Zusammenfassung
Mit dem vermehrten Auftreten von Pneumokokken mit eingeschränkter Empfindlichkeit gegenüber Penicillin und von Methicillin-resistentem Staphylococcus aureus wurden in Schweden Forderungen laut, durch zielgerichtete Maßnahmen einem Überschreiten kritischer Schwellenwerte der Resistenzraten vorzubeugen. Anfangs der 1990er Jahre fand sich Schweden aufgrund niedriger Antibiotika-Resistenzraten und eines geringen Antibiotikaverbrauchs in einer sehr günstigen Ausgangssituation. Eine Durchsicht der bisherigen schwedischen Erfahrungen im Lichte neuer und zukünftiger Herausforderungen war das Ziel der vorliegenden Arbeit. Daten zur Resistenzsituation in Schweden, zu Antibiotikaverbrauch, Meldungen anzeigepflichtiger Erkrankungen, Ausbruchskontrolle und Notfallpläne sowie einschlägige wissenschaftlicher Publikationen wurden ausgewertet. In Schweden ist durch gut etablierte mikrobiologische Diagnostiklaboratorien und durch die Möglichkeit, klinische Proben ohne finanzielle Restriktionen zum kulturellen Erregernachweis einsenden zu können, der Aufbau von Resistenz-Surveillancesystemen erleichtert. Antibiotikaverbrauchsdaten können für den Humanbereich seit über 20 Jahren problemlos erhoben werden. Gesetzliche Vorgaben erlaubten die Bildung intersektoraler Gruppen, sogenannter Strama (Swedish Strategic Programme Against Antibiotic Resistance)-Gruppen, zur Resistenzüberwachung auch in den Bereichen Veterinärmedizin und Lebensmittelproduktion auf regionaler Basis. Als Schwachstelle für die Surveillance von Antibiotikaresistenzen wurden unzureichende Datenverarbeitungssysteme ausgemacht. Die Grundstruktur eines dezentralisierten Überwachungssystems hat dazu geführt, dass sich sowohl geplante Maßnahmen als auch konkrete Vorgaben regional sehr unterschiedlich entwickelt haben. Die Tatsache, dass es Schweden bislang gelungen ist, die Problematik der antimikrobiellen Resistenz weitgehend zu beherrschen, kann mit der engen Kooperation zwischen Humanbereich und Vetrinärmedizin und den – mit Unterstützung der Regierung – bereits frühzeitig gesetzten Maßnahmen erklärt werden. Durch laufende Überarbeitung der einschlägigen Gesetze und der Surveillance-Systeme wird derzeit versucht, dem rezenten Anstieg von Breitspektrumbetalaktamasen-bildenden Keimen in Schweden und dem dadurch bedingten Anstieg des Antibiotikaverbrauchs entgegen zu wirken.
Summary
Sweden has been in the favorable situation of having limited antibiotic resistance and low antibiotic consumption. When pneumococci with reduced susceptibility to penicillin and methicillin-resistant Staphylococcus aureus emerged during the 1990s, professionals and relevant authorities called for extensive action plans to avoid the critical threshold levels of resistance experienced in other countries. The purpose of this paper is to examine Swedish experiences in light of new and future challenges by reviewing Swedish data on antibiotic resistance and antibiotic use, notifications, outbreak control, action plans and scientific papers. The tradition of liberal performance of clinical cultures, together with well functioning diagnostic laboratories, has formed a basis for close collaboration and development of surveillance within quality assurement programs. For more than 20 years the pharmacy monopoly in Sweden has made it possible to collect well defined data on antibiotic sales at the county level with almost 100% coverage. Multisectorial collaboration was set up in regional Strama (Swedish Strategic Programme Against Antibiotic Resistance) groups. Large diagnosis-prescribing surveys have been undertaken, and the concept of basic hygiene precautions was introduced, together with extensive programs for early case finding. However, surveillance has been hampered by inadequate IT systems and some difficulties in collecting relevant data on antibiotic sales at the national level. Also, a decentralized system with 21 counties and regions has resulted in divergence of action plans and rules. The containment of antibiotic resistance thus far may be explained by the early response in human and veterinary medicine and close multisectorial collaboration, supported by the government, before problems got out of hand. Nevertheless, rapidly growing problems with bacteria that produce extended beta-lactamases have recently emerged and antibiotic sales have started to increase again. The outcome of ongoing revision of legislation and surveillance will have great impact on the future possibilities of limiting antibiotic resistance in Sweden.
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Struwe, J. Fighting antibiotic resistance in Sweden – past, present and future. Wien Klin Wochenschr 120, 268–279 (2008). https://doi.org/10.1007/s00508-008-0977-6
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DOI: https://doi.org/10.1007/s00508-008-0977-6