Thank Martin Luther that ciprofloxacin could cure your gonorrhoea? Ecological association between Protestantism and antimicrobial consumption in 30 European countries

Abstract

Background: Higher consumption of antimicrobials plays an important role in driving the higher prevalence of antimicrobial resistance in Southern compared to Northern Europe. Poor controls on corruption (CoC), high uncertainty avoidance (UA) and performance vs. cooperation orientation (POCO) of societies have been found to explain much of this higher consumption in Southern European countries. We hypothesized that these predictors were in turn influenced by the Protestant Reformation in the 16th century onwards. Methods: We used structural equation modelling (SEM) to assess the relationships between country-level proportions being Protestant, CoC, UA, POCO and four markers of antimicrobial consumption in the community (all antibacterials, cephalosporin, macrolides and fluoroquinolones). Results: The proportion of a country that was Protestant was negatively correlated with the consumption of all antibacterials. SEM revealed that UA predicted all antibacterial consumption (direct effect coef. 0.15, 95% Confidence Interval [CI] 0.04-0.26). The proportion Protestant exerted an indirect effect on consumption (coef. -0.13, 95% CI -0.21- -0.05). This effect was mediated predominantly via its effect on UA (direct effect coef. 0.15, 95% CI 0.04-0.26). The model explained 37% of the variation in consumption. Similar results were obtained for each of the other three classes of antimicrobials investigated. Conclusions: Our results are compatible with the theory that contemporary differences in antimicrobial consumption in Europe stem in part from cultural differences that emerged in the Reformation. These findings may explain the differential efficacy of similar antibiotic stewardship campaigns in Northern and Southern European populations.

WGS of Commensal Neisseria Reveals Acquisition of a New Ribosomal Protection Protein (MsrD) as a Possible Explanation for High Level Azithromycin Resistance in Belgium

“…The consumption of macrolides and cephalosporins is high in the general Belgian population compared to other European countries [ 44 , 45 ]. This has been linked to a combination of cultural factors (such as a high uncertainty avoidance index), and various structural factors that retard antibiotic stewardship campaigns [ 46 , 47 , 48 , 49 ]. Consumption is considerably higher in MSM attending our STI clinics than the general population [ 50 ].…”

Persistence: Myth and Mystery

“…For example, a recent paper asked "Thank Martin Luther (Kenyon and Fatti 2020)that ciprofloxacin could cure your gonorrhoea?" The paper examines the consumption of antimicrobial medicine in 30 European countries and shows a strong 'effect' of Protestantism -which is then rationalized by uncertainty avoidance and a preference for cooperation over performance in Catholic countries are to blame (Kenyon and Fatti 2020). Apart from the doubts one might reasonably have about a cross-country study with 30 observations, it is clear that the association with (historical) Protestantism does not create particular insight into the origins of resistant "super-bugs".…”