Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
Children's Hospital 1, Ho Chi Minh City, Vietnam.
PLoS One. 2020 Nov 4;15(11):e0241760. doi: 10.1371/journal.pone.0241760. eCollection 2020.
Treatment guidelines do not recommend antibiotic use for acute respiratory infections (ARI), except for streptococcal pharyngitis/tonsillitis and pneumonia. However, antibiotics are prescribed frequently for children with ARI, often in absence of evidence for bacterial infection. The objectives of this study were 1) to assess the appropriateness of antibiotic prescriptions for mild ARI in paediatric outpatients in relation to available guidelines and detected pathogens, 2) to assess antibiotic use on presentation using questionnaires and detection in urine 3) to assess the carriage rates and proportions of resistant intestinal Enterobacteriaceae before, during and after consultation.
Patients were prospectively enrolled in Children's Hospital 1, Ho Chi Minh City, Vietnam and diagnoses, prescribed therapy and outcome were recorded on first visit and on follow-up after 7 days. Respiratory bacterial and viral pathogens were detected using molecular assays. Antibiotic use before presentation was assessed using questionnaires and urine HPLC. The impact of antibiotic usage on intestinal Enterobacteriaceae was assessed with semi-quantitative culture on agar with and without antibiotics on presentation and after 7 and 28 days.
A total of 563 patients were enrolled between February 2009 and February 2010. Antibiotics were prescribed for all except 2 of 563 patients. The majority were 2nd and 3rd generation oral cephalosporins and amoxicillin with or without clavulanic acid. Respiratory viruses were detected in respiratory specimens of 72.5% of patients. Antibiotic use was considered inappropriate in 90.1% and 67.5%, based on guidelines and detected pathogens, respectively. On presentation parents reported antibiotic use for 22% of patients, 41% of parents did not know and 37% denied antibiotic use. Among these three groups, six commonly used antibiotics were detected with HPLC in patients' urine in 49%, 40% and 14%, respectively. Temporary selection of 3rd generation cephalosporin resistant intestinal Enterobacteriaceae during antibiotic use was observed, with co-selection of resistance to aminoglycosides and fluoroquinolones.
We report overuse and overprescription of antibiotics for uncomplicated ARI with selection of resistant intestinal Enterobacteriaceae, posing a risk for community transmission and persistence in a setting of a highly granular healthcare system and unrestricted access to antibiotics through private pharmacies.
This study was registered at the International Standard Randomised Controlled Trials Number registry under number ISRCTN32862422: http://www.isrctn.com/ISRCTN32862422.
治疗指南不建议使用抗生素治疗急性呼吸道感染（ARI），除非是链球菌性咽炎/扁桃体炎和肺炎。然而，抗生素经常被用于治疗患有 ARI 的儿童，而这种治疗通常缺乏细菌感染的证据。本研究的目的是 1）评估轻度儿科门诊 ARI 患者的抗生素处方是否符合可用指南和检测到的病原体，2）使用问卷调查和尿液 HPLC 检测来评估就诊时的抗生素使用情况，3）评估咨询前后肠道肠杆菌科的携带率和耐药比例。
前瞻性招募了越南胡志明市儿童医院 1 号的患者，在首次就诊和 7 天后的随访中记录了诊断、处方治疗和结局。使用分子检测方法检测呼吸道细菌和病毒病原体。使用问卷和尿液 HPLC 检测就诊前的抗生素使用情况。在就诊时和就诊后 7 天和 28 天使用琼脂半定量培养，检测有无抗生素，评估抗生素使用对肠道肠杆菌科的影响。
2009 年 2 月至 2010 年 2 月期间共招募了 563 名患者。除 2 名患者外，其余 563 名患者均接受了抗生素治疗。大多数是第二代和第三代口服头孢菌素和阿莫西林，加或不加克拉维酸。72.5%的患者呼吸道标本中检测到呼吸道病毒。根据指南和检测到的病原体，抗生素使用分别被认为是不适当的，占 90.1%和 67.5%。就诊时，父母报告 22%的患者使用过抗生素，41%的父母不知道，37%的父母否认使用过抗生素。在这三组中，通过 HPLC 在患者尿液中检测到六种常用抗生素，分别占 49%、40%和 14%。在使用抗生素期间观察到第三代头孢菌素耐药肠道肠杆菌科的暂时选择，同时还选择了对氨基糖苷类和氟喹诺酮类的耐药性。
我们报告了在复杂的 ARI 中过度使用和过度处方抗生素，导致了耐药肠道肠杆菌科的选择，这对社区传播和在高度细分的医疗体系和通过私人药店不受限制地获得抗生素的环境中的持续存在构成了风险。
该研究在国际标准随机对照试验编号注册处注册，编号为 ISRCTN32862422：http://www.isrctn.com/ISRCTN32862422。
