COLLECTIVE AWAKENING AND PROGRESSIVE MOBILIZATION OF FRENCH PUBLIC HEALTH AUTHORITIES

4. COLLECTIVE AWAKENING AND PROGRESSIVE MOBILIZATION OF FRENCH PUBLIC HEALTH AUTHORITIES

Over the past 10 years, several actions have been promoted by French pub- lic health authorities to optimise antibiotic use and thereby control bacterial resistance to them. In 1996, National Guidelines for the Good Use of Antibiotics in Hospitals were published by the French National Agency for Medical Practice Evaluation (Agence Nationale pour le Développement de l’Evaluation Médicale, 1996). Hospital drug committees had to target antibiotic use and implement the in-hospital monitoring of antibiotics. The use of patient- identified prescriptions for antibiotics was recommended to be followed by sys- tematic re-evaluation of these prescriptions 3 days after their initiation.

The French National Report on the Use of Antibiotics in the Community was issued in 1998 (Observatoire National des Prescriptions et Consommations des Médicaments, 1998). That evaluation promoted by the French Health Products Safety Agency (AFSSAPS) suggested for the first time that 50% of community antibiotic prescriptions were unnecessary. In 1999, the French Institute for Public Health Surveillance (InVS, Institut de Veille Sanitaire) published the National Report on the Control of Bacterial Resistance in which

a scheme was defined for the surveillance and control of antimicrobial resis- tance (Groupe de travail sur la Maîtrise de la résistance aux antibiotiques, 1999). In addition, that report identified the need to promote and support research in different domains (microbiology, pharmacoepidemiology, socio- economy, public health [Guillemot and Courvalin, 2001]).

Also in that year, antibiotic use was investigated for the first time in all French healthcare centres (Direction des Etudes Médico-Economiques et de l’Information Scientifique, 2002). Sixty-six per cent of the centres reported that their institution had established guidelines on antibiotic use and this was

Antibiotic Use in the Community: The French Experience 589

Table 1. Characteristics of different French data sources on antibiotic consumption Data source

Weaknesses Sales data,

Data provider

Strengths

Annual data (Outpatient and

Pharmaceutical

Exhaustiveness

firms (annual drug Available for each year Do not precisely hospital care)

reflect the use firms to AFSSAPS)

sales declared by

since 1988

EDSSM CREDES, INSEE Available since 1960 Based on a sample (outpatient care)

Reflects real acquisition of the population, during a 3-month period

Information on

Only every 10 years symptoms (not clinical

Only at a national diagnoses) are available

level Healthcare and

CREDES Available for each year Based on a sample Health insurance

between 1988 and 1998, of the population, survey

during two 1- month (ambulatory care)

and every 2 years

since 1998

periods each year. Only every 2 years

Reflects real use

Only at a national level

Information on symptoms (not clinical diagnoses) are available

EPAS CNAMTS

Prospective data

Based on a sample

collection

of the population Individual follow-up of

Does not precisely

antibiotic use

reflect the exact deliveries. No clinical information

Health insurances CNAMTS,

Exhaustiveness

information CANAM, MSA system

Detailed and precise No clinical information on galenic

information

formulation and

No information packaging form of each

on posology

drug Individual follow-up of antibiotic use may be possible in the future

Notes: AFSSAPS: French Health Products Safety Agency; EDSSM: Decennial Inquiry on Health and Medical Care; CREDES: Centre for Research and Documentation on Health Economics; EPAS: Permanent Sample of Health Insured Individuals; CNAMTS: French National Employees’ Health Insurance; CANAM: French National Independent Workers’ Health Insurance; MSA: French National Farmers’ Health Insurance; INSEE: National Institute for Statistics and Economic Studies.

590 Agnès Sommet and Didier Guillemot more likely for those with an on-site drug committee, a specialist in infectious

diseases or in hospitals with more than 200 beds. Only 21% of the centres had patient-identified antibiotic delivery, while 43% had mixed records for patient- identified and global delivery of antibiotics. Prescription monitoring was fully computerised in about 15% of the centres.

More recently a childhood infection-prevention programme was promoted with an information campaign tailored to physicians and parents in the south of France (Carbon et al., 2002; Pradier et al., 2003). One of the main innovations of that experimental programme was its use of peer counselling of prescribers, which has been incorporated into the National Programme to Preserve Antimicrobial Efficacy, launched in October 2002.

That national programme, which is scheduled to run from 2002 to 2005 (Cremieux et al., 2001) has seven objectives: (1) to improve the public’s and physicians’ information on the importance of appropriate antibiotic use and the risks of overprescribing; (2) to perform a rapid diagnostic test for strepto- coccal tonsillitis, available for all health professionals; (3) to improve appro- priate antibiotic use in hospital care; (4) to improve information exchanges between the community and hospital and in particular in the counselling pro- vided by the specialist for the prescription of antibiotics in the community; (5) to improve training of prescribers; (6) to improve surveillance of both antibiotic consumption and bacterial resistance of the main pathogens both in the community and in the hospital; and (7) to improve the national coordina- tion of these different actions. To achieve these objectives, a national commit- tee representing professionals and the different scientific and public health agencies has been asked to monitor the implementation of the plan.

The last piece of the French puzzle will probably be put in place over the next few months. The parliament will have to define the national public health policy for the next 5 years. Antibiotic resistance will probably be one of the objectives having top priority with the aim of reducing antibiotic use in the community by 25% in order to decrease the rate of penicillin non-susceptible pneumococci to less than 30%.

Because the national plan to preserve the efficacy of antibiotics started in October 2002, it is still too early to evaluate its impact on antibiotic consump- tion and bacterial resistance. A retro-prospective analysis will take into account immediate historical and future data (2000–5) from different sources available in France (Table 1).