Effects of Restrictive-prescribing Stewardship on Antibiotic Consumption in Primary Care in China: An Interrupted Time Series Analysis, 2012-2017
Authors: Wang Xuemei , Tang Yuqing , Liu Chenxi , Liu Junjie , Cui Youwen , Zhang Xinping 
Published: July 2020

Abstract
Background:The overuse of antibiotics has been a major public health problem worldwide, especially in low- and middle- income countries (LMIC). However, there are few policies specific to antibiotic stewardship in primary care and their effectiveness are still unclear. This study aimed to evaluate the effects of a restrictive-prescribing stewardship on antibiotic consumption in primary care so as to provideevidence-based suggestions for prudent use of antibiotics.Methods:Monthly antibiotic consumption data were extracted from Hubei Medical Procurement Administrative Agency (HMPA) system from Sept 1, 2012, to Aug 31, 2017. Quality Indictors of European Surveillance of Antimicrobial Consumption (ESAC QIs) combined with Anatomical Therapeutic Chemical (ATC) classification codes and DDD per 1000 inhabitants per day (DID) methodologywere applied to measure antibiotic consumption. An interrupted time series analysis was performed to evaluate the effects of restrictive-prescribing stewardship on antibiotic consumption.Results: Over the entire study period, a significant reduction (declined by 32.58%) was observed in total antibiotic consumption, which declined immediately after intervention (coefficient=-2.4518, P=0.005) and showed a downward trend (coefficient =-0.1193, P=0.017).Specifically,the use of penicillins, cephalosporins and macrolides/lincosamides/streptogramins showed declined trends after intervention (coefficient=-0.0553, P=0.035; coefficient=-0.0294, P=0.037; coefficient=-0.0182, P=0.003, respectively). An immediate decline was also found in the contribution of β-lactamase-sensitive penicillins of total antibiotic use (coefficient=-2.9126, P=0.001). However, an immediate increase in the contribution of third and fourth-generation cephalosporins (coefficient=5.0352, P=0.005) and an ascending trend in the contribution of fluoroquinolones (coefficient=0.0406, P=0.037) were observed after intervention. The stewardship led to an immediate increase in the ratio between broad- and narrow-spectrum antibiotic use (coefficient=1.8747, P=0.001) though they both had a significant downward trend (coefficient=-0.0423, P=0.017; coefficient=-0.0223, P=0.006, respectively). An immediate decline (coefficient=-1.9292, P=0.002) and an ascending trend (coefficient=-0.0815, P=0.018) were also found in the oral antibiotic use after intervention, but no significant changes were observed in the parenteral antibiotic use. Conclusions:Restrictive-prescribing stewardship in primary care was effective in reducing total antibiotic consumption, especially use of penicillins, cephalosporins and macrolides/lincosamides/streptogramins. However, the intervention effects were mixed. Stronger administrative regulation focusing on specific antibiotics, such as the third and fourth-generation cephalosporins, fluoroquinolones, broad-spectrum antibiotics and parenteral antibiotics, is in urgent need in the future.