Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Without effective antibiotics, the prevention and treatment of infections would be compromised. The UK’s 20-year vision for antimicrobial resistance sets out how the UK will contribute to containing and controlling AMR by 2040. One of the key strategies is to optimise the use of antimicrobials in humans, by improving prescribing behaviours. Studies have shown that at least 20% of antibiotics prescribed in primary care in England are inappropriate. These indicators look at how antibiotic prescribing has changed over time, both in England and internationally.
In England, the total consumption of antibiotics in primary and secondary care declined by 9%, from 20 Defined Daily Doses (DDDs) per 1,000 inhabitants per day in 2014 to 18.2 DDDs per 1,000 inhabitants per day in 2018 (data not shown). This overall decrease will contribute towards the UK’s five-year national action plan that set a target to reduce UK antimicrobial use in humans by 15% by 2024.
While most antibiotic prescribing occurs in General Practice (72% of total prescribing in 2018), consumption in this setting has declined over time (a 13% decrease since 2014). This contrasts to prescribing in other community settings that has continued to increase, despite accounting for a relatively small proportion of overall antimicrobial prescribing (3.9% of total prescribing in 2018).
Antibiotic consumption has also increased within secondary care for inpatients (a 9.7% increase since 2014), but stayed constant for outpatients. This is partly due to antibiotic shortages and replacements of a single broad-spectrum antibiotic with two or three narrower antibiotics that have the same clinical impact. The NHS Standard Contract 2020/21 includes a target for NHS trusts to reduce antibiotic usage by 2% by March 2021 and by a further 1% in each subsequent contract year.
The Organisation for Economic Co-operation and Development (OECD) collects data on antibiotic prescribing in different countries, using a system of Defined Daily Doses (DDDs) to measure the volume of drugs. Between 2000 and 2011, the volume of antibiotics prescribed in the UK increased from 12.7 DDDs per 1,000 inhabitants per day to 16.5 DDDs per 1,000 inhabitants per day. In 2012, there was a break in the time series as the data source changed to cover England only. In England, the volume of antibiotics prescribed in 2012 was 19.4 DDDs per 1,000 inhabitants per day, and this decreased slightly to 18 DDDs per 1,000 inhabitants per day in 2018.
The volume of antibiotics prescribed in primary care in England is about average of the comparator countries. While the recent decrease in volume prescribed is promising, England’s prescribing levels are approximately double that of the Netherlands. Antibiotic prescribing is high in Greece, France and Italy, and is low in the Netherlands, Austria and Germany.
Quinolones and cephalosporins are considered second-line antibiotics in most prescribing guidelines. They should be restricted for situations where first-line antibiotics have failed. It is important that they are used sparingly, to avoid drug-resistant bacteria developing. The European Centre for Disease Prevention and Control (ECDC) collects international data on the use of quinolones and cephalosporins. Some countries supply data for primary care only (denoted by ¹ in the chart), others supply data for secondary care only (denoted by ²), and some supply data for both primary and secondary care (denoted by ³).
In the UK, the percentage of antibiotics prescribed that were quinolones or cephalosporins decreased from 9.3% in 2000 to 3.9% in 2016 and has since remained roughly stable. The UK performs the best out of the comparator countries, while Italy performs the worst.
It is important to note that the UK provides data for primary care only. The comparator countries that provide data for secondary care only have a higher percentage of antibiotics prescribed that were quinolones or cephalosporins – 43% in Italy and 20% in Denmark in 2018. The three countries which have the lowest percentage of quinolones and cephalosporins prescribed (the UK, Sweden and Ireland) all provide data for primary care only. This may reflect differences in the severity of the case-mix of infections, with hospitalised patients having more severe infections that have not responded to first-line antibiotics.
About this data
Antibiotic consumption is expressed as the number of defined daily doses (DDDs) per 1,000 inhabitants per day. DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. DDDs are assigned to each active ingredient(s) in a given therapeutic class by international expert consensus. DDDs do not necessarily reflect the average daily dose actually used in a given country.
Definitions and comparability for the OECD indicator is taken directly from the OECD report Health at a Glance 2019: OECD indicators. Detailed information about the definitions, source and methods for each country can be found here.
Data for Spain, United Kingdom (England from 2012) and Portugal include data for primary care physicians only. Data for Canada, Ireland and New Zealand include only those dispensed by community pharmacies. Data for Denmark, Finland, France and Sweden include drugs dispensed in hospitals. Data for Australia include prescriptions dispensed at community pharmacies, private hospital pharmacies and public hospital outpatients and admitted day patients. Results for Canada only include data from the provinces of British Columbia, Manitoba and Saskatchewan.
Denominators comprise the population held in the national prescribing database, rather than the general population.
Countries may provide sales data, reimbursement data, or both. Sales data include the consumption of antibiotics obtained with or without prescription, while reimbursement data only include antibiotics obtained with prescription. The extent of consumption not included when using reimbursement data varies by country. Data for Austria, Belgium, Germany and the United Kingdom are reimbursement data. Data for Finland, France, Greece, Ireland, the Netherlands and Sweden are sales data. Data for Portugal and Spain are both reimbursement and sales data. For more information, see the ECDC website.