Antibiotic Use in the European Union

Abstract & commentary

Synopsis: Data obtained during 1997 showed that sales of antibiotics for nonhospital use varied 4-fold among the 15 member states of the European Union during 1997 with France, Spain, Portugal, and Belgium being the biggest consumers and Sweden, Denmark, Germany, and The Netherlands being the lowest consumers.

Source: Cars O, et al. Lancet. 2001;357:1851-1853.

In a comparison of antibiotic use in countries of the European Union (EU), the amount of antibiotics sold in each country was converted to the defined daily dose (DDD), which is a unit based on the average daily dose used for the main indication of the drug. Most of the data on national sales were purchased from a private company that relies on various sources including manufacturers, wholesalers, pharmacies, prescribers, and hospitals and makes national estimates. The number of inhabitants in each country was obtained from EUROSTAT, the agency that collects such data for the EU. France consumed the most antibiotics, 4 times more than The Netherlands, which consumed the least. Broad-spectrum penicillins accounted for 39% of all sales followed by macrolides and lincosamides (17%), tetracyclines (14%), and cephalosporins (10%) and together made up 80% of all sales in th EU. The broad-spectrum penicillins were also the most frequently prescribed in each country except for Finland and Germany which consumed more tetracyclines, Sweden and Denmark which preferred narrow spectrum beta-lactam antibiotics (data not shown on the ), and Austria in which the macrolides were most frequently prescribed. There was also marked variation between countries in the consumption across every class of antibiotics. For instance, cephalosporins accounted for 1 in 5 antibiotics prescribed in Greece but were rarely used in The Netherlands, while quinolones were most widely used in Portugal. Cars and colleagues also remarked on how different the pattern of antibiotic uses was in 2 neighboring countries—Belgium and the Netherlands—that share a common language. The variation in outpatient antibiotic use in the EU was thought not to reflect widely differing patterns of bacterial infection but rather different historical, cultural, and social factors as well as disparities in health care systems between the 15 countries. Cars et al concluded with a challenge to member states to perform proper epidemiological studies on antibiotic prescribing and resistance.

Comment by J. Peter Donnelly, PHD

Table-Antibiotic Use in the European Union
Proportion of drugs sold per country
DDD per
1000 inhabitants
DDD relative to
The Netherlands
& lincosamides
Tetracyclines Cephalosporins Proportion of all
drugs sold
France 36.51 4.1 52% 16% 9% 10% 87%
Spain 32.44 3.6 56% 18% 4% 8% 86%
Portugal 28.83 3.2 42% 13% 9% 11% 75%
Belgium 26.72 3 41% 15% 19% 11% 86%
Luxembourg 25.58 2.9 41% 18% 16% 11% 86%
Italy 23.99 2.7 47% 21% 2% 13% 83%
Greece 22.69 2.5 34% 20% 12% 21% 87%
Finland 19.34 2.2 20% 10% 28% 11% 69%
Ireland 18.34 2 44% 14% 19% 7% 84%
United Kingdom 18.04 2 38% 18% 20% 5% 81%
Austria 13.8 1.5 23% 26% 13% 9% 71%
Germany 13.58 1.5 20% 19% 24% 7% 70%
Sweden 13.51 1.5 10% 7% 22% 4% 43%
Denmark 11.35 1.3 21% 17% 9% 0% 47%
The Netherlands 8.96 1 32% 14% 26% 1% 73%

The differences noted in antibiotic use in the EU for a single year are remarkable and defy explanation but are not surprising. The EU aspires to harmonize everything from the quality of cucumbers to standardizing sausage, but on the ground each country still maintains its traditions, beliefs, culture, and habits—all of which exert a much greater influence on all aspects of daily life including, apparently, antibiotic preference. This is even tactily acknowledged by multinational pharmaceutical companies who would like to treat the EU as a single sector of the globe but still maintain offices in each country to deal with the local market. The differences between Belgium and The Netherlands are indeed noteworthy. They are even reflected in the trade names given to some drugs such as itraconazole, which is known in Belgium (and indeed everywhere else) as Sporanox. In The Netherlands, it is called Trisporal. Similarly, ceftazidime is known as Fortaz in The Netherlands, but across the border in Belgium it is known as Glazidim. However, only part of Belgium speaks Dutch (or Flemish). French is spoken in the other part, which may well have as much influence on antibiotic use as it does on cuisine and couture.

Whatever the reasons for the variation in antibiotic use in the EU, it is tempting to speculate about this being the explanation for differences in resistance rates since the northern countries like The Netherlands, Sweden, and Denmark have the lowest rates of antibiotic resistance in the EU. Countries like France, Greece, Italy, and Spain have some of the highest rates. These differences might simply reflect a North-South divide or even division between the Protestant and Catholic/Orthodox countries. Certainly these data are tantalizing and should encourage more research to explore further the link between antibiotic resistance and both higher consumption and the preference for certain antibiotic classes. I am also curious to know what a similar investigation into the pattern of antibiotic use between the states of the United States. The union is older than the EU and governed by federal regulations rather than a council. If there was greater uniformity between the states than that seen in the EU, central regulation could alter antibiotic use. However, if there was similar variation, other means would have to be sought to ensure a more rational use of the precious resources of antibiotics.