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SDG 3: Antimicrobial resistance

Abstract

Background

Non-university hospitals are the major provider of inpatient care in Germany, serving 89% of acute care hospital beds. Although surveillance data on antimicrobial use in hospitals are widely available, data on prescription quality are rare.

Aim

We aimed to provide an in-depth analysis of antimicrobial prescribing patterns and quality in southwest German non-university hospitals.

Methods

During 2021, we performed three point prevalence surveys (PPS) in 10 non-university hospitals, representing ca 10% of hospital beds in the federal state of Baden-Württemberg (11 million inhabitants). Demographic and clinical information were collected. We assessed the overall performance of 14 validated process quality indicators (QI) covering infection diagnostics, antimicrobial therapy and documentation.

Results

Of 8,560 patients analysed, 2,861 (33%) received at least one antimicrobial. Most (2,789, 80%) antimicrobial prescriptions were for therapeutic indications. Most frequently prescribed agents were beta-lactam/beta-lactamase inhibitors (1,120, 40%) in therapeutic and cefuroxime (269, 37%) in prophylactic indications. According to the World Health Organization’s Access, Watch, Reserve classification, the Access-to-Watch ratio was 0.73. Overall adherence to QIs was low and varied substantially (27–93%), with documentation, possible streamlining and switching to oral therapy exhibiting the lowest fulfilment rates (< 50%).

Conclusion

The results indicate a need to improve antimicrobial prescribing quality in non-university hospitals. The high prevalence of antimicrobial use in our setting underlines the demand for sustainable antimicrobial stewardship programmes in this sector. Our QI-based PPS approach can be used to identify key targets for future antimicrobial stewardship interventions. The results indicate a need for further legislation on antimicrobial stewardship.

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2024-11-14
2024-11-16
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References

  1. Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629-55.  https://doi.org/10.1016/S0140-6736(21)02724-0  PMID: 35065702 
  2. Holmes AH, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176-87.  https://doi.org/10.1016/S0140-6736(15)00473-0  PMID: 26603922 
  3. Davey PG, Marwick C. Appropriate vs. inappropriate antimicrobial therapy. Clin Microbiol Infect. 2008;14(Suppl 3):15-21.  https://doi.org/10.1111/j.1469-0691.2008.01959.x  PMID: 18318875 
  4. Marquet K, Liesenborgs A, Bergs J, Vleugels A, Claes N. Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis. Crit Care. 2015;19(1):63.  https://doi.org/10.1186/s13054-015-0795-y  PMID: 25888181 
  5. de With K, Allerberger F, Amann S, Apfalter P, Brodt H-R, Eckmanns T, et al. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection. 2016;44(3):395-439.  https://doi.org/10.1007/s15010-016-0885-z  PMID: 27066980 
  6. Willemsen I, Groenhuijzen A, Bogaers D, Stuurman A, van Keulen P, Kluytmans J. Appropriateness of antimicrobial therapy measured by repeated prevalence surveys. Antimicrob Agents Chemother. 2007;51(3):864-7.  https://doi.org/10.1128/AAC.00994-06  PMID: 17210766 
  7. Global PPS. Global PPS. [Accessed: 30 Aug 2023]. Available from: https://www.global-pps.com/project/
  8. European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals, 2022-2023. Stockholm: ECDC; May 2024. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/healthcare-associated-point-prevalence-survey-acute-care-hospitals-2022-2023.pdf
  9. Spivak ES, Cosgrove SE, Srinivasan A. Measuring Appropriate Antimicrobial Use: Attempts at Opening the Black Box. Clin Infect Dis. 2016;63(12):1639-44.  https://doi.org/10.1093/cid/ciw658  PMID: 27682070 
  10. Schouten JA, Berrevoets MAH, Hulscher ME. Quality Indicators to Measure Appropriate Antibiotic Use: Some Thoughts on the Black Box. Clin Infect Dis. 2017;64(9):1295.  https://doi.org/10.1093/cid/cix172  PMID: 28329185 
  11. Först G, Fellhauer M, Hug MJ, Probst W, Ranft D. Antibiotic Stewardship in deutschen Krankenhäusern. [Antibiotic Stewardship in German hospitals – results of a survey]. Krankenhauspharmazie.2018;39(7):304-10.
  12. Fätkenheuer G, Kern WV, Salzberger B. An urgent call for infectious diseases specialists. Infection. 2016;44(2):269-70.  https://doi.org/10.1007/s15010-016-0886-y  PMID: 26965723 
  13. Kern WV, Fätkenheuer G, Tacconelli E, Ullmann A. Übersichtsartikel: Klinische Infektiologie in Deutschland und Europa. [Infectious diseases as a clinical specialty in Germany and Europe]. Z Evid Fortbild Qual Gesundhwes. 2015;109(7):493-9.  https://doi.org/10.1016/j.zefq.2015.09.015  PMID: 26593764 
  14. Aghdassi SJS, Schwab F, Hansen S, Peña Diaz LA, Behnke M, Gastmeier P, et al. The quality of antimicrobial prescribing in acute care hospitals: results derived from a national point prevalence survey, Germany, 2016. Euro Surveill. 2019;24(46):1900281.  https://doi.org/10.2807/1560-7917.ES.2019.24.46.1900281  PMID: 31771705 
  15. Först G, Kern WV, Weber N, Querbach C, Kleideiter J, Knoth H, et al. Clinimetric properties and suitability of selected quality indicators for assessing antibiotic use in hospitalized adults: a multicentre point prevalence study in 24 hospitals in Germany. J Antimicrob Chemother. 2019;74(12):3596-602.  https://doi.org/10.1093/jac/dkz364  PMID: 31504603 
  16. Walker SV, Steffens B, Sander D, Wetsch WA. Implementation of Antibiotic Stewardship Improves the Quality of Blood Culture Diagnostics at an Intensive Care Unit of a University Hospital. J Clin Med. 2022;11(13):3675.  https://doi.org/10.3390/jcm11133675  PMID: 35806960 
  17. Surat G, Vogel U, Wiegering A, Germer C-T, Lock JF. Defining the Scope of Antimicrobial Stewardship Interventions on the Prescription Quality of Antibiotics for Surgical Intra-Abdominal Infections. Antibiotics (Basel). 2021;10(1):73.  https://doi.org/10.3390/antibiotics10010073  PMID: 33466628 
  18. Buyle FM, Metz-Gercek S, Mechtler R, Kern WV, Robays H, Vogelaers D, et al. Prospective multicentre feasibility study of a quality of care indicator for intravenous to oral switch therapy with highly bioavailable antibiotics. J Antimicrob Chemother. 2012;67(8):2043-6.  https://doi.org/10.1093/jac/dks145  PMID: 22566589 
  19. Federal Statistical Office of Germany. Statistischer Bericht Grunddaten der Krankenhäuser 2022. [Statistical report. Basic data of hospitals 2022]. Wiesbaden: Federal Statistical Office of Germany; 2023. German. Available from: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/_inhalt.html#_kbvmsesxl
  20. Zimmermann N, Allen R, Fink G, Först G, Kern WV, Farin-Glattacker E, et al. Antimicrobial Stewardship with and without Infectious Diseases Specialist Services to Improve Quality-of-Care in Secondary and Tertiary Care Hospitals in Germany: Study Protocol of the ID ROLL OUT Study. Infect Dis Ther. 2022;11(1):617-28.  https://doi.org/10.1007/s40121-021-00552-1  PMID: 34751941 
  21. Haute Autorité de santé (HAS). Fiche descriptive 2018. Thème Infections Associées aux Soins (IAS). [Descriptive sheet 2018. Healthcare-associated infections (HAI) theme]. Saint Denis: HAS; Feb 2018. French. Available from: https://www.has-sante.fr/upload/docs/application/pdf/2016-04/2016_has_fiche_descriptive_icatb_2.pdf
  22. Giesen R, Fink G, Först G, Allen R, Zimmermann N, Hornuss D, et al. Antimicrobial Stewardship of 10 non-university hospitals in Germany - an evaluation of core elements and processes. 33rd European Congress of Clinical Microbiology and Infectious Diseases (ECCMID); 15-18 April 2023. Copenhagen, Denmark. Abstract P2377.
  23. van den Bosch CMA, Hulscher MEJL, Natsch S, Wille J, Prins JM, Geerlings SE. Applicability of generic quality indicators for appropriate antibiotic use in daily hospital practice: a cross-sectional point-prevalence multicenter study. Clin Microbiol Infect. 2016;22(10):888.e1-9.  https://doi.org/10.1016/j.cmi.2016.07.011  PMID: 27432770 
  24. Arcenillas P, Boix-Palop L, Gómez L, Xercavins M, March P, Martinez L, et al. Assessment of Quality Indicators for Appropriate Antibiotic Use. Antimicrob Agents Chemother. 2018;62(12):e00875-18.  https://doi.org/10.1128/AAC.00875-18  PMID: 30249698 
  25. Thern J, de With K, Strauss R, Steib-Bauert M, Weber N, Kern WV. Selection of hospital antimicrobial prescribing quality indicators: a consensus among German antibiotic stewardship (ABS) networkers. Infection. 2014;42(2):351-62.  https://doi.org/10.1007/s15010-013-0559-z  PMID: 24326986 
  26. Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC, Adriaenssens N, Huttner B, et al. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother. 2018;73(suppl_6):vi3-16.  https://doi.org/10.1093/jac/dky114  PMID: 29878216 
  27. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.  https://doi.org/10.1016/j.jbi.2008.08.010  PMID: 18929686 
  28. World Health Organization (WHO). WHO Access, Watch, Reserve (AWaRe) classification of antibiotics for evaluation and monitoring of use. Geneva: WHO; 2021. Available from: https://www.who.int/publications/i/item/2021-aware-classification
  29. O’Riordan F, Shiely F, Byrne S, Fleming A. Quality indicators for hospital antimicrobial stewardship programmes: a systematic review. J Antimicrob Chemother. 2021;76(6):1406-19.  https://doi.org/10.1093/jac/dkab034  PMID: 33787876 
  30. Monnier AA, D’Onofrio V, Willemsen I, Kluytmans-van den Bergh MFQ, Kluytmans JAJW, Schuermans A, et al. , i-4-1 Health Study Group. Practice testing of generic quality indicators for responsible antibiotic use in nine hospitals in the Dutch-Belgian border area. J Hosp Infect. 2022;129:153-61.  https://doi.org/10.1016/j.jhin.2022.07.030  PMID: 35998836 
  31. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74.  https://doi.org/10.2307/2529310  PMID: 843571 
  32. Aghdassi SJS, Hansen S, Peña Diaz LA, Gropmann A, Saydan S, Geffers C, et al. Healthcare-associated infections and the use of antibiotics in German hospitals. Dtsch Arztebl Int. 2024;121(9):277-83.  https://doi.org/10.3238/arztebl.m2024.0033  PMID: 38471129 
  33. Versporten A, Zarb P, Caniaux I, Gros M-F, Drapier N, Miller M, et al. Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. Lancet Glob Health. 2018;6(6):e619-29.  https://doi.org/10.1016/S2214-109X(18)30186-4  PMID: 29681513 
  34. Plachouras D, Kärki T, Hansen S, Hopkins S, Lyytikäinen O, Moro ML, et al. Antimicrobial use in European acute care hospitals: results from the second point prevalence survey (PPS) of healthcare-associated infections and antimicrobial use, 2016 to 2017. Euro Surveill. 2018;23(46):1800393.  https://doi.org/10.2807/1560-7917.ES.23.46.1800393  PMID: 30458917 
  35. Kern WV, Steib-Bauert M, Baumann J, Kramme E, Först G, de With K. Impact of the COVID-19 Pandemic on Inpatient Antibiotic and Antifungal Drug Prescribing Volumes in Germany. Antibiotics (Basel). 2024;13(9):837-54.  https://doi.org/10.3390/antibiotics13090837  PMID: 39335010 
  36. Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen. Deutsche nationale Punkt-Prävalenzerhebung zu nosokomialen Infektionen und Antibiotika-Anwendung 2022 – Abschlussbericht. [German national point prevalence survey on nosocomial infections and antibiotic use 2022 - Final report]. 2023. German. Available from: https://www.nrz-hygiene.de/files/Projekte/PPS%202022/PPS_2022_Abschlussbericht_Final_Upload.pdf
  37. Pauwels I, Versporten A, Drapier N, Vlieghe E, Goossens H, Koraqi A, et al. Hospital antibiotic prescribing patterns in adult patients according to the WHO Access, Watch and Reserve classification (AWaRe): results from a worldwide point prevalence survey in 69 countries. J Antimicrob Chemother. 2021;76(6):1614-24.  https://doi.org/10.1093/jac/dkab050  PMID: 33822971 
  38. Schouten JA, Hulscher MEJL, Wollersheim H, Braspennning J, Kullberg BJ, van der Meer JW, et al. Quality of antibiotic use for lower respiratory tract infections at hospitals: (how) can we measure it? Clin Infect Dis. 2005;41(4):450-60.  https://doi.org/10.1086/431983  PMID: 16028151 
  39. Püschmann H, Haferkamp G, Scheppokat K-D, Wegner M. Vollständigkeit und Qualität der ärztlichen Dokumentation. Dtsch Arztebl. 2006.
  40. Cotta MO, Robertson MS, Upjohn LM, Marshall C, Liew D, Buising KL. Using periodic point-prevalence surveys to assess appropriateness of antimicrobial prescribing in Australian private hospitals. Intern Med J. 2014;44(3):240-6.  https://doi.org/10.1111/imj.12353  PMID: 24372683 
  41. Först G, Kern WV, Weber N, Querbach C, Kleideiter J, Knoth H, et al. Clinimetric properties and suitability of selected quality indicators for assessing antibiotic use in hospitalized adults: a multicentre point prevalence study in 24 hospitals in Germany. J Antimicrob Chemother. 2019;74(12):3596-602.  https://doi.org/10.1093/jac/dkz364  PMID: 31504603 
  42. van den Bosch CMA, Hulscher MEJL, Natsch S, Wille J, Prins JM, Geerlings SE. Applicability of generic quality indicators for appropriate antibiotic use in daily hospital practice: a cross-sectional point-prevalence multicenter study. Clin Microbiol Infect. 2016;22(10):888.e1-9.  https://doi.org/10.1016/j.cmi.2016.07.011  PMID: 27432770 
  43. Farida H, Rondags A, Gasem MH, Leong K, Adityana A, van den Broek PJ, et al. Development of quality indicators to evaluate antibiotic treatment of patients with community-acquired pneumonia in Indonesia. Trop Med Int Health. 2015;20(4):501-9.  https://doi.org/10.1111/tmi.12452  PMID: 25529504 
  44. Thern J, de With K, Strauss R, Steib-Bauert M, Weber N, Kern WV. Selection of hospital antimicrobial prescribing quality indicators: a consensus among German antibiotic stewardship (ABS) networkers. Infection. 2014;42(2):351-62.  https://doi.org/10.1007/s15010-013-0559-z  PMID: 24326986 
  45. Monnier AA, Schouten J, Le Maréchal M, Tebano G, Pulcini C, Stanić Benić M, et al. Quality indicators for responsible antibiotic use in the inpatient setting: a systematic review followed by an international multidisciplinary consensus procedure. J Antimicrob Chemother. 2018;73(suppl_6):vi30-9.  https://doi.org/10.1093/jac/dky116  PMID: 29878221 
  46. Hermanides HS, Hulscher MEJL, Schouten JA, Prins JM, Geerlings SE. Development of quality indicators for the antibiotic treatment of complicated urinary tract infections: a first step to measure and improve care. Clin Infect Dis. 2008;46(5):703-11.  https://doi.org/10.1086/527384  PMID: 18230045 
  47. van den Bosch CMA, Geerlings SE, Natsch S, Prins JM, Hulscher MEJL. Quality indicators to measure appropriate antibiotic use in hospitalized adults. Clin Infect Dis. 2015;60(2):281-91.  https://doi.org/10.1093/cid/ciu747  PMID: 25266285 
  48. Pollack LA, Plachouras D, Sinkowitz-Cochran R, Gruhler H, Monnet DL, Weber JT, Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) Expert Panel on Stewardship Structure and Process Indicators. A Concise Set of Structure and Process Indicators to Assess and Compare Antimicrobial Stewardship Programs Among EU and US Hospitals: Results From a Multinational Expert Panel. Infect Control Hosp Epidemiol. 2016;37(10):1201-11.  https://doi.org/10.1017/ice.2016.115  PMID: 27418168 
An in-depth analysis of antimicrobial prescription quality in 10 non-university hospitals, in southwest Germany, 2021
<p class="citation"> <span>Citation style for this article:</span> <span class="meta-value authors"> <a href="/search?value1=Gesche+F%C3%B6rst&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Först Gesche</a>, <a href="/search?value1=Roland+Giesen&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Giesen Roland</a>, <a href="/search?value1=Geertje+Fink&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Fink Geertje</a>, <a href="/search?value1=Matthias+Sehlbrede&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Sehlbrede Matthias</a>, <a href="/search?value1=Nicole+Wimmesberger&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Wimmesberger Nicole</a>, <a href="/search?value1=Rebekka+Allen&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Allen Rebekka</a>, <a href="/search?value1=Kerstin+Meyer&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Meyer Kerstin</a>, <a href="/search?value1=Sabine+M%C3%BCller&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Müller Sabine</a>, <a href="/search?value1=Hanna+Niese&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Niese Hanna</a>, <a href="/search?value1=Sina+Polk&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Polk Sina</a>, <a href="/search?value1=Barbara+Reistle&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Reistle Barbara</a>, <a href="/search?value1=Carolin+Schuhmacher&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Schuhmacher Carolin</a>, <a href="/search?value1=Andreas+von+Ameln-Meyerhofer&option1=author&noRedirect=true" class="nonDisambigAuthorLink">von Ameln-Meyerhofer Andreas</a>, <a href="/search?value1=Kim+Winter&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Winter Kim</a>, <a href="/search?value1=Dave+Wirth&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Wirth Dave</a>, <a href="/search?value1=Winfried+V+Kern&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Kern Winfried V</a>, <a href="/search?value1=Erik+Farin-Glattacker&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Farin-Glattacker Erik</a>, <a href="/search?value1=Siegbert+Rieg&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Rieg Siegbert</a>, <a href="/search?value1=the+ID+ROLL+OUT+Study+group&option1=author&noRedirect=true" class="nonDisambigAuthorLink">the ID ROLL OUT Study group</a></span>. An in-depth analysis of antimicrobial prescription quality in 10 non-university hospitals, in southwest Germany, 2021. <a href="/content/ecdc">Euro Surveill.</a> 2024;29(46):pii=2400156. <a href="https://doi.org/10.2807/1560-7917.ES.2024.29.46.2400156" title="doi link" target="_blank">https://doi.org/10.2807/1560-7917.ES.2024.29.46.2400156</a> <span class="ES_Article_citation"> <span class="generated">Received</span>: 11 Mar 2024;&nbsp;&nbsp; <span class="generated">Accepted</span>: 02 Jul 2024 </span> </p>
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