Antibiotic stewardship
Antibiotic Stewardship (ABS) describes a broad concept for the responsible, targeted use of antibiotics in infectious diseases.
The German Society for Infectious Diseases (DGI) describes ABS as “a programmatic, sustainable endeavor by a medical institution to improve and ensure a rational anti-infectious prescription practice ... (with) strategies or measures that improve the quality of anti-infectious treatment in terms of selection, dosage, application and Ensure the duration of use in order to achieve the best clinical treatment result while observing minimal toxicity for the patient. "
Due to the different health systems, ABS is partly dependent on national or regional circumstances. The present article deals primarily with the situation in Germany.
Background, history
Among the various drug groups, antibiotics can on the one hand cause - in some cases not inconsiderable - side effects and on the other hand contribute to the development of resistance . Therefore, their use must be carefully considered.
The development of resistance after the use of antibiotics initially affects the individual patient, in whom the (more) resistant bacteria can later trigger the disease and are then more difficult to treat with antibiotics. In addition, these pathogens can also be transmitted to other individuals - directly or via the environment - and can then cause disease and be less treatable for them. The development of resistance thus becomes a general health or public health problem.
In the case of many infectious diseases, it is impossible to differentiate between bacterial and viral infections in everyday practice. Using the example of a flu-like infection , viruses are the cause in perhaps 90% of cases, against which antibiotics are ineffective. Nevertheless, antibiotics are often prescribed in doctors' offices for flu-like infections because doctors fear that these could be the few exceptions for a bacterial cause, or that the patient could develop bacterial pneumonia .
It has been discussed for 50 years that a significant proportion of antibiotic administration is unnecessary or untargeted, and that this is a major factor in increasing resistance. In order to slow down or even reverse this negative development, a number of measures have been developed and implemented in human medicine, which are referred to in the English-speaking world as "antimicrobial stewardship" or "antibiotic stewardship". These terms, which are synonymous in themselves, denote two sides of the same coin: on the one hand, the resistance problem and, on the other hand, the responsible use of antibiotics. Initially, the "pathogen side" - that is, the observation of the resistant pathogens - was in the foreground; it has now grown to a large extent. In contrast, the “regulation side” came into focus with a delay. Accordingly, this part of ABS is not yet standardized or is currently in a dynamic development process.
The use of antibiotics in animals plays a special role, especially in livestock breeding; Here antibiotics are used not only for the direct treatment of infection, but also for disease prevention and even for fattening animals .
aims
The primary goal of Antibiotic Stewardship is to prevent or reduce infectious diseases or deaths caused by resistant bacteria. Prior to this, there is the reduction of resistant bacteria in individual people or in the environment around them. This in turn is achieved by reducing the use of antibiotics: fewer, and more targeted, antibiotic applications lead to less resistance and thus to fewer illnesses and deaths.
Health policy framework
There is now awareness of the need for ABS at all levels of health policy worldwide: This includes the World Health Organization (WHO), the European Center for Disease Prevention and Control (ECDC), national health authorities such as the German Robert Koch Institute (RKI) , but also non-governmental organizations (NGOs) such as the BUKO pharmaceutical campaign.
In Germany, the German Antibiotic Resistance Strategy (DART 2020) was added to the political agenda in 2015. The German Medical Association, for example, developed an ABS training framework.
Areas of activity, actors
ABS can be used wherever antibiotics are prescribed, i.e. in inpatient and outpatient medicine (as well as veterinary medicine). Accordingly, the primary actors are the prescribing doctors.
Obviously, ABS first found its way into the hospital, because this is where the resistant pathogens were mostly discovered, and this is where many broad-based antibiotics were administered. Around 2010, ABS approaches gradually emerged in the clinics. Since a good 80% of the antibiotics used in humans are prescribed in the outpatient sector, outpatient medicine was also taken into account in ABS from around the mid-2010s.
An antibiotic stewardship initiative has been founded throughout Germany to document and promote previous ABS developments across locations and disciplines.
Interdisciplinarity
An antibiotic prescription is a more complex process that makes the inclusion of other specialist disciplines useful. Particularly noteworthy are microbiology , which provides the treating physician with information on pathogens and their resistance, if any, in the individual patient, but also general information on local infection and resistance processes, or pharmacy - pharmacists can provide important information on antibiotic drugs Medicinal substances supplement such as dosage and side effects spectrum.
Inpatient medicine
For inpatient medicine, there are now longer experiences with ABS. The structural requirements and processes are modeled in a comprehensive guideline. In addition to such a maximum approach, however, the creation of smaller ABS teams with a restricted agenda also makes sense.
Outpatient medicine
For outpatient medicine there is no concept that is comparable to inpatient medicine in the form of a guideline. This has partly historical reasons (see above), but also reflects the greater professional variability of outpatient medicine compared to inpatient medicine, as well as its degree of organization - mostly single or double practices with only limited capacity for such measures.
In order to lay the foundations here, in November 2018 the Robert Koch Institute invited the ABS projects that have so far been outstanding in the outpatient sector, including AnTiB, ARena, RAI, RESIST and WASA.
These projects work with different approaches, including medical training and communication, but also communication with patients, as well as other partially innovative approaches.
activities
ABS is understood to mean a wide variety of measures that are intended to influence that a rational antibiotic decision is made in an individual doctor-patient consultation. These measures can be divided into various categories, with some overlaps.
Medical education
Medical education measures include medical training (or medical studies), continuing medical education (to become a specialist) and, finally, continuing medical education (after the specialist). It is not known to what extent ABS is already included in the curricula of the medical faculties or specialist groups. In any case, there is already a large number of offers for advanced medical training.
Patient education and empowerment
When prescribing antibiotics, the patient's express wish for an antibiotic can play a special role. It therefore makes sense to inform (future) patients about the mode of action of antibiotics, their mostly lacking effect in certain common diseases such as colds and their potentially harmful effects, especially the promotion of resistance.
This can be done by means of information from institutions such as health authorities or health insurance companies, but also through media information campaigns. Information material for notices or for display in practices can also be used. There is the assumption that patients who have been trained in this way develop a more critical attitude towards antibiotics and can help determine their use in dialogue with the prescribing doctor in the sense of empowerment (see prescription).
Communication measures
Communication about the appropriate treatment of infections can take place within the medical profession or in the doctor-patient interaction. Within the medical profession, the most important communication level is the publication of specialist articles in textbooks or specialist articles in specialist journals. In addition to this “hierarchical” communication, important communication also takes place “on an equal footing” within the framework of medical quality circles. Magazine articles on ABS are becoming increasingly available, and the ABS topic is also increasing in quality circles.
Communication between doctor and patient as to whether an antibiotic is medically necessary is particularly important where patients express an - from the doctor's point of view - inadequate desire for an antibiotic. There is still a need for training for doctors to better “take” their patients with them when making this decision. Aids can also be used, such as the "info recipe generator", which explains the current decision-making process to the patient in an understandable manner, or the so-called "prescription for needs", with which the doctor hands out an antibiotic prescription to suitable patients, who then redeem them (only) when they deteriorate should.
Laboratory tests
A distinction can be made between non-specific and specific tests, or between rapid tests and routine tests.
Non-specific tests such as B. CRP and PCT indicate the extent of inflammation, or even provide hints as to whether a bacterial infection is present. Specific tests such as the streptococcal rapid test can provide more detailed information on suspected infectious agents and influence the decision or the selection of the antibiotic. These tests are also available as quick tests .
In addition, the “gold standard” for a rational antibiotic decision would be detection of the pathogen, usually by means of bacterial culture (or by means of serology or histology), combined with resistance testing for the most suitable antibiotic. Such tests, however, are not always available, sometimes only deliver results after days, or are ambiguous, so that the antibiotic decision often has to be made without determining the pathogen and resistance.
Scores and guidelines
In certain areas, scores exist as quick decision-making aids, e.g. B. the McIsaac score in pediatrics.
Guidelines exist for a number of infectious diseases, for example from the Working Group of Scientific Medical Societies (AWMF) or the German Society for General Medicine and Family Medicine (DEGAM). These guidelines are often aimed at inpatient treatment. For the outpatient sector, on the other hand, there is still a need for expansion, both in terms of the breadth of the topics and its usefulness in the busy daily practice. Also, guidelines specially developed in the infectious field cannot deal with a geographically sometimes quite different infection and resistance process. At this point, a new format of local recommendations for action is currently developing. In addition to the local resistance aspect, these can also have other advantages, such as the development of a “local regulation culture” which, through their “bottom-up” approach, involving as many local actors as possible, may lead to greater acceptance than the “top down” “Guidelines of the professional associations.
Feedback and restriction measures
Another ABS measure is to provide prescribers with information about the amount and type of antibiotics they are prescribing. This can be linked to comparative information (“benchmarking”) on the specialist group or region. In this context, targeted feedback to frequent writers is also discussed, possibly combined with mandatory follow-up training. However, it can be assumed that positive motivation is more effective than sanctioning, at least in the outpatient sector.
In large parts of the EU, especially in the German-speaking countries of Germany, Austria and Switzerland, prescription antibiotics are mandatory. In some EU countries, however, antibiotics can be purchased without a prescription. This probably contributes to a not inconsiderable degree to the development of resistance.
In hospitals in Germany there is the procedure of the "senior doctor's prescription", i. This means that certain medications cannot be requested by all doctors working at the hospital, but only by senior physicians. However, this procedure is not established across the board or with a view to prescribing antibiotics. This hierarchical principle could also be extended to the presence of certain additional qualifications, e.g. B. an ABS qualification.
Below such a status-related prescription competence, similar to z. B. in the food sector, a traffic light system for easy orientation between antibiotics with different side effects or resistance potentials are used. However, such a system is not yet sufficiently developed.
Effects
The extent to which the measures described are effective can be measured at different levels, according to the stated goals. This should be done in order to identify those measures with the best potential. Since the corresponding target values depend on many different factors, in particular on the surrounding infection process, an assessment of ABS effects is not easy.
Morbidity and mortality from resistant bacteria
Morbidity: In the outpatient area, treatment diagnoses are only mapped very roughly and imprecisely, so that no reasonable statistics can currently be derived from them. In the hospital, however, diagnoses can be recorded and evaluated in a more differentiated manner. This is where there is currently the greatest potential for development through hospital information systems , which can also record microbiological data.
Mortality: In Germany, a death can only be assigned to an infectious disease caused by resistant bacteria in exceptional cases. This is mainly due to the fact that the death certificates are usually only filled out very superficially and corresponding information is not available in the outpatient sector. In the inpatient sector, due to the aforementioned better differentiation of diagnostic data, an assignment of deaths to specific infection situations would be more possible, which in practice has so far appeared difficult and not very meaningful.
Pathogen and resistance events
As already described, extensive surveillance systems for resistant pathogens already exist in Germany at least .
Antibiotic consumption
The German Antibiotic Resistance Strategy (DART) also introduced intensive antibiotic resistance surveillance (ARS), which is integrated into a corresponding EU-wide (EARS-Net) or global (GLASS) surveillance system.
See also
literature
(A German-language textbook does not seem to be available; instead, examples are given to review articles in journals)
- Der Anesthesist, Volume 67, Issue 1, January 2018 (Cover topic "Antibiotic Stewardship")
- Federal Health Gazette - Health Research - Health Protection, Volume 61, Issue 5, May 2018 (Title topic "Antibiotic resistance - a complex challenge for society as a whole")
Individual evidence
- ↑ DGI: Definition of Antibiotic Stewardship: https://www.dgi-net.de/fort-und-weiterbildung/antibiotic-stewardship-abs/
- ↑ Medline / PubMed Medical Subject Headings (MeSH): https://www.ncbi.nlm.nih.gov/mesh/2023144
- ↑ Robert Koch Institute (RKI): Antibiotic Resistance Surveillance: https://ars.rki.de
- ↑ WHO: World Antibiotic Awareness Week: https://www.who.int/campaigns/world-antibiotic-awareness-week/world-antibiotic-awareness-week-2018
- ↑ ECDC: Antimicrobial stewardship: https://ecdc.europa.eu/en/publications-datadirectory-guidance-prevention-and-controlprudent-use-antibiotics/antimicrobial
- ↑ Robert Koch Institute (RKI): https://www.rki.de/DE/Content/Service/Presse/Pressemitteilungen/2018/04_2018.html
- ↑ BUKO pharmaceutical campaign: Race against time - strategies against antibiotic resistance: https://bukopharma.de/images/pharmabriefspezial/2017/2017_01_spezial_Antibiotika_Wettlauf.pdf
- ↑ German Antibiotic Resistance Strategy (DART 2020): https://www.bundesgesundheitsministerium.de/themen/praevention/antibiotika-resistenzen/antibiotika-resistenzstrategy.html
- ↑ German Medical Association: Structured curricular advanced training “Antibiotic Stewardship (ABS)” - Rational anti-infective strategies: https://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/Fortbildung/Antibiotic_Stewardship.pdf
- ↑ Antibiotic Stewardship Initiative: https://www.antibiotic-stewardship.de
- ↑ Working Group of Medical and Scientific Societies (AWMF): “Strategies for ensuring the rational use of antibiotics in hospitals”: https://www.awmf.org/leitlinien/detail/ll/092-001.html
- ^ Antibiotic therapy in Bielefeld (AnTiB): http://www.antib.de
- ↑ Antibiotic Therapy in Bielefeld (AnTiB) - A local project to promote the rational prescription of antibiotics in outpatient paediatrics: http://link.springer.com/article/10.1007/s00103-019-02978-y
- ↑ Avoid the development of antibiotic resistance sustainably: https://www.arena-info.de
- ↑ Rational use of antibiotics through information and communication (RAI): http://www.rai-projekt.de/
- ↑ Avoidance of RESISTANCE through adequate use of antibiotics for acute respiratory infections: https://www.kbv.de/html/resist.php
- ↑ Effectiveness of antibiotics training in the resident medical profession (WASA): http://www.wasa.helmholtz-hzi.de/
- ↑ National Association of Statutory Health Insurance Physicians (KBV): Quality Circle: https://www.kbv.de/html/qualitaetsommunikel.php
- ↑ RAI project: Infozept generator: http://www.infozeptgenerator.de
- ↑ project ANTIB: Recommendations Pediatrics: http://www.uni-bielefeld.de/gesundhw/ag2/antib/praxis-paed.html
- ↑ physicians' association Westfalen-Lippe (KVWL) pp 26-27: https://www.kvwl.de/mediathek/kompakt/pdf/2018_10.pdf
- ↑ Pharmazeutische Zeitung: https://www.pharmazeutische-zeitung.de/2017-07/antibiotika-als-otc-verboten-und-doch-haeufige-praxis/
- ^ Robert Koch Institute: Antibiotic Resistance Surveillance (ARS): https://ars.rki.de
- ↑ EARS-Net: https://www.ecdc.europa.eu/en/about-us/partnerships-and-networks/disease-and-laboratory-networks/ears-net
- ↑ WHO: GLASS: https://www.who.int/glass/en/
Web links
- Robert Koch Institute (RKI)