DETERMINANTS OF ANTIBIOTIC CONSUMPTION

3. DETERMINANTS OF ANTIBIOTIC CONSUMPTION

It is a very difficult task to explain or to speculate as to why antibiotic use in the French community is so high. Despite clear guidelines on antibiotic use for presumed viral respiratory tract infection (PVRTI) over the last 10 years, the proportion of patients with PVRTI for whom antibiotics were prescribed remained high. Furthermore, antibiotic use tended to increase between 1984 and 1995, to treat acute media otitis and bronchitis, but remained almost stable for rhinopharyngitis or tonsillitis (Observatoire National des Prescriptions et Consommations des Médicaments, 1998)

In contrast to certain northern European countries, in France, acute otitis media is considered as a pathology requiring antibiotic therapy. No element explaining the increased prescription of antibiotics for bronchitis has been clearly identified. The frequency of antibiotic prescriptions in sore throats reached 90% in 1984. Obviously, no increase would be expected but no sponta- neous decrease occurred despite a viral cause of circa two thirds of these infec- tions. Although the frequency of rhinopharyngitis infections treated by antibiotics rose, the proportion of these infections treated with antibiotics was not really modified, suggesting either an enhanced incidence of these infections or more consultations for them. At the present time, approximately 80 million antibiotic prescriptions per year are written for the 60 million inhabitants of continental France. One of the hypotheses to explain the important increase of antibiotic use could be the increased incidence of these diseases, especially

Antibiotic Use in the Community: The French Experience 587 PVRTI in children (Holmes et al., 1996). In France as in others countries, epi-

demiologically documented data concerning these community infections are lacking. Thus, reasons for the enhanced antibiotic exposure of community populations is far from being clearly documented.

3.1. Sociocultural and historical factors

A reason for the late collective awakening to the potential impact of popu- lation exposure to antibiotic may be the traditional approach of microbiology in France where infectious agents are studied at bacterial strain and at patient levels, rather than on an epidemiological scale.

Another fact is that in France, regardless of the pharmaceutical class, drug consumption is very high. In 2002, national expenditure on health was esti- mated at 139 billion euros, representing 9.5% of GND with the main part attributed to drug consumption (286 billion euros) (Fenina and Geffroy, 2002). In particular, antibiotics, psychotropic agents and drug for venous insuffi- ciency are overprescribed, in comparison to other European countries (Bouvenot, 1999; Garattini, 1998; Pelissolo et al., 1996).

Because antibiotic exposure is also high in other south-western European nations—Spain, Portugal, and Belgium (Cars et al., 2001)—this distribution could reflect the influence of sociocultural factors.

Another factor is the collective concept of antibiotics. These drugs are con- sidered by a major part of the French population to be very powerful drugs with few and minor side effects. Patients often believe that antibiotics are the answer for many infections (Hamm et al., 1996). Recently, before the onset of the national campaign for the optimisation of antibiotic use in the community, the CNAMTS promoted a survey on the public’s perception of antibiotics: 39% of the questioned people thought that antibiotics were effective against viral infections. Their expectations might have a major impact on over- prescribing, regardless of doctors’ opinions (Macfarlane et al., 1997).

3.2. Medical density

It is well known that patient pressure influences doctors’ decisions to pre- scribe, even when antibiotics are clinically unnecessary (Butler et al., 1998). In an area where medical density is high (303 general practitioners/100,000 inhabitants in France, 424 in Spain, 554 in Italy) (WHO Estimation of Health Personnel, 2003), patient pressure may be stronger when patients who did not receive an antibiotic are dissatisfied and could very easily consult another general practitioner.

588 Agnès Sommet and Didier Guillemot

3.3. Pharmaceutical firms pressure

The main objective of pharmaceutical firms, like other producers, is to generate profits. Antimicrobial agents represent the fourth most common ther- apeutic class for pharmaceutic expenditures, after cardiovascular, neurocere- bral, and digestive system treatments (Lancry et al., 2002). Because antibiotics account for a large part of industry profit in France, production and promotion is, historically, one of the highest among European countries (European Federation of Pharmaceutical Industries and Associations, 2003). In fact phar- maceutical firms may have generated a culture of use by pressuring physicians to prescribe. This situation is now probably behind us.