JAC Advance Access originally published online on June 5, 2007
Journal of Antimicrobial Chemotherapy 2007 60(2):440-444; doi:10.1093/jac/dkm194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Antimicrobial use in Finnish acute care hospitals: data from national prevalence survey, 2005
1 Finnish Hospital Infection Program (SIRO), National Public Health Institute, Department of Infectious Disease Epidemiology, Helsinki, Finland 2 Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
* Correspondence address. Helsinki University Central Hospital, Department of Medicine, Division of Infectious Diseases, Meilahti Hospital, 2nd Floor, PO Box 340, FIN-00029 HUS, Finland. Tel: +358-504272155; Fax: +358-947171485; E-mail: mari.kanerva{at}hus.fi
Received 2 March 2007; returned 5 April 2007; revised 27 April 2007; accepted 6 May 2007
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
Objectives: In Finland, use of antimicrobials in ambulatory care is moderate, but some reports suggest that hospital use is higher than in other European countries. We evaluated the amount and type of antimicrobials administered in Finnish acute care hospitals.
Patients and methods: We analysed data collected in the national prevalence survey of nosocomial infections (NIs) during February–March 2005 in all tertiary care, all secondary care and 25% of other acute care hospitals. All inpatients present on the study day in acute care wards for adults were included (n = 8234). The names and use-days of antimicrobials in Anatomical Therapeutic Class groups J01–J05 were collected on the study day and retrospectively for the previous 6 days.
Results: On the study day, 39% of patients had received at least one, 14% at least two and 3% at least three antimicrobials; patients with NI represented 21%, 29% and 45% of these groups, respectively. The prevalence of patients receiving any antimicrobial was 53% in intensive care patients and varied in other specialties from 0% in ophthalmology to 63% in dental and oral surgery. Within a 7 day period, the total use of antibacterial agents (J01) was 64 use-days per 100 patient-days. Cephalosporins were the most frequently used antimicrobials, followed by quinolones and metronidazole.
Conclusions: The prevalence and spectrum of antimicrobial use in Finnish acute care hospitals were high. NI patients contributed markedly to the total usage. The NI survey with a 7 day data collection period provided insights into the use-density of antimicrobials.
Keywords: antibiotic use , drug consumption , nosocomial infection , Finland
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
In Finland, use of antimicrobials in ambulatory care, expressed as defined daily dose (DDD) per 1000 inhabitants, is at the mean level of all European countries according to retrospective data collection by the European Surveillance of Antimicrobial Consumption (ESAC) for 1997–2003.1 The consumption of antimicrobials in hospitals was one of the highest in Europe, but this finding may be distorted by the difficulty in separating ambulatory and hospital usage, especially in healthcare centres and nursing homes in remote areas.2 The use of hospital-specific antibiotics (i.e. carbapenems, glycopeptides, aminoglycosides and third- and fourth-generation cephalosporins) was, however, consistent with the European mean. No other national data of antibiotic consumption in Finnish acute care hospitals have previously been published.
The Finnish Hospital Infection Program (SIRO) conducted the first national prevalence survey of nosocomial infections (NIs) in 30 Finnish acute care hospitals during February–March 2005.
Our objective is to analyse the amount and type of antimicrobials administered in acute care hospitals based on data collected in this national survey.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
In Finland (population 5.2 million), the national healthcare system is organized in 20 geographically and administratively defined hospital districts (HDs). Fifteen HDs have only secondary and other acute care hospitals, and also five provide tertiary care services. All acute care hospitals were invited by sending a letter to chief executive officers responsible for infection control in all HDs. All 5 tertiary (university) care hospitals (range of number of beds, 443–1181), all 15 secondary (central) care hospitals (144–364 beds) and 10 (25% of 40) other (local) acute care hospitals (51–227 beds) took part in the survey. All inpatients present on the study day in acute care wards for adults were examined (n = 8234). Infection control practitioners, who attended a 1 day training course organized by SIRO, collected data with link nurses and ward staff. The study protocol, a standardized case report form, written definitions for all study variables, practical exercises, code lists and unmodified Centers for Disease Control and Prevention definitions of NI3 in Finnish as well as a help desk during the data collection were provided by SIRO. Data on patient characteristics (e.g. age, sex, medical specialty, admission date and co-morbidity using McCabe classification),4 NIs (symptomatic and/or under treatment) and causative microbes were collected.
Data on antimicrobials were recorded on the study day and retrospectively for the previous 6 days (a 7 day window), allowing us to estimate use-density among the study population. No data on dose, timing or dosing interval of antimicrobials or on antimicrobials administered as surgical prophylaxis in operating theatres were recorded. Had the drug been used at any time during the day, the whole day was considered a use day. Data on antimicrobials (classes J01–J05 and metronidazole; P0AB01) included their generic or trade names [recorded as fifth-level Anatomical Therapeutic Class (ATC) codes and further aggregated into fourth- or third-level ATC codes] and route of administration. The first five antimicrobials on patient charts were recorded.
Patient-days were calculated by subtracting the date of admission from the study day date and adding 1 day. Had the patient been hospitalized for more than 1 week, only 7 days were counted.
Categorical variables were analysed with 
2 test and continuous variables with the Mann–Whitney U-test. All tests were two-tailed and P values of < 0.05 were considered statistically significant. Multivariable logistic regression was used to assess dependence between different explanatory variables and antimicrobial usage on the study day. Statistical analyses were performed with SPSS (version 14.0, Chicago, USA).
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
On the study day, 39% (3224/8234) of patients received at least one, 14% (1136/8234) at least two and 3% (268/8234) at least three antimicrobials (J01–J05); the 703 patients with NI represented 21%, 29% and 45% of these patient groups, respectively. Most of the patients (n = 3221) were given antibacterials (J01) and 77 peroral metronidazole (P01AB01). Patients who received antimicrobials on the study day were significantly older (64 years versus 58 years; P < 0.001), were more often male (53% versus 42%; P < 0.001) and had more severe co-morbidity (McCabe class 2 or 3; 49% versus 32%; P < 0.001) than patients who received no antimicrobials. The prevalence of any antimicrobial on the study day varied by hospital type, being highest (45%) in other acute care hospitals and lowest (36%) in secondary care hospitals; in tertiary care hospitals, the respective figure was 40%.
Data on medical specialty were available for 7886 patients (96%). More than half of the intensive care (IC) patients had antimicrobials on the study day, and the prevalence of patients with antimicrobials varied in different non-IC specialties from 0% in ophthalmology to 63% in dental and oral surgery (Table 1). In a multivariable logistic regression model, age, male gender, NI, severity of co-morbidity, medical specialty and hospital type were all significant explanatory variables for receiving an antimicrobial drug on the study day, with the highest adjusted odds ratio being 34.1 (95% CI, 24.1–48.2) for NI.
|
Accurate data for calculating patient-days were available for 8115 patients (99%). Within a 7 day window, total use of antibacterials (J01 and P01AB01) was 64 use-days per 100 patient-days. It was 81 in IC and varied in non-IC specialties from 0 in ophthalmology and 24 in obstetrics and gynaecology to 66 in general surgery, 73 in internal medicine, 91 in pulmonology and 106 in dental and oral surgery. The usage varied between hospital types and also between individual hospitals (Table 2). Administration of antimycotics (J02), antimycobacterials (J03) and antivirals (J05) was highest in tertiary care hospitals, accounting for 15% of all systemic antimicrobial use.
|
Cephalosporins, especially second-generation cephalosporins, were the most frequently used antibacterials (nearly 40% of all use), followed by fluoroquinolones and metronidazole (Table 3). Other acute care hospitals used even more cephalosporins or fluoroquinolones than secondary and tertiary care hospitals. Secondary care hospitals used more penicillins and tertiary care hospitals used more clindamycin, carbapenems and aminoglycosides than the two other hospital types. Of all antimicrobials, 60% were given intravenously.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
Our study provides an overview of antimicrobial use in Finnish acute care hospitals. The prevalence of antimicrobial use was high; more than one-third of patients had received an antimicrobial or antibacterial on the study day. In previous studies with a similar study design, from 16% (Denmark), 18% (Germany), 28% (Scotland) to 40% (USA) of hospital patients were given antibacterials.5,6 NIs contributed markedly to the usage in our study. This aspect further underlines the importance of prevention of NIs.
The prevalence of usage as well as antimicrobial use measured as use-days per 100 patient-days varied between specialties and hospital types. These were highest in dental and oral surgery and pulmonology. It was higher in other acute care hospitals than in tertiary or secondary care hospitals, which may partly be due to patients receiving antimicrobials being discharged to other acute care hospitals after first being treated in tertiary and secondary care hospitals. There were also differences in the type of antimicrobials used, e.g. carbapenems, between different hospital types, which may be due to case mix of patients related to the level of care, but also differences in local prescribing policy.
In many European countries, penicillins are the most used group according to the ESAC data describing hospital antibiotic use in Europe.2 In Finland, cephalosporins, fluoroquinolones and metronidazole are prescribed more frequently than penicillins. One reason for this is probably that intravenous co-amoxiclav is not available in Finland. Our data are in line with ESAC results showing that cephalosporins and fluoroquinolones are the most used antibiotics, accounting for approximately half of all antimicrobials prescribed in different types of hospitals in Finland.
DDDs are usually used to measure antibacterial consumption in hospitals.7 These figures may be discordant with days of therapy (DOT) or prescribed (PDD) or recommended (RDD) daily doses per 100 patient-days, due to descriptions in DDD index. National data on DOTs, PDDs or RDDs are scarce. Total adult antibacterial use in 130 US hospitals was 78 DOTs/100.7 German university hospitals and non-university hospitals used 122 and 50–67 PDDs/100 in IC areas and 55 and 29 PDDs/100 in internal medicine, respectively.8,9 In one German study the respective figures were 87 and 59–67 RDDs/100 for university and non-university ICUs.10 Our figures, expressed as use-days, were closer to DOTs, PDDs or RDDs than DDDs. Although antibacterial use in Finnish acute care hospitals (64 use-days per 100 patient-days) seemed relatively high, due to methodological differences in data collection, direct comparison with other countries is not possible. We also included peroral metronidazole use in antibacterials, as only little of it is used on parasitic diseases in Finnish hospitals. Metronidazole was the third largest group of antimicrobials in our study. We collected data on the whole use-day regardless of dosage interval or dose applied. This can lead to an overestimation of usage. However, we did not record antibiotics administered in operating rooms, which in turn reduces the estimate. Moreover, point prevalence data are always susceptible to chance.
Despite these limitations, our study showed that a prevalence survey is a feasible tool for collecting data on antimicrobial use in hospitals. Data collection over a 7 day window period shed light on the use-density of antimicrobials.
|
Transparency declarations |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
None to declare.
|
Acknowledgements |
|---|
Finnish Prevalence Survey Study group:
National Public Health Institute, SIRO: N. Agthe, T. Möttönen; Etelä-Karjala Central Hospital: M. Kauppinen, K. Laurila, P. Suomalainen, R. Vuorela; Forssa Hospital: I. Ryhtä, R. Vastamäki; HUS, Hyvinkää Hospital: M. Helén, K. Hietaniemi, T. Varis; HUS, Jorvi Hospital: P. Carlson, L. Eliin, J. Nieminen, K. Skogberg; HUS, Lohja Hospital: R. Salminen, M.-L. Yrjönsalo; HUS, Peijas Hospital: A.-M. Kimmo, K. Sandberg, T. Tuppurainen; HUS, Porvoo Hospital: K. Mattila; Helsinki University Central Hospital: A. Aalto, V.-J. Anttila, C. Estlander, M. Hämäläinen, M. Jalkanen, M. Kanerva, T. Kuutamo, T. Lappalainen, P. Mattila, D. Pipping, M. Ratia, K. Sammalkorpi, L. Simons, P. Tommila, I. Tötterman; Kainuu Central Hospital: P. Lehtinen, S. Torvinen; Kanta-Häme Central Hospital and Riihimäki Hospital: M. Eklund, M. Fellman, J. Mikkola; Keski-Pohjanmaa Central Hospital: L. Haapaniemi, A. Junka; Keski-Suomi Central Hospital: A. Jakobsson, J. Leppäaho-Lakka, S. Pätsi, M. Rummukainen, T. Tiitinen, M. Liikka; Kuopio University Central Hospital: S. Hämäläinen, I. Koivula, A.-M. Rissanen, E. Ruotsalainen, H. Teräsvirta; Kymenlaakso Central Hospital and Kuusankoski Hospital: K. Hannola, T. Marttinen, J. Palosara, R. Pietikäinen; Länsi-Pohja Central Hospital: U. Kaukoniemi, T. Nurkkala-Pitko; Lappi Central Hospital: M. Broas, J. Isojärvi, H. Jägerroos, E. Jänkälä, P. Niemi, S. Pöyry, L. Räisänen; Lapponia Hospital: M. Leukka; Mikkeli Central Hospital: S. Dahl, P. Ijäs, P. Kärkkäinen, S. Vuorinen; Oulu University Central Hospital: H. Heikkilä, T. Kaija, I. Teirilä; Päijät-Häme Central Hospital: J. Haapala, M. Härkönen, A. Reiman, J. Salonen, H. Sarkkinen Pohjois-Karjala Central Hospital: H. Sihvola, P. Turunen; Raahe Hospital: H. Taskila, L. Virranniemi; Satakunta Central Hospital: S. Huttunen, E. Rintala, R. Uusitalo-Seppälä; Savonlinna Central Hospital: T. Pulli, A. Sistonen; Seinäjoki Central Hospital: A. Panttila J. Saikku, M. Tapanainen; Tampere University Central Hospital: R. Levola, J. Lumio, J. Sinkkonen; Turku University Central Hospital: R. Peltonen, M. Routamaa, K. Terho; Vaasa Central Hospital: N. Elomaa, B. Eriksén-Neuman.
The study has been performed as a part of Finnish Hospital Infection Program (SIRO), which is financed by the National Public Health Institute and by the Ministry of Social Affairs and Health.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionTransparency declarationsReferences |
|---|
1 Ferech M, Coenen S, Malhotra-Kumar S, et al. European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother (2006) 58:401–7.
2
Vander Stichele RH, Elseviers MM, Ferech M, et al. Hospital consumption of antibiotics in 15 European countries: results of the ESAC Retrospective Data Collection (1997–2002). J Antimicrob Chemother (2006) 58:159–67.
3 Garner JS, Jarvis WR, Emori TG, et al. CDC definitions. Am J Infect Control (1988) 16:128–40.[CrossRef][Web of Science][Medline]
4
McCabe W, Jackson G. Gram-negative bacteremia. Arch Intern Med (1962) 110:83–91.
5 Gastmeier P, Sohr D, Forster D, et al. Identifying outliers of antibiotic usage in prevalence studies on nosocomial infections. Infect Control Hosp Epidemiol (2000) 21:324–8.[CrossRef][Web of Science][Medline]
6 Seaton RA, Nathwani D, Burton P, et al. Point prevalence survey of antibiotic use in Scottish hospitals utilising the Glasgow Antimicrobial Audit Tool (GAAT). In: Int J Antimicrob Agents (2007) 29:693–9.[CrossRef][Medline]
7 Polk RE, Fox C, Mahoney A, et al. Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis (2007) 44:664–70.[CrossRef][Web of Science][Medline]
8 de With K, Bergner J, Buhner R, et al. Antibiotic use at German university hospitals (Project INTERUNI-II). Results for medical intensive care, hematology-oncology, and other medical service areas. Med Klin (Munich) (2004) 99:347–54.[Medline]
9 Kern WV, de With K, Steib-Bauert M, et al. Antibiotic use in non-university regional acute care general hospitals in southwestern Germany, 2001–2002. Infection (2005) 33:333–9.[CrossRef][Web of Science][Medline]
10 de With K, Meyer E, Steib-Bauert M, et al. Antibiotic use in two cohorts of German intensive care units. J Hosp Infect (2006) 64:231–7.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||