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Antimicrobial Stewardship The French experience

Dr JR Zahar

Infection Control Unit – Angers-Hospital- Angers University

07-2014

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Antimicrobial stewardship: why do we need to make it even more now ?

• Recent epidemiological data have urge us to modify our

behaviour

– The spread of ESBL-PE

– The emergence of EPC

• What is new?

– More Multidrug Resistant Bacteria carriers !

• Antibiotics seem to play a major role

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Recent epidemiological data have urge us to

modify our behaviour

Woerther et al, CMR 2013 ECDC data, EuSCAPE project 2013

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More Multi Drug Resistant carriers

Tosh et al, Clin Inf Dis 2012

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Antibiotics seem to play a major role

Derde et al, Lancet inf Dis 2013

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Is France an example to follow?

• The French experience

• Is regarded as exemplary

• Is regulary evoked in the litterature

• France is a one of the European countries wich political

mobilisation for the control of bacterial resistance is

among the most activate

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Points I will consider

• An overview of different recommandations

• The principal results

• Some critics highlight the limit of our politics

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Various recommendations

1995-2000 Five years plan to control MDR

2000 Implementation of a national network for

MDR surveillance

2002-2005 Quadri annual plan to preserve antibiotics

Consensus conference

• How to improve the quality of antibiotics in health

care facilities?

• Quality = preserve the collective interest without

harming the interests of the individual patient.

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Various recommendations

1995-2000 Five years plan to control MDR

2000 Implementation of a national network for MDR surveillance

2002-2005 Quadri annual plan to preserve antibiotics

Objectives: reduce by 30% the antibiotic consumption

2002 Consensus conference

2002 Creation of the antibiotics commissions

2005-2008 National plan to preserve antibiotics

Objectives: reduce by 10% over 3 year period

2008 The Good use of antibiotics guidelines

2010 The Good use of carbapenems

2013 The list of critical antibiotics

Establish the antibiotic referent

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The « French » list of critical antibiotics

• Inducing resistance • Fluroquinolones

• Third G CSP

• Beta lactams with inhibitors

• Last resort antibiotics • Carbapenems

• Tigecycline

• Colistin

• Fosfomycin

• Temocillin

• Phenicols

• Daptomycin/linezolid

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Guidelines for Healthcare organisations !!

2008

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Antibiotic public campaign

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What was the contents of the plans

• Introduce training

• Information

• Develop help tools for prescriptions

• Improve the interface hospital/community

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Many recommandations and Guidelines, but

any results?

www.ecdc. europa.eu

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Many recommandations and Guidelines, but

any results?

BEH n°42-43/2012

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Many recommandations and Guidelines, but

any results?

www.ecdc. europa.eu

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What about the consumption?

18 Chahwakilian et al, JAC 2011

-6%

-22%

19 Chahwakilian et al, JAC 2011

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-16% ! Over a 10 year-period

2011

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Public consumption

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Healthcare consumption

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Healthcare consumption

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National survey 2012 vs. 2006 : % of patients

treated with antibiotics

2006 2012 Evolution

Patients Patients treated with

antibiotics Patients

Patients treated

with antibiotics

N N % N N % %

149 887 37 471 25,0 147 195 37 461 25,4 +1,8

Medical ward 75 889 19 778 26,1 80 904 21 892 27,1 +3,8

Surgical ward 49 846 13 645 27,4 43 487 11 412 26,2 -4,1

ICU 5 126 2 545 49,6 5 811 2 832 48,7 -1,8

LTCF 47 160 2 000 4,2 22 292 945 4,2 -0,0

Total 281 661 45 516 16,2 266 954 45 461 17,0 +5,4

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National survey 2012 vs 2006:

+82,7%

+31,0%

+96,7%

+62,9%

+37,0%

+28,5%

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Why are the expected results reserved ?

• 2218 patients were included

• CP were associated with another antibiotic in 70% of cases

• Indications • Severe infection 15% of cases

• Risk factors for MDR 21% of cases

• Aggravation under an other antibiotic 14% of cases

Enquête SPA-Carb – ICAAC 2012

How Carbapenems are Used in French Health-Care Facilities in 2011

Prospective study including 10 consecutive patients receiving CP

34% Community acquired 17% without any

microbiological sample

30% with a duration over 10 days

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Why are the expected results reserved ?

• 3964 patients were included

• 41% had an ongoing antibiotic therapy

• 21% surgical antimicrobial prophylaxis > 1 day

• 41% had more than one drug

• 27% had a duration of antimicrobial therapy > 7 days

Point prevalence survey of antibiotic use in French hospitals in 2009

Robert et al, JAC 2012

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Why are the expected results reserved ?

Pulcini et al, CMI 2011

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Why are the expected results reserved ?

Pulcini et al, CMI 2011

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Why are the expected results reserved ?

Pulcini et al, CMI 2011

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Why are the expected results reserved ?

Pulcini et al, CMI 2011

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Why are the expected results reserved ?

Dyar et al, Med Mal Inf 2013

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Conclusions

• Many things have been done in France

• At the bedside the application is variable

• Our politic is « too much » based on restrictive

measures

• Educational measures are urgently needed

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Thank you for your attention