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

Feasibility and validity of using healthcare databases to conduct cross-national comparative studies of opioid use, its determinants and consequences

PURPOSE

A cross-national comparative (CNC) study about opioid utilization would allow the identification of strategies to improve pain management and mitigate risk. However, little is known about the accessibility and validity of information in healthcare databases internationally. This study aimed to identify the feasibility of using healthcare databases to conduct a CNC study of opioid utilization and its associated consequences.

METHODS

A cross-sectional survey was launched in March 2018, including experts interested in CNC studies comparing opioid utilization by purposeful sampling. An electronic survey was used to collect database characteristics, medicine information, and linkage information of each aggregate-level dataset (AD) and individual patient-level dataset (IPD).

RESULTS

Overall, participants from 21 geographical regions reported 18 ADs and 19 IPDs. Information on dispensed medications is available from 17 ADs and 17 IPDs. Of the 16 ADs that include primary care settings, only 9 ADs can obtain information from secondary care settings. Fourteen IPDs included patients' characteristics or could be retrieved from linkage databases. Although most ADs are publicly accessible (n = 13), only five IPDs can be accessed without extra cost.

CONCLUSION

Most ADs could be used to report opioid utilization in a primary care setting. IPDs with linkage databases should be applied to identify potential determinants, clinical outcomes, and policy impact. Data access restrictions and governance policies across jurisdictions can be challenging for timely analysis and require further collaboration.

Point prevalence survey of antibiotic utilization in secondary care hospital in the United Arab Emirates

Objectives

The present study was carried out to identify and report the pattern of antibiotics prescribing to determine the adherence to the international empirical and therapeutic guidelines of antibiotic use.

Methods

A point prevalence survey took place at a selected date of January 26, 2020, in which data collection was performed to all the patients present in the hospital who used at least one systemic antibiotic agent as an inpatient from 00:00 am until midnight of that day. This was performed using European Surveillance of Antimicrobial Consumption (ESAC - audit tool). The participated hospital in this point prevalence study represents a major government hospital in the UAE. Descriptive statistics were used and results were expressed using standard statistical methods.

Results

Out of the 125 hospitalized patients, a total of 41 (32.8%) patients were included in the survey and treated with different trends of antibiotics on the date point prevalence survey. The total number prescribed antibiotics was 54 with a higher percentage of treatment indication (70.4%), compared to prophylaxis indication (29.6%). The combinations of penicillin's win in being the most commonly used agents by a percent of 31.5%, including the use of Amoxicillin-clavulanic acid by 22.2% and Piperacillin-tazobactam with 9.3%. The compliance with local/international guidelines accounts for 78.0% of the treated & prophylaxis patients.

Conclusions

Considerable results have been obtained which can assure the quality improvement of the antibiotic use in the studied hospital.

Thank Martin Luther that ciprofloxacin could cure your gonorrhoea? Ecological association between Protestantism and antimicrobial consumption in 30 European countries

Background: Higher consumption of antimicrobials plays an important role in driving the higher prevalence of antimicrobial resistance in Southern compared to Northern Europe. Poor controls on corruption (CoC), high uncertainty avoidance (UA) and performance vs. cooperation orientation (POCO) of societies have been found to explain much of this higher consumption in Southern European countries.  We hypothesized that these predictors were in turn influenced by the Protestant Reformation in the 16th century onwards. Methods: We used structural equation modelling (SEM) to assess the relationships between country-level proportions being Protestant, CoC, UA, POCO and four markers of antimicrobial consumption in the community (all antibacterials, cephalosporin, macrolides and fluoroquinolones). Results: The proportion of a country that was Protestant was negatively correlated with the consumption of all antibacterials. SEM revealed that UA predicted all antibacterial consumption (direct effect coef. 0.15, 95% Confidence Interval [CI] 0.04-0.26). The proportion Protestant exerted an indirect effect on consumption (coef. -0.13, 95% CI -0.21- -0.05). This effect was mediated predominantly via its effect on UA (direct effect coef. 0.15, 95% CI 0.04-0.26). The model explained 37% of the variation in consumption.  Similar results were obtained for each of the other three classes of antimicrobials investigated. Conclusions: Our results are compatible with the theory that contemporary differences in antimicrobial consumption in Europe stem in part from cultural differences that emerged in the Reformation. These findings may explain the differential efficacy of similar antibiotic stewardship campaigns in Northern and Southern European populations.

Data Sources for Drug Utilization Research in Latin American countries - a cross-national study: DASDUR-LATAM Study

PURPOSE

Drug utilization research (DUR) contributes to inform policymaking and to strengthen health systems. The availability of data sources is the first step for conducting DUR. However, documents that systematize these data sources in Latin American (LatAm) countries are not known. We compiled the potential data sources for DUR in the LatAm region.

METHODS

A network of DUR experts from nine LatAm countries was assembled and experts conducted: (i) a website search of the government, academic, and private health institutions; (ii) screening of eligible data sources, and (iii) liaising with national experts in pharmacoepidemiology (via an on-line survey). The data sources were characterized by accessibility, geographic granularity, setting, sector of the data, sources and type of the data. Descriptive analyses were performed.

RESULTS

We identified 125 data sources for DUR in nine LatAm countries. Thirty-eight (30%) of them were publicly and conveniently available; 89 (71%) were accessible with limitations, and 18 (14%) were not accessible or lacked clear rules for data access. From the 125 data sources, 76 (61%) were from the public sector only; 46 (37%) were from pharmacy records; 43 (34%) came from ambulatory settings and; 85 (68%) gave access to individual patient-level data.

CONCLUSIONS

Although multiple sources for DUR are available in LatAm countries, the accessibility is a major challenge. The procedures for accessing DUR data should be transparent, feasible, affordable and protocol-driven. This inventory could permit a comparison of drug utilization between countries identifying potential medication-related problems that need further exploration.

Sources of antibiotics pollutants in the aquatic environment under SARS-CoV-2 pandemic situation

During the last decades, the growth of concern towards different pollutants has been increasing due to population activities in large cities and the great need for food production by the agri-food industry. The effects observed in specific locations have shown the impact over the environment in air, soil and water. Specifically, the current pandemic of COVID-19 has brought into the picture the intensive use of different medical substances to treat the disease and population intensive misuse. In particular, the use of antibiotics has increased during the last 20 years with few regulations regarding their excessive use and the disposal of their residues from different sources. Within this review, an overview of sources of antibiotics to aquatic environments was done along with its impact to the environment and trophic chain, and negative effects of human health due prolonged exposure which endanger the environment, population health, water, and food sustainability. The revision indicates the differences between sources and its potential danger due toxicity, and accumulation that prevents water sustainability in the long run.

Consumption of antibiotics in the community, European Union/European Economic Area, 1997-2017: data collection, management and analysis

OBJECTIVES

This article introduces a series of articles on antibiotic consumption in the community between 1997 and 2017, which provide an update of previous articles covering the periods 1997-2003 and 1997-2009.

METHODS

In this article, differences in participating countries, the ATC/DDD classification system, and data collection, validation and analysis between the current and previous series are described.

RESULTS

In the previous series, 33 European countries provided valid data for further analysis, while the current series focused on 30 countries belonging to the EU or the European Economic Area (EEA). For both series, data were collected in accordance with the WHO ATC classification system. While the previous series reported data in accordance with the ATC/DDD index 2011, the current series employed the ATC/DDD index 2019. Both series focused on consumption of antibacterials for systemic use (ATC J01) and collected data expressed in DDD per 1000 inhabitants per day and packages per 1000 inhabitants per day. When studying consumption expressed in packages per 1000 inhabitants per day, countries reporting total care data, i.e. community and hospital sector combined, were included in the previous series but excluded in the current series. While the previous series used non-linear mixed models to evaluate time trends in antibiotic consumption, the current series allowed for inclusion of change-points with a data-driven location. In addition, both series assessed the composition and quality of antibiotic consumption in the EU/EEA.

CONCLUSIONS

The updated analyses of two decades of ESAC-Net data provide the most comprehensive and detailed description of antibiotic consumption in the community in Europe.

Monitoring outpatient antibiotic utilization using reimbursement and retail sales data: a population-based comparison in France, 2012-17

OBJECTIVES

To assess whether a retail sales database could be used to monitor antibiotic utilization in the outpatient setting at the national level.

METHODS

We extracted 2012-17 outpatient antibiotic extrapolated retail sales (IQVIA's Xponent) and reimbursement data from the National Health Insurance (SNDS) in metropolitan France. We compared estimates of antibiotic use and consumption [number of antibiotic drug deliveries (DrID) and defined daily doses (DID) per 1000 inhabitants per day]. We relied on relative differences, Pearson's r statistics and time series using autoregressive integrated moving average (ARIMA) modelling to study: (i) differences in point estimates, (ii) correlation, and (iii) consistency in time trends between Xponent and SNDS. The analysis was conducted overall and in subgroups (age groups, therapeutic classes, major antimicrobial agents and regions).

RESULTS

We analysed approximately 377 million antibiotic drug deliveries, comprising nearly 3.4 billion DDDs. Overall, Xponent slightly overestimated SNDS point estimates with yearly relative differences of +3.5% for DrID and +3.3% for DID. Peaks in relative differences were observed for July and August months. Relative differences were <5% in most subgroups, except for fosfomycin and three French regions. Overall and across most subgroups, the correlation between Xponent and SNDS monthly aggregated estimates was almost perfect (r ≥ 0.992 for all subgroups, except for one region). ARIMA modelling showed high consistency between Xponent's and SDNS's DrID time series, but detected timepoints where the series significantly diverged.

CONCLUSIONS

IQVIA's Xponent and SNDS data were highly consistent. Xponent database seems suitable for monitoring outpatient antibiotic utilization in France.

Is There a Resistance Threshold for Macrolide Consumption? Positive Evidence from an Ecological Analysis of Resistance Data from Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium

If we were to keep macrolide consumption below a certain threshold, would this reduce the probability of macrolide resistance emerging? No study that we are aware of has addressed this question. We, therefore, assessed at a country level if there was a macrolide consumption threshold for the selection of a prevalence of macrolide resistance of over 5% in Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium. In this ecological-level analysis, we found evidence for a macrolide consumption threshold of 1.3 defined daily doses per 1,000 inhabitants per day (DID) for M. genitalium, 1.8 DID for T. pallidum, and 2.3 DID for S. pneumoniae. Our results provide further motivation for macrolide stewardship campaigns that strive to reduce macrolide consumption to levels below at least 2 DID.

Global Trends in Antimicrobial Use in Food Animals from 2017 to 2030

Demand for animal protein is rising globally and has been facilitated by the expansion of intensive farming. However, intensive animal production relies on the regular use of antimicrobials to maintain health and productivity on farms. The routine use of antimicrobials fuels the development of antimicrobial resistance, a growing threat for the health of humans and animals. Monitoring global trends in antimicrobial use is essential to track progress associated with antimicrobial stewardship efforts across regions. We collected antimicrobial sales data for chicken, cattle, and pig systems in 41 countries in 2017 and projected global antimicrobial consumption from 2017 to 2030. We used multivariate regression models and estimated global antimicrobial sales in 2017 at 93,309 tonnes (95% CI: 64,443, 149,886). Globally, sales are expected to rise by 11.5% in 2030 to 104,079 tonnes (95% CI: 69,062, 172,711). All continents are expected to increase their antimicrobial use. Our results show lower global antimicrobial sales in 2030 compared to previous estimates, owing to recent reports of decrease in antimicrobial use, in particular in China, the world's largest consumer. Countries exporting a large proportion of their production are more likely to report their antimicrobial sales data than countries with small export markets.

Gonorrhoea treatment combined with population-level general cephalosporin and quinolone consumption may select for Neisseria gonorrhoeae antimicrobial resistance at the levels of NG-MAST genogroup: An ecological study in Europe

OBJECTIVES

The prevalence of Neisseria gonorrhoeae NG-MAST genogroup G1407, associated with decreased susceptibility to extended-spectrum cephalosporins and fluoroquinolone resistance, has declined in Europe and it switched from circulating predominantly in men who have sex with men (MSM) in 2009-2010 to heterosexuals in 2013. We hypothesise that changes to gonorrhoea treatment guidelines combined with differences in country-level consumption of cephalosporins and quinolones contributed to this shift.

METHODS

Linear regression was used to evaluate the association between changes in prevalence of G1407 between 2009-2010 and 2013 and country-level consumption of quinolones and cephalosporins in 2011/12 in 20 European countries.

RESULTS

Whilst the prevalence of G1407 declined between 2009-2010 and 2013 in the EU/EEA, its absolute prevalence increased by 10% or more in three countries. The national prevalence of G1407 in 2013 was positively associated with population-level general cephalosporin and quinolone consumption in the preceding 2 years. The association between the prevalence of G1407 and proportion of the national sample derived from MSM was non-significant in 2009-2010 and was negative in 2013.

CONCLUSIONS

Our results are broadly compatible with the hypothesis that changes in gonorrhoea therapy to the more efficacious ceftriaxone (plus azithromycin) from 2010 to 2011 onwards resulted in a reduced prevalence of the resistance-associated G1407 overall but in MSM in particular. High population-level consumption of quinolones and cephalosporins in certain countries then contributed to the selection of G1407 predominantly in heterosexuals in these countries.

Availability of secondary healthcare data for conducting pharmacoepidemiology studies in Colombia: A systematic review

Real-world evidence (RWE) is emerging as a fundamental component of the post-marketing evaluation of medicinal products. Even though the focus on RWE studies has increased in Colombia, the availability of secondary data sources to perform this type of research is not well documented. Thus, we aimed at identifying and characterizing secondary data sources available in Colombia. We performed a systematic literature review on PubMed, EMBASE, and VHL using a combination of controlled vocabulary and keywords for the concepts of electronic health records, epidemiologic studies and Colombia. A total of 323 publications were included. These comprised 123 identified secondary data sources including pharmacy dispensing databases, government datasets, disease registries, insurance databases, and electronic heath records, among others. These data sources were mostly used for cross-sectional studies focused on disease epidemiology in a specific population. Almost all databases (95%) contained demographic information, followed by pharmacological treatment (44%) and diagnostic tests (39%). Even though the database owner was identifiable in 94%, access information was only available in 44% of the articles. Only a pharmacy-dispensing database, local cancer registries, and government databases included a description regarding the quality of the information available. The diversity of databases identified shows that Colombia has a high potential to continue enhancing its RWE strategy. Greater efforts are required to improve data quality and accessibility. The linkage between databases will expand data pooling and integration to boost the translational potential of RWE.

Strong association between adolescent obesity and consumption of macrolides in Europe and the USA: An ecological study

BACKGROUND

The reasons underpinning the large variations in the prevalence of childhood obesity are inadequately understood. Individual level studies have found that macrolide consumption at a young age increases the risk of subsequent obesity. We hypothesized that differences in population level consumption of macrolides may explain part of the variation in the prevalence of childhood obesity.

METHODS

Mixed effects beta regression was used to assess the association between the prevalence of childhood obesity in countries in Europe/ states in the United States and population level consumption of macrolides and total antibiotics. Different time lags between consumption and obesity measurement were used.

RESULTS

We found that in both the USA and Europe, population level consumption of macrolides was positively associated with subsequent childhood obesity prevalence. According to our model, the observed differences in population-level macrolide consumption in Europe/USA would translate into a 13%/72% higher odds of childhood obesity 5 years later. The association held regardless of the lag period used between exposure and outcome. The association with total antibiotic consumption was more equivocal.

CONCLUSIONS

Reducing macrolide consumption to that of low consumption countries may result in considerable reductions in childhood obesity.

Gonococcal resistance can be viewed productively as part of a syndemic of antimicrobial resistance: an ecological analysis of 30 European countries

BACKGROUND

It is unclear how important bystander selection is in the genesis of antimicrobial resistance (AMR) in Neisseria gonorrhoeae.

METHODS

We assessed bystander selection in a novel way. Mixed-effects linear regression was used to assess if country-level prevalence of gonococcal AMR in 30 European countries predicts homologous AMR in other bacteria. The data used was from the European Antimicrobial Resistance Surveillance Network.

RESULTS

The prevalence of gonococcal ciprofloxacin resistance was found to be positively associated with AMR prevalence in E. coli (coef. 0.52; P = 0.007), Acinetobacter spp. (coef. 0.13; P = 0.044) and Pseudomonas aeruginosa (coef. 0.36; P = 0.020) but not Klebsiella pneumoniae. Azithromycin resistance in N. gonorrhoeae was positively associated with macrolide resistance in Streptococcus pneumoniae (coef. 0.01; P = 0.018). No association was found for cephalosporins.

CONCLUSIONS

Gonococcal AMR is linked to that in other bacteria. This finding is likely explained by high antimicrobial consumption in affected populations and provides additional motivation for strengthening antimicrobial stewardship programs.

Outcomes After Surgery for Unilateral Dominant Primary Aldosteronism in Sweden

Background

Primary aldosteronism (PA) is the most common cause of secondary hypertension. Surgery is the mainstay of treatment for unilateral dominant PA, but reported cure rates varies. The aim of the present study was to investigate contemporary follow-up practices and cure rates after surgery for PA in Sweden.

Methods

Patients operated for PA and registered in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009–2015 were identified. Patient data were extracted, and follow-up data (1–24 months) was recorded. Doses of antihypertensive medication and potassium supplementation were calculated using defined daily doses (DDD), and the Primary Aldosteronism Surgical Outcome (PASO) criteria were used to evaluate outcomes.

Results

Of 190 registered patients, 171 (47% female, mean age 53 years, median follow-up 3.7 months) were available for analysis. In 75 patients (44%), missing data precluded evaluation of biochemical cure according to the PASO criteria. Minimal invasive approach was used in 168/171 patients (98%). Complication rate (Clavien-Dindo >3a) was 3%. No mortality was registered. Pre/postoperatively 98/66% used antihypertensives (mean DDD 3.7/1.5). 89/2% had potassium supplementation (mean DDD 2.0/0) before/after surgery. Complete/partial biochemical and clinical success according to the PASO criteria were achieved in 92/7% and 34/60%, respectively.

Conclusion

In this study, reflecting contemporary clinical practice in Sweden complete/partial biochemical and clinical success after surgery for PA was 92/7% and 34/60%. Evaluation of biochemical cure was hampered by lack of uniform reporting of relevant outcome measures. We suggest mandatory reporting of surgical outcomes using the PASO criteria for all units performing surgery for PA.

Antibiotic Utilization Trends in Two State Hospitals of Mongolia from 2013 to 2017

Background. The study aimed to evaluate inpatient antibiotic use in both the State Second Hospital and State Third Hospital in Mongolia, using the WHO developed and standardized ATC/DDD methodology. Methods. Data were collected from the State Second Hospital and State Third Hospital which are major public hospitals that provide health care for approximately one fifth of the Mongolian population. Antibiotic utilization was monitored retrospectively for five years (2013–2017) using the ATC/DDD methodology and data were presented in DDD/ admission and DDD/100 bed days. Statistical analysis was performed using a Student’s t-test for parametric data. A P value of ≤0.05 was considered to be statistically significant. Results. The annual consumption rates in the State Second Hospital were stable over time while in the State Third Hospital consumption rates varied considerately between years. Overall, the total antibiotic consumption rate was very high, but has decreased in both hospitals. The rate of consumption of all antibiotics was approximately twice that in the State Third Hospital (421.7 DDD/100 bed days) between 2013 and 2017 when compared with the State Second Hospital (199.7 DDD/ 100 bed days), P<0.001). The seven most frequently used antibiotics comprised approximately 75% of all DDDs in both hospitals, in the period 2013–2017; being: amoxicillin, cefazolin, cefotaxime, ceftriaxone, clarithromycin, ciprofloxacin, and nitroxoline. However, this was not consistent when considering the individual years, since in 2015 and 2016, these seven active agents represented approximately 50%. Conclusion. This is the first hospital-based study of antibiotic consumption rates reported in Mongolia. In addition to very high consumption rates, large differences occurred between the hospitals investigated. Inappropriate and high levels of antibiotic use lead to increased costs and also increased nosocomial infection rates with potentially resistant species. The Government and health professionals need to take more active roles in improving and promoting quality antibiotic use among inpatients.

Trends and patterns of antibiotic consumption in China's tertiary hospitals: Based on a 5 year surveillance with sales records, 2011-2015

The consumption of antibiotics is a major driver in the development of antimicrobial resistance. This study aims to identify the trends and patterns of the total antibiotic consumption in China's tertiary hospitals from 2011 to 2015 by retrospectively analyzing aggregated monthly surveillance data on antibiotic sales made to 468 hospitals from 28 provinces. Antibiotic consumption was expressed in DDD per 1,000 inhabitants per day (DID). We compared population weighted antibiotic consumption patterns in China with European countries using indicators from the European Surveillance of Antimicrobial Consumption (ESAC). Total antibiotic consumption, including all the specific antibiotic class except for aminoglycoside antibacterials, were significantly increased during the study period from an average of 7.97 DID in 2011 to 10.08 DID in 2015. In 2015, the eastern regions of China consumed the most antibiotics using population denominator while the western regions consumed the most using inpatient denominator. Cephalosporins accounted for 28.6% of total DID, followed by beta-lactam-beta-lactamase inhibitor combinations (20.0%), macrolides (17.4%), and fluoroquinolones (10.5%). Antibiotic in parenteral form accounted for nearly half of all antibiotics. Although over the past few years major efforts had been made to reduce the risks of excessive antibiotic use through antibiotic stewardship, total antibiotic consumption showed a significant upward trend during the study period. A consistent preference for cephalosporins, macrolides, beta-lactam-beta-lactamase inhibitor combinations, as well as parenteral preparations was observed.

Discordance between imaging and immunohistochemistry in unilateral primary aldosteronism

OBJECTIVE

Correct subtyping of primary aldosteronism (PA) is essential for good surgical outcomes. Adrenal vein sampling (AVS) and/or computed tomography (CT) are used for PA subclassification. Clinical and/or biochemical improvement after surgery, however, is not always achieved in patients with presumed unilateral PA. We aimed to identify the pitfalls in PA subclassification leading to surgical treatment failures.

PATIENTS AND DESIGN

We retrospectively studied 208 patients who underwent adrenal vein sampling (AVS) for PA subclassification in a tertiary referral centre, between January 2009 and August 2016. Simultaneous bilateral AVS was performed before and after cosyntropin administration. We implemented immunohistochemistry for aldosterone synthase (CYP11B2) and 17α-hydroxylase/17,20 lyase (CYP17A1) in adrenal glands resected from patients without improvement of PA after surgical treatment and from those with limitations in AVS interpretation.

RESULTS

Of 55 patients who underwent adrenalectomy, three (5.5%) had no improvement of PA. All three patients underwent partial adrenalectomy to remove a CT-detected nodule present on the same side with AVS lateralization. Immunohistochemistry revealed a CYP11B2-negative nodule in both cases available. All patients who underwent total adrenalectomy based on AVS lateralization benefitted from surgery, including three patients with unilateral unsuccessful AVS and aldosterone suppression in the catheterized side vs inferior vena cava.

CONCLUSIONS

Radiographically identified adrenal nodules are not always a source of PA, even when ipsilateral with AVS lateralization. These data caution against reliance on imaging findings, either alone or in conjunction with AVS, to guide surgery for PA.

Antibiotic Utilization in Pediatric Hospitalized Patients - A Single Center Study

BACKGROUND:

Antibiotics are among the most commonly prescribed drugs in paediatrics. In most cases, antibiotics are started on an empirical basis, without proof of a bacterial infection, either before the start of therapy or afterwards.

AIM:

The main objective of this study was to analyse the consumption of antibiotics in hospitalised paediatric patients.

MATERIAL AND METHODS:

This retrospective study investigated the consumption of antimicrobials in defined daily doses (DDDs according to the Anatomical Therapeutical Chemical/DDD index) in Pulmonology, Gastroenterology and Nephrology Departments at Pediatric Clinic of the tertiary hospital. The data on the consumption of antimicrobials were collected for five years by using properly designed form. The consumption was related to days of hospital care.

RESULTS:

The most utilised antibiotics group in all three departments Pulmonology, Gastroenterology and Nephrology Departments were penicillins. Cephalosporins were mostly used in Pulmonology department. Metronidazole and Chloramphenicol were used in minimal quantities in all three departments.

CONCLUSION:

This study demonstrates that surveillance programs on antibiotic resistance should be established and accompanied by analyses of drug utilisation data which can aid in the creation of valid cross-national studies on antibiotic usage and resistance, to motivate improvements in prescribing and guideline-directed antibiotic prescribing.

Guidance on the Selection of Appropriate Indicators for Quantification of Antimicrobial Usage in Humans and Animals

An increasing variety of indicators of antimicrobial usage has become available in human and veterinary medicine, with no consensus on the most appropriate indicators to be used. The objective of this review is therefore to provide guidance on the selection of indicators, intended for those aiming to quantify antimicrobial usage based on sales, deliveries or reimbursement data. Depending on the study objective, different requirements apply to antimicrobial usage quantification in terms of resolution, comprehensiveness, stability over time, ability to assess exposure and comparability. If the aim is to monitor antimicrobial usage trends, it is crucial to use a robust quantification system that allows stability over time in terms of required data and provided output; to compare usage between different species or countries, comparability must be ensured between the different populations. If data are used for benchmarking, the system comprehensiveness is particularly crucial, while data collected to study the association between usage and resistance should express the exposure level and duration as a measurement of the exerted selection pressure. Antimicrobial usage is generally described as the number of technical units consumed normalized by the population at risk of being treated in a defined period. The technical units vary from number of packages to number of individuals treated daily by adding different levels of complexity such as daily dose or weight at treatment. These technical units are then related to a description of the population at risk, based either on biomass or number of individuals. Conventions and assumptions are needed for all of these calculation steps. However, there is a clear lack of standardization, resulting in poor transparency and comparability. By combining study requirements with available approaches to quantify antimicrobial usage, we provide suggestions on the most appropriate indicators and data sources to be used for a given study objective.

Trends and patterns of antibiotic consumption in Shanghai municipality, China: a 6 year surveillance with sales records, 2009-14

OBJECTIVES

The objective of this study was to identify the trends and patterns of total antibiotic use in Shanghai from 2009 to 2014.

METHODS

Sales records were collected from a minimum of 160 hospitals and 241 primary healthcare settings and used as a proxy for consumption. Antibiotic sales expressed in DDD per 1000 inhabitants per day (DID) were calculated. We compared patterns of antibiotic use in the Shanghai municipality, populated by 24 million inhabitants, with European countries using indicators from the European Surveillance of Antimicrobial Consumption (ESAC).

RESULTS

Total antibiotic use was highest at 25.9 DID in 2010, fell to 17.8 DID in 2012 and remained stable thereafter. The majority of this reduction occurred over 6 months in 2011. In 2014, two-thirds of the antibiotic sales were to hospitals (serving both inpatients and outpatients) and one-third to primary healthcare institutions. Cephalosporins accounted for 50.2% of total DID, followed by macrolides (18.2%), quinolones (16.0%) and penicillins (7.3%). A fifth of all antibiotics were used in parenteral form.

CONCLUSIONS

We have successfully used aggregated sales data to monitor antibiotic usage across a large urban population over a 6 year period. A rapid, substantial and sustained reduction in antibiotic usage across the entire health system occurred. This coincided with several interventions across hierarchies in the health sector, including a national campaign. The patterns of antibiotic use indicate persistent preferences for cephalosporins, macrolides, quinolones and parenteral preparations. Further efforts are needed to investigate and improve the quality of antibiotic use.

Systematic review of cross-national drug utilization studies in Latin America: methods and comparability

PURPOSE

We systematically review the cross-national drug utilization studies performed in Latin America (LA) in order to analyze the methods applied and assess the validity of the data to ensure the comparability.

METHODS

A systematic search in Medline, Embase, and BIREME was performed. Drug utilization studies including LA countries and comparing drug exposure data on volume were included. The data validity was judged independently by two authors as having low, medium, high, or unclear risk of bias.

RESULTS

Out of 1191 articles, 25 were kept for full text reading. Finally, five studies were selected. Eight different Latin American countries were involved in the comparisons. The selected studies analyzed wholesale data from a private research company collecting information from the private healthcare sector. In three studies, a high risk of bias in the extrapolation method applied was identified. In one study, a risk of data collection bias was detected. The most frequent limitation detected by the original authors was related to the unavailability of information from the public sector in LA.

CONCLUSION

Drug utilization studies comparing data cross-nationally are scarce in LA. In general, validity of the comparisons is hampered by a potential risk of extrapolation bias given the lack of available data on drug consumption from the public healthcare sector. Setting up systems to remediate this situation is a future challenge for researchers and (supra)national authorities in the region.

Sales of macrolides, lincosamides, streptogramins, and amoxicillin/clavulanate in the in- and outpatient setting in 10 European countries, 2007-2010

Monitoring the use of antibiotics is relevant due to the public health impact of microbial resistance, adverse effects, and costs. We present data on the consumption of macrolides, lincosamides, streptogramins and amoxicillin/clavulanate (AMC) between 2007 and 2010 in the in-and outpatient healthcare setting in 10 European countries provided by IMS Health. Antibiotics were classified according to the anatomical therapeutic chemical classification and consumption was expressed in defined daily doses/1000 inhabitants/day (DIDs). We analysed the number of prescriptions by diagnostic codes between 2008 and 2010, based on the International Classification of Diseases, 10th revision (ICD-10). These ICD-10 codes were grouped into four main categories: respiratory infections, genitourinary infections, other infections and other diagnoses. In 2010, the consumption of macrolides and lincosamides ranged from 0.45 DIDs (Sweden) to 5.46 DIDs (Italy), and from 0.04 DIDs (Denmark) to 1.00 DID (Germany), respectively. Streptogramins were available in France, Germany, Italy, Norway, Spain and United Kingdom with a consumption of <0.001 DID exclusively in the hospital setting. The consumption of AMC ranged from <0.001 DIDs (Norway) to 11.67 DIDs (Spain). During the study period, the consumption of macrolides decreased, the consumption of AMC increased in most of European countries, and lincosamides varied very slightly. Macrolides and AMC were mainly prescribed for respiratory infections in all countries but United Kingdom, where most of the prescriptions were assigned to diagnostic codes not clearly related with an infection. Lincosamides were prescribed for the respiratory infections and other infections groups. There was a wide inter-country variability in the percentage of the prescriptions assigned to each of the diagnostic categories. The inter-country differences in the consumption of these antibiotics and their prescription by diagnostic categories point to an inappropriate use of antibiotics.

Role of Pharmacovigilance in India: An overview

Pharmacovigilance (PV) plays a key role in the healthcare system through assessment, monitoring and discovery of interactions amongst drugs and their effects in human. Pharmaceutical and biotechnological medicines are designed to cure, prevent or treat diseases; however, there are also risks particularly adverse drug reactions (ADRs) can cause serious harm to patients. Thus, for safety medication ADRs monitoring required for each medicine throughout its life cycle, during development of drug such as pre-marketing including early stages of drug design, clinical trials, and post-marketing surveillance. PV is concerns with the detection, assessment, understanding and prevention of ADRs. Pharmacogenetics and pharmacogenomics are an indispensable part of the clinical research. Variation in the human genome is a cause of variable response to drugs and susceptibility to diseases are determined, which is important for early drug discovery to PV. Moreover, PV has traditionally involved in mining spontaneous reports submitted to national surveillance systems. The research focus is shifting toward the use of data generated from platforms outside the conventional framework such as electronic medical records, biomedical literature, and patient-reported data in health forums. The emerging trend in PV is to link premarketing data with human safety information observed in the post-marketing phase. The PV system team obtains valuable additional information, building up the scientific data contained in the original report and making it more informative. This necessitates an utmost requirement for effective regulations of the drug approval process and conscious pre and post approval vigilance of the undesired effects, especially in India. Adverse events reported by PV system potentially benefit to the community due to their proximity to both population and public health practitioners, in terms of language and knowledge, enables easy contact with reporters by electronically. Hence, PV helps to the patients get well and to manage optimally or ideally, avoid illness is a collective responsibility of industry, drug regulators, clinicians and other healthcare professionals to enhance their contribution to public health. This review summarized objectives and methodologies used in PV with critical overview of existing PV in India, challenges to overcome and future prospects with respect to Indian context.

How to measure and monitor antimicrobial consumption and resistance

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance.

Antibiotic use in eastern Europe: a cross-national database study in coordination with the WHO Regional Office for Europe

BACKGROUND

There are no reliable data on antibiotic use in non-European Union (EU) southern and eastern European countries and newly independent states. We aimed to collect valid, representative, comparable data on systemic antimicrobial use in these non-EU countries of the WHO European region.

METHODS

Validated 2011 total national wholesale antibiotic-use data of six southern and eastern European countries and regions and seven newly independent states were analysed in accordance with the WHO anatomical therapeutic chemical (ATC)/defined daily doses (DDD) method and expressed in DDD/1000 inhabitants per day (DID).

FINDINGS

Total (outpatients and hospital care) antibiotic use ranged from 15·3 DID for Armenia to 42·3 DID for Turkey. Co-amoxiclav was mainly used in Georgia (42·9% of total antibiotic use) and Turkey (30·7%). Newly independent states used substantial quantities of ampicillin and amoxicillin (up to 55·9% of total antibiotic use in Azerbaijan). Montenegro and Serbia were the highest consumers of macrolides (15·8% and 19·5% of total antibiotic use, respectively), mainly azithromycin. Parenteral antibiotic treatment is common practice: 46·4% of total antibiotic use in Azerbaijan (mainly ampicillin; 5·3 DID) and 31·1% of total antibiotic use in Tajikistan (mainly ceftriaxone; 4·7 DID).

INTERPRETATION

This study provides publicly available total antibiotic-use data for 13 non-EU countries and areas of the WHO European region. These data will raise awareness of inappropriate antibiotic use and stimulate policy makers to develop action plans. The established surveillance system provides a method to develop quality indicators of antibiotic use and to assess the effect of policy and regulatory actions.

FUNDING

Netherlands Ministry of Health, Welfare, and Sport, and EU.

A compilation of research working groups on drug utilisation across Europe

Background

The assessment of the benefit-risk of medicines needs careful consideration concerning their patterns of utilization. Systems for the monitoring of medicines consumption have been established in many European countries, and several international groups have identified and described them. No other compilation of European working groups has been published.

As part of the PROTECT project, as a first step in searching for European data sources on the consumption of five selected groups of medicines, we aimed to identify and describe the main characteristics of the existing collaborative European working groups.

Findings

Google and bibliographic searches (PubMed) of articles containing information on databases and other sources of drug consumption data were conducted. For each working group the main characteristics were recorded.

Nineteen selected groups were identified, focusing on: a) general drug utilisation (DU) research (EuroDURG, CNC, ISPE’S SIG-DUR, EURO-MED-STAT, PIPERSKA Group, NorPEN, ENCePP, DURQUIM), b) specific DU research: b.1) antimicrobial drugs (ARPAC, ESAC, ARPEC, ESGAP, HAPPY AUDIT), b.2) cardiovascular disease (ARITMO, EUROASPIRE), b.3) paediatrics (TEDDY), and b.4) mental health/central nervous system effects (ESEMeD, DRUID, TUPP/EUPoMMe). Information on their aims, methods and activities is presented.

Conclusions

We assembled and updated information on European working groups in DU research and in the utilisation of five selected groups of drugs for the PROTECT project. This information should be useful for academic researchers, regulatory and health authorities, and pharmaceutical companies conducting and interpreting post-authorisation and safety studies. European health authorities should encourage national research and collaborations in this important field for public health.

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.

Outpatient systemic antimycotic and antifungal use in Europe: new outcome measure provides new insight

To broaden our understanding of outpatient systemic antimycotic and antifungal use in Europe, use data in defined daily doses (DDD) were complemented with data in packages and the results were compared. Within the European Surveillance of Antimicrobial Consumption project and using the Anatomical Therapeutic Chemical (ATC) classification, data on outpatient use of all 14 antimycotics (12) and antifungals (2) for systemic use (ATC J02 and D01B), aggregated at the level of the active substance, were collected for 2009. Their use was expressed in DDD per 1000 inhabitants per day (DID) and in packages per 1000 inhabitants per day (PID) (WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD version 2011). In total, 24 countries delivered data in DID; 13 countries also delivered data in PID. In DID, Belgium had the highest (3.24 DID) and Romania the lowest (0.38 DID) total outpatient antimycotic and antifungal use. In PID, Greece had the highest (0.44 PID) and Sweden the lowest (0.08 PID) use. In DID, terbinafine was the most used substance in 19/24 countries (10/13 countries providing DID and PID data). In PID, fluconazole was the most used substance in all 13 countries. Combining DID and PID data substantially improved the interpretation of total outpatient antimycotic and antifungal use in Europe, and both outcome measures should be used for surveillance of these compounds. High use of fluconazole in PID might be more relevant for surveillance of antimicrobial consumption in relation to resistance than high use of terbinafine in DID.

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.

The Nordic prescription databases as a resource for pharmacoepidemiological research--a literature review

PURPOSE

All five Nordic countries have nationwide prescription databases covering all dispensed drugs, with potential for linkage to outcomes. The aim of this review is to present an overview of therapeutic areas studied and methods applied in pharmacoepidemiologic studies using data from these databases.

METHODS

The study consists of a Medline-based structured literature review of scientific papers published during 2005-2010 using data from the prescription databases in Denmark, Finland, Iceland, Norway, and Sweden, covering 25 million inhabitants. Relevant studies were analyzed in terms of pharmacological group, study population, outcomes examined, type of study (drug utilization vs. effect of drug therapy), country of origin, and extent of cross-national collaboration.

RESULTS

A total of 515 studies were identified. Of these, 262 were conducted in Denmark, 97 in Finland, 4 in Iceland, 87 in Norway, and 61 in Sweden. Four studies used data from more than one Nordic country. The most commonly studied drugs were those acting on the nervous system, followed by cardiovascular drugs and gastrointestinal/endocrine drugs. A total of 228 studies examined drug utilization and 263 focused on the effects and safety of drug therapy. Pregnant women were the most commonly studied population in safety studies, whereas prescribers' adherence to guidelines was the most frequent topic of drug utilization studies.

CONCLUSIONS

The Nordic prescription databases, with their possibility of record-linkage, represent an outstanding resource for assessing the beneficial and adverse effects of drug use in large populations, under routine care conditions, and with the potential for long-term follow-up.

Healthcare expenditures and increasing antimicrobial consumption in Turkey

OBJECTIVES

The aim of this study was to assess the trend in antimicrobial consumption in Turkey between 2007 and 2010.

METHODS

Antimicrobial consumption data were obtained from Intercontinental Medical Statistics Turkey office. The total antimicrobial consumption data were calculated as Defined Daily Dose (DDD)/1000 inhabitant-days. The correlation between the previous five-year period and association with the main indicators of economy and healthcare services of the country were assessed.

RESULTS

Total utilization of antibiotics increased from 33.7 to 38.8 DDD/1000 inhabitant-days between 2007 and 2010. A steady increase took place during the study period. When this period was compared with the previous period (between 2001 and 2006), a similar trend was found. Turkey's total healthcare expenditure 2001 to 2010 increased from 4.5 billion Turkish Liras to 32 billion Turkish Liras.

CONCLUSION

In Turkey, antibiotic consumption increased steadily in recent years, with a close relation to government healthcare support policy, rising health expenditures and other economical indicators.

Analysing policy interventions to prohibit over-the-counter antibiotic sales in four Latin American countries

OBJECTIVES

To describe and evaluate policies implemented in Chile, Colombia, Venezuela and Mexico (1995-2009) to prohibit antibiotic OTC sales and explore limitations in available data.

METHODS

We searched and analysed legislation, grey literature and peer-reviewed publications on regulatory interventions and implementation strategies to enforce prohibition of OTC antibiotic sales. We also assessed the impact using private sector retail sales data of antibiotics studying changes in level and consumption trends before and after the policy change using segmented time series analysis. Finally, we assessed the completeness and data quality through an established checklist to test the suitability of the data for analysis of the interventions.

RESULTS

Whereas Chile implemented a comprehensive package of interventions to accompany regulation changes, Colombia's reform was limited to the capital district and Venezuela's limited to only some antibiotics and without awareness campaigns. In Mexico, no enforcement was enacted. The data showed a differential effect of the intervention among the countries studied with a significant change in level of consumption in Chile (-5.56 DID) and in Colombia (-1.00DID). In Venezuela and Mexico, no significant change in level and slope was found. Changes in population coverage were identified as principal limitations of using sales data for evaluating the reform impact.

CONCLUSION

Retail sales data can be useful when assessing policy impact but should be supplemented by other data sources such as public sector sales and prescription data. Implementing regulatory enforcement has shown some impact, but a sustainable, concerted approach will be needed to address OTC sales in the future.

The effect of levofloxacin and moxifloxacin on cardiovascular functions of rats with streptozotocin-induced diabetes

Fluoroquinolone antibiotics cause rare, but clinically important, adverse events including hyperglycaemia and hypoglycaemia. The present study focuses on the possible effect of levofloxacin and moxifloxacin on the cardiovascular functions of rats with type I diabetes. Both antibiotics caused bradycardia. Levofloxacin but not moxifloxacin caused hypoglycaemia in diabetic rats and an increase in amplitude of the ST segment revealed by electrocardiogram (ECG) analysis of isolated hearts. In pressurized mesenteric arteries, levofloxacin did not affect the endothelium-derived hyperpolarising factor (EDHF) pathway or its main components, the small-conductance Ca(2+) activated potassium (SK(Ca)) and intermediate-conductance Ca(2+) activated potassium (IK(Ca)) channels. In moxifloxacin-treated rats, an increase in the EDHF response was observed, which was largely attributed to SK(Ca)-activation. In conclusion, levofloxacin and moxifloxacin use appeared to vary but with no evidence of impairment of the cardiovascular function. However, it is still possible that these antibiotics may produce different effects if there are co-morbidities and therefore their use must be with care.

Antimicrobial agent exposure and the emergence and spread of resistant microorganisms: issues associated with study design

Antibiotics are essential agents that have greatly reduced human mortality due to infectious diseases. Their use, and sometimes overuse, have increased over the past several decades in humans, veterinary medicine and agriculture. However, the emergence of resistant pathogens is becoming an increasing problem that could result in the re-emergence of infectious diseases. Antibiotic prescription in human medicine plays a key role in this phenomenon. Under selection pressure, resistance can emerge in the commensal flora of treated individuals and disseminate to others. However, even if the effects of antimicrobial use on resistance is intuitively accepted, scientific rationales are required to convince physicians, legislators and public opinion to adopt appropriate behaviours and policies. With this review, we aim to provide an overview of different epidemiological study designs that are used to study the relationship between antibiotic use and the emergence and spread of resistance, as well as highlight their main strengths and weaknesses.

[Use of prescription drugs in Spain and Europe]

OBJECTIVE

To compare the Spanish prescription drug consumption with that of European countries.

DESIGN

A review of the literature and data sources for prescription drug consumption.

SETTING

European countries; last three decades.

PARTICIPANTS

Included therapeutic groups where the available information allowed a comparison of the consumption in Spain with that of other European countries.

MEASUREMENTS

Studies, reports, or data sources were included in which the consumption was expressed in DHD (DDD/1000 inhabitants per day).

RESULTS

It was possible to compare 18 therapeutic groups: drugs for peptic ulcer (A02B), glucose lowering drugs (A10), antithrombotic agents vitamin K antagonists (B01AA), antihypertensives (C02), diuretics (C03), peripheral vasodilators (C04), beta-blocking agents (C07), calcium channel blockers (C08), agents acting on the renin-angiotensin system (C09), lipid-lowering drugs (C10), antibacterials for systemic use (J01), antiinflammatory & antirheumatic products non-steroids (M01A), opioid analgesics (N02A), antipsychotics (N05A); anxiolytics (N05B), hypnotics & sedatives (N05C), antidepressants (N06A) and drugs for obstructive airway diseases (R03). With regard to the European average (100), the Spanish consumption of these therapeutic groups was: N02A, 37; C07, 40; B01AA, 41; C03, 70; N05C, 72; C10, 75; C08, 76; N05A, 77; TH01, 97; N06A, 98; C09, 104; M01A, 101; R03, 101; C02, 107; A10, 114; N05B, 137; A02B, 150 and C04, 234.

CONCLUSIONS

The Spanish consumption of most of the therapeutic groups was very close to the average of the group of the countries where it was possible to compare it, or clearly below average, with the exception of the consumption of drugs for peptic ulcer, anxiolytics and peripheral vasodilators, which considerably exceeded the average of the group.

European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe (1997-2009)

OBJECTIVES

To describe total outpatient systemic antibiotic use in Europe from 1997 to 2009 and to analyse statistically trends of total use and composition of use over time.

METHODS

For the period 1997-2009, data on outpatient use of systemic antibiotics aggregated at the level of the active substance were collected and expressed in defined daily doses (WHO, version 2011) and packages per 1000 inhabitants per day (DID and PID, respectively). Outpatient antibiotic (ATC J01) use in DID in the 33 European countries able to deliver valid data was analysed using longitudinal and compositional data analyses.

RESULTS

Total outpatient antibiotic use in 2009 varied by a factor of 3.8 between the countries with the highest (38.6 DID in Greece) and lowest (10.2 DID in Romania) use. For Europe, a significant increase was found in total outpatient antibiotic use, as well as a significant seasonal variation, which decreased over time from 1997 to 2009. Relative use of penicillins and quinolones significantly increased over time with respect to sulphonamides and trimethoprim, and relative use of quinolones increased with respect to macrolide/lincosamide/streptogramin as well. More detailed analyses of these major antibiotic subgroups will be described in separate papers.

CONCLUSIONS

Outpatient antibiotic use in Europe measured as DID has increased since 1997, whereas seasonal variation has decreased over time. European Surveillance of Antimicrobial Consumption (ESAC) data on outpatient antibiotic use in Europe enable countries to audit their antibiotic use. Complemented by longitudinal and compositional data analyses, these data provide a tool for assessing public health strategies aimed at reducing antibiotic resistance and optimizing antibiotic prescribing.

Surveillance system for hepatitis C infection: A practical approach

Hepatitis C virus (HCV) infection is a serious public health concern throughout the world. Despite its public health prominence, however, how surveillance systems for hepatitis C should be designed is still a challenging issue especially in developing countries such as Iran. Establishing a surveillance system needs an ongoing process of case investigation, data collection, analysis of data and also dissemination of data to public health professionals and health care providers.This review article tries to provide the best recommendations for planning and implantation a surveillance system for HCV infection.

A permission system for carbapenem use reduced incidence of drug-resistant bacteria and cost of antimicrobials at a general hospital in Japan

Some drug management systems have been established in Japanese hospitals to reduce medical costs and regulate drug usage. Among the many available prescription drugs, antimicrobials should be given special attention because their inappropriate use often leads to sudden outbreaks of resistant bacteria. As drug specialists, pharmacists should monitor the use of all drugs, particularly antimicrobials. Carbapenems are a class of broad-spectrum antimicrobials that are widely used to treat infections worldwide. However, their inappropriate use has led to an increase in the incidence of drug-resistant bacteria and consequently, medical costs, at hospitals. To reduce inappropriate use and drug resistance, we have established a permission system to control the use of carbapenems at the Japanese Red Cross Nagoya Daiichi Hospital. In this study, we retrospectively evaluated the applicability of the new permission system compared to that of the notification system and the non control system for 14 months each. The two management systems were able to maintain total antibiotic use density and control the outbreak of drug-resistant bacteria (P. aeruginosa, E. coli, and K. pneumoniae). The number of carbapenem prescriptions was decreased dramatically when this permission system was enforced. Compared to the non control system, the cost of antimicrobials was reduced by $757,470 for the 14-month study period using the permission system. These results suggest that our system to control the use of antimicrobials can efficiently suppress the incidence of drug-resistant bacteria and medical costs at hospitals.