Outpatient Antibiotic Use — France vs Germany: A Cultural Lesson
Outpatient Antibiotic Use— France vs Germany: A Cultural Lesson
Abstract & Commentary
Synopsis: The French use antibiotics quite differently from the Germans, for a variety of reasons, including cultural factors and regulations, in addition to physician habits and patient expectations.
Source: Harbarth S, Albrich W, Brun-Buisson C. Outpatient antibiotic use and prevalence of antibiotic-resistant pneumococci in France and Germany: A sociocultural perspective. Emerg Infect Dis. 2002;8(12):1460-1467.
You might expect france and germany to be very similar in their antibiotic prescribing and antimicrobial resistance patterns in that they are contiguous, have comparable socio-economic status, and a national health service. But such is not the case. More than 45% of the pneumococci identified in France in 1998 were nonsusceptible to penicillin, whereas only 7% were so in Germany. The same differences were noted with erythromycin resistance (47% vs 4%, respectively). These disparities correlate with contrasts in antibiotic prescribing with France the highest in Europe with defined daily doses almost 3 times as high as in Germany (36/1000 vs 13.6/1000), which is among the lowest.1 The differences in antibiotic resistance were thought to be more likely the result, rather than the cause, of the differing use of antimicrobials.
Harbarth and associates made an extensive effort to review every possible facet of the literature to find information that may be relevant to the differing use of antimicrobials, and they found a number of factors that likely relate. Although the dates and definitions of the information varied considerably, a number of interesting factors emerged.
Physician habits were clearly different in French compared with German physicians, with the French much more likely to prescribe antibiotics. A 1991 survey in France found approximately a quarter of the population was taking antibiotic therapy. They were also more likely to use newer and broad-spectrum ones such as cephalosporins and quinolones, whereas the Germans relied much more on penicillins, tetracycline, and co-trimoxazole. German physicians were also more likely to use a higher dose of antibiotics than the French. The Germans were also less likely to prescribe antibiotics on the first office visit for acute bronchitis (7% vs 31%) and more likely to order diagnostic tests such as blood tests and chest x-rays (43% vs 21%) instead.
Patient expectations were also different. Office visits in France were considerably more frequent per capita in Germany, and more than half of the patients expected an antibiotic for the "flu." The Germans were more likely to try nonprescription medicines and homeopathy than the French and had a stronger belief in allowing infections to run their course to stimulate the immune system—as well as a fear that antibiotics would undermine it.
There were also interesting social and cultural differences that may well relate to the frequency of infections and antimicrobial resistance, especially in children, for whom most antibiotics are prescribed. Infections may be more likely because breast feeding is not as common with the French and usually practiced for a shorter period of time. Day care is almost universal for French compared with German children and often starts at a younger age.
Economic incentives and regulations of the pharmaceutical industry also appear to play a role. Retail prices for antimicrobials are considerably less in France than in Germany. In France, pharmacies profit more from selling expensive antibiotics, whereas the volume of medications is more important in Germany. Generic antibiotics are used far more frequently in Germany than France (38% vs < 5%).
Comment by Alan D. Tice, MD, FACP
This is a nice review and comparison of oral antimicrobial prescribing with considerable insight into the complex factors that affect them. There are aspects of culture and regulations, which affect use, as well as simple physician prescribing beliefs and patient expectations. It takes understanding of antibiotic use to a new level and points out how any improvements must consider multiple factors. It is not simply a matter of training doctors to change, especially with the "grudging" responses noted of the French.
While the high antibiotic resistance figures for France may not simply be a reflection of higher antibiotic use, it is likely so.
This article also brings up the question of what the correct rate of antimicrobial use is. Are the Germans right? Or are the French? Or is appropriate use somewhere in the middle? While the present consensus is to try to reduce use, there are some concerns that it is possible to go too far. Otitis media is one of the most frequent reasons for prescribing antibiotics. In countries where antibiotic use for ear infections is low, the incidence of mastoiditis seems to be higher. Although the numbers are not significant statistically, the question is an important one. With reduced use of antimicrobials, will we see more rheumatic fever, meningitis, or other infections, which may otherwise be suppressed by the present widespread use of antibiotics throughout the world?
Another consideration is cost, which varies with the perspective taken. Use of new and broad-spectrum antibiotics increases the cost of medications and benefits the pharmaceutical industry. However, the expense of diagnostic testing before prescribing an antibiotic may well outstrip the cost of the drug. Frequent office visits for a perceived need for an antibiotic prescription may increase health care costs. Antimicrobial resistance also takes its toll in terms of secondary costs of medical care and likely loss of life. The cost to society depends on the outcome being valued.
Other questions about antibiotic use revolve around whether the goal should be lives saved or money spent. Should it be for the individual, whose life may be at stake, or society, which benefits little from antibiotic therapy?
The future of antimicrobial resistance and appropriate use is a challenging one with a need for more insight into social, cultural, and regulatory factors such as this. Only through data gathering and a broad perspective on inquiry can we learn the best approaches.
Reference
1. Cars O, Molstad S, Melander A. Variation in antibiotic use in the European Union. Lancet. 2001;357:1851-1853.
The French use antibiotics quite differently from the Germans, for a variety of reasons, including cultural factors and regulations, in addition to physician habits and patient expectations.Subscribe Now for Access
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