Antibacterials for systemic use

Antibacterial agents are intended to treat or prevent various bacterial infections. They are of major importance to public health as bacterial infections may be potentially life threatening and a detrimental complication of surgeries. Thereby, bacterial resistance rendering the antibacterial agent inefficient is a threat to human health. Excessive and incorrect use of antibacterial agents contributes to bacterial resistance and causes environmental damage. The use of antibacterial agents and the types of agents used across countries is therefore of relevance to follow.
25 min.

Antibacterials for systemic use

Antibacterial agents are all active towards bacteria, but the different agents are active towards different bacteria. Some are predominantly active towards bacteria with a cell wall, G+ bacteria, some towards bacteria without a cell wall, Gram- bacteria and some are active towards a combination of the two. Based on their antibacterial spectrum, the agents may be referred to as narrow or broad-spectrum antibacterial agents. Furthermore, they may be predominantly towards bacteria living in conditions with oxygen, aerobic, or without oxygen, anaerobic conditions.

The classification of antibacterial agents may be made according to the bacteria they are active towards, upon their pharmacology or the chemical group they belong to. In the ATC system, antibacterial agents for systemic use are classified in J01. Most subdivisions at the ATC 2nd levels are by the main chemical structure, as e.g., the macrolides, lincosamides and streptogramins which have a similar mechanism of action are classified in the same ATC 2nd level (J01F). Another deviation is that the beta-lactam antibacterial agents are split into penicillins (J01C) and other beta-lactam antibacterial agents (J01D). The use of the most important antibacterial agents, as classified in the ATC system, are illustrated in the below graphs. The graphs present the systemic use e.g., when used as tablets, capsules, mixtures or intravenously administered. The penicillins are commonly used antibacterial agents, see the green column in Figure 1B. They are therefore further described and illustrated in more detail below.

Throughout the entire time series there is some variation in the use of the different antibacterial agents in the Nordic countries. The reasons for these differences may include varying therapeutic traditions, differences in bacterial resistance, and other considerations. For example, there may be variation in the use of tetracyclines (J01A), such as doxycycline, tetracycline, and lymecycline, see blue column in Figure 1B. They inhibit bacterial protein synthesis by binding to a subunit of the bacterial ribosome and have a broad antibacterial spectrum. However, tetracyclines face challenges related to resistance and environmental impact due to their stability.  

Otherwise, Norway stands out with a high use of “other” antibacterials (J01X), shown in dark blue. Specifically, methenamine (J01XX05) is frequently used in Norway as a preventive measure against urinary tract infections. In some countries, the use of macrolides, lincosamides and streptogramins (J01F) is significant. These antibiotics can serve as alternatives to penicillins or be used to treat mycobacterial infections.

Note: Please see the legend description below the graph.

Note to Figure 1A: J01 Antibacterials for systemic use. Total sales of all systemic antibacterial agents are included.

No visible data columns for one country indicates no available data that year for that country. More data available in database.

Note: Please see the legend description below the graph.

Note to Figure 1B: J01A Tetracyclines, J01C Beta-lactam antibacterials penicillins, J01D Other beta-lactam antibacterials, J01E Sulphonamides and trimethoprim, J01F Macrolides lincosamides and streptogramins, J01M Quinolone antibacterials, J01X Other antibacterials. 

A few J01 ATC 2nd levels, Amphenicols (J01B) e.g chloramphenicol, Aminoglycosides (J01G) and Combinations (J01R)  are not illustrated in the graph. These are still included in the total sales of antibacterial agents for systemic use, J01, see “Go to database” for a tabular format. In the database you may also find the sales of aminoglycosides (J01G). Agents classified as antimycobacterials with the main indication tuberculosis or lepra (J04) are not included.

To examine a specific group or a selection of groups, you can remove groups by clicking on the labels to the right of the graph.  To see the time series animation, click play. 

No visible data columns for one country indicates no available data that year for that country. More data available in database.

Penicillins

The penicillins were among the first systemic antibacterial agents to come into common use. The first penicillins to come into use were the beta-lactamase sensitive penicillins (J01CE) which has been supplemented with beta-lactamase resistant penicillins (J01CF) and penicillins with extended spectrum (J01CF). Regarding bacterial resistance, it is encouraged, if possible, to use beta-lactamase sensitive penicillins which have a narrower antibacterial spectrum, and to reserve the use of penicillins with extended spectrum. 

Beta-lactamase is an enzyme produced by bacteria that breaks down the beta-lactam ring, a chemical structure critical to the function of beta-lactam agents. The production of beta-lactamase is therefore an important bacterial resistance mechanism. Beta-lactamase inhibitors (J01CG and J01CR) have been developed to be effective even when bacteria produce the beta-lactamase enzyme. While beta-lactamase resistant penicillins are less susceptible to  this enzyme, they have a limited antibacterial spectrum.

The graph below illustrates the use of various penicillins in the Nordic countries.  As you can see, there is some variation in their usage. 

Note: Please see the legend description below the graph.

Note to Figure 2A: J01C Beta-lactam antibacterials, penicillins. Total sales of all systemic penicillins are included.

No visible data columns for one country indicates no available data that year for that country. More data available in database.

Note: Please see the legend description below the graph.

Note to Figure 2B: J01CA Penicillins with extended spectrum, J01CE Beta-lactamase sensitive penicillins, J01CF Beta-lactamase resistant penicillins, J01CR Combinations of penicillins incl. beta-lactamase inhibitors.

To examine a specific group or a selection of chemical groups, you can remove groups by clicking on the labels to the right of the graph. To see the time series animation, click play.

 No visible data columns for one country indicates no available data that year for that country. More data available in database.