High antibiotic use and resistance among children under five : acute respiratory infections : knowledge and behaviour of caregivers and healthcare providers in Vietnam

Background: Increased bacterial resistance is threatening the therapeutic effectiveness of antibiotics. High level of antibiotic use is probably the main factor driving the emergence of resistance. Streptococcus pneumoniae is the most significant bacterial cause of community-acquired pneumonia, which is the leading cause of deaths among children under five worldwide.

Main aim: To investigate proportion of antibiotic resistance and antibiotic use for acute respiratory infections (ARIs) among children under five, and describe knowledge and behaviour of caregivers and healthcare providers (HCPs) regarding antibiotic use for childhood illness in Vietnam.

Methods: This thesis consists of quantitative and qualitative studies. In Papers I and III, 828 caregivers were interviewed using a structured questionnaire and 823 children under five were followed for a 28-day period to collect data on daily illness symptoms and drug use. Clinical examinations were done and nasopharyngeal samples were taken. Etest and disk-diffusion were used to test antibiotic susceptibility of 421 S. pneumoniae isolates. Paper II is a qualitative study with six focus group discussions with mothers, fathers and grandmothers. Paper IV used a self-completed structured questionnaire with 392 HCPs regarding management of children under five with ARIs.

Results: Of the 421 pneumococcal isolates, 95% were resistant to at least one antibiotic and 60% were multidrug-resistant (I). The resistance to co-trimoxazole, tetracycline, phenoxymethylpenicillin, erythromycin and ciprofloxacin was 78%, 75%, 75%, 70% and 28%, respectively. Low resistance was noted for amoxicillin (4%), benzylpenicillin (4%), and cefotaxime (2%). The intermediate resistance to amoxicillin was 32%. Resistance to commonly used antibiotics was higher among children who had used antibiotics recently (I). Self-treatment was prominent among urban participants, whereas compliance and trust in physicians were more common among rural participants. Caregivers perceived antibiotic use as mandatory for illness with fever (II). During the most recent illness, antibiotics were given to 71%, 86% and 32% of children with mild ARI, severe ARI, and other illness, respectively (III). In the 28-day period, 62% of children used antibiotics. Most of the antibiotic courses were used for mild ARIs (528/843). Most of the incorrect treatment (82%) reported has been recommended by HCPs (III). Only 27% of HCPs demonstrated correct knowledge regarding the consequences of resistance and 19% regarding the antibiotic treatment for ARIs (IV). In the most recent encounter with a sick child, antibiotics were recommended in 90%, 87%, and 78% for treatment of mild ARIs, severe ARIs, and other illness, respectively (IV).

Conclusions: Resistance to commonly used antibiotics and multidrug-resistance of S. pneumoniae is markedly high. High dose of amoxicillin is the only oral antibiotic that can possibly be used when treatment is required for community-acquired pneumococcal infections. Most of children had used antibiotics unnecessarily during their most recent illness and in the 28-day period during the study. There is a serious lack of knowledge on appropriate antibiotic use among the HCPs as well as the caregivers. Antibiotics are often prescribed or dispensed for common colds.

List of scientific papers

I. Hoa NQ, Trung NV, Larsson M, Eriksson B, Phuc HD, Chuc NT, Lundborg CS (2010). "Decreased Streptococcus pneumoniae susceptibility to oral antibiotics among children in rural Vietnam: a community study." BMC Infect Dis 10: 85
https://pubmed.ncbi.nlm.nih.gov/20356399

II. Hoa NQ, Ohman A, Lundborg CS, Chuc NT (2007). "Drug use and health-seeking behavior for childhood illness in Vietnam--a qualitative study." Health Policy 82(3): 320-9. Epub 2006 Nov 21
https://pubmed.ncbi.nlm.nih.gov/17118482

III. Hoa NQ, Chuc NTK, Phuc HD, Eriksson B, Larsson M, Stålsby Lundborg C (2010). "Unnecessary antibiotic use for mild acute respiratory infections in 28-day follow-up of 823 children under five in rural Vietnam." (Submitted)

IV. Hoa NQ, Larson M, Kim Chuc NT, Eriksson B, Trung NV, Stålsby CL (2009). "Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers knowledge, practical competence and reported practice." Trop Med Int Health 14(5): 546-55. Epub 2009 Mar 19
https://pubmed.ncbi.nlm.nih.gov/19320870