Content uploaded by Robert H. Vander Stichele
Author content
All content in this area was uploaded by Robert H. Vander Stichele on Jan 30, 2018
Content may be subject to copyright.
Outpatient Antibiotic Use in Europe and Association with Resistance: A Cross-National Database Study
Abstract
Resistance to antibiotics is a major public-health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Our aim was to assess outpatient use of antibiotics and the association with resistance.
We investigated outpatient antibiotic use in 26 countries in Europe that provided internationally comparable distribution or reimbursement data, between Jan 1, 1997, and Dec 31, 2002, by calculating the number of defined daily doses (DDD) per 1000 inhabitants per day, according to WHO anatomic therapeutic chemical classification and DDD measurement methodology. We assessed the ecological association between antibiotic use and antibiotic resistance rates using Spearman's correlation coefficients.
Prescription of antibiotics in primary care in Europe varied greatly; the highest rate was in France (32.2 DDD per 1000 inhabitants daily) and the lowest was in the Netherlands (10.0 DDD per 1000 inhabitants daily). We noted a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics. We also recorded striking seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics. We showed higher rates of antibiotic resistance in high consuming countries, probably related to the higher consumption in southern and eastern Europe than in northern Europe.
These data might provide a useful method for assessing public-health strategies that aim to reduce antibiotic use and resistance levels.
... Outpatient settings in high income countries (HIC) are known to be the level of care where most antibiotics are prescribed, and often inappropriately [24]. A recent literature review on antibiotic prescription practices in LMIC and primary health care (PHC) highlighted that antibiotics are highly prescribed also in these settings, often exceeding 50% of overall medical consultations, with a high proportion of inappropriate use [25]. ...
Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.
... Antibiotic resistance is one of the most pressing global public health challenges of the 21st century [1][2][3][4][5]. It is driven largely by the misuse and overuse of antibiotics, which has accelerated the emergence of resistant bacteria [6]. ...
Antibiotic resistance poses a critical global health threat, largely driven by inappropriate antibiotic use. Pharmacists, as accessible healthcare providers, play an essential role in antimicrobial stewardship. This study aimed to assess the attitudes, practices, and awareness of Bulgarian pharmacists regarding antibiotic use and antimicrobial resistance (AMR). A cross-sectional survey was conducted from February 2023 to June 2024, involving 117 pharmacists from various practice settings across Bulgaria. Participants were divided into two groups based on their agreement with the statement that antibiotics are overprescribed. Results showed that 69.8% of participants agreed that antibiotics are overprescribed. This group demonstrated significantly greater awareness of the public health risks associated with irrational antibiotic use, stronger beliefs in the importance of pharmaceutical consultations, and higher concern over dispensing antibiotics without a prescription. No significant differences were found in beliefs regarding antibiotic resistance linked to animal use or patient adherence to medication instructions. The findings suggest that while Bulgarian pharmacists recognize key aspects of their role in combating AMR, certain knowledge gaps remain. Their strong support for pharmaceutical consultations underscores the potential to enhance antibiotic stewardship efforts through pharmacist-led interventions. Addressing gaps through targeted education and training may further strengthen pharmacists’ contributions to rational antibiotic use and AMR mitigation.
... 1 A recent investigation into the global burden of AMR estimated that in 2019 there were 4.95 million human deaths associated with AMR, including 1.27 million directly attributable to AMR. 2 While AMR is generally considered a more significant problem in human medicine than veterinary medicine, it is increasingly recognised in the animal health sector, including equine practice. [3][4][5][6][7] Antimicrobial use (AMU) has been shown to be a key driver of AMR, [8][9][10] so optimisation of AMU is a target for mitigation of AMR. 2 There is a growing body of evidence documenting AMU in horses; however, most of these reports are purely quantitative, 11,12 or questionnaires based on hypothetical clinical scenarios or practice policies [13][14][15] with little information on the quality of antibiotic prescribing. A recent study, which evaluated antibiotic prescriptions for horses in UK veterinary practices, 16 did reveal more information on prescribing practices and identified areas for improvement in AMU, including a need to reduce empiric use of European Medicines Agency (EMA) Category B antibiotics (third-generation cephalosporins, fluoroquinolones and polymyxins) 17 and to improve submission of samples for bacterial culture to guide AMU. ...
Background
Antimicrobial resistance (AMR) is increasingly recognised in equine medicine. Antimicrobial use (AMU) is a key driver of AMR.
Objectives
To pilot a point prevalence survey (PPS), based on the Global‐PPS used in human hospitals, to obtain data on antibiotic prescribing and AMR in equine hospitals and to identify targets for improvement in AMU.
Study Design
Point prevalence survey.
Methods
Eight equine hospitals located in Australia, Belgium, South Africa, the United Kingdom and the United States were recruited. Data on AMU were collected from all in‐patients on antibiotic treatment at 08h00 on four selected study days throughout the study year (2022).
Results
In total, 742 patients, 310 (41.8%) surgical and 432 (58.2%) nonsurgical cases, were evaluated and 58.7% (182/310) surgical and 25.9% (112/432) nonsurgical patients were on antibiotics. The most prescribed antibiotics were penicillin, gentamicin and trimethoprim sulfonamides. In 45.2% (215/476) of prescriptions, use was prophylactic. Therapeutic use was based on a biomarker in 48.8% (127/260) of treatments. A sample was submitted for culture in 56.9% (148/260) of therapeutic treatments. A positive culture result was reported from 49.3% (73/148) of samples, with an antibiogram available for 90.4% (66/73) of the positive cultures. An antibiotic use stop/review date was not recorded in 59.5% (283/476) of uses.
Main Limitations
This PPS was a pilot study with a relatively small sample size and likely does not reflect AMU in all types of equine hospitals in all geographic locations.
Conclusions and Clinical Relevance
The PPS identified multiple ways in which antibiotic prescribing could be improved. Targets identified for stewardship interventions included empiric use of European Medicines Agency Category A and B antibiotics, the high prevalence of prophylaxis and the lack of use of a stop/review date. The survey could be used as a repeatable tool to assess stewardship interventions in equine hospitals.
... Inappropriate use of antibiotics harms patients and contributes to the rise of antimicrobial resistance (AMR). [1][2][3] In children, early antibiotic exposure could lead to adverse long-term health outcomes, such as asthma, obesity and neurodevelopmental disorders. 4 Exposure to antibiotics is associated with potential side effects, as well as risks of reduced efficacy of future use of antibiotics due to the emergence of resistant bacteria. ...
Introduction
Inappropriate antibiotic use is a major driver of antimicrobial resistance. However, the scope of literature and its prevalence across world regions remain largely unknown, as do the most common indicators and study designs used. In this study, we summarised the current literature on inappropriate use of antibiotics by world regions. We also provided the first global estimates of the overall amount of antibiotics that are potentially used inappropriately each year.
Methods
We considered both patient and provider-mediated inappropriate antibiotic use. We reviewed 412 studies published between 2000 and 2021 and used beta regression and marginal contrasts to compare prevalence of inappropriate use by study design, indicator, world region, and national income level. Country-level sales of antibiotics from 2022 were combined with inappropriate antibiotic use estimates derived from two study designs (clinical audits and patient interviews) and one indicator (lack of indication) to estimate the amount of antibiotics inappropriately used globally.
Results
Clinical audits (50.1%, 208/412) and ‘non-prescription’ use (37.1%, 153/412) were the most common study design and indicator, respectively, used to estimate inappropriate antibiotic use. Inappropriate antibiotic use prevalence was ~6% higher in low-income and middle-income than in high-income countries. However, this difference disappeared after accounting for a proxy of access to care: physicians per capita. Globally, based on clinical audits, patient interviews and lack of indication, the estimated proportion of inappropriate antibiotic use was 29.5%, 36.5% and 30.8%, respectively, with an average of ~30% (~13 000 000 kg) the equivalent of the annual antibiotic consumption in China.
Conclusions
Inappropriate antibiotic use is highly prevalent across all countries regardless of national income level, with a third of global antibiotic consumption potentially due to unnecessary prescription (‘lack of indication’). Antibiotic stewardship efforts and defining internationally standardised indicators are needed to track progress in reducing the occurrence of inappropriate antibiotic use where necessary, as well as identifying gaps in access to care.
... In the USA, it is estimated that up to 50% of the antibiotic prescriptions for ARTIs in PC are unnecessary [10]. Southern and Eastern European countries report the highest prescriptions rates overall [11]. Moreover, paediatricians prescribe in Southern Europe antibiotics more frequently than their couterparts in Central and Northern Europe [12]. ...
Background
Inappropriate antibiotic prescription in paediatric uncomplicated acute respiratory tract infections (ARTIs) in primary care (PC) settings contributes to antimicrobial resistance. We aimed (1) to identify and describe educational interventions and their components to optimise antibiotic prescription for paediatric uncomplicated ARTIs in PC, and (2) to map contextual factors that may influence antibiotic prescription and the implementation of interventions.
Methods
We searched three electronic databases (Medline, CINAHL and Epistemonikos) to identify reviews on the effectiveness of educational interventions and contextual factors, for optimising antibiotic prescription (Concept) in paediatric uncomplicated ARTIs (Population) in PC (Context). We included reviews that reported explicitly the search strategy used. Two previously calibrated reviewers independently screened the literature, extracted data, and assessed the methodological limitations. We applied the “best-fit framework synthesis approach”, based on the main constructs of the Consolidated Framework for Implementation Research, and coded the data deductively by groups of analysis for reviews reporting effectiveness (e.g. antibiotic or consultation rate) or by thematic synthesis for reviews reporting contextual factors (e.g. healthcare professionals’ knowledge) based on a logic model.
Results
We identified 11 reviews evaluating education intervention and their characteristics, including 182 interventions with at least one educational component (educational intervention plus another type, educational or non-educational), with 136 providing information on characteristics and effectiveness. Successful interventions’ characteristics were related to the kind of intervention (e.g. communication skill training), mode of delivery (e.g. face to face), and target population (e.g. parents/caregivers). From the 22 reviews on contextual factors, healthcare professionals’ attitudes and perceptions, knowledge, and health system and professionals’ teams’ organization (inner setting), were the most frequent themes; less information was available on individuals´ characteristics (parents/children) and on outer setting (e.g. policies).
Conclusion
We identified a large number of heterogeneous educational interventions. Combining educational interventions plus another type targeting both parents/caregivers and healthcare professionals, and considering their needs and their context may improve antibiotic prescribing in children. Further research is needed on consultation rate, knowledge, attitudes, and satisfaction outcomes and contextual factors, as well as on the cost-effectiveness of the interventions.
Registration
The protocol was published in OSF iRegistries in May 2021 (Elizondo-Alzola, U).
... Without effective countermeasures, this figure is estimated to reach 10 million by 2050, leading to USD $100 trillion in economic losses worldwide 1 . It is likely that the misuse and overuse of antibiotics contribute to the problem of AR [2][3][4] . However, the inappropriate use of antibiotics is still prevalent worldwide, especially in developing countries 5 . ...
To understand the reasons for the public’s irrational use of antibiotics based on the health belief model (HBM). A questionnaire survey was conducted based on cluster random sampling in Chongqing, China. The public’s antibiotic use behaviors, knowledge, perceived threat of diseases [both short-term upper respiratory tract infections (URTIs) and long-term antibiotic resistance (AR)], perceived value of antibiotic use (benefits and harm), self-efficacy, antibiotic availability and social influences were measured. Structural equation modeling (SEM) was applied to test the fitness of the survey data with the theoretical framework based on the HBM. A total of 815 respondents were enrolled. The irrational use of antibiotics was prevalent among the public (mean: 2.95, SD = 2.12). The public had limited knowledge about antibiotic use (average 29.17% correct answers to 8 questions), a high perceived threat of AR (mean = 2.46, SD = 0.64) and a moderate perceived threat of URTIs (mean = 2.13, SD = 1.04). They also perceived high benefits (mean = 2.57, SD = 0.68) and moderate harm (mean = 2.16, SD = 0.83) from antibiotic use. In addition, respondents had easy access to antibiotics (mean = 2.38, SD = 0.80), perceived a high prevalence of use of antibiotics by relatives (mean = 2.40, SD = 0.65) and had a moderate level of self-efficacy in using antibiotics (mean = 1.97, SD = 0.75). The SEM results showed that higher levels of the perceived threat of URTIs, perceived benefits of antibiotic use, self-efficacy, antibiotic availability and social influence were associated with more irrational antibiotic use behavior (p < 0.005). Moreover, higher knowledge indirectly led to irrational use of antibiotics by promoting self-efficacy (p < 0.001) and the perceived threat of URTIs (p < 0.005). To curb the irrational use of antibiotics, improving knowledge alone is insufficient. A systematic approach addressing multiple dimensions of health beliefs is critical. This includes: (1) targeted public education campaigns emphasizing the limited efficacy of antibiotics for viral infections and reframing perceptions of antibiotic “benefits”; (2) regulatory measures to restrict non-prescription antibiotic sales in pharmacies; (3) clinical guidelines and training to reduce unnecessary antibiotic prescriptions by healthcare providers; and (4) community-level interventions leveraging social norms to discourage inappropriate antibiotic use. Policymakers should prioritize interventions that address both individual perceptions (e.g., fear of untreated infections) and systemic drivers (e.g., antibiotic accessibility).
... Antibiotic Resistance occurs when a bacterium can withstand antibiotic exposure [1]. The increasing use of antibiotics in and out of the medical field is contributing significantly to the creation of resistance in bacteria [2]. Illnesses produced by resistant bacteria are becoming increasingly prevalent, and certain illnesses have evolved [3]. ...
Objective
Antimicrobial resistance is a significant global health challenge, exacerbated by unnecessary antibiotic prescribing. Respiratory tract infections (RTIs) are common reasons for antibiotic prescribing in primary care, despite most being viral or bacterial infections that are self-limiting. C-reactive protein (CRP) point-of-care tests (POCTs) are promising tools to support antibiotic stewardship by guiding the management of lower RTIs (LRTIs). The aim of this study was to develop best practice guidance for using CRP POCT in the management of LRTIs in primary care.
Design
Scoping review findings informed guidance statements, which were then evaluated through a three-round Delphi process with an expert panel via web-based questionnaires. Statements focused on intended use, detection of bacterial LRTIs, communication strategies, device features, performance and ease of use of CRP POCT.
Setting and participants
The panel of experts included 19 healthcare professionals across several specialties, including general practitioners, community pharmacists, hospital pharmacists and respiratory physicians.
Main outcome measures
Panellists rated each guidance statement using a 5-point Likert scale, with acceptance, revision or rejection determined using predefined cut-off scores for medians and interquartile ranges. Statements were revised between rounds using the feedback provided by panellists.
Results
In the first round, 49 statements were evaluated; 16 were accepted, nine removed and 24 revised for the second round. Of the 24 statements evaluated in the second round, 17 were accepted and seven were revised. In the third round, consensus was reached on four of the seven statements presented, resulting in 37 final guidance statements. These statements covered key areas, including the appropriate use of CRP POCTs to guide antibiotic prescribing, CRP cut-off values, integration with clinical decision rules, device performance and operational considerations, training requirements and financial reimbursement. The panel emphasised the need for structured guidelines to align CRP POCT use with clinical context and highlighted its role in improving diagnostic confidence while supporting antibiotic stewardship.
Conclusions
This study provides a set of best practice guidance statements to support the use of CRP POCT in the management of LRTIs in primary care. Dissemination and further research are required to assess their impact.
The worldwide health emergency of antibiotic resistance makes medical treatments less effective and leads to higher death statistics. The widespread problem of antibiotic resistance stems from the extreme and improper use of antibiotics in medical practices, livestock operations, and agricultural farms. Big data analytics integration serves as an innovative method to predict, monitor, and reduce antibiotic resistance by implementing big data analytics systems. This research adopts a methodical approach to scrutinize the WHO Global Antimicrobial Resistance and Use Surveillance System alongside different national healthcare records available to the public. The assessment of resistance trends region-based predictions and outbreak forecasts is performed using machine learning algorithms with supporting artificial intelligence models. The prediction accuracy gets boosted the application of regression analysis, clustering and neural networks as statistical methods. The evaluation section of the study demonstrates how big data performs in healthcare facilities to monitor systems and make on-the-spot decisions. The presented research demonstrates how big data maintains its essential position for the surveillance and early detection of antibiotic resistance. The predictive models reveal important patterns about antibiotic resistance, which helps leaders and healthcare experts with researchers, to create focused strategies to fight antimicrobial resistance. The current challenges involving data standardization with privacy issues and real-time data access cannot hinder big data analytics from achieving substantial effects on fighting antibiotic resistance worldwide. Sustained development of artificial intelligence surveillance systems alongside multi-disciplinary relationships creates essential conditions to protect antibiotic effectiveness in the future.
Background
Studies relating the usage of antibiotics with extended-spectrum cephalosporin resistance (ESC-R) rates from clinical isolates in nursing homes (NHs) are rare. We investigated associations between the intensity of NH-level antibiotic consumption (ABC) and the frequency of ESC-R expressing urinary Escherichia coli, Klebsiella spp. and Proteus spp. isolates from NH residents.
Materials and methods
We used retrospective data on ABC and ESC-R counts aggregated by NH and year between 2017 and 2022 from NHs of canton Vaud in Switzerland. Negative binomial regression was used to relate ABC intensity, expressed as DDDs per 1000 resident days, with counts of ESC-R expressing bacteria.
Results
Fifty-four NHs were included cumulatively accounting for 6601 urinary isolates, of which 5028 E. coli, 999 Klebsiella spp. and 574 Proteus spp. Among these, the 6-year ESC-R cumulative incidence was 10.3% (E. coli 12.6%, Klebsiella spp. 3.8% and Proteus spp. 1.2%). Median annual overall ABC varied between 31.3 and 44.2 DDDs per 1000 resident days. There was no association between overall ABC, most antibiotic categories and ESC-R cumulative incidence. The consumption of cephalosporins [adjusted incidence rate ratio (aIRR): 1.023, 95% CI: 1–1.047] and carbapenems (aIRR: 1.542, 95% CI: 1.018–2.336) was independently associated with increased incidence.
Conclusion
No association was found between overall ABC and ESC-R rates. Cephalosporin consumption showed a modest association, while for carbapenems this could reflect therapeutic use. These findings highlight the need for enhanced surveillance and resident-level data to better understand antibiotic resistance drivers in this setting.
The ECO.SENS study is the first international survey to investigate the prevalence and susceptibility of pathogens causing community-acquired acute uncomplicated urinary tract infections (UTIs). Midstream urine samples were taken for culture and for testing for the presence of leucocytes from 4734 women not older than 65 years presenting with symptoms of acute UTI at 252 community health care centres in 17 countries. Recognized urinary tract pathogens were identified and the susceptibility to 12 antimicrobials determined. Pathogens were present in 3278 (69.2%) patients, Escherichia coli accounting for 77.0% of isolates. In E. coli, 42% of the isolates were resistant to one or more of the 12 antimicrobial drugs investigated. Resistance was most common to ampicillin (29.8%) and sulfamethoxazole (29.1%), followed by trimethoprim (14.8%), trimethoprim/sulfamethoxazole (14.1%) and nalidixic acid (5.4%). Resistance in E. coli to co-amoxiclav, mecillinam, cefadroxil, nitrofurantoin, fosfomycin, gentamicin and ciprofloxacin was <3%. However, co-amoxiclav resistance was apparent in Portugal (9.3%) as was resistance to the quinolones, nalidixic acid and ciprofloxacin, in Portugal (11.6% and 5.8%, respectively) and Spain (26.7% and 14.7%, respectively). Overall, Proteus mirabilis were less resistant to ampicillin (16.1%) and more resistant to trimethoprim (25.5%) than E. coli, whereas Klebsiella spp. were more resistant to ampicillin (83.5%) and fosfomycin (56.7%). 'Other Enterobacteriaceae' were more resistant to the broad spectrum beta-lactams (ampicillin 45.9%, co-amoxiclav 21.3% and cefadroxil 24.6%), nitrofurantoin (40.2%) and fosfomycin (15.6%). In Staphylococcus saprophyticus resistance development was rare. Overall, antimicrobial resistance was lowest in the Nordic countries and Austria and highest in Portugal and Spain.
Background
Europe is a continent with strong public healthcare systems, but diverging antibiotic policies and resistance patterns.AimsTo describe the performance and methodological approach in a retrospective data collection effort (1997–2001), through an international network of surveillance systems, aiming to collect publicly available, comparable and reliable data on antibiotic use in Europe.MethodsA central multidisciplinary management team co-ordinated a network of national representatives, liasing with national data providers and bodies responsible for antibiotic policy. The data collected were screened for bias, using a checklist. We focused on detection bias in sample and census data; errors in assigning medicinal product packages to the Anatomical Therapeutic Chemical Classification (ATC); errors in calculations of defined daily doses (DDD) per package; bias by over-the-counter sales and parallel trade; and bias in ambulatory care (AC)/hospital care (HC) mix. Datasets were corrected after national feedback, and classified as valid; valid but with minor bias; not valid.ResultsOf the 31 participating countries, 21 countries delivered AC data suitable for cross-national comparison (14 for all 5 years). Of these, 17 countries provided data on a quarterly basis for at least 1 year. For HC, 14 countries were able to deliver valid data (nine for all 5 years). A valid estimate of the total exposure of national populations to human antibiotic consumption could be made in 17 countries.Conclusion
In cross-national comparisons of antibiotic consumption in Europe, methodological rigour in correcting for various sources of bias and checking the validity of ATC/DDD assignment is needed.
Trends in the use of antimicrobials in France between 1980–1981 and 1991–1992 were analyzed. Data were obtained from surveys
of health and ambulatory care, which were based on national probability samples. In a 3-month period in 1980, 17% of the population
of France was treated with an antibiotic, compared with 25% in 1991 (P < .001). The frequency of respiratory tract infections with a presumed viral etiology that were diagnosed and treated with
antibiotics increased by 86% for adults and 115% for children in the 11-year period. The proper use of cephalosporins must
be encouraged, and vigilance is required in view of the increased improper use of fluoroquinolones, mainly for respiratory
tract infections with a presumed viral etiology.
This thesis describes the set up of a European antimicrobial resistance surveillance system (EARSS) and its contribution to the Community strategy against antimicrobial resistance. EARSS is set up as an international network of national surveillance systems, collecting comparable and validated antimicrobial resistance data for public health purposes. The objectives, infrastructure and data management aspects of the surveillance system were defined by consensus of leading microbiologists and epidemiologists in Europe. At the kick-off meeting the community-acquired pathogen S. pneumoniae and the hospitalacquired pathogen S. aureus were chosen as most relevant pathogens to start surveillance for in EARSS. During the same meeting the EARSS protocol for susceptibility testing was developed, aiming to standardise data collection to allow for comparison of susceptibility data among participants. To minimise sample bias, it was decided to report only the first isolate of S. pneumoniae from blood and cerebrospinal fluid and the first S. aureus isolate from blood. This European initiative acted as a catalyst for national surveillance systems.
To determine the storage of antibiotics in Spanish households and to analyse its source.
Quantitative study carried out by telephone interview with housewives or head of the family members in 1,000 households that have been chosen at random and by agreement with a proportion of the territorial distribution of the Spanish population.
In 42% of households that have been approached, one (88.1%) or more antibiotic packets were present, being a result of a doctor's prescription in two thirds of cases. In most cases (71.9%) amoxycillin was the antibiotic found. Concerning the pharmaceutical forms, 55% corresponded to solid oral (pills, tablets, capsules), 45% liquid oral forms (syrups, suspensions, sachets), whereas parenteral vials were not identified. Only in the 19% of households with antibiotic packets (8% of the total) there was a member of the family under antibiotic treatment. The economic evaluation of the non administrated antibiotic doses, present in households was about 5,000 millions pesetas. Over 3,000 millions pesetas had been financed by Health Public Administration.
The storage of antibiotics in households is an important factor which increments the cost, reduces the efficiency and decreases the quality of the antibiotic treatment at the community level.