Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community.

BACKGROUND: Over 90% of antibiotics for human use in Europe are prescribed in primary care. We assessed the congruence between primary care treatment guidelines for skin infections and commensal Staphylococcus aureus (S. aureus) antimicrobial resistance levels in community-dwelling persons. METHODS: The prevalence of antimicrobial resistance in S. aureus was analysed by taking nose swabs from healthy primary care patients in nine European countries (total N = 32,032). Primary care treatment guidelines for bacterial skin infections were interpreted with respect to these antimicrobial resistance patterns. First- and second-choice recommendations were assessed and considered congruent if resistance to the antibiotic did not exceed 20%. RESULTS: We included primary care treatment guidelines for impetigo, cellulitis, folliculitis and furuncle. Treatment recommendations in all countries were consistent: most of the first-choice recommendations were beta-lactams, both for children and adults. Antimicrobial resistance levels were low, except for penicillin (on average 73% resistance). Considerable variation in antimicrobial resistance levels was found between countries, with Sweden displaying the lowest levels and Spain the highest. In some countries resistance to penicillin and azithromycin was significantly higher in children (4-17 years) compared with adults. CONCLUSIONS: Most of the first- and second-choice recommendations in the treatment guidelines for skin infections were congruent with commensal S. aureus antimicrobial resistance patterns in the community, except for two recommendations for penicillin. Given the variation in antimicrobial resistance levels between countries, age groups and health care settings, national data regarding antimicrobial resistance in the community should be taken into account when updating or developing primary care treatment guidelines.

The appropriateness of prescribing antibiotics in the community in Europe: study design.

BACKGROUND: Over 90% of all antibiotics in Europe are prescribed in primary care. It is important that antibiotics are prescribed that are likely to be effective; however, information about antibiotic resistance in the community is incomplete. The aim of our study is to investigate the appropriateness of antibiotic prescribing in primary care in Europe by collecting and combining patterns of antibiotic resistance patterns and antibiotic prescription patterns in primary care. We will also evaluate the appropriateness of national antibiotic prescription guidelines in relation to resistance patterns. METHODS/DESIGN: Antibiotic resistance will be studied in an opportunistic sample from the community in nine European countries. Resistance data will be collected by taking a nose swab of persons (N = 4,000 per country) visiting a primary care practice for a non-infectious disease. Staphylococcus aureus and Streptococcus pneumoniae will be isolated and tested for resistance to a range of antibiotics in one central laboratory. Data on antibiotic prescriptions over the past 5 years will be extracted from the electronic medical records of General Practitioners (GPs). The results of the study will include the prevalence and resistance data of the two species and 5 years of antibiotic prescription data in nine European countries. The odds of receiving an effective antibiotic in each country will be calculated as a measure for the appropriateness of prescribing. Multilevel analysis will be used to assess the appropriateness of prescribing. Relevant treatment guidelines of the nine participating countries will be evaluated using a standardized instrument and related to the resistance patterns in that country. DISCUSSION: This study will provide valuable and unique data concerning resistance patterns and prescription behaviour in primary care in nine European countries. It will provide evidence-based recommendations for antibiotic treatment guidelines that take resistance patterns into account which will be useful for both clinicians and policy makers. By improving antibiotic use we can move towards controlling the resistance problem globally.

Antibiotic Exposure and Other Risk Factors for Antimicrobial Resistance in Nasal Commensal Staphylococcus aureus: An Ecological Study in 8 European Countries.

OBJECTIVES: Antimicrobial resistance (AMR) has become a global public health concern which threatens the effective treatment of bacterial infections. Resistant Staphylococcus aureus (including MRSA) increasingly appears in individuals with no healthcare associated risks. Our study assessed risk factors for nasal carriage of resistant S. aureus in a multinational, healthy, community-based population, including ecological exposure to antibiotics. METHODS: Data were collected in eight European countries (Austria, Belgium, Croatia, France, Hungary, the Netherlands, Spain and Sweden). Commensal AMR patterns were assessed by collecting 28,929 nasal swabs from healthy persons (aged 4+). Ecological exposure to antibiotics was operationalized as systemic antibiotic treatment patterns, extracted from electronic medical records of primary care practices in which the participants were listed (10-27 per country). A multilevel analysis related AMR in nasal commensal S. aureus to antibiotic exposure and other risk factors (e.g. age and profession). RESULTS: Of the 6,093 S. aureus isolates, 77% showed resistance to at least one antibiotic. 7.1% exhibited multidrug resistance (defined as resistance to 3 or more antibiotic classes), and we found 78 cases MRSA (1.3%). A large variation in antibiotic exposure was found between and within countries. Younger age and a higher proportion of penicillin prescriptions in a practice were associated with higher odds for carriage of a resistant S. aureus. Also, we found higher multidrug resistance rates in participants working in healthcare or nurseries. CONCLUSIONS: This study indicates that in a population with no recent antibiotic use, the prescription behavior of the general practitioner affects the odds for carriage of a resistant S. aureus, highlighting the need for cautious prescribing in primary care. Finally, since variation in AMR could partly be explained on a national level, policy initiatives to decrease AMR should be encouraged at the national level within Europe.

Fusidic acid resistance in Staphylococcus aureus nasal carriage strains in nine European countries.

AIM: To evaluate fusidic acid resistance pheno- and geno-typically in nasal carriage Staphylococcus aureus isolated from general practice patients in nine European countries. MATERIALS & METHODS: Phenotypic fusidic acid resistance was determined by disc diffusion and MIC values, and genotypically by a PCR detecting fusA-E genes. The main analysis was performed on methicillin-susceptible S. aureus strains, because methicillin-resistant S. aureus isolates were scarce. RESULTS: Overall S. aureus fusidic acid resistance was low (<10%). fusC was the predominant mechanism of resistance and associations were found between resistance genes and specific spa types. CONCLUSION: S. aureus strains showed low resistance to fusidic acid, making this antibiotic an appropriate choice in the treatment of methicillin-susceptible S. aureus skin infections in general practice patients in the nine participating European countries.

Evidence-based primary care treatment guidelines for skin infections in Europe: a comparative analysis.

BACKGROUND: In Europe, most antibiotics for human use are prescribed in primary care. Incorporating resistance data into treatment guidelines could improve appropriate prescribing, increase treatment effectiveness and control the development of resistance. OBJECTIVES: This study reviews primary care treatment guidelines for bacterial skin infections across Europe and assesses to what extent they are based on antibiotic resistance data. METHODS: Thirteen primary care treatment guidelines were obtained from eight countries across Europe. Both the treatment recommendations and the underlying evidence were assessed. The class and dose of recommended antibiotics were investigated and compared using the World Health Organisation's standardized volume of Defined Daily Dose. Furthermore, analysis investigated whether guidelines included references to scientific publications about antibiotic resistance data, and whether these were of national origin. RESULTS: Guidelines were included regarding common skin infections in primary care: Impetigo, Cellulitis, Erysipelas, Folliculitis and Furuncle. RESULTS showed a high agreement across Europe: all recommended antibiotics are of the beta-lactam class and mainly in the small spectrum. The advised treatment durations are consistent; the dosages, however, vary considerably, with the highest dosages recommended in Sweden. Seven guidelines (54%) did not include scientific references related to resistance. CONCLUSION: There may be a lack of relevant national data on resistance. This study highlights the need to collect more national resistance data (particularly regarding beta-lactams) to create stronger evidence-based treatment guidelines for skin infections in Europe.

Prevalence and resistance of commensal Staphylococcus aureus, including meticillin-resistant S aureus, in nine European countries: a cross-sectional study.

BACKGROUND: Information about the prevalence of Staphylococcus aureus resistance to antimicrobial drugs has mainly been obtained from invasive strains, although the commensal microbiota is thought to be an important reservoir of resistance. We aimed to compare the prevalence of nasal S aureus carriage and antibiotic resistance, including meticillin-resistant S aureus (MRSA), in healthy patients across nine European countries. METHODS: In this cross-sectional study, nasal swabs were obtained from 32,206 patients recruited by family doctors participating in existing nationwide family doctor networks in Austria, Belgium, Croatia, France, Hungary, Spain, Sweden, the Netherlands, and the UK. Eligible patients were aged 4 years or older (≥ 18 years in the UK) and presented with a non-infectious disorder. Swabs were sent to national microbiological laboratories for identification and isolation of S aureus. Antibiotic resistance testing was done at one central microbiological laboratory. We established the genotypic structure of the isolated MRSA strains with the spa typing method. FINDINGS: S aureus was isolated from 6956 (21 · 6%) of 32,206 patients swabbed. The adjusted S aureus prevalence for patients older than 18 years ranged from 12 · 1% (Hungary) to 29 · 4% (Sweden). Except for penicillin, the highest recorded resistance rate was to azithromycin (from 1 · 6% in Sweden to 16 · 9% in France). In total, 91 MRSA strains were isolated, and the highest MRSA prevalence was reported in Belgium (2 · 1%). 53 different spa types were detected-the most prevalent were t002 (n = 9) and t008 (n = 8). INTERPRETATION: The prevalence of S aureus nasal carriage differed across the nine European countries assessed, even after correction for age, sex, and family doctor. Generally, the prevalence of resistance, including that of MRSA, was low. The MRSA strains recorded showed genotypic heterogeneity, both within and between countries. FUNDING: European Commission, 7th Framework Programme(grant agreement 223083).