Too many antibiotics are still used in Germany, which promotes the development of resistance. Antibiotic Stewardship (ABS) plays an important role in preventing resistance. Dr. Katja De With, clinical infectiologist at the University Hospital Dresden and one of the pioneers in the field of rational antibiotic use, reported on the status quo at the online congress of the German Society for Internal Medicine (Deutsche Gesellschaft für Innere Medizin, DGIM).
Antibiotic Stewardship means a programmatic, sustained effort by a medical institution (clinic or doctor's practice) or a health care system to improve and ensure rational prescribing practices of anti-infectives.
The first ABS S3 guideline for the hospital sector was developed at the end of 2009, followed by a first ABS expert network meeting at the end of 2011, and the first ABS course for DGIM members was held in November 2015. In 2017/2018, the S3 guideline was revised, and in May 2020, a position paper of the ART Commission (Anti-Infective, Resistance and Therapy) on structural and personnel requirements for rational anti-infective prescription in hospitals was published.
The ART position paper assumes a minimum staffing level for the ABS team of 1 full-time equivalent (FTE) per 500 beds. The position paper contains a concise overview of the tasks and functions of the ABS team. An ABS visit should take place regularly and include the evaluation of antibiotic therapies with regard to indication, choice of substance, dosage, type of application and duration of therapy, taking guidelines into account.
With the ABS approach, De With's team was able to reduce antibiotic use at Dresden University Hospital by 20% in five years. Above all, the infectious disease rounds in intensive care units made a decisive contribution to this. All patients are examined to find out why they are given antibiotics. If no plausible reason can be identified, the therapy is stopped.
What has to be done in individual cases is decided by De With together with the doctors, microbiologists and pharmacists of the clinic. Often the medication is also adjusted. Background: Many patients are initially given an antibiotic without the causative agent of the infection being known. When laboratory tests later identify the pathogen, targeted treatment can be given.
De With emphasised that ABS should not only be about reducing antibiotic consumption, but also about improving treatment quality at the same time. To make ABS programmes clinically successful, more interdepartmental infectious disease expertise is needed.
Antibiotic Stewardship is an effective prevention strategy against the development of multi-resistant pathogens, emphasised Prof. Dr. Pia Hartmann, infectiologist at the Dr. Wisplinghoff Laboratory, Cologne. In her view, however, there are some problems in the practice and implementation of ABS:
Hartmann emphasised that Antibiotic Stewardship and hygiene measures form an indispensable alliance to control multi-resistant pathogens. However, both measures are personnel- and time-consuming and fail to achieve their purpose if the necessary personnel resources are not made available.
ABS is necessarily an interface of hygiene, microbiology, infectiology and pharmacy (guideline of the Association of the Scientific Medical Societies, AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften)) in order to meet the complex challenge of rational antibiotic prescription. The therapy is always preceded by the correct diagnosis - here the microbiologist and especially the infectiologist can be helpful.
What can digital medicine do for Antibiotic Stewardship? Prof. Dr. Jörg Janne Vehreschild from the German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung, DZIF) presented the digital tools available to date for optimising antibiotic use. In the area of information, these are queries from the electronic patient file, the unit dose system, antibiotic consumption surveillance and surveillance of multi-resistant pathogens. In the area of interaction, they are telemedicine and video consultation, and in the area of collaboration, they are cloud platforms, document processing and low-threshold exchange.
Digital medicine for the ABS offers "many additional tools, but not a panacea", Vehreschild emphasised. It simplifies access to up-to-date, high-quality and clear information and can also help to steer interventions and make them more effective. However, decision-making aids based on inference engines require very careful consideration.
Extended-spectrum-beta-lactamases (ESBL) forming bacteria are among the problem germs and are responsible for many infections in hospitals. Clinically, ESBL-forming Escherichia coli, Klebsiella and other gram-negative bacteria are particularly significant. They have a significant influence on mortality and length of hospitalisation. As Prof. Dr. Christoph Lübbert, Chief Physician of the Clinic for Infectious Diseases at Klinikum St. Georg, Leipzig, reported, the combination of piperacillin/tazobactam carbapenems seems to be clinically inferior in the treatment of patients with a bacteraemic infection caused by ESBL-formers, according to recent data. Early carbapenem therapy should therefore be considered for patients at high risk of invasive infection by ESBL-formers with a bacteraemic course.
Reference:
127th Annual Meeting of the German Society of Internal Medicine (DGIM); Session: "Less is more - Intelligent use of antibiotics", 17 April 2021.