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Dtsch Med Wochenschr 2020; 145(06): 383-392
DOI: 10.1055/a-0993-1164
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Antibiotic Stewardship bei ambulant erworbener Pneumonie

Antibiotic Stewardship in Community-Acquired Pneumonia
Fabian Leo
,
Miriam Songa Stegemann
,
Florian Maurer
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Abstract

Antibiotic stewardship (ABS) denotes structured and continuous measures to improve the quality of prescribing anti-infectives. The aim is to achieve optimal treatment results and to minimize undesirable effects, especially the emergence of antibiotic resistance. This review summarizes the most important ABS principles based on recently published studies with implications for the management of community-acquired pneumonia. Local guidelines, education and training and “prospective audit and feedback” are established strategies to improve the management of patients with community-acquired pneumonia. However, the implementation of ABS programs requires trained personnel and may be impeded by limited structural and time resources. Hence, electronic health records and computer-based interventions are useful support for ABS programs and offer potential to facilitate ABS in inpatient and outpatient care. PCR-based rapid diagnostic tests, PCT-guided algorithms and penicillin allergy testing are suitable procedures to supplement ABS programs.

Antibiotic Stewardship (ABS) bezeichnet strukturierte und kontinuierliche Maßnahmen zur Verbesserung der Verordnungsqualität von Antiinfektiva. Ziel ist, dadurch optimale Behandlungsergebnisse zu erreichen und unerwünschte Wirkungen, v. a. Antibiotikaresistenzen, zu minimieren. Anhand aktueller Studien mit ABS-Implikationen für das Management der ambulant erworbenen Pneumonie fasst diese Übersicht die wichtigsten ABS-Prinzipien zusammen.

Schlüsselwörter

Verordnungsverhalten - Procalcitonin-gesteuerte Algorithmen - elektronische Patientenakte - strukturierte Fortbildung - Penicillinallergie-Testung

Key words

prescribing behavior - PCR-controlled algorithms - electronic patient record - structured training - penicillin allergy testing


Publication History

Article published online:
19 March 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 

  • Literatur

  • 1 Jenkins TC, Stella SA, Cervantes L. et al Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations. Infection 2013; 41: 135-144 . doi:10.1007/s15010-012-0362-2
    CrossrefPubMedGoogle Scholar
  • 2 Nussenblatt V, Avdic E, Cosgrove S. What is the role of antimicrobial stewardship in improving outcomes of patients with CAP?. Infect Dis Clin North Am 2013; 27: 211-228 . doi:10.1016/j.idc.2012.11.008
    CrossrefPubMedGoogle Scholar
  • 3 Viasus D, Vecino-Moreno M, De La Hoz JM. et al Antibiotic stewardship in community-acquired pneumonia. Expert Rev Anti Infect Ther 2017; 15: 351-359 . doi:10.1080/14787210.2017.1274232
    CrossrefPubMedGoogle Scholar
  • 4 De With K, Wilke K, Kern WV. et al S3-Leitlinie: Strategien zur Sicherung rationaler Antibiotika-Anwendung im Krankenhaus. AWMF-Registriernummer 092/001 – update 2018/2019..
    PubMedGoogle Scholar
  • 5 Schuts EC, Hulscher M, Mouton JW. et al Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016; 16: 847-856 . doi:10.1016/s1473-3099(16)00065-7
    CrossrefPubMedGoogle Scholar
  • 6 Davey P, Marwick CA, Scott CL. et al Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2: Cd003543 . doi:10.1002/14651858.CD003543.pub4
    PubMedGoogle Scholar
  • 7 Cusini A, Herren D, Butikofer L. et al Intra-hospital differences in antibiotic use correlate with antimicrobial resistance rate in Escherichia coli and Klebsiella pneumoniae: a retrospective observational study. Antimicrob Resist Infect Control 2018; 7: 89 . doi:10.1186/s13756-018-0387-0
    CrossrefPubMedGoogle Scholar
  • 8 Livorsi DJ, Reisinger HS, Stenehjem E. Adapting Antibiotic Stewardship to the Community Hospital. JAMA network open 2019; 2: e199356 . doi:10.1001/jamanetworkopen.2019.9356
    CrossrefPubMedGoogle Scholar
  • 9 Cole KA, Rivard KR, Dumkow LE. Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies. Curr Infect Dis Rep 2019; 21: 33 . doi:10.1007/s11908-019-0689-2
    CrossrefPubMedGoogle Scholar
  • 10 Ewig S, Höffken G, Kern WV. et al S3-Leitlinie: Behandlung von erwachsenen Patienten mit ambulant erorbener Pneumonie – update 2016. Pneumologie 2016; 70: 151-200
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Marquet K, Liesenborgs A, Bergs J. et al Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis. Crit Care 2015; 19: 63 . doi:10.1186/s13054-015-0795-y
    CrossrefPubMedGoogle Scholar
  • 12 Havey TC, Hull MW, Romney MG. et al Retrospective cohort study of inappropriate piperacillin-tazobactam use for lower respiratory tract and skin and soft tissue infections: Opportunities for antimicrobial stewardship. Am Journal Infect Control 2015; 43: 946-950 . doi:10.1016/j.ajic.2015.05.020
    PubMedGoogle Scholar
  • 13 Haas MK, Dalton K, Knepper BC. et al Effects of a Syndrome-Specific Antibiotic Stewardship Intervention for Inpatient Community-Acquired Pneumonia. Open forum infectious diseases 2016; 3: ofw186 . doi:10.1093/ofid/ofw186
    CrossrefPubMedGoogle Scholar
  • 14 Konig R, Cao X, Oswald M. et al Macrolide combination therapy for hospitalised CAP patients? An individualised approach supported by machine learning. Eur Respir J 2019; DOI: 10.1183/13993003.00824-2019.
    CrossrefPubMedGoogle Scholar
  • 15 Farkas A, Sassine J, Mathew JP. et al Outcomes associated with the use of a revised risk assessment strategy to predict antibiotic resistance in community-onset pneumonia: a stewardship perspective. J Antimicrob Chemother 2018; 73: 2555-2558 . doi:10.1093/jac/dky202
    CrossrefPubMedGoogle Scholar
  • 16 Tang SY, Zhang SW, Wu JD. et al Comparison of mono- and combination antibiotic therapy for the treatment of Pseudomonas aeruginosa bacteraemia: A cumulative meta-analysis of cohort studies. Exp Ther Med 2018; 15: 2418-2428 . doi:10.3892/etm.2018.5727
    PubMedGoogle Scholar
  • 17 Parente DM, Cunha CB, Mylonakis E. et al The Clinical Utility of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening to Rule Out MRSA Pneumonia: A Diagnostic Meta-analysis With Antimicrobial Stewardship Implications. Clin Infect Dis 2018; 67: 1-7 . doi:10.1093/cid/ciy024
    CrossrefPubMedGoogle Scholar
  • 18 Burk M, El-Kersh K, Saad M. et al Viral infection in community-acquired pneumonia: a systematic review and meta-analysis. Eur Resp Rev 2016; 25: 178-188 . doi:10.1183/16000617.0076-2015
    PubMedGoogle Scholar
  • 19 Andrews D, Chetty Y, Cooper BS. et al Multiplex PCR point of care testing versus routine, laboratory-based testing in the treatment of adults with respiratory tract infections: a quasi-randomised study assessing impact on length of stay and antimicrobial use. BMC Infect Dis 2017; 17: 671 . doi:10.1186/s12879-017-2784-z
    CrossrefPubMedGoogle Scholar
  • 20 Brendish NJ, Malachira AK, Armstrong L. et al Routine molecular point-of-care testing for respiratory viruses in adults presenting to hospital with acute respiratory illness (ResPOC): a pragmatic, open-label, randomised controlled trial. Lancet Respir Med 2017; 5: 401-411 . doi:10.1016/s2213-2600(17)30120-0
    CrossrefPubMedGoogle Scholar
  • 21 Saarela E, Tapiainen T, Kauppila J. et al Impact of multiplex respiratory virus testing on antimicrobial consumption in adults in acute care: a randomized clinical trial. Clin Microbiol Infect 2019; DOI: 10.1016/j.cmi.2019.09.013.
    CrossrefPubMedGoogle Scholar
  • 22 Brendish NJ, Malachira AK, Beard KR. et al Impact of turnaround time on outcome with point-of-care testing for respiratory viruses: a post hoc analysis from a randomised controlled trial. Eur Respir J 2018; 52 DOI: 10.1183/13993003.00555-2018.
    CrossrefPubMedGoogle Scholar
  • 23 Lowe CF, Payne M, Puddicombe D. et al Antimicrobial stewardship for hospitalized patients with viral respiratory tract infections. Am J Infect Control 2017; 45: 872-875 . doi:10.1016/j.ajic.2017.03.025
    CrossrefPubMedGoogle Scholar
  • 24 Schuetz P, Bolliger R, Merker M. et al Procalcitonin-guided antibiotic therapy algorithms for different types of acute respiratory infections based on previous trials. Expert Rev Anti Infect Ther 2018; 16: 555-564 . doi:10.1080/14787210.2018.1496331
    CrossrefPubMedGoogle Scholar
  • 25 Kamat IS, Ramachandran V, Eswaran H. et al Procalcitonin to distinguish viral from bacterial pneumonia: A systematic review and meta-analysis. Clin Infect Dis 2019; DOI: 10.1093/cid/ciz545.
    CrossrefPubMedGoogle Scholar
  • 26 Blasi F, Garau J, Medina J. et al Current management of patients hospitalized with community-acquired pneumonia across Europe: outcomes from REACH. Respir Res 2013; 14: 44 . doi:10.1186/1465-9921-14-44
    CrossrefPubMedGoogle Scholar
  • 27 Johansson N, Kalin M, Tiveljung-Lindell A. et al Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clin Infect Dis 2010; 50: 202-209 . doi:10.1086/648678
    CrossrefPubMedGoogle Scholar
  • 28 Wittermans E, Vestjens SMT, Bos WJW. et al The extent of microbiological testing is associated with alteration of antibiotic therapy in adults with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2019; 38: 1359-1366 . doi:10.1007/s10096-019-03561-8
    PubMedGoogle Scholar
  • 29 Schimmel JJ, Haessler S, Imrey P. et al Pneumococcal urinary antigen testing in US hospitals: A missed opportunity for antimicrobial stewardship. Clin Infect Dis 2019; DOI: 10.1093/cid/ciz983.
    CrossrefPubMedGoogle Scholar
  • 30 Andreo F, Ruiz-Manzano J, Prat C. et al Utility of pneumococcal urinary antigen detection in diagnosing exacerbations in COPD patients [published correction appears in Respir Med. 2010 Jun;104(6):923]. Respir Med 2010; 104(3): 397-403 . doi:10.1016/j.rmed.2009.10.013
    CrossrefPubMedGoogle Scholar
  • 31 Athanassa Z, Makris G, Dimopoulos G. et al Early switch to oral treatment in patients with moderate to severe community-acquired pneumonia: a meta-analysis. Drugs 2008; 68: 2469-2481 . doi:10.2165/0003495-200868170-00005
    CrossrefPubMedGoogle Scholar
  • 32 Sallach-Ruma R, Phan C, Sankaranarayanan J. Evaluation of outcomes of intravenous to oral antimicrobial conversion initiatives: a literature review. Expert Rev Clin Pharmacol 2013; 6: 703-729 . doi:10.1586/17512433.2013.844647
    CrossrefPubMedGoogle Scholar
  • 33 Hanretty AM, Gallagher JC. Shortened Courses of Antibiotics for Bacterial Infections: A Systematic Review of Randomized Controlled Trials. Pharmacotherapy 2018; 38: 674-687 . doi:10.1002/phar.2118
    CrossrefPubMedGoogle Scholar
  • 34 Uranga A, Espana PP, Bilbao A. et al Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Internal Med 2016; 176: 1257-1265 . doi:10.1001/jamainternmed.2016.3633
    PubMedGoogle Scholar
  • 35 El Moussaoui R, de Borgie CA, van den Broek P. et al Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ Clin Res 2006; 332: 1355 . doi:10.1136/bmj.332.7554.1355
    CrossrefPubMedGoogle Scholar
  • 36 Yi SH, Hatfield KM, Baggs J. et al Duration of Antibiotic Use Among Adults With Uncomplicated Community-Acquired Pneumonia Requiring Hospitalization in the United States. Clin Infect Dis 2018; 66: 1333-1341 . doi:10.1093/cid/cix986
    CrossrefPubMedGoogle Scholar
  • 37 Avdic E, Cushinotto LA, Hughes AH. et al Impact of an antimicrobial stewardship intervention on shortening the duration of therapy for community-acquired pneumonia. Clin Infect Dis 2012; 54: 1581-1587 . doi:10.1093/cid/cis242
    CrossrefPubMedGoogle Scholar
  • 38 Foolad F, Huang AM, Nguyen CT. et al A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumonia. J Antimicrob Chemother 2018; 73: 1402-1407 . doi:10.1093/jac/dky021
    CrossrefPubMedGoogle Scholar
  • 39 Schuetz P, Wirz Y, Sager R. et al Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2017; 10: Cd007498 . doi:10.1002/14651858.CD007498.pub3
    PubMedGoogle Scholar
  • 40 Schuetz P, Beishuizen A, Broyles M. et al Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimized clinical use. Clin Chem Lab Med 2019; 57: 1308-1318 . doi:10.1515/cclm-2018-1181
    CrossrefPubMedGoogle Scholar
  • 41 Walsh TL, DiSilvio BE, Hammer C. et al Impact of Procalcitonin Guidance with an Educational Program on Management of Adults Hospitalized with Pneumonia. Am J Med 2018; 131: 201 . doi:10.1016/j.amjmed.2017.08.039
    CrossrefPubMedGoogle Scholar
  • 42 Trubiano JA, Thursky KA, Stewardson AJ. et al Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation. Clin Infect Dis 2017; 65: 166-174 . doi:10.1093/cid/cix244
    CrossrefPubMedGoogle Scholar
  • 43 Shenoy ES, Macy E, Rowe T. et al Evaluation and Management of Penicillin Allergy: A Review. Jama 2019; 321: 188-199 . doi:10.1001/jama.2018.19283
    CrossrefPubMedGoogle Scholar
  • 44 Sacco KA, Bates A, Brigham TJ. et al Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis. Allergy 2017; 72: 1288-1296 . doi:10.1111/all.13168
    CrossrefPubMedGoogle Scholar
  • 45 Justo JA, Kufel WD, Avery L. et al Penicillin Allergy Skin Testing in the Inpatient Setting. Pharmacy 2019; 7 DOI: 10.3390/pharmacy7030120.
    CrossrefPubMedGoogle Scholar
  • 46 Kufel WD, Justo JA, Bookstaver PB. et al Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting. Pharmacy 2019; 7 DOI: 10.3390/pharmacy7030136.
    CrossrefPubMedGoogle Scholar
  • 47 Berrevoets MAH, Pot J, Houterman AE. et al An electronic trigger tool to optimise intravenous to oral antibiotic switch: a controlled, interrupted time series study. Antimicrob Resist Infect Control 2017; 6: 81 . doi:10.1186/s13756-017-0239-3
    CrossrefPubMedGoogle Scholar
  • 48 Moradi T, Bennett N, Shemanski S. et al Use of procalcitonin and a respiratory polymerase chain reaction panel to reduce antibiotic use via an EMR alert. Clin Infect Dis 2019; DOI: 10.1093/cid/ciz1042.
    CrossrefPubMedGoogle Scholar
  • 49 Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Curr Infect Dis Rep 2019; 21: 29 . doi:10.1007/s11908-019-0683-8
    CrossrefPubMedGoogle Scholar
  • 50 Wattengel BA, Sellick JA, Skelly MK. et al Outpatient Antimicrobial Stewardship: Targets for Community-acquired Pneumonia. Clin Thera 2019; 41: 466-476 . doi:10.1016/j.clinthera.2019.01.007
    PubMedGoogle Scholar
  • 51 Gulliford MC, Prevost AT, Charlton J. et al Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ Clin Res 2019; 364: l236 . doi:10.1136/bmj.l236
    PubMedGoogle Scholar
  • 52 Mikolajewska A, Witzenrath M. Ambulant erworbene Pneumonie bei Erwachsenen. Dtsch Med Wochenschr 2020; 145: 1-12 . doi:10.1055/a-0993-0874
    Article in Thieme ConnectPubMedGoogle Scholar