Antimicrobial stewardship program for gastrointestinal surgeries at a Vietnamese tertiary hospital.

Background: Antimicrobial Stewardship Programs (ASP) have been applied widely in high-resource countries to prevent surgical site infections (SSI). Evidence favoring ASP interventions (ASPi) in gastrointestinal surgeries from low and middle-income countries has been limited, especially in antimicrobial prophylaxis. We aimed to investigate this gap at a Vietnamese tertiary hospital. Methods: We conducted a retrospective cohort study on patients undergoing clean-contaminated surgeries in 2015 who received standard of care (SoC) or SoC + ASPi. Primary outcome was 30-day SSI incidence. Secondary outcomes included length of stay (LoS) after surgery (days), cost of antibiotics, and cost of treatment (USD). Results were controlled for multiplicity and reported with treatment effect and 95% confidence interval (95%CI). A predictive model was built and cross-validated to detect patients at high risk of SSI. Results: We included 395 patients for analysis (48.1% being female, mean age 49.4 years). Compared to patients receiving SoC, those with SoC + ASPi had a lower incidence of 30-day SSI (-8.8, 95%CI: -16.0 to -1.6, p = 0.042), shorter LoS after surgery (-1.1 days, 95%CI: -1.8 to -0.4, p = 0.004), and lower cost of antibiotics (-37.3 USD, 95%CI: -59.8 to -14.8, p = 0.012) and treatment (-191.1 USD, 95%CI: -348.4 to -33.8, p = 0.042). We estimated that by detecting patients at high risk of SSI with the predictive model and providing prophylactic measures, we could save 398120.7 USD per 1,000 cases of SSI. Conclusion: We found that ASPi were associated with a reduction in risks of SSI, hospital stays, and cost of antibiotics/treatment in a Vietnamese tertiary hospital.

Effects of antivirals on patients with COVID-19 breakthrough.

BACKGROUND: Antivirals have been given widely for patients with COVID-19 breakthrough in Asian countries, creating a "black market" for unapproved and unprescribed medications. More evidence is needed to clarify the benefits of antivirals in these settings. METHODS: We conducted a random-sampling retrospective cohort study at a general hospital in Vietnam. We recruited patients with mild-to-moderate COVID-19 breakthrough who were given either standard of care (SoC) alone or SoC + antiviral. Primary outcome was residual respiratory symptoms that lasted > 7 days. Secondary outcome was long COVID-19, diagnosed by specialized physicians. We used logistic regression to measure odds ratio (OR), in addition to a sensitivity and subgroup analyses to further explore the results. RESULTS: A total of 142 patients (mean age 36.2 ± 9.8) were followed. We recorded residual symptoms in 27.9% and 20.3% of the SoC and SoC + antiviral group, while the figures for long COVID-19 were 11.8% and 8.1%, respectively. Antiviral use was not significantly associated with lower the risks of residual symptoms (OR = 0.51, 95% CI: 0.22-1.20, p = 0.12) or long COVID-19 (OR = 0.55, 95% CI: 0.16-1.90, p = 0.35). The sensitivity and subgroup analyses did not show any significant differences between the study groups (all p > 0.05). CONCLUSION: Antivirals were not associated with faster resolution of respiratory symptoms or lower risks of long COVID-19. Further studies should focus on different antivirals to confirm their effects on different sub-populations. Meanwhile, antivirals should only be used in very high-risk patients to avoid excessive costs and harms.

Intra-generational social mobility and mortality among older men in the Concord Health and Ageing in Men Project: A cohort study.

Objectives: We examined associations between intra-generational social mobility (reflected in life-course socioeconomic trajectories) and mortality, among older men. Methods: Data came from a prospective Australian community-based cohort of older men. Social mobility was defined by socioeconomic indicators from three points in the life-course: educational attainment (late adolescence-early adulthood), occupation (mid-life), and current sources of income (older age). We defined indicators of social mobility trajectory (6 categories; reflecting the direction of social mobility) and social mobility status (2 categories; mobile or non-mobile). We used Cox regression to examine associations with mortality, adjusting for age, country of birth, and living arrangement. Results: We followed 1568 men (mean age 76.8, SD 5.4) for a mean duration of 9.1 years, with 797 deaths recorded. Moving upward was the predominant social mobility trajectory (36.0%), followed by mixed trajectories (25.1%), downward (15.1%), stable low (12.2%), stable high (7.6%), and stable middle (4.0%). Men with downward (Hazard ratio 1.58, 95% CI 1.13 to 2.19) and stable low socioeconomic trajectories (1.77, 1.25 to 2.50) had higher mortality risks than men with stable high socioeconomic trajectories, while men with upward trajectories had similar risks to those with stable high trajectories. 76.2% of the participants were classified as having mobile status; no associations were evident between binary social mobility status and mortality. Discussions: These findings suggest cumulative and persistent exposure to disadvantaged socioeconomic conditions across the life-course, rather than social mobility, is associated with increased mortality. For each stage of the life-course, addressing socioeconomic disadvantage may reduce inequities in mortality.

Clinical use of remdesivir in COVID-19 treatment: a retrospective cohort study.

OBJECTIVES: This study investigated remdesivir's clinical use to provide direct evidence of effectiveness for a low-middle income Asian setting. DESIGN: A one-to-one propensity score matching retrospective cohort study. SETTING: A tertiary hospital with COVID-19 treatment facilities in Vietnam. PARTICIPANTS: A total of 310 patients in standard of care (SoC) group were matched with 310 patients in SoC+remdesivir (SoC+R) group. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was time to critical progression, defined as all-cause mortality or critical illness. The secondary outcomes were length of oxygen therapy/ventilation and need for invasive mechanical ventilation. Outcome reports were presented as HR, OR or effect difference with 95% CI. RESULTS: Patients receiving remdesivir had a lower risk for mortality or critical illness (HR=0.68, 95% CI 0.47 to 0.96, p=0.030). Remdesivir was not associated with a shorter length of oxygen therapy/ventilation (effect difference -0.17 days, 95% CI -1.29 to 0.96, p=0.774). The need for invasive mechanical ventilation was lower in SoC+R group (OR=0.57, 95% CI 0.38 to 0.86, p=0.007). CONCLUSIONS: This study's results showing remdesivir's benefits in non-critical patients with COVID-19 may be extrapolated to other similar low-middle income countries, allowing more regimens for limited resource areas and reducing poor outcomes and equity gap worldwide.

Knowledge and medication adherence of oral anticoagulant-taking patients in Vietnam.

Background: Oral anticoagulants for venous thromboembolism are not thoroughly managed in ambulatory settings in low-/middle-income countries, primarily because of patients' neglect of medication knowledge and adherence. Objectives: This study was conducted to investigate patient knowledge, adherence, and the associated factors at a Vietnamese tertiary hospital, serving as a reference for educational programs in other local and regional health care facilities. Methods: A randomly recruited cross-sectional study was conducted on patients using vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC). The primary and secondary outcomes were the knowledge score (in percent) and adherence to oral anticoagulants. Student's t-tests or chi-squared tests were used to compare the crude differences in mean or proportion between patients taking VKA and DOAC. Regression models were conducted to adjust the potential confounders and determine factors associated with patient knowledge and adherence. Results: A total of 199 patients were included. After adjusting for potential confounders, patients receiving a DOAC had similar knowledge scores and levels of adherence compared with those taking VKA, with both groups being suboptimal. Previous counseling was associated with higher knowledge. Better medication knowledge, female sex, and no history of venous thromboembolism were associated with better adherence. Conclusion: Good knowledge and adherence of oral anticoagulant-taking patients remain limited in Southeast Asian clinical practice. Further studies in similar settings should examine the associations between these factors and the effectiveness of the regimens. More effective measures targeting patient knowledge and adherence should be implemented to optimize anticoagulation therapy, improve the patients' outcomes, and mitigate the associated adverse effects.

One Health: An Effective and Ethical Approach to Leptospirosis Control in Australia.

The increasing concerns over emerging infectious diseases and potential pandemics led to the formation of One Health, a collaborative, multidisciplinary approach to address the risks from human-animal-ecosystem interactions. This multi-sectoral approach is specifically important in Australia, a biodiverse country with unique flora, fauna, and many infectious diseases, including leptospirosis. Leptospirosis is a relatively rare but potentially fatal zoonosis, with an attributed mortality of around 60,000 deaths per year worldwide. In recent years, sporadic cases and alarming outbreaks of leptospirosis have been notified in many states and territories of Australia, noteworthily in 2018 and 2019. The sudden outbreaks in these two years have raised a question about the possibility of a more severe menace or a potential threat to both humans and animals. Amid the fight against leptospirosis, One Health has been shown to be an excellent and ideal framework, especially in Australia, the country that has taken the lead in zoonosis control using this approach. In this review, the focus will be put on the effectiveness and ethics of One Health in leptospirosis control under the Australian setting to further advocate the implementation of this framework for many other infectious diseases.

A New Hope in the Fight Against Antimicrobial Resistance with Artificial Intelligence.

Recent years have witnessed the rise of artificial intelligence (AI) in antimicrobial resistance (AMR) management, implying a positive signal in the fight against antibiotic-resistant microbes. The impact of AI starts with data collection and preparation for deploying AI-driven systems, which can lay the foundation for some effective infection control strategies. Primary applications of AI include identifying potential antimicrobial molecules, rapidly testing antimicrobial susceptibility, and optimizing antibiotic combinations. Aside from their outstanding effectiveness, these applications also express high potential in narrowing the burden gap of AMR among different settings around the world. Despite these benefits, the interpretability of AI-based systems or models remains vague. Attempts to address this issue had led to two novel explanation techniques, but none have shown enough robustness or comprehensiveness to be widely applied in AI and AMR control. A multidisciplinary collaboration between the medical field and advanced technology is therefore needed to partially manage this situation and improve the AI systems' performance and their effectiveness against drug-resistant pathogens, in addition to multiple equity actions for mitigating the failure risks of AI due to a global-scale equity gap.

Role of clinical pharmacists in epilepsy management at a general hospital in Vietnam: a before-and-after study.

BACKGROUND: Clinical pharmacists have an important role in inter-professional healthcare collaboration for epilepsy management. However, the pharmacy practices of managing epilepsy are still limited in Vietnam, deterring pharmacists from routine adjustments of antiepileptic drugs, which could decrease the patients' quality of life. This study aimed to assess the effectiveness of pharmacist interventions in epilepsy treatment at a Vietnamese general hospital. METHODS: A before-and-after study was conducted from January 2016 to December 2018. All patients with a diagnosis of epilepsy and being treated at the investigated hospital were recruited and screened for eligibility and exclusion criteria. The primary outcome was the proportion of patients in good control of their epilepsy (with two seizures or less in a year). The secondary outcome was the number of patients maintaining optimized concentrations within the therapeutic range of carbamazepine (4-12 mg/L), phenytoin (10-20 mg/L), or valproic acid (50-100 mg/L). Collected data were analyzed using two proportions Z-test or Chi-square test. RESULTS: A total of 141 participants were enrolled in the study. While most patients were given lower prescribed daily doses than the recommendations from the World Health Organization, over 56% of the participants still experienced adverse drug effects. More than half of the patients received at least one pharmacists' intervention, which increased by 25.0% the effectiveness of the therapy (p < 0.001) and by 14.6% the number of patients with optimized drug concentrations (p = 0.018). CONCLUSION: Epilepsy management requires a multiple-stepped and comprehensive approach, with a focus on the health and safety of the patients. As part of the healthcare team, pharmacists need to engage at every stage to monitor the patient's response and determine the most effective treatment with the fewest adverse drug reactions. Trial registration ClinicalTrials.gov, NCT04967326. Registered July 19, 2021-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04967326.

The prognosis of diabetic patients with high ankle-brachial index depends on the coexistence of occlusive peripheral artery disease.

OBJECTIVES: High ankle-brachial index (ABI) (>1.40) is associated with poor cardiovascular disease (CVD) prognosis. Concomittant peripheral artery disease (PAD) is frequent, although undetectable with the ABI in this situation. We assessed the prognostic value of a high ABI according to the coexistence of occlusive PAD in diabetics. METHODS: In this retrospective longitudinal study, we reviewed the data of 403 consecutive diabetic patients (hospitalized in tertiary care teaching hospital) who had a Doppler assessment of their lower limbs between 1999 and 2000. They were classified as "normal" when Doppler waveform patterns (DWP) were normal and ABI within the 0.91 to 1.39 range, "occlusive-PAD (O-PAD)" when ABI ≤0.90, or in case of abnormal DWP with normal ABI, "isolated medial calcinosis (IMC)" if ABI ≥1.40 with normal DWP, and "mixed disease (MD)" when ABI ≥1.40 with abnormal DWP. The primary outcome was the occurrence of any of the following events: death, stroke or transient ischemic attack (TIA), and acute coronary syndrome. RESULTS: The patients (65.6 ± 13.2 years, 54.6% females) were classified as normal (14.4%), O-PAD (48.4%), IMC (16.4%), and MD (20.8%). During a mean follow-up of 6.5 years, the event-free survival curves of O-PAD and MD groups showed equally poorer prognosis than the IMC and normal groups. Adjusted for age, sex, diabetes type and duration, traditional CVD risk factors, chronic kidney disease, CVD history and treatments, the presence of occlusive disease (hazard ratio [HR]: 2.21, 1.16-4.22, P = .016), but not medial calcinosis, was significantly associated with the primary outcome. CONCLUSIONS: In diabetics with ABI >1.40, only those with concommittant occlusive PAD have poorer prognosis.