Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis

Abstract

IntroductionThe inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China.MethodsSearches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only).ResultsIntervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies.ConclusionsInterventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

Prevalence, drivers and surveillance of antibiotic resistance and antibiotic use in rural China: Interdisciplinary study

“…The results from different methodological approaches converge to enhance their validity; thus our exit survey finding that roughly a quarter of those attending low level health facilities for common RTIs (those most frequently diagnosed in primary care including bronchitis/tracheitis, upper respiratory tract infection, pharyngitis, common cold, pneumonia/ PLOS GLOBAL PUBLIC HEALTH bronchopneumonia and tonsillitis) or UTIs had received antibiotics for previous illness episodes in the past year, and that two-thirds of these were from a hospital pharmacy, concords with our observational data on antibiotic prescribing practices in these facilities. The findings that a further third of clinic patients had obtained antibiotics outside hospital pharmacies, and that nearly 90% of retail pharmacy customers had not previously sought treatment elsewhere, further suggest that over-the-counter purchasing of antibiotics as a first resort for everyday health problems is not uncommon, and this is consistent with previous studies that provide evidence for purchasing of antibiotics without prescription in various settings and population groups in China despite ongoing government efforts to restrict this [25]. From the perspective of patients, frequent antibiotic prescribing for common RTIs in clinics reinforces perceptions that antibiotics are appropriate for common symptoms, indirectly validating their direct purchasing of antibiotics to self-treat such symptoms.…”

“…Interviews with doctors confirmed that while they know these conditions may not all be bacterial, they are concerned about the possibility of secondary infections and, in these settings where patients have low incomes and can rarely afford time off work and domestic duties, they regard patient recovery as most reliably ensured by prescribing broad spectrum antibiotics, in combination with an anti-viral traditional Chinese medicine to cover all possible causes. Previous studies have identified uncertainty about treatment and lower levels of professional training as associated with higher levels of antibiotic prescribing [ 25 ]. Suboptimal antibiotic prescribing is exacerbated by short consultations with limited history-taking and non-disclosure of prior antibiotic consumption by patients.…”

“…Microbiological sampling and semi-structured observations were conducted in all eight health facilities, while exit surveys, interviews and observations in retail pharmacies were conducted in the first three study areas (six healthcare facilities and all local pharmacies, which varied from 4–8 in each study area). We also completed a complementary systematic scoping review to identify key influences on antibiotic use in China, the results of which are published separately [ 25 ].…”

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

“…Detailed content of the messages is given in Table 1 . Each of these messages was based on the main drivers of excessive antibiotics as identified from our previous studies [ 27 ] and has specific aims. For example, the message, to be sent out on day 1, aims to build trust and assure the patient not to worry about common RTI symptoms and most of which will start to mitigate within a few days and disappear within about 1 week.…”