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Background: Antimicrobial stewardship (AMS) programs are effective tools for improving antibiotic prescription quality. Their implementation requires the regular surveillance of antibiotic consumption at the patient and institutional level. Our study captured and analyzed antibiotic consumption density (ACD) for hospitalized pediatric patients., Method: We collected antibacterial drug consumption data for 2020 from hospital pharmacies at 113 pediatric departments of acute care hospitals in Germany. ACD was calculated as defined daily dose (DDD, WHO/ATC Index 2019) per 100 patient days (pd). In addition, we analyzed the trends in antibiotic use during 2013-2020., Results: In 2020, median ACD across all participating hospitals was 26.7 DDD/100 pd, (range: 10.1-79.2 DDD/100 pd). It was higher at university vs. non-university hospitals (38.6 vs. 25.2 DDD/100 pd, p < 0.0001). The highest use densities were seen on oncology wards and intensive care units at university hospitals (67.3 vs. 38.4 DDD/100 pd). During 2013-2020, overall ACD declined (- 10%) and cephalosporin prescriptions also decreased (- 36%). In 2020, cephalosporins nevertheless remained the most commonly dispensed class of antibiotics. Interhospital variability in cephalosporin/penicillin ratio was substantial. Antibiotics belonging to WHO AWaRe "Watch" and "Reserve" categories, including broad-spectrum penicillins (+ 31%), linezolid (+ 121%), and glycopeptides (+ 43%), increased over time., Conclusion: Significant heterogeneity in ACD and prescription of different antibiotic classes as well as high prescription rates for cephalosporins and an increased use of reserve antibiotics indicate improvable antibiotic prescribing quality. AMS programs should urgently prioritize these issues to reduce antimicrobial resistance., (© 2023. The Author(s).)

Background: The consumption of antifungal agents increased over the last decade, resulting in the development of resistant organisms and causing a significant pharmaco economic burden. Antifungal drugs are widely used for the treatment of systemic fungal infections and high-risk patients, especially with severe hematological or oncological conditions. Up to date, there are no reliable and systematically reported data on the consumption of antifungal substances on a nationwide level available. The presented study gives an update to the previously published multicenter study investigating antifungal consumption in different settings from five university hospital centers in Germany from 2001 to 2003., Methods: Consumption data for systemic antifungal drugs were obtained through the hospital pharmacies for 2001-2003 and 2008-2011 regarding the medical and surgical services of five university hospital centers in Germany (A-E). Drug use densities were calculated as yearly RDDs/100 patient days. These calculations were performed for the surgical and medical services, and independently for surgical and medical ICUs, as well as for the hematology-oncology services., Results: We report an increased utilization of systemic antifungal drugs in both study periods. The mean drug use density (mean value of all 5 hospitals) in the medical services increased by 24% between 2001 and 2003. In 2011, this value was 37% above the level from 2001 (12.4 RDD/100 patient days in 2001, 15.4 RDD/100 patient days in 2003, 17.0 RDD/100 patient days in 2011). The 4-year average drug use density (2008-2011) of medical services ranged between 11.6 RDD/100 patient days (hospital E) and 23.8 RDD/100 patient days (hospital A). Drug use densities were in medical intensive care units 29.4 RDD/100 patient days and hematology-oncology services 49.9 RDD/100 patient days., Conclusions: Despite the variability of the prescribing patterns between the tertiary hospitals, the presented pharmaco-epidemiological data are a cornerstone for the initiation and implementation of effective antifungal stewardship programmes and might serve as important benchmarking information for other hospitals with similar structures and baseline settings.

Purpose: Simple, valid, and evidence-based indicators to measure the quality of antimicrobial prescribing in acute-care hospitals are urgently needed and increasingly requested by policymakers. The aim of this study was to develop new consensus quality indicators (QIs) for hospital antibiotic stewardship (ABS) and infection management which will be further evaluated for internal quality management and external quality assessment in Germany., Methods: Based on an extensive literature review, the Austrian-German hospital ABS Guideline Committee and selected members of the German ABS Expert Network discussed and drafted a list of 99 potential indicators for hospitals that reflect structural prerequisites for ABS (35 items), ABS core activities (18 items), additional ABS measures (5 items), and process of care indicators (both generic and disease-specific-12 and 29 items, respectively). Questionnaires were mailed to German ABS experts and healthcare professionals with further education in ABS. Participants scored (on a nine-point Likert scale) relevance (clinical, ecological/resistance, economical/expenses) and presumed practicability (six categories: clarity of definition, effort to collect data, barrier to implementation, verifiability, suitability for external quality assessment, quality gap), taking into account their local work environment. The scores were processed according to the RAND/UCLA appropriateness method, and QIs were judged relevant if the median (clinical + ecological and/or economical) scores were >6. The indicators thus assessed to be potentially relevant were then filtered according to their practicability. Highly relevant QIs with borderline practicability scores and items with disagreements and overlapping areas were re-discussed in a final multidisciplinary panel consensus workshop convened in November 2012., Results: Of the 340 questionnaires that were mailed, 75 questionnaires were completed and returned. Of 99 initially proposed items, 32 were excluded due to insufficient scores. Of the remaining 67 items, 21 structural and 21 process of care QIs were finally selected, including four QIs with high clinical and ecological but limited economical relevance, and three QIs with high clinical and economical but limited ecological relevance. Among the selected QIs, efforts to collect data and implementation barriers were scored as suboptimal in many cases., Conclusions: A catalog of consensus structural and process of care ABS-QIs was established. These should undergo further pilot and feasibility studies in the German hospital healthcare sector. The panelists were most critical regarding resource use/complexity issues and presumed implementation barriers. How this may limit applicability of QIs remains to be determined.

Background: Hospital antibiotic use is usually measured by calculating the volume as the number of daily doses defined by the World Health Organization/Anatomical Therapeutic Chemical (WHO/ATC) index (DDDs) divided by a denominator indicating clinical activity, such as the number of occupied bed days. Previous studies have found discrepancies between DDDs, daily doses as recommended in practice guidelines (recommended daily doses, RDDs), and truly prescribed daily doses (PDDs). Very few studies have quantified these discrepancies., Methods: A point prevalence survey was carried out in defined acute care service areas of a large German state university hospital. Of the 941 adult inpatients present on the day of the survey for whom adequate information was available, 267 (28%) had 471 prescriptions for antimicrobial drugs on that specific day. A check for any additional antimicrobial drug prescriptions for these 267 patients during the six days immediately preceding the survey day yielded a total of 2,304 PDDs, of which 1,754 were antibacterial agents. The latter antibacterial drug PDDs constituted the basis for analysis. The proportion of PDDs different from RDDs and from DDDs was evaluated, and the deviations were calculated. RDD dose definitions corresponded to the local practice guideline recommendations of antibiotic therapy for adult hospitalized patients with normal renal function., Results: Of the 1,754 PDDs, 625 were matching DDD dose definitions (36%), and 1,024 (58%) were matching RDD dose definitions (p < 0.01). Corresponding values for patients with impaired renal function (creatinine clearance < 50 ml/min) were 36% and 42%, respectively. Large DDD discrepancies (< 50% of prescribed doses matching DDD definitions) were noted for beta-lactams and macrolides, while large RDD discrepancies were observed for aminoglycosides. Compared with PDDs, the use of DDDs as the measurement of hospital antibiotic use overestimated antibiotic use volumes by 32%, while the use of RDD led to a slight underestimation (-9%)., Conclusion: The use of DDDs as currently defined by WHO/ATC for measuring hospital antibiotic consumption may be associated with a substantial overestimation of antibiotic use density, while using practice guideline-derived RDDs may yield more valid antibiotic exposure estimates that would be helpful in cross-sectional and longitudinal analyses of antibiotic consumption.

Objective: Outpatient antibiotic use in Germany differs substantially between eastern and southern parts of the country (low use) and the western part (high use). Whether similar regional variation exists in hospital antibiotic consumption is not known. We investigated this issue using a convenience sample of 145 hospitals providing data for the year 2003., Methods: Data on hospital consumption of systemic antibiotics in Anatomical Therapeutic Chemical (ATC) class J01 were obtained from acute care hospitals that participated in an IMS survey and had complete data (dispensed drugs and patient-days per year) for at least one non-pediatric, non-psychiatric department or ward. A total of 275 non-ICU surgical departments/wards, 229 non-ICU non-surgical (general medicine, haematology-oncology, neurology/stroke) departments/wards, and 184 ICUs were analysed. Data were expressed in DDD (WHO/ATC definition version 2003) or daily doses adapted for recommendations in hospitalized patients (RDD) per 100 patient days (DDD/100 and RDD/100)., Findings: The weighted mean over all departments/wards was 49.6 DDD/100 or 31.3 RDD/100, respectively. As expected, ICU antibiotic use density was much higher than use in non-ICU areas, and use in haematology-oncology was higher than in other non-surgical departments/wards. In univariate analyses, region, hospital bed-size category, university affiliation and haematology-oncology as specialty were associated with use density, but these associations were only partly confirmed in multivariate logistic regression analyses of factors associated with excess (> or = 75%) use density which showed university affiliation and haematology-oncology but not hospital location to be independently associated with comparatively high use., Conclusions: Antibiotic use density in German acute care hospitals does not appear to differ significantly between regions. Overall hospital consumption of antibiotics in this country appears to be similar to what has been described from other parts of Europe. In comparative analyses of hospital antibiotic consumption, data need to be adjusted at least for university affiliation and haematology-oncology.

Objective: According to recent surveys, outpatient antibiotic prescribing in Germany has been comparatively low among European countries. We assessed regional variation in outpatient antibiotic use within Germany both for overall use as well as for specific antibiotic drug classes., Methods: Prescription data for the year 2003 covering approximately 90% of the total population were analysed using the ATC/WHO defined daily dose (DDD) methodology. Data were expressed in DDD per 1,000 persons covered by the insurance and day (DID)., Results: Outpatient antibiotic prescribing in 2003 was 13.6 DID and ranged between 9.2 and 17.9 DID in the different regions examined. Low consumption regions were eastern and southern states. High consumption areas were in the west near the French and Belgian border. This regional prescribing pattern was similar for children and adults. Penicillins were the most frequent prescribed drugs, but their use density showed a relatively large regional variation (factor 3.5), with relatively low prescription frequency in the eastern states. In almost all regions quinolones were used more often than trimethoprim-sulfamethoxazole., Conclusion: The regional variation in recent outpatient antibiotic prescribing in Germany is substantial. The relatively high antibiotic use in the western part of the country is remarkable, remains unexplained and requires further study.

Background: Hospital antibiotic use can be measured by calculating daily doses as defined by the WHO/ATC index (DDD) divided by the number of patient or occupied bed days. We wondered whether changes in antibiotic use density over time at a university hospital using this data format are similar in order of magnitude when compared with a different, alternative dose definition and the number of admissions rather than the number of patient days as denominator., Methods: Data obtained from the hospital pharmacy for the medical and surgical services of a 1,000-bed university hospital for the period 1992 through 2003 were expressed both in daily doses per 100 patient days and daily doses per admission. A PDD dose definition (prescribed daily doses), defining doses that reflect the usually prescribed dose in adult hospitalized patients with normal renal function was compared with the WHO/ATC 2001 DDD dose definitions. The percent changes using the different data formats between two 3-year averages (1992-1994 and 2001-2003) were calculated., Results and Conclusion: The DDD/100 patient days data format overestimated antibiotic use density changes in this hospital both in medicine (81% vs 48%) as well as in surgery (69% vs 39%) when compared with PDD/100 patient days. Due to changes in the number of admissions and length of stay over the years, the percent change between the two periods expressed in doses per 100 patient days in addition differed substantially from that estimated by using the DDD per admission or PDD per admission data format. Studies evaluating the evolution of hospital antibiotic use need to address the limitations and adequacy of the different data formats.

Background: A previous study from Germany showed high antibiotic use in university hospitals, particularly in intensive care units (ICU) and hematology-oncology services, but there has been no information about recent antibiotic use in non-university hospitals. In the present study, we collected data from 40 non-university regional general hospitals located in the southwestern part of the country, and analyzed use density in the medical and surgical services of these hospitals., Materials and Methods: Hospital pharmacy records for the calendar years 2001 and 2002 were evaluated. The number of defined daily doses (DDD, definition according to the WHO/ATC 2001 index) and prescribed daily doses (PDD) per 100 patient days (DDD/100 or PDD/100, respectively) were calculated to compare antibiotic use densities in medical and surgical services. Data for surgery included various subspecialties and gynecology., Results: Antibiotic use in the participating hospitals increased minimally between 2001 and 2002 both in medicine as well as in surgery. Use density in internal medicine (ICU areas excluded) in the year 2002 ranged between 13.5 and 93.7 DDD/100 with a weighted mean of 49.9 DDD/100 (corresponding to 28.6 PDD/100, respectively). Values for surgery were lower with a weighted mean of 43.4 DDD/100 (corresponding to 26.1 PDD/100, range, 10 to 65.4 DDD/100), respectively. Hospital size was not a strong predictor of use density, while large differences were observed between intensive care areas and normal wards. Mean use densities in intensive care areas in 2002 were 105.6 DDD/100 (or 49.7 PDD/100) in medical intensive care units, 116.9 DDD/100 (or 61.2 PDD/100) in surgical intensive care units, and 112.7 DDD/100 (or 66.7 PDD/100) in mixed, interdisciplinary intensive care units. Betalactams made up > 50% of all PDDs, while fluoroquinolones were the second most frequently prescribed drugs (15% of all PDDs). Fluoroquinolones were usually given orally. Overall glycopeptide and aminoglycoside use was < 1 PDD/100., Conclusion: This recent data from a large regional nonuniversity acute care hospital sample confirms that hospital antibiotic use density largely depends on patient care areas and less on hospital size. Surprisingly low use was observed for glycopeptides and aminoglycosides. The data may be useful as a benchmark for further pharmaco-epidemiologic evaluation and focused drug use control interventions.

Background: A previous study has shown considerable variation in glycopeptide use from 1992 through 1994 among four university hospitals in southern Germany. Active antimicrobial management in one of the hospitals was associated with the containment of glycopeptide consumption in the medical and surgical service at < 1.5 defined daily doses (DDD)/100 patient days in the subsequent period. In the present study, more recent data on comparative glycopeptide use in German university hospitals were analyzed., Materials and Methods: Hospital pharmacy records from 1998 through 2000 were evaluated. The number of DDD (definition according to the World Health Organization [WHO]/Anatomic and Therapeutic Classification [ATC] index) per 100 patient days was calculated to compare glycopeptide use in different medical and surgical service areas between eight German university hospitals., Results: The 3-year averages in recent glycopeptide use for the eight hospitals ranged between 1.3 and 8.8 DDD/100 patient days in the medical services, and between 0.7 and 1.8 DDD/100 patient days in the surgical services. Only one of the eight hospitals showed medical service glycopeptide use of < 1.5 DDD/100 patient days. In most hospitals, glycopeptide use was higher in the medical intensive care units (ICU) (median 8.6; range 4.3 to 12 DDD/100 patient days, data for the year 2000) than in the surgical ICUs (median 6.7; range 1.2 to 8.6 DDD/100 patient days, data for the year 2000). High use was also observed for hematology-oncology services (median 7.5; range 2.7 to 15.7 DDD/100 patient days, data for the year 2000)., Conclusion: These recent data from a larger hospital sample confirm large variations in glycopeptide use, identify hematology-oncology services as a significant prescribing source along with ICUs, and indicate areas of probable overuse of glycopeptide antibiotics. The data may be useful as a benchmark for further focused drug use control interventions., (Copyright Urban and Vogel)