Human Medicine

In 2021, the total consumption of antibacterial agents (in hospital and outpatient care combined, ATC code J01) was 8.6 defined daily doses (DDD) per 1000 inhabitants per day. The total consumption of antibiotics has slightly decreased in recent years. However, during the COVID-19 pandemic, a greater decrease was observed. Antibiotic consumption in the outpatient sector accounts for about 85% of total consumption. In Switzerland, antibiotic consumption differs mainly in the outpatient sector, where consumption is higher in the French and Italian-speaking regions than in the German-speaking region.

The European Surveillance of Antimicrobial Consumption Network (ESAC-Net), coordinated by the European Centre for Disease Prevention and Control (ECDC), collects and analyses data on antibiotic consumption from 30 EU/EEA countries. Compared to these European countries, the overall consumption of antibiotics in both the outpatient and inpatient sectors in Switzerland is comparatively low.

According to the World Health Organization, at least 60% of total antibiotic consumption should be accounted for by antibiotics from the “Access” group. In Switzerland, the relative share of antibiotic consumption in the “Access” group has increased in recent years and has been above the WHO target of 60% for the first time in 2019.

The total consumption of antibiotics for systemic use (ATC group J01) in the outpatient sector, summed up to 7.3 defined daily doses (DDD) per 1000 inhabitants per day in 2021. Consumption has been declining since 2014. While it was a slight decline until 2019, a sharp decline in consumption was observed in the COVID-19 pandemic years.

Penicillins are the most commonly used antibiotic category in the outpatient sector.

Consumption of penicillins ranked first among antibiotic classes, amounting to 38% of the total antibiotic consumption in 2021. It was followed by the consumption of tetracyclines (17%, ATC code J01A), macrolides, lincosamides and streptogramins (12%, ATC code J01F), fluoroquinolones (11%, ATC code J01MA), other antibacterials (8%, ATC code J01X), sulfonamides and trimethoprim (7%, ATC code J01E) and beta-lactam antibacterials other than penicillins (including cephalosporins, 6%, ATC code J01D).

The use of “Access” antibiotics is steadily increasing in the outpatient sector.

The World Health Organization (WHO) has developed a classification system for antibiotics which divides existing antibiotics into three categories: Access, Watch and Reserve (“AWaRe”). Antibiotics from the “Access” category should be preferred in general due to their effectiveness and their moderate contribution to the development of resistances compared with other antibiotics. The “Watch” category includes antibiotics which are only indicated for a limited number of infections and more prone to be a target of antibiotic resistance and thus prioritized as targets of stewardship programs and monitoring, while “Reserve” antibiotics are only used as a last resort.

The proportion of the “Access” group in Switzerland has been above the WHO target of 60% for the first time in 2019,mainly due to the decrease in the consumption of Watch antibiotics in the outpatient setting. In recent years, the percentage of “Access” antibiotics in the outpatient setting has steadily increased, while the percentage of watch antibiotics has decreased.

Antibiotics are most commonly prescribed for lower urinary tract and upper respiratory tract infections.

The number of antibiotic prescriptions issued by general practitioners were 19.5 per 1000 consultations in 2021 (27.8 in 2019 and 25.4 in 2020), corresponding to a decrease of 30% between 2019 and 2021. Antibacterial prescriptions were prescribed most frequently for urinary tract infections (40%), followed by upper respiratory tract infections (23%) and skin and soft tissue infections (18%). Fosfomycin (33% of antibacterials used for UTI), fluoroquinolones (19%), nitrofurantoin (19%) and trimethoprim-sulfamethoxazol (18%) were the most prescribed antibacterials for lower urinary tract infections. For lower respiratory tract infections, amoxicillin-clavulanic acid (33%), macrolides (32%) and amoxicillin (11%) were the most prescribed antibacterial classes. Among respiratory tract infections, antibiotics were prescribed most frequently for sinusitis (19%), followed by acute bronchitis (15%), pneumonia (14%), streptococcal pharyngitis (13%) and otitis media (12%).

Antibiotics were most frequently prescribed for upper respiratory infections (72%), followed by skin and soft tissue infections (10%), lower respiratory infections (9%), and urinary tract infections (7%). Amoxicillin (68% of all antibacterials used for upper respiratory infections) and amoxicillin-clavulanic acid (19%) were the most frequently prescribed antibacterials.

Different antibiotic use depending on age group.

Penicillins with an extended spectrum (namely amoxicillin) were the antibiotic group most commonly used among children aged less than two years (58% of the total antibiotic consumption in 2021) and between 2–11 years (41%), whereas penicillins associated with beta-lactamase inhibitors were the most frequently used antibiotics in the age groups 18–64 (26%) and > 65 (23%). Seniors aged 65 and over were relatively high consumers of fluoroquinolones (17%) of their total antibiotic consumption (Bar-Chart).

There are relatively strong differences in the prescription of antibiotics for different age groups. For example, in the French-speaking region of Switzerland, for children under 2 years of age, penicillins with extended spectrum (amoxicillin) are mainly prescribed, whereas in the Italian-speaking region of Switzerland, the combination of amoxicillin with clavulanic acid (comb. of penicillins) is more common (Line-Chart).

Penicillins in combination with beta lactamase inhibitors are the most commonly used antibiotics in the inpatient sector.

The total consumption of antibiotics (ATC group J01) for systemic use in the swiss inpatient sector was 50.5 DDDs per 100 bed-days (using data from the sentinel network of acute care hospitals) in 2021. The antibiotic consumption in the inpatient sector in Switzerland has been relatively stable in recent years. Small regional differences in the consumption of antibiotics have been observed throughout Switzerland. A lower consumption in the Italian-speaking part could be explained by the fact that this part does not have a university hospital center.

With almost one third of all antibiotics used in Swiss hospitals, penicillins in combination with a beta-lactamase inhibitor (ATC code J01CR), especially amoxicillin-clavulanic acid, are the most commonly used antibiotics. Also, cephalosporins (ATC code J01DB-DE), especially the 2nd-generation cephalosporin cefuroxime or the 3rd generation-cephalosporin ceftriaxone, were widely used. While most antibiotic classes show a stable or slightly increasing consumption trend, the consumption of fluoroquinolones has decreased significantly in recent years.

“Access” antibiotics account for half of the antibiotics consumed in hospitals.

The WHO has developed a classification system for antibiotics which divides existing antibiotics into three categories: Access, Watch and Reserve (“AWaRe”) [1]. Antibiotics from the “Access” category should be preferred in general due to their effectiveness and their moderate contribution to the development of resistances compared with other antibiotics. The “Watch” category includes antibiotics which are only indicated for a limited number of infections, while “Reserve” antibiotics are only used as a last resort.

Consumption of “Access” and “Watch” antibiotics in Swiss hospitals has remained largely unchanged in recent years. The consumption of antibiotics in the “reserve” group is low, accounting for about 1% of total consumption across the hospital.

Larger hospitals tend to have higher antibiotic use

A classification of acute care hospitals into small hospitals (up to 200 beds), medium-sized hospitals (200-500 beds) and large hospitals (over 500 beds) illustrates that due to more complex cases, larger hospitals tend to have a higher antibiotic consumption than smaller hospitals. However, the antibiotic consumption of hospitals within a hospital category can be highly variable.

ANRESIS is linked with several hospital pharmacies across Switzerland.

Hospital pharmacies linked with ANRESIS