[e-drug] Antibiotic use and resistance in Vietnam

E-drug: Antibiotic use and resistance in Vietnam
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[E-druggers, Below is the abstract of a PhD thesis on antibiotic use
in Vietnam, which was presented in December 2003. The topic
concerns me a lot, as the inappropriate use of antimicrobial agents
in the world continues to receive relatively little attention. The
thesis documents practices in antibiotic use, and interestingly, the
large difference between what providers say they will do (to
simulated clients) and what they do in reality. This suggests that
correct knowledge on antibiotic use is only one of the determinants
of good use. The good news is that antibiotic use can be changed,
provided well designed interventions are implemented. The full
thesis can be downloaded. For E-druggers interested in the issue
of determinants of antibiotic use in developing countries, the
following publications may be of interest:
- Radyowijati A, Haak H. Determinants of antimicrobial use in the
developing world. Child Health Research Project. Special Report,
Volume 4, Number 1, 2002.
http://www.childhealthresearch.org/doc/AMR_vol4.pdf
- Radyowijati A, Haak H. Improving antibiotic use in low-income
countries: An overview of evidence on determinants. Social
Science and Medicine, 57(4), 733-744, August 2003.
HH]

"Antibiotic Use and Resistance: Assessing and Improving Provision
and Utilization of Antibiotics and Other Drugs in Vietnam"

Mattias Larsson

Full thesis available for download from:
http://diss.kib.ki.se/2003/91-7349-630-8/

Abstract

Background:
In Vietnam there were shortages of drugs until the end of the
1980's. In 1986 the "Doi Moi" economic reforms towards market
economy were initiated. An expanding private health care sector
emerged and the per capita drug consumption has increased
dramatically.
Aim:
To assess drug provision in the public and private sectors,
antibiotic use and resistance in the community, as well as the
effect of an intervention package aimed at improving case
management in private pharmacies in Vietnam.
Methods:
Drug utilization was assessed in 6 provinces using 2400
prescriptions, 1200 drugs, 200 interviews with doctors and 200
medical records (I). Community antibiotic use and bacterial
resistance was assessed among 200 children 1-5 years of age in
the rural Bavi district using a questionnaire and disc diffusion
tests (11). Antibiotic prescribing was assessed in relation to
serum levels of C-reactive protein among 100 children 1-6 years
who received antibiotic treatment (III), A randomized control trial
assessed the effect of an intervention package (enforcement of
regulation, education and peer influence) on case management
of childhood mild respiratory infection, male sexually transmitted
disease and dispensing of prescription only drugs (antibiotics and
steroids) in 60 private pharmacies in Hanoi. Knowledge was
assessed through interviews with a structured questionnaire pre
and post intervention and practice through simulated client
method with five encounters per pharmacy after each intervention
(IV, V & VI).
Results:
Essential drugs were available in remote areas. The average
number of drugs per prescription was high and injections were
common (I) In Bavi 75% of the children had been treated with
antibiotics within one month preceding the study, most commonly
ampicillin, penicillin or amoxicillin. Of the carers deciding on
treatment 67% consulted a drug seller, 22% a doctor and I I%
decided themselves. Of the antibiotics 80% were purchased from
private drug outlets. Of S. pneumoniae and, H. influenzae 90%
and 68% were resistant to at least one antibiotic, respectively
(88% and 32% to tetracycline, 32% and 44% to trimethoprim/
sulphonamide and 25% and 24% to chloramphenicol,
respectively). There was a significant difference in ampicillin and
penicillin resistance between the group of children previously
treated with beta lactam antibiotics and the group of children not
having received antibiotics (11). Elevated CRP concentrations
(>10 mg/L) were detected in only 17% of the children who had
received antibiotic prescription (III). Of the pharmacy staff 20%
stated that they would dispense antibiotics for a child with cough,
in practice 83% of the pharmacies did. Fifty three percent stated
that they would ask the patient questions related to breathing, in
practice 10% did; Eighty one percent stated that antibiotics are
not effective in short courses, in practice 47% dispensed for
courses less than 5 days. Only 36% of the cases were handled
according to guidelines (IV). Compliance with the prescription
regulation was weak. Sixty percent said that they would not
dispense steroids without prescription. In practice all but one
pharmacy did (V). The intervention pharmacies improved
significantly compared to the control pharmacies in all tracer
conditions. For mild respiratory infections, antibiotic dispensing
decreased and questions regarding rapid breathing increased.
For sexually transmitted diseases, advice to go to the doctor and
dispensing the correct symptomatic treatment increased.
Dispensing of prednisolone and cephalexin decreased and
prescription requests increased (VI).
Conclusion:
Considering the common practice of self-medication with
antibiotics through private pharmacies and high levels of
antibiotic resistance there is a need to improve drug utilization
and provision in Vietnam. Promoting Good Pharmacy Practice
standards towards improving case management in private
pharmacies is likely to have a major public health impact.

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