Low Prevalence of Antibiotic Resistance and High Level of Antibiotic Consumption in Rural China: Interdisciplinary Study

Abstract Background: We tested the feasibility of determining the prevalence and epidemiology of antibiotic resistance in rural China and investigated patterns and drivers of antibiotic use for common respiratory and urinary tract infections (RTI/UTI). Methods: (i) Observations and exit interviews in eight village clinics and township health centres and 15 retail pharmacies; (ii) Urine, throat swab and sputum samples from patients to identify potential pathogens and test susceptibility; (iii) 103 semi-structured interviews with doctors, patients, pharmacy workers and antibiotic-purchasing customers; (iv) Assessment of completeness and accuracy of electronic patient records through comparison with observational data. Results: 87.9% of 1123 recruited patients were prescribed antibiotics, most of whom had RTIs. Antibiotic prescribing for RTIs was not associated with presence of bacterial pathogens but with longer duration of infection (OR=3.33) and presence of sore throat (OR=1.64). Fever strongly predicted prescription of intravenous antibiotics (OR=2.87). Resistance rates in bacterial pathogens isolated were low compared with national data. 25.8% of patients reported antibiotics use pre-clinic visit. Only 56.2% of clinic patients and 53% of pharmacy customers could confirm their prescription included antibiotics. Diagnostic uncertainty, economic need, understanding of antibiotics as anti-inflammatory and limited doctor-patient communication were identified as drivers of antibiotic use. Completion and accuracy of e-records was variable. Conclusions: Despite high levels of antibiotic prescribing and self-medication, prevalence of antibiotic resistance in this rural population is currently relatively low. More systematic use of e-records could improve antibiotic surveillance in rural facilities.