To the Editor—China ranks first among the world’s most frequent users of antibiotics. 1 In the hospital setting, ~70% of inpatients and ~20% of outpatients in China are prescribed antibiotics by doctors, which are both twice WHO’s expectation for these rates. 2 In many developed countries and in the United States, these rates are ~30% of inpatients and ~15% of outpatients. The overuse of antibiotics not only may adversely affect their therapeutic efficacy but also may substantially increase the cost of health care and lead to lethal toxic or allergic reactions. Approximately 14,738,000 incidents of moderate-to-severe adverse effects related to antibiotic abuse are reported annually in China, and between 2001 and 2005, ~150,000 patients died annually of antibiotic abuse or overuse. 3 Moreover, off-label and blind use of antibiotics without pathogen culture and sensitivity test can lead to increased antimicrobial resistance. 4 Furthermore, the case-fatality rate of drug-resistant infections reached 11.7% in hospitalized patients in China in 2011. 5 Based on the data provided in the Mohnarin report, 6 between 2007 and 2008 the detection rates of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE) were 73.6% and 79.5%, respectively, in 20 hospitals in China. These rates are by far the highest in history.
The irrational clinical practice of antibiotic use in China is mainly characterized by high frequency and intensity, long duration, high dose, abuse without definite indications, and the combination of multiple antibiotics without the support of evidence. The “7 deadly sins” behind antibiotic abuse in China include (1) blind dependence on antibiotics on the part of the patient, (2) lack of awareness of proper use of antibiotics on the part of the doctor, (3) compulsory acquisition of interest on the part of the hospital, (4) enormous loopholes in the drug sale and purchase market, (5) lack of strict management systems, (6) ineffective administrative supervision, 7 – 9 and (7) longstanding hospital systems that compensate doctors according to their prescription practices. In addition, antibiotic abuse in animal husbandry is almost an open secret in China. Some scholars worry that the Chinese people will regret these lax antimicrobial policies and that China may even enter a “post-antibiotic era” in which antibiotics are not longer effective, which would undoubtedly constitute a humanitarian disaster.
Antibiotic abuse and other pressing public health challenges have attracted the attention of policy makers in the Chinese government. In May 8, 2012, the Chinese government officially issued an “unprecedentedly strict” (the network-based language prevailing in China) document concerning the management of clinical application of antibiotic agents. Mr. Xiaowei Ma, Deputy Minister of the Ministry of Health of China, said that the Ministry of Health would take further measures to curb antibiotic abuse (1) by including further intensifying the management of clinical application of antibiotic agents by setting up relevant policies, (2) by strictly implementing regulations about staged management of antibiotic agents and the prescription review system, (3) by progressively enhancing the construction of networks on clinical application of antibiotics and supervision of dynamic surveillance as well as early warning on antibiotic resistance, and (4) by immediately taking specific actions to rectify improper clinical application of antibiotic agents. 10
Beyond China, antibiotic abuse has become a serious social issue threatening public health all over the world. We need to raise public awareness about the harmful nature of antibiotic abuse. Media should emphasize the importance of the rational use of antibiotics, and measures should be taken to improve public knowledge of both risks and benefits of antimicrobial therapy. In addition, education of doctors should be improved to ensure that they comply with such guidelines as well as the widely accepted recommendations for proper clinical diagnosis and treatment. Returning public hospitals to the track of public service, mobilizing the enthusiasm of medical workers, and preventing them from abusing antibiotics for personal gains are key to achieving the rational use of antibiotics.
Financial support: No financial support was provided relevant to this article.
Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.