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A2872 - Reducing Antibiotic for Child Upper Respiratory Infections in Rural China: An RCT, Process Evaluation and Cost-Effectiveness Analysis
Author Block: X. Wei1, Z. Zhang2, J. Walley3, J. Hicks3, B. Dawkins4, J. Zeng5, M. Lin5; 1Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, 2China Global Health Research and Development, Shenzhen, China, 3Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom, 4Academic Unit of Health Economics, University of Leeds, Leeds, United Kingdom, 5Guangxi Centre for Disease Control, Nanning, China.
Rationale:
Inappropriate antibiotic prescribing contributes to generating drug resistance globally. We implemented and evaluated the effectiveness, and cost-effectiveness, of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients in rural China.
Methods:
We conducted a pragmatic, cluster randomised controlled trial with a 6-month intervention period. 12 clusters were allocated to the intervention and 13 to the control, with outcomes based on prescription records. Clusters were primary care township hospitals in Guangxi. The intervention included clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief caregiver education. Control was usual care. The primary outcome was the antibiotic prescription rate: the cluster-level proportion of prescriptions for upper respiratory tract infections in 2 to 14-year-old outpatients. In our cost-effectiveness analysis, we took a health-care provider perspective, measuring costs of consultation (time cost of doctor), prescription monitoring process and peer-review meetings (time cost of participants) and medication costs. We also conducted 35 in-depth interviews to understand how interventions were adapted to make an impact, and cost-effectiveness analysis. Trial registration: ISRCTN14340536.
Results:
Between baseline (the three months prior to intervention implementation) and endline the antibiotic prescription rate dropped from 82% to 40% in the intervention arm, and from 75% to 70% in the control arm. After adjustment for baseline antibiotic prescribing and potentially confounding covariates this endline difference represented an intervention effect (absolute risk reduction in antibiotic prescribing) of -29% (95% CI: -42%, -16%; P=0.0002). The cost of implementing the intervention was $390.65 (SD $145.68) per healthcare facility, showing an incremental cost of $0.03 per per cent point reduction in antibiotic prescription rate. Process evaluation showed training for doctors appeared essential while effective peer-reviews, including goal-setting, monitoring, feedback and action-planning, were pivotal in reducing irrational use of antibiotics.
Conclusion:
Pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced inappropriate prescribing of antibiotics for childhood respiratory infections in China, and the invention was cost-effective. The intervention can be adapted to other developing countries with similar challenges.