26 Chapter 2 Results Statistical analysis Fourteen European countries (Denmark, Estonia, Finland, Ireland, Italy, Latvia, Lithuania, The Netherlands, Norway, Poland, Slovenia, Spain, Sweden and the UK) were identified in which the GPs act as gatekeepers and from which data on antibiotic prescriptions and SDRMs could be obtained. Volumes of antibiotic use in primary care and hospital care The volume of antibiotic prescriptions in primary care decreased over the course of our observation period (2011–2020) in seven countries (Denmark, Finland, Italy, The Netherlands, Norway, Sweden and the UK—see Figure 1 ). Ireland, Italy, Poland and Spain had the highest volumes of antibiotic prescriptions in primary care in 2020, with DDDs between 16 and 17 per 1000 inhabitants per day. The volume of antibiotic prescriptions was in all countries at its lowest in the year 2020. The proportion of antibiotic prescriptions in hospital care compared with the total volume of antibiotic prescriptions ranged from a low of 7.4% in Poland to a high of 16.6% in Latvia. Prevalence of resistant micro organisms MDR E. coli was the SDRM with the lowest prevalence in most countries (Figure 2). The prevalence ranged from 1.2% (Norway) to 14.6% (Italy). The prevalence of MRSA was stable over the period 2011–2020 in most countries. Four countries (Ireland, Italy, Poland and Spain) had a prevalence above 10% for MRSA. The prevalence decreased over the observation period only in Ireland and the UK. Macrolide-resistant S. pneumoniae had the highest prevalence of the three SDRMs, with seven countries reporting a mean prevalence above 10% during the period 2011–2020. Patterns of antimicrobial selection pressure The cumulative primary care ASI in Italy and Spain was about three times higher than in the Netherlands and Sweden, whereas the volume of antibiotic prescribing in primary care in DDD was twice as high in Italy and Spain as The Netherlands and Sweden (Figure 3). Tetracyclines and penicillin were the largest contributors to the cumulative primary care ASI in all countries, respectively ranging from 3.6% (Italy) to 39.8% (Sweden) and from 22.9% (Norway) to 50.7% (Spain). Within the penicillin antibiotic group, penicillin combinations (ATC code J01CR) (e.g. amoxicillin/clavulanate) were the largest contributor to the cumulative primary care ASI in eight countries.
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