Country Resistance Snapshot
A total of 22 million antibiotic prescriptions are written each year in Australia: one for every man, woman and child, said pharmacist Mr Bell. This is above the Organisation for Economic Co-operation and Development (OECD) average and, per capita, twice that of Scandinavia.
Partly this is due to the lack of financial incentive to discourage antibiotic prescribing or use. The cost of most antibiotics is heavily subsidised; and the structure of healthcare in Australia means doctors are effectively competing for patients, said Mr Bell: “Patients can choose to go to those who are more generous with their antibiotic prescribing”.
A 2010 guideline outlines the principles for rational antibiotic use, utilising the MIND ME mnemonic:9
Microbiology guides therapy wherever possible
Indications should be evidence based
Narrowest spectrum required
Dosages appropriate to the site and type of infection
Minimize duration of therapy
Ensure monotherapy in most situations
Early stage Australian data on antimicrobial stewardship programmes show similar results to the US, where such an approach has reduced antibiotic use by 22–36%.10
“Antibiotic resistance is a very important problem, particularly in respiratory tract and urinary tract infections”, said Prof. Pignatari. Despite the existence of national and international guidelines on antibiotic resistance, Prof. Pignatari felt these are ineffective. The main barriers to the implementation of rational antibiotic use on community-acquired infections are empiric treatment, patient pressure and a lack of availability of quick laboratory diagnostic tests.
In addition, accessibility of antibiotics through pharmacy sales is prevalent, despite regulations, which prevent their dispensing in the absence of a prescription. An analysis of Escherichia coli resistance in Säo Paolo revealed ‘hot spots’ of ciprofloxacin resistance13. “We know exactly the pharmacies that are selling these drugs,” he added.
A new approach to this problem has been in place since 2010. Pharmacies are required to retain antibiotic prescription for one month after dispensing. It is enforced by law with the potential for pharmacies to be closed. “This works,” concluded Prof. Pignatari. “We spent 20 years with guidelines and recommendations that did not work. Now, in one year, we have a 17% reduction in the number of antibiotics used”.
Germany is not a high antibiotic prescribing country, which runs counter to the fact that, in general, it is a high-prescribing nation with a poly-pharmacy problem, said Prof. Altiner. Acute respiratory and urinary infections are common presenting conditions in primary care. While German physicians are aware of antibiotic resistance, nonrational prescribing is common, with many different antibiotics prescribed.
In an analysis of patient consultations, German GPs were found to be good communicators with sufficient time for discussion; however, this communication did not cover antibiotics5. This learning is important: “Even in a low prescribing country there is still potential to reduce further by addressing doctor-patient communications”.
Interventions to reduce prescribing include DART (Deutsche Antibiotika-Resistenzstrategie), which encompasses surveillance on resistance and resistance development, education, co-ordination and research; guidelines on acute cough, earache, rhinosinusitus, dysuria and oral antibiotics are available. But Prof. Altiner commented: “Having a guideline is one thing, implementing it is another”.
Italy has the most inappropriate use of antibiotic therapy for upper respiratory tract infections in Europe, revealed Dr Sessa. These infections are the driver for antibiotic use, with 30% of infections resulting in a prescription and numbers peaking in line with influenza rates. Of these, “sore throat is probably the lead infection for inappropriate antibiotic use”.
During the period 1999–2007, antibiotic use in Italy increased by 13%, with overuse of parenteral antibiotics, oral cephalosporins and quinolones. “There are wide regional differences,” Dr Sessa added. “The south of Italy, compared to the north of Italy, has about three times the amount of antibiotic use”.
Another issue is that it is possible to obtain antibiotics from some pharmacies, even though they are not available without prescription and this practice is not officially permitted.
Measures to tackle inappropriate antibiotic use include guidelines and an annual patient campaign that runs on TV, radio and print. This advises patients to defend their defences, not to use antibiotics for the common cold and flu, only use antibiotics given by the doctor and take antibiotics according to directions.
Dr Sessa pointed out: “If antibiotic prescribing was as low as the average of six low-consumption regions, it could save €316m17”.
The Netherlands has a relatively low rate of antibiotic consumption. Yet, four out of five antibiotic prescriptions are from primary care, of which 60% are for respiratory tract disorders, said Prof. van der Velden.
The Dutch sore throat guideline advises that antibiotic treatment is not based on a specific diagnosis. “Antibiotics are only used for patients with severe illness or with serious risk of complications. With just Centor criteria it is difficult to predict who will benefit from antibiotics”, Prof. van der Velden added.
How the guideline works in daily practice has been analysed using 452 detailed described consultations for sore throat. Antibiotics were given to 30% of patients; over 50% of prescriptions were not in line with the guideline.
In a GP-targeted Dutch intervention trial to optimize antibiotic prescription for respiratory tract infections, education on guidelines, and information on patient expectations and communication reduced antibiotic prescribing by 12%. “In the Netherlands we are still intervening to further reduce antibiotic use,” said Prof. van der Velden.
Russia has a low rate of antibiotic prescribing. However, Prof. Kozlov warned this does not reflect over-the-counter antibiotic use. “They are not on display but 52% of pharmacies do sell antibiotics”.
An issue of key concern is the high frequency of inappropriate antibiotic prescribing for viral infections. “For acute pharyngitis, the prescribing rate is around 90%. Around twothirds of children will get antibiotics, around 89% for sore throat and 98% for acute bronchitis”, explained Prof. Kozlov.
Other issues include inadequate antibiotic choice for empirical therapy, inappropriate combinations of antibiotics and the predominance of parental antibiotic use in the outpatient sector. As a result, current data show resistance is rising for penicillin and quinolones, while cephalosporin remains stable.
Behavioural interventions can make a difference. A recent multi-faceted intervention study to improve the management of sore throat in Smolensk outpatient settings provided educational materials for physicians, free GABHS testing and patient information leaflets. As a result, the frequency of inappropriate antibiotic use dropped by over 20%23.
Communicable diseases, such as infections and HIV, pose the greatest health burden in South Africa, said Prof. Essack. While HIV poses a greater health threat, antibiotic stewardship is vital to the survival of HIV patients.
“South Africa has a two-tier, fragmented healthcare system of public and private healthcare”, explained Prof. Essack. In the public sector, indiscriminate over-prescribing of antibiotics is coupled with underuse, due to inadequate access/availability of essential drugs, plus non-compliance. In the private sector, indiscriminate prescribing is also fuelled by patient demand and supplemented by self-medication. Underuse via poor or non-compliance is also seen.
There is greater use of older antibiotics in the public sector and newer agents in the private sector. “In the private sector, the antibiotic resistance rate is lower but there is a broader range of drugs against which resistance exists because antibiotic choice is unrestricted”, summarized Prof. Essack.
Rational antibiotic prescribing is achieved in the public sector by way of treatment guidelines and the essential drugs list and a national antibiotic stewardship programme enjoying endorsement from the public and private healthcare sectors is in its inception phase.
As one of the worst countries in the world for antibiotic resistance, Thailand offers opportunities for learning. Common cold and sore throat sufferers almost always receive broad spectrum antibiotic plus symptomatic treatment, as part of the endemic polypharmacy culture.
In common with other parts of the world, antibiotic accessibility is an issue, with availability for purchase through drugstores and private clinics. In drug stores, often the pharmacist is not present; the owner may not be a qualified healthcare professional and not aware of the need for rational antibiotic use.
There is no national antibiotic stewardship policy, although a local Antibiotics Smart Use campaign has been in operation since 2007, focusing on rational antibiotic prescribing in sore throat, urinary tract infections, diarrhoea due to food poisoning and simple wounds.
The focus has been on educating healthcare professionals and Government support workers in hospitals via a lecture tour. Educational materials are provided for healthcare professionals and information leaflets for patients. Data show this approach has positive results, with 30% fewer patients receiving antibiotics, compared to control.
Respiratory tract infections account for 60% of UK antibiotic use, although there is a wide variation in the type of antibiotics prescribed, said Dr Duerden.
While national guidelines on respiratory tract infections advocate limiting antibiotic use and the adoption of a delayed prescribing strategy18, Dr Duerden believes most GPs would be unable to summarise the guidance.
Recent data on a GP education programme run through 68 practices in Wales with 480,000 patients found that intensive training on consultation skills resulted in a only 4% reduction in antibiotic use26. “It may be that the training was too complicated, with a lot of time spent doing online consultation skills”, commented Dr Duerden on the reasons for the modest reduction rate.
A simple solution to improve antimicrobial stewardship could be to pay doctors to reduce their antibiotic prescribing through incentive schemes, he suggested. But there would remain an issue over consistency: “If I dissuade them from having an antibiotic in primary care, they then should not be able to go to another GP or their accident and emergency department and get one”.
As one of the largest countries in the world, the United States of America has been alert to the need to communicate the issue of antibiotic resistance for 17 years. Since 2003, under the banner of the Get Smart campaign, promoting adherence to appropriate prescribing guidelines while reducing demand for antibiotics among healthy adults and parents of young children has been a key education initiative for the Center for Disease Control and Prevention.
The Get Smart campaign has focused on upper respiratory tract infections as these account for 75% of all antibiotics prescribed in US general practice; 68% of doctor consultations for these infections end in a prescription, with four out five being unnecessary27.
The Get Smart campaign has taken a multi-stranded approach to communications, creating guidelines, healthcare professional and patient educational and behavioural change materials, coupled with an annual national media strategy that runs through TV, radio and outdoor media. The effectiveness of the campaign has also been evaluated and has demonstrated a reduction in antibiotic use for paediatric otitis media infections (down from 61 per 100 visits in 1997, to 47.5 in 2007), as well as fewer consultations for acute upper respiratory tract infections in children and an overall 25% drop in prescriptions for viral infections28.