Key findings
This study reveals useful findings on antibiotic use and microbiological test results for patients presenting RTIs symptoms at rural and township care settings in Anhui, China. It documents an antibiotic prescription rate as high as 87.8% and most frequent use of broad-spectrum and multiple antibiotics. It demonstrates that nearly one third (30.8%) of the specimens were isolated with pathogenic bacteria or asymptomatic carrier with the top bacteria strains being K. pneumonia, H. influenza, H. parainfluenzae, P. aeruginosa and S. aureus and the highest resistance rate being K. pneumoniae to ampicillin followed by S.pneumoniae to Clindamycin, H. influenzae to Trimethoprim/ Sulfaisoxazole and H. parainfluenzae to Ampicillin.
Implications in context of other research and for policy
The above study findings have important implications for antibiotics stewardship. The high rate of antibiotics prescriptions contradicts a common belief among policymakers in China that excessive antibiotics use is being brought under control as a result of the nationwide Special Antibiotics Use Rectification program (initiated in 2011) and the New Health System Reforms [
19,
20]. These initiatives focus on antibiotics use at secondary and tertiary hospitals. Given that about 57% of China’s vast population lives in rural and township areas and over 70% of antibiotics prescriptions occur at settings in these areas [
21,
22], there is a clear need for added attention on excessive antibiotics use at these settings and communities.
The frequent use of broad-spectrum and multiple (2 or more) antibiotics calls for stewardship programs aiming at not only reducing the number of prescriptions but also promoting single and narrow-spectrum antibiotics. Most of the broad-spectrum antibiotics, especially quinolones, cephalosporins and amoxi-clav, have strong resistance driving effect; while use of multiple antibiotics often acts as an even greater driver. This prevalent use of broad-spectrum and multiple antibiotics may be attributed mainly to medical uncertainty though decisions on which specific antibiotics to use depends on a variety of factors including availability, price, sensitivity, adverse effects and other characteristics of the antibiotics under concern [
23‐
27]. Rural and township healthcare doctors in China work in a difficult situation in which microbiological tests are unavailable and it is hard to tell the pathogen and its sensitivity to specific antibiotics from clinical symptoms/ history. So, they tend to view broad-spectrum or combined antibiotics as a safer strategy than narrow spectrum antibiotics since the former have greater chance of hitting the actual pathogen [
28,
29].
The microbiological test results indicate the feasibility of such tests for rural and township care attendees in resource-poor rural China. As described in our separate protocol paper, the testing proceeded by collecting specimens at the rural and township care settings and sending the specimens to a tertiary hospital with a microbiological lab via existing transportation services [
14]. We collected and tested 1068 specimens out of 1073 RTI patients. Our overall rate of bacteria detection was 30.8% which is compatible with published results for similar population groups [
30]. These all suggest that the testing is acceptable to both patients and physicians and the test results are relatively reliable.
The difference between the resistance rates tested in this study and that from higher level settings suggests a need for incorporating rural and township care settings into China’s national antibiotics use and resistance surveillance systems. Our study indicates that antibiotics resistance rates among rural and township care attendees are substantially lower than that among patients of hospitals forming the national antibiotics resistance surveillance network, being 2.5% vs 56.6% for K.
pneumonia to cefazolin, 58.0% vs 60.3% for H.
influenzae to ampicillin, 5.9% vs 25.2% for P.
aeruginosa to piperacillin, 35.3% vs 61.5% for S.
aureus to erythromycin and 80.0% vs 89.9% for S.
pneumoniae to clindamycin [
30]. These differences in resistance between hospitals and primary care would imply lower general antibiotics prescribing, and especially more narrow-spectrum antibiotics. However, as mentioned above, doctors at primary care settings are practicing the opposite.
The early healthcare seeking together with the high rate of antibiotics prescription highlights the importance of educating doctors and patients to postpone antibiotics prescription and use. The study found that over 60% of visits to the village clinics or health centers happened within 4 days after onset of infection symptoms and the mean time of visits was 6 days. This is relatively short as compared to that from western nations. Studies from Europe of lower RTIs have documented a mean time lag of 4 to 12 days [
31]. Early visits to clinics with a clear expectation to get antibiotics merits adequate attention in future interventions.
Both the profiles of detectable pathogen and asymptomatic carrier bacteria have important implications. Detection of pathogen bacteria (e.g., S.
aureus, M.
catarrhalis, S.
pneumoniae,
βhaemolytic streptococci and E.
coli) should inform clinical treatment decision-making. Although detection of the asymptomatic carrier may not necessarily cause the infections, it may be used as indirect or surrogate indicators for assessing antibiotic resistance. Perhaps the biggest barrier to microbiological evidence-based antibiotics use for primary care doctors at present may be the delay due to sending specimens to and getting results from higher level labs in addition to time needed for bacteria cultivation and test. Point of care tests may help overcome this barrier. Unfortunately, such tests are generally not available in China [
32]. This lack of external validity and clinical uncertainty in primary care together with the links between antibiotics prescription and the number of days until care seeking call for more patient education and more use of a delayed prescribing strategy.
Strengths and limitations of the study
This study has both strengths and limitations. It is the first study that collected data from healthcare providers and users via a non-participative observation whilst most of the existent research on antibiotics use in China uses data from medical records or reports by medical care givers who may be incentivized to omit recording overuse or misuse of antibiotics so as to meet relevant policy requirements. It is also the first study that performed both microbiological testing and clinical data collection at rural and township care settings and thus enables cross-linking between data from different sources. However, the study suffers from limited number of patients and site clinics. It involved only 8 site clinics or health centers from a single province. So, readers are cautioned about the generalization of the findings to other parts of China, thought the social, cultural and economic background of Anhui is similar to the majority of areas in the nation. The non-participative observation may also have intervened, to some extent, the routine encounters between the patients and doctors and the prescription behaviors being observed though we had arranged a two-week preparation for each site clinic to allow the field researchers to build trust with the doctors. The paper tried to use pure clinical diagnoses to evaluate the other findings; while in reality, it is generally hard to separate the diagnoses of respiratory tract infection and common cold, furthermore pharyngitis and tonsillitis.