News and Opinions  –  2017

Lessons learned from 20 years of working to improve antibiotic use in Sweden

2017-11-01

In the early 1990s, a group of clinical specialists in Sweden realized that action was needed against antibiotic resistance, as multi-drug resistant pneumococci were increasingly seen among children. Although Sweden has a well-structured health care system, the antibiotic stewardship efforts were weak and not coordinated. While some physicians had seen the huge impact of antibiotics on health first-hand, many seemed oblivious to the consequences of overuse.

Strama-in-WHO-Bulletin-November-2017, a group of authors review the work done by the Swedish strategic programme against antibiotic resistance (Strama) during the last 20 years and summarize some lessons that have been learned over the years.

Multidisciplinary work

Since its inception, Strama has worked across sectors and disciplines, adopting a OneHealth perspective. One component of this perspective is that as antibiotic resistance crosses boundaries, so must all work to contain it. Groups of engaged health care professionals were organized on a local level, and these groups formed a nation-wide council as a platform for the work. The Strama-program started gaining both influence and funding gradually and is today an integral part of Swedish health care. The local groups adapt national initiatives and guidelines to local conditions, and identify barriers and needs to be addressed. Strama has been active in creating treatment guidelines, monitoring antibiotic use, setting national targets for outpatient use, surveillance of antibiotic resistance, infection control and communication.

Guidelines

Treatment guidelines are created for national level use, but need to be implemented and in some sense adapted to local level circumstances. For this purpose, the network of local groups has been instrumental – guidelines are not just imposed from above, but are anchored in the clinical experience of the region. Good guidelines need to include diagnostic criteria, assessments of risks and benefits, give clear advice on how to use antibiotics and monitor actual prescription rates.

Monitoring use

A key factor for monitoring antibiotic use is access to reliable statistics. In Sweden, statistics on antibiotic prescriptions and sales are recorded, so Strama made the data available to prescribers, policy makers, health care providers and the media. The statistics generated great interest, especially the variations between different clinics and regions. However, the statistics did not contain information on diagnoses and did not have sufficient resolution to be able to identify where improvement was necessary. Also, statistics are generally presented as defined daily doses per 1000 inhabitants and year, which is not a good measure for antibiotics.

For the purpose of reducing unnecessary use, targets indicating how many prescriptions are acceptable were developed. Such targets need to be viewed on sufficiently high levels –for example a region rather than a health centre, as some centres serves patients with a higher need of antibiotics. Signs of undertreatment were also incorporated in the monitoring framework.

Empiric therapy is a major source of inappropriate prescribing. The Swedish system has been well built to incorporate surveillance into the routine clinical diagnostics. Access to data on resistance has therefore been easy to accomplish through improving communication between the laboratories and prescribers. However, since the patients from whom samples are taken are ill, they are not representative of the whole population in the country. The resistance levels may be thus be overestimated.

Hygiene

It is evident that it is better to prevent getting an infection than to treat it. Following up on basic hygiene measures such as dress codes and hand hygiene were introduced early in Sweden, but to maintain compliance, the measures need to be supported by all levels. For this, evidence of cost-effectiveness and maintaining physical conditions that minimize transmission need to be communicated to decision makers.

Communication

Communication to both the general public and to prescribers is also important. For the individual, the adverse effects of their unnecessary use needs to be made clear. This is a daunting task, as antibiotic resistance and overuse does not have a “face”. There is not one disease called “antibiotic resistance”, which can be easily communicated through media. For the prescribers, the situation is somewhat easier, and regular reports of resistance and summaries of guidelines have been well received.

Future challenges

Overall, Strama has played an instrumental role in decreasing antibiotic use on all levels in Sweden over the past 20 years. No measurable negative consequences on public health have been seen, and rates of resistance have stayed comparably low so far. As the problem of resistance can never be solved, only managed, it is important to keep the work ongoing and secure resources for that work. The experiences so far show that the model of working bottom-up, close to prescribers, has been successful and should be continued.

Timeline of Swedish work against antibiotic resistance

1986 – Antimicrobial growth promotion in animals banned
1994 – Annual point prevalence studies started
1995 – Strama founded
1999 – Sweden joined EARS-Net
2000 – First Swedish National Action Plan
2009 – National quantitative target proposed
2012 – Intersectoral coordinating mechanism formed

Further reading

Article: Mölstad s, Löfmark S, Carlin K et al. Lessons learnt during 20 years of the Swedish strategic program against antibiotic resistance. Bulletin of the World Health Organization, Article ID: BLT.16.184374