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Annual report 2014

Surveillance data 2000 – 2014 Hospital stay data 2000-2012

Surveillance of bloodstream infections in

Belgian hospitals (‘SEP’)

OD Public Health and Surveillance Service: Healthcare-associated Infections & antimicrobial resistance Rue J. Wytsman 14 |1050 Bruxelles | Belgique www.wiv-isp.be

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Division Healthcare-associated infections & Antimicrobial resistance | June 2015 | Brussels, Belgium Edited by: Dr Boudewijn Catry | Head of Service | Rue J. Wytsmanstraat 14 | 1010 Brussel

Internal reference Nr: PHS/2015/031

Deposit Nr : D/2015/2505/43

ISSN: 2295-8711

Authors : Dr Naïma Hammami Dr Marie-Laurence Lambert Contact : naima.hammami@wiv-isp.be The project is financed by The federal public service of health, food chain safety and environment The Flemish community (Flemish Quality Indicators – VIP2), The ’Fédération Wallonie – Bruxelles Santé’.

Science at the service of Public health, Food chain safety and Environment.

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Acknowledgments The authors wish to thank all the participating hospitals for their continuous efforts to provide data, the members of the Working Group "septicaemia" for their advice helping to improve the monitoring of bloodstream infections in the hospital and Sylvanus Fonguh for his contribution in development of the data collection tool.

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List of abbreviations

adm. Number admissions

BC Blood culture

BSI Bloodstream infection

CAR Carbapenem

C3G 3th generation cephalosporin

CLABSI Central Line-Associated Bloodstream Infection

CNS Coagulase negative Staphylococcus

CVC Central vascular catheter / venous catheter

CRBSI Central line Related Bloodstream Infection

d Days

EARS-Net European Antimicrobial Resistance Surveillance Network (ECDC)

ECDC European Centre for Disease Control, Stockholm, SE

E. coli Escherichia coli

ESBL Extended spectrum beta lactamase

ET Endotracheal tube

G-BAC Gram negative bacilli

gly Glycopeptide

HA-BSI Hospital-acquired bloodstream infection

I Intermediate (resistance)

ICU Intensive care unit

LOS Length of stay

meti Methicillin

MO Microorganism

MRB multi-resistant bacteria

MRSA Methicillin resistant Staphylococcus aureus

NPOA Not present on admission

NSIH National Surveillance of Infections in Hospitals (www.nsih.be), Belgium

pd Patient days

PPS-HAI & AB

Point Prevalence Survey of Healthcare-associated infections and Antimicrobial use in European acute care hospitals (ECDC)

R Resistant

RHM/MZG résumé hospitalier minimal/ minimale ziekenhuisgegevens

SEP (Surveillance of) Septicémies (à l’hôpital) / van septicemieën (in het ziekenhuis) / surveillance of bloodstream infections in the hospital (BE)

SSI Surgical Site Infections

STRHCG Other haemolytic Streptococci (C, G)

VRE Vancomycin resistant enterococcus

WIV-ISP Wetenschappelijk Instituut Volksgezondheid - Institut Scientifique de Santé Publique – Scientific Institute of Public Health

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Executive summary

Background Bloodstream infections acquired in the hospital (HA-BSI) are an important cause of morbidity and mortality. Many HA-BSI, especially those associated to an invasive device, are preventable. The surveillance programme for BSI in the hospital (SEP) exists in Belgium since 1992. The surveillance protocol has been reviewed in 2012, with an emphasis on the usefulness of the data collection for guidance and evaluation of preventive actions. Since 2014, the participation for a minimum of 3 months per year became a legal obligation for all acute care hospitals in Belgium. This implies registration of standardized data for each BSI episode acquired in the hospital (HA-SEP: by definition, BSI occurring 2 days or more after admission of the patient in the hospital). The report provides a summary of the surveillance data from Belgium for the period 2000-1014.

Participation of hospitals The participation of hospitals has increased considerably in the recent years. In 2014, 130 hospitals registered their data for at least 3 months and 62 (48%) recorded data for the full year. This continuous participation over the year serves best the purpose of surveillance as a tool for prevention, and it also demonstrates the interest of hospitals for the problem of HA-BSI.

Annual trends The mean incidence in 2014 was 7.9 HA-BSI / 10 000 patient-days and in intensive care unit (ICU) 39.8 / 10 000 patient-days. This incidence appears relatively stable since 2000. There was a great variability between hospitals (figure 1) and between the regions. The incidence was higher in teaching hospitals, and in Brussels (of 8 academic hospitals participating in 2014, 4 are in Brussels). The incidence was the lowest in Flanders.

Figure 1 : Distribution of hospital-acquired bloodstream infections incidence across hospitals, Belgian surveillance data 2000-2014

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The BSI associated to a central venous catheter (probable or confirmed by a culture of catheter) seemed to increase these past 3 years.

Figure 2. Incidence of hospital-acquired bloodstream infections associated to central venous catheter, Belgian surveillance data 2000-2014

SEP associated to a CVC (total): HA-BSI with CVC as ‘suspected’ origin (confirmed, or not) + HA-BSI without other identified origin (origin ‘unknown’) and presence of CVC. The latter category represents 25% of the total in 2014. CV-BSI confirmed : if the same microorganism was found in the catheter culture; BSI=bloodstream infection, N=number

The distribution of the microorganisms involved in HA-BSI changed with an increase in the incidence of HA-BSI due to Gram-negative microorganisms (Escherichia coli, Klebsiella pneumoniae) and a decrease of HA-BSI due to Staphylococcus aureus.

Figure 3 : Mean incidence of hospital-acquired bloodstream infections per microorganism, Belgian

surveillance data 2000-2014

N=number; pd=patient days

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Description of episodes and their probable origin. In 2014, a total of 6 847 HA-BSI episodes were recorded; 86% met the definition 'at least one blood culture with a pathogen' (in 13% the definition 'a skin contaminant was isolated in at least 2 different blood cultures' was met). One episode out of 5 (21%) was acquired in the ICU. For half of the episodes, the time to onset was 13 days or more after admission (median for BSI acquired in ICU: 10 days or more after admission). Half of the patients were more than 71 years old. One out of 5 (19%) patients died, but the causal link with HA-BSI is impossible to determine. The most common origin of HA-BSI - confirmed or probable - is a central venous catheter (CVC, 26%), followed by a urinary tract infection (20%). These proportions differ according to whether the infection is acquired in the ICU or not (figure 4). For 45% of the HA-BSI, the origin is confirmed (the same organism was isolated from blood cultures, and the site considered to be the source of infection). An invasive device is associated directly (vascular catheter) or indirectly (urinary catheter, intubation) in 43% of the HA-BSI.

Figure 4 : Probable origin of bloodstream infections acquired in intensive care unit (ICU) versus other units, Belgian surveillance data 2014

Intensive care units Other units

* CVC: central venous catheter; includes ‘CVC as suspected origin’, or ‘presence of CVC within 2 days of onset of infection without other identified cause’. The latter category represents 25% of the total of the origins attributed to the CVC. * SSI : surgical site infection

Microorganisms and antimicrobial resistance markers. The most common microorganisms in 2014 (HA-BSI) were E. coli (21%), coagulase-negative Staphylococcus (15%) and Staphylococcus aureus (11%). Half of hospitals reported no cases of HA-BSI caused by MRSA; the mean incidence was 0.16 MRSA-BSI / 10,000 patient-days. A comparison of resistance phenotypes between 2013 and 2014 is presented in table 1.

CVC* 34%

Other catheter/ invasive

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Unknown 9%

Pulmonary 23%

Digestive 10%

Urinary 10%

SSI 5% Other 5%

Secondary infection

53% CVC* 24%

Other catheter/ invasive

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Pulmonary 7%

Digestive 12%

Urinary 23%

SSI 4% Other 9%

Secondary infection

55%

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Table 1 : Proportion of hospital-acquired bloodstream infections resistant to antimicrobials, Belgian surveillance data 2013-2014

Microorganisms Hospitals reporting at

least 1 case (%)

2013 2014 2013 2014

N (%) N (%) (N=115) (N= 130 )

S. aureus Meti R 151/685 (22%) 146/831 (17.6%) 68% 50%

Gly R 0/685 (0%) 4/831 (0.5%) 0% 3%

E. faecalis Gly R 2/237 (0.6%) 0/390 (0%) 1% 0%

E. faecium Gly R 7/197 (3.6%) 11/278 (4%) 5% 8%

E. coli C3G 162/1334 (12.1%) 234/1559 (15%) 56% 56%

CAR 4/1334 (0.3%) 9/1559 (0.6%) 4% 5%

K.pneumoniae C3G 79/376 (21.0%) 141/504 (28%) 36% 47%

CAR 9/376 (2%) 18/504 (3.5%) 7% 7%

E.cloacae C3G 90/219 (41.1%) 94/248 (37.9%) 36% 32%

CAR 3/219 (1.4%) 4/248 (1.6%) 3% 2%

P. aeruginosa CAR 53/315 (17%) 65/395 (16.5%) 31% 31%

Acinobacter spp. CAR 5/105 (5%) 11/139 (7.9%) 6% 6%

Meti=Methicillin; Gly=glycopeptides (vancomycin, teicoplanin) ; CAR=carbapenem (Imipenem, meropenem,

doripenem) ; C3G=cephalosporin 3e generation (cefotaxim, ceftriaxon, ceftazidim) ; Gly=glycopeptid ;

*R-CAR includes (Intermediate and resistant), N=number Key points Participation to the surveillance of hospital-acquired BSI is compulsory from 2014.

The incidence of hospital-acquired BSI is relatively stable since 2000, and fairly consistently: o higher in teaching hospitals o higher in Brussels, lower in Flanders. o higher in intensive care units (5 times more in 2014)

There is a great variability between hospitals, which suggests there is an important potential for prevention.

In total, 43% of hospital-acquired BSI are associated either directly or indirectly to an invasive device (vascular catheter, urinary catheter, endotracheal tube). It is a priority target for prevention.

With regard to causal microorganisms : o increase of Enterobacteriaceae (E. coli, K. pneumoniae) o increase between 2013 and 2014 of the resistance of these microorganisms to 3rd

generation cephalosporin and carbapenems.

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Content table

1. INTRODUCTION .................................................................................................................................... 12 2. METHOD ............................................................................................................................................ 12

2.1. Surveillance programme coordinated by the Scientific institute of Public Health (WIV-ISP) 12 2.1.1. Participation and definitions ................................................................................................ 12 2.1.2. Analysis ................................................................................................................................ 13 2.2. Hospital stay data ................................................................................................................... 13

3. RESULTS DATA HOSPITAL SURVEILLANCE .................................................................................................. 14 3.1. Trends 2000-2014 ................................................................................................................... 14 3.1.1. Participation ......................................................................................................................... 14 3.1.2. Trends of incidences ............................................................................................................ 15

3.1.2.1. Annual incidence of hospital-acquired, and ICU-acquired bloodstream infections .... 15 3.1.2.2. Annual mean incidence of BSI acquired in the hospital per region ............................. 16 3.1.2.3. Distribution of incidences between hospitals .............................................................. 16

3.1.2.4. Incidence of central-line associated versus central-line related BSI ....................... 17 3.1.2.5. Incidence per microorganism and per resistant profile ........................................... 19

3.1.3. Evolution of proportions per case definition ....................................................................... 21 3.2. Data 2014 ............................................................................................................................... 22 3.2.1. Description of BSI episodes .................................................................................................. 22

3.2.1.1. Per case definition.................................................................................................... 22 3.2.1.2. Per speciality of service where BSI was diagnosed .................................................. 22 3.2.1.3. Probable origin of HA-BSI and presence of invasive device..................................... 22 3.2.1.4. Time to infection (infection date – admission date) ................................................ 25 3.2.1.5. Description of patients and status end of follow up ................................................ 25

3.2.2. Microbiological data and antimicrobial resistance .............................................................. 25 3.2.2.1. Microorganisms ....................................................................................................... 25 3.2.2.2. Resistance to antimicrobials for phenotype markers .............................................. 26

4. RESULTS DATA HOSPITAL STAY (RHM/MKG) ........................................................................................... 29 5. INTERNATIONAL COMPARISONS .............................................................................................................. 30 6. COMPARISON WITH OTHER SOURCES FOR BELGIAN DATA ON ANTIMICROBIAL RESISTANCE ................................ 32 7. DISCUSSION ........................................................................................................................................ 33 8. CONCLUSION ET RECOMMENDATIONS ..................................................................................................... 35 9. ANNEXES ............................................................................................................................................ 36

9.1. Calculation of incidences ........................................................................................................ 36 9.2. Participation per region .......................................................................................................... 37 9.3. Annual incidence of bloodstream infections acquired in the teaching and non-teaching hospitals, Belgian surveillance data ..................................................................................................... 38 9.4. Annual incidence of bloodstream infections associated or related to central lines, Belgian surveillance data .................................................................................................................................. 39 9.5. Distribution of incidence by bed size and length of stay ........................................................ 40 9.6. Number microorganisms, episodes and patients with bloodstream infections .................... 42 9.7. Origins 2014 ............................................................................................................................ 43 9.8. BSI with invasive device .......................................................................................................... 45 9.9. Microorganisms 2014 ............................................................................................................. 46 9.10. Microorganism per origin - 2014 ............................................................................................ 49 9.11. Resistance to antimicrobials ................................................................................................... 50 9.12. Origin of bloodstream infections acquired outside of the hospital ....................................... 50

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List of tables Table 1 : Hospital participation by trimester in BSI surveillance, Belgium 2000-2014 ..................................... 14 Table 2 : Incidence of bloodstream infections acquired in Belgian hospitals (hospital wide and intensive care units), surveillance data 2000-2014 .................................................................................................................... 15 Table 3 : Proportion of HA-BSI resistant to antimicrobials, Belgian surveillance data 2013-2014 ............... 20 Table 4 : Bloodstream infections acquired in the hospital and ICU per case definition, Belgian surveillance data 2000-2014 .............................................................................................................................................................. 21 Table 5 : Bloodstream infections by case definition, Belgian surveillance data 2014 ........................................ 22 Table 6 : Bloodstream infections by speciality of ward, Belgian surveillance data 2014 ................................... 22 Table 7 : Probable and confirmed origin of bloodstream infections acquired in hospital, Belgian surveillance data 2014 ........................................................................................................................................................................ 23 Table 8 : Microorganisms isolated in bloodstream infections, Belgian surveillance data 2014 ........................ 26 Table 9 : Resistance to antimicrobials, Belgian surveillance data 2014 ................................................................ 27 Table 10 : Incidence density for bloodstream infections caused by resistant microorganisms, Belgian surveillance data 2014 ................................................................................................................................................... 28 Table 11: Incidence of hospital-acquired bloodstream infections based on hospital stay data versus surveillance data, 2000-2012 ........................................................................................................................................ 29 Table 12: Mean incidence density and exposure to invasive devices – international comparisons ................. 30 Table 13: Microorganisms and resistance to antimicrobials – international comparisons ................................ 31 Table 14: Resistance to antimicrobials – Belgian comparisons surveillance data, MRSA surveillance data & EARS-net data ............................................................................................................................................................... 32 Table 15 : Calculation of mean incidences and mean of the incidences, Belgian surveillance data ................ 36 Table 16: Hospital participation by region, Belgian surveillance data 2000-2014 .............................................. 37 Table 17 : Incidence of bloodstream infections acquired in the hospital and at ICU, Belgian surveillance data 2000-2014 .............................................................................................................................................................. 38 Table 18 : Incidence of bloodstream infections associated or related to central lines, Belgian surveillance data 2000-2014 .............................................................................................................................................................. 39 Table 19 : Number microorganisms, episodes and patients with bloodstream infection, Belgian surveillance data 2014 ........................................................................................................................................................................ 42 Table 20 : Bloodstream infections acquired at the hospital (≥2d), per origin and speciality of service, Belgian surveillance data 2014 .................................................................................................................................... 43 Table 21 : Bloodstream infections not acquired in hospital (<2d), per origin and speciality of service, Belgian surveillance data 2014 .................................................................................................................................... 44 Tableau 22 : BSI with invasive device, Belgian surveillance data 2014 ................................................................ 45 Table 23 : CLABSI per case definition et microbiological documentation, Belgian surveillance data 2014 .. 45 Table 24 : Microorganisms causing bloodstream infections, Belgian surveillance data 2014 ........................... 46 Table 25 : Microorganisms, per suspected origin of hospital-acquired bloodstream infection, Belgian surveillance data 2014 ................................................................................................................................................... 49 Table 26 : Resistance to antimicrobials for BSI acquired in the hospital, Belgian surveillance data 2014 ..... 50 Table 27 : Origin of bloodstream infections acquired outside of hospital, Belgian surveillance data 2014 ... 50

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List of figures Figure 1 : Mean incidence of bloodstream infection (BSI) acquired in the hospital per region, Belgian surveillance data 2000-2014 ......................................................................................................................................... 16 Figure 2 : Distribution of hospital and ICU acquired BSI incidence across hospitals, Belgian surveillance data 2000-2014 .............................................................................................................................................................. 17 Figure 3: Mean incidence central-line associated (CLABSI) versus related (CRBSI) BSI hospital wide, and ICU-acquired, Belgian surveillance data 2000-2014 ................................................................................................ 18 Figure 4 : Trends in proportions of incidence BSI associated to a central venous catheter, Belgian surveillance data 2000-2014 ......................................................................................................................................... 19 Figure 5 : Microorganism specific incidence, Belgian surveillance data 2000-2014 ........................................... 19 Figure 6 : Incidence of HA-BSI caused by resistant microorganisms, Belgian surveillance data 2013-14 ..... 20 Figure 7 : BSI acquired in the hospital with devices, Belgian surveillance data 2014 ........................................ 23 Figure 8 : Probable origin of bloodstream infections acquired at ICU versus other wards, Belgian surveillance data 2014 ................................................................................................................................................... 24 Figure 9: Mean incidence density for BSI acquired in the hospital and associated to a central line (CLABSI) per region, Belgian surveillance data 2000-2014 ...................................................................................................... 40 Figure 10 : Incidence density of BSI acquired in the hospital by bed size, Belgian surveillance data 2014 ... 40 Figure 11 : Incidence density of BSI acquired in the hospital by length of stay, Belgian surveillance data 2014 ................................................................................................................................................................................. 41 Figure 12 : Incidence density of BSI acquired in the hospital teaching versus non-teaching, Belgian surveillance data 2014 ................................................................................................................................................... 41

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1. INTRODUCTION Bloodstream infections acquired in the hospital (HA-BSI) cause considerable morbidity and mortality and have an important potential for prevention, especially for those associated with invasive devices.(1) In 2011, a point prevalence survey in European hospitals documented that 1.1% of surveyed patients developed a healthcare-associated BSI.(2) Belgium follows these severe infections through a specific hospital-wide surveillance programme since 1992. The incidence density of central line associated BSI is also included as outcome indicator in the national quality indicator project (http://www.nsih.be/download/IQ/IQ_rapport%20final_adapt%E9%20selon%20commentaires%20PRs_final_vs3.pdf). The hospital-wide surveillance programme on HA-BSI in Belgium provides a standardized measurement tool allowing hospitals to follow their own trends at hospital and intensive care unit (ICU) level, and also to calculate incidences at national level. This report describes the trends in incidences of HA-BSI from the years 2000 to 2014. Data for the year 2014 are described in more detail, including causal microorganisms (MO) and their antimicrobial resistance profile. In 2013, the surveillance protocol was simplified and updated including new case definitions and a strong focus was put on the usefulness of surveillance at local level as a tool for prevention. An online data entry tool was also developed which displays results in real time (http://nsihweb.wiv-isp.be/).

2. METHOD

2.1. Surveillance programme coordinated by the Scientific institute of Public Health (WIV-ISP)

2.1.1. Participation and definitions

Since 1 July 2014, participation in the surveillance programme for Septicaemia (SEP) became obligatory (Royal decree 08-01-2015) for a minimum of 3 months per year. Details on the participation criteria and the modalities for data collection can be found in the revised protocol (http://www.nsih.be/download/SEP/SEP_protocol_v4.2_FR.pdf). Only lab confirmed bloodstream infections (BSI) are recorded. In short, a hospital-acquired bloodstream infection (HA-BSI) is defined as a BSI occurring 2 days or more after admission at the declaring hospital (infection date – admission date ≥ 2d). Similarly, a bloodstream infection acquired in the intensive care unit (ICU) is defined as a BSI occurring 2 days or more after admission in the ICU. The other BSI (occurring <2d after admission, for example community acquired or acquired in other hospital, long term care facility) can be registered optionally.

Since 2013, the central line-associated infections are defined in accordance with the Centre of Disease Control and Prevention (CDC, US), as a HA-BSI not related to an infection at another site and with a central venous catheter (CVC) in place at the time of, or within 2 days before onset of the BSI.

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2.1.2. Analysis

This report analyses surveillance data for the period from the first quarter of 2000 to the last quarter of 2014 (the national data base was closed on the 5nd of April 2014). The main focus of this report is HA-BSI (≥ 2d). Other BSI (<2d) also have been included for the analysis of the antimicrobial resistance patterns.

In order to allow for comparison of incidences over time, we used the same case definitions (excluding BSI defined by only 1 blood culture (BC) with skin contaminant).

The mean aggregated annual incidences (see annex 9.1 for details on the calculation of the incidence) are expressed as :

Mean incidence1 of HA-BSI per 1 000 admissions (cumulative incidence) or per 10 000 patient days (pd) (incidence density).

Mean and median of the incidences2 of HA-BSI per 1 000 admissions, or per 10 000 pd. The numerator only includes HA-BSI

We adjusted for the number of trimesters by participation per hospital in the calculation of the mean national incidence. The BSI occurring within 2 days after admission to the hospital were excluded from the calculation of the incidences. The mean ICU-BSI incidences were calculated with in the numerator the ICU-acquired BSI and in the denominator the total of admission or patient days in the ICU (including patients staying < 2 days in ICU).

All statistical analysis was performed using STATA, version 10.1. Boxplot were generated with basic

commands in STATA (95%)

2.2. Hospital stay data In Belgium, each hospital stay gives rise to a formal registration (RHM/MZG – ‘résumé hospitalier minimal’/ ‘minimale ziekenhuisgegevens’ or minimum hospital data set). Diagnoses are coded using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification).(3) We have analysed the hospital stays with an ICD9 code 038.01-038.09 (‘Septicemia’) from 2000 to 2012 (latest available year). From 2008 onwards a new variable has been introduced – “diagnosis not present on admission“, which means that the complication occurred after admission. The data provided in this report are provided by the Federal Public Service of Public Health (‘Service Fédéral Santé Publique’ / ‘Federale Overheidsdienst, SPF-FOD)’ and include all hospital stays in Belgium, with the exception of psychiatric stays, and one-day stays. The calculation of the incidences based on these data was compared to the mandatory hospital surveillance data.

1 Mean incidence: total of HA-BSI/total denominators (all participating hospitals) 2 Mean of the incidences: total incidences/total hospitals with available denominators (per trimester and year)

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3. RESULTS DATA HOSPITAL SURVEILLANCE

3.1. Trends 2000-2014

3.1.1. Participation There was a substantial increase in the number of hospitals participating for at least 3 months, and also for a full year to the surveillance programme; 48% of hospitals participated for a full year in 2014. See Annex 9.2 for the participation stratified by region.

Table 1 : Hospital participation by trimester in BSI surveillance, Belgium 2000-2014

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participating 1 trimester

N hospitals participating 2

trimesters

N hospitals participating 3

trimesters

N hospitals participating 4

trimesters Total

2000 22 38 17 24 101

2001 24 9 8 24 65

2002 19 7 5 27 58

2003 29 34 6 25 94

2004 30 9 4 27 70

2005 32 10 6 26 74

2006 31 13 7 34 85

2007 35 9 5 41 90

2008 35 11 6 38 90

2009 35 7 3 38 83

2010 30 12 4 33 79

2011 24 6 5 30 65

2012 32 12 4 31 79

2013 40 19 7 49 115

2014 45 18 5 62 130

BSI: bloodstream infection

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3.1.2. Trends of incidences

3.1.2.1. Annual incidence of hospital-acquired, and ICU-acquired bloodstream infections

Table 2 provides insight in the incidences at hospital and ICU level from 2000-2014. The hospital incidence density was the highest in 2005-2006 (9.1/10 000 patient days (pd)) and the lowest in 2012 (7.4/10 000 pd). The mean incidence density in ICU was the highest in 2003-2004 (48.3/10000 pd) and the lowest in 2012 (31.8/10 000 pd). However, hospital participation fluctuated over consecutive years. The mean incidence density in participating teaching hospitals is consistently much higher than in non-teaching hospitals (12.6 versus 7.1/10 000 pd in 2014, see annex 9.3 and annex 9.5, figure 12). In 2014, the median number of HA-BSI (P25-P75) in a Belgian hospital was 14 episodes (7-28) per trimester.

Table 2 : Incidence of bloodstream infections acquired in Belgian hospitals (hospital wide and intensive care units), surveillance data 2000-2014

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Acquired in hospital

N hospitals* 101 65 58 94 70 73 85 90 90 83 79 65 77 111 118

N trimesters 245 162 156 215 168 173 214 232 227 210 198 171 196 285 316

N BSI acquired in hospital 4 830 3 658 3 333 5 075 3 985 4 239 4 997 4 847 4 468 4 039 3 683 3 222 3 726 5 327 6 287

Mean incidence 1000 adm** 6.1 6.6 6.8 6.8 7.1 7.0 6.9 6.6 6.3 6.2 5.9 5.9 5.4 5.6 5.7

Mean incidence 10 000 pd** 7.8 8.3 8.5 8.3 8.8 9.0 9.1 8.6 8.1 8.2 7.9 7.9 7.4 7.9 7.9

Median incidence 10 000 pd 7.1 7.0 7.2 6.7 8.2 8.0 7.4 6.8 6.2 6.4 6.5 6.8 6.5 6.8 6.4

Acquired in Intensive care unit

N hospitals* 79 59 50 76 55 60 61 58 53 51 50 42 48 70 90

N trimesters 165 130 128 165 124 139 150 139 134 131 137 101 106 175 224

N BSI acquired in ICU 732 634 564 961 667 797 872 716 680 595 544 465 506 965 1170

Mean incidence 1000 adm** 16.6 18.3 18.7 20.8 21.2 20.3 20.4 19.1 18.5 16.3 14.5 17.8 13.7 18.1 18.1

Mean incidence 10 000 pd** 47.2 45.7 42.9 47.6 48.3 44.4 45.4 42.3 40.5 37.0 35.1 39.1 31.8 41.8 39.8

Median incidence 10 000 pd 33.2 32.2 35.4 35.7 44.6 37.7 36.9 37.4 42.4 29.4 31.2 38.1 26.7 41.2 34.1

*Hospitals included in the calculation of incidence when denominator per trimester of participation is available; BSI: Bloodstream infection; ICU: intensive care unit; adm: admissions; pd: patientdays, **Mean incidence: total BSI acquired in hospital or ICU/ total denominator

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The incidence density for BSI acquired in the ICU was 5 times higher compared to the hospital-wide incidence in 2014, but 75% of HA-BSI are located outside the ICU (see table 6). In 2014, only 5 hospitals provided complete data for the calculation of the incidence density at the neonatal intensive care unit (13 trimesters): mean 20/10 000 pd.

3.1.2.2. Annual mean incidence of BSI acquired in the hospital per region

Figure 1 compares the mean incidence of HA-BSI across the three regions of Belgium from 2000-2014. The mean incidence has almost consistently been lowest in Flanders and highest in Brussels. There is a higher concentration of teaching hospitals in Brussels; 4/15 participating hospitals, compared to 3/62 in Flanders and 1/41 in Wallonia participating in 2014.

Figure 1 : Mean incidence of bloodstream infection (BSI) acquired in the hospital per region, Belgian surveillance data 2000-2014

N: number; pd: patient-days

3.1.2.3. Distribution of incidences between hospitals

Figure 2 shows that there is a large variability between hospitals in the incidence of hospital-acquired and ICU acquired bloodstream infections. When stratified by bed size (proxy for case mix of patients) the variation within each subgroup remains important (see annex 9.5 – figure 10 & 12).

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Figure 2 : Distribution of hospital and ICU acquired BSI incidence across hospitals, Belgian surveillance data 2000-2014

BSI acquired in hospital BSI acquired in ICU

ICU; intensive care unit, BSI; bloodstream infection Boxplot generated with basic commands in STATA (95%)

3.1.2.4. Incidence of central-line associated versus central-line related BSI

Central line-associated bloodstream infections (CLABSI) refers to a BSI where a central venous catheter (CVC) is the probable source of infection, central-line related BSI refers to a BSI where a CVC is the microbiologically confirmed source of infection (for exact definitions, see protocol).(4) The mean CLABSI incidence per 10 000 patient days (hospital-wide) increased from 2012 to 2014, while the CLABSI rate at the ICU increased in 2013 (see also annex 9.4). In 2014, the mean CLABSI incidence per 10 000 pd stabilized at 2.1 at hospital level and 13.3 at ICU level; the median (P25-P75) number of CLABSI and central line-related bloodstream infections (CRBSI) acquired in the hospital was respectively 3 episodes (0-6) and 2 (0-5) per trimester; in the ICU it was respectively 1 (0-2) and 0 (0-1) per trimester. The mean incidence has almost consistently been the lowest in Flanders (3 participating university hospitals) and the highest in Brussels (4 university hospitals) (see annex 9.4, figure 9). In 2014, the mean CLABSI incidence density in teaching hospitals was 2 times higher than in non-teaching hospitals, while the mean CLABSI incidence at ICU was 4 times higher than at hospital level (see annex 9.4). More or less 30% of CLABSI are diagnosed in the ICU and the predominant causal microorganisms for CLABSI in 2014 remained coagulase negative Staphylococcus (39%, see annex 9.10).

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Figure 3: Mean incidence central-line associated (CLABSI) versus related (CRBSI) BSI hospital wide, and ICU-acquired, Belgian surveillance data 2000-2014

CLABSI (probable central line origin)= Central line associated bloodstream infections, including BSI with central venous catheter as suspected origin and “unknown” origin with a CVC present in the 2 days before onset of infection; pd=patient days; CRBSI (confirmed central line origin)=Central line related bloodstream infection including BSI with central venous catheter as suspected origin which has been confirmed (same microorganism) by a catheter culture ICU; intensive care unit, BSI; bloodstream infection, N; number

There has been a change in the definition for CLABSI in 2013 which takes into account the BSI with a CVC as suspected origin, and BSI with no other origin (unknown) and a CVC present within 2 days before the onset of the BSI. Figure 4 shows that more or less a quarter of the total CLABSI in 2014, consists of BSI where no other causes have been identified (i.e. origin unknown) and a CVC present. This proportion remains stable over time.

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Figure 4 : Trends in proportions of incidence BSI associated to a central venous catheter, Belgian surveillance data 2000-2014

SEP associated to CVC total: HA-SEP with CVC as ‘suspected’ origin (confirmed or not) + HA-SEP with origin ‘unknown’ and presence of a CVC within 2 days before onset of infection; Suspected CVC-BSI :HA-SEP with suspected origin ‘CVC’; BSI bloodstream infection, N; number, pd; patient-days, CVC; central venous catheter

3.1.2.5. Incidence per microorganism and per resistant profile

Figure 5 shows the mean incidence of HA-BSI acquired in hospitals for the most common microorganisms. The incidence of HA-BSI caused by Escherichia coli, Klebsiella pneumonia and coagulase negative Staphylococcus remained high in 2014. The bloodstream infections associated with E. coli were mostly related with urinary infections [43% (672/1 559), from which 42% (282/672) had an urinary catheter], and in patients hospitalized in geriatric departments (18%) or ICU (15%).

Figure 5 : Microorganism specific incidence, Belgian surveillance data 2000-2014

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Table 3 and Figure 6 show the evolution of resistant strains (proportion and incidence density) in 2013-14.

Table 3 : Proportion of HA-BSI resistant to antimicrobials, Belgian surveillance data 2013-2014

Microorganisms Hospitals reporting at

least 1 case (%)

2013 2014 2013 2014

N (%) N (%) (N=115) (N= 130 )

S. aureus Meti R 151/685 (22%) 146/831 (17.6%) 68% 50%

Gly R 0/685 (0%) 4/831 (0.5%) 0% 3%

E. faecalis Gly R 2/237 (0.6%) 0/390 (0%) 1% 0%

E. faecium Gly R 7/197 (3.6%) 11/278 (4%) 5% 8%

E. coli C3G 162/1334 (12.1%) 234/1559 (15%) 56% 56%

CAR 4/1334 (0.3%) 9/1559 (0.6%) 4% 5%

K.pneumoniae C3G 79/376 (21.0%) 141/504 (28%) 36% 47%

CAR 9/376 (2%) 18/504 (3.5%) 7% 7%

E.cloacae C3G 90/219 (41.1%) 94/248 (37.9%) 36% 32%

CAR 3/219 (1.4%) 4/248 (1.6%) 3% 2%

P. aeruginosa CAR 53/315 (17%) 65/395 (16.5%) 31% 31%

Acinobacter spp. CAR 5/105 (5%) 11/139 (7.9%) 6% 6%

Meti=Methicillin; Gly=glycopeptides (vancomycin, teicoplanin) ; CAR=carbapenem (Imipenem, meropenem, doripenem) ; C3G=cephalosporin 3e generation (cefotaxim, ceftriaxon, ceftazidim) ; *R-CAR includes (Intermediate and resistant)

Overall, there was an increase in proportion and incidence of BSI caused by Gram-negative resistant strains, while the resistance in Gram-positive MO decrease.

Figure 6 : Incidence of HA-BSI caused by resistant microorganisms, Belgian surveillance data 2013-14

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3.1.3. Evolution of proportions per case definition A pathogen microorganism was isolated in the majority of HA-BSI the hospital and ICU.

Table 4 : Bloodstream infections acquired in the hospital and ICU per case definition, Belgian surveillance data

2000-2014

Bloodstream infection acquired in hospital Bloodstream infection acquired in ICU

1BC pathogen 2BC skin contaminant Total 1BC pathogen 2BC skin contaminant Total

Year N % N % N N % N % N

2000 3 814 79 1 016 21 4 830 581 74 200 26 781

2001 2 987 82 671 18 3 658 543 81 126 19 669

2002 2 840 84 541 16 3 381 480 81 114 19 594

2003 4 257 84 818 16 5 075 776 79 202 21 978

2004 3 365 84 622 16 3 987 573 83 116 17 689

2005 3 649 86 597 14 4 246 708 83 144 17 852

2006 4 295 86 702 14 4 997 797 85 140 15 937

2007 4 232 87 615 13 4 847 719 86 116 14 835

2008 3 862 86 606 14 4 468 686 89 89 11 775

2009 3 520 87 519 13 4 039 589 82 128 18 717

2010 3 286 89 414 11 3 700 567 89 67 11 634

2011 2 840 88 382 12 3 222 462 88 66 12 528

2012 3 058 86 479* 13 3 537 455 85 80* 15 535

2013 4 765 87 734* 13 5 499 999 85 175* 15 1 174

2014 5 884 86 963* 14 6 847 1 226 83 245* 17 1 471

ICU=intensive care unit ; BC=blood culture ; *includes neonatal BSI (≥1 BC coagulase negative staphylococci)

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3.2. Data 2014

3.2.1. Description of BSI episodes

3.2.1.1. Per case definition

Among the 9 321 BSI registered during 344 trimesters by 130 hospital sites in 2014, 6 847 were acquired in hospital (73%) and 1 471 (21%) acquired in ICU. In the majority of cases bacterial pathogens were isolated in the blood culture.

Table 5 : Bloodstream infections by case definition, Belgian surveillance data 2014

BSI acquired in hospital Other BSI

(<2d)

Bloodstream infection

acquired in ICU

acquired in non-ICU

N (%) N (%) N (%)

BSI with ≥1BC pathogen 1 226 (83) 4 658 (87) 2 342 (95)

BSI with ≥2BC skin contaminant 189 (13) 706 (13) 132 (5)

BSI neonatology with ≥1BC CNS 56 (4) 12 (0) 1 (0)

Total BSI (excluding case definition ‘unkown’) 1 471 (100) 5 376 (100) 2 475 (100)

BSI=bloodstream infection; BC=blood culture ; CNS=coagulase negative staphylococci; ICU=intensive care unit, N=number; d=days

3.2.1.2. Per speciality of service where BSI was diagnosed

A quarter of the HA-BSI were diagnosed in ICU, but not necessarily acquired in ICU.

Table 6 : Bloodstream infections by speciality of ward, Belgian surveillance data 2014

Speciality N %

Internal medicine 1 930 28

Gastro-enterology 407

Cardiology 245

Pneumology 186

Nephrology 129

Intensive care unit 1 696 25

Surgery 1 066 15

Geriatrics, care for the elderly 908 13

Haemato-Oncology 872 13

Other 242 4

Pediatrics 78 1

Obstetrics/Gynaecology 55 1

Total 6 847 100

3.2.1.3. Probable origin of HA-BSI and presence of invasive device

A CVC or urinary infection is the probable (suspected) origin for more than 45% of all bloodstream infections acquired in the hospital. A CVC represents the main origin in all hospital wards (21-44%),

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except in geriatrics where infections secondary to urinary infections are the most frequent (35%) (see annex 9.7, table 20). More than 69% (556/1 813) of CLABSI are not acquired in the ICU.

Table 7 : Probable and confirmed origin of bloodstream infections acquired in hospital, Belgian surveillance data 2014

Origin Bloodstream infection acquired in hospital

N confirmed (%) N probable (%) Total (%)

Central venous catheter (CVC)* 778 (43) 1 035 (57) 1 813 (26)

Urinary infection 1 105 (81) 256 (19) 1 361 (20)

with catheter 552 122 674

Gastro-intestinal infection 219 (28) 568 (72) 787 (11)

Pulmonary infection 447 (60) 293 (40) 740 (11)

with endotracheal tube/cannula 228 51 279

Other secondary infections** 196 (33) 392 (67) 588 (9)

Surgical site infection 184 (70) 79 (30) 263 (4)

Peripheral and other catheter 88 (42) 120 (58) 208 (3)

Invasive manipulation 30 (34) 59 (66) 89 (1)

Unknown 0 998 (100) 998 (15)

Total 3 047 (45) 3 800 (55) 6 847 (100)

* includes BSI recorded as “unknown origin”, but CVC in place 2 days or more before BSI diagnosed. These make up 75% of total BSI associated with a CVC; ** skin/soft tissue and other secondary origin ; Confirmed=same microorganism in blood culture and in probable origin

Overall, 45% of clinically suspected origins were documented (same microorganism was found in blood culture(s) and suspected origin) and the proportions of confirmation varied per origin (for ICU and other services, see annex 9.8, table 22). Figure 7 shows details on the presence of invasive devices in 2 957/6 847 (43%) of bloodstream infections acquired in the hospital, from which 1 630 / 2 957 (55%) were documented.

Figure 7 : BSI acquired in the hospital with devices, Belgian surveillance data 2014

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Figure 8 shows that the main origins for BSI acquired in ICU were CVC and pulmonary infections (34% et 23% respectively), while in other (non ICU) wards, urinary infections (23%) and CVC (24%) were most frequently suspected. See annex 9.7, table 21 for origins of BSI not acquired in the hospital.

Figure 8 : Probable origin of bloodstream infections acquired at ICU versus other wards, Belgian surveillance data 2014

* regroups bloodstream infection (BSI) caused by « cental venous catheter (CVC) » AND BSI with « unknown » origin and CVC present in 2 days before onset of infection, ICU; intensive care unit

Central venous catheter (CVC)*

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manipulation 4%

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Secondary infection 53%

BSI aquired in ICU

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Pulmonary; 7%

Digestive; 12%

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Surgical; 4%

Other; 9%

Secondary infection; 55%

BSI acquired in non-ICU

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3.2.1.4. Time to infection (infection date – admission date)

The delay in appearance (P25-P75) of bloodstream infections acquired in the hospital and in the ICU is respectively 13 days (6-25) and 10 days (5-21) after admission in hospital or ICU. Delays between insertion of CVC and CLABSI diagnosis have not been calculated because insertion dates of the central line (optional data) were missing for more than 80% of episodes).

3.2.1.5. Description of patients and status end of follow up

Among the 6 314 patients with a bloodstream infection acquired in the hospital, 42% were women. The median age (P25-P75) was 72 years (59-82) for women and 70 (59-80) for men. The majority of patients had 1 infectious episode, caused by 1 MO; 7% had 2 episodes of BSI or more during their stay; 9% of the episodes involved more than one MO (see annex 9.6 – table 19). The crude mortality for BSI acquired in the hospital and in ICU were respectively 19% and 26%, however there was a substantial amount of missing data for status at end of follow-up (resp. 23 and 26%). Our data do not allow determining a causal link between death and infection.

3.2.2. Microbiological data and antimicrobial resistance

3.2.2.1. Microorganisms

In 2014, a total of 7 542 microorganisms (MO) were registered as etiological agent for the 6 847 BSI acquired in the hospital and 1 647 MO for the 1 471 BSI acquired in ICU. Table 8 shows that the Enterobacteriaceae and Gram-positive cocci remained the most frequently isolated MO (see annex 9.9 –table 24 for details). The most frequent MO per origin are shown in Table 25 (annex 9.10); E. coli in BSI secondary to urinary tract (46%), digestive tract (32%) and surgical site infections (22%) - coagulase negative staphylococci in CLABSI (39%) and other catheters (26%). A skin contaminant was the only causal MO in 668/1 813 (37%) of CLABSI, from which 323 (48 %) were confirmed by a culture of the catheter (see annex 9.8, table 23).

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Table 8 : Microorganisms isolated in bloodstream infections, Belgian surveillance data 2014

BSI ≥2d hospital SEP ≥2d ICU Others (SEP <2d)

Microorganism n % n % n %

Gram – bacilli Enterobacteriaceae 3 132 42 608 37 1 402 53

Escherichia coli 1 559 21 200 12 1 062 40

Klebsiella pneumoniae 504 7 127 8 120 5

Enterobacter cloacae 248 3 67 4 32 1

Klebsiella oxytoca 163 2 36 2 26 1

Proteus mirabilis 153 2 35 2 56 2

Serratia marescens 142 2 54 3 18 1

Enterobacter aerogenes 122 2 27 2 21 1

Other/not identified * 241 3 62 4 67 2

Gram + cocci 3 069 41 692 42 967 36

Coagulase-negative staphylococci 1 150 15 295 18 141 5

Staphylococcus aureus 831 11 150 9 290 11

Enterococcus faecalis 390 6 111 7 68 3

Enterococcus faecium 278 4 79 5 22 1

Streptococcus sp., other 180 2 25 1 124 5

Streptococcus pneumoniae 69 1 9 1 160 6

Other/not identified * 171 2 23 1 162 6

Gram - bacilli (non Enterobacteriaceae)

661 8 180 11 127 5

Pseudomonas aeruginosa 395 5 145 9 71 3

Morganella species 78 1 26 1 16 1

Other/not identified * 188 2 9 1 40 2

Fungi 378 5 103 7 18 1

Candida albicans 189 3 58 4 6 0

Candida glabrata 88 1 28 2 6 0

Other/not identified * 101 1 17 1 6 0

Anaerobic bacilli 205 3 45 3 72 3

Bacteroides fragilis 82 1 17 1 30 1

Autres Gram + bacilli 62 1 17 1 21 1

Autres Gram – cocci 12 0 0 0 21 1

Autres – non identifiés 23 0 2 0 6 0

Total 7 542 100 1 647 101 2 634 100

*microorganisms causing <50 episodes BSI acquired in hospital/year; BSI=bloodstream infection; ICU=intensive care unit

3.2.2.2. Resistance to antimicrobials for phenotype markers

Table 9 shows the resistance to antimicrobials in 2014 (more details in annex 9.11). The resistance of BSI acquired outside of the hospital is lower. See table 11-12 for comparison of resistance data for specific MO with data from national and international surveillance programmes.

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Table 9 : Resistance to antimicrobials, Belgian surveillance data 2014

Hospitals Isolates

Acquired in hospital Not acquired in hospital

Microorganism Resistance N % N % N %

Gram + cocci

S. aureus Meti 69 53 146/831 17.6 37/290 12.8

Gly 5 4 4/831 0.5 0/290 0

E. faecalis Gly 1 1 0/390 0 1/68 1.5

E. faecium Gly 11 9 11/278 4 1/22 4.5

Gram – bacilli Enterobacteriaceae

E. coli C3G 78 60 234/1559 15.0 76/1062 7.2

CAR 10 8 9/1559 0.6 2/1062 0.2

K. pneumoniae C3G 63 48 141/504 28.0 (12)/120 10.0

CAR 10 8 18/504 3.5 0/120 0.0

E. cloacae C3G 45 65 94/248 37.9 (6)/32 18.8

CAR 4 3 4/248 1.6 0/32 0.0

P. mirabilis C3G 3 2 2/153 1.3 1/56 1.8

CAR 2 2 2/153 1.3 0/56 0.0

K. oxytoca C3G 19 15 25/163 15.3 (2)/26 7.7

CAR 1 1 1/163 0.6 0/26 0.0

E. aerogenes C3G 43 33 66/122 54.1 (9)/21 42.9

CAR 2 2 (2)/122 1.6 0/21 0.0

Serratia spp. C3G 19 15 32/146 21.9 (6)/20 30.0

CAR 0 0 0/146 0.0 0/20 0.0

Gram - bacilli (non-enterobacteriaceae)

P. aeruginosa CAR 42 32 65/395 16.5 (7)/71 9.9

Acinobacter spp. CAR 11 8 11/139 7.9 0/8 0

Meti=Methicillin ; Gly=glycopeptides (vancomycin, teicoplanin) ; CAR=carbapenems (Imipenem, meropenem, doripenem) ; C3G=cephalosporin 3th generation (cefotoxim, ceftriaxon, ceftazidim) ; *R-CAR included (Intermediate and resistant), N=number

3.2.2.3. Specific incidence bloodstream infections caused by resistant microorganisms

Table 10 shows the distribution and the mean of the incidences density for the 3 most common pathogens. The majority of hospitals report zero cases of BSI caused by resistant strains. The Flemish quality indicator project (VIP2) includes reporting incidence of HA-BSI caused by MRSA: 75% of hospitals report an incidence below 0.25/10 000 pd, corresponding to a median (min-max) of 0 HA-BSI MRSA (0-4) per hospital-trimester.

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Table 10 : Incidence density for bloodstream infections caused by resistant microorganisms, Belgian surveillance data 2014

Gram + Gram -

S. aureus E. coli K. pneumoniae

Phenotype Meti R C3G R CAR (I_R) C3G R CAR (I_R)

N episodes 146 234 9* 141 18**

Hospital-trimesters (N=316) reporting 0 episodes (%)

230 (73) 200 (63) 307 (97) 225 (71) 302 (96)

Incidence / 10.000 pd.

Mean of incidences 0.16 0,23 0.01 0.15 0.01

P25 0 0 0 0 0

(median) P50 0 0.14 0 0 0

P75 0.25 0.39 0 0.25 0

Meti=Meticillin ; CAR=carbapenems (Imipenem, meropenem, doripenem) ; C3G=3th generation cephalosporins (cefotoxim, ceftriaxon, ceftazidim) ; R-CAR includes (Intermediate et resistant); N=number; I=intermediate; R=resistant, P25=percentile 25, P75=percentile 75; * 2/9 are sensitive to C3G, ** 2/18 are sensitive to C3G

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4. RESULTS DATA HOSPITAL STAY (RHM/MKG) Hospital stay records mentioning a secondary diagnostic code of “septicaemia” remained stable from 2000 to 2012. The secondary diagnosis is about comorbity (existed before admission) or a complication (occurred after admission). Since 2008 the RHM/MZG (résume hospitalier minimal/minimale klinische gegevens) also introduced a variable ‘present (or not) on admission’ (NPOA), which means that the complication occurs after admission. This corresponds to the definition of a nosocomial infection, although the timing of acquisition is not specified with NPOA. Incidences computed using these data should in theory be similar to SEP surveillance data. Table 11 shows that RHM/MZG provide lower estimates than the surveillance but the gap is narrowing over time (60 to 25%) due to estimates from surveillance decreasing, and estimates from RHM/MKG increasing over the year. These differences deserves a deeper evaluation.

Table 11: Incidence of hospital-acquired bloodstream infections based on hospital stay data versus surveillance data, 2000-2012

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Total BSI (ICD9 code 038.0-9) 19 796 21 903 22 203 23 538 22 743 22 972 23 158 22 988 23 989 25 025 25 804 26 369 27 202

BSI as secondary diagnostic code

15 599 17 501 17 600 18 733 18 047 17 934 17 616 16 825 16 953 16 993 16 975 17 253 17 672

BSI NPOA / / / / / / / / 7 292 8 345 8 507 8 611 8 650

Incidence

BSI NPOA*/10 000 pd (a) / / / / / / / / 4.8 5.6 5.7 5.7 5.8

BSI secondary**/10 000 pd (b) 10.3 11.5 11.8 12.7 12.4 12.4 12.3 11.9 11.1 11.3 11.3 11.5 11.9

Surveillance BSI/10 000 pd***(c) 7.8 8.3 8.5 8.3 8.8 9.0 9.1 8.6 8.1 8.2 7.9 7.5 7.5

Validation a/c / / / / / / / / 59 68 72 76 77

Validation b/c 132 139 139 153 141 138 135 138 137 138 143 153 159

BSI : bloodstream infection; pd : patient days; *RHM/MKG: assuming those ‘not present at admission’ (NPOA) are hospital-acquired BSI , **RHM/MKG: secondary diagnosis is about comorbidity (existed before admission) or a complication (occurred after admission), *** incidences based on BSI surveillance data

The code BSI secondary was higher compared to when using our surveillance data, while the differences with our surveillance data seem to increase over time (30-60%).

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5. INTERNATIONAL COMPARISONS The HA-BSI remained higher at hospital and ICU level in Belgium compared to Quebec, Canada. The comparison with France is difficult because this ICU-based surveillance included data on patients hospitalised in ICU for at least 2 days. In comparison, the incidences in Belgium at ICU level would therefore be higher if these data take into account only the at risk patients in the denominator.

Table 12: Mean incidence density and exposure to invasive devices – international comparisons

Belgium Quebec(5) France(7) ** Last year available 2014 04/2013 – 03/2014 2013 Surveillance mandatory, hospital wide Volontary, hospital wide ICU N hospitals 130 77 186 (213 ICU)

Incidences mean BSI acquired in hospital /10 000 pd 7.8 5,4 (5.2-5.7) / BSI acquired in ICU / 10 000 pd** 39,8 14,7 (13,2-16,2) 32,2 CLABSI acquired in ICU 13,3/ 10 000 pd 5,5/ 10 000 pd (4.6-6.5) 6.1/10 000 catheter days

Exposition to invasive device BSI with CVC 1 813/6 847 (26%) 507/2 689 (19%) 16% BSI with peripheral /other catheter 208/6 847 (3%) / 9%

ICU : intensive care unit ; pd : patient-days ; ET :endotracheal tube; BSI: bloodstream infection; CLABSI : central-line associated infections; CVC: central venous catheter, N:number; ** surveillance data on patients admitted > 2d in ICU, in Quebec (CA) & SEP surveillance Belgium the denominator includes all patients admitted at ICU

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Our results on antimicrobial resistance in bacteraemia are coherent with those reported by Canada, France and Europe (EARS-Net). Overall, data shows a decrease (less pronounced) in the proportion of MRSA and an increase in the proportion of E. coli and K pneumonia resistant to 3th generation cephalosporin. Resistance against carbapenems for E. coli remains rare in Europe, but continues to increase for K pneumonia and P. aeruginosa.

Table 13: Microorganisms and resistance to antimicrobials – international comparisons

Belgium Quebec(5) France – Multi-resistant bacteria (MRB) (8)

Europe -EARS-Net £ %R (95% IC) (9)

Last year available 2014 04/2013 – 03/2014 2012 2013

Surveillance mandatory, hospital wide Voluntary, hospital wide Voluntary, 1 181 hospitals 30 EU countries -lab network

Microbiology Top 3 mo E. coli (21%), CNS (15%),

S. aureus (11%) S. aureus (21%), E. coli (21%)

Klebsiella sp. & Enterococcus sp. (10%)

CNS (15%), S. aureus (11%), E. coli (10%)

/

Antimicrobial resistance (%) % (N tested) – trend since 2013 % (N tested) – trend since 2013

% (N tested) – trend since 2011

% - trend since 2012

MRSA 18 (831) - decrease 17 (602) – decrease 20,4 (742) – decrease 18 (stable)

E. coli

C3G 15 (1 559) - increase 13 (507) - increase / 12,6 (increase)

CAR 0,6 (1 559) - increase 0 (4) - stable 0.2 -stable 0,2% (increase)

K. pneumoniae

C3G 28 (504) - increase 0 (7) - increase / 30 (increase) CAR 3.5 (504) - increase 0 (4) - stable 1.1-stable 8,3 (increase)

P. aeruginosa CAR 17 (395) - stable 12 (113)- stable / 17,6 (increase)

E. faecium Gly 4 (278) - stable 13 (78)- stable / VRE 8,9 (increase)

E. faecalis Gly 0 (390) - stable 0 (141) -stable / high-level aminogly 30,9(increase)

Mean incidence (/10 000 pd) Incidence resistant MO MRSA 0,16 – decrease since 2013

E.coli C3G-R 0,27 – increase since 2013 E.coli CAR-R 0,01 – stable since 2013 K. pneumoniae C3G-R 0,15 – stable 2013 - CAR-R 0,01 – stable since 2013

/ MRSA 0,37 - stable E. coli ESBL 3.1-increase K. pneu. ESBL 1.1-increase

/

MO=microorganism ; CNS=coagulase negative Staphylococcus ; MRB= multi-resistant bacteria; ESBL= extended spectrum ϐlactamase ; £blood cultures & cerebrospinal fluid from nosocomial and other infections; Gly=glycopeptides; CAR= carbapenem; C3G=Third generation cephalosporin ; MRSA=methicillin resistant S. aureus ; VRE=vancomycin resistant enterococci; pd=patient-days; N=number

32

6. COMPARISON WITH OTHER SOURCES FOR BELGIAN DATA ON ANTIMICROBIAL RESISTANCE Our results on proportions of resistance strains were higher than those reported by the EARS-net and those from the Belgian surveillance on resistant bacteria in 2013. (10) The first includes cultures from blood and cerebrospinal fluid from nosocomial and other infections, the second includes clinical samples from all sites for nosocomial and other infections. These differences in sample origin makes comparisons with our results difficult. In comparison, EARS-Net reports also an increase in the proportion of E. coli and K. pneumoniae resistant to C3G de 2009 à 2013 and the Belgian surveillance on resistant MO, an increase in resistance to ESBL.

Table 14: Resistance to antimicrobials – Belgian comparisons surveillance data, MRSA surveillance data & EARS-net data

Belgian surveillance BSI - 2014 Belgian surveillance on resistant

bacteria– 2013 (10) EARS-Net – 2013 (9)

Antimicrobial resistance markers N Ω

%

resistanceΩ

Incidence density

/10 000pd N ¥ %

resistance¥

Incidence density

/10 000pdß N £

%

resistance£

Trend since 2012

S. aureus 1 121 33 543

MRSA

16.3 0.16

17.4 0.1 1 612 16,9 (15-19) stable

E. coli 2 621

C3G

11.8 0.23 ESBL: 69 078 ESBL: 6.5 ESBL: 0.3 4 051 8 (7-9) increase

Carbapenems

0.4* 0.01 69 772** 0,06** 0.05** 4 246 <0,1 (0-0) stable

K. pneumoniae 624

C3G

24.5 0.15 ESBL: 11 527 ESBL:12.8 ESBL: 0.1 594 15,3 (15-18) decrease

Carbapenems

2.9* 0.01 11 645** 1.4 ** 0.2 ** 618 0,3 (0-1) decrease

P. aeruginosa

Carbapenems 466 15.5* / / / 518 11 (8-14) increase

BSI=bloodstream infection; MO=microorganisms; pd=patient days; *CAR (imipenem, meropenem, doripenem) intermediate / resistant; **Meropenem I/R including clinical and screening

samples; ESBL=extended spectrum beta-lactamase; Ω includes blood cultures (nosocomial / other) ; ß only including blood cultures; £ includes blood cultures & cultures of cerebrospinal

fluid (nosocomial / other) ;¥ includes clinical samples from all sites (nosocomial / other) from acute/chronic hospitals; EARS-net= European Antimicrobial Resistance Surveillance Network (ECDC); I=intermediate; R=resistant; MRSA=methicillin resistant Staphylococcus aureus

7. DISCUSSION Participation An increased number of hospitals participated in the surveillance programme – this is of course related to the mandatory participation (Royal Decree 08/01/2015). Half of them provided data for a complete year, despite the legal obligation being to provide data for only three months per year. The continuous participation over the year may indicate the importance given to these severe infections, but also the feasibility of the registration (median number of HA-BSI per trimester was 14).

Incidences The incidence at hospital level appears relatively stable after a peak in 2006, while the incidence (cumulative and density) at ICU level decreased from 2004 till 2012, and increased in 2013-2014. However, the interpretation of time trends remains difficult since there is an important variation in participating hospitals and by consequence we do not compare the same hospitals over the years. A study conducted in collaboration with an external partner explored ways to improve trends analyses by selecting hospitals which participated at least 5 years between 2000 and 2014 using mixed-effects negative binomial regression modelling with hospital as a random factor (11). This study identified a decreasing trend (-0.5%) both hospital-wide and in the ICU. However, the changes per year were not significant (p=0.055). A sensitivity analysis evaluated the influence on the incidence trends when changing the hospital selection criteria (i.e. minimum 3 or 10 years of surveillance participation). The recommendation from this study was to assess incidence trends in Belgium by selecting hospitals participating at least one trimester during 3 years (not necessarily consecutive) during the observation period. Note that this will soon be the case for all hospitals, given that participation is now mandatory. In 2014, the mean incidence density hospital wide was 7.9/10 000 pd, comparable with the preceding year. It was consistently higher in ICU, in the 8 participating teaching hospitals, and in Brussels (4 teaching hospitals participating in Brussels) where the patients are expected to be more complex and vulnerable to severe infections. Incidence varied widely across hospitals and ICU. This can be partly explained by differences in case mix, but sub-analysis by bed size or by teaching hospitals showed that the variability remains within these (more comparable) subgroups of hospitals. This suggests that there may remain an important potential for infection prevention of HA-BSI (mainly device associated). (12;13) The mean ICU incidence calculated for 37 ICUs (13 hospitals) participating to the Belgian ICU surveillance in 2012 (NSIH-ICU) was 27/10 000 pd.(6) The denominator included only the population at risk for ICU-acquired BSI (those staying more than 2 days in ICU), unlike the ‘SEP’ surveillance which includes all patients admitted in ICU. Estimates from the SEP surveillance data should therefore provide lower estimates than those from the ICU surveillance. It is in fact the opposite. Reasons are unclear, but the fact that a lower number of ICUs participate to the ICU surveillance (N= 37 in 2012) can play a role. There are only a few comparable data at the international level (see table 11), but our results are higher than those registered by the hospital-wide surveillance programme in Quebec (monitoring hospital-wide).(5) We also compared our surveillance data with the hospitals stay data (RHM/MZG) which gathers information on all the hospital stays in Belgium. Although ICD-9 codes may provide a suitable measure of overall septicaemia, it does not include infection timing to allow distinction between hospital onset and community-onset. However, since 2008 a code ‘not present at admission’ was

34

mandated. The incidence of BSI calculated when using hospital stay data (code ‘not present at admission’) was lower than that calculated when using our surveillance data, and the difference between the two measures decreased from 2008-2012. This may be due to the fact that this code was only introduced in 2008 and that users slowly integrate this new code in their work. We will continue to compare the two data source in order to assess the validity of the surveillance data. In 2014, the mean CLABSI rate hospital wide was 2.2 which is an increase since 2012. However, there has been a change in the case definition for CLABSI which resulted in classifying as “CLABSI” some episodes of HA-BSI that would have been previously classified as “BSI of unknown origin”. This corresponds to 25% of the total CLABSI’s, however this proportion has been constant in the calculation of the incidence over time and will continued to be followed over time. There is at any rate room for improvement in Belgium, as many studies have demonstrated that CLABSIs are largely preventable (1;14;15) Because of the workload that the counting of catheter days represents, these data are collected optionally. In practice these data are not collected, and by consequence we cannot adjust for the ratio of exposure i.e. the proportion of hospital days during which patients were exposed to a CVC. We however performed a study exploring the validity of sampling weekdays in ICU order to obtain estimated central line days and created rules for sampling based on the number of central line days per ICU trimester.(16) These rules for sampling in ICU units will be integrated in the next revised protocol.

Description of episodes For 85% of reported episodes, a pathogen has been isolated in a blood culture. Few episodes are reported on neonatal ICU (2%). This may be due to the fact that we do not include in this monitoring, neonatal septicaemia based on clinical symptoms only.

Origin and invasive devices Central venous catheters remain the most frequent origin of BSI acquired in hospital (26%) and in the ICU (34%). Secondary sepsis from an urinary or pulmonary infection come in second (20%) and third (11%) position. An invasive device was present in respectively 41% of episodes due to urinary infections (urinary catheter) and in 29% of pulmonary episodes (endotracheal tube / cannula) episodes. In total, an association with an invasive device is reported in 43% of HA-BSI. Microbiological confirmation was available for (42%) of these episodes. These data highlight the potential for HA-BSI prevention including measures aiming to reduce exposure to invasive devices (less insertion of devices, shorter duration). Several studies have demonstrated that the actions of prevention are successful to reduce the incidence of BSI particularly those related to CVC.(1;14;15;17) Since 2013, Belgium includes the CLABSI incidence as an indicator of the quality of hospital care (http://www.nsih.be/surv_iq/Introduction_fr.html ).

Microorganisms and resistance to antimicrobials The report identified decreasing trends in incidence of Gram-positive bacteria (S. aureus) and increasing trends in Gram-negative bacteria (E. coli, K. pneumonia). Also, the proportion of methicillin resistance in S. aureus (MRSA) continues to decrease while the proportion of resistance to 3th generation cephalosporin in Gram- negative (E. coli, K. pneumonia) continues to increase. This is consistent with the data from other national and international sources.(5;8-10) The slight increase in carbapenem resistance in K. pneumoniae need to be closely monitored.

35

8. CONCLUSION ET RECOMMENDATIONS The participation increased compared to previous years, a consequence of the surveillance becoming mandatory since 2014. However, the proportion of hospital participating for the full year also increased which attests of the interest and feasibility of this surveillance system. The incidences at hospital seem to decrease after a peak in 2006 and those at ICU level reached a peak in 2004 but increased again in 2013 and 2014. Variability is high between hospitals and regions. The increase in trend was also noticed for the bloodstream infections associated to a central line. However, the interpretation of the trend remains difficult due to the variable participation of hospitals over the years. The incidence of bloodstream infections caused by E. coli and K. pneumoniae continue to increase over the observation period. The resistance profiles in this surveillance are comparable with those from EARS-net: decreasing proportions for MRSA and increasing proportions of resistance for 3rd generation cephalosporin for E. coli and K. pneumonia. The results highlighted that there is room for improvement for preventive actions in the Belgian hospitals, with as priority target the bloodstream infections associated with invasive devices.

36

9. ANNEXES

9.1. Calculation of incidences

Table 15 : Calculation of mean incidences and mean of the incidences, Belgian surveillance data

Incidences NUMERATOR DENOMINATOR HOPITAL (ALL services)

Cumulative mean incidence bloodstream infections acquired in hospitals / 1 000 admissions

∑ N SEP ≥2 days in hospital

∑ Total admissions* (£)

Mean incidence density bloodstream infections acquired in hospital / 10 000 patient days

∑ Total patient days* (£)

Mean of cumulative incidences bloodstream infections acquired in hospitals / 1 000 admissions

∑ (cumulative incidences SEP ≥2days in hospital/1 000 admissions) Total N participating hospitals with

available denominators Mean of incidence density bloodstream infections acquired in hospital / 10 000 patient days

∑ (incidence density SEP ≥2days in hospital/ 10 000 patient days)

ICU Cumulative mean incidence bloodstream infections acquired in ICU / 1 000 admissions ICU

∑ N SEP ≥2 days in ICU

∑ Total admissions ICU (£)

Mean incidence density bloodstream infections acquired in ICU / 10 000 patient days ICU

∑ Total patient days ICU (£)

Mean of cumulative incidences bloodstream infections acquired in ICU / 1 000 admissions ICU

∑ (cumulative incidences SEP ≥2days in ICU/1 000 admissions ICU) Total N participating hospitals with

available denominators for ICU Mean of incidence density bloodstream infections acquired in ICU / 10 000 patient days ICU

∑ (incidence density SEP ≥2days in ICU/ 10 000 patient days ICU)

SEP=septicaemia/bloodstream infection, ICU=intensive care unit, *see protocol for included services

(£) For the calculation of the mean incidence, we performed an adjustment for the number of trimesters of participation by hospital; when a hospital participated for more than one trimester, we calculated the mean of the numerators and denominators by dividing by the number of trimesters of participation (for each hospital and per year).

The mean incidence at ICU level are calculated by including in the numerator the number of bloodstream infections acquired in ICU (≥2 days in ICU) and in the denominator the TOTAL number of admissions or patient days in ICU (including patients staying < 2 days in ICU). Therefore, it includes in the denominator a lot of patients who are not at risk for acquiring a bloodstream infection in ICU.

37

9.2. Participation per region

Table 16: Hospital participation by region, Belgian surveillance data 2000-2014

Year Flanders Brussels Wallonia Total

2000 69 5 27 101

2001 33 7 25 65

2002 24 4 30 58

2003 58 6 30 94

2004 30 7 33 70

2005 31 9 34 74

2006 41 12 32 85

2007 42 12 36 90

2008 44 13 33 90

2009 41 9 33 83

2010 36 11 32 79

2011 30 9 26 65

2012 37 9 33 79

2013 56 16 43 115

2014 69 16 45 130

9.3. Annual incidence of bloodstream infections acquired in the teaching and non-teaching hospitals, Belgian surveillance data

Table 17 : Incidence of bloodstream infections acquired in the hospital and at ICU, Belgian surveillance data 2000-2014

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Acquired in teaching hospital

N hospitals* 4 4 3 5 4 5 5 5 6 6 4 4 4 7 8

N trimesters 11 11 9 15 10 12 18 17 16 14 9 10 11 17 25

N BSI acquired in teaching hospital 708 805 555 1 080 696 863 1 231 1 162 1 166 927 681 788 849 1 121 1 700

Mean incidence 1000 adm** 10.4 12.0 9.6 12.8 12.3 12.0 13.1 10.9 10.8 10.1 10.0 10.6 10.3 9.1 8.0

Mean incidence 10 000 pd** 13.9 14.1 11.7 15.2 15 15.4 17.6 15.2 15.4 14.9 14.7 14.4 15.2 13 12.6

Acquired in non-teaching hospitals

N hospitals* 97 61 54 89 66 68 80 85 84 77 74 61 73 104 110

N trimesters 234 151 146 200 158 161 196 215 211 196 188 161 179 268 291 N BSI acquired in non-teaching hospital 4 122 2 853 2 778 3 995 3 292 3 376 3 766 3 685 3 302 3 112 3 002 2 434 2 674 4 206 4 654

Mean incidence 1000 adm** 5.8 5.9 6.5 6.2 6.6 6.3 6.2 6.0 5.6 5.5 5.4 5.2 4.9 5.2 5.2

Mean incidence 10 000 pd** 7.3 7.5 8.1 7.6 8.2 8.2 8.1 7.7 7 7.1 7.1 7 6.6 7.2 7.1

*Hospitals included in the calculation of incidence when denominator per trimester of participation is available; BSI: bloodstream infection; adm: admissions; pd: patient days, N: number

**Mean incidence: total BSI acquired in hospital / total denominator

39

9.4. Annual incidence of bloodstream infections associated or related to central lines, Belgian surveillance data

Table 18 : Incidence of bloodstream infections associated or related to central lines, Belgian surveillance data 2000-2014

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Acquired in hospital

N hospitals* 101 65 58 94 70 73 85 90 90 83 79 65 77 111 117

N trimesters 245 162 156 215 168 173 214 232 227 210 198 171 196 285 312

N CRBSI acquired in hospital 1 053 858 727 1 130 981 1 122 1 267 1 194 1 015 980 879 724 808 1426 1720

N CLABSI acquired in hospital 824 685 604 912 700 784 861 835 707 649 558 519 589 1013 1293

mean CLABSI incidence 10 000 pd** 1.7 2.0 1.8 1.8 2.1 2.2 2.1 2.0 1.8 1.7 1.8 1.7 1.7 2.1 2.2

median CLABSI incidence 10 000 pd 1.3 1.5 1.5 1.5 1.5 1.6 1.6 1.5 1.3 1.2 1.2 1.2 1.3 1.4 1.6

mean CRBSI incidence 10 000 pd** 1.3 1.5 1.5 1.5 1.5 1.6 1.6 1.5 1.3 1.2 1.2 1.2 1.3 1.4 1.7

median CRBSI incidence 10 000 pd 1.2 1.3 1.2 1.1 1.3 1.2 1.0 1.1 0.8 0.8 0.7 0.7 0.7 0.9 0.9

Acquired in Intensive care unit

N hospitals* 79 59 50 76 55 60 61 58 53 51 50 42 48 70 90

N trimesters 165 130 128 165 124 139 150 139 134 131 137 101 106 175 224

N CLABSI acquired in ICU 273 191 163 280 201 266 276 227 212 240 187 154 190 376 389

mean CLABSI incidence 10 000 pd** 18.2 15.6 11.9 13.5 14.0 14.7 13.4 12.6 12.4 13.4 11.9 12.3 11.6 15.7 13.3

median incidence 10 000 pd 12.2 10.7 8.4 10.5 9.5 10.9 10.5 7.1 12.5 7.8 5.1 4.7 7.3 12.6 9.4

Acquired in teaching hospital

N hospitals* 4 4 3 5 4 5 5 5 6 6 4 4 4 7 8

N trimesters 11 11 9 15 10 12 18 17 16 14 9 10 11 17 25

CLABSI 176 224 173 309 287 357 506 506 406 417 309 265 307 461 563

mean CLABSI incidence 10 000 pd** 2.4 2.5 2.8 3.7 5.4 5.3 6.6 5.6 4.3 5.0 4.6 3.9 5.1 4.7 4.2

Acquired in non-teaching hospital

N hospitals* 97 61 54 89 66 68 80 85 84 77 74 61 73 104 110

N trimesters 234 151 146 200 158 161 196 215 211 196 188 161 179 268 291

CLABSI 960 716 634 945 749 839 838 831 710 646 649 512 557 1142 1313

mean CLABSI incidence 10 000 pd** 1.7 1.9 1.7 1.6 1.8 1.8 1.6 1.6 1.4 1.2 1.4 1.4 1.4 1.7 1.9

*Hospitals included in the calculation of incidence when denominator per trimester of participation is available; BSI: Bloodstream infection; pd: patient days; CLABSI: central line associated bloodstream

infections; CRBSI: central line related bloodstream infections; **Mean incidence: total BSI acquired in hospital / total denominator

Figure 9: Mean incidence density for BSI acquired in the hospital and associated to a central line (CLABSI) per region, Belgian surveillance data 2000-2014

CLABSI=Central line associated bloodstream infections, including BSI with central line as suspected origin and “unknown” origin with a CVC present in the 2 days before onset of infection; pd=patient days;

9.5. Distribution of incidence by bed size and length of stay The variability between hospitals when stratifying by bed size remain important. This suggests that differences in case mix do not fully explain the variability between Belgian hospitals (figure 8). The incidence density in chronic hospitals (defined as a mean length of stay ≥16 days) is significantly lower (figure 9, ANOVA, F test=0,004), while it is significantly higher in the 8 teaching hospitals (figure 10, ANOVA, F test=0,0000).

Figure 10 : Incidence density of BSI acquired in the hospital by bed size, Belgian surveillance data 2014

1.7

1.8 2.1

1.4

2.0

2.9 2.8

0

1

2

3

4

5

6

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

CLA

BSI

/ 1

0 0

00

pd

Year

Belgium

Flanders

Wallonia

Brussels

mean 6.6mean 7.7

mean 7.3 mean 8.5

010

20

30

Incid

en

ce r

ate

>200

bed

s (N

hos

p 36

)

200-

399

beds

( N h

osp

46)

400-

599

beds

(N h

osp

21)

>=60

0 be

ds (N

hos

p 15

)

41

Figure 11 : Incidence density of BSI acquired in the hospital by length of stay, Belgian surveillance data 2014

Figure 12 : Incidence density of BSI acquired in the hospital teaching versus non-teaching, Belgian

surveillance data 2014

Boxplot generated with basic commands in STATA (95%)

mean 7.9mean 2.9

010

20

30

Incid

en

ce r

ate

los

<16d

(107

hos

pita

ls)

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(11

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itals)

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30

Incid

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ate

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teac

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(110

hos

pita

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teac

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42

9.6. Number microorganisms, episodes and patients with bloodstream infections

Table 19 : Number microorganisms, episodes and patients with bloodstream infection,

Belgian surveillance data 2014

Bloodstream infection ≥2d

hospital Bloodstream infection ≥2d

ICU

n % n %

N microorganisms (MO) 7,542 100 1647 100

N episodes 6,848 100 1471 100

episode with 1 MO 6,246 91 1316 90

episode with 2 MO 510 8 134 9

episode with 3 MO 92 1 21 1

N patients 6,314 100 1338 100

patients with 1 episode 5,871 93 1242 92

patients with 2 episode 367 6 88 7

patients with ≥3 episode 76 1 8 1

ICU; intensive care unit, d; days, MO; microorganism; N; number

9.7. Origins 2014

Bloodstream infections acquired at the hospital

Table 20 : Bloodstream infections acquired at the hospital (≥2d), per origin and speciality of service, Belgian surveillance data 2014

Origin Geriatrics Oncology Intensive care

unit£ Internal

medicine Paediatrics Surgery Other Total

n % n % n % n % n % n % n % n %

CVC* 143 16 383 44 556 33 398 21 37 47 268 25 28 9 1813 26

Urinary infection 322 35 99 11 172 10 407 21 1 1 261 24 99 33 1361 20 Digestive/abdominal 60 7 115 13 182 11 278 14 11 14 131 12 10 3 787 11

Pulmonary 80 9 44 5 374 22 167 9 4 5 44 4 27 9 740 11 Other secondary infections 88 10 72 8 112 7 183 9 6 8 90 8 37 12 588 9 Surgical site infection 8 1 4 0 84 5 38 2 2 3 108 10 19 6 263 4

Other catheter 20 2 24 3 53 3 74 4 4 5 28 3 5 2 208 3

Invasive device 9 1 9 1 6 0 49 3 0 0 12 1 4 1 89 1

Unknown 178 20 122 14 157 9 336 17 13 17 124 12 68 23 998 15

Total 908 100 872 100 1696 100 1930 100 78 100 1066 100 297 100 6847 100

*If origin « unknown », but central venous catheter (CVC) present within 2 d before onset of infection, the origin was recoded as « CVC » ; £ includes neonatal ICU, d: days, n: number.

44

Bloodstream infections not acquired in hospital

Table 21 : Bloodstream infections not acquired in hospital (<2d), per origin and speciality of service, Belgian surveillance data 2014

Origine Geriatrics Oncology Intensive care unit£

Internal medicine Paediatrics Surgery Other Total

n % n % n % n % n % n % n % n %

CVC* 0 0 30 16 4 2 51 6 5 6 5 1 12 3 107 4

Urinary infection 184 49 35 19 52 22 214 25 9 12 165 48 133 35 792 32 Digestive/abdominal 36 10 21 11 36 15 180 21 6 8 30 9 61 16 370 15

Pleuro-pulmonary 47 13 20 11 68 28 117 13 15 19 12 4 29 8 308 12 Other secondary infections 56 15 29 15 40 17 141 16 23 30 39 11 50 13 378 15 Surgical site infection 0 0 2 1 7 3 9 1 0 0 30 9 6 2 54 2

Other catheter 0 0 2 1 1 0 11 1 1 1 1 0 3 1 17 1 Invasive manipulation 0 0 3 2 1 0 18 2 0 0 27 8 14 4 63 3

Unknown 51 14 47 25 31 13 128 15 18 23 33 10 75 20 383 15

Total 374 100 189 100 240 100 869 100 77 100 342 100 383 100 2 474 100

*If origin « unknown », but central venous catheter (CVC) present within 2 d before onset of infection, the origin was recoded as « CVC » ; £ includes neonatal ICU, ICU; intensive care unit, d; days, n; number

9.8. BSI with invasive device

Tableau 22 : BSI with invasive device, Belgian surveillance data 2014

Acquired in

ICU Acquired in

non-ICU Total acquired

in hospital

BSI with invasive device N (%) N (%) N (%)

CLABSI 497 (100) 1 316 (100) 1 813 (100)

CVC <2d and documented (CRBSI) 206 (42) 572 (43) 778 (43)

Urinary infection 144 (100) 1029 (100) 1 361 (100)

Urinary catheter <7d 109 (72) 509 (49) 674 (50)

Urinary catheter unknown 16 (17) 169 (16) 185 (17)

Urinary catheter and documented 92 (64) 408 (40) 552 (41)

Pulmonary infection 339 (100) 321 (100) 740 (100)

ET/canule 268 (79) 35 (11) 279 (38)

inconnu 25 (10) 27 (8) 52 (9)

ET/canule et documentée 189 (56) 28 (8) 228 (31)

CLABSI=Central line associated bloodstream infections, including BSI with central line as suspected origin and “unknown” origin with a CVC present in the 2 days before onset of infection; CRBSI=central line related bloodstream infection, if the suspected CVC origin has been confirmed by a culture of the catheter tip ET= endotracheal tube ; Documented=same microorganism was found in blood culture and suspected origin ICU; intensive care unit, d; days, n; number, CVC; central venous catheter

A skin contaminant was the exclusive causal MO in 668/1 813 (37%) of CLABSI, from which 323 (48 %) were confirmed by a culture of the catheter.

Table 23 : CLABSI per case definition et microbiological documentation, Belgian surveillance data 2014

Case definition Confirmation micro

BSI with pathogen

BSI with skin contaminant

BSI neonatal with skin

contaminant Total

confirmed 455 304 19 778 (43)

Not confirmed/unknown 690 310 35 1035 (57)

1 145 (63) 614 (34) 54 (3) 1 813 (100)

*CLABSI= central-line associated bloodstream infection : regroups the BSI with origin « CVC » and those with origin « unknown » but in which a central venous catheter (CVC) was present in the two days before onset of BSI; Documented =same microorganism in blood cultures and suspected origin

46

9.9. Microorganisms 2014

Table 24 : Microorganisms causing bloodstream infections, Belgian surveillance data 2014

BSI acquired in

hospital BSI acquired in ICU BSI <2d in hospital

Microorganism N % N % N %

Escherichia coli 1559 20.7 200 12.14 1062 40.32

Staphylococcus aureus 831 11.02 150 9.11 290 11.01

Staphylococcus epidermidis 739 9.8 188 11.41 85 3.23

Klebsiella pneumonia 504 6.68 127 7.71 120 4.56

Pseudomonas aeruginosa 395 5.24 145 8.8 71 2.7

Enterococcus faecalis 390 5.17 111 6.74 68 2.58

Enterococcus faecium 278 3.69 79 4.8 22 0.84

Enterobacter cloaca 248 3.29 67 4.07 32 1.21

Candida albicans 189 2.51 58 3.52 6 0.23

Staphylococcus other 186 2.47 52 3.16 20 0.76

Streptococcus other 180 2.39 25 1.52 124 4.71

Klebsiella oxytoca 163 2.16 36 2.19 26 0.99

Proteus mirabilis 153 2.03 35 2.13 56 2.13

Coag-neg staphylococci 145 1.92 33 2 36 1.37

Serratia marescens 142 1.88 54 3.28 18 0.68

Enterobacter aerogenes 122 1.62 27 1.64 21 0.8

Candida glabrata 88 1.17 28 1.7 6 0.23

Bacteroïdes fragilis 82 1.09 17 1.03 30 1.14

Staphylococcus haemolyticus 80 1.06 22 1.34 3 0.11

Morganella sp. 78 1.03 26 1.58 16 0.61

Streptococcus pneumonia 69 0.91 9 0.55 160 6.07

Acinetobacter baumannii 49 0.65 10 0.61 2 0.08

Citrobacter freundii 40 0.53 11 0.67 12 0.46

Streptococcus sp., not specified 39 0.52 3 0.18 22 0.84

Bacteroides sp., other 38 0.5 14 0.85 6 0.23

Stenotrophomonas maltophilia 37 0.49 9 0.55 1 0.04

Acinetobacter other 36 0.48 1 0.06 5 0.19

Candida parapsilosis 36 0.48 8 0.49 0 0.00

Clostridium other 35 0.46 3 0.18 24 0.91

Acinetobacter sp, not specified 34 0.45 2 0.12 0 0.00

Streptococcus agalactiae 29 0.38 6 0.36 46 1.75

Staphylococcus, not specified 26 0.34 7 0.43 3 0.11

Enterococcus sp., other 24 0.32 2 0.12 3 0.11

Pseudomonadaceae family, other 24 0.32 5 0.3 2 0.08

Candida tropicalis 19 0.25 4 0.24 0 0.00

Citrobacter diversus 19 0.25 6 0.36 7 0.27

Gram positive cocci, other 18 0.24 1 0.06 0 0.00

Anaerobes, other 17 0.23 3 0.18 4 0.15

Lactobacillus sp. 17 0.23 6 0.36 2 0.08

Candida other 16 0.21 2 0.12 0 0.00

Haemophilus influenzae 15 0.2 1 0.06 13 0.49

Proteus vulgaris 13 0.17 3 0.18 4 0.15

47

BSI acquired in

hospital BSI acquired in ICU BSI <2d in hospital

Acinetobacter iwoffii 12 0.16 0 0 1 0.04

Bacteroïdes sp. 12 0.16 3 0.18 2 0.08

Corynebacterium sp. 12 0.16 6 0.36 4 0.15

Listeria monocytogenes 12 0.16 0 0 9 0.34

Prevotella sp. 12 0.16 4 0.24 3 0.11

Citrobacter sp., other 11 0.15 2 0.12 0 0.00

Enterococcus sp, not specified 11 0.15 1 0.06 5 0.19

G-BAC, non enterobacteriaceae, other 11 0.15 1 0,1 10 0.38

Bacteroides sp., not specified 10 0.13 2 0.12 1 0.04

Candida krusei 10 0.13 2 0.12 0 0,0

Citrobacter sp., not specified 10 0.13 1 0.06 1 0.04

Enterobacter sp., other 10 0.13 3 0.18 2 0.08

Streptococcus HCG 10 0.13 2 0.12 27 1.03

Streptococcus pyogenes 10 0.13 0 0 43 1.63

Yeast, other 10 0.13 0 0 3 0.11

Other bacteria sp., not specified 10 0.13 0 0 1 0.04

Hafnia sp. 9 0.12 2 0.12 0 0.00

Aeromonas sp. 8 0.11 1 0.06 7 0.27

Bacteroides sp., other 8 0.11 1 0.06 0 0.00

Enterobacter sp., not specified 8 0.11 1 0.06 0 0.00

Anaerobes, not specified 7 0.09 2 0.12 0 0.00

Enterobacteriaceae sp., other 7 0.09 1 0.06 1 0.04

G-BAC, non enterobacteriaceae, not spec. 7 0.09 0 0 2 0.08

Klebsiella sp., other 7 0.09 1 0.06 1 0.04

Providencia sp. 7 0.09 3 0.18 8 0.30

Achromobacter sp. 6 0.08 2 0.12 1 0.04

Acinetobacter haemolyticus 6 0.08 0 0 0 0.00

Fungi sp., other 6 0.08 0 0 1 0.04

Moraxella catharralis 6 0.08 0 0 5 0.19

Gram+bacilli, other 5 0.07 2 0.12 3 0.11

Klebsiella sp., not specified 5 0.07 0 0 1 0.04

Salmonella sp., not specified 5 0.07 0 0 1 0.04

Actinomyces sp. 4 0.05 1 0.06 5 0.19

Campylobacter sp. 4 0.05 1 0.06 5 0.19

Candida sp., not specified 4 0.05 0 0 0 0.00

Gram+bacilli, not specified 4 0.05 0 0 1 0.04

Gram positive cocci, not specified 4 0.05 1 0.06 10 0.38

Pseudomonas sp., not specified 4 0.05 0 0 1 0.04

Serratia sp., not specified 4 0.05 1 0.06 0 0.00

Clostridium difficile 3 0.04 0 0 1 0.00

Flavobacterium sp. 3 0.04 0 0 0 0.00

Acinetobacter calcoaciticus 2 0.03 0 0 0 0.00

Alcaligenes sp. 2 0.03 0 0 0 0.00

Burkholderia cepacia 2 0.03 2 0.12 1 0.04

Enterobacter agglomerans 2 0.03 0 0 1 0.04

Morganella sp., not specified 2 0.03 0 0 1 0.04

48

BSI acquired in

hospital BSI acquired in ICU BSI <2d in hospital

Enterobacter gergovia 1 0.01 0 0 0 0.00

Enterobacter sakazakii 1 0.01 0 0 0 0.00

Gram negative cocci, not specified 1 0.01 0 0 1 0.04

Gram negative cocci, other 1 0.01 0 0 1 0,0

Haemophilus sp., other 1 0.01 0 0 0 0.00

Haemophilus parainfuenza 1 0.01 0 0 0 0.00

Legionella sp. 1 0.01 0 0 0 0.00

Moraxella sp., other 1 0.01 0 0 3 0.11

Neisseria meningitidis 1 0.01 0 0 9 0.34

Nocardia sp. 1 0.01 0 0 0 0.00

Pasteurella sp. 1 0.01 0 0 5 0.19

Propionibacterium sp. 1 0.01 0 0 3 0.11

Proteus sp., not specified 1 0.01 1 0.06 0 0.00

Proteus sp., other 1 0.01 1 0,1 3 0.11

Salmonella entiritidis 1 0.01 0 0,0 0 0.00

Yersinia sp. 1 0.01 0 0,0 0 0.00

Filaments other 0 0,0 0 0,0 2 0.08

Salmonella Typhimurium 0 0,0 0 0,0 3 0.12

Serratia liquefaciens 0 0,0 0 0,0 2 0.08

Enterobacteria not specified 0 0,0 0 0,0 2 0.08

Neisseria sp., other 0 0,0 0 0,0 1 0.04

Salmonella, other 0 0,0 0 0,0 1 0.04

Shigella sp. 0 0,0 0 0,0 1 0.04

Total 7 542 100 1 647 100 2 634 100

Subject to amendments to the bacteriological nomenclature; G -=gram negatif ; G+=gram positif ; G-BAC= Gram bacil ; STRHCG= Other streptococci haemolytic (C, G) ; sp.=species

9.10. Microorganism per origin - 2014

Table 25 : Microorganisms, per suspected origin of hospital-acquired bloodstream infection, Belgian surveillance data 2014

Microorganism Central line* Art./periph.

catheter/inv.proc. Urinary Pulmonary Surgical Digestive Other Unknown Total

n % n % n % n % n % n % n % n % n %

Enterobacteriaceae 411 21 100 30 1066 73 363 46 134 44 509 55 162 25 387 35 3 132 42

Escherichia coli 124 6 47 14 672 46 104 13 66 22 298 32 66 10 182 17 1 559 21

Klebsiella pneumoniae 94 5 11 3 132 9 93 12 24 8 60 6 31 5 59 5 504 7

Enterobacter cloacae 51 3 10 3 40 3 38 5 14 5 42 5 18 3 35 3 248 3

Proteus mirabilis 15 1 2 1 86 6 12 2 4 1 12 1 7 1 15 1 153 2

Klebsiella oxytoca 37 2 10 3 38 3 23 3 0 0 18 2 9 1 28 3 163 2

Other/not identified* 90 5 20 6 98 7 93 12 26 9 79 9 31 5 68 6 505 7

Gram + cocci 1235 62 191 58 231 16 234 29 107 35 217 23 380 59 474 43 3 069 41

Staphylococcus aureus 225 11 70 21 56 4 108 14 44 15 20 2 176 27 132 12 831 11

Coag-neg. staphylococci 774 39 84 26 24 2 27 3 22 7 9 1 78 12 132 12 1 150 15

Enterococcus faecalis 85 4 12 4 96 7 16 2 19 6 58 6 30 5 74 7 390 5

Enterococcus faecium 71 4 11 3 31 2 11 1 14 5 78 8 20 3 42 4 278 4

Other/not identified* 80 4 14 6 24 1 72 9 8 3 52 6 76 12 94 9 420 6

Gram - bacilli 126 6 19 6 107 7 156 20 21 7 66 7 56 9 110 10 661 9

Pseudomonas aeruginosa 50 3 9 3 88 6 116 15 12 4 47 5 29 5 44 4 395 5

Other/not identified* 76 4 10 3 19 1 40 5 9 3 19 2 27 4 66 6 266 4

Fungi 181 9 13 4 44 3 22 3 13 4 34 4 22 3 49 4 378 5

Candida albicans 93 5 5 2 21 1 11 1 7 2 14 2 12 2 26 2 189 3

Other/not identified* 88 4 8 2 23 2 11 1 6 2 20 2 10 2 23 2 189 3

Anaerobic bacilli 13 1 4 1 6 0 9 1 19 6 94 10 18 3 42 4 205 3

Gram - cocci 3 0 2 1 1 0 5 1 0 0 0 0 0 0 1 0 12 0

Gram + bacilli 22 1 0 0 1 0 4 1 5 2 6 1 5 1 19 2 62 1

Other bacteria 1 0 0 0 2 0 2 0 3 1 1 0 1 0 13 1 23 0

Total 1 992 100 329 100 1 458 100 795 100 302 100 927 100 644 100 1 095 100 7 542 100

*If origin was « unknown », but no other cause found and CVC (central venous catheter) present in the 2 days before start of infection, the origin was analysed as «central line ».

9.11. Resistance to antimicrobials

Table 26 : Resistance to antimicrobials for BSI acquired in the hospital, Belgian surveillance data 2014

N Resistance N %

S. aureus 831 oxa_S & gly_S 674 81

oxa_R & gly_S 137 17

Gly_R 4 0.5

E. faecalis 390 ampi_S & gly_S 299 0.8

Ampi_S & gly_R 0 0

Gly_R 0 0

E. faecium 278 ampi_S & gly_S 21 0.1

Ampi_S & gly_R 1 0

Gly_R 11 4

E. coli 1 559 C3G_S 1241 80

C3G_R & non-ESBL* 34 2

C3G_R & ESBL+ * 154 10

CAR_I/R 9 0.6

K. pneumoniae 504 C3G_S 321 64

C3G_R & non-ESBL* 17 3

C3G_R & ESBL+ * 94 19

CAR_I/R 18 3.5

P. aeruginosa 352 CAZ_S & CAR_S 260 74

CAZ_R & CAR_S 15 4

CAZ_S & CAR_I/R 27 8

CAZ_R & CAR_I/R 26 7

Acinobacter spp. 139 CAR_I/R 11 8

*ESBL missing for E.coli; 35%, for K. pneumoniae 27%; Meti=Methicillin ; Gly=glycopeptides (vancomycin, teicoplanin) ; CAR=carbapenems (Imipenem, meropenem, doripenem) ; C3G=cephalosporin 3th generation (cefotoxim, ceftriaxon, ceftazidim) ;*R-CAR included (Intermediate and resistant), N=number

9.12. Origin of bloodstream infections acquired outside of the hospital

Table 27 : Origin of bloodstream infections acquired outside of hospital, Belgian surveillance data 2014

Origin bloodstream infections not acquired in hospital N (%)

Day hospital 32 (4)

Ambulatory care in hospital 70 (8)

Ambulatory care outside hospital 1 (0)

Other hospital 9 (1)

Other institution 75 (9)

Community 631 (75)

Other 28 (3)

Total 846 (100)

Missing data (1629/2475 BSI not acquired in hospital =66%)

51

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