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Chansamouth V, Chommanam D, Roberts T, Keomany S, Paphasiri V, Phamisith C, Sengsavang S, Detleuxay K, Phoutsavath P, Bouthavong S, Douangnouvong A, Vongsouvath M, Rattana S, Keohavong B, Day NP, Turner P, van Doorn HR, Mayxay M, Ashley EA, Newton PN. Evaluation of trends in hospital antimicrobial use in the Lao PDR using repeated point-prevalence surveys-evidence to improve treatment guideline use. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 27:100531. [PMID: 35846979 PMCID: PMC9283659 DOI: 10.1016/j.lanwpc.2022.100531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Antimicrobial use (AMU) is a key driver of antimicrobial resistance (AMR). There are few data on AMU, to inform optimizing antibiotic stewardship, in the Lao PDR (Laos). METHODS Point prevalence surveys (PPS) of AMU were conducted at four-month intervals in six general hospitals across Laos from 2017 to 2020, using modified Global-PPS data collection tools. The surveys focused on AMU amongst hospitalized inpatients. FINDINGS The overall prevalence of inpatient AMU was 71% (4,377/6,188), varying by hospital and survey round from 50·4% (135/268) to 88·4% (61/69). Of 4,377 patients, 44% received >one antimicrobial. The total number of prescriptions assessed was 6,555. Ceftriaxone was the most commonly used (39·6%) antimicrobial, followed by metronidazole (17%) and gentamicin (10%). Pneumonia was the most common diagnosis among those prescribed antimicrobials in both children aged ≤5 years (29% among aged ≤1 year and 27% among aged >1 to ≤5years) and adults aged ≥15 years at 9%. The percentage of antimicrobial use compliant with local treatment guidelines was 26%; inappropriate use was mainly found for surgical prophylaxis (99%). Adult patients received ACCESS group antimicrobials less commonly than children (47% vs 63%, p-value<0·0001). Most WATCH group prescriptions (99%) were without a microbiological indication. INTERPRETATION AMU among hospitalized patients in Laos is high with frequent inappropriate use of antimicrobials, especially as surgical prophylaxis. Continued monitoring and enhanced antimicrobial stewardship interventions are needed in Lao hospitals. FUNDING The Wellcome Trust [Grant numbers 220211/Z/20/Z and 214207/Z/18/Z] and bioMérieux.
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Affiliation(s)
- Vilada Chansamouth
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
- Microbiology Laboratory, Mahosot Hospital, Vientiane City, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Danoy Chommanam
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
| | - Tamalee Roberts
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | | | | | | | | | | | | | | | - Anousone Douangnouvong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
- Microbiology Laboratory, Mahosot Hospital, Vientiane City, Lao PDR
| | - Sommana Rattana
- Department of Healthcare and Rehabilitation, Ministry of Health, Vientiane City, Lao PDR
| | - Bounxou Keohavong
- Department of Food and Drug, Ministry of Health, Vientiane City, Lao PDR
| | - Nicholas P.J. Day
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul Turner
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
| | - H. Rogier van Doorn
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Oxford University Clinical Research Unit, Hanoi, Viet Nam
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of Health, Vientiane Lao PDR
| | - Elizabeth A. Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N. Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane City, Lao PDR
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Perales NA, Wei D, Khadka A, Leslie HH, Hamadou S, Yama GC, Robyn PJ, Shapira G, Kruk ME, Fink G. Quality of clinical assessment and child mortality: a three-country cross-sectional study. Health Policy Plan 2021; 35:878-887. [PMID: 32577749 DOI: 10.1093/heapol/czaa048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 11/14/2022] Open
Abstract
This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2-59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Compliance with diagnostic and danger sign protocols during sick-child visits was observed by trained assessors. We computed facility- and district-level compliance indicators for patients aged 2-59 months and used multivariate multi-level logistic regression models to estimate the association between clinical assessment quality and mortality at age 2-59 months in the catchment areas of the observed facilities. A total of 13 618 live births were analysed and 1818 sick-child visits were directly observed and used to rate 643 facilities. Eight percent of observed visits complied with 80% of basic diagnostic protocols, and 13% of visits fully adhered to select general danger sign protocols. A 10% greater compliance with diagnostic protocols was associated with a 14.1% (adjusted odds ratio (aOR) 95% CI: 0.025-0.244) reduction in the odds of mortality at age 2-59 months; a 10% greater compliance with select general danger sign protocols was associated with a 15.3% (aOR 95% CI: 0.058-0.237) reduction in the same odds. The results of this article suggest that compliance with recommended clinical protocols remains poor in many settings and improvements in mortality at age 2-59 months could be possible if compliance were improved.
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Affiliation(s)
- Nicole A Perales
- School of Public Health, University of California Berkeley, 2121 Berkeley Way, Berkeley, CA 94720, USA
| | - Dorothy Wei
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
| | - Aayush Khadka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA.,Graduate School of Arts and Sciences, Harvard University, 350 Massachusetts Avenue, Cambridge MA 02138, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
| | - Saïdou Hamadou
- Health, Nutrition and Population Unit, The World Bank, 1818 H Street NW, Washington, DC 20433, USA
| | | | - Paul Jacob Robyn
- Health, Nutrition and Population Unit, The World Bank, 1818 H Street NW, Washington, DC 20433, USA
| | - Gil Shapira
- Development Research Group, The World Bank, 1818 H Street NW, Washington, DC 20433, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
| | - Günther Fink
- Swiss Tropical and Public Health Institute and University of Basel, Socinstrasse 57, Basel 4051, Switzerland
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Maina M, McKnight J, Tosas-Auguet O, Schultsz C, English M. Using treatment guidelines to improve antibiotic use: insights from an antibiotic point prevalence survey in Kenya. BMJ Glob Health 2021; 6:e003836. [PMID: 33419928 PMCID: PMC7798408 DOI: 10.1136/bmjgh-2020-003836] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Michuki Maina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Nairobi, Kenya
- Amsterdam UMC, Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Olga Tosas-Auguet
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Constance Schultsz
- Amsterdam UMC, Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
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Choonara I. Evaluation of rational prescribing in paediatrics. BMJ Paediatr Open 2021; 5:e001045. [PMID: 33817349 PMCID: PMC7970256 DOI: 10.1136/bmjpo-2021-001045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Imti Choonara
- Child Health, University of Nottingham School of Medicine, Derby, UK
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Ayieko P, Irimu G, Ogero M, Mwaniki P, Malla L, Julius T, Chepkirui M, Mbevi G, Oliwa J, Agweyu A, Akech S, Were F, English M. Effect of enhancing audit and feedback on uptake of childhood pneumonia treatment policy in hospitals that are part of a clinical network: a cluster randomized trial. Implement Sci 2019; 14:20. [PMID: 30832678 PMCID: PMC6398235 DOI: 10.1186/s13012-019-0868-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 02/04/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) revised its clinical guidelines for management of childhood pneumonia in 2013. Significant delays have occurred during previous introductions of new guidelines into routine clinical practice in low- and middle-income countries (LMIC). We therefore examined whether providing enhanced audit and feedback as opposed to routine standard feedback might accelerate adoption of the new pneumonia guidelines by clinical teams within hospitals in a low-income setting. METHODS In this parallel group cluster randomized controlled trial, 12 hospitals were assigned to either enhanced feedback (n = 6 hospitals) or standard feedback (n = 6 hospitals) using restricted randomization. The standard (network) intervention delivered in both trial arms included support to improve collection and quality of patient data, provision of mentorship and team management training for pediatricians, peer-to-peer networking (meetings and social media), and multimodal (print, electronic) bimonthly hospital specific feedback reports on multiple indicators of evidence guideline adherence. In addition to this network intervention, the enhanced feedback group received a monthly hospital-specific feedback sheet targeting pneumonia indicators presented in multiple formats (graphical and text) linked to explicit performance goals and action plans and specific email follow up from a network coordinator. At the start of the trial, all hospitals received a standardized training on the new guidelines and printed booklets containing pneumonia treatment protocols. The primary outcome was the proportion of children admitted with indrawing and/or fast-breathing pneumonia who were correctly classified using new guidelines and received correct antibiotic treatment (oral amoxicillin) in the first 24 h. The secondary outcome was the proportion of correctly classified and treated children for whom clinicians changed treatment from oral amoxicillin to injectable antibiotics. RESULTS The trial included 2299 childhood pneumonia admissions, 1087 within the hospitals randomized to enhanced feedback intervention, and 1212 to standard feedback. The proportion of children who were correctly classified and treated in the first 24 h during the entire 9-month period was 38.2% (393 out of 1030) and 38.4% (410 out of 1068) in the enhanced feedback and standard feedback groups, respectively (odds ratio 1.11; 95% confidence interval [CI] 0.37-3.34; P = 0.855). However, in exploratory analyses, there was evidence of an interaction between type of feedback and duration (in months) since commencement of intervention, suggesting a difference in adoption of pneumonia policy over time in the enhanced compared to standard feedback arm (OR = 1.25, 95% CI 1.14 to 1.36, P < 0.001). CONCLUSIONS Enhanced feedback comprising increased frequency, clear messaging aligned with goal setting, and outreach from a coordinator did not lead to a significant overall effect on correct pneumonia classification and treatment during the 9-month trial. There appeared to be a significant effect of time (representing cumulative effect of feedback cycles) on adoption of the new policy in the enhanced feedback compared to standard feedback group. Future studies should plan for longer follow-up periods to confirm these findings. TRIAL REGISTRATION US National Institutes of Health-ClinicalTrials.gov identifier (NCT number) NCT02817971 . Registered September 28, 2016-retrospectively registered.
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Affiliation(s)
- Philip Ayieko
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas Julius
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mercy Chepkirui
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Irimu G, Ogero M, Mbevi G, Agweyu A, Akech S, Julius T, Nyamai R, Githang’a D, Ayieko P, English M. Approaching quality improvement at scale: a learning health system approach in Kenya. Arch Dis Child 2018; 103. [PMID: 29514814 PMCID: PMC6278651 DOI: 10.1136/archdischild-2017-314348] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Grace Irimu
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - George Mbevi
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Ambrose Agweyu
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Samuel Akech
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Thomas Julius
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Rachel Nyamai
- Maternal, Newborn, Child and Adolescent Health Unit, Ministry of Health, Nairobi, Kenya
| | | | - Philip Ayieko
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Mike English
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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