PHA-Exchange> Antibiotic use and resistance: Assessing and improving utilisation and provision of antibiotics and other drugs

[Aviva]

From: "Levitt, Daniel (HANOI/HHA)" <dlevitt at usaid.gov>
 

This is important worldwide despite the fact that data are from Vietnam!  Your 
country (if in the Third World)  is probably not too different...
Claudio
  _____  

Larsson, Mattias
Antibiotic use and resistance: Assessing and improving utilisation and
provision of antibiotics and other drugs in Vietnam 



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. 
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