PARTICIPATION:

1. Who can participate in the inpatient Global-PPS?
2. Which antimicrobials should I include?
3. Can I also include oral antibiotics that are not absorbed into the blood?

INCLUSION CRITERIA – PATIENTS:

1. What are the inclusion criteria for patients in the inpatient protocol?
2. Should I include patients if the 1st dose of the antimicrobial is administered 1 hour after the survey?
3. The ward under surveillance on a particular day is completely occupied (bed occupation=100%), and some patients who normally belong to this ward are admitted on another ward. Should I also count these patients who are admitted on another ward?
4. Should patients receiving hospital-at-home care or Outpatient Parenteral (IV) Antibiotic Therapy (OPAT) be counted as inpatients?
5. How should I count mothers and babies admitted on a Gynaecology-Obstetrics ward? Which mothers and babies are included or excluded?

INCLUSION CRITERIA – DEPARTMENTS & WARDS:

1. Can multiple departments participate in the survey?
2. Should psychiatric wards be included?

PARTICIPATION

1. Who can participate in the inpatient Global-PPS?

Any hospital admitting inpatients can participate in the inpatient module, both in the basic and healthcare-associated infections module. Other healthcare facilities with admitted patients can also participate, such as revalidation centres, long-term healthcare facilities, nursing homes.

If you have a mixed facility or mixed departments, consisting of inpatient beds and outpatient beds/consultation rooms, please survey these patients separately in the Global-PPS. Please survey all inpatient beds following the inpatient protocol and outpatient beds/consultation rooms following the outpatient protocol.

Pharmacies cannot participate in the Global-PPS, since our method is focused on prescribing and not dispensing patterns.

2. Which antimicrobials should I include?

All antibiotics for systemic use (J01), antifungals (J02) and antimycotics (D01BA) for systemic use, antimalarials (P01B), antivirals for systemic use (J05), drugs for treatment of tuberculosis (J04A), antibiotics used as intestinal anti-infectives (A07AA), and nitroimidazole derivatives used as antiprotozoal agents (P01AB) are included in the Global-PPS. Antimicrobials for topical use are excluded (including creams, eye drops, ear drops, etc.).

For the Global-PPS antimicrobials are recorded according to the WHO ATC classification system. Please find a list of all included antimicrobial agents under Documents > ‘antimicrobial list’.

3. Can I also include oral antibiotics that are not absorbed into the blood?

Oral antibiotics that are not absorbed by the gastro-intestinal tract into the blood, and hence are locally active, are included in the Global-PPS. These antibiotics fall under the WHO ATC class of A07AA, the intestinal anti-infectives.

However, please exclude antibiotics for topical or vaginal use, such as nystatin creams. Oral nystatin formulations, e.g. for oropharyngeal candidiasis, can be included.

Please find all specific intestinal anti-infectives and other antimicrobials included in the Global-PPS under Documents > ‘antimicrobial list’.

INCLUSION CRITERIA – PATIENTS

1. What are the inclusion criteria for patients in the inpatient protocol?

All patients admitted on a ward (excluding day admissions such as endoscopy or renal units) at 8 a.m (or another time point of your choosing, but preferably when patients who stayed overnight have not been discharged yet). These patients are the denominator. The number of all admitted patients and beds should be filled in on the Ward form.

All patients admitted on the same ward receiving antimicrobial treatment are included as numerator. Please fill in a Patient form for each of these patients.

Exclude day hospitalizations and outpatients (these can be surveyed according to the outpatient module), and exclude patients admitted after 8 a.m. (or your respective time point) on the day of the survey. All patients who do not meet the inclusion criteria should be excluded from both the numerator and denominator data.

2. Should I include patients if the 1^st dose of the antimicrobial is administered 1 hour after the survey?

If the 1^st dose of the antimicrobial is scheduled to be administered after the survey, do not include this antimicrobial in the survey. Record this patient in the denominator, but do not include this patient in the numerator: i.e., do not fill in a Patient Form for this patient.

Exception: if the patient was previously on e.g. parenteral antibiotic use, which was stopped the day before the survey, but a new oral antibiotic was started a few hours after the survey, you should consider this antibiotic as an ongoing antibiotic and hence include this antibiotic and this patient in the survey. Record the parenteral antibiotic in this case, as the oral antibiotic was started after the survey.

3. The ward under surveillance on a particular day is completely occupied (bed occupation=100%), and some patients who normally belong to this ward are admitted on another ward. Should I also count these patients who are admitted on another ward?

No, only count the patients (and beds) physically present in the ward you are auditing on the day of the PPS.  Look at the actual situation of the specific ward at the time of the PPS.

4. Should patients receiving hospital-at-home care or Outpatient Parenteral (IV) Antibiotic Therapy (OPAT) be counted as inpatients?

No, these patients should not be counted as inpatients in the survey if they are not admitted in the hospital. For example, if a nurse administers IV antibiotics at the patient’s home or if they are reviewed in the hospital without being re-admitted, they are not considered inpatients. While such patients may technically be classified as inpatients, their care resembles that of day patients, and they should be excluded from the Global-PPS.

5. How should I count mothers and babies admitted on a Gynaecology-Obstetrics ward? Which mothers and babies are included or excluded?

Mothers who deliver in a polyclinic and are discharged within 24 hours of admission, along with their babies, are considered day care admissions and should be excluded from the survey. These are defined as ambulatory care patients (day cases).

Additionally, always follow the inclusion criteria as defined in protocol:

• Include women who were admitted before 8 a.m. and still present at 8 a.m. Women admitted after 8 a.m. are excluded and should not be counted in either the denominator or numerator.
• Babies present on the ward before 8 a.m. should be counted (unless they fall under day care admission, as noted above). Babies born after 8 a.m. are excluded from the survey.

INCLUSION CRITERIA – DEPARTMENTS & WARDS

1. Can multiple departments participate in the survey?

Yes, we recommend that you survey the entire hospital if you participate for the first time in the Global-PPS (to obtain baseline data for all wards).

If it is not your first time participating in the Global-PPS with your hospital, you can also survey a selection of the departments, but we recommend that you include all wards for a certain main activity (medical, surgical, ICU): e.g., all adult ICU wards, all paediatric surgical departments, etc. We recommend this so that you collect sufficient data by activity, and subsequently, you will obtain valid rates by activity. For smaller hospitals (<250 beds), it remains advisable to survey the entire hospital.

2. Should psychiatric wards be included?

Yes, also include the psychiatric wards/cases. Encode these wards as PSY-AMW (Psychiatry). This allows for the differentiation of these wards in the analyses, as prescribing patterns are likely different from those of other adult medical wards.

1. How often is the Global-PPS conducted?
2. When is the best time to conduct the survey?
3. Do all departments need to be surveyed on the same day?
4. How long should I survey the department?
5. Is it possible to participate multiple times within one survey period?
6. Can data be collected retrospectively?

1. How often is the Global-PPS conducted?

There are three survey periods every year: January-April, May-August, September-December.

In the inpatient modules, you can participate once per period, i.e. up to three times a year. Hospitals are free to choose if they wish to participate once, twice or three times a year.

2. When is the best time to conduct the survey?

The best time to conduct a survey is on a day that is representative of the usual practice on the ward. Often, this is a weekday, not during the weekend and not on a holiday.

3. Do all departments need to be surveyed on the same day?

No, you can survey departments on different days. However, you should survey the entire department on one day; you cannot split up the department and survey it on different days.

4. How long should I survey the department?

Each department should be surveyed on a single day at a specific point in time, such as 8 a.m. (or a different time of your choosing, but preferably before patients who stayed overnight have been discharged ).

5. Is it possible to participate multiple times within one survey period?

No, unfortunately, it is not possible to participate more than once during a single survey period in the Global-PPS. You can take part up to three times a year—once in each survey period—but no more than that.

6. Can data be collected retrospectively?

Yes, it is certainly possible to collect data retrospectively if all mandatory variables can be captured in the patient forms. Please also make sure you collect the data for one point in time, on one day. Please do not capture longitudinal data since this method is a point prevalence survey.

DATA COLLECTION – GENERAL:

1. How should the data be recorded and submitted?
2. Are there specific forms or templates for data collection?

DATA COLLECTION – PATIENTS:

1. What patient data need to be collected for the survey?
2. Do I need to record the weight for adult, pediatric and neonatal patients?
3. When should I consider a treatment based on a biomarker?
4. What is classified under the category “other biomarker” regarding the type of biomarker?
5. What should I record for the start date of the antimicrobial?
6. How should I report the route of administration?
7. How should I report the dose?
8. How should I report the dose for children?
9. How should I record the dose of an antibiotic with enzyme inhibitor?
10. How should I record fixed-dose combinations of active antimicrobials?
11. How should I report the dose for antimicrobials prescribed a few times per week?
12. How should parenteral (IV) continuous infusion be reported?
13. How should I record the diagnosis?
14. Which diagnostic code should I choose if the diagnosis is uncertain?
15. What diagnosis should I choose for patients with sepsis of known origin, e.g. urosepsis?
16. What if an incorrect diagnosis was made and was only discovered during the audit?
17. When should I classify an infection as a Community-Acquired Infection (CAI) and when as a Hospital-Associated Infection (HAI)?
18. How should I encode an antimicrobial prescribed for prophylaxis?
19. How should I record the Reason in Notes?
20. How do I record guideline compliance?
21. How do I record guideline compliance for combination therapies?
22. What if the dose or duration of the prescription are not compliant to guidelines?
23. What does the question mean: “Is a stop/review date documented?”
24. When should I consider a treatment as Targeted treatment, and when as Empiric?
25. What microorganisms and resistance types should I report for targeted treatments?
26. Which invasive devices are scored under the HAI module — HAI MODULE QUESTION

DATA COLLECTION – DEPARTMENTS & WARDS:

1. On the Ward Form, what is meant by the number of eligible patients and the number of beds?
2. How do I survey a department with patients of different activities?
3. What if I have a department with mixed activities, but no fixed number of beds attributed to both activities? What do I enter for the number of beds on the Ward form?
4. How do I survey a department with patients of different specialities?
5. What if I have a ward with no patients receiving antimicrobial therapy?
6. What if my Ward names changed compared to previous years?
7. How should I define and encode a Coronary Care Unit (CCU)?
8. When defining a NICU department, should I specify the level of care?
9. How should I define a Gyneacology-Obstetrics ward?

DATA COLLECTION – GENERAL

1. How should the data be recorded and submitted?

Data should be recorded in the Ward forms and Patient forms. Please find all forms under Documents. Please print these forms in preparation of the survey, and collect all information on these forms. Afterwards, you can enter them in the web application (see FAQ section on ).

2. Are there specific forms or templates for data collection?

Yes, there are Ward and Patient forms for the inpatient module. If you participate in the additional healthcare-associated infections module, there’s also an HAI form. Please find all forms under Documents.

DATA COLLECTION – PATIENTS

View the questions & answers here.

DATA COLLECTION – DEPARTMENTS & WARDS

1. On the Ward Form, what is meant by the number of eligible patients and the number of beds?

Total number of eligible patients = Total number of patients (whether on antibiotics or not, thus all patients) admitted and occupying a bed on the ward at 8 a.m. on the day of the survey.

Total number of beds = Total number of available beds on the ward, whether occupied or not.

The number of eligible patients, i.e. the first denominator, allows us to calculate antimicrobial use rates (N patients on antibiotics at 8 a.m. on the day of the survey / total number of patients present on the ward at 8 a.m. on the day of the survey).

The number of beds, i.e. the second denominator, allows us to calculate bed occupancy (N patients admitted on the ward at 8 a.m. on the day of the survey / total N beds available on the ward at 8 a.m. on the day of the survey).

The term ‘eligible’ refers to these admitted patients corresponding to the inclusion and exclusion criteria defined by the protocol . E.g. exclude outpatients, day hospitalizations, day surgery, and exclude patients admitted after 8 a.m. (all these patients are excluded from the denominator and of course also from the numerator).

2. How do I survey a department with patients of different activities?

Please use one Ward form and enter the department as one ward. On the Ward form, tick ‘mixed activity’. Collect the number of beds and number of admitted patients separately for each activity. E.g., if you have medical and surgical patients in one ward, count the number of medical beds, the number of admitted medical patients, the number of surgical beds and the number of admitted surgical patients, and fill this in on the Ward form.

For each patient, write down the appropriate activity on the Patient form.

Note: if you e.g. have medical patients in a surgery ward but they do not undergo surgery, please encode them as medical patients and define the ward as a mixed ward. For us, it does not matter what the typical activity of the ward is. It only matters what type of activity the patients receive.

Example:

• If a patient develops a surgical site infection after surgery and is admitted in the hospital, you should classify this patient under activity Medical if the patient was already admitted as medical patient at 8 a.m. on the day of the survey. Define this ward then as a mixed ward. If the patient underwent surgery at 8 a.m. on the day of the survey and was not yet admitted, please classify this patient under activity Surgical.

3. What if I have a department with mixed activities, but no fixed number of beds attributed to both activities? What do I enter for the number of beds on the Ward form?

If you have a ward with mixed activities, but with no fixed number of beds attributed to both activities, please divide the empty available beds over the two activities using the ratio of admitted patients in both activities. E.g. if you have 30 beds, of which 20 occupied, where 16 patients are surgical and 4 are medical, then the number of beds attributed to surgery should be: 16/20 * 30 = 24. The number of medical beds are 4/20 * 30 = 6.

4. How do I survey a department with patients of different specialities?

If you have many beds/admitted patients for each specialty, you can treat this department as if it were two different departments, i.e. create two Ward forms for this department and enter them separately into the application.

If you have very few beds for one of the specialties, or for all of the specialties, you can use one Ward form and enter the department as one ward. You can write down the specialty with the most beds and/or admitting the most patients.

Examples:

• if you have a mixed PICU and NICU department with few (NICU) bed or admitted patients, please encode this as PICU department.
• If you have a mix of pneumology and cardiology patients, please split them up if you have sufficient beds, since pneumology patients may have a different risk of being on antibiotics than cardiology patients.

5. What if I have a ward with no patients receiving antimicrobial therapy?

Please complete the Ward form with the total number of beds and admitted patients, but do not fill in any Patient form. Please also enter this in the application in the same way: complete the Ward form, do not create any Patient forms. In your results, the antimicrobial use prevalence will be zero for this department.

6. What if my Ward names changed compared to previous years?

Please fill in the correct, current names on the paper Ward form, and change the names under ‘Departments’ in the web-based application before you enter your survey data.

7. How should I define and encode a Coronary Care Unit (CCU)?

Encoding the CCU depends on the level of service offered:

• If it is a slightly more caring ‘general cardiac medical ward’ with (some) monitored beds it is medical. Encode as an AMW (Adult Medical Ward) with activity Medicine.
• If the ward has a doctor at all times and the nurse-to-patient ratio is 1:3 or better (1:2 or 1:1) then it is an adult-ICU. Encode as AICU (Adult Intensive Care Unit) with activity Intensive Care.

8. When defining a NICU department, should I specify the level of care?

Define the department as a NICU department (code NICU). For later analyses, you can define in the Ward name the highest level of specialty (NICU level 1, level 2 or level 3) or the level presenting the most patients if a NICU covers several levels.

• NICU–level 1: Special care only Neonatal Units
• NICU–level 2: Medium Neonatal Units. High dependency care + short term Intensive Care. Low birth weight newborns care.
• NICU–level 3: Large Neonatal Units. Tertiary referral care. Very low birth weight care.

9. How should I define a Gyneacology-Obstetrics ward?

A Gynaecology-Obstetric ward may admit several types of patients among which 1) healthy pregnant women who have not yet delivered, 2) healthy women who have delivered, with their baby, 3) pregnant women in observation with pathology, 4) non-pregnant women admitted with a gynaecological pathology.

Encode this ward into two wards:

1. Ward 1 counts all women whether they are pregnant or not, having a pathology or not. Encode this ward as AMW (Adult Medical Ward), with main activity Medicine. If a considerable number of surgery patients are admitted as well, count the attributable beds and patients with suspected or confirmed surgery and define the ward with MIXED activity (thus medicine and surgery). Attribute the number of beds and patients among the two different activities. Note: include also patients in the delivery room if they were present on the ward on the day of the survey at 8 a.m.
2. Ward 2 counts all babies born before 8 a.m. on the day of the survey. Count the number of baby beds and the number of babies admitted (born) before 8 a.m. (=denominator). Encode this supplementary ward as a NMW (Neonatal Medical ward). Name this ward preferably ‘nursery’ ward.

1. Where can I enter data?
2. How can I validate data?
3. What kind of results do I obtain after data entry?
4. How do I obtain the results?

1. Where can I enter data?

Data can be entered within our web application. Please find more detailed instructions in the user manuals in the application. To begin, ensure you’re logged in and have registered your institution. After that, select the appropriate survey period for which you collected data. Then, follow these steps for data entry: (1) create your departments under ‘Departments’, (2) create a new ward under ‘Surveys’ > ‘New ward’, (3) add new patients under ‘Surveys’ > ‘New patient’.

2. How can I validate data?

You can validate data by going to ‘Surveys’ > ‘Subscribed’ and clicking the validation button. A new page with validation errors will pop up, which you will first need to resolve before final validation. Please find more detailed instructions in the user manuals in the web application.

Please note that you can only validate your data if you have entered at least 10 patients.

3. What kind of  results do I obtain after data entry?

You can obtain the results in different ways: an Excel export, feedback slides, and customizable results in the interactive module.

The Excel file contains your raw data. In this file, each row is one antimicrobial prescription. Some variables will be automatically added, such as ATC-codes, AWaRe classification and DDDs. You can download this within the Global-PPS application.

You obtain the feedback report in a PDF-file, where all data are pre-analysed. You can download this feedback report after finalizing your units and survey. There are three reports you can download: (1) the one-point feedback report, with results for your hospital for one survey period, (2) the merged feedback report, with results for multiple hospitals you coordinate for one survey period, and (3) the longitudinal feedback report, with results for your hospital for multiple survey periods up until 2022. Please note the longitudinal feedback report is not supported after 2022, please use the interactive module for your longitudinal results.

The interactive module offers a customizable tool within the Global-PPS web application, where you can easily create your own results. You can create longitudinal graphs for your hospital in this tool, adding additional filters as you like.

4. How do I obtain the results?

You can download all results from within our web application:

• Excel report: go to ‘Surveys’ > ‘Export’ and it will be automatically downloaded. If you wish to export your results for a different survey, first go to ‘Surveys’ > ‘Subscribe’ and select the appropriate survey under ‘Action’. Then download the export for this survey.
• One-point feedback report: Go to ‘Surveys’ > ‘Subscribed’ and validate your data for the survey you wish to download your feedback report for. After validation, you can download the report by going to ‘Surveys’ > ‘Subscribed’ and then clicking the button under ‘Action’. Your feedback report will be sent to you by email.
• Merged feedback report: Go to ‘Surveys’ > ‘Merged Feedback’ and select the hospitals and survey period for which you would like to download a feedback report. Your feedback report will be sent to you by email.
• Longitudinal feedback report: Go to ‘Surveys’ > ‘Longitudinal Feedback’. Please note you can only download a feedback report for the years 2015-2022. Your feedback report will be sent to you by email.
• Interactive feedback report: Go to ‘Surveys’ > ‘Interactive feedback’ and select the results you would like to see, including the additional filters you would like to apply.