Pilotprojekt einer pädiatrischen Antibiotic-Stewardship-Initiative am Dr. von Haunerschen Kinderspital – neue Wege der pädiatrischen Infektiologie

 

 Buy Article Permissions and Reprints

Zusammenfassung

Hintergrund:

Der zunehmende Anteil multiresistenter Erreger ist eines der zentralen Probleme der modernen Medizin. Antibiotic-Stewardship-(ABS-)Programme sind wichtige Hilfsmittel, um den Antibiotikaverbrauch einzuschränken und damit der Resistenzentwicklung entgegenzuwirken. Eine zunehmende Anzahl von Kinderkliniken sind dabei, ABS-Programme zu etablieren, wobei international bisher nur wenige Daten bezüglich der Implementierung und Effektivität dieser Programme im Bereich der Pädiatrie vorliegen.

Methoden:

Das Dr. von Haunersche Kinderspital ist eine Kinderklinik der Maximalversorgung mit allen notwendigen Fachabteilungen. Ein ABS-Programm wurde etabliert, wobei die Kernmaßnahmen der Inneren Medizin übernommen wurden. Die spezifischen antimikrobiellen Substanzen sowie die entsprechenden klinischen Endpunkte wurden an die Situation der Pädiatrie angepasst. Kernmaßnahmen waren 1. ein „pro­spektives Audit mit Feedback – nach Verordnung“ sowie 2. eine „Restriktion und Freigabe – vor Verordnung“. Das ABS-Team besteht aus einem pädiatrischen Infektiologen, einer Assistentin in der Weiterbildung sowie einer Apothekerin mit infektiologischer Erfahrung.

Resultate:

Durch die Implementierung eines pädiatrischen ABS-Programms konnte der Verbrauch antimikrobieller Substanzen in unserer Klinik signifikant gesenkt werden. Die erwarteten Kosteneinsparungen werden ca. 330 000 € pro Jahr betragen; zudem konnte der Verbrauch von Breitspektrumantibiotika, Glykopeptiden und Antimykotika signifikant reduziert werden.

Zusammenfassung:

Antibiotic-Stewardship-(ABS-)Programme können effektive Maßnahmen sein, um den Antibiotikaverbrauch einzuschränken. Nationale Guidelines sollten für die Pädiatrie in Deutschland von den Fachgesellschaften erarbeitet werden.

Abstract

Background:

The steady increase in antimicrobial resistance is of growing concern in healthcare. Antibiotic Stewardship [ABS] Strategies are important tools to control antibiotic use and ­prevent antimicrobial resistance. An increasing number of institutions are developing ABS initiatives also in pediatrics. However, few data are available assessing the implementation and efficiency of these pediatric ABS programs.

Methods:

At the Dr. von Hauner Children’s Hospital, Ludwig-Maximilian University, a ter­tiary care pediatric reference center, a pediatric ABS Team has been implemented. Key structural elements were the same as for adult patients, but antimicrobials agents selected for monitoring and appropriate clinical endpoints are different in pediatrics.

Key features were: 1. prospective-audit with feedback and formulary restriction and 2. pre-authorization (also referred to as prior approval). The ABS team consisted of one pediatric infectious disease specialist, one clinical fellow in pediatric infectious diseases, and one clinical pharmacist with training in infectious diseases.

Results:

With the implementation of a pedia­tric ABS strategy we could significantly influence antimicrobial consumption in our hospital. Cost-savings are estimated to be above 330 000 € per year, and concomitantly the use of broad-spectrum antibiotics and antifungal compounds was significantly reduced.

Conclusion:

Antibiotic Stewardship [ABS] Strategies may be an effective tool to control antibiotic use in the setting of a large tertiary pediatric teaching hospital. A national guideline for ABS initiatives may help to further improve rational use of antibiotics in the hospital setting.

• Literatur

• 1 Babor F, Schuster F, Mackenzie C et al. Invasive aspergillosis in pediatric oncology patients: a rare event with poor prognosis – case analysis to plan better targeted prophylactic or therapeutic measurement. Klin Padiatr 2012; 224: 160-165
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Calil R, Marba ST, Von Nowakonski A et al. Reduction in colonization and nosocomial infection by multiresistant bacteria in a neonatal unit after institution of educational measures and restriction in the use of cephalosporins. Am J Infect Control 2001; 29: 133-138
  CrossrefPubMedGoogle Scholar
• 3 Cohen ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science 1992; 257: 1050-1055
  CrossrefPubMedGoogle Scholar
• 4 Coleman RW, Rodondi LC, Kaubisch S et al. Cost-effectiveness of prospective and continuous parenteral antibiotic control: experience at the Palo Alto Veterans Affairs Medical Center from 1987 to 1989. Am J Med 1991; 90: 439-444
  CrossrefPubMedGoogle Scholar
• 5 Cooper MA, Shlaes D. Fix the antibiotics pipeline. Nature 2011; 472: 32
  CrossrefPubMedGoogle Scholar
• 6 Davey P, Brown E, Fenelon L et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database System Rev 2005; CD003543
  PubMedGoogle Scholar
• 7 Dellit TH, Owens RC, McGowan JE et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159-177
  CrossrefPubMedGoogle Scholar
• 8 Enoch DA, Butler MJ, Pai S et al. Clostridium difficile in children: colonisation and disease. J Infect 2011; 63: 105-113
  CrossrefPubMedGoogle Scholar
• 9 Frank MO, Batteiger BE, Sorensen SJ et al. Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clin Perform Qual Health Care 1997; 5: 180-188
  PubMedGoogle Scholar
• 10 Herigon JC, Hersh AL, Gerber JS et al. Antibiotic management of Staphylococcus aureus infections in US children’s hospitals, 1999–2008. Pediatrics 2010; 125: e1294-e1300
  CrossrefPubMedGoogle Scholar
• 11 Hersh AL, Beekmann SE, Polgreen PM et al. Antimicrobial stewardship programs in pediatrics. Infect Control Hospit Epidemol 2009; 30: 1211-1217
  PubMedGoogle Scholar
• 12 Krenn T, Fleischhack G, Moser O et al. Bloodstream infections in paediatric cancer patients. Prospective comparative study in 2 university hospitals. Klin Padiatr 2011; 223: 335-340
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Lehrnbecher T, Groll AH. Micafungin: a brief review of pharmacology, safety, and antifungal efficacy in pediatric patients. Pediatr Blood Cancer 2010; 55: 229-232
  CrossrefPubMedGoogle Scholar
• 14 Leistner R, Piening B, Gastmeier P et al. Nosocomial infections in very low birthweight infants in Germany: current data from the National Surveillance System NEO-KISS. Klin Padiatr 2013; 225: 75-80
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Newland JG, Hersh AL. Purpose and design of antimicrobial stewardship programs in pediatrics. Pediatr Infect Dis J 2010; 29: 862-863
  PubMedGoogle Scholar
• 16 Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol 2012; 36: 431-436
  CrossrefPubMedGoogle Scholar
• 17 Porta A, Hsia Y, Doerholt K et al. Comparing neonatal and paediatric antibiotic prescribing between hospitals: a new algorithm to help international benchmarking. J Antimicrob Chemother 2012; 67: 1278-1286
  CrossrefPubMedGoogle Scholar
• 18 Rahal JJ, Urban C, Horn D et al. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998; 280: 1233-1237
  CrossrefPubMedGoogle Scholar
• 19 Simon A, Kaiser P, Berner R et al. The Paed IC project – Antibiotic stewardship and hospital hygiene to prevent infection with resistant pathogens. Klin Padiatr 2013; 225: 93-95
  PubMedGoogle Scholar
• 20 Spellberg B, Powers JH, Brass EP et al. Trends in antimicrobial drug development: implications for the future. Clin Infect Dis 2004; 38: 1279-1286
  CrossrefPubMedGoogle Scholar
• 21 Standiford HC, Chan S, Tripoli M et al. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol 2012; 33: 338-345
  CrossrefPubMedGoogle Scholar
• 22 Tamma PD, Cosgrove SE. Antimicrobial stewardship. Infect Dis Clin North Am 2011; 25: 245-260
  CrossrefPubMedGoogle Scholar
• 23 Tamma PD, Jenh AM, Milstone AM. Prolonged β-lactam infusion for Gram-negative Infections. Pediatric Infect Dis J 2011; 30: 336-337
  CrossrefPubMedGoogle Scholar
• 24 Tamma PD, Putcha N, Suh YD et al. Does prolonged β-lactam infu­sions improve clinical outcomes compared to intermittent infusions? A meta-analysis and systematic review of randomized, controlled trials. BMC Infect Dis 2011; 11: 181
  CrossrefPubMedGoogle Scholar
• 25 Tragiannidis A, Dokos C, Lehrnbecher T et al. Antifungal chemoprophylaxis in children and adolescents with haematological malignancies and following allogeneic haematopoietic stem cell transplantation: review of the literature and options for clinical practice. Drugs 2012; 72: 685-704
  CrossrefPubMedGoogle Scholar
• 26 Valcourt K, Norozian F, Lee H et al. Drug use density in critically ill children and newborns: analysis of various methodologies. Pediatr Critic Care Med 2009; 10: 495-499
  PubMedGoogle Scholar