Cecilia Stålsby Lundborg

Self-medication with antimicrobial drugs in Europe

Antimicrobial drug self-medication occurs most often in eastern and southern Europe and least often in northern and western Europe.

Meeting the challenge of antibiotic resistance.

A concerted global response is needed to tackle rising rates of antibiotic resistance, say Otto Cars and colleagues

Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and the healthcare system

BACKGROUND Self-medication with antibiotics occurs among the population in Europe, particularly in southern and eastern countries. We studied the impact of predisposing factors (e.g. attitudes and knowledge concerning antibiotic use and self-medication) and enabling factors (country wealth and healthcare system factors) on self-medication with antibiotics in Europe. METHODS In this follow-up of a previous European survey, we interviewed a subsample of 1101 respondents. A multilevel analysis with two levels (respondent and country) was performed. Variables that were statistically significantly different between users and non-users of self-medication were considered for inclusion into the multilevel regression analyses. RESULTS Predisposing factors included individual-level characteristics. High perceived appropriateness of self-medication with antibiotics for bronchitis and an attitude favouring antibiotic use for minor ailments were related to a higher likelihood of self-medication. Enabling factors included individual and country data. At the individual level, perceived availability of antibiotics without a prescription was related to increased probability of self-medication. At the country level, higher gross domestic product (wealth) and exact dispensation of prescribed tablet quantities by pharmacies were independently associated with lower likelihood of self-medication. CONCLUSIONS Interventions aimed at preventing self-medication should include public education, enforcing regulations regarding the sale of antibiotics, and implementing laws for dispensing exact prescribed tablet quantities in pharmacies. With the included determinants, we explained almost all the variance at the country level, but not at the individual level. Future studies to increase our understanding of determinants of self-medication with antibiotics should focus on individual-level factors such as doctor-patient relationships and patient satisfaction.

Antibiotic Prescription Rates Vary Markedly Between 13 European Countries

There is a lack of data on antibiotic utilization in most European countries. In this study, information about the number of antibiotic prescriptions was obtained for Austria, Belgium, Finland, France, Germany, Greece, Italy, The Netherlands, Portugal, Spain and the UK from the Institute for Medical Statistics Health Global Services in the UK. For Denmark and Sweden the information was obtained from the Danish Medicines Agency (Laegemiddelstyrelsen) and the National Corporation of Swedish Pharmacies (Apoteket AB), respectively. Between 1994 and 1997 the number of prescriptions per 1,000 inhabitants increased in France and Greece whilst Portugal, Spain and Sweden reported a decrease. In 1997, Greece (1,350), Spain (1,320) and Belgium (1,070) had the highest numbers of antibiotic prescriptions per 1,000 inhabitants in the Anatomical Therapeutic Chemical classification system for drugs group J01 while The Netherlands (390), Sweden (460) and Austria (480) had the lowest. The most common antibiotic drug was extended-spectrum penicillin in 6/13 countries, macrolides in Austria, Finland, Germany and Italy, phenoxymethylpenicillin in Denmark and Sweden and cephalosporins in Greece. The variation in the number of antibiotic prescriptions per 1,000 inhabitants between the 13 European countries was substantial in terms of both total use and use of different antibiotics.

Antibiotics and antibiotic-resistant bacteria in waters associated with a hospital in Ujjain, India

BackgroundConcerns have been raised about the public health implications of the presence of antibiotic residues in the aquatic environment and their effect on the development of bacterial resistance. While there is information on antibiotic residue levels in hospital effluent from some other countries, information on antibiotic residue levels in effluent from Indian hospitals is not available. Also, concurrent studies on antibiotic prescription quantity in a hospital and antibiotic residue levels and resistant bacteria in the effluent of the same hospital are few. Therefore, we quantified antibiotic residues in waters associated with a hospital in India and assessed their association, if any, with quantities of antibiotic prescribed in the hospital and the susceptibility of Escherichia coli found in the hospital effluent.MethodsThis cross-sectional study was conducted in a teaching hospital outside the city of Ujjain in India. Seven antibiotics - amoxicillin, ceftriaxone, amikacin, ofloxacin, ciprofloxacin, norfloxacin and levofloxacin - were selected. Prescribed quantities were obtained from hospital records. The samples of the hospital associated water were analysed for the above mentioned antibiotics using well developed and validated liquid chromatography/tandem mass spectrometry technique after selectively isolating the analytes from the matrix using solid phase extraction. Escherichia coli isolates from these waters were tested for antibiotic susceptibility, by standard Kirby Bauer disc diffusion method using Clinical and Laboratory Standard Institute breakpoints.ResultsCiprofloxacin was the highest prescribed antibiotic in the hospital and its residue levels in the hospital wastewater were also the highest. In samples of the municipal water supply and the groundwater, no antibiotics were detected. There was a positive correlation between the quantity of antibiotics prescribed in the hospital and antibiotic residue levels in the hospital wastewater. Wastewater samples collected in the afternoon contained both a higher number and higher levels of antibiotics compared to samples collected in the morning hours. No amikacin was found in the wastewater, but E.coli isolates from all wastewater samples were resistant to amikacin. Although ciprofloxacin was the most prevalent antibiotic detected in the wastewater, E.coli was not resistant to it.ConclusionsAntibiotics are entering the aquatic environment of countries like India through hospital effluent. In-depth studies are needed to establish the correlation, if any, between the quantities of antibiotics prescribed in hospitals and the levels of antibiotic residues found in hospital effluent. Further, the effect of this on the development of bacterial resistance in the environment and its subsequent public health impact need thorough assessment.

Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe?

BackgroundAntibiotics are widely-used medicines for which a more prudent use has been advocated to minimize development of resistance. There are considerable cross-national differences that can only partially be explained by epidemiological difference and variations in health care structure. The aim of this study was to explore whether cross-national differences in use of antibiotics (prescribed and non-prescribed) are associated with differences between national cultures as described in Hofstedes model of cultural dimensions (Power Distance, Individualism, Masculinity, Uncertainty Avoidance and Long-Term Orientation).MethodsCountry-level data of prescribed antibiotic use and self-medication with antibiotics were correlated to country-specific scores of cultural dimensions obtained from Hofstede. Data on use of antibiotics were provided by three European studies, based on different methods and/or countries: Self-medication with Antibiotics and Resistance in Europe (SAR), based on a survey in 2003 on reported use of antibiotics in 19 countries, the European Surveillance on Antimicrobial Consumption, based on distribution and reimbursement of antibiotics in ambulatory care (1997–2002), and the 2002 interview-based Eurobarometer study, asking whether respondents had taken antibiotics in the previous 12 months. These studies provided data on antibiotics use for 27 European countries in total, for which scores of cultural dimensions were also available. The SAR-study differentiated between prescribed antibiotics and self-medication with antibiotics.ResultsSignificant positive correlations were found for Power Distance Index with use of prescribed antibiotics in the three studies (rho between 0.59 and 0.62) and with self-medication (rho = 0.54) in the SAR study. Positive significant correlations were found for the Uncertainty Avoidance Index with the use of antibiotics as reported in two studies (rho between 0.57 and 0.59; for the SAR study the correlations were insignificant). Masculinity was not significantly correlated, except in one study after controlling for GDP (r = 0.81). For Individualism and Long-Term Orientation no significant correlations were found.ConclusionPower Distance is a cultural aspect associated with antibiotic use, suggesting that the culture-specific way people deal with authority is an important factor in explaining cross-national differences in antibiotic use. There are indications that Uncertainty Avoidance also plays a role but further research is needed to better understand the complex effect of cultural dimensions.

Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries.

BackgroundLittle is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO4) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case).MethodsWe used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data.FindingsPrior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO4 and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO4 than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO4, and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries.ConclusionTranslating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.

Diagnosis-prescribing surveys in 2000, 2002 and 2005 in Swedish general practice: Consultations, diagnosis, diagnostics and treatment choices

The aim of this study is to present diagnostic patterns, diagnostics used and antibiotic treatment in relation to guidelines in 3 repeated diagnosis-prescription studies conducted simultaneously in general practice in 5 Swedish counties, during 1 week in November 2000, 2002 and 2005. General practitioners (GPs) at the participating health centres were asked to complete a form for all patients with symptoms of an infectious disease. During the studied periods a total of 15,371 consultations was registered. Consultations with GPs diagnosed as respiratory tract infection (RTI), especially consultations for sore throat, decreased considerably between y 2000 and 2005. The percentage of patients allocated an RTI diagnosis and prescribed an antibiotic declined significantly from 54% to 49% and the decline was most pronounced among children. Penicillin V remained the dominant antibiotic prescribed throughout the study periods. For lower urinary tract infections there was a significant change in choice of prescribed antibiotics with an increase for pivmecillinam and nitrofurantoin and a decrease for trimethoprim, in accordance with recommendations. The results indicate a quite close adherence to current guidelines, with changes in the pattern of consultations as well as in the management of infectious diseases in general practice in Sweden.

Infections and antibiotic prescribing in Swedish nursing homes: A cross-sectional study

The aim of this study was to present and assess the treatment of infections in Swedish nursing homes. It included 58 nursing homes with 3002 residents. During 3 months, nurses in the nursing homes recorded all infections requiring a physicians opinion. Of the 889 infectious episodes, 84% were treated with antibiotics. Many of the antibiotics were issued after indirect contact with the physician (38%). Indications for antibiotics were in 55% of the cases urinary tract infections (UTI), in 17% skin and soft-tissue infections and in 15% respiratory tract infections (RTI). The most common antibiotics were penicillins (38%), followed by quinolones (23%) and trimethoprim (18%). For the major indication, lower UTI in women, half of the cases were not treated according to the recommendations. The main concerns were length of treatment and overprescribing of quinolones. For the second major diagnosis, pneumonia, the high use of doxycycline could be questioned. Continuing education on infections and their treatment in nursing homes is needed. Training should preferably include both physicians and nurses as a high proportion of antibiotics is issued without direct contact with the physician.

Antibiotic prescribing in outpatients : a 1-week diagnosis-prescribing study in 5 counties in Sweden.

A diagnosis-antibiotic prescribing study initiated by the Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance was performed in 5 counties in Sweden (total 1,290,000 inhabitants) during 1 week in November 2000. The aims of the study were to analyse diagnoses and antibiotics prescribed for outpatients and to appraise the feasibility of the data collection method. Physicians in primary care and departments of ENT, paediatrics and infectious diseases completed a questionnaire for each patient with an infectious disease complaint, including information about age, sex, diagnosis, diagnostic methods used and treatment. When an antibiotic was prescribed, the type and duration of treatment were noted. A total of 7,071 forms were returned, of which 7,029 included information on diagnosis; infections of the respiratory tract, urinary tract and the skin or soft tissues were responsible for 70%, 14% and 10% of the visits, respectively. Antibiotics were prescribed in 59% of all cases and phenoxymethylpenicillin was the most commonly prescribed antibiotic. Of the forms returned, 94% emanated from primary care centres. In conclusion, this study provides information on the treatment pattern associated with various diagnoses and the pattern of use of various antibiotics. Such a study is relatively simple to perform and entails only a small extra workload for the participants.