Country data on AMR in Vietnam in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicines and clinical outcome

Single nucleotide polymorphisms and penicillin non-susceptibility among invasive Streptococcus pneumoniae from Vietnam and India: Insights from a comparative genomics study

OBJECTIVES

Streptococcus pneumoniae (S. pneumoniae) is a significant cause of global morbidity and mortality across all age groups. Antimicrobial resistance (AMR), particularly penicillin resistance, is a significant treatment challenge. The study investigates AMR patterns among S. pneumoniae isolates from Vietnam, a country with high penicillin non-susceptibility, and India which in comparison has lower penicillin non-susceptibility. The present study focuses on penicillin resistance-associated genes and single nucleotide polymorphisms (SNPs), that contribute to pathogenicity.

METHODS

Invasive S. pneumoniae belonging to serotypes 23F (n = 13) and 19F (n = 20) genome sequences from Vietnam (n = 13) and India (n = 20) were retrieved and annotated to identify core genes. These genes were screened for antimicrobial resistance using the database. The genome sequences were mapped to a reference genome to detect the gene variants and were analysed for identifying specific mutations that contribute to pathogenicity.

RESULTS

Annotations identified pbp1a, pbp2b, and pbp2x (pbpX) as relevant AMR genes. In Vietnam, pbpX was a core gene, with 41 SNPs detected, of which 7 were deleterious mutations contributing to penicillin resistance. In contrast, pbpX was completely absent in the Indian genomes analysed.

CONCLUSIONS

The current study highlights the genetic basis of penicillin non-susceptibility among invasive S. pneumoniae serotypes 23F and 19F and focuses on regional variations in resistance between India and Vietnam. The pbpX was identified as a core gene among penicillin-resistant pneumococci in Vietnam. In India, the absence of pbpX highlights genomic diversity, distinct from the uniformity observed in Vietnamese genomes. The study further predicts that deleterious SNPs are associated with pathogenicity.

Determinants of antibiotic prescribing in primary care in Vietnam: a qualitative study using the Theoretical Domains Framework

BACKGROUND

To formulate effective strategies for antimicrobial stewardship (AMS) in primary care, it is crucial to gain a thorough understanding of factors influencing prescribers' behavior within the context. This qualitative study utilizes the Theoretical Domains Framework (TDF) to uncover these influential factors.

METHODS

We conducted a qualitative study using in-depth interviews and focus group discussions with primary care workers in two provinces in rural Vietnam. Data analysis employed a combined inductive and deductive approach, with the deductive aspect grounded in the TDF.

RESULTS

Thirty-eight doctors, doctor associates, and pharmacists participated in twenty-two interviews and two focus group discussions. We identified sixteen themes, directly mapping onto seven TDF domains: knowledge, skills, behavioral regulation, environmental context and resources, social influences, social/professional role and identity, and optimism. Factors driving unnecessary prescription of antibiotics include low awareness of antimicrobial resistance (AMR), diagnostic uncertainty, prescription-based reimbursement policy, inadequate medication supplies, insufficient financing, patients' perception of health insurance medication as an entitlement, and maintaining doctor-patient relationships. Potential factors facilitating AMS activities include time availability for in-person patient consultation, experience in health communication, and willingness to take action against AMR.

CONCLUSION

Utilizing the TDF to systematically analyze and present behavioral determinants offers a structured foundation for designing impactful AMS interventions in primary care. The findings underscore the importance of not only enhancing knowledge and skills but also implementing environmental restructuring, regulation, and enablement measures to effectively tackle unnecessary antibiotic prescribing in this context.

Understanding Acceptability and Willingness-to-pay for a C-reactive Protein Point-of-care Testing Service to Improve Antibiotic Dispensing for Respiratory Infections in Vietnamese Pharmacies: A Mixed-methods Study

Background

Pharmacies are popular first points of contact for mild infections in the community. Pharmacy services in many countries have expanded to include vaccines and point-of-care tests. In low- and middle-income countries such as Vietnam, poor enforcement of regulations results in substantial volumes of over-the-counter antibiotic sales. Point-of-care tests could provide an economically viable way to reduce antibiotic sales, while still satisfying customer demand for convenient healthcare. C-reactive protein point-of-care testing (CRP-POCT) can reduce antibiotic prescribing for respiratory illness in primary care. Here, we explore the acceptability and feasibility of implementing CRP-POCT in pharmacies in Vietnam.

Methods

We conducted a mixed-methods study between April and June 2021. A customer exit survey with 520 participants seeking acute respiratory infection treatment at 25 pharmacies evaluated acceptability and willingness-to-pay (WTP) for CRP-POCT and post-service satisfaction. Factors driving customers" acceptance and WTP were explored through mixed-effects multivariable regression. Three focus group discussions with customers (20 participants) and 12 in-depth interviews with pharmacists and other stakeholders were conducted and analyzed thematically.

Results

Antibiotics were sold to 81.4% of patients with CRP levels <10 mg/L (antibiotics not recommended). A total of 96.5% of customers who experienced CRP-POCT supported its future introduction at pharmacies. Patients with antibiotic transactions (adjusted odds ratio [aOR], 2.25; 95% confidence interval [CI], 1.13-4.48) and those suffering acute respiratory infection symptoms for more than 3 days (aOR, 2.10; 95% CI, 1.08-4.08) were more likely to accept CRP-POCT, whereas customers visiting for children (aOR, 0.20; 95% CI, .10-.54) and those with preference for antibiotic treatment (aOR, 0.45; 95% CI, 0.23-0.89) were less likely to accept CRP-POCT. A total of 78.3% (95% CI, 74.8-81.7) of customers were willing to pay for CRP-POCT, with a mean cost of US$2.4 (±1.1). Customer's income and cost of total drug treatment were associated with increased WTP. Enablers for implementing CRP-POCT included customers' and pharmacists' perceived benefits of CRP-POCT, and the impact of COVID-19 on perceptions of POCT. Perceived challenges for implementation included the additional burden of service provision, lack of an enabling policy environment, and potential risks for customers.

Conclusions

Implementing CRP-POCT at pharmacies is a feasible and well-accepted strategy to tackle the overuse of antibiotics in the community, with appeal for both supply and demand sides. Creating an enabling policy environment for its implementation, and transparent discussion of values and risks would be key for its successful implementation.

Antibiotic Resistance Profile and Bio-Control of Multidrug-Resistant Escherichia coli Isolated from Raw Milk in Vietnam Using Bacteriophages

E. coli is an important zoonotic pathogen capable of causing foodborne illness and bovine mastitis. Bacteriophages have been increasingly considered a promising tool to control unwanted bacteria. The aim of this study is to determine the antibiotic resistance profile of E. coli isolated from raw milk and the efficacy of phage in controlling multidrug-resistant E. coli in raw milk. Antibiotic susceptibility testing showed the highest resistance rates of E. coli isolates to co-trime (27.34%) and ampicillin (27.34%), followed by streptomycin (25.18%), tetracycline (23.02%), and the lowest resistance rates to ciprofloxacin, gentamycin, and ceftazidime, all at a rate of 2.16%. All isolates were susceptible to meropenem. Of the 139 E. coli isolates, 57 (41.01%) were resistant to at least one antibiotic, and 35 (25.18%) were classified as MDR strains. Molecular characterization indicated that 5 (3.6%) out of the 139 isolates were STEC strains carrying stx1 gene. Seven (5.04%) isolates were phenotypically identified as ESBLEC, and four isolates (2.88%) were resistant to colistin. The results of the genotypic test revealed that four out of seven ESBLEC strains carried both blaTEM and blaCTX-M-1, two harbored blaTEM, and one possessed blaCTX-M-1, while mcr-1 was detected in all four colistin-resistant E. coli isolates. In particular, one isolated E. coli strain (EM148) was determined to be a multidrug-resistant strain simultaneously carrying blaTEM, blaCTX-M-1, and mcr-1. A total of eight phages were successfully recovered from raw milk. The application of phage PEM3 significantly reduced viable counts of multidrug-resistant host EM148 in raw milk by at least 2.31 log CFU/mL at both 24 °C and 4 °C.

Evaluation of screening algorithms to detect rectal colonization with carbapenemase-producing Enterobacterales in a resource-limited setting

Objectives

To improve and rationalize the detection of carbapenemase-producing Enterobacterales (CPE) in rectal swabs in a high-prevalence and resource-constrained setting, addressing surveillance challenges typically encountered in laboratories with limited resources.

Methods

A point prevalence survey (PPS) was conducted on 15 August 2022, in a provincial children's hospital in northern Vietnam. Rectal swab samples of all admitted children were collected and plated on a selective medium for carbapenem-resistant Enterobacterales (CRE). Species identification and antimicrobial susceptibility testing (AST) were performed by MALDI-TOF, and VITEK2 XL and interpreted according to CLSI breakpoints (2022). Carbapenemases were detected by the carbapenem inactivation method (CIM) and quantitative real-time PCR (qRT-PCR).

Results

Rectal swab samples were obtained from 376 patients. Of 178 isolates growing on the CRE screening agar, 140 isolates were confirmed as Enterobacterales of which 118 (84.3%) isolates were resistant to meropenem and/or ertapenem. CIM and PCR showed that 90/118 (76.3%) were carbapenemase producers. Overall, 83/367 (22.6%) were colonized by CPE. Klebsiella pneumoniae, Escherichia coli and Enterobacter cloacae complex were the most common CPE detected, with NDM as the predominant carbapenemase (78/90; 86.7%). Phenotypic resistance to meropenem was the best predictor of CPE production (sensitivity 85.6%, specificity 100%) compared with ertapenem resistance (95.6% sensitivity, 36% specificity). CIM was 100% concordant with PCR in detecting carbapenemases.

Conclusions

These findings underscore the effectiveness of meropenem resistance as a robust indicator of the production of carbapenemases and the reliability of the CIM method to detect such carbapenemases in resource-limited settings where the performance of molecular methods is not possible.

Public perception and community-level impact of national action plans on antimicrobial resistance in Vietnam

Objectives

Vietnam was the first country from the WHO Western Pacific Region to adopt a national action plan (NAP) on antimicrobial resistance (AMR) in 2013. The multilayered nature of AMR requires coordination across 'One Health' sectors, dedicated financing, multistakeholder involvement, and widespread community engagement to implement the action plans. This study explores the perceived impact of NAP implementation at the community level.

Methods

Key informant interviews (KIIs) were used for data collection during 2021. An interview tool was used for the KIIs and purposive sampling was used to identify study participants from Vietnam. The study participants were those engaged with a substantial scale of antimicrobial usage, diagnosis of infections or concerned with antimicrobial content in effluents in their professional life. Twelve KIIs were conducted with participants from human health, animal health and the environmental sector. The data were entered into Microsoft Excel, and manifest and latent content analysis was done.

Results

The analysis highlighted themes such as limited public awareness of AMR, ongoing capacity building and quality assurance initiatives, implementation of guidelines and regulations for AMR containment, sustained investment in improving infrastructure, and challenges relating to accountability whilst prescribing and selling antibiotics.

Conclusions

There were many positive critical developments during the NAP implementation period in Vietnam towards AMR mitigation. For better impact, there is a need to revitalize the implementation machinery of NAPs by improving the enforcement capacity of regulations, cross-sectoral collaboration and promoting community ownership.

Evaluation of the impact before and after the application of an antimicrobial stewardship program at Dong Thap General Hospital, Vietnam, from 2017 to 2021

Background

Vietnam has one of the highest rates of antibiotic resistance in Asia. In 2020, the Vietnam Minister of Health introduced new legislation for the implementation of an antimicrobial stewardship program (ASP). The evidence for the effectiveness of ASP in small hospitals and hospitals located in provinces was limited compared with larger-scale and central city hospitals.

Aim

Evaluation of the impact before and after the introduction of an antimicrobial stewardship program at Dong Thap General Hospital, from 2017 to 2021.

Methods

Retrospective data was collected from June 2017 to June 2021. The impact of the ASP on changes in antibiotic use and the clinical outcome associated with the implementation of the ASP was evaluated using autoregressive integrated moving average modelling of controlled interrupted time-series analysis.

Results

There was a significant and sustained decrease in antibiotic consumption level (step change) in 2 indicators, DOT/1000PD (129.55; P<0.01) and LOT/1000PD (99.95, P<0.01), immediately after the ASP intervention. There were no statistically significant changes identified in terms of consumption with DDD/1000PD, or in the clinical outcomes. The results showed no statistically significant change in consumption trend (ramps) in all evaluated indicators. No statistically significant changes in consumption levels and trends were observed in the control group.

Conclusion

The ASP implemented in Dong Thap General Hospital from 2017 to 2021 showed a considerable influence on antibiotic consumption as indicated by the DOT/1000 PD and LOT/1000 PD during the initial stages. Moreover, controlling antibiotic consumption did not negatively impact patient outcomes.

Antibiotic Knowledge, Antibiotic Resistance Knowledge, and Antibiotic Use: A Cross-Sectional Study among Community Members of Bangkok in Thailand

This study aimed to explore antibiotic knowledge, antibiotic resistance knowledge, and antibiotic use among adults in Bangkok, Thailand. This is a secondary analysis of cross-sectional data generated from a sample of 161 individuals living in Bangkok. Participants completed an online self-administered questionnaire developed by the World Health Organization. Descriptive analysis, the chi-square test, and multiple logistic regression analyses were performed. The sample comprised more females (56.5%) than males (42.2%). The majority of responders (67.7%) were between the ages of 18 and 40. More than half of the respondents mistakenly believed that antibiotics could treat colds and flu (54.7% and 47.2%, respectively). About 54.7% were aware that antibiotic resistance could harm them and their families. The chi-square test results showed that the levels of education were associated with antibiotic knowledge (p = 0.012), antibiotic resistance knowledge (p < 0.001), and antibiotic use (p = 0.023). Multiple logistic regressions showed that respondents with at least a bachelor's degree or higher had better knowledge of antibiotics. Respondents who worked in the profession had better knowledge of antibiotic resistance. Respondents with sufficient incomes were more likely to use antibiotics. Baseline data from the study will be useful in antibiotic stewardship and public health campaigns among Bangkok residents.