Evaluating antimicrobial stewardship strategies and capacity building through participatory action research and a network approach in Vietnam

在越南，监测数据显示，医院中重要病原体的耐药比例高得惊人，而且还在不断增加。抗菌素管理（AMS）一直是改善抗生素使用的一项重要国家战略，然而，由于缺乏资源、技能和能力，在资源有限的医院，实施进展缓慢。其中包括区医院，这是公共卫生保健系统的第一住院点，在缺乏微生物实验室服务的情况下，通常根据经验给予首次静脉注射抗生素。因此，通过辅助医疗服务网络与省级医院连接是支持地区医院获得外部可用资源以实施辅助医疗服务的一种潜在方法。在这个拟议的为期四年的研究项目中，牛津大学越南临床研究中心（OUCRU）和国家热带病医院将与两个医院网络合作，采用参与式行动研究方法，以评估通过两个地方网络提供的辅助医疗服务项目的有效性、成本和实施结果。2)通过参与性行动研究和网络参与，发展省级和地区医院实施辅助医疗服务的工作人员能力；3)探索在这些辅助医疗服务医院网络中支持有效实施辅助医疗服务方案的机会和背景因素。每个医院网络将由一个省级医院和五个相连的地区医院组成，这些医院是根据我们以前的研究以及医院领导和医疗辅助队工作人员的承诺确定的。医院医疗辅助队的工作人员（参与者）将参与一个反复的反思周期，他们将收集和分析数据，确定要实施的行动和干预措施，观察过程，反思和评估结果，为持续的行动提供信息。研究小组将为医院员工提供医疗辅助队相关技能和研究方法的培训，以收集和分析数据、评估和确定干预措施、制定和评估实施情况。医院工作人员将利用来自国家指南和世界卫生组织工具包的证据和指导，确定可能的干预措施，并制定符合当地条件的医院具体行动计划。研究结果和学习经验将在定期的医院团队会议和网络会议上进行分享和讨论。我们将在整个研究过程中采用混合方法设计，包括员工调查、访谈和焦点小组讨论，以了解流程，评估实施方面，包括成本、可行性、可接受性、可持续性和可扩展性，并探索基于网络方法实施AMS的机会和环境因素。将从医院信息系统中提取纵向常规数据，以评估抗生素使用和临床结果（住院死亡率和住院时间）的共同主要结果措施。我们还将在实施前和实施后12个月两个时间点对所有医院的2000名患者进行调查，以调查AMS对耐药菌定植的潜在影响。这项研究产生的证据对于越南等资源有限的国家的决策者和医院在制定和实施适合当地的辅助医疗方案方面将是重要的。这项研究还将建立地方医院及其工作人员在评估、规划、实施和评价其辅助医疗服务干预措施方面的能力和自主权，并通过参与性行动研究进程提高研究人员在实施科学和吸引当地伙伴方面的能力。将发展和加强本地医疗辅助队网络，以提高资源调动、激励和医院参与实施。

In Vietnam, surveillance data showed alarmingly high and increasing drug-resistant proportions of important pathogens in hospitals. Antimicrobial stewardship (AMS) has been an important national strategy to improve antibiotic use, however, implementation has been slow at resource-limited hospitals due to lack of resources, skills and capacity. These include district hospitals, the first-point of hospitalization in the public healthcare system where first intravenous antibiotics are usually given empirically in the absence of microbiology lab services. Connecting with provincial-level hospitals through AMS networks is therefore a potential approach to support district hospitals in accessing external available resources for AMS implementation. In this proposed four-year research project, Oxford University Clinical Research Unit Vietnam (OUCRU) and National Hospital for Tropical Diseases will work with two hospital networks in a participatory action research approach to 1) to evaluate the effectiveness, costs and implementation outcomes of AMS programmes delivered through the two local networks, 2) to develop staff capacity in provincial and district hospitals in AMS implementation through participatory action research and network involvement, and 3) to explore opportunities for and contextual factors to support effective implementation of AMS programmes in these AMS hospital networks. Each hospital network will consist of one provincial hospital and five connecting district hospitals identified based on our previous research and the commitment of hospital leadership and AMS staff. Hospital AMS staff (participants) will be involved in an iterative reflective cycle where they will collect and analyse data and determine actions and interventions to implement, observe the process, and reflect and evaluate the outcomes to inform continuing actions. The research team will train hospital staff on AMS related skills and research methods to collect and analyse data, assess and identify interventions, develop and evaluate the implementation. Hospital staff will use evidence and guidance from national guidelines and World Health Organisation's toolkit to identify possible interventions and make hospital-specific action plans contextualized to their local conditions. Results and learning experience will be shared and discussed in regular hospital team meetings and network meetings facilitated by the researchers. We will use a mixed methods design throughout the research including staff survey, interviews and focus group discussions to understand the process, assess implementation aspects including costs, feasibility, acceptability, sustainability and scalability, and explore opportunities and contextual factors for AMS implementation based on the network approach. Longitudinal routine data will be extracted from hospital information systems to evaluate co-primary outcome measures of antibiotic use and clinical outcomes (in-hospital mortality and length of stay). We will also conduct a survey of 2000 patients in all hospitals at two time points, before and 12 months after implementation started, to investigate the potential impact of AMS on colonization of drug-resistant bacteria. Evidence generated from this research will be important for policy makers and hospitals in resource-limited settings like Vietnam in developing and implementing locally adapted AMS programmes. This research will also build the capacity and ownership of local hospitals and their staff in assessing, planning, implementing and evaluating their AMS interventions, and increase the capacity of research staff in implementation science and engaging local partners through the participatory action research process. Local AMS networks will be developed and strengthened to increase resource mobilization, motivation and participation of hospitals in the implementation.