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Trends in antibiotic use in France

Due to the development of bacterial resistance, the inappropriate use of antibiotics has consequences for the whole community. This issue gained so much in importance that the authorities have developed surveillance programs and promoted actions in order to control antibiotics use since the beginning of 2000s, resulting in a reduction in their consumption in ambulatory and hospital sectors in the last decade.

However, this reduction was more marked at the beginning of the study period, and an increasing trend has been observed for a few years. A detailed analysis of the results reveals that the French ambulatory consumption, which remains one of the highest in Europe, is very heterogeneous.

Women consume more than men, consumption varies significantly according to the age groups, and most important, considerable regional disparities are observed. In qualitative terms, the consumption of penicillin, alone or in association, remains predominant. The development of the use of some molecules, described as “reserve antibiotics”, is all the more worrisome that the innovation is currently too weak to respond to therapeutic dead-ends facing prescribers.

Multidrug-resistant bacteria (MDRB) in hospital settings: extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE) and meticillin-resistant Staphylococcus aureus (MRSA), BMR-RAISIN Surveillance Network, 2002-2010

Control of multidrug-resistant bacteria (MDRB) spread among health care facilities (HCF) is part of the French national infection control programme since the mid 1990s. Since 2002, meticillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE) isolated from clinical specimen are specific targets of the national surveillance coordinated by the National Early Warning, Investigation and Surveillance Network (RAISIN).

In 2010, 933 healthcare facilities participated in the survey, representing an increase of 91% compared to 2002. In 2010, the global incidence density (ID) was 0.40 per 1,000 patient days for MRSA ([95% CI:0.39-0.41]) and 0.39 for ESBLE. Globally, from 2002 to 2010, MRSA ID decreased by 43% from 0.72 (CI [0.70-0.74]) to
0.41 (CI [0.39-0.42]) (p

These results suggest a positive impact on MRSA epidemics of MDR control program implemented in HCFs. However, the increase of ESBLE ID, particularly
of ESBL E. coli, is a major concern and should mobilize the medical community as a whole.

The European Antimicrobial Resistance Surveillance Network (EARS-Net): results 2001-2010 and situation of France in Europe

Since 2001, France has been participating in the European Antibiotic Resistance Surveillance System (EARSS) for Staphylococcus aureus, Escherichia coli et Klebsiella pneumoniae in bactaeremia through several networks federated in the “Observatoire national de l’épidémiologie de la résistance bactérienne aux antibiotiques (ONERBA)”. The proportion of strains resistant to meticillin in S. aureus (MRSA) decreased from 2001 to 2010 (33.2 to 21.5 %). This decrease occurred in bacteraemia diagnosed during the first 2 days after hospital admission (25 to 17%) as well as in late bacteraemia: during the 2nd week (34 to 25%), 3rd week (45 to 27%) or later (53 to 36%).

The proportion of strains resistant to 3rd generation cephalosporins (3GC) in E. coli remained stable from 2002 to 2005 (around 2%), but increased later
(8.6% in 2010), 2/3 of these strains producing extended-spectrum β-lactamases (ESBL). The increase was higher in late bacteraemia: 2 to 7% within the first
2 days after admission, but 2 to 13% during the 3rd week and 4 to 15% later.

In 2010, the proportions of R-strains were highest in intensive care units (13.2%) and lowest in gynaecology-obstetrics (1.5%). The proportion of strains resistant to 3GC in K. pneumoniae increased from 2005 to 2010 (4.9% to 19.3%). 3/4 of these strains were shown to produce ESBL. The increase was higher in late bacteraemia: 3 to 13% within the first 2 days after admission, but 4 to 28% during 3rd week and 13 to 33% later.

Proportions of R-strains were highest in intensive care units (38% in 2010). EARSS results showed that France i) belongs to the few European countries
where the proportion of MRSA in S. aureus markedly decreased during the last years, ii) was in a median situation in 2010 for E. coli resistance to 3GC
but in a less favourable one than in 2008 due to a higher increase than in Scandinavian countries, and iii) was in an unfavourable situation in 2010
for resistance rate to 3GC in K. pneumoniae, dropping from the 5th to 15th rank in Europe between 2005 and 2010. These results suggest that the spread
of this type of resistance is not sufficiently controlled (mainly related to ESBL) for both these species.

Antibiotic use in French healthcare facilities:ATB-RAISIN Network, 2008-2010

The ATB-RAISIN National Surveillance Network was set up to monitor trends in antibiotic use in hospitals from 2008. Data retrospectively collected each year, by voluntary hospitals were: hospital status; number of patients-days (PD); antibiotic consumption for inpatients, expressed in number of defined daily doses (DDD) per 1000 PD.

In 2010, antibiotic use in 1,115 participating hospitals was 374 DDD/1,000 PD, with variations according to hospital status and region. In 662 hospitals participating each year, antibiotic use slightly increased by 3% each year: 366, 378 and 389 DDD/1,000 PD from 2008 to 2010. Major increases occurred in
the use of ceftriaxone (+28%) and carbapenems (+31%). Despite national action plans, antibiotic use did not decrease in French hospitals. Increase in
carbapenem use was also reported in other European countries, illustrating the urgent need to better control the use of these last-line agents.

Considering these trends, emphasis will be reinforced on the rational use of antibiotics such as carbapenems. In this context, ATB-RAISIN network will
help assessing the impact of the national programme and will be useful to promote experience sharing between hospitals.

Establishing a control of carbapenems prescriptions: experience from a multidisciplinary team in the Fort-de-France Teaching Hospital, Martinique

In February 2011, due to very high ESBLE incidence and occurrence of a first cluster of cases of Acinetobacter baumannii resistant to imipenem (ABRI), the team from the Antibiotic Committee in the Fort-de-France Teaching Hospital introduced new modalities for the monitoring and the stewardship of carbapenems whose one-year results are presented hereafter.

The team (pharmacist, microbiologist, infectious disease physicians) analyses daily each carbapenems prescription and contacts the prescribers to confirm
the treatment, suggest its interruption or spectrum reduction. Meanwhile, the consumption of broad-spectrum antibiotics in 12 targeted care units is
analyzed quarterly.

In one year, 347 prescriptions were analyzed resulting in a spectrum reduction in 21.7% of the cases, in an interruption in 12.7% or validation of treatment
in 65.7%. As a consequence, the consumption of carbapenems dropped by 48.2% (8,9 Defined Daily Doses per 1000 patient-days (DDD/1000 PD) in 2011 vs. 17 DDD/1000 PD in 2010) saving 119,222 euros.

These results are encouraging. This control system should be extended to the whole of Martinique and to other classes of broad spectrum antibiotics. Prioritization of a multidrug-resistant regional plan by the Regional Health Authorities should generate the necessary human and material resources.

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