فهرست مطالب zahra jahangard rafsanjani

Healthcare-associated infections (HAIs) in intensive care unit (ICU) patients significantly complicate the normal hospitalization process and affect patients’ condition, length of hospitalization, mortality, and treatment cost. In this study, we aimed to determine the prevalence and economic burden of HAIs.

The study involved all patients with a confirmed HAIs (based on CDC/NHSN case-definitions); in the general ICU of a tertiary university hospital in Tehran, from April 2020 to March 2021. The patients’ information, including length of hospitalization, outcome, type and cost of prescribed antibiotics, were recorded.

During the study period, 119 HAIs were found in 1395 (43% F / 57% M) patients. The prevalence of nosocomial infections was 8.53%. The mean duration of hospitalization in all ICU patients was 4.7 ± 3.1 days, and 31.85 ± 18.96 days in patients with HAIs. The most common organisms involved in HAIs are Acinetobacter baumannii (54.6%), Klebsiella pneumoniae (30.3%), E. coli (15.1%), and Enterococcus spp. (12%). Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 36.08, 17.57, and 8.86, respectively. The total cost of antibiotics for HAIs was € 105,407. Among these, the highest consumption costs were for carbapenems, followed by colistin and caspofungin.

This study showed the high burden of nosocomial infections in ICUs. Strategies for more strict infection prevention and control are necessary to reduce this burden.

Pain is an unpleasant experience and a subjective term that is associated with tissue damage. Cancer patients experience pain for a myriad of reasons, from disease related to treatment causes and unrelated to both of these categories.
Opioids are the mainstay in the treatment of moderate to severe cancer pain. Progressive opioid dose increases can cause opioid-induced hyperalgesia (OIH).
OIH has no definite management, here we present a 47-year-old cancer patient with OIH and her management.

Adherence to capecitabine, an effective oral chemotherapy agent, is essential in achieving treatment response in cancer. In this study, we aimed to investigate factors associated with non-adherence to capecitabine in a sample of patients with gastrointestinal cancer. We enrolled 98 patients with colon, rectal or gastric cancers who were undergoing treatment with capecitabine as part of their single or multi-agent chemotherapy regimen. The patients were followed during cohort time up to four consecutive cycles of their chemotherapy. For adherence measurement, the participants were asked to bring back the leftover medicines at the time of follow-up visits and were considered adherent if they had taken ≥95% of their prescribed dose. The mean adherence rate was 97.7%, and the patients were adherent to capecitabine in 93.1% of their cycles. The patients who underwent neoadjuvant chemotherapy were significantly less adherent to capecitabine (60%) as compared with adjuvant (95.2%) and palliative chemotherapy (94.6%) [P=0.004]. Multivariable logistic regression revealed that neoadjuvant chemotherapy and the presence of nausea and mucositis were inversely associated with adherence rate. We did not find any association between adherence and any of our laboratory findings. Our findings suggest a high adherence rate to capecitabine among patients with gastrointestinal cancers. Neoadjuvant chemotherapy and the presence of nausea and mucositis may play a significant role in non-adherence to capecitabine.

Taxane-induced pain is a disabling condition. This trial was conducted to assess the effects of melatonin on preventing paclitaxel-associated acute and chronic pain or decreasing its severity in patients with breast cancer.

This randomized, double-blind, placebo-controlled clinical trial was conducted on breast cancer women who received weekly paclitaxel (80 mg/m2) with or without trastuzumab after using doxorubicin + cyclophosphamide. The intervention group randomly received oral melatonin (10 mg/day) or placebo, which started from the first night of chemotherapy and continued through the planned 12 weeks of chemotherapy. The level of arthralgia-myalgia as acute pain was assessed every day in both groups using the Brief Pain Inventory (BPI). The Douleur Neuropathique 4 questionnaire (DN4) and National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 5.0 were used to measure chemotherapy-induced peripheral neuropathy as chronic pain.

Seventeen patients were enrolled in each group randomly. The incidence of neuropathy according to a DN4 score ≥ 4 was significantly lower in the melatonin group versus the placebo group at week 12 compared to baseline (5 vs 11, P-value= 0.039). In addition, the mean neuropathy severity was significantly lower in the melatonin group over time (β= -0.051, P-value= 0.01). However, there were no significant differences in the mean worst and least pain scores over the twelve cycles of treatment between arms (P-value= 0.633 and 0.34, respectively).

Co-administration of melatonin in women with breast cancer decreased the incidence of severe paclitaxel-associated neuropathy but melatonin was not effective against acute pain.

Oral mucositis is considered a frequent complication of conditioning regimen in patients undergoing hematopoietic stem cell transplantation (HSCT). Mucositis develops due to direct and indirect damage to the epithelial cells and production of reactive oxygen species (ROS). Vitamin E has shown positive effects in reducing production of ROS or improving its elimination. The aim of this study was to evaluate the effects of vitamin E mouthwash in lowering the incidence and severity of acute mucositis in patients undergoing allogenic HSCT.

The current study was designed as a double bind, placebo controlled randomized clinical trial. Eighty patients were randomized in a 1 to 1 method to receive either placebo or vitamin E mouthwash. Patients in vitamin E group received 400 International Units of vitamin E in form of mouthwash twice daily and placebo group received a mouthwash with equal composition but without vitamin E, starting the day of the chemotherapy initiation and continuing it for 14 days.  

Vitamin E mouthwash effectively reduced the duration of oral mucositis compared to placebo (P-value 0.02). The difference between placebo and vitamin E groups in terms of mucositis severity did not reach statistical significance (P=0.35). No difference in length of hospital stay was observed (P=0.46).

Vitamin E mouthwash could effectively reduce the duration of oral mucositis in allogenic HSCT patients. Further studies are required to show the effects of topical vitamin E in preventing the development of oral mucositis.

Resistance to antibiotics is a worldwide concern and community pharmacies can play a strategic role in controlling this issue through rationalizing antibiotic consumption. Considering that dispensing any type of antibiotics without a prescription is prohibited in according to Iran’s regulations, this study was conducted to quantify the rate of antibiotic dispensing without a prescription by pharmacists in Tehran, Iran. A descriptive cross-sectional study was conducted from September 2016 through May 2017. Two scenarios of common infectious symptoms including sore throat and dysuria were simulated by pharmacy student in three different regions of Tehran. Each scenario was performed in three levels of demand including requesting for any medicine, asking for a stronger medicine and direct request for an antibiotic. A total of 388 pharmacy visits were acceptable including 195 and 193 pharmacies for dysuria and sore throat, respectively. Antibiotics were provided in 39.9% of dysuria (67.5% in the first level of demand) and in 52.3% of sore throat (49% in the first level of demand) simulations. The time devoted by the pharmacists to each case was less than 60 second in more than 90% of the cases. The completion of the course of antibiotic therapy was emphasized by pharmacists in only 18% of cases in both scenarios. Our findings revealed that antibiotic dispensing without a prescription is a routine practice in community pharmacies in Tehran, Iran. Unfortunately, patient assessment and evaluation of the symptoms are not performed properly by pharmacists as well.

With respect to the high cost and limited availability of albumin, its use must be restricted to indications strongly supported by solid scientific evidence. It was anticipated that with the implementation of the National Health Reform Plan (NHRP), the consumption of albumin would increase as the result of decreasing patients’ out‑of‑pocket costs. This study aimed to evaluate the efficacy of protocol implementation on the rationalization of albumin use in surgery wards of Cancer Institute of Imam Khomeini Hospital Complex, Tehran, Iran.

This pre‑post interventional study was conducted in 32‑month phases from January to November 2014 in an Iranian University hospital. The first phase was before the implementation of NHRP, the second phase was after NHRP, and the last one was after the intervention. The first and second phases were conducted retrospectively. Data extraction was performed by a hospital pharmacist. During the third phase, the physicians were mandated to adhere to a local albumin protocol which had been prepared by clinical pharmacy service and approved by drug and therapeutic committee. Appropriateness of prescriptions regarding indication, dose, and duration based on local guideline was compared among groups.

Although hospital bed‑days of care remained consistent among phases, albumin was prescribed for 40, 45, and 8 patients during first, second, and third phases, respectively. This shows about 80% reduction of drug prescriptions in the last phase. The mean duration/dose of albumin in inappropriate indications reduced significantly from 11.3 ± 8.2 days/24.7 ± 21.2 vials in the second phase to 2.6 ± 1.7 days/5.6 ± 3.5 vials in the third phase, respectively (P = 0.001 and P = 0.003).

Interactive collaboration through guideline implementation seems effective in rationalizing the use of high‑cost medications such as albumin.

Surgical site infection (SSI) is defined as infections occurring within 30 days after a surgical operation or within one year if an implant is left in place after the procedure. Antibiotic prophylaxis formed as part of surgical care to reduce SSI. Antibiotic prescription pattern for SSI prophylaxis and it's concordance withAmerican Society of Health-System Pharmacists(ASHP) guideline were evaluated throughout this study.

This study was conducted in Imam Khomeini hospital, cancer institute. Patients with cancer who underwent abdominal surgery were included in this study. The information about type of antibiotic used for prophylaxis, dose, initiation time, and duration were collected during study. Compliance was assessed with the ASHP guideline for every aspect of antibiotic prophylaxis. SSI was assessed during 30 days after surgery.

All the patents needed antibiotic prophylaxis among them,only 103 patients received it. Antibiotic choice, dose and initiation time of prophylaxis were concordant with ASHP guideline in 36.3%, 1.6% and 60.5%, respectively. Unlike the ASHP, the duration of prophylaxis was more than 24 hours in all patients. Finally, 32 patients experienced SSI during 30 days after surgical procedure.

This study showed poor adherence to guideline in various aspects such as type, dose and duration of antibiotics for SSI prophylaxis. It is essential to implement interventions to improve the rational use of antibiotics in this setting

One of the most frequent complications of high-dose chemotherapy regimen before hematopoietic stem cell transplantation (HSCT) is oral mucositis (OM). Vitamin D (VD) has well-known immunoregulatory, anti-inflammatory, and antioxidant properties.

This study aimed to evaluate the association of baseline VD levels with OM as well as neutrophil and platelet engraftments in patients with multiple myeloma, Hodgkin’s and non-Hodgkin’s lymphoma after autologous HSCT.

A sample of 71 patients was included after obtaining informed consent. Serum samples were collected in the morning prior to the administration of conditioning regimen to measure the baseline 25-OH-D. OM was examined daily during hospital stay. The WHO scale was used for scoring the OM. Absolute neutrophil count and platelet count were determined daily from transplantation until engraftment.

Patients aged between 18 to 65 years. Mean length of hospital stay was 15.8±5.7 days. OM was detected in 44/71 (62.0%) of patients. Mean time to the engraftment of neutrophils and platelets were 11.8±4.0 and 17.2±7.3 days, respectively. Mean level of baseline 25-OH-D was 17.5±14.0 ng/ml. VD deficiency (<20 ng/ml) was diagnosed in 51/71 (71.8%) of patients. No association between baseline 25-OH-D levels and the incidence of OM (P=0.69) or OM grade 3-4 (P=0.46) was found. No significant correlations were detected between the baseline 25-OH-D and engraftment time of neutrophils (P=0.46) or platelets (P=0.17).

The prevalence of VD deficiency was high among adult HSCT patients at the time of transplantation. No association was found between low baseline VD with post-HSCT OM and engraftment time.

Thrombocytopenia has been reported as an adverse effect of numerous medicines including vancomycin. Due to contribution of other suspected causes and lack of a standard diagnostic test, vancomycin-induced thrombocytopenia has been less addressed in clinical practice. In the current study, we present a suspected case initially diagnosed as heparininduced thrombocytopenia but further workup proposed vancomycin as the offending medicine. Following discontinuation of vancomycin, the thrombocytopenia resolved which confirmed the diagnosis of vancomycin induced thrombocytopenia. We tended to highlight vancomycin-induced thrombocytopenia which is usually not considered in differential diagnosis of thrombocytopenia in comparison with heparin induced thrombocytopenia which is well known for clinicians; a scenario commonly encountered in clinical practice. This is important regard to high possibility of concomitant use of vancomycin and heparin in every day clinical practice. In accordance with educational aims of the current case, differential diagnosis of thrombocytopenia and clinical approach to thrombocytopenia is well documented in this patient.

Radiotherapy as an important treatment modality in head and neck cancer diminishes reactive oxygen system which causes damages to the normal cell/ tissue function and cell cycle regulation. Selenium involve in both antioxidant and antiinflammatory systems. In this study, we aimed to investigate whether there is a difference between selenium levels before and after radiotherapy and the effects of serum selenium levels on radiotherapy oral mucositis (OM) patients undergoing radiation for head and neck cancer. This prospective study includes 42 head and neck cancer patients treated by external beam radiotherapy at the Cancer Institution of Imam Khomeini Hospital, Tehran University of Medical Sciences. Plasma selenium concentrations were determined before and after radiotherapy. The grade of oral mucositis was evaluated weekly from the first day until resolving OM by the WHO oral toxicity scale. The mean patient age was 54.7±13.2 years. For most of the patients, the histopathological diagnosis of cancer was squamous cell carcinoma (N=28 (66.7%)). There was no significant difference in serum Selenium levels before and after radiotherapy (85.4±30.6 before radiation and 90.3±33.3 after radiation, P >0.05). Moreover, there was no significant difference between levels of Se after radiotherapy in patients who developed severe oral mucositis and who did not. In our study, we couldn’t find any significant difference in the levels of Selenium before and after radiotherapy and also there was no association between Selenium levels and oral mucositis developing.

Linezolid has been recognized as a safe and effective medicine against a wide variety of Gram-positive pathogens.
The primary objective of this study was to assess utilization appropriateness of linezolid and explore the efficiency of protocol intervention to proceed to rational drug usage.
The project was conducted in a referral teaching hospital from September 2015 to January 2017 in two phases. In the first step, a six-month survey was performed to evaluate the prescribing appropriateness of linezolid. Patients receiving linezolid were identified using hospital IT system and the medical charts were analyzed based on accurate indications and duration of linezolid prescription. Subsequently, a restrictive protocol was developed and communicated after a consensus by Drug and Therapeutics Committee in May 2016. After introduction of the protocol, an active daily surveillance of patients was done by hospital pharmacists. The appropriateness of linezolid utilization and infectious consultations were compared before and after protocol implementation.
In the first phase of the study, the indication of linezolid was appropriate in 56.2% of cases and improved considerably to 68.6% (P value: 0.04) after protocol enforcement. Furthermore the duration of the linezolid consumption was correct in 66.6% of patients, increasing to 88.5% after protocol introduction (P value 0.07). In the first step, 56.9% of linezolid prescriptions were based on infectious disease consultation which enhanced remarkably to 87.5% in the second step (P value 0.001), while, 65.5% and 73.8% of these consultations were appropriate in the study surveys respectively.
The protocol intervention could improve appropriate prescribing of linezolid in the hospital setting. However, ongoing audit studies are recommended to maintain the rational prescription of linezolid.

Hepatic dysfunction in patients who have undergone allogeneic haematopoietic stem cell transplantation (HSCT) is a major cause of morbidity and mortality. The aim of this study is to evaluate the incidence of post-transplantation hepatic complications in these patients.
A total of 121 patients (age above 15 with no abnormality in their hepatic tests) participated in the study. The influence of a variety of risk factors on the incidence, type, and pattern of hepatic dysfunction as well as the length of hospital stay related to these complications were studied.
As a whole, 76 patients (62%)—44 males and 32 females—were diagnosed with hepatic dysfunction after transplantation. As many as 31(25%) of the patients showed increased measures in their hepatic enzyme, while 45(37%) of them ended up with both abnormal enzyme measure and clinical symptoms including diarrhoea, skin rash, jaundice, and anorexia. The hepatic dysfunction rates owing to drug toxicity and GVHD (21.5% and 16.5%, respectively) proved to be the highest in our study. Analysing risk factors, the immunosuppressive regimen could affect the type of hepatic dysfunction—i.e., less patients with GVHD were found in the group who received ATG in their regimen (p-value =0.034).
According to these findings, the immunosuppressive regimen can play a role in preventing the incidence of GVHD. Less occurrence of hepatic complications, especially GVHD, may lead to less clinical symptoms and time of hospital stay.

Prolongation of the QT interval is a recognized adverse effect of fluoroquinolone antibiotics. This effect on ventricular repolarization can potentially lead to life-threatening arrhythmias such as Torsade de pointes. Torsade de pointes is a polymorphic form of ventricular tachycardia identified by twisting of the QRS axis around an isoelectric point. We report a case of torsade de pointes induced by ciprofloxacin treatment. The patient experienced an acquired QT interval prolongation followed by Torsade de pointes arrhythmia with ciprofloxacin administration for ileostomy closure surgery and unfortunately expired.

Gross hematuria or macroscopic hematuria is a high risk urologic condition that might occur in different settings. In the case of continued gross hematuria, blood clot size may grow and lead to complete obstruction of urinary outflow. Placement of three-way catheter, continuous bladder irrigation with normal saline, and cystoscopy are conventional treatments. Here we introduce a case with urinary obstruction who did not respond to conventional therapies. A subject of Hodgkin lymphoma with urinary obstruction caused by heavy gross hematuria was presented to emergency department. Three-way catheter was inserted to facilitate urination. However, there was no urinary drainage and bladder was distended. Consequently, 100 ml solution of hydrogen peroxide 0.15% was prepared and administered into the bladder to irrigate and evacuate the clots. A single intravesical infusion of hydrogen peroxide rapidly resolved urinary obstruction and improved patient distress. After administration of hydrogen peroxide solution, blood clots and bloody urine were evacuated successfully. These findings suggest that an intravesical injection of hydrogen peroxide can induce dissolution of blood clots and may be a simple and efficient therapy for urinary obstruction due to gross hematuria.

Since albumin imposes a relatively high cost to a healthcare system, drug use evaluation for this drug is much more important. This study wants to evaluate pattern of albumin use in a large university affiliated hospital in Tehran, Iran. A concurrent, cross-sectional study was performed in “Shaheed Rajaei” Cardiovascular, Medical and Research Center. All inpatient adults that were prescribed albumin during the study period were evaluated to register the indications for albumin usage according to the evidence-based guidelines. Only for five patients (4%) the albumin prescriptions were justifiable. Of these cases, intractable edema was the leading cause of albumin misuse (73 patients; 60.8%). The total 1468 vials of Albumin were prescribed for 120 patients during the study period. The most common reasons to prescribe albumin were acute normovolemic (34%), cardiac failure (0.83%), resistance edema with Albumin>2g/dL (61%), nephrotic syndrome (0.83%), plasmapheresis (1.67%), ascetic (1.67%). These data, together with previous national studies highly suggest a mandatory need for educational measures for practicing physicians along with strict regulations for prescription strategies regarding expensive drugs such as albumin.

Background and Surveillance studies evaluating antimicrobial susceptibilities are of great value in preventing the spread of resistant pathogens by elucidating the trend of resistance in commonly used antibiotics and as a consequence providing information for prescribing the most appropriate agent. This study is a longitudinal antimicrobial resistance surveillance study designed to evaluate the trend in antimicrobial resistance to gram negative microorganisms from 2007 to 2010. During a four-year period (2007–2010) isolates derived from all patients admitted to infectious diseases ward of Imam Khomeini Hospital, the major referral center for infectious disease in Iran with the highest admission rates, were evaluated. Based on disk diffusion method and zone of inhibition size, the microorganism was regarded as to be sensitive, resistant or has intermediate susceptibility to the antimicrobial agents. The widest spread Gram-negative microorganism in all of isolates taken together in our study was E.coli (30%) followed by Stenotrophomonas maltophilia in 28.6% and Enterobacter spp. in 11.9%, respectively. The susceptibility to amikacin, imipenem, piperacillin/tazobactam, and nitrofurantoin was equal or above 50% for all microorganisms over four years. However, the susceptibility to ampicillin, ampicillin/sulbactam, cefotaxim, and ceftriaxone was less than 50% in derived isolates during the study period. In conclusion, the finding of the present study revealed that resistance rate to common antimicrobial agents in Iran is growing and isolates were susceptible mostly to broad-spectrum antibiotics including imipenem and piperacillin/tazobactam.

Hepatitis B is one of the most common infectious diseases worldwide that can be transmitted by blood transfusion. The hepatitis B virus (HBV) has eight different genotypes that show different geographical distributions and clinical manifestations. This study aims to investigate the sequence of the HBV polymerase gene and the frequency of HBV genotypes among Iranian blood donors.The sera of 223 blood donors who were positive for hepatitis B surface antigen (HBsAg) as determined by the ELISA method were selected. HBV DNA was extracted from the sera of 134 blood donors by a commercial kit, and the entire polymerase gene was amplified by nested-PCR. HBV genotypes were determined by direct sequencing of the HBV polymerase gene. Phylogenetic trees were constructed by the neighbor-joining (NJ) method.No known base mutations were found in the entire HBV polymerase gene of infected blood donors, and only genotype D was detected among HBV-infected blood donors. The sub-genotype D1 of HBV was dominant in the subjects.This study shows that antiviral-resistant mutations, such as lamivudine-resistant HBV strains, do not exist naturally among Iranian blood donors. More studies on the full-length HBV genomes are required to determine genome evolution of HBV among infected Iranian blood donors.