• October 14, 2014

    All staff working in hospital pharmacies must have an employment contract with the recpective medical facility which opened the pharmacy. This is provided in the draft amendment to the Ordinance No.28 of the Ministry of Health on the work of pharmacies. The text includes also the pharmacies of the psychiatric, skin and cancer dispensaries, and inpatient hospices.

    The document also provides that for every two assistant pharmacists there must be one master of pharmacy in the hospital pharmacies. If the medical facility has over 400 beds, or has at least ten wards, the pharmacy has to have at least one master of pharmacy with specialty “Clinical Pharmacy” or with such specialization. The same goes for the oncology centers.

    The draft amendments also provide the working hours in hospital pharmacies to be determined by the medical facilities and impose the obligations on the Master pharmacists to attend to the patients during non-office hours in emergencies.

    The hospital pharmacies are also obliged to maintain a five days reserve of drugs, medical devices and other consumables.

    The period within which the health facilities must bring their work in accordance with the new requirements is three years.

    All draft amendments to the Ordinance and the motives for them are uploaded on the website of the Ministry of Health.

  • Community-acquired pneumonia (CAP) is a common infectious disease of the lungs that occurs with significant morbidity and mortality.

    In Europe and America about 4 million cases of CAP lead to 1 million hospitalizations annually. Incidence of pneumonia is variable and depends on patient’s age, increasing in the age group over 60 years. All modern studies show that mortality in patients with CAP depends on the severity of the inflammatory process. The highest mortality occurs in patients with severe pneumonia treated in intensive care and requiring mechanical ventilation.

    Pneumonia is defined as an acute infection of the lung parenchyma, which occurs with:

    1.at least two of the following symptoms: fever, chills, severe coughing (with orwithout expectoration) or chronic cough with change in the color of the sputum, pleural pain, shortness of breath;

    2.auscultatory evidence of pneumonia (crepitation or late inspiratory crackles on restricted area, bronchial breathing);

    3.new infiltrative changes in the X-ray of the chest, for which there is no other explanation (pulmonary edema or infarction).

    Depending on the causative bacteria, pneumonias are divided into typical and atypical. The most common agents are bacteria which grow outside the host cell. Extracellular bacteria are Pnevmokokokite, Haemophilus and Moraxella and the more rare – Klebsiella, Coli. They cause the typical pneumonia, which in our country accounts for about 75% of cases.

    The most common cause of pneumonia in our country is Streptococcus pneumoniae. In our country, this microorganism is characterized by a not very high level of penicillin resistance and a tendency towards a reduction in recent years. This fact is due largely to the improvement of the antibiotic strategy for the treatment of CAP in our country.

    Haemophilus influenzae is the second most common cause of typical pneumonia, but is the most common cause of acute exacerbation of chronic bronchitis. In infants and elderly patients substantial part of pneumonia is caused by S. aureus. In recent years, a reduction of methicillin resistance of staphylococci is observed.

    Atypical community-acquired pneumonias represent a diagnostic and therapeutic challenge. They are about 15 to 25% of the community-acquired infections in the lower respiratory tract. Agents of atypical CAP are microorganisms that are difficult to cultivate.

    Legionellosis is evidenced by microbiological detection of the antigen in the urine of the patient, or by genetic, culture and serologic methods

    Treatment of CAP

    Even in hospital settings, using all diagnostic methods, the etiologic pathogen is evidenced in no more than 40-50 % of pneumonia. For this reason, the initial treatment is almost always empirical. The empirical approach to the prescription of antibiotic is based on the probability of a particular pathogen to cause disease in a particular patient. The decision on the selection of antimicrobial agent depends on many factors such as patient age, severity of condition, concomitant diseases, immune suppression, venue of treatment (outpatient or inpatient), characterization of the sensitivity of microorganisms in the geographical area and others. The conditions to be met by an empirical antibiotic treatment are the widest possible spectrum of activity, rapid and high concentration in the bronchial tree and lungs, less adverse events and convenient administration.

    During the last decades professional organizations and associations in various countries around the world have established guidelines for the treatment of CAP in adults, in order to facilitate the physicians in the choice of strategy. The Bulgarian guidelines for the treatment of CAP are based on previously existing consensus, but are consistent with the characteristics of epidemiology, etiology and risk factors in our

    Place Severity Treatment
    Subgroup Recommended Alternative
    Outpatient All Beta – lactam and/or macrolide Levofloxacin
    Hospital Mild/moderate Penicillin ± macrolide, Beta – lactam ± macrolide,  cephalosporin ІІ – ІІІ ± macrolide Levofloxacin
    Hospital Severe cephalosporin ± macrolide ІІІ generation cephalosporin ± levofloxacin
    Hospital Severe and risk for P. aeruginosa Anti-pseudomonal cephalosporin + ciprofloxacin Acyl Ureido penicillin beta-lactamase inhibitor + ciprofloxacin or with carbapenem + ciprofloxacin

    For inpatients it is recommended to begin the antibiotic therapy immediately after the confirmation of the CAP diagnosis.
    The usual duration of antimicrobial therapy is 7-10 days. For intracellular pathogens such as Legionella spp., the treatment should be at least 14 days.
    The sequential antibiotic therapy is an important component of the antibacterial treatment of pulmonary diseases. It reduces the cost of treatment, shortens the hospitalization. When the intravenous antibiotic infusion may be replaced with an oral medicament depends on the assessment of the clinical response and the evaluation of the symptoms – cough, sputum expectoration, dyspnea, fever, and leukocytosis. Most often this term is three days from the initiation of treatment, after improvement of cough and shortness of breath, normalization of body temperature, reduction of leukocytosis, and in the presence of well-functioning gastrointestinal tract. When the causative pathogen is not identified, the antibiotic must be similar to the venous.

    Tchaikapharma High Quality Medicines provides on the Bulgarian market antibiotics with the following trade names:

    JF 491 Climox (Amoxicillin/Clavulanic acid ) 875mg/125mg x 14 tabl.

    JF 509 Lifurox (Cefuroxime) 500 mg x 10 tabl.

    JF 499 Levor (Levofloxacin) 500 mg x 10 tabl.

    JF 400 Klacar (Clarithromycin) 500 mg x 14 tabl.

    JF 515 Klacar XL (Clarithromycin) 500 mg x 7 tabl.

    The price of all these antibiotics is BGN 14.99.

  • October 7, 2014

    The elderly people in our country are satisfied with the General Practitioners and pharmacists, because they in details and clearly explain them the diseases and drug therapies and are considerate and kind to them. This shows a study of the problems of the elderly in Bulgaria conducted by the newly created think-tank “Solidarity with elders”. The study is based on in-depth interviews of elderly living alone in the capital, it is combined with the country representative data on the problems of people over 70 years of age.

    Part of the problems of the elderly in Bulgaria and the base for their possible solution were presented on the occasion of the International Day of the Elderly people on the 1st of October.

    The survey data shows that only a quarter of the elderly people are able to visit alone their General Practitioner because of reduced mobility. Nearly 80% of people who regularly visit a doctor and pharmacy have more than one disease and take many medications.

    Among the problems of the elderly are such as lack of circle of friends, difficulties associated with the lack of recreation areas in institutions, hospitals and commercial buildings. It is clear from the survey that leaving the home is also a problem for people over 70 years, because of fears of the state of urban infrastructure and the dynamics of the urban environment.

  • Vyara Vragova of the patient organization “Type 2 diabetes” said that the General Practitioners neglect the problem of type 2 diabetes. According to her the General Practitioners “do not pay much attention” to the possible diabetic symptoms. “It is no secret that the medical check-ups do not actually take place”, she said. Vragova indicated also waiting for access to a specialist as a problem.

    “The access to specialists is limited because of administrative procedures,” said the endocrinologist from Hospital “Alexandrovska” Dr. Natalia Temelkova. “At the moment due to different administrative procedures actually in type 2 diabetes the specialist is not required – something against which we professionals protest,” she said, adding that the next frame agreement must be changed. “The diabetes, I think, should be exclusive duty of the endocrinologists,” she said explicitly.

    Dr. Temelkova presented statistics that about 435 000 people in our country with diabetes, which our health care system “knows” – the number of people who use the services of the NHIF. She said that a cignificant number of patients, however, buy their own drugs, especially in the early stages of diabetes and outside the register. According to her, the likely total number of diabetics in the country is about 600 000 people.

    For 2013, the total number of people with diabetes worldwide is estimated at 382 million. She sais that about 175 million are undiagnosed, adding that according to forecasts by 2030 the number of people with this disease will increase by 40%.

    Dr Temelkova said that 80% of the people with diabetes are from countries with medium and low economic development. Diabetes is the most common cause of blindness, chronic renal failure, for the non-traumatic amputations of the lower limbs. She pointed out that in these patients, the incidence of stroke is two to four times greater, and eight of ten diabetics die of cardiovascular disease.

    On the occasion of the World Day against diabetes on November 14th in Bulgaria began a massive information campaign “Openly about Diabetes” with special focus on the balanced diet.

  • The National Health Insurance Fund announced that on the last day of September National it received the funds for this July needed to pay the difference in user fee for pensioners to general practitioners and dentists.

    From the beginning of this year the pensioners pay user fee BGN 1.00 for examination instead of  BGN 2.90. The difference is covered by the state. For this purpose in the budget were allocated BGN 8 million, but medical professionals complained of delays.

    The cash for overcoming the delay amounted to BGN 1 592 096.00 and was transfered from the budget of the Ministry of Health under a procedure established by law. They will be distributed according to the requests of the Regional Health Insurance Funds.

    The press release of the NHIF noted that on August 21st of this year the Director of the NHIF Rumyana Todorova and the Minister of Health Miroslav Nenkov established rules for determining and providing transfers. On August 26th of this year the Fund sent a letter to the Ministry of Health regarding the need for transfer of funds for July, and in a letter dated September 11th of  this year reminded that the transfer has not taken place yet.

    On the same day the Director of the NHIF requested the assignment of cash for payment of  the difference in the user fee for the outpatient care for pensioners for August 2014 also.

    The press release reminds that the user fee payable for inpatient treatment in  hospitals remains BGN 5.80 and is mandatory for pensioners by age and contribution period and for other health insuranced if they are not exempted from payment.