Shanghai hospitals to ban antibiotic infusions for coughs and colds

by MICHAEL WOODHEAD
Not before time, some of the more advanced and enlightened provinces of China are to ban the widespread practice of giving patients antibiotic infusions for common colds.

Visit any emergency department or outpatient department in a major Chinese hospital and you will see row after row of patients hooked up to IV infusion lines. These are people who have coughs, cold and fevers and are given intravenous antibiotics as routine therapy. In most other countries this would be seen as an absurd, unscientific and harmful overtreatment, but in China it is the norm. There is an almost superstitious belief among Chinese people that an infusion is a panacea.

Many doctors have spoken out against the practice but until now hospitals and health authorities have done nothing to curb the practice. That may be all about to change. The Jiangsu health department has put hospitals on notice by saying that from 1 July 2016 infusions will no longer be permitted as routine therapy in outpatient departments of major hospitals (2nd and 3rd level). This will include city hospitals in cities such as Shanghai.

In a recent interview with People's Daily, Xuzhou Medical College Professor Wu Yunming said the most appropriate treatment for a cold was to take a simple antipyretic such as aspirin, rest and drink plenty of fluid.

"Sick people going to hospital for an infusion has become a long established bad habit, which is one of the important factors for antibiotic drug misuse," he said.

Professor Wu said it was a practice that must be stopped but it would require a change of thinking among the public as well as among the medical profession.

He said strict rules were needed to ban infusions because although doctors were aware that they were inappropriate, self regulation and guidelines had failed to curb their use. Professor Wu said it was typical for an outpatient department to have 200 patients in a morning having infusions - and not unknown for up to 700 patients a day receive such treatment. This was highly profitable for hospitals, which charged 100-200 per infusion, he said.

"Hospitals are businesses and infusions represent a significant source of revenue for them," he noted.

A reporter who visited a major hospital found that healthcare staff were sceptical about the planned ban. They say their was widespread patient expectation and demand for infusions, and if tertiary hospitals did not offer them then patients would simply go to smaller hospitals or local community health clinics that would still provide them.

Professor Wu said rational use of antibiotics was an important issue because antibiotic infusions could cause anaphylactic reactions, increase resistance and also cause other major side effects on the kidney and liver. Infusions also wasted a lot of workforce capacity and resources as nurses had to set up and monitor infusions. He said there needed to be a system-wide plan and implementation of the infusion ban, with an emphasis on social responsibility for hospitals and professional responsibility for doctors.

A spokesman for the Jiangsu department of health said it would be issuing a 'blacklist' of more than 50 medical conditions for which infusion was not permitted.

Antibiotics in China: not quite there yet

by MICHAEL WOODHEAD
Regular readers of this blog will know that antibiotic misuse is one of my real bugbears about medicine in China. Seeing rows of patients in emergency departments routinely hooked up to infusions of broad spectrum antibiotics for fevers is a symbol of everything that is wrong with healthcare in the PRC.

Well it seems that I'm in good company in deploring this unwelcome practice. As part of Antibiotic Resistance Awareness Week, the World Health Organisation has taken China to task for its misuse of antibiotics. In a new global report it singles out China for having particularly poor usage and knowledge of antibacterials. A survey reveals that more than 60% of Chinese think, incorrectly, that colds and flu can be treated by antibiotics. A similar proportion have used antibiotics in the past few months and one in four bought them over the counter rather than obtain them on prescription. And while 67% were aware of the term ‘antibiotic resistance, few realised that cutting down on antibiotic use was the way to tackle it.

The WHO states that China is one of the worst offenders for antibiotic misuse and blames the lack of awareness among the citizenry for this problem. For a country that prides itself on such a good education system, how can Chinese be so badly informed about such an important matter?

The head of the pharmacy department at the Beijing Union Medical College Hospital, Zhang Jichun, says many Chinese demand antibiotics as a "quick fix". At the hospital if doctors say that antibiotics are inappropriate for patients with a fever or a cough they are rebuked with: "my illness so bad, why don't you give me an infusion for it?" Doctors say patients accuse them of not taking their illness seriously and demand "give me an infusion quickly so I will recover quickly and can get back to work!"

The WHO says it hopes the new report will raise awareness about antibiotic overuse and the risk of resistance in China. I'm not holding my breath.

Alibaba Health, iKang, Online consultations, Tobacco advertising ban, Antibiotics in food, HIV discrimination

by MICHAEL WOODHEAD

Hello and welcome to another week of China Healthcare. As China makes headlines around the world for its slowing economy, few have remarked that China's entrepreneurs are taking a different and more rosy view by re-focusing on healthcare. This week the Alibaba internet billionaire Jack Ma has issued a $2.5 billion vote of confidence in the prospect for online pharmacy in China by transferring his pharmacy e-commerce section to Alibaba Health ("Ali Jiankan" or alijk.com).  According to the WSJ, "Alibaba said the deal would position it to sell prescription pharmaceuticals should China’s reforms allow retailers to move in that direction".

At the same time, Forbes has profiled another internet millionaire who has made his fortune by turning to health. Zhang Ligang made his first fortune by founding the travel booking site e-Long, but he is more famous for building a chain of private clinics under the banner iKang. And if China really does shift to a more private healthcare system, companies like iKang should be at the forefront of the wave.

The NHFPC has banned online medical diagnosis. In a statement this week the health ministry said medical consultations cannot be conducted online as there have been too many cases of unqualified people offering medical advice, purporting to be experts. The ban does not seem to apply to accredited hospitals that have approved programs. What this means for online doctor apps such as Spring Rain (www.chunyuyisheng.com) remains to be seen.

Children in China are exposed to a wide variety of antibiotics in food, which may promote resistance. A study in Shanghai that tested the urine of more than a 1000 children aged between 8 and 11 years of age found that as most had traces of at least one antibiotic and many had several antibiotics in their system.  Altogether 18 different antibiotics were found in the urine of Shanghai children, reflecting the high levels of antibiotics used in food production in China. This was confirmed by another report out this week which noted that the Chinese food and livestock industries use 100,000 tons of antibiotics  a year to promote growth in animals reared for their meat.

A total ban on tobacco advertising n China has been urged by the WHO. The head of the China office of WHO said China had a treaty obligation to phase out tobacco advertising, and should start to do so at retail points of sale. However, the powerful state-owned tobacco industry might baulk at that. The relative power of the health and tobacco industry was shown this week when health minister Li Bin noted that new graduates could earn twice as much in the tobacco industry compared to medical graduates working in hospitals. She made the point that the basic salary for a university graduate working in the tobacco industry was 4571 yuan a month compared to only 2100 yuan a month for a junior doctor. Li Bin said there was a need to learn from Adam Smith and pay the market rate for medical graduates - and this would mean patients being prepared to pay higher medical fees.

And finally the question arises of whether anti-HIV discrimination still exists in the China's hospitals. A patient at the Sichuan University Huaxi Hospital says he was refused surgery when doctors discovered his HIV positive status. The man said he had been scheduled to have surgery for haemangioma but it was cancelled and he was told that he would instead be kept 'under observation' instead. The hospital rejected the discrimination claim, saying that it was standard practice to keep patients under observation before going ahead with surgery for this condition.

When it comes to health, for China the numbers are staggering

by Michael Woodhead
In western countries hardly a week goes by without some disease condition being put in the spotlight in a press release saying "Condition X affects Y million people a year and costs Z million dollars". 
If industry has a stake in the matter then this is usually followed by a statement saying that the Condition X is underdiagnosed and undertreated and if only we used Drug A or Test B then we would avoid prevent much suffering and save the health budget in the the long run.
This sort of thing is now happening with health conditions in China, except the numbers are bigger by a factor of ten or even a hundred. Take osteoporosis, for example. An analysis published this week shows that there are about 2.3 million osteoporotic fractures a year in China, costing $10 billion in health costs. And if you think that's bad, wait until you see their projection for 2050 - the researchers estimate that with the ageing population there will be 6 million fractures a year costing $25 billion. And as predicted, the report's authors say that "screening and intervention policies must urgently be identified in an attempt to minimize the impact of fractures on the health of the burgeoning population as well as the healthcare budget."

A similar dire warning was made this week for hypertension and diabetes in China. An article in the Journal of the American College of Cardiology said that China was facing a cardiovascular disease epidemic as three out of four Chinese people are in poor cardiovascular shape due unhealthy eating, smoking and obesity. On a similar note, a study from Shenyang showed that 50% of older adults had hypertension and poor cholesterol levels. And a report in The Lancet this week shows that China has 300 million smokers and that tobacco causes 1 million premature deaths a year. The numbers are so big they are incomprehensible. And yet at least the Lancet offers a workable solution: cigarette taxes. It says that if cigarette taxes were raised by 50% this would result in 231 million years of life gained over 50 years and also produce an additional US$703 billion in extra tax revenues from the excise tax. The overall effect would be to relieve financial burden on the poor by avoiding diseases such as lung cancer and the consequent medical bills and time off work. But does Xi Jinping have the gumption to increase cigarette taxes?

For yet another set of mind boggling numbers turn to the example of cervical cancer. With no Pap test screening program, tens of thousands of Chinese women develop this disease and die of it each year, even though it is preventable. Western countries have long had screening programs and are now tackling cervical cancer with the HPV vaccine for young women. Some health economists have crunched the numbers for China and estimated that a national vaccination program of HPV vaccine for 9-15 year old girls, between 2006 and 2012 would have prevented 381,000 cervical cancer cases and 212,000 related deaths. They say that a HPV vaccination program could be implemented in China at a cost of about $50 per girl for the whole set of vaccinations and program costs. In total this would cost China about $160 million, but would ultimately prevent hundreds of thousands of deaths from cervical cancer - and also be cost effective.

A final example: stomach cancer. This causes  hundreds of thousands of deaths in China every year. And yet researchers have found that regular use of low dose aspirin could reduce the risk of stomach cancer (and other common cancers such as colorectal cancer) by as much as 40%. In other words, if Chinese people took a regular dose of aspirin they could avoid many fatal cancers, not to mention the protective cardiovascular benefits against stroke and heart attack. Whether these would be outweihed by increased bleeding risk remains to be seen.

I think what I am trying to say here is that when it comes to ill health in China, the numbers are often too large to be imagined. But that also means that measures that produce only modest reductions in rates of disease can also have major impacts on the absolute numbers of illness.

And while talking of high rates, let's return to my favourite bugbear about healthcare in China - the infusion. I have been guilty in the past of blaming backward thinking among the Chinese masses for insisting on having an infusion for every ailment. I hope I haven't hurt the feelings of the Chinese people and perhaps I owe them an apology. A study from a bog standard Hubei hospital shows that a staggering 96% of antibiotics used in the hospital wee given parenterally (ie by injection or infusion rather than orally). The authors of the report contrast this with the rates of about 30% of IV antibiotic use seen in European hospitals.

However, they blame the profit motive among hospital managers for the widespread use of antibiotic infusions - noting that hospitals depend on drug sales for a major part of their income. Therefore it will be interesting to see what happens when the Chinese government tries to eliminate this source of income for hospital by introducing cost price pharmaceutical billing this year (ie not charging a markup).  How will hospitals  fund their services? The government only covers about 20% of their running costs. There are already predictions that costs will be shifted to medical procedures - and trigger even more overservicing.

At least there is some discussion taking place of these kinds of problems and some in the government are acknowledging that there is still a long way to go in health reform. This week a very frank and bleak account of the ills of rural Chinese health system was published. Doctors and hospital managers said quite bluntly that the rural healthcare system in China is being hollowed out - older doctors are retiring, and nobody is taking their place. Young doctors do not want to work in rural hospitals, partly because the ban on commissions from pharmaceuticals means they can make only a tiny income. And patients do not want to be treated in them. And so the county and township hospitals are becoming ghost hospitals - deserted compared to the overcrowded city hospitals, where rural Chinese flock when they have a serious health problem.

Fact of the week: Chinese primary care (community health centre) doctors earn only 3000-4000 yuan a month. Primary care doctors account for only 4% of doctors in China.

Drug resistant bacteria - just how much of a problem are they in a typical Chinese hospital?

by Michael Woodhead
With broad spectrum antibiotics easily available over the counter in China  - and the Chinese cultural expectation of an antibiotic as the magic bullet for every viral fever - it's not surprising that drug resistance is a major problem in the PRC. 
But just how common is the problem for a typical provincial hospital? The rather worrying answer is quite a big problem. A study carried out in the Liaocheng People's Hospital in Shandong has found that one in three bacteria samples obtained from around the hospital were multi-drug resistant. Researchers at the hospital took almost 10,600 microbial samples from around the hospital and found that  33.4% were multi-drug resistant pathogens such as ESBLs producing E. coli and A. baumannii. The blackspots for resistant bacteria were in surgical departments and the intensive care department. Samples obtained from respiratory and secretions were the greatest source of resistant bacteria. The obvious consequences of these multi-drug resistant bacteria are treatment failure, longer hospital stays, increased mortality, and higher hospitalisation costs. As the authors conclude, their findings show the need for much greater attention to antibiotic resistance, especially from respiratory cases and surgical wounds.

Survey reveals the bad antibiotic habits of Mainland Chinese

by Michael Woodhead
Chinese people have developed bad habits of antibiotic misuse such as self medicating with OTC products, not finishing the course and hoarding leftover antibiotics for later use, a new study shows.
Doctors at the University of Hong Kong made the worrying findings when they surveyed recent Chinese immigrants on their knowledge and attitudes towards antibiotic use.  They conducted focus group interviews with 56 recent migrants from mainland China and also conducted phone surveys with 134 Chinese and 1600 Hong Kong residents.
The survey showed that both Chinese and Hong Kong-born Chinese had many erroneous beliefs about antibiotics, including the belief that they were effective against viruses and the common cold. One in ten Chinese patients had never heard of antibiotic resistance and most believed that antibiotic would weaken the immune system. A significant minority of Chinese believed antibiotics had significant side effects such as drowsiness or loss of appetite, and said they would stop taking antibiotics when the symptoms had cleared up rather than finishing the full course. About one in seven said they would  keep leftover antibiotics and store them in the fridge to 'recycle' them for later use. A similar proportion said they would seek to self medicate with antibiotics bought over the counter  - sometimes for 'prevention' of infections - even though OTC sale is illegal in Hong Kong.
In the focus groups, many mainland Chinese said they were accustomed to the IV antibiotic infusions that are routinely given to feverish patients in China, and they believed that the oral antibiotics prescribed by doctors in Hong Kong were less effective and led to the infection persisting for longer. However, some respondents said they trusted doctors in Hong Kong more than those in China, and tended to accept their advice on antibiotics and would not ask for antibiotics if they were not recommended.
The researchers from the University of Hong Kong said their survey dispelled the myth that mainland Chinese demanded more antibiotics from doctors. It showed that many recent mainland Chinese migrants had acquired some knowledge of appropriate antibiotic usage during their stay in Hong Kong, but the knowledge was not always translated into practice. They suggested that antibiotic education campaigns were needed for both Hong Kong Chinese and their mainland counterparts.

Today's Top 10 China medical news stories

1. China is to launch a national cervical cancer screening program to test 10 million Chinese women annually, the National Health and Family Planning Commission says. The move follows concerns about increasing rates of cervical cancer, especially in women under 35. China has 130,000 new cervical cancer cases a year and up to 30,000 deaths a year due to the disease.

2. Vaccination rates have fallen as much as 30% since the hepatitis B vaccine safety scare over the deaths of 17 infants, immunisation experts say. They said the drop in vaccination rates could put up to 500,000 infants at risk of serious vaccine-preventable diseases.

3. In a landmark study, Shanghai clinicians have shown that pulse oximetry is a simple and accurate method for detecting major congenital heart disease in newborn babies in China. Writing in the Lancet, they say the method should be used in all maternity hospitals.

4. Salmonella in China is becoming resistant to most antibiotics including ciprofloxacin, ceftriaxone and azithromycin, "posing huge threat to public health and infection control" say clinicians in the journal Antimicrobial Agents and Chemotherapy.

5. A Beijing doctor was punched by the husband of a pregnant woman who said the doctor had pinched her stomach and threatened to kill her. The woman admitted she had first cursed the doctor when she believed she had been ignored by him.

6. Seven leading hospitals in China have signed an alliance agreement to for a National Team to tackle difficult diseases.

7. Kindergartens in Beijing have been struck by the norovirus gastro bug and dozens of children are showing symptoms such as diarrhoea and vomiting.

8. Young Chinese people do not wish to pursue a career in the medical sector, as jobs in medical services were ranked lowest in a survey of desirable careers by recruitment site zhaopin.

9. Complaints about fake drugs and medical devices being sold online are the most frequent calls to the China Food and Drug Administration hotline.

10. Hospital clinics in Shanghai are overflowing with three-four hour waiting times and yet community clinics are sitting almost empty and 'general practitioners see few patients because the public has little confidence in the level of services provided, according to an article in China Daily.

Infusion madness: patients in Nanchang hospitals consuming gallons of IV antibiotics

by Michael Woodhead
Health experts in Nanchang, Jiangxi have admitted that their city's hospitals are some of the worst offenders in China when it comes to the practice of allowing patients to unnecessary IV infusions. 
In a country where the average person consumes eight bottles of IV infusion fluid per year, Nanchang is above the national average. Dr Yuan Zhaokang, head of the Nanchang University department of public health, says 90% of people are not aware of the risks and harms of IV infusions and yet between 60-70% of people in outpatient departments are given them. Of these patients, 75% don't need the infusions and could be given oral medicines instead. Dr Yuan says China's rate of IV antibiotic use is10 times higher than the international average, meaning that most intravenous antibiotics given in China are unnecessary.
In theory, the public are told that they should not have an injection when an oral medicine will suffice, but in practice in China this order has been turned on its head, Dr Yuan says.
A Sichuan emergency medicine director, Dr Zhen Tao says he opposes routine use of IV drips for people with colds, but it is hard to change the public mindset.
"People believe that IV infusions are more effective and work faster than oral medicine - but they are wrong," he says. Given a choice, patients always demand "infusion first", and few are aware that this directly contradicts the WHO advice for "never give an IV infusion when an IM injection will suffice, and never given an injection when oral medicine will be sufficient".
While this message is slowly getting across to more educated adults, the situation for children is getting worse, says Dr Zhen. Whenever the weather gets cold or the season changes, the hospital's infusion room is crowded with children who have colds who are attached to IV infusion bottles.
A common cold is a minor viral illness - so why do all Chinese insist on having unnecessary antibiotics by intravenous infusion? Dr Zhen says one reason is the pressure from parents with 'inflexible' thinking and attitudes. Another reason is that hospitals make money from infusions.
"Families want a quick cure-all and hospitals want a quick profit. When these two factors come together the result is bad medicine," says Dr Zhen.
The craze for children to have infusions especially worries Dr Zhen because he says it can weaken their health. Antibiotics not only kill pathogens, they also kill the 'good' bacteria that children need for developing an immune system and digestive health, he says. This is especially so for children who have repeated infusions, which become a vicious circle, where more treatments are requested because the child gets sicker and more prone to infections.
As well as increasing antibiotic resistance, IV infusions of antibiotics often cause many other serious health problems, including life-threatening anaphylaxis and other allergic reactions, phlebitis and injection site reactions, circulatory overload and heart failure as well as pyrexia (high fever), Dr Zhen warns.
The only people who really need IV infusions are those who have swallowing disorders, gastric malabsorption problems and the acutely  critically ill patient, he said.

Shenzhen clinics show over-prescribing of antibiotics can be curbed by removing financial incentives for doctors

by Michael Woodhead
Antibiotic prescribing fell significantly when Shenzhen community clinics severed their ties with hospitals and dropped the financial incentives to prescribe them, a study has shown.
Published in the journal Family Practice, the study by Dr Liang Xiaoyun and colleagues at Beijing Normal University shows that prescribing of antibiotics fell by about 10% when the governance model of community  clinics in Shenzhen's Baoan district was changed by government in 2009. Under the new independent model, doctors no longer received financial incentives for prescribing. After the reform, the number of young children receiving antibiotics decreased by 9%. The costs of antibiotic prescriptions also fell because doctors tended to prescribe cheaper first generation antibiotics instead of more expensive newer drugs. The study authors said their findings showed that "changes in governance structure model can have positive effects on the antibiotic prescribing behaviour of providers. This short-term effect might have an important
implication for community health reform in China."

News in brief: Saturday 15 February

China's widespread misuse and overuse of antibiotics needs to be curbed, according to an article published in the BMJ this week. Dr Li Yan who works at Nottingham Trent University in the UK, writes that pressure from patients and perverse financial incentives are just two of many factors that have contributed a high rate of antibiotic use that is ten times higher than that of the US. Antibiotic overuse leads to resistance and causes numerous adverse events, she says. New regulations introduced by the Chinese health department need to be fully implemented, she adds, and there also needs to be a major public education campaign to improve awareness about antibiotics and reduce demand, she suggests.

A Hunan official has been found guilty of selling fake medical licences to six "black (bogus) doctors" who had not passed any medical exams. The records department workers sold the medical licences for 45,000 yuan to people who set up private medical clinics and pharmacies. The official was sentenced to eight months in jail and the medical licences were cancelled, Xinhua reports.

Almost 16,600 Chinese people died of infectious diseases in 2013, with HIV being the main cause of death, the National Health and Family Planning Commission has announced. There were more than 6.4 million infectious disease cases reported, of which AIDS, tuberculosis, rabies, hepatitis and hemorrhagic fever were the most deadly diseases, while hepatitis, tuberculosis, syphilis, dysentery and gonorrhea were the most prevalent, ECNS reports.

Curbing antibiotic overuse in China will need major reforms - researchers

by Michael Woodhead

China’s new get-tough approach to overuse of antibiotics is having some impact, but there are still huge obstacles  to reversing the tide of antibiotic resistance, researchers from Zhejiang say.

Rates of antibiotic prescribing in hospitals have declined slightly since mandatory curbs and punishments were introduced in 2009, according to a new analysis by Dr Xiao Yonghong and colleagues at the Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou.

In a review published in PLOS Medicine, Dr Xiao says antibiotic overuse will continue to be a major problem for China unless further restrictions are introduced on hospitals profiting from antibiotic sales, OTC sales of antibiotics and the use of antibiotics in animal feeds.

The analysis notes that misuse of antibiotics in China has led to high rates of antibiotic resistance. The prevalence of superbugs such as MRSA ranges from 50% to over 71%, the researchers note. This is not surprising given that hospitals derive much of their profits for the sales of medications, of which antibiotics are the most commonly prescribed.

Initial reforms to promote better antibiotic stewardship introduced in 2006 have not been successful because they were voluntary and not complied with, the review found. However, stricter mandatory measures introduced since 2009 have begun to show effect on antibiotic use, figures show.

Hospitals were compelled to draw up antibiotic management strategies and set targets with audits. In some cases, hospital managers were dismissed and clinicians had their prescribing rights withdrawn for failing to address the problem of antibiotic overuse.

After these reforms were implemented,  the percentage of prescriptions for antimicrobials decreased from 68% to 58% for inpatients and from 25% to 15% for outpatients.

This is a significant downturn, says Dr Xiao, but a number of issues still need to be addressed to ensure further improvements in antibiotic use.

Overuse of antibiotics continues through OTC sales and in animal feed, but regulation of these areas is hampered because authority is divided between the State Food and Drug Administration, the Ministry of Agriculture and the ministry of Health.  There is also a need for education of clinicians and the public on the need for antibiotic stewardship, says Dr Xiao.

“Finally, and critically, the government should widen the healthcare reforms and provide financial guarantees to medical institutions to ensure that economic incentives from drug sales are eliminated. This will return healthcare institutions to a not-for-profit status and aid professional standards,” the researchers conclude.

Read the full article at: PLOS Medicine

New rules for rational antibiotic use in China

by Xiao Yonghong and Li Lanjuan
On Aug 1, 2012, China formally implemented a decree issued by its Ministry of Health on administrative regulations for clinical use of antibacterial agents. This ruling defines all aspects of antibiotic use in hospitals, including selection, procurement, prescription, use, monitoring, and legal responsibility, and is the strictest regulation yet for antibiotic management in China. The major purpose of the new regulations is to ensure rational use of antimicrobial agents.
China has extensively reformed its health-care system, which is expected to ultimately give all citizens access to basic medical care. To achieve this aim, the current profit-orientated philosophy in public hospitals should be completely abandoned, and administration of drugs, including antimicrobial agents, should be rationalised. Irrational long-term use of antibiotics allowed by current hospital managements strategies in China has generated antibiotic-resistant bacterial strains, despite the health-care authority releasing several sets of guidelines during the past 10 years to promote rational use, including principles for clinical use of antibiotics (2004), a national formulary (2008), and guides for hospital drug therapeutic committee (2002). Bacterial resistance is now a major problem in China.
In a national survey, 60% of isolates of some species were drug resistant, including meticillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing Escherichia coli, quinolone-resistant E coli, and carbapenem-resistant Pseudomonas aeruginosa, and Acinetobacter baumannii.  Rational use of antimicrobial agents and the implementation of other methods to prevent resistance from worsening have become crucial.
The recently introduced regulations for antibiotic use incorporate the internationally accepted notion of antimicrobial stewardship, and include some administrative requirements tailored to the Chinese health-care system. The regulations also include specific instructions for leaders of medical institutions who are responsible for the rational administration of antimicrobial agents, for establishing an effective antibacterial drug-management system, and for forming a working group composed of infectious disease physicians, pharmacists, microbiologists, and managers. Medical institutions must ensure that antibiotics are classified as non-restricted, restricted, or special-grade. Physicians and pharmacists need specific training in antibiotic prescription before they are granted different levels of prescribing privileges depending on their professional title. The health-care authority will set administrative goals for institutions, review of antibacterial drug prescriptions, regularly publish information about antibacterial drug use in hospitals, commend physicians who closely follow the regulations, and impose penalties on medical staff who violate them.
The regulations also encourage medical institutions to explore alternative strategies to improve the rational use of antibacterial drugs, such as diverse antibiotic use, active intervention for antibiotic use, implementation of clinical guidelines, and hospital infection control. At the same time, pharmaceutical companies should implement a standardised drug-promotion procedure and stop attempting to increase drug sales for economic incentives. Medical institutions need to regularly report the use of antibacterial drugs to the health-care authority. To improve the administration of antibiotics, institutions that seriously or persistently violate the regulations will be appropriately penalised by the authority, by means such as downgrading the hospital to a lower level of classification, and dismissing the leaders of the institutes involved. Medical staff who seriously violate the regulations could lose permission to prescribe antibacterial drugs, have their professional qualification revoked, or even be prosecuted if their actions have serious consequences.
To promote the implementation of these regulations, in 2011 the Chinese Ministry of Health initiated a 3 year campaign with a special task force in antibiotic management. By strict implementation of these regulations and the introduction of legal penalties, the rational use of antibiotics in public medical institutions can be enforced quickly and efficiently. Although these steps are appropriate to reduce antibiotic use in the current Chinese health-care system, long-term management of the strategies needs more planning and the establishment of a sustainable back-up system such as antibiotic stewardship professionals, guidelines, ongoing staff training, and procedures for identifying illegal practice. Unfortunately, antibiotic sales in high-street pharmacies are not within the legal jurisdiction of the regulation.
Source: Lancet Infectious Diseases

Antibiotic resistance in China promoted by farm animal feeding practices

Widespread and unregulated use of antibiotics in animal feed in China is causing the emergence and release of antibiotic resistance genes  to the environment, according to a study that found 'diverse, abundant, and potentially mobile antibiotic resistance genes in Chinese pig farm.
Writing in the Proceeds of the National Academy of Sciences, Chinese and US researchers say that antibiotic resistance genes  are emerging contaminants posing a potential worldwide human health risk. Intensive animal husbandry is believed to be a major contributor to the increased environmental burden of ARGs. They say that despite the volume of antibiotics used in China, little information is available regarding the corresponding antibiotic resistance genes associated with animal farms.
Therefore, they assessed type and concentrations of  antibiotic resistance genes at three stages of manure processing to land disposal at three large-scale (10,000 animals per year) commercial swine farms in China. In-feed or therapeutic antibiotics used on these farms include all major classes of antibiotics except vancomycins. High-capacity quantitative PCR arrays detected 149 unique resistance genes among all of the farm samples, the top 63  antibiotic resistance genes being enriched 192-fold up to 28,000-foldcompared with their respective antibiotic-free manure or soil controls. Antibiotics and heavy metals used as feed supplements were elevated in the manures, suggesting the potential for coselection of resistance traits. The potential for horizontal transfer of ARGs because of transposon-specific ARGs is implicated by the enrichment of transposases—the top six alleles being enriched 189-fold (median) up to 90,000-fold in manure—as well as the high correlation between  antibiotic resistance genes and transposase abundance. In addition, abundance of  antibiotic resistance genes correlated directly with antibiotic and metal concentrations, indicating their importance in selection of resistance genes.
Source: PNAS

China tells WHO that traditional medicine will help overcome antibiotic resistance problem


China's position at WHO meeting on antibiotic resistance:
"Every person alive today has benefited from the development of antimicrobial drugs but their effectiveness is under threat. Studies in China show a  frightening increase in antibiotic-resistant bacteria such as MRSA. In 
China, 6.8 percent of tuberculosis cases detected are  multi-drug-resistant, far higher than the 2 percent average in most developed countries.
Chinese doctors routinely hand out multiple doses of antibiotics for simple maladies like the sore throats which increase the chance of bacteria becoming resistant to antibiotics. China's Ministry of Health has 
enforced strict rules to curb the widespread overuse of antibiotics in hospitals. Antibiotics will now be classified into three categories for restricted, unrestricted and special use, based on factors such as safety, efficacy, price and drug resistance. All the patients using antibiotics must complete their course to prevent bacteria to become 
resistant. All antibiotics should be made under high standards so that they are effective against the bacteria.
Hospitals are usually known as the sources of all diseases .Codes of practice have been drawn up for doctors, nurses and health care workers to prevent the spread of Hospital acquired infections. Good hygiene within 
hospitals can have a major impact on HAIs such as doctors washing their hands.Guidelines about the clothing the doctors and other staff should wear also prevent spreading of diseases.
China believes that using Chinese herbs is an alternative to antibiotics as it has the same aim as antibiotics to cure the patient. The proper use of Chinese herbal formulas can not only inhibit bacterial, viral and 
fungal infections, but also minimize the need for antibiotics with their adverse side effects.Scientist are still carrying out tests to know exactly how effective they are at destroying bacteria.
The delegate of China believes that if all these precautionary measures are  taken less number of bacteria’s will become resistant to antibiotics and reduced  number of people will be affected by these diseases 
reducing the threat to humanity."
Source: Admun

Hospital antibiotic use declines by 6% due to curbs

Report claims antibiotic use fell from 25% to 19%

China's national campaign to crack down on prescription drug abuse appears to be making progress, after figures revealed a drop of 6 percentage points in the use of antibiotics in hospitals from 2008 to 2011.
An annual report by the Chinese Academy of Social Sciences on China's pharmaceutical market showed top-level hospitals in 21 provinces reported antibiotics use dropped from 25 percent in 2008 to 19 percent in 2011.
"The report illustrates the success we've made in the campaign," said Zhu Hengpeng, senior associate of the Institute of Economics, at the Chinese Academy of Social Sciences.
"Antibiotics abuse drives up medicine costs," he added.
The side effects of antibiotics use can lead to more serious problems, including damage to organs, and disorders associated with the body's resistance to disease.
Many Chinese believe wrongly that antibiotics can reduce inflammation, meaning they are often misused to treat maladies like toothaches and fevers, according to experts.
In recent years, China attached growing importance to the issue, and have been urging hospitals to take more care when prescribing antibiotics.
In the latest move, it launched a surveillance system in July to document cases of antibiotic-resistant bacteria at 1,349 large public hospitals across the country.
Media reports have suggested that antibiotics overuse results in about 80,000 deaths in China a year, and could cost 80 billion yuan ($12.8 billion) to treat.
However, officials from the Ministry of Health said no reliable research can prove the numbers.
Elsewhere in the report, figures showed that antibiotics still account for a smaller proportion of drug misuse in China, compared with drugs acting on the nervous system, which increased by 1.6 percentage points in use and drugs for treating tumors, which rose 1.3 percentage points.
Statistics from several city and provincial health bureaus revealed that tumors have now became the top life-threatening disease in China.
In Beijing, one in four deaths was the result of a tumor in 2010, and incidence of breast cancer in Beijing jumped by 130 percent from 2000 to 2009.
Zhi Xiuyi, director of Capital Medical University's Department of Oncology, said that a combination of pollution, stress and modern lifestyles were contributing to the rises.
Apart from drug use, the report also listed the top 10 pharmaceutical companies now operating in China, in terms of market penetration of top-level hospitals.
The global giant AstraZeneca topped the list, half of which consisted of foreign companies.
Source: China Daily

Antibiotics found in the Yellow Sea

Significant levels of the antibiotics erythromycin, sulfamethoxazole and trimethoprim have been found in the offshore waters of the Bohai Sea and the Yellow Sea. Researchers from the State Key Laboratory of Organic Geochemistry, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences say that although the concentrations were low, they nevertheless posed ecological risks  to some sensitive aquatic organisms, including Synechococcus leopoliensis and Pseudokirchneriella subcapitata.
Source: Environmental Pollution

Antibotic resistance leaks from labs into China's rivers

Leakage of plasmids used in Chinese labs into rivers is promoting the spread of resistance

Researchers report that antibiotic resistance genes used in Chinese molecular biology and genetic engineering experiments may have reached the environment. 
In six Chinese rivers, researchers found bacterial DNA carrying these synthetic genes (Environ. Sci. Technol). Still experts call for more studies to confirm the results and pinpoint specific sources of the genes.
Heavy use of antibiotics in hospitals and on farms has polluted the environment with bacteria carrying genes that confer resistance to the drugs. Once in the environment, the microbes can quickly transfer the genes to other bacteria, leading to antibiotic-resistant strains that can cause severe and sometimes untreatable infections.
But these resistance genes also are cheap, powerful tools for biologists. In so-called molecular cloning studies, researchers introduce the genes into synthetic versions of plasmids, which are small, circular molecules of DNA found in bacteria. The synthetic plasmids also include another gene that the scientists want to study. By treating the bacteria with the antibiotic, the researchers can ensure that the microbes that survive contain both the resistance gene and their gene of choice.
To make sure that the plasmids don’t escape the lab, academic institutions in the U.S. follow special procedures to treat waste from the experiments before disposing of it: They kill any remaining microbes with high heat and sometimes then incinerate the waste.
Researchers sampled six rivers (A through F) throughout eastern China and found synthetic antibiotic resistance genes in all of them.
Industrial scientists have also used molecular cloning to engineer crops and bacteria for biofuel production and environmental remediation. To prevent the spread of antibiotic resistance, however, most genetically modified crops are now produced without these genes.
But because this technique is still commonly used in molecular biology labs, some researchers have been concerned that these experiments could release resistance genes into the environment. To search for antibiotic-resistance genes introduced by synthetic plasmids, Jun-Wen Li at the Institute of Health and Environmental Medicine, in Tianjin, China, and his colleagues took water samples from six Chinese rivers downstream of densely populated cities. They extracted plasmids from the samples and transferred the DNA into Escherichia coli. Then they screened the bacteria for a gene commonly used in academic and industrial labs that confers resistance to the antibiotic ampicillin. To determine if a gene in a sample came from a manmade source, they used polymerase chain reaction to look for sequences unique to several synthetic plasmids.
The researchers found synthetic resistance genes in all six rivers. Of all of the ampicillin-resistance plasmids they found in the rivers, about 27% had the synthetic vector-sourced gene.
Justin J. Donato, a biochemist at the University of St. Thomas, in St. Paul, Minn., says the study provides the first definitive evidence that genetic constructs from the lab have reached the environment. Given that no one previously had reported observing these synthetic plasmids in the environment, Donato is surprised by how prevalent they are. He says the study requires replication especially to rule out the possibility of sample contamination from plasmids already in Li’s laboratory.
Source: Chemical Engineering News

Shanghai residents now use antibiotics appropriately

City campaign persuaded residents and doctors not to misuse antibiotics

A recent health survey found that 90 percent of respondents were using antibiotics properly last year following a local government education campaign to curb overuse of the drugs, Shanghai's health promotion authority has announced.
The survey's results show that the local government's education efforts are paying off, said Gu Xiping, a press officer from the Shanghai Municipal Health Promotion Committee.
"Fewer residents are taking antibiotics as a panacea, or asking doctors to prescribe them when they aren't needed," Gu told the Global Times. "Doctors are reducing the amount of antibiotics they prescribe to patients due to both the campaign and a regulation issued last year that capped the amount and types of antibiotics that each doctor can prescribe."
The Shanghai Municipal Health Promotion Committee interviewed 3,375 residents this year about how they use antibiotics. About 80 percent said they understand the importance of restricting their use of antibiotics, a 28 percent increase from 2010, according to a committee press release. The proportion of respondents found to be using antibiotics properly had increased from 75 percent in 2010.
The average amount of antibiotics used for each patient in Shanghai's public hospitals fell by 20 percent from 2010 following the campaign, according to the press release.
Still, patients in Shanghai continued to receive antibiotics at a far higher rate than the world average. About 60 percent of patients treated at local hospitals, including outpatients, were given antibiotics in 2011, according to a study by local health authorities that was published on the news website Eastday.com.
Only 10 percent of patients around the world are treated with antibiotics on average, Du Wenmin, vice director of the Shanghai Clinical Center for Drug Adverse Reactions, told China Radio International.
A major reason for the overuse in China comes from patients, who often insist that doctors proscribe them antibiotics regardless of whether the proscription is necessary, said Zhen Jianying, a doctor from a community health center.
The problem not only wastes medical resources but can also seriously damage a patient's health, said Xu Wensheng, director of the Infectious Disease Department from Changzheng Hospital. "Overusing antibiotics can cause patients to grow resistant to the drugs, which can become a big problem for them in the future," Xu told the Global Times. "It can lead to liver and kidney damage. It is also a waste of money for patients if they are given unnecessary and expensive antibiotics."
The committee has sent educational brochures to more than 621,000 residents detailing the problems of overusing antibiotics.
Source: Global Times.

Eradication regimens have poor efficacy against H. pylori in China

Most of the first and second line eradication drug regimens have poor efficacy against H. pylori infection in Chinese patients, a study from Nanjing has shown.
Researchers from the Department of Gastroenterology at the First Affiliated Hospital of Nanjing Medical University assessed the efficacy of standard sequential therapy for H pylori (five days of treatment with a proton pump inhibitor [PPI] and an antibiotic such as amoxicillin followed by five days of treatment with the PPI and two other antibiotics such as clarithromycin and tinidazole) and the efficacy of levofloxacin-containing triple therapy and levofloxacin-containing sequential therapy.
Their study showed that the H pylori eradication rate was 83% for the standard sequential therapy compared to 81% for levofloxacin-containing triple therapy and 87% for levofloxacin-containing sequential therapy.
The researchers conclude that : "standard sequential therapy and seven-day levofloxacin triple therapy produce unacceptably [low] therapeutic efficacy in China. Only levofloxacin-containing sequential therapy achieved borderline acceptable result. None of the regimens tested reliably achieved 90% or greater therapeutic efficacy in China."
Read more: Helicobacter

News in brief ...

Cholera becoming resistant to antibiotics in China

Antibiotic resistance is observed with increasing frequency among epidemic Vibrio cholerae strains in China, researchers from Beijing have warned.
Since the 1990s strains of V. cholerae have shown a rapid increase in the prevalence of resistance to antibiotics such as  nalidixic acid, tetracycline and trimethoprim/sulfamethoxazole.
This study serves as a warning of the rapid dissemination of resistance in the past 20 years," say researchers from the State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing.
Read more: International Journal of Antimicrobial Agents.

China's medical demand for helium creates world shortage

A shortage of helium caused by increasing demand for MRI machines in China is beginning to affect other countries - and even Disneyland balloons.
Tokyo Disney Resort has suspended sales of Disney-character balloons, and at least one hospital in the country has suspended use of MRI because of a lack of helium .
In hospitals, liquid helium is used to cool electromagnets inside MRI machines
However gas wholesalers say helium stock have run out as demand for helium for hospital use has increased mainly in emerging countries such as China. This has resulted in an at least threefold increase in helium prices in the last decade, greatly increasing the cost of semiconductor production, which relies heavily on helium.
Furthermore, due to an accident at a helium production facility in the United States, the supply-demand balance has been very tight since July, according to an Iwatani division chief. The situation may not improve until next spring at the earliest, observers say.
Read more: Daily Yomiuri

Elderly Chinese suffer from untreated depression

Depression is a common condition among older patients attending primary care clinics in Beijing, and most people do not receive treatment, a study. has found.
 A study of 1275 adults aged over 60 years at a primary care clinic in urban China found that 11% had major depression, with depression more likely to occur in older people, females and those with a  lower educational level or living alone.
Less than 1% of these patients received treatments and yet more than 60% of patients with depression initially remained depressed throughout the 12-month follow-up period.
Read more: Journal of Affective Disorders.

Rural areas urgently need newborn hearing screening

Urgent measures should be taken by the Chinese government to promote newborn hearing screening in the rural areas, researchers say.
Newborn hearing screening has been successfully implemented in Chinese cities , but not in rural areas, according to the authors of a new report.
Researchers screened for hearing problems in 11,568 babies born in five rural areas of Hubei. Overall, about 92%  newborns had normal hearing but 8% had a high-risk of hearing loss. While 71% newborns passed the initial screening test, 58 infants were diagnosed as hearing loss, and the prevalence of congenital hearing loss among newborns in rural areas was 0.5% .
Read more: International Journal of Pediatric Otolaryngology

Spinal fractures increasingly common in elderly Chinese

There has been a five fold increase in spinal fractures among older people over the let decade, new findings from Sichuan show.
Doctors from the Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing reviewed hospital records on all patients who was 60 years of age or older with spinal fracture at two university-affiliated hospitals between January 2001 and May 2011.  A total of 996 patients with spinal fractures were identified, of whom 35% were males. The annual incidence of spinal fractures among the elderly rose from 24 to 130 cases per 100,000 hospital admissions between 2001 and 2010.
The causes of spinal fractures include traumatic spinal fractures (72%), osteoporotic fracture with no specific cause (27%) and spinal fracture caused by tumour and tuberculosis (2%).
The lumbar region was the most common region of spinal fracture, followed by the thoracic and the cervical regions. Lumbar spinal fractures and thoracic spinal fractures were more commonly seen as a result of accidental falls from low heights and osteoporotic spinal fractures respectively. Spinal fractures usually occur outdoors causing by accidental falls from low heights, most frequently happen on the road.
Read more: Injury

Hospitals tricked into buying shoddy dentures

An unlicensed denture processing factory in Beijing has been ordered to suspend production for allegedly using recycled metal materials to make dentures.
The Beijing Jingjiayi Denture Processing Centre is also accused of using illegal cleansing cream to whiten the dentures to meet the requirement of hospitals and clinics.
The factory, in the city's Tongzhou District, has been ordered to suspend production after a local law enforcement team found it had no license following an undercover investigation by the newspaper.
The investigation found the factory melted recycled residue of metal materials to make dentures and used shoe polish and furniture cleansing products to whiten and brighten the dentures.
Since the purity of the metal was lower, the dentures would unavoidably have small holes on them. The poorly-made dentures were also likely to cause irritation in the mouth and other oral diseases if they were not disinfected under strict conditions, according to Shao Dongsheng, a former prosthodontist with Beijing Stomatological Hospital.
The unlicensed dentures and false teeth were sold to small- and medium-sized hospitals and dental clinics in Beijing at low prices.
Read more: Shanghai Daily