Healthcare-associated infections and antimicrobial use in Belgian nursing homes: results of three point prevalence surveys between 2010 and 2016

Background

Belgium monitors the burden of healthcare-associated infections (HAIs) and antimicrobial use in nursing homes (NHs) by participating in the European point prevalence surveys (PPSs) organised in long-term care facilities (HALT surveys). We present the main findings of the three national PPSs conducted in NHs participating in at least one of these surveys, and in a cohort that participated in all three consecutive surveys.

Methods

All NHs were invited to voluntarily participate and conduct the survey on one single day in May-September 2010 (HALT-1), in April-May 2013 (HALT-2) or in September-November 2016 (HALT-3). Data were collected at institutional, ward and resident level. A detailed questionnaire had to be completed for all eligible (i.e. living full time in the facility since at least 24 h, present at 8:00 am and willing to participate) residents receiving at least one systemic antimicrobial agent and/or presenting at least one active HAI on the PPS day. The onset of signs/symptoms had to occur more than 48 h after the resident was (re-)admitted to the NH.

Results

A total of 107, 87 and 158 NHs conducted the HALT-1, HALT-2 and HALT-3 survey, respectively. The median prevalence of residents with antimicrobial agent(s) increased from 4.3% (95% confidence interval (CI): 3.5-4.8%) in HALT-1 to 4.7% (95% CI: 3.5-6.5%) in HALT-2 and 5.0% (95% CI: 4.2-5.9%) in HALT-3. The median prevalence of residents with HAI(s) varied from 1.8% (95% CI: 1.4-2.7%) in HALT-1 to 3.2% (95% CI: 2.2-4.2%) in HALT-2 and 2.7% (95% CI: 2.1-3.4%) in HALT-3. Our post-hoc analysis on the cohort (n = 25 NHs) found similar trends. In all three surveys, respiratory tract infections were most frequently reported, followed by skin/wound infections in HALT-1 and urinary tract infections in HALT-2 and HALT-3. Antimicrobials were most commonly prescribed for the therapeutic treatment of an infection: 66.4% in HALT-1, 60.9% in HALT-2 and 64.1% in HALT-3. Uroprophylaxis accounted for 28.7%, 35.6% and 28.4% of all prescriptions, respectively.

Conclusions

None withstanding the limitations peculiar to the study design, the PPSs enabled us to assess the occurrence of and to increase awareness for HAIs and rational antimicrobial use in NHs at both local and national level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00818-1.

Diagnosis, prevention and control of urinary tract infections: a survey of routine practices in Belgian nursing homes

Background

Urinary tract infections (UTIs) are one of the most frequently reported infections in older adults and the most common reason for antimicrobial prescribing in nursing homes (NHs). In this vulnerable population, both a good diagnosis and prevention of these infections are crucial as overuse of antibiotics can lead to a variety of negative consequences including the development of multidrug-resistant organisms.

Objective

To determine infection prevention and control (IPC) and diagnostic practices for UTIs in Belgian NHs.

Methods

Local staff members had to complete an institution-level questionnaire exploring the availability of IPC practices and resources and procedures for UTI surveillance, diagnosis, and urinary catheter and incontinence care.

Results

UTIs were the second most common infections in the 87 participating NHs (prevalence: 1.0%). Dipstick tests and urine cultures were routinely performed in 30.2% and 44.6% of the facilities, respectively. In non-catheterised residents, voided or midstream urine sampling was most frequently applied. Protocols/guidelines for urine sampling, urinary catheter care and incontinence care were available in 43.7%, 45.9% and 31.0% of the NHs, respectively. Indwelling catheters were uncommon (2.3% of the residents) and urinary retention (84.9%) and wound management (48.8%) were the most commonly reported indications. Only surveillance was found to significantly impact the UTI prevalence: 2.2% versus 0.8% in NHs with or without surveillance, respectively (P < 0.001).

Discussion

This survey identified key areas for improving the diagnosis and prevention of UTIs, such as education and training regarding the basics of urine collection and catheter care.

Antimicrobial use in European long-term care facilities: results from the third point prevalence survey of healthcare-associated infections and antimicrobial use, 2016 to 2017

Antimicrobials are commonly prescribed and contribute to the development of antimicrobial resistance in long-term care facilities (LTCFs). In 2010, the European Centre for Disease Prevention and Control initiated point prevalence surveys (PPS) of healthcare-associated infections and antimicrobial use in European LTCFs, performed by external contractors as the Healthcare-Associated infections in Long-Term care facilities (HALT) projects. Here, we investigated prevalence and characteristics of antimicrobial use and antimicrobial stewardship indicators in European LTCFs in 2016–17. Twenty-four European Union/European Economic Area (EU/EEA) countries, the former Yugoslav Republic of Macedonia and Serbia participated in the third PPS in European LTCFs. Overall, 4.9% (95% confidence interval: 4.8–5.1) of LTCF residents in the EU/EEA participating countries received at least one antimicrobial. The most commonly reported Anatomical Therapeutic Chemical (ATC) groups were beta-lactam antibacterials/penicillins (J01C), other antibacterials (J01X) (e.g. glycopeptide antibacterials, polymyxins), quinolones (J01M), sulfonamides and trimethoprim (J01E), and other beta-lactams (J01D). Urinary tract infections and respiratory tract infections were the main indications for antimicrobial prescription. This PPS provides updated and detailed information on antimicrobial use in LTCFs across the EU/EEA that can be used to identify targets for future interventions, follow-up of these interventions and promote prudent use of antimicrobials in European LTCFs.

Prevalence of multidrug-resistant organisms in nursing homes in Belgium in 2015

Objectives

Following two studies conducted in 2005 and 2011, a third prevalence survey of multidrug-resistant microorganisms (MDRO) was organised in Belgian nursing homes (NHs) using a similar methodology. The aim was to measure the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase producing Enterobacteriaceae (ESBLE) and carbapenemase-producing Enterobacteriaceae (CPE) in NH residents. Risk factors for MDRO carriage were also explored.

Methods

Up to 51 randomly selected residents per NH were screened for MDRO carriage by trained local nurses between June and October 2015. Rectal swabs were cultured for ESBLE, CPE and VRE, while pooled samples of nose, throat and perineum and chronic wound swabs were obtained for culture of MRSA. Antimicrobial susceptibility testing, molecular detection of resistance genes and strain genotyping were performed. Significant risk factors for MDRO colonization MDRO was determined by univariate and multivariable analysis.

Results

Overall, 1447 residents from 29 NHs were enrolled. The mean weighted prevalence of ESBLE and MRSA colonization was 11.3% and 9.0%, respectively. Co-colonization occurred in 1.8% of the residents. VRE and CPE carriage were identified in only one resident each. Impaired mobility and recent treatment with fluoroquinolones or with combinations of sulphonamides and trimethoprim were identified as risk factors for ESBLE carriage, while for MRSA these were previous MRSA carriage/infection, a stay in several different hospital wards during the past year, and a recent treatment with nitrofuran derivatives. Current antacid use was a predictor for both ESBL and MRSA carriage.

Conclusions

In line with the evolution of MRSA and ESBL colonization/infection in hospitals, a decline in MRSA carriage and an increase in ESBLE prevalence was seen in Belgian NHs between 2005 and 2015. These results show that a systemic approach, including surveillance and enhancement of infection control and antimicrobial stewardship programs is needed in both acute and chronic care facilities.

Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017

Point prevalence surveys of healthcare-associated infections (HAI) and antimicrobial use in the European Union and European Economic Area (EU/EEA) from 2016 to 2017 included 310,755 patients from 1,209 acute care hospitals (ACH) in 28 countries and 117,138 residents from 2,221 long-term care facilities (LTCF) in 23 countries. After national validation, we estimated that 6.5% (cumulative 95% confidence interval (cCI): 5.4-7.8%) patients in ACH and 3.9% (95% cCI: 2.4-6.0%) residents in LTCF had at least one HAI (country-weighted prevalence). On any given day, 98,166 patients (95% cCI: 81,022-117,484) in ACH and 129,940 (95% cCI: 79,570-197,625) residents in LTCF had an HAI. HAI episodes per year were estimated at 8.9 million (95% cCI: 4.6-15.6 million), including 4.5 million (95% cCI: 2.6-7.6 million) in ACH and 4.4 million (95% cCI: 2.0-8.0 million) in LTCF; 3.8 million (95% cCI: 3.1-4.5 million) patients acquired an HAI each year in ACH. Antimicrobial resistance (AMR) to selected AMR markers was 31.6% in ACH and 28.0% in LTCF. Our study confirmed a high annual number of HAI in healthcare facilities in the EU/EEA and indicated that AMR in HAI in LTCF may have reached the same level as in ACH.

Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017

Point prevalence surveys of healthcare-associated infections (HAI) and antimicrobial use in the European Union and European Economic Area (EU/EEA) from 2016 to 2017 included 310,755 patients from 1,209 acute care hospitals (ACH) in 28 countries and 117,138 residents from 2,221 long-term care facilities (LTCF) in 23 countries. After national validation, we estimated that 6.5% (cumulative 95% confidence interval (cCI): 5.4-7.8%) patients in ACH and 3.9% (95% cCI: 2.4-6.0%) residents in LTCF had at least one HAI (country-weighted prevalence). On any given day, 98,166 patients (95% cCI: 81,022-117,484) in ACH and 129,940 (95% cCI: 79,570-197,625) residents in LTCF had an HAI. HAI episodes per year were estimated at 8.9 million (95% cCI: 4.6-15.6 million), including 4.5 million (95% cCI: 2.6-7.6 million) in ACH and 4.4 million (95% cCI: 2.0-8.0 million) in LTCF; 3.8 million (95% cCI: 3.1-4.5 million) patients acquired an HAI each year in ACH. Antimicrobial resistance (AMR) to selected AMR markers was 31.6% in ACH and 28.0% in LTCF. Our study confirmed a high annual number of HAI in healthcare facilities in the EU/EEA and indicated that AMR in HAI in LTCF may have reached the same level as in ACH.

Infection due to travel-related carbapenemase-producing Enterobacteriaceae, a largely underestimated phenomenon in Belgium

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) are emerging worldwide, representing a major threat for public health. Early CPE detection is crucial in order to prevent infections and the development of reservoirs/outbreaks in hospitals. In 2008, most of the CPE strains reported in Belgium were imported from patients repatriated from abroad. Actually, this is no longer the case.

OBJECTIVES AND METHODS

A surveillance was set up in Belgian hospitals (2012) in order to explore the epidemiology and determinants of CPE, including the link with international travel/hospitalization. The present article describes travel-related CPE reported in Belgium. Different other potential sources for importation of CPE are discussed.

RESULTS

Only 12% of all CPE cases reported in Belgium (2012-2013) were travel related (with/without hospitalization). This is undoubtedly an underestimation (missing travel data: 36%), considering the increasing tourism, the immigration from endemic countries, the growing number of foreign patients using scheduled medical care in Belgium, and the medical repatriations from foreign hospitals. The free movement of persons and services (European Union) contributes to an increase in foreign healthcare workers (HCW) in Belgian hospitals. Residents from nursing homes located at the country borders can be another potential source of dissemination of CPE between countries. Moreover, the high population density in Belgium can increase the risk for CPE-dissemination. Urban areas in Belgium may cumulate these potential risk factors for import/dissemination of CPE.

CONCLUSIONS

Ideally, travel history data should be obtained from hospital hygiene teams, not from the microbiological laboratory. Patients who received medical care abroad (whatever the country) should be screened for CPE at admission.

Risk factors for methicillin resistant Staphylococcus aureus: a multi-laboratory study

Background

The present study aimed to investigate the dose response relationship between the prescriptions of antimicrobial agents and infection/colonization with methicillin resistant Staphylococcus aureus (MRSA) taking additional factors like stay in a health care facility into account.

Methods

Multi-centre retrospective study on a cohort of patients that underwent microbiological diagnostics in Belgium during 2005. The bacteriological results retrieved from 17 voluntary participating clinical laboratories were coupled with the individual antimicrobial consumption patterns (July 2004-December 2005) and other variables as provided by pooled data of health insurance funds. Multivariate analysis was used to identify risk factors for MRSA colonization/infection.

Results

A total of 6844 patients of which 17.5% died in the year 2005, were included in a logistic regression model. More than 97% of MRSA was associated with infection (clinical samples), and only a minority with screening/colonization (1.59%). Factors (95% CI) significantly (p≤<0.01) associated with MRSA in the final multivariate model were: admission to a long term care settings (2.79–4.46); prescription of antibiotics via a hospital pharmacy (1.30–2.01); age 55+ years (3.32–5.63); age 15–54 years (1.23–2.16); and consumption of antimicrobial agent per DDD (defined daily dose) (1.25–1.40).

Conclusions

The data demonstrated a direct dose-response relationship between MRSA and consumption of antimicrobial agents at the individual patient level of 25–40% increased risk per every single day. In addition the study indicated an involvement of specific healthcare settings and age in MRSA status.

Development and assessment of national performance indicators for infection prevention and control and antimicrobial stewardship in European long-term care facilities

BACKGROUND

Healthcare-associated infections in long-term care facilities (LTCFs) are of increasing importance.

AIM

To develop consensus national performance indicators (NPIs) for infection control (ICPI) and antimicrobial stewardship (ASPI) in LTCFs, and assess the performance of 32 European countries against these NPIs.

METHODS

Previously established European standards were the basis for consensus and the same iterative approach with national representatives from the 32 countries. A World Health Organization scoring system recorded how close each country was to implementing each standard.

FINDINGS

The 42 agreed component indicators were grouped into six NPI categories: 'national programme', 'guidelines', 'expert advice', 'IC structure' (not present in the ASPI), 'surveillance' and 'composite'. 'Guidelines' scored the highest mean total possible score (60%, range 20-100%), followed by 'composite' (53%, range 30-100%), 'expert advice' (48%, range 20-100%), 'surveillance' (47%, range 20-83%), 'national programme' (42%, range 20-100%) and 'IC structure' (39%, range 20-100%). Although several scores were low, some countries were able to implement all NPIs, indicating that this was feasible. Most NPIs were very significantly related, indicating that they were considered to be important by the countries. 'Guidelines' and 'IC structure' were significantly related to European region (P ≤ 0.05). Accreditation/inspection was not evident in seven (22%) countries, nine (28%) countries had accreditation/inspection that included IC assessments, and seven (22%) countries had accreditation/inspection that included IC and antimicrobial stewardship assessments. Multi-variable analysis found that only the NPI and the ICPI 'expert advice' were associated with accreditation/inspection which included IC and antimicrobial stewardship.

CONCLUSION

The identified gaps represent significant potential patient safety issues. The NPIs should serve as a basis for monitoring improvements over the coming years.

Epidemiology of multidrug-resistant microorganisms among nursing home residents in Belgium

OBJECTIVES

A national survey was conducted to determine the prevalence and risk factors of methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamases-producing Enterobacteriaceae (ESBLE) and vancomycin-resistant enterococci (VRE) among nursing home residents in Belgium.

METHODS

A random stratified, national prevalence survey was conducted in nursing home residents who were screened for carriage of ESBLE, MRSA and VRE by multisite enriched culture. Characteristics of nursing homes and residents were collected by a questionnaire survey and were analysed by multilevel logistic regression analysis.

RESULTS

Of 2791 screened residents in 60 participating nursing home, the weighted prevalence of ESBLE and MRSA carriage were 6.2% (range: 0 to 20%) and 12.2% (range: 0 to 36%), respectively. No cases of VRE were found. No relationship was found between ESBLE and MRSA prevalence rates within nursing homes and the rate of co-colonization was very low (0.8%). Geographical variations in prevalence of MRSA and ESBLE and in distribution of ESBL types in nursing home residents paralleled that of acute hospitals. Risk factors of ESBLE carriage included previously known ESBLE carriage, male gender, a low level of mobility and previous antibiotic exposure. Risk factors for MRSA colonization were: previously known MRSA carriage, skin lesions, a low functional status and antacid use.

CONCLUSIONS

A low prevalence of ESBLE carriage was found in nursing home residents in Belgium. The prevalence of MRSA carriage decreased substantially in comparison to a similar survey conducted in 2005. A low functional status appeared as a common factor for ESBLE and MRSA carriage. Previous exposure to antibiotics was a strong predictor of ESBLE colonization while increased clustering of MRSA carriage suggested the importance of cross-transmission within nursing homes for this organism. These results emphasize the need for global coordination of the surveillance of MDRO within and between nursing homes and hospitals.

Parenteral versus oral administration of systemic antimicrobials in European nursing homes: a point-prevalence survey

BACKGROUND

Residents in long-term care facilities are predisposed to healthcare-associated infections that are likely caused by antimicrobial-resistant micro-organisms. Long-term care facilities are increasingly able to offer parenteral antimicrobial treatment but there are few data on the use and appropriateness of such treatment in this setting. Information on the use of parenteral antimicrobials and associated factors in long-term care facilities is necessary to assess the risks and benefits of this treatment and to support the development of antimicrobial policies aimed at minimizing the emergence and spread of antimicrobial resistance.

OBJECTIVE

The aim of this study was to describe the extent of parenteral and oral antimicrobial use in participating European nursing homes (NHs) and to analyse the resident characteristics and determinants associated with route of antimicrobial administration.

METHODS

Data on resident characteristics and antimicrobials were collected by means of a point-prevalence survey. Logistic regression was used to analyse the data.

RESULTS

Based on data from 21 European countries for 2046 antimicrobial prescriptions, an average of 9.0% (range by country: 0.0-66.7%) of treatment was administered parenterally. Multivariate analysis showed that residents receiving parenteral antimicrobials had greater morbidity, such as increased risk of having a urinary catheter (p < 0.001), a vascular catheter (p < 0.001), impaired mobility (p = 0.007) and disorientation (p = 0.005). Residents receiving parenteral antimicrobials also had been admitted more recently into the NH (p = 0.007). Empirical treatment of respiratory tract infections (RTIs) accounted for the majority of parenteral antimicrobials, while prophylaxis of urinary tract infection (UTI) was the most common indication for oral antimicrobials. Beta-lactam antibacterials (cephalosporins and aminopenicillins) were the predominant classes used.

CONCLUSIONS

Our study showed that risk and care-load factors (i.e. the presence of a urinary or vascular catheter, impaired mobility, disorientation and relatively short length of stay) were associated with parenteral administration of antimicrobials in NHs. Furthermore, both the indication and the class of antimicrobial agent used were associated with administration route. For empirical treatment of RTIs, antimicrobials were most often administered parenterally.

Indications for antimicrobial prescribing in European nursing homes: results from a point prevalence survey

PURPOSE

In light of the emerging problem with multiresistant microorganisms in nursing homes (NHs), the European Surveillance of Antimicrobial Consumption NH subproject was set up to measure and describe antimicrobial use across Europe. The aim of this paper was to investigate the indications for antimicrobial use and hence identify targets for quality improvement.

METHODS

Data were obtained from a point prevalence survey conducted in 323 NHs across 21 European countries. A resident questionnaire had to be completed for each resident receiving an antimicrobial, collecting data such as compound name and indication for antimicrobial prescribing. Four main indications for antimicrobial use were recorded: nasal decolonisation of methicillin-resistant Staphylococcus aureus (MRSA) carriage with mupirocin, prophylactic, empirical, and microbiologically documented treatments. The latter three treatment types were further subdivided according to the targeted infections.

RESULTS

In total, 1966 residents were treated with 2046 antimicrobials. Empirical treatments were most common (54.4% of all antimicrobial therapies; prevalence: 3.39 per 100 eligible residents), followed by prophylactic (28.8%; prevalence: 1.87%) and microbiologically documented (16.1%; prevalence: 1.01%) regimes. MRSA decolonisation with nasal mupirocin (0.7%; prevalence: 0.02%) was uncommon. Antimicrobials were most frequently prescribed for the prevention or treatment of urinary (49.5%; prevalence: 3.23%) and respiratory (31.8%; prevalence: 1.81%) tract infections. A very high proportion of uroprophylaxis was reported (25.6% of all prescribed antimicrobials; prevalence: 1.67%).

CONCLUSIONS

The indications for antimicrobial prescribing varied markedly between countries. We identified uroprophylaxis as a possible target for quality improvement.

Rapid emergence of carbapenemase-producing Enterobacteriaceae isolates in Belgium

We report on the evolution and epidemiology of carbapenem non-susceptible Enterobacteriaceae (CNSE) including carbapenemase-producing Enterobacteriaceae (CPE) in Belgium between January 2007 and April 2011. Significantly higher numbers of CNSE and of CPE were detected in 2010 and 2011 compared to the years 2007 to 2009. The majority of patients carrying CPE did not have history of travel abroad. The rapid emergence of autochthonous CPE strains in Belgium since 2010 warrants strengthened epidemiological surveillance at national level.

The burden of healthcare‐associated infections in European long‐term care facilities

Since 2006, several projects have been initiated in Europe to describe the distribution and characteristics of infection control programs in long&#x2010;term care facilities and to quantify the burden of infections, antimicrobial resistance, and antimicrobial use in long&#x2010;term care facilities. This article summarizes the results and activities that are underway.

Trends in production of extended-spectrum beta-lactamases among Enterobacteriaceae of clinical interest: results of a nationwide survey in Belgian hospitals

OBJECTIVES

to assess the frequency and diversity of extended-spectrum β-lactamases (ESBLs) in Enterobacteriaceae isolates in Belgium.

METHODS

during 2006 and 2008, non-duplicate clinical isolates of Enterobacteriaceae resistant to ceftazidime and/or cefotaxime were collected in 100 Belgian hospitals. ESBL production was confirmed by phenotypic and genotypic tests. MICs of 13 antimicrobial agents were determined by Etest. ESBL-encoding genes were identified by PCR sequencing and the bla(CTX-M) environment was characterized by PCR mapping. Selected isolates were genotyped by PFGE, multilocus sequence typing analysis and phylogenetic grouping by PCR.

RESULTS

overall, 733 isolates were confirmed as ESBL producers. Carbapenems and temocillin were active against ≥ 95% of all tested isolates. Co-resistance to co-trimoxazole and to ciprofloxacin was found in almost 70% and 80% of the strains, respectively. Overall, Escherichia coli (49%), Enterobacter aerogenes (32%) and Klebsiella pneumoniae (9%) represented the most prevalent species. Isolates harboured predominantly TEM-24 (30.7%), CTX-M-15 (24.2%) and TEM-52 (12.1%). Compared with 2006, the proportion of CTX-M-type enzymes increased significantly in 2008 (54% versus 23%; P < 10(-6)), mostly linked to a rising proportion of CTX-M-15-producing E. coli. TEM-24 decreased (19% in 2008 versus 43% in 2006; P < 10(-6)) during the same period, while the prevalence of TEM-52 remained unchanged (10% in 2008 versus 14% in 2006; not significant). Over 80% of the CTX-M-15-producing E. coli isolates clustered into a single PFGE type and phylogroup B2, corresponding to the sequence type (ST) 131 clone. Intra- and inter-species gene dissemination (CTX-M-15, CTX-M-2 and CTX-M-9) and wide epidemic spread of the CTX-M-15-producing E. coli ST131 clone in several Belgian hospitals were observed.

CONCLUSIONS

the rapid emergence of multiresistant CTX-M-15-producing E. coli isolates is of major concern and highlights the need for further surveillance in Belgium.

Infections in residents of nursing homes

Infectious diseases are a very common occurrence in nursing homes. While the reasons for preventing infections are the same in nursing homes and in acute hospitals, several considerations relevant to prevention of infection differ in nursing homes. Infection control measures should be based upon the particularities of the specific setting of a nursing home and its residents.

Methicillin-resistant Staphylococcus aureus colonization is associated with higher mortality in nursing home residents with impaired cognitive status

OBJECTIVES

To assess the effect of methicillin-resistant Staphylococcus aureus (MRSA) colonization on morbidity and mortality of nursing home residents.

DESIGN

Three-year cohort study from 2000 to 2003.

SETTING

Twenty-three nursing homes of all types and regions in the northern part of Belgium (Flanders).

PARTICIPANTS

Two thousand eight hundred fourteen nursing home residents.

MEASUREMENTS

The consequences of MRSA colonization on mortality and hospitalization were studied, adjusting for potential confounders. Dates and cause of death and hospitalization were collected every 6 months during 3 years of follow-up.

RESULTS

After adjustment for age, sex, and Charlson comorbidity index, the risk for 36-month mortality remained significantly higher in MRSA carriers (hazard ratio (HR) = 1.4, 95% confidence interval (CI) = 1.1-1.8) than in noncarriers. The effect of MRSA on mortality was dependent on the degree of cognitive impairment, with the highest effect in patients with severe cognitive impairment (adjusted HR = 1.8, 95% CI = 1.1-2.8) and absence of effect in residents with good mental status (adjusted HR = 0.8, 95% CI = 0.43-1.62). Deaths were more frequently reported to be infection-related in MRSA carriers. No association was found between MRSA colonization and hospitalization for any reason, but during follow-up, MRSA carriers were twice as frequently hospitalized for respiratory tract infections.

CONCLUSION

Colonization of MRSA in Belgian nursing home residents was associated with higher mortality. This excess mortality was restricted to residents with impaired cognitive function, probably reflecting differences in therapeutic approaches, in delay of diagnosis of pneumonia and other acute disorders in these patients, or in both.

Evaluation of Charlson's comorbidity index in elderly living in nursing homes

The object of this article was to validate the predictive value of Charlson's comorbidity index for the prediction of short-term mortality or morbidity in elderly people. The design was a cohort study comparing survival and hospitalization in institutionalized elderly people with different levels of comorbidity at baseline. The setting was 16 Flemish nursing homes for the elderly. The subjects were 2,727 inhabitants of which full data were available for 2,624. The outcome measures were hazard ratios resulting from Cox regression analysis, comparing 6 months survival in patients with moderate and a high level to low level of comorbidity. Odds ratios resulting from multiple logistic regression analysis comparing the occurrence of at least one hospitalization during the follow-up period in surviving patients of the same groups. Mortality adjusted for age group was significantly increased in patients with a moderate (HR = 2.00) and even more in those with a high level (HR = 3.62) of comorbidity. Hospitalization was more frequent in both groups (OR = 1.54 and 2.19, respectively), with statistical significance only being reached for the highest group. Adjustment for age, gender, mobility status, and disorientation did not change the general picture. Charlson's comorbidity index is a predictor of short-term mortality in institutionalized elderly patients and, to a lesser extend, also of hospitalization. These results support its use as a measure for introducing comorbidity as a covariable in longitudinal studies with a geriatric population.

Belgian coca-cola-related outbreak: intoxication, mass sociogenic illness, or both?

An epidemic of health complaints occurred in five Belgian schools in June 1999. A qualitative investigation described the scenario. The role of soft drinks was assessed by using a case-control study. Cases were students complaining of headache, dizziness, nausea, vomiting, abdominal pain, diarrhea, or trembling. Controls were students present at school on the day of the outbreak but not taken ill. An analysis was performed separately for school A, where the outbreak started, and was pooled for schools B-E. In school A, the attack rate (13.2%) was higher than in schools B-E (3.6%, relative risk = 3.6, 95% confidence interval (CI): 2.5, 5.3). Exclusive consumption of regular Coca-Cola (school A: odds ratio (OR) = 29.7, 95% CI: 1.32, 663.6; schools B-E: OR = 7.3, 95% CI: 2.9, 18.0) and low mental health score (school A: OR = 16.1, 95% CI: 1.3, 201.9; schools B-E: OR = 3.1, 95% CI: 1.5, 6.6) were independently associated with the illness. In schools B-E, consumption of Fanta, consumption of Coca-Cola light, and female gender were also associated with the illness. It seems reasonable to attribute the first cases of illness in school A to regular Coca-Cola consumption. However, mass sociogenic illness could explain the majority of the other cases.

Epidemiology of nosocomial bloodstream infections in Belgium, 1992-1996

The main results of the bloodstream infection (BSI) component of the Belgian National Programme for the Surveillance of Hospital Infections (NSIH project) are reported. From October 1992 to September 1996, 117 hospitals (59.1% of Belgian acute-care institutions) reported 13678 nosocomial BSIs. The incidence was 7.05 BSI episodes per 10000 patient-days. The incidence of BSI increased with hospital size and over time. Bloodstream infections were secondary to an infectious body site in 40.3% of the episodes, catheter-related in 23.5%, and of unknown origin in 36.2%. The associated in-hospital mortality was 31.4% and was highest in BSIs secondary to a respiratory tract infection (49.3%). In intensive care units, the incidence of BSI was 38.5 per 10000 patient-days. Coagulase-negative staphylococci were the most prevalent microorganisms (22%), followed by Staphylococcus aureus (14.1%) and Escherichia coli (13.5%). In catheter-related BSIs, these proportions were 41.9%, 18.8%, and 2.3%, respectively. The proportion of polymicrobial episodes was 9.9%. Methicillin resistance in Staphylococcus aureus was 22.3%. With its high participation rate, the NSIH project has characterized the epidemiology of nosocomial BSIs in Belgium during the period studied.

Prevention of transmission of tuberculosis in hospitals; a survey of practices in Belgium, 1995

In July 1995, a questionnaire survey was made of nosocomial tuberculosis (TB) prevention practices in Belgian hospitals. Of 122 respondents (response rate: 64%), 93% had hospitalized at least one TB patient, and 11% at least one multi-resistant TB case, during 1994. Effective prevention measures were not uniformly applied: only 96% isolated contagious TB patients, and only 84% isolated patients suspected of contagious T.B. In six hospitals, TB patients and those with human immunodeficiency virus (HIV) were mixed. Wearing of masks by personnel entering a TB patient's room was routine in 96%, but in only 24% of these was the mask adequate for filtering 1 micron particles. Moreover, some centres made use of seemingly unnecessary measures, for example routine use of disposable crockery (50%) and enhanced room cleaning (66%). Expensive prevention measures were rarely applied: UV lamps in 12%; HEPA filters in air conditioning in 2%. Tuberculin skin testing at some stage of employment, was routinely performed by 82% of respondents, but varied according to the type of personnel: doctors and temporary staff were significantly under-assessed. Lowest conversion rates among staff were observed in hospital with the least TB admissions but high rates were observed in hospitals of all sizes. The risk of acquiring TB in Belgian hospitals exists and precautions taken to prevent transmission are not sufficient. The situation could be improved by following national guidelines and a general adoption of proven effective practices, and by abandoning expensive and ineffective measures.

Methicillin-resistant Staphylococcus aureus epidemiology and control in Belgian hospitals, 1991 to 1995. Groupement pour le Dépistage, l'Etude et la Prévention des Infections Hospitalières

OBJECTIVES

To describe the Belgian methicillin-resistant Staphylococcus aureus (MRSA) surveillance network, the evolution of methods used in Belgian hospitals for MRSA detection and control, and MRSA incidence from 1994 to 1995.

DESIGN, SETTING, AND PARTICIPANTS

Questionnaire surveys; infection control physicians from acute-care hospitals in Belgium.

INTERVENTION

Publication of national guidelines for MRSA control in 1993.

RESULTS

The participation rate in surveys ranged from 42% to 57% of hospitals. In 1995, 88% of participants detected MRSA strains by disk diffusion tests, with little improvement in standardization since 1991. More centers employed the oxacillin agar screen method (27%), automated systems (29%), or a combination of methods (29%) than in 1991 (P < .005). Between 1991 and 1995, the proportion of hospitals reporting MRSA control measures increased from 68% to 95% (P < .01). Practices that were used increasingly included patient placement in private room (from 50% to 93%, P < .01) and hand decontamination with antiseptic (from 43% to 87%, P < .01). The proportion of centers that reported screening MRSA carriers and treating them topically increased two- and threefold, respectively (P < .05). Surveillance data from 1994 to 1995 showed that MRSA represented a mean of 21.3% of S aureus clinical isolates (range, 1.6% to 62.4%). The median incidence of nosocomial MRSA acquisition was 2.8 per 1,000 admissions, with a wide range (0 to 13.7 per 1,000 admissions) across hospitals of all sizes. The median incidence decreased over the first three semesters of surveillance in hospitals with continuous participation.

CONCLUSION

MRSA detection and control measures have improved in Belgian hospitals after publication of national guidelines. However, MRSA incidence rates show the persistence of nosocomial transmission, with large variations between centers. The national MRSA surveillance network should indicate whether control efforts eventually will curb the problem.

[Methods in surgical antibacterial prophylaxis in Belgium, 1992-1995]

Since 1992, the Belgian network for the surveillance of nosocomial infections runs a system of voluntary surveillance of surgical wound infections, including the perioperative antibiotic prophylaxis patterns. From 1992 to 1995, the global rate of prophylaxis was 71%, calculated on 44,728 interventions from 72 hospitals, but in 11.4% of operations for which prophylaxis is indicated, it was not given. On the other hand, prophylaxis was prescribed in 55.6% of operations where it was not indicated. At least 4 out of 10 courses were inappropriate with respect to indication, duration or day of administration. Fifteen percent of all courses exceeded 2 days (28% in genitourinary surgery, and 20% in abdominal surgery). In orthopedic surgery, recommended indications were not followed in 42% of operations. To improve the prescribing of antibiotic prophylaxis in Belgium, local surveillance of prophylaxis patterns and the implementation of guidelines describing good practices should be priorities at the hospital level. At the national level, recommendations about the indications for prophylaxis should be updated and disseminated.

International comparison of results of infection surveillance: The Netherlands versus Belgium

OBJECTIVE

To explore the potential benefit of comparing results from two national surveillance networks.

DESIGN

Two prospective multicenter cohort studies of surgical wound infections (SWI).

SETTING

Thirty-five and 62 acute-care hospitals in The Netherlands (NL) and Belgium (B), respectively, from October 1, 1991, to June 30, 1992.

RESULTS

The participation was equivalent in the two countries: 27% (NL) and 28% (B) of all acute-care hospitals. Marked differences emerged between the Dutch and Belgian crude infection rates and the specific rates by wound class and other risk factors. Because the case-mix in the countries is quite different, comparisons can be made only by specific surgical category. The results for inguinal hernia repair and for appendectomy are compared as an example. In herniorrhaphies, the difference in infection rate (0.4% [NL] versus 1.2% [B]) is not explained by differences in the distribution of risk factors. The shorter hospital stay in The Netherlands (4 days [NL] versus 6 days [B]), the more effective postdischarge surveillance in Belgium, and the fact that more than two thirds of the detected infections occurred after the first postoperative week probably can account for most of the difference. There was a striking difference in prophylaxis use (3.7% [NL] versus 41.9% [B]). In appendectomies, the Dutch patient population shows on average a higher risk profile, and surgery is urgent much more often in The Netherlands (78.3%) than in Belgium (49.2%). The infection rate is higher in The Netherlands, especially among the patients without prophylaxis, which again is employed less frequently there.

CONCLUSION

We conclude that international comparisons yield interesting insights regarding quality of care, reaching beyond the field of nosocomial infection prevention. This is an argument in favor of more harmonization between surveillance networks.

A computerized nationwide network for nosocomial infection surveillance in Belgium

OBJECTIVE

To assess the feasibility of computerized nationwide surveillance of nosocomial infections in Belgium, and to obtain preliminary national and hospital-specific incidence data.

DESIGN

Prospective multicenter cohort study of surgical wound infections (SWI).

SETTING

All 218 acute care hospitals in Belgium in the period October 14 to December 14, 1991.

RESULTS

Eighty-five of 218 acute care hospitals (39%) succeeded in collecting the required information and in completing this pilot study, although 50% of the participating hospitals had no previous experience in nosocomial infection surveillance. Seventy percent of the small-size hospitals (< 200 beds) did not participate, mainly because of shortages of manpower. A lack of collaboration from clinicians was a problem in most participating hospitals. SWI postdischarge surveillance was most successful when based on information collected by the surgeons at the surgical outpatient clinic; by this method, postdischarge information was obtained on 43.9% of all surgical procedures. A total of 201 infections were observed among 10,537 operations, with a crude incidence rate of 1.91 per 100 operations or 1.51 per 1,000 person-days of observation. Infection rates by operation type and risk indicators are congruent with those of the literature. Survival analysis showed that the overall cumulative infection risk at 21 days postprocedure attained 81.6% of the 30-days risk.

CONCLUSION

This nationwide network for nosocomial infection surveillance has introduced the practice of computerized surveillance of performance in a large number of hospitals. Still, several aspects of the surveillance demand to be improved: the collaboration of the clinicians, the quality of the data, and the postdischarge surveillance methodology.