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Over the counter: tracking inappropriate antibiotic supply by pharmacies in Vietnam

Oversupply of antibiotics is driving drug-resistant infections
University of Sydney-led research finds that inappropriate antibiotic supply is common in community pharmacies across Vietnam, a practice that contributes to antimicrobial resistance.

Antimicrobial resistance (AMR) is a major public health problem. The World Health Organization has declared AMR, where infections no longer respond to antibiotics and other antimicrobial medicines, one of the leading public health threats in the world today.

AMR undermines the capacity of available antimicrobials to prevent and treat common infections. Without action, drug-resistant infectious diseases will become increasingly prominent, with serious health consequences for people around the world, including increased mortality and more severe illness.

The overuse of antibiotics is a major driver of AMR and can also contribute to underdiagnosis of infections and delayed hospital admission. In low- and middle-income countries in particular, where there may be barriers to accessing medical services, private pharmacies are a key source of antibiotic supply.

New research led by University of Sydney academics has tracked the scale of the problem in Vietnam, where there is a high number of private pharmacies across the country. The study, published in The Lancet Regional Health, surveyed 949 randomly selected private pharmacies across 40 districts in Vietnam, and found that inappropriate supply of antibiotics was common. 

High rates of inappropriate supply

The study used trained actors to attend pharmacies as patients across northern and southern Vietnam, acting out several common clinical scenarios. These included an adult requesting treatment for a sibling with symptoms of a viral upper respiratory tract infection (URTI) and for a child with acute diarrhoea, respectively – common infections not ordinarily requiring antibiotic treatment.

In two final scenarios, actors directly requested un-prescribed antibiotics, or handed over a valid prescription in order to gauge whether appropriate advice was given on antibiotic use.

The research found that antibiotics were inappropriately supplied to 92 percent of adults (291 of 316) requesting treatment for URTI symptoms; to 84 percent of adults (267 of 317) making a direct request for antibiotics; and to 43 percent of adults (135 of 316) requesting treatment for children with acute diarrhoea symptoms – all without a prescription.

In only 49 percent of pharmacies did patients receive advice about their antibiotic use. A minority of pharmacy staff (11 percent) advised on when to stop taking antibiotics.

“These findings that a majority of community pharmacies across Vietnam dispensed antibiotics without a clear clinical indication, and without a prescription, are greatly concerning. Such inappropriate use, as well as the lack of appropriate clinical advice, contributes to antibiotic resistance at a local and global scale,” said Professor Gregory Fox, a respiratory physician and epidemiologist who was part of the research team.

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The finding that over 90 percent of patient actors were given antibiotics for viral URTIs is actually slightly lower than a previous study conducted in southern Vietnam in 2003, according to Dr Shukry Zawahir, a postdoctoral research associate in the Faculty of Medicine and Health. “But it highlights overall that the issue hasn’t improved over the last two decades,” he said. “These practices are at odds with professional ethics for pharmacists and the regulatory framework in Vietnam, which mandates prescription-only use of antibiotics.”

The study also noted that a high proportion of antibiotics supplied to the patient actors were broad spectrum antibiotics, such as cephalosporins and fluoroquinolones, that have been classified by the WHO as “critically important antimicrobials.” This indicates that their use should be reserved for certain severe infections, especially in children, and they should not be sold over the counter without prescription.

“Improving stewardship of antimicrobials means saving them so they can be used when we really need them,” said Dr Justin Beardsley, a Senior Lecturer at the Sydney Institute for Infectious Diseases.  

“Handing out critically important antimicrobials for self-limiting illnesses is storing up trouble for the future.”

Addressing the drivers

Previous research has noted that inappropriate supply of antibiotics may be driven by factors including a lack of knowledge among pharmacy staff, a fear of losing customers in overcrowded markets, and a lack of regulatory enforcement.

In this study, the authors found that almost all antibiotics were supplied with minimal pressure from the customer, suggesting an onus on pharmacy staff to improve clinical practices.

Handing out critically important antimicrobials for self-limiting illnesses is storing up trouble for the future
Dr Justin Beardsley

A majority of the pharmacies surveyed in the research were small drug stores in rural parts of the country, and the challenge of medical access in these settings was highlighted as another factor requiring attention.

The study states that expanding the provision of affordable medical care in rural areas of Vietnam would help enable patients to access expert advice regarding antimicrobial use, avoiding the need for over-the-counter sales of antibiotics.

“Our findings indicate there is an urgent need to work with community pharmacies to improve clinical practices. This could involve strengthened guidance about antimicrobial use among trainees, as well as improved oversight and reporting requirements related to the dispensing practices of private pharmacies across the country,” said Dr Zawahir.

“Altering public perceptions around antibiotics could help pharmacy staff to be appreciated for providing quality advice and appropriate symptomatic treatments, particularly in rural areas where access to affordable medical care may be more limited.”

The paper includes co-authors from the University of Sydney’s Central Clinical School, the Sydney Institute for Infectious Diseases, the School of Public Health and the Woolcock Institute of Medical Research, as well as researchers from the National Institute of Hygiene and Epidemiology in Hanoi, the Karolinska Institute in Stockholm, the Australian National University, the Ministry of Health in Vietnam, the Hanoi University of Pharmacy, the National Lung Hospital in Vietnam, the George Institute for Global Health Australia, and the University of New South Wales. The study was funded by a grant from the Australian Department of Foreign Affairs and Trade.

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