Proposals for a more effective antibiotic policy in Belgium
Authors: Leroy Roos , Christiaens Wendy , Maertens de Noordhout Charline , Hanquet Germaine 
Published: January 2025

SCIENTIFIC REPORT 23 -- 1 INTRODUCTION 23 -- 1.1 SHORT DESCRIPTION OF THE PROBLEM 23 -- 1.1.1 Antibiotic resistance 23 -- 1.1.2 Antibiotic use in Belgium 24 -- 1.1.3 The concept of prudent antimicrobial/antibiotic use 24 -- 1.1.4 One Health approach 24 -- 1.1.5 Belgian Antibiotic Policy Coordination Committee (BAPCOC) 24 -- 1.1.6 Difficult to obtain significant improvements 24 -- 1.2 RESEARCH QUESTIONS & SCOPE 25 -- 1.3 TERMINOLOGY 25 -- 1.4 METHODOLOGY 26 -- 1.5 STRUCTURE OF THE REPORT 26 -- 2 ANTIBIOTIC USE AND ITS LINK WITH ANTIBACTERIAL RESISTANCE 27 -- 2.1 WHAT IS ANTIMICROBIAL RESISTANCE? 27 -- 2.1.1 Antibacterial resistance, a natural phenomenon .27 -- 2.1.2 How do bacteria become resistant? 27 -- 2.1.3 How does antibiotic resistance spread? 28 -- 2.1.4 Multidrug resistant organisms 28 -- 2.1.1 Resistance in community and healthcare acquired infections 29 -- 2.2 WHAT IS PRUDENT ANTIBIOTIC USE? 29 -- 2.3 USE AND MISUSE OF ANTIBIOTICS .30 -- 2.4 THE BURDEN OF ANTIBACTERIAL RESISTANCE 30 -- 2.5 TIME FOR ACTION 32 -- 3 ANTIBIOTICS IN BELGIUM 33 -- 3.1 WHO CAN PRESCRIBE ANTIBIOTICS IN BELGIUM? 33 -- 3.1.1 Human sector 33 -- 3.1.2 Veterinary sector 34 -- 3.2 WHO CAN OBTAIN ANTIBIOTICS IN BELGIUM AND HOW? 34 -- 3.2.1 Human sector 34 -- 3.2.2 Who can administer antibiotics to animals and who is allowed to keep stocks of medicines at farms? 35 -- 3.3 FINANCIAL ASPECTS 36 -- 3.3.1 Human sector 36 -- 3.3.2 Veterinary sector 42 -- 3.4 ACTORS INVOLVED, INSPIRED BY THE VIABLE SYSTEMS MODEL 43 -- 3.4.1 Introduction 43 -- 3.4.2 Human sector 43 -- 3.4.3 Veterinary sector 50 -- 4 ANTIBIOTIC USE AND ANTIMICROBIAL RESISTANCE 54 -- 4.1 HOW TO MEASURE ANTIBIOTIC USE 54 -- 4.1.1 Human sector 54 -- 4.1.2 Veterinary sector 59 -- 4.2 HOW IS ANTIBIOTIC USE MONITORED? 61 -- 4.2.1 Human sector 61 -- 4.2.2 Veterinary sector 65 -- 4.3 DATA ON ANTIBIOTIC USE IN BELGIUM, IN A EUROPEAN CONTEXT 68 -- 4.3.1 Human sector 68 -- 4.3.2 Veterinary sector 83 -- 4.4 ANTIBIOTIC USE IN THE BELGIAN AMBULATORY AND HOSPITAL SECTOR FURTHER EXPLORED 90 -- 4.4.1 Methods 90 -- 4.4.2 Results 92 -- 5 DETERMINANTS OF ANTIBIOTIC PRESCRIPTION AND USE 104 -- 5.1 DETERMINANTS OF ANTIBIOTIC PRESCRIBING IN HUMAN MEDICINE 104 -- 5.1.1 Determinants of antibiotic prescription in Belgium 105 -- 5.1.2 Determinants of antibiotic prescription in other regions 110 -- 5.1.3 Determinants of antibiotic use by patients 116 -- 5.1.4 Limitations 119 -- 5.2 DETERMINANTS OF ANTIBIOTIC PRESCRIPTION AND CHOICE IN VETERINARY MEDICINE 120 -- 5.2.1 Methods 120 -- 5.2.2 Determinants of antibiotic prescription 121 -- 5.2.3 Determinants of antibiotic choice 126 -- 5.2.4 Limitations 127 -- 6 INTERVENTIONS TO PROMOTE THE PRUDENT USE OF ANTIBIOTICS 128 -- 6.1 INTERVENTIONS TO PROMOTE THE PRUDENT USE OF ANTIBIOTICS IN THE HUMAN SECTOR 128 -- 6.1.1 Belgian interventions to promote the prudent use of antibiotics 128 -- 6.1.2 Interventions that have been implemented and evaluated elsewhere 153 -- 6.2 INTERVENTIONS TO PROMOTE THE PRUDENT USE OF ANTIBIOTICS IN THE VETERINARY SECTOR 167 -- 6.2.1 Introduction 167 -- 6.2.2 Nation-wide interventions to promote prudent antibiotic use 169 -- 6.2.3 European initiatives 173 -- 6.2.4 Concluding remarks 173 -- 6.2.5 Examples from abroad 173 -- 6.3 OTHER ASPECTS TO CONSIDER IN DEVELOPING INTERVENTIONS AIMING TO CHANGE PRESCRIPTION BEHAVIOUR 177 -- 7 STAKEHOLDER CONSULTATION AND SYSTEMS MAPPING 178 -- 7.1 INTRODUCTION 178 -- 7.2 APPROACH 178 -- 7.3 SYSTEMS MAP 179 -- 7.3.1 Concept and syntax of the systems map developed in this research 180 -- 7.3.2 The status of the systems map 181 -- 7.3.3 Use of systems maps 182 -- 7.4 METHODS 184 -- 7.4.1 Selection of stakeholders 184 -- 7.4.2 Interview guide 184 -- 7.4.3 Coding of interviews .185 -- 7.4.4 Internal review of the systems map 185 -- 7.4.5 Stakeholder review of the systems map 187 -- 7.4.6 Stakeholder deliberation on suggested improvements of antibiotics policy 187 -- 7.5 FINDINGS 187 -- 7.5.1 Main features of the systems map 187 -- 7.5.2 Description and presentation of the systems map 190 -- 7.5.3 Assessment of the scope of the systems map 219 -- 7.5.4 Stakeholders suggestions to improve antibiotic policy, prescription and use 220 -- 7.6 DISCUSSION 230 -- 7.7 CONCLUSION 232 -- 8 OTHER CHALLENGES WITH REGARD TO ANTIBIOTIC POLICY IN BELGIUM 233 -- 8.1 ACCESS TO THE RIGHT ANTIBACTERIAL PRODUCT NOT STRAIGHTFORWARD 233 -- 8.1.1 Background 233 -- 8.1.2 The availability of antibiotics in Belgium 235 -- 8.2 MISMATCH BETWEEN ANTIBIOTIC PACKAGE SIZE AND GUIDELINES FOR THEIR USE LEADING TO SELF-MEDICATION 238 -- 8.3 ETHICAL CHALLENGE: INDIVIDUAL VS. COLLECTIVE RESPONSIBILITY 241 -- 9 JOINT EC  ECDC ONE HEALTH COUNTRY VISIT TO BELGIUM  KEY ISSUES WITH REGARD TO ANTIBIOTIC USE 242 -- 9.1 HUMAN HEALTH  ECDC 242 -- 9.1.1 Observations made by ECDC 242 -- 9.1.2 Key recommendations made by ECDC 245 -- 9.2 ANIMAL HEALTH - DG HEALTH AND FOOD SAFETY 247 -- 9.2.1 Observations made by DG Health and Food Safety 247 -- 9.2.2 Considerations for possible future actions 250 -- 10 DISCUSSION 251 -- 11 HOW CAN THE SITUATION BE IMPROVED? 253 -- 11.1 DEVELOP A NATIONAL ONE HEALTH AMR ACTION PLAN 253 -- 11.2 STRENGTHEN ANTIBIOTIC STEWARDSHIP IN ACUTE CARE HOSPITALS 254 -- 11.3 ROLL OUT LOCAL ANTIBIOTIC STEWARDSHIP TEAMS IN THE AMBULATORY SECTOR 255 -- 11.4 DEVELOP ANTIBIOTIC STEWARDSHIP IN NURSING HOMES 255 -- 11.5 IMPROVE THE PROFESSIONAL EDUCATION ON PRUDENT ANTIBIOTIC PRESCRIPTION AND USE, AND DEVELOP AND IMPLEMENT INTERVENTIONS TARGETING PSYCHOLOGI CAL, SOCIAL AND INSTITUTIONAL DETERMINANTS OF BEHAVIOURAL CHANGE 256 -- 11.6 RECOGNISE MEDICAL MICROBIOLOGY AND INFECTIOLOGY AS MEDICAL SPECIALTY AND PROVIDE REMUNERATION FOR THEIR ADVICE 257 -- 11.7 IMPROVE THE AVAILABILITY OF OLD/NARROW SPECTRUM ANTIBIOTICS 257 -- 11.8 PUT INTO PRACTICE THE DELIVERY OF THE EXACT NUMBER OF ANTIBIOTIC TABLETS IN PHARMACIES OPEN TO THE PUBLIC 258 -- 11.9 IMPROVE THE COMPLIANCE WITH EVIDENCE-BASED PRESCRIPTION GUIDELINES 258 -- 11.10 MAKE USE OF THE (FUTURE) MANDATORY IMPLEMENTATION OF E-PRESCRIBING TO IMPROVE THE PRUDENT PRESCRIPTION OF ANTIBIOTICS 259 -- 11.11 CONSIDER TAKING STRUCTURAL MEASURES TO IMPROVE THE PRUDENT PRESCRIPTION AND USE OF ANTIBIOTICS 259 -- 11.12 PERFORM A HEALTH TECHNOLOGY ASSESSMENT ON POINT OF CARE TESTING FOR THE DIAGNOSIS OF INFECTIOUS DISEASES IN THE BELGIAN AMBULATORY CARE CONTEXT 259 -- 11.13 STIMULATE BEHAVIOURAL CHANGE AMONG THE GENERAL PUBLIC AS WELL AS THE PRESCRIBERS TOWARDS MORE PRUDENT USE OF ANTIBIOTICS 260 -- 11.14 STRENGTHEN VETERINARIANS COUNSELLING ROLE 260 -- 11.15 CHANGE PRESCRIBING BEHAVIOUR OF HIGH ANTIBIOTIC PRESCRIBERS 261 -- 11.16 MONITOR AND STIMULATE RESEARCH ON ANTIBIOTIC USE AND AMR IN THE SECTOR OF COMPANION ANIMALS 261 -- 11.17 STIMULATE BIOSECURITY IMPROVEMENTS AS AN ALTERNATIVE TO ANTIBIOTIC USE 261 -- 11.18 ENFORCE COMPLIANCE WITH THE LEGISLATION ON ANIMAL WELFARE 262 -- 11.19 MAKE THE USE OF ANTIBIOTICS AS MEANS TO INTENSIFY ANIMAL PRODUCTION SUPERFLUOUS 263 -- 11.20 AVOID SELF-MEDICATION BY MINIMIZING STOCKS AT FARMS AND BY ADJUSTING PACKAGE SIZES .263 -- 11.21 DEFINE NEW GOALS REGARDING ANTIBIOTICS IN THE VETERINARY SECTOR 264