Change-points in antibiotic consumption in the community, European Union/European Economic Area, 1997-2017

Abstract

Objectives: Surveillance of antibiotic consumption in the community is of utmost importance to inform and evaluate control strategies. Data on two decades of antibiotic consumption in the community were collected from 30 EU/European Economic Area (EEA) countries. This article reviews temporal trends and the presence of abrupt changes in subgroups of relevance in antimicrobial stewardship.

Methods: For the period 1997-2017, data on yearly antibiotic consumption in the community, aggregated at the level of the active substance, were collected using the WHO ATC classification and expressed in DDD (ATC/DDD index 2019) per 1000 inhabitants per day. We applied a range of non-linear mixed models to assess the presence of changes in the consumption of antibacterials for systemic use (ATC group J01) and eight antibiotic subgroups.

Results: For the majority of the studied groups, a country-specific change-point model provided the best fit. Depending on the antibiotic group/subgroup and on the country, change-points were spread out between 2000 and 2013.

Conclusions: Due to the heterogeneity in antibiotic consumption in the community across EU/EEA countries, a country-specific change-point model provided the better fit. Given the limitations of this model, our recommendation for the included countries is to carefully interpret the country-specific results presented in this article and to use the tutorial included in this series to conduct their own change-point analysis when evaluating the impact of changes in regulations, public awareness campaigns, and other national interventions to improve antibiotic consumption in the community.

Figure 1.

Evolution of consumption of antibacterials for systemic use (ATC J01) in the community, expressed in DDD (ATC/DDD index 2019) per 1000 inhabitants per day for 30 EU/EEA countries, 1997–2017 (unlabelled lines).

Figure 2.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of antibacterials for systemic use (ATC J01) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. Abbreviations: AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

Figure 3.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of cephalosporins (ATC J01DB, J01DC, J01DD and J01DE) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

Figure 4.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of combinations of sulphonamides and trimethoprim (ATC J01EE) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

Figure 5.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of macrolides (ATC J01FA) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

Figure 6.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of fluoroquinolones (ATC J01MA) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

Figure 7.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of extended-spectrum penicillins and of combinations of penicillins combined (ATC J01CA and J01CR) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

Figure 8.

Estimated country-specific trend after the change-point versus location of the country-specific change-point for the consumption of nitrofuran derivatives (ATC J01XE) in the community obtained from fitting Model 5 on yearly data from 26 EU/EEA countries, 1997–2017. Dotted lines indicate averages. Country labels in black indicate an increase in the trend after versus before the change-point. Country labels in purple indicate a decrease in the trend after versus before the change-point. For Spain, private prescription data are included from 2016 onwards. For Ireland, consumption of nitrofurantoin (J01XE01) was not included. AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CZ, Czechia; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; EL, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LU, Luxembourg; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.