Methods
A quantitative research was conducted on ECDC findings and combined with a literature review to document current antibiotic resistance rates in Poland, as well as initiatives to improve antibiotic prescribing. The literature review was not a systematic review; however, it included most cited expert publications. Simple statistical analyses were performed to help identify any trends where pertinent. We have used such approaches in previous publications to assess the influence of current antibiotic strategies as well as help plan future activities [
13,
14,
16,
17]. Table
1 presents the measures which were used to assess the quality of antibiotic prescribing in Poland, in ambulatory care, during the past 10 years (i.e. from 2007 to 2016) based on ECDC, WHO and other suggested indicators among the J01 ATC class [
19,
21,
32‐
34]. Linear regression analysis was used to assess any significant changes in the trends of the quality indicator measures (continuous variable) over the study period from 2007 to 2016; hence five regression models were conducted; one model per each quality indicator measure, but with time as the independent factor in all of the five models.
Table 1
Indicators used to assess the quality of antibiotic prescribing
Consumption of antibacterials for systemic use (J01) expressed in defined daily doses per 1000 inhabitants per day (DIDs) | Total consumption J01 |
Consumption of beta-lactamase sensitive penicillins (J01 CE) expressed as percentage of the total consumption of antibacterials for systemic use (J01); i.e. relative consumption of beta-lactamase sensitive penicillins | J01 CE% |
Consumption of combination of penicillins, including beta-lactamase inhibitor (J01CR) expressed as percentage of the total consumption of antibacterials for systemic use (J01); i.e. relative consumption of combination of penicillins, including beta-lactamase inhibitor | J01CR% |
Consumption of third- and fourth-generation cephalosporins (J01(DD + DE)) expressed as percentage of the total consumption of antibacterials for systemic use (J01); i.e. relative consumption of third- and fourth-generation cephalosporins | J01DD + DE% |
Consumption of fluoroquinolones (J01MA) expressed as percentage of the total consumption of antibacterials for systemic use (J01); i.e. relative consumption of fluoroquinolones | J01MA% |
Ratio of the consumption of broad-spectrum (J01(CR + DC + DD+(F-FA01))) to the consumption of narrow-spectrum penicillins, cephalosporins and macrolides (J01(CE + DB + FA01)) | J01B/N% |
Ambulatory care, including general practitioner prescribing and out-patient dispensing (children and adult patients), was chosen for comparative purposes, as this contains the highest proportion of antibiotic use in Poland. In 2016, antibiotic consumption was 23.98 Defined Daily Doses per 1000 inhabitants per day (DIDs) within ambulatory (community) care, while only 1.36 DIDs within hospital sector [
19]. In addition, comparative figures are available across Europe in recent years via ECDC. The only exceptions are Cyprus and Romania, where the authorities provided total consumption data, i.e. including in-patient use, as they were unable to separate out the different components.
The findings for Poland in 2016 were also compared with other European countries including those with the highest and lowest values for each indicator, with a special emphasis on neighbouring CEE countries, to again provide future guidance. Descriptive statistics were used to summarise the study variables. Univariate linear regression was used to evaluate any annual trend change in the study outcomes during the study period.
Discussion
There is currently a variable situation regarding antibiotic prescribing in Poland. Poland is at the high end of antibiotic utilization in recent years; at almost 24 DIDs in 2016, appreciably higher than Estonia, Latvia or Slovenia. In addition, consumption grew significantly by about 8% between 2007 and 2016; however, appreciably lower than the 36% increase in total worldwide antibiotic consumption during the past decade [
6]. There are also concerns with the low level of prescribing of beta-lactamase sensitive penicillins in Poland, compared for instance with Slovakia, Finland, Slovenia or Sweden. However, encouragingly prescribing rates for these penicillins have been growing in recent years. Encouragingly as well, there was relatively low consumption of combination penicillins and third- and fourth-generation cephalosporins in Poland, with a slight decrease over the years.
There was also a relatively low level of fluoroquinolone consumption in Poland versus other European countries (at 5.9% in 2016). However, there are concerns regarding the growth of fluoroquinolone prescribing in Poland in recent years, expressed as a percentage of the total antibiotic consumption (Table
2). The use of fluoroquinolones, due to their numerous side effects, should be limited to situations where there are no other therapeutic options available. One of the most important side effects of the use of fluoroquinolones is (among others)
Clostridium difficile infections (CDI) [
11]. The Polish hospitals reported almost the highest crude incidence density of community-associated CDI incidence densities (1.4 cases/10,000 patient-days) in Europe (EU/EEA mean was only 0.8 cases/10,000 patient-days) [
43]. Consequently, there is an urgent need to educate physicians in Poland about the appropriate use of fluoroquinolones, unless this is a consequence of high antimicrobial resistance in Poland to other antibiotics. This will be investigated further in future research projects.
There are also concerns at the extent of prescribing of broad versus narrow spectrum antibiotics in Poland, their consumption ratios in 2016 being very high level at 25.81% of total antibiotic consumption versus for instance 0.68% in Finland. Fortunately, this ratio is decreasing in Poland.
This variable picture regarding current antibiotic utilisation patterns in Poland may well reflect the relative lack of educational activities by the NHF and the MoH among physicians. We do know that there is a lack of preparedness among physicians in Poland for educational activities in the field of rational antibiotic therapy. In addition, we are aware that research in area of medical education has shown that problem-based learning curricula are rarely introduced in a country with a high ‘power distance’ and ‘uncertainty avoidance’, which currently includes Poland [
44]. This is confirmed by both high total consumption antibiotics versus other European countries and a high proportion (ratio) of broad-spectrum antibiotics. The notion of power distance refers to the degree of hierarchy in a country and it has been defined by Hofstede as the extent to which the less powerful members of organizations and institutions accept and expect that power is distributed unequally [
45]. The notion of uncertainty avoidance deals with a society’s tolerance for uncertainty and ambiguity. A higher score indicates that people feel uncomfortable in novel, unknown or surprising situations [
45].
Overall, integrated activities around appropriate antibiotic prescribing in the pre- and post-graduate training of physicians and dentists should be particularly important. Currently, the concept of antimicrobial stewardship (AMS) is not included in the curricula of studies and specializations except for specialization for microbiologists. However, in the Polish health care system there are very few physicians-microbiologists (only 110 professionally active in 2018). There could also be the involvement of other specialists in hospitals, such as hospital pharmacists, as part of Drugs and Therapeutic Committees helping with the implementation and monitoring of AMS programs [
46].
Other direct measures, which could be recommended for implementation in Poland, include the introduction of limitations in antibiotic prescribing within ambulatory care in Poland, through their stratification, similar to the Republic of Srpska (Bosnia and Herzegovina) or Slovenia, or a basic positive list of medicines with reference prices and a supplementary list which includes more expensive medicines [
13,
16]. In the Republic of Srpska amoxicillin, benzathine-phenoxymethylpenicillin, cefalexin, doxycycline, erythromycin, phenoxymethylpenicillin, and sulfamethoxazole with trimethoprim are reimbursed between 90 to 100%; with norfloxacin reimbursed 50%; with 100% co-payment for all other antibiotics [
16]. In Slovenia, the national health insurance company has instigated prescribing restrictions for amoxicillin/clavulanic acid, third-generation cephalosporins, fluoroquinolones and the macrolides together with their place in therapy i.e., first, second or third line, to enhance antibiotic prescribing [
13]. Such activities can potentially be applied in Poland to reduce excessive prescribing of broad-spectrum antibiotics.
Promoting and spreading knowledge on antibiotics, as medicines designated for combatting bacterial infections but ineffective against viruses, is urgently needed. The education campaigns should be targeted not only at physicians, but also patients, especially because other factors should be taken into consideration. These include the relative cost of prescribed antibiotic and the cost of medical consultations. Educational programmes, including academic detailing and providing decision support systems, have improved antibiotic use, although some of the results have been modest [
8,
47,
48]. Feedback to physicians, especially high prescribers of antibiotics, has also worked well [
49]. Enhancing physician communication skills, as well as the availability of point-of-care testing, can also reduce inappropriate prescribing of antibiotics for acute respiratory tract infections [
50,
51]. Although not confirmed by prospective studies, it might be expected that in countries where medical consultations and the cost of antibiotics is high, there will be a lower likelihood for excessive use of antibiotics. Unfortunately, from this perspective, prices of commonly prescribed antibiotics are usually low in Poland, which may result in increased consumption and secondary antibiotic resistance. In contrast, ambulatory patients usually must pay out-of-pocket for microbiological diagnostic tests, which are very often more expensive than prescribed antibiotics. This may result in underutilization of diagnostic testing due to financial reasons.
Consequently, other avenues will be important for improving antibiotic utilization. The provision of health services is overwhelmingly focused on the treatment of infections rather than their prevention in Poland. This applies to many elements of infection control programmes, regarding both nosocomial and non-hospital infections. Notably, hand hygiene should be mentioned, since the existing level of knowledge of its rules is not sufficient among medical personnel and the compliance with recommendations is rather low in Poland. Intensive educational campaigns, addressed to both medical and social workers, are highly required. The more specific procedures, aiming to prevent certain forms of infections (e.g. ‘bundle strategies’ for prevention of device-associated infections in intensive care units, including small sets of evidence-based practices which have been proven to improve patient outcomes, when applied together) should be actively promoted and implemented. A more effective interdisciplinary education and cooperation between physicians and staff of microbiological laboratories are necessary, and implementation of fast and modern diagnostic methods is crucial. AMR surveillance is largely underdeveloped, and the scale of AMR in Poland may be underestimated. This is despite a relatively high consumption of antibiotics and some alarming trends for certain bacteriological strains. These are considerations for the future.
Conclusions
Whilst the coordinated system of monitoring AMR rates in Poland was initiated almost 20 years ago, it remains underdeveloped, similarly to appropriate strategies to address AMR. The role of microbiological diagnostics, and efforts to prevent infections, is currently underestimated by physicians, who put a greater emphasis on treatment rather than prevention.
Total consumption of antibacterials for systemic use and relative consumption of beta-lactamase sensitive penicillins were characterized by small but statistically significant average annual increases between 2007 and 2016. Overall, Poland has one of the highest rates of total consumption of antibiotics among European countries. Although indicators such as the prevalence of MRSA are within the average values observed in the EU, in case of P. aeruginosa, K. pneumoniae and Acinetobacter there is over 50% resistance to fluoroquinolones, in invasive infections cases in Poland (highest prevalence rates among the EU countries).
Since the limited educational activities among physicians and dentists may play an important role in the current antibiotic consumption patterns, integrated actions focusing on appropriate antibiotic prescribing in the pre- and post-graduate training should be instigated and followed up at national level. The introduction of limitations in antibiotic prescribing within ambulatory care, through their stratification, is also recommended. Education campaigns targeted also to patients are urgently needed as well. Overall, taking actions to improve antibiotic utilisation should be in focus of health policy actions in Poland.