Overprescribing of antibiotics to children in rural Vietnam

Determinants of antibiotic prescribing in primary care in Vietnam: a qualitative study using the Theoretical Domains Framework

BACKGROUND

To formulate effective strategies for antimicrobial stewardship (AMS) in primary care, it is crucial to gain a thorough understanding of factors influencing prescribers' behavior within the context. This qualitative study utilizes the Theoretical Domains Framework (TDF) to uncover these influential factors.

METHODS

We conducted a qualitative study using in-depth interviews and focus group discussions with primary care workers in two provinces in rural Vietnam. Data analysis employed a combined inductive and deductive approach, with the deductive aspect grounded in the TDF.

RESULTS

Thirty-eight doctors, doctor associates, and pharmacists participated in twenty-two interviews and two focus group discussions. We identified sixteen themes, directly mapping onto seven TDF domains: knowledge, skills, behavioral regulation, environmental context and resources, social influences, social/professional role and identity, and optimism. Factors driving unnecessary prescription of antibiotics include low awareness of antimicrobial resistance (AMR), diagnostic uncertainty, prescription-based reimbursement policy, inadequate medication supplies, insufficient financing, patients' perception of health insurance medication as an entitlement, and maintaining doctor-patient relationships. Potential factors facilitating AMS activities include time availability for in-person patient consultation, experience in health communication, and willingness to take action against AMR.

CONCLUSION

Utilizing the TDF to systematically analyze and present behavioral determinants offers a structured foundation for designing impactful AMS interventions in primary care. The findings underscore the importance of not only enhancing knowledge and skills but also implementing environmental restructuring, regulation, and enablement measures to effectively tackle unnecessary antibiotic prescribing in this context.

Antimicrobial Resistance Patterns of Pathogens Isolated from Patients with Wound Infection at a Teaching Hospital in Vietnam

Purpose

At a teaching Hospital in Vietnam, the persistently high incidence of diagnosed wound infection poses ongoing challenges to treatment. This study seeks to explore the causative agents of wound infection and their antimicrobial and multidrug resistance patterns.

Methods

A cross-sectional study was conducted at the Department of Microbiology, Military Hospital 103, Vietnam. Data on microorganisms that caused wound infection and their antimicrobial resistance patterns was recorded from hospitalized patients from 2014 to 2021. Using the chi-square test, we analyzed the initial isolation from wound infection specimens collected from individual patients.

Results

Over a third (34.9%) of wound infection samples yielded bacterial cultures. Staphylococcus aureus was the most prevalent bacteria, followed by Pseudomonas aeruginosa. Worryingly high resistance rates were observed for several antibiotics, particularly among Gram-negative bacteria. Ampicillin displayed the highest resistance (91.9%), while colistin and ertapenem remained the most effective. In Gram-positive bacteria, glycopeptides like teicoplanin and vancomycin (0% and 3.3% resistance, respectively) were most effective, but their use was limited. Clindamycin and tetracycline showed decreasing effectiveness. Resistance rates differed between surgical and non-surgical wards, highlighting the complex dynamics of antimicrobial resistance within hospitals. Multidrug resistance (MDR) was substantial, with Gram-negative bacteria exhibiting a 63.6% MDR rate. Acinetobacter baumannii showed the highest MDR rate (88.0%).

Conclusion

This study investigated wound infection characteristics, antibiotic resistance patterns of common bacteria, and variations by hospital ward. S. aureus was the most prevalent bacteria, and concerning resistance rates were observed, particularly among Gram-negative bacteria. These findings highlight the prevalence of multidrug resistance in wound infections, emphasizing the importance of infection control measures and judicious antibiotic use.

C-reactive protein point of care testing in the management of acute respiratory infections in the Vietnamese primary healthcare setting - a cost benefit analysis

Aim

We assess the cost-benefit implications of C-reactive protein (CRP) testing in reducing antibiotic prescription for acute respiratory infection in Viet Nam by comparing the incremental costs of CRP testing with the economic costs of antimicrobial resistance averted due to lower antibiotic prescribing.

Findings

Patients in the CRP group and the controls incurred similar costs in managing their illness, excluding the costs of the quantitative CRP tests, provided free of charge in the trial context. Assuming a unit cost of $1 per test, the incremental cost of CRP testing was $0.93 per patient. Based on a previous modelling analysis, the 20 percentage point reduction in prescribing observed in the trial implies a societal benefit of $0.82 per patient. With the low levels of adherence to the test results observed in the trial, CRP testing would not be cost-beneficial. The sensitivity analyses showed, however, that with higher adherence to test results their use would be cost-beneficial.

Antibiotic prescribing and dispensing for acute respiratory infections in children: effectiveness of a multi-faceted intervention for health-care providers in Vietnam

Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries.

Objective: To evaluate a multi-faceted intervention targeting health-care-providers’ (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs.

Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010–2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively.

Results: Knowledge improved in the intervention group for ARI aetiology by 28% (Δ_{Decrement control arm} 10%), antibiotic use for mild ARIs by 15% (Δ_{Decrement control arm} 13%) and for severe ARIs by 14% (Δ_{Improvement control arm} 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δ_{mean improvement} 1.17); less so in the control group (Δ_{mean improvement} 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (Δ_{Decrement control arm} 3%).

Conclusions: The intervention significantly improved HCPs’ knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

Point-of-care C-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in Vietnamese primary health care: a randomised controlled trial

Background

Inappropriate antibiotic use for acute respiratory tract infections is common in primary health care, but distinguishing serious from self-limiting infections is difficult, particularly in low-resource settings. We assessed whether C-reactive protein point-of-care testing can safely reduce antibiotic use in patients with non-severe acute respiratory tract infections in Vietnam.

Method

We did a multicentre open-label randomised controlled trial in ten primary health-care centres in northern Vietnam. Patients aged 1–65 years with at least one focal and one systemic symptom of acute respiratory tract infection were assigned 1:1 to receive either C-reactive protein point-of-care testing or routine care, following which antibiotic prescribing decisions were made. Patients with severe acute respiratory tract infection were excluded. Enrolled patients were reassessed on day 3, 4, or 5, and on day 14 a structured telephone interview was done blind to the intervention. Randomised assignments were concealed from prescribers and patients but not masked as the test result was used to assist treatment decisions. The primary outcome was antibiotic use within 14 days of follow-up. All analyses were prespecified in the protocol and the statistical analysis plan. All analyses were done on the intention-to-treat population and the analysis of the primary endpoint was repeated in the per-protocol population. This trial is registered under number NCT01918579.

Findings

Between March 17, 2014, and July 3, 2015, 2037 patients (1028 children and 1009 adults) were enrolled and randomised. One adult patient withdrew immediately after randomisation. 1017 patients were assigned to receive C-reactive protein point-of-care testing, and 1019 patients were assigned to receive routine care. 115 patients in the C-reactive protein point-of-care group and 72 patients in the routine care group were excluded in the intention-to-treat analysis due to missing primary endpoint. The number of patients who used antibiotics within 14 days was 581 (64%) of 902 patients in the C-reactive protein group versus 738 (78%) of 947 patients in the control group (odds ratio [OR] 0·49, 95% CI 0·40–0·61; p<0·0001). Highly significant differences were seen in both children and adults, with substantial heterogeneity of the intervention effect across the 10 sites (I²=84%, 95% CI 66–96). 140 patients in the C-reactive protein group and 137 patients in the routine care group missed the urine test on day 3, 4, or 5. Antibiotic activity in urine on day 3, 4, or 5 was found in 267 (30%) of 877 patients in the C-reactive protein group versus 314 (36%) of 882 patients in the routine treatment group (OR 0·78, 95% CI 0·63–0·95; p=0·015). Time to resolution of symptoms was similar in both groups. Adverse events were rare, with no deaths and a total of 14 hospital admissions (six in the C-reactive protein group and eight in the control group).

Interpretation

C-reactive protein point-of-care testing reduced antibiotic use for non-severe acute respiratory tract infection without compromising patients' recovery in primary health care in Vietnam. Health-care providers might have become familiar with the clinical picture of low C-reactive protein, leading to reduction in antibiotic prescribing in both groups, but this would have led to a reduction in observed effect, rather than overestimation. Qualitative analysis is needed to address differences in context in order to implement this strategy to improve rational antibiotic use for patients with acute respiratory infection in low-income and middle-income countries.

Funding

Wellcome Trust, UK, and Global Antibiotic Resistance Partnership, USA.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing bacterial complications in children aged two months to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August week 1, 2015) and EMBASE (1974 to August 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotic prescriptions with placebo or no treatment in children aged two months to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated, so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.We found no studies assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

There is insufficient evidence for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing complications in children aged two to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1950 to May week 2, 2013) and EMBASE (1974 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCT) or quasi-RCTs comparing antibiotic prescriptions with placebo or non-treatment in children up to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.No studies were found assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

The quality of evidence currently available does not provide strong support for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Drug use and self-medication among children with respiratory illness or diarrhea in a rural district in Vietnam: a qualitative study

Aims

To explore the knowledge, attitudes, and behaviors of parents in their use of drugs for respiratory illness or diarrhea among children under 5 years of age, and to understand factors influencing self-medication.

Methods

A qualitative study was conducted, using in-depth interviews with two drug sellers and three health care providers, and four focus-group discussions with mothers of children under 5 years of age. Verbatim transcriptions were analyzed, and emerging themes and categories identified, using content analysis.

Results

Use of a number of different drugs was reported, including broad-spectrum antibiotics and corticosteroids. There was poor awareness of side-effects, antibiotic resistance, and drug efficacy. Factors influencing self-medication were perceptions of the illness in the child, waiting time, and convenience, the attitudes of public health medical staff, insufficient drug supply in public health facilities, and poor control of prescribed drugs on the market.

Conclusion

Misuse and misconceptions regarding drug use gave rise to considerable problems. Mothers’ knowledge and attitudes to illness and health care services played an important role in determining the nature of self-medication. Financial barriers were not the only obstacle to adequate treatment. Health services should be more accessible and responsive to the needs of the population.

Perspectives on child diarrhoea management and health service use among ethnic minority caregivers in Vietnam

BACKGROUND

In Vietnam, primary government health services are now accessible for the whole population including ethnic minority groups (EMGs) living in rural and mountainous areas. However, little is known about EMGs' own perspectives on illness treatment and use of health services. This study investigates treatment seeking strategies for child diarrhoea among ethnic minority caregivers in Northern Vietnam in order to suggest improvements to health services for EMGs and other vulnerable groups.

METHODS

The study obtained qualitative data from eight months of field work among four EMGs in lowland and highland villages in the Northern Lao Cai province. Triangulation of methods included in-depth interviews with 43 caregivers of pre-school children (six years and below) who had a case of diarrhoea during the past month, three focus group discussions (FGDs) with men, and two weeks of observations at two Communal Health Stations (CHGs). Data was content-analyzed by ordering data into empirically and theoretically inspired themes and sub-categories assisted by the software NVivo8.

RESULTS

This study identified several obstacles for EMG caregivers seeking health services, including: gender roles, long travelling distances for highland villagers, concerns about the indirect costs of treatment and a reluctance to use government health facilities due to feelings of being treated disrespectfully by health staff. However, ethnic minority caregivers all recognized the danger signs of child diarrhoea and actively sought simultaneous treatment in different health care systems and home-based care. Treatments were selected by matching the perceived cause and severity of the disease with the 'compatibility' of different treatments to the child.

CONCLUSIONS

In order to improve EMGs' use of government health services it is necessary to improve the communication skills of health staff and to acknowledge both EMGs' explanatory disease models and the significant socio-economic constraints they experience. Broader health promotion programs should address the significant gender roles preventing highland mothers from seeking health services and include family elders and fathers in future health promotion programs. Encouraging existing child health care practices, including continued breastfeeding during illness and the use of home-made rehydration solutions, also present important opportunities for future child health promotion.

Randomised primary health center based interventions to improve the diagnosis and treatment of undifferentiated fever and dengue in Vietnam

Background

Fever is a common reason for attending primary health facilities in Vietnam. Response of health care providers to patients with fever commonly consists of making a presumptive diagnosis and proposing corresponding treatment. In Vietnam, where malaria was brought under control, viral infections, notably dengue, are the main causes of undifferentiated fever but they are often misdiagnosed and inappropriately treated with antibiotics.

This study investigate if educating primary health center (PHC) staff or introducing rapid diagnostic tests (RDTs) improve diagnostic resolution and accuracy for acute undifferentiated fever (AUF) and reduce prescription of antibiotics and costs for patients.

Methods

In a PHC randomized intervention study in southern Vietnam, the presumptive diagnoses for AUF patients were recorded and confirmed by serology on paired (acute and convalescence) sera. After one year, PHCs were randomized to four intervention arms: training on infectious diseases (A), the provision of RDTs (B), the combination (AB) and control (C). The intervention lasted from 2002 until 2006.

Results

The frequency of the non-etiologic diagnosis "undifferentiated fever" decreased in group AB, and - with some delay- also in group B. The diagnosis "dengue" increased in group AB, but only temporarily, although dengue was the most common cause of fever. A correct diagnosis for dengue initially increased in groups AB and B but only for AB this was sustained. Antibiotics prescriptions increased in group C. During intervention it initially declined in AB with a tendency to increase afterwards; in B it gradually declined. There was a substantial increase of patients' costs in B.

Conclusions

The introduction of RDTs for infectious diseases such as dengue, through free market principles, does improve the quality of the diagnosis and decreases the prescription of antibiotics at the PHC level. However, the effect is more sustainable in combination with training; without it RDTs lead to an excess of costs.

Respiratory impedance and response to salbutamol in asthmatic Vietnamese children

There is a high incidence of pediatric asthma in Vietnam, but little lung function data are available. The aim of the study was to compare respiratory resistance (Rrs), reactance (Xrs), and responses to salbutamol between asthmatic and healthy primary school children in Hanoi. Because respiratory mechanics vary along the breathing cycle, measurements were assessed separately in inspiration (Rrsi, Xrsi) and expiration (Rrse, Xrse).Inpatients with doctor-diagnosed asthma were measured 2-3 days following admission using the forced oscillation technique (FOT) at a single frequency (8 Hz). Z-scores and responses to salbutamol were compared between 102 asthmatics and 98 controls, and accuracy of group classification by FOT parameters was assessed by Youden index, an indicator to the proportion of subjects correctly classified in each group.In asthmatics versus controls, Rrsi-but not Rrse-was significantly larger and both Xrsi and Xrse were significantly more negative (P < 0.01). Both Rrs and Xrs responses to salbutamol were significantly larger in asthmatics than controls (P < 0.001). Youden indexes indicated response to salbutamol generally had better diagnostic values than Z-scores and was best discriminative first with Rrsi, then with Xrse.It is concluded that different FOT characteristics may be described in asthmatic and healthy Vietnamese children. The diagnostic value of each parameter depends upon the breathing cycle. Most useful in practice probably is the response to salbutamol measured by Rrsi.

Care-seeking in the development of severe community acquired pneumonia in Ugandan children

BACKGROUND

Improved case management of paediatric pneumonia is recognised as a key strategy for pneumonia control. Since symptoms of pneumonia and malaria often overlap, there are concerns that children with pneumonia are treated with antimalarial drugs. There is a need to describe how children with severe pneumonia have been managed prior to their arrival at hospital, including possible risks of developing more severe disease.

METHODS

A case-series study of 140 children, aged 2-59 months, with severe radiologically verified pneumonia at Mulago Hospital, Kampala was undertaken. Caretakers were interviewed about initial symptoms, treatment given and care sought. Using WHO definitions, children were clinically classified as having severe or very severe pneumonia.

RESULTS

The children had been ill for a median of 7 days before arrival at hospital, 90/140 (64%) had received treatment at home, and 72/140 (51%) had seen another health-care provider prior to presentation at hospital. Altogether, 32/140 (23%) children had reportedly received antibiotics only prior to admission, 18/140 (13%) had received anti-malarials only and 35/140 (25%) had received both. Being classified as very severe pneumonia was more common among children who had received anti-malarials only (OR 5.5, 1.8-16.4).

CONCLUSIONS

Although the majority of caretakers were able to recognise the key symptoms of pneumonia, they did not respond with any immediate care-giving action. Since progression from first recognition of pneumonia symptoms to severe disease is rapid, management guidelines regarding timing of care-seeking need to be clearly defined. The reason why children who sought health facility care failed to improve should be investigated. Meanwhile, there is a need to increase caretakers' and health workers' awareness of the urgency to act promptly when key pneumonia symptoms are observed.

Drug use and health-seeking behavior for childhood illness in Vietnam--a qualitative study

OBJECTIVES

To describe and understand health-seeking behavior and drug use among caregivers, in particular antibiotics, for childhood illnesses in Vietnam.

METHODS

A total of six focus group discussions were conducted with child care providers. A thematised interview guide was used and qualitative content analysis was applied. Meaning units in the texts dealing with the same content material were identified, condensed and compared until several emerging themes were found. Finally, similarities and differences in the views between rural and urban groups were described.

RESULTS

Self-treatment and self-medication were prominent in the urban groups, whereas compliance and trust in doctors were more common among the rural participants. Misuse and misconceptions regarding the properties of drugs were reported leading to worries about irrational drug use in the community. Despite the widespread use of private services in both areas, the public health service was reported to be the most trusted recourse for serious cases.

CONCLUSIONS

Qualitatively different ways of using drug and health care services are reported for childhood sickness in rural and urban Vietnam. These results provide rich information for the development of quantitative studies on drug use for children and point to the need to involve all health facilities in consideration.

Selection of antibiotic-resistant pathogens in the community

In recent years, the importance of the community as a breeding ground for antibiotic-resistant pathogens is being recognized. Prescription of antimicrobial drugs for viral infections, inadequate dosage, use of long-acting macrolides and broad-spectrum antibiotics, and accessibility of over-the-counter antibiotics in many countries are the main drivers of increasing resistance. Education of physicians and the public on the correct use of antibiotics, introduction of rapid and reliable laboratory methods to distinguish between viral and bacterial infections, and offering economic incentives to the pharmaceutical industry to develop new drugs appear to be key issues in the confrontation with this serious public health problem.