title: Implementation of an intensified antibiotic stewardship programme targeting third-generation cephalosporin and fluoroquinolone use in an emergency medicine department.
abstract: BACKGROUND
  Early initiation of antimicrobial treatment for acute infection is an important task in the emergency department (ED) with a likely impact on the hospital-wide antibiotic use pattern. We implemented an antibiotic stewardship (ABS) programme focused on non-trauma emergency patients at a large university hospital centre targeting broad-spectrum cephalosporin and fluoroquinolone use.
  
  
  METHODS
  Guidelines and focused discussion groups emphasised reduced prescription of third-generation cephalosporins and fluoroquinolones and encouraged penicillins. Antibiotic consumption expressed as monthly drug density in WHO-Anatomical Therapeutic Chemical defined and locally recommended daily doses (DDD and RDD) per 100 patient days was analysed before (January 2008 to October 2011) and after starting the intervention (January 2012 to October 2013). We performed a before-and-after uncontrolled interventional study using interrupted time-series (ITS) analysis in one ED to investigate ABS intervention-related effects in a quasiexperimental research setting.
  
  
  RESULTS
  The mean monthly total antibiotic use density declined from 111 RDD (138 DDD) per 100 patient days before the intervention to 86 RDD (128 DDD) per 100 patient days after starting the intervention. Among the different antibacterial drug classes, the consumption of third-generation cephalosporins showed the largest reduction and dropped significantly by -68% between preintervention and postintervention periods. Using the RDD dataset, ITS confirmed a highly significant postintervention change in level of third-generation cephalosporins (-15.2, 95% CI (-24.08 to -6.311)) and a corresponding increase in the use of aminopenicillin/betalactamase inhibitor formulations (+6.6, 95% CI (4.169 to 9.069)). The drug use densities for fluoroquinolones and for overall antibiotics declined, however, the postinterventional level changes missed statistical significance--overall (95% CI (-39.99 to 0.466), fluoroquinolones 95% CI (-11.72 to 4.333)).
  
  
  CONCLUSIONS
  An intensified ABS programme using non-restrictive tools targeting third-generation cephalosporin and fluoroquinolone use in the setting of a large academic hospital emergency medicine department is feasible and effective. The intervention may serve as a model for other emergency medicine departments at hospitals with a similar structure and baseline situation.
authors.affiliation: Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany.
authors.forename: Johannes P
authors.initials: JP
authors.lastname: Borde
authors.affiliation: Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany.
authors.forename: Winfried V
authors.initials: WV
authors.lastname: Kern
authors.affiliation: Pharmacy Service, University Medical Center, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Hug
authors.affiliation: Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany.
authors.forename: Michaela
authors.initials: M
authors.lastname: Steib-Bauert
authors.affiliation: Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
authors.forename: Katja
authors.initials: K
authors.lastname: de With
authors.affiliation: Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany Department of Emergency Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany.
authors.forename: Hans-Jörg
authors.initials: HJ
authors.lastname: Busch
authors.affiliation: Institute of Medical Biometry and Informatics, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Kaier
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002511:Cephalosporins / Q000627:therapeutic use*; D024881:Drug Resistance, Bacterial; D004363:Drug Utilization / Q000706:statistics & numerical data*; D017723:Drug Utilization Review; D004636:Emergency Service, Hospital; D024841:Fluoroquinolones / Q000627:therapeutic use*; D017144:Focus Groups; D005858:Germany; D006785:Hospitals, University; D006801:Humans
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D024841:Fluoroquinolones