| ObjectivesAntimicrobial resistance caused by the irrational use of antimicrobials has become a global public health problem.Identifying and evaluating the current status of antimicrobial use is a prerequisite for management and an effective feedback for intervention implementation.This study aimed to evaluate the rationality of antimicrobial use from three perspectives of medical institutions,retail pharmacies and residents,in order to provide evidence for optimizing antimicrobial management strategies in China.MethodsMedical institutions are the most important source of antimicrobial use for the population.Based on the Center for Antibacterial Surveillance database,this study finally obtained 282,479 outpatient prescriptions and 86,070 inpatient records from 52 general hospitals in two provinces from 2012 to 2016 through extracting and sorting the data.The chi-square trend test and time series analysis were adopted to examine the annual and monthly changes in the rate of antimicrobial use(RAU),the rate of antimicrobial combination use(RACU),and the proportion of antimicrobial combination use(PACU)in outpatients and inpatients.Multiple groups of simplified international indicators based on frequency and ratio were used to evaluate the rationality of the types and quality of antimicrobial use in medical institutions.Retail pharmacies are another important source of antimicrobial use,in addition to medical institutions.Based on a “simulated client” survey design,this study investigated 675 community pharmacies in nine provinces across China from July 2017 to September 2018 using a multi-stage sampling method.Besides,220 online pharmacies with antimicrobial sales were investigated between November and December 2018.The chi-square test was used to compare the differences in the irregulated sale practice of antimicrobials(ISPA)in community and online pharmacies with different characteristics.The ISPA in community pharmacies include sale with over-the-counter,sale with a prescription self-provided by the pharmacy.Except for above two ISPAs,online pharmacies were added the sale on expired prescriptions.Furthermore,the multilevel model and Logistic regression analysis were used to explore the factors relating the ISPAs in community and online pharmacies.Residents,the main body of antimicrobial use,their usage behaviors are also an important aspect of rationality evaluation.Based on a cross-sectional survey design,this study carried out a nationwide resident survey from July 2018 to September 2018 using an online questionnaire method,and finally obtained 15,526 valid questionnaires.The chi-square test was used to compare the differences in self-medication with antimicrobials(SMA),self-storage with antimicrobials(SSA),and non-adherence to antimicrobial treatment(NDAT)among residents with different characteristics.Moreover,Logistic regression analysis was adopted to identify the related factors of various irrational usage behaviors.Further,structural equation modeling was used to explore the risk pathways of “self-storage-self-medication-non-compliance” and the intrinsic relationship with medication knowledge.ResultsPart 1 Evaluation of the rationality of antimicrobial use in medical institutionsIn outpatient prescriptions and inpatient records of 52 general hospitals,the chi-square trend tests showed a decrease in the RAU in outpatients and inpatients from20.17% and 58.32% in 2012 to 12.94% and 51.48% in 2016,respectively(P<0.05).The RACU and PACU in outpatient and inpatient patients also showed a significant downward trend(P<0.05).Time series analysis showed no obvious seasonality in each indicator,and only the RAU and RACU in outpatients and RACU in inpatients showed a significant downward trend after model fitting.Analysis of the types of antimicrobial use showed that the proportion of injectable antimicrobial use in outpatients and inpatients accounted for 36.58% and 88.04%,respectively,by 2016.In the subgroup classification,there was no significant change in the annual use proportion and use structure of each subclass of antimicrobials in both outpatients and inpatients,except for an increasing trend in the proportion of cephalosporins used in inpatients,with the broad-spectrum cephalosporins far exceeded other classes and held the first place.The quality indicators of antimicrobial structure showed that the usage rate of penicillin containing β-lactamase inhibitor compounds was slowly increasing in outpatients and inpatients.The broad-spectrum/narrow-spectrum antimicrobial drug ratio was slowly increasing in outpatients,but this ratio decreased in inpatients,the usage rates of broad-spectrum antimicrobials were still7.76 and 2.90 times more common than narrow-spectrum antimicrobials in outpatients and inpatients by 2016.The quality indicators for safe usage of antimicrobials showed that the annual useage ratio and use structure of all types of antimicrobials classified by AWa Re did not change significantly,with the total usage ratio of cautionary class antimicrobials accounting for 42.23% and 38.81% for outpatients and inpatients,respectively,which was significantly higher than the usage ratio of 24.86% and 29.32%for accessible class antimicrobials.Part 2 Evaluation of the rationality of antimicrobial sale in retail pharmaciesOf the 675 community pharmacies and 220 online pharmacies,86.81% and 79.09%had ISPAs,respectively.Of the community pharmacies with ISPA,96.93% sold antimicrobials of over-the-counter,and 3.07% sold antimicrobials through prescriptions self-provided by pharmacy.Of the online pharmacies with ISPA,67.82% sold antimicrobials of over-the-counter,25.29% sold antimicrobials on expired prescriptions,and 6.90% sold antimicrobials through prescriptions self-provided by pharmacy.Among community pharmacies,there was a statistical difference in the rate of ISPA in pharmacies with different city levels and different quality of pharmacy services(P<0.05).Among online pharmacies,there was a statistical difference in the rate of ISPA in pharmacies with or without purchase monitoring prompts on the webpage and in pharmacies with different quality of pharmacy services(P<0.05).Furthermore,the multilevel models for community pharmacies and Logistic regression analysis for online pharmacies showed that the community pharmacies in the central and western regions were 1.94 times and 2.30 times more likely than pharmacies in the eastern to the incidence of ISPA after adjusting for other variables(P<0.05).Community pharmacies at the prefectural and county levels were 6.71 and 5.37 times more likely than community pharmacies in provincial capitals to engage in ISPA(P<0.05).Community(OR=3.62,95%CI: 1.93-6.77)and online(OR=3.03;95% CI: 1.22-7.54)pharmacies with poor quality pharmacy services were at increased risk of ISPA.Part 3 Evaluation of rationality of antimicrobial use in residentsOf the 15,526 residents validly surveyed,37.12% had SMA in the past six months,67.88% had SSA in the past six months,and 53.27% had NDAT when taking antimicrobials.The incidence of missing antibiotics,increasing antibiotic dosage,decreasing antibiotic dosage,and discontinuing antibiotics among residents was 48.27%,15.21%,25.51% and 77.96%,respectively.Logistic regression analysis showed that age,education level,self-reported health status,and knowledge level of antimicrobials were common predictors of various irrational usage behaviors after adjusting other variables.Spearman test showed that the residents’ self-medication,self-storage and non-compliance behaviors were positively correlated with each other.Further construction of a structural equation model of“self-storage-self-medication-non-compliance” showed that the model fitted well.The path coefficient for residents’ self-storage behavior to self-medication behavior was0.37(P<0.001),and for self-medication behavior to non-compliance behavior was 0.39(P<0.001).In this model,there was a significant negative correlation between the level of residents’ knowledge and above three irrational usage behaviors.Conclusion1.The RAU in Chinese medical institutions decreased significantly,which to a certain extent reflected that the administrative interventions adopted by the Chinese government had achieved better results in reducing the excessive use of antimicrobials in medical institutions.However,some phenomena of irrational use still existed,mainly manifested by a high proportion of injectable antimicrobial use,the widespread use of broad-spectrum antimicrobials and the low proportion of accessible antimicrobial use.It is suggested that while controlling the rate of clinical antimicrobials use in China,further attention should be paid to the rationality of the types and internal structure of antimicrobial use,so as to achieve the internal goal of rational use of antimicrobials in medical institutions.Besides,this part of the study analyzed data from two provinces in China.It is necessary to conduct a nationwide study based on the Center for Antibacterial Surveillance database.2.The situation of ISPAs in community and online pharmacies in China was serious,and the irregulated sale practice of antimicrobials showed diversification and regional differences.Therefore,there is an urgent need to strengthen the administrative supervision of the regulated sale of antimicrobials in retail pharmacies,introduce social supervision mechanisms,and develop national guidelines for pharmacy services in retail pharmacies to promote the regulated sale of antimicrobials in China.3.The prevalence of residents’ SMA,SSA,and NDAT was common in China.There was a strong correlation between the three types of irrational behavior of antimicrobial use and all were influenced by the level of antimicrobial knowledge of the population.While strengthening the management of antimicrobials in medical institutions and the regulating the rational sale of antimicrobials in retail pharmacies,it is necessary to carry out a nationwide action plan and implement comprehensive intervention strategies to promote the rational use of antimicrobials among residents. |
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