Review
Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme

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Summary

Increasing use of antibiotics and the spread of resistant pneumococcal clones in the early 1990s alarmed the medical profession and medical authorities in Sweden. Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance) was therefore started in 1994 to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics and development of new knowledge. Between 1995 and 2004, antibiotic use for outpatients decreased from 15·7 to 12·6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5–14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Although the epidemic spread in southern Sweden of penicillin-resistant Streptococcus pneumoniae was curbed, the national frequency increased from 4% to 6%. Resistance remained low in most other bacterial species during this period. This multidisciplinary, coordinated programme has contributed to the reduction of antibiotic use without measurable negative consequences. However, antibiotic resistance in several bacterial species is slowly increasing, which has led to calls for continued sustained efforts to preserve the effectiveness of available antibiotics.

Introduction

Bacterial resistance to antibiotics, both at the individual and community levels, is an unavoidable side-effect of consumption of these drugs.1 Antibiotic resistance limits the available treatment options and causes increased morbidity and mortality as well as increased costs because of failure of the empirical therapy.2, 3 During the past two decades, resistance to antibiotics has become a major public-health concern, mainly caused by national and international spread of multiresistant bacterial clones and the declining interest from the pharmaceutical industry in research and development of new antibacterial drugs.

Sweden has a population of about 9 million, and its national health-care insurance system encompasses all inhabitants. The 21 county councils have the main responsibility for health care, which is supplied mainly by public providers, but also by private providers through contracts with the county councils. Primary and secondary care is organised through each county council, and regional university hospitals provide tertiary care services. All outpatient pharmacies belong to one parastatal company, Apoteket AB, which has about 900 pharmacies in the country. The financing of health care is mainly public. Approximately 8·3% of gross national product was spent on health care in 2004, and of this approximately 13·4% was spent on drugs. There is co-payment for both health care and drugs, with separate ceiling costs. On average, about 24% of medicine costs are paid by patients, but the reimbursement is stepwise with full co-payment of up to 900 Swedish krona (US$118) per year. Dental care is not included in health-care reimbursement.

In Sweden, antibiotic use increased constantly during the 1980s and the beginning of the 1990s. The detection of several multiresistant pneumococcal clones in the early 1990s among young children, especially in day-care centres in Skåne county in southern Sweden, alarmed the medical profession and the medical authorities, and prompted coordinated efforts to prevent further spread of these resistant clones.4 A national organisation, Strama (the Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance), was initiated in 1994 and came into action in 1995. The overall aim of Strama is to preserve the effectiveness of available antimicrobial agents. Although pneumococcal resistance in the community was the first target of Strama, the programme has continuously expanded, and today comprises activities within many fields, including primary care, hospital care, nursing homes, and day-care centres. Since 2000, Strama has received financial support from the Swedish government. The aim of this Review is to describe the Strama programme and summarise the results of the first 10 years.

Section snippets

National level

Strama is composed of a national steering group and regional Strama groups in every Swedish county (panel). The national Strama group includes a broad representation of professional organisations and relevant authorities. The main objectives of the national group are to coordinate activities for the containment of antibiotic resistance at the national level. Activities include the analysis of trends in antibiotic resistance and consumption, identification of gaps in knowledge, initiation of

Antibiotic use

Data on outpatient antibiotic sales has been available in Sweden since 1974 from Apoteket AB (the National Corporation of Swedish Pharmacies) in defined daily doses (DDD) per 1000 inhabitants per day, according to WHO guidelines,5 and as the number of prescriptions per 1000 inhabitants per year for different age-groups and geographical areas. All regional Strama groups are given regional data on antibiotic use by local pharmacists.

Between 1995 and 2004, total antibiotic use (excluding

Antibiotic resistance

In Sweden, there are 30 clinical microbiological laboratories, with at least one laboratory for each county. The antimicrobial susceptibility testing methods of Swedish laboratories are well standardised through the work of the Swedish Reference Group of Antibiotics, methodology subcommittee (SRGA-M), and the 30 laboratories.13 Species-specific susceptibility breakpoints are used. Validation of susceptibility testing by histogram analysis is done annually, and internal control is done daily or

Infection control

The use of alcohol handrub rather than soap handwashing has been recommended for disinfection of hands between patient contacts in Swedish hospitals since the 1970s. Sweden has been one of few countries with less than 1% resistance to meticillin among invasive isolates of S aureus. However, recent spread of MRSA in a few hospitals in Sweden has underscored the need for increasing activities in the field of infection control. Between 1997 and 2000, the largest Swedish outbreak of an endemic

Indicators for detecting antibiotic underprescribing

From the national registry of diagnosis in hospital care (National Board of Health and Welfare), the number of patients with acute sinusitis, quinsy (peritonsillar abscess), and acute mastoiditis was followed for different age-groups between 1987 and 2003. According to this registry, hospital admissions for acute mastoiditis, quinsy, and acute rhinosinusitis in children were stable or decreased during this period (figure 4).6 Thus, there were no signs of underprescribing. We also noted a large

Other activities

In 2000, the National Board of Health and Welfare, in close cooperation with Strama, prepared a national action plan to contain antibiotic resistance in Sweden.26 The objectives of this plan are used in the development of the annual work plans for Strama activities.

New national guidelines were developed for the treatment of acute otitis media in 2000, for acute pharyngotonsillitis and impetigo in 2002, and for acute sinusitis in 2005. The guidelines for the treatment of UTIs was updated in

Comparison with other countries and future perspectives

Non-prescribed use of antibiotics is very low in Sweden compared with other European countries.27, 28 The survey of hospital admissions for certain infectious diagnoses that may be related to below optimum antibiotic use showed that these diagnoses have been stable or declining, despite the reduction in prescribing to children (figure 4); these findings are in agreement with a UK study.29

Antibiotic use varies between countries, but also with regard to class of antibiotics, dosage, and treatment

Benefits and limitations

The Strama project was not designed to be scientifically evaluated, but instead to be an ongoing coordinated national effort to decrease antibiotic use and spread of resistance. The project lacks a validated control, but antibiotic use has not decreased in the neighbouring countries of Denmark, Norway, or Finland.43 We believe that the coordination of different professions and authorities, and the decentralised organisation with regional groups for the dissemination and implementation of

Conclusions

In Sweden, Strama has played a major part in the reduction of total antibiotic use, in preserving phenoxymethylpenicillin as the drug of choice in most respiratory tract infections, and may have limited the spread of multiresistant pneumococcal clones. To reach the long-term aim to preserve the effectiveness of antibiotics, improved basic hygiene precautions, improved antibiotic treatments in terms of choice, dosage, and length of treatment, and further reductions in antibiotic use are needed.

Search strategy and selection criteria

Data for this Review were identified through reference lists of relevant papers and the authors own files. Additionally, data were identified by searches of PubMed. English language papers only were reviewed. No date restrictions were set in these searches.

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