Prevalence and risk factors for antibiotic utilization in Chinese children

Antibiotic utilization is a major driver of antibiotic resistance, which is becoming a serious public health threat, imposing a direct effect on morbidity, mortality, and financial burden [1‐3]. It was reported that China was the second largest consumer of antibiotics, and up to 57% of the increase in antibiotic consumption in the hospital sector among BRICS countries (Brazil, Russia, India, China, and South Africa) was attributable to China [4]. In addition, China also has the most rapid growth rate of antibiotic resistance worldwide [5].

Antibiotics are the most widely prescribed therapy among all medications given to children [6, 7]. It was reported that the proportion of children with antibiotic prescription in the hospital settings was between 22% and 78 %[8‐13], at the same time, inappropriate antibiotic prescription was the most common in pediatric clinical practice [14, 15]. About 50% of antibiotics were prescribed to children who were suffering from viral infection or non-infectious diseases, and the proportion of antibiotic prescriptions under 15 years old was three times than other ages [16, 17]. In addition, antibiotic abuse and misuse can also result in adverse events and drug toxicity due to children’s special physiological condition [18]. Children who prescribed antibiotics were more likely to have a subsequent acute bronchitis episode [19, 20]. China Antimicrobial Resistance Surveillance System (CARSS) showed that the proportions of gram-positive bacteria isolated from children and newborns was 45.5% in 2017, which were higher than that of the adults [21]. Children may have little or even no benefit from antibiotics [22], therefore, promotion of rational use of antibiotics and reduction in antibiotic resistance in children has become an urgent problem [23, 24]. To combat this problem, the Chinese government has launched relevant policies continuously since 2009. In 2009, to improve rational use of medicines, China government enacted the national essential medicines scheme, which aimed to curb the use of antibiotics by breaking the financial relation between drug prescription and physician income. Zero-mark-up policy was introduced to primary healthcare centers (PHCs) firstly in 2009, then followed by secondary hospitals in 2012, and expanded in tertiary hospitals in 2016 [25]. Hierarchical management was carried out for the clinical use of antibacterial drugs, which includes three levels: unrestricted use, restricted use and special use, according to safety, effect, drug resistance, and price in 2012 [26]. Since 2013, to improve antibiotic utilization in public hospitals, National Antibiotic Stewardship Program (NASP) was implemented nationwide which limits the proportion of outpatient antibiotic prescriptions and inpatient antibiotic prescriptions in hospitals to 20% and 60%, respectively [27]. National action plan combating antimicrobial resistance proposed to carry out health education on the rational use of antibiotics in primary and secondary schools [28].

Recently, the number of studies on the prevalence of antibiotic utilization in Chinese children has increased greatly, while sparse studies explored risk factors. Assessment of risk factors for antibiotic utilization in children may lead to a better understanding of the prevalence rates of antibiotics utilization and therefore leading to a more effective preventive strategy. In addition, most of the relevant studies were published in Chinese, with only a few in English language, which caused a lack of awareness of antibiotic utilization in China worldwide. There has not been an in-depth, up-to-date, and comparative analysis of the contemporary literature reporting the prevalence and risk factors for antibiotic utilization in Chinese children. In this study, we aimed to summarize the proportion of antibiotic usage among outpatients, inpatients, and self-medication, and investigate the major risk factors for antibiotic utilization in Chinese children.

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline [29]. The protocol was registered with PROSPERO (CRD42020200172) (Table S1 in Additional file 1).

The prevalence of antibiotic utilization in Chinese children was high. The overall prevalence of antibiotic utilization among outpatients and inpatients was 63.8% and 81.3%, respectively, and caregivers’ self-medicating with antibiotics for children at home was 37.8%.

Two literature reviews reported a prevalence of 89% or 90.6% for antibiotic utilization in Chinese children, which was higher than that in our study [108, 132]. Compared to before 2010, the prevalence of antibiotics in children has decreased, which was 93.0 % [108, 132]. However, our results were still much higher than the standard values of 20% for outpatient and 60% for inpatient with antibiotic prescriptions issued in an antimicrobial stewardship policy by Chinese government [133]. In addition, the prevalence of antibiotic utilization for children in China was higher than that in the USA (17%-29% ) [134]. According to the ARPEC (Antibiotic Resistance and Prescribing in European Children) report, the prevalence of antibiotic utilization from 226 hospitals in 41 countries was 36.7 % [12]. The overall prevalence of caregiver’s self-medicating of antibiotics for children at home was 37.8%, which was similar to the Chang et.al’ s finding (37.67% ) [122], but lower than that in India (69.4% ) [135].

Children are more susceptible to infection due to their unique peculiarities of body size, surface area, drug metabolism, and excretion, which may be associated with high antibiotic prevalence. However, acute upper respiratory infections (AURIs) are the most common condition associated with the excessive use of antibiotics [136]. Most AURIs are caused by viral infection and usually resolved after three to seven days [137]. However, the use rate of antiviral drugs in the treatment of AURIs in children is low, and most of physicians choose newer, broad-spectrum antibiotics [45]. Therefore, identifying the characteristics of childhood diseases and encouraging the prescriptions of older, narrow-spectrum antibiotics rather than newer, broad-spectrum antibiotics plays an important role in the process of rational use of antibiotics. For school student, there is no systematic teaching on antibiotics, therefore, it is difficult for them to identify antibiotics. In addition, students in different regions have varieties of understandings of antibiotics. The awareness of antibiotics utilization in central urban areas is higher than that of urban and rural areas and counties in suburbs, in addition, the awareness of antibiotics utilization in high school students is higher than that in junior high school and vocational high school [121]. Therefore, more efforts should be made to improve the cognition of student in different regions and different types of school.

The high prevalence of antibiotic utilization in children might have a strong association with physicians, such as lacking of skills and knowledge, pressure from patient, physician-patient relationship, economic incentive and profit from prescribing medicine, lacking of pathogen detection or low pathogen detection rate.

First, physicians in high-level hospitals are more likely to receive training on rational use of antibiotics than those in primary hospitals [138]. Physicians who has not attend related training are more likely to prescribe antibiotics [139]. Sometimes routine training for village doctors is held regularly, however, the content of training is repeated without new course, so the training seems not effective [140]. Therefore, continuous education can narrow the knowledge gap among physicians in different levels of hospital, meanwhile, the quality of education also should be emphasized.

Secondly, many caregivers faithfully embrace the effectiveness of antibiotics and injections over other regimens, and they will actively ask these therapies when visiting doctors. When physicians feel pressure from patients, about 70% of them would prescribe antibiotic [139]. On the other hand, the physician-patient relationship in China is highly strained [141]. Because there is no formal appointment system, patients generally prefer morning consultations, and there is long wait time and short consultations, which cause dissatisfaction among parents [142]. Therefore, some physicians protect themselves by regarding antibiotics as a weapon, especially expensive and injectable ones when they perceive that parents are dissatisfied [77]. They believe that prescribing antibiotics not only satisfy the patients’ claims, but further ease the strained doctor-patient relationship [143].

Thirdly, economic incentive and profit from prescribing medicine also lead physicians to prescribe antibiotics. Antibiotics, which account for approximately 20% of all drug sales in general hospitals [47], are the most frequently used medicine in Chinese medical facilities. In some regions, doctors’ income covered by government funds and profits from drug sales is virtually nail, these changes are not associated with improved antibiotic use. This may partly due to the low salary of medical staff, which motivates the personnel to seek additional income by providing other services and selling pharmaceutical products [144]. In addition, patient retention also could increase the income of physicians. In village clinic, if physicians adopt wait-and-watch policy or prescribe only antiviral drugs for fevers or the common cold, the caregivers would be dissatisfied with the village doctor, and would visit other village doctors. Furthermore, the primary caregivers would not return to the clinic the next time when their child had disease [120]. This may be a reason for the high prevalence of antibiotic utilization in children.

Fourthly, we found that pathogen detection rate among inpatients was 44.7% in our study, which was similar to the result in another study [108]. Antibiotic use without a clear indication is common [126], it is difficult for physicians to distinguish viral infection and bacterial infection, because the diagnostic tests, such as a routine blood test or C-reactive test, are not available in rural settings in China, so they make decisions based on clinical experience without clear indications. However, differentiating definitively between bacterial and viral causes of respiratory infections based on signs and symptoms alone is seldomly possible, and this imprecision and concern about missed bacterial diagnosis likely drives over-prescription of antibiotics [145]. Therefore, additional tools are necessary to physicians.

Parents’ perceptions and practices of how to use medicines have important effect on the management of childhood illness [146]. Through meta-analysis, we found that parents who had considerable misunderstandings may contribute to inappropriate antibiotic use. We found that 66% of caregivers believed that antibiotics could cure infection caused by viruses, a higher percentage than that was found in a pan-European study (54% ) [147]. Furthermore, half of the parents believed that antibiotics could cure common cold. Some parents often overestimate the benefits of antibiotics [148], and consider them as panacea [149]. For caregivers with correct recognition of antibiotics, the self-directed medication rate is lower than the doctor-dependent medication rate [115]. Thus, parents should receive more health education about antibiotics to improve the ability of antibiotic cognition. In addition, one study reported that about 60% of parents asked for doctors to prescribe antibiotics [150], and those who took antibiotic previously were more likely to put pressure on physicians to get them once again [151]. Other inappropriate behaviors include portraying severity of illness, or providing positive experience with use of antibiotic voluntary. However, sometimes, some physicians might misunderstand the willingness of the parents who just would like to ask for an advice or explanation from physicians rather than an antibiotic prescription [152]. Therefore, strategies for effective communication with patients and the prudent prescription of antibiotics are important. In addition, through meta-analysis, we found the overall prevalence of caregiver’s self-medicating of antibiotics for children at home was 37.8%, the result was lower than Yu et.al ’s finding [117]. The reasons for the prevalence of self-medicating children with antibiotics are multifactorial. Storing antibiotics at home increases the probability of medicating children with antibiotics, almost 50% of the caregivers keep antibiotics at home for children [153]. Parents who keep antibiotics at home prefer to self-medicate their children rather than directly seeking advice from a medical professional [122], and people tend to use the same drugs when they confronted similar symptoms based on their experience [154]. In addition, most of home-stored antibiotics are reported to be left over from previous prescriptions [113].

Having purchased antibiotics from retail pharmacies without a physician’s prescription is a critical factor contributing to self-medicating children with antibiotics. As early as 2004, the Chinese government introduced antimicrobial resistance targeted policies, banning the over-the-counter sale of antibiotics [155]. In addition, there is a separate counter displaying antibiotics and labeled “prescription-only medicine” posted to indicating customer antibiotics can only be sold with a prescription. However, in fact, more than 80% pharmacies dispensed antibiotics without a valid prescription. On the one hand, pharmacies dispensed the antibiotics without any prescription; on the other hand, dispensed them with a prescription provided by the pharmacy itself [156]. In addition, in 2012, to supervise the dispensing of medicines and ensure the safety of rational drug use, Chinese government launched the 12th five-year plan on drug safety, which called for all community and hospital pharmacies should have licensed pharmacists on duty during business hours by 201 5[157]. However, when dispensing the antibiotics, most pharmacy staff neither ask information of client nor provide relevant information about antibiotics. Through meta-analysis, we found that about 37% of caregivers do not know that antibiotics should only be obtained with a doctor’s prescription. Although the purchase of antibiotics without a prescription is forbidden by State Food and Drug Administration regulations, customers nevertheless have easy access to antibiotics in most areas. Therefore, stringent implementation of regulations concerning non-prescribed antibiotics in retail pharmacies is essential to restrict access to antibiotics.

Our study has several limitations. First, the heterogeneity across studies was statistically significant and the available data were insufficient to explain all the observed heterogeneity across studies. Second, age groups, hospital wards and characteristics of hospitalized children may also factors influence prevalence of antibiotic prescription. However, it was impossible to conduct meta-analyses due to a smaller number of studies assessing these factors. Third, there are few studies reported the antibiotic utilization in rural areas, however, as there is a rural population of nearly 800 million in China, antibiotic misuse in rural areas may be more serious, and we will investigate antibiotic use among children in rural areas. In addition, only published literatures were included, and potential publication bias cannot be neglected.

The prevalence of antibiotic utilization is much higher than the standard. The overall prevalence of antibiotic utilization among outpatients, inpatients, and caregiver’s self-medicating at home were 63.8%, 81.3%, and 37.8% respectively. The high prevalence of antibiotics is associated with multiple factors, including at children level (e.g. distribution of disease, lacking of skills and knowledge), and physician level (e.g. lacking of skills and knowledge, pressure from patient, physician-patient relationship, economic incentive and profit from prescribing medicine, lacking of pathogen detection or low pathogen detection rate), and caregiver level (e.g. lacking of skills and knowledge, put pressure on physician to get antibiotics, behavior of self-medicating with antibiotics at home for children) and retail pharmacies level (e.g. sale antibiotics without prescription) and hospital level (e.g. ward capacity). Efforts to improve the prevalence of antibiotic utilization require multisector cooperation, and long-term efforts should target at both children and caregivers, and also prescribers, like health education or training on the proper use of antibiotics and powerful supervision. Further studies should focus on antibiotic utilization of children, especially in rural area.