Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU.
Date: 2017-06-01
Institutions: Directorate-General for Health and Food Safety
Subjects: antibiotic, consumer protection, disease prevention, health policy, medicinal product, medicine, public health

Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Antimicrobial resistance and 
causes of non-prudent use 
of antibiotics in human 
medicine in the EU 

April 2017  

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

John Paget (NIVEL) 
Dominique Lescure (NIVEL) 
Ann Versporten (University of Antwerp) 
Herman Goossens (University of Antwerp) 
François Schellevis (NIVEL) 
Liset van Dijk (NIVEL) 

EUROPEAN COMMISSION 

Directorate-General for Health and Food Safety 
Directorate C— Public Health, Country Knowledge, Crisis Management 
Unit SANTE C3 — Crisis Management and Preparedness in Health 

Contact: Charles Price 

E-mail: SANTE-CONSULT-C3@ec.europa.eu 

European Commission 
B-1049 Brussels 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Antimicrobial resistance and 
causes of non-prudent use 
of antibiotics in human 
medicine in the EU 

April 2017  

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

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The information and views set out in this final report of the ARNA project are those of the author(s) and do 
not  necessarily  reflect  the  official  opinion  of  the  Commission.  The  Commission  does  not  guarantee  the 
accuracy  of  the  data  included  in  this  study.  Neither  the  Commission  nor  any  person  acting  on  the 
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Luxembourg: Publications Office of the European Union, 2017 

ISBN 978-92-79-66537-0 
DOI: 10.2875/326847 

© European Union, 2017 
Reproduction is authorised provided the source is acknowledged. 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Contents 

3. 

2. 

Executive summary ........................................................................................... 8 
Introduction ............................................................................................15 
1. 
1.1.  Background .........................................................................................15 
1.2.  The need to integrate measures .............................................................18 
1.3.  Aims of the ARNA project ......................................................................19 
1.4.  The structure and content of the report ...................................................20 
The use of antibiotics in the EU .................................................................22 
Introduction.........................................................................................22 
2.1. 
2.2.  Antibiotic consumption rates in the EU ....................................................23 
2.2.1.  Methods ........................................................................................23 
2.2.2.  Antibiotic consumption ....................................................................25 
2.2.3.  Use of antibiotics without a prescription ............................................30 
2.3.  Comparison of prescription and non-prescription use ................................32 
2.4.  A literature survey of antibiotic use without a prescription .........................33 
2.4.1.  Methods ........................................................................................33 
2.4.2.  Search results and study characteristics ............................................34 
Patient perspective .........................................................................38 
2.4.3. 
Pharmacist/pharmacy perspective ....................................................42 
2.4.4. 
Internet ........................................................................................43 
2.4.5. 
2.5.  Discussion and selection of Member States for the ARNA project ................43 
Explaining differences in antibiotic use across the EU ...................................45 
3.1. 
Introduction.........................................................................................45 
3.2.  Determinants: a literature review ...........................................................46 
3.2.1.  Methods ........................................................................................46 
3.2.2.  Search results ................................................................................47 
Population perspective ....................................................................47 
3.2.3. 
The pharmacist’s perspective ...........................................................50 
3.2.4. 
The healthcare-system and country perspective .................................52 
3.2.5. 
3.2.6.  Discussion .....................................................................................53 
3.3.  Eurobarometer data ..............................................................................55 
3.3.1.  Methods ........................................................................................55 
3.3.2.  Results .........................................................................................56 
3.3.3.  Discussion .....................................................................................60 
3.4.  Policies and measures on antibiotic use in EU Member States ....................60 
3.4.1. 
Introduction ..................................................................................60 
3.4.2.  Methods ........................................................................................60 
Legal framework ............................................................................63 
3.4.3. 
3.4.4.  National policy measures .................................................................69 
3.4.5.  Surveillance and auditing ................................................................74 
3.4.6.  Discussion .....................................................................................77 
The use of antibiotics without a prescription in seven EU Member States ........78 
4.1. 
Introduction.........................................................................................78 
4.2.  Methods ..............................................................................................79 
4.2.1. 
Patient survey................................................................................79 
4.2.2.  GPs and pharmacists survey ............................................................80 
4.3.  The use of antibiotics without a prescription: patients ...............................82 
4.3.1. 
The frequency of non-prescription use ..............................................82 
4.3.2.  Where do patients get antibiotics without a prescription? ....................83 
4.3.3.  Reasons for use and side effects ......................................................85 
4.3.4.  Why do patients self-medicate?........................................................85 
Information provision .....................................................................89 
4.3.5. 

4. 

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5. 

6. 

4.4.  Views from GPs and pharmacists ............................................................90 
4.4.1. 
The use of antibiotics without a prescription ......................................90 
4.4.2.  Where do patients get antibiotics without a prescription? ....................92 
4.4.3.  Opinions on the use of antibiotics .....................................................97 
Interventions by GPs and pharmacists ............................................ 101 
4.4.4. 
4.5.  Summary and discussion ..................................................................... 102 
Good practices in the EU ........................................................................ 104 
5.1. 
Introduction....................................................................................... 104 
5.2.  Methods ............................................................................................ 104 
5.2.1.  Review of reviews ........................................................................ 104 
5.2.2.  Member State survey .................................................................... 105 
5.3.  Good practices on the patient and public health levels ............................ 108 
5.4.  Good practices on the HCP level ........................................................... 110 
5.5.  Policy options..................................................................................... 114 
5.6.  Multifaceted interventions ................................................................... 117 
5.7.  The effectiveness of the interventions ................................................... 118 
5.8.  Summary and discussion ..................................................................... 119 
Expert opinions and consensus statement on policy options ........................ 120 
Introduction....................................................................................... 120 
6.1. 
6.2.  Methods ............................................................................................ 121 
6.3.  Public health campaigns ...................................................................... 122 
6.4.  Healthcare professionals ..................................................................... 123 
6.5.  Policy options..................................................................................... 124 
6.6.  EU interventions ................................................................................. 125 
6.7.  The results of the expert meeting compared with the scientific evidence ... 126 
6.8.  Conclusions ....................................................................................... 127 
Policy  measures  to  enhance  more  prudent  use  of  antibiotics  in  six  EU  Member 

7. 
States 128 

8. 
9. 

7.1. 
Introduction....................................................................................... 128 
7.2.  Methods ............................................................................................ 129 
7.3.  Main results per Member State ............................................................. 131 
7.4.  Actions proposed in multiple countries .................................................. 137 
Patient level ................................................................................ 138 
7.4.1. 
7.4.2. 
Professional level ......................................................................... 138 
7.4.3.  Healthcare-system level ................................................................ 138 
Interventions that were mentioned in one Member State ................... 139 
7.4.4. 
Consensus statement on the prudent use of antibiotics .............................. 145 
Conclusions and discussion ..................................................................... 148 
9.1. 
Identifying  key  factors  that  drive  non-prescription  use  and  level  of 
reinforcement .............................................................................................. 148 
9.2.  Good practices ................................................................................... 152 
9.3.  Policy options for more prudent use of antibiotics ................................... 153 
9.4.  ARNA conference statement................................................................. 155 
References..................................................................................................... 156 
Appendix A.  Questionnaire Member State survey ............................................ 161 
Appendix B.  Questionnaire surveys in seven EU Member States ........................ 170 
B.1.  Patient questionnaire .......................................................................... 170 
B.2.  GP questionnaire ................................................................................ 187 
B.3.  Pharmacist questionnaire .................................................................... 199 

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Country codes 

The following country codes are used in this report: 

AT: Austria 
FR: France 
NL: Netherlands 
BE: Belgium 
HR: Croatia 
NO: Norway 
CY: Cyprus 
HU: Hungary 
PL: Poland 
CZ: Czech Republic 

IE: Ireland 
PT: Portugal 
DE: Germany 
IS: Iceland 
RO: Romania 
DK: Denmark 
IT: Italy 
SI: Slovenia 
EE: Estonia 
LT: Lithuania 

SR: Slovakia 
EL: Greece 
LU: Luxembourg 
SE: Sweden 
ES: Spain 
LV: Latvia 
UK: United Kingdom 
FI: Finland 
MT: Malta 

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Executive summary 

Antimicrobial resistance: a public health problem 

1. 
Antimicrobial  resistance  (AMR)  is  an  increasing  worldwide  public  health  problem  with 
important  implications  for  the  European  Union  (EU).  When  antibiotics  become 
ineffective,  bacterial  infections  lead  to  increased  morbidity,  use  of  healthcare, 
mortality and cost.1 2 3 4 Globally, estimates suggest that AMR leads to 700 000 deaths 
per  annum.4  For  the  EU,  the  European  Centre  for  Disease  Prevention  and  Control 
(ECDC) has estimated that AMR currently causes 25 000 deaths annually and losses of 
at least EUR 1.5 billion per annum in extra healthcare costs and productivity.5 

An important driving force behind AMR is the non-prudent use of antimicrobial agents 
in  both  humans  and  animals.2  3  Reducing  the  unnecessary  consumption  of  antibiotics 
can  therefore  have  a  powerful  impact  upon  resistance.4  Several  reports  have  been 
published  in  recent  years  that  outline  measures  to  reduce  the  consumption  of 
antibiotics, 
for  Economic  Cooperation  and 
Development  (OECD)2  and  the  AMR  review  group.4  A  variety  of  actions  have  been 
proposed,  including  global  awareness  campaigns,  increasing  financial  resources  for 
infectious  diseases  in  the  healthcare  sector,  the  development  of  new  antibiotics  and 
policies aimed at the reduction of antibiotic use. 

for  example  by  the  Organisation 

Worldwide, the focus of research and policy actions has been on prescribed antibiotics, 
with  much  less  attention  being  paid  to  the  human  use  of  antibiotics  without  a 
prescription. This while the use of antibiotics without a prescription represents a non-
prudent use of antibiotics because of its lack of medical guidance.6 Reducing the use of 
antibiotics  without  a  prescription  will  contribute  to  controlling  bacterial  resistance. 7 
Strategies,  therefore,  to  improve  the  prudent  use  of  antibiotics  in  the  EU  and  its 
Member States should include action to address antibiotic use without a prescription. 

Aims of the ARNA project 

2. 
This report describes the results of the ARNA (‘Antimicrobial resistance and the causes 
of non-prudent use of antibiotics’) project, which was carried out under a contract with 
the  European  Commission  (Directorate-General  for  Health  and  Food  Safety).  Most  of 
the data collection and work on the project took place from July 2014 to June 2016. 

The ARNA project aimed to: 
1.  identify  key  factors  that  drive  the  sales  and  non-prudent  use  of  antibiotics  in 

human medicine obtained without a prescription; 

2.  assess the level of enforcement of the legislation regarding ‘prescription-only’ use 

of antimicrobial agents in the EU; 

3.  document good practices aimed at strengthening more prudent use of antibiotics; 
4.  develop policy options for more prudent use of antibiotics. 

To  achieve  these  goals,  a  wide  range  of  activities  were  performed  within  the  ARNA 
project. These activities are listed in Box 1. 

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Box 1. 

Activities within the ARNA project. 

The frequency of antibiotic use without a prescription (Chapter 2) 
  A summary of existing data on antibiotic use  in  the  EU  Member States from  the European 
Surveillance  of  Antimicrobial  Consumption  Network  (ESAC-Net)  and  the  2013  and  2016 
Eurobarometer surveys on the use of antibiotics. 

  A  systematic  literature  review  of  the  prevalence  of  the  use  of  antibiotics  without  a 

prescription. 

Explaining differences in non-prescription use across the EU (Chapter 3) 
  A  literature  review  of  the  determinants  of  antibiotic  use  without  a  prescription  on  the 

population, healthcare-professional (HCP) and healthcare-system levels. 

  An  analysis  of  the  2013  Eurobarometer  survey  data.  These  data  are  used  to  study 

determinants of antibiotic use for all 28 EU Member States. 

  An  online  survey  among  ministries  of  health  and  national  experts  to  describe  policy 
measures that EU Member States have taken on a healthcare-system level to enhance the 
prudent use of antibiotics. 

Use of antibiotics without a prescription in seven EU Member States (Chapter 4) 
 

Interview  surveys  among  patients  who  used  antibiotics  without  a  prescription,  general 
practitioners  (GPs)  and  pharmacists  in  seven  Member  States  (Cyprus,  Estonia,  Greece, 
Hungary, Italy, Romania and Spain). 

Good practices in the EU (Chapter 5) 
  A literature review of good practices such as policy measures or interventions. 
  An online survey  among  ministries of  health  and  national experts to  collect information on 

measures and interventions not described in the literature. 

Expert  opinions  and  a  consensus  statement  on  policy  options  to  reduce  the  use  of  antibiotics 
without a prescription in the EU (Chapter 6) 

  An expert meeting with a group of 20 experts from nine EU Member States and two non-EU 
Member  States.  The  experts  reviewed  and  discussed  interventions  that  EU  Member  States 
could use to reduce the non-prudent use of antibiotics. 

Policy  measures  to  enhance  more  prudent  use  of  antibiotics  in  six  EU  Member  States 
(Chapter 7) 
  Country-dialogue  meetings  were  held  in  six  EU  Member  States  (Cyprus,  Greece,  Hungary, 
Italy,  Romania  and  Spain).  Each  Member  State  had  a  local  organiser  and  all  the  relevant 
stakeholders were represented by the participants in the meetings. 

Consensus statement on the prudent use of antibiotics (Chapter 8) 
 

An international conference was held on 17 June 2016 to discuss the results of the project, 
as  well  as  to  conclude  the  ARNA  project  with  an  overview  of  actions.  Sixty  participants, 
from  21  EU  Member  States,  attended  the  conference.  The  main  conclusions  and 
recommendations  were  summarised  in  the  ARNA  Utrecht  conference  statement  on  the 
prudent use of antibiotics. 

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The use of antibiotics without a prescription 

3. 
The first part of the ARNA project focused on the frequency of antibiotic use without a 
prescription.  Data  from  the  2013  and  2016  Eurobarometer  surveys  suggest  that  the 
proportion of antibiotics that were used without a prescription increased from 5 % of 
all antibiotics used in 2013 to 7 % in 2016.8 However, rates varied across EU Member 
States.  The  highest  rates  were  found  in  Greece,  Romania  and  Cyprus,  both  in  2013 
and in 2016. 

The  two  prevailing  sources  of  antibiotics  without  a  prescription  are  over-the-counter 
(OTC) selling in pharmacies and the use of leftover antibiotics. In Member States such 
as Greece, Cyprus and Romania, antibiotic use without a prescription is mainly driven 
by OTC selling in pharmacies. Between 80 % and 100 % of all the most recently used 
courses of antibiotics without a prescription had been bought in a pharmacy. In other 
Member  States,  such  as  Italy,  Hungary  and  Spain,  the  use  of  leftover  antibiotics  is 
also  an  important  source  of  non-prescription  use.  The  Eurobarometer  data  suggest 
that  the  internet  does  not  seem  to  be  an  important  source  for  obtaining  antibiotics 
without  a  prescription.  Finally,  the  analysis  revealed  a  positive,  but  moderate, 
association between prescription use and non-prescription use of antibiotics. 

The selection of Member States for the ARNA project 
Surveys  regarding  the  use  of  antibiotics  without  a  prescription  were  performed  in 
seven  Member  States,  among  patients,  pharmacists  and  GPs.  The  seven  Member 
States  were  chosen  on  the  basis  of  the  2013  Eurobarometer  survey (a)  as  this  is  the 
only  source  that  both  includes  all  EU  Member  States  and  measures  antibiotic  use  in 
exactly the same way. The main criterion for selecting the seven ARNA countries was 
the level of antibiotic use without a prescription. The Member States with high rates of 
non-prescription  antibiotic  use  measured  as  a  percentage  of  total  use  were:  Cyprus 
(10 %),  Estonia  (6 %),  Greece  (16 %),  Hungary  (8 %),  Romania  (20 %)  and  Spain 
(8 %).  Italy  (4 %)  was  not  on  the  list  of  top  Member  States,  but  was  chosen,  in 
agreement  with  the  European  Commission,  due  to  regional  differences  in  use.  There 
was higher use in southern Italy and lower use in the north. 

4.  Key  factors  that  drive  the  non-prudent  use  of  antibiotics 

obtained without a prescription 

The assessment of determinants of antibiotic use without a prescription shows that it 
is  a  complex  phenomenon  that  can  be  partly  explained  by  various  determinants  on 
different  levels,  such  as  the  patient,  the  healthcare  professional  (HCP)  and  the 
healthcare system. An extensive literature review showed that the scientific literature 
has  mainly  focused  on  patient-level  factors  that  might  drive  the  use  of  antibiotics 
without  a  prescription.  The  literature  results  were  inconclusive  for  sociodemographic 
factors such as for the patient’s gender, age and educational level, and for the location 
of  the  pharmacy.  Despite  this,  some  determinants  were  consistently  found  to  be 
associated  with  the  use  of  antibiotics  without  a  prescription.  These  are  discussed 
below. 

Patient level 
On the patient level, a lack of knowledge of antibiotics is associated with higher use of 
antibiotics  without  a  prescription.  This  result  was  confirmed  in  a  secondary  data 
analysis  of  the  2013  Eurobarometer  data.  Here,  differences  between  EU  Member 
States  in  the  rates  of  non-prescription  use  —  relative  to  the  use  of  prescription 
antibiotics  —  can  be  explained  in  part  by  differences  in  the  level  of  knowledge  and 

(a)  The choice for the ARNA countries was made in 2014. 

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attitudes  towards  antibiotics.  The  patient  interviews  in  the  seven  ARNA  countries 
further  supported  the  importance  of  a  lack  of  knowledge  as  a  determinant  for  non-
prudent use. Knowledge about antibiotics among patients who use antibiotics without 
a  prescription  was  found  to  be  lower  compared  to  the  general  population  in  the 
Eurobarometer surveys. 

A  lack  of  knowledge  is  also  reflected  in  the  main  reasons  why  patients  use  an 
antibiotic without a prescription in the seven ARNA countries. Influenza, common cold, 
sore  throat,  cough,  fever  and  headache  are  all  common  reasons  given  for  using 
antibiotics without a prescription. Finally, a previously prescribed antibiotic treatment 
is the main motivation for patients to use antibiotics without a prescription in all seven 
Member  States.  This  determinant  was  also  found  in  some  of  the  studies  included  in 
the literature review. 

Healthcare professional (HCP) level 
The  knowledge  and  attitudes  of  pharmacists  regarding  antibiotics  is  also  important. 
The better the knowledge, and the more reluctant the attitude of the pharmacist, then 
the  less  likely  he  or  she  will  be  to  dispense  antibiotics  without  a  prescription.  Other 
pharmacist-  and  pharmacy-related  characteristics,  such  as  the  location  of  the 
pharmacy and the age and gender of the pharmacist, did not have an association with 
the  use  of  antibiotics  without  a  prescription.  However,  pharmacists  in  smaller 
pharmacies seem to be more likely to dispense antibiotics without a prescription. 

Patient  requests  for  an  antibiotic  are  a  driving  factor  for  non-prudent  use  that  was 
mentioned  by  both  pharmacists  and  GPs  who  were  interviewed  in  the  seven  ARNA 
countries. GPs and pharmacists do not always fulfil the requests from these patients, 
however some of them sometimes do prescribe or dispense an antibiotic when there is 
patient pressure or there is shared decision-making with the patient. Pharmacists also 
report  that  they  fear  that  customers  will  otherwise  go  to  another  pharmacy.  In  the 
ARNA  countries (b),  cooperation  between  pharmacists  and  GPs  on  the  issue  of 
antibiotic use is limited and could be strengthened. 

Health-system level 
On  the  healthcare-system  level,  a  literature  review  found  that  dispensing  the  exact 
number of tablets instead of whole packages reduces the use of antibiotics without a 
prescription. Moreover, a survey among ministries of health (MoHs) and experts in all 
EU Member States revealed that OTC sales of antibiotics are illegal in some countries 
for most, but not all, antibiotics. The main exceptions concern topical antibiotics. From 
this  survey,  we  also  conclude  that  actions  are  being  taken  by  all  Member  States  to 
reduce the non-prudent use of antibiotics, but the type and intensity of actions differ 
by  Member  State.  The  most  common  measures  were  ‘surveillance  of  resistance  and 
antibiotic  use’, 
‘media  campaigns’.  Antibiotic 
stewardship  programmes  were  reported  by  eight  Member  States.  The  different 
measures are aimed at reducing the non-prudent use of antibiotics but their effect on 
the use of antibiotics without a prescription has not been measured. 

interventions’  and 

‘educational 

Conclusions: the key factors 
Based  on  the  analysis  of  determinants,  we  conclude  that  interventions  and  policies 
that  simultaneously  target  patients  and  HCPs  will  be  more  effective  than  approaches 
targeting  just  one  of  them.  An  increasing  amount  of  awareness  and  knowledge  is 
needed  from  both  groups  —  patients  and  professionals  —  in  order  to  induce 

(b)  The  ARNA  countries  are  the  seven  Member  States  selected  for  the  in  depth  study:  Cyprus,  Estonia, 

Greece, Hungary, Italy, Romania and Spain. 

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behavioural  change.  Moreover,  the  enforcement  of  laws  and  regulations  is  necessary 
to ensure the sustainability of behavioural change. 

5. 

Enforcement of legislation regarding the ‘prescription-only’ 
use of antimicrobial agents in the EU 

In  the  EU,  all  Member  States  have  legislation  requiring  that  antibiotics  are  only 
dispensed with a medical prescription. OTC sales of antibiotics are illegal in all Member 
States,  although  there  are  some  exceptions  in  a  number  of  them  —  for  example 
creams or eye drops that contain antibiotics. 

Despite this legal framework, we found that significant amounts of OTC sales occur in 
several  Member  States  (see  Section 3  above).  These  findings  highlight  the  need  for 
Member  States  to  enforce  existing laws  better  in  order  to  ensure  antibiotics  are  only 
available with a prescription. 

6.  Documenting  good  practices  aimed  at  strengthening  more 

prudent use of antibiotics 

In May 2015, the WHO urged all countries to have multisector national action plans to 
address  AMR  in  place  by  2017.  The  EU  ministers  of  health  have  also  called  upon 
Member  States  to  have  such  a  plan.  The  ARNA  study  showed  that  14  EU  Member 
States had such a national antibiotic plan or plan to combat AMR. Nevertheless, 26 EU 
Member  States  had  activities  to  enhance  the  prudent  use  of  antibiotics,  with 
surveillance  systems  looking  at  both  AMR  and  antibiotic  use.  This  is  the  most 
important  national  policy,  but  others  include  educational  interventions,  found  in  20 
Member States, and media campaigns, found in 19. 

Evidence  from  the  literature  shows  that  education  and  information,  provided  for  the 
public  and  for  HCPs,  are  effective  interventions  in  enhancing  the  prudent  use  of 
antibiotics. This is in line with the finding that a lack of knowledge of antibiotics, both 
among patients and HCPs, is a key driving force for the non-prudent use of antibiotics. 
For  HCPs,  other  effective  interventions  exist  such  as  providing  assistance  via 
technological  support  tools  or  guidelines.  On  the  policy  level,  cooperation  between 
different  stakeholders  such  as  HCP  organisations,  patient  organisations  and 
policymakers is important. So too is the creation of national committees that stimulate 
information  promoting  research  and  monitoring  such  as  the  Strama  programme  in 
Sweden. 

Overall,  the  most  effective  way  to  stimulate  the  prudent  use  of  antibiotics  is  the 
implementation  of  a  combination  of  interventions  on  different  levels  simultaneously, 
repeated  over  a  number  of  years.  In  many  other  Member  States,  a  variety  of 
initiatives  were  found.  Examples  include  the  setting  of  targets  for  a  reduction  in  the 
number  of  antibiotic  prescriptions  and  the  measurement  of  adherence  to  treatment 
recommendations (c). Providing the infrastructure for monitoring the use of antibiotics, 
both  nationally  and  regionally,  is  another  example (d).  Moreover,  policymakers  can 
encourage  professional  associations  to  identify  and  monitor  indicators  of  rational 
prescribing and the control of sales of antibiotics (e). However, given that many of the 
interventions  have  not  been  properly  evaluated,  especially  those  on  a  healthcare-
system level, it is difficult to be sure whether all of the interventions are effective. This 
is  an  area  that  requires  further  attention.  However,  we  found  that  many  initiatives 

(c)  E.g. http://strama.se/about-strama/?lang=en; https://guidelines.nhg.org/ 
(d)  E.g. http://www.eurosurveillance.org/viewArticle.aspx?ArticleId=19036 
(e)  E.g. http://fingertips.phe.org.uk/profile/amr-local-indicators 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

exist.  Member  States  across  the  EU  can  learn  from  each  other  how  to  develop 
activities better in order to promote the prudent use of antibiotics. 

7.  Developing  policy  options  for  more  prudent  use  of 

antibiotics 

Expert opinion: proposed interventions 
Within the context of the ARNA project, a group of experts discussed and agreed a set 
of  interventions  that  EU  Member  States  can  use  in  order  to  reduce  the  non-prudent 
use of antibiotics. 

Public health/patient-level interventions 
Public health campaigns should be integrated into multifaceted interventions which are 
tailored to both the profile of a specific Member State and to important target groups, 
including patients with low health literacy. Patients should be educated, for example, 
on  when  to  consult  their  doctor  or  pharmacist  and  when  an  antibiotic  is  appropriate. 
Mass-media messages should also be supported by pharmacists and GPs. 

CPHCP-level interventions 
The  communication  skills  of  HCPs  towards  their  patients  should  be  improved,  taking 
into account the health literacy of patients. These skills should be supported by patient 
information.  Collaboration  between  HCPs,  and  especially  between  GPs  and 
pharmacists,  should  be  strengthened.  HCPs  should  also  be  made  familiar  with 
guidelines  for  the  prudent  use  of  antibiotics.  Finally,  point-of-care  tests  may  be  of 
additional value but there is still no clear evidence of this. 

Policy option interventions 
National  plans  to  combat  AMR  should  be  further  encouraged  and  the  laws  banning 
OTC sales need to be enforced more stringently in some Member States. To promote 
this enforcement, incentives — preferably positive, but negative ones too — should be 
used to promote the prudent use of antibiotics. The experts also found that antibiotic 
packaging  should  be  tailored  to  the  course  of  treatment  and  that  the  length  of  time 
that  antibiotic  prescriptions  should  be  limited  and  maybe  the  period  that  they  are 
valid,  i.e.  the  period  during  which  the  patient  can  fill  the  prescription,  should  be 
harmonised  across  all  EU  Member  States.  These  currently  vary  from  2 weeks  to 
1 year.  In  addition,  delayed  prescribing  should  be  encouraged.  Surveillance  is, 
however,  according  to  the  expert  group,  only  useful  if  it  includes  quality  indicators 
meaning indicators that are tailored to a certain diagnosis. 

EU-level interventions 
The  experts  agreed  that  the  EU’s  European  Antibiotic  Awareness  Day  is  an  excellent 
initiative  but  needs  to  be  complemented  with  activities  and/or  interventions  on  a 
national  level  in  order  to  produce  sustainable  behavioural  change.  Another  issue 
discussed  was  benchmarking,  which  was  considered  a  powerful  approach  as  Member 
States in the EU want to do their best, and this stimulates action. Moreover, it helps to 
improve  transparency,  which  is  important  for  governance.  Benchmarking  should  be 
encouraged on both a national and a regional level. 

ARNA countries: plans for action 
The  ARNA  project  organised  country-dialogue  meetings  in  cooperation  with  national 
authorities in six Member States (Cyprus, Greece, Hungary, Italy, Romania and Spain) 
to which all relevant stakeholders were invited. These events aimed to generate action 
plans to combat the non-prudent use of antibiotics. We found that each Member State 
has  its  own  problems  and,  therefore,  different  approaches  were  discussed  and 

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included  in  each  of  the  action  plans.  The  action  plans  also  demonstrated  some 
similarities. Common actions included: the need for large-scale educational campaigns 
with clear messages and focused on health literacy; increasing the use and availability 
of rapid tests; and stimulating vaccination programmes, such as against influenza, in 
order to reduce bacterial infections. Other actions that were frequently cited included: 
educational  programmes  for  HCPs;  the  use  of  electronic  medical  records  to  monitor 
treatments more effectively; and the development of simple treatment guidelines that 
are  easy  to  disseminate.  Common  actions  also  included  the  involvement  of  all 
stakeholders,  in  particular  patient  groups  and  stimulating  collaboration  between 
primary and secondary care. 

ARNA Utrecht conference statement, 17 June 2016 
A  final  conference  was  held  to  conclude  the  ARNA  project  and  to  discuss  further 
actions  to  reduce  the  non-prudent  use  of  antibiotics.  A  conference  statement  was 
discussed and agreed which summarises the final conclusions of the ARNA project.  It 
was  agreed  that  there  is  a  need  for  clear  leadership  in  all  EU  Member  States  as  the 
development  and  implementation  of  national  plans  to  combat  AMR,  such  as  the 
national  antibiotic  resistance  plan  in  Spain,  should  be  in  place  before  mid  2017 
according  to  the  WHO.  Better  collaboration  is  also  needed  on  the  local,  national, 
European  and  global  levels.  The  establishment  of  multidisciplinary  professional 
networks,  such  as  Strama  in  Sweden,  Bapcoc  in  Belgium  and  SWAB  in  the 
Netherlands,  create  important  structures  that  support,  coordinate  and  stimulate 
interventions  in  EU  Member  States.  Regarding  the  prudent  use  of  antimicrobials  in 
human  medicine,  multifaceted  approaches  are  needed  that  target  prescribers,  the 
general public and healthcare as a whole. 

There  is  a  need  to  combine  interventions,  such  as  measures  to  restrict  antibiotic 
prescribing,  patient  education  to  improve  health  literacy,  and  multi-  or  inter-
professional  collaboration.  It  is  important  to  recognise  that  the  prudent  use  of 
antimicrobials is the responsibility of all stakeholders. A variety of interventions can be 
taken  on  different  levels  including,  among  others,  the  general  public,  healthcare 
workers, the health system and the EU. This was also discussed with the experts and 
in the six country-dialogue meetings. 

Importantly,  there  were  many  similarities  between  the  conclusions  of  the  conference 
statement,  the  expert  meeting  and  the  six  country-dialogue  meetings.  As  such,  the 
conference  statement  can  be  used  by  EU  Member  States,  as  well  as  stakeholders 
within  each  Member  State,  to  establish  their  own  programmes  to  enhance  more 
prudent use of antibiotics. 

More  information  on  the  ARNA  project  can  be  found  on  the  ARNA  website: 
https://www.nivel.nl/en/arna 

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1. 

Introduction 

This  report  describes  the  results  of  the  ARNA  (‘Antimicrobial  resistance  and 
causes  of  non-prudent  use  of  antibiotics’)  project.  The  ARNA  project  was 
aimed at enhancing the prudent use of antibiotics in the European Union (EU), 
with  an  emphasis  on  the  use  of  antibiotics  without  a  prescription.  The  ARNA 
project  was  carried  out  under  a  contract  with  the  European  Commission’s 
Directorate-General for Health and Food Safety. 

1.1.  Background 

Antimicrobial resistance 
Antimicrobials can be divided into groups based on the organisms that they target, for 
example  antibacterials  which  act  on  bacteria  (commonly  known  as  antibiotics), 
antivirals which act on viruses and antifungals which act on fungi. Although resistance 
to  antifungals  is  increasing,  the  number  of  infections  with  drug-resistant  fungi  is  far 
smaller  than  those  caused  by  antimicrobial-resistant  bacteria (f).  Antibiotics  are  the 
focus of the ARNA project and this report. 

Antimicrobial  resistance  (AMR)  is  defined  as  the  ability  of  an  organism  to  grow  or 
survive  in  the  presence  of  high levels  of  antimicrobials  (antibiotics).  The  existence  of 
AMR in humans is gained either through gene mutation or by the acquisition of genetic 
information from other bacteria though horizontal gene transfer (g). The development 
of  AMR  is  a  natural  phenomenon  in  microorganisms,  and  is  accelerated  by  the 
selection  pressure  exerted  by  the  use  or  misuse  of  antibiotics  in  humans  and 
animals (h).  The  misuse  of  antibiotics  includes  the  use  of  dosages  that  are  either  too 
high  or  too  low  or  the  use  of  the  wrong  type  of  antibiotics  (including  the  use  of 
antibiotics  to  treat  conditions  that  are  not  caused  by  a  bacterial  infection).  The 
development of resistance is a normal evolutionary process for microorganisms, but it 
is  accelerated  by  the  selective  pressure  exerted  by  widespread  use  of  antibiotics.1 
Indeed, the development of each new antibiotic has been followed by the detection of 
resistance.  Until  the  1970s,  many  new  antibiotics  were  developed  to  which  most 
common  pathogens  were  initially  fully  susceptible,  but  the  last  complete  new  classes 
of  antibiotics  were  discovered  during  the  1980s  (Monobactam  and  Daptomycin),  and 
efforts to combat AMR are therefore highly important.1 

Antimicrobial resistance: a public health problem 
Antibiotics are considered to be one of the greatest discoveries of the 20th century, as 
they save millions of lives from once deadly diseases. AMR is an increasing worldwide 
public  health  problem  and  the  WHO  currently  considers  it  to  be  one  of  the  three 
greatest threats to human health for the next decades (i). 

Established  and  newly  emerging  infectious  diseases  are  increasingly  threatening 
people’s health as AMR makes it more difficult to treat bacterial infections effectively.1 
2 3 4 If antibiotics become ineffective, these infections will lead to increased morbidity, 
an  increased  burden  on  healthcare  and,  eventually,  premature  deaths.4  5  The 
economic consequences include loss of productivity and increased costs of diagnostics 

(f)  http://www.jpiamr.eu/document-library/strategicresearchagenda 
(g)  http://www.jpiamr.eu/document-library/strategicresearchagenda 
(h)  http://www.jpiamr.eu/document-library/strategicresearchagenda 
(i)  http://www.jpiamr.eu/document-library/strategicresearchagenda 

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and treatment.2  9 Estimates suggest that, globally, AMR currently leads to the deaths 
of 700 000 people per year.4 This is more than the number of people that currently die 
from cancer.4 In the United States, the yearly cost of AMR to the health system alone 
has  been  estimated  at  USD 21-34 billion,  accompanied  by  more  than  8 million 
additional days  in hospital.10
  For  the  EU,  the  European  Centre  for  Disease  Prevention 
and  Control  (ECDC)  has  estimated  that  AMR  causes  25 000  deaths  annually  and 
results in extra healthcare costs and productivity losses of at least EUR 1.5 billion.5 

The  impact  on  particularly  vulnerable  patients  is  most  obvious.  In  Europe,  an  ageing 
population  and  the  increasing  prevalence  of  conditions  such  as  obesity  and  diabetes 
will contribute to an increase in the number of vulnerable members of society who are 
at  a  higher  risk  of  mortality  and  morbidity  from  infections  which  are  resistant  to 
antibiotics. 

Antimicrobial resistance: public health action 
AMR  is  a  complex  public  health  challenge,  and  no  single  strategy  or  intervention  will 
be  sufficient  to  fully  counter  the  emergence  and  spread  of  infectious  organisms  that 
become resistant to the available antimicrobial drugs.11 Antibiotics have been misused 
both  in  humans  and  animals  because  of  several  factors,  such  as  their  low  cost,  easy 
availability  (OTC  in  some  countries),  poor  understanding  of  their  curative  limits  and 
economic  factors  (the  use  of  antibiotics  as  animal  growth  promoters).  Coordinated 
public  health  actions  need  to  be  taken  in  these  diverse  sectors  of  society  to  address 
and control AMR. 

The WHO is leading efforts to address AMR on a global level. In Europe, public health 
action  is  being  carried  out  by  the  Commission,  ECDC,  EU  Member  States  (e.g.  the 
Joint  Programming  Initiative  on  Antimicrobial  Resistance,  WHO  and  various 
professional bodies (e.g. the European Society for Clinical Microbiology and Infectious 
Diseases and the Pharmaceutical Group of the European Union). The European Union 
has put in place an action plan against AMR for the period 2011-2016. This action plan 
is intended to prevent the spread of microbial infections, ensure the appropriate use of 
antimicrobials and undertake research into effective ways to combat resistance (j). 

Action  to  combat  AMR  needs  to  recognise  that  the  use  of  antimicrobials  and  the 
resulting  patterns  of  AMR  in  human  and  animal  health  are  linked  by  interactions 
through  direct  physical  contact,  the  food  chain  and  the  environment.  Therefore, 
measures  to  combat  the  spread  of  AMR  for  human  health  also  need  to  include 
corresponding  actions  in  the  animal  health  field  and  require  multidisciplinary 
collaboration.  This  is  the  basis  for  the  One  Health  approach  to  action  on  AMR 
recommended  by  WHO  and  followed  by  the  EU.  For  instance,  there  has  been  an  EU-
wide ban on the use of antibiotics as growth promoters since 2006, with veterinarians 
only allowed to use antibiotics to prevent and fight bacterial infections (k). 

The use of antibiotics: a driving force for AMR 
The  global  demand  for  antibiotics  is  rapidly  increasing,  and  a  major  driving  force  for 
AMR is the non-prudent use of antimicrobial agents both in humans and animals.e.g. 2 3 
This  is  partly  as  a  result  of  improved  access  to  life-saving  medicines  because  of 
economic  development  around  the  world  (e.g.  Asia),  but  also  because  antibiotics  are 
used unnecessarily rather than because there is a genuine medical need.4 

(j)  Communication  from  the  Commission  to  the  European  Parliament  and  the  Council  —  Action  plan 

against the rising threats from antimicrobial resistance, COM(2011) 748, 15 November 2011. 

(k)  http://www.jpiamr.eu/document-library/strategicresearchagenda 

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Within the EU, ESAC-Net monitors the use of antibiotics in humans. Figures from this 
surveillance network show large differences in the human consumption of antibiotics.3 
In 2014, the outpatient consumption of antibiotics for systemic use ranged from 10.6 
defined  daily  doses  (DDD)  per  1 000  inhabitants  per  day  in  the  Netherlands  to  34.1 
DDD per 1 000 inhabitants per day in Greece (l). Other Member States with high levels 
of antibiotic use in humans include, for example, Romania, France, Belgium and Italy. 
In  EU  Member  States,  higher  levels  of  AMR  are  generally  observed  where  there  is  a 
higher level of antibiotic use3, suggesting that a reduction in unnecessary consumption 
of antibiotics can have a powerful impact on resistance.4 

Over the last few years, several reports have been published which address measures 
to  reduce  the  consumption  of  antibiotics,  for  example  by  the  OECD2  and  the  AMR 
review  group.4  The  reports  call  for  a  variety  of  policies,  including  global  awareness 
campaigns, increasing financial resources for the infectious diseases healthcare sector, 
the  development  of  new  antibiotics  and  policies  aimed  at  the  reduction  of  antibiotic 
use. 

AMR has been an important public health issue in Europe and was one of the priorities 
of  the  Dutch  Council  Presidency  during  the  first  half  of  2016.  Indeed  the  EU  Member 
States reached an agreement in June 2016 on how to combat AMR (m), which included 
the  requirement  for  each  Member  State  to  have  a  One  Health  action plan  to  address 
AMR in both the human and the veterinary sectors and the need to take measures to 
ensure the prudent use of antibiotics in humans and animals. The Commission-funded 
ARNA project focuses on this last group of measures as it aims to support policies to 
decrease the non-prudent use of antibiotics, with a specific focus on antibiotics without 
a medical prescription. 

The use of antibiotics without a prescription 
Within  the  EU,  a  considerable  proportion  of  all  antibiotics  are  obtained  without  a 
prescription.8  Both  in  2009  and  2013,  data  from  the  Eurobarometer  surveys, 
commissioned  by  the  Commission,12  13  showed  that  5 %  of  all  antibiotics  that  were 
used  in  the  EU  were  obtained  without  a  prescription.  In  2016,  this  percentage 
increased  slightly  to  7 %  (Eurobarometer  data,  2016).  Antibiotic  use  without  a 
prescription is more substantial in some Member States, such as Greece, Romania and 
Cyprus,  where  over  10 %  of  all  antibiotics  that  are  consumed  are  not  issued  by  a 
doctor.12 13 

The use of antibiotics without a prescription has different forms. One is OTC sales by 
pharmacists without a prescription. Although, throughout the whole EU, antibiotics for 
human  use  are  legally  available  only  with  a  prescription  issued  by  a  healthcare 
professional  (Directive  2001/83/EC),  OTC  selling  still  exists  in  some  Member  States 
(see  Chapters 2  to  4  for  more  information).  Other  forms  of  non-prescription  use  are 
the  use  of  leftover  antibiotics  or  buying  through  the  internet.8  The  reason  why  it  is 
important  to  pay  attention  to  the  use  of  antibiotics  without  a  prescription  is  that  it 
represents  a  non-prudent  form  of  antibiotic  use  due  to  a  lack  of  medical  guidance 
accompanying the use.6 Eventually, this can lead to adverse effects and to increasing 
numbers of drug-resistant microorganisms.14 Reducing the use of antibiotics without a 
prescription  to  a  minimal  level  will  contribute  to  the  control  of  bacterial  resistance. 7 
Therefore,  strategies  to  improve  the  prudent  use  of  antibiotics  in  the  EU  and  its 

(l)  http://ecdc.europa.eu/en/eaad/antibiotics-get-informed/antibiotics-resistance-

consumption/Documents/antibiotics-consumption-EU-data-2015.pdf 

(m)  https://www.rijksoverheid.nl/ministeries/ministerie-van-volksgezondheid-welzijn-en-

sport/nieuws/2016/06/17/nauwere-europese-samenwerking-tegen-dure-geneesmiddelen-en-
antibioticaresistentie (lastly read June 21 2016) 

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Member States should include antibiotic use without a prescription. The ARNA project, 
therefore, focuses on this use. 

1.2.  The need to integrate measures 

There  is  a  large  amount  of  variation  between  EU  Member  States  in  the  use  of 
antibiotics,  both  with  and  without  a  prescription.  These  differences  cannot  be 
explained  by  differences  in  morbidity  rates  alone.  Previous  studies  showed  that  the 
differences  between  countries  in  the  use  of  antibiotics  and  other  medicines  are 
determined  by  a  complex  mix  of  factors  on  different  levels.6  15-17  18  19  The  use  of 
medicines,  including  antibiotics,  occurs  within  the  context  of  healthcare  systems  that 
vary  widely  in  how  they  provide  for  the  health  needs  of  individuals,  groups, 
communities  and  wider  society  due  to  differences  in  political,  historical,  cultural  and 
socioeconomic  traditions.  As  a  result,  the  organisational  arrangements  for  healthcare 
differ  considerably  between  EU  Member  States.  Therefore,  policymakers  across  the 
Member  States  may  make  distinctly  different  decisions  regarding  their  own 
population’s  access  to  medicines.  Moreover,  doctors  make  decisions  specific  to  their 
individual  patients  with  regard  to  their  choices  between  treatment  options.  At  the 
same  time,  patients’  behaviour  varies  in  relation  to  how  they  seek  treatment.  As  a 
result, variation in the use of medicines is largely determined by each Member State’s 
healthcare system. 

Variation in the use of prescribed antibiotics was reviewed in an article in  The Lancet 
by Cars et al. in 2001.20 They argued that the large variation they observed in the use 
of  antibiotics  is  unlikely  to  be  caused  by  differences  in  the  frequency  of  bacterial 
infections.  The  authors  concluded  that  the  attitudes  of  physicians  and  patients  to 
antibiotics,  their  historical  backgrounds,  cultural  and  social  factors  and  disparities  in 
healthcare  systems  were  also  important  factors  in  determining  the  antibiotic-
prescribing  patterns  observed.  The  importance  of  cultural  diversity  in  antibiotic 
prescribing  was  also  stressed  in  a  study  by  Deschepper  et  al.  (2008),  who  identified 
several  cultural  aspects  associated  with  antibiotic  use,  such  as  the  relationships 
between  HCPs  and  patients  and  those  between  professionals.17  As  such,  it  has  been 
shown  that  single  causes  of  variation in  the  use  of  antibiotics  with  a  prescription  are 
often difficult to identify, as various elements may play a particular role. 

In  order  to  understand  the  causes  of  certain  patterns  of  antibiotic use,  an integrated 
approach  that  includes  all  relevant  processes  and  regulations  within  a  healthcare 
system is needed. This integrated approach includes all the relevant levels and all the 
actors within those levels. This helps both to understand the use of antibiotics in the 
context  of  the  healthcare  system  and  to  assist  in  the  development  of  good  practices 
and optimal pharmaceutical policies. This probably holds true for the use of antibiotics 
both  with  and  without a  prescription.  The  ARNA  project  therefore  used  an  integrated 
approach in order to attempt to distinguish the levels where factors influence the use 
of antibiotics. These factors can be found on different levels. 

1.  The healthcare-system level, including the cultural background and regulations 
that  focus  on  relevant  processes  and  regulations  within  the  healthcare  setting. 
Examples  of  factors  on  this level include  regulations  that  apply to  the dispensing 
of  antibiotics,  the  enforcement  of  the  law  not  to  dispense  antibiotics  without  a 
prescription, the existence of national guidelines for the use of antibiotics and the 
culture within a country regarding the use of antibiotics. 

2.  The  healthcare-professional  level,  where  the  focus  is  on  the  behaviour  of 
prescribers and pharmacists with regard to prescribing and the OTC dispensing of 
antibiotics.  Factors  that  may  have  an  impact  upon  the  dispensing  of  antibiotics 

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without  a  prescription  may,  for  example,  include  the  knowledge  and  attitudes  of 
pharmacists  towards  antibiotics,  the  willingness  of  GPs  to  prescribe  antibiotics, 
patient pressure and competition with other pharmacies. 

3.  The patient level, with a focus on the behaviour of patients with regard to the use 
of  antibiotics.  Factors  that  may  play  a  role  here  include,  for  example,  the 
knowledge and attitudes of the patient, the costs of the doctor’s consultation and 
the cost of the antibiotics. 

The  ultimate  use  of  antibiotics  without  a  prescription  is  determined  by  the  interplay 
between  different  factors  on  these  three  different  levels.  All  these  levels,  therefore, 
need to be taken into account, not only when studying the use of antibiotics but also 
when  attempting  to  improve  the  prudent  use  of  antibiotics.  The  ARNA  project  uses 
these  three  levels  within  all  its  activities  aimed  at  enhancing  the  prudent  use  of 
antibiotics. 

1.3.  Aims of the ARNA project 

Notwithstanding the studies previously quoted, relatively little attention has been paid 
to  explaining  the  differences  in  the  level  of  use  of  antibiotics  without  a  prescription, 
nor  to  policies  and  measures  that  specifically  target  the  reduction  of  antibiotic  use 
without a prescription. The ARNA project aimed to fill this gap. 

More specifically, the ARNA project aimed to: 
1. 

identify the key factors that drive the sales and non-prudent use of antibiotics in 
human medicine obtained without prescription; 

2.  assess  how  far  the  level  of  enforcement  of  the  legislation  regarding  the 

‘prescription-only’ use of antimicrobial agents within the EU is enforced; 

3.  document good practices aimed at strengthening more prudent use of antibiotics; 
4.  develop policy options for more prudent use of antibiotics. 

To  achieve  these  goals,  a  wide  range  of  activities  were  performed  within  the  ARNA 
project. These activities are listed in the next sections in the report. 

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1.4.  The structure and content of the report 

The structure of the report is described below. After the title of each chapter, we state 
to  which  of  the  four  objectives  in  Section  1.3 it  contributes.  Each  chapter  starts  with 
an introduction, followed by a section in which the methods are described in detail. 

Chapter 2:  The use of antibiotics without a prescription (objective 1) 
A major aim of the ARNA project was to identify factors that drive the sales and non-
prudent use of antibiotics obtained without a prescription. In order to understand the 
factors  that  influence  different  types  of  non-prudent  use  in  EU  Member  States  it  was 
important  to  have  an  overview  of  the  use  of  antibiotics  in  general,  and  the  use  of 
antibiotics  without  a  prescription  in  particular.  Chapter  2  provides  this  overview.  It 
consists of the following elements: 
 

a  summary  of  existing  data  on  antibiotic  use  in  the  EU  Member  States  from  the 
European  Antimicrobial  Resistance  Surveillance  Network  and  the  last  two 
Eurobarometer surveys on the use of antibiotics8 13; 
a  literature  review  of  the  prevalence  of  the  use  of  antibiotics  without  a 
prescription. 

 

Based upon the results in this chapter, seven Member States were selected for further 
in-depth  analyses  (Chapter  4)  and  country-dialogue  meetings.  Here,  policy  options 
these  Member  States  could  use  to  reduce  the  non-prudent  use  of  antibiotics  were 
discussed with policymakers and other relevant stakeholders (Chapter 6) (n). 

Chapter  3:  Explaining  differences  in  the  non-prescription  use  of  antibiotics 
across the EU (objectives 1/2) 
Chapter  3  provides  insight  into  the  factors  that  drive  the  use  of  antibiotics  without a 
prescription. The following methods were used: 
 

a  literature  review  of  the  determinants  on  the  population,  HCP  and  healthcare-
system levels of the use of antibiotics without a prescription; 
an analysis of the 2013  Eurobarometer survey  — these data enabled us to study 
the determinants for all 28 EU Member States in one analysis; 
an  online  survey  among  ministries  of  health/national  experts  to  describe  the 
differences  in  policies  taken  by  Member  States  on  a  healthcare-system  level  to 
enhance the prudent use of antibiotics. 

 

 

Chapter 4: The use of antibiotics  without  a prescription  in  seven EU Member 
States (objective 1) 
In some Member States the level of antibiotic use without a prescription is higher than 
in  others.  In  Chapter  2,  seven  Member  States  were  selected  that  have  a  relatively 
high  level  of  non-prescription  use  of  antibiotics  (Cyprus,  Estonia,  Greece,  Hungary, 
Italy, Romania and Spain). For these seven Member States, more detailed insight into 
the  nature  of  their  antibiotic  use  was  obtained  through  surveys  where  patients  who 
used  antibiotics  without  a  prescription  were  interviewed,  along  with  GPs  and 
pharmacists. 

Chapter 5: Good practices in the EU (objective 3) 
Documenting good practices aimed at reducing the non-prudent use of antibiotics was 
another  major  aim  of  the  ARNA  project.  The  following  methods  were  used  to  collect 
information on good practices: 
 

a literature review of good practices such as policy measures or interventions; 

(n)  For the country-dialogue meetings six out these seven Member States were selected. 

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20 

 
 
 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

 

an online survey among ministries of health/national experts (see also Chapter 3) 
to  collect  information  on  measures  and  interventions  not  described  in  the 
literature. 

Chapter  6:  Expert  opinions  and  a  consensus  statement  on  policy  options  to 
reduce the use in the EU of antibiotics without a prescription(objective 4) 
Chapter 6 is the first of three chapters that focus on the development of policy options 
for more prudent use of antibiotics. It describes the results of a meeting with a group 
of  20  experts  from  nine  EU  Member  States  and  two  non-EU  countries.  The  experts 
reviewed  and  discussed  interventions  that  Member  States  could  potentially  use  to 
reduce the non-prudent use of antibiotics. The  results from this expert meeting were 
used as important input for meetings in the seven selected Member States, showing a 
relatively high level of antibiotic use without a prescription (see chapter 2). 

Chapter  7:  Towards  approaches  to  enhance  more  prudent  use  in  six  EU 
Member States (objective 4) 
As a part of the ARNA project, country-dialogue meetings were held in six of the seven 
Member  States  on  which  an  in-depth  analysis  was  performed  —  see  Chapter  4 
(Cyprus,  Greece,  Hungary,  Italy,  Romania  and  Spain) (o).  These  meetings  were 
organised  using  local  people  participating  in  decision-making  about  the  strategy  and 
taking a lead in the selection of the priorities to be pursued in their respective Member 
States.  The  participants  were  representatives  of  all  relevant  stakeholders  who  were 
invited  by  the  local  organiser,  thus  ensuring  a  bottom-up  approach.  The  ARNA  team 
supported  the  local  organisers  by  providing  data,  part  of  which  were  specific  to  their 
Member  State,  from  the  ARNA  study  (Chapters  2  to  4)  and  also  suggestions  for 
policies  that  resulted  from  the  literature  review  (Chapter  5)  and  the  expert  meeting 
(Chapter 6). 

Chapter 8: Consensus statement on the prudent use of antibiotics (objective 4) 
An  international  conference  was  held  to  discuss  the  results  of  the  project  and  to 
conclude the ARNA project with an overview of actions. Sixty participants representing 
21  Member  States  attended.  The  main  conclusions  and  recommendations  were 
summarised  in  the  ARNA  Utrecht  conference  statement  on  the  prudent  use  of 
antibiotics, which is included in Chapter 8. 

Chapter  9:  Conclusion  and  discussion  on  the  use  of  antibiotics  without  a 
prescription 
The final chapter draws the overall conclusions of the ARNA project regarding the use 
of antibiotics without a prescription and discusses the findings. 

(o)  There was no country-dialogue meeting held in Estonia as there were far fewer problems with the use 

of non-prescribed antibiotics than was anticipated. 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

2.  The use of antibiotics in the EU 

Main findings 

 

 

 

 

 

 

 

Large variations in antibiotic use are observed within the EU, in use both with and without a 
prescription. There is a positive, but moderate, association between the amount of 
prescription use and the amount of non-prescription use of antibiotics at the country level. 
The Netherlands is the Member State with lowest antibiotic use with a prescription (in 
2014); Greece has the highest use. 
In the Eurobarometer surveys (2013, 2016), Greece, Romania and Cyprus are the three 
Member States where patients most frequently report the use of antibiotics without a 
prescription. Other Member States with high levels of antibiotic use without a prescription 
include Italy, Lithuania, Malta and Spain (results from the literature). 
Buying OTC from a pharmacy is the prevailing source of obtaining an antibiotic without a 
prescription, followed by the use of pills left over when a course was not completed. 
Greek and Spanish studies show that the majority of pharmacists are willing to sell 
antibiotics OTC. 
Non-prescription use of antibiotics most frequently occurs when treating upper or lower 
respiratory tract infections. 
Although OTC selling through the internet is a much debated topic, no EU studies were 
found that addressed this topic. 

2.1.  Introduction 

A major aim of the ARNA project was to assess the non-prudent use of antibiotics in 
the  EU  and  to  identify  factors  that  drive  the  sales  and  the  non-prudent  use  of 
antibiotics  obtained  without  a  prescription.  Non-prescription  use  of  antibiotics  occurs 
in  various  ways,  such  as  OTC  sales  without  a  prescription,  the  use  of  pills  left  over 
when  a  course  was  not  completed  or  antibiotics  obtained  through  the  internet.6  In 
order to understand the factors that influence different types of non-prudent use in EU 
Member States (see Chapters 3 and 4), it is important to have an overview of the use 
of antibiotics in general and the use of non-prescription antibiotics in particular. 

In recent years, numerous data have repeatedly been collected on antibiotic use in the 
EU, for example through the ECDC’s ESAC-Net (outpatient consumption data) and the 
Eurobarometer  survey.  The  Eurobarometer  data  include  information  on  self-reported 
non-prescription  use  of  antibiotics.  The  scientific  literature  is  another  source  for 
information  on  non-prescription  use  of  antibiotics.  Thus,  two  different  data  sources 
were used to analyse and describe the use of antibiotics: 
1.  existing data on prescription and non-prescription use (Section 2.2); 
2.  scientific literature (Section 2.3). 

The selection of Member States for the in-depth analysis in Chapter 4 was made based 
upon  the  figures  in  this  chapter.  This  chapter  thus  sets  the  scene  with  regard  to  the 
frequency of antibiotic use across the EU as a basis for the chapters that follow. 

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2.2.  Antibiotic consumption rates in the EU 

2.2.1.  

Methods 

The following databases were used to describe antibiotic consumption across the EU. 

1.  European Surveillance of Antimicrobial Consumption Network (ESAC-Net). 
Data on the use of antibiotics in the community within the EU have been collected by 
the ECDC’s ESAC-Net. These data are publicly available through the ECDC website (p). 
The  data  sources  for  ESAC-Net  are  national  sales  and  reimbursement  data,  including 
information from national drug registries. It should be noted that Romania and Cyprus 
provided  data  including  both  the  outpatient  and  the  hospital  sector.  Spanish  data 
included  reimbursement  data  rather  than  whole  sales  data.  This  means  that  the  use 
without a prescription and of other non-reimbursed courses of antibiotics in Spain was 
not included. 

2.  Eurobarometer survey data (q). 
Eurobarometer  data  available  to  the  public  were  retrieved  through  Gesis.2  These 
included  self-reported  data  collected  by  a  questionnaire.  The  retained  variables 
included  those  relating  to  ‘reported  actual  self-medication  with  antibiotics  during  the 
last  year’.  The  Eurobarometer  survey  has  run  since  the  1970s.  The  mission  of 
Eurobarometer is to monitor public opinion in the EU.  Each  year a survey is  made  of 
citizens of EU Member  States, and as such the Eurobarometer constitutes a repeated 
cross-sectional  design.  Each  year  a  multistage,  random  sample  is  taken.  Firstly,  a 
random selection of sampling points or areas is taken after stratification for the type of 
area (metropolitan, urban and rural areas) (r). Next, a cluster of addresses is selected 
from  an  area  chosen  using  standard  random  route  procedures,  beginning  with  an 
initial  randomly  selected  address.  Finally,  one  member  from  each  of  the  households 
living  at  these  addresses  is  selected  by  a  random  procedure  (e.g.  the  first-birthday 
method).  Only  one  person  is  interviewed  in  each  household.  Questionnaires  are 
developed  in  English  and  French  and  translated  into  the  other  relevant  languages 
using  the  principle  of  back-translation  by  independent  translators.  Interviews  take 
place at the respondents’ homes. The Eurobarometer studies are run and coordinated 
by TNS opinion®. 

There  are  special  topics  in  addition  to  the  standard  questionnaire  modules  in  the 
Eurobarometer. One of these special topics is AMR. Data about AMR were collected in 
2009, 2013 and 2016.  In this report, data from 2013 and 2016 are  used.  Data were 
collected through interviews in all 28 Member States. Table 2.1 shows the number of 
respondents  per  Member  State  in  2013  and  2016.  In  this  chapter,  data  are  included 
from  questions  on  whether  or  not  the  respondent  used  antibiotics,  and  if  so  whether 
this  was  on  prescription  or  not.  In  case  a  respondent  used  an  antibiotic  without  a 
prescription, the source from which this antibiotic was obtained was asked for. 

(p)  http://ecdc.europa.eu/en/eaad/antibiotics-get-informed/antibiotics-resistance-

consumption/Pages/data-reports.aspx 

(q)

https://dbk.gesis.org/dbksearch/SDesc2.asp?ll=10&notabs=&af=&nf=&search=&search2=&db=E&

no=5852 

(r)  http://www.gesis.org/eurobarometer-data-service/survey-series/standard-special-eb/sampling-and-

fieldwork/ 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 2.1.  Number of respondents participating in the Eurobarometer survey on 

AMR in 2013 and 2016 by EU Member State (absolute numbers). 
(Source: Eurobarometer surveys.8 13) 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czech Republic 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Ireland 

Italy 

Latvia 

Lithuania 

Luxembourg 

Malta 

Netherlands 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

United Kingdom 

Total number of respondents in 
2013 

Total number of respondents in 
2016 

1 034 

1 006 

1 025 

1 000 

506 

1 026 

1 010 

1 008 

1 003 

1 053 

1 505 

1 002 

1 033 

1 001 

1 025 

1 018 

1 023 

502 

500 

1 013 

1 000 

1 007 

1 053 

1 000 

1 005 

1 008 

1 000 

1 314 

1 011 

1 007 

1 040 

1 057 

500 

1 047 

1 010 

1 004 

1 008 

1 045 

1 563 

1 008 

1 058 

1 016 

1 033 

1 032 

998 

501 

501 

1 041 

1 015 

1 010 

1 014 

1 038 

994 

1 053 

1 035 

1 330 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Data analyses 

ESAC-Net data 
The data on antibiotic consumption in the community are presented for 2014 (s). Two 
indicators are presented. 
  The  number  of  DDD  per  1 000  inhabitants  per  day  based  on  the  anatomical 
therapeutic  chemical  (ATC)  classification  and  the  DDD  measurement  unit (t) 
(Figure  2.1).  This  indicator  takes  into  account  the  number  of  antibiotic  doses 
consumed and its potential ecological effect on the development of AMR. 

  The number of packages per 1 000 inhabitants dispensed per day according to the 
ATC  classification  (Figure  2.2).  This  indicator  does  not  take  into  account  dosage 
information. It is a good proxy for the number of antibiotic treatment courses. 

Eurobarometer data 
Descriptive analyses as reported in the 2013 and 2016 Eurobarometer reports on AMR 
are presented.8 21 These include: 
 
 

the percentage of respondents using an antibiotic in 2013 and 2016; 
the percentage of respondents using the antibiotic with or without a prescription in 
2013 and 2016; 
the percentage of respondents using non-prescription oral antibiotics in 2013 and 
2016, divided by the source from which the antibiotic was obtained. 

 

respondents 

Combined analysis of ESAC-net and Eurobarometer data 
Outpatient  antibiotic  consumption  data,  expressed  in  DDD  per  1 000  inhabitants  per 
day,  for  2013  were  linked  to  the  2013  Eurobarometer  data.  The  average  proportion 
(percentage)  of 
taking  an  antibiotic  without  a  prescription 
(Eurobarometer  data)  was  calculated  as  the  sum  of  the  number  of  respondents  who 
reported  having  obtained  antibiotics  as  follows:  (1)  without  a  prescription  from  a 
pharmacy;  (2)  without  a  prescription  from  elsewhere;  (3)  left  over  from  a  previous 
course;  or  (4)  do  not  remember  spontaneously.  This  is  then  divided  by  the  total 
number  of  respondents  who  have  taken  an  oral  antibiotic  during the last  12  months. 
This ratio is expressed as a percentage (per 100 respondents) by country. 

2.2.2.  

Antibiotic consumption 

Antibiotic consumption in the community: ESAC-Net data 

DDD/1 000 inhabitants/day 
The ESAC data include antibiotic consumption in the community. Figure 2.1 shows that 
the Netherlands had the lowest consumption in 2014 (10.6 DDD/1 000 
inhabitants/day) and Greece the highest (34.1 DDD/1 000 inhabitants/day). This 
indicates a 3.2-fold difference between the Netherlands and Greece. The five Member 
States with the highest levels of outpatient antibiotic consumption includes Greece, 
Romania, France, Belgium and Italy. 

(s)  http://ecdc.europa.eu/en/eaad/antibiotics-get-informed/antibiotics-resistance-

consumption/Pages/data-reports.aspx 

(t)  ATC 

classification 

system:  Guidelines 

for  ATC 

classification 

and  DDD 

assignment. 

http://www.whocc.no/ 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Figure 2.1.  Consumption of antibiotics for systemic use in the community by 

antibiotic group in EU Member States, 2014 (expressed in DDD per 
1 000 inhabitants per day). (Source: ESAC-Net.) 

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26 

 
 
 
 
 
 
 
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Packages per 1 000 inhabitants per day 
The EU mean of the number of packages dispensed per day amounts to 3.0 packages 
per  1 000  inhabitants (u).  The  median  (2.0  packages/1 000  inhabitants/day)  is  much 
lower  than  the  mean,  indicating  that  there  are  a  few  countries  where  the  use  is 
substantially above the arithmetic mean of the European Union. Figure 2.2 shows that 
the three Member States where the most packages are dispensed include France (4.6 
packages/1 000  inhabitants/day),  Italy  (3.7  packages/1 000  inhabitants/day)  and 
Greece (3.6 packages/1 000 inhabitants/day). 

Figure 2.2.  Antibiotic consumption in the community for systemic use in 21 EU 
Member States, 2014 (expressed in packages per 1 000 inhabitants per 
day). (Source: ESAC-Net.) 

(u)  Romania  and  Cyprus  reported  data  for  the  total  care  sector  and  could,  therefore,  not  report  data  on 
the  package  level  (in  the  hospital  sector  consumption  is  often  reported  by  units  because  of  its 
parenteral use (e.g. vials). Nor could other EU Member States provide data on this indicator. 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Eurobarometer data 

Respondents who used an antibiotic 
Both in 2013 and 2016, about 35 % of EU inhabitants who were interviewed reported 
using  at  least  one  oral  antibiotic  during  the  last  12  months.8  The  observed  variation 
between  EU  Member  States  is  considerable,  reflecting  the  same  variation  as  shown 
with  the  outpatient  antibiotic  consumption  data  from  ESAC-Net.  In  2016,  a  2.7-fold 
difference  in  use  was  found  between  Sweden,  the  Member  State  with  the  lowest 
proportion  of  people  who  reported  taking  at  least  one  antibiotic  (18 %),  and  Malta, 
with  the  highest  proportion  of  people  (48 %)  (Figure  2.3).  This  difference  is  higher 
than  in  2013  when  a  twofold  difference  between  Malta  (highest  use,  48 %)  and 
Sweden (lowest use, 24 %) was observed. 

The  percentage  of  respondents  who  reported  using  an  antibiotic  in  2016  was  lower 
compared to 2013 in 15 Member States: Belgium, Cyprus, Denmark, Finland, France, 
Germany,  Latvia,  Lithuania,  Luxembourg,  the  Netherlands,  Portugal,  Romania, 
Slovenia,  Sweden  and  the  United  Kingdom.  However,  there  are  also  six  Member 
States  for  which  an  increase  of  at  least  2 %  in  the  number  of  respondents  who 
reported  having  used  an  antibiotic  was  observed:  Bulgaria,  Greece,  Hungary,  Italy, 
Poland and Spain. The largest increase was observed for Spain (+ 9 %), Italy (+ 7 %) 
and Hungary (+ 5 %).  Decreases in the number  of respondents  who  reported having 
used an antibiotic were, for example, found for Romania (– 9 %) and Cyprus (– 6 %). 

Figure 2.3.  Percentage  of  respondents  who  reported  having  taken  at  least  one 
antibiotic over the last 12 months in 2013 and 2016 for the EU Member 
States (percentages). (Source: Eurobarometer, 2013 and 2016.) 

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28 

 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Respondents who used prescribed antibiotics 
The Eurobarometer data also include self-reported information on patients’ sources of 
antibiotics.  Figure  2.4  shows  the  percentage  of  patients  who  reported  that  the 
antibiotics that they took were prescribed, expressed as a percentage of all those who 
used  an  antibiotic (v).  In  all  EU  Member  States,  the  vast  majority  of  antibiotics  were 
obtained with a prescription. And yet, differences between Member States can still be 
observed.  In Greece, 79 %  of  respondents reported that the antibiotics used in 2016 
were  prescribed,  while  in  Sweden  this  figure  was  98 %  in  both  2013  and  2016. 
Member  States  other  than  Greece  with  relatively  low  levels  of  prescribed  antibiotics 
included Romania, Cyprus and Latvia. There was a slight decrease in the percentage of 
respondents  who  had  obtained  antibiotics  without  a  prescription.  In  the  2016 
Eurobarometer report it was stated that these changes were likely caused by a slight 
change in the way the question was asked (w). 

Figure 2.4.  Percentage  of  users  of  an  antibiotic  over  the  last  12  months  who 
reported  having  obtained  their  medication  with  a  prescription  in  2013 
and  2016  for  the  28  EU  Member  States  (percentages).  (Source: 
Eurobarometer, 2013 and 2016.) 

(v)  Figures on non-prescription use can be found in the next section. 
(w)  Literal text from report: ‘In the 2016 survey, the order of the first four response options was rotated, 
whereas  in  2013  the  order  was  kept  constant.  This  is  likely  to  have  affected  the  proportions  giving 
individual answers. When examining changes since 2013, the analysis therefore focuses on change for 
combined  responses,  based  on  two  groupings:  “from  a  medical  practitioner”  (either  “from  a  medical 
prescription”  or  “administered  by  a  medical  practitioner”)  and  “not  from  a  medical  practitioner”  (all 
other sources).’ 

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29 

 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Use of antibiotics without a prescription 

2.2.3.  
The Eurobarometer provides additional information on the use of antibiotics without a 
medical prescription (x). There is a wide variation between Member States in the self-
reported use of non-prescription antibiotics. The highest use can be found in Romania 
(in 2013, 20 % of all users of an antibiotic in the last 12 months used non-prescription 
antibiotics;  in  2016,  16 %)  and  Greece  (in  2013,  16 %;  in  2016,  20 %).  For  the 
following  Member  States  an  increase  in  the  use  of  antibiotics  without  a  prescription 
between  2013  and  2016  was  observed:  Bulgaria,  Cyprus,  Croatia,  Finland,  Germany, 
Latvia, Lithuania, and Poland.8 

Both the 2013 and 2016 Eurobarometer surveys also contain self-reported information 
about  how  non-prescription  oral  antibiotics  were  obtained,  firstly  from  a  pharmacy, 
secondly from elsewhere or thirdly where the respondent had some pills left over from 
a previous course (see Figure 2.5). In most Member States with a relatively high level 
of  use  of  antibiotics  without  a  prescription,  the  prevailing  source  for  obtaining 
antibiotics was the pharmacy. This group of Member States includes Bulgaria, Croatia, 
Cyprus, Estonia, Greece, Hungary, Ireland (2013), Latvia (2016), Portugal (2016) and 
Romania. This implies that allowing OTC sales or not enforcing the law on OTC sales of 
antibiotics  is  a  major  driver  for  the  use  of  antibiotics  without  a  prescription.  Also,  in 
the United Kingdom, although it has a lower use of antibiotics without a prescription, 
OTC sales are the main source. Although the Eurobarometer asks for oral antibiotics, 
respondents who used, for example, eye drops, which are freely available in a number 
of  Member  States,  such  as  the  United  Kingdom,  may  have  answered  they  used  an 
antibiotic without a prescription. It is not clear to what extent respondents could have 
included  topical  use  of  antibiotics,  which  could  have  distorted  the  results  obtained. 
This  may  apply  to  the  results  from  Denmark,  where  a  high  proportion  of  non-
prescription use obtained without a prescription is classified as ‘from elsewhere’. Also, 
in  Lithuania  the  proportion  of  antibiotics  obtained  without  a  prescription  from 
elsewhere is higher than in other Member States. As the Eurobarometer reports do not 
specify  what  these  other  sources  are,  it  is  hard  to  elaborate  on  the  reasons  why 
Denmark and Lithuania have higher percentages than other Member States. 

There  are  also  Member  States  where  the  use  of  leftover  antibiotics  contribute  to  the 
use of antibiotics without a prescription. A  Member State with a relatively high use in 
2013 where leftover antibiotics contributed more to the non-prescription of antibiotics 
is  Spain.  This  is  in  line  with  data  suggesting  that  fewer  antibiotic  treatments  or 
prescriptions  have  been  issued  but  at  higher  doses  (see  ESAC-Net  results;  the 
difference  in  the  two  indicators:  number  of  DDD/1 000  inhabitants/day  and  the 
number of packages/1 000 inhabitants/day). These figures are also consistent with the 
possibility that Spanish patients often do not finish their antibiotic courses, resulting in 
antibiotic  medication  remaining  that  can  be  consumed  at  a  later  time.  A  similar 
pattern,  where  the  use  of  leftover  antibiotics  is  the  prevailing  source  of  non-
prescription  use,  is  also  seen  in  Italy  and  several  other  Member  States  (e.g.  Austria, 
Slovakia, the Netherlands). 

(x)  2013 

Eurobarometer 

data: 

https://dbk.gesis.org; 

http://ec.europa.eu/dgs/health_food-

safety/amr/docs/eb445_amr_generalreport_en.pdf 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Figure 2.5.  Percentage  of  non-prescription  oral  antibiotics  broken  down  by  the 
means  by  which  respondents  obtained  the  antibiotic  for  the  28  EU 
Member  States  in  2013  and  2016  (percentage  of  all  respondents  who 
reported  having  used  an  oral  antibiotic  during  the  last  12  months). 
(Source: 2013 and 2016 Eurobarometer surveys.) 

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31 

 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

2.3.  Comparison of prescription and non-prescription use 

A  comparison  of  the  outpatient  antibiotic  consumption  (ESAC-Net  data)  and 
the  self-reported  use  of  antibiotics  without  a  prescription  (Eurobarometer 
data) 
A  pertinent  question  concerns  what  relationships  there  may  be  between  prescription 
use and non-prescription use of antibiotics. One possible assumption is that the use of 
non-prescription  antibiotics  might  be  higher  in  Member  States  with  a  low  use  of 
prescribed antibiotics because citizens might turn to other sources than a prescription. 
However, another assumption might be that in Member States where many antibiotics 
are prescribed there is a more positive attitude towards antibiotic use in general. This 
would  then  result  in  a  high  level  of  both  prescription  and  non-prescription  use. 
Knowledge of the patterns of antibiotic use in a country may therefore be relevant to 
developing policies to combat non-prudent use. 

Figure  2.6  reports  overall  volumes  of  outpatient  antibiotic  consumption  expressed  in 
DDD/1 000  inhabitants/day  for  the  year  2013  next  to  the  percentage  of  respondents 
who  reported  the  use  of  an  antibiotic  without  a  prescription  for  the  same  year 
(Eurobarometer  data).  The  highest  percentages  of  respondents  who  reported  having 
used  an  antibiotic  without  a  prescription  during  the  last  12  months  in  relation  to 
overall  outpatient  antibiotic  consumption  were  observed  for  Greece  (16 %)  and 
Romania (20 %). Greece and Romania also belong to the group of Member States with 
higher  volumes  of  outpatient  antibiotic  consumption  (expressed  in  DDD/1 000 
inhabitants/day; see Figures 2.1 and 2.6). 

However,  both  in  Member  States  with  low  volumes  of  outpatient  antibiotic 
consumption  (the  Netherlands,  Sweden,  Slovenia)  and in  those  with  high  volumes  of 
outpatient antibiotic consumption (France, Luxembourg), there are fewer than 5 % of 
all antibiotic users who reported having used an antibiotic without a prescription in the 
previous  12  months.  Further  statistical  analyses  showed  a  positive linear  relationship 
between  the  number  of  respondents  who  reported  using  an  antibiotic  without  a 
prescription  during  the  last  12  months  (2013  Eurobarometer  data)  and  the  2013 
volumes  of  outpatient antibiotic consumption (ESAC-Net data, 2013).  These analyses 
showed  a  correlation  coefficient  of  r = 0.36  (Spearman’s  correlation:  significant  at 
p < 0.05)  and  an  r-squared  of  0.13  (Figure  2.6).  This  means  that  there  is  a  positive 
association  between  the  amount  of  prescription  use  and  non-prescription  use  of 
antibiotics at the Member State level. However, the association is moderate. 

April 2017  

32 

 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Figure 2.6.  Amount of outpatient antibiotic consumption expressed in DDD/1 000 

inhabitants/day (source: 2013 ESAC-Net data) in relation to the 
percentage of respondents who reported having taken an oral antibiotic 
obtained without a prescription in the previous 12 months. (Source: 
2013 Eurobarometer data.) 

of 

Percent-
age 
respond-
ents  who 
reported 
having 
taken  an 
oral 
antibiotic 
obtained 
without a 
prescrip-
tion 
the 
previous 
12 
months 

in 

Amount  of outpatient antibiotic consumption expressed in DDD/1 000 inhabitants/day 

2.4.  A literature survey of antibiotic use without a prescription 

A literature survey was conducted to explore further the volume and nature of the use 
of antibiotics without a prescription both within the EU and in other Western countries. 
While the Eurobarometer data only include information on the use by patients, in the 
literature review other perspectives, such as that of the pharmacist, were explored as 
well. 

2.4.1.  

Methods 

Search strategy 
A comprehensive literature search was conducted in the scientific electronic databases 
PubMed,  Scopus  and  Embase  for  studies  published  from  January  2000  to  September 
2014.  There  was  no  limitation  on  the  language.  In  addition,  the  electronic  searches 
were supplemented by manual searches of the reference lists and citation tracking of 
articles that were selected on the basis of their relevance (see below). 

The  search  string  included  the  following  search  terms  and  their  equivalents: 
antibacterial  agents,  drug  resistance  or  antibiotic;  non-prescription,  over-the-counter 
or self-medication; and Europe, Anglo-Saxon countries or other Western or European 
countries.  Suitable  search  strategies  were  developed  for  Scopus  and  Embase,  using 
adaptations  of  the  PubMed  search  string.  The  following  search  terms  were  used  for 

April 2017  

33 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

exclusion  of  publications:  animal  use,  plant  and  agricultural  use,  hospital  use  and 
other countries. 
Relevant  websites  were  searched  in  order  to  cover  relevant  grey  literature  including 
those  of  the  ministries  of  health  of  EU  Member  States,  national  regulatory  offices, 
public  health  institutes  and  EU  websites.  Search  terms  that  were  used  included  the 
following: self-medication, over-the-counter use, antibiotics and antimicrobial agents. 
Documents  were  searched  for  the  2000-2014  period.  The  search  terms  were 
translated into each Member State’s national official language or languages. 

Selection criteria 
A publication was selected if it met all of the following criteria: (1) the publication has 
as one of its main subjects use of antibiotics without a prescription; (2) the publication 
addresses  the  volume  and  nature  of  use  and/or  determinants  of  OTC  use  of 
antibiotics (y);  (3)  the  publication  addresses  OTC  use  of  antibiotics  within  the 
geographical context of at least one EU Member State or other Western, European or 
Anglo-Saxon country; (4) the publication is robust, in either a professional or scholarly 
manner,  in  that  it  is  a  scientifically  peer-reviewed  study  or  a  publication  from  a 
government  or  professional  association;  and  (5)  the  publication  was  published 
between 2000 and 2014. The following types of articles were excluded: any paper that 
focused  on  antibiotics  in  animals,  antibiotics  used  for  plant  agriculture  or  antibiotics 
used in hospital settings; and papers about studies in other countries. 

Data synthesis and analysis 
The titles of the hits retrieved through the search were each screened by two authors 
(a  combination  of  either  DL,  JP  and  LvD).  This  was  followed  by  a  screening  of  the 
remaining abstracts by the same authors. Disagreements were resolved by discussion 
between the two reviewers. Full texts were judged by one author (DL), who consulted 
one of the other authors (LvD) if there were doubts about whether or not to include a 
publication.  One  author  (DL)  then  extracted  data  from  the  publications  included  and 
one other author (LvD) checked the data that were extracted. For each study included 
in the review (n= 59), the following general items of information were extracted from 
the  papers:  first  author,  year  of  publication,  country,  focus  of  the  publication, 
population,  sample  size,  antibiotics  consumed,  source  of  antibiotics,  symptoms  for 
which the drugs were used and volume of use. 

Search results and study characteristics 

2.4.2.  
The  search  in  the  electronic  databases  resulted  in  2 678  hits  (1 624  hits  in  PubMed, 
806 in Scopus, 248 in Embase). Of these, 2 456 hits were unique. Screening of titles 
resulted  in  a  total  of  638  potentially  relevant  articles.  Subsequent  screening  of  the 
corresponding  abstracts  yielded  100  abstracts  that  were  potentially  relevant  for  this 
study. From these 100 publications, the full texts were obtained. Finally, after reading 
the full text, 45 articles were included in the review. By using the snowball method, 30 
additional  articles  were  included  for  full-text  analyses.  Of  these,  14  were  included  in 
this  review,  which  resulted  in  a  total  of  59  articles  (Figure  2.7).  These  publications 
were published in 42 different journals. 

(y)  A  combined  search  was  performed  for  the  literature  review  on  the  volume  and  nature  of  non-
prescription  use  (this  chapter)  and  for  the  literature  review  on  determinants  of  off-label  use 
(Chapter 3). 

April 2017  

34 

 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

were 

from: 

The  grey  literature  search  resulted  in  nine  possibly  relevant  documents.  The 
documents 
Italy 
Sweden 
Spain 
(http://www.agenziafarmaco.it), 
(http://www.folkhalsomyndigheten.se/about-folkhalsomyndigheten-the-public-health-
agency-of-sweden),  the  United  Kingdom  (http://dh.gov.uk)  and  the  United  States 
(http://www.cdc.gov).  However,  after  translating  and  reading  the  texts,  none  of  the 
articles  were  included  in  the  literature  review  as  they  did  not  provide  any  usable 
information about self-medication with antibiotics. 

(http://www.msc.es), 

(http://www.rki.de), 

Germany 

Figure 2.7.  Flow diagram of the study selection process. 

2 678  citations  identified  through 
Pubmed,  Scopus  and  Embase 
database searching 

2 456 
removed 

records  after  duplicates 

2 456 records screened on title 

1 818 records excluded 

700 records screened on abstract 

538 records excluded 

130  articles  selected  for  full  text 
analyses 
from 
snowball method) 

articles 

(30 

9  articles  from  the  grey  literature 
search 

62  articles  via 
method 

the  snowball 

Extracted data from 59 articles 
(14 
method) 

articles 

from 

snowball 

59  records  excluded 
records of the databases  
16  records  excluded 
records of the snowball method 

from  the 

from  the 

Countries and perspective 
Table  2.2  shows  in  which  countries  the  studies  included  were  performed.  Within  the 
EU, most studies were performed in Spain (n = 12), followed by Greece (n = 6). Nine 
studies  included  multiple  countries,  mostly  spread  across  Europe.  Outside  of  the  EU, 
most  studies  were  found  from  the  United  States  (n = 13).  Most  studies  used  the 
patient  perspective,  meaning  that  data  were  collected  on  patient  behaviour  and 
perceptions  on  the  use  of  antibiotics  without  a  prescription,  followed  by  studies  from 
the pharmacist’s perspective. 

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35 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 2.2.  Countries  in  which  studies  were  performed  and  the  perspectives  which 
were  used;  literature  review  regarding  the  volume  and  nature  of 
antibiotic use without a prescription (n = 59 publications). 
Other 
(n = 2) 

Country 

Total 

Patient’s 
perspective 
(n = 47) 

Pharmacist’s 
perspective 
(n = 10) 

Croatia 
Czech Republic 
Greece 
Denmark 
Hungary 
Italy 
Lithuania 
Malta 
Poland 
Romania 
Spain 
Sweden 
United Kingdom 

Multiple Western countries 

Other  countries 
Former Yugoslav Republic of 
Macedonia 
United States of America 
Russia 
New Zealand 
Serbia 

1 
1 
4 
1 

2 
1 
1 
2 
2 
7 
1 
2 

8 

2 

11 
1 

2 

1 

5 

1 

1 
1 

1 

1 

1 
1 
6 
1 
2 
2 
1 
1 
2 
2 
12 
1 
2 

8 

1 

13 
1 
1 
1 

Design 
The vast majority of the 47 articles that analysed data from the patient’s perspective 
used  a  quantitative  cross-sectional  design.  Three  articles  used  a  qualitative  design. 
The  10  studies  from  a  pharmacist’s/pharmacy’s  perspective  used  a  variety  of 
methods:  cross-sectional  studies,  semi-structured  interviews  and  prospective  studies 
to examine how easy it is to obtain antibiotics at a pharmacy (z). 

Study population 
Table 2.3 describes the patient populations in the included studies. It shows that most 
studies focused on adults (43 out of 47 studies). Most studies focused on the general 
adult population. However, a substantial number of studies included a specific group, 
such  as  immigrants  (n = 9).  These  were  mainly  studies  on  immigrants  to  the  United 
States  from  Latin  American  countries.  Other  studies  focused  on  visitors  to  the 
pharmacy or female heads of households. Three studies included children and another 
seven  chose  parents  of  children  —  in  different  age  categories  —  as  their  study 
population.  The  studies  from  the  pharmacist  perspective  all  included  community 
pharmacists  (data  not  in  table).  The  studies  clearly  included  a  wide  variety  of  study 
populations, making it hard to compare results as they refer to different populations in 
different contexts. 

(z)  Two studies used a different perspective (the internet). 

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36 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 2.3.  Study  populations’  characteristics 

in  47  studies  with  a  patient 
perspective  included  in  the  literature  review  regarding  the  volume  and 
nature of antibiotic use without a prescription. 

Adults 
Total,  
including the following specific groups: 
 migrants 
 visitors of pharmacies who wanted an antibiotic 
 housewives/female heads of family 
 students 
 other specific groups 
Children and their parents 
Total children themselves, 
including the following categories: 
 10-17 years 
 visiting emergency department 
 unknown 

Number of studies* 
43** 

9 
3 
2 
2 
8 
Number of studies 
3 

1 
1 
1 

Total parents of children, 
including the following age categories: 
 0-4 years 
 0-12 years 
 0-16 years 
 0-18 years 
 5-18 years 
 15-17 years 
* Some studies included both adults and children. 
** Some studies were on adults in general, other studies included specific patient groups. 

1 
2 
1 
1 
1 
1 

7 

Outcome measures 
The  use  of  antibiotics  without  a  prescription  can  be  measured  in  different  ways. 
Table 2.4 shows that, out of the 47 studies that used a patient perspective, 36 studies 
measured the use of antibiotics without a prescription. Nine studies had the intended 
use  of  antibiotics  as  one  of  the  outcome  measures.  Eight  studies  measured  the 
storage of medication left over after a course of treatment. The period of time used in 
measuring  the  use  of  antibiotics  without  a  prescription  varied  across  studies  (see 
Table  2.5,  next  section).  Reports  over  the  past  12  months  are  most  often  used,  but 
some studies have asked patients to report whether they have ever used an antibiotic 
without a prescription. 

Six  studies  from  the  pharmacist’s  perspective  looked  at  the  estimated  dispensing  of 
antibiotics, while one focused on intended dispensing. Three studies had the response 
of the pharmacist to the request of an actor for an antibiotic without a prescription as 
an outcome measure. 

April 2017  

37 

 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 2.4.  Outcome  measures  in  studies  included  in  the  literature  review  on  the 
volume  and  nature  of  antibiotic  use  without  a  prescription  (n = 59 
studies). 

Patient perspective 

Use without a prescription, general 
Intended self-medication 
Storage of antibiotics 
Pharmacist perspective 

Estimated dispensing of antibiotics without a prescription 
Response to request from an actor for an antibiotic without a prescription 
Intention to dispense an antibiotic without a prescription 
* Some studies included more than one outcome measure. 

Number of 
studies* 
36 
9 
8 
Number of 
studies 
6 
3 
1 

There  should  be  caveats  about  the  interpretation  of  the  results  due  to  the  different 
ways of measuring and defining non-prescription use across the studies included. Any 
interpretation  should  keep  in  mind  that  they  are  dependent  on  the  study  design  and 
the number of respondents that participated in the study. 

2.4.3.  

Patient perspective 

Use of antibiotics without a prescription 
Table  2.5  summarises  the  findings  from  studies  that  used  a  patient  perspective. 
Results  from  qualitative  studies  and  studies  where  requests  for  antibiotics  in  a 
pharmacy  were  measured,  rather  than  actual  use,  were  excluded  from  the  table. 
Where studies included more countries and reported information on the country level, 
data for individual countries are included in Table 2.5. 

Studies  in  which  patients  were  asked  to  report  whether  they  have  ever  used 
antibiotics  without  a  prescription  generally  show  a  higher  prevalence  of  non-
prescription use compared to studies in which patients reported over a certain period 
of  time,  usually  the  past  12  months (aa).  The  highest  percentage  of  patients  who  had 
ever  used  antibiotics  without  a  prescription  was  found  in  a  study in  Greece  (75 %  of 
adults),22  followed  by  Lithuania  (62.4 %  of  adults).16  Austria  and  Belgium  are  the 
countries in western  Europe where the highest percentages of patients who had ever 
used  an  antibiotic  without  a  prescription  were  reported,  18.8 %  and  18.1 % 
respectively. This is lower than in other countries that were included in the same study 
such as Croatia, Czech Republic, Italy and Malta.16 

Lower  percentages  were  found  in  studies  that  report  use  of  antibiotics  without  a 
prescription  over  the  last  12  months.  The  study  that  found  the  highest  prevalence  is 
from  Greece  (44.6 %  of  adults),23  followed  by  Italy  (32.7 %  of  parents  of  children 
aged  5-18  years)24  and  Lithuania.25  Here  again,  studies  in  western  and  northern 
Europe  reported  lower  percentages  of  patients  who  used  antibiotics  without  a 
prescription. The highest percentage was found for the United Kingdom (12 %).17 This 
might be explained by the fact that in the United Kingdom, some topical antibiotics are 
available OTC. 

(aa)  For sentences that introduce paragraphs, references can be found in the text that follows and in tables. 

April 2017  

38 

 
 
 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Intention to self-medicate with an antibiotic 
In addition to studies on the actual use of antibiotics without a prescription, there are 
also studies that measured patients’ intention to self-medicate with an antibiotic in the 
future. The findings are in line with the results for actual use. The highest percentages 
of  patients  who  have  the  intention  to  self-medicate  are  found  in  studies  in  Lithuania 
(45 %),25 Romania (43.1 %),6 Slovakia (32.4 %)6 and Spain (31.4 %).6 Compared to 
other  countries  in  the  western  part  of  Europe,  studies  in  Ireland  and  the  United 
Kingdom  reported  a  relatively  high  percentage  of  patients  who  intend  to  self-
medicate.6 

Storage of antibiotics 
Several studies made an inventory of the number of households that stored antibiotics 
obtained  without  a  prescription.  Although  the  percentages  varied  across  studies,  a 
considerable number of households do store antibiotics. A study in Italy, for example, 
found  that  57 %  of  all  respondents  stored  antibiotics.  In  two  studies  in  Spain,  37 % 
and 50 % of respondents indicated that they have stored antibiotics.6 26 High levels of 
storage  of  antibiotics  were  also  found  in  Croatia  (46 %)27,  Greece  (40 %)28,  Malta 
(35 %)29  and  Romania  (32.1 %).6  A  few  studies  compared  the  use  of  antibiotics 
without a prescription among patients who stored antibiotics at home with those who 
did not. As can be expected, use is higher among patients who have stored antibiotics 
at home. 

Requesting antibiotics in pharmacies 
Three  studies  looked  at  the  number  of  requests  made  for  antibiotics  without  a 
prescription  in  community  pharmacies  in  Spain.  One  study  found  that  23.8 %  of  all 
requests  for  antibiotics  were  for  a  course  without  a  prescription.30  The  two  other 
studies found higher percentages: 53.5 % and 57.5 % respectively.31 32 

April 2017  

39 

 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 2.5.  Results on use, intention to use and storage of antibiotics gained 

without a prescription; literature review regarding the volume and 
nature of antibiotic use without a prescription (n = 59 studies). 

Country (1st author) 

Year 

Participants 

Time period 

Storage 

Austria (Grigoryan)6 
Austria (Grigoryan)16 
Belgium (Grigoryan) 
Belgium (Grigoryan)16 
Croatia (Aljinović-Vučić)27  

2006 
2008 
2006 
2008 
2005 

Croatia (Grigoryan)6  
2006 
Croatia (Grigoryan)16 
2008 
Czech Republic (Andrajati)33  2005 
Czech Republic (Grigoryan)6  2006 
Czech Republic (Grigoryan)16  2008 
Denmark (Muscat)34 
2006 
Denmark (Grigoryan)6 
2006 
Greece (Mitsi)22 
2005 
Greece (Papaioannidou)28 
2009 
Greece (Skliros)23 
2010 
Greece (Tsiligianni)35  
2012 

Ireland (Grigoryan)6 
Italy (Di Matteo)36 
Italy (Grigoryan)6 
Italy (Grigoryan)16 
Italy (Napolitano)37  

Lithuania (Berzanskyte)25 
Lithiania (Grigoryan)6 
Lithuania (Grigoryan)16  
Luxembourg (Grigoryan)6 
Malta (Borg)38 
Malta (Grigoryan)6 
Malta (Grigoryan)16 
Netherlands (Grigoryan) 6 
Netherlands (Grigoryan)16 
Poland (Olczak)39 
Poland (Grigoryan)6 
Poland (Muras)40 
Romania (Grigoryan)6 
Romania (Damian)41  
Slovakia (Grigoryan)6 
Slovenia (Grigoryan)6 
Spain (Gonzales)26 

Spain (Grigoryan)6 
Spain (Väänänen)42 
Spain (Carrasco-Garrido)43 
Spain (Mira)44 
Sweden (Svensson)45 
Sweden (Grigoryan)6  
Sweden (Grigoryan)16 
United Kingdom (McNulty)46 

2006 
2005 
2006 
2008 
2013 

2006 
2006 
2008 
2006 
2002 
2006 
2008 
2006 
2008 
2006 
2006 
2013 
2006 
2014 
2006 
2008 
2006 

2006 
2006 
2008 
2014 
2004 
2006 
2008 
2006 

Past 12 months 
Ever 
Past 12 months 
Ever 
For antibiotics 
stored in home 
Last 12 months 
Ever 
Last 12 months 
Last 12 months 
Ever 
Past 12 months 
Past 12 months 
Ever 

Past 12 months 
Current storage 

Past 12 months 
Past 12 months 
Past 12 months 
Ever 
Past 12 months 

Past 12 months 
Past 12 months 
Ever 
Past 12 months 
Ever 
Past 12 months 
Ever 
Past 12 months 
Ever 

Past 12 months 
Ever 
Past 12 months 
Past 6 months 
Past 12 months 
Past 12 months 
Current 

Past 6 months 
2 weeks 
Not clear 
Past 12 months 
Past 12 months 
Ever 
Past 12 months 

442 adults 
101 adults 
1 734 adults 
99 adults 
287 medical 
students 
615 adults 
96 adults 
1 169 adults 
1 169 adults 
100 adults 
1 881 adults 
1 881 adults 
173 adults 
140 adults 
1 130 adults 
40 families (85 
persons) 
793 adults 
213 adults 
213 adults 
80 adults 
419 parents of 
children 5-18 y 
746 adults 
747 adults 
101 adults 
675 adults 
175 adults 
541 adults 
99 adults 
1 634 adults 
116 adults 
938 adults 
935 adults 
891 adults 
430 adults 
281 students 
546 adults 
1 134 adults 
1 000 female 
head household 
204 adults 
533 adults 
19 514 adults 
1 526 adults 
690 adults 
704 adults 
103 adults 
6 983 
households with 
children 
7 120 adults 
675 adults 
95 adults 

Intention 
to use 

7.3 

8.0 

5.2 

12.3 

46 

21.2 

20.5 

7.5 
6.4 

8.0 
8.4 

40 
27 
17 

10.0 
57 
56.9 

16.9 
17.9 

13 
13.2 

15.0 
24.3 
24.3 

29 

22.7** 

33.3 

13.2 
35 
26.9 

45 
44.9 

8.3 

22.8 

3.6 

8.5 

13.7 

11.5 

32.1 

43.1 

30.2 
18.3 
37 

32.4 
28.0 

50.0 

31.4 

4 
4.3 

11 
11.8 

Use 

0.9 
18.8 
0.9 
18.1 
37 

3.1 
37.5 
0.5/1.6* 
0.7 
21 
3.5 
7 
75 
25 
44.6 
0.7 

1.4 
6 
6.2 
21.3 
32.7 

22 
21 
62.4 
0.9 
19/11* 
5.6 
29.3 
0.1 
2.5 
13 
3.3 
41 
19.8 
44 
4.2 
1.7 

15.2 
11.5 
< 1 % 
6 
< 1 % 
0.4 % 
12.6 
4.6 

4.8 
12 
15.8 

3.1 

United Kingdom (McNulty)47 
2007 
United Kingdom (Grigoryan)6  2006 
United Kingdom (Grigoryan)16  2008 
Combined results for multiple countries without presenting results for individual countries 
Central, western, northern EU 
19 Member States 
(Grigoryan)15 

Ever 
Past 12 months 
Ever 

Past 12 months 

15 548 adults 

2007 

16.6 

7.4 

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40 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Non EU-countries 
Macedonia (Boseveska)48 

2012 

Macedonia (Ivanovska)49 

2013 

Russia (Stratchounski)50 
United States (Ceaser)51 
United States (Richman)52 

2003 
2000 
2001 

United States (Edwards)53 

2002 

United States (Céspedes)54 

2006 

United States (Landers)55 

2010 

239 persons 10-
67 years 
402 adults, 122 
children 

900 families 
101 adults 
1 363 patients 
admitted to 
emergency dept 
801 parents 
with children 
Unknown 
(Latino) 
100 female 
head household 

- 

12 months 
(storage) 
6 months (use 
for URTI) 
Current 
Ever 
Ever 

Past 12 months 

Past 12 months 

Past 12 months 

72.1 

83.6 
25.7 

* Adults/children. 
** Of those who never self-medicated. 
*** Same figures can be found in Tesar 2008. 

13.4 

17.8/1.8 
* 

17 

8.2 

26 

23.6 % of all 
antibiotic 
courses 

Sources of antibiotics without a prescription 
Several  studies  suggested  that  patients  obtain  antibiotics  without  a  prescription  in 
different ways (see also Section 2.2.3). Buying antibiotics OTC and the use of leftover 
medication are the main sources of antibiotics without a prescription. In some studies 
buying  OTC  is  clearly  dominant,23  25  29  while  in  other  studies  the  use  of  leftover 
medication is the source that is most frequently mentioned.14 24 26 39 56 No clear pattern 
across  countries  can  be  observed.  Friends,  family  members  and  neighbours  are  the 
third important source of antibiotics without a prescription (see table 2.6). 

Table 2.6.  Sources  for  obtaining  antibiotics  without  a  prescription.  (Source: 
Literature  review  regarding  the  volume  and  nature  of  antibiotic  use 
without a prescription (n = 59 studies).) 
Pharmacy 

Country (1st author) 

Year  Number of 

Left-over 
medication 

Other/ 
unknown 

users 

Denmark (Muscat)34 
2006 
Greece (Mitsi)22 
2005 
Greece (Skliros)23 
2010 
Italy (Napolitano)37  
2013 
Lithuania (Berzanskyte)25 
2006 
Malta (Borg)38 
2002 
Poland (Olczak)39 
2006 
Poland (Muras)40 
2013 
Spain (Gonzales)26 (storage)  2006 
Non EU-countries 
United States (Céspedes)54 

2006 

66 
129 
508 
137 
298 
168 
122 
372 
370 

192 

From 
family, 
friends, 
etc. 

40.4 
76.2 
43.2 
86.0 
85.7 
? 
13.4 
14.3 

31 

64 
30.2 
15.3 
68.6 
23.2 
4.8 
56.4 
73.1 
84.9 

61 

36 
7.1 
1.3 

4.8 

0,01 

22.3 
7.2 

6.1 
4.8 
18.2 
12.6 
0.8 

Type of antibiotic 
Fewer  than  half  of  all  studies  (n = 25)  reported  which  type  of  antibiotic,  or  group  of 
antibiotics,  patients  used  or  requested.  Both  broad-spectrum  antibiotics  (amoxicillin, 
ciprofloxacin, cefaclor and norfloxacin) and narrow-spectrum antibiotics (azithromycin 
or  penicillins)  were  being  used  or  requested  by  patients  to  treat  their  symptoms  on 
their  own  initiative.  The  antibiotics  most  often  used  or  requested  were  penicillin 
derivates.6 30-32 34 36 57 58 

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Type of symptoms or disease 
Thirty-one  studies  included  information  on  the  symptoms  for  which  antibiotics  were 
used  or  requested.  The  most  common  reasons  for  patients  to  use  non-prescribed 
antibiotics  were  upper  or  lower  respiratory  tract  infections  such  as  sore  throat  or 
bronchitis.6  14  15  23  25  29-32  34  38  41  56-61  Other  reasons  stated  included  fever,23  56  57  60 
urinary tract infections,15 30 38 41 57 dental problems,6 15 24 30-32 36 56-58 kidney infections,38 
flu,31 36 38 57 60 sinusitis61 and prophylaxis.36 

Pharmacist/pharmacy perspective 

2.4.4.  
Ten  studies  using  a  pharmacist  or  pharmacy  perspective  were  included  in  the 
literature review: two from Greece, five from Spain, one from Slovakia, one from the 
United  States  and  one  from  New  Zealand.  The  eight  EU  studies  included  information 
on  dispensing  behaviour,  either  based  on  pharmacists’  self-reports  or  on  pharmacy 
staffs’ reactions to actors posing as patients (see Table 2.7 for references). All studies 
except  one,  in  Spain,  found  that  in  over  40 %  of  all  pharmacies,  antibiotics  were 
dispensed  even  though  the  patient  did  not  have  a  prescription  (see  Table  2.7).  The 
two  non-EU  studies  also  indicated  a  high  degree  of  intention  to  sell  antibiotics  OTC 
(not in table).62 63 

Table 2.7.  The  dispensing  of  antibiotics  without  a  prescription  in  pharmacies. 
(Source: literature review regarding the volume and nature of antibiotic 
use without a prescription; n = 7 studies.) 

Country (1st author) 

Year 

Number of 
participants 

Way of 
measuring 
dispensing 

Percentage of 
pharmacist 
dispensing 
antibiotics without 
a prescription 

Greece (Contopoulos)64  
Greece (Plachouras)65 
Spain (Caamano Isorna)66 
Spain (Llor)67 68 
Spain (Simó)69 
Spain (Zapata)70 
Slovakia (Markovic-Pekovic)71 

2001 
2010 
2004 
2009 /2010 
2013 
2014 
2012 

98 
174 
164 
197 
50 
286 
131 

Mystery guest 
Mystery guest 
Self-report 
Mystery guest 
Mystery guest  
Self-report 
Mystery guest 

77.6 
72.4 
65.9 
45.2 
8 
64.7 
58 

The  most 
frequently  offered  antibiotics  were  penicillins,  macrolides  and 
fluoroquinolones.  Pharmacists dispensed  different types  of broad-spectrum antibiotics 
such as amoxicillin, cephalosporin or norfloxacin.64 66 67 69 The studies that involved an 
actor posing as a patient presented one or more cases to the pharmacists in order to 
see  whether  they  would  sell  an  antibiotic  without  a  prescription  for  that  particular 
case. A study in Greece, for example, distinguished between a case where the patient 
had a low fever versus a patient with a high fever. Pharmacists, who were confronted 
with  cases  of  high  fever  sold  antibiotics  OTC  more  often  (86 %)  compared  to 
pharmacists  who  were  confronted  with  low-fever  cases.  However,  even  when 
presented with patients with low fever, still over two thirds of the pharmacists sold an 
antibiotic  OTC  (69 %).64  A  study  in  Spain,  described  in  two  articles,  showed  that 
pharmacy  staff  were  most  inclined  to  dispense  antibiotics  when  the  actor  presented 
with  a  urinary  tract  infection.67  68  Here  79.7 %  of  pharmacy  staff  sold  an  antibiotic 
without  a  prescription.  These  percentages  were  considerably  lower  for  sore  throat 
(34.8 %) and acute bronchitis (16.9 %).67 68 

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Internet 

2.4.5.  
The use of antibiotics obtained via the internet is considered to be a growing problem. 
However,  only  a  single  US  study  was  found  that  explicitly  focused  on  the  use  of  an 
antibiotic acquired through the internet without a prescription.72 Of 138 unique online 
vendors  of  medicines,  36.2 %  sold  antibiotics  without  a  prescription.  They  were  also 
likely  to  sell  antibiotics  in  courses  that  exceed  the  number  of  days  an  antibiotic  is 
needed. 

2.5.  Discussion  and  selection  of  Member  States  for  the  ARNA 
project 

Main findings 
There is a large variation in outpatient antibiotic consumption in the EU as is shown by 
data  from  ESAC-Net  and  Eurobarometer  surveys,  and  by  an  extensive  literature 
review of 59 studies.  This large variation is found for the use of antibiotics both with 
and without a prescription. The ESAC-Net data and Eurobarometer surveys show that 
there  is  a  positive  but  moderate  association  between  the  levels  of  consumption  of 
prescribed  and  non-prescribed  antibiotics  at  the  country  level.  However  different 
patterns  of  use  exist.  Some  Member  States,  such  as  Greece,  Romania  and  Cyprus, 
show  high  levels  of  both  prescription  and  non-prescription  use,  while  Member  States 
such  as  the  Netherlands  and  Sweden  have  low  levels  of  both  prescription  and  non-
prescription use. Estonia is a Member State with a low level of use of antibiotics with a 
prescription,  but  a  relatively  high  level  of  use  without  a  prescription.  For  a  Member 
State  such  as  France  the  opposite  holds  true.  Buying  OTC  from  a  pharmacy  is  the 
prevailing  source  of  an  antibiotic  without  a  prescription,  followed  by  the  use  of 
medication  left  over  from  a  previous  treatment  by  the  patient  or  another  household 
member.8  13  This  is  the  case  in  most  EU  Member  States,  but  in  some  (Luxembourg, 
Austria,  Belgium  and  Spain)  leftover  medication  is  the  main  source  of  antibiotics 
without a prescription.8 13 

Strengths and limitations 
There is large variation in the methods used between studies included in the literature 
survey,  for  example  the  way  in  which  outcome  variables  are  measured,  the  size  and 
nature of the populations that are included and the period for which use is measured. 
Data  cannot,  therefore,  be  compared  easily.  Moreover,  studies  from  the  patient’s 
perspective  are  based  on  self-reported  data.  Self-reporting  can  induce  socially 
desirable responding, and as such the use of antibiotics without a prescription may be 
underestimated.73 This not only holds true for the studies in the literature review, but 
also  for  the  Eurobarometer  surveys.  A  strength  of  the  Eurobarometer  surveys8  13  is 
that they include all EU Member States and measure use  of antibiotics in exactly the 
same way in all Member States, making it possible to compare between them. Overall, 
despite  the  variety  in methods  used,  the  results in  this  chapter  show  that  the  use  of 
antibiotics without a prescription is still occurring across the EU and needs attention. 

Selection of Member States for the ARNA project 
The  ARNA  study  pays  particular  attention  to  the  use  of  antibiotics  without  a 
prescription.  Based  on  the  results  from  previous  studies,  seven  Member  States  were 
selected  to  perform  surveys  into  the  use  of  antibiotics  without  a  prescription  among 
citizens, pharmacists and GPs (see Chapter 4). As the Eurobarometer surveys are the 
only  data  source  that  include  all  EU  Member  States  and  measure  use  in  exactly  the 
same  way,  it  was  decided  to  select  Member  States  on  the  basis  of  the  2013 

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Eurobarometer  survey (bb).  The  European  Commission  requested  that  the  ARNA  team 
include five large and two small Member States in the project.  The main criterion for 
selecting  a  Member  State  was  the  level  of  antibiotic  use  without  a  prescription.  Two 
small  Member  States  with  high  percentages  of  such  use  were  Cyprus  (10 %  of  all 
antibiotic use was without a prescription) and Estonia (6 %).13 The four large Member 
States with the highest use included Romania (20 %), Greece (16 %), Hungary (8 %) 
and Spain (8 %). Italy (4 %) was not in the top-five large Member States with a high 
use  of  non-prescription  antibiotics,  but  was  chosen,  in  agreement  with  the 
Commission, because of its regional differences in use.74 75 

(bb)  The choice for the ARNA countries was made in 2014. 

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3.  Explaining  differences  in  antibiotic  use  across  the 

EU 

Main findings 

Literature review 
A  literature  review,  including  41  studies,  found  that  the  use  of  antibiotics  without  a 
prescription is a complex phenomenon that can only be explained by looking at a variety of 
determinants  on  different  levels.  The  results  for  sociodemographic  factors  such  as  gender, 
the age and educational level of the patient and the location of the pharmacy (rural versus 
urban)  in  this  regard  were  inconclusive.  Examples  of  determinants  found  in  the  literature 
that were associated with a higher use of antibiotics without a prescription include: 
 

on  the  patient  level,  a  lack  of  knowledge  about  antibiotics  and  a  previous  successful 
experience with the use of antibiotics; 
on the HCP level, insufficient knowledge on the part of the pharmacist; 
on  the  healthcare-system  and  country  level,  the  dispensing  of  whole  packages  of 
antibiotics rather than the exact amount of pills needed. 

 
 

Eurobarometer data 
 

In Chapter 2, differences were noted between EU Member States in the level of use of 
antibiotics without a prescription. Further analyses of the Eurobarometer in this chapter 
suggest that differences between Member States can partly be explained by differences 
in the level of knowledge, information use and attitudes towards antibiotics among the 
general population. 
Countries with high levels of antibiotic use without a prescription, after correcting for 
the level of knowledge, information use and attitudes towards antibiotics, include the 
ARNA countries Hungary, Cyprus, Greece, Italy and Estonia. 

Ministries of health survey 
 

All 28 EU Member States have a legal framework that either promotes the prudent use 
of antibiotics or prohibits the sale of antibiotics without a prescription. 
A number of EU Member States report that OTC sales are illegal but that there are 
exceptions for topical antibiotics such as creams and eye drops. One Member State 
reported that fuzaridin can be obtained without a prescription. 
Despite the legal framework, a number of EU Member States reported that patients can 
obtain antibiotics OTC from pharmacies in their country. 
The survey indicated that antibiotics are frequently available over the internet without a 
prescription. 
Actions are being taken by all EU Member States to reduce the non-prudent use of 
antibiotics, but the type and intensity of actions differs by country. Only one Member 
State reported that there were no national measures. 
The main policy differences between the ARNA countries and the other EU Member 
States were the existence of, firstly, national antibiotic plans, of which there were fewer 
among the ARNA countries, and, secondly, national surveillance systems in outpatient 
care. Here too there were fewer among the ARNA countries. 

 

 

 

 

 

 

3.1.  Introduction 

Chapter  2  noted  large  variations  between  EU  Member  States  in  antibiotic  use  both 
with  and  without  a  prescription.  These  differences  can  have  several  causes.  The 
current  chapter  aims  to  identify  determinants  of  the  use  of  antibiotics  without  a 
prescription.  The  use  of  antibiotics  without  a  prescription  is  a  complex  phenomenon 
that appears in different forms and can have negative public health effects. Therefore, 
it  is  important  to  identify  the  determinants  that  drive  patients  to  use  antibiotics 
without  a  prescription.  These  determinants  can  be  found  on  different  levels.  These 

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are:  in  the  general  population,  such  as  the  behaviour  of  individuals;  among  HCPs, 
such  as  the  services  they  provide;  and  in  the  healthcare  system,  for  example 
legislation.  Knowledge  about  determinants  on  these  different  levels  is  necessary  to 
stimulate  targeted  interventions  aimed  at  achieving  more  prudent  use  of  antibiotics. 
However, little information currently exists about the factors on these different levels. 
Therefore, the ARNA team performed a literature review in order to gain an overview 
of  the  determinants  of  antibiotic  use  without  a  prescription  on  three  levels:  the 
population,  the  HCP  and  healthcare-system  levels.  Moreover,  an  additional  analysis 
was  performed  using  the  2013  Eurobarometer  to  study  determinants  of  non-
prescription  use  within  the  EU.  Finally,  we  also  collected  information  on  regulations 
and policy measures taken to improve rational antibiotic use in EU Member States. 

3.2.  Determinants: a literature review 

3.2.1.  Methods 

Search strategy 
A  comprehensive  and  systematic  literature  search  was  conducted  in  PubMed,  Scopus 
and  Embase.  We  searched  for  studies  published  between  January  2000  and 
September  2014  without  a  limitation  on  language  or  type  of  study.  The  following 
search terms were used: (antibacterial agents OR drug resistance OR antibiotic) AND 
(non-prescription  OR  over-the-counter  OR  self-medication)  AND  (Europe  OR  Anglo-
Saxon countries OR other western or European countries). Studies on both actual use 
and the intention to use were included. The electronic searches were supplemented by 
manual  searches  of  reference  lists  and  citation  tracking  of  selected  articles.  This 
search was combined with the one in Chapter 2 (see Section 2.3). After checking the 
data  it  appeared  that  the  studies  of  determinants  in  non-European  countries  seemed 
less  relevant  for  the  European  situation  as  all  of  them,  except  one,  focused  on  the 
Latino population in the United States and not on the general population (cc). 

Selection criteria 
Publications were selected if the two following criteria were met: (1) the focus  of the 
study  is  on  the  determinants  of  use  of  antibiotics  without  a  prescription  within  the 
geographical context of at least one EU Member State or other European country; (2) 
the publication describes a quantitative empirical study. Articles were excluded if they 
focused on antibiotics in hospital settings, or animal or plant agriculture. 

Data synthesis and analysis 
Firstly,  the  titles  were  each  screened  by  two  authors  (a  combination  of  DL,  JP  and 
LvD).  Then  the  same  authors  screened  the  abstracts.  Next,  the  first  author  (DL) 
extracted  data  from  the  selected  publications.  Another  author  (LvD)  checked  the 
extracted data. Disagreements were resolved by discussion between the two authors. 
The determinants were categorised according to three levels. 
1.  Population  level:  individual  characteristics  and  behaviours  such  as  gender, 

knowledge or preferences. 

2.  HCP  level:  characteristics  and  behaviour  of  HCPs,  their  services  and  the 
organisation  they  work  in,  such  as  professional  knowledge  or  providing  patients 
with information about their medicines. 

3.  Healthcare-system level: the characteristics of healthcare systems such as access, 

payment, quality or organisation 

(cc)  Readers  who  are  interested  in  receiving  to  receive  information  on  these  studies  can  contact  the 

authors of the report. 

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Finally, for each determinant, the effect upon self-medication was extracted (‘positive’, 
‘negative’ or ‘no effect’). 

3.2.2.  Search results 
The  search  resulted  in  a  total  of  2 678  records  (1 624  records  in  PubMed,  806  in 
Scopus,  248  in  Embase),  of  which  2 456  hits  were  unique.  The  screening  of  titles 
resulted  in  a  total  of  638  potentially  relevant  publications.  The  subsequent  screening 
of the corresponding abstracts yielded 100 publications that were potentially relevant. 
By using the snowball method, 30 additional publications were regarded as potentially 
of  interest.  After  screening,  41  articles  appeared  to  be  of  interest  for  part  of  the 
review. For more details on the studies, see Chapter 2 (Table 2.2). 

3.2.3.  Population perspective 
Table  3.1  shows  an  overview  of  the  determinants  that  were  studied  using  a  patient 
perspective (dd).  Numerous  determinants  have  been  researched  in  relation  to  the  use 
of  antibiotics  without  a  prescription.  Sociodemographic  characteristics  are  the  most 
frequently  studied  determinants,  followed  by  characteristics  related  to  treatment. 
Other  determinants  focus  on  the  patient’s  health  condition,  the  relationship  of  the 
patient  with  the  HCP  and  the  patient’s  view  of  how  the  healthcare  system  influences 
patients’  choices.  In  the  text  below  we  discuss  determinants  that  were  addressed  in 
three or more studies. 

Sociodemographic characteristics 
The association between age and the use of antibiotics without a prescription has been 
researched in 15 studies and published in 16 articles in countries across Europe. Two 
studies  that  collected  data  in  19  European  countries  report  on  the  same  population 
and  are  counted  as  one  study6  58.  Seven  studies  did  not  find  an  association  between 
age and the use of antibiotics without a prescription.14  16  25  42  46  49  76  One study found 
that  younger  citizens  were  more  likely  to  use  antibiotics  without  a  prescription,6  58 
while  two  other  studies  found  that  older  citizens  were  more  likely  to.22  33  The 
remaining  studies  used  different  categorisations  for  age  but  a  general  picture  arises 
from these studies.32  43  56  77  78 Citizens between the ages of 16 and 50 years, the age 
at  which  people  study  or  work,  are  more  likely  to  use  antibiotics  without  a 
prescription. This is in line with the findings of a study  that suggested that employed 
people in higher managerial positions use antibiotics without a prescription more often 
compared  to  people  who  are  retired  —  the  reference  category  in  that  study.25 
However, three other studies did not find an effect for employment status.42 43 49 

Fifteen studies, published in 16 articles, studied differences between men and women 
in  the  use  of  antibiotics  without  a  prescription.  Seven  studies  did  not  find  any 
differences.6  16  25  42  44  46  56  58  Of  the  remaining  studies,  five  found  that  women  used 
antibiotics without a prescription more often,22 25 35 43 77 while three studies found that 
men did so.30 31 78 The findings were not clustered within certain countries or related to 
the population under study. As such, no conclusions for gender can be drawn from the 
literature.  The  same  holds  for  marital  status.  Two  Spanish  studies  found  no 
association between marital status and the use of antibiotics without a prescription.42 
43  One  study,  which  included  three  countries  in  Europe  (Italy,  the  Netherlands, 
Russia),  found  that  single  people  use  antibiotics  without  a  prescription  more  often 
compared to people who are married.78 

Educational level was included as a determinant in eight studies and published in nine 
articles. Half of the studies found that higher-educated people used antibiotics without 

(dd)  For sentences that introduce paragraphs, references can be found in the text that follows and in tables. 

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a  prescription  more  often.6  22  43  46  58  The  other  half  of  the  studies  did  not  find 
differences  in  relation  to  the  level  of  education.16  25  29  49  As  such,  a  low  level  of 
education  does  not  seem  to  be  associated  with  the  use  of  antibiotics  without  a 
prescription.  Finally,  patients  who  have  less  time  to  visit  a  doctor  more  often  use  of 
antibiotics without a prescription.28 56 

Another  determinant  that  attracted  much  attention,  being  covered  in  nine  studies, 
published in 10 articles, is where people live or, more specifically, whether this is in a 
rural or an urban area. It can be hypothesised that access to doctors is better in urban 
areas  compared  to  rural  areas,  especially  in  countries  with  a  low  population  density. 
This means that in urban areas it is easier to obtain a prescription. However, there are 
also  more  pharmacies  in  urban  areas  and  as  such,  theoretically,  better  access  to 
antibiotics  without  a  prescription.  The  literature  is  inconclusive.  In  six  studies,  no 
differences were found between people from urban and rural areas.6 16 26 39 49 57 58 Two 
studies, those from Poland and Lithuania, reported higher use of antibiotics without a 
prescription  in  rural  areas,14  25  while  one  other  study,  among  Romanian  students, 
reported higher use in urban areas.41 

Characteristics related to treatment 
The association between the knowledge of antibiotics and beliefs about antibiotics, on 
the one hand, and the use of antibiotics without a prescription, on the other, has been 
regularly studied. Eight studies addressed different aspects  of knowledge and beliefs. 
Three  studies  showed  that  better  knowledge  of  several  aspects  of  antibiotic  use  is 
associated  with  less  use  of  antibiotics  without  a  prescription.16  44  56  These  aspects 
include,  for  example,  knowledge  of  resistance,  adverse  effects  and  appropriate 
reasons  for  antibiotic  treatment.  Two  studies  from  the  United  Kingdom,  however, 
found  the  opposite,  that  better  knowledge  of  antibiotics  was  associated  with  greater 
use of medication that has been left over.46 47 A Greek study found that the belief that 
the  doctor  would  prescribe  them  an  antibiotic  anyway  was  a  reason  for  18 %  of  the 
participants  to  buy  an  antibiotic  OTC28.  Another  Greek  study  showed  that  the  belief 
that antibiotics are safe because they are easily available was associated with a higher 
level  of  antibiotic  use  without  a  prescription.35  An  international  study  in  11  countries 
demonstrated that the belief that antibiotics can be stored and used again was related 
to  an  increased  use  of  antibiotics  without  a  prescription.78  Storage  of  antibiotics  in 
itself is a determinant of future use,6  29  46  57 as is the use of medication left over from 
previously  prescribed  courses.15  46  78  A  successful  previous  use  of  antibiotics,  either 
with  or  without  a  prescription,  induces  the  use  of,  or  intention  to  use,  antibiotics 
without a prescription.28 29 31 34 44 

Characteristics related to health and disease 
Four  studies  included  general,  self-reported,  health  status  as  a  determinant  of 
antibiotic  use  without  a  prescription.  Two  studies  found  that  poor  health  status  was 
associated with more use of antibiotics without a prescription.56 78 However, one other 
study  found  that  better,  self-reported,  health  was  associated  with  more  use  of 
antibiotics  without  a  prescription,43  and  another  study  found  no  association  at  all.42 
Other studies looked at the association between having a chronic disease and the use 
of  antibiotics  without  a  prescription.  Three  studies,  published  in  four  articles,  found 
that  patients  with  a  chronic  disease  are  less  likely  to  use  an  antibiotic  without  a 
prescription  compared  to  people  who  are  healthy.6  25  43  58  Two  studies  found  no 
differences in this regard.16 42 

Characteristics related to HCPs and the health system 
HCPs  can  influence  the  patient’s  choice  to  use  antibiotics  without  a  prescription.  This 
was  shown  in  two  studies  that  found  that  patients  used  antibiotics  without  a 
prescription following the advice of a pharmacist to do so. Over a quarter (27 %) of all 

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respondents  in  an  Italian  study  of  parents  of  adolescents  and  parents  of  students, 
stated that they had received such advice from a pharmacist.56 A Greek study among 
a  general  sample  of  adults  found  a  comparable  proportion  (25 %).28  In  a  Spanish 
study, 6.5 % of all respondents were advised to use antibiotics without a prescription, 
but the authors did not specify by whom this advice was provided.31 

The patient’s choice to use antibiotics without a prescription cannot only be influenced 
by  HCPs,  but  also  by  factors  related  to  the  healthcare  system  itself.  A  lack  of 
reimbursement  for  prescribed  antibiotics  was  found  to  be  a  reason  to  use  antibiotics 
without a prescription in a study among adults in 19 European countries,6 but not in a 
smaller follow-up study in 11 of those countries.16 In a Greek study, it was found that 
a lack of healthcare insurance coverage was associated with higher use  of antibiotics 
without  a  prescription28,  but  a  study  in  the  nearby  former  Yugoslavian  Republic  of 
Macedonia did not find such an association.49 

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Table 3.1.  Determinants  of  the  use  of  antibiotics  without  a  prescription  studied 
from  the  population  perspective;  systematic  literature  review  (n = 30 
publications). 

Determinant 

Sociodemographic characteristics 
  Age6 14 16 22 25 32 42-44 46 49 56-58 77 78 
  Gender: women16 22 25 31 35 42-44 49 56 58 77 78 
Education: higher education6 16 22 25 29 34 43 46 49 58 
 
Location: rural area6 14 16 25 26 33 39 41 49 58 
 
  Occupational and employment status25 42 43 49 
  Marital status: single78 42 43 
Financial situation49 
 
  Socioeconomic status 46 
 

Parents (versus other adults)22 

Treatment-related determinants 
 

Lack of knowledge and incorrect beliefs on antibiotics16 35 
44 46 47 56 60 78 

  Storage for future needs6 29 46 57 
  Successful treatment in past28 29 31 34 44 
  Use of prescribed antibiotics15 46 78 
  Self-medication with medicines other than antibiotics27 
  Need for antibiotics (e.g. during holiday/sudden illness)28 
 

Perceived availability of antibiotics16 

Health- and disease-related 
  Having a chronic disease6 16 25 42 43 58 
  Health status: good42 43 56 78 
 

Lifestyle43 

Healthcare professional-related 
  Advice from a pharmacist or from lay persons28 31 56 
 
  Attending a physician43 56 
  Healthcare professional as household member27 

Lack of information provision78 

Healthcare system-related 
  No complete reimbursement/insurance issues6 16 28 49 
 
* Higher management/unemployed more compared to retired. 
** Different associations for different lifestyle behaviours in one study. 

Lack of time or money to visit a doctor28 29 

Association with determinant 
(No of articles) 
Positive 
Association 

Negative 
association 

No 
association 

See text 
3 

1 

1 

2 

3 
1 
1 

8 
4 
6 
3 

1 

1 

2 
1 
1** 

1 

2 

5 
4 
2 
1* 

6 

4 
4 
3 
1 
1 
1 

2 
1** 

3 
1 
1 
1 

2 
2 

3.2.4.  The pharmacist’s perspective 
This section reports on the potential determinants of the use of antibiotics without a 
prescription taken from studies that used a pharmacist perspective. The literature 
search was directed to other HCPs as well, but only studies with a pharmacist 
perspective were found. Table 3.2 shows a summary of the results of these eight 
studies. Most studies were from Spain (n = 5),66-70 with two studies from Greece 64 65 
and one study from the Republika Srpska (part of Bosnia and Herzegovina).71 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Pharmacy and pharmacist characteristics 
The age and gender of the pharmacist were, in most studies, not associated with the 
dispensing  of  antibiotics  without  a  prescription.67-70  Only  one  Spanish  study,  from 
2004,  found  that  younger  pharmacists  were  more  inclined  to  dispense  antibiotics 
without a prescription.66 As age does not seem to be associated with OTC selling, it is 
not  surprising  that  no  associations  found  with  the  number  of  years  of  practical 
experience  as  a  pharmacist.66  70  Nor  were  there  any  differences  found  in  the  level  of 
dispensing  of  antibiotics  without  a  prescription  between  pharmacies  in  rural  and  in 
urban areas.65  67  68  70 This was also the case between different cities.69 The results for 
the association between pharmacy ownership and the dispensing of antibiotics without 
a  prescription  are  inconclusive.  One  Spanish  study  found  that  pharmacy  owners  are 
more  likely  to  dispense  antibiotics  without  a  prescription,66  while  a  more  recent 
Spanish  study  and  the  study  from  Republika  Srpska  found  no  association  with 
pharmacy ownership.70 71 The size of the pharmacy does, however, seem to matter, at 
least in Spain. Two Spanish studies found that in smaller pharmacies more antibiotics 
were dispensed without a prescription than in larger pharmacies.68 69 The study by Llor 
et  al.  (2010),  for  example,  found  that  63 %  of  the  small  pharmacies  dispensed 
antibiotics  without  a  prescription,  whereas  this  was  only  12 %  of  the  largest 
pharmacies.68 The authors concluded: ‘Large pharmacies, that probably have a greater 
income,  more  closely  followed  the  prevailing  legislation  of  not  selling  antibiotics  to 
patients without a prescription.’68 

Factors related to health and treatment 
Zapata-Cachafeiro  et  al.  (2014)  studied  the  impact  of  knowledge  and  attitudes  of 
pharmacists  on  their  dispensing  behaviour.70  They  concluded  that  insufficient 
knowledge  was  associated  with  dispensing  of  antibiotics  without  a  prescription.  They 
measured  knowledge  with  statements  such  as  ‘antibiotic  resistance  is  an  important 
health issue’, ‘the fact that an antibiotic is prescribed to a patient will not influence the 
appearance  of  resistance’  and  ‘when  dispensing  antibiotics,  I  warn  the  patient  about 
the  importance  of  correct  therapeutic  compliance’.  They  also  found  that  pharmacists 
who  were  more  complacent  were  more  likely  to  dispense  antibiotics  without  a 
prescription.70  This  was  measured  by  the  statement:  ‘antibiotics  are  sometimes 
dispensed  without  a  prescription  because  the  patient  is  known  to  have  difficulty  in 
gaining access to a doctor’. External responsibility was another factor that was related 
to  the  dispensing  of  antibiotics  without  a  prescription.  This  is  true  in  the  sense  that 
pharmacists who seek causes for AMR outside themselves, such as society, regulation 
and  their  patients,  were  more  likely  to  dispense  antibiotics  without  a  prescription. 
Finally,  Zapata-Cachafeiro  et  al.  found  that  an  indifferent  attitude  towards  AMR  was 
associated with a higher level of dispensing of antibiotics without a prescription.70 

Another  study  found  that  arguments  related  to  patient  safety,  such  as  concerns  for 
allergies  or  complications,  were  a  reason  for  pharmacists  not  to  dispense  antibiotics 
without  a  prescription.64  This  study  also  found  that  pharmacists  were  more  likely  to 
dispense an antibiotic without a prescription in cases where they were confronted with 
a patient with a high temperature — either simulated or not — than when the patient 
had a low temperature.64 Arguments related to health were also found to be a reason 
for  not  dispensing  antibiotics  without  a  prescription  in  a  Spanish  study,  but  these 
arguments  were  not  further  specified  in  the  publication.67  A  wait-and-see  principle  is 
also sometimes used, as was shown in a study by Markovic-Pekovic.71 

Factors related to the patient 
Only a few studies from the pharmacist perspective included patient characteristics as 
a determinant. The age, gender and socioeconomic status of the patient do not seem 
to influence the decision of the pharmacist to dispense antibiotics without a 
prescription.67 68 However, it was reported in one study that pharmacists with a patient 

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population with high socioeconomic status received more requests to dispense 
antibiotics without a prescription.66 A study by Camaano-Isorma et al. (2004) showed 
that a higher proportion of pharmacists dispense antibiotics without a prescription in 
cases where they know the patient (59 %) than in cases where they do not know the 
patient (34 %).66 

Regulation 
Regulations in Greece for dispensing certain antibiotics have become stricter. Since 
2003 the regulations state that: ‘a separate specific prescription form needs to be 
filled in by the prescriber, justifying the choice of any fluoroquinolone or third 
generation cephalosporin prescribed orally, before the drug is dispensed’.65 The reason 
for implementing this measure was to preserve the efficacy of these antibiotics. 
However, according to Plachouras et al. there is no reinforcement of the regulation.65 
They studied whether the regulation had an impact on the dispensing of antibiotics 
without a prescription and found that it appears that the implementation of this 
regulation was ‘effective in reducing, although not eliminating, inappropriate 
dispensing’. 

3.2.5.  The healthcare-system and country perspective 
There  are  fewer  studies  of  the  determinants  of  the  use  of  antibiotics  without  a 
prescription on the healthcare-system level. Three studies on this level were included 
in  the  review,  two  of  which  were  also  included  in  Section  3.2.5  (population 
perspective).16 17 78 

Dispensing regulation 
Both Grigoryan et al. (2008) and Kardas et al. (2007) studied whether the dispensing 
regulation  in  a  country  was  associated  with  the  use  of  antibiotics  without  a 
prescription.16  78 Grigoryan’s study included 10 European countries and Israel, four of 
which had a regulation that allowed for the dispensing of the exact amount of tablets 
instead  of  the  whole  package  (the  Czech  Republic,  Israel,  the  Netherlands  and  the 
United  Kingdom).  It  was  found  that  the  likelihood  in  these  countries  of  using 
antibiotics  without  a  prescription  was  lower  compared  to  the  seven  countries  where 
whole packages were dispensed.16 Kardas et al, who included 11 countries, worldwide, 
in their study, came to the same conclusion.78 

Wealth 
The  Grigoryan  2008  study  also  looked  at  the  association  between  a  country’s  wealth 
and  the  use  of  antibiotics  without  a  prescription,  expressed  as  the  gross  domestic 
product. They concluded that the higher the gross domestic product of a country, the 
less likely it is that its citizens use antibiotics without a prescription.16 

Cultural impact 
Cultural  factors  are  known  to  play  an  important  role  in  the  use  of  antibiotics.e.g.79 
Deschepper et al(2008) looked at the impact of cultural dimensions on both prescribed 
and  non-prescribed  antibiotics.17  They  used  Hofstede’s  model  of  cultural  dimensions. 
Hofstede  distinguished  six  dimensions  along  which  cultural  values  can  be  compared 
with other cultures: individualism, collectivism, uncertainty avoidance, power distance 
(strength  of  social  hierarchy),  masculinity–femininity  (task  orientation  versus  person 
orientation); long-term–short-term orientation and indulgence–restraint.80 Deschepper 
et  al.  included  27  EU  Member  States  in  their  study.  They  only  found  one  significant 
association  between  these  cultural  dimensions  and  the  use  of  antibiotics  without  a 
prescription,  namely  for  power  distance.  Power  distance  refers  to  the  degree  of 
hierarchy  in  a  country.  Deschepper  et  al.  hypothesised  and  found  that,  in  countries 
with a hierarchical system, the use  of antibiotics would be more favoured because of 

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the ‘doctor-knows-best attitude’. This might hold for prescribed antibiotics, but less so 
for antibiotics used without a prescription. Yet, it becomes unclear how Deschepper et 
al. interpret the finding that more power distance leads to more use of non-prescribed 
antibiotics.80 

3.2.6.  Discussion 
This review of the literature shows that the use of antibiotics without a prescription is 
a  complex  phenomenon  that  is  driven  by  a  variety  of  determinants  that  act  on 
different levels. On the population level, the use of antibiotics without a prescription is, 
for example, associated with the storage of antibiotics at home, previous experiences 
with  antibiotic  treatment  and  a  lack  of  knowledge (ee).  The  association  between  the 
sociodemographic  characteristics  of  patients  and  the  use  of  antibiotics  without  a 
prescription  is,  however,  not  consistent  as  contradictory  results  were  found  (see 
Table 3.1). For example, it was found that non-prescription use is not associated with 
education level in highly educated persons, while better knowledge of several aspects 
of  antibiotic  use  is  associated  with  less  use  of  antibiotics  without  a  prescription.  This 
implies  that  highly  educated  people  do  not  necessarily  have  a  better  knowledge  of 
antibiotic  usage.  On  the  pharmacy  level,  the  knowledge  and  attitudes  of  the 
pharmacist  towards  antibiotics  seem  important.64  67  70  71  Other  pharmacist-  and 
pharmacy-related  characteristics,  such  as  location  and  the  age  and  gender  of  the 
pharmacist,  do  not  seem  to  have  an  association  with  the  use  of  antibiotics  without a 
prescription.65  67  68  70  However,  pharmacists  in  smaller  pharmacies  seem  to  be  more 
likely  to  dispense  antibiotics  without  a  prescription.68  69  Dispensing  the  exact  amount 
of  antibiotics  prescribed  instead  of  whole  packages  seems  to  reduce  the  use  of  non-
prescription antibiotics.16 78 

This  review  provides  an  overview  of  the  determinants  that  are  associated  with  self-
medication  and  could  therefore  be  used  to  frame  interventions.  Based  upon  the 
results, it can be concluded that interventions and policies that simultaneously target 
patients  and  HCPs  might  be  more  effective  than  single-factor  approaches.  For  both 
groups — patients and professionals — increased awareness and knowledge is needed 
in  order  to  bring  about  behavioural  change.  Moreover,  the  enforcement  of  laws  and 
regulations  is  necessary  to  ensure  the  sustainability  of  behavioural  change.  The 
studies included in this review paid little attention to the enforcement of laws, while in 
many  European  and  western  countries  obtaining  antibiotics  without  a  prescription  is 
illegal. These insights were used in the expert meeting that was organised within the 
context of the ARNA project (see Chapter 6). 

The review had some limitations. Despite our comprehensive search, it is possible that 
we did not find all the information about the non-prescription use of antibiotics due to 
publication  bias.  Still,  we  found  a  large  variety  of  studies  that  did  focus  on  this  use. 
Another limitation is how far the studies we included can be compared. This is because 
of  the  different  outcome  measures  they  presented  and  the  variety  of  study  designs. 
Moreover, little information was found on the determinants on the healthcare-system 
level.  On  the  pharmacy  level,  the  majority  of  studies  included,  five  out  of  the  eight, 
were  from  Spain.  Moreover,  there  was  a  limited  number  of  studies  focusing  on  the 
pharmacist,  and  no  studies  were  found  that  took  into  account  the  prescriber’s 
perspective.  And  yet,  HCPs  are  key  players  in  educating  their  patients  about  the 
proper  use  of  medicines.  As  such,  more  research  is  needed  on  the  perspective  of 
HCPs. We will look at this again in Chapter 4  of this report. The same is true for the 
healthcare-system level. There is still much to be explored in the role of governments 
and other institutions in the prudent use of antibiotics, including the use of antibiotics 

(ee)  For exact references, see Table 3.1. 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

without a prescription. Section 3.4 provides more insight into the efforts of EU Member 
States in this respect. 

Table 3.2.  Determinants  of  the  use  of  antibiotics  without  a  prescription  studied 
from  the  pharmacist’s  perspective;  systematic  literature  review  (n  = 8 
studies). 

Determinant 
Pharmacy and pharmacist characteristics 
  Gender 
  Age 

Years of experience as a pharmacist 

 
  Ownership of the pharmacy 

 

Location of the pharmacy 

  Size of the pharmacy 

Treatment- and health-related characteristics 
  Knowledge and beliefs/attitudes towards 

antibiotics 

 

Patient safety 

  Health/diagnoses 

  Wait-and-see advice 

Patient-related characteristics 
  Age of patient 
  Gender of patient 
  Socioeconomic status of patient  

 

Patient known by pharmacist 

Regulation  
  Restrictions on the prescribing of certain 

antibiotics 

Results 

No difference67-70 
One study: younger pharmacists more often 
dispense antibiotics without a prescription66 
Other studies: no association67 69 70 
No association66 70 
One study: owners dispense antibiotics without 
a prescription more often than other 
pharmacists66 
Other studies: no association70 71 
No differences between rural and urban areas65 
67-70 
Small pharmacies more often dispense 
antibiotics without a prescription than large 
pharmacies68 69  

Insufficient knowledge, an indifferent attitude 
towards antibiotics, complacency and external 
responsibility associated with more dispensing 
of antibiotics without a prescription70 
Concerns about patient drug allergies and 
complications were a reason for not dispensing 
antibiotics64 
One study found that in 57 out of 108 
pharmacies, where no antibiotics were sold 
without a prescription, health-related 
arguments were used to justify this decision 
(no more specific information)67 
Another study found that for a more severe 
diagnosis more antibiotics were dispensed 
without a prescription64 
One study found that patients were told to 
come back if the patient’s situation did not 
improve71 

No association68 
No difference68 
One study: higher-socioeconomic-status 
population, fewer requests for antibiotics 
without a prescription66 
Other studies: no association67 68 
Pharmacists are more likely to dispense an 
antibiotic to patients they know66 

Restriction  in  regulation  for  certain  antibiotics 
those  antibiotics  being 
led 
dispensed without a prescription65 

fewer  of 

to 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

3.3.  Eurobarometer data 

Methods 

3.3.1.  
The  Eurobarometer  data  enable  the  determinants  for  all  28  EU  Member  States  to  be 
studied simultaneously. In the Eurobarometer, respondents were asked whether they 
has  used  an  antibiotic  during  the  last  12  months,  and  if  so  they  were  asked  for  the 
source (see next section). 

Data source 
Eurobarometer  2013  data  were  used  to  study  the  determinants  of  non-prescription 
use of antibiotics in the 28 EU Member States. These Eurobarometer data are publicly 
available  and  were  retrieved  through  Gesis (ff).2  Eurobarometer  data  include  self-
reported  data  collected  by  a  questionnaire  which  included  questions  related  to 
‘reported  actual  self-medication  with  antibiotics  during  the  last  year’.  For  a  more 
detailed  description  of  sampling  methods  and  data  collection,  see  Section  2.2.1. 
Patients  who  used  an  antibiotic  were  selected  for  the  analysis  in  this  section.  The 
characteristics  of  patients  who  used  an  antibiotic  without  a  prescription  were 
compared to those who had a prescription. 

Variables 

Antibiotic use 
Respondents  were  asked  whether  they  had  used  an  oral  antibiotic  during  the  last 
12 months,  and  if  so  they  were  asked  for  the  source  (see  also  Chapter  2).  Patients 
were divided into two groups: 
 
 

those who took antibiotics with a prescription (value = 0); 
those who took antibiotics without a prescription (value = 1). 

Determinants 
The  following  variables  were  included  as,  based  on  the  literature  review,  they  were 
expected to have an impact (gg) on the choice to use antibiotics without a prescription 
instead of with a prescription (see Section 3.2). 
  Sociodemographic  variables:  gender,  age  (six  levels),  professional  status  (eight 
levels),  socioeconomic  status  (three  levels),  marital  status  (four  categories), 
degree  of  urbanisation  of  location  (three  categories),  educational  level  (five 
categories); 

  Antibiotic-related  variables:  knowledge  of  antibiotics  (number  of  correctly 
answered  questions  out  of  four  questions),  source  for  obtaining  information  on 
antibiotics,  attitude  towards  antibiotics  and  reason  or  indication  for  the  use  of 
antibiotics. 

  Country: dummy variables for all EU Member States were created. 
  Other: satisfaction with own life (four categories). 

(ff)  2013 

Eurobarometer 

data: 

https://dbk.gesis.org; 

http://ec.europa.eu/dgs/health_food-

safety/amr/docs/eb445_amr_generalreport_en.pdf 

(gg)  Although  the  results  for  sociodemographic  variables  were  inconclusive  in  the  review,  they  are  still 

taken into account in the analyses as some studies in the review showed an association. 

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Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Analyses 
The characteristics of users of antibiotics without a prescription (value 1) versus those 
who  used  an  antibiotic  with  a  prescription  (value  0)  were  analysed  with  a  logistic 
regression  analysis.  Firstly,  a  model  was  estimated  including  dummy  variables  for  all 
Member  States  except  Finland,  which  had  the  lowest  use  of  antibiotics  without  a 
prescription  and  therefore  served  as  the  reference.  As  we  were  interested  in  fixed 
effects  we  included  Member  States  as  dummy  variables  and  did  not  use  a  multilevel 
model.  However,  we  also  estimated  a  multilevel  model  where  Member  State  was 
included  as  a  random  effect.  This  provides  insight  in  the  extent  to  which  variation in 
self-medication  can  be  explained  by  differences  between  Member  States.  Next, 
sociodemographic  variables  were  added  to  the  model,  and  finally  variables  on 
knowledge  and  attitude  towards  antibiotics  were  included  (full  model).  As  the  full 
model  was  not  stable  due  to  the  fact  that  it  included  many  variables,  a  model  was 
estimated  that  only  included  variables  that  were  significant  (p  < 0.05)  in  the  full 
model. 

Variables included in the final model were as follows. 
  Gender (reference: male). 
 

Age  in  six  categories  (< 25  years  (ref),  25-34  years,  35-44  years,  45-54  years, 
55-64 years, 65 years and older). 
Knowledge of antibiotics: a respondent received a score of ‘1’ if all four items were 
answered correctly and ‘0’ if one or more items were answered incorrectly (hh). 
The  source  from  which  information  was  obtained:  HCP  (reference  category), 
family/friends, media/communication campaigns or no information at all. 
Attitude towards antibiotics (‘Everyone has a role to play to ensure that antibiotics 
remain effective’) 1 = totally agree; 4 = totally disagree. 

 

 

 

The  health  symptoms  the  antibiotics  treated  were  used  as  control  variables  as  it  can 
be expected that antibiotics used for more severe health conditions are more likely to 
be  prescribed  by  a  doctor.  Models  for  a  single  EU  Member  State  could  not  be 
estimated,  as  for  most  the  number  of  patients  who  used  an  antibiotic  without  a 
prescription was too low. 

3.3.2.  

Results 

Table  3.3  shows,  for  the  all  of  the  EU  Member  States,  the  characteristics  of  all 
antibiotic  users  both  with  or  without  a  prescription.  Patients  who  used  antibiotics 
without  a  prescription  were  younger  and  more  often  male  compared  to  patients  who 
had  a  prescription.  They  were  also  less  often  informed  and  fewer  patients  had  good 
knowledge of antibiotics. 

(hh)  A same variable was constructed in which there were at least three correct as opposed to two or fewer 
answered  correctly.  This  variable  was  a  weaker  predictor  of  non-prescription  use  than  the  one 
ultimately used, which contained four correct answers. 

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56 

 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.3.  The characteristics of users of antibiotics divided between users who had 

a prescription and those who had not. (Source: Eurobarometer 2013.)* 

Users of prescription 
antibiotics 
(n = 9 341) 

Users of non-prescription 
antibiotics 
(n = 562) 

(percentage 

Sociodemographic variable 
Male 
Age: 
 < 25 years 
 25-34 years 
 35-44 years 
 45-54 years 
 55-64 years 
 65 years and older 
Antibiotic-related variable 
Knowledge 
of 
persons with four correct answers 
from 
on 
knowledge)** 
Attitude  (‘Everyone  has  a  role  to 
play  to  ensure  that  antibiotics 
remain  effective’  1 = 
totally 
agree; 4 = totally disagree) 
Source of information: 
 HCP 
 family/friends 
 media/communication campaigns 
 no information at all 
* Only variables included in the final model. 
** Statements: 

statements 

four 

n 
3 709 

1 084 
1 308 
1 498 
1 507 
1 589 
2 355 

2 022 

 % 
39.7 

11.6 
14.0 
16.0 
16.1 
17.0 
25.2 

28.5 

8 662 

1.7 
(average) 

1 723 
187 
1 773 
5 463 

18.9 
2.0 
19.4 
59.7 

n 
278 

102 
94 
106 
110 
80 
70 

40 

512 

61 
20 
92 
383 

 % 
49.5 

18.2 
16.7 
18.9 
19.6 
14.2 
12.5 

10.2 

1.9 
(average) 

11.0 
3.6 
16.6 
68.9 

1: Antibiotics kill viruses. 
2: Antibiotics are effective against colds and flu. 
3: The unnecessary use of antibiotics makes them become ineffective. 
4: Taking antibiotics often has side effects such as diarrhoea. 

*** There is a significant difference between users of prescription antibiotics and users of non-prescription 
antibiotics on all variables (gender, age, knowledge, attitude and source of information, for all variables: P 
< 0.000). 

Analyses 
Logistic  regression  analyses  were  then  performed  in  the  next  step.  Finland  was  the 
Member State with the lowest level of antibiotic use without a prescription and served 
as the reference. Table 3.4 shows that, if not corrected for patient characteristics, 18 
Member  States  are  found  to  have  a  significantly  higher  proportion  of  users  of 
antibiotics  without  a  prescription  among  all  antibiotic  users  than  Finland  —  the 
Member  State  with  the  lowest  level  of  non-prescription  use  in  2013.  These  Member 
States  logically  include  all  seven  Member  States  selected  for  undergoing  in-depth 
surveys  within  the  context  of  the  ARNA  project:  Cyprus,  Estonia,  Greece,  Hungary, 
Italy, Romania and Spain. It should be noted that confidence intervals for the Member 
State estimates are wide, meaning that the estimates are less accurate. 

When  including  sociodemographic  variables  (gender,  age),  knowledge  and  source  of 
information and health symptoms for which antibiotics were used in the analysis, the 
following, additional, Member States do not differ significantly from Finland: Bulgaria, 
Croatia,  Latvia,  Portugal,  Slovakia,  Spain  and  Sweden.  Moreover,  the  differences  for 
all the Member States are smaller in the final model. This means that the differences 
between countries can partly be explained by factors such as, knowledge, attitude and 
information received.  

April 2017  

57 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table  3.4  shows  that,  compared  to  people  who  had  a  prescription  for  their  last 
antibiotic course, people who used an antibiotic without a prescription: 
 
are more often male; 
 
are younger; 
 
have less knowledge of antibiotics; 
 
less often think that everyone has a role in keeping antibiotics effective; and 
  more  often  obtain  information  about  antibiotics  from  sources  other  than 

healthcare professionals or no information at all. 

Despite  this  finding,  differences  between  Member  States  still  remain. This  means  not 
all variation is explained by the model. The Member States that still differ significantly 
from Finland in the final model are a mixed group. They include the following: Austria, 
Belgium,  Cyprus,  Denmark,  Greece.  Hungary,  Ireland,  Lithuania  and  Romania. 
Belgium,  Cyprus,  Greece,  Italy  and  Romania  all  fall  in  the  highest  quartile  (Q1)  of 
countries  with  a  high  overall  outpatient  consumption  of  antibiotics  according  to  the 
ESAC-Net data (see Chapter 2). This might imply that these Member States generally 
have  a  culture  where  the  use  of  antibiotics  is  more  generally  accepted  than  in 
others.17  Also,  the  high  level  of  use  of  prescribed  antibiotics  might  provide  persons 
with opportunities to keep antibiotics in stock (see literature review, Section 3.2). This 
seems  to  be  true  for  Belgium  and  Italy,  two  Member  States  with  a  relatively  high 
share  of  the  use  of  leftover  antibiotics  (see  Figure  2.5).  In  Cyprus,  Greece,  and 
Romania, non-prescription use of antibiotics is mainly driven by OTC selling. The level 
of  reinforcement  of  the  laws  not  to  sell  OTC  may  be  lower  than  in  other  Member 
States  in  the  EU  (see  Chapter  7).  The  other  Member  States  with  high  levels  of 
antibiotic  use  without  a  prescription  are  spread  across  all  the  other  quartiles  in  the 
ESAC-Net data (Q2: Ireland; Q3: Austria, Lithuania, Denmark; Q4: Estonia, Hungary). 
It should be noted that in Denmark, Italy and Austria some antibiotics for topical use 
can  be  sold  OTC,  which  may  explain  the  level  of  non-prescription  use  in  these 
countries  (see  results  of  the  Member  State  survey,  Section  3.4).  In  Estonia  and 
Hungary, the level of reinforcement of the laws not to sell  OTC may be lower than in 
other Member States. 

April 2017  

58 

 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.4.  Determinants of the use of antibiotics without a prescription versus 

those with; logistic regression analysis. (Source: Eurobarometer 2013.)* 

Country model 
(n = 9 903) 

Final model 
(country model plus 
extra variables) 
(n = 7 015) 

Odds 
ratio 

95 % CI 

P-value  Odds 
ratio 

95 % CI 

P-value 

6.3 
6.3 
3.3 
4.5 
1.7 
6.6 
Ref. 
1.6 
1.8 
6.9 
4.4 
5.2 
4.0 
1.0 
2.8 
1.2 
4.1 
3.0 
2.0 
5.0 
2.5 
5.6 
5.5 
13.1 
5.2 
5.0 
18.5 
2.3 

< 0.01 
10.6  2.5-45.6 
< 0.01 
9.9 
2.3-42.6 
< 0.01 
13.7  3.2-58.0 
< 0.01 
2.2-41.9 
9.6 
0.43 
0.4-10.9 
2.0 
< 0.01 
2.1-40.7 
9.3 
Ref. 
Ref. 
Ref. 
0.17 
0.6-14.1 
3.0 
0.25 
2.6 
0.5-12.8 
< 0.01 
14.3  3.4-60.0 
< 0.01 
12.8  3.0-54.3 
< 0.01 
12.1  2.8-51.1 
0.05 
1.0-23.4 
4.9 
0.41 
0.4-12.9 
2.1 
0.05 
1.0-22.0 
4.6 
0.10 
0.8-19.1 
3.8 
0.01 
1.8-33.5 
7.7 
0.01 
1.5-29.2 
6.7 
0.08 
0.9-20.5 
4.2 
0.04 
1.1-24.4 
5.1 
0.07 
4.0 
0.9-17.9 
< 0.01 
18.9  4.4-80.7 
10.8  2.5-46.2 
< 0.01 
31.5  7.6-130.2  < 0.01 
< 0.01 
14.0  3.3-59.8 
< 0.01 
1.7-33.0 
7.5 
40.3  9.9-164.7  < 0.01 
< 0.01 
13.4  3.2-56.7 

EU Member State 
Austria 
Belgium 
Bulgaria 
Croatia 
Czech Republic 
Denmark 
Finland 
France 
Germany 
Ireland 
Latvia 
Lithuania 
Luxembourg 
Malta 
Netherlands 
Poland 
Portugal 
Slovakia 
Slovenia 
Sweden 
United Kingdom 
Cyprus 
Estonia 
Greece 
Hungary 
Italy 
Romania 
Spain 
Sociodemographic 
variable 
Sex (ref = male) 
Age 
 < 25 yrs 
 25-34 yrs 
 35-44 yrs 
 45-54 yrs 
 55-64 yrs 
 65 yrs and older 
Antibiotic-related 
Knowledge* 
Attitude  
Source of information: 
 HCP 
 family/friends 
 media/communication 
campaigns 
 no information at all 
* Figures in bold are significant at P < 0.05, corrected for health symptoms 

Ref. 
0.9 
0.7 
0.9 
0.7 
0.4 

Ref. 
3.1 
1.8 

0.5 
1.2 

0.6 

1.9 

1.3-26.2 
1.4-27.6 
0.7-15.7 
1.0-20.3 
0.3-9.4 
1.4-30.8 
Ref. 
0.3-7.9 
0.4-9.3 
1.6-30.4 
1.0-19.5 
1.2-23.1 
0.8-20.7 
0.1-7.3 
0.5-14.6 
0.2-7.2 
0.9-18.5 
0.7-13.9 
.4-11.3 
1.0-24.7 
0.6-11.6 
1.2-25.6 
1.2-24.6 
3.1-55.0 
1.2-23.3 
1.1-23.2 
4.4-78.4 
0.5-11.3 

0.02 
0.02 
0.16 
0.05 
0.56 
0.02 
Ref. 
0.59 
0.50 
0.01 
0.05 
0.03 
0.10 
0.99 
0.23 
0.87 
0.07 
0.16 
0.42 
0.05 
0.24 
0.03 
0.02 
< 0.01 
0.03 
0.04 
< 0.01 
0.29 

0.5-07 

< 0.01 

Ref. 
0.6-1.2 
0.5-1.1 
0.6-1.3 
0.5-1.0 
0.2-0.6 

0.3-07 
1.1-1.4 

Ref. 
1.6-6.0 
1.1-2.7 

Ref. 
0.42 
0.12 
0.61 
0.07 
< 0.01 

< 0.01 
< 0.01 

Ref. 
< 0.01 
0.01 

1.4-2.7 

< 0.01 

April 2017  

59 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

3.3.3.  Discussion 
This section provided a secondary analysis of the 2013 Eurobarometer data.13  In line 
with  the  results  in  Chapter  2,  it  showed  that  there  are  large  differences  between  EU 
Member  States  in  the  use  of  antibiotics  without  a  prescription.  These  differences  can 
be explained in part by differences in the level of knowledge of their inhabitants. This 
is  in  line  with  the  findings  from  the  literature  review  in  which  knowledge  of  and 
attitudes  towards  antibiotics  were  also  related  to  non-prescription  use.  Also  with 
regard to  other determinants, the  results from the  Eurobarometer analyses generally 
confirmed the results of the literature review as described in Section 3.2. 

The  analysis  of  the  Eurobarometer  data  in  this  section  showed  that  younger  people 
more  often  use  antibiotics  without  a  prescription,  which  is  in  line  with  the  studies  in 
the literature  review that found that people having attained a working age or  an age 
to  pursue  further  education  are  more  likely  to  use  antibiotics  without  a  prescription. 
Contrary  to  the  literature,  The  Eurobarometer  data  found  that  men  more  often  use 
antibiotics without a prescription. Reasons for this may be differences in the sampled 
population or differences in the formulation of questions. 

The analysis using the Eurobarometer data had some limitations. Firstly, the number 
of people who used an antibiotic without a prescription was very low in some Member 
States.  This number was,  on average, 20 people per  Member State.  However, it was 
much  lower  in  Member  States  such  as  Finland,  Sweden  and  the  Netherlands. 
Therefore,  the  estimates  on  the  Member  State  level  are  less  accurate,  which  was 
shown  by  the  large  confidence  intervals  and  the  fact  that  a  model  including  all 
potential  determinants  was  not  stable.  The  low  number  of  respondents  in  some 
Member  States  was  also  the  reason  that  no  multilevel  analyses  were  performed. 
Secondly,  the  Eurobarometer  data  only  included  a  limited  number  of  relevant 
determinants. 

3.4.  Policies  and  measures  on  antibiotic  use  in  EU  Member 

States 

3.4.1.  Introduction 
We  investigated  policy  measures  that  EU  Member  States  have  taken  on  the  level  of 
the  healthcare  system  to  enhance  the  prudent  use  of  antibiotics.  This  involved  using 
an  online  survey  among  representatives  of  ministries  of  health  and  Member  State 
experts.  This  survey  —  referred  to  as  the  Member  State  survey  —  included 
respondents from all 28 Member States (see Table 3.5). This section summarises the 
main findings. We first assessed the legal framework regarding antibiotic use in the EU 
Member  States.  This  included,  in  particular,  the  dispensing  systems,  which  were  the 
only  factor  that  was  associated  with  lower  levels  of  antibiotic  use  without  a 
prescription  in  the  literature  review.  We  then  reviewed  national  policy  measures  and 
finally  auditing  and  surveillance  activities.  The  aim  of  this  review  was  to  identify 
differences in policy measures between the ARNA countries and the rest of the EU. 

3.4.2. Methods 
Data  were  collected  from  ministries  of  health  and  other  key  stakeholders  in  all  EU 
Member  States  using  an  online  questionnaire  combined  with  written  or  telephone 
reminders. 

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60 

 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Questionnaire 
The  questionnaire  was  developed  in  collaboration  with  the  University  of  Antwerp  and 
DG  Health  and  Food  Safety.  Various  versions  from  the questionnaire  were discussed. 
The final version included 32 questions. 

The survey contained questions on: 
1.  national antibiotic plans; 
2.  national measures to enhance the prudent use of antibiotics, including laws and 

3. 

legal regulations, national policy measures, surveillance and auditing; 
legal provisions for the prescription of antibiotics in each Member State, including 
laws and regulations regarding outpatient care and the sale of OTC antibiotics. 

The use of a structured questionnaire with predefined answers has the advantage that 
it  is  easier  to  complete  and  less  time-consuming  for  participants.  However,  in-depth 
information  is  harder  to  gather  with  the  questionnaires.  We  have,  therefore,  offered 
sufficient space in the questionnaire for remarks (see Annex A). The survey was web-
based  and  the  data  were  collected  in  collaboration  with  the  NIVEL  Data  Collection 
Survey Team. 

National contact persons 
National  contact  persons  were  identified  in  all  28  EU  Member  States.  These  were 
people  working  at  ministries  of  health,  national  health-insurance  boards,  national 
institutes  of  public  health  and,  where  applicable,  institutes  for  rational  use  of 
medicines or other key stakeholders. The list of national contact persons was collected 
using  various  methods.  These  included:  referring  to  attendance  lists  of  scientific 
meetings; using the support from the University of Antwerp and DG Health and Food 
Safety;  referring  to  contacts  from  previous  projects  (e.g.  APRES);  using  the  survey 
itself  (see  question  32,  Annex  A);  checking  national  websites  and  scientific 
publications; and telephone calls to national contact persons. 

The  final  list  included  93  contact  persons,  with  generally  two  or  more  people  per 
Member  State,  though  we  only  had  one  for  Cyprus  and  Luxembourg.  For  some 
Member  States  we  had  six  (the  Netherlands)  or  even  eight  (United  Kingdom).  The 
contact  persons  were  mainly  contacted  by  email,  but,  at  the  later  stage  of  data 
collection, we also contacted people by phone. 

Multiple responses from the same Member State 
For  Member  States  from  where  there  were  multiple  responses,  we  assumed  the 
responses  from  the  ministry  of  health  or  the  national  institute  of  public  health  were 
the most complete for the questions related to ‘Legal and regulatory regulations’ and 
‘Surveillance and auditing’. For the questions related to ‘National policy measures’ we 
also considered the responses from other organisations, such as universities. 

Respondents 
Table 3.5 presents an overview of the institutes that responded to the survey. We had 
a  range  of  responses,  which  included  responses  from  ministries  of  health  (five), 
national institutes of public health (five), universities (four) and national agencies for 
medicines  (three).  We  received  a  group  response  from  Austria’s  Federal  Ministry  of 
Health  and  Women’s  Affairs.  We  had  three  responses  from  the  Ministry  of  Health, 
Social and Family Affairs in Hungary. Four Member States gave just two responses. 

April 2017  

61 

 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.5.  Overview of the institute affiliations of the survey respondents. (Source: 

Member State survey.) 

Member State 

Respondent’s organisation 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

5. Cyprus 

Federal Ministry of Health 

University of Antwerp 

Medical institute of the Ministry of Interior 

Institute of Public Health Croatia 

Nicosia General Hospital and Ministry of Health 

6. Czech Republic 

National Public Health Institute 

7. Denmark 

Statens Serum Institut 

8. Estonia 

9. Finland 

10. France 

State Agency of Medicines 

Ministry of Social Affairs and Health 

Centre de Coordination de la Lutte contre les Infections  

Nosocomiales Sud-Ouest (University of Bordeaux) 

11. Germany 

Robert Koch Institute 

12. Greece 

Hellenic Centre for Disease Control and Prevention 

13. Hungary 

Ministry of National Resources 

Semmelweis University 

Szeged University 

14. Ireland 

15. Italy 

16. Latvia 

Health Protection Surveillance Centre 

National Institute of Health 

State Agency of Medicines 

17. Lithuania 

Institute of Hygiene 

18. Luxembourg 

Ministry of Health 

19. Malta 

Mater Dei Hospital 

20. Netherlands 

University Medical Centre Utrecht 

National Antibiotic Committee 

21. Poland 

Depart. of Family Medicine, Medical University of Lodz 

National Medicines Institute 

22. Portugal 

Ministry of Health 

23. Romania 

National Institute of Public Health 

24. Slovakia 

25. Slovenia 

26. Spain 

Regional Public Health Authority (Trencin) 

University Medical Centre Ljubljana 

The Spanish Agency of Medicines and Medical Devices 

27. Sweden 

The Public Health Agency of Sweden (2×) 

Swedish Strategic Programme for the Rationale Use of  

Antimicrobial Agents and Surveillance of Resistance 

28. United Kingdom  Department of Health 

April 2017  

62 

 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

3.4.3.  
National legislation, or regulations, in EU Member States 

Legal framework 

Respondents in the Member State  survey were asked  if there were any national laws 
or legal regulations for ambulatory (outpatient) care to reduce the non-prudent use of 
antibiotics  in  their  country  concerning  the  one  or  more  of  the  following  areas: 
restrictive  prescribing,  use  of  delayed  medical  prescriptions,  unused  antibiotics, 
preventive  medical  strategies,  the  use  of  prices  and  economic  incentives  and 
statutory/legal guidelines  on antibiotic usage.  Laws  or  regulations to reduce the non-
prudent use of antibiotics in outpatient care were reported in all the 20 Member States 
who  responded  to  this  question.  The  most  common  laws,  or  regulations,  concern: 
‘Restrictive  prescribing’  (nine  Member  States)  and  ‘Statutory/legal  guidelines  on 
antibiotic usage’ (five Member States) (see Table 3.6). 

Most  Member  States  (19,  see  Table  3.7)  have  legislation  that is  aimed  specifically  at 
prohibiting antibiotic use without a prescription (ii), although seven Member States did 
not  indicate  that  they  had  specific  legislation  on  antibiotics  (Czech  Republic,  Estonia, 
France,  Latvia,  Lithuania,  Slovakia  and  Slovenia).  Yet,  all  26  Member  States  who 
responded to the question about whether the law requires antibiotics to be dispensed 
with  a  prescription  indicated  that  this  was  the  case.  Denmark  and  Ireland  did  not 
respond.  The  laws  usually  cover  both  systemic  and  topical  antibiotics,  but  there  are 
exceptions. A prescription is, sometimes, not required for topical antibiotics. 

(ii) 

In the questionnaire this was referred to as self-medication. 

April 2017  

63 

 
 
 
 
 
 
 
 
                                           
Table 3.6.  EU Member States with laws or regulations to reduce the non-prudent use of antibiotics in outpatient care. (Source: 

Member State survey.) 

Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Member State 

Yes/No 

Restrictive 
prescribing 

Delayed 
prescriptions 

Unused 
antibiotics 

Preventive 
strategies 

Price & 
economic 
incentives 

Legal 
guidelines on 
antibiotic 
usage 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

5. Czech Republic 

6. Denmark 

7. Finland 

8. France 

9. Germany 

10. Ireland 

11. Latvia 

12. Lithuania 

13. Luxembourg 

14. Malta 

15. Poland 

Yes 

No answer 

Yes 

Yes 

Yes 

Yes 

No answer 

Yes 

No answer 

No answer 

Yes 

Yes 

Yes 

Yes 

Yes 

16. Portugal 

No answer 

17. Netherlands 

18. Slovakia 

19. Slovenia 

20. Sweden 

Yes 

Yes 

Yes 

Yes 

21. United Kingdom 

No answer 

Yes 

Yes 

Yes 

Yes 

No answer 
No answer 
Yes 

22. Cyprus 

23. Estonia 

24. Greece 

25. Hungary 

26. Italy 
27. Romania 
28. Spain 

April 2017  

Yes 

Yes 

Yes 
Yes 

Yes 

Yes 

Yes 
Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Other 

Two laws 

National Drug Formulary 

Strict enforcement 

Legally non-binding guidelines  

Non-prescribed use of antibiotics 

Restrictive prescribing primary care 

OTC is legally forbidden 

OTC is legally forbidden 

64 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.7.  EU  Member  States  with  legal  regulations  regarding  the  use  of  antibiotics  without  a  prescription.  (Source:  Member 

State survey.) 

Member State 

Use without a prescription in law 

Yes 

Yes 

Yes 

Yes 

No 

Yes 

No answer 

No 

Yes 

No answer 

No 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

No 

No 

Yes 

Yes 

Yes 

No 

Yes 

Yes 

Yes 

Yes 
Yes 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

5. Czech Republic 

6. Denmark 

7. Finland 

8. France 

9. Germany 

10. Ireland 

11. Latvia 

12. Lithuania 

13. Luxembourg 

14. Malta 

15. Poland 

16. Portugal 

17. Netherlands 

18. Slovakia 

19. Slovenia 

20. Sweden 

21. United kingdom 

22. Cyprus 

23. Estonia 

24. Greece 

25. Hungary 

26. Italy 

27. Romania 
28. Spain 

April 2017  

Prescriptions only by doctors. Antibiotics only available in pharmacies. Prescriptions required for antibiotics* 

It is not legal for a pharmacist to provide antibiotics without a prescription 

The Health Act (Ministry of Health of Bulgaria) 

Antibiotic consumption is not allowed 

Antibiotics are only sold on prescription by a doctor 

Nothing more than enforcement of legislation on the prescription-only use of antibiotics 

Antibiotics are drugs which require a prescription 

There is no legislation aimed specifically at prohibiting self-medication. However, there is a regulation that lists criteria 
that define whether medicinal products (drugs) should be distributed as prescription-only medicines. All antibiotics are 
authorised as a prescription-only medicine 

Antibiotics are prescription-only medicines in the country 

Anti-infective agents, including topicals, are prescription-only medicines according to the Medicines Act of Malta 

All antibiotics are available only with a prescription (one exception is fuzaridin. There is a soft recommendation to return 
leftover antibiotics to pharmacies 
Selling antibiotics OTC is illegal, both at the pharmacy and online 

Pharmacies are not allowed to dispense antibiotics without prescriptions 

It is illegal to sell antibiotics OTC 

No answer 

It is illegal to sell antibiotics OTC and for pharmacies to dispense antibiotics without a prescription 

Antibiotics belong on a drug list for which a prescription is mandatory for their procurement 

Antibiotics are prescription-only medicines. Online shopping is prohibited and antibiotics are categorised as prescription-
only 
Good pharmaceutical practice and classification rules for releasing human medical products 

Antibiotics cannot be sold without a prescription at the pharmacy 
The law on the rational use of medicines and medical devices regulates the prescription conditions for medicines. There 
are also three legal categories of restricted prescription medicines covering hospitals, specialists and the community 

65 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Legal provisions for the prescribing of antibiotics: dispensing 
The literature review (Section 3.1) showed that in countries where antibiotics are dispensed 
in  whole  packages,  instead  of  the  exact  number  of  pills  prescribed,  more  people  are  in 
possession of leftover antibiotics and the frequency of self-medication is higher.16 78 

We assessed how antibiotics are dispensed in the EU Member States (Table 3.8) and found 
that  pharmacists  dispense  whole  packages  in  16  out  of  the  23  Member  States  who 
responded to this question. Four did not know and one failed to answer. 

We  also  assessed  whether  GPs  are  permitted  to  prescribe  so-called  delayed  prescriptions. 
We  found  that  this  was  possible  in  13  Member  States  (out  of  27  responses,  Table  3.8). 
When giving a delayed prescription, the doctor advises the patient to collect the prescription 
only  if  symptoms  persist  or  become  worse  and  the  objective  is  to  reduce  overall  antibiotic 
usage.81 

Table 3.8. 

Laws and regulations regarding outpatient care across the EU: how antibiotics 
are dispensed. (Source: Member State survey.) 

Pharmacists have to 
dispense the exact number 
of pills/items/flacons 
Austria 
Bulgaria 
Cyprus 
Hungary 
Netherlands 
Slovakia 
Slovenia 
United Kingdom 

Pharmacists can dispense 
incomplete packages 

GPs are allowed to prescribe 
a delayed prescription 

Bulgaria 
Estonia 
Netherlands 
Poland 
Romania 
Slovakia 
United Kingdom  

Belgium 
Croatia 
Cyprus 
Denmark 
Germany 
Hungary 
Ireland 
Italy 
Luxembourg 
Malta 
Netherlands 
Sweden 
United Kingdom 

Legal provisions for the prescription of antibiotics: OTC sales 
Table  3.9  shows  whether  antibiotics  can  be  purchased  OTC  at  a  pharmacy  without  a 
prescription from a doctor. All EU Member States indicated that this is either illegal or only 
possible in some cases — for example in Denmark for creams and vaginal antibiotics. 

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66 

 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Legal provisions for the prescription of antibiotics: the internet 
Twelve  Member  States  indicated  that  the  internet  (see  Table  3.9)  is  an  illegal  way  of 
acquiring  antibiotics  in  their  country.  Indeed,  a  number  of  respondents  indicated  that 
antibiotics can be bought on the internet without a prescription in their own country (seven 
Member States) or from others (five Member States) (jj). 

Despite these findings, figures from the patient surveys  carried out in the ARNA countries, 
including  Estonia,  suggest  that  the  internet  does  not  play  an  important  role  in  providing 
patients with antibiotics on a regular basis (when patients were asked about where they had 
obtained  the  last  course  of  antibiotics  without  a  prescription,  internet  sources  (e.g. 
e-pharmacies) were hardly ever mentioned in the seven ARNA countries — see 4.3.2). 

Comparison of the ARNA countries with the other EU Member States 
We  could  not  find  any  clear  differences  between  the  ARNA  countries  and  those  countries 
outside of the project with regard to questions about their ‘legal framework’. This suggests 
that the high levels of non-prescription antibiotic use in the ARNA countries does not appear 
to be explained by their legal frameworks but due to other factors. 

(jj)  These are answers provided by the respondents; we were not able to validate those answers 

April 2017  

67 

 
 
 
 
 
 
 
 
 
                                           
Table 3.9.  Sales of OTC antibiotics at pharmacies without a prescription from a GP and illegal ways of acquiring antibiotics 

for the 28 EU Member States. (Source: Member State survey.) 

Member State 

Possible to purchase antibiotics OTC? 

Estimate of 
OTC (%) 

Illegal ways of getting antibiotics (e.g. internet 
or through another country) 

Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

No, but there are a couple of exceptions 

-  

No 

No, it is illegal except for creams, eye drops 

0-10 % 

Yes, internet 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

It is illegal, but in some pharmacies it is common 

No, it is illegal (but Tyrosur is available as a gel) 

5. Czech Republic 

No, it is illegal 

6. Denmark 

Yes, for specific antibiotics (creams / vaginal drugs) 

7. Finland 

8. France 

9. Germany 

10. Ireland 

11. Latvia 

No, it is illegal 

No, it is illegal 

No, it is illegal 

No, it is illegal 

No, it is illegal 

12. Lithuania 

It is illegal, but in reality it is possible in some cases 

13. Luxembourg 

No, it is illegal 

14. Malta 

15. Poland 

No, but there is one exception (nitrofurantoin) 

16. Portugal 

It is not allowed, but in some pharmacies it is common practice 

17. Netherlands 

No, it is illegal, but in some pharmacies may happen 

18. Slovakia 

19. Slovenia 

20. Sweden 

No, it is illegal 

No, it is illegal 

No, it is illegal 

21. United Kingdom 

Yes, for specific antibiotics (eye drops) 

22. Cyprus 

23. Estonia 

24. Greece 

No, it is illegal 

No, it is illegal 

It is illegal, but in some cases it may happen 

8 % 

5 % 

5 % 

-  

0 % 

0 % 

-  

-  

-  

5 % 

-  

No 

Don’t know 

No 

Yes, maybe internet (foreign countries) 

Yes, may occur via internet 

Don’t know 

Don’t know 

Don’t know 

Don’t know 

Yes, via internet, markets (Russia and Belarus) 

Don’t know 

3 % 

5 % 

-  

-  

0 % 

0 % 

0 % 

-  

0 % 

-  

No 

Yes, online/internet 

No 

Don’t know 

No 

Yes, internet 

Yes, internet 

Yes, illegal dispensing by pharmacists and internet 

Yes, from other countries or illegal internet pharmacies 

Online shopping 

No, it is illegal 

1-5 % 

Yes, online, through ‘telephone prescribing’ 

25. Hungary 

Some local antibiotics are available OTC 

0-1 % 

No 

26. Italy 

No, it is illegal except for creams, eye drops 

27. Romania 

It is illegal, but in some pharmacies it is common 

28. Spain 
ARNA countries: numbers 22-28. 

No, it is illegal 

-  

-  

Don’t know 

Online shopping 

4 % 

No 

April 2017  

68 

 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

National policy measures 

3.4.4.  
National policy measures to enhance the prudent use of antibiotics 
Twenty-six  Member  States  indicated  that  they  have  started,  or,  in  the  case  of  Latvia,  will 
start,  national  policy  measures  to  enhance  the  prudent  use  of  antibiotics  in  their  country 
(see Table 3.10). Only Slovenia indicated that they have no such policies. 

surveillance of resistance and antibiotic use (26 Member States); 
educational interventions (20 Member States); 

The five most common policy measures are: 
 
 
  media campaigns (19 Member States); 
 
 

training of HCPs (17 Member States); 
campaigns for healthcare workers (11 Member States). 

Training for healthcare professionals 
Training for HCPs — doctors and pharmacists — in good practices regarding the prescription 
of  antibiotics  was  reported  in  21  Member  States  (see  Table  3.11).  Malta  and  the  United 
Kingdom indicated that this was not the case and five countries did not know. 

The  total  number  of  Member  States  responding  to  this  question  was  greater  than  the 
previous  question  (21  versus  17  Member  States).  This  may  reflect  the  nature  of  the  two 
questions, with one question asking about national policy measures and the other asking a 
more general question about the existence of training for HCPs. 

Do professional bodies publish treatment guidelines? 
Twenty-three  Member  States  reported  that  a  professional  body  in  their  country  publishes 
treatment  guidelines  regarding  the  prescription  of  antibiotics  for  the  management  of 
infectious diseases (see Table 3.11). This was not the case in Italy and the United Kingdom, 
but  in  the  later  the  National  Institute  for  Health  and  Care  Excellence  publishes  treatment 
guidelines (kk). Three Member States did not know if there were professional guidelines. 

(kk)  https://www.nice.org.uk/guidance?unlid=310756116201461222831 

April 2017  

69 

 
 
 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.10.  National  policy  measures  to  enhance  the  prudent  use  of  antibiotics  in  the  28  EU  Member  States.  (Source: 

Member State survey.) 

National policy measures to enhance the prudent use of antibiotics 

Member State 

Media campaigns 

Surveillance 
resistance and 
use 

Educational 
interventions 

Alternative 
products 

Restrictive 
prescribing 

Prevent self-
medication (e.g. 
internet) 

Strengthen 
pharmacy 
regulations 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

5. Czech Republic 

Yes, started   

6. Denmark 

7. Finland 

8. France 

9. Germany 

10. Ireland 

11. Latvia 

12. Lithuania 

13. Luxembourg 

14. Malta 

15. Poland 

16. Portugal 

17. Netherlands 

18. Slovakia 

19. Slovenia 

20. Sweden 

Yes, started 

Yes, started   

Yes, started 

Yes, started   

Yes, started 
Yes, near 
future 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

No 

Yes, started 

21. United Kingdom 

Yes, started 

22. Cyprus 

23. Estonia 

24. Greece 

25. Hungary 

26. Italy 

27. Romania 

28. Spain 

April 2017  

Yes, started 

Don’t know 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

Yes, started 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

70 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.10. (cont.) National policy measures to enhance the prudent use of antibiotics in the 28 EU Member States. (Source: 

Member State survey.) 

Member State 

Antibiotic waste 

Collaboration 
with healthcare 
workers 

Campaigns 
healthcare 
workers 

Training HCPs 

Antibiotic 
stewardship 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

5. Czech Republic 

6. Denmark 

7. Finland 

8. France 

9. Germany 

10. Ireland 

11. Latvia 

12. Lithuania 

13. Luxembourg 

14. Malta 

15. Poland 

16. Portugal 

17. Netherlands 

18. Slovakia 

19. Slovenia 

20. Sweden* 

21. United Kingdom 

22. Cyprus 

23. Estonia 

24. Greece 

25. Hungary 

26. Italy 

27. Romania 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

28. Spain 
  Sweden also mentioned the Strama program; ARNA countries: numbers 22-28 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

April 2017  

71 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Table 3.11.  Training for HCP professionals — doctors and pharmacists — in good practices regarding the prescription of 

antibiotics in the 28 EU Member States. (Source: Member State survey.) 

Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Member State 

Training for 
HCPs 

1. Austria 

2. Belgium 

3. Bulgaria 

4. Croatia 

5. Czech Republic 

6. Denmark 

7. Finland 

8. France 

9. Germany 

10. Ireland 

11. Latvia 

Yes 

Yes 

Yes 

Yes 

Yes 

Definition of the training (summary) 

Within education and after education 

Reference provided 

At university and postgraduate education 

Croatian symposium on antibiotic resistance 

Pre- and postgraduate training 

Don’t know 

- 

Yes 

Yes 

Yes 

Prudent use of antibiotics, national treatment guidelines, 

prescription-only medicines, pharmacists advise patients 

Training during their curriculum 

Courses on antibiotic stewardship 

Don’t know 

Don’t know 

- 

- 

12. Lithuania 

Yes 

There are some training course in universities 

21. United Kingdom  No 

- 

13. Luxembourg 

Don’t know 

14. Malta 

15. Poland 

16. Portugal 

17. Netherlands 

18. Slovakia 

19. Slovenia 

20. Sweden 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

22. Cyprus 

23. Estonia 

24. Greece 

25. Hungary 

Yes 

Yes 

Yes 

Yes 

26. Italy 

Don’t know 

27. Romania 

Yes 

28. Spain 
ARNA countries: numbers 22-28.

Yes 

April 2017  

- 

- 

Training for HCPs or recommendations on antibiotic policy and therapy 

In-service training provided by local, regional and national AMR structures 

GPs during vocational training and postgraduate courses 

Antibiotic stewardship training, Vienna 

Don’t know 

Postgraduate training since 2010 and different symposia 

Educational outreach programmes, antibiotic feedback 

Included in medical and pharmacy curricula 

Further education 
Training for GPs. National public health agency organises mandatory postgraduate 
seminars 

Postgraduate courses 

- 
Graduate/postgraduate curricula of medicine and pharmacy students’ courses and 
workshops during national conferences of societies 
Training is provided by hospitals and healthcare authorities. Education is not well 
connected and this is being addressed 

No 

Yes 

Yes 

72 

Professional body publishing 
treatment guidelines 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Don’t know 

Don’t know 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

No 

Yes 

Yes 

Yes  
Yes, but for several infections 
guidelines are lacking and existing 
guidelines are out of date 

 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

National antibiotic plans 
Figure 3.1 presents an overview of whether there is a national antibiotic plan document that 
sets out activities regarding the promotion of appropriate use of antibiotics, responsibilities, 
budget and timeline in each Member State. Approximately half of the Member States have a 
national antibiotic plan (14 out of 28 Member States), but of the seven ARNA countries only 
two (Greece and Spain) had such a plan in 2015. These figures are lower compared to those 
in  a  survey  carried  out  by  the  European  Commission  which  found  that  21  Member  States 
had  a  national  plan  (in  addition  two  Member  States  reported  that  a  plan  was  under 
preparation and another two indicated they were carrying out these activities although they 
have no formal action plans) (ll). 

Figure 3.1.  National antibiotic plans in the 28 EU Member States. (Source: Member State 

survey.) 

A comparison of the ARNA countries with the other EU Member States 
Table  3.12  summarises  the  number  of  ‘national  policy  measures’  for  the  ARNA  and  non-
ARNA  countries.  ARNA  countries  have  a  national  action  plan  less  often  than  other  EU 
Member  States.  However,  besides  that,  the  ARNA  countries  have  similar  policy  measures 
compared to the other Member States. 

(ll)  http://ec.europa.eu/dgs/health_food-safety/amr/docs/amr_projects_3rd-report-councilrecprudent.pdf 

April 2017  

73 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.12.  National policy measures: comparison between ARNA countries and the other 

EU Member States. (Source: Member State survey.) 

National antibiotic plan 
Media campaigns 
Surveillance of resistance and use 
Educational interventions 
Restrictive prescribing 
Prevent self-medication 
Strengthening pharmacy regulations 

Number of countries 
‘yes’ 
Other 22 MS 
12 
14 
20 
14 
6 
5 
5 

Number of countries 
‘yes’ 
ARNA 6 
2 
5 
6 
6 
4 
4 
4 

Surveillance and auditing 

3.4.5.  
The  surveillance  or  audit  procedures  in  outpatient  care  that  target  prescribing 
practices for antibiotics 
Twenty Member States reported that they had started, or intended to start, surveillance or 
audit  procedures  targeted  at  antibiotic  prescribing  practices  in  outpatient  care  (see 
Table 3.13).  Five  reported  they  did  not  have  this  type  of  surveillance  system  (Finland, 
Germany,  Poland,  Cyprus  and  Estonia).  In  addition,  it  was  not  known  to  exist  in  Croatia, 
Romania or the United Kingdom. 

Surveillance systems in outpatient care: different HCPs 
The Member State survey included questions about the existence of surveillance systems in 
outpatient  care  for  different  HCPs.  It  found  that  GPs  and  paediatricians  are  the  best 
covered, but systems also exist for pharmacists, dentists and nurses. Sweden stood out as 
having surveillance systems for all HCPs, but other Member States, such as the Netherlands 
and Spain, also have extensive surveillance systems. 

Surveillance systems in outpatient care: feedback to HCPs 
HCPs  in  15  Member  States  receive  feedback  regarding  the  results  of  the  surveillance 
procedures.  In  two  there  was  no  feedback  and  six  did  not  know.  The  feedback  normally 
comprises conclusions and recommendations (eight Member States) and a benchmark (five 
Member  States).  No  feedback  was  provided  from  Croatia,  Cyprus,  Estonia  and  the  United 
Kingdom. 

April 2017  

74 

 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.13.  Existence  of  a  surveillance  or  audit  procedure  among  HCPs  which  targets 
antibiotic prescribing practices in outpatient care in the 28 EU Member States. 
(Source: Member State survey.) 

Member State 
1. Austria 
2. Belgium 
3. Bulgaria 
4. Croatia 
5. Czech Republic 
6. Denmark 
7. Finland 
8. France 
9. Germany 
10. Ireland 
11. Latvia 
12. Lithuania 
13. Luxembourg 
14. Malta 

15. Netherlands 

16. Poland 

17. Portugal 
18. Slovakia 
19. Slovenia 
20. Sweden 
21. United Kingdom 
22. Cyprus 
23. Estonia 
24. Greece 
25. Hungary 
26. Italy 
27. Romania 
28. Spain 
ARNA countries: numbers 22-28. 

Surveillance or audit procedure 

Yes 
Yes 
Yes 
Don’t know 
Intentions to start 
Yes 
No 
Yes 
No 
Intentions to start 
Intentions to start 
Intentions to start 
Intentions to start 
Yes 

Yes 

No 

Yes 
Yes 
Yes 
Yes 
Don’t know 
No 
No 
Intentions to start 
Yes 
Yes 
Don’t know 
Yes 

Surveillance systems in outpatient care: other types of surveillance systems 
The Member State survey (see Table 3.13) identified many alternative or ‘other’ surveillance 
systems investigating factors such as side effects, misuse of antibiotics and OTC sales. They 
mainly  concerned  side  effects  (reported  in  17  Member  States)  and  misuse  of  antibiotics 
(eight Member States). 

Comparison of the ARNA countries with the other EU Member States 
The only difference we found between the ARNA and non-ARNA countries with regard to the 
‘Surveillance and auditing’ question was the existence of surveillance or audit procedures in 
outpatient care. The ARNA countries have less well-developed surveillance systems. 

April 2017  

75 

 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 3.14.  Other national or regional surveillance systems. (Source: Member State survey.) 

Other national or regional antibiotic surveillance systems 

Misuse by citizens 
Yes 

Incidents 
Yes 
Yes 
Yes 

Member State 
1. Austria 
2. Belgium 
3. Bulgaria 
4. Croatia 
5. Czech Republic 
6. Denmark 
7. Finland 
8. France 
9. Germany* 
10. Ireland 
11. Latvia 
12. Lithuania 
13. Luxembourg 
14. Malta 

15. Netherlands 

16. Poland* 

17. Portugal 
18. Slovakia 
19. Slovenia 

Side effects 
Yes 
Yes 
Yes 
Yes 
Yes 
- 
- 
Yes 

- 
Yes 
Yes 

- 

Yes 
Yes 
Yes 

- 
- 

- 

- 

Yes 
Yes 

Yes 
Yes 

20. Sweden 
21.United Kingdom 
22. Cyprus* 
23. Estonia* 
24. Greece 
25. Hungary 
26. Italy 
27. Romania 
Yes 
28. Spain 
* No surveillance system in place; ARNA countries: numbers 22-28. 

Yes 
Yes 
Yes 
Yes 
Yes 

Yes 

OTC sales 

Other 

Yes 

Yes 

- 
- 

- 

- 

Yes 

Yes 

Yes 

Yes 

- 
- 

- 

- 

Yes 

Yes 

- 
- 

- 

- 

Yes 

Yes 

Yes 

Yes 
Yes 
Yes 

April 2017  

76 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Discussion 

3.4.6.  
The Member States survey collected responses from all 28 Member States. The survey 
showed that they all have a legal framework that prohibits the sale of antibiotics OTC, 
although a number of Member States (six) report that there are exceptions for topical 
antibiotics such as creams and eye drops. 

Despite  the  legal  framework,  a  number  of  Member  States  reported  that  patients  can 
obtain antibiotics OTC from pharmacies in their country. When asked about the levels 
of OTC sales, most Member States indicated it was 0 % or 1 %, with the exception of 
Belgium  (0-10 %),  Malta  (1-5 %),  Poland  (3 %),  Spain  (4 %),  Croatia  (5 %),  the 
Czech  Republic  (5 %),  Lithuania  (5 %),  Portugal  (5 %)  and  Bulgaria  (8 %). 
Interestingly,  the  level  of  OTC  sales  may  not  be  as  bad  as  believed  by  the  country 
experts,  as  the  Eurobarometer  findings  for  2016  tended  to  show  lower  percentages 
(e.g.  the  Eurobarometer  estimate  for  Belgium  was  3 %,  1 %  for  Malta,  2 %  for  the 
Czech Republic and 3 % for Portugal). 

The survey indicated that antibiotics are frequently available over the internet without 
a prescription, but the ARNA surveys have shown that this is not an important source 
in the  seven  Member  States  that  were  surveyed  (see  4.3.2).  Leftover  antibiotics  and 
antibiotics obtained from family or friends play a much more important role. 

The  survey  showed  that  actions  are  being  taken  by  all  Member  States  to  reduce  the 
non-prudent use of antibiotics; but the type and intensity of actions differs by country. 
Only  Slovenia  indicated  that  there  were  no  national  measures.  The  most  common 
measures  were 
‘educational 
interventions’  and  ‘media  campaigns’.  Antibiotic  stewardship  programmes  were  only 
reported by eight Member States. 

‘surveillance  of  resistance  and  antibiotic  use’, 

The  only  clear  differences  between  the  ARNA  countries  and  the  other  EU  Member 
States were: (1) the existence of national antibiotic plans, of which there were fewer 
among  the  ARNA  countries;  and  (2) national  surveillance  systems  in outpatient  care, 
of which again there were fewer among the ARNA countries. 

Our survey had a number of limitations. First, we were dependent upon the knowledge 
of  the  national  contact  persons.  We  selected  the  contact  persons  carefully,  but  our 
survey  covered  some  areas,  such  as  the  legal  context  and  regulations,  that  may  not 
have been fully covered by the respondent’s expertise. A second limitation was that a 
couple of the questionnaires were not fully completed, so we are  missing information 
for  some  Member  States,  for  example  Ireland.  These  factors  may  explain  why  we 
found  fewer  Members  States  had  a  national  antibiotic  plan  compared  to  a  survey 
carried  out  by  the  European  Commission,  which  found  that  21  Member  States  had  a 
national plan (in addition, two reported that a plan was under preparation and another 
two  indicated  they  were  carrying  out  these  activities  although  they  have  no  formal 
action plans) (mm). 

(mm)  http://ec.europa.eu/dgs/health_food-safety/amr/docs/amr_projects_3rd-report-councilrecprudent.pdf 

April 2017 

 77 

 
 
 
 
 
 
 
 
 
 
 
                                           
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

4.  The  use  of  antibiotics  without  a  prescription  in 

seven EU Member States 

Main findings 

The  results  are  based  upon  telephone  interviews  in  seven  Member  States  (Cyprus,  Estonia, 
Greece,  Hungary,  Italy,  Romania  and  Spain)  with:  2 601  patients  who  had  used  an  antibiotic 
without a prescription over the last 18 months; 712 GPs; and 702 pharmacists. 

Patients 
 

 

 

 

The use of antibiotics without a prescription is still common in Cyprus, Greece, Hungary, 
Italy, Romania and Spain, but less common in Estonia. 
OTC buying is the most common source for obtaining antibiotics in Romania, Greece and 
Hungary. In the four other Member States (Cyprus, Estonia, Italy and Spain) most patients 
make use of antibiotics left over from previous courses. The internet is not an important 
source for obtaining antibiotics. 
Respondents from Greece and Cyprus are the most convinced that antibiotics can easily be 
obtained from GPs, pharmacists and members of their social network. Respondents from 
Estonia, Hungary and Italy are the least convinced. 
Knowledge about antibiotics among patients who use antibiotics without a prescription is 
lower than among the general population. As such, it is important to educate patients 
further on antibiotics. 

HCPs 
  A majority of GPs and pharmacists receive requests from patients to prescribe or dispense 
an antibiotic even though there is no medical indication. Most GPs and pharmacists do not 
always fulfil the requests from these patients. Yet some of them sometimes do prescribe or 
dispense an antibiotic in such cases, mainly because of patient pressure or as a result of 
shared decision-making with the patient. Pharmacists also fear that customers will go to 
another pharmacy. 

  GPs and pharmacists are aware that the use of antibiotics is a problem in their respective 
Member States. A majority of the GPs and pharmacists interviewed believe that it is a 
greater problem in their own Member State than in others. 

  Cooperation between pharmacists and GPs on the issue of antibiotic use is limited and could 

be strengthened. 

4.1.  Introduction 

This  chapter  provides  greater  insight  into  the  nature  of  non-prudent  antibiotic  use  in 
seven  EU  Member  States.  We  focus,  especially,  on  the  use  of  antibiotics  without  a 
prescription.  The  Member  States  we  investigated  are  Cyprus,  Estonia,  Greece, 
Hungary, Italy, Romania and Spain. They were selected because they had a relatively 
high  level  of  antibiotics  that  are  used  without  a  prescription  (see  also  Section  2.4). 
Three surveys were carried out: one among patients who used an antibiotic without a 
prescription  over  the  last  18  months,  one  with  community  pharmacists  and  one  with 
GPs.  A  wide  array  of  topics,  all  related  to  the  use  of  antibiotics,  were  addressed  in 
these surveys (see  Section 4.2 and Annex A). The results were used  as input for the 
country-dialogue  meetings  that  were  held  in  the  ARNA  countries.  During  these 
meetings  stakeholders  in  each  Member  State  discussed  solutions  to  address  the 
problem of the non-prudent use of antibiotics (see Chapter 6). 

April 2017 

 78 

 
 
 
 
 
 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

4.2.  Methods 

Three surveys were carried out between 1 December 2014 and 26 February 2015 by a 
research organisation in each individual Member State affiliated to the TNS NIPO. TNS 
NIPO coordinated the surveys. The following surveys were carried out. 
 

A patient survey in each Member State among a net sample of 400 patients who 
used an antibiotic without a prescription over the last 18 months (In Estonia 200 
citizens were interviewed) (Section 4.2.1). 
A GP survey among a net sample of 100 GPs in each Member State (Section 
4.2.2). 

 

  A pharmacist survey among a net sample of 100 community pharmacists in each 

Member State (Section 4.2.2). 

4.2.1.  Patient survey 

Data collection 
Patients  were  approached  for  a  telephone  interview.  Those  respondents  who  wanted 
to  participate  were  asked  whether  they  had  used  antibiotics  over  the  last  18  months 
and, if so, whether this was with or without a prescription. Respondents who answered 
that they either bought the antibiotic without a prescription (antibiotics bought OTC or 
via the internet) or used antibiotics left over from previous courses were included for 
further  questions.  All interviews  were  held  in  the  national language  of  the  respective 
Member State. Table 4.1 shows how the respondents were sampled  for each Member 
State and when the fieldwork took place. 

The  data  collection  was  concluded  once  400  respondents  had  been  interviewed  who 
used antibiotics without a prescription. Between 4 000 and 20 000 people were called 
in each Member State in order to reach this number of patients. Of the 165 694 people 
who were approached, 65 103 agreed to participate in the survey and 29 647 of them 
had used an antibiotic over the last 18 months. A total of 2 601 respondents had used 
antibiotics  without  a  prescription  and  were  therefore  involved  in  the  interview.  The 
other 62 502 had not used an antibiotic without a prescription. They were only asked 
for their age and gender. Appendix X includes a flow chart with more details about the 
response. 

April 2017 

 79 

 
 
 
 
 
 
 
 
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 4.1.  Data  collection  among  citizens  in  seven  EU  Member  States  (telephone 

Member 
State 

Cyprus 

Estonia 

Greece 

Hungary 

Italy 

Romania 

Spain 

interviews). 

Sample selection 

Random through 
telephone numbers 
Random through 
telephone numbers 
Random through 
telephone numbers 
Random through 
telephone numbers 
Random through 
telephone numbers 
Random through 
telephone numbers 
Random through 
national telephone 
number directories 

Number of 
interviews 

Fieldwork dates 

Number of 
citizens 
called 
23 410 

400 

200 

400 

400 

400 

401 

400 

3.12.2014 

16.1.2015 

21.1.2015 

26.2.2015 

26 780 

15.12.2014 

20.1.2015 

28 358 

16.12.2014 

23.2.2015 

26 688 

3.12.2014 

9.2.2015 

31 312 

7.1.2015 

20.2.2015 

11 964 

9.12.2014 

19.2.2015 

17 182 

Total 
NB: The coverage for all Member States is national. For Cyprus and Estonia, the sample covers the areas 
under the control of the Republic of Cyprus and the Republic of Estonia. 

165 694 

2 601 

Questionnaire 
The  questionnaire  included  34  topics.  Firstly,  respondents  were  asked  about  the  last 
course  of  antibiotics  they  had  taken  without  a  prescription  during  the  previous 
18 months.  They  were  then  questioned  about  where  the  antibiotic  was  obtained,  the 
reasons  for  taking  it  and  the  length  of  the  course.  The  second  part  of  the 
questionnaire  contained  questions  about  potential  side  effects  and  information 
received  on  how  to  use  the  antibiotics  in  a  prudent  manner.  Thirdly,  questions  were 
asked about knowledge and attitudes towards antibiotics. Finally, there were questions 
about  the  sociodemographic  status  of  the  respondents.  This  included:  gender,  age, 
urbanisation, employment status, educational level, health insurance, the patient’s GP, 
smoking  behaviour,  perceived  health  and  chronic  conditions.  The  complete 
questionnaire can be found in Appendix B. 

Statistical analyses 
Descriptive analyses were performed (frequencies, means). 

4.2.2.  GPs and pharmacists survey 

Data collection 
In each Member State, except Cyprus, data from pharmacists and GPs were collected 
in  telephone  interviews  in  the  national  language.  In  Cyprus  data  were  collected 
through face-to-face interviews in Greek. In all Member States, we aimed to achieve a 
net  sample  of  about  100  pharmacists  and  100  GPs  interviewed.  Tables  4.2  and  4.3 
include more information about the data sample selection, the number of professionals 
approached for an interview and the dates of the fieldwork. It shows that the response 
rates vary widely between Member States. In Italy and Spain especially the response 
was low. Response among GPs was lower than among pharmacists. 

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Table 4.2.  Data collection from GPs in seven EU Member States. 

Method 

Sample selection 

Member 
State 
Cyprus 

Estonia 

Greece 

Hungary 

Italy 

Romania 

Face-to-face  

Telephone 
interviews 
Telephone 
interviews 
Telephone 
interviews 
Telephone 
interviews 

Telephone 
interviews 

Spain 

Telephone 
interviews 

Randomly selected 
from Cyprus GP list 
Randomly from full list 
of Estonian GPs 
Own list of the NIPO 
team 
TNS Hoffmann 
database 
Sample was selected 
from the database of 
the provider 
Sample was based on 
the incidence reported 
by the National 
Medical College 
Random through a list 
of 11 000 contacts 

Number of 
interviews 
100 

Fieldwork dates 

Population 

5.12.2014 

13.1.2015 

123 

100 

16.1.2015 

19.1.2015 

214 

100 

16.12.2014 

9.1.2015 

1 903 

111 

1.12.2014 

15.1.2015 

1 560 

100 

15.12.2014 

4.2.2015 

8 773 

101 

7.1.2015 

13.2.2015 

147 

100 

5.12.2014 

22.12.2014 

4 230 

Total 
NB: The coverage for all countries is national. For Cyprus and Estonia, the sample covers the areas under 
the control of the Republic of Cyprus and the Republic of Estonia. 

712 

16 950 

Table 4.3.  Data collection from pharmacists in seven EU Member States. 

Method 

Sample selection 

Member 
State 
Cyprus 

Estonia 

Greece 

Hungary 

Italy 

Romania 

Face-to-face 

Telephone 
interviews 

Telephone 
interviews 
Telephone 
interviews 
Telephone 
interviews 

Telephone 
interviews 

Spain 

Telephone 
interviews 

Randomly from the 
list of registered 
pharmacies in Cyprus 
Randomly through full 
list of Estonian 
pharmacies 
Out of the own list of 
the TNS NIPO team 
TNS Hoffmann 
database 
Sample was selected 
from the database of 
the provider 
Sample was based on 
the incidence reported 
by the National 
Medical College 
Random through a list 
of 5 000 contacts 

Number of 
interviews 
100 

Fieldwork dates 

Population 

3.12.2014 

10.1.2015 

120 

100 

16.1.2015 

19.1.2015 

196 

100 

102 

100 

16.12.2014 

9.1.2015 

487 

1.12.2014 

15.1.2015 

363 

15.12.2014 

15.1.2015 

662 

100 

7.1.2015 

13.2.2015 

172 

100 

5.12.2014 

22.12.2014 

4 837 

Total 
NB: The coverage for all countries is national. For Cyprus and Estonia, the sample covers the areas under 
the control of the Republic of Cyprus and the Republic of Estonia. 

702 

6 837 

Questionnaire 
The  questionnaires  for  GPs  and  pharmacists  each  contained  32  questions.  The  large 
majority  of  the  questions  were  the  same  but  some  were  different  because  of  the 
different  roles  of  GPs  and  pharmacists.  Questions  included  seeking  information  on: 
patients  who  request  antibiotics  without  a  prescription;  the  response  to  these 
requests;  the  reasons  patients  buy  antibiotics  without  a  prescription; the  information 
professionals provide to patients; misconceptions among patients; opinions on the use 
of antibiotics without a prescription; and possible solutions to diminish this use. Lastly, 
background  information  was  gathered  about  age,  gender,  the  year  the  HCP  became 
qualified  and  the  type  of  organisation  they  work  in.  The  complete  questionnaires  for 
the GPs and pharmacists can be found in Appendix B. 

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Statistical analyses 
Descriptive  analyses  were  performed  to  identify  frequencies  and  means.  It  is 
important to note that many pharmacists answered ‘no’ to the question: ‘Can patients 
buy  certain  oral  antibiotics  at  your  pharmacy  without  a  prescription?’.  The  response 
rates  to  some  of  the  subsequent  questions  are  low  as  the  questions  were  not 
applicable if the pharmacist did not dispense antibiotics without a prescription. 

4.3.  The use of antibiotics without a prescription: patients 

4.3.1.  The frequency of non-prescription use 

Respondents who had used antibiotics 
Of all the citizens in the seven EU Member States who were interviewed (n = 65 103), 
almost  half  (45.5 %)  had  used  oral  antibiotics  in  the  last  18  months.  Among  those 
who  had  used  antibiotics  (n  = 29 647),  8.7 %  had  used  them  without  a  prescription. 
The  highest  percentages  of  patients  who  had  used  antibiotics  without  a  prescription 
were  found  in  Greece,  Cyprus  and  Romania.  The  lowest  percentages  were  found  in 
Hungary and Estonia (Table 4.4). Three quarters of the respondents (75 %) used their 
last  course  of  non-prescribed  antibiotics  for  themselves,  the  other  quarter  for  their 
child (25 %). The number  of persons who had used antibiotics without a prescription 
for their children is highest in Italy (35 %), Spain (29 %) and Hungary (25 %) (nn). 

Table 4.4. 

Country 

The number of people approached for an interview and the number of 
people who used antibiotics without a prescription in the last 18 months 
(percentage; calculated on the basis of the total number of respondents 
who used an antibiotic). 

Percentage of persons who 
used an antibiotics without a 
prescription of all interviewed 
respondents 
(n = 65 103) 

Percentage of persons who 
used an antibiotics without a 
prescription of users of 
antibiotics 
(n = 29 647) 

% 

N* 

% 

N* 

Cyprus 
Estonia 
Greece 
Hungary 
Italy 
Romania 
Spain 
* N for which percentage is calculated. 

11.7 % 
1.2 % 
12.0 % 
2.3 % 
4.3 % 
10.2 % 
3.4 % 

3 423 
16 779 
3 330 
17 205 
9 313 
3 936 
11 795 

21.3 % 
3.0 % 
26.9 % 
5.9 % 
8.5 % 
26.9 % 
6.3 % 

1 882 
6 312 
1 487 
6 676 
4 687 
2 300 
6 303 

NB:  From  now  on,  all  results  refer  to  the  respondents  who  used  antibiotics 
without  a  prescription  as  they  are  the  respondents  who  completed  the  full 
interview (n = 2 601). 

(nn)  The  figures  differ  from  those  in  the  Eurobarometer  data,  as  the  Eurobarometer  data  ask  for  the  last 

12 months, whereas in this survey we asked for the last 18 months. 

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Among patients who took antibiotics without a prescription themselves, more than two 
thirds  were  aware  of  other  antibiotic  users  in  their  social  environment,  such  as  their 
partner or family. Around one third of patients in Greece (34 %), Hungary (37 %) and 
Romania  (32 %)  were  aware  of  others  who  use  antibiotics  without  a  prescription. 
Among patients who were aware of antibiotic users in their environment, over half of 
the  respondents  mentioned  their  extended  family  (56 %)  and  almost  half  mentioned 
their partner (46 %). The partner was most frequently mentioned in Hungary (49 %) 
and  Italy  (65 %);  in  other  Member  States,  this  was  the  extended  family  (Cyprus 
(57 %), Estonia (47 %), Greece (71 %), Spain (65 %) and Romania (53 %)). 

4.3.2.  Where do patients get antibiotics without a prescription? 

The source of the last course of antibiotics in the previous 18 months 
Respondents  who  used  antibiotics  without  a  prescription  were  asked  how  they 
obtained  their  last  course  (Figure  4.1).  The  pharmacy  was  the  most  frequently 
mentioned  source  in  Romania  (69 %),  Greece  (51 %),  and  Hungary  (51 %).  In  the 
other  Member  States  most  people  reported  using  antibiotics  left  over  from  previous 
courses  (Italy  (87 %),  Cyprus  (60 %),  Estonia  (56 %),  Spain  (53 %)).  Internet 
sources such as e-pharmacies were hardly ever mentioned (not shown in Figure 4.1). 
The  other  sources  are:  without  a  prescription  from  a  pharmacy  during  my  holiday  in 
my own country (1.5 %); without a prescription from a pharmacy during my holiday in 
another  country  (1.2 %);  and  without  a  prescription  from  a  dentist,  nurse  or  other 
HCP (5 %). 

When  patients  use  leftover  antibiotics  they  most  frequently  use  those  antibiotics 
remaining  from  a  previous  course  (71 %),  followed  by  those  remaining  from  their 
children’s  treatment  (14 %).  Other  ways  of  obtaining  such  leftover  antibiotics  are 
through  their  partner  (4 %),  friends  (0.5 %)  or  family  (6 %).  This  trend  is  the  same 
for all countries. 

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Figure 4.1.  Source  from  which  patients  obtained  the  last  course  of  antibiotics 
without a prescription in the previous 18 months (oo) (as a percentage of 
all  persons  who  used  an  antibiotic  without  a  prescription).  (Source: 
ARNA patient survey among users of antibiotics without a prescription.) 

Respondents who store leftover antibiotics 
More than half of the respondents from Greece (56 %) reported that they had leftover 
antibiotics  from  a  previous  course  (Figure  4.2).  In  the  six  other  Member  States,  the 
percentage of respondents who reported having leftover antibiotics is below 50 %, but 
is still one third in Italy (32 %) and more than one third in the other Member States. 

(oo)  The figure only presents the categories which included more than three per cent of the respondents.  

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Figure 4.2.  Did  the  patient  use  all  antibiotics  dispensed  for  the  last  treatment  or 
not?  (As  a  percentage  of  all  persons  who  used  an  antibiotic  without  a 
prescription.)  (Source:  ARNA  patient  survey  among  users  of  antibiotics 
without a prescription.) 

Reasons for use and side effects 

4.3.3.  
Patients  use  antibiotics  without  a  prescription  for  various  reasons.  Influenza,  the 
common cold, sore throat, cough, fever and headache are all common reasons to use 
antibiotics  without  a  prescription  (45 %  of  users).  Furthermore,  patients  use 
antibiotics  on  their  own  initiative  for  bronchitis  (11 %)  or  urinary  tract  infections 
(6 %).  Antibiotics  are  less  often  used  for  diseases  such  as  pneumonia  (3 %)  or  skin 
infections  (4 %).  There  are  no  major  differences  between  the  Member  States  with 
regard to the reasons why patients use antibiotics without a prescription. 

Side  effects  of  non-prescription  antibiotics  are  experienced  by  7 %  of  all  interviewed 
patients.  The  highest  percentage  of  patients  reporting  side  effects  was  found  in  Italy 
(8 %),  the  lowest  in  Romania  (5 %).  Because  a  small  proportion  mentioned  side 
effects the absolute number of patients per Member State reporting a side effect was 
low (ranging from 14 in Estonia to 31 in Italy). Therefore, we only provide figures for 
the total group of patients (n = 169). The most frequently mentioned side effect was 
an  upset  stomach  (33 %  of  all  patients  who  reported  a  side  effect),  followed  by 
diarrhoea  (30 %)  and  allergic  reactions  (12 %).  Rash  was  mentioned  by  5 %  of  the 
patients  and  two  patients  mentioned  having  experienced  renal  failure.  It  should  be 
noted  that  38 %  reported  ‘other  side  effects’ (pp).  Six  patients  (4 %)  refused  to 
answer the question or did not know. 

Why do patients self-medicate? 

4.3.4.  
Patients  have  different  motivations  for  using  antibiotics  without  a  prescription 
(Figure 4.3).  The  most  frequently  mentioned  is  that  the  same  antibiotics  were 
previously prescribed by a qualified doctor (61 % overall). In Italy, the percentage of 
patients who mentioned this as a reason was 88 %, which is the highest of all Member 
States.  Other  important  reasons  mentioned  included  an  expectation  of  quick  relief 
(22 %)  and  saving  time  instead  of  first  going  to  the  doctor  (15 %).  In  Cyprus  and 
Hungary,  respectively  15 %  and  31 %  of  patients  indicated  that  they  used  leftover 
antibiotics  without  a  prescription  because  they  were  previously  provided  by  a 
pharmacist or chemist personnel without prescription. In Hungary, almost one quarter 

(pp)  These side effects were not further specified. 

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of  patients  (24 %)  also  mentioned  that  the  triviality  of  their  symptoms  was  a 
motivation. 

Figure 4.3.  Most  commonly  mentioned  motivations  for  using  antibiotics  without  a 
prescription by users of non-prescription antibiotics (as a percentage of 
all  persons  who  used  an  antibiotic  without  a  prescription).  (Source: 
ARNA patient survey among users of antibiotics without a prescription.) 

Total 
Previously prescribed by doctor: 61 % 
Quick relief: 22 % 
Saving time: 15 % 

Spain 
Previously prescribed by doctor: 68 % 
Quick relief: 36 % 
Saving time: 24 % 
Triviality of symptoms: 24 % 

Cyprus 
Previously prescribed by doctor: 59 % 
Previously given by HCP without prescription: 
15 % 
Quick relief: 9% 

Hungary 
Previously prescribed by doctor: 41% 
Quick relief: 38% 
Previously given by HCP without prescription: 
31% 

Estonia 
Previously prescribed by doctor: 53% 
Quick relief: 26% 
Own motivation: 20% 

Italy 
Previously prescribed by doctor: 88% 
Quick relief: 5% 
Saving time: 5% 
Own motivation: 5% 

Greece 
Previously prescribed by doctor: 66% 
Quick relief: 30% 
Saving time: 21% 

Romania 
Previously prescribed by doctor: 51% 
Previously given by HCP without prescription: 16% 
Saving time: 13% 

Does knowledge about antibiotics influence their effectiveness and 
appropriate use? 
The respondents, who had all used an antibiotic without a prescription over the last 18 
months,  were  asked  about  their  knowledge  of  antibiotics.  A  minority  of  the 
respondents  (24 %)  knew  that  antibiotics  are  not  effective  against  viruses.  This  is 
clearly lower than the percentage that was found among the general population in the 
2016  Eurobarometer  survey.  Here  43 %  provided  the  correct  answer.8  Respondents 
from  Estonia  (31 %)  and  Italy  (34 %)  most  often  provided  the  correct  answer.  Four 
out  of  ten  respondents  (39 %)  correctly  knew  that  antibiotics  are  ineffective  against 
the  flu  and  colds.  Again,  this  percentage  is  lower  than  in  the  general  population  as 
measured  in  the  Eurobarometer  (56 %).8  A  large  variation  exists  between  the  seven 
Member States in our survey. In Italy, two thirds of the users of antibiotics without a 
prescription provided the correct answer, while in Hungary this was only 18 %. There 
is less variation between Member States concerning the knowledge of side effects such 
as  diarrhoea.  Overall,  48 %  of  the  respondents  provided  the  correct  answer.  This 
figure  was  66 %  in  the  general  population  in  the  2016  Eurobarometer  data.  In  the 
ARNA survey, Romania stands out. There only 35 % of the users of antibiotics without 
a  prescription  correctly  knew  about  side  effects.  A  majority  of  users  of  antibiotics 
without  a  prescription  knew  that  antibiotics  become 
ineffective  when  used 
inappropriately  (79 %).  This  is  only  slightly  lower  than  in  the  general  population  in 
2016 (84 %).8 In Greece, 92 % of the users of antibiotics without a prescription knew 
antibiotics  can  become  ineffective  if  used  inappropriately.  In  Romania  this  is  only 
68 %. 

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Figure 4.4.  Knowledge  about  antibiotics  among  users  of  antibiotics  without  a 
prescription:  percentage  of  respondents  with  correct  answer  (as  a 
percentage of all persons who used an antibiotic without a prescription). 
(Source:  ARNA  patient  survey  among  users  of  antibiotics  without  a 
prescription.) 

Can antibiotics treat bronchitis? 
Respondents  were  asked  whether,  in  a  variety  of  situations,  they  believed  it  to  be 
appropriate  to  get  antibiotics  without  a  prescription  to  treat  bronchitis.  (Figure  4.5). 
More than a quarter of the respondents thought it is appropriate to get antibiotics for 
bronchitis  in  cases  where  they  have  no  time  to  go  to  the  doctor  (26 %).  This 
percentage  was  highest  in  Hungary  (35 %),  Romania  (34 %)  and  Spain  (32 %).  For 
other  situations,  the  opinions  of  respondents  from  the  different  Member  States  were 
more  specific.  In  Spain,  almost  a  quarter  of  the  respondents  believed  it  to  be 
appropriate  to  get  antibiotics  without  a  prescription  in  a  normal  situation  during  the 
week (23 %) and one third believed it to be appropriate in cases where the doctor has 
no  time  to  see  the  patient  immediately  (32 %).  One  third  of  respondents  from 
Hungary  (32 %)  and  Italy  (32 %)  believed  it  to  be  appropriate  to  obtain  antibiotics 
during the week without a prescription when there was an important event coming up 
or a holiday abroad. Respondents from Cyprus (30 %) and Greece (28 %) think non-
prescription  use  is  appropriate  when  a  consultation  with  a  doctor  is  too  expensive. 
Again,  it  should  be  stressed  that  these  figures  apply  to  patients  who  had  used  an 
antibiotic without a prescription over the last 18 months. 

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Figure 4.5.  The  use  of  antibiotics  without  a  prescription  for  bronchitis  in  different 
situations:  percentage  of  patients  who  think it  is  appropriate  to  use  an 
antibiotic in this situation (as a percentage of all persons who had used 
an  antibiotic  without  a  prescription.)  (Source:  ARNA  patient  survey 
among users of antibiotics without a prescription.) 

The perceived availability of antibiotics among non-prescription users 
Respondents  were  asked  about  the  availability  of  antibiotics  (Figure  4.6).  One  in  five 
respondents  (21 %)  stated  that  they  can  easily  convince  their  GP  to  prescribe  an 
antibiotic. The highest  percentage  of  respondents who stated they  can convince their 
GP is found in Cyprus (32 %). The lowest is found in Spain (14 %), Italy (15 %) and 
Hungary (16 %). More than one third of all respondents (38 %) agreed that they can 
easily  obtain  antibiotics  from  their  pharmacist  without  having  a  prescription.  This 
opinion  was  most  strongly  held  in  Greece  (67 %),  Romania  (49 %)  and  Cyprus 
(44 %),  and  least  strongly  held  in  Estonia  (11 %).  The  internet  is  not  considered  a 
source  from  which  antibiotics  can  easily  be  obtained  according  to  the  respondents. 

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Only one out of ten respondents (11 %) agreed with the statement that antibiotics are 
easily obtained via the internet. In Greece and Cyprus this percentage was higher than 
the  average:  20 %  and  16 %  respectively.  Family,  friends  and  neighbours  are  a 
source  where  antibiotics  without  a  prescription  can  easily  be  obtained  according  to 
one third  (32 %)  of  all  respondents.  Again,  in  Greece  (44 %)  and  Cyprus  (47 %), 
more  respondents  than  in  the  other  countries  state  that  they  can  easily  obtain 
antibiotics without a prescription from family, friends and neighbours. In Hungary, for 
example,  this  percentage  is  only  16 %.  Overall,  respondents  in  Greece  and  Cyprus 
were most convinced that antibiotics can easily be obtained from the different sources, 
while respondents in Estonia, Hungary and Italy were least convinced. This pattern is 
in line with the level of antibiotic use without a prescription. 

Figure 4.6.  Percentage of persons who agree that antibiotics can easily be obtained 
from  different  sources*  (as  a  percentage  of  all  persons  who  used  an 
antibiotic without a prescription). (Source: ARNA patient survey among 
users of antibiotics without a prescription.) 

* Figures include respondents who agreed or strongly agreed with the statement. 

4.3.5.  

Information provision 

The provision of information on how to use antibiotics 
Among  the  respondents  who  obtained  an  antibiotic  without  a  prescription,  three 
quarters  (74 %)  received  information  about  how  to  use  them  (Figure  4.7).  The 
number  of  people  who  received  information  was  highest  in  Hungary  and  Estonia 
(respectively 83 % and 81 %) and lowest in Greece and Italy (respectively 64 % and 
67 %). In Romania this percentage was 79 %, in Spain 76 % and in Cyprus 69 %. 

The  highest  proportion  of  respondents  were  instructed  about  the  importance  of 
completing the full course of antibiotics (55 % of all respondents) and the requirement 
to only take the antibiotics for the prescribed period and at the correct dosage (59 %) 
(Figure  4.6).  About  a  quarter  (28 %)  of  all  respondents  were  told  not  to  give  the 
antibiotics  to  others  such  as  family  and  friends.  Only  16 %  of  all  respondents  were 
asked  to  return  unused  antibiotics  to  the  pharmacy.  For  all  items,  the  lowest 
proportion of respondents who reported being informed about these issues was found 
in Cyprus and the highest proportion in Spain. 

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Figure 4.7.  Percentage  of  patients  who  received  information  on  antibiotics  (as  a 
percentage of all persons who used an antibiotic without a prescription) 
(multiple answer question). (Source: ARNA patient survey among users 
of antibiotics without a prescription.) 

* Figures include respondents who said ‘yes’ to the statement. 

Who provides information? 
Half  of  respondents  who  obtained  antibiotics  without  a  prescription  received 
information  about  their  proper  use  from  a  GP.  For  those  receiving  them  from 
pharmacy  staff,  the  figure  was  43 %.  The  reason  that  the  GP  is  the  most  mentioned 
source of information may be that respondents have previously obtained an antibiotic 
from  their  doctor  for  the  same  or  another  health  symptom  and  as  such  received 
information about its use. Sources including other  HCPs (9 %), the internet (3 %)  or 
other  media  (1 %)  seem  to  be  less  relevant.  There  were  differences  between  the 
seven  Member  States  in  what  the  main  source  of  information  was.  The  GP  was  the 
most  frequently  mentioned  source  of  information  in  Cyprus  (57 %),  Estonia  (53 %), 
Greece  (58 %),  Spain  (50 %)  and  Italy  (87 %).  In  Hungary  (57 %)  and  Romania 
(74 %),  pharmacy  staff  members  were  the  most  frequently  mentioned  source  for 
information. 

4.4.  Views from GPs and pharmacists 

In  total,  712  general  practitioners  and  702  pharmacists  were  interviewed  about  the 
use of antibiotics without a prescription. 

The use of antibiotics without a prescription 

4.4.1.  
Over the last 12 months, the majority of GPs (73 %) and of pharmacists (87 %) were 
confronted  with  patients  who  requested  oral  antibiotics  even  though  these  were  not 
indicated  for  use  with  their  diagnosis  (Table  4.5a).  The  proportion  of  HCPs  with  this 
experience is highest in Cyprus (pharmacists: 98 %; GPs: 89 %) and lowest in Estonia 
(pharmacists: 53 %, GPs: 39 %). 

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Table 4.5a.  The percentage of GPs who stated they have been asked by patients to 

prescribe an oral antibiotic for reasons that are not indicated by their 
diagnosis total and by Member State (as a percentage of all GPs 
interviewed). (Source: ARNA GP survey.) 
Total 

Estonia  Greece 

Romania 

Hungary 

Cyprus 

Italy 

Spain 

Percentage of 
GPs 
Number of 
respondents*  711 
100 
* Total number that answered the question. 

100 

73 

89 

39 

97 

99 

58 

111 

75 

86 

100 

101 

74 

100 

Table 4.5b.  The percentage of pharmacists who stated they have been asked by 

patients to deliver an oral antibiotic without a prescription, total and by 
Member State (as a percentage of all pharmacists interviewed). 
(Source: ARNA pharmacist survey.) 
Total 

Estonia  Greece 

Romania 

Hungary 

Cyprus 

Italy 

Spain 

Percentage of 
pharmacists 
Number of 
respondents*  702 
100 
* Total number that answered the question. 

100 

87 

98 

53 

96 

82 

90 

97 

100 

102 

100 

100 

98 

100 

There are also differences between  Member States and between HCPs in the average 
number of patients who had requested oral antibiotics in the last month as estimated 
by GPs and pharmacists (Tables 4.6a and 4.6b). Pharmacists who reported the highest 
numbers  of  patients  during  the  last  month  are  located  in  Greece  (21  patients  on 
average)  and  Italy  (18).  GPs  in  Romania  (43)  and  Spain  (34)  reported  the  most 
requests  for  an  antibiotic  when  their  patient’s  diagnosis  does  not  indicate  prescribing 
one. 

Table 4.6a.  The average number of patients per month who, according to GPs, ask 
their GP for an oral antibiotic for reasons that are not indicated by their 
diagnosis, total and by Member State (n = 497 GPs). (Source: ARNA GP 
survey.) 

Mean 
Number of 
respondents 

Total 
12.9 

Cyprus 
10.6 

Estonia  Greece 
4.3 

21.2 

Hungary 
6.0 

Italy 
17.6 

Romania 
12.1 

Spain 
10.7 

497 

81 

36 

92 

55 

74 

86 

73 

Table 4.6b.  The average number of patients per month who, according to 

pharmacists, ask the pharmacist for oral antibiotics without having a 
prescription, total and by Member State (n = 594 pharmacists). 
(Source: ARNA pharmacist survey.) 

Total 
21.2 

Cyprus 
14.3 

Estonia  Greece 
4.0 

14.9 

Hungary 
3.7 

Italy 
23.8 

Romania 
43.4 

Spain 
34.3 

594 

92 

50 

96 

82 

88 

97 

89 

Mean 
Number of 
respondents 

Pharmacists  who  sell  OTC  were  asked  which  types  of  antibiotics  they  sell  without  a 
prescription.  Table  4.7  shows  that  amoxicillin  in  clearly  the  most  dispensed  oral 
antibiotic without a prescription in all Member States. It is dispensed as monotherapy 
and  as  combination  therapy.  Other  antibiotics  that  were  frequently  mentioned  are 
clarithromycin, ciprofloxacin and azithromycin. 

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Table 4.7. 

Top five most-sold antibiotics without a prescription, percentage of by 
pharmacists who state that they sell over the counter, total and per 
Member State. (Source: ARNA pharmacist survey.)* 

Total (n = 136) 

Cyprus (n = 27) 

Greece (n = 62) 

Italy (n = 13) 

Romania (n = 26) 

Amoxicillin 
Amoxicillin and enzyme inhibitor 
Clarithromycin 
Ciprofloxacin 
Azithromycin 
Amoxicillin 
Amoxicillin and enzyme inhibitor 
Clarithromycin 
Ciprofloxacin 
Azithromycin 
Amoxicillin 
Clarithromycin 
Cefaclor 
Amoxicillin and enzyme inhibitor 
Azithromycin 
Amoxicillin 
Amoxicillin and enzyme inhibitor 
Cefixime 
Ciprofloxacin 
Clarithromycin 
Amoxicillin 
Amoxicillin and enzyme inhibitor 
Ciprofloxacin 
Clarithromycin 
Cefalexin 
Cefuroxime 
Sulfamethoxazole-trimethoprim 
Clarithromycin 

89 % 
29 % 
22 % 
17 % 
15 % 
93 % 
37 % 
22 % 
26 % 
22 % 
90 % 
32 % 
19 % 
16 % 
15 % 
69 % 
46 % 
8 % 
15 % 
8 % 
96 % 
50 % 
42 % 
31 % 
27 % 
27 % 
27 % 
27 % 

* The number of pharmacists in Estonia, Hungary and Spain was too low to include them in this table but 
their answers are included in the total group. 

4.4.2. Where do patients get antibiotics without a prescription? 

Buying antibiotics without a prescription at the pharmacy 
Greece  is  the  only  Member  State  where  a  majority  of  pharmacists  (65 %)  indicated 
that patients can buy antibiotics without a prescription in their pharmacy. In Estonia, 
all  the  pharmacists  we  interviewed  indicated  that  patients  cannot  buy  antibiotics 
without  a  prescription.  The  same  was  true  for  a  large  majority  of  the  pharmacists  in 
the other five ARNA countries (Figure 4.8). 

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Figure 4.8.  The proportion of pharmacists who indicated that customers can buy 
certain oral antibiotics at their pharmacy without a prescription (as a 
percentage of all pharmacists; n = 611 pharmacists). (Source: ARNA 
pharmacist survey.) 

The number of other pharmacists who sell antibiotics OTC 
Almost half of the GPs interviewed (46 %) stated that they know pharmacists who sell 
antibiotics  without  a  prescription  (Figure  4.9).  This  percentage  is  highest  in  Greece 
(97 %)  and  lowest  in  Estonia  (3 %).  These  percentages  are  higher  than  those  that 
pharmacists  report  about  themselves.  However,  when  asking  pharmacists  about  OTC 
dispensing  of  antibiotics  by  other  pharmacists,  a  similar  pattern  can  be  seen.  They 
estimate  that  colleague  pharmacists  are  more  often  inclined  to  sell  antibiotics  OTC 
(Figure  4.8).  More  than  one  third  of  the  pharmacists  stated  that  they  know  other 
pharmacists  who  sell  antibiotics  OTC  (36 %).  Again,  this  percentage  is  highest  in 
Greece (64 %) and lowest in Estonia (4 %). 

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Figure 4.9.  The number of pharmacists, total and by Member State, who personally 

know colleagues in their Member State who sell antibiotics OTC (as a 
percentage of all pharmacists; n = 702 pharmacists). (Source: ARNA 
pharmacist survey.) 

How do pharmacists react to patients’ requests for antibiotics without a 
prescription? 
Pharmacists who indicated that they sometimes sell antibiotics were asked what their 
principal  reaction  is  to  requests  from  patients  who  want  antibiotics  without  a 
prescription  (Figure  4.10).  One-third  (34 %)  said  that  they  sometimes  do  sell  them 
and  sometimes  do  not.  One-third  (33 %)  advise  customers  to  first  visit  a  GP.  A 
quarter  (25 %)  advise  using  alternatives.  In  Cyprus  and  Italy  the  most  frequently 
mentioned  reaction  is  to  sometimes  sell  and  sometimes  not.  In  Greece,  the  most 
frequently mentioned reaction is to advise the customer to go to the GP first, whereas 
in Spain and Romania it is to provide alternatives for antibiotics. These results should 
be interpreted with caution, however, given the small number of respondents. 

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Figure 4.10. The reaction of pharmacists, total and by Member State, to requests 

from patients for an antibiotic without a prescription (qq) as reported by 
pharmacists (as a percentage of pharmacists who sell antibiotics OTC; n 
= 136 pharmacists). (Source: ARNA pharmacist survey; Estonia and 
Hungary are excluded from the figure as the number of respondents was 
fewer than five.) 

How do GPs react to patients’ requests for antibiotics? 
GPs were asked what their principal reaction is when a patient asks for a prescription 
for  antibiotics  when  there  is  no  indication  to  use  an  antibiotic  (Figure  4.11).  The 
principal reaction of almost half of the GPs (47 %) is to advise the patient to wait and 
come back if the symptoms persist or become worse. A quarter (26 %) always refuse 
to  prescribe  an  antibiotic,  while  17 %  sometimes  prescribe  an  antibiotic  and 
sometimes refuse. In Estonia (54 %), Cyprus (66 %), Romania (64 %), Spain (43 %) 
and Greece (42 %), the most frequently mentioned principal reaction is to advise the 
patient to wait and come back if the symptoms continue or become worse. In Hungary 
and  Italy  three  reactions  are  equally  common.  These  are:  sometimes  to  give  a 
prescription  and  sometimes  not;  always  to  refuse;  and  to  advise  to  wait  and  come 
back if the symptoms persist or get worse (Figure 4.10). 

(qq)  There were no responses from Estonia to this question.  

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Figure 4.11. The reaction of GPs, total and by Member State, to requests from 

patients for an antibiotic when an antibiotic is not indicated as reported 
by GPs themselves (as a percentage of all GPs; n = 518 GPs). (Source: 
ARNA GP survey.) 

Reasons  for  prescribing  or  dispensing  antibiotics  even  though  there  was  no 
medical indication 
GPs  and  pharmacists  who  prescribed  or  delivered  antibiotics  when  they  were  not 
indicated  were  asked  why  they  did  so.  Not  all  GPs  and  pharmacists  answered  this 
question  as  not  all  of  them  reported  prescribing  or  dispensing  antibiotics  when  not 
indicated. The results are only presented for Member States where more than 10 GPs 
or  pharmacists  responded.  For  GPs  these  were:  Greece  (12);  Estonia  (16);  Hungary 
(18); and Italy (26). For pharmacists these were: Cyprus (13); Greece (20); and Italy 
(13).  The  main  reasons  given  by  both  GPs  and  pharmacists  for  prescribing  or 
dispensing antibiotics while not indicated are pressure from the customer (GPs: 45 %, 
pharmacists:  39 %)  and  as  a  result  of  shared  decision-making  with  the  customer 
(GPs: 41 %, pharmacists: 45 %). The fear that customers will go to another pharmacy 
where  they  would  probably  get  the  antibiotics  anyway  is  a  reason  for  29 %  of  the 
pharmacists to sell antibiotics in cases where these are not indicated. 

Guidelines 
GPs  were  asked  if  their  colleagues  generally  adhere  to  antibiotic  prescribing 
guidelines. Overall, more than two thirds of GPs (68 %) have the impression that their 
colleagues always, or mostly, adhere to national guidelines. GPs are most confident in 
Estonia,  with  93 %  believing  that  their  colleagues  always  or  mostly  follow  the 
guidelines. Other Member States where two thirds or more of the GPs think that their 
colleagues  always  or  mostly  follow  the  guidelines  include:  Spain  (90 %);  Hungary 
(71 %);  Romania  (70 %);  and  Italy  (67 %).  In  Greece  (45 %)  and  Cyprus  (37 %), 
fewer than half of the  GPs interviewed believe that their colleagues always  or mostly 
follow  the  guidelines.  In  Cyprus,  23 %  of  the  GPs  interviewed  believe  that  their 
colleagues do not follow the guidelines at all. In Greece this percentage is 7 %. 

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Opinions on the use of antibiotics 

4.4.3.  
Pharmacists  and  GPs  were  asked  about  their  opinion  on  five  statements  regarding 
antibiotic  use.  The  statement  most  widely  supported  is  that  the  use  of  antibiotics 
without  a  prescription  increases  the  risk  of  antibiotic  resistance  (Figures  4.12  and 
4.13).  In  almost  all  Member  States  over  90 %  of  pharmacists  and  GPs  agreed  with 
this statement. A majority of pharmacists in all Member States (from 52 % in Estonia 
to 95 % in Italy) and GPs (from 60 % in Estonia to 98 % in Cyprus) agreed that the 
use  of  antibiotics  without  a  prescription  is  a  problem  in  the  treatment  of  respiratory 
infections. 

Pharmacists and GPs were more divided over whether the use of antibiotics without a 
prescription is not an issue among the population visiting their respective pharmacies 
or  practices.  A  majority  of  pharmacists  and  GPs  in  Estonia  (80 %/81 %),  Hungary 
(55 %/53 %) and Italy (55 %/64 %) agreed with this statement, whereas a majority 
of pharmacists and GPs in Greece disagreed (61 %/73 %). 

In all Member States except for Estonia and Hungary, the majority of pharmacists and 
GPs agreed that the use of antibiotics without a prescription is a significant problem in 
their own Member State. In Hungary, almost half of the GPs and pharmacists thought 
that the use of antibiotics without a prescription is a problem, whereas in Estonia only 
a  small  minority  believe  there  is  a  problem.  GPs  and  pharmacists  were  also  asked 
whether  the  use  of  antibiotics  without  a  prescription  is  a  significant  problem  in 
Member  States  other  than  their  own.  Except  for  Estonia,  GPs  and  pharmacists  in  all 
Member States believe that other Member States have fewer problems than their own 
when it comes to the use of antibiotics. 

Figure 4.12. The percentage of pharmacists (strongly) agreeing with five statements 

on antibiotic use, total and by Member State (as a percentage of all 
pharmacists; n = 702 pharmacists). (Source: ARNA pharmacist survey.) 

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Figure 4.13.  Number  of  GPs  (strongly)  agreeing  with  five  statements  on  antibiotic 
use,  total  and  by  Member  State  (as  a  percentage  of  all  GPs;  n  = 712 
GPs). (Source: ARNA GP survey.) 

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Pressure to prescribe or dispense antibiotics 

Pharmacists 
In  Greece,  Spain  and  Cyprus,  a  majority  of  pharmacists  who  sell  antibiotics  OTC 
reported  feeling  under  pressure  to  do  so.  In  Italy  and  Romania,  a  majority  of 
pharmacists  who  sell  antibiotics  OTC  indicated  that  they  did  not  feel  this  pressure 
(Figure 4.14). Overall, empowered customers (80 %) and the fear that customers will 
go  to  another  pharmacy  (36 %)  are  the  most  important  reasons  for  feeling  this 
pressure. This was the case in all Member States. 

Figure 4.14. 

The percentage of pharmacists who feel pressured by patients to sell 
antibiotics  without  a  prescription,  total  and  by  Member  State  (as  a 
percentage  of  all  pharmacist  who  sell  antibiotics  over  the  counter;  n 
= 136  pharmacists).  (Source:  ARNA  pharmacist  survey;  Estonia  and 
Hungary  were  excluded  because  there  were  fewer  than  five 
respondents.) 

GPs 
A  clear  majority  of  GPs  in  Estonia  (72 %),  Greece  (69 %)  and  Italy  (65 %)  reported 
that  they  sometimes  felt  under  pressure  to  prescribe  antibiotics  when  they  are  not 
indicated.  In  Spain  (53 %)  and  Hungary  (55 %)  just  over  half  of  the  GPs  indicated 
that  they  felt  the  same,  while  in  Cyprus  (47 %)  and  Romania  (41 %)  slightly  fewer 
than  half  of  the  GPs  feel  this  pressure  (Figure  4.15).  The  main  reasons  for  feeling 
pressured  are  comparable  to  those  that  were  mentioned  by  the  pharmacists: 
empowered patients (63 %) and the fear that patients will go to another GP (18 %). 

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Figure 4.15. 

The  percentage  of  GPs  who  feel  under  pressure  to  prescribe 
antibiotics  when  not  indicated,  total  and  by  Member  State  (as  a 
percentage of all GPs; n = 518 GPs). (Source: ARNA GP survey.) 

Pharmacists  who  reported  selling  antibiotics  OTC  and  all  GPs  were  asked  whether  or 
not they feel constraints put upon them in what they can do as an HCP to prevent the 
use  of  antibiotics  without  a  prescription.  More  than  half  of  the  GPs  (59 %)  and 
pharmacists (52 %; n = 49) stated that they do not feel constrained in what they can 
do.  Among  those  who  feel  constrained,  the  most  frequently  mentioned  reasons  were 
patient  pressure  (GPs:  50 %;  pharmacists:  52 %)  and,  for  pharmacists,  the  feeling 
they  have  to  do  everything  possible  to  cure  the  patient  (50 %).  GPs  from  Cyprus, 
Greece and Spain appear to believe that there need to be changes in the behaviour of 
pharmacists  as  almost  half  of  these  GPs  (49 %)  feel  constrained  because  of  OTC 
selling of antibiotics by pharmacists. 

A  majority,  80 %  on  average,  of  pharmacists  who  dispense  antibiotics  OTC  reported 
that  they  always  provide  information  about  the  use  and  side  effects  of  antibiotics  to 
patients who buy them without a prescription. Only 4 %, on average, say they never 
provide information (Figure 4.16). 

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Figure 4.16.  Pharmacists providing information to patients who receive an antibiotic 
without  a  prescription  as  reported  by  pharmacists,  total  and  by 
Member  State  (percentage  of  all  pharmacists  who  sell  over  the 
counter;  n  =  136  pharmacists).  (Source:  ARNA  pharmacist  survey; 
Estonia  and  Hungary  excluded  because  there  were  fewer  than  five 
respondents.) 

4.4.4. 

Interventions by GPs and pharmacists 

The system of dispensing antibiotics 
It was shown in Chapter 3 that in some Member States whole packages of antibiotics 
are dispensed even when they contain more antibiotics than needed. This is reflected 
in the answers given by the pharmacists in the surveys. In all Member States, a large 
majority  of  pharmacists  dispense  antibiotics  in  whole  packages.  The  exception  was 
Romania,  where  more  than  two  thirds  of  the  pharmacists  said  they  dispense  the 
precise number of prescribed units (tablets, capsules). In Greece, Spain, Hungary and 
Italy  all  pharmacists  said  they  dispensed  a  whole  package.  In  Estonia  this  was  91 % 
and in Cyprus 74 % (Figure 4.17). 

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Figure 4.17.  The way pharmacists dispense antibiotics (precise number of pills, strip 
of  pills,  whole  package),  total  and  by  Member  State  (as  a  percentage 
of  all  pharmacists;  n  = 702  pharmacists).  (Source:  ARNA  pharmacist 
survey.) 

Professional meetings between HCPs 
In  all  seven  Member  States  where  the  survey  was  held  a  minority  of  the  GPs  and 
pharmacists  stated  that  they  collaborate  with  the  other  profession.  Overall,  3 %  of 
GPs  (range  1 %-9 %)  and  7 %  of  pharmacists  (range  1 %-18 %)  reported 
participating  in  a  meeting  together  with  the  other  profession.  Having  meetings  with 
colleagues from the same profession (only pharmacists or only GPs) is more common. 
The figure was 20 % among GPs and 17 % among pharmacists. 

National campaigns to reduce the use of OTC antibiotics 
Four out of ten pharmacists are aware of national campaigns in their Member State to 
reduce the use of OTC antibiotics. More than half of the pharmacists are aware of such 
campaigns  in  Cyprus  (56 %),  Greece  (55 %),  Italy  (59 %)  and  Spain (58 %).  In  the 
other  Member  States  this  percentage  is  lower:  Romania  (29 %),  Hungary  (14 %), 
Estonia (8 %). For GPs the pattern is the same. 

The need to reduce non-prescription antibiotics 
The majority of GPs (89 %) and pharmacists (81 %) interviewed believe that patients 
should  use  fewer  non-prescription  antibiotics.  Both  professions  agree  that  public 
education  is  an  absolute  necessity  if  this  goal  is  to  be  attained  (GPs:  83 %; 
pharmacists:  88 %).  However,  GPs  and  pharmacists  do  not  agree  on  other  ways  to 
achieve a reduction in non- prescription antibiotics. While GPs consider it necessary to 
enforce  the  law  by  regulating  the  sale  of  antibiotics  (56 %)  and  strengthening 
pharmacy  regulations  (49 %),  pharmacists  believe  it  is  more  important  to  prevent 
self-medication  from  other  sources  (54 %)  and  to  provide  information  on  local 
patterns of antibiotic resistance (54 %). 

4.5.  Summary and discussion 
Chapter  2  showed  that,  in  2016,  between  2 %  (Sweden)  and  20 %  (Greece)  of  all 
antibiotics that were used in EU Member States were used without a prescription. The 
ARNA  survey  was  performed  in  seven  Member  States  with  a  relatively  high  level  of 
non-prescription use of antibiotics. It specifically focused on use without a prescription 
during  the  last  18  months.  The  results  showed  that  in  the  seven  Member  States 
selected,  the  use  of  antibiotics  without  a  prescription  is  still  common  in  all  except 

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Estonia.  Purchasing  antibiotics  OTC  is  the  most  common  source  in  Romania,  Greece, 
and  Hungary.  In  the  four  other  Member  States  (Cyprus,  Estonia,  Italy,  Spain),  most 
people  make  use  of  leftover  antibiotics  from  previous  courses.  The  internet  is  not  an 
important source for obtaining antibiotics. 

Respondents from Greece and Cyprus were most convinced that antibiotics can easily 
be  obtained  from  GPs,  pharmacists  and  members  of  their  social  network,  while 
respondents  from  Estonia,  Hungary  and  Italy  were  least  convinced  about  this. 
Influenza, the common cold, sore throat, cough, fever and headache were all common 
reasons  to  use  antibiotics  without  a  prescription.  A  previously  prescribed  antibiotic 
treatment  is  the  main  motivation  for  patients  in  all  seven  Member  States  to  use 
antibiotics without a prescription. 

Knowledge about antibiotics among patients who use antibiotics without a prescription 
is lower than among the general population (Eurobarometer 2016). In Chapter 3 it is 
shown  that  knowledge  is  an  important  determinant  of  antibiotic  use  without  a 
prescription. As such, it is important to educate patients further about antibiotic use. 
Pharmacists and GPs can play an important role in this process. 

Pharmacists  and  GPs  were  also  interviewed  within  the  context  of  the  ARNA  project, 
and  an  important  finding  was  that  a  large  majority  are  asked  by  their  patients  to 
prescribe  or  dispense  an  antibiotic  even  though  there  is  no  medical  indication.  Most 
GPs  and  pharmacists  do  not  always  fulfil  these  requests.  As  such,  they  try  to  avoid 
irrational  use  of  antibiotics.  However,  some  agree  that  they  sometimes  prescribe  or 
deliver  an  antibiotic  in  such  a  situation,  mainly  because  of  patient  pressure  or  as  a 
result  of  shared  decision-making  with  the  patient.  Moreover,  in  some  Member  States 
pharmacists  fear  that  patients  will  otherwise  simply  go  to  another  pharmacy.  The 
surveys also found that GPs and pharmacists are aware that the use of antibiotics is a 
problem  in  their  respective  Member  States.  Interestingly,  a  majority  of  the  GPs  and 
pharmacists interviewed believe that it is a bigger problem in their own Member State 
than in other countries in Europe. 

There are some limitations to the surveys, such as the low response rates, especially 
in the GP and pharmacist surveys (e.g. Estonia). As a non-response analysis was not 
possible,  it  is  not  clear  whether  the  GPs  and  pharmacists  who  participated  in  the 
surveys are representative of their overall group. Moreover, self-reports are known to 
sometimes lead to outcomes that are too positive, for example because of a tendency 
towards  providing  socially  desirable  answers.  In  addition,  despite  the  explanation 
about what an antibiotic is, we are not sure that every respondent has understood this 
well, and that they may have confused antibiotics with other medicines. Nevertheless, 
the  findings  provide  insights  into  the  views  of  patients,  GPs  and  pharmacists  on 
antibiotics.  It  also  showed  that  they  find  antibiotic  use  without  a  prescription  a 
problem in their respective Member States. As such, the findings were valuable for the 
rest  of  the  ARNA  project  where  solutions  and  interventions  were  discussed  with 
stakeholders  in  the  country-dialogue  meetings  (see  Chapter  6).  For  each  Member 
State, factsheets were  made with the results from the  surveys  comparing the results 
for  the  country  to  the  overall  results  for  all  Member  States.  It  should  be  noted  that 
Estonia  stood  out  in  all  three  surveys,  indicating  that  the  problem  of  antibiotic  use 
without  a  prescription  was  less  important  than  anticipated.  On  the  basis  of  these 
results, it was decided that no country-dialogue meeting was necessary in Estonia. 

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5.  Good practices in the EU 

Main findings 

  Our literature review and EU Member State survey showed a wide variety of interventions 
that have been implemented across the EU to promote more prudent use of antibiotics. 
  Most of the interventions, which have been evaluated and shown to be effective, focus on 
education  and  information  provision  for  the  general  public  and  HCPs  (GPs  and 
pharmacists). 
For  HCPs  there  are  other  effective  interventions,  such  as  providing  assistance  through 
technological support tools or guidelines. 

 

  On  a  policy  level,  cooperation  is  important,  alongside  the  creation  of  local  and  national 

committees, stimulating research and monitoring AMR. 

  Multifaceted  campaigns,  comprising  a  combination  of  interventions  on  different  levels, 
implemented simultaneously and repeated over time, have proven to be most effective. 
  Despite  these  findings,  effectiveness  studies  that  could  provide  evidence  are  lacking  for 

some interventions. There is a need for better-quality evaluation studies. 

5.1.  Introduction 
Member  States  across  the  EU  are  implementing  a  diverse  range  of  interventions  in 
response to the threat of rising AMR rates. These aim to promote more prudent use of 
antimicrobial  agents.  They  range  from  broad  multisectoral  and  multifaceted  national 
programmes  to  combat  AMR  to,  at  the  other  end  of  the  scale,  educational 
interventions aimed at specific target populations or HCPs. 

In this chapter we will provide an overview of the different interventions based on two 
sources of information: a comprehensive literature review (2000-2015); and a survey 
of experts in all 28 EU Member States (see ‘Methods’ below). The interventions will be 
presented  on  three  levels:  (1)  patients  and  the  general  public;  (2)  HCPs;  and  (3) 
general policy options. 

The  overall  aim  of  this chapter  is  to  provide  an  overview  of  good  practices  in the  EU 
and to identify what actions Member States can take to reduce the non-prudent use of 
antimicrobial agents in the EU. 

5.2.  Methods 

5.2.1.  Review of reviews 
We  performed  a  comprehensive  search  in  Pubmed  for  systematic  literature  reviews 
published between January 2000 and December 2015, with no limit on the language. 
The  search  string  included  the  following  search  terms  and  their  equivalents: 
(antibacterial agents OR drug resistance OR antibiotic) AND (outcome assessment OR 
health  promotion  OR  intervention  studies)  AND  (review  literature  as  topic  OR  meta-
analysis as topic) AND (Europe OR Anglo-Saxon countries OR America). 

We  chose  a  review  of  reviews  as  we  wanted  to  obtain  a  comprehensive  overview  of 
interventions and to avoid unnecessary duplication of effort. The search was restricted 
to  the  outpatient  setting  as  the  vast  majority  of  antibiotics  are  prescribed  in  this 
setting and the ARNA project had an outpatient focus. 

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Titles  and  abstracts  were  screened  by  two  readers.  The  first  reader  extracted  data 
from  the  publications  and  these  were  checked  by  the  other  reader.  Disagreements 
were resolved by discussion between the two review authors. 

The  following  information  was  extracted  for  each  review:  first  author;  year  of 
publication;  type  of  interventions;  number  of  studies  included;  time  period;  patient 
group  and  main  conclusions;  level  of  intervention,  such  as  patient,  HCP,  healthcare 
system  or  EU-wide;  specific  area;  content  of  intervention;  and,  if  possible,  whether 
the  intervention  was  effective.  An  intervention  was  defined  as  effective  if  the 
evaluation  showed  any  influence  on  the  consumption,  prescription  or  dispensing  of 
antibiotics. This could either be a general effect, such as a decrease in the prescribing 
of antibiotics, or a specific effect, such as a reduction in the mean number of units of a 
specific antibiotic prescribed. 

The PubMed search, carried out from August to December 2015, resulted in a total of 
206  hits.  Screening  of  titles  and  abstracts  resulted  in  a  total  of  eight  potentially 
relevant abstracts. After reading the full texts, one article (Kaki, 2011) was excluded 
as it only focused on studies within an intensive-care setting. This resulted in a total of 
seven relevant reviews (see Table 5.1). 

5.2.2.  Member State survey 
National  contact  persons  were  identified  by  the  ARNA  team  in  all  28  EU  Member 
States.  These  were  mostly  people  working  at  ministries  of  health,  national  health 
insurance boards, national institutes of public health and, where applicable, institutes 
for the rational use of medicines. The people were contacted by email. At a later stage 
they were also contacted directly by phone. 

An online questionnaire included 32 questions covering the following topics. 
1. 
2. 

National antibiotic plans. 
National measures to enhance the prudent use of antibiotics, including laws and 
legal regulations, national policy measures, surveillance and auditing. 
Legal provisions for the prescription of antibiotics in each Member State, 
including laws and regulations regarding outpatient care and the sale of OTC 
antibiotics. 

3. 

The  Member  State  survey  collected  a  total  of  70  documents  and  websites  related  to 
national  policy  measures  obtained  from  15  Member  States:  Austria,  Croatia,  Cyprus, 
Denmark,  French,  Hungary,  Germany,  Ireland,  Italy,  Lithuania,  Malta, 
the 
Netherlands, Slovenia, Sweden and Spain. 

After reviewing the full texts of the documents and websites, 56 documents/websites 
were considered relevant and provided additional information to the review of reviews. 

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Table 5.1.  Characteristics of the seven articles included in the review of reviews on good practices. 
Author 

Patient group  Conclusions 

Period 

Type of 
interventions 
Interventions to 
improve antibiotic 
prescribing practices in 
outpatient care 

Number of 
studies 
79 

1966-2000 

General 
population 

Arnold 
(2005)82 

Arroll 
(2003)83 

Drekonja 
(2015)84 

Delayed prescriptions 

5 

1966-2003 

50 

2000-2013 

Effect of outpatient 
antimicrobial 
stewardship 
programmes on 
prescribing, microbial 
outcomes and costs 

Patients with 
upper 
respiratory 
tract infections 
General 
population 

Holstiege 
(2014)85 

Computer-aided clinical 
decision support 
systems (CDSS) for 
improving antibiotic 
prescribing in primary 
care 

7 

From 
inception to 
2013 

General 
population 

April 2017 

 106 

— Simple, single intervention studies (printed educational materials) generally 
resulted in small, sometimes statistically significant, changes in prescribing 
behaviour 

— All studies examining the effect of educational meetings utilising interactive 

workshops had statistically significant results 

— The effects of doctors’ reminders were mixed and the number of studies too 

small to draw any clear conclusions 

— Patient educational materials, along with limited physician education, produced 
small changes in the prescribing rate of antibiotics for viral respiratory tract 
infections 

— Multifaceted interventions involving doctors, patient and community education 

consistently produced moderate changes in prescribing behaviours 

— All studies demonstrated that when patients were asked to delay obtaining or 
collecting an antibiotic prescription, they were much less likely to collect it 
than those offered an immediate prescription 

— It appears that interventions aimed at increasing the prescribing of certain 
recommended first-line antibiotics for specific infections are more likely to 
produce substantial changes in prescribing than those interventions targeting 
overall inappropriate antibiotic use 

— There is a consistent reduction in the use of antibiotics in all five controlled 

trials 

— Outpatient antimicrobial stewardship interventions of all types were associated 

with favourable changes in antimicrobial prescribing 

— Changes in prescribing did not adversely affect patient outcomes or drug costs, 

although these outcomes were not universally reported 

— Laboratory testing to aid antimicrobial stewardship, especially procalcitonin 

and CRP assays, appears to be a promising tool that can be used to decrease 
antimicrobial prescribing 

— Efforts to improve provider communication with patients also showed 

promising results 

— Five out of seven trials showed significant effects in improving antibiotic-

prescribing behaviour 

— CDSS show a promising effectiveness in improving antibiotic-prescribing 

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Huttner86 
(2010) 

Wang 
(2015)87 

Wirtz 
(2013)88 

Large-scale public 
campaigns in high-
income countries 

Antibiotic stewardship 
programmes with a 
specific focus on 
France 

Policy interventions to 
prohibit OTC antibiotic 
sales in four Latin 
American countries 

22 

2007-2008 

2000-2014 + 
letters to 
relevant 
organisations 

1995-2009 
+ review of 
legislation 

61 

Documents 
and 
legislation 
from the 
four 
countries 

All campaigns 
focused on 
respiratory 
tract infections 
General 
population 

— The evaluation of effectiveness is a weak point of numerous campaigns. 

Several campaigns have not been evaluated and the scope and quality of 
evaluation of the remaining ones varied greatly 

— The measures implemented in France and abroad were usually more 

persuasive than restrictive 

— The positive impact of the campaigns on antibiotic use was demonstrated. But 

it is not clear if it was positive in all countries 

General 
population 

— It seems that a more comprehensive set of interventions including the 

involvement of stakeholders, promoting changes in prescribing behaviour and 
a public education campaign, can enhance the uptake of the policies. However, 
the interventions have to be sustained over time 

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5.3.  Good practices on the patient and public health levels 

The review of reviews and Member State survey showed that interventions on the patient 
and  public  health  levels  have  predominantly  focused  on  providing  patients  with 
information  and  education  to  increase  their  knowledge  about  antibiotics  and  AMR  (see 
Table 5.2). 

Table 5.2.  Overview of interventions on the patient and public health levels and 

source. 

Source  

Patient 
information 
and education 

Patient educational materials82 (information documents, flyers)  Literature 
Literature 
Combination of pamphlets, posters, website, letters, 
guidelines, seminars, distribution of cold care kits to 
administer the correct medication at home (no use of mass 
media)86 
Facebook page with information about antibiotics and how to 
use them properly (see example) 
School materials for children (see example) 
Online campaign about antibiotics (see example) 
Posters for waiting rooms, brochures and handouts focusing 
on the appropriate use of antibiotics 
Television spots86 

Survey: SE 
Survey: IT 
Survey: DK 

Survey: HR 

Literature 

Example: public health campaign in Croatia — Facebook 
Croatia created a Facebook page with information about antibiotics and how they should 
be used properly. 

Source (Croatia): https://www.facebook.com/reciNEantibioticima?fref=ts 

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Example: online public health campaign in Italy 

A website was created for an online campaign in the Italian Region of Emilia-
Romagna (in the north of Italy) about: ‘Antibiotics. It’s a shame to use them badly. 
Effective if necessary, harmful if abused’, which consists of posters, brochures and 
YouTube videos. 

Source (Italy): http://salute.regione.emilia-romagna.it/antibiotici 

Example: EU project — public health campaign for children 
The ‘e-Bug’ project is led by Public Health England’s Primary Care Unit and involves 
a consortium of 28 international partner countries (mostly EU Member States). 

Source (United Kingdom): http://www.e-bug.eu 

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5.4.  Good practices on the HCP level 

The  review  of  reviews  and  Member  State  survey  showed  that  various  interventions  are 
being  implemented  on  the  HCP  level  to  promote  more  prudent  use  of  antibiotics 
(Table 5.3). 

Table 5.3.  Overview of interventions on the HCP level and source. 

Source 
Literature 
Literature 
Literature 
Literature 
Literature 
Literature 
Survey: AT 
Literature 
Literature 

Campaigns86 
Printed educational materials82 
Academic detailing82 
Educational meetings89 
Audit and individualised feedback82 84 
Communication skill training for providers82 
Practical training in the field of antimicrobial stewardship 
Computer-aided clinical decision support systems84 85 
Online resources for information (material available to GP for 
patient education)87 
E-learning course about AMR or antibiotic prescribing 
Online toolkit for responsible use of antibiotics 
Anti-infection tool IT system: registering antibiotic prescriptions, 
healthcare associated infections 
Delayed prescribing82 84 90 
GP charter sign confirming compliance with official 
recommendations for prescribing antibiotics87 
Doctor’s reminder (offering summary of evidence for prescribing 
for acute otitis media)82 
Documents allowing doctors to help patients who do not speak 
English (guidance, education, tools)87 
Rapid antigen testing/C-reactive protein testing/point-of-care 
tests82 
Development and implementation of antimicrobial prescribing 
guidelines with evidence-based recommendations for diagnosis 
and treatment82 
Online guidelines for the treatment of different kinds of diseases  Survey: AT, HR, 
MT, NL, SE, DK, 
FR, IE 
Survey: SE 

Survey: NL, DE 
Survey: NL 
Survey: SE 

Literature 
Literature 

Literature 

Literature 

Literature 

Literature 

Education 

Techno- 
logical 
support 
tools 

Prescribing 
antibiotics 
and 
diagnostics 

Guidelines 

Professional 
meetings 

Local guidelines and memoranda, adapted to local needs, are 
produced based on national recommendations 
Organisation of conferences and meetings with GPs to raise 
awareness for the need to reduce antibiotic useuse82 
One-off payment (independent of practice performance)82 

Financial 
incentive 
Surveillance  Strengthening control measures and prevention of infections by 
intensifying surveillance of the implementation of measures by 
health professionals 
Strengthen the surveillance of antibiotic consumption 
A policy of not reimbursing some agents, such as cefuroxime, 
was implemented to discourage its prescription87 

Financial 
constraints 

Literature 

Literature 

Survey: CY 

Survey: CY 
Literature 

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Educational interventions 
We found that EU Member States often target HCPs with a wide range of interventions to 
stimulate the prudent use of antibiotics (see Table 5.3). Many of the interventions focus 
on  the  continuous  education  of  HCPs  through,  for  example,  the  use  of  campaigns.  This 
has been proved to have a positive effect.82 

Material available to GPs for patient education by country (Wang et al. 2015) 

Material available to GP for patient education 
Region, year 
Country 
National, 2010 
Canada 
Regional, 2010 

Available material 
Recommendations, models of delayed prescriptions 
Recommendations, mobile applications, information for 
patients in case of otitis and other health symptoms 

Ireland 

National, 1999 
National, 2013  

Online recommendations 
Posters, advice for patients when antibiotics are not 
prescribed, in case of delayed prescription 

Luxembourg 

National, 2012 

Advice for patients given by the doctor when antibiotics are 
not prescribed, and in case of viral infection 

Norway 

Regional, 2006 

Articles, recommendations 

Sweden 

National, 1995 

Advice for patients concerning common infections in 
primary care settings, available in several languages 

United 
Kingdom 

National, 2012 

Recommendations, training for doctors, advice for patients 
in several languages 

United States 

Regional, 1997 
Regional, 1995 

Training for HCPs, online resources for patients 
Advice for patients given by the doctor when antibiotics are 
not prescribed, and in case of viral infection, posters 

Feedback  on  antibiotic  prescribing  and  dispensing  is  another  common  intervention.  The 
feedback is provided to give HCPs insight into their own behaviour.  Part of the Swedish 
strategic  programme  against  antibiotic  resistance  is  to  give  feedback  on  the  personal 
prescribing patterns of GPs, allowing them to compare their prescribing pattern with their 
closest colleagues (rr). The same happens in peer review groups in the Netherlands (ss). 

Technological interventions 
Evidence  demonstrates  the  importance  of  technological  support  tools  for  improving 
antibiotic  prescribing  and  dispensing.  Computer-aided  clinical  decision  support  systems 
are  popular  and  effective.84  85  Another  example  is  that  HCPs  can  find  online  support  on 
how to communicate with targeted patient groups.87 

(rr)  Source: Member State survey, see: http://strama.se/?lang=en 
(ss)  Source: Member State survey, see: http://www.medicijngebruik.nl/fto (in Dutch). 

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Prescribing and diagnostics 
A number of interventions give guidance on antibiotic prescribing. Rapid antigen testing82 
and delayed prescribing82 84 90 especially are seen as effective measures to stimulate more 
prudent use of antibiotics. The latter is a strategy  in which the patient is asked to wait, 
usually  24  to  48  hours  after  a  visit  to  a  clinic,  in  order  to  determine  if  an  antibiotic  is 
needed for an illness. Another  example is the signature of a  charter by the GP in which 
he or she pledges to comply with official recommendations for prescribing antibiotics.87 

Training of GPs/guidelines for good practices by country (Wang et al. 2015) 

Training of GPs/guidelines for good practice 
Intervention 
Country 
Computerised decision aids: these tools help to choose an 
United States 
agent better, rather than decrease the amount of 
prescribed antibiotics 

Denmark, some Canadian 
provinces (Alberta), United 
States, Finland, Norway, 
Sweden 

Scotland 

The Netherlands 

Mobile applications to assist doctors in their practice 

Courses for HCPs are available on the internet to teach 
them about antibiotic use and bacterial resistance 

GPs regularly organise peer groups to discuss their 
prescription profiles with pharmacists 

North Carolina (United States), 
United Kingdom, the 
Netherlands 

Raising awareness among GPs and training them in 
antibiotic stewardship begins in the course of their 
studies. Courses on this issue and a final examination 
have already been implemented 

Diagnostic tests by country (Wang et al. 2015) 

Diagnostic tests 
Country 
France, United States, Italy, 
Luxembourg, Germany, Finland, 
Norway, Sweden 

Intervention 
Recommend use of diagnostic tests to determine whether 
or not antibiotic therapy is required 

Belgium, the Netherlands 

Do not recommend any diagnostic tests and antibiotics, 
except in very specific cases 

Ireland 

Delayed prescription 

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Guidelines 
Making  clear  and  easily  available  treatment  guidelines  available  for  all  HCPs  is  another 
intervention that has been identified to promote the prudent prescribing and dispensing 
of antibiotics.82 The guidelines should be kept up to date by using new scientific evidence. 
They should also be adapted to local needs. Some countries have already integrated this 
into  their  national  antibiotic  plans.  For  example,  the  national  programme  for  control  of 
antibiotic  resistance  in  Croatia  states  that  good  clinical  practice  in  the  use  of  antibiotics 
should be promoted. This is to be achieved by  developing guidelines based  on  evidence 
related  to  the  rational use  of  antibiotics  and  through  encouraging  the  adoption  of  these 
evidence-based guidelines (tt). 

Source (Ireland): http://www.antibioticprescribing.ie 

Other 
Further  interventions  include  surveillance  and  those  involving  financial  incentives  to 
promote  evidence-based  prescribing.  This 
is  the  case  with  Sweden’s  Strama 
programme (uu).  Other  finance-related  interventions  involve  simply  not  reimbursing 
certain antibiotics.87 

(tt)  Source: Member State survey. 
(uu)  http://strama.se/?lang=en 

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5.5.  Policy options 

The review of reviews and Member State survey showed that a range of interventions are 
being used on a policy level to promote more prudent use of antibiotics (Table 5.4). 

Table 5.4.  Overview of interventions on the policy level and their source. 

Regulatory 
measures 

Prohibition of OTC antibiotic sale 
Enforce nationwide and involve pharmacies in promoting this88 
Inspections of pharmacies 
Prohibit the splitting up of packages in order to sell antibiotic 
pills individually 
Changes to the financial or healthcare system such as the 
reform of primary care82 

Source 
Literature 
Literature 
Literature 

Literature 

Cooperation  Develop, strengthen and maintain intersectoral and 

Local 
committees 

Improve 
prudent use 

Publicity 

Survey: SE 

Survey: SE 

Survey: 
HR, CY, SE 
international cooperation and commitments 
Survey: 
Establishment of multidisciplinary networks dedicated to the 
FR, SE, ES 
correct use of antibiotics 
Political support and involvement of stakeholders and politicians  Survey: SE 
Survey: CY 
Local committees to monitor antibiotic use 
Survey: SE 
Establishment of local strategic programmes against AMR 
responsible for such things as the surveillance of antibiotic 
consumption 
Development of platforms to exchange information between 
local and national levels 
Reimbursement based on performance to encourage, strengthen 
and intensify the efforts towards promoting patient safety in the 
county councils 
Set national targets for the reduction of antibiotic prescriptions 
e-Health Agency: pharmaceutical sales statistics, delivered by 
all registered pharmacies 
Provide prescribers with an overview of their personal 
prescribing of antibiotics, conduct analysis of prescribing and 
draw conclusions on compliance with local treatment 
recommendations 
Supervise and monitor the use of antibiotics in order to preserve 
their effectiveness 
Collaboration between the public health agency and local 
laboratories, which enables national and local monitoring with 
good geographic coverage 
Encourage professional associations to identify and monitor 
indicators of rational prescribing or control of sales of antibiotics 
Annual report with, for example, data on human surveillance of 
antibiotic use and resistance 
The marketing and promotion of antibiotics should not work 
against the aims of the plan of action. Prescribers of antibiotics 
should have access to impartial information 
Exploitation and dissemination of information and knowledge 
generated 
Website support, for example with information about 
campaigns, symposiums, European Antibiotic Awareness Days 
(EAAD) and other EU initiatives such as e-Bug 

Survey: 
NL, SE 
Survey: SE 

Survey: FR 
Survey: SE 

Survey: 
HR, HU, ES 

Survey: SE 

Survey: SE 

Survey: ES 

Survey: HR 

Survey: HR 

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Regulatory measures 
Regulatory measures can contribute to more prudent use of antibiotics. Examples include 
the  prohibition  of  OTC  antibiotic  sales,  together  with  the  inspection  of  pharmacies  and 
the  nationwide  enforcement  of  laws.88  In  the  EU,  OTC  sales  are  illegal  but  the  Member 
State  survey  showed  that  countries  differ  in  the  extent  to  which  they  enforce  this  law. 
Another  regulatory  measure  is  related  to  the  delivery  of  the  precise  number  of 
pills/items/flacons needed for a treatment course.16 

The last point has been assessed in Spain by the national antibiotic plan and it was found 
to be a complicated issue as it involves a number of changes to the delivery chain (e.g. 
opening  packages,  repackaging  and  adding  product  instructions),  some  of  which  are 
regulatory  (e.g.  cutting  the  blister  packages  for  distribution  to  patients).  Spain  has  also 
looked  at  changing  the  way  primary  packages  are  produced  (e.g.  packages  in  different 
sizes or delivery of large batches plus product  instructions), but this is also complicated 
and poses a number of challenges. 

When  this  point  was  discussed  by  the  ARNA  Expert  Group  it  was  noted  that  there  are 
concerns  from  pharmacists  about  opening  packages,  cutting  the  blisters  and  adding 
product  instruction  (e.g.  it  will  slow  down  the  dispensing  process).  Furthermore, 
pharmacies  do  not  receive  reimbursement  to  print  the  extra  product  leaflets  and  some 
Member  States  reported  pharmacies  do  not  have  the  technology  to  print  the  product 
leaflets. 

Cooperation 
In  order  to  implement  interventions,  cooperation  and  collaboration  are  needed.  For 
instance, international cooperation is needed for pan-European campaigns, while national 
plans to combat AMR require collaboration from various stakeholders in different sectors 
such  as  the  healthcare,  regulatory  and  agricultural  ones.  Additionally,  support  from 
relevant  stakeholders  is  important.  An  important  example  is  the  EAAD,  which  is  an 
annual  European  public  health  initiative  that  takes  place  on  18  November  to  raise 
awareness about the threat to public health of antibiotic resistance and the importance of 
prudent  antibiotic  use  (see  below).  This  initiative  also  supports  national  and  local 
committees  and  encourages  the  exchange  of  information  between  the  local  and  the 
national  levels (vv).  Furthermore,  the  Swedish  survey  results  indicated  that  cooperation 
between professional associations should be encouraged in order to identify and monitor 
the indicators of rational prescribing and to control sales of antibiotics (ww). 

(vv)  http://ecdc.europa.eu/en/eaad/Pages/Home.aspx 
(ww)  Source: Member State survey. 

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Source (ECDC): http://ecdc.europa.eu/en/eaad/Pages/Home.aspx 

Supporting prudent use by national stakeholders 
The  Member  State  survey  showed  that  national  stakeholders,  such  as  professional 
organisations,  the  ministry  of  health  or  the  medicines  agency,  can  support  HCPs  and 
patients  to  enhance  the  prudent  use  of  antibiotics.  Examples  include  the  setting  of 
targets  for  a  reduction  in  the  number  of  antibiotic  prescriptions  and  to  measure 
adherence  to  treatment  recommendations (xx).  Another  example  is  to  provide  the 
infrastructure  for  monitoring  the  use  of  antibiotics  both  nationally  and  regionally (yy). 
Moreover,  policymakers  can  encourage  professional  associations  to  identify  and  monitor 
the indicators of rational prescribing and the control of antibiotic sales (zz). 

Source (France): http://antibioclic.com/ 

(xx)  E.g. http://strama.se/about-strama/?lang=en; https://guidelines.nhg.org/ 
(yy)  E.g. http://www.eurosurveillance.org/viewArticle.aspx?ArticleId=19036 
(zz)  E.g. http://fingertips.phe.org.uk/profile/amr-local-indicators 

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Source (Spanish Society of Medical Microbiology): 
http://seimc.org/documentoscientificos.php?mn_MP=3&mn_MS=117 

Public health campaigns 
Public health campaigns can contribute to the raising of awareness of the problem of AMR 
(see  example  below).86  Annual  surveillance  data  can  also  be  published  in  order  to  help 
raise awareness.91 

Source (United Kingdom): Huttner et al. 2012 

5.6.  Multifaceted interventions 
One  important  finding  from  the  review  of  reviews  is  that  multifaceted  campaigns  with 
their interventions on both the patient or public health level and the HCP level are more 
often effective. Examples include: 
 

the combination of printed educational materials for both doctors and their patients, 
together with educational meetings led by opinion leaders; 
the combination of group discussions on guidelines, training in communication skills 
and providing information regarding C-reactive protein (CRP) testing;84 
the combination of at least four interventions in the areas of pamphlets and posters, 
print  media,  billboards,  radio,  television,  websites,  letters,  guidelines,  academic 

 

 

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detailing or educational outreach, seminars and individual feedback about prescribing 
behaviour.82 

An  example  of  a  Member  State  where  multifaceted  interventions  are  implemented  is 
Slovenia,  where  there  have  been  a  number  of  activities in  which  the Ministry  of  Health, 
the  National  Committee  for  the  Rational  Use  of  Antimicrobials  and  academic  units  are 
involved.  The  focus 
is  on  four  areas:  education,  engineering,  economics  and 
enforcement.  They  target  patients  and  HCPs  with  interventions  in  each  of  these  four 
areas (aaa). 

Having a national action plan can often clarify the roles of each organisation or individual, 
encourage  work  in  an  multifaceted  manner  and  establish  clear  targets  (see  example 
below for Sweden). 

Source (Sweden): http://strama.se/wp-content/uploads/2016/06/swedish-strategy-to-combat-antibiotic-
resistance-1.pdf 

5.7.  The effectiveness of the interventions 
Evidence  regarding  the  effectiveness  of  the  interventions  was  often  weak  because  they 
were  not,  or  were  not  properly,  evaluated.  Furthermore,  the  quality  of  the  published 
studies  varied  greatly.81  In  addition,  studies  provided  limited  information  on  the 
sustainability  of  interventions  or  whether  they  could  increase  in  size  to  accommodate  a 
growing amount of work. 

There is a need to have better knowledge about the effectiveness of interventions.81 This 
will help decisions on whether an intervention should be implemented or continued. One 
area where there was an important lack of evidence of effectiveness was the healthcare-
system level. 

(aaa)  Source: Member State survey. 

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5.8.  Summary and discussion 
The  review  of  reviews  and  the  Member  State  survey  showed  that  a  large  number  and 
variety of interventions have been initiated across the EU to promote the prudent use of 
antibiotics, of which some examples are summarised in the box below. The interventions 
range from fully coordinated activities within a national antibiotic plan to combat AMR, to 
actions  aimed  at  certain  groups,  such  as  healthcare  workers,  or  even  smaller 
interventions targeted at specific populations, such as children. 

It is difficult, however, to be sure whether many of the interventions are effective. This is 
because many of the interventions have not been properly evaluated, especially those on 
a  healthcare-system  level.  This,  therefore,  is  an  area  that  requires  further  attention. 
However,  we  found  that  many  initiatives  exist,  and  Member  States  across  the  EU  can 
learn from each other in order to better develop activities  that will promote the prudent 
use of antibiotics in each of them. 

Box 5.1. 

Examples of good practice across the EU. 

Patient level 
  Croatia created a Facebook page with information about antibiotics and how they should be 

 

 

used properly. 
The Italian region of Emilia-Romagna (in the north of Italy) held an online campaign about: 
‘Antibiotics. It’s a shame to use them badly: effective if necessary, harmful if abused’, which 
consists of posters, brochures and YouTube videos: http://www.salute.regione.emilia-
romagna.it/antibiotici 
The e-Bug project is led by Public Health England’s Primary Care Unit and involves a 
consortium of 28 international partner countries (mostly EU Member States): http://www.e-
bug.eu/ 

HCP level 
  The  Netherlands  has  a  strong  system  of  peer  review  groups  where  GPs  and  pharmacists 
meet to discuss pharmacotherapy. Those groups strengthen the cooperation between GPs and 
pharmacists: https://www.medicijngebruik.nl/fto 
The  Swedish  strategic  programme  against  antibiotic  resistance  (Strama)  includes  feedback 
on  the  personal  prescribing  patterns  of  GPs,  allowing  them  to  compare  their  prescribing 
pattern  with 
to  avoid  over-prescription: 
http://strama.se/?lang=en 

their  closest  colleagues, 

for  example 

 

Healthcare-system level 
 

The  European  Antibiotics  Awareness  Day  is  an  annual  European  public  health  initiative  that 
takes place on 18 November to raise awareness about the threat to public health of antibiotic 
use: 
resistance 
http://ecdc.europa.eu/en/eaad/Pages/Home.aspx 

importance 

antibiotic 

prudent 

and 

the 

of 

Multifaceted 
 

In  Slovenia  there  have  been  a  number  of  activities  in  which  the  Ministry  of  Health,  the 
National  Committee  for  the  Rational  Use  of  Antimicrobials  and  academic  units  are  involved. 
The focus is on four areas: education, engineering, economics and enforcement.  They  target 
patients and HCPs with interventions in each of these four areas. 
In  Spain  the  national  antibiotic  plan  was  introduced  in  2014,  with  its  main  aim  being  to 
enhance  the  prudent  use  of  antibiotics  using  a  One  Health  approach.  As  such,  a  lot  of 
initiatives  are  already  developed  in  Spain.  The  national  antibiotic  plan  is  coordinated  by  the 
Medicines Agency (AEMPS). 

 

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6.  Expert  opinions  and  consensus  statement  on  policy 

options 

The main findings of the expert meeting 

Twenty  experts  discussed  and  agreed  a  set  of  interventions  that  could  reduce  the  use  of 
antibiotics without a prescription in EU Member States: 

Public health campaigns 
 
 
  Messages  in  mass-media  campaigns  should  be  consistent  with  information  from 

There is a need to implement multifaceted interventions that are evaluated correctly. 
It is important to take into account people’s health literacy. 

pharmacists and GPs. 

HCPs 
 

 

Efforts should be made to strengthen collaboration between HCPs, and especially between 
GPs and pharmacists. 
Rapid diagnostic tests such as those  performed  at the patient’s bedside, rather than in a 
laboratory,  could  help,  but  more  research  is  needed  to  assess  their  integration  into 
outpatient care. 

Policy options 
 

National antibiotic plans or national plans to combat AMR help support activities in the field 
and the prudent use of antibiotics. 

 

  Where  OTC  sales  are  occurring  in  EU  Member  States,  enforcement  practices  need  to  be 
strengthened.  The  use  of  sanctions,  positive  or  negative,  needs  to  be  considered,  but 
positive incentives are preferable. 
It  is  advisable  that  antibiotic  packages  be  tailored  to  the  course  of  treatment.  This, 
however, would be a complicated issue for countries to address and implement, as it will 
require a number of regulatory modifications because the legal framework would need to 
be adapted. 
The  length  of  time  that  antibiotic  prescriptions  are  valid  should  be  shorter  than  is 
traditional, as this would help avoid the misuse of antibiotics. 
Appropriate use of delayed prescribing should be encouraged. 

 

 

6.1.  Introduction 

We gathered 20 experts from nine EU Member States. One was representing a European 
organisation  —  the  Pharmaceutical  Group  of  the  EU  —  and  two  were  from  countries 
outside  of  the  EU  —  Norway  and  Switzerland.  They  discussed  and  agreed  a  set  of 
interventions that could reduce the use of antibiotics without a prescription in EU Member 
States. 

The experts reviewed four types of interventions. 
1.  Public health campaigns. 
2.  Interventions among HCPs. 
3.  Interventions on the health policy level. 
4.  EU interventions. 
In this chapter, we provide a summary of the findings for each type of intervention. 

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6.2.  Methods 

The ARNA team organised a one-day expert meeting on 30 October 2015. It included 20 
experts from around Europe. The objective of the meeting was to discuss and agree a set 
of  interventions  based  on  the  literature  review  of  reviews  (Chapter  5),  to  complement 
that  set  with  other  policy  measures  and  interventions  that  are  based  on  expert  opinion 
and  to  decide  upon  the  interventions  that  are  considered  most  feasible  to  be 
implemented in EU Member States. 

A  total  of  16  experts  were  invited  to  participate  in  the  meeting.  Invitees  were  scientific 
experts and policy advisors with expertise in prudent use of antibiotics in outpatient care. 
Of  the  16  invitees,  three  were  not  able  to  attend  the  meeting.  Suitable  replacements 
were  searched  for  and  an  additional  expert  (from  Spain)  was  proposed  and  invited. 
Eventually,  apart  from  the  research  team,  15  experts  from  11  European  countries 
participated;  the  Netherlands  (three),  Switzerland  (one),  Norway  (one),  Hungary  (one), 
Denmark  (one),  France  (one),  Italy  (one),  Poland  (one),  Spain  (three),  Belgium  (one) 
and the United Kingdom (one). 

The  meeting  included  four  sessions  according  to  the  levels  of  interventions  (patient, 
professional,  healthcare  system,  EU).  Each  session  started  with  an  introduction  to  the 
area and a presentation of the findings from the literature review, followed by a thorough 
discussion about the content of the presentation (e.g. used methods and generalisability 
to other countries) and the pros and cons of interventions to stimulate more prudent use 
of antibiotics in the outpatient setting. 

At  the  end  of  the  meeting  a  consensus  statement  was  drafted  and  presented  to  the 
experts  to  agree  upon.  A  consensus  statement is  defined  as  a  comprehensive  summary 
of  the  opinions  of  an  independent  panel  of  experts,  usually  multidisciplinary,  about  a 
particular  scientific  or  medical  issue (bbb).  Its  aim  is  to  advance  the  understanding  of  an 
issue  and  to  provide  guidance  to  healthcare  professionals.  After  the  meeting  the 
consensus statement was circulated for approval to all experts. 

Participating experts 
External:  Ria  Benko  (Hungary),  Lars  Bjerrum  (Denmark),  Robert  Cohen  (France),  Céire 
Costelloe  (United  Kingdom),  Cesar  Hernandez  García  (Spain),  Benedikt  Huttner 
(Switzerland), Siri Jensen (Norway), Przemyslaw Kardas (Poland), Antonio López (Spain), 
Carl  Llor  (Spain),  Wim  Opstelten  (the  Netherlands),  Annalisa  Pantosti  (Italy),  Anja 
Schreijer (the Netherlands), Theo Verheij (the Netherlands), Jamie Wilkinson (Belgium). 

ARNA  team:  Liset  van  Dijk  (NIVEL),  John  Paget  (NIVEL),  Anna  de  Jong  (NIVEL),  Ann 
Versporten  (University  of  Antwerpen),  Dominique  Lescure  (NIVEL),  Francois  Schellevis 
(NIVEL, chair) 

(bbb)  Miller-Keane  Encyclopedia  &  Dictionary  of  Medicine,  Nursing,  &  Allied  Health,  seventh  edition,  2003; 

http://medical-dictionary.thefreedictionary.com/consensus+statement 

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6.3.  Public health campaigns 

Expert opinions — main conclusions 
  Public health campaigns should be integrated into multifaceted interventions that 

 

are evaluated correctly. 
Interventions should be tailored to a country’s specific profile and to specific 
target groups. 

  Patients should be educated about when to consult their doctor or pharmacist and 

when an antibiotic is appropriate. 

  People’s health literacy should be taken into account. Messages should be framed 

in such a way that patients remember and learn the right information. 

  Mass-media messages should be consistent with information and be supported by 

pharmacists and GPs. 

A  first  set  of  interventions  that  was  discussed  during  the  expert  meeting  was  aimed  at 
the  general  public.  More  specifically,  public  health  campaigns  were  discussed.  The 
experts stressed the need to carefully select messages that are suitable for public health 
campaigns. 

First and foremost, the experts stressed that public health campaigns in  themselves are 
not  sufficient  and  that  a  multifaceted  approach  is  required  in  order  to  accomplish 
behavioural  changes  in  patients.  This  means  that  public  health  campaigns  should  be 
combined with other interventions such as restrictive prescribing measures, working with 
HCPs and information on leftover antibiotics and on completing a treatment. 

When  combined  with  other  strategies,  the  function  of  public  health  campaigns  is  to 
educate the general population on important issues such as when to consult their doctor 
or  pharmacist.  Patients  also  need  to  be  educated,  for  example  through  a  leaflet,  about 
different  aspects  of  antibiotic  use,  such  as  finishing  their  full  course  of  antibiotics,  what 
should  be  done  with  leftover  antibiotics  and  the  need  to  use  antibiotics  prudently.  The 
experts underlined the importance of taking into account the notion of health literacy. For 
example, do people know the difference between antibiotics and other drugs? Maybe they 
do  not  know  what  their  GP  has  prescribed  them.  Moreover,  the  experts  agreed  that 
public  health  campaigns  should  be  specifically  tailored  to  the  culture  and  healthcare 
system  of  each  country  as,  for  example,  the  resources  available,  or  the  healthcare 
associations,  will  differ.  The  experts  argued  that  the  public  health  campaigns  should  be 
continued  over  a  long  period,  while  it  is  important  that  the  messages  are  also 
communicated  very  carefully.  The  European  Antibiotic  Awareness  Day  was  seen  as  a 
good example of a campaign that has continued over a long period and that can be used 
to communicate and build consistent public health messages. Campaigns should involve 
GPs,  paediatricians  and  pharmacists  as  the  public’s  trust  in  these  professionals  is  high 
and  their  support  for  a  campaign  might  convince  patients  of  the  messages  the  public 
health campaign communicate. Lastly, appropriate indicators are needed to measure the 
impact of public health campaigns. 

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6.4.  Healthcare professionals 

Expert opinions — main conclusions 
  Attention should be paid to the skills needed to communicate properly with patients, 

taking into account their health literacy and supported by patient information. 

  Collaboration between HCPs, and especially between GPs and pharmacists, should be 

promoted and strengthened. 

  HCPs should be made familiar with guidelines for the prudent use of antibiotics. 
  Rapid diagnostic tests could be of additional value but there is still no clear evidence 

regarding this point. 

The  second  set  of  interventions  that  was  discussed  by  the  experts  was  aimed  at  HCPs. 
One  topic  the  experts  agreed  on  was  the  need  for  HCPs  to  have  good  communication 
skills  adapted  to  the  needs  of  their  patients,  taking  into  account  patient  literacy.  The 
experts agreed that improvements in the general health literacy skills of patients will help 
improve  communication  between  HCPs  and  patients.  This  is  not  only important  for  care 
delivered  during  office  hours  but  also  for  out-of-office  hours.  The  experts  stressed  that 
intervention to improve prudent use of antibiotics should include a focus on out-of-hours 
prescriptions — that is those issued when GP  practices are closed and replaced by a GP 
on-call  service.  Such  consultations  result  in  a  high  proportion  of  antibiotic  prescriptions 
for  example  in  Denmark,  where  half  of  antibiotic  prescriptions  are  made  by  telephone 
without the patient being physically seen or examined by the prescriber. 

The  experts  agreed  that  HCPs  need  to  be  educated  about  antibiotics  and  also  about 
treatment  guidelines,  as  these  are  important  to  acquaint  HCPs  with  good  standards  of 
care. The experts also mentioned that raising awareness and improving education is not 
enough. Targeted interventions are also needed in order to help change long established 
habits  in  antibiotic  prescription.  The  World  Health  Organisation’s  regional  office  for 
Europe  (WHO  EURO)  has  developed  the  TAP  (Tailoring  Appropriate  Antibiotic  Use 
Programmes)  tool.  This  includes  a  step-by-step  approach  to  develop  interventions 
targeted  at  changing  behaviour  regarding  antibiotic  use  in  both  patients  and 
professionals. 

There was a general consensus that collaboration between HCPs is important, especially 
between  GPs  and  pharmacists,  for  example  to  ensure  consistent  clear  and  uniform 
messages to patients. The objective for policymakers and professional organisations is to 
encourage  a  collaborative  environment  by  providing  HCPs  with  support,  training  and 
better tools to do their work. 

Among  the  tools  that  can  support  HCPs  are  rapid  diagnostic  tests  such  as  C-reactive 
protein  (CRP)  tests  to  detect  an  inflammation,  or  rapid  strep  tests  (RST)  for  bacterial 
pharyngitis. There was no consensus amongst the experts about whether rapid diagnostic 
tests lead to an increase in the overall adherence of patients to taking antibiotics. There 
are  also  additional  costs  associated  with  rapid  diagnostic  tests.  Training  in  the 
appropriate  use  of  rapid  diagnostic  tests  is  also  an  important  issue  for  HCPs.  However, 
training  is  not  available  in  several  countries.  It  was  felt  that  the  rapid  diagnostic  tests 
need  to  support  the  diagnosis  made  by  GPs.  This  is  a  critical  point  and  needs  to  be 
properly evaluated before these tests are introduced more widely. 

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6.5.  Policy options 

Expert opinions — main conclusions 
  National antibiotic plans or national plans to combat AMR should support activities in 

the field. 

  Practices enforcing the refusal to provide antibiotics without a prescription should be 

encouraged. 

  Sanctions, positive or negative, should be used to promote adequate use of 

antibiotics (positive incentives are preferable). 

  Packages should be tailored to the course of the treatment. 
  The length of time that antibiotic prescriptions are valid should be agreed and 

harmonised across all EU Member States. 

  Surveillance is only useful if it includes quality indicators. 
  Delayed prescribing should be encouraged. 

The  third  intervention  level  discussed  in  the  expert  meeting  was  the  policy  level.  The 
experts  felt  that  national  antibiotic  plans  or  national  plans  to  combat  AMR  can  help 
establish  policy  objectives  and  targets  that  should  include  measurable  indicators.  These 
plans  should  aim to  achieve  cooperation  between  all  stakeholders,  such  as  ministries  of 
health,  ministries  of  agriculture  and  HCPs.  This,  in  turn,  can  create  important  changes 
within  an  individual  country.  For  example,  in  Spain,  six  ministries  and  61  scientific 
societies have come together as part of its national antibiotic plan. 

The  experts  stressed  the  importance  of  enforcing  laws  discouraging  the  provision  of 
antibiotics  without  a  prescription.  With  regard  to  the  use  of  sanctions  to  promote 
appropriate use, the experts agreed that positive rewards, for those who are doing well, 
will  work  better  than  sanctions,  although  negative  sanctions  are  sometimes  needed  or 
required. Sanctions should preferably be accompanied by educational support in order to 
encourage better behaviour. 

The experts agreed that, in principle, tailor-made antibiotic dispensing  — that is to give 
the  exact  number  of  pills  needed  for  a  course  —  is  the  right  way  forward.  This  would 
mean that incomplete packages might have to be dispensed. Thus, in many countries, it 
will  require  a  number  of  regulatory  modifications  as  the  legal  framework  would  need  to 
be  adapted  or  created.  The  experts  from  Spain  and  the  Pharmaceutical  Group  of  the 
European Union indicated that the manufacturers influence the size of the package that is 
available  on  the  market.  How  this  could  be  changed  has  been  considered  in  detail  in 
Spain and it would involve modifications to the delivery chain. Thus, in order to  change 
the delivery chain safely, the manner in which the primary packages are produced needs 
to  be  changed,  for  example  by  producing  packages  in  different  sizes  or  through  the 
delivery  of  large  batches  plus  product  instructions.  There  are  also  concerns  from 
pharmacists  that  opening  packages,  cutting  the  blisters  and  adding  product  instructions 
can  slow  down  the  dispensing  process.  In  addition,  pharmacies  do  not  receive 
reimbursement for printing the extra product leaflets, and  some countries reported  that 
pharmacies  do  not  have  the  technology  to  print  the  product  leaflets.  There  are  also 
questions about whether patients would be entirely happy with incomplete packages; as 
such,  patients  will  also  need  to  be  educated  in  order  to  persuade  them  that  this  is  the 
best way forward. 

There  was  a  consensus  among  the  experts  that  the  validity  of  a  prescription  for  an 
antibiotic should be shorter than for other medicines, for example for 2 weeks only. This 
might  then  help  avoid  the  misuse  of  antibiotics.  However,  two  types  of  prescriptions 
would then have to be  considered,  one  for antibiotics and one for other medicines. This 
may be difficult to implement in practice. In France this approach was not a success, as 

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GPs did not like to use two forms. In Poland, however, prescriptions for antibiotics are, in 
any  case,  only  valid  for  7 days,  and  this  does  not  cause  any  major  problems  for  either 
patients or prescribers. 

The  experts  indicated  that  delayed  prescribing  is  a  common  practice  in  some  countries, 
for example in the United Kingdom, and there is evidence that it reduces antibiotic use. A 
study in the Netherlands found that only one third of patients who were offered a delayed 
prescription actually ended up collecting their antibiotics. However, there does need to be 
good  communication about these healthcare issues, as the patients need to  be properly 
informed about how to use a delayed prescription. 

According to the experts, there is a need to define quality indicators,  meaning indicators 
that are tailored to a certain diagnosis, and to link these to clinical data, as ‘total use’ in 
a country does not offer sufficient detail as an indicator. For example, the average level 
of antibiotic use in a country may be moderate but it may differ across diseases. Finally, 
the experts discussed the need for pharmacists to be able to review the clinical diagnoses 
so  that  they  can  check  the  prescription  properly.  In  some  countries  the  information 
concerning  diagnoses  is  not  shared  for  reasons  of  privacy  and  this  affects  the  ability  of 
the  pharmacists  to  check  the  appropriateness  of  the  antibiotic  when  considering  the 
diagnosis and the local guidelines. 

6.6.  EU interventions 

Expert opinions — main conclusions 
  Public health campaigns: the EU’s European Antibiotic Awareness Day is an excellent 
initiative but needs to be complemented with activities or interventions on a national 
level to produce a sustainable change in behaviour. 

  Benchmarking: this is a very effective approach, as countries in Europe want to do 

their best and it stimulates action. 

  Benchmarking also helps improve transparency, which is important for governance 

and compliance. 

  Benchmarking should be encouraged at a regional level in Member States. 

The last set of interventions that were discussed were EU-level interventions. There was 
a  general  consensus  among  the  experts  that  mass-media  campaigns  such  as  the 
European  Antibiotic  Awareness  Day  on  18  November  are  good  initiatives,  as  they  raise 
awareness  across  the  whole  EU  and  AMR  is  a  problem  that  goes  beyond  borders. 
Moreover,  the  fact  that  the  EAAD  occurs  every  year  is  of  value,  as  it  is  known  that 
repetition is needed to get messages across. Moreover, by joining forces at the EU-level, 
Member States do not all have to develop their own campaigns but can learn from each 
other, which can save resources. 

The  EAAD  and  other  public  campaigns  should  be  supported  by  other  interventions  (see 
also  Section  6.2),  as  public  campaigns  in  themselves  are  not  sufficient  to  produce 
sustainable behavioural change. 

Another intervention at the EU level that was discussed was the benchmarking of issues 
such  as  antibiotic  prescription  rates,  AMR  rates  or  policies  to  reduce  antibiotic  use 
between  Member  States.  Benchmarking  also  helps  to  improve  transparency,  which  is  a 
good  thing  for  governance  and  compliance.  Benchmarking  at  the  Member  State  level 
does not provide insight into regional differences within a country, and as such national 
overall figures might not provide the most valuable information. An example is the case 
of Italy, where there are clear differences between the north and the south parts of the 
country.  Benchmarking  of  regional  differences  within  countries  thus  should  also  be 
encouraged according to the experts. 

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6.7.  The  results  of  the  expert  meeting  compared  with  the 
scientific evidence 

In Chapter 5 we produced an overview of effective interventions on three levels based on 
scientific  knowledge.  These  levels  were  those  of  the  patient’s  health,  the  HCP  and  the 
healthcare  system.  In  this  section  we  compare  the  interventions  based  on  scientific 
knowledge  with  the  interventions  formulated  by  the  expert  meeting  to  create  a  more 
elaborate overview of effective interventions. 

The patient’s health 
The effectiveness of the public educational campaigns, as found by the literature review, 
was  also  underlined  by  the  experts.  Moreover,  the  experts  stressed  the  need  for 
multifaceted  campaigns  that  include  these  public  campaigns.  This  is  also  supported  by 
the  scientific  evidence.  Sustainable  behavioural  change  can  be  achieved  by  activities  on 
all levels. 

The HCP 
The  experts  agreed  with  the  scientifically  proven  effectiveness  of  educational 
interventions  and  professional  meetings  to  stimulate  collaboration  between  different 
HCPs. In addition, the experts noted that these professionals should agree to the use of 
uniform  messages  and  that,  in  order  to  do  so,  they  need  to  obtain  good,  specific 
communication  skills  while  taking  into  account  patients’  health  literacy.  Although  the 
literature  showed  the  positive  effects  of  the  use  of  rapid  diagnostic  tests,  the  experts 
were  less  certain  about  their  effectiveness.  Moreover,  the  use  of  rapid  diagnostic  tests 
will lead to additional costs and training for HCPs to ensure they are used appropriately. 

The healthcare system 
The literature showed that changes to the financial and healthcare system are effective in 
stimulating  more  prudent  use  of  antibiotics.  In  addition,  the  experts  suggested 
developing  and  implementing  national  antibiotic  plans,  the  use  of  sanctions  and  the 
dispensing of exact dosages. 

At the EU level 
In  contrast  to  the  scientific  evidence,  the  experts  emphasised  the  need  for  mass-media 
campaigns  at  the  EU  level  to  raise  awareness.  In  addition,  the  experts  also  considered 
benchmarking important. They believe it is a powerful tool as it triggers  Member States 
to perform well and it improves transparency. 

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X 

X 
X 

X 

X 
X 
X 

X 

X 
X 

X 

X 

X 
X 

X 

X 
X 

X 

X 

X 
X 

X 

X 

X 

X 

    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Table 6.1. 

List of effective interventions based on the literature review and the expert 
meeting consensus statement. 

Interventions on the different levels 

Scientific 
evidence 
based? 

Expert 
opinion 
based? 

Population 
 

Educate patients (when to consult their doctor or pharmacist, when 
an antibiotic is appropriate) 

HCP 
 
 

 

 
 
 

 

 

 

 
 

 

Technological support tools 
Initiatives to stimulate appropriate prescribing (physician 
reminders) 
Antimicrobial prescribing guidelines (standards for good antibiotic 
use) 
Financial measures 
(Continuous) education 
Rapid diagnostic tests (these tests could be of additional value but 
there is still no clear evidence regarding this point) 
Professional meetings/collaboration between HCPs needs to be 
promoted and strengthened, especially between GPs and 
pharmacists 

Healthcare system 
 
 
 

Financial/healthcare system changes 
Delayed prescribing 
National antibiotic plans could be of help for supporting activities in 
the field 
Look at the legal framework for not providing antibiotics without 
prescription and how to enforce the framework in the field 
(investigate sanctions on pharmacists) 
Use of sanctions, positive or negative, to promote adequate use of 
antibiotics (positive sanctions are preferable) 
Packages should be tailored to the course of treatment 
The length of time antibiotic prescriptions are valid should be 
agreed (e.g. 2 weeks) and harmonised across all EU Member States 
Surveillance is only useful if it includes quality indicators 

Multifaceted  interventions  to  have  an  influence  on  different 
levels 

X 

EU 
 

 

Public health campaigns: the EU European Antibiotic Awareness Day 
needs to be complemented with activities or interventions on a 
national level to produce sustainable behavioural change 
Benchmarking 

6.8.  Conclusions 
The 1-day meeting brought together experts from across Europe to discuss policy options 
to  reduce  the  use  of  antibiotics  without  a  prescription.  The  experts  complemented  the 
work  of  the  ARNA  project  as  they  could  assess  the  evidence  collected  by  the  project, 
provide input on the different policy options, including new ones, and  provide the latest 
developments  in  the  field  that  might  not  yet  have  been  published.  In  addition,  the 
experts  work  for  national  and  international  bodies  and  so  bring  with  them  the  latest 
knowledge regarding the different policy options. As seen above (see Table 6.1), many of 
the points raised by the experts were also supported by the scientific literature. However, 
the  experts  also  proposed  interventions  that  were  not  supported  by  the  scientific 
literature. These included the use of incentives to promote adequate use of antibiotics or 
the  use  of  benchmarking  at  the  EU  level.  This  probably  reflects  the  fact  that  some 
interventions  have  not  been  evaluated  or  are  difficult  to  evaluate,  and  supports  the 
decision to use experts to complement the work of the ARNA team. 

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7. 

Policy  measures  to  enhance  more  prudent  use  of  antibiotics 
in six EU Member States 

Main findings 

The country-dialogue meetings resulted in six action plans for each Member State with various 
interventions on different levels. Each  Member State  has its own issues to be addressed but 
the action plans showed similarities. The most important interventions included in the action 
plans are summarised below. 

 

Patient level. 

o  Educational  campaigns  on  a  large  scale,  with  clear  messages  and  focused  on 

health literacy. 
Increase the use and availability of rapid tests. 

o 
o  Stimulate better use of vaccinations to reduce infections. 

 

HCP level. 

o  Education:  lifelong learning,  including the  study  of  infectious-disease  medicine  in 

the curricula of HCPs. 

o  Health literacy: improve the way HCPs communicate with patients. 
o  Monitor practices and provide feedback. 
o  Stimulate collaboration between HCPs, in particular GPs and pharmacists. 
o 
o  Develop up-to-date guidelines that are local and easy to disseminate. 

Increase the use of electronic tools. 

 

Healthcare-system level. 

Involve all important stakeholders, including patient organisations. 

o 
o  Stimulate collaboration between the community and hospital sectors and between 

the public and private sectors. 

o  Produce good scientific evidence and data. 
o  Develop a national plan to combat AMR. 

7.1.  Introduction 

Six country-dialogue meetings were held in EU Member States where studies among GPs, 
pharmacists  and  the  general  population  were  performed  by  ARNA.  The  Member  States 
involved  were  Cyprus,  Greece,  Hungary,  Italy,  Romania  and  Spain.  There  was  no 
country-dialogue meeting in Estonia as the problem of non-prescribed antibiotic use was 
much lower than anticipated. 

The aims of the country-dialogue meetings were: 
 

to obtain insight into the extent to which stakeholders in the six countries recognise 
the results of the ARNA analyses (see Chapter 4), while at the same time creating an 
awareness of the problem; 
to  discuss  policy  options  based  on  the  results  of  the  ARNA  project  and  propose 
amendments and additions; 
to  formulate  recommendations  specific  to  individual  Member  States  in  order  to 
stimulate the prudent use of antibiotics. 

 

 

This chapter describes the main results from each of the meetings, including a summary 
of  the  main  discussion  points  and  a  list  of  action  points.  The  chapter  starts  with  a 
description of how the country-dialogue meetings were organised and then presents the 
main results per Member State. It then draws general and specific conclusions regarding 
them. Detailed information, including each of the country-dialogue meeting reports, can 
be found in a separate report. 

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7.2.  Methods 

A collaborating partner was identified in each of the six Member States who was able to 
organise the  country-dialogue meeting. These  were usually based at a national institute 
or  at  a  university.  They  prepared  the  meeting together  with  the  ARNA  team.  The  ARNA 
team provided a factsheet for each Member State, with a summary of the findings of the 
analyses  of  the  surveys  (see  Chapter  4)  and  a  template  for  the  meeting  programme. 
Stakeholders were invited by the local organisers. The meetings were organised in 2016 
and  were  attended  by  13-30  stakeholders  per  Member  State,  including  HCPs  (GPs, 
pharmacists and paediatricians), consumer organisations, experts in the field of AMR and 
policymakers.  Information  on  the  local  organiser,  the  date  of  the  meeting,  the  number 
and type of participants and the programme can be found in Box 7.1. 

All  the  meetings  resulted  in  action  plans  that  stakeholders  considered  important  to 
enhance  the  prudent  use  of  antibiotics  in  their  Member  State.  The  country-dialogue 
meeting  report,  which  included  the  action  plan,  was  then  prepared  by  the  ARNA  team 
and  returned  to  the  collaborating  partner  to  be  revised  and  checked  before  being 
finalised. 

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Details of country-dialogue meetings. 

Box 7.1. 
Cyprus 
Local organiser 

Location and date 

Participants 

Programme 

Greece 
Local organiser 

Location and date 

Participants 

Programme 

Hungary 
Local organisers 

Location and date 

Participants 

Programme 

Italy 
Local organisers 
Location and date 

Participants 

Programme 

National Antibiotics Committee of Cyprus (AMR national focus point) (Niki 
Paphitou) 
Nicosia, 23 April 2016 

28  participants  including  microbiologists,  specialists  in  infectious-disease 
medicine,  paediatricians,  GPs,  pharmacists,  representatives  from  the 
veterinary sector and infection-control practitioners 

Presentation of the ARNA results 
Presentations by local stakeholders 
Group discussions on policy options 
Plenary presentation, recommendations and further steps 

The  Committee  of  HCDCP  for  the  Promotion  of  the  Prudent  use  of 
Antimicrobials (Flora Kontopidou) 
Athens, 29 May 2016 

15  participants  representing  national  professional  societies  and  public 
stakeholders 

Presentation of ARNA results 
Presentations by local stakeholders 
Group discussions on policy options 
Plenary presentation, recommendations and further steps 

University  of  Szeged  (Ria  Benkő,  Mária  Matuz,  Gyöngyvér  Soós), 
Hungarian  Chamber  of  Pharmacists  (Attila  Horváth-Sziklai,  Gabor 
Pongrácz) 
Budapest, 4 March 2016 

13  participants  from  the  National  Institute  for  Health  Development,  the 
Hungarian  Federation  of  Drug  Companies  and  the  Ministry  of  Health, 
Social  and  Family  Affairs,  doctors’  and  pharmacists’  organisations, 
asthma and allergy patient organisation 

Presentation ARNA results 
Presentations  by  local  stakeholders  and  by  experts  from  Sweden  (Jenny 
Hellman,  Public  Health  Agency)  and  Norway  (Salvesen  Blix,  National 
Institute of Public Health) 
Group discussions on policy options 
Plenary presentation, recommendations and further steps 

Instituto Superiore de Sanità (Annalisa Pantosti) 
Rome, 15 April 2016 

24 participants attended the meeting. Italian institutes and organisations 
were represented, such as the Agenzia Italiana Del Farmaco, Federazione 
Italiana  Medici  Pediatri,  the  Federazione  Ordini  Farmacist  Italiani  and  a 
national consumer organisation 

Presentation of Italian data 
Presentation of ARNA results 
Group  discussions  about  interventions  on  regulatory  and  on  professional 
and patient levels 
Recommendations and further steps 

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Romania 
Local organisers 
Location and date 

Participants 

Programme 

Spain 
Local organisers 

Location and date 

Participants 

Programme 

Romanian Ministry of Health (Alexandru Rafila) 
Bucharest, 26 April 2016 

19  participants  from  national  stakeholders  and  focal  points  for  the 
rational  use  of  drugs  in  Romania,  directors  and  professionals  who 
prescribe and dispense antibiotics 

Presentation of ARNA results 
Presentations by local stakeholders 
Group discussions on policy options 
Plenary presentation, recommendations and further steps 

AEMPS,  the  Spanish  Agency  for  Medicines  and  Medical  Devices  (Antonio 
López and Eduardo Padilla) 
Madrid, 11 March 2016 

29  participants  attended  the  meeting.  Various  stakeholders  were 
represented  such  as  the  AEP  (the  Spanish  Association  of  Primary  Care 
Paediatricians),  SEFAC  (the  Spanish  Society  of  Community  Pharmacists) 
and SEMG (the Spanish Society of General and Family Medicine), plus the 
national consumer organisation 
Presentation of ARNA results 
Presentations by local stakeholders 
Group discussions on policy options 
Plenary presentation, recommendations and further steps 

7.3.  Main results per Member State 

This  section  summarises  the  main  points  of  discussion  and  outcomes  of  the  country-
dialogue meetings in all Member States. It should be noted that in some Member States 
the stakeholders had discussed the subject of non-prudent use of antibiotics beforehand, 
whereas in others, such as Hungary and Italy, it was the first time the stakeholders had 
met each other. For some  Member States it was also the first time  consumer or patient 
organisations had been involved. What became clear during all meetings was that action 
to  reduce  the  use  of  antibiotics  without  a  medical  prescription  is  considered  as  part  of 
broader  plans  to  combat  AMR.  Therefore,  the  discussions  in  all  six  Member  States  were 
not only focused on actions to reduce the use of antibiotics without a prescription but on 
potential interventions in general. These were summarised in a short action plan. Below 
we describe the main results of each country-dialogue meeting. As the focus of the ARNA 
project is on the use of antibiotics without a prescription, a box with proposed actions to 
reduce this use is included for each Member State. Section 7.4 contains a comparison of 
the main proposed interventions for all six Member States. As such, Section 7.4 includes 
more information on specific interventions. 

Reports  of  the  meetings  for  each  Member  State  —  with  all  actions  — can  be  found  in  a 
report that has been published separately. 

Cyprus 
The national strategy was adopted in April 2013, and can be viewed as a national action 
plan with goals that are in various stages of implementation, including the following. 
 
  Develop structured national guidelines on infection control. 
  Develop national guidelines on appropriate antibiotic use. 
  Develop  an  effective  system  for  inappropriate  antibiotic  use  restriction  in  both  the 

Achieve an effective infection-control programme with feedback. 

public and the private sectors. 

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  Develop an audit tool to monitor compliance with guidelines in hospitals. 
 

Establish  an  antibiotic  stewardship 
coordinate/audit programs as appropriate. 
Ensure continuous surveillance of hospital-associated infections and antimicrobial use 
in hospitals. The ECDC protocol is being employed. 
Strengthen education and awareness on appropriate antibiotic use among healthcare 
workers and the public. 
Ensure  continued  full  and  wide  distribution  of  all  promotional  for  the  European 
Antibiotics Awareness Day materials to all stakeholders (ccc). 

in  each  hospital 

team/committee 

 

 

 

to 

The  main  action  proposed  by  Cypriot  stakeholders  was  to  implement  a  national  action 
plan  for  improving  antibiotic  use  in  Cyprus  through  this  Cyprus  national  strategy  to 
combat  AMR.  This  covers  both  the  public  and  the  private  sectors,  involving  all 
stakeholders.  Overall,  Cypriot  stakeholders  agreed  that  there  was  a  need  for  national 
guidelines  on  antibiotic  use  in  outpatient  care  in  order  to  establish  a  standardised 
educational  background.  Moreover,  there  is  a  need  for  better  cooperation  between  the 
public  and  private  sectors  by,  for  example,  improving  the  information  technology 
systems  and  digitalising  the  prescription  forms.  At  the  moment,  however,  there  is  no 
national health system, which makes it difficult to implement strategies in primary care. 
This  is  especially  true  for  the  private  sector,  where  there  is  a  complete  lack  of  control. 
Box 7.2 shows issues that were discussed on the use of antibiotics without a prescription. 

Box 7.2. 

Examples  of  issues  discussed  on  the  use  of  antibiotics  without  a 
prescription in Cyprus. 

Patient level 
 

Education of the public to increase awareness, for example by media campaigns, such as 
on the use of leftovers by district posters in the offices, or by using stickers on the boxes 
stating that you should not use leftovers. 

HCP level 
 
 

Education of professionals on how to deal with leftover medication. 
Considering incentives (positive and negative) for pharmacists to comply with the law that 
antibiotics  should  only  be  dispensed  with  a  prescription.  There  is  a  legal  provision  for  a 
financial  penalty  upon  non-compliance,  however  there  is  doubt  that  this  is  an  effective 
measure. 

Healthcare-system level 
 

Improve enforcement of the law by strengthening the team of inspectors  at the Ministry 
of Health. 
Introduction of electronic prescriptions and dispensing so what the pharmacist dispenses 
can be controlled. 
Dispense the exact number of antibiotics. 

 

 

Greece 
Greece  has  updated  guidelines  for  the  prudent  use  of  antibiotics  and  many  educational 
activities  for  GPs  across  the  country,  along  with  a  strong  legal  framework  on  antibiotic 
use, but enforcement of the law should be improved. Therefore, the Greek stakeholders 
agreed  that  there  is  a  need  for  greater  political  interference.  An  important  issue  is 
pressure  from  patients  who  request  antibiotics  when  they  are  not  indicated.  Policy 
options  are  needed  to  manage  this  pressure  and  to  change  the  mentality  within  Greek 
society.  Greece  has  a  national  antibiotic  plan,  which  is  mainly  focused  on  antibiotic 
stewardship in healthcare facilities. The workshop acknowledged the need for a national 

(ccc)  Cyprus  has  been  a  very  active  participant:  distribution  of  leaflets  to  patients  visiting  the  public  health 
sector,  infographics  in  hospitals,  letters  to  GPs,  TV  videos,  billboards  on  big  highways,  materials  for  the 
veterinary sector. 

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strategy  for  antibiotic  use  in  the  ambulatory  care  sector.  This  strategy  should  enhance 
the implementation of following aspects. 
 

Education at all levels. Pharmacies have mandatory courses, though not all pharmacy 
schools  teach  at  the  same  standards.  Moreover,  physicians  and  pharmacists  should 
go through lifelong learning and training constantly. 
Raising  public  awareness.  Messages  need  to  be  communicated  to  the  public  in  the 
simplest way. 

 

  Diagnostic tools. The introduction of rapid diagnostic tests, which must be mandatory 

 

and performed by the clinicians at the bedside. 
Communication  and  collaboration.  An  improvement  in  the  communication  between 
professionals,  such  as  doctors  and  pharmacists,  through  the  introduction  of  an 
electronic prescription tool. 

  Monitoring of compliance. Strict government monitoring of compliance with the OTC 

 

ban and other illegal sources of antibiotics. 
Surveillance.  Improvement  in  the  surveillance  of  antibiotic  consumption  and  the 
evaluation of results to guide the design and implementation of specific targets. 

Box 7.3 shows issues that were discussed on the use of antibiotics without a prescription. 

Box 7.3. 

Examples  of  issues  discussed  on  the  use  of  antibiotics  without  a 
prescription in Greece. 

Patient level 
  Create a communication strategy reaching out to the public, for example by means of a 

public information campaign, in order to provide information to patients and raise 
awareness that an antibiotic is a special drug and should not be taken OTC and should not 
be requested or provided any more for every minor symptom. Include civil society in 
conveying the message. 

HCP level 
 

Acknowledge the problem of leftovers: how should we decrease storage and usage, what 
factors can help, what is the role of healthcare professionals? 
Patients should have continuous and easy access to a medical prescription for antibiotics. 

 

Healthcare-system level 
 
 
 

Establishment of a national strategy regarding the use of antibiotics in ambulatory sector. 
Promotion of the Health professionals training at graduate and postgraduate level. 
Enhancing the suitability of prescription through the promotion of rapid diagnostic tests to 
health professionals and their easy access to the national guidelines. 

Hungary 
In  Hungary,  the  ARNA  country-dialogue  meeting  was  the  first  time  for  stakeholders  to 
meet  and  discuss  AMR.  They  mentioned  different  areas  in  Hungary  that  prevent  more 
prudent use of antibiotics. These are as follows. 
 

The  healthcare  system  lacks  an  antibiotic  policy.  Stakeholders  are  not  supported  in 
the collection and analysis of medical information. 
There are no clear guidelines. Although a number of guidelines have been published, 
many diseases and professions lack proper guidelines. 
There is limited financial support for public health programmes. 
There  is  a  lack  of  feedback  for  HCPs.  However,  while  feedback  would  be  useful,  it 
costs  GPs  time  and,  at  the  same  time,  receiving  feedback  on  how  badly  they  are 
performing will not motivate them to act in the right way. 
There are many older GPs, which makes change more difficult. 

 

 
 

 

The stakeholders came up with a set of potential interventions (see Section 7.4). Most of 
these  proposals  were  on  the  use  of  antibiotics  in  general.  The  experts  did  not  feel  that 
the  use  of  antibiotics  without  a  prescription  was  a  large  problem  in  Hungary  as  OTC 
dispensation is strictly regulated in Hungary.  It was felt that there was a strong need to 

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better inform the public on the prudent use of antibiotics, including discouraging the use 
of  leftover  antibiotics  without  a  prescription  (see  Box 7.4).  Also,  it  was  felt  that  the 
curriculum  of  healthcare  professionals  should  pay  more  attention  to  infectious  diseases 
and  AMR.  The  stakeholders  emphasised  that  the  National  Institute  of  Public  Health  and 
the  Health  Development  Institute  should  take  the  lead  with  regard  to  an  action  plan  to 
improve the prudent use of antibiotics. 

Box 7.4. 

Examples  of  issues  discussed  on  the  use  of  antibiotics  without  a 
prescription in Hungary. 

 

 

Teach patients to bring back leftover antibiotics to the pharmacy and, as such, discourage 
the use of leftover antibiotics. 
Include  communication  experts in  reaching  patients  with  messages to  improve  their  use 
of antibiotics so that patients react in a proper way. 

 

 

Italy 
In Italy, the participants of the country-dialogue meeting felt it was important that their 
Member  State  should  develop  a  national  plan  to  combat  AMR.  It  should  contain 
multifaceted  interventions  and  should  demonstrate  the  need  for  an  increase  in 
vaccinations  to  prevent  the  use  of  antibiotics.  In  addition,  the  participants  discussed 
various problems that prevent the prudent use of antibiotics. These are as follows. 
 

A  lower  rate  of  vaccinations,  resulting  in  an  increased  risk  of  disease  and  therefore 
increased antibiotic use. 
Insufficient attention to diagnostics, even though the technology to identify the cause 
of an infection is available in some cases, such as for a sore throat. 
Italian  pharmacists  are  not  allowed  to  give  incomplete  packages  because  of  the 
reimbursement system. To change this practice would be expensive and difficult. 
Information about how to use antibiotics prudently is not widespread. 

 
  Many  antibiotics  are  bought  out  of  pocket,  which  increases  the  amount  of  leftover 
antibiotics and makes it difficult to control whether the antibiotics are appropriate. 
There is a lack of new antibiotics. This increases the problem of antibiotic resistance 
to the current drugs available. This is a problem across the EU. 
There are difficulties in encouraging professional participation and thus strengthening 
the professional position. 
There  is  very  little  awareness  of  the  problem  due  to  a lack  of  national guidelines in 
Italy. 

 

 

 

  Health literacy is low. This should be the main focus of campaigns. 
 

A systematic approach is lacking, such as towards interventions and guidelines. 

In addition, there are some cultural aspects which play a role in the non-prudent use of 
antibiotics. 
 
 
 

There is a tradition of using leftover antibiotics. 
Antibiotics are often immediately prescribed in multiple, possibly excess, doses. 
In the south the misuse of antibiotics is a greater problem than in the northern part 
of Italy. 

Based  on  this  background,  different  interventions  were  proposed  both  for  the  use  of 
antibiotics  in  general  (see  Section  7.4)  and  for  the  use  of  antibiotics  without  a 
prescription. The stakeholders stressed the need for commitment in order to ensure that 
the  action  plan  formulated  will  be  effective.  Firstly,  the  commitment  of  the  regions  is 
needed as each regional government is responsible for local activities. Secondly, national 
and  political  commitment  is  needed  to  increase  collaboration  between  all  the  different 
actors so that they use similar methods of measurement and agree on how aspects need 
to be measured. 

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Box 7.5. 

Examples  of  issues  discussed  on  the  use  of  antibiotics  without  a 
prescription in Italy. 

Patient level 
 

Introduce educational campaigns with simple and clear instructions to increase awareness 
about  the  consequences  of  non-prudent  use  of  antibiotics  and  include  doctors  and 
pharmacists in educational campaigns to get the messages on prudent use across. 

HCP level 
 

Strengthen  patient-provider  education  by  putting  more  emphasis  on  communication  in 
university curricula. 

Health-system level 
 

Change the regulatory environment  in  order  to reduce  the  possibility to store  antibiotics 
at home (leftover antibiotics). 
Put a limit on the number of packages of antibiotics for prescription. 

 

Romania 
In Romania, the stakeholders in the country-dialogue meeting stated that the problem of 
OTC use of antibiotics mainly lies within the lack of knowledge of the population and the 
pressure  put  on  pharmacists  to  sell  antibiotics  over  the  counter,  although  this  is  not 
allowed.  Many  Romanians  who  cannot  afford  to  visit  a  GP  immediately  go  to  the 
pharmacy  and  hope  to  get  an  antibiotic  there.  The  Romanian  stakeholders  not  only 
considered  the  use  of  antibiotics  to  be  a  problem,  but  also  the  fact  that  antibiotics  are 
often prescribed when not needed. There was discussion about interventions to improve 
the use of antibiotics at the level of the general population, the HCPs and the healthcare 
system. The main findings and actions discussed were as follows. 
 

The  need  to  ensure  a  multifaceted  approach  with  representation  and  collaboration 
between all stakeholders. 

  Developing and implementing a national AMR strategy. 
 

The  need  to  provide  knowledge  and  create  awareness  among  the  public  regarding 
self-medication  and  antibiotic  resistance  through  the  organisation  of  national  public 
information campaigns. 
Releasing funds for organising educational campaigns. 
Enforcing health authorities to adopt a ‘prescription-only’ policy for antibiotics. 

 
 
  Dispensing the exact number of tablets. 
  Developing national therapeutic antibiotic guidelines. 
  Monitoring  local  AMR  profiles  and  adapting  local  antibiotic  prescribing  guidelines  to 

 

these results. 
Enhancing  adherence  to  antibiotic  guidelines  through  the  application  of  a 
smartphone. 
Introducing electronic drug prescribing. 

 
  Organising medical training among professional organisations. 
  Developing a platform for online courses targeting professionals and the public. 
 

Extending  existing  programmes  of  surveillance  and  control  of  AMR  and  healthcare-
associated infections. 

All  initiatives  and  ideas  need  to  be  combined  in  one  antibiotic  stewardship  plan.  The 
National  Committee  needs  to  make  a  long-term  plan,  in  which  the  Institute  of  Public 
Health could take the lead. 

Box 7.6 shows issues that were discussed on the use of antibiotics without a prescription. 

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Box 7.6. 

Examples  of  issues  discussed  on  the  use  of  antibiotics  without  a 
prescription in Romania. 

Patient level 
 

Educational  campaigns  for  patients  with  the  following  as  the  main  message:  ‘only  use 
antibiotics  that  are  prescribed  by  physicians’.  Multiple  media  should  be  used  to  get  this 
message across. 

HCP level 
 

In Romania, psychiatric medicines are given  out on special prescription. This should also 
be the case for antibiotics. 

Healthcare-system level 
 
 

Providing the patient the exact number of antibiotics needed, not the whole package. 
There should be an administrative rule for pharmacists to never deliver antibiotics without 
a medical prescription. Bringing back leftovers to the pharmacy is assessed as not  being 
feasible. 

Spain 
The  main  objective  of  the  country-dialogue  meeting  was  to  formulate  specific 
recommendations to encourage the prudent use of antibiotics, with a special emphasis on 
self-medication.  To  this  end,  the  meeting  was  divided  into  two  parts.  In  the  first  part, 
representatives  of  the  ARNA  group  presented  data  on  the  use  of  antibiotics  without  a 
prescription in  the  European  Union  and  the  effectiveness  of  interventions  to  reduce  this 
consumption  based  on  scientific  literature  and  expert  opinions.  Representatives  of 
Spanish  organisations  also  presented  their  work  focusing  on  the  prudent  use  of 
antibiotics.  The  second  part  of  the  meeting  included  a  workshop  where  three  working 
groups discussed and prioritised actions to further reduce the consumption of antibiotics 
without a prescription in Spain. Each working group had its own topic, as follows. 
1.  Measures to address the prescribing and dispensing of antibiotics when they are not 

indicated. 

2.  Measures to address the storage of antibiotics at home and the use of these leftover 

antibiotics (from previous prescriptions). 

3.  Measures to strengthen the position of health professionals to feel less pressured by 

patients in making decisions regarding the prescribing and dispensing of antibiotics. 

In  Spain  the  national  antibiotic  plan  (NAP)  was  introduced  in  2014,  with  its  main  aim 
being to enhance the prudent use of antibiotics using a One Health approach. As such, a 
lot  of  initiatives  are  already  being  developed  in  Spain.  The  NAP  is  coordinated  by  the 
Medicines  Agency  (AEMPS).  The  ARNA  workshop  fitted  into  processes  that  had  already 
been  initiated  as  part  of  the  NAP.  Stakeholders  agreed  during  the  meetings  on  how  to 
combat  the  problem  of  AMR.  The  consensus  document  that  was  prepared  as  a  result  of 
the  meeting  was  approved  by  all  participants  and  will  be  used  as  part  of  the  national 
strategy  to  improve  the  prudent  use  of  antibiotics.  Key  elements  of  the  consensus 
document included the following. 
 

Awareness-raising  campaigns 
pharmacies and primary care centres, all providing the same message. 
Information, education and training for HCPs. 
The implementation of guidelines. 
The implementation of support systems for prescribing. 
The  development  of  a  national  surveillance  network  of  antibiotic  consumption  and 
AMR. 
The implementation of a rapid diagnostic test. 

including  TV  spots,  brochures 

for  patients 

 
 
 
 

in 

 
  Delayed prescribing of antibiotics. 

The  AEMPS,  as  the  coordinator  of  the  NAP,  has  a  leading  role  in  the  implementation  of 
these actions, and cooperates with other stakeholders involved. 

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Box 7.7 shows issues that were discussed on the use of antibiotics without a prescription. 
This  box  differs  from  those  of  the  other  Member  States  as  the  Spanish  report  included 
not  only  actions  but  also  information  who  would  sponsor  the  action  and  which  party 
would be the vehicle. 

Actions on the use of antibiotics without a prescription in Spain. 

Sponsor 

Vehicle 

Box 7.7. 
Action 
Awareness-raising campaigns 
General population: 
‘Importance and consequences of 
the inappropriate use of antibiotics’ 

Type 

TV spot 

General population: 
‘Return of leftover antibiotics. 
Collection points Sigre’ 

Explanatory 
brochures in 
pharmacies 

 General population: 
‘Prohibition of dispensation of 
antibiotics without a medical 
prescription’ 

Informative 
brochures and 
posters in 
pharmacies 

Information/education/training campaigns 
Healthcare professionals: 
‘Regulations on the prohibition of 
sale of antibiotics without a medical 
prescription’ 

Informative notes  National 

Healthcare professionals: 
‘Prudent use of antibiotics’ 

Ongoing training 
courses  

National 
action plan on 
antibiotic 
resistance 
(AEMPS) 
National 
action plan on 
antibiotic 
resistance 
(AEMPS) 
National 
action plan on 
antibiotic 
resistance 
(AEMPS) 

action plan on 
antibiotic 
resistance 
(AEMPS) 
National 
action plan on 
antibiotic 
resistance 
(AEMPS) 

Ministry of Health, Social 
Services and Equality 

General Council of 
Professional Associations of 
Pharmacists 
SEFAC 

General Council of 
Professional Associations of 
Pharmacists 
SEFAC 

General Council of 
Professional Associations of 
Pharmacists 

SEFAC 
General Council of 
Professional Associations of 
Pharmacists 
General Council of 
Professional Associations of 
Physicians 
Ministry of Education 
Ministry of Health, Social 
Services and Equality 
(Professional Regulation) 

General Council of 
Professional Associations of 
Pharmacists 
SEFAC 

Autonomous communities 

Health policy and legislation 
Healthcare professionals: 
Discussion forum on the compulsory 
nature of a registry of dispensation 
of antibiotics in pharmacies 

National health system: 
Coordination between healthcare 
professionals from different health 
settings 

Work meetings 

Establishment of 
the programmes 
of Optimised 
Antibiotic Use 
(PROA) in Primary 
Care 

National 
action plan on 
antibiotic 
resistance 
(AEMPS) 
National 
action plan on 
antibiotic 
resistance 
(AEMPS) 

7.4.  Actions proposed in multiple countries 
All  six  Member  States  proposed  to  continue  the  collaboration  that  was  started  or 
encouraged by the ARNA project and the country-dialogue meetings. 

Stakeholders  in  all  six  Member  States  discussed  potential  interventions  and  policy 
measures  for  their  country.  The  action  plans  that  were  developed  included  ideas  for 
interventions on different levels. The context of each  Member State is crucial in defining 
what  actions  can  be  taken.  Interventions  that  are  feasible  for  one  Member  State  might 
not have a similar effect in another. Moreover, some  Member States  have already done 
more  than  others.  Nevertheless,  a  number  of  similarities  can  be  observed  in  the  action 
plans. 

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7.4.1.  Patient level 
Table  7.1  shows  that  all  Member  States  consider  education  campaigns  targeted  at 
patients to be a crucial element in enhancing the prudent use of antibiotics. The actions 
they have proposed differ slightly, but one issue that was mentioned in several  Member 
States was the wish to target a broader public while at the same time focusing on specific 
groups of patients who are more likely to use antibiotics non-prudently. Overall, the need 
to  take  the  patient’s  health  literacy  into  account  was  recognised.  Related  to  this  is  the 
wish for simple and clear messages. 

Another  intervention  which  was  frequently  reported  was  an  increase  in  the  use  and 
availability of rapid tests. These supporting decision-making about whether an antibiotic 
is  indicated  for  a  particular  patient.  Significantly,  such  interventions  are  made  at  the 
point  where  the  patients  and  HCPs  meet.  A  final  intervention  that  was  mentioned  in 
multiple  Member  States  was  the  need  to  stimulate  better  use  of  vaccines.  Our  study 
showed  that  influenza  is  a  common  reason  for  patients  to  use  non-prescription 
antibiotics.  Influenza  vaccination  lowers  the  incidence  of  flu  and,  as  such,  indirectly 
reduces the non-prudent use of antibiotics. 

7.4.2.  Professional level 
Table  7.2  shows  that  all  Member  States  consider  the  education  of  professionals  to  be  a 
crucial  element  in  enhancing  the  prudent  use  of  antibiotics.  AMR  and  antibiotic  usage 
should  be  integrated  into  national  training  curricula,  including  continuous  education 
programmes and lifelong learning. Professionals’ communication skills are also important 
and must take into account the need to communicate with patients who have a low level 
of  literacy.  Surveillance  and  monitoring  of  the  use  of  antibiotics  are  also  considered 
important. Most Member States have a surveillance system in place (Chapter 3), and this 
could be used for benchmarking and providing feedback. 

Improved collaboration in primary care, especially between GPs and pharmacists, is also 
considered  to  be  important.  Professionals  can  also  have  an  important  role  in  patient 
campaigns.  A  powerful  instrument  is  the  development  and  implementation  of  clinical 
guidelines  to  guide  doctors  in  their  prescribing  and  to  support  pharmacists  in  not 
dispensing  OTC  despite  patient  pressure.  Finally,  electronic  recording  and  support  of 
prescribing and dispensing is considered useful. 

7.4.3.  Healthcare-system level 
The  third  level  for  which  interventions  were  discussed  was  the  healthcare-system  level. 
First of all, national action plans and antimicrobial stewardship (ddd) were mentioned. Both 
the  WHO  and  the  Commission  have  urged  and  agreed  that  countries  formulate  national 
action  plans,  including  all  aspects  of  antibiotic  use,  while  applying  a  One  Health 
approach.  Four  of  the  six  Member  States  do  not  yet  have  an  action  plan,  while  Cyprus 
and Spain do have one (ARNA Ministry of Health Survey, June 2015). 

The  importance  of  guidelines  was  also  stressed  at  the  healthcare-system  level.  While 
guidelines  need  to  be  developed  and  used  at  the  professional  level,  there  is  a  need  for 
coordination  and  support  for  implementation  at  the  healthcare-system  level  by  national 
stakeholders. Cooperation is not only considered important between HCPs in primary care 
but  also  by  all  stakeholders  at  regional  and  national  levels  (including  patient  and 
consumer organisations) in order to enhance the prudent use of antibiotics. Collaboration 
is  also  important  between  different  sectors  in  the  healthcare  sector:  primary  and 
secondary care, private and public sectors. In order to enhance cooperation and actions 

(ddd)  Antimicrobial stewardship is a coordinated programme that promotes the appropriate use of antimicrobials 
(including antibiotics), improves patient outcomes, reduces microbial resistance and decreases the spread 
of infections caused by multidrug-resistant organisms (http://www.apic.org/Professional-Practice/Practice-
Resources/Antimicrobial-Stewardship). 

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taken  by  different  stakeholders  and  professionals,  coordination  and  leadership  is 
necessary.  In  Spain,  the  Medicines  Agency  has  a  coordinating  role  in  the  national 
antibiotic  plan.  Other  Member  States  felt  that  their  ministries  of  health  or  their  national 
institutes of public health could play such role. 

7.4.4.  Interventions that were mentioned in one Member State 
There  were  many  similarities  between  the  Member  States  in  the  action  plans  they 
formulated,  however,  each  had  its  own  specific  focus,  and  most  Member  States 
formulated  specific  ideas  for  interventions  that  were  not  mentioned  by  any  of  the 
others (eee). 

Cyprus 
In  Cyprus,  the  participants  in  the  country-dialogue  meeting  stressed  that  healthcare 
reforms  are  needed  to  stimulate  more  prudent  use  of  antibiotics.  Moreover,  healthcare 
insurance  needs  to  be  reconsidered  in  order  to  limit  the  reimbursement  of  antibiotics. 
Another intervention, not mentioned in the other  Member States, was to strengthen the 
regulation  of  medical  representatives  from  the  pharmaceutical  industry  covering  such 
actions  as  offering  free  gifts.  Official  bodies  and  regulations  are  needed  to  regulate 
industry  activities.  The  stakeholders  from  Cyprus  also  mentioned  the  importance  of 
handling antibiotics for which the date for safe use has passed. 

Greece 
The internet is seen as an important upcoming source for obtaining antibiotics without a 
prescription.  The  stakeholders  from  Greece  underlined  the importance  of  banning illegal 
sources of antibiotics found on the internet. Another point that was raised in Greece was 
the availability of interventions in other Member States and the opportunity, therefore, of 
benefitting from the progress made elsewhere and to implement interventions that have 
proven to be effective in other Member States. 

Italy 
Unique  action  points  from  Italy  included  limiting  the  prescription  of  antibiotics,  focusing 
on a global plan instead of single interventions and taking into consideration the role of 
industry in the national plan. 

Spain 
The  Spanish  stakeholders  emphasised  the  important  role  of  nurses  in  its  action  plan, 
which  was  elaborated  upon  in  various  interventions  regarding  public  health  campaigns, 
HCPs  and  health  policy  and  regulation.  Nurses  could,  for  example,  contribute  to  more 
prudent  use  of  antibiotics  by  analysing  the  first  aid  cabinet  in  each  household.  In 
addition,  GPs  should  then  follow  up  with  visits  to  the  patient  to  make  sure  they  comply 
with their treatment. Another point that was only mentioned in Spain was to encourage 
the  sharing  of  patients’  medical  history  in  order  to  make  this  information  accessible  to 
HCPs. 

(eee)  The main interventions mentioned in Hungary and Romania were also mentioned in other Member States. 

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Table 7.1. 

Education 

Interventions on the patient level suggested at country-dialogue meetings.* 
Cyprus 
 Educate the 

community; increase 
awareness, for 
example, by media 
campaigns, district 
posters in offices 

 Scale up the 
campaigns 

 Use of leaflets that 
are distributed by 
pharmacists 
 More dramatic 

campaigns with 
striking pictures are 
needed 

Rapid tests 

 Stimulate the use of 
point-of-care tests 
and differentiate 
between different 
infections 

Greece 
 Train patients, 
challenge their 
mentality and 
encourage them to 
comply 

 There is a need for 

new communication 
channels with the 
public 

 Communicate to a 

broader public 
 Promotion to the 

public of 
understandable and 
simple messages 
regarding the 
avoidance of self-
medication and the 
supply of antibiotics 
without a medical 
prescription 

 Stimulate the use of 

rapid bacterial 
infection test tests 
 Put the test on the 

shelves of the 
pharmacists or 
provide it through 
the government 

Hungary 
 Education of the 
public should be 
supported and start 
in early school years 

 Health literacy 

should be improved 
for the adult 
population 

 Use mass media 
 Prevention of 

infections through 
education — 
washing hands 

 Educational 

campaigns should be 
repeated over the 
years 

 Use communication 
experts to ensure 
patients react in the 
proper way 

Italy 
 Educational 
campaigns 

 Simple and clear 
instructions to 
increase awareness 
about the 
consequences of 
non-prudent use 
 Health or e-health 

literacy 

 Broaden the 

targeted public by 
using new media in 
the campaigns, such 
as Twitter and 
Facebook 

 Not only a global 
focus but also a 
focus on specific 
groups as different 
groups need 
different approaches 

 Increase the 

availability of rapid 
bacterial infection 
tests, stimulate its 
use and reassure 
parents of children 

Romania 
 Educate the public 
regarding antibiotic 
use 

Spain 
 Educational 

campaigns on a 
large scale 

 Directed at patients 

and those 
accompanying them, 
such as children, in 
primary care 
consultations 
 All information 

provided to patients 
should come directly 
from HCPs; 
everyone should 
provide the same 
message 

 Use rapid bacterial 
infection tests paid 
for by the patient 

 Use of rapid 
diagnostic 
techniques in 
primary care centres 
 Give legal character 

to rapid tests 

Vaccinations 

 Focus on 

 Stimulate better use 

 There is a lack of 

extensive 
vaccinations which 
might help reduce 
the demand for 
antibiotic use. Italy 
is not putting 
enough attention 
into diagnostics 
even though the 
technology is 
available 
* More interventions are mentioned in each Member State; these can be found at www.nivel.nl/eu/arna 

vaccinations. This 
year (2016) there 
was an extensive 
national campaign 
for promoting of 
influenza vaccination 
to public and 
healthcare 
professionals  

of influenza 
vaccinations (30-
40 % get destroyed) 

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Table 7.2. 

Education 

Hungary 
 Increase 

Greece 
 Expand mandatory 
education of final-
year medical 
students 

Interventions on the professional level suggested at country-dialogue meetings.* 
Cyprus 
 Educate all HCPs 
involved early in 
their careers about 
AMR, in that they 
should not give 
antibiotics in 
packages and on 
how to communicate 
with patients 
 Target specific 

Italy 
 Develop professional 
skills such as in the 
epidemiology of the 
field they work in 
 Health or e-health 

awareness among 
professionals and 
include 
AMR/infectious-
disease medicine 
as a topic in 
training 

 More training is 
needed on a 
postgraduate level 

literacy for 
professionals; priority 
for universities to 
teach professionals 
about patient 
communication 

 Begin lifelong 

training of GPs 

Romania 
 Provide information 
from the moment 
they finished their 
curricula 

subgroups such as 
GPs, paediatricians 
and pharmacists 
 Educate through 
surveillance and 
online 
questionnaires 

 Strengthen the role 

of inspectors 
 Monitoring and 

feedback 

 Introduction of 

quality indicators 

 Benchmarking 

Surveillance/ 
Monitoring 

 Further improve the 
mandatory courses 
for pharmacists 

 Infection and 

hygiene mandatory 
in nursing schools 
and for post 
graduates 

 Hygiene inspectors. 
There is a need for 
control and 
monitoring of the 
compliance with the 
regulations 
 Improving the 
surveillance of 
antibiotic use using 
the electronic 
prescription 
database 

 Improve feedback to 

HCPs 

 Educational 

campaigns with 
simple and clear 
messages 

 Focus too on the 

different approaches 
required for specific 
groups 

 Provide feedback 
to HCP (although 
this will take time) 

 Stimulate GPs to 

review the data and 
provide feedback 

Spain 
 Campaigns to make 
them aware of the 
legal regulations and 
the need to adapt 
therapeutic guidelines 
to the local 
epidemiology of 
antibiotic resistance 
 Educational/training 

interventions through 
professional 
associations 

 Focusing on joint 
training of HCPs 
 Take the health 

literacy of patients 
into account when 
attempting to 
communicate 

 Establish surveillance 

system 

 Obligation of registry 

of antibiotic 
dispensing 

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Collaboration 

 Stimulate 

collaboration 
between 
organisations and 
institutes by 
organising 
workshops and 
congresses 

Campaigns 

 Promote  

GP–pharmacist 
collaboration 
 Meetings and 

distance monitoring 
platforms for 
pharmacists 

 There is the need for 
a national campaign 
with simple and 
understandable 
messages to the 
public that come 
from all relevant 
stakeholders, 
including HCPs 

Guidelines 

 Prescribe the proper 

 Extensive 

amount of 
antibiotics 

 Develop guidelines 
that are easy to 
read, such as pocket 
guides that are easy 
to disseminate 
 Adapt the existing 

guidelines and see if 
society at large 
adopts them 

 Strengthen 
regulation 

 Electronic recording 

and prescribing 
should be 
implemented 
 Improve the IT 

system and digitise 
prescription forms 

dissemination of 
guidelines and their 
integration into the 
platform of 
electronic 
prescription 

 Monitoring 

compliance with 
national guidelines 
using the electronic 
prescription 
database, for GPs 
and hospital 
prescribers 

 Pharmacists should 
record prescriptions 
electronically 

 Make e-platform/ 

system more 
accessible 

 Use of mobile device 

Electronic 
recording and 
support 

 Stimulate 

collaboration between 
HCPs 

 Include professionals 
in campaigns as they 
have greater contact 
with patients 

 Professional 

standards should 
be increased and 
promoted 
 Inform about 

guidelines simply 
and practically, for 
example using 
pocketbook 
treatment 
guidelines 

 Write specific 
guidelines for 
professionals, 
including dentists, 
provide them in a 
booklet or pocket-
sized guide and 
ensure that they are 
implemented 
 Regulate the 

prescription of 
antibiotics 

 Application on the 
smartphone with 
regular guideline 
updates to enhance 
the adherence of 
guidelines 

 Administrative rule 
for pharmacists to 
never deliver 
antibiotics without a 
prescription 

 Raise awareness of 
the importance of 
mutual collaboration 
 Increase cooperation 

and coordination 
between HCPs 

 Coordinate 

therapeutic decisions 
between different 
professions 

 Active participation in 
the patient campaigns 

 Provide consensual 
and coordinated 
training for all levels 
of healthcare. This 
should be oriented 
towards patient care 
according to their 
characteristics and 
also those of the 
infectious process 
 Compliance with the 

legal regulations 

 Implementation of the 

guidelines for 
prescribing should be 
incorporated into the 
electronic prescription 
system 

 Establishment of an 

antibiotics dispensing 
registry in pharmacies 

to prescribe 
* More interventions are mentioned in each Member State; these can be found at www.nivel.nl/eu/arna 

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Interventions on a healthcare-system level suggested at country-dialogue meetings.* 
Cyprus 
  Cyprus has a national 

Hungary 

Greece 
  The national plan for 
antibiotic use in the 
ambulatory sector is 
in process and is part 
of the national action 
plan to combat AMR 

Italy 
  Create a national 
antibiotic plan 
  Check the current 
situation and 
monitor the results 
of the actions taken 

Table 7.3. 

National 
action plan/ 
stewardship 

Guidelines 

Collaboration 

action plan 

  The national guidelines 
should include specific 
protocols with regard to 
antibiotic prescribing 

  Stricter and new 

regulations about safe 
use of antibiotics, which 
should be placed on the 
outside of packages 
  Work with relevant 

societies so they can 
feel a sense of 
ownership with the 
guidelines 

  Collaboration between 
the private and public 
sectors is needed 
  Involve the scientific 
community and the 
public and private 
sectors in developing 
guidelines 

  Inform all parties about 

decisions taken 
  Involve patient 
organisations 

  Establish a joint 

team involving 
various 
professionals to 
develop antibiotic 
stewardship 

 

Involve all 
stakeholders and 
experts including 
patient 
organisations 
  Create an alliance 
of patients and 
professionals 

  stimulate 

collaboration 
between the 
community and 
hospitals 

  Collaboration 

 

between outpatient 
and inpatient 
setting 

  There is need for 
instruments to 
exchange 
information 
Involve local 
associations 
Involve patient 
organisation 

 

 

Intersectoral 
approaches are 
needed which 
include the 
agriculture and 
human sectors 

  Promote 

collaboration 
between public 
health services and 
the pharmaceutical 
sector 
Involve the patient 
organisations 

Romania 
 

Integrate all 
measures into one 
antibiotic 
stewardship plan 

Spain 
  The national plan 

for antibiotic 
resistance supports 
the different 
initiatives 

  Update the 

  Make 

national guidelines 

implementation 
compulsory 

  It is important to 

have a coordinated 
attitude and shared 
methodology 
involving primary 
care units, 
emergency care 
units, hospitals, 
different 
professionals, 
societies and 
institutions 

Coordination 

  Broaden the scope of 

  More committees 

the current committee 
in order to get medical 
associations, the society 

are needed 

  Promote networks 
at regional level 
  Build up operational 
teams at local level 

  Appoint 

coordinators for 
antibiotic 
stewardship 

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of GPs, paediatricians, 
the scientific community 
and the public involved 

Leadership 

  The Ministry of Health 
should take the lead 

who work in 
antibiotic 
stewardship 

  Establish national 
objectives by the 
Ministry of Health to 
endorse agreement 
between the 
national and 
regional levels 
  The Ministry of 

Health should 
coordinate the 
different networks 

  National and 
political 
commitment is 
needed to increase 
collaboration 

  The commitment of 

the regions is 
needed  

  Establish 

committees in 
hospitals for 
controlling 
antibiotic use, 
including 
microbiologists 

  The Institute of 
Public Health 
should establish 
a national 
committee 
  The first task of 
the national 
committee is to 
make a plan 

  The visibility of 

  The National 

political leadership 
is needed 

  The ministries need 
to be committed 

  Promotion among 

politicians is needed 

  Leadership and 

implementation of 
the law is needed 

Institute of Public 
Health and the 
Health 
Development 
Institute have to 
take the lead as 
they probably have 
the authority to 
apply for grants for 
antibiotic-related 
programmes 

Dispensing 
system 

 Dispense the antibiotics 

in tablets 

Research/ 
data 

 Concrete data are 

  There is need for 

needed 

studies that record 
good practices from 
pharmacists and 
GPs 

  Stimulate the 

gathering of trend 
data 

  Production of 

scientific knowledge 
in a simplified way 

  Collect data on 

antibiotic use and 
resistance and 
make them freely 
available at and 
regional levels 
  Participate in ECDC 

surveillance 

  Collaborative 

research between 
academics and 
professions 

  Support academic 

research 

  Write and distribute 

periodic reports on 
AMR 

* More interventions are mentioned in each Member State; these can be found at www.nivel.nl/eu/arna 

April 2017  

144 

  The Medicines 

Agency has the lead 

  Recommend 

adaptation of the 
formats to the 
duration of the dose 
and treatment  
  Share medical 
history; make 
information 
accessible 

 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

8.  Consensus  statement  on  the  prudent  use  of 

antibiotics 

A final conference was organised to conclude the ARNA project. Sixty people from 21 EU 
Member States attended the event, which was held at the Jaarbeurs conference centre in 
Utrecht, the Netherlands, on 17 June 2016. There were presentations by representatives 
from  DG  Health  and  Food  Safety,  the  Dutch  Ministry  of  Health,  Welfare  and  Sport,  the 
WHO Regional Office for Europe,  the ECDC, the ARNA team,  various  experts in the field 
of  antibiotics  and  representatives  from  the  six  EU  Member  States  where  the  country-
dialogue meetings had been held. 

An  ARNA  conference  statement  was  discussed  during  the  conference  and  participants 
were asked to provide their comments and feedback in writing in the week following. The 
final  conference  statement  (consensus  statement)  for  the  ARNA  project  is  reproduced 
below. 
ARNA  website 
(http://www.nivel.nl/eu/arna). 

found 

also 

text 

The 

can 

the 

full 

on 

be 

Towards more prudent use of antibiotics in the European Union: 
ARNA Conference 2016 

ARNA Utrecht conference statement, 17 June 2016 

The conference reviewed what needs to be done to achieve more prudent and 
appropriate use of antibiotics in the Member States of the European Union (EU), 
with a special emphasis on non-prescription use. 

1.  Background 
Antimicrobial  resistance  (AMR)  is  a  public  health  threat  for  Europe  and  the  world.  The 
threat  needs  to  be  confronted  through  a  comprehensive  One  Health  approach,  with 
action  on  more  prudent  and  appropriate  use  of  antibiotics  in  the  human  and  animal 
sectors,  the  development  of  new  antibiotics  and  the  implementation  of  the  WHO  Global 
AMR Action Plan. 

There  is  a  need  for  clear  leadership  in  all  EU  Member  States  by  the  development  and 
implementation  of  national  plans  to  combat  AMR  which  should  be  in  place  before  mid 
2017.1 Better collaboration is needed on a local, national, European and global level. The 
establishment  of  multidisciplinary  professional  networks,  like  the  Strama  in  Sweden, 
Bapcoc  in  Belgium  and  the  SWAB  in  the  Netherlands,  create  important  structures  that 
support, coordinate and stimulate interventions in EU Member States. 

Regarding the prudent use of antimicrobials in human medicine, multifaceted approaches 
are needed that target prescribers, the general public and healthcare as a whole. There is 
a need to combine interventions, for example restrictive antibiotic prescribing measures, 
patient education to improve health literacy and multi-/inter-professional collaboration. It 
is important to recognise that the prudent use of antimicrobials is a responsibility for all 
stakeholders. 

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2.  General public 
 

 

Public  health  campaigns  [Council  of  the  EU (fff),  21.1.h]  should  be  integrated  into 
multifaceted interventions that are correctly evaluated. 
It  is  very  important  to  help  educate  patients  to  understand  and  manage  their 
conditions  so  that  they  do  not  self-medicate  (When  to  consult  a  doctor  or 
pharmacist? When is an antibiotic appropriate?). 

  Messages  and  interventions  need  to  take  people’s  health  literacy  into  account:  the 
messages  and  support  needs  to  be  framed  in  such  a  way  that  patients  remember 
and learn the right information. 
Innovative  ways  to  educate  the  general  public  should  be  encouraged,  for  example, 
the implementation of campaigns in schools like the e-Bug project (http://e-bug.eu). 
information  provided  by 

  Mass-media  messages  should  be  consistent  with 

 

pharmacists and general practitioners (GPs). 

  Mass-media  messages  need  to  be  tailored  to  the  country-specific  profile  and  target 

groups in each EU Member State. 

3.  Healthcare workers 
 

Special  attention  should  be  paid  to  the  communication  skills  of  healthcare 
professionals  towards  their  patients,  taking  into  account  the  health  literacy  of 
patients and supported by patient information. 
Efforts need to be taken to promote and strengthen collaboration between healthcare 
professionals,  and  especially  between  GPs,  paediatricians  and  pharmacists,  such  as 
through regular professional meetings. 

 

  Healthcare  professionals  should  also  be  familiar  with  treatment  guidelines  that 

recommend a prudent use of antibiotics. 

  National  treatment  guidelines  [Council  of  the  EU,  22.5]  need  to  be  developed  that 
are  readily  available  to  practising  doctors  such  as  through  pocket  handbooks.  They 
should also be distributed to pharmacists who can then help to increase the number 
of prescriptions which adhere to such guidelines, if required. 

 

  National treatment guidelines should be country  specific, but to avoid  duplication of 
efforts  the  evidence  should  be  published  in  English  and  made  available  on  a  public 
website. 
The use of sanctions, positive or negative, to promote the adequate use of antibiotics 
should be encouraged. Positive incentives are preferable [Council of the EU, 21.1.g]. 
The  use  of  point-of-care  tests  to  support  clinical  diagnoses  should  be  explored,  so 
that antibiotics are only used for bacterial infections. 
AMR  and  antibiotic  usage  should  be  integrated  into  national  training  curriculums, 
including continuous education programmes, for example postgraduate education, of 
HCPs (physicians, pharmacists, nurses). 

 

 

4.  Health system measures 
 

By mid 2017 all EU Member States [Council of the EU, 21.1] should have developed 
national  plans  to  combat  AMR  that  are  aligned  with  the  WHO  Global  Action  Plan  on 
Antimicrobial  Resistance  and  with  standards  and  guidelines  established  by 
intergovernmental 
bodies 
(http://www.who.int/drugresistance/global_action_plan/en). 
In EU Member States where antibiotics are available OTC without a prescription, the 
enforcement of existing laws should be strengthened. 
To avoid self-medication with leftover antibiotics, packages should be tailored to the 
course of the treatment. 
The  surveillance  of  AMR  resistance  in  primary  and  secondary  care  should  be 
supported and strengthened [Council of the EU1, 21.1.c]. 
Surveillance of antibiotic treatments should be performed in primary care and quality 
indicators should be used [Council of the EU1, 21.1.c]. 

 

 

 

 

(fff)  Council  of  the  European  Union  conclusions  of  17  June  2016  —  The  next  steps  under  a  One  Health 

approach to combat antimicrobial resistance. 

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 

The use of delayed prescribing should be encouraged. 

5.  EU policy measures 
 

EU-wide education initiatives such as the European Antibiotic Awareness Day should 
be  supported  and  encouraged.  These  activities  need  to  be  complemented  by 
interventions on a national or local level to produce sustainable behavioural changes. 
The  length  of  time  that  antibiotic  prescriptions  are  valid  across  the  EU  should  be 
assessed. They currently range from 2 weeks to a full year. 
Benchmarking  is  a  powerful  tool  in  the  EU,  as  countries  want  to  do  their  best  and 
benchmarking  stimulates  action.  Benchmarking  also  helps  improve  transparency 
which  is  important  for  good  governance  and  compliance  in  the  EU  [Council  of  the 
EU1, 22.1.g]. 

6.  Other policy measures 
 

The  scope  of  supervisory  committees  in  the  field  of  AMR  should  be  broadened  to 
include all relevant stakeholders, including patient organisations. 
Vaccination  programmes,  such  as  against  influenza,  should  be  stimulated  and 
supported  as  these  prevent  infection  and  thereby  the  inappropriate  use  of 
antimicrobials. 
Regarding  influenza  vaccination,  best  practices  should  be  shared  between  Member 
States  relating  to  the  delivery  of  influenza  vaccination  by  other  HCPs  (nurses  and 
pharmacists). 
Countries  should  produce  and  develop  scientific  evidence,  for  example  the 
assessment  of  AMR  rates,  so  that  decisions  are  evidence  based  in  all  EU  Member 
States. 
The  use  of  electronic  medical  records  should  be  increased  to  register  the  use  of 
antibiotics and evaluate treatment patterns and outcomes better. 
The  exchange  of  best  practices  between  Member  States  concerning  the  use  of 
electronic  medical  records  should  be  supported,  and  in  particular  the  use  of  shared 
medical  records  between  HCPs.  These  practices  can  encourage  the  prudent  use  of 
antimicrobials  in  that  they  can  prevent  double  dosing,  interactions,  adverse  drug 
reactions  and  ‘shopping  around’  different  prescribers  for  multiple  courses  of 
antibiotics. 
EU Member States should integrate the use of targets into national plans to combat 
AMR,  for  example  targets  for  antibiotic  use  measured  in  defined  daily  doses  (DDD) 
per 1 000 000 inhabitants per day, or antibiotic prescribing quality indicators. 
A  ‘whole’  healthcare  approach  should  be  taken  to  address  the  prudent  use  of 
antimicrobials, one that integrates both primary and secondary care. 
All  EU  Member  States  are  encouraged  to  stimulate  and  develop  antibiotic 
stewardship initiatives, in, for example, secondary and/or primary care. 

 

 

 

 

 

 

 

 

 

 

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9.  Conclusions and discussion 

This  report  describes  the  results  of  the  ARNA  project,  which  was  commissioned  by  the 
European Commission (DG Health and Food Safety). The ARNA project aimed to: 
1. 

identify key factors that drive the sales and non-prudent use of antibiotics in human 
medicine obtained without a prescription; 

2.  assess the level of enforcement of the legislation regarding ‘prescription-only’ use of 

antimicrobial agents in the EU; 

3.  document good practices aimed at strengthening more prudent use of antibiotics; 
4.  develop policy options for more prudent use of antibiotics. 

The  ARNA  project  resulted  in  the  ARNA  Utrecht  meeting  statement,  which  summarises 
the necessary actions to achieve more prudent use of antibiotics in the Member States of 
the  European  Union,  with  a  special  emphasis  on  non-prescription  use.  In  this  final 
chapter,  we  summarise  and  discuss  the  main  findings  of  the  ARNA  study.  We  pay 
particular attention to the use of antibiotics without a prescription, as this was the main 
focus  of  the  ARNA  project.  The  findings  will  be  discussed  for  each  of  the  four  aims.  For 
each topic there will be a short discussion followed by a box with the main conclusions. 

9.1.  Identifying  key  factors  that  drive  non-prescription  use  and 

level of reinforcement 

Amount and sources of the use of antibiotics without a prescription 
The first aim of the project was to identify key factors that drive sales and non-prudent 
use  of  antibiotics  without  a  prescription  in  human  medicine.  Before  identifying  these 
drivers,  the  amount  of  and  sources  of  the  use  of  antibiotics  without  a prescription  were 
analysed. Most antibiotics in the European Union are dispensed after a prescription by a 
medical  practitioner.  However,  data  from  the  2013  and  2016  Eurobarometer  surveys 
showed that the proportion of antibiotics in the EU that were used without a prescription 
increased  from  an  average  of  5 %  of  all  antibiotics  used  in  2013  to  7 %  in  2016.8  The 
highest  rates  were  found  in  Greece,  Romania  and  Cyprus  in  both  2013  and  2016.  The 
Member  State  survey  showed  that  OTC  sales  of  antibiotics  are  illegal  in  all  Member 
States,  although  there  are  some  exceptions  in  a  number  of  countries  —  for  example 
creams or eye drops that contain antibiotics. Despite this legal framework, we found that 
illegal  OTC  sales  occur  in  various  Member  States.  In  Member  States  such  as  Greece, 
Cyprus  and  Romania,  antibiotic  use  without  a  prescription  is  driven  by  OTC  sales  in 
pharmacies.  Between  80%  and  100 %  of  all  last  courses  of  antibiotics  without  a 
prescription  were  bought  in  a  pharmacy  in  these  Member  States.  In  other  Member 
States,  such  as  Italy,  Hungary  and  Spain,  the  use  of  leftover  antibiotics  is  (also)  an 
important source of non-prescription use. 

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Conclusions 
  Despite legal arrangements on antibiotics being prescription-only medicines, there is 

still use of antibiotics without a medical prescription in the EU. 

  There  is  variation in  the  use  of  antibiotics  without  a  prescription  across  EU  Member 
States.  Some  Member  States  with  a  high  level  of  non-prescription  use  also  have  a 
high  level  of  prescription  use,  such  as  Greece  and  Cyprus,  while  others  such  as 
Hungary and Estonia have a relatively high level of non-prescription use but a lower 
level of non-prescription use. 

  The  two  prevailing  sources  of  antibiotics  without  a  prescription  are  OTC  sales  in 
pharmacies  and  the  use  of  leftover  antibiotics.  Buying  antibiotics  without  a 
prescription  via  the  internet  did  not  prove  to  be  a  major  source  for  antibiotic  use 
without a prescription. 

Based  upon  the  results,  it  can  be  concluded  that  interventions  and  policies  that 
simultaneously  target  patients  and  HCPs  might  be  more  effective  than  single-factor 
approaches.  For  both  groups  —  patients  and  professionals  —  an  increasing  awareness 
and  knowledge  is  needed  in  order  to  bring  about  behavioural  change.  Moreover,  the 
enforcement  of  laws  and  regulations  is  necessary  to  ensure  the  sustainability  of 
behavioural  change.  The  studies  included  in  this  review  paid  little  attention  to  the 
enforcement of laws, while in many European and Western countries obtaining antibiotics 
without a prescription is illegal. These insights were used in the expert meeting that was 
organised within the context of the ARNA project (see Chapter 6). 

The  review  had  some  limitations.  Despite  our  comprehensive  search,  it  is  possible  that 
we  did  not  find  all  the  information  about  the  non-prescription  use  of  antibiotics  due  to 
publication  bias.  Still,  we  found  a  large  variety  of  studies  that  did  focus  on  this  use. 
Another limitation is how far the studies we included can be compared. This is because of 
the  different  outcome  measures  they  presented  and  the  variety  of  study  designs. 
Moreover,  little  information  was  found  on  the  determinants  on  the  healthcare-system 
level. On the pharmacy level, the majority of studies included — five out of the eight — 
were  from  Spain.  Moreover,  there  was  a  limited  number  of  studies  focusing  on  the 
pharmacist,  and  no  studies  were  found  that  took  into  account  the  prescriber’s 
perspective. And yet, HCPs are  key players in educating their patients about the proper 
use of medicines. As such, more research is needed on the perspective of HCPs. We will 
look at this again in Chapter 4 of this report. The same is true for the healthcare-system 
level. There is still much to be explored in the role of governments and other institutions 
in  the  prudent  use  of  antibiotics,  including  the  use  of  antibiotics  without  a  prescription. 
Section 3.4 provides more insight into the efforts of EU Member States in this respect. 

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Factors  driving  the  use  of  antibiotics  without  a  prescription:  a  complex 
phenomenon 

Patient level 
The  literature  review  showed  that  most  evidence  for  drivers  in  previous  studies  was 
sought for at the patient level. Knowledge about antibiotics was found to be lower among 
patients  who  use  antibiotics  without  a  prescription  compared  to  the  general  population 
(Source:  Eurobarometer  analysis,  Chapter  3).  Also,  the  review  of  the  literature  showed 
that knowledge is a crucial factor when it comes to the prudent use of antibiotics. A lack 
of knowledge is, for example, reflected in the main reasons why patients use an antibiotic 
without a prescription in the seven ARNA countries. Influenza, common cold, sore throat, 
cough, fever and headache are all common reasons given by patients for using antibiotics 
without  a  prescription,  while  these  are  conditions  for  which  usually  no  antibiotic  is 
needed. 

HCPs 
In  the  literature  review  we  only  found  a  limited  number  of  studies  focusing  on  the 
pharmacist,  and  no  studies  were  found  that  took  into  account  the  prescriber’s 
perspective. And yet, HCPs are  key players in educating their patients about the proper 
use  of  medicines.  The  literature  that  was  available  showed  that  not  only  is  patients’ 
knowledge  an  important  factor  in  reducing  the  non-prudent  use  of  antibiotics,  but  also 
the  knowledge  and  attitudes  of  pharmacists  regarding  antibiotics  are  critical.  The  better 
the knowledge, and the more reluctant the attitude of the pharmacist towards antibiotic 
use,  the  less  likely  he  or  she  will  dispense  antibiotics  without  a  prescription.  Improving 
knowledge and attitudes should be accompanied by patient campaigns against the use of 
non-prescription antibiotics. This is important as both pharmacists and GPs in the seven 
ARNA countries mentioned pressure  from patients requesting an antibiotic as a relevant 
factor.  GPs  and  pharmacists  do  not  always  fulfil  the  requests  from  these  patients, 
however  some  of  them  sometimes  do  prescribe  or  dispense  an  antibiotic  when  there  is 
patient  pressure  or  there  is  shared  decision-making  with  the  patient. Another  reason  to 
dispense  an  antibiotic  in  such  situations  was  the  fear  on  the  part  of  pharmacists  that 
patients would go to another pharmacy. 

Healthcare system 
OTC  sales  of  antibiotics  without  a  prescription  are  prohibited  by  law  in  all  EU  Member 
States,  with  the  exception  of  some  specific  antibiotics  in  some  countries.  However, 
antibiotics are still being sold over the counter in some Member States. The highest rates 
of  illegal  sales  of  antibiotics  without  a  prescription  were  found  in  Greece,  Cyprus  and 
Romania. It was found in the ARNA survey that patients in Greece and Cyprus were most 
convinced  that  they  can  easily  obtain  antibiotics  without  a  prescription  from  the 
pharmacy.  The  literature  lacked  thorough  analyses  of  the  impact  of  the  healthcare 
system on non-prescription use of antibiotics, yet experts and policymakers argued that 
the lack of enforcement of laws to prohibit OTC sales of antibiotics influences the use of 
antibiotics without a prescription. Another driver for the use of  leftover antibiotics at the 
healthcare-system level is the dispensing of whole pre-packed packages of antibiotics. 

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Conclusions 
Antibiotic  use  without  a  medical  prescription  is  a  complex  phenomenon  that  can  be 
explained on different levels. 

Patient level 
  At the patient level, knowledge about antibiotics is the most crucial factor to prevent 

the use of antibiotics without a prescription. 

  Patient education on antibiotics should be improved, and special attention is needed 

for patients with low literacy skills. 

HCP level 
  At the HCP level, the knowledge and attitudes of pharmacists regarding antibiotics is 
critical to prevent the use of antibiotics without a prescription in the ARNA countries: 
the  better  the  knowledge,  and  the  more  reluctant  the  attitude  of  the  pharmacist 
towards antibiotic use, then the less likely he or she will dispense antibiotics without 
a prescription. 

  HCPs should be educated about antibiotics and about guidelines on antibiotic use and 
their communication skills should be trained so that they can serve the needs of each 
individual patient and can handle patient pressure if needed. 

  There  is  not  much  evidence  in  the  literature  on  drivers  of  antibiotic  use  without  a 
prescription  at  the  HCP  level  and  studies  only focused  on  the  pharmacist.  HCPs  are 
key players in educating their patients about the proper use  of antibiotics. As such, 
more research is needed on the perspective of HCPs. 

Healthcare-system level 
  The lack of enforcement of laws to prohibit OTC sales of antibiotics influences the use 
of  antibiotics  without  a  prescription,  and  enforcement  should  be  improved,  for 
example by a system of rewards and sanctions. 

  Dispensing  whole  pre-packed  packages  of  antibiotics  enhances  the  use  of  leftover 
antibiotics,  but  changing  this  may  require  changes  in  the  legal  framework  or  may 
involve modifications. 

  There  is  not  much  evidence  in  the  literature  review  on  drivers  of  antibiotic  use 

without a prescription at the healthcare-system level. 

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9.2.  Good practices 
Another aim of the ARNA project was to document good practices aimed at strengthening 
the  prudent  use  of  antibiotics.  While  the  study  focused  on  non-prescription  use  of 
antibiotics, this part included practices to increase prudent use of antibiotics in outpatient 
care  in  general.  Good  practices  were  identified  that  targeted  patients,  healthcare 
professionals  and  the  healthcare  system.  Examples  of  good  practices  include  the 
following. 
  Patient level: 
o 

information  campaigns  to  increase  the  knowledge  of  patients  on  prudent  use 
of antibiotics, such as online campaigns. 

  HCP level: 

o  educational 

interventions  such  as  practical 

training 

in  antimicrobial 

stewardship or academic detailing; 
technological support tools such as clinical-decision-support systems; 

o 
o  professional  meetings  such  as  peer  group  meetings  of  general  practitioners 
and  pharmacists  and  feedback  on  prescribing  patterns  (e.g.  the  Netherlands, 
Sweden); 

o  guidelines for rational prescribing; 
o  surveillance of antibiotic consumption. 

  Healthcare-system level: 

o 

the  European  Antibiotics  Awareness  Day,  which  also  acts  as  a  trigger  for 
attracting attention for prudent use of antibiotics in EU Member States at both 
the patient and the HCP level; 

o  antimicrobial stewardship programmes. 

  Multilevel: 

o  multifaceted  campaigns  with  consistent  information  about  prudent  use  of 

antibiotics targeting the general population and healthcare professionals. 

From the review of the literature, the expert meeting and the country-dialogue meetings 
it  became  clear  that,  given  the  complex  of  factors  that  induce  the  use  of  antibiotics 
without a prescription, interventions and policies that simultaneously target patients and 
HCPs  will  be  more  effective  than  approaches  targeting  just  one  of  them.  An  increasing 
awareness and knowledge is needed from both groups — patients and professionals — in 
order  to  induce  behavioural  change.  Targeted  interventions  are  needed  too  in  order  to 
change long-established habits in antibiotic prescription. The World Health Organisation’s 
regional  office  for  Europe  (WHO  EURO)  has  developed  the  TAP  (Tailoring  Appropriate 
Antibiotic  Use  Programmes)  tool.  This  includes  a  step-by-step  approach  to  develop 
interventions  targeted  at  changing  behaviour  regarding  antibiotic  use  in  both  patients 
and professionals. Moreover, the sustainability of behavioural change should be ensured. 

Still, it should be noted that as many of the interventions so far have not been properly 
evaluated, especially those on a healthcare-system level, it is difficult to be sure whether 
all interventions will be effective. This is an area that requires further attention. 

Conclusions 
  A  wide  variety  of  good  practices  to  enhance  prudent  use  of  antibiotics  exist  with  a 

strong focus on healthcare professionals (see above). 

  Multifaceted targeted interventions that simultaneously target patients and HCPs will 

be more effective than approaches targeting just one of them. 

  Proper  evaluation  of  the  effectiveness  of  interventions  requires  further  attention  as 

for many interventions. 

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9.3.  Policy options for more prudent use of antibiotics 

The  last  aim  of  the  ARNA  project  was  to  develop  policy  options.  During  the  expert 
meeting, the country-dialogue meetings and the final conference numerous policy options 
were  discussed  at  different  levels.  These  focused  on  both  non-prescription  and 
prescription  use  of  antibiotics.  This  section  does  not  include  conclusions  but  lists  the 
major policy options mentioned at different stages of the ARNA project. 

Policy options with regard to sources of non-prescription use 
It  is  important  to  distinguish  between  the  different  sources  of  non-prescription  use  of 
antibiotics  as  they  partly  ask  for  different  solutions.  In  the  expert  meeting  and  the 
country-dialogue meetings, different policy options were mentioned to combat both types 
of non-prudent use. 

 
 

Policy options to discourage OTC selling of antibiotics include: 
  where  OTC  sales  are  occurring  in  EU  Member  States,  legal  enforcement  practices 
need to be strengthened, for example by strengthening the team of inspectors; 
incentives for pharmacists not to sell OTC; 
creating  awareness  among  healthcare  professionals,  including  pharmacists,  on  non-
prudent use of antibiotics and the role of OTC sales; 
creating awareness in the general public that antibiotics should only  be used after a 
prescription from a medical practitioner. 

 

Policy options to discourage the use of leftover antibiotics include: 
 

delivering  the  exact  number  of  antibiotics  needed  and  prescribed  instead  of 
delivering whole packages; 
avoiding over-prescription by doctors so that the chance of having leftover antibiotics 
is reduced; 
educating the public to increase awareness  on  not to use leftover antibiotics and to 
return  leftover  antibiotics  to  the  pharmacy,  for  example  by  using  posters  in  the 
offices or by stickers on medication boxes stating that leftovers should not be used; 
educating professionals on how to deal with leftover medication. 

 

 

 

Policy options aimed at the public 
In the ARNA expert meeting and in the country-dialogue meetings the lack of knowledge 
on  antibiotics  and  the  importance  of  education  of  the  public  were  discussed,  and  it  was 
agreed that the knowledge of the public should be improved. Special attention should be 
given to patients with low literacy skills, and communication should be adapted in such a 
way  that  it  is  understandable  for  this  target  group  as  well.  The  following  policy  options 
were distinguished to improve knowledge of the public. 
  Media campaigns: patients should be educated about when to consult their doctor or 
pharmacist and  when an antibiotic is appropriate. People’s health literacy  should be 
taken  into  account.  Messages  should  be  framed  in  such  a  way  that  patients 
remember  and  learn  the  right  information  and  consistency  is  needed  in  the 
information  provided  by  mass  media  to  the  general  population  and  by  healthcare 
professionals to patients. 

  Encourage  innovative  ways  to  educate  the  general  public,  for  example  the 
implementation of campaigns in schools like the e-Bug project (http://e-bug.eu). 

  Mass-media  messages  should  be  consistent  with 

information  provided  by 
pharmacists  and  GPs.  As  such,  campaign  activities  aimed  at  the  population  and 
patients should be synchronised with activities aimed at healthcare professionals. 

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Policy options aimed at HCPs 
During  the  expert  meeting  it  was  agreed  that  professionals  need  to  have  good 
communication skills adapted to the needs of their patients.  The expert meeting agreed 
that HCPs need to be educated about antibiotics and treatment guidelines and that they 
need to collaborate. An environment should be created that supports HCPs and does not 
penalise  them  when,  for  example,  they  do  not  follow  the  treatment  guidelines.  The 
objective  should  be  to  encourage  a  collaborative  environment  by  providing  support, 
training  and  better  tools  to  do  their  work.  The  following  main  policy  options  were 
distinguished. 
  Training  of  skills  to  communicate  properly  with  patients,  taking  into  account  their 
health literacy, should be started at university. Messages should be framed in such a 
way that patients remember and learn the right information. 

  Promotion  of  collaboration  between  HCPs,  and  especially  between  GPs  and 
pharmacists, in jointly taking responsibility for prudent prescribing and prudent use of 
antibiotics, for example through regular professional meetings. 
Integration  of  AMR  and  antibiotic  usage  into  national  training  curricula,  including 
continuous  education  programmes,  for  example  postgraduate  education  of  HCPs 
(physicians,  pharmacists,  nurses),  including  awareness  of  non-prescription  use  of 
antibiotics. 

 

Policy options at the healthcare-system level 
Experts  and  the  country-dialogue  meetings  in  the  ARNA  countries  highlighted  the 
importance  of  enforcing  laws  that  prohibit  the  provision  of  antibiotics  without  a 
prescription.  The  experts  agreed  that  positive  rewards  for  those  who  are  doing  well will 
work  better  than  negative  sanctions  for  those  who  are  not  complying.  However,  it  was 
stated  that  negative  sanctions  are  sometimes  needed  or  required.  Sanctions  should  be 
integrated  into  an  educational  spirit  in  order  to  encourage  better  behaviour.  During  the 
expert  meeting  and  most  of  the  country-dialogue  meetings  it  was  also  argued  that  it 
should  be  possible  to  dispense  incomplete  packages  or  to  adjust  the  sizes  of  packages. 
However,  this  may  require  changes  in  the  legal  framework  in  some  countries  or  would 
involve  modifications  to  the  medication  delivery  chain,  which  may  in  turn  pose  risks  to 
public health such as opening the packages or cutting the blister packs. Thus, in order to 
change  the  delivery  chain  safely,  the  manner  in  which  the  primary  packages  are 
produced needs to be changed, for  example by producing packages in different  sizes or 
through  the  delivery  of  large  batches  plus  product  instructions.  To  summarise,  policy 
options at the healthcare-system level include the following. 
 

In EU Member States where antibiotics are available OTC without a prescription, the 
enforcement  of  existing  laws  should  be  strengthened,  accompanied  by  media 
campaigns to explain the relevance of this law. 

  Legislation  should  be  initiated  to  allow  and  facilitate  dispensing  of  the  exact  amount 
of  antibiotics  prescribed  to  avoid  leftovers,  although  this  option  is  not  easy  to 
implement. 

  Policymakers should work with GP and pharmacist associations to implement different 

interventions to encourage prudent use of antibiotics. 

  Complement  the  European  Antibiotic  Awareness  Day  with  activities  and/or 
interventions at national level in order to realise sustainable behavioural change. 

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9.4.  ARNA conference statement 

The  ARNA  project  was  concluded  with  the  ARNA  conference  statement,  which  was 
formulated  during the  final  conference  on  17  June  2016.  The  conference  reviewed  what 
needs  to  be  done  to  achieve  more  prudent  and  appropriate  use  of  antibiotics  in  the 
Member States of the European Union. It was concluded that the threats caused by AMR 
should  be  confronted  through  a  comprehensive  One  Health  approach,  with  action  on 
more  prudent  and  appropriate  use  of  antibiotics  in  the  human  and  animal  sectors,  the 
development  of  new  antibiotics  and  the  implementation  of  the  WHO  Global  AMR  Action 
Plan.  Important  conditions  to  achieve  this  include  clear  leadership  and  better 
collaboration  at  the  local,  national,  European  and  global  levels.  Regarding  the  prudent 
use of antimicrobials in human medicine, multifaceted approaches are needed that target 
prescribers,  the  general  public  and  healthcare  as  a  whole.  There  is  a  need  to  combine 
interventions,  for  example  restrictive  antibiotic  prescribing  measures,  patient  education 
to  improve  health  literacy  and  multi-/inter-professional  collaboration.  Most  of  all,  it  is 
important  to  recognise  that  the  prudent  use  of  antimicrobials  is  a  responsibility  for  all 
stakeholders. 

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Appendix A.  Questionnaire Member State survey 

Survey — Non-prudent use of antibiotics in Europe: public health measures and 
legislation 

The survey has 32 questions. You can stop completing the survey at any moment and 
you will return to the last question you completed via the URL link. 

We understand that you may not be able to answer all of the questions; please skip 
these questions and continue the survey. 

Non-prudent use of antibiotics means antibiotics that are used in insufficient dosages or 
when patients receive or consume incorrect or unnecessary antibiotics. 

Please complete the survey in English. 

Please identify yourself 

NB: We are collecting this information so that we can contact you if we have any 
questions regarding your responses to the survey. We will not report names in our 
Report (only institution names) and once data collection is complete we will only work 
with an anonymous database. 

Name and surname*:____________________________ 

Email address*:________________________________ 

Institution:____________________________________ 

Your position:_________________________________ 

Your area(s) of expertise:________________________ 

*Obligatory 

Type of organisation that you work for: 

  Ministry of Health 
  National Health Insurance Board 
  Institute for the Rational Use of Medicines 
  National Public Health Institute 
  Professional organisation 
  Patient organisation 
  Other: ________ 

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National Antibiotic Plan 

1.  Is there a National Antibiotic Plan document that sets out activities regarding the 

promotion of appropriate use of antibiotics, responsibilities, budget and timeline in 
your country? 

  Yes 
  No (please skip to question 4) 
  Don’t know 

2.  If yes, is the National Antibiotic Plan publicly available? 
  Yes, please provide a reference, link or attach the Plan:_______________ 
  No, it is a draft version 
  No, other reason:____________________ 
  Don’t know 

3.  Is there a national framework or institution that is responsible for assessing, 

monitoring and evaluating the National Antibiotic Plan? 
  Yes, namely:____________________________________ 
  No 
  Don’t know 

National measures to enhance the prudent use of antibiotics 

NATIONAL LAWS AND LEGAL REGULATIONS 

NB: In this section we are only interested in national laws and regulations. The next 
section (questions 9-16) covers national policy measures. 

4.  We would like to know if there are any national laws or legal regulations for 

ambulatory (outpatient) care to reduce the non-prudent use of antibiotics in your 
country concerning the following areas (multiple responses are possible): 

  Restrictive prescribing 
  Use of delayed medical prescriptions* 
  Unused antibiotics 
  Preventive medical strategies 
  Use of prices and economic incentives 
  Statutory/legal guidelines on antibiotic usage 
  Other, please specify:__________________________________ 

* A delayed medical prescription means the antibiotic is prescribed without an 

immediate delivery of the antibiotic: the patient is advised to use the prescription 
only when the natural course of the illness develops differently than expected or 

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foreseen, or when specific criteria are met as indicated by the prescriber. They are 
also known as ‘back-pocket’, ‘back-up’ or ‘as needed’ prescriptions. 

5.  Could you describe the national laws or legal regulations which aim to reduce the 

non-prudent use of antibiotics in your country? 
Explanation: If possible, we would like to receive the link for websites or another 
source (e.g. report) where we can find more information about the laws and 
regulations. If the text is translated into English, please provide the link. 

National laws or regulations 

Year 

Source 

  Don’t know 

6.  Is there any legislation in your country aimed specifically at prohibiting self-

medication? 
Explanation: When using the term self-medication, we mean individuals who use 
antibiotics without a medical prescription to self-administer treatment. Individuals 
can use the following sources to obtain antibiotics without a prescription: (1) Left-
overs from a previous treatment that they have stored at home; (2) At the 
pharmacy without a prescription (‘over-the-counter’); (3) Online shopping/e-
pharmacies. 

  Yes 
  No 
  Don’t know 

7.  Please briefly describe the content of this legislation? 

  Not known 

8.  Are the laws and regulations to enhance the prudent use of antibiotics being 

enforced and monitored in your country? 

  Yes, by who:____________________________________ 
  Partly, by who:__________________________________ 
  No 
  Don’t know 

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NATIONAL POLICY MEASURES 

9.  Are there any national policy measures in your country to enhance the prudent 
use of antibiotics in ambulatory (outpatient) care (including national campaigns 
and interventions)? 
  Yes, already started 
  Yes, in the (near) future 
  No 
  Don’t know 

10. What kind of national policy measures are implemented to enhance the prudent 

use of antibiotics? 
NB: Multiple responses are possible 

  National media campaigns to raise awareness among the general public 
  Surveillance of antibiotic resistance and antibiotic use 
  Educational interventions 
  Promote research and development of alternative products 
  Restrictive/conservative/appropriate prescribing policies 
  Prevent self-medication from other sources (e.g. internet) 
  Strengthen pharmacy regulations 
  Campaigns to manage antibiotic waste (medicine-waste-collection services to 

avoid misuse of antibiotics) 

  Promote collaboration between healthcare professionals (e.g. general practitioners 

and pharmacists) 

  Using healthcare professionals (e.g. general practitioners and pharmacists) in 

campaigns to promote and conduct awareness on the use of antibiotics 
  Training healthcare professions (e.g. general practitioners, pharmacists and 
pharmacy students) in antimicrobial resistance and antimicrobial resistance-
related issues 

  Providing antibiotic stewardship in primary care settings 
  Other, please specify:_________________________ 
  There are no current national measures concerning antibiotic 

prescribing/dispensing 

  Don’t know 

11. Are there results/evidence for the effectiveness of the above-mentioned national 

measures? 
Explanation: If possible, we would like to receive the link for the website or 
another source where we can find more information about the effectiveness of 
these measures. Multiple responses are possible. 

  Yes, see the following websites:_________________________ 
  Yes, see the following publications:________________________ 
  Current, there is an evaluation of the following policy measures:______________ 
  No 
  Don’t know 

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12. Could you provide us with a Report or URL link that describes the content of 

national measures aimed at reducing the non-prudent use of antibiotics in your 
country? 

National policy measures 

Year 

  Don’t know 

13. Do healthcare professionals (e.g. physicians and pharmacists) receive training on 

good practices regarding the prescription of antibiotics? 

  Yes, please specify what training:___________________________________ 
  No 
  Don’t know 

14. Is there a professional body in your country that publishes treatment guidelines 

regarding the prescription of antibiotics for the management of infectious 
diseases? 

  Yes, see the following websites:_________________________ 
  No 
  Don’t know 

15. Can you give us examples of good-practice projects that have been implemented 
to encourage more prudent use of antimicrobial agents in your country, including 
good practices to reduce/mitigate the consumption of antimicrobial use without a 
prescription? 
NB: Multiple responses are possible 

  Yes, see the following websites:_________________________ 
  Yes, see the attached report/publication:_________________________ 
  Yes, please describe:__________________________________________ 
  No 
  Don’t know 

16. Can you give us the contact details of persons, research groups or organisations 

in your country that we can contact to obtain more information about these good-
practice activities? 

  Yes, contact details:_________________________ 
  Don’t know 

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SURVEILLANCE AND AUDITING  

17. Does a surveillance or audit procedure exist in your country among healthcare 
professionals which targets antibiotic prescribing practices in ambulatory care? 

  Yes 
  No, there is no surveillance system (please skip to question 21) 
  There are intentions to start a surveillance among GPs targeting their antibiotic 

prescribing practice 

  Don’t know 

18. What type of surveillance system exists or are planned for the following 

healthcare professionals? You can tick all the relevant answer categories (more 
answers per discipline are possible). 

Obligatory 
surveillance 
system 

Voluntary 
surveillance 
system 

Electronic 
surveillance 
system 

Surveillance 
system on 
paper 

Covers all 
antibiotics 

Covers 
certain 
antibiotics 

General 
practitioner 
Paediatrician 

Dentist 

Pharmacist 

Nurse 

Other, 
specify 

   

   
   
   
   
   

   

   
   
   
   
   

   

   
   
   
   
   

   

   
   
   
   
   

   

   
   
   
   
   

   

   
   
   
   
   

There is no 
surveillance 
system for 
this 
discipline 
   

   
   
   
   
   

19. Do healthcare professionals receive feedback of the results of the surveillance 

procedure? 

NB: Multiple responses are possible 
  Yes, personal feedback 
  Yes, feedback with a benchmark 
  Yes, feedback provides conclusions and/or recommendations 
  Yes, feedback incorporates eventual implications 
  No 
  Don’t know 

20. Does another national or regional system to the one described above exist to 

report and survey the following issues? 

NB: Multiple responses are possible 

Side-effects of antibiotics 

Misuse of antibiotics by citizens 

Incidents with antibiotics 

Over-the-counter antibiotic sales 

Other, specify 

Yes 

   
   
   
   
   

No 

   
   
   
   
   

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Legal provisions for the prescription of antibiotics in your country 

LAWS AND REGULATIONS REGARDING AMBULATORY (OUTPATIENT) CARE 

21. Is it required by law that antibiotics are prescribed by a medical prescription? 
  Yes, all antibiotics (for systemic and topical use) 
  Yes, all antibiotics except for topical use (e.g. creams and eye drops) 
  Some antibiotics require a medical prescription and some do not, please 

specify:___________ 

  No 
  Other, please specify:_________________ 
  Don’t know 

22. Do regional (provincial or other) differences exist in the legal provisions within 

your country? 

  Yes, please specify:______________________ 
  No 
  Don’t know 

23. Are there healthcare professionals other than a medical doctor (general 

practitioner, paediatrician, etc.) or dentist who can prescribe an antibiotic 
prescription? 

NB: Multiple responses are possible 
  Pharmacist 
  Nurse 
  Non-practising clinician (e.g. medical doctor involved in research lab, clinician 

involved in politics….) 

  Other medical / healthcare worker (e.g. veterinarian), 

specify:___________________ 

  Other, please specify:__________________________________ 
  No-one else than a practising medical doctor or dentist can prescribe antibiotics 
  Don’t know 

24. Do pharmacists in your country have to dispense the exact prescribed amount of 

antibiotic pharmaceutical forms (pills, tablets, vials or other)? 
  Yes 
  No 
  No, but there are specific margins specifying how many more or less a 

pharmacist can dispense 
Please specify amount or %:______________________________________ 

  No, please specify: __________________________ 
  Don’t know 

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25. Can pharmacists dispense incomplete packages of antibiotics in your country? 

NB: Multiple responses are possible 

  Yes, antibiotics can be sold by individual blister 
  Yes, antibiotics can be sold by reconstitute pack 
  Yes, antibiotics can be sold by number of pills/items/flacons 
  No, all antibiotics are dispensed by a ‘complete package’ 
  Don’t know 

26. Are general practitioners allowed to prescribe antibiotics with a delayed medical 

prescription? 

  Yes 
  No, forbidden by law 
  No, but a general practitioner / general practitioners might deliver antibiotics on 

delayed prescription 

  Other, please specify:_____________________________ 
  Don’t know 

OVER-THE-COUNTER ANTIBIOTICS 

Over-the-counter (OTC) antibiotics are antibiotics that can be purchased at the pharmacy 
without a medical prescription from the general practitioner. 

27. Is it possible for pharmacists to sell antibiotics over-the-counter in your country? 
  No, it is forbidden by law 
  It is not allowed, but in some pharmacies it can be common practice 
  Yes, for specific antibiotics, please specify: _________________ 
  Yes, it is allowed 
  Other, please specify: ________________ 
  Don’t know 

28. Can you give an estimate of the percentage of pharmacists in your country who 

sell antibiotics over-the-counter? 

29. Are there any other (illegal) ways patients can obtain antibiotics in your country? 
(e.g. online shopping, internet pharmacies, with a prescription from another 
country) 

  Yes, please specify:_________________________ 
  No 
  Don’t know 

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30. Is it possible to buy antibiotics: 

a) Online with a prescription from your country? 
  Yes  
  No 
  Don’t know 

b) Online without a prescription from your country? 
  Yes  
  No 
  Don’t know 

c) Online with a prescription from another country? 
  Yes  
  No 
  Don’t know 

d) Online without a prescription from another country? 
  Yes  
  No 
  Don’t know 

e) Somewhere else than a pharmacy in your country? 
  Yes  
  No 
  Don’t know 

In this last section of the questionnaire, it is possible to make any final statements that 
you find relevant with respect to the regularisation of antibiotics in your country. 

31. Is there any other statement you wish to make with respect to the regularisation 

of antibiotics in your country / region. Please feel free to specify below: 

32. In case you have ticked several times ‘don’t know’. Could you please provide us 
a link to any other organisation, institution or person who would be able to further 
complete this questionnaire. Please specify: 

Thank you very much for completing this questionnaire! 

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Appendix B.  Questionnaire surveys in seven EU Member 
States 

B.1.  Patient questionnaire 

Name of survey 
ARNA patient questionnaire NIVEL 

This questionnaire was written according to TNS quality procedures 
checked by  

TNS Company 

TNS 

Repeating  study  (if 
this 
survey  has  been  previously 
conducted) 

Name of survey 

ARNA patient questionnaire NIVEL 

Version 

Contact 

Panel 

3 

Duration of questionnaire 

0 

Sample size 

Sample description 

Quota 

gross: 
net: 0 

If  several  countries:  indicate 
the countries 

If several targets 

Check-in site 

Comments 

www.tns-nipo.com 

0 

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T1:  

Dear 

Text 

sir/madam, 

You are invited to participate in a research study about the use of antibiotics. With this study we want to 
gain  knowledge  about  the  amount  of  people  in  Europe  using  antibiotics  and  the  reasons  for  doing  this. 
antibiotics.  
This 

information 

important 

consumer 

improve 

know 

on 

to 

to 

is 

This research project is being conducted by NIVEL (Netherlands Institute for Health Services Research), 
TNS/Kantar  Health  and  the  University  of  Antwerp.  The  project  is  funded  by  the  European  Commission. 

The  interview  will  require  approximately  15  minutes  to  complete.  Your  answers  will  be  entirely 
anonymous.  Participation  is  strictly  voluntary  and  you  may  choose  not  to  participate  at  any  time.  

Your participation in the study is greatly appreciated! 

B1: Screener and introductory questions 

Begin block 

T2:  

Text 

We would like to start with some questions relating to the use of antibiotics. 

Q1: v1oral 

Single coded 

Have  you  or  your  child  orally  taken  any  antibiotics  such  as  tablets,  powder  or  syrup  in  the  last  18 
months? 

Instruction for the interviewer: We only want to include respondents that used oral antibiotics. When 
someone used other forms of antibiotics (e.g. injections, crèmes or eye drops) they are excluded. 
With children we mean your children (all ages) that are living in your household. 

1  Yes, I have 
2  Yes, my child(ren) have 
3  Yes, my children and I have 
4  No 
    GO TO Q101 
99  Don’t know/Don’t remember/Refuse 
    GO TO Q3301 

*Position fixed 

ASK ONLY IF Q1 = 4  

Q101: v2oral 

Single coded 

Has any other person in your household orally taken any antibiotics such as tablets, powder or syrup in 
the last 18 months? 

Instruction for the interviewer: We only want to include respondents that used oral antibiotics. When 
someone used other forms of antibiotics (e.g. injections, crèmes or eye drops) they are excluded. 

1  Yes 
    GO TO Q102 
2  No 
    GO TO Q3301 
3  Don’t know/Don’t remember/Refuse 
    GO TO Q3301 

TNS NIPO 

G7620b 

© TNS 12-11-2014 

Version number: 2 

 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

ASK ONLY IF Q101 = 1  

Q102: V3oral 

Single coded 

Can I speak to that person in your household? 

Instruction for the interviewer: if the person is home and willing to participate you have to ask Q1 again. 
Otherwise you can make an appointment to call back,  

1  Yes, he/she will come at the phone and participate in the research 
2  No, make an appointment to call back 
3  No, this person does not want to participate 
    GO TO Q3301 

Q2: v2source 

Multi coded 

How did you obtain these courses of antibiotics in the last 18 months? 

Read the different answer categories 

Explanation: If you used antibiotics for yourself and for your children, the answers should be given for all 
joint antibiotic courses. 
Explanation code 3: With leftovers we mean antibiotics that you have stored at home or that you 
received from family/friends 

1  From a medical prescription 
    GO TO Q3301 
2  Administered by a medical practitioner 
    GO TO Q3301 
3  You had some left over from a previous course 

4  Without prescription from a pharmacy 

5  Online shopping/e-pharmacies 

6  Without prescription from a pharmacy during my vacation in my own country 
7  Without prescription from a pharmacy during my vacation in another country 
8  Without prescription from my dentist/nurse/other healthcare professional 
9  Without prescription from elsewhere 

99  Don’t know/Don’t remember/Refuse 
*Exclusive *Position fixed 
    GO TO Q3301 

T3:  

Text 

From  now on, all  questions will  be related to  the  use  of antibiotics that you received without a medical 
prescription  from  your  doctor  or  another  healthcare  professional.  By  this  we  mean  antibiotics  you  have 
bought  or  received  at  the  pharmacy,  on  the  internet  or  somewhere  else.  Besides,  we  mean  antibiotics 
that you may have left over from a previous course. These could have been antibiotics with or without a 
medical prescription. 

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ASK ONLY IF Q1 = 1  

Q301: v3course 

Single coded 

During the last 18 months, how many courses of antibiotics without a medical prescription did you follow? 

Explanation: We mean all joint courses of antibiotics that you obtained from the different sources.  

1  1 course 
2  2-3 courses 
3  4 courses or more 
99  Don’t know/Refuse 

ASK ONLY IF Q1 = 2  

*Position fixed 

Q302: v3course 

Single coded 

During the last 18 months, how many courses of antibiotics without a medical prescription did your child 
follow? 

Explanation: We mean all joint courses of antibiotics that you obtained for your child from the different 
sources.  

1  1 course 
2  2-3 courses 
3  4 courses or more 
99  Don’t know/Refuse 

ASK ONLY IF Q1 = 3  

*Position fixed 

Q303: v3course 

Single coded 

During the last 18  months, how many courses  of  antibiotics without a medical prescription did you and 
your child follow? 

Explanation: We mean all joint courses of antibiotics that you and your child obtained from the different 
sources. 

1  1 course 
2  2-3 courses 
3  4 courses or more 
99  Don’t know/Refuse 

*Position fixed 

B1: Screener and introductory questions 

End block 

B2: Last course with antibiotics without medical prescription 

Begin block 

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ASK ONLY IF Q1 = 1  

T401:  

Text 

The  following  questions  relate  to  the  last  time  you  used  antibiotics  without  a  medical  prescription  for 
yourself.  

Explanation: Antibiotics without  a medical prescription  from  your doctor can be antibiotics that you had 
left  over  from  a  previous  course  or  antibiotics  that  you  bought  at  the  pharmacy,  the  internet  or 
somewhere else. 

ASK ONLY IF Q1 = 2  

T402:  

Text 

The following questions relate to the last time your child used antibiotics without a medical prescription. 

Explanation: Antibiotics without  a medical prescription  from  your doctor can be antibiotics that you had 
left  over  from  a  previous  course  or  antibiotics  that  you  bought  at  the  pharmacy,  the  internet  or 
somewhere else. 

ASK ONLY IF Q1 = 3  

T403:  

Text 

The  following  question  relates  to  the  last  time  you  or  your  child  used  antibiotics  without  a  medical 
prescription. 

Explanation: Antibiotics without  a medical prescription  from  your doctor can be antibiotics that you had 
left  over  from  a  previous  course  or  antibiotics  that  you  bought  at  the  pharmacy,  the  internet  or 
somewhere else. 

ASK ONLY IF Q1 = 3  

Q4: v4who 

Single coded 

Was  the  last  course  with  antibiotics that  you  received  without  a  medical prescription  for  yourself  or  for 
(one of) your child(ren)? 

Explanation: With the last course with antibiotics without a medical prescription we mean the last time 
you used antibiotics for one or more days in order to relieve the symptoms. 

1  For myself 
2  For (one of) my child(ren) 
99  Don’t know/Refuse 

*Position fixed 

ASK ONLY IF Q4 = 1,99  

T501:  

Text 

From  now  on,  all  questions  are  related  to  your  last  course  with  antibiotics  that  you  received  without  a 
medical prescription! 

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ASK ONLY IF Q4 = 2  

T502:  

Text 

From  now  on,  all  questions  are  related  to  your  child’s  last  course  with  antibiotics  that  you  received 
without a medical prescription! 

Q98: bepalen voor zelf of voor kind 

Single coded 

Dummy 

1  yourself 
2  your child 

Q99:  

Dummy 

1  you 
2  your child 

Q5: v5last 

Hulpvraag — wordt niet getoond aan de respondent 

Single coded 

Hulpvraag — wordt niet getoond aan respondent 

Single coded 

How  did  you  obtain  the  last  course  of  antibiotics  without  a  medical  prescription  that  <answer  question 
99> used in the last 18 months? 

Read the different answer categories 

Explanation code 1: With leftovers we mean antibiotics that you have stored at home  

1  You had some left over from a previous course 
2  Without prescription from a pharmacy 
3  Online shopping/e-pharmacies 

4  Without prescription from a pharmacy during my vacation in my own country 
5  Without prescription from a pharmacy during my vacation in another country 
6  Without prescription from my dentist/nurse/other healthcare professional 
7  Without prescription from elsewhere 
99  Don’t know/Refuse 
*Position fixed 

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ASK ONLY IF Q5 = 1  

Q6: v5last 

Single coded 

Were those leftovers from a previous course you followed yourself or from somebody else? 

1  They were from a previous course I followed 

2  They were from a previous course my child followed 

3  They were from my partner 

4  They were from friends 

5  They were from family 

6  Other 

99  Don’t know/Refuse 
*Position fixed 

B2: Last course with antibiotics without medical prescription 

End block 

B3: Type of antibiotics used + reason for using antibiotics without a 
medical prescription 

Begin block 

T6:  

Text 

The following questions also relate  to the  last course  of antibiotics that <answer question  99> received 
without a medical prescription. The questions are about the type of antibiotics you used and the reason 
for needing them. 

Q7: v7time 

Single coded 

When was the last time <answer question 99> used antibiotics without a medical prescription? 

1  A week ago 
2  A month ago 
3  A half year ago 
4  More than a half year ago 
99  Don’t know/Refuse 

*Position fixed 

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Q8: v8reason 

Single coded 

What was the reason for using antibiotics without a medical prescription for <answer question 98>? 

1  Pneumonia (an infection causing an inflammation of one or both lungs) 
2  Bronchitis (the swelling of the airways that lead to the lungs. It often starts the same way as the 
flu or common cold. Yet, bronchitis is characterised by a painful and severe cough) 
3  Flu/common cold/sore throat/cough/fever/headache 
4  Diarrhea 
5  Urinary tract infection 
6  Skin or wound infection 
7  Other  
99  Don’t know/Refuse 

*Position fixed 

Q9: v9disp 

Single coded 

How were the antibiotics dispensed? 

1  Tablets 
2  Capsules 
3  Syrup for oral use 
4  Powder 
5  Other 
99  Don’t know/Refuse 

*Position fixed 

Q10: v10dur 

Single coded 

How  many  days  did  <answer  question  99> use  the  last  course  of  antibiotics  without  a  medical 
prescription? 

1  1 — 3 days 
2  4 — 7 days 
3  More than a week (more than 7 days) 
99  Don’t know/Refuse 

*Position fixed 

Q11: v11use 

Single coded 

Did <answer question 99> use all the antibiotics that were dispensed? 

1  Yes, I used all of them 
2  No, I had some leftover antibiotics 
3  Other 
99  Don’t know/Refuse 

*Position fixed 

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Q12: v12moti 

Multi coded 

What was your motivation to use this last course of antibiotics without a medical prescription for <answer 
question 98>? 

Read the different answer categories 

Explanation code 3: When the respondent has experience with the antibiotic (for previous courses) and is 
satisfied with that experience.  
Explanation code 6: E.g. when the respondent had some leftovers, did not see the doctor or prefers 
cheaper antibiotics 
Explanation code 7: E.g. because the respondent has a busy working schedule 

1  Previously prescribed by qualified doctor 
2  Previously given by pharmacist/medical store personnel without prescription 
3  You have your own motivation as you like this/these antibiotics 
4  My doctor is reluctant to prescribe antibiotics 
5  Previously given/told by friend/family during any illness 
6  Cost saving 
7  Saving time instead of first going to the doctor 
8  Triviality of the symptoms/ mild illness that does not merit seeing a physician 
9  Quick relief 
10  Other 
99  Don’t know/Refuse 

*Exclusive *Position fixed 

Q13: v13reim 

Single coded 

Were the costs of this last course of antibiotics without a medical prescription reimbursed by your health 
insurance? 

Explanation: with health insurance we mean both public and private health insurances 

1  Complete reimbursement 
2  Patient co-payment 
3  No reimbursement 
4  I am not insured/have no health insurance 
99  Don’t know/Refuse 

*Position fixed 

B3: Type of antibiotics used + reason for using antibiotics without a 
medical prescription 

End block 

B4: Experienced (side) effects  

T7:  

Begin block 

Text 

The following questions relate to experienced positive or negative effects of the last course of antibiotics 
without medical prescription <answer question 98>. 

Q14: v14better 

Single coded 

When <answer question 99> last used antibiotics without a medical prescription, did they help? 

1  Yes 
2  No 
99  Don’t know/Refuse 

*Position fixed 

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Q15: v15ad 

Single coded 

During the last course of antibiotics without a medical prescription, did <answer question 99> encounter 
any adverse side effects? 

1  Yes 
2  No 
99  Don’t know/Refuse 

*Position fixed 

ASK ONLY IF Q15 = 1  

Q16: v16ef 

Multi coded 

Which side effects did <answer question 99> experience during the last course with antibiotics without a 
medical prescription? 

Explanation code 3: the inappropriate use of antibiotics can mask the correct diagnosis and delay 
appropriate therapy.  

1  Diarrhea 
2  Rash 
3  Masked diagnosis of infectious disease 
4  Renal failure 
5  Allergic reactions 
6  Upset stomach 
7  Other 
99  Don’t know/Refuse 

B4: Experienced (side) effects  

B5: Information about prudent use 

T8:  

*Exclusive *Position fixed 

End block 

Begin block 

Text 

The following questions are related to the last used course of antibiotics for <answer question 98> that 
you  received  without  a  medical  prescription.  We  would  like  to  know  whether  you  received  information 
about how to use these antibiotics. 

Q17: v17advice 

Single coded 

Did you receive advice or information about how to use the antibiotics without a medical prescription for 
<answer question 98>? 

Explanation: We mean information or advice from the source where you obtained the antibiotics.  

1  Yes 
2  No 
99  Don’t know/Refuse 
*Position fixed 

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ASK ONLY IF Q17 = 1  

Q18: v18where 

Multi coded 

From whom or where did you obtain this information about how to use the antibiotics properly? 

1  Pharmacy staff 
2  General practitioner (doctor) 
3  Other healthcare professional 
4  Internet 
5  National campaign 
6  Other media (than the internet/national campaign) 
7  Other 
99  Don’t know/Refuse 

*Exclusive *Position fixed 

ASK ONLY IF Q17 = 1  

Q19: v19info 

Multi coded 

What  information  did  you  obtain  about  the  use  and  side-effects  of  antibiotics  without  a  medical 
prescription? 

read the different answer categories 

1  Complete the full course of antibiotics 
2  Only take the antibiotics over the prescribed period at the correct dose 
3  Do not give your antibiotics to anyone else 
4  Return outdated of unused antibiotic (leftovers) to the pharmacy 
5  Advise about how to act if the condition persists or if the infection becomes worse 
6  Information about conditions under which the antibiotics should not be taken 
7  Information about possible medical allergies 
8  Information about side-effects (like soft stools, diarrhea, mild stomach upset) 
9  Information about drug interaction 
10  Other 
99  Don’t know/Refuse 

*Exclusive *Position fixed 

B5: Information about prudent use 

End block 

B6: Other person’s use of antibiotics without a medical prescription  Begin block 

T9:  

Text 

The next question is about other person’s use of antibiotics without a medical prescription. 

Q20: v20envi 

Single coded 

Are  there  people  around  you  (i.e.  partner  and/or  family)  who  use  any  antibiotic  without  a  medical 
prescription? 

1  Yes 
2  No 
99  Don’t know/Refuse 

*Position fixed 

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ASK ONLY IF Q20 = 1  

Q21: v21person 

Multi coded 

Can you tell us which persons in your near environment take antibiotics without a medical prescription? 

Read the different answer categories 

1  Partner 
2  Extended 
3  Neighbours 
4  Friends 
5  Other 
99  Don’t know 
88  Refuse 

family 

*Exclusive *Position fixed 

B6: Other person’s use of antibiotics without a medical prescription  End block 

B7: Knowledge and attitudes about antibiotics in general 

Begin block 

T10:  

Text 

Contrary  to  the  previous  questions,  the  following  questions  are  not  only  related  to  the  last  course  of 
antibiotics  used  that  you  received  without  a  medical  prescription.  These  questions  are  about  the  use  of 
antibiotics  in  general  over  the  last  18  months.  These  questions  relate  to  your  knowledge  and  attitude 
about antibiotics in general. 

Q22: v22knowa-f 

Matrix 

For each of the following statements, please tell me whether you agree or disagree. 

Strongly 
Disagree 

Disagree 

 
 

 

 

 
 

 

 

Neither 
agree/ nor 
disagree 
 
 

 

 

Agree 

Strongly 
Agree 

Not sure 

Refuse 

 
 

 

 

 
 

 

 

 
 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Antibiotics kill viruses 
Antibiotics are effective 
against  a  cold  and  the 
flu 
Taking antibiotics often 
has  side-effects  such 
as diarrhea 
If antibiotics have been 
prescribed before, they 
will  be  required  again 
for  similar  symptoms 
in the future 
A 
antibiotics 
ailments 
necessary 
Unnecessary  use  of 
antibiotics  make  them 
become ineffective 

for 
for  minor 
not 

prescription 

is 

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Q23: v23stata-d 

Matrix 

Think about the last 18 months. To what extent do you agree or disagree with the following statements: 

Strongly 
Disagree 

Disagree 

 

 

 

 

Neither 
agree/ nor 
disagree 
 

 

Agree 

Strongly 
Agree 

 

 

 

 

Not sure/ 
not 
applicable 
 

 

Refuse 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

easily 

I  can  easily  convince 
my GP to prescribe me 
antibiotics 
get 
I 
can 
antibiotics 
from  my 
pharmacist  without  a 
medical prescription 
can 
I 
antibiotics 
internet  without 
medical prescription 
can 
I 
antibiotics 
family, 
neighbours 

get 
from  my 
or 

easily 
from 

get 
the 
a 

friends 

easily 

Q24: v24bron 

Multi coded 

Just imagine you have bronchitis and you think you need antibiotics. In which of the following situations 
do you believe it is appropriate to get antibiotics without a medical prescription? 

Read the different answer categories 

Interviewer instruction: Read the different answer categories and ask if it is appropriate to receive 
antibiotics without prescription in the view of the respondent. In case the respondent answers ‘yes’ then 
mark/tick/check off this answer category. In case the respondent answers ‘no’ then leave the square 
empty. 

Explanation: Bronchitis is the swelling of the airways that lead to the lungs. It often starts the same way 
as the flu or common cold. Yet, bronchitis is characterised by a painful and severe cough. 
Explanation code 1: Do you think it is appropriate to get antibiotics without prescription for your 
bronchitis when you have no other symptoms/illnesses and it is a normal work/living week without 
important events. You have the time to go to your regular practitioner for a diagnosis.  
Explanation code 2: Do you think it is appropriate to get antibiotics without prescription for your 
bronchitis when your are on your holiday (you cannot see your own general practitioner) and there is an 
important event coming up that requires a lot of your energy. 

1  During the week in a normal situation 
2  During the week with an important event coming up or holiday abroad 
3  You have no time to go to the doctor 
4  When the doctor has no time to see you immediately  
5  When a consultation with a doctor is too expensive 
9999999 
Don’t know 
88  Refuse 



B7: Knowledge and attitudes about antibiotics in general 

End block 

B8: Background 

Begin block 

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T11:  

Text 

The last section  of  the questionnaire  refers to background or biographical information. Although we are 
aware  of  the  sensitivity  of  the  questions  in  this  section,  the  information  is  anonymous  and  allow  us  to 
compare groups of respondents. 

Q25: v25area 

Single coded 

Which of the following best describes the area you live in? 

Read the different answer categories 

1  Urban 
2  Suburban 
3  Rural 
99  Don’t know/Refuse 

*Position fixed 

Q26: v26edu 

Single coded 

What is the highest educational level you have completed? 

1  Low 
2  Medium 
3  High 
99  Don’t know/Refuse 

*Position fixed 

Q27: v27job 

Single coded 

Which of the following categories best describes your primary area of employment? 

Read the different answer categories 

1  Self-employed 
2  Employee at a company/business 
3  Government employee 
4  Incapacitated, unfit for work 
5  Out of work and/or looking for work 
6  Retired 
7  A student 
8  A housewife/houseman 
9  Other 
99  Don’t know/Refuse 

Q28: v28ins 

Do you have health insurance? 

*Position fixed 

Multi coded 

Explanation: with national health insurance we mean a public insurance. With a community/social 
insurance we mean an health insurance provided by an employer or organisation. 

1  Yes, I am covered by the national (public) health insurance 
2  Yes, I am covered by private health insurance 
3  Yes, I am covered by a community/social healthcare insurance 
4  Other 
5  No, I am not insured 
8888888 
Don’t know/Refuse 

*Exclusive *Position fixed 

*Exclusive *Position fixed 

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Q29: v29doc 

Single coded 

Do  you  usually  visit  the  same  general  practitioner  (doctor)  or  the  same  practice  (including  a  primary 
centre)? 

1  Yes 
2  No 
3  Other 
99  Don’t know/Refuse 

Q30: v30smoke 

Do you currently smoke? 

1  Yes 
2  No 
99  Don’t know/Refuse 

*Position fixed 

Single coded 

*Position fixed 

ASK ONLY IF Q98 = 1  

Q3101: v31health 

Single coded 

How is your health in general at the moment? 

1  Excellent 
2  Good 
3  Fair 
4  Bad 
5  Very 
99  Don’t know/Refuse 

bad 
*Position fixed 

ASK ONLY IF Q98 = 2  

Q3102: v31health 

Single coded 

How is the health of your child in general at the moment? 

1  Excellent 
2  Good 
3  Fair 
4  Bad 
5  Very 
99  Don’t know/Refuse 

bad 
*Position fixed 

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ASK ONLY IF Q98 = 1  

Q3201: v32chro 

Multi coded 

Do you suffer from  any  long-standing respiratory illness or  condition or another  long-standing illness  or 
condition? 

1  Yes, asthma 
2  Yes, chronic obstructive pulmonary disease 
3  Yes, emphysema 
4  Yes, diabetes mellitus 
5  Yes, cardiovascular disease 
6  Yes, hypertension 
7  Yes, other 
8  No 
99  Don’t know/Refuse 

*Exclusive *Position fixed 

ASK ONLY IF Q98 = 2  

Q3202: v32chro 

Multi coded 

Does  your  child  suffer  from  any  long-standing  respiratory  illness  or  condition  or  another  long-standing 
illness or condition? 

1  Yes, asthma 
2  Yes, chronic obstructive pulmonary disease 
3  Yes, emphysema 
4  Yes, diabetes mellitus 
5  Yes, cardiovascular disease 
6  Yes, hypertension 
7  Yes, other 
8  No 
99  Don’t know/Refuse 

Q3301: v33age 

Max 100 

What is your age? 

*Exclusive *Position fixed 

Numeric 

Scripter notes: insert a ‘refuse’ button 

ASK ONLY IF Q98 = 2  

Numeric 

Q3302: v33age 

Max 100 

What is the age of your child? 

Scripter notes: insert a ‘refuse’ button 

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    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q3401: v34sexe 

What is your gender? 

Single coded 

Instruction interviewer: Only ask if you are not sure and if the question is about the respondent him-
/herself! 

1  Male 
2  Female 
88  Refuse 

Q3402: v34sexe 

What is the gender of your child? 

1  Male 
2  Female 
88  Refuse 

B8: Background 

ASK ONLY IF Q98 = 2  

Single coded 

End block 

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B.2. GP questionnaire 

Name of survey 
ARNA GP questionnaire NIVEL 

Client name 

Author(s) 
Tim van de Voorn 

This questionnaire was written according to TNS quality procedures 

checked by  

TNS Company 

TNS 

Repeating  study  (if 
this 
survey  has  been  previously 
conducted) 

Name of survey 

ARNA GP questionnaire NIVEL 

Version 

Author(s) 

Contact 

Panel 

2 

Tim van de Voorn 

Duration of questionnaire 

0 

Sample size 

Sample description 

Quota 

gross: 
net: 0 

If  several  countries:  indicate 
the countries 

If several targets 

Check-in site 

Comments 

www.tns-nipo.com 

0 

April 2017  

187 

 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
T1:  

Dear 

Text 

sir/madam, 

You are invited to participate in a research study about the use of antibiotics, with a specific focus on the 
use  of  antibiotics  without  a  medical  prescription.  We  would  like  to  obtain  more  insight  into  the  role 
general  practitioners  have  in  the  use  of  antibiotics  without  a  medical  prescription.  When  patients  use 
antibiotics  without  medical  prescription  from  their  healthcare  professional,  we  call  this  self-medication. 
They  can  obtain  the  antibiotics  without  medical  prescription  at  the  pharmacy  in  your  own  country  or  in 
another  European  country.  Moreover,  patients  can  use  antibiotics  they  had  left  over  from  a  previous 
course.  Information  about  this  subject  is  necessary  because  patients  who  use  antibiotics  without  a 
medical  prescription  don’t  always  do  this  adequately.  As  a  possible  result,  antibiotics  may  become 
ineffective.  

This research project is being conducted by NIVEL (Netherlands Institute for Health Services Research), 
TNS/Kantar  Health  and  the  University  of  Antwerp.  The  project  is  funded  by  the  European  Commission. 

The  interview  will  require  approximately  10  minutes  to  complete.  Your  answers  will  be  entirely 
anonymous. Participation is strictly voluntary and you may refuse to participate at any time. Moreover, it 
is  possible  for  you  to  indicate  when  a  specific  question  is  not  applicable  for  your  country.  

Your participation in the study will be highly appreciated! 

B1: Do patients use antibiotics without a medical prescription? 

Begin block 

T2:  

Text 

We  will  begin  with  some  questions  about  patients  who  use  antibiotics  without  a  medical  prescription. 
These  patients  use  antibiotics  to  self-administer  treatment  for  often  unmanaged,  undiagnosed  physical 
ailments.  They  obtained  or  purchased  the  antibiotics  without  medical  prescription  for  example  at  the 
pharmacy in their own country or on vacation or on the internet. Besides they could have used  leftover 
antibiotics from a previous course from themselves or from their friends, family. 

Q1: v1aware 

Single coded 

During  the  last  12  months,  were  you  aware  of  patients  who  use  oral  antibiotics  without  a  medical 
prescription? 

1  Yes 
2  No 
    GO TO Q8 
3  Not sure 
    GO TO Q8 
7777777 
Not applicable 
    GO TO Q8 
9999999 
Don’t know/Refuse 
    GO TO Q8 


*Position fixed 


*Position fixed 

TNS NIPO 

G7620c 

© TNS 13-11-2014 

Version number: 3 

 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q2: v2ask 

Max 1000 

ASK ONLY IF Q1 = 1  

Numeric 

During  one  month,  how  many  patients  on  average,  request  oral  antibiotics  for  reasons  you  would  not 
prescribe an antibiotic (e.g. for minor ailments/viruses) in your practice? 

Instructions interviewer: we would like to receive an absolute number from the respondent. If the 
respondent gives an percentage, ask if the respondent could try to give an absolute number. 

In case the respondent don’t know —> Can you give an estimation of the number of patients that ask for 
antibiotics for reasons you would not prescribe an antibiotic in your practice (e.g. for minor ailments or 
viruses)?  

Scripter notes: Please add a ‘Don’t know/Refuse’ button with code 9999999 
And a ‘Not applicable’ button with code 7777777 

Also, the title of this don’t know answer is v2b (instead of v2ask) 

Q3: v5reason 

Multi coded 

Do  you  know  what  the  reasons  are  for  your  patients  to  use  oral  antibiotics  without  a  medical 
prescription? 

Read the different answer categories 
Explanation: By antibiotics without a medical prescription, we mean e.g. antibiotics purchased at the 
pharmacy without medical prescription, leftovers from previous courses or antibiotics purchased online. 
Explanation code 4: E.g. when the patient had some leftovers, did not see the doctor or prefers cheaper 
antibiotics 
Explanation code 5: E.g. because of busy working schedules 

1  Patients have their own motivations because a qualified doctor has previously prescribed 
this/antibiotics to them in the past 
2  Patients have their own motivations because they were previously given by pharmacist/medical 
store personnel without a prescription 
3  Previously given/told by friend/family of the patient during any illness 
4  Cost savings 
5  Saving time instead of going to the doctor first  
6  Mild illness that does not merit seeing a physician or quick relief 
7  Other 
9999999 
Don’t know/Refuse 


*Exclusive *Position fixed 

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    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q4: v6react 

Single coded 

How do you usually react to patients who demand for antibiotics when these are not indicated? 

Explanation: For instance for minor ailments or a viral infection. 

1  I refer them to the pharmacy with an antibiotic prescription 
2  Sometimes I give a prescription for the antibiotics, sometimes I refuse to give a prescription for 
antibiotics 
3  I always refuse to give them an antibiotic prescription 
4  I refer them to the pharmacy without an antibiotic prescription 
5  I advise them to wait and come back when the symptoms persist/become worse 
6  Other 
9999999 
Don’t know/Refuse 


*Position fixed 

ASK ONLY IF Q4 = 1,2  

Q5: v7sel 

Multi coded 

What are your main reasons to prescribe antibiotics for complaints which not require an antibiotic course 
(e.g. minor ailments/viral infections)? 

Read the different answer categories 

1  Pressure from the patient (verbal patients and/or frequent consultation) 
2  Social or current vulnerable status of the patient (e.g. homeless) 
3  Shared decision-making with the patient 
4  Pressure from the pharmacist to sell antibiotics 
5  Threat to lose the business 
6  Fear that patients will go to another general practitioner, where they would probably get a 
prescription for antibiotics  
7  Competition from the internet 
8  Lack of national guidelines and regulations 
9  When patients are ill, I prescribe them antibiotics 
10  I end up prescribing an antibiotic because I have no time to spend explaining why an antibiotic 
for him/her is not needed 
11  Other 
9999999 
Don’t know/Refuse 


*Exclusive *Position fixed 

Q6: v10pres 

Single coded 

Do  you  sometimes  feel  pressured  to  prescribe  antibiotics  when  they  are  not  indicated  (e.g.  for  minor 
ailments)? 

Explanation:  
-Do you have the feeling that you sometimes prescribe antibiotics only because the patient requests 
these antibiotics, even when an antibiotic course is not necessary?  
-Do you have the feeling you do anything to please your patients? 
-Do you find it difficult to refuse to prescribe antibiotics to (some of) your patients? 

1  Yes 
2  No 
9999999 
Don’t know/Refuse 


*Position fixed 

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ASK ONLY IF Q6 = 1  

Q7: v11presex 

Multi coded 

What is or are the reason(s) for feeling this pressure? 

Read the different answer categories 

1  Diagnostic uncertainty 
2  Verbal patients 
3  Financial losses 
4  Threat to lose the business 
5  Pressure from pharmacist companies/enterprises 
6  Fear that patients will go to another general practitioner 
7  Competition from the internet 
8  Other 
9999999 
Don’t know/Refuse 



Q8: v8guide 

Single coded 

Do you have the feeling that general practitioners in  your country follow the national guidelines for the 
appropriate way of prescribing antibiotics? 

1  Always 
2  For the major part 
3  In the minority of cases 
4  Not at all 
5  Not sure 
6  There are no national guidelines 
9999999 
Don’t know 
8888888 
Refuse  *Position fixed 


*Position fixed 


B1: Do patients use antibiotics without a medical prescription? 

End block 

B2: Misconceptions among patients  

T3:  

Begin block 

Text 

The  following  question  is  about  common  misconceptions  from  patients  about  antibiotics.  Therefore  we 
would like to ask you if you can put yourself in the place of the regular patient and think about what their 
conceptions  are.  Also,  think  of  questions  patients  often  ask  that  indicate  a  lack  of  knowledge  about 
antibiotics. 

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Q9: v18custa — f 

Matrix 

We  would  like  to  know  to  what  extent  you  agree  or  disagree  with  the  following  statements  about  the 
conceptions of patients: 

Read the different answer categories 

Strongly 
Disagree 

Disagree 

 

 

 

 

 

 

 

 

Neither 
agree/ nor 
disagree 
 

 

 

 

Agree 

Strongly 
Agree 

Not sure 

Refuse 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patients  believe  that 
antibiotics kill viruses 
Patients  believe  that 
antibiotics are effective 
against  a  cold  and  the 
flu 
Patients  believe  that 
antibiotics  do  not  have 
side effects 
Patients  believe  that  if 
antibiotics  have  been 
prescribed before, they 
will  be  required  again 
for  similar  symptoms 
in the future 
Patients  believe  that  a 
prescription 
for 
for  minor 
antibiotics 
ailments 
not 
necessary  
Patients  believe  that 
they  can  stop  taking 
the  antibiotics  when 
the symptoms are over 

is 

B2: Misconceptions among patients  

End block 

B3: Do pharmacists sell antibiotics without a medical prescription?  Begin block 

T4:  

Text 

The  following  questions  relate  to  pharmacists  in  your  country  who  sell  antibiotics  without  a  medical 
prescription. 

Q10: v19other 

Single coded 

Do you personally know pharmacists in your country who sell antibiotics without a medical prescription? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know 
8888888 
Refuse  *Position fixed 


*Position fixed 

*Position fixed 


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Q11: v20perc 

Max 10000 

Numeric 

We also would like to know if you think there are (other) pharmacists in your country who sell antibiotics 
without a medical prescription. In general, can you give an estimation of the percentage of pharmacists 
in your country doing this? 

Instructions interviewer: we would like to receive an percentage from the respondent. If the respondent 
gives an absolute number, ask if the respondent could try to give a percentage. 

Scripter notes: Please add a don’t know and refuse butten with codes 9999999 and 8888888 respectively 

B3: Do pharmacists sell antibiotics without a medical prescription?  End block 

B4: Do pharmacists sell antibiotics without a medical prescription?  Begin block 

T5:  

Text 

The following question relates to your opinion on the use of antibiotics without a medical prescription. 

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Q12: v21stata — e 

Matrix 

We would like to know to what extent you agree or disagree with the following statements: 

Read the different answer categories 

Strongly 
disagree 

Disagree 

 

 

Neither 
agree/nor 
disagree 
 

Agree 

Strongly 
agree 

Not sure 

Refuse 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The use of antibiotics 
without a medical 
prescription increases 
the risk of antibiotic 
resistance 
The use of antibiotics 
without a medical 
prescription is a 
problem in the 
treatment of 
respiratory infections  
The use of antibiotics 
without a medical 
prescription is not an 
issue among the 
population visiting my 
own medical practice 
The use of antibiotics 
without a medical 
prescription is a 
significant problem in 
my country 
The use of antibiotics 
without a medical 
prescription is a 
significant problem in 
other countries within 
Europe 

B4: Do pharmacists sell antibiotics without a medical prescription?  End block 

B5: Possible solution(s) to diminish the use of antibiotics without a 
medical prescription  

Begin block 

T6:  

Text 

The next few questions are about possible solutions to diminish the use of antibiotics without a medical 
prescription. This means that the questions are only about non-prescribed antibiotics. 

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Q13: v22red 

Single coded 

Do you think that the amount of antibiotics patients are taking without a medical prescription should be 
reduced? 

Explanation: We mean the antibiotics patients receive without medical prescription from their general 
practitioner or from another healthcare professional.  

1  Yes 
    GO TO Q14 
2  No 
    GO TO Q17 
7777777 
Not applicable 
    GO TO Q17 
9999999 
Not sure/Refuse 
    GO TO Q17 

Q14: v23achieve 

How could this be achieved? 


*Position fixed 


*Position fixed 

Multi coded 

Read the different answer categories 

Instructions interviewer: Only thick the answer category ‘Other’ if the respondent spontaneously gives an 
answer that doesn’t resembles any of the existing answer categories.  

1  Public education (national media campaigns) to reduce misconceptions about the use of 
antibiotics for minor ailments 
2  Enforcement of the laws regulating the sale of antibiotics 
3  Dispensing regulation: dispensing exact numbers of antibiotic tablets 
4  Education for healthcare professionals 
5  More restrictive/conservative/appropriate prescribing by general practitioners 
6  Preventing of self-medication from other sources (e.g. internet) 
7  Strengthening pharmacy regulations 
8  Informing the medical guidelines more often 
9  Providing more information on local resistance patterns 
10  Other 
9999999 
Don’t know/Refuse 


*Exclusive *Position fixed 

Q15: v24lim 

Single coded 

Do you feel limited in what you can do as healthcare professional against the use of antibiotics without a 
medical prescription? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 


*Position fixed 

*Position fixed 

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Q16: v25expl 

Could you explain why? 

ASK ONLY IF Q15 = 1  

Multi coded 

Read the different answer categories 

Explanation code 3: if the patient repeatedly ask for antibiotics and tries to convince you to sell the 
antibiotics 
Explanation code 8: selling antibiotics over-the-counter by pharmacists 

1  You feel you have to do everything possible to cure the patient 
2  Costs 
3  Patient pressure  
4  Legal issues 
5  Company/enterprise pressures 
6  Public health considerations 
7  Cooperation of all pharmacists/general practitioners 
8  OTC by pharmacists 
9  Other 
9999999 
Don’t know/Refuse 


*Exclusive *Position fixed 

Q17: v26cam 

Single coded 

Are there any national campaigns to reduce the use of antibiotics without a medical prescription that you 
are aware of? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 

Q18: v27prof 


*Position fixed 

*Position fixed 

Multi coded 

Are  there  any  professional  meetings  about  the  use  of  antibiotics  in  your  country  that  you  have 
participated in? 

Explanation: With professional meetings we mean meetings between general practitioners and/or 
pharmacists and general practitioners that discuss problems concerning the use of antibiotics (for 
example PTAMs (Pharmaco Therapy Audit Meetings)).  

1  Yes, between general practitioners 
2  Yes, between pharmacists and general practitioners 
3  Yes, between general practitioners and other healthcare professionals 
4  No 
5  Other 
9999999 
Don’t know/Refuse 


*Exclusive *Position fixed 

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Q19: v28suf 

Single coded 

Do you receive  sufficient information  about the use  of antibiotics without a medical prescription in your 
community? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 


*Position fixed 

*Position fixed 

B5: Possible solution(s) to diminish the use of antibiotics without a 
medical prescription  

End block 

B6: Background 

T7:  

Begin block 

Text 

The last section of the questionnaire refers to your (professional) background situation. Although we are 
aware  of  the  sensitivity  of  the  questions  in  this  section,  the  information  is  anonymous  and  allow  us  to 
compare groups of respondents. 

Q20: v29age 

Max 100 

What is your age? 

Numeric 

Scripter notes: Please add a ‘Refuse’ button with the code 9999999 

Q21: v30type 

What is the type of your practice? 

1  Public 
2  Private 
3  Group 
4  Other 
9999999 
Refuse  *Position fixed 

Q22: v31gra 

Min 1960 | Max 2014 

In what year did you graduate? 

Single coded 

practice 



Numeric 

Scripter notes: Please add a ‘Refuse’ button with code 9999999 

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Q23: v32sexe 

What is your gender? 

1  Male 
2  Female 
9999999 
Refuse  *Position fixed 

B6: Background 

Single coded 

Instruction interviewer: Only ask if you are not sure! 



End block 

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B.3. Pharmacist questionnaire 

Name of survey 

ARNA pharmacist questionnaire NIVEL 

This questionnaire was written according to TNS quality procedures 

TNS Company 

TNS 

Repeating  study  (if 
this 
survey  has  been  previously 
conducted) 

Name of survey 

ARNA pharmacist questionnaire NIVEL 

Version 

Contact 

Panel 

3 

Duration of questionnaire 

0 

Sample size 

Sample description 

Quota 

gross: 
net: 0 

If  several  countries:  indicate 
the countries 

If several targets 

Check-in site 

Comments 

www.tns-nipo.com 

0 

April 2017  

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    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

T1:  

Dear 

Text 

sir/madam, 

You  are  invited  to  participate  in  a  research  study  about  the  use  of  antibiotics,  with  a  specific 
focus  on  non-prescribed  antibiotics.  We  would  like  to  obtain  more  insight  into  the  role  of 
pharmacists in selling antibiotics over the counter without a medical prescription  and to assess 
the  issue  of  self-medication.  Customers  can  obtain  antibiotics  for  self-medication  at  the 
pharmacy  in  your  own  country  or  in  another  European  country.  Moreover,  customers  can  use 
antibiotics  they  had  left  over  from  a  previous  course.  Information  about  this  subject  is 
necessary as customers who use antibiotics without a medical prescription don’t always do this 
ineffective.  
adequately. 

antibiotics  may 

possible 

become 

result, 

As 

a 

This  research  project  is  being  conducted  by  NIVEL  (Netherlands  Institute  for  Health  Services 
Research),  TNS/Kantar  Health  and  the  University  of  Antwerp.  The  project  is  funded  by  the 
Commission. 
European 

The interview will require approximately 15 minutes to complete. Your answers will be entirely 
anonymous.  Participation  is  strictly  voluntary  and  you  may  refuse  to  participate  at  any  time. 
Moreover,  it  is  possible  for  you  to  indicate  when  a  specific  question  is  not  applicable  for  your 
country.  

Your participation in the study will be highly appreciated! 

B1: Do customers request antibiotics?  

Begin block 

T2:  

Text 

We  will  begin  with  some  questions  about  customers  who  have  requested  antibiotics  without  a 
medical prescription from their general practitioner or another healthcare professional. 

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Q1: v1aware 

Single coded 

During the last 12 months, did customers in your pharmacy request for oral antibiotics without 
a medical prescription? 

Instruction for the interviewer: We only want to know if the respondent was aware of the use of oral 
antibiotics among customers. When customers used other forms of antibiotics (e.g. injections, creams or 
eye drops) this means you should tick the answer category ‘No’. 

Explanation:  
-With self-medication we mean individuals who use non-prescribed antibiotics for unmanaged and/or 
undiagnosed physical ailments. 

-We also mean customers who asked for oral antibiotics without a medical prescription but did not 
receive them at your pharmacy.  

1  Yes 
2  No 
    GO 
3  Not 
    GO 
7777777 
Not applicable 
    GO 
8888888 
Refuse  *Position 
    GO TO B3 

Q2: v2ask 

Max 1000 

TO 

TO 

TO 

B3 
sure 
B3 

*Position fixed 
B3 

fixed 

Numeric 

During one month, how many customers in your pharmacy, on average, ask for oral antibiotics 
without having a medical prescription? 

Instructions interviewer: we would like to receive an absolute number from the respondent. If the 
respondent gives a percentage, ask if the respondent could try to give an absolute number. 

In case the respondent doesn’t know: Could you give an estimation of the number of customers that ask 
for antibiotics without a medical prescription? 

Scripter notes: include a ‘Don’t know/Refuse’’ button with code 9999999 

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Q3: v3otc 

Single coded 

Can customers buy certain oral antibiotics at your pharmacy without a medical prescription? 

1  Yes 
2  No 
    GO 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 
    GO TO B3 

Q4: v4type 

TO 

B3 

*Position fixed 

*Position fixed 

Multi coded 

During  the  last  12  months,  which  type  of  oral  antibiotics  did  you  sell  without  a  medical 
prescription at least once? We are interested in the generic names of these oral antibiotics. 

Instructions interviewer: Only read the different answer categories when the respondent cannot answer 
the question on his/her own (the answer categories are in alphabetical order).  

1  Amoxicillin 

2  Amoxicillin and enzyme inhibitor 
3  Azithromycin 
4  Bacampicillin 
5  Benzathine phenoxymethylpenicillin 
6  Cefaclor 
7  Cefalexin 
8  Cefixime 
9  Cefpodoxime 
10  Ceftibuten 
11  Ceftriaxone 
12  Cefuroxime 
13  Ciprofloxacin 
14  Clarithromycin 
15  Clindamycin 
16  Doxycycline 
17  Flucloxacillin 
18  Fosfomycin 
19  Josamycin 
20  Levofloxacin 
21  Moxifloxacin 
22  Norfloxacin 
23  Phenoxymethylpenicillin 
24  Pivmecillinam 
25  Roxithromycin 
26  Sulfamethoxazole+trimethoprim 
27  Other 
9999999 
Don’t know/Refuse 



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Q5: v5reason 

Multi coded 

Do  you  know  what  the  reasons  are  for  customers  to  buy  antibiotics  without  a  medical 
prescription at the pharmacy? 

Read the different answer categories 

Explanation code 4: E.g. when the customer had some leftovers, did not see the doctor or prefers 
cheaper antibiotics 
Explanation code 5: E.g. because of the customer has a busy working schedule 

NB: From now on, when we refer to ‘antibiotics’, we mean ‘oral antibiotics’ 

1  Patients have their own motivations because a qualified doctor has previously prescribed 
this/antibiotics to them in the past. Patients have their own motivations because they were previously 
given antibiotics by a pharmacist/medical store personnel with 
2  Patients have their own motivations because they were previously given by pharmacist/medical 
store personnel without a prescription 
3  Previously given/told by friend/family of the customer during any illness 
4  Cost saving 
5  Saving time instead of going to the doctor first 
6  Mild illness that does not merit seeing a physician or quick relief 
7  Other 
9999999 
Don’t know/Refuse 



Q6: v6react 

Single coded 

How do you usually react to customers who request antibiotics without a medical prescription? 

1  I sell them antibiotics 
2  Sometimes I sell the antibiotics, sometimes I refuse to sell the antibiotics 
3  I always refuse to sell the antibiotics 
4  I give alternatives (like other drugs/treatments) 
5  I tell the customer to visit the physician first 
6  Other 
9999999 
Don’t know/Refuse 



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    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

ASK ONLY IF Q6 = 1,2  

Q7: v7sel 

Multi coded 

What are your main reasons for selling antibiotics without a medical prescription? 

Read the different answer categories 

1  Pressure from the customer (e.g. verbal customer) 
2  Social or current vulnerable status of the customer (e.g. homeless) 
3  Shared decision-making with the customer 
4  Pressure from the GP to sell antibiotics 
5  Threat to lose the business 
6  Fear that customers will go to another pharmacy, where they would probably get the antibiotics 
7  Competition from the internet 
8  Lack of national guidelines and regulations 
9  When patients are ill, I sell them antibiotics 
10  Other 
9999999 
Don’t know/Refuse 



ASK ONLY IF Q6 = 1,2  

Q8: v8why 

Single coded 

Do you ask customers why they request antibiotics without a medical prescription? 

1  Yes, always 
2  Yes, sometimes 
3  Never 
9999999 
Don’t know/Refuse 

ASK ONLY IF Q6 = 2,3,4,5  

Q9: v9not 

Multi coded 

What are your main reasons for NOT selling antibiotics without a medical prescription? 

Read the different answer categories 

1  Administrative reasons 
2  Legal requirements 
3  Because of possible antibiotic resistance 
4  Risk for the customer for using the wrong antibiotics 
5  Risk for the customer for adverse antibiotic reactions 
6  Risk for the customer for a wrong diagnosis 
7  Risk for the customer for the wrong use of antibiotics 
8  Other 
9999999 
Don’t know/Refuse 





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    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q10: v10pres 

Single coded 

Do you sometimes feel pressured to sell antibiotics without a medical prescription? 

Explanation:  
-Do you have the feeling you sometimes sell antibiotics only because the customer requests these 
antibiotics, even when an antibiotic course is not necessary?  
-Do you have the feeling you do anything to please your customers? 
-Do you find it difficult to refuse the selling of antibiotics to (some of) your customers? 

1  Yes 
2  No 
9999999 
Don’t know/Refuse 

ASK ONLY IF Q10 = 1  

Q11: v11presex 

Multi coded 

What are the reasons for feeling this pressure? 

Read the different answer categories 

1  GP pressures 
2  Verbal customers 
3  Financial losses 
4  Threat to lose the business 
5  Pressure from pharmaceutical companies/enterprises 
6  Fear that customers will go to another pharmacy 
7  Competition from the internet 
8  Other 
9999999 
Don’t know/Refuse 





Q12: v12illa-e 

Matrix 

Could you tell me in which way you agree or disagree with any community pharmacist who sells 
antibiotics without a medical prescription for the following illnesses? 

Strongly 
disagree 

Disagree 

Urinary tract infection 
Sore throat 
Acute bronchitis 
Coughs 
Common cold 

 
 
 
 
 

 
 
 
 
 

Neither 
agree/nor 
disagree 
 
 
 
 
 

Agree 

Strongly 
agree 

 
 
 
 
 

 
 
 
 
 

Not 
sure/not 
applicable 
 
 
 
 
 

Refuse 

 
 
 
 
 

B1: Do customers request antibiotics?  

End block 

B2: Information provided to customers  

Begin block 

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T4:  

Text 

The next set of questions is about the information you provide to customers who buy antibiotics 
without a medical prescription. 

Q13: v13pro 

Single coded 

Do you provide information about the use and side-effects of antibiotics to customers who buy 
antibiotics without a medical prescription? 

1  Yes, always 
2  Yes, sometimes 
3  No, never 
9999999 
Don’t know/Refuse 

Q14: v14how 

Multi coded 

In which way do you provide the information to the customer? 

1  Orally 
2  Written 
3  With a standard leaflet 
4  Other 
9999999 
Don’t know/Refuse 





Q15: v15info 

Multi coded 

What kind of information do you provide these customers with about the use and side-effects of 
antibiotics? 

Read the different answer categories 

1  None 
2  Complete the full course of antibiotics 
3  Only take the antibiotics over the prescribed period at the correct dose 
4  Do not give your antibiotics to anyone else 
5  Return outdated or unused antibiotics (leftovers) to the pharmacy 
6  Advise about how to act if the condition persists/if the infection becomes worse 
7  Information about conditions under which the antibiotics should not be taken 
8  Information about possible medical allergies 
9  Information about side-effects (like soft stools, diarrhea, mild stomach upset) 
10  Information about drug interaction 
11  Other 
9999999 
Don’t know/Refuse 

*Exclusive 



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Q16: v16que 

Single coded 

Do customers ask any questions about the use and side-effects of antibiotics they buy without a 
medical prescription? 

1  Yes, 
2  Yes, sometimes 
3  No, 
9999999 
Don’t know/Refuse 

ASK ONLY IF Q16 = 1,2  

Q17: v17queco 

Multi coded 

In general, about which of the following subjects do customers ask questions? 

Read the different answer categories 

1  The appropriate way of intake 
2  Duration of intake 
3  Safety in combination with current medication 
4  Side-effects 
5  Adverse reactions 
6  Miss a dose of antibiotics 
7  Disposal of antibiotics 
8  The effect of the antibiotic 
9  The end of the antibiotic course 
10  The use of leftover antibiotics 
9999999 
Don’t know/Refuse 

B2: Information provided to customers  

End block 

B3: Misconceptions among customers  

Begin block 

T5:  

Text 

The following question is about common misconceptions from customers about antibiotics (with 
or without a medical prescription). Therefore we would like to ask you if you can put yourself in 
the place of the regular customer and think about what their misconceptions are. Also, think of 
questions costumers often ask that indicate a lack of knowledge about antibiotics. 

always 

never 




April 2017  

207 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q18: v18custa-f 

Matrix 

We  would  like  to  know  to  what  extent  you  agree  or  disagree  with  the  following  statements 
about the conceptions of customers: 

Strongly 
disagree 

Disagree 

 

 

 

 

 

 

 

 

Neither 
agree/nor 
disagree 
 

 

 

 

Agree 

Strongly 
agree 

Not sure 

Refuse 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Customers  believe  that 
antibiotics kill viruses 
Customers  believe  that 
antibiotics are effective 
against  a  cold  and  the 
flu 
Customers  believe  that 
antibiotics  do  not  have 
side effects 
Customers  believe  that 
if antibiotics have been 
prescribed before, they 
will  be  required  again 
for  similar  symptoms 
in the future 
Customers  believe  that 
for 
prescription 
a 
for  minor 
antibiotics 
ailments 
not 
necessary 
Customers  believe  that 
they  can  stop  taking 
the  antibiotics  when 
the symptoms are over 

is 

B3: Misconceptions among customers  

End block 

B4:  Do  (other)  pharmacists  sell  without  a  medical 
prescription? 

Begin block 

T9:  

Text 

The next questions relate to pharmacists in your country who sell antibiotics without a medical 
prescription. 

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208 

 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q19: v19other 

Single coded 

Do  you  personally  know  pharmacists  in  your  country  who  sell  antibiotics  without  a  medical 
prescription? 

1  Yes 
2  No 
9999999 
Don’t know 

8888888 
Refuse 

Q20: v20perc 

Max 100 





Numeric 

We also would like to know if you think there are (other) pharmacists in your country who sell 
antibiotics  without  a  medical  prescription.  In  general,  can  you  give  an  estimation  of  the 
percentage of pharmacists in your country doing this? 

Instructions interviewer: we would like to receive a percentage from the respondent. If the respondent 
gives an absolute number, ask if the respondent could try to give a percentage. 

Scripter notes: include a ‘Don’t know’ and a ‘refuse’ button 

B4:  Do  (other)  pharmacists  sell  without  a  medical 
prescription? 

End block 

B5:  Opinion  on  the  use  of  antibiotics  without  a  medical 
prescription 

Begin block 

T6:  

Text 

The  following  question  relates  to  your  opinion  on  the  use  of  antibiotics  without  a  medical 
prescription. 

April 2017  

209 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q21: v21stata-e 

Matrix 

We  would  like  to  know  to  what  extent  you  agree  or  disagree  with  the  following  statements: 
(matrix question) 

Strongly 
disagree 

Disagree 

 

 

Neither 
agree/nor 
disagree 
 

Agree 

Strongly 
agree 

Not sure 

Refuse 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The use of antibiotics 
without a medical 
prescription increases 
the risk of antibiotic 
resistance 
The use of antibiotics 
without a medical 
prescription is a 
problem in the 
treatment of 
respiratory infections  
The use of antibiotics 
without a medical 
prescription is not an 
issue among the 
population visiting my 
pharmacy 
The use of antibiotics 
without a medical 
prescription is a 
significant problem in 
my country 
The use of antibiotics 
without a medical 
prescription is a 
significant problem in 
other countries within 
Europe 

B5:  Opinion  on  the  use  of  antibiotics  without  a  medical 
prescription 

End block 

B6:  Possible  solution(s)  to  diminish  the  use  of  antibiotics 
without a medical prescription 

Begin block 

T7:  

Text 

The next few questions are about possible solutions — for your country or Europe — to diminish 
the use of antibiotics without a medical prescription. 

April 2017  

210 

 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q22: v22red 

Single coded 

Do  you  think  that  the  amount  of  antibiotics  without  a  medical  prescription  that  customers  are 
using should be reduced? 

Explanation: We mean the amount of antibiotics that customers receive without medical prescription from 
their general practitioner or from another healthcare professional.  

1  Yes 
2  No 
    GO TO Q26 
9999999 
Don’t know/Refuse 
    GO TO Q26 

Q23: v23achieve 

How could this be achieved? 



Multi coded 

Read the different answer categories 

Instructions interviewer: Only tick the answer category ‘Other’ if the respondent spontaneously gives an 
answer that doesn’t resemble any of the given answer categories.  

1  Public education (national media campaigns) to reduce misconceptions about the use of 
antibiotics for minor ailments 
2  Enforcement of the laws regulating the sale of antibiotics 
3  Dispensing regulation: dispensing exact numbers of antibiotic tablets 
4  Education for healthcare professionals 
5  More restrictive/conservative/appropriate prescribing by general practitioners 
6  Self-medication from other sources should be prevented (e.g. internet) 
7  Strengthening pharmacy regulations 
8  Inform the medical guidelines more often 
9  Provide more information on local resistance patterns 
10  Other 
9999999 
Don’t know/Refuse 



Q24: v24lim 

Single coded 

Do you feel limited in what you can do as a healthcare professional against the use antibiotics 
without a medical prescription? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 


*Position fixed 

*Position fixed 

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    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q25: v25expl 

Could you explain why? 

ASK ONLY IF Q24 = 1  

Multi coded 

Read the different answer categories 

Explanation code 3: if the customer repeatedly asks for antibiotics and tries to convince you to sell the 
antibiotics 

1  You feel you have to do everything possible to cure the customer 
2  Costs 
3  Customer pressure 
4  Legal issues 
5  Pressure from company/enterprise  
6  Public health considerations 
7  Cooperation of all pharmacists/general practitioners 
8  Inappropriate prescribing by general practitioners 
9  Other 
9999999 
Don’t know/Refuse 


*Position fixed 

Q26: v26cam 

Single coded 

Are there any national campaigns to reduce the use of antibiotics without a medical prescription 
that you are aware of? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 

Q27: v27prof 


*Position fixed 

*Position fixed 

Multi coded 

Are there any professional meetings about the use of antibiotics without a medical prescription 
in your country that you have participated in? 

Explanation: With professional meetings we mean meetings between pharmacists and/or pharmacists 
and general practitioners that discuss problems concerning the use of antibiotics (for example PTAMs 
(Pharmaco Therapy Audit Meetings)).’ 

1  Yes, between pharmacists 
2  Yes, between pharmacists and general practitioners 
3  Yes, between pharmacists and other healthcare professionals 
4  No 
5  Other 
9999999 
Don’t know/Refuse 



April 2017  

212 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q28: v28suf 

Single coded 

Do  you  receive  sufficient  information  about  antibiotic  use  without  a  medical  prescription  from 
your professional community? 

1  Yes 
2  No 
7777777 
Not applicable 
9999999 
Don’t know/Refuse 


*Position fixed 

*Position fixed 

B6:  Possible  solution(s)  to  diminish  the  use  of  antibiotics 
without a medical prescription 

End block 

B7: Background 

Q33:: extra UA 

Begin block 

Single coded 

In general, when distributing antibiotics to your customers, do you usually deliver the antibiotics 
in: 

Read the different answer categories 

1  A whole package 
2  A strip of pills 
3  The precise number of required pills 
9999999 
Don’t know/Refuse 


*Position fixed 

T8:  

Text 

The last section of the questionnaire refers to your (professional) background. Although we are 
aware  of  the  sensitivity  of  the  questions  in  this  section,  the  information  is  anonymous  and 
allows us to compare groups of respondents. 

Q29: v29age 

Max 100 

What is your age? 

Numeric 

Scripter notes: include a ‘refuse’ button 

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213 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU 

Q30: v30type 

Single coded 

What is the type of pharmacy you work in? 

1  Community pharmacy 
2  Hospital pharmacy 
3  Clinical pharmacy 
4  Ambulatory care pharmacy 
5  Consultant pharmacy 
6  Other  
7  Refuse 

Q31: v31gra 

Min 1960 | Max 2014 

In what year did you graduate? 

Numeric 

Q32: v32sexe 

What is your gender? 

1  Male 
2  Female 
8888888 
Refuse 

B7: Background 

Scripter notes: include a ‘refuse’ button 

Single coded 

Instruction interviewer: Only ask if you are not sure! 



End block 

April 2017  

214 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HOW TO OBTAIN EU PUBLICATIONS 

Free publications: 

•  one copy: 

via EU Bookshop (http://bookshop.europa.eu); 

•  more than one copy or posters/maps: 

from the European Union’s representations (http://ec.europa.eu/represent_en.htm);  
from the delegations in non-EU countries 
(http://eeas.europa.eu/delegations/index_en.htm);  
by contacting the Europe Direct service (http://europa.eu/europedirect/index_en.htm) 
or calling 00 800 6 7 8 9 10 11 (freephone number from anywhere in the EU) (*). 

(*)  The information given is free, as are most calls (though some operators, phone boxes or hotels may 
charge you). 

Priced publications: 

•  via EU Bookshop (http://bookshop.europa.eu). 

 
 
 
 
 
 
 
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doi: 10.2875/326847  
ISBN 978-92-79-66537-0