Antibiotic policies in Central Eastern Europe

Analysis of citizens' subjective perception of safe antibiotic use in European Union countries

OBJECTIVES

Antibiotic consumption is high and varies between different European Union countries. One of the reasons could be different subjective perception of safe antibiotic use. The aim of our study was to analyse citizens' subjective perception of safe antibiotic use in the European Union countries in the context of different antibiotic policies. Some countries are prepared comprehensive national strategies and action plans and implement many activities in different areas while other countries implement actions only in particular fields and even do not have prepared strategy or action plan.

METHODS

This article is based on conception of security by Barry Buzan. Variables collected from the Special Eurobarometer public opinion on Antimicrobial Resistance in European Union countries in 2016 were used for creation the factor of subjective perception of safe antibiotic use. Six contextual factors were selected from the scientific literature and their impact on subjective perception of safe antibiotic use was investigated.

RESULTS

High differences in subjective perception of safe antibiotic use were observed in countries despite general European Union recommendations on antibiotic policy. The highest subjective perception of safe antibiotic use was in Netherlands, Finland, Sweden, Luxembourg, and Denmark. Significant negative correlation was observed between factor of subjective perception of safe antibiotic use and antibiotic consumption (r=-0.41, p<0.05). Created factor of information and communication technology (ICT) development, gross domestic product (GDP) and health expenditure had impact on subjective perception of safe antibiotic use (t=4.69, p<0.01). Consumption of antibiotics also had influence on subjective perception of safe antibiotic use (t=-2.43, p<0.05).

CONCLUSIONS

Individuals' subjective perception of safe antibiotic use which is related to antibiotic consumption highly varies between different EU countries despite general EU recommendations on antibiotic policies and depends on ICT development, GDP, health expenditure and consumption of antibiotics.

Analysis of global prevalence of antibiotic resistance in Acinetobacter baumannii infections disclosed a faster increase in OECD countries

Acinetobacter baumannii is one of the most challenging nosocomial pathogens due to the emergence and widespread of antibiotic resistance. We aimed to provide the first analysis of global prevalence of antibiotic resistance in A. baumannii infections, by synthesizing data and knowledge through a systematic review. We searched studies reporting antibiotic resistance in A. baumannii infections using the Medline, Embase, Web of Science, and Cochrane databases from January 2000 to December 2016. Studies were eligible if they investigated and reported antibiotic resistance in A. baumannii infections with inpatients or outpatients in hospital. Our investigation showed a high prevalence of resistance to the common prescribed antibiotics in A. baumannii infections in both OECD (Organization for Economic Co-operation and Development) and non-OECD countries. Strikingly, though OECD countries have substantially lower pooled prevalence of resistance compared to non-OECD countries based on the data during 2006-2016, a further investigation in a time scale disclosed a faster increase in OECD countries during the past 11 years, and currently both of them have a comparable prevalence of resistance (2011-2016). Tigecycline and colistin are still active but their resistances are expected to become common if the preventative measures are not taken. Antibiotic resistance in A. baumannii infection developed fast and is a crisis for both OECD and non-OECD countries. A "post-antibiotic era" for A. baumannii infection is expected in the next 10-20 years without immediate actions from pharmaceutical companies and governments.

Faecal carriage of antibiotic resistant Escherichia coli in asymptomatic children and associations with primary care antibiotic prescribing: a systematic review and meta-analysis

Background

The faecal reservoir provides optimal conditions for the transmission of resistance genes within and between bacterial species. As key transmitters of infection within communities, children are likely important contributors to endemic community resistance. We sought to determine the prevalence of antibiotic-resistant faecal Escherichia coli from asymptomatic children aged between 0 and 17 years worldwide, and investigate the impact of routinely prescribed primary care antibiotics to that resistance.

Methods

A systematic search of Medline, Embase, Cochrane and Web of Knowledge databases from 1940 to 2015. Pooled resistance prevalence for common primary care antibiotics, stratified by study country OECD status. Random-effects meta-analysis to explore the association between antibiotic exposure and resistance.

Results

Thirty-four studies were included. In OECD countries, the pooled resistance prevalence to tetracycline was 37.7 % (95 % CI: 25.9–49.7 %); ampicillin 37.6 % (24.9–54.3 %); and trimethoprim 28.6 % (2.2–71.0 %). Resistance in non-OECD countries was uniformly higher: tetracycline 80.0 % (59.7–95.3 %); ampicillin 67.2 % (45.8–84.9 %); and trimethoprim 81.3 % (40.4–100 %). We found evidence of an association between primary care prescribed antibiotics and resistance lasting for up to 3 months post-prescribing (pooled OR: 1.65, 1.36–2.0).

Conclusions

Resistance to many primary care prescribed antibiotics is common among faecal E. coli carried by asymptomatic children, with higher resistance rates in non-OECD countries. Despite tetracycline being contra-indicated in children, tetracycline resistance rates were high suggesting children could be important recipients and transmitters of resistant bacteria, or that use of other antibiotics is leading to tetracycline resistance via inter-bacteria resistance transmission.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1697-6) contains supplementary material, which is available to authorized users.

Global prevalence of antibiotic resistance in paediatric urinary tract infections caused by Escherichia coli and association with routine use of antibiotics in primary care: systematic review and meta-analysis

OBJECTIVES

To systematically review studies investigating the prevalence of antibiotic resistance in urinary tract infections caused by Escherichia coli in children and, when appropriate, to meta-analyse the relation between previous antibiotics prescribed in primary care and resistance.

DESIGN AND DATA ANALYSIS

Systematic review and meta-analysis. Pooled percentage prevalence of resistance to the most commonly used antibiotics in children in primary care, stratified by the OECD (Organisation for Economic Co-operation and Development) status of the study country. Random effects meta-analysis was used to quantify the association between previous exposure to antibiotics in primary care and resistance.

DATA SOURCES

Observational and experimental studies identified through Medline, Embase, Cochrane, and ISI Web of Knowledge databases, searched for articles published up to October 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were eligible if they investigated and reported resistance in community acquired urinary tract infection in children and young people aged 0-17. Electronic searches with MeSH terms and text words identified 3115 papers. Two independent reviewers assessed study quality and performed data extraction.

RESULTS

58 observational studies investigated 77,783 E coli isolates in urine. In studies from OECD countries, the pooled prevalence of resistance was 53.4% (95% confidence interval 46.0% to 60.8%) for ampicillin, 23.6% (13.9% to 32.3%) for trimethoprim, 8.2% (7.9% to 9.6%) for co-amoxiclav, and 2.1% (0.8 to 4.4%) for ciprofloxacin; nitrofurantoin was the lowest at 1.3% (0.8% to 1.7%). Resistance in studies in countries outside the OECD was significantly higher: 79.8% (73.0% to 87.7%) for ampicillin, 60.3% (40.9% to 79.0%) for co-amoxiclav, 26.8% (11.1% to 43.0%) for ciprofloxacin, and 17.0% (9.8% to 24.2%) for nitrofurantoin. There was evidence that bacterial isolates from the urinary tract from individual children who had received previous prescriptions for antibiotics in primary care were more likely to be resistant to antibiotics, and this increased risk could persist for up to six months (odds ratio 13.23, 95% confidence interval 7.84 to 22.31).

CONCLUSIONS

Prevalence of resistance to commonly prescribed antibiotics in primary care in children with urinary tract infections caused by E coli is high, particularly in countries outside the OECD, where one possible explanation is the availability of antibiotics over the counter. This could render some antibiotics ineffective as first line treatments for urinary tract infection. Routine use of antibiotics in primary care contributes to antimicrobial resistance in children, which can persist for up to six months after treatment.

The long-term effects of restrictive interventions on consumption and costs of antibiotics

In the last decade, Slovenia introduced restrictive measures for some antibiotic classes in ambulatory care as well as regulatory interventions to reduce costs. The aim of this study was to analyse the effects of these interventions on consumption and costs of antibiotics in ambulatory care. Consumption data were expressed in defined daily doses/1000 inhabitants per day (DID), number of packages/1000 inhabitants per day and number of prescriptions/1000 inhabitants per year. In 2000, Slovenia introduced restrictive measures for prescription of amoxicillin/clavulanic acid (AMC) and fluoroquinolones, in 2005 for oral third-generation cephalosporins and in 2009 for macrolides. Segmented regression analysis of interrupted time series was used to estimate the effects of restrictive interventions on antibiotic consumption. Total outpatient consumption of antibacterial drugs decreased by 29.65% from 20.27 DID in 1999 to 14.26 DID in 2012. Three years after the introduction of restrictions, consumption of AMC, fluoroquinolones and macrolides decreased by 29.3%, 23.8% and 28.8%, respectively, compared with the year before the intervention, and of non-restricted antibiotics by 3.3% (in 2003). Twelve years after the introduction of restrictive interventions, use of AMC and fluoroquinolones decreased by 28.1% and 28.5%, respectively, and use of non-restricted antibiotics by 18.8% (in 2012). In the same time period, the costs of AMC and fluoroquinolones were reduced by 63.3% and 52.4%, respectively, and of non-restricted antibiotics by 46.9%. Restrictive interventions in ambulatory care are effective in reducing antibiotic consumption and costs. Restrictive interventions had a significantly greater impact on consumption 3 years post-intervention than after 12 years.

Point prevalence survey on antibiotic use in a Croatian Infectious Disease Hospital

Antibiotic use is the driving force for increasing antibiotic resistance. A large proportion of antibiotics in hospitals are used inadequately. The objective of this study was to evaluate antibiotic use at the Hospital for Infectious Diseases through point-prevalence surveys conducted in 2006, 2008, and 2009. Point prevalence surveys were part of the European Surveillance on Antimicrobial Consumption (ESAC) Hospital Care Subproject and patients' data were collected following ESAC protocol. Additionally, the adequacy of antimicrobial therapy and administration of the first line antibiotic according to the local guidelines were assessed by an infectious disease doctor and a clinical microbiologist. In the study period among the 599 patients admitted to hospital, 352 (58·8%) received antibiotics. Out of 448 antimicrobial treatments, 313 (69·9%) were administered parenterally and 135 (30·1%) orally. Altogether in years 2006, 2008, and 2009 the most commonly prescribed antibiotics were ceftriaxone (19·9%), co-amoxiclav (15·4%), ciprofloxacin (12·3%), narrow spectrum penicillins (6·5%), and penicillinase resistant penicillins (5·6%). Most (82·6%) of the treated infections were community acquired infections. The predominating diagnoses were urinary tract infections and infections with no primary site defined, followed by skin, soft tissue and bone and joint infections. The overall adequacy of antimicrobial therapy was 82% and the first line antibiotic according to the local guidelines was administered with high frequency for central nervous system and cardiovascular infections (100%), and low for ear, nose, and throat infections, urinary tract infections, lower respiratory tract and bone and joint infections (23·0%, 51·6%, 52·5%, 65·0%, respectively) which indicates a significant overuse of antibiotics for diagnoses listed. The results of an individual point prevalence survey provided reliable and representative data for the hospital. Point-prevalence surveys proved to be a valuable method for detecting targets for antibiotic prescribing improvement and they clearly showed that our local hospital guidelines offered too many choices of antibiotic treatment for each clinical indication and needed revision.

Assessing the impact of national antibiotic campaigns in Europe

Because of evidence of causal association between antibiotic use and bacterial resistance, the implementation of national policies has emerged as a interesting tool for controlling and reversing bacterial resistance. The aim of this study was to assess the impact of public policies on antibiotic use in Europe using a differences-in-differences approach. Comparable data on systemic antibiotics administered in 21 European countries are available for a 11-year period between 1997 and 2007. Data on national campaigns are drawn from the public health literature. We estimate an econometric model of antibiotic consumption with country fixed effects and control for the main socioeconomic and epidemiological factors. Lagged values and the instrumental variables approach are applied to address endogeneity aspects of the prevalence of infections and the adoption of national campaigns. We find evidence that public campaigns significantly reduce the use of antimicrobials in the community by 1.3-5.6 defined daily doses per 1,000 inhabitants yearly. This represents an impact of roughly 6.5-28.3 % on the mean level of antibiotic use in Europe between 1997 and 2007. The effect is robust across different measurement methods. Further research is needed to investigate the effectiveness of policy interventions targeting different social groups such as general practitioners or patients.

A one-year prospective study on the antibiotic resistance of E. coli strains isolated in urinary specimens of children hospitalized at the University Pediatric Medical Center in Novi Sad, Serbia

PURPOSE

Urinary tract infections (UTIs), the most common serious bacterial infections in children, are frequently caused by Escherichia coli. The purpose of this study was to investigate E. coli resistance/multidrug resistance to antibiotics most frequently used for UTIs.

METHODS

Children 0-18 years of age, hospitalized at the University Pediatric Hospital in Novi Sad, Serbia, were included in a 1-year observational prospective study. The microbiological analysis was performed using the standard Kirby-Bauer disk diffusion method. The results were analyzed using WHONET 5.4 software.

RESULTS

E. coli was isolated from 61.7 % of positive urine specimens. In general, higher average E. coli antibiotic resistance was found in infants and toddlers compared to children and adolescents (33.4 vs. 25.0 %) (p < 0.0001). Furthermore, it was observed that the average resistance to all the tested antibiotics was higher in boys than in girls (37.0 vs. 25.1 %) (p < 0.0001). E. coli was highly susceptible to piperacillin/tazobactam (>93.1 %), amikacin (86.3 %), quinolones (>75.0 %), and penems (>96.6 %). The prevalence of multiresistant E. coli strains was significantly higher in infants and toddlers (72.3 vs. 36.8 %) (p < 0.0001).

CONCLUSIONS

E. coli, a common cause of UTIs in children admitted to pediatric hospitals, is highly resistant/multidrug-resistant to commonly used antibiotics. Higher average resistance is found in infants and toddlers than in children and adolescents, as well as in boys compared to girls. These findings are important for the regional empiric therapy of UTIs and call for actions to decrease E. coli antibiotic resistance.

Social-economic factors and irrational antibiotic use as reasons for antibiotic resistance of bacteria causing common childhood infections in primary healthcare

The most prevalent childhood bacterial infections in primary healthcare are respiratory, gastrointestinal and urogenital infections. The main aim of this paper was to consider factors (socio-economic factors and irrational antibiotic use) that contribute to the development of bacterial resistance, as well as measures that resulted in a reduction of this problem. Computerized search through the Medline of published articles on antibiotic resistance from 1996 to 2011 in English or Serbian was completed in August 2011. Combinations of used terms were antimicrobial/antibacterial/antibiotic and resistance/susceptibility in pediatric/children, and Streptococcus pneumoniae/Streptococci/Haemophilus influenzae/Salmonellae/Escherichia coli/Shigella/Staphylococcus aureus as well as antibiotics/antimicrobials/antibacterials and consumption/utilization/use. In many developing countries, antibiotic dispensing and its use in medicine, cattle breeding and agriculture are inadequately regulated, or existing laws are not being appropriately implemented. In addition, human travel contributes to antimicrobial drug resistance around the world. All of these factors have led to a very high level of bacterial resistance. On the contrary, in countries with a clearly defined and implemented legal framework concerning antibiotic prescribing, dispensing and utilization, the use of antibiotics is under constant surveillance. That resulted in a significantly lower antibacterial resistance. In conclusion, bacterial resistance could be reduced by the implementation of systemic and long-term measures at a country level as well as at all levels of healthcare. In order to reduce bacterial resistance, antibiotic use needs to be precisely regulated, and regulations should be coherent with practice. The international community must have a more active role in solving this global problem.

Antibiotic stewardship and consumption: findings from a pan-European hospital study

OBJECTIVES

Much has been written about antibiotic stewardship although less is known about the structure and content of antibiotic policies at hospital level. As part of the European Commission Concerted Action Antibiotic Resistance Prevention And Control (ARPAC) Project, data on antibiotic stewardship were collated and relationships investigated by antibiotic consumption in European hospitals.

METHODS

A questionnaire survey on antibiotic stewardship factors was completed by 170 hospitals from 32 European countries. Data on committees, antibiotic formularies and policies addressing empirical therapy and prophylaxis were collated. Data on antibiotic use, expressed as defined daily doses per 100 occupied bed-days (DDD/100 BD), were provided by 139 hospitals from 30 countries, and 124 hospitals provided both data sets. Six key indicator stewardship variables were analysed by European region, case mix and antibiotic consumption.

RESULTS

Hospitals from Northern and Western Europe were more likely to convene antibiotic committees or drugs and therapeutic committees compared with those from Southern and South-Eastern Europe (P < 0.001). One-fifth of hospitals had neither an antibiotic committee nor a policy. Hospital antibiotic policies commonly included recommendations on individual drugs, drug choices, dosage, duration and route but were less likely to contain information on side effects and cost. There were no significant differences by median total (J01) antibiotic consumption, although other antibiotic subgroups differed by stewardship indicators.

CONCLUSIONS

Policies and practices relating to antibiotic stewardship varied considerably across European hospitals. These data provide a benchmark for newer European strategies tackling antibiotic resistance. More work is required to achieve harmonization of recommended practice, particularly in hospitals from Southern Europe.

Antibiotic resistance of commensal Escherichia coli of food-producing animals from three Vojvodinian farms, Serbia

Commensal bacteria of food-producing animals are considered an important reservoir of antibiotic resistance. The aim of this study was to determine the current prevalence of resistance to 18 different antibiotics in animal commensal Escherichia coli isolated from food-producing animals from three different farms with specific modes of antimicrobial use. A very high prevalence of resistance was found to tetracycline, a moderate level to streptomycin, ampicillin, cefalothin and nalidixic acid and a low of resistance to the other tested antibiotics. Resistance to two or more antibiotics was observed among all swine E. coli, 63.2% of broiler isolates and 37.5% of cattle isolates. The results show that commensals of food-producing animals from Vojvodina region are important reservoirs of resistance to older-generation antibiotics.

Antibiotic susceptibility, serotype distribution and vaccine coverage of nasopharyngeal and oropharyngeal Streptococcus pneumoniae in a day-care centre in St. Petersburg, Russia

The objectives were to study serotypes and antibiotic susceptibility of Streptococcus pneumoniae carried by healthy children attending a day-care centre in St. Petersburg. S. pneumoniae colonization was investigated in 125 children aged 16-70 months. Antibiotic susceptibility was determined by E-test and disk diffusion. 83 S. pneumoniae cases were isolated in 75/125 (60%) children: 36/75 (48%) in the nasopharynx, 12/75 (16%) in the oropharynx and 27/75 (36%) in both. Carriage rates were 100%, 68%, 72%, 46% and 54% in children aged 12-23, 24-35, 36-47, 48-59 and >or=60 months, respectively. 97.6% of isolates were susceptible to penicillin. 61.4%, 32.5%, 19.3%, 16.7% and 6% isolates were non-susceptible to trimethoprim/sulfamethoxazole, tetracycline, clindamycin, erythromycin and chloramphenicol, respectively. 20.5% of isolates were multidrug resistant (MDR). 45% of isolates were of serotypes included in the 7-valent pneumococcal conjugate vaccine (7V-PCV); 64.9%, 56.8%, 32.4% and 27% of 7V-PCV serotypes were resistant to trimethoprim/sulfamethoxazole, tetracycline, clindamycin and erythromycin, respectively. The respective figures for MDR isolates were 100%, 94.1%, 70.6% and 76.5%; 76.5% of all MDR isolates were covered by 7V-PCV.

IN CONCLUSION

1) resistance to trimethoprim/sulfamethoxazole and tetracycline was high; 2) resistance to macrolides was higher than in other Russian regions; 3) 7V-PCV coverage was modest, but the vaccine may potentially reduce MDR-S. pneumoniae.

Antibiotic susceptibility of Neisseria gonorrhoeae in Arkhangelsk, Russia

OBJECTIVES

To characterise comprehensively the antibiotic susceptibility of Neisseria gonorrhoeae in Arkhangelsk, Russia, and to investigate whether the recommended treatment guidelines are updated and effective.

METHODS

The susceptibility of N gonorrhoeae isolates, cultured during June-November 2004 mainly from consecutive patients with gonorrhoea (n = 76) in Arkhangelsk, to penicillin G, ampicillin, cefixime, ceftriaxone, ciprofloxacin, erythromycin, azithromycin, kanamycin, spectinomycin and tetracycline was analysed using Etest. Nitrocefin discs were used for beta-lactamase detection.

RESULTS

The levels of intermediate susceptibility and resistance to the different antibiotics were as follows: penicillin G 76%, ampicillin 71%, cefixime 0%, ceftriaxone 3%, ciprofloxacin 17%, erythromycin 54%, azithromycin 14%, kanamycin 49%, spectinomycin 0% and tetracycline 92%. Of the isolates 55 (72%) were determined as multiresistant--that is, they showed intermediate susceptibility or resistance to three or more classes of antibiotics. However, none of the isolates were beta-lactamase producing.

CONCLUSIONS

In Arkhangelsk, and presumably in many other areas of Russia, penicillins, ciprofloxacin, erythromycin, azithromycin, kanamycin and tetracycline should not be used in the treatment of gonorrhoea if the results of antibiotic susceptibility testing are not available. In Russia, optimised, standardised and quality-assured antibiotic susceptibility testing needs to be established in many laboratories. Subsequently, continuous local, regional and national surveillance of antibiotic susceptibility is crucial to detect the emergence of new resistance, monitor changing patterns of susceptibility and be able to update treatment recommendations on a regular basis.

The issue of antimicrobial resistance in human medicine

Antibiotics are used worldwide in human medicine and agriculture. In many cases the use of antibiotics is unnecessary or questionable. Consumption of antibiotics is linked to bacterial resistance. In hospitals, most common resistant bacteria include methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and Gram-negative rods including Enterobacteriaceae and Pseudomonas aeruginosa. Vancomycin intermediate and resistant S. aureus, described just recently, represent a new treatment challenge. In the community, penicillin and macrolide-resistant pneumococci developed several decades ago and are now present all over the world. More recently, community-acquired methicillin-resistant S. aureus has become a problem in several countries causing skin infections but also severe diseases. Resistance to co-trimoxazole in Escherichia coli has changed empirical treatment of urinary tract infections, one of the most common causes of the visit to the physician's office. Several reports and studies trying to limit the use of antibiotics have shown that antimicrobial resistance of bacteria can be reversed, but in general the problem is far from being solved. World Health Assembly and the European Community Council have recognized the problem of antibiotic resistance as a priority. The relationship between agricultural use of antimicrobials and antibacterial resistance in humans should be further investigated.

Activity of meropenem and comparators against Pseudomonas aeruginosa and Acinetobacter spp. isolated in the MYSTIC Program, 2002-2004

This study examines the susceptibilities of meropenem and other broad-spectrum antimicrobials tested against bacterial isolates collected from hospitalized patients during 2002-2004 from worldwide medical centers participating in the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program. The in vitro activity of meropenem and 5 comparator antimicrobial agents was assessed against Pseudomonas aeruginosa and Acinetobacter spp. Generally, the susceptibility of Australasian and North American isolates was higher than that of the European and South American isolates. The rank order of activity of the antimicrobial agents tested against a worldwide collection of P. aeruginosa was piperacillin/tazobactam (77.7% susceptible) > meropenem (75.4%) > ceftazidime (70.0%) > imipenem (69.7%) > gentamicin (66.1%) > ciprofloxacin (62.0%). Against a worldwide collection of Acinetobacter spp. meropenem (76.1% susceptible) was the most active compound followed by imipenem (74.7%) > gentamicin (51.9%) > ciprofloxacin (40.5%) > piperacillin/tazobactam (39.8%) > ceftazidime (38.1%). The carbapenems appear to be a valuable option for the treatment of serious nosocomial infections caused by P. aeruginosa or Acinetobacter spp. over a broad geographical region.

An overview of the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program: 1997-2004

This overview provides a summary of the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program over an 8-year period from 1997 to 2004. The evolution of the MYSTIC Program is described, as well as its design compared with other surveillance programs. In addition, the global MYSTIC Program data, published to date, are summarized, and the empiric use of carbapenems, their current indications, and meropenem usage versus resistance was discussed. From 1997 to 2004, 120 medical centers that were actively prescribing meropenem in 32 countries worldwide participated in the program. The MYSTIC Program results demonstrate the sustained potency and continued effectiveness of meropenem globally against clinically relevant Gram-negative and Gram-positive pathogens including extended spectrum beta-lactamase- and AmpC beta-lactamase-producing organisms, which may also display resistance to the fluoroquinolones and/or aminoglycosides. Furthermore, in centers actively prescribing meropenem, resistance to meropenem is not increasing despite greater resistance among the comparator antimicrobial agents. Thus, antipseudomonal carbapenems such as meropenem and imipenem remain an effective treatment option.

Antimicrobial susceptibility and molecular analysis of Enterococcus faecalis originating from endodontic infections in Finland and Lithuania

BACKGROUND/AIMS

Enterococcus faecalis strains with multiple antibiotic resistances can cause infections that are difficult to treat. The microbial flora in treatment-resistant apical periodontitis is dominated by E. faecalis, and is a potential source of infections at other sites.

MATERIAL AND METHODS

Sensitivities to a range of antibiotics were determined for 59 endodontic E. faecalis isolates from Finland and Lithuania. The DNA sequence of the gene responsible for the species' intrinsic quinupristin-dalfopristin resistance, lsa, was determined from two isolates with diminished resistance. Four pairs of isolates from the same root canal were typed by pulsed-field gel electrophoresis.

RESULTS

A high prevalence of resistance to rifampicin was found, whereas all isolates were susceptible or showed intermediate susceptibility to penicillin and ampicillin and four isolates were unusually susceptible to cefotaxime. No vancomycin or high-level gentamicin resistance was detected. Nine of 59 isolates were susceptible to quinupristin-dalfopristin. A fully quinupristin-dalfopristin-susceptible isolate also susceptible to clindamycin produced a truncated Lsa polypeptide, and an isolate with borderline quinupristin-dalfopristin-susceptibility had mutations proximal to the predicted ribosomal binding site. Pulsed-field gel electrophoresis showed that the same root canal could harbor two different strains of E. faecalis during the course of the same infection.

CONCLUSION

Despite the differing antibiotic usage in Finland and Lithuania, E. faecalis from endodontic infections in these countries showed similar susceptibility patterns with levels of resistance considered typical for the species, and decreased resistance to clindamycin and quinupristin-dalfopristin as well as lesions in the lsa gene which were similar to those described in other clinical isolates.

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.

Analysis of the causes and consequences of decreased antibiotic consumption over the last 5 years in Slovenia

OBJECTIVES

Compared with European countries, the use of antibiotics in Slovenia is moderate. In the period 1999-2002 an 18.67% decrease in outpatient antibiotic consumption was noted. The aim of the present study was to analyse this decrease and its consequences.

METHODS

The data on outpatient antibiotic consumption were obtained from the Institute of Public Health and Health Insurance Institute of Slovenia and expressed in defined daily doses (DDD)/1000 inhabitant-days. The number of media publications on 'antibiotic drugs' and 'bacterial resistance' during the study period was obtained. In 2000, the prescription of co-amoxiclav and fluoroquinolones was restricted because of a constant increase in the consumption of these drugs. The data on incidence of acute mastoiditis and penicillin resistance among invasive pneumococci were obtained.

RESULTS

The total outpatient consumption of antibacterials increased from 15.21 DDD/1000 inhabitant-days in 1996 to 20.08 in 1999, and decreased to 16.97 in 2003. The consumption of restricted antibiotics decreased from 7.29 in 1999 to 5.25 DDD/1000 inhabitant-days in 2003. There was a positive correlation between antibiotic consumption and the number of newspaper articles (r=0.92), and a negative correlation between the number of diagnostic tests and antibiotic consumption (r=-0.73 for the C-reactive protein test and -0.68 for the streptococcal antigen detection test). Reduced antibiotic consumption was paralleled by a decrease in penicillin resistance among invasive pneumococci. No increase in mastoiditis cases was observed in spite of reduced antibiotic consumption.

CONCLUSION

Restriction of antibiotic prescription proved to be effective in reducing outpatient antibiotic consumption. The effect was prolonged and affected restricted antibiotics as well as non-restricted drugs.