LAUSR

Abstract Background The acquisition of antibiotics without a prescription is recognised as a major cause of misuse of antibiotics, and a contributor to anti-microbial resistance (AMR) globally. Levels of AMR in China are among the highest in the world. The aim of this study was to assess ease of access to antibiotics without prescription across the three regions of mainland China. Methods Using the simulated patient method, we did a cross-sectional survey using purposive sampling, in retail pharmacies in urban and rural areas of 13 provinces in China from July to September, 2017. The simulated patients were medical students who described very mild upper respiratory tract symptoms, following a standardised protocol. They recorded the details of the pharmacy and their experience. This included whether they were given an antibiotic and at what stage in the protocol, whether the pharmacy was part of a chain or independent, whether the attending pharmacist attending them had a licence, and whether there was a sign stating prescriptions were required for antibiotic. We used χ2 tests to compare categorical variables. Ethical approval was obtained from Zhejiang University Research Ethics Committee. Findings Complete data were obtained from 1106 pharmacies. Antibiotics were obtained in 925 pharmacies (83·6%, 95% CI 81·5–85·8). There were differences between provinces, ranging from 57% in Zhejiang to 98·8% in Guizhou There were no significant differences in access to antibiotics by level of city, county, or township (p=0·25), whether the pharmacy was part of a chain or independent (p=0·23), whether a licensed pharmacist was attending (p=0·82), or whether there was a standard sign saying that prescriptions were required for antibiotics (p=0·19). Pharmacists overall provided a poor standard of service, with very little questioning about the students' symptoms or no explanation about correct use of antibiotics. Interpretation It is very easy to obtain antibiotics without a prescription in retail pharmacies in China. Given that effective anti-microbial stewardship programmes have been introduced in many hospital settings in China, especially at tertiary level, the failure of the government to enforce the existing law on prohibition of antibiotic sales without prescription is all the more concerning. Such enforcement should be addressed as a matter of urgency, alongside a targeted public education campaign. Funding This work was supported by Zhejiang University Explorative Research Programme (Number GW-17–04).