Antimicrobial resistance: A case by case study
We look at a number of successful initiatives already underway in a number of EU member states to reduce antibiotic use.
For human use, the French have conducted national plans to reduce antibiotic use among the general public since 2002. A series of nationwide mass media campaigns, including TV and radio, saw overall antibiotic consumption fall by 10.7 per cent by 2013.
- From 2002 until 2006, the national health insurance ran a campaign designed to break the public's expectation that their physician would prescribe antibiotics as a matter of course, using the slogan; "Antibiotics are not automatic".
- From 2007 until 2009, the emphasis shifted to stopping individuals with viruses using antibiotics, this time with the slogan; "An antibiotic cannot heal".
- 2010 saw the focus shift to best practice. This highlighted diseases where antibiotics were inappropriate, including tonsillitis and bronchitis with the message "Antibiotics, if you use them incorrectly, they will be less strong".
To reduce antibiotic use in animal health settings, the French introduced the 'Ecoantibio Plan' in 2011. This seeks to reduce veterinary use of antibiotic by 25 per cent by 2016.
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The plan works on prescribing animals with antibiotics when strictly necessary in closely monitored amounts.
Since its introduction, the 'Ecoantibio Plan' has seen the global volume of antibiotics sold fall by 11 per cent between 2012 and 2013, a total of 34 per cent since its introduction.
Malta has used new dispensing practices and a greater degree of public awareness to reduce the use of non-prescribed antibiotics among the general population. The initiative began in 2003 using a two-pillar strategy focusing on both pharmacists and the general public.
Given that Mediterranean countries have a history of overuse of antibiotics, the campaign in Malta shows how much can be achieved using the right tools.
The first pillar began by targeting the public with information on how antibiotics are ineffective against colds, flu and sore throat. At the same time, there was a poster and leaflet campaign that highlighted the risks and hazards of inappropriate use, including growing resistance and adverse reactions.
The second pillar, targeting pharmacists, encouraged peer-led initiatives among pharmacists, especially through professional societies. This helped highlight the problem and supported effective intervention. It was coupled with a change to the regulatory system that allowed reviews of dispensing practices in pharmacies, with a specific focus on over-the counter dispensing of antibiotics.
Since their introduction in 2002, these measures have seen the percentage of people claiming to have obtained antibiotics from a pharmacy or other sources without a doctor's prescription fall from 19 per cent to less than two per cent.
An important aspect of antibiotic treatment is that patients complete the appropriate course of treatment.
The Spanish authorities realised that many antibiotics that had been on the market for a long time contained more tablets than current clinical practice deemed necessary. The dosage had been defined at the time of their original authorisation and never updated.
In September 2011, the Spanish health authorities convened an expert working group with the objective of reviewing the pack sizes for oral antibiotics.
As well as the government representatives, the panel featured a GP, a paediatrician and a pharmacist. They reviewed pack sizes for all available oral antibiotics and made proposals to optimise the treatment schedule according to the most up to date clinical practice.
Eventually, over 900 packages were adjusted. According to ECDC ESAC-Net surveillance data, this has delivered a significant reduction in antibiotic consumption in terms of number of packages per 1,000 inhabitants and per day. This is attributed to the fact the precise number of pills per pack led to fewer prescriptions.
An effective way to avoid the need for antimicrobial use in veterinary settings is to prevent animals from contracting diseases in the first place.
Biosecurity is an important aspect in delivering this. A higher level of biosecurity reduces the risk of disease and the risk that any disease spreads throughout the herd. Less disease and a lower risk of transmission inevitably reduces the level of antimicrobials required.
Ghent University in Belgium has developed a freely available online tool that helps farmers assess and quantify the biosecurity level of their pig herds and poultry flocks. The tool uses an online questionnaire and provides immediate and detailed feedback. In addition, the website acts as an extensive resource of information on biosecurity measures on pig and poultry farms.
The system for pigs has been available since 2009 and for poultry since 2012. The pig version is now used in 28 countries throughout the world, and has an anonymous database of over 1250 herds.
The system has also been used in several national and European research projects where the quantitative description of the biosecurity is linked to production and health characteristics of the herds. This has produced a number of scientific publications that describe the importance of biosecurity in animal production and demonstrates how improving this leads to lower requirements for antimicrobials.
There is a weak correlation between animal consumption of antibiotics and human resistance, argues Rick Clayton.
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