Among the 30 doctors interviewed from all participating clinical facilities, over half indicated that diagnostic uncertainty drives antibiotic prescribing. The perceived need to provide effective treatment and ensure patient safety frequently resulted in combined prescribing (orally or intravenously) of an antibiotic and a Traditional Chinese Medicine preparation regarded as anti-viral:
“As a doctor, I think that if you aren't sure then all you can do is choose to use both types together. Because if you can't confirm what it is and if you only use, say, antibiotics (kang sheng su), anti-inflammatories (xiao yan), when in fact it is a viral infection, then you won't have good results. So all you can do is use the two together in combination” (2-1-20180131).
Although those interviewed were aware that unnecessary antibiotic use contributes to antibiotic resistance, without access to microbiological support, uncertainty regarding type of bacterial infection produced a preference for broad-spectrum and combination antibiotics:
“…if you aren’t certain what type of microbial infection (jun gan ran) it is, then generally you would use broad-spectrum antibiotics (kang sheng su)… sometimes combining two or three is definitely a bit better. Why do I say a bit better? It’s because you aren’t certain which type of antibiotic (kang sheng su) is better for the infection” (2-1-20180201).
Such prescribing practices were described as protecting patient safety (including preventing risk of secondary infection), satisfying perceived patient demand for rapidly effective treatment, and safeguarding doctors against the potential reputational risk of failing to treat successfully.
”Now, the patients are anxious to achieve quick success and get instant benefits, if you do not use antibiotics, if the effect is not good, the patient will bring you trouble.” [1-2-20170626]
Some doctors linked this concern, along with the difficulty of refusing to prescribe antibiotics, to the low social status of both rural doctors and the poor populations they serve:
“The social status of the base-level clinicians is low. […] If the medical treatment works to [the patient’s] recovery, it is your job done; but if it doesn’t work, you are to be blamed.[…] Many families here are the ‘left-behind’ households, with young parents working as migrants away in the city [while grandparents look after the children]. Clinicians end up bearing the brunt if any social problems arise. (2-1-20180115).
Some doctors also highlighted the need to earn income for themselves and their health facility as driving their prescribing practices. Following the successful implementation of the Essential Medicines Policy (2009), health facilities cannot mark up the costs of oral medicines, but provision of clinical services including tests and parenteral drug administration are economically important: “But now the hospital in order to raise income, they give patient infusion treatment easily” [2-1-20180115]; “If you give the patient infusion, the effect is faster, it will attract more patients, the income will be better.”[1-2-20170625]
A further driver of frequent antibiotic use is the characterisation of antibiotics as ‘anti-inflammation medicine’. As described elsewhere,(9) biomedical and local understandings of infection and inflammation are elided in contemporary clinical practice in these settings. Most doctors used either the colloquial descriptor (xiaoyan yao, literally ‘anti-inflammation medicine’) or the specific drug name (e.g. amoxicillin) rather than the biomedical term for antibiotics in patient consultations, explaining this as necessary for communication:
“The commoners won’t understand if I say ‘antibiotics’ (kangshengsu). They do not know ‘antibiotics’ (kangsheng su), they only know ‘anti-inflammation medicine’ (xiaoyan yao)” (2-1-20180115).
“I use the drug name of antibiotics to communicate with patient”; […] If you say antibiotic or antibacterial drug, they can’t understand” [1-2-20170625]
Interviews with patients, however, overwhelmingly confirmed that common symptoms of infection including sore throat, coughing, fever, redness and swelling are recognised as indicating the presence of inflammation. Since antibiotics are ‘anti-inflammation medicine’ (xiaoyan yao), patients logically regard antibiotics as appropriate treatment and frequently referred to medical experiences as a source of this knowledge:
Interviewer: 'How do you know, that when you have a cold or a cough, that you need to take anti-inflammatories?'
Interviewee: 'Everyone knows it. When you go to the drug store, drug salespersons or pharmacists will tell you this; if you go to clinics, doctors will tell you this.'