Marcia Frellick

April 28, 2015

COPENHAGEN, Denmark — The cultural variation in the use of antibiotics comes down to two things — confidence in dealing with uncertainty and how far people feel from the center of power — according to Michael Borg, MD, from Mater Dei Hospital in Msida, Malta, a country with a high level of antibiotic resistance.

"It's not the prescribing we have to address, it's the behavior," he said here at the 25th European Congress of Clinical Microbiology and Infectious Diseases.

Althugh there is agreement on the definition of responsible use of antibiotics between low- and high-resistance countries — choosing the correct antibiotic for the appropriate indication in the correct dose at the right time — practice patterns vary, Dr Borg explained.

For example, the use of antibiotics for the treatment of colds and sore throat ranged from 10% in the Netherlands to more than 80% in some Mediterranean countries, he reported. And the use broad-spectrum antibiotics is more common in high-resistance countries in Europe, he said.

Dr Borg's research was inspired by the work of Dutch anthropologist Geert Hofstede, who described two factors: power distance, or the perception of how much power one has; and uncertainty avoidance. High levels of both predict high levels of antibiotic resistance.

In cultures that display a great deal of discomfort dealing with ambiguity, more antibiotics are prescribed — and for more dubious presentations, such as cold and sore throat — and more broad-spectrum drugs are used, he said.

The correlation is weaker for power distance. "People with power tend to make all the decisions on their own, with no or very little involvement from those with lesser power." And lack of teamwork doesn't help the situation, he pointed out.

Education, motivation, and system change are needed in high-resistance countries, he said.

At his own hospital, the system for prescribing broad-spectrum antibiotics has changed, Dr Borg said. There is no longer a list of antibiotics you can use; instead, an algorithm is used to determine which drug is right for the information entered. Each doctor or senior assistant completes a request for antibiotics, and a copy is sent to department leaders.

This new system lessens uncertainty in a culture that strives to avoid it.

The extra steps are educational and motivational, he explained. However, the oversight has not been popular with prescribing physicians.

Doctors in the Netherlands have a different perspective, said Inge Gyssens, MD, from Hasselt University in Diepenbeek, Belgium.

Low-Resistance Countries

The Netherlands has strong evidence-based guidelines and a very strong network of primary care societies for disseminating the information, Dr Gyssens explained. That's one of the reasons for the difference in quinolone use among European countries; Greece ranks at the top of the list with the most use, and the Netherlands is at the bottom with almost no use.

Primary care physicians know the rules, she said, such as stop when you don't have evidence of infection and use shorter courses when you don't have complicated infections. Recommendations for hospitals are guided by the low resistance rates.

"The cultural difference you have to keep in mind is that the Dutch like guidelines," she said.

But that is not the case in Malta, said Dr Borg.

"Issue the guidelines and the primary care physicians will follow; that's the culture of the Netherlands. You collaborate, you discuss, but once you come to a consensus, everyone follows the line. Just come to my country and see how the consensus on driving is going," he said.

The differences might explain why some interventions are completely successful in some countries and extremely difficult to implement in others.

Slovenia in the Middle

In Slovenia, the level of resistance is in the middle. That likely stems from the fact that the country has been independent for only 2 decades, said Bojana Beović, MD, from the University Medical School in Ljubljana, Slovenia.

"My personal experience is that we will be most successful in changing behavior if we start with students and young physicians," she told Medscape Medical News.

In her hospital, opinions on antibiotic prescribing vary greatly among physicians, she reported. Surgeons, hematologists, and intensive care doctors are sometimes particularly hard to reach with recommendations for antibiotic use, she explained.

"They care for very sick patients and they do not want someone to intervene," she said. "That's understandable, but we are really in a crisis with antibiotics. We have to take care with each dose."

Dr Borg and Dr Beović have disclosed no relevant financial relationships. Dr Gyssens reports relationships with AstraZeneca, Cubist, MSD, Bayer, Pfizer, ECDC and Reed Business.

25th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID). Presented April 26, 2015.

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