Improving appropriate antimicrobial use among pregnant and postpartum women, and children under 5 years old in hospitals in Lao PDR

Context

Lao People’s Democratic Republic (Lao PDR) is in Southeast Asia, a region where antimicrobial resistance (AMR) has been on the rise in recent years. In 2016, the Lao PDR Ministry of Health (MOH) established the Global Antibiotic Resistance Partnership committee which served as a technical working group reviewing scientific evidence for combatting AMR and providing evidence to the MOH AMR surveillance and control committee. In 2017, the AMR policy was endorsed, and the National Action Plan (NAP) was put into effect from 2019 to 2023.

The NAP addresses the problem of AMR within the framework of One Health and aims to enhance Lao PDR’s capability for using modern technology for the diagnosis of AMR in the country. The key activities in this NAP include:

1. Setting up the standardized reference laboratory (National Centre for Laboratory and Epidemiology-NCLE)
2. Strengthening laboratory capacity through biannual training on laboratory techniques and AMR surveillance
3. Monitoring AMR and antimicrobial use (AMU), including appropriateness, in human and animal feeds and food products
4. Establishing a centralised laboratory database for AMR surveillance data

Problem

Overuse and misuse of antibiotics is frequently reported for obstetric conditions and procedures, with potential impacts for both the mother and the baby, as well as increased antibiotic resistance. In Lao PDR, the use of antibiotics is widely practiced for both self-medication and by health practitioners. In a study of 608 patients hospitalized at the obstetric and gynaecological wards, 23% of them received antibiotic prescriptions, and 14% of 1,885 children who came for healthcare services at paediatric wards received antibiotic prescriptions. Many of these prescriptions could be unnecessary.

Efforts to develop and adapt antibiotic stewardship guidelines (including infection prevention and control) in the healthcare system could prevent the AMR situation from worsening. During a recent visit with healthcare providers (clinicians) and the IPC team at the central, provincial, and district levels, an antimicrobial stewardship (AMS) programme team found multiple treatment and IPC guidelines for obstetric and paediatric patients were mentioned as reference guidelines, suggesting that different health facilities are using different practices on antimicrobial prescription, which are not all up to date. For this reason, updated and standardised treatment and IPC guidelines could increase appropriate antimicrobial prescriptions among healthcare providers at all levels in Lao PDR.

Project overview

This project aims to improve and sustain the appropriate use of antibiotics in hospitals among pregnant and postpartum women and children under 5 years of age. The project includes four hospitals at different levels of the healthcare system: a central hospital (Maternal and Newborn Hospital), a provincial hospital (Vientiane Provincial Hospital), and two district hospitals (Fueng and Vangvieng Hospital). The specific objectives of the project are to:

1. Identify existing and missing elements, and possible enablers for and barriers to implementing an AMS programme at the four hospital levels
2. Design and implement a multi-modal quality improvement AMS program following the WHO AMS Toolkit in the four hospitals
3. Assess the cost-effectiveness of appropriate AMU in obstetric and paediatric wards in the healthcare system to inform policy recommendations to sustain AMS initiatives through scale up guidelines
4. To identify barriers and enablers (including acceptability, feasibility, and appropriateness) to uptake and behaviour change of AMS interventions around appropriate use of antibiotics
5. Inform policies and scale up the AMS program for sustainability of appropriate use of antibiotics among target groups

Outcomes

The expected outcomes of the project are:

• improved appropriate antibiotic prescription amongst healthcare providers in the obstetric and paediatric outpatient and inpatient wards of four study hospitals
• improved AMS programme in hospitals
• evidence generated on the cost impact of implementing the AMS programme in hospitals
• improved policies and scale-up of the AMS programme to sustainably facilitate the appropriate use of antibiotics