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

Inappropriate prescription of intravenous antibiotics at a tertiary children's hospital in China

BACKGROUND

Antibiotics are one of the most frequently prescribed medication classes worldwide. Inappropriate prescription of antibiotics has increased the risk of drug-resistant infections and associated mortality. The aim of this study was to examine the patterns of intravenous antibiotics prescribing in emergency and outpatient departments of a tertiary children's hospital in China.

METHODS

Data on intravenous prescriptions dispensed by the emergency and outpatient department from January 1, 2015 to May 31, 2016 were extracted from the information system of the Children's Hospital of Fudan University. Prevalence of intravenous antibiotics use and the suitability of intravenous antibiotic prescription were evaluated on the basis of a completed microbiological examination, antibiotics susceptibility testing, and dose prescribed for patients diagnosed with pneumonia, acute bronchitis, fever, and acute upper respiratory infection (AURI) patients. The prescription rate was expressed as the number of intravenous antibiotic prescriptions per total number of prescriptions.

RESULTS

Overall, 94.2% of pediatric patients and 78.5% of issued intravenous prescriptions were for antibiotics. beta-lactam antibacterial (90.5%) and macrolides (18.5%) were the most commonly used categories of antibiotics, while cefuroxime (28.8%) was the most used antibiotic. Besides, pneumonia (31.3%), acute bronchitis (14.1%), fever (6.5%), and AURI (5.5%) were the most commonly recorded infections. However, in these four diseases, the rate of conducting microbiological examination was 0.3%, 0.2%, 2.1%, and 2.8%, respectively. Approximately, 52.1%, 40.0%, 40.4%, and 30.5% of intravenous antibiotic prescriptions were inappropriately used in pneumonia, acute bronchitis, fever, and AURI, respectively. Doses higher and lower than the recommended were often for each of these four diseases.

CONCLUSIONS

The frequency of intravenous antibiotic prescription was high in pediatric emergency and outpatient departments. Inappropriate use of intravenous antibiotics commonly occurred in pneumonia, acute bronchitis, fever, and AURI. Appropriate interventions and prevention strategies need to be developed to curtail inappropriate prescribing of antibiotics.

Trends and Patterns of Antibiotic Prescriptions in Primary Care Institutions in Southwest China, 2017-2022

Purpose

To explore the prescription patterns and usage trends of antibiotics within primary care institutions located in underdeveloped regions of China from 2017 to 2022.

Methods

A retrospective analysis of antibiotic prescriptions was conducted from 25 primary care institutions in Guizhou Province during the period of 2017-2022. Antibiotic prescriptions were categorized into appropriate and inappropriate use. Appropriate use is further categorized into preferred medication, and antibiotics can be used or substituted. Inappropriate use is further categorized into unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics. Factors associated with inappropriate use were investigated using generalized estimation equations. Holt-Winters and SARIMA models were employed to predict the number of inappropriate antibiotic prescriptions as the alternative model.

Results

A total of 941,924 prescriptions were included, revealing a decreasing trend in both the number and inappropriate rates of antibiotic prescriptions from 2017 to 2022. Diseases of the respiratory system (70.66%) was the most frequent target of antibiotic use, with acute upper respiratory infections of multiple and unspecified sites representing 52.04% of these cases. The most commonly used antibiotics were penicillins (64.44%). Among all prescriptions, inappropriate antibiotic prescriptions reached 66.19%. Physicians aged over 35, holding the title of associate chief physician and possessing more than 11 years of experience were more likely to prescribe antibiotics inappropriately. The phenomenon of inappropriate antibiotic use was commoner among children aged five or younger. By comparing model parameters, it was determined that the SARIMA model outperforms the Holt-Winters model in predicting the number of inappropriate antibiotic prescriptions among primary care institutions.

Conclusion

The number and inappropriate rates of antibiotic prescriptions in southwest China exhibited a downward trend from 2017 to 2022, but inappropriate prescription remains a serious problem in primary care institutions. Therefore, future efforts should focus on strengthening physician education, training, and clinical practice. Additionally, physicians' awareness of common misconceptions about inappropriate antibiotic use must be improved, and the prescribing behavior of physicians who fulfill patients' expectations by prescribing antibiotics needs to be modified.

Characterization of consumption and costs of antimicrobials in intensive care units in a Brazilian tertiary hospital

Background

The consumption of antimicrobials and the growing resistance of infectious agents to these drugs are not related only to health issues, but also to economic parameters.

Objectives

The study objective was to evaluate the consumption of antimicrobials in General and Covid-19 Intensive Care Units (ICUs) and the impact on institutional costs in the largest institute of a tertiary public hospital.

Methods

This is a quantitative and retrospective study, which analyzed consumption, through the Defined Daily Dose (DDD), and the annual direct cost of antimicrobials in Reais (R$) and Dollars (US$), from January to December 2021.

Results

The total annual consumption (DDD/1000 patient-day) of antimicrobials in the ICUs was 14,368.85. β-Lactams had the highest total annual value, with a DDD/1000 patient-day of 7062.98, being meropenem the antimicrobial that reached the highest consumption (3107.20), followed by vancomycin (2322.6). Total consumption was higher in Covid-19 ICUs than in General ICUs, and the annual direct cost of antimicrobials in ICUs was US$560,680.79.

Conclusions

The study showed high consumption of broad-spectrum antimicrobials, highlighting the importance of structuring programs to manage the use of antimicrobials, both to reduce antimicrobial consumption and hospital costs, consolidating rational use even in pandemic scenarios.

Development and Application of a Reference Manual for Diagnosis and Rational Use of Antimicrobial Agents for Outpatient Primary Care (Digestive System Part): A Delphi Study

Purpose

To establish a concise and easy-to-understand reference manual for outpatient primary care providers, promoting correct diagnosis of digestive system diseases and rational antimicrobial use.

Methods

The establishment of the manual encompassed two processes: the development of a draft manual and the validation of the manual. The development process was based on a literature review and expert discussion. The manual comprises portions for disease diagnosis and rationality of antimicrobial use. The validation process employed a two-round Delphi technique, collecting consensus through paper-based or mail-based communications. The response of the Delphi group was assessed by the level of authority and commitment of the panelists and the degree of agreement among them. Furthermore, the manual was preliminarily applied among primary care physicians.

Results

A total of 29 panelists completed the Delphi working process. They were authoritative in their professional fields with authority coefficients of 0.813 and 0.818 for the two portions of the manual, respectively. The level of commitment of the panelists was measured by response rates, which were 100.00% and 96.67% for Round 1 and 2. After two rounds, a consensus was achieved with the consensus rates for the two portions of the manual being greater than 65% and 70%, respectively. Kendall W-tests had P-values < 0.001 in both rounds. This reference manual provides 200 diagnostic indicators for 29 common digestive diseases and recommendations for the rational use of antimicrobial agents for 13 categories of digestive diseases. The primary care physicians who used the reference manual reported high satisfaction and frequent usage.

Conclusion

Based on a collective consensus of professionals, a reference manual has been established, to provide a concise and easy-to-understand guide specifically for physicians and pharmacists in outpatient primary care. It could facilitate rapid learning to improve the accuracy of diagnosis and treatment for digestive disorders.

Seasonal distribution and dynamic evolution of antibiotics and evaluation of their resistance selection potential and ecotoxicological risk at a wastewater treatment plant in Jinan, China

The seasonal distribution and dynamic evolution of antibiotics in wastewater from main treatment areas and in sludge and their resistance selection potential and ecotoxicological risk were studied at a municipal wastewater treatment plant in Jinan, East China. Ten antibiotics were selected, and all were detected in wastewater and sludge samples, with fluoroquinolones showing the highest detection concentrations and frequencies. Seasonal fluctuations in the antibiotic concentrations in the influent, effluent, and sludge were observed, with the highest values in winter in most cases. The dynamic evolution of antibiotics during the treatment process differed among the seasons. The antibiotic removal efficiencies were incomplete, ranging from - 40.47 to 100%. Mass balance analysis showed that sulfonamides, roxithromycin, and metronidazole were mainly removed through biological processing, whereas fluoroquinolones, doxycycline, and chloramphenicol were removed through sludge adsorption. Levofloxacin, as well as a mixture of the 10 antibiotics from the effluent, could pose a low ecotoxicological risk to Daphnia in the receiving waters. Additionally, levofloxacin and ciprofloxacin in the effluent and ciprofloxacin and metronidazole in the sludge may facilitate the selection of antibiotic-resistant bacteria in the environment.

Taste Perceptions of Common Pediatric Antibiotic Suspensions and Associated Prescribing Patterns in Medical Residents

OBJECTIVE

Palatability of medication is an important factor for adherence, especially in pediatric populations that tend to use oral suspensions for antibiotic therapy. Our study is the first to evaluate the impact of taste on prescribing patterns of antibiotic suspensions. The objective was to determine if taste testing common antibiotic suspensions altered prescribing patterns of medical residents, through data extracted from the electronic health record.

METHODS

After assessing 5 “primer” tastes (sweet, salty, bitter, sour, umami [savory]), residents were randomized to sample 6 antibiotic suspensions to rate their taste perception. A 12-month retrospective and prospective analysis of outpatient prescribing practices of the residents followed, and the results were compared to the resident cohort randomized to no taste test.

RESULTS

The 43 residents prescribed 207 liquid antibiotic prescriptions for 176 patients, with no difference in patient characteristics between residents in the taste test versus non–taste test group. Although amoxicillin was most preferable and amoxicillin-clavulanate least, the only significant finding was a greater prescribing rate of cefdinir among those who had tasted it and an inverse relationship between cephalexin taste preference and percentage prescribing amoxicillin in the taste group. Residents who tasted were poor in identifying primer tastes, but this did not impact prescribing patterns.

CONCLUSIONS

Among 6 commonly prescribed antibiotic suspensions, amoxicillin remains a highly preferred taste among prescribers. Interestingly, after the taste test there was a significantly greater prescribing rate of cefdinir among those who had tasted it and somewhat lower prescribing rate for amoxicillin-clavulanate.

Delirium associated with the use of macrolide antibiotics: a review

OBJECTIVE

This review aimed to explore and summarise available cases of delirium suspected to be associated with the use of macrolide antibiotics reported in the literature and the United States Food and Drug Administration's Adverse Event Reporting System (FAERS) database.

METHODS

Electronic searches of the literature were conducted in four online databases: PubMed/MEDLINE, Scopus, Web of Science and Serbian Citation Index (SCIndeks). A search of FAERS database was also conducted to supplement the findings of the literature search. Descriptive statistics, narrative summation and tabulation of the extracted data were made.

RESULTS

Cases of delirium which satisfied inclusion criteria were found for clarithromycin, azithromycin, erythromycin and telithromycin. Delirium was described in patients of various age groups, including children. Drug-drug interactions may have contributed to its occurrence in some of the cases. Average time to onset of delirium was 2.5 days for azithromycin and 3.3 days for clarithromycin.

CONCLUSIONS

Considering that these drugs may be a possible cause of delirium, clinicians should be aware that timely recognition of this possible side effect can lead to earlier discontinuation of the culprit drug, reduce time spent in a delirious state and improve patients' outcomes.KEY POINTSCases of delirium which satisfied inclusion criteria were found for clarithromycin, azithromycin, erythromycin and telithromycin.Cases of delirium were described in patients of various age groups, including children.Drug-drug interactions may have contributed to the occurrence of delirium in some of the cases.Time to onset of delirium ranged from 2 to 3.5 days (mean: 2.5 days) for azithromycin and from 1 to 7 days (mean: 3.3 days) for clarithromycin.Cessation of the macrolide antibiotic seems to be the best management strategy, although some of the patients may, in addition, require antipsychotics.

Association of sarcopenia with a higher risk of infection in patients with type 2 diabetes

AIMS

This study aimed to determine whether patients with type 2 diabetes and sarcopenia had a higher risk of infection.

STUDY DESIGNS

A cross-sectional study and a follow-up study were performed.

METHOD

A total of 2562 patients were enrolled and assessed for body composition and infection status. They were classified into four groups according to body fat (BF) and muscle mass index (ASMI): obese, sarcopenic, sarcopenic obese, and normal. Among these, 275 patients were followed for a median follow-up period of 1.84 years to evaluate the relationship of changes in skeletal muscle with infection status.

RESULTS

The sarcopenic and sarcopenic obese groups showed a higher risk of infection, an increase by 49.6% (OR = 1.496, 95% CI 1.102-2.031) and 42.4% (OR = 1.424, 95% CI 1.031-1.967) compared with the normal group, and also had a higher risk of respiratory infection, an increase by 56.0% (OR = 1.560, 95% CI 1.084-2.246) and 57.4% (OR = 1.574, 95% CI 1.080-2.293), respectively. Patients with the increased ASMI (OR = 0.079, 95% CI 0.021-0.298) represented a lower risk of infection than those with the decreased ASMI. Even a minor change (OR = 0.125, 95% CI 0.041-0.378) against age was beneficial to lowering the risk of infection. However, no association was found in the changes of body mass index and BF with infection status.

CONCLUSIONS

Sarcopenia, especially in patients with diabetes who are also obese, increases the risk of infection. Maintaining or improving muscle mass is expected to reduce infections.

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.

Management of hospitalized influenza A patients during the season 2018/19 : Comparison of three medical departments and the effect on outcome and antibiotic usage

BACKGROUND

Diagnosis and treatment of influenza patients are often provided across several medical specialties. We compared patient outcomes at an infectious diseases (ID), a rheumatology (Rheu) and a pulmonology (Pul) department.

MATERIAL AND METHODS

In this prospective observational multicenter study we included all influenza positive adults who were hospitalized and treated at flu isolation wards in three hospitals in Vienna during the season 2018/2019.

RESULTS

A total of 490 patients (49% female) with a median age of 73 years (interquartile range [IQR] 61-82) were included. No differences regarding age, sex and most underlying diseases were present at admission. Frequencies of the most common complications differed: acute kidney failure (ID 12.7%, Rheu 21.2%, Pulm 37.1%, p < 0.001), acute heart failure (ID 4.3%, Rheu 17.1%, Pulm 14.4%, p < 0.001) and respiratory insufficiency (ID 45.1%, Rheu 41.5%, Pulm 56.3%, p = 0.030). Oseltamivir prescription was lowest at the pulmonology flu ward (ID 79.6%, Rheu 90.5%, Pulm 61.7%, p < 0.001). In total 176 patients (35.9%) developed pneumonia. Antibiotic selection varied between the departments: amoxicillin/clavulanic acid (ID 28.9%, Rheu 63.8%, Pulm 5.9%, p < 0.001), cefuroxime (ID 28.9%, Rheu 1.3%, Pulm 0%, p < 0.001), 3rd generation cephalosporins (ID 4.4%, Rheu 5%, Pulm 72.5%, p < 0.001), doxycycline (ID 17.8%, Rheu 0%, Pulm 0%, p < 0.001). The median length of stay was significantly different between wards: ID 6 days (IQR 5-8), Rheu 6 days (IQR 5-7) and Pulm 7 days (IQR 5-9.5, p = 0.034). In-hospital mortality was 4.3% and did not differ between specialties.

CONCLUSION

We detected differences in oseltamivir usage, length of in-hospital stay and antibiotic choices for pneumonia. Influenza-associated mortality was unaffected by specialty.

Patterns of antibiotic prescribing and appropriateness for respiratory tract infections in a teaching hospital in Jordan

BACKGROUND

Inappropriate use of antibiotics is a public health concern that promotes antibiotic resistance globally. This study aimed to investigate the patterns of antibiotic prescribing for respiratory tract infections (RTIs) in Jordan to encourage judicious antibiotic prescribing.

METHODS

The researchers conducted a retrospective secondary analysis of oral antibiotics prescribed in the family medicine clinics in a teaching university hospital in Jordan in 2017. Antibiotic prescribing rates and the types of antibiotics prescribed were analysed. Patients' age, gender, type of insurance, and the RTIs diagnosis were investigated as possible factors that could be associated with inappropriate antibiotic prescribing for RTIs.

RESULTS

Our findings revealed that 20 133 prescriptions, (27.3%) of all the prescriptions issued in the family medicine clinics included an antibiotic. Penicillins accounted for 52.7% of all the antibiotics prescribed, followed by macrolides (21.6%) and cephalosporins (16.4%). The most common indication for prescribing the antibiotics was RTIs (51.1%). The majority of antibiotics prescribed for respiratory diagnosis were for upper RTIs (URTI) (61.5%), followed by otitis media (16.9%) and tonsillitis (15.4%). Only 28.8% of all the antibiotics prescribed were appropriate and indicated. Older patients were significantly more likely to be prescribed an antibiotic compared to the younger (P < .001). Also, hospital employees and university employees were significantly more likely to be prescribed an antibiotic compared to the Ministry of Health employees (P < .001).

CONCLUSIONS

Antibiotics were inappropriately prescribed, and their prescribing rate was high in the outpatient setting in the family medicine clinics studied in Jordan. This calls for policy-level interventions to promote judicious antibiotic prescribing to minimise the avoidable burden of microbial resistance and unnecessary expenditure.

Characteristics of prescriptions and costs for acute upper respiratory tract infections in Chinese outpatient pediatric patients: a nationwide cross-sectional study

BACKGROUND

To understand the characteristics of prescriptions and costs in pediatric patients with acute upper respiratory infections (AURI) is important for the regulation of outpatient care and reimbursement policy. This study aims to provide evidence on these issues that was in short supply.

METHODS

We conducted a retrospective cross-sectional study based on data from National Engineering Laboratory of Application Technology in Medical Big Data. All outpatient pediatric patients aged 0-14 years with an uncomplicated AURI from 1 January 2015 to 31 December 2017 in 138 hospitals across the country were included. We reported characteristics of patients, the average number of medications prescribed per encounter, the categories of medication used and their percentages, the cost per visit and prescription costs of drugs. For these measurements, discrepancies among diverse groups of age, regions, insurance types, and AURI categories were compared. Kruskal-Wallis nonparametric test and Student-Newman-Keuls test were performed to identify differences among subgroups. A multinomial logistic regression was conducted to examine the independent effects of those factors on the prescribing behavior.

RESULTS

A total of 1,002,687 clinical records with 2,682,118 prescriptions were collected and analyzed. The average number of drugs prescribed per encounter was 2.8. The most frequently prescribed medication was Chinese traditional patent medicines (CTPM) (36.5% of overall prescriptions) followed by antibiotics (18.1%). It showed a preference of CPTM over conventional medicines. The median cost per visit was 17.91 USD. The median drug cost per visit was 13.84 USD. The expenditures of antibiotics and CTPM per visit (6.05 USD and 5.87 USD) were among the three highest categories of drugs. The percentage of out-of-pocket patients reached 65.9%. Disparities were showed among subgroups of different ages, regions, and insurance types.

CONCLUSIONS

The high volume of CPTM usage is the typical feature in outpatient care of AURI pediatric patients in China. The rational and cost-effective use of CPTM and antibiotics still faces challenges. The reimbursement for child AURI cases needs to be enhanced.

The Effects of County Public Hospital Reform on the Consumption and Costs of Antibiotics: Evidence from a Quasinatural Experiment in Jiangsu, China

Background

Overuse of antibiotics is a major driver for rapid spread of antimicrobial resistance worldwide, particularly common in China. The close linkage between hospital revenue and sales of drugs has become the key incentive for overprescription of antibiotics. Since 2009, the Chinese government implemented a series of measures to cut off the link, including removing the markup of drugs, increasing financial subsidies, and adjusting charges for medical service.

Objective

To evaluate the impacts of county public hospital reform on the consumption and costs of procured antibiotics in Jiangsu province.

Methods

A quasiexperiment design was conducted in Jiangsu province where 99 county public hospitals implemented the reform successively in different periods. Of these, 37 county public hospitals implemented the reform since January 2013, which were regarded as the intervention group, and the remaining 62 hospitals were included in the control group. A difference-in-differences (DID) analysis with generalized linear regressions was used on the procurement records of antibiotics from January 2012 to December 2013. Modified Park test was used for family distribution and Box–Cox test for log link. Placebo tests were employed to test the common-trend hypothesis of two groups.

Results

For the intervention group, the average volume of procured restricted antibiotics and injectable antibiotics increased by 24.12% and 2.75% while the costs increased by 19.01% and 9.09%, respectively. The average costs per DDD of restricted and injectable antibiotics were much higher than unrestricted and oral antibiotics. The DID results showed that the reform had a positive impact on the average volume (p = 0.005) and costs (p = 0.001) of nonrestricted antibiotics. In addition, the implementation of the reform was associated with a reduction in volume (p = 0.031) and costs (p = 0.043) of procured oral antibiotics. The reform also contributed to an increase in average costs per DDD of total antibiotics (p = 0.049).

Conclusions

The reform is effective in reducing the consumption and costs of unrestricted and oral antibiotics, but it has failed to reduce the consumption and costs of expensive restricted and injectable antibiotics, leading to increased burden of diseases. It is critical that the health policy initiatives can deincentivize overuse of antibiotics at both hospital and individual physician's levels. The reform should enforce government financial support, improve hospital governance, optimize performance evaluation, and establish specialized management approach for antibiotic use.

Antibiotic use among hospitalized adult patients in a setting with limited laboratory infrastructure in Freetown Sierra Leone, 2017-2018

OBJECTIVES

Our study aimed to assess antibiotic use in adult inpatients in the context of limited laboratory services at the main tertiary hospital in Sierra Leone.

DESIGN

A cross-sectional study of consecutive adult inpatients (≥18 years) between October 2017 and February 2018 at Connaught Hospital in Freetown.

RESULTS

A total of 920 patients were interviewed, of which 753 (81.8%) had at least one antibiotic. Complete data was captured for 688 (91.0%) patients. The median age was 41 years and 52.8% were male. Fever was reported in 41.5% of patients, though 85.1% had no leukocyte count prior to antibiotic use and none had a bacterial culture. Indications for prescribing were surgical prophylaxis (15.7%), pneumonia (15.1%), and trauma (5.8%). Cephalosporins (25.9%), penicillins (23.2%), and imidazoles (20.8%) were commonly prescribed.

CONCLUSION

We found high rates of antibiotic use, of which most was not based on laboratory evidence. Lack of oversight and microbiological support are drivers of poor prescribing in many developing countries, which lack financial resources and serve a sicker population. Greater investments are needed to establish antimicrobial stewardship programs and provide clinicians with diagnostic support to enable improvements in patient outcomes and curb the spread of antibiotic resistance.

Clinical pattern of antibiotic overuse and misuse in primary healthcare hospitals in the southwest of China

Purpose

Overuse and misuse of antibiotics are the primary risk factors for antibiotics resistance. Inadequate professional competence of primary care physicians might exacerbate these problems in China. This retrospective study aims to document the clinical pattern of antibiotics use and its overuse and misuse rates in rural primary care institutions and to evaluate the association between antibiotics use and characteristics of physicians and their patients.

Methods

Medical records from 16 primary care hospitals in rural areas of Guizhou province, China were obtained from the Health Information System in 2018. Classification of unnecessary use, incorrect spectrum of antibiotic, escalated use of extended spectrum and combined antibiotics use was based on the Guiding Principle of Clinical Use of Antibiotics (2015, China) and guidelines from the US Centers for Disease Control and Prevention. Generalized Estimating Equations were employed to determine predictive factors for inappropriate antibiotics use.

Results

A total of 74,648 antibiotics prescriptions were retrieved. Uncomplicated respiratory infection was the most common disease accounting for 58.6% of all prescriptions. The main antibiotic group used was penicillins (51.5%) followed by cephalosporins and macrolides (14% each). Of 57,009 patient visits, only 8.7% of the antibiotic prescriptions were appropriate. Combined use, escalated use of extended spectrum antibiotics, incorrect spectrum and unnecessary antibiotics use was found in 7.8%, 1.9%, 4.3% and 77.3% of patient visits, respectively, of which 28.7% were given intravenously. Antibiotics misuse was significantly more likely among newly employed physicians with lower levels of professional education. Adult patients and those who had public insurance had a higher risk of being prescribed unnecessary antibiotics.

Conclusion

Overuse of antibiotics for uncomplicated respiratory infection and use of cephalosporins, macrolides and injection antibiotics in primary care are the major problems of clinical practice in rural areas of Guizhou.

The impact of the national action plan on the epidemiology of antibiotic resistance among 352,238 isolates in a teaching hospital in China from 2015 to 2018

Background

We sought to understand the epidemiology and characteristics of antimicrobial resistance (AMR) and the impact of the National Action Plan (NAP) on AMR. This information will be critical to develop interventions and strengthen antibiotic stewardship in hospital settings in China.

Methods

Cross-sectional data collection from the hospital information management system from 1 January 2015 to 30 August 2018. Variables included patient age, sex, diagnosis, hospital department and antibiotic sensitivity test. T-test for two samples method was applied to compare the results before and after NAP implementation. Multivariate analysis with binary logistic regression was conducted to examine the associations of risk factors for antimicrobial resistance.

Results

In total there were 352,238 isolates in the final analysis after excluding contamination strains and isolates with incomplete information. More than 50% of patients were > 66 years old. 62% were male. 40% of the total samples were sputum. Among the total sample, the total resistance rate was 42% among all isolates. The rate of resistance to all antibiotics declined by 5.3% (95% CI 4.96-5.64%, p < 0.0001) and culture positivity rate declined by 9.8% (95% CI 9.22-10.34%, p < 0.0001) after NAP. Logistical regression showed that the NAP had effect with an adjusted odds ratio of 0.76 (95% CI 0.71-0.81, p = 0.002). Being male, age > 65 years, ICU department, diagnosed with certain diseases were more likely to be associated with antimicrobial resistance.

Conclusions

Antibiotic resistance rates were high in this teaching hospital. However, the introduction of the China NAP since 2016 followed by hospital policy emphasis was associated with a declining AMR trend. Policies will need to incorporate antimicrobial stewardship with a focus on certain departments, with infection control practices and with increases in vaccination coverage among elderly.

Exposure of Adults to Antibiotics in a Shanghai Suburban Area and Health Risk Assessment: A Biomonitoring-Based Study

An extensive exposure to antibiotics has been demonstrated in children and pregnant women by biomonitoring, but data from general adults remain limited. In the current study, we studied 822 adults aged 21-75 years in Shanghai in 2017 and analyzed 18 common antibiotics (five veterinary antibiotics (VAs), four human antibiotics (HAs), and nine human/veterinary antibiotics (H/VAs)) in spot urine by liquid chromatography coupled to high-resolution mass spectrometry. All 18 antibiotics were detected in urine with an overall detection frequency of 45.9% and the detection frequency for each ranged from 0.1% to 15.2%. HAs, VAs, H/VAs, and VAs+H/VAs were detected in 4.4%, 11.6%, 38.0, and 44.5% of urine samples, respectively. Adults with the sum of estimated daily exposure dose of all the antibiotics below 1.55 μg/kg/day accounted for 89.1% of adults tested positive. A hazard index value beyond one was seen in 7.2% of adults based on microbiological effect. Ciprofloxacin was the biggest contributor to HI and its hazard quotient value more than one was seen in 5.6% of adults. These findings indicated an extensive exposure to low-dose multiple antibiotics in adults in Shanghai and some adults were at health risk related to the disturbance of gut microbiota.

Antibiotic Expenditure by Public Healthcare Institutions in Shandong Province in China, 2012-2016

Background: Overuse of antibiotics may not only increase the burden of antimicrobial resistance, but also accelerate the growth of healthcare expenditures. China has issued a series of policies to improve antibiotic use and reduce the cost of medicine in healthcare institutions. This study aimed to evaluate the trends of antibiotic expenditure in public healthcare institutions in Shandong from 2012 to 2016 and to assess antibiotic expenditure by drug class and the level of healthcare institutions.

Methods: We collected data from the centralized bidding procurement (CBP) system in Shandong province between 2012 and 2016. Governmental health facilities including secondary and tertiary hospitals, and urban and rural primary healthcare centers (PHCs) procured antibiotics via this system. Antibiotics were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. Antibiotic expenditure was assessed using total annual expenditure (US dollars) and expenditure per person per year (US dollars).

Results: The overall antibiotic expenditure was $717 million in 2016, a 56% increase compared to 2012. Parenteral antibiotics accounted for 84% of the total antibiotic expenditure in 2016. Most of the antibiotics were procured by secondary and tertiary hospitals (33 and 44%, respectively). The expenditures continuously increased in secondary hospitals, tertiary hospitals, and urban PHCs from 2012 to 2016, while antibiotic procurement decreased in urban PHCs since 2015. The third-generation cephalosporins (J01DD) were among the top five ATC classes of antibiotics in all healthcare institutions. Fluoroquinolones (J01MA) were commonly procured by tertiary hospitals, rural and urban PHCs. The expenditure on carbapenems (J01DH) raised sharply in tertiary hospitals.

Conclusions: The overall antibiotic expenditure kept increasing in the public healthcare institutions in Shandong. The trends of increasing expenditure began to decline in 2016, which may be associated with antibiotic stewardship initiatives. The expenditure for expensive and critical important classes of antibiotics increased, therefore it is of importance to develop policies on improving the rational use of antibiotics.

Predictors of urinary antibiotics in children of Shanghai and health risk assessment

BACKGROUND

An extensive exposure to antibiotics has been confirmed in children, but the predictors and potential health risk remain unclear.

OBJECTIVE

To investigate the predictors of antibiotics in urine and potential health risk in children of Shanghai.

METHODS

We selected 284 school children aged 8-11 years from a central area of Shanghai, China, in 2017. Ultra-performance liquid chromatography coupled with high-resolution mass spectrometry was used to measure 20 antibiotics, including four human antibiotics (HAs), six veterinary antibiotics (VAs), 10 human/veterinary antibiotics (H/VAs), and three metabolites in first morning urine. Logistic regression model was used to examine the associations of 17 variables related to demographic and socioeconomic factors, recent antibiotic use, drinking water intake, food consumption, and anthropometric measurements with the detection frequency of HAs, VAs, or H/VAs in urine. After daily intake was estimated, health risk was assessed for VAs and H/VAs by using hazard quotient (HQ) and hazard index (HI) based on microbiological or toxicological effects.

RESULTS

The detection frequencies of 20 antibiotics and three metabolites ranged from 0 to 27.8% with an overall detection frequency being 56.0%. The detection frequency of HAs increased with age and screen time at weekend. Sex, age, family income and screen time were positively associated with the detection frequencies of VAs and H/VAs. Children reporting antibiotic use in the past three months had a higher detection frequency of HAs. Children with a higher consumption frequency of dairy products had a higher detection frequency of VAs + H/VAs, but a lower detection frequency of HAs. An increased overall detection frequency of all antibiotics was seen in children with higher consumption frequencies of aquatic products, livestock and poultry meat, or milk and dairy products. HQ >1 was only found for ciprofloxacin (5.6%) and ofloxacin (0.4%) based on microbiological effect. HI >1 was found in 6.0% of children for microbiological effect and none was found for toxicological effect.

CONCLUSIONS

Predictors for antibiotics in urine for children included sex, age, family income, screen time, clinical use, and animal-derived food consumption. There was potential health risk for children with exposure to antibiotics.

Multi-level analysis of bacteria isolated from inpatients in respiratory departments in China

Background

With the different situation for clinical antibiotic usage and its management in different regions and medical institutions, the antimicrobial resistance varied in different level. However, the epidemiological data of multi-drug resistant (MDR) strains from the department of respiration is limited. Thus, this study aims to investigate the epidemiology of bacteria isolated from inpatients of respiratory departments, and analyze the distribution variation of major multi-drug resistant bacteria in China.

Methods

Based on data from China Antimicrobial Resistance Surveillance System (CARSS) in 2015, 50,417 non-duplicate isolates obtained from inpatients of respiratory departments from 91 general hospitals in seven regions of China were enrolled in the study. The distribution of methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Escherichia coli (CREC) and Klebsiella pneumoniae (CRKP), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and Acinetobacter baumannii (CRAB), extended-spectrum β-lactamases-producing E. coli (ESBL-EC) and K. pneumoniae (ESBL-KP), were further analyzed by geographic regions, age groups, wards and specimen types.

Results

The major specimens type were sputum (81.6%, 41,131/50,417), followed by blood (5.3%, 2,649/50,417), urine (4.5%, 2,249/50,417) and bronchoalveolar lavage fluid (BALF) (3.2%, 1,620/50,417). The top four bacteria species isolated from sputum and BALF were similar: K. pneumonia (18.9% and 14.8%, respectively), P. aeruginosa (13.6% and 22.2%, respectively), A. baumannii (11.3% and 11.9%, respectively) and S. pneumonia (11.1% and 9.6%, respectively). The four most common bacteria species were K. pneumonia (17.2%), P. aeruginosa (12.1%), A. baumannii (10.4%) and S. pneumonia (10.1%) in tertiary hospitals but K. pneumonia (20.8%), P. aeruginosa (16.3%), E. coli (11.3%) and A. baumannii (6.9%) in secondary hospitals. The top four bacteria species in respiratory intensive care unit (RICU) were A. baumannii (25.8%), P. aeruginosa (13.1%), K. pneumonia (12.2%) and S. aureus (9.2%). The prevalence of CRKP, CRPA and CRAB in tertiary hospitals was significantly higher than that in secondary hospitals (5.2% vs. 2.5%, 23.8% vs. 12.8% and 53.5% vs. 33.9%, respectively) (all P<0.05). However, the prevalence of ESBL-EC in secondary hospitals was higher than in tertiary ones (63.9% vs. 55.0%, P=0.011). The prevalence of MRSA, CRKP, CRAB, CRPA, ESBL-EC, ESBL-KP in RICU were higher than that in non-ICU respiratory departments (76.5% vs. 35.7%, 20.1% vs. 4.1%, 90.6% vs. 45.5%, 64.2% vs. 19.3%, 47.2% vs. 28.3% and 43.0% vs. 11.2%, respectively) (all P<0.01). Among seven regions in China, central area had the highest detection rates of MRSA (70.3%, 237/337), CRPA (30.9%, 376/1,218), CRAB (71.8%, 487/678) and ESBL-KP (38.8%, 241/621). The prevalence of ESBL-EC and ESBL-KP in pediatric group (68.2% and 55.3%, respectively) was higher than that in geriatric group (54.2% and 27.1%, respectively) and adult group (51.1% and 15.1%, respectively) (all P<0.001).

Conclusions

In China, the predominant bacterial pathogens in the respiratory ward were Enterobacteriaceae and non-fermentative bacteria. High prevalence of ESBL-EC and ESBL-KP isolated from lower respiratory tract (LRT) was revealed in primary hospitals and pediatric patients.