Impact of the COVID-19 pandemic on community antibiotic consumption in the EU/European Economic Area: a changepoint analysis.

OBJECTIVES: A decrease in community antibiotic consumption in Europe has been observed during the COVID-19 pandemic. The magnitude of this decrease, how fast after the outbreak it occurred, whether it was sustained during the pandemic and whether the seasonal variation in antibiotic consumption was affected, have not yet been evaluated in detail. METHODS: Data on community antibiotic consumption were available from the European Surveillance of Antimicrobial Consumption Network for 28 EU/European Economic Area (EEA) countries between 2010 and 2021. Antibiotic consumption was expressed as DDDs per 1000 inhabitants per day (DID). The impact of the pandemic on antibiotic consumption was investigated using descriptive statistics and non-linear mixed changepoint models for quarterly and yearly data. RESULTS: The decrease in overall antibiotic consumption between 2019 and 2020 (-3.4 DID; -18.6%) was mainly due to a decrease in the consumption of penicillins [Anatomical Therapeutic Chemical (ATC) code J01C] (-1.9 DID; -23.0%), other ß-lactam antibacterials (J01D) (-0.6 DID; -25.8%) and macrolides, lincosamides and streptogramins (J01F) (-0.5 DID; -17.4%) and was sustained during 2021. The changepoint analysis of yearly data (28 countries) estimated a decrease of 3.3 DID in overall antibiotic consumption (J01) between 2019 and 2020. The analysis of quarterly data (16 countries) estimated a decrease in overall antibiotic consumption (J01) of 4.0 DID and a decrease in seasonal variation of 1.2 DID between the first and second quarters of 2020. CONCLUSIONS: The changepoint analysis indicated a significant, sudden and steep decrease in community antibiotic consumption in the EU/EEA immediately after the start of the COVID-19 outbreak in Europe, as well as a decrease in its seasonal variation.

The use of aminopenicillins in animals within the EU, emergence of resistance in bacteria of animal and human origin and its possible impact on animal and human health.

Aminopenicillins have been widely used for decades for the treatment of various infections in animals and humans in European countries. Following this extensive use, acquired resistance has emerged among human and animal pathogens and commensal bacteria. Aminopenicillins are important first-line treatment options in both humans and animals, but are also among limited therapies for infections with enterococci and Listeria spp. in humans in some settings. Therefore, there is a need to assess the impact of the use of these antimicrobials in animals on public and animal health. The most important mechanisms of resistance to aminopenicillins are the ß-lactamase enzymes. Similar resistance genes have been detected in bacteria of human and animal origin, and molecular studies suggest that transmission of resistant bacteria or resistance genes occurs between animals and humans. Due to the complexity of epidemiology and the near ubiquity of many aminopenicillin resistance determinants, the direction of transfer is difficult to ascertain, except for major zoonotic pathogens. It is therefore challenging to estimate to what extent the use of aminopenicillins in animals could create negative health consequences to humans at the population level. Based on the extent of use of aminopenicillins in humans, it seems probable that the major resistance selection pressure in human pathogens in European countries is due to human consumption. It is evident that veterinary use of these antimicrobials increases the selection pressure towards resistance in animals and loss of efficacy will at minimum jeopardize animal health and welfare.

Nursing home residents with suspected urinary tract infections: a diagnostic accuracy study.

BACKGROUND: Urinary tract infections (UTIs) are one of the most common infections in nursing homes (NHs). A high error rate of a UTI diagnosis based solely on clinical criteria is to be expected in older persons as they often present infections in an atypical way. A study was set up to assess the diagnostic value of signs/symptoms and urine dipstick testing in identifying UTIs in NH residents and to explore whether C-reactive protein (CRP) measured by point-of-care testing (POCT) can help in the diagnosis. METHODS: During a three month prospective multicentre study, urine sampling for culture, POCT CRP and urinary dipstick testing were performed in each NH resident with a suspected UTI. UTIs were defined according to Stone et al., i.e. criteria based upon the presence of a set of signs/symptoms and a positive urine culture. RESULTS: Eleven NHs and 1 263 residents participated. Sixteen out of 137 recorded UTI suspicions were confirmed. Acute dysuria (positive likelihood ratio (LR +): 7.56, 95% confidence interval (CI): 3.94-14.5) and acute suprapubic pain (LR + : 11.4, 95% CI: 3.58-35.9) were found to be significant predictors. The combined nitrite and leucocyte esterase urine dipstick test (one or both positive) had a 96.0% negative predictive value (95% CI: 80.5-99.3%). The sensitivity of a positive CRP test (≥ 5 mg/L) was 60.0% (95% CI: 32.3-83.7%). Antimicrobials were prescribed in 60.2% of suspected but unconfirmed UTIs and in 92.3% of confirmed UTIs. CONCLUSIONS: Using a stringent definition, only 11.7% of our suspicions were confirmed. Besides acute dysuria and suprapubic pain, we were not able to prove that any other clinical sign/symptom or POCT CPR adds useful information to the UTI diagnosis. We confirmed the findings of earlier research that urine dipstick tests are useful in ruling out UTIs and identified a potential overuse of antimicrobials in our NH population.

Fluoroquinolone resistance in Escherichia coli isolates after exposure to non-fluoroquinolone antibiotics: a retrospective case-control study.

OBJECTIVES: To investigate whether prior exposure to non-fluoroquinolone antibiotics increases the risk of fluoroquinolone resistance in Escherichia coli. METHODS: This was a secondary analysis of data collected retrospectively in a case-control study linking microbiological test results (isolated bacteria and their susceptibility) of urine samples routinely collected from primary, secondary and tertiary care patients in Belgium with information on prior antibiotic use at the patient level up to 1 year previously. RESULTS: In urine samples from 6125 patients, 7204 E. coli isolates were retrieved [1949 fluoroquinolone-resistant isolates (cases) and 5255 fluoroquinolone-susceptible isolates (controls)]. After adjusting for potential confounders (including fluoroquinolone use) and correcting for multiple testing there were lower odds of fluoroquinolone resistance in E. coli isolates after exposure to cefazolin (OR = 0.65; 95% CI = 0.52-0.81; P = 0.00014) and higher odds after exposure to trimethoprim/sulfamethoxazole (OR = 1.56; 95% CI = 1.23-1.97; P =0.00020) or nitrofurantoin (OR = 1.50; 95% CI = 1.23-1.84; P =0.000083). A sensitivity analysis excluding samples with antibiotic use during the 6 months prior to the sampling date confirmed the higher odds of fluoroquinolone resistance after exposure to trimethoprim/sulfamethoxazole and nitrofurantoin. CONCLUSIONS: Assuming no residual confounding or other biases, this study suggests that exposure to non-fluoroquinolone antibiotics, i.e. trimethoprim/sulfamethoxazole and nitrofurantoin, might be causally related to fluoroquinolone resistance in E. coli isolates from urinary samples. Future prospective research is needed to confirm non-fluoroquinolone antibiotics as potential drivers of fluoroquinolone resistance.

Time trend of prevalence and susceptibility to nitrofurantoin of urinary MDR Escherichia coli from outpatients.

OBJECTIVES: To assess the time trend of the prevalence of urinary MDR Escherichia coli in Belgian outpatients (2005 versus 2011-12), the antibiotic susceptibility of urinary MDR E. coli, and the time trend of non-susceptibility to nitrofurantoin, i.e. first-line treatment for uncomplicated urinary tract infections (UTIs), of urinary MDR E. coli (2005 versus 2011-12). METHODS: In this secondary analysis of a multicentre study, which collected a convenience sample of voluntary participating laboratories (15 and 8 in 2005 and 2011-12, respectively), we analysed antimicrobial susceptibilities (ampicillin, amoxicillin/clavulanate, cefalotin, ciprofloxacin, nitrofurantoin and trimethoprim/sulfamethoxazole) of urinary E. coli. MDR was defined as resistance to three or more of these agents. The prevalence of MDR E. coli and its non-susceptibility to nitrofurantoin was compared between 2005 and 2011-12 using a generalized estimating equation model. RESULTS: MDR status could be determined for 9704 and 12512 urinary E. coli isolates from 7911 and 9441 patients in 2005 and 2011-12, respectively, with most patients being women (79% in both study periods). The prevalence of MDR increased from 28.4% (2758/9704) in 2005 to 34.3% (4286/12512) in 2011-12 (adjusted OR 1.305; 95% CI 1.220-1.397). Within the MDR isolates, the prevalence of nitrofurantoin non-susceptibility decreased from 23.2% (623/2684) in 2005 to 10.7% (455/4253) in 2011-12 (adjusted OR 0.424; 95% CI 0.363-0.494). CONCLUSIONS: Despite a high prevalence of MDR E. coli in urinary samples from Belgian outpatients, nitrofurantoin could still be recommended as first-line empirical treatment in uncomplicated UTIs.

The use of aminoglycosides in animals within the EU: development of resistance in animals and possible impact on human and animal health: a review.

Aminoglycosides (AGs) are important antibacterial agents for the treatment of various infections in humans and animals. Following extensive use of AGs in humans, food-producing animals and companion animals, acquired resistance among human and animal pathogens and commensal bacteria has emerged. Acquired resistance occurs through several mechanisms, but enzymatic inactivation of AGs is the most common one. Resistance genes are often located on mobile genetic elements, facilitating their spread between different bacterial species and between animals and humans. AG resistance has been found in many different bacterial species, including those with zoonotic potential such as Salmonella spp., Campylobacter spp. and livestock-associated MRSA. The highest risk is anticipated from transfer of resistant enterococci or coliforms (Escherichia coli) since infections with these pathogens in humans would potentially be treated with AGs. There is evidence that the use of AGs in human and veterinary medicine is associated with the increased prevalence of resistance. The same resistance genes have been found in isolates from humans and animals. Evaluation of risk factors indicates that the probability of transmission of AG resistance from animals to humans through transfer of zoonotic or commensal foodborne bacteria and/or their mobile genetic elements can be regarded as high, although there are no quantitative data on the actual contribution of animals to AG resistance in human pathogens. Responsible use of AGs is of great importance in order to safeguard their clinical efficacy for human and veterinary medicine.

The health and economic impact of acute gastroenteritis in Belgium, 2010-2014.

Acute gastroenteritis (AGE) remains a common condition in both low- and high-income countries. In Belgium, however, there is currently a lack of information on the societal health and economic impact of AGE. We conducted a retrospective study using mortality and cause-of-death data, hospital data, primary care data, health interview survey data and other published data. We estimated the burden of illness during a 5-year period (2010-2014) in Belgium in terms of deaths, patients admitted to hospitals, patients consulting their general practitioner (GP) and cases occurring in the community. We further quantified the health impact in terms of disability-adjusted life years (DALYs) and the economic impact in terms of cost-of-illness estimates. We estimated 343 deaths, 27 707 hospitalised patients, 464 222 GP consultations and 10 058 741 episodes occurring in the community (0.91 cases/person) on average per year. AGE was associated with 11 855 DALYs per year (107 DALY per 100 000 persons). The economic burden was estimated to represent direct costs of €112 million, indirect costs of €927 million (90% of the total costs) and an average total cost of €103 per case and €94 per person. AGE results in a substantial health and economic impact in Belgium, justifying continued mitigation efforts.

Systemic antifungal drug use in Belgium-One of the biggest antifungal consumers in Europe.

BACKGROUND: Reports on the consumption of systemic antifungal drugs on a national level are scarce although of high interest to compare trends and the associated epidemiology in other countries and to assess the need for antifungal stewardship programmes. OBJECTIVES: To estimate patterns of Belgian inpatient and outpatient antifungal use and provide reference data for other countries. METHODS: Consumption records of antifungals were collected in Belgian hospitals between 2003 and 2016. Primary healthcare data were available for the azoles for the period 2010-2016. RESULTS: The majority of the antifungal consumption resulted from prescriptions of fluconazole and itraconazole in the ambulatory care while hospitals were responsible for only 6.4% of the total national consumption and echinocandin use was limited. The annual average antifungal consumption in hospitals decreased significantly by nearly 25% between 2003 and 2016, due to a decrease solely in non-university hospitals. With the exception of specialised burn centres, antifungals are mostly consumed at ICUs and internal medicine wards. A significant decline was also observed in the consumption of azoles in primary health care, attributed to itraconazole. The major part of azoles was prescribed by generalists followed by dermatologists. CONCLUSIONS: In spite of the downward trend in annual use of systemic antifungal drugs, Belgium remains one of the biggest consumers in Europe.

Antibiotic consumption in Belgian acute care hospitals: analysis of the surveillance methodology, consumption evolution 2003 to 2016 and future perspectives.

BackgroundStudies have demonstrated the link between antimicrobial consumption and the development of antimicrobial resistance. Surveillance of antimicrobial consumption is an action point of the European Commission's 'One Health Action Plan Against Antimicrobial Resistance'.AimThis study aims to compare two methodologies for antibiotic consumption surveillance, investigate the 14-year evolution of antibiotic consumption in Belgian acute care hospitals and discuss future perspectives.MethodsWe compared self-reported data (old methodology) and reimbursement data (new methodology) of national antibiotic consumption surveillance in hospitals. Descriptive analyses were performed on the reimbursement data collected per year and per trimester (2003-2016), per hospital and per unit. Antibiotic consumption was compared with European Surveillance of Antimicrobial Consumption Network (ESAC-Net) results.ResultsThe median differences for defined daily doses (DDDs)/1,000 patient days and DDDs/1,000 admissions were 3.09% and 3.94% when comparing the old vs new methodology. Based on reimbursement data, the median antibiotic consumption in 2016 in 102 Belgian acute care hospitals was 577.1 DDDs/1,000 patient days and 3,890.3 DDDs/1,000 admissions with high variation between hospitals (interquartile ranges (IQR): 511.3-655.0 and 3,450.0-4,400.5, respectively), and similar to 2015. Based on DDDs/1,000 patient days, the magnitude of consumption is comparable with the Netherlands, Denmark and Sweden, but is higher when based on DDDs/1,000 admissions.ConclusionAntibiotic consumption in Belgian acute care hospitals has remained overall stable over time. However, the high variation across hospitals should be further investigated. This surveillance data could be used for benchmarking and assessing interventions to improve antibiotic consumption in these hospitals.

Public health risk of antimicrobial resistance transfer from companion animals.

Antimicrobials are important tools for the therapy of infectious bacterial diseases in companion animals. Loss of efficacy of antimicrobial substances can seriously compromise animal health and welfare. A need for the development of new antimicrobials for the therapy of multiresistant infections, particularly those caused by Gram-negative bacteria, has been acknowledged in human medicine and a future corresponding need in veterinary medicine is expected. A unique aspect related to antimicrobial resistance and risk of resistance transfer in companion animals is their close contact with humans. This creates opportunities for interspecies transmission of resistant bacteria. Yet, the current knowledge of this field is limited and no risk assessment is performed when approving new veterinary antimicrobials. The objective of this review is to summarize the current knowledge on the use and indications for antimicrobials in companion animals, drug-resistant bacteria of concern among companion animals, risk factors for colonization of companion animals with resistant bacteria and transmission of antimicrobial resistance (bacteria and/or resistance determinants) between animals and humans. The major antimicrobial resistance microbiological hazards originating from companion animals that directly or indirectly may cause adverse health effects in humans are MRSA, methicillin-resistant Staphylococcus pseudintermedius, VRE, ESBL- or carbapenemase-producing Enterobacteriaceae and Gram-negative bacteria. In the face of the previously recognized microbiological hazards, a risk assessment tool could be applied in applications for marketing authorization for medicinal products for companion animals. This would allow the approval of new veterinary medicinal antimicrobials for which risk levels are estimated as acceptable for public health.

Ambient Air Pollution-related Mortality in Dairy Cattle: Does It Corroborate Human Findings?

BACKGROUND: Despite insights for humans, short-term associations of air pollution with mortality to our knowledge have never been studied in animals. We investigated the association between ambient air pollution and risk of mortality in dairy cows and assessed effect modification by season. METHODS: We collected ozone (O3), particulate matter (PM10), and nitrogen dioxide (NO2) concentrations at the municipality level for 87,108 dairy cow deaths in Belgium from 2006 to 2009. We combined a case-crossover design with time-varying distributed lag models. RESULTS: We found acute and delayed associations between air pollution and dairy cattle mortality during the warm season. The increase in mortality for a 10 µg/m increase in 2-day (lag 0-1) O3 was 1.2% (95% confidence interval [CI] = 0.3%, 2.1%), and the corresponding estimates for a 10 µg/m increase in same-day (lag 0) PM10 and NO2 were 1.6% (95% CI = 0.0%, 3.1%) and 9.2% (95% CI = 6.3%, 12%), respectively. Compared with the acute increases, the cumulative 26-day (lag 0-25) estimates were considerably larger for O3 (3.0%; 95% CI = 0.2%, 6.0%) and PM10 (3.2%; 95% CI = -0.6%, 7.2%), but not for NO2 (1.4%; 95% CI = -4.9%, 8.2%). In the cold season, we only observed increased mortality risks associated with same-day (lag 0) exposure to NO2 (1.4%; 95% CI = -0.1%, 3.1%) and with 26-day (lag 0-25) exposure to O3 (4.6%; 95% CI = 2.2%, 7.0%). CONCLUSIONS: Our study adds to the epidemiologic findings in humans and reinforces the evidence on the plausibility of causal effects. Furthermore, our results indicate that air pollution associations go beyond short-term mortality displacement. (See video abstract at http://links.lww.com/EDE/B105.).

Mortality related to cold and heat. What do we learn from dairy cattle?

Extreme temperatures are associated with increased mortality among humans. Because similar epidemiologic studies in animals may add to the existing evidence, we investigated the association between ambient temperature and the risk of mortality among dairy cattle. We used data on 87,108 dairy cow deaths in Belgium from 2006 to 2009, and we combined a case-crossover design with distributed lag non-linear models. Province-specific results were combined in a multivariate meta-analysis. Relative to the estimated minimum mortality temperature of 15.4°C (75th percentile), the pooled cumulative relative risks over lag 0-25 days were 1.26 (95% CI: 1.11, 1.42) for extreme cold (1st percentile, -3.5°C), 1.35 (95% CI: 1.19, 1.54) for moderate cold (5th percentile, -0.3°C), 1.09 (95% CI: 1.02, 1.17) for moderate heat (95th percentile, 19.7°C), and 1.26 (95% CI: 1.08; 1.48) for extreme heat (99th percentile, 22.6°C). The temporal pattern of the temperature-mortality association was similar to that observed in humans, i.e. acute effects of heat and delayed and prolonged effects of cold. Seasonal analyses suggested that most of the temperature-related mortality, including cold effects, occurred in the warm season. Our study reinforces the evidence on the plausibility of causal effects in humans.

Pleuromutilins: use in food-producing animals in the European Union, development of resistance and impact on human and animal health.

Pleuromutilins (tiamulin and valnemulin) are antimicrobial agents that are used mainly in veterinary medicine, especially for swine and to a lesser extent for poultry and rabbits. In pigs, tiamulin and valnemulin are used to treat swine dysentery, spirochaete-associated diarrhoea, porcine proliferative enteropathy, enzootic pneumonia and other infections where Mycoplasma is involved. There are concerns about the reported increases in the MICs of tiamulin and valnemulin for porcine Brachyspira hyodysenteriae isolates from different European countries, as only a limited number of antimicrobials are available for the treatment of swine dysentery where resistance to these antimicrobials is already common and widespread. The loss of pleuromutilins as effective tools to treat swine dysentery because of further increases in resistance or as a consequence of restrictions would present a considerable threat to pig health, welfare and productivity. In humans, only one product containing pleuromutilins (retapamulin) is authorized currently for topical use; however, products for oral and intravenous administration to humans with serious multidrug-resistant skin infections and respiratory infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA), are being developed. The objective of this review is to summarize the current knowledge on the usage of pleuromutilins, resistance development and the potential impact of this resistance on animal and human health.

Prevalence of hospital-associated infections and its association with discharge destinations and hospital readmissions in Brussels, Belgium, from 2008 to 2020: A hospital-based, cross-sectional study.

OBJECTIVES: To examine time trends of hospital-associated infections (HAIs) in people living in the Brussels-Capital Region, and to evaluate the consequences for hospitals and long-term care facilities (LTCFs). DESIGN: Cross-sectional analyses of yearly hospital administrative data. SETTING: All Belgian hospitals and discharge destinations, focusing on LTCFs. PARTICIPANTS: All individuals from the Brussels-Capital Region hospitalized for >1 day throughout Belgium between 2008 and 2020 (N = 1,915,572). METHODS: We calculated HAI prevalences and then, adjusting for confounders, the odds of being discharged to a LTCF or being readmitted within 30 days postdischarge after an HAI. HAIs included hospital-associated bloodstream infections, hospital-associated urinary tract infections, hospital-associated pneumonia, ventilator-associated pneumonia, and surgical-site infections. RESULTS: Between 2008 and 2020, we identified 77,004 HAIs. Changes in time trends occurred. We observed a decrease of all HAIs from 2012 to 2014 from 5.17% to 2.19% (P < .001) and an increase from 2019 to 2020 from 3.38% to 4.06% (P < .001). Among patients with HAIs, 24.36% were discharged to LTCFs and 13.51% underwent early readmission. For stays ≥4 days, HAIs were associated with higher odds of LTCF discharge (adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.22-1.28), but with lesser odds of early readmission (aOR, 0.88; 95% CI, 0.85-0.90). CONCLUSIONS: Administrative data can be useful to detect HAIs trends, but they seem to underestimate the burden compared to surveillance systems. Risk factors of readmission should be identified during hospital stays to ensure continuity of care. Considering the results from 2020 coinciding with the COVID-19 pandemic, monitoring the impact of HAIs should continue.

Using a Stakeholder Analysis to Implement the Belgian One Health National Report for Antimicrobial Use and Resistance.

(1) Background. Antimicrobial resistance (AMR) poses a substantial global health threat with profound economic implications. Acknowledging the imperative for a One Health (OH) strategy to combat this menace, Belgium introduced an annual national OH report, known as the "BELMAP report," encompassing antimicrobial use (AMU) and AMR, with the first edition completed in 2021. The integration of innovations for the healthcare system demands a meticulously planned process. (2) Methods. We introduced a three-step stakeholder analysis (SA) as a prospective framework for navigating this new report process, fostering complementary collaboration, pinpointing obstacles, suggesting approaches to overcome them, and facilitating national policy development. The SA unfolds in three steps: stakeholders identify and list their relevant activities, assess their positions regarding the BELMAP report, and complete "actor mapping" of national AMR and AMU stakeholders. (3) Results. Stakeholder identification reveals a fragmented landscape of AMR and AMU activities across Belgium. Assessment of stakeholder positions uncovers diverse expectations, collaborative challenges, and resource considerations. "Actor mapping" identifies key stakeholders, emphasizing the importance of high-interest and high-power actors. (4) Conclusions. This SA approach not only provides insights into the present stakeholder landscape in Belgium, it can also serve as a blueprint for other countries in the process of developing OH reports.

Prevalence, risk factors and genetic diversity of methicillin-resistant Staphylococcus aureus carried by humans and animals across livestock production sectors.

OBJECTIVES: This study aimed to assess the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in animals and humans on veal, dairy, beef and broiler farms and to compare the risk for human MRSA carriage with that of strictly horticulture farmers. The genetic background, resistance phenotypes and genotypes and toxin gene content of the isolated MRSA strains were compared with MRSA collected on MRSA clonal complex (CC)398-positive pig farms. METHODS: MRSA carriage isolates were genotyped (spa, SCCmec and multilocus sequence typing), resistance to 16 antimicrobials was determined and resistance and toxin genes were detected. RESULTS: MRSA carriage rates were higher (P<0.01) on veal farms (calves, 64%; farmers, 72%) compared with on dairy (cows, 1%), beef (cows, 5%; farmers, 11%), broiler (pooled broths, 5%; farmers, 3%) and horticulture (farmers, 3%) farms. The intensity of animal contact was identified as a risk factor for human MRSA carriage. The vast majority of MRSA (n=344), including those from pigs, were CC398 (98%). SCCmec V(5C2), V(5C2&5)c, IV(2B) and IV(2B&5) predominated. MRSA CC130 and CC599 carrying mecC were detected in beef and dairy cattle. MRSA from veal calves were significantly more resistant than MRSA from pigs (P<0.01). A few isolates, including mecC-carrying MRSA, harboured pyrogenic superantigen toxins. Human- and animal-derived MRSA from individual farms showed similar characteristics. CONCLUSIONS: This systematic cross-sector survey revealed a high prevalence of multiresistant livestock-associated MRSA on Belgian veal calf farms as compared with other farm types. MRSA harbouring mecC was detected at a low frequency in beef and dairy cows, but not in humans.

COVID-19 Clusters in Belgian Nursing Homes: Impact of Facility Characteristics and Vaccination on Cluster Occurrence, Duration and Severity.

COVID-19 severely affected nursing home residents from March 2020 onwards in Belgium. This study aimed to model the impact of vaccination and facility characteristics on cluster occurrence, duration and severity in this setting. Possible clusters were identified between June 2020 and January 2022, based on the Belgian COVID-19 surveillance in nursing homes. Median attack rates (AR) among residents and staff, case hospitalization rates (CHR) and case fatality rates (CFR) were calculated. A negative binomial model was used to identify the association between nursing home characteristics and the number of cases, hospital admissions and deaths and the duration of the cluster. A total of 2239 clusters were detected in more than 80% of nursing homes. Most of these (62%) occurred before the start of COVID-19 vaccination (end of December 2020). After vaccination, the number of clusters, the AR among residents and staff, the CHR and the CFR dropped. Previous cluster(s) and vaccination decreased the number of cases, hospital admissions and deaths among residents. Previous cluster experience and having started vaccination were protective factors. We recommend continued implementation of targeted interventions such as vaccination, large-scale screening and immediate implementation of additional infection prevention and control measures.

Immunovirological and environmental screening reveals actionable risk factors for fatal COVID-19 during post-vaccination nursing home outbreaks.

Coronavirus Disease 2019 (COVID-19) vaccination has resulted in excellent protection against fatal disease, including in older adults. However, risk factors for post-vaccination fatal COVID-19 are largely unknown. We comprehensively studied three large nursing home outbreaks (20-35% fatal cases among residents) by combining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) aerosol monitoring, whole-genome phylogenetic analysis and immunovirological profiling of nasal mucosa by digital nCounter transcriptomics. Phylogenetic investigations indicated that each outbreak stemmed from a single introduction event, although with different variants (Delta, Gamma and Mu). SARS-CoV-2 was detected in aerosol samples up to 52 d after the initial infection. Combining demographic, immune and viral parameters, the best predictive models for mortality comprised IFNB1 or age, viral ORF7a and ACE2 receptor transcripts. Comparison with published pre-vaccine fatal COVID-19 transcriptomic and genomic signatures uncovered a unique IRF3 low/IRF7 high immune signature in post-vaccine fatal COVID-19 outbreaks. A multi-layered strategy, including environmental sampling, immunomonitoring and early antiviral therapy, should be considered to prevent post-vaccination COVID-19 mortality in nursing homes.

Prospective study on quantitative and qualitative antimicrobial and anti-inflammatory drug use in white veal calves.

OBJECTIVES: To document and quantify drug use in white veal calves, an intensive livestock production system where multidrug resistance is abundantly present. METHODS: Drug consumption data were prospectively collected on 15 white veal production cohorts (n = 5853 calves) in Belgium (2007-09). Treatment incidences (TIs) based on animal defined daily dose (ADD), prescribed daily dose (PDD) and used daily dose (UDD) were calculated. Risk factors were identified by linear regression. RESULTS: The average TI(ADD) of antimicrobial treatments was 416.8 ADD per 1000 animals at risk. Predominantly, oral group antimicrobial treatments were used (95.8%). Of the oral group antimicrobial treatments, 12% and 88% were used for prophylactic or metaphylactic indications, respectively. The main indication for group and individual drug use was respiratory disease. The most frequently used antimicrobials (group treatments) were oxytetracycline (23.7%), amoxicillin (18.5%), tylosin (17.2%) and colistin (15.2%). Deviations from the leaflet dosage recommendations were frequently encountered, with 43.7% of the group treatments underdosed (often oxytetracycline and tylosin to treat dysbacteriosis). In 33.3% of the oral antimicrobial group treatments a combination of two antimicrobial preparations was used. Smaller integrations used more antimicrobials in group treatments than larger ones (P < 0.05); an integration is defined as a company that combines all steps of the production chain by having its own feed plant and slaughterhouse and by placing its calves in veal herds owned by producers that fatten these calves for this integration on contract. Producers used higher dosages than prescribed by the veterinarian in cohorts with a single caretaker (P < 0.01). CONCLUSIONS: The present study provided detailed information on the intensive antimicrobial use in the white veal industry. Reduction can only be achieved by reducing the number of oral group treatments.

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.