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Larsson, MattiasAntibiotic use and resistance : Assessing and improving utilisation and provision of antibiotics and other drugs in VietnamOnsdagen den 17 december 2003, kl. 13.00. Aulan, plan 2, Norrbackahuset, Karolinska Sjukhuset. |
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| ISBN: 91-7349-630-8 | Diss: 03:548 |
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.
Fiftythree 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.
Keywords: Antibiotic use, antibiotic resistance, private pharmacies, case management, knowledge, practice, interventions, enforcement of regulation, education, peer influence
List of papers
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Pharmaceutical sector in transition--a cross sectional study in Vietnam. Falkenberg T, Nguyen TB, Larsson M, Nguyen TD, Tomson G Southeast Asian J Trop Med Public Health, 2000; 31(3): 590-7 |
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Antibiotic medication and bacterial resistance to antibiotics: a survey of children in a Vietnamese community. Larsson M, Kronvall G, Chuc NT, Karlsson I, Lager F, Hanh HD, Tomson G, Falkenberg T Trop Med Int Health, 2000; 5(10): 711-21 |
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Assessing routine antibiotic prescribing in relation to C-reactive protein in capillary blood of children in rural Vietnam. Larsson M, Falkenberg T, Dardashti A, Ekman T, Chuc NTK, Kronvall G Manuscript |
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Management of childhood acute respiratory infections at private pharmacies in Vietnam. Chuc NT, Larsson M, Falkenberg T, Do NT, Binh NT, Tomson GB Ann Pharmacother, 2001; 35(10): 1283-8 |
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Private pharmacy staff in Hanoi dispensing steroids - theory and practice. Larsson M, Binh NT, Tomson G, Chuc NTK, Falkenberg T Manuscript |
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Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. Chuc NT, Larsson M, Do NT, Diwan VK, Tomson GB, Falkenberg T J Clin Epidemiol, 2002; 55(11): 1148-55 |
