The report describes Sweden’s work on containment of antibiotic resistance, characterised by long-term, structured measures and collaborations on local, national and international levels of many disciplines and sectors. The ambition is that the report or chosen chapters and examples can be seen and used as a “tool-box” and give inspiration to other organisations and countries that want to develop or further strengthen their work on rational antibiotic use and resistance surveillance within human medicine. The report has been produced within a collaboration project between the Indian National Center for Disease Control (NCDC) and the Public Health Agency of Sweden as a part of the countries’ work for rational antibiotic use and improved surveillance of antibiotic resistance. The project has been financed by Sida.
The antibiotic consumption in Sweden has decreased substantially since the mid-1990s. Sweden has a relatively low use of antibiotics per capita and favourable resistance conditions. Sweden was early to initiate long-term and structured measures, characterised by work on both national and local levels coordinated by the Strama network.
Factors that may explain the favourable situation in Sweden include regulated sales of antibiotics and high coverage of data on antibiotic sales. Within the Swedish healthcare there is a tradition of relatively frequent sampling and culturing of patients, which generates data for continuous resistance surveillance. Over all, the laboratory standard is high. Part of the strategy has been implementation of treatment recommendations for common infections in outpatient care resulting in a sustained decrease in antibiotic consumption. There are also directives for basal hygiene routines for all health care workers to reduce contact transmission. Sweden has a strong core of specialists in clinical microbiology and infectious diseases who play a key role in promoting rational use of antibiotics and have done so from an early stage.
National, local and cross-sectoral collaboration
The Swedish work is characterised by involvement on local and national levels, and there are platforms for exchange of information between the two levels. Political support and commitment for the work is strong and many stakeholders are involved. A national action plan was published in 2000 which has been important for the continuous work. Based on the action plan, the government submitted a proposition concerning a strategy for coordinated work towards the containment of antibiotic resistance and healthcare-related diseases, which was adopted by the parliament in March 2006. The action plan as well as the proposition have a cross-sectoral approach. As an extension of the strategy, a national intersectoral coordinating mechanism was established in 2012 for work on the containment of antibiotic resistance and healthcare-associated infections jointly run by the National Board of Health and Welfare and the Swedish Board of Agriculture. It involves cooperation between 20 authorities active within public health, animal health, food and the environment.
Joint international efforts are important. Sweden has several bilateral collaborations and is actively involved in global efforts to contain antibiotic resistance through cooperation with actors in other countries, the EU and the WHO.
Strama – the Swedish strategic programme against antibiotic resistance
Strama plays a central role on both a national and regional level and has brought about many initiatives, being a driving force on issues concerning antibiotic resistance. Strama was formed in the mid-1990s as a voluntary network of agencies and organisations on a national level, tied together by a network of local Strama groups. The organisation as well as the financing of Strama has successively been more formalised. The overall aim from the start has been to work to safeguard the efficiency of antibiotic treatment.
There are local Strama groups in every region, most often under the leadership of the county medical officer for communicable disease control. A prerequisite for effective preventive work is that different competencies work together to exchange experiences and with problem-solving. The composition of the Strama groups may vary, but they generally contain physicians from primary care as well as hospital specialties, pharmacists and clinical bacteriologists, in some groups dentists, and sometimes nurses. Cooperation with local pharmaceutical committee and infection control unit is also ongoing.
Swedish experience demonstrates that work for rational use should be carried out close to the prescriber. A key component in the work of the Strama groups is the regular meetings with the prescribers with feedback of resistance and prescription data analysis in relation to treatment recommendation. Within an increasing number of regions, IT-systems are now being constructed so that feedback can be given on an individual level to enable every physician to compare their prescribing with that of their closest colleagues. The national guidelines form the basis of local guidelines and have an impact through the local engagement.
On a national level The Public Health Agency of Sweden works, with support from the Strama advisory council, for an interdisciplinary, locally approved model by ensuring involvement of all relevant stakeholders including national and local authorities and professional and non-profit organisations. Central activities include producing treatment recommendations and knowledge base documents, information, conducting studies, international monitoring, training of physicians, and advocacy.
Resistance monitoring with good geographic coverage
National and local monitoring forms the basis for developing treatment recommendations and following resistance development and implementing and measuring the effect of interventions. Resistance monitoring in Sweden is mainly done on a voluntary basis and has good geographic coverage based on an established collaboration between the Public Health agency and local laboratories. The majority of patients in Swedish hospitals are cultured prior to antibiotic treatment. Data generated from clinical cultures, along with data from screening and transmission tracing of antibiotic-resistant bacteria form the basis of the resistance surveillance. Epidemiological typing is carried out on all notifiable forms of resistance. Sweden is actively working for quality assured methodology and has since many years used the common breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST).
The Public Health Agency of Sweden is responsible for national monitoring and analysis of antibiotic resistance. Four different systems are used in Sweden for national coverage of resistance surveillance; Res-Net, EARS-Net, SMI-Net and Svebar. Svebar is a system to which all culture findings from the country's laboratories are automatically transferred on a daily basis. This allows for an early alert on findings of very serious antibiotics resistance.
Monitoring of antibiotic consumption includes all sales
The Swedish eHealth Agency maintains pharmaceutical sales statistics, delivered by all registered pharmacies. At the national level, the Public Health Agency of Sweden is responsible for the surveillance, analysis and feedback of statistics on antibiotic consumption in human medicine. The surveillance allows for continuous information with good coverage of the amount of antibiotics consumed in Sweden. There is a lack of adequate IT systems for diagnosis-linked prescribing data, needed for the information on why the antibiotics have been prescribed and to follow the adherence to the treatment recommendations. Several initiatives have been taken to set up registers and systems that automatically generate diagnosis linked data in outpatient care as well as in inpatient care, such as the Anti-Infection Tool IT system for registering of antibiotic prescriptions and healthcare-associated infections.
Evidence based treatment recommendations give support to the prescriber
National recommendations set a standard for when antibiotics are indicated. They are important for reaching similar management in the country and to reduce overprescribing. The Medical Products Agency and the Public Health Agency of Sweden have published national recommendations for treatment of common infections in outpatient care. To gain the highest possible credibility and acceptance they are written in consensus with experts representing several medical specialties from both out-patient and hospital care. National care programmes for infections in inpatient care have been developed by the Swedish Society of Infectious Diseases, a nationwide group consisting mainly of infectious disease specialists. Local organisations such as Strama groups and pharmaceutical committees are key actors for the dissemination and implementation of recommendations in healthcare settings. Based on national recommendations, local guidelines and memoranda adapted to local needs are produced.
Information for health care workers and the public
No sales of antibiotics is directly directed toward patients – only the prescribers can prescribe antibiotics in Sweden. Still, the patients' knowledge, attitudes and expectations affect the prescribers. Information targeting both health care workers, patients, the public and the media is therefore part of the strategic work. The Public Health Agency of Sweden and local Strama groups have a continuous cooperation on communication efforts and strategies. Brochures and apps for smartphones with summarised treatment recommendations, patient information, posters at health clinics, brochures for elderly and parents of younger children, education at children's health centres, school material, shorter films for the web and TV as well as a website "antibiotics or not" are examples of produced information material. The Strama groups also share their experiences at recurrent Strama Days and through the web portal Strama.se.
Statistics over antibiotic sales and – resistance provide central information and are produced and communicated both locally and nationally. The Public Health Agency of Sweden compiles and analyses national data together with the National Veterinary Institute in the SWEDRES/SVARM annual report and continuously on its website and in electronic newsletters. Strama groups publish local statistics on local websites, news letters and emails. The Public Health Agency of Sweden and the Strama groups often coordinate press releases on data from international, national and local surveillance to reach both national and local media. Sweden also participate in the yearly European antibiotic awareness day (18th of November), coordinated by the European Centre for Disease Control to draw attention to the importance of rational use in all Europe. ECDC also produces information material targeting different groups in conjunction with the day. Joint efforts on many levels are important in the communication of the work for containing antibiotic resistance.