SURVEILLANCE OF

BLOODSTREAM

INFECTIONS IN BELGIAN

HOPITALS

Workgroup meeting

19 November 2018

Els Duysburgh, MD, MPH, PhD

Els.duysburgh@sciensano.be

Objectives meeting

Presentation bloodstream infection (BSI) surveillance results: 2018 report – data up to and including 2017

Discussion

• Results national report

• Protocol: update 2019

• Healthdata BSI surveillance registration and reporting

General remark: overall very similar findings since 2013

2

Contents

Introduction

•Background

•Objectives

Main results report 2018

•Participation

•Hospital-associated bloodstream infections (HABSI)

Incidences 2013-2017

Description of bloodstream infection episodes 2017

Microorganism (MO) and antimicrobial resistance

Recommendations

Discussion

3

INTRODUCTION

Background

National surveillance of BSI in hospitals

•Case-based - laboratory confirmed

•Mandatory since 2014 (minimum 3 months)

•HABSI

infection date – admission date ≥2

5 BackgroundBackground

Objectives of BSI surveillance

Monitor

• HABSI and CLABSI trends

• Causal microorganism (MO) and their resistance profile

Level

• Hospital-wide and intensive care unit (ICU)

• National

Tool for prevention

6 ObjectivesObjectives

Data up to and including 2017

MAIN RESULTS REPORT 2018

Participation 2017

105 of the 109 (96%) eligible hospitals reported data for at least one quarter

57% hospitals reported the whole year

8 ParticipationParticipation

HABSI and CLABSI trends 2013-2017

Year 2013 2014 2015 2016 2017

Cumulative incidence per 1,000 admissions

mean – hospital-wide* 5.4 5.6 5.7 5.2 5.5

mean – ICU-level** 14.1 13.9 13.5 14.8 13.8

Incidence density per 10,000 patient-days

mean – hospital-wide* 7.5 7.8 8.0 7.6 8.2

mean – ICU-level** 32.0 31.6 29.8 31.9 29.8

Incidence HABSI, hospital-wide and at ICU-level, Belgium 2013-2017

Notes:

* Total HABSI/total patient-days at hospital-level

** Total ICU-associated BSI/total patient-days at ICU-level

Incidences 2013-2017

HABSI and CLABSI trends 2013-2017

Mean incidence HABSI per 10,000 patient days, Belgium 2013-2017

Hospital-wide ICU

Incidences 2013-2017

HABSI and CLABSI trends 2013-2017

Mean incidence central line-associated bloodstream infection (CLABSI)

per 10,000 patient days, Belgium 2013-2017

Hospital-wide ICU

Incidences 2013-2017

Variation HABSI incidence between

hospitals, Belgium 2017

P, percentiles

Unit of analysis is reporting quarter

HABSI/10,000

patient-days

smallest 0.4

P 25 4.5

P 50 (median) 6.9

P 75 9.5

largest 23.4

Incidences 2013-2017

Microorganism specific HABSI, 2000-

2017

HABSI mean incidence per microorganism (MO), Belgium 2000-

2017

Incidences 2013-2017

HABSI characteristics, Belgium 2017

• Total 10,463 BSI of which 7,821 HABSI

• 20% (1,558) ICU-associated BSI

Department of HABSI diagnosis, Belgium 2017

Department %

Medical department 24

ICU 22

Surgery 14

Geriatrics 15

Hemato-oncology 14

Paediatrics 1

Obstetrics/gynaecology 1

Other 9

Total 100

Description of BSI episodes 2017

HABSI characteristics, Belgium 2017

Hospital-wide ICU

Invasive device-associated: directly (CL or

peripheral catheter) or indirectly (urinary

catheter or endotracheal tube)

38% 55%

CLABSI 23% 32%

Central line-related bloodstream infection

(confirmed CLABSI)8% 11%

Suspected source confirmed 43%

Median (IQR) time to infection 12 (6-24) days 10 (5-19) days

Crude mortality 20% 29%

Description of BSI episodes 2017

Source HABSI, Belgium 2017

Hospital-wide

ICU

Description of BSI episodes 2017

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

Most frequent isolated MO in BSI,

Belgium 2017

HABSI Other BSI

N % N %

E. coli 1,908 23 1,082 38

S. aureus 881 10 298 11

S. epidermidis 728 9 82 3

K. pneumoniae 650 8 154 5

E. faecium 453 5 41 1

P. aeruginosa 419 5 62 2

MO and antimicrobial resistance

Microorganism and antimicrobial

resistance

Antimicrobial resistance in S. aureus strains isolated from hospital-

associated bloodstream infections, Belgium 2013-2017

MO and antimicrobial resistance

Microorganism and antimicrobial

resistance

Antimicrobial resistance in E. coli strains isolated from hospital-

associated bloodstream infections, Belgium 2013-2017

MO and antimicrobial resistance

Microorganism and antimicrobial

resistance

Antimicrobial resistance in K. pneumoniae strains isolated from

hospital-associated bloodstream infections, Belgium 2013-2017

MO and antimicrobial resistance

Microorganism and antimicrobial

resistance

Antimicrobial resistance in E. cloacae strains isolated from

hospital-associated bloodstream infections, Belgium 2013-2017

MO and antimicrobial resistance

Microorganism and antimicrobial

resistance

Antimicrobial resistance in P. aeruginosa strains isolated from

hospital-associated bloodstream infections, Belgium 2013-2017

MO and antimicrobial resistance

Microorganism and antimicrobial

resistance

Antimicrobial resistance in E. faecium strains isolated from

hospital-associated bloodstream infections, Belgium 2013-2017

MO and antimicrobial resistance

RECOMMENDATIONS

For policy makers

• Further support and enable infection control teams at hospitals in

their responsibilities and tasks to decrease HABSI. This includes

ensuring a clear framework and ensuring enough human and

financial resources.

• Enhance the creation at hospital level of a supportive, safe, secure

and not judging environment in which internal quality audits can be

implemented.

• Support the organisation of BSI surveillance data validation and the

assessment on why the HABSI incidence did not changed during the

past five years.

• Continue supporting a national organised surveillance of HABSI

Recommendations

For hospitals

• Assess if there is still room for decrease of HABSI and implement

actions and activities to establish HABSI decrease. For this, the

organisation of internal HABSI audits is suggested. A supporting,

safe, secure and not judging environment is key to have audits

successfully implemented and such environment needs to be

established.

• Continue recording and reporting HABSI data in the national BSI

surveillance to be able to evaluate the HABSI situation at hospital

level over time and evaluate the impact of locally implemented

activities to decrease HABSI incidences.

Recommendations

For Sciensano

• Validation of surveillance data. Comparing, at hospital and ward

level, data from the surveillance with data received through the

MZG/RHM could be a first step in this validation.

• Assess reasons why there is no decline in HABSI incidence in

Belgian hospitals at national level during the past five years.

• Continue implementing the continuous surveillance of BSI in

Belgian hospitals which includes a yearly update of protocol and

data collection tool.

• Further improve the Healthdata data collection and reporting tool.

• Assess if data recording and reporting cannot be further simplified

and streamlined in the future.

Recommendations

DISCUSSION

1. Validation: Comparing MZG/RHM with

BSI surveillance data

Discussion

2. CLABSI reporting by CL-days or patient

days?

• In 2017, CL-days: 4 hospitals (hospital wide)

33 ICU (out of 128 that provided denominators)

• Impact reduction CL-days as preventive intervention on CLABSI

incidence: simulation example

• Use of CL-days to monitor preventive intervention decrease of CL-

days (N CL-days/N patient-days)

Discussion

Before intervention After intervention change

(after-before)/before

Patient-days 10,000 10,000 0%

CL-days 5,000 3,000 -40%

CLABSI 15 10 -33%

CLABSI/1,000 CL-days 3.0 3.3 +10%

CLABSI/1,000 patient-days 1.5 1.0 -33%

3. Periodicity in HABSI and CLABSI

incidence

• Research: Time series analysis shows periodicity assess this

further.

Discussion

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References

32

NSIHweb

http://www.nsih.be/nsih/nsih_nl.asp and http://www.nsih.be/nsih/nsih_fr.asp

Protocol ‘BSI in hospitals’ (revised 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

Healthdata

https://healthdata.wiv-isp.be/

http://www.healthdata.be/dcd

https://support.healthdata.be