The Reduction in Antibiotic Use in Hospitals.

Sepsis is associated with high rates of comorbidity and death (1– 7). Treatment with antibiotics represents a milestone in the management of septic diseases. It is indisputable that timely antibiotic treatment improves survival (8– 11). Retrospective analyses have shown that mortality increases to over 50% when treatment with antibiotics is delayed (12– 14). Administration of antibiotics within 60 min of “diagnosis of infection/sepsis” is one of the quality indicators of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) (15), although no mandatory detailed algorithm for the diagnosis is provided. Many patients present indicators of systemic inflammatory response syndrome (SIRS) (16, 17) on admission without sepsis being confirmed later. For many years, therefore, young clinicians have been taught that antibiotics should be given early (within 60 min) in all cases of severe infection. Also for pneumonia, guidelines advise immediate antibiotic treatment (18). However, this approach risks unnecessary administration of antibiotics to many patients who fulfill the criteria of SIRS but in fact have neither sepsis nor pneumonia. It is undisputed that antibiotic use in Europe—including Germany—is excessively high (19– 21). According to the GERMAP report on the consumption of antimicrobials and the spread of antimicrobial resistance in human and veterinary medicine in Germany (22), the antibiotic use density in this country is ca. 57 defined daily doses (DDD) per 100 patient days. This leads to various problems, one of which is increased antibiotic resistance, e.g., the rise in the rate of multiresistant (3-MRGN) Escherichia coli from 5.1% in 2008 to 8.8% in 2013 (23). Another consequence is the spread of Clostridium difficile infections. It is therefore crucial to identify patients with sepsis and avoid giving antibiotics to patients with non-septic diseases. A campaign to systematically reduce antibiotic use in Germany was launched in 2011 (19). An S3 guideline on strategies for the rational use of anti-infectives (antibiotic stewardship) was published in December 2013 (24). The study presented here was designed to answer the following questions: Can the use of antibiotics in a hospital be decreased? If antibiotic use is reduced, do deaths from sepsis and pneumonia increase as a result? Does the reduced use of antibiotics affect antimicrobial resistance?