1. Relationship between resistance, antibiotic policies, and clinical guidelines in the community ? Government interventions on Antibiotic Policy in Belgium*
Paul M. Tulkens
Cellular and Molecular Pharmacology Unit
Centre for Clinical Pharmacy
Catholic University of Louvain, Brussels, Belgium
* disclaimer: although I have tried to produce an unbiased report, this is not an official account Refer to and for official documents.
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

2. Government interventions …
why ?
actions oriented towards the public
campaigns
campaigns
actions oriented towards the GP's
guidelines
reimbursement changes
where are we now ?
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

3. The consumption problem …40 30
Belgium (10 mill. inhab.) had a larger AB consumption than most EU countries
this consumption had remained constantly high over the period 20
Belgium
EU-range
Cars et al., Lancet 357:1851, 2001) 10
Outpatient Antibiotic Sales (DDD/1,000 inh./day) 30 25
Belgian Institute of Pharmacoepidemilogy [IPhEB-IFEB]) 20
1996
1997
1998
1999
Year
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

4. The resistance problem: the case of S. pneumoniae …
macrolides 40
tetracyclines 35
penicillin* intermediate 30
penicillin* full resistant
1/3 patients 25
percentage 20 15
1/5 patients 10 5 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 20
* all -lactams (= penicillins, cephalosporins, …)
year
Belgian Reference Laboratory for pneumococci, Louvain (Leuven), 2000
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

5. Relation consumption-resistance
Risk of resistance to -lactams among invasive isolates of Streptoccus pneumoniae regressed against
outpatient sales of beta-lactam antibiotics in 11 European countries
resistance data are from 1998 to 1999; antibiotic sales data 1997.
DDD = defined daily doses
Bronzwaer SL, Cars O, et al. Emerg Infect Dis 2002 Mar;8(3):278-82
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

6. The 1st round campaigns (2000-2002) : What were the messages ? …
less…
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

7. The 1st round campaigns (2000-2002) : What were the messages ? …
and better …
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

8. Success of this 1st round of public campaigns …
significant reduction of AB sales measured as DDD (about 5-10 %) during the influenza epidemic periods (sales = prescriptions in Belgium)
no significant-side effect detected
cost-effective for public health
Bauraind et al., JAMA 2004; 292: ;
more details on
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

9. The 2d round of campaigns: antibiotics are useless…
cyclist breeches are what you need in case of flu…
get a (full) telephone card and you will feel better…
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

10. The 2d round campaigns: What are the messages ? …
Do not take antibiotics in case of
common cold
acute bronchitis
flu
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

11. The 2d round campaigns: What are the messages ? …
When should be use antibiotics ?
bacterial infections
pneumonia
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

12. The 2d round campaigns: What are the messages ? …
Why is the useless consumption of antibiotics dangerous ?
bacterial get resistant
lack of new antibiotics
Do children need more antibiotics ?
No …
uselss antibiotics reduce the development of the immune defenses
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

13. Guidelines (for GP's)…
From the Belgian Antibiotic Policy Coordination Committee
acute otitis media (11/2001)
acute sore throat (11/2001)
acute cystitis in women (11/2001)
acute pyelonephritis (8/2002)
acute rhinosinusitis (11/2004)
From the National Institute for Sickness and Invalidity Insurance
upper and lower respiratory tract infections (10/2000)
acute enteric and urogenital infections (10/2001)
analysis of the available literature
ranking of evidence level (RCT, meta-analyses, expert opinion)
analysis and recommendations by a Jury
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

14. Other (more compulsory) actions …
Antibiotic Feedback …
provide GP's (and some specialists) in formations about their individual prescriptions in comparison with those of colleagues (local groups, county, country …)
together with indicators of quality, based on approved guidelines
improvement by comparison with peers
detection of major outliers …
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

15. Feedback: examples http://www.inami.be
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

16. Feedback: examples you are here Belgian data: 99 percentile
other local colleagues
Belgian data:
99 percentile
25-75% interval
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

17. Are all these actions effective ?
global antibiotic usage
curbing resistance
quality of service to patients
cost containment
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

18. Antibiotic use in PID,
H. Goossens, presentation to Press – 5 Dec 2005
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

19. Same data but in DDD … http://www.inami.be
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

20. Did we solve the S. pneumoniae resistance problem ?
macrolides
tetracyclines 40
penicillin* intermediate
penicillin* full resistant 35 30 25
percentage 20 15 10 5 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 1 2 3 4
year
H. Goossens, presentation to Press – 5 Dec 2005
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

21. Quality of service to patients ?
All we can say, so far is that the (limited) changes seen have not been accompanied by detectable increases in infectious diseases-related morbidities or mortalities …
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

22. Antibiotic reimbursements
Cost containment ? …
Antibiotic reimbursements
by Soc. Sec. in Belgium (€)
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

23. Antibiotic total expenses in Belgium (1997-2004)
H. Goossens, presentation to Press – 5 Dec 2005
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

24. Could Belgium do better ? (and does it need to ?)
we still use a lot of amoxiclav (about 50 % of all -lactams and about 1.6 x the amount of amoxicilline)
"first choices", as mentioned in guidelines, are not
followed
there is still a very large (2-3 fold) seasonal variation in relation of flu epidemics (vs. almost no variat. in Holland…)
the "message" does not go through…
in DDD, Belgians are still "high level" consumers ( 21 per 1,000 inhab. and per day; UK 14; The Netherlands  9…)
are we different and why ?
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

25. The doctor's view (and dilemma) …*
the "Belgian" socio-cultural environment is such …
I want to preserve my relation with the patient …
the employer (the kindergarten…) presses for prescription…
I have difficulty ascertaining the diagnostic …
patients won't wait ..
I simply have no time to loose with my patients…
guidelines are ill-adapted and not correctly updated …
I don’t see resistance in my patients…
If I don't prescribe, the hospital (or another GP) will criticize me, and will prescribe…
Industry is pressing me …
all these campaigns aim only at saving money for the Social Security …
* from literature survey (Tulkens et al., in prepar.)
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

26. Future (concerted) actions ? *
towards the public:
make better focused public campaigns (and make them more credible)
towards GP's
reinforce the positive aspect of the guidelines and update them regularly …
try to understand their position and do address their problems
towards Industry
control, in a positive fashion, advertisement to professionals
set price-volume contracts and/or renewed economic framework
towards the Regulatory
revise SPC's on a timely and regular fashion in relation to epidemiology and "good practice"
do not allow generics to use "old" SPCs and/or to deviate from "good practice"
* those are my ideas … but some are shared by others…
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

27. Future (concerted) actions ? *
towards the public:
make better focused public campaigns (and make them more credible)
towards GP's
reinforce the positive aspect of the guidelines and update them regularly …
try to understand their position and do address their problems
towards Industry
control, in a positive fashion, advertisement to professionals
set price-volume contracts and/or renewed economic framework
towards the Regulatory
revise SPC's on a timely and regular fashion in relation to epidemiology and "good practice"
do not allow generics to use "old" SPCs and/or to deviate from "good practice"
Belgian GP's are strongly invited (aka do need) to prescribe at least 27% of "low cost" drugs (aka generics)
* those are my ideas … but some are shared by others…
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006

28. Conclusions … All that needs to be addressed…
Resistance, antibiotic policies and clinical guidelines in the community --
Brussels - 18 Jan 2006