1. 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

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

3. 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

4. “If you cannot measure it, you cannot improve it”
Lord Kelvin,

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

6. Methicillin-Resistant Staph. aureus in Europe, 2006

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

8. 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

9. 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

10. 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.

11. Regional Variation of Outpatient Antibiotic Use in Italy

12. Regional Variation of Outpatient Antibiotic Use in Germany

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

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

15. 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

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

17. 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

18. 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

19. Belgium: a Federal Country...

20. 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

21. 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 ( )

22. Belgium www.antibiotics-info.be
> 2004

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

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

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

26. Outpatient Antibiotic Use in EUR, 1997-200653 52 52 50 46 45 44
178
170
174
169 39 42
153 38
EUR, miljoenen
146
139
122
123
108

27. 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

28. 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

29. 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

30. 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

31. Suggested logo/slogan

32. 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

33. 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

34. The European Union is making the Difference!
“The European Dream emphasizes community relationships over individual autonomy, cultural diversity over assimilation, quality of life over the accumulation of wealth, sustainable development over unilateral material growth, deep play over unrelenting toil, universal human rights and the rights of nature over property rights, over global cooperation over the unilateral exercise of power”
From: The European Dream, by Jeremy Rifkin