Rational antibiotic use in China: lessons learnt through introducing surgeons to Australian guidelines

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Background

Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs.

Methods

We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR).

Results

We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs.

Conclusion

We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions.

Trial registration

PROSPERO: CRD42021252715.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01209-4.

Drug utilization, rationality, and cost analysis of antimicrobial medicines in a tertiary care teaching hospital of Northern India: A prospective, observational study

BACKGROUND:

The burden of bacterial infections is huge and grossly under-represented in the current health-care system. Inappropriate use of antimicrobial medicines (AMMs) poses a potential hazard to patients by causing antibiotic resistance. This study was conducted to assess the: (i) AMM consumption and use patterns in patients attending the outpatients and inpatients of Medicine and Surgery departments of the hospital. (ii) Appropriateness of the AMM in the treatment prescribed, and (iii) cost incurred on their use in admitted patients.

MATERIALS AND METHODS:

An observational, prospective study was conducted among inpatients and outpatients of the Medicine and Surgery departments of a tertiary care hospital of northern India. Analysis of 2128 prescriptions and 200 inpatient records was performed using a predesigned format. The use of AMMs was reviewed using anatomical therapeutic chemical classification and defined daily doses (DDDs). To evaluate the expenditure incurred on AMMs, ABC analysis was performed.

RESULTS:

AMMs were prescribed to 37.9% outpatients and 73% of admitted patients. The percentage encounters with AMMs was 40.6% (medicine) and 25.6% (surgery) outpatients. The total DDDs/100 patient days of AMMs in medicine and surgery were 3369 and 2247. Bacteriological evidence of infection and AMM sensitivity was present in only 8.5% of cases. Over 90% of AMMs were prescribed from the hospital essential medicines list. Most of the AMMs were administered parenterally (64.9%). Multiple AMMs were prescribed more to inpatients (84.2% vs. 4.2% outpatients). Overall, expenditure on AMM was 33% of the total cost of treatment on medicine. ABC analysis showed that 74% of the expenditure was due to newer, expensive AMM, which constituted only 9% of the AMM used. The AMM therapy was found to be appropriate in 88% of cases as per Kunin's criteria for rationality.

CONCLUSION:

AMMs are being commonly prescribed without confirmation of AMM sensitivity in the hospital. A large proportion of expenditure is being incurred on expensive AMM used in a few number of patients. There is a need for developing a policy for rational use of AMM in the health facility.

Prospective study on the overuse of blood test-guided antibiotics on patients with acute diarrhea in primary hospitals of China

BACKGROUND

Overuse with antibiotics in the treatment of infectious diseases has become a central focus of public health over the years. The aim of this study was to provide an up-to-date evaluation of the blood test-guided antibiotic use on patients with acute diarrhea in primary hospitals of China.

MATERIALS AND METHODS

A cross-sectional survey was conducted on 330 patients with acute diarrhea in Shanghai, People's Republic of China, from March 2013 to February 2016. These patients were treated with or without antibiotics based on the results of their blood tests, including examinations of C-reactive protein (CRP), white blood cells (WBC), and the percentage of neutrophils (Neu%). The infection types, which included bacterial, viral, and combination diarrhea, were determined by microbiological culture methods. Antibiotics used in non-bacterial diarrhea patients were considered misused and overused.

RESULTS

There were significant overall differences in the clinical characteristics and blood tests between patients with diarrhea with a bacterial infection and patients with other types of infections. The patients were divided into four grading groups (0-3) according to the number of the positive results from three blood testes (CRP, WBC, and Neu%). The misuse rates of antibiotics in each group (0-3) were 81.3%, 71.1%, 72.4%, and 64.9%, respectively.

CONCLUSION

In this prospective study, the current diagnostic criteria (CRP, WBC, and Neu%) based on blood tests are not reliable in diagnosing bacterial diarrhea or guiding antibiotics use. To limit antibiotic overuse, a rapid and accurate differentiation of bacterial diarrhea from other types of diarrhea is pivotal.

Examination of psychosocial predictors of Chinese hospital pharmacists' intention to provide clinical pharmacy services using the theory of planned behaviour: a cross-sectional questionnaire study

OBJECTIVES

Main study aim was as follows: (1) to explore the usefulness of the theory of planned behaviour (TPB) model in predicting Chinese hospital pharmacists' intention to provide clinical pharmacy services (CPSs), including auxiliary CPSs and core CPSs; (2) to identify the main factors affecting the Chinese hospital pharmacists' intention to provide core CPSs based on TPB quantitatively.

DESIGN

Cross-sectional questionnaire study.

SETTING

The study was conducted in 22 general hospitals in seven cities located in the eastern and western part of China.

PARTICIPANTS

416 hospital pharmacists (292 (70.2%) female) entered and completed the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Quantitative responses with hospital pharmacists' intention, attitude, subjective norms (SNs) and perceived behavioural control (PBC) over provision of CPSs and their past behaviour (PB)-related CPSs.

RESULTS

The structural equation model analysis found that attitude (p=0.0079, β=0.12), SN (p=0.038, β=0.10) and the pharmacists' intention to provide auxiliary CPSs (p=0.0001, β=0.63) significantly predicted of their intention to provide core CPSs, accounting for 54.0% of its variance. Attitude (p=0.0001, β=0.35), PBC (p=0.0182, β=0.12) and PB (p=0.0009, β=0.15) are significant predictors of pharmacists' intention, accounting for 21% of the variance in pharmacists' intention to provide auxiliary CPSs.

CONCLUSIONS

The TPB with the addition of PB is a useful framework for predicting pharmacists' intention to provide CPSs in Chinese hospital care context. Strategies to improve hospital pharmacists' intention to provide CPSs should focus on helping the individuals related medical care see the value of CPSs, altering their perception of social pressure towards core CPSs and the removal of obstacles that impede the translation of intentions into behaviour.

A multicenter point-prevalence survey of antibiotic use in 13 Chinese hospitals

BACKGROUND

The use of antibiotics is considered a major determinant of the development of resistance in organisms. This study assessed current patterns of antibiotic prescription and provides background for quality improvement in general hospitals in Hubei, China.

METHODS

A point-prevalence study was performed in November 2008. All inpatients on the day of the survey were included in the analysis.

RESULTS

On the day of the study, 6904 patients (56%) were receiving antibiotic therapy; the highest rate occurred in the ICU (90%), and the lowest occurred in the medical wards (39%). The most commonly used antibiotics were β-lactam antibiotics, including cephalosporins (40%) and piperacillin (19%), followed by fluoroquinolones (14%).

CONCLUSIONS

Our data indicated a high rate of antibiotic use in Chinese hospitals. These findings suggest important areas for intervention and the implementation of antibiotic stewardship policies in Chinese hospitals. A multi-faceted strategy should be implemented at the national level in China and should include education, regulation, and greater financial support from the government.

Adherence to American society of health-system pharmacists surgical antibiotic prophylaxis guidelines in a teaching hospital

Objective:

Surgical site infections are the second most common type of adverse events occurring in hospitalized patients, whereas an estimated 40-60% of these infections are thought to be preventable. Choice of regimen, administration timing or duration of antibiotic prophylaxis is reported to be inappropriate in approximately 25-50% of cases. We tried to evaluate an antibiotic administration pattern for surgical antibiotic prophylaxis in a teaching hospital.

Methods:

This study was conducted at the general surgery and orthopedic wards of a teaching hospital affiliated with Mazandaran University of Medical Sciences. The medical records of admitted patients who underwent different surgical procedures were reviewed. Compliance was assessed with the recommendations of the American Society of Health-System Pharmacists' guidelines for every aspect of antibiotic prophylaxis. All data were coded and analyzed by SPSS16 software using Student's t-test and Chi-square test.

Findings:

During 1 year, 759 patients who underwent different surgeries were included in the study. Mean age of patients was 32.02 ± 18.79 years. Hand and foot fractures repair were the most frequent surgery types. About 56.4% of administered prophylactic antibiotics were in accordance with the American Society of Health System Pharmacists (ASHP) guidelines regarding prophylaxis indication. The most commonly antibiotic used was cefazolin and antibiotic choices were appropriate in 104 of 168 surgical procedures (62%). Gentamicin, metronidazole and ceftriaxone were the most frequently antibiotics that used inappropriately. Only in 100 of 168 procedures, duration was concordant with the ASHP guideline, whereas in 68 procedures, duration was longer than recommended time. In 98 procedures, the dose was lower and in one procedure, it was higher than recommended doses.

Conclusion:

Although such guidelines have been in place for many years, studies showed that much inappropriate antibiotic use as prophylaxis and poor adherence to guidelines are still major issues. It is essential for surgeons to be aware to consider the best antibiotic choices, dose and duration based on reliable guidelines for antibiotic prophylaxis.

Evaluation of the effects of comprehensive reform on primary healthcare institutions in Anhui Province

BACKGROUND

In 2009, the Chinese Central Communist Party and the China State Council started to implement comprehensive healthcare reforms. The first round of reforms, involving Anhui province, was from 2009 to 2011, and focused on primary healthcare institutions. This study conducts an initial assessment of the effects of specific parts of the reforms in Anhui.

METHODS

Mixed quantitative and qualitative methods were adopted for data collection. Seven hundred and three health institutions from 15 counties were randomly chosen. The practices, development, effects, problems, and other relevant information related to the reform were classified into four aspects: medicine management; personnel systems and income distribution mechanisms; compensation mechanisms for primary healthcare institutions; and strengthening the primary healthcare system. The effects of reform were analyzed by evaluating changes in compensation channels, visit costs, diagnosis and treatment structure, hardware, structures, efficiency, and behavior.

RESULTS

A new system for authorizing drugs resulted in a total of 857 new drugs being accessible at agreed prices through primary healthcare institutions in Anhui. The cost of the average outpatient visit decreased from 35.29 RMB to 31.64 RMB, although for inpatients, the average cost increased from 799.05 RMB to 992.60 RMB. The number of healthcare personnel decreased, but their workloads increased. The total revenue from government sources increased by 41.09%, and the proportion of revenue from drugs decreased by 25.19%. The rate of diagnosis and treatment visits and outpatient visits to primary healthcare institutions increased. Finally, between 2008 and 2010, 1,195 standardized township hospitals, 14,134 village clinics, and 1,234 community health service institutions were constructed.

CONCLUSION

The reform of primary healthcare institutions in Anhui has improved the personnel structures surrounding frontline healthcare workers, increased their incomes, improved work efficiency, and changed the compensation patterns of primary healthcare institutions, improved hardware, reduced drug prices, and, to some extent, improved the diagnosis and treatment structure. However, the reforms have not radically changed the behavior of medical workers or the visit patterns of patients. Approaches such as strengthening performance evaluation, and carrying out initiatives to further mobilize frontline healthcare workers, enhance rational drug use through improved training and educate patients, should be undertaken in the future.

Pharmacist interventions for prophylactic antibiotic use in urological inpatients undergoing clean or clean-contaminated operations in a Chinese hospital

OBJECTIVES

To evaluate the impact and cost-benefit value of pharmacist interventions for prophylactic antibiotic use in surgical patients undergoing clean or clean-contaminated operations.

METHODS

A pre-to-post intervention study was performed in the Department of Urological Surgery of a tertiary hospital. Patients admitted from January through June 2011, undergoing clean or clean-contaminated surgery, served as the pre-intervention group; patients admitted from January through June 2012 formed the post-intervention group. Pharmacist interventions were performed for the surgeries in the post-intervention group. The criteria for the rational use of antibiotic prophylaxis were established by the hospital administration. The pharmacist interventions included real-time monitoring of medical records and controlling of the prescriptions of prophylactic antibiotics against the criteria. The pre- and post-intervention groups were then compared to evaluate the outcomes of the pharmacist interventions. A cost-benefit analysis was performed to determine the economic effects of implementing the pharmacist intervention on preoperative antibiotic prophylaxis.

RESULTS

After the pharmacist intervention, a significant decrease was found in the rate of no indications for prophylactic antibiotic use (p = 0.004), the rate of broad-spectrum antibiotic use (p<0.001), the rate of drug replacement (p<0.001) and the rate of prolonged duration of prophylaxis (p<0.001). Significant reductions were observed in the mean antibiotic cost (p<0.001), the mean duration of antibiotic prophylaxis (p<0.001) and the mean number of antibiotics used (p<0.001). A significant increase was observed in the rate of correct choice of antibiotics (p<0.001). The ratio of the net mean cost savings for antibiotics to the mean cost of pharmacist time was approximately 18.79:1.

CONCLUSION

Real-time interventions provided by a clinical pharmacist promoted rational use of prophylactic antibiotics, with a significant reduction in antibiotic costs, thus leading to favorable economic outcomes.

The impact of clinical pharmacy services in China on the quality use of medicines: a systematic review in context of China's current healthcare reform

INTRODUCTION

Recently, China initiated an ambitious healthcare reform aiming to provide affordable and equitable basic health care to all by 2020. To meet these goals, new policies issued by China's Ministry of Health mandate clinical pharmacy services be integrated into China's hospitals. This review aims to highlight the impact of clinical pharmacy services on the quality use of medicines in hospitals in China.

METHODS

Both English and Chinese databases were used. For the English databases, Web of Science, Medline, International Pharmaceutical Abstracts and Embase were searched using the following keywords ('pharmacists' OR 'pharmacy' OR 'pharmaceutical services/pharmaceutical care') AND ('China'). For the Chinese database, Chinese Biomedical Literature Database on disc was searched using the following keywords ('clinical pharmacist' OR 'clinical pharmacy' OR 'pharmaceutical care' OR 'pharmaceutical services'). Articles were then retrieved from WanFang database and China Knowledge Resource Integrated Database.

RESULTS

A total of 75 published papers were included in this review. The majority of studies were conducted in the inpatient setting (68%), which included clinical pharmacy interventions such as educating doctors and patients, evaluating and monitoring the implementation of hospital policies and/or reviewing medications on the ward. In the outpatient setting, the majority of studies conducted involved educating patients. Clinical pharmacy services frequently focused on antimicrobials (44%). More than half of these studies employed an administrative intervention alongside the clinical pharmacy service.

CONCLUSION

Clinical pharmacy services in China, with its unique healthcare system and cultural nuances, appear to positively influence patient care and the appropriate use of medications. From the published literature, it is expected that clinical pharmacy services can make a strong contribution to China's healthcare reform with further governmental and educational support.

Systematic review of interventions on antibiotic prophylaxis in surgery in Chinese hospitals during 2000-2012

OBJECTIVE

To systematically review intervention studies on antibiotic prophylaxis in clean or clean-contaminated surgery in Chinese hospitals from 2000 to 2012.

METHODS

Published peer reviewed articles, unpublished documents and reports, and gray literature were identified through searching CNKI, CBM, VIP, PubMed (MEDLINE), WHO database, and the official websites of the Ministry of Health of China, provincial health authorities and medical university internal publications.

RESULTS

Eighty-two studies were identified. Circulation and localization of central rules, regulations and guidelines; clinical pharmacists' involvement; technical, administrative, and managerial strategies were the mostly adopted interventions. Except one study, all claimed effectiveness of interventions. Limited effects were observed for non-indicated clean surgery. Huge gaps still existed between the international agreed guidelines and the claimed best performance following interventions. The following were critical to have more effective interventions: recognition, acceptance, and enforcement strategies of rules, regulations, and guidelines; intervention persistence and intensity; health information system; removal of health system perverse incentives; patient-doctor relationship; public education; and access to unbiased medicines information. A total 4 of 82 studies were pre-post studies with control; all others were simple pre-post studies without control. Simple measurement of the outcome indicators as an average for pre-post intervention groups and changes in between failed to distinguish the real intervention effect from confounding factors, and failed to adjust underlying trends.

CONCLUSIONS

Interventions on surgical antibiotic prophylaxis in Chinese hospitals during 2000-2012 brought limited positive effects. There are still huge gaps between the Chinese situation and internationally agreed standards. More advanced study methodologies are needed to have better documentation of evidence of the most effective interventions.

National Essential Medicines List and policy practice: a case study of China's health care reform

Background

In 2009, China implemented the national essential medicines system by enacting the National Essential Medicines List 2009. According to the policy of this system, primary health care institutions can only stock and use essential medicines on the prescribed List. Meanwhile, each province can choose to make its own list of supplemented medicines. The goal of the study is to provide suggestions for emerging problems and identify future policy-making trends.

Methods

In this study, we statistically analyzed the National Essential Medicines List 2009 and lists of supplemented medicines of all 29 provinces. We also examined the rationality of such medicines based on the DELPHI method and literature review, after which we studied the provincial supplements in relation to the national essential medicines system.

Results

We demonstrated that the National Essential Medicines List 2009 provides a comprehensive coverage of diseases as well as reasonable varieties of drugs for their treatment. The average number of supplemented medicines in 29 provinces is 207, with each medicine included in 2.9 provincial lists on average. Only 2.6% supplemented medicines are included by more than half of the provinces (>15), indicating great regional variance. Among the 32 most frequently supplemented medicines, only 18 meet the selection principles, including two with strict usage restrictions.

Conclusion

The structure and selection of the National Essential Medicines List 2009 are relatively reasonable. The main problems, however, include the excessive and non-scientific selection of medicines on the supplemented medicines list. The function of the provincial lists of supplemented medicines has not been achieved, which has influenced the effectiveness of the national essential medicines system in China.

Revisiting current "barefoot doctors" in border areas of China: system of services, financial issue and clinical practice prior to introducing integrated management of childhood illness (IMCI)

BACKGROUND

Under-5-years child mortality remains high in rural China. Integrated management of childhood illness (IMCI) was introduced to China in 1998, but only a few rural areas have been included. This study aimed at assessing the current situation of the health system of rural health care and evaluating the clinical competency of village doctors in management of childhood illnesses prior to implementing IMCI programme in remote border rural areas.

METHODS

The study was carried out in the border areas of Puer prefecture of Yunnan province. There were 182 village doctors in the list of the health bureau in these border areas. Of these, 154 (84.6%) were recruited into the study. The local health system components were investigated using a qualitative approach and analyzed with triangulation of information from different sources. The clinical component was assessed objectively and quantitatively presented using descriptive statistics.

RESULTS

The study found that the New Rural Cooperative Medical Scheme (NRCMS) coordinated the health insurance system and the provider service through 3 tiers: village doctor, township and county hospitals. The 30 RMB per person per year premium did not cover the referral cost, and thereby decreased the number of referrals. In contrast to available treatment facilities and drug supply, the level of basic medical education of village doctors and township doctors was low. Discontent among village doctors was common, especially concerning low rates of return from the service, exceptions being procedures such as injections, which in fact may create moral hazards to the patients. Direct observation on the assessment and management of paediatric patients by village doctors revealed inadequate history taking and physical examination, inability to detect potentially serious complications, overprescription of injection and antibiotics, and underprescription of oral rehydration salts and poor quality of counseling.

CONCLUSION

There is a need to improve health finance and clinical competency of the village doctors in the study area.

The determinants of the antibiotic resistance process

BACKGROUND

The use of antibiotic drugs triggers a complex interaction involving many biological, sociological, and psychological determinants. Resistance to antibiotics is a serious worldwide problem which is increasing and has implications for morbidity, mortality, and health care both in hospitals and in the community.

OBJECTIVES

To analyze current research on the determinants of antibiotic resistance and comprehensively review the main factors in the process of resistance in order to aid our understanding and assessment of this problem.

METHODS

We conducted a MedLine search using the key words "determinants", "antibiotic", and "antibiotic resistance" to identify publications between 1995 and 2007 on the determinants of antibiotic resistance. Publications that did not address the determinants of antibiotic resistance were excluded.

RESULTS

The process and determinants of antibiotic resistance are described, beginning with the development of antibiotics, resistance and the mechanisms of resistance, sociocultural determinants of resistance, the consequences of antibiotic resistance, and alternative measures proposed to combat antibiotic resistance.

CONCLUSIONS

Analysis of the published literature identified the main determinants of antibiotic resistance as irrational use of antibiotics in humans and animal species, insufficient patient education when antibiotics are prescribed, lack of guidelines for treatment and control of infections, lack of scientific information for physicians on the rational use of antibiotics, and lack of official government policy on the rational use of antibiotics in public and private hospitals.

Factors influencing antibiotic prescribing in China: an exploratory analysis

OBJECTIVES

China has very high rates of antibiotic resistance and a health care system that provides strong incentives for over-prescribing. This paper describes the findings of a qualitative study in a province of southern China that seeks to assess knowledge, attitudes, and practices in relation to the use of antibiotics.

METHODS

Semi-structured interviews with patients and health workers at provincial, county, township, and village level. Interviews used four probes (common cold, cough, mild diarrhoea and tiredness) where antibiotics were not indicated, supplemented by questions on knowledge, attitudes, and practices. These data were supplemented by two focus groups, with medical students and pharmacists, and discussions with participants at a national conference on antibiotic use.

RESULTS

Coughs and diarrhoea are almost universally treated with antibiotics, while the cold is normally treated with antivirals instead or as well. Many physicians are aware that the cold is usually self-limiting but believe that they can speed recovery and that they are responding to patient expectations. Most physicians and many patients are aware of the phenomenon of antibiotic resistance, although it is often seen as a property acquired by the patient and not the micro-organism. Physicians face financial incentives to prescribe, with profit splitting with pharmaceutical suppliers. Sales profits form a major part of a hospital's income. National guidance on use of antibiotics is fragmentary and incomplete.

CONCLUSION

The misuse of antibiotics poses considerable risks. Effective action will require a multi-faceted strategy including education, based on an understanding of existing beliefs, the replacement of perverse incentives with those promoting best practice, and investment in improved surveillance. Much of this will require action at national level.