The economic burden of urinary tract infections in women visiting general practices in France: a cross-sectional survey.

BACKGROUND: Urinary tract infections (UTIs) are among the most common bacterial infections. Despite this burden, there are few studies of the costs of UTIs. The objective of this study was to determine the costs of UTIs in women over 18 years of age who visit general practitioners in France. METHODS: The direct and indirect costs of clinical UTIs were estimated from societal, French National Health Insurance and patient perspectives. The study population was derived from a national cross-sectional survey entitled the Drug-Resistant Urinary Tract Infection (Druti). The Druti included every woman over 18 years of age who presented with symptoms of UTI and was conducted in France in 2012 and 2013 to estimate the annual incidence of UTIs due to antibiotic-resistant Enterobacteriaceae in women visiting general practitioners (GPs) for suspected UTIs. RESULTS: Of the 538 women included in Druti, 460 were followed over 8 weeks and included in the cost analysis. The mean age of the women was 46 years old. The median cost of care for one episode of a suspected UTI was €38, and the mean cost was €70. The annual societal cost was €58 million, and €29 million of this was reimbursed by the French National Health Insurance system. In 25 % of the cases, the suspected UTIs were associated with negative urine cultures. The societal cost of these suspected UTIs with negative urine cultures was €13.5 million. No significant difference was found between the costs of the UTIs due to antibiotic-resistant E. coli and those due to wild E. coli (p = 0.63). CONCLUSION: In the current context in which the care costs are continually increasing, the results of this study suggests that it is possible to decrease the cost of UTIs by reducing the costs of suspected UTIs and unnecessary treatments, as well as limiting the use of non-recommended tests.

Methicillin-resistant Staphylococcus aureus among a network of French private-sector community-based-medical laboratories.

OBJECTIVE: The aim of this study was to estimate the frequency of methicillin-resistant Staphylococcus aureus (MRSA) strains in the French community and the proportion of Panton-Valentine (PVL)-MRSA. DESIGN: A cross-sectional study was made during a 3-month period in 2003 through a network of private-sector, community-based medical laboratories selected throughout France: the Labville network. Each MRSA isolate was included and characterized by French National Reference Center for Staphylococci. The total number of S. aureus isolates was also collected. RESULTS: Among the 283 patients infected or colonized by MRSA, 166 (59%) were considered as healthcare-associated, 14 (5%) as nursing-associated and 39 (14%) as community-acquired. The proportion of methicillin resistance among S. aureus was 14%. Taking into account the sampling design, the incidence of MRSA cases in French outpatients was estimated to be 0.50 [CI95%: 0.41-0.60] per 10,000 inhabitants. The molecular analysis confirmed that 80.6% belong to the Lyon clone, the most prevalent hospital MRSA clone spreading in France and 10.6% to a closely related clone. An emerging MRSA clone containing the tst1 gene was detected in six patients and the PVL-positive ST80 clone only in one, 22-year-old, patient. CONCLUSION: Most of MRSA cases diagnosed in the community in France, in 2003, were elderly with specific risk factors and harbored hospital strains. The prevalence of PVL-MRSA remained low.

[Implementing a community surveillance network to monitor antimicrobial resistance: the Labville network]. / Mise en oeuvre d'un réseau de surveillance de la résistance bactérienne aux antibiotiques en ville: le réseau Labville.

BACKGROUND: In France, antimicrobial resistance monitoring is based on the contribution of many microbiological partners and networks, especially hospital laboratories. In order to complete this surveillance, the InVS implemented a network based on private-sector laboratories (PSL): the Labville network. METHOD: Stratified by French region, 69 PSL were randomly selected. The microbiological analysis results, including anonymized individual patient data, are translated into an appropriate data format within an automated reading process. This data is then sent to InVS through a secure Internet connection. RESULTS: The specifications of the automated system were defined according to a feasibility study conducted in 2003. The first stage of the project consisted in defining a global strategy for the reading of printed microbiological results. Then, the parameters were adapted for each PSL using a set of specific analysis over two to three weeks. After validation by InVS, the reading strategy was applied on to routinely printed results. The strategy was definitely validated after four month of a daily data transmission. The general approach needs to be adapted to each PSL and undergoes several adjustments. This long step of the project still requires microbiological expertise. CONCLUSION: The automated data extraction process used for Labville project is innovating. It is not affected by the compatibility and diversity of computing systems and reduces the biologist's workload. The Labville network is a challenging project motivating future development of other electronic surveillance networks.

Impact of a five-year surveillance of central venous catheter infections in the REACAT intensive care unit network in France.

Central venous catheter (CVC)-related infections (CRIs) are a key target for infection control in intensive care units (ICUs). The aim of this study was to describe temporal trends of CRI incidence in a network of volunteer ICUs in Northern France. During a 4 month surveillance period each year, all CVCs in place for more than 48h were prospectively followed until removal or patient discharge. Standard clinical and microbiological criteria were used to define colonization and CRI. The standardized incidence ratio (SIR) was estimated by dividing the number of observed CRIs by the number of expected CRIs, which was computed using a logistic regression model including risk factors for CRI. CRI incidence and SIR were fed back to ICUs as a benchmark at the end of each period. From 2001 to 2005, 135 ICUs participated for at least one surveillance period. Overall, 11 703 CVC in 9182 patients (122 495 CVC-days) were included. CRI incidence was 2.8 per 1000 CVC-days. Among 35 ICUs that participated for three or more consecutive periods, CRI incidence decreased significantly by 58.6%. SIR also decreased significantly from the first to the third surveillance period in these ICUs. These results suggest that surveillance programmes have a significant impact on CRI risk in ICUs and remain an important strategy for combating nosocomial infections in these settings.

[Risk of hepatitis C related to traditional medicine: a case control study in Ho Chi Minh City, Vietnam]. / Risque d'hépatite C lié à des pratiques traditionnelles: une étude cas témoins à Ho-Chi-Minh-Ville, Vietnam.

BACKGROUND: The transmission of hepatitis C virus (HCV) is strongly associated with blood transfusion and drug abuse. However, in about a third of HCV-infected subjects, the risk factors are not clearly identified though some cases are likely to be healthcare associated. In an Asian country such as Vietnam, invasive procedures used for traditional and beauty care could be potential risk factors. The aim of the present study was to identify the risk factors of HCV infection in a population sample in Ho Chi Minh City. METHOD: A case-control study matched by gender and age was performed among blood adults donors at the Centre of hematological diseases and blood transfusion. Cases were defined as blood donors with HCV-positive Elisa. Controls were selected at random among ELISA HCV-negative donors. A standardized questionnaire was used to collect data focusing on invasive medical procedures, beauty care and on invasive procedures related to traditional medicine. RESULT: Among the 80 cases and 240 controls, the independent predictors of anti-HCV positivity using a stepwise logistic regression were: blood transfusion, intravenous drug abuse, acupuncture, ventoused scarification and practice of scarification (adjusted odds ratio and IC95%: 3.8 [1.1-13.1], 3.5 [1.7-7.3], 5.4 [2.3-12.7], 5.4 [2.5-11.7], 6.6 [1.6-26.4] respectively). The other risk factors such as past hospitalization surgery, tattooing, being a healthcare worker, or practising tattooing or piercing were not associated with HCV infection. CONCLUSION: To be exposed to ventoused scarifications or acupuncture are risk factors for the transmission of HCV in Vietnam. A wide information campaign on hygiene practices for general population as well as the practitioners is needed to ensure safer health cares in traditional medicine.

[Evaluation of practices involving a cross infection risk in anaesthesia]. / Evaluation des pratiques en anesthésie exposant au risque infectieux par transmission croisée.

OBJECTIVE: The practice of anaesthesiology has the potential for transmitting a number of infectious agents to the patient. In France, several recent cases have been identified, so that a wide survey on anaesthesiology practice has been enhanced. METHODS: An anonymous questionnaire, based on the recommendations of the French Society of Anaesthesiology and Intensive Care (Sfar), was send to 8,771 anaesthesiologists and intensive care practitioners and to 2,070 nurses practicing anaesthesiology. RESULTS: A total of 1,343 questionnaires were analyzed (response rate of 12.4%). The study shows that some recommendations were routinely applied, such as: availability of alcohol-based hand hygiene solution in operating rooms (94%), use of antimicrobial filters for respiratory circuits (99%), use of single-use laryngoscope blades (77%), aseptic technique for central venous catheterization (99%), hand hygiene after contact with body fluids (96%). In contrast, the study showed that some recommendations were partially applied: hand hygiene practice (52%), wear of gloves when a risk of blood exposure exists (23%), cleaning of reusable laryngoscope blades (19%), and incorrect wear of masks (71%). The reuse of the same syringe for several patients was described in 2% of the responses. CONCLUSION: This results, similar to those previously described in the literature, must be followed by appropriate training and education of anaesthesia personnel, implementation of the recommendations, and evaluation of practices. Reuse of the same syringe for several patients have to be eradicated because of the high risk of viral transmission.

[Standardized incidence ratio: a risk index for catheter-related infection surveillance in intensive care units (REACAT network) in Northern France]. / Ratio standardisé d'incidence: un indice de risque pour la surveillance des infections liées aux cathéters veineux centraux en réanimation adulte (réseau REACAT) dans l'inter-région Nord.

BACKGROUND: Nosocomial infection surveillance is one of the major indicators used to compare health care quality in hospital settings. Wards participating in a network with standardized methods can be compared. We propose a risk index adjusted for catheter-related infection (CRI) specific risk factors in the setting of a CRI surveillance network in intensive care units (ICU): the standardized incidence ratio (SIR). METHODS: All central venous catheters (CVC) inserted for more than 48h were prospectively followed until CVC removal or patient discharge in a yearly 4-month surveillance. Standard clinical and microbiological criteria were used to define colonization and CRI. A logistic regression model, developed on a 3-year pooled database, was used as a predictive model of CRI. Expected number of CRI was calculated and compared with the observed number of CRI to estimate SIR for each year and for each ICU per year. RESULTS: From 2000 to 2003, 108 ICU participated in at least one of the 3 surveillance periods, including 6414 CVC. Overall, 239 CRI were identified (incidence density (ID): 3.6 CRI/1000 CVC-days). At multivariate analysis, duration of CVC placement (1.1 [1.0-1.1]), rank (1.7 [1.1-2.2]) and site of CVC insertion (1.6 [1.2-2.1]), use of CVC for antibiotic therapy (0.5 [0.3-0.7]), organ failure at CVC removal (2.2 [1.5-3.2]), infection at another site at CVC removal ([1.9 [1.4-2.6]) were significantly associated with CRI. During the last period of surveillance, 14 ICU had a DI higher than 5.5 CRI/1000 CVC-days. More CRI than expected were significantly observed in two wards including one which followed less than 20 CVC. CONCLUSION: The REACAT surveillance system assesses a novel and reliable risk index which enables identification of ICU with a higher CRI risk and to focus on prevention.

[Significant reduction of nosocomial infectious: stratified analysis of prevalence national studies performed in 1996 and 2001 in French north interegion]. / Réduction significative des infections nosocomiales: analyse stratifiée des enquêtes nationales de prévalence conduites en 1996 et 2001 dans l'inter-région Nord.

BACKGROUND: In France, repeated prevalence studies of nosocomial infections (NI) are part of governmental plan against NI built in 1995 by the Ministry of Health. To evaluate strand of NI prevalence, we performed a comparative analysis of two successive national point-prevalence surveys occurring in 1996 and 2001 for the Northern France. METHOD: Comparison concerned the hospitals, which participated in the two studies of 1996 and 2001 in Northern France. The studies were designed as a point-prevalence survey on voluntary basis. For each patient, risk factors and presence of active NI at the day of the study were recorded on standardised form. Criteria of NI used were these of "100 recommendations" of CTIN and of CCLIN North guideline. Prevalence rate (PR) and frequency of risk factors were compared. The risk factors significantly linked to NI by logistic regression were used to build a score of five risk levels of NI (PREVARISK) allowing an adjusted comparison of the 2 years. RESULTS: Total of 161 hospitals participated at the two studies, including respectively 61 422 and 58 749 patients. Between 1996 and 2001, crude PR of infected patients and of NI decreased respectively from 7.8% to 7.3% and 9.0% to 8.0% (P < 10(-4)), so then relative decreases were of 6.4% and 11.1%. In contrast, the frequency of risk factors, except surgery in the past 30 days, significantly increased. Risk factors included in PREVARISK were: age >65 years, immunosuppression, surgery in the past 30 days, urinary tract and central catheter. In patients with a low risk level (PREVARISK = 0), the relative decrease of infected patients and NI PR were of 17% and 19%. The decrease was not significant for patients with high risk level (PREVARISK >/= 3). CONCLUSION: Our analyses show a decrease of PR adjusted on risk factors, especially in patients with a low risk level. These result suggest an efficacy of program against NI in studied hospitals especially for patients for whom NI would be potentially avoidable.

[Nosocomial risk factors of hepatitis C infection. A multicenter study in a hospital-based population]. / Facteurs de risque nosocomiaux de l'infection par le virus de l'hépatite C. Une étude multicentrique en population hospitalière.

PURPOSE: Drug abuse and blood transfusion are well known risk factors for hepatitis C virus (HCV) infection. However, the route of transmission remains undetermined for 30% of HCV infections. The potential for nosocomial transmission of HCV in health care settings has been suggested but remains poorly estimated. The aim of the study was to assess the prevalence and to identify risk factors for hepatitis C virus (HCV) infection in hospitalized patients frequently exposed to invasive procedures. METHOD: A multi-center sero-prevalence study was conducted in hospitalized patients who underwent invasive procedures in interventional radiology wards in 6 University hospitals in Paris between 1998 and 1999. Each patient presenting in the ward was consecutively interviewed by a medical investigator. Data were collected on a standardized questionnaire including items on socio-demographic characteristics, past exposure to intravenous drug use, blood transfusions, underlying diseases and type and number of previous invasive procedures. Before procedure, HCV antibody testing (ELISA) was performed in all patients after informed consent. In all HCV-positive patients, HCV viremia was detected using polymerase chain reaction. RESULTS: Overall, 91 of 944 (9.7%) patients were HCV-positive, of whom 90% had positive viremia and 10 were identified HCV positive by the screening. HCV prevalence decreased with age and ranged from 4.5% to 22% according to center. Logistic regression analysis showed that intravenous drug use, history of blood transfusions and endoscopy were found as independent risk factors for HCV infection (odds ratio [CI95%]: 77.3 [23.3-256.3], 4.7 [2.7-8.2] et 1.20 [1.01-1.44]). No other risk factor for nosocomial or iatrogenic transmission was identified. CONCLUSION: The results suggest that, except for blood transfusions, other healthcare-related procedures may partly explain HCV transmission. This emphasizes the need to reinforce compliance with standard precautions of hygiene.

Surveillance of methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBLE) in Northern France: a five-year multicentre incidence study.

In order to measure the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and of Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBLE), and to evaluate the impact of the national guidelines for multidrug-resistant bacteria (MDRB) prevention in hospitals of Northern France, a multicentre study was conducted for three months every year starting in 1996, in volunteer hospital laboratories. All clinical specimens positive for MRSA and ESBLE were prospectively surveyed. During the five-year surveillance period, the overall proportion of MRSA was 38.4% in the 28,534 strains of S. aureus, and that of ESBLE was 11.4% in the 6121 strains of Klebsiella pneumoniae and 47.7% in the 2353 strains of Enterobacter aerogenes. The overall incidence rates of clinical specimens positive for MRSA, ESBL-K. pneumoniae and E. aerogenes were 0.84. 0.05 and 0.12/1000 hospital-days (HD), respectively. In the 23 hospitals that participated in the survey every year, the proportion and incidence of ESBLE decreased. Hence, despite recommendations as for isolation precautions, MRSA remains poorly controlled and requires more effective measures.

Mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak.

BACKGROUND: Mycobacterium xenopi spinal infections were diagnosed in 1993 in patients who had undergone surgical microdiscectomy for disc hernia, by nucleotomy or microsurgery, in a private hospital. Contaminated tap water, used for rinsing surgical devices after disinfection, was identified as the source of the outbreak. Several cases were recorded in the 4 years after implementation of effective control measures because of the long time between discectomy and case detection. The national health authorities decided to launch a retrospective investigation in patients who were exposed to M xenopi contamination in that hospital. METHODS: Mailing and media campaigns were undertaken concurrently to trace exposed patients for spinal infections. Patients were screened by magnetic resonance imaging (MRI), and the scans were reviewed by a radiologist who was unaware of the diagnosis. Suspected cases had discovertebral biopsy for histopathological and bacteriological examination. FINDINGS: Of 3244 exposed patients, 2971 (92%) were informed about the risk of infection and 2454 (76%) had MRI. Overall, 58 cases of M xenopi spinal infection were identified (overall cumulative frequency 1.8%), including 26 by the campaign (mean delay in detection 5.2 years, SD 2.4, range 1-10 years). Multivariate analysis showed that the risk of M xenopi spinal infection was related to nucleotomy and high number of patients per operating session. INTERPRETATION: Failures in hygiene practices could result in an uncontrolled outbreak of nosocomial infection. Patients who have been exposed to an iatrogenic infectious hazard should be screened promptly and receive effective information.

Long-term central venous catheter infection in HIV-infected and cancer patients: a multicenter cohort study.

OBJECTIVES: To evaluate and compare the risk of long-term central venous catheter (CVC) infection in human immunodeficiency virus (HIV)-infected and cancer patients. DESIGN: Prospective multicenter cohort study based on active surveillance of long-term CVC manipulations and patient outcome over a 6-month period. SETTING: Services of infectious diseases and oncology of 12 university hospitals in Paris, France. PARTICIPANTS: In 1995, all HIV and cancer patients with solid malignancy were included at the time of long-term CVC implantation. RESULTS: Overall, 31.6% of long-term CVC infections were identified in 32% of 201 HIV and 5% of 255 cancer patients. Most were associated with bacteremia, most commonly coagulase-negative staphylococci. The long-term CVC time-related infection risk was greater in HIV than in cancer patients (3.78 vs 0.39 infections per 1,000 long-term CVC days; P<.001). The independent risk factors of long-term CVC infection were as follows: in HIV patients, frequency of long-term CVC handling and neutropenia; in cancer patients, poor Karnofsky performance status; in both HIV and cancer patients, recent history of bacterial infection. The risk of long-term CVC infection was similar for tunneled catheters and venous access ports in each population. CONCLUSIONS: Prevention of long-term CVC infection should focus first on better sterile precautions while handling long-term CVC, especially in HIV patients who have frequent and daily use of the long-term CVC.