Encouraging rational antibiotic use in childhood pneumonia: a focus on Vietnam and the Western Pacific Region
Phuong et al. Pneumonia
Encouraging rational antibiotic use in childhood pneumonia: a focus on Vietnam and the Western Pacific Region
Nguyen T. K. Phuong 0 1
Tran T. Hoang
Pham H. Van
Stephen M. Graham
Ben J. Marais 1
0 Respiratory Department, Da Nang Hospital for Women and Children , Da Nang , Vietnam
1 Infectious Disease Team, The Children's Hospital at Westmead and Discipline of Paediatrics and Adolescent Medicine, University of Sydney , Sydney, NSW , Australia
Globally, pneumonia is considered to be the biggest killer of infants and young children (aged <5 years) outside the neonatal period, with the greatest disease burden in low- and middle-income countries. Optimal management of childhood pneumonia is challenging in settings where clinicians have limited information regarding the local pathogen and drug resistance profiles. This frequently results in unnecessary and poorly targeted antibiotic use. Restricting antibiotic use is a global priority, particularly in Asia and the Western Pacific Region where excessive use is driving high rates of antimicrobial resistance. The authors conducted a comprehensive literature review to explore the antibiotic resistance profile of bacteria associated with pneumonia in the Western Pacific Region, with a focus on Vietnam. Current management practices were also considered, along with the diagnostic dilemmas faced by doctors and other factors that increase unnecessary antibiotic use. This review offers some suggestions on how these issues may be addressed.
Childhood pneumonia is a major contributor to under-5
mortality, especially in developing countries [1, 2]. In the
Western Pacific Region, the highest burden of childhood
pneumonia and pneumonia-related deaths occur in six
countries: Cambodia, China, Laos, Papua New Guinea, the
Philippines and Vietnam . These countries report at least
0.2 pneumonia episodes per child year—more than 10
times the rates reported in developed countries from the
same region such as Australia, New Zealand and Japan .
The management of childhood pneumonia is problematic
in settings where a microbiological diagnosis is rarely
pursued and the drug resistance profiles of common bacteria
which cause respiratory disease are not readily available .
In many Asian countries this encourages excessive use of
broad-spectrum antibiotics, irrespective of the child’s
disease severity. In the authors’ experience, children are
frequently hospitalized with pneumonia to administer
intravenous antibiotics, despite relatively mild disease.
Unnecessary hospitalization for intravenous antibiotics
increases healthcare cost, as well as treatment-related
complications and the likelihood of nosocomial disease
transmission. In order to encourage more rational use of
intravenous antibiotics in children with
communityacquired pneumonia, the authors performed a
comprehensive review of common bacterial pathogens and
their reported drug resistance profiles in the Western
Pacific Region—Vietnam in particular. Factors that
increase unnecessary antibiotic use (and measures that
might reduce use) were also considered. PubMed,
Google Scholar and Embase databases were searched
using the following terms: antibacterial agents OR
antibiotics OR drug therapy AND community acquired
pneumonia OR acute respiratory tract infection AND
child OR children OR childhood. Manuscript titles
and abstracts were reviewed to identify original
research papers that included children less than 5 years
of age with pneumonia, with a geographic focus on
Vietnam and the Western Pacific Region. In addition,
the references of selected publications were reviewed,
and co-authors suggested additional relevant papers.
The term ‘acute respiratory tract infection (ARTI)’
describes all acute infections that involve the lungs or
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airways (upper and lower). The World Health
Organization (WHO) defines ‘pneumonia’ as a child
with tachypnoea, with or without signs of respiratory
distress. Given the huge overlap in how these terms
are applied in clinical practice, the authors considered
‘pneumonia’ and acute lower respiratory tract
infection (LRTI) to be synonymous for the purpose of this
Common bacterial pathogens
Bacteria classically described to cause
communityacquired pneumonia in children include Streptococcus
pneumoniae, Haemophilus influenzae type b (Hib) and
Staphylococcus aureus . Table 1 presents an overview
of pathogens commonly associated with acute LRTIs in
children less than 5 years of age. With enhanced
diagnostic tools, respiratory viruses and atypical bacteria
such as Mycoplasma pneumonia are commonly detected
in children with community-acquired pneumonia,
particularly in studies from the Western Pacific Region [7–
9]. This review focused on bacterial pathogens because
they are the major cause of pneumonia-related mortality
and the primary indication for antibiotic use. However,
it is important to appreciate that accurate differentiation
between viral and/or bacterial infection is a major
challenge to clinicians and complicates management .
This review provides a brief overview of the most
common bacterial pathogens and their reported drug
resistance profiles from surveys conducted in the Western
Table 1 Pathogens commonly associated with pneumonia or
acute lower respiratory tract infection in children less than
5 years of agee
Neonates Group B streptococcus
Enteric (gram negative) bacteria
RSV Respiratory Syncytial Virus, Staphylococcus aureus includes methicillin
resistant strains (MRSA); Haemophilus influenzae includes type b and other
aDisease greatly reduced in settings with universal access to conjugated
vaccines; bTypically considered as “atypical bacteria” requiring macrolide
therapy; cmainly in unvaccinated babies, in older children it can present as a
chronic cough; dThe risk of tuberculosis is dependent on the likelihood of
Mycobacteria tuberculosis exposure/infection, which is a particular problem in
areas with uncontrolled tuberculosis transmission
eAdapted from [3, 6]
The development of resistance mutations against
multiple antibiotics is well documented in S. pneumoniae, as
well as the expansion of resistant clones under antibiotic
pressure. Resistance has been recorded against penicillin,
tetracycline, cotrimoxazole, chloramphenicol,
fluoroquinolones and macrolides [5, 11, 12]. Although the
correlation between in vitro and in vivo resistance remains
contentious, it is generally assumed that penicillin (at
adequate dosages) should still be effective against
pneumococcal pneumonia (not meningitis) caused by
strains with low or intermediate levels of resistance
in vitro . This is difficult to verify, as many factors
that influence the outcome of pneumonia
treatment—such as underlying comorbid conditions, disease severity
and supportive treatment—are poorly described in
historical datasets and adequately powered head-to-head
comparisons are rare [14–16]. Another important factor
to take into consideration is the roll-out of
pneumococcal conjugate vaccines. Routine administration of
pneumococcal conjugate vaccine (PCV) in infancy has
led to major reductions in pneumonia hospitalization
and invasive pneumococcal disease in young children
. Given that the most common drug resistant strains
were included in 7- and 13-valent pneumococcal
conjugate vaccines, drug resistant pneumococcal disease has
been greatly reduced in areas with high vaccine uptake
, while reductions in strain carriage also reduced
secondary pneumonia cases among older adults .
However, recent studies from Canada and the United
Kingdom demonstrated substantial increases in
multidrug resistant non-vaccine serotypes in both colonizing
and invasive strains since introducing PCV13, with
similar findings for colonizing strains after introducing
PCV7 in Korean children [19–21].
High penicillin and macrolide resistance rates have
been reported in published surveys, but many of these
surveys included select patient populations and used
minimal inhibitory concentration (MIC) breakpoints
with variable stringency, and were also done prior to
routine PCV delivery [5, 22, 23]. The use of variable
MIC breakpoints in different studies is a major source of
confusion and complicates study comparison. MIC
breakpoints defined by the Clinical and Laboratory
Standards Institute (CLSI) are widely used in the United
States, while Europe has adopted the European
Committee on Antimicrobial Susceptibility Testing (EUCAST)
standards. They use broadly similar in vitro methods
and specify MIC breakpoints by considering the
pharmacokinetic–pharmacodynamic (PK-PD) properties of
the drug, the clinical site of disease and the specific
mechanism of drug resistance . Studies have shown
reasonable comparability between antibiotic
susceptibility profiles using revised CLSI and EUCAST breakpoints
[25, 26], but some significant differences remain. Against
S. pneumoniae and H. influenzae, cefuroxime and
cefaclor breakpoints still produce divergent results .
Global surveillance efforts would be greatly enhanced if
uniform surveillance criteria can be agreed upon and
MIC breakpoint definitions harmonized.
A study conducted in 11 Asian countries reported a
low (0.7%; 365/2184) prevalence of penicillin resistance
in S. pneumoniae from non-meningeal isolates,  but
it used an MIC breakpoint of ≥8 μg/ml as recommended
by CLSI, which is much higher than the >0.06 μg/ml
breakpoint proposed by EUCAST. A small case series of
children with S. pneumoniae septicemia in China
reported high drug resistance rates (96%; 24/25) , but
MIC breakpoints were not specified. In Malaysia, 18%
(5/28) of S. pneumoniae isolated from blood in children
with community-acquired pneumonia was resistant to
penicillin (using revised CLSI breakpoints) . Since
nasopharyngeal carriage may create a reservoir of
resistant S. pneumoniae clones, it is important to monitor
resistance in carriage specimens as well .
Nasopharyngeal S. pneumoniae carriage has been
reported in 17% (102/614) of healthy Chinese children;
51% were resistant to macrolides by the E-test method
. In rural Vietnam, S. pneumoniae carriage has been
detected in 50% of children, with higher rates in those
less than 2 years of age (6–23 months). The resistance
rate to amoxicillin and benzylpenicillin was low (4%; 17/
421), based on revised CLSI breakpoints, but 95% were
resistant to at least one antibiotic (cotrimoxazole 78%,
erythromycin 70%, ciprofloxacin 28%) . A more
recent Vietnamese survey confirmed excellent penicillin
susceptibility in S. pneumoniae isolates from respiratory
specimens (penicillin 87% using revised CLSI
breakpoints), although cephalosporin and macrolide
susceptibility was poor (cefuroxime 19%, cefaclor 8%;
azithromycin 4%) . This supports the Vietnam
national guidance to use high dose (90 mg/kg/day)
amoxicillin as first-line treatment of community-acquired
pneumonia in children .
Although the prevalence of H. influenzae type b (Hib)
has declined dramatically with widespread roll-out of
conjugated Hib vaccine [32, 33], it remains prevalent in
settings with poor vaccine uptake. B-lactamase
production is commonly associated with Hib infection. In
Vietnam, 41% of respiratory Hib isolates produced
βlactamase and 14% were β-lactamase non-producing
ampicillin-resistant . However, it is impossible to
differentiate clinical infection from asymptomatic
colonization using respiratory specimens from
nonsterile sites. In China, Hib carriage decreased from 36%
in 2000 to 19% in 2012, but β-lactamase-producing
isolates increased from 4 to 31% over the same time
period. Amoxicillin/clavulanic acid and 2nd or 3rd
generation cephalosporins remained universally effective
. Despite the national Hib vaccine roll-out in
Vietnam, Hib remains a common invasive pathogen
, but this is expected to decrease as vaccine uptake
improves. With increased vaccination uptake, the role of
other encapsulated H. influenzae strains have increased
. A study in China found that 100% of H. influenzae
strains identified in the sputum of children with
pneumonia were non-typable; 1% (2/279) were
β-lactamasepositive and 5% were β-lactamase non-producing
ampicillin-resistant or intermediately resistant .
S. aureus remains a common cause of
communityacquired pneumonia. Pioneering lung puncture studies
performed in Chile and Papua New Guinea identified S.
aureus as a common pathogen in children with
community-acquired pneumonia . More recent
studies found the pathogen predominantly in children at the
severe end of the pneumonia disease spectrum, with
increased frequency in severely malnourished children [38,
39]. S. aureus also poses particular problems following
influenza or measles infection, and as a secondary
infection in hospitalized children [38, 40, 41]. A major
challenge has been the emergence of methicillin-resistant S.
aureus (MRSA) and more recently, a decrease in
vancomycin susceptibility [42, 43]. Among positive S. aureus
blood cultures in Australian and New Zealand children,
MRSA has been reported in 13% (142/1,073) with three
times the average rate (incidence rate ratio, 3 [95%, CI:
2–4]), found among Aboriginal and Pacific Islander
populations [44, 45]. A recent Malaysian survey reported
MRSA in 8% (3/38) of children with
communityacquired S. aureus bacteremia; 32% had skin or soft
tissues infections and 32% had community-acquired
pneumonia . A study assessing the prevalence of
heterogeneous vancomycin-intermediately-resistant S.
aureus (hVISA) in Asian countries (including South
Korea, Taiwan, Hong Kong, Thailand, the Philippines,
Vietnam, India and Sri Lanka) reported that among 462
MRSA isolates, 3.5% were hVISA, with the highest
prevalence in South Korea and Vietnam (7.0%) . A
more extensive report on antibiotic resistance in 15
hospitals throughout Vietnam found MRSA in 20% of
children and adults with S. aureus bacteremia; vancomycin
resistance rates were very low .
Mycoplasma pneumoniae is highly prevalent in children
diagnosed with pneumonia in the Western Pacific
Region . M. pneumoniae is inherently resistant to all
βlactams antibiotics and vancomycin, because it does not
have a cell wall. With excessive macrolide use in recent
years, reported macrolide resistance is near universal
(90–100%) in parts of Asia . Most countries report
high rates of macrolide resistance (Japan 89% [49, 50],
China 83–98% [5, 51, 52], South Korea 63% , Hong
Kong 47% , Taiwan 23% ), although the methods
for M. pneumoniae susceptibility testing are poorly
standardized. M. pneumoniae remains susceptible to
macrolides in Australia where it is less frequently used .
Resistance to tetracyclines and fluoroquinolones have
not been reported in clinical isolates and may provide a
treatment alternative in some children, although reduced
in vitro susceptibility has been reported . However,
most M. pneumoniae cases recover either without
antibiotic treatment or despite documented drug resistance,
thus the clinical value of antibiotic treatment remains
Treatment of ARTIs is a major driver of antibiotic use
in children. It is important for clinicians to be familiar
with the most common bacterial causes, their local drug
resistance profiles and the likely impact of antibiotic
therapy (both positive and negative) in order to develop
a rational treatment approach. Because a timely and
definitive bacteriological diagnosis is currently impossible,
empiric antibiotic treatment is justified in any acutely ill
child. However, there is a need to critically consider
factors that promote unnecessary and irrational antibiotic
use, especially in children who are not acutely ill.
Factors promoting irrational antibiotic use
Antibiotic use generates selective pressure that increases
the prevalence of drug resistant strains; hence, strategies
to improve rational antibiotic use are important to
protect antibiotics as a precious resource. A study of
antibiotic use in Vietnamese hospitals showed that a large
proportion of in-patients received inappropriate
antibiotic therapy . The main factors that promote
unnecessary antibiotic use in the Western Pacific Region,
using Vietnam as an exemplar, are listed below.
Unrestricted antibiotic access
Given unrestricted access to over-the-counter
antibiotics, treatment of any respiratory infection with
antibiotics is a common practice in Vietnam, Malaysia, and
South Korea . In Vietnam, the Pharmaceutical Law
passed in 2005 requires an antibiotic prescription, but
38% of caregivers still access antibiotics without any
formal medical assessment ; even injectable antibiotics
can be acquired at local shops without prescription .
In the Western Pacific Region, antibiotic use before
presentation to a doctor is common; more than 40% in
Mongolia  and more than 50% of children admitted
with ARTIs in the Philippines . A study in nine
international sites—Colombia, Ghana, India, Mexico,
Pakistan, South Africa (2 sites), Vietnam and
Zambia—found that the use of antibiotics in the 48 h prior to
hospital admission was associated with treatment failure
(OR: 1.8; 95% CI: 1.27–2.66) . In addition,
agricultural use of antibiotics remains essentially unregulated in
most Asian countries, with high rates of colistin and
cephalosporin use in the pig and poultry industries,
resulting in increased rates of drug-resistant infections
in human populations [65, 66].
Unrealistic expectations and limited awareness
Limited awareness among the general public (including
politicians) is a challenge in all settings; the WHO
recently launched a program to increase awareness about
antimicrobial resistance and the need for more prudent
antibiotic use . In response, country-specific
strategies to limit antimicrobial resistance have been
launched in the United Kingdom, the United States and
Australia [67–69], but few Asian countries have followed
suit. Unrealistic public expectation is a major factor
driving excessive antibiotic use [59, 70]. A study in rural
Vietnam showed that just 13% of caregivers had correct
knowledge about acute respiratory infections and 38% of
caregivers self-managed common colds by buying
antibiotics without prescription at the local pharmacy . In
Malaysia, 67% of people believed antibiotics to be
effective against viral infections, with 47% using antibiotics
during a common cold . Moreover, antibiotic use is
strongly influenced by cultural preferences and beliefs.
Patients in Vietnam and China believe injectable
antibiotics are more potent than oral options, and readily
access injectable antibiotics without prescription . A
lack of adequate knowledge is also a problem among
healthcare providers. A study in Vietnam demonstrated
poor awareness about the risks and consequences of
drug resistance among rural health-care providers
when treating ARTIs; only 19% complied with
recommended guidelines and 79% used antibiotics for
common colds .
Table 2 provides an overview of physician-related factors
that explains some of the excessive antibiotic use seen in
Vietnam and parts of the Western Pacific Region. The
difficulty in accurately differentiating viral from bacterial
pneumonia is a major challenge in all settings. A study
in Finland showed that of the routine blood tests, only
the C-reactive protein (CRP) level differed significantly
between bacterial and viral pneumonia patients .
Most children with dense lobar infiltrates on chest
radiograph had laboratory evidence of a bacterial
infection, but interstitial infiltrates were seen in both viral
and bacterial pneumonia . A recent
randomizedcontrolled trial in Vietnam showed that point-of-care
Table 2 Physician related factors that contribute to excessive
antibiotic use in the Western Pacific Region
Factor identified Examples from the Western Pacific Region
Professional hierarchy • Junior physicians adopt the prescription
habits of senior physicians without rigorous
discussion or review of the evidence .
• In Vietnam, inappropriate antibiotic use is
a particular problem in obstetrics, gynecology
and surgery wards where professional
hierarchy is most pronounced 
• Doctors and patients often prefer
newer and more expensive antibiotics,
which are considered more “powerful” 
• Physicians provide antibiotics to help
individual patients; potential societal risks
are not considered ;
• In the absence of functional microbiology
services, physicians have limited information
on local drug-resistance profiles and the impact
of excessive antibiotic use;
• Doctors strive for patient satisfaction
and if patients request antibiotics it is
usually prescribed [70, 87]; In Korea, 73% of
doctors prescribe antibiotics for a common
cold if requested by parents ; In Malaysia,
67% of patients believe that antibiotics help for
viral infections 
• Doctors have no time or motivation to
explain the rationale for not using antibiotics
• Fear of poor patient outcomes is
often listed as a key motivation for
the use of broad-spectrum antibiotics
by doctors [58, 59, 89]
• Fear of litigation is not yet a major
driver in the Western Pacific, but is likely
to become a more prominent factor with
increased development 
offer better bedside guidance in the near future, assisting
more appropriate antibiotic use.
Because most child pneumonia deaths are caused by
bacterial pathogens, current WHO guidelines
recommend antibiotic use in all pneumonia cases, as defined
by the presence of fast breathing. This approach may
encourage the overuse of antibiotics, especially in children
without danger signs who present with wheezing as a
sign of reactive airway disease, which usually indicates a
viral infection. Audible wheezing has been noted in 49%
of Vietnamese children admitted with ‘pneumonia’ ,
which may identify a subgroup that does not require
antibiotics . WHO guidelines previously advised
intravenous antibiotics in all children diagnosed with severe
pneumonia (signs of respiratory distress), but oral
amoxicillin was found to be effective in 92% (948/1,025)
of children with a clinical diagnosis of severe pneumonia
in Pakistan . Subsequent trials demonstrated that
home-based treatment can be applied to a wide variety
of settings . A multi-center study conducted in
Bangladesh, Egypt, Ghana and Vietnam reported 9%
(95% CI: 7–11%) treatment failure with 5 days of high
dose oral amoxicillin (80–90 mg/kg/day), varying from
6% (95% CI: 3–10%) in Ghana to 13% (95% CI: 8–18%)
in Vietnam . A sizeable (but unknown) proportion
of cases enrolled in these “clinical pneumonia” studies
would have had viral infections. Therefore, it is not clear
how much “treatment failure” actually resulted from
inadequate antibiotic treatment for bacterial pneumonia;
most children found to be “unresponsive to antibiotics”
probably had viral pneumonia [78, 79]. Despite the
available evidence, most doctors in Vietnam routinely
hospitalize children with “clinical pneumonia” to
administer intravenous antibiotics; unnecessary hospitalization
increases both healthcare cost and the risk of
Actions and recommendations to improve rational
antibiotic use in both the community and hospital
environment are summarized in Table 3. Unrestricted antibiotic
access and self-medication are firmly entrenched in
Vietnam and most other Asian countries . Given the
multiple vested interests that protect the status quo,
strong regulation and effective law enforcement will be
required to limit excessive antibiotic use. In addition to
public education programs, better training of healthcare
providers to critically review the need for antibiotic use
is essential . Only 31% of countries in the Western
Pacific Region report high awareness of antimicrobial
resistance among their healthcare providers . An
educational program in Indonesia, including face-to-face
clinician visits and group discussions, significantly
Fear of poor patient
outcome or litigation
Inadequate • Near universal use of empiric broad spectrum
microbiology services antibiotics is common in places with poor
microbiology services [70, 87].
• In Vietnam, antibiotic use was reduced in
hospitals with functional microbiology
Financial incentives to • Doctors’ prescribing habits is influenced by
use antibiotics personal income generated and incentives
provided by pharmaceutical companies
[70, 86, 87]. In China, as in many other
Western Pacific countries, drug prescriptions
supplement a doctor’s income .
• In South-Korea drug dispensing by health
care workers was banned in 2000, resulting
in major reductions in antibiotic use 
CRP testing reduced inappropriate antibiotic use for
non-severe ARTIs . A previous
randomizedcontrolled trial in China investigated whether serum
pro-calcitonin (PCT) could reduce unnecessary
antibiotic use , but although the mean duration of
antibiotic treatment was shorter in the PCT group, the
antibiotic prescription rate was higher. It is hoped that
rapid point-of-care testing for common respiratory
viruses and biomarkers of severe bacterial infection will
Table 3 Actions and recommendations to improve rational
reduced the use of injectable drugs , but has not
Universal Hib and PCV
Provide information on local
drug resistance patterns
Eliminate perverse incentives
• Limit over-the-counter availability of
antibiotics; establish strong national
policies for appropriate antibiotic
regulation; implement measures to ensure
• Improved national surveillance of
antimicrobial resistance and adherence
to treatment guidelines
• Regulate agricultural use of antibiotics
• Increase general awareness of adverse
effects associated with excessive
• Educate parents, caretakers, politicians
and the general community about the
benefits of restricted antibiotic use
• Make Hib and PCV universally
available free of charge
• Maintain high uptake of other
vaccines (e.g. pertussis and measles)
• Maintain a network of functional
microbiology laboratories, with
adequate quality assurance and sharing
• Each hospital should have an
antimicrobial stewardship program and
a Drug and Therapeutics Committee
with access to reliable and up-to-date
data on antibiotic usage and drug
• Each hospital should have regular/
annual antibiotic use audits led by
pharmacists or infectious disease
• Develop national/regional consensus
treatment guidelines that consider the
international evidence base, as well as
local disease etiology and drug
Educate medical students and • Include antimicrobial stewardship in
trainees the undergraduate medical, nursing
and pharmacy curriculum
• Highlight the growing drug resistance
problem and need for prudent use
PCV pneumococcal conjugate vaccine, Hib Haemophilus influenzae type b
aIn addition, a detailed assessment of pneumonia case management should
be conducted to understand clinical decision-making and provide more
pragmatic guidance to clinicians in the field. Exemplars of comprehensive national
strategies to address antimicrobial resistance and limit excessive antibiotic use
include the United Kingdom, the United States and Australia [67–69]
been replicated elsewhere.
In 2013, the WHO facilitated a meeting of Western
Pacific Region countries in Manila to identify feasible
antimicrobial resistance (AMR) strategies , but this
has not yet translated into revised childhood pneumonia
guidance or management practices. In Vietnam, the
strengthen laboratory surveillance and reduce irrational
antibiotic use. The project covers 16 participating
hospitals , but outside of the participating hospitals AMR
surveillance remains weak. Laboratory capacity to assist
microbiological diagnosis and guide clinical management
is insufficient throughout the region . Functional
antibiotic stewardship programs have been established in
some countries, but this should become standard
practice and be adapted to the local context . An
antibiotic stewardship program in Chinese hospitals set
targets for antibiotic prescriptions and penalized doctors
who prescribed antibiotics inappropriately . After
2 years, antibiotic prescriptions decreased by 58–68% in
inpatients and 15–25% in outpatients . An
antimicrobial stewardship program is currently being
implemented in Vietnam (through VINARES), but the scope
of the program is limited and there is a need for similar
programs, including regular audits of antibiotic use, in
every hospital .
Optimal child pneumonia management presents an
opportunity to reduce excessive antibiotic use in the
Western Pacific Region. However, encouraging the rational
use of antibiotics requires education of healthcare
professionals, facilitation of cultural change, improved
establishment of functional
microbiology laboratories to monitor disease etiology
and drug resistance patterns, together with the removal
of inappropriate incentives and effective enforcement of
national regulations to restrict antibiotic use in
healthcare and agriculture.
ARTI: Acute respiratory tract infection; AMR: Antimicrobial resistance; CRP:
Creactive protein; CLSI: Clinical and Laboratory Standards Institute;
CI: Confidence interval; EUCAST: European Committee on Antimicrobial
Susceptibility Testing; H. influenzae: Haemophilus influenzae; Hib: Haemophilus
influenzae type b; hVISA: Heterogeneous vancomycin-intermediate S.aureus;
MRSA: Methicillin resistant staphylococcus aureus; MIC: Minimal inhibitory
concentration; M. pneumoniae: Mycoplasma pneumonia;
PKPD: Pharmacokinetic-pharmacodynamic; PCV: Pneumococcal conjugate
vaccine; PCT: Procalcitonin; S. aureus: Staphylococcus aureus; S.
pneumoniae: Streptococcus pneumoniae; VINARES: Vietnam resistance project;
WHO: World Health Organization
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