European surveillance of antimicrobial consumption (ESAC): data collection performance and methodological approach

Antibiotic resistance in primary care in Austria - a systematic review of scientific and grey literature

Background

Antibiotic resistance is an increasing challenge for health care services worldwide. While up to 90% of antibiotics are being prescribed in the outpatient sector recommendations for the treatment of community-acquired infections are usually based on resistance findings from hospitalized patients. In context of the EU-project called "APRES - the appropriateness of prescribing antibiotic in primary health care in Europe with respect to antibiotic resistance" it was our aim to gain detailed information about the resistance data from Austria in both the scientific and the grey literature.

Methods

A systematic review was performed including scientific and grey literature published between 2000 and 2010. Inclusion and exclusion criteria were defined and the review process followed published recommendations.

Results

Seventeen scientific articles and 23 grey literature documents could be found. In contrast to the grey literature, the scientific publications describe only a small part of the resistance situation in the primary health care sector in Austria. Merely half of these publications contain data from the ambulatory sector exclusively but these data are older than ten years, are very heterogeneous concerning the observed time period, the number and origin of the isolates and the kind of bacteria analysed. The grey literature yields more comprehensive and up-to-date information of the content of interest. These sources are available in German only and are not easily accessible. The resistance situation described in the grey literature can be summarized as rather stable over the last two years. For Escherichia coli e.g. the highest antibiotic resistance rates can be seen with fluorochiniolones (19%) and trimethoprim/sulfamethoxazole (27%).

Conclusion

Comprehensive and up-to-date antibiotic resistance data of different pathogens isolated from the community level in Austria are presented. They could be found mainly in the grey literature, only few are published in peer-reviewed journals. The grey literature, therefore, is a very valuable source of relevant information. It could be speculated that the situation of published literature is similar in other countries as well.

A point prevalence survey of antibiotic use in four acute-care teaching hospitals utilizing the European Surveillance of Antimicrobial Consumption (ESAC) audit tool

The objective of this research was to assess current patterns of hospital antibiotic prescribing in Northern Ireland and to determine targets for improving the quality of antibiotic prescribing. A point prevalence survey was conducted in four acute teaching hospitals. The most commonly used antibiotics were combinations of penicillins including β-lactamase inhibitors (33·6%), metronidazole (9·1%), and macrolides (8·1%). The indication for treatment was recorded in 84·3% of the prescribing episodes. A small fraction (3·9%) of the surgical prophylactic antibiotic prescriptions was for >24 h. The results showed that overall 52·4% of the prescribed antibiotics were in compliance with the hospital antibiotic guidelines. The findings identified the following indicators as targets for quality improvement: indication recorded in patient notes, the duration of surgical prophylaxis and compliance with hospital antibiotic guidelines. The results strongly suggest that antibiotic use could be improved by taking steps to address the identified targets for quality improvement.

Cardiovascular and metabolic safety profiles of the fluoroquinolones

INTRODUCTION

Certain fluoroquinolones share similar indications of use. A comparison among Cardiovascular and metabolic (i.e., dysglycemia) safety profiles of the fluoroquinolones might be particularly useful for the prescribers' decision-making process as well as to hypothesize future researcher purposes.

AREAS COVERED

A literature search was conducted using keywords apt to identify information on safety profile of the fluoroquinolones. Publications concerned with descriptive and etiological surveys were manually reviewed.

EXPERT OPINION

Cardiac alterations and blood glucose impairments might be associated with any fluoroquinolone. However, the benefit/risk profile of these agents could be stratified for the single compounds. Several predisposing factors, such as diabetes, heart illnesses and their related pharmacotherapies, might exacerbate the risk of potentially serious adverse events. In this context, the opportunity of the more appropriate choice among different fluoroquinolones could be applicable.

Antimicrobial use and indication-based prescribing among general practitioners in Eastern Croatia: comparison with data from the European Surveillance of Antimicrobial Consumption project

AIM

To investigate antibiotic consumption in a sample of physicians from Osijek-Baranja county in Eastern Croatia and to determine the volume of prescribed antimicrobials and assess the appropriateness of prescribing practices.

METHODS

Analysis of routine prescribing data was carried out in 30 primary care practices in both urban and rural communities of eastern Croatia, corresponding to a total population of 48000 patients. Prescribing practices were studied over a period of 3 years, from 2003 to 2005. Both the quantity of antimicrobials and differences and similarities between individual practitioners were analyzed.

RESULTS

Urban and rural practices did not significantly differ in regard to the volume of antimicrobials prescribed. However, significant differences were found between individual physicians. Total consumption was 17.73 defined daily doses per 1000 inhabitants per day or 6456.85 defined daily doses per 1000 inhabitants per year. The 10 most frequently used antimicrobials (93.70% of the total quantity) were amoxicillin, co-amoxiclav, co-trimoxazole, cephalexin, norfloxacin, penicillin V, azithromycin, cefuroxime, doxycycline, and nitrofurantoin. Sore throat was the most frequent reason for prescribing antibiotics.

CONCLUSION

Prescription of medicines in Osijek-Baranja county was characterized by high consumption of broad-spectrum penicillins, combined penicillins, combined sulfonamides and long-acting macrolides (azithromycin), together with disproportionately low use of doxycycline and erythromycin. The use of combined sulfonamides and azithromycin in this part of Croatia was among the highest in Europe. Great differences between prescribers in regard to indication-based prescribing have been found, and future studies should examine the factors behind these heterogeneous practices.

Safety profile of the fluoroquinolones: analysis of adverse drug reactions in relation to prescription data using four regional pharmacovigilance databases in Italy

BACKGROUND

Fluoroquinolones are widely used both in primary care and in hospital settings. Since the last comparison performed in Italy on the safety profiles of different fluoroquinolones, a new molecule, prulifloxacin, has been introduced into the market and several warnings concerning this class of drugs have been released. The aim of this study was to reassess the safety profiles of fluoroquinolones using the database of the Italian Interregional Group of Pharmacovigilance (IGP) and the administrative data of fluoroquinolone prescriptions.

METHODS

All adverse drug reactions (ADRs) reported in four Italian regions (Lombardy, Veneto, Emilia Romagna and Tuscany) were retrieved from the IGP database. Consumption data (defined daily dose [DDD]/1000 inhabitants/day) were used as denominators. Both single reports and all ADRs (classified by System Organ Classes and MedDRA Preferred Term [PT]) due to fluoroquinolones were considered as numerators of each analysis, comparing two periods (2005 vs 2006). All fluoroquinolones with at least ten reports per year were included in the analysis.

RESULTS

On the basis of 272 reports (532 single ADRs or PTs), patients did not show any statistically significant differences between 2005 and 2006 in terms of sex, age and number of concurrent medications. After adjustment for drug consumption, moxifloxacin showed the highest reporting rate (84.6 reports/DDD/1000 inhabitants/day; 15.4 serious reports/DDD/1000 inhabitants/day) followed by prulifloxacin (72.2; 22.2 serious) and levofloxacin (55.3; 30.6 serious) in 2005. An increment of ADR/report rates was observed over the 2 years for all fluoroquinolones except prulifloxacin, which had the lowest ADR reporting rate in 2006 (25.0; 12.5 serious). In 2006, the rate of serious ADRs associated with prulifloxacin was lower than with ciprofloxacin, while in 2005 serious events were almost equal for both compounds (55.6 vs 47.6 serious ADRs/DDD/1000 inhabitants/day). Ciprofloxacin showed the highest proportion of cutaneous PTs (e.g. rash, exanthema). Tendinopathies were mainly due to levofloxacin.

CONCLUSIONS

These data suggest that different fluoroquinolones are characterized by different rates and types of ADRs. Among them, prulifloxacin was associated with more ADRs than other fluoroquinolones in 2005 but with fewer ADRs in 2006, when its consumption increased. Although these findings may represent an encouraging perspective towards a more appropriate use of fluoroquinolones because of their individual safety profiles, further pharmacoepidemiological studies must be performed to substantiate these results.

Prescribing patterns of antiparkinsonian agents in Europe

In the 1990 s, previous knowledge and randomized controlled trials supported the establishment of today's therapeutic recommendations in Parkinson's disease (PD). Scientific evidence allows different options for the treatment of PD. Patterns of use of antiparkinsonian agents (APA) across European countries may thus reflect these options. We wanted to describe patterns of use of APA in Europe and characterize the changes in prescription habits between 2003 and 2007. We investigated APA outpatient sales in 26 European countries where all commercially available APA were studied. Data for molecules and brand names were collected through IMS Health. Treatment per 1000 inhabitants daily (DID) was obtained from the WHO defined daily dose. Prescription pattern changes were evaluated by market share. Prescription patterns varied widely. In most countries, levodopa/dopamine agonists accounted for half of the drug use; whereas in others, anticholinergics, MAO inhibitors and amantadine prevailed. The greatest increase occurred with monoamine oxidase inhibitors and levodopa. There was an increase in dopamine agonists and a decrease in anticholinergics. For a 6.8% dose consume increase, there was a 41.1% sales increase (in euro). We showed an increase in the consumption of APA over 5 years. There was significant heterogeneity in the use of APA in Europe, suggesting differences in drug treatment. Costs of medication increased more than did dose consume, implying an increase in the cost of individual patient treatment. Published evidence does not explain the observed differences in the prescribing of APA.

["Look to Norway"--but for how long?]

Internationally, Norway receives positive attention mainly in the context of Winter Olympics or peace initiatives. However, an Associated Press article recently suggested that the Norwegian health care system had "found the Solution to Killer Superbug". Furthermore, Norway was proclaimed "The Most Infection Free Country in the World". What my be the reality behind such headlines, and how shall we as a nation maintain a favourable situation? Physicians in Scandinavian countries and the Netherlands have a long tradition for modest prescription of antibiotics, and are trained to use agents with a narrow antimicrobial spectre whenever possible. This is probably the main reason why these countries have had less antibiotic resistance than others. The number of antibiotics marketed in a country correlates positively with total drug consumption. Until 1992, Norwegian authorities could reject marketing of new compounds if national experts found no medical need for them. The foresight of senior colleagues has led to the number of marketed antibiotics in Norway, even today, being 10-fold lower than in some other European countries. The national surveillance programme, NORM, reports antimicrobial resistance in human pathogens on an annual basis. For example, national levels of MRSA and ESBL-producing Enterobacteriaceae are still very low whereas ampicillin and ciprofloxacin resistance in E coli and high- level gentamicin resistance in enterococci cause some concern. Norway has well-established epidemiological surveillance systems in the fields of microbiology and infectious diseases. Nevertheless, more knowledge is needed on how antibiotics are used in hospitals. Two national strategic plans (since 2003) have emphasized the explicit importance of antibiotic surveillance to counteract future antibiotic resistance problems. To fulfil national ambitions, there is an urgent need for economic grants to this field; the human resources are there and as eager to start as Olympic performers!

Socioeconomic determinants of outpatient antibiotic use in Europe

Objectives

Outpatient antibiotic consumption widely varies across Europe. The investigation of the causes of such variation may help to identify interventions that would improve the efficient use of antibiotics. The aim of this study was to assess the impact of socioeconomic determinants and the role played by information about bacterial resistance.

Methods

Comparable data on systemically administered antibiotics and socioeconomic determinants in 17 European countries were available between 2000 and 2005. We estimated an ad hoc econometric model by means of a hybrid log–log functional form and random effects generalised least squares regressions. Lagged values and the instrumental variable method were applied to address endogeneity of bacterial resistance and infections. Bacterial resistance was measured by the rate of penicillin non-susceptible Streptococcus pneumoniae isolates (PNSP) and methicillin-resistant Staphylococcus aureus (MRSA).

Results

The population income, demographic structure, density of general practitioners and their remuneration method appeared to be significant determinants of antibiotic consumption. Although countries with higher levels of bacterial resistance exhibited significantly higher levels of per capita antibiotic use, ceteris paribus, the responsiveness of antibiotic use to changes in bacterial resistance was relatively low (0.09–0.18).

Conclusions

The study confirms that socioeconomic factors should be taken into account while explaining differences in outpatient antibiotic use across countries. The impact of supply-side factors and incentives attached to payment schemes for physicians need to be considered in government interventions to reduce inequalities and improve effectiveness in antibiotic utilisation.

Comparison of sales and reimbursement data regarding outpatient antibiotic use in a northern Italian Region

PURPOSE

To evaluate the accuracy of systemic antibiotic use statistics, based on the reimbursement data of the Emilia-Romagna Region (Italy), focusing on agents prescribed for urinary tract infections.

METHODS

Reimbursement data were obtained from the drug prescription database that includes all outpatient drug prescriptions reimbursed by the Regional Health Service in 2007. Reimbursements were compared to sales data, provided by International Medical Statistics (IMS) Health.

RESULTS

The reimbursement data of the Emilia-Romagna Region significantly underestimates the actual use of systemic antibiotics when compared to sales. The overall underestimation of antibiotic use is 19%, ranging from 7% for second-third-generation cephalosporins to 98% for nitrofurantoin. Considering agents prescribed for urinary tract infections (UTIs), use of nitrofurantoin and sulfamethoxazole-trimethoprim are more underestimated while fluoroquinolones and fosfomycin are less underestimated than the average for systemic antibiotics.

CONCLUSIONS

Sales data from community pharmacies are important for accurate estimation of systemic antibiotic use in Emilia-Romagna especially for agents, such as nitrofurantoin, purchased without reimbursement in most cases.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient systemic antimycotic and antifungal use in Europe

OBJECTIVES

To assess the total outpatient systemic antimycotic and antifungal use in Europe, and to identify the antimycotic and antifungal substances most commonly used.

METHODS

Within ESAC (www.esac.ua.ac.be), using the anatomical therapeutic chemical (ATC) and defined daily dose (DDD) classification, data on outpatient use of all 14 antimycotics (12) and antifungals (2) for systemic use (ATC J02 and D01B, respectively), aggregated at the level of the active substance, were collected for 2007. Use was expressed in DDD (WHO ATC/DDD, version 2008) per 1000 inhabitants per day (DID). Only countries for which data on both J02 and D01B use were available were included in the analysis.

RESULTS

In 20 European countries (data for Cyprus and Estonia include hospital use), total outpatient systemic antimycotic and antifungal use varied by a factor of 6.7 between the country with the highest (3.03 DID in Belgium) and the country with the lowest (0.45 in Croatia) use. Terbinafine, ketoconazole, itraconazole and fluconazole represented >94% of the total outpatient antimycotic and antifungal use in all countries. Terbinafine use represented >50% of the total systemic antimycotic and antifungal use in 16 out of 20 countries (not in Croatia, Italy, Luxembourg and Bulgaria).

CONCLUSIONS

We present for the first time a standardized and validated data set of outpatient systemic antimycotic and antifungal use in Europe. Our study demonstrates a variation of antimycotic and antifungal use in Europe, as striking as that of antibiotic use. The ESAC data facilitate the auditing of antimycotic and antifungal prescribing, and the evaluation of the implementation of guidelines and public health policies to promote their judicious use.

Variation in outpatient antibiotic prescribing in the United States

OBJECTIVE

To evaluate variation in outpatient antibiotic utilization among US commercial health plans and the implications of this variation for cost and quality.

STUDY DESIGN AND METHODS

We measured antibiotic utilization rates among 229 US commercial health plans that participated in the 2005 Healthcare Effectiveness Data and Information Set. Rates were adjusted to account for health plan age and sex distribution. To estimate antibiotic costs, we multiplied utilization data for each drug class by national estimates of intraclass distribution of drugs, duration of therapy, and median average wholesale price.

RESULTS

Antibiotic utilization rates varied markedly among plans, ranging from 0.64 antibiotic fills per member per year (PMPY) at the 5th percentile of plans to 1.08 fills PMPY at the 95th percentile, with a mean of 0.88 (SD +/- 0.15) antibiotic fills PMPY. US census region was the strongest predictor of antibiotic utilization. Antibiotic costs averaged $49 PMPY and ranged from $34 to $63 PMPY among plans at the 5th and 95th percentiles of cost, respectively. If a health plan with 250,000 members at the 90th percentile of antibiotic costs reduced its costs to the 25th percentile, annual drug cost savings would be approximately $4.1 million.

CONCLUSIONS

Antibiotic utilization varies substantially among commercial health plans and is not accounted for by differences in the age and sex distribution of plan members. Because reducing rates of antibiotic utilization is likely to lower costs and improve quality, high-utilizing plans may reap considerable rewards from investing in programs to reduce the overuse of antibiotics.

The use of driving impairing medicines: a European survey

Aim

To analyse the consumption of a number of medicines with a known potential for increasing the risk of road traffic accidents in the general population of Europe.

Methods

Questionnaires were distributed through the European Drug Utilization Research Group (EuroDURG) and Post-Innovation Learning through Life-events of drugs (PILLS) networks. A total of 30 countries (the current EU Member States, Iceland, Norway and Switzerland) were asked to supply data on the use of driving impairing medicines for the period 2000–2005, aggregated at the level of the active substance and presented in Defined Daily Doses (DDDs) per 1000 inhabitants per day.

Results

National utilization data were provided by 12 of the 30 countries. Based on these data, a considerable increase in consumption was only seen for the antidepressants and the selective serotonin reuptake inhibitors. A slight increase, decrease or no increase was seen for the rest of the drugs studied (i.e. opioids, antipsychotics, anxiolytics, hypnotics and sedatives, drugs that are used in addictive disorders and antihistamines). Limitations were encountered when data on driving impairing medicines were compared between countries (e.g. variation in the data sources and providers, population coverage, inclusion of hospital data, use of divergent ATC/DDD versions) and, therefore, a cross-national comparison could not be performed.

Conclusions

During the study period, trends within countries showed slight to no increase in the consumption of selected medicinal drug groups, with the exception of the antidepressants and the selective serotonin reuptake inhibitors: they showed a remarkable increased use during the study time-frame. Our results illustrate that it is still difficult to perform a valid and comprehensive collection of drug utilization data on driving impairing medicines. Therefore, efforts to harmonize data collection techniques are required and recommended.

Antimicrobial drug use and resistance in Europe

Routine surveillance data indicate a relation between use and resistance and support interventions designed to reduce antimicrobial consumption at a national level in Europe.

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.

Exposure to antibacterial agents with QT liability in 14 European countries: trends over an 8-year period

AIMS

(i) To classify antibacterial agents with QT liability on the basis of the available evidence, and (ii) to assess trends in their consumption over an 8-year period (1998-2005) in 14 European countries.

METHODS

Current published evidence on QT liability of antibiotics was retrieved through MEDLINE search and joined to official warnings from regulatory agencies. Each drug was classified according to an already proposed algorithm based on the strength of evidence: from group A (any evidence) to group E (clinical reports of torsades de pointes and warnings on QT liability). Consumption data were provided by the European Surveillance of Antibacterial Consumption (ESAC) project and were expressed as defined daily doses per 1000 inhabitants per day (DID).

RESULTS

Among 21 detected compounds, nine [six fluoroquinolones (FQs) and three macrolides (MACs)] belonged to group E. Use of group E drugs ranged from 1.3 (Sweden) to 4.1 DID (Italy) in 1998 and from 1.2 (Sweden) to 6.5 DID (Italy) in 2005. Significant exposure was observed in Italy and Spain (6.5 and 3.8 DID, respectively, in 2005). Only Denmark, Sweden and UK showed a slight decrease in use. Exposure to clarithromycin increased in 10 out of 14 countries, with a marked increment in Italy (3 DID in 2005).

CONCLUSIONS

Notwithstanding regulatory measures, in 2005 there was still significant exposure to antibacterials with strong evidence of QT liability and, in most countries, it was even increased. This warrants further investigation of appropriateness of use and suggests closer monitoring of group E drugs. Physicians should be aware when prescribing them to susceptible patients.

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis

BACKGROUND

Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed.

RESEARCH DESIGN AND METHODS

We searched the Cochrane Collaboration's Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics.

RESULTS

Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair.

CONCLUSIONS

QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.

A comparison of antimicrobial usage in human and veterinary medicine in France from 1999 to 2005

OBJECTIVES

The antimicrobials allowed and amounts sold in veterinary and human medicine in France were compared to see if the same antimicrobial drugs are used in veterinary and human medicine, and to the same extent.

METHODS

Registers of all approved antimicrobial commercial products, kept by the French Agency for Veterinary Medicinal Products (AFSSA ANMV) for animals and the French Health Products Safety Agency (AFSSAPS) for humans, were compared to determine whether the same antimicrobials were approved in 2007 for use in both human and animal populations. Sales data were collected from pharmaceutical companies between 1999 and 2005 by the AFSSA ANMV and AFSSAPS. Usage of the different antimicrobial anatomical therapeutic chemical (ATC) classes in human and veterinary medicines was recorded. Data were expressed in tonnes of active ingredients and were then related to the animal and human biomasses to compare usages expressed in mg/kg.

RESULTS

All antimicrobial ATC classes were used in both human and veterinary medicine. Tetracyclines accounted for the most sales in veterinary medicine. beta-Lactams predominated in human medicine. A decrease in the amounts consumed by both human and animal populations was observed during the study. In 2005, 760 tonnes were used in human medicine and 1320 tonnes in veterinary medicine, corresponding to 199 and 84 mg/kg of live weight in human and animal populations, respectively.

CONCLUSIONS

The same antimicrobial drugs were used in human and veterinary medicines but the quantitative patterns of use were different. Expression of antimicrobial usage is a key point to address when comparing usage trends.

European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe

BACKGROUND AND OBJECTIVE

Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug-specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data.

METHODS

27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997-2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA-RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1-6 interval and if there was consensus (number of scores within the 1-3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators-values were updated with 2004 ESAC data.

RESULTS

22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected.

CONCLUSION

12 of the proposed ESAC-based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.

Large variation in antibacterial use among Norwegian nursing homes

A cross-sectional descriptive study among Norwegian nursing homes was conducted in 2003 to examine pharmacoepidemiological characteristics of antibacterials in nursing homes and also to estimate their share of overall antibacterial use in Norway. Antibacterial data were collected for ATC group J01 antibacterials for systemic use, A07AA09 vancomycin and P01AB01 metronidazole in DDDs/y. The amount of drugs principally prescribed for urinary tract infections (UTI) were depicted and used as an indicator for the treatment frequency for UTI in the nursing homes. Prescription of antibacterials in the 133 nursing homes that delivered data varied - from 4 to 44 DDD/100 bed-d. The urinary prophylactic agent, methenamine, represented nearly half of DDDs used, mean 7.3 DDD/100 bed-d. Penicillins with extended spectrum (J01CA) were most frequently used, followed by trimethoprim and sulfonamides (J01E), mean 2.3 and 1.5 DDD/100 bed-d, respectively. On average, 49% of the therapeutic antibacterials were drugs used for UTI, range 12%-88%. In 2003, the nursing home setting purchased an estimated 6% of human antibacterial use in Norway. Nursing homes represent an important share of national human use of antibacterials. The large variation in antibacterial use between facilities underlines the need for increased focus on rational prescribing in nursing homes.

[Lessons to be drawn from one year of surveillance of Escherichia coli in a urology department]

Escherichia coli (E. coli) is the micro-organism most frequently identified in urinary tract infections in adults. The authors analysed the nalidixic acid resistance rate of E. coli isolated over 12 consecutive months in a urology department.

MATERIAL AND METHOD

All E. coli-positive bacteriological examinations from a urology department during 2004 were retrospectively reviewed. Seventy five bacteriological examinations from 68 patients were positive for E. coli, corresponding to 67 urine cultures, 6 blood cultures and 2 drained collections. Twenty patients had taken fluoroquinolones during the previous 6 months and 10 patients were diabetic. A nalidixic acid-resistant (NR) E. coli was isolated in 11 patients (16%) aged 22 to 81 years (median: 58 years). Patients with nalidixic acid-resistant (NR) E. coli were compared to patients with nalidixic acid-susceptible (NS) E. coli.

RESULTS

Predictive factors for nalidixic acid resistance of E. coli were fever higher than 38.4 degrees C (p = 0.022), leukocytosis (p = 0.002) and use of fluoroquinolones during the previous 6 months (p = 0.046).

CONCLUSIONS

Prescription of a non-fluoroquinolone antibiotic may be preferable in the case of recent use of fluoroquinolones and signs of severe infection (leukocytosis and fever higher than 38.4 degrees C).

Antimicrobial use in Europe and antimicrobial resistance in Streptococcus pneumoniae

The study presented here determined the relationship between antimicrobial resistance in Streptococcus pneumoniae and the use of antimicrobial agents in 15 different European countries. Pneumococcal isolates (n = 1974) recovered from patients with community-acquired respiratory tract infections during the winter of 2004-2005 in 15 European countries were characterized. The overall percentages of isolates demonstrating intermediate or complete resistance to penicillin, erythromycin, tetracycline, trimethoprim-sulfamethoxazole (TMP-SMX) and ciprofloxacin were 24, 24.6, 19.8, 26.7 and 2%, respectively, as determined using the broth microdilution MIC method recommended by the Clinical and Laboratory Standards Institute. The overall and mean antimicrobial consumption levels (ACL)--i.e., the defined daily doses per 1,000 inhabitants per day--were obtained from the European Surveillance of Antimicrobial Consumption project for each of the 15 countries for the years 1998-2004. Using linear regression analysis, the mean annual ACL for beta-lactams, macrolides, tetracyclines, TMP-SMX and fluoroquinolones in each country was compared to the country-specific resistance rates determined in 2004-2005. The rate of overall antimicrobial use in all 15 European countries was significantly associated with antimicrobial resistance in S. pneumoniae. There was variation among the different antimicrobial classes as drivers of resistance, with beta-lactams having the strongest association.

Surveillance of outpatient antibiotic consumption in Spain according to sales data and reimbursement data

OBJECTIVES

National data on antibiotic consumption are needed in order to interpret trends in antibiotic resistance. We compared antibiotic prescription reimbursement data and sales data in Spain.

METHODS

Data covering the years 2002, 2004 and 2005 were examined. Reimbursement data for ambulatory care were provided by the Spanish Agency for Medicines and Healthcare Products and sales data by International Medical Statistics Health. Quantities were standardized using the defined daily dose per 1000 inhabitants per day (DID) in accordance with the anatomical therapeutic classification.

RESULTS

Sales data increased from 26.33 DID in 2002 to 28.12 DID in 2004 and 28.93 DID in 2005. Estimates based on equivalent reimbursement data were ~30% lower and increased from 18.01 DID in 2002 to 18.48 DID in 2004 and 19.29 DID in 2005. The differences were greatest for amoxicillin, amoxicillin/clavulanic acid, clarithromycin and cefuroxime.

CONCLUSIONS

Antibiotic consumption as estimated from reimbursement data is substantially less than that from sales data. This finding has major implications for national surveillance of antibiotic consumption.

Antifungal use in intensive care units

OBJECTIVES

To provide benchmarking data on antifungal use in intensive care units (ICUs), to analyse risk factors and to look for correlations with antibiotic use data and structure parameters.

METHODS

Antimicrobial use data for 13 ICUs were obtained from computerized databases from January 2004 through June 2005. Antimicrobial usage density (AD) is expressed as daily defined doses/1000 patient-days. Correlations were calculated by the Spearman correlation or for binomic variables by the two-sided Wilcoxon test. A multivariate regression analysis was performed to identify independent risk factors for the outcome 'antifungal use'.

RESULTS

Mean systemic antifungal drug use was 93.0, the range being between ADs of 18.9 and 232.2. ICUs treating transplant patients had a significantly higher mean antifungal usage at 152.9 compared with ICUs not treating transplant patients where the AD was 46.0. Fluconazole was the most frequently prescribed antifungal (mean AD 69.6) followed by amphotericin B (11.4) and voriconazole (6.2). Antifungal use correlated significantly with the consumption of quinolones, carbapenems and extended-spectrum penicillins, but not with total antibiotic use and not with the type of ICU or university status. In the multivariate linear regression analysis, two parameters, i.e. high quinolone use (P = 0.002) and ICUs which treat transplant patients (P = 0.027), were independent risk factors for a high level of antifungal use.

CONCLUSIONS

Antifungal use was heterogeneous in German ICUs with the mean AD lying at 93. Benchmarking data might provide a useful method for assessing strategies that aim to reduce antifungal use in ICUs. However, data should be stratified for ICUs with and without transplant patients.

Antibiotic use in ambulatory care in Europe (ESAC data 1997-2002): trends, regional differences and seasonal fluctuations

PURPOSE

The ESAC project (European Study on Antibiotic Consumption) aims to collect antibiotic-use data through a European network of national surveillance systems. This paper reports on the retrospective data collection in ambulatory care for the period 1997-2002.

METHODS

Valid data of antibiotic consumption of 24 European countries for 2002 and of 18 countries for the entire 6-year period was classified according to the Anatomical Therapeutic Chemical Classification (ATC) and expressed in defined daily dose (DDD) per 1000 inhabitants per day (DID). Overall and subgroup comparison of antibiotic consumption over time as well as between geographical clusters was performed.

RESULTS

Total use of antibiotics in Europe remained at a median level of 20 DID in the period 1997-2002 with a wide variation between countries ranging from 9.8 DID in The Netherlands to 32.2 DID in France. A substantial increase in subclass consumption of co-amoxiclav and fluoroquinolones was noted while the use of narrow-spectrum penicillins, erythromycin, quinolones and sulfonamides decreased. Total consumption as well as seasonal fluctuations showed remarkable geographical clustering with low consumption and low variation between summer and winter in the North, high consumption patterns in the South and a mixed model in the East.

CONCLUSIONS

Within the ESAC project, valid time series of antibiotic-use data are publicly available now, enabling to improve the study of determinants of use, the evaluation of governmental antibiotic consumption policies and the investigation of the associated emergence of antibiotic resistance.

Comparison of Outpatient Systemic Antibacterial Use in 2004 in the United States and 27 European Countries

The European Surveillance of Antimicrobial Consumption (ESAC) project collects data on antibacterial use in Europe, applying the Anatomic Therapeutic Chemical classification system and defined daily dose methodology, as recommended by the World Health Organization. Comparable data for the United States have been collected from IMS Health. The IMS Health sales data, processed according to ESAC methodology, suggest that outpatient antibacterial use in the United States is high (only 3 of 27 European countries used more) and is mainly characterized by a shift towards newer antibiotics.

Geographical stability of enterococcal antibiotic resistance profiles in Europe and its implications for the identification of fecal sources

This manuscript describes the use of a recently developed microbial source tracking (MST) technique to determine sources of fecal bacteria (enterococci) from four separate European countries. The investigation aimed to evaluate whether the origin of bacterial populations from France, Spain, and Sweden (n = 456) could be predicted using a library of antibiotic resistance patterns of enterococci of known origin assembled in the United Kingdom (n = 2739). Bacterial isolates were exposed to a battery of 31 antibiotic tests and classified into source groups using discriminant function analysis (DFA). Results showed that while on average 72% of the U.K. isolates could be correctly classified as originating from either municipal wastewater (MW), livestock, or wild birds, only 43% of non-U.K. isolates could be successfully classified into the same source categories. The results suggested that patterns of resistance amongst isolates contained in the U.K. library were not representative of those found in the other locations and that it may not be possible to share libraries over large distances, such as those in this study. Future MST studies using antibiotic resistance analysis (ARA) in Europe may therefore require the assembly of watershed specific libraries, increasing the cost of such studies.

Surveillance of antibiotic use in hospitals: methods, trends and targets

A standardised antibiotic surveillance system is an essential requirement of all antibiotic control strategies. Antibiotic use can be quantified accurately using patient-level surveillance, although this is not feasible for most hospitals. Instead, population-level surveillance is a more realistic alternative for ongoing and systematic monitoring of antibiotic use. Monitoring of aggregate, ward-supply data on a monthly basis, stratification by patient care area, and analysis by the anatomical therapeutic chemical/defined daily dose (ATC/DDD) system, adjusting for bed-occupancy, provides a clear picture of antibiotic consumption density and time-trends within a hospital. When usage rates are supplemented and interpreted according to changes in hospital resource indicators, benchmarking is facilitated. This provides an efficient tool for triggering and targeting antibiotic control interventions.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient penicillin use in Europe

BACKGROUND

Data on outpatient penicillin use in Europe were collected from 25 countries within the ESAC project, funded by DG SANCO of the European Commission, using the WHO ATC/DDD methodology.

METHODS

For the period 1997-2003, data on outpatient use of systemic penicillins aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Of the 'Penicillins' (J01C), outpatient use of narrow-spectrum penicillins (J01CE), broad-spectrum penicillins (J01CA), penicillinase-resistant penicillins (J01CF) and combinations with beta-lactamase inhibitors (J01CR) in 25 European countries was analysed in detail.

RESULTS

Total outpatient penicillin use in 2003 varied by a factor of 4 between the country with the highest (15.27 DID in Slovakia) and lowest use (3.86 DID in the Netherlands). Narrow-spectrum penicillins, broad-spectrum penicillins and combinations with beta-lactamase inhibitors were used most in 4, 12 and 9 countries, respectively. Penicillin use increased by more than 1 DID in nine countries, whereas it decreased by more than 1 DID in two countries (Czech Republic, France). An increase of the use of combinations with beta-lactamase inhibitors by more than 10% in 10 countries coincided with an equal decrease of broad-spectrum penicillins in seven countries and narrow-spectrum penicillins in three countries.

CONCLUSION

Penicillins represent the most widely used antibiotic class in all 25 participating countries; albeit with considerable variation of their use patterns. A distinct shift from narrow-spectrum penicillins to broad-spectrum penicillins, and specifically their combinations with beta-lactamase inhibitors, was observed during the period 1997-2003.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe

BACKGROUND

The ESAC project, granted by DG SANCO of the European Commission, is an international network of surveillance systems, aiming to collect comparable and reliable data on antibiotic use in Europe. Data on outpatient antibiotic use were collected from 34 countries using the ATC/DDD methodology.

METHODS

For the period 1997-2003, data on outpatient use of systemic antibiotics aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Outpatient antibiotic (ATC J01) use in 25 European countries, able to deliver valid data, was analysed.

RESULTS

Total outpatient antibiotic use in 2003 varied by a factor of 3 between the country with the highest (31.4 DID in Greece) and the country with the lowest (9.8 DID in the Netherlands) use. General use patterns in individual countries as well as trends during the period 1997-2003 are described in this paper, while major antibiotic classes (penicillins, cephalosporins, macrolides/lincosamides/streptogramins and quinolones) will be analysed in detail in separate papers.

CONCLUSION

The ESAC project established for the first time a credible alternative to industry sources for the collection of internationally comparable data on antibiotic use in Europe, based on cooperation between regulatory authorities, scientific societies, health insurers and professional organizations. These data provide a tool for assessing public health strategies aiming to optimize antibiotic prescribing.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient cephalosporin use in Europe

BACKGROUND

Data on outpatient cephalosporin use in Europe were collected from 25 countries within the ESAC project, funded by DG SANCO of the European Commission, using the WHO ATC/DDD methodology.

METHODS

For the period 1997-2003, data on outpatient use of systemic cephalosporins aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Use was analysed in detail, using the new ATC codes J01DB, J01DC, J01DD and J01DE, introduced in the 2005 issue of the WHO ATC index and assigned to the four cephalosporin generations.

RESULTS

Total outpatient cephalosporin use in 2003 varied by a factor of 270 between the country with the highest (6.18 DID in Greece) and lowest (0.02 DID in Denmark) use. First-, second- and third-generation cephalosporins were used most in 6, 16 and 3 countries, respectively. We observed fourth-generation use (mainly cefepime) in ambulatory care in 11 countries. From 1997 to 2003 cephalosporin use decreased in 13 countries, in France by more than 1 DID. A relative increase of second-generation (mainly cefuroxime) or third-generation use (mainly cefpodoxime or cefixime) by more than 10% in 12 countries coincided with an equally large decrease of first-generation use in eight countries (mainly cefadroxil, cefalexin or cefatrizine). In six countries, first-generation use increased, second-generation use decreased or both occurred.

CONCLUSION

The new ATC codes allow a more detailed description of outpatient cephalosporin use. The variation in antibiotic use in Europe is most extreme for this class of antibiotics, suggesting that in many countries in Europe these antibiotics are prescribed inappropriately.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient quinolone use in Europe

BACKGROUND

Data on outpatient quinolone use in Europe were collected from 25 countries within the ESAC project, funded by DG SANCO of the European Commission, using the WHO ATC/DDD methodology.

METHODS

For the period 1997-2003, data on outpatient use of systemic quinolones aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Because a new DDD for levofloxacin was published in the ATC 2004 index (0.5 g instead of 0.25 g) all data were recalculated accordingly. Quinolone use was analysed in detail, using a classification into three generations based on their pharmacokinetic and in vitro potency profiles, which determines the area of clinical use.

RESULTS

Total outpatient quinolone use in 2003 varied by a factor of 12 between the country with the highest (3.10 DID in Portugal) and lowest (0.25 DID in Denmark) quinolone use. The second-generation quinolones represented more than 50% of the quinolone use (mainly ciprofloxacin) except for Croatia, where the first-generation was used most (mainly norfloxacin). In 22 countries, the use of second and/or third-generation quinolones increased at the expense of the use of first-generation quinolones. The new so-called respiratory quinolones (levofloxacin and moxifloxacin) represented more than 10% of quinolone use in 12 countries, with extreme seasonal variation in all these countries except for one.

CONCLUSION

There has been a substantial change in the use pattern of quinolones between 1997 and 2003, since the introduction of quinolones that are effective for the treatment of respiratory tract infections. These quinolones are not the first-line antibiotics for this indication and therefore quinolone use should in general still be limited and not show substantial seasonal variation.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient macrolide, lincosamide and streptogramin (MLS) use in Europe

BACKGROUND

Data on outpatient macrolide, lincosamide and streptogramin (MLS) use in Europe were collected from 25 countries within the ESAC project, funded by DG SANCO of the European Commission, using the WHO ATC/DDD methodology.

METHODS

For the period 1997-2003, data on outpatient use of systemic MLS aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Macrolide use was analysed in detail, using a classification based on their mean plasma elimination half-life.

RESULTS

Total outpatient MLS use in 2003 varied by a factor of 11 between the country with the highest (9.36 DID in Greece) and lowest (0.85 DID in Sweden) use. MLS use showed high seasonal variation. Short-, intermediate- and long-acting macrolides were used most in 6, 18 and 1 countries, respectively (mainly erythromycin, clarithromyin and azithromycin, respectively). Lincosamide use was observed in all countries (mainly clindamycin) and substantial streptogramin use only in France (pristinamycin). From 1997 to 2003, MLS use increased in 14 countries and was most pronounced in Greece (increase of >5 DID). Except for Sweden, a relative increase of intermediate- (mainly clarithromycin) and/or long-acting (mainly azithromycin) macrolide use was observed, at the expense of short-acting macrolide (mainly erythromycin) use.

CONCLUSION

The observed differences between European countries in the levels of MLS use and the extreme seasonal variations in their use suggest that this class of antibiotics is prescribed inappropriately in many countries. The MLS classification developed here facilitates a more comprehensive description of macrolide use in Europe. These data (collected as part of ESAC) could promote investigations that lead to a deeper understanding of the link between macrolide use and resistance.

Hospital consumption of antibiotics in 15 European countries: results of the ESAC Retrospective Data Collection (1997–2002)

OBJECTIVES

To collect reliable, comparable and publicly available data on hospital use of antibiotics in Europe aggregated at the national level (1997-2002).

METHODS

Consumption data of systemic antibiotics in Anatomical Therapeutic Chemical (ATC) class J01 were collected and expressed in defined daily doses (DDD) per 1000 inhabitants per day. Valid data for 2002 were available for 15 countries, and 6 year trends for 10 countries. Comparison with ambulatory care (AC) consumption data was possible in 14 countries.

RESULTS

In 2002, median national hospital antibiotic consumption in Europe was 2.1 DDD/1000 inhabitants/day in Europe, ranging from 3.9 in Finland and France to 1.3 in Norway and Sweden. Hospital care (HC) consumption as a proportion of total antibiotic consumption ranged from 17.8% to 6.4%. The consumption of hospital-specific antibiotics ranged from 0.43 DDD/1000 inhabitants/day in Greece and 0.08 in Sweden. Six-year trends in consumption were stable, except for rising co-amoxiclav exposure and more rapid market penetration of new antibiotics (e.g. levofloxacin) in some countries. There was a strong, positive correlation between the extent of antibiotic use in AC and in HC (Spearman coefficient 0.745; P = 0.002), both for overall use and for use of five main classes (not macrolides and 'others'). In contrast to AC consumption no substantial seasonal variation in consumption was observed.

CONCLUSIONS

It was cumbersome but feasible to collect ecological data on hospital antibiotic consumption in a set of 15 European countries on a retrospective basis, illustrating substantial cross-national variations in the extent and distribution of exposure to antibiotics in hospital care.

Outpatient use of systemic antibiotics in Croatia

According to the results of the European Surveillance of Antimicrobial Consumption (ESAC), outpatient antibiotic use in Croatia in 2001 (17.6 DDD per 1000 inhabitants per day) was comparable to the median use of 24 European countries, which were able to deliver valid data.

The history of the Drug Utilization Research Group in Europe

Following the recommendations from a World Health Organization (WHO)/Euro symposium Consumption of drugs in 1969, a common classification system for drugs was developed, the Anatomical Therapeutic Chemical (ATC), and a technical unit of comparison, the Defined Daily Dose (DDD), as a comparative unit of drug use. This was found to be robust across therapeutic classifications, dosing forms and diverse populations. To maintain and develop the ATC/DDD system a WHO-Collaborating Centre was established in Oslo. As this was found to be of global interest the centre now reports to the WHO headquarters in Geneva. An informal WHO Drug Utilization Research Group (WHO-DURG), later the EuroDURG, has by now met 28 times in Europe. Since 1994 in Stockholm all these meetings have been with ISPE (International Society for Pharmacoepidemiology) when meeting in Europe. The main focus was initially to improve drug utilization through cross-national drug utilization studies based on the ATC/DDD methodology as they revealed large differences between and within countries that could not easily be explained by morbidity differences alone. These observed differences have led to the expansion of the area to include social, economic and qualitative methods with a more generalized public health focus. One of the most recent contributions was the development of drug use quality indicators.

The more antibacterial trade names, the more consumption of antibacterials: a European study

Recent studies have shown large differences in the use of antibacterial agents among European countries. We found a relationship between community consumption and the number of trade names of oral antibacterial agents. This relationship was observed in countries in which consumption was high, as well as in countries in which it was low, and in markets that were opened or were not opened to the sale of copies of original agents.

Molecular epidemiology of macrolide-resistant Streptococcus pneumoniae isolates in Europe

In many European countries, the level of pneumococcal resistance to macrolides has now passed the level of resistance to penicillin G. A total of 82 erythromycin A-resistant isolates of Streptococcus pneumoniae were collected by 11 laboratories in seven European countries. All of the isolates were tested for antimicrobial susceptibility, analyzed for clonal relatedness by multilocus sequence typing, and characterized for macrolide resistance genotypes. The prevalence of the macrolide resistance genotypes varied substantially between countries. In France (87.5% of all strains), Spain (77.3%), Switzerland (80%), and Poland (100%), strains were predominantly erm(B) positive, whereas higher levels of mef(A)-positive strains were reported from Greece (100%) and Germany (33.3%). Macrolide resistance was caused by the oligoclonal spread of some multilocus sequence types, but significant differences in clonal distribution were noted between France and Spain, countries from which high levels of macrolide resistance have been reported. Overall, sequence type 81 (Spain23F-1 clone) was by far the most widespread. The mainly erm(B)-positive serotype 14 clone (sequence type 143), first reported in Poland in the mid-1990s, is now widespread in France.

Outpatient antibiotic use in Europe and association with resistance: a cross-national database study

BACKGROUND

Resistance to antibiotics is a major public-health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Our aim was to assess outpatient use of antibiotics and the association with resistance.

METHODS

We investigated outpatient antibiotic use in 26 countries in Europe that provided internationally comparable distribution or reimbursement data, between Jan 1, 1997, and Dec 31, 2002, by calculating the number of defined daily doses (DDD) per 1000 inhabitants per day, according to WHO anatomic therapeutic chemical classification and DDD measurement methodology. We assessed the ecological association between antibiotic use and antibiotic resistance rates using Spearman's correlation coefficients.

FINDINGS

Prescription of antibiotics in primary care in Europe varied greatly; the highest rate was in France (32.2 DDD per 1000 inhabitants daily) and the lowest was in the Netherlands (10.0 DDD per 1000 inhabitants daily). We noted a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics. We also recorded striking seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics. We showed higher rates of antibiotic resistance in high consuming countries, probably related to the higher consumption in southern and eastern Europe than in northern Europe.

INTERPRETATION

These data might provide a useful method for assessing public-health strategies that aim to reduce antibiotic use and resistance levels.

Indicators of prescribing quality in drug utilisation research: report of a European meeting (DURQUIM, 13-15 May 2004)

An invitational expert meeting on indicators of prescribing quality was held on 13-15 May 2004, bringing together--from 19 European countries, the US, Canada, and Australia--40 researchers specialized in the development and application of indicators. The meeting was organized by the European Drug Utilization Research Group (EuroDURG), the Belgian National Health Insurance Institute (RIZIV-INAMI), and the World Health Organisation Regional Office for Europe (WHO-Euro). The field of prescribing quality was defined and delineated from the medical error field. A conceptual grid for classifying quality indicators was discussed, combining two axes (a drug/disease/patient axis and a structure/process/outcome axis). In addition, available databases were listed for continuous monitoring of drug utilization in Europe, with a description of the content and the richness of the collected data, as well as the impact on the potential and limitations to develop quality indicators. The importance of the origin of data for validity assessment was stressed, as data on drug utilization may originate from physician sources (prescribing data), from pharmacist or health insurer sources (distribution data), or directly from patient sources (compliance data). The different aspects of validity and their methods of assessment were listed. An overview of the (in)appropriate uses of indicators was given. The state of the art of the development and application of prescribing quality indicators in all represented countries was made, together with a first draft of a database of prescribing quality indicators, already subjected to validation procedures.