New study: combat antimicrobial resistance with a combination of interventions

Antimicrobial resistance (AMR) is an increasing worldwide public health problem with important implications for the European Union (EU). An important driving force behind AMR is non-prudent use of antimicrobial agents . Reducing the unnecessary consumption of antibiotics can therefore have a powerful impact upon resistance. The ARNA project aimed to assess non-prudent use of antibiotics in the European Union (EU) and to encourage policies that lead to a more prudent use of antibiotics. The project focused on the use of antibiotics without a prescription and was performed by NIVEL and the University of Antwerp. The European Commission funded the ARNA project. Recently, the report of the study was published.

In the  European Union, the proportion of antibiotics that were used without a prescription increased from 5% of all antibiotics used in 2013 to 7% in 2016. However, rates varied across EU Member States.

The highest rates were found in Greece, Romania and Cyprus, both in 2013 and 2016. The two prevailing sources of antibiotics without a prescription are over-the-counter (OTC) selling in pharmacies and the use of leftover antibiotics. Surveys  among patients, pharmacists and GPs were then performed in seven countries with a high level of antibiotic use without a prescription: Cyprus, Estonia, Greece, Hungary, Italy, Romania, and Spain. The main criterion for selecting these countries was their high use of antibiotics without a prescription. The survey showed that an increasing awareness and knowledge is needed from both patients and professionals in order to reduce the use of antibiotics without a prescription. Therefore,  interventions and policies that simultaneously target patients and HCPs will be more effective than approaches targeting just one of them. 

Interventions
A literature review combined with the opinions of European experts showed that the most effective way to stimulate the prudent use of antibiotics is the implementation of a combination of interventions on different levels simultaneously, which are repeated over a number of years.  Examples include, the setting of targets for a reduction in the number of antibiotic prescriptions , the measurement of adherence to treatment recommendations and providing the infrastructure for monitoring the use of antibiotics, both nationally and regionally.  

Country dialogue meetings
Policy Dialogue Meetings were held in Cyprus, Estonia, Greece, Hungary, Italy, Romania, and Spain. These meetings, organized in cooperation with national policy makers and stakeholders aimed to generate action plans to combat the non-prudent use of antibiotics. It was shown that each country has its own problems but there were also similarities in the actions that were proposed. Common actions included for example: the need for large-scale educational campaigns with clear messages and focused on health literacy, educational programmes for health care professionals and the development of simple treatment guidelines that are easy to disseminate. Common actions also included the involvement of all stakeholders, in particular, patient groups and stimulating collaboration between primary and secondary care. 

ARNA Utrecht Meeting Statement
A final conference was held to conclude the ARNA project and to discuss further actions to reduce the non-prudent use of antibiotics. A conference statement was discussed and agreed. It was agreed that there is a need for clear leadership in all EU Member States to combat AMR. Better collaboration is also needed on a local, national, European and global level. The establishment of multidisciplinary professional networks create important structures that support, coordinate and stimulate interventions in EU Member States. Regarding the prudent use of antimicrobials in human medicine, multifaceted approaches are needed that target prescribers, the general public and healthcare as a whole. 

NIVEL, Netherlands institute for health services research coordinated the project and was involved in all activities reported in the ARNA report. The University of Antwerp was partner and involved in the analysis of data on antibiotic consumption, the country dialogue meetings and the organization of the final conference. TNS NIPO, Amsterdam, performed the field work of the surveys in six countries. Download the report (pdf) or visit the European Commission webpage on Antimicrobial Resistance.