Update on the “Choosing Wisely” initiative in infectious diseases in Germany

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Abstract

Purpose

The Choosing Wisely ^® initiative is an international campaign addressing over- and underuse of diagnostic and therapeutic measures in infectious diseases among others. Since 2016, the German Society for Infectious Diseases (DGI) has constantly designed new items in this regard. Here we report the most recent recommendations.

Methods

The recommendations of the DGI are part of the “Klug entscheiden” initiative of the German Society of Internal Medicine (DGIM). Topics for the new items were suggested by members of the DGI, checked for scientific evidence and consented within the DGI and the DGIM before publication.

Results

The new recommendations are: (1) individuals with immune-suppression, advanced liver cirrhosis or renal insufficiency should receive a dual pneumococcal vaccination. (2) In case of positive blood cultures with Candida spp . thorough diagnostics and treatment should be initiated. (3) In case of suspected meningitis, adult patients should receive dexamethasone and antibiotics immediately after venipuncture for blood cultures and before potential imaging. (4) In case of suspected meningitis a CT scan before lumbar puncture should not be ordered—except for symptoms indicating high CSF pressure or focal brain pathology or in cases of severe immune-suppression. (5) In patients with suspected severe infections, a minimum of two pairs of blood cultures should be drawn using separate venipunctures prior to antibiotic therapy—regardless of body temperature. There is no need of a minimum time interval in between the blood draws.

Conclusion

Applying these new Choosing Wisely ^® recommendations will increase patient safety and the value of health care.

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Most cited references 27

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ESCMID guideline: diagnosis and treatment of acute bacterial meningitis.

D van de Beek, C Cabellos, O. Dzupova … (2016)

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Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials.

D Andes, N Safdar, J Baddley … (2012)

Invasive candidiasis (IC) is an important healthcare-related infection, with increasing incidence and a crude mortality exceeding 50%. Numerous treatment options are available yet comparative studies have not identified optimal therapy. We conducted an individual patient-level quantitative review of randomized trials for treatment of IC and to assess the impact of host-, organism-, and treatment-related factors on mortality and clinical cure. Studies were identified by searching computerized databases and queries of experts in the field for randomized trials comparing the effect of ≥2 antifungals for treatment of IC. Univariate and multivariable analyses were performed to determine factors associated with patient outcomes. Data from 1915 patients were obtained from 7 trials. Overall mortality among patients in the entire data set was 31.4%, and the rate of treatment success was 67.4%. Logistic regression analysis for the aggregate data set identified increasing age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02; P = .02), the Acute Physiology and Chronic Health Evaluation II score (OR, 1.11; 95% CI, 1.08-1.14; P = .0001), use of immunosuppressive therapy (OR, 1.69; 95% CI, 1.18-2.44; P = .001), and infection with Candida tropicalis (OR, 1.64; 95% CI, 1.11-2.39; P = .01) as predictors of mortality. Conversely, removal of a central venous catheter (CVC) (OR, 0.50; 95% CI, .35-.72; P = .0001) and treatment with an echinocandin antifungal (OR, 0.65; 95% CI, .45-.94; P = .02) were associated with decreased mortality. Similar findings were observed for the clinical success end point. Two treatment-related factors were associated with improved survival and greater clinical success: use of an echinocandin and removal of the CVC.

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Etiology of Community-Acquired Pneumonia: Increased Microbiological Yield with New Diagnostic Methods

Niclas Johansson, Mats Kalin, Annika Tiveljung-Lindell … (2010)

Abstract Background The microbial etiology of community-acquired pneumonia (CAP) is still not well characterized. During the past few years, polymerase chain reaction (PCR)-based methods have been developed for many pathogens causing respiratory tract infections. The aim of this study was to determine the etiology of CAP among adults—especially the occurrence of mixed infections among patients with CAP—by implementing a new diagnostic PCR platform combined with conventional methods. Methods Adults admitted to Karolinska University Hospital were studied prospectively during a 12-month period. Microbiological testing methods included culture from blood, sputum, and nasopharyngeal secretion samples; sputum samples analyzed by real-time quantitative PCR for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; nasopharyngeal specimens analyzed by use of PCR; serological testing for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and viruses common in the respiratory tract; and urine antigen assays for detection of pneumococcal and Legionella pneumophila antigens. Results A microbial etiology could be identified for 67% of the patients (n = 124). For patients with complete sampling, a microbiological agent was identified for 89% of the cases. The most frequently detected pathogens were S. pneumoniae (70 patients [38]) and respiratory virus (53 patients [29]). Two or more pathogens were present in 43 (35%) of 124 cases with a determined etiology. Conclusions By supplementing traditional diagnostic methods with new PCR-based methods, a high microbial yield was achieved. This was especially evident for patients with complete sampling. Mixed infections were frequent (most commonly S. pneumoniae together with a respiratory virus).

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Author and article information

Contributors

Rika Draenert:

ORCID: http://orcid.org/0000-0001-6049-3626

rika.draenert@med.uni-muenchen.de

Journal

Journal ID (nlm-ta): Infection

Journal ID (iso-abbrev): Infection

Title: Infection

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0300-8126

ISSN (Electronic): 1439-0973

Publication date (Electronic): 10 March 2020

Publication date PMC-release: 10 March 2020

Publication date (Print): 2020

Volume: 48

Issue: 3

Pages: 317-321

Affiliations

[1 ]GRID grid.5252.0, ISNI 0000 0004 1936 973X, LMU Klinikum, Stabsstelle Antibiotic Stewardship, , Ludwig-Maximilians-University, ; Munich, Germany

[2 ]GRID grid.6190.e, ISNI 0000 0000 8580 3777, Division of Infectious Diseases, Department of Internal Medicine, , University of Cologne, ; Cologne, Germany

Author information

Rika Draenert http://orcid.org/0000-0001-6049-3626

Article

Publisher ID: 1400

DOI: 10.1007/s15010-020-01400-z

PMC ID: 7256090

PubMed ID: 32157610

SO-VID: b5677e46-e995-4cb7-b61a-388c89213811

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 3 February 2020

Date accepted : 6 February 2020

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ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: choosing wisely,infectious diseases,vaccination,meningitis,blood cultures

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ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: choosing wisely, infectious diseases, vaccination, meningitis, blood cultures

Update on the “Choosing Wisely” initiative in infectious diseases in Germany

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Point-of-Care Testing for Infectious Diseases Super Collection

Most cited references 27

ESCMID guideline: diagnosis and treatment of acute bacterial meningitis.

Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials.

Etiology of Community-Acquired Pneumonia: Increased Microbiological Yield with New Diagnostic Methods

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