A Potential Way to Decrease the Know-Do Gap in Hospital Infection Control in Vietnam: "Providing Specific Figures on Healthcare-Associated Infections to the Hospital Staff Can 'Wake Them Up' to Change Their Behaviour".

Adequate infection control plays a key role in preventing healthcare-associated infections (HAIs). This study aimed to explore staff perceptions of hospital infection control in a rural and an urban hospital in Vietnam. Individual interviews were conducted with hospital managers, and focus group discussions were conducted with doctors, nurses and cleaning workers separately. Content analysis was applied. An interview guide including discussion points on HAIs, hand hygiene and healthcare waste management was used. Generally, the staff were knowledgeable of hospital infection control, but they were not aware of the situation in their own hospital, and infection control practices in the hospitals remained poor. Reported difficulties in infection control included lack of resources, poor awareness and patient overload. A main theme emerged: 'Making data on HAIs available for health workers can improve their awareness and motivate them to put their existing knowledge into practice, thus decreasing the know-do gap in infection control'. This could be a feasible intervention to improve infection control practice in the hospitals with limited resources, high workload and patient overload.

Knowledge and self-reported practices of infection control among various occupational groups in a rural and an urban hospital in Vietnam.

Staff practice, driven by knowledge, plays a decisive role in hospital infection control. This study aimed to assess and compare knowledge and self-reported practices of infection control among various occupational groups in a rural and an urban hospital in Vietnam. Questionnaires consisting of items on knowledge and practices were collected from 339 hospital staff with varying occupations. For analysis, total knowledge or practice score ranged from 0-15. Mood's median test was performed to compare median scores. Post-hoc analysis of ordinal logistic regression models was applied to test differences in scores among occupational groups. The majority of hospital staff had good or adequate knowledge (median score: rural = 11.8; urban = 12), but the score range was wide (1.4-14.5). Self-reported practices in the urban hospital were likely to be better than in the rural one (p = 0.003). Self-reported practices yet not completely satisfactory, indicating the need for continuing professional development in both settings. Overall, cleaners had lower scores than both physicians and nurses, highlighting the need for tailored education in this topic. Future infection control strategies within the hospitals might want to assess the difference between the staff's self-reported practice and their actual real practice. These findings can be of value in many other similar settings.

Antibiotic prescribing and dispensing for acute respiratory infections in children: effectiveness of a multi-faceted intervention for health-care providers in Vietnam.

BACKGROUND: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries. OBJECTIVE: To evaluate a multi-faceted intervention targeting health-care-providers' (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs. METHODS: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010-2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively. RESULTS: Knowledge improved in the intervention group for ARI aetiology by 28% (ΔDecrement control arm 10%), antibiotic use for mild ARIs by 15% (ΔDecrement control arm 13%) and for severe ARIs by 14% (ΔImprovement control arm 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δmean improvement 1.17); less so in the control group (Δmean improvement 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (ΔDecrement control arm 3%). CONCLUSIONS: The intervention significantly improved HCPs' knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

Antibiotic Resistance and Antibiotic Resistance Genes in Escherichia coli Isolates from Hospital Wastewater in Vietnam.

The environmental spread of antibiotic-resistant bacteria has been recognised as a growing public health threat for which hospitals play a significant role. The aims of this study were to investigate the prevalence of antibiotic resistance and antibiotic resistance genes (ARGs) in Escherichia coli isolates from hospital wastewater in Vietnam. Wastewater samples before and after treatment were collected using continuous sampling every month over a year. Standard disk diffusion and E-test were used for antibiotic susceptibility testing. Extended-spectrum beta-lactamase (ESBL) production was tested using combined disk diffusion. ARGs were detected by polymerase chain reactions. Resistance to at least one antibiotic was detected in 83% of isolates; multidrug resistance was found in 32%. The highest resistance prevalence was found for co-trimoxazole (70%) and the lowest for imipenem (1%). Forty-three percent of isolates were ESBL-producing, with the blaTEM gene being more common than blaCTX-M. Co-harbouring of the blaCTX-M, blaTEM and qepA genes was found in 46% of isolates resistant to ciprofloxacin. The large presence of antibiotic-resistant E. coli isolates combined with ARGs in hospital wastewater, even post-treatment, poses a threat to public health. It highlights the need to develop effective processes for hospital wastewater treatment plants to eliminate antibiotic resistant bacteria and ARGs.

Antibiotics in Wastewater of a Rural and an Urban Hospital before and after Wastewater Treatment, and the Relationship with Antibiotic Use-A One Year Study from Vietnam.

Hospital effluents represent an important source for the release of antibiotics and antibiotic resistant bacteria into the environment. This study aims to determine concentrations of various antibiotics in wastewater before and after wastewater treatment in a rural hospital (60 km from the center of Hanoi) and in an urban hospital (in the center of Hanoi) in Vietnam, and it aims to explore the relationship between antibiotic concentrations in wastewater before wastewater treatment and quantities of antibiotics used in the rural hospital, over a period of one year in 2013. Water samples were collected using continuous sampling for 24 h in the last week of every month. The data on quantities of antibiotics delivered to all inpatient wards were collected from the Pharmacy department in the rural hospital. Solid-phase extraction and high performance liquid chromatography-tandem mass spectrometry were used for chemical analysis. Significant concentrations of antibiotics were present in the wastewater both before and after wastewater treatment of both the rural and the urban hospital. Ciprofloxacin was detected at the highest concentrations in the rural hospital's wastewater (before treatment: mean = 42.8 µg/L; after treatment: mean = 21.5 µg/L). Metronidazole was detected at the highest concentrations in the urban hospital's wastewater (before treatment: mean = 36.5 µg/L; after treatment: mean = 14.8 µg/L). A significant correlation between antibiotic concentrations in wastewater before treatment and quantities of antibiotics used in the rural hospital was found for ciprofloxacin (r = 0.78; p = 0.01) and metronidazole (r = 0.99; p < 0.001).

Improved knowledge and reported practice regarding sexually transmitted infections among healthcare providers in rural Vietnam: a cluster randomised controlled educational intervention.

BACKGROUND: Healthcare providers (HCPs) play a critical role in controlling the spread of sexually transmitted infections (STI) through early and accurate diagnosis, appropriate treatment and prevention counselling. This study aimed to assess the effectiveness of an educational intervention about STI on knowledge and reported practice among HCPs and to explore which determinants may influence the intervention's effects. METHODS: A cluster randomized controlled educational intervention was carried out in a rural district, Vietnam. 32 communes of the district were randomized into two arms, with 160 HCPs in an STI intervention arm and 144 in a control arm. The STI intervention comprised interactive training with basic STI knowledge, case scenarios, and poster distribution. Questionnaires to evaluate knowledge and reported practice were completed three times: before, during and after the intervention. Correct answer was scored as 1; "do not know", incorrect answer was scored as 0. Univariate and multilevel multivariate analyses were applied. RESULTS: Of the maximum 56 points, the mean knowledge score increased significantly in the STI intervention arm and in the control arm post-intervention (37.2 to 48.4, and 32.7 to 41.7, respectively). In multivariate regression analysis, knowledge improvement in the intervention arm was significantly higher than that in the control arm (regression coefficient = 2.97, p = 0.008). Other factors which positively influenced the increase in knowledge were being between 35 and 50 years old, having intermediate professional training, being a pharmacist or working at a village level (regression coefficient: 2.81, 4.43, 5.53 and 7.91, respectively). Post-intervention, the mean reported practice score increased significantly in the STI intervention arm (from 17.6 to 21.8) and insignificantly in the control arm (maximum 36 points). Factors which positively influenced the increase in reported practice were being between 35 and 50 years old, having intermediate professional training, or working at a pharmacy/drugstore (regression coefficient: 2.15, 3.33 and 3.22, respectively). CONCLUSIONS: This study indicates that an educational intervention including interactive training and multi-faceted interventions may be effective in improving STI knowledge and reported practice of HCPs at grassroots level, particularly among pharmacists, HCPs who work in villages or pharmacies/drugstores, and who initially have low STI knowledge.

Antibiotic sales in rural and urban pharmacies in northern Vietnam: an observational study.

BACKGROUND: The irrational overuse of antibiotics should be minimized as it drives the development of antibiotic resistance, but changing these practices is challenging. A better understanding is needed of practices and economic incentives for antibiotic dispensing in order to design effective interventions to reduce inappropriate antibiotic use. Here we report on both quantitative and qualitative aspects of antibiotic sales in private pharmacies in northern Vietnam. METHOD: A cross-sectional study was conducted in which all drug sales were observed and recorded for three consecutive days at thirty private pharmacies, 15 urban and 15 rural, in the Hanoi region in 2010. The proportion of antibiotics to total drug sales was assessed and the revenue was calculated for rural and urban settings. Pharmacists and drug sellers were interviewed by a semi-structured questionnaire and in-depth interviews to understand the incentive structure of antibiotic dispensing. RESULTS: In total 2953 drug sale transactions (2083 urban and 870 rural) were observed. Antibiotics contributed 24% and 18% to the total revenue of pharmacies in urban and rural, respectively. Most antibiotics were sold without a prescription: 88% in urban and 91% in rural pharmacies. The most frequent reported reason for buying antibiotics was cough in the urban setting (32%) and fever in the rural area (22%). Consumers commonly requested antibiotics without having a prescription: 50% in urban and 28% in rural area. The qualitative data revealed that drug sellers and customer's knowledge of antibiotics and antibiotic resistance were low, particularly in rural area. CONCLUSION: Over the counter sales of antibiotic without a prescription remains a major problem in Vietnam. Suggested areas of improvement are enforcement of regulations and pricing policies and educational programs to increase the knowledge of drug sellers as well as to increase community awareness to reduce demand-side pressure for drug sellers to dispense antibiotics inappropriately.

High prevalence of antibiotic resistance in commensal Escherichia coli among children in rural Vietnam.

BACKGROUND: Commensal bacteria represent an important reservoir of antibiotic resistance genes. Few community-based studies of antibiotic resistance in commensal bacteria have been conducted in Southeast Asia. We investigated the prevalence of resistance in commensal Escherichia coli in preschool children in rural Vietnam, and factors associated with carriage of resistant bacteria. METHODS: We tested isolates of E. coli from faecal samples of 818 children aged 6-60 months living in FilaBavi, a demographic surveillance site near Hanoi. Daily antibiotic use data was collected for participating children for three weeks prior to sampling and analysed with socioeconomic and demographic characteristics extracted from FilaBavi's re-census survey 2007. Descriptive statistics were generated, and a logistic regression model was used to identify contributions of the examined factors. RESULTS: High prevalences of resistance were found to tetracycline (74%), co-trimoxazole (68%), ampicillin (65%), chloramphenicol (40%), and nalidixic acid (27%). Two isolates were resistant to ciprofloxacin. Sixty percent of isolates were resistant to three or more antibiotics. Recent sulphonamide use was associated with co-trimoxazole resistance [OR 3.2, 95% CI 1.8-5.7], and beta-lactam use with ampicillin resistance [OR 1.8, 95% CI 1.3-2.4]. Isolates from children aged 6-23 months were more likely to be resistant to ampicillin [OR 1.8, 95% CI 1.3-2.4] and co-trimoxazole [OR 1.5, 95% CI 1.1-2.0]. Associations were identified between geographical areas and tetracycline and ampicillin resistance. CONCLUSIONS: We present high prevalence of carriage of commensal E. coli resistant to commonly used antibiotics. The identified associations with recent antibiotic use, age, and geographical location might contribute to our understanding of carriage of antibiotic resistant commensal bacteria.

Decreased Streptococcus pneumoniae susceptibility to oral antibiotics among children in rural Vietnam: a community study.

BACKGROUND: Streptococcus pneumoniae is the most significant bacterial cause of community-acquired pneumonia among children under five years worldwide. Updated resistance information of S. pneumoniae among children is essential to adjust the recommendations for empirical treatment of community-acquired pneumonia, which will have immense implications for local and global health. This study investigated the prevalence of antibiotic resistance in isolated strains of S. pneumoniae and relationship with antibiotic use and demographic factors of children under five in rural Vietnam in 2007. METHODS: In Bavi district, 847 children 6 to 60 months were selected from 847 households. The main child-caregivers in the households were interviewed weekly using structured questionnaires to collect information of daily illness symptoms and drug use for the selected child over a four-week period (from March through June 2007). In the 3rd week, the children were invited for a clinical examination and to collect nasopharyngeal samples for S. pneumoniae identification. Etest and disk diffusion were used to test antibiotic susceptibility. RESULTS: Of 818 participating children, 258 (32%) had ongoing respiratory infections, 421 (52%) carried S. pneumoniae, and 477 (58%) had used antibiotics within the previous three weeks. Of the 421 isolates, 95% were resistant to at least one antibiotic (401/421). 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%. Multidrug-resistance was seen in 60%. The most common pattern was co-resistance to co-trimoxazole, tetracycline and erythromycin. The proportion of children carrying resistant bacteria was higher among the children who had used antibiotics in the previous three weeks. CONCLUSIONS: Resistance to commonly used antibiotics and multidrug-resistance of S. pneumoniae in the area is remarkably high. High-dose amoxicillin is the only investigated oral antibiotic that can possibly be used for treatment of community-acquired pneumococcal infections. Strategies to promote appropriate prescribing and dispensing of effective antibiotics should be immediately implemented for the benefit of local and global health.

Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers' knowledge, practical competence and reported practice.

OBJECTIVE: To assess knowledge, practical competence and reported practices among health-care providers about antibiotics to treat acute respiratory infections in children under five in rural Vietnam. METHOD: Health-care providers prescribing or dispensing western drugs for children self-completed a structured questionnaire. Recommendations concerning antibiotic use from WHO and national guidelines were used to assess the appropriateness of reported treatment of acute respiratory infections. RESULTS: Ninety-six per cent of 409 eligible health care providers participated. Only 27% demonstrated correct knowledge regarding the consequences of resistance. Seventy-nine per cent would use antibiotics for common colds with fever, and 21% in cases with no fever. Nineteen per cent had overall knowledge compliant with recommended guidelines. Stated antibiotic use in written scenarios for common colds (81%) was not significantly different from that for non-referral cases of pneumonia (87%). The proportion of antibiotic use in the common cold scenario was significantly lower among health-care providers who had the correct overall knowledge. According to reported symptoms from the most recent encounter with a sick child, the diseases seen were 62% mild acute respiratory infections, 19% severe, and 19% non-respiratory infections. Among those, antibiotics, most commonly beta-lactams, were used in 90%, 87% and 78% of cases, respectively. CONCLUSIONS: Antibiotics are often prescribed or dispensed to treat common colds. Interventions to change prescribing and dispensing practices should be developed and implemented in collaboration with local and national paediatricians. Continuous training of health-care providers, particularly drug sellers, is important.

Drug use and health-seeking behavior for childhood illness in Vietnam--a qualitative study.

OBJECTIVES: To describe and understand health-seeking behavior and drug use among caregivers, in particular antibiotics, for childhood illnesses in Vietnam. METHODS: A total of six focus group discussions were conducted with child care providers. A thematised interview guide was used and qualitative content analysis was applied. Meaning units in the texts dealing with the same content material were identified, condensed and compared until several emerging themes were found. Finally, similarities and differences in the views between rural and urban groups were described. RESULTS: Self-treatment and self-medication were prominent in the urban groups, whereas compliance and trust in doctors were more common among the rural participants. Misuse and misconceptions regarding the properties of drugs were reported leading to worries about irrational drug use in the community. Despite the widespread use of private services in both areas, the public health service was reported to be the most trusted recourse for serious cases. CONCLUSIONS: Qualitatively different ways of using drug and health care services are reported for childhood sickness in rural and urban Vietnam. These results provide rich information for the development of quantitative studies on drug use for children and point to the need to involve all health facilities in consideration.