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Antimicrobial Stewardship in Belgium
Chapter 19.6
Antimicrobial Stewardship in Belgium Patrick Lacor* and Peter Messiaen** *
UZ Brussel, Brussel, Belgium Jessaziekenhuis, Hasselt, Belgium
**
Belgium has a publicly funded health-care system organized both on a federal level (compulsory health-care insurance and financing of hospitals) and on the level of the federated communities (preventive care and health promotion). Self-employed general practitioners constitute a strong and broad base for primary health care. The vast majority of secondary and tertiary care hospitals are public, university, or semiprivate institutions publicly funded. Patients are free to choose their own medical professionals. The health-care provider has a large degree of therapeutic freedom and is paid on a fee-for-service base. Overall, the health-care system scores reasonably good in terms of accessibility [1]. Almost 99% of the population is covered by mandatory health insurance funded mainly by taxes; costs are paid up front and for a large proportion reimbursed. The patient’s own contribution can run up till 17.7% of overall costs [2]. Antibiotics are nearly 100% reimbursed as “essential medicines.” Antibiotic use is mostly contained in the standard fee for hospital admission. In 1999, the multidisciplinary Belgian Antibiotic Policy Coordination Committee (BAPCOC) was created by royal decree [3] with the objective to reduce development and spread of antibiotic resistance. The committee reports on the use of antibiotics and the evolution of antibiotic resistance in Belgium sets up campaigns to promote rational use in the community and to improve hand hygiene compliance in hospitals and publishes guidelines for antibiotic use in primary and hospital care. “Antibiotic management teams” were introduced in all acute care hospitals, with well-defined responsibilities such as monitoring the use of antibiotics and the evolution of
Antimicrobial Stewardship. http://dx.doi.org/10.1016/B978-0-12-810477-4.00040-4 Copyright © 2017 Elsevier Inc. All rights reserved.
255
256 SECTION
D AMS Experiences Around the World
microbial resistance in the hospital and issuing local practice guidelines on antibiotic treatment and prophylaxis [4,5]. The public campaigns launched in the 2000–01 winter decreased outpatient antibiotic use by 36% over 7 years when expressed as PID, the number of packages/1000 inhabitants/day [6]. This longitudinal trend in PID differed from the estimates using DID, the defined daily dose (DDD)/1000 inhabitants/ day. Data from the European Surveillance of Antimicrobial Consumption (ESAC) show that the consumption of antibiotics for systemic use in the Belgian community in 2014 amounted to 28.2 in DID, which is above the population-weighted EU/EEA mean consumption [7] but to 2.41 in PID, which is below the mean. The question was raised whether the number of packages might not be a better proxy of antibiotic prescribing than the number of DDDs [6,8]. In the hospital sector, Belgium ranked rather favorably in 2013, staying below the mean consumption (in DDD). Future research should focus on the tools most reliable to evaluate the use of antibiotics, on other factors predicting antibiotic resistance [9] and on how to make interventions most effective. Efforts should be continued to improve the quality of prescription, avoiding over- and underprescription [10]. This requires a strong political commitment and a joint engagement of the many involved players, integrated in the BAPCOC 2014–19 strategic plan [11].
REFERENCES [1] OECD. Health at a glance 2015: OECD indicators, Paris: OECD Publishing; 2015. http://dx. doi.org/10.1787/health-glance-2015-en. [2] Gerkens S, Merkur S. Belgium: health system review. Health Syst Trans 2010;12(5):1–266. [3] Goossens H, Coenen S, Costers M, De Corte S, De Sutter A, Gordts B, et al. Achievements of the Belgian Antibiotic Policy Coordination Committee (BAPCOC). Eurosurveillance 2008;13(46):1–4. [4] Van Gastel E, Costers M, Peetermans WE, Struelens MJ. Nationwide implementation of antibiotic management teams in Belgian hospitals: a self-reporting survey. J Antimicrob Chemother 2010;65:576–80. [5] Lambert ML, Bruyndonckx R, Goossens H, Hens N, Aerts M, Catry B, et al. The Belgian policy of funding antimicrobial stewardship in hospitals and trends of selected quality indicators for antimicrobial use, 1991-2010: a longitudinal study. BMJ Open 2015;5:e006916. http://dx. doi.org/10.1136/bmjopen-2014-006916. [6] Coenen S, Gielen B, Blommaert A, Beutels Ph, Hens N, Goossens H. Appropriate international measures for outpatient antibiotic prescribing and consumption: recommendations from a national data comparison of different measures. J Antimicrob Chemother 2014;69:529–36. [7] http://ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx. [8] Bruyndonckx R, Hens N, Aerts M, Goossens H, Molenberghs G, Coenen S. Measuring trends of outpatient antibiotic use in Europe: jointly modelling longitudinal data in defined daily doses and packages. J Antimicrob Chemother 2014;69:1981–6. [9] Blommaert A, Marais C, Hens L, Coenen S, Muller A, Goossens Beutels P. Determinants of between-country differences in ambulatory antibiotic use and antibiotic resistance in Europe: a longitudinal observational study. J Antimicrob Chemother 2014;69:535–47.
Belgium Chapter
19.6 257
[10] Coenen S, Costers M, De Corte S, De Sutter A, Goossens H. The first European Antibiotic Awareness Day after a decade of improving outpatient antibiotic use in Belgium. Acta Clin Belg 2008;63:296–300. [11] http://consultativebodies.health.belgium.be/sites/default/files/documents/policy_paper_ bapcoc_executive_summary_2014-2019_english.pdf.
Antimicrobial Stewardship in Belgium Patrick Lacor* and Peter Messiaen** *
UZ Brussel, Brussel, Belgium Jessaziekenhuis, Hasselt, Belgium
**
Belgium has a publicly funded health-care system organized both on a federal level (compulsory health-care insurance and financing of hospitals) and on the level of the federated communities (preventive care and health promotion). Self-employed general practitioners constitute a strong and broad base for primary health care. The vast majority of secondary and tertiary care hospitals are public, university, or semiprivate institutions publicly funded. Patients are free to choose their own medical professionals. The health-care provider has a large degree of therapeutic freedom and is paid on a fee-for-service base. Overall, the health-care system scores reasonably good in terms of accessibility [1]. Almost 99% of the population is covered by mandatory health insurance funded mainly by taxes; costs are paid up front and for a large proportion reimbursed. The patient’s own contribution can run up till 17.7% of overall costs [2]. Antibiotics are nearly 100% reimbursed as “essential medicines.” Antibiotic use is mostly contained in the standard fee for hospital admission. In 1999, the multidisciplinary Belgian Antibiotic Policy Coordination Committee (BAPCOC) was created by royal decree [3] with the objective to reduce development and spread of antibiotic resistance. The committee reports on the use of antibiotics and the evolution of antibiotic resistance in Belgium sets up campaigns to promote rational use in the community and to improve hand hygiene compliance in hospitals and publishes guidelines for antibiotic use in primary and hospital care. “Antibiotic management teams” were introduced in all acute care hospitals, with well-defined responsibilities such as monitoring the use of antibiotics and the evolution of
Antimicrobial Stewardship. http://dx.doi.org/10.1016/B978-0-12-810477-4.00040-4 Copyright © 2017 Elsevier Inc. All rights reserved.
255
256 SECTION
D AMS Experiences Around the World
microbial resistance in the hospital and issuing local practice guidelines on antibiotic treatment and prophylaxis [4,5]. The public campaigns launched in the 2000–01 winter decreased outpatient antibiotic use by 36% over 7 years when expressed as PID, the number of packages/1000 inhabitants/day [6]. This longitudinal trend in PID differed from the estimates using DID, the defined daily dose (DDD)/1000 inhabitants/ day. Data from the European Surveillance of Antimicrobial Consumption (ESAC) show that the consumption of antibiotics for systemic use in the Belgian community in 2014 amounted to 28.2 in DID, which is above the population-weighted EU/EEA mean consumption [7] but to 2.41 in PID, which is below the mean. The question was raised whether the number of packages might not be a better proxy of antibiotic prescribing than the number of DDDs [6,8]. In the hospital sector, Belgium ranked rather favorably in 2013, staying below the mean consumption (in DDD). Future research should focus on the tools most reliable to evaluate the use of antibiotics, on other factors predicting antibiotic resistance [9] and on how to make interventions most effective. Efforts should be continued to improve the quality of prescription, avoiding over- and underprescription [10]. This requires a strong political commitment and a joint engagement of the many involved players, integrated in the BAPCOC 2014–19 strategic plan [11].
REFERENCES [1] OECD. Health at a glance 2015: OECD indicators, Paris: OECD Publishing; 2015. http://dx. doi.org/10.1787/health-glance-2015-en. [2] Gerkens S, Merkur S. Belgium: health system review. Health Syst Trans 2010;12(5):1–266. [3] Goossens H, Coenen S, Costers M, De Corte S, De Sutter A, Gordts B, et al. Achievements of the Belgian Antibiotic Policy Coordination Committee (BAPCOC). Eurosurveillance 2008;13(46):1–4. [4] Van Gastel E, Costers M, Peetermans WE, Struelens MJ. Nationwide implementation of antibiotic management teams in Belgian hospitals: a self-reporting survey. J Antimicrob Chemother 2010;65:576–80. [5] Lambert ML, Bruyndonckx R, Goossens H, Hens N, Aerts M, Catry B, et al. The Belgian policy of funding antimicrobial stewardship in hospitals and trends of selected quality indicators for antimicrobial use, 1991-2010: a longitudinal study. BMJ Open 2015;5:e006916. http://dx. doi.org/10.1136/bmjopen-2014-006916. [6] Coenen S, Gielen B, Blommaert A, Beutels Ph, Hens N, Goossens H. Appropriate international measures for outpatient antibiotic prescribing and consumption: recommendations from a national data comparison of different measures. J Antimicrob Chemother 2014;69:529–36. [7] http://ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx. [8] Bruyndonckx R, Hens N, Aerts M, Goossens H, Molenberghs G, Coenen S. Measuring trends of outpatient antibiotic use in Europe: jointly modelling longitudinal data in defined daily doses and packages. J Antimicrob Chemother 2014;69:1981–6. [9] Blommaert A, Marais C, Hens L, Coenen S, Muller A, Goossens Beutels P. Determinants of between-country differences in ambulatory antibiotic use and antibiotic resistance in Europe: a longitudinal observational study. J Antimicrob Chemother 2014;69:535–47.
Belgium Chapter
19.6 257
[10] Coenen S, Costers M, De Corte S, De Sutter A, Goossens H. The first European Antibiotic Awareness Day after a decade of improving outpatient antibiotic use in Belgium. Acta Clin Belg 2008;63:296–300. [11] http://consultativebodies.health.belgium.be/sites/default/files/documents/policy_paper_ bapcoc_executive_summary_2014-2019_english.pdf.