Determinants of non-prescription antibiotic dispensing in Chinese community pharmacies from socio-ecological and health system perspectives

The prevalence of self-medication and its associated factors among college students: Cross-sectional study from Saudi Arabia

Background

Self-medication with OTC or prescription drugs is widespread, may impair health, and leads to microbial resistance. Self-medication treats symptoms without a prescription. Self-medication is common among students across disciplines. Thus, this study evaluates medical and non-medical students' self-medication prevalence, knowledge, and variables.

Methods

352 people completed a verified 25-item online questionnaire from September 5 to November 17, 2021. Self-medication and demographic characteristics such as gender, professional college, and family income were examined using a chi-square test of independence.

Results

210 (59.6 %) participants were from the College of Medicine, and 142 (40.34 %) were from other professional health colleges. Health professional students self-medicated 55.9 %. This research found substantial connections between self-medication knowledge, gender, and family income. With a p-value of 0.0001, 32 % of women agreed that self-medication is safe, compared to 15.8 % of men. Female students were more likely than boys (61.9 % vs 38.1 %, p-value = 0.0291) to self-medicate as their initial therapy. Family income was also related to self-medication; 69.6 % of low-income pupils self-medicated to reduce doctor visits, p-value = 0.0477.

Conclusion

Students of all majors self-medicate. Medical students were more informed about generic drug safety and administration. There were substantial unfavorable sentiments regarding self-medication, highlighting the need for educational health activities to raise student understanding of its risks.

Assessment of the operation status of electronic prescription at community pharmacies in Chengdu, China: a simulated patient study

BACKGROUND

Information and technologies relevant to eHealth have developed rapidly over the past two decades. Based on this, China piloted "Internet + " pattern and some regions piloted electronic prescription services to explore telepharmacy services.

OBJECTIVE

To describe the processes and assess the operation status of electronic prescription services mode for community pharmacies in China.

METHODS

The simulated patient methodology was used to conduct a cross-sectional study in 317 community pharmacies from six districts in Chengdu, China in 2019. Simulated patients expressed three levels of service demands based on scenario about acute upper respiratory tract infections to evaluate the recommendation strength of electronic prescription services and telepharmacy service in community pharmacies. The descriptive statistics was completed to obtain the characteristics of the visit process, student t-test and χ2 test (P < 0.05 was considered statistically significant) were used for inferential statistical analysis to determine differences in characteristics and degree of recommendation between pharmacies.

RESULTS

Three Hundred Seventeen record sheets were effectively collected. The third-party platform was recommended in 195 (61.5%) interactions. The main reason for not recommending is non-prescription dispensing of prescription drugs (27.1%). 90.3% interactions waited less than 1 min, the counseling duration was less than 5 min in all interactions, and most community pharmacies had good network conditions (81.5%). 97.4% remote physicians offered professional counseling, only 22.1% of the pharmacists provided medication advice.

CONCLUSIONS

The electronic prescription services mode for community pharmacies in Chengdu provides a convenient drug purchase process but remains some problems. For example, prescribing drugs without a prescription and services provided by pharmacists was poor, etc. The relevant supporting policies should be improved in future development process.

The Role of Uncertainty and Negative Emotion in Chinese Parents' Self-Medication of Children with Antibiotics

Parents self-medicating their children with antibiotics (SMA) without consulting healthcare professionals is a common practice in China. Previous research has focused primarily on examining the socioeconomic factors that contribute to the prevalence of SMA. This study adopts and extends the theory of planned behavior to understand the cognitive and emotional factors that are associated with parental SMA in China. The responses to an online survey were collected from 961 parents of children aged 6-12 years old, primarily from Gansu, Shandong, and Shaanxi provinces. More than half of the participants (66.5%) engaged in parental SMA. Amoxicillin, Cephradine, and Azithromycin were the most frequently selected antibiotics used for children. Structural equation modeling showed that uncertainty was positively associated with negative emotions, which were in turn positively associated with attitude toward SMA. Uncertainty was also negatively associated with perceived behavioral control (PBC), but the association between PBC and SMA behavior was not significant. Attitude and subjective norm were both positively associated with SMA behavior. The relationship between subjective norm and attitude was also positive. Understanding the psychological factors driving parental SMA may inform tailored interventions to promote responsible antibiotic use among parents.

"Handing out non-prescribed antibiotics is storing up trouble for the next generation!" Unpacking multistakeholder views of drivers and potential solutions in Ethiopia

BACKGROUND

Antibiotic resistance is a global health crisis, with inappropriate antibiotic use often being linked to non-prescribed antibiotic dispensing practices. This study aimed to examine the perspectives of multiple stakeholders on the drivers and potential solutions for non-prescribed antibiotic dispensing in Ethiopian community drug retail outlets (CDROs). Despite the prescription only use policies, the practice remains prevalent in Ethiopia. Many factors are thought to contribute to this issue, although little research is available for non-urban settings.

METHODS

A phenomenological qualitative study was conducted. Pharmacy professionals (owners or employees) working in non-urban towns CDROs were selected through a simulated client study, which identified CDROs that had dispensed antibiotics without a prescription. Some high-level decision makers in the Ethiopian health system were also purposively selected. Interviews were conducted in-person and over the phone or via Zoom. The interview data were transcribed verbatim, translated to English, and thematically analysed. NVivo 12 software was used to assist with coding.

RESULTS

CDRO pharmacy professionals (n = 18) and five decision makers were interviewed. Most professionals (61%) were pharmacists working in drug stores, with one to 11 years of work experience. Several contributing factors were identified at the level of patients, CDRO staff, and the healthcare system. These included economic interests, inadequate knowledge and inappropriate attitudes about antibiotic use or supply, and issues within the healthcare system included inaccessibility and insufficient capacity, absence of or a weak enforcement of prescription-only regulations or service supervision. Additionally, patient-related factors included a lack of knowledge and inappropriate attitudes about antibiotics use and their supply, previous successful treatment experience and a culture of seeking out antibiotics.

CONCLUSIONS

A complex set of modifiable factors related to patients, CDRO staff and healthcare system were identified that contribute to the non-prescribed supply of antibiotics. Due to this complexity, a single solution will not resolve the issues. Therefore, a range of multifaceted solutions have been suggested, including stricter regulation, increasing availability and accessibility of healthcare services, collaboration, and local consensus-building among CDROs, regular training for CDRO staff, and using community social events to educate the public about responsible use of antibiotics.

Practice of pharmaceutical services and prescription analysis in internet-based psychiatric hospitals during COVID-19 pandemic in Wuxi, China

Objective

To study the practice of pharmaceutical services in internet-based psychiatric hospitals, and to analyze the prescriptions to ensure the safety and efficacy of internet-based medication in Wuxi, China.

Methods

All 1,259 internet-based prescriptions from our hospital in 2022 were collected, and data on patients' age, gender, diagnosis, medications used, medication types, dosage forms, rationality of medication use, and reasons for irrationality were analyzed through descriptive statistics.

Results

In the electronic prescriptions of internet-based psychiatric hospitals, females accounted for the majority (64.50%), with a female-to-male ratio of 1.82:1. Middle-aged and young adults accounted for the majority of patients (57.50%). There were 47 diagnosed diseases involved, with 89 types of medications used and 1,938prescriptions issued. Among them, there were 78 types of western medicine with 1,876 prescriptions (96.80%), and 11 types of traditional Chinese medicine with 62 prescriptions (3.20%). The main medications used were anti-anxiety and antidepressant medications (44.94%) and psychiatric medications (42.21%). The dosage forms were all oral, with tablets (78.53%), capsules (17.54%), and solution preparations (2.17%) being the top three in frequency. According to the prescription review results, the initial pass rate of internet-based system review was 64.26%. After intervention by the internet-based system and manual review by pharmacist reviewers, the final pass rate of internet-based prescriptions reached 99.76%.

Conclusion

The practice of pharmaceutical services and prescription analysis in internet-based psychiatric hospitals could significantly improve medication rationality, which fills the research gap in this field. In addition, it promotes the transformation of pharmaceutical service models.

A cross-sectional study on substandard and falsified medicines (fake or counterfeit drugs) in UK pharmacies during the COVID-19 pandemic

BACKGROUND

Failure of the Falsified Medicines Directive (FMD) in the UK could mean that substandard and falsified medicines (SFs) enter the supply chain. Does this risk patients' health? Readiness to implement FMD, and prevalence of SFs vs. regulator detection were assessed.

RESEARCH DESIGN AND METHODS

A total of 12,040 primary care pharmacies across England were invited (April 2021-March 2022). Respondent postcodes were used to extract deprivation scores. Information request was placed with the medicine's agency. Survey findings were used to calculate probability and power of a simulated trial.

RESULTS

A total of 208 participants responded: Of the seven who identified SFs, all but one reported it; 61% were ready to implement FMD, 74.1% had adequate resources, 54.8% expected improved patient safety, and 17.8% had ever reported SFs. SFs were prevalent in deprived areas. Bayesian simulation shows 438 (p = 0.030) incidences with a 3% probability of SFs prevalence. The agency identified 15,238 SFs units in the supply chain (2019 and 2020). Results are credible, reliable, and generalisable, with corroborated longitudinal persistence.

CONCLUSIONS

FMD or equivalent processes need to be urgently reinstated. Deprived children may be more affected. Pharmacists are worried about liability. All health consultations should assess safety, and effectiveness of medicines. Findings should inform policy, systems planning, surveillance, and evaluations.

Antibiotic Culture: A History of Antibiotic Use in the Second Half of the 20th and Early 21st Century in the People’s Republic of China

Antimicrobial resistance is now widely regarded as a global public health threat. A growing number of studies suggest that antibiotic resistance is higher in China than in most western countries. Despite the current official regulation prohibiting pharmacies from the unrestricted selling of antibiotics, there is little sign of declining consumer demand. China now ranks as the second largest consumer of antibiotics in the world, after India. Drawing on published historical data, unpublished archival documents, and recently collected oral interviews, this paper provides a historical overview of antibiotic use and abuse in the People’s Republic of China (PRC) from the second half of the 20th century to the present. It demonstrates how the political demand for health improvement, along with the state-sponsored popularization of allopathic medicine, on the one hand, and the lack of access to adequate medical care for the majority of the population, as well as the existing culture of self-medication, on the other hand, are working in tandem to create antibiotic dependency in China. In addition, the privatization and marketization of biomedicine and health care in post-Mao China have helped to build a new and ever-thriving network of production, distribution, and marketing of antibiotics, which has often proven difficult for the authorities to monitor. At the same time, increased purchasing power and easier accessibility created by this new network of production, distribution, and marketing have further contributed to the prevalence of antibiotic overuse in the late 20th and early 21st centuries.

Healthcare System Distrust and Non-Prescription Antibiotic Use: A Cross-Sectional Survey of Adult Antibiotic Users

Antibiotic resistance is a major public health concern driven by antibiotic overuse. Antibiotic stewardship programs are often limited to clinical settings and do little to address non-prescription antibiotic use in community settings. This study investigates the association between non-prescription antibiotic use and healthcare system distrust in the United States and Mexico. An online survey was deployed in the United States and Mexico with enhanced sampling through in-person recruiting in the border region. Non-prescription antibiotic use was defined as having bought or borrowed non-prescription oral or injectable antibiotics within the last 3 years. The survey included a previously validated 10-item scale to measure healthcare system distrust. Logistic regression was used to model the use of non-prescription antibiotics by the level of healthcare system distrust, adjusted for demographic characteristics and antibiotic knowledge. In total, 568 survey participants were included in the analysis, 48.6% of whom had used non-prescription oral or injectable antibiotics in the last 3 years. In the fully adjusted regression model, the odds of using non-prescription antibiotics were 3.2 (95% CI: 1.8, 6.1) times higher for those in the highest distrust quartile versus the lowest. These findings underscore the importance of community-based antibiotic stewardship and suggest that these programs are particularly critical for communities with high levels of healthcare system distrust.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Investigate Non-EPI Vaccination Recommendation Practice from a Socio-Ecological Perspective: A Mixed-Methods Study in China

The uptake of non-EPI vaccines, such as influenza and pneumonia vaccines, are very low in China compared to other countries. In China, immunization services are provided by dedicated vaccination service providers (VSPs), and their recommendation is the key to improve vaccine uptake. This study explores VSP recommendation practices for non-EPI vaccines from a socio-ecological perspective. A mixed-methods study, combining a questionnaire survey and key informant interviews, was conducted in Anhui, Shaanxi, and Guangdong provinces. 555 VSPs completed the valid questionnaire, and 49 VSPs participated in in-depth interviews. Among the surveyed VSPs, 51.54% stated that they always or often recommended non-EPI vaccines in work, and the remaining half reported that they sometimes or never recommended non-EPI vaccines. Most VSPs interviewed communicated about non-EPI vaccines with the public in an informed style, not a presumptive one, and provided the public with all the decision-making latitude. The infrequent recommendation of non-EPI vaccines was widely prevalent among Chinese VSPs regardless of their individual characteristics, and was mainly driven by the interpersonal relationship, institutional arrangement, and public policy. Firstly, the VSPs were concerned about conflicts arising from the recommendation of self-paid vaccines and the risk of adverse reactions following vaccination. Secondly, high workloads left them insufficient time to communicate about non-EPI vaccines. Thirdly, there was no performance assessment or financial incentive for VSPs to recommend non-EPI vaccination, and their main responsibility was around EPI vaccination. Therefore, multi-level socio-ecological systems around non-EPI vaccination should be improved to optimize the communication between VSPs and the public, which include a better system of legal redress to resolve potential misunderstandings between the VSPs and the public, more effective workload management through whole-process health information system and strengthening public health workforce, and the introduction of performance assessment and appropriate incentives on non-EPI vaccination.

Reliability and validity evaluation of the appropriate antibiotic use self-efficacy scale for Chinese adults

Background

Antibiotic resistance is one of the greatest threats to global public health. Inappropriate use of antibiotics can lead to an increase in antibiotic resistance. Individual self-efficacy in the appropriate use of antibiotics plays a key role, especially in China where the population has easy access to antibiotics. However, there are no tools available to assess the self-efficacy of appropriate antibiotic use for Chinese adults. We aimed to translate and develop a Chinese version of the Appropriate Antibiotic Use Self-Efficacy Scale (AAUSES), and validate its reliability and validity.

Methods

A total of 659 adults were recruited to participate in the questionnaire. The original version scale was first translated into Chinese using the backward and forward translation procedures. The internal consistency reliability of the scale was measured by the Cronbach alpha coefficient, the test-retest reliability, and the corrected item-total correlation. The validity of the scale was assessed by the content validity index, exploratory factor analysis, and confirmatory factor analysis.

Results

The content validity index of the scale was 0.96. Exploratory factor analysis (EFA) supported a 4-factor structure of the translated questionnaire, and the discriminant validity of the scale was good. Confirmatory factor analysis (CFA) showed in the model fitness index, the chi-square degree of freedom was 2.940, the goodness-of-fit index(GFI) was 0.929, the incremental fit index (IFI) was 0.908, the comparative fit index(CFI) was 0.906, root mean square error of approximation(RMSEA) was 0.077, and standardized root mean residual (SRMR) was 0.0689, and the model fitting indexes were all in the acceptable range. Cronbach alpha coefficient for the scale was 0.910. The test-retest reliability was 0.947, and the corrected item-total correlations for the items ranged from 0.488 to 0.736. Self-efficacy for appropriate antibiotic use in adults varied by education, occupation, income, place of residence, and whether or not they had heard of antibiotic resistance.

Conclusions

The results indicated that the Chinese version of the AAUSES had good reliability and validity. Therefore, it can be considered a tool to evaluate the appropriate antibiotic use self-efficacy of adults in China.

Cluster randomised controlled trial to assess a tailored intervention to reduce antibiotic prescribing in rural China: study protocol

INTRODUCTION

Up to 80% of patients with respiratory tract infections (RTI) attending healthcare facilities in rural areas of China are prescribed antibiotics, many of which are unnecessary. Since 2009, China has implemented several policies to try to reduce inappropriate antibiotic use; however, antibiotic prescribing remains high in rural health facilities.

METHODS AND ANALYSIS

A cluster randomised controlled trial will be carried out to estimate the effectiveness and cost effectiveness of a complex intervention in reducing antibiotic prescribing at township health centres in Anhui Province, China. 40 Township health centres will be randomised at a 1:1 ratio to the intervention or usual care arms. In the intervention group, practitioners will receive an intervention comprising: (1) training to support appropriate antibiotic prescribing for RTI, (2) a computer-based treatment decision support system, (3) virtual peer support, (4) a leaflet for patients and (5) a letter of commitment to optimise antibiotic use to display in their clinic. The primary outcome is the percentage of antibiotics (intravenous and oral) prescribed for RTI patients. Secondary outcomes include patient symptom severity and duration, recovery status, satisfaction, antibiotic consumption. A full economic evaluation will be conducted within the trial period. Costs and savings for both clinics and patients will be considered and quality of life will be measured by EuroQoL (EQ-5D-5L). A qualitative process evaluation will explore practitioner and patient views and experiences of trial processes, intervention fidelity and acceptability, and barriers and facilitators to implementation.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Biomedical Research Ethics Committee of Anhui Medical University (Ref: 20180259); the study has undergone due diligence checks and is registered at the University of Bristol (Ref: 2020-3137). Research findings will be disseminated to stakeholders through conferences and peer-reviewed journals in China, the UK and internationally.

TRIAL REGISTRATION NUMBER

ISRCTN30652037.

Non-prescription antibiotic use for cough among Chinese children under 5 years of age: a community-based cross-sectional study

OBJECTIVE

This study aimed to investigate the non-prescription use of antibiotics for cough among children under 5 years in China.

DESIGN

A community-based cross-sectional survey.

SETTING

A face-to-face interview based on a standard questionnaire in the community from October to December 2019.

PARTICIPANTS

A total of 3102 children under 5 years of age were enrolled with probability proportionate to size sampling method. The children's caregivers provided the responses as their agents.

OUTCOME MEASURES

Cough in the past month, non-prescription use of antibiotics after cough.

RESULTS

1211 of 3102 children were reported to have a cough in the past month. Of these, 40.2% (487/1211) were medicated with antibiotics, and 18.7% (91/487) of these were not prescribed. Cephalosporins were the most frequently used antibiotic (52.8%), and community pharmacies were the main source (53.7%). Children who coughed for 1-2 weeks (OR 1.73, 95% CI 1.03 to 2.90) or 3-4 weeks (OR 2.39, 95% CI 1.08 to 4.97), with runny nose (OR 1.86, 95% CI 1.13 to 3.19) or those whose family annual income between ¥50 000 and ¥100 000 (OR 4.44, 95% CI 1.52 to 18.95) had a higher risk of non-prescription use of antibiotics than those coughing for <1 week, without runny nose or with family annual income <¥50 000.

CONCLUSIONS

Our findings indicated that a high proportion of infants and young children had been treated with antibiotics for cough, and nearly one in five of them were used without prescription. More public health campaigns and further education on the appropriate use of antibiotics are needed to ensure the rational treatment of cough in children.

Non-biomedical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis

BACKGROUND

In the past two decades, human antibiotic consumption has increased globally, contributing to the emergence and spread of antimicrobial resistance and calling for urgent effective actions.

OBJECTIVES

To systematically identify and collate studies exploring non-biomedical factors influencing healthcare consumers' antibiotic use globally, in order to inform future interventions to improve antibiotic use practices.

METHODS

Data sources: PubMed, EMBASE, PsycINFO, and Cochrane.

STUDY ELIGIBILITY CRITERIA

Original and empirical studies that identified factors for healthcare consumers' antibiotic use.

PARTICIPANTS

Healthcare consumers. Assessment of risk of bias: Adapted BMJ survey appraisal tools, the Critical Appraisal Skills Programme checklist, and the Mixed Methods Appraisal Tool were utilised for quality assessment. Methods of data synthesis: The Social Ecological Framework and Health Belief Model were employed for data synthesis. We did random-effects meta-analyses to pool the odds ratios of risk factors for antibiotic use.

RESULTS

We included 71 articles for systematic review and analysis: 54 quantitative, nine qualitative, and eight mixed-methods studies. Prevalent non-prescription antibiotic uses and irresponsible prescriptions were reported globally, especially in low-to-middle income countries. Barriers to healthcare - wait time, transportation, stigmatization - influenced people's antibiotic use practices. Further, lack of oversight and regulation in the drug manufacturing and weak supply chain have led to the use of substandard or falsified antibiotics. Knowledge had mixed effects on antibiotic use behaviours. Meta-analyses identified pro-attitudes towards self-medication with antibiotics, relatives having medical backgrounds, older age, living in rural areas, and storing antibiotics at home to be risk factors for self-medication with antibiotics.

CONCLUSIONS

Non-prescription antibiotic use and irresponsible prescriptions in the community are prevalent in all WHO regions and largely driven by a mixed collection of non-biomedical factors specific to the respective setting. Future AMR strategies should incorporate implementation science approach for community-based complex interventions that addresses drivers of the target behaviours tailored to local contexts.

Understanding parental self-medication with antibiotics among parents of different nationalities: a cross-sectional study

Background

There is an increasing trend on the practices of parental self-medication with antibiotics (PSMA) around world, accelerating the antibiotic abuse. This study aims to examine the nationality differences in the practices of PSMA and knowledge, attitudes and practices (KAP) toward antibiotic use, and understand the practices of PSMA among parents of various nationalities in China.

Methods

A cross-sectional study based on a structured questionnaire survey was conducted in Xi’an, Shaanxi Province, China, from September 2018 to October 2018. A total of 299 respondents participated in. The practices of PSMA (a dichotomous variable) and KAP toward antibiotic use (a continuous variable) served as dependent variables. Participant’s nationality was regarded as the independent variable. Binary logistic regression and ordinary least square regression were employed to examine the association between parent’s nationality and the practices of PSMA, and KAP toward antibiotic use, respectively.

Results

121 (40.88%) Chinese, 100 (33.76%) other Asians and 75 (25.34%) Occidentals were included in final analysis, with a sample size of 296. Chinese were more likely to practice PSMA (OR = 7.070; 95% CI 1.315, 38.01), with worse knowledge (Coef. = − 0.549; 95% CI − 1.021, − 0.078), attitudes (Coef. = − 3.069; 95% CI − 4.182, − 1.956) and practices (Coef. = − 1.976; 95% CI − 3.162, − 0.790) toward antibiotic use, compared to their Occidental counterparts. The main reasons for the practices of PSMA were enough previous medication experience (80.49%) and same ailments with no need to see a doctor (39.02%), with common symptoms such as fever (60.98%) and cough (58.54%). Purchasing antibiotics at pharmacies (92.08%) and using leftover antibiotics (26.83%) were usual approaches.

Conclusions

The study highlights the gaps in the practices of PSMA and KAP toward antibiotic use among parents of different nationalities. The access to obtain antibiotics from pharmacies reflects the pharmacists’ unaware of laws on prescription of antibiotics, fierce competition in the pharmacy market, and the government’s lax supervision in China. It suggests the need to improve pharmacists’ training, enforce current legislations on pharmacy market regarding the sale of antibiotics, and provide practical and effective educational interventions for residents about antibiotic use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41256-021-00226-y.

A scoping review of global aminoglycoside antibiotic overuse: A potential opportunity for primary ototoxicity prevention

BACKGROUND

Aminoglycosides are widely used, broad-spectrum antibiotics with significant potential for ototoxicity. Global efforts to prevent ototoxicity must account for aminoglycoside overuse and non-prescription use.

OBJECTIVES

The goals of this study were to a) estimate the prevalence of aminoglycoside overuse by synthesizing evidence on self-medication, over the counter (OTC) availability, and household antibiotic storage for later use, and to report the specific aminoglycosides used and the predictors of overuse, and b) leverage this information to comment on potential risk of ototoxicity.

METHODS

Two systematic search strings were conducted to extract peer-reviewed articles published from 2005 to 2020. The first focused on overuse of aminoglycoside antibiotics. The second focused on potentially ototoxic effects of aminoglycosides related to drug overuse.

RESULTS

A total of 26 articles were included (first search string: n = 21; second search string: n = 5). The prevalence of aminoglycoside self-medication was high and household storage and OTC availability of aminoglycosides was common. Gentamicin was the most commonly overused aminoglycoside. No studies provided information on antibiotic dosing or resultant toxicities, including ototoxicity.

CONCLUSIONS

The limited available evidence indicates that antibiotic overuse (self-medication, home storage, and non-prescription availability) is relatively common, especially in low resource settings, and that aminoglycoside antibiotics comprise a variable, but concerning, proportion of non-prescribed antibiotics. Additional evidence is needed to evaluate the relationship between these dispensing patterns and ototoxicity.

Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review

BACKGROUND

For decades, antibiotics have been excessively consumed around the world, contributing to increased antimicrobial resistance (AMR) and negatively impacting health outcomes and expenditures. Antibiotic use in China accounts for half of worldwide antibiotic consumption, which mainly takes place in outpatient and community settings, and often unnecessarily for self-limiting community-acquired infections. This study aimed to identify and assess factors of inappropriate use of antibiotics in the Chinese context to inform the development of interventions to mitigate inappropriate consumption in the absence of clinical indications.

METHODS

We conducted a mixed-methods systematic review and included empirical studies with original data conducted in mainland China, Hong Kong and Taiwan that investigated factors of antibiotic use in the community including outpatient care among patients, caregivers and prescribers. We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, Google Scholar and one Chinese database CNKI (China Knowledge Resource Integrated Database), using a combination of the key terms 'antibiotic', 'antimicrobial', 'use', 'consumption', 'behaviour', 'prescribe' and related syntax for all peer-reviewed publications published before June 2020. Health Belief Model was employed for data synthesis.

FINDINGS

Fifty-four studies were included in the full-text review: 44 quantitative, 5 qualitative and 5 mixed-methods studies. Despite a high AMR awareness, public perception/misconception of antibiotic efficacy and easy access to antibiotics for self-limiting conditions drive inappropriate demand and use in the community including primary care setting. Providers' prescribing behaviours are influenced by financial incentives, lack of diagnostic capacity and concerns over complications.

CONCLUSIONS

Inappropriate outpatient and community antibiotic use is influenced by non-biomedical factors at the individual, community, health system and societal levels in mainland China, contributing to a high antibiotic use rate. This study calls for context-tailored One Health interventions, restrictive antibiotic drug policy and multifaceted antibiotic stewardship programmes that simultaneously address drivers of inappropriate use from both the supply-side and demand-side within and beyond clinical settings.

PROSPERO REGISTRATION NUMBER

CRD42019139591.

No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies

BACKGROUND

Non-prescription dispensing of antibiotics, one of the main sources of antibiotic misuse or over use, is a global challenge with detrimental public health consequences including acceleration of the development of antimicrobial resistance, and is facilitated by various intrinsic and extrinsic drivers. The current review aimed to systematically summarise and synthesise the qualitative literature regarding drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries.

METHODS

Four electronic databases (PubMed, CINAHL, Scopus and Google Scholar) and reference lists of the relevant articles were searched. The Joanna Briggs Institute's Critical Appraisal Checklist for qualitative studies was used to assess the quality of included studies. The enhancing transparency in reporting the synthesis of qualitative research statement was used to guide reporting of results. Data were coded using NVivo 12 software and analysed using both inductive and deductive thematic analysis.

RESULTS

A total of 23 articles underwent full text review and 12 of these met the inclusion criteria. Four main themes were identified in relation to facilitators of non-prescribed sale of antibiotics among community drug retail outlets: i) the business orientation of community drug retail outlets and tension between professionalism and commercialism; ii) customers' demand pressure and expectation; iii); absence of or a lax enforcement of regulations; and iv) community drug retail outlet staff's lack of knowledge and poor attitudes about antibiotics use and scope of practice regarding provision.

CONCLUSIONS

This review identified several potentially amendable reasons in relation to over the counter dispensing of antibiotics. To contain the rise of antibiotic misuse or over use by targeting the primary drivers, this review suggests the need for strict law enforcement or enacting new strong regulation to control antibiotic dispensing, continuous and overarching refresher training for community drug retail outlet staff about antibiotic stewardship, and holding public awareness campaigns regarding rational antibiotic use.

The General Population's Inappropriate Behaviors and Misunderstanding of Antibiotic Use in China: A Systematic Review and Meta-Analysis

The general population has increasingly become the key contributor to irrational antibiotic use in China, which fuels the emergence of antibiotic resistance. This study aimed to estimate the prevalence of the general population’s irrational use behaviors of antibiotics and identify the potential reasons behind them. A systematic review and meta-analysis were performed concerning four main behaviors relevant to easy access and irrational use of antibiotics and common misunderstandings among the population about antibiotics. Four databases were searched, and studies published before 28 February 2021 were retrieved. Medium and high-level quality studies were included. Random effects meta-analysis was performed to calculate the prevalence of the general population’s irrational behaviors and misunderstandings relevant to antibiotic use. A total of 8468 studies were retrieved and 78 met the criteria and were included. The synthesis showed the public can easily obtain unnecessary antibiotics, with an estimated 37% (95% CI: 29–46) of the population demanding antibiotics from physicians and 47% (95% CI: 38–57) purchasing non-prescription antibiotics from pharmacies. This situation is severe in the western area of China. People also commonly inappropriately use antibiotics by not following antibiotic prescriptions (pooled estimate: 48%, 95% CI: 41–55) and preventatively use antibiotics for non-indicated diseases (pooled estimate: 35%, 95% CI: 29–42). Misunderstanding of antibiotic use was also popular among people, including incorrect antibiotic recognition, wrong antibiotic use indication, inappropriate usage, and ignorance of potential adverse outcomes. Over-and inappropriate use of antibiotics is evident in China and a multifaceted antibiotic strategy targeted at the general population is urgently required.

Self-prescribing of antibiotics by patients seeking care in Indian emergency departments

STUDY OBJECTIVE

Antibiotic resistance is a global health threat. India has one of the highest rates of antibiotic use in the world. The objective of this study was to evaluate the prevalence of self-prescribed antibiotic use of patients presenting with febrile and infectious disease-related complaints to Indian emergency departments.

METHODS

This was a prospective observational study conducted at 6 Indian emergency departments (EDs) between January 1, 2019 and December 31, 2019. Adult patients who presented with a chief complaint of febrile illness or infectious disease complaints were included. Our principal outcomes of interest were self-prescribed use of antibiotics within the prior 6 months or for the presenting complaint. We queried respondents about source of antibiotics as well as about demographic characteristics that influenced use.

RESULTS

A total of 1421 patients were enrolled. Sixty percent (n = 856) of respondents reported using antibiotics in the prior 6 months or for their current complaint. Those who reported self-prescribing antibiotics either in the past or currently had at least some college education (P < 0.001), tended to use the pharmacy (P < 0.001) or the ED (P = 0.001) for their care when sick, and were more likely to have some comorbid conditions (P = 0.014) as compared to the group that did not self-prescribe antibiotics. The most common reason respondents reported self-prescribing antibiotics was because they did not want to wait to see their doctor (n = 278, 33%). Thirty-five percent of patients who were self-prescribed antibiotics before presentation did not receive and were not prescribed antibiotics in the ED, at discharge, or both.

CONCLUSIONS

Self-prescribing of antibiotics occurs commonly in India. This use increases the risk for resistance due to inappropriate or unnecessary use. Promotion of antibiotic stewardship is needed to curtail such use.

Rodrigues D, Figueiras A, Zapata-Cachafeiro M, Roque F, Herdeiro MT. Antibiotic Dispensation without a Prescription Worldwide: A Systematic Review

Antibiotic resistance still remains a major global public health problem and the dispensing of antibiotics without a prescription at community pharmacies is an important driver of this. MEDLINE, Pubmed and EMBASE databases were used to search and identify studies reporting the dispensing of non-prescribed antibiotics in community pharmacies or drugstores that sell drugs for human use, by applying pharmacy interviews/questionnaires methods and/or simulated patient methods. Of the 4683 studies retrieved, 85 were included, of which 59 (69.4%) were published in low-and middle-income countries. Most of the papers (83.3%) presented a percentage of antibiotic dispensing without a prescription above 60.0%. Sixty-one studies evaluated the active substance and the most sold antibiotics without a prescription were amoxicillin (86.9%), azithromycin (39.3%), ciprofloxacin (39.3%), and amoxicillin-clavulanic acid (39.3%). Among the 65 articles referencing the diseases/symptoms, this practice was shown to be mostly associated with respiratory system problems (100.0%), diarrhea (40.0%), and Urinary Tract Infections (30.8%). In sum, antibiotics are frequently dispensed without a prescription in many countries and can thus have an important impact on the development of resistance at a global level. Our results indicate the high need to implement educational and/or regulatory/administrative strategies in most countries, aiming to reduce this practice.

Knowledge, attitude, and practices of community pharmacy staff toward antimicrobial stewardship programs: a cross-sectional study from Northeastern China

BACKGROUND

Antimicrobial resistance is one of the most significant challenges of the twenty-first century, and the illegal sale of antimicrobial drugs at community pharmacies is a driver of antimicrobial resistance. This study explores the knowledge, attitudes, and practices (KAP) of pharmacy staff toward antimicrobial stewardship programs (ASPs).

METHODS

We conducted a descriptive cross-sectional study among community pharmacy staff in Northeastern China, from April 1 to 31 May 2019, using a self-administered KAP questionnaire comprising 20 items. The data analysis was carried out by employing Mann-Whitney and Kruskal-Wallis tests.

RESULTS

A response rate of 98.5% (394/400) was obtained. The majority of participants (94.9%) demonstrated a good understanding of antimicrobial use, but they lacked an adequate understanding of ASPs. Nearly half of the participants (40.6%) reported that they sold antimicrobials to patients without a prescription. Education level, age, occupation, and experience were all significantly associated (P < 0.05) with participants' median ASPs scores. Besides, the presence of a licensed pharmacist (OR 46.327, 95% CI 2.443-878.451, P = 0.011) was the main factor associated with the pharmacy staff's understanding of antimicrobial use policies.

CONCLUSIONS

The participants' knowledge of antimicrobials was good, and their attitudes regarding ASPs were positive, but their practices regarding ASPs were poor.

Parental self-medication with antibiotics for children promotes antibiotic over-prescribing in clinical settings in China

Background

Self-medication with antibiotics (SMA) is one of the most dangerous inappropriate antibiotic use behaviors. This study aims to investigate the impact of parental SMA for children before a consultation on their doctor’s subsequent antibiotic prescribing behavior, including intravenous (IV) antibiotic use in the clinical setting of China.

Methods

A cross-sectional survey was conducted between June 2017 and April 2018 in three provinces of China. A total of 9526 parents with children aged 0–13 years were investigated. Data from 1275 parents who had self-medicated their children and then visited a doctor in the past month were extracted and analyzed.

Results

One-third (410) of the studied children had parental SMA before the consultation and 83.9% of them were subsequently prescribed antibiotics by doctors. Children with parental SMA were more likely to be prescribed antibiotics (aOR = 7.79, 95% CI [5.74–10.58]), including IV antibiotics (aOR = 3.05, 95% CI [2.27–4.11]), and both oral and IV antibiotics (aOR = 3.42, 95% CI [2.42–4.84]), than children without parental SMA. Parents with SMA behaviors were more likely to request antibiotics (aOR = 4.05, 95% CI [2.59–6.31]) including IV antibiotics (aOR = 2.58, 95% CI [1.40–4.76]), and be fulfilled by doctors (aOR = 3.22, 95% CI [1.20–8.63]).

Conclusions

Tailored health education for parents is required in both community and clinical settings to discourage parental SMA for children. The doctors should not prescribe unnecessary antibiotics to reinforce parents’ SMA behaviors. We recommend expanding the current IV antibiotics ban in outpatient settings of China to cover outpatient pediatrics.