Tomorrow is the European Antibiotic Awareness Day: one of these days in that the Dutch feel proud…., when the rest of (most of) Europe recognizes and acknowledges that the Netherlands do a fantastic job in controlling antibiotic resistance. How? Difficult to say, and may be the “diagnosis” should be established by exclusion. Here are at least 3 reasons that did NOT contribute to our success (although many think otherwise)…..

1. Excellent hand hygiene

Although widely considered the most important measure for infection control, including prevention of bacterial transmission, the quantitative support for this claim is lacking. Hand hygiene is like good weather: Few will be against it (I also like good weather). In what probably was the largest study (24 hospitals, representative for the total of about 75) hand hygiene adherence was 20% and all hospitals had the low resistance rates, characteristic for our country. Without an established dose-relationship (what adherence is needed for what effect), we will keep on reading that hand hygiene is not good enough, and adherence should improve. Moreover, we will keep on attributing success to better hand hygiene, even if adherence was not measured (and other data prove otherwise), see.

2. Excellent adherence to guidelines in hospitalized patients

Be reassured: we Dutch are no better than you! Treatment for (presumed) community-acquired pneumonia (CAP) is a frequent reason for antibiotic use. For patients hospitalized with CAP in 2008/9 adherence to guideline recommendations based on severity scoring was 30-40%, see. As these guidelines stimulated the unnecessary use of broad-spectrum antibiotics, non-adherence might have contributed to our low rates of resistance. We are now updating the CAP guideline, which will make our small country great again, as it could be a small step towards less unnecessary antibiotic use. We may even improve adherence, but then remember we already had low resistance rates when we did not adhere.

3. Massive reduction in antibiotic use in the agricultural industry

Our country is the 4^th most crowded in the world, probably with the highest animal biomass per square meter. Until 2010 we used >500.000 kg antibiotics per year in the agricultural industry, and antibiotic resistance was high among animals. This changed drastically after 2011 and by now antibiotic use has been reduced by 58%. Yet, as of yet, the decline in resistance in animals is much less impressive, without evidence that human infection rates have declined. Actually, we see now more VRE outbreaks than when VRE was highly prevalent in animals. I welcome this massive reduction in antibiotic use, but do remember that we (humans) were already low when they (animals) were high.

So, antibiotic resistance is complex and putting all bets on one of the above interventions may not solve the problem. The approach must be multifactorial, with a quantitative evaluation of the local factors contributing to the  problem.  So, what did work? I will think some more on SDD, Calvinism among GPs, clinical microbiology, stochasticity and pre-Trump isolationism. I’ll let you know, when I know more.