Rational use of antimicrobials for health (Health Focus)

Draft: Wang Zheping

"Doctor, my throat hurts, you can prescribe me some antibiotics." "Check the blood picture first, and then you can be prescribed if there is an infection." Not long ago, Xu Xiaoai, a resident of Beijing's Chaoyang District, went to the Shuangjing Community Health Service Center for treatment, and one mouth was rejected by the doctor on duty. Xu Xiaoai sighed: "Antibiotics are getting stricter and stricter!"

The problem of drug resistance due to antimicrobial abuse has become a major challenge in the field of global public health. According to a report by the World Health Organization, at least 700,000 people worldwide currently die each year from drug-resistant diseases. As the efficacy of key medicines has decreased, the economic and health implications of drug resistance have become apparent. If countries do not take measures, humanity will face the catastrophic effects of the "problem of runaway drug resistance".

In recent years, the mainland has implemented key supervision of antibacterial drugs, the clinical use and intensity of antibacterial drugs have dropped significantly, and the level of rational drug use has been continuously improved, which has effectively protected the health of the people.

Establish a monitoring network for the clinical application of antimicrobial drugs and a monitoring network for bacterial drug resistance to curb the improper use of antibacterial drugs

"We went to 3 provinces to check the use of antibacterial drugs, got off the plane and went directly into the hospital, checked the medical records, checked the dosage, and interviewed immediately if there was a problem." Hu Yin, director of the National Rational Drug Use Monitoring Office, clearly remembers the situation of leading the team to conduct surprise inspections more than a decade ago.

Hu Yin told reporters that there are 6 sub-categories of systemic anti-infective drugs, and antibacterial drugs used in clinical practice account for about 84%. Mainland China was once one of the countries with high antibacterial drug use and intensity, and in 2010, the amount of clinical use of antibacterial drugs in the country accounted for about 24% of the total amount of Western medicine.

Promoting the rational use of antibacterial drugs and finding out the "bottom of the family" is the premise. "Before the establishment of the antimicrobial clinical application monitoring network, there was a lack of systematic and reliable data on the use of antimicrobial drugs in mainland China." Yang Xiaoqiang, a researcher at the Pharmaceutical Affairs Management Research Department of the Hospital Management Research Institute of the National Health Commission, said that in 2005, the mainland began to establish a nationwide monitoring network for the clinical application of antibacterial drugs and a monitoring network for bacterial drug resistance. Up to now, the antibacterial drug clinical application monitoring network has covered more than 7,000 hospitals in 31 provinces, autonomous regions, municipalities directly under the Central Government and the Xinjiang Production and Construction Corps, and the bacterial drug resistance monitoring network has nearly 4,000 member units. Through the "two networks" monitoring, the relevant departments can timely grasp the application of antibacterial drugs and the changing trend of bacterial resistance, which provides a reference and basis for formulating antibacterial drug application and management policies.

Curbing the improper use of antibacterial drugs is fundamental to institutional norms. In 2016, multi-departmental linkage established a joint prevention and control mechanism to deal with bacterial drug resistance, and regularly analyzed and judged the management of antibacterial drugs in the mainland and the situation of bacterial drug resistance.

In recent years, the National Health Commission and other relevant departments have issued a series of targeted documents to regulate the use of antibacterial drugs. For example, the Administrative Measures for the Clinical Application of Antibacterial Drugs, which was implemented in August 2012, established a hierarchical management system for the clinical application of antibacterial drugs, clarified the whole process of selection, procurement, clinical use, monitoring and early warning, intervention and withdrawal of antibacterial drugs in medical institutions, and stipulated supervision and management and legal responsibilities. The National Health Commission clearly requires that the reasonable use of antimicrobial drugs be included in hospital reviews, performance appraisals of public hospitals, rational drug use appraisals, etc., and appropriately increase the weight of assessments.

The implementation of various policies and measures has effectively improved the irrational use of antibacterial drugs. At the end of 2021, the proportion of the total amount of antimicrobial clinical drugs in Western medicines in the country has dropped to about 11%. According to the data of the National Antimicrobial Clinical Application Monitoring Network, the antibacterial drug use rate of inpatients in the member units of the National Antimicrobial Clinical Application Monitoring Network Center dropped from 62.3% in 2011 to 34.1% in 2020; the use rate of antibacterial drugs in outpatients also dropped from 16.2% in 2011 to 6.5% in 2020; in 2020, the intensity of antibacterial drug use decreased by 34% compared with 2011.

Antimicrobial use and intensity declined, but it did not affect the level of infection control, with the prevalence of nosocomial infections falling from 3.2% in 2012 to 1.9% in 2020.

Strengthen the scientific management and professional guidance in the hospital, and improve the technical content of the clinical use of antibacterial drugs

To promote the rational use of clinical antibacterial drugs, the scientific management of medical institutions is the most critical. Since 2015, many public hospitals across the country have successively carried out the work of "scientific management of antibacterial drugs", optimized the management process, strengthened technical guidance, and made full efforts on the word "reasonable".

"Our hospital's pharmaceutical affairs management committee has set up an antimicrobial working group to emphasize science at the antimicrobial selection stage." Zhang Bo, director of the Department of Pharmacy of Peking Union Medical College Hospital, believes that this is the most cutting-edge guarantee for rational drug use, and also lays the foundation for follow-up scientific management. Not only that, Peking Union Medical College Hospital has its own approach to the management of antibacterial drugs, especially high-level antibacterial drugs: no compulsory administrative intervention, more emphasis on technical guidance.

In December 2015, Peking Union Medical College Hospital took the lead in carrying out antibacterial drug management projects for inpatients in China. After completing the routine rounds at 9:00 a.m. every day, pharmacist Yang Yang will review the medical orders of the whole hospital to use carbapenems and fluoroquinolone antibacterial drugs, and the preliminary review will be released without problems, and those who have doubts will discuss with the infectious disease doctor and give specific suggestions for clinical medication. Li Taisheng, chairman of the Infectious Diseases Branch of the Chinese Medical Association and director of the Department of Infectious Diseases of Peking Union Medical College Hospital, told reporters that this multidisciplinary team was led by the hospital medical office, and more than a dozen experts from multiple departments such as the Hospital Infection Office, the Department of Infectious Internal Medicine, the Department of Pharmacy, the Department of Laboratory Medicine, and the Information Management Center participated together.

"Issues such as drug selection, dosage and method are submitted, and we will discuss with the pharmacist to give professional advice." Fan Hongwei said that the opinions include many aspects, such as antibacterial drugs do not need to be used to the limit level, patients with poor liver and kidney function should adjust the dosage of drugs, and some need further examination to determine the use of drugs. Written opinions will be formed for problems and timely feedback.

According to Zhang Bo, these written opinions will be sent to the clinical department, and the antibacterial drug working group will also track the patient's infection control and the doctor's adoption of the opinion. The project has been implemented for more than 6 years, and has covered more than 40 wards in more than 20 departments, and the adoption rate of opinions has exceeded 60%.

Technical guidance has enabled more clinicians to have a more accurate grasp of the rational use of antimicrobials. Ge Ying told reporters that when the project was first launched, sometimes more than a dozen written opinions had to be issued a day, and now, sometimes even one opinion a day is not needed, which also reflects the improvement of the doctor's medication level.

"In the past, the clinical application management of antimicrobial drugs was mainly based on administrative intervention, and now it is gradually moving towards multidisciplinary professional collaboration." Yang Xiaoqiang introduced that at the end of 2020, 18 medical institutions became the first batch of "antibacterial drug management evaluation research bases in medical institutions". At present, more and more medical institutions have incorporated the scientific management of antibacterial drugs into their daily work, and some county and municipal hospitals have also carried out the project.

Committed to the training of clinicians, pharmacists and public science, establish a long-term mechanism for the rational use of antibacterial drugs

In November 2020, a doctor in the emergency department of a top three hospital in Beijing was complained about not prescribing antibiotics to an elderly patient. This common cold patient has taken 3 kinds of antibiotics have not worked, Ben wanted to receive antibiotic drip treatment in the hospital, did not expect that the doctor not only did not prescribe, but let him stop the previous antibiotics, only to eat drugs to improve symptoms.

Experts said the doctor's handling was not wrong. However, in life, misconceptions such as "take some antibiotics to prevent" and "get better quickly with high-grade antibiotics" are common. In 2015, a World Health Organization survey showed that 61 percent of respondents in China believed antibiotics could treat a cold or flu.

The public's lack of awareness of antibacterial drugs and the existence of wrong medication habits among the masses have become a bottleneck in solving the problem of antibacterial drug abuse.

In recent years, the National Health Commission has done a lot of work in health education and health literacy promotion, and has always focused on publicizing rational drug use. For example, in the "World Antimicrobial Awareness Week" in November every year, relevant science popularization activities will be launched in various places. Fan Hongwei suggested that doctors should also take on the responsibility of educating patients, strengthen the training of doctors' communication skills, and let patients accept the knowledge and concept of rational drug use. At the same time, it is even more necessary to educate patients with the actual effect of rational drug use.

Antibacterial drugs are used rationally in clinical practice, and the shortcomings are at the grassroots level. Infectious disease doctors, clinical microbial examiners and clinical pharmacists are the "iron triangle" supported by antibacterial drug management technology, while many grass-roots hospitals have insufficient support capacity of the "iron triangle", which directly affects the improvement of management level.

Yang Xiaoqiang said that the relevant training work has been carried out and is constantly tilted to the grass-roots level. At the same time, the expert group with the goal of helping and supporting has also actively conducted in-depth research at the grass-roots level, found problems in a timely manner, and carried out capacity building guidance.

Li Taisheng told reporters that the "antibacterial drug management project study class" of Peking Union Medical College Hospital has been carried out for 5 years, and more than 150 professionals have been trained for the whole country through small class teaching and working groups.

Since 2019, the Shanghai Antimicrobial Clinical Application and Management Expert Committee has set up more than a dozen on-site supervision groups, and has successively gone deep into 56 hospitals to conduct on-site "consultations" to help hospitals find problems and shortcomings in the rational use and management of antibacterial drugs, feedback one by one, and require hospitals to rectify in a timely manner.

"Through special rectification, the irrational clinical use of antibacterial drugs has been effectively curbed, but the gap between the vast geographical areas of the mainland and the rational use of drugs between regions still exists, especially for special groups and children' rational use of drugs." Hu Yin said that it is necessary to establish a monitoring and long-term management mechanism for the rational use of antibacterial drugs, improve the awareness of the whole society about the harm of abusing antibiotics, and strive to safeguard people's health.

People's Daily ( 2022-05-06 19th edition)