This national-level study is the first of its kind, which reports on the trend, consumption, and expenditure of quinolone antibiotics over a period in China, providing an opportunity to restructure their policies regarding antibiotic use. Quinolones are broad-spectrum antibiotics widely used to treat multiple infectious diseases due to their optimal pharmacokinetic characteristics. Unfortunately, their irrational use is continuously increasing worldwide, including China; thus, amplifying antibiotic resistance risk (26).
From 2015 to 2018, there is a slight decrease in the consumption of J01M antibiotics in China (25.7% in 2015 vs 23.5% in 2018). Like our results, a decreasing pattern in the use of quinolones was reported in a recent study conducted in Shandong province of China, which analyzed the antibiotic procurement data from 2012 to 2017 (27). These results could be attributed to the implementation of numerous interventions including strict antibiotic use policies including hospital-based antimicrobial stewardship programs implemented by the Chinese government to restrict the irrational use of antibiotics in hospitals and community (28, 29). Besides, in 2012, the Ministry of Health launched Administrative Rules for the Clinical Use of Antibiotics which is playing a pivotal role in minimizing the antibiotic use in different hospital settings as reported in other studies (30). The government has implemented punishments if healthcare professionals and institutions violate the laws and rules of rational antibiotic use, including the loss of accreditation, downgrade in service fees, and dismissal of managers. In severe cases, the doctors could be stopped to prescribe antibiotics, and their medication registration could be revoked. Still, there is a need to do more work to minimize the level of all antibiotics, including quinolones in all hospital settings of China, to meet the recommendations of the WHO.
Furthermore, since 2015, a systematic restructuring of public hospitals has been undertaken nationally. The most integral component of these reforms is the extension of Zero Mark-up Drug Policy (ZMDP) to prevent antibiotic misuse in secondary and tertiary hospitals. ZMDP has clearly shown a reduction in irrational prescribing of antibiotic use as found in various studies (27, 31).
Levofloxacin was the most frequently used quinolone antibiotic in our study from 2015–2018 (59.3% in 2015 to 61.3% in 2018). Similar results were found by a previous study where the use of levofloxacin was greater than 30% of the total consumption of quinolones in each year (32). Likewise, levofloxacin was among the top five most-used antibiotics in a Shandong study (27). This increasing use of levofloxacin has also amplified the risk of resistance in different infections, including tuberculosis (33).
In our study, the use of the parenteral form of quinolone antibiotics remains nearly static from 2015 to 2018 (27.9% in 2015, 27.1% in 2018). This slight decline is still far from the standard limits. A high proportion of parenteral quinolone expenditure (more than 80% of the total expenditure in 2018) were found in our study, which is as per previous studies (27). In developing countries, including China, people often prefer the injectable form of antibiotics as they consider them more potent and effective to eradicate their infections. Therefore, some patients force healthcare professionals to prescribe the parenteral form of antibiotics, only (34).
There is a significantly higher consumption of quinolones in rural PHCs and tertiary hospitals than in other healthcare settings, which is alarming. A large number of studies have also reported similar results (35, 36). The management and use of quinolones in these hospital settings should be controlled by enforcing strict policies launched by the Chinese government. It is advisable that an optimal and effective system should be enforced to determine the irrational use of antibiotics within hospital (37, 38). Those antibiotics, used irrationally should be placed on the restricted list, and only written permission should be obtained from the doctors whenever they need such type of antibiotics. This will help in the prudent use of antibiotics within the hospital. Besides, continuous training programs should be launched for all healthcare professionals aimed at the judicial use of antibiotics and antibiotic resistance to equip them with the latest advancements (39, 40). To enhance health literacy specifically about antibiotics, public education campaigns should be instituted regularly to provide awareness of the prudent use of antibiotics (41). This will also help in reducing the pressure of patient demands about prescribing antibiotics.
Certain limitations should be taken into consideration. First, the antibiotic purchase record of the institution is unable to differentiate between inpatient medication and outpatient medication. Therefore, this study could not investigate the use of antibiotics in outpatient and inpatient settings. Second, this study could not find the antibiotics, which were expired or discarded during storage; likewise, it’s difficult to estimate the length of time of storage of antibiotics in the inventory after purchasing by using sales data. Despite the above limitations, this is a pioneer national-level study, which has highlighted the expenditure and consumption of quinolones from 2015 to 2018 in China.