Retrospective survey of the efficacy of mandatory implementation of the Essential Medicine Policy in the primary healthcare setting in China: failure to promote the rational use of antibiotics in clinics
Introduction
Bacterial resistance has become a public health challenge worldwide, with drug-resistant bacterial infections in patients leading to high morbidity and mortality [1]. China is one of the countries with a severe bacterial resistance problem: in 2011, the prevalences of meticillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, and carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii in tertiary hospitals were 50.5%, 71.2%, 23.4% and 56.8%, respectively [2]. Furthermore, in non-central city hospitals in 2011, the prevalences of ESBL-producing E. coli, macrolide-resistant Streptococcus pneumoniae and quinolone-resistant E. coli were as high as 64.8%, 97.1% and 57.4%, respectively [3]. Moreover, 17.4%, 25.0%, 71.2% and 44.4% of the healthy population in Nanjing carry MRSA, ESBL-producing Klebsiella pneumoniae, erythromycin-resistant S. pneumoniae and sulfamethoxazole-resistant Haemophilus influenzae, respectively, in their nasopharynx [4]. If this problem is not tackled urgently, it may lead to the disastrous situation where humankind eventually lacks effective drugs against bacterial infections. This is emphasised by the warning issued by the World Health Organization (WHO) in 2011, which stated ‘combat drug resistance: no action today, no cure tomorrow’ [1], [5], [6].
Use of antibiotics and the occurrence of bacterial resistance are closely associated. In particular, inappropriate use of antibiotics (e.g. excessive prescription and unregulated use) promotes the occurrence and spread of resistant micro-organisms [7]. In the last 10 years, Chinese regulatory agencies imposed a number of measures, which were implemented in a stepwise fashion, to regulate the use of antibiotics in general hospitals [8]. These measures successfully reduced antibiotic sales and the frequency of antibiotic-containing prescriptions in general hospitals in China. However, those measures had less involvement with the primary medical institutions of China (Chinese medical service institutions consist of three-level hospitals: primary clinical service such as described in the investigation, secondary hospitals and tertiary hospitals). These institutions provide basic healthcare services to most of the population: the National Health and Family Planning Commission of China showed that in 2012, 6.888 billion patient visits occurred nationally, of which 4.109 billion (59.65%) occurred in primary medical institutions [9]. However, these institutions tend to be relatively poorly managed and their staff less well trained than those in general hospitals. These factors mean that inappropriate use of antibiotics is more prominent in these institutions and this is likely to have a large impact on the development of bacterial resistance in China [10].
To promote rational antibiotic use, the WHO has developed a serial of strategies, including the Essential Medicine Policy (EMP), and implementation of the EMP has been shown to have had a positive effect in several countries [11], [12], [13]. Development of a National Essential Drugs List (NEDL) is the core component of the EMP. The NEDL was developed in China in 1982 for the first time but without implementation. Therefore, in 2009 the government disseminated the primary institution version of the NEDL and launched a series of actions to ensure implementation of the EMP in primary healthcare institutions following the initiation of a new round of healthcare reform [14]. To understand the impact of the EMP on the rational use of antibiotics in China, this retrospective investigation was conducted. Antibiotic usage before and after implementation of the EMP in representative urban and rural primary medical institutions in China was compared.
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Participants
Representative primary medical institutions in China that had implemented the EMP and were located in various regions with differing levels of socioeconomic development were selected for this survey. Specifically, there were 24 rural township health centres (RTHCs) from two underdeveloped inland provinces (Jilin and Henan; four RTHCs each), three developed coastal provinces (Shandong, Jiangsu and Zhejiang; four RTHCs each) and the city of Beijing (four RTHCs). There were also 24 city community
Results
A total of 48 primary medical institutions participated in this study, of which 9 were excluded from the analysis (6 because the original data were incomplete and 3 because their data failed the quality control audits, i.e. >50% of the patient records in an institution failed quality control). Thus, 39 primary medical institutions were included in the analysis, of which 8, 6, 4, 7, 8 and 6 were from Jilin, Henan, Shandong, Jiangsu, Zhejiang and Beijing, respectively. Of the 39 institutions, 23
Discussion
Improving the rationality of antibiotic use is critical for curbing bacterial resistance. This is particularly necessary in primary medical institutions because they serve most of the patients in the population. The present study showed that there is considerable inappropriate use of antibiotics in Chinese primary medical institutions: many different antibiotics are used, antibiotics are very frequently prescribed, the antibiotic treatment duration is often unnecessarily long, the indication is
Acknowledgments
The authors thank all members of the investigational team who collected the data. They also thank all of the investigated institutions for providing information and assistance during the study.
Funding: This study was carried out with grants from the National Natural Science Foundation of China [81361138021].
Competing interests: None declared.
Ethical approval: Not required.
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