Background
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 resistancesets 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.
Antibiotic consumption by provider
In England, the total consumption of antibiotics in primary and secondary care declined by 15%, from 19 Defined Daily Doses (DDDs) per 1,000 inhabitants per day in 2017, to 16 DDDs per 1,000 inhabitants per day in 2021 (data not shown). This overall decrease will contribute towards the UK’s five-year national action plan, which aims to accomplish a reduction in antimicrobial use in humans by 2024.
While most antibiotic prescribing occurs in general practice (72% of total prescribing in 2021), consumption in this setting has declined over time (a 24% decrease since 2014). This contrasts with prescribing in ‘other community’ settings, which has flatlined, accounting for a relatively small proportion of overall antimicrobial prescribing (4% of total prescribing in 2021).
Antibiotic consumption within secondary care has remained the same for inpatients but has decreased by 27% for hospital 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 2022/23includes a target for NHS trusts to reduce antibiotic usage by 1% by March 2023.
Antibiotic prescriptions by country
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 2013 and 2019, the volume of antibiotics prescribed in the UK fell from 20 DDDs per 1,000 inhabitants per day to 18 DDDs per 1,000 inhabitants per day.
The volume of antibiotics prescribed in primary care in the UK is slightly higher than average among the comparator countries. While the recent decrease in volume prescribed is promising, as of 2019, the UK’s prescribing levels were approximately double that of the Netherlands. Antibiotic prescribing is high in Greece, France and Spain and is low in the Netherlands, Japan and Canada.
Second-line antibiotic prescriptions by country
Quinolones and cephalosporins are considered second-line antibiotics in most prescribing guidelines. Their use should be restricted to 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.
In the UK, the percentage of antibiotics prescribed that were quinolones or cephalosporins decreased from 9% in 2000 to 4% 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 three countries that have the lowest percentage of quinolones and cephalosporins prescribed (the UK, Sweden, and Ireland) all provide data for primary care only. The comparator countries that provide data for secondary care only had a higher percentage of antibiotics prescribed that were quinolones or cephalosporins – 40% in Italy and 19% in Denmark in 2019. Prescriptions in both these countries fell by 43% and 77% respectively between 2019 and 2021, possibly due to care disruptions brought on by the Covid-19 pandemic. The difference in prescription between countries that provide data for primary and secondary care only 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.
OECD data
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, the United Kingdom (England from 2012) and Portugal include data for primary care physicians only. Data for Canada, Ireland and New Zealand include only antibiotics 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.
ECDC data
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.