Effect of an Intensified Antibiotic Stewardship Program at an Orthopedic Surgery Department.

Background: Institutional programs such as antibiotic stewardship (ABS) programs offer possibilities to monitor and modify antibiotic usage with the aim of reducing antibiotic resistance. In orthopedic units that treat peri-prosthetic joint infections (PJIs), ABS programs are still rare, however, there is extensive use of high-risk antibiotic agents and an increased risk for the occurrence of Clostridium difficile infections (CDIs). Patients and Methods: An ABS program was implemented at the Department of Orthopedic Surgery at a university hospital. Quarterly antibiotic consumption was measured in defined daily doses (DDDs) per 100 patient-days (PDs) at 10 quarters before the intervention and seven quarters after the intervention. The effect of the new antibiotic policy on drug use rates was evaluated using an interrupted time-series analysis. Estimated changes over time in the incidence of CDIs (cases per 1,000 PDs) were analyzed. Results: A remarkable percentual reduction in second-generation cephalosporin use of 83% (p < 0.001; pre-intervention level, 81.486 DDDs/100 patient-days; post-intervention level, 13.751 DDDs/100 PDs) and clindamycin administration of 78% (p < 0.001; pre-intervention level, 18.982 DDDs/100 PDs; post-intervention level, 4.216 DDDs/100 PDs) was observed after implementation of ABS interventions. Total antibiotic use declined by 25% (p < 0.001; pre-intervention level, 129.078 DDDs/100 PDs; post-intervention level, 96.826 DDDs/100 PDs). Conclusions: This research assessed the positive impact of an intensified ABS program at an orthopedic department specializing in PJIs. Antibiotic stewardship program interventions encourage the reduction of total antibiotic usage and especially high-risk antibiotic agents, associated with the development of antimicrobial resistance.

[Antibiotic prophylaxis for transrectal prostate biopsy : In the context of restricted indications for fluoroquinolones and antibiotic stewardship]. / Antibiotikaprophylaxe bei transrektaler Prostatabiopsie : Im Kontext von Fluorchinolon-Indikationsrücknahme und Antibiotic Stewardship.

BACKGROUND: Transrectal prostate biopsy (TRPB) is the gold standard for prostate cancer diagnosis and among the most common urological interventions. Short-term antibiotic prophylaxis (PAP) is recommended for TRPB. Fluoroquinolone-PAP as standard of care needs to be revaluated due to the restrictions on the use of fluoroquinolone antibiotics by the German Federal Institute for Drugs and Medical Devices. OBJECTIVES: The aim of the study was to analyze clinical practice of PAP for TRPB with focus on infectious complications and potential differences between fluoroquinolone-PAP and cotrimoxazole-PAP. METHODS: We performed a retrospective monocentric study of clinical and microbiological characteristics of patients with TRPB between 3 January 2019 and 28 January 2021. RESULTS: A total of 508 men were included; median age was 68 years. In all, 55.9% of our cohort received cotrimoxazole-PAP and 40.0% fluoroquinolone-PAP. Postinterventional complications occurred in 5.5%, of those 50.0% were infectious complications. Complication rate did not differ between patients with fluoroquinolone-PAP and cotrimoxazole-PAP. Urinary cultures in case of postinterventional complications yielded pathogens with antimicrobial resistance against the used PAP substance indicating selection of resistant bacteria. CONCLUSION: Cotrimoxazole-PAP for TRPB is not associated with an increase of infectious complications compared to fluoroquinolone-PAP. Cultures obtained prior to TRPB to identify antimicrobial resistance facilitate targeted PAP and therefore can reduce complications.

Use of monoclonal antibody therapy for nosocomial SARS-CoV-2 infection in patients at high risk for severe COVID-19: experience from a tertiary-care hospital in Germany.

Additional treatment options for coronavirus disease (COVID-19) are urgently needed, particularly for populations at high risk of severe disease. This cross-sectional, retrospective study characterized the outcomes of 43 patients with nosocomial severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with and without treatment using monoclonal SARS-CoV-2 spike antibodies (bamlanivimab or casirivimab/imdevimab). Our results indicate that treatment with monoclonal antibodies results in a significant decrease in disease progression and mortality when used for asymptomatic patients with early SARS-CoV-2 infection.

Rates of bacterial co-infections and antimicrobial use in COVID-19 patients: a retrospective cohort study in light of antibiotic stewardship.

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Bacterial co-infections are associated with unfavourable outcomes in respiratory viral infections; however, microbiological and antibiotic data related to COVID-19 are sparse. Adequate use of antibiotics in line with antibiotic stewardship (ABS) principles is warranted during the pandemic. We performed a retrospective study of clinical and microbiological characteristics of 140 COVID-19 patients admitted between February and April 2020 to a German University hospital, with a focus on bacterial co-infections and antimicrobial therapy. The final date of follow-up was 6 May 2020. Clinical data of 140 COVID-19 patients were recorded: The median age was 63.5 (range 17-99) years; 64% were males. According to the implemented local ABS guidelines, the most commonly used antibiotic regimen was ampicillin/sulbactam (41.5%) with a median duration of 6 (range 1-13) days. Urinary antigen tests for Legionella pneumophila and Streptococcus peumoniae were negative in all cases. In critically ill patients admitted to intensive care units (n = 50), co-infections with Enterobacterales (34.0%) and Aspergillus fumigatus (18.0%) were detected. Blood cultures collected at admission showed a diagnostic yield of 4.2%. Bacterial and fungal co-infections are rare in COVID-19 patients and are mainly prevalent in critically ill patients. Further studies are needed to assess the impact of antimicrobial therapy on therapeutic outcome in COVID-19 patients to prevent antimicrobial overuse. ABS guidelines could help in optimising the management of COVID-19. Investigation of microbial patterns of infectious complications in critically ill COVID-19 patients is also required.

Assessing the quality of drug information provided by hospital pharmacies using a fictitious enquiry and simulated real-life conditions.

OBJECTIVES: Guidelines for drug information (DI) provided by hospital pharmacists call for quality assurance procedures; however, no method of evaluation is internationally agreed on. The procedure should be feasible, reproducible and representative for real-life quality. We tested a new approach using a fictitious enquiry under simulated real-life conditions for quality assessment of DI by German hospital pharmacists. METHODS: A fictitious enquiry was submitted under simulated real-life conditions (study part I; test week announced, but not exact day; response time given). An expert panel determined content-related (three essential, and up to seven additional items of useful information) and structural requirements for answers and performed blinded evaluations. To compare quality of routine DI answers (study part II), five recently answered routine enquiries could retrospectively be evaluated for plausibility (binary scale 0/1) and structural requirements. RESULTS: Of 62 hospital pharmacies opting to participate, 45 (71%) entered study part I and 18 (40%) entered study part II. In study part I, 28 participants (62%) presented three essential contents, 11 (24%) two, five (11%) one, and one none. Additional useful information was given in 44-80%. Structural requirements achieved mixed results with low scores for logical conclusion deduction and reference presentation. In study part II, plausibility for the 90 recently answered routine enquiries was rated good (median 0.91, range 0.53-1). Concerning structural requirements, overall comparable results were achieved with minor variations compared with study part I. Thus, the quality of DI was judged to be comparable between study parts I and II. CONCLUSIONS: An open quality assessment procedure with a fictitious enquiry under simulated real-life conditions can successfully be used for quality measurement of DI of hospital pharmacists and identifies areas for improvement.

[Erratum to: Strategy for university emergency room management at the beginning of an epidemic using COVID-19 as an example]. / Erratum zu: Strategie einer universitären Notaufnahme für das COVID-19-Management im Rahmen einer beginnenden Epidemie.

[This corrects the article DOI: 10.1007/s10049-020-00759-8.].

[Strategy for university emergency room management at the beginning of an epidemic using COVID-19 as an example]. / Strategie einer universitären Notaufnahme für das COVID-19-Management im Rahmen einer beginnenden Epidemie.

Due to the increasing number of COVID-19 infections worldwide, all hospitals are faced with the challenge associated with the pandemic. In particular, emergency rooms must prepare and implement completely new workflows. This applies in particular to patient screening and selection (triage). Close cooperation with other specialist areas such as hygiene, infectiology or virology is also necessary in order to implement appropriate treatment concepts before, during and after the diagnosis is completed. In addition, communication and quality and risk management are highly relevant in addition to the clinical aspects. This article uses COVID-19 as an example to describe how emergency rooms can prepare for a pandemic.

Prevalence of third-generation cephalosporin-resistant Enterobacterales colonization on hospital admission and ESBL genotype-specific risk factors: a cross-sectional study in six German university hospitals.

OBJECTIVES: To assess the admission prevalence of third-generation cephalosporin-resistant Enterobacterales (3GCREB) and to assess whether risk factors vary by ß-lactamase genotype. METHODS: Adult patients were recruited within 72 h of admission to general wards of six university hospitals in 2014 and 2015. Rectal swabs were screened for 3GCREB and isolates were analysed phenotypically and genotypically. Patients were questioned on potential risk factors. Multivariable analyses were performed to identify risk factors for 3GCREB colonization and for specific ß-lactamases. RESULTS: Of 8753 patients screened, 828 were 3GCREB positive (9.5%). Eight hundred and thirteen isolates were available for genotyping. CTX-M-15 was the most common ESBL (38.0%), followed by CTX-M-1 (22.5%), CTX-M-14 (8.7%), CTX-M-27 (7.5%) and SHV-ESBL (4.4%). AmpC was found in 11.9%. Interestingly, 18 Escherichia coli isolates were AmpC positive, 12 of which (67%) contained AmpC on a gene of plasmid origin [CMY (n = 10), DHA (n = 2)]. Risk factors for 3GCREB colonization varied by genotype. Recent antibiotic exposure and prior colonization by antibiotic-resistant bacteria were risk factors for all ß-lactamases except CTX-M-14 and CTX-M-27. Travel outside Europe was a risk factor for CTX-M-15 and CTX-M-27 [adjusted OR (aOR) 3.49, 95% CI 2.88-4.24 and aOR 2.73, 95% CI 1.68-4.43]. A previous stay in a long-term care facility was associated with CTX-M-14 (aOR 3.01, 95% CI 1.98-4.59). A preceding hospital stay in Germany increased the risk of CTX-M-15 (aOR 1.27, 95% CI 1.14-1.41), while a prior hospital stay in other European countries increased the risk of SHV-ESBL colonization (aOR 3.85, 95% CI 1.67-8.92). CONCLUSIONS: The detection of different ESBL types is associated with specific risk factor sets that might represent distinct sources of colonization and ESBL-specific dissemination routes.

Strategies for increasing diagnostic yield of community-onset bacteraemia within the emergency department: A retrospective study.

Bloodstream infections (BSI) are associated with high mortality. Therefore, reliable methods of detection are of paramount importance. Efficient strategies to improve diagnostic yield of bacteraemia within the emergency department (ED) are needed. We conducted a retrospective analysis of all ED encounters in a high-volume, city-centre university hospital within Germany during a five-year study period from October 2013 to September 2018. A time-series analysis was conducted for all ED encounters in which blood cultures (BCs) were collected. BC detection rates and diagnostic yield of community-onset bacteraemia were compared during the study period (which included 45 months prior to the start of a new diagnostic Antibiotic Stewardship (ABS) bundle and 15 months following its implementation). BCs were obtained from 5,191 out of 66,879 ED admissions (7.8%). Bacteraemia was detected in 1,013 encounters (19.5% of encounters where BCs were obtained). The overall yield of true bacteraemia (defined as yielding clinically relevant pathogens) was 14.4%. The new ABS-related diagnostic protocol resulted in an increased number of hospitalised patients with BCs collected in the ED (18% compared to 12.3%) and a significant increase in patients with two or more BC sets taken (59% compared to 25.4%), which resulted in an improved detection rate of true bacteraemia (2.5% versus 1.8% of hospital admissions) without any decrease in diagnostic yield. This simultaneous increase in BC rates without degradation of yield was a valuable finding that indicated success of this strategy. Thus, implementation of the new diagnostic ABS bundle within the ED, which included the presence of a skilled infectious disease (ID) team focused on obtaining BCs, appeared to be a valuable tool for the accurate and timely detection of community-onset bacteraemia.

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.

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.

Integrated IT Platform for Coordination of Diagnosis, Treatment, and Aftercare of Prosthetic Joint Infections.

BACKGROUND/AIM: Prosthetic joint infections (PJI) are difficult to diagnose and treat. For a correct diagnosis, an array of information has to be processed and weighted. Successful treatment depends on the diagnosis, timing, and surgical strategy paired with treatment of the infectious agent. The complexity and interdisciplinarity needed cause difficulties concerning decision-making, the communication between disciplines, and the execution of a treatment strategy. The aim of this study was to develop a software platform to enhance the collection of information for the diagnosis of PJI, the interdisciplinary decision-making process, the communication between team members, and continuous evaluation of treatment. PATIENTS AND METHODS: In regular planning sessions with an information technology (IT) specialist, a concept for an IT solution was chosen and the tool was designed in an interdisciplinary approach. RESULTS: The tool has been used as a trial version since June 2017. It consists of 14 user interfaces with 431 items. A total of 117 patients with 118 infections have been entered and the strategy decided upon and communicated using 298 infection board documents outlining the treatment. The tool is now being used to organize the infections board agenda, schedule patient case discussions, document the relevant data and treatment plan, as well as communicate with the other teams involved in the treatment. CONCLUSION: Using the developed tool enables the infections team to work collaboratively and under division of labor on each case, rendering the work flow more efficient for each team member.

Incidence of infections due to third generation cephalosporin-resistant Enterobacteriaceae - a prospective multicentre cohort study in six German university hospitals.

Background: Infections caused by third generation cephalosporin-resistant Enterobacteriaceae (3GCREB) are an increasing healthcare problem. We aim to describe the 3GCREB infection incidence and compare it to prevalence upon admission. In addition, we aim to describe infections caused by 3GCREB, which are also carbapenem resistant (CRE). Methods: In 2014-2015, we performed prospective 3GCREB surveillance in clinically relevant patient specimens (screening specimens excluded). Infections counted as hospital-acquired (HAI) when the 3GCREB was detected after the third day following admission, otherwise as community-acquired infection (CAI). Results: Of 578,420 hospitalized patients under surveillance, 3367 had a 3GCREB infection (0.58%). We observed a similar 3GCREB CAI and HAI incidence (0.28 and 0.31 per 100 patients, respectively). The most frequent pathogen was 3GCR E. coli, in CAI and HAI (0.15 and 0.12 per 100 patients). We observed a CRE CAI incidence of 0.006 and a HAI incidence of 0.008 per 100 patients (0.014 per 1000 patient days). Conclusions: Comparing the known 3GCREB admission prevalence of the participating hospitals (9.5%) with the percentage of patients with a 3GCREB infection (0.58%), we conclude the prevalence of 3GCREB in university hospitals to be about 16 times higher than suggested when only patients with 3GCREB infections are considered. Moreover, we find the HAI and CAI incidence caused by CRE in Germany to be relatively low.

Validation of adapted daily dose definitions for hospital antibacterial drug use evaluation: a multicentre study.

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 ß-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.

Susceptibility to cephalosporin combinations and aztreonam/avibactam among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission.

As part of the multicentre Antibiotic Therapy Optimisation Study (ATHOS), minimum inhibitory concentrations (MICs) were determined for cephalosporins alone and in combination with the ß-lactamase inhibitors tazobactam, clavulanic acid and avibactam against third-generation cephalosporin-resistant Escherichia coli, Klebsiella spp. and Enterobacter spp. isolates collected in German hospitals. MIC50/90 values were 0.25-4 mg/L for cefepime/tazobactam, 0.25-2 mg/L for ceftazidime/avibactam, 0.125-0.5 mg/L for ceftaroline/avibactam, 0.5-4 mg/L for cefpodoxime/clavulanic acid and 0.25-1 mg/L for aztreonam/avibactam, depending on the underlying resistance mechanism and organism. Based on in vitro testing, ß-lactam antibiotics play an important role in the treatment of infections due to ß-lactamase-producing organisms.

Susceptibility to penicillin derivatives among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission.

As part of the multicenter Antibiotic Therapy Optimisation Study-the largest study on the prevalence of third-generation cephalosporin-resistant Enterobacteriaceae carriage upon hospital admission-minimum inhibitory concentration values were generated for ampicillin/sulbactam, amoxicillin/clavulanic acid, piperacillin/tazobactam, mecillinam, mecillinam/clavulanic acid, and temocillin against third-generation cephalosporin-resistant Escherichia coli, Klebsiella species and Enterobacter species.