Search

We collected data from 10 EU/EEA countries on 240 COVID-19 outbreaks occurring from July−October 2021 in long-term care facilities with high vaccination coverage. Among 17,268 residents, 3,832 (22.2%) COVID-19 cases were reported. Median attack rate was 18.9% (country range: 2.8–52.4%), 17.4% of cases were hospitalised, 10.2% died. In fully vaccinated residents, adjusted relative risk for COVID-19 increased with outbreak attack rate. Findings highlight the importance of early outbreak detection and rapid containment through effective infection prevention and control measures.

We assessed the impact of COVID-19 on healthcare workers (HCWs) from data on 2.9 million cases reported from nine countries in the EU/EEA. Compared to non-HCWs, HCWs had a higher adjusted risk of hospitalization (IRR 3.0 [95% CI 2.2-4.0]), but not death (IRR 0.9, 95% CI 0.4-2.0).Article Summary LineHealthcare workers are hospitalized more frequently than non-healthcare workers when adjusting for age, sex, and comorbidities.

Background Europe's population is ageing. Long-term care facilities (LTCFs) for this vulnerable population are often relatively homelike with low staff-to-resident ratios. In 2016-2017, ECDC coordinated its third point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European long-term care facilities (LTCFs). It included collection of data on structure and process indicators (SPIs) of infection prevention and control (IPC) and antimicrobial stewardship, to support countries' identification of national and local interventions in LTCFs. Methods In each country, national contacts recruited a convenience sample of LTCFs. National/LTCF PPS teams used a standard protocol that included case definition algorithms (adapted US CDC/SHEA definitions) applied to each resident with signs/symptoms of infection on the PPS day, and questions for LTCF staff on SPIs of IPC and antimicrobial stewardship activities. Denominators indicate the number of responses available for analysis. Results 3,052 LTCFs in 24 EU/EEA countries were recruited, with 102,301 residents included. The prevalence of HAIs (residents with ≥1 HAI) was 3.7%. Although 1,524/1,623 (94%) LTFS had a hand hygiene (HH) protocol, only 1,046/1,585 (66%) LTCFs had organised ≥1 HH training session for care professionals during the previous year. 1,185/1,561 (76%) LTCFs reported IPC training of nursing and paramedical staff. Only 340/1,639 (21%) of LTCFs reported training on appropriate prescribing and 493/1,623 (30%) LTCFs had provided feedback to GPs on antimicrobial consumption. On the PPS day, annual antimicrobial consumption data were available to only 530/1,623 (32%) LTCFs. Conclusions Even in LTCFs with the capacity to perform this PPS, IPC training was non-ubiquitous and antimicrobial stewardship activities, including training, were rarely reported. ECDC encourages EU/EEA countries to recruit LTCFs to participate in future PPSs, to allow them to benchmark HAI rates and practices. Key messages The prevalence of healthcare-associated infections in European long-term care facilities (LTCFs) highlights their requirement for infection prevention and control (IPC) and antimicrobial stewardship. This multi-national point prevalence survey (PPS) indicates that European countries can consider reinforcing IPC, antimicrobial stewardship practices and participation in PPSs in LTCFs.

The cumulative incidence of coronavirus disease (COVID-19) cases is showing similar trends in European Union/European Economic Area countries and the United Kingdom confirming that, while at a different stage depending on the country, the COVID-19 pandemic is progressing rapidly in all countries. Based on the experience from Italy, countries, hospitals and intensive care units should increase their preparedness for a surge of patients with COVID-19 who will require healthcare, and in particular intensive care.

Summary Background In 2011–2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs). Aim To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data. Methods In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted using a linear model including data from the PPS. Findings The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40). Conclusion Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

Point-prevalence surveys (PPSs) are often used to estimate the prevalence of healthcare-associated infections (HAIs). Methods for estimating incidence of HAIs from prevalence have been developed, but application of these methods is often difficult because key quantities, like the average length of infection, cannot be derived directly from the data available in a PPS. We propose a new theory-based method to estimate incidence from prevalence data dealing with these limitations and compare it to other estimation methods in a simulation study. In contrast to previous methods, our method does not depend on any assumptions on the underlying distributions of length of infection and length of stay. As a basis for the simulation study we use data from the second study of nosocomial infections in Germany (Nosokomiale Infektionen in Deutschland, Erfassung und Prävention - NIDEP2) and the European surveillance of HAIs in intensive care units (HAI-Net ICU). The new method compares favourably with the other estimation methods and has the advantage of being consistent in its behaviour across the different setups. It is implemented in an R-package prevtoinc which will be freely available on CRAN (http://cran.r-project.org/).

Burden of AMR Collaborative Group:National Institute of Health Dr Ricardo Jorge, Lisbon, Portugal (Prof M Caniça PhD, Vera Manageiro PhD) Free PMC Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6300481/ Background: Infections due to antibiotic-resistant bacteria are threatening modern health care. However, estimating their incidence, complications, and attributable mortality is challenging. We aimed to estimate the burden of infections caused by antibiotic-resistant bacteria of public health concern in countries of the EU and European Economic Area (EEA) in 2015, measured in number of cases, attributable deaths, and disability-adjusted life-years (DALYs). Methods: We estimated the incidence of infections with 16 antibiotic resistance–bacterium combinations from European Antimicrobial Resistance Surveillance Network (EARS-Net) 2015 data that was country-corrected for population coverage. We multiplied the number of bloodstream infections (BSIs) by a conversion factor derived from the European Centre for Disease Prevention and Control point prevalence survey of health-care-associated infections in European acute care hospitals in 2011–12 to estimate the number of non-BSIs. We developed disease outcome models for five types of infection on the basis of systematic reviews of the literature. Findings: From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 (95% uncertainty interval [UI] 583 148–763 966) infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. These infections accounted for an estimated 33 110 (28 480–38 430) attributable deaths and 874 541 (768 837–989 068) DALYs. The burden for the EU and EEA was highest in infants (aged

Background Healthcare-associated infections (HAIs) pose a major challenge to health systems. Burden of disease estimations in disability-adjusted life years (DALYs) are useful for comparing and ranking HAIs. Aim To estimate the number of five common HAIs, their attributable number of deaths and burden for Germany. Methods We developed a new method and R package that builds on the approach used by the Burden of Communicable Diseases in Europe (BCoDE) project to estimate the burden of HAIs for individual countries. We used data on healthcare-associated Clostridioides difficile infection, healthcare-associated pneumonia, healthcare-associated primary bloodstream infection, healthcare-associated urinary tract infection and surgical-site infection, which were collected during the point prevalence survey of HAIs in European acute-care hospitals between 2011 and 2012. Results We estimated 478,222 (95% uncertainty interval (UI): 421,350–537,787) cases for Germany, resulting in 16,245 (95% UI: 10,863–22,756) attributable deaths and 248,920 (95% UI: 178,693–336,239) DALYs. Despite the fact that Germany has a relatively low hospital prevalence of HAIs compared with the European Union/European Economic Area (EU/EEA) average, the burden of HAIs in Germany (308.2 DALYs/100,000 population; 95% UI: 221.2–416.3) was higher than the EU/EEA average (290.0 DALYs/100,000 population; 95% UI: 214.9–376.9). Our methodology is applicable to other countries in or outside of the EU/EEA. An R package is available from https://CRAN.R-project.org/package=BHAI. Conclusion This is the first study to estimate the burden of HAIs in DALYs for Germany. The large number of hospital beds may be a contributing factor for a relatively high burden of HAIs in Germany. Further focus on infection prevention control, paired with reduction of avoidable hospital stays, is needed to reduce the burden of HAIs in Germany.

Point prevalence surveys of healthcare-associated infections (HAI) and antimicrobial use in the European Union and European Economic Area (EU/EEA) from 2016 to 2017 included 310,755 patients from 1,209 acute care hospitals in 28 countries. After national validation, we estimated that 6.5% (cumulative 95% confidence interval (cCI): 5.4-7.8%) patients in acute care hospitals had at least one HAI (country-weighted prevalence). On any given day, 98,166 patients (95% cCI: 81,022-117,484) in acute care hospitals had an HAI; 3.8 million (95% cCI: 3.1-4.5 million) patients acquired an HAI each year. Our study confirmed a high annual number of HAI in healthcare facilities in the EU/EEA.

Summary Background In 2016–17 the European Centre for Disease Prevention and Control (ECDC) organized the second point prevalence survey (PPS) of healthcare-associated infections (HCAIs) and antimicrobial use in European acute care hospitals. This survey included a validation study to maximize the accuracy of case identification and classification. Aim ECDC developed case vignettes to assess the performance of the national validation teams. Methods Case vignettes were developed by two medical doctors with experience in the management of HCAIs and antimicrobial stewardship. The case vignettes were based on actual clinical cases. The distribution of HCAIs among the case vignettes reflected the distribution of HCAIs in the previous PPS. All case vignettes were pilot-tested by three expert raters. Agreement among the expert raters was measured using kappa statistics. Findings Sixty case vignettes were developed. Twenty-nine of them were HCAI cases and 31 were cases without an HCAI. The inter-rater reliability using kappa statistics was 0.78 for the presence of HCAI and 0.89 for the antimicrobial use, respectively. Conclusion The agreement between the expert raters was very good for antimicrobial use and good for the presence of HCAI. Case vignettes can be a tool to support standardization of surveillance, improving the validity and comparability of the data.

International audience

Summary Background In 2011–12, the European Centre for Disease Prevention and Control (ECDC) held the first Europe-wide point-prevalence survey of health-care-associated infections in acute care hospitals. We analysed paediatric data from this survey, aiming to calculate the prevalence and type of health-care-associated infections in children and adolescents in Europe and to determine risk factors for infection in this population. Methods Point-prevalence surveys took place from May, 2011, to November, 2012, in 1149 hospitals in EU Member States, Iceland, Norway, and Croatia. Patients present on the ward at 0800 h on the day of the survey and who were not discharged at the time of the survey were included. Data were collected by locally trained health-care workers according to patient-based or unit-based protocols. We extracted data from the ECDC database for all paediatric patients (age 0–18 years). We report adjusted prevalence for health-care-associated infections by clustering at the hospital and country level. We also calculated risk factors for development of health-care-associated infections with use of a generalised linear mixed-effects model. Findings We analysed data for 17 273 children and adolescents from 29 countries. 770 health-care-associated infections were reported in 726 children and adolescents, corresponding to a prevalence of 4·2% (95% CI 3·7–4·8). Bloodstream infections were the most common type of infection (343 [45%] infections), followed by lower respiratory tract infections (171 [22%]), gastrointestinal infections (64 [8%]), eye, ear, nose, and throat infections (55 [7%]), urinary tract infections (37 [5%]), and surgical-site infections (34 [4%]). The prevalence of infections was highest in paediatric intensive care units (15·5%, 95% CI 11·6–20·3) and neonatal intensive care units (10·7%, 9·0–12·7). Independent risk factors for infection were age younger than 12 months, fatal disease (via ultimately and rapidly fatal McCabe scores), prolonged length of stay, and the use of invasive medical devices. 392 microorganisms were reported for 342 health-care-associated infections, with Enterobacteriaceae being the most frequently found (113 [15%]). Interpretation Infection prevention and control strategies in children should focus on prevention of bloodstream infections, particularly among neonates and infants. Funding None.

Introduction Since 2000, a considerable increase in the number of Clostridium difficile infections (CDIs) leading to substantial morbidity, mortality and attributable costs has been observed, at least in North America and Europe [1]. Changes in the epidemiology of CDI have been mainly attributed to the emergence of a new hypervirulent strain called PCR ribotype 027, causing numerous outbreaks in North America and Europe [2,3] and, to a lesser extent, PCR ribotype 078 [1,4,5]. In addition, patients not previously considered to be at risk for the disease (e.g., without recent antibiotic therapy or hospitalisation) have also been described [1,6-8]. The European CDI study (ECDIS), initiated and funded by the European Centre for Disease Prevention and Control (ECDC), showed that the incidence of CDI varied from hospital to hospital [9]. In 2008, a weighted mean incidence of 4.1 cases (range: 0.0–36.3) per 10,000 patient-days per hospital reported by the ECDIS study was almost 70% higher than that reported in a previous European surveillance study in 2005 (2.45 cases per 10,000 patient-days per hospital, range: 0.13–7.1) [9,10]. ECDIS also revealed the contribution of strains other than PCR ribotype 027 and that some of these strains, notably PCR ribotypes 015, 018 and 056, could cause severe CDI. In response to the emerging problems associated with C. difficile, an ECDC working group published background information about the changing epidemiology of CDI, CDI case definitions and surveillance recommendations [2]. To support European Union (EU)/European Economic Area (EEA) Member States in increasing their capacity for CDI surveillance, ECDC also initiated and funded a new project – ECDIS-Net – to develop a European surveillance protocol and enhance laboratory capacity for diagnosis and typing of C. difficile in EU/EEA Member States. In 2011, a survey of existing CDI surveillance systems in European countries was performed as part of the ECDIS-Net project. The results of this survey, presented here, were later used to develop a standardised pan-European CDI surveillance protocol, which was tested in a three-month pilot study in 2013 [11]. Data collection in the ECDC-coordinated Europe-wide hospital-based CDI surveillance, using a finalised version of this piloted protocol, began on 1 January 2016 [12]. Methods National coordinators for this study were identified through the members of ECDC’s Healthcare-Associated Infections surveillance Network (HAI-Net) and via representatives for the ECDIS study [9]. A link to a web-based questionnaire was sent to these national coordinators to assess the characteristics of existing CDI surveillance systems in European countries. If the national coordinators indicated that CDI was under surveillance in their country, the surveillance protocols were requested and used to augment the information obtained via the questionnaire. Information on the national CDI surveillance systems was entered using a web- based electronic form designed for the purpose of this study. Results Between 6 June and 15 July 2011, 33 of the 35 national coordinators approached from 31 European countries responded to the web-based questionnaire (Iceland and Wales did not respond). Four surveillance systems were excluded from further analysis, as they were not ongoing, comprehensive nationwide surveillance systems, i.e. they were completed one-off studies (two studies from Spain), only regional (Switzerland) or focused only on outbreaks (one system of the Netherlands). In 14 countries, the national coordinators indicated that surveillance of CDI was in place. Of these, surveillance protocols were available from 10 surveillance systems. Thus, 18 CDI surveillance systems from 14 European countries (Austria, Belgium, Bulgaria, Denmark, Finland, France, Germany, Hungary, Ireland, the Netherlands, Sweden and three countries of the United Kingdom (UK), England, Northern Ireland and Scotland) remained available for analysis. Of the 18 surveillance systems, all but one reported national CDI rates annually.

The article ECDC definitions and methods for the surveillance of healthcare‑associated infections in intensive care units.

A national survey was conducted to determine the prevalence, risk factors and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) carriage among nursing home (NH) residents in Belgium.A random stratified, cross-sectional prevalence survey was conducted in NH residents who were screened for MRSA carriage by multisite enriched culture. Characteristics of NHs and residents were collected by a questionnaire survey and analysed by two-stage logistic regression modelling. MRSA isolates were genotyped by PFGE, staphylococcal cassette chromosome mec (SCCmec) typing, multilocus sequence typing (MLST) and resistance genes.Of 2953 residents screened in 60 NHs, 587 (19.9%) were MRSA carriers. Risk factors included hospital contact, antibiotic exposure, impaired mobility and skin lesions at the resident level, and lack of MRSA surveillance, lack of antibiotic therapeutic formulary and the combination of less-developed infection control activities and a high ratio of physicians to residents at the institution level. MRSA isolates showed eight major types, three of which were predominant: B2-ST45-SCCmec IV (49%; where ST stands for sequence type); A21-ST8-SCCmec IV (13%); and A20-ST8-SCCmec IV (10%). Each was recovered in 55, 21 and 25 NHs, respectively. The geographical distribution of NH genotypes paralleled that of acute-care hospitals.A high prevalence of MRSA carriage in NH residents was associated with hospital care, co-morbidities and less-developed coordination of institutional care. The predominant MRSA strains from NH residents and hospitalized patients of the same area were identical. Strengthening and coordination of MRSA surveillance and control activities are warranted within and between NHs and hospitals.

We assessed methicillin-resistant Staphylococcus aureus (MRSA) in persons on 49 swine farms in Belgium. Surveys showed that 48 (37.8%) persons carried MRSA ST398 and 1 (0.8%) had concurrent skin infection. Risk factors for carriage were MRSA carriage by pigs, regular contact with pigs and companion animals, and use of protective clothing., SCOPUS: ar.j, info:eu-repo/semantics/published

Intensive care unit (ICU) patients are highly susceptible to hospital-acquired infections due to their poor health and many invasive therapeutic treatments. The effect on mortality of acquiring such infections is, however, poorly understood. Our goal is to quantify this using data from the National Surveillance Study of Nosocomial Infections in ICUs (Belgium). This is challenging because of the presence of time-dependent confounders, such as mechanical ventilation, which lie on the causal path from infection to mortality. Standard statistical analyses may be severely misleading in such settings and have shown contradictory results. Inverse probability weighting for marginal structural models may instead be used but is not directly applicable because these models parameterize the effect of acquiring infection on a given day in ICU, versus "never" acquiring infection in ICU, and this is ill-defined when ICU discharge precedes that day. Additional complications arise from the informative censoring of the survival time by hospital discharge and the instability of the inverse weighting estimation procedure. We accommodate this by introducing a new class of marginal structural models for so-called partial exposure regimes. These describe the effect on the hazard of death of acquiring infection on a given day s, versus not acquiring infection "up to that day," had patients stayed in the ICU for at least s days.

Many countries in Europe have created national systems for the surveillance of healthcare associated infections (HCAI). The Hospitals in Europe Link for Infection Control through Surveillance (HELICS) has provided a standardised approach to surveillance of HCAI and formed a 'network of networks' to enable data from hospitals contributing to national networks also to be submitted to the HELICS database. This paper describes the set of surgical site infection surveillance data collected in 2004. It includes 111,361 operations in six categories of surgical procedure from 14 countries. The analysis demonstrates that incidence density provides a better measure for comparison than cumulative incidence as it takes some account of difference in length of post-operative stay and post-discharge surveillance. Comparisons should also take account of differences in mix of procedures, variation in risk factors and sensitivity of case finding. This rich dataset provides a unique opportunity to explore variation in rates of SSI and improve understanding of factors that impact on inter-country comparisons.

We present a pilot validation study performed on 10 European Union (EU) Member States, of a point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in Europe in 2011 involving 29 EU/European Economic Area (EEA) countries and Croatia. A total of 20 acute hospitals and 1,950 patient records were included in the pilot study, which consisted of validation and inter-rater reliability (IRR) testing using an in-hospital observation approach. In the validation, a sensitivity of 83% (95% confidence interval (CI): 79–87%) and a specificity of 98% (95% CI: 98–99%) were found for HAIs. The level of agreement between the primary PPS and validation results were very good for HAIs overall (Cohen’s κappa (κ):0.81) and across all the types of HAIs (range: 0.83 for bloodstream infections to 1.00 for lower respiratory tract infections). Antimicrobial use had a sensitivity of 94% (95% CI: 93–95%) and specificity of 97% (95% CI: 96–98%) with a very good level of agreement (κ:0.91). Agreement on other demographic items ranged from moderate to very good (κ: 0.57–0.95): age (κ:0.95), sex (κ: 0.93), specialty of physician (κ: 0.87) and McCabe score (κ: 0.57). IRR showed a very good level of agreement (κ: 0.92) for both the presence of HAIs and antimicrobial use. This pilot study suggested valid and reliable reporting of HAIs and antimicrobial use in the PPS dataset. The lower level of sensitivity with respect to reporting of HAIs reinforces the importance of training data collectors and including validation studies as part of a PPS in order for the burden of HAIs to be better estimated.

Sepsis is a frequent cause of death in very-low-birthweight infants and often results in neurological impairment. Its attributable risk of sequelae has not been systematically assessed. To establish an outcome tree for mapping the burden of neonatal sepsis, we performed systematic literature searches to identify systematic reviews addressing sequelae of neonatal sepsis. We included cohort studies and performed meta-analyses of attributable risks. Evidence quality was assessed using GRADE. Two systematic reviews met inclusion criteria. The first included nine cohort studies with 5,620 participants and five outcomes (neurodevelopmental impairment, cerebral palsy, vision impairment, hearing impairment, death). Pooled risk differences varied between 4% (95% confidence interval (CI):2–10) and 13% (95% CI:5–20). From the second review we analysed four studies with 472 infants. Positive predictive value of neurodevelopmental impairment for later cognitive impairment ranged between 67% (95% CI:22–96) and 83% (95% CI:36–100). Neonatal sepsis increases risk of permanent neurological impairment. Effect size varies by outcome, with evidence quality being low to very low. Data were used to construct an outcome tree for neonatal sepsis. Attributable risk estimates for sequelae following neonatal sepsis are suitable for burden estimation and may serve as outcome parameters in interventional studies.

SummaryHealthcare-associated infection (HCAI), patient safety, and the harmonization of related policies and programmes are the focus of increasing attention and activity in Europe. Infection control training for healthcare workers (HCWs) is a cornerstone of all patient safety and HCAI prevention and control programmes. In 2009 the European Centre for Disease Prevention and Control (ECDC) commissioned an assessment of needs for training in infection control in Europe (TRICE), which showed a substantial increase in commitment to HCAI prevention. On the other hand, it also identified obstacles to the harmonization and promotion of training in infection control and hospital hygiene (IC/HH), mostly due to differences between countries in: (i) the required qualifications of HCWs, particularly nurses; (ii) the available resources; and (iii) the sustainability of IC/HH programmes. In 2013, ECDC published core competencies for infection control and hospital hygiene professionals in the European Union and a new project was launched [‘Implementation of a training strategy for infection control in the European Union’ (TRICE-IS)] that aimed to: define an agreed methodology and standards for the evaluation of IC/HH courses and training programmes; develop a flexible IC/HH taxonomy; and implement an easily accessible web tool in ‘Wiki’ format for IC/HH professionals. This paper reviews several aspects of the TRICE and the TRICE-IS projects.

OBJECTIVES: To assess the effect of methicillin-resistant Staphylococcus aureus (MRSA) colonization on morbidity and mortality of nursing home residents. DESIGN: Three-year cohort study from 2000 to 2003. SETTING: Twenty-three nursing homes of all types and regions in the northern part of Belgium (Flanders). PARTICIPANTS: Two thousand eight hundred fourteen nursing home residents. MEASUREMENTS: The consequences of MRSA colonization on mortality and hospitalization were studied, adjusting for potential confounders. Dates and cause of death and hospitalization were collected every 6 months during 3 years of follow-up. RESULTS: After adjustment for age, sex, and Charlson comorbidity index, the risk for 36-month mortality remained significantly higher in MRSA carriers (hazard ratio (HR)= 1.4, 95% confidence interval (CI) = 1.1–1.8) than in noncarriers. The effect of MRSA on mortality was dependent on the degree of cognitive impairment, with the highest effect in patients with severe cognitive impairment (adjusted HR =1.8, 95% CI =1.1–2.8) and absence of effect in residents with good mental status (adjusted HR =0.8, 95% CI =0.43–1.62). Deaths were more frequently reported to be infection-related in MRSA carriers. No association was found between MRSA colonization and hospitalization for any reason, but during follow-up, MRSA carriers were twice as frequently hospitalized for respiratory tract infections. CONCLUSION: Colonization of MRSA in Belgian nursing home residents was associated with higher mortality. This excess mortality was restricted to residents with impaired cognitive function, probably reflecting differences in therapeutic approaches, in delay of diagnosis of pneumonia and other acute disorders in these patients, or in both.

Background: Data on outpatient penicillin use in Europe were collected from 25 countries within the ESAC project, funded by DG SANCO of the European Commission, using the WHO ATC/DDD methodology. Methods: For the period 1997-2003, data on outpatient use of systemic penicillins aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Of the 'Penicillins' (J01C), outpatient use of narrow- spectrum penicillins (J01CE), broad-spectrum penicillins (J01CA), penicillinase-resistant penicillins (J01CF) and combinations with beta- lactamase inhibitors (J01CR) in 25 European countries was analysed in detail. Results: Total outpatient penicillin use in 2003 varied by a factor of 4 between the country with the highest (15.27 DID in Slovakia) and lowest use (3.86 DID in the Netherlands). Narrow-spectrum penicillins, broad-spectrum penicillins and combinations with beta-lactamase inhibitors were used most in 4, 12 and 9 countries, respectively. Penicillin use increased by more than 1 DID in nine countries, whereas it decreased by more than 1 DID in two countries (Czech Republic, France). An increase of the use of combinations with beta- lactamase inhibitors by more than 10% in 10 countries coincided with an equal decrease of broad-spectrum penicillins in seven countries and narrow-spectrum penicillins in three countries. Conclusion: Penicillins represent the most widely used antibiotic class in all 25 participating countries ; albeit with considerable variation of their use patterns. A distinct shift from narrow- spectrum penicillins to broad-spectrum penicillins, and specifically their combinations with beta-lactamase inhibitors, was observed during the period 1997-2003.

In 2002-03, the Belgian government subsidized in part the activities of local Antibiotic Managers (AMs) in 36 hospitals selected based on the presence of an operational multidisciplinary Antibiotic Management Team (AMT). AMs were trained as Internists (28), Microbiologists (13) and Hospital Pharmacists (13). The hospitals were representative of Belgian hospitals in affiliation, regional origin and size. The financing scheme allowed the implementation of 175 antibiotic management interventions, with a mean of 5 interventions/hospital. The activities reported in the first 9-month progress reports were analyzed according to national guidelines for AMTs. All hospitals irrespective of size or affiliation had undertaken a wide range of measures: review of formulary (29), implementation of new clinical guidelines (24), restricted access to selected antibiotics (25), improvement of antibiotic susceptibility testing methods (12), development of antibiotic consumption database (35) and analysis of antibacterial susceptibility data (31). Advertisement type categorization of communication methods showed that education of prescribers was based on multimodal communication. All hospitals used at least one passive method, 39% at least one active method and 55% at least one personalized method. The quality of communication was higher in hospitals with teaching affiliation. In conclusion, hospitals that received a financial incentive under theAMT pilot phase have developed multimodal antibiotic policy interventions independently of the hospital size and teaching status. Extension to all Belgian hospitals appears warranted. The impact of AMTs and AMs on the quality of use of antibiotics and trends of antibiotic resistance and cost will be monitored based on standardized indicators.

Mycotoxins are naturally occurring toxic chemical compounds produced by fungi infesting agricultural crops both during crop growth and storage. Such secondary metabolites, when ingested, can produce toxic syndromes in humans. This study is the first survey that documents the occurrence of mycotoxins in stored barley in Tibet Autonomous Region [P.R. China]. Twenty-five samples of barley collected from Tibet were analyzed for the presence of aflatoxins, fumonisins, ochratoxins, zearalenone, deoxynivalenol, and T-2 toxin using an easy, sensitive, competitive direct enzyme-linked immunosorbent assay. Ninety-six percent of the samples were contaminated with zearalenone at concentrations ranging from 25 to 270 µg/kg. Seventy-six percent of the samples were contaminated with T-2 toxin at concentrations ranging from 1 to 163 µg/kg. In contrast, deoxynivalenol was observed in only 12% of the samples, with toxin concentrations ranging from 25 to 270 µg/kg. Aflatoxin was observed in only 4% of the contamina...

Resume Pendant les annees 1990, plusieurs reseaux nationaux et regionaux de surveillance des infections acquises en reanimation ont ete crees en Europe. Malgre le fait que la plupart de ces reseaux partagent des objectifs generaux semblables, les details de leurs methodologies different de maniere tres importante, lies au fait que la plupart de ces protocoles emanent d’un processus de consensus au sein d’un groupe d’experts national ou regional. Les differences concernent non seulement les definitions des infections nosocomiales proprement dites, mais egalement des questions comme les criteres d’inclusion des patients et des unites, la definition du terme « nosocomial », d’un jour d’exposition a un dispositif invasif ou d’une infection associee a un dispositif, si les facteurs de risque sont recueillis pour toute l’unite ou pour chaque patient individuellement, le type de facteurs de risque et d’infections inclus et la definition des indicateurs utilises pour les comparaisons inter-unites. Dans le cadre du reseau europeen pour la surveillance des maladies transmissibles coordonne par la commission europeenne, le groupe HELICS a analyse les methodes possibles pour la comparaison des donnees inter-reseaux et a propose une nouvelle approche consensuelle afin d’ameliorer la comparabilite dans le futur.

Background The “Assessment of Infection Control Training Needs in Europe (TRICE)” project (commissioned by the ECDC in 2010) highlighted significant differences amongst European Countries (EC) in existing Infection Control /Hospital Hygiene (IC/HH) training courses. In March 2013 ECDC published the “Core competencies for infection control and hospital hygiene professionals in the European Union” (EIC/HHCC) aimed at standardising IC/HH training in Europe. The current ECDC commissioned project “Implementation a Strategy for Infection Control Training …

Training Infection Control in Europe (TRICE) in 2010 identified significant differences within European Countries (EC) in the existence of Infection Control /Hospital Hygiene (IC/HH) courses and their compliance with the Improving Patient Safety in Europe (IPSE, 2008) recommended Core Competencies. The need to improve official recognition of “IC/HH degrees” for healthcare professionals also emerged. TRICE further developed, agreed EIC/HHCC with two tiers, published by ECDC in March 2013 as a Technical Document.

Summary Background Healthcare-associated infections in long-term care facilities (LTCFs) are of increasing importance. Aim To develop consensus national performance indicators (NPIs) for infection control (ICPI) and antimicrobial stewardship (ASPI) in LTCFs, and assess the performance of 32 European countries against these NPIs. Methods Previously established European standards were the basis for consensus and the same iterative approach with national representatives from the 32 countries. A World Health Organization scoring system recorded how close each country was to implementing each standard. Findings The 42 agreed component indicators were grouped into six NPI categories: ‘national programme', ‘guidelines', ‘expert advice', ‘IC structure' (not present in the ASPI), ‘surveillance' and ‘composite'. ‘Guidelines' scored the highest mean total possible score (60%, range 20–100%), followed by ‘composite' (53%, range 30–100%), ‘expert advice' (48%, range 20–100%), ‘surveillance' (47%, range 20–83%), ‘national programme' (42%, range 20–100%) and ‘IC structure' (39%, range 20–100%). Although several scores were low, some countries were able to implement all NPIs, indicating that this was feasible. Most NPIs were very significantly related, indicating that they were considered to be important by the countries. ‘Guidelines' and ‘IC structure' were significantly related to European region ( P ≤ 0.05). Accreditation/inspection was not evident in seven (22%) countries, nine (28%) countries had accreditation/inspection that included IC assessments, and seven (22%) countries had accreditation/inspection that included IC and antimicrobial stewardship assessments. Multi-variable analysis found that only the NPI and the ICPI ‘expert advice' were associated with accreditation/inspection which included IC and antimicrobial stewardship. Conclusion The identified gaps represent significant potential patient safety issues. The NPIs should serve as a basis for monitoring improvements over the coming years.

S Brusaferro, B Cookson, R Gallagher, P Hartemann, J Holt, S Kalenic, W Popp, G Privitera, C Varela Santos, C Suetens, L Arnoldo, G Cattani, E Fabbro Dipartimento di Scienze Mediche e Biologiche, Universita degli Studi di Udine, Udine, Italy University College London, London, United Kingdom Royal College of Nursing, London, United Kingdom Universite de Lorraine, Nancy, France Staten Serum Institute, Copenhagen, Denmark University of Zagreb, Zagreb, Croatia University Hospital of Essen, Essen, Germany University of Pisa, Pisa, Italy ECDC, Stockholm, Sweden Contact: joe.cattani@libero.it Background The Training Infection Control in Europe project (TRICE, 2010) highlighted significant differences amongst European Countries (EC) regarding the existence of Infection Control / Hospital Hygiene (IC/HH) courses and the need to improve official recognition of ‘‘IC/HH degrees’’ for healthcare professionals. In March 2013, ECDC published a Technical Document with recommended European IC/HH Core Competencies (EIC/HHCC) as proposed by the TRICE project (1). Objective To perform a comparative analysis of EIC/HHCC and documents describing disciplines related to IC/HH, such as Public Health, Epidemiology, Medical Microbiology and Infectious Diseases and explore possible harmonisation of European standards for mutual recognition of European training courses. The main purpose was to provide information needed to promote the endorsement and the adoption of the EIC/HHCC in training courses and for these to be mutually recognised within EC. These objectives were components of the ECDC funded TRICE-Implementation Strategy project. Results Documents collected were related to: Public Health (ASPHER), Epidemiology of communicable diseases (ECDC) Medical Microbiology (EUPHEM) and Infectious Diseases (UEMS). Alignment with the EIC/HHCC competencies (n.101) was: 57% for ASPHER, 56% for Epidemiology ECDC, 40% for Infectious Diseases, 20% Medical Microbiology UEMS and 64% for EUPHEM. In the Program Management area (n. 24 competencies) poor alignment has been identified for Infectious Diseases 38%, Medical Microbiology (UEMS) 17% and Public Health Microbiology (EUPHEM) 4%. Searches of the www and review of several European courses, thus far suggest that the European Credit Transfer and Accumulation System (ECTS) appears to be the standard currently recognized in Europe for mutual recognition of training initiatives, although ECTS is not necessarily required by some Universities and harmonization of methods provides an immediate way forward. Conclusions Almost all documents examined revealed the need better alignment with the TRICE EIC/HHCC. ECTS could be considered as the basis for mutual recognition for IC/HH training initiatives designed according to TRICE EIC/HHCC. European Centre for Disease Prevention and Control. Core competencies for infection control and hospital hygiene professionals in the European Union. Stockholm: ECDC; 2013. Key message More alignment with EIC/HHCC will be required for relevant training courses. These post-graduate courses should also adopt the Bologna Process recommendations for ECTS. Open access testing for nutrition competences of food service personnel Enni Mertanen

Background Surveillance of healthcare-associated infections (HAI) is a valuable measure to decrease infection rates. Across Europe, inter-country comparisons of HAI rates seem limited because some countries use US definitions from the US Centers for Disease Control and Prevention (CDC/NHSN) while other countries use European definitions from the Hospitals in Europe Link for Infection Control through Surveillance (HELICS/IPSE) project. In this study, we analyzed the concordance between US and European definitions of HAI. Methods An international working group of experts from seven European countries was set up to identify differences between US and European definitions and then conduct surveillance using both sets of definitions during a three-month period (March 1st -May 31st, 2010). Concordance between case definitions was estimated with Cohen’s kappa statistic (κ). Results Differences in HAI definitions were found for bloodstream infection (BSI), pneumonia (PN), urinary tract infection (UTI) and the two key terms “intensive care unit (ICU)-acquired infection” and “mechanical ventilation”. Concordance was analyzed for these definitions and key terms with the exception of UTI. Surveillance was performed in 47 ICUs and 6,506 patients were assessed. One hundred and eighty PN and 123 BSI cases were identified. When all PN cases were considered, concordance for PN was κ = 0.99 [CI 95%: 0.98-1.00]. When PN cases were divided into subgroups, concordance was κ = 0.90 (CI 95%: 0.86-0.94) for clinically defined PN and κ = 0.72 (CI 95%: 0.63-0.82) for microbiologically defined PN. Concordance for BSI was κ = 0.73 [CI 95%: 0.66-0.80]. However, BSI cases secondary to another infection site (42% of all BSI cases) are excluded when using US definitions and concordance for BSI was κ = 1.00 when only primary BSI cases, i.e. Europe-defined BSI with ”catheter” or “unknown” origin and US-defined laboratory-confirmed BSI (LCBI), were considered. Conclusions Our study showed an excellent concordance between US and European definitions of PN and primary BSI. PN and primary BSI rates of countries using either US or European definitions can be compared if the points highlighted in this study are taken into account.

The prevalence, distribution, and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) in Belgian pig farms has been investigated. To that end, nasal samples were collected from 1,500 pigs on 50 farms randomly selected over Belgium. Both closed (breeding or farrow-to-finish) and open (fattening) farms were included. Within closed farms different age groups were investigated. A total number of 663 (44%) pigs belonging to 34 (68%) farms carried MRSA. According to their management practice, MRSA was detected on 94% of the open farms and 56% of the closed farms. Focusing on the in-herd prevalence among fattening pigs for both management systems, a significantly higher rate was found in open farms (72%) compared to closed farms (26%). Within the closed farms, piglets (41%) showed a higher MRSA prevalence than sows (26%) and fattening pigs (26%). All strains tested were ST398 and showed mainly spa-type t011, as commonly found on pig herds in Europe. Less dominating spa-types were t034, t567, and t2970. The MRSA strains carried two SCCmec-types, type IVa or V. All 643 MRSA strains were resistant to tetracycline and additional resistances to trimethoprim (97%), lincosamides (73%), macrolides (56%), aminoglycosides (48%), and fluoroquinolones (32%) were found. Multiresistance (defined as resistance to four or more non-beta-lactam antimicrobial classes) was found in 63% of the tested strains. In conclusion, a high prevalence of MRSA was found in Belgian pig farms, with the highest prevalence in open farms. In accordance with other European countries, age-related and management-related differences in MRSA prevalence were observed that should be considered when control strategies are outlined.

Summary Background Patients admitted to intensive-care units are at high risk of health-care-associated infections, and many are caused by antimicrobial-resistant pathogens. We aimed to assess excess mortality and length of stay in intensive-care units from bloodstream infections and pneumonia. Methods We analysed data collected prospectively from intensive-care units that reported according to the European standard protocol for surveillance of health-care-associated infections. We focused on the most frequent causative microorganisms. Resistance was defined as resistance to ceftazidime ( Acinetobacter baumannii or Pseudomonas aeruginosa ), third-generation cephalosporins ( Escherichia coli ), and oxacillin ( Staphylococcus aureus ). We defined 20 different exposures according to infection site, microorganism, and resistance status. For every exposure, we compared outcomes between patients exposed and unexposed by use of time-dependent regression modelling. We adjusted results for patients' characteristics and time-dependency of the exposure. Findings We obtained data for 119 699 patients who were admitted for more than 2 days to 537 intensive-care units in ten countries between Jan 1, 2005, and Dec 31, 2008. Excess risk of death (hazard ratio) for pneumonia in the fully adjusted model ranged from 1·7 (95% CI 1·4–1·9) for drug-sensitive S aureus to 3·5 (2·9–4·2) for drug-resistant P aeruginosa . For bloodstream infections, the excess risk ranged from 2·1 (1·6–2·6) for drug-sensitive S aureus to 4·0 (2·7–5·8) for drug-resistant P aeruginosa . Risk of death associated with antimicrobial resistance (ie, additional risk of death to that of the infection) was 1·2 (1·1–1·4) for pneumonia and 1·2 (0·9–1·5) for bloodstream infections for a combination of all four microorganisms, and was highest for S aureus (pneumonia 1·3 [1·0–1·6], bloodstream infections 1·6 [1·1–2·3]). Antimicrobial resistance did not significantly increase length of stay; the hazard ratio for discharge, dead or alive, for sensitive microorganisms compared with resistant microorganisms (all four combined) was 1·05 (0·97–1·13) for pneumonia and 1·02 (0·98–1·17) for bloodstream infections. P aeruginosa had the highest burden of health-care-acquired infections because of its high prevalence and pathogenicity of both its drug-sensitive and drug-resistant strains. Interpretation Health-care-associated bloodstream infections and pneumonia greatly increase mortality and pneumonia increase length of stay in intensive-care units; the additional effect of the most common antimicrobial resistance patterns is comparatively low. Funding European Commission (DG Sanco).

The main objective was to study the impact of in-hospital bacteraemia caused by Staphylococcus aureus on mortality within 90 days after admission. We compared methicillin-resistant S. aureus (MRSA) with methicillin-susceptible S. aureus (MSSA).The study population consisted of adult residents of Tayside, Scotland, UK, from 1 January 2005 to 30 September 2006 who had a new admission to Ninewells Hospital between 1 July 2005 and 30 June 2006. All patients (n = 3132) in the same wards as the patients infected with S. aureus were included. We addressed key weaknesses in previous studies by using a cohort design and applying a multistate model, which addressed the temporal dynamics. Critically, the model recognized that death and discharge from the hospital are competing events and that delay in discharge independently increases the risk of death.The cohort included 3132 patients, of whom 494 died within 90 days after admission, 34 developed MRSA bacteraemia and 26 MSSA bacteraemia in the hospital. In comparison with patients without S. aureus bacteraemia, the death hazard was 5.6 times greater with MRSA [95% confidence interval (CI) 3.36-9.41] and 2.7 times greater with MSSA bacteraemia (95% CI 1.33-5.39). After adjustment for co-morbidity, hospitalization, age and sex, the death hazard was 2.9 times greater with MRSA (95% CI 1.70-4.88) and 1.7 times greater with MSSA bacteraemia (95% CI 0.84-3.47).Time-dependent models such as the proposed multistate model are necessary to address the temporal dynamics of admission, infection, discharge and death. The impact of S. aureus bacteraemia on mortality should be considered on two levels: the burden of disease, i.e. nosocomial infection with S. aureus bacteraemia, and the burden of resistance to methicillin.

Item does not contain fulltext Hand hygiene represents the single most effective way to prevent healthcare-associated infections. The World Health Organization, as part of its First Global Patient Safety Challenge, recommends implementation of multi-faceted strategies to increase compliance with hand hygiene. A questionnaire was sent by the European Centre for Disease Prevention and Control to 30 European countries, regarding the availability and organisation of their national hand hygiene campaigns. All countries responded. Thirteen countries had organised at least one national campaign during the period 2000-2009 and three countries were in the process of organising a national campaign. Although the remaining countries did not have a national campaign, several reported regional and local hand hygiene activities or educational resources on national websites.

We report here baseline data from the first year of compulsory surveillance of Clostridium difficile infections (CDI) in hospitals in Belgium. Between 1 July 2007 and 30 June 2008, 2,704 CDI were reported: 12% were recurrent and 66% were hospital-associated (half of which occurred 15 days or more after admission). CDI was considered the cause of death (direct or indirect) for 10% of the episodes. The median incidence of CDI was 1.5 per 1,000 admissions and 1.9 per 10,000 hospital-days for all cases, and 0.9 per 1,000 admissions, and 1.1 per 10,000 hospital-days for hospital-associated cases. Further investigation of risk stratification by average length of stay in the reporting hospitals is warranted as a way to improve the comparability of indicators across hospitals and surveillance systems. In spite of methodological issues, the surveillance of CDI in Belgian hospitals has been able to produce robust baseline data that should allow monitoring of trends at hospital and national level, and provide a basis for international comparisons. Remaining challenges are to define and monitor targets for the control of CDI, and to improve the individual feed-back of data at hospital level.

The Italian Nosocomial Infections Surveillance in Intensive Care Units (ICUs) (SPIN-UTI) project of the Italian Study Group of Hospital Hygiene (GISIO - SItI) was undertaken to ensure standardisation of definitions, data collection and reporting procedures using the Hospital in Europe Link for Infection Control through Surveillance (HELICS)-ICU benchmark. Before starting surveillance, participant ICUs met in order to involve the key stakeholders in the project through participation in planning. Four electronic data forms for web-based data collection were designed. The six-month patient-based prospective survey was undertaken from November 2006 to May 2007, preceded by a one-month surveillance pilot study to assess the overall feasibility of the programme and to determine the time needed and resources for participant hospitals. The SPIN-UTI project included 49 ICUs, 3053 patients with length of stay >2 days and 35 498 patient-days. The cumulative incidence of infections was 19.8 per 100 patients and the incidence density was 17.1 per 1000 patient-days. The most frequently encountered infection type was pneumonia, Pseudomonas aeruginosa being the most frequent infection-associated micro-organism, followed by Staphylococcus aureus and Acinetobacter baumannii. Site-specific infection rates for pneumonia, bloodstream infections, central venous catheter-related bloodstream infections and urinary tract infections, stratified according to patient risk factors, were below the 75th centile reported by the HELICS network benchmark. The SPIN-UTI project showed that introduction of ongoing surveillance should be possible in many Italian hospitals. The study provided the opportunity to participate in the HELICS project using benchmark data for comparison and for better understanding of factors influencing risks.

Since 2006, the European Centre for Disease Prevention and Control (ECDC) has been addressing the new CDI situation. Considering the worrying evolution of CDI in Northern America, reports of Type 027 CDI outbreaks in Belgium, The Netherlands and the UK in 2005, and the preliminary results of an EU-wide study conducted in 2005 by the ESCMID Study Group for C. difficile (ESGCD), ECDC convened a group of experts consisting of members of ESGCD, epidemiologists from healthcare-associated surveillance networks from the European Union (EU) and from the US Centers for Disease Control and Prevention (CDC). This ECDC working group recognised the emergence of a new CDI problem in some EU Member States and the potential for spread to other countries and decided to act.

Recent outbreaks of Clostridium difficile-associated diarrhoea (CDAD) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America, Japan and Europe. Definitions have been proposed by the European Centre of Disease Prevention and Control (ECDC) to identify severe cases of CDAD and to differentiate community-acquired cases from nosocomial CDAD (http://www.ecdc.europa.eu/documents/pdf/Cl_dif_v2.pdf). CDAD is mainly known as a healthcare-associated disease, but it is also increasingly recognised as a community-associated disease. The emerging strain is referred to as North American pulsed-field type 1 (NAP1) and PCR ribotype 027. Since 2005, individual countries have developed surveillance studies to monitor the spread of this strain. C. difficile type 027 has caused outbreaks in England and Wales, Ireland, the Netherlands, Belgium, Luxembourg, and France, and has also been detected in Austria, Scotland, Switzerland, Poland and Denmark. Preliminary data indicated that type 027 was already present in historical isolates collected in Sweden between 1997 and 2001.

Infectious diseases are a very common occurrence in nursing homes. While the reasons for preventing infections are the same in nursing homes and in acute hospitals, several considerations relevant to prevention of infection differ in nursing homes. Infection control measures should be based upon the particularities of the specific setting of a nursing home and its residents.

To assess the effect of methicillin-resistant Staphylococcus aureus (MRSA) colonization on morbidity and mortality of nursing home residents.Three-year cohort study from 2000 to 2003.Twenty-three nursing homes of all types and regions in the northern part of Belgium (Flanders).Two thousand eight hundred fourteen nursing home residents.The consequences of MRSA colonization on mortality and hospitalization were studied, adjusting for potential confounders. Dates and cause of death and hospitalization were collected every 6 months during 3 years of follow-up.After adjustment for age, sex, and Charlson comorbidity index, the risk for 36-month mortality remained significantly higher in MRSA carriers (hazard ratio (HR) = 1.4, 95% confidence interval (CI) = 1.1-1.8) than in noncarriers. The effect of MRSA on mortality was dependent on the degree of cognitive impairment, with the highest effect in patients with severe cognitive impairment (adjusted HR = 1.8, 95% CI = 1.1-2.8) and absence of effect in residents with good mental status (adjusted HR = 0.8, 95% CI = 0.43-1.62). Deaths were more frequently reported to be infection-related in MRSA carriers. No association was found between MRSA colonization and hospitalization for any reason, but during follow-up, MRSA carriers were twice as frequently hospitalized for respiratory tract infections.Colonization of MRSA in Belgian nursing home residents was associated with higher mortality. This excess mortality was restricted to residents with impaired cognitive function, probably reflecting differences in therapeutic approaches, in delay of diagnosis of pneumonia and other acute disorders in these patients, or in both.

Methods for national surveillance of nosocomial infections in intensive care units (ICUs) applied in the different European member states have for a long time been too heterogeneous to allow for meaningful comparisons of results.1 In February 2003, network coordinators and clinical experts from the national surveillance systems were convened by the DG Public Health co-funded HELICS (Hospitals in Europe Link for Infection Control through Surveillance) project and agreed on a common protocol in order to standardize surveillance methods.2 Since then, several member states have adapted their national protocol to comply with the HELICS format while others have used the protocol to start or pilot new surveillance networks (Lithuania, Slovakia, Scotland, Italy, Norway). Here, we report on the main results of 2004 and 2005 of the European network for the surveillance of ICU-acquired infections.

As a result of the reports of outbreaks of diarrhoea due to Clostridium difficile North American Pulse field type 1, PCR ribotype 027, toxinotype III in North America, United Kingdom, the Netherlands and Belgium, two different surveillance systems for C. difficile-associated diarrhoea were set up in Belgium

Background: Data on more than a decade of outpatient quinolone use were collected from 33 European countries within the European Surveillance of Antimicrobial Consumption (ESAC) project, funded by the European Centre for Disease Prevention and Control (ECDC). Methods: For the period 1997– 2009, data on outpatient use of systemic quinolones aggregated at the level of the active substance were collected using the Anatomical Therapeutic Chemical (ATC)/defined daily dose (DDD) method (WHO, version 2011), and expressed in DDD and packages per 1000 inhabitants per day (DID and PID, respectively). Using a classification based on pharmacokinetic and in vitro potency profiles, quinolone use was analysed with regard to trends over time, seasonal variation and composition. Results: Total outpatient quinolone use in 2009 varied by a factor of 7.5 between the country with the highest (Italy, 3.61 DID) and the country with the lowest (the UK, 0.48 DID) quinolone use. The second-generation quinolones accounted for .50% of quinolone use (mainly ciprofloxacin), except for Croatia, where first-generation quinolones (mainly norfloxacin) were mostly used. A significant increase in outpatient quinolone use was found for Europe, as well as a large seasonal variation, which increased significantly over time from 1997 to 2009. Relative use of third-generation quinolones significantly increased over time with respect to the use of second-generation quinolones, while the relative use of both significantly increased with respect to the firstgeneration quinolones. Levofloxacin and moxifloxacin (respiratory quinolones) represented .10% of quinolone outpatient use in 17 countries, with extreme seasonal variation in all countries. Conclusions: There was a substantial increase and change in the pattern of quinolone use between 1997 and 2009, a period during which quinolones that are effective for the treatment of respiratory tract infections were introduced. These quinolones are not the first-line antibiotics for this indication and their use should generally be limited, and quinolones should ideally show no substantial seasonal variation in terms of their use.

Received 23 August 2005; returned 2 November 2005; revised 12 April 2006; accepted 16 April 2006Background: Data on outpatient cephalosporin use in Europe were collected from 25 countries within theESACproject,fundedbyDGSANCOoftheEuropeanCommission,usingtheWHOATC/DDDmethodology.Methods: For the period 1997–2003, data on outpatient use of systemic cephalosporins aggregated at theleveloftheactivesubstancewerecollectedandexpressedinDDD(WHO,version2004)per1000inhabitantsper day (DID). Use was analysed in detail, using the new ATC codes J01DB, J01DC, J01DD and J01DE,introduced in the 2005 issue of the WHO ATC index and assigned to the four cephalosporin generations.Results:Totaloutpatientcephalosporinusein2003 variedby a factorof270between the countrywiththehighest (6.18 DID in Greece) and lowest (0.02 DID in Denmark) use. First-, second- and third-generationcephalosporinswereusedmostin6,16and3countries,respectively.Weobservedfourth-generationuse(mainly cefepime) in ambulatory care in 11 countries. From 1997 to 2003 cephalosporin use decreased in13countries,inFrancebymorethan1DID.Arelativeincreaseofsecond-generation(mainlycefuroxime)orthird-generationuse(mainlycefpodoximeorcefixime)bymorethan10%in12countriescoincidedwithanequallylargedecreaseoffirst-generationuseineightcountries(mainlycefadroxil,cefalexinorcefatrizine).In six countries, first-generation use increased, second-generation use decreased or both occurred.Conclusion: The new ATC codes allow a more detailed description of outpatient cephalosporin use. Thevariation in antibiotic use in Europe is most extreme for this class of antibiotics, suggesting that in manycountries in Europe these antibiotics are prescribed inappropriately.Keywords: antibiotic use, cephalosporins, drug consumption, pharmacoepidemiology, ambulatory care, Europe