Lancet Global Health: Promoting rational use of antibiotics in China

CITATION: Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trial
Prof Xiaolin Wei, Zhitong Zhang, Prof John D Walley, Joseph P Hicks, Jun Zeng, Simin Deng, Yu Zhou, Jia Yin, Prof James N Newell, Prof Qiang Sun, Guanyang Zou, Prof Yan Guo, Prof Ross E G Upshur, Dr Mei Lin,
Published: 25 October 2017


Background: Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China.

Methods: We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period…

Findings: We recruited all 25 eligible township hospitals in the two counties (14 hospitals in Rong county and 11 in Liujiang county), and randomly allocated 12 to the intervention group and 13 to the control group. We implemented the intervention in three internal pilot clusters between July 1, 2015, and Dec 31, 2015, and in the remaining nine intervention clusters between Oct 1, 2016 and March 31, 2016. Between baseline (the 3 months before implementation of the intervention) and endline (the final 3 months of the 6-month intervention period) the antibiotic prescription rate at the individual level decreased from 82% (1936/2349) to 40% (943/2351) in the intervention group, and from 75% (1922/2548) to 70% (1782/2552) in the control group. After adjusting for the baseline antibiotic prescription rate, stratum (county), and potentially confounding patient and prescribing doctor covariates, this endline difference between the groups represented an intervention effect (absolute risk reduction in antibiotic prescribing) of -29% (95% CI -42 to -16; p=0·0002).

Interpretation: In China’s primary care setting, pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced prescribing of antibiotics for childhood upper respiratory tract infections.

Best wishes, Neil

Member, HIFA Project on Information for Prescribers and Users of Medicines

Let’s build a future where people are no longer dying for lack of healthcare information – Join HIFA:

Further to my message a few minutes ago I just saw there is an excellent linked Comment on the study. Thanks to The Lancet Global Health’s OA policy I am able to reproduce it at length below.

CITATION: Reducing antibiotic prescriptions for childhood upper respiratory tract infections
Gary W K WongEmail the author Gary W K Wong
Published: 25 October 2017

Reducing antibiotic prescriptions for childhood upper respiratory tract infections

Resistance to antibiotics has become a major health threat worldwide, and one of the most important contributing factors is the widespread overuse of antimicrobials. This problem is most severe in low-income and middle-income countries (LMICs), where physicians have few resources for investigations and diagnosis, along with inherent concerns about missing an underlying bacterial infection… Poor knowledge and awareness among caregivers of children also results in inappropriate demand for antibiotic prescriptions for their children…

The study by Xiaolin Wei and colleagues in The Lancet Global Health9 provides important evidence regarding effective interventions in reducing unnecessary antibiotic prescriptions in rural China. The investigators did a cluster-randomised controlled trial, stratified by county, comparing the effectiveness of an intervention programme to reduce antibiotic prescribing with usual care in 25 township hospitals in rural Guangxi province, a low-income area in the southwest of China. The authors aimed to reduce antibiotic prescriptions in children older than 2 years of age with a diagnosis of an upper respiratory tract infection. Their intervention has two important components: first, they set up a comprehensive educational programme for participating doctors, including an interactive training session to improve their knowledge of appropriate use of antibiotics and monthly peer-review meetings to provide feedback. Second, they developed leaflets and an educational video that was played on a loop in the waiting area to educate the caregivers of the children. For children visiting these township hospitals with a diagnosis of upper respiratory tract infection, baseline antibiotic prescription rates were shockingly high at 82% and 75% in the intervention group and control group, respectively. The total duration of the trial including the initial pilot period and the full intervention period was 9 months. The results showed that the antibiotic prescription rate decreased from 82% to 40% in the intervention group and from 75% to 70% in the control group. The difference in the reduction between the two groups was highly significant, with an absolute reduction in antibiotic prescribing rate in the intervention group versus the control group of 29% (95% CI -42 to -16; p=0·0002).

Since antibiotic-prescribing behaviour and physicians’ concerns about treating upper respiratory tract infections are very similar across the world, it is highly likely that such an intervention would also be effective in other settings with a similar health care reimbursement system. One important remaining question is the sustainability of such prescribing behaviour once the intervention is stopped. Some form of re-enforcement or maintenance education is probably needed in order to sustain such a change in behaviour. Given the problems of antibiotic resistance and the cost of inappropriate antibiotic prescriptions, the benefits of these programmes will probably far exceed the costs needed to run them. In the emergency departments of large hospitals in Chinese cities like Beijing or Shanghai, children are often seen to be connected to an intravenous line receiving antibiotics, despite a diagnosis of relatively mild febrile respiratory illness. Further studies are needed to test whether or not such an educational programme is effective in changing the prescribing behaviour of physicians in these large hospitals, since the remuneration system and the parental expectations differ to those in the rural areas of China. Replication studies are needed to confirm if such programme is effective in other LMICs that may have different remuneration systems and expectations.

Best wishes, Neil

Member, HIFA Project on Information for Prescribers and Users of Medicines

Let’s build a future where people are no longer dying for lack of healthcare information – Join HIFA:

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