We systematically conducted a nationwide survey on the implementation and current status of AMS program in 140 tertiary hospitals, covering 26 provinces in China. In this survey, AMS program was implemented in 99.3% (139/140) of the responding hospitals, which was higher than that in the studies conducted in developed countries such as the US and Netherland [20, 21]. AMS program has been required to be implemented in China since 2011. Furthermore, in the past decade, a relatively systematical management system and advanced technical support framework have been established by the Chinese government, contributing to setting up AMS program in the hospitals. The hospitals surveyed were all tertiary hospitals which were likely to be larger, urban and have better access to medical resource and financial support. As adequate manpower and funding are identified as main barriers to developing AMS program, tertiary hospitals surveyed were probably more capable of policy execution and AMS program implementation when comparing with other hospitals [22, 23, 24].
Leadership and teamwork are paramount prerequisites for successful and effective implementation of AMS program. The survey demonstrated that hospital presidents were heading AMS program in most hospitals. Different from our result, previous studies found that AMS team was more likely to be led by pharmacists or infectious disease physicians in the US [20, 25]. According to the management regulations and technical specifications issued by the Chinese government, hospital presidents were appointed as the leaders of AMS program. It is emphasized that a wide range of health professionals could provide unique support in achieving the over-all goal of AMS [26, 27, 28]. Obviously, the hospital presidents possess the supreme power, and it is beneficial for ordering commanding and dedicating necessary human resources for the program when the hospital presidents take charge of AMS program. Under this circumstances, financial support could be also guaranteed, which greatly augments the capacity and influence of the program. Furthermore, the survey confirmed that pharmacy departments exerted a critical role in AMS implementation. It is recommended that along with infectious disease physicians, pharmacists are considered as the core members as drug expertise in AMS team .
In the survey, most infectious disease departments were still occupied by the management of common communicable diseases such as hepatitis and tuberculosis. Also, infectious disease physicians played a limited role in AMS program implementation in most hospitals. This finding was similar with the result in a prior study . The tertiary hospitals in China has been required to establish infectious disease departments since the outbreak of severe acute respiratory syndrome in 2013. The main duties of the departments are to treat various infectious diseases, address AMR and deal with infectious disease emergence. However, when comparing with the developed countries, our finding revealed that the effectiveness of infectious disease department in antimicrobial rational use promotion and AMR confinement needs to be strengthened. The limited privilege of infectious disease physicians would undoubtedly restrict the impact of AMS on antimicrobial rational use and AMR confinement in China. This may be partly attributed to the shortage of adequately trained physicians interested in infectious diseases and the lack of consciousness of AMR control of the physicians. Hence, it is imperative that the infectious disease department and the physicians should attach great importance to their commitment to AMS implementation.
Clinical pathways and hospital-specific guidelines for main infection syndromes are identified as an effective way to standardize antimicrobial prescription for specific infectious syndromes. In our survey, most hospitals developed clinical pathways. The Chinese government has made great efforts to implementing clinical pathways and establishing diagnosis related group system, which exert a catalyzing effect on the development of clinical pathways in AMS program [30, 31]. Unlike clinical pathways, hospital-specific guidelines were only developed in 33.6% (47/140) hospitals surveyed. The majority of the guidelines in the hospitals surveyed were for urinary tract infection and upper respiratory tract infection. This was basically in accordance with the morbidity of infectious diseases in China and the guideline for AMS program by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America . Previous studies showed that the implementation of hospital-specific guidelines was associated with optimal antimicrobial use by increasing the likelihood of sufficient initial therapy, narrower-spectrum antimicrobial use, shorter therapy duration and timely switch from intravenous to oral antimicrobials [32, 33, 34, 35, 36, 37, 38]. Hence, multi-discipline collaboration of AMS program in development of hospital-specific guidelines for infectious diseases should be emphasized.
Our findings highlighted the ongoing difficulties in antimicrobial usage measurement, which has long been considered as an essential opponent to promote AMS . Although up to 138 hospitals surveyed reported antimicrobial usage on a regular basis, most of them tracked antimicrobial use using define daily dose (DDD) and ranked antimicrobials based on usage and expenditure. Neither indicator was appropriate and optimal for benchmarking [40, 41]. Specifically, although DDD is a direct and widely adopted metric for antimicrobial usage measurement and comparison, the limitations of DDD are obvious. Unlike number of days of therapy which is recommended as the first option for antimicrobial usage measurement in the US, DDDs is not an applicable measuring tool in pediatric setting and is not an optimal metric for individuals with renal and/or liver impairment because of the dose reduction [8, 42]. Previous study also showed that some hospitals in China might mechanically define DDDs by restricting the total dosage of antimicrobials during infectious disease treatment . This would result in antimicrobial underuse and even possibly exacerbate AMR. The limited access to computerized pharmacy data may also narrow the options of tracking antimicrobial usage. We also found that there was a lack of evaluating AMS outcome from the clinical and the economic perspective. Of note, optimizing patient outcomes and confining AMR is the primary goal of AMS . The outcome measurement would provide useful information on the effectiveness of strategies used and assist in adjusting AMS program. Moreover, cost savings could be achieved by optimized antimicrobial use, shorter duration and avoidance of unnecessary antimicrobials. This will in turn motivate the implementation of AMS program. Hence, there is a necessity to identify appropriate metrics for antimicrobial use, AMR outcome, patient outcome and expenditure and establish a comprehensive evaluation system for the program.
Our study has some limitations. Firstly, though up to 140 tertiary hospitals participated in the survey, they only accounted for 5.5% (140/2548) of all tertiary hospitals in China . The relatively small sample size and low response rate may introduce non-response bias and affect generalizability given the extensive application of antibiotics and increasing emergence of AMR in tertiary hospitals in China. Secondly, the survey solely assessed tertiary hospitals on AMS implementation. In contrast to primary care setting, tertiary hospitals have better access to medical resource and more funding for AMS development, which may lead to over-estimation in our results. We aim to extend the survey to obtain information on this topic in primary care setting in the future. Furthermore, the hospitals participated in this survey voluntarily. Therefore, the respondents might be those most interested or active in AMS than non-respondents, which probably provided an optimistic view of the results.