ArticlesOutpatient antibiotic use in Europe and association with resistance: a cross-national database study
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.
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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,
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