Analysis Of Antibiotic Prescription Literature And Clinical Data Of Respiratory Department In Chinese Medicine Hospital And Western Hospital

Background:Improper use of antibiotics and its consequence,resistance of antibiotics,is a major public health problem worldwide.Chinese government put forward a series of policies and regulations to enhance the proper use of antibiotics in the clinic.The National Stewardship for Clinical Use of Antimicrobials and The Regulation for Clinical Use of Antimicrobials put forward by the government in April 2011 and May 2012 was called the most stringent stewardship and regulation.And this became a milestone for the clinical use of antibiotics in China.Antibiotics prescription rates in Respiratory Departments are outstanding.Acute lower respiratory tract infections(ALRTIs)(excluding pneumonia)are one of the most outstanding areas for improper use of antibiotics.Chinese herbal medicines are widely prescribed in respiratory departments of traditional Chinese medicine(TCM)hospitals.The antibiotic prescription rates in TCM hospitals might be different from western medicine(WM)hospitals.In October 2015,the Chinese government signed agreement of the government of the United Kingdom(UK)to control improper use of antibiotics and resistance of antibiotics.Centre for Evidence-Based Chinese Medicine,Beijing University of Chinese Medicine signed agreement with Department of Primary Care,University of Southampton,UK,to collaborate and to work for finding evidence for TCM herbal medicine for reducing use of antibiotics in ALRTIs,and develop herbal solutions for ALRTIs.AimsTo find evidence for TCM herbal medicines in helping reducing prescription rates of antibiotics in the treatment of ALRTIs,and to identify potential herbal medicines for promoting in the international market.1)By obtaining prescription rates of respiratory departments of health care services of China,to compare the changes of antibiotic prescription rates before,during and after the stewardship,and to compare the differences between geographic regions,levels of health care services,and types of health care services(TCM hospitals and WM hospitals.2)By analyzing prescriptions for ALRTIs,especially acute trachitis/bronchitis,of AAA tertiary TCM hospital in Beijing,to picture the patent herbal medicines and antibiotics used and the prescription rates of herbal medicine and antibiotics.MethodsLiteratures reporting antibiotics prescription rates of respiratory departments/clinics were comprehensively searched(until March 2017)from four major Chinese literature databases,China National Knowledge Infrastructure Database(CNKI),Wanfang Database on Academic Institutions in China(Wanfang),VIP database for Chinese Technical Periodicals(VIP),Chinese Biomedical Literature Database online(SinoMed)and PubMed.Selected items from The REporting of studies conducted using Observational Routinely-collected health Data(RECORD)Statement were adopted to appraise the quality of the literatures.All health care services with usable data were stratified by geographic region(east,middle,west and northeast.level of city development,level(primary,secondary and tertiary)and type(western/integrative&TCM)of health care services(?,?,?)and type.Time of prescription collected was classified to be before,during and after the stewardship.Comparisons of the prescription rates between different levels,region and types of the health care services during,before and after the stewardship were conducted.Each TCM health care service was matched with at least one WM health care service re the level and region.Hypothesis test,stepwise multiple regression analysis and meta-analysis for proportions were used.Electro prescriptions(2013 to 2015)of the respiratory department of the sample TCM hospital were obtained.Prescriptions relevant to ALRTIs excluding pneumonia were included.Prescriptions with diagnosis of acute trachitis/bronchitis were further stratified.Prescription rates of antibiotics and herbal medicines were calculated.Antibiotics and herbal medicines with the highest frequencies of were identified.Prescriptions with subsequent visits were further analyzed to see the changes of medicines prescribed.Descriptive statistics and hypothesis test was used.Results1.Prescription rates of antibiotics in the respiratory departments in health care services of China before,during and after the most stringent antibiotics stewardship:a literature study 1.1 Impact of the Antibiotics Stewardship for the prescription rates in respiratory departments of health care services in ChinaTwo hundred and fifty six literatures,including twenty papers(8849prescriptions,4063 patients)from 19 TCM hospitals and 236 papers(91621 prescriptions,92892patients)from 221 hospitals were analyzed.The prescriptions were from 29 provinces/autonomous regions/municipalities over 20 years' range(1997 to 2016).196 papers were reporting data from wards of respiratory departments,38 papers were from the out-patient departments and 23 papers reported mixed data.Prescription rates from the wards:After the implementation of the Stewardship,prescription rates of antibiotics in the east part of China have been declined by 16%,and were lower than the middle,west and north-east part of China.In the west and north-east of China,Prescription rates dropped during the stewardship but rebounded after the stewardship.In the middle,the prescription rates continued to increase even during the stewardship.The wards of tertiary hospitals responded to the Stewardship best.The prescription rates dropped by 16%after the Stewardship,and were the lowest in all level of hospitals.The prescription rates from the secondary and primary hospitals maintained or decreased during the Stewardship,but rebounded afterwards.In general,prescription rates from TCM hospitals dropped greatly(62%)comparing to that of the WM hospitals(11%)and were lower than WM hospitals after the Stewardship.We are unable to find obvious pattern for the change of prescription rates from the out-patient clinics and from the mixed data,since the number of papers was much less.Resources of prescriptions(ward,clinic,mixed),time periods in which prescription rates were calculated and geographic regions were impact factors of the prescription rates.Prescription rates were higher in wards,before the Stewardship and in the west.1.2 Comparisons of the prescription rates of antibiotics in TCM and WM health care servicesIn the matched data,each of the 20 TCM hospitals(4249 prescriptions,44099 patients)were matched with 1-40 WM hospitals(3679 prescriptions,32565 patients).Then we further selected the most similar WM hospital for each of the TCM hospital.In the east,prescription rates from the wards of tertiary TCM hospitals were 90%,59%and 31%before,during and after the Stewardship,lower than that of the WM hospitals 92%,87%and 74%;in secondary hospitals,prescription rates of TCM hospitals were 70%and 62%during and after the Stewardship,lower than that of WM hospitals,which were 73%and 73%.In the central China,prescription rates from the wards of tertiary TCM hospitals were 92%during the Stewardship,lower than that of the WM hospitals 94%;in the north-east China,prescription rates from TCM hospitals were 81%during the Stewardship,lower than that of the WM hospitals(85%).In the west,prescription rates before and during the Stewardship were 95%and 92%,higher than that of the WM hospitals(92%and 85%).In the out-patient clinics,in the east,prescription rates of TCM hospitals were 49%and 55%before and during the Stewardship,while the rates of WM hospitals were 67%and 48%;in the central,prescription rates in TCM hospitals were 86%and 80%during and after the Stewardship,while in the WM hospitals that were 74%and 88%.In the one-to-one matched data,in the east,prescription rates of wards of TCM hospitals were lower than that of the WM hospitals.In the west,it was on the contrary.2.Use of TCM herbal medicines and antibiotics for the treatment of ALRTIs in a AAA tertiary TCM hospital in Beijing:a prescription analysis104989 consecutive prescriptions for ALRTIs from the out-patient clinic and emergency were identified from the electro prescription database of the sample hospital.Among them,prescriptions for acute trachitis and bronchitis were 4309.The prescription rate for antibiotics was 16.89%(95%CI,16.7%-17.1%)in the prescriptions for ALRTIs,and 45.81%for acute trachitis and bronchitis,which is significantly lower than what was reported in the literatures(60%-100%).Cephalosporin ?(29.41%),?(28.61%)and macrolides(24.01%)were the antibiotics with the highest frequencies.Prescription rates for TCM herbs were 92.09%(95%CI,91.3%-92.9%),among which,48.69%were not used together with antibiotics,while 43.40%together with antibiotics.In the TCM herbal medicine prescriptions,33.98%were patent medicines,24.99%were decoctions and the others were mixed.74.07%of the TCM patent medicines were over-the-counter(OTC)medicines.TCM patent medicines with the highest frequencies were Niuhuang Shedan Chuanbei oral liquid(17.13%),Lanqin oral liquid(12.86%),Jinhua Qinggan granual(7.08%),Suhuang Zhike Capsule(7.03%)and Compond Xianzhuli oral liquid(6.91%).Prescription rates of antibiotics for patients that were prescribed to take blood tests were lower than who were not.Prescription rates stratified by gender,age,seasons,upper respiratory tract infections and radio photography of lung were not significantly different.Since the symptoms were not fully recorded in the prescriptions,and nearly all the patients were prescribed herbal medicine,we are unable to explore their influences for the prescription of antibiotics.In the revisiting patients(439),187/228 whom were prescribed TCM herbal medicines without combination of antibiotics in the first visits were prescribed herbs again.While 11(4.82%)of them were further prescribed antibiotics.In the 199 patients who were prescribed herbs together with antibiotics in the first visits,48(24.12%)maintained the same treatments,14(7.04%)cancelled herbal treatment,92(46.23%)cancelled antibiotics.Only 12 patients were prescribed antibiotics without herbs in the first visit,and 5 of them maintained the same treatment.Conclusions:In the wards of the respiratory departments of TCM hospitals in the east,central and north-east of China,the prescription rates of antibiotics were lower than that were in the WM hospitals,and the implementation of the Stewardship were better.In the west,prescription rates of antibiotics were higher than WM hospitals.In the tertiary hospitals of TCM,prescription rates were lower than WM hospitals.Prescription rates of antibiotics in the out-patient clinics were unable to identify any pattern.In the sample tertiary TCM hospital in Beijing,prescription rates of antibiotics for acute trachitis/bronchitis were much lower than the reports from literatures.Prescription rate for herbal medicines was 92.09%in acute trachitis/bronchitis patients.In the patients who were prescribed TCM herbal medicines without antibiotics,82.02%maintained the treatments,while 4.81%were prescribed antibiotics in the second visits.In the patients who were prescribed TCM herbal medicines together with antibiotics,46.23%cancelled antibiotics in the second visits.In our literature study,there were great variety in the numbers of the papers from different time periods,geographic regions,levels of hospitals and wards/clinics,the prescription rates of antibiotics varied greatly.And also the number of the papers from TCM hospitals was much less than the numbers of papers from WM hospitals.Such limitations led to insufficient data in some stratums and in matching data,and this also induced high heterogeneity in meta-analysis.The results and conclusions of our literature study were limited by such drawbacks.In our real-world prescription analysis in the sample hospital,insufficient information for symptoms/disease conditions,low revisit rate and unavailable blood and radio examination results,limited our exploration for the treatment effects and their relation with the prescriptions.