INFECTION CONTROL and ANTIBIOTIC STEWARDSHIP IN FRANCE

Jean CARLET MD Infection Preventionist, Intensivist Groupe Hospitalier Paris St Joseph France Consultant, in particular for WHO

The current organization for control of HCAI in France

5 Interrregional coordinating centers for Infection Control (C-CLIN)

+ 22 Regional antennas

Regional Regulatory agencies

Healthcare institutions

Inf. Control Committee (ICC, CLIN), Drug Com, AB com.

Inf. Control Team (ICT, EOH), AB referent

Link nurses / physicians in wards

Advisory Board for the National Program (GROUPILIN)

NI Unit

Expert Committee (CTINILS, HCSP)

Indicator n°1: Global indicator of IC organisation and activities (ICALIN)

First published in 2005, based on the 2004 annual report from each hospital (ICT + management)

A 100 points score including 3 components: Organization (33 pts) Resources (33 pts) Activities (34 pts)

A rating system : class A to E (F) Percentiles of distribution (NHS method) Reference year for construction of the score and

identifying classes: 2003 data Stratified by hospital category (11)

http://www.icalin.sante.gouv.fr/index.php

Indicator n°2: ICSHA

Computing the personalised target : minimal no. of HR per patient-day for each of 10 subspecialties

Medicine : 7 Rehabilitation : 5 Surgery : 9 LT care : 4 Obstetrics : 8 Home-care : 2 Intensive Care : 40 Psychiatry : 2 Hemodialysis : 6 HR / session ED : 2 HR / visit

The target objective for a given HCF is the sum of all targets for each

activity performed in the HCF, according to the no. of patient-days. Classes OP : 10 - 30 - 70 - 90 % of the personalised objective

Volume (L) of AHR products used per year HCF-specific minimum target, according to activities

0

20

40

60

80

A B C D E F (NR)Class

Perc

enta

ge o

f HC

Fs

2005, all HCFs

2005, Univ. Hosp.

2005, released Jan. 2007 ~ 2800 healthcare facilities

Indicator n°2: Alcohol-based products consumption (ICSHA)

C class: 30-70% of expected consumption

ICSHA : Evolution 2005-2006 Evolution des classes ICSHA (%)

0%

10%

20%

30%

40%

50%

2005 3.3% 3.0% 23.8% 46.9% 23.0%

2006 5.3% 6.2% 39.0% 39.4% 10.2%

A B C D E

8

9

La friction en image : une technique rapide

Film sur la friction = 30 secondes voir si possible

Pour en savoir plus, la technique filmée : http://www.sante-sports.gouv.fr/dossiers/sante/mission-mains-propres/outils-campagne/

10

Les 5 indications de l’hygiène des mains selon l’OMS

2. Foster improved organisation of care and practices having an impact on infectious risks (2)

Improve the quality of care delivered to infected patients 2008 target: An antibiotic drugs committee and a physician

for antibiotic counselling is available in 100% of HCF. (Indicator n°4)

2008 target: Protocols for appropriate use of antibiotics are available in all hospitals, and antibiotic consumption is monitored (indicator n°4 ).

Distribution des classes ICATB 2006 (%)

0%

5%10%

15%20%

25%

30%35%

40%45%

50%

2006 13.0% 19.5% 39.0% 19.4% 9.1%

A B C D E

Indicator n°4: Good antibiotic use (ICATB)

Recommandations hôpital

ANDEM-ANAES-HAS 1996 and 2008 100 Recommandations DGS 1999 : n° 58 Plan « Antibiotiques » novembre 2001 Circulaire DGS-DHOS 2/5/02 14e Conférence de consensus de la SPILF, 2002 Plan de lutte contre les infections nosocomiales - tableau

de bord BMR, SHA et consommation des antibiotiques Accord-cadre Assurance-Maladie / hôpitaux 2006 (loi

Sécurité Sociale 2004) Guide méthodologique pour le suivi des consommations

antibiotiques (2006)…

ABT prescriptions from 2001-02 to 2006-07 (Oct-March periods)

3. Optimise the collection and use of surveillance data

Improve the quality and adequacy of data collection for surveillance of NI Objective 2008 : 100% of HCF performing surgery have organised

the surveillance of SSI (indicator n°3).

Optimise the use of various sources of information, to improve and broaden our ability to prevent and control emerging infectious risks Objective 2008 : 100% of HCF have organised a procedure for

raising alerts of sentinel events, and one person is identified as in charge of the procedure (law, art. R.6111-12 to -17).

Indicator no.3: Surveillance of SSI (SURVISO)

Surveillance of SSI

Year 2005 2006

No. HCF 669 788

Percent 59,7% 71.5%

Total HCF performing surgery 1121 1102

NB1 : Having organised SSI surveillance in ≥ 75% surgical wards is the 2008 target from the national Program 2005-2008. NB2: HCF with surgery and no SSI surveillance will be penalised en 2008.

Impact of Surveillance on SSI Risk

System No. patients Time period SSI reduction

Prezies (H) Genbels et al. IJQHC 2006

21 920 5 years - 57%

KISS (G) Brandt et al. ICME 2006

119 114 4 years - 25%

RAISIN (F) Astagneau P. JHI 2009

964 128 8 years - 30%

SSI incidence 2004 – NNIS = 0 HELICS and NNIS Networks, Carlet J, Astagneau P,

ICHE 2009 PROCEDURE FRANCE EU USA

Cholecystectomy

0.5 0.79 0.68

Hip Replacement

1.88 1.41 0.86

C Section 1.53 2.17 2.71

Colon Surgery

5.9 6.14 3.98

CABG 8.1 3.66 3.39

Surveillance and Alerts

French national NI surveillance system: Alerts and sentinel events

Prevalence surveys

National network of networks (RAISIN, 2001), on specific

surveillance programs (standardised methods)

http://www.invs.sante.fr/raisin/

RAISINRAISIN

Sentinel events notification: objectives

Detection of sentinel events at the local,

regional or national level

Promote and contribute to the investigation and early control of emerging

infections and outbreaks

Develop / reinforce recommendations for prevention

Criteria for notification of alert events (decree 26/07/2001)

• Notification of specific Infections

Rare/unusual infection

agent: species / characteristics / resistance marker

Site of infection

Contaminated medical device

Procedure potentially exposing other patients

Associated with fatalities

Caused by a pathogen from environmental source

Specific infections requiring notification (MDO) (e.g., tuberculosis, legionellosis)

• (Especially when several confirmed or probable cases)

Notification to CCLIN and Ddass

Tansmission to InVS

Monthly notifications received at the InVS, France, 01/08/2001 to 31/12/2007 (N=5,357)

0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

août-

01

oct-0

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déc-0

1

févr-0

2

avr-0

2

juin-

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août-

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déc-0

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févr-0

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avr-0

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juin-

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oct-0

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déc-0

6

févr-0

7

avr-0

7

juin-

07

août-

07

oct-0

7

déc-0

7

Month of notification

Notif

icatio

ns (N

)

+20% p.year

Median delay: 9 days c. 30% HCF have notified at least once

Detection of emerging infections or outbreaks (some examples) 04/2006 : Clostridium difficile 027

08/2005 : Salmonella enterica serotype Worthington

07/2005 : VRE (Lesens & al, ICHE 2006)

12/2004 : Enterobacter sakazakii

06/2004 : Klebsiella pneumoniae imipenem-R

06/2004 : endophtalmic infections associated with a topical anaesthetic

09/2003 : Acinetobacter baumannii BLSE VEB-1 (Naas & al, EID 2005)

Surveillance and Alerts

French national NI surveillance system: Alerts and sentinel events

Prevalence surveys

National network of networks (RAISIN, 2001), on specific

surveillance programs (standardised methods)

http://www.invs.sante.fr/raisin/

RAISINRAISIN

39

830

1 533

2 337

0

500

1 000

1 500

2 000

2 500

1990 1996 2001 2006

Year

Faci

litie

s (N

)

National Prevalence surveys 438 474 (95%) beds − 99% of public hosp beds − 75% of semi-private beds (PSPH) − 90% of private hosp beds

Results of the 2006 survey, France

N %

Infected patients 17 817 4.97

- Same hospital 14 382 4.01

- From another facility 3 515 0.98

Infections 19 294 5.38

- Acquired in same hospital 15 551 4.34

- Imported from another facility 3 721 1.04

Re-analysing the 2001 data Change in methods: exclusion of asymtomatic bacteriuria and of patients

admitted on the day of survey prevalence of infected patients, 2001 = 5.4%

Analysis On the 1,351 facilities having participated to both surveys Adjusted on characteristics of hospital, wards, and patients’ risk factors

(severity and invasive devices) Results

550 637 patients surveyed for HAI prevalence of infected patients: -12% (aOR = 0.88) prevalence of MRSA infection: - 41% (aOR = 0.60)

Comparison 2001-2006

MRSA Trends: Prevalence of MRSA-infected Patients, France, 2001 - 2006

0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80

Others

Cancer centres

Rehabilitation / LTC

Military hospitals

Private hospitals

Local hospitals

Psychiatric hospitals

General hospitals

University hospitals

Type

of h

ealth

care

faci

lity

Prevalence of MRSA-infected patients (%)

2001

2006

Overall MRSA prevalence: 0.49% to 0.29% (- 41%) Multivariate analysis: ORa=0.60

- 47%

- 37%

- 62%

- 11%

- 34%

- 24%

- 53%

- 41%

Prevalences compared in 1 351 healthcare facilities participating in both surveys.

Prevalence of Nosocomial Infections, France 2006. http://www.invs.sante.fr/beh/2007/51/_

33

25.524.7

36.6

20

22

24

26

28

30

32

34

36

38

40

2001 2002 2003 2004 2005 2006

EARSSAZAY (CHU)IdF(CHG)Reussir

EARSS & Contributing Networks, France 2001-2006 Prevalence of MRSA among S.aureus blood isolates

V. Jarlier, for the ONERBA AMRB Network of Networks

Trends in Incidence of MRSA, France 2003-2006

0,4

0,5

0,6

0,7

0,8

0,9

1,0

2003 2004 2005 2006

Year

Inci

denc

e of

MRS

A /

1000

Pt-

days

Acute Care

Rehabilitation-LTC

Overall

216 HCF

2006 vs 2003: -11% 2006 vs 2003: -14% 2006 vs 2003: -7%

B Misset Submitted Chi square test for trends : carriage : p < 0.0001, bacteremia : p = 0.0003 B

HA-MRSA per 1000 patient-days

0,0

0,2

0,4

0,6

0,8

1,0

1,2

Year

Carr

iage

0,00

0,02

0,04

0,06

0,08

0,10

0,12

0,14

0,16

0,18

Bact

erem

ia

Carriage Bacteremia

Carriage 1,06 1,09 0,80 0,75 0,55 0,37 0,42

Bacteremia 0,07 0,17 0,08 0,07 0,05 0,02 0,02

1999 2000 2001 2002 2003 2004 2005

MRSA trends (%R), EARSS, 1999 – 2006

Netherlands (Denmark)

Finland

Belgium

UK

Portugal

Germany France

Slovenia

Turkey

EARSS Annual Report 2006 - http://www.earss.rivm.nl.

Courtesy: Grundmann et al. (EARSS, Sept 2009), Harbarth S for Sarkoleon

MRSA bacteremia in Europe, 2008

Vincent Jarlier Sept 2009

0,51

1,16

0,15

0,61

0,00

0,20

0,40

0,60

0,80

1,00

1,20

1,40

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

SARM Hôpitaux court séjourBLSE Hôpitaux court séjour

Rate of incidence (/1,000DHs) of MRSA and ESBL enterobacteria

38 Univ. hospitals of Paris area 1996-2008

50 % (control programme)

x 3

Vincent Jarlier Sept 2009

Rate of incidence (/1,000DHs) of different species of ESBL enterobacteria

38 Univ. hospitals of Paris area 1996-2008

2002

0,00

0,05

0,10

0,15

0,20

0,25

0,30

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

année

dens

ité d

'inci

denc

e (1

000j

h) incidence E.coli BLSEincidence K.pneumoniae BLSEincidence E.cloacae BLSEincidence autres entérobact. BLSE

K.pneumoniae

E.coli

E. cloacae

Vincent Jarlier Sept 2009

Rate of incidence (/1,000DHs) of ESBL E. coli 38 Univ. hospitals of Paris area 1996-2008

0,000,200,400,600,801,001,201,401,601,80

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008année

dens

ité d

'inci

denc

e

Hôpitaux court séjour dont SI-Réa dont medecine dont chirurgieHôpitaux SSR-SLD

Acute care hosp

ICU

Rehab. & long term h

19 mars 2004 - MEDEC

Evolution des ventes des antibiotiques en France

Antibiotic Consumption in Hospital Care in 2002Absolute numbers in 15 countries

0

1

2

3

4

5

LV FI FR HR LU GR EE SI MT PL DK SK HU SE NO

DD

D p

er 1

000

inh.

per

day

How often do Europeans take antibiotics and where from, Nov.-Dec. 2009

0

10

20

30

40

50

60

70It

aly

Mal

ta

Spai

n

Rom

ania

Irel

and

Slov

akia

Cypr

us

Fran

ce

Uni

ted

King

dom

Luxe

mbo

urg

Lith

uani

a

Aust

ria

Hun

gary

Belg

ium

Bulg

aria

Esto

nia

Gre

ece

Czec

h Re

p.

Port

ugal

Pola

nd

Finl

and

Latv

ia

Net

herla

nds

Den

mar

k

Ger

man

y

Slov

enia

Swed

en

Took

ora

l ant

ibio

tics d

urin

g th

e pa

st 1

2 m

onth

s (%

resp

onde

nts)

Country

Other/Do not know

Left-over from previous course

At a pharmacy, without a prescription

With medical prescription or administed by doctor

Source: Eurobarometer 338 / 72.5 ”Antimicrobial resistance”, November-December 2009.

POTENTIAL INDICATORS

Quantitative indicators -Antibiotic usage, total or by class, national regional, local or individual -Antibiotic resistance, national, regional, using antibiotic / micro-organism couples as markers (Ex: macrolide and pneumococcus, E. Coli an quinolones…) - But …is this really « quality »?

Quantitative indicators

- Appropriateness of AB prescribing, according to guidelines, consensus conferences… - Treating only bacterial infections (E. test, CRP) - Appropriateness of AB timing - Severe infections, Sepsis, Septic shock - Meningitis - Concept of pre-hospital therapy - Re-assessment of therapy at day 2 or 3 - For a few patients (UTI) - By phone, e-mail, texto…

AntibiotherapyAntibiotherapy during septic shock….the during septic shock….the Golden Hours KUMAR A CCM 2006, 34 Golden Hours KUMAR A CCM 2006, 34

15891589--9696

Contracts with Insurance Systems Pay for Performance

-Recommandations must be very strong -Rather difficult for antibiotics, because

• Many different infections • Many different antibiotics • Weakness of the microbiological diagnosis • Frequency of empirical therapy

- French « AcBUS » for upper airways infections

Organizational Indicators

-Awareness of GPs concerning the issue of antibiotics, Resistance, and relationship between both -Academic detailing (CNAM) - Sharing knowledge and prescriptions with others: peer review, « Home Care », networks… -Relationship with hospitals, Ability to ask for advice -Importance of informatics +++

Potential dangers of Quality Indicators

The exemple of Community acquired pneumonia in the ER -The delay between admission to the ER and antibiotic therapy is a quality indicator in the USA - But this reduces the member of patients with a microbiological diagnosis, and increases combination therapy Ref. : WATCHER, RM Annals Int. Med 2008,149;29-32

CONCLUSION -Antibiotics an special drugs. They need a special management -It is more difficult in primary care than in the hospital -Quantitative indicators are important, but they are not synonymous of quality -Qualitative indicators are mandatory, but far more difficult to obtain -The patient Vs the community This is still a research issue -Never forget the importance of diagnosis

0,5

0,7

0,9

1,1

1,3

1,5

1,7

1,9

2,1

2,3

1 2 3 4 5 6 7 8 9 10 110

1

2

3

4

5

6

7

8

QUINOLONES

MRSA per 1000 pat-days

Taux d’incidence annuelle de SARM acquis pour 100 patients et consommations de SHA pour 1000 journées

18,99

17,5

10,066,96

23,09 23,9525,15 26,25

29,427,52

0,99

0,730,65

0,44 0,29 0,330,23

0,11 0,13 0,13

0

4

8

12

16

20

24

28

32

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

0,2

0,4

0,6

0,8

1

1,2

Consommation de SHA année 2009

Taux de SARM acquis (septembre 2009)

AP-HP 1993

Portage de Staphylococcus aureus résistant à la méticilline (SARM)

Patients hospitalisés plus de 24 heures Taux d’incidence annuelle pour 100 patients

de 1993 à 2009 (décembre 2009)

0,13

0,65

0,130,11

0,230,330,290,44

0,940,75

0,96

1,23

0,78 0,81 0,64

0,99

0,73

0

0,2

0,4

0,60,8

1

1,2

1,4

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

acquis % importés %

(31/10/04) (31/10/04)

%

Taux d’incidence annuelle de SARM acquis pour 100 patients et consommations de SHA pour 1000 journées

18,99

17,5

10,066,96

23,09 23,9525,15 26,25

29,427,52

0,99

0,730,65

0,44 0,29 0,330,23

0,11 0,13 0,13

0

4

8

12

16

20

24

28

32

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

0,2

0,4

0,6

0,8

1

1,2

Consommation de SHA année 2009

Taux de SARM acquis (septembre 2009)

MORTALITY AFTER AMPUTATION LISTER 1870

Mortality

1864-1866Before antiseptic method 35 16 46%

1867-1869After antiseptic method 40 6 15%

55

La friction : Une technique efficace

Après Savon  doux 30 sec

Avant  lavage

Après savon antiseptique      30 sec

Après friction 30 sec

Elimination des bactéries