Consumption of quinolones in the community, European Union/European Economic Area, 1997-2017

Recent developments of topoisomerase inhibitors: Clinical trials, emerging indications, novel molecules and global sales

The nucleic acid topoisomerases (TOP) are an evolutionary conserved mechanism to solve topological problems within DNA and RNA that have been historically well-established as a chemotherapeutic target. During investigation of trends within clinical trials, we have identified a very high number of clinical trials involving TOP inhibitors, prompting us to further evaluate the current status of this class of therapeutic agents. In total, we have identified 233 unique molecules with TOP-inhibiting activity. In this review, we provide an overview of the clinical drug development highlighting advances in current clinical uses and discussing novel drugs and indications under development. A wide range of bacterial infections, along with solid and hematologic neoplasms, represent the bulk of clinically approved indications. Negative ADR profile and drug resistance among the antibacterial TOP inhibitors and anthracycline-mediated cardiotoxicity in the antineoplastic TOP inhibitors are major points of concern, subject to continuous research efforts. Ongoing development continues to focus on bacterial infections and cancer; however, there is a degree of diversification in terms of novel drug classes and previously uncovered indications, such as glioblastoma multiforme or Clostridium difficile infections. Preclinical studies show potential in viral, protozoal, parasitic and fungal infections as well and suggest the emergence of a novel target, TOP IIIβ. We predict further growth and diversification of the field thanks to the large number of experimental TOP inhibitors emerging.

Deciphering the Intricate Interplay in the Framework of Antibiotic-Drug Interactions: A Narrative Review

Drug interactions are a significant and integral part of the concept of medication-related adverse events, whether referring to potential interactions or those currently observed in real-world conditions. The high global consumption of antibiotics and their pharmacokinetic and pharmacodynamic mechanisms make antibiotic-drug interactions a key element that requires continuous study due to their clinical relevance. In the present work, the current state of knowledge on antibiotic-drug interactions, which are less studied than other drug-drug interactions despite their frequent use in acute settings, has been consolidated and updated. The focus was on the interactions of the commonly used antibiotics in clinical practice, on the characteristics of the geriatric population susceptible to interactions, and on the impact of online drug interaction checkers. Additionally, strategies for optimizing the management of these interactions, including spacing out administrations, monitoring, or avoiding certain combinations, are suggested. Sustained research and careful monitoring are critical for improving antibiotic safety and efficacy, especially in susceptible populations, to enhance precision in managing antibiotic-drug interactions.

A Decade of Antimicrobial Resistance in Human and Animal Campylobacter spp. Isolates

Objectives: Campylobacter spp. remain a leading cause of bacterial gastroenteritis worldwide, with resistance to antibiotics posing significant challenges to treatment and public health. This study examines profiles in antimicrobial resistance (AMR) for Campylobacter isolates from human and animal sources over the past decade. Methods: We conducted a comprehensive review of resistance data from studies spanning ten years, analyzing profiles in resistance to key antibiotics, ciprofloxacin (CIP), tetracycline (TET), erythromycin (ERY), chloramphenicol (CHL), and gentamicin (GEN). Data were collated from various regions to assess global and regional patterns of resistance. Results: The analysis reveals a concerning trend of increasing resistance patterns, particularly to CIP and TET, across multiple regions. While resistance to CHL and GEN remains relatively low, the high prevalence of CIP resistance has significantly compromised treatment options for campylobacteriosis. Discrepancies in resistance patterns were observed between human and animal isolates, with variations across different continents and countries. Notably, resistance to ERY and CHL showed regional variability, reflecting potential differences in antimicrobial usage and management practices. Conclusions: The findings underscore the ongoing challenge of AMR in Campylobacter, highlighting the need for continued surveillance and research. The rising resistance prevalence, coupled with discrepancies in resistance patterns between human and animal isolates, emphasize the importance of a One Health approach to address AMR. Enhanced monitoring, novel treatment strategies, and global cooperation are crucial for mitigating the impact of resistance and ensuring the effective management of Campylobacter-related infections.

Biochar-derived dissolved organic matter enhanced the release of residual ciprofloxacin from the soil solid phase

Biochar has been utilized to reduce ciprofloxacin (CIP) residues in soil. However, little is known about the effect of biochar-derived dissolved organic matter (DOM) on residual CIP transformation. Thus, we analyzed the residual soil CIP as influenced by biochar generated from rice straw (RS3 and RS6), pig manure (PM3 and PM6), and cockroach shell (CS3 and CS6) at 300 °C and 600 °C. The three-dimensional excitation-emission matrix (3D-EEM), parallel factor analysis (PARAFAC) and two-dimensional correlation spectral analysis (2D-COS) were used to describe the potential variation in the DOM-CIP interaction. Compared with CK, biochar amendment increased the water-soluble CIP content by 160.7% (RS3), 55.2% (RS6), 534.1% (PM3), 277.5% (PM6), 1160.6% (CS3) and 703.9% (CS6), indicating that the biochar feedstock controlled the soil CIP release. The content of water-soluble CIP was positively correlated with the content of dissolved organic carbon (r = 0.922, p < 0.01) and dissolved organic nitrogen (r = 0.898, p < 0.01), suggesting that the major influence of the water-soluble CIP increase was DOM. The fluorescence quenching experiment showed that the interaction between DOM and CIP triggered static quenching and the creation of a DOM complex. The mean log K of protein-like material (4.977) was higher than that of terrestrial humus-like material (3.491), suggesting that the protein-like material complexed CIP was more stable than the humus-like material. Compared with pyrolysis at 300 °C, pyrolysis at 600 °C decreased the stability of the complex of protein-like material and CIP by 0.44 (RS), 1.689 (PM) and 0.548 (CS). This result suggested that the influence of temperature change was more profound on PM biochar-derived DOM than on RS and CS. These insights are essential for understanding CIP transportation in soil and controlling CIP contamination with biochar.

Levofloxacin-induced MexS mutation triggers imipenem-relebactam resistance in a KPC-producing Pseudomonas aeruginosa

OBJECTIVES

Imipenem-relebactam (IMR), a novel β-lactam/β-lactamase inhibitor combination, is recommended for infections caused by difficult-to-treat Pseudomonas aeruginosa. This study aimed to investigate the evolution trajectory of IMR resistance under the selection of levofloxacin in P. aeruginosa.

METHODS

Antimicrobial susceptibility testing, complete genome sequencing and gene manipulation experiments were performed. Quantitative reverse transcription PCR for specific genes and porin levels were detected. Evolution trajectory was simulated in vitro by induction assay.

RESULTS

P. aeruginosa HS347 and HS355 were isolated from abdominal drainage of two neighbouring patients (S and Z) undergoing surgery of colon carcinoma in Shanghai, China, with the latter patient having received levofloxacin. They were closely related ST16 strains, and both carried blaKPC-2 plasmids highly similar to those of P. aeruginosa endemic clones from Zhejiang province, where patient Z had received enteroscopy before this admission. Acquisition of resistance was observed for both IMR and fluoroquinolones in HS355, likely prompted by treatment with levofloxacin. The T274I substitution in MexS (putative oxidoreductase), upregulated efflux pump operon mexEF-oprN and decreased production of porin OprD leading to cross-resistance to fluoroquinolones and IMR, which was also verified by in vitro mutant selection under levofloxacin selection.

CONCLUSIONS

The emergence of a rare blaKPC-2-plasmid-bearing ST16 clone implies the horizonal spread and inter-regional dissemination of a high-risk plasmid-clone combination, representing a public health challenge. Levofloxacin exposure can select for mexS inactivating mutation, which in turn leads to IMR resistance phenotype, implicating the role of an unrelated, widely used antimicrobial agent in insidiously triggering the development of cross resistance to a latest β-lactam/β-lactamase inhibitor combination.

Metal Oxide Nanostructures (MONs) as Photocatalysts for Ciprofloxacin Degradation

In recent years, organic pollutants have become a global problem due to their negative impact on human health and the environment. Photocatalysis is one of the most promising methods for the removal of organic pollutants from wastewater, and oxide semiconductor materials have proven to be among the best in this regard. This paper presents the evolution of the development of metal oxide nanostructures (MONs) as photocatalysts for ciprofloxacin degradation. It begins with an overview of the role of these materials in photocatalysis; then, it discusses methods of obtaining them. Then, a detailed review of the most important oxide semiconductors (ZnO, TiO₂, CuO, etc.) and alternatives for improving their photocatalytic performance is provided. Finally, a study of the degradation of ciprofloxacin in the presence of oxide semiconductor materials and the main factors affecting photocatalytic degradation is carried out. It is well known that antibiotics (in this case, ciprofloxacin) are toxic and non-biodegradable, which can pose a threat to the environment and human health. Antibiotic residues have several negative impacts, including antibiotic resistance and disruption of photosynthetic processes.

Bilateral Acute Iris Transillumination (BAIT): A Rare Syndrome Possibly Associated with COVID-19 and Moxifloxacin Use. A Report of 2 Cases

Bilateral acute iris transillumination (BAIT) is a rare clinical entity, presumed to be associated with preceding upper respiratory tract infection and/or use of certain antibiotics, marked by bilateral acute loss of iris pigment epithelium with pigment dispersion in the anterior chamber and trabecular meshwork, which can cause elevated intraocular pressure and glaucoma, and with iris transillumination and sphincter paralysis which lead to photophobia and blurry vision. We report the first two cases of BAIT in our center which both had a history of preceding COVID-19 (coronavirus disease 2019) and moxifloxacin use. With more awareness, ophthalmologists might diagnose more cases, and thus gain more information regarding the link between COVID-19 and BAIT, which might be underdiagnosed since it is rare or easily misdiagnosed as some more common diseases with similar features.

Effects of Single and Combined Ciprofloxacin and Lead Treatments on Zebrafish Behavior, Oxidative Stress, and Elements Content

Even though the toxic effects of antibiotics and heavy metals have been extensively studied in the last decades, their combined adverse impact on aquatic organisms is poorly understood. Therefore, the objective of this study was to assess the acute effects of a ciprofloxacin (Cipro) and lead (Pb) mixture on the 3D swimming behavior, acetylcholinesterase (AChE) activity, lipid peroxidation level (MDA-malondialdehyde), activity of some oxidative stress markers (SOD-superoxide dismutase and GPx-glutathione peroxidase), and the essential elements content (Cu-copper, Zn-zinc, Fe-iron, Ca-calcium, Mg-magnesium, Na-sodium and K-potassium) in the body of zebrafish (Danio rerio). For this purpose, zebrafish were exposed to environmentally relevant concentrations of Cipro, Pb, and a mixture for 96 h. The results revealed that acute exposure to Pb alone and in mixture with Cipro impaired zebrafish exploratory behavior by decreasing swimming activity and elevating freezing duration. Moreover, significant deficiencies of Ca, K, Mg, and Na contents, as well as an excess of Zn level, were observed in fish tissues after exposure to the binary mixture. Likewise, the combined treatment with Pb and Cipro inhibited the activity of AChE and increased the GPx activity and MDA level. The mixture produced more damage in all studied endpoints, while Cipro had no significant effect. The findings highlight that the simultaneous presence of antibiotics and heavy metals in the environment can pose a threat to the health of living organisms.

Antimicrobial Consumption from 2017 to 2021 in East Trinidad and Tobago: A Study in the English-Speaking Caribbean

An antimicrobial consumption (AMC) study was performed in Trinidad and Tobago at the Eastern Regional Health Authority (ERHA). A retrospective, cross-sectional survey was conducted from 1 November 2021 to 30 March 2022. Dosage and package types of amoxicillin, azithromycin, co-amoxiclav, cefuroxime, ciprofloxacin, levofloxacin, moxifloxacin, nitrofurantoin and co-trimoxazole were investigated. Consumption was measured using the World Health Organization’s Antimicrobial Resistance and Consumption Surveillance System methodology version 1.0, as defined daily doses (DDD) per 1000 population per day (DID). They were also analyzed using the ‘Access’, ‘Watch’ and ‘Reserve’ classifications. In the ERHA, AMC ranged from 6.9 DID to 4.6 DID. With regards to intravenous formulations, the ‘Watch’ group displayed increased consumption, from 0.160 DID in 2017 to 0.238 DID in 2019, followed by a subsequent drop in consumption with the onset of the COVID-19 pandemic. Oral co-amoxiclav, oral cefuroxime, oral azithromycin and oral co-trimoxazole were the most highly consumed antibiotics. The hospital started off as the higher consumer of antibiotics, but this changed to the community. The consumption of ‘Watch’ group antibiotics increased from 2017 to 2021, with a drop in consumption of ‘Access’ antibiotics and at the onset of COVID-19. Consumption of oral azithromycin was higher in 2021 than 2020.

Efficient Removal of Methylene Blue and Ciprofloxacin from Aqueous Solution Using Flower-like, Nanostructured ZnO Coating under UV Irradiation

Flower-like ZnO architectures assembled with many nanorods were successfully synthesized through Thermionic Vacuum Arc, operated both in direct current (DC-TVA) and a pulsed mode (PTVA), and coupled with annealing in an oxygen atmosphere. The prepared coatings were analysed by scanning-electron microscopy with energy-dispersive X-ray-spectroscopy (SEM-EDX), X-ray-diffraction (XRD), and photoluminescence (PL) measurements. By simply modifying the TVA operation mode, the morphology and uniformity of ZnO nanorods can be tuned. The photocatalytic performance of synthesized nanostructured ZnO coatings was measured by the degradation of methylene-blue (MB) dye and ciprofloxacin (Cipro) antibiotic. The ZnO (PTVA) showed enhancing results regarding the photodegradation of target contaminants. About 96% of MB molecules were removed within 60 min of UV irradiation, with a rate constant of 0.058 min−1, which is almost nine times higher than the value of ZnO (DC-TVA). As well, ZnO (PTVA) presented superior photocatalytic activity towards the decomposition of Cipro, after 240 min of irradiation, yielding 96% degradation efficiency. Moreover, the agar-well diffusion assay performance against both Gram-positive and Gram-negative bacteria confirms the degradation of antibiotic molecules by the UV/ZnO (PTVA) approach, without the formation of secondary hazardous products during the photocatalysis process. Repeated cyclic usage of coatings revealed excellent reusability and operational stability.

Low concentrations of ciprofloxacin alone and in combination with paracetamol induce oxidative stress, upregulation of apoptotic-related genes, histological alterations in the liver, and genotoxicity in Danio rerio

Nowadays, there are countless articles about the harmful effects of paracetamol (PCM) in non-target organisms. Nonetheless, information regarding the toxicity of ciprofloxacin (CPX) and the CPX-PCM mixture is still limited. Herein, we aimed to evaluate the hepatotoxic and genotoxic effects that ciprofloxacin alone and in combination with paracetamol may induce in Danio rerio adults. For this purpose, we exposed several D. rerio adults to three environmentally relevant concentrations of PCM (0.125, 0.250, and 0.500 μg/L), CPX (0.250, 0.500, and 1 μg/L), and their mixture (0.125 + 0.250, 0.250 + 0.500, and 0.500 + 1 μg/L) for 96 h. The blood samples showed CPX alone and in combination with PCM damaged the liver function of fish by increasing the serum levels of liver enzymes alanine aminotransferase and alkaline phosphatase. Moreover, our histopathological study demonstrated liver of fish suffered several tissue alterations, such as congestion, hyperemia, infiltration, sinusoidal dilatation, macrovascular fatty degeneration, and pyknotic nuclei after exposure to CPX alone and in combination with PCM. Concerning oxidative stress biomarkers and the expression of genes, we demonstrated that CPX and its mixture, with PCM, increased the levels of antioxidant enzymes and oxidative damage biomarkers and altered the expression of Nrf1, Nrf2, BAX, and CASP3, 6, 8, and 9 in the liver of fish. Last but not least, we demonstrated CPX alone and with PCM induced DNA damage via comet assay and increased the frequency of micronuclei in a concentration-dependent manner in fish. Overall, our results let us point out CPX, even at low concentrations, induces hepatotoxic effects in fish and that its combination with PCM has a negative synergic effect in the liver of this organism.

Lab-In-Syringe automation of deep eutectic solvent-based direct immersion single drop microextraction coupled online to high-performance liquid chromatography for the determination of fluoroquinolones

Lab-In-Syringe direct immersion single drop microextraction is proposed as an automated sample pretreatment methodology and coupled online to HPLC with fluorescence detection for the determination of fluoroquinolones in environmental waters. For the first time, a drop of a natural deep eutectic solvent (NADES), synthesized from hexanoic acid and thymol, has been used as an extractant in automated single-drop microextraction. The extraction procedure was carried out within the 5 mL void of an automatic syringe pump. A 9-position head valve served the aspiration of all required solutions, air, waste disposal, and hyphenation with the HPLC instrument. Sample mixing during extraction was done by a magnetic stirring bar placed inside the syringe. Only 60 μL of NADES were required omitting toxic classical solvents and improving the greenness of the proposed methodology. By direct injection, linear working ranges between 0.1 and 5 μg L^-1 were achieved for all fluoroquinolones. The limit of quantification values and enrichment factors ranged from 20 ng L^-1 to 30 ng L^-1 and 35 to 45, respectively. Accuracies obtained from the analysis of spiked surface water and wastewater treatment plant effluent analysis at two concentration levels (0.5 and 4 μg L^-1) ranged from 84.6% to 119.7%, with RSD values typically <3%.

Consumption of Antibacterials for Systemic Use in Slovakia: A National Study and the Quality Indicators for Outpatient Antibiotic Use

This paper aims to analyse the consumption of antibiotics in the Slovak health care system from 2011 to 2020. The data source on the consumption of antibiotics is sales data from SUKL and NCZI. The study employed the ATC/DDD Index and focused on the consumption of antibiotics in the primary care sector. Total antibiotic consumption decreased from 19.21 DID in 2011 to 13.16 DID in 2020. Consumption of beta-lactamase-sensitive penicillins, expressed as a percentage of the total consumption of antibiotics, decreased from 8.4% in 2011 to 4.2% in 2020. Consumption of the combination of penicillins, including beta-lactamase inhibitor, expressed as a percentage of the total consumption of antibiotics, increased from 16.2% in 2011 to 17.9% in 2020. Consumption of third- and fourth-generation cephalosporins, expressed as the percentage of the total consumption of antibiotics, increased from 2.0% in 2011 to 4.6% in 2020. Consumption of fluoroquinolones, expressed as the percentage of the total consumption of antibiotics, decreased from 10.7% in 2011 to 8.6% in 2020. Overall, antibiotic consumption significantly changed in Slovakia from 2011 to 2020. The ratio of the consumption of broad-spectrum to the consumption of narrow-spectrum penicillins, cephalosporins and macrolides decreased from 14.98 in 2011 to 13.38 in 2020.

Consumption of macrolides, lincosamides and streptogramins in the community, European Union/European Economic Area, 1997-2017

OBJECTIVES

Data on the consumption of macrolides, lincosamides and streptogramins (MLS) in the community were collected from 30 EU/European Economic Area (EEA) countries over two decades. This article reviews temporal trends, seasonal variation, presence of change-points and changes in composition of the main subgroups of MLS.

METHODS

For the period 1997-2017, data on consumption of MLS, i.e. ATC group J01F, in the community and aggregated at the level of the active substance, were collected using the WHO ATC/DDD methodology (ATC/DDD index 2019). Consumption was expressed in DDD per 1000 inhabitants per day and in packages per 1000 inhabitants per day. Consumption of MLS was analysed and presented as trends, seasonal variation, presence of change-points and compositional changes, using a classification based on mean plasma elimination half-life for macrolides.

RESULTS

In 2017, consumption of MLS in the community expressed in DDD per 1000 inhabitants per day varied by a factor of 13 between countries with the highest (Greece) and the lowest (Sweden) consumption. Consumption of MLS did not change significantly up to 2003, after which it significantly increased up to 2007. No significant change was observed after 2007. Consumption of MLS showed high seasonal variation. The proportional consumption of long-acting macrolides significantly increased over time compared with that of intermediate-acting macrolides, and proportional consumption of the latter increased compared with that of short-acting macrolides.

CONCLUSIONS

Consumption of MLS did not change significantly over time during 2007-2017, while the proportional consumption of long-acting macrolides increased. Seasonal variation remained high, which suggests that MLS are still prescribed inappropriately in many countries.

Quality appraisal of antibiotic consumption in the community, European Union/European Economic Area, 2009 and 2017

Objectives

The quality of antibiotic consumption in the community can be assessed using 12 drug-specific quality indicators (DSQIs) developed by the European Surveillance of Antimicrobial Consumption (ESAC) project. We compared quality in 2009 and 2017 in the EU/European Economic Area (EEA) and evaluated the impact of using different DDD values (ATC/DDD indices 2011 and 2019) for the 2009 quality assessment using these DSQIs and a joint scientific opinion (JSO) indicator.

Methods

We calculated the 12 DSQIs and the JSO indicator for 2017 and for 2009 for EU/EEA countries able to deliver values. For each of the indicators we grouped the 2017 and 2009 indicator values into four quartiles. To evaluate changes in quality between 2009 and 2017, we used the quartile distribution of the 2009 indicator values in 30 EU/EEA countries as benchmarks. In addition, we compared the quality assessment for 2009 using the ATC/DDD indices 2011 and 2019.

Results

In 2017, a difference in the quality of antibiotic consumption in the community between northern and southern EU/EEA countries remained, but also several eastern EU/EEA countries shifted towards lower quality. Quality of antibiotic consumption decreased between 2009 and 2017 in particular indicator values for penicillin, quinolone, relative β-lactam and broad- versus narrow-spectrum antibiotic consumption, and seasonal variation. Using different ATC/DDD indices did not substantially change countries’ ranking based on their DSQI values.

Conclusions

The quality of antibiotic consumption in the community as measured by the DSQIs further decreased between 2009 and 2017, especially in Southern and Eastern European countries. A continuous effort to improve antibiotic consumption is essential to reduce antibiotic consumption in general and the use of broad-spectrum antibiotics in particular.

Consumption of antibiotics in the community, European Union/European Economic Area, 1997-2017

Objectives

Data on antibiotic consumption in the community were collected from 30 EU/EEA countries over two decades. This article reviews temporal trends, seasonal variation, presence of change-points and changes in the composition of the main antibiotic groups.

Methods

For the period 1997–2017, data on consumption of antibiotics, i.e. antibacterials for systemic use (ATC group J01), in the community, aggregated at the level of the active substance, were collected using the WHO ATC/DDD methodology (ATC/DDD index 2019). Consumption was expressed in DDD per 1000 inhabitants per day and in packages per 1000 inhabitants per day. Antibiotic consumption was analysed based on ATC-3 groups, and presented as trends, seasonal variation, presence of change-points and compositional changes.

Results

In 2017, antibiotic consumption in the community expressed in DDD per 1000 inhabitants per day varied by a factor 3.6 between countries with the highest (Greece) and the lowest (the Netherlands) consumption. Antibiotic consumption in the EU/EEA did not change significantly over time. Antibiotic consumption showed a significant seasonal variation, which decreased over time. The number of DDD per package significantly increased over time. The proportional consumption of sulphonamides and trimethoprim (J01E) relative to other groups significantly decreased over time, while the proportional consumption of other antibacterials (J01X) relative to other groups significantly increased over time.

Conclusions

Overall, antibiotic consumption in the community in the EU/EEA did not change during 1997–2017, while seasonal variation consistently decreased over time. The number of DDD per package increased during 1997–2017.

Impact of changing reimbursement criteria on the use of fluoroquinolones in Belgium

Objectives

The criteria for the reimbursement of fluoroquinolones changed in Belgium on 1 May 2018. This study aims to quantify the difference in fluoroquinolone use after this change, and to assess the timing and persistence of this effect, both in terms of total reimbursed fluoroquinolone use and its relative proportion.

Methods

Longitudinal reimbursement data on fluoroquinolone use in the Belgian community from January 2017 to November 2018 were analysed to identify a change in reimbursed fluoroquinolone use expressed in DDD per 1000 inhabitants per day (DID), using a set of non-linear mixed models including change-points. In addition, longitudinal data on the relative proportion of prescribed fluoroquinolones from January 2017 to December 2018 were analysed to identify a change in the relative proportion of prescribed fluoroquinolones using generalized estimation equations including change-points.

Results

Fluoroquinolone use dropped significantly immediately after the change in reimbursement criteria, from 2.21 DID (95% CI: 2.03–2.38) to 0.52 DID (95% CI: 0.48–0.56) and from 9.14% (95% CI: 8.75%–9.56%) to 6.52% (95% CI: 6.04%–7.04%). The observed decrease in fluoroquinolone use persisted over time.

Conclusions

While fluoroquinolone use was still above the target of 5% after the change in reimbursement criteria, its implementation helped to lower fluoroquinolone use in Belgium.

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

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.

Analysing the trend over time of antibiotic consumption in the community: a tutorial on the detection of common change-points

OBJECTIVES

This tutorial describes and illustrates statistical methods to detect time trends possibly including abrupt changes (referred to as change-points) in the consumption of antibiotics in the community.

METHODS

For the period 1997-2017, data on consumption of antibacterials for systemic use (ATC group J01) in the community, aggregated at the level of the active substance, were collected using the WHO ATC/DDD methodology and expressed in DDD (ATC/DDD index 2019) per 1000 inhabitants per day. Trends over time and presence of common change-points were studied through a set of non-linear mixed models.

RESULTS

After a thorough description of the set of models used to assess the time trend and presence of common change-points herein, the methodology was applied to the consumption of antibacterials for systemic use (ATC J01) in 25 EU/European Economic Area (EEA) countries. The best fit was obtained for a model including two change-points: one in the first quarter of 2004 and one in the last quarter of 2008.

CONCLUSIONS

Allowing for the inclusion of common change-points improved model fit. Individual countries investigating changes in their antibiotic consumption pattern can use this tutorial to analyse their country data.

Consumption of antibiotics in the community, European Union/European Economic Area, 1997-2017: data collection, management and analysis

OBJECTIVES

This article introduces a series of articles on antibiotic consumption in the community between 1997 and 2017, which provide an update of previous articles covering the periods 1997-2003 and 1997-2009.

METHODS

In this article, differences in participating countries, the ATC/DDD classification system, and data collection, validation and analysis between the current and previous series are described.

RESULTS

In the previous series, 33 European countries provided valid data for further analysis, while the current series focused on 30 countries belonging to the EU or the European Economic Area (EEA). For both series, data were collected in accordance with the WHO ATC classification system. While the previous series reported data in accordance with the ATC/DDD index 2011, the current series employed the ATC/DDD index 2019. Both series focused on consumption of antibacterials for systemic use (ATC J01) and collected data expressed in DDD per 1000 inhabitants per day and packages per 1000 inhabitants per day. When studying consumption expressed in packages per 1000 inhabitants per day, countries reporting total care data, i.e. community and hospital sector combined, were included in the previous series but excluded in the current series. While the previous series used non-linear mixed models to evaluate time trends in antibiotic consumption, the current series allowed for inclusion of change-points with a data-driven location. In addition, both series assessed the composition and quality of antibiotic consumption in the EU/EEA.

CONCLUSIONS

The updated analyses of two decades of ESAC-Net data provide the most comprehensive and detailed description of antibiotic consumption in the community in Europe.