BMJ 2016;354:i4192 doi: 10.1136/bmj.

i4192 (Published 3 August 2016)

Page 1 of 3

Feature

FEATURE
ANTIMICROBIAL RESISTANCE

Saving antibiotics for when they are really needed: the

Dutch example
Doctors have responded well to the call to reduce unnecessary antibiotic prescriptions. But what
about farming? The Dutch have shown that antibiotic use can be slashed in agriculture too. So why
isnt everybody doing it? Tony Sheldon reports
Tony Sheldon journalist
Netherlands

Dutch healthcare uses the fewest antibiotics in the world, is

the bold and justifiable claim of the Dutch Health Council, the
governments independent scientific advisers. The country has
had low use for decades.1 Yet in veterinary medicine the
Netherlands, the worlds second largest exporter of agri-food
products (after the United States), was, until a few years ago,
among the highest users. This mismatch sparked action that saw
the country cut antibiotic use in farm animals by nearly 60%
from 2007 to 2015.2 3

Today the Netherlands has one of the lowest levels of

antimicrobial resistance in the world, and it believes the only
way to keep resistance levels down is for health and agricultural
sectors everywhere to work together in what it calls a One
Health approach.
If we want to control a problem in healthcare we need to act
everywhere where antibiotics are used. Because of the
continuous evolution of resistance, any reservoir could be a
source of resistant organisms to humans, says Dik Mevius,
head of the National Reference Laboratory on Antimicrobial
Resistance in Animals at the Central Veterinary Institute at
Wageningen University.

In June, after pushing the issue for six months while holding
the rotating EU presidency, the Netherlands convinced the 28
countries of the EU to commit to launching One Health national
antimicrobial resistance action plans by mid-2017.4

Edith Schippers, Dutch health minister, said that even though

countries have different situations and are at different stages in
developing national plans to tackle antimicrobial resistance,
differences between member states cannot be a reason to hinder
progress and avoid taking necessary action.
The new action plans are supposed to include measures to avoid
routine preventive use of antibiotics in agriculture and restrict
animal use of antibiotics that are of critical importance to human
health, such as carbapenems.

They should also include measureable goals adapted to fit each

countrys circumstances. A European One Health network will,
in turn, support the national plans and allow countries to
exchange information on their progress.

Antibiotics are used in huge quantities in farming, and entire

herds are often treated when a single animal falls sick or to
prevent a herd catching a disease. The EU banned the use of
antibiotics to promote animal growth in 2006 and is also now
talking about introducing a ban on preventive use of antibiotics.

Some EU countries are already clamping down as much as the

Netherlands (Denmark, Sweden), and others are taking some
additional measures (Germany, UK). But so far there has been
little transmission of resistant organisms from animals to humans
(apart from people working in close contact with animals), and
many countries, particularly those grappling with high levels
of resistance in humans, such as meticillin resistant
Staphylococcus aureus (MRSA), do not see reducing use in
agriculture as a priority.

How did the Dutch do it?

Use of antibiotics by the intensive poultry, pig, and cattle farms

in the Netherlands more than doubled between 1990 and 2007.
By 2010 the country topped a European league table of the use
of antibacterial agents per weight of slaughtered animal.5

Systematic preventive use of antibiotics was simply cheaper

than stringent hygiene and infection control measures. MRSA,
endemic in the pig population, spread to farmers and vets;
resistant bacteria producing extended spectrum lactamase
(ESBL), endemic in poultry, were linked to a human death.6
There was momentum for change. This was unacceptable, in
a country with 17 million people in a small area with the
production of 450 million broiler chickens a year, who were at
that time all shedding ESBLand in a country where healthcare
was so well controlled, says Mevius.

tonysheldon5@cs.com
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BMJ 2016;354:i4192 doi: 10.1136/bmj.i4192 (Published 3 August 2016)

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FEATURE

As a result the Dutch Veterinary Medicines Authority was

launched, a trusted public-private partnership of food producers,
vets, and government. Within two years it had data on antibiotic
use from 40 000 farms. Mevius says: We knew which farms
used two or three times as much as others. We also knew the
vets who were prescribing more, and we were then able to start
benchmarking. We created an awareness.
At the same time parliament rapidly agreed an ambitious, if
unscientific, target of 50% reduction. A massive 58.1% in six
years followed. Today, patterns of use still vary, and a further
30% fall is still thought possible.

Mevius was surprised: We thought that in a country which has

very industrialised animal production it would be difficult to
change habits. It was in fact very easy. This shows there was
a huge overuse of antibiotics in livestock.

And crucial to the success was that it was carried out privately
by all the parties involved in animal production while the
government just imposed the targets. It was a top-down
decision to do something and a bottom-up implementation that
was the success, says Mevius.

Different medical culture

The story is different in humans. Dutch doctors dont
overprescribe antibiotics and Dutch patients dont demand them.
Studies over decades have consistently shown the Netherlands
to be among the European leaders for prudent antimicrobial use
in human health.1 Public health experts estimate 15% of the
population are prescribed antibiotics by their primary care doctor
in any one year, half or a third of the proportion in southern
European countries. The latest 2013 figures show the
Netherlands with 11 daily doses of antibiotics per 1000
population, half of the UKs rates.7 Equally, rates of MRSA
infection are among the lowest, at about 0.5% among the general
population.
In the Netherlands antibiotics must be supplied on prescription,
with primary care, which has a strong gatekeeper function in
Dutch healthcare, accounting for 80%. A culture of cautious
prescribing has been built up over decades through general
practitioners acceptance of strict professional guidance.
Indications for use, type, and dosage are issued by the College
of General Practitioners (NHG). Recent statistics show use is
continuing to decline, with a 6% fall recorded between 2011
and 2014 in daily doses of antibiotics dispensed by pharmacies.8
Jaap van Dissel, director of the Centre for Infectious Disease
Control at the National Institute for Public Health and the
Environment, says: GPs are convinced that many indications
should not be treated with an antibiotic, even though they are
in other countries. He cites the example of acute otitis media
in children.

We know from studies that the positive benefits of antibiotics

are limited. The infection causes a couple of hours pain, which
could be treated by paracetamol,9 he says.

Roger Damoiseaux, professor of general practice at Utrecht

University Medical Centre, helped draw up the NHG guidelines
advising against using antibiotics in children aged over 2 years
for common problems, including tonsillitis and sinusitis. He
has seen rates of antibiotic use fall for these conditions since
1990. Younger GPs, in particular, prescribe less. The guidelines
are really working. Training, since [the guidelines] came out,
has played a major part in bringing down the rates of
unnecessary prescribing.

Yet the Netherlands continues to push for a further 50%

reduction in both incorrect prescribing and avoidable healthcare
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related infection from 2015 to 2020. It has recently launched a

publicity campaign to increase national awareness of the need
to avoid using antibiotics whenever possible.

Can other countries follow the Dutch

example?
The Dutch are fortunate. Their country and population are
relatively small, perhaps making it easier to bring all the
necessary players on board to cooperate in a One Health
approach. Dutch hospital architecture allows for the option of
single rooms, so patients can be easily isolated to control
outbreaks of infection such as Clostridium difficile. Dutch
farmers all have computerised systems, unlike in many countries,
which allow monitoring and comparisons of antibiotic use.
The Dutch also consciously decided to make antimicrobial
resistance a priority sooner than most countries. Decades of
work on hospital infection through the Prevention Working
Group and promoting prudent antimicrobial use through the
Working Party on Antibiotic Policy (http://www.swab.nl/
english) means that these issues are foremost in the minds of
the professionals, says van Dissel.

In some countries the agricultural sector may be a reluctant to

act if it is more cost effective to use preventive antibiotics at
moments of risk, such as when weaning piglets, than to take
measures to improve hygiene. Meanwhile Meviuss plea to act
everywhere is easier to ignore if multidrug resistant Klebsiella
or MRSA is already endemic in hospitals.
Although actions have to fit the cultural context of each
country, Van Dissel fears that in some it is a less important
topic than others. We are now at a point where we need to
convince policy makers, including on a European level, that
these are important issues. It is a matter of the priorities of the
politicians.

In the UK, the Department for Environment, Food and Rural

Affairs is leading a five year antimicrobial resistance strategy
in animals for 2013-18.10 This encourages good farm
management, biosecurity, and animal husbandry to reduce the
risk of disease and minimise the need for antibiotic use in
animals. In May, a review of antimicrobial resistance by
economist Jim ONeill commissioned by the UK government
and the Wellcome Trust, highlighted reducing the extensive
and unnecessary use of antibiotics in agriculture as one of four
main interventions.11

Whether the EU health ministers agreement under the Dutch

presidency will give the One Health approach a further boost
in the post-Brexit UK remains to be seen. But it has been largely
welcomed elsewhere.

Sascha Marschang, policy manager of the Brussels based

network of not-for-profit health organisations, the European
Public Health Alliance, told The BMJ that while the agreement
the Dutch achieved during their EU presidency was progress,
she feared the plans risk not being concrete enough for the
scale and urgency of the threat. Crucially, she urged that
stronger legislation is needed to remove any financial incentives
to individuals and institutions to use antimicrobials gratuitously.
Instead, across Europe, vets and farmers should rather be
incentivised to reduce prophylactic use and improve animal
welfare to reduce the need for antimicrobials.
The Dutch believe that the US and Canada are also following
their achievements with interest. Any solution would need to
be global. The ONeill report pointed out that in the US, 70%
(by weight) of antibiotics defined as medically important for

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BMJ 2016;354:i4192 doi: 10.1136/bmj.i4192 (Published 3 August 2016)

Page 3 of 3

FEATURE

humans by the Food and Drug Administration, were sold for

use in animals.

Dutch health minister Schippers highlighted the importance of

international action to her EU colleagues at the June meeting.
She stressed that antibiotic resistance would be on the agenda
for the United Nations General Assembly in New York this
September. She and other Dutch representatives will be there.
Competing interests: I have read and understood BMJ policy on
declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer
reviewed.
1

European Centre for Disease Prevention and Control, European Food Safety Authority,
European Medicines Agency. ECDC/EFSA/EMA first joint report on the integrated analysis
of the consumption of antimicrobial agents and occurrence of antimicrobial resistance in
bacteria from humans and food-producing animals. EFSA J 2015;13:4006doi:10.2903/j.
efsa.2015.4006.
Mevius D, Heerderik D. Reduction of antibiotic use in animals lets go Dutch.J Verbr
Lebensm 2014;9:177. doi:10.1007/s00003-014-0874-z.

For personal use only: See rights and reprints http://www.bmj.com/permissions

3
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9

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11

Speksnijder DC, Mevius DJ, Bruschke CJ, Wagenaar JA. Reduction of veterinary
antimicrobial use in the Netherlands. The Dutch success model. Zoonoses Public Health
2015;62(Suppl 1):79-87. doi:10.1111/zph.12167. pmid:25421382.
European Council. Council conclusions on the next steps under a One Health approach
to combat antimicrobial resistance. Press release, 17 Jun 2016. www.consilium.europa.
eu/en/press/press-releases/2016/06/17-epsco-conclusions-antimicrobial-resistance.
Grave K, Torren-Edo J, Mackay D. Comparison of the sales of veterinary antibacterial
agents between 10 European countries. J Antimicrob Chemother 2010;65:2037-40. doi:
10.1093/jac/dkq247 pmid:20587611.
Sheldon T. Dutch doctors warn of dangers of overuse of antibiotics in farming. BMJ
2010;341:c5677. doi:10.1136/bmj.c5677.
CBS. Within Europe, antibiotics use lowest in the Netherlands. https://www.cbs.nl/en-gb/
news/2016/06/within-europe-antibiotics-use-lowest-in-the-netherlands.
ZonMw. Antibiotic resistance programme. 2015. http://www.zonmw.nl/uploads/tx_
vipublicaties/Prorammatekst_Antibiotica_Resistentie.pdf).
Van Buchem FL, Dunk JH, vant Hof MA. Therapy of acute otitis media: myringotomy,
antibiotics, or neither? A double-blind study in children. Lancet 1981;318:883-7.http://
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6117681&
dopt=Abstractdoi:10.1016/S0140-6736(81)91388-X.
Department of Health. Department of Food Agriculture and Rural Affairs, UK five year
antimicrobial resistance strategy 2013 to 2018. www.gov.uk/government/uploads/system/
uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf.
Review on microbial resistance. Tackling drug-resistant infections globally: final report
and recommendations. May 2016. http://amr-review.org/.

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