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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. [ABSTRACT FROM AUTHOR]

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 pharmacoepidemiologic evaluation and focused drug use control interventions. [ABSTRACT FROM AUTHOR]

An important prerequisite for ascertaining rational antibiotic prescribing is the availability and evaluation of antibiotic use data. In this study we report evolving trends of antibiotic use in German hospitals during the last decade.Using drug dispensing data from acute care hospital pharmacies, we calculated yearly antibiotic use density values for the period from 2012/13 through to 2021/22. Use density was expressed as daily doses per 100 patient days, using both hospital adapted doses of antibiotics (" recommended daily dose ", RDD) as well as WHO-" defined daily doses " (DDD). The 2021/22 data were extrapolated to estimate the hospital consumption in DDD per 1000 population and day.The overall antibiotic use density remained stable during the observation period. It was 41.9 RDD/100 patient days (median, n=169 hospitals, interquartile range 35-48 RDD/100) in the year 2012/13 and 42.1 RDD/100 (median, n=329, interquartile range 35-48 RDD/100) in the year 2021/22, respectively. The estimated national use per population in 2021/22 was 1.85 DDD per 1000 inhabitants and day. The antibiotic use levels in university hospitals (54.0 RDD/100) were higher than in non-university hospitals that showed a similar use density across different hospital size categories (medians between 39.8 and 44.0 RDD/100). Overall, penicillin use increased over time (change in proportion +63%), while fluoroquinolones (- 54%) and first and second generation cephalosporins (- 41%) were prescribed less frequently. Antibiotic use density in intensive care units was approximately twice as high as in normal wards. High levels of antibiotic use were also observed in haematology-oncology divisions at teaching hospitals (median 96.8 RDD/100), in urology (medians between 65.1 and 70.5 RDD/100) and oto-rhino-laryngology (medians between 49.1 and 60.9 RDD/100) and urology divisions.During the last decade, there was no increasing use of antibiotics in German acute care hospitals. We observed shifts in selected drug classes, in particular an increasing use of penicillins. The estimated hospital antibiotic consumption per population was slightly above the European average., Competing Interests: W.V.K. erhielt Forschungsbeihilfen vom Deutschen Zentrum für Infektionsforschung (DZIF), Vortragshonorare von Biomèrieux und Beraterhonoare von der Stiftung Warentest. Er ist ordentliches Mitglied der Arzneimittelkommission der deutschen Ärzteschaft und aktuell Vorstand der Akademie für Infektionsmedizin e.V. F.D. erhielt Vortragshonorare von Lilly, Janssen und Gilead sowie Beraterhonorare von Lilly und Sandoz. Er war von 2018-2020 Präsident des Bundesverbandes Deutscher Krankenhausapotheker e.V. (ADKA) und ist Mitglied der Arzneimittelkommission Deutscher Apotheker. Die sonstigen Autoren erklären, dass keine Interessenkonflikte bestehen., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: The patterns and intensity of inpatient antibiotic prescribing vary according to medical specialty., Objectives: Analysis of recent data on antibiotic use density in hospital departments of urology in Germany., Methods: Annual surveillance data of 107 departments for the period 2022/2023 were evaluated. We used a daily dose definition adapted for adult hospitalized patients (recommended daily doses, RDD), and 100 patient days as the denominator (RDD/100)., Results: The overall median antibiotic use density was 71 RDD/100 with a wide range between 15.9 and 138.7 RDD/100 but no significant differences according to hospital size. Fluoroquinolones (median 6.0 RDD/100) were prescribed as the fourth most frequent antibiotic class after broad-spectrum cephalosporins (median 16.2 RDD/100), aminopenicillin/beta-lactamase inhibitor combinations (median 10.8 RDD/100), and broad-spectrum penicillins (piperacillin-tazobactam and piperacillin) (median 8.9 RDD/100). The ratio between penicillin and cephalosporin RDD per hospital ranged from 6:94 to 98:2 (overall 52:48). The proportion of aminoglycosides (< 1%) and parenteral fosfomycin (< 0.1%) was very small. Cotrimoxazole (median 4.0 RDD/100) was less frequently prescribed than fluoroquinolones. The proportion of oral agents was 44.7% overall, with only small differences according to hospital size. Oral fosfomycin, pivmecillinam, nitrofurantoin, and nitroxoline were much less frequently prescribed than oral beta-lactams, fluoroquinolones, and cotrimoxazole., Conclusion: The overall antibiotic use density in urological hospital departments varied substantially in 2022/2023. Beta-lactam antibiotics were the most frequently used antibiotics, while fluoroquinolones (often as oral agents) continued to be prescribed with a large range similar to overall antibiotic use and independent of hospital size. Inpatient prescribing of the agents recommended and typically used for uncomplicated cystitis was rare. Penicillins and cotrimoxazole should more often be considered as the treatment option. Aminoglycosides and parenteral fosfomycin should be discussed in cases of otherwise drug-resistant pathogens., Competing Interests: Einhaltung ethischer Richtlinien Interessenkonflikt W.V. Kern, J. Baumann, G. Först, E. Kramme, M. Steib-Bauert, J. Kranz, G. Magistro und K. de With geben an, dass kein Interessenkonflikt besteht.Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s).)

Background: Previous studies found that the coronavirus disease 2019 (COVID-19) pandemic had a variable impact on the consumption of antimicrobial drugs in human medicine, with trends in several European countries differing between community and inpatient prescribing., Aim: This study analysed changes in the volumes and use density of antibacterial and antifungal drugs dispensed in acute care hospitals in Germany between 2019 and 2022., Methods: Surveillance data for the four years available from 279 hospitals were expressed as the total volumes of daily doses or as use density (daily doses per 100 patient/occupied bed days) per year and analysed descriptively, using recommended hospital-adapted daily dose definitions (RDDs) and (as sensitivity analysis) WHO/ATC-defined daily dose definitions (DDD). Hospitals were stratified according to size (number of beds), university affiliation, and location (East, West, South)., Results: There were significant decreases in both the total number of patient days and antibacterial drug volumes in 2020 through 2022 compared with 2019. The relative changes between 2019 and 2020, 2021, and 2022 were -12.8%, -13.5%, and -13.3% for patient days, and -9.7%, -11.0%, and -10.1% for antibacterial RDDs, respectively. Broad-spectrum betalactams, notably piperacillin-tazobactam and carbapenems, increased in volume, unlike most other drug classes. The resulting antibacterial drug use density was slightly but significantly increased, with pooled means (and medians) of 43.3 (40.0) RDD/100 in 2019 compared to 44.8 (41.7), 44.5 (40.80), and 44.9 (41.7) RDD/100 in the years 2020 through 2022, respectively. Antifungal drug volumes and use density increased after 2019 and peaked in 2021 (the difference between 2019 and 2021 for total volumes was +6.4%, and that for pooled mean use density values was +22.9%, respectively). These trends were similar in the different hospital strata and comparable when DDDs instead of RDDs were used., Conclusions: Similar to what has been observed in a majority of European countries, the total volume of antibacterial drug use in German acute care hospitals decreased with the pandemic, without a rebound phenomenon in 2022. In association with restricted hospital capacities and presumably more immunocompromised general medicine patients, however, inpatient prescribing of (primarily broad-spectrum) antibacterials and of antifungal drugs increased.

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).)

Objectives: To analyse the influence of antibiotic consumption on healthcare-associated healthcare onset (HAHO) Clostridioides difficile infection (CDI) in a German university hospital setting., Methods: Monthly ward-level antibiotic consumption measured in DDD/100 patient days (pd) and CDI surveillance data from five university hospitals in the period 2017 through 2019 were analysed. Uni- and multivariable analyses were performed with generalized estimating equation models., Results: A total of 225 wards with 7347 surveillance months and 4 036 602 pd participated. With 1184 HAHO-CDI cases, there was a median incidence density of 0.17/1000 pd (IQR 0.03-0.43) across all specialties, with substantial differences among specialties. Haematology-oncology wards showed the highest median incidence density (0.67/1000 pd, IQR 0.44-1.01), followed by medical ICUs (0.45/1000 pd, IQR 0.27-0.73) and medical general wards (0.32/1000 pd, IQR 0.18-0.53). Multivariable analysis revealed carbapenem (mostly meropenem) consumption to be the only antibiotic class associated with increased HAHO-CDI incidence density. Each carbapenem DDD/100 pd administered increased the HAHO-CDI incidence density by 1.3% [incidence rate ratio (IRR) 1.013; 95% CI 1.006-1.019]. Specialty-specific analyses showed this influence only to be valid for haematological-oncological wards. Overall, factors like ward specialty (e.g. haematology-oncology ward IRR 2.961, 95% CI 2.203-3.980) or other CDI cases on ward had a stronger influence on HAHO-CDI incidence density (e.g. community-associated CDI or unknown association case in same month IRR 1.476, 95% CI 1.242-1.755) than antibiotic consumption., Conclusions: In the German university hospital setting, monthly ward-level carbapenem consumption seems to increase the HAHO-CDI incidence density predominantly on haematological-oncological wards. Furthermore, other patient-specific factors seem to be equally important to control HAHO-CDI., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: In hospitalized patients, the duration of antibiotic therapy for uncomplicated pneumonia is often longer than recommended in clinical guidelines. Consequences include increased risk of Clostridioides difficile infection and the emergence of antibiotic resistance. Reducing the duration of antibiotic therapy is an important goal of antibiotic stewardship (ABS) programs., Objective: To evaluate the impact of a computerized physician order entry (CPOE)-based ABS intervention on treatment duration in respiratory infections and on antibiotic use., Methods: A new type of prescription tool featuring a "soft stop order" was introduced into the CPOE system in the Respiratory Medicine department of a Thorax Center. The effect of this intervention was evaluated after 24 weeks using a retrospective before-and-after study design., Results: A total of 210 patients were evaluated (preintervention group n = 109, postintervention group n = 101). Mean antibiotic treatment duration decreased from 9.59 days to 7.25 days (p < 0.001). It was reduced from 9.93 to 7.21 days (p < 0.001) in community-acquired pneumonia, 10.21 to 7.81 days (p = 0.05) in hospital-acquired pneumonia and 7.81 to 6.83 days (p = 0.14) in COPD exacerbations. The proportion of patients treated according to clinical guidelines increased from 35.8% to 69.3% (p < 0.001). The mean quarterly antibiotic use density was 41.2 RDD/100 PD (recommended daily doses per 100 patient days) before the intervention and decreased to 34.03 RDD/100 PD after the intervention (p = 0.037)., Conclusion: Our study demonstrates the short-term effectiveness of a CPOE-based ABS intervention to reduce antibiotic treatment duration for uncomplicated pneumonia. This approach may be particularly suitable for hospitals with limited ABS resources., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: The capability to measure and monitor the quality of antibiotic prescribing is an important component of antibiotic stewardship (ABS) programmes. Several catalogues of consensus-based structure and process-of-care quality indicators (QIs) have been proposed, but only a few studies have tested and validated ABS QIs in practice tests. This multicentre study determined the clinimetric properties and suitability of a set of 33 process QIs for ABS that had earlier been developed and in part recommended in a German-Austrian hospital ABS practice guideline., Methods: Two point prevalence surveys were conducted in a convenience sample of 24 acute care hospitals throughout Germany, and data of all screened adult inpatients with prescription of a systemic antibiotic at a given day (n=4310) were included in the study. For each QI, the following clinimetric properties were assessed: applicability, feasibility, performance, case mix stability and interobserver reliability., Results: Eighteen QIs were considered sufficiently feasible, applicable and reliable, and had adequate room for improvement. The finally selected QIs primarily cover antibiotic therapy of common infections (bloodstream infection, pneumonia and urinary tract infection), while two of the QIs each address surgical prophylaxis and general aspects of antibiotic administration., Conclusions: Practice tests may be important to test the suitability of consensus process-of-care QIs in the field of hospital ABS. The 18 selected QIs considered suitable enough for hospital ABS in this study should be regarded as priority QIs useful for internal quality control and assurance. More research and additional practice tests may be needed to confirm their suitability for external quality assessment schemes., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The WHO/ATC (Anatomical Therapeutic Chemical) index DDD (WHO-DDD) is commonly used for drug consumption measurement. Discrepancies between WHO-DDD and actual prescribed daily doses (PDD) in hospitals have prompted alternative dose definitions adapted to doses recommended in hospital practice guidelines [recommended daily doses (RDD)]., Methods: In order to validate RDD we performed modified point prevalence surveys in 24 acute care hospitals and recorded 20620 PDD of antibiotics given to 4226 adult patients on the day of the survey and the 6 preceding days. We calculated RDD and WHO-DDD and compared them with PDD., Results: The rate of RDD corresponding to PDD was higher than the corresponding rate for WHO-DDD (pooled data, 55% versus 30%) and the differences were similar across the hospital sample, but varied according to drug/drug class, route of administration, indication and renal function. RDD underestimated actual consumption by 14% overall, while WHO-DDD overestimated total antibacterial consumption by 28% (pooled data; median values RDD -10% versus WHO-DDD +32%). The deviations of estimated from actual drug use volumes were largest for β-lactams (RDD -11% versus WHO-DDD +49%), in particular for penicillins (-11% versus +64%), if WHO-DDD were used., Conclusions: Hospital antibiotic consumption surveillance systems using current WHO-DDD should address the uneven discrepancies between actual prescribing and consumption estimates according to drug class that may lead to misclassification in benchmark analyses. We recommend using validated RDD as a supplementary measure to the WHO-DDD for detailed analyses., (© The Author 2017. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: In view of increasing rates of bacterial resistance and Clostridium difficile infections efforts to enhance appropriate and intelligent antibiotic prescribing have become important. A prerequisite is the availability of reliable antibiotic use data. So far antibiotic consumption data in this country had only a very limited coverage of acute care hospitals., Methods: We obtained drug dispensing data from 109 German acute care hospital pharmacies and calculated yearly antibiotic use density values stratified for hospital size and type of service / department. Antibiotic use density was expressed as daily doses per 100 patient days (occupied bed days). For daily dose definition, both hospital adapted doses of antibiotics ("recommended daily dose", RDD) as well as the official WHO-defined daily doses (DDD) were used., Results: The overall antibiotic use density was 43.5 RDD/100 patient days (median) with an interquartile range of 36-48 RDD/100 - corresponding to a median of 64.4 DDD/100 (interquartile range, 53-73 DDD/100). The antibiotic use levels in university hospitals were higher than in non-university hospitals that, in turn, showed similar antibiotic use density values across different hospital size categories. Antibiotic use density values for intensive care units were approximately twice as high as for normal wards but the proportion of antibiotic doses prescribed in intensive care per hospital-wide consumption was only 12 % (non-university hospitals) to 18 % (university hospitals). Extensive antibiotic use was also observed in university hospital hematology-oncology departments. Overall, cephalosporins were used slightly more frequently than penicillins, and fluoroquinolones were the third most frequently prescribed drug class. The proportion of first and second generation cephalosporins, and of third and fourth generation cephalosporins ranged between 5-37 % and between < 1 to 29 % of all dispensed antibiotic doses across the hospitals, respectively. The top five used drugs were cefuroxime, piperacillin-tazobactam, ceftriaxon, metronidazole und ciprofloxacin., Conclusions: Prescribing of antibiotics on almost every second day of hospitalization was extensive and highly variable, and the frequent use of cephalosporins is noteworthy. It is possible that the development of resistance and the rate of Clostridium difficile infection is associated with the diverse antibiotic use intensity and preferences for prescribing of cephalosporins and fluoroquinolones. Continuous antibiotic use surveillance and evaluation of prescribing patterns in acute care with feedback and benchmarking will help optimizing antibiotic use and better assessing strategies to minimize resistance and Clostridium difficile infection, and eventually improve patient safety., (© Georg Thieme Verlag KG Stuttgart · New York.)

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.

Introduction: Early initiation of antimicrobial treatment for acute infection is an important task in the emergency department (ED) with a likely impact on the hospital-wide antibiotic use pattern. We implemented an antibiotic stewardship (ABS) programme focused on non-trauma emergency patients at a large university hospital centre targeting broad-spectrum cephalosporin and fluoroquinolone use., Methods: Guidelines and focused discussion groups emphasised reduced prescription of third-generation cephalosporins and fluoroquinolones and encouraged penicillins. Antibiotic consumption expressed as monthly drug density in WHO-Anatomical Therapeutic Chemical defined and locally recommended daily doses (DDD and RDD) per 100 patient days was analysed before (January 2008 to October 2011) and after starting the intervention (January 2012 to October 2013). We performed a before-and-after uncontrolled interventional study using interrupted time-series (ITS) analysis in one ED to investigate ABS intervention-related effects in a quasiexperimental research setting., Results: The mean monthly total antibiotic use density declined from 111 RDD (138 DDD) per 100 patient days before the intervention to 86 RDD (128 DDD) per 100 patient days after starting the intervention. Among the different antibacterial drug classes, the consumption of third-generation cephalosporins showed the largest reduction and dropped significantly by -68% between preintervention and postintervention periods. Using the RDD dataset, ITS confirmed a highly significant postintervention change in level of third-generation cephalosporins (-15.2, 95% CI (-24.08 to -6.311)) and a corresponding increase in the use of aminopenicillin/betalactamase inhibitor formulations (+6.6, 95% CI (4.169 to 9.069)). The drug use densities for fluoroquinolones and for overall antibiotics declined, however, the postinterventional level changes missed statistical significance--overall (95% CI (-39.99 to 0.466), fluoroquinolones 95% CI (-11.72 to 4.333))., Conclusions: An intensified ABS programme using non-restrictive tools targeting third-generation cephalosporin and fluoroquinolone use in the setting of a large academic hospital emergency medicine department is feasible and effective. The intervention may serve as a model for other emergency medicine departments at hospitals with a similar structure and baseline situation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Restricted use of third-generation cephalosporins and fluoroquinolones has been linked to a reduced incidence of hospital-acquired infections with multidrug-resistant bacteria. We implemented an intensified antibiotic stewardship (ABS) programme in the medical service of a university hospital center aiming at a reduction by at least 30% in the use of these two drug classes., Methods: The ABS programme was focused on the 300-bed medical service. Prescription of third-generation cephalosporins was discouraged, whereas the use of penicillins was encouraged. Monthly drug use density was measured in WHO-ATC defined and locally recommended daily doses (DDD and RDD) per 100 patient days, to evaluate trends before (01/2008 to 10/2011) and after starting the intervention (1/2012 to 3/2013). The effect was analysed using interrupted time-series analysis with six non-intervention departments as controls., Results: Following initiation of the ABS intervention, overall antibiotic use in the medical service declined (p < 0.001). There was a significant intervention-related decrease in the use of cephalosporins and fluoroquinolones (p < 0.001) outperforming the decreasing baseline trend. Trend changes observed in some of the control departments were smaller, and the difference between trend changes in the medical service and those in control departments were highly significant for overall use and cephalosporin use reductions (p < 0.001) as well as for the increasing use of penicillins (p < 0.001). Mean use density levels (in RDD per 100 patient days) dropped for cephalosporins from 16.3 to 10.3 (-37%) and for fluoroquinolones from 17.7 to 10.1 (-43%), respectively. During the same period, the use of penicillins increased (15.4 to 18.2; 18%). The changes in expenditures for antibiotics in the medical service compared to control services minus programme costs indicated initial net cost savings likely to be associated with the programme., Conclusion: An intensified ABS programme targeting cephalosporin und fluoroquinolone use in the setting of a large academic hospital is feasible and effective. The intervention may serve as a model for other services and hospitals with a similar structure and baseline situation.

Background: There is much discussion about which measure or bundle of measures is most efficient in hospital antibiotic management programs, and it is often unknown which parts of such programs are readily available. The ABS International group conducted a survey to estimate the prevalence and characteristics of country-specific hospital antibiotic management programs and program components. This paper summarizes the results for Germany., Methods: The survey was conducted in April and May 2007. A questionnaire with various items related to hospital antibiotic management including control of consumption and availability of diagnostic microbiology was sent to hospital pharmacists through the ADKA (Bundesverband Deutscher Krankenhausapotheker). The questionnaires were analyzed by calculating mean scores for the various items and topics., Main Findings: Of 400 questionnaires sent, 48 were returned and evaluable. Most respondents represented general hospitals in the southern part of Germany. Items that scored high were related to frequency of evaluation of antibiotic resistance data (4.48), availability of (simple) management tools for antibiotic prescribing (4.05), and control of antibiotic consumption (4.02). Items related to the availability of trained and dedicated antibiotic management officers scored very low., Conclusions: Shortage of trained and dedicated personnel may limit the organization of effective antibiotic management in many German hospitals.

Background: Sales data indicate a major increase in the prescription of antifungal drugs in the last two decades. Many new agents for systemic use that only recently have become available are likely to be prescribed intensively in acute care hospitals. Sales data do not adequately describe the developments of drug use density. Given the concerns about the potential emergence of antifungal drug resistance, data on drug use density, however, may be valuable and are needed for analyses of the relationship between drug use and antifungal resistance., Methods: Hospital pharmacy records for the years 2001 to 2003 were evaluated, and the number of prescribed daily doses (PDD, defined according to locally used doses) per 100 patient days were calculated to compare systemic antifungal drug use density in different medical and surgical service areas between five state university hospitals., Results: The 3-year averages in recent antifungal drug use for the five hospitals ranged between 8.6 and 29.3 PDD/100 patient days in the medical services (including subspecialties and intensive care), and between 1.1 and 4.0 PDD/100 patient days in the surgical services, respectively. In all five hospitals, systemic antifungal drug use was higher in the hematology-oncology service areas (mean, 48.4, range, 24 to 101 PDD/100 patient days, data for the year 2003) than in the medical intensive care units (mean, 18.3, range, 10 to 33 PDD/100) or in the surgical intensive care units (mean, 10.7, range, 6 to 18 PDD/100). Fluconazole was the most prescribed antifungal drug in all areas. In 2003, amphotericin B consumption had declined to 3 PDD/100 in the hematology-oncology areas while voriconazole use had increased to 10 PDD/100 in 2003., Conclusion: Hematology-oncology services are intense antifungal drug prescribing areas. Fluconazole and other azol antifungal drugs are the most prescribed drugs in all patient care areas while amphotericin B use has considerably decreased. The data may be useful as a benchmark for focused interventions to improve prescribing quality.

Objectives: To compare rates of in vitro fluoroquinolone resistance of bacterial isolates obtained from inpatients of two haematology-oncology services with high and low fluoroquinolone consumption., Methods: Two hospitals with consistently high (A) and low (B) fluoroquinolone use in their haematology-oncology services between the years 1999 and 2002 were identified in a hospital antibiotic use surveillance project. Rates of in vitro resistance to fluoroquinolones in inpatients of the services were determined for Escherichia coli and coagulase-negative staphylococcal bloodstream isolates, and also for Pseudomonas aeruginosa and Staphylococcus aureus isolates from any site., Results: Fluoroquinolone resistance of E. coli was significantly higher in hospital A than in hospital B, but there was no such correlation between fluoroquinolone use and resistance rates for P. aeruginosa and staphylococci., Conclusion: The impact of antibiotic consumption on the prevalence of resistance may differ widely between different pathogens. Interventions using ecological analyses of the relationship between hospital antibiotic use and resistance need to consider pathogen-specific dynamics in the emergence and control of bacterial resistance.

In view of increasing rates of antibiotic resistance worldwide and decreased research and development of new antibacterial compounds, programmes helping to better understand the complex relationship between antibiotic consumption and emergence of resistance have gained importance. Consequently, in addition to increased support for research projects that establish prospective surveillance and evaluation of antibiotic resistance and antimicrobial drug use, the EU has passed directives addressing political leadership in this respect. Information on antibiotic use in Germany is now available from databases independent from cost-oriented market research studies. This information allows estimation of antibiotic use in ambulatory and hospital care as compared with to other EU countries. According to results of current projects, the frequency of national antibiotic use in ambulatory care in Germany (4948 defined daily doses per 1000 population per year) falls within the lower third of EU countries. Upper boundaries in regional variation in antibiotic use are still much lower than values for high-use countries like France, Spain and Portugal. Hospital antibiotic use, in contrast, appears to be in the range of that reported for other countries. However, only rough estimates of hospital antibiotic use are available for Germany as well as most other EU countries due to data usually derived from non-representative hospital sampling.

In a pilot study we established a hospital antibiotic use database from which estimates for antibiotic consumption in German hospitals (expressed as defined daily doses per 100 patient days, DDD/100) can be retrieved for both benchmarking and antibiotic use and resistance research purposes. Data from eight university hospitals (1998-2000) showed a mean antibiotic use density of 60.1 DDD/100 in the surgical and 79.3 DDD/100 in the medical services. Antibiotic use was higher in the intensive care units (surgery: 146 DDD/100, medicine: 187 DDD/100) than in haematology-oncology services (110.8 DDD/100) or in other surgical (51.6 DDD/100) and medical (66 DDD/100) service areas. There were major differences in the use of specific antibacterial drug classes between service areas. The established database allows detailed analysis in antibacterial drug use and can be linked to bacterial resistance surveillance databases.

Background: Excessive antibiotic use increases the risk of development and dissemination of bacterial resistance. A comparative analysis of the correlation between hospital antibiotic consumption and rates of bacterial resistance is needed for a better understanding of the complex relationship between antibiotic use and resistance. Apart from economic and market research studies, estimates of antibiotic consumption in German hospitals, however, are not available., Methods: In a pilot project (INTERUNI-II), retrospective data from eight university hospital pharmacies covering the period 1998, 1999, and 2000 were collected to obtain estimates for the antibiotic use densities in the medical services of teaching hospitals. Antibiotic use densities were expressed as prescribed daily doses per 100 occupied bed days (PDD/100). The definition of prescribed daily doses was according to guidelines for antimicrobial therapy in adults with normal renal and hepatic function used in the participant hospitals. Means and ranges of antibiotic use densities were separately assessed for medical intensive care units (MICU), hematology-oncology services (HEMONC), and other medical services (OTHER MED)., Results: Mean antibiotic use density in internal medicine was 55.2 PDD/100 overall, ranging between 39.4 and 75.8 PDD/100 in the eight participant hospitals. In seven hospitals antibiotic use density increased during the years of observation. Antibiotic use was higher in MICU areas (3-year average, 122.3; range, 98-167 PDD/100) than in HEMONC (3-year average, 86.9; range, 67.8-129.4 PDD/100) and OTHER MED areas (3-year average, 42.8; range, 31.7-50.6 PDD/100). There was an increasing use of oral antibiotics resulting in a substantial proportion of oral agents among all antibacterial drugs outside MICU areas (year 2000, HEMONC, range, 36-74% of all PDD; OTHER MED, range, 43-59% of all PDD). beta-lactam antibiotics were the most frequently prescribed drugs (3-year average, 22.6 PDD/100). 56% of beta-lactam PDD belonged to the class of broad-spectrum beta-lactams (ranges, MICU, 49-82%; HEMONC, 61-89%; OTHER MED, 24-58%). Fluoroquinolones were the second most prescribed drug class (3-year average, 13 PDD/100). They were most frequently used in HEMONC (3-year average, MICU, 14.5; HEMONC 26.5; and OTHER MED 8.6 PDD/100, respectively). There was considerable variation between participant hospitals in the use of specific drug classes in given patient care areas., Conclusion: This retrospective study showed significant variation in overall and specific antibacterial drug class use between German teaching hospital medical services and defined patient care areas. Given the variation in the obtained estimates, targeted prospective hospital antibiotic use surveillance with fast data acquisition and analysis might offer an excellent opportunity to evaluate the impact of differences in antibiotic use and of revised therapy guidelines on the evolution of nosocomial bacterial resistance.

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)