Improving Antibiotic use through a Nationwide Decentralized Project

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Improving Antibiotic use through a Nationwide
Decentralized Project A Nine-Year Experience
Cars O, Stålsby Lundborg C, Mölstad S Swedish
Strategic Programme for the Rational use of
Antimicrobial Agents and Surveillance of
Resistance (STRAMA), Sweden Problem Statement In
the early 1990s, an increase in
penicillin-resistant pneumococci (PRP) in
children in southern Sweden led to the creation
of a multiprofessional national network of
experts from all main stakeholders in the
antibiotic field to address the problem.
Objectives To describe antibiotic use and
resistance patterns in different regions, age
groups, and patient populations and to reduce
inappropriate antibiotic use, especially in
primary care, in order to hold antimicrobial
resistance (AMR) at the lowest possible
level. Design Randomized controlled trials,
different types of quasi-experimental designs,
time-series analysis, and cross-sectional
studies, depending on possibilities in each
situation. Setting and Population All Swedish
counties, mainly in the area of public primary
care, with data collection through pharmacies and
primary care services. Intervention National
media and information campaigns, aimed at
influencing consumers and prescribers, were
developed and implemented with the collaboration
of various stakeholders such as Drug and
Therapeutic Committees (DTCs) and pharmacies. In
addition, multifaceted interventions, mainly
targeting general practicioners and focusing on
specific subject areas appropriate to local
needs, were developed and carried out.
Interventions included development of local
treatment guidelines and implementation of the
guidelines through educational outreach that
utilized discussion as well as group and/or
individual feedback on prescriptions and written
simulated cases. Outcome Measures National and
local dispensing data in general, and divided by
age and sex, expressed as defined daily
dose/1,000 inhabitants per day (DDD/TID) or
number of prescriptions per ATC code resistance
frequencies in key pathogens. Results National
antibiotic sales decreased by 22 from 1993 to
2002 (17.7 to 13.9 DDD/TID). National dispensing
of macrolides decreased among children 06 years
from 3.7 DDD/TID in 1993 to 1 DDD/TID in 2002.
Use of quinolones for uncomplicated urinary tract
infection decreased from 21 to 12 (plt0.05)
between 2000 and 2002, in accordance with
guidelines, in five counties that conducted a
diagnosis-prescribing study. Unexplained wide
variations in antibiotic sales data between
counties and communities is seen antibiotic
prescriptions per 1,000 children 06 years varied
from 400 to 1,400 per year in 1998, and between
250 and 1,000 in 2002. For the age group above
80, variation was between 600 and 1,700.
Antibiotic resistance in general is stable. For
PRP, a decrease in incidence from 100 to 53 per
100,000 inhabitants was seen for children 06
years from 1997 to 2002. Conclusions There were
significant changes in total antibiotic use in
targeted groups and antibiotic classes. Marginal
or no increase in national resistance rates has
been seen, in contrast to the situation in many
other countries. PRP incidence has decreased
among children 06 years.
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• Sweden
• Population 8.867 million
• Total expenditure on health as of GDP 8.7
• Life expectancy 80.4 years
• Under five mortality rate per 1000 3.5
• Mainly publicly funded healthcare
• Drug sales are exclusively through the National
  Corporation of Swedish Pharmacies (Apoteket AB),
  owned by the state and non profit-orientated
•  

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Background In the early 1990s, an increase in
penicillin-resistant pneumococci (PRP) in
children in southern Sweden led to the creation
of a multiprofessional national network of
experts from all main stakeholders in the
antibiotic field to address the problem. Its
main objectives are to describe antibiotic use
and resistance patterns in different regions, age
groups, and patient populations and to reduce
inappropriate antibiotic use, especially in
primary care, in order to hold antimicrobial
resistance (AMR) at the lowest possible
level. STRAMA The Swedish Strategic programme for
the Rational Use of Antimicrobial Agents and
Surveillance of Resistance STRAMA was
established in 1995 following discussions between
several national authorities and organisations.
The main aim was to create a decentralised
organisation to establish a broad base throughout
the country. Through the County Medical Officers
at least one regional STRAMA-group was
established in each county. The national
management board of STRAMA is made up of the
following Swedish public bodies and
organisations The Institute for Infectious
Disease Control, The Association of County
Medical Officers, The National Board of Health
and Welfare, The Medical Products Agency, The
Society of Medicine's Reference Group on
Antibiotics, The Infection Control Association,
The Federation of County Councils, The
Association of Local Authorities, Apoteket AB,
The National Veterinary Institute and The Board
of Agriculture. Since 2000 STRAMA has financial
support from the Swedish the government.    
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Local STRAMA groups In each county at least one
STRAMA-group has been formed. The County Medical
Officers for Communicable Diseases are acting as
chairmen of these regional groups which include
specialists from different medical fields e.g.
general practice, infectious diseases, ENT,
paediatrics, clinical microbiology, as well as
pharmacists. The group's main objective is to
evaluate the local utilisation of antibiotics and
the local pattern of bacterial resistance as well
as to implement guidelines for treatment of
common infectious diseases.
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Drug consumption data Since 1975, the national
Corporation of Swedish Pharmacies produces sales
statistics on medicines. Data can be presented as
out patient care divided in sex and age or
hospital care data. To facilitate studies from a
medical point of view, defined daily doses (DDD)
as well as number of prescriptions are used as a
unit of comparison. The DDD for a drug is
established on the basis of the assumed average
dose per day for the drug given to adults for its
main indication. This classification together
with the Anatomical Therapeutic chemical (ATC)
classification system is recommended and
continuously updated by WHO. Resistance data In
Sweden surveillance of certain resistant
pathogens are regulated in the Communicable
Disease Act. Reports of isolated
penicillin-resistant Streptococcus pneumoniae,
methicillin-resistant Staphylococcus aureus and
vancomycin-resistant enterococci. Notification
shall be done to The Swedish Institute for
Infectious Disease Control. In addition to this a
combined surveillance and quality control
programme has been in place since 1994 where 30
microbiological laboratories, using standardized
methods, collect quantitative data for defined
antibiotics in consecutive clinical isolates of a
number of bacterial species.
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• Intervention National media and information
  campaigns, aimed at influencing consumers and
  prescribers, were developed and implemented with
  the collaboration of various stakeholders such as
  Drug and Therapeutic Committees (DTCs) and
  pharmacies. In addition, multifaceted
  interventions, mainly targeting general
  practitioners and focussing on specific subject
  areas appropriate to local needs, were developed
  and carried out. Interventions included
  development of local treatment guidelines and
  implementation of the guidelines through
  educational outreach that utilized discussions as
  well as group and/or individual feedback on
  prescriptions and written simulated cases.
• Examples of local projects
• Parent education in day care centres
• Educational material about infections and
  antibiotics
• for 10 year old school children
• Written simulated cases as educational tools in
  infectious diseases
• Evaluation of antibiotic treatment for acute
  otitis media among children
• Nosocomial infections within community nursing
  homes
• Infections in primary care antibiotic use in
  relation to diagnosis
•   

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• Results
• National antibiotic sales decreased by 22 from
  1993 to 2002 (17.7 to 13.9 DDD/TID), even more
  prominent in children 0-6 years (Figure 1).
• National dispensing of macrolides decreased
  among children 06 years from 3.7 DDD/TID in 1993
  to 1 DDD/TID in 2002 (Figure 2).
• Use of quinolones for uncomplicated urinary
  tract infection decreased from 21 to 12
  (plt0.05) between 2000 and 2002 in accordance with
  guidelines, in five counties that conducted a
  diagnosis-prescribing study (Figure 3).
• However the same study showed an continued high
  consumption for acute bronchitis (Figure 4).
• Unexplained wide variations in antibiotic sales
  data between counties and communities was seen
  antibiotic prescriptions per 1,000 children 06
  years varied from 400 to 1,400 per year in 1998,
  and between 250 and 1,000 in 2002. For the age
  group above 80, variation was between 600 and
  1,700. Antibiotic resistance in general is
  stable. For PRP, a decrease in incidence from 100
  to 53 per 100,000 inhabitants was seen for
  children 06 years from 1997 to 2002.
•   

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• Conclusions
• A nationwide decentralised system for rational
  antibiotic use has been effective in Sweden for
  10 years.
• There were significant changes in total
  antibiotic use especially for children.
• Resistance levels for upper respiratory tract
  pathogens has been stable.
• PRP incidence has decreased among children 0-6
  years.

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• Examples of references
• Mölstad S, Cars O. Major Change in the Use of
  Antibiotics following a National Programme
  Swedish Strategic Programme for the Rational use
  of Antimicrobial Agents and Surveillance of
  Resistance (STRAMA). Scand J Infect Dis
  199931191-195.
• Ekdahl K, Cars O. Role of communicable disease
  control measures in affecting the spread of
  resistant pneumococci the Swedish model. Clin
  Microbiol Infect 199954S48-4S54.
• Stålsby Lundborg C, Olsson E, Mölstad S, and the
  Swedish Study Group on Antibiotic Use. Antibiotic
  prescribing in outpatients a one-week
  diagnosisprescribing study in five counties in
  Sweden. Scand J Infect Dis 200234442,48.
• Andre M, Odenholt I, Schwan A, Axelsson I,
  Eriksson M, Hoffman M, Molstad S, Runehagen A,
  Stålsby Lundborg C, Wahlstrom R Swedish Study
  Group on Antibiotic Use. Upper respiratory tract
  infections in general practice diagnosis,
  antibiotic prescribing, duration of symptoms and
  use of diagnostic tests. Scand J Infect Dis.
  200234880-6.
• Andre M, Mölstad S, Stålsby Lundborg C, Odenholt
  I, Axelsson I, Eriksson M, Runehagen A, Schwan Å.
  Management of urinary tract infections in primary
  care a repeated 1-week diagnosis-prescribing
  study in 5 counties in 2000 and 2002. Accepted in
  Scand J Infect Dis.
• www.strama.se