Too heavy on amoxicillin/clavulanate, too light on penicillin V

16 November 2021


By Mark Thomas, Associate Professor in Infectious Diseases, University of Auckland 

To highlight World Antimicrobial Awareness Week (18-24 November) Dr Thomas gives an overview on the antibiotic dispensing rates across multiple countries.

The figure below shows the total per capita amount of antibiotics dispensed in the community for New Zealand,1 Australia,2 the United Kingdom,3 Denmark,4 the Netherlands5 and Sweden6during 2018 (blue bars). The amount of antibiotic dispensed per capita in Australia and New Zealand was a little more than twice that in the Netherlands and Sweden, and about one and a half times that in Denmark and the United Kingdom.

The figure also shows the proportion of total community antibiotic dispensing that was comprised by amoxicillin/clavulanate (red bars), and by penicillin V (green bars). The differences between nations are even greater than for the total amount of antibiotic dispensed per capita. For example, amoxicillin/clavulanate comprised 27.5 percent of total community antibiotic dispensing in New Zealand, but only 2.1 percent in Sweden and less than 5 percent in Denmark and the UK. And penicillin V comprised only 1.5 percent of total community antibiotic dispensing in New Zealand, but 25.8 percent in Denmark and 29.9 percent in Sweden.

Doctors in New Zealand have come to regard amoxicillin/clavulanate as an antibiotic for common use, and penicillin V as an antibiotic for very rare use. The data from Sweden and Denmark clearly show that some other nations have very different perceptions of how these medicines should be used. The agency that advises on antibiotic dispensing in Sweden has recommended, for many years, that at least 80 percent of antibiotic prescriptions for children aged less than six years should be for penicillin V. 

The widespread use of amoxicillin/clavulanate and the negligible use of penicillin V in New Zealand is exactly the opposite of what we were taught as medical students: wherever possible to use a narrow spectrum agent in preference to a broad-spectrum agent. Our prescribing practice is in large part a consequence of successful marketing by pharmaceutical companies decades ago, that led to a prescribing culture passed down from one generation of doctors to the next. Different prescribing practices in other nations may be a reflection of more effective constraints on pharmaceutical marketing in those nations and/or more effective education about the benefits of wise antibiotic prescribing. 

Fortunately, we have it in our power to consider these issues and our own prescribing practice.

References 

  1. Thomas M, et al. Reduced community antibiotic dispensing in New Zealand during 2015-2018: marked variation in relation to primary health organisation. NZ Med J 2020;133(1518):33-42.
  2. Australian Commission on Safety and Quality in Healthcare. AURA 2021: Fourth Australian report on antimicrobial use and resistance in human health. At: https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/
  3. European Centre for Disease Prevention and Control. Antimicrobial consumption database. At: https://www.ecdc.europa.eu/en/antimicrobial-consumption/database/distribution-by-antimicrobial-grou
  4. Danmap 2019- Use of antimicrobial agents and occurrence of antimicrobial resistance in bacteria from food animals, food and humans in Denmark. At: https://www.danmap.org/reports/2020
  5. Nethmap 2021. Consumption of antimicrobial agents and antimicrobial resistance among medically important bacteria in the Netherlands in 2021. At: https://www.rivm.nl/publicaties/nethmap-2021-consumption-of-antimicrobial-agents
  6. Swedres-Svarm 2020.Sales of antibiotics and occurrence of resistance in Sweden At: https://www.sva.se/en/our-topics/antibiotics/svarm-resistance-monitoring/swedres-svarm-reports/