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Investigation on the knowledge level of the rational application of antimicrobial drugs among pharmacists in medical institutions in Shanxi Province
  1. Zhimin Xue,
  2. Zhixing Guo,
  3. Ruiling Zhao
  1. Childrens Hospital of Shanxi, Taiyuan, Shanxi, China
  1. Correspondence to Dr Ruiling Zhao, Childrens Hospital of Shanxi, Taiyuan 030013, Shanxi, China; xuezhm654321{at}163.com

Abstract

Objective To investigate the knowledge of the rational use of antibiotics among pharmacists in medical institutions in Shanxi Province, People’s Republic of China, in order to determine the problems and provide support for the correct management of antibiotics.

Methods A questionnaire survey was conducted, which included the basic information of the respondents, the basic knowledge of antimicrobial management, and the related knowledge of antimicrobial drugs.

Results 462 pharmacists were investigated. The average score of the knowledge related to the rational use of antibiotics was 10.49±4.05. It showed that the hospital type, grade, pharmacist’s education, professional title and working years all had an effect on the pharmacist’s mastery of antimicrobial-related knowledge (p<0.05). Multivariate logistic regression analysis showed that hospital grade and pharmacist’s education were the main influencing factors (p<0.05).

Conclusion Pharmacists have insufficient knowledge about the rational application of antibacterial drugs. It is essential to strengthen the training of management regulations and the application of antibacterial drugs.

  • pharmacopoeia
  • pharmacy administration
  • pharmacy service
  • hospital
  • drug incompatibility
  • drug monitoring

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Data are available upon reasonable request.

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Introduction

The rational use of antimicrobial drugs can effectively improve the clinical effects, avoid or reduce adverse drug reactions or adverse drug events, lower medical costs, and reduce the incidence of bacterial resistance. It is a task that requires long-term adherence by medical institutions to continuously strengthen the management of the clinical application of antimicrobial drugs, so as to ensure medical quality and curb bacterial resistance. On 24 April 2012, the order, ‘Administrative Measures for Clinical Application of Antibiotics’ was formerly issued by the Ministry of Health, which was implemented formally on 1 August 2012.1

In 2011 the National Health and Family Planning Commission launched a 3 year ‘Special Rectification Action for Clinical Application of Antibiotics’ on a national scale.2–6 Since then, the management of antimicrobial drugs has been normalised, which has achieved certain effects such as decreasing the abuse of antimicrobial drugs and delaying bacterial resistance. To better promote antimicrobial management, the National Health Commission of the People’s Republic of China released the notice on continuously succeeding at work of the management of the clinical application of antimicrobial drugs in 2020, which required changes to the pharmaceutical service model and exerted the pharmacist’s leading role in the management of antimicrobial drugs. To enable pharmacists to play their role in the management of antimicrobial drugs better, from a pharmacist’s point of view, this study investigated the knowledge level of the rational use of antimicrobial drugs among pharmacists in medical institutions at all levels in Shanxi Province, with the aim to provide references for decision-making of the related departments and for standardised management of hospitals.

Objects and methods

Research objects

The approximate random method was conducted and the respondents were the pharmacists from medical institutions in 11 cities in Shanxi Province. The inclusion criteria of pharmacists were: hire date >12 months; and on-the-job pharmacy professionals.

Research methods

Research tools

After checking the related literature in the CNKI, Wanfang Data and Pubmed Database, and combining it with the guiding principles for clinical application of antimicrobial drugs and relevant policy documents of management, the questionnaire survey was designed.

The survey included two parts. The first part comprised information on the respondents, including their hospital grade, department, professional title, age and number of working years. The second part concerned the pharmacists’ mastery of antimicrobial-related knowledge. This part consisted of three items: national countermeasures for antimicrobial drugs; administrative rules, regulations and guiding principles of antimicrobial drugs; and related knowledge of the rational use of antimicrobial drugs. There were two questions about the management strategy for antimicrobial drugs, eight questions about the administrative rules, regulations and guiding principles of the management of antimicrobial drugs, and 10 questions about the related knowledge of the rational use of antimicrobial drugs, for a total of 20 questions.

They were single-choice questions and multiple-choice questions. One point was awarded for each correct answer, but no points were awarded for missing or wrong answers. Thus, there was a maximum score of 20 in total. In order to ensure the validity and correctness of the questionnaire, the contents of the questionnaire was verified by vice-senior or superior experts in antimicrobial drug management in our hospital. Before the formal survey, 50 pharmacists were randomly selected for the pre-survey, and the questionnaire was modified according to the problems found in the pre-survey results. The final questionnaire was determined, and a reasonable completion time was estimated.

Investigation method

Before starting the investigation, the researchers contacted the hospital’s pharmacy department by telephone to obtain permission and support. The designed questionnaire was imported into the Sojump Technology Network platform, and the link of the questionnaire was sent to the heads of the pharmacy departments of the hospitals participating in the study by WeChat, who would then forward it to the pharmacists to fill in anonymously. Before the investigation, the respondent’s permission was obtained and the purpose of the investigation was explained to them. The investigation was anonymous and was not connected to the performance appraisal of the department. Any logical errors, duplicates, missing items, important information supplied incorrectly and other unreasonable data were deleted.

Quality control of questionnaire survey

The respondent using the same IP address could only answer the survey once. The respondents were aged between 18 and 60 years, and their answers should not have logical errors. According to the completion time of the pre-survey collected, the questionnaire with the completion time of the whole piece less than 3 min would be screened out, so as to ensure its quality.

Evaluation standard of the questionnaire results

The answer to the knowledge point in the questionnaire about the rational application of antimicrobial drugs was calculated and analysed term by term. Among them, ‘the correct answer rate’ (hereinafter referred to as CAR) was the proportion of pharmacists who answered the questions correctly. The calculation formula was: the correct answer rate (%)=the total number of the pharmacists who answered the questions in this part correctly/(the number of questions in this part×the number of the qualified respondents)×100%. The total score of the questionnaire on antimicrobial-related knowledge was 20 points. The questionnaires were divided into a high-score group (based on scores ≥50% (≥10 points)) and a low-score group (scores <50% (<10 points)).

Statistical method

SPSS 25.0 software was used for statistical analysis. Demographic characteristics were described as classified variables. The high-score group and low-score group were divided as described above. With the score as the dependent variable and the demographic characteristic and medical institution type as independent variables, single variate analysis was performed first by the χ2 test. Factors with p<0.05 were selected for unconditioned multivariate logistic regression analysis (α ingress=0.05, α deletion=0.10) to analyse the influence of different demographic characteristics and medical institution type on the scores.

Results

Basic characteristics of the respondent

This survey started on 1 March 2019 and ended on 15 March. A total of 475 questionnaires were collected, of which 13 were excluded and 462 were valid with an efficient response rate of 97.26%. Among them, the male pharmacists accounted for 24.46% and the female pharmacists accounted for 75.54%, with the number of working years mainly concentrating in 5–9 years and 20–29 years accounting for 28.14% and 23.59%, respectively. Their age was mainly from 25 to 34 years old and from 35 to 44 years old (38.53% and 29.65%, respectively), and their education backgrounds were bachelor’s degree accounting for 62.99%, Master’s degree or higher accounting for 14.94%, and others accounting for 22.08%. Pharmacists from tertiary medical institutions accounted for 61.47% of the entire population, and pharmacists from second-class medical institutions or lower accounted for 38.53%. Among them, pharmacists from general hospitals accounted for 63.85%, and pharmacists from specialised hospitals accounted for 20.35%. The pharmacists investigated with a primary professional title accounted for 33.12%, intermediate 30.09%, and senior 4.39%.

Correct answer rate of rational application of antibiotics

The results showed that the average CAR of the first item about management strategy of antimicrobial drugs was 86.91%, the average CAR of the second item about administrative rules, regulations and guiding principles of antimicrobial drugs was 64.75%, the average CAR of the third item about related knowledge of rational use of antimicrobial drugs was 35.76%, and the average total CAR was 52.47%. The CAR of questions 11, 12, 14, 17 and 19 was 23.59%, 23.81%, 16.67%, 22.08% and 23.81%, respectively, and all were lower than 30%. Among them, question 8, ‘How long does it take to complete the related procedures of skip-level application of an antimicrobial drug for special use?’ the CAR was the highest, at 90.91%. For question 14, ‘What are the following circumstances under which you think the combined use of antimicrobial drugs is required?’ the CAR was the lowest, at 16.67%. See table 1 for details.

Table 1

The situation of knowledge of the rational application of antimicrobial drugs

The statistics of score of rational application of antimicrobial drugs

In this survey, the average score of the relevant knowledge of antimicrobial drugs of the respondents was 10.49±4.05 (highest score 20; lowest score 4).

The answers of the investigated pharmacists were analysed in this survey from seven aspects, including sex, degree of education, medical institution type, professional title, number of working years, age, and hospital grade, and the following conclusions were drawn. (1) There was no significant difference between the score and the pharmacists’ sex. (2) There was a significant difference between the degree of education of the pharmacists and their scores (p<0.05). The higher the degree of education of the pharmacists, the higher the score. But there was no significant difference in the score between the pharmacist with an undergraduate degree and the pharmacist with a Master’s degree. (3) There was a significant difference among different types of medical institutions (p<0.05). The pharmacists from general hospitals and specialised hospitals overall scored higher than those from the traditional Chinese medicine (TCM) hospitals and other medical institutions. (4) There was a significant difference among the pharmacists with different professional titles (p<0.05). From the assistant pharmacist to the deputy-chief pharmacist, the higher their professional title the higher they scored. There was no significant difference among the pharmacist-in-charge, deputy-chief pharmacist and chief pharmacist. (5) There was a significant difference among the investigated pharmacists with different working years (p<0.05). As a whole, the longer the pharmacists had worked, the higher they scored. But the pharmacists who had worked for over 30 years did not score higher. (6) There was no significant difference in scores among pharmacists of different ages. (7) There was a significant difference between the hospital grades and scores (p<0.05). Pharmacists from tertiary hospitals scored higher than those from other medical institutions. See table 2 for details.

Table 2

Statistics of knowledge score of the rational application of antimicrobial drugs

Single variate analysis of the influence factors of the knowledge level of rational use of antibacterial drugs

The analysis of the single variate of the respondent, general demography and medical institution type was conducted; except for sex and number of working years which showed no statistical significance, all the other variables had an effect on the knowledge level of antibacterial drugs.

Multivariate analysis of the influence factors of the knowledge level of rational use of antibacterial drugs

The indexes of χ2 test results with statistical significance were included in the multivariate model. The model was built with the stepwise regression method, with a −2 log likelihood value of 586.154 and a χ2 value of 0.360 (p<0.001). See table 3 for the variable and assignment with the logistic regression analysis method. Multivariate logistic regression analysis was carried out with the score as the dependent variable (0=low-score group, 1=high-score group), and with the independent variables of education, medical institution type, professional title, number of working years and hospital grade. The result showed the medical institution type, hospital grade and education were associated with the higher knowledge level of the rational use of antibacterial drugs. See table 4 for details.

Table 3

Description of independent variable

Table 4

Analysis of factors influencing the knowledge score of the rational application of antimicrobial drugs

Discussion and suggestions

Knowledge level of the pharmacist on the rational use of antibacterial drugs

The results of this survey reflect the fact that the current knowledge level of pharmacists about antimicrobial drugs desperately needs to be improved. According to the results, the CAR of usage indications for antimicrobial drugs, prophylactic medication and drug combination, the dosage adjustment of antimicrobial drugs for patients with liver and renal insufficiency, and the selection of antimicrobial drugs for common diseases by the pharmacists, was relatively low, especially for clinical medication, the knowledge of which was lacking in the extreme. For example, the CAR for the combined use of antimicrobial drugs, and the CAR for the use of antimicrobial drugs and the prophylactic use of antimicrobial drugs, indicated that the respondents generally lacked knowledge about the clinical use of antimicrobial drugs. Analysing the causes, the positions of pharmacists in hospitals included drug dispensing, hospital preparations, clinical pharmacy, pharmaceutical research and so on, their work nature was quite different,7 and they mastered different pharmaceutical knowledge. Pharmacists also did not focus on the study of clinical use in their work practice.

The CAR for the theme for 2011 World Health Day, ‘No action today, No cure tomorrow’, was slightly high, and the reason was that the theme for World Health Day was advertised in different ways and there was a higher awareness rate among pharmacists. We can see the importance of these advertisements. Pharmacists in hospital had changed their work mode from the drug-centred model to the patient-centred model of pharmacy service, which needed to improve the professional level of pharmacists. It was suggested to increase the frequency of training and assessment in the medical institutions, and train pharmacists at different positions and levels according to their requirements.8 Meanwhile, pharmacists should actively take part in the study, and medical institutions should emphasise the importance of training on the clinical use of antimicrobial drugs.

Influence of educational background and professional title on knowledge level of antimicrobial drugs

The educational background and professional title of pharmacists would mainly affect their knowledge level of antimicrobial drugs. The higher the education degree of pharmacists, the better they are at mastering knowledge about antimicrobial drugs. This indicated that the highly-educated pharmacists had a more solid knowledge reserve and a more accurate understanding of antimicrobial knowledge in all aspects; they were also the main work force of the current pharmacist team.

Professional title also had an effect on the knowledge level of antimicrobial drugs. Pharmacists lack of knowledge of antimicrobial drugs might be related to fewer years of clinical work, less experience, and less mastery and application of knowledge. The pharmacist-in-charge, who has worked in the front line for a long time, has had more opportunities to access the relevant theoretical knowledge and practical application of antimicrobial drugs. Because the deputy-chief and chief pharmacists were mainly engaged in management work in the hospital, they applied the knowledge of antimicrobial drug use relatively less. Therefore, it is necessary to strengthen the continuing education and training of pharmacists based on their positions, put what they have learnt into practice, learn at work, and apply what they had learnt to work.

Influence of grade and nature of medical institutions on the knowledge level of antimicrobial drugs

It was found in this survey that pharmacists from medical institutions of different grades and different nature had different levels of knowledge of antimicrobial drugs. Pharmacists from tertiary hospitals had relatively higher knowledge levels of antimicrobial drugs. According to the survey, hospitals at different grades showed an uneven distribution of talent. The highly-educated pharmacists were mainly concentrated in tertiary hospitals.9 They focused on continuing education and training of pharmacists in tertiary hospitals, so as to enable the pharmacists to have access to the latest theoretical knowledge and knowledge of rational drug use.

However, there were almost no highly-educated pharmacists in community hospitals, and they also had few opportunities for continuing education. Due to the knowledge structure and work nature of TCM hospitals, they had a poor knowledge about the application of antibacterial drugs. It was particularly urgent to carry out education and training on knowledge updating of antibacterial drugs in small and medium-sized hospitals.10

This article conducted a questionnaire survey of 462 pharmacists, and included the basic situation of the survey subjects, and basic knowledge and use of antibacterial drug management. Analysis shows that hospital type, level, pharmacist’s educational background, professional title, and number of working years has an effect on the pharmacist’s knowledge of antibacterial drugs. The results suggest that pharmacists have insufficient knowledge about the rational application of antibacterial drugs and need to strengthen antibacterial drug management regulations and training in their use. Through a large number of investigations, specific results have been obtained. This is helpful for pharmacists to use antibacterial drugs rationally and is beneficial for patients to restore their health. Through this research, it is very helpful to directly predict the level of pharmacists in the future, so as to conduct reasonable training and reduce medical accidents.

Bacterial resistance and rational use of antimicrobial drugs are problems that need to be solved urgently by medical institutions; they are also major concerns for society at large. If pharmacists want to play an increasing role in promoting the rational application of antimicrobial drugs, it is imperative that measures are taken to improve their knowledge of these agents. The survey was conducted on the network platform. While maximising the efficiency of information acquisition, there are still disadvantages, such as answer interference and under-representation of the entire population of the samples (such as the uneven distribution of pharmacist numbers in hospital at all levels), which will lead to certain restrictions on the extrapolation of the conclusions. A more efficient investigation method could be developed in the future, based on internet technology, to provide important support for future research.

What this paper adds

What is already known on this subject

  • To investigate the knowledge of rational use of antibiotics among pharmacists in medical institutions in Shanxi Province, in order to determine the problems and then to provide support for the correct management of antibiotics.

What this study adds

  • This research is very helpful for directly predicting the level of pharmacists in the future, in order to conduct reasonable training and reduce medical accidents.

Abstract translation

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by Ethics Committee of Shanxi Children's Hospital.

Acknowledgments

The study was also supported by the fund of Shanxi Children's Hospital (201949). We also thank all those who helped perform the investigation.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • EAHP Statement 4: Clinical Pharmacy Services.

  • Contributors ZX designed this study and contributed to the data collection, analysis and interpretation, and manuscript drafting. ZG participated in the manuscript revision and language modifications. RZ helped to revise the manuscript critically for important intellectual content and gave final approval of the version to be published. All authors approved the final manuscript as submitted and agreed to be responsible for all aspects of the work.

  • Funding Hospitals Research Fund of Children’s Hospital of Shanxi / Women Health Center of Shanxi (No. 201949) [Introduction of the author] ZX, Master’s Degree; pharmacist in charge; research direction: clinical pharmacy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.