an analysis of the sniv dataset 2016 regarding the...

Advicereport|SNIVprotocolanddata2016|ArsenBarseghian

ANANALYSISOFTHESNIVDATASET2016REGARDINGTHEANTIBIOTICUSEINDIFFERENTNURSINGHOMESAnadvisoryreportonthepossibleimprovementsoftheSNIVprotocol

SUPERVISORS: Onlocation:prof.Dr.LindaVerhoefUniversity:prof.dr.KatjaTaxisScience,Business&Policy:prof.dr.Gert-JanEuverink

Educationalinstitution: UniversityofGroningen,FacultyofMathematicsandNaturalSciencesSpecializationScience,Business&Policy

Author:ArsenBarseghianStudentnumber:s1825852 MasterProgramme:MedicalPharmaceuticalSciencesInternshipOrganisation:RIVMDate:08-07-2017

Advicereport|SNIVprotocolanddata2016|ArsenBarseghian2

Disclaimer

This report has been produced in the framework of an educational program at the University ofGroningen,Netherlands,FacultyofMathematicsandNaturalSciences,ScienceBusinessandPolicy(SBP)Curriculum.Norightsmaybeclaimedbasedonthisreport,otherthandescribedintheformalinternshipcontract. Citations are only possible with explicit reference to the status of the report as a studentinternshipproduct.


ContentsListofTablesandFigures.............................................................................................................................4

Listofabbreviations.....................................................................................................................................5

Prologue.......................................................................................................................................................6

Executivesummary......................................................................................................................................7

I.Introduction..............................................................................................................................................8

IIa.Selectionofnursinghomesandresidents............................................................................................14

Participatingnursinghomesandresidents............................................................................................15

IIb.Datacollection.....................................................................................................................................16

Reasonsfornoparticipation..................................................................................................................16

IIIa.Residentcharacteristics.......................................................................................................................17

IIIb.Dataanalysis.......................................................................................................................................20

IIIc.Statisticalanalysis................................................................................................................................20

ABuseindifferentperiods.....................................................................................................................22

ABuseindifferentnursinghomes.........................................................................................................24

ABuseindifferentspecialisms...............................................................................................................27

VariationinABuseinNHsandthemeanofABuseintheNetherlands................................................32

Conclusionofscienceresults.................................................................................................................35

IV/VAdvice/Implementation.....................................................................................................................36

DigitalizationoftheElectronicaClientsDossier(ECD)...........................................................................36

SNIVparticipationcertificate(includingatraining)...............................................................................37

Selfregistration......................................................................................................................................39

References..................................................................................................................................................40

AppendixI..................................................................................................................................................43

Appendix2.................................................................................................................................................44

Appendix3.................................................................................................................................................45

Appendix4.1..............................................................................................................................................46

Appendix4.2..............................................................................................................................................47


ListofTablesandFigures

Table1.ConditionfortheSNIVprotocol...................................................................................................14Table2.In-andexclusioncriteriaforclients..............................................................................................15Table3.Usabledataofthedatabaseusedforthestudy...........................................................................18Table4.FactorsusedinthisstudytocorrelatetoABuse.........................................................................20Table5.Medicineclassesusedinnursinghomesin2016.........................................................................22Table6.Medicineclassesusedindifferentnursinghomesin2016..........................................................24Table7.PercentageoftheantibioticuseofdifferentspecialismsofallthenursinghomesinApril201628Table8.PercentageoftheantibioticuseofdifferentdepartmentsofallthenursinghomesinNovember2016...........................................................................................................................................................29Table9.SWOT-analysisofthefirstadvice.................................................................................................37Table10.SWOT-analysisofthesecondadvice..........................................................................................38Table11.SWOT-analysisofthethirdadvice..............................................................................................39

Figure1.Registrationofinfectionduringadmission.................................................................................11Figure2.ParticipantsinAprilandNovember2016...................................................................................15Figure3.Reasonsgivenbynursinghomeclusterswhenaskedwhythedoordon’tparticipatetotheSNIVprotocolin2016.................................................................................................................................17Figure4.AmountofDDDsper1000residents/dayinnursinghomesin2016..........................................23Figure5.ABusepernursinghomeinApril2016.......................................................................................25Figure6.ABusepernursinghomeinNovember2016..............................................................................26Figure7.ABuseperspecialisminApril2016.............................................................................................30Figure8.ABuseperspecialisminNovember2016...................................................................................31Figure9.VariationinABusersinnursinghomesbetweenandwiththenursinghomeclustersinApril2016...........................................................................................................................................................33Figure10.VariationinABusersinnursinghomesbetweenandwiththenursinghomeclustersinNovember2016..........................................................................................................................................34


ListofabbreviationsAB: AntibioticsATC: AnatomicTherapeuticChemicalclassificationBRMO: BijzonderResistantMicro-OrganismsDDD: DefinedDailyDoseECD: ElectronicallyClientDossierESBL: ExtendedSpectrumBeta-LactamaseHCAI: HealthCareAssociatedInfectionLRTI: LowerrespiratorytractinfectionMDRO:Multi-DrugResistantOrganismMRSA: MethicillinResistantStaphylococcusAureusNHs: NursinghomesPEG: PercutaneousendoscopicgastrostomyPG: PsychogeriatricRIVM: RijksinstituutVolksgezondheidenMilieu(NationalInstituteforPublicHealthandEnvironment)SNIV: SurveillanceNetwerkInfectieziektenVerpleeghuizenSPSS: StatisticalPackagefortheSocialSciences(statisticalcomputerprogramme)SWOT: Strength,Weakness,OpportunityandThreatsUTI: UrinarytractinfectionVRE: VancomycinResistantEntrococciWHO: WorldHealthOrganisationWIP: WorkgroupInfectionPrevention


PrologueThisrapportisdirectedtotheRIVMwiththemaingoaltoadvicetheRIVMabouttheprocessinwhichtheSNIVprotocolisbeingexecutedandhowmoreparticipantscanbemotivatedtoenrollintothisregistrationprocess.Inthepast6months,Ihavelearnedalotandinmoredetailabouthowtoorganizemyworkproperly.Ihavelearnedtosetupdeadlinesandberesponsibleforthem,workinginateamandexplainingmyworkdevelopments.MajoradvanceshavebeenachievedinmySPSSworkingmethodandIhavelearnedtoworkwiththestatisticalprogramR.ThebiggestimprovementisthatIhavelearnedtolookatacompanyinadifferentway.Toseethebiggerpicturewhenaproblemisdefinedandtoseehowtheseproblemscanbesolved.MeaningIknowhowtostartandwheretostartlookingwhenaproblemisdefined.IwouldliketothankeveryoneattheRIVMwhohasworkedwithmeinthepast6months,whereIimmediatelyfeltathome.SpecialthanksgotoLindaVerhoef,KatiHalonen,RudyHertroys,EmmaSmid,PaulBergervoet,SuzannevandeHoefandSabinedeGreefffortheextrahelpandguidestheyhavegivenme.IwouldliketothanktheSNIVteamforpointingouttheimportanceofpracticalworkandlettingmejointhemtoperformtheregistrationforthepointprevalencestudy.Thisshowedmetheimportanceandthelevelofaccuracythatisneededfortheregistrationprocess.Finally,Iwouldliketothankprof.dr.Gert-JanEuverinkandprof.dr.KatjaTaxisfortheireducational/scientificsupportandsupervisionduringmy6monthsinternshipattheRIVM.Ihopethatyouwillfindthisreportbothinformativeasenjoyabletoread.ArsenBarseghianUtrecht,7August2017


Executivesummary

EveryyeartheNationalInstituteforPublicHealthandtheEnvironment(RIVM)collectsalargeamountofdata regarding the antibiotic use of nursing homes in theNetherlands. This is called the surveillancenetwerkinfectieverpleeghuizen(SNIV).Thisnetworkiscreatedtomonitortheinfectionsthatoccurinnursinghomeseveryyearandtoalarmthenursinghomesforpotentialoutbreaks.TheproblemwiththecurrentsituationisthateveryyearlessnursinghomestendtoparticipatetothevoluntarySNIVprotocol.ThemaingoalofthisstudywastoresearchwhichresultscouldbeobtainedwiththecollecteddataofSNIV2016,whatthecollecteddatameansandhowtheSNIVprotocolcanbeimprovedsoeventuallymorenursinghomeswillparticipate.TheresultsshowedthattheAmoxicillinClavulanicacidwasthemostprescribeddruginthenursinghomesandtheurinarytractinfectionisthemostcommoninfectioninthenursinghomes.AzithromycinhasthehighestprescribeddoseinonenursinghomeandtheaverageusageinnursinghomesinAprilwas5.81%with8nursinghomespassing thisaverageand inNovember6.46%with9nursinghomespassing thisaverage.There were twomain reasons from all the nursing homes to not to participate to the current SNIVprotocol.Thenursinghomedidnothaveenoughtimetocarryouttheregistrationortheydidnothaveenoughpersonneltoparticipate,meaningtheyweretobusy.Analyzingthisproblem,theadvicetoofferhelptothenursinghomeswithlimitedtimewasintroduced,meaningthatRIVMpersonnelcangotothenursinghomeandcarryouttheregistrationforthem.ThissavestimeandresourcesforthenursinghomeandtheRIVMcancollectmoredatathanbefore.ThisadvicewasfoundtobesogoodthattheRIVMdecidedtoimplementitimmediately,causingmorenursinghomestoparticipate.Inthefuture,thesystemcanbeimprovedbydigitalizingthewholeprocess,meaningthatthenursinghomesdonothavetodotheregistrationanymorebuttheRIVMcanlogintotheirelectronicallyclient’sdossier(ECD)andcollecttheneededinformationwithouthavingtogotothenursinghomeorthenursinghomeshavingtomaketime.


I.Introduction

Worldwide,antibiotics(ABs)areoneofthemostknownanduseddrugs.Alsoinnursinghomes,asubstantialamountofantibioticsisused.Apercentageof47-79%ofalltheresidentsinanursinghomeisatleastonceayeartreatedwithantibiotics1.Themassiveuseofantibioticscontributestotheresistanceofbacteriaagainstantibioticsamongtheelderlyinnursinghomes.Thiscontributestotherisingchanceofinfectionsthataremoreaggressive,deathandsocialcosts(burden).Manydifferentorganizationsareworkingonawarenessandpreventionofresistanceandinfectionsamongpatients.TheWorkgroupInfectionPrevention(WIP)attheNationalInstituteforPublicHealthandEnvironment(RIVM)hasdevelopedguidelinestopreventthespreadofresistantbacteriaamongpeople2.OtherorganizationstrytoincreasetheawarenessofthedangersofincreasingantibioticuseandsoloweringtheamountoftotalABusedamongpatients.ABresistanceduetoexcessiveuseofABhasbecomeasignificantproblemworldwide.ThelowestamountofMultiDrugResistantOrganisms(MDROs)areseenintheNetherlandsandothercountriesinnorthernEurope.ThisisduethefactthatintheNetherlandsthesearchanddestroypolicyisdeveloped3.Thispolicyimpliesundertakingafewstepstocontainthediseaseinsteadofrespondingtoanoutbreak.ThiscomprisesconstantscreeningtodetectthecarriersofaMDROanddestroythebacteria.Possibleoutbreaksarebeingpreventedbyscreeningpeoplewhoarebeingsuspectedforcarryinga3.PeopleatriskareamongstotherpeoplefromforeigncountrieswhovisitedthehospitalorpeoplewhohadcontactwithpeoplecarryingorinfectedwithaMDRO.Thesepersonsaretreatedimmediatelyorputinquarantine.Peoplethatarehospitalizedhavetofillinaformwerethehavetoansweriftheyhavearoommatewhois/wasacarrierofanMDRO,theyworkwithcattleandiftheyhavebeenincontactwitha foreignhospital in the last year.By screeningand treating thesepeople, thehospitalminimizes thechanceofanoutbreakThepeoplewhoaretreated,havetoundergoafewscreeningsandtestnegativefortheMDRObeforetheyareconsideredcured.Thispolicydecreasesthechanceofanoutbreakanddealswiththeproblembeforeitbecomeshazardous.In2060,thepopulationof80yearsandolderwillaccountfor12%4ofthetotalpopulationofEurope.Theseelderlyarethemostvulnerableforinfectionsandareinneedofthemostcare.Mostoftheelderlywillgotoanursinghomeandliveinaclosedenvironmentwithapopulationofelderlylivingneareachother,increasingthechanceoftransmissionofinfections(MDRO)evenmore.Asthetreatmentofbacterialinfectionsaregettingmoredifficultaftereverytreatment,thisdevelopmentisbecomingathreatforthenationalhealthandinmoreparticularthehealthoftheelderly.TheRIVMisalreadymorethana100yearsthededicatedorganisationconcerningthepublicandenvironmentalhealthwithmorethan1,500employees5.TheRIVMhasacentralroleintreatinginfectiondiseasesandnationalpreventionandscreeningsprograms.Itisalsoknownasthetrustedadvisorforthesociety.


PointsofconcernfortheRIVMareeffectivetreatinginfectiondiseases,keepingthepopulationhealthy,makingsuregoodcareisprovided,thesafetyofthepopulationandimprovingthestatusoftheenvironment.TheRIVMcollectinformationanddataaboutallthesesubjectsandspreadstheknowhowbetweenpolicyworkers,scientists,inspectorsandforthemostofthesesubjectsalsoamongthepopulation.Everyyearnumerousrapportsaremadefilledwithadvicesbouttheenvironment,publichealthetc.TounderstandforwhotheRIVMworksandwhoisinterestedintherapportstheymake,hereisalistofalltheclientsoftheRIVM:

• TheMinistryofHealth,WelfareandSport• TheMinistryofInfrastructureandEnvironment• TheMinistryofEconomicAffairs• theEuropeanUnion• theUnitedNations• TheWorldHealthOrganization

TogetabetterinsightintheABuseandtheinfectiondiseasesinnursinghomes,theDutchgovernmenthasdevelopedanetworkcalledtheSurveillanceNetwerkInfectieziektenVerpleeghuizen(SNIV)6.TheSNIVisanetworkofnursinghomes,whichperformasurveillanceofABuseonnationallevel.Thedataisreceivedfromnursinghomesthattwiceayear(AprilandNovember),voluntarilyparticipatetotheSNIVprotocol.Thecollecteddatafromallthenursinghomesisanalyzed,comparedtothenationalmeanandsentbacktothecorrespondingnursinghomes.Inadditiontothis,thedataisusedforstatisticallyanalysesindifferentstudies.TherearetwokindsofSNIVsurveillanceprotocols.Theoneisapointprevalencesurveyandtheotheroneisanincidencesurvey7,8.Thesetwokindsofsurveillanceprotocolsaremadetomonitortheoccurrenceofhealthcareassociatedinfections(HCAIs)onacontinuebasisandoneonapointprevalencebasis.TheIncidencemeasurementsstartedin2009wheretheparticipatingnursinghomessendeveryweektheincidenceofthecurrentinfectionsintheirnursinghomes.Thisisdonetomonitorthedeterminantsoftransmissioninordertoimprovetheinfectionpreventionandtherapyinnursinghomesandeveninthehospitals.Thesurveillanceisperformedelectronically,whichmeansthatallthecollecteddataistransferredtothedatasetofRIVM.Andfinallythenursinghomesareaskedtosendtwomonstersofpatientswithinfluenza-likesymptomstotheRIVMforsurveillancediagnostics.Theprevalence(incontrarytotheincidencesurveillance)isperformedtwiceayear(AprilandNovember)wherethepresenceoftools(urinecatheterforexample)isregisteredbutantibioticuseinthatdayaswell.DuringthismeasurementthefollowingHCAIsarebeingmonitored:

• Sepsis/bacteraemia• Lowertractrespiratoryinfections• Urinetractinfections• Gastro-intestinalinfections• Bacterialconjunctivitis


Thisprotocolisdevelopedbytheteamworkofexpertslikegeriatricians,adviser’sinfectionprevention,physicianmicrobiologistsandwiththeRegionaalZorghygiëneNetwerkNijmegenenOmstreken(REZON).WiththeprevalencemeasurementstheoccurrenceofHCAIscouldbeevaluatedonanationallevel.ThedatacollectedcouldbeareasontostartaninterventionofevensupplementaryresearchinaspecificnursinghomeanditcouldalsomapthehighriskpopulationsfortheRIVM.Duringthissurveillancenodataiscollectedabouttheskinandwoundinfections.ThisisdonebytheChronischewondvandeLandelijkePrevalentiemetingZorgproblemen(LPZ)8whichisdoneinAprilandNovemberaswell.InthisstudywewillfocusontheprevalencepartoftheSNIVandnotontheincidence.Whenthenursinghomesregisternewclientstheyhavetocheckforinfectionsandiftheclientcomesfromahospitalorothernursinghometheycheckifthereisatreatmentonthatmoment.Ifthisisthecasethanitischeckiftheinfectionwaspresentonthedayofadmission.Infectionsoccurredbefore48hoursafterregistrationareconsideredinfectionsduringregistration,meaningitisnotahealthcareassociatedinfection.ThisisdonetopreventunknownHCAIandinfectionswiththeotherresidents.Thereisacertainprotocolwhichthenursinghomeshavetofollowinordertoidentifytheinfectionintherightwaymeaningonthedayofregistration9.AsseeninFigure1,thereisaprotocolwhichthenursinghomeshavetofollow.ThefigureillustratesdifferentsituationsinwhichthenursinghomeshavetoregistertheinfectionasaHCAI,asaninfectionfromahospital,ainfectionfromanothernursinghomeorainfectionfromaunknownsource.Afewexamplesofhowtheidentificationworkswillbegivenbelow:ExampleB1.Theclientisregisteredinanursinghomefromahospitalandbefore48hoursaninfectionisfound.ThismeansthattheinfectionisnotaHCAIbutaninfectionduringregistrationmeaningithappenedinthehospitalExampleB7.Onthedayofregistration,theclientistreatedforaninfection.Betweenthefirstnursinghomeandtheregistrationtothenewnursinghometheclienthasbeeninahospital.ThismeansthattheinfectionisnotaHCAIfromthecurrenthospitalbutisoriginatedfromthelastnursinghome.ExampleBD.Onthedayofregistrationaninfectionispresentanditoccurredbefore48hoursofregistration.ItisunknownwheretheclientcomesfrommeaningitisnotaHCAIbutaninfectioninanunknownsource.


Figure1.Registrationofinfectionduringadmission


EveryyeartheRIVMcollectsasmuchaspossibleparticipantsforthisSNIVprotocolsothedatasetwillbeasbigaspossiblefortheresultstobeasreliableaspossible.TheparticipationrateofthenursinghomestotheSNIVprotocolaredecliningeveryyearandcomparedtoforeigncountries,therearelessnursinghomesparticipatingtothesurveillancesysteminTheNetherlands.Thiswillbethecentralsubjectofthisadvisoryreport:

InwhatwayhasthecurrentSNIVprotocolbeimprovedsomorenursinghomesandnursinghomeclusterwillbemotivatedtoparticipate?

Toanswerthisquestion,themainquestionhastobedividedintotwosub-question:

• ForwhatreasondonursinghomesnotparticipatetotheSNIV?• HowistheSNIVregistrationperformedandhowmanynursinghomesdidparticipatein2016?

ThesecondgoalofthisstudyismappingtheABuseoftheparticipatingnursinghomesandfindoutwhatthereasonisforthedifferenceinABusebetweenthenursinghomes.AcorrelationbetweenABuseandtheoccurrenceofinfectiondiseasesorevenABresistancewillbesoughtindifferentnursinghomes.ThisreportpresentstheresultsoftheSNIVdatasetof2016Toanswerthesequestionsaliteratureresearchhastobeperformed.ThiswillincreasetheknowledgeabouttheSNIVprotocolandgivemoreinsightinwhataretheweakpointsofthemethodinwhichtheSNIVregistrationisperformed.TogainmoreknowledgeaboutthereasonwhythenursinghomesdonotwanttoparticipatenursinghomeswillbeaskedforthereasonwhentheydeclinetheofferofparticipationtotheSNIVregistrationtroughwhichthelargestreasonfornotparticipationwillbeidentified.Byknowingthereason,itwillmakeitmucheasiertosolvetheproblem.Thesecond(science)questionofthereportwillbeansweredbycalculusandstatisticalanalysisthroughwhichmoreinsightwillbeobtainedintheusedantibioticsinallthedifferentparticipatingnursinghomes.ThiswillhelptounderstandwhichantibioticsareusedthemostandwhatarethemostcommonHCAIsintheNetherlands.Theadvicereportisconstructedinthefollowingway:Inchapter2,amoredetailedviewwillbecreatedinthewaytheSNIVregistrationisperformed.AresearchwillbeperformedinhowtheSNIVregistrationprocessworks,whattheconditionsarefortheparticipantsbutalsowhattheworkingconditionsarefortheRIVMitself.Whattheinandexclusioncriteriaareforthenursinghomesandtheirresidentsandfinallywhoactuallydidparticipate.ThiswillbecomparedtothegeneralamountofnursinghomesintheNetherlandsin2016.Bydoingthisaparticipationratecanbecreatedsothiscanbecomparedtodifferentcountries.ThiswillgiveamoredetailedviewofalltheparticipatingnursinghomesinthetwodifferentperiodsoftheSNIVregistrationandofthenursinghomeswhichparticipatedinbothperiods(overlap).Furtherinchapter2thereasonfornoparticipationwillberesearchedanddiscussed.Agraphwillbecreatedfromalltheanswersofalltheapproachednursinghomesandbydoingthisthemostgivenreasoncanbeseen.


Thenursinghomeswillbeaskedaswellwhentheywillparticipateiftheywontsothereasonofthenursinghomesthatwillneverparticipatecanbeknown.Byknowingwhythesenursinghomesdonotparticipatethisreasoncanbesolved.Inchapter3aresearchwiththecollectedSNIVdatasetof2016willbeperformed.Aglobalviewoftheantibioticuseindifferentnursinghomesandthedifferentkindofantibioticsusedinthesenursinghomeswillbecreated.BeforetheresultscanbeusedthevalueshavetobecalculatedintoDefinedDailyDoses(DDDs).Thisisaninternationalvaluethatisusedtocalculatethedosageofmedicine.ByconvertingthedosageusedintoDDDstheresultscanbecomparedwithinternationalvaluesandresultsofforeignnursinghomes.Withthisinformationgraphsandtablescanbecreatedshowingwhichnursinghomehadthemostantibioticsusedinwhichperiodenwhichantibioticwasthemostused.ThiswillgiveamoredetailedviewoftheHCAIsthatoccurinthenursinghomesintheseperiodsandhowtheyaretreated.Moreinformationabouttheantibioticuserswillbecollectedandfinallythenursinghomeswhichdifferthemostfromtheirnursinghomesclustersconcerningantibioticuse.Andhowtheydifferfromthenationalaverageantibioticuse.Alltheinformationcollectedwillbeusedtoseeifthenursinghomesdiffersignificantlyinthedifferentsituationsfromeachotherandwhatthismeans.Chapter4andchapter5areusedtoevaluatetheresultsfromchapter2.ThisisdoneinordertogiveanadviceinhowtoimprovetheSNIVpointprevalenceregistrationprocesssomorenursinghomeswillbemotivatedtoparticipated.InthesechaptersmultipleadviceswillbegivenbutaSWOTanalysisforeachadvicewillbeperformed.Thestrengths,weaknesses,opportunitiesandthethreatsofeachadvicewillbeevaluatedinordertoseeifitisfeasible.Inthesechapterstheimplementationoftheadviceswillbecoveredandwillbeexplainedhoweveryadvicewillhavetobeexecutedforittobeimplementedinthecorrectway.Theinternshipandadvicereportiswritteninthetimeperiodof9February2017until11August2017inordertointegratethescienceandpolicypartintothisreport.Inthisreportthescienceisusedasabackgroundinformationsothepolicypartcanbecorrected/improvedintherightway.Thesciencepartisneededforthereadertoknowwhatwillimproveandwhatkindofimpacttheimprovementofthepolicypartwillhavewhentheadvicesareimplemented.ThebackgroundoftheinternisMedicalPharmaceuticalSciencesandtheinternhasabachelordegreeinPharmacywhichdidcomeinhandybecausethereportismainlyaboutantibioticuseandtheeffectsofit.Duringthisreporttheinternissupervisedbyprof.dr.LindaVerhoef(RIVMsupervisor),prof.dr.Gert-JanEuverink(ScienceBusinessPolicysupervisor)andKatja


IIa.SelectionofnursinghomesandresidentsEachyear,theRIVMapproachesallnursinghomesintheNetherlandsbymailortelephonetoinvitethemtoparticipateintheSNIVprevalencestudy.ParticipationinSNIVisfreeofchargeforallnursinghomesandnursinghomescanparticipatevoluntarily.Thenursinghomescanchoosetoparticipateonceortwiceayear,i.e.inAprilorinNovember.Tobeincludedintheprevalencestudy,thenursinghomeshadtohave50ormorebedstoensurereliableprevalence.Inordertokeepthedatacollectionandinformationreleaseconsistenttowardsthenursinghomes,conditionsweremade.Theseconditions,whichRIVMhastofollowinordertobeabletoperformtheSNIVprevalencestudyarelistedinTable1.Table1.ConditionfortheSNIVprotocol Conditions1.

TheSNIV-teammustorganizeandprovidetheyearlyscheduleoftheprevalenceresearchinthemonthsofAprilandNovember.Nopatientsareallowedtobeincludedtothestudyexceptinthesetwomonths.

2. EveryyeartheSNIV-teamorganizesaninformationalmeetingfortheparticipatingnursinghomes

3. ThenursinghomesarefreetodecideifitparticipatesinAprilorNovemberorboth4. Participationisfreeofchargeforthenursinghomes5. Alltheparticipatingspecialistgeriatriciansneedtobeinformedabouttheconditions6. Aplanofactionshouldbepresentedstatingthewaythesurveillancewillbeperformed7. Thedefinitionsoftheinfectiondiseasesscreenedduringthesurveillancemustbeacceptedby

theparticipatingnursinghomes.8. Foreachdepartmenttheclientsmustberegisteredonthesameday9. Onlyoneregistrationformperclientmustbecompleted.Ifaclientistransferredtoanother

departmentandisregisteredagain,onlythefirstregistrationdatewillbeused.10. Toreceivereliabledatathespecialistgeriatricians(intraining),basisdoctor,nurse-practitioner

orexpert-infectionpreventionhavesufficientexperienceandtrainingtoperformthesurveillance.Doubtfulcausesareinternallyinvestigated.

11. ThedataiselectronicallydeliveredtoSNIV(throughOSIRIS,awebapplicationoradatafileaccordingtothedataspecificationsofSNIV)withinfourweeksafterthelastregistrationday.(ScreeningsinAprilbefore1stofJuneandscreeningsinNovemberbefore1stofJanuary)

12. AftertheexhibitofdatatotheSNIV,alltheparticipatingnursinghomesreceiveanautomatizedrapportwiththeirprevalencenumbersofeveryinfectiondiseaseincomparisonwiththenationalgeneral.Ifthenursinghomehasmorethanonelocationandwantsarapportperlocationtheneverylocationhastosendhisapplyingform.Thisrapportwillbesentonlyifthelocationhasmorethan50beds.

13. ExternalvalidationbytheSNIV-teamwillbeperformedatrandomAllresidentsinanursinghomeareincludedduringtheSNIVprevalencestudyexcepttheoneswhodonotpassthecriteria.Asseenin

Table2,toparticipatetotheSNIVprevalencestudyalltheparticipatingresidentshavetofollowtheseconditions.Bysettingtheseconditions,theRIVMmakessurethatthedataisnotbiased.


Table2.In-andexclusioncriteriaforclients Clientsconditions1. Thissurveillanceisonlyforclientswithspecialistgeriatricians2. Clientswhoareincludedlessthan48hoursafterregistrationarenotincludedinthe

surveillance3. Residentswhoareinfectedandareregisteredinthenursinghomelessthantwoweeksawill

notbeincluded4. Clientswhodiedoraredischargedonthedayofregistrationareincludedinthesurveillance5. Ifduringthesurveillanceanoutbreakoccurs(forexampletheNorovirus)thehospitalcanstill

participateintheprevalencestudy.ParticipatingnursinghomesandresidentsSeventhousandninehundredtwenty-threeresidentsfrom75differentnursinghomesand23differentnursinghomeclustersparticipatedinthepointprevalencestudyoftheRIVMin2016.The75nursinghomesbelongtodifferentgroups(nursinghomeclusters),thesenursinghomeclustersconsistofdifferentnursinghomelocationsownedrunbyoneorganization.Fifty-twoofthetotalamountofnursinghomesparticipatedinApriland36participatedinNovember.Therewasanoverlapof13nursinghomes,whichparticipatedinbothAprilandNovemberasseeninTable3.ThisisalsodepictedinFigure2,showingtheparticipationandoverlapofthenursinghomeclustersandnursinghomeswhoparticipatedbothinAprilandinNovember.

April14Nursinghomeclusters52Nursinghomes4025residents

November9Nursinghomeclusters23Nursinghomes3898residents

Overlap6NHclusters13NHs

Figure2.ParticipantsinAprilandNovember2016


IIb.DatacollectionThenursinghomesdeliverthedatabycompletingaregistrationformforeachinhabitantofthenursinghome(resident),statingwhethertheyareusingaspecificmedicineandiftheyhaveaninfectionaccordingtofivedefinitionsbasedonclinicalcriteria(Table1):sepsis/bacteremia,lowerrespiratoryinfection,urinarytractinfection,gastrointestinalinfectionandbacterialconjunctivitis.Duringthisstudyonlyquestionsabouttheantibioticsprescribed,infectioncasesandtheresistancecarriersamongthesubjectswillbeused.Theformisreadandcompletedbythespecialistgeriatricians10.Preferably,theformsforallthesubjectshavetobecompletedinonedaybutthisisnotpossible.Theformsarecompletedperspecialisminoneday,howevertheregistrationforonenursinghomecanbedoneinonemonth.Asthegeriatricianshavelimitedrecoursesandtime,theyspreadtheregistrationoveramonthandfillintheformsasifitwasdayoneofregistration.AllthedataisthensenttotheRIVMwheredataarechecked,cleanedandanalyzed.Inonemonth,eachparticipatingnursinghomereceivesinformationabouttheirprevalenceofinfectionsandantibioticusagecomparedtotheotherparticipatingnursinghomesintheNetherlands.ReasonsfornoparticipationWhenthenursinghomeswereapproachedforparticipationtotheSNIVprotocolin2016,thecalleralsoaskedwhytheydidordidnotwanttoparticipate(Figure3).Thisisdonetofindthesourceofthedecliningtrendintheparticipationrateandtoknowhowtomotivatemorenursinghomestoparticipateinthefuture.In2016,75nursinghomesparticipatedtotheSNIVprotocol.Knowingthattherewere2377nursinghomesintotalintheNetherlands11thismeansthatonly3.2%ofallthenursinghomesintheNetherlandsparticipatedtotheSNIVprotocol.In2015,theamountofnursinghomesparticipatedtotheSNIVprotocolwhere75meaningadeclineof3nursinghomes.OthercountrieslikeGermanyandAmericahavethesamesurveillancesystemwheretheamountofABuseisbeingmonitored(eithercontinuouslyorincidentally).IncontrarytotheNetherlands,theparticipationrateinthosecountriesismuchhigher.InMinnesotaforexample,anABusesurveillancewasperformedand393nursinghomesdidparticipatewithaparticipationrateof96%12,whichis30timeshigherthanintheNetherlands.AsseeninFigure3therearemanyreasonsgiventonotparticipate,whichvariesfromnointeresttonotimeorrecourses.Thedifferentcolouredcirclescorrespondtotheanswersfor(no)participation.Thenursinghomeswhichdidnotparticipateandsaidthatwillnotparticipateinthefuturearethemostinterestingnursinghomes,sincetheyhaveonemainissueandbelievethatthiswillneverbesolvedsotheycannotparticipate.Theforemostreasongivenbythesenursinghomeswasalackoftimeandresources.ThismeansthattheadvicegiventotheRIVMmusttaketheproblemofthesenursinghomesintoconsideration.Theadvicesmustsolvethelackofresourcesoreventime.


Figure3.Reasonsgivenbynursinghomeclusterswhenaskedwhythedoordon’tparticipatetotheSNIVprotocolin2016.Thesizeofthecirclescorrespondentstotimesthereasonisgiven(1-5).Theoverlapbetweenthecirclesmeansthatanursinghomeclustershavemorethanonereason.ThecolormeansthatthereasongivenbyanursinghomeclusterdidparticipatetotheSNIV(green),didnotparticipate(red),didnotparticipatethisyearbutwillparticipatethenext(orange)anddidnotparticipatethisyearanditisnotknownwhentheywill(blue)

IIIa.ResidentcharacteristicsTable3showsalltheinformationcollectedfromtheSNIVdataset.DatawascollectedinAprilandNovember.ThesedataarechosenbecausetheyaresimilarinweatherconditionsandamountofABused.TheresultsshowthatthiscorrespondstotheamountofDDDsusedbythenursinghomes.InApril45.25DDDs/1000residents/daywasusedandinNovember51.37DDDs/1000residents/day.Thisonlydiffers6.12DDDs,whichisnotsignificant.AsstatedinTable3,inApril,68.7%ofthetotalpopulationwasfemaleandinNovember65.9%.OfthepopulationofApril,thelargestgroupofpeople(47.5%)isbetweentheageof80and89,whichisalsothecaseinNovember(44.4%).ThebiggestpartofthetotalpopulationisinthePGdepartment(56.0%),followedbythesomaticdepartmentwith34.5%andthesmallestpopulationisintherehabilitationdepartmentwith9.5%ofthetotalpopulationinNovember.Aprilhasthesamedistributionwith58.4%atthePGdepartment,33.4%inthesomaticdepartmentand8.2%comesfromtherehabilitationdepartment.


Table3.Usabledataofthedatabaseusedforthestudy 2016April

Total(%)

2016AprilZI(%)

2016NovTotal(%)

2016NovZI(%)

Nursinghomeclusters 14(Total23) 15(Total23)NursinghomeLocations 52(Total75) 36(Total75)Inhabitants 4025(Total

7923)83(2.1) 3898(Total7923) 119(3.1)

Man/woman 1259/2766 25/58 1330/2568 42/77Age:

- <60- 60-69- 70-79- 80-89- >90

121(3.0)250(6.2)696(17.3)1910(47.5)1048(26.0)

3(2.4)4(1.6)11(1.6)45(2.4)20(1.9)

132(3.4)316(8.1)849(21.8)1730(44.4)871(22.3)

3(2.3)7(2.2)23(2.7)65(3.8)21(2.4)

Specialism:- Somatic- Revalidation- Psychogeriatric

13463312348

30(2.3)10(3.0)43(1.8)

13433712184

60(4.5)24(6.5)35(1.6)

Livingconditions:- Privatebathroom- Privatetoilet- Multi-personroom- Singleroom

140814225223503

21(1.5)21(1.5)78(14.9)5(0.01)

118412277823116

33(2.8)37(3.0)95(12.1)24(0.8)

HealthCareassociatedInfections:- Sepsis/bacteraemia- LRTI- Urinarytractinfection- Gastro-intestinalinfection- Bacterialconjunctivitis

2166312

03967133

Antibioticsuse 234 68(29.1) 252 101(40.1)TwotypesofAntibioticsuse 11 4(36.4) 17 5(29.4)DDDsper1000residents/day 45.25 51.37Aidingtools

- urethracatheter- suprapubiccatheter- peripheralcatheter- tracheostomy- PEG-catheter

(n=353)244671338

(n=12)9(3.7)1(1.5)0(0)0(0)2(5.3)

(n=498)3218431049

(n=28)14(4.4)9(10.7)1(33.3)4(40)0(0)

CarriersBRMO- MRSA- ESBL- VRE- Clostridiumdifficile- Norovirus

(n=72)1947411

(n=3)1(5.3)2(4.3)0(0)0(0)0(0)

(n=68)356136

(n=6)0(0)3(5.4)0(0)0(0)3(50)

Monsterstaken 338 2(0.6) 0 0(0)


Furthermore,therewerefivetypesofinfections:Sepsis/bacteraemia,infectionsofthelowerrespiratorytract,urinarytractinfection,gastrointestinalinfectionandbacterialconjunctivitis,ofwhichtheprevalenceinAprilwererespectively:2,16,63,1and2andinNovember:0,39,67,13and3.ThemostcommoninfectionisUrinarytractinfection(UTI).Seventy-fivepercentoftheparticipantswhohaveaHealthCareAssociatedInfection(HCAI)haveUTIinApril.InNovember,themostcommoninfectionisagaintheUTIwith56.3%ofthetotalpopulationofparticipantswithaHCAI.AsseeninTable3,thegroupwiththemostcathetersisparticipantswithaurethralcatheter.ThisappliesforAprilaswellasforNovember.Fromalltheparticipantswithacatheter,thegroupwiththepercutaneousendoscopicgastrostomy(PEG)-catheterhadthehighestamountofHCAIsApril(5.3%).InNovember,thegroupwithtracheostomy(40%)hadthehighestamountofHCAIs.InhabitantswhohaveasingleroomhavetheleastHCAIsandthepeoplewithamulti-personroomhavethemost.ThisdistributionisthesameforAprilandforNovember.AsseeninTable3therewasaparticipationof75nursinghomesin2016.IntheNetherlands,2372nursinghomesprovidetheelderlyhomeandcare12Meaning3.2%ofallthenursinghomesparticipatedin2016totheSNIVprotocol.Thenursinghomesdidnothavetherequiredtimeorpersonneltocollectalltheinformation,neededtoparticipate.ThedifferenceofHCAIprevalencewasthehighestfortheresidentsof80-89yearsofage.ThiswasthecaseforAprilandNovemberbutalthoughtheamountofresidentsofthatagewerelessinNovember,theamountofresidentswithaHCAIwerehigherinNovember.Thereasonforthiscouldbetheperiodofmeasurement.AlthoughthefluisnottreatedwithABandisnotconsideredanHCAI,theeffectofaflucouldbeanLRTIresultinginatreatmentwithanAB.Alltheparticipatingnursinghomesconsistedofthreespecialisms:somaticcare,revalidationandthepsychogeriatriccare.TheamountofincludedresidentsperspecialismdidnotdifferbetweenthetwoperiodsbuttheamountofHCAIsdid.Thedifferencesarenotsignificant,buttherevalidationdepartmenthasinbothperiodsahigherpercentageofHCAIthantheothertwodepartments.Theexpectationwasthatthepsychogeriatricwouldhaveahigherpercentagebecauseoftheconditionoftheresidentslivingthere13.ThereasonthattherevalidationdepartmenthasahigherHCAIpercentagecouldbeassociatedwiththatthoseresidentscomefromthehospitaloranoperationandhavebeenmoreincontactwithsuchinfections.ThisisalsoseenintheamountofABusedinthisdepartment.AsseeninFigure7andFigure8,thehighestamountofABusedinAprilandinNovemberwasintherevalidationdepartment.MeaningthattherecouldbeacorrelationbetweenABuseandHCAIs.Everynursinghomehasdifferentconditionswheretheresidentslivein.AsseeninTable3,residentslivinginasingleroomhavealowerchanceofobtainingaHCAIcomparedtothosesharingaroom,despitetheeffectbeingnotstatisticallysignificant.MostcommonHCAIinbothperiodswastheUrinarytractinfection.Also,theurinarycatheterswerethecathetersmostusedbytheresidents.Asstatedbefore,thereisacorrelationbetweencatheteruseandUTI14.ThiscouldbethereasonforthehigherprevalenceofUTIs.Tobesurethisisthecase,moreresearchhastobedoneconcerningthedifferentfactorsandconditionswheretheresidentslivein.


IIIb.DataanalysisAsseeninTable4,thefollowingfactorsareinvestigatedfortheirpossiblecorrelationwithantibioticusage.DuringtheSNIVregistration,thegeriatriciansalsofillalistofpossiblefactorsthatcouldinfluencetheuseorresistancetoantibiotics.

Thislistconsistsofdifferentfactorsthatarenotallproventoinfluencetheantibioticuse.SpecialistsaddorremoveeveryyearfactorsthatcouldinfluencethisandthefactorsarechosenfromownexperienceorwhatatthattimewasproventoplayaroleinABresistance.ThismeansthatthelistchangeseveryyearandstaysuptodateconcerningfactorsthatmayinfluenceABuseorresistance.

Table4.FactorsusedinthisstudytocorrelatetoABuse Factors1. Age2. Gender3. Livingconditions4. HCAI5. Specialism6. HavingacatheterIIIc.StatisticalanalysisUsingSPSS,informationaboutthetotalamountofantibioticsusednationwide,totalamountofantibioticsusedinnursinghomesandindifferentdepartmentsofthenursinghomeswillbeanalyzedandevaluated.SignificancebetweenvariablesofinterestwillbecalculatedthroughanindependentTtestinSPSSversion24.0.0.1.Thetotaldoseofantibioticusewillbecalculatedindefineddailydoses,makingitpossibletocomparedrugconsumptionbetweennursinghomes.Thedefineddailydose(DDD)wascreatedinconjunctionwiththeAnatomicalTherapeuticChemical(ATC)classification.Thistechnicalunitisassignedtoeachdrugattheirfifthlevelofclassification.TheDDDrepresentstheaveragemaintenancedoseperdayinadultsfortheirindication15.TheATCcodesandtheDDDsarealldescribedintheWorldHealthOrganizationCollaboratingCentre16withaDDDandanATCcodeforeverydrug.Normally,antibioticconsumptionisexpressedinDDDper1000inhabitants/dayforpatientsoutsideofahospitalandDDDper100beddaysforpatientsinhospitals.Becausethisresearchconcernsnursinghomesinsteadofhospitals,theDDDswillbeexpressedinDDDper1000residents/dayifthecollecteddataissufficient.(asseeninRoukensetal.17astudyaboutSurveillanceofantimicrobialsuseinDutchlong-termcarefacilities).ToconvertthedataintoanumberofDDDs,theATCclassificationsandthequantityofdrugsusedisneeded.Toexplainthisinmoredetail,belowanexampleisgiven.


Example1A47-year-oldmanreceivesaprescriptionforatotalof24ciprofloxacin500mgtablets.TheamountofDDDsinthisprescriptioncanbecalculatedbymultiplyingthetotalreceiveddrugsbytheDDDconversionfactoroftheappropriatedrugs(ThiscanbefoundintheWHOCC16.Meaningifthedoseoftheprescribedtabletis500mgandtheATC/DDDforthatspecificdrugis1gramthenonetabletcorrespondsto0.5DDD.0.5multipliedbythetotalamountofciprofloxacinprescribedequals12DDD.Therefore,aprescriptionof24times500mgciprofloxacintabletsequalstoatotalof12DDD.Thisdatacannowbecomparedorstoredforevaluation.ForthecalculationoftheDDDs,thefollowingformulaisused:

𝐷𝐷𝐷 =𝑁𝑖%

&'(𝑋

𝑁𝑖%

&'( =𝑁1+𝑁2+𝑁𝐾𝑁 =𝐷 ∙ 𝐴(Totalmgofprescribedmedicine)𝐷 =Dose𝐴 =Timesaday𝑋 =mg/DDDAmoxicillinClavulanicacidwasprescribedthreetimes625mg.625mgAmoxicillinClavulanicacidconsistof125mgClavulanicacidand500mgoftheworkingcomponentAmoxicillin.TheATCcodeisJ01CR02(www.whocc.no)withaDDDof1000mg.𝑁=500∙3D:500mgA:3X:1000mg𝐷𝐷𝐷= .//∙0

(///

𝐷𝐷𝐷=1.5Meaningthatatotalof1.5DDDAmoxicillinClavulanicacidwasprescribedExample2Apointprevalencestudywasperformedinanursinghomewith50inhabitants.Twoofthe50peopleusedantibiotics.Atotalof400mgNitrofurantoinand1000mgCiprofloxacinwasprescribed.ATCcodesoftheNitrofurantoinandCiprofloxacinareJ01XE01andJ01MA02withaDDDof200mgand1000mg,meaning2DDDofNitrofurantoinand1DDDofCiprofloxacinwasprescribedthatday.Thisamountmustbedividedby50andmultipliedby1000tocalculatetheDDDper1000inhabitantsperday.Meaning40DDDofNitrofurantoinand20DDDofCiprofloxacinwasprescribedper1000inhabitantsperdayinthisnursinghome.


ABuseindifferentperiodsTheresultsshowthatantimicrobialsforsystemicuse(J01)accountfor99.43%inApriland99.77%inNovemberofalltheantibioticsregisteredfortheinhabitantsofthe75participatingnursinghomes.Theremaining0.57%inApriland0.23%inNovembercorrespondstoantimycoticsforsystemicuse(J02).AsseeninTable5,inAprilthetopfivemedicineclassesusedareJ01C,J01F,J01X,J01MandJ01AwithJ01Casthemostfrequentusedclass(36.71%).AmoxicillinClavulanicacid(27.14%),Amoxicillin(7.47%),Flucloxacillin(2.08%)andDicloxacillin(0.02%)belongtothisclassandarethemostusedbeta-lactamantibacterialsinAprilbythenursinghomes.InNovember,thetopfivemedicineclassesusedareJ01C,J01X,J01F,J01MandJ01AwithJ01Casthemostfrequentusedclass(39.28%).AmoxicillinClavulanicacid(27.08%),Amoxicillin(8.21%),Flucloxacillin(2.78%)andFenticillin(1.21%)belongtothisclassandarethemostusedbeta-lactamantibacterialsinAprilbythenursinghomes.Table5.Medicineclassesusedinnursinghomesin2016

AsseeninFigure4(Appendix2),duringtheperiodsofAprilandNovemberthemostfrequentusedclassofantimicrobialistheAmoxicillinClavulanicacidwith12.28DDDinApriland13.91DDDinNovember(DDDsper1000residents/day).ThesecondmostfrequentprescribedantimicrobialistheNitrofurantoinwith6.96DDDinApriland8.76DDDinNovember.UnlikeAmoxicillinClavulanicacid,Nitrofurantoinbelongstotheclassofotherantimicrobials(J01X).

ATC %DDDApril ATC %DDDNovJ01 99.43 J01 99.77J01C 36.71 J01C 39.28J01F 18.03 J01X 21.45J01X 17.33 J01F 19.14J01M 13.21 J01M 11.62J01A 5.55 J01A 4.36


Figure4.AmountofDDDsper1000residents/dayinnursinghomesin2016

AprilandNovemberdonotdifferforantimicrobialsusedbythenursinghomes.InAprilandinNovember,17typesofantimicrobialswereusedtotreattheresidentsandtheyonlydifferintheprescribedDDDs(asseeninFigure4),whichisinAprilatotalof45.25DDDper1000residents/dayandinNovember51.37DDDper1000residents/day.Thisdifferenceisnotsignificant.ThecategoriesofantibioticsintheperiodsAprilandNovemberarethesameandtheyonlydifferintheamountused.Thismeansthattheseantibioticsarethemostcommonusedantibiotics.Almostalloftheprescribedantibioticsarebroad-spectrum,meaningthattheyareusedtotreatavarietyofbacterialinfectionsandsoincreasingthechanceofashortandsuccessfultherapy18.Becauseoftheempiricalknowledgeofthegeriatriciansabouttheantibioticsusedforthesetypeofinfections,abroadspectrumprescriptionisfavorable.Byprescribingthis,nocultureneedstobegrown,whichmakespatientscanbetreateditfasterandeasier.

NovembershowedhigherABusethanApril,differingby6.12DDD/1000residents/day.ThereasonfortheextrausersinNovembercouldbethatthemedicineareusedmoreprophylacticinNovemberthaninApril.NovemberistheperiodthatpossiblymoreLowerrespiratorytractinfections(LRTI)occurifthefluseasonhasanearlystart,sotopreventcomplicationsgeriatriciansmightusemoreantibiotics.Itisnotonemedicinethatisusedmore,asseeninFigure4alltheantibioticsareusedabout1DDDmore,showingamoregeneralpictureforthisdifference.ThemostcommonusedantibacterialsaretheJ01C(Beta-lactamantibiotics,penicillin’s),whichwasmentionedinthestudyofMcCleanetal19astudyaboutEuropeansurveillanceofantimicrobialconsumption.InthisclasstheAmoxicillinClavulanicacidfollowedbyAmoxicillinandFlucloxacillinwherethemostuseddrugsinApril.

0

10

20

30

40

50

60

April Nov

DDDs/1000re

siden

ts/day

DDDuseperperiod J02AAntimycoticsforsystemicuse

J01XOtherantibacterials

J01MQuinoloneantibacterials

J01GAminoglycosideantibacterials

J01FMacrolides,LincosamideandStreotogramins

J01Esulfonamidesandtrimethoprim

J01DOtherbeta-lactamantibacterials

J01CBeta-lactamantibacterials,penicillines

J01ATetracyclines


ThesameappliedforNovemberandJ01Cwasagainthemostusedantibioticclass.ThismeansthattheBetalactamantibiotics,penicillinsarethemostcommonusedABsintheparticipatingnursinghomes.ThisdoeshowevernotmeanthatthisisthemostusedantibioticintheNetherlands,sinceonly3.2%ofallthenursinghomesintheNetherlandsparticipatedtotheSNIVprotocol.TobeabletomakeastatementaboutthemostusedantibioticintheNetherlands,alargerstudyhastobeperformedwithmoreparticipants.

Inthisstudy,AmoxicillinClavulanicacidwasthemostuseddruganditisadrugthatismainlyusedtotreatRespiratoryinfections,Urinarytractinfections,skinandsoftpartinfectionsandinfectionofthebonesandjoints20.AsseeninTable1,themostcommoninfectionsinanursinghomeareUTI,lowerrespiratorytractinfectionsandBacterialconjunctivitis.Asmentionedbefore,AmoxicillinClavulanicacidisabroadspectrumantibiotic.Therefore,beforementionedconditions/infectionscanbetreatedwithAmoxicillinClavulanicacid.ThiscouldbeoneofthereasonswhythisantibioticisthemostuseddrugofallthenursinghomesinAprilandNovember20.

ABuseindifferentnursinghomesThemostfrequentprescribedantimicrobialclassinAprilandNovemberistheantibacterialforsystemicuse(J01)whichaccountsfor99.01%inApriland99.75%inNovember(Table6).Remaining0.99%inApriland0.25%inNovembercorrespondentstotheclassofantimycoticsforsystemicuse(J02).AsseeninTable6,inAprilthetopfivemedicineclassesusedareJ01C,J01F,J01X,J01MandJ01AwithJ01Casthemostfrequentusedclass(36.48%).AmoxicillinClavulanicacid(29.76%),Amoxicillin(5.22%)andFlucloxacillin(1.49%)belongtothisclassandarethemostusedbeta-lactamantibacterialsinAprilbythenursinghomes.InNovember,thetopfivemedicineclassesusedareJ01C,J01X,J01F,J01MandJ01AwithJ01Casthemostfrequentusedclass(38.45%).AmoxicillinClavulanicacid(24.88%),Amoxicillin(7.16%),Flucloxacillin(6.13%)andFenticillin(0.26%)belongtothisclassandarethemostusedbeta-lactamantibacterialinAprilbythenursinghomes.Table6.Medicineclassesusedindifferentnursinghomesin2016ATC %DDDApril ATC %DDDNovJ01 99.01 J01 99.75J01C 36.48 J01C 38.45J01F 25.84 J01X 23.43J01X 16.24 J01F 22.08J01M 8.84 J01M 8.20J01A 6.98 J01A 4.42


AsseeninFigure5,inApril,thenursinghomewiththemostfrequentDDDprescriptionwasnursinghome1withatotalof590.42DDD/1000residents/day.Thisis431DDDhigherthanthesecondhighestnursinghome(Nursinghome2with159DDD).ThemeanDDDsprescribedinApril2016was64.16.Azithromycinwasprescribedfor486.25DDDsinnursinghome1inApril2016bringingit526.26DDDs/1000residents/dayaboveaverage.Azithromycinisthesecondmostfrequentusedmedicine,asAmoxicillinClavulanicacidhasthehighestDDDsprescriptions.ThetotalamountofprescribedAmoxicillinClavulanicacidwasintotal801.76DDDs.Azithromycinwasprescribedfor591.02DDDs.AmoxicillinClavulanicacidwasprescribedin21ofthenursinghomesandAzithromycininonlyfournursinghomes,bringingittothesecondplaceinApril2016.ThetotalDDDprescriptiondifferencebetweennursinghome1and2isnotsignificant.

InNovember,thenursinghomewiththemostfrequentDDDprescriptionwasnursinghome22withatotalof333.33DDD/1000residents/day.Thisis119DDDshigherthanthesecondhighestnursinghome(nursinghome43with214.29DDD).ThemeanDDDsprescribedinNovember2016was70.83DDD.Azithromycinwasprescribedfor303.03DDDsinnursinghome22inNovember2016bringingit232.2DDDs/1000residents/dayaboveaverage.

0

100

200

300

400

500

600

1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930313233343536373839404142

Used

DDD

s/1000re

siden

ts/day

Participatingnursinghomes

ABuseperNHinAprilJ01CF Dicloxacilline

J02ACItraconazol

J01EBSulfamethizol

J01EETrimethoprim/SulfametrolJ01FAClaritromycine

J01DDCeftrixaon

J01XAVancomycine

J01CFFlucloxacilline

J01MANorfloxacine

J01XXFosfomycine

J01FFClindamycine

J01EATrimethoprim

J01CAAmoxicillline

J01MACiprofloxacine

J01AADoxycycline

J01XENitrofurantoïne

J01FAAzitromycine

Figure5.ABusepernursinghomeinApril2016


AzithromycinisthesecondmostfrequentusedmedicineforAmoxicillinClavulanicacidhasthehighestDDDsprescriptions.AmoxicillinClavulanicacidwasintotalprescribed546.39DDDsandAzithromycin409.46DDD.AmoxicillinClavulanicacidwasprescribedin18ofthenursinghomesandAzithromycininonlyfournursinghomesbringingittothesecondplaceinApril2016.ThetotalDDDprescriptiondifferencebetweennursinghome22andnursinghome43isnotsignificant.

Likeinthepreviouspart,theusedantibioticsinAprilarethesameasinNovember.Thenursinghomesmayhaveguidelinesofantibioticusethattheyuse,meaningthattheusedantibioticswillalwaysbethesameuntilanewdrugisinventedoraddedtotheABguidelines.Clearly,themostusedclassofantibioticswillbeJ01,sincethiswasalreadythecaseintheresultsoftheperiods.Atanursinghomelevel,theABuseisalsoevaluated.AsseeninFigure6,themostuseddrugistheAmoxicillinClavulanicacidfollowedbyAzithromycin.ThedifferencebetweenthesetwoprescriptionsisthattheAmoxicillinClavulanicacidisprescribedin21differentnursinghomesandtheAzithromycininonlyfour.Azithromycinisadrugthatismainlyusedforchronicalinfectionoftherespiratorytractforexamplechronicalbronchitisofpneumonia,infectionsinthethroat,shares(tonsillitis),cavities(sinusitis),earinfections,urinarytractinfectionsandskininfections.However,thisdrugisnotthefirstchoicefortheindicationsmentionedbefore.AmoxicillinClavulanicacidis,meaningthatatfirstAmoxicillinClavulanicacidwillbegiventotheresidentandifthatdoesnotwork,thenAzithromycinwillbeused.AsseeninFigure5andFigure6,thereisapeakinAprilandNovemberforthenursinghomes1and22thathaveusedAzithromycin.ThesenursinghomeshavethehighestusedDDDper1000residents/day.

0

100

200

300

400

500

600

22 43 44 23 19 45 17 46 47 48 21 49 50 3 51 52 53 54 55 9 56 15 57 58 59 60 61 37 62 63 64

Used

DDD

s/1000re

siden

ts/day

Participatingnursinghomes

ABuseperNHinNovemberJ01GBGentamicine

J02ACItraconazol

J01CEFeneticilline

J01XAVancomycine

J01XXLinezolide

J01FAClaritromycine

J01EETrimethoprim/Sulfametrol

J01MANorfloxacine

J01EATrimethoprim

J01XXFosfomycine

J01FFClindamycine

J01XDMetronidazol

J01AADoxycycline

J01CFFlucloxacilline

Figure6.ABusepernursinghomeinNovember2016


ThereasoninbothnursinghomesfortheDDDistheAzithromycinusage,whichis486.25DDDinApriland303.03DDDinNovember.ThereasonforthishighusagecouldbeanoutbreakinthenursinghomeswhereahighdosageofAzithromycinhadtobeusedtocuretheinfectedresidents.MeaningtherewasanoutbreakinAprilandinNovember.AsseenintheleafletofAzithromycin,21AzithromycinisabroadspectrumdruganditisusedforLRTI,earinfections,skininfectionsandUTImeaningthatthisdrugcanbethesecondlinedrugsthatgeriatriciansprescribemakingitthesecondmostuseddruginthenursinghomes.NotshowninthegraphbutapartoftheresultsisthattherewasameasurementofAmphotericinB.Theresultsshowedthattherewasaprescriptionofthreetimesof625mgofAmphotericinB.OneDDDofAmphotericinBis35mg16meaningthattherewouldbeanincreaseof260.05DDDforthatspecificnursinghome,bringingittoatotalof325.97DDD.Nowthiswouldnotbesignificanthigherthantherest,howeveritwasimpossibletoimaginethatonepersonwouldhavereceived260.05DDDinoneday.Thisiswhyitisremovedfromtheresultsandnottakenintoconsiderationforthecalculations.AreasonforthiserrorcouldbethatthedoctorwhofilledintheamountmadeamistakeandwroteAMFB(AmphotericinB)insteadofAMCL(AmoxicillinClavulanicacid),butthiscouldnotbechecked.TheassumptionwasmadethathewantedtowriteAMCLbecauseasmentionedinthemethods,AmoxicillinClavulanicacidisprescribedinadoseof625mgofwhich500mgistheworkingcomponent.ThisisnotthecasewithAmphotericinBbutthedoseintheresultsshowedthat3times625mgwasused.Therefore,itwasassumedthattheAmphotericinBissupposedtobeAmoxicillinClavulanicacidandsoitwasnotusedintheresults.

AsseeninthegraphsofABusepernursinghomeandAbuseperperiod,thereisadifferenceintheamountofDDDsused.TheDDDsintheABusepernursinghomeismuchhigherbecauseofthewaythedefineddailydosehastobecalculated,thisisbecausetheDDDisper1000residents/1day.TheDDDmustbecalculatedforeveryquestionmeaningthatwhenDDDiscalculatedfortheperiod,theamountofuseddrugswillbedividedbyadifferentamountofpeoplethenwhenitiscalculatedpernursinghome.Thisresultsindifferentvaluesforeverycalculation.

ABuseindifferentspecialismsEverynursinghomeparticipatingtheSNIVprotocolin2016hadthreespecialisms:thesomatic,revalidationandthepsychogeriatricdepartments.Thesomaticdepartmentisforthepeoplewhosufferachronicillnessandhavetobeconstantlytreated.Therevalidationdepartmentisthedepartmentwherepatientscomefromahospitalthathavetorecoverafterasurgeryforexample.Thepsychogeriatricdepartmentisthedepartmentwhichisspecializedintreatingofmentaldisordersinpatientswitholdage.Table7andFigure7displaytheantibioticuseinthedifferentspecialismsofallthenursinghomestogetherinApril.AsseeninThevalueshavebeennotedinDDD/1000residents/day.AsseeninTable7andTable8,ofalltheantimicrobialsusedinthesomatic,revalidationandpsychogeriatricdepartments,thesystemicuse(J01)accountsfor100%intherevalidationandpsychogeriatricinAprilandinthesomaticandrevalidationdepartmentinNovember.


InthesomaticdepartmentinAprilontheotherhand,99.79%ofalltheantibioticsusedweresystemicuse(J01)andinNovember99.09%weresystemicinthepsychogeriatricdepartment.Theremainingpercentagewhereantimycoticsforsystemicuse(J02).Everydepartmenthasadifferenttopfivemedicineclassesusedin2016(Appendix3).AsseeninTable7andFigure7,themostfrequentclassofmedicineusedinAprilinthesomaticdepartmentwastheJ01C(31.32%).Themostfrequentusedbeta-lactamantibacterialsinAprilwhere:AmoxicillinClavulanicacid(23.01%)andAmoxicillin(8.31%).AsseeninTable8andFigure8,inNovemberthetopfivemedicineclassesusedwhereJ01C,J01F,J01M,J01XandJ01AwithJ01Casthemostfrequentusedclass(40.27%).AmoxicillinClavulanicacid(29.46%),Amoxicillin(6.44%),Flucloxacillin(3.45%)andFenticillin(0.91%)belongtothisclassandarethemostusedbeta-lactamantibacterialsinNovemberinthesomaticdepartment.InApril,themostfrequentclassofmedicineusedintherevalidationdepartmentwastheJ01F(34.86%).Themostfrequentusedmacrolides,lincosamidesandstreptograminsinAprilwhere:Azithromycin(26.03%)andClindamycin(8.83%).InNovemberthetopfivemedicineclassesusedwhereJ01C,J01F,J01X,J01MandJ01EwithJ01Casthemostfrequentusedclass(31.30%).AmoxicillinClavulanicacid(24.29%),Amoxicillin(4.68%)andFlucloxacillin(2.34%)belongtothisclassandarethemostusedbeta-lactamantibacterialsinNovemberintherevalidationdepartment.InAprilthemostfrequentclassofmedicineusedinthepsychogeriatricdepartmentwastheJ01C(48.69%).Themostfrequentusedbeta-lactamantibacterialsinAprilwhere:AmoxicillinClavulanicacid(35.60%),Amoxicillin(9.40%)andFlucloxacillin(3.69%)InNovemberthetopfivemedicineclassesusedwhereJ01C,J01X,J01M,J01AandJ01EwithJ01Casthemostfrequentusedclass(40.73%).AmoxicillinClavulanicacid(24.44%),Amoxicillin(14.47%)andFlucloxacillin(1.82%)belongtothisclassandarethemostusedbeta-lactamantibacterialsinNovemberinthepsychogeriatricdepartment.Table7.PercentageoftheantibioticuseofdifferentspecialismsofallthenursinghomesinApril2016Somatic Revalidation Psychogeriatric

J01C 31,32 J01F 34,86 J01C 48,69

J01F 26,26 J01X 27,47 J01X 22,83J01M 12,91 J01C 21,78 J01M 14,44J01A 12,77 J01M 11,77 J01D 8,07J01X 9,28 J01E 3,92 J01E 4,98J01E 6,18 J01D 0,00 J01F 4,13J02A 1,28 J01A 0,00 J01A 0,00J01D 0,00 J02A 0,19 J02A 0,00


Table8.PercentageoftheantibioticuseofdifferentdepartmentsofallthenursinghomesinNovember2016Somatic Revalidation Psychogeriatric

J01 100 J01 100 J01 99.09J01C 40.27 J01C 31.30 J01C 40.73J01F 25.05 J01F 27.07 J01X 33.49J01M 13.81 J01X 26.90 J01M 10.87J01X 13.21 J01M 10.63 J01A 7.24J01A 4.60 J01E 4.09 J01E 5.42J01E 2.75 J01A 0.00 J01F 1.34J01G 0.31 J02A 0.00 J02A 0.91J02A 0.00 J01G 0.00 J01G 0.00

InApril,thespecialismwiththemostfrequentDDDprescriptionwasthedepartmentofrevalidationwithatotalof76.99DDD/1000residents/day(Table7).Thisis18.88DDDhigherthanthesecondhighestdepartment(somatic58.11DDD).ThemeanDDDsprescribedinApril2016was55.60.ThemostfrequentusedantibioticsinthesomaticdepartmentareAzithromycin(13.59DDD)andAmoxicillinClavulanicacid(13.37DDD)inApril2016bringingit2.51DDDs/1000residents/dayaboveaverage.ThemostfrequentusedantibioticsintheRevalidationdepartmentareAzithromycin(20.04DDD),Nitrofurantoin(18.88DDD)andAmoxicillinClavulanicacid(13.60DDD)inApril2016bringingit21.39DDDs/1000residents/dayaboveaverage.AndfinallythemostfrequentusedantibioticsinthepsychogeriatricdepartmentareAmoxicillinClavulanicacid(11.29DDD)andNitrofurantoin(6.81DDD)inApril2016bringingitwith32.71DDDintotal22.79DDD/1000residents/dayunderaverageusage.InApril2016,thethreespecialismsuseddifferentamountofantibiotics.TherevalidationdepartmenthadthehighestamountofDDDsused(76.99DDD/1000residents/day)followedbysomatic(58.11DDD/1000residents/day)andthelowestamountofDDDswereusedbythepsychogeriatricdepartment(32.71DDD/1000residents/day).Thedifferencebetweenthedepartmentssomaticandrevalidationisnotsignificant.Soisthedifferencebetweenrevalidation-psychogeriatricandsomatic–psychogeriatric.


AsseeninFigure8inNovember,thedepartmentwiththemostfrequentDDDprescriptionwasrevalidationwithatotalof115.29DDD/1000residents/day.Thisis34.41DDDhigherthanthesecondhighestdepartment(Somatic58.11DDD).ThemeanDDDsprescribedinApril2016was73.82.ThemostfrequentusedantibioticsinthesomaticdepartmentareAmoxicillinClavulanicacid(23.83DDD),Azithromycin(16.72DDD)andCiprofloxacin(10.80DDD)inNovember2016bringingit7.06DDDs/1000residents/dayaboveaverage.AsseeninTable8,themostfrequentusedantibioticsintheRevalidationdepartmentareAmoxicillinClavulanicacid(28DDD),Nitrofurantoin(25.61DDD)andAzithromycin(15.71DDD)inApril2016bringingit41.47DDDs/1000residents/dayaboveaverage.AndfinallythemostfrequentusedantibioticsinthepsychogeriatricdepartmentareNitrofurantoin(7.10DDD)andAmoxicillinClavulanicacid(6.18DDD)inNovember2016bringingitwith25.29DDDintotal48.53DDD/1000residents/dayunderaverageusage.InNovember2016,thethreespecialismsuseddifferentamountofantibiotics.TherevalidationdepartmenthadthehighestamountofDDDsused(117.99DDD/1000residents/day)followedbysomatic(81.61DDD/1000residents/day)andthelowestamountofDDDswereusedbythepsychogeriatricdepartment(25.29DDD/1000residents/day).Thedifferencebetweenthespecialismsomatic-revalidationandsomatic-psychogeriatricisnotsignificantbutthedifferencebetweenrevalidation-psychogeriatricis(p<0.05(CI0.80-9.79)).InApril,theSomaticdepartmentused13.59DDDAzithromycin,13.37DDDAmoxicillinClavulanicacidand4.09DDDofNitrofurantoin.

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J01DOtherbeta-lactamantibacterials

J01CBeta-lactamantibacterials,penicillinesJ01ATetracyclines

Figure7.ABuseperspecialisminApril2016


TheRevalidationdepartmentused20.04DDDAzithromycin,13.60DDDAmoxicillinClavulanicacidand18.88DDDofNitrofurantoin.Finally,thepsychogeriatricdepartmentused11.29DDDAmoxicillinClavulanicacidand6.81DDDofNitrofurantoinInNovember,theSomaticdepartmentused16.72DDDAzithromycin,23.83DDDAmoxicillinClavulanicacidand7.63DDDofNitrofurantoin.TheRevalidationdepartmentused15.71DDDAzithromycin,28.00DDDAmoxicillinClavulanicacidand25.61DDDofNitrofurantoin.Finally,thepsychogeriatricdepartmentused6.81DDDAmoxicillinClavulanicacidand7.10DDDofNitrofurantoin

Figure8.ABuseperspecialisminNovember2016

Afterunderstandingtheroleofeveryspecialism,therevalidationdepartmentappearstohavethehighestamountofDDDsbecausetheseresidentsarerecoveringandhavetogobacktothesocietyassoonaspossible.Thesomaticdepartmentwillbesecondbecauseofthechronicillnessesmeaningtheyhavetousethemedicinefortherestoftheirlivesandthepsychogeriatricdepartmentwillbethirdasthenursinghomesneedtotakethecost-benefitintoconsiderationfortreatingthesepeople.AsseeninFigure7andFigure8,intherevalidationdepartmenthadthemostusedDDDsfollowedbythesomaticandfinallythepsychogeriatricdepartment.

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J01FMacrolides,LincosamideandStreotogramins

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J01CBeta-lactamantibacterials,penicillines

J01ATetracyclines


Asseeninthegraphs,threetypeofdrugsarethemainuseddrugsandhavethehighestDDDs.ThesedrugsaretheAzithromycin,AmoxicillinClavulanicacidandtheNitrofurantoin,whichallarebroad-spectrumantibiotics.Nitrofurantoinisabroad-spectrumantibioticmainlyusedforacuteUTI,short-livedprophylaxisbytransurethralinterventionsorsurgeryoftheurinarytractandforlong-termtreatmentoftheUTI(6months)21.ThismeansthatNitrofurantoinis,justliketheothertwoantibiotics,usedforthemostoccurringinfection.Therefore,itisplausibletheusagewillbehighinallthedepartments.AsseeninthegraphsofFigure7andFigure8,theDDDsusedinAprilandNovemberdiffer.ItseemsthattheamountofDDDsusedislessinAprilthaninNovember.ThiswasseeninthediscussionoftheDDDsusedintheperiods,soitwasexpected.WhencomparingAprilwithNovemberthesomaticdepartmentdiffers20DDD,therevalidationdiffersalmost40DDDandthepsychogeriatrichasdeclinedwithadifferenceofalmost10DDD.Themostnoticeabledifferenceisattherevalidationdepartment.Asexplainedbefore,themoreuseofantibioticsinNovembercouldbeaprophylacticchoiceinordertopreventpatient’sformbeinginfected.Theobservationthattheantibioticuseislargerintherevalidationdepartmentfitswellinthatconclusion,asthesepatientscomefromahospitalafterasurgeryforexampleandsotopreventthemfrombeinginfectedwithbacteriaafterthistheyhavetotakeprophylacticantibiotics.MeaningthatthisdepartmentwillhaveahighDDDused.ThereasonwhyinNovembertheusagerisescouldbebecausethegeriatriciansknowempiricallythatthereisahighertendencyofgettinginfectedwithaLRTIforexampleinNovemberthaninApril,meaningthattheusageofantibioticswillriseinthatspecificperiod.

VariationinABuseinNHsandthemeanofABuseintheNetherlandsTherewasavariationbetweenthenursinghomeclusters(mean)andthenursinghomescorrespondingtothosenursinghomeclusters.AsseeninFigure9(Appendix4.1),thelargestdifferences(+/-10%)betweenthenursinghomeantibioticprescriptionsandthenursinghomeclustersprescriptionarewiththefollowingnursinghomes:E,LandM.NursinghomeclusterEhadapercentageof8.3usersandthenursinghomewiththehighestuser’sratehadapercentageof25.NursinghomeclusterLhadameanof5.6%usersandthenursinghomewiththehighestuser’sratehadapercentageof15.6.NursinghomeclusterMhadapercentageof14.7usersandthenursinghomewiththehighestuser’sratehadapercentageof30.8.NursinghomeclustersC,I,J,N,O,P,T,UandWhadonlyonenursinghomeintheirclustermeaningthosenursinghomeclusterscouldnotdifferfromthemeanusage.Thenursinghomeswiththesmallestdifference(+/-1%)wereFandR.


Thenationalmeanpercentageofallthenursinghomestogetherwas5.81%.

Bluestripescorrespondtomeanvalueofthenursinghomeclusters.

InNovember,thevariationremainsbetweenthenursinghomeclustersandtheircorrespondingnursinghomes.AsseeninFigure10(Appendix4.2),thelargestdifferences(+/-10%)betweenthenursinghomeantibioticprescriptionsandthenursinghomeclustersprescriptioniswithnursinghomeG.NursinghomeclusterGhadapercentageof8.7usersandthenursinghomewiththehighestuser’sratehadapercentageof28.6.Thenursinghomeswiththesmallestvariation(+/-1%)wereAandF.NursinghomeclustersC,N,O,P,T,UandWhadonlyonenursinghomeintheirclustermeaningthosenursinghomeclusterscouldnotdifferfromthemeanusage.Thenationalmeanpercentageofallthenursinghomestogetherwas6.46%.

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Figure9.VariationinABusersinnursinghomesbetweenandwiththenursinghomeclustersinApril2016


Figure10.VariationinABusersinnursinghomesbetweenandwiththenursinghomeclustersinNovember2016Bluestripescorrespondtomeanvalueofthenursinghomeclusters

Figure9describesthepercentageofresidentswhoreceivedanantibioticinApril.Thefiguredescribeshowmuchthenursinghomesdifferfromthepercentageoftheirnursinghomeclusterandalsohowmuchthenursinghomeclustersandtheirnursinghomesdifferfromthenationalmeanpercentage.Asseeninthisfigure,thereare22nursinghomesthatusemoreantibioticsthanthenationalaverageandtherearefournursinghomeclustersthathaveahigherpercentageofantibioticusersthanthenationalaverage.ForthenursinghomesinNovemberappliesthesame.AsseeninFigure10,19nursinghomesand7nursinghomeclustershaveahigheruserpercentagethanthenationaluserpercentage.Itisapossibilitythateverynursinghomeclusterhashisownguidelinesaboutantibioticuseandsothenursinghomescorrespondingtothatspecificnursinghomeclusterwillallhavethesamepercentageofantibioticuse.AsseeninFigure9andFigure10,inAprilandNovemberthiswasnotthecase.FivenursinghomeclustersinAprilandtwonursinghomeclustersinNovemberhadnursinghomesthatdifferedmorethan5%fromthepercentageofthenursinghomeclusters.Thedifferencewasnotsignificantbutthepercentagewasnotthesameasthenursinghomecluster.Thereasonforthiscouldbethattherewasanoutbreakinthosespecificnursinghomesandtheyhadtousemoreantibioticsoreventhefollowing.Severalnursinghomeclustersandnursinghomeshaveahigherpercentageofantibioticusethanthenationalaveragesincetherearenogovernmentalrestrictionsforantibioticuse,thereareonlyguidelinesandrules22.Forthenursinghomesandthenursinghomeclustersitisgoodtoknowwheretheystandcomparedtothenationalaverage.Knowingthatanursinghomeisusingmoreantibioticthanthenationalaveragemightmakethenursinghomeornursinghomeclusterslookinmoredetailintotheirusage.Theremightbeasmalloutbreakforexamplewithoutthestaffknowing.

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Althoughtheappropriatenessoftheantibioticprescriptioninnursinghomesin2016wasnotstudiedinthisresearch,therehavebeenstudiesthatdid22–27.AsstatedbyStuartEtalinastudyabouttheantibioticuseandmisuse,thereareseveralcasesofinappropriateantibioticprescribinginnursinghomesItisknownthatitismoredifficulttodiagnosetheelderlywithaninfectionbecauseofthenon-typicalsymptomsthattheymighthave19.Thismeansthatantibioticmighthavebeenunnecessaryprescribedandusedinsomecaseswheretheresultsshowedthatthereisauseofanantibiotic.Thiscouldinfluencetheresultsinawaythattheresultsmightbeoverestimated.Theinfectionsmightevenbemoredifficulttotreatbecauseofthehigherdiversityofcausativepathogensthatcomewithage19.

Conclusionofscienceresults72NursinghomesdidparticipatetotheSNIVprevalencesurveyin2016ThemostcommonreasonfornursinghomestonottoparticipatetotheSNIVprotocolwas:lackingofresourcesandtimeTheresultsshowthatin2016theantibioticuseinDDDs/1000residents/daywashigherinNovemberbutthedifferencebetweenAprilandNovemberwasnotsignificant.IngeneralAmoxicillinClavulanicacidwasthemostuseddrugbynursinghomesperperiod.MeaningthatintotalitwasthemostuseddruginDDDs/1000residents/day.AzithromycinwasthemostuseddruginAprilandNovemberpernursinghome.Meaningthatithadthehighestprescribeddose(DDDs/1000residents/day)inonenursinghomecomparedtotherestoftheantibiotics.UTIisthemostcommoninfectionfollowedbyLRTIinAprilandNovemberintheparticipatingnursinghomes.TherevalidationdepartmenthasinAprilandNovemberthehighestamountofprescribedDDDs/1000residents/daycomparedtotheresofthespecialism.ThePGdepartmenthastheleastamountopprescribedDDDs/1000residents/dayInAprilthenationalaverageprescriptionratewas5.81%with8nursinghomespassingthisaverageandinNovember6.46%with9nursinghomespassingthisaverage


IV/VAdvice/ImplementationForeveryadviceaStrengths,Weaknesses,OpportunitiesandThreats(SWOT)-analysiswillbeperformed.Bydoingso,thegivenadvicecanbeanalyzed,meaningthatthestrengthoftheadvicecanbeanalyzedtoseewhatthebenefitsare.Theweaknessesoftheadvicearethepointsthateitherstillhavetobeimprovedtomaketheadvicebetteroraretheweakpointsoftheadvice.Theopportunitiesoftheadvicecanbeanalyzedtoseewhattherewillchangeinthefutureaftertheadviceisimplementedandwhataretheimprovementsforinthefuture.Thethreatsoftheadvicearethepointsthatcouldinfluencethecompanylateron,meaningwhatwillhavetobedonetoexecutetheadviceandwillcausedifficultiesorevenmakethesituationforthecompanymoredifficultinthefuture.

DigitalizationoftheElectronicaClientsDossier(ECD)BymakingtheECDofallthenursinghomesremotelyaccessibletheRIVMwillbeabletoaccessthedatafromoffice,resultinginthattheregistrationnolongerhavetobeperformedbythegeriatricians.Heorshenolongerhastochooseadayandregisteralltheclientsofthenursinghome.Theregistrationformsnolongerhavetobefilledinandallthemedicationuseofalltheclientsnolongerhastobewrittendown.AdatasafeismadebytheRIVMwhereallthedatacanbestored.EverydayageriatricobserveshispatientsandwriteseverythingdownintheECD.Themedicationthatisprescribed,theproblemsthattheclientsencounter,thesituationoftheclientetc.Thisallisstoredinafileofthespecificclientandisstoredinthecomputer.Bydigitalizingthisprocedure,thestoredinformationwillbesendtothedatasafeonline,meaningthatthedataissenteverydaytothedatasafewherealltheinformationabouttheclientsofeverynursinghomeisstored.Withthisdatastoredinthedatasafe,thegeriatriciansnolongerhavetoperformthiswholeprocessagainononespecificday.TheRIVMcansimplygettheinformationoutofthedatasafeononespecificdayandnotethevaluesintheSNIVdataset.AsseeninTable9,thestrengthsareinthecategoryofsimplifyingtheprocessandimprovingthedata.Nosubjectisskippedandnodataislostbecauseitisalldigitalandtheopportunitiesshowthatwiththismethodanew,betterandmainlylargerdatasetwillbecreatedwhichcanbeusedforfuturestudies.Theadvicehasalsoweaknessesandtheyalltendtowardsthedatasafeitself.Itisnotmadeyetandthereisnobudgettomakeit.However,thebiggestweaknessisthattherearemultipleECDsinuse.TherearenorulesabouttheECDsoftware,meaningthatalmosteverynursinghomeusesadifferentECD.SoalltheECDsoftwaremakershavetoparticipatewiththisprocessandadjusttheirsoftwaresoeverydayitwillsendallthedatatothedatasafe.Thiswillonlybedoneifthenursinghomesdemandit.Thenextpointofconcernisthesafetyofthedataset.Thedataisonlineinadatasafemeaningitcanbehackedandstolenortheservercancrash,meaningthatallthestoreddatawillbegone.Tosolvethis,thedatasafecanhaveaback-upeveryweeksonolargeamountofdatawillbelostifthesystemcrashes.Toensurethatthedatawillnotbestolenbyhackers,thesystemhastobeprotectedatalltimeswiththelatesttechnology.


Table9.SWOT-analysisofthefirstadvice

SWOT-analysisStrengths Weaknesses

• Fasterregistration• Lessresourcesneeded• Nooneisskipped• Noinformationislost• Analysescanbeperformedfaster• Datacanbecollectedeasierwhen

morestudiesareconducted

• Theonlinedatasafestillhastobemade

• AllthedifferentECDshavetobemadetosupportthissystem

• Thereisnobudgetforthissystem

Opportunities Threats• Abiggerdatasetforfuturestudies• Morenursinghomescanparticipate• Moredatacanbecollected• Moreanddifferentstudiescanbe

performedwiththegrowingdataset

• DependedoftheECDcreators• Ifthedatasafecrasheseverything

willbeerased• Ifhacked,itisnolongeranonymous

andalldatacanbepublished

SNIVparticipationcertificate(includingatraining)AccordingtoFigure3,thenursinghomeshavenotimeorresourcesfortheregistrationtoparticipatetotheSNIVprotocol.TomotivatetheNHstodedicatetimefortheregistration,amethodneedstobemadesotheywillbemoremotivatedtoparticipate.Becausethenursinghomesarenotownedbythegovernment(thegovernmentcannotforcethemtoparticipate),thestickandcarrotmodelcanbeusedinthissituation.Thestickandcarrotmodelstandsforforceandpersuasion,inourexamplethestickstandsforforce.AsmentionedbeforetheNHscannotbeforcedtoparticipatetotheSNIVprotocolmeaningthecarrothastobeused(motivation).AgoodwaytomotivatetheNHstoparticipateistohandsomething,whichtheycanusetoshowthequalityoftheNHwhenclientswanttocomeandlivethere.Whatthegovernmentcoulddo,ishandoutcertificatestotheNHswhoparticipatetotheSNIVprotocolstatingthattheNHswhichhavethesecertificatesarefullyawareoftheinfectionsandtheamountofantibioticsusedintheirNHs.AndalistwillbemadewhichshowsthenamesoftheNHswhichhavethecertificatesoeveryonewillbeaware.ThiswillcreateatrustworthinesstowardstheclientslivingintheNHsaswellastothefamiliesoftheresidents.Whatwillhappen,isthatalltheNHswillwantthiscertificateandtheirnameonthelistaseveryonewouldwanttheirelderlyparentstogotoaNHwhichisawareofalltheinfectionsinsteadofaNHwhichisnot.Inadditiontothis,thegeriatricianscanbetrainedinthecorrectwayofregistrationsothecollecteddatawillalwaysbecorrectandwithlessmistakes.ThisisabenefitforbothRIVMandtheNHs.AsseeninTable10,oneofthestrengthsisthatnomarketingisneededtoconvincetheNHstoparticipate.


ThecurrentwaytoapproachparticipatingNHsistocallthemandaskiftheywanttoparticipateandsomeofmarketingtoconvincetheNHsthatitisalsointheirinteresttoparticipate.ThiswillnolongerbeneededbecausetheNHswillsee(carrot)thebenefitsandbemotivatedtoparticipate,meaningthattheywillcalltoparticipateinsteadoftheRIVMcallingtheNHs.EventuallymoreNHswillparticipateandthedatasetwillgrow,meaningmoredatawillbeavailablefordifferentstudiesthatcanbeperformedinthefuture.Theweaknessesoftheadvicearethatthereisnocertificatemadeyet.Thegovernmenthastobeconvincedofthepotentialsofthismethodandtheyhavetoprocessanddecideifitisagoodmethod,meaningthisisnotsomethingthatwillbeappliedinafewmonths.ThebiggestthreatisthattheNHsmightnotsendinrealdatabuttheywillsenddatajusttogetthecertificate,meaningthesentdatacanbefalsepositiveorfalsenegative.ThiscanbesolvedbysendingRIVMpersonneltorandomlyselectedNHstocheckiftheyaresendingtherightdata.Thiswilllowerthechanceofbiaseddata.Table10.SWOT-analysisofthesecondadvice


• MoreNHswillparticipateinordertoreceivethecertificate

• MorepatientswillgototheNHswithacertificate

• NomarketingisneededtoconvinceNHtoparticipate

• Structuredwayofcollectingdata• NHswithacertificateobtainacertain

trustworthiness

• Acertificatehastobemade• TraininghastobegiventotheNHsin

ordertocollectthedatainthesameway

• TheRIVMpushestheproblemtothegovernmentinsteadofsolvingititself

• Abudgetisneeded

Opportunities Threats• InthefuturemoreNHswill

participateinordertoreceivethecertificate

• PatientswillonlygotoNHswithacertificate

• Moredatawillbecollectedandcanalsobeusedfordifferentfuturestudies

• Thecollecteddatacanbefalsepositiveorfalsenegative

• ThereisachancethatRIVMworkershavetogotoNHstosurveillancethedatacollectionmethodinordertoreceivecorrectdata

• Dependentofthegovernmentatalltimes

• Abudgethastobemade


Selfregistration

Asmentionedbefore,theregistrationofthepatientsisperformedbyageriatricianoftheNH.HeorshechoosesonedayinAprilorinNovembertoanswerallthequestionsintheregistrationformforalltheclientsinaNHandsendsittotheRIVMtobeanalyzed.AsseeninFigure3,themainreasonfornotparticipationisthelackingofrecoursesandtimefortheregistration.Awaytosolvethisproblemisbytakingthisobstacleoutofthewayanddoingthisforthem,meaningthattheRIVMpersonnelgoestoaNHanddoestheregistrationforthem,savingtimeandresources.AsseeninTable11,bysendingRIVMpersonneltoNHstoperformtheregistration,theNHswillsavetimeandresources,theRIVMpersonnelcancollectthedatathatisneededandifsomethingischangeditcandirectlybeappliedmeaningthedataisalwayscorrect.Oneofthebestpointsisthatitcanbeapplieddirectlyandnoextrabudgetisneeded.PositiveeffectsofthismethodarethatmoreNHswillwanttoparticipate,meaningmoredatawillbecollectedandstoredforfuturestudies.ThedownsideofthismethodisthatwhenmoreNHswanttoparticipate,theworkloadwillincreasemeaningmoreRIVMpersonnelhastogotoNHsandmorepeoplehavetobehiredfortheregistration.Thiscanbedonebyhiringspecialistsparttime,onlyfortheregistrationtwiceayear.TheotherdownsideisthattheNHsmaynottrustthedatacollectorsandnotallowthemtoseethedatameaningregistrationcannotbeperformed.ThisadvicewaspresentedtothestaffofRIVMduringtheSNIVmeeting.Becauseofitsbenefitsandsimplicity,itwasimplementedrightawaycausingariseofparticipationof40%.ThismethodwillnotonlybeusedfortheSNIVprotocolbutalsoforotherstudieswhereregistrationhastobedone.Theorganizationofchoicewillbeaskediftheywanttoparticipateandwhenrejected,thesolutionofself-registrationbyRIVMpersonnelcanbesuggested.Table11.SWOT-analysisofthethirdadvice


• Safestime• Safesresources• Geriatriciansdon’thavetodothe

registration• Collecteddataismorereliableand

collectedmorestructured• Noextrabudgetisneeded

• RIVMpersonnelhavetogototheNHsmeaningthedailyworkhastowait

Opportunities Threats• MoreNHswillparticipate• Moredatawillbecollectedandmore

differentstudiescanbeperformedinthefuture

• Morereliableinformationwillbecollected

• Whendifferentdataisneededitcandirectlybecollected

• NHsmaynottrustthedatacollectorsandnotallowtheregistration

• ThemoreNHsparticipatethemorepersonnelhavetobehiredtoperformtheregistration


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AppendixIInfectiontype Definition

Sepsis/bacteremia Tobeidentifiedassepsis/bacteremiatheresidentsmustbediagnosedwithatleasttwoofthefollowingclinicalsymptomswithoutanyothervisiblecause.

- Fever- Hypotension(systolicpressure<90mmHg)- Oliguria- Doctordiagnosisincludingstartofanantibiotic(unlessforexampleterminal

patients)- Positivebloodsamples

Lowerrespiratoryinfection

BasedontheGraffelmanetalandMacfarlaneetalAtleastthreeofthefollowingsymptomshavetobeidentifiedordeteriorate.

- Fever>37.9°Corfeverinthepast48hours- Dyspneaorcoughing(productiveornon-productive)- Tachypnea,malaiseorconfusedandnewfocaldisorderwith

auscultationofthelungs

Urinarytractinfection BasedontheVERENSO-guidelinesTobeidentifiedasaurinarytracttheresidentsofthenursinghomesmustmeetthefollowingcriteria:

- Micturitionrelatedcomplaintsand/orsymptoms- Presenceofbacteriuria- Signsofinflammation- Onlyurinecatheterrelatedifin7daysbeforeregistrationa

urinecatheterisused.Gastrointestinalinfection

Theresidentsofthenursinghomesmustbediagnosedwithatleastoneofthesecriteriatobeidentifiedwithagastrointestinalinfection:

- Threetimesormoreliquidstool(aberrantofnormalfortheresidentandfrequencyisnotimportantwhenincontinencematerialsused)\

- Orliquidstoolandtwoofthefollowingsymptoms:• Fever,vomiting,nausea,stomachache,abdominalcramps

andbloodorslimeinthestool- Orvomitingandtwoofthefollowingsymptoms:

• Fever,nausea,stomachache,abdominalcrampsandbloodorslimeinthestool

- Orvomitingthreetimesin24hours:withoutadditionalcomplaints(ifvomitingdoesnotcorrespondentwithdruguse)andnootherreasonisknown

Bacterialconjunctivitis

Theresidentsofthenursinghomesmustbediagnosedwithatleastthesecriteriatobeidentifiedwithabacterialconjunctivitis*:

- Painorrednessorpurulentsecretionoftheconjunctivaoradjoiningtissuelikeeyes,cornea,lacrimalglandsorglandsMaypole(>24hours)*Symptomsdidnotariseduetoallergicreaction.


Appendix2AntibioticUseinallthenursinghomesDDDs/1000residents/1day

ATC April Nov J01AA Doxycycline 2.51 2.24 J01CA Amoxicillline 3.38 4.22 J01CE Feneticilline 0.00 0.62 J01CF Flucloxacilline 0.94 0.00 J01CF Dicloxacilline 0.01 0.00 J01CF Flucloxacilline 0.00 1.43 J01CR Amoxicillline/Clavulaanzuur 12.28 13.91 J01DD Ceftrixaon 1.50 0.00 J01EA Trimethoprim 1.88 1.43 J01EC Sulfamethoxazol 0.26 0.00 J01EE Trimethoprim/Sulfametrol 0.25 0.50 J01FA Claritromycine 0.38 0.50 J01FA Azitromycine 6.46 7.03 J01FF Clindamycine 1.32 2.30 J01GB Gentamicine 0.00 0.08 J01MA Ciprofloxacine 5.23 5.85 J01MA Norfloxacine 0.75 0.12 J01XA Vancomycine 0.38 0.00 J01XE Nitrofurantoïne 6.96 8.76 J01XX Fosfomycine 0.50 2.01 J01XX Linezolide 0.00 0.25 J02AC01 Fluconazole 0.25 0.00 J02AC Itraconazol 0.01 0.12

Total 45.25 51.37


Appendix3AntibioticuseofallthethreespecialismsinAprilDDDs/1000residents/1day

April Somatic Revalidation Psychogeriatric J01A Tetracyclines 7.43 0.00 0.00 J01C Beta-lactam antibacterials, penicillines 18.2 16.77 15.44

J01D Other beta-lactam antibacterials 0.00 0.00 2.56

J01E sulfonamides and trimethoprim 3.59 3.02 1.58

J01F Macrolides, Lincosamide and Streotogramins 15.26 26.84 1.31

J01M Quinolone antibacterials 7.5 9.06 4.58

J01X Other antibacterials 5.39 21.15 7.24

J02A Antimycotics for systemic use 0.74 0.15 0.00

AntibioticuseofallthethreespecialismsinNovemberDDDs/1000residents/1day

November Somatic Revalidation Psychogeriatric

J01A Tetracyclines 3.71 0.00 1.83

J01C Beta-lactam antibacterials, penicillines 32.57 36.09 10.3

J01E sulfonamides and trimethoprim 2.97 7.42 1.37 J01F Macrolides, Lincosamide and Streotogramins 20.26 31.21 0.34 J01G Aminoglycoside antibacterials 0.25 0.00 0.00

J01M Quinolone antibacterials 11.17 12.26 2.75

J01X Other antibacterials 10.68 31.01 8.47

J02A Antimycotics for systemic use 0.00 0.00 0.23


Appendix4.1AmountofantibioticprescriptionsinallthenursinghomesinApril

NH % of antibiotic prescriptions A 8.9 9.2 8.3 B 10.7 12.8 9.5 7.2 10.2 15.9 C 6.6 6.6 D 0 0 0 0 0 0 E 0 F 2.6 3.4 0 G 8.7 11.8 2.6 28.6 10.4 H 0 0 0 0 I 0 0 0 0 0 J 0 0 0 K 8 11.2 5.3 7.3 10.6 3.9 L 0 0 M 0 0 N 2.8 2.8 O 4.7 4.7 P 9.1 9.1 Q 2.9 2.5 3.2 R 1.9 1.3 0 9.1 S 3.2 6.6 5 5 0 0 T 7.4 7.4 U 3.2 3.2 V 0 0 0 W 11.8 11.8


Appendix4.2AmountofantibioticprescriptionsinallthenursinghomesinApril

NH % of antibiotic prescriptions A 7.9 9.9 4.1 B 0 0 0 0 0 0 C 3.2 3.2 D 2.9 5.9 2.3 3 2.4 3.9 1 E 8.3 7.7 4.2 6.9 25 8.9 2.8 3.4 8.7 8.33 F 5.3 5.6 4.3 G 0 0 0 0 0 H 1.6 3.8 0 I 1.6 1.6 J 15 15 K 0 0 0 0 0 0

L 5.6 3.8 0 2.2 15.6 4.7 2.6 0 4.3 M 14.7 7.1 4 7.1 22.7 22.7 10 8.3 20.8 30.8 22.6 N 0 0 O 2.9 2.9 P 0 0 Q 3.1 0 3.1 R 0 0 0 0 S 4.3 11.8 6.2 0 0 0.8 T 0 0 U 0 0

V 2.9 0 4.2 6.3 W 0 0

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