Antibiotic resistance in Vanuatu: Developing an evidence base to inform locally relevant strategies to respond to the growing challenge.

Abstract

Antimicrobial resistance including antibacterial resistance (ABR) is a major global health problem. Increased use and misuse of antibiotics are key drivers of ABR. Surveillance and research, optimising the use of antibiotics through antibiotic guidelines and antibiotic stewardship programmes (ASPs), and infection prevention and control programs are all essential to containing ABR. Evidence suggested antibiotics were over and unnecessarily prescribed during COVID-19, especially in some LMICs. The aim of this thesis is to develop an evidence base to inform locally relevant strategies to manage and respond to ABR in Vanuatu. The five objectives involved in achieving this aim are addressed in the following paragraphs. First, to understand the epidemiological situation regarding ABR in PICTs, I conducted a scoping review and found evidence of widespread ABR in Pacific Island Countries and Territories (PICTs). The most frequently occurring gram-positive pathogen was Staphylococcus aureus (S. aureus) and rates of methicillin resistant S. aureus (MRSA) were highly variable. Several gram-negative bacteria listed on the World Health Organization's (WHO) Priority Pathogen List were present. Second, to investigate the epidemiology of ABR in Vanuatu, I conducted a descriptive study into pathogen occurrence and ABR in specimens collected for culture and testing at Vila Central Hospital (VCH) laboratory from January 2017 to December 2019. The findings showed S. aureus was the major pathogen, and the rate of MRSA was low at 3%. Data about ABR was scarce, suggesting surveillance and research across all health settings is urgently needed for monitoring and reporting. Third and fourth, to investigate the influence of COVID-19 on Ni-Vanuatu health workers' knowledge, beliefs, and practices (KBPs) regarding antibiotic prescribing and awareness of ABR and antibiotic consumption at VCH, respectively. Firstly, I conducted a before-after mixed methods study by administering a KBPs survey and in-depth interviews at baseline (2018) and follow-up (2022). I found that COVID-19 influenced antibiotic prescribing and awareness of ABR. Health workers' knowledge and beliefs about antibiotic prescribing improved and their awareness of ABR was heightened. I also collected the monthly quantities of antibiotics dispensed, before (2018 - 2020) and during the COVID-19 pandemic (2020 - 2021), from the dispensary at VCH. Using WHO's ATC/DDD index, I calculated the number of DDDs prescribed to inpatients and outpatients during the two study periods and used interrupted time series analysis to assess the impact of the pandemic on consumption. I found that inpatient consumption increased during the pandemic. Finally, I conducted a systematic review into the strategies used to implement and promote adherence to guidelines in low- and lower-middle-income countries (LLMICs). I found multifaceted interventions to be the most effective including audit and feedback, combined with other quality strategies. Clinical decision support systems, used with mobile technologies were shown to be easy to implement, but impediments in LLMICs must be overcome before widespread use can be realised. I found few studies reported prescriber involvement in guideline development, and little evidence of formalised ASPs in LLMICs.

These results provide robust evidence to support the following recommendations: strengthen laboratory infrastructure, capacity, capability, and expertise; establish systems for surveillance of ABR, and antibiotic consumption and usage; complete Vanuatu's national antibiotic prescribing guidelines with an active implementation plan; formalise ASPs and strategies in all healthcare settings; and provide opportunities for continuing inter- and intra-professional development. Together, these recommendations will contribute towards optimising antibiotic prescribing, containing ABR, and supporting Vanuatu's ongoing preparedness efforts to manage future public health events. Show more