Southern Europe

3.1. Southern Europe

In Spain the problem of antimicrobial resistance, mainly among community- acquired bacterial pathogens, resulted in the generation of a Task Force by the Ministry of Health to address the problem (Baquero et al., 1996). Members of this panel were academic experts in clinical microbiology, infectious diseases (in both children and adults), internal medicine, clinical epidemiology, veterinary micro- biology, and public health administration. The proposals of this task force were included in the document “Antibiotic resistance in Spain: what can be done” whose objective was to provide a comprehensive framework to support the neces- sary actions. The recommendations of this task force included all aspects and interested parts of the problem and is a paradigm of a global approach to the issue of antibiotic policies as a way to fight antimicrobial resistance:

1. Data on Antibiotic resistance: (a) Continuous collection of data on resistance in human isolates, isolates

from animals, and food of animal origin. (b) Detection of antibiotics and antibiotic resistance in the environment. (c) Continuous collection of data on human consumption of antibiotics. (d) Regular estimation of direct uncontrolled procurement of antibiotics by

the public.

548 Moyssis Lelekis and Panos Gargalianos

2. Physicians (the prescribers): (a) Periodic collection of pharmacotherapeutic antimicrobial profiles of

office-based physicians. (b) Periodic updating of physicians concerning consensus recommendations on clinical and laboratory diagnosis of the most common community- acquired infections and possible treatment protocols.

(c) Assurance of easy access for community-based clinicians to microbio- logical laboratories and data on local resistance patterns of the more frequent pathogens.

(d) Promotion of education on rational use of antibiotics. (e) Optimization of the medical consultation time spent per patient in com-

munity clinics. (f) Establishment of committees on antibiotic policies at the national, regional, and local levels.

3. Patients and consumers: (a) Dissemination of information about antibiotic resistance. (b) Dissemination of information to the food industry on the dangers of

uncontrolled use of antibiotics in feed or water for therapeutic or pro- phylactic purposes.

4. Pharmacists (the dispensers): (a) Promotion of pharmacists as agents for the rational use of antimicrobials. (b) Continuous inspection to prevent the over the counter delivery of

antibiotics.

5. Veterinary medicine: (a) Standardization of veterinarians prescription forms for the therapeutic

or prophylactic use of antimicrobials in animals. (b) Encouragement of the rational use of antimicrobials in veterinary medicine and as growth promoters including specific education on antibiotic use in veterinary schools.

6. Pharmaceutical industry: (a) Support to the industry for research and development of new antibiotics

to overcome resistance. (b) Provision of incentives for the companies ready to cooperate in various ways for the control of resistance.

7. The Health administration: (a) Consideration of the potential impact on antibiotic resistance should be

incorporated into the evaluation of new antimicrobials. (b) Provision of better information in package inserts. (c) Establishment of programs for rational use of antibiotics in humans. (d) Reevaluation of products used as feed additives and of antibiotics used

in veterinary medicine.

National Policies and Antibiotic Prescribing 549 (e) Organization of local or regional committees for identifying outbreaks of

resistant organisms and for analyzing and instituting control procedures. (f ) Evaluation of the role of vaccines in the control of antimicrobial resistance.

Indirect information on the efficacy of the above extensive measures is available through a recent publication concerning antibiotic consumption in Spain from 1985 to 2000 (Bengoa et al., 2002). The data analysis states clearly, that consumption had three periods. During the first one (1985–1989), there was a mild decreasing trend, while during the second lasting until 1995, there was a generalised increase in all antibiotic classes. During the third period, beginning in 1996, there is a sustained and generalized decline of antibiotic consumption. This last significant decrease is attributed by the authors to the campaign launched by public administration, to promote the rational use of these agents (Bengoa et al., 2002).

In Greece, in the 1980s, extremely high resistance rates were reported among important nosocomial pathogens, which correlated well with very high antibiotic consumption in hospitals (ESGAR, 1987; Giamarellou et al., 1986). As a result, an antibiotic restriction policy was established in Greek hospitals in late 1980s concerning the newer and more potent antibiotics. In fact, a restrictive order form was introduced for third generation cephalosporins, carbapenems, gly- copeptides, newer quinolones, and aztreonam. Even though this policy has never been subject to regular audit, sporadic reports showed that it worked, at least in the beginning (Giamarellou and Antoniadou, 1997; Lelekis et al., 1993). Since it was apparent that the compliance to this policy had a downwards route, the policy was reinforced in 2003, with a regulatory order by the Ministry of Health.

In the year 2000, the National Committee for Nosocomial Infections published a guide for antimicrobial chemotherapy and prophylaxis for the hos- pitalized patient. The guide was distributed to all hospital doctors. In late 2002, an audit performed in two tertiary care hospitals and three provincial sec- ondary care ones, revealed that 76% of physicians were aware of the existence of this guide and 61% had a copy. However, only 49% of those who had it, used it on a regular basis for their everyday practice (Lelekis et al., 2003). It is worth noting that hospital formularies do not exist in Greek hospitals and a significant number of generics are used, (five for ciprofloxacin and four for cefuroxime in many hospitals).

In the community, according to state regulations, antibiotics should be dispensed only with a physician’s prescription. However there is no control what- soever to detect and punish the over the counter sale of antibiotics which contin- ues in significant rate (Contopoulos-Ioannidis et al., 2001). By regulatory order oral third generation cephalosporins and newer quinolones are restricted in the community. However the exceptions in this order for quinolones allows a

550 Moyssis Lelekis and Panos Gargalianos significant consumption of these agents (ESAC, 2003). A campaign for the public

has been initiated since year 2001. It includes television spots and booklets dis- couraging the over the counter sale of antibiotics and their use in cases of viral infections. Moreover a guide for the use of antibiotics in the community is being prepared and will soon be distributed to ambulatory care physicians. Besides interventions for antibiotic prescribing, there has been a change in the willingness of microbiologists to refer antibiotic resistance rates for the most important pathogens to a centralized resistance surveillance system. Thus, it is now easier to have data in a more generalized level (Vatopoulos et al., 1999).

In Italy, a nationwide survey was conducted in year 2000 to quantify the prevalence in Italian hospitals of policies aimed to reduce the emergence and dissemination of resistant strains (Moro et al., 2003). The overall response rate was 80% (428/535). Of the respondents, 9.6% claimed to have implemented a surveillance system of antimicrobial resistance, 90% had a hospital formulary in place, 50% had a pharmacy committee, and 18% had an antibiotic policy subcommittee that met at least once a year in 1999. Restriction policies were implemented on 41% based on written justifications for antibiotics and 8% pro- vided susceptibility results for first line antibiotics only. In only 11% of cases, antibiotic consumption was monitored, by using the defined daily dose (DDD) as a unit of measure. Moreover 58.6% claimed to have defined clinical prac- tice guidelines for hand washing, 36.4% for isolation procedures and 1.6% for the control of methicillin-resistant Staphylococcus aureus (MRSA) infections. The overall conclusion of this survey was that there is a lot more to be done in Italy concerning antibiotic policies.