suspension to treat the infection. The pediatrician recommended flushing the cut to help clear up the infection. Two days later, Ahmed was brought by his mother to the ER with ₒ high grade fever of 40 C, coughing up blood and difficulty of breathing. The doctor told the mother that he has developed pneumonia, and decided to put him on IV ceftriaxone. Another doctor at the ER department has suggested checking for MRSA, and the results came out to confirm that it was MRSA!! The doctor then switched Ahmed to vancomycin. He became better quickly after that.

• Starting an antimicrobial without paying • •

attention for the possibility of MRSA Shifting to another antimicrobial again without taking specimen for specific identification of the pathogenic microbial agent. The mother should have been told to monitor the response to the prescribed treatment so that treatment failure may be detected earlier before the case gets complicated by a secondary infection or spread to other sites.

Solutions

• Differential diagnosis of infections • •

should include CA- MRSA among other suspected infections. Empirical prescribing of antibiotics should be according to approved guidelines. If MRSA is suspected an adequate specimen should be taken for culture and sensitivity before starting the empirical treatment.

Lesson learnt: CA- MRSA is becoming more common, and should be properly detected and treated

Sudan JournalofofRational RationalUse UseofofMedicine Medicine Sudan Journal

Practice Issues

Antibacterial Resistance (AMR): Urgent Actions Needed ! Senario

A 52 years old female admitted as an inpatient to the surgical unit for planned hysterectomy. She was well prepared for the postoperative period. One day following the operation she developed post operation urinary retention and her doctor decided to insert a urinary catheter, which was removed on day 4 of the operation. The following day (day 5), the patient developed 38.3 Ë&#x161;C fever and complained of suprapubic tenderness. Microbial Gram stain has detected Gram negative bacilli which was suspected to be E. coli infection and sent the midstream void urine specimen for culture and sensitivity, the doctor put her empirically, on IV ciprofloxacin with no improvement for two days, when the culture and sensitivity has revealed E. coli at > 105 , sensitivity has shown resistance to co-amoxiclave, ciprofloxacin, ceftriaxone, ceftazidine and amikacin and sensitive to imipenem, so therapy with imipenem was instituted intravenously until the 8th day of operation with remarkable improvement, then shifted to oral agent and discharged to home.

Problems

This is a hospital acquired multidrug resistant E.coli infection. Multi-drug resistant E. coli is recently, increasing in number, both as nosocomial and community acquired 1. Empirical antibiotic prescribing without considering the microbial sensitivity profile of that hospital, by merely recognizing the causative bacteria. Absence of antibiotic policy to guide both specific or empirical prescribing of antibiotics.

Enterobacteriaceae like E. coli and Klebsiella pneumoniae, are known to produce extended-spectrum B-lactamases (ESBLs), which are highly effective at inactivating B-Lactam antibiotics. ESBLs are difficult to detect, plasmid mediated, resistant to all B-lactam antibiotics Sudan Journal of Rational Use of Medicine

except cephamycins (cefoxitin), and carbapenems and frequently resistant to aminoglycosides and quinolonones. Known risks associated with development of this resistance are long-term antibiotic exposure, prolonged ICU stay, higher rates of ceftazidim and other third-generation cephalosporins use and/or aminoglycosides and instrumentation or catheterization1, the latter was the source of infection in this case.

Solutions

All bacteriological laboratories in all hospitals must develop an antimicrobial sensitivity profile (antibiogram) for the most commonly recovered microorganisms in those hospitals. Antibacterial prescribing must be guided by culture and sensitivity with selection of the agent of narrowest spectrum of activity.

Lesson learnt Effective infection control programs should involve all stakeholders at different levels, including: At the facility level, control measures should be in place, under the supervision of the Pharmacy and Therapeutic Committee (PTC), programs must include; adherence to policies and Standard Treatment Guidelines, isolation of individuals infected with resistant strains, hand hygiene, barrier precautions, and environmental control measures. Management guidelines and formularies to monitor prescribing and dispensing practice and the use of guidelines should be developed. At the level of the prescribers and dispensers, Rational Use of Medicines programs should be introduced in education of both undergraduates and postgraduates. Reference 1. Zaeinalabdin M. (2012). Antibiotics use in hospitals. A survey done in Royal Care International Hospital (personal communication).

Practice Issues

Irrational Use of Antibiotics for Upper Respiratory Tract Infection (URTI)

Habab K. Elkhair

Senario

16 years old male was referred to the chest clinic Omdurman Teaching Hospital as a case of severe bronchial asthma; he was on salbutamol syrup and prednisolone tablets. He presented with cough and difficulty of breathing for more than three weeks with history of similar condition for the last five years. He has been treated as a case of URTI and pneumonia and sometimes as bronchial asthma. Also he had a history of headache, nasal block and sometimes nose stuffiness. Medication history included repeated use of many types of antibiotics without complete improvement. No history of culture or gram stain for either sputum or blood. On examination he looked ill, febrile and dyspenic. Chest X ray showed signs of bronchoectisasis, and High Resolution Computed Tomography (HRCT) was requested. HRCT showed bronchial changes

at the upper and right zone in addition to prebronchial fibrotic changes. Culture results revealed resistance to amoxicillin, cephalexin, and clarithromycin, and sensitive to ceftazidime. It was eventually diagnosed as bronchoecectasis secondary to chronic sinusitis. The patient was treated with ceftazidime injection 500 mg 8 hourly and he was scheduled a regular follow up with a chest physician.

Problem Multiple irrational use of antibiotics for URTI lead to antimicrobial resistance and permanent complications such as bronchiectasis.

Solutions

â&#x20AC;˘ To avoid repeated use of antibiotics â&#x20AC;˘

without any clear indication. In case of using antibiotics many times without response full screening for the patient should be performed. If there is still need to use antibiotics culture and sensitivity testing should be performed.

Sudan Journal of Rational Use of Medicine

Standards Treatment Guidelines

Lower Urinary Tract Infection

Introduction Lower urinary tract infection is confined to the urinary bladder is also known also as cystitis. Cystitis is a common infection that affects both sexes but more common in females and the elderly. The infection is often endogenous, caused by microorganisms originating from the patient’s own bowl. Infection is acquired by faecal-genital route, often via periurethral colonization and ascending to the bladder. Infection is facilitated by partial or complete obstruction. The most common causative agents are Escherichia coli, Proteus mirabilis and Klebsiella pneumoniae. Staphylococcus saprophyticusis encountered in young female patients, while Enterococcus spp. infects more commonly elderly persons. Candida spp. is of doubtful clinical significance if associated with catheters.

Signs, Symptoms and History Patients with cystitis are usually afebrile and the predominating symptoms are dysuria and increased frequency of micturition. They usually present with typical manifestation that is hard

Sudan Journal of Rational Use of Medicine

to miss. They sometimes complain of suprapubic heaviness, discomfort or pain. Occasionally the urine may be bloody. Infection in children tends to manifest with different symptoms, depending on the age of the child. In children less than 2 years, the symptoms are nonspecific. The child may present with vomiting and fever. When children are over 2 years, they present with more localized symptoms such as frequency dysuria and flank pain.

Referral criteria

• Relapse is defined as infection that occurs •

1-2 weeks after cessation of antibiotic therapy and may be caused by the same organism. Reinfection which is defined as infection that occurs every 2-3 years to several times a year and is usually caused by different organisms. Reinfection may be associated with structural abnormality of the urinary tract.

Standards Treatment Guidelines

11 Pharmacological Management

Investigations Urine analysis: Ideally, midstream urine (MSU) specimen is collected in a sterile container for microscopic examination and culture (contamination from the distal urethra is common). Urine is examined microscopically for white blood cells (pus cells), red blood cells and bacteria. The presence of > 8 pus cells per high power field is suggestive of urinary tract infection. In Gram negative infection other than Pseudomonas spp. bacteriuria may also be demonstrated by positive nitrite test. Nitrite is formed by bacterial metabolism of nitrate. Then Semi-quantitative culture is done. Growth of > 100,000 colony forming units /ml confirms the diagnosis.

Non Pharmacological Management

Treatment is usually empirical using the appropriate antibiotic and should be started as soon as possible in order to avoid complications. Collect midstream urine for culture before commencing therapy.

• Adult: Nitrofurantoin 100 mg orally every •

12 hours for five days OR TrimethoprimSulfamethoxazole (TMP-SMX) 480 mg every 12 hours for five days. Children: Nitrofurantoin 2mg/kg (max 50 mg) orally every 12 hours for five days or Trimethoprim-Sulfamethoxazole (TMPSMX) 5 mg/kg every 12 hours for five days.

Follow up:

If the patient did not respond after three days of treatment, change the antibiotic according Patients should be advised to take plenty of fluids to the sensitivity report. Continue treatment for 7-14 days with the new antibiotic, according to with frequent emptying of the bladder. response.

Signs:

Pathogens:

• Frequent micturition turbid urine

E.Coli, Proteus mirabilii, Klebsiella, Entero- bacter, staphylococcus

• Dysuria

• Suprapubic pain

Empiric Rx: • Nitrofurantoin

Alternative Rx: • TMP/SMX (if not resistant)

Reference Sudan National Standard Treatment Guidelines, Directorate General of Pharmacy, Federal Ministry of Health, Sudan, 2014

Sudan SudanJournal JournalofofRational RationalUse UseofofMedicine Medicine

Articles

Antibiotics Resistance: An Overview of the Situation In Sudan

Mohamed E. Ahmed 1 ntibiotic resistance is a global concern that seriously requires global solutions. Antibiotic stewardship is a set of activities and polices developed to improve patient outcomes, contain development of resistance and increase cost effectiveness. Stewardship can decrease antibiotics use by 20-40%, reduce incidence of health-care-associated infections (Clostridium difficile, MRSA, and others), lengths of hospital stay, and prevalence of bacterial resistance. Typically, antibiotic stewardship has been developed in the hospital context in resourcerich countries, but stewardship activities should be expanded to primary care on a national level. They should be implemented by all health-care facilities and should be part of accreditation programs as well.

In Sudan, the situation is even more complicated by general inappropriate use of antibiotics that may have led to the development of resistance; imprudent use of antibiotics, availability of too many antibiotic brands for the same generic with no clear quality control measures, routine use of antibiotics in livestock for treatment and use of sub-therapeutic doses for animals' growth promotion 2. This short communication is intending to address some of these practices: • Lack of regulation of antibiotic prescribing and dispensing in our healthcare settings. Antibiotics can be easily obtained as selfmedication without prescriptions and there is no official prescription form. • Antibiotic overuse; even when not indicated like in cases of viral infections. A serious misconception shared by some professionals is the role of antibiotics in wound healing. Treatment of an abscess is surgical drainage only; however, still antibiotics are regularly used. Another public wrong concept about antibiotics is their use in curing most of acute health problems. The development of resistance as a result of this overuse will offset its effect later in life when it is needed by the same person to combat sepsis.

Ideally, stewardship teams should include an infectious diseases physician, a clinical pharmacist, a clinical microbiologist, information system specialist, infection control professional, and a hospital epidemiologist. Several European countries were successful in controlling • Spontaneous antimicrobial prescribing antibiotic resistance through implementation of when treating pyrexia which is often comprehensive national strategies 1. diagnosed empirically as malaria by symptoms and anti-malarial therapy are Complexity of situation in Sudan: taken with or without blood film test. Failure • General inappropriate use of to respond is often followed by anti-typhoid antibiotic. treatment based either on persistence of the pyrexia or on a wrong interpretation of • Availability of too many the Widal test result. brands for the same generic. • Sub therapeutic doses for • The issue of prescribing by generics versus animal growth promotion. brand name is debatable, as impression • Routine use of antibiotic for there is a great variation in the efficacy; the animal treatment. question whether the administration of poor 1. ElRasheid Ahmed MS, Professor of Surgery, University of Khartoum, rasheid@usa.net

Sudan Journal of Rational Use of Medicine

Articles

quality antibiotics will contribute to the antibiotic resistance? Common sense will answer positively. â&#x20AC;˘ There is a major concern about using prophylactic antibiotics in surgical operations, nearly 60% patients undergoing surgical operations in Khartoum teaching hospital were found to receive un-necessary course of 7 days antibiotics for clean and clean contaminated operations 2 Moreover, the estimated un-indicated antibiotic prescription in the surgical, orthopedics and obstetrical wards in the year 2010 was 1000 SDG. Even the approved antibiotic policy for prophylaxis has failed to solve this problem. Strategies to control antibiotic resistance, according to the suggested global solutioninclude, but are not restricted to, good health-care infrastructure and health insurance for all; limited drug advertising; surveillance of antibiotic use and to detect resistance in human beings and animals; policies for prudent antibiotic use in human beings and animals; standardized infection control policies and sufficient staffing; antibiotic stewardship programs in hospitals and other health-care facilities; and isolation or decontamination of

patients with resistant organisms. Essential elements of an antibiotic policy include a stable and restrictive list of antibiotics in use, standard treatment guidelines, audit and feedback of prescriptions, surveillance of bacterial resistance and antibiotic use, and education at all levels. Regarding, our local Sudanese settings, other important policies can be added; restriction of purchased antimicrobial agents to very few worldwide recognized companies which encourage them to offer low prices in exchange for closing the market to those few versions, the co-ordination with veterinary health authorities to combat the irrational use of antibiotics in livestock. In order to improve the level of knowledge of healthcare professionals about antibiotic use, proper training should be scheduled in the CPD program (Continuous Professional Development). Hospitals must have guidelines on antibiotic use monitored by clinical pharmacist. The microbiology laboratory should provide doctors with drug sensitivity data and a monthly report about the consumption rate and types of the prescribed antibiotics as well to guide in selecting the proper empirical antibiotics.

References: 1. Ramanan Laxminarayan, Adriano Duse, Chand Wattal et al. Antibiotic resistance â&#x20AC;&#x201C; the need for global solution. The Lancet. 2013, 13(12): 1057- 1098. 2.

Mathew AG, Cissell R, Liamthong S. Antibiotic resistance in bacteria associated with animals: a United States perspective of livestock production. Foodborne Pathog. 2007, 4(2):33-115.

Sami Jalal, Seif I Mahad, Mohamed E, Ahmed. Antibiotics prophylaxis in elective surgery in Khartoum Teaching Hospital: current practice and surgical site infection. 2010, 46 (3), 132 - 141.

Sudan Journal of Rational Use of Medicine

Research Articles

Prevalence of Co-amoxiclav Resistance in Urinary Tract Infections(UTI) in Khartoum State

Abeer F. Abojabal1, El amin I. Elnima2

Introduction

ntibiotic resistance is a worldwide public health problem that continues to grow. It occurs when strains of bacteria in the human body become resistant to antibiotics due to improper use of antibiotics1. This problem began with the Sulphonamide resistant organisms such as Streptococcus pyogenes which emerged after using the drug in a wide spectrum especially among the Second World War. The prevalence of resistance varies between geographical regions and over time. The choice of antimicrobial should be guided by local or national resistance surveillance data and treatment guidelines2. Wide spread overuse and insufficient dose of antibiotics has been described in African, South American and Asian countries3. A survey of WHO (2000) showed that in Sudan primary health care 62% of patients receive antibiotics and reported this percent as the highest in Africa4. Co-amoxiclav is the British approved name, for the combination antibiotic consisting of the semisynthetic antibiotic amoxicillin and the Î˛-lactamase inhibitor clavulanate potassium (clavulanic acid) 5 . It was designed to overcome resistance to amoxycillin-mediated by B-lactamases produced by Staphylococcus species. Co-amoxiclav is listed in Sudan Essencial medicines list. Urinary tract infections are one of the most common infectious diseases diagnosed in out-patients as well as in hospitalized patients. According to the annual health statistical 1. Pharmacy Specialization Board, abeer.f.s@hotmail.com 2. Professor of Microbiology, University of Khartoum

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report there are 3270 cases of pyelonephritis and 343 cases of cystitis in Sudan at 20076. It has been observed that Co-amoxiclav is highly consumed at hospital and community pharmacies, much evidence support the view that the total consumption of antimicrobials is the critical factor in selecting resistance. Resistance to antibiotic used to treat UTI may convert simple UTI to complicated infections that spread to other parts of the body and become difficult to cure.

Objectives The purpose of this study was to determine the prevalence of Co-amoxiclav resistance among bacteria strains responsible for UTI, and suggest solutions for containment of antibiotic resistance.

Methods A retrospective descriptive cross sectional study, this is a data was collected from the records of microbiology labs of five teaching hospitals at Khartoum State (Khartoum Teaching Hospital, Khartoum North Teaching Hospital, Omdurman Military Hospital, Ibn Sina Hospital, and Soba University Hospital) by using data collection sheet. Urine specimens of 432 patients with UTI attended the five hospitals from January 2008 to January 2009 were randomly selected. Data analysis was done using SPSS 13.0 (Statistical Package for Social Sciences) software for analysis of quantitative data.

Results and Discussion In the specimens studied Escherichia coli were the most commonly isolated bacteria representing 60.2% followed by Kelebsilla 20.8%, then Staph aureus 12.7% and pseudomonas aerginosa 6.3%. The levels of Co-amoxiclav resistance in the 5 teaching

Research Articles hospitals in Khartoum State appeared to be dramatic and worrisome. The total resistance rate to Co-amoxiclav was found to be 73% (n=432) as shown in (figure 1). The resistance rate to Co-amoxiclav was found to be in E.coli 78.5%, Klebsiella spp 67.8%, Staph. aureus 41.8%, Pseudomonas aeruginosa 96.3% as shown in (figure 2), There was no relation found between the gender of patient and the resistance rate to Co-amoxiclav among E.coli, Klebsiella, P. aeruginosa and S.aureus (P value >0.05). Susceptibility testing should be adopted as a basic routine laboratory procedure in hospitals and clinics in order to guide appropriately on the right choice of antibiotics. Prescribing Co-amoxiclav in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria7.

3.7%

100.0% 90.0%

21.5% 32.2%

80.0% 58.2%

70.0% 60.0%

96.3%

50.0% 40.0%

78.5% 67.8%

30.0% 41.8%

20.0% 10.0% 0.0%

E. coli

Klebsiella

Staph. aureus

psudomonas aerugenosa P.aeruginosa

Resistant Susceptible

Figure 2: Resistance rate of bacterial types to Co-amoxiclav

References 1. WHO Global Strategy for Containment of Antimicrobial Resistance. World Health Organization Department of Communicable Disease Surveillance and Response. WHO/ CDS/CSR/DRS/2001.2 p 11 -35.

(118) 27%

(314) 73%

Resistant

Susceptible

Figure 1: Total resistance rate of bacteria to Co-amoxiclav at the five teaching hospitals.

Conclusions and Recommendations High prevalence of resistance to Co-amoxiclav was observed among bacterial strains responsile for UTIs (E.coli, Klebsiella, P.aeruginosa, Staph. aurues). Co-amoxiclav should not be given empirically in UTI. Infection control programs, Pharmacy and therapeutic committees, and antibiotics prescribing policies should be established.

2. Avorn JL, Barrett JF, Davey PG, McEwen SA, TF O’Brien and SB Levy. Antibiotic resistance: synthesis of recommendations by expert policy groups Alliance for the Prudent. Use of Antibiotics. Boston, MA, United States of America.WHO/CDS/CSR/DRS/2001.10-11. 3. Improving antibiotic prescribing in Hai Phong Province, Viet Nam: the ‘‘antibiotic-dose’’ indicator. Bulletin of the World Health Organization, 2001, 79 (4). 4. Holloway.K. Antimicrobial resistance, who contributes to misuse of antimicrobials? . Essential Drugs Monitor. WHO journal. 2000 (9), 28-29. 5. British National Formulary (BNF) .53, UK. March 2007.1and2 P; 284-285. 6. Urinary tract infections (http://www.emedicinehealth.com/ urinary_tract_infections/article_em.htm . Accssed;12 march 2009).. 7. Prescribing information (Augmentin ), AG:AL16 December 2006 (http://us.gsk.com/products/assets/us_augmentin. pdf accessed; 25 Februarys 2009).

Sudan Journal of Rational Use of Medicine

News

News Alyaa F. AL-Mahdi

Widespread antibiotic resistance across all WHO regions WHO. April 2014

The World Health Organization (WHO) published a new report on antibiotic resistance from 114 member countries which has shown that antibiotic resistance is now a major threat to public health. “Without urgent, coordinated action by many stakeholders, the world is headed for a postantibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill” says Dr Keiji Fukuda, WHO’s Assistant Director-General for Health Security. The key findings from the report include the following: • Data obtained for E.Coli, K.Pneumoniae and S.aureus showed that the proportion resistant to commonly specified antibacterial drugs such as fluoroquinolones and third generation cephalosporins exceeded 50% in many settings.

• Resistance to carbapenems, which is the

last resort antibiotic, has been reported with Klebsiella P. in all WHO regions.

• Resistance has been shown in both

gonorrhoea and tuberculosis in most WHO regions.

The WHO urges that member states continue in surveillance studies to identify other areas where microorganisms have developed resistance to commonly used antimicrobials.

Vitamin D levels are associated with improved outcomes for cancer patients Journal of Clinical Endocrinology and Metabolism. April 2014

Li and colleagues have published a metaanalysis that includes 17,000 patients on the association between high circulating vitamin D Sudan Journal of Rational Use of Medicine

levels and outcomes in patients diagnosed with cancer. The study found that overall survival for colorectal and breast cancer patients in the highest quartile of circulating 25-hydroxyvitamin D levels was significantly better than it was for those in the lowest quartile of 25-hydroxyvitamin D levels. Overall survival was also significantly better for lymphoma patients in the highest 25-hydroyvitamin D quartile compared with those in the lowest quartile.

India Moves to repair its reputation as a safe exporter of cheap affordable drugs Reuters. April 2014

India is launching a campaign to repair its reputation as a global supplier of cheap highquality drugs, responding to bans imposed by U.S. Food and Drug Administration (FDA) on several suppliers. As part of the charm offensive, New Delhi has invited global regulators - including the FDA to visit Indian production units to get first-hand evidence of measures taken to ensure the quality of locally manufactured generics. ''Our quality standards are among the best in the world. If a neutral audit is done, it will find our true capabilities and strengths,'' Ashutosh Gupta, chairman of the Pharmaceuticals Export Promotion Council (Pharmexcil), which groups more than 3,700 exporters. Worries about quality control in India's $15 billion drug industry have come to the fore in the past year as plants run by Ranbaxy Laboratories Ltd and rival Wockhardt Ltd have been barred from sending drugs to the United States after falling short of the FDA's ''good manufacturing practices''. Gupta said that although the FDA has issued import alerts over issues of data documentation, testing facilities and procedures at Indian facilities, there was no issue with drug quality.

Sudan Jornal of Rational Use of Medicine

Focus

Antimicrobial Resistance (AMR) 2014 Global Situation

Extracted By: Einas S. Elwali 1

ntimicrobial resistance (AMR) is currently increasingly becoming a serious global public health threat that requires a prompt action across all governmental and societal sectors. The AMR threatens the effective prevention and treatment of an ever increasing range of bacterial, parasitical , viral and fungal infections. The World Health Organization (WHO) has responded in 2014 to this challenging situation by publishing its first global report surveillance of antimicrobial resistance, with data provided by 114 countries. The report concluded that;

• The third generation cephalosporine, which was the last resort drug for Gonnorhea has been associated with treatment failure in 10 of the developed countries, while 36 countries have reported decreased susceptibility to the drug.

219 million people of whom 660.000 died. Resistance of malaria to the earlier antimalrial drugs in malaria endemic areas has led to replacement of these drugs by artemisinin based regimen. However, resistant starins to artemisinin is now spreading or emerging in other new regions jeopardizing the new beneficial protocol as well.

• Multidrug resistant tuberculosis (MDR)

cases are increasing, rated at 6% of newly diagnosed cases and 20% of previously treated cases with substantial variations in frequencies among different countries.

• There is an indication of increasing level

of resistance to non-nucleoside reverse transcriptase (NNRTI) class of drug used to treat HIV; this is particularly noticeable in Africa, where the prevalence of resistance has reached 3.4% in 2009.

ANTIMICROBIAL • Patients who develop infections caused by multidrug resistant bacteria such as CE RESISTAN MRSA tend to stay in hospital longer, using more resources than other patients. • Resistant E coli urinary tract infections Report Global to oral fluroquinolones is now very widly • Key tools to tackle antibiotic resistance; spread. like basic systems to track and monitor ce on Surveillan the problem, do not seem to exist in • Resistance of infections caused by

Staphylococcus aureus, both community or hospital acquired to first line drugs are now very common. The methicillin resistant Staph. aureus (MRSA) now exceeds 20% rates in all of the WHO regions.

• Resistance to Carbapenam antibiotics-

which were considered the last resort for life threatening intestinal infections has exceeded the rate of 50% in all regions of the world.

• Malaria is a public health problem,

many countries.

• Coordinated and prompt actions are

urgently required to minimize emergence and spread of AMR.

Extracted from: Antimicrobial resistance (AMR) global report on surveillance. World Health Organization. ISBN 978 92 4 156474 8, 2014.

reported by the WHO in 2010 to affect

1. Planning and Policies Directorate, Directorate General of Pharmacy

2014

Sudan SudanJournal JournalofofRational RationalUse UseofofMedicine Medicine

Useful Tips

General Guidance on Preparation of Injectable Medicines Eslam A. Eltoom

Ensure that your preparation area is clean, uncluttered and free from distraction.

Check that you have the correct medicine and diluents (look at the name and strength). Check the packaging of your medicine and diluents, it should be undamaged and within the expiry date.

Clean your hands with alcohol gel for (30 seconds) Or with water and soap for (60 Seconds) Then put on disposable protective gloves.

Peel open wrappers carefully and arrange all ampoules, vials, syringes and needles neatly in the tray.

Always use 'non-touch' technique when preparing the antibiotics. Never touch the ends of needles, nozzle of syringes, necks of ampoules or rubber bungs. Never re-sheath a needle and always use a sharps bin. If you think you may have contaminated the needle, syringe or vial during the procedure (by touching or dropping) then discards it and start again.

Prepare your injectable medicine by the relevant method a) Drawing up a diluent (withdrawing solution from an ampoule into a syringe). b) Drawing up an antibiotic (withdrawing solution/suspension from a vial into a syringe) . c) Adding diluent to a powdered medicine vial and then drawing into a syringe (reconstituting powder in a vial and drawing the resulting solution/suspension into a syringe). d) Adding a medicine to an infusion bag.

7. Discard the ampoule and syringe with needle as whole in the sharps bin.

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Questions and Answers

Q&A Sawsan E. Ahmed

Q. What is antimicrobial resistance? A. Antimicrobial resistance (AMR) is resistance

of a microorganism to an antimicrobial medication to which it was originally sensitive. Resistant organisms (they include bacteria, fungi, viruses and some parasites) are able to resist antimicrobials, such as antibiotics, antifungals, antivirals, and antimalarial, so that standard treatments become ineffective and infections carry on increasing risk of spread to others.

Q. Why is antimicrobial resistance a global concern?

A. It may leads to death because Infections caused by resistant microorganisms often fail to respond to the standard treatment, so resulting in prolonged sever illness and a greater risk of death. Many infectious diseases risk becoming untreatable and uncontrollable, and the risk of spreading resistant microorganisms by infectious patients is increased because AMR reduces the effectiveness of treatment, thus patients remain infectious for a longer time. AMR increases the costs of health care because more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the economic burden to families and societies.

Q. What are the factors that may

accelerate the emergence and spread of AMR?

A. AMR is considered a natural phenomenon.

However, certain human actions accelerate its spread. Underlying factors that may accelerate the spread of AMR include: inappropriate use of antimicrobial medicines, poor infection prevention and control practices, insufficient

diagnostic, prevention and therapeutic tools, weak or absent antimicrobial resistance surveillance and monitoring systems and inadequate systems to ensure quality and uninterrupted supply of medicines.

Q. What are the most important ways to prevent AMR?

A. AMR is a complex problem driven by many interconnected factors hence single, isolated interventions has little impact and coordinated actions are required. Unnecessary prescribing and overprescribing of antibiotics should be rationalized. This occurs when people expect doctors to prescribe antibiotics for a viral illness (antibiotics do not work against viruses) or when antibiotics are prescribed for conditions that do not require them, complete the entire course of the prescribed antibiotic so that it can be fully effective and not breed resistance. It is also important to practice good hygiene and use appropriate infection control procedures.

Q. What are the precautions that

could be followed in healthcare facilities in order to minimize the spread of AMR?

A. Since healthcare facilities could be a source

of transmission of AMR; implementation of standard precautions will minimize the risk of transmission of infection from person to person, even in high-risk situations.

The recommended precautions to be followed in all healthcare facilities in order to minimize the spread of AMR include good personal hygiene, such as hand washing before and after patient contact, the appropriate use of alcohol-based hand rub solutions, the use of barrier equipment such as gloves, gowns and masks, appropriate handling and disposal of sharps (for example, needles) and clinical waste (waste generated during patient care) and aseptic techniques.

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Success Stories

Pharmacists' Union, South Darfur State If We Can Do it, So Can You!

Mihad A. Mohamed1, Asia M. Zareiba 1, Eilaf M. Alaajeb 1

he Pharmacists Union in South Darfur State has been inactive for a long period of time. In 2011, the extraordinary General Assembly for the Union of pharmacists met in South Darfur and a new Union was formed. The union comprised of young pharmacists who showed great enthusiasm and determination. It sets a clear vision to improve the public health practice in general and the pharmaceutical profession practice in particular. The Unionâ&#x20AC;&#x2122;s secretary of Media and Culture first step was to communicate with the Central Government of South Darfur to gain support. The Union found the best way is to gather all stakeholders and partners in an event for advocacy and support. The Union planned to run a workshop on Professional Development with an aim to improve the quality of service in health in South Darfur on the subject of professional development. Cooperation between members of the Media Office and Scientific Office began by planning to organize the workshop. This included sponsoring of the workshop, to contacting the specialists, and collecting samples of prescriptions with the most common medical errors in the State to be discussed at the workshop.

To further enrich the discussions, contact was made with Professor Abdalla Elkhawad and Dr. Kamal Mohamed Ahmed (Alomda) from Khartoum State. Despite the distance and the security issues in South Darfur they agreed to attend giving us more moral support which has filled us with more enthusiasm, will, and determination. The challenge was too big for the newly formed Union. The Financial Secretary did not have enough money to run such a workshop; the money was the first and most important hurdle. After a number of meetings and consultations, a proposal to cover the cost was made to all pharmacists in the State. Furthermore, a partnership with the health insurance in the State of South Darfur was formed which gave more financial support and helped lift some of the burden. The health insurance in the State of South Darfur has invited another speaker Professor Elrasheid Ahmed Abdalla. After the partnership, committees were convened in a way that each committee consisted of a representative from the Union and another from the Health Insurance. The workshop was successfully conducted. The

1. Medicine supply fund , South Darfur Ministry of Health , South Darfur State

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Success Stories opening day was attended by the Governor of South Darfur, the Minister of Health, and the Minister for Social Welfare. A number of papers were presented covering a variety of issues including Rational Use of Medicine, antimicrobial prophylaxis in the surgical wards, and pharmaceutical promotion. everybody praised the efforts that resulted in a successful event.

the beautiful nature of Nyala. Guests received a warm reception and were taken to a picnic to the Valley of Nyala attended by the majority of workers in the field of health in South Darfur including specialists, doctors, pharmacists, and general physicians. This gathering was a good chance for networking and further strengthening the relationships.

We realized that, by determination, we can The success of the workshop was not only in achieve anything. If we can do it so can you! the papers presented and fruitful discussions but it was also a golden opportunity to show

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Continuous Medical Education

How to Compact Antimicrobial Resistance (AMR)

A Ghada O. Shouna

ntimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it was previously sensitive. AMR is a consequence of the use, particularly the misuse, of antimicrobial medicines and develops when a microorganism mutates or acquires a resistance gene1. During the past 10 to 15 years, antimicrobial resistance increased dramatically and is acknowledged to be one of the most serious threats to the treatment of infectious diseases; it is a threat to all branches of medical and public health practice2. It is recognized as a key public health concern for both developed and developing countries due to its potentially alarming socioeconomic impact on health. Besides wasting lives, hampering the control of infectious diseases, and increasing the costs of health care, antimicrobial resistance jeopardizes healthcare gains to society, threatens health security, damages trade and economies and threatens a return to the pre-antibiotic era 3. The cause of antimicrobial resistance is not hard to discover. In the past 50 years, people in both developed and developing worlds have accepted antibiotics as their right to obtain a prescription at the first sign of a minor infection or treat themselves with a handful of cheap antibiotics. As a result, these valuable drugs started to lose their magic effect.

on antimicrobial resistance contributes to poor understanding of the scale of the problem and deters an effective response to it. It also makes it difficult to regularly update diagnostic and treatment guidelines based on strong scientific evidence and to implement effective measures to prevent and control infections Fragmented health services and lack of access to quality-assured medicines at an affordable price often lead patients to take incomplete courses of treatment or to resort to sub-standard medicines, which create ideal conditions for the selection of resistant organisms. The absence of legislations regulating the quality and use of antimicrobials and poor enforcement efforts foster the unauthorized dispensing of antimicrobials by poorly trained persons and contribute to indiscriminate use. In addressing the issue of the increasing development of antimicrobial resistance, the World Health Organization has introduced a policy package, to combat AMR, stating the actions to be taken by governments to stimulate change, the package includes: 1. Governments must commit to a comprehensive national plan against antimicrobial resistance that brings together all the required recommended measures. This calls for: • The establishment of a national intersectional steering committee to guide actions by several stakeholders under the overall stewardship of the government; • Allocation of adequate resources;

Though actions to combat antimicrobial resistance have been taken forward, unfortunately it has through individual programs and institutions - where the effort is often fragmented and not comprehensive. Hence, the problem of antimicrobial resistance has not been prioritized by national governments.

• Setting an accountability framework, with measurable indicators and annual reports;

In order to develop effective strategies to combat AMR, the problems need to be well understood. The paucity of surveillance data

• Tracking antimicrobials use;

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• Building strong public awareness. 2. Strengthening the surveillance and laboratory capacity. • Surveillance of antimicrobial resistant organisms; • Capacity building of laboratories to ensure

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reliable and rapid test results on which to base prescribing decisions; • Developing standard protocols to assess antimicrobial resistance trends consistently over time and across geographical areas; • Regular reporting and dissemination of surveillance data – at regional and global levels; • Expansion of antimicrobial resistance surveillance systems to veterinary services. 3. Governments must ensure sustainable access to essential medicines of assured quality. • Presence of an effective national body to develop the essential medicines list based on standard treatment guidelines. • Provide sufficient public financing for essential medicines, including recommended antimicrobials; • Efficient systems for managing drug procurement and distribution to avoid interruptions in supply or wastage. • Comprehensive drug regulations; • Presence of an independent national drug regulatory authority that is responsible and accountable for all aspects of drug regulation. 4. The rational use of antimicrobials for containing antimicrobial resistance. • The promotion of national standard treatment guidelines; • Proper training and supervision of health personnel; • Mechanisms to make diagnostic support available; • Antimicrobials should only be dispensed with a prescription and this should be strictly enforced in all pharmacies; • Independent and unbiased information on antimicrobial use should be provided to health personnel and consumers;

financial incentives to providers; • The overuse and misuse of antimicrobials in animals for human consumption must be addressed through surveillance of antimicrobial use in animals destined for food; • Training of veterinarians and farmers. 5. Policies and practices for the prevention and control of infections are crucial in fighting antimicrobial resistance. • A proper organizational structure for developing and managing infection control policies and practices (in health facilities and communities). 6. Operational research and research and development to make new tools available are to combat antimicrobial resistance. • Improving current diagnostic tests and antimicrobials and designing incentives to engage industry in the development of new tools; • Regulatory bottle-necks need to be eliminated and resources must be mobilized for rapid access to new tools. Single, isolated interventions proved to have little impact. Strong leadership and political will are required to bring about bold changes in policies, organize health systems and legislative structures as required, and translate knowledge and recommendations into practice. References 1. World Health Organization. Rational Use of Medicine. http://www.who.int/medicines/areas/rational_use/en/ (accessed 2011 ). 2. Conly J. Antimicrobial resistance in Canada. Canadian Medical Association Journal. 2002, 167(8). 3. World Health Organization. Antimicrobial resistance, Fact sheet N°194. http://who.int/mediacentre/factsheets/ fs194/en/ (accessed 2011).

• Promotional activities by pharmaceutical companies should be regulated and monitored to prevent industry from misinforming patients and from offering Sudan Journal of Rational Use of Medicine

Continuous Medical Education

Antibiograms Samia A. Gumaa1

What are antibiograms? Antibiograms are cumulative susceptibility testing results, organized in the form of a summary table or a histogram, which may be used by clinicians, infection control personnel, pharmacists and microbiologists as a reference guide to community or hospital specific bacterial resistance patterns 1. A typical antibiogram displays the total number of bacterial isolates tested against a range of antimicrobials and includes the percentage of bacterial isolates susceptible or resistant to each antimicrobial agent tested. The factor that converts antimicrobial therapy from empiric to rational is in-vitro susceptibility testing and reporting. Hospital antibiograms may summarize susceptibility testing results of local bacterial isolates submitted to the hospital's clinical microbiology laboratory for an entire hospital by inpatient, outpatient, and intensive care units or by individual wards.

Antibiogram uses:

• Assess local susceptibility rates. • Aid in selecting appropriate antibiotics therapy. • Monitoring resistance trends over time within institution 2. • Reduce inappropriate antimicrobial usage.

What is hospital antibiogram used for? Hospital antibiograms are commonly used to help guide empiric antimicrobial therapy before specific patient’s culture results are available. They are an important component of detecting and monitoring trends in antimicrobial resistance provided they are constructed using standardized methods that allow inter- / intrahospital comparisons. They must fully comply with the Clinical Laboratory Standards Institute (CLSI) standards 3; if not the methods used to conduct antibiograms should be clearly delineated. Antibiograms that include duplicate

bacterial isolates can over-estimate rates of resistance. Traditionally, clinical laboratories have manually tabulated these data but increasingly automated methods are being utilized by various laboratory information systems.

What are the limitations of Antibiograms? 1. Having limited value for tracking antimicrobial resistance and guiding empiric treatment. 2. They provide susceptibility data but they do not differentiate between pathogens and colonizers. 3. They reveal qualitative measures of susceptibility but do not provide quantitation data such as Minimum Inhibitory Concentration (MIC). Hospital laboratories usually generate antibiograms every 6 – 12 months; the data is then entered into an antibiogram data-base. Limitations of hospital antibiograms is that they don’t sort out community acquired infections from nosocomial infections. Some laboratories may not thoroughly unduplicate their data, thus giving a larger number of resistant isolates than is the case. Hospital-level cumulative antibiograms can be used for local surveillance of antimicrobial resistance. A uniform approach to susceptibility testing will increase the amount of data that can be aggregated, increasing representativeness and generalizability of results. A coordinated approach among laboratories within a defined surveillance area will help to overcome weaknesses of this surveillance method. Specification of both the clinical and technical elements of cumulative antibiograms will support antimicrobial prescribing and Antimicrobial Stewardship (AMS) in general. In addition, specification of the cumulative antibiograms can eventually support national

1. Consultant Microbiologist at Royal Care International Hospital (RCIH), Khartoum, Sudan.

Sudan Journal of Rational Use of Medicine

Continuous Medical Educatio9 surveillance, mapping and monitoring of antimicrobial resistance.

Disadvantages of aggregated cumulative antibiogram: 1. Data at the hospital level may estimate the proportion of drug resistance in the population served by those hospitals, but does not reflect the actual neighborhood surrounding the facility. So, it is important to define the specific groups served by the hospital. 2. Does not allow evaluation by age or other variables of interest such as race and gender. 3. Lack of patient and/or case â&#x20AC;&#x201C; specific data eliminates opportunity for more in-depth analysis.

Antibiogram is the first step before framing the antibiotic policy In spite of the limitations of antibiograms they are very important tools for helping clinicians in the rational selection of an empirical antimicrobial therapy especially in rural areas where facilities for Antimicrobial Susceptibility Tests (AST) are not available. Hospital laboratory susceptibility testing is routinely performed and antibiograms are commonly available. If computerized summary techniques are in place, laboratory staff effort is limited to sending a current antibiogram to the health department but unfortunately this is not the case in most of our hospitals in Sudan. At Royal Care International Hospital (RCIH), in the microbiology laboratory, antibiograms are prepared manually for the more common isolates against the antimicrobials that are currently found in the hospital formulary and represent potential clinical options for clinicians. They are prepared annually in the form of Histograms (Fig.1) showing the number of resistant, sensitive isolates against the different antimicrobial agents according to the CLSI guidelines, and performance standards for AST. These are distributed to the

clinicians to assist them to choose the correct antimicrobial drugs for empirical therapy before the laboratory reports are available, and warn them of the emergence of antimicrobial resistant pathogens. Appropriately and continuously collected data for antimicrobial resistance surveillance can be used to develop annual antibiograms. These shall detect shifts in susceptibility, serve as a basis for empiric therapy, formulary decisions, and change in prescribing and infection control practices. Antibiotic policy is one of the mandatory requirements for Joint Commission International (JCI) accreditation. The future of antibiograms would be the incorporation of patient related data to make information more reliable and for predicting outbreaks.

Antibiogram of E.coli isolates at RCIH July 2011 â&#x20AC;&#x201C; July 2012

References 1. Fridkin SK, Edwards, JR, Tenover FC, Gaynes RP, McGowan JE Jr. Antimicrobial resistance prevalence rates in hospital antibiograms reflect prevalence rates among pathogens associated with hospital-acquired infections. Clin Infect Dis. 2001 Aug: 33(3):30-324. 2. Joshi S. Hospital antibiogram: a necessity. Indian J Med Microbiol. 2010 Oct-Dec: 28(4):80-277. 3. The National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Susceptibility Testing; Fourteenth Informational Supplement. Wayne, PA, 2004. (NCCLS Document M100-S14)

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Continuous Medical Education

Antibiotic Policy for Hospital

Mohamed A. Zeinelabdin, Randa A. Al mahdi

ntimicrobial resistance has become a major health problem worldwide. Resistant microbes are associated with very frequent treatment failures with first line drugs and expensive second line agents, which increases risk of death 1. Imprudent and overuse of antibiotics is a positive pressure on the pathogenic microbes that involves genetic selection, which on turn, leads to emergence of resistant strains that spreads to other patients (cross infection). Production of newer more effective antibacterial agents is not proceeding by a parallel pace to that of development of resistance to older agents, beside the fact that, the new antibiotics currently in the pipeline may not be effective against certain new mutations of killer bacteria that could turn into a pandemic soon, specifically, those which are grouped under the acronym 'ESKAPE' namely; Enterococcus faecium (vancomycin resistant enterococci), Staphilococcus aureus (MRSA), Klebsiella and Esherisha coli that produce extended specrum betalactamase enzymes ESBL, Acinetobacter baumannii, Psudomonas aeruginosa and Enterobacter spp 1.

The antimicrobial drugs are a nonrenewable resource The effective strategy to limit the spread of antibiotic resistance should be done by a multifaceted approach. The campaign must involve all the stakeholders; patients, doctors, policy makers and decision makers and should be centered on preserving the currently available effective agents, maximizing infection control practices via Sudan Journal of Rational Use of Medicine

antibiotic stewardship with clearly determined objectives; recognizing trends of antibiotic resistance in each health institution, reporting antibiotic resistance in individual patients and offering prompt treatment to eradicate the infection and development and implementation of antibiotic policy 1. The antibiotic policy must be developed to optimize choice and dose of the antimicrobial agent in their different uses; prophylaxis, empiric and definitive therapy. It should include specific recommendations for different high risk population groups, like the immunocompromized, patients with nosocomial and community acquired infections. The antibiotic prescribing must be according to standard treatment guidelines (STG). The approved policy then must be regularly monitored, revised periodically and reports written. There is no antibiotic policy that suits all. Ideally, an antibiotic policy should be developed and tailored to each health care setting separately. However, the developed antibiotic policy should be based on the following factors: antibiotic agent spectrum of activity, the pharmacokinetics and pharmacodynamics of the drug, its adverse effect profile, the potential of an agent to develop resistance, special patient population group and the cost of the drug 2. An important consideration in the antibiotic policy, is that levels of prescribing must be determined according to the category of the individual antibiotic agent, which can be one of those shown in figure 1. Effective stewardship ensures that every patient gets the maximum benefit from the antibiotics, avoids unnecessary harm from allergic reactions and side effects, and helps preserve the life-saving potential of these drugs for the future. Some good policies can be selected for stewardship taking into consideration:

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Category A (open use)

• Including all first line drugs that can be prescribed by all doctors. • Examples are: Benzylpenicillin, Phenoxymethylpenicillin, Flucloxacillin , Ampicillin, Amoxycillin, Amoxycillin / Clavulanic, Erythromycin, Azithromycin / Clarithromycin, Cefazolin/Cefradin, Cefuroxime, Cefalexin, Doxycycline, Minocycline, Tetracycline Gentamycin •

Category B (criteria- based

Category C (restricted use

•

• •

Including the restricted agents that can be prescribed only after consultation of treating team. Examples are: Acyclovir inj, Azithromycin PO/IV, Amphotericin B, Ceftriaxone, Cefotaxime, Cefoxitin, Clindamycin IV, Ciprofloxacin IV, Fluconazole IV & PO, Levofloxacin

Including the reserve agents that can be prescribed only by designated experts 1. Exampes are: Ceftazidim, Amikacin, Cefipime, Imipenem / Meropenem, Piperacillin, Teicoplanin, Valganciclovir, Vancomycin.

Figure1: Category of individual antibiotic agent

statistical data on antibiotic use practice, however, very few studies done in Sudanese hospitals have found increasing rates of development of resistance and absence of antibiotics policy and called urgently for development of antibiotic stewardship 3,4. A unique experience in Sudan, is the approval and implementation of antibiotic policy by the private Royal Care Hospital in Khartoum, the claimed purpose of this policy was to select effective agents with minimum toxicity and promote cost-effective antimicrobial utilization PT&C is considered an advisory organizational to minimize the emergence of resistance 5. line of communication between the medical References staff and the pharmacy department and a 1. World Health Organization, Regional office for South East Asia, 2011. Step by step approach for development policy recommending body to medical staff and and implementation of antibiotic policy and standard administration of the hospital on matters related treatment guidelines. to therapeutic uses of drugs. 2. Howell L, ed. Global risks 2013, eighth edition: an • • • • • • • • •

Restrictive Antibiotic Formulary Antimicrobial Prescribing Policy Antimicrobial Prescribing Form Antibiotic-Use Guidelines Antibiotic Rotation/Cycling Antibiotics Surgical Prophylaxis Guide Automatic stop dates IV to Oral Switch Pharmacy and Therapeutic Committee (PT&C) • Infection Control surveillance

initiative of the Risk Response Network. World Economic Infection control committee team should typically Forum, 2013. be multidisciplinary including members with 3. Kheder S I, Altayeb I, Shaddad S, AlKheder I.Optimizing different specialties; infectious diseases, internal Antibiotic drug use in surgery: An intervention strategy medicine, surgery, pediatrics, clinical microbiology, in Sudanese hospitals to combat emergence of bacterial resistance. SUDJMS .2011, 6(4): 239- 250. pharmacology and hospital pharmacy. Of 6- 10 members, one must have skills on conducting 4. Kheder I. Cephalosporines usage and resistance trend in a Sudanese hospital surgical wards. 2011, 11(3): 1- 6. good literature and systematic review 1. 5. Zeinalabdin MA. Antibiotic hospital policy. Royal care Sudan, like other third world countries lacking International hospital. 2011.

Sudan Journal of Rational Use of Medicine

Continuous Medical Education

Multi Drug Resistant Tuberculosis

Habab K. Elkhair

ulti-drug-resistant tuberculosis (MDR-TB) is defined as tuberculosis that is resistant to both isoniazid and rifampicin, the two most powerful firstline treatment anti-TB drugs 2, (with or without resistance to other anti-TB drugs 1). Isolates that are multi resistant to any other combination of anti-TB drugs but not to INH and RMP are not classified as MDR-TB.

Isoniazid is the best bactericidal drug. Rifampicin is the best sterilizing drug. Therefore loss of response to both drugs means that patients remain infectious for much longer, both in the community and in hospital, that treatment is required for at least 12 and possibly more than 24 months, and that less effective and more toxic second-line drugs have to be used. As of 2013, 3.7% of new tuberculosis cases have MDR-TB. Levels are much higher in those previously treated for tuberculosis - about 20%. WHO estimates that there were about

Sudan Journal of Rational Use of Medicine

0.5 million new MDR-TB cases in the world in 2012.

Epidemiology The prevalence of MDR-TB in Sudan is estimated to be 1.8% in new smear-positive TB and 19% among re-treatment cases which represent an estimated total of about 590 cases 2. These estimates have a large confidence interval because there has been no drug resistance survey conducted. One is planned in 2014 to provide better estimates and guide efforts in MDR-TB diagnosis and treatment.

MDR-TB management Diagnosis of MDR is carried out in the National Reference Lab and the patients are registered and treated in Abu Anja hospital, in Khartoum State. New wards with adequate infection control design are under construction and will be functional at the end of 2014. Second line drugs were made available in the country in 2008 with support from Sudan government and since 2010 the drugs are

Continuous Medical Education being provided by Green Light Committee (GLC) and funded by the global fund. Since then more diagnosed MDR-TB cases are being enrolled on treatment. Guidelines and SOPs for MDR testing have been developed. However, they have not been implemented adequately therefore only few retreatment cases are being screened for MDR. The program to treat MDR-TB is still in an early stage and based in Abu Anja hospital in Khartoum. It has enrolled 68 cases in 2011 out of 122 cases diagnosed in 2010-2011, and 53 cases in 2012 out of 116 diagnosed the same year.

Impact of MDR-TB MDR has serious implications affecting patient and health system. For patients MDR increases incidences of treatment failure and further resistance, and it increases both morbidity and mortality from tuberculosis. At social level beside the physcological trauma for the patient it poses a financial burden on the family. At health system level it increases the cost of treatment and present a high risk of spreading the disease among new patients

Risk factors for MDR TB A. Health care provider and system related:

• Delay in diagnosis and treatment of TB. • Inadequate regimen i.e. inappropriate •

combination, dosing system and dosage or quality of anti-tuberculosis medications. Failure of health care provider to ensure that patients are taking their medication regularly.

B. Patients’ related: • Non adherence to TB medications.

Mechanism of M. tuberculosis drug resistance 1. Cell wall: The cell wall of M. tuberculosis consists of complex lipids, and it acts as a permeability barrier from drugs. 2. Drug modifying & inactivating enzymes: The M. tuberculosis genome codes for certain enzymes that make it drug resistant. The enzymes usually phosphorylate, acetylate, or adenylate the drug compounds. 3. Drug efflux systems. 4. Mutations: Spontaneous mutations in the M. tuberculosis genome can give rise to proteins that make the bacterium drug resistant, depending on the drug action.

Prevention of MDR-TB There are several ways that drug resistance to TB, and drug resistance in general, can be prevented: 1. Early diagnosis; 2. Adequate regimen and completion of treatment (regular digestion and completion of the treatment period); 3. Patients with HIV/AIDS should be identified and diagnosed as soon as possible. They lack the immunity to fight the TB infection and are at great risk of developing drug resistance; 4. Surveillance of contacts and high risk groups e.g. family members refuges, internally displaced, immunosuppressed with focus on HIV/AIDS , people in close contact, etc.; 5. Research: Much research and funding is needed in the diagnosis, prevention and treatment of TB and MDR-TB.

• Retreatment groups (defaulters, treatment failure).

• Spent time in area with high prevalence,

came from area of high MDR prevalence, in contact with patient with MDR TB.

References 1. Ormerod L P. Multidrug-resistant tuberculosis (MDR-TB): epidemiology, prevention and treatment. Br Med Bull (2005) 73-74 (1): 17-24. doi: 10.1093/bmb/ldh047 2. WHO, epidemiology of MDR TB, 2012.

Sudan Journal of Rational Use of Medicine

Pharmacovigilance Awareness

Pharmacovigilance and Drug Safety

P Randa A. Al mahdi

harmacovigilance is a critical tool to complete the monitoring of safety and effectiveness of new medicines and detection of rare adverse effects of drugs. It is considered as phase IV postmarketing surveillance, since pre-marketing studies generate incomplete information on medicines safety by using limited number of human volunteer patients; excluding the sensitive groups like; the elderly, pregnant women and children. Moreover, domestic people from certain countries like Sudan are also not usually included in these premarketing clinical trials.

The Uppsala Monitoring Centre (UMC) had established standardized reporting system by all national centres, and facilitated communication between countries to promote rapid identification of signals. Sudan has established a national pharmacovigilance center in 2005 and joined UMC in 2008 under the supervision of the National Medicines and Poisons Board (NMPB). Accordingly the Medicines and Poisons Act 2009 was approved, which specified all the conditions and requirements for registrations of

Sudan Journal of Rational Use of Medicine

medicines, cosmetics and medical devices in relation to their safety, effectiveness, quality and protection of consumers.

The national pharmacovigilance system aims to:

• improve patient care and safety in relation to use of medicines, medical devices and herbs.

• improve public health and safety in relation to use of medicines.

• contribute to the assessment of benefit,

harm, effectiveness and risks of medicines, encouraging their safe and rational costeffective use.

• promote understanding, education and

clinical training in pharmacovigilance activities and its effective communication to the health care professionals and the public.

Pharmacovigilance specific objectives were determined to take place in three stages; the first to increase and promote awareness of healthcare professionals as to foster a culture of notification, the second was to engage several healthcare professionals and other stakeholders in drug monitoring and dissemination of information. The third was to achieve operational efficiencies of the national center to become a benchmark of the global drug monitoring system.

Preparation of manuscripts

the text, separated by a period. Introduction: This section should provide the reader with sufficient background information to evaluate the results of the research. An extensive review of the literature is not needed in this section. It should also give the rationale for and objectives of the study that is being reported. Methods: Sufficient information must be provided so that the reader will understand the methodology and be able to repeat the experiment. Results: The results section should be written in such a manner to provide information by means of text, tables and figures. Results and discussion may be combined or there may be a separate discussion section. If a discussion section is included, place extensive interpretations of results in this section. Do not repeat the results. Give numbers to figures and tables in the order in which they are mentioned in the text. All figures and tables must be cited in the text. Conclusions and recommendations: Acknowledge personal, financial and institutional assistance at the end of this section. References: Use the Vancouver reference system. Cite 6 references maximum. Ethical clearance is a requirement for all researches from 2012 onward.

1. Research papers

Any case that is related to RUM will be considered. The manuscript should include the following setting: complete description of the case, consequences and outcome and finally follow up if applicable. Suggestions for solutions should be included. Words count should not exceed 400 words.

Guide for authors

Scope of the journal:

Rational use of medicines (RUM) issues directed to health care providers and medical students.

Suitability of publication:

All topics related to the different aspects of RUM will be evaluated by the editorial board. Prospective authors with a subject(s) or questions about the suitability of their papers or materials are invited to request an opinion from the Editorial Board. (sjrum@khmic.org).

Avoid plagiarism How to submit materials:

Manuscripts can be handed over directly to the Directorate General of Pharmacy as soft copy or by e-mail (sjrum@khmic.org).

Types of manuscripts: 1. Research papers. 2. Case reports. 3. Thematic topics. 4. Success stories.

All manuscripts must be typed in Arial font size 12, with 1.5 line spacing. Manuscripts must be in Word. Page margins on all sides must be at least 2.5 cm wide. You can use either English or American spelling but not both on the same manuscript. Original research will have the priority of publications. Author(s) name and affiliations should be clearly written. Contact person, telephone number and e-mail address should be included. Total words count should not exceed 800 words including references, tables, table captions, figure legends, and footnotes. Maximum of three tables and figures are accepted. The manuscript should be divided into sections. Each section should have a separate heading. Subheadings take the form of paragraph lead-ins (should be bold case), indented and run in with

2. Case reports

3. Thematic topics

Any topic related to rational medicine use is considered. The manuscript should not exceed 400 words.

4. Success stories

Any story that reflects rational use of medicine and positive changes towards rational medicines use is welcomed. The manuscript should not exceed 400 words. NOTE: Accepted manuscripts may be subjected to minor/appropriate changes prior to publishing. Please check the website for previous issues and updates www.sjrum.sd

Sudan Jornal of Rational Use of Medicine

Higher Pharmacy Coordination Board (HPCB) Centeral Medical Supplies Public Corporation

Higher Pharmacy Coordination Board

General Directorate of Pharmacy

National Medicines and Poisons Board

The Federal Ministry of Health has established the Higher Pharmacy Coordination Board (HPCB) according to the Ministerial Resolution number 5 for the year 2014. The HPCB aims to improve the quality of pharmaceutical services in Sudan with maximum utilization of the limited resources. The main tasks of the Board are: • Coordination of the activities of the main public pharmacy organizations: General Directorate of Pharmacy, National Medicine and Poison Board, Central Medical Supplies. • Implementation of the Sudan National Medicine Policy (NMP) in accordance with the 25-year pharmacy strategic plan.

Republic of Sudan Federal Ministry of Health Directorate General of Pharmacy National Medicines Information Centre and Reference Library Algama Street Tel. 0183749255, 0183772843 Fax: 0183749256 Website: www.nmicrl.sd

www.sjrum.sd

Email: sjrum@khmic.org NMICRL staff Sarah A. Kareem Hassan

B. Pharm, M. Pharm, MBA

Badreldin Said Hagnour

B. Pharm, FPSM

Nuha Haj Ali

B. Pharm, MCP

Eslam A. Mohammed

B. Pharm, FPSM