- Email: [email protected]
Antibiotic usage in Nordic countries
International Journal of Antimicrobial Agents 18 (2001) 279– 282 www.ischemo.org
Antibiotic usage in Nordic countries Tom Bergan * Institute of Medical Microbiology, Kaptein W. Wilhelmsen of Frues, Uni6ersity of Oslo, Rikshospitalet, Oslo 0027, Norway
Abstract The consumption of antibacterials has remained relatively stable in Scandinavia and is low compared with most other countries. Measured as ‘Defined Daily Doses’ (DDD), the highest consumption is found in Iceland and Finland, and the lowest in Denmark and Norway. The consumption in Iceland, Finland and Sweden is about twice that in Norway. The distribution of different classes of antimicrobials shows striking differences. Phenoxymethyl and benzylpenicillin make up about 55% of the DDDs in Sweden and 40% of the DDDs in Denmark and Norway, whereas the narrow-spectrum penicillins represent 20% of the DDDs in Iceland. Fluoroquinolones are little used except in Sweden where they account for about 10% of DDDs. The use of cephalosporins ranges from 1% (in Denmark) to 15% (in Finland) and between 3 and 5% in the other countries. The policy that narrow-spectrum penicillins may be used when necessary but broad-spectrum compounds should be avoided has the positive effect that there is greater susceptibility in the Nordic countries to these antibiotics than elsewhere. © 2001 Published by Elsevier Science B.V. on behalf of the International Society of Chemotherapy. Keywords: Antibiotic consumption; Nordic countries
The focus of our interest is the use of antimicrobial agents. Table 1 shows the sales of different antimicrobials in Norway. Over a five-year period, the only change is in the use of antiviral agents. The consumption of all other antimicrobials is stable and is at a very low level. The use of antimicrobials is probably reflected in the total consumption. Fig. 1 shows striking differences in the consumption of pharmaceutical products per capita between countries. Among the developed countries shown, USA, Japan and France use most products and Norway the least, following Denmark and Switzerland. Sweden and Finland are in the lower 50%. Antimicrobials make up an increasingly higher proportion as a function of the total consumption per capita and the new antimicrobials are expensive. Public spending as a percentage of public health care is particularly low in Norway followed by Denmark and Switzerland. Among other things, public spending means reimbursement. The UK, Japan and France rate fairly high but Finland and Sweden, which have higher consumption per capita, also have a higher ratio of public spending and use more antimicrobials than Norway and Denmark. * Tel.: +47-2307-1146; fax: +47-2307-1147. E-mail address: [email protected] (T. Bergan).
The more circumscribed distribution system and consequently the less costly distribution system is related to use as is shown by the higher number of inhabitants per pharmacy in Norway and Denmark than elsewhere. The greatest number of pharmacies per inhabitant is found in Greece and Spain (Fig. 2). Consumption of systemic antibacterials has remained fairly stable in the entire Nordic region throughout the 1990s (Fig. 3). Differences between the countries have been reduced but in 1995, the consumption still ranged from 12.7 to 21.3 DDDs per 1000 inhabitants per day. Iceland has long had the highest level of consumption, followed by Finland and Sweden, while Denmark has had the lowest. The recent Danish figures, however, do not include hospital sales that constitute around 10% of the total consumption in the other countries involved. The 1995 figures for Norway and the Faroe Islands were higher than those for Denmark, even if 10% use is added to the Danish figures. In 1995, sales increased in Finland, but fell slightly in Iceland, putting Finland at the top of the statistics for systematically acting antibacterials. The choice of antimicrobials varies relatively widely between the countries. The proportion of total consumption of antifungals and antibacterials as exem-
0924-8579/01/$20 © 2001 Published by Elsevier Science B.V. on behalf of the International Society of Chemotherapy. PII: S 0 9 2 4 - 8 5 7 9 ( 0 1 ) 0 0 3 8 2 - X
280
T. Bergan / International Journal of Antimicrobial Agents 18 (2001) 279–282
Table 1 Sales of antimicrobials (DDD/1000 inhabitants/24 h) in Norway [1]
Antibacterials Antimycobacterials Antimycotics Antivirals
1994
1995
1996
1997
1998
15.4 0.27 0.09 0.06
15.6 0.28 0.09 0.07
14.5 0.28 0.08 0.09
14.8 0.27 0.08 0.30
14.4 0.29 0.09 0.36
plified by tetracyclines was about a quarter in 1995 in all the countries except Denmark, where it was 13%, and in the Faroe Islands, where it was only 8%. Benzylpenicillin used in Finland and Iceland is relatively low, while its share of total consumption in 1995 was about one-third in Denmark, Norway, and Sweden, and 43% in the Faroe Islands. Broad-spectum penicillins, mainly the aminopenicillins—ampicillin, ampicillin prodrugs and amoxycillin—are used largely in Iceland, Denmark and the Faroe Islands. These antibiotics accounted for more than 20% of the antimicrobials in all these countries, but only about 10% in Norway and Sweden, and 15% in Finland. In Finland, there is a relatively high consumption of cephalosporins. In 1995, the figure was 3.0 DDD per 1000 inhabitants per day. In all the other countries, it was less than 1 DDD per 1000 inhabitants per day, and in Denmark close to zero. Cephalosporins may also be used in Denmark in hospitals, but the exact figures are not known. In Finland, cephalosporins are used in outpatient care mainly for skin and middle ear infections. The growth in consumption was levelling off in 1995, presumably as a consequence of critical discussion following reports that the use of certain antibiotics
had been accompanied by diarrhoea that could be life threatening. The use of new macrolides (azithromycin, roxithromycin and clarithromycin) is increasing, especially in Finland where the consumption of erythromycin is decreasing and is lower than in the other countries. Use of erythromycin started to decline in Finland in 1995, following reports of increased resistance among group A b-haemolytic streptococci in 1992. The consumption of new macrolides in Finland was about twice as high as that of erythromycin but was only a small proportion of the macrolide consumption in the other countries. Clarithromycin in combination with other antibiotics is also used in the eradication of Helicobacter pylori. The incidence of peptic ulcer treatment is increasing and will presumably be reflected in the sales of the antimicrobials concerned. Drug choice is greatly influenced by treatment costs and different choices of antimicrobials may be reflected in price differences between countries. In terms of wholesale prices in 1995, one DDD of a particular antibiotic was cheapest in Norway and most expensive in Finland. Denmark is excluded from this calculation, as details of hospital sales data are not available. If an
Fig. 1. Pharmaceutical consumption per capita in the OECD in 1997 [2].
T. Bergan / International Journal of Antimicrobial Agents 18 (2001) 279–282
281
Fig. 2. Inhabitants per pharmacy in Europe in 1996 [2].
Fig. 3. Sales of antibacterials for systemic use [3].
index of 100 were assigned to the price level in Norway, corresponding figures for antibiotics in the other countries would be 101 for Iceland, 122 for Sweden and 138 for Finland. The usage level of antimicrobials influences resistance more than costs, i.e. increasing number of resistant bacteria resulting from the over-consumption of antimicrobials. Such problems have been encountered in Iceland where penicillin-resistant pneumococci have been spreading; in Finland, group A streptococci have developed erythromycin resistance. In Sweden, fluoroquinolones are used in urinary tract infections more than in other Nordic countries and a warning of
growing resistance has recently been issued on the basis of a similar experience in Spain. Preliminary findings suggesting declining resistance because of diminished use of antibiotics have been reported from Iceland, and Finland (unpublished results). Vancomycin has remained the one antibiotic to which human pathogen have so far not developed resistance in Scandinavia. The use of vancomycin should be carefully restricted to ensure that the usually susceptible Gram-positive organisms remain susceptible. Consumption figures from the Nordic countries show that the use of vancomycin has continued to be very limited—in 1995 it was 0.01 DDD per 1000
282
T. Bergan / International Journal of Antimicrobial Agents 18 (2001) 279–282
inhabitants per day in Finland, Iceland, Norway and Sweden. Danish figures were not available. The level and structure of consumption of antibiotics reveal very little about the quality of treatment. A more detailed assessment of differences and their significance requires data concerning the infections and the causative microorganisms against which the different antibiotics were used. It is also important to know what proportions of particular infections are treated with antibiotics. Studies from the Nordic countries have shown that acute tonsillitis is treated in a very similar manner in Denmark, Norway, Finland and Sweden, while there are appreciable differences in the treatment of acute otitis. Reimbursement arrangements for systemically acting antibiotics have recently been changed in Norway and Denmark. From the beginning of 1996, patients in Norway have not been entitled to reimbursement of drug cost in acute infections. This has been the case in Iceland since 1991. In Denmark, the rate of reimbursement for antibiotics was reduced in 1996 from 75 to 49.8%, and tetracyclines are no longer reimbursable. In Finland, since 1994, antimicrobials for chronic urinary
infections have been reimbursed at a rate of 50% instead of the earlier 75%— all other antimicrobials are also in the 50% reimbursement category. In all the Nordic countries, the consumption of benzyl and phenoxymethylpenicillin is greater than in most other countries. These have been used despite some opposition, for the initial treatment of pneumonia, because of the remaining favourable susceptibility. Most antimicrobials used are antibacterial as, e.g. in Norway and their total consumption is increasing. The use of penicillins and cephalosporins has increased butthat of tetracyclines and sulphonamides have decreased.
References [1] Tall og fakta 2000. Legemidler og helsevesen. [Figures and facts 2000. Drugs and health care]. Norwegian Association of Pharmaceutical Manufacturers. Oslo, 2000. p 1 – 46. [2] Legemiddleforbruket I Norge [Drug consumption in Norway] 1994 – 1998. Norsk Medisinaldepot. Oslo, 1999. p. 41 and 129 – 138. [3] Nordic statistics on Medicines 1993 – 1995. Nordiska Lakemedelsnamnden. Upssala, 1996. p. 92 – 95.
Antibiotic usage in Nordic countries Tom Bergan * Institute of Medical Microbiology, Kaptein W. Wilhelmsen of Frues, Uni6ersity of Oslo, Rikshospitalet, Oslo 0027, Norway
Abstract The consumption of antibacterials has remained relatively stable in Scandinavia and is low compared with most other countries. Measured as ‘Defined Daily Doses’ (DDD), the highest consumption is found in Iceland and Finland, and the lowest in Denmark and Norway. The consumption in Iceland, Finland and Sweden is about twice that in Norway. The distribution of different classes of antimicrobials shows striking differences. Phenoxymethyl and benzylpenicillin make up about 55% of the DDDs in Sweden and 40% of the DDDs in Denmark and Norway, whereas the narrow-spectrum penicillins represent 20% of the DDDs in Iceland. Fluoroquinolones are little used except in Sweden where they account for about 10% of DDDs. The use of cephalosporins ranges from 1% (in Denmark) to 15% (in Finland) and between 3 and 5% in the other countries. The policy that narrow-spectrum penicillins may be used when necessary but broad-spectrum compounds should be avoided has the positive effect that there is greater susceptibility in the Nordic countries to these antibiotics than elsewhere. © 2001 Published by Elsevier Science B.V. on behalf of the International Society of Chemotherapy. Keywords: Antibiotic consumption; Nordic countries
The focus of our interest is the use of antimicrobial agents. Table 1 shows the sales of different antimicrobials in Norway. Over a five-year period, the only change is in the use of antiviral agents. The consumption of all other antimicrobials is stable and is at a very low level. The use of antimicrobials is probably reflected in the total consumption. Fig. 1 shows striking differences in the consumption of pharmaceutical products per capita between countries. Among the developed countries shown, USA, Japan and France use most products and Norway the least, following Denmark and Switzerland. Sweden and Finland are in the lower 50%. Antimicrobials make up an increasingly higher proportion as a function of the total consumption per capita and the new antimicrobials are expensive. Public spending as a percentage of public health care is particularly low in Norway followed by Denmark and Switzerland. Among other things, public spending means reimbursement. The UK, Japan and France rate fairly high but Finland and Sweden, which have higher consumption per capita, also have a higher ratio of public spending and use more antimicrobials than Norway and Denmark. * Tel.: +47-2307-1146; fax: +47-2307-1147. E-mail address: [email protected] (T. Bergan).
The more circumscribed distribution system and consequently the less costly distribution system is related to use as is shown by the higher number of inhabitants per pharmacy in Norway and Denmark than elsewhere. The greatest number of pharmacies per inhabitant is found in Greece and Spain (Fig. 2). Consumption of systemic antibacterials has remained fairly stable in the entire Nordic region throughout the 1990s (Fig. 3). Differences between the countries have been reduced but in 1995, the consumption still ranged from 12.7 to 21.3 DDDs per 1000 inhabitants per day. Iceland has long had the highest level of consumption, followed by Finland and Sweden, while Denmark has had the lowest. The recent Danish figures, however, do not include hospital sales that constitute around 10% of the total consumption in the other countries involved. The 1995 figures for Norway and the Faroe Islands were higher than those for Denmark, even if 10% use is added to the Danish figures. In 1995, sales increased in Finland, but fell slightly in Iceland, putting Finland at the top of the statistics for systematically acting antibacterials. The choice of antimicrobials varies relatively widely between the countries. The proportion of total consumption of antifungals and antibacterials as exem-
0924-8579/01/$20 © 2001 Published by Elsevier Science B.V. on behalf of the International Society of Chemotherapy. PII: S 0 9 2 4 - 8 5 7 9 ( 0 1 ) 0 0 3 8 2 - X
280
T. Bergan / International Journal of Antimicrobial Agents 18 (2001) 279–282
Table 1 Sales of antimicrobials (DDD/1000 inhabitants/24 h) in Norway [1]
Antibacterials Antimycobacterials Antimycotics Antivirals
1994
1995
1996
1997
1998
15.4 0.27 0.09 0.06
15.6 0.28 0.09 0.07
14.5 0.28 0.08 0.09
14.8 0.27 0.08 0.30
14.4 0.29 0.09 0.36
plified by tetracyclines was about a quarter in 1995 in all the countries except Denmark, where it was 13%, and in the Faroe Islands, where it was only 8%. Benzylpenicillin used in Finland and Iceland is relatively low, while its share of total consumption in 1995 was about one-third in Denmark, Norway, and Sweden, and 43% in the Faroe Islands. Broad-spectum penicillins, mainly the aminopenicillins—ampicillin, ampicillin prodrugs and amoxycillin—are used largely in Iceland, Denmark and the Faroe Islands. These antibiotics accounted for more than 20% of the antimicrobials in all these countries, but only about 10% in Norway and Sweden, and 15% in Finland. In Finland, there is a relatively high consumption of cephalosporins. In 1995, the figure was 3.0 DDD per 1000 inhabitants per day. In all the other countries, it was less than 1 DDD per 1000 inhabitants per day, and in Denmark close to zero. Cephalosporins may also be used in Denmark in hospitals, but the exact figures are not known. In Finland, cephalosporins are used in outpatient care mainly for skin and middle ear infections. The growth in consumption was levelling off in 1995, presumably as a consequence of critical discussion following reports that the use of certain antibiotics
had been accompanied by diarrhoea that could be life threatening. The use of new macrolides (azithromycin, roxithromycin and clarithromycin) is increasing, especially in Finland where the consumption of erythromycin is decreasing and is lower than in the other countries. Use of erythromycin started to decline in Finland in 1995, following reports of increased resistance among group A b-haemolytic streptococci in 1992. The consumption of new macrolides in Finland was about twice as high as that of erythromycin but was only a small proportion of the macrolide consumption in the other countries. Clarithromycin in combination with other antibiotics is also used in the eradication of Helicobacter pylori. The incidence of peptic ulcer treatment is increasing and will presumably be reflected in the sales of the antimicrobials concerned. Drug choice is greatly influenced by treatment costs and different choices of antimicrobials may be reflected in price differences between countries. In terms of wholesale prices in 1995, one DDD of a particular antibiotic was cheapest in Norway and most expensive in Finland. Denmark is excluded from this calculation, as details of hospital sales data are not available. If an
Fig. 1. Pharmaceutical consumption per capita in the OECD in 1997 [2].
T. Bergan / International Journal of Antimicrobial Agents 18 (2001) 279–282
281
Fig. 2. Inhabitants per pharmacy in Europe in 1996 [2].
Fig. 3. Sales of antibacterials for systemic use [3].
index of 100 were assigned to the price level in Norway, corresponding figures for antibiotics in the other countries would be 101 for Iceland, 122 for Sweden and 138 for Finland. The usage level of antimicrobials influences resistance more than costs, i.e. increasing number of resistant bacteria resulting from the over-consumption of antimicrobials. Such problems have been encountered in Iceland where penicillin-resistant pneumococci have been spreading; in Finland, group A streptococci have developed erythromycin resistance. In Sweden, fluoroquinolones are used in urinary tract infections more than in other Nordic countries and a warning of
growing resistance has recently been issued on the basis of a similar experience in Spain. Preliminary findings suggesting declining resistance because of diminished use of antibiotics have been reported from Iceland, and Finland (unpublished results). Vancomycin has remained the one antibiotic to which human pathogen have so far not developed resistance in Scandinavia. The use of vancomycin should be carefully restricted to ensure that the usually susceptible Gram-positive organisms remain susceptible. Consumption figures from the Nordic countries show that the use of vancomycin has continued to be very limited—in 1995 it was 0.01 DDD per 1000
282
T. Bergan / International Journal of Antimicrobial Agents 18 (2001) 279–282
inhabitants per day in Finland, Iceland, Norway and Sweden. Danish figures were not available. The level and structure of consumption of antibiotics reveal very little about the quality of treatment. A more detailed assessment of differences and their significance requires data concerning the infections and the causative microorganisms against which the different antibiotics were used. It is also important to know what proportions of particular infections are treated with antibiotics. Studies from the Nordic countries have shown that acute tonsillitis is treated in a very similar manner in Denmark, Norway, Finland and Sweden, while there are appreciable differences in the treatment of acute otitis. Reimbursement arrangements for systemically acting antibiotics have recently been changed in Norway and Denmark. From the beginning of 1996, patients in Norway have not been entitled to reimbursement of drug cost in acute infections. This has been the case in Iceland since 1991. In Denmark, the rate of reimbursement for antibiotics was reduced in 1996 from 75 to 49.8%, and tetracyclines are no longer reimbursable. In Finland, since 1994, antimicrobials for chronic urinary
infections have been reimbursed at a rate of 50% instead of the earlier 75%— all other antimicrobials are also in the 50% reimbursement category. In all the Nordic countries, the consumption of benzyl and phenoxymethylpenicillin is greater than in most other countries. These have been used despite some opposition, for the initial treatment of pneumonia, because of the remaining favourable susceptibility. Most antimicrobials used are antibacterial as, e.g. in Norway and their total consumption is increasing. The use of penicillins and cephalosporins has increased butthat of tetracyclines and sulphonamides have decreased.
References [1] Tall og fakta 2000. Legemidler og helsevesen. [Figures and facts 2000. Drugs and health care]. Norwegian Association of Pharmaceutical Manufacturers. Oslo, 2000. p 1 – 46. [2] Legemiddleforbruket I Norge [Drug consumption in Norway] 1994 – 1998. Norsk Medisinaldepot. Oslo, 1999. p. 41 and 129 – 138. [3] Nordic statistics on Medicines 1993 – 1995. Nordiska Lakemedelsnamnden. Upssala, 1996. p. 92 – 95.