Outpatient Antibiotic Use and Prevalence of Antibiotic-Resistant Pneumococci in France and Germany: A Sociocultural Perspective

Stephan Harbarth, Werner Albrich, Christian Brun-Buisson


Emerging Infectious Diseases. 2002;8(12) 

In This Article


This report represents a unique attempt to combine different data sources to give a more complete picture of sociocultural and economic forces influencing the ecology of antibiotic use and pneumococcal resistance in two large European countries. The published literature regarding the prevalence of antibiotic-resistant pneumococci provides convincing evidence that France and Germany have sharply different rate. The reasons for the observed resistance gap are multifactorial and include substantial differences in physicians' and patients' attitudes towards antibiotics; sociocultural and economic factors; and disparities in regulatory practices. Studies are remarkably consistent in documenting the high frequency with which antibiotics are used in France for upper respiratory tract infections without appropriate microbiologic rationale. Unfortunately, despite the widespread publication of recommendations over the last decade and some modest modifications in the pattern of antibiotic utilization[61], the willingness of French general practitioners to change their antibiotic-prescribing habits has been at best grudging and at worst nonexistent[29,67]. As shown in a recently published survey from the United States[68], little evidence suggests that national guidelines alone, particularly when they emphasize societal concerns, have much impact on individual antibiotic-prescribing behavior. Therefore, much more attention needs to be focused on patient expectations and perceptions of illness and the constraints of medical practice (39). Major improvements are needed in communicating to individual patients[69] and in informing the general public about the risks of inappropriate antibiotic use[13,70]. In November 2001, the former French Minister of Health, Dr. Bernard Kouchner, took an important step in this direction by allocating 30 million euros for public awareness campaigns about antibiotic misuse and resistance[71]. In this respect, France may also learn from the experience of countries like the United States, Canada, Belgium, and Sweden, which all managed to reduce excessive antibiotic use on a national level[19,72,73,74]. In particular, a number of Scandinavian studies have suggested that national antibiotic policies together with public information campaigns and changes in reimbursement policies can be effective[55,75].

In Germany, low prevalence of pneumococcal resistance coincides with less antibiotic consumption, selection of narrow-spectrum antibiotics, higher dosing of amino-penicillins, and possibly, better treatment compliance[2]. Thus, learning from Germany's experience with regard to the low prevalence of penicillin-resistant pneumococci may have some value for other countries. However, German health authorities should be careful in regard to the increasing spread of antibiotic-resistant pneumococci[11,76]. A rational approach to the control of antibiotic-resistant pneumococci and the surveillance of antibiotic use in the outpatient setting are urgently warranted in Germany to preserve the still favorable situation.

An interesting question remains about whether differences in national antibiotic-prescribing patterns affect the rates of illness and death from complications of respiratory tract infections. A recent study[77] showed, for instance, that the Netherlands, a country with low antibiotic prescription rates for acute otitis media, had an incidence rate of acute mastoiditis of 3.8/100,000 person-years, whereas in countries with very high prescription rates, incidence rates were considerably lower, ranging from 1.2 to 2.0/100,000 person-years. A conservative approach and withholding of antibiotics in the treatment of acute otitis media may also have increased the occurrence of acute mastoiditis in Germany[78]. A recently published article[79] indirectly suggests that the low rates of Haemophilus influenzae type B meningitis in some countries, particularly in Asia, may be due at least partially to extensive antibiotic use. However, no recently published, representative surveillance data exist about illness and death from complications of common respiratory tract infectious in France or Germany. Future international studies about the use of outpatient antibiotics[80] should include cross-country surveillance data for serious infectious complications such as mastoiditis, acute rheumatic fever, meningitis, or suppurative complications of pharyngitis[81].

Finally, we argue that effects exerted at the macro-level by the cultural and socioeconomic environment contribute substantially to the observed differences in prescribing practices and related antibiotic resistance rates. Consequently, failure to understand the sociocultural and economic perspectives of antibiotic consumption and resistance will lead to inadequate conclusions about the chances of success for possible interventions. More research to inform decision-makers on the determinants of the variation in antibiotic use and resistance patterns is urgently needed.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.