Unpacking Antibiotic Use in Chinese EDs: What COVID-19 Taught Us (and Didn’t)

Hey there! Let’s chat about something super important in healthcare: how we use antibiotics, especially when we’re feeling under the weather with those pesky acute upper respiratory infections (AURIs) – you know, the common cold, sore throats, that kind of stuff. We all get them, right? And often, we might think, “Hmm, maybe I need an antibiotic.” But here’s the kicker: most of these infections are caused by viruses, and antibiotics only work on bacteria. Using them when they’re not needed is a big deal because it helps create “superbugs” – bacteria that are resistant to antibiotics. Not cool.

This problem of antibiotic overuse is global, but it’s particularly noticeable in places like emergency departments (EDs). Why? Well, EDs are busy, doctors need to make quick decisions, and sometimes it’s easier to just prescribe an antibiotic “just in case.”

So, some smart folks decided to dig into this very issue in China, looking specifically at EDs and how the whole COVID-19 pandemic might have shaken things up. They pulled data from a massive database covering prescriptions for AURIs from 108 hospitals across China between 2018 and 2023. That’s a lot of prescriptions – nearly 2 million! They wanted to see the trends, the patterns, and the impact of the pandemic. And guess what? They found some pretty eye-opening stuff.

The Lay of the Land: Before and During the Study

Before diving into the COVID-19 impact, let’s look at the baseline. The study period covered 2018 through 2023. Right off the bat, they saw that the number of prescriptions for AURIs dipped significantly in 2020, likely because of China’s strict pandemic control measures keeping people home and reducing the spread of *all* respiratory bugs, not just COVID. By 2023, visits were up again but still hadn’t hit those pre-pandemic levels.

Over the entire study period, the antibiotic prescription rate (APR) for AURIs in these EDs was a whopping 58.44%. That means more than half the people showing up with a cold or sore throat walked out with an antibiotic prescription. Compared to guidelines that suggest this rate should be below 20% in places like Europe, that’s quite high. Adults were more likely to get antibiotics than kids under 18. Interestingly, the APR for the common cold specifically (ICD-10 code J00) was lower at 31.83%, and it actually went down over the study period.

What Kind of Antibiotics Were They Using?

This is where it gets even more interesting. The study looked at the types of antibiotics prescribed.

• Most prescriptions were for oral antibiotics (60.78%).
• The vast majority (92.04%) were given as monotherapy (just one antibiotic).

But the *types* of antibiotics were a bit concerning. The most frequently prescribed were:

• Cephalosporins (56.27%)
• Macrolides (like azithromycin) (21.23%)
• Quinolones (like levofloxacin) (15.08%)

Within the cephalosporins, third-generation (50.57%) and second-generation (43.90%) were the most common. Azithromycin and levofloxacin were also high on the list.

Breaking it down by age, kids under 18 got more azithromycin, cefixime, and cefaclor. Older folks (65+) saw more quinolones. The study even noted 52 kids aged 8-18 got systemic fluoroquinolones, which is generally discouraged in children due to potential side effects.

Are They Following the Rules? Guideline Adherence and “Watch” List Drugs

Here’s a less-than-great finding: only 22.26% of antibiotic prescriptions for AURIs actually followed the first-line guideline recommendations. The guidelines often suggest things like amoxicillin, azithromycin, or first-generation cephalosporins as initial choices. While azithromycin was frequently used (it’s a first-line option), levofloxacin, a *second-line* antibiotic, was the third most common for monotherapy and also popped up a lot in combinations. Prescribing second-line drugs, especially in combinations not recommended by guidelines, is a red flag for potential overuse and driving resistance.

Even more concerning was the classification of these antibiotics according to the WHO’s AWaRe categories (Access, Watch, Reserve). These categories help guide appropriate use to preserve antibiotic effectiveness. “Access” drugs are preferred first-line treatments, “Watch” drugs should be used more cautiously due to higher resistance potential, and “Reserve” drugs are last resorts.

Turns out, a massive 83.82% of the prescriptions for AURIs were for Watch-group antibiotics! This aligns with other studies showing a high reliance on broad-spectrum drugs in China. Elderly patients were particularly likely to receive these Watch-group drugs. This widespread use of broad-spectrum antibiotics like second and third-generation cephalosporins is a major contributor to the high proportion of Watch-group drugs and fuels concerns about resistance.

The COVID-19 Twist: Consumption vs. Prescription Rate

Now, let’s talk about the pandemic’s impact. Using a fancy statistical method called Interrupted Time Series (ITS) analysis, the researchers looked at trends before, during, and after key points in the pandemic.

At the very beginning of the pandemic (around early 2020), the study found something interesting:

• Antibiotic *consumption* (measured in Defined Daily Doses or DDDs) saw a significant decline. People were using fewer antibiotics overall.
• However, the antibiotic *prescription rate* (APR) – the percentage of AURI patients getting *any* antibiotic – didn’t change significantly at this initial point.

This might seem counterintuitive, but the researchers suggest it could be due to the overall drastic drop in ED visits for AURIs during the strict lockdown period. Fewer people were coming in, so total consumption went down, but the *likelihood* of getting an antibiotic if you *did* come in for an AURI didn’t necessarily change much at that specific moment.

The significant drop in consumption was seen across various antibiotic types, including cephalosporins, macrolides, and quinolones. Watch-group antibiotics also saw a decline in consumption, but it was slightly less pronounced than the decline for Access-group antibiotics.

The Post-Pandemic Rebound: A Worrying Trend

Fast forward to early 2023, when China significantly relaxed its COVID-19 control measures. What happened then?

The ITS analysis revealed a concerning trend:

• Both antibiotic *consumption* and the antibiotic *prescription rate* (APR) for AURIs showed a substantial upward trend after the restrictions were lifted.

While neither metric had returned *exactly* to pre-pandemic levels by the end of the study period (2023), the rapid increase is a major red flag. This rebound aligns with what other countries saw after lifting restrictions, likely fueled by a resurgence of respiratory infections (both viral and bacterial).

Interestingly, the pandemic didn’t seem to significantly impact the APR for patients under 18, which contrasted with trends in older age groups.

The rebound in consumption was also seen across most antibiotic classes. And when looking at the AWaRe categories, Watch-group antibiotics showed a *more substantial* rebound in consumption compared to Access-group antibiotics in the post-restriction period. This suggests that the reliance on these broader-spectrum drugs is coming back strong.

Why Does This Matter? And What Can We Do?

This study confirms that antibiotic overuse for AURIs is a big problem in Chinese EDs, with a heavy leaning towards broad-spectrum, Watch-group antibiotics. The low adherence to guidelines is concerning. The pandemic caused a temporary dip in *consumption* (likely due to fewer visits), but the *rate* of prescribing didn’t initially drop significantly, and now both are climbing back up after restrictions lifted.

One potential reason for the preference for cephalosporins over narrower-spectrum penicillins (like amoxicillin, often a first-line choice elsewhere) might be the requirement for skin testing before giving penicillins in China. This adds an extra step and might make doctors opt for cephalosporins, even if they are broader spectrum. However, recent evidence suggests routine skin testing for beta-lactams like amoxicillin isn’t always necessary and might hinder the use of these preferred first-line drugs.

So, what’s the takeaway? We need to get serious about antimicrobial stewardship in EDs. The study suggests several things:

• Beef up Stewardship Programs: Create and strengthen programs specifically for EDs to guide appropriate antibiotic use.
• Stick to AWaRe: Prioritize “Access” group antibiotics (like amoxicillin) when clinically appropriate, reserving “Watch” and “Reserve” drugs.
• Rethink Skin Testing: Re-evaluate the need for routine penicillin skin testing in guidelines to make narrower-spectrum options more accessible.
• Use Better Diagnostics: Develop and implement rapid diagnostic tests to help figure out if an infection is bacterial or viral, reducing the need for guessing and empirical antibiotic use.
• Educate Everyone: Provide targeted education for both healthcare providers and patients about appropriate antibiotic use.

Of course, the study had limitations – they couldn’t see all the clinical details, the diagnosis coding might not be perfect, and the data was mostly from larger hospitals. But even with those caveats, the picture is clear: we’re using too many antibiotics for AURIs in Chinese EDs, often the wrong kind, and the post-COVID rebound means we can’t let our guard down. Reinforcing stewardship efforts is crucial to fight the growing threat of antimicrobial resistance.

Source: Springer