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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
1
déc-0
1
févr-0
2
avr-0
2
juin-
02
août-
02
oct-0
2
déc-0
2
févr-0
3
avr-0
3
juin-
03
août-
03
oct-0
3
déc-0
3
févr-0
4
avr-0
4
juin-
04
août-
04
oct-0
4
déc-0
4
févr-0
5
avr-0
5
juin-
05
août-
05
oct-0
5
déc-0
5
févr-0
6
avr-0
6
juin-
06
août-
06
oct-0
6
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