Relationship between consumption of MRSA-active antibiotics and burden of MRSA in acute care hospitals in Catalonia, Spain.

OBJECTIVES: To analyse the possible relationship between consumption of old and new MRSA-active antibiotics and burden of MRSA in acute care hospitals in Catalonia during the period 2007-12. METHODS: Fifty-four hospitals participating in the VINCat Programme were included. Proportion of MRSA (resistant isolates of Staphylococcus aureus per 100 isolates of S. aureus tested), incidence of new cases of infection [new cases of MRSA per 1000 occupied bed-days (OBD)] and incidence of cases of bacteraemia (MRSA bacteraemia cases per 1000 OBD) were determined to estimate the annual MRSA burden. Antibiotic consumption was calculated in DDD/100 OBD. Cost was expressed in euros/100 OBD. RESULTS: MRSA rates remained stable over the study period, with the proportion of MRSA ranging from 20% to 22.82% in 2007 and 2012, respectively (P=0.864). Consumption of old MRSA-active antibiotics (vancomycin and teicoplanin) did not change significantly, with values from 1.51 to 2.07 DDD/100 OBD (P=0.693). Consumption of new MRSA-active antibiotics (linezolid and daptomycin) increased significantly, with values rising from 0.24 to 1.49 DDD/100 OBD (P<0.001). Cost increased by almost 200%. CONCLUSIONS: A widespread and steady increase in consumption of new MRSA-active antibiotics was observed among acute care hospitals in Catalonia, in spite of a stable MRSA burden. At the same time, consumption of old drugs remained stable. Such trends resulted in a significant increase in cost. Our findings suggest that factors other than the proportion of methicillin resistance among S. aureus may influence the use of old and new MRSA-active antibiotics in the clinical setting.

How to measure and monitor antimicrobial consumption and resistance.

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance.

The development and successful implementation of the VINCat Program.

In 2006 the VINCat Program was established in order to develop and support a standardized surveillance system of hospital-acquired infections (HAI). All acute care hospitals included in the public health system network of Catalonia (Spain) were invited to participate. The aim was to provide risk-adjusted, procedure-specific rates for most relevant infections. Data are collected by the local multidisciplinary infection control teams and transmitted electronically to the Coordinating Centre, which acts as the core of a network of infection control committees and has the support of a Technical Advisory Committee. The program website provides updated information on program activities, training workshops, aggregated data on past infection rates and access to databases, manuals and protocols. During the period 2007-2011, 64 hospitals have joined the program: 9 tertiary, 16 district and 39 small hospitals, providing records on 4.044 episodes of catheter-related blood stream infections, 14.389 elective colorectal surgical interventions, 14.214 hip and 29.599 knee arthroplasties, among the most significant indicators. Nowadays, it appears that VINCat has been successfully implemented and is well established as the official HAI surveillance program in Catalonia. Determinants for success have been: the maintenance of a close contact between the hospitals and the coordinating center, the timely and regular data feedback to institutions, the program's contribution towards reducing HAIs, the ongoing efforts to improve performance and, a key factor, the perception among the infection control professionals of the value added by the program to their daily work in different ways. Adequate funding, commitment of infection control teams and the generous collaboration of experts from different specialties are essential for maintaining the success of the VINCat Program.

Antibiotic consumption at 46 VINCat hospitals from 2007 to 2009, stratified by hospital size and clinical services.

The aim of the study was to assess the evolution of antibiotic consumption in acute care hospitals in Catalonia (population 7.5 million), according to hospital size and department, during the period 2007-2009. The methodology used for monitoring antibiotic consumption was the ATC/DDD system, and the unit of measurement was DDD/100 occupied bed-days (DDD/100 OBD). Hospitals were stratified according to size: I) large university hospitals (with more than 500 beds); II) medium-sized hospitals (between 200 and 500 beds); and III) small hospitals (fewer than 200 beds). The consumption was also analyzed and stratified according to department: medical, surgical and intensive care unit (ICU). Specific training in data management on antibiotic consumption was given to all participant hospitals before the implementation of the program. The mean antibiotic (J01) consumption, calculated in DDD/100 OBD, increased although without statistical significance (p=0.640): 74.68 (2007), 75.13 (2008) and 78.04 (2009). The values of the medians expressed in DDD/100 OBD in group I were 83.27 (in 2007), 82.16 (2008) and 86.93 (2009), in group II 72.60 (2007), 70.78 (2008) and 75.17 (2009) and in group III 65.66 (2007), 69.32 (2008) and 72.39 (2009). Antibiotic consumption was higher in large hospitals than in medium-sized or small hospitals. Catalan hospitals recorded an increase of 4.49% from 2007 to 2009, especially due to the rising use of carbapenems, cephalosporins, monobactams and the other antibiotic groups.

Antibiotic consumption trends among acute care hospitals in Catalonia (2008-2016): impact of different adjustments on the results.

OBJECTIVES: Hospital antibiotic consumption is measured using defined-daily-doses (DDD) divided by bed days. However,other denominators as discharges could provide a more accurate interpretation of consumption. The main objective was to analyze trends of antibiotic consumption among hospitals in Catalonia during the period 2008-2016, using both DDD/100 bed days and DDD/100 discharges. METHODS: Retrospective, descriptive, and longitudinal study performed among acute care hospitals affiliated to VINCat Program. Antibiotic consumption was expressed using the Anatomical Therapeutic Chemical/DDD classification and trends with a mixed linear model. Trends after using both DDD/100 bed days and DDD/100 discharges were determined and compared. RESULTS: Overall antibiotic consumption from 2008 to 2016 increased by 10.24% (P < 0.001) DDD/100 bed days, but remained stable (-0.87%, P = 0.051) in DDD/100 discharges. Although DDD and discharges remained unchanged, a significant reduction in bed days (-9.63%) and length of stay (-8.19%) was observed. A worrisome increase in the consumption of carbapenems and anti-MRSA drugs was noticed. CONCLUSION: Whereas a significant upward trend in antibiotic consumption in DDD/100 bed days was noticed, DDD/100 discharges remained stable. The description of both indicators seems therefore essential for a correct interpretation of data.

Widespread increase of empirical carbapenem use in acute care hospitals in Catalonia, Spain.

INTRODUCTION: The overall increase in the use of carbapenems could lead to the selection of carbapenem-resistant bacteria. The objectives of this study were to analyze carbapenem use from 2008 to 2015 and their prescription profile in 58 hospitals affiliated to the VINCat Programme (nosocomial infection vigilance system). METHODS: Retrospective, longitudinal and descriptive study of carbapenem use. Consecutive case-series study, looking for carbapenem prescription characteristics, conducted in January 2016. Use was calculated in defined daily doses (DDD)/100 patient-days (PD); prescription profiles were assessed using a standardized survey. RESULTS: Carbapenem use increased 88.43%, from 3.37 DDD/100-PD to 6.35 DDD/100-PD (p<0.001). A total of 631 patients were included in the prescription analysis. Carbapenems were prescribed empirically in 76.2% of patients, mainly for urinary tract and intra-abdominal infections due to suspicion of polymicrobial mixed infection (27.4%) and severity (25.4%). CONCLUSION: A worrying increase in carbapenem use was found in Catalonia. Stewardship interventions are required to prevent carbapenem overuse.

Consumption of systemic antifungal agents among acute care hospitals in Catalonia (Spain), 2008-2013.

Objective To know the patterns and consumption trends (2008-2013) of antifungal agents for systemic use in 52 acute care hospitals affiliated to VINCat Program in Catalonia (Spain). Methods Consumption was calculated in defined daily doses (DDD)/100 patient-days and analyzed according to hospital size and complexity and clinical departments. Results Antifungal consumption was higher in intensive care units (ICU) (14.79) than in medical (3.08) and surgical departments (1.19). Fluconazole was the most consumed agent in all type of hospitals and departments. Overall antifungal consumption increased by 20.5%during the study period (p = 0.066); a significant upward trend was observed in the consumption of both azoles and echinocandins. In ICUs, antifungal consumption increased by 12.4% (p = 0.019). Conclusions The study showed a sustained increase in the overall consumption of systemic antifungals in a large number of acute care hospitals of different characteristics in Catalonia. In ICUs there was a trend towards the substitution of older agents by the new ones.

Widespread increase of empirical carbapenem use in acute care hospitals in Catalonia, Spain / Aumento generalizado del uso empírico de carbapenemas en los hospitales de agudos en Cataluña, España

Introduction: The overall increase in the use of carbapenems could lead to the selection of carbapenem-resistant bacteria. The objectives of this study were to analyze carbapenem use from 2008 to 2015 and their prescription profile in 58 hospitals affiliated to the VINCat Programme (nosocomial infection vigilance system). Methods: Retrospective, longitudinal and descriptive study of carbapenem use. Consecutive case-series study, looking for carbapenem prescription characteristics, conducted in January 2016. Use was calculated in defined daily doses (DDD)/100 patient-days (PD); prescription profiles were assessed using a standardized survey. Results: Carbapenem use increased 88.43%, from 3.37 DDD/100-PD to 6.35 DDD/100-PD (p < 0.001). A total of 631 patients were included in the prescription analysis. Carbapenems were prescribed empirically in 76.2% of patients, mainly for urinary tract and intra-abdominal infections due to suspicion of polymicrobial mixed infection (27.4%) and severity (25.4%). Conclusion: A worrying increase in carbapenem use was found in Catalonia. Stewardship interventions are required to prevent carbapenem overuse

Introducción: El aumento global del consumo de carbapenemas podría seleccionar bacterias resistentes a los carbapenemas. Los objetivos del estudio fueron analizar el consumo de carbapenemas entre 2008-2015 y su perfil de prescripción en 58 hospitales afiliados al Programa VINCat. Métodos: Estudio retrospectivo, longitudinal y descriptivo de consumo de carbapenemas. Estudio de series de casos consecutivos buscando características de la prescripción realizado en enero de 2016. Consumo calculado en dosis diarias definidas (DDD)/100 pacientes/días (PD); perfil de prescripción evaluado mediante una encuesta estandarizada. Resultados: El consumo de carbapenemas aumentó un 88,43%, de 3,37 DDD/100 PD a 6,35 DDD/100 PD (p < 0,001). Se incluyeron 631 pacientes en el análisis de prescripción. Un 76,2% recibió carbapenemas empíricamente para infecciones del tracto urinario e intra-abdominales por sospecha de infección mixta polimicrobiana (27,4%) y gravedad (25,4%). Conclusión: Se produjo un preocupante aumento del consumo de carbapenemas en Cataluña, por lo que son necesarias intervenciones específicas para evitar su uso excesivo

How to measure and monitor antimicrobial consumption and resistance / Medición y monitorización del consumo de antibióticos y resistencias bacterianas

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance

El daño colateral más importante derivado del uso de los antibióticos es la aparición de resistencias bacterianas. La prescripción inadecuada de los antibióticos está íntimamente relacionada con este efecto, observado globalmente a nivel mundial, pero principalmente en países con recursos económicos limitados. La estrecha vigilancia del consumo de los antibióticos puede ser de gran ayuda para identificar cuáles son los problemas relacionados con la prescripción de estos fármacos e introducir las estrategias necesarias para evitarlos, tanto en el ámbito ambulatorio como en el hospitalario. La dosis diaria definida, referida a la dosis usual de un antimicrobiano concreto, destinada al tratamiento diario de un paciente, se ha considerado útil para el estudio de las tendencias de consumo de los antibióticos en el hospital. Esta unidad se ha introducido en diversas fórmulas que incluyen diversos denominadores correspondientes a la actividad hospitalaria, entre ellos el número de camas, ingresos y altas. Todo ello, con el objetivo de obtener una serie de indicadores estandarizados que se utilizan para efectuar comparaciones sobre el uso de antibióticos entre distintos hospitales y países. Los sistemas de información del laboratorio son las fuentes primarias de datos para la preparación de informes acumulados de sensibilidad. Esta información es útil para planificar tratamientos empíricos y adoptar medidas de control de infección. Entre las iniciativas supranacionales de vigilancia de la resistencia, la red EARS-Net proporciona información acerca de las tendencias de resistencia en Europa. La resistencia es consecuencia de la presión selectiva de los antimicrobianos, aunque en ocasiones estos agentes también promueven la resistencia al favorecer la aparición de mutaciones seleccionadas posteriormente. Múltiples estudios indican la relación entre el uso de antimicrobianos y la aparición de resistencias. Aunque en algunos casos una disminución del uso de un antimicrobiano se asocia a una reducción en las tasas de resistencia a este, en muchas otras situaciones no sucede así, debido a la corresistencia o al bajo coste biológico del mecanismo implicado. Son necesarios nuevos antimicrobianos, que junto con medidas de control de infección ayudarán a paliar el problema de la resistencia

The development and successful implementation of the VINCat Program

In 2006 the VINCat Program was established in order to develop and support a standardized surveillance system of hospital-acquired infections (HAI). All acute care hospitals included in the public health system network of Catalonia (Spain) were invited to participate. The aim was to provide risk-adjusted, procedures pecificrates for most relevant infections. Data are collected by the local multidisciplinary infection control teams and transmitted electronically to the Coordinating Centre, which acts as the core of a network of infection control committees and has the support of a Technical Advisory Committee. The program website provides updated information on program activities, training workshops, aggregated data on past infection rates and access to databases, manuals and protocols. During the period 2007-2011, 64 hospitals have joined the program: 9 tertiary, 16 district and 39 small hospitals, providing records on 4.044 episodes of catheter-related blood stream infections, 14.389 elective colorectal surgical interventions, 14.214 hip and 29.599 knee arthroplasties, among the most significant indicators. Nowadays, it appears that VINCat has been successfully implemented and is well established as the official HAI surveillance program in Catalonia. Determinants for success have been: the maintenance of a close contact between the hospitals and the coordinating center, the timely and regular data feedback to institutions ,the program’s contribution towards reducing HAIs, the ongoing efforts to improve performance and, a key factor, the perception among the infection control professionals of the value added by the program to their daily work in different ways. Adequate funding, commitment of infection control teams and the generous collaboration of experts from different specialties are essential for maintaining the success of the VINCat Program (AU)

En el año 2006 se estableció el Programa VINCat con el fin de desarrollar y mantener un sistema normalizado de vigilancia de las infecciones nosocomiales (HAI). Se invitó a participar a todos los hospitales de agudos incluidos en la red del sistema de salud pública de Cataluña (España). El objetivo era proporcionarlas tasas específicas, ajustadas al riesgo, de las infecciones más relevantes asociadas a procedimientos. Los datos son recogidos por los equipos locales multidisciplinarios de control de la infección y transmitidos electrónicamente al Centro Coordinador, que actúa como el núcleo de una red de comisiones de infecciones y cuenta con el apoyo de un Comité Técnico Asesor. El sitio web del programa ofrece información actualizada sobre las actividades del programa, las reuniones técnicas de formación, los datos agregados sobre las tasas de infección y el acceso a bases de datos, manuales y protocolos. Durante el período 2007-2011, 64 hospitales se han incorporado al programa: 9 hospitales de tercer nivel,16 medios y 39 centros de pequeño tamaño, proporcionando los registros de 4.044 episodios de infecciones de bacteriemia de catéter, 14.389 intervenciones quirúrgicas electivas colorrectales, 14.214 de cadera y29.599 artroplastias de rodilla, entre los indicadores más significativos. Hoy día parece que el Programa VINCat se ha aplicado con éxito y se ha consolidado como el programa(..) (AU)