742 www.thelancet.com/infection Vol 14 August 2014 Articles Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data Thomas P Van Boeckel, Sumanth Gandra, Ashvin Ashok, Quentin Caudron, Bryan T Grenfell, Simon A Levin, Ramanan Laxminarayan Summary Background Antibiotic drug consumption is a major driver of antibiotic resistance. Variations in antibiotic resistance across countries are attributable, in part, to different volumes and patterns for antibiotic consumption. We aimed to assess variations in consumption to assist monitoring of the rise of resistance and development of rational-use policies and to provide a baseline for future assessment. Methods With use of sales data for retail and hospital pharmacies from the IMS Health MIDAS database, we reviewed trends for consumption of standard units of antibiotics between 2000 and 2010 for 71 countries. We used compound annual growth rates to assess temporal differences in consumption for each country and Fourier series and regression methods to assess seasonal differences in consumption in 63 of the countries. Findings Between 2000 and 2010, consumption of antibiotic drugs increased by 36% (from 54 083 964 813 standard units to 73 620 748 816 standard units). Brazil, Russia, India, China, and South Africa accounted for 76% of this increase. In most countries, antibiotic consumption varied significantly with season. There was increased consumption of carbapenems (45%) and polymixins (13%), two last-resort classes of antibiotic drugs. Interpretation The rise of antibiotic consumption and the increase in use of last-resort antibiotic drugs raises serious concerns for public health. Appropriate use of antibiotics in developing countries should be encouraged. However, to prevent a striking rise in resistance in low-income and middle-income countries with large populations and to preserve antibiotic efficacy worldwide, programmes that promote rational use through coordinated efforts by the international community should be a priority. Funding US Department of Homeland Security, Bill & Melinda Gates Foundation, US National Institutes of Health, Princeton Grand Challenges Program. Introduction Antibiotic drugs have reduced the burden of common infectious diseases and become essential for many medical interventions. 1,2 However, antibiotic-resistant pathogens have emerged and spread among human and animal populations worldwide. 3,4 Pathogens such as meticillin-resistant Staphylococcus aureus (MRSA) 5 and carbapenem-resistant Enterobacteriaceae (CRE) 6 have become a global problem. The loss of efficacy against common pathogens has not only led to a shift towards more expensive antibiotic drugs in high-income countries, but also to increased morbidity and mortality in low-income and middle-income countries, where affordability of second-line drugs restricts their use. 1 The emergence of drug-resistant bacterial strains is due to the selection pressure (an external force that reduces reproductive success of some individuals in a population) imposed by use of antibiotics. The intensity of this natural event is driven by a population’s volume of consumption of antibiotic drugs, whether use is appropriate or not. 7–11 Identification of spatial and temporal trends in antibiotic consumption is important to understand the epidemiology of antibiotic resistance. First, identification of regions in which rate of consumption of antibiotics per person is high or rising can rapidly predict where the threat of new resistant infections will be greatest 12 and can help to inform initiatives to preserve antibiotic efficacy. 13,14 Second, mapping of the distribution of antibiotic consumption provides a baseline for the assessment of efforts for future antibiotic drug reduction. Although some estimates have been made, a com- prehensive analysis has not been completed. In the USA, the ResistanceMap project 12 mapped the distribution of use of cephalosporins, macrolides, penicillins, fluoro- quinolones, tetracyclines, and trimethoprim. Goossens and colleagues 8 made a detailed inventory of antibiotic use in the European Union and neighbouring countries. 15 In 1987, Col and colleagues 16 first attempted to estimate the global use of antibiotic drugs with data for a few countries. In this report, we aim to assess antibiotic consumption patterns from 2000 to 2010 for 16 groups of antibiotic drugs in 71 countries. Methods We used IMS Health MIDAS (IMS Health, Danbury, CT, USA) to quantify antibiotic drug consumption. With use of national sample surveys done by pharmaceutical sales distribution channels (ie, from manufacturer to wholesaler to retailer), this database estimates antibiotic consumption from the volume of antibiotics sold in retail and hospital pharmacies. In each sector, data are collected regularly to estimate direct sales from antibiotic drug manufacturers Lancet Infect Dis 2014; 14: 742–50 Published Online July 10, 2014 http://dx.doi.org/10.1016/ S1473-3099(14)70780-7 See Comment page 667 Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA (T P Van Boeckel PhD, Q Caudron PhD, Prof B T Grenfell PhD, Prof S A Levin PhD); Center for Disease Dynamics, Economics, and Policy, Washington, DC, USA (Prof R Laxminarayan, S Gandra MD, A Ashok MPP); Princeton Environmental Institute, Princeton, NJ, USA (Prof R Laxminarayan, Prof S A Levin, Prof B T Grenfell); Public Health Foundation of India, New Delhi, India (Prof R Laxminarayan); Beijer Institute of Ecological Economics, Stockholm, Sweden (Prof S A Levin); and Fogarty International Center, National Institutes of Health, Bethesda, MD, USA (Prof B T Grenfell) Correspondence to: Prof Ramanan Laxminarayan, Princeton Environmental Institute, Princeton, NJ 08544, USA rlaxmina@princeton.edu