, Volume 45, Issue 3, pp 263–268 | Cite as

The “Choosing Wisely” initiative in infectious diseases

  • Clara LehmannEmail author
  • Reinhard Berner
  • Johannes R. Bogner
  • Oliver A. Cornely
  • Katja de With
  • Susanne Herold
  • Winfried V. Kern
  • Sebastian Lemmen
  • Mathias W. Pletz
  • Bernhard Ruf
  • Bernd Salzberger
  • Hans Jürgen Stellbrink
  • Norbert Suttorp
  • Andrew J. Ullmann
  • Gerd Fätkenheuer
  • Norma Jung



“Choosing Wisely” is a growing international campaign aiming at practice changes to improve patient health and safety by both, conduct of essential and avoidance of unnecessary diagnostic, preventive and therapeutic procedures. The goal is to create an easily recognizable and distributable list (“Choosing Wisely items”) that addresses common over- and underuse in the management of infectious diseases.


The German Society of Infectious Diseases (DGI) participates in the campaign “Klug Entscheiden” by the German Society of Internal Medicine. Committee members of the (DGI) listed potential ‘Choosing Wisely items’. Topics were subjected to systematic evidence review and top ten items were selected for appropriateness. Five positive and negative recommendations were approved via individual member vote.


The final recommendations are: (1) Imperatively start antimicrobial treatment and remove the focus in Staphylococcus aureus bloodstream infection. (2) Critically ill patients with signs of infection need early appropriate antibiotic therapy. (3) Annual influenza vaccination should be given to individuals with age >60 years, patients with specific co-morbidities and to contact persons who may spread influenza to others. (4) All children should receive measles vaccine. (5) Prefer oral formulations of highly bioavailable antimicrobials whenever possible. (6) Avoid prescribing antibiotics for uncomplicated upper respiratory tract infections. (7) Do not treat asymptomatic bacteriuria with antibiotics. (8) Do not treat Candida detected in respiratory or gastrointestinal tract specimens. (9) Do not prolong prophylactic administration of antibiotics in patients after they have left the operating room. (10) Do not treat an elevated C-reactive protein (CRP) or procalcitonin with antibiotics for patients without signs of infection.


Physicians will reduce potential harm to patients and increase the value of health care when implementing these recommendations.


Choosing Wisely Infectious diseases Recommendations 


Compliance with ethical standards

Conflict of interest

No potential conflict of interest relevant to this manuscript was reported by the authors.


  1. 1.
    Kaasch AJ, Barlow G, Edgeworth JD, et al. Staphylococcus aureus bloodstream infection: a pooled analysis of five prospective, observational studies. J Infect. 2014;68:242–51.CrossRefPubMedGoogle Scholar
  2. 2.
    López-Cortés LE, Del Toro MD, Gálvez-Acebal J, et al. Impact of an evidence-based bundle intervention in the quality-of-care management and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis. 2013;57:1225–33.CrossRefPubMedGoogle Scholar
  3. 3.
    Fries BL, Licitra C, Crespo A, et al. Infectious diseases consultation and the management of Staphylococcus aureus bacteremia. Clin Infect Dis. 2014;58:598–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Thwaites GE, Edgeworth JD, Gkrania-Klotsas E, et al. Clinical management of Staphylococcus aureus bacteraemia. Lancet Infect Dis. 2011;11:208–22.CrossRefPubMedGoogle Scholar
  5. 5.
    Holland TL, Arnold C, Fowler VG. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA. 2014;312:1330–41.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Levy MM, Artigas A, Phillips GS, et al. Outcomes of the surviving sepsis campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis. 2012;12:919–24.CrossRefPubMedGoogle Scholar
  7. 7.
    Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589–96.CrossRefPubMedGoogle Scholar
  8. 8.
    Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637.CrossRefPubMedGoogle Scholar
  9. 9.
    Bödeker B, Remschmidt C, Schmich P, Wichmann O. Why are older adults and individuals with underlying chronic diseases in Germany not vaccinated against flu? A population-based study. BMC Public Health. 2015;15:618.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Uyeki TM. Preventing and controlling influenza with available interventions. N Engl J Med. 2014;370:789–91.CrossRefPubMedGoogle Scholar
  11. 11. Accessed 19.10.2016 2016.
  12. 12.
    Mina MJ, Metcalf CJ, de Swart RL, Osterhaus AD, Grenfell BT. Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality. Science. 2015;348:694–9.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2012;CD004407.Google Scholar
  14. 14.
  15. 15.
  16. 16.
    MacGregor RR, Graziani AL. Oral administration of antibiotics: a rational alternative to the parenteral route. Clin Infect Dis. 1997;24:457–67.CrossRefPubMedGoogle Scholar
  17. 17.
    Nathwani D, Lawson W, Dryden M, et al. Implementing criteria-based early switch/early discharge programmes: a European perspective. Clin Microbiol Infect. 2015;21:S47–55.CrossRefPubMedGoogle Scholar
  18. 18.
    Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother. 2014;69:234–40.CrossRefPubMedGoogle Scholar
  19. 19.
    Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996-2010. JAMA. 2014;311:2020–2.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Hersh AL, Jackson MA, Hicks LA. Diseases AAoPCoI. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013;132:1146–54.CrossRefPubMedGoogle Scholar
  21. 21.
    Zalmanovici trestioreanu A, Lador A, Sauerbrun-Cutler MT, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev. 2015;4:534.Google Scholar
  22. 22.
    Weiskopf J, Scott S. Asymptomatic bacteriuria, what are you treating? JAMA Intern Med. 2015;175:344–5.CrossRefPubMedGoogle Scholar
  23. 23.
    Nicolle LE. Management of asymptomatic bacteriuria in pregnant women. Lancet Infect Dis. 2015;15:1252–4.CrossRefPubMedGoogle Scholar
  24. 24.
    Coussement J, Abramowicz D. Should we treat asymptomatic bacteriuria after renal transplantation? Nephrol Dial Transplant. 2014;29:260–2.CrossRefPubMedGoogle Scholar
  25. 25.
    Meersseman W, Lagrou K, Spriet I, et al. Significance of the isolation of Candida species from airway samples in critically ill patients: a prospective, autopsy study. Intensive Care Med. 2009;35:1526–31.CrossRefPubMedGoogle Scholar
  26. 26.
    Lindau S, Nadermann M, Ackermann H, et al. Antifungal therapy in patients with pulmonary Candida spp. colonization may have no beneficial effects. J Intensive Care. 2015;3:31.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Cornely OA, Bassetti M, Calandra T, et al. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients. Clin Microbiol Infect. 2012;18:19–37.CrossRefPubMedGoogle Scholar
  28. 28.
    Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283.CrossRefPubMedGoogle Scholar
  29. 29.
    ten Oever J, Netea MG, Kullberg BJ. Utility of immune response-derived biomarkers in the differential diagnosis of inflammatory disorders. J Infect. 2016;72:1–18.CrossRefPubMedGoogle Scholar
  30. 30.
    Galarraga B, Khan F, Kumar P, Pullar T, Belch JJ. C-reactive protein: the underlying cause of microvascular dysfunction in rheumatoid arthritis. Rheumatology (Oxford). 2008;47:1780–4.CrossRefPubMedGoogle Scholar
  31. 31.
    Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med. 1999;340:448–54.CrossRefPubMedGoogle Scholar
  32. 32.
    Auer J, Berent R, Eber B, et al. C-reactive protein in patients with acute myocardial infarction. Circulation. 2004;109:E20.CrossRefPubMedGoogle Scholar
  33. 33.
    Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing wisely–the politics and economics of labeling low-value services. N Engl J Med. 2014;370:589–92.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014;89:990–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Jung N, Lehmann C, Fätkenheuer G. The, “Choosing Wisely”: initiative in infectious diseases. Infection. 2016;44:283–90.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Clara Lehmann
    • 1
    • 2
    Email author
  • Reinhard Berner
    • 3
  • Johannes R. Bogner
    • 4
  • Oliver A. Cornely
    • 1
    • 2
    • 5
  • Katja de With
    • 6
  • Susanne Herold
    • 7
  • Winfried V. Kern
    • 8
  • Sebastian Lemmen
    • 9
  • Mathias W. Pletz
    • 10
  • Bernhard Ruf
    • 11
  • Bernd Salzberger
    • 12
  • Hans Jürgen Stellbrink
    • 13
  • Norbert Suttorp
    • 14
  • Andrew J. Ullmann
    • 15
  • Gerd Fätkenheuer
    • 1
    • 2
  • Norma Jung
    • 1
  1. 1.Department I of Internal MedicineUniversity of CologneCologneGermany
  2. 2.German Center for Infection Research (DZIF), Partner Site Bonn-CologneCologneGermany
  3. 3.Department of Pediatrics, University Hospital Carl Gustav CarusTechnische Universität DresdenDresdenGermany
  4. 4.Department of Infectious Diseases, Med Klinik IVUniversity Hospital MunichMunichGermany
  5. 5.Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (ZKS Köln)University of CologneCologneGermany
  6. 6.Clinical Infectious Diseases and Antibiotic Stewardship UnitCarl Carus University HospitalDresdenGermany
  7. 7.Department of Internal Medicine IIUniversity of Giessen and Marburg Lung Center (UGMLC)GiessenGermany
  8. 8.Division of Infectious Diseases, Department of MedicineAlbert-Ludwigs-University Hospital and Medical CenterFreiburgGermany
  9. 9.Division of Infection Control and Infectious DiseasesUniversity Hospital RWTH AachenAachenGermany
  10. 10.Center for Infectious Diseases and Infection ControlJena University HospitalJenaGermany
  11. 11.Division of Infectious Diseases and Tropical MedicineLeipzigGermany
  12. 12.Department of Internal Medicine IUniversity Hospital RegensburgRegensburgGermany
  13. 13.Infectiology Center Hamburg (ICH)HamburgGermany
  14. 14.Department of Internal Medicine/Infectious Diseases and Pulmonary MedicineCharité-Universitätsmedizin BerlinBerlinGermany
  15. 15.Division of Infectious Diseases, Department of Internal Medicine IIUniversitätsklinikum, Julius Maximilian’s UniversityWürzburgGermany

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