What has alarmed European governments, regulators and industry is that despite a growing availability of public information
regarding antibiotic resistance, there continues to be a surprising level of misinformation and complacency around Europe.
In 2009, a pan-European survey was conducted on behalf of the European Commission to assess antibiotic awareness across the
region.4 A total of 26761 facetoface interviews were carried out across 27 EU member states between November and December 2009. The
timing of the interviews was designed to reflect the periods before and after European Antibiotic Awareness Day. The initial
intention was to evaluate progress in public awareness and behaviour following a similar, although briefer survey, in 2002.5 Overall, however, the 2009 survey revealed worrying gaps in people's understanding of the issues surrounding antibiotic
resistance even among those indicating exposure to previous public awareness initiatives.
As in 2002, around 40% of respondents indicated that they had taken antibiotics over the previous year, with greater usage
being found in southern European countries. However, in the 2009 results, it was found that onethird of European respondents
had taken antibiotics for a viral infection such as a cold or the flu.4 A disappointing outcome was the fact that a large number of respondents stated that new information provided on antibiotics
did not change their initial viewpoint.
The lack of knowledge retention following public campaigns on antibiotic awareness is also problematic. A recent paper in
the Journal of Antimicrobial Chemotherapy examined the effect of the 2008 English public antibiotic campaigns.6 Among respondents in England, there was only a small increase in recollection of campaign posters. In light of these results,
the authors called for better auditing of the effectiveness of public campaigns and for better planning of such initiatives.
They recommended targeting patients in physician waiting rooms and involving physicians themselves to relay the information.
Despite such disappointing outcomes, some national awareness campaigns have been reported as successes. In Belgium, a series
of national public campaigns have been running since 2000, primarily over winter periods, and the initiatives have been given
a high profile.7 The campaign was in two parts; one aimed at providing information to the public on the main issues (e.g. booklets and TV
campaigns) and another providing specific clinical recommendations to healthcare professionals. The 2002 public campaign pieces
had titles such as "Use antibiotics less frequently, but better", "Save antibiotics, they may save your life", and "Talk to
your doctor, talk to your pharmacist". In 2004 it became more specific with one campaign piece entitled "Antibiotics are ineffective
for common cold, acute bronchitis and flu". For healthcare professionals, the Belgian Antibiotic Policy Coordination Committee
(BAPCC) produced evidence-based guidelines using scientific methodology for the appropriate use of antibiotics in particular
conditions, such as sore throat and acute cystitis in women. All general practitioners received copies. Each year a consortium,
including scientific colleges for general practitioners and the Federal Knowledge Centre for Healthcare, examined antibiotic
prescribing data and provided feedback to GPs on their conclusions. All these primary care physicians were also invited to
discuss these feedback reports with their peers in specially convened sessions.
Outpatient use of antibiotics, expressed in the number of reimbursed packages per 1000 inhabitants per day, dropped by a third
between the 1997–1998 and the 2006–2007 winter seasons in Belgium. Apart from antibiotic usage, some benefits could also be
shown in terms of actual resistance levels. This was most apparent when examining the proportion of nonsusceptible isolates
of Streptococcus pneumoniae. For example, between 2000 and 2008, penicillin resistance decreased from 18% to 10% and macrolide
resistance from 36% to 25%.7
The positive outcome in Belgium was followed by similar measures in France in 2001 through a campaign designed to counteract
the idea that antibiotics should be used for viral infections.8 The campaign used the slogan "Antibiotics Are Not Automatic". As well as distributing information to the public, the authorities
promoted better testing measures and guidelines directly to physicians through a process known as "academic detailing". When
the two winters before the campaign were compared with five winters following the campaign, a dramatic effect was noted. A
decline by 26.5% in the number of antibiotic prescriptions was achieved, which was more than the desired 25% target and the
drop was seen in all French regions and age groups.
Such positive results appear to show that an effective and ongoing public campaign can have a real impact, but it still raises
important questions about how such campaigns should be organised. From the Belgian and French experiences, a multi-faceted
approach that focuses on both public and professional awareness has been recommended.7,8 However, given different medical practices across the EU, as well as patient attitudes and behaviour, it would be presumptuous
to assume that a campaign that has been successful in one country can automatically achieve success elsewhere. This is why
European Antibiotic Awareness Day initiative has the potential to break new ground, as it takes into account the variations
across the EU.