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Orwa SA, Gudnadottir U, Boven A, Pauwels I, Versporten A, Vlieghe E, Brusselaers N. Global prevalence of antibiotic consumption during pregnancy: A systematic review and meta-analysis. J Infect 2024; 89:106189. [PMID: 38844084 DOI: 10.1016/j.jinf.2024.106189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Antibiotic use during pregnancy is widespread with notable variations across regions. METHODS This systematic review and meta-analysis (Prospero protocol CRD42023418979) examines the prevalence and variability of antibiotic use in pregnancy globally and regionally, considering different methodologies and maternal characteristics. We searched Embase, PubMed, and Web of Science for observational studies published in English from the year 2000 and onwards. Random-effect meta-analyses were used to pool the prevalence of antibiotic consumption during pregnancy, presented as percentages with 95% confidence intervals (CI). Joanna Briggs Institute Critical appraisal checklist for prevalence studies was used for bias assessment. FINDINGS Overall, 116 studies (14 from Africa, 24 from the Americas, six from Eastern Mediterranean, 57 from Europe, four from South-East Asia and 11 from Western Pacific) were included (33,821,194 pregnancies). The majority of studies (84.5%) were appraised with a low risk of bias. The prevalence of antibiotic consumption during pregnancy ranged between 0.04 to 90%, with a pooled estimate of 23.6% (95% CI: 20.1-27.5, I2 =100%). Low-income countries had the highest pooled prevalence (45.3%, 95% CI: 15.4-79.1, I2 =99.6%). Regionally, the Western Pacific had the highest pooled prevalence (34.4%, 95% CI: 13.4-64.1, I2 =100%). The prevalence of antibiotic consumption during pregnancy increased over time in the Americas and Western Pacific. The studies exhibited considerable heterogeneity (I2 >95%), and the trim-and-fill method estimated a potential 10% underestimation of the overall pooled prevalence, suggesting publication bias. INTERPRETATION This meta-analysis suggests that about 1/4 of women worldwide use antibiotics during pregnancy. This study suggests a high prevalence of antibiotic consumption during pregnancy with disparities according to region and level of country income, ethnicity and whether antibiotics were prescribed or self-medicated. There was a variability in reported findings across age categories, potential bias from small sample sizes, and language bias from including only studies published in English.
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Affiliation(s)
- Sheila A Orwa
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Unnur Gudnadottir
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Annelies Boven
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium; Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Ines Pauwels
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Ann Versporten
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Erika Vlieghe
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium; Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; General Internal Medicine, Infectious Diseases and Tropical Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nele Brusselaers
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
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Thi TVL, Canh Pham E, Dang-Nguyen DT. Evaluation of children's antibiotics use for outpatient pneumonia treatment in Vietnam. Braz J Infect Dis 2024; 28:103839. [PMID: 38996808 PMCID: PMC11321292 DOI: 10.1016/j.bjid.2024.103839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/01/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVE Antibiotic resistance is increasing globally, associated with many failures in pneumonia treatment. This study aimed to evaluate antibiotic use in children treated for outpatient CAP (Community-Acquired Pneumonia). METHODS A cross-sectional descriptive retrospective study was conducted, focusing on data from outpatient prescriptions for pneumonia in patients aged 2‒192 months in 2019‒2021. RESULTS All antibiotic prescriptions are considered empiric as no documented bacterial and viral tests exist for children with non-severe CAP. Single antibiotic therapy (66%) had a 2-fold higher rate than combination therapy (34%). Amoxicillin/clavulanic acid (50.77%) and azithromycin (30.74%) were the most commonly prescribed in both single and combination therapies, thus determining antibiotic cost (80.15%). Besides, azithromycin (97.92%), cefuroxime (86.26%), and cefpodoxime (60.48%) were prescribed with high adherence to dose guidelines, except for amoxicillin (34.57%). These medicines are prescribed highly compliant (>83%) with dosing interval guidelines. Furthermore, significantly more brand-name antibiotics (56.5%) are prescribed than generic antibiotics (43.5%). In particular, antibiotic class, antibiotic origin, and antibiotic therapies showed significant association with rational antibiotic prescriptions for dose and dose interval (p < 0.05). CONCLUSIONS Amoxicillin/clavulanic acid is the most frequently prescribed medicine and the most inappropriate due to non-compliance with dose guidelines for CAP treatment. Generic antibiotic use for single therapy should be encouraged based on rapid and accurate diagnostic testing for viruses and bacteria to reduce antibiotic resistance in developing countries. Moreover, the study result has also shown that therapies and antibiotics (class and origin) exhibited significant association with rational prescriptions for CAP treatment for pediatrics.
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Affiliation(s)
- Tuong Vi Le Thi
- University of Medicine and Pharmacy at Ho Chi Minh City, Faculty of Pharmacy, Ho Chi Minh City, Viet Nam; City Children's Hospital, Faculty of Pharmacy, Department of Pharmacology - Clinical Pharmacy, Ho Chi Minh City, Viet Nam
| | - Em Canh Pham
- Hong Bang International University, Faculty of Pharmacy, Ho Chi Minh City, Viet Nam.
| | - Doan-Trang Dang-Nguyen
- University of Medicine and Pharmacy at Ho Chi Minh City, Faculty of Pharmacy, Ho Chi Minh City, Viet Nam.
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Nguyen PT, Nguyen TT, Huynh LT, Graham SM, Marais BJ. Clinical algorithm reduces antibiotic use among children presenting with respiratory symptoms to hospital in central Vietnam. Pneumonia (Nathan) 2023; 15:11. [PMID: 37488633 PMCID: PMC10367404 DOI: 10.1186/s41479-023-00113-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 06/29/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE To assess the safety and utility of a pragmatic clinical algorithm to guide rational antibiotic use in children presenting with respiratory infection. METHODS The effect of an algorithm to guide the management of young (< 5 years) children presenting with respiratory symptoms to the Da Nang Hospital for Women and Children, Vietnam, was evaluated in a before-after intervention analysis. The main outcome was reduction in antibiotic use, with monitoring of potential harm resulting from reduced antibiotic use. The intervention comprised a single training session of physicians in the use of an algorithm informed by local evidence; developed during a previous prospective observational study. The evaluation was performed one month after the training. RESULTS Of the 1290 children evaluated before the intervention, 102 (7.9%) were admitted to hospital and 556/1188 (46.8%) were sent home with antibiotics. Due to COVID-19, only 166 children were evaluated after the intervention of whom 14 (8.4%) were admitted to hospital and 54/152 (35.5%) were sent home with antibiotics. Antibiotic use was reduced (from 46.8% to 35.5%; p = 0.009) after clinician training, but adequate comparison was compromised. The reduction was most pronounced in children with wheeze or runny nose and no fever, or a normal chest radiograph, where antibiotic use declined from 46.7% to 28.8% (p < 0.0001). The frequency of repeat presentation to hospital was similar between the two study periods (141/1188; 11.9% before and 10/152; 6.6% after; p = 0.10). No child represented with serious disease after being sent home without antibiotics. CONCLUSIONS We observed a reduction in antibiotic use in young children with a respiratory infection after physician training in the use of a simple evidence-based management algorithm. However, the study was severely impacted by COVID-19 restrictions, requiring further evaluation to confirm the observed effect.
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Affiliation(s)
- Phuong Tk Nguyen
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam.
- Sydney Vietnam Initiative, The University of Sydney, Sydney, Australia.
| | - Tam Tm Nguyen
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Lan Tb Huynh
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Stephen M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Ben J Marais
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, Westmead, Australia
- Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, Australia
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4
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Nguyen PTK, Robinson PD, Fitzgerald DA, Marais BJ. The dilemma of improving rational antibiotic use in pediatric community-acquired pneumonia. Front Pediatr 2023; 11:1095166. [PMID: 36846166 PMCID: PMC9945262 DOI: 10.3389/fped.2023.1095166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/10/2023] [Indexed: 02/11/2023] Open
Abstract
Pneumonia is the number one cause of disease and deaths in children under five years old, outside the neonatal period, with the greatest number of cases reported from resource-limited settings. The etiology is variable, with not much information on the local etiology drug resistance profile in many countries. Recent studies suggest an increasing contribution from respiratory viruses, also in children with severe pneumonia, with an increased relative contribution in settings that have good vaccine coverage against common bacterial pathogens. Respiratory virus circulation was greatly reduced during highly restrictive measures to contain the spread of COVID-19 but rebounded once COVID-19 restrictions were relaxed. We conducted a comprehensive literature review of the disease burden, pathogens, case management and current available prevention of community acquired childhood pneumonia, with a focus on rational antibiotic use, since the treatment of respiratory infections is the leading cause of antibiotic use in children. Consistent application of revised World Health Organisation (WHO) guidance that children presenting with coryzal symptoms or wheeze can be managed without antibiotics in the absence of fever, will help to reduce unnecessary antibiotic use, as will increased availability and use of bedside inflammatory marker tests, such as C-reactive protein (CRP) in children with respiratory symptoms and fever.
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Affiliation(s)
- Phuong T K Nguyen
- Department of General Medicine, The Children's Hospital Westmead, Westmead, NSW, Australia
| | - Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital Westmead, NSW, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital Westmead, NSW, Australia.,The University of Sydney, Discipline of Child and Adolescent Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Ben J Marais
- The University of Sydney, Discipline of Child and Adolescent Health, Faculty of Medicine and Health, Sydney, NSW, Australia.,Department of Infectious Diseases, The Children's Hospital Westmead, Westmead, NSW, Australia
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Bregman S, Thau E, Pusic M, Perez M, Boutis K. A Performance-Based Competency Assessment of Pediatric Chest Radiograph Interpretation Among Practicing Physicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 44:28-34. [PMID: 36728983 DOI: 10.1097/ceh.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/19/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION There is limited knowledge on pediatric chest radiograph (pCXR) interpretation skill among practicing physicians. We systematically determined baseline interpretation skill, the number of pCXR cases physicians required complete to achieve a performance benchmark, and which diagnoses posed the greatest diagnostic challenge. METHODS Physicians interpreted 434 pCXR cases via a web-based platform until they achieved a performance benchmark of 85% accuracy, sensitivity, and specificity. Interpretation difficulty scores for each case were derived by applying one-parameter item response theory to participant data. We compared interpretation difficulty scores across diagnostic categories and described the diagnoses of the 30% most difficult-to-interpret cases. RESULTS 240 physicians who practice in one of three geographic areas interpreted cases, yielding 56,833 pCXR case interpretations. The initial diagnostic performance (first 50 cases) of our participants demonstrated an accuracy of 68.9%, sensitivity of 69.4%, and a specificity of 68.4%. The median number of cases completed to achieve the performance benchmark was 102 (interquartile range 69, 176; min, max, 54, 431). Among the 30% most difficult-to-interpret cases, 39.2% were normal pCXR and 32.3% were cases of lobar pneumonia. Cases with a single trauma-related imaging finding, cardiac, hilar, and diaphragmatic pathologies were also among the most challenging. DISCUSSION At baseline, practicing physicians misdiagnosed about one-third of pCXR and there was up to an eight-fold difference between participants in number of cases completed to achieve the standardized performance benchmark. We also identified the diagnoses with the greatest potential for educational intervention.
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Affiliation(s)
- Stacey Bregman
- Dr. Bregman: Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Dr. Thau: Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Dr. Pusic: Division of Pediatric Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard University; Boston, MA. Dr. Perez: Department of Diagnostic Imaging, University of Toronto, Ontario, Canada. Dr. Boutis: Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Torumkuney D, Kundu S, Vu GV, Nguyen HA, Pham HV, Kamble P, Truong Ha Lan N, Keles N. Country data on AMR in Vietnam in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicines and clinical outcome. J Antimicrob Chemother 2022; 77:i26-i34. [PMID: 36065731 PMCID: PMC9445855 DOI: 10.1093/jac/dkac214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action. OBJECTIVES To review the current situation with respect to AMR in Vietnam and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize any further rises in AMR within Vietnam and improve patient outcomes. METHODS National initiatives to address AMR in Vietnam, antibiotic use and prescribing, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines for CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from clinicians in Vietnam were sought to contextualize this information. CONCLUSIONS In Vietnam there have been some initiatives addressing AMR; Vietnam was the first country in the Western Pacific Region to develop a national action plan to combat AMR, which according to the WHO is being implemented. Vietnam also has one of the highest rates of AMR in Asia due, in part, to the overuse of antimicrobial drugs, both in the animal health sector and in humans in both hospitals and the community. In addition, despite a 2005 law requiring antibiotic prescription, there is unrestricted access to over-the-counter antibiotics. Several global surveillance studies provide antibiotic susceptibility data for CA-RTI pathogens in Vietnam including Survey of Antibiotic Resistance (SOAR) and SENTRY (small isolate numbers only). For management of the common CA-RTIs in Vietnam there are several country-specific local antibiotic prescribing guidelines and in addition, there is a range of international guidelines referred to, but these may have been created based on pathogen resistance patterns that might be very different to those in Vietnam. Expert clinician opinion confirms the high resistance rates among common respiratory pathogens. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Vietnam, could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical outcomes for patients.
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Affiliation(s)
- Didem Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | | | - Giap Van Vu
- Respiratory Center, Bach Mai Hospital, Hanoi 100000, Vietnam
| | - Hoang Anh Nguyen
- The National Centre for Drug Information and Adverse Drug Reactions Monitoring, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Hung Van Pham
- University of Medicine and Pharmacy, 217 Hong Bang Street, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Praveen Kamble
- GlaxoSmithKline, 252, Dr Annie Besant Road, Worli, 400030 Mumbai, India
| | - Ngoc Truong Ha Lan
- GlaxoSmithKline Vietnam, Unit 701, 235 Dong Khoi, District 1, Ho Chi Minh City, Vietnam
| | - Nergis Keles
- GlaxoSmithKline, Büyükdere Cad. No: 173, 1. Levent Plaza B Blok 34394 Levent, Istanbul, Türkiye
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Nguyen TKP, Bui BBS, Ngo QC, Fitzgerald DA, Graham SM, Marais BJ. Applying lessons learnt from research of child pneumonia management in Vietnam. Paediatr Respir Rev 2021; 39:65-70. [PMID: 33158773 DOI: 10.1016/j.prrv.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 02/03/2023]
Abstract
Pneumonia is the leading cause of paediatric hospitalisation in Vietnam, placing a huge burden on the health care system. Pneumonia is also the main reason for antibiotic use in children. Unfortunately many hospital admissions for child pneumonia in Vietnam are unnecessary and inappropriate use of antibiotics is common, as in the rest of Asia, with little awareness of its adverse effects. We explored the value of an alternative approach that, instead of focusing on the identification of children with severe bacterial pneumonia, focuses on the identification of children with 'unlikely bacterial pneumonia' to improve patient care and rational antibiotic use. Implementing improved models of care require pragmatic management algorithms that are well validated, but it is ultimately dependent on financial structures, management support and evidence-based training of healthcare providers at all relevant levels. Apart from better case management, sustained reductions in the pneumonia disease burden also require increased emphasis on primary prevention.
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Affiliation(s)
- T K P Nguyen
- Respiratory Department, Da Nang Hospital for Women and Children, Viet Nam.
| | - B B S Bui
- Discipline of Paediatrics, Hue University of Medicine and Pharmacy, Viet Nam
| | - Q C Ngo
- Vietnam Respiratory Society, Ha Noi, Viet Nam
| | - D A Fitzgerald
- Respiratory Medicine, The Children's Hospital at Westmead, The University of Sydney, Australia
| | - S M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia; International Union Against Tuberculosis and Lung Diseases, Paris, France
| | - B J Marais
- Discipline of Child and Adolescent Health, The Children's Hospital at Westmead, The University of Sydney, Australia
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8
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Nguyen PTK, Tran HT, Tran TS, Fitzgerald DA, Graham SM, Marais BJ. Predictors of Unlikely Bacterial Pneumonia and Adverse Pneumonia Outcome in Children Admitted to a Hospital in Central Vietnam. Clin Infect Dis 2021; 70:1733-1741. [PMID: 31132089 DOI: 10.1093/cid/ciz445] [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] [Received: 04/12/2019] [Accepted: 05/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pneumonia is the leading cause of antibiotic use and hospitalization in Vietnam. There is a need for better prediction of unlikely bacterial pneumonia and adverse pneumonia outcome in order to guide hospital admission and improve rational antibiotic use. METHODS All children under 5 admitted with pneumonia (per clinician assessment) to the Da Nang Hospital for Women and Children were prospectively enrolled. Children were classified as having likely or unlikely bacterial pneumonia and followed for outcome assessment. A Bayesian model averaging approach was used to identify predictors of unlikely bacterial pneumonia and adverse pneumonia outcome, which guided the development of a pragmatic management algorithm. RESULTS Of 3817 patients assessed, 2199 (57.6%) met World Health Organization (WHO) pneumonia criteria. In total, 1594 (41.7%) children were classified as having unlikely and 129 (3.4%) as having likely bacterial pneumonia. The remainder (2399; 62.9%) were considered to have disease of uncertain etiology. Factors predictive of unlikely bacterial pneumonia were no fever, no consolidation on chest radiograph, and absolute neutrophil count <5 × 109/L at presentation, which had a negative predictive value (NPV) for likely bacterial pneumonia of 99.0%. Among those who met WHO pneumonia criteria, 8.6% (189/2199) experienced an adverse outcome. Not having any WHO danger sign or consolidation on chest radiograph had an NPV of 96.8% for adverse pneumonia outcome. CONCLUSIONS An algorithm that screens for predictors of likely bacterial pneumonia and adverse pneumonia outcome could reduce unnecessary antibiotic use and hospital admission, but its clinical utility requires validation in a prospective study.
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Affiliation(s)
- Phuong T K Nguyen
- Discipline of Child and Adolescent Health, Sydney Medical School, the Children's Hospital at Westmead, University of Sydney, Australia.,Da Nang Hospital for Women and Children, Vietnam
| | - Hoang T Tran
- Da Nang Hospital for Women and Children, Vietnam
| | - Thach S Tran
- Clinical Studies and Epidemiology, Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst
| | - Dominic A Fitzgerald
- Discipline of Child and Adolescent Health, Sydney Medical School, the Children's Hospital at Westmead, University of Sydney, Australia.,Respiratory Medicine, the Children's Hospital at Westmead, University of Sydney
| | - Stephen M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Australia
| | - Ben J Marais
- Discipline of Child and Adolescent Health, Sydney Medical School, the Children's Hospital at Westmead, University of Sydney, Australia
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Nguyen PT, Tran HT, Fitzgerald DA, Graham SM, Marais BJ. Antibiotic use in children hospitalised with pneumonia in Central Vietnam. Arch Dis Child 2020; 105:713-719. [PMID: 32079569 DOI: 10.1136/archdischild-2019-317733] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/11/2019] [Accepted: 01/22/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Excessive use of antibiotics has been noted in children with respiratory tract infections in Vietnam, but antibiotic use in hospitalised children is poorly documented. Antibiotic use and direct healthcare costs in children hospitalised with pneumonia in central Vietnam were assessed. METHODS A prospective descriptive study of children under 5 years old admitted with a primary admission diagnosis of 'pneumonia' to the Da Nang Hospital for Women and Children over 1 year. RESULTS Of 2911 children hospitalised with pneumonia, 2735 (94.0%) were classified as 'non-severe' pneumonia by the admitting physician. In total, 2853 (98.0%) children received antibiotics. Intravenous antibiotics were given to 336 (12.3%) children with 'non-severe' and 157/176 (89.2%) children with 'severe' pneumonia; those with 'non-severe' pneumonia accounted for 68.2% (336/493) of intravenous antibiotics given. Only 19.3% (95/493) of children on intravenous antibiotics were stepped down to an oral antibiotic. Cefuroxime was the preferred oral agent, and ceftriaxone was the preferred injectable agent. Hospital admission for oral antibiotics in 'non-severe' pneumonia was a major cost driver, with an average direct cost of US$78.9 per patient, accounting for 54.0% of the total hospitalisation cost in the study cohort. In addition, 336 (12.3%) children with non-severe pneumonia received intravenous antibiotics without indication, accounting for a further 23.2% of hospitalisation costs. CONCLUSION Limiting unnecessary hospitalisation and considering early intravenous to oral step down antibiotic will reduce direct health system costs and morbidity in children with respiratory tract infections in Vietnam.
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Affiliation(s)
- Phuong Tk Nguyen
- Department of Respirology, Da Nang Hospital for Women and Children, Da Nang, Vietnam .,Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Hoang T Tran
- Department of Neonatology, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Dominic A Fitzgerald
- Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, New South Wales, Australia.,Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Steve M Graham
- Department of Paediatrics, Centre for International Child Health, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia, Melbourne, Victoria, Australia
| | - Ben J Marais
- Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, New South Wales, Australia
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Nguyen PT, Tran HT, Truong HT, Nguyen VT, Graham SM, Marais BJ. Paediatric use of antibiotics in children with community acquired pneumonia: A survey from Da Nang, Vietnam. J Paediatr Child Health 2019; 55:1329-1334. [PMID: 30773763 DOI: 10.1111/jpc.14413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/27/2018] [Accepted: 01/23/2019] [Indexed: 11/28/2022]
Abstract
AIM To characterise paediatricians' antibiotic-prescribing behaviour when managing community acquired pneumonia. METHODS We conducted a knowledge and attitudes survey of paediatric doctors practicing at a regional provincial hospital in central Vietnam over a 2-week period (from 12 December 2017 to 29 December 2017). RESULTS Of 79 eligible paediatric doctors, 69 (87.3%) completed the questionnaire, of whom 65 (94.2%) thought that antibiotics were overused in Vietnam. Thirty-eight doctors (55.1%) indicated that they routinely hospitalised children with pneumonia to provide intravenous antibiotics. Most doctors reported discharging children with non-severe pneumonia after 5 days (76.9%) and those with severe pneumonia after 7-10 days (88.4%); older doctors generally continued intravenous antibiotics for longer. The two most important factors driving discharge decisions were clinical assessment (95.6%) and completion of the full course of intravenous antibiotics (80.0%). Antibiotic prescription was influenced by local guidelines (62.3%), drugs used before admission (50.0%) and the opinion of senior clinicians (37.7%). Most doctors believed antibiotic stewardship was necessary (98.6%) and that over-the-counter use of antibiotics should be restricted (97.1%). CONCLUSIONS Paediatricians recognised an urgent need for more effective regulation and antibiotic stewardship in Vietnam. Routinely completing a full course of intravenous antibiotics leads to unnecessary and prolonged hospitalisation.
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Affiliation(s)
- Phuong Tk Nguyen
- Discipline of Paediatrics and Adolescent Medicine, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia.,Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Hoang T Tran
- Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | | | - Vu T Nguyen
- Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Steve M Graham
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Ben J Marais
- Discipline of Paediatrics and Adolescent Medicine, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
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Emerging Antibiotic Resistance in Mycoplasma Microorganisms, Designing Effective and Novel Drugs / Therapeutic Targets: Current Knowledge and Futuristic Prospects. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2019. [DOI: 10.22207/jpam.13.1.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Haenssgen MJ, Charoenboon N, Do NTT, Althaus T, Khine Zaw Y, Wertheim HFL, Lubell Y. How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions. Trials 2019; 20:111. [PMID: 30736818 PMCID: PMC6368827 DOI: 10.1186/s13063-019-3215-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 01/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, “Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?” Methods We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients’ and healthcare workers’ adherence to the biomarker test results, and patient exclusion to gauge the potential “impact” of CRP point-of-care testing on the population level. Results We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system. Conclusions Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment. Trial registration ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013. Electronic supplementary material The online version of this article (10.1186/s13063-019-3215-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco J Haenssgen
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK. .,CABDyN Complexity Centre, Saïd Business School, University of Oxford, Park End Street, Oxford, OX1 1HP, UK. .,Global Sustainable Development, University of Warwick, Ramphal Building, Coventry, CV4 7AM, UK. .,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Nutcha Charoenboon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Nga T T Do
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam
| | - Thomas Althaus
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Yuzana Khine Zaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Heiman F L Wertheim
- Oxford University Clinical Research Unit (OUCRU), National Hospital for Tropical Diseases, 78 Giai Phong Street, Hanoi, Vietnam.,Medical Microbiology Department, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, 6525, Netherlands
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
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13
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Morre R, Sobi K, Pameh W, Ripa P, Vince JD, Duke T. Safety, Effectiveness and Feasibility of Outpatient Management of Children with Pneumonia with Chest Indrawing at Port Moresby General Hospital, Papua New Guinea. J Trop Pediatr 2019; 65:71-77. [PMID: 29660106 PMCID: PMC6366396 DOI: 10.1093/tropej/fmy013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Implementing the World Health Organization (WHO) recommendations on home-based management of pneumonia with chest indrawing is challenging in many settings. In Papua New Guinea, 120 children presenting with the WHO definition of pneumonia were screened for danger signs, comorbidities and hypoxaemia using pulse oximetry; 117 were appropriate for home care. We taught mothers about danger signs and when to return, using structured teaching materials and a video. The children were given a single dose of intramuscular benzylpenicillin, then sent home on oral amoxicillin for 5 days, with follow-up at Days 2 and 6. During the course of treatment, five (4%) of the 117 children were admitted and 15 (13%) were lost to follow-up. There were no deaths. Treating children with pneumonia with chest indrawing but no danger signs is feasible as long as safeguards are in place-excluding high-risk patients, checking for danger signs and hypoxemia and providing education for mothers and follow-up.
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Affiliation(s)
- Rose Morre
- Department of Paediatrics, Port Moresby General Hospital, Port Moresby, NCD, Papua New Guinea.,Mt Hagen General Hospital, Mt Hagen, WHP, Papua New Guinea
| | - Kone Sobi
- Department of Paediatrics, Port Moresby General Hospital, Port Moresby, NCD, Papua New Guinea
| | - Wendy Pameh
- Child Health Discipline, School of Medicine and Health Sciences, University of PNG, Taurama Campus, Port Moresby, NCD, Papua New Guinea
| | - Paulus Ripa
- Mt Hagen General Hospital, Mt Hagen, WHP, Papua New Guinea
| | - John D Vince
- Child Health Discipline, School of Medicine and Health Sciences, University of PNG, Taurama Campus, Port Moresby, NCD, Papua New Guinea
| | - Trevor Duke
- Child Health Discipline, School of Medicine and Health Sciences, University of PNG, Taurama Campus, Port Moresby, NCD, Papua New Guinea.,Centre for International Child Health, University of Melbourne, MCRI, Parkville, Victoria, Australia
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14
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Marais BJ, Williams S, Li A, Ofrin R, Merianos A, Negin J, Firman J, Davies R, Sorrell T. Improving emergency preparedness and response in the Asia-Pacific. BMJ Glob Health 2019; 4:e001271. [PMID: 30775010 PMCID: PMC6352770 DOI: 10.1136/bmjgh-2018-001271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/26/2018] [Accepted: 12/03/2018] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ben J Marais
- Centre for Research Excellence in Emerging Infectious Diseases (CREID) and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
| | - Stephanie Williams
- Department of Foreign Affairs and Trade, Indo-Pacific Centre for Health Security, Canberra, Australia
| | - Ailan Li
- Division of Health Security and Emergencies, WHO Health Emergencies Programme, WHO Western Pacific Regional Office, Manila, Philippines
| | - Roderico Ofrin
- WHO Health Emergencies Programme, WHO South-East Asia Regional Office, New Delhi, India
| | - Angela Merianos
- Pacific Health Security, WHO Communicable Disease and Climate Change Division, Suva, Fiji
| | - Joel Negin
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Firman
- Department of Health, Office of Health Protection, Canberra, Australia
| | - Robin Davies
- Department of Foreign Affairs and Trade, Indo-Pacific Centre for Health Security, Canberra, Australia
| | - Tania Sorrell
- Centre for Research Excellence in Emerging Infectious Diseases (CREID) and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
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15
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Fox-Lewis S, Pol S, Miliya T, Day NPJ, Turner P, Turner C. Utilization of a clinical microbiology service at a Cambodian paediatric hospital and its impact on appropriate antimicrobial prescribing. J Antimicrob Chemother 2018; 73:509-516. [PMID: 29186330 PMCID: PMC5890681 DOI: 10.1093/jac/dkx414] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/25/2017] [Accepted: 10/11/2017] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial resistance threatens human health worldwide. Antimicrobial misuse is a major driver of resistance. Promoting appropriate antimicrobial use requires an understanding of how clinical microbiology services are utilized, particularly in resource-limited settings. Objectives To assess the appropriateness of antimicrobial prescribing and the factors affecting utilization of the established clinical microbiology service (CMS). The CMS comprises the microbiology laboratory, clinical microbiologists (infection doctors) and antimicrobial treatment guidelines. Methods This mixed-methods study was conducted at a non-governmental Cambodian paediatric hospital. Empirical and post-culture antimicrobial prescriptions were reviewed from medical records. The random sample included 10 outpatients per week in 2016 (retrospective) and 20 inpatients per week for 4 weeks in the medical, neonatal and intensive care wards (prospective). Post-culture prescriptions were assessed in patients with positive blood and cerebrospinal fluid cultures from 1 January 2014 to 31 December 2016. Focus group discussions and semi-structured interviews with clinicians explored barriers and facilitators to use of the CMS. Results Only 31% of outpatients were prescribed empirical antimicrobials. Post-culture prescriptions (394/443, 89%) were more likely to be appropriate than empirical prescriptions (447/535, 84%), based on treatment guidelines, microbiology advice and antimicrobial susceptibility test results (P = 0.015). Being comprehensive, accessible and trusted enabled CMS utilization. Clinical microbiologists provided a crucial human interface between the CMS and physicians. The main barriers were a strong clinical hierarchy and occasional communication difficulties. Conclusions Antimicrobial prescribing in this hospital was largely appropriate. A culturally appropriate human interface linking the laboratory and physicians is essential in providing effective microbiology services and ensuring appropriate antimicrobial prescribing in resource-limited settings.
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Affiliation(s)
- Shivani Fox-Lewis
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford OX3 7FZ, UK
| | - Sreymom Pol
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Road, Ratchawithi District, Bangkok 10400, Thailand
| | - Thyl Miliya
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
- Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
| | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford OX3 7FZ, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Road, Ratchawithi District, Bangkok 10400, Thailand
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford OX3 7FZ, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Road, Ratchawithi District, Bangkok 10400, Thailand
- Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
| | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford OX3 7FZ, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Ratchawithi Road, Ratchawithi District, Bangkok 10400, Thailand
- Angkor Hospital for Children, PO Box 50, Siem Reap, Cambodia
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