Rational antibiotic use in China: lessons learnt through introducing surgeons to Australian guidelines

BACKGROUND: World-wide concern about increasing antibiotic resistance has focused attention on strategies to improve antibiotic use. This research adapted Australian best-practice guidelines on the prophylactic use of antibiotics in surgery to a Beijing teaching hospital and then used them as a quality assessment and improvement tool, supplemented by educational interventions. Qualitative data about factors influencing antibiotic use was also obtained. METHODS: Australian and international guideline materials were amalgamated with the help of Chinese experts. Antibiotics prescribed for surgical prophylaxis in 60 consecutive patients undergoing clean or clean-contaminated surgery (120 total) were then compared with guideline recommendations in three phases; a pre-intervention period from June to August, 2002, an intervention period from June to August 2003 and post-intervention period from September to November 2003. During the intervention phase, feedback about prescriptions not in accord with the guideline was discussed with around 25 prescribers every two weeks. In addition, local factors influencing antibiotic use were explored with 13 junior surgeons and 8 high level informants. RESULTS: While agreement was reached on the principles of antibiotic surgical prophylaxis there was no consensus on detail. Of 180 patients undergoing clean surgery throughout all phases of the study, antibiotic prophylaxis was administered to 78% compared to 98% of the 180 patients undergoing clean-contaminated surgery. Second and third generation cephalosporin antibiotics predominated in both low-risk clean and clean-contaminated operations. The timing of prophylaxis was correct in virtually all patients. The duration of prophylaxis was less than 24 hours in 96% of patients undergoing clean surgery compared to only 62% of patients undergoing clean-contaminated surgery. The intervention produced no improvement in the duration of prophylaxis nor the overuse and inappropriate choice of unnecessary broad-spectrum and expensive drugs. Interviews and focus groups revealed that an important explanation for the latter problem was Chinese government policy which expected hospitals to support themselves largely through the sale of drugs. CONCLUSION: Improving antibiotic use in China will require hospital funding reform, more authoritative best-practice guidelines, and hospital authorities embracing quality improvement.