Antibiotic use and resistance : assessing and improving utilisation and provision of antibiotics and other drugs in Vietnam

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 (II). 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.

List of scientific papers

I. Falkenberg T, Nguyen TB, Larsson M, Nguyen TD, Tomson G (2000). Pharmaceutical sector in transition--a cross sectional study in Vietnam. Southeast Asian J Trop Med Public Health. 31(3): 590-7.
https://pubmed.ncbi.nlm.nih.gov/11289028

II. Larsson M, Kronvall G, Chuc NT, Karlsson I, Lager F, Hanh HD, Tomson G, Falkenberg T (2000). Antibiotic medication and bacterial resistance to antibiotics: a survey of children in a Vietnamese community. Trop Med Int Health. 5(10): 711-21.
https://pubmed.ncbi.nlm.nih.gov/11044266

III. Larsson M, Falkenberg T, Dardashti A, Ekman T, Chuc NTK, Kronvall G (2003). Assessing routine antibiotic prescribing in relation to C-reactive protein in capillary blood of children in rural Vietnam. [Manuscript]

IV. Chuc NT, Larsson M, Falkenberg T, Do NT, Binh NT, Tomson GB (2001). Management of childhood acute respiratory infections at private pharmacies in Vietnam. Ann Pharmacother. 35(10): 1283-8.
https://pubmed.ncbi.nlm.nih.gov/11675861

V. Larsson M, Binh NT, Tomson G, Chuc NTK, Falkenberg T (2003). Private pharmacy staff in Hanoi dispensing steroids - theory and practice. [Manuscript]

VI. Chuc NT, Larsson M, Do NT, Diwan VK, Tomson GB, Falkenberg T (2002). Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. J Clin Epidemiol. 55(11): 1148-55.
https://pubmed.ncbi.nlm.nih.gov/12507680