title: Socioeconomic Determinants of Antibiotic Consumption in the State of São Paulo, Brazil: The Effect of Restricting Over-The-Counter Sales.
abstract: BACKGROUND
  Improper antibiotic use is one of the main drivers of bacterial resistance to antibiotics, increasing infectious diseases morbidity and mortality and raising costs of healthcare. The level of antibiotic consumption has been shown to vary according to socioeconomic determinants (SED) such as income and access to education. In many Latin American countries, antibiotics could be easily purchased without a medical prescription in private pharmacies before enforcement of restrictions on over-the-counter (OTC) sales in recent years. Brazil issued a law abolishing OTC sales in October 2010. This study seeks to find SED of antibiotic consumption in the Brazilian state of São Paulo (SSP) and to estimate the impact of the 2010 law.
  
  
  METHODS
  Data on all oral antibiotic sales having occurred in the private sector in SSP from 2008 to 2012 were pooled into the 645 municipalities of SSP. Linear regression was performed to estimate consumption levels that would have occurred in 2011 and 2012 if no law regulating OTC sales had been issued in 2010. These values were compared to actual observed levels, estimating the effect of this law. Linear regression was performed to find association of antibiotic consumption levels and of a greater effect of the law with municipality level data on SED obtained from a nationwide census.
  
  
  RESULTS
  Oral antibiotic consumption in SSP rose from 8.44 defined daily doses per 1,000 inhabitants per day (DID) in 2008 to 9.95 in 2010, and fell to 8.06 DID in 2012. Determinants of a higher consumption were higher human development index, percentage of urban population, density of private health establishments, life expectancy and percentage of females; lower illiteracy levels and lower percentage of population between 5 and 15 years old. A higher percentage of females was associated with a stronger effect of the law.
  
  
  CONCLUSIONS
  SSP had similar antibiotic consumption levels as the whole country of Brazil, and they were effectively reduced by the policy.
authors.affiliation: Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.|Course of Medicine, Health Sciences Sector, Federal University of Paraná, Curitiba, Brazil.
authors.forename: Breno S
authors.identifier: http://orcid.org/0000-0002-2843-3196
authors.initials: BS
authors.lastname: Kliemann
authors.affiliation: Infection Control Department, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.|Department of Infectious Diseases and LIM54, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil.
authors.forename: Anna S
authors.initials: AS
authors.lastname: Levin
authors.affiliation: Infection Control Department, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: M Luísa
authors.initials: ML
authors.lastname: Moura
authors.affiliation: Infection Control Department, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
authors.forename: Icaro
authors.initials: I
authors.lastname: Boszczowski
authors.affiliation: MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: James J
authors.initials: JJ
authors.lastname: Lewis
mesh_terms: D000900:Anti-Bacterial Agents / Q000191:economics / Q000600:supply & distribution*; D001938:Brazil; D004363:Drug Utilization / Q000191:economics / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007880:Legislation, Drug; D008297:Male; D004366:Nonprescription Drugs / Q000191:economics / Q000600:supply & distribution; D010594:Pharmacies / Q000191:economics / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D012959:Socioeconomic Factors
chemical_list: D000900:Anti-Bacterial Agents; D004366:Nonprescription Drugs