antimicrobial stewardship the french experience ralph zahar.pdfdr jr zahar infection control unit...
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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?
BEH n°42-43/2012
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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