Trends in Antimicrobial Consumption and Resistance in Europe and the First Annual Antibiotic Day Herman Goossens University of Antwerp, Belgium Vice-Chair Belgian Antibiotic Policy Coordination Committee (BAPCOC) Co-ordinator of ESAC Chair Technical Advisory Group ECDC EU Antibiotic Day

We made great progress in Europe since ... October 18, 2001.

Outline of Presentation Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance At population level At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions

“If you cannot measure it, you cannot improve it” Lord Kelvin, 1824-1907

EARSS Participating countries: 31 27 EU Member States 1 Applicant countries Turkey 3 Other countries Iceland, Israel, Norway

Methicillin-Resistant Staph. aureus in Europe, 2006

Fluoroquinlone-Resistant E.coli in Europe, 2001-2006

Outline of Presentation Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance At population level At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions

ESAC Participating countries: 34 27 EU Member States 2 Applicant countries Croatia, Turkey 5 Other countries Former Republic of Macedonia, Iceland, Israel, Norway, Russia, Switzerland

Total Outpatient Antibiotic Use in 25 European Countries in 2006 (on-going validation for some countries) * Greece, Cyprus, Lithuania, Bulgaria: total care, i.e. hospital and primary care combined. ** Spain: reimbursement data, which do not include over-the-counter sales without a prescription.

Regional Variation of Outpatient Antibiotic Use in Italy

Regional Variation of Outpatient Antibiotic Use in Germany

ESAC Longitudinal Survey in 18 Hospitals in Europe: Total, Parenteral and Oral Use of Antibacterials in 2005

ESAC Point Prevalence Survey in 20 Hospitals in Europe: Length of Pre-operative Prophylaxis in Surgery

Outline of Presentation Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance At population level At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions

Correlation Between Macrolide Use and Macrolide-Resistant Strept Correlation Between Macrolide Use and Macrolide-Resistant Strept. pneumoniae Goossens et al, Lancet 2005

Effect of Macrolide versus Placebo Use on Temporal Changes of Proportion of Macrolide-Resistant Oral Streptococci Mean preantibiotic carriage of Mac-R streptococci was 28% Use of both Clar and Azi resulted in a huge increase in resistant streptococci which persisted for at least 6 months (P  0.01) Macrolide use is the single most important driver for the emergence of macrolide resistance Temporal changes in proportion of macrolide-resistant oral streptococci following use of either azithromycin or clarithromycin. Since, the number of volunteers was halved in Month 6, the 1st graph includes all 204 volunteers till Day 42 and the 2nd graph includes only volunteers for whom we could acquire the Month 6 sample. Errorbars denote the standard error of means. Macrolide-resistant streptococci were detected in all volunteers in the Day 0 samples, before the antibiotic course was started. Average baseline prevalence of macrolide-resistant streptococci was 28% and did not differ significantly between the four groups. Following azithromycin or clarithromycin use, the mean resistance proportions at each time point when compared to their respective placebos showed a significant increase (P≤ 0.01 overall) in macrolide-resistant streptococci that persisted for >6 months. Comparing the two macrolides, differences in mean macrolide resistance were not significant immediately following azithromycin and clarithromycin use (P=0.8), decreased significantly faster in the clarithromycin group than the azithromycin group in w1 and w3 (P<= 0.001), and became non-significant in w6 and m6 (P=0.07 and 0.6, respectively).   Malhotra et al, Lancet 2007

Outline of Presentation Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance At population level At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions

Belgium: a Federal Country...

Strategies to Curb Resistance in Belgium Seven multimedia campaigns to promote the prudent use of antibiotics in outpatients Two national campaigns to promote hand hygiene in hospitals Antibiotic management teams in ALL Belgian hospitals Several practice guidelines Antibiotic guide for ambulatory care Improve infection control practices (better financing and clear organisation) Finance surveillance programmes on antibiotic use and resistance in humans and animals

Belgium Media Campaigns: Switch from Threat to Negative Message Actors: Ad hoc Working Group and “Question Santé/Omtrent Gezondheid” Approach: Inform the public in general on the use and misuse of antibiotics and on the risk of bacterial resistance Slogan: ”Use antibiotics less frequently but better” Actors: Ad hoc Working Group and Social Marketing agency (Duval Guillaume, Antwerp) Approach: Tackle directly the hot spots of unjustified antibiotic treatment: viral respiratory tract infections Slogan: “Antibiotics don’t work against acute bronchitis, flu and common colds” First 3 campaigns (2000–2003) Latter campaigns (2004 - 2008)

Belgium www.antibiotics-info.be 1999 - 2003 > 2004

Outpatient Antibiotic Use in Belgium Packages per 1,000 inhabitants per day 1997 – 2006, July to June Verpakkingen per 1,000 inwoners per dag

Antibiotic Resistance of S. pneumoniae in Belgium. 1985 - 2007 National Reference Centre S. pneumoniae (University of Leuven)

Antibiotic Resistance of Throat Isolates of S. pyogenes in Belgium National Reference Centre S. pyogenes (University of Antwerp)

Outpatient Antibiotic Use in EUR, 1997-2006 53 52 52 50 46 45 44 178 170 174 169 39 42 153 38 EUR, miljoenen 146 139 122 123 108

Outline of Presentation Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance At population level At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions

Why do we need another awareness day? Awareness days have shown to mobilise people, politicians, resources, ... (Drinking and Driving; AIDS Day) Consolidate “healthy” situation of low antibiotic use and resistance (e.g. North) or reverse situation of emerging resistance (e.g. South) Success of national campaigns in Belgium and France: reduction of antibiotic use and resistance in primary care and hospitals Empty pipeline of new antibiotics; new rapid diagnostic tests not yet available The EC supports many public health and research programmes which allow to measure the impact of campaigns and provide materials: ECDC: EARSS (antibiotic resistance), ESAC (antibiotic use), … DG SANCO: e-BUG (educational packs for children), … DG RESEARCH: GRACE (qualitative research), CHAMP (database on campaigns, questionnaires, economic impact), … EUROPE IS READY TO KICK OFF AN EU ANTIBIOTIC DAY

How did we get here? September 07: AMR focal group unanimously agreed on need for EU Antibiotic Day October 07: Member States and MEPs support the idea of an EU Antibiotic Day October 07: ECDC’s Director launches first EU Antibiotic Day for…18 November 2008 January 08: Installation of Technical Advisory Group at ECDC March 08: Selection of logo, slogans, etc

What will be done? By ECDC: By Member States: Development of slogan, logo & key messages Launch of public website Delivery of media toolkit Press conference in European Parliament on 18 November By Member States: Press conference with Health experts & AMR experts National conference on AMR involving doctors, pharmacists, vets & dentists Editorials in national medical journals Letter from Health Minister to all doctors Leaflets & posters for general public Development of in-school activities for children & parents TV spots

Suggested logo/slogan

Outline of Presentation Antibiotic resistance in Europe (EARSS) Antibiotic consumption in Europe (ESAC) Link between use and resistance At population level At individual level Strategies to curb resistance in Belgium EU Antibiotic Day Conclusions

Conclusions: what can be done Conclusions: what can be done? First EU Antibiotic Day on November 18, 2008 Reduce unnecessary antibiotic use (e.g. in patients with common colds and flu) Raise awareness that overuse of antibiotics will increase antibiotic resistance, through increasing awareness of the public (e.g. public campaigns), professsionals (e.g. undergraduate and postgradute education), and children (e.g. educational packs in schools). Ensure that public campaigns employ techniques of social marketing and use appropriate quality indicators and outcome measures, such as antibiotic use and resistance Monitor adverse effects associated with a reduction in antibiotic prescribing Support the use of rapid point-of-care diagnostic tests which result in reduced antibiotic prescribing Provide incentives for benchmarking of antibiotic prescribing in hospitals and nursing homes through quality indicators, such as Longitudinal and Point Prevalence Surveys

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