Abstract
Abstract Although restricting over-the-counter (OTC) antimicrobial drug sales is recommended globally, no data track its effect on antimicrobial resistance (AMR) in bacteria. We evaluated the effect of a national policy restricting OTC antimicrobial sales, put in place in November 2010, on AMR in a metropolitan region of São Paulo, Brazil. We reviewed associations between antimicrobial sales from private pharmacies and AMR in 404,558 Escherichia coli and 5,797 Streptococcus pneumoniae isolates using a dynamic regression model based on a Bayesian approach. After policy implementation, a substantial drop in AMR in both bacterial species followed decreased amoxicillin and trimethoprim/sulfamethoxazole sales. Conversely, increased ciprofloxacin sales were associated with increased ciprofloxacin resistance, and extended spectrum β-lactamases–positive E. coli isolates and azithromycin sales increases after 2013 were associated with increased erythromycin resistance in S. pneumoniae isolates. These findings suggest that restricting OTC antimicrobial sales may influence patterns of AMR, but multifaceted approaches are needed to avoid unintended consequences.
Highlights
antimicrobial resistance (AMR) in a metropolitan region of São Paulo, Brazil
During the study period, sales of the oral antimicrobial drugs we studied in the São Paulo metropolitan region decreased from 7.86 to 7.65 DID, and we observed a pronounced drop in sales after the 2010 implementation of the restriction policy
Our study suggests that a policy to ban OTC sales of antimicrobial drugs may have influenced a decrease in AMR in a large population
Summary
AMR in a metropolitan region of São Paulo, Brazil. We reviewed associations between antimicrobial sales from private pharmacies and AMR in 404,558 Escherichia coli and 5,797 Streptococcus pneumoniae isolates using a dynamic regression model based on a Bayesian approach. Increased ciprofloxacin sales were associated with increased ciprofloxacin resistance, and extended spectrum β-lactamases–positive E. coli isolates and azithromycin sales increases after 2013 were associated with increased erythromycin resistance in S. pneumoniae isolates. These findings suggest that restricting OTC antimicrobial sales may influence patterns of AMR, but multifaceted approaches are needed to avoid unintended consequences. In November 2010, the National Health Surveillance Agency of Brazil (Agência Nacional de Vigilância Sanitária [ANVISA], https://www.gov.br/anvisa/pt-br) implemented a restriction policy requiring a medical prescription to purchase antimicrobials [4]; OTC sales had been common before the policy took effect. We evaluated the effect of this policy during 2008–2016 on AMR in 2 bacteria that frequently cause community-acquired infections before and after the restriction policy was initiated
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