Long-term outcomes of an educational intervention to reduce antibiotic prescribing for childhood upper respiratory tract infections in rural China: Follow-up of a cluster-randomised controlled trial

Abstract

BackgroundInappropriate antibiotic prescribing causes widespread serious health problems. To reduce prescribing of antibiotics in Chinese primary care to children with upper respiratory tract infections (URTIs), we developed an intervention comprising clinical guidelines, monthly prescribing review meetings, doctor–patient communication skills training, and education materials for caregivers. We previously evaluated our intervention using an unblinded cluster-randomised controlled trial (cRCT) in 25 primary care facilities across two rural counties. When our trial ended at the 6-month follow-up period, we found that the intervention had reduced antibiotic prescribing for childhood URTIs by 29 percentage points (pp) (95% CI −42 to −16).Methods and findingsIn this long-term follow-up study, we collected our trial outcomes from the one county (14 facilities and 1:1 cluster randomisation ratio) that had electronic records available 12 months after the trial ended, at the 18-month follow-up period. Our primary outcome was the antibiotic prescription rate (APR)—the percentage of outpatient prescriptions containing any antibiotic(s) for children aged 2 to 14 years who had a primary diagnosis of a URTI and had no other illness requiring antibiotics. We also conducted 15 in-depth interviews to understand how interventions were sustained.In intervention facilities, the APR was 84% (1,171 out of 1,400) at baseline, 37% (515 out of 1,380) at 6 months, and 54% (2,748 out of 5,084) at 18 months, and in control facilities, it was 76% (1,063 out of 1,400), 77% (1,084 out of 1,400), and 75% (2,772 out of 3,685), respectively. After adjusting for patient and prescribing doctor covariates, compared to the baseline intervention-control difference, the difference at 6 months represented a 6-month intervention-arm reduction in the APR of −49 pp (95% CI −63 to −35; P < 0.0001), and compared to the baseline difference, the difference at 18 months represented an 18-month intervention-arm reduction in the APR of −36 pp (95% CI −55 to −17; P < 0.0001). Compared to the 6-month intervention-control difference, the difference at 18 months represented no change in the APR: 13 pp (95% CI −7 to 33; P = 0.21). Factors reported to sustain reductions in antibiotic prescribing included doctors’ improved knowledge and communication skills and focused prescription review meetings, whereas lack of supervision and monitoring may be associated with relapse. Key limitations were not including all clusters from the trial and not collecting returned visits or sepsis cases.ConclusionsOur intervention was associated with sustained and substantial reductions in antibiotic prescribing at the end of the intervention period and 12 months later. Our intervention may be adapted to similar resource-poor settings.Trial registrationISRCTN registry ISRCTN14340536.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…Typically, a medical consultation is not needed for URTIs if symptoms resolve within ten days URTIs are frequently viral in origin, generally self-limiting and hardly ever life-threatening 88,196,197 . However, some children can develop pneumonia, which requires hospitalization and specialized treatment 198 .…”

“…URTIs, which include infections of the nose, nasal cavity, pharynx, and larynx with the subglottic area of the trachea, are the most common infections seen in ambulatory care 17,28,[75][76][77][78][79][80][81][82][83] . The majority of these infections are viral in origin, involving any part [more or less] of the upper respiratory tract 80,[83][84][85][86][87][88] , and will typically resolve without the use of antibiotics 21,83,85,[89][90][91][92][93][94][95] . Consequently, the inappropriate use of antibiotics in respiratory tract infections (RTIs) will appreciably enhance AMR rates, with antimicrobial use in RTIs currently seen as the greatest misuse of antimicrobials worldwide 88,96 .…”

“…In light of growing AMR rates and the implications of this, there is an urgent need to review key issues relating to the use of antibiotics for patients with URTIs as well as potential strategies to reduce irrational use to guide future activities. This is because a considerable proportion of antibiotics prescribed and dispensed worldwide are in ambulatory care, and, as mentioned, predominantly for URTIs 21,82,85,88,90,[116][117][118] . There is also a need to focus on LMICs, including sub-Saharan Africa, because infectious disease rates are higher in LMICs than in developed countries, there is extensive self-purchasing of antibiotics in LMICs because of their relatively easy availability, and issues surrounding their inappropriate use have been less well researched and understood in LMICs compared with higher income countries 43,45,49,100,104,[119][120][121][122][123][124] .…”

“…There is also a need to focus on LMICs, including sub-Saharan Africa, because infectious disease rates are higher in LMICs than in developed countries, there is extensive self-purchasing of antibiotics in LMICs because of their relatively easy availability, and issues surrounding their inappropriate use have been less well researched and understood in LMICs compared with higher income countries 43,45,49,100,104,[119][120][121][122][123][124] . A considerably higher percentage of patients with URTIs are inappropriately treated in LMICs compared with high-income countries 88 . In addition, much of the increase in antibiotic consumption in recent years has been in LMICs including Brazil, China, India and South Africa 11,[125][126][127] .…”

“…Neither do we consider antibiotic availability, which can also be a concern in LMICs 149 . The key issue discussed in this paper is the identification of potential ways to reduce rising AMR rates given the high global priority via the appropriate management of URTIs in LMICs 29,88,125,150 .…”