On 10 July, the Hong Kong government launched the Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2017-2022).

One of the highlights in the plan is to strengthen surveillance on antimicrobial resistance (AMR) in healthcare settings. Doctors will be asked to report the antimicrobial use through the existing electronic health record system put in place by the government. Participation by doctors is entirely voluntary and no punishments are put into place, even if doctors are unable to report prescriptions on a timely manner.

The plan is certainly seen as an encouraging move as the government puts into place a strategic framework to address the growing prevalence of antibiotic-resistance bacteria. According to statistics from the Department of Health (DH), the number of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) cases has increased five-fold since 2007. The superbug health crisis is imminent.

However, such initiative also comes amidst the situation where doctors in Hong Kong are increasingly been held responsible by the government and public, or even seen as the prime culprit accountable for AMR. Is this true?

Level of antimicrobial use among Hong Kong doctors


In 2012, DH has published a survey on the use of antibiotics among doctors in Hong Kong. Results revealed 30% of doctors ‘never’ prescribe antibiotics to patients with flus and another 62% only prescribing antibiotics ‘sometimes’ to patients. Only 8% of the respondents admitted to be ‘always’ or ‘very often’ to prescribing antibiotics.

Frequency of prescribing antibiotics to patients with URTIs / cold / flu. Source: DH
Frequency of prescribing antibiotics to patients with URTIs / cold / flu. Source: DH

Another survey investigating the use of antibiotics among general practitioners in Hong Kong also found that only 5.2% of patient encounters with upper respiratory tract infection (URTI) were prescribed antibiotics.

When it comes to acute cough, a study published in npj Primary Care Respiratory Medicine in 2016 found out doctors only prescribed antibiotics in 6.8% of the cases, of which amoxicillin was the most common antimicrobial prescribed (61.3%).

Nevertheless, both the studies did note that doctors were more likely to prescribe antibiotics if patients requested for it and that private healthcare centers were more likely to prescribe antibiotics compared to private settings.

“Patients seem to show increasing awareness about antibiotics as they ask doctors whether it is necessary to take them,” according to President of the Doctors Union Dr Henry Chiu-fat Yeung when he was responding to the government’s initiative, saying the system would “help a little”.

“Fewer patients request doctors to prescribe antibiotics unnecessarily, but of course the public still needs better awareness,” he added.

Comparing to European countries, Hong Kong doctors also had a significantly lower level of prescription which falls in line with the ideal prescription levels of antibiotics to prevent its abuse and overuse. According to a cross-sectional observational study published in BMJ with primary care clinicians across 13 countries, there is a 53% overall likelihood of prescribing antibiotics.

Regulating the use of antibiotics in agriculture and aquaculture industry


While the public’s perception of antibiotics prescription largely falls under the scope of doctors and medicinal purposes, the agriculture industry remains to be one of the largest consumer of antibiotics. In fact, domestic farms and animal could play a bigger role in the overuse of antibiotics especially with its usage largely remaining unregulated.

In China alone, the nation consumes almost half of the world’s antibiotics supply whilst being the largest manufacturer of antibiotics in the world. In 2013, China consumes 162,000 tons of antibiotics from more than 200 varieties with a roughly equal split amongst domestic and medicinal purposes.

Local animal farm operators often add antibiotics into animal feed.
Local animal farm operators often add antibiotics into animal feed.

"The usage of antibiotics in China is very high, it's almost half of the world usage when we compare it with international studies," said Guang-Guo Ying of the Guangzhou Institute of Geochemistry under the Chinese Academy of Sciences. “There is also no monitoring of antibiotics being used in animals. Local animal farm operators often add antibiotics into animal feed to prevent diseases and boost production.”

This high consumption of antibiotics has eventually found its way into the environment as well with many of China’s rivers having very high levels of antibiotics within them. One in particular, the Pearl River, which flows into the ocean past Hong Kong, had one of the highest concentration of antibiotics owing to the large scale of farming carried out along the region of the river.

The situation is similar In the United States, with approximately 80% of antibiotics use within the agriculture and aquaculture industry. With primary uses of speeding growth, preventing infections and warding of pests, antibiotics are an essential tool for the agriculture and aquaculture industry in the country.

Unfortunately, the unregulated usage and low price of non-pharmaceutical-grade antibiotics means that the drug is often judiciously overused resulting in a growing antimicrobial resistance throughout the community. In response to this, the FDA banned the use of the antibiotic fluoroquinolone in poultry in 2005 with further restriction on antibiotics in the agriculture sector in 2012 and 2013.

Nevertheless, the ban alone did not provide a realistic solution to the problem with monitoring (all farming sectors) a near impossible feat and the wide spectrum of antibiotics available to farmers in the market. Till today, both Europe and America are still grappling with the issue of antibiotics overuse in the agriculture industry while trying to find a viable solution.

Meanwhile in Hong Kong, the government also plans to ban farmers from giving antibiotics to animals unless it is prescribed by vets. This move is further supplemented by additional training given to vets by the Agriculture, Fisheries and Conservation Department (AFCD). Unlike the plan for doctors, farmers will be legally mandated to keep records of antibiotic usage with penalties applying to those who fail to comply.

Taking a step back to look at the AMR crisis


The growing problem of AMR is a realistic one and a future “global crisis” as described by the World Health Organization. While it is easy to pin the blame on antibiotics over-prescription on doctors and the healthcare setting, sometimes a broader perspective is required to gain a full understanding of the situation at hand.

Few realize that the agriculture industry is responsible for a great deal of antibiotics consumption and over usage which also trickle down towards the end-consumer.

While doctors in Hong Kong should do the best they can by being prudent with antibiotics prescription having one of the lowest rates of antibiotic prescription compared to its peers, the antibiotic crisis will not be solved by pointing fingers and shifting blame but, a big part of solving it comes from knowing what came be done to help the situation. MIMS

Read more:
China bans last-resort antibiotic in animal feed amidst growing resistance
First new antibiotic in a decade aims to counter growing bacterial resistance
Five controversial healthcare policies over CY Leung’s five-year term

Sources:
http://www.scmp.com/news/hong-kong/health-environment/article/2102072/hong-kong-doctors-asked-report-antibiotics-use
http://www.nejm.org/doi/full/10.1056/NEJMp1311479
http://www.scmp.com/news/china/society/article/1823298/antibiotics-coursing-through-chinas-waterways-research-finds
https://www.nature.com/articles/npjpcrm201580
https://apfmj.biomedcentral.com/articles/10.1186/1447-056X-8-5
http://www.bmj.com/content/bmj/338/bmj.b2242.full.pdf
http://www.info.gov.hk/gia/general/201707/10/P2017071000364.htm
http://www.legco.gov.hk/yr16-17/english/panels/hs/papers/hs20170717-ppr201710-e.pdf
http://www.chp.gov.hk/files/pdf/survey_on_use_of_antibiotics_among_medical_doctors_in_hk_eng.pdf