illin (Supplementary Figure 3). The targeted organ systems of antimicrobial prescriptions varied by age. In infants (aged ≤1 year), antimicrobial prescriptions targeted the respiratory system in 230/754 (31%). In older children and adults, prescriptions were most commonly for the gastrointestinal system at 103/317 (32%) and 1,459/5,093 (29%), respectively (Supplementary Figure 4). Targeted therapy based on microbiology results was documented for 75/4,377 (2%) patients or 88/6,555 (1%) prescriptions. Culture results were only available for 58/75 (77%) patients (Burkholderia pseudomallei infection for 28/58 (48%), followed by Escherichia coli infection for 8/58 (14%), and Staphylococcus aureus infection for 7/58 (12%)). Of 75 patients with confirmed infection, tuberculosis was diagnosed in 17 (23%) patients by either microscopy or GeneXpert (Supplementary Table 5). Among survey hospitals, confirmed diagnoses based on laboratory results were mostly (52/75 (69%) from Mahosot Hospital patients.
Among 4,255 (97%) patients (6,433 (98%) prescriptions) who received antibiotics, the use of ACCESS antibiotics over these four years made up 3,244/6,433 (50%) prescriptions, while WATCH antibiotics accounted for 3,156/6,433 (49%). No RESERVE group antibiotic prescription was captured in this study. However, antibiotics from the ‘Not recommended” group of WHO AWaRe were prescribed to 33/4,255 (0·8%) patients, including ceftriaxone-sulbactam in 30/33 (91%) and cefoperazone-sulbactam in 3/33 (9%). Among the WATCH group used, 44/3,156 (1%) were based on microbiology results while no prescriptions of antibiotics in the ‘Not recommended’ group were suggested by microbiology results. ACCESS antibiotics were more commonly used in children (63%) than adults (47%) (p < 0·0001). ACCESS group use was highest in infants aged ≤1 year at 77% (578/754) and 52% (199/384) in children aged between >1 and ≤5 years, 46% (141/309) in children aged between >5 and ≤14 years, and 47% (2,326/4,986) in adults (Supplementary Figure 5). Use of ACCESS group antibiotics varied by hospitals in each survey and ranged from 44%-59% prescriptions. Use of WHO AWaRE ‘Not recommended’ antibiotics was only found in Mahosot Hospital in 33/2,029 (2%) prescriptions (Figure 3).
Figure 3Overall use of antibiotics of different AWaRE classifications in six survey hospitals in Laos, from 2017 to 2020.
was performed, with the percentage of antimicrobial prescriptions adherent to the guidelines increasing from 26% (1,136/4,397) for the pre-2021 guidelines to 38% (1,964/5,129) for the 2021-guidelines. At the same time the percentage of prescriptions that could not be assessed decreased from 33% (2,158/6,555) to 22% (1,426/6,555) and the percentage that were not adherent to guidelines decreased from 74% (3,261/4,397) to 62% (3,165/5,129). More details on antimicrobial use in relation to pre-2021 guidelines versus 2021-guidelines are in supplementary table 6.
Based on pre-2021 guidelines, adherence to the guidelines was more common among children aged ≤5 years at 44% (450/1,024) than for older children aged >5 to ≤14 years and adults at 20% (686/3,373). Prescriptions not adherent to the guidelines were found most commonly in obstetric/gynaecology departments at 98% (637/648), followed by surgery departments at 81% (1,011/1,248). The five most common indications for prescriptions without guidelines to assess against were eye, cardiovascular system, bone and joints, male genital conditions, and skin and soft tissue problems at 97% (33/34), 94% (33/35), 90% (162/180), 89% (81/91) and 76% (407/535), respectively. The top five indications for prescriptions without guidelines to assess, based on 2021-guidelines, were eye, male genital conditions, cardiovascular system, central nervous system and skin and soft tissue at 94% (32/34), 81% (81/91), 51% (18/35), 46% (80/174) and 38% (202/535), respectively.
Pneumonia was the most common indication identified for antimicrobial prescription in both children and adults; the proportion of pre-2021 guideline adherence in children for which treatment guidelines were available was high, at 77% (166/216) in those aged ≤1 year, 72% (76/105) in children aged >1 to ≤5 years and 56% (10/18) in children aged >5 to ≤14 years but it was much lower in adults at 6% (26/465) (p < 0·0001). The proportions of prescriptions adhering to the pre-2021 guidelines were 51% (157/304) for sepsis, 69% (48/70) for meningoencephalitis, 64% (35/55) for suspected typhoid fever, 86% (67/78) for suspected rickettsial infections, and 78% (52/67) for melioidosis (both suspected and confirmed). Of 29 patients (all ages) with microbiologically confirmed melioidosis, antimicrobial prescriptions for two (7%) patients did not adhere to the guidelines.
These first assessments of AMU in Laos found that almost three-quarter of hospitalised patients were receiving antimicrobial treatment on the day of the survey. Third generation cephalosporins (42%), penicillins (17%), nitroimidazoles (16·8%), aminoglycosides (10·4%) and macrolides (3·2%) were the most commonly used antimicrobials. AMU prevalence varied across hospitals over time, and was as high as 88·4% in some hospitals on occasions. This is an alarming message for Laos. This prevalence is higher than reported from other regions of the globe. Our results show higher AMU than the overall proportion from the Global-PPS of 303 hospitals in 53 countries at 34%, in which the highest proportion was from African countries at 50%. The proportion of antimicrobial use in six East and South Asian countries (29 hospitals) was 37% and 42% in west and central Asian countries (27 hospitals in nine countries).
and in Vietnam was 67·4% of 7,571 inpatients from 36 general hospitals in 2008.
Data from a single survey in two hospitals in Yangon, Myanmar, in 2019 showed that antimicrobial use in inpatients was 63·4% (1,255/1,980).
In six hospitals in Indonesia in 2019, 62% of 1,602 inpatients received antimicrobial(s) during the survey period.
Point prevalence survey of antibiotic use across 13 hospitals in Uganda.
and Nigeria 80·1% of 321 patients in one survey round in three hospitals.
Variations in antibiotic use across India: multi-centre study through global point prevalence survey.
whilst surveys in a high income country such as the USA, western and northern Europe showed that BL/BLIs (including, amoxicillin/clavulanic acid, ampicillin/sulbactam, piperacillin/tazobactam) were most commonly prescribed, followed by 3rd or 4th generation cephalosporins, fluoroquinolones or glycopeptides.
Significant regional differences in antibiotic use across 576 us hospitals and 11 701 326 adult admissions, 2016–2017.
(47% (42/90) from urine and 51% (56/109) from blood in 2020).
choice of empirical antibiotic treatment must be carefully considered to ensure that patients receive the most appropriate treatment.
The proportion of antimicrobial use adherent to the local pre-2021 treatment guidelines in this study was 26%, while 33% of prescriptions could not be evaluated because of missing guidelines or unknown/unclear indications. Comparison with adherence to 2021-guidelines found an increase in guidelines adherence to 35% and the proportion of use which could not be assessed reduced from 25% to 14%. This is much lower than estimates of appropriate antimicrobial use from other Asian countries (Vietnam (69·2%) in 2008, Myanmar (31·9%) in 2019, Indonesia (52·2%) in 2019 and India (77·4%) in 2017).
Globally, the appropriateness of antimicrobial prescriptions based on local guidelines has been shown to range from 64·1% (Latin America) to 85·8% (North America).
and systematic monitoring and feedback on AMU in hospitals in Laos (https://clinicaltrials.gov/ct2/show/NCT04914793), will hopefully lead to increased appropriate use of antimicrobials in Lao hospitals over time. Existing evidence has suggested that guidelines can improve the quality of antimicrobial prescribing. However other factors such as education, policy and public engagement also play important roles in sustainably improving the appropriateness of antimicrobial use.
and, as shown here, in Laos. Improving rational use of surgical antibiotic prophylaxis is challenging in low- and middle-income countries. Appropriate approaches such as comprehensive guidelines, monitoring of the use, feedback and improving/updating physician's knowledge should be considered.
The WHO AWaRe list is being used increasingly in many countries to monitor the rational use of antibiotics.
Encouraging AWaRe-ness and discouraging inappropriate antibiotic use-the new 2019 Ess