Background for Different Use of Antibiotics in Different Countries

Sir—We read the article about the quantitative and qualitative differences in antibiotic prescribing between British Columbia and Denmark [1] with great interest. We agree with the authors that the increasing use of fluoroquinolones and new macrolides is worrying, because it may increase the risk for emergence of a greater number of resistant microorganisms. With use of a different method, we performed a study that compared the prescribing of antibiotics in Spain and Denmark [2]. In Spain, a similar phenomenon to the one in British Colombia was observed, with an increase in the use of new antibiotics. We agree that among the main reasons for the difference in antibiotic use are the different opinions and traditions regarding how to treat infections that exist in different countries. We have verified this by comparing, for example, the existing general practice guidelines for the treatment of streptococcal tonsillitis or of the exacerbation of chronic obstructive pulmonary disease in Denmark and Spain. In Denmark, narrow-spectrum penicillin is recommended for both infections, whereas in Spain, only broad-spectrum antibiotics are recommended. A vicious circle is thus created. In an attempt to cover these pathogens, the prescribing of broad-spectrum antibiotics favors a more rapid expansion of resistant microorganisms. In Denmark, where rates of resistance are very low, narrow-spectrum antibiotics are still the most frequently used antibiotics in primary health care, thus perpetuating a low prevalence of resistant microorganisms. We would like to emphasize the fact that different methods of organizing health care services may have a considerable influence on the pattern of antibiotic prescribing. Variables such as the type of health care financing system, the number of doctors per inhabitant, and the average time spent with the patient may lead to different prescribing habits. It is known, for example, that countries with a greater number of doctors per inhabitant use more antibiotics than do countries with a smaller number of doctors per inhabitant [3], and that doctors who spend more time with their patients prescribe fewer antibiotics [4]. The permissive policy of the sale of antibiotics without a prescription (i.e., over-the-counter policy), which exists in Spain but not in Denmark, is another potential reason for the difference. Other factors to take into account are the number of pharmacies per inhabitant (10 times greater in Spain than in Denmark), the pressures from the pharmaceutical industry, and the antibiotics available. In Spain, penicillin V is only marketed in doses of 200 mg and 600 mg, a fact about which the pharmaceutical industry's representatives do not inform doctors. Different policies concerning subsidization of antibiotics may also have an influence. In Denmark, fluoroquinolones and cephalosporines are not subsidized by the national health care service. In conclusion, we believe that different methods of organizing health care services, different subsidization policies, and different impacts of pharmaceutical marketing should be taken into account when trying to explain differences in the pattern of antibiotic prescribing. These factors may indeed explain some of the differences that exist between neighboring countries, such as between Belgium and The Netherlands [5]. Antibiotic resistance may spread across borders. Countries with a high prevalence of resistance may serve as a source of bacterial resistance for countries with low prevalence. Studies comparing consumption of antibiotics in different countries are therefore important, and the article by Patrick et al. [1] contributes to our understanding in this field. However, more knowledge about the background of these differences is needed to stem the increasing use of new antibiotics and the increasing prevalence of resistant microorganisms. Potential conflicts of interest. All authors: no conflicts.