AWaRe classification analysis for European countries with ARIMA forecasts to assess prescribing patterns and 'One...

Antimicrobial resistance is a major threat to public health, with a well-established link between antibacterial consumption and bacterial resistance. Stewardship needs to focus on reducing overall consumption and optimising the quality of prescribing. The European Union's 'One Health' approach aims for at least 65% of antibacterial consumption to be in the 'Access' category of the AWaRe framework until 2030.

This study advances the field by shifting the focus from simply quantifying antibacterial consumption to a nuanced assessment of prescribing quality. Prudent and problematic prescribing behaviour is identified in past and projected trends, both for individual countries and European regions. Progress towards the EU's 'One Health' targets for the human sector is assessed and compared with total antibacterial consumption.

This study analyses data from 1997-2023 and predicts future proportions of AWaRe drug classes for European countries until 2030, using the ARIMA(1,0,1) model. The distribution and changes of the AWaRe groups were analysed to assess prescribing behaviour. Total antibacterial consumption is compared with findings of the 'One Health' targets, and bivariate correlation analyses are performed.

Robust forecast models were developed for the AWaRe classification for 30 European countries. In 2030, the 'Access' group is projected to exceed 65% in Iceland, Denmark, Ireland, Latvia, Finland, France, the Netherlands, Sweden, Lithuania, the United Kingdom, Belgium and Estonia. On the other hand, low shares are expected for Greece (43.8%), Slovakia and Bulgaria (45.9%), Italy (47.3%), Malta (49.9%), Cyprus (50.9%), Hungary (51.8%) and Romania (53.4%). The other 10 countries fall in between, with shares ranging from 56.4% to 64.7%. Of particular concern are Italy, Cyprus and Malta, with low'Access'shares, high consumptions and worsening trends, in contrast to the exemplary performance of Iceland, Norway and Denmark. Germany stands out for its worryingly excessive use of 'Reserve'. Most forecasts were considered reliable, although some showed moderate or poor fit.

The findings predict that many European countries are unlikely to meet the EU's 'One Health' target by 2030. Countries with higher'Access'shares and lower total consumption tend to have lower levels of bacterial resistance, while those with high consumption and problematic prescribing patterns face higher levels of resistance. While most Northern European countries are considered to have a prudent use of medicines, problematic use is observed particularly in Southern and Eastern Europe, a practice being apparent across many medicine classes. Regional differences in prescribing patterns highlight the need for tailored interventions. For certain countries, particularly in Northern Europe, the high proportion of unclassified substances suggests that the AWaRe classification may not fully capture the range of antibacterial substances used.