1 Institut Pasteur, 2528 rue du Dr Roux, 75724 Paris Cedex 15; 2 Centre de Recherche et de Documentation en Economie de la Santé, Paris; 3 INSERM U444, Paris, France
Received 13 January 2004; returned 19 March 2004; revised 21 April 2004; accepted 29 May 2004
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Abstract |
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Methods: The analysis used data provided by a representative annual nationwide survey of health care consumption in the community.
Results: The frequency of antibiotic use increased from 4.7 per 100 person-months in 1992 to 7.3 in 1995, and remained stable from 1998 to 2000. Children under 7 years of age were three times more strongly exposed to antibiotics than older subjects. Respiratory tract infections of probable viral aetiology and sore throat accounted for >50% of antibacterial prescriptions.
Conclusions: We identified two major priorities for campaigns designed to reduce antibiotic exposure of the French population in the community, namely respiratory tract infections of presumed viral origin, and children under 7 years of age.
Keywords: pharmacoepidemiology , anti-infectives , public health
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Introduction |
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In order to alert public health authorities, several European scientific meetings have been held over the past 5 years, including: the European Union Conference on The Microbial Threat, 910 September 1998, Copenhagen, Denmark; the European Conference on Antimicrobial Resistance, 1315 June 2001, Visby, Sweden; and the European Conference on Antibiotic Use in Europe, 1517 November 2001, Brussels, Belgium. To control this phenomenon, national and European health authorities have recently begun to support surveillance of antibiotic use13 and to promote judicious use of antimicrobials.14
As detailed information on antibiotic use in the community has been lacking since 1992,15 we analysed trends in antibiotic use in France from 1992 to 2000.
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Materials and methods |
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The survey uses a one-stage random household sampling procedure based on affiliation to the French national health insurance system. All persons living in sampled households are included in the study. Each individual is given a questionnaire on which to prospectively report all medical events and drug acquisitions during two 1-month periods, one in spring and one in autumn. These two periods are chosen to take into account seasonal variations in drug use and morbidity. The information is collected by phone, or by face-to-face interview if phone contact is not possible. Investigators contact the households twice during each 1-month period, to check the accuracy of individual information. Medical personnel then control the consistency of the recorded information.
Antimicrobials were defined as orally administered drugs belonging to the following groups: penicillins, cephalosporins, macrolides and lincosamides, quinolones, tetracyclines and others. Antibiotic acquisitions were examined according to the Anatomic Therapeutic Chemical classification.17
The following diagnoses, coded according to the Ninth International Classification of Diseases (ICD-9),18 were studied: acute nasopharyngitis (codes 460.0, 460.1 and 460.2), acute tracheitis (464.1 and 464.2), acute bronchitis (466.0, 466.1, 466.2, 493.9 and 490.9), influenza (487.9), otitis media (381 and 382), sinusitis (461 and 473), laryngitis (464.0), sore throat (462, 463 and 784.1), chronic bronchitis (491, 492 and 494), pneumonia (480, 481, 482, 483, 484, 485 and 486), lower urinary tract infection (041.4, 595.0 and 646.6) and gastroenteritis (009.0, 009.1, 009.2 and 558). Respiratory tract infection of presumed viral aetiology (RTIPV) was defined as acute nasopharyngitis, acute tracheitis, acute bronchitis or influenza. The following skin disorders were also included in the study: ICD-9 codes 191.4, 120.2, 120.3, 120.7, 1907, 1912, 1709, 1710, 1711, 1713, 1714, 1715, 1719, 1721 and 1764; as well as dental disorders 090.1 and 110.1.
Statistical analysis
We first broadly described the frequency of antibiotic acquisition according to age, regardless of the year of survey, and age-related trends from 1992 to 2000. Secondly, we analysed the antibiotic classes used in each indication, separately for children (15 years) and adults (>15 years).
In order to describe annual trends in antibiotic exposure, we estimated each year the mean weekly frequency of antibiotic acquisition for each survey period, calculated as the number of acquisitions per week divided by the number of persons investigated during the corresponding week. These frequencies were averaged for the periods studied, and were expressed as the observed frequency of antibiotic acquisition per 100 person-months (Ao). We separately examined annual trends in the following four age classes: <7 years, 715 years, 1665 years and >65 years.
Twenty-two per cent of the study weeks overlapped with the annual 'flu-like syndrome (FLS) epidemic in France, as reported by the national sentinel system Sentiweb.19 We thus estimated the frequency of antibiotic acquisition corrected for epidemic variations in FLS (Ac), by subtracting from the number of acquisitions in each epidemic week (defined as weeks with >60 FLS cases/100 000 inhabitants) the number of acquisitions explained by FLS, as predicted by a linear model linking antibiotic acquisition to the incidence of FLS during epidemic weeks.
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Results |
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Discussion |
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One important finding in this analysis is the very frequent use of antibiotics among children: antibiotic consumption among children under 7 years of age is at least three times higher than among older individuals. These results confirm that, in the community, the majority of antibacterial agents are used for RTIPV, an indication for which these drugs are not beneficial.25 Assuming that sore throat is also due to viral infection in at least 80% of cases,26 the proportion of unnecessary antibiotic acquisitions in France probably exceeds 50% in both adults and children.
HCHI provides important information on antibiotic acquisition in the community, because of its representative and standardized data collection method. Its major value for assessing temporal trends in antibiotic use is the use of the same methodology over a long period of time. Nevertheless, the HCHI has several major limitations. One potential weakness is that the appropriateness of diagnoses cannot be medically assessed. Second, it is not known whether patients completed the course of medication. Furthermore, because the survey considers only two 1-month periods each year, extrapolation of the results to yearly antibiotic exposure may be inappropriate. Nevertheless, the survey designs were identical each year. Thus, analyses of antibiotic use according to age and indication, as well as annual trends in antibiotic use, are not likely to be biased over time.
We found no decrease in antibiotic use in France since 1992, even if it may have been overestimated during weeks with a high incidence of FLS. Correction of antibiotic acquisition for the incidence of FLS offers a more precise estimation of antibacterial drug use.
In conclusion, we have developed a method for analysing trends in antibiotic use in the community, taking into account epidemic-related variations, as a decision aid for public health antibiotic policies. Two original features of our work are the analysis of antibiotic use according to age and the combining of data on antibiotic use with symptoms related to antibiotic acquisition. Thus, in order to control the antibiotic resistance selection process in the community population, this study identifies two major priorities for campaigns designed to reduce antibiotic exposure of the French population in the community, namely respiratory tract infections of presumed viral origin, and children under 7 years of age.
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Acknowledgements |
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Footnotes |
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References |
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