NATIONAL REPORT ON
CONSUMPTION OF SYSTEMIC ANTIMICROBIAL AGENTS
IN BELGIAN HOSPITALS
2007 - 2013
Science at the service of Public Health, Food Chain Safety and Environment
Healthcare-associated infections & Antimicrobial resistance | September 2015 | Brussels, Belgium
Main editor: Dr Boudewijn CATRY, Head of service | Rue J.Wytsmanstraat 14| 1050 Brussels
Deposit Number: D/2015/2505/57
This report was made possible thanks to the participation of most Belgian acute hospitals and large chronic care
hospitals to the surveillance. We would like to thank all healthcare professionals who, on behalf of their institutions,
devoted time, efforts and patience in order to provide us with the required data.
We are also very grateful to all the professionals involved locally in their hospitals, antimicrobial stewardship
programme teams and/or infection control teams, who in the course of the fight against the spread of bacterial
resistance, contacted us to share their suggestions, questions, concerns and advices in order to improve the
surveillance.
Special thanks to the representatives and members of the Working Group “Hospital Medicine” who guided us in the
elaboration of the national report.
A. INGENBLEEK1; E. VAN GASTEL²; M. COSTERS2; M.-M. GOOSSENS1;
B. CATRY1; K. MAGERMAN3
1
Healthcare-Associated Infections and Antimicrobial Resistance; Public Health & Surveillance; Scientific Institute of
Public Health; Rue Juliette Wytsmanstraat 14 - 1050 Brussels
2
Belgian Antibiotic Policy Coordination Committee (BAPCOC); FOD Volksgezondheid, Veiligheid van de Voedselketen
en Leefmilieu; Place Victor Horta plein 40/10 - 1060 Brussels
3
Laboratoriumgeneeskunde Microbiologie; Virga Jesse Ziekenhuis; Stadsomvaart 11 - 3500 Hasselt
Nota Bene:
Despite all the care that the authors have brought during the elaboration of this report and appendices, some
mistakes or errors might have escaped from their attention. Should you point out such errors, or should you have
questions or comments concerning these results, please feel free to contact the redaction team, especially the main
author, Anne.Ingenbleek@wiv-isp.be.
Thank you.
Page | 2
Table of contents
List of abbreviations
4
Executive summary
5
1. Introduction
6
2. Objectives of the surveillance
7
3. Methodology
8
3.1. Concerned institutions and data sources
8
3.2. Data collection and data flow
9
3.3. National analyses
4. Characteristics of participating hospitals
11
12
4.1. Participation
12
4.2. Length of stay in acute healthcare settings
14
5. Overview of the antimicrobial consumption (hospital-wide, J01 & J02)
15
5.1. Overall consumption in acute healthcare settings
15
5.2. Overall consumption in chronic hospitals
19
6. Antimicrobial consumption in acute hospitals, per speciality
21
6.1. Antimicrobial consumption in acute non-paediatric departments
22
6.2. Antimicrobial consumption in intensive care units
27
6.3. Antimicrobial consumption in haematology and oncology units
30
6.4. Antimicrobial consumption in paediatrics
33
7. Insight into the antimicrobial consumption
36
7.1. Most used products, in non-paediatric departments
36
7.2. Most used products, in intensive care units and in haematology and oncology units
38
7.3. Variability of consumption, for selected products
40
7.3.1.
Ampicillin and amoxicillin (J01CA01 & J01CA04)
40
7.3.2.
Combinations of penicillins and enzyme inhibitors (J01CR)
41
7.3.3.
Third and fourth generation cephalosporins (J01DD & J01DE)
42
7.3.4.
Carbapenems (J01DH)
43
7.3.5.
Colistin (J01XB01)
44
7.3.6.
Fluoroquinolones (J01MA)
45
7.3.7.
Vancomycin and teicoplanin (J01XA01 & J01XA02)
47
7.4. Relative antimicrobial consumption
48
8. Concluding remarks
50
9. References
52
Page | 3
List of abbreviations
AB1
AntiBacterial agents
ABC
AntiBacterial agents Consumption
AM2
AntiMicrobial agents
AMC
AntiMicrobial agents Consumption
AMT
Antimicrobial Management Team
ATC
Anatomical Therapeutic Chemical (classification system)
BAPCOC
Belgian Antibiotics Policy COordination Committee
1GC
1st-Generation Cephalosporins
2GC
2nd-Generation Cephalosporins
3GC
3rd-Generation Cephalosporins
4GC
4th-Generation Cephalosporins
DDA
Daily Dose Administrated
DDD
Defined Daily Dose
HAO
HAematology and/or Oncology units
ICU
Intensive Care Units
IQR
InterQuartile Range
IT
Information Technologies
FPS
Federal Public Service Health, Food Chain Safety & Environment (equivalent to a Ministry of Health)
FQ
FluoroQuinolones
LoS
Length of Stay
MDRO
Multi-Drug Resistant Organism
NPD
Non-Paediatric Departments
P
Percentile
PED
PaEDiatric wards
TOT
TOTal (hospital-wide: all hospital departments and wards surveyed)
WHO
World Health Organization
WIV-ISP
Wetenschappelijk Instituut Volksgezondheid – Institut scientifique de Santé Publique
1
2
The antibacterial agents are grouped in the class J01 of the ATC/DDD index (cfr. 2.Objectives of the surveillance and footnote).
The antimicrobial agents belong to several classes of the ATC/DDD index: J01, J02, J04, J05, A07, D01, P01, P02 (ibidem).
Page | 4
Executive summary
About 90% of acute hospitals have properly delivered their antimicrobial consumption (AMC) data to the
surveillance BeH-SAC. The data have been analysed at the national level, per category of size, per academic status
and per level of healthcare. The participation of large chronic hospitals is fragmentary, which hamper surveying
those settings at the national level. The average length of stay (LoS) in acute hospital is decreasing from year to year;
this is particularly observable in non-paediatrics departments (NPD), and in NPD of small and primary hospitals.
After several years of regular increase, 2013 shows, both in terms of daily consumption and in terms of consumption
over a stay, a decrease in the overall antibacterial agents (J01) use in acute hospitals as compared to the previous
year (-3.1% and -8.4% respectively). In 2013, the 2013 median hospital-wide antibacterial consumption (ABC) in
acute facilities was 544 DDD / 1000 patient-days or 3609 DDD / 1000 admissions. The combinations of penicillins
with an enzyme inhibitor (J01CR) form nearly 40% of the total antibacterial (J01) use and are the most used ATCsubclass in acute hospitals. They are followed by the fluoroquinolones (J01MA) representing about 1/8th of the total
antibacterial use. The first-generation cephalosporins (J01DB), the penicillins with expended spectrum (J01CA) and
the class of “other antibiotics” (J01X) cover each 6 to 7% of the total J01 use. The decrease of AMC use seen in 2013
is mostly due to an important drop of use of J01CR in general (or primary) hospitals. General hospitals with teaching
missions (also called secondary hospitals) appear to be the place where the decrease in the global antibacterial
consumption is more evident. The ABC in teaching (tertiary) hospitals is significantly higher than in the other
hospitals. The analysis of the appropriateness of AM use cannot be performed based on these surveillance data; for
such a perspective, a more specific data collection or data source need to be operated.
Intensive care units (ICUs) of academic hospitals show an AMC per stay which is more than four times higher than
the AMC in non-academic hospitals. In haematology and oncology units (HAO), the AMC per stay from 2007 to 2013
is presenting a clear and regular decrease in general hospitals, but an uneven increase in secondary and in tertiary
hospitals. Interpreting results for those highly-specialised wards anyway require caution. Analyses for paediatrics are
difficult to draw, because several factors of interpretation (like the age and an appropriate measure of treatment for
children) are missing in the surveillance BeH-SAC.
The surveillance enables on the contrary to identify which products and molecules are most used and whether their
use is increasing with the time. In such a situation, the pressure of selection is maximized, fuelling the risk to
generate and spread antimicrobial resistance. High variability of AMC within the same category of hospitals indicates
possible improvements to be brought through antimicrobial stewardship programmes. The surveillance BeH-SAC
does not have the means to assess the quality of the prescriptions made in hospitals, but provides grounded figures
based on which experts from the Belgian Antibiotic Policy Coordination Committee can establish thresholds, targets
and indicators of good practices meaningful in Belgium.
As antimicrobial stewardship programmes are still recently developed strategies, further international research and
validations need to be launched and achieved concerning the methodological approaches and tools to be used in this
field.
Page | 5
1. Introduction
Is it still needed to repeat that the phenomenon of antimicrobials resistance has reached worrying proportions, as
various resistant germs are spreading throughout countries, in the hospital sector as well as in the ambulatory
sector? [1,2,3] Not to health professionals, for sure. But it might be relevant to underline that fighting against this
global health threat requires permanent efforts and a coordinated long-term implementation of multidisciplinary
strategies [4,5,6,7] aiming at reducing selective pressure exerted by antimicrobial agents on the one hand and at
containing the dissemination of resistant pathogens on the other hand [6,8,9], in the community and in
hospitals [2,5,9], in long-term care facilities [10] as well as in animal husbandry [4,11,12]. In the ambulatory sector,
such strategies will intend, for instance, at raising both the general public and the practitioners’ awareness regarding
the proper use of antimicrobial drugs. In the healthcare sector, great endeavours are expected in order to
circumscribe healthcare-associated infections and set up efficient antimicrobial stewardship programmes [8,13].
Since 1999, Belgium has implemented and is funding a body at the federal level, the Belgian Antibiotic Policy
Coordination Committee (BAPCOC), whose country-wide overall aim is to hamper and contain the spread of
antimicrobial resistances [14,15]. The BAPCOC has launched public education campaigns on antibiotic use and on
hand hygiene, edited national treatment guidelines for general and hospital health practitioners, promoted and
supports hospital antimicrobial management teams (AMTs) [14,15]; it gathers medical and scientific expertise to
define adequate national policies; it also carries out studies, trainings and strategic evaluations in healthcare settings
at the national level [14,15].
The BAPCOC has motivated the implementation, under the management of the Scientific Institute of Public Health
(WIV-ISP), of a compulsory national surveillance on consumption of systemic antibacterial agents (J01) in all hospitals
providing acute healthcare and in large settings dispensing chronic healthcare. Hospitals remain indeed the utmost
place wherefrom antimicrobial resistances can arise and scatter [8]. This quantitative survey, able to serve both the
local and the national needs for data, is assumed to be part of wider antimicrobial stewardship programmes.
In 2007, a surveillance protocol was finalised at once with a web-based data collection application called NSIHweb;
together, they offer hospitals a standardized calculation methodology as well as a centralized recording system. As
soon as data are entered in the application, the end-user, an authorized person only, can instantly view the inhospital consumption trends (longitudinal analyses) as well as basic national comparative indicators (point analyses).
Hospitals data are stored on a secured server at the WIV-ISP and further used to draw national consumption trends
over time. In 2010, the surveillance has been extended to other anti-infective agents like systemic antimycotic
drugs (J02), although the name of the programme was kept unchanged. In the present document, the acronym BeHSAC will be used to refer to it, which stands for “Belgian Hospitals - Surveillance of Antimicrobial Consumption”.
We are here presenting some of the results of the surveillance BeH-SAC since it has started in 2007 until the year
2013. A selection of outputs has been carried out under the supervision of the board of the BAPCOC’s working
group. Further results and more detailed figures are gathered in a joint document entitled “Appendices to the
national Report on Consumption of systemic Antimicrobial Agents in Belgian Hospitals, 2007-2013” which can be
downloaded from the NSIH.be webpages (www.wiv-isp.be/nsih).
Page | 6
2. Objectives of the surveillance
The Belgian surveillance BeH-SAC on antimicrobial agents consumption3 (AMC) in hospitals has been set up to fulfil
three complementary objectives:

Provide Belgian hospitals with a standardised methodology of evaluation that takes into account the latest
international recommendations with regard to antimicrobial consumption.

Enable Belgian hospitals, especially those who do not have a dedicated program or service at their disposal,
to monitor their own AMCs, to identify any molecules and/or departments that may be problematic, and to
follow up related correction actions taken by the AMTs.

Provide meaningful indicators and reliable figures and trends on hospital antimicrobial agents consumption
at national level.
Antimicrobial agents (AM) encompass several classes and subclasses of anti-infective drugs which are best classified
according to the WHO international ATC/DDD system4. In the ATC/DDD system, each combination associating four
components is given a reference drug quantity : the Defined Daily Dose (DDD). Those four components are i/ an
organ (or a body site of action), ii/ a product (an active substance or combination of active substances), iii/ an
expected physiological effect on a human adult weighting 70 kg, and iv/ a route of administration. These ATC/DDD
classification and system are widely used in Europe and around the world. They allow for useful international
overviews and trend comparisons. Nevertheless, they are not fully representative of the clinical guidelines and habits
of a particular context and only apply to adult patients.
In Belgium, the ATC classification is used as such, without any modification. In addition, a Daily Dose Administrated
system (DDA) is also commonly used. The Belgian DDA system has been elaborated to match the local clinical
recommendations and practices; besides the four elements incorporated in the ATC/DDD index, it also takes into
account the concentration of the drug packages. In this manner, packages intended to paediatric patients are
associated with a reduced reference drug quantity and the AMC for such patients can be better estimated. This
implies that DDA must be updated according to the evolution of the practices and to the products available on the
“market”; the current list of DDA, which is much wider than the ATC/DDD index, needs further validation and could
therefore not be used in the present report, to analyse the AMC trends.
3
Despite certain conceptual nuances that could be implied, the wordings “consumption” and “use” are here equally utilized to
refer to the drugs that have been removed from the hospital pharmacy stocks, then distributed to hospitalised patients and
recorded into the hospital invoicing system.
4
ATC/DDD WHO classification: see http://www.whocc.no/atc_ddd_index and following webpages.
Page | 7
3. Methodology
3.1. Concerned institutions and data sources
The participation to the surveillance BeH-SAC is mandatory for all acute healthcare and for large chronic healthcare
facilities (which means those having 150 or more beds) because such institutions receive annually public funds to
support their AMTs’ actions. Chronic hospitals are all specialised institutions (psychiatry, rehabilitation, geriatrics).
Along with this hospital-based quantitative surveillance on AMC carried out independently by the WIV-ISP, AMTs
must also submit to the BAPCOC an administrative report about the local strategies and activities they have
implemented during the year. Part of the funding provided is hence specifically dedicated to the reporting so as to
measure the whole programme’s efficacy. Other types of settings where medical services are provided (long-term
care facilities, day-care centres, etc.) might be better evaluated with other methodologies tailored for their types of
activities.
Hospitals should preferably deliver their data per site of activity, with as many datasets than there are sites
constituting each institution. In such case, the consumption trends can be followed per site, at the very local level,
which is supposed to be the optimal monitoring situation. In practice, it happens that some patients are transferred
several times for specific cares to other sites of the same institution and that the administrative follow up of those
patients is registered under a unique site. This occurs for instance, when a site dedicated to geriatric patients or to
rehabilitation activities sends inpatients for some days to acute care departments located in another site of the same
merger and then brings them back to their original hospitalisation wards. Accordingly, the surveillance could then be
carried out at the level of the administrative entity. In this report, “hospital” stands for “merger”, which is the entity
as seen by the federal Administration. According to the BAPCOC’s advice for the elaboration of national trends and
results, data of several sites belonging to a same administrative entity have indeed been merged together into one
batch. Therefore, the analyses presented here are made at a level that is slightly different than those presented in
the NSIHweb application.
Data on consumption (numerator data) are extracted out of the hospital (pharmacy) routine invoicing systems.
Hospitals must provide the total number of treatment doses that have been provided to inpatients and that are
recorded in the invoicing systems for future reimbursement. The surveillance covers all substances belonging to the
following ATC classes: A07A, J01, P01AB, J02, D01BA and J04. These classes correspond to those enclosed in the
European Surveillance of Antimicrobial Consumption-Network (ESAC-Net) project, with the exception of antiviral
products (J05). Each single prescribed treatment dose falling under the surveyed AM ATC classes must be integrated
into the computations, specifying whether it has been given in the adult or paediatric sector. In this report, though,
we have reduced the AMC to the two main classes J01 and J02, because the data quality check has shown over
consecutive years that other ATC classes were poorly reported by hospitals.
In order to establish a certain level of comparison between hospitals, the consumptions are weighted by some of the
hospital’s activity characteristics (denominator data). Aggregated data such as number of admissions and number of
patient-days (occupied bed-days) were therefore also supplied by hospitals. The source of these data is the
Admission-Discharge-Transfer system, each hospital is equipped with. At the time of setting-up the surveillance, the
possibilities of secure, fast and confidential individual data collection were fastidious and data linkage was limited.
Thus, patients’ records like the age or the diagnosis were not registered, nor any information related to the
prescriber.
Page | 8
3.2. Data collection and data flow
Upon invitation sent by the BAPCOC (data call), hospitals must furnish their data aggregated at least yearly. They can
also participate on a monthly basis, which involves that both consumption and activity data should be supplied per
month. As mentioned earlier, some participating hospitals provide their data for each individual site of activity,
whereas others take part through a single dataset on behalf of a whole merger.
All inpatient wards are included in the surveillance but outpatient activities and consultations such as emergencies
and day clinic are excluded. According to the protocol, denominator data related to psychiatric beds are excluded
because including them could induce a non-negligible underestimation of the antimicrobial inpatient consumption
rate. The argument behind this exclusion criterion is that patients admitted in those beds are usually not affected by
any infectious condition and hence seldom need antimicrobial agents, while their hospitalisations are often longer
than the somatic patients’ average stays. Constituting a particular inpatient group, their contribution to the
denominators might be overwhelming as compared to their share in the numerators. In a practical way, to minimise
the workload, the AMC attributed to those patients, which has a limited impact on the total AMC, is included in the
data collection whereas their stays must be left out of the denominator data.
The mandatory aspect of the surveillance concerns the AMC in the entire hospital (also identified as hospital-wide or
total – TOT – consumption) on the one side and the AMC in the paediatric wards (PED) and in the non-paediatric
departments (NPD) on the other side. The consumption at the entire hospital level corresponds to the sum of the
consumption in PED and in NDP. The NPD consumption includes all medical, surgical and specialised wards that are
not specifically dedicated to paediatric inpatients; this means that the label NPD includes intensive care units (ICU)
as well as haematology and/or oncology units (HAO). Because these two last types of units are known to be places
with highest AMC, hospitals can also provide, on a voluntary basis, their consumption data collected specifically
about their ICUs and/or their HAO. This opportunity to follow high-density areas of AMC has been kept as optional
due to the heavy workload it might represent for some institutions.
Figure 3.1. Concept of the BeH-SAC dataflow on NSIHweb application (S. Vaerenbergh, WIV-ISP)
Page | 9
The WIV-ISP is annually editing an updated and comprehensive list of all AM products included in the surveillance,
describing their characteristics such as the strength of the active substance per single dose of treatment, its national
unique identification code, its labelling, etc. This list, also called “national register”, serves as a frame for the
preparation of a template blank file (a spread sheet) that hospitals can then fill in, either manually or using computer
programs, depending on the IT maturity of the institution.
Product by product, the number of single doses of treatment that have been dispensed during a specified period of
time must be counted up, based on the invoices produced by the hospital. Totals are written down on the spread
sheet which can then uploaded on the application NSIHweb, which will copy the batch and add it to the national
AMC database hosted on a secured WIV-ISP server (Figure 3.1). This completes the numerator part of the
declaration. Hospital activity (denominator) data are entered manually on a dedicated NSIHweb page.
After entering the data, end-users can immediately view their own results online. Once all required data are
submitted and upon interactive request (by an authorised person and via a local computer), NSIHweb instantly
converts the billing data per product into hospital consumption per ATC code, in terms of DDD weighted for the
hospital inpatient activity. Results are displayed using graphs and tables. These automated transformations are
called instant feed-backs. Hospitals can get three different types of feed-backs. One establishes a one-time
comparison of consumptions for a specific ATC-class or product between the hospital and the national related
parameters (means, medians, percentiles). Another feed-back focuses on the hospital’s own results over the time
(trends). A third one allows exporting partial datasets on an electronic spread sheet.
Page | 10
3.3. National analyses
Delivered data have first been tested for completeness, stability across the years and reliability (correctness of the
totals). During the preliminary analyses, hospitals with outlying results were identified. In case of missing or
inconsistent data, hospitals were contacted for revision and indeed, more reliable data were mostly re-uploaded.
Only validated data are presented in this report. In small-sized groups, descriptive statistical parameters, including
position parameters, can present important true variations.
Based on a BAPCOC’s experts advise, the multidose packages (mainly syrups) have been discarded during the
computations, because they are mainly intended to children and induce an important overestimation of the
paediatric AMC. Even if only one spoon of syrup is administrated to a young patient, the full bottle, containing often
12, 16 or more doses, is systematically invoiced because a bottle cannot be shared into one single treatment dose.
Unless otherwise specified, the results presented in this report are based on the medians of individual hospitals
data. For most antimicrobial agents, the consumption do not follow a normal distribution. Medians are used instead
of means, to limit the influence of extreme values. To go further and be consistent, percentiles are preferred to
standard deviations. Graphs were generated using STATA (version 10). Boxplots display the median, the interquartile range (IQR, delimited by the P25 and P75), upper and lower whiskers (computed as the adjacent values of
respectively P75+1.5 IQR and P25-1.5 IQR), as well as outliers (outside dots). Stacked graphs are plotting, for each
class or subclass of products, the value of the median hospital in that specific class or subclass. Which means that
national stacked graphics are not representing the real consumption in a single hospital that would be the “median
hospital” in Belgium, but rather are summing up real figures coming from different hospitals to picture out the
median consumption per subclass. A consequence of this computation might be a slight overestimation of the
national consumptions and trends as compared to real hospital consumptions. While analysing the consumption
variability between hospitals, the test of Kruskal-Wallis for two or more small and/or non-parametric samples with a
significance threshold set at p < 0.05 has been applied, based on a first visual screening of box-plots indicating a
possible variation between groups.
Page | 11
4. Characteristics of participating hospitals
4.1. Participation
In order to match the international usual denomination with the administrative classification of Belgian hospitals
(cfr. Federal Public Service Health, Food Chain Safety & Environment, FPS), “general hospitals” are assimilated to
primary hospitals, whereas the category “general hospitals with teaching missions” is associated with the secondary
level of care; eventually, academic hospitals are identified as being the third level of the healthcare system.
Following a request made by the working group “Hospital Medicine”, acute general hospitals, whether they have
teaching missions or not, are also grouped, in this report, into a category called “Non-teaching hospitals”, in contrast
with the “teaching” or academic hospitals. The academic group is constituted by the seven university hospitals
(UZAntwerp, UZGent, KULeuven, ULiège, ULBruxelles, UCLouvain, UZBrussel) plus the site Mont-Godinne and the
Institut Bordet in Brussels. The latter is specialised in cancer treatment, has no ward dedicated to paediatric patients
and belongs to the group of hospitals with 400 beds or less. The participation according to the Belgian classification
of hospital is illustrated in the Table 4.1.
Table. 4.1. Hospitals with validated participation to the surveillance of antimicrobial consumption and rate of participation,
per level of healthcare settings, Belgium, 2007-2013
Expected
2007
2008
2009
2010
2011
2012
Effective
2013 participation in participation
2012
General Hospitals
General Hospitals with teaching
missions
Academic Hospitals
Chronic
TOTAL
rate
35
74
76
75
75
72
64
82
87.8 %
12
8
2
57
13
9
3
99
13
9
3
101
13
9
6
103
13
9
5
102
12
9
4
97
10
9
1
84
13
9
6
110
92.3 %
100 %
66.7 %
88.2 %
A participation rate has been computed for the year 2012 based on the FPS administrative list of hospitals and is also
presented in Table 4.1. The effective participation rates obtained do not always reach thresholds that could be
expected in the framework of a compulsory surveillance. It happened that technical or structural re-organisation
(merging, moving, new computer environment, etc.) temporarily hampered some healthcare settings to take part in
the surveillance (for one or several months), which invalidated their yearly totals. Other hospitals did not provide
any data nor explanations for several consecutive years. In the analysis of the participation rate, it should also be
noticed that hospital setups undergo changes, such as merging, which can be administratively registered with a
certain delay. Furthermore, changes do occur on a monthly-basis whereas there is a unique mode of participation to
the surveillance for each year. We therefore expect that the non-participation is partly due to a slight time gap
between the administrative listing and the field reality.
Participants must at least deliver their data split within paediatric (PED) and non-paediatric departments (NPD), as
long as such departments do exist in the healthcare setting (e.g.: chronic hospitals only have non-paediatric
departments and all wards of paediatric hospitals are registered under paediatrics). Table 4.2 provides a picture of
the participation per type of unit. The sum of the AMC use in PED and in NPD corresponds to the consumption in the
whole hospital (TOT). The data provision for other specific wards - intensive care units (ICU) and haemato-oncology
(HAO) - is not mandatory. The AMC use in those specific wards is included in the NPD consumption.
The data must be aggregated at least on a yearly basis. About one third of all participants provide a higher level of
details, with monthly-aggregated data. The national results and trends are computed at the hospital-wide level,
mostly for the need of a global overview and for comparisons with other countries. At a local level, where the
members of the AMTs have a sound understanding of their setting, specific results per department or ward (PED,
NPD, ICU or HAO) are certainly more significant and are thus also provided.
Page | 12
Table. 4.2. Acute hospitals with validated participation to the surveillance of antimicrobial consumption,
per type of departments, Belgium, 2007-2013
2007 2008 2009 2010 2011 2012 2013
HOSPITAL-WIDE (TOT)
55
96
98
97
97
93
83
PAEDIATRICS (PED)
51
89
91
87
88
84
73
NON-PAEDIATRIC UNITS (NPD)
54
95
97
96
96
92
79
INTENSIVE CARE UNITS (ICU)
43
65
71
74
71
69
63
HAEMATO-ONCOLOGY UNITS (HAO)
19
20
24
25
23
22
20
Due to the technical constraints at the moment the NSIHweb application was build, online feedbacks could not be
provided taking into account the hospital size. To address this lacking information, we have performed in this
national report the analyses according to the hospitals size, in terms of number of beds in the whole hospital
(administratively speaking). The participation to the surveillance per category of size is displayed hereunder in
Table 4.3. Hospitals having 400 beds or less represent nearly half of all Belgian acute hospitals (48%). Hospitals
having from 401 to 800 beds represent a third of all participants and big facilities, with more than 800 beds weight
for just a little less than a fifth of participants (19%). Those categories of hospital size based on the number of beds,
proposed by the BAPCOC’s experts, are used in other programmes related to healthcare-associated infections. The
first institutions who have joined the BeH-SAC and other healthcare improvement programmes implemented by the
BAPCOC are mostly big hospitals, with a large bed capacity. Their efforts in the domain are somehow seen as
“pioneering”. Smaller institutions have mostly joined the programmes later, when they had more resources to adopt
organisational changes. Therefore, the categorisation per hospital size carries an historical approach, which is
meaningful to many concerned healthcare practitioners.
Table. 4.3. Acute hospitals with validated participation to the surveillance of antimicrobial consumption,
per category of hospital size, Belgium, 2007-2013
2007 2008 2009 2010 2011 2012 2013
<= 400 beds
19
46
46
45
47
43
37
401 - 800 beds
21
31
33
33
32
32
29
> 800 beds
15
19
19
19
18
18
17
TOTAL
55
96
98
97
97
93
83
Page | 13
4.2. Length of stay in acute healthcare settings
The hospital-wide average length of stay (LoS) in acute settings is slowly but regularly decreasing between 2007 and
2013, with an average yearly rate of -1.1% (-6.8% over the whole period). For detailed figures on LoS, see the part A
of the Appendices. More specifically, the decrease reaches 11.4% in non-paediatric departments (NPD) when all
acute hospitals are grouped together. To go further, the decrease is more pronounced in NPD of general (primary)
hospitals and of small settings (400 beds or less), with a similar rate of -13.6% over the seven years. When looking at
the evolution of LoS in paediatrics (PED), very different patterns are visible, depending on the categorisation used.
PED in primary and small-sized hospitals show a decrease (-13.5% and 18,9% respectively); on the contrary, PED of
tertiary and large-sized settings show an increase (4.9% and 8.3%). PED of mid-sized hospitals (401-800 beds) display
a 10.5% reduction of the LoS between 2007 and 2013. Surprisingly, secondary hospitals, which involves about 12 PED
services, present a remarkable change from four days in 2007 to six days in 2013. Although the trend is also seen (in
a lesser extent, though) when means are used instead of medians, conclusions on small clusters must be drawn with
much cautiousness.
For this reason, the evolutions of the average LoS in specialised departments such as intensive care units (ICU) and
haematology and/or oncology (HAO) should be analysed globally (all hospitals together). Under this conditions, it
can be mentioned that LoS in ICU show a very slight increase (less than 5% over all the years) while the LoS in HAO is
more stable around a value of 10 days.
Evolution of length of stay in Belgian acute hospitals
per type of department
100
90
80
70
60
50
40
30
20
10
Hospital-wide
Paediatrics
Non-Paediatrics
Intensive Care Units
2013 (10.1)
2012 (9.25)
2011 (9.95)
2010 (9.80)
2009 (9.81)
2008 (10.5)
2007 (10.3)
2013 (6.39)
2012 (6.51)
2011 (6.31)
2010 (6.49)
2009 (6.06)
2008 (5.69)
2007 (6.05)
2013 (7.02)
2012 (7.28)
2011 (7.38)
2010 (7.51)
2009 (7.51)
2008 (7.67)
2007 (7.88)
2013 (3.28)
2012 (3.32)
2011 (3.39)
2010 (3.40)
2009 (3.32)
2008 (3.42)
2007 (3.69)
2013 (6.87)
2012 (6.96)
2011 (7.12)
2010 (7.19)
2009 (7.15)
2008 (7.35)
2007 (7.38)
0
Haemato-oncology
X axis: Year (median length of stay). Acute hospitals only
Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 4.1. Evolution of the median length of stay (in days) in acute hospitals, per type of department, Belgium, 2007-2013
Looking at the hospital as a whole, at paediatrics or at non-paediatrics, one can observe that patient’s stays in
Belgian acute hospitals are shortening (Figure 4.1). When the investigation is brought in terms of category of
hospitals, though, conclusions are more nuanced. Depending on the grouping and on the types of department or
unit that are looked at, the median LoS can evolve along the time with significantly divergent trends. As a matter of
consequence, it will be important, while examining the AMC in Belgian hospitals, to take into account both
calculations in terms of DDD / 1000 patient-days and of DDD / 1000 admissions in order to obtain a more thorough
and balanced understanding of the phenomenon.
Page | 14
5. Overview of the antimicrobial consumption (hospital-wide, J01 & J02)
5.1. Overall consumption in acute healthcare settings
According to the data collected by BeH-SAC, the year 2013 shows a decrease in the antibacterial agents (J01) use as
compared to the previous year (Fig. 5.1). This decrease is covering the total (TOT) antibacterial consumption (ABC),
meaning all paediatric (PED) and non-paediatric departments (NPD) combined together and can be seen both in
terms of daily consumption (-3.1%) and in terms of consumption over a stay (-8.4%) (Table 5.1). This constitutes
encouraging news, because the ABCC was previously slowly but quite regularly increasing with an average yearly rate
of 1.6%, passing from 520 in 2007 to 560 DDD / 1000 patient-days in 2012. The increase looks smaller when the
analysis is done using the indicator DDD / 1000 admissions (showing a total growth of 4.1% over 5 years). This
discrepancy, related to which indicator is chosen, can be explained by the reduction of the average hospital length of
stay (LoS).
Antibiotic (J01) use in Belgian acute hospitals
hospital-wide consumption
1,000
14,000
900
12,000
800
10,000
DDD / 1000 admissions
700
600
500
400
8,000
6,000
300
4,000
200
2,000
100
2013
2012
2011
2010
2009
2008
2007
2013
2012
2011
2010
2009
2008
0
2007
0
Acute hospitals only
Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 5.1. Trends and distribution of antibacterial agents (J01) consumption in all acute hospitals, hospital-wide,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Table 5.1. Distribution of antibacterial (J01) and of systemic antimycotic (J02) consumption agents in all acute hospitals,
hospital-wide, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Antimicrobial agents (J01 & J02) hospital-wide consumption in acute hospitals
DDD / 1000 patient-days
J02
J01
2007
Page | 15
Frequency
Mean
P25
Median
P75
Frequency
Mean
P25
Median
P75
2008
2009
2010
2011
DDD / 1000 admissions
2012
2013
2007
2008
2009
2010
2011
2012
2013
55
541.7
459.9
519.8
621.2
96
529.9
461.0
523.7
595.5
99
541.9
468.4
544.6
603.7
97
544.1
478.9
544.0
608.2
97
556.9
484.2
556.8
624.9
93
568.6
495.8
560.9
633.5
83
538.2
479.0
543.7
604.1
54
4112
3338
3783
4874
96
3936
3399
3802
4500
98
3947
3355
3842
4330
96
3971
3546
3913
4334
97
4075
3505
3912
4363
92
4000
3386
3939
4405
82
3683
3206
3609
4357
45
41.6
21.8
26.8
48.3
86
29.1
14.3
21.8
36.8
90
25.8
11.8
19.2
33.1
91
29.2
13.1
22.5
35.6
91
30.5
14.9
24.3
36.6
88
31.7
13.5
24.0
37.9
80
30.5
13.8
22.6
32.5
44
300
144
211
331
86
215
106
170
255
89
185
81
141
232
90
211
94
177
275
91
223
97
174
249
87
221
105
177
245
79
206
92
162
217
As far as systemic antimycotic agents (J02) are concerned, no clear trends can be identified, as the median
consumption of this ATC-subclass fluctuates within a margin of about 25% around 22 DDD / 1000 patient-days and
167 DDD / 1000 admissions. The inter-hospitals variability of the antimycotic agents consumption is large and not
clearly decreasing as years are passing (Table 5.1 and Fig. 5.2).
Systemic antimycotic (J02) use in Belgian acute hospitals
hospital-wide consumption
250
2,000
200
DDD / 1000 admissions
1,500
150
100
1,000
500
50
2013
2012
2011
2010
2009
2008
2007
2013
2012
2011
2010
2009
2008
0
2007
0
Acute hospitals only
Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 5.2. Trends and distribution of systemic antimycotic agents (J02) consumption in all acute hospitals, hospital-wide,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
To verify whether these encouraging results observed in 2013 were based on a true reduction of the ABC or were a
statistical artefact due to a smaller number of participant for that year, the same analysis has be done on a reduced
sample of hospitals who have consistently provided their AMC data since 20085. The results of this smaller sampling
are shown in Table 5.2 and in Fig. 5.3. and confirm the observations made at the wider level.
Table 5.2. Distribution of antibacterial agents (J01) and of systemic antimycotic agents (J02) consumption in acute hospitals
participating consistently since 2008, hospital-wide, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions,
Belgium, 2008-2013
Antimicrobial agents (J01 & J02) hospital-wide consumption in acute hospitals participating consistently since 2008
DDD / 1000 patient-days
J02
J01
2008
5
Frequency
Mean
P25
Median
P75
Frequency
Mean
P25
Median
P75
78
537.5
461.1
524.4
590.6
68
31.1
14.4
24.3
37.9
2009
78
547.7
477.0
549.2
603.7
68
27.8
11.8
20.9
34.1
2010
78
543.6
478.9
543.8
605.1
68
29.5
12.9
21.9
36.3
2011
78
550.5
484.2
554.1
617.4
68
32.3
15.1
25.8
37.1
DDD / 1000 admissions
2012
78
567.4
495.8
559.3
626.1
68
33.0
15.0
23.1
39.0
2013
78
539.5
479.5
544.9
603.0
68
31.0
13.8
22.6
32.5
2008
78
3953
3391
3754
4502
68
230
106
171
264
2009
77
3978
3463
3849
4490
67
202
86
167
252
2010
77
3919
3536
3867
4274
67
212
90
176
273
2011
78
3966
3502
3784
4359
68
230
102
178
268
2012
77
3965
3385
3876
4415
67
229
109
179
282
2013
77
3674
3206
3602
4252
67
208
97
164
213
The year 2007 was discarded because at the start of the surveillance, not all hospitals were able to provide (good quality) data.
Page | 16
Antibiotic (J01) use in Belgian acute hospitals
hospital-wide consumption, in hospitals participating consistently since 2008
1,000
8,000
800
DDD / 1000 admissions
6,000
600
400
4,000
2,000
200
2013
2012
2011
2010
2009
2008
2013
2012
2011
2010
2009
0
2008
0
Acute hospitals only (n = 78)
Source:
WIV-ISP.
Surveillance
of antimicrobial agents
in Belgian hospitals
Figure
5.3.
Trends
and distribution
of antibacterial
agents (J01) consumption in acute hospitals participating consistently
since 2008, hospital-wide, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2008-2013
Stacked graphs, as those presented in the Figure 5.4, enable an easy visualisation of the part that different ATCsubclasses take amongst the yearly total AMC. Penicillins combined with an enzyme inhibitor (J01CR) were already
known to be the most used group of AB. They are followed by the fluoroquinolones (FQ, J01MA) and the 1rstgeneration cephalosporins (1GC). The generic subclass called “Other antibacterials” (J01X) comes behind and
includes products having very different application. This group of AB will hence been carefully looked at later in this
report.
Antimicrobial agents (J01 & J02) use in Belgian hospitals
in acute healthcare hospitals (hospital-wide)
1,000
4,000
950
Defined Daily Doses / 1000 admissions
900
850
3,500
800
750
3,000
700
650
600
2,500
550
500
2,000
450
400
1,500
350
300
250
1,000
200
150
500
100
50
(6
.8
7)
(6
.9
6)
20
13
(7
.1
2)
20
12
20
11
(7
.1
9)
20
10
(7
.1
4)
(7
.3
5)
20
09
(7
.3
8)
20
08
20
07
(6
.8
7)
(6
.9
6)
20
13
20
12
(7
.1
2)
20
11
(7
.1
9)
20
10
(7
.1
4)
20
09
20
08
20
07
(7
.3
5)
0
(7
.3
8)
0
X axis: Year (National median length of stay). Y axis: Stacked bars are made by summing the median hospital consumption for each ATC-class
Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 5.4. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, hospital-wide,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 17
Nevertheless, following the evolution across the time of each of those ATC-subclasses on stacked graphs presents
some difficulties. The Figure 5.5 better address the examination of time trends within each ATC-subclass. The latter
clearly shows that the overall AMC drop observed in 2013 is mainly caused by the fall of consumption in the J01CR
family, meaning the combinations of penicillins with an enzyme inhibitor (J01CR). The AMC drop is further reinforced
by a smaller use of fluoroquinolones (J01MA) for the year 2013. In terms of daily treatment, the ATC-subclasses that
have been more used across the time are, after the J01CR until 2012, the penicillins with extended spectrum (J01CA),
the 3CG (J01DD) and 1CG (J01DB). An increase is also visible for the carbapenems (J01DH). The aminoglycosides
(J01G) constitute the only group where a regular and constant decreased can be noticed.
Antimicrobial agents consumption trends in acute hospitals
Per ATC subclasses - Hospital-wide
250
200
150
100
50
0
Per ATC subclasses - Hospital-wide
J0
1E
J0
1D
E
J0
1C
E
J0
1G
J0
2
J0
1D
C
J0
1D
H
J0
1F
J0
1C
F
A
J0
1X
J0
1D
D
B
J0
1C
J0
1D
J0
1C
R
J0
1M
Antimicrobial agents consumption trends in acute hospitals
2,000
2007
2008
2009
2010
2011
2012
2013
Note: National median consumption; all acute hospitals
1,500 Participation: 2007 n=55; 2008 n=96; 2009 n=99; 2010 n=97; 2011 n=97; 2012 n=93; 2013 n=83
1,000
500
2007
2008
2009
2010
2011
2012
J0
1E
J0
1D
E
J0
1C
E
J0
1C
F
J0
1D
H
J0
1D
C
J0
1G
J0
2
J0
1F
J0
1D
D
J0
1X
B
A
J0
1C
J0
1D
J0
1M
J0
1C
R
0
2013
Figure 5.5. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute hospitals, hospital-wide,
Participation: 2007 n=54; 2008 n=96; 2009 n=98; 2010 n=96; 2011 n=97; 2012 n=92; 2013 n=82
expressed in DDD
/ 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Note: National median consumption; all acute hospitals
Page | 18
5.2. Overall consumption in chronic hospitals
To our knowledge, only six chronic hospitals are subjected to a participation to BeH-SAC. Due to their very different
goals, patterns and populations, chronic hospitals cannot be compared with acute healthcare settings; in this
national report, they are hence set and analysed apart.
DDD / 1000 patient-days
Antibacterial agents (J01) consumption in Belgian chronic hospitals
350
300
250
200
150
100
50
0
2007
2008
2009
2010
2011
2012
2013
Figure 5.6. Time trends of antibacterial agents (J01) consumption in chronic hospitals, hospital-wide,
expressed in DDD / 1000 patient-days, Belgium, 2007-2013
Only one chronic hospital has provided AMC data for all the seven years of the surveillance. In that hospitals, the
consumption both for J01 and J02 are evolving toward a reduction. Two hospitals have participated for four years
and the three others for only three years (Fig. 5.6). The AMC in chronic healthcare settings must be interpreted
independently from each other, at the hospital-level.
If any conclusion can be drawn at the national level, much caution must be taken, because of the small number of
participants. Yearly results obtained from less than three participants have a low representativeness and thus
reliability. The rough picture of the AMC in those long-term care settings gives nevertheless the idea that it is
regularly declining from 2007 to 2012 (see Fig. 5.7).
Page | 19
Antimicrobial agents (J01 & J02) use in Belgian hospitals
in chronic healthcare hospitals (hospital-wide)
600
Defined Daily Doses / 1000 admissions
11,000
10,000
500
9,000
8,000
400
7,000
6,000
300
5,000
4,000
200
3,000
2,000
100
1,000
0
07
20
1)
2.
(4
08
20
1)
5.
(5
09
20
7)
5.
(4
10
20
4)
0.
(5
11
20
2)
1.
(5
12
20
9)
7.
(4
0
07
20
1)
2.
(4
08
20
1)
5.
(5
09
20
7)
5.
(4
10
20
4)
0.
(5
11
20
2)
1.
(5
12
20
9)
7.
(4
X axis: Year (National median length of stay). Y axis: Stacked bars are made by summing the median hospital consumption for each ATC-class
In 2013: only one chronic hospital has participated, results not shown. Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 5.7. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in chronic hospitals, hospital-wide,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2012
Page | 20
6. Antimicrobial consumption in acute hospitals, per speciality
6.1. Antimicrobial consumption in acute non-paediatric departments
The daily consumption of all antibiotic agents (J01) in non-paediatric departments of all acute hospitals was slightly
but regularly increasing between 2007 and 2012. The year 2013 shows a stabilisation around
550 DDD / 1000 patient-days. Between 2007 and 2012, respectively more than 94% and about 96% of the J01 and
J02 hospital-wide use occur in non-paediatric departments. For the year 2013, these ratios were reduced to
respectively 90% and 93%.
When categorized per size, “small” (hospitals with 400 beds or less), “medium” (hospitals having from 401 to 800
beds) and “large” (hospitals with more than 800 beds), non-paediatric departments of acute healthcare settings
present an uneven pattern of antibiotic agents (J01) consumption (see Fig. 6.1 and Appendices, Tables E5 & E6).
Whether the analysis of the global ABC is done per patient-days or per admissions, the size – measured in terms of
number of beds – does not seem to be a marker of difference between acute hospitals. The levels and trends of
consumption are close, there is no particular patterns to be observed. This categorisation is therefore, in this case, of
little interest.
Antibiotic (J01) use in Belgian acute hospitals, per hospital size
all non-paediatric units
1,000
14,000
900
12,000
800
10,000
DDD / 1000 admissions
700
600
500
400
8,000
6,000
300
4,000
200
2,000
100
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
2007
2008
2009
2010
2011
2012
2013
0
Small
Medium
Large
Small
Medium
Large
Category of hospital size: Small: <= 400 beds; medium: 401-800 beds; large: > 800 beds.
Acute hospitals only. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.1. Trends and distribution of antibacterial agents (J01) consumption in acute hospitals, per hospital size,
non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
On the contrary, the categorisation per level of healthcare shows more regular trends (Fig. 6.2). A 15% increase in
the J01 use per patient-days is clearly seen until 2012 in the primary healthcare settings but the use per admissions
appears to be quite stable around 4000 DDD / 1000 admissions (see Appendices, Tables E3 & E4). In general
hospitals with teaching missions, or secondary healthcare settings, the trend in terms of DDD / 1000 patient-days
was decreasing until 2013, when the ABC got higher than in 2012. Still in secondary settings, the global ABC per
admissions has regularly shrunk of 17% between 2007 and 2013, included.
There are only nine tertiary or teaching hospitals in Belgium; their ABC distributional parameters are thus prone to
important variability around almost 700 DDD / 1000 patient-days and over 5000 DDD / 1000 admissions. This allows
to pinpoint the fact that the level of ABC in those highly specialized healthcare settings is significantly higher than in
Page | 21
non-teaching hospitals, both in terms of consumption per day (≈27%) and per stay (≈20%). The same observations
can be made for the J02 consumption (see Fig. 6.3).
Antibiotic (J01) use in Belgian acute hospitals, per level of healthcare
all non-paediatric units
1,000
14,000
900
12,000
800
10,000
DDD / 1000 admissions
700
600
500
400
8,000
6,000
300
4,000
200
2,000
100
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Acute hospitals only
Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.2. Trends and distribution of antibacterial agents (J01) consumption in acute hospitals, per level of healthcare,
non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Systemic antimycotic (J02) use in Belgian acute hospitals, per academic status
all non-paediatric units
250
2,000
200
DDD / 1000 admissions
1,500
150
100
1,000
500
50
Non-teaching
Teaching
Non-teaching
2013
2012
2011
2010
2009
2008
2007
2013
2012
2011
2010
2009
2008
2007
2013
2012
2011
2010
2009
2008
2007
2013
2012
2011
2010
2009
2008
0
2007
0
Teaching
Acute hospitals only
Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.3. Trends and distribution of antimycotic agents (J02) consumption in acute hospitals, per academic status,
non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
More precisely and as shown in the Figure 6.4 hereafter, a large part of the dissimilarity between non-teaching and
teaching hospitals leans on some specific products; namely, the β-lactamase resistant penicillins (J01CF, ratio 1:3),
Page | 22
the 4GC (J01DE, ratio 1:8), the carbapenems (J01DH, ratio 3:8), the vancomycin (J01XA01, ratio 1:4), colistin
(J01XB01, ratio 1:2) and the antimycotic agents (J02, ratio 1:4). The case-mix observed in those academic highlyequipped facilities partially justifies different therapeutic needs and AMC consumption practices. In spite of this
rationale, further inquiries should be carried out on this disparity, at the national level as well as at the hospital level
by AMT’s, taking as much as possible into account the diagnosis that was made and the patient’s conditions.
Figure 6.4. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, per academic
status, non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
The Figure 6.5 indicated that if primary and secondary hospitals have, in patient-days, quite close consumption
patterns, they noteworthy differ in terms of use per admissions. Secondary hospital clearly display decreasing AMCs
due mainly to a reduced use of combinations of penicillins with enzyme inhibitor (J01CR), of FQ (J01MA) and of
penicillins with extended spectrum (J01CA). The evolutions of the AMC per ATC-subclass and per healthcare level are
presented in Figures 6.6, 6.7 and 6.8. Among primary acute hospitals, a lessening of use seems to be visible only in
the group of aminoglycosides (J01G).
Page | 23
Antimicrobial agents (J01 & J02) use in Belgian acute hospitals
in non-paediatric departments, per level of healthcare
1,000
950
5,500
900
5,000
Defined Daily Doses / 1000 admissions
850
800
750
700
650
600
550
500
450
400
350
300
250
4,500
4,000
3,500
3,000
2,500
2,000
1,500
200
1,000
150
100
500
50
Primary
Secondary
20
2007
(
2008 8.1
( 3
2009 7.8 )
( 0
2010 7.7 )
( 3
1
20 1 7.6 )
( 6
2012 7.4 )
13 (7. 1)
3
20 (7.06)
2007 2)
(7
0
20 8 . 5
( 9
2009 7.6 )
( 9
2010 7.5 )
( 0
2011 7.2 )
( 8
2012 7.2 )
13 (7. 6)
0
20 (7.05)
2007 3)
(
2008 7.6
( 0
2009 7.1 )
( 7
2010 7.1 )
( 8
2011 7.0 )
( 9
2012 7.2 )
13 (7. 1)
(6 20)
.9
5)
0
20
2007
(
2008 8.1
( 3
2009 7.8 )
( 0
1
20 0 7.7 )
( 3
2011 7.6 )
( 6
2012 7.4 )
13 (7. 1)
3
20 (7.06)
2007 2)
(
2008 7.5
( 9
2009 7.6 )
( 9
2010 7.5 )
( 0
2011 7.2 )
( 8
2012 7.2 )
13 (7. 6)
0
20 (7.05)
2007 3)
(
2008 7.6
( 0
2009 7.1 )
( 7
2010 7.1 )
( 8
2011 7.0 )
( 9
1
20 2 7.2 )
13 (7. 1)
(6 20)
.9
5)
0
Tertiary
Primary
Secondary
Tertiary
X axis: Year (National median length of stay). Y axis: Stacked bars are made by summing the median hospital consumption for each ATC-class
Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 6.5. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals,
per level of healthcare, non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions,
Belgium, 2007-2013.
Antimicrobial agents(J01 & J02) consumption in Belgian acute primary hospitals
in non-paediatric departments, per ATC-subclasses
250
1,500
DDD / 1000 admissions
200
150
100
1,000
500
50
2009
2010
2011
2012
2008
2009
J0
2
J0
1C
F
J0
1D
H
J0
1D
C
J0
1G
J0
1E
J0
1C
E
J0
1A
2007
J0
1D
R
J0
1M
J0
1C
2013
J0
1F
J0
1D
D
J0
1C
A
2008
B
J0
1X
2007
J0
2
J0
1D
H
J0
1D
C
J0
1G
J0
1E
J0
1C
E
J0
1D
E
J0
1C
J0
1M
J0
1D
B
J0
1X
J0
1D
D
J0
1F
J0
1C
A
J0
1C
F
0
R
0
2010
2011
2012
2013
Acute primary hospitals only. Participation: 2007 n=35; 2008 n=74; 2009 n=76; 2010 n=75; 2011 n=75; 2012 n=72; 2013 n=64.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.6. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute primary hospitals,
non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 24
Antimicrobial agents(J01 & J02) consumption in Belgian acute secondary hospitals
in non-paediatric departments, per ATC-subclasses
250
1,500
DDD / 1000 admissions
200
150
100
1,000
500
50
2007
2008
2009
2010
2011
2012
2013
J0
2
J0
1C
F
J0
1D
B
J0
1C
A
J0
1D
C
J0
1F
J0
1D
H
J0
1D
D
J0
1D
E
J0
1E
J0
1G
J0
1C
E
J0
1X
R
J0
1M
J0
1C
J0
2
J0
1C
A
J0
1D
B
J0
1D
C
J0
1C
F
J0
1F
J0
1D
H
J0
1D
D
J0
1D
E
J0
1G
J0
1C
E
J0
1E
J0
1C
J0
1X
0
R
J0
1M
0
2007
2008
2009
2010
2011
2012
2013
Acute secondary hospitals only. Participation: 2007 n=12; 2008 n=13; 2009 n=13; 2010 n=13; 2011 n=13; 2012 n=12; 2013 n=10.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.7. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute secondary hospitals,
non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Antimicrobial agents(J01 & J02) consumption in Belgian acute tertiary hospitals
in non-paediatric departments, per ATC-subclasses
250
1,500
DDD / 1000 admissions
200
150
100
1,000
500
50
2007
2008
2009
2010
2011
2012
2013
J0
1M
J0
1C
F
J0
1X
J0
1D
H
J0
1C
A
J0
1F
J0
1D
D
J0
1D
B
J0
1D
E
J0
1E
J0
1D
C
J0
1G
J0
1C
E
J0
2
R
J0
1C
J0
1M
J0
1C
F
J0
1X
J0
1D
H
J0
1C
A
J0
1F
J0
1D
D
J0
1D
B
J0
1D
E
J0
1E
J0
1D
C
J0
1G
J0
1C
E
J0
1C
J0
2
0
R
0
2007
2008
2009
2010
2011
2012
2013
Acute tertiary hospitals only. Participation: 2007 n=8; 2008 n=9; 2009 n=9; 2010 n=9; 2011 n=9; 2012 n=9; 2013 n=9.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.8. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute tertiary hospitals,
non-paediatric departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 25
Regarding the secondary level of healthcare, many ATC-subclasses show a fall of consumption, as suggested by the
regular decline on Figure 6.5. The consumption of some specific products did increase during the first years of the
surveillance (see for instance the J01X or J02), but the two or three last years mostly show a stabilisation. Among
tertiary hospitals, figures are there again more prone to statistical variability, but raised consumptions can be
identified for the resistant penicillins (J01CF) or the 2GC (J01DC) and clear reductions take shape for instance for 1GC
(J01DB), 4GC (J01DE) or for quinolones (J01M).
It appears from the overall analyses of the BeH-SAC, that depending on the denominator and the stratification used,
the conclusions on the AMC can vary, reflecting an intricate situation. It is important to underline that the
calculations are based on all the non-psychiatric hospital stays, including those during which no AM drugs have been
prescribed. It would be interesting to perform restrictive computations on hospital stays during which patients have
actually been treated with antimicrobial agents, in order to get more precise outcomes. Depending on the evolution
of a campus (site) specialisation, the number of hospital stays that do not require any antimicrobial treatment might
for instance increase along the years. In such case, an indicator like the number of DDD / 1000 treated admissions
would provide a sturdier picture of the antimicrobial stewardship practices in the campus. Although hospitals have
the possibility to submit the number of treated admissions in their settings in the NSIHweb application, very few
provide them and a national analysis with respect to this aspect does not worth considering. We also have to
acknowledge that the web-based application that is currently online can collect this type of data, but the feedbacks
provided online do not perform any computation based on them, which by consequence discourage hospitals to
further provide this information.
Page | 26
6.2. Antimicrobial consumption in intensive care units
Intensive care units and the highly-specialised haematology and oncology wards are identified as being places
involving sensitive, last-line molecules and broad AMC. The possibility has hence be given to hospitals to survey, on a
voluntary basis, their AM use in these specific wards via NSIHweb. Not all healthcare settings did provide their data;
results shown hereunder have therefore a lesser level of representativeness and are subjects to greater statistical
variations, due to smaller sample sizes.
In our database, eight to nine per cent of the antibiotic (J01) non-paediatric use occur in intensive care units (ICU),
while haematology and oncology units (HAO) are responsible for about three to five per cent of the ABC in nonpaediatrics. As regard to antimycotic agents (J02), HAO units have a greater consumption of J02, with a 22 to 30%
share, depending on the years; ICU are accountable for 18 to 22% of the J02 use in NPD. The AMC in HAO is
presented in next section.
The Figure 6.9 exposes a five to six-fold higher antimicrobial agents use per stay in ICUs of tertiary as compared to
the use in primary hospitals. Alone, the LoS does not justify such a contrast and of course, the type and severity of
the cases taken in charge in those two types of settings are assumed to be the main factors explaining this important
difference. Further case-based investigations on the quality of the treatment could nonetheless be enlightening.
Figure 6.9. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, per level
of healthcare, intensive care units, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
The ICU results for the year 2008 in teaching hospitals look to present outstanding values, but it is not the case. The
little number of hospitals participating in that category implies that the median could move much along a widely
spread distribution (see Appendices, Tables F3 & F4). After verification, no outlier has been identified in the dataset
and no data has thus been discarded; interpretations must take these statistical limitations into account.
The analyse, per hospital size, of the AMC in ICUs shows that “large” hospitals have massively increased the total
amount of AM given during a stay, although the LoS did not vary much (Fig 6.10). But precautions due to statistical
variations, as highlighted here above, should be applied here again. The results for ICUs of large acute hospitals show
Page | 27
indeed very different patterns of consumption depending on the indicator used for the evaluation: the consumption
per patient-day varies around levels similar than those found in the other types of hospitals. But the figures
computed per stay show a higher and increasing AM use in large hospitals between 2007 and 2013 in those large
healthcare settings, which is worth a closer examination.
Antimicrobial agents (J01 & J02) use in Belgian hospitals
in acute healthcare hospitals (intensive care units) per hospital size
2,000
19,000
18,000
1,800
1,400
1,200
1,000
800
600
16,000
Defined Daily Doses / 1000 admissions
1,600
17,000
15,000
14,000
13,000
12,000
11,000
10,000
9,000
8,000
7,000
6,000
5,000
4,000
400
3,000
2,000
200
1,000
Small
Medium
Large
20
2007
(
2008 5.6
( 0
2009 5.7 )
( 9
2010 5.3 )
( 1
1
20 1 6.4 )
( 9
2012 5.5 )
13 (6. 1)
5
20 (6.40)
2007 3)
(
2008 6.2
( 1
2009 5.5 )
( 8
2010 6.7 )
( 3
2011 6.2 )
( 8
1
20 2 9.1 )
13 (6. 3)
6
20 (6.12)
2007 9)
(1
0
20 8 0.
( 5
2009 5.9 )
( 0
2010 8.8 )
( 1
1
20 1 8.1 )
( 6
2012 10. )
13 (10 3)
(1 .2)
1.
9)
0
20
2007
(
2008 5.6
( 0
2009 5.7 )
( 9
1
20 0 5.3 )
( 1
2011 6.4 )
( 9
1
20 2 5.5 )
13 (6. 1)
5
20 (6.40)
2007 3)
(6
0
20 8 . 2
( 1
2009 5.5 )
( 8
2010 6.7 )
( 3
2011 6.2 )
( 8
2012 9.1 )
13 (6. 3)
6
20 (6.12)
2007 9)
(1
0
20 8 0.
( 5
2009 5.9 )
( 0
2010 8.8 )
( 1
1
20 1 8.1 )
( 6
2012 10. )
13 (10 3)
(1 .2)
1.
9)
0
Small
Medium
Large
Category of hospital size: Small: <= 400 beds; Medium: 401-800 beds; Large: > 800 beds. Chronic hospitals excluded.
X axis: Year (National median length of stay). Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 6.10. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, per category
of hospital size, intensive care units, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
One can observe an overall decrease in the average AM patient-day use in “small” hospitals (with 400 beds or less),
while their LoS is being almost constant; in particular, the use of J01CR is decreasing. The same type of analysis in
medium-sized hospitals seems to show a relative variation of the AMC, with a median around
1200 DDD / 1000 patient-days; for both these categories of hospital size, the AM use per stay varies from year to
year but indicates a quite stable level of consumption (see Fig. 6.9). As mentioned just before, large hospitals, which
are partly constituted by secondary and partly with tertiary hospitals, present an important expansion of the AM
consumption, mainly based on β-lactamase resistant penicillins (J01CF), the 3GC (J01DD), the other antibiotics group
(J01X) and the antimycotic agents (J02). Less than ten hospitals are using amphenicols (J01BA), in amounts that differ
widely.
The evolution of the AMC per ATC-subclasses in ICUs of non-teaching and of teaching hospitals are displayed in
Figures 6.11 and 6.12. In non-teaching institutions, the ICU consumption of the large-spectrum penicillins combined
with an enzyme inhibitor (J01CR) is dominating all other ATC-subclasses of drugs. The carbapenems (J01DH) are the
second most used group of antibiotics. The use of FQ (J01MA) and of β-lactamase resistant penicillins (J01CF) is
increasing both in terms of patient-days and in terms of stay. Fourth-generation cephalosporins (J01DE) are being
switched with 3GC (J01DD).
Page | 28
Antimicrobial agents (J01 & J02) consumption in Belgian acute non-teaching hospitals
in intensive care units, per ATC-subclasses
400
350
2,000
DDD / 1000 admissions
300
250
200
150
1,500
1,000
100
500
50
2007
2008
2009
2010
2011
2012
2013
J0
1M
J0
1D
D
J0
1X
J0
1F
J0
1C
A
J0
1C
F
J0
1D
B
J0
1D
E
J0
1G
J0
1D
C
J0
1E
J0
1C
E
H
J0
2
R
J0
1D
J0
1C
J0
1F
J0
1C
F
J0
1C
A
J0
1D
B
J0
1D
E
J0
1G
J0
1E
J0
1D
C
J0
1C
E
D
J0
1X
J0
1D
H
J0
1M
J0
1D
J0
1C
R
0
J0
2
0
2007
2008
2009
2010
2011
2012
2013
Acute non-teaching hospitals only. Participation: 2007 n=36; 2008 n=58; 2009 n=63; 2010 n=66; 2011 n=63; 2012 n=61; 2013 n=55.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.11. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute non-teaching hospitals,
intensive care units, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
In teaching hospitals, trends are less clearly depicted: several ATC groups, like the antimycotic agents (J02), the 3GC
(J01DD) or the heterogeneous group called “other antibiotics” (J01X) display an augmented use in patient-days but a
diminished consumption per stay. According to both indicators, however, the 4GC (J01DE) are less and less used.
Antimicrobial agents(J01 & J02) consumption in Belgian acute teaching hospitals
in intensive care units, per ATC-subclasses
400
10,000
9,000
350
8,000
DDD / 1000 admissions
300
250
200
150
7,000
6,000
5,000
4,000
3,000
100
2,000
50
1,000
2007
2008
2009
2010
2011
2012
2013
2007
2008
A
J0
1C
F
J0
1M
J0
1E
J0
1G
J0
1B
J0
1D
C
J0
1D
E
J0
1D
B
J0
1C
D
J0
1F
H
J0
1D
J0
1D
J0
1X
J0
2
R
J0
1C
J0
1G
J0
1D
C
J0
1D
E
J0
1D
B
J0
1C
E
J0
1F
J0
1E
J0
1X
J0
1D
H
J0
1C
A
J0
1D
D
J0
1C
F
J0
1M
J0
1C
J0
2
0
R
0
2009
2010
2011
2012
2013
Acute teaching hospitals only. Participation: 2007 n=7; 2008 n=7; 2009 n=8; 2010 n=8; 2011 n=8; 2012 n=8; 2013 n=8.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.12. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute teaching hospitals,
intensive care units, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 29
6.3. Antimicrobial consumption in haematology and oncology units
With no surprise to clinicians, antimycotic agents (J02) are the most used ATC-subclass in haematology and oncology
units (HAO). In non-teaching hospitals, about a quarter of the AMC (J01 & J02) used in HAO is due to systemic
antifungal drugs (J02), of which 80% is fluconazole (J02AC01). In HAO units of teaching hospitals, these proportions
are respectively a third of the AMC, of which about two third rely on fluconazole. Those are approximate figures,
because they do not take additional antimicrobial agents under surveillance such as the antiprotozoals (P01AB) and
the antimycobaterial drugs (J04) into account for the total AMC.
Antimicrobial agents (J01 & J02) use in Belgian hospitals
in acute healthcare hospitals (haematology & oncology units) per academic status
16,000
1,500
15,000
1,400
14,000
1,200
1,100
1,000
900
800
700
600
500
400
Defined Daily Doses / 1000 admissions
1,300
13,000
12,000
11,000
10,000
9,000
8,000
7,000
6,000
5,000
4,000
2,000
100
1,000
0
0
Non-teaching
Teaching
20
07
20 (1
08 0.3
20 (10 )
09 .5
20 (1 )
10 0.2
20 (9. )
11 94
20 (9 )
12 .52
20 (9. )
13 25
(9 )
.8
2)
20
07
20 (8
08 .51
20 (10 )
09 .5
20 (9 )
10 .60
20 (9. )
11 80
20 (1 )
12 0.1
20 (9 )
13 .96
(1 )
0.
6)
3,000
200
20
07
20 (10
08 .3
20 (10 )
09 .5
20 (10 )
10 .2
20 (9. )
11 94
20 (9. )
12 52
20 (9. )
13 25
(9 )
.8
2)
20
07
20 (8.
08 51
20 (10 )
09 .5
)
20 (9.
10 60
)
20 (9.
11 80
20 (10 )
12 .1
20 (9. )
13 96
(1 )
0.
6)
300
Non-teaching
Teaching
X axis: Year (National median length of stay). Y axis: Stacked bars are made by summing the median hospital consumption for each ATC-class
Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 6.13. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, per academic
status, haemato- & oncology, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Expressed in DDD / 1000 admissions, a decreasing trend of AMC is visible in HAO units of acute non-teaching
hospitals. In teaching hospitals and using the same unit, it seems on the contrary that HAO are using more
antimicrobial agents in recent years (Figure 6.13). The analysis per level of healthcare allows to specify that the
manifest reduction of AM use is due to primary healthcare settings. Secondary healthcare settings have indeed a
consumption pattern showing a rise of consumption, just like tertiary hospitals (Figure 6.14). The variations observed
do not always coincide with the variations of LoS.
Referring to the categories of hospital size which are requested by the BAPCOC working group, conclusions are there
also easier drawn based on the consumption in DDD / 1000 admissions (see Figure 6.15). Medium-sized hospitals,
having from 401 to 800 beds, are those where the AMC has shrunk. The group of “small” hospitals presents an
important increase during the three first years of the surveillance, followed during the four next years by a dramatic
fall. A hypothesis that could explain this evolution is that this might be the reflection of a tendency towards the
specialisation of Belgian hospitals. In the course of reorganisations, that regularly occur among Belgian hospitals,
“small” institutions who, before 2010, were using more and more AM drugs in their HAO might have handed over
those units to other bigger healthcare settings. If this supposition is confirmed, one could further assume, based on
the impressive drop of the AMC, that HAO units remaining in hospitals with 400 beds or less are performing well in
terms of antimicrobial stewardship.
Page | 30
Figure 6.14. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, per level
of healthcare, haemato- & oncology, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Antimicrobial agents (J01 & J02) use in Belgian hospitals
in acute healthcare hospitals (haematology & oncology units) per hospital size
15,000
1,400
14,000
1,300
13,000
1,200
1,100
1,000
900
800
700
600
500
400
Defined Daily Doses / 1000 admissions
1,500
12,000
11,000
10,000
9,000
8,000
7,000
6,000
5,000
4,000
2,000
100
1,000
0
0
Small
Medium
Large
20
2007
(
2008 9.8
( 4
2009 10. )
( 0
2010 10. )
( 4
1
20 1 10. )
( 8
2012 8.7 )
13 (9. 8)
0
20 (7.74)
2007 8)
(
2008 10.
( 3
2009 10. )
( 8
2010 10. )
( 6
2011 8.8 )
( 8
1
20 2 9.0 )
13 (8. 0)
7
20 (8.96)
2007 6)
(1
0
20 8 0.
( 3
2009 10. )
( 0
2010 9.4 )
( 7
1
20 1 9.8 )
( 4
2012 10. )
13 (11 8)
(1 .3)
0.
7)
3,000
200
20
2007
(
2008 9.8
( 4
2009 10. )
( 0
1
20 0 10. )
( 4
2011 10. )
( 8
1
20 2 8.7 )
13 (9. 8)
0
20 (7.74)
2007 8)
(1
0
20 8 0.
( 3
2009 10. )
( 8
2010 10. )
( 6
2011 8.8 )
( 8
2012 9.0 )
13 (8. 0)
7
20 (8.96)
2007 6)
(1
0
20 8 0.
( 3
2009 10. )
( 0
2010 9.4 )
( 7
1
20 1 9.8 )
( 4
2012 10. )
13 (11 8)
(1 .3)
0.
7)
300
Small
Medium
Large
Category of hospital size: Small: <= 400 beds; Medium: 401-800 beds; Large: > 800 beds. Chronic hospitals excluded.
X axis: Year (National median length of stay). Source: WIV-ISP. Surveillance of antimicrobial agents use in Belgian hospitals
Figure 6.15. Distribution per ATC-subclasses of antimicrobial agents (J01 & J02) consumption in acute hospitals, per category of
hospital size, haemato- & oncology, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Looking at the volume of drugs employed, the J02 subclass is followed by the combinations of penicillins and enzyme
inhibitors (J01CR). According to both our indicators along the time, the use of that latter group is decreasing in nonteaching hospitals but increasing in teaching ones. The carbapenems (J01DH) look to be more and more prescribed
in HAOs of non-teaching institutions, although not reaching the levels used in academic hospitals, where their use
Page | 31
present a V-shape pattern. Those results are visible in the Figures 6.16 and 6.17 hereafter. Here again, all indicators
and all settings seem to indicate that 4GC (J01DE) are spared.
Antimicrobial agents (J01 & J02) consumption in Belgian acute non-teaching hospitals
in haemato- & oncology units, per ATC-subclasses
350
3,000
300
2,500
DDD / 1000 admissions
250
200
150
2,000
1,500
1,000
100
500
50
2007
2008
2009
2010
2011
2012
J0
2
J0
1C
R
J0
1M
J0
1D
H
J0
1X
J0
1D
E
J0
1D
D
J0
1F
J0
1C
F
J0
1E
J0
1C
A
J0
1D
C
J0
1G
J0
1C
E
J0
1A
0
J0
2
J0
1C
R
J0
1M
J0
1D
E
J0
1D
H
J0
1X
J0
1D
D
J0
1F
J0
1C
F
J0
1E
J0
1C
A
J0
1D
C
J0
1G
J0
1C
E
J0
1A
0
2013
2007
2008
2009
2010
2011
2012
2013
Acute non-teaching hospitals only. Participation: 2007 n=12; 2008 n=13; 2009 n=16; 2010 n=17; 2011 n=15; 2012 n=14; 2013 n=12.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.16. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute non-teaching hospitals,
haemato- & oncology, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Antimicrobial agents(J01 & J02) consumption in Belgian acute teaching hospitals
in haemato- & oncology units, per ATC-subclasses
500
7,000
450
6,000
400
5,000
DDD / 1000 admissions
350
300
250
200
4,000
3,000
150
2,000
100
1,000
50
2007
2008
2009
2010
2011
2012
2013
J0
2
J0
1C
R
J0
1D
H
J0
1X
J0
1M
J0
1D
E
J0
1F
J0
1E
J0
1C
F
J0
1C
A
J0
1D
D
J0
1G
J0
1D
F
J0
1D
C
J0
1A
0
J0
2
J0
1C
R
J0
1D
E
J0
1M
J0
1D
H
J0
1X
J0
1E
J0
1F
J0
1C
F
J0
1C
A
J0
1D
D
J0
1D
C
J0
1D
F
J0
1G
J0
1A
0
2007
2008
2009
2010
2011
2012
2013
Acute teaching hospitals only. Participation: 2007 n=7; 2008 n=7; 2009 n=8; 2010 n=8; 2011 n=8; 2012 n=8; 2013 n=8.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.17. Time trends, per ATC-subclasses, of antimicrobial agents (J01 & J02) consumption in acute teaching hospitals,
haemato- & oncology, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 32
6.4. Antimicrobial consumption in paediatrics
Following a recommendation made by the BAPCOC working group “Hospital Medicine”, products distributed as
syrups have been inventoried and removed from the paediatric dataset only, where this type of formulation is
mainly used, because full bottles are systematically billed to patients instead of single doses of treatment, regardless
of the regimen actually prescribed. This discard is impacting the evaluation of the AMC consumption in paediatrics,
in the sense of a slight underestimation rather than a prior possible gross overestimation.
The recommendations of the BAPCOC’s working group were also not to use the DDD as measurement unit, because
DDDs are actually defined based on a 70-kg adult physiology and needs. We have accordingly computed the
consumption in mg of product and have converted the systemic colistin into its equivalent in mg [16]. Then the
quantity in mg have been weighted by the denominator data, as for the previous computations. In this situation,
however, the methodology forbids to sum quantities of a product given through different ways of administration,
nor can be summed amounts used for different products, even if they belong to the same ATC-subclass. Results of
the 15 most used products are presented in Figures 6.18 to 6.21, based on the academic status and for enteral and
parenteral products separately.
Products belonging to the group of penicillins (J01C) should be the most represented drugs. As regard to the
parenteral route of administration, cephalosporins are also expected to be widely represented.
The surveillance BeH-SAC can only be used to identify which antimicrobial agent or group of agents should be
present. The monitoring of AMC in paediatrics is probably more useful at local level, where AMTs know their settings
and can interpret fluctuations. This is true as long as the data follow the same methodology, from year to year (no
different interpretations affecting the data collection, depending on the person who gather the data). It is not clear
whether all hospitals encode their neonatology units into paediatrics or in ICU. This point is an additional factor of
uncontrolled variability. Monitoring the AMC in paediatrics would benefit from the availability of both DDA and
additional information on the patient’s class of age, allowing for more useful results.
The implementation of antimicrobial stewardship programmes especially intended to neonatology and paediatric
patients could be a relevant strategy to fight the problem of antimicrobial resistance in a niche that is often regarded
as ancillary or even negligible. Basic principles that could sustain such a strategy are promoted by the European
Society for Paediatric Infectious Diseases [17]
Page | 33
Most used enteral antimicrobial agents (J01 & J02) in paediatrics
in acute non-teaching Belgian hospitals
40,000
quantity (in mg) / 1000 admisions
10,000
8,000
6,000
4,000
30,000
20,000
10,000
2,000
n
Li
n
et ezo
ro
lid
ni
d
Ly azo
m
le
C ecy
la
rit clin
h
Ph
ro e
m
en
Fl
yc
ox
u
in
ym clo
xa
et
ci
hy
lp l l i n
en
C
ip icill
ro
i
flo n
xa
ci
C
n
ef
Az adr
ith oxi
l
ro
m
yc
Fo
in
sf
o
C myc
lin
da in
m
yc
i
O
flo n
xa
ci
n
in
yc
ci
lli
ox
i
Am
ox
i
M
Am
in
hi
b
y
am
io
c
en
z
&
M
o
Ly xici
ll
m
e c in
M
et ycli
ro
ne
ni
da
C
la
zo
rit
l
h
Ph
ro e
m
en
Fl
ox
uc yci
n
ym
lo
xa
et
ci
hy
lp l l i n
en
ic
illi
C
n
ef
C adr
ip
ro oxil
flo
Le xa
vo cin
flo
Fo xac
in
sf
o
Az my
ci
ith
ro n
m
y
O cin
flo
xa
ci
n
lid
Am
yc
ez
o
Li
n
y
am
io
c
en
z
M
&
ox
i
Am
in
0
in
hi
b
0
Acute non-teaching hospitals only.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.18. Time trends consumption of the 15-most used enteral antimicrobial agents (J01 & J02), in acute non-teaching
hospitals, paediatrics, expressed in mg / 1000 patient-days and in mg / 1000 admissions, Belgium, 2007-2013
Most used parenteral antimicrobial agents (J01 & J02) in paediatrics
in acute non-teaching Belgian hospitals
1.0e+06
quantity (in mg) / 1000 admisions
250000
200000
150000
100000
50,000
800000
600000
400000
200000
y
Am
ox
i
&
en
z
y
en
z
&
ox
i
Am
i
Am nhi
b
ox
ic
Am illin
pi
ci
C
Pi
l
pe efo lin
r & tax
en ime
z
Fl y in
uc
hi
b
lo
xa
ci
C
ll
ef
Im
tri in
ax
ip
en
C
on
ef
em
ur e
ox
an
im
d
e
en Ce
fe
zy
pi
m
m
e
e
in
hi
b
Te itor
m
oc
il
O lin
xa
ci
llin
C
e
Be
nz fazo
yl
pe lin
ni
ci
C
ll
ef
t a in
zi
di
m
e
0
i
Am nhi
b
ox
ic
Am illin
pi
ci
C
llin
Pi
pe efo
r & tax
en ime
z
Fl y in
uc
hi
b
lo
xa
ci
C
llin
ef
ur
ox
C
ef ime
tri
ax
on
C
e
ef
Im
ep
ip
im
en
e
em
O
xa
an
ci
llin
d
T
e
en
zy mo
ci
m
llin
e
in
hi
bi
to
C
r
ef
az
C
o
ef
l
t a in
z
M idim
er
op e
en
em
0
Acute non-teaching hospitals only.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.19. Time trends consumption of the 15-most used parenteral antimicrobial agents (J01 & J02), in acute non-teaching
hospitals, paediatrics, expressed in mg / 1000 patient-days and in mg / 1000 admissions, Belgium, 2007-2013
Page | 34
Most used enteral antimicrobial agents (J01 & J02) in paediatrics
in acute teaching Belgian hospitals
100000
quantity (in mg) / 1000 admisions
15,000
10,000
5,000
80,000
60,000
40,000
20,000
ol
e
ox
ac
en
in
zy
i
Am nhi
b
Ph
ox
en
ic
il
ox
ym Ofl lin
o
et
hy xac
in
lp
en
ic
Ly
illi
m
ec n
yc
Fl
lin
uc
e
lo
C xac
ip
ro illin
fl
Vo oxa
ci
ric
on n
az
C
ol
ef
ur e
ox
im
C
e
ef
ad
C
r
ox
lin
il
da
Az my
ci
ith
n
ro
Le my
vo cin
flo
xa
ci
n
da
z
or
fl
Am
ox
i
&
N
et
ro
ni
M
&
M
ox
i
Am
0
en
zy
in
et
hi
ro
b
ni
da
zo
le
O
flo
xa
N
or cin
Ph
flo
en
xa
ox
c
A
ym mo in
x
et
hy icill
in
lp
en
C
ip icill
ro
in
flo
xa
Ly
c
m
ec in
yc
Fl
lin
uc
e
lo
Vo xac
ric illin
on
az
C
o
ef
u r le
C oxim
lin
da e
m
yc
C
in
ef
ad
Le
ro
vo
xi
l
fl
Az oxa
ci
ith
ro n
m
yc
in
0
Teaching hospitals only.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.20. Time trends consumption of the 15-most used enteral antimicrobial agents (J01 & J02), in teaching hospitals,
paediatrics, expressed in mg / 1000 patient-days and in mg / 1000 admissions, Belgium, 2007-2013
Most used parenteral antimicrobial agents (J01 & J02) in paediatrics
in acute teaching Belgian hospitals
1.0e+06
quantity (in mg) / 1000 admisions
150000
100000
50,000
800000
600000
400000
200000
in
Pi
p
er
&
en
zy
in
en
zy
er
&
Pi
p
Am hib
pi
c
Am C
ef illin
ox
o
i & tax
en ime
zy
in
C
h
ef
ta ib
z
Va idim
nc
e
om
Fl
uc yci
n
lo
xa
ci
llin
C
ef
az
C
ef olin
ur
ox
M
im
e
Be rop e
nz en
e
yl
pe m
ni
ci
C
ll
ef
tri in
ax
on
Am e
ik
a
Te cin
M mo
et
ci
l
ro
ni lin
da
zo
le
0
Am hib
p
Am Ce icill
in
fo
ox
t
ax
i&
en ime
zy
in
C
h
ef
ta ib
zi
Va dim
nc
e
om
Fl
uc yci
n
lo
xa
c
C
ef illin
ur
ox
i
C me
ef
az
M
er olin
op
en
C
em
e
Be ftria
xo
nz
ne
yl
pe
ni
ci
l
Am lin
ik
a
Te cin
M mo
et
ci
llin
ro
ni
da
zo
le
0
Teaching hospitals only.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 6.21. Time trends consumption of the 15-most used parenteral antimicrobial agents (J01 & J02), in teaching hospitals,
paediatrics, expressed in mg / 1000 patient-days and in mg / 1000 admissions, Belgium, 2007-2013
In paediatrics as in non-paediatric wards, the most used product is the combination of amoxicillin and enzyme
inhibitor (J01CR02), but in a lower proportion, that turns around 25%. Therefore, the ratio sensitive penicillins over
combinations of penicillins with enzyme inhibitors (J01CA/J01CR) is having a better achievement in terms of
antimicrobial stewardship. The overall trends of consumption in paediatrics are mostly influenced by few products:
while the amoxicillin, in association with the clavulanic acid or not, are less used in recent years, ampicillin, mostly
injectable, is on the rise.
Page | 35
7. Insight into the antimicrobial consumption
7.1. Most used products, in non-paediatric departments
In the previous part of this report, the overview has been presented based on groups of antimicrobial agents,
according to the ATC classification. But certain products carry their own intrinsic interest. This section is hence
aiming at describing the consumption patterns of some of those important products.
The most used molecules in acute healthcare settings are presented in the Figure 7.1 and 7.2, based on their
academic status. The outstanding consumption of the combination amoxicillin and clavulanic acid (J01CR02), as
compared to all other products, somehow squeezes most of the bars at the bottom of the charts, making the reading
less comfortable. One can globally notice that in teaching as in non-teaching institutions, the most used drugs are
also more and more used on a daily basis, few exceptions set apart.
15 most used antimicrobial agents (J01 & J02) in Belgian acute non-teaching hospitals
in non-paediatric departments
1,500
DDD / 1000 admissions
200
150
100
1,000
500
50
2008
2009
2010
2011
2012
&
ox
i
Am
C
C
en
z
&
ox
i
Am
2007
en
zy
in
ip
ro hib
flo
xa
c
Pi
pe Ce in
r & faz
o
en
li
zy n
Fl
i
uc nhi
b
lo
xa
M
ci
ll
ox
ifl in
ox
Fl
ac
uc
i
on n
M azo
er
l
op e
en
C
em
ef
ur
ox
im
C
ef
e
tri
ax
C
lin one
da
M
et myc
ro
in
ni
da
Am zole
ox
ic
Te illin
m
C
oc
la
i
rit
hr llin
om
yc
in
0
y
in
hi
ef b
az
C
o
i
p
lin
Pi
pe rofl
r & oxa
en cin
zy
i
Fl
uc nhib
lo
xa
c
Fl
uc illin
on
M azo
er
l
op e
en
M
em
ox
ifl
ox
ac
C
ef
in
tri
ax
on
C
ef
ur e
ox
C
lin ime
da
C
m
la
yc
rit
in
hr
om
yc
Te
in
m
oc
Am illin
ox
M
ic
et
illi
ro
n
ni
da
zo
le
0
2013
2007
2008
2009
2010
2011
2012
2013
Acute non-teaching hospitals only. Participation: 2007 n=46; 2008 n=86; 2009 n=88; 2010 n=87; 2011 n=87; 2012 n=83; 2013 n=70.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 7.1. Time trends of the 15 most used antimicrobial agents (J01 & J02) in acute non-teaching hospitals, non-paediatric
departments, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
In non-teaching hospitals, those exceptions concern amoxicillin (J01CA04) and cefuroxim (J01DC02), a 2GC. The
temocillin (J01CA17) used against Gram-negative multi-drug resistant organisms (MDRO) and meropenem
(J01DH02), active against both Gram-positive and Gram-negative MDRO are both on the raise. Cipro- and
moxifloxacin, the two most used fluoroquinolones (J01MA) in non-teaching hospitals are likewise more and more
used along the years.
In teaching hospitals, flucloxacillin (J01CF05) as well as the combination of piperacillin and tazobactam (J01CR05) are
the two most used products after J01CR02; both show a massive growth of consumption between 2007 and 2013.
Vancomycin (J01XA01), meropenem (J01DH02) and moxifloxacin (J01MA14) display also a noticeable increase, while
cefepime (J01DE01, a 4GC) and cefazolin (J01DB04) have undergone an important reduction of use over the same
period of time.
Page | 36
15 most used antimicrobial agents (J01 & J02) in Belgian teaching hospitals
in non-paediatric departments
200
1,500
DDD / 1000 admissions
150
100
1,000
500
50
2009
2010
2011
2012
2013
uc
l
Fl
en
z
Am
2008
Pi
p
ox
i&
en
z
uc
l
Fl
Pi
p
ox
i&
Am
2007
y
in
hi
b
o
er
xa
&
ci
llin
en
zy
C
in
ip
ro hib
flo
xa
Fl
ci
uc
on n
M azo
er
op le
en
em
C
ef
Va azo
lin
nc
om
yc
C
in
ef
ep
i
Am me
M
pi
ci
et
llin
ro
ni
da
zo
C
ef
le
Am uro
ph xim
ot
e
e
C
la ricin
rit
B
hr
om
yc
C
ef
in
tri
ax
on
e
0
y
in
hi
b
o
er
xa
ci
&
llin
en
zy
in
Fl
hi
uc
on b
az
C
ip
r o o le
flo
xa
M
ci
er
op n
en
em
C
ef
az
Va
ol
in
nc
om
yc
in
C
ef
ep
im
Am
e
pi
M
ci
et
llin
ro
ni
da
zo
C
e
le
Am furo
x
ph
im
ot
e
e
C
la ricin
rit
B
hr
om
yc
C
ef
in
tri
ax
on
e
0
2007
2008
2009
2010
2011
2012
2013
Teaching hospitals only. Participation: 2007 n=8; 2008 n=9; 2009 n=9; 2010 n=9; 2011 n=9; 2012 n=9; 2013 n=9.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 7.2. Time trends of the 15 most used antimicrobial agents (J01 & J02) in teaching hospitals, non-paediatric departments,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Fluconazole (J02AC01), a large-spectrum systemic antifungal, is ranking n°6 and n°4 of the most used products in
respectively non-teaching and teaching hospitals. Moreover, in this latter type of healthcare settings, another
antifungal agent is also ranking n°13 despite its recognized side-effects and toxicity: the amphotericin B, used in
serious systemic fungal infections. Both molecules, show in both types of settings a V-shape consumption pattern.
Page | 37
7.2. Most used products, in intensive care units and in haematology and oncology units
Remarkably, meropenem is the second and the third most used product in ICUs of respectively non-teaching and
teaching hospitals, whereas vancomycin occupies the 13th and 7th position, respectively. In ICUs of academic
institutions, colistin, another last-resort MDRO-active drug can be found among the top 10 most used products. Here
again, the variability due to a small populations is important. It seems however that in these highly-specialized
wards, the most commonly administrated products are also more intensively used along the years, which might
indicate that the bacterial selective pressure is evolving toward a convergence on few key molecules.
15 most used antimicrobial agents (J01 & J02) in Belgian acute non-teaching hospitals
in intensive care units
300
2,000
1,500
DDD / 1000 admissions
200
100
1,000
500
en
z
Pi
p
Am
2007
2008
2009
2010
2011
2012
M
&
ox
i
en
z
Pi
p
M
&
ox
i
Am
y
in
hi
er
b
o
er
pe
ne
&
en
m
zy
in
Fl
hi
uc
on b
az
C
ip
r o o le
flo
xa
C
c
ef
ta in
zi
Fl
di
m
uc
e
lo
xa
c
C
ef illin
tri
ax
on
C
ef e
az
ol
in
C
ef
e
Va pim
nc
e
o
Le my
vo cin
flo
x
M
ox acin
ifl
ox
ac
in
A
M m ik
et
ro acin
ni
da
zo
le
0
y
in
hi
er
b
o
pe
er
ne
&
en
m
zy
in
Fl
hi
uc
on b
az
Fl
ol
uc
e
lo
xa
C
ci
ip
llin
ro
flo
xa
C
c
ef
ta in
zi
di
C
m
ef
e
tri
ax
on
C
e
ef
az
ol
in
O
xa
Le
ci
l
l
vo
in
flo
xa
ci
C
n
ef
e
Va pim
nc
e
o
M myc
ox
in
ifl
ox
ac
Am in
ik
ac
in
0
2013
2007
2008
2009
2010
2011
2012
2013
Acute non-teaching hospitals only. Participation: 2007 n=36; 2008 n=58; 2009 n=63; 2010 n=66; 2011 n=63; 2012 n=61; 2013 n=55.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 7.3. Time trends of the 15 most used antimicrobial agents (J01 & J02) in acute non-teaching hospitals, intensive care
units, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
15 most used antimicrobial agents (J01 & J02) in Belgian teaching hospitals
in intensive care units
200
5,000
4,000
DDD / 1000 admissions
150
100
3,000
2,000
50
1,000
2007
2008
2009
2010
2011
2012
2013
M
er
er ope
n
&
en em
zy
i
Am Flu nhi
ox con b
i&
az
en ole
zy
Fl
i
uc nhi
b
lo
xa
ci
Va
nc llin
om
yc
in
C
ol
is
C
tin
ef
ta
zi
C
ip dim
ro
e
M flox
et
ac
ro
in
ni
da
zo
O
le
rn
id
az
o
l
A
e
C mp
i
la
rit cilli
n
hr
Am om
y
ph
ot cin
er
ic
i
C
ef n B
tri
ax
on
e
0
Pi
p
Am
ox
i
&
en
z
y
in
Fl
hi
uc
on b
a
zo
M
e
Pi
l
pe rop e
en
r&
en em
zy
i
Fl
uc nhib
lo
xa
ci
Am llin
p
Va icil
lin
nc
om
yc
C
ef
t a in
zi
C
ip dim
ro
e
flo
xa
ci
n
C
M
et olis
tin
ro
ni
da
zo
C
e
le
Am furo
ph xim
ot
e
e
C
la ricin
rit
B
hr
om
yc
C
ef
in
tri
ax
on
e
0
2007
2008
2009
2010
2011
2012
2013
Teaching hospitals only. Participation: 2007 n=7; 2008 n=7; 2009 n=8; 2010 n=8; 2011 n=8; 2012 n=8; 2013 n=8.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 7.4. Time trends of the 15 most used antimicrobial agents (J01 & J02) in teaching hospitals, intensive care units,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 38
The important year-to-year variability of the AMC use in HAO is likely to limit the drawing of clear and specific
conclusions on this domain. Nevertheless, the ranking of the most used products in HAO and their level of
consumption is likely to give a reliable picture of local practices. Meropenem (J01DH02) and the combination
piperacillin and enzyme inhibitor (J01CR05) are for instance more and more used, whatever the academic status the
hospital has (see Fig. 7.5 & 7.6).
15 most used antimicrobial agents (J01 & J02) in Belgian acute non-teaching hospitals
in haemato- & oncology units
300
2,500
DDD / 1000 admissions
2,000
200
100
1,500
1,000
500
2008
2009
2010
2011
2012
uc
o
Fl
&
Am
ox
i
uc
o
Fl
&
ox
i
Am
2007
na
z
en ole
zy
C
i
n
ip
ro hib
flo
xa
M
c
Pi
e
pe rop in
r&
en
en em
zy
in
hi
C
b
e
Am
fe
ph pim
ot
e
e
Vo rici
ric n B
on
a
Fl
uc zol
e
lo
xa
ci
Va
nc llin
o
M
et myc
ro
in
ni
Po da
zo
sa
le
co
na
M
ox zole
ifl
ox
C
la
ac
N
i
ys rith
ro n
ta
m
tin
(in ycin
te
st
in
al
)
0
na
z
en ole
zy
in
hi
b
O
xa
ci
llin
C
ef
e
C
ip pim
Pi
pe roflo e
r&
xa
en cin
zy
in
M
hi
er
b
o
Po pe
sa nem
co
na
V
z
N
ys anc ole
ta
om
tin
yc
(in
in
te
st
Fl
uc inal
)
Am lox
ac
ph
i
ot llin
M eric
et
ro in B
ni
da
M
zo
ox
le
ifl
ox
ac
C
ef
i
ur n
ox
im
e
0
2013
2007
2008
2009
2010
2011
2012
2013
Acute non-teaching hospitals only. Participation: 2007 n=12; 2008 n=13; 2009 n=16; 2010 n=17; 2011 n=15; 2012 n=14; 2013 n=12.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 7.5. Time trends of the 15 most used antimicrobial agents (J01 & J02) in acute non-teaching hospitals, haemato- &
oncology units, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
15 most used antimicrobial agents (J01 & J02) in Belgian teaching hospitals
in haemato- & oncology units
4,000
400
3,000
DDD / 1000 admissions
2,000
0
0
le
Am
ox
i
C
na
zo
Fl
uc
o
2007
2008
2009
2010
2011
2012
2013
Fl
uc
o
1,000
ef
ep
&
en ime
zy
in
M
hi
er
b
Am op
en
ph
em
ot
er
Le icin
Pi
vo
B
pe
f
r & loxa
en cin
zy
Va inh
ib
nc
om
M
et
yc
ro
in
ni
da
Fl
uc zole
lo
xa
C
ci
ip
llin
ro
flo
xa
Vo
ci
ric
on n
C
az
la
rit
ol
e
hr
om
y
Am cin
pi
C
as cilli
n
po
fu
ng
in
100
n
ph azo
le
ot
er
ic
in
Am Me
ox rop B
en
i&
e
Pi
e
pe nz m
y
r&
in
en hib
zy
in
Le
vo hib
flo
xa
ci
C
n
ef
e
Va pim
nc
e
o
M
et myc
ro
in
ni
da
Fl
uc zol
e
lo
x
Vo ac
ric illin
o
C naz
ip
ro ole
flo
xa
Am cin
p
i
C
as cilli
n
po
C
fu
la
ng
rit
i
n
hr
om
yc
in
200
Am
300
2007
2008
2009
2010
2011
2012
2013
Teaching hospitals only. Participation: 2007 n=7; 2008 n=7; 2009 n=8; 2010 n=8; 2011 n=8; 2012 n=8; 2013 n=8.
Note: National median consumption. Source: WIV-ISP. Surveillance of antimicrobial agents in Belgian hospitals
Figure 7.6. Time trends of the 15 most used antimicrobial agents (J01 & J02) in teaching hospitals, haemato- & oncology units,
expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 39
7.3. Variability of consumption, for selected products
7.3.1. Ampicillin and amoxicillin (J01CA01 & J01CA04)
Studying the variability of the antimicrobial consumption is a way to identify contexts where certain products are
used with a large panel of practices. Among those practices, some can be validated, while others should be
improved. The surveillance BeH-SAC does not have the means to assess the quality of the prescriptions made in a
hospital, but can provide grounded figures allowing for the establishment of thresholds of “usual levels of
consumption”. Hospitals getting results outside of this framework are encouraged to have a deeper look at their AM
practices, to verify whether and how to improve them.
Concerning ampicillin and amoxicillin, which are penicillins with extended spectrum, NPD of primary hospitals are
relatively grouped around a constant median of 20 DDD / 1000 patient-days and in the same time, count a certain
number of outliers. The variability in ICUs, regardless of the level of healthcare the hospital belongs to, is
unsurprisingly wide (see also the Figures in the Appendices H1).
Variability of antimicrobial agents consumption in Belgian acute hospitals
Ampicillin & Amoxicillin (J01CA01 & J01CA04)
Non-Paediatrics
Intensive Care Units
Haemato-oncology
250
200
150
100
50
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & level of healthcare. See also Appendices for detailed figures
Per academic status. Acute hospitals only.
Figure 7.7. Trends and distribution of ampicillin and amoxicillin (J01CA01 & J01CA04) consumption in acute hospitals, per type of
departments and level of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 40
7.3.2. Combinations of penicillins and enzyme inhibitors (J01CR)
Amoxicillin & enzyme inhibitor and piperacillin & enzyme inhibitor (J01CR05 & J01CR02)
Globally, combinations of penicillins including an enzyme inhibitor (J01CR) are used in intensive care units (ICU)
1.5 times as much as in all non-paediatric wards grouped together. Regarding the combination amoxicillin and
clavulanic acid, tertiary hospitals seems to share more common practices as compared to primary and secondary
hospitals, especially in ICUs, where the level of consumption is lower and the variability of consumption is
significantly reduced. Regarding the combination of piperacillin and tazobactam, all types of categorisation seem to
indicate not only a raise of consumption, but also a raise of variability of consumption.
Distribution and variability of amoxicillin & enzyme inhibitor (J01CR02) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
800
600
400
200
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Distribution and variability of piperacillin & enzyme inhibitor (J01CR05) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
400
300
200
100
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.8. Trends and distribution of combinations of penicillins and enzyme inhibitors (J01CR) consumption in acute hospitals,
per type of departments and level of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions,
Belgium, 2007-2013
Page | 41
7.3.3. Third and fourth generation cephalosporins (J01DD & J01DE)
Together, the C3G and C4G display a very large variability in the use, both in ICU and in HAO of all three types of
categorisation, per academic status, per level of healthcare and per category of hospital size (see complementary
Figures in Appendices H3). The fact that NPD are less concerned by such a high variability is naturally justified by the
severity and complexity of cases admitted in those ICU and HAO departments, as those molecules are last-resort
treatments. It is also likely that local therapeutic practices and guidelines widely differ from one hospital to another.
In this case, proposing national guidelines and targets might be fruitful with regard to the improvement of the
antimicrobial prescription of third- and fourth-generation cephalosporins.
Distribution and variability of third- & fourth-generation cephalosporins (J01DD & J01DE) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
500
400
300
200
100
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.9. Trends and distribution of third- and fourth-generations cephalosporins (J01DD & J01DE) consumption in acute
hospitals, per type of departments and level of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions,
Belgium, 2007-2013
Page | 42
7.3.4. Carbapenems (J01DH)
According to the BeH-SAC data, there is a wide variation of carbapenems consumption, with a use in NPD of tertiary
hospitals that is significantly higher than in other types of hospitals. The variability of carbapenems in ICUs of
primary hospitals is larger than in ICUs of tertiary hospitals.
Distribution and variability of carbapenems (J01DH) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
500
400
300
200
100
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.10. Trends and distribution of carbapenems (J01DH) consumption in acute hospitals, per type of departments and level
of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 43
7.3.5. Colistin (J01XB01)
The consumption of colistin is associated with the cares provided in ICUs. In those specialised intensive wards, the
variation of use goes from nearly zero to more than 100 DDD / 1000 patient-days. The median consumption is
increasing from year to year in primary and in tertiary settings. Secondary hospitals seem on the contrary be better
controlling their consumptions since the period 2010-2011, when it was at its maximum observed (see also Figures
H5 in the Appendices).
Distribution and variability of colistin (J01XB01) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
250
200
150
100
50
Primary
Secondary
2011
2012
2013
2009
2010
2013
2007
2010
2011
2012
2008
2009
2012
Tertiary
2013
2007
2008
2009
2010
2011
2012
2013
Secondary
2009
2007
2008
2009
2010
2011
2012
2013
Primary
2010
2007
2008
2009
2010
2011
2012
2013
Tertiary
2011
2007
2008
2009
2010
2011
2012
2013
Secondary
2007
2007
2008
2009
2010
2011
2012
2013
Primary
2008
2007
2008
2009
2010
2011
2012
2013
0
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.11. Trends and distribution of colistin (J01XB01) consumption in acute hospitals, per type of departments and level of
healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 44
7.3.6. Fluoroquinolones (J01MA)
The use of fluoroquinolones (FQ) is mentioned as a risk factor for the appearance of acquired bacterial resistance, as
well as for the selection of intrinsic resistant bacteria like Clostridium difficile [18]. Although the use of FQ in the
ambulatory sector is, in Belgium, very high, the consumption of FQ in Belgian hospital is reasonable as compared to
other European countries. Moxifloxacin is, however showing an increasingly level of consumption.
7.3.6.1.
All fluoroquinolones except moxifloxacin
The categorisation per level of healthcare allows to distinguish different patterns between hospitals. Primary
hospitals have both for the FQ in general and for moxifloxacin in particular a large variability. NPDs of secondary
hospitals show a clear reduction of the variability of FQ consumption.
Distribution and variability of fluoroquinolones except moxifloxacin (J01MA but J01MA14) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
400
300
200
100
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.12. Trends and distribution of fluoroquinolones (J01MA) consumption except moxifloxacin (J01MA14) in acute
hospitals, per type of departments and level of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions,
Belgium, 2007-2013
Page | 45
7.3.6.2.
Moxifloxacin (J01MA14)
Distribution and variability of moxifloxacin (J01MA14) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
250
200
150
100
50
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.13. Trends and distribution of moxifloxacin (J01MA14) consumption in acute hospitals, per type of departments and
level of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions, Belgium, 2007-2013
Page | 46
7.3.7. Vancomycin and teicoplanin (J01XA01 & J01XA02)
Upon request from the working group ‘Hospital Medicine’, the consumption of vancomycin and teicoplanin have
been summed up. Teaching hospitals are unsurprisingly showing a level of use significantly higher than non-teaching
hospitals, regardless of the unit (NPD, ICU or HAO) where the observation is made. The analyses are showing that
primary and small hospitals have a certain number of outliers (see additional Figures in Appendices, H7). Such
different characteristics of use are indicating a field to be further investigated thanks to audits or diagnostic-based
studies.
Distribution and variability of vancomycin & teicoplanin (J01XA01 & J01XA02) consumption
per healthcare level, in Belgian acute hospitals
Non-Paediatrics
Intensive Care Units
Haemato-oncology
250
200
150
100
50
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
0
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Graph per type of departments & healthcare level. See also Appendices for detailed figures
Acute hospitals only.
Figure 7.14. Trends and distribution of vancomycin and teicoplanin (J01XA01 & J01XA02) consumption in acute hospitals,
per type of departments and level of healthcare, expressed in DDD / 1000 patient-days and in DDD / 1000 admissions,
Belgium, 2007-2013
Page | 47
7.4. Relative antimicrobial consumption
Combinations of penicillins and enzyme inhibitors (J01CR) form the far most used subclass of antibacterial agents.
The use of J01CR drugs remains quite stable in teaching hospitals, fluctuating around 210 DDD / 1000 patient-days
between 2007 and 2013, while in non-teaching hospitals, it was rising from 205 in 2007 to 230 DDD / 1000 patientdays in 2012, then is dropping to its initial level in 2013. Due to the weight of this ATC class and the fact that more
than 90% of Belgian hospitals are non-teaching ones, if the latter decline could be confirmed and sustained during
the future years and without compensation on other ATC subclasses, it will have a substantial impact on the global
national AMC in the hospital sector. J01CR indeed count for 41% and 31% of the total antibiotics (J01) use in
respectively non-teaching and teaching hospitals in 2012. Studying further the proportions of most used ATC classes
or products in non-paediatrics can be made based on Graph 7.15 (see also tables in the Appendices).
After the J01CR, the most frequently used antibiotics are the cephalosporins whose use is stable along the years
(around 17% of all J01) and equivalent regardless of the academic status of hospitals. The group is constituted on the
one hand by the first- (J01DB; C1G) and second-generation (J01DC; C2G) cephalosporins which are, relatively
speaking, the most and increasingly consumed within the group, and on the other hand by the third- (J01DD; C3G)
and fourth-generation (J01DE; C4G) cephalosporins which are less and less used in both types of hospitals. In
Belgium, cefepime is the only fourth-generation cephalosporin used; its consumption has decreased by half since the
start of the surveillance.
Then comes the group of fluoroquinolones (J01MA) with a relative weight of about 13% of all used antibiotics (J01).
This class shows at the national level a very slight decrease from 2007 to 2013, despite a more manifest and regular
decrease in the academic sector.
%
%
%
90
J01CR/J01C
80
C1G+C2G/cephalo
J01C/J01
70
J01CR/J01
60
C3G + C4G/cephalo
J01XA/J01X
50
all cephalo/J01
J01CA/J01CR
40
J01CA/J01C
J01MA/J01
30
J01CF/J01C
J01DE01/cephalo
20
J01X/J01
10
J01DH/J01
J01CE/J01C
0
2007 2008 2009 2010 2011 2012 2013
Non-teaching acute hospitals
Teaching hospitals
J01: Antibacterial agents for systemic use
J01C: β-lactam antibacterials, penicillins
J01CE: β-lactamase sensitive penicillins
J01CF: β-lactamase resistant penicillins
J01CR: Combinations of penicillins, including β-lactamase inhibitors
J01DE01: Cefepime
J01DH: Carbapenems
J01X: Other antibacterials
J01XA: Glycopeptide antibacterials
C2G: 2nd-generation cephalosporins
C3G: 3rd-generation cephalosporins
All acute hospitals
J01CA: Penicillins with extended spectrum
J01MA: Fluoroquinolones
C1G: 1rst-generation cephalosporins
C4G: 4th-generation cephalosporins
Figure 7.15. Relative use (in % of DDD used) of different ATC antibacterial classes in non-paediatric departments of acute
hospitals, per academic status, Belgium, 2007-2013
Page | 48
The ratio J01CA / J01CR (penicillins with extended spectrum / combinations of penicillins and enzyme inhibitors)
serves as an indicator of appropriate antimicrobial stewardship practices. As regard to this indicator in Belgium,
although the year 2013 seems to provide encouraging results, there is no clear trend demonstrating any ultimate
successful application of local strategies on this aspects. β-lactamase resistant penicillins (J01CF), carbapenems
(J01DH) as well as glycopeptide antibacterial agents (J01XA) are twice more used in teaching settings as compared to
other hospitals (see Appendices, section E).
Table 7.1. Relative consumption (in % of DDD used) of systemic antibacterial agents in non-paediatric departments of acute
hospitals, per academic status, BeH-SAC, Belgium, 2007-2013.
Non-teaching hospitals
Teaching hospitals
All acute hospitals
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
2007
2008
2009
2010
2011
2012
2013
J01C / J01
49.5
50.6
51.0
50.7
50.7
51.4
49.6
43.9
44.0
44.2
44.2
44.1
45.5
45.3
48.1
49.3
49.7
49.5
49.4
50.2
48.6
J01CR / J01
39.8
41.2
41.4
41.0
41.1
41.3
38.5
29.9
29.6
30.2
29.1
29.8
30.8
29.6
37.3
39.0
39.3
38.8
38.9
39.1
36.4
J01CA / J01CR
12.4
11.6
11.3
11.5
11.1
12.1
13.8
17.4
20.0
17.8
21.0
20.2
20.1
22.7
13.4
12.8
12.2
12.8
12.5
13.4
15.6
All cephalo / J01
17.1
16.5
15.9
16.2
17.0
16.6
18.5
17.7
18.4
18.6
17.8
17.8
16.7
17.0
17.3
16.9
16.4
16.5
17.2
16.6
18.2
J01DH / J01
2.9
3.1
3.4
3.5
3.5
3.3
3.3
5.9
5.6
5.3
6.0
6.1
6.4
6.7
3.7
3.6
3.7
3.9
4.0
3.9
4.1
J01MA / J01
13.9
13.7
13.4
14.0
13.9
13.6
13.2
13.2
12.5
12.8
11.7
11.2
10.5
10.2
13.7
13.5
13.3
13.6
13.4
13.0
12.5
J01X / J01
7.3
7.1
7.3
7.1
6.7
6.7
6.9
7.5
8.1
8.1
8.9
9.1
8.9
8.7
7.4
7.3
7.4
7.4
7.1
7.1
7.3
J01: Antibacterial agents for systemic use
J01C: β-lactam antibacterials, penicillins
J01CR: Combinations of penicillins, including β-lactamase inhibitors
J01DH: Carbapenems
J01MA: Fluoroquinolones
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All cephalo: all cephalosporins
J01X: Other antibacterial agents
8. Concluding remarks
Data of the mandatory Belgian surveillance of systemic antimicrobial consumption (AMC) for the years 2007-2013
are descriptively analysed. In non-paediatric units (NPD) and in terms of daily treatment (Defined Daily Doses
[DDD] / 1000 patient-days), the global consumption of antibacterial agents (J01) in acute hospitals indicates at first
an increase (median from circa 520 in 2007 to 560 DDD for 1000 days of hospitalisation in 2012); then the year 2013
shows a stabilisation or even a decrease of the AMC at 554 DDD / 1000 patient-days. Taken into account the
variation across time in the lengths of stay, it appears that patients admitted in acute hospitals have received an
average overall constant dose of 4 DDD of antimicrobial agents per stay.
Due to fragmentary data, national conclusions regarding chronic healthcare setting have a low level of
representativeness. However, a tendency to a decreasing consumption is noticed. Trend analyses can be carried out
at the hospital level.
In the non-paediatric sector, combinations of penicillins including an enzyme inhibitor (J01CR) form the far most
used subclass of antimicrobial agents, followed by the four generations of cephalosporins combined together
(J01DB, J01DC, J01DD & J01DE) and by the fluoroquinolones (J01MA). The penicillins (J01C) counted for more than
40% of the total antibiotics (J01) use. Over consecutive years, several of the more often administrated drugs are also
more intensively used. This remark especially applies for ciprofloxacin, ceftriaxone, temocillin and flucloxacillin. In
the same NPDs, the increasing usage of moxifloxacin seems to flatten during the two last available years, but
requires anyway attention. Globally, the AMC is higher in teaching rather than in non-teaching hospitals. This
difference particularly lean on all subclasses of penicillins (J01C) except combinations including an enzyme inhibitor
(J01CR), the three first generations of cephalosporins and the nitrofuran derivatives (J01XE).
Small hospitals, who mostly have initiated an Antimicrobial Stewardship team (AMT) later (2006-2007 instead of
2002) have, according to their administrative reports, developed various stewardship local activities [19], although
the impact of those efforts are difficult to identify at the national level.
On average in acute care hospitals, more than one patient out of five admitted in NPD and in haemato-oncology
(HAO) is daily treated with a J01CR combinations as well as up to one out of three patients in intensive care units
(ICU). The high variability of prescription for particular key products leading to higher level of antibacterial
resistance, especially in ICUs of primary and secondary hospitals and in HAO units of tertiary hospitals would be
interesting aspects to further investigate through more appropriate methodology and more detailed data sources.
Globally, an important variability of consumption was seen in paediatrics, especially pronounced in non-teaching
hospitals. But the analysis of the AMC in paediatrics remains difficult to perform, because of methodological
limitations.
The aggregated data that are analysed in this report provide an overview both on the national level of consumption
as well on the variability between hospitals and groups of hospitals. It is not the objective of the surveillance to look
at the appropriateness of the prescribed treatment. Such a study requires more indication-driven data (as regard to
the pathology and to patient’s characteristics), but can be efficiently guided thanks to the results obtained here.
Because of the important workload that the data collection is imposing to the AMTs, the BeH-SAC’s Steering
Committee has approved a change in the data collection methodology, whereby the same administrative
information (invoicing data), routinely recorded are going to be re-used using a new and automatized data flow. The
changes are currently under testing. Along with these adaptations, it would be useful, although not easy, to define
clear statistical parameters, indicators and targets for the Belgian context, as well as specific products and hospital
wards, for which the national AMC consumption should be carefully monitored.
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The control of antimicrobial resistances in hospitals leans on several complementary approaches, among which
antimicrobial stewardship programmes are cornerstones [20]. The surveillance of hospital antimicrobial
consumption should be associated with complementary outcomes measurements such as the antimicrobial
resistance and the patients’ outcomes [21]. This field of activity is still in an early stage and different methodological
tools and indicators are used in different contexts [21,22,23]. Furthermore, international works and agreements on
these methodological issues are much expected and should be further supported.
Regarding the BeH-SAC, the accurate specification of which hospital sites do participate under a leading site is not
clearly available. Nor is the possibility to check that all the concerned wards and beds are indeed included into the
consumption datasets that hospitals have delivered. Let us notice that if within a “merger”, data for each and all
specific sites were not provided, it is assumed that aggregated data have been delivered under the code of the
principal hospital site. When the composition of a merger changes (a site is detached or on the contrary is
integrated), often the whole structure of the hospital is modified: the bed-capacity is different, some medical
specialities can be reorganized, etc. This is likely to alter the hospital case-mix and can ultimately influence the global
AMC consumption. Moreover, such changes take place most of the during at some point during the year, which
means that the yearly aggregated data that will be provided by the hospital cover at least two different settings. The
surveillance is not able to take these changes into account and cannot archive them for information. At the national
level, these approximations are balancing each other; the global Belgian trends are likely equally meaningful. On the
contrary, they have an impact on the local interpretation of results and AMTs have the responsibility to integrate
their own historical facts while analysing their performances. The tendency in Belgium is a greater specialisation of
sites and the constitution of larger mergers, with an overall declining number across the time.
Beside the DDD unit of measurement, the surveillance BeH-SAC would much benefit from the update and validation
of the existing Daily Dose Administred (DDA) list, another unit of measurement specifically developed and adapted
to the Belgian context, which could hence be integrated in future national and hospital-based analyses. The national
AMC trends should be better described when using the DDA. Especially concerning the monitoring of the paediatric
consumption, a reliable and comprehensive list of DDA would be a key tool of assessment. Obviously, the making of
that DDA list requires time and expertise, among other precious resources.
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