kern - antibiotic stewardship programmes & antibiotic...
TRANSCRIPT
![Page 1: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/1.jpg)
Winfried V. KernAbteilung InfektiologieUniversitätsklinikum Freiburg
«Antibiotic Stewardship»programmes & antibiotic resistance
www.if-freiburg.de
![Page 2: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/2.jpg)
� Definition� Healthcare quality & patient safety aspects� Research aspects
Agenda
![Page 3: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/3.jpg)
…ongoing effort by a healthcare institution to optimize antimicrobial use among hospitalized patients to ...
- improve patient outcomes- ensure cost-effective therapy, and - reduce adverse sequelae of antimicrobial use (including antimicrobial resistance).
MacDougall & Polk CMR 2005
What is „Antibiotic Stewardship“?
![Page 4: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/4.jpg)
…ongoing effort by a healthcare institution to optimize antimicrobial use among hospitalized patients to ...
- improve patient outcomes- ensure cost-effective therapy, and - reduce adverse sequelae of antimicrobial use (including antimicrobial resistance).
MacDougall & Polk CMR 2005
What is „Antibiotic Stewardship“?
system
![Page 5: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/5.jpg)
Dennis Maki 1998
“The development of new antibiotics without having mechanisms to ensure their appropriate use is much like supplying your alcoholic patients with a finer brandy.“
![Page 6: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/6.jpg)
![Page 7: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/7.jpg)
… assumptions
� prescribing is (often) suboptimal
![Page 8: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/8.jpg)
… assumptions
� prescribing is (often) suboptimal (and often too excessive)
![Page 9: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/9.jpg)
… assumptions
� prescribing is (often) suboptimal (and often too excessive) and induces resistance
![Page 10: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/10.jpg)
… assumptions
� prescribing is (often) suboptimal (and often too excessive) and reduces resistance
� “optimized” (and/or reduced) prescribing improves outcomes and can minimize or even reverse antimicrobial resistance
![Page 11: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/11.jpg)
Bratzler et al Arch Surg 2005
![Page 12: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/12.jpg)
Ansari et al CID 2009
*20 hospitals, 11,571 patients, 30% with antibiotics
… European data (ESAC-PPS 2006*)
![Page 13: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/13.jpg)
ESAC investigators 2011
*50 hospitals, 28 countries
… European data (ESAC-PPS 2008*)
![Page 14: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/14.jpg)
Zarb et al Eurosurv 2012
*66 hospitals, 23 countries
… European data (ESAC-PPS 2010*)
… surgical prophylaxis exceeded one day in 61% of cases
![Page 15: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/15.jpg)
• 9% n=776 Turkey 2009• 11% n=107 France 2003• 15% n=104 France 2009• 20% n=1079 UK 2007• 20% n=2306 Israel 2001• 22-27% n=539 Switzerland 2007• 24% n=166 Spain 2003• 29% n=493 Croatia, 2005• 17-37%, n=1270 Switzerland 2010• 30% n=129 USA 2003• 31% n=177 Italy 2008• 35% n=105 France 2003• 36% n=281 Turkey 2003• 37% n=938 Netherlands 2007• 43% n=189 Spain 2003• 44% n=378 Turkey 2005• 47% n=223 Turkey 2005• 47% n=173 Switzerland 2004• 54% n=156 Turkey 2000• 64% n=438 Croatia 2007• 66% n=122 France 2007
Burden of hospital-wide „inadequate“ antibiotic prescriptions
![Page 16: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/16.jpg)
… assumptions
� prescribing is (often) suboptimal (and often too excessive) and induces resistance
![Page 17: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/17.jpg)
This is where a large graphic or chart can go.
Antibiotikaverbrauch (definierte Tagesdosen [DDD]/1000 Tage)
403020100
% P
enic
illin
-nic
htem
pfin
dlic
he
Pne
umok
okke
n
60
50
40
30
20
10
0
USA
UK
Sweden
Spain
Portugal
NorwayNetherlands
LuxemburgItaly
Ireland
Iceland
Greece
Germany
France
FinlandDenmark
Canada
BelgiumAustria
Australia
Alb
rich
et a
l. E
mer
g In
fect
Dis
2004
Taiwan
![Page 18: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/18.jpg)
![Page 19: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/19.jpg)
70%
75%
80%
85%
90%
95%
100%
1994 1995 1996 1997 1998
Gra
m-n
egat
ive
baci
lliP
erce
nt im
ipen
em-s
usce
ptib
le
0
10
20
30
40
50
60Im
ipenemD
DD
per 1000 pt days
Group -level dataGroup -level data
Clin Infect Dis 2001; 33: 1462-68
![Page 20: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/20.jpg)
0.10
0.20
0 20 40 60 800.00
0.30
Days in hospital
No imipenem
Imipenem
Individual-level dataP
roba
bilit
y of
res
ista
nce
Adjusted hazard ratio: 5.7 (95% CI, 3.7 - 8.7)
Clin Infect Dis 2001; 33: 1462-68
![Page 21: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/21.jpg)
Limitations
� to consider
� the limited evidence provided by purelyobservational (vs interventional studies)
� individual-level or group-level analysis(ecological bias)
![Page 22: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/22.jpg)
0
1
2
3
4
5
6
7
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
% F
Q R
esis
tanc
e
0
10
20
30
40
50
60
70
80
90
100
DD
D/1
000
patie
nt-d
ays
E. coli (r = 0.79; p = 0.002)
FQR-EC and FQ Use
Lautenbach, SHEA, 2002
![Page 23: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/23.jpg)
0
1
2
3
4
5
6
7
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
% F
Q R
esis
tanc
e
0
2000
4000
6000
8000
10000
12000
DJI
A
E. coli (r=.96; p<.001)
FQR-EC and the Dow Jones Index
Courtesy: Y. Carmeli
![Page 24: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/24.jpg)
… assumptions
� prescribing is (often) suboptimal (and often too excessive) and reduces resistance
� “optimized” (and/or reduced) prescribing improves outcomes and can minimize or even reverse antimicrobial resistance
![Page 25: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/25.jpg)
� local guidelines, audit/education with feedback� “improvement in antimicrobial prescription
included among the annual objectives linked to economic incentives in every department”
CMI 2013
Interventions –Endpoint: prescribing quality
![Page 26: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/26.jpg)
Cisneros et al CMI 2013
![Page 27: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/27.jpg)
Cisneros et al CMI 2013
![Page 28: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/28.jpg)
Cisneros et al CMI 2013
![Page 29: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/29.jpg)
Cisneros et al CMI 2013
![Page 30: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/30.jpg)
Limitations
� consider endpoints
�prescribing density
�prescribing quality
�cost (from which perspective)
�patient outcomes
vs
� „microbial“ endpoints)
![Page 31: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/31.jpg)
![Page 32: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/32.jpg)
![Page 33: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/33.jpg)
![Page 34: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/34.jpg)
![Page 35: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/35.jpg)
![Page 36: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/36.jpg)
Bean et al. JAC 2005
Drug resistance in E. coli „without“ apparent selection pressure
![Page 37: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/37.jpg)
Limitations
� to consider
�design of interventional studies
�experimental (e.g. cluster-randomized) vs quasi-experimental (e.g. controlled before/after)
�analysis (e.g. time-series analysis, adverseevents)
![Page 38: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/38.jpg)
Change: DDD/100 P
t test +0.54 0.2
Slope -0.266 <0.001
Ansari et al JAC 2003Courtesy: Peter Davey, Dundee (UK)
Intervention to Reduce Use of A le rt Antibiotics
0
2
4
6
8
10
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48Months
DD
D/1
00 b
ed-d
ays
![Page 39: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/39.jpg)
Kim et al JAC 2008
Baseline Intervention Postintervention
![Page 40: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/40.jpg)
Limitations
� sustainability often not described
�which component is the most critical ? (and needs most investment)
![Page 41: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/41.jpg)
Limitations
�background epidemiology may bedifferent
� confounding: cultural environment & prevalent „prescribing etiquette“� risk forlimited transferability/generalizability ??
�be aware of potentially adverse effects !!
![Page 42: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/42.jpg)
… assumptions & strategies
� what is “optimized” and/or “reduced” ? �no use by indication�shorter treatment�PK/PD-optimized treatment (dosing)�use (or switch to) the “ecologically” (“collateral
damage”) best-performing drugs
![Page 43: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/43.jpg)
e.g. Bronchitis
![Page 44: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/44.jpg)
![Page 45: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/45.jpg)
![Page 46: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/46.jpg)
e.g. Uncomplicated UTI
https://www.escmid.org/escmid_library/online_lecture_library/material/?mid=25322
![Page 47: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/47.jpg)
� double-blind trial � n=253 women (18-70 years old)� diclofenac vs norfloxacin for 3 days (with
fosfomycin 3 g as rescue treatment)� resolution of symptoms (day 3):
� 50% vs 77% (risk difference 27%, 95%CI 15-38%)� 61% of patients in the diclofenac group ever
consumed antibiotics
https://www.escmid.org/escmid_library/online_lecture_library/material/?mid=25322
![Page 48: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/48.jpg)
� double-blind trial � n=253 women (18-70 years old)� diclofenac vs norfloxacin for 3 days (with
fosfomycin 3 g as rescue treatment)� resolution of symptoms (day 3):
� 50% vs 77% (risk difference 27%, 95%CI 15-38%)� 61% of patients in the diclofenac group ever
consumed antibiotics
https://www.escmid.org/escmid_library/online_lecture_library/material/?mid=25322
![Page 49: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/49.jpg)
… assumptions & strategies
� what is “optimized” and/or “reduced” ? �no use by indication�shorter treatment�PK/PD-optimized treatment (dosing)�use (or switch to) the “ecologically” (“collateral
damage”) best-performing drugs
![Page 50: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/50.jpg)
… assumptions & strategies
� what is “optimized” and/or “reduced” ? �no use by indication�shorter treatment�PK/PD-optimized treatment (dosing)�use (or switch to) the “ecologically” (“collateral
damage”) best-performing drugs
![Page 51: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/51.jpg)
Malhotra-Kumar et al. Lancet 2007; 369:482-490
Macrolide
resistanceam
ongoral streptococci
![Page 52: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/52.jpg)
• Plazebokontrollierte Studie mit Amoxicillin (3x1g, n=37) oder Plazebo(n=38) über 1 Woche
• Rachenspülungen untersucht bis Tag 28 auf Streptokokken mit verminderter Empfindlichkeit auf Penicillin und Amoxicillin
• Ergebnisse:
�� Malhotra-Kumar et al ; K-1579
Makrolide verändern nachhaltig die Mundhöhlenflora –Amoxicillin auch ??
![Page 53: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/53.jpg)
… assumptions & strategies
� what is “optimized” and/or “reduced” ? �no use by indication�shorter treatment�PK/PD-optimized treatment (dosing)�use (or switch to) the “ecologically” (“collateral
damage”) best-performing drugs
![Page 54: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/54.jpg)
� Some milestone studies, e.g. the „3F“ (French Fluoroquinolone Free-Study):multicenter trial showing substantial MRSA reductionfollowing a 90% fluoroquinolone reduction(Charbonneau et al CID 2006) (!!)
Fluoroquinolone studies
![Page 55: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/55.jpg)
� Recently many more „3C“ and „3C+“ studies3C: ↓Ceph + ↓Cipro/other FQs = ↓C. difficile
3C+: ↓Ceph + ↓Cipro/other FQs = ↓C. difficile ± ESBL ± MRSA
Ceph + Fluorquinolone studies
![Page 56: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/56.jpg)
Talpaert et al JAC 2011
![Page 57: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/57.jpg)
Talpaert et al JAC 2011
![Page 58: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/58.jpg)
Talpaert et al JAC 2011
![Page 59: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/59.jpg)
[109]Dancer et al IJAA 2013
![Page 60: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/60.jpg)
Summary
� „Stewardship“ is important but complex
�Best evidence so far regarding impact on C.difficile infection
�Very limited evidence for impact on MDR gram-negatives
�Many more interventional studies(hospital and outpatient setting) areneeded
![Page 61: Kern - Antibiotic stewardship programmes & antibiotic ...antibiotikaresistenz-urogenitale-infektionen.de/Downloads/Kern...Winfried V. Kern Abteilung Infektiologie Universitätsklinikum](https://reader031.vdocuments.site/reader031/viewer/2022021916/5e0f7b6435280630964a3f37/html5/thumbnails/61.jpg)