Is nationwide special campaign on antibiotic stewardship program effective on ameliorating irrational antibiotic use in China? Study on the antibiotic use of specialized hospitals in China in 2011–2012

A comprehensive point prevalence survey of the quality and quantity of antimicrobial use in Chinese general hospitals and clinical specialties

Antimicrobial resistance (AMR) is a serious, worldwide public health crisis. Surveillance of antimicrobial use forms part of an essential strategy to contain AMR. We aimed to conduct a national point prevalence survey (PPS) on antimicrobial use, and to compare this data with similar international surveillance programs to provide a reference for future AMR strategy development in China. Twenty general hospitals encompassing 10,881 beds and 10,209 inpatients around the country participated the survey using a standardized protocol, at 8am of someday from October 10th to November 31st, 2019. Of the patients, 37.00% (3777/10209) received antimicrobial agents, 31.30% (1630/5208) had surgical operations, and 76.63% (1249/1630) received prophylactic antibiotic. The prevalence of antimicrobial use in medical, surgical, and intensive care units (ICU) patients was 38.84% (1712/4408), 32.07% (1670/5208), and 66.61% (395/593), respectively. Of prescriptions, 5.79% (356/6151) were made in the absence of indication. The intensity of antimicrobial use was 61.25 DDDs/100 patient days, while the intensity of use in internal medicine, surgery, and ICU were 67.79, 45.81, 124.45 DDDs/100 patient days, respectively. Only 11.62% (715/6151) of prescriptions had a reason described in the patient record. Furthermore, 8.44% (210/2487), 14.19% (424/2989), and 12% (81/675) of the prescriptions in internal medicine, surgery, and ICU had a recorded indication, respectively. The review and stop date recorded for antimicrobial therapy was 43.73% (1976/4518). Of the patients, 38.07% (1438/3777) received combination therapy. The classes of antimicrobials prescribed were limited, and the proportion of prescriptions encompassed by the top 20 antimicrobial agents was 75.06% (4617/6151). The prevalence of antimicrobial use in China is close to that of Sweden, the UK, and Canada, but lower than that in India, and higher than that in Switzerland. The data described in this report indicate that the quality of antimicrobial prescriptions requires improvement in China. Further, hospitals should implement professional interventions to improve the rational use of antimicrobials.

A review of tungsten trioxide (WO3)-based materials for antibiotics removal via photocatalysis

Antibiotics are extensively used in human medicine and animal breeding. The use of antibiotics has posed significant risks and challenges to the natural water environment. On a global scale, antibiotics have been frequently detected in the environment, azithromycin (254-529 ng·L^-1), ciprofloxacin (245-1149 ng·L^-1), ofloxacin (518-1998 ng·L^-1), sulfamethoxazole (1325-5053 ng·L^-1), and tetracycline (31.4-561 ng·L^-1) are the most detected antibiotics in wastewater and surface water. Abuses of antibiotics has caused a significant threat to water resources and has seriously threatened the survival of human beings. Therefore, there is an urgent need to reduce antibiotic pollution and improve the environment. Researchers have been trying to develop effective methods and technologies for antibiotic degradation in water. Finding efficient and energy-saving methods for treating water pollutants has become an important global topic. Photocatalytic technology can effectively remove highly toxic, low-concentration, and difficult-to-treat pollutants, and tungsten trioxide (WO₃) is an extremely potential alternative catalyst. Pt/WO₃ photocatalytic degradation efficiency of tetracycline was 72.82%, While Cu-WO₃ photocatalytic degradation efficiency of tetracycline was 96.8%; WO₃/g-C₃N₄ photocatalytic degradation efficiency of ceftiofur was 70%, WO_3/W photocatalytic degradation efficiency of florfenicol was 99.7%; WO₃/CdWO₄ photocatalytic degradation efficiency of ciprofloxacin was 93.4%; WO₃/Ag photocatalytic degradation efficiency of sulfanilamide was 96.2%. Compared to other water purification methods, photocatalytic technology is non-toxic and ensures complete degradation through a stable reaction process, making it an ideal water treatment method. Here, we summarize the performance and corresponding principles of tungsten trioxide-based materials as a photocatalytic catalyst and provide substantial insight for further improving the photocatalytic potential of WO₃-based materials.

Detection Limits of Antibiotics in Wastewater by Real-Time UV–VIS Spectrometry at Different Optical Path Length

Real-time monitoring of antibiotics in hospital and pharmaceutical wastewater using ultraviolet–visible (UV–Vis) spectroscopy is considered a promising method. Although gas chromatography–mass spectrometry (GC–MS) and other methods can detect antibiotics with quite low limits of detection (LOD), they possess various limitations. UV–Vis spectroscopy combined with chemometric methods is a promising choice for monitoring antibiotics. In this study, two immersed in situ UV–Vis sensors were used to explore the relationship between absorption spectra and antibiotics and study the influence of the optical path length on the LOD. The LODs of sensor 2 using a 10 cm optical path is up to 300 times lower than that of sensor 1 using a 0.5 mm optical path. Moreover, multiple antibiotics in the wastewater were investigated in real-time manner. The absorption spectra of 70 groups of wastewater samples containing different concentrations of tetracycline, ofloxacin, and chloramphenicol were measured. The results indicate that the nine wavelengths selected by interval partial least squares (iPLS) after the second derivative pretreatment have better predictability for ofloxacin and the six wavelengths selected by competitive adaptive reweighted sampling (CARS) after the first derivative. The multi-fold cross-validation results indicate that the model has a good predictive ability.

Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis

INTRODUCTION

The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China.

METHODS

Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only).

RESULTS

Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies.

CONCLUSIONS

Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review

The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.

Trends and Patterns of Antibiotics Use in China's Urban Tertiary Hospitals, 2016-19

Objectives: This study aimed to identify the trends in antibiotics utilization and patients costs, evaluating the effect of the policy and exploring factors associated with the irrational use of antibiotics. Methods: Based on the Cooperation Project Database of Hospital Prescriptions, data were collected from 89 tertiary hospitals in nine cities in China during 2016-2019. The study sample consisted of prescription records with antibiotics for 3,422,710 outpatient and emergency visits and 26, 118, 436 inpatient hospitalizations. Results: For outpatients, the proportion of treated with antibiotics declined from 14.72 to 13.92% significantly (p < 0.01). The proportion of antibiotic costs for outpatients decreased from 5.79 to 4.45% significantly (p < 0.01). For emergency patients, the proportion of treated with antibiotics increased from 39.31 to 43.45% significantly (p < 0.01). The proportion of antibiotic costs for emergency patients decreased from 36.44 to 34.69%, with no significant change (p = 0.87). For inpatients, the proportion of treated with antibiotics increased from 23.82 to 27.25% significantly (p < 0.01). The proportion of antibiotic costs for outpatients decreased from 18.09 to 17.19% with no statistical significance (p = 0.89). Other β-lactam antibacterials (1,663.03 ten thousand DDD) far exceeded other antibiotics categories. Stablely ranked first, followed by Macrolides, lincosamide and streptogramins (965.74 ten thousand DDD), Quinolone antibacterials (710.42 ten thousand DDD), and β-lactam antibacterials, penicillins (497.01 ten thousand DDD). Conclusions: The proportion of treated with antibiotics for outpatients and inpatients meet the WHO standards. The antibiotics use varied by different survey areas, clinical departments, patient gender, patient age and antibiotics categories. More efforts should focus on improving the appropriateness of antibiotics use at the individual level.

Inadequate knowledge on appropriate antibiotics use among clients in the Moshi municipality Northern Tanzania

BACKGROUND

Poor knowledge concerning appropriate antibiotic use significantly influences the misuse of antibiotics within the community, especially in developing countries where there are weaker health systems to regulate antibiotic dispensing. Antibiotic misuse leads to antibiotic resistance. This study assessed knowledge of appropriate antibiotic use among buyers in the Moshi municipality, Northern Tanzania.

METHODS

We conducted a cross-sectional study in Moshi municipality between April and May 2017. Adults who bought antibiotics at drug outlets were invited to participate in the study. An exit interview was conducted with participants to collect their demographics and assess their knowledge concerning appropriate use of antibiotics. A logistic regression model was performed to determine factors associated with correct knowledge concerning antibiotic use.

RESULTS

A total of 152 adults with a median age of 30.5 (IQR 25-42) years, were enrolled in the study. Slightly over half (n = 89, 58.6%), responded that they should stop antibiotics after finishing the dose as directed. Half (n = 77, 50.7%) thought that it was acceptable to share antibiotics with other individuals and over half of respondents (n = 95, 65.1%) thought that they should request the same antibiotics if they had used them to treat a similar illness in the past. Only 38 (25%) had adequate knowledge about the use of antibiotics. Sore throat and flu were respectively identified by 62.5% and 46.1% of respondents as conditions that can be treated with antibiotics. Higher levels of education (aOR = 4.11 95%CI = 1.44-11.71) and having health insurance (aOR = 9.05 95%CI = 3.35-24.45) were associated with better levels of knowledge concerning antibiotic use in various illnesses.

CONCLUSION

There is inadequate knowledge concerning the indications for antibiotics and their appropriate usage. Health promotion campaigns are needed to educate the population about appropriate antibiotic use and reduce their irrational use.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Characteristics of Clostridium difficile isolates and the burden of hospital-acquired Clostridium difficile infection in a tertiary teaching hospital in Chongqing, Southwest China

BACKGROUND

Clostridium difficile infection (CDI), especially hospital-acquired Clostridium difficile infection (HA-CDI), continues to be a public health problem and has aroused great concern worldwide for years. This study aimed to elucidate the clinical and epidemiological features of HA-CDI and the characteristics of C.difficile isolates in Chongqing, Southwest China.

METHODS

A case-control study was performed to identify the clinical incidence and risk factors of HA-CDI. C. difficile isolates were characterised by polymerase chain reaction (PCR) ribotyping, multilocus sequence typing (MLST), toxin gene detection and antimicrobial susceptibility testing.

RESULTS

Of the 175 suspicious patients, a total of 122 patients with antibiotic-associated diarrhea (AAD) were included in the study; among them, 38 had HA-CDI. The incidence of AAD and HA-CDI was 0.58 and 0.18 per 1000 patient admissions, respectively. Chronic renal disease and cephalosporin use were independent risk factors for HA-CDI. Fifty-five strains were assigned into 16 sequence types (STs) and 15 ribotypes (RTs). ST2/RT449 (8, 14.5%) was the predominant genotype. Of the 38 toxigenic isolates, A + B + CDT- isolates accounted for most (34, 89.5%) and 1 A + B + CDT+ isolate emerged. No isolate was resistant to vancomycin, metronidazole or tigecycline, with A-B-CDT- being more resistant than A + B + CDT-.

CONCLUSIONS

Different genotypes of C. difficile strains were witnessed in Chongqing, which hinted at the necessary surveillance of HA-CDI. Adequate awareness of patients at high risk of HA-CDI acquisition is advocated and cautious adoption of cephalosporins should be highlighted.

Impact of national interventions to promote responsible antibiotic use: a systematic review

BACKGROUND

Global recognition of antimicrobial resistance (AMR) as an urgent public health problem has galvanized national and international efforts. Chief among these are interventions to curb the overuse and misuse of antibiotics. However, the impact of these initiatives is not fully understood, making it difficult to assess the expected effectiveness and sustainability of further policy interventions. We conducted a systematic review to summarize existing evidence for the impact of nationally enforced interventions to reduce inappropriate antibiotic use in humans.

METHODS

We searched seven databases and examined reference lists of retrieved articles. To be included, articles had to evaluate the impact of national responsible use initiatives. We excluded studies that only described policy implementations.

RESULTS

We identified 34 articles detailing interventions in 21 high- and upper-middle-income countries. Interventions addressing inappropriate antibiotic access included antibiotic committees, clinical guidelines and prescribing restrictions. There was consistent evidence that these were effective at reducing antibiotic consumption and prescription. Interventions targeting inappropriate antibiotic demand consisted of education campaigns for healthcare professionals and the general public. Evidence for this was mixed, with several studies showing no impact on overall antibiotic consumption.

CONCLUSIONS

National-level interventions to reduce inappropriate access to antibiotics can be effective. However, evidence is limited to high- and upper-middle-income countries, and more evidence is needed on the long-term sustained impact of interventions. There should also be a simultaneous push towards standardized outcome measures to enable comparisons of interventions in different settings.

Agreement between units of measure for paediatric antibiotic utilisation surveillance using hospital pharmacy supply data

Background:

Drug utilisation studies from paediatric hospitals that do not have access to patient level data on medication use are limited by a lack of standardised units of measures that reflect the varying daily dosage requirements among patients. The World Health Organization’s defined daily dose is frequently used in adult hospitals for benchmarking and longitudinal analysis but is not endorsed for use in paediatric populations.

Objective:

Explore agreement between standard adult-based defined daily doses (DDD) and paediatric estimates of daily injectable antibiotic use in a Paediatric Intensive Care Unit that does not have access to individual patient-level data.

Methods:

Hospital pharmacy antibiotic use reports and age-specific occupied bed-day data from 1 January 2010 to 31 May 2016 were extracted. Paediatric reference dosages and frequencies for antibiotics were defined and applied to three paediatric units of measure. Measures were applied to extracted data, agreement between antibiotic use measured in the adult DDD and each of the paediatric measures was assessed visually via Bland-Altman plots and linear regression for each antibiotic.

Results:

Thirty one different antibiotics were used throughout the study period. Despite varying daily dosages in grams, the daily use of vials was unchanged from birth to 18 years for thirteen antibiotics. Agreement between DDD and vial-based measures was closer than the total recommended daily dose that did not account for wastage during preparation and administration. Vial-based measures were unaffected by vial size changes due to drug shortage.

Conclusions:

Agreement between the DDD and vial-based measures of use supports the use of DDD for select antibiotics that may be targeted by antimicrobial stewardship programs. Vial based measures should be further explored in hospitals with single vial policies; detailed understanding of hospital practice is needed before inter-hospital comparisons are made.

Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map

BACKGROUND

Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans.

METHODS AND FINDINGS

Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review.

CONCLUSIONS

To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published.

PROTOCOL REGISTRATION

PROSPERO CRD42017067514.

A multicenter point prevalence survey of antibiotic use in Punjab, Pakistan: findings and implications

OBJECTIVES

In line with the recent global action plan for antimicrobial resistance, this is the first time such a comprehensive antimicrobial point prevalence survey has been undertaken in Pakistan, the sixth most populous country.

METHODS

This point prevalence survey (PPS) was conducted in 13 hospitals among 7 different cities of Pakistan. The survey included all inpatients receiving an antibiotic on the day of PPS. A web-based application was used for data entry, validation, and reporting as designed by the University of Antwerp (www.global-pps.com).

RESULTS

Out of 1954 patients, 1516 (77.6%) were treated with antibiotics. The top three most reported indications for antibiotic use were prophylaxis for obstetrics or gynaecological indications (16.5%), gastrointestinal indications (12.6%) and lower respiratory tract infections (12.0%). The top three most commonly prescribed antibiotics were ceftriaxone (35.0%), metronidazole (16.0%) and ciprofloxacin (6.0%). Out of the total indications, 34.2% of antibiotics were prescribed for community-acquired infections (CAI), 5.9% for healthcare-associated infections (HAI), and 57.4% for either surgical or medical prophylaxis. Of the total use for surgical prophylaxis, 97.4% of antibiotics were given for more than one day.

CONCLUSIONS

Unnecessary prophylactic antibiotic use is extremely high, and broad-spectrum prescribing is common among hospitals in Pakistan. There is an urgent need to work on the  national action plan of Pakistan on antibiotic resistance to address this.

Antimicrobial stewardship for acute-care hospitals: An Asian perspective

Inappropriate use of antibiotics is contributing to a serious antimicrobial resistance problem in Asian hospitals. Despite resource constraints in the region, all Asian hospitals should implement antimicrobial stewardship (AMS) programs to optimize antibiotic treatment, improve patient outcomes, and minimize antimicrobial resistance. This document describes a consensus statement from a panel of regional experts to help multidisciplinary AMS teams design programs that suit the needs and resources of their hospitals. In general, AMS teams must decide on appropriate interventions (eg, prospective audit and/or formulary restriction) for their hospital, focusing on the most misused antibiotics and problematic multidrug-resistant organisms. This focus is likely to include carbapenem use with the goal to reduce carbapenem-resistant gram-negative bacteria. Rather than initially trying to introduce a comprehensive, hospital-wide AMS program, it would be practical to begin by pilot testing a simple program based on 1 achievable core intervention for the hospital. AMS team members must work together to determine the most suitable AMS interventions to implement in their hospitals and how best to put them into practice. Continuous monitoring and feedback of outcomes to the AMS teams, hospital administration, and prescribers will enhance sustainability of the AMS programs.

Effectiveness of Antibiotic Use Management in Tianjin (2011-2013): A Quasi-Experimental Study

BACKGROUND In this study we investigated changes in the status of antibiotic use in Tianjin since the implementation of the Antibiotic Stewardship Program (ASP) (2011-2013), as well as existing problems, strategies, and outcomes to promote rational clinical antibiotic use. MATERIAL AND METHODS A quasi-experimental study was performed to investigate situations of antibiotic use in secondary and tertiary general hospitals in Tianjin from April 2011 to 2013. Five major indicators were analyzed: percentage of antibiotic use in inpatient cases (%), antibacterial use density (AUD), proportion of prophylactic antibiotic application for type I surgical incision, compliance rate of medication administration 0.5-2.0 h before such procedures, and antibiotic prophylaxis for ≤24 h in patients receiving these surgeries. RESULTS There was a decrease in the percentage of antibiotic use across general hospitals (60.38% to 46.88%), in AUD (51.60% to 35.37%), and in the proportion of prophylactic antibiotic applications for type I incisions (86.67% to 25.08%). For patients undergoing these procedures, there was an increased compliance rate of medication administration of 0.5-2.0 h prior to surgery (86.38% to 100%), and of antibiotic prophylactic use for ≤24 h (40.30% to 96.37%). CONCLUSIONS Implementation of the ASP campaign has reduced irrational antibiotic use, promoted rational antibiotic use, and delayed antibiotic resistance.

Antimicrobial prescribing patterns in a large tertiary hospital in Shanghai, China

Whilst the 'Principles of clinical use of antibiotics' was released by the Ministry of Health of the People's Republic of China in 2004, limited research has been conducted to evaluate the quality of antibiotic use in real-world practice. In this study, we sought to examine antimicrobial prescribing patterns in a large tertiary hospital in Shanghai, China. De-identified outpatient and emergency department pharmacy records containing antimicrobials were extracted from the hospital electronic health records system. Antimicrobial prescribing patterns and out-of-pocket medical costs for antimicrobials were evaluated by patient demographics and the primary diagnosis. Antimicrobial prescriptions stratified by patient age group (<5, 5-17, 18-49, 50-64 and ≥65 years) were also examined. A total of 363 642 antimicrobial prescriptions in 2014 were obtained, corresponding to 197 781 unique patients. Approximately 18% of antimicrobial-containing prescriptions were for acute upper respiratory infection and bronchitis, 15% for fever or cough, 5% for gastritis and duodenitis and non-infective gastroenteritis and colitis, and 7% for other diagnoses without clear indications of bacterial infection. Cephalosporins were the most frequently prescribed antibiotic class (55%). Age-specific antimicrobial prescriptions showed different patterns between children and adults. A total of US$4.6 million were spent as out-of-pocket costs on antimicrobials in 2014, and the median antimicrobial cost per prescription was $9. Unnecessary antibiotic use is still common in real-world clinical practice and remains a public health challenge. Antibiotic-related medical expenditure also presents an important economic burden.

Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review

The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.

Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey

We aimed to assess the current status of infectious diseases (ID), clinical microbiology (CM) and infection control (IC) staffing in hospitals and to analyse modifiers of staffing levels. We conducted an Internet-based survey of European Society of Clinical Microbiology and Infectious Diseases members and affiliates, collecting data on hospital characteristics, ID management infrastructure, ID/IC-related activities and the ratio of physicians per 100 hospital beds. Regression analyses were conducted to examine factors associated with the physician-bed ratio. Five hundred sixty-seven hospital responses were collected between April and June 2015 from 61 countries, 81.2% (384/473) from Europe. A specialized inpatient ward for ID patients was reported in 58.4% (317/543) of hospitals. Rates of antibiotic stewardship programmes (ASP) and surveillance activities in survey hospitals were high, ranging from 88% to 90% for local antibiotic guidelines and 70% to 82% for programmes monitoring hospital-acquired infections. The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13). In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device-related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). Factors independently associated with higher ratios included compliance with European Union of Medical Specialists standards, smaller hospital size, tertiary-care institution, presence of a travel clinic, beds dedicated to ID and a CM unit. More than half of respondents estimated that additional staffing is needed for appropriate IC or ID management. No standard of physician staffing for ID/CM/IC in hospitals is available. A ratio of 1.21/100 beds will serve as an informed point of reference enabling ASP and infection surveillance.

Pharmacovigilance in China: issues of concern identified through an analysis of the Chinese Adverse Drug Reaction Information Bulletin 2001 to 2014

WHAT IS KNOWN AND OBJECTIVE

The Adverse Drug Reaction Information Bulletin (ADRIB), issued by China Food and Drug Administration (CFDA), is a major source of information on drugs causing safety concerns in China. As the publication is only published in Chinese, we undertook an analysis of the reports in the ADRIB since its first publication in 2001 to give international readers a better appreciation of the pharmacovigilance issues addressed.

METHODS

Every issue of the ADRIB was scrutinized, and the issues addressed as well as the drugs involved are summarized and discussed.

RESULTS AND DISCUSSION

From 2001 to 2014, 109 items of ADR information have been reported. The antimicrobial agents were most often the subject of discussion. There were 28 traditional Chinese medicines (TCMs) discussed. Among the ADRs addressed, the adverse reactions of the skin and its appendages were most frequent. About two-fifths of the ADRs arose from the inherent properties of the active substance, and a majority of the ADRs were caused by off-label use, irrational drug combinations and misuse in special populations.

WHAT IS NEW AND CONCLUSION

Many of the pharmacovigilance issues addressed were similar to those considered by Western Drug Regulatory Agencies. The pharmacovigilance issues relating to Chinese traditional medicines are less well addressed internationally, and these would be of particular value as the use of such medicines increases in the West.

Human-use antibacterial residues in the natural environment of China: implication for ecopharmacovigilance

Antibacterial residues in the natural environment have been of increasing concern due to their impact on bacteria resistance development and toxicity to natural communities and ultimately to public health. China is a large country with high production and consumption of antibacterials for its population growth and economic development in recent years. In this article, we summarized the current situation of human-use antibacterial pollution in Chinese water (wastewaters, natural and drinking waters) and solid matrices (sludge, sediment, and soil) reported in 33 peer-reviewed papers. We found that, although there are adequate wastewater treatment systems in China, human-use antibacterial residues in the natural environment were reported almost throughout the whole country. Three most frequently prescribed classes of antibacterials in China, including quinolones, macrolides, and β-lactam, were also the predominant classes of residues in Chinese environment, manifested as the high concentration and detection frequency. In view of this alarming situation, we have presented that ecopharmacovigilance (EPV) might be implemented in the antibacterial drug administration of China, as the active participation of the pharmaceutical industry and drug regulatory authorities from the diffuse source of antibacterial pollution. Considering EPV experience of developed countries together with the actual conditions of China, we have identified some approaches that can be taken, including:• Focus on education;• Further strengthening and persevering the antibacterial stewardship strategies and pharmaceutical take-back programs in China;• Designing greener antibacterials with better degradability in the environment;• Implementing environmental risk assessment prior to launch of new drugs;• Strengthening collaboration in EPV-related areas.

The world alliance against antibiotic resistance: consensus for a declaration

Antibiotic resistance is increasing worldwide and has become a very important threat to public health. The overconsumption of antibiotics is the most important cause of this problem. We created a World Alliance Against Antibiotic Resistance (WAAAR), which now includes 720 people from 55 different countries and is supported by 145 medical societies or various groups. In June 2014, WAAAR launched a declaration against antibiotic resistance. This article describes the process and the content of this declaration.

Success stories of implementation of antimicrobial stewardship: a narrative review

It has been increasingly recognized that antimicrobial stewardship (AMS) has to be a key component of any efforts that aim to mitigate the current global antimicrobial resistance (AMR) crisis. It has also become evident that AMR is a problem that cannot be tackled by single institutions or physicians, but needs concerted actions at regional, national and supra-national levels. However, it is easy to become discouraged, given the problems that are often encountered when implementing AMS. The aim of this review is to highlight some of the success stories of AMS strategies, and to describe the actions that have been taken, the outcomes that have been obtained, and the obstacles that have been met. Although the best approach to effective AMS remains elusive and may vary significantly among settings, these diverse examples from a range of healthcare contexts demonstrate that effective AMS is possible. Such examples will inform others and encourage them to formally evaluate and share their results with the global stewardship community.