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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: els.duysburgh@wiv-isp.be
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
10
ABB
REVI
AtIo
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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
0.5
1.0
1.5
2.0
2.5
2013 2014 2015 2016
CLAB
SI/1
0,00
0 pd
Year
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
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
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2013
2014
2015
2016
Isol
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MO
in H
A-BS
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,000
pd
Year
Escherichia coli
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.
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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.
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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)
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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)
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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
0
2
4
6
8
10
12
2013 2014 2015 2016
HA-B
SI/1
0,00
0 pd
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
mean incidence per 10,000 pd 0.6 0.7 0.8 0.6
Possible ClABSI
N* 421 465 460 420
mean incidence per 10,000 pd 0.6 0.5 0.5 0.4
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
0.0
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Confirmed +probable +possibleConfirmed +probable
Confirmed
ClABSI, central line-associated bloodstream infections; pd, patient-days
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
0.00.20.40.60.81.01.21.41.61.82.0
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Isol
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Escherichia coli
Staphylococcus aureus
Klebsiella pneumonia
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
HA-BSI, hospital-associated bloodstream infection; pd, patient-days
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
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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%
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
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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
Other/not identified* 173 2 32 2 157 6
Gram-neg. bacilli: non-enterobacteriaceae 626 8 162 9 114 4
Pseudomonas aeruginosa 392 5 123 7 60 2
Other/not identified* 234 3 39 2 54 2
Fungi 449 5 138 8 21 1
Candida albicans 227 3 78 5 12 0
Candida glabrata 109 1 35 2 4 0
Other/not identified* 113 1 25 1 5 0
Anaerobic bacilli 249 3 53 3 97 4
Bacteroides fragilis 102 1 20 1 31 1
Other/not identified* 147 2 33 2 66 3
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
Mean incidence per 10,000 pd* 0.00 0.00 0.01 0.01
Hospitals with ≥ one R case 0 4 7 6
% hospitals with ≥ one R case 0 3 5 4
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
Mean incidence per 10,000 pd* 0.26 0.29 0.32 0.29
Hospitals with ≥ one R case 69 76 91 91
% hospitals with ≥ one R case 58 57 64 65
Carbapenem (imipenem, meropenem, doripenem)
nR 4 11 16 9
%R 0.3 0.7 0.9 0.5
Mean incidence per 10,000 pd* 0.01 0.01 0.02 0.01
Hospitals with ≥ one R case 4 10 12 8
% hospitals with ≥ one R case 3 8 8 6
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 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
third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime)
nR 97 159 206 230
%R 25.7 31.1 35.0 34.3
Mean incidence per 10,000 pd* 0.13 0.18 0.21 0.23
Hospitals with ≥ one R case 45 64 67 76
% hospitals with ≥ one R case 38 48 47 54
Carbapenem (imipenem, meropenem, doripenem)
nR 9 19 34 43
%R 2.4 3.7 5.8 6.4
Mean incidence per 10,000 pd* 0.01 0.02 0.04 0.04
Hospitals with ≥ one R case 9 11 18 23
% hospitals with ≥ one R case 8 8 13 16
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 K
. pne
umon
iae
Year
Third generationcephalosporin
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
third generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime)
nR 96 95 114 113
%R 43.8 38.8 36.7 35.3
Mean incidence per 10,000 pd* 0.13 0.11 0.12 0.12
Hospitals with ≥ one R case 45 42 58 61
% hospitals with ≥ one R case 38 32 41 44
Carbapenem (imipenem, meropenem, doripenem)
nR 3 4 10 10
%R 1.4 1.6 3.2 3.1
Mean incidence per 10,000 pd* 0.00 0.00 0.01 0.01
Hospitals with ≥ one R case 3 4 9 9
% hospitals with ≥ one R case 3 3 6 6
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 E
. clo
acae
Year
Third generationcephalosporin
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
Carbapenem (imipenem, meropenem, doripenem)
nR 55 66 59 61
%R 17.3 16.7 14.7 15.6
Mean incidence per 10,000 pd* 0.08 0.07 0.06 0.06
Hospitals with ≥ one R case 28 41 39 34
% hospitals with ≥ one R case 24 31 27 24
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
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
Mean incidence per 10,000 pd* 0.01 0.01 0.02 0.02
Hospitals with ≥ one R case 5 10 14 10
% hospitals with ≥ one R case 4 8 10 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 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%
Less than 10 isolates reported
Numbers refer to numbers of hospitals that contributed data
13 the color scale used in the maps is similar to those used by ECDC.
37
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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%
Less than 10 isolates reported
Numbers refer to number of hospitals that contributed data
38
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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 hospitals included in calculation of incidence* 74 90 89 89
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
39
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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
mean incidence per 10,000 pd 4.5 4.1 3.7 3.4
Probable ClABSI
N* 71 80 81 89
mean incidence per 10,000 pd 3.0 2.8 2.7 3.0
Possible ClABSI
N* 112 100 99 88
mean incidence per 10,000 pd 4.7 3.5 3.3 2.9
total clabSi
N* 289 297 291 279
mean incidence per 10,000 pd 12.1 10.5 9.7 9.3
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
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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
ClABSI, central line-associated bloodstream infections; pd, patient-days
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*
Other catheter/ Invasive manipulation
Unknown
Mucosal barrier injury
Other secondary infections
Gastro-intestinal infection
Pulmonary infections
Surgical site infections
Urinary tract infections
Secondary to an infection at another body site
* 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
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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
* Includes ‘confirmed’, ‘probable’ and ‘possible’ ClABSI
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
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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
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(9) NSIH. National surveillance of hospital associated bloodstream infections (hospital-wide), http://www.nsih.be/surv_sep/beschrijving_en.asp http://www.nsih.be/surv_sep/beschrijving_nl.asp, http://www.nsih.be/surv_sep/beschrijving_fr.asp. [assessed April 2017]
(10) lambert Ml. Indicateurs de qualité en hygiène hospitalière dans les hôpitaux aigus, Données 2015. http://www.nsih.be/download/IQ/QI_Report_2015_Nl.pdf, http://www.nsih.be/download/IQ/QI_Report_2015_FR.pdf. NSIH 2016.
(11) Centers for Disease Control and Prevention (CDC). ICD-9-CM official Guidelines for Coding and Reporting (https://www.cdc.gov/nchs/data/icd/icd9cm_guidelines_2011.pdf ). 2011.
(12) Jans B, Denis o, Goossens H, Glupczynski y Surveillance van antibioticaresistente bacteriën in Belgische ziekenhuizen: Jaarrapport 2015. http://www.nsih.be/download/MRSA/MRSA_ESBl_CPE_y2015/RAPPoRt_AMR_y2015_Nl.pdf. NSIH 2017. Brussels, Belgium, Scientific institute for Public Health.
(13) Centers for Disease Control and Prevention (CDC). Bloodstream Infection Event (Central line-Associated Bloodstream Infection and non-central line-associated Bloodstream Infection) - January 2017. 2016. http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf.
(14) WHo. Report on the Burden of Endemic Health Care-Associated Infection Worldwide: A systematic review of the literature. 2011.
(15) Horstman MJ, li yF, Almenoff Pl, Freyberg RW, trautner BW: Denominator Doesn’t Matter: Standardizing Healthcare-Associated Infection Rates by Bed Days or Device Days. Infect Control Hosp Epidemiol 2015, 36: 710-716.
(16) Centers for Disease Control and Prevention (CDC). Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance. 2016. http://www.cdc.gov/nhsn/pdfs/pscmanual/2psc_identifyinghais_nhsncurrent.pdf.
(17) Backman lA, Melchreit R, Rodriguez R: Validation of the surveillance and reporting of central line-associated bloodstream infection data to a state health department. Am J Infect Control 2010, 38: 832-838.
(18) Masia MD, Barchitta M, liperi G, Cantu AP, Alliata E, Auxilia F et al.: Validation of intensive care unit-acquired infection surveillance in the Italian SPIN-UtI network. J Hosp Infect 2010, 76: 139-142.
(19) Rich Kl, Reese SM, Bol KA, Gilmartin HM, Janosz t: Assessment of the quality of publicly reported central line-associated bloodstream infection data in Colorado, 2010. Am J Infect Control 2013, 41: 874-879.
(20) European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals 2011-2012. 2013. Stockholm, ECDC.
(21) European Centre for Disease Prevention and Control (ECDC). Antimicrobial resistance surveillance in Europe 2015. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). 2017. Stockholm, ECDC.
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 hospitals included in calculation of incidence* 100 111 120 113
N hospital-quarters 260 311 354 354
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 hospitals included in calculation of incidence* 18 21 22 22
N hospital-quarters 48 56 60 59
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
* Includes ‘confirmed’, ‘probable’ and ‘possible’ ClABSI
** 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
HA-BSI, hospital-associated bloodstream infection; pd, patient-days
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
NEx
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
Gram-neg. bacilli: non-enterobacteriaceae
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
Gram-neg. bacilli: non-enterobacteriaceae
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
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