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China’s misuse of antibiotics should be curbed

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1083 (Published 12 February 2014) Cite this as: BMJ 2014;348:g1083
  1. Yan Li, lecturer, School of Arts and Humanities, Nottingham Trent University, Nottingham, United Kingdom
  1. yan.li{at}ntu.ac.uk

Pressure from patients and perverse financial incentives are just two of many factors that conspire to encourage potentially dangerous overuse of antibiotics in China, writes Yan Li

China has a high rate of antibiotic use for inpatients and outpatients. On average, each Chinese person consumes 138 g of antibiotics a year—10 times that consumed in the United States. About 75% of patients with seasonal influenza are estimated to be prescribed antibiotics, and the rate of antibiotic prescription for inpatients is 80%.1 The World Health Organization recommends a maximum of 30%.2 About 97% of surgical patients in China are given antibiotics.3

In many primary healthcare centres in China, antibiotics are regarded as a panacea. However, they have no effect on viral infections such as the common cold. They are also ineffective against sore throats, which are usually viral and resolve spontaneously.4

Antibiotic misuse is not helpful to treatment and can damage the body in different ways. Irrational use of antibiotics can lead to drug resistance, toxicity, and allergic reactions.5 The effectiveness of antibiotics is under threat from misuse in China because of diseases mutating to develop immunity. Diseases as diverse as syphilis and the hospital superbug meticillin resistant Staphylococcus aureus are thriving as they adapt to China’s antibiotic heavy environment.6 China has the world’s most rapid growth rate of resistance as a result of antibiotics abuse.1

Another cost of antibiotics misuse is adverse drug reactions. For example, between 2001 and 2005 there were an estimated 14 738 000 incidents each year of moderate to severe adverse reactions to antibiotics, and over this period an estimated 150 000 patients died as a result.7 In the 690 000 cases of adverse drug reactions reported to have occurred in 2010, the most commonly misused antibiotics were cephalosporins, penicillins, and quinolones.3

Several factors are involved in antibiotics misuse. Firstly, on the demand side, many Chinese patients view antibiotics as a panacea or cure-all and therefore demand them even when they are not indicated. Patients may also demand newer antibiotics, perceiving them to be more effective. When patients do not receive treatment by an injection or a drip they think that they are not being treated with a high standard of care. Secondly, on the supply side, doctors might overprescribe antibiotics because they lack professional knowledge about rational use, because they want to prevent potential infections, or simply because they think this is what patients want.8

Financial motivations also play an important part. The Chinese government subsidises 8% of the running costs of hospitals, leaving the remaining 92% to be funded by charging for care. Drug sales currently account for more than 50% of all hospital revenues, and antibiotics account for 47% of all drug sales, on which hospitals are allowed to charge a 15% mark-up. In many hospitals, doctors’ incomes are also closely linked to their prescription of specific drugs, and bonuses from their hospitals and kickbacks from companies augment their incomes.6

Moreover, antibiotics are prescription drugs. In theory, pharmacies are not allowed to sell antibiotics directly to customers without a doctor’s prescription. However, in reality people can easily buy antibiotics on the street without prescriptions.

China’s local and national health authorities are stepping up their efforts to fight antibiotic misuse. In 2011 Beijing’s municipal health bureau surveyed antibiotic use at 165 hospitals across the city. Those found to be overusing the drugs would have their rankings downgraded—a move that would directly affect the fees they could charge.2 In April 2012 China’s health ministry issued a law on the Management Method for Clinical Use of Antimicrobials to establish a hierarchical management system for clinical use of antibiotics. The law, which came into effect in August 2012, clarifies the processes for selection, procurement, and clinical use of antimicrobials in medical institutions; surveillance and early warning monitoring; and intervention and withdrawal of the drugs.9 The regulation puts in place restrictions on doctors when prescribing antibiotics and asks them to prescribe them carefully, on the basis of a comprehensive check of the patient’s symptoms and blood and urine test results.10

Misuse of antibiotics is a longstanding problem in China and requires more coordinated efforts to deal with it. Although we have regulations on the rational use of antibiotics, without enforcement and strict penalties for transgressors these are ineffective.

Public education is also important. Efforts are needed to improve public awareness about the dangers of antibiotics misuse. A widespread public advertising campaign is needed, with information materials placed in examination rooms at hospitals, advising that antibiotics are inappropriate for the treatment of simple colds and flu.

Education of medical staff needs to be better. Regulations need to be presented with detailed guidance for the use of antibiotics (such as types, doses, and treatment courses) that also covers the operation of different medical departments, doctors’ qualifications to write prescriptions, and the availability and sale of antibiotics.

Moreover, it is essential to reform the compensation mechanism for public hospitals; to increase doctors’ incomes to eliminate the practice of hospitals subsidising medical services with drug sales; and to enforce existing drug regulations in China.9

The threat of antibiotic misuse is likely to become one of the greatest challenges to Chinese and, potentially, global health. On a positive note, China’s new reform of the health system plans to include a pharmaceutical policy with a strategy for the rational use of antibiotics. I hope for its success.

Notes

Cite this as: BMJ 2014;348:g1083

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I declare that I have no conflicts of interest.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

References

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