Lässt sich die Antibiotikaverordnungspraxis im Krankenhaus durch hausinterne Richtlinien beeinflussen?

Zusammenfassung

Hintergrund: Krankenhausinterne Leit- bzw. Richtlinien sind im Rahmen des „Antibiotic Stewardship“ (ABS) ein wichtiger Baustein zur Steuerung der antiinfektiven Therapie. Wir untersuchten, ob ein Leitfaden die Verordnungspraxis beeinflusst.

Methoden: Am Universitätsklinikum Halle (Saale) wurde ein Leitfaden für die empirische antimikrobielle Therapie und mikrobiologische Diagnostik eingeführt. Wichtigste Ziele waren eine Reduktion des Verbrauchs von Drittgenerationscephalosporinen und Fluorchinolonen, eine Verringerung des Selektionsdrucks für Enterokokken und multiresistente gramnegative Erreger sowie eine Abnahme der Clostridium difficile-Infektionen. Zudem wurde angestrebt, die mikrobiologische Probenentnahmefrequenz als Basis für verbesserte Deeskalationstherapien zu optimieren. 12 Monate nach Einführung des Leitfadens wurden Veränderungen des Antibiotikaverbrauchs, der Erreger- und Resistenzstatistik sowie der Blutkulturentnahmefrequenz untersucht.

Ergebnisse: Der Verbrauch an Drittgenerationscephalosporinen (-18,6 %) und Fluorchinolonen (-9,8 %) war rückläufig, bei jedoch gleichzeitigem Anstieg des Verbrauchs von Breitspektrum- und Intermediärspektrum-Penicillinen (+ 23,8 % bzw. + 37 %) sowie von Carbapenemen (+ 11,9 %). Das Gesamtvolumen verschriebener Antiinfektiva blieb unverändert. Die Zahl der Enterokokken-Isolate (-18,3 %) sowie der Clostridium difficile-Infektionen war deutlich rückläufig (-26,3 %). Gramnegative Erreger, insbesondere ESBL-Bildner, wurden im Rahmen ausgeweiteter Screening-Untersuchungen häufiger nachgewiesen. Die Rate an Blutkulturen/1000 Patiententage blieb unbeeinflusst.

Folgerung: Hausinterne Richtlinien für die antiinfektive Therapie erscheinen als ein geeignetes Instrument, um das Verordnungsverhalten und den Selektionsdruck für einzelne Erregergruppen zu steuern. Der Gesamtverbrauch an Antiinfektiva ließ sich dadurch in unserer Untersuchung nicht nennenswert beeinflussen.

Abstract

Background: In-house guidelines are an essential tool of antibiotic stewardship (ABS) programs to guide antimicrobial therapy. We studied the effect of in-house guidelines adapted to the local pathogen and resistance epidemiology on prescribing behavior.

Methods: At the University Hospital Halle (Saale) guidelines for the antimicrobial therapy and essential microbiological diagnostics were introduced. Main objectives were reducing the use of third generation cephalosporines and fluoroquinolones, decreasing selection pressure for enterococci and multidrug-resistant Gram-negative bacteria, minimizing Clostridium difficile infections (CDI), and improving microbiological diagnostics to enhance de-escalation strategies. 12 months thereafter a comparison of antibiotic consumption, pathogen and resistance statistics and use of blood cultures was performed.

Results: There was a decrease of third-generation cephalosporines (-18.6 %) and fluoroquinolones (-9.8 %), while consumption of broad- and intermediate-spectrum penicillins (+23.8 % and +37 %) as well as carbapenems (+11.9 %) increased. The total volume of prescribed anti-infectives remained unchanged. The number of enterococcal isolates (-18.3 %) and CDI (-26.3 %) decreased considerably. Gram-negatives, particulary ESBL-producing Enterobacteriaceae, were detected more frequently due to an expanded screening program. The rate of blood cultures/1000 patient-days was unaffected.

Conclusion: In-house guidelines for the empiric antiinfective therapy appear to be suitable to influence the prescribing behavior and the selection pressure on individual pathogen groups. The total volume of antibiotic prescriptions was not affected in this study.

Schlüsselwörter

Antibiotika - Antibiotic Stewardship (ABS) - Resistenz - Verordnungsverhalten - hausinterne Richtlinien - Leitlinien - Adhärenz

Keywords

antibiotics - antibiotic Stewardship (ABS) - resistance - prescribing practice - in-house Guidelines - adherence

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