Open Access Highly Accessed Research article

A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance

Brian G Bell1*, Francois Schellevis23, Ellen Stobberingh4, Herman Goossens5 and Mike Pringle1

Author Affiliations

1 Division of Primary Care, University of Nottingham, University Park, Nottingham NG7 2RD, UK

2 NIVEL (Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, the Netherlands

3 Department of General Practice and Elderly Care Medicine/EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands

4 Caphri University of Maastricht/Maastricht, University Hospital, Medical Microbiology, P.Debyelaan 25, 6229 HX Maastricht, the Netherlands

5 University of Antwerpen, Universitair Ziekenhuis Antwerpen, Laboratory of Medical Microbiology, Wilrijkstraat 10, B-2650 Edegem, Belgium

For all author emails, please log on.

BMC Infectious Diseases 2014, 14:13  doi:10.1186/1471-2334-14-13

Published: 9 January 2014



Greater use of antibiotics during the past 50 years has exerted selective pressure on susceptible bacteria and may have favoured the survival of resistant strains. Existing information on antibiotic resistance patterns from pathogens circulating among community-based patients is substantially less than from hospitalized patients on whom guidelines are often based. We therefore chose to assess the relationship between the antibiotic resistance pattern of bacteria circulating in the community and the consumption of antibiotics in the community.


Both gray literature and published scientific literature in English and other European languages was examined. Multiple regression analysis was used to analyse whether studies found a positive relationship between antibiotic consumption and resistance. A subsequent meta-analysis and meta-regression was conducted for studies for which a common effect size measure (odds ratio) could be calculated.


Electronic searches identified 974 studies but only 243 studies were considered eligible for inclusion by the two independent reviewers who extracted the data. A binomial test revealed a positive relationship between antibiotic consumption and resistance (p < .001) but multiple regression modelling did not produce any significant predictors of study outcome. The meta-analysis generated a significant pooled odds ratio of 2.3 (95% confidence interval 2.2 to 2.5) with a meta-regression producing several significant predictors (F(10,77) = 5.82, p < .01). Countries in southern Europe produced a stronger link between consumption and resistance than other regions.


Using a large set of studies we found that antibiotic consumption is associated with the development of antibiotic resistance. A subsequent meta-analysis, with a subsample of the studies, generated several significant predictors. Countries in southern Europe produced a stronger link between consumption and resistance than other regions so efforts at reducing antibiotic consumption may need to be strengthened in this area. Increased consumption of antibiotics may not only produce greater resistance at the individual patient level but may also produce greater resistance at the community, country, and regional levels, which can harm individual patients.

Antibiotic resistance; Antibiotic usage; Community-acquired infections; Meta-analysis