Antibiotic prescription patterns in children and neonates in China
Authors: Jiaosheng Zhang, Yuejie Zheng, Yonghong Yang
Journal: The Lancet Global Health (2019)

We would like to add some additional thoughts to the Article to which we contributed on antibiotic prescribing surveys (July, 2019),1Hsia Y Lee BR Versporten A et al.Use of the WHO Access, Watch, and Reserve classification to define patterns of hospital antibiotic use (AWaRe): an analysis of paediatric survey data from 56 countries.Lancet Glob Health. 2019; 7: e861-e871Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar which is the first global study to describe the paediatric patterns of WHO's Access, Watch, and Reserve classification, encompassing antibiotic prescriptions for 23 572 patients from 56 countries. 18 hospitals in nine provinces in China joined this project, and supplied the second highest number of antibiotic prescriptions for children and neonates in the study (3788), which accounted for 28·1% of the cases from 85 hospitals in 23 countries and regions in the Global Antimicrobial Resistance, Prescribing, and Efficacy Among Neonates and Children (GARPEC) network. As described in that article, China has the lowest proportion of Access antibiotic use (7·8%) and the second highest proportion of Watch antibiotic use (74·1%). The pattern of antibiotic prescriptions in China was markedly different from that in other countries. This difference is due to various reasons, which we describe here. First, the antibiotic gentamicin is the Access antibiotic most used globally for infections caused by Gram-negative bacteria, and is recommended by many guidelines around the world for children and neonates.2Sharland M Manual of childhood infections.4th edn. Oxford University Press, New York2016Google Scholar In China, however, national antimicrobial guidelines forbid prescription of gentamicin for children younger than 8 years because of possible risk of hearing loss. As an alternative, third-generation cephalosporins, which are classified as Watch antibiotics, are commonly recommended for neonates and children.3Committee of Experts on Rational Drug Use of National Health and Family Planning Commission of the PRCAntimicrobial treatment of common pediatric infectious diseases.in: Bureau of Medical Administration of National Health and Family Planning Commission of the PRC Committee of Experts on Rational Drug Use of National Health and Family Planning Commission of the PRC National guideline of antimicrobial treatment. People's Medical Publishing House, Beijing2012: 12-19Google Scholar Second, in China, a skin test is required before penicillins can be prescribed (including when given orally), whereas these Access antibiotics are commonly recommended for children by WHO and other countries. This test is not necessary before prescribing cephalosporins. Inconvenience in clinical practice and false-positive skin tests for penicillins limit their use and promote the prescription of cephalosporins. In addition, some penicillins (eg, ampicillin) are not available in many hospitals in China. Third, the use of macrolides was very high (20·1%) in China.4Zhang JS Liu G Zhang WS et al.Antibiotic usage in Chinese children: a point prevalence survey.World J Pediatr. 2018; 4: 335-343Crossref Scopus (16) Google Scholar Macrolides are classified as Watch antibiotics for lower respiratory tract infections, the most common indicator to prescribe antibiotics. Finally, according to the latest survey on knowledge, attitude, and practice of antibacterial agents among Chinese paediatricians, macrolides and third-generation cephalosporins are the two antibiotics that they are most willing to prescribe.5National Health and Family Planning Commission Expert Committee on Rational Use of Medicines for Children Pharmaceutical GroupInvestigation on the rational use of antibacterial agents by Chinese pediatricians in 2016.Zhonghua Er Ke Za Zhi. 2018; 12: 897-906Google Scholar It is time to improve the antibiotic stewardship for children and neonates on the basis of local antimicrobial resistance, the availability and instructions for use of antibiotics, and other factors, to reduce the level of Watch antibiotics, since they play such an important role in increasing antimicrobial resistance in China. This research was funded by Sanming Project of Medicine in Shenzhen (SZSM201512030), Shenzhen Healthcare Research Project (SZLY2018016), and the Penta Foundation. We declare no competing interests. Use of the WHO Access, Watch, and Reserve classification to define patterns of hospital antibiotic use (AWaRe): an analysis of paediatric survey data from 56 countriesThere is substantial global variation in the proportion of AWaRe antibiotics used in hospitalised neonates and children. The AWaRe classification could potentially be used as a simple traffic light metric of appropriate antibiotic use. Future efforts should focus on developing and evaluating paediatric antibiotic stewardship programmes on the basis of the AWaRe index. Full-Text PDF Open Access