Fighting antibiotic resistance in Sweden--past, present and future

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 assurance 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.