Cleaning up China's Medical Cabinet-An Antibiotic Take-Back Programme to Reduce Household Antibiotic Storage for Unsupervised Use in Rural China: A Mixed-Methods Feasibility Study

Enhancing environmental sustainability through a household pharmaceuticals take-back program in Jordan

Most homes have unwanted, discarded, unused, or expired pharmaceuticals. These pharmaceuticals can pose health risks if they are not properly disposed of. Active pharmaceutical ingredients have been detected in water resources at an alarming level globally and recently in Jordanian waters. Unfortunately, no programs or regulations are addressing this problem in Jordan. This study aims to provide a comprehensive evaluation of the stakeholders' potential involvement in establishing a pharmaceutical take-back program in Jordan. The study was designed to determine the focal points of establishing a pharmaceutical take-back program using a qualitative cross-sectional approach and using a force field analysis to put together a plan for a successful program in Jordan. The study conducted three surveys using structured questionnaires and interviews with officials to evaluate the attitude toward the pharmaceutical take-back program, awareness of environmental impacts, and current conditions of household pharmaceuticals in Jordan. The questionnaires were assigned to the public, pharmaceutical manufacturers, and pharmaceutical warehouses. The interviews were conducted with the Ministry of Environment, pharmaceutical manufacturers, and pharmaceutical warehouses. Most of the pharmaceutical producers (85% manufacturers and 94% warehouses) refused to participate voluntarily in the program due to the extra cost incurred. On the other hand, the public and the Ministry of Environment were supportive of establishing the program. The study revealed that there is a lack of awareness among the public toward household pharmaceuticals. About 77% of the public questionnaire respondents reported they had not received any information on how to dispose safely of their unwanted pharmaceuticals. Also, about 61% reported that they have concerns that household pharmaceuticals might contaminate the water resources in Jordan. Following the questionnaires' analysis, the study determined the main forces against establishing a pharmaceutical take-back program as the unwillingness of producers to participate, weak logistic support, lack of public awareness, and low public participation. A force field analysis (FFA) was conducted based on the forces determined from the questionnaires. Accordingly, the study recommends developing a comprehensive legislation and regulatory framework for household pharmaceuticals' recovery, establishing a monitoring entity, securing funds, and implementing a long-term awareness and education plan to support the establishment of a pharmaceutical take-back program in Jordan.

Teicoplanin associated gene tcaA inactivation increases persister cell formation in Staphylococcus aureus

Staphylococcus aureus is part of normal human flora and is widely associated with hospital-acquired bacteremia. S. aureus has shown a diverse array of resistance to environmental stresses and antibiotics. Methicillin-resistant S. aureus (MRSA) is on the high priority list of new antibiotics discovery and glycopeptides are considered the last drug of choice against MRSA. S. aureus has developed resistance against glycopeptides and the emergence of vancomycin-intermediate-resistant, vancomycin-resistant, and teicoplanin-resistant strains is globally reported. Teicoplanin-associated genes tcaR-tcaA-tcaB (tcaRAB) is known as the S. aureus glycopeptide resistance operon that is associated with glycopeptide resistance. Here, for the first time, the role of tcaRAB in S. aureus persister cells formation, and ΔtcaA dependent persisters' ability to resuscitate the bacterial population was explored. We recovered a clinical strain of MRSA from a COVID-19 patient which showed a high level of resistance to teicoplanin, vancomycin, and methicillin. Whole genome RNA sequencing revealed that the tcaRAB operon expression was altered followed by high expression of glyS and sgtB. The RNA-seq data revealed a significant decrease in tcaA (p = 0.008) and tcaB (p = 0.04) expression while tcaR was not significantly altered. We knocked down tcaA, tcaB, and tcaR using CRISPR-dCas9 and the results showed that when tcaA was suppressed by dCas9, a significant increase was witnessed in persister cells while tcaB suppression did not induce persistence. The results were further evaluated by creating a tcaA mutant that showed ΔtcaA formed a significant increase in persisters in comparison to the wild type. Based on our findings, we concluded that tcaA is the gene that increases persister cells and glycopeptide resistance and could be a potential therapeutic target in S. aureus.

Estimating antibiotics use in major cities in China through wastewater-based epidemiology

Antibiotics have been widely used for disease treatment and may pose adverse effects on human health due to increasing presence of antibiotic-resistant genes in environment. Therefore, it is important to understand antibiotic use in a specific region or country. China is a major producer of antibiotic and has a large number of consumers. In this work, wastewater samples were collected from 76 wastewater treatment plants in 31 major cities covering all of the geographic regions of China. Concentrations of eight metabolites of sulfonamide, quinolone and macrolide antibiotics were determined. The consumption levels of corresponding antibiotics were estimated based on wastewater-based epidemiology (WBE) approach. Desmethyl ofloxacin, desethylene norfloxacin, desmethyl azithromycin and N⁴-acetyl sulfamethoxazole were detected in all or the overwhelming majority of wastewater samples. The estimated ∑8Antibiotics consumption levels ranged from 275.1 ± 139.4 mg/1000 inh/d (Nanchang) to 3860.9 ± 1332.3 mg/1000 inh/d (Harbin) with a mean level of 1170.0 ± 452.1 mg/1000 inh/d. Quinolones accounted for the highest proportion (74.3%, national average contribution) in the total consumption level, with norfloxacin being the dominant one (38.4%), followed by ofloxacin (29.1%) and ciprofloxacin (6.8%). The ∑8Antibiotics consumption level in northern China (1517.0 ± 1022.8 mg/1000 inh/d) was statistically higher than the level in southern China (1060.7 ± 989.1 mg/1000 inh/d) (t-test, p < 0.05). In contrast, no significant difference was found between eastern (1256.2 ± 1105.1 mg/1000 inh/d) and western China (988.3 ± 474.5 mg/1000 inh/d) (t-test, p > 0.05). The overview of antibiotics consumption derived from this work can serve as a baseline to assess the implementation of related plans/policies in China.

Pharmaceutical pollution sources and solutions: Survey of human and veterinary medication purchasing, use, and disposal

Human and veterinary pharmaceuticals offer many benefits, but they also pose risks to both the environment and public health. Life-cycle stewardship of medications offers multiple strategies for minimizing the risks posed by pharmaceuticals, and further insight is required for developing best practices for pharmaceutical management. The goal of this study was to clarify points of intervention for minimizing environmental and public health risks associated with pharmaceuticals. Specifically, our objectives were to provide insight on purchasing, use, and disposal behaviors associated with human and veterinary medications. This study used a state-wide representative sample of Vermont adults (n = 421) to survey both human and veterinary pharmaceuticals as potential sources of the unintended consequences of prescribed and over-the-counter (OTC) medications. The majority (93%) of respondents had purchased some form of medication within the past twelve months, including OTC (85%), prescription (74%), and veterinary (41%) drugs. Leftover drugs of any kind were reported by 59% of respondents. While 56% of people were aware of drug take-back programs, the majority reported never being told what to do with leftover medications by their physician (78%), pharmacist (76%), or veterinarian (53%). Among all respondents, take-back programs were the most common disposal method (22%), followed by trash (19%), and flushing (9%), while 26% of respondents reported keeping unused drugs. Awareness of pharmaceutical pollution in the environment and having received information about proper disposal were both significantly associated with participation in take-back programs. These findings indicate that a large volume of drugs are going unused annually, and that only a portion of leftover medications are returned to take-back programs where they can be appropriately disposed. Our results warrant further investigation of clinical interventions that support lower dose prescribing and dispensing practices in order to reduce the unintended environmental and public health consequences of pharmaceuticals within the consumer sphere. In addition, our findings suggest that directed efforts to raise awareness of proper disposal may be more effective than broad awareness campaigns, and we recommend research on the efficacy of providing disposal instructions on drug packaging.

Large-scale survey of parental antibiotic use for paediatric upper respiratory tract infections in China: implications for stewardship programmes and national policy

BACKGROUND

Inappropriate use of antibiotics for upper respiratory tract infections (URTIs) in Chinese children is rampant. Parents' decision-making processes with respect to treatment choices and antibiotic use for paediatric URTIs were investigated to identify key constructs for effective interventions that target the public.

METHODS

Data were collected between June 2017 and April 2018 from a random cluster sample of 3188 parents of children aged 0-13 years across three Chinese provinces, representing different stages of economic development. Risk factors of parents' treatment choices and antibiotic use for paediatric URTIs were assessed using binary and multinomial logistic regressions, adjusting for socio-demographic characteristics.

RESULTS

A total of 1465 (46.0%) children of the 3188 parents who self-diagnosed their children with a URTI were given antibiotics, with or without prescription. Among these children, 40.5% were self-medicated with antibiotics by their parents and 56.1% obtained further antibiotic prescriptions at healthcare facilities. About 70% of children (n=2197) with URTI symptoms sought care; of these, 54.8% obtained antibiotic prescriptions and 7.7% asked for antibiotic prescriptions, with 79.4% successfully obtaining them. Those perceiving antibiotics as effective for treating the common cold and fever (adjusted odds ratio [aOR]=1.82[95% confidence interval, 1.51-2.19] and 1.77[1.47-2.13], respectively), who had access to non-prescription antibiotics (aOR=5.08[4.03-6.39]), and with greater perceived severity of infection (aOR=2.01[1.58-2.56]), were more likely to use antibiotics.

CONCLUSIONS

Multifaceted, context-appropriate interventions are vital to untangle the perpetual problem of self-medication, over-prescription and ill-informed demands for antibiotics. The findings in this study emphasise the need to prioritise interventions that enhance clinical training, neutralise the pressure from patients for antibiotics, educate on appropriate home care, discourage antibiotic self-medication and improve antibiotic dispensing.

Decisions to use antibiotics for upper respiratory tract infections across China: a large-scale cross-sectional survey among university students

OBJECTIVES

To investigate the decision-making process of Chinese university students with respect to antibiotic use for upper respiratory tract infections (URTIs).

DESIGN

A cross-sectional questionnaire study.

SETTING

The participants recruited from six universities across all Chinese regions from September to November 2015.

PARTICIPANTS

A total of 2834 university students sampled across six Chinese regions who self-reported experiencing symptoms of URTI within the past month completed the survey.

OUTCOME MEASURES

The prevalence of decisions for treatment and antibiotic use for URTIs as well as knowledge about antibiotic use were measured by a self-administrated questionnaire. Using regular and multinomial logistic regression a nd adapted health belief model, we identified and measured a number of variables as potential risk factors for antibiotic misuse behaviours in order to explain and predict people's treatment decisions and antibiotic use including knowledge, perceptions, access to antibiotics and cues to action.

RESULTS

Of the 2834 university students who self-diagnosed a URTI, 947 (33.4%) self-reported having taken antibiotics; among them, 462 (48.8%) used non-prescription antibiotics, which came principally from left-over prescriptions (29.0%) and over-the-counter purchases at retail pharmacies (67.3%). One in four who sought care pressured their doctors for antibiotics; all received them. Those who perceived greater severity of the disease, had access to antibiotics, perceived benefits of using antibiotics (for the common cold: adjusted OR (aOR)=2.55, 95% CI 1.93 to 3.38 or as anti-inflammatory drugs: aOR=1.35, 95% CI 1.12 to 1.63), and were cued to action (eg, seeing presence of fever: aOR=2.05, 95% CI 1.62 to 2.60 or self-diagnosing their current infection as severe: aOR=1.86, 95% CI 1.41 to 2.45), keeping antibiotics at home (aOR=2.27, 95% CI 1.83 to 2.81) and access to over-the-counter antibiotics (aOR=2.00, 95% CI 1.63 to 2.45), were more likely to misuse antibiotics.

CONCLUSIONS

Misconceptions of antibiotic efficacy and easy access to antibiotics-with or without a prescription-were associated with antibiotic misuse among Chinese university students, which calls for context-appropriate multifaceted interventions in order to effectively reduce antibiotic misuse.