ANTIBIOTIC USE IN FRANCE

2. ANTIBIOTIC USE IN FRANCE

2.1. Data sources

Historically, the first description of the evolution of antibiotic use in the community in France was obtained from the Enquête Décennale sur la Santé et les Soins Médicaux (EDSSM, Decennial Inquiry on Health and Medical

Antibiotic Policies: Theory and Practice. Edited by Gould and van der Meer Kluwer Academic / Plenum Publishers, New York, 2005

584 Agnès Sommet and Didier Guillemot Care). The survey is a source of information on health and outpatient care that

has been conducted every 10 years since 1960. It uses a one-stage probability sampling procedure based on the last population census. The sampling unit is the household (all persons living in each house sampled are included), and the survey covers a 3-month period. All household members are asked to note every medical event, physician consultation, diagnosis as stated by the practi- tioner, and drug purchase that occurred during the 3-month period. Investigators visit households five times during this period, to check the accu- racy of each individual’s information. Results of this inquiry, based on broad representative samples of the French population (⬎20,000 inhabitants) with a response rate exceeding 90%, are representative of an entire year, excluding the summer months. The first evaluations of antibiotic consumption using the EDSSM database, are relatively recent. These analyses intended to compare trends in antibiomicrobial drug use in the French community between 1981 and 1992. By extrapolation, the annual estimation was 0.7 antibiotic purchases per person and year in 1981 (Guillemot et al., 1998). The main antibiotic classes bought were ␤-lactams and macrolides. The overall annual estimate of antibiotic use increased to 1.2 antibiotic purchases per person and year in 1991. Penicillins remained the main antibiotic class used, while cephalo- sporins came in second, rising to 20.8% annual rate use. Between 1980 and 1991, the overall annual rate of antibiotic use increased by an average of 3.9% each year for children and 3.0% for adults. In 1980, respiratory tract infections with presumed viral aetiology (acute nasopharyngitis, acute tracheitis, acute bronchitis, influenza) were already the leading indications for antimicrobial use. These clinical situations were also associated with the strongest augmen- tation of antibiotic use between 1980 and 1992. The frequency of these diag- noses treated with antibiotics, rose by 115% for children and by 86% for adults during this period. Because antibiotic use in such circumstances cannot be jus- tified, unnecessary antibiotic use can be estimated at ⬎50%.

Antibiotic use in the French population can also be estimated from differ- ent independent databases. The mandatory annual reporting by pharmaceutical companies of their antibiotics sales in France, also represent a major source of information. These data have been available since 1988. The French Health Products Safety Agency (AFSSAPS, Agence Française de Sécurité Sanitaire et des Produits de Santé) currently analyses these data by counting the number of boxes of antibiotics sold. The results were recently reported by the European Surveillance of Antimicrobial Consumption (ESAC). Since the recorded infor- mation enables accurate identification of each galenic formulation and pack- aging form of each drug, the results can be expressed as defined daily dose (DDD) per person and year. The estimations of French antibiotic sales rose from 12.8 DDD per person and year in 1997 to 13.3 DDD per person and year in 2001. This increase is in keeping with European comparisons obtained by

Antibiotic Use in the Community: The French Experience 585 analysing Information Medical Services (IMS) databases as recently published

(Cars et al., 2001). According to that analysis, antibiotic sales in France were estimated at 36.5 DDD per 1,000 inhabitants per day (DID) in 1997, that is,

13.3 DDD per person and year. Pertinently, in 2001, outpatient care accounted for 90% of the overall antibiotic sales, as opposed to 10% for hospital use. ␤-Lactams represent circa 60% of total use and the very high consumption of broad-spectrum penicillins, cephalosporins, and macrolides can be noted for every year (Elseviers et al., 2003). The strength of the AFSSAPS database is its exhaustiveness and its potential availability since 1988. But it only provides national and annual data, without more precise information on regional trends or monthly or weekly rates.

France, like other European countries, is not lacking in databases. In addi- tion to those cited above, other sources are available (Table 1). For example, the Centre for Research and Documentation on Health Economics (CREDES, Centre de Resource et de Documentation en Economie de la Santé) conducts an annual survey devoted to the surveillance of healthcare expenditures in France. The recent analysis of these data clearly showed that children are the predominant consumers of antibiotics. Children under 6 years old are around four times more exposed than adults (Sommet et al., submitted). Moreover, the French national health insurance (CNAMTS, Caisse Nationnale d’Assurance Maladie des Travailleurs Salariés, CANAM, Caisse Nationnale d’Assurance Maladie des Professions Indépendantes, MSA, Mutualité Sociale Agricole) can provide quasi-exhaustive information on antibiotic deliveries. These data are currently being analysed to determine the impact of the French national campaign “to preserve the efficacy of antibiotics.”

2.2. Units of measurement

The DDD system was developed by an independent scientific committee participating in the WHO Collaborative Centre for Drug Statistics Methodology to measure and compare drug use at an international level (WHO, 2001). DDD is recognised worldwide and is very useful to compare countries. Nevertheless, since DDD is based on a theoretical daily dose, it does not necessarily reflect the recommended or prescribed daily dose. In France, antibiotic prescriptions follow recommendations established by the French Society of Infectious Diseases in collaboration with the French National Drug Agency. French daily recommended doses are often higher than DDD. For example, the DDD for amoxicillin is 1 g per person per day, whereas the French recommended dose for pneumonia is 3 g per person per day (Quatrième Conférence de Consensus en Thérapeutique Anti-Infectieuse, 1992). For this reason, application of the DDD system could overestimate the frequency of antibiotic use. Thus, the

586 Agnès Sommet and Didier Guillemot frequency of new antibiotic prescriptions for a defined period of time (gener-

ally 1 year) and expressed as the number of new antibiotic courses per person and year, cannot be extrapolated from results of antibiotic consumption expressed as DDD. As Wessling et al. showed the number of real antibiotic users and the number estimated by the DDD system differed by 4–28% (Wessling and Boethius, 1990). Nevertheless, new prescription frequencies for a defined period of time is an important indicator to monitor therapeutic practices and should be studied within the framework of a public health plan.

Another reason for the difference noted between DDD and prescribed dose is that DDD is defined as a dose for an adult. What does antibiotic use expressed in DDD mean in two different geographic areas where the numbers of children differ? This difference leads to major difficulties in comparison, for example, of rural and urban zones, to affirm differences in terms of anti- biotic exposure. Therefore, to take these variations into account, France will probably use both DDD and frequencies of new antibiotic prescriptions as tools for antibiotic consumption surveillance.