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Eurosurveillance, Volume 11, Issue 2, 12 January 2006
Articles

Citation style for this article: Editorial team. Ensuring prudent use of antimicrobials in human medicine: forceful action needed in Europe. Euro Surveill. 2006;11(2):pii=2873. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2873

Ensuring prudent use of antimicrobials in human medicine: forceful action needed in Europe

Editorial team (eurosurveillance.weekly@hpa.org.uk), Eurosurveillance editorial office

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;
• Research.

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 [1] .

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 [2], 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 resistance
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 throughout Europe.

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, http://www.earss.rivm.nl), 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 (EUCAST, http://www.escmid.org/sites/index_f.aspx?par=2.4) 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 plans;
• 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 developing countries

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 link: http://europa.eu.int/comm/health/ph_threats/com/comm_diseases_cons01_en.htm.

References:
  1. Report from the Commission to the Council on basis of member states’ reports on the implementation of the Council Recommendation (2002/77/EC) on the prudent use of antimicrobial agents in human medicine. COM (2005) 0684. Brussels: Commission of the European Communities; 22 December 2005. (http://europa.eu.int/comm/health/ph_threats/com/mic_res/com684_en.pdf)
  2. DIRECTIVE 2004/27/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 31 March 2004 amending Directive 2001/83/EC on the Community code relating to medicinal products for human use (Text with EEA relevance). Official Journal of the European Union 2004; L 136/34: 30.4.2004. (http://europa.eu.int/eur-lex/pri/en/oj/dat/2004/l_136/l_13620040430en00340057.pdf)

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