Antibiotic use and resistance in Belgium: the impact of two decades of multi-faceted campaigning

Objective: To present an overview of almost two decades of multi-faceted campaigning by the Belgian Antibiotic Policy Coordination Committee (BAPCOC) and partners, and its impact on public and prescribers' awareness, outpatient antibiotic use, its cost and antimicrobial resistance in Belgium.Methods: Awareness of both public and prescribers was assessed through pre- and post-campaign interviews and surveys. Outpatient antibiotic use was evaluated using national reimbursement data expressed in number of defined daily doses and packages (a good proxy for treatments) per 1000 inhabitants per day (DID and PID, respectively) from July 1997 to June 2018. Its cost was studied using the same data expressed in number of euros per 1000 inhabitants per day. Antimicrobial resistance was evaluated between 1986 and 2017 using national data on the proportion of Streptococcus pneumoniae isolates not susceptible to penicillins, macrolides and tetracyclines.Results: Antibiotic awareness improved significantly, with general practitioners preferred by 87.5% of respondents as source of information. The Belgian outpatient antibiotic use has decreased by 12.8% in DID and by 42.8% in PID in the 2017-2018 winter compared to the winter before the start of its public awareness campaigns (1999-2000). This evolution coincided with decreasing costs for antibiotics and decreasing antimicrobial resistance. Despite multi-faceted campaigning, outpatient antibiotic use and use of broad-spectrum antibiotics, especially fluoroquinolones and amoxicillin with clavulanic acid, are still high in Belgium.Conclusion: Almost two decades of multi-faceted campaigning coincide with improvements in antibiotic awareness among the public and prescribers, outpatient antibiotic use and resistance. Nevertheless, additional efforts are needed to reach the targets set in BAPCOC's national action plan 2014-2019. Therefore, a new national action plan was developed for 2020-2024 using a One Health approach.

Nosocomial Intravascular Catheter Infections with Extended-spectrum Beta-lactamase-producing Escherichia coli in Calves after Strain Introduction from a Commercial Herd

An outbreak of intravascular catheter-related infections by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli in calves in an animal teaching hospital is reported. Pulsed-field gel electrophoresis was used for strain typing to determine the origin and dissemination of these strains. All 19 strains harboured the blaCTX-M-14, and six strains also overexpressed their chromosomal AmpC gene. Evidence on the introduction of the strain from a beef herd, experiencing neonatal diarrhoea and increased mortality, to the clinic through admission of diarrhoeic calves was provided. Strains isolated from phlebitis cases from other herds up to 5 months later showed a high similarity with the initial strain, suggesting that the strain had become nosocomial. The catheter infections with ESBL/AmpC-producing E. coli resulted in a prolonged hospitalization, increased anti-microbial use and mortality. This report points towards the potential dangers of the emergence of ESBL/AmpC-producing bacteria in susceptible food animals and warns farmers and veterinarians for the facility by which they are introduced into another environment.

Risico op colistineresistentie neemt toe

In een recent artikel uit China werd overdraagbare resistentie tegen colistine beschreven die gevonden werd bij Escherichia (E. coli) bekomen uit voedselproducerende dieren, vlees en ziekenhuispatiënten (Liu et al., 2015). Heel recent werd deze resistentie onder meer ook gevonden in Denemarken, Frankrijk, het Verenigd Koninkrijk en België. Colistine wordt beschouwd als een van de laatste behandelopties tegen multiresistente bacteriën in de humane gezondheidszorg, voornamelijk bij patiënten met mucoviscidose. Alertheid voor colistineresistentie is geboden en het nieuwe resistentiemechanisme dient zorgvuldig te worden opgespoord bij dier- en mensgerelateerde bacteriën.

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.

Characteristics and challenges of the modern Belgian veal industry

In this paper, the modern Belgian veal industry is situated in a European context, and an overview is provided of the major past, present and future challenges for veal production. The production of white veal requires a specific diet and housing conditions to assure a controlled iron anemic state resulting in pale carcasses. In response to the increasing public concern about animal welfare, legal limits for hemoglobin (in 1990), the provision of a minimum quality of solid feed to assure ruminal health and group housing from the age of eight weeks on (in 2007), have been implemented sector-wide. The integrated structure of the sector likely made it possible to realize these radical changes at relatively short notice. Despite the pioneers role the veal industry played in the development of quality labels for food safety and all efforts made towards improved nutrition and housing, the veal production remains highly liable to public criticism on welfare issues. Nowadays, especially the intensive antimicrobial use in relation to high levels of antimicrobial resistance in commensal, pathogenic and zoonotic bacteria in veal calves is strongly criticized. The future challenge lies in the development of veal production systems, which require only few antibiotics, but safeguard animal welfare and revenue.

Infections acquired in intensive care units: results of national surveillance in Belgium, 1997-2010

BACKGROUND AND AIM

To describe the methodology and output of the Belgian surveillance for infections acquired in intensive care units (ICUs) between 1997 and 2010.

METHODS

Since 1997, ICUs in acute care hospitals in Belgium have been encouraged by federal law to participate in a national multi-centre prospective observational surveillance programme. A protocol and software tool for data collection was developed, and the case definitions and methodology follow those of the European Centre for Disease Prevention and Control.

FINDINGS

For 2010, 18 hospitals provided data on 59 observation quarters, 6478 ICU patients and 52,593 ICU patient-days. The mean incidence rates of ICU-acquired pneumonia and intubation-associated pneumonia were 13 per 1000 patient-days and 12 per 1000 intubation-days, respectively. The mean incidence rates of ICU-acquired bloodstream infections, central vascular catheter (CVC)-associated bloodstream infections and CVC-associated primary bloodstream infections were 3.2 per 1000 patient-days, 2.6 per 1000 catheter-days and 2.3 per 1000 catheter-days, respectively. Between 1997 and 2010, stable trends in ICU-acquired pneumonia and bloodstream infections were observed, together with decreasing trends for intubation-associated pneumonia and CVC-associated bloodstream infections, and a stable trend for CVC-associated primary bloodstream infections.

CONCLUSIONS

In Belgium, national surveillance of ICU-acquired infections allows acute care hospitals to track the incidence of infections at local level, enabling comparison with national and European reference data. Between 1997 and 2010, the incidence of ICU-acquired infections increased and the incidence of device-associated infections decreased.

The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use

A standardised methodology for a combined point prevalence survey (PPS) on healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals developed by the European Centre for Disease Prevention and Control was piloted across Europe. Variables were collected at national, hospital and patient level in 66 hospitals from 23 countries. A patient-based and a unit-based protocol were available. Feasibility was assessed via national and hospital questionnaires. Of 19,888 surveyed patients, 7.1% had an HAI and 34.6% were receiving at least one antimicrobial agent. Prevalence results were highest in intensive care units, with 28.1% patients with HAI, and 61.4% patients with antimicrobial use. Pneumonia and other lower respiratory tract infections (2.0% of patients; 95% confidence interval (CI): 1.8–2.2%) represented the most common type (25.7%) of HAI. Surgical prophylaxis was the indication for 17.3% of used antimicrobials and exceeded one day in 60.7% of cases. Risk factors in the patient-based protocol were provided for 98% or more of the included patients and all were independently associated with both presence of HAI and receiving an antimicrobial agent. The patient-based protocol required more work than the unit-based protocol, but allowed collecting detailed data and analysis of risk factors for HAI and antimicrobial use.

Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene

Four consecutive one-month campaigns were organised to promote hand hygiene in Belgian hospitals between 2005 and 2011. The campaigns included a combination of reminders in wards, educational sessions for healthcare workers, promotion of alcohol-based hand rub use, increasing patient awareness, and audits with performance feedback. Prior and after each one month intervention period, the infection control teams measured hand hygiene compliance of healthcare workers by direct observation using a standardised observation roster. A total of 738,367 opportunities for hand hygiene were observed over the four campaigns. Compliance with hand hygiene significantly increased from 49.6% before to 68.6% after the intervention period for the first, from 53.2% to 69.5% for the second, from 58.0% to 69.1% for the third, and from 62.3% to 72.9% for the fourth campaign. The highest compliance rates were consistently observed in paediatric units. Compliance rates were always markedly lower among physicians than nurses. After patient contact and body fluid exposure risk, compliance rates were noticeably higher than before patient contact and performing aseptic procedures. We conclude that repeated countrywide campaigns to promote hand hygiene result in positive long-term outcomes. However, lower compliance rates among physicians compared with nurses, before patient contact, and before performing aseptic procedures remain challenges for future campaigns.

Nosocomial and non-nosocomial Clostridium difficile infections in hospitalised patients in Belgium: compulsory surveillance data from 2008 to 2010

Surveillance of Clostridium difficile infection (CDI) is compulsory in Belgian hospitals. Our objectives were to compare incidence and case characteristics of nosocomial infections (Nc-CDI) with onset of diarrhoea more than two days after hospital admission, with non-nosocomial cases (Nnc-CDI). The database included inpatients from 2008 to 2010. Of 8,351 cases reported by 150 hospitals, 3,102 (37%) were classified as Nnc-CDI and 5,249 (63%) as Nc-CDI. In 2010, the mean incidence per 1,000 admissions was 0.95 for Nc-CDI and 0.56 for Nnc-CDI. Both incidences were relatively stable over the three years, with a slight decrease in 2010 (p<0.01). Onset of symptoms in Nnc- CDI cases took place in the community (57.1%), nursing homes (14.2%) or hospitals (17.5%); data for 11.2%were missing. Nnc-CDI cases were younger than Nc-CDI (median age 75 vs. 79 years, p<0.001), and more likely to be women (62% vs. 57%, p<0.001) and to have pseudomembranous colitis (5.3% vs. 1.6%, p<0.001). In 2009, C. difficile ribotype 027 was found in 32 of 70 reporting hospitals compared with 19 of 69 in 2010 (p<0.03). Although our study population only included hospitalised patients, the results do not support the hypothesis of an increase in the incidence of severe community-associated CDI.

Nosocomial and non-nosocomial Clostridium difficile infections in hospitalised patients in Belgium - compulsory surveillance data from 2008 to 2010

Surveillance of Clostridium difficile infection (CDI) is compulsory in Belgian hospitals. Our objectives were to compare incidence and case characteristics of nosocomial infections (Nc-CDI) with onset of diarrhoea more than two days after hospital admission, with non-nosocomial cases (Nnc-CDI). The database included inpatients from 2008 to 2010. Of 8,351 cases reported by 150 hospitals, 3,102 (37%) were classified as Nnc-CDI and 5,249 (63%) as Nc-CDI. In 2010, the mean incidence per 1,000 admissions was 0.95 for Nc-CDI and 0.56 for Nnc-CDI. Both incidences were relatively stable over the three years, with a slight decrease in 2010 (p<0.01). Onset of symptoms in Nnc-CDI cases took place in the community (57.1%), nursing homes (14.2%) or hospitals (17.5%); data for 11.2% were missing. Nnc-CDI cases were younger than Nc-CDI (median age 75 vs. 79 years, p<0.001), and more likely to be women (62% vs. 57%, p<0.001) and to have pseudomembranous colitis (5.3% vs. 1.6%, p<0.001). In 2009, C. difficile ribotype 027 was found in 32 of 70 reporting hospitals compared with 19 of 69 in 2010 (p<0.03). Although our study population only included hospitalised patients, the results do not support the hypothesis of an increase in the incidence of severe community-associated CDI.

Timeliness of syndromic influenza surveillance through work and school absenteeism

In this paper, we investigate the usefulness of work and school absenteeism surveillance as an early warning system for influenza. In particular, time trends in daily absenteeism rates collected during the A(H1N1)2009 pandemic are compared with weekly incidence rates of influenza-like illness (ILI) obtained from the Belgian Sentinel General Practitioner (SGP) network. The results indicate a rise in absenteeism rates prior to the onset of the influenza epidemic, suggesting that absenteeism surveillance is a promising tool for early warning of influenza epidemics. To convincingly conclude on the usefulness of absenteeism data for early warning, additional data covering several influenza seasons is needed.

Efficacy of metaphylactic florfenicol therapy during natural outbreaks of bovine respiratory disease

The efficacy of an injectable formulation of florfenicol (300 mg/mL) as metaphylactic control of naturally occurring bovine respiratory disease (BRD) was evaluated in two double-blind randomly controlled field studies on two Dutch veal calf herds (A and B). Cattle aged not older than 3 months and in the direct presence of calves with clinical respiratory disease were randomly allocated to treatment with 40 mg/kg florfenicol subcutaneously (s.c.) a positive control treatment (12.5 mg/kg tilmicosin p.o. twice daily for five consecutive days in herd A, and 12.5 mg/kg doxycycline p.o. twice daily for five consecutive days in herd B), or a negative control (one placebo saline s.c. administration on D0). The predominant respiratory pathogens present in pretreatment respiratory samples from affected animals were Mycoplasma bovis and Pasteurella multocida in outbreaks A and B, respectively. Metaphylactic administration of florfenicol resulted in a statistically significant weight gain, decreased rectal temperature for five consecutive days after treatment and decreased metaphylactic failure percentages compared with both positive and negative control groups. In summary, these studies demonstrated that a single s.c. injection of florfenicol is effective and practical for control of the bacterial component of BRD in veal calves.

Tetracycline-resistance in lactose-positive enteric coliforms originating from Belgian fattening pigs: Degree of resistance, multiple resistance and risk factors

Between March and October 2003 a field study was conducted in 50 randomly selected pig herds to assess the degree of tetracycline-resistance in lactose-positive enteric coliforms (LPEC) originating from fattening pigs and to evaluate the combined effects of various husbandry conditions on the development and persistence of antimicrobial-resistant bacteria. Data on housing, management and antimicrobial-drug consumption were collected, as well as faecal samples at three production stages: end of the nursery period (mean age: 72 days), end of the grower period (mean age: 125 days) and end of the finisher period (mean age: 186 days). The degree of tetracycline-resistant LPEC was determined by means of an agar dilution method. Tetracycline-resistant LPEC were found in every herd. The overall degree of tetracycline-resistance in LPEC was 56.8% (S.D. 22.4%). Only a very weak relation was found between the degrees of TETR in the different production stages within the same herd, indicating that the degree of TETR is mainly associated with the production stage rather than with the farm as a whole. The risk factor analysis showed that besides the antimicrobial-drug use, other factors like inside pen hygiene can influence the development and maintenance of antimicrobial-resistant bacteria in the gastrointestinal tracts of pigs. It was also observed that tetracycline-resistance in commensal Escherichia coli is often linked with resistance to other antimicrobial drugs like ampicillin and trimethoprim-sulphonamides. These results illustrate that the epidemiology of antimicrobial resistance is influenced by antimicrobial-drug use, cross-resistance development and non-antimicrobial risk factors.

Detection of tetracycline-resistant and susceptible pasteurellaceae in the nasopharynx of loose group-housed calves

The aim of the present study was to determine which Pasteurella and Mannheimia species are present in the upper respiratory tract of healthy calves with no history of antimicrobial treatment prior to sampling. The presence of subpopulations of tetracycline-resistant Pasteurellaceae was also investigated. Nasal swabs from 61 loose group-housed, clinically healthy calves, 1 to 4 months old, from 16 dairy herds were inoculated aerobically on a selective medium (Columbia agar with 5% ovine blood and 16 mg/L bacitracin) with or without 4 mg/L oxytetracycline (OTC). A total of 43 strains belonging to the family Pasteurellaceae were isolated from 38 calves (62.3%) out of 13 herds (81.3%). The predominant organisms were Pasteurella multocida subsp. multocida (57.4%), Mannheimia varigena (4.9%) and M. haemolytica (3.2%). Growth of Pasteurellaceae on the OTC-containing medium was seen only with samples from two herds (6 animals; 9.8%), and on only one farm this proved to be an OTC-resistant subpopulation. Minimum inhibitory concentration (MIC) determinations by means of agar dilution confirmed a low prevalence of OTC-resistant Pasteurellaceae, with overall MIC(50) and MIC(90) values of 0.25 and 32 mg/L, respectively. These data do not support the hypothesis that the relative high frequency of tetracycline-resistant P. multocida isolates from fatal cases of bovine respiratory disease is related to the presence of minor tetracycline-resistance subpopulations within this species.

Variability in Antimicrobial Resistance amongSalmonella entericaStrains from Fattening Pigs and Sows

The aim of this study was to determine the prevalence of antibiotic resistance and different resistance patterns for Salmonella isolates collected from Belgian sows and fattening pigs at different ages and at slaughter. The most frequently isolated serotypes were S. Typhimurium (42.3%), S. Derby (25.1%), S. Goldcoast (7.3%), and S. Infantis (4.8%). All 901 isolates were submitted to antimicrobial susceptibility testing for 14 compounds using the disc agar diffusion test. The highest percentage of resistance was found to oxytetracycline (34.2%), streptomycin (32.5%), sulfamethizole (27.6%), and ampicillin (24.9%). Three of the isolates showed resistance to cephalosporins and none to second-generation fluoroquinolones. Multiresistance (resistance to > or =2 antimicrobials) was observed in 33.2% of the strains. Differences in resistance patterns were observed between and within serotypes as well as genotypes. A significant lower proportion (p < 0.01) of resistant strains was recovered in fecal samples from sows (23/56) than from fattening pigs during the weaning (30/30), growing (79/85), and finishing periods (45/52). The proportion of resistant strains recovered from fecal samples taken at the herd (154/167) was higher than in the samples collected at the slaughterhouse (75/140). When designing antimicrobial resistance surveillance programs for Salmonella in pigs, it is important to take multiple samples within each herd from both sows and fattening pigs at different time points.

Fatal meningitis in a calf caused by Mannheimia varigena

Mannheimia varigena was identified as the etiologic agent of meningitis in a young Belgian White Blue heifer calf. Species identification of the bacterium was done by phenotyping and molecularly confirmed by tDNA-PCR. Standard bacteriological examination might fail to differentiate species belonging to the genus Mannheimia.

Antimicrobial resistance in livestock

Antimicrobial resistance may become a major problem in veterinary medicine as a consequence of the intensive use and misuse of antimicrobial drugs. Related problems are now arising in human medicine, such as the appearance of multi-resistant food-borne pathogens. Product characteristics, dose, treatment interval and duration of treatment influence the selection pressure for antimicrobial drug resistance. There are theoretical, experimental and clinical indications that the emergence of de novo resistance in a pathogenic population can be prevented by minimizing the time that suboptimal drug levels are present in the infected tissue compartment. Until recently, attention has been focused on target pathogens. However, it should be kept in mind that when antimicrobial drugs are used in an individual, resistance selection mainly affects the normal body flora. In the long term, this is at least equally important as resistance selection in the target pathogens, as the horizontal transfer of resistance genes converts almost all pathogenic bacteria into potential recipients for antimicrobial resistance. Other factors contributing to the epidemiology of antimicrobial resistance are the localization and size of the microbial population, and the age, immunity and contact intensity of the host. In livestock, dynamic herd-related resistance patterns have been observed in different animal species.