A Successful Campaign Against Antibiotic Overuse

John G. Bartlett, MD


November 06, 2009

Antibiotic overuse, especially for viral infections in children, is a major problem that was addressed by a multiyear national program in France. This Viewpoint discusses the results of this program, which was successful in reducing antibiotic use by more than the initial goal of 25%.

Significant Reduction of Antibiotic Use in the Community After a Nationwide Campaign in France, 2002-2007

Sabuncu E, David J, Bernède-Bauduin C, et al
PLoS Med. 2009;6:e1000084

Article Summary

Background: Data from the European Union previously showed that France had the greatest use of antibiotics, and this correlated with the rates of multidrug-resistant pneumococci. The assumption was that antibiotic use was responsible for this experience, which was particularly worrisome because of the dearth of new antibiotics to deal with this and other resistance problems. Consequently, the French government initiated a long-term nationwide campaign to reduce antibiotic overuse.

The program, named “Keep Antibiotics Working,” was launched in 2001 and targeted the general public as well as healthcare professionals. The effort emphasized reduction in antibiotic use for viral respiratory infections, particularly in children, who account for over 40% of the antibiotic prescriptions. The goal of the program was to reduce antibiotic prescriptions by 25%.

Purpose: The study was designed to determine the effectiveness of this campaign.

Methods: Data were analyzed for the 62 million citizens of France who were cared for by about 54,000 primary care physicians. National data were readily obtained by the National Health Service using the French Sentinel Network that collects and tabulates the necessary information regarding patient demographics, drug-related data, prescription date, diagnosis, etc. Particular attention was paid to flu-like illness described as fever, myalgia, and respiratory symptoms.

Results: The data were evaluated for 2007 with over 453 million patient encounters. The preintervention period was 2000 to 2002 and the study period was 2003 to 2007.

During the implementation phase, there was a 26.5% reduction in the total number of antibiotic prescriptions per 100 inhabitants for a flu-like illness. The decline was seen throughout the country and applied to all therapeutic classes except fluoroquinolones. The greatest decrease was 35.8% in children aged 6-15 years. These results were accompanied by a decrease in resistance by Staphylococcus pneumoniae to penicillin (from 47% to 32%) and to macrolides (from 49% to 36%). The results by antibiotic class for the last year of analysis compared with baseline are shown in the Table.

Table. Mean Number of Antibiotic Prescriptions per 100 Inhabitants Between October and March and Percentage Change Compared With Baseline

Antibiotic 2002-2002
(Year 5)
Change vs Baseline (%)
All 72.4 56.6 -21.9
Penicillins 27.0 20.2 -25.3
Cephalosporins 16.3 12.3 -24.6
Fluoroquinolones 4.2 4.7 +12.8
Macrolides 16.4 11.5 -30.1
Tetracyclines 3.1 3.0 -3.7
Other 5.3 4.8 -8.0


Conclusion: The authors concluded that this national campaign was associated with a marked reduction in unnecessary prescription of antibiotics, particularly in children.


France has a reputation of having the highest per capita uses for antibiotics, with prior rates of 33 defined daily doses (DDD)/1000 persons/day. At the other end of the spectrum was The Netherlands, with 9 DDD/1000 persons/day. For comparison, the US data show 24 DDD/1000 persons/day. This was an extraordinarily successful campaign that actually achieved a 26.5% reduction in the number of antibiotic prescriptions for 5 winters after launch compared with 2 baseline winters. Thus, they actually exceeded the campaign goal of a 25% reduction.

The major reduction was in pediatric patients, and the decrease applied to all classes of antibiotics except fluoroquinolones, which showed a 13% increase. It is noted in an accompanying editorial[1] that the campaign cost 100 million Euros (approximately 143 million US dollars), considered extremely costly considering a successful Belgian campaign cost only about 400,000 Euros (US$570,000)/year. However, the editorialists also point out that the national campaigns in Greece, Spain, England, and Australia have failed to show any impact, so they concluded by congratulating the French for their success.

Possible deficits in this paper include the assumption that there was no harm and the potential contamination by disease reduction from the pneumococcal 7-valent conjugate vaccine (Prevnar) that became widely used by the end of 2006.



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