title: Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community.
abstract: BACKGROUND
  Over 90% of antibiotics for human use in Europe are prescribed in primary care. We assessed the congruence between primary care treatment guidelines for skin infections and commensal Staphylococcus aureus (S. aureus) antimicrobial resistance levels in community-dwelling persons.
  
  
  METHODS
  The prevalence of antimicrobial resistance in S. aureus was analysed by taking nose swabs from healthy primary care patients in nine European countries (total N = 32,032). Primary care treatment guidelines for bacterial skin infections were interpreted with respect to these antimicrobial resistance patterns. First- and second-choice recommendations were assessed and considered congruent if resistance to the antibiotic did not exceed 20%.
  
  
  RESULTS
  We included primary care treatment guidelines for impetigo, cellulitis, folliculitis and furuncle. Treatment recommendations in all countries were consistent: most of the first-choice recommendations were beta-lactams, both for children and adults. Antimicrobial resistance levels were low, except for penicillin (on average 73% resistance). Considerable variation in antimicrobial resistance levels was found between countries, with Sweden displaying the lowest levels and Spain the highest. In some countries resistance to penicillin and azithromycin was significantly higher in children (4-17 years) compared with adults.
  
  
  CONCLUSIONS
  Most of the first- and second-choice recommendations in the treatment guidelines for skin infections were congruent with commensal S. aureus antimicrobial resistance patterns in the community, except for two recommendations for penicillin. Given the variation in antimicrobial resistance levels between countries, age groups and health care settings, national data regarding antimicrobial resistance in the community should be taken into account when updating or developing primary care treatment guidelines.
authors.affiliation: Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118-124, Utrecht, The Netherlands. e.vanbijnen@nivel.nl.
authors.forename: Evelien M E
authors.initials: EM
authors.lastname: van Bijnen
authors.forename: W John
authors.initials: WJ
authors.lastname: Paget
authors.forename: Casper D J
authors.initials: CD
authors.lastname: den Heijer
authors.forename: Ellen E
authors.initials: EE
authors.lastname: Stobberingh
authors.forename: Cathrien A
authors.initials: CA
authors.lastname: Bruggeman
authors.forename: François G
authors.initials: FG
authors.lastname: Schellevis
mesh_terms: D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D017963:Azithromycin / Q000494:pharmacology / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000188:drug therapy; D024881:Drug Resistance, Bacterial; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D009296:Nasal Cavity / Q000382:microbiology; D010406:Penicillins / Q000494:pharmacology / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards*; D013207:Staphylococcal Skin Infections / Q000188:drug therapy* / Q000382:microbiology; D013211:Staphylococcus aureus / Q000187:drug effects / Q000302:isolation & purification; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D010406:Penicillins; D017963:Azithromycin