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Policy  –  Examples from the field

Sweden’s national strategy

There was a rapid increase in resistance to penicillin among pneumococci in southern Sweden in the early 1990s. It soon became evident that a coordinated national strategy was needed to deal with the problem, which lead to the foundation of the Swedish strategic programme against antibiotic resistance, Strama, in 1995.

Strama was formed as a voluntary network of authorities and organizations on the national level, working in close connection to a network of local Strama groups in all 21 counties of Sweden. The broad representation of authorities and expert bodies at national level helped to establish a firm basis and a wide perspective. The local groups are multi-professional teams with representatives from general medicine, infectious diseases, pediatrics, clinical microbiology, infection control/hospital hygiene, pharmacies and other experts.

A platform for knowledge sharing and implementation

Strama has been a platform on both national and local level for gathering stakeholders, for knowledge exchange, for identifying needs and for implementation of treatment guidelines and other policies. The overall goal of Strama has been to secure effective treatment of bacterial infections for the current and future generations. Primary means to reach this goal has been general awareness raising on antibiotic resistance, advocating for improving hygiene in the community and health care facilities and working towards a rational use of antibiotics (minimizing inappropriate use). Strama defines rational use as the percentage of antibiotic prescriptions in compliance with current treatment recommendations.

Support by the government

From year 2000, Strama has received financial support from the Swedish government at the national level, and from the county councils at the local level. Presently, the Public Health Agency of Sweden is the host of Strama at the national level (see Figure 1).

Strama coordination and feedback flow explained in the text
Figure 1. Illustration of STRAMA’s relationship with other actors. “Even though other actors have been larger, Strama has since the formation in 1995 often contributed with coordination and energy, by having the focus on this one only topic and by the structure of networks with close collaboration of national and regional/local levels.”

Activities and interventions

Among the many activities and strategic interventions conducted by the Strama network are the following:

National Level:

  • Arranging annual meetings for all concerned actors, both national and local
  • Monitoring and analysing the development of resistance
  • Monitoring and analysing the use of antibiotics
  • Regular revisions of national treatment recommendations
  • Developing a knowledge base and a repository of training material
  • Monitor international developments
  • Carrying out surveys regarding antibiotic prescription
  • Communicating the issue of antibiotic resistance to healthcare professionals, the media, the general public and decision-makers

Local level:

  • Monitoring local resistance and prescribing patterns.
  • Participating in annual point prevalence studies on health care associated infections
  • Deciding on annual activity plans and targets.
  • Feed-back to prescribers through regular visits to general practioners and hospital clinics
  • Local adaptation of national treatments guidelines.
  • Training of health care professionals
  • Arranging local awareness campaigns targeting the general public

Over the 20 years of Strama´s existence, significant changes have occurred of the knowledge attitudes and behavior of prescribers, other health care personnel and the general public. Inappropriate antibiotic prescribing has been substantially reduced and the level of antibiotic resistance among common pathogens are among the lowest in the EU countries.

Possible success factors:

  • Decentralized organization with local members of Strama groups that are committed to the issue of antibiotic resistance
  • Working through a bottom-up approach, close to the antibiotic providers and anchoring initiatives at the local level
  • Governmental support, mandate and funding
  • Access to data on resistance and antibiotic use
  • Multidisciplinary collaboration on the national and local levels
  • Credible, scientifically based messages and actions
  • Clear communication and media strategy

Selected Resources

Resource Description
Strama website The official strama website offers a wide range of resources from examples of clinical guidelines to data on antibiotic use and resistance.
Lessons learnt during 20 years of the Swedish strategic programme against antibiotic resistance Paper describing the development of Strama, its main strategies and lessons learnt over 20 years of working to improve antibiotic use in Sweden.
Swedish work on containment of antibiotic resistance – tools, methods and experiences A report on how Sweden has worked towards relatively low use of antibiotics per capita and favorable antibiotic resistance conditions.
Swedish work on containment of antibiotic resistance – in brief A brief summary of Sweden has worked towards relatively low use of antibiotics per capita and favourable antibiotic resistance conditions.
Strama – a Swedish working model for containment of antibiotic resistance An article describing how Strama is organized and how they work towards reduced antibiotic resistance.
Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama Program A 10 year follow up on the Strama program.
Swedish strategy to combat antibiotic resistance This strategy outlines the Swedish efforts and directions in order to help international actors who would like to benefit from the Swedish experience.

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