Surveillance of bloodStream infectionS in belgian hoSpitalS (Sep) · 2017-06-30 · AUTHORS Els...

Surveillance of bloodStream infectionS in belgian hoSpitalS

(Sep)report 2017

AUTHORS

Els DUySbURgH, MD, MPH, PHDMarie-Laurence LAMbERT, MD, MPH, PHD

Surveillance of bloodStream infectionS in belgian hoSpitalS

(Sep)report 2017

Data up to and including 2016

Unit Healthcare-associated infections & antimicrobial resistance | June 2017 | Brussels, BelgiumEdited by: Dr Boudewijn Catry | Head of Unit | Rue J. Wytsmanstraat 14 | 1050 BrusselPHS Report 2017-013ISSN: 2506-9640

Contact: [email protected]

The project is financed by

Acknowledgments

The authors wish to thank all the participating hospitals for their continuous efforts to provide data, the members of the Working group ‘bloodstream infections’ for their help in improving the bloodstream infection surveillance protocol, Sylvanus Fonguh, Xavier Pretlot and Cedric Malache for their contribution in development of the data collection tool, and Elise Wilputte for the lay-out of this report.

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Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172.1. Surveillance programme coordinated by the scientific institute of Public Health

(WIV-ISP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172.1.1. Participation and definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172.1.2. Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

2.2. Hospital stay data comparison of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

3. Results surveillance bloodstream infection in hospitals, 2013-2016. . . . . . . . . . . . . . . . . . . . . . .193.1. Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193.2. Hospital-associated bloodstream infections, hospital-wide. . . . . . . . . . . . . . . . . . . . . . . . . .20

3.2.1. Incidences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203.2.1.1. Incidences hospital-associated bloodstream infections . . . . . . . . . . . . . . . . . . . . . .203.2.1.2. Incidence central line-associated bloodstream infections according to

case definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213.2.1.3. Microorganism specific hospital-associated bloodstream infections

incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223.2.1.4. Distribution of incidences by hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

3.2.2. Description of bloodstream infection episodes, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . .253.2.2.1. Case definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253.2.2.2. Department where the hospital-associated bloodstream infection was

diagnosed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253.2.2.3. origin of hospital-associated bloodstream infection. . . . . . . . . . . . . . . . . . . . . . . . .263.2.2.4. time to infection (infection date – admission date) . . . . . . . . . . . . . . . . . . . . . . . . . .273.2.2.5. Patients’ characteristics and end-of-follow-up status. . . . . . . . . . . . . . . . . . . . . . . . .27

3.2.3. Microorganisms and resistance profiles for marker phenotypes . . . . . . . . . . . . . . . .273.2.3.1. Microorganisms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273.2.3.2. Resistance data for selected microorganisms, 2013-2016 . . . . . . . . . . . . . . . . . . . .293.2.3.3. Antimicrobial resistance by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

3.3. Intensive care unit-associated bloodstream infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .383.3.1. Incidences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

3.3.1.1. Incidences of intensive care unit-associated bloodstream infections . . . . . . . . .383.3.1.2. Incidence of intensive care unit-associated central line-associated

bloodstream infections according to case definition. . . . . . . . . . . . . . . . . . . . . . . . .393.3.2. Description of intensive care unit-associated bloodstream infections, 2016. . . . . .40

3.3.2.1. origin of intensive care unit-associated bloodstream infections. . . . . . . . . . . . . .403.3.2.2. time to infection (infection date – admission date) . . . . . . . . . . . . . . . . . . . . . . . . . .413.3.2.3. End-of-follow-up status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

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3.3.3. Microorganisms and resistance profiles for marker phenotypes . . . . . . . . . . . . . . . . .413.3.3.1. Microorganism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .413.3.3.2. Resistance to antimicrobials for marker phenotypes . . . . . . . . . . . . . . . . . . . . . . . .41

4. Hospital stay data (RHM/MZG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

5. Comparisons between different sources of Belgian antimicrobial resistance data . . . . . . . . .44

6. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

7. Conclusion and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Annexes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .491. Calculation of incidences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .492. Participation by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .493. Hospital-associated bloodstream infections mean incidences in tertiary and

other hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .504. Hospital-wide central line-associated bloodstream infections by case definition . . . . .525. Central line-associated bloodstream infections incidences in tertiary versus

other hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .526. Distribution of hospital-associated blood stream infection incidences by type

of hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .537. Hospital-associated bloodstream infections by origin and speciality/department . . . .548. Invasive device associated hospital-associated bloodstream infections . . . . . . . . . . . . . .559. Number microorganism, episodes and patients with hospital-associated

bloodstream infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5510. End-of-follow-up status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5511. Exhaustive list of microorganisms isolated from bloodstream infections,

Belgian acute care hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5612. Microorganism by suspected (clinical) origin of the bloodstream infection . . . . . . . . . .5913. Microorganism resistance profiles, additional data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6014. Antimicrobial resistance by region, additional data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6315. Intensive care unit-associated central line-associated bloodstream infections

according to case definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6516. Hospital stay data (RHM/MZG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

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TablesTable 1 | Resistance in microorganism isolated from hospital-associated bloodstream

infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Table 2 | Participation in the surveillance of bloodstream infections in Belgian hospitals, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Table 3 | Incidence hospital-associated bloodstream infections (hospital-wide), Belgium 2013-2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Table 4 | Mean incidence central line-associated bloodstream infections, hospital-wide, according to case definition, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Table 5 | Bloodstream infections per case definition, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 6 | Department of hospital-associated bloodstream infection diagnosis, Belgium 2016 . . . . 25

Table 7 | Confirmed and non-confirmed origin of hospital-associated bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Table 8 | Hospital-associated bloodstream infections associated with invasive devices, Belgium 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Table 9 | Microorganisms isolated in bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . 28

Table 10 | Antimicrobial resistance in S. aureus strains isolated from hospital-associated bloodstream infections, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Table 11 | Antimicrobial resistance in E. coli strains isolated from hospital-associated bloodstream infections, Belgium 2013-2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Table 12 | Antimicrobial resistance in K. pneumoniae strains isolated from hospital-associated bloodstream infections, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Table 13 | Antimicrobial resistance in E. cloacae strains isolated from hospital-associated bloodstream infections, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Table 14 | Antimicrobial resistance in P. aeruginosa strains isolated from hospital-associated bloodstream infections, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Table 15 | Antimicrobial resistance in E. faecium strains isolated from hospital-associated bloodstream infections, Belgium 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Table 16 | Resistance in microorganism isolated from hospital-associated bloodstream infections by region, Belgium 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Table 17 | Incidence intensive care unit-associated bloodstream infections, Belgium 2013-2016. . . 38

Table 18 | Mean incidence central line-associated bloodstream infections at intensive care unit according to case definition, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Table 19 | Intensive care unit-associated bloodstream infections associated with invasive devices, Belgium 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Table 20 | Resistance in microorganisms isolated from ICU-associated bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Table 21 | Comparison of antimicrobial resistance data from two different surveillances, Belgium 2015 and 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Table 22 | Calculation of mean incidences, surveillance of bloodstream infections in Belgian hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Table 23 | Participation in the surveillance of bloodstream infections in Belgian hospitals by region, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

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Table 24 | Hospital-associated bloodstream infections incidences in tertiary and other acute care hospitals, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Table 25 | Hospital-associated bloodstream infections incidences in tertiary and non-tertiary hospitals by region, Belgium 2013-2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Table 26 | Central line-associated bloodstream infections, hospital-wide, according to case definition (proportions)*, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Table 27 | Central line-associated bloodstream infections* incidences in tertiary and non-tertiary hospitals, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Table 28 | Hospital-associated bloodstream infections by origin and speciality, Belgium 2016 . . . . . 54

Table 29 | Hospital-associated bloodstream infections associated with invasive devices, Belgium 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Table 30 | Number microorganism, episodes and patients with hospital-associated bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Table 31 | End-of-follow-up status patients with hospital-associated bloodstream infections diagnosed, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Table 32 | Microorganism isolated as etiological agents for bloodstream infections, exhaustive list, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Table 33 | Microorganism from hospital-associated bloodstream infection by origin, Belgian acute care hospitals, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Table 34 | Antimicrobial resistance among hospital-associated bloodstream infections, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Table 35 | Hospitals with at least one resistant microorganism isolated from hospital-associated bloodstream infections, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Table 36 | Antimicrobial resistance in microorganism isolated from hospital-associated and non-hospital-associated bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Table 37 | Resistance in microorganism isolated from non-hospital-associated bloodstream infections by region, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Table 38 | Hospitals with at least one resistant microorganism isolated from hospital-associated bloodstream infection by region, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Table 39 | Intensive care unit-associated central line-associated bloodstream infections according to case definition (proportions)*, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . 65

Table 40 | Incidence of hospital-associated bloodstream infections based on hospital stay data versus surveillance data, Belgium 2000-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

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figureS

Figure 1 | Distribution of incidence of hospital-associated bloodstream infections, tertiary versus other hospitals, Belgium, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 2 | Mean incidence central line-associated bloodstream infection hospital-wide, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 3 | Hospital-associated bloodstream infections mean incidence per microorganism, Belgium 2000-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 4 | origin of hospital-associated bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . 14

Figure 5 | Mean incidence hospital-associated bloodstream infections, hospital-wide, by region, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Figure 6 | Mean incidence central line-associated bloodstream infections (confirmed, probable, and possible), hospital-wide, Belgium 2013-2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Figure 7 | Hospital-associated bloodstream infections mean incidence per microorganism, Belgium 2000-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Figure 8 | Hospital-associated bloodstream infections: incidence distribution across hospitals, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Figure 9 | Hospital-associated bloodstream infections: incidence distribution across hospitals, by region and by hospital category, Belgium 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Figure 10 | Variation hospital-associated bloodstream infections between hospitals, Belgium 2016 24

Figure 11 | origin of hospital-associated bloodstream infections, Belgium 2016 . . . . . . . . . . . . . . . . . . . 26

Figure 12 | Percentage of methicillin resistant S. aureus strains isolated from hospital-associated bloodstream infections, by province, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Figure 13 | Percentage of E. coli strains resistant to third generation cephalosporin isolated from hospital-associated bloodstream infections, by province, Belgium 2016 . . . . . . . . . . . . . . . . 36

Figure 14 | Percentage of K. pneumoniae strains resistant to third generation cephalosporin isolated from hospital-associated bloodstream infections, by province, Belgium 2016 . . 37

Figure 15 | Mean incidence of intensive care unit-associated bloodstream infections, by region, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Figure 16 | Mean incidence central line-associated bloodstream infections (confirmed, probable, and possible) in intensive care units, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Figure 17 | origin of intensive care unit-associated bloodstream infections, Belgium 2016 . . . . . . . . . 40

Figure 18 | Hospital-associated bloodstream infections mean incidences in tertiary and non-tertiary hospitals by region, Belgium 2013-2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Figure 19 | Hospital-associated bloodstream infections distribution across hospitals by hospitals classified by number of beds and by acute care hospital versus long-term care facility, Belgium 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

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ABB

REVI

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AbbREviATiOnSadm Admissions

bC Blood culture

bSi Bloodstream infection

CAR Carbapenem

C3g third generation cephalosporin

CDC Centres for Disease Control and Prevention

Ci Confidence interval

CL Central line

CLAbSi Central line-associated bloodstream infection

CRbSi Central line-related bloodstream Infection

EARS-net European Antimicrobial Resistance Surveillance Network (ECDC)

ECDC European centre for disease prevention and control

E.cloacae Enterobacter cloacae

E. coli Escherichia coli

E. faecalis Enterococcus faecalis

E. faecium Enterococcus faecium

ET Endotracheal tube

EU European Union

gly Glycopeptide

HA-bSi Hospital-associated bloodstream infection

iCU Intensive care unit

iQR interquartile range

K. pneumonia Klebsiella pneumonia

Mbi Mucosal barrier injury

MO Microorganism

MRSA Methicillin resistant Staphylococcus aureus

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

pd Patient-days

P. aeruginosa Pseudomonas aeruginosa

R Resistant

RHM/MZg Résumé hospitalier minimal/Minimale ziekenhuisgegevens

S. aureus Staphylococcus aureus

S. epidermidis Staphylococcus epidermidis

SD Standard deviation

UTi Urinary tract infection

Wiv-iSP Wetenschappelijk Instituut Volksgezondheid - Institut Scientifique de Santé Publique – Scientific Institute of Public Health

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gLOSSARycentral line-associated bloodstream infection (clabSi)

• Confirmed: Bloodstream infection (BSI) with clinical suspicion that a central line (Cl) is the cause of the BSI and the association between the BSI and the Cl is microbiologically confirmed (same micro-organism found in blood culture and on Cl). this is also called central line-related BSI (CRBSI).

• Probable: BSI with clinical suspicion that a Cl is the cause of the BSI but no microbiological confirmation. • Possible: BSI not secondary to an infection at another body site – origin recorded in the surveillance form

as ‘unknown’ - but Cl present within the two days prior to the BSI.

hospital-associated bloodstream infection (ha-bSi)

BSI with date of BSI diagnosis (or first positive blood culture) two days or more after admission at the hospital (infection date – admission date ≥ 2 days).

intensive care unit-associated bloodstream infection (icu-associated bSi)

BSI with date of BSI diagnosis (or first positive blood culture) two days or more after admission at the intensive care unit (ICU).

non hospital-associated bloodstream infection (non-ha-bSi)

BSI diagnosed prior to the second day of hospitalisation.

tertiary hospital

tertiary hospital includes hospitals defined in the list of the Belgian ministry of health (Dienst Datamanagement - Directoraat-Generaal Gezondheidszorg)1 under ‘type hospital’ (soort ziekenhuis – type hôpital) as:

• University hospital (Universitair ziekenhuis - Hôpital universitaire), and• General hospital with university characteristics (Algemeen ziekenhuis met universitair karakter - Hôpital

général à caractère universitaire)

long-term care facility

A long-term care facility is defined as a hospital in which the average length of stay of more than 14 days.

acute care hospital

An acute care hospital is defined as a hospital with the average length of stay of 14 days or less.

1 list dated April 2016: Adressenlijst ziekenhuizen 04/2016 - liste d’adresses des hôpitaux 04/2016

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EXECUTivE SUMMARybackground

Hospital-associated bloodstream infections (HA-BSI) are an important cause of morbidity and mortality. Many HA-BSI, especially those associated with an invasive device, are preventable. the surveillance programme on bloodstream infections (BSI) in Belgian hospitals exists since 1992. the surveillance protocol has been reviewed in 2013, with a focus on the usefulness of data collection for guidance and evaluation of preventive actions. Since 2014, participation in the surveillance, for a minimum of 3 months per year, is mandatory for all acute care hospitals (long-term care facilities if >150 beds). this implies the registration of standardized data for each HA-BSI episode (by definition, BSI occurring 2 days or more after admission).

this report provides a summary of the Belgian surveillance data up to and including 2016.

results

1. Hospital participation In 2016, 140 hospitals registered data for at least 3 months and 90 (64%) did so for the whole year. Participation throughout the year serves best the objective of surveillance as a tool for prevention at hospital level.

2. incidences

2.1. Hospital-associated bloodstream infections In 2016, the mean incidence of HA-BSI was 7.8/10,000 patient-days (pd) hospital-wide, and 29.8/10,000 pd for the bloodstream infections occurring two days or more after admission at the intensive care unit (ICU). these figures are comparable with previous years. Incidence in tertiary hospitals was higher than in other hospitals although variation was large in both groups (see boxplot Figure 12).

Figure 1 | Distribution of incidence of hospital-associated bloodstream infections, tertiary versus other hospitals, belgium, 2016

010

2030

40H

A-B

SI/1

0,00

0 pd

Other hospitals Tertiary hospitals

HA-BSI, hospital-associated bloodstream infections; pd, patient-days

2 the boxplots display the median incidence (red line in the orange box) of the HA-BSI per 10,000 patient-days per hospital per participat-ing quarter. the box limits represent the P25 and P75 values, the grey whiskers mark the lower and upper adjusted values (respectively P25 - 1.5 IQR and P75 + 1.5 IQR) and the dots represent the outliers (outside values).

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2.2. Central line-associated bloodstream infections Central line-associated bloodstream infections (ClABSI) are classified as ‘confirmed’ (clinical suspicion that central line is the cause of the bloodstream infection, with microbiological confirmation), ‘probable’ (clinical suspicion, no microbiological confirmation), and ‘possible’ (bloodstream infection not secondary to an infection at another body site – origin recorded in surveillance form as ‘unknown’ - but central line present within the two days prior to the BSI). Compared to 2013, the ClABSI incidence decreased in 2016 (Figure 2). In 2016, 41% of all ClABSI were ‘confirmed’, 34% ‘probable’, and 25% ‘possible’.

Figure 2 | Mean incidence central line-associated bloodstream infection hospital-wide, belgium 2013-2016

0.0

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Confirmed +probable +possibleConfirmed +probable

Confirmed

ClABSI, central line-associated bloodstream infections; pd, patient-days

2.3. Hospital-associated bloodstream infections per microorganismsMicroorganism specific incidences of HA-BSI for the most common microorganisms since 2000 are given in Figure 33. this graph illustrates long-term time trends of an increase in Gram-negative microorganisms (E. coli and K. pneumonia). the incidence of HA-BSI with S. aureus remained more or less the same. the incidence of HA-BSI due to K. pneumoniae has more than doubled since 2000.

Figure 3 | Hospital-associated bloodstream infections mean incidence per microorganism, belgium 2000-2016

0.00.20.40.60.81.01.21.41.61.82.0

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Staphylococcus aureus

Klebsiella pneumonia

Pseudomonas aeruginosa

Enterococcus faecalis

HA-BSI, hospital-associated bloodstream infections; Mo, microorganism; pd, patient-days

3 Historical data included because despite protocol changes in 2013, this indicator provides meaningful data on long-term time trends interpretation.

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3. Description of hospital-associated bloodstream infection episodes, 2016In 2016, a total of 7,627 HA-BSI episodes were recorded; 88% of these met the definition ‘at least one blood culture with a pathogen’ and 11% the definition ‘a skin contaminant was isolated in at least two different blood cultures’. one episode out of five (21%) occurred two days or later after admission in ICU (definition of ICU-associated bloodstream infection).

Median number of days between admission in hospital and onset of HA-BSI was 13 days. Median age of the patients was 71 years of age. Almost one out of five patients (18%) with HA-BSI died. However, the causal link of this outcome with HA-BSI is impossible to determine with our data.

the most common origin of HA-BSI, hospital-wide, was a central line (23%)4, followed by urinary tract infection (22%) (Figure 4). In ICU the most common origin was a central line (33%) followed by pulmonary infection (24%). For 48% of the HA-BSI (hospital-wide) the origin of the infection was confirmed (same microorganism isolated from blood cultures and the site considered to be the source of infection). An invasive device was associated directly (central line) or indirectly (urinary catheter, endotracheal tube) in 40% of the hospital-wide HA-BSI and in 58% of the ICU-associated BSI.

Figure 4 | Origin of hospital-associated bloodstream infections, belgium 2016

23%

5%

13% 12%

3% 11%

4%

22%

7%

59%

Secondary to an infection at another body site

Central line*

Other catheter/ Invasive manipulation

Unknown

Gastro-intestinal infection

Mucosal barrier injury

Pulmonary infection

Other secondary infection

Urinary tract infection

Surgical site infection

* Includes ‘confirmed’, ‘probable’ and ‘possible’ central line associated bloodstream infection

4. Microorganisms and antimicrobial resistance profilesthe most common microorganisms (Mo) isolated from HA-BSI in 2016 were E. coli (23%), S. aureus (11%), and S. epidermidis (9%). less than half of the hospitals reported a case of HA-BSI caused by a methicillin resistant S. aureus (MRSA) (table 1).

Antimicrobial resistance for selected marker phenotypes is shown in table 1. Between 2013 and 2016, fol-lowing changes in proportion of resistant Mo were statistically significant:

• for S. aureus, decrease in methicillin resistance (from 20.8% to 15.7%) and, increase in resistance to glycopeptides (from 0.0% to 0.7%)5,

• for K. pneumoniae, increase in resistance to third generation cephalosporins (from 25.7% to 34.3%) and carbapenems (2.4% to 6.4%),

• for E. cloacae, decrease in resistance to third generation cephalosporins (from 43.8% to 35.3%)other changes (if any) were not statistically significant.

4 Including ‘confirmed’, ‘probable’ and ‘possible’ ClABSI5 Positive glycopeptide resistance results from a peripheral laboratory should be confirmed by a reference laboratory. this is not always

done, and we cannot exclude some false-positive among these results [1,2].

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Table 1 | Resistance in microorganism isolated from hospital-associated bloodstream infections, belgium 2016

microorganisms% hospitals with >= one resistant

case*antibiotics n resistant/

tested % (n=140)

Staphylococcus aureus Meti 137/874 16 47

Gly 6/874 1 4

Enterococcus faecalis Gly 1/406 0.2 1

Enterococcus faecium Gly 15/344 4 7

Escherichia coli C3G 282/1,847 15 65

CAR 9/1,847 1 6

Klebsiella pneumonia C3G 230/671 34 54

CAR 43/671 6 16

Enterobacter cloacae C3G 113/320 35 44

CAR 10/320 3 6

Pseudomonas aeruginosa CAR 61/392 16 24

Acinetobacter spp. CAR 3/117 3 2

C3G, third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidim); CAR, carbapenems (imipenem, meropenem, doripenem); Gly, glycopeptides (vancomycin, teicoplanin); Meti, Methicillin; N, number.

* Hospitals participate 1, 2, 3 or 4 quarters

Future of surveillance • Validation of the data: data were never validated since the start of the surveillance.• transition to new software-platform (Healthdata) in July 2017.

Conclusions - key points • Participation in the surveillance of HA-BSI is mandatory since 2014. there is an increase in the proportion

of hospitals contributing data for the entire year (64% in 2016). • the incidence of HA-BSI, at 7.8/10,000 patient-days, has changed little in the last years, and findings are

fairly consistent: º Higher incidence in tertiary hospitals

º Higher incidence in ICU (in 2016, about four times higher incidence in ICU than the one found hospital-wide)

º there is a large variation in HA-BSI incidence between hospitals. this suggests a potential for prevention and/or a need for data validation.

º Compared to 2013 the incidence of central line-associated bloodstream infections decreased. Among HA-BSI in 2016, 40% HA-BSI were directly (Cl – 23%) or indirectly (urinary catheter or endotracheal tube) associated with an invasive device. these infections associated with invasive devices are a priority target for prevention.

º the most common microorganisms isolated from HA-BSI were E. coli and S. aureus. Since 2000, the incidence of HA-BSI with E. coli and K. pneumonia has increased.

• Since 2013, methicillin resistance in S. aureus has decreased, while resistance to third generation cephalosporins and carbapenems in K. pneumoniae has increased.

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1. inTRODUCTiOnHospital-associated bloodstream infections (HA-BSI) cause considerable morbidity and mortality and have an important potential for prevention, especially for those associated with invasive devices [3-8]. In Belgium, a national hospital-wide surveillance system for HA-BSI exists since 1992 [9]. the incidence density of central line-associated bloodstream infections (ClABSI) is also included as outcome indicator in the national quality indicator project that focuses on hospital infection control and prevention [10].

the surveillance programme on HA-BSI in Belgian hospitals provides a standardized tool (1) to allow hospitals to follow-up their own HA-BSI and associated antimicrobial resistance trends at hospital and intensive care unit (ICU) level, and (2) to analyse data at national level.

Participation in the surveillance for a minimum of one quarter a year is for all acute care hospitals and for long-term care facilities if >150 beds legally required since July 2014 (Royal decree 08-01-2015) [9]. the surveillance protocol has been reviewed in 2013. the updated protocol aimed to focus on the usefulness of the surveillance as a tool for prevention at hospital level. An online data entry tool was also developed which displays local hospital based results in real time (http://nsihweb.wiv-isp.be/).

this report describes trends in incidences of HA-BSI, causal microorganisms (Mo), and their antimicrobial resistance profiles until 2016 and provides a more detailed description of the 2016 BSI data.

http://nsihweb.wiv-isp.be/

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2. METHODS

2.1. SURvEiLLAnCE PROgRAMME COORDinATED by THE SCiEnTiFiC inSTiTUTE OF PUbLiC HEALTH (Wiv-iSP)

2.1.1. participation and definitions

Participation criteria details and modalities for data collection can be found in the latest version of the protocol dated January 2016 (http://www.nsih.be/download/SEP_protocol_v4%203_Nl.pdf and http://www.nsih.be/download/SEP_protocol_v4.3_FR.pdf).

only laboratory confirmed bloodstream infections (BSI) are recorded. the surveillance uses the criterion ‘BSI occurring two days or more after admission’ as proxy-indicator for a BSI acquired in a hospital. BSI defined as such are called ‘hospital-associated bloodstream infections’. Similarly, an ICU-associated BSI is defined as a BSI occurring two days or more after admission at the ICU. Registration of HA-BSI is mandatory. BSI occurring <2d after admission (for example community acquired or acquired in another hospital or long-term care facility) can be registered optionally.

the suspected origin of the BSI is based on clinical identification. If this suspected origin is a central line (Cl) we identify, based on the registration in the data entry tool6, three different ClABSI case definitions:

• Confirmed: BSI with clinical suspicion that a Cl is the cause of the BSI and the association between the BSI and the Cl is microbiologically confirmed (same Mo found in blood culture (BC) and on Cl).

• Probable: BSI with clinical suspicion that a Cl is the cause of the BSI but no microbiological confirmation.

• Possible: BSI not secondary to an infection at another body site – origin recorded in the surveillance form as ‘unknown’ – but Cl present within the two days prior to the BSI.

2.1.2. data analysis

this report presents the analysis, mainly descriptive, of surveillance data up to 2016 (database data as per 8 April 2017). Historical data (collected before the protocol revision in 2012) are not always comparable and because of this data from before 2013 are not always included in this report. they have been used only for trends in Mo specific incidence data. For data on HA-BSI before 2013, see previous reports [9].

Details on the methods used to compute incidences are given in Annex 1. In brief, the mean incidence was computed as the sum of numerators divided by the sum of denominators. to calculate medians7 the reporting quarter was used as unit of analysis.

to compare the HA-BSI incidences of the three Belgian regions we applied direct standardisation. For this we used the hospital population (number patient-days) distribution between tertiary and non-tertiary hospitals in Brussels as standard (reference) population.

A Pearson chi-square test was used to check differences in antimicrobial resistance between regions.

Boxplots and funnel plots were used to assess variability of data. A boxplot consist of a box with whiskers and may have some dots below or above these whiskers. the line in the box displays the median value, the box limits represent the P25 and P75 values, the whiskers mark the lower and upper adjusted values (respectively P25 - 1.5 IQR and P75 + 1.5 IQR) and the dots represent the outliers (outside values). In a Funnel plot an estimate of a parameter is plotted against a measure of its precision, here number of HA-BSI per 10,000 pd against size of the hospital (number of patient-days). Funnel plots gives a visual identification of outliers – curved lines (above or below 2SD (95%) and 3 SD (99.7%)).

6 Registration under ‘2.2 presumed origin BSI’ as ‘central vascular catheter’ (is Cl) or as ‘if origin central vascular catheter, mucosal barrier injury or unknown; central vascular catheter present in the 2 days prior to the infection’ (http://www.nsih.be/surv_sep/docs/user%20manual%20SEP%20website%20%282%29_nl.pdf and http://www.nsih.be/surv_sep/docs/User%20manual%20SEP%20siteweb%282%29_fr.pdf )

7 Median: incidences of the HA-BSI per hospital per quarter divided by total hospital-quarters. Mean and median include only data for which the denominator (number admissions or patient-days) is available.

http://www.nsih.be/download/SEP_protocol_v4%203_NL.pdf

http://www.nsih.be/download/SEP_protocol_v4.3_FR.pdf

http://www.nsih.be/download/SEP_protocol_v4.3_FR.pdf

http://www.nsih.be/surv_sep/docs/user%20manual%20SEP%20website%20%282%29_nl.pdf

http://www.nsih.be/surv_sep/docs/user%20manual%20SEP%20website%20%282%29_nl.pdf

http://www.nsih.be/surv_sep/docs/User%20manual%20SEP%20siteweb%282%29_fr.pdf

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We fitted a negative binomial regression model with hospital as random effect and 2013 as reference year to explore trends in incidence of HA-BSI, ClABSI and antimicrobial resistant isolates. to assess whether trend observed in proportions of resistant Mo among all Mo isolated were statistically significant, we used chi-square for trends.

Regarding resistance; ‘intermediary’ resistance was categorized in the analysis as ‘resistant’.

Data was analysed in StAtA 14.1. (StataCorp lP, College Station, texas, USA) except, for the funnel plots that were designed using the tool developed by the ‘Association of Public Health observatories - Public Health England’8.

2.2. HOSPiTAL STAy DATA COMPARiSOn OF FinDingS

In Belgium, each hospital stay has to be formally registered (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) [11]. We analysed hospital stay data with an ICD9 code 038.01-038.09 (‘septicemia’) from 2000 to 2014 (most recent available data). In 2008 a new variable has been introduced – ‘diagnosis not present on admission’, which means that the complication occurred after admission.

Data in this report was provided by the Federal Public Service Health, Food chain safety and Environment (Federale overheidsdienst Volksgezondheid, Veiligheid van de Voedselketen en leefmilieu/Service public fédéral Santé publique, Sécurité de la Chaîne alimentaire et Environnement).

8 http://www.apho.org.uk/default.aspx?RID=39403 - Analytical tools for Public Health: Funnel plot for rates (including directly stan-dardised rates)

http://www.apho.org.uk/default.aspx?RID=39403

http://www.apho.org.uk/resource/view.aspx?RID=47240

http://www.apho.org.uk/resource/view.aspx?RID=47240

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3. RESULTS SURvEiLLAnCE bLOODSTREAM inFECTiOn in HOSPiTALS, 2013-2016

3.1. PARTiCiPATiOn

the number of hospitals participating for at least one quarter is quite stable since 2014; the year participation at the surveillance became mandatory (table 2). this is also the case for each of the three Belgian regions separately (Annex 2, table 23). the number of hospitals participating for a whole year increased since 2013 (table 2).

In 2016, 140 hospitals participated in the surveillance of BSI in Belgian hospital. 90 (64%) hospitals participated the whole year. Altogether, data for 428 quarters were submitted from which 413 (96%) quarters had denominator data available.

Table 2 | Participation in the surveillance of bloodstream infections in Belgian hospitals, Belgium 2013-2016

n hospitals participating (%)*

n participating quarters 2013 2014 2015 2016

At least 1 quarter 119 (100) 133 (100) 143 (100) 140 (100)

1 quarter 41 (35) 42 (32) 41 (29) 37 (26)

2 quarters 17 (14) 17 (13) 15 (10) 8 (6)

3 quarters 6 (5) 4 (3) 3 (2) 5 (4)

4 quarters (whole year) 55 (46) 70 (53) 84 (59) 90 (64)

total hospital-quarters313 368 416 428

N, number

* Hospitals as identified by their NSIH code designed for surveillance purposes (www.nsih.be)

http://www.nsih.be

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3.2. HOSPiTAL-ASSOCiATED bLOODSTREAM inFECTiOnS, HOSPiTAL-WiDE

3.2.1. incidences

3.2.1.1. Incidences hospital-associated bloodstream infectionsthe incidence of HA-BSI in Belgian hospitals remained more or less stable since 2013 with no statistically significant changes in the observed trend (table 3 and Figure 5).

Table 3 | incidence hospital-associated bloodstream infections (hospital-wide), belgium 2013-2016

Year 2013 2014 2015 2016

N hospitals included in calculation of incidence* 118 132 142 135

N hospital-quarters 308 367 414 413

N HA-BSI 5,497 6,864 7,848 7,530

Cumulative incidence per 1,000 adm

mean** 5.5 5.6 5.7 5.3

median*** 5.1 4.7 4.7 4.6

Incidence density per 10,000 pd

mean** 7.7 7.7 8.2 7.8

median*** 6.5 6.2 6.3 6.2

adm, admissions; HA-BSI, hospital-associated BSI; N, number; pd, patient-days

* Hospitals included when denominator of the participating quarter was available is quarter

** total hospital-associated BSI/total denominator

*** Unit of analysis used to calculate median is quarter

Figure 5 | Mean incidence hospital-associated bloodstream infections, hospital-wide, by region, belgium 2013-2016

7.8

9.8

7.6 7.3

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4

6

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2013 2014 2015 2016

HA-B

SI/1

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Year

Belgium

Brussels

Wallonia

Flanders

HA-BSI, hospital-associated bloodstream infections; pd, patient-days

Figure 5 shows also HA-BSI incidences by region. Compared to 2013 the incidences decreased in Brussels and Wallonia and increased in Flanders; however none of these findings are statistically significant.

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HA-BSI incidences are higher in Brussels compared to the two other regions. Since Brussels has more tertiary hospitals9,10, observed differences in incidence of hospital-associated bloodstream infections could be the result of confounding by type of facility (tertiary versus other types) as we found that HA-BSI incidence in tertiary hospitals was persistently higher than in other hospitals (Annex 3, table 24 and 25, Figure 18). We therefore applied on the 2016 data direct standardization to control for potential confounding. As standard population we used the hospital population of Brussels (patient-days per type of facility), to which we applied rates observed in all three regions to obtain standardized rate ratios. After standardization the HA-BSI incidence rate in Brussels was found to be similar to those of Flanders and Wallonia. Standardized rate ratios for the latter regions were 0.97 and 0.95 respectively when compared to Brussels.

the incidence of HA-BSI in tertiary hospitals per 10,000 patient-days (pd) increased statistically significantly from 9.7 in 2013 to 11.6 in 2016 (incidence rate ratio 1.23 with 95% CI [1.01-1.49]). In non-tertiary hospitals the incidence decreased slightly however this decrease is not statistically significant (Annex 3, table 24 and Figure 18).

In 2016, the median number of HA-BSI episodes in Belgian hospitals was 12 (IQR 6-22) episodes per quarter.

3.2.1.2. Incidence central line-associated bloodstream infections according to case definitionCentral line-associated bloodstream infection (ClABSI) refers to a HA-BSI with a central vascular catheter or central line (Cl) as the suspected source of the infection. In 2016, 41% were confirmed ClABSI, 34% probable ClABSI and 25% possible ClABSI. these proportions remained more or less the same each year (Annex 4, table 26) and incidences varied accordingly (table 4). Comparing 2013 to 2016, ClABSI incidence (three case definitions together) decreased from 2.1 ClABSI/10,000 pd to 1.8 ClABSI/10,000 pd, this decrease is statistically significant (incidence rate ratio 0.86 with 95% CI [0.76-0.97]) (Figure 6).

the mean ClABSI incidence (three case definitions together) remained about two times as high in tertiary hospitals compared with other hospitals (Annex 5, table 27).

Table 4 | Mean incidence central line-associated bloodstream infections, hospital-wide, according to case definition, belgium 2013-2016

Year 2013 2014 2015 2016

Confirmed ClABSI

N* 605 765 910 704

mean incidence per 10,000 pd 0.8 0.9 0.9 0.7

Probable ClABSI

N* 455 600 736 597


Possible ClABSI

N* 421 465 460 420


total clabSi

N* 1,481 1,830 2,106 1,721

mean incidence per 10,000 pd 2.1 2.1 2.2 1.8 ClABSI, central line-associated bloodstream infection; N, number; pd, patient-days

* Includes only those episodes for which a denominator is available

9 ‘tertiary hospitals’ include the hospitals defined as ‘university hospital’ and ‘general hospital with university characteristics’ in the ‘Adressenlijst ziekenhuizen 04/2016 - Liste d’adresses des hôpitaux 04/2016’ published by FoD volksgezondheid - santé publique.

10 Proportion (absolute numbers and %) of tertiary hospitals participating by region in 2016; - Brussels: 6/17 (35%) - Flanders: 8/67 (12%) - Wallonia: 8/51 (16%)

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Figure 6 | Mean incidence central line-associated bloodstream infections (confirmed, probable, and possible), hospital-wide, belgium 2013-2016

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In 2016, the median number of hospital-wide ClABSI (including confirmed, probable and possible cases) was 2 (IQR 0-6) episodes per quarter.

3.2.1.3. Microorganism specific hospital-associated bloodstream infections incidenceMo specific incidences of HA-BSI since 2000 for the most common Mo are given in Figure 7. this graph illustrates long-term time trends of an increase in Gram-negative Mo (E. coli and K. pneumonia) the incidence of HA-BSI with S. aureus remained more or less the same. Since 2000, the incidence of HA-BSI with K. pneumoniae as causal Mo more than doubled.

Figure 7 | Hospital-associated bloodstream infections mean incidence per microorganism, belgium 2000-2016

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Pseudomonas aeruginosa

Enterococcus faecalis

HA-BSI, hospital-associated bloodstream infection; Mo, microorganism; pd, patient-days

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3.2.1.4. Distribution of incidences by hospital In 2016, similar to previous years, there was a large variation in the incidence of HA-BSI between hospitals as shown in the boxplot11 and funnel plot12 below (Figures 8 and 10). In both graphs several outliers are noticed. Incidence is higher in tertiary hospitals, in Brussels, in bigger hospitals and in acute care hospitals (Figure 9 and Annex 6, Figure 20), however within group variation seems larger than between group variation.

It would be useful to examine the outliers (extreme values) more in-depth to find and understand the reason of these values and the variation.

Figure 8 | Hospital-associated bloodstream infections: incidence distribution across hospitals, belgium 2016

010

2030

40H

A-B

SI/1

0,00

0 pd

HA-BSI, hospital-associated bloodstream infection; pd, patient-days

Figure 9 | Hospital-associated bloodstream infections: incidence distribution across hospitals, by region and by hospital category, belgium 2016

010

2030

40H

A-B

SI/1

0,00

0 pd

Flanders Wallonia Brussels

010

2030

40H

A-B

SI/1

0,00

0 pd

Other hospitals Tertiary hospitals


11 the boxplots display the median incidence (red line in the orange box) of the HA-BSI per 10,000 patient-days per hospital per participat-ing quarter. the box limits represent the P25 and P75 values, the grey whiskers mark the lower and upper adjusted values (respectively P25 - 1.5 IQR and P75 + 1.5 IQR) and the dots represent the outliers (outside values).

12 Funnel plots are a graphical aid for institutional comparisons. An estimate of the parameter is plotted against a measure of its precision, here number of HA-BSI per 10,000 pd against size of the hospital (number of patient-days). Funnel plots gives a visual identification of outliers – curved lines (above or below 2SD (95%) and 3 SD (99.7%)) and are used to assess outliers and validate data.

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Figure 10 | variation hospital-associated bloodstream infections between hospitals, belgium 2016

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

0 20000 40000 60000 80000 100000 120000

HA-B

SI p

er 1

0,00

0 Pa

tient

day

s, 2

016

Patient days

Mean incidences HA-BSI per hospital per quarter, 2016

DataAverage2SD limits3SD limits

Source: HCAI Data Capture System Note: Population is adjusted due to Standardisation Calculations

HA-BSI, hospital-associated bloodstream infection; SD, standard deviation

the funnel plot gives a visual identification of outliers; above or below 2SD (95%) and 3SD (99.7%).

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3.2.2. description of bloodstream infection episodes, 2016

In 2016, 140 hospitals registered together 10,106 BSI of which 7,627 were reported as HA-BSI. twelve (2.9%) of the 413 quarters with available denominator data, had no episode of HA-BSI reported. these 12 quarters represented 8 different hospitals.

3.2.2.1. Case definitionAn overview of the BSI by case definition is given in table 5.

Table 5 | bloodstream infections per case definition, belgium 2016

case definition*hospital-associated bSi non-ha-bSi

n (%) n (%)

At least one BC positive for a recognised pathogen 6,699 (88) 2,373 (96)

At least two different BC positive for the same skin con-taminant microorganisms 874 (11) 104 (4)

only one positive BC for a coagulase negative staphylo-coccus (this applies only to neonatal cases) 54 (1) 2 (0)

total analysed bSi 7,627 (100) 2,479 (100)BSI, bloodstream infection; CNS, coagulase negative staphylococci; BC, blood culture; N, number; pos., positive

* Excluding case definition unknown

3.2.2.2. Department where the hospital-associated bloodstream infection was diagnosedAlmost a quarter of all HA-BSI were diagnosed in ICU (table 6). of these ICU diagnosed BSI, 1,586 (89%) were ICU-associated BSI (see chapter 3.3 ICU findings).

Table 6 | Department of hospital-associated bloodstream infection diagnosis, belgium 2016

department n %

Medical department 1,809 24

Gastro-enterology 531 7

Cardiology 247 3

Pneumology 186 2

Nephrology 145 2

Other 700 9

ICU* 1,777 23

Surgery 1,120 15

Geriatrics 1,130 15

Hemato-oncology 881 12

Pediatrics 113 1

obstetrics/gynaecology 64 1

other 733 10

total 7,627 100ICU, intensive care unit

* ‘Diagnosed in ICU’ is different than ‘ICU-associated’

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3.2.2.3. Origin of hospital-associated bloodstream infectiontwenty-three percent of HA-BSI were associated with a central line (Cl) (table 7, Figure 11). this was the main single suspected origin of HA-BSI diagnosed in ICU, oncology and paediatrics. At the other departments, being geriatrics, the medical department, obstetrics/gynaecology, and surgery, urinary tract infection (UtI) was the main suspected origin (Annex 7, table 28). 68% of all ClABSI was not diagnosed in ICU.

the definition of mucosal barrier injuries (MBI) as a possible origin of HA-BSI was introduced in 2015. In 2015, only 20 cases from 6 different hospitals were reported. this increased to 208 cases reported by 31 different hospitals in 2016 (table 7).

Forty eight percentage of the clinically suspected sources were confirmed (same Mo found in blood culture(s) and suspected origin). the proportion of confirmation varies by origin (table 7).

Table 7 | Confirmed and non-confirmed origin of hospital-associated bloodstream infections, belgium 2016

origin

hospital-associated bloodstream infection

confirmed non-confirmed total

n % n % n %ClABSI* 716 20 1,027 26 1,743 23

Urinary tract infection 1,384 38 261 7 1,645 22

with catheter 617 108 725

Gastro-intestinal infection 234 6 684 17 918 12

Pulmonary infection 490 13 342 9 832 11

with endotracheal tube/cannula 224 52 276

Surgical site infection 227 6 110 3 337 4

Peripheral and other catheter 162 4 130 3 292 4

Mucosal barrier injury 60 2 148 4 208 3

Invasive manipulation 34 1 52 1 86 1

other secondary infection** 262 7 283 7 545 7

Unknown 92 3 929 23 1,021 13

total 3,666 100 3,961 100 7,627 100ClABSI, central line-associated bloodstream infection; N, number

* Includes ‘probable’ and ‘possible’ ClABSI

** Skin/soft tissue and other

Figure 11 | Origin of hospital-associated bloodstream infections, belgium 2016

23%

5%

13% 12%

3% 11%

4%

22%

7%

59%


Central line*


Unknown



Pulmonary infection

Other secondary infection

Urinary tract infection

Surgical site infection

* Includes ‘confirmed’, ‘probable’ and ‘possible’ central line-associated bloodstream infection

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Hospital-associated bloodstream infections associated with invasive devicesForty percentage of all HA-BSI were infections associated directly or indirectly with an invasive devise among which 57% (1,719/3,036) were confirmed (Annex 8, table 29).

table 8 shows that 725 (44%) of all HA-BSI with a UtI as origin were catheter associated. of these 725 cases, 617 cases (85%) were confirmed (same Mo found in blood culture(s) and on device). Regarding HA-BSI with a pulmonary infections as suspected origin, 33% of these BSI were endotracheal tube (Et) associated of which 81% were confirmed.

Table 8 | Hospital-associated bloodstream infections associated with invasive devices, belgium 2016

ha-bSi

ha-bSi n %

ClABSI* 1,743 100

Confirmed (CRBSI) 716 41

Urinary tract infection 1,645 100

Urinary catheter present 725 44

Presence urinary catheter unknown 170 10

Urinary catheter as origin of HA-BSI is confirmed 617 38

Pulmonary infection 832 100

Endotracheal tube present 276 33

Presence endotracheal tube unknown 84 10

Endotracheal tube as origin of HA-BSI is confirmed 224 27

Peripheral and other catheter associated BSI 292 100

Confirmed 162 55

BSI, bloodstream infection; ClABSI, central line-associated bloodstream infection; CRBSI, central line-related bloodstream infection; HA-BSI, hospital-associated bloodstream infection; N, number

* Includes ‘confirmed’, ‘probable’ and ‘possible’ ClABSI

3.2.2.4. Time to infection (infection date – admission date)Median time to onset of HA-BSI was 13 days (IQR 6-25) after hospitalisation.

3.2.2.5. Patients’ characteristics and end-of-follow-up statusAmong 7,088 patients with a HA-BSI, 41% were women. the median age was 71 years of age (IQR 59-81). the majority of patients had one infectious episode, caused by one Mo; 6% had two HA-BSI episodes or more; 6% of the episodes involved more than one Mo (Annex 9, table 30).

the crude mortality for HA-BSI was 18% however there was a substantial amount of missing data for status at end-of-follow-up (27% missing data) (Annex 10, table 31). our data do not allow determining a causal link between death and infection.

3.2.3. microorganisms and resistance profiles for marker phenotypes

3.2.3.1. MicroorganismsIn 2016, 8,186 Mo were identified as etiological agent for 7,627 HA-BSI, 1,716 Mo as etiological agent for 1,586 ICU-associated BSI, and 2,622 Mo for 2,479 non-hospital-associated BSI (table 9). table 9 gives the data for the Mo that caused at least 50 episodes of HA-BSI in 2016 (for data on Mo with less than 50 episodes see Annex 11, table 32). Enterobacteriaceae and Gram-positive cocci were the most frequently isolated Mo-families.

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Table 9 | Microorganisms isolated in bloodstream infections, belgium 2016

ha-bSi icu-associated bSi non-ha-bSimicroorganism n % n % n %

Gram-neg. bacilli: enterobacteriaceae 3,721 45 660 38 1,442 55

Escherichia coli 1,847 23 216 13 1,064 41

Klebsiella pneumoniae 671 8 141 8 138 5

Enterobacter cloacae 320 4 99 6 35 1

Klebsiella oxytoca 179 2 30 2 35 1

Proteus mirabilis 163 2 22 1 68 3

Serratia marescens 118 1 46 3 10 0

Enterobacter aerogenes 108 1 27 2 16 1

Morganella species 93 1 23 1 21 1

Citrobacter freundii 52 1 14 1 4 0

Other/not identified* 170 2 42 2 51 2

Gram-pos. cocci 3,053 37 686 40 899 34

Staphylococcus aureus 874 11 174 10 273 10

Staphylococcus epidermidis 708 9 168 10 65 2

Enterococcus faecalis 406 5 95 6 67 3

Enterococcus faecium 344 4 107 6 20 1

Streptococcus sp., other 189 2 23 1 115 4

Other coagulase-negative staphylococci 142 2 42 2 23 1

Streptococcus pneumoniae 78 1 8 0 168 6

Staphylococcus haemolyticus 72 1 25 1 0 0

Coag-neg. staphylococci, not specified 67 1 12 1 11 0


Gram-neg. bacilli: non-enterobacteriaceae 626 8 162 9 114 4

Pseudomonas aeruginosa 392 5 123 7 60 2


Fungi 449 5 138 8 21 1

Candida albicans 227 3 78 5 12 0

Candida glabrata 109 1 35 2 4 0


Anaerobic bacilli 249 3 53 3 97 4

Bacteroides fragilis 102 1 20 1 31 1


Gram-pos. bacilli 55 1 9 1 25 1

Gram-neg. cocci 13 0 4 0 15 1

other and not identified 20 0 4 0 9 0

total 8,186 100 1,716 100 2,622 100BSI, bloodstream infection; HA-BSI, hospital-associated bloodstream infection; ICU, intensive care unit; n, number; neg., negative; pos., positive

* other includes microorganism causing <50 episodes of HA-BSI/year

the most frequent found Mo by origin are given in Annex 12, table 33 and were:

• E. coli in BSI secondary to urinary tract (50%), gastro-intestinal (27%), pulmonary (15%) and surgical site (19%) infection and MBI (30%)

• S. epidermidis in ClABSI (27%), and • S. aureus in BSI with origin a peripheral or other catheter or invasive manipulation (20%).

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3.2.3.2. Resistance data for selected microorganisms, 2013-2016 table 10 to 15 give for S. aureus, E. coli, K. pneumoniae, E. cloacae, P. aeruginosa, and E. faecium, the number and proportion of resistant Mo isolated from HA-BSI, the mean incidence of HA-BSI with a resistant Mo per 10,000 patient-days and the number and proportion of hospitals in which at least one resistant Mo was identified, from 2013 till 2016.

More hospitals reported at least one HA-BSI with a third generation cephalosporin (C3G) resistant E. coli strain than with a methicillin resistant S. aureus.

1. Staphylococcus aureus

Table 10 | Antimicrobial resistance in S. aureus strains isolated from hospital-associated bloodstream infections, belgium 2013-2016

Year 2013 2014 2015 2016 N strains 669 839 967 874

N hospitals** 119 133 143 140

Methicillin

nR 139 147 148 137

%R 20.8 17.5 15.3 15.7

Mean incidence per 10,000 pd* 0.19 0.16 0.15 0.14

Hospitals with ≥ one R case 60 64 69 66

% hospitals with ≥ one R case 50 48 48 47

Glycopeptides (vancomycin, teicoplanin)

nR 0 4 7 6

%R 0.0 0.5 0.7 0.7




N, total number; nR, number resistant Mo; pd, patient-days; R, resistant

* total HA-BSI/total patient-days for all hospitals participating at least one quarter

** Hospitals participate 1, 2, 3 or 4 quarters

0

5

10

15

20

25

30

35

40

45

2013 2014 2015 2016

% re

sista

nt S

. aur

eus

Year

Methicillin

Glycopeptides

the decrease in proportion of methicillin resistant S. aureus (MRSA) (p<0.01) and in the incidence of HA-BSI with a MRSA (2016 compared to 2013, incidence rate ratio 0.73 with 95% CI [0.56-0.95]) are both statistically significant. this is also the case for the increase in proportion of glycopeptides (Gly) resistant S. aureus (p=0.05). Changes in the incidence of HA-BSI with a S. aureus resistant to Gly are not statistically significant.

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2. Escherichia coli

Table 11 | Antimicrobial resistance in E. coli strains isolated from hospital-associated bloodstream infections, belgium 2013-2016

year 2013 2014 2015 2016

N strains 1,334 1,587 1,780 1,847

N hospitals** 119 133 143 140

third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime)

nR 187 259 308 282

%R 14.0 16.3 17.3 15.3




Carbapenem (imipenem, meropenem, doripenem)

nR 4 11 16 9

%R 0.3 0.7 0.9 0.5







0

5

10

15

20

25

30

35

40

45

2013 2014 2015 2016

% re

sista

nt E

. col

i

Year

Third generationcephalosporin

Carbapenem

None of the trends in proportion of E. coli resistant to C3G or to carbapenems (CAR) and in the incidence of HA-BSI with a resistant E. coli are found to be statistically significant.

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3. Klebsiella pneumoniae

Table 12 | Antimicrobial resistance in K. pneumoniae strains isolated from hospital-associated bloodstream infections, belgium 2013-2016

year 2013 2014 2015 2016

N strains 378 512 588 671

N hospitals** 119 133 143 140


nR 97 159 206 230

%R 25.7 31.1 35.0 34.3





nR 9 19 34 43

%R 2.4 3.7 5.8 6.4







0

5

10

15

20

25

30

35

40

45

2013 2014 2015 2016

% re

sista

nt K

. pne

umon

iae

Year


Carbapenem

the increase in proportion of K. pneumoniae resistant to C3G (p<0.01) and to CAR (p<0.01) and the increase in the incidence of HA-BSI with K. pneumoniae resistant to C3G (2016 compared to 2013, incidence rate ratio 1.75 with 95% CI [1.32-2.33]) and resistant to CAR (2016 compared to 2013, incidence rate ratio 3.45 with 95% CI [1.61-7.40]) are all statistically significant.

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4. Enterobacter cloacae

Table 13 | Antimicrobial resistance in E. cloacae strains isolated from hospital-associated bloodstream infections, belgium 2013-2016

year 2013 2014 2015 2016

N strains 219 245 311 320

N hospitals** 119 133 143 140


nR 96 95 114 113

%R 43.8 38.8 36.7 35.3





nR 3 4 10 10

%R 1.4 1.6 3.2 3.1







0

5

10

15

20

25

30

35

40

45

2013 2014 2015 2016

% re

sista

nt E

. clo

acae

Year


Carbapenem

the decrease in proportion of E. cloacae resistant to C3G (p=0.04) is statistically significant. However, the decrease in incidence of HA-BSI with E. cloacae resistant to C3G is not statistically significant. Increase in proportion of E. cloacae resistant to CAR and in the incidence of HA-BSI with CAR resistant E. cloacae are also not statistically significant.

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5. Pseudomonas aeruginosa

Table 14 | Antimicrobial resistance in P. aeruginosa strains isolated from hospital-associated bloodstream infections, belgium 2013-2016

Year 2013 2014 2015 2016

N strains 318 395 402 392

N hospitals** 119 133 143 140


nR 55 66 59 61

%R 17.3 16.7 14.7 15.6







0

5

10

15

20

25

30

35

40

45

2013 2014 2015 2016

% re

sitan

t P. a

erug

inos

a

Year

Carbapenem

the decrease in the proportion of P. aeruginosa resistant to CAR and in the incidence of HA-BSI with P. aeruginosa resistant to CAR are not statistically significant.

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6. Enterococcus faecium

Table 15 | Antimicrobial resistance in E. faecium strains isolated from hospital-associated bloodstream infections, belgium 2013-2015

Year 2013 2014 2015 2016

N strains 197 285 376 344

N hospitals** 119 133 143 140

Glycopeptides (vancomycin, teicoplanin)

nR 7 11 18 15

%R 3.6 3.9 4.8 4.4







0

5

10

15

20

25

30

35

40

45

2013 2014 2015 2016

% re

sista

nt E

. fae

cium

Year

Glycopeptides

the increase in the proportion of E. faecium resistant to Gly and in the incidence of HA-BSI with E. faecium resistant to Gly are not statistically significant.

Additional data on Mo isolated from the HA-BSI and their resistance profile are given in Annex 13, table 34 and 35. We found that compared to HA-BSI, and for almost all Mos resistance is lower in BSI when acquired outside the hospital (defined as non-HA-BSI) (Annex 13, table 36).

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3.2.3.3. Antimicrobial resistance by region table 16 gives for each region the number and proportion of resistant Mo isolated from HA-BSI in 2016. Across the three regions, more or less the same resistance proportions are found, except for MRSA in HA-BSI which has, similar to our findings for 2015, a statistically significant higher proportion in Wallonia compared with the proportions found in Flanders (p<0.001) and Brussels (p=0.006) but there is no statistically significant difference for this proportion when comparing Flanders with Brussels. the proportion of K. pneumoniae resistance to C3G is statistically significant higher in Wallonia compared with the proportion in Brussels (p=0.03) and Flanders (p<0.001) and in Brussels compared with Flanders (p=0.03).

the number and proportion per region of the resistant Mo isolated from non-hospital-associated BSI and the number and proportion of hospitals with at least one case of a BSI with a resistant Mo are given in Annex 14, table 37 and 38.

Table 16 | Resistance in microorganism isolated from hospital-associated bloodstream infections by region, belgium 2016

brussels flanders Wallonia

microorganism antibiotics n n % n n % n n % Gram-pos. cocci

S. aureus Meti 159 22 13.8 490 58 11.8 225 57 25.3

Gly 159 0 0.0 490 3 0.6 225 3 1.3

All Enterococcus spp Gly 209 12 5.7 401 7 1.7 182 8 4.4

E. faecalis Gly 98 0 0.0 219 1 0.5 89 0 0.0

E. faecium Gly 99 6 6.1 162 3 1.9 83 6 7.2

Gram-neg. bacilli:

enterobacteriaceae

C3G 801 183 22.8 1,918 366 19.1 1,002 265 26.4

CAR 801 25 3.1 1,918 26 1.4 1,002 27 2.7

E. coli C3G 365 62 17.0 1,017 141 13.9 465 79 17.0

CAR 365 2 0.5 1,017 3 0.3 465 4 0.9

K. pneumoniae C3G 164 59 36.0 293 70 23.9 214 101 47.2

CAR 164 15 9.1 293 10 3.4 214 18 8.4

E. cloacae C3G 75 28 37.3 160 52 32.5 85 33 38.8

CAR 75 4 5.3 160 4 2.5 85 2 2.4

P. mirabilis C3G 34 0 0.0 77 6 7.8 52 0 0.0

CAR 34 1 2.9 77 1 1.3 52 0 0.0

K. oxytoca C3G 33 4 12.1 104 24 23.1 42 9 21.4

CAR 33 1 3.0 104 1 1.0 42 1 2.4

E. aerogenes C3G 27 13 48.1 62 32 51.6 19 11 57.9

CAR 27 0 0.0 62 3 4.8 19 1 5.3

Serratia spp C3G 26 3 11.5 64 9 14.1 44 12 27.3

CAR 26 0 0.0 64 0 0.0 44 1 2.3

Gram-neg. bacilli: non enterobacteriaceae

P. aeruginosa CAR 92 18 19.6 188 27 14.4 112 16 14.3

A. baumannii CAR 4 0 0.0 33 1 3.0 11 1 9.1

Acinetobacter spp. CAR 11 0 0.0 75 2 2.7 31 1 3.2

C3G, third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidim); CAR, carbapenems (imipenem, meropenem, doripenem); Gly, glycopeptides (vancomycin, teicoplanin); Meti, Methicillin; Mo, microorganism; N, total number Mo; n, number resistant Mo; neg., negative; pos., positive; R, resistant; %, percentage resistant Mo

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the proportion MRSA and the proportion of C3G resistant E. coli and K. pneumonia strains isolated from HA-BSI by province is given in the three maps below (Figure 12 to 14)13.

Figure 12 | Percentage of methicillin resistant S. aureus strains isolated from hospital-associated bloodstream infections, by province, belgium 2016

<1%

1% - <5%

5% - <10%

10% - <25%

25% - <50%

>=50%

Less than 10 isolates reported

Numbers refer to number of hospitals that contributed data

Figure 13 | Percentage of E. coli strains resistant to third generation cephalosporin isolated from hospital-associated bloodstream infections, by province, belgium 2016

<1%

1% - <5%

5% - <10%

10% - <25%

25% - <50%

>=50%


Numbers refer to numbers of hospitals that contributed data

13 the color scale used in the maps is similar to those used by ECDC.

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Figure 14 | Percentage of K. pneumoniae strains resistant to third generation cephalosporin isolated from hospital-associated bloodstream infections, by province, belgium 2016

<1%

1% - <5%

5% - <10%

10% - <25%

25% - <50%

>=50%


Numbers refer to number of hospitals that contributed data

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3.3. inTEnSivE CARE UniT-ASSOCiATED bLOODSTREAM inFECTiOnS

• In 2016, 1,586 (21%) of the total HA-BSI were ICU-associated BSI reported by 417 different ICU quarters.• From these 417 different ICU quarters data, 355 (85%) could be matched with complete (3 months)

denominator data. • these 355 matched ICU quarters represented 89 different hospitals and 898 (57%) of the total of 1,586

ICU-associated BSI.

Description of characteristics of ICU-associated BSI in 2016 includes data from all 1,586 identified ICU-associated BSI. Calculation and analysis of incidences only include those ICU-associated BSI with matching denominator data.

3.3.1. incidences

3.3.1.1. Incidences of intensive care unit-associated bloodstream infectionsthe incidence of ICU-associated BSI in Belgium did not change much during the past three years (table 17 and Figure 15). Regional data for 2016 shows the highest incidences in Wallonia and the lowest in Flanders. Changes in trends in incidences per 10,000 patient-days at national and regional level were found to be not statistically significant.

Table 17 | incidence intensive care unit-associated bloodstream infections, belgium 2013-2016

Year 2013 2014 2015 2016


N ICUs-quarters included in calculation of incidence** 259 332 356 355

N ICU-associated BSI 754 956 911 898

Cumulative incidence per 1,000 adm

mean*** 14.6 15.4 14.2 14.3

median**** 11.1 12.3 11.9 11.8

Incidence density per 10,000 pd

mean*** 31.7 33.7 30.4 29.8

median**** 24.3 26.1 23.8 23.3

adm, admissions; BSI, bloodstream infection; ICU, intensive care unit; N, number; pd, patient-days

* Hospitals included when ICU-denominator of the participating quarter was available

** Several hospitals have more than 1 ICU unit and report data of more than 1 ICU unit for 1 quarter

*** total ICU-associated BSI/total denominator

**** Unit of analysis used to calculate median is quarter

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Figure 15 | Mean incidence of intensive care unit-associated bloodstream infections, by region, belgium 2013-2016

29.8

35.1 31.4

26.0

0

5

10

15

20

25

30

35

40

2013 2014 2015 2016

ICU

ass

ocia

ted

BSI/

10,0

00 p

d

Year

Belgium

Wallonia

Brussels

Flanders

BSI, bloodstream infections; ICU, intensive care unit; pd, patient-days

3.3.1.2. Incidence of intensive care unit-associated central line-associated bloodstream infections according to case definition

Each of the different ClABSI case definitions in ICU is represented by a similar proportion of about 1/3 of the total ICU-associated ClABSI (Annex 15, table 39).

Since 2013, ClABSI incidence in ICU decreased for the three different case definitions (table 18 and Figure 16). this decrease, from 12.1 ClABSI (three case definitions together)/10,000 pd in 2013 to 9.3 ClABSI/10,000 pd in 2016 is statistically significant (incidence rate ratio 0.78 with 95% CI [0.63-0.98]). In 2016, the mean ClABSI incidence in ICU per 10,000 patient-days for the three case definitions together was 9.3; more than five times higher than the hospital-wide incidence.

Table 18 | Mean incidence central line-associated bloodstream infections at intensive care unit according to case definition, belgium 2013-2016

Year 2013 2014 2015 2016

Confirmed ClABSI

N* 106 117 111 102


Probable ClABSI

N* 71 80 81 89


Possible ClABSI

N* 112 100 99 88


total clabSi

N* 289 297 291 279


ClABSI, central line-associated bloodstream infection; ICU, intensive care unit; N, number; pd, patient-days

* Includes only those episodes for which a denominator is available

40

RES

Ult

S SU

RVEI

llA

NCE

Blo

oD

StRE

AM

INFE

CtI

oN

IN H

oSP

ItA

lS, 2

013-

2016

Figure 16 | Mean incidence central line-associated bloodstream infections (confirmed, probable, and possible) in intensive care units, belgium 2013-2016

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2013 2014 2015 2016

CLAB

SI/1

0,00

0 pd

Year

Confirmed +probable +possible

Confirmed +probable

Confirmed


In 2016, the median (IQR) number of ICU-associated ClABSI was one (0-2) episode per quarter.

3.3.2. description of intensive care unit-associated bloodstream infections, 2016

3.3.2.1. Origin of intensive care unit-associated bloodstream infectionsIn 2016, one third of the ICU-associated BSI were Cl-associated infections (Figure 17).

Figure 17 | Origin of intensive care unit-associated bloodstream infections, belgium 2016

33%

4%

9%

11% 1%

24%

4%

9%

5%

54%

Central line*


Unknown


Other secondary infections


Pulmonary infections

Surgical site infections

Urinary tract infections


* Includes ‘confirmed’, ‘probable’ and ‘possible’ central line-associated bloodstream infections

bloodstream infections associated with invasive devices the proportion of ICU-associated BSI associated directly or indirectly with invasive devices was higher compared to the proportions of these kind of BSI found hospital-wide. In 2016, 40% (3,036) of all hospital-wide HA-BSI were directly or indirectly associated with invasive devices compared to 58% (916) of ICU-associated BSI (table 19).

41

RESU

ltS

SURV

EIll

AN

CE B

loo

DSt

REA

M IN

FEC

tIo

N IN

Ho

SPIt

AlS

, 201

3-20

16

Table 19 | intensive care unit-associated bloodstream infections associated with invasive devices, belgium 2016

icu-associated bSiicu-associated bSi n %

ClABSI* 525 100

Confirmed (CRBSI) 183 35

Urinary tract infection 139 100

Urinary catheter present 97 70

Presence urinary catheter unknown 14 10

Urinary catheter as origin of HA-BSI is confirmed 91 65

Pulmonary infection 373 100

Endotracheal tube present 233 62

Presence endotracheal tube unknown 45 12

Endotracheal tube as origin of HA-BSI is confirmed 193 52

Peripheral and other catheter associated BSI 61 100

Confirmed 36 59 BSI, bloodstream infection; ClABSI, central line-associated bloodstream infection; CRBSI, central line-related bloodstream infection; ICU, intensive care unit; N, number


In 2016, 31% of ClABSI (all case definitions together) were diagnosed in ICU (Annex 7, table 28).

3.3.2.2. Time to infection (infection date – admission date)In 2016, ICU-associated BSI appeared with a median delay of 10 days (IQR 6-19 days) after admission in ICU.

3.3.2.3. End-of-follow-up statustwenty six percentage of patients with ICU-associated BSI died. However, status at end-of-follow-up was missing for 32% of the episodes. our data do not allow determining a causal link between death and infection.

3.3.3. microorganisms and resistance profiles for marker phenotypes

3.3.3.1. MicroorganismA total of 1,716 Mo were identified as etiological agent for 1,586 ICU-associated BSI (table 9 above). Similar to the hospital-wide HA-BSI, E. coli, S. aureus and S. epidermidis were the most frequent identified Mo.

3.3.3.2. Resistance to antimicrobials for marker phenotypes Number and proportion of resistant Mo among the Mo isolated from the ICU-associated BSI are given in table 20. the proportion of resistant strains isolated from the ICU-associated BSI are similar to the proportion found hospital-wide.

42

RES

Ult

S SU

RVEI

llA

NCE

Blo

oD

StRE

AM

INFE

CtI

oN

IN H

oSP

ItA

lS, 2

013-

2016

Table 20 | Resistance in microorganisms isolated from iCU-associated bloodstream infections, belgium 2016

antibioticsmicroorganism

icus with >= one resistant case of icu-

associated bSi*- n=188n n % n %

Gram-pos. cocci

S. aureus Meti 174 27 16 23 12

Gly 174 0 0 0 0

All Enterococcus spp Gly 210 8 4 6 3

E. faecalis Gly 95 0 0 0 0

E. faecium Gly 107 5 5 4 2

Gram-neg. bacilli:

enterobacteriacea

C3G 660 178 27 81 43

CAR 660 24 4 14 7

E. coli C3G 216 31 14 27 14

CAR 216 1 0 1 1

K. pneumoniae C3G 141 57 40 39 21

CAR 141 15 11 9 5

E. cloacae C3G 99 37 37 31 16

CAR 99 3 3 3 2

P. mirabilis C3G 22 0 0 0 0

CAR 22 0 0 0 0

K. oxytoca C3G 30 9 30 9 5

CAR 30 1 3 1 1

E. aerogenes C3G 27 14 52 14 7

CAR 27 1 4 1 1

Serratia spp C3G 50 7 14 7 4

CAR 50 1 2 1 1

Gram-neg. bacilli: non-enterobacteriaceae

P. aeruginosa CAR 123 28 23 24 13

A. baumannii CAR 2 0 0 0 0

Acinetobacter spp. CAR 9 0 0 0 0

BSI, bloodstream infection; C3G, third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidim); CAR, carbapenems (imipenem, meropenem, doripenem); Gly, glycopeptides (vancomycin, teicoplanin); ICU, intensive care unit; Meti, Methicillin; Mo, microorganism; N, total number Mo or total number of ICUs; n, number resistant Mo or number of ICUs; neg., negative; pos., positive; %, percentage resistant Mo

* ICUs participate 1, 2, 3 or 4 quarters

43

Ho

SPIt

Al

StAy

DAt

A (R

HM

/MZG

)

4. HOSPiTAL STAy DATA (RHM/MZg)Since 2008, the RHM/MZG registration includes for each diagnosis a variable ‘present (or not) on admission’ (the date of onset is not registered). An infection ‘not present on admission’ is the exact definition of a ‘nosocomial’ infection. In theory, the incidence of hospital stays with an ICD9 code 038.01-038.09 (‘septicemia’) coded as ‘not present on admission’ should therefore be comparable to the incidence of HA-BSI calculated from surveillance data. the RHM/MZG data is exhaustive and therefore (if valid), the number of episodes measures the burden of hospital-related bloodstream infections in Belgium.

table 40 in Annex 16 shows the RHM/MZG data with an ICD9 code 038.01-038.09 from 2000 to 2014. the incidence of ‘BSI as secondary diagnosis’ reported by the ‘hospital stay data (RHM/MZG)’ remained quite stable since 2001. the definition ‘BSI as secondary diagnosis’ refers to a comorbidity (existed before admission) or a complication (occurred after admission).

In 2014 (last available data), there were a total of 6,022 hospital-stays with a diagnosis of septicaemia not present on admission, a sharp (unexplained) drop from 9,651 episodes in 2012. this gave an incidence of 3.0 septicaemia not present on admission/1,000 admissions (corresponding incidence calculated from the national surveillance data in 2014 was 5.6 HA-BSI/1,000 admissions). there is no immediate explanation for this difference in incidence as well as for the sharp drop between 2012 and 2014 of septicaemia not present on admission in the RHM/MZG registration. Validation of data would be useful in this context.

44

Co

MPA

RISo

NS

BEtW

EEN

DIF

FERE

Nt

SoU

RCES

oF

BElG

IAN

AN

tIM

ICRo

BIA

l RE

SISt

AN

CE D

AtA

5. COMPARiSOnS bETWEEn DiFFEREnT SOURCES OF bELgiAn AnTiMiCRObiAL RESiSTAnCE DATA

We compared antimicrobial resistance results from the Surveillance of BSI in Belgian hospitals with the Surveillance of multi-resistant bacteria in Belgian hospitals (table 21) [12]. the surveillance on resistant bacteria in Belgian hospitals includes a wide variety of clinical samples (e.g. urine-, sputum-, stool-, blood-, and wound-sample) from community and hospital-acquired infections.

As expected, resistance profiles are higher in hospital-associated bloodstream infections as compared to data that include community samples, but overall, these resistance data are comparable and validate each other (table 21).

Tabl

e 21

| C

ompa

riso

n of

ant

imic

robi

al re

sist

ance

dat

a fr

om tw

o di

ffere

nt su

rvei

llanc

es, b

elgi

um 2

015

and

2016

Surv

eilla

nce

of b

Si in

bel

gian

hos

pita

ls

(n h

ospi

tals

= 1

40)1

Surv

eilla

nce

of re

sist

ant m

o in

bel

gian

ho

spit

als

(n h

ospi

tals

= d

epen

ding

of m

o

betw

een

123

and

55)

mic

roor

gani

smh

a-b

Sino

n h

a-b

Si2

clin

ical

sam

ples

– a

ll si

tes

- fro

m h

ospi

tal-

asso

ciat

ed a

nd o

the

infe

ctio

ns3

Year

of i

sola

tion

2016

2016

2015

ant

ibio

tics

mar

kers

nnr

%r

nnr

%r

nnr

%r

S. a

ureu

s

MRS

A87

413

715

.727

327

9.9

33,0

405,

0484

15.4

Gly

R87

46

0.7

273

00.

0N

AN

AN

A

E. co

li

C3G

1,84

728

215

.31,

064

105

9.9

62,2

055,

3765

8.6

CAR

1,84

79

0.5

1,06

41

0.1

97,5

0313

160.

1

K. p

neum

onia

e

C3G

671

230

34.3

138

2215

.911

,171

2,32

1520

.8

CAR

671

436.

413

81

0.7

18,0

7273

364.

1

P. a

erug

inos

a

CAR

108

5651

.916

425

.0N

AN

AN

A

A. b

aum

anni

i

CAR

482

4.2

41

25.0

1,20

458

74.

8

E. fa

eciu

m

Gly

R34

415

4.4

203

15.0

2,25

140

1.8

BSI,

bloo

dstr

eam

infe

ctio

n; C

3G, t

hird

gen

erat

ion

ceph

alos

porin

(cef

otax

ime,

cef

tria

xone

, cef

tazi

dim

); CA

R, c

arba

pene

ms

(imip

enem

, mer

open

em, d

orip

enem

); G

ly,

glyc

opep

tides

(van

com

ycin

, tei

copl

anin

); H

A-B

SI, h

ospi

tal-a

ssoc

iate

d bl

oods

trea

m in

fect

ions

; MRS

A, m

ethi

cilli

n re

sist

ant

S. a

reus

; N, t

otal

num

ber

Mo

; nR,

num

ber

resi

stan

t Mo

; NA

, not

ava

ilabl

e; R

, res

ista

nt: %

R, p

erce

ntag

e re

sist

ant M

o1 t

his

surv

eilla

nce

incl

udes

the

resu

lts o

f blo

od s

ampl

es (b

lood

cul

ture

s) o

f HA

-BSI

and

non

HA

-BSI

. 2 N

on H

A-B

SI a

re o

ptio

nally

repo

rted

in th

is s

urve

illan

ce.

3 thi

s su

rvei

llanc

e in

clud

es th

e re

sults

of a

ll cl

inic

al s

ampl

es (e

.g. u

rine-

, spu

tum

-, st

ool-,

blo

od-,

and

wou

nd-s

ampl

e) c

olle

cted

for d

iagn

ostic

reas

ons

in th

e pr

esen

ce

of c

linic

al s

igns

and

cov

ers

acut

e ho

spita

ls a

nd lo

ng-t

erm

car

e fa

cilit

ies

[12]

. 4 In

clud

es o

nly

the

MRS

A c

ases

from

acu

te h

ospi

tals

. 5 In

clud

es M

o re

sist

ant t

o th

ird a

nd fo

urth

gen

erat

ion

ceph

alos

porin

6 In

clud

es M

o fr

om c

linic

al a

nd s

cree

ning

sam

ples

– in

clud

es o

nly

resi

stan

ce to

mer

open

em7

Incl

udes

onl

y re

sist

ance

to m

erop

enem

45

DIS

CUSS

IoN

6. DiSCUSSiOnHospital participation in this surveillance programme is high. this is linked to the mandatory participation (Royal Decree 08/01/2015). though, 64% of the hospitals participated throughout the year while participation is only mandatory for a minimum of three months a year. Continuous surveillance serves better the objective of surveillance as a tool for prevention and workload involved in surveillance of bloodstream infections is reasonable (in 2016, the median number of HA-BSI episodes per hospital per quarter was 12 episodes).

2013 was the first year that all the surveillance data was collected after the protocol was updated and a new online data collection tool installed. Since updated indicator definitions are not fully comparable, for most of our analysis, we decided to include only those data collected using the new protocol. only for reporting HA-BSI per Mo historical data from before 2013 were included because despite protocol changes, this indicator provides meaningful data.

In 2016 the mean incidence was 7.8 HA-BSI/10.000 patient-days and 1.8 ClABSI/10.000 patient-days. Different used methods makes comparisons with other countries difficult [13,14]. For example, in Belgium, we do not use as an indicator ClABSI/Cl-days. the reason is that when implementing one of the recommended interventions to reduce ClABSI, being the decrease of exposure to a Cl (meaning decrease in Cl-days), this intervention might lead to a proportional increase in the ClABSI/Cl-days if the decrease in the numerator is less than the decrease in the denominator. A recent study has suggested that patient-days and Cl-days were equally effective adjustment metrics for comparing healthcare-associated infection rates [15]. Despite the mentioned challenges in comparisons of HA-BSI and ClABSI incidences between countries, the heavy burden of these infections on healthcare systems locally and worldwide is generally recognised [14].

Also differences in used surveillance definitions makes comparisons with other countries difficult. For example, in the Belgian surveillance the suspected origin of the BSI is based on clinical identification. this approach differs from the one used by the American Centres for Disease Control and Prevention (CDC) where identification of the suspected origin is based on a set of well-defined criteria for each suspected origin [13,16]. Also the ClABSI definition as formulated in the Belgian surveillance protocol differs from the definition formulated by CDC. Different than for the Belgian definition, the CDC ClABSI definition includes the requirement that a central line (Cl) should have been present for at least two calendar-days prior to the BSI (with the day of Cl-insertion being calendar-day one) and that the Cl should be present on the day of the BSI occurrence or the day before.

Mean incidences of HA-BSI were higher in tertiary hospitals and at the ICU departments. Variation within these groups was also important. this suggests a potential for prevention of HA-BSI. Differences in reporting between hospitals cannot be excluded and calls for data validation. Since the start of the BSI surveillance in Belgium, data has never been validated. Validation study results published in peer reviewed journals points consistently towards ClABSI under-reporting [17-19]. outlier data identified using funnel plots should be investigated as a priority to exclude possible differences in reporting as a reason for the deviation, confirm (or not) the ‘outlier’ status, and act accordingly. A validation study is planned for beginning 2018. the study includes the development of a tool to be used by local hospital staff to enable them to validate their own data.

In 2016, 7,627 HA-BSI were registered in the surveillance. Among these infections 40% were directly (central line – 23%) or indirectly (urinary catheter or endotracheal tube) associated with an invasive device. the ClABSI proportion is lower than the proportion of 33.2% ClABSI among all HA-BSI found in the European 2011-2012 point prevalence survey on healthcare associated infections [20]. these infections directly or indirectly associated with invasive devises are a priority target for prevention.

the most common Mo isolated from HA-BSI were E. coli (23%) and S. aureus (11%). this is similar to the European 2011-2012 point prevalence survey findings, where the two Mo most frequently isolated from healthcare-associated infections were also E. coli (15.9%) and S. aureus (12.3%) [20]. A secular trend in an increase of Gram-negative Mo in HA-BSI has been observed in Belgium.

the decreasing trend in methicillin resistance S. aureus is confirmed in 2016, as is the increasing trend in resistance to C3G and CAR in K. pneumoniae. these trends are observed in several other countries in Europe

46

DIS

CUSS

IoN

[21]. In 2016, 15.3% from the E. coli strains isolated from HA-BSI was resistant to C3G and 0.5% resistant to CAR. For K. pneumoniae these findings were 34.3% and 6.4%, respectively. Data from EARS-Net for 2015 shows for E. coli an EU population-weighted mean percentage of resistance in invasive isolates (blood or cerebrospinal fluid) to C3G of 13.1% and to CAR of 0.1% and for K. pneumoniae are these percentages respectively 30.3% and 8.1%. Similar to our findings at national level, between 2012 and 2015 a significant increasing trend in isolated C3G resistant E. coli was observed for the EU population-weighted mean percentage, yet for our 2016 findings at national level this trend is no longer statistically significant (most recent EARS-net data are from 2015) [21].

By means of additional validation, we compared our findings with an other sources of Belgian antimicrobial resistance data that have a different methodology [12]. our estimates come from hospital-associated infections, unlike estimates from the other source which include also community-acquired infections. As expected, antimicrobial resistance in our surveillance are higher but overall, this resistance data is comparable and validate each other.

the overall burden of HA-BSI in Belgium, as reported from MKG/RHM, was 3.0/1.000 admissions in 2014 (last available data), but might be an underestimation. Data from surveillance lead to an estimation that was 87% higher.

LimitationsSurveillance data has never been validated. A validation study is planned for beginning 2018.

47

CoN

ClU

SIo

N A

ND

REC

oM

MEN

DAt

IoN

S

7. COnCLUSiOn AnD RECOMMEnDATiOnSthere is no statistically significant change in the incidence of HA-BSI in Belgium hospitals since 2013. However, comparing 2013 to 2016, the ClABSI incidence decrease is statistically significant (decrease of 14% with 95% CI [0.76-0.97]). Among HA-BSI in 2016, 40% HA-BSI were directly (Cl – 23%) or indirectly (urinary catheter or endotracheal tube) associated with an invasive device. these infections associated with invasive devices are a priority target for prevention.

the mean incidence of HA-BSI, to be estimated in 2016 as 7.8/10,000 patient-days, has changed little during the last years, and findings are fairly consistent, with higher incidence in tertiary hospitals and in ICU. In 2016, the mean HA-BSI incidence in ICU was almost four times higher than the hospital-wide incidence.

A large variation in HA-BSI incidence between hospitals was observed. this suggests a potential for prevention, however there is a need for data validation.

the most common Mo isolated from HA-BSI were E. coli and S. aureus. Since 2000, the incidence of E. coli and K. pneumonia HA-BSI has increased. Since 2013, methicillin resistance in S. aureus has decreased, while resistance to C3G and CAR in K. pneumoniae has increased. Validation of resistance profiles is also further needed.

48

REF

EREN

CES

REFEREnCES

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http://www.nsih.be/download/MRSA/MRSA_ESBL_CPE_Y2015/RAPPORT_AMR_Y2015_NL.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/2psc_identifyinghais_nhsncurrent.pdf

49

AN

NEx

ES

AnnEXES

1. Calculation of incidences

Table 22 | Calculation of mean incidences, surveillance of bloodstream infections in belgian hospitals

incidences numerator denominator

hospital-wide

mean cumulative incidence HA-BSI/1,000 admissions

∑ N BSI ≥2 days in hospital

∑ total admissions

mean incidence density HA-BSI/10,000 patient-days

∑ total patient-days

icu

mean cumulative incidence iCU-associated BSI/1,000 admissions ICU

∑ N BSI ≥2 days in ICU

∑ total admissions ICU

mean incidence density ICU-associated BSI/10,000 patient-days ICU

∑ total patient-days ICU

HA-BSI, hospital-associated bloodstream infection; ICU, intensive care unit; N, number; ∑, sum

the mean incidence numerator in ICU includes the number of ICU-associated BSI (≥2 days in ICU) and the denominator includes the totAl number of admissions or patient-days in ICU (including patients staying < 2 days in ICU). this means that the denominator includes patients who are not at risk for acquiring an ICU-associated BSI.

For the incidence calculation only those hospitals and ICU unit with available and matching denominator data for the reporting quarter and year were included in the analysis. We noticed that this data was often missing for the ICUs mainly because in the database, the names/codes used to identify ICUs in the registration of the HA-BSI episodes (numerator data) did not match the ICU names/codes used by the same hospital to enter denominator data.

2. Participation by region

In all three Belgian regions the number of participating hospitals remained quite stable since 2014 (table 23). In 2016, in Brussels 67% of the hospitals participated a full year, this was the case for 72% of the hospitals in Flanders and 53% of the hospitals in Wallonia.

Table 23 | Participation in the surveillance of bloodstream infections in belgian hospitals by region, belgium 2013-2016

Yearnumber of hospitals*

brussels flanders Wallonia total2013 17 58 44 119

2014 16 71 46 133

2015 18 74 51 143

2016 18 71 51 140

* Hospitals as identified by their NSIH code

50

AN

NEx

ES

3. Hospital-associated bloodstream infections mean incidences in tertiary and other hospitals

Table 24 | Hospital-associated bloodstream infections incidences in tertiary and other acute care hospitals, belgium 2013-2016

Year 2013 2014 2015 2016

non-tertiary hospital



N HA-BSI 3,620 4,199 4,622 4,693

mean incidence 1,000 adm** 5.0 4.8 4.6 4.5

mean incidence 10,000 pd** 6.9 6.6 6.6 6.5

tertiary hospital



N HA-BSI 1,877 2,665 3,226 2,837

mean incidence 1,000 adm** 6.7 7.5 8.6 7.6

mean incidence 10,000 pd** 9.7 10.4 12.5 11.6

adm, admissions; HA-BSI, hospital-associated BSI; N, number; pd, patient-days

* Hospitals included when denominator of the participating quarter was available

** total HA-BSI/total denominator

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2013 2014 2015 2016

HA-B

SI/1

0,00

0 pd

Year

Tertiaryhospitals

Non-tertiaryhospitals

51

AN

NEx

ES

Tabl

e 25

| H

ospi

tal-a

ssoc

iate

d bl

oods

trea

m in

fect

ions

inci

denc

es in

tert

iary

and

non

-ter

tiary

hos

pita

ls b

y re

gion

, bel

gium

201

3-20

16

bru

ssel

s f

land

ers

Wal

loni

aYe

ar

2013

2014

2015

2016

2013

2014

2015

2016

2013

2014

2015

2016

non

-ter

tiar

y ho

spit

al

N h

ospi

tals

incl

uded

in c

alcu

latio

n of

inci

denc

e*11

1012

1151

6266

5938

3942

43

N q

uart

ers

3437

3637

132

174

200

195

9410

011

812

2

N H

A-B

SI

395

443

418

360

1,94

12,

606

2,90

62,

917

1,28

41,

150

1,29

81,

416

mea

n in

cide

nce

1,00

0 ad

m**

6.0

5.5

5.8

4.7

4.4

4.5

4.3

4.2

6.1

5.1

4.9

5.0

mea

n in

cide

nce

10,0

00 p

d**

8.2

7.6

8.1

6.1

6.2

6.5

6.4

6.4

8.0

6.6

6.7

6.9

tert

iary

hos

pita

l

N h

ospi

tals

incl

uded

in c

alcu

latio

n of

inci

denc

e*6

66

67

88

85

78

8

N q

uart

ers

2121

2121

1721

2222

1014

1715

N H

A-B

SI

1,15

61,

206

1,28

31,

198

443

985

1,36

01,

157

278

474

583

482

mea

n in

cide

nce

1,00

0 ad

m**

8.8

8.9

9.4

8.9

4.2

6.1

8.6

6.8

6.6

7.9

7.5

7.0

mea

n in

cide

nce

10,0

00 p

d**

11.6

12.2

13.1

12.1

6.7

8.5

12.4

11.5

10.1

11.8

11.6

10.7

adm

, adm

issi

ons;

HA

-BSI

, hos

pita

l-ass

ocia

ted

BSI;

N, n

umbe

r; pd

, pat

ient

-day

s

* H

ospi

tals

incl

uded

whe

n de

nom

inat

or o

f the

par

ticip

atin

g qu

arte

r was

ava

ilabl

e

** t

otal

HA

-BSI

/tot

al d

enom

inat

or

Figu

re 1

8 |

Hos

pita

l-ass

ocia

ted

bloo

dstr

eam

infe

ctio

ns m

ean

inci

denc

es in

tert

iary

and

non

-ter

tiary

hos

pita

ls b

y re

gion

, bel

gium

201

3-20

16

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2013

2014

2015

2106

HA-BSI/10,000 pd

Year

Tert

iary

hos

pita

ls

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2013

2014

2015

2106

Year

Oth

er h

ospi

tals

Brussels

Wallonia

Flan

dres

HA

-BSI

, hos

pita

l-ass

ocia

ted

bloo

dstr

eam

infe

ctio

n; p

d, p

atie

nt-d

ays

52

AN

NEx

ES

4. Hospital-wide central line-associated bloodstream infections by case definition

Table 26 | Central line-associated bloodstream infections, hospital-wide, according to case definition (proportions)*, belgium 2013-2016

Year 2013 2014 2015 2016clabSi n % n % n % n %Confirmed 609 41 765 42 912 43 716 41

Probable 455 31 600 33 736 35 597 34

Possible 422 28 465 25 464 22 430 25

total 1,486 100 1,830 100 2,112 100 1,743 100

ClABSI, central line associated bloodstream infection; N, number

* Includes all ClABSI episodes (also those without denominator)

5. Central line-associated bloodstream infections incidences in tertiary versus other hospitals

Table 27 | Central line-associated bloodstream infections* incidences in tertiary and non-tertiary hospitals, belgium 2013-2016

Year 2013 2014 2015 2016

non-tertiary hospital

N hospitals included in calculation of incidence** 100 111 120 113

N quarters 260 311 354 354

N ClABSI 848 1,018 1,111 979

mean incidence 10,000 pd*** 1.6 1.6 1.6 1.4

tertiary hospital

N hospitals included in calculation of incidence** 18 21 22 22

N quarters 48 56 60 59

N ClABSI 633 812 995 742

mean incidence 10,000 pd*** 3.3 3.2 3.9 3.0

ClABSI, central line-associated bloodstream infection; N, number; pd, patient day


** Hospitals included when denominator of the participating quarter was available

*** total ClABSI/total denominator

53

AN

NEx

ES

6. Distribution of hospital-associated blood stream infection incidences by type of hospital

Figure 19 | Hospital-associated bloodstream infections distribution across hospitals by hospitals classified by number of beds and by acute care hospital versus long-term care facility, belgium 2016

010

2030

40H

A-B

SI/1

0,00

0 pd

<200 beds 200-399 beds 400-599 beds >600 beds

010

2030

40H

A-B

SI/1

0,00

0 pd

Acute care hospital Long-term care facility


54

AN

NEx

ES

7. Hospital-associated bloodstream infections by origin and speciality/department

Tabl

e 28

| H

ospi

tal-a

ssoc

iate

d bl

oods

trea

m in

fect

ions

by

orig

in a

nd sp

ecia

lity,

bel

gium

201

6

Spec

ialit

yg

eria

tric

sin

tens

ive

care

uni

tm

edic

al

depa

rtm

ent

obs

tetr

ics/

gy

naec

olog

yo

ncol

ogy

paed

iatr

ics

Surg

ery

oth

erto

tal

ori

gin

n%

n%

n%

n%

n%

n%

n%

n%

n%

Cl**

135

1255

731

369

206

928

032

4842

232

2111

616

1,74

323

Urin

ary

trac

t inf

ectio

n44

840

173

1040

022

1828

9311

87

302

2720

328

1,64

522

Gas

tro-

inte

stin

al in

fect

ion

898

221

1227

715

35

9711

44

145

1382

1191

812

Pulm

onar

y in

fect

ion

888

404

2318

310

00

415

54

595

527

832

11

Surg

ical

site

infe

ctio

n18

286

539

214

222

02

213

912

375

337

4

Perip

hera

l and

oth

er c

athe

ter

212

644

835

12

202

33

323

689

292

4

MBI

30

141

161

00

161

1814

120

00

020

83

Inva

sive

man

ipul

atio

n6

18

035

21

26

10

015

115

286

1

oth

er se

cond

ary

infe

ctio

ns96

893

514

98

1219

536

76

807

558

545

7

Unk

now

n22

620

157

925

814

914

128

1522

1911

610

105

141,

021

13

tota

l1,

130

100

1,77

710

01,

809

100

6410

088

110

011

310

01,

120

100

733

100

7,62

710

0Cl

, cen

tral

line

; MBI

, muc

osal

bar

rier i

njur

y

* M

edic

al d

epar

tmen

t inc

lude

s; c

ardi

olog

y, g

astr

o-en

tero

logy

, nep

hrol

ogy,

neu

rolo

gy, p

neum

olog

y, u

rolo

gy, a

nd o

ther

inte

rnal

med

icin

e

** In

clud

es c

onfir

med

, pro

babl

e an

d po

ssib

le C

lABS

I

55

AN

NEx

ES

8. invasive device associated hospital-associated bloodstream infections

Table 29 | Hospital-associated bloodstream infections associated with invasive devices, belgium 2016

confirmed non-confirmed total ha-bSi

invasive device n % total ha-bSi n % total

ha-bSi n % total ha-bSi

ClABSI 716 20 1,027* 26* 1,743 23

Urinary tract infection with catheter 617 17 108 3 725 10

Pulmonary infection with Et/cannula 224 6 52 1 276 4

Peripheral/other catheter 162 4 130 3 292 4

total invasive device asso-ciated HA-BSI 1,719 47 1,317 33 3,036 40

total HA-BSI 3,666 100 3,961 100 7,627 100

BSI, bloodstream infection; ClABSI, central line-associated bloodstream infection; d, days; Et, endotracheal tube; HA-BSI, hospital-associated bloodstream infection; N, number

* Includes ‘probable’ and ‘possible’ ClABSI

9. number microorganism, episodes and patients with hospital-associated bloodstream infections

Table 30 | number microorganism, episodes and patients with hospital-associated bloodstream infections, belgium 2016

ha-bSi n %

N episodes 7,627 100

episode with 1 microorganism 7,139 94

episode with 2 microorganisms 410 5

episode with 3 microorganisms 78 1

N patients 7,088 100

patients with 1 episode 6,644 94

patients with 2 episodes 375 5

patients with ≥3 episodes 69 1

HA-BSI, hospital-associated bloodstream infection; N, number

10. End-of-follow-up status

Table 31 | End-of-follow-up status patients with hospital-associated bloodstream infections diagnosed, belgium 2016

end-of-follow-up status %

Died* 18

Still admitted 11

Discharged 44

Unknown 27

* Causality between death and HA-BSI cannot be implied

56

AN

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ES

11. Exhaustive list of microorganisms isolated from bloodstream infections, belgian acute care hospitals

Table 32 | Microorganism isolated as etiological agents for bloodstream infections, exhaustive list, belgium 2016

ha-bSi non-ha-bSimicroorganism n % n %Escherichia coli 1,847 23 1,064 41

Staphylococcus aureus 874 11 273 10

Staphylococcus epidermidis 708 9 65 2

Klebsiella pneumonia 671 8 138 5

Enterococcus faecalis 406 5 67 3

Pseudomonas aeruginosa 392 5 60 2

Enterococcus faecium 344 4 20 1

Enterobacter cloaca 320 4 35 1

Candida albicans 227 3 12 0

Streptococcus other 189 2 115 4

Klebsiella oxytans 179 2 35 1

Proteus mirabilis 163 2 68 3

Staphylococcus other 142 2 23 1

Serratia marescens 118 1 10 0

Candida glabrata 109 1 4 0

Enterobacter aerogenes 108 1 16 1

Bacteroïdes fragilis 102 1 31 1

Morganella sp. 93 1 21 1

Streptococcus pneumonia 78 1 168 6

Staphylococcus haemolyticus 72 1 0 0

Coag-neg staphylococci, not specified 67 1 11 0

Citrobacter freundii 52 1 4 0

Bacteroides sp., other 49 1 13 0

Acinotobacter baumannii 48 1 4 0

Stenotrophomonas maltophilia 47 1 0 0

Candida parapsilosis 38 0 0 0

Streptococcus agalactiae 38 0 65 2

Citrobacter diversus 36 0 11 0

Clostridium other 35 0 16 1

Acinetobacter other 33 0 2 0

Staphylococcus, not specified 28 0 8 0

Anaerobes, other 26 0 18 1

Candida other 25 0 2 0

Acinetobacter sp, not specified 23 0 1 0

Enterococcus sp., other 23 0 10 0

Gram-neg bacilli, non enterobacteriaceae, other 22 0 12 0

Streptococcus pyogenes 21 0 38 1

Candida tropicalis 20 0 0 0

Proteus vulgaris 20 0 4 0

Enterococcus sp., not specified 19 0 0 0

57

AN

NEx

ES

ha-bSi non-ha-bSimicroorganism n % n %Gram positive cocci, other 17 0 8 0

Pseudomonadaceae family, other 16 0 3 0

Enterobacter sp., other 15 0 0 0

Enterobacteriaceae sp., other 15 0 0 0

Listeria monocytogenes 15 0 7 0

Citrobacter sp., other 14 0 0 0

Other haemol. Streptococcae 13 0 21 1

Bacillus sp. 12 0 2 0

Actinomyces sp. 11 0 5 0

Bacteroides sp., not specified 11 0 3 0

Corynebacterium sp. 11 0 4 0

Prevotella sp. 11 0 7 0

Serratia sp., other 11 0 0 0

Streptococcus sp., not specified 11 0 3 0

Yeast, other 11 0 1 0

Anaerobes, not specified 10 0 6 0

Lactobacillus sp. 10 0 5 0

Haemophilus influenzae 9 0 12 0

Hafnia sp. 9 0 0 0

Candida krusei 8 0 0 0

Citrobacter sp., not specified 7 0 0 0

Gram negative cocci, other 7 0 0 0

Gram-pos bacilli, other 7 0 6 0

Klebsiella sp., other 7 0 4 0

Acinetobacter haemolyticus 6 0 1 0

Acinetobacter lwoffii 6 0 4 0

Campylobacter sp. 6 0 7 0

Klebsiella sp., not specified 6 0 1 0

Providencia sp. 6 0 5 0

Enterobacter agglomerans 5 0 0 0

Fungi sp., other 5 0 1 0

Gram-neg bacilli, non enterobacteriaceae, not specified 5 0 2 0

Salmonella sp., not specified 5 0 11 0

Other bacteria 4 0 2 0

Candida sp., not specified 4 0 1 0

Propionibacterium sp. 4 0 3 0

Achromobacter sp. 3 0 0 0

Aeromonas sp. 3 0 0 0

Gram positive cocci, not specified 3 0 1 0

Moraxella sp., other 3 0 0 0

Serratia liquefaciens 3 0 0 0

Burkholderia cepacia 2 0 0 0

Enterobacter sp., not specified 2 0 0 0

Table 32 (continued) | Microorganism isolated as etiological agents for bloodstream infections, exhaustive list, belgium 2016

58

AN

NEx

ES

ha-bSi non-ha-bSimicroorganism n % n %Pseudomonas sp., not specified 2 0 0 0

Salmonella, other 2 0 2 0

Serratia sp., not specified 2 0 0 0

Acinetobacter calcoaceticus 1 0 0 0

Agrobacterium sp. 1 0 0 0

Other bacteria, not specified 1 0 0 0

Clostridium difficile 1 0 0 0

Enterobacter sp, not specified 1 0 2 0

Enterobacter sakazakii 1 0 1 0

Filaments other 1 0 0 0

Fungi, not specified 1 0 0 0

Gram negative cocci, not specified 1 0 0 0

Moraxella sp., not specified 1 0 1 0

Neisseria sp., other 1 0 1 0

Nocardia sp. 1 0 0 0

Pasteurella sp. 1 0 2 0

Proteus sp., other 1 0 2 0

Salmonella Typhimurium 1 0 3 0

Salmonella Typhi or Paratyphi 1 0 1 0

Neisseria meningitidis 0 0 10 0

Moraxella catharralis 0 0 2 0

Salmonella entiritidis 0 0 2 0

Staphylococcus haemolyticus 0 0 2 0

Stenotrophomonas maltophilia 0 0 2 0

Aeromonas sp. 0 0 1 0

Enterococcus sp., not specified 0 0 1 0

Gardnerella sp. 0 0 1 0

Gram negative cocci, other 0 0 1 0

Gram-pos bacilli, not specified 0 0 1 0

Hafnia sp. 0 0 1 0

Serratia sp., other 0 0 1 0

Unidentified 3 0 2 0

total 8,186 100 2,622 100BSI, bloodstream infection; HA-BSI, hospital-associated bloodstream infection; N, number; neg., negative; pos., positive; sp, species

Table 32 (continued) | Microorganism isolated as etiological agents for bloodstream infections, exhaustive list, belgium 2016

59

AN

NEx

ES

12. Microorganism by suspected (clinical) origin of the bloodstream infectionTa

ble

33 |

Mic

roor

gani

sm fr

om h

ospi

tal-a

ssoc

iate

d bl

oods

trea

m in

fect

ion

by o

rigi

n, b

elgi

an a

cute

car

e ho

spita

ls, 2

016

clu

rina

ry tr

act

infe

ctio

n

gas

tro-

inte

stin

al

infe

ctio

n

pulm

onar

y in

fect

ion

Surg

ical

sit

e in

fect

ion

peri

pher

al

and

othe

r ca

thet

er a

nd

inva

siva

ni-

pula

tion

mbi

oth

er*

unk

now

nto

tal

fam

ily m

o -

mo

n

%n

%n

%n

%n

%n

%n

%n

%n

%n

%

Gra

m-n

eg b

acill

i: en

tero

bact

eria

ceae

387

211,

364

7957

154

431

4814

639

119

3095

4415

827

450

423,

721

45

Esch

eric

hia

coli

107

687

250

289

2713

415

7119

4712

6530

6210

200

191,

847

23

Kleb

siel

la p

neum

onia

e99

518

611

969

117

1324

624

616

724

485

867

18

Ente

roba

cter

clo

acae

633

453

596

475

175

174

63

214

454

320

4

Prot

eus m

irabi

lis6

010

56

131

101

62

31

00

61

141

163

2

Kleb

siel

la o

xyto

ca30

240

230

322

26

25

15

28

133

317

92

Serr

atia

mar

esce

ns22

119

111

136

45

13

10

09

213

111

81

Ente

roba

cter

aer

ogen

esis

171

332

162

172

62

41

10

20

121

108

1

oth

er/n

ot id

entifi

ed*

432

644

575

485

113

164

21

264

484

315

4

Gra

m-p

os c

occi

1,10

560

209

1225

224

262

2914

138

229

5880

3732

655

449

423,

053

37

Stap

hylo

cocc

us a

ureu

s21

712

493

131

113

1370

1980

203

116

828

161

1587

411

Stap

hylo

cocc

us e

pide

rmid

is49

827

111

40

81

144

6617

21

264

797

708

9

Ente

roco

ccus

faec

alis

794

111

664

628

327

715

410

527

545

440

65

Ente

roco

ccus

faec

ium

704

161

106

1018

218

522

627

1218

349

534

44

oth

er/n

ot id

entifi

ed*

241

1322

165

695

1112

346

1238

1787

1511

511

721

9

Gra

m-n

eg b

acill

i: no

n-en

tero

bact

eria

ceae

112

610

26

596

144

1628

720

523

1154

984

862

68

Pseu

dom

onas

aer

ugin

osa

483

865

323

110

1221

65

111

536

643

439

25

oth

er/n

ot id

entifi

ed*

643

161

273

344

72

154

126

183

414

234

3

Fung

i19

110

533

565

344

185

185

21

244

535

449

5

Cand

ida

albi

cans

985

322

212

233

51

113

10

122

242

227

3

Cand

ida

glab

rata

422

111

222

61

51

31

00

51

151

109

1

oth

er/n

ot id

entifi

ed*

513

101

131

51

82

41

10

71

141

113

1

Ana

erob

ic b

acill

i20

13

011

411

91

3810

41

146

234

242

249

3

Gra

m-p

os b

acill

i15

12

012

13

04

14

13

12

010

155

1

Gra

m-n

eg c

occi

30

00

00

40

00

00

00

10

50

130

oth

er a

nd n

ot id

entifi

ed4

01

02

03

00

01

01

03

15

020

0

tota

l1,

837

100

1,73

410

01,

066

100

890

100

375

100

395

100

218

100

591

100

1,08

010

08,

186

100

Cl, c

entr

al li

ne; M

BI, m

ucos

al b

arrie

r inj

ury;

Mo

, mic

roor

gani

sm; n

, num

ber;

neg.

, neg

ativ

e; p

os.,

posi

tive

* Sk

in/s

oft t

issu

e an

d ot

her

60

AN

NEx

ES

13. Microorganism resistance profiles, additional dataTa

ble

34 |

Ant

imic

robi

al re

sist

ance

am

ong

hosp

ital-a

ssoc

iate

d bl

oods

trea

m in

fect

ions

, bel

gium

201

3-20

16

ant

ibio

tics

mic

roor

gani

sm

201

3 2

014

201

520

16

nn

%n

n%

nn

%n

n%

Gra

m-p

os. c

occi

S. a

ureu

sM

eti

669

139

20.8

839

147

17.5

967

148

15.3

874

137

15.7

Gly

669

00.

083

94

0.5

967

70.

787

46

0.7

All E

nter

ococ

cus s

ppG

ly53

215

2.8

710

192.

780

223

2.9

792

273.

4

E. fa

ecal

is

Gly

328

30.

939

01

0.3

394

20.

540

61

0.2

E. fa

eciu

mG

ly19

77

3.6

285

113.

937

618

4.8

344

154.

4

Gra

m-n

eg. b

acill

i:

ente

roba

cter

iace

ae

C3G

2,57

353

620

.83,

162

702

22.2

3,52

181

023

.03,

721

814

21.9

CAR

2,57

324

0.9

3,16

240

1.3

3,52

173

2.1

3,72

178

2.1

E. co

liC3

G1,

334

187

14.0

1,58

725

916

.31,

780

308

17.3

1,84

728

215

.3

CAR

1,33

44

0.3

1,58

711

0.7

1,78

016

0.9

1,84

79

0.5

K. p

neum

onia

eC3

G37

897

25.7

512

159

31.1

588

206

35.0

671

230

34.3

CAR

378

92.

451

219

3.7

588

345.

867

143

6.4

E. cl

oaca

eC3

G21

996

43.8

245

9538

.831

111

436

.732

011

335

.3

CAR

219

31.

424

54

1.6

311

103.

232

010

3.1

P. m

irabi

lisC3

G13

34

3.0

155

21.

315

52

1.3

163

63.

7

CAR

133

00.

015

51

0.6

155

10.

616

32

1.2

K. o

xyto

caC3

G11

72

1.7

164

2917

.721

043

20.5

179

3720

.7

CAR

117

21.

716

41

0.6

210

41.

917

93

1.7

E. a

erog

enes

C3G

101

6160

.411

764

54.7

103

5452

.410

856

51.9

CAR

101

33.

011

72

1.7

103

11.

010

84

3.7

Serr

atia

spp

C3G

101

33.

014

938

25.5

112

2017

.913

424

17.9

CAR

101

22.

014

90

0.0

112

21.

813

41

0.7

Gra

m-n

eg. b

acill

i: no

n-en

tero

bact

eria

ceae

P. a

erug

inos

aCA

R31

855

17.3

395

6616

.740

259

14.7

392

6115

.6

baum

anni

iCA

R38

513

.250

612

.056

35.

448

24.

2

Acin

etob

acte

r spp

.CA

R10

35

4.9

139

117.

915

26

3.9

117

32.

6

C3G

, thi

rd g

ener

atio

n ce

phal

ospo

rin (

cefo

taxi

me,

cef

tria

xone

, cef

tazi

dim

); CA

R, c

arba

pene

ms

(imip

enem

, mer

open

em, d

orip

enem

); G

ly, g

lyco

pept

ides

(va

ncom

ycin

, tei

copl

anin

); M

eti,

met

hici

llin;

n,

num

ber r

esis

tant

Mo

; N, t

otal

num

ber M

o; n

eg.,

nega

tive;

pos

., po

sitiv

e; %

, per

cent

age

resi

stan

t Mo

61

AN

NEx

ES

Tabl

e 35

| H

ospi

tals

with

at l

east

one

resi

stan

t mic

roor

gani

sm is

olat

ed fr

om h

ospi

tal-a

ssoc

iate

d bl

oods

trea

m in

fect

ions

, bel

gium

201

3-20

16

hos

pita

ls w

ith

>= o

ne re

sist

ant c

ase*

2013

(n=1

19)

2014

(n=1

33)

2015

(n=1

43)

2016

(n=1

40)

mic

roor

gani

sma

ntib

ioti

csn

%n

%n

%n

%

Gra

m-p

os. c

occi

S. a

ureu

sM

eti

6050

6448

6948

6647

Gly

00

43

75

64

All E

nter

ococ

cus s

ppG

ly12

1015

1117

1217

12

E. fa

ecal

is

Gly

22

11

21

11

E. fa

eciu

mG

ly5

410

814

1010

7

Gra

m-n

eg. b

acill

i:

ente

roba

cter

iace

ae

C3G

9782

107

8012

688

117

84

CAR

1815

2317

4028

4029

E. co

liC3

G69

5876

5791

6491

65

CAR

43

108

128

86

K. p

neum

onia

eC3

G45

3864

4867

4776

54

CAR

98

118

1813

2316

E. cl

oaca

eC3

G45

3842

3258

4161

44

CAR

33

43

96

96

P. m

irabi

lisC3

G4

32

22

15

4

CAR

00

11

11

21

K. o

xyto

caC3

G20

1721

1626

1829

21

CAR

22

11

32

32

E. a

erog

enes

C3G

3832

3728

3424

3525

CAR

22

22

11

43

Serr

atia

spp

C3G

1714

2217

1510

1914

CAR

22

00

21

11

Gra

m-n

eg. b

acill

i: no

n-en

tero

bact

eria

ceae

P. a

erug

inos

aCA

R28

2441

3139

2734

24

A. b

aum

anni

iCA

R5

43

23

22

1

Acin

etob

acte

r spp

.CA

R5

48

66

43

2

C3G

, thi

rd g

ener

atio

n ce

phal

ospo

rin (

cefo

taxi

me,

cef

tria

xone

, cef

tazi

dim

); CA

R, c

arba

pene

ms

(imip

enem

, mer

open

em, d

orip

enem

); G

ly, g

lyco

pept

ides

(va

ncom

ycin

, tei

copl

anin

); M

eti,

Met

hici

llin;

Mo

, m

icro

orga

nism

; N, n

umbe

r par

ticip

atin

g ho

spita

ls; n

, num

ber o

f hos

pita

ls re

port

ing

at le

ast o

ne re

sist

ant M

o; n

eg.,

nega

tive;

pos

., po

sitiv

e

* H

ospi

tals

par

ticip

ate

1, 2

, 3 o

r 4 q

uart

ers

62

AN

NEx

ES

Table 36 | Antimicrobial resistance in microorganism isolated from hospital-associated and non-hospital-associated bloodstream infections, belgium 2016

ha-bSi non-ha-bSi hospitals with >= one

resistant case* - n=140

microorganism antibiotics n n % n n % n %Gram-pos. cocci

S. aureus Meti 874 137 15.7 273 27 9.9 71 51

Gly 874 6 0.7 273 0 0.0 6 4

All Enterococcus spp Gly 792 27 3.4 98 8 8.2 21 15

E. faecalis Gly 406 1 0.2 67 0 0.0 1 1

E. faecium Gly 344 15 4.4 20 3 15.0 12 9

Gram-neg. bacilli:

enterobacteriacea

C3G 3,721 814 21.9 1,442 154 10.7 117 84

CAR 3,721 78 2.1 1,442 3 0.2 40 29

E. coli C3G 1,847 282 15.3 1,064 105 9.9 9 6

CAR 1,847 9 0.5 1,064 1 0.1 9 6

K. pneumoniae C3G 671 230 34.3 138 22 15.9 80 57

CAR 671 43 6.4 138 1 0.7 24 17

E. cloacae C3G 320 113 35.3 35 10 28.6 61 44

CAR 320 10 3.1 35 1 2.9 9 6

P. mirabilis C3G 163 6 3.7 68 3 4.4 6 4

CAR 163 2 1.2 68 0 0.0 2 1

K. oxytoca C3G 179 37 20.7 35 4 11.4 31 22

CAR 179 3 1.7 35 0 0.0 3 2

E. aerogenes C3G 108 56 51.9 16 4 25.0 39 28

CAR 108 4 3.7 16 0 0.0 4 3

Serratia spp C3G 134 24 17.9 11 1 9.1 20 14

CAR 134 1 0.7 11 0 0.0 1 1


P. aeruginosa CAR 392 61 15.6 60 4 6.7 36 26

A. baumannii CAR 48 2 4.2 4 1 25.0 3 2

Acinetobacter spp. CAR 117 3 2.6 12 1 8.3 4 3

BSI, bloodstream infection; C3G, third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidim); CAR, carbapenems (imipenem, meropenem, doripenem); Gly, glycopeptides (vancomycin, teicoplanin); HA-BSI, hospital-associated bloodstream infection; Meti, Methicillin; Mo, microorganism; N, total number Mo; n, number resistant Mo or number of hospitals; neg., negative; pos., positive; %, percentage resistant Mo

* Hospitals participate 1, 2, 3 or 4 quarters - includes all BSI (HA-BSI and non-HA-BSI)

63

AN

NEx

ES

14. Antimicrobial resistance by region, additional data

Table 37 | Resistance in microorganism isolated from non-hospital-associated bloodstream infections by region, belgium 2016

microorganism antibioticsbrussels flanders Wallonia

n n % n n % n n % Gram-pos. cocci

S. aureus Meti 48 5 10 148 16 11 77 6 8

Gly 48 0 0 148 0 0 77 0 0

All Enterococcus spp Gly 22 2 9 49 4 8 27 2 7

E. faecalis Gly 14 0 0 38 0 0 15 0 0

E. faecium Gly 5 0 0 9 2 22 6 1 17

Gram-neg. bacilli:

enterobacteriaceae

C3G 275 26 9 813 92 11 354 36 10

CAR 275 0 0 813 2 0 354 1 0

E. coli C3G 200 23 12 612 65 11 252 17 7

CAR 200 0 0 612 1 0 25 0 0

K. pneumoniae C3G 23 1 4 72 11 15 43 10 23

CAR 23 0 0 72 1 1 43 0 0

E. cloacae C3G 9 2 22 19 5 26 7 3 43

CAR 9 0 0 19 0 0 7 1 14

P. mirabilis C3G 15 0 0 35 2 6 18 1 6

CAR 15 0 0 35 0 0 18 0 0

K. oxytoca C3G 10 0 0 21 3 14 4 1 25

CAR 10 0 0 21 0 0 4 0 0

E. aerogenes C3G 2 0 0 10 2 20 4 2 50

CAR 2 0 0 10 0 0 4 0 0

Serratia spp C3G 1 0 0 7 1 14 3 0 0

CAR 1 0 0 7 0 0 3 0 0

Gram-neg. bacilli: non enterobacteriaceae

P. aeruginosa CAR 10 0 0 32 4 13 18 0 0

A. baumannii 4 0 0 3 1 33 1 0 0

Acinetobacter spp. CAR 2 0 0 6 1 17 4 0 0

C3G, third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidim); CAR, carbapenems (imipenem, meropenem, doripenem); Gly, glycopeptides (vancomycin, teicoplanin); Meti, Methicillin; Mo, microorganism; N, total number Mo; n, number resistant Mo; neg., negative; pos., positive; %, percentage resistant Mo

64

AN

NEx

ES

Table 38 | Hospitals with at least one resistant microorganism isolated from hospital-associated bloodstream infection by region, belgium 2016

microorganism antibiotics

hospitals with >= one resistant case*brussels (n=18) flanders (n=71) Wallonia (n=51)

n % n % n %Gram-pos. cocci

S. aureus Meti 10 56 29 41 27 53

Gly 0 0 3 4 3 6

All Enterococcus spp Gly 5 28 6 8 6 12

E. faecalis Gly 0 0 1 1 0 0

E. faecium Gly 4 22 2 3 4 8

Gram-neg. bacilli:

enterobacteriaceae

C3G 18 100 57 80 42 82

CAR 7 39 19 27 14 27

E. coli C3G 14 78 46 65 31 61

CAR 2 11 3 4 3 6

K. pneumoniae C3G 14 78 27 38 35 69

CAR 5 28 8 11 10 20

E. cloacae C3G 12 67 30 42 19 37

CAR 3 17 4 6 2 4

P. mirabilis C3G 0 0 5 7 0 0

CAR 1 6 1 1 0 0

K. oxytoca C3G 3 17 20 28 6 12

CAR 1 6 1 1 1 2

E. aerogenes C3G 7 39 10 14 18 35

CAR 0 0 3 4 1 2

Serratia spp C3G 3 17 6 8 10 20

CAR 0 0 0 0 1 2


P. aeruginosa CAR 7 39 16 23 11 22

A. baumannii CAR 0 0 1 1 1 2

Acinetobacter spp. CAR 0 0 2 3 1 2

C3G, third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidim); CAR, carbapenems (imipenem, meropenem, doripenem); Gly, glycopeptides (vancomycin, teicoplanin); Meti, Methicillin; Mo, microorganism; N, number participating hospitals; n, number of hospitals reporting at least one resistant Mo; neg., negative; pos., positive; R, resistant

* Hospitals participate 1, 2, 3 or 4 quarters - includes all BSI (HA-BSI and non-HA-BSI)

65

AN

NEx

ES

15. intensive care unit-associated central line-associated bloodstream infections according to case definition

Table 39 | intensive care unit-associated central line-associated bloodstream infections according to case definition (proportions)*, belgium 2013-2016

Year 2013 2014 2015 2016clabSi n % n % n % n %Confirmed 170 36 202 40 221 39 183 35

Probable 128 27 133 26 187 33 170 32

Possible 170 36 173 34 158 28 172 33total 468 100 508 100 566 100 525 100

ClABSI, central line-associated bloodstream infection; ICU, intensive care unit; N, number

* Includes all ClABSI episodes (also those without denominator)

66

AN

NEx

ES

16. Hospital stay data (RHM/MZg)Ta

ble

40 |

inci

denc

e of

hos

pita

l-ass

ocia

ted

bloo

dstr

eam

infe

ctio

ns b

ased

on

hosp

ital s

tay

data

ver

sus s

urve

illan

ce d

ata,

bel

gium

200

0-20

14

20

0020

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

1220

1320

14

hos

pita

l sta

y da

ta (r

hm

/mZg

)1

tota

l BSI

21

,188

23,4

9823

,963

25,6

3624

,963

25,4

7125

,567

25,0

9725

,697

26,8

5127

,659

28,1

8829

,156

30,3

5130

,232

BSI a

s sec

onda

ry d

iagn

osis

2 16

,991

19,0

9619

,360

20,7

9220

,067

20,2

2319

,832

18,7

1218

,657

18,8

1718

,826

19,0

7219

,613

20,2

1019

,918

BSI n

ot p

rese

nt o

n ad

mis

sion

3 N

AN

AN

AN

AN

AN

AN

AN

A8,

122

9,33

49,

560

9,62

29,

651

7,89

16,

022

Inci

denc

e BS

I as s

econ

dary

di

agno

sis2 /1

0,00

0 pd

10

.611

.912

.213

.213

.013

.113

.012

.312

.212

.512

.612

.713

.213

.713

.7

Inci

denc

e BS

I as s

econ

dary

di

agno

sis2 /1

,000

adm

9.1

10.3

10.5

11.2

10.8

10.8

10.6

10.0

9.8

9.8

9.7

9.8

9.9

10.3

10.1

Inci

denc

e BS

I not

pre

sent

on

adm

issi

on3 /1

0,00

0 pd

5.3

6.2

6.4

6.4

6.5

5.4

4.1

Inci

denc

e BS

I not

pre

sent

on

adm

issi

on3 /1

,000

adm

4.3

4.9

4.9

4.9

4.9

4.0

3.0

Surv

eilla

nce

of b

Si in

bel

gian

hos

pita

ls d

ata4

HA

-BSI

/10,

000

pd7.

77.

7

HA

-BSI

/1,0

00 a

dm

5.5

5.6

adm

, adm

issi

on; B

SI, b

lood

stre

am in

fect

ion;

HA

-BSI

, hos

pita

l-ass

ocia

ted

bloo

dstr

eam

infe

ctio

n; N

A, n

ot a

vaila

ble;

RH

M/M

ZG, r

ésum

e ho

spita

lier m

inim

al/m

inim

ale

ziek

enhu

is g

egev

ens;

pd,

patie

nt-d

ays

1 D

iagn

osis

cod

ed u

sing

ICD

9 co

de 0

38.0

-92

Seco

ndar

y di

agno

sis

com

prom

ises

com

orbi

dity

(exi

sted

bef

ore

adm

issi

on) o

r a c

ompl

icat

ion

(occ

urre

d af

ter a

dmis

sion

)3 A

ssum

ing

thos

e BS

I ‘no

t pre

sent

at a

dmis

sion

’ are

HA

-BSI

4 In

clud

es o

nly

thos

e da

ta c

olle

cted

usi

ng th

e re

view

ed p

roto

col C

entr

al li

ne-a

ssoc

iate

d bl

oods

trea

m in

fect

ions

Published by: Dr Myriam Sneyers

© Scientific Institute of Public HealthoPERAtIoNAl DIRECtoRAtE PUBlIC HEAltH AND SURVEIllANCEJuliette Wytsmanstraat 141050 Brussels - Belgiumwww.wiv-isp.be

Surveillance of bloodStream infectionS in belgian hoSpitalS (Sep) · 2017-06-30 · AUTHORS Els...

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