Antibiotic Sales in Primary Care in Hubei Province, China: An Analysis of 2012-2017 Procurement Records

Social and cultural determinants of antibiotics prescriptions: analysis from a public community health centre in North India

This paper explores the socio cultural and institutional determinants of irresponsible prescription and use of antibiotics which has implications for the rise and spread of antimicrobial resistance (AMR). This study describes the patterns of prescription of antibiotics in a public facility in India and identifies the underlying institutional, cultural and social determinants driving the irresponsible use of antibiotics. The analysis is based on an empirical investigation of patients' prescriptions that reach the in-house pharmacy following an outpatient department (OPD) encounter with the clinician. The prescription analysis describes the factors associated with use of broad-spectrum antibiotics, and a high percentage of prescriptions for dental outpatient department prescribed as a precautionary measure. This paper further highlights the need for future research insights in combining socio-cultural approach with medical rationalities, to further explore questions our analysis highlights like higher antibiotic prescription, etc., Along with the recommendations for further research.

Green Chemometric Determination of Cefotaxime Sodium in the Presence of Its Degradation Impurities Using Different Multivariate Data Processing Tools; GAPI and AGREE Greenness Evaluation

Four eco-friendly, cost-effective, and fast stability-indicating UV-VIS spectrophotometric methods were validated for cefotaxime sodium (CFX) determination either in the presence of its acidic or alkaline degradation products. The applied methods used multivariate chemometry, namely, classical least square (CLS), principal component regression (PCR), partial least square (PLS), and genetic algorithm-partial least square (GA-PLS), to resolve the analytes' spectral overlap. The spectral zone for the studied mixtures was within the range from 220 to 320 nm at a 1 nm interval. The selected region showed severe overlap in the UV spectra of cefotaxime sodium and its acidic or alkaline degradation products. Seventeen mixtures were used for the models' construction, and eight were used as an external validation set. For the PLS and GA-PLS models, a number of latent factors were determined as a pre-step before the models' construction and found to be three for the (CFX/acidic degradants) mixture and two for the (CFX/alkaline degradants) mixture. For GA-PLS, spectral points were minimized to around 45% of the PLS models. The root mean square errors of prediction were found to be (0.19, 0.29, 0.47, and 0.20) for the (CFX/acidic degradants) mixture and (0.21, 0.21, 0.21, and 0.22) for the (CFX/alkaline degradants) mixture for CLS, PCR, PLS, and GA-PLS, respectively, indicating the excellent accuracy and precision of the developed models. The linear concentration range was studied within 12-20 μg mL^-1 for CFX in both mixtures. The validity of the developed models was also judged using other different calculated tools such as root mean square error of cross validation, percentage recoveries, standard deviations, and correlation coefficients, which indicated excellent results. The developed methods were also applied to the determination of cefotaxime sodium in marketed vials, with satisfactory results. The results were statistically compared to the reported method, revealing no significant differences. Furthermore, the greenness profiles of the proposed methods were assessed using the GAPI and AGREE metrics.

Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province

BACKGROUND

Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example.

METHODS

Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results.

RESULTS

Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs.

CONCLUSIONS

The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.

Antibiotic Use in China’s Public Healthcare Institutions During the COVID-19 Pandemic: An Analysis of Nationwide Procurement Data, 2018–2020

Background: The overuse of antibiotics is a serious public health problem and a major challenge in China, and China lacks up-to-date evidence on the nationwide antibiotic use in different healthcare settings. The changes of China’s antibiotic use under the COVID-19 pandemic are still unknown.

Objective: This study aimed to investigate the use of antibiotics in China’s public medical institutions based on a three-year nationwide surveillance and to examine the impact of the COVID-19 pandemic on China’s antibiotic consumption.

Methods: This study used nationwide drug procurement data from the China Drug Supply Information Platform (CDSIP). We retrospectively analyzed antibiotic procurement data of 9,176 hospitals and 39,029 primary healthcare centers (PHCs) from 31 provinces in mainland China from January 2018 to December 2020. Antibiotic utilization was measured by defined daily doses (DDDs) and DDD per 1,000 inhabitants per day (DID). Generalized linear regression models were established to quantify the impact of the COVID-19 pandemic on antibiotic use.

Results: The total antibiotic consumption among all healthcare settings increased from 12.94 DID in 2018 to 14.45 DID in 2019, and then dropped to 10.51 DID in 2020. More than half of antibiotics were consumed in PHCs, especially in central regions (59%–68%). The use of penicillins (J01C) and cephalosporins (J01D) accounted for 32.02% and 28.86% of total antibiotic consumption in 2020. During 2018–2020, parenteral antibiotics accounted for 31%–36% of total antibiotic consumption; the proportion is more prominent in central and western regions and the setting of hospitals. Access category antibiotics comprised 40%–42% of the total utilization. Affected by COVID-19, the antibiotic consumption was significantly dropped both in hospitals (β = −.11, p < .001) and PHCs (β = −.17, p < .001), as well as in total (β = −.14, p < .001). Significant increments were observed in the proportion of total antibiotics (β = .02, p = .024) consumed in hospitals (against the consumption in all healthcare settings), as well as parenteral antibiotics (β = 1.73, p = .001).

Conclusion: The consistent preferred use of penicillin and cephalosporin, as well as injections, among China’s public healthcare institutions should draw concern. China’s antibiotic consumption significantly declined during the COVID-19 pandemic, which brings opportunities for antibiotic use management in China.

Urinary antibiotic level of school children in Shanghai, East China, 2017-2020

In recent years, an extensive exposure to antibiotics from various sources has been demonstrated in China by the biomonitoring method, but the temporal trend remains little known. The study aim was to explore the temporal trend of exposure to antibiotics and associated health risk in children. A dynamic child cohort was established in Shanghai, East China between 2017 and 2020. A total of 684 school children aged 7-11 years were included, and 280 in 2017, 279 in 2018, 288 in 2019, and 287 in 2020 participated in annual surveys. Twenty-three typical antibiotics and three metabolites from five categories (four tetracyclines, five qinolones, six macrolides, eight sulfonamides, and three phenicols), bisphenol A (BPA), and monobutyl phthalate (MBP) were determined in urine. Logistic regression analysis with generalized estimating equations was conducted to investigate the associations between various variables and the detection frequency of antibiotics in urine. Seventeen antibiotics and three metabolites were found in 51.9% of all urine samples. Compared to 2017, the detection frequency in urine reduced 31.8% in 2020 for all antibiotics (58.2% vs 39.7%) and reduced 36.8%-55.8% for tetracyclines (11.4% vs 7.0%), qinolones (34.3% vs 21.3%), macrolides (8.6% vs 3.8%), sulfonamides (16.4% vs 8.7%), and phenicols (19.3% vs 12.2%). After accounting for personal characteristics, food consumption, and urinary BPA and MBP, a decreasing temporal trend of detection frequencies was observed from 2017 to 2020 for most antibiotics. Urinary concentration, estimated daily intake, and acceptable daily intake-based health risk of antibiotics showed a temporal trend similar to detection frequency. There was an extensive exposure to antibiotics in children. However, a decreasing temporal trend occurred for the exposure during the period from 2017 to 2020. The trend was likely to be caused by decreased antibiotic use and/or decreased residues in food and/or drinking water.

Analysis of Antibiotic Consumption by AWaRe Classification in Shandong Province, China, 2012-2019: A Panel Data Analysis

Introduction: This study aims to examine the changes in trends and patterns of clinical consumption of antibiotics in Shandong, China based on Access, Watch, and Reserve (AWaRe) Classification after 10-years national antibiotic stewardship. Methods: Antibiotic consumption data of all health care institutions for the period of 2012-2019 were obtained from the Drug Centralized Bidding Procurement System of Shandong. Shandong is a province that has the second-largest population in China. Five of the 16 cities in Shandong were high-income areas (HIAs) and the other 11 cities were grouped into upper-middle-income areas (UMIAs). The main outcome measures were the antibiotic consumption rates (DDD per 1,000 inhabitants per day, DID) and the proportions of different groups of antibiotics. Results: The overall antibiotic consumption rate increased from 12.859-15.802 DID between 2012 and 2014, then continuously decreased to 9.771 DID in 2019. The consumption rate of access, watch, and reserve antibiotics have reduced since 2014 with a compound annual growth rate of -10.1, -9.0, and -8.1%, respectively. During 2012-2019, the access group proportion reduced from 50.0 to 44.9%, while the proportion of the watch group increased from 42 to 45.2%. The antibiotic consumption rate increased from 2012 to 2019 (from 7.38 to 9.12 DID) in the HIAs but sharply decreased in the UMIAs from 2014 to 2019 (from 17.94 to 10.05 DID). The watch antibiotics had the highest proportion of consumption in the HIAs (55.3% in 2019), while the access group had the highest proportion of consumption in the UMIA (49.5% in 2019). Conclusion: The antibiotic stewardship policies launched in the last 10 years have contributed to reducing the clinical antibiotic consumption in Shandong. These policies have different effects on areas with different economic levels. The pattern of antibiotic consumption is still inappropriate in China as the watch group of antibiotics was consumed the most.

Antibiotics (Macrolides and Lincosamides) Consumption Trends and Patterns in China's Healthcare Institutes. Based on a 3 Year Procurement Records, 2015-2017

In this study, we investigated the trends and patterns of antibiotic consumption (macrolides and lincosamides) in China’s healthcare institutions from 2015 to 2017. The China Drug Supply Information Platform (CDSIP) was officially launched in 2015. We collected records from this national centralized bidding procurement system between 2015 and 2017. The use of J01F antibiotics (macrolides or lincosamides) was calculated in a defined daily dose per 1000 inhabitants per day (DID).Purchase data from 70,366 national medical facilities included in the CDSIP were collected. The procurement data of 66,007 medical facilities have not changed over 3 years. There is a slight decline in the consumption of J01F antibiotics, which decreased from 3.03 DID in 2015 to 2.91 DID in 2017. Azithromycin (20.6%) was the most commonly used antibiotic in 2017 among all classes, followed by clindamycin (17.9%) and erythromycin (13.7%). Parenteral antibiotics accounted for 32.0% of total antibiotic consumption and 59.6% of total antibiotics expenditure in 2017. The overall consumption of most antibiotics decreased slightly over the 3-yearstudy period. This may be owing to China’s health-related policies in the past few years. A gap still exists in antibiotic use between regions and dosage forms. Further studies are needed to optimize antibiotic prescribing and reduce antibiotic resistance.

Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians

Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO "Watch and Reserve" list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO "Watch and Reserve" list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

National Consumption of Antimicrobials in Tanzania: 2017-2019

Objective: Surveillance of antimicrobial consumption is essential to the national action plan for antimicrobial resistance (AMR) as stipulated in the Global Action Plan on AMR and the Tanzanian National Action Plan on AMR. Given the paucity of antimicrobial consumption data in sub-Saharan Africa region, the objective of this study was to measure antimicrobial consumption in Tanzania.

Methods: From 2017 to 2019, data on all antimicrobials imported into Tanzania were obtained from the Tanzania Medicines and Medical Devices Authority Data, augmented with purchasing data from the Medical Stores Department and data from local manufacturers. Data were collected and analyzed in accordance with the World Health Organization Anatomical Therapeutic Chemical and defined daily doses (DDD) methodology.

Results: The average DDD per 1,000 inhabitants per day (DDD/1,000/D) for all antimicrobials was 80.8 ± 39.35. The DDD/1,000/D declined from 136.41 in 2017 to 54.98 in 2018 and 51.02 in 2019. Doxycycline, amoxicillin, and trimethoprim-sulfamethoxazole were the most frequently consumed antibiotics during these years, accounting for 20.01, 16.75, and 12.42 DDD/1,000/D, respectively. The majority of antimicrobial consumption in Tanzania occurred in the private sector, with the proportion of private-sector antibiotic consumption increasing annually from 2017 to 2019. Based on AWaRe classification >90% of antimicrobial consumption was Access class medications, with Watch and Reserve class medications accounting for <10% and <1%, respectively.

Conclusion: The private sector use of antimicrobials is significantly increasing and should be carefully monitored in accordance with national policies. Future work is necessary to increase reporting of antimicrobial consumption patterns in sub-Saharan Africa.

Analysis of Antibiotic Use Patterns and Trends Based on Procurement Data of Healthcare Institutions in Shaanxi Province, Western China, 2015-2018

Overuse of antibiotics has caused a series of global problems, especially in the underdeveloped western regions where healthcare systems are fragile. We used antibiotic procurement data of all healthcare institutions to analyze the total amount, patterns and trends of antibiotic use in Shaanxi Province, western China between 2015 and 2018. Antibiotic utilization was quantified using the standard Anatomical Therapeutic Chemical (ATC)/Defined daily dose (DDD) methodology. The World Health Organization’s “Access, Watch and Reserve” (AWaRe) classification and European Surveillance of Antimicrobial Consumption (ESAC) drug-specific quality indicators were also adopted to evaluate the appropriateness and quality of antibiotic utilization. Overall, antibiotic consumption decreased from 11.20 DID in 2015 to 10.13 DID (DDDs per 1000 inhabitants per day) in 2016, then increased to 12.99 DID in 2018. The top three antibiotic categories consumed in 2018 were J01C (penicillins) 33.58%, J01D (cephalosporins) 29.76%, and J01F (macrolides) 19.14%. Parenteral antibiotics accounted for 27.41% of the total consumption. The largest proportion of antibiotic use was observed in primary healthcare institutions in rural areas, which accounts for 51.67% of total use. Consumption of the Access group, the Watch group, the Reserve group of antibiotics was 40.31%, 42.28% and 0.11%, respectively. Concurrently, the consumption of J01D and the percentage of J01 (DD + DE) (third and fourth generation cephalosporins) were at a poor level according to the evaluation of ESAC quality indicators. The total antibiotic consumption in Shaanxi Province had been on an upward trend, and the patterns of antibiotic use were not justified enough to conclude that it was rational. This is partly because there was high preference for the third and fourth generation cephalosporins and for the Watch group antibiotics.

Escherichia coli Resistance to Fluoroquinolones in Community-Acquired Uncomplicated Urinary Tract Infection in Women: a Systematic Review

Antibiotic resistance is a threat to public health, and uncomplicated urinary tract infections (uUTIs) are an example of this concern. This systematic review (International Prospective Register of Systematic Reviews [PROSPERO] ID: CRD42020156674) is the first to determine the prevalence of Escherichia coli resistance to fluoroquinolones in women with community-acquired uUTI. PubMed and Embase searches were conducted; 38 studies fulfilled eligibility criteria and were included in the systematic review. Within Europe, ciprofloxacin resistance in E. coli isolates varied between countries and increased in some from 2006 to 2008 and 2014 to 2016, specifically in the United Kingdom (0.5% to 15.3%), Germany (8.7% to 15.1%), and Spain (22.9% to 30.8%), although methodologies and settings were often not comparable. In Asia, there was a substantial increase in ciprofloxacin resistance during 2008 to 2014 from 25% to more than 40%. In North America, resistance to ciprofloxacin also increased between 2008 and 2017, from 4% to 12%. Data exploring different age groups did not show a consistent relationship with resistance, whereas two studies found that fluoroquinolone resistance was higher in postmenopausal women than premenopausal women. One study indicated a link between fluoroquinolone resistance and uUTI recurrence. These findings may have implications for the empirical treatment of uUTI with fluoroquinolones globally, but more data are needed to fully understand regional situations and impact patient management.

Patterns of Antibiotic Prescription in Colombia: Are There Differences between Capital Cities and Municipalities?

The use of antibiotics is the most important modifiable risk factor for the development of microorganism resistance. A cross-sectional study of outpatients receiving antibiotic prescriptions registered in a population database in Colombia was conducted. The characteristics of the consumption in capital cities and small municipalities was studied and the AWaRe classification was used. AWaRe classifies antibiotics into three stewardship groups: Access, Watch and Reserve, to emphasize the importance of their optimal use and potential harms of antimicrobial resistance. A total of 182,397 patients were prescribed an antibiotic; the most common were penicillins (38.6%), cephalosporins (30.2%) and fluoroquinolones (10.9%). ‘Access’ antibiotics (86.4%) were the most frequently prescribed, followed by ‘Watch’ antibiotics (17.0%). Being 18 or older, being male, living in a municipality, having one or more comorbidities and urinary, respiratory or gastrointestinal disorders increased the probability of receiving ‘Watch’ or ‘Reserve’ antibiotics. Penicillin and urinary antiseptic prescriptions predominated in cities, while cephalosporin and fluoroquinolone prescriptions predominated in municipalities. This analysis showed that the goal set by the WHO Access of mainly using Access antibiotics is being met, although the high use of Watch antibiotics in municipalities should be carefully studied to determine if it is necessary to design specific campaigns to improve antibiotics use.

Quality of primary health care in China: challenges and recommendations

China has substantially increased financial investment and introduced favourable policies for strengthening its primary health care system with core responsibilities in preventing and managing chronic diseases such as hypertension and emerging infectious diseases such as coronavirus disease 2019 (COVID-19). However, widespread gaps in the quality of primary health care still exist. In this Review, we aim to identify the causes for this poor quality, and provide policy recommendations. System challenges include: the suboptimal education and training of primary health-care practitioners, a fee-for-service payment system that incentivises testing and treatments over prevention, fragmentation of clinical care and public health service, and insufficient continuity of care throughout the entire health-care system. The following recommendations merit consideration: (1) enhancement of the quality of training for primary health-care physicians, (2) establishment of performance accountability to incentivise high-quality and high-value care; (3) integration of clinical care with the basic public health services, and (4) strengthening of the coordination between primary health-care institutions and hospitals. Additionally, China should consider modernising its primary health-care system through the establishment of a learning health system built on digital data and innovative technologies.

Antibiotic Consumption Trends in China: Evidence From Six-Year Surveillance Sales Records in Shandong Province

Background

The overuse of antibiotics is a serious public health problem in China, causing a high rate of antimicrobial resistance. This study identified the trends of antibiotic consumption in China to provide evidence for further intervention.

Method

The six-year surveillance data on antibiotic sales from 2012 to 2017, which served as a proxy for consumption, were collected from 39 public health care facilities in Shandong province, including three tertiary hospitals, six secondary hospitals, and 30 primary health centers. Based on the Anatomical Therapeutic Chemical (ATC)/DDD methodology, antibiotic consumption was formulated in defined daily doses (DDD) per 1,000 inhabitants per day (DID).

Results

The total antibiotic consumption among all health care settings increased from 16.07 DID in 2012 to a peak of 17.44 DID in 2015 and then decreased to 11.35 DID in 2017 with a 34.90% reduction. J01C (beta-lactam antimicrobials, penicillin), the most frequently used antibiotic class, accounted for 36.32% of the total DID. Consumption of carbapenems increased from 0.029 DID in 2012 to 0.08 DID in 2017. Parenteral antibiotics accounted for nearly 40% of the total consumption. Compared with the 2012 figures, the 2017 consumption showed a small increase in hospital sector that was compensated by the decrease in community care.

Conclusion

A substantial reduction in total antibiotic consumption was observed in China from 2012 to 2017. However, the extensive consumption of broad-spectrum antimicrobials, high proportion of parenteral antibiotic use, and increased use of last-resort antibiotics attracted public health concerns.