Search

Antibiotic stewardship requires clear insight into antibiotic overuse and the syndromes that lead to prescription. The aim of this study was to estimate the proportion of antibiotic prescriptions attributable to acute lower respiratory tract infections (LRTIs) during the cold season. Using individual data from the French National Health Insurance (NHI) database, weekly time series were constructed of outpatient antibiotic (beta-lactams and macrolides) prescriptions between January 2010 and December 2017. Time series were also constructed of tenth edition of the International Classification of Diseases (ICD-10) discharge diagnoses from a national network of emergency departments (EDs), stratified by specific syndromes (pneumonia, bronchitis, bronchiolitis and influenza-like illness). The number of outpatient antibiotic prescriptions attributable to these syndromes during the cold season in France was modeled and estimated for the entire population, young children (≤5 years) and the elderly (≥75 years). LRTIs accounted for 40% (95% confidence interval [95% CI]: 29, 52) of outpatient antibiotic use during the cold season for the entire population, including 23% (95% CI: 13, 33) and 17% (95% CI: 13, 22) for bacterial and viral infections, respectively. In children and the elderly, viral LRTIs were the reason for 38% (95% CI: 31, 46) and 20% (95% CI: 16, 25) of outpatient antibiotic use, respectively (with bronchiolitis accountable for half of use in young children). In the entire population and in children, respectively, outpatient antibiotic overuse attributable to viral LRTIs was estimated to be 289 (95% CI: 221, 374) and 1588 (95% CI: 1295, 1922) prescriptions per 100 000 inhabitants per week. These results highlight the major role of viral infections in driving antibiotic prescriptions, particularly in young children.

International audience; Background: The impact of antibiotic resistance (AMR) on initial hospital management has been extensively studied but its consequences after hospital discharge remain largely unknown. We aimed to analyze hospital care trajectories, cumulative length of hospital stays (c-LOS) and associated costs of care over a 1-year period after hospitalization with incident AMR infection.Method: All incident bacterial infection-related hospitalizations occurring from January 1, 2015, to December 31, 2015 and recorded in the French national health data information system were extracted. Bacterial resistance ICD-10 codes determined six infection status. Inpatient and outpatient care consumption and associated costs were studied. The impact of resistance on c-LOS was estimated using a Poisson regression. A sequence analysis through optimal matching method was conducted to identify hospital trajectories along with an extrapolation.Finding: Of the 73,244 patients selected, 15.9% had AMR infection, thus providing 58,286 incident AMR infections after extrapolation. c-LOS was significantly longer for infections with resistant bacteria, reaching 20.4 days and 2.9 additional days IC95%[2.6; 3.2] for skin and soft tissue infections. An estimated 29,793 (51.1%) patients had hospital readmission within the following year, for a total cost of €675 million. Five post-discharge trajectories were identified: Post-hospitalization mainly at home (68.4% of patients); Transition to home from rehabilitation care (12.3%); Early death (

Introduction L’antibioresistance (AR) va croissante parmi les microorganismes cause d’infections des voies urinaires (IVU), pouvant mener jusqu’a des impasses therapeutiques. Plusieurs facteurs de risque d’IVU a bacteries AR ont ete reveles dans la litterature, mais peu font consensus. Nous avons etudie les facteurs associes a l’AR chez les patients hospitalises pour IVU, a partir du Systeme national des donnees de sante (SNDS). Methodes Les hospitalisations incidentes (2015 − 2017) pour IVU en DP dues a des Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa ou enterocoques ont ete identifiees en medecine, chirurgie, orthopedie. Seuls les sejours pour lesquels la bacterie a ete identifiee sont concernes. Les cas (avec AR) ont ete apparies (1 :1) aux controles (sans AR) sur l’âge, le sexe, l’infection, l’annee d’admission et l’espece bacterienne. Les infections associees aux soins (IAS) et communautaires (IC) ont ete distinguees et les regressions logistiques conditionnelles stratifiees sur le sexe. Resultats Au total, 98,4 % des cas (6606 IC et 3001 IAS) ont ete apparies. Pour l’ensemble des facteurs, sur fenetre de 12 mois, le risque etait augmente uniquement lorsque l’exposition etait dans les trois mois precedant l’infection. Pour toutes les infections, la consommation d’antibiotiques augmentait le risque d’AR, avec un OR atteignant 3,84 [3,04 − 4,85] pour ≥ 3 delivrances chez les hommes avec IAS. Les antibiotiques a large spectre, qu’ils soient ou non rattaches a un antecedent d’IVU, etaient particulierement associes a l‘AR (OR : 2,59 [2,15 − 3,11] et 1,35 [1,18 − 1,53]). Une procedure chirurgicale sur les voies urinaires etait facteur de risque pour les hommes avec IC (1,39 [1,14 − 1,69]) et les femmes avec IAS (1,72 [1,37 − 2,17]). Avoir sejourne > 7 jours en unite de soins intensifs (USI) augmentait faiblement le risque pour les hommes avec IAS (1,44 [1,03 − 2,02]). Le diabete, l’immunosuppression, les maladies neurologiques, les pathologies des voies urinaires et la grossesse n’etaient pas associees a la resistance. Discussion/Conclusion Cette etude confirme l’importance des antibiotiques a large spectre sur le risque d’IVU a bacterie AR, et suggere d’ameliorer la prevention lors des procedures chirurgicales et sejours prolonges en USI.

Objectives: The aim was to quantify the effects of selective digestive tract decontamination (SDD) consisting of a mouth paste and gastro-enteral suspension, selective oropharyngeal decontamination with a mouth paste (SOD) and 1-2% chlorhexidine (CHX) mouthwash on eradication and acquisition of carriage of third-generation cephalosporin-resistant Enterobacterales (3GCR-E) and carbapenem-resistant Gram-negative bacteria (CR-GNB) in Intensive Care Unit (ICU) patients. Methods: This was a nested cohort study within a cluster-randomized cross-over trial in six European countries and 13 ICUs with 8665 patients. Eradication and acquisition during ICU stay of 3GCR-E and CR-GNB were investigated separately in the rectum and respiratory tract for the three interventions and compared with standard care (SC) using Cox-regression competing events analyses. Results: Adjusted cause specific hazard ratios (CSHR) for eradication of rectal carriage for SDD were 1.76 (95% CI 1.31-2.36) for 3GCR-E and 3.17 (95% CI 1.60-6.29) for CR-GNB compared with SC. For the respiratory tract, adjusted CSHR for eradication of 3GCR-E were 1.47 (0.98-2.20) for SDD and 1.38 (0.92-2.06) for SOD compared with SC, and for eradication of CR-GNB these were 0.77 (0.41- 1.45) for SDD and 0.81 (0.44-1.51) for SOD, compared with SC. Adjusted CSHRs for acquisition of rectal carriage during SDD (compared with SC) were 0.51 (0.40-0.64) for 3GCR-E and of 0.56 (0.40-0.78) for CR-GNB. Adjusted CSHRs for acquiring respiratory tract carriage with 3GCR-E compared with SC were 0.38 (0.28-0.50) for SDD and 0.55 (0.42-0.71) for SOD, and for CR-GNB 0.46 (0.33-0.64) during SDD and 0.60 (0.44-0.81) during SOD, respectively. SOD was not associated with eradication or acquisition of 3GCR-E and CR-GNB in the rectum. Conclusions: Among mechanically ventilated ICU patients, SDD was associated with more eradication and less acquisition of 3GCR-E and CR-GNB in the rectum than SC. SDD and SOD were associated with less acquisition of both 3GCR-E and CR-GNB than SC in the respiratory tract. info:eu-repo/semantics/publishedVersion

Massive use of antibiotics has led to increased bacterial resistance to these drugs, making infections more difficult to treat. Few studies have assessed the overall antimicrobial resistance (AMR) burden, and there is a paucity of comprehensive data to inform health policies. This study aims to assess the overall annual incident number of hospitalised patients with AMR infection in France, using the National Hospital Discharge database. All incident hospitalisations with acute infections in 2016 were extracted. Infections which could be linked with an infecting microorganism were first analysed. Then, an extrapolation of bacterial species and resistance status was performed, according to age class, gender and infection site to estimate the total number of AMR cases. Resistant bacteria caused 139 105 (95% CI 127 920–150 289) infections, resulting in a 12.3% (95% CI 11.3–13.2) resistance rate. ESBL-producing Enterobacteriaceae and methicillin-resistant Staphylococcus aureus were the most common resistant bacteria (>50%), causing respectively 49 692 (95% CI 47 223–52 142) and 19 493 (95% CI 15 237–23 747) infections. Although assumptions are needed to provide national estimates, information from PMSI is comprehensive, covering all acute bacterial infections and a wide variety of microorganisms.

Introduction L’impact de l’antibioresistance sur la prise en charge hospitaliere initiale a ete abondamment etudiee mais ses consequences apres la sortie d’hospitalisation demeurent largement inconnues. L’objectif de cette etude est d’etudier l’impact de la resistance bacterienne sur la duree cumulee des rehospitalisations sur une periode de 12 mois apres un sejour infectieux. Methodes Une liste de codes CIM-10 regroupant les infections bacteriennes de six sites infectieux a permis d’identifier les patients hospitalises pour ces infections en 2015. Seules les hospitalisations en MCO pour infections incidentes ont ete retenues. L’incidence a ete definie par l’absence d’hospitalisation avec la meme infection au cours de l’annee precedente. Le statut de l’infection a ete determine par la presence ou l’absence d’un code de resistance : resistant versus sensible respectivement. Sur une periode de 12 mois, la duree d’hospitalisation cumulee (MCO, SSR, HAD) a ete calculee pour l’ensemble des patients. L’impact de la resistance a ete estime par une regression de Poisson ajuste par : statut de l’infection, sexe, âge, score de Charlson, categories d’infections, germes, antecedent d’hospitalisation et statut hospitalier (public/prive). Resultats Un total de 73 244 patients ont ete selectionnes, dont 11 680 (15,9 %) avec resistance et 61 564 (84,1 %) avec infection sensible. Dans l’analyse multivariee, la duree d’hospitalisation est plus importante toutes activites confondues pour les infections a germes resistants (infections genito-urinaires : 1,3 jours en plus IC95 % [1,2 ; 1,4] atteignant 15,6 jours ; infections de la peau et des parties molles : 2,9 jours en plus [2,6 ; 3,2] atteignant 20,4 jours) a l’exception des infections du cœur et du mediastin (−2,5 jours [−2,9 ; −2,1], soit 27,5 jours d’hospitalisation cumules). Les secteurs d’activite contribuant le plus a cette augmentation sont les hospitalisations en MCO pour une infection et en HAD. Discussion/Conclusion La resistance aux antibiotiques a un impact sur la duree cumulee d’hospitalisations des patients au-dela de l’hospitalisation initiale a travers les sejours en MCO pour infection et en HAD.

Introduction L’antibioresistance est une menace majeure pour la sante publique. Peu d’etudes decrivent la prise en charge hospitaliere apres infection a germe antibioresistant. L’objectif de cette etude est de decrire et d’identifier les trajectoires de soins hospitalieres et le cout de prise en charge a 12 mois d’une hospitalisation pour infection a germe resistant. Methodes Une liste de codes CIM-10 regroupant les infections bacteriennes de six sites infectieux a permis d’identifier les patients hospitalises pour ces infections en 2015. Seules les infections incidentes (sans hospitalisation en MCO avec infection l’annee precedente) presentant un code de resistance ont ete retenues. Toute la consommation de soins hospitaliers (MCO, SSR, HAD) a ete etudiee sur une periode de 12 mois suivant la sortie de l’hopital. Pour les patients rehospitalises au moins une journee, une analyse de sequence a ete effectuee pour identifier des trajectoires hospitalieres types. Pour chaque trajectoire, une description des patients et les couts (hospitaliers et ambulatoires) associes sont presentes. Resultats Au total, 58 286 patients ont ete hospitalises en 2015 pour une infection incidente a bacterie resistante et 29 793 (51,1 %) ont ete rehospitalises au moins une journee au cours du suivi. Cinq trajectoires hospitalieres ont ete identifiees: post-hospitalisation principalement a domicile (68,4 % des patients) ; transition en SSR vers le domicile (12,3 %) ; deces precoce (9,7 %) ; deces tardif (7,4 %) ; sejour prolonge en SSR (2,2 %). Les durees cumulees hospitalieres les plus longues (> 250 j) etaient observees suite a une infection osteoarticulaire, et une mortalite elevee concernait les infections du cœur et du mediastin ou des voies respiratoires basses. Ces trajectoires de soins ont un cout total estime a 700 millions d’euros avec un cout par patient observe allant jusqu’a 68 922 euros pour la trajectoire « Sejour prolonge en SSR ». Discussion/Conclusion La moitie des patients hospitalises pour infection resistante est rehospitalisee dans l’annee qui suit. Nous observons des disparites importantes dans les trajectoires et leurs couts selon les categories d’infections.

Importance: The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective: To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, Setting, and Participants: Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum β-lactamase–producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions: Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main Outcomes and Measures: The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results: A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, −0.6% to 1.1%), 0.6% (95% CI, −0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and Relevance: Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care. Trial Registration: ClinicalTrials.gov NCT02208154

Introduction La resistance aux antibiotiques est une menace majeure pour la sante publique avec 33 000 morts en Europe en 2015. L’objectif de cette etude est d’estimer son cout hospitalier en 2015, selon la perspective de l’Assurance maladie, a partir d’une etude cas-temoins appariee a partir du PMSI. Methodes Toutes les hospitalisations survenues en 2015 en lien avec une infection bacterienne sont extraites du PMSI. Les categories d’infection, les germes et la resistance aux antibiotiques sont identifiees a l’aide de codes CIM-10. Les sejours avec code de resistance sont definis comme des cas et ceux sans code de resistance comme temoins. Les informations sur les depenses de soins, les comorbidites et les caracteristiques demographiques des patients ont egalement ete extraites. Nous avons effectue une etude cas-temoin appariee pour determiner l’excedent des remboursements verses pour les sejours avec une resistance. Les cas et les temoins ont ete apparies selon les variables suivantes : sexe, âge, score de Charlson, categorie d’infection, rang de codage de l’infection (code infectieux en DP ou DAS), micro-organisme et statut hospitalier (public ou prive). Resultats L’analyse s’est focalisee sur les sejours ne presentant qu’une infection et un germe afin d’identifier le germe responsable. Ainsi, 52 921 cas ont ete apparies (98,2 % des cas). Le cout global sur les cas identifies atteint 109,3 millions d’euros apres extrapolation a tous les sejours avec resistance, avec une moyenne de 1103 euros par sejour (IC95 % : 1006–1198). Une extrapolation a l’ensemble des sejours presentant une infection et dont la presence de resistance est inconnue, montre que le cout global pourrait atteindre 287,1 millions d’euros si tous les cas etaient identifies. Des resultats similaires sont obtenus en utilisant un appariement desequilibre (1 a 5 temoins par cas) et une regression lineaire. Discussion/Conclusion La resistance aux antibiotiques represente une charge financiere additionnelle importante pour l’Assurance maladie en France. Notre etude confirme la necessite de renforcer les programmes de prevention des infections dues a des germes resistants.

Previous clinical trials suggested that inhaled nitric oxide (iNO) could have beneficial effects in sickle cell disease (SCD) patients with acute chest syndrome (ACS). To determine whether iNO reduces treatment failure rate in adult patients with ACS, we conducted a prospective, double-blind, randomized, placebo-controlled clinical trial. iNO (80 ppm, N = 50) gas or inhaled nitrogen placebo (N = 50) was delivered for 3 days. The primary end point was the number of patients with treatment failure at day 3, defined as any one of the following: (1) death from any cause, (2) need for endotracheal intubation, (3) decrease of PaO2/FiO2 ≥ 15 mmHg between days 1 and 3, (4) augmented therapy defined as new transfusion or phlebotomy. The two groups did not differ in age, gender, genotype, or baseline characteristics and biological parameters. iNO was well tolerated, although a transient decrease in nitric oxide concentration was mandated in one patient. There was no significant difference in the primary end point between the iNO and placebo groups [23 (46 %) and 29 (58 %); odds ratio (OR), 0.8; 95 % CI, 0.54–1.16; p = 0.23]. A post hoc analysis of the 45 patients with hypoxemia showed that those in the iNO group were less likely to experience treatment failure at day 3 [7 (33.3 %) vs 18 (72 %); OR = 0.19; 95 % CI, 0.06–0.68; p = 0.009]. iNO did not reduce the rate of treatment failure in adult SCD patients with mild to moderate ACS. Future trials should target more severely ill ACS patients with hypoxemia. NCT00748423.

Resume La rage humaine est une maladie virale rare a l’origine d’un tableau aspecifique d’encephalite ou de syndrome paralytique aigus. Les notions de contact avec un chien ou de voyage dans un pays a risque dans les semaines precedentes constituent les clefs du diagnostic mais peuvent parfois manquer. L’hydrophobie et l’aerophobie sont deux signes evocateurs mais inconstants. L’imagerie cerebrale, l’analyse du liquide cephalorachidien et l’electroencephalogramme ne montrent aucun signe specifique et servent essentiellement a eliminer les diagnostics alternatifs. Le diagnostic de rage repose sur la recherche de l’ARN de Lyssavirus grâce a une RT-PCR realisee sur une biopsie cutanee ou sur les secretions salivaires. Il n’y a pas de traitement etiologique de la rage rendant la maladie constamment mortelle. Nous presentons ici le cas d’un patient de 57 ans atteint de rage dans sa forme encephalique puis paralytique au retour d’un voyage au Mali, pour lequel le diagnostic fut pose tardivement. Ce cas clinique illustre la difficulte diagnostique lorsque la notion de contage avec un chien enrage fait defaut.

Defined daily doses (DDD) are the gold standard indicator for quantifying prescriptions. Since 2014, the European Centre for Disease Prevention and Control (ECDC) has also been using the number of packages per 1,000 inhabitants per day (ipd), as a surrogate for prescriptions, to report antibiotic consumption in the community and to perform comparisons between European Union (EU) countries participating in the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). In 2015, consumption was reported to range across Europe from 1.0 to 4.7 packages per 1,000 ipd. Our analysis showed that consumption of antibiotics for systemic use per 1,000 ipd was on average 1.3 times greater in France than in Belgium when considering prescriptions in the numerator, 2.5 times greater when considering packages and 1.2 times greater when considering DDD. As long as the same metrics are used over time, antibiotic consumption data aggregated and disseminated by ECDC are useful for assessing temporal trends at the European level and within individual countries; these data may also be used for benchmarking across EU countries. While DDD - although imperfect - are the most widely accepted metric for this purpose, antibiotic packages do not appear suitable for comparisons between countries and may be misleading.

Resume La maitrise de la diffusion des bacteries multi-resistantes endemiques reste un objectif majeur en France, mais des controverses persistent sur les methodes necessaires a employer pour y parvenir. Plusieurs grandes etudes recentes sont venues cependant eclairer le debat. Une etude controlee de l’isolement/regroupement des patients porteurs de SARM n’a pas montre d’efficacite de cette mesure dans le contexte d’une prevalence tres elevee et d’une observance tres reduite de l’hygiene des mains. L’etude de l’administration des veterans aux Etats-Unis montre un impact notable du depistage systematique associe aux precautions complementaires (PC) sur le taux d’infection a SARM, mais ceux-ci sont associes a d’autres mesures de prevention des infections. L’etude soutenue par le NIH (« STAR-ICU »), de meme que celle sur l’utilisation systematique des « precautions barriere » sont celles dont la methodologie est la plus solide, randomisees en grappes, et ne montrent pas d’effet du depistage et isolement ou du port de gants et blouses systematiques sur la prevention de la transmission des SARM ou d’ERV. La « decontamination » des malades de reanimation par des toilettes systematiques a la chlorhexidine a permis d’obtenir une reduction des taux d’infection a SARM et des bacteriemies, notamment « primaires ». Une grande etude de l’efficacite de la decontamination systematique (sans depistage ni isolement) des malades par toilettes a la chlorhexidine et mupirocine nasale a montre la superiorite de cette strategie sur la reduction des infections a SARM et bacteriemies acquises en reanimation par rapport au depistage et PC en l’absence de decontamination. Enfin, l’etude MOSAR a permis de confirmer l’efficacite du renforcement des precautions standard et de l’hygiene des mains, associee aux toilettes a la chlorhexidine, et l’absence d’apport supplementaire du depistage, meme rapide par PCR, et de l’isolement dans le contexte d’une observance elevee de l’hygiene des mains. Aucune de ces etudes n’a evalue simultanement l’exposition aux antibiotiques.

The international project MOSAR was conducted in five rehabilitation centers; patients were screened for rectal carriage of extended-spectrum β-lactamase (ESBL)-producing members of the Enterobacteriaceae . Among 229 Klebsiella pneumoniae isolates, four clonal groups (CG) or complexes (CC) prevailed: CG17 in France, CG101 in Italy, CG15 in Spain, and CC147 in Israel. ESBLs, mainly CTX-Ms, were produced by 226 isolates; three isolates expressed AmpC-like cephalosporinases. High genetic diversity of K. pneumoniae populations was observed, with specific characteristics at each center.

Twenty-three hospital laboratories from Europe and Israel participated in an external quality assessment (EQA) of the culture-based detection of methicillin-resistant Staphylococcus aureus (MRSA). Participants also reported the MRSA prevalence in clinical cultures and patient screening specimens, as well as the MRSA screening practices employed at their hospitals. An EQA panel of 18 samples consisting of two MRSA harbouring SCCmec IV and I, and one strain each of methicillin-resistant coagulase-negative S. epidermidis, methicillin-sensitive S. aureus and Escherichia coli as pure strains or in mixtures at 1071 cfu absolute loads was analysed by the 23 participants. Seventeen (74%) participants identified 17 or more samples correctly. Of these, 15 (88%) utilised a chromogenic medium alone (ChromID, bioMérieux; BBL CHROMagar, BD Diagnostics; MRSA Select, Bio-Rad Laboratories) or combined with a conventional medium and up to three confirmatory tests. Proportions of MRSA among S. aureus isolated from clinical cultures varied widely, even among hospitals within countries, ranging from 1120% to 6170%. MRSA carriage rates were less variable (020%) between countries. Almost all participants (n = 22, 96%) screened patients for MRSA carriage during 20092010, of which 15 (68%) screened intensive care unit (ICU) patients alone or combined with other targeted high-risk groups, and 10 (45%) combined nasal screening with another body site.

Resume L’usage des carbapenemes va croissant a mesure de l’extension des resistances aux antibiotiques chez les bacilles a Gram negatifs, particulierement des betalactamases a spectre etendu ; il fait craindre la perte d’activite de cette classe, du fait de l’apparition des carbapenemases. Ces recommandations de la Commission des anti-infectieux de l’Assistance publique-Hopitaux de Paris (AP–HP) visent a encourager un usage raisonne et aussi limite que possible des quatre molecules disponibles de la classe, en comparant leurs avantages respectifs et precisant leurs modalites d’utilisation et leurs indications en pratique clinique, ainsi que les alternatives possibles.

Introduction The massive use of antibiotics has led to a significant increase of bacterial resistance to these drugs, making infections more difficult to treat; antimicrobial resistance has become a major public health issue. Few studies have assessed the total burden of antimicrobial resistance, and there is a paucity of comprehensive population-based data. In 2014, because of the impact of antimicrobial resistance on public health, the World Health Organization revised its codification of infections and antimicrobial resistance in the 10th revision of the international classification of diseases (ICD-10), which is used in the French Hospital Discharge Database (PMSI). In France, special attention was given to resistance causing therapeutic difficulties leading to additional specific codes in ICD-10. These improvements are an opportunity to use national healthcare database in order to reduce assumptions and to base burden estimations on actual nationwide data. This study aims to estimate the overall situation of antimicrobial resistance in France based on the PMSI. Methods Study population was incident hospitalizations with an acute infection caused by Streptococcus, Staphylococcus, Enterobacteriaceae or another Gram negative bacteria in 2015. Hospitalizations with infections were identified in the PMSI database from established lists of ICD-10 corresponding to infections, microorganisms and resistances codes. Stays (> 1 day) with an admission between January 1 and December 31, were selected when at least one code of infection was present in principal, related, or significant associated diagnosis. Patients hospitalized with infections in the 12 months preceding the admission were excluded. Using medical-administrative databases for a different objective from their original purpose leads to difficulties, in particular in the context of infectious disease: diagnoses are not related, and some information could be unknown. First, stays were usable only if the infection, the microorganism and the potential resistance could be related. For these stays, bacteria were considered susceptible when no resistance was recorded. Second, if no bacterial species was noted (i.e. because the physician considered irrelevant/unnecessary to obtain microbiological sample or because the culture results may be negative, etc.), the causal agent and its resistance status were extrapolated from the stays with usable information, according to sex, age (7 categories) and site of infection (11 categories). Resulting stays were described, characteristics of infections with resistant bacteria analyzed and the burden of resistance in France estimated. Results In 2015, 979,902 incident hospitalizations with an acute infection were selected. Bacteria species was recorded in 30% of the cases. After extrapolation, it was estimated that bacterial resistance was associated with 111,177 incident infections in France, corresponding to 11.3% of all incident infections. These infections were mostly of the urinary and genital tracts (25.2%), lower respiratory tract (21.1%), gastrointestinal and abdominal (20.7%) and skin and soft tissues infections (14.2%). Among resistant bacteria, the most frequently detected were ESBL-producing Escherichia coli (28.6%), methicillin resistant Staphylococcus aureus (MRSA, 19.9%), and Klebsiella pneumoniae ESBL (5.2%). MRSA and ESBL-producing Enterobacteriaceae (ESBL-PE) were estimated to cause 22,081 and 39,600 infections annually, respectively. Conclusions This study is the first study to evaluate the burden of resistance from a national comprehensive database. Resistance rates among blood infection estimated from the sample (ESBL-PE, MRSA and VRE) were in accordance with those provided by EARS-net, validating the extrapolation. This study also confirms the importance of ESBL-PE and MRSA in the overall burden of resistance.

a, b, c. Table a, table b, table c have been added as supplementary material. Table a presents the methodology, parameters and main results of 3 studies estimating the morbidity and mortality of multidrug-resistant bacteria infections : the European study, the US study and our French study. Table b compares the ratios used for estimating the incidence of non-invasive infections in the European study and Santé publique France study. Table c compares the ratios used for estimating mortality associated with infections due to MDRB in the European study and Santé publique France study [31–34]. (PDF 285 kb)

Objective.We determined the percentage of healthcare workers' (HCWs') hands contaminated with Clostridium difficile spores after caring for patients with C. difficile infection (CDI) and risk factors associated with contamination.Design.Prospective study.Setting.A French university hospital.Methods.We compared the hand contamination rate among HCWs caring for patients with CDI (exposed group; n = 66) with that among an unexposed group (n = 44). Spores of C. difficile were recovered from the hands of HCWs after rubbing their fingers and palms in alcohol shortly after patient care. Associations between hand contamination and HCW category, type (patient or environment), and risk level (high or low risk) of HCW contacts and their respective duration as well as use of gloves were analyzed by bivariate and multivariate analysis.Results.C. difficile spores were detected on 24% of HCWs' hands in the exposed group and on 0% in the unexposed group (P < .001). In the exposed group, logistic regression, which adjusted for high-risk contact (ie, exposure to fecal soiling), contact with the environment, and contact with or without use of gloves, revealed that high-risk contact (adjusted odds ratio [aOR] per 1 contact increment, 2.78; 95% confidence interval [CI], 1.42–5.45; P = .003) and at least 1 contact without use of gloves (aOR, 6.26; 95% CI, 1.27–30.78; P = .02) were independently associated with HCW hand contamination by C. difficile spores.Conclusions.Nearly one-quarter of HCWs have hands contaminated with C. difficile spores after routine care of patients with CDI. Hand contamination is positively associated with exposure to fecal soiling and lack of glove use.

In a 2008-2011 survey, 17,945 patients in 18 hospital units in Europe and Israel were screened for carriage of Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae , resulting in identification of 124 positive patients. The isolates were dominated by Klebsiella pneumoniae sequence type 258 (ST258) KPC-2 and ST512 KPC-3, mainly from Greece and Italy, respectively, whereas Israeli isolates were of diverse species, clones, and KPC variants. Various bla KPC platforms were observed, among which IncFII K -FIB K plasmids with bla KPC-2/-3 genes in the Tn 4401 a transposon prevailed.

Resume La reanimation, « epicentre de la resistance aux antibiotiques », est et restera la discipline medicale ou les infections nosocomiales sont les plus frequentes. Cette situation est evidemment due a la conjonction de la frequence d'utilisation des dispositifs invasifs, de la reduction des defenses associee a l'immunodepression relative secondaire a la pathologie aigue et de la frequence croissante — avec le vieillissement de la population — des pathologies chroniques associees. Pour autant, la frequence des infections nosocomiales est en baisse, et non pas en augmentation comme le laisse souvent craindre la presentation au public d'episodes complaisamment mediatises a l'exces. Une information objective du public sur ces questions est indispensable. Ce document a vocation didactique tente de reunir de maniere synthetique les notions essentielles sur la physiopathologie, les facteurs de risque, l'interpretation et la comparabilite des taux d'infection observes en reanimation, et les principales mesures preventives qui nous sont accessibles actuellement. Les reanimateurs ont depuis longtemps, et continuent, de travailler activement sur les problemes poses par ces infections et les meilleures methodes de leur prevention, et les resultats obtenus dans certains domaines tels que les bacteries multiresistantes aux antibiotiques sont demonstratives. Les propositions d'indicateurs de processus et de resultats presentees dans ce document doivent permettre aux services de reanimation de temoigner de leur engagement dans la lutte contre les infections nosocomiales.

Resume Introduction Les exacerbations sont la principale cause de morbidite et de mortalite des malades atteints de broncho-pneumopathie chronique obstructive (BPCO). Les infections bacteriennes et virales en sont les principaux facteurs favorisants et la strategie antibiotique est discutee. En l’absence d’infection patente, le benefice d’une antibiotherapie systematique dans le traitement curatif des exacerbations de BPCO reste controverse. Materiel et methodes Cet essai se propose d’evaluer l’efficacite d’une antibiotherapie precoce sur la duree des symptomes chez des patients hospitalises pour exacerbation de BPCO en reanimation ou en secteur de surveillance continue. Il s’agit d’un essai multicentrique randomise, controle en double-aveugle, comparant l’effet de l’administration precoce (≤ 24 h) de l’association amoxicilline-acide clavulanique pendant 7 jours a un placebo. Les malades inclus sont ceux porteurs d’une BPCO et n’ayant pas de syndrome infectieux franc ou de broncho-pneumopathie aigue a l’admission en reanimation, ni de dysfonction viscerale autre que respiratoire. Les malades recevant une corticotherapie prolongee, hospitalises recemment ou ayant recu un traitement antibiotique depuis > 24 h ne sont pas inclus. Les therapeutiques medicales associees sont administrees de facon aussi standardisee que possible (traitement bronchodilatateur inhale ; pas de corticotherapie systemique). Resultats attendus Une reduction de 20 % de la duree des symptomes d’exacerbation est attendue. Il est prevu d’inclure 520 malades au total durant 18 mois dans 15 centres de reanimation medicale polyvalente et respiratoire. Les criteres de jugement secondaires sont la frequence des infections survenant durant le sejour en reanimation, la consommation globale d’antibiotiques, la frequence d’intubation et la duree de l’assistance ventilatoire, la duree de sejour et la mortalite en reanimation et intra hospitalieres.

Resume Cette revue generale analyse le risque d’infection chez les malades de reanimation porteurs de staphylocoques dores resistants a la meticilline (SARM), et les consequences des infections a SARM, en evaluant si leur risque de morbi-mortalite, et les couts associes a ces infections different de ceux des infections a germes sensibles. Environ 30 a 50 % des malades porteurs de SARM acquierent une infection. Ce risque augmente avec l’intensite de la colonisation, la rapidite d’acquisition du portage, et avec l’administration d’antibiotiques. Le risque de mortalite des infections a SARM est eleve, mais n’apparait pas superieur a celui des infections a SAMS, sauf peut-etre dans le cas des infections postoperatoires, et leurs consequences en termes de duree de sejour et de couts medicaux sont similaires. Il est cependant evident que s’agissant d’infections secondaires pour une large part a une transmission croisee, les consequences humaines et economiques de l’acquisition de SARM sont tres lourdes et potentiellement evitables.

Introduction L’antibioresistance est devenue une priorite mondiale. En France, les donnees de reseaux de surveillance ont permis d’estimer le poids des infections a germe multi-resistant aux antibiotiques a 158 000 cas annuels. Depuis 2014, l’enrichissement de l’antibioresistance dans la CIM-10 fait du PMSI un nouvel outil d’investigation dans ce domaine. Ainsi, a partir des donnees du Sniiram, le programme PhiBRA cherche a evaluer les consequences epidemiologiques et medico-economiques des resistances aux antibiotiques. Un travail preliminaire a ete realise a partir des donnees de l’EGB pour etudier la qualite de l’information sur la resistance au sein du PMSI. Methodes Les hospitalisations de plus d’une journee avec un code CIM-10 d’infection ou de resistance en diagnostic principal, relie ou associe ont ete selectionnees. Le PMSI ne permettant pas de relier les diagnostics, seuls les sejours avec une association coherente entre l’infection, le germe et la resistance etaient conserves. Des algorithmes ont ete crees afin de hierarchiser certains diagnostics, retrouver des germes, identifier des couples germe-resistance specifiques et/ou corriger des associations incoherentes. Resultats En 2014, 3300 sejours avec une infection et un germe precise ont ete identifies et 665 (16,8 %) ont ete retrouves par des algorithmes. Parmi les associations germe et resistance rapportees, 28,9 % etaient impossibles : la moitie a pu etre corrigee. In fine, plus de 10 % des infections etaient dues a un germe resistant aux antibiotiques. Moins de 10 % des E.coli et 15,5 % des K. pneumoniae etaient secreteurs de BLSE, 18,9 % des Staphylococcus aureus etaient resistants a la meticilline. Malgre une exclusion d’associations, ces estimations sont tres proches de celles issues du reseau EARS-net France en 2014 (8,0 %, 21,2 % et 17,4 % respectivement). Discussion/conclusion Le PMSI montre une rapide adaptation au codage et representera rapidement un materiel de qualite pour mesurer les consequences de l’antibioresistance. Ces resultats seront completes des donnees de 2015. L’amelioration des pratiques de codage et l’evolution des codes d’antibioresistance pourront ainsi etre evaluees dans un contexte de valorisation.

Necrotizing fasciitis (NF) are rare and severe soft tissue infections associated with a high mortality rate. In order to assess the management of NF in French-speaking intensive care units (ICUs), we conducted a survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR).Online self-administered survey.A link to an online survey was sent by email to 4620 anesthesiologists and/or intensivists and was available online from January to February 2014.One hundred and seventy-five physicians (3.8%) who worked in 135 ICUs filled out the online survey. Among respondents, 42% reported having managed up to two patients with NF during the previous year; 59% and 72% of respondents reported not having a surgical and a medical specialist consultant, respectively. A delayed access to the operating room (OR) of more than 6hours was reported in 31% of cases and access to the OR was reported not to be routinely considered as a priority in 13% of cases. Only 17% of respondents reported that time to transfer to the OR was never a cause for delayed surgery. The main causes for delayed surgery were: delayed diagnosis (45%), delayed validation of surgical intervention (37%), and difficulty of access to the OR (8%). Finally, 83% of respondents estimated that creating dedicated multidisciplinary teams for managing NFs could lead to improving outcomes.This survey illustrates the heterogeneous management of NF in French-speaking ICUs and points out several logistical aspects that should be improved to reduce the time to the first surgical debridement.

Resume Les fasciites sont caracterisees par l'atteinte necrosante des fascias, et leurs risques evolutifs, fonctionnel et vital. Un diagnostic precoce, devant des signes cutanes parfois discrets, associes a un syndrome septique (encephalopathie, insuffisance renale, hypotension), permet de commencer la reanimation et decider d'un probable traitement chirurgical. Trois formes principales se distinguent: les fasciites streptococciques, plus souvent monomicrobiennes, parfois associees a un syndrome de ≪ choc toxique streptococcique ≫ (STSS); les fasciites et myosites clostridiennes, souvent polymicrobiennes en cas de plaie associee; enfin, les gangrenes mixtes et ≪ synergistiques ≫, toujours polymicrobiennes (aero-anaerobie). D'autres formes ≪ primitives ≫ de diverses etiologies, habituellement monomicrobiennes, surviennent sur des terrains particuliers. Le pronostic depend de l'âge, des comorbidites, et surtout de la gravite du syndrome septique et de son expression. La reanimation initiale est dominee par le traitement de l'etat septique, avec une composante hypovolemique marquee. Le traitement antibiotique de reference est la penicilline G pour les formes streptococciques et clostridiennes; il comporte une association active sur les enterobacteries, les streptocoques et enterocoques et les anaerobies (incluant les Bacteroides ) dans les autres cas ou les cas d'etiologie incertaine. Dans les formes avec choc toxinique, l'association a la penicilline de clindamycine ou de rifampicine est recommandee, pour leur activite sur la production d'exotoxines; l'administration d'immunoglobulines non specifiques apparait egalement utile. L'interet de l'oxygenotherapie hyperbare n'est pas demontre. La prevention des complications de la reanimation prolongee comporte en particulier la prise en charge precoce du deficit nutritionnel preexistant ou rapidement installe, et la prevention des accidents thrombo-emboliques frequents.

In a randomized trial conducted in 27 intensive care units, we compared the clinical efficacy and safety of piperacillin-tazobactam (TAZ; 4 g/0.5 g q.i.d.) and of ceftazidime (CAZ; 1 g q.i.d.), both combined with amikacin (7.5 mg/kg b.i.d.), as therapy for ventilator-associated pneumonia (VAP; acquired after > or =48 hours of mechanical ventilation). VAP was diagnosed with use of protected samples and quantitative cultures, and outcome was assessed blindly from treatment. Of 204 patients suspected of having VAP and randomized to a treatment arm of the study, 127 (64%) had bacteriologically confirmed infections, of which 37% were polymicrobial and 32% involved Pseudomonas aeruginosa; 115 patients (51 TAZ and 64 CAZ recipients) remained evaluable as per protocol. Clinical/bacteriologic cure rates (TAZ vs. CAZ, 51% vs. 36%; 95% confidence interval of difference, -0.2% to 30.2%), and 28-day mortality rates (16% vs. 20%) were similar; however, fewer bacteriologic failures occurred with TAZ (33% vs. 51%; P = .05). We conclude that the two regimens were of equivalent clinical efficacy in therapy for confirmed VAP.

The study aims were: (i) to define the prevalence of and risk factors for colonization by extended spectrum β-lactamase (ESBL) -producing Enterobacteriaceae (EPE) among healthcare workers (HCWs) and family members (FMs) of EPE-colonized patients in rehabilitation units and (ii) to compare EPE isolates from these three groups. The study included 286 FMs of 194 EPE-carrying patients identified in five rehabilitation units located in Israel, Italy, France and Spain. The EPE were detected in rectal swabs from 26 (9%) of 286 FMs screened. In multivariate analyses, older age of FM, greater mean number of hours spent with the patient, being a daughter or a female spouse of a patient, and chronic lung disease of the patient were significantly associated with carriage in the FM. Escherichia coli was the most common organism (76%), followed by Klebsiella pneumoniae (19%). Isolates were typed by pulsed field gel electrophoresis and multilocus sequence typing, and ESBLs were identified by PCR sequencing. A comparison of paired species isolates from FMs and their respective patient showed that 17 of 23 strains were indistinguishable. EPE were detected in 35 (3.5%, E. coli = 34) of the 1001 HCWs screened. Feeding patients was associated with EPE carriage by HCWs. Only 7 of 23 E. coli subclones cultured from HCWs were also represented among 376 patient-derived ESBL-producing E. coli isolates from the same rehabilitation units. In Spain, a higher proportion of HCWs and FMs were ESBL carriers than elsewhere (p

Les catheters intravasculaires sont de plus en plus frequemment utilises en reanimation, comme dans les services hors de la reanimation, pour l’administration de liquides, de transfusions, de medicaments divers, l’alimentation parenterale..Si les infections de ces corps etrangers intravasculaires sont beaucoup mieux maitrisees qu’auparavant, elles restent la premiere cause de bacteriemies nosocomiales, et sont responsables d’une morbidite elevee, sinon d’une mortalite importante. Ainsi, Wenzel et Edmond [1] avaient estime en 2006 que pres de 10 millions de jourscatheters etaient utilises aux Etats-unis, provoquant pres de 50 000 bacteriemies par an et 17 000 deces; les estimations plus recentes du groupe du CDC font etat de 15 millions de jours-catheters et 85 000 bacteriemies, mais d’un nombre de deces plus faible et incertain [2]. En France, le reseau national de surveillance RAISIN-Rea decrit entre 2005 et 2010 un taux d’infection beaucoup plus faible, de l’ordre de 1/1000 jourscatheter [3].

The prospective project MOSAR was conducted in five rehabilitation units: the Berck Maritime Hôpital (Berck, France), Fondazione Santa Lucia (Rome, Italy), Guttmann Institute (GI; Barcelona, Spain), and Loewenstein Hospital and Tel-Aviv Souraski Medical Center (TA) (Tel-Aviv, Israel). Patients were screened for carriage of Enterobacteriaceae resistant to expanded-spectrum cephalosporins (ESCs) from admission until discharge. The aim of this study was to characterize the clonal structure, extended-spectrum β-lactamases (ESBLs), and acquired AmpC-like cephalosporinases in the Escherichia coli populations collected. A total of 376 isolates were randomly selected. The overall number of sequence types (STs) was 76, including 7 STs that grouped at least 10 isolates from at least three centers each, namely, STs 10, 38, 69, 131, 405, 410, and 648. These clones comprised 65.2% of all isolates, and ST131 alone comprised 41.2%. Of 54 STs observed only in one center, some STs played a locally significant role, like ST156 and ST393 in GI or ST372 and ST398 in TA. Among 16 new STs, five arose from evolution within the ST10 and ST131 clonal complexes. ESBLs and AmpCs accounted for 94.7% and 5.6% of the ESC-hydrolyzing β-lactamases, respectively, being dominated by the CTX-M-like enzymes (79.9%), followed by the SHV (13.5%) and CMY-2 (5.3%) types. CTX-M-15 was the most prevalent β-lactamase overall (40.6%); other ubiquitous enzymes were CTX-M-14 and CMY-2. Almost none of the common clones correlated strictly with one β-lactamase; although 58.7% of ST131 isolates produced CTX-M-15, the clone also expressed nine other enzymes. A number of clone variants with specific pulsed-field gel electrophoresis and ESBL types were spread in some locales, potentially representing newly emerging E. coli epidemic strains.

Repeated outbreaks of vancomycin-resistant Enterococcus faecium (VRE) occurred between 2004 and 2010 in Assistance Publique--Hopitaux de Paris (AP-HP), a 23,000-bed multi-hospital institution. From August 2004 to December 2005, the French guidelines for preventing cross-transmission of multiresistant bacteria were applied. Because the number of VRE cases continued to increase, an institutional control programme was implemented from January 2006 onwards: it foresees stopping transfer of VRE and contact patients, separating VRE and contact patients in distinct cohorts, intervention of a central infection control team to support local teams, and quick application of measures as soon as first VRE cases are identified. Between August 2004 and December 2010, 45 VRE outbreaks occurred in 21 of the 38 AP-HP hospitals, comprising 533 cases. Time series analysis showed that the mean number of cases increased by 0.8 cases per month (95% confidence interval (CI): 0.3 to 1.3, p=0.001) before, and decreased by 0.7 cases per month after implementation of the programme (95% CI: -0.9 to -0.5, p