How do people obtain antibiotics in European countries: an overview Dominique L. Monnet, Programme Coordinator Senior Expert, Scientific Advice Unit & the National Antimicrobial Resistance Focal Points ecdc.europa.eu
Determinants of Self-Medication With Antibiotics in Europe Self-medication with antibiotics in Europe is the result of: poor awareness about the indications and risks of using antibiotics (predisposing factors) availability of antibiotics without having to consult a physician, either directly at a pharmacy or from rests of previous prescriptions (enabling factors) Source: SAR, SANCO SPC333; Grigoryan et al. J Antimicrob Chemother 8;61:117-79.
Spain Greece Portugal Netherlands Italy Germany Austria Sweden United Kingdom Obtained their last course of antibiotic without a medical prescription (% antibiotic users) Ireland Denmark Finland Belgium France Luxembourg Antibiotics Obtained Over-The-Counter: Special Eurobarometer, 1 1 8 6 4 Source: Special Eurobarometer 183-3 (58.), 3. 3
Lithuania Romania Spain Malta Croatia Slovakia United Kingdom Ireland Belgium Austria Czech Republic Poland Sweden Netherlands Luxembourg Obtained at least one course of antibiotic, by source (% respondents) Slovenia Italy Denmark Source of Antibiotics: SAR Study, -3 (1) 6 With a prescription Other source (e.g., left-over from previous course, relative, friend) Over-the-counter, directly at a pharmacy 4 Source: SAR, SANCO SPC333; Grigoryan et al. (unpublished data). 4
Lithuania Romania Spain Italy Malta Slovakia Poland Croatia Slovenia Ireland United Kingdom Luxembourg Belgium Austria Czech Republic Denmark Sweden Netherlands Self-medication with antibiotics, by source (% respondents) Self-Medication With Antibiotics, by Source: SAR Study, -3 () 5 Other source (e.g., left-over from previous course, relative, friend) Over-the-counter, directly at a pharmacy 15 1 5 Source: SAR, SANCO SPC333; Grigoryan et al. (unpublished data). 5
ECDC Survey, September 8 E-mail questionnaire 9 National Antimicrobial Resistance Focal Points (may have delegated their reply - or part of - to a competent person/national institution) Questions: According to your knowledge, how frequently are packages of systemic antibiotics sold without a prescription at pharmacies in your country (this includes situations where a prescription is provided after the dispensation) current situation in 8? What is the legal status for dispensation of packages of systemic antibiotics at pharmacies in your country (national legislation)? Copies of national scientific publications Copies of national legislation 6
Thank you! Sigrid Metz-Gercek (Austria), Samuel Coenen (Belgium), Todor Kantardjiev & Mihail Petrov (Bulgaria), Despo Pieridou- Bagatzouni (Cyprus), Jiří Vlček & Jan Švihovec (Czech Rep.), Niels Frimodt-Møller (Denmark), Kuulo Kutsar (Estonia), Pirkko Paakkari & Pentti Huovinen (Finland), Jean-Michel Azanowsky (France), Tim Eckmanns & Inge Mücke (Germany), Anastasia Antoniadou & Helen Giamarellou (Greece), Karolina Böröcz (Hungary), Robert Cunney (Ireland), Pietro Folino Gallo (Italy), Uga Dumpis (Latvia), Rolanda Valinteliene (Lithuania), Elisabeth Heisbourg & Marcel Bruch (Luxembourg), Peter Zarb (Malta), Inge C. Gyssens, Larissa Grigoryan & Flora M. Haaijer- Ruskamp (Netherlands), Waleria Hryniewicz (Poland), Cristina Costa (Portugal), Anda Băicuş (Romania), Leonard Siegfried (Slovakia), Milan Čižman (Slovenia), José Campos (Spain), Anders Tegnell & Gunilla Skoog (Sweden), Sally Wellsteed & MHRA (UK), Karl Kristinsson & Haraldur Briem (Iceland), Gunnar Skov Simonsen (Norway) 7
No. countries Frequency of Packages of Systemic Antibiotics Being Sold Without a Prescription at Pharmacies, 8 (1) 5 15 1 5 Very rarely (<1% disp.) Rarely (1-5% disp.) Sometimes (5.1-1% disp.) Commonly (>1% disp.) Source: National Antimicrobial Resistance Focal Points et al., 8. 8
Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom Iceland Norway Frequency of Packages of Systemic Antibiotics Being Sold Without a Prescription at Pharmacies, 8 () 5 4 Commonly (>1% disp.) 3 Sometimes (5.1-1% disp.) Rarely (1-5% disp.) 1 Very rarely <1% disp.) Source: National Antimicrobial Resistance Focal Points et al., 8. 9
% users who obtained last antibiotic course OTC (Eurobarometer, ) % users who obtained OTC antibiotics (SAR study, -3) Comparison with Previous Surveys 6 4 15 countries 17 countries 8 6 4 very 1 rarely some- 3 commonly 4 5 very 1 rarely some- 3 commonly 4 5 rarely times rarely times Freq. antibiotics dispensed OTC (National AMR Focal Points, 8) Freq. antibiotics dispensed OTC (National AMR Focal Points, 8) Source: Special Eurobarometer 183-3 (58.), 3; SAR, SANCO SPC333; Grigoryan et al. (unpublished data); National Antimicrobial Resistance Focal Points et al., 8. 1
No. countries Legal Status for Dispensation of Packages of Systemic Antibiotics at Pharmacies (National Legislation) 5 15 1 5 Only with a prescription Depends on the situation Without a prescription Source: National Antimicrobial Resistance Focal Points et al., 8. 11
Prescription Only Medicine Status to Pharmacy Status, United Kingdom From October 8, it is possible for UK patients who are asymptomatic but who have a diagnosed genital infection with Chlamydia to obtain from pharmacists (without a prescription) a single dose of azithromycin, representing a complete treatment course. Applications for a similar change have been submitted to the Medicines and Healthcare Products Regulatory Agency (MHRA) for: Trimethoprim for uncomplicated UTI Nitrofurantoin for uncomplicated UTI Source: Sally Wellsteed (National AMR Focal Point, UK) & BSAC. 1
% users who obtained last antibiotic course OTC (Eurobarometer, ) Exploring Determinants (1) 6 NS R =.67 P<.1 4 4 6 8 1 %interviewed who know that antibiotics do not kill viruses (Eurobarometer, 1) Source: Special Eurobarometer 183-3 (58.), 3; Eurobarometer 55., 1. 13
% users who obtained last antibiotic course OTC (Eurobarometer, ) % users who obtained last antibiotic course OTC (Eurobarometer, ) Exploring Determinants () 6 R =.8 P=.4 6 R =.67 P<.1 4 4 4 6 8 1 5 6 7 8 Persons very or fairly satisfied with their health care system (%, 1999) Responsiveness of health care system (index, 1999) Source: Special Eurobarometer 183-3 (58.), 3; Eurostat, 1; World Health Report,. 14
% users who obtained last antibiotic course OTC (Eurobarometer, ) Annual revenues from sales of pharmaceuticals per public pharmacy (Million PPP US$, 1997) Exploring Determinants (3) 6.5 NS.4 4.3..1 R =.59 P=.1 5, 1, 15,, 5, 1, 15,, No. inhabitants per public pharmacy (1997) No. inhabitants per public pharmacy (1997) Source: Special Eurobarometer 183-3 (58.), 3; GIRP and IMS Health. 15
Conclusion Despite being illegal, over-the-counter dispensation of systemic antibiotics still occurs in several EU Member States. The extent to which this occurs should be further assessed in all 7 Member States and EEA/EFTA countries, as well as candidate countries by, e.g. performing a new Eurobarometer survey. Countries that did not participate in the SAR study as well as those countries that have taken action since should consider a national study based on the SAR protocol. 16