Like in many other countries, antibiotic use in Sweden increased steadily during the 1980's and early 1990's. At the same time, a rapid spread of multidrug-resistant pneumococci was seen among children in southern Sweden. In the early 1990s, a group of clinical specialists and medical authorities realized that action was needed to halt this development, and initiated the Swedish strategic programme against antibiotic resistance - Strama. Since then, Strama has worked to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics. Here, selected components of Strama's work to improve antibiotic use are described together with lessons learnt in the process.
The formation of Strama
Although Sweden has a well-structured health care system, the antibiotic stewardship efforts were weak and not well coordinated. While some physicians had seen the huge impact of antibiotics on health first-hand, many seemed oblivious to the consequences of overuse. Strama was formed in 1995 and started as a voluntary network of professional organizations and government authorities. 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. A key component for establishing a long-term, sustainable effort has been to work through a bottom-up approach, working closely with antibiotic providers and anchoring efforts at the local level.
Data on antibiotic use a key driver for change
Sweden has good access to antibiotic sales data both on the community and hospital levels. Through Strama, such data were made available to antibiotic prescribers, policy makers, health care providers and the media. It generated great interest, especially with regard to the large and unexplained geographical variations and variations between clinics. Comparison of such data among the medical profession led to discussions and initiated interventions to improve rational use. Today, antibiotic use data are openly shared on a regular basis. Based on sales figures, significant reductions in antibiotic use has occurred in Sweden (Figure 1).
Assessing the quality of prescribing
However, sales data do not include for which indications the antibiotics are prescribed, and cannot be used to assess the quality of antibiotic prescribing. To be able to measure this, diagnosis-related prescribing data are needed. Several point-prevalence studies (PPS) on the indications for antibiotic prescriptions have been performed both in community and hospital care over the years. In Sweden, rational use of antibiotics has been defined as adherence to the current national treatment guidelines. PPS in the community have shown a decrease in antibiotic use for acute otitis media, acute tonsillitis and acute bronchitis in concordance with the guidelines. For hospitalized patients, compliance with guidelines for treatment of community-acquired pneumonia and uncomplicated female cystitis has significantly improved.
Feedback to prescribers
One important factor that have contributed to this success is the regular face-to face feedback to prescribers of their prescribing patterns and of the antibiotic resistance situation. The local groups provide feedback to prescribers in hospitals and in primary care. They visit each health center in the region regularly and present collated prescription data. This is an effective and organized way of providing information directly to the prescriber and at the same time provide an opportunity to discuss the results.
For the purpose of reducing unnecessary antibiotic use, Strama developed targets for how many prescriptions are acceptable. In 2009, a national long term target was proposed for antibiotic use in outpatient care aiming at no more than 250 prescriptions per 1000 inhabitants per year. The targets were based on regional epidemiological studies in primary health care looking at the number of community infections and antibiotic prescriptions. The target was then included as one part in a special commitment from the Swedish Government to improve patient safety during 2011-2014 (, see p. 28-30). Measurable yearly goals were set. The County Councils, the entities responsible for organizing health care in Sweden, were rewarded with financial incentives for meeting goals.
View targets on a relevant level
An important lesson here is that such targets need to be viewed on sufficiently high levels –for example a region rather than a health facility, as some facilities serves patients with a higher need of antibiotics. Signs of undertreatment were also incorporated in the monitoring framework to detect potential negative effects of setting a target. During these years the total mean number of prescriptions of antibiotics to outpatients decreased by 15 percent from 381 to 325 prescriptions per 1000 inhabitants and year without any measurable negative consequences.
A national quantitative target for antibiotic use in hospitals has been considered unfeasible in Sweden. Hospitals vary too much with respect to size and types of patients.
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 Strama groups has been instrumental –guidelines are not just imposed from above, but are anchored in the clinical experience of the region. A lesson learned from this work is that good national guidelines should include diagnostic criteria for each disease, assessments of risks and benefits of antibiotic use, and give clear advice on when to use or not use antibiotics.
For more information about the organisation and work of Strama, see POLICY – Examples from the field – Sweden’s national strategy
|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 (PDF)||A report on how Sweden has worked towards relatively low use of antibiotics per capita and favorable antibiotic resistance conditions. For a summary, see Swedish work on containment of antibiotic resistance – in brief. Tools, methods and experiences|
|Swedish work against antibiotic resistance – a one health approach||Case report describing how Sweden has worked across sectors to minimize the effects of antibiotic resistance.|
|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. (Paywall)|