Assessing and improving rational antimicrobial use in urban and rural health care facilities in Vietnam

Do Thi Thuy Nga (2017). Assessing and improving rational antimicrobial use in urban and rural health care facilities in Vietnam. PhD thesis The Open University.



The global problem of antimicrobial resistance (AMR) is particularly pressing in developing countries including Vietnam, where the infectious disease burden is high and cost constrains the replacement of older antimicrobials with newer, more expensive ones. Along with surveillance and infection control, responsible use of antimicrobials is one of the main objectives of the Vietnam National Action Plan on combating AMR. This thesis aims to get a better understanding of how antimicrobials are used in the Vietnamese community and how its use can be improved, to tailor evidence-based interventions and inform policies in controlling AMR.

To assess the current situation of community access and use of antimicrobials and identify determinants associated with current practice, an observational study was conducted in 30 private pharmacies in northern Vietnam. This study was followed by a randomised controlled trial (RCT) to evaluate a point of care (POC) C-reactive protein (CRP, a biomarker of inflammation) test in reducing unnecessary antimicrobial prescribing for patients with non-severe acute respiratory infections (ARI) and analysis of the economic impact and acceptance of this intervention among users.

In private pharmacies, profit incentives coupled to poor knowledge about AMR are key drivers of over the counter dispensing of antimicrobials regardless the existence of regulations. Using a simple rapid blood test to identify customers who do not benefit from antimicrobial therapy would be a potential solution. Primary healthcare stations where over-prescription of antimicrobials for self-limiting infections are common, were chosen for the intervention. CRP POC testing reduced unnecessary AB use for ARI patients without compromising patient’s recovery. This supports and extends findings from European trials by showing that such a stewardship approach is applicable even in resource constrained settings. However, there were several obstacles identified among users regarding test adherence associated with large between-site heterogeneity that need to be addressed to maximize the intervention’s effect in the future. More importantly, our cost analysis indicated that to encourage adoption at scale, proper funding mechanisms to balance the invested costs and achieve global impact on AMR is recommended.

In summary, antimicrobial use in Vietnam is largely uncontrolled both in the community and the healthcare system leading to overuse and over-prescription for non-severe ARI. Use of commercially available CRP tests can be an effective, scalable and economically viable approach, even in highly resource-constrained settings. For the future, we are looking at ways to optimise use of POC biomarker testing in primary healthcare and private pharmacy setting. The potential for biomarker based tests to be combined with rapid pathogen detection, enhancing test algorithm adherence, use of CRP tests with equal financial incentives as as selling of antimicrobials and introducing pay for performance mechanisms may be crucial parts for optimisation.

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