Background and Objective:
Although antibiotic use is one of the most important contributors to antimicrobial resistance (AMR), there is also evidence that their correlation is not always perfect. In fact, other factors (e.g., economic development and governance quality) may explain differences in AMR levels observed between countries. Here, we used ecological data to evaluate how governance indicators relate to antibiotic use and AMR in 30 European countries.

Methods:
We used data from the World Bank Databank, ECDC atlas, and ESAC-Net databases to compile a dataset of six governance indicators (voice and accountability, political stability, government effectiveness, regulatory quality, rule of law, and control of corruption); AMR proportions for 25 combinations of pathogens and antibiotics; and the amount of antibiotics consumed in the community. AMR proportions and governance indicators were also aggregated into an overall measure of AMR and a governance index.

Results:
Except for political stability, all governance indicators were inversely correlated with the proportions of: Acinetobacter spp. and Pseudomonas aeruginosa resistant to all classes of antibiotics under consideration; Klebsiella pneumoniae resistant to fluoroquinolones, third generation cephalosporins, and aminoglycosides; Escherichia coli resistant to fluoroquinolones and third generation cephalosporins; and Staphylococcus aureus resistant to methicillin (p-values<0.001). Linear regression analyses showed that an increase in the governance index resulted in significant decreases of overall antibiotic consumption (p<0.001) and AMR proportion (p=0.006). A mediation analysis showed that the governance index had an indirect effect on AMR via reducing antibiotic consumption, which accounted only for 35% of the total effect.

Conclusion:
These findings supported the hypothesis that other factors sustain the uncontrolled spread of resistant pathogens in countries with poor governance. For this reason, reducing antibiotic use alone is unlikely to solve the AMR problem, and more interventions are needed to increase governance effectiveness at all levels.