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Clinical Diagnosis and Treatment of Common Respiratory Tract Infections

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Clinical Diagnosis and Treatment of Common Respiratory Tract Infections Shen et al. BMC Fam Pract (2021) 22:87 https://doi.org/10.1186/s12875-021-01448-2 RESEARCH ARTICLE Open Access Clinical diagnosis and treatment of common respiratory tract infections in relation to microbiological profles in rural health facilities in China: implications for antibiotic stewardship Xingrong Shen1,2, Jilu Shen3, Yaping Pan4, Jing Cheng2, Jing Chai2, Karen Bowker5, Alasdair MacGowan5, Isabel Oliver6, Helen Lambert7 and Debing Wang1,2* Abstract Background: This paper tries to describe prevalence and patterns of antibiotics prescription and bacteria detection and sensitivity to antibiotics in rural China and implications for future antibiotic stewardship. Methods: The study was implemented in one village clinic and one township health center in each of four rural resi- dential areas in Anhui Province, China. It used mixed-methods comprising non-participative observations, exit-survey and microbiological study. Observations were conducted to record clinical diagnosis and antibiotic prescription. Semi-structured questionnaire survey was used to collect patient’s sociodemographic information and symptoms. Sputum and throat swabs were collected for bacterial culture and susceptibility testing. Results: A total of 1068 (51.0% male vs 49.0% female) patients completed the study with diagnosis of respiratory tract infection (326,30.5%), bronchitis/tracheitis (249,23.3%), pharyngitis (119,11.1%) and others (374, 35.0%). They pro- vided 683 sputum and 385 throat swab specimens. Antibiotics were prescribed for 88% of the RTI patients. Of all the specimens tested, 329 (31%) were isolated with bacteria. The most frequently detected bacteria were K. pneumonia (24% in all specimens), H. infuenza (16%), H. parainfuenzae (15%), P. aeruginosa (6%), S.aureus (5%), M. catarrhalis (3%) and S. pneumoniae (2%). Conclusions: The study establishes the feasibility of conducting microbiological testing outside Tier 2 and 3 hospitals in rural China. It reveals that prescription of antibiotics, especially broad-spectrum and combined antibiotics, is still very common and there is a clear need for stewardship programs aimed at both reducing the number of prescrip- tions and promoting single and narrow-spectrum antibiotics. Keywords: Antibiotic, Respiratory tract infection, Primary care, Diagnosis, Microbiological, China *Correspondence: [email protected] 1 School, of Public Health, Anhui Medical University, Hefei, Anhui, China Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Shen et al. BMC Fam Pract (2021) 22:87 Page 2 of 9 Background that 1:35 patients presenting to their general practition- Antimicrobial resistance (AMR) has become one of the ers with acute cough have microbiological sampling; biggest threats to global health [1, 2]. It leads to higher while the same sample proportion is only about 1:5 at fnancial costs, prolonged hospital stays and increased secondary and tertiary medical care settings [14]. Tese patient mortality. Data from 76 countries including data indicate that resistance rates to key antibiotics based China show that global antibiotics consumption grew on biased laboratory data may be over-emphasized [15– by more than 39% between 2000 and 2015 and China 18]. Similarly, the often reported reduction in antibiotics consumes the second largest amount of antibiotics in prescription rate derived from paper or electronic medi- the world [3] with a prescription rate twice that recom- cal records may also be misleading since such records in mended by the World Health Organization (WHO). most primary clinics in China are incomplete or inac- Rural areas have higher antibiotic prescribing rates than curate and the bulk of antibiotics is used at primary care urban areas [4]. According to a survey in rural areas of settings. Shandong and Ningxia, 89% and 77% of the prescriptions Tis paper tries to describe prevalence and patterns contained antibiotics for patients clinically diagnosed of antibiotics prescription and bacteria detection and as having upper respiratory tract infections (RTIs) [5]. sensitivity to antibiotics in rural China and implica- Another survey of prescriptions from village clinics in tions for future antibiotic stewardship. It uses data middle-east China showed that the proportion of antibi- from a mixed methods project co-sponsored by China otics prescribed for RTIs accounted for 87% [6]. Te Chi- National Natural Science Foundation and UK Research nese government has introduced a number of regulations and Innovation [14]. to control antibiotic use in the last decade, but these have not played a signifcant role in rural areas [7]. Methods Te majority of people in China live in rural and town- Tis study is part of the ‘pathways to optimizing antibiotic ship areas. Physicians in these areas mainly provide two use in Anhui: identifying key determinants in community kinds of services for residents, the treatment of common and clinical settings’ project. It used mixed-methods con- infectious diseases (mainly RTIs), and the management sisting of qualitative interviews, non-particative obser- of chronic diseases. Te excessive antibiotics prescrip- vations, semi-structured surveys and microbiological tions mostly occur in treating common RTIs. A range studies. Te study protocol has been published separately of possible reasons for unnecessary use of antibiotics by [14]. Tis paper used mainly the quantitative data from rural and township physicians have been identifed. It is the study. not uncommon for them to prescribe antibiotics ‘just in case’, due to a desire to reduce medical, legal and reputa- tion risk in the face of diagnostic uncertainty [8]. Antibi- Setting otics may also be used unnecessarily under the driver of Te study was implemented in one village clinic and one income interests, including prescribing of inappropriate township health center in each of four rural residen- antibiotics for particular diseases, unnecessary escala- tial areas in Anhui Province, China. Anhui Province is tion (for example prescribing more expensive and broad- located in the middle east of China and has a population spectrum antibiotics when cheaper and more specifc of 68.6 million of whom 57% live in rural areas. It has 968 antibiotics can give the same result) and intravenous use hospitals, 1,941 community and 1,398 township health [9, 10]. In addition, most rural and township physicians centers, and 15,288 village clinics. in China have to distinguish bacterial or virus infection based on patient-reported symptoms because microbio- Participants logical facilities are not available at most front-line health Te study aimed to recruit 1,000 patients presenting with care settings [11]. respiratory infection [14]. Inclusion criteria were male or Most research on AMR in China has drawn on female patients who were: a) 18 years or older and able patient data collected in urban specialist hospitals. to give consent to participate in the microbiological study Te often asserted high burden of AMR in China may and exit survey; b) presenting to the recruitment site for be misleading since current assumptions are based on his/her current illness for the frst time during the study potential pathogens isolated in selected microbiology period; and c) observed as having one or more of the fol- laboratories enrolled in the national surveillance system lowing: exacerbation of chronic obstructive pulmonary and it is uncertain if this refects the incidence of resist- disease (COPD), upper respiratory tract infection with ance in non-hospitalized patients with mild to moderate productive cough or sore throat. Selection of these con- infection receiving antibiotics, most of whom do not have ditions was based on the consideration that there may samples sent to the laboratory [12, 13]. UK data indicates be diferences between patients with diferent clinical Shen et al. BMC Fam Pract (2021) 22:87 Page 3 of 9 diagnosis (e.g., higher chances for identifying bacteria were prescribed for the symptomatic RTI patients. Two and antibiotics resistance among patients with exac- researchers performed the examination independently erbation of COPD than those with cough and/or a sore and discordances were solved by discussions between throat). Acute otitis and rhinosinusitis were not included them. For data from the semi-structured exit-survey, only because these diseases happen mainly in children while the structured items were used in this study. Tis paper this study population comprised only adults (over reports on descriptive analysis of: a) social demographics 18-year-old). (sex, age and educations) of patients recruited; b) antibi- Patients were selected via “consecutive sampling” otics use by clinical diagnosis; c) percentages of patients in which, when a start date had been determined, the identifed with specifc types of bacteria by groups of recruitment continued daily (7 days a week) thereaf- clinical diagnosis; and d) prevalence rates of resistance ter, between 8am-5 pm or 9am- 6 pm on alternate days, of most frequently identifed bacteria to commonly used until the target numbers had been reached. All incom- antibiotics.
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