Outpatient antibiotic use and prevalence of antibiotic-resistant pneumococci in France and Germany: a sociocultural perspective.
01 Dec 2002-Emerging Infectious Diseases (Centers for Disease Control and Prevention)-Vol. 8, Iss: 12, pp 1460-1467
TL;DR: The prevalence of penicillin-nonsusceptible pneumococci is sharply divided between France and Germany, and the overarching importance of a sociocultural approach to preventing antibiotic resistance in the community is emphasized.
Abstract: The prevalence of penicillin-nonsusceptible pneumococci is sharply divided between France (43%) and Germany (7%). These differences may be explained on different levels: antibiotic- prescribing practices for respiratory tract infections; patient-demand factors and health-belief differences; social determinants, including differing child-care practices; and differences in regulatory practices. Understanding these determinants is crucial for the success of possible interventions. Finally, we emphasize the overarching importance of a sociocultural approach to preventing antibiotic resistance in the community.
Citations
More filters
TL;DR: Routine surveillance data indicate a relation between use and resistance and support interventions designed to reduce antimicrobial consumption at a national level in Europe.
Abstract: Our study confronts the use of antimicrobial agents in ambulatory care with the resistance trends of 2 major pathogens, Streptococcus pneumoniae and Escherichia coli, in 21 European countries in 2000-2005 and explores whether the notion that antimicrobial drug use determines resistance can be supported by surveillance data at national aggregation levels. The data obtained from the European Surveillance of Antimicrobial Consumption and the European Antimicrobial Resistance Surveillance System suggest that variation of consumption coincides with the occurrence of resistance at the country level. Linear regression analysis showed that the association between antimicrobial drug use and resistance was specific and robust for 2 of 3 compound pathogen combinations, stable over time, but not sensitive enough to explain all of the observed variations. Ecologic studies based on routine surveillance data indicate a relation between use and resistance and support interventions designed to reduce antimicrobial drug consumption at a national level in Europe.
468 citations
Cites background from "Outpatient antibiotic use and preva..."
...However, additional or alternative factors need to be taken into account (28)....
[...]
TL;DR: This study correlated outpatient antibiotic use with prevalence of penicillin-nonsusceptible Streptococcus pneumoniae, macrolide-resistant S. pneumoniae (MRSP), and macrolides- resistant S. pyogenes (MRGAS) in 20 countries to find out how antibiotic selection pressure on a national level affectsStreptococcal resistance.
Abstract: We correlated outpatient antibiotic use with prevalence of penicillin-nonsusceptible Streptococcus pneumoniae (PNSP), macrolide-resistant S. pneumoniae (MRSP), and macrolide-resistant S. pyogenes (MRGAS) in 20 countries. Total antibiotic use was correlated with PNSP (r = 0.75; p < 0.001), as was macrolide use with MRSP (r = 0.88; p < 0.001) and MRGAS (r = 0.71; p = 0.004). Streptococcal resistance is directly associated with antibiotic selection pressure on a national level.
380 citations
Cites background from "Outpatient antibiotic use and preva..."
...In previous cross-country comparisons of Germany, France, and the United States (5,30), we suggested that socioeconomic, cultural, and behavioral determinants have a major impact on outpatient antibiotic prescribing practices and resistance prevalence in respiratory pathogens on a national level....
[...]
...It was lowest in Scandinavian countries (1% in Norway, 2% in Denmark, 4% in Sweden) and the Netherlands (1%); of medium level in Germany (7%), the United Kingdom (11%), Austria (12%), Belgium, and Italy (both 13%); and high in Portugal (29%), Greece (31%), United States (34%), France (43%), and Spain (50%)....
[...]
...The relationship between total outpatient antibiotic consumption and rates of PNSP was analyzed for 20 countries (Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, United Kingdom, and United States)....
[...]
...Recently, McCormick et al. have shown that variation in pneumococcal resistance in the United States is best explained by geographic variation in antibiotic selection pressure, rather than by clonal dynamics (8)....
[...]
...Data for the United States were extracted from IMS data (10)....
[...]
TL;DR: Bundles of measures that must be implemented simultaneously and worldwide are presented in this document and include antibiotics, which represent a treasure for humanity, must be protected and considered as a special class of drugs.
Abstract: Resistance to antibiotics has increased dramatically over the past few years and has now reached a level that places future patients in real danger. Microorganisms such as Escherichia coli and Klebsiella pneumoniae, which are commensals and pathogens for humans and animals, have become increasingly resistant to third-generation cephalosporins. Moreover, in certain countries, they are also resistant to carbapenems and therefore susceptible only to tigecycline and colistin. Resistance is primarily attributed to the production of beta-lactamase genes located on mobile genetic elements, which facilitate their transfer between different species. In some rare cases, Gram-negative rods are resistant to virtually all known antibiotics. The causes are numerous, but the role of the overuse of antibiotics in both humans and animals is essential, as well as the transmission of these bacteria in both the hospital and the community, notably via the food chain, contaminated hands, and between animals and humans. In addition, there are very few new antibiotics in the pipeline, particularly for Gram-negative bacilli. The situation is slightly better for Gram-positive cocci as some potent and novel antibiotics have been made available in recent years. A strong and coordinated international programme is urgently needed. To meet this challenge, 70 internationally recognized experts met for a two-day meeting in June 2011 in Annecy (France) and endorsed a global call to action ("The Pensieres Antibiotic Resistance Call to Action"). Bundles of measures that must be implemented simultaneously and worldwide are presented in this document. In particular, antibiotics, which represent a treasure for humanity, must be protected and considered as a special class of drugs.
334 citations
Cites background from "Outpatient antibiotic use and preva..."
...In a survey conducted in the USA, nearly half (48%) of respondents indicated that they expected an antibiotic when they visit a doctor [72] In another survey, more than 50% of French interviewees expected an antibiotic for the treatment of influenza-like illness [73]....
[...]
...Supplementary list of the main issues discussed (references [72-78])....
[...]
TL;DR: How the volume and appropriateness of antibiotic use in hospitals vary between countries, hospitals, and physicians is described.
Abstract: Antibiotics have dramatically changed the prognoses of patients with severe infectious diseases over the past 50 years. However, the emergence and dissemination of resistant organisms has endangered the effectiveness of antibiotics. One possible approach to the resistance problem is the appropriate use of antibiotic drugs for preventing and treating infections. This Review describes how the volume and appropriateness of antibiotic use in hospitals vary between countries, hospitals, and physicians. At each specific level-cultural, contextual, and behavioural-we discuss the determinants that influence hospital antibiotic use and the possible improvement strategies to make it more appropriate. Changing hospital antibiotic use is a challenge of formidable complexity. On each level, many determinants play a part, so that the measures or strategies undertaken to improve antibiotic use need to be equally diverse. Although various strategies for improving antibiotic use are available, a programme with activities at all three levels is needed for hospitals. Evaluating these programme activities in a way that provides external validity of the conclusions is crucial.
296 citations
TL;DR: Determinants likely to influence the future epidemiology and health impact of antimicrobial-resistant infections are described and will ultimately optimize preventive strategies for an unpredictable future.
Abstract: At the beginning of the 21st century, antimicrobial resistance is common, has developed against every class of antimicrobial drug, and appears to be spreading into new clinical niches. We describe determinants likely to influence the future epidemiology and health impact of antimicrobial-resistant infections. Understanding these factors will ultimately optimize preventive strategies for an unpredictable future.
286 citations
Cites background from "Outpatient antibiotic use and preva..."
...Antimicrobial use is affected by reimbursement policies, financial incentives, and healthcare regulation (19)....
[...]
...Although the interplay between health beliefs and demand of antimicrobial drugs is widely recognized, few, if any, systematic studies exist about the future influence of the cultural setting on antimicrobial drug use and related resistance rates (19)....
[...]
References
More filters
TL;DR: A novel area of research was born, adding new perspectives to conventional studies of health inequalities, and the debate on income inequality versus mortality acted as a strong stimulus for further work on factors such as social cohesion and social capital.
Abstract: Papers pp 13, 16, 20, 23
In 1992, the BMJ published a now famous paper showing a strong negative correlation between income inequality and life expectancy. Among nine Western industrialised countries those which had less income inequality seemed to have higher life expectancy.1 A few years later this was replicated in analyses looking at income inequality and mortality in states within the United States—analyses which seemed more secure because of having more and better quality data. 2 3 These findings, which suggested that income inequality is bad for the health of the whole population and not only for those with the lowest incomes, were seen to have important implications. Reducing the inequality would be in everyone's interest, including those with higher incomes.
A novel area of research was born, adding new perspectives to conventional studies of health inequalities. These had tended to focus on relations between socioeconomic factors and health of the individual, while the findings on income inequality suggested that contextual effects of inequality might be just as important. Considerable dissent, however, emerged on the explanation of these effects. Some favoured softer psychosocial pathways (for example through feelings of relative deprivation, or disruption of social cohesion) while others favoured harder material pathways (for example through underinvestment in public resources).4–6 Support was found for some of these mechanisms, which are also important in their own right, and the debate on income inequality versus mortality acted as a strong stimulus for further work on factors such as social cohesion and social capital.7 Although most of …
851 citations
TL;DR: There was profound variation in use of different classes of antibiotics, and detailed knowledge of antibiotic use is necessary to implement national strategies for optimum antibiotic use, and to address the threat posed by resistant microorganisms.
712 citations
"Outpatient antibiotic use and preva..." refers background in this paper
...6 DDD/1,000 population/day in Germany (Figure 3) (19)....
[...]
...Analyses of national sales data from Germany and France are summarized in Figure 3 (18,19)....
[...]
...This feature contributes to the observed trend in France of using newer antibiotics; in Germany, by contrast, narrow-spectrum, generic agents are more commonly used (19)....
[...]
...Overall, among 18 industrialized countries, Germany had the third lowest and France had the highest antibiotic utilization rate in the outpatient setting throughout the 1990s (18,19)....
[...]
...In addition, Germany had a higher relative use of narrow-spectrum penicillins, cotrimoxazole, and tetracyclines and a much lower use of broad-spectrum penicillins, cephalosporins, and fluoroquinolones, compared to France (2,19)....
[...]
TL;DR: For example, this paper found that doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients, and that possible patient benefit outweighed theoretical community risk from resistant bacteria.
Abstract: Objectives: To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help. Design: Qualitative study with semi-structured interviews. Setting: General practices in South Wales. Subjects: 21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection. Main outcome measures: Subjects9 experience of management of the illness, patients9 expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing. Results: Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing “against the evidence” uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief. Conclusions: This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors9 prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.
681 citations
TL;DR: It is shown that in Europe antimicrobial resistance is correlated with use of beta-lactam antibiotics and macrolides.
Abstract: In Europe, antimicrobial resistance has been monitored since 1998 by the European Antimicrobial Resistance Surveillance System (EARSS). We examined the relationship between penicillin nonsusceptibility of invasive isolates of Streptococcus pneumoniae (an indicator organism) and antibiotic sales. Information was collected on 1998-99 resistance data for invasive isolates of S. pneumoniae to penicillin, based on surveillance data from EARSS and on outpatient sales during 1997 for betalactam antibiotics and macrolides. Our results show that in Europe antimicrobial resistance is correlated with use of beta-lactam antibiotics and macrolides. ntimicrobial resistance is a growing problem worldwide, requiring international approaches. The World Health Organization (WHO) and the European Commission have recognized the importance of studying the emergence and determinants of resistance and the need for strategies for its control (1-3). In European countries, antimicrobial resistance has been monitored in selected bacteria from humans since 1998 through the European Antimicrobial Resistance Surveillance System (EARSS). Funded by the European Commission, EARSS is an international network of national surveillance systems intended to collect comparable and reliable resistance data. The purpose of EARSS is to document variations in antimicrobial resistance over time and place and to provide the basis for and assess the effectiveness of prevention programs and policy decisions. One of the indicator organisms in EARSS is Streptococcus pneumoniae. It was included for three reasons: it is of major clinical importance for pneumonia, bacterial meningitis, and otitis media; many countries have reported that its resistance to penicillin is increasing; and S. pneumoniae is representative of organisms that are transmitted in the community. A major risk factor for the development of resistance is
626 citations
TL;DR: It is suggested that a low daily dose and a long duration of treatment with an oral beta-lactam contribute to the selective pressure in promoting pharyngeal carriage of penicillin-resistant S pneumoniae.
Abstract: Context.—The spread of drug-resistant Streptococcus pneumoniae in the community is a public health problem in developed and developing
nations, but whether antibiotic use is responsible for the increase in drug
resistance is not known.Objective.—To analyze the relationship between penicillin-resistant S pneumoniae (PR Sp) pharyngeal carriage and
characteristics of β-lactam use.Design.—Observational study of children attending 20 randomly sampled schools.Setting.—The Loiret, in the center of France.Participants.—A total of 941 children, 3 to 6 years old.Main Outcome Measure(s).—Pharyngeal carriage of S pneumoniae, antibiotic
use, and medical events during the preceding 30 days. Pneumococcal penicillin
G sodium minimal inhibitory concentrations and serotyping were performed.Results.—Medical illnesses and the use of antibiotics were not associated with
PR Sp carriage. However, oral β-lactam use was
associated with an increased risk of PR Sp carriage
(odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1-8.3; P=.03). Children treated by low daily doses of an oral β-lactam
(defined as lower than clinical recommendations) had an increased risk of
PR Sp carriage, as compared with children who did
not (OR, 5.9; 95% CI, 2.1-16.7; P =.002). A treatment
of long duration (>5 days) with a β-lactam was associated with an increased
risk of PR Sp carriage (OR, 3.5; 95% CI, 1.3-9.8; P=.02).Conclusions.—Our results suggest that a low daily dose and a long duration of treatment
with an oral β-lactam contribute to the selective pressure in promoting
pharyngeal carriage of PR Sp.
575 citations
"Outpatient antibiotic use and preva..." refers background in this paper
...(24) also demonstrated that frequent low-level prescribing of penicillin selects for resistant strains of S....
[...]