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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, timeseries 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 0–6 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% (p<0.05) 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 0–6 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 0–6 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 0–6
years.
Sweden
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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
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. It’s 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.
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.
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.
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
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 0–6 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% (p<0.05) 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 0–6 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 0–6 years from
1997 to 2002.
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.
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 1999;31:191-195.
 Ekdahl K, Cars O. Role of communicable disease control measures
in affecting the spread of resistant pneumococci: the Swedish model.
Clin Microbiol Infect 1999;5:4S48-4S54.
 Stålsby Lundborg C, Olsson E, Mölstad S, and the Swedish Study
Group on Antibiotic Use. Antibiotic prescribing in outpatients – a oneweek diagnosis–prescribing study in five counties in Sweden. Scand J
Infect Dis 2002;34:442,48.
 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.
2002;34:880-6.
 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