Reducing antibiotic overuse in rural China
Authors: Nga Thi Thuy Do, Behzad Nadjm, Kinh V Nguyen, H Rogier van Doorn, Sonia Lewycka
Journal: The Lancet Global Health (2018)

We commend Xiaolin Wei and colleagues1Wei X Zhang Z Walley JD et al.Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trial.Lancet Glob Health. 2017; 5: e1258-e1267Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar for developing an antibiotic stewardship intervention at township hospitals in rural China, and for testing its impact on antibiotic prescribing for paediatric outpatients on a large scale through a cluster-randomised trial. Their findings should strengthen the impetus for the much needed roll-out of antibiotic stewardship interventions in primary health care in Asian countries. There is mounting evidence that clinician-targeted interventions can reduce antibiotic prescriptions in outpatient settings,2Tonkin-Crine SK Tan PS van Hecke O et al.Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews.Cochrane Database Syst Rev. 2017; 9 (CD012252.)PubMed Google Scholar but much of the previous research has been done in high-income countries, and this study from China provides additional weight to support such an approach in Asia. However, unlike high-income countries, many Asian countries have poorly enforced systems for regulating access to antibiotics, and antibiotics are available from multiple sources, often without a prescription. In a trial of clinician-targeted point-of-care diagnostic tests to reduce antibiotic prescribing for mild respiratory infections in Vietnam,3Do NT Ta NTD Tran NTH et al.Point-of-care C-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in Vietnamese primary health care: a randomised controlled trial.Lancet Glob Health. 2016; 4: e633-e641Summary Full Text Full Text PDF PubMed Scopus (98) Google Scholar patients were interviewed at screening and follow-up, and it was found that 10% of patients had already consumed antibiotics before attending a primary health-care centre and 30% went on to obtain them from another source when they were not prescribed antibiotics. Wei and colleagues do not describe the use of antibiotics from alternative sources, possibly because of the scale of their study. This would have been useful information to provide a comprehensive picture of the intervention's impact on antibiotic use. Furthermore, reductions in antibiotic use in high-income countries have been achieved not only through reduced prescription rates, but also through reduced consultation rates for mild respiratory infections.4Chahwakilian P Huttner B Schlemmer B Harbarth S Impact of the French campaign to reduce inappropriate ambulatory antibiotic use on the prescription and consultation rates for respiratory tract infections.J Antimicrob Chemother. 2011; 66: 2872-2879Crossref PubMed Scopus (48) Google Scholar In light of this evidence and the widespread access to antibiotics outside the formal health-care system, tackling both supply and demand will be essential to achieve sustainable reductions in population-level antibiotic use. There is an absence of interventions to reduce unnecessary antibiotic use through targeting awareness and communication in Asian settings.5Godinho N Bezbaruah S Nayyar S et al.Antimicrobial resistance communication activities in South East Asia.BMJ. 2017; 358: j2742Crossref PubMed Scopus (3) Google Scholar Strategic, multi-pronged communication campaigns involving a mixture of media channels, as well as innovative community-based strategies to encourage behaviour change, are needed to change public perception about the role of antibiotics for treating upper respiratory tract infections. As Wei and colleagues suggest, longer-term follow-up is also needed to see whether reductions are sustained. In Do and colleagues' study in Vietnam,3Do NT Ta NTD Tran NTH et al.Point-of-care C-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in Vietnamese primary health care: a randomised controlled trial.Lancet Glob Health. 2016; 4: e633-e641Summary Full Text Full Text PDF PubMed Scopus (98) Google Scholar despite a similarly sized reduction in antibiotic prescribing during the study, qualitative research findings (unpublished) showed that most health providers returned to previous prescribing practice after the study had finished. In addition to patient demands and fear of complications, pressures for clinics to dispense stocks so they can receive replenishments and incentives from pharmaceutical companies for health-care workers to dispense antibiotics, mean that simply providing guidelines and improving knowledge might not be enough to sustain behaviour change. We declare no competing interests. Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trialIn China's primary care setting, pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced prescribing of antibiotics for childhood upper respiratory tract infections. Full-Text PDF Open AccessReducing antibiotic overuse in rural ChinaXiaolin Wei and colleagues (October, 2017)1 report their findings on the effect of training and educational interventions for physicians and caregivers on antibiotic use within paediatric settings in rural China. The study is meaningful, not only for China, but also from a global health perspective given the serious consequences of antibiotic misuse and overuse.2 Although the study is commendable and the results seem positive, some issues and obstacles might undermine the feasibility, sustainability, and generalisability of the proposed intervention strategy. Full-Text PDF Open Access