['Evidence-based' perioperative antibiotic prophylaxis policy in Belgian hospitals after a change in the reimbursement system]. / Perioperatief antibiotisch profylaxebeleid in de Belgische ziekenhuizen 'evidence-based' door afgestemd vergoedingensysteem.

The costs of antibiotics in Belgian hospitals are nearly fully reimbursed by the health insurance. Such a situation is not conductive to rational drug use. A new reimbursement system for perioperatively-administered antibiotics in Belgian hospitals was implemented in May 1997 by Royal Decree. A reimbursement code for antibiotic use was linked to the reimbursement of surgical interventions. This code represents a reimbursement which covers 75% of the cost of perioperative prophylaxis based on optimal indication, dose, and duration as recommended by international and Belgian consensus guidelines. The actual antibiotic prescribed during the 72-hour perioperative period (the day before, during and after surgery) is reimbursed at only 25% of its full cost. Thus, if the perioperative prophylactic antibiotic regimen complies with the evidence-based guidelines, the costs of antibiotic prescribing will be fully reimbursed by the health insurance (75% of the standard +25% of the actual costs). The new reimbursement system does not apply to antibiotics which are prescribed for treatment of intercurrent infections; these antibiotics continue to be fully reimbursed. Annual expenditures for antibiotics, for both antibiotic treatment and prophylaxis, nationwide and per hospital, have shown marked improvements in perioperative antibiotic use after the decree was implemented. Surgeons' adherence to the evidence-based standard of prophylactic antibiotic use has improved over time. In conclusion, rapid implementation of the perioperative antibiotic prophylaxis policy was achieved through changes in the reimbursement of antibiotics for surgery patients.

Decreasing antibiotic resistance of Enterobacteriaceae by introducing a new antibiotic combination therapy for neutropenic fever patients.

Prompt empiric antibiotic therapy is of critical importance for patients with neutropenic fever. However, a major concern with important clinical consequences is the emergence of bacterial resistance to antibiotics. After using ceftazidime with a glycopeptide as initial empiric therapy for neutropenic fever, we were confronted with a 75% reduced susceptibility rate to ceftazidime of inducible Enterobacteriaceae collected in 1994. The initial empiric therapy was therefore replaced in May 1995 by a combination of cefepime with amikacin, with addition of a glycopeptide after 48 h if necessary. After this change, we observed a significant decrease in reduced susceptibility of inducible Enterobacteriaceae, not only to ceftazidime, but also to amikacin, cotrimoxazole and ciprofloxacin. There was also a decrease in reduced susceptibility of non-inducible Enterobacteriaceae, such as Klebsiella spp, to ceftazidime. The reduction of resistance may be related at least in part to the combined use of cefepime together with an aminoglycoside. This study shows that it is possible to reverse bacterial resistance by modifying the antibiotic regimen used.

Surgical prophylaxis in Belgian hospitals: estimate of costs and potential savings.

Between 1991 and 1995 the Belgian National Program for Surveillance of Hospital Infections (NSIH) collected data on perioperative antibiotic prophylaxis in 72 acute care hospitals. From the costs of prophylactic antibiotics for six categories of surgical procedure and from discharge summaries for hospitalization episodes nationwide, annual drug costs were estimated for 73% of Belgian surgical activity. Costs of antibiotics used in these surgical activities were estimated at 386-410 million Belgian francs (Bf) per year (US$12.1-12.9 million). After agreeing recommendations for best practice, the hypothetical costs of 'optimal' antimicrobial prophylaxis were calculated for the same selection of surgical procedures. It was calculated that savings of at least 194 million Bf (US$6.1 million) could be made if recommendations were followed closely. Only the costs borne by the National Health Insurance Institute for reimbursement of the dispensed drugs were considered in this study. Other direct costs, such as those related to drug storage, dispensing and administration, were not included.

An outbreak of Burkholderia cepacia with septicemia on a cardiology ward.

During a 3-day period, eight patients developed septicemia with Burkholderia cepacia. Heparin injection was found to be a risk factor. Heparin was diluted with dextrose solution, which was aspirated from a 1-L bag. B cepacia, genotypically identical to the blood isolates, was isolated from this bag.

Nosocomial septicaemias in a cardiologic ward. A case-control study.

Nosocomial septicaemias were studied in a cardiologic ward at the University Hospital of Antwerp, Belgium. The incidence of nosocomial infections was found to be 2.7 per 1,000 admissions per year. A case-control study suggested that in contrast with coronarography and pacemaker implantation, percutaneous transluminal coronary angioplasty may be a risk factor for nosocomial septicaemia (OR 4.5, 95% confidence interval 0.7-33.4).

Macromolecular creatine kinase type 1: a serum marker associated with disease.

The prevalence of circulating macromolecular creatine kinase type 1 (macro CK type 1 or CK-immunoglobulin complexes) is significantly higher in a patient population selected for CK isoenzyme assay than in age- and sex-matched blood donors (n = 1304). In greater than 8000 patients studied, 49 individuals with macro CK type 1 were identified, yielding an overall prevalence of 0.61%. Macro CK type 1 complexes occurred more frequently in women and in patients older than 70 years, and were often associated with complications of cardiovascular disease, life-threatening conditions, and poor outcome. These latter clinical associations could arise, at least partly, from the selection of patients for whom CK isoenzyme analysis was ordered.

Evaluation of the LOGIC system for the rapid identification of members of the family Enterobacteriaceae in the clinical microbiology laboratory.

The LOGIC identification system (J.D. Perry, M. Ford, N. Hjersing, and F.K. Gould, J. Clin. Pathol. 41: 1010-1012, 1988) for gram-negative rods, performed with microdilution plates instead of tubes, was evaluated for strains isolated from all tested specimens except those obtained from stools (for which a different strategy was followed). Systematically extended with the oxidase test and lactose fermentation, it proved to be very reliable and extremely simple and economical.

Detection of macroenzymes in serum by high-performance gel permeation chromatography.

A rapid high-performance gel permeation chromatographic method to confirm the presence of enzymes with abnormally high relative molecular masses (macroenzymes) in serum is described. The technique requires 200 microliters of serum, can be automated and has been implemented for the analysis of creatine kinase (CK), lactate dehydrogenase, amylase, and alkaline phosphatase (ALP) activities. Serum fractionation according to relative molecular mass is completed within 21 min, and 84-106% of enzyme activities are recovered in the eluted fractions. The elution patterns obtained make possible the differentiation of 40 samples containing at least 10 U/l immunoglobulin-enzyme complexes, aggregated mitochondrial CK or membrane fragments carrying ALP activity from 40 control samples without these high-mass enzyme forms.