Antibiotics: City dwellers and children take the most

March 11, 2020.  

ZEF “One Health” researchers take a close look at 73 studies on the use of antibiotics

City dwellers take more antibiotics than people in rural areas; children and the elderly use them more often than middle-aged people; as education increases, the use of antibiotics decreases, but only in rich countries: These are three of the more conspicuous trends that researchers from the NRW Research College "One Health and Urban Transformation" at the University of Bonn have identified in a recent study. In it, they evaluated 73 publications on the use of antibiotics in the outpatient sector around the globe. The topic is of great importance: too many antibiotics are still being administered. A possible consequence is resistance: There are already hardly any effective drugs available against some bacteria. The study will be published in May in the International Journal of Hygiene and Environmental Health, but it is already available online.

Most antibiotics are taken by patients whose disease does not require hospitalization. In Germany, these cases account for approximately 85 percent of all antibiotic prescriptions; EU-wide the rate is even slightly higher. But what factors promote the use of antibiotics in the outpatient healthcare sector? Scientists have been interested in this question for some time. It is largely undisputed that too many antibiotics are administered. This promotes the development of resistance and thus ensures that these weapons, which are actually the sharpest weapons against bacterial infections, slowly become blunted.

The current study summarizes the current state of knowledge on this problem. In it, the participating scientists have evaluated a total of 73 publications on the driving factors of antibiotic use in the outpatient sector. "We were not only interested in individual parameters such as age or education, but also in geographical connections and socio-cultural factors," explains ZEF-researcher Dennis Schmiege, who is doing his doctorate at the University of Bonn under the supervision of Prof. Mariele Evers (Geographical Institute) and Prof. Thomas Kistemann (Institute for Hygiene and Public Health).

Six-hundred possible influencing variables evaluated

Together with his colleague, ZEF senior researcher Dr. Timo Falkenberg, he evaluated almost 600 variables and combined them into about 45 groups. For each of the groups, the overview paper lists whether they are to be considered significant influencing factors according to the current study situation. It is relatively well documented that children and seniors are more likely to swallow antibiotics than middle-aged people. In contrast, a higher level of education tends to have a braking effect. However, this correlation is reversed in poorer countries - "probably because there it is more likely to be the better educated people who either have access to the health care system or who can afford to visit a doctor or buy a drug at all," assumes Schmiege.

Among the geographical parameters, the discrepancy between urban and rural areas is striking: some publications show that the use of antibiotics is higher in urban areas. "We assume that this has something to do with better access to doctors' surgeries and pharmacies," said Schmiege. In fact, the density of doctors also seems to be one of the driving factors. In contrast, higher drug prices reduce the quantity of antibiotics sold.

Comparatively little research has been carried out into the socio-cultural parameters that promote the use of antibiotics. Thus, the national culture seems to have a certain influence: For example, the citizens of "masculine" societies, which are considered to be more competition-oriented, use more antibiotics on average. The situation is similar in societies that are classically more concerned with avoiding uncertainty. "Overall, however, we still see a clear need for research in this area," emphasizes Dennis Schmiege.

Elsewhere, the study situation also shows a clear imbalance: countries with lower and middle incomes are clearly underrepresented compared to richer ones - another point that future research projects should help to remedy, the scientist believes.

The study was conducted within the framework of the NRW Research College "One Health and Urban Transformation", which is a graduate college funded by the Ministry of Culture and Science of the State of NRW. It is conducted by the University of Bonn in cooperation with the Bonn-Rhein-Sieg University of Applied Sciences (H-BRS) and the United Nations University - Institute for Environment and Human Security (UNU-EHS) in Bonn. Further information on the Research Training Group is available on the website

Press release launched by Bonn University (in German):

Online publication: Dennis Schmiege, Mariele Evers, Thomas Kistemann und Timo Falkenberg: What drives antibiotic use in the community? A systematic review of determinants in the human outpatient sector; International Journal of Hygiene and Environmental Health;


Translated with (free version)


Timo Falkenberg

Dr. Timo Falkenberg