Relationship between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from 47 French hospitals.

OBJECTIVE: To investigate relationships between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from hospitals. METHODS: We conducted an observational study that used retrospective data from 2002 and linear regression to model relationships. Hospitals were asked to collect data on consecutive S. aureus and P. aeruginosa isolates, consumption rates for antibiotics (ie, anti-infectives for systemic use as defined by Anatomical Therapeutic Chemical class J01), and hospital characteristics, including infection control policies. Rates of methicillin resistance in S. aureus and rates of ceftazidime and ciprofloxacin resistance in P. aeruginosa were expressed as the percentage of isolates that were nonsusceptible (ie, either resistant or intermediately susceptible) and as the incidence of nonsuceptible isolates (ie, the number of nonsuceptible isolates recovered per 1,000 patient-days). The rate of antimicrobial consumption was expressed as the number of defined daily doses per 1,000 patient-days. SETTING: Data were obtained from 47 French hospitals, and a total of 12,188 S. aureus isolates and 6,370 P. aeruginosa isolates were tested. RESULTS: In the multivariate analysis, fewer antimicrobials showed a significant association between the consumption rate and the percentage of isolates that were resistant than an association between the consumption rate and the incidence of resistance. The overall rate of antibiotic consumption, not including the antibiotics used to treat methicillin-resistant S. aureus infection, explained 13% of the variance between hospitals in the incidence of methicillin resistance among S. aureus isolates. The incidence of methicillin resistance in S. aureus isolates increased with the use of ciprofloxacin and levofloxacin and with the percentage of the hospital's beds located in intensive care units (adjusted multivariate coefficient of determination [aR(2)], 0.30). For P. aeruginosa, the incidence of ceftazidime resistance was greater in hospitals with higher consumption rates for ceftazidime, levofloxacin, and gentamicin (aR(2), 0.37). The incidence of ciprofloxacin resistance increased with the use of fluoroquinolones and with the percentage of a hospital's beds located in intensive care ( aR(2), 0.28). CONCLUSIONS: A statistically significant relationship existed between the rate of fluoroquinolone use and the rate of antimicrobial resistance among S. aureus and P. aeruginosa isolates. The incidence of resistant isolates showed a stronger association with the rate of antimicrobial use than did the percentage of isolates with resistance.

Determinants of glycopeptides consumption in hospitals.

The aim of this study was to describe consumption of glycopeptides and to study factors associated with their use in 47 French hospitals. Consumption of glycopeptides for systemic use (defined daily doses per 1,000 patient-days: DDD/1,000 PD and per 100 admissions), number of methicillin-resistant Staphylococcus aureus (MRSA) (percentage and incidence per 1,000 patient-days), and number of venous central lines and hospital characteristics (size, length of stay, number of beds: total and for each hospital inpatient areas and antibiotic policies) were recorded from January, 2002, through December, 2002. Multiple linear regression was performed to check for hospital characteristics. The median rate of total consumption of glycopeptides was 4.11(range 0.21-27.22) DDD per 1,000 PD with higher consumption in large public hospitals and in intensive care areas (median 46.51; range 7.19-134) than in surgery areas (median 4.5; range 0.17-24.76). The consumption of glycopeptides correlated with MRSA incidence, but not with the proportion of MRSA. In the multivariate analysis, the incidence of MRSA and the number of beds in surgery areas were independent predictors of total glycopeptides use in the hospital, expressed in DDD per 1,000 PD (R2 adjusted, 0.39). The incidence of MRSA, the number of venous central lines, and the number of beds in the medicine areas were significant determinants associated with higher consumption of glycopeptides expressed in DDD per 100 admissions (R2 adjusted, 0.73). To reduce glycopeptides use in hospitals, the first effort required is that hospitals focus increased attention on the prevention of cross transmission for MRSA between patients but also on the use of the venous central line. Furthermore, hospitals have to compare their data with others to identify overuse of glycopeptides and to plan control interventions.

Infection control practices and infectious complications in dermatological surgery.

The aim of this study was to assess infection control practices and their impact upon infectious complications in skin surgery conducted by private dermatologists. A prospective study was carried out by 73 volunteers belonging to the Surgical Group of the Société Française de Dermatologie over a period of three months. Data were collected for surgical procedures performed during this period, including the excision of all benign or malignant tumours, but excluding sebaceous cysts and pyodermas. A total of 3491 dermatological surgical procedures were included in the survey. Post-operative infections occurred in 67 patients (1.9%), with superficial suppuration accounting for 92.5% of surgical site infections. The incidence was higher in the excision group with a reconstructive procedure (4.3%) than in excisions alone (1.6%). Infection control precautions varied according to the site of procedure; multivariate analysis showed that haemorrhagic complications were an independent factor for infection in both types of surgical procedure. The male gender, immunosuppressive therapy and not wearing sterile gloves were independent factors for infections occurring following excisions with reconstruction. Not all of the procedures needed the use of a hospital theatre. It is clear that for excisions with a reconstructive procedure or for certain anatomical sites, such as the nose, there should be more emphasis upon infection control precautions. Further studies are needed to establish optimal guidelines for this kind of surgery.

Contribution of tap water to patient colonisation with Pseudomonas aeruginosa in a medical intensive care unit.

This study examined tap water as a source of Pseudomonas aeruginosa in a medical intensive care setting. We prospectively screened specimens of patients, tap water and hands of healthcare workers (HCWs) over a six-month period in a 16-bed medical intensive care unit. Molecular relatedness of P. aeruginosa strains was investigated by pulsed-field gel electrophoresis. A total of 657 tap water samples were collected from 39 faucets and 127 hands of HCWs were sampled. P. aeruginosa was found in 11.4% of 484 tap water samples taken from patients' rooms and in 5.3% of 189 other tap water samples (P<0.01). P. aeruginosa was isolated from 38 patients. Typing of 73 non-replicate isolates (water samples, hands of HCWs and patients) revealed 32 major DNA patterns. Eleven (52.4%) of the 21 faucets were contaminated with a patient strain, found before isolation from tap water in the corresponding room in nine cases, or from the neighbouring room in two cases. Among seven P. aeruginosa strains isolated from HCW hands, the genotype obtained was the same as that from the last patient they had touched in six cases, and in the seventh with the last tap water sample used. More than half of P. aeruginosa carriage in patients was acquired via tap water or cross-transmission. Carriage of P. aeruginosa by patients was both the source and the consequence of tap water colonisation. These results emphasise the need for studies on how to control tap water contamination.

[Relationship between antibiotic policies and antibiotic consumption in hospitals]. / Relation entre politique de bon usage et consommation des antibiotiques dans les établissements de santé.

OBJECTIVE: The authors had for aim to study the relationship between antibiotic policies and antibiotic consumption in hospitals. DESIGN: A component analysis was used to summarize the various measures of the antibiotic policies developed by hospitals. Antibiotics consumption was expressed as a number of Daily Defined Doses per 1,000 patient-days. The relation was studied by a multiple linear regression model with adjustment on hospital activity. RESULTS: The first component illustrated an active program of antibiotic policies associating: a local antibiotic committee, an infectious diseases consultant, written local guidelines for prescriptions and restrictive measures before dispensing. The highest antibiotic consumption was associated with active policies, especially for carbapenems, glycopeptides, and aminoglycosides. However the relationship differed according to the type of hospital, with lower antibiotic consumption, especially for penicillins, in private hospitals that had more active policies. CONCLUSION: The difference between public and private hospitals could be explained by the type of institution but also by the unit used to measure antibiotic consumption.

[How should research protocols be implemented in the field?]. / Comment mettre en oeuvre des protocoles de recherche sur le terrain?

The hepatitis issue is a major public health concern, especially the widespread expansion of HCV infection among drug users. Prevention is focused on the prevention of risky behaviors (injection, needle and material sharing). Research is needed to improve our comprehension of the relatively low efficiency of actions taken in this field. We need better knowledge of the users' present practices, patterns of use and contexts of consumption but also about their own knowledge or beliefs about this infection. These qualitative studies should be conducted with a direct contact with users in the field: streets, drug scenes, low threshold structures, addiction therapy centres, physicians networks... These are not easy fields for study because of different reasons linked with the structures per se but also with the particular public involved. Some specific difficulties are presented as well as some means of coping with them. Experience has shown that it is possible to handle these issues and to conduct such studies.

[Reservoirs and transmission of Pseudomonas aeruginosa in intensive care unit]. / Réservoirs et transmission de Pseudomonas aeruginosa en réanimation médicale.

OBJECTIVE: The authors had for aim to study reservoirs and transmission of Pseudomonas aeruginosa in an intensive care unit. DESIGN: A 6-month prospective descriptive study was made on water samples, samples from hands of health care workers, and clinical samples. P. aeruginosa strains were compared by pulsed-field gel electrophoresis. RESULTS: Among the 211 patients hospitalized during the study, 14 (6.6%) were infected by P. aeruginosa. Out of 494 water samples, 80 were contaminated by P. aeruginosa. The regularly disinfected water taps were more rarely contaminated than the others (P<10(-5)). Out of 140 hand samples, one showed contamination from an infected patient. CONCLUSIONS: aeruginosa cross transmission was observed during this study. We should follow strict hygienic precautions such as wearing gloves and performing thorough alcoholic rub disinfection. Water taps are often contaminated and require regular disinfection.

[Policies for the use of antibiotic in 99 Southwestern French hospitals in 2002]. / Politique d'utilisation des antibiotiques: état des lieux dans 99 établissements de santé de l'interrégion Sud-Ouest.

OBJECTIVE: Increasing antimicrobial resistance in bacteria is a major health problem and requires the implementation of stringent policies to optimize the use of antibiotics. DESIGN: In 2003 the authors conducted a study in southwestern French hospitals, using a questionnaire to assess the implementation of antibiotic policies according to national guidelines issued by the French government in 2002. RESULTS: The most frequent actions quoted by the 99 respondents were: issuing of a list of available antibiotics, issuing of information regarding antibiotic consumption and bacterial resistance, and control of antibiotics dispensation. Local guidelines were available in 45% of hospitals for curative treatment and in 87% for antibioprophylaxis in surgery. The evaluation of antibiotic use and computer links between clinical settings, pharmacy and microbiology lab were the less widespread measures. The number and type of actions were related to hospital size and activity. CONCLUSIONS: These findings support that policies for an appropriate use of antimicrobials should be reinforced by issuing treatment guidelines and specific tools for dispensation and evaluation. This survey also emphasizes the need for appropriate policies relating to the size and medical activities of healthcare institutions.

Agrobacterium radiobacter as a cause of pseudobacteremia.

Agrobacterium radiobacter was isolated from 15 blood cultures collected from 15 newborns. Contamination of blood cultures was suspected because, in most cases, the babies' illnesses seemed incompatible with infection. A radiobacter was isolated from citrated tubes used for clotting-factor studies. Review of venipuncture technique revealed that occasionally the coagulation study tubes were being inoculated before the blood-culture bottles. This investigation demonstrated how an environmental source coupled with faulty technique caused a cluster of false-positive blood cultures.

Epidemiological study of an outbreak of infection with Staphylococcus aureus resistant to lincosamides and streptogramin A in a French hospital.

A significant increase in the incidence of isolates of methicillin-resistant Staphylococcus aureus (MRSA), that were also resistant to lincosamides and streptogramin A (LSA-MRSA), was observed in a French university hospital. Twenty-seven isolates from the outbreak were characterised, including 17 isolates from a plastic surgery ward and six control strains of MRSA. The strains were examined by antibiotyping and biotyping, and by three molecular methods: plasmid analysis, ribotyping and insertion sequence (IS) typing with IS256 sequence as a probe. Antibiotyping (five antibiotypes) was discriminatory because of the uncommon resistance phenotype of the epidemic strain. Biotyping (three biotypes), DNA plasmid analysis (four profiles) and ribotyping (two profiles) were poorly sensitive, in contrast to IS-typing (12 profiles). By the latter method, a coefficient of similarity (percentage similarity) compared to the predominant IS profile was calculated. Strains with a coefficient of similarity > or = to 82% were considered as highly related to the epidemic strain, while those with a coefficient of similarity < or = to 40% were regarded as distant. Results obtained with the five markers confirmed that an outbreak of hospital infection had occurred in the plastic surgery ward, with spread of the epidemic strain throughout the hospital.

Investigation of an outbreak of Ralstonia pickettii in a paediatric hospital by RAPD.

In 1995, over a 5-day period, Ralstonia pickettii was isolated from six separate blood cultures from six paediatric patients in four different units of the Bordeaux paediatric hospital. The patients did not present fever or any other symptom of septicaemia. Epidemiological investigation cast suspicion on distilled water and 0.05% aqueous solutions of chlorhexidine used for topical disinfection as the source of R. pickettii. The organism was isolated from three of the seven distilled water specimens and from seven of the thirty-seven chlorhexidine specimens collected. Conventional biochemical tests showed no differences between isolates and antimicrobial agent susceptibility testing indicated that the six blood cultures contained the same strain of R. pickettii. This was confirmed by RAPD (random amplified polymorphic DNA) analysis. The primers P3 (5'AGACGTCCAC3') and P15 (5'AATGGCGCAG3') from the kit 'OPH Operon' (Bioprobe Systems, Montreuil, France) were used. The chlorhexidine solutions and the distilled water used to prepare the solutions were contaminated with various strains of R. pickettii including the patient strain. The distilled water originating from the local pharmacy had been deionized on an ion-exchange resin. Circumstantial evidence points to this water treatment as the source of contamination. RAPD proved to be a discriminatory and reproducible technique in this context, but antibiotyping was also very helpful in detecting outbreak and was equally discriminatory.

Use of antibiotics in hospitals in south-western France.

Data on the use of antibiotics were collected by means of a questionnaire from 49 hospitals in south-western France. Use was expressed as a usage density rate: number of defined daily doses (DDDs) per 1000 patient-days. The average use of antibiotics amounted to 402 DDDs per 1000 patient-days and varied between 60 and 734. In acute-care wards, the amount of antibiotic use increased with the size of the hospital: 461 DDDs per 1000 patient-days for group A (<100 beds), 510 DDDs per 1000 patient-days for group B (more than 100 and less then 300 beds) and 676 DDDs per 1000 patient-days for group C (>300 beds). The rate of use differed among different types of hospital areas and varied from 58 for psychiatry departments to more than 1273 DDDs per 1000 patient-days for the infectious diseases departments. Broad-spectrum penicillins were the most frequently prescribed antibiotics. Fluoroquinolone and third-generation cephalosporin use were relatively uniform in the three size categories. This study shows that it is possible for a hospital to benchmark its consumption with other hospitals that are similar in size. In this way, surveillance of antibiotic use can aid hospitals in targeting infection control efforts.

Electronic ventilator temperature sensors as a potential source of respiratory tract colonization with Stenotrophomonas maltophilia.

Stenotrophomonas maltophilia (S. maltophilia) is an important cause of nosocomial infection among ventilated and immunocompromised patients, and among patients receiving broad-spectrum antimicrobials. We report a cluster of patients in a surgical intensive care unit who were colonized or infected with S. maltophilia. An epidemiological investigation was initiated after surveillance data revealed that eight patients were culture-positive from sputum for S. maltophilia in the preceding month. Review of respiratory care procedures revealed that when mechanical ventilators were serviced between patients, the electronic temperature probes used with servo-controlled humidifiers were wiped with inadequate disinfection. We collected cultures of case-patient room surfaces, sinks and ventilator equipment. S. maltophilia was recovered from room surfaces, ventilator expiratory circuits and a temperature sensor which had been kept in ambient air after disinfection. Patients and environmental isolates were examined by RAPD-PCR. Three clinical isolates and one environmental isolate had the same profile, which suggests cross-contamination or common source exposure. The outbreak was controlled by adequate disinfection of the temperature sensors. No single epidemic strain was identified but several observations support the conclusion that the temperature probes contributed to the outbreak.

A hospital outbreak of gastroenteritis possibly related to the contamination of tap water by a small round structured virus.

Small round structured viruses (SRSVs) are a major cause of gastroenteritis in institutions and sensitive new molecular techniques allow rapid diagnosis and the establishment of control measures. In January 1999, a 10 day-long outbreak of gastroenteritis in a re-education ward, was reported by a hospital hygiene department. A potential common source of contamination was tap water. The stools of six patients with gastroenteritis and seven tap water samples from the hospital ward, were tested for SRSV by reverse transcription and polymerase chain reaction (RT-PCR): three stools and four water samples, all bacteriologically negative, were SRSV-positive. Nucleotide sequencing of a fragment of the SRSV polymerase gene showed that the sequences of the positive samples (two patients and four water samples) were identical (genogroup II). We cannot exclude interhuman transmission of SRSV together with viral soiling of some taps in the ward, but this hospital infection was more likely due to the transient contamination of the ward supply of drinking water with a SRSV strain.

[Incidence of cancer in Martinique 1981-1982]. / Incidence des cancers en Martinique en 1981-1982.

A systematic registration of morbidity from cancers was started in 1981 and 1982 in the french department of Martinique. In the course of two years 1081 new cases of cancers were recorded for a population of 320 000. The survey gives information on topography, differences for sex and ages. The morbidity survey allows comparison with the incidence rate of cancers in other departments of France or other countries.

[Bronchial symptoms and respiratory function in the natural gas extraction industry. The role of Pi phenotype and chemical pollution]. / Symptômes bronchiques et fonction respiratoire dans l'industrie d'extraction des gaz naturels. Rôle du phénotype Pi et de la pollution chimique.

The aim of this study was to measure, in workers in the chemical industry, the frequency of symptoms and/or alteration in respiratory function according to the Pi phenotype and the occupational environment of each subject. 188 men (mean age 33) participated in a cross sectional study which included: a questionnaire on the working conditions, smoking habits and respiratory symptoms, a lung function test assessing bronchial flow rates, residual volume and CO lung transfer, laboratory investigations with determination of the Pi phenotype, blood concentration of alpha-1-antitrypsin (alpha-1-AT) and antielastase activity in the serum, a study of outdoor environment in each occupation. The Pi phenotype was divided as MM (75.5%) and non MM (24.5%). Both serum alpha 1AT concentration and antielastase activity were lower in non MM subjects than in MM ones. There was no difference between the 2 groups for age, smoking, working conditions, bronchial symptoms or respiratory function values that were within a normal range. The MM subjects stated that they were more exposed to dust, gas and cold; their absence from work for respiratory disorders was more frequent although in a non significant manner and their flow rates at low lung volumes was paradoxically worse than in non MM subjects. It is concluded that neither the outdoor environment nor the Pi phenotype play a role in the respiratory risk which requires, to be more comprehensively evaluated, a prospective study.

[Is length of stay in the recovery room a risk factor for cross infections?]. / Le séjour en salle de surveillance postinterventionnelle peut-il être à l'origine de transmissions croisées?

OBJECTIVE: To assess cross contamination for patients at the time of their stay in the recovery room (RR). STUDY DESIGN: Prospective study. PATIENTS AND METHODS: A prospective survey over 3 weeks with 75 adult patients admitted to RR after thoracic or neck surgery. Samples for bacterial analysis were systematically taken from all patients before they left the operating theatre and just before discharge of RR (nose-throat and skin adjacent to the surgical wound). During this period, hand's health care workers (HCW) and environmental surfaces were sampled. RESULTS: There were 3 groups of patients: endoscopy (41%), thoracic surgery (39%). And thyroidectomy (20%), 392 samples were analysed. Potentially pathogenic floras were found on the admission for 25 patients and at discharge for 31 patients. A pathogenic flora was detected at discharge in 13 patients, whereas none was found at admission in RR. These patients were principally in the thyroidectomy group and their stay in RR was longer than 20 minutes. There is no significant difference concerning the nosocomial risk between 3 groups. Pathogenic flora was found in 19% of HCW (8 of 42). CONCLUSION: Cross contamination can exist in recovery room and educative measures are to be taken regarding handwhashing, isolation precautions and environmental cleaning.

[Medical liability: new obligations concerning information of patients on infectious risks]. / Responsabilité médicale: les nouvelles obligations en matière d'information sur les risques infectieux.

Nosocomial infections have always been considered as "unbearable" by patients and public opinion. Court decisions progressively evolved to a greater compensation until the 4 March 2002 law, "relative to the rights of patients and to the healthcare system quality" which set up a very specific protocol for liability and access to compensation, whether care is given in public or private practice. Furthermore, this law has determined new obligations concerning information of patients, especially concerning nosocomial infections which must be acknowledged by physicians.

Easily available adjustment criteria for the comparison of antibiotic consumption in a hospital setting: experience in France.

Hospitals in France are encouraged to monitor antibiotic consumption (AbC) and it is known that this differs among hospitals. The aim of the current study was to identify relevant and easily available adjustment criteria for the purpose of benchmarking. We analysed data from 34 public non-teaching hospitals and 43 private hospitals located in south-western France and overseas departments using retrospective data from 2005. This study investigated the relationship between AbC expressed as defined daily doses per 1000 patient-days (DDD/1000 PDs) or per 100 admissions (DDD/100 admissions) and the number of venous central lines, the number of episodes of bacteraemia and various hospital characteristics. The relationship was tested using multiple linear analyses. The median total AbC in public hospitals was 395 DDD/1000 PDs (range, 196-737) and 341 DDD/100 admissions (range, 180-792). In private hospitals this was 422 DDD/1000 PDs (range, 113-717) and 212 DDD/100 admissions (range, 38-510). The best model for public hospitals included the proportion of PDs in surgery, intensive care and medical wards and explained 84% of the variability in AbC expressed as DDD/1000 PDs. For private hospitals, the mean length of stay and the proportion of PDs in surgery and medical wards explained 68% of the variability in AbC expressed as DDD/100 admissions. Overall, this French experience shows that relevant adjustment criteria for the comparison among hospitals are easily available. It is important that each country establish its own model considering the intrinsic peculiarities of the hospital system and taking into account both indicators (DDD/1000 PDs or DDD/100 admissions) to design the best model.