Investigación original / Original research Trends in antibiotic utilization in eight Latin American countries, 1997–2007 Veronika J. Wirtz,1 Anahí Dreser,1 and Ralph Gonzales 2 Suggested citation Wirtz VJ, Dreser A, Gonzales R. Trends in antibiotic utilization in eight Latin American Countries, 1997–2007. Rev Panam Salud Publica. 2010;27(3):219–25. ABSTRACT Objective. To describe the trends in antibiotic utilization in eight Latin American countries between 1997–2007. Methods. We analyzed retail sales data of oral and injectable antibiotics (World Health Or- ganization (WHO) Anatomic Therapeutic Chemical (ATC) code J01) between 1997 and 2007 for Argentina, Brazil, Chile, Colombia, Mexico, Peru, Uruguay, and Venezuela. Antibiotics were aggregated and utilization was calculated for all antibiotics (J01); for macrolides, lin- cosamindes, and streptogramins (J01 F); and for quinolones (J01 M). The kilogram sales of each antibiotic were converted into defined daily dose per 1 000 inhabitants per day (DID) ac- cording to the WHO ATC classification system. We calculated the absolute change in DID and relative change expressed in percent of DID variation, using 1997 as a reference. Results. Total antibiotic utilization has increased in Peru, Venezuela, Uruguay, and Brazil, with the largest relative increases observed in Peru (5.58 DID, +70.6%) and Venezuela (4.81 DID, +43.0%). For Mexico (–2.43 DID; –15.5%) and Colombia (–4.10; –33.7%), utilization decreased. Argentina and Chile showed major reductions in antibiotic utilization during the middle of this period. In all countries, quinolone use increased, particularly sharply in Venezuela (1.86 DID, +282%). The increase in macrolide, lincosaminde, and streptogramin use was greatest in Peru (0.76 DID, +82.1%), followed by Brazil, Argentina, and Chile. Conclusions. Analyzing antibiotic utilization in Latin America presents a series of chal- lenges. Creating policy-relevant evidence based on antimicrobial consumption patterns is needed in order to foster policies aimed at improving appropriate use of antibiotics in the region. Key words Pharmacoepidemiology; anti-bacterial agents; drug resistance, microbial; national drug policy; Latin America. Resistance to antibiotics is an impor- broad-spectrum antibiotics. Over the last among other initiatives funded by the tant public health problem as it leads two decades, it has been clearly estab- European Union, is creating evidence to to treatment failures (with incumbent lished that high levels of community an- inform public health policies on use and morbidity and mortality) and the in- tibiotic consumption correlate with high surveillance of consumption (3). It has creased empirical use of more costly levels of community resistance to antibi- triggered an unprecedented wave of an- otics (1–3). Consequently, learning about tibiotic consumption data all over Eu- 1 Health Systems Research Centre, National Insti- the patterns of community antibiotic rope (4–6), national campaigns to im- tute of Public Health, Cuernavaca, Mexico. Send consumption is fundamental in order to prove antibiotic use (7), and many correspondence to: Veronika J. Wirtz, Health Sys- tems Research Centre, National Institute of Public design regional and local interventions research studies to extend surveillance Health, Av. Universidad 655, Cuernavaca 62100, directed at optimizing the use of these and other interventions to improve an- Mexico; e-mail: [email protected]. important medicines. tibiotic use (8). In many other parts of the 2 Division of General Internal Medicine, University of California, San Francisco, United States of In Europe, the European Surveillance world, particularly developing coun- America. on Antibiotic Consumption (ESAC), tries, measuring consumption of antibi- Rev Panam Salud Publica 27(3), 2010 219 Original research Wirtz et al. • Antibiotic utilization in eight Latin American countries otics presents a major challenge; it tradi- ies of antibiotic utilization patterns (16), based on the proportion of a given coun- tionally has received little attention and, among them the ESAC project (3). For try’s total medication market volume consequently, modest funding (9). Infor- analysis, we used the WHO ATC classi- that was distributed via retail sector ver- mation systems are scarce and unreli- fication and the defined daily dose sus government (15). These data were able; local studies are time and resource (DDD) system of WHO for 2008 (17). available for specific years for each coun- intensive, and extrapolating consump- The unit of analysis provided was try: 2008 data for Colombia and Uru- tion from the local to the national level kilogram of sales per year aggregated by guay; 2007 data for Argentina, Brazil, has major limitations (10). country, which we converted to defined and Peru; 2004 data for Mexico; 2001 data In Latin America, the Pan American daily dose per 1 000 inhabitants per day for Venezuela; and 2000 data for Chile. Conference on Antimicrobial Resistance (DID). We obtained population informa- The funding source of this study did held in 1998 concluded that among the tion from the Pan American Health not play a role in study design; in collec- main priorities for the region were mea- Organization database (18). For the tion, analysis, and interpretation of data; suring and reporting antibiotic consump- eight countries studied, we analyzed the in writing the report; and in the decision tion (11). Although notable advances trend of antibiotic consumption mea- to submit the paper for publication. have occurred in regional surveillance of sured as DID between 1997 and 2007 resistance (12), the patterns and severity and carried out a cross-sectional analy- RESULTS of antimicrobial consumption in Latin sis of the main therapeutic groups of an- American countries have been monitored tibiotics consumed in 2007. We also con- Figure 1 presents national antibiotic only sporadically (13, 14). The objective ducted focused analyses on the use of utilization rates in eight Latin American of this study was to describe the trends in two therapeutic classes of antibiotics: countries between 1997 and 2007. In antibiotic consumption in eight Latin macrolide, lincosamindes, and strep- 1997, Mexico (15.69 DID) had the highest American countries between 1997 and togramins (J01 F) and quinolone (J01 M). antibiotic utilization followed by Ar- 2007. They were selected because of recent gentina (14.37 DID) and Chile (14.07 observations that macrolide resistance DID). The three countries with the low- MATERIALS AND METHODS among Streptococcus pneumoniae and est utilization in 1997 were Peru (7.91 group A streptococcus is associated DID), Brazil (6.51 DID), and Uruguay We used routinely collected retail sales with azithromycin consumption (be- (5.43 DID). By 2007, Argentina (16.64 data on antibiotics (World Health Orga- cause of its long half-life) (19, 20) and DID) and Venezuela (15.99 DID) headed nization (WHO) Anatomic Therapeutic that new patterns of fluoroquinolone re- the list of countries in antibiotic use fol- Chemical (ATC) code J01) between 1997 sistance are emerging among S. pneumo- lowed by Peru (13.50 DID), Mexico and 2007 from eight Latin American coun- niae as well as among enteric and geni- (13.26 DID), and Chile (12.53). Signifi- tries: Argentina, Brazil, Chile, Colombia, tourinary pathogens (21). cantly lower was antibiotic use in Mexico, Peru, Uruguay, and Venezuela. In order to calculate national rates of Uruguay (8.90 DID), Colombia (8.09 Only antibiotic formulations with sys- antibiotic utilization based on national DID), and Brazil (7.01 DID), with the temic absorption or delivery (oral or par- population estimates, we adjusted the lowest utilization rates of the eight coun- enteral) were taken into account; excluded numerator for antibiotic sales volume tries studied. were products with topical and vaginal or rectal application. We chose countries with the largest pharmaceutical markets FIGURE 1. Trends of national antibiotic utilization in eight Latin American countries, 1997–2007 in Latin America. The data were derived from a health 18.00 care consultancy organization, which re- 16.00 lies on reports of a sample of retail wholesalers and, in addition, on infor- 14.00 mation provided by a sample of pharma- cies in some countries (15). All data pro- 12.00 vided by the health care consultancy organization were national antibiotic 10.00 sales to retail sectors (direct sales in pri- 8.00 vate pharmacies and indirect sales in pri- vate clinics and hospitals) and do not in- 6.00 clude antibiotics purchased by the public sector (government providers). Given 4.00 the Latin American context in which re- 2.00 strictions to sell antibiotics only with a Defined daily dose per 1 000 inhabitants day medical prescription are not enforced, 0.00 the data include sales both with and 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 without prescriptions. These data repre- Year sent the industry standard for estimating Argentina Colombia Uruguay Brazil Mexico Venezuela national retail sales volume of medica- tions and have been widely used in stud- Chile Peru 220 Rev Panam Salud Publica 27(3), 2010 Wirtz et al. • Antibiotic utilization in eight Latin American countries Original research In terms of relative change using 1997 its baseline rate (–1.53 DID, –10.9%). With macrolides, lincosamindes, and strep- as a baseline, antibiotic utilization has in- respect to the average change (1.07 DID) togramins and the group of quinolones. creased in Peru (5.58 DID, +70.6%), in all eight countries between 1997 and Examining 10-year trends for macro- Uruguay (3.48 DID, 64.0%), and Vene- 2007, Colombia showed the largest per- lide, lincosaminde, and streptogramin zuela (4.81 DID, +43.0%), whereas in centage decrease (–483.2%) and Peru antibiotics showed large increases in Mexico (–2.43 DID, –15.5%) and Colom- showed the largest percentage increase Peru (0.76 DID, +82.1%), Brazil (+0.41 bia (–4.10 DID, –33.7%) it has declined (+421.5%) (Table 1). DID, +61.5%), and Argentina (0.74 DID, (Table 1).