Multiresistente Erreger – Antibiotic Stewardship

Die adäquate Behandlung von Infektionen ist eine wichtige Aufgabe in der Intensivmedizin, die für das Überleben der Patienten oft ausschlaggebend ist. Typischerweise finden sich auf Intensivstationen daher in der Regel hohe Anwendungsdichten von Antibiotika. In Anbetracht einer besorgniserregenden Resistenzentwicklung ist es dringend geboten, den Einsatz von Antiinfektiva zu optimieren, um den Resistenzdruck zu verringern. AntibioticStewardship versucht, das Infektionsmanagement durch interdisziplinäre Zusammenarbeit auf mehreren Ebenen zu verbessern. Übergeordnetes Ziel von ABS ist eine Verlangsamung der Resistenzentwicklung zur Schonung der wertvollen Ressource „Antibiotikum“. Insbesondere die Intensivstation ist ein wichtiges Betätigungsfeld für AntibioticStewardship. Der vorliegende Artikel diskutiert praktische Aspekte sowie die verfügbare Evidenz für AntibioticStewardship.

The adequate management of infections is an important task in critical care medicine which has an effect on patient outcome. As a result, the prevalence of antiinfective therapy is high in intensive care units. In the face of an unsettling development of worldwide microbial resistance, an optimization and reduction of antiinfective therapy is necessary. Antibiotic stewardship tries to improve antiinfective therapy with an interdisciplinary approach. One overall objective of antibiotic stewardship is the reduction of resistance induction in order to preserve the therapeutic efficiency of antibiotics. Intensive care units are important fields of action for antibiotic stewardship interventions. This article reviews available evidence and some practical aspects for antibiotic stewardship.

Kernaussagen

• Die weltweite Resistenzentwicklung erfordert eine Einschränkung des Antibiotikaeinsatzes, um den Resistenzdruck zu verringern.

• Antibiotic Stewardship bietet ein evidenzbasiertes Maßnahmenbündel zur Optimierung des Antibiotikaeinsatzes, das auch bei kritisch kranken Patienten auf der Intensivstation angewendet werden kann.

• Nachteilige Auswirkungen eines zurückhaltenderen Antibiotikaeinsatzes auf das Patienten-Outcome konnten bisher nicht nachgewiesen werden.

• Interventionen im Sinne von ABS stützen sich auf eine krankenhausweite Infrastruktur, welche die Grundlagen für ein interdisziplinär unterstütztes Infektionsmanagement schaffen.

• Zu den Strategien von Antibiotic Stewardship gehören die resistogrammgerechte Deeskalation, die Verkürzung der Therapiedauer sowie der qualifizierte Einsatz der mikrobiologischen Diagnostik.

• Die Therapie lebensbedrohlicher Infektionen ist eine intensivmedizinische Kernkompetenz. Die Kenntnisse des Intensivmediziners in der Infektionsbehandlung eignen sich in besonderer Weise zur Einbettung in Antibiotic-Stewardship-Programme.

Schlüsselwörter:

Antibiotic Stewardship - Intensivmedizin - Resistenzentwicklung

Keywords:

antibiotic stewardship - intensive care medicine - antibiotic resistance

• Literatur

• 1 Gastmeier P, Schroder C, Behnke M et al. Dramatic increase in vancomycin-resistant enterococci in Germany. The Journal of antimicrobial chemotherapy 2014; 69: 1660-1664
• 2 Maechler F, Pena Diaz LA, Schroder C et al. Prevalence of carbapenem-resistant organisms and other Gram-negative MDRO in German ICUs: first results from the national nosocomial infection surveillance system (KISS). Infection 2015; 43: 163-168
• 3 Meyer E, Gastmeier P, Deja M et al. Antibiotic consumption and resistance: data from Europe and Germany. Int J Med Microbiol 2013; 303: 388-395
• 4 Meyer E, Schwab F, Schroeren-Boersch B et al. Dramatic increase of third-generation cephalosporin-resistant E. coli in German intensive care units: secular trends in antibiotic drug use and bacterial resistance, 2001 to 2008. Crit Care 2010; 14
• 5 Boucher HW, Talbot GH, Benjamin Jr. DK et al. 10 x '20 Progress--development of new drugs active against gram-negative bacilli: an update from the Infectious Diseases Society of America. Clin Infect Dis 2013; 56: 1685-1694
• 6 Bartlett JG, Gilbert DN, Spellberg B. Seven ways to preserve the miracle of antibiotics. Clin Infect Dis 2013; 56: 1445-1450
• 7 Roberts JA, Abdul-Aziz MH, Lipman J et al. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. Lancet Infect Dis 2014; 14: 498-509
• 8 Dellit TH, Owens RC, McGowan Jr 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
• 9 S3-Leitlinie Strategien zur Sicherung rationaler Antibiotika-Anwendung im Krankenhaus. AWMF-Registernummer 092/001. 2013
• 10 Dalhoff K, Abele-Horn M, Andreas S et al. Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie. Pneumologie 2012; 66: 707-765
• 11 Dimopoulos G, Poulakou G, Pneumatikos IA et al. Short- vs long-duration antibiotic regimens for ventilator-associated pneumonia: a systematic review and meta-analysis. Chest 2013; 144: 1759-1767
• 12 Sawyer RG, Claridge JA, Nathens AB et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med 2015; 372: 1996-2005
• 13 Prkno A, Wacker C, Brunkhorst FM et al. Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock – a systematic review and meta-analysis. Crit Care 2013; 17
• 14 De Waele JJ, Lipman J, Akova M et al. Risk factors for target non-attainment during empirical treatment with beta-lactam antibiotics in critically ill patients. Intensive Care Med 2014; 40: 1340-1351
• 15 Taccone FS, Laterre PF, Dugernier T et al. Insufficient beta-lactam concentrations in the early phase of severe sepsis and septic shock. Critical care 2010; 14
• 16 Davey P, Brown E, Charani E et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. The Cochrane database of systematic reviews CD 003543 2013; 4
• 17 Borde JP, Kaier K, Steib-Bauert M et al. Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center. BMC infectious diseases 2014; 14: 201-201
• 18 Lafaurie M, Porcher R, Donay JL et al. Reduction of fluoroquinolone use is associated with a decrease in methicillin-resistant Staphylococcus aureus and fluoroquinolone-resistant Pseudomonas aeruginosa isolation rates: a 10 year study. J Antimicrob Chemother 2012; 67: 1010-1015
• 19 Talpaert MJ, Gopal Rao G, Cooper BS et al. Impact of guidelines and enhanced antibiotic stewardship on reducing broad-spectrum antibiotic usage and its effect on incidence of Clostridium difficile infection. The Journal of antimicrobial chemotherapy 2011; 66: 2168-2174
• 20 Wagner B, Filice GA, Drekonja D et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America 2014; 35: 1209-1228
• 21 Rimawi RH, Mazer MA, Siraj DS et al. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Critical care medicine 2013; 41: 2099-2107
• 22 Lewis GJ, Fang X, Gooch M et al. Decreased resistance of Pseudomonas aeruginosa with restriction of ciprofloxacin in a large teaching hospital's intensive care and intermediate care units. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America 2012; 33: 368-373
• 23 Kaki R, Elligsen M, Walker S et al. Impact of antimicrobial stewardship in critical care: a systematic review. The Journal of antimicrobial chemotherapy 2011; 66: 1223-1230
• 24 Katsios CM, Burry L, Nelson S et al. An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients. Critical care 2012; 16
• 25 Hohn A, Heising B, Hertel S et al. Antibiotic consumption after implementation of a procalcitonin-guided antimicrobial stewardship programme in surgical patients admitted to an intensive care unit: a retrospective before-and-after analysis. Infection 2015; 43: 405-412
• 26 Elligsen M, Walker SA, Pinto R et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012; 33: 354-361
• 27 Eliakim-Raz N, Yahav D, Paul M et al. Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection – 7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2013; 68: 2183-2191
• 28 Havey TC, Fowler RA, Daneman N. Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis. Crit Care 2011; 15
• 29 Rubinstein E, Keynan Y. Short-course therapy for severe infections. International journal of antimicrobial agents 2013; 42: 22-24
• 30 Timsit JF, Soubirou JF, Voiriot G et al. Treatment of bloodstream infections in ICUs. BMC infectious diseases 2014; 14: 489-489
• 31 De Waele JJ, Bassetti M, Martin-Loeches I. Impact of de-escalation on ICU patients' prognosis. Intensive care medicine 2014; 40: 1583-1585
• 32 Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive care medicine 2014; 40: 32-40
• 33 Gonzalez L, Cravoisy A, Barraud D et al. Factors influencing the implementation of antibiotic de-escalation and impact of this strategy in critically ill patients. Critical care 2013; 17
• 34 Khasawneh FA, Karim A, Mahmood T et al. Antibiotic de-escalation in bacteremic urinary tract infections: potential opportunities and effect on outcome. Infection 2014; 42: 829-834
• 35 Leone M, Bechis C, Baumstarck K et al. De-escalation versus continuation of empirical antimicrobial treatment in severe sepsis: a multicenter non-blinded randomized noninferiority trial. Intensive Care Med 2014; 40: 1399-1408
• 36 Mokart D, Slehofer G, Lambert J et al. De-escalation of antimicrobial treatment in neutropenic patients with severe sepsis: results from an observational study. Intensive Care Med 2014; 40: 41-49
• 37 Dellinger RP, Levy MM, Rhodes A et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine 2013; 39: 165-228
• 38 Wong G, Sime FB, Lipman J et al. How do we use therapeutic drug monitoring to improve outcomes from severe infections in critically ill patients?. BMC infectious diseases 2014; 14: 288-288