trends in antimicrobial consumption and resistance in europe and the first annual antibiotic day...
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Trends in Antimicrobial Consumption and Resistance
in Europe and the First Annual Antibiotic Day
Herman Goossens
University of Antwerp, Belgium
Vice-Chair Belgian Antibiotic Policy Coordination Committee (BAPCOC)
Co-ordinator of ESAC
Chair Technical Advisory Group ECDC EU Antibiotic Day
We made great progress in Europe
since ... October 18, 2001.
Outline of Presentation
Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance
• At population level
• At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions
““If you cannot If you cannot measure it, measure it, you cannotyou cannot improve it”improve it”
Lord Kelvin, 1824-1907Lord Kelvin, 1824-1907
EARSS Participating countries: 31
2727 EU Member States EU Member States
11 Applicant countries Applicant countries
TurkeyTurkey
3 3 Other countriesOther countries Iceland, Iceland, Israel, Israel, NorwayNorway
Methicillin-Resistant Staph. aureus in Europe, 2006
Fluoroquinlone-Resistant E.coli in Europe, 2001-2006
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%N
O (1
117)
EE
(116
)
SE (2
904)
FI (1
543)
IS (9
9)
NL
(214
0)
FR (4
610)
GR
(950
)
SI (5
26)
HR
(527
)
BE
(111
8)
LU
(191
)
UK
(187
9)
PL (1
53)
IE (1
184)
AT
(133
6)
CZ
(180
9)
BG
(155
)
HU
(723
)
IT (8
26)
IL (8
62)
PT (7
54)
ES
(281
6)
DE
(104
0)
MT
(84)
CY
(57)
RO
(47)
TR
(782
)
Country code (average number of isolates reported per year)
% fl
uoro
quin
olon
e re
sist
ance
2001
2002
2003
2004
2005
2006
Outline of Presentation
Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance
• At population level
• At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions
ESAC Participating countries: 34
2727 EU Member States EU Member States
22 Applicant countries Applicant countriesCroatia,Croatia,TurkeyTurkey
55 Other countries Other countries Former Republic of Macedonia,Former Republic of Macedonia,
Iceland, Iceland, Israel, Israel,
Norway, Norway, Russia, Russia,
Switzerland Switzerland
Gre
ece
*
Cy
pru
s*
Fra
nce
Ita
ly
Be
lgiu
m
Lux
em
bo
urg
Po
rtu
ga
l
Slo
va
kia
Isra
el
Ire
lan
d
Cro
ati
a
Ice
lan
d
Sp
ain
**
Lith
ua
nia
*
Fin
lan
d
Bu
lga
ria
*
Hu
ng
ary
Sw
ed
en
Cze
ch R
ep
.
No
rwa
y
De
nm
ark
Slo
ve
nia
Au
stri
a
Ne
the
rla
nd
s
Ru
ssia
n F
ed
.
0
5
10
15
20
25
30
35
Other J01 classesSulfonamides and trimethoprim (J01E)Quinolones antibacterials (J01M)Macrolides, lincodamides and strep-togramins (J01F)Tetracyclines (J01A)Other beta-lactam antibacterials (J01D)Beta-lactam antibacterials, penicillins (J01C)
DD
D p
er 1
00
0 in
h.
per
day
Total Outpatient Antibiotic Use in 25 European Countries in 2006
(on-going validation for some countries)
* Greece, Cyprus, Lithuania, Bulgaria: total care, i.e. hospital and primary care combined.** Spain: reimbursement data, which do not include over-the-counter sales without a prescription.
Regional Variation of Outpatient Antibiotic Use in Italy
0
5
10
15
20
25
30
35
Tota
l use
in D
ID
J01X
J01R
J01M
J01G
J01F
J01E
J01D
J01C
J01B
J01A
Regional Variation of Outpatient Antibiotic Use in Germany
0
2
4
6
8
10
12
14
16
18
20
Saarla
ndPfa
lz
Nordr
hein
Rhein
hess
enTr
ier
Niede
rsac
hsen
Wes
tfale
n-Li
ppe
Brem
en
Hesse
n
Koble
nz
Hambu
rgBun
d
Schle
swig
-Hol
stein
Nordb
aden
Bayer
n
Sachs
en-A
nhal
t
Berlin
Mec
kl.-V
orpo
mm
ern
Brand
enbu
rg
Sachs
en
DID
0
50
100
150
5 17 15 4 14 16 2 20 3 18 7 11 10 9 13 1 19 8 6
Hospital
DD
D/
10
0 b
ed
-days
Parenteral Oral
ESAC Longitudinal Survey in 18 Hospitals in Europe:
Total, Parenteral and Oral Use of Antibacterials in 2005
ESAC Point Prevalence Survey in 20 Hospitals in Europe:
Length of Pre-operative Prophylaxis in Surgery
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
80,0
90,0
Per
cen
t o
f th
erap
ies
Prophylaxis one dose Prophylaxis one day Prophylaxis >1 day
Outline of Presentation
Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance
• At population level
• At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions
Correlation Between Macrolide Use and Macrolide-Resistant Strept. pneumoniae
Goossens et al, Lancet 2005
Organism year of isolation [source of information]
Antibiotic resistance
Antibiotic use - ATC group
(year of data)
No. of countries
Spearman correlation (r)
(confidence interval)
P-value
S. pneumoniae
1999/2000 [8]
Erythromycin Macrolides - J01FA
(1998) 16
0.83
(0.67-0.94) < 0.001
Consumption of macrolides (J01FA) in DID, AC 1998
6543210
Ery
trom
ycin
res
ista
nt S
. pne
umon
iae
(%)
60
50
40
30
20
10
0
UK
SE
PT
NONL
LU
IT
IE
GR
FR
FI
ES
DK
DE
BE
AT
Effect of Macrolide versus Placebo Use on Temporal Changes of Proportion of Macrolide-Resistant Oral Streptococci
Malhotra et al, Lancet 2007
• Mean preantibiotic carriage of Mac-R streptococci was 28%
• Use of both Clar and Azi resulted in a huge increase in resistant streptococci which persisted for at least 6 months (P 0.01)
• Macrolide use is the single most important driver for the emergence of macrolide resistance
Outline of Presentation
Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance
• At population level
• At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions
Belgium: a Federal Country...
Strategies to Curb Resistance in Belgium
Seven multimedia campaigns to promote the prudent use of antibiotics in outpatients
Two national campaigns to promote hand hygiene in hospitals
Antibiotic management teams in ALL Belgian hospitals Several practice guidelines Antibiotic guide for ambulatory care Improve infection control practices (better financing
and clear organisation) Finance surveillance programmes on antibiotic use and
resistance in humans and animals
Belgium Media Campaigns: Switch from Threat to Negative Message
Actors: Ad hoc Working Group and “Question Santé/Omtrent Gezondheid”
Approach: Inform the public in general on the use and misuse of antibiotics and on the risk of bacterial resistance
Slogan: ”Use antibiotics less frequently but better”
Actors: Ad hoc Working Group and Social Marketing agency (Duval Guillaume, Antwerp)
Approach: Tackle directly the hot spots of unjustified antibiotic treatment: viral respiratory tract infections
Slogan: “Antibiotics don’t work against acute bronchitis, flu and common colds”
First 3 campaigns (2000–2003) Latter campaigns (2004 - 2008)
Belgiumwww.antibiotics-info.be
1999 - 2003 > 2004
Outpatient Antibiotic Use in BelgiumPackages per 1,000 inhabitants per day
1997 – 2006, July to June
97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06
0
0.5
1
1.5
2
2.5
3
3.5
4
Other J01 classes
Sulfonamides and tri-
methoprim (J01E)
Quinolones (J01M)
Macrolides, lincosamides
and streptogramins (J01F)
Tetracyclines (J01A)
Cephalosporins and other
beta-lactams (J01D)
Penicillins (J01C)
Pa
cka
ge
s p
er
10
00
inh
. pe
r d
ay
-32%
-1.0%-3.4%
-6.4%
-9.1%
-6.9%
-7.5%-3.8%
-3.6%
Ver
pakk
inge
n pe
r 1,
000
inw
oner
s pe
r da
g
Antibiotic Resistance of S. pneumoniae in Belgium. 1985 -
2007
0
5
10
15
20
25
30
35
40
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 1 2 3 4 5 6 7
Year
Pe
rce
nta
ge
peniG tetra erythro ofloxacine
National Reference Centre S. pneumoniae (University of Leuven)
Antibiotic Resistance of Throat Isolates of S. pyogenes in
Belgium. 2002 – 2007
0
2
4
6
8
10
12
14
16
18
2002 2003 2004 2005 2006 2007
year
per
cen
tage
erythromycin
National Reference Centre S. pyogenes (University of Antwerp)
Outpatient Antibiotic Use in EUR,
1997-2006
0
50
100
150
200
250
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
State Patients
EU
R, m
iljo
enen
169153
122
146139
123 108
174178170
5352 52 50
4645
44
39 4238
Outline of Presentation
Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance
• At population level
• At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions
Why do we need another awareness day?
Awareness days have shown to mobilise people, politicians, resources, ... (Drinking and Driving; AIDS Day)
Consolidate “healthy” situation of low antibiotic use and resistance (e.g. North) or reverse situation of emerging resistance (e.g. South)
Success of national campaigns in Belgium and France: reduction of antibiotic use and resistance in primary care and hospitals
Empty pipeline of new antibiotics; new rapid diagnostic tests not yet available
The EC supports many public health and research programmes which allow to measure the impact of campaigns and provide materials:
• ECDC: EARSS (antibiotic resistance), ESAC (antibiotic use), …
• DG SANCO: e-BUG (educational packs for children), …• DG RESEARCH: GRACE (qualitative research), CHAMP
(database on campaigns, questionnaires, economic impact), …EUROPE IS READY TO KICK OFF AN EU ANTIBIOTIC
DAY
How did we get here?
September 07: AMR focal group unanimously agreed on need for EU Antibiotic Day
October 07: Member States and MEPs support the idea of an EU Antibiotic Day
October 07: ECDC’s Director launches first EU Antibiotic Day for…18 November 2008
January 08: Installation of Technical Advisory Group at ECDC
March 08: Selection of logo, slogans, etc
What will be done?
By ECDC:• Development of slogan, logo & key messages
• Launch of public website
• Delivery of media toolkit
• Press conference in European Parliament on 18 November
By Member States:• Press conference with Health experts & AMR experts
• National conference on AMR involving doctors, pharmacists, vets & dentists
• Editorials in national medical journals
• Letter from Health Minister to all doctors
• Leaflets & posters for general public
• Development of in-school activities for children & parents
• TV spots
Suggested logo/slogan
Outline of Presentation
Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance
• At population level
• At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions
Conclusions: what can be done?First EU Antibiotic Day on November
18, 2008
• Reduce unnecessary antibiotic use (e.g. in patients with common colds and flu)
• Raise awareness that overuse of antibiotics will increase antibiotic resistance, through increasing awareness of the public (e.g. public campaigns), professsionals (e.g. undergraduate and postgradute education), and children (e.g. educational packs in schools).
• Ensure that public campaigns employ techniques of social marketing and use appropriate quality indicators and outcome measures, such as antibiotic use and resistance
• Monitor adverse effects associated with a reduction in antibiotic prescribing
• Support the use of rapid point-of-care diagnostic tests which result in reduced antibiotic prescribing
• Provide incentives for benchmarking of antibiotic prescribing in hospitals and nursing homes through quality indicators, such as Longitudinal and Point Prevalence Surveys
The European Union is making the Difference!
“The European Dream emphasizes community relationships over individual autonomy, cultural diversity over assimilation, quality of life over the accumulation of wealth, sustainable development over unilateral material growth, deep play over unrelenting toil, universal human rights and the rights of nature over property rights, over global cooperation over the unilateral exercise of power”
From: The European Dream, by Jeremy Rifkin