Background: Antibiotics are widely used in clinics, livestock farms and the aquaculture industry. A variety of antibiotics in foods and drinking water may lead to important and inadvertent dietary exposure However, the profile of dietary exposure to antibiotics in humans is not well-explored. East China is an economically developed area with a high usage of antibiotics and a high rate of antibiotic resistance (ABR). This study aimed to evaluate the total intake level of antibiotics in humans via foods and drinking water based on a community population in East China. Methods: A total of 600 local residents from 194 households were recruited into this study in Deqing County of Zhejiang Province since June 2019. Each subject was asked to fill a food frequency questionnaire to report their daily consumption of foods and drinking water. Tap water samples were collected from ten households and twenty-one antibiotics of five categories were selected to detect in drinking water. Data of antibiotic residues in animal-derived foods were obtained from the notification of unqualified edible agricultural products after special supervision sampling inspection in Deqing County. The human dietary exposure to antibiotics was estimated by combining the data of antibiotic contamination in foods and drinking water, and the information of dietary consumption. Results: Of twenty-one antibiotics selected, subjects were exposed to a total of sixteen antibiotics, ranging from 15.12 to 1128 μg/day via two main dietary routes (animal-derived foods and drinking water). The overall dietary exposure level varied greatly in the antibiotics detected and their sources. Compared with other antibiotics, enrofloxacin made the most contributions in terms of dietary exposure, with a median exposure level of 120.19 μg/day (IQR: 8.39–698.78 μg/day), followed by sulfamethazine (median: 32.95 μg/day, IQR: 2.77–162.55 μg/day) and oxytetracycline (median: 28.50 μg/day, IQR: 2.22–146.58 μg/day). The estimated exposure level via drinking water (at the ng/day level, median: 26.74 ng/day, IQR: 16.05–37.44 ng/day) was significantly and substantially lower than those via animal-derived foods (at the μg/day level, median: 216.38 μg/day, IQR: 87.52–323.00 μg/day). The overall dietary exposure level also showed differences in sex and age. Males and youths were more likely to be exposed to antibiotics via dietary routes than others. Conclusions: The community population investigated in East China was extensively exposed to multiple antibiotics via dietary routes. Long-term exposure to low-dose antibiotics in animal-derived foods was the primary dietary exposure route, compared with drinking water. Enrofloxacin contributed to the major body burden of dietary exposure, based on the combination of consumption of aquatic products and considerable enrofloxacin residues in them. Although the human dietary exposure level to antibiotics via drinking water and animal-derived foods ranged from ng/day to μg/L, their chronic toxicity and the accumulation and spread of ABR may be potential hazards to humans. Therefore, long-term monitoring of antibiotic contaminations in foods and drinking water, and human dietary antibiotic exposure is warranted.

Antibiotic resistance is a global health challenge that threatens human and animal lives, especially among low-income and vulnerable populations in less-developed countries. Its multi-factorial nature requires integrated studies on antibiotics and resistant bacteria in humans, animals, and the environment. To achieve a comprehensive understanding of the situation and management of antibiotic use and environmental transmission, this paper describes a study protocol to document human exposure to antibiotics from major direct and indirect sources, and its potential health outcomes. Our mixed-methods approach addresses both microbiological and pathogen genomics, and epidemiological, geospatial, anthropological, and sociological aspects. Implemented in two rural residential areas in two provinces in Eastern China, linked sub-studies assess antibiotic exposure in population cohorts through household surveys, medicine diaries, and biological sampling; identify the types and frequencies of antibiotic resistance genes in humans and food-stock animals; quantify the presence of antibiotic residues and antibiotic resistance genes in the aquatic environment, including wastewater; investigate the drivers and behaviours associated with human and livestock antibiotic use; and analyse the national and local policy context, to propose strategies and systematic measurements for optimising and monitoring antibiotic use. As a multidisciplinary collaboration between institutions in the UK and China, this study will provide an in-depth understanding of the influencing factors and allow comprehensive awareness of the complexity of AMR and antibiotic use in rural Eastern China.

Inappropriate antibiotic use may lead to antibiotic resistance, which has become a serious global crisis. Addressing suboptimal antibiotic use in the general population can play a significant role in the fight against antimicrobial resistance. This study aims to describe antibiotic use and sources of acquisition, and to identify factors influencing antibiotic access among rural community residents in Eastern China. A cross-sectional survey was conducted from July to August 2020, and 1494 participants from two villages in Eastern China were enrolled. Information was obtained using face-to-face interviews with a structured electronic questionnaire. Chi-squared and multinominal logistic regression analysis were used to explore possible determinants. In total, 1379 participants were eligible for the analysis. In the past 12 months, nearly half the respondents had taken any antibiotic (48.4%), and this proportion varied across marital status and age group. Two thirds of them (59.9%) obtained antibiotics from medical facilities with a prescription when they last took antibiotics, while 17.7% and 22.4% chose retail pharmacies and other sources, respectively. Multinominal analysis found that a higher proportion obtained antibiotics outside medical facilities among those aged 15 to 44 years, unmarried, non-white collar workers, with more years of education, lower annual household income per capita and lower levels of antibiotic knowledge. The antibiotic use behavior of rural community residents in Eastern China remains suboptimal. Antibiotic use and access behaviors need to be further addressed. Effective antibiotic stewardship in non-medical facility sources and training programs targeted for rural Chinese is warranted in future.

There are growing concerns that the coronavirus disease of 2019 (COVID-19) pandemic may change antibiotic use patterns and accelerate antibiotic resistance, but evidence from the community level is lacking. This study aims to estimate the impact of the COVID-19 outbreak on the antibiotic use patterns among a community population in Eastern China. A self-administered medicine diary was used to collect information on antibiotic use from July 2019 to June 2021 among a rural community in Eastern China. We analyzed the changes in antibiotic use patterns over five months from August to December 2019 and the corresponding months in 2020. The risk of antibiotic use and its changes were measured with the incidence rate (IR) and relative risk (RR). In total, 1111 participants were eligible for the final analysis (440 in 2019 and 671 in 2020). After the COVID-19 outbreak, antibiotic use increased by 137% (5.43 per 100 person months in the 2019 vs. 12.89 per 100 person months in the 2020), and after the adjustment of covariates, the adjusted RR was 1.72 (95% CI: 1.10~2.34). It was higher among those who were women (RR = 2.62), aged 35–59 years old (RR = 2.72), non-farmers (RR = 2.75), had less than six years of education (RR = 2.61), had an annual household income over CNY 100,000 (USD 14,940) (RR = 2.60), and had no history of chronic diseases (RR = 2.61) (all p < 0.05). The proportion of cephalosporins consumed increased from 54.29% in 2019 to 64.92% in 2020 (p = 0.011). Among those aged 35 years and older, the proportion of antibiotics obtained from medical facilities increased, while the proportion obtained from retail pharmacies, homes, and other sources decreased (all p < 0.05). The COVID-19 outbreak changed antibiotic use patterns in this study population (Eastern China) significantly. More efforts to monitor and enhance antibiotic stewardship activities at the community level are needed in future.