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Liu R, Xue Q, Guan X, Li G, Zhang T, Wang D, Zhao L, Shen X. The effect of a tailored message package for reducing antibiotic use among respiratory tract infection patients in rural Anhui, China: a cluster randomized controlled trial protocol. Trials 2023; 24:637. [PMID: 37794507 PMCID: PMC10548556 DOI: 10.1186/s13063-023-07664-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Antibiotics are over-used for patients with respiratory tract infections (RTIs) in primary care, especially in the rural areas of China. METHODS A cluster randomized controlled trial (RCT) will be carried out to estimate the effectiveness of a tailored message package for educating patients to reduce antibiotic use for symptomatic respiratory tract infections (RTIs). In the intervention group, patients will receive 12 short messages in 12 consecutive days. The whole process of the message design, modification, translation (of substitution variables), and sending will be facilitated by a user-friendly mini-computer program. The primary measure for assessment is the reduction in number of days in which antibiotics are used by patients with symptomatic RTIs. The secondary measures include (1) patients' knowledge about and attitude toward antibiotics; (2) patients' quality of life (EQ-5D-5L) and symptom severity and duration; (3) times of re-visits to clinics and antibiotics re-prescription for the same RTI episode; and (4) times of re-occurrence of RTIs and related health service seeking and antibiotics consumption. DISCUSSION This study will determine the efficacy of a 12-message intervention to educate patients to reduce excessive antibiotic use in rural China. TRIAL REGISTRATION ISRCTN29801086 . Registered on 23 September 2022.
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Affiliation(s)
- Rong Liu
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
| | - Qun Xue
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
| | - Xiaoqin Guan
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
| | - Guocheng Li
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
| | - Tingting Zhang
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, BS8 2PN UK
| | - Debin Wang
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
- Center for Appropriate Technology Research in Health Services and Management, Anhui Medical University, Hefei, Anhui China
| | - Linhai Zhao
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
| | - Xingrong Shen
- School of Health Services Management, Anhui Medical University, Hefei, Anhui China
- Center for Appropriate Technology Research in Health Services and Management, Anhui Medical University, Hefei, Anhui China
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Lambert H, Shen X, Chai J, Cheng J, Feng R, Chen M, Cabral C, Oliver I, Shen J, MacGowan A, Bowker K, Hickman M, Kadetz P, Zhao L, Pan Y, Kwiatkowska R, Hu X, Wang D. Prevalence, drivers and surveillance of antibiotic resistance and antibiotic use in rural China: Interdisciplinary study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001232. [PMID: 37556412 PMCID: PMC10411760 DOI: 10.1371/journal.pgph.0001232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 05/22/2023] [Indexed: 08/11/2023]
Abstract
This study aimed to characterise antibiotic prescribing and dispensing patterns in rural health facilities in China and determine the community prevalence of antibiotic resistance. We investigated patterns and drivers of antibiotic use for common respiratory and urinary tract infections (RTI/UTI) in community settings, examined relationships between presenting symptoms, clinical diagnosis and microbiological results in rural outpatient clinics, and assessed potential for using patient records to monitor antibiotic use. This interdisciplinary mixed methods study included: (i) Observations and exit interviews in eight village clinics and township health centres and 15 retail pharmacies; (ii) Urine, throat swab and sputum samples from patients to identify potential pathogens and test susceptibility; (iii) 103 semi-structured interviews with doctors, patients, pharmacy workers and antibiotic-purchasing customers; (iv) Assessment of completeness and accuracy of electronic patient records through comparison with observational data. 87.9% of 1123 recruited clinic patients were prescribed antibiotics (of which 35.5% contained antibiotic combinations and >40% were for intravenous administration), most of whom had RTIs. Antibiotic prescribing for RTIs was not associated with presence of bacterial pathogens but was correlated with longer duration of infection (OR = 3.33) and presence of sore throat (OR = 1.64). Fever strongly predicted prescription of intravenous antibiotics (OR = 2.87). Resistance rates in bacterial pathogens isolated were low compared with national data. 25.8% of patients reported antibiotics use prior to their clinic visit, but only 56.2% of clinic patients and 53% of pharmacy customers could confirm their prescription or purchase included antibiotics. Diagnostic uncertainty, financial incentives, understanding of antibiotics as anti-inflammatory and limited doctor-patient communication were identified as key drivers of antibiotic use. Completion and accuracy of electronic patient records were highly variable. Prevalence of antibiotic resistance in this rural population is relatively low despite high levels of antibiotic prescribing and self-medication. More systematic use of e-records and in-service training could improve antibiotic surveillance and stewardship in rural facilities. Combining qualitative and observational anthropological methods and concepts with microbiological and epidemiological investigation of antibiotic resistance at both research design and analytic synthesis stages substantially increases the validity of research findings and their utility in informing future intervention development.
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Affiliation(s)
- H. Lambert
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - X. Shen
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - J. Chai
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - J. Cheng
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - R. Feng
- Library Department of Literature Retrieval and Analysis, Anhui Medical University, Hefei, China
| | - M. Chen
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - C. Cabral
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - I. Oliver
- Field Service, National Infection Service, UK Health Security Agency, Bristol, United Kingdom
| | - J. Shen
- Fourth Affiliated Hospital of Anhui Medical University, Hefei, China
| | - A. MacGowan
- Severn Pathology, North Bristol NHS Trust, Bristol, United Kingdom
| | - K. Bowker
- Severn Pathology, North Bristol NHS Trust, Bristol, United Kingdom
| | - M. Hickman
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - P. Kadetz
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - L. Zhao
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Y. Pan
- First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - R. Kwiatkowska
- Field Service, National Infection Service, UK Health Security Agency, Bristol, United Kingdom
| | - X. Hu
- Anhui Provincial Hospital, Hefei, China
| | - D. Wang
- School of Health Services Management, Anhui Medical University, Hefei, China
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Xu X, Zhang K, Ma H, Shen X, Chai J, Tang M, Du Y, Xue Q, Guan X, Li G, Wang D. Differences in service and antibiotics use following symptomatic respiratory tract infections between 2016 and 2021 in rural Anhui, China. Epidemiol Infect 2022; 150:e117. [PMID: 35610736 PMCID: PMC9254148 DOI: 10.1017/s0950268822000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In the past 10-15 years, the government of China has made various efforts in tackling excessive antibiotics use. Yet, little is known about their effects at rural primary care settings. This study aimed to determine the impact of government policies and the COVID-19 pandemic on antibiotic prescribing practices at such settings utilizing data from separate studies carried out pre- and during the pandemic, in 2016 and 2021 in Anhui province, China, using identical sampling and survey approaches. Data on antibiotics prescribed, diagnosis, socio-demographic, etc., were obtained through non-participative observation and a structured exit survey. Data analysis comprised mainly descriptive comparisons of 1153 and 762 patients with respiratory infections recruited in 2016 and 2021, respectively. The overall antibiotics prescription rate decreased from 89.6% in 2016 to 69.1% in 2021, and the proportion of prescriptions for two or more classes of antibiotics was estimated as 35.9% in 2016 and 11.0% in 2021. There was a statistically significant decrease in the number of days from symptom onset to clinic visits between the year groups. In conclusion, measures to constrain excessive prescription of antibiotics have led to some improvements at the rural primary care level, and the COVID-19 pandemic has had varying effects on antibiotic use.
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Affiliation(s)
- Xiuze Xu
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Kexin Zhang
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Huan Ma
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Xingrong Shen
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Jing Chai
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Mengsha Tang
- School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Yanan Du
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Qun Xue
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Xiaoqin Guan
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Guocheng Li
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, Meishan Road 81, Hefei, Anhui 230032, China
- Author for correspondence: Debin Wang, E-mail:
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Xingrong S, Rui F, Jing C, Jing C, Oliver I, Lambert H, Wang D. Relationships Between Diagnosis, Bacterial Isolation, and Antibiotic Prescription in Out Patients With Respiratory Tract Infection Symptoms in Rural Anhui, China. Front Public Health 2022; 10:810348. [PMID: 35223737 PMCID: PMC8864097 DOI: 10.3389/fpubh.2022.810348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThis paper aims to explore the direct associations of antibiotics prescription with clinical diagnosis and bacterial detection. It also analyses the relations of clinical diagnosis with symptoms and bacterial detection, with a hope of revealing indirect links to antibiotic prescription.MethodsThe study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. Observations were conducted to record clinical diagnosis and antibiotic prescription. A semi-structured questionnaire survey was used to collected patients' sociodemographic information and reported symptoms. Sputum and throat swabs were collected for bacterial culture.ResultsAmong 1,068 patients presenting in the study settings who received a diagnosis of respiratory tract infection (RTI), 87.8% of prescriptions included an antibiotic and 35.8% included two or more antibiotics. Symptomatic RTI patients to the site clinics were diagnosed mainly as having upper respiratory tract infection (32.0%), bronchitis/tracheitis (23.4%), others (16.6%), pharyngitis (11.1%), common cold (8.0%), pneumonia/bronchopneumonia (4.6%) and tonsillitis (4.3%). These clinical diagnosis were associated with symptoms to a varied degree especially for upper respiratory tract infection and bronchitis/tracheitis. Prescription of any antibiotics was positively associated with diagnosis of bronchitis/tracheitis (OR: 5.00, 95% CI: 2.63–9.51), tonsillitis (OR: 4.63, 95% CI: 1.48–14.46), pneumonia/bronchopneumonia (OR: 4.28, 95% CI: 1.40–13.04), pharyngitis (OR: 3.22, 95% CI: 1.57–6.59) and upper respiratory tract infection (OR: 3.04, 95% CI: 1.75–5.27). Prescription of two or more antibiotics was statistically significant related to diagnosis of bronchitis/ tracheitis (OR: 2.20, 95% CI: 1.44–3.35) or tonsillitis (OR: 2.97, 95% CI: 1.47–6.00). About 30% of the patients were identified with some type of bacteria. Bacteria detection was linked with pharyngitis (OR: 0.50, 95% CI: 0.28–0.88) but not prescription of antibiotics.ConclusionsAntibiotics prescription were found with a strong relation to diagnosis of RTIs given by the clinician but was not associated with the presence of bacteria in patient samples. Part of the diagnosis may have been given by the clinician to justify their antibiotics prescription. There is clear need to use additional measures (e.g., symptoms) in conjunction with diagnosis to supervise or audit excessive antibiotics use.
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Affiliation(s)
- Shen Xingrong
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Feng Rui
- Department of Literature Review and Analysis, Library of Anhui Medical University, Hefei, China
| | - Chai Jing
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Cheng Jing
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Isabel Oliver
- National Infection Service, Public Health England, Bristol, United Kingdom
| | - Helen Lambert
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, Hefei, China
- *Correspondence: Debin Wang
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Cong W, Chai J, Zhao L, Cabral C, Yardley L, Yao GL, Zhang T, Cheng J, Shen X, Liu R, Little P, Stuart B, Hu X, Sun YH, Oliver I, Zheng B, Lambert H, Wang D. Cluster randomised controlled trial to assess a tailored intervention to reduce antibiotic prescribing in rural China: study protocol. BMJ Open 2022; 12:e048267. [PMID: 34980608 PMCID: PMC8724711 DOI: 10.1136/bmjopen-2020-048267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Wenjuan Cong
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Jing Chai
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Linhai Zhao
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Christie Cabral
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Lucy Yardley
- School of Psychological Sciences, University of Bristol, Bristol, UK
| | - Guiqing Lily Yao
- University of Leicester Department of Health Sciences, Leicester, UK
| | - Tingting Zhang
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Jing Cheng
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - XingRong Shen
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Rong Liu
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Paul Little
- Primary Care and Population Science, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care and Population Science, University of Southampton, Southampton, UK
| | - Xiaowen Hu
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Ye-Huan Sun
- Department of Epidemiology and Biostatistics, Anhui Medical University, Hefei, Anhui, China
| | - Isabel Oliver
- National Infection Service, Public Health England South Region, Bristol, UK
| | - Bo Zheng
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Helen Lambert
- Population Health Sciences, University of Bristol, Bristol, UK
| | - DeBin Wang
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
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Zhang T, Shen X, Liu R, Zhao L, Wang D, Lambert H, Cabral C. The impact of COVID-19 on primary health care and antibiotic prescribing in rural China: qualitative study. BMC Health Serv Res 2021; 21:1048. [PMID: 34610843 PMCID: PMC8490966 DOI: 10.1186/s12913-021-07082-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/21/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In China, the primary health care (PHC) system has been designated responsible for control and prevention of COVID-19, but not treatment. Suspected COVID-19 cases presenting to PHC facilities must be transferred to specialist fever clinics. This study aims to understand the impact of COVID-19 on PHC delivery and on antibiotic prescribing at a community level in rural areas of central China. METHODS Qualitative semi-structured interviews were conducted with 18 PHC practitioners and seven patients recruited from two township health centres and nine village clinics in two rural residential areas of Anhui province. Interviews were transcribed verbatim and analysed thematically. RESULTS PHC practitioners reported a major shift in their work away from seeing and treating patients (due to government-mandated referral to specialist Covid clinics) to focus on the key public health roles of tracing, screening and educating in rural areas. The additional work, risk, and financial pressure that PHC practitioners faced, placed considerable strain on them, particularly those working in village clinics. Face to face PHC provision was reduced and there was no substitution with consultations by phone or app, which practitioners attributed to the fact that most of their patients were elderly and not willing or able to switch. Practitioners saw COVID-19 as outside of their area of expertise and very different to the non-COVID-19 respiratory tract infections that they frequently treated pre-pandemic. They reported that antibiotic prescribing was reduced overall because far fewer patients were attending rural PHC facilities, but otherwise their antibiotic prescribing practices remained unchanged. CONCLUSIONS The COVID-19 pandemic had considerable impact on PHC in rural China. Practitioners took on substantial additional workload as part of epidemic control and fewer patients were seen in PHC. The reduction in patients seen and treated in PHC led to a reduction in antibiotic prescribing, although clinical practice remains unchanged. Since COVID-19 epidemic control work has been designated as a long-term task in China, rural PHC clinics now face the challenge of how to balance their principal clinical and increased public health roles and, in the case of the village clinics, remain financially viable.
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Affiliation(s)
- Tingting Zhang
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Xingrong Shen
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Rong Liu
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Linhai Zhao
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Debin Wang
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christie Cabral
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Shen X, Shen J, Pan Y, Cheng J, Chai J, Bowker K, MacGowan A, Oliver I, Lambert H, Wang D. Clinical diagnosis and treatment of common respiratory tract infections in relation to microbiological profiles in rural health facilities in China: implications for antibiotic stewardship. BMC FAMILY PRACTICE 2021; 22:87. [PMID: 33957884 PMCID: PMC8103749 DOI: 10.1186/s12875-021-01448-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 04/29/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND This paper tries to describe prevalence and patterns of antibiotics prescription and bacteria detection and sensitivity to antibiotics in rural China and implications for future antibiotic stewardship. METHODS The study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. It used mixed-methods comprising non-participative observations, exit-survey and microbiological study. Observations were conducted to record clinical diagnosis and antibiotic prescription. Semi-structured questionnaire survey was used to collect patient's sociodemographic information and symptoms. Sputum and throat swabs were collected for bacterial culture and susceptibility testing. RESULTS A total of 1068 (51.0% male vs 49.0% female) patients completed the study with diagnosis of respiratory tract infection (326,30.5%), bronchitis/tracheitis (249,23.3%), pharyngitis (119,11.1%) and others (374, 35.0%). They provided 683 sputum and 385 throat swab specimens. Antibiotics were prescribed for 88% of the RTI patients. Of all the specimens tested, 329 (31%) were isolated with bacteria. The most frequently detected bacteria were K. pneumonia (24% in all specimens), H. influenza (16%), H. parainfluenzae (15%), P. aeruginosa (6%), S.aureus (5%), M. catarrhalis (3%) and S. pneumoniae (2%). CONCLUSIONS The study establishes the feasibility of conducting microbiological testing outside Tier 2 and 3 hospitals in rural China. It reveals that prescription of antibiotics, especially broad-spectrum and combined antibiotics, is still very common and there is a clear need for stewardship programs aimed at both reducing the number of prescriptions and promoting single and narrow-spectrum antibiotics.
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Affiliation(s)
- Xingrong Shen
- School, of Public Health, Anhui Medical University, Hefei, Anhui China
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
| | - Jilu Shen
- Department of Clinical Laboratory, the Fourth Affiliated Hospital of Anhui Medical University, Hefei, Anhui China
| | - Yaping Pan
- Department of Clinical Laboratory, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui China
| | - Jing Cheng
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
| | - Jing Chai
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
| | - Karen Bowker
- Infection Sciences, Severn Pathology, North Bristol NHS Trust, Pathology Building, Southmead Hospital, Westbury-On-Trym, Bristol, BS10 5NB UK
| | - Alasdair MacGowan
- Infection Sciences, Severn Pathology, North Bristol NHS Trust, Pathology Building, Southmead Hospital, Westbury-On-Trym, Bristol, BS10 5NB UK
| | - Isabel Oliver
- Field Service, National Infection Service, Public Health England, 3rd floor, 2 Rivergate, Bristol, BS1 6EH UK
| | - Helen Lambert
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Debing Wang
- School, of Public Health, Anhui Medical University, Hefei, Anhui China
- School of Health Service Management, Anhui Medical University, Hefei, Anhui China
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8
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Feng Z, Hayat K, Huang Z, Shi L, Li P, Xiang C, Gong Y, Chang J, Jiang M, Yang C, Zhao M, Ji W, Fang Y. Knowledge, attitude, and practices of community pharmacy staff toward antimicrobial stewardship programs: a cross-sectional study from Northeastern China. Expert Rev Anti Infect Ther 2020; 19:529-536. [PMID: 32945697 DOI: 10.1080/14787210.2021.1826307] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Zhitong Feng
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Khezar Hayat
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Zhe Huang
- School of Business Administration, Shenyang Pharmaceutical University, Shenyang, China
| | - Li Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Pengchao Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Cheng Xiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Yilin Gong
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Minghuan Jiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Mingyue Zhao
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Wenjing Ji
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, China.,Shaanxi Centre for Health Reform and Development Research, Xi'an, China.,Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China's Western Technological Innovation Harbor, Xi'an, China
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9
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Chen M, Kadetz P, Cabral C, Lambert H. Prescribing Antibiotics in Rural China: The Influence of Capital on Clinical Realities. FRONTIERS IN SOCIOLOGY 2020; 5:66. [PMID: 33869472 PMCID: PMC8022764 DOI: 10.3389/fsoc.2020.00066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/27/2020] [Indexed: 05/29/2023]
Abstract
Primary care clinicians in rural China are required to balance their immediate duty of care to their patients with patient expectations for antibiotics, financial pressures, and their wider responsibilities to public health. The clinicians in our sample appear to make greater efforts in managing immediate clinical risks and personal reputation than in considering the long-term consequences of their actions as potentially contributing to antimicrobial resistance. This paper employs Bourdieu's theory of capital to examine the perspectives and practices of Chinese primary care clinicians prescribing antibiotics at low-level health facilities in rural Anhui province, China. We examine the institutional context and clinical realities of these rural health facilities and identify how these influence the way clinicians utilize antibiotics in the management of common upper respiratory tract infections. Confronted with various official regulations and institutional pressures to generate revenues, informants' desire to maintain good relations with patients coupled with their concerns for patient safety result in tensions between their professional knowledge of "rational" antibiotic use and their actual prescribing practices. Informants often deferred responsibility for antimicrobial stewardship to the government or upper echelons of the healthcare system and drew on the powerful public discourse of "suzhi" (human quality) to legitimize their liberal prescribing of antibiotics in an imagined socioeconomic hierarchy. The demands of both practitioners' and patients' social, cultural, and economic forms of capital help to explain patterns of antibiotic prescribing in rural Chinese health facilities.
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Affiliation(s)
- Meixuan Chen
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Department of Anthropology, Durham University, Durham, United Kingdom
| | - Paul Kadetz
- Center for Global Health, School of Public Health, Zhejiang University, Hangzhou, China
| | - Christie Cabral
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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10
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Kwiatkowska R, Shen X, Lu M, Cheng J, Hickman M, Lambert H, Wang D, Oliver I. Patients without records and records without patients: review of patient records in primary care and implications for surveillance of antibiotic prescribing in rural China. BMC Health Serv Res 2020; 20:564. [PMID: 32571303 PMCID: PMC7310238 DOI: 10.1186/s12913-020-05308-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We need to monitor patterns of antibiotic prescribing in order to develop and evaluate antibiotic stewardship interventions in rural China. As part of a multidisciplinary study of antibiotic use in Anhui Province we assessed the validity of electronic records (e-records) as a source of surveillance data. METHODS One township healthcare centre and one village clinic were selected in each of three different counties. Patients with symptoms of Upper Respiratory Tract Infection (URTI), exacerbation of Chronic Obstructive Pulmonary Disease (COPD) or Urinary Tract Infection (UTI) were recruited consecutively. Researchers observed and documented clinic consultations and interviewed each of the study participants. E-records were compared to clinic observations and patient interviews. RESULTS A total of 1030 patients were observed in clinic. Antibiotics were prescribed in 917 (89%) of consultations. E-records were created only for individuals with health insurance, with considerable between-site variation in completeness (0 to 98.7% of clinic consultations) and in the timing of documentation (within-consultation up to weeks afterwards). E-record accuracy was better in relation to antibiotics (82.8% of e-records accurately recorded what was prescribed in clinic) than for diagnosis and symptoms (45.0 and 1.1% accuracy). Only 31 participants (3.0%) presented with UTI symptoms. CONCLUSIONS We have confirmed very high rates of outpatient antibiotic prescribing in rural Anhui province. E-records could provide useful information to inform stewardship interventions, however they may be inaccurate and/or biased. Public Health authorities should focus on improving technical infrastructure and record-keeping culture in outpatient settings. Further research is needed into community treatment of UTIs.
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Affiliation(s)
- Rachel Kwiatkowska
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol Medical School, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.
- Field Service, National Infection Service, Public Health England, 3rd floor, 2 Rivergate, Bristol, BS1 6EH, UK.
| | - Xingrong Shen
- School of Health Service Management, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Manman Lu
- School of Health Service Management, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Jing Cheng
- School of Health Service Management, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Matthew Hickman
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol Medical School, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Isabel Oliver
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol Medical School, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
- Field Service, National Infection Service, Public Health England, 3rd floor, 2 Rivergate, Bristol, BS1 6EH, UK
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