Are we using antibiotics responsibly? : assessing antibiotic use in rural Shandong province, China

Background: Tackling the misuse and overuse of antibiotics is critical both for global sustainable development and for reducing social inequalities in the world. The World Health Organisation Global Action Plan on antimicrobial resistance calls on all Member States to develop multi-sectoral National Action Plans and to “monitor and promote optimization of antimicrobial use at national and local levels”. There is a particular need to assess how antibiotics are being used in resource-limited settings, which tend to have the highest burdens of infections and of antibiotic resistance. In such settings antibiotics are commonly overused and misused in agriculture too, emphasizing the need for One Health approaches. In 2010, China was estimated to be the second largest consumer of antibiotics for human use by total volumes, and the largest consumer of antibiotics within food animal production. Information on antibiotic use in human healthcare in rural areas is lacking in China, as is knowledge of the volumes and patterns of antibiotic use in agriculture, particularly in backyard pig farms which remain highly prevalent. Aim: To assess how antibiotics are being used for humans and on backyard pig farms in a rural region in China. Methods: All studies were conducted in rural areas of Shandong province, located in eastern China. Two main methods were used: analyses of prescriptions from healthcare facilities, and surveys of doctors', rural residents' and backyard pig farmers' knowledge, attitudes and practices concerning antibiotic use and resistance. In Paper I we assessed the rates and types of antibiotics prescribed for patients with common cold diagnoses during one month at thirty healthcare facilities in three different counties. These healthcare facilities covered three different levels in the rural healthcare system: village clinics, township health centres and county hospitals. All 188 doctors working at the healthcare facilities were invited to participate in a questionnaire on knowledge and attitudes towards antibiotic use. In Paper II we prospectively monitored antibiotic prescribing over a 2.5 year period at eight village clinics located around a single town in a rural county. We conducted individual prescriberlevel analyses in order to assess the extent of variations in prescribing practices, focussing on prescriptions containing diagnoses of likely viral acute upper respiratory tract infections (AURI). In Paper III we assessed the knowledge, attitudes and practices towards antibiotic use and resistance of 769 rural residents living in the twelve villages that are served by the village clinics in Paper II. In Paper IV we assessed the knowledge, attitudes and practices towards antibiotic use in pigs of the 271/769 rural residents who had backyard pig farms. We also observed the rates and types of antibiotics stored in households for use in humans and pigs in Papers III and IV. Results: Over half of all prescriptions with a common cold diagnosis at healthcare facilities in Paper I contained at least one antibiotic, as did almost two-thirds of the prescriptions for likely viral AURIs at village clinics in Paper II. The majority of antibiotics prescribed were broad-spectrum. Antibiotics were more likely to be prescribed on common cold prescriptions from village clinics than on prescriptions from higher level healthcare facilities. There was widespread variation in the antibiotic prescribing practices of individual village doctors. Significant gaps existed between doctors' knowledge and attitudes, and their actual prescribing practices, despite a majority of doctors reporting that they had recently attended training on rational antibiotic use. Rural residents and backyard pig farmers had low levels of knowledge about what antibiotics are and when they should be used. Rural residents more frequently thought that antibiotics are needed for infectious conditions than for non-infectious conditions, but they did not differentiate significantly between infections caused by bacteria, where antibiotics may be needed, and those caused by viruses, where they are not. Rural residents commonly reported acquiring antibiotics without prescriptions, as well as using leftover antibiotics. Similarly, backyard pig farmers reported frequently using antibiotics in healthy pigs when they are not needed, and purchasing antibiotics without consulting veterinarians. Backyard pig farmers had differences in their knowledge, attitudes and practices towards antibiotic use in humans compared with other rural residents, and these appeared to be inter-related with their knowledge, attitudes and practices towards antibiotic use in pigs. Household storage of antibiotics for human use was common, and similar to levels identified in previous studies in Asia; storage of antibiotics on backyard pig farms was also frequent, and many of the stored antibiotics are considered to be critically important for human medicine. Conclusions: The work in this thesis strongly suggests that antibiotics are not being used responsibly enough for humans and on backyard pig farms in the study region: doctors, rural residents and backyard pig farmers in rural Shandong province are frequently overusing and misusing antibiotics. There is a need to investigate which additional drivers are causing doctors to prescribe antibiotics unnecessarily, despite knowing that they are not needed. Rural residents' and backyard pig farmers' knowledge and attitudes may be contributing to overuse and misuse of antibiotics, for example through having expectations to receive antibiotics from healthcare professionals in situations for which they are not clinically needed. In resource-limited settings, high quality, cross-sectoral assessments of antibiotic use at a small number of study sites can provide valuable insights into how responsibly antibiotics are being used.