Bollettino epidemiologico nazionale

The principal outcome of the inappropriate use of antibiotics is to expose people unnecessarily to a risk: instead of the expected benefits, there is a lesser or greater risk of adverse reactions. In the case of antibiotics, there is an addition reason for concern in that the use of these drugs is a determinant of antibiotic resistance. The recent First National Report on the Use of Drugs in Italy, published by the National Observatory for the Utilization of Drugs of the Ministry of Health (www.sanita.it/osmed) reported that not only were antibiotics one of the most commonly prescribed drug categories, but also that there were major regional differences in prescribing practices.

 

In 1999, antibiotics represented approximately 16% of total pharmaceutical costs in Italy, and, on average, 219 packets were prescribed per 100 persons. In terms of standard doses (daily defined doses-DDD, that represent the number of doses for each drug that are necessary for one day of adult treatment), 22 DDD were consumed per 1000 persons per day. This measure can be interpreted as the number of persons who are taking antibiotics on a given day. In addition to this figure, which is limited to ambulatory settings, an additional 2 DDD per 1000 persons per day are used in hospital settings.

 

From regional monitoring data, it is possible in some cases to obtain additional information on the users of antibiotics. For example, in Umbria, which is located in central Italy and which has an overall consumption level similar to the national mean, 44% of the general population, including 43% of men and 46% of women received at least one antibiotic prescription in 1999. The highest levels of use were seen in children under 5 years, approximately 70% of whom received at least one antibiotic prescription, and those over 65 years, an estimated 50% of whom received at least one such prescription.

 

In the first half of 2000, among the more than100 antibiotics prescribed in the country, six (clarithromycin, cefonicid, amoxacillin with clavulinic acid, ceftriaxone, azithromycin, and ciprofloxacin) accounted for 50.5% of total expenses for antibiotics.

 

In Italy, in addition to a high mean level of antibiotic consumption, there is a great deal of regional variability as well as a consistent geographic trend (Figure 1). In the first half of 2000, antibiotic use ranged from 13 DDD per 1000 persons in Friuli Venezia Giulia in northeast Italy to 34 DDD per 1000 persons in Campania in southern Italy. The regional differences further increased when the analysis was limited to those antibiotics for which Italian law requires a written justification, with values ranging from 0.1 DDD per 1000 persons per day in Friuli Venezia Giulia and Veneto (also in northeastern Italy) to 0.9 DDD per 10000 residents per day in Campania. A similar level of variability was observed for injectable antibiotics. Despite the highly restricted indications for injectable antibiotics, their use in Italy remains high and accounts for 6% of the DDD and 34% of the antibiotic expenses.

 

Regional differences such as those observed in Italy cannot be easily explained by differences in levels of morbidity. The most likely explanation for the variability is different prescribing practices by physicians in the different regions. Another source of variability is related to the varying levels of functioning of the drug use monitoring system. Those regions with the most restrained use of antibiotics are those where the monitoring systems have been functioning the longest.

 

Because of the risks associated with inappropriate antibiotic use, which include induction of bacterial resistance as well as adverse reactions, even limited changes in prescribing practices could have important health consequences and reduce health care costs. An important step will be to share the results of studies on prescribing practices with physicians and to develop interventions designed to reduce the level of inappropriate prescriptions.