Elsevier

The Lancet

Volume 365, Issue 9459, 12–18 February 2005, Pages 579-587
The Lancet

Articles
Outpatient antibiotic use in Europe and association with resistance: a cross-national database study

https://doi.org/10.1016/S0140-6736(05)17907-0Get rights and content

Summary

Background

Resistance to antibiotics is a major public-health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Our aim was to assess outpatient use of antibiotics and the association with resistance.

Methods

We investigated outpatient antibiotic use in 26 countries in Europe that provided internationally comparable distribution or reimbursement data, between Jan 1, 1997, and Dec 31, 2002, by calculating the number of defined daily doses (DDD) per 1000 inhabitants per day, according to WHO anatomic therapeutic chemical classification and DDD measurement methodology. We assessed the ecological association between antibiotic use and antibiotic resistance rates using Spearman's correlation coefficients.

Findings

Prescription of antibiotics in primary care in Europe varied greatly; the highest rate was in France (32·2 DDD per 1000 inhabitants daily) and the lowest was in the Netherlands (10·0 DDD per 1000 inhabitants daily). We noted a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics. We also recorded striking seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics. We showed higher rates of antibiotic resistance in high consuming countries, probably related to the higher consumption in southern and eastern Europe than in northern Europe.

Interpretation

These data might provide a useful method for assessing public-health strategies that aim to reduce antibiotic use and resistance levels.

Introduction

Antibiotic resistance is a major public-health problem worldwide, and international efforts are needed to counteract its emergence. There is much information on the prevalence of resistance in human pathogens, and these data show that there are substantial geographic differences in the proportion of resistance to various classes of antibiotics in Europe.1 Although rates of antibiotic resistance remain low in northern European countries, these rates are reaching alarming levels in southern and central Europe. Antibiotic consumption is increasingly being recognised as the main cause of this emerging resistance, and differential selection pressure of antibiotics could be responsible for some of these differences.2

The highest rates of antibiotic prescriptions for systemic use are in primary care, and respiratory tract infection is the most common indication. Monitoring antibiotic use should accompany surveillance programmes on antibiotic resistance. However, data for their use are scarce and not freely available, and the factors that determine differences in use are not fully understood. Moreover, national databases use different methods for drug classification and for measuring antibiotic use. However, temporal trends and regional differences are important triggers for action and investigation, and benchmarking by comparisons between countries should be an important stimulus to quality improvement. Additionally, development, implementation, and assessment of guidelines need information about practice of antibiotic prescribing, which will inform local or national prescribing policies.

On Nov 15, 2001, a European Union (EU) Council recommendation3 stated that specific strategies should continue to gather data for antibiotic use. The European Surveillance of Antimicrobial Consumption (ESAC) project, granted by the European Commission, is an international network of surveillance systems aiming to obtain comparable and reliable data about antibiotic use in Europe. Here, we present the first results of the ESAC project for outpatient antibiotic use and we relate these consumption data to existing resistance data.

Section snippets

Data collection

32 countries joined the ESAC project, including all 15 original EU countries, nine of the ten most recent member states (but not Cyprus), four applicant countries (Bulgaria, Croatia, Romania, and Turkey), two of the three European free trade association/European economic area countries (Iceland and Norway, but not Liechtenstein), Russia, and Switzerland. We obtained data for use of systemic antibiotics in ambulatory care grouped according to active substance in the drug, for 1997–2002, in

Results

Outpatient antibiotic use differed significantly in Europe, varying by a factor of 3·2 between the country with the highest rate (32·2 DID in France) and the country with the lowest rate (10·0 DID in the Netherlands) (figure 1). We noted significant differences across Europe, with antibiotic use being low in northern, moderate in eastern, and high in southern regions. Figure 2 shows the seasonal fluctuation of outpatient antibiotic use in the ten European countries that provided quarterly data.

Discussion

We identified significant variation in outpatient antibiotic use in Europe. Seasonal fluctuations were high in southern and eastern European countries, whereas in northern European countries the increase in antibiotic use during winter was less than 25%. We also showed a correlation between antibiotic resistance and outpatient antibiotic use in Europe.

Data for outpatient antibiotic use have been reported with various units of measurement, but to compare data from different regions or countries,

References (32)

  • RH Vander Stichele et al.

    European surveillance of antimicrobial consumption (ESAC): data collection performance and methodological approach

    Br J Clin Pharmacol

    (2004)
  • WC Albrich et al.

    Antibiotic selection pressure and resistance in Streptococcus pneumoniae and Streptococcus pyogenes

    Emerg Infect Dis

    (2004)
  • M Bergman et al.

    Effect of macrolide consumption on erythromycin resistance in Streptococcus pyogenes in Finland in 1997–2001

    Clin Infect Dis

    (2004)
  • S Bronzwaer

    European antimicrobial resistance surveillance as part of a community strategy [dissertation]

    (2003)
  • H Goossens et al.
  • G Kahlmeter

    An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO-SENS project

    J Antimicrob Chemother

    (2003)
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