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Antibiotic use varies substantially among adults: a cross-national study from five European Countries in the ARITMO project

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An Erratum to this article was published on 10 September 2015

Abstract

Purpose

To examine patterns of outpatient and community antibiotic use among adults in five European countries.

Methods

We used healthcare data of 28.8 million adults from six population-based ARITMO project databases to ascertain information on systemic antibiotic use in Denmark (2000–2008), the Netherlands (1999–2010), Italy (2000–2010), the UK (1996–2009), and Germany (2004–2008). We estimated overall, and age-group and sex specific antibiotic use as defined daily doses (DDD) per 1000 inhabitants per day. We computed annual age- and sex-standardized population prevalence of antibiotic use per 1000 persons-years (p-y) and the mean duration (in days) of antibiotic use.

Results

The overall antibiotic use varied from 8.7 DDD per 1000 inhabitants per day in the UK to 18.1 DDD in Denmark, representing a 2.1-fold geographical variation. In all countries, prescribing was relatively high among individuals aged 15–19 years; lower in those aged 20–50 years; and then increased steadily reaching 41.8 DDD per 1000 inhabitants per day in individuals ≥85 years in Denmark. After age- and sex-standardization, prevalence of antibiotic use varied threefold from 160.2/1000 p-y in the UK to 421.1/1000 p-y in Italy. The ratio of broad- to narrow-spectrum penicillin, cephalosporin, and macrolide use varied from 0.6 in Denmark to 120.2 in Italy. Women used more antibiotics than men did in all countries. Across countries, the mean duration of antibiotic use varied 1.3 to 21.1-fold for different antibiotics.

Conclusions

Antibiotic use is high in women and the elderly. Prescribing patterns vary substantially across European countries, both according to overall consumption, user prevalence, duration, and narrow- versus broad-spectrum antibiotics.

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References

  1. The European Centre for Disease Prevention and Control (ECDC). Antimicrobial resistance surveillance in Europe: annual report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). 2013. http://www.ecdc.europa.eu/en/publications/Publications/antimicrobial-resistance-surveillance-europe-2012.pdf. Accessed 21 Nov 2014.

  2. World Health Organization 2014. Antimicrobial resistance: global report on surveillance. 2014. http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1. Accessed 23 June 2014.

  3. European Centre for Disease Prevention and Control. European Medicines Agency. The bacterial challenge: time to react. 2009. http://www.ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf. Accessed 20 Jan 2014.

  4. European Centre for Disease Prevention and Control. Surveillance of antimicrobial consumption in Europe 2011. Stockholm: ECDC; 2014. http://www.ecdc.europa.eu/en/publications/Publications/antimicrobial-consumption-europe-surveillance-2011.pdf. Accessed 21 Nov 2014.

  5. Versporten A, Coenen S, Adriaenssens N, Muller A, Minalu G, Faes C, et al. European Surveillance of Antimicrobial Consumption (ESAC): outpatient cephalosporin use in Europe (1997–2009). J Antimicrob Chemother. 2011;66:vi25–35.

    Article  CAS  PubMed  Google Scholar 

  6. Coenen S, Adriaenssens N, Versporten A, Muller A, Minalu G, Faes C, et al. European Surveillance of Antimicrobial Consumption (ESAC): outpatient use of tetracyclines, sulphonamides and trimethoprim, and other antibacterials in Europe (1997–2009). J Antimicrob Chemother. 2011;66:vi57–70.

    CAS  PubMed  Google Scholar 

  7. Sacchetti E, Trifiro G, Caputi A, Turrina C, Spina E, Cricelli C, et al. Risk of stroke with typical and atypical anti-psychotics: a retrospective cohort study including unexposed subjects. J Psychopharmacol. 2008;22:39–46.

    Article  PubMed  Google Scholar 

  8. Mazzaglia G, Mantovani LG, Sturkenboom MC, Filippi A, Trifiro G, Cricelli C, et al. Patterns of persistence with antihypertensive medications in newly diagnosed hypertensive patients in Italy: a retrospective cohort study in primary care. J Hypertens. 2005;23:2093–100.

    Article  CAS  PubMed  Google Scholar 

  9. Bourke A, Dattani H, Robinson M. Feasibility study and methodology to create a quality-evaluated database of primary care data. Inform Prim Care. 2004;12:171–7.

    PubMed  Google Scholar 

  10. Grant RL, Drennan VM, Rait G, Petersen I, Iliffe S. First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using the health improvement network primary care database. PLoS Med. 2013;10(8):e1001505.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Coloma PM, Schuemie MJ, Trifiro G, Gini R, Herings R, Hippisley-Cox J, et al. Combining electronic healthcare databases in Europe to allow for large-scale drug safety monitoring: the EU-ADR Project. Pharmacoepidemiol Drug Saf. 2011;20(1):1–11.

    Article  PubMed  Google Scholar 

  12. Trifiro G, Coloma PM, Rijnbeek PR, Romio S, Mosseveld B, Weibel D, et al. Combining multiple healthcare databases for postmarketing drug and vaccine safety surveillance: why and how? J Intern Med. 2014;275(6):551–61.

    Article  CAS  PubMed  Google Scholar 

  13. WHO Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) Classification System: Guidelines for ATC Classification and DDD Assignment 2011. http://www.whocc.no/filearchive/publications/2011guidelines.pdf. Accessed 14 Oct 2013.

  14. Weist K, ESAC-Net participants and the Antimicrobial Resistance and Healthcare-associated Infections (ARHAI) programme at ECDC. ECDC publishes its first data on antimicrobial consumption in Europe. Euro Surveill. 2013;7:20419.

  15. Vaccheri A, Bjerrum L, Resi D, Bergman U, Montanaro N. Antibiotic prescribing in general practice: striking differences between Italy (Ravenna) and Denmark (Funen). J Antimicrob Chemother. 2002;50:989–97.

    Article  CAS  PubMed  Google Scholar 

  16. Ternhag A, Hellman J. More on U.S. outpatient antibiotic prescribing, 2010. N Engl J Med. 2013;369:1175.

    Article  CAS  PubMed  Google Scholar 

  17. Huttner B, Harbarth S. Variations in outpatient antimicrobial use between and within countries: an ongoing mystery. Infection. 2010;38:1–2.

    Article  CAS  PubMed  Google Scholar 

  18. Veninga CC, Lundborg CS, Lagerlov P, Hummers-Pradier E, Denig P, Haaijer-Ruskamp FM. Treatment of uncomplicated urinary tract infections: exploring differences in adherence to guidelines between three European countries. Drug Education Project Group. Ann Pharmacother. 2000;34:19–26.

    Article  CAS  PubMed  Google Scholar 

  19. Cadieux G, Tamblyn R, Dauphinee D, Libman M. Predictors of inappropriate antibiotic prescribing among primary care physicians. CMAJ. 2007;177:877–83.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Wang KY, Seed P, Schofield P, Ibrahim S, Ashworth M. Which practices are high antibiotic prescribers? A cross-sectional analysis. Br J Gen Pract. 2009;59:e315–20.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–413.

    Article  PubMed  Google Scholar 

  22. Hulscher ME, van der Meer JW, Grol RP. Antibiotic use: how to improve it? Int J Med Microbiol. 2010;300(6):351–6.

    Article  PubMed  Google Scholar 

  23. Zhang Y, Steinman MA, Kaplan CM. Geographic variation in outpatient antibiotic prescribing among older adults. Arch Intern Med. 2012;172(19):1465–71.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Harbarth S, Albrich W, Brun-Buisson C. Outpatient antibiotic use and prevalence of antibiotic-resistant pneumococci in France and Germany: a sociocultural perspective. Emerg Infect Dis. 2002;8(12):1460–7.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Butler CC, Hood K, Verheij T, Little P, Melbye H, Nuttall J, et al. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ. 2009;338:b2242.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  26. Boggon R, Hubbard R, Smeeth L, Gulliford M, Cassell J, Eaton S, et al. Variability of antibiotic prescribing in patients with chronic obstructive pulmonary disease exacerbations: a cohort study. BMC Pulm Med. 2013;13:32.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Molstad S, Erntell M, Hanberger H, Melander E, Norman C, Skoog G, et al. Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme. Lancet Infect Dis. 2008;8(2):125–32.

    Article  CAS  PubMed  Google Scholar 

  28. Monnet DL, Molstad S, Cars O. Defined daily doses of antimicrobials reflect antimicrobial prescriptions in ambulatory care. J Antimicrob Chemother. 2004;53(6):1109–11.

    Article  CAS  PubMed  Google Scholar 

  29. Safrany N, Monnet DL. Antibiotics obtained without a prescription in Europe. Lancet Infect Dis. 2012;12(3):182–3.

    Article  PubMed  Google Scholar 

  30. Napolitano F, Izzo MT, Di Giuseppe G, Angelillo IF. Public knowledge, attitudes, and experience regarding the use of antibiotics in Italy. PLoS One. 2013;8(12):e84177.

    Article  PubMed Central  PubMed  Google Scholar 

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Acknowledgments

The current study is part of the EU-funded ARITMO study which aims to assess the utilisation and arrhythmogenic potential of antiinfectives, antihistamines and antipsychotics. ARITMO is a Research and Development project funded by the Health Area of the European Commission under the VII Framework Program (FP7/2007–2013) under Grant agreement no. 241679-the ARITMO project.

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

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Authors and Affiliations

  1. Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Olof Palmes Alle 43-45, Aarhus N, 8200, Aarhus, Denmark

    Anil Mor, Trine Frøslev, Reimar Wernich Thomsen & Mette Søgaard

  2. Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands

    Alessandro Oteri, Peter Rijnbeek, Miriam C. Sturkenboom & Gianluca Trifirò

  3. Leibniz Institute for Prevention Research and Epidemiology, BIPS, Bremen, Germany

    Tania Schink & Edeltraut Garbe

  4. Genomedics, Health Search, Florence, Italy

    Serena Pecchioli

  5. Health Search, Italian College of General Practitioners, Florence, Italy

    Francesco Innocenti

  6. PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands

    Irene Bezemer

  7. Department of Pharmacology, University of Bologna, Bologna, Italy

    Elisabetta Poluzzi

  8. Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy

    Gianluca Trifirò

Authors
  1. Anil Mor
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  2. Trine Frøslev
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  13. Gianluca Trifirò
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Corresponding author

Correspondence to Anil Mor.

Appendix

Appendix

See Tables 4, 5, 6, 7 and Figs. 5, 6, 7.

Table 4 Antibiotic use as DDDs per 1000 inhabitants per day in countries according to age groups
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Table 5 Age- and sex-standardized annual prevalence of antibiotic use per 1000 person-years according to antibiotic chemical substances
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Table 6 Mean duration of antibiotic chemical substances use (in days) per prescription according to country
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Table 7 Annual prevalence of broad- and narrow-spectrum penicillin, cephalosporin, and macrolides use per 1000 person-years
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Fig. 7
figure 7

Overall volume of antibiotics as DDDs per 1000 inhabitants per day by country and sex. DDDs defined daily doses, DID DDD per 1000 inhabitants per day, AUH Aarhus University Hospital, ERD Emilia-Romagnia regional database, GePaRD German Pharmacoepidemiological Research Database, THIN The Health improvement network

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Mor, A., Frøslev, T., Thomsen, R.W. et al. Antibiotic use varies substantially among adults: a cross-national study from five European Countries in the ARITMO project. Infection 43, 453–472 (2015). https://doi.org/10.1007/s15010-015-0768-8

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