1. STRAMA A 10 year perspective Swedish Strategic programme for the Rational use of Antimicrobial Agents and Surveillance of Resistance www.strama.se

2. How it all started Increasing incidence of Pc-resistant pneumococci (PRP) in Southern Sweden from ~2% to 8-15% in early 1990s Deterring international experiences Who is responsible for action? Discussion between competent authorities and professional organizations resulted in the formation of a national network for containment and professional organizations resulted in the formation of a national network for containment of antibiotic resistance (January 1995) of antibiotic resistance (January 1995) Increasing incidence of Pc-resistant pneumococci (PRP) in Southern Sweden from ~2% to 8-15% in early 1990s Deterring international experiences Who is responsible for action? Discussion between competent authorities and professional organizations resulted in the formation of a national network for containment and professional organizations resulted in the formation of a national network for containment of antibiotic resistance (January 1995) of antibiotic resistance (January 1995)

3. Coordination -nationally -locally Credibility -the messages need to be scientifically sound Communication -directed towards different target groups Collaboration -with other countries, EU and WHO

4. STRAMA - Primary objectives 1.Create a cross-sectorial national forum to - share information - formulate national strategies - support and initiate research activities - collaborate with media

6. Guidelines does not work unless they are implemented ! Implementation does not work unless there is local comittment and educational outreach !

7. STRAMA - Primary objectives 2. Stimulate the formation of regional/local STRAMA - groups in every county

8. STRAMA-groups were formed in every county. The County Medical Officers for Communicable have a leading role in these groups which include specialists from different medical fields The main objective is to evaluate the use antibiotics and antibacterial resistance in the region and to improve prescribing patterns

9. STRAMA 1994-1999 Voluntary basis 2000-2002 Supported by the Swedish Government with approx 310.000 EUR yearly 2003 - 2005 Support increased to 840.000 EUR yearly

10. How did we use the financial Support from the Government? Tools for local implementation of guidelines Sales statistics, Resistance data National projects, new knowledge Newsletter, website Fund for local projects Educational activities “ STRAMA-days” Following the international scenario

11. Intensive care Hospital care Nursing homes Primary care Day care centres School children STRAMA projects initiated in many areas Barriers to implementation Clinical trials

12. MMM L K H F P O R E D T S W U AB C X Z Y AC BD I G N 450-600 600-750 750-900 Number of antibiotic prescriptions per 1000 children 0-6 years 900-1050 MMM L K H F P O R E D T S W U AB C X Z Y AC BD I G N 1999 2001 MMM L K H F P O R E D T S W U AB C X Z Y AC BD I G N 1997 1050-1200 MMM L K H F P O R E D T S W U AB C X Z Y AC BD I G N 1995

13. Sales of Antibiotics in the Nordic Countries 1978-2004 DDD/1000 inhabitants/day

14. MRSA in Europe 2004. Data from EARSS.

15. Patient Prescriber Authorities MEDIA

17. STRAMA Success factors ? Culture and tradition Involving all stakeholders Voluntary No blame-game Bridging the gap between science and politics

18. EU and antibiotic growth promoters (AGPs) Sweden bans AGPs 1986 SE and FI when EU members, derrogations1995 Avoparcin – EU ban Dec 1996 Swedish Report 1997 AGP that are also used in medicine banned1999 SSC report 1999 No more AGPs in EU from 2006

19. Coordination -nationally -locally Credibility -the messages need to be scientifically sound Communication -directed towards different target groups Collaboration -with other countries, EU and WHO