http://10.24945/MVF.04.17.1866-0533.2029

>> As the current health report from the Techniker Krankenkasse shows, doctors are now prescribing antibiotics more carefully, at least for colds. “This trend reversal is going in the right direction,” says Tim Steimle, head of the pharmaceuticals department at TK. Nevertheless, systemic antibiotics are still among the most frequently prescribed drugs in the J01 market, with an average of 4.9 DDD per GKV insured person in 2016. However, the falling overall consumption in the outpatient statutory health insurance market can be confirmed: while this was a total of 382 million DDD in 2013, it fell to 355 million DDD in 2016. It is also noticeable that in the 7-year period from 2010-2016, 2013 had the highest consumption levels of systemic antibiotics, after which the numbers fell steadily (source: regioMA, INSIGHT Health). A possible reason for the high value in 2013 could be the lower influenza vaccination rate in 2012. As data from INSIGHT Health shows, vaccinations decreased by 12 percent compared to 2011, while at the same time the 2012/2013 season was characterized by a severe flu wave and moderate effectiveness of the influenza vaccination (see RKI, 2013). As a result, many patients with flu symptoms may have received antibiotic prescriptions. On the one hand, this could be a phenomenon of misuse, in that doctors prescribe antibiotics for viral infections without checking for bacterial involvement, either out of their own decision or under pressure from the patient. Or, on the other hand, whether the antibiotics were used effectively for the adequate treatment of secondary superinfections cannot be assessed at this point.
Macrolides are used less frequently
When looking at the individual substance classes in the systemic antibiotic market, the broad-spectrum penicillins have the largest DDD share in the statutory health insurance at 32.6 percent - including the antibiotic amoxicillin, which has been approved since 1981, with 28.3 percent in the first quarter of 2017 alone. As shown in Figure 1, this class, often referred to as standard therapeutic agents, is the most frequently prescribed alongside cephalosporins, fluoroquinolones and macrolide antibiotics. However, while the latter accounted for the most prescriptions at 24.7 percent in 2010, seven years later macrolides ranked behind the oral broad-spectrum penicillins (source: regioMA, INSIGHT Health). This trend may be due to increasing resistance rates, which are significantly higher especially in southern Europe and particularly affect pneumococci (see Paul-Ehrlich-Gesellschaft, 2013). Compared to the macrolides, the oral broad-spectrum penicillins increased their prescription share by 4.1 percent within the observation period.
As can also be seen from Figure 1, the proportion of prescriptions for oral cephalosporins is consistently high. It was only in 2016 that this class of substances, at 20.8 percent, fell below the prescription shares of oral broad-spectrum penicillins and macrolides at 21.5 percent each (source: regioMA, INSIGHT Health). Just as many representatives of cephalosporins are considered second-line agents in antibiotic therapy, fluoroquinolones should, if possible, only be used for serious, life-threatening infections. Coupled with the fact that this class of substances has been undergoing a new risk assessment by the European Medicines Agency since the beginning of the year due to severe side effects, it will be exciting to see how the proportion of prescriptions for the individual classes will continue to develop (see WIdO, 2017).
New substances and
Reserve antibiotics
In the outpatient statutory health insurance market for systemic antibiotics, 61 different substances were prescribed in the first quarter of this year. The majority of these active ingredients can usually be used to treat the most common bacterial infections in a targeted and successful manner. However, more and more bacterial strains are showing resistance, which doctors then have to resort to reserve or newer antibiotics to combat. Newly approved antibiotics of the last decade were expressly developed to overcome resistance and the new introductions since 2011 have also been directed against problem germs such as multi-resistant or gram-negative bacteria. In 2016 these were the lipoglycopeptides oritavancin and dalbavancin and this year the combination of cephalosporin and beta-lactamase inhibitor (ceftazidime + avibactam). As of July 7, 2017, the vfa lists 15 broad-spectrum antibiotics and 10 antibiotics or anti-infectives against certain bacterial strains in phase III studies. These numbers make it clear that the efforts of scientists, pharmaceutical companies and politicians to advance antibiotic development are making a difference. Nevertheless, just 19 new preparations have come onto the German market since the turn of the millennium. From 1981 to 1999 there were 42 (see vfa, 2017). In addition to new substances, reserve antibiotics are the treatment option if the standard antibiotic fails or does not appear to be suitable. However, the assignment differs depending on the source, with the following classification being based on the 20th WHO list of essential medicines from March 2017.
Based on the WHO classification into reserve and watch groups, it can be seen that the DDD proportions of these antibiotics in the outpatient SHI market are not increasing. Rather, they have leveled off at around 25 percent in the last three years. However, depending on the categorization of antibiotics used and the sector under consideration, the amount of reserve antibiotics can be significantly higher. In a report by the GERMAP working group on antibiotic consumption and the spread of antibiotic resistance from 2015, the DDD shares for reserve antibiotics are around 41 percent. Regardless of the different figures, the consumption of reserve antibiotics is estimated to be too high.
Few antibiotics in Brandenburg
Compared to other European countries, Germany is in the bottom third when it comes to antibiotic consumption in DDD per 1,000 inhabitants and is therefore well below the EU average (see Surveillance of antimicrobial consumption in Europe, 2012). But clear differences in antibiotic consumption can also be seen within Germany. As Figure 2 shows, the fewest daily doses were prescribed in Brandenburg in 2016, at 3.0 DDD per insured person. In general, it can be seen that in 2016 the consumption of antibiotics in the West is higher than in the East (source: regioMA, INSIGHT Health). The causes of this east-west gradient are not known. It is assumed, among other things, that doctors in the new federal states are continuing the efforts of the former GDR to limit prescriptions and establish stricter indications (cf. ZI, 2010). It remains to be seen whether these effects will level out with the generational change in the medical profession and the strong demographic change. There currently seems to be a need for action primarily in the old federal states. The Association of Statutory Health Insurance Physicians and health insurance companies in North Rhine, for example, have recognized this. In order to reduce the oversupply of systemic antibiotics, doctors with an above-average number of antibiotic prescriptions receive information letters. In addition, the KV has concluded a contract with the BKK North West regional association for the targeted use of antibiotics and the prevention of resistance. Participating practices should carry out rapid tests before administering antibiotics if a throat infection is suspected; in the case of urinary tract and wound infections, antibiograms should be carried out before administering antibiotics (see KVNO aktuell, 2016).
Resistance avoidance:
Objectives and measures
The causes of resistance are high consumption, too short a time taken by the patient and non-targeted use. The widespread use of antibiotics in animal fattening is also believed to be responsible for the emergence of numerous human-pathogenic, multi-resistant germs. The new antibiotic resistance strategy “DART 2020”, adopted by the federal government in 2015, addresses the causes. In addition to improving treatment options, awareness and competence in dealing with antibiotics should be promoted and research and development should also be supported. Among other things, the antibiotic consumption surveillance set up at the Robert Koch Institute in 2014 was continuously expanded (see BMG, 2016 and RKI, 2015). The Innovation Fund supports projects with a transfer into everyday care. This is where, for example, the nationwide project RESIST (prevention of resistance through adequate use of antibiotics) by vdek and other partners comes into play. Measures such as feedback reports on prescribing behavior and training for better doctor-patient communication are intended to contribute to reducing the general rate of antibiotic prescriptions for acute respiratory infections and to promote the use of broad-spectrum antibiotics in line with guidelines (see vdek, 2017).
Another project supported by the Innovation Fund is ARENA (Sustainably averting the development of antibiotic resistance). The aim is to implement different interventions - such as IT-supported decision-making aids, quality circles and data-based, individual feedback - into everyday German care and thus optimize the indication-based use of antibiotics as well as cross-sector care for infections (cf. MVF 01/2017). The legislature passed regulations for antibiotics in the new Drug Supply Strengthening Act of May 2017. Diagnostics for antibiotic therapy are to be included in the uniform assessment standard by the end of 2017. Furthermore, in the future, the resistance situation will be taken into account when forming fixed amount groups and assessing the additional benefit. In June 2017, the EU also reaffirmed the importance of incentive systems for the development of new antibiotics as part of its updated “Action Plan against Antimicrobial Resistance” (see vfa, 2017). Joint efforts to ensure needs-based supply and to prevent the spread of resistant germs have not only gained national attention and importance but have also long since become an urgent international responsibility. <<

Authors:
Kathrin Pieloth and Marie Moos