Combating antimicrobial resistance: quality standards for prescribing for respiratory infections in Vietnam
Authors: Ryan Li, H Rogier van Doorn, Heiman F L Wertheim, Luong N Khue, Ngo T B Ha, Vu Q Dat, Chu T Hanh, Do T T Nga, Nghiem N M Trang, Behzad Nadjm, Francoise Cluzeau, Nguyen V Kinh, Nguyen V Trung, Nguyen T L Huong, Ngo Q Chau, La Q Huong, Le T Thao, Le T A Hong, Tran T M Oanh, Jasmin Islam, C Michael Roberts, Kalipso Chalkidou
Journal: The Lancet Global Health (2016)

Antimicrobial resistance is recognised as a serious global health threat requiring global action. However, much work remains to translate global strategies to combat antimicrobial resistance into national policy and action. In low-income and middle-income countries where vulnerable health-care systems require investment within constrained budgets, antimicrobial resistance strategies might not be prioritised, and indeed equitable versus restricted access to antibiotics present a conflicting challenge.1Abdula N Macharia J Motsoaledi A Swaminathan S VijayRaghavan K National action for global gains in antimicrobial resistance.Lancet. 2016; 387: e3-e5Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar Engaging the right stakeholders nationally and contextualising scientific evidence to address concrete policy issues moves antimicrobial stewardship strategies into action.2Wertheim HF Chandna A Vu PD et al.Providing impetus, tools, and guidance to strengthen national capacity for antimicrobial stewardship in Viet Nam.PLoS Med. 2013; 10: e1001429Crossref PubMed Scopus (41) Google Scholar High-burden diseases present an important starting point. In Vietnam, severe acute respiratory tract infections and chronic obstructive pulmonary disease (COPD) together account for 8% of mortality.3GBD profile: Vietnam. Institute for Health Metrics and Evaluation, Seattle, WA2010http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_vietnam.pdfGoogle Scholar However, antibiotic prescribing is often inappropriate in preclinical and clinical disease stages, and is commonly done against local and international evidence-based guidelines.4Hoa NQ Larson M Kim Chuc NT Eriksson B Trung NV Stålsby CL Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers' knowledge, practical competence and reported practice.Trop Med Int Health. 2009; 14: 546-555Crossref PubMed Scopus (32) Google Scholar, 5Nga do TT Chuc NT Hoa NP et al.Antibiotic sales in rural and urban pharmacies in northern Vietnam: an observational study.BMC Pharmacol Toxicol. 2014; 15: 6Crossref PubMed Scopus (135) Google Scholar The Ministry of Health (MOH), Vietnam, issued a national action plan on antimicrobial resistance in June, 2013, supported by WHO.6WHOViet Nam signs aide-memoire to combat antimicrobial resistance. World Health Organization, Geneva2015http://www.wpro.who.int/mediacentre/releases/2015/20150722/en/Google Scholar Building on their situation analysis of antimicrobial resistance and surveillance,7Global Antibiotic Resistance Partnership–Vietnam National Working GroupSituation analysis. Antibiotic use and resistance in Vietnam. CDDEP, October, Washington DC2010http://www.cddep.org/sites/default/files/vn_report_web_1_8.pdfGoogle Scholar and previous MOH success to establish national quality standards for acute stroke,8Hinh LD Quality standards for management of stroke in Vietnam.Viet J Neurol. 2014; 9 (in Vietnamese).: 7-11Google Scholar Oxford University Clinical Research Unit and the Vietnam MOH convened a working group to develop evidence-informed quality standards for appropriate inpatient antibiotic prescribing for community-acquired pneumonia and acute exacerbation of COPD. Quality standards translate best practice recommendations from international guidelines into high-priority, implementable, and measurable clinical activities relevant for the local context, through local stakeholder collaboration. In June, 2016, we presented the draft of the quality standards for community-acquired pneumonia and acute exacerbation of COPD to a national committee convened by MOH, comprising MOH officials, and over 40 managers, physicians, pharmacists, and microbiologists from central and provincial hospitals across Vietnam. Although there was rapid consensus to adopt international principles of matching route of administration to duration of administration, matching breadth of spectrum to disease severity, and justifying any deviation, there was equal recognition that international standards need local adaptation. Thus, the committee agreed on the need for thorough clinical diagnostic assessment, including medical and antibiotic histories, using locally available microbiological tests to inform antibiotic prescription. However, in an environment with high prevalence of antimicrobial resistance, patients self-medicating with over-the-counter antibiotics before presenting to hospital, and absence of national surveillance, determining appropriate first-line therapy was more challenging than establishing the standards for thorough clinical diagnostic assessment.5Nga do TT Chuc NT Hoa NP et al.Antibiotic sales in rural and urban pharmacies in northern Vietnam: an observational study.BMC Pharmacol Toxicol. 2014; 15: 6Crossref PubMed Scopus (135) Google Scholar, 7Global Antibiotic Resistance Partnership–Vietnam National Working GroupSituation analysis. Antibiotic use and resistance in Vietnam. CDDEP, October, Washington DC2010http://www.cddep.org/sites/default/files/vn_report_web_1_8.pdfGoogle Scholar Further collection and analysis of susceptibility data from the Vietnam resistance network of 16 hospitals2Wertheim HF Chandna A Vu PD et al.Providing impetus, tools, and guidance to strengthen national capacity for antimicrobial stewardship in Viet Nam.PLoS Med. 2013; 10: e1001429Crossref PubMed Scopus (41) Google Scholar will allow formal standards to be recommended. Establishing national quality standards coproduced with local clinicians is a massive step towards combating antimicrobial resistance in Vietnam. Additionally, local evidence, engagement, and contextualisation are critical for transforming global discourse into global action on antimicrobial resistance. Implementation will be challenging, but with national opinion leaders championing the cause, we have great optimism for success. We declare no competing interests.