Academic journal article Bulletin of the World Health Organization

Lessons Learnt during 20 Years of the Swedish Strategic Programme against Antibiotic resistance/Programme Strategique Suedois Contre la Resistance Aux Antibiotiques-20 Annees d'enseignements/Las Lecciones Aprendidas En 20 Anos del Programa Estrategico Sueco Contra la Resistencia a Los Antibioticos

Academic journal article Bulletin of the World Health Organization

Lessons Learnt during 20 Years of the Swedish Strategic Programme against Antibiotic resistance/Programme Strategique Suedois Contre la Resistance Aux Antibiotiques-20 Annees d'enseignements/Las Lecciones Aprendidas En 20 Anos del Programa Estrategico Sueco Contra la Resistencia a Los Antibioticos

Article excerpt

Introduction

The high global use of antibiotics, the rapid spread of multidrug-resistant bacteria and the lack of new, effective antibiotics has led to an imminent threat to health systems and global development. The responsibility of national governments for taking action to contain antibiotic resistance was reinforced in the global action plan on antimicrobial resistance adopted at the May 2015 World Health Assembly. (1) A core strategy for controlling resistance is to coordinate efforts through a national action plan. In Sweden, such a plan was first developed in 2000. It built on the work of the Swedish strategic programme against antibiotic resistance, known as Strama, a nationwide structured and continuously evolving collaboration against antibiotic resistance that has been in place since 1995. (2)

The programme was triggered by a rapid spread of penicillin-resistant pneumococci among children in southern Sweden in the early 1990s. (3) It started as a voluntary network of government authorities and professional organizations and with the formation of multiprofessional groups in local administrative areas. (4) From the start, the programme applied a One Health approach to antibiotic resistance, working across sectors and multiple disciplines. (5) Already in 1986, the use of antibiotics in animal feed for growth promotion was banned in Sweden. Since 2012, an intersectoral coordinating mechanism, presently consisting of 25 agencies and organizations within the public health, animal health, food and the environmental sectors, is in place.

Levels of antibiotic use and resistance in Sweden are now among the lowest among the European Union (EU) countries, both in the human and animal sectors. (6-8) Between 1992 and 2016, the number of prescriptions per 1000 inhabitants per year in outpatient care, including primary health care, decreased by 43%, from 560 to 318, while among children aged 0-4 years they decreased by 73%, from 1328 to 349 (Fig. 1). (10) Adherence to treatment recommendations has been increasing gradually and, notably, sales of antibiotics used for respiratory tract infections have decreased. For several indications there has been a major shift from broad- to narrow-spectrum antibiotics in primary and hospital care, in line with recommendations. (11,12) Important factors for change include setting a national target for the number of prescriptions in outpatient care and defining quality indicators based on treatment recommendations, as well as providing local feedback to prescribers.

This paper outlines the stepwise development of the strategic programme against antibiotic resistance in Sweden over a period of 20 years. We describe the structure, key functions and interventions of the initiative across different working areas in human medicine. We hope that the strategies described and the lessons learnt could inform countries starting to implement their own national action plans against antibiotic resistance.

Commitment at all levels

The government in Sweden is responsible for overall policy on health care, with the responsibility for delivery and financing of health care decentralized to 21 county councils. The financing of the strategic programme against antibiotic resistance has been an evolving process and much of the progress was initially achieved through voluntary work. Funding has gradually increased and become more formalized, now amounting to approximately 2 million euros ([euro]) at the national level, and an estimated [euro] 3-5 million for the work of the local groups.

The local multiprofessional groups function as links between the national and local levels (Box 1). They serve as a mechanism to adapt national initiatives to local conditions. For example by facilitating the implementation of treatment recommendations and by identifying and overcoming barriers to improved antibiotic use and infection control. Typically, they include physicians and other health-care professionals from general practice (primary health care) and departments of infectious diseases, paediatrics, ear nose and throat, clinical microbiology, infection control units and pharmacy. …

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