Ensuring prudent use of antimicrobials in human medicine: forceful
action needed in Europe
In November 2001, the Council of the European Union adopted
a Recommendation (2002/77/EC) outlining actions to support the prudent use
of antimicrobials in human medicine.
Member states were recommended to put in place a national strategy for
tackling antimicrobial resistance in human medicine. National strategies
should include at least the following points:
• Surveillance of antimicrobial resistance and antimicrobial use;
• Control and prevention of antimicrobial resistance;
• Education and training about the problem;
In 2005, European Union (EU) member states, and other states in the European
Economic Area were asked to their progress in implementing the Recommendation
as basis for future actions. The European Commission received reports from
all 25 member states, Iceland, Norway and Bulgaria and issued a summary
report to the Council on 22 December  .
Surveillance of antimicrobial resistance and use
Almost all countries have systems in place that monitor antimicrobial use.
Fourteen of the 28 countries reported unhindered access to data on antimicrobial
resistance. The majority of countries have coordinated actions to improve
prescribing practices, although eight countries reported no such actions.
No country had continuous feedback on prescribing practices of practitioners.
Among the problems that countries faced in implementing surveillance and
feedback were lack of sustained financial basis, unclear legal status, and
regulation of privacy problems.
Control and prevention of antimicrobial resistance measures
Although it has been illegal to sell antibiotics without a prescription
throughout the European Union since October 2005 , it was recognised
that this practice occurred in seven countries. No country was able to estimate
the proportion of antimicrobials sold without prescription. Sixteen countries
have measures in place to enforce regulations for prescription only use
of systemic antimicrobials.
Most countries have nationally accepted guidelines on appropriate use of
antimicrobials for surgical prophylaxis and other common human infections,
although very few countries have monitored the impact of these guidelines
on prescribing practices.
Twenty two countries report having a national programme for hospital hygiene
and infection control, which include details of standard procedures, number
of staff and organisation, in place. Eighteen countries have national guidelines
for control of multiresistant pathogens, which are, however, mostly only
concerned with methicillin-resistant Staphylococcus aureus.
Education and training of professionals and general public on antimicrobial
Not all European health professional trainees receive training on control
of antimicrobial resistance, although they do receive some relevant training
after they have received their profession qualifications.
All but six countries have conducted campaigns in the past five years to
raise awareness on topics related to antimicrobial resistance. Most of these
educational activities were directed at health professionals rather than
the general public.
The Council has recommended that each state have in place national or regional
committees to coordinate the implementation of the Council Recommendation.
Twenty EU countries, two EEA countries and Bulgaria have such a body. The
responsibilities and legal status of these committees varies widely.
Progress at European Community level
The European Medicines Agency (EMEA) is working with national regulation
authorities to make the Summary of Product Characteristics for antimicrobials
consistent in all countries. This will help to define which products (apart
from antibiotics, all of which are prescription only) are prescription only
In recent years the Commission has co-funded a number of projects dealing
with the problem of antimicrobial resistance such as two very large surveillance
networks. The European Antimicrobial Resistance Surveillance System (EARSS,
which collects and compares pathogen resistance data according to a common
protocol currently from about 800 laboratories from 28 countries. European
Surveillance on Antimicrobial Consumption (ESAC, http://www.esac.ua.ac.be)
implemented a prospective data collection system, based on a validated register
of available antibiotic products according to an international classification.
In 2003, the European Committee on Antimicrobial Susceptibility Testing
began receiving financial support from the European Commission. The aim
of EUCAST is to harmonise the definition and measurement of antimicrobial
resistance among the EU member states. EUCAST is helping to devise pan-European
education for laboratory scientists on antimicrobial testing and standard
reference methods. The Commission has also co-funded a self-medication and
anti-microbial resistance project to assess the problem of self medication
with antibiotics in Europe and preliminary results are available on the
Commission's website at http://europa.eu.int/comm/health/ph_threats/com/mic_res/am_sar_project_en.htm.
Current priorities defined by the Commission are:
• Ensuring all countries have developed and implemented national action
• Ensuring all countries have an appropriate national/regional committees
to coordinate national action and the implementation of the Council Recommendation;
• Encouraging the ability of data to be broken down into lower levels (at
local level, hospitals, pathogens);
• Improving feedback on prescribing practices;
• Improving collaboration between human and animal health sectors on antibiotic
resistance and antibiotic use in all countries;
• Tackling self-medication by education of the general public, and ensuring
there are clear measures to enforce prescription-only use of systemic antimicrobials;
• Encouraging production of nationally accepted guidelines recommending
appropriate antibiotic treatment, at least for the most common human infections;
• Encouraging governments to ensure that each hospital and nursing home
should have its own infection control committee/system in place. Countries
should consider making infection control part of the accreditation procedure
for hospitals and nursing homes;
• Exchanging best practice concerning antimicrobial resistance, vaccination
campaigns and hygiene/infection control between member states;
• Extension of resistance surveillance to cover antivirals and anti-parasitic
agents as well as antibacterial agents.
The European Centre for Disease Prevention and Control (ECDC) is now taking
a leading role in operating European surveillance in the area of antimicrobial
resistance, and can help member states to make a difference in the coordination
of prevention and control of antimicrobial resistance.
As antimicrobial resistance is a global problem with impact on European
countries, it is important to maintain close links with EU external actions,
such as those strengthening pharmaceutical policies and health systems in
Not only is the emergence of resistance under selective pressure of antibiotic
use a problem, but the spread of resistance in healthcare settings is another
important driver of the resistance problem. It is expected that healthcare-associated
infections will constitute an increasing burden of disease in European societies,
and the Commission has opened a public consultation on strategies to prevent
and control healthcare-associated infections. This consultation is open
until 20 January 2006 and contributions are welcome through the following