A new study published in The Lancet Infectious Diseases suggests the Chinese government's efforts to reign in non-prescription antibiotic sales could face an uphill climb.
The study, conducted by a team of researchers with China's Xi'an Jiaotong University, recruited Chinese medical students to visit more than 2,400 community pharmacies across China and request antibiotics for a child with diarrhea or an adult friend with an upper respiratory tract (URTI) infection. In nearly half of the pediatric diarrhea and 70% of the URTI interactions, antibiotics were handed out without a prescription, and consultation or advice on antibiotic use was rarely offered. Pharmacies in rural areas were more likely to be offenders.
Curbing non-prescription antibiotic sales in the nearly half-a-million community pharmacies across China was one of the aims of a 5-year national action plan to improve rational use of antibiotics issued by the Chinese government in 2016. The government said it hoped to eliminate the problem by 2020. But the authors of the study say the results of these simulated antibiotic requests cast doubt on that goal.
"Our findings raise concerns about whether China can achieve its 2020 national goal to end non-prescription antibiotic sales," they write.
For the study, the researchers recruited and trained 48 medical students from Xi'an Jiaotong University to be simulated clients and present one of two antibiotic-seeking scenarios in 2,411 community pharmacies in six Chinese provinces (Hunan, Sichuan, Zhejiang, Henan, Shandong, and Shaanxi).
In one scenario, a pair of students pretended to be the parents of a 5-year-old child with diarrhea. Twenty-five minutes later, another pair of students would enter the same pharmacy and present themselves as friends of a 20-year-old college student with URTI symptoms. Those scenarios were chosen because pediatric diarrhea and adult URTI are the two conditions most associated with antibiotic misuse, in China and worldwide.
During the simulated interactions, which took place in July and August 2017, the students would gradually increase their demand until an antibiotic was dispensed or the request was refused. The demands began with a request for medicine to alleviate the patient's symptoms, then grew to "Can you give me some antibiotics?" and, finally, "I would like some amoxicillin or cephalosporins."
The students were also trained to analyze the interaction and to identify whether the attending pharmacy staff member was a pharmacist or pharmacy assistant, or whether a licensed pharmacist was on duty.
Overall, there were 4,822 interactions in the 2,411 pharmacies. Non-prescription dispensing of antibiotics occurred in 1,169 of the interactions (48.5%) involving pediatric diarrhea and 1,690 of the interactions (70.1%) involving adult URTI. Significant differences in non-prescription dispensing were observed between regions and between rural and urban community pharmacies, with 54.4% and 75.2% of rural pharmacies handing out antibiotics for diarrhea and URTI, respectively, compared with 39.9% and 62.7% of urban pharmacies. Most of the antibiotic dispensing occurred after the second and third level of demand.
A pharmacist was available at only 35% of the pharmacies during the simulated visits. While pharmacy staff asked for more information about the patient's condition in 64.5% of the pediatric diarrhea and 78.6% of the URTI scenarios, they asked about drug allergy history in only 16.7% and 29.2% of those scenarios, respectively. When antibiotics were dispensed, appropriate advice on how to take them was offered in only 21.5% of the diarrhea interactions and 23.8% of the URTI interactions.
After adjusting for co-variates and regional variations, the researchers determined that non-prescription dispensing of antibiotics was less likely to occur in urban pharmacies (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34 to 0.70), pharmacies where a pharmacist was on site (OR, 0.66; 95% [CI], 0.56 to 0.78), and in chain pharmacies (OR, 0.75; 95% CI, 0.62 to 0.89).
Among the 213 pharmacies in Shaanxi that were part of the study and had been surveyed since 2011, the researchers noted a significant decrease in non-prescription antibiotic dispensing for both pediatric diarrhea interactions (from 72.3% in 2011 to 50.2% in 2017) and adult URTI interactions (from 95.8% in 2011 to 69.5% in 2017).
"Our findings highlight the urgency for policy makers to develop multifaceted approaches to stewardship of antibiotic use in retail settings, including stricter regulation, enforcement of both the prescription-only policy and pharmacist-on-duty rules, pharmacy staff training, and public education, and also the establishment of a systematic electronic network to monitor changes in the practice over time," the authors conclude.
Part of the problem, part of the solution
In an accompanying editorial, Aubrey Kalungia, MSc, of the University of Zambia and Brian Godman, PhD, of the University of Strathclyde in Scotland write that the study highlights the significant role that community pharmacies—frequently the first point of contact with the healthcare system—play in inappropriate antibiotic use not only in China but in other low- and middle-income countries (LMICs) as well.
They cite research estimating that non-prescription sales of antibiotics from pharmacies accounts for as much as 93% of antibiotic dispensing in LMICs.
Several factors, including patient pressure, financial pressure, poor levels of education, and weak enforcement of regulations, drive this issue. But Kalungia and Godman argue that if community pharmacists receive better antimicrobial stewardship education and training, they can be part of the solution.
"Consequently, community pharmacists are a crucial component to improve the management of patients with URTIs and paediatric diarrhoea, particularly because they are often the first health-care professional that patients consult," they write. "Notwithstanding that community health campaigns are more challenging in LMICs, by championing pharmacists as antibiotic guardians, they can take the lead to improving antibiotic use in the community and reduce antimicrobial resistance."
Oct 3 Lancet Infect Dis study
Oct 3 Lancet Infect Dis commentary