Antibiotic use in German university hospitals 1998–2000 (Project INTERUNI-II)☆
Introduction
Excessive antibiotic use increases the risk of the development and dissemination of bacterial resistance. The relationship between antibiotic use and resistance, however, is complex and dynamic [1], [2], [3]. Many confounding variables need to be considered [4], [5]. Ecological analyses often cannot account for multiple confounding variables [6]. Surveys of antibiotic use and resistance in hospitals, for example, need to provide data for specific departments or services rather than for the whole hospital to adjust for case-mix [7], [8], [9]. Also, correlational analyses of specific drug use and resistance rates may be confounded by varying rates of alternative drug use and potentially associated varying risks of induced multidrug resistance [10], [11], [12]. Recent research programmes; therefore, have tried to focus on the establishment of more comprehensive databases covering different regions and different settings in similar formats, thus allowing statistical modelling and perhaps prediction models that can be tested in interventional studies at the local level [13]. Such databases are available in several countries, and several projects and programmes associated with them reportedly are very successful. Notable examples are the Danish Integrated Antimicrobial Resistance Monitoring and Research Programme (DANMAP) [14], the Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance (STRAMA) [15], and project Intensive Care Antimicrobial Resistance Epidemiology (ICARE) of the Rollins School of Public Health of Emory University and the Division of Healthcare Quality Promotion at Centers for Disease Control and Prevention (CDC) in the US [10].
In Germany, a large country with over 80 million inhabitants and more than 2000 hospitals in 16 NUTS-1-level regions (corresponding to federal states), there have been national surveys of antimicrobial drug prescriptions in ambulatory care published on a yearly basis [16], while hospital antibiotic use databases have not been available outside private economic and market research surveys until recently. Two antibiotic use surveillance networks, both supported by governmental funds and coordinated by physician-scientists from the University of Freiburg, are now operating in this country. One is project SARI (Surveillance of Antibiotic Use and Resistance in Intensive Care, http://www.sari-antibiotika.de), an intensive care oriented surveillance programme similar to ICARE [17]. The second is the Medical Antibiotic Use Surveillance and Evaluation (MABUSE) network that aims at integrating ambulatory and hospital care antibiotic use and resistance surveillance and research at regional levels. MABUSE projects initially have included an interhospital comparison of antibiotic use and expenditures at university hospitals, and ambulatory care antibiotic use surveillance at regional level [18], [19]. In a pilot study (INTERUNI-II) using retrospective data, the network has now established a hospital antibiotic use database designed for prospective data entry from representative regional hospital samples. The present study summarises the main results from the INTERUNI-II pilot survey that covered the medical and surgical services from eight university hospitals located in six states.
Section snippets
Materials and methods
Data from eight university hospital pharmacies covering the period 1998–1999–2000 were collected and entered into a WindowsXP-Access database. The database is similar to the ABC Calc developed by the Danish Statens Serum Institut [http://www.escmid.org [20]], but offers the advantage of including all antimicrobial drugs (including combinations) marketed in Germany (under their trade name or identified by a specific identification code, the so-called PZN). Also it allows for interactive flexible
Results
Mean antibiotic use density during the study period was 60.1 DDD/100 (range, 42–70) in the surgical services, and 79.3 DDD/100 (range, 52–104) in the medical services, respectively (Fig. 1). Values increased between 1998 and 2000 by 16% for the surgical services, and by 20% for the medical services, respectively. At most sites, β-lactam antibiotics were the most frequently used drugs (means, surgical services, 38.8 DDD/100; medical services, 38.0 DDD/1000), but proportions varied. The
Discussion
Germany is a large country with a federal state health system organisation, but responsibility for administering and providing health care is delegated to non-state entities, including national and regional associations of health care providers, state hospital associations, non-profit insurance funds, private insurance companies and voluntary organisations. It has therefore been difficult to provide representative national estimates of hospital antibiotic consumption. Limited data on antibiotic
Acknowledgements
This study was supported by the Meta-Alexander-Foundation and BMBF grant 01 KI 9951. MABUSE (Medical Antibiotic Use Surveillance and Evaluation) is an antibiotic use surveillance network supported by the German Society of Infectious Diseases.
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Other members of the MABUSE-INTERUNI-II project team were Franz Daschner (Freiburg), Matthias Herrmann (Homburg/Saar), Gert Höffken (Dresden), Bernd Salzberger (Regensburg), Eberhard Straube (Jena), Reinhard Marre & Peter Kern (Ulm)