Antibiotic consumption in French nursing homes between 2018 and 2022: A multicenter survey.

OBJECTIVES: Monitoring antibiotic consumption is a key component to steer antimicrobial stewardship programs, including in nursing homes. We analyzed changes in antibiotic consumption in French nursing homes during 5 years, including the COVID-19 pandemic, to identify potential priorities for improvement. DESIGN: A multicenter survey was conducted between 2018 and 2022. SETTING: The study was conducted across 220 French nursing homes with on-site pharmacies. METHOD: Antibiotic consumption data were collected from pharmacy records and are expressed as defined daily doses per 1,000 resident days. Antibiotic indicators promoted by health authorities were calculated from quantitative data to evaluate the quality of prescribing. RESULTS: Antibiotic consumption significantly decreased between 2018 and 2022, particularly during the coronavirus disease 2019 (COVID-19) pandemic, despite a slight increase in 2022. During the study period, the most used antibiotic classes were penicillins (61.9% in 2022) followed by cephalosporins (10.5%), macrolides-lincosamides-streptogramins (7.3%) then fluoroquinolones (7.0%). Amoxicillin-clavulanic acid was the most consumed antibiotic; amoxicillin and ceftriaxone ranked second and third. Azithromycin consumption increased from 2020, as did the indicator regarding broad-spectrum antibiotics. CONCLUSIONS: The decreasing trend in antibiotic use and control of fluoroquinolone use over the study period suggest compliance with antibiotic use guidelines. However, changes in the use of broad-spectrum antibiotics and the substantial use of amoxicillin-clavulanic acid, although it is rarely a first-line antibiotic, highlight the need for antimicrobial stewardship activities and the usefulness of antibiotic consumption surveillance to identify priorities.

Factors associated with better alcohol hand rub in 2020. Results from the French national audit "Pulpe'friction".

Background: The application of alcohol-based hand rub on hands (ABHR) can prevent the transmission of microorganisms. But, in some situations the practices remain perfectible. Aim: The aim of this study was to assess the self-reported ABHR practices of healthcare workers (HCWs) and to identify the factors associated with better ABHR compliance. Methods: A cross-sectional study was conducted using the French national "Pulpe'friction" audit, from 1st January 2020 to 31st December 2020, in healthcare facilities and social welfare facilities in France. Data were analyzed using descriptive statistics and multivariate logistic regression models. Results: Of the 6769 HCWs, the average ABHR compliance was 75% "before patient contact," 95% "before an invasive technique," 86% "after patient contact," and 79% "after contact with patient surroundings." The main reported barriers were the availability, the discomfort and the harmfulness of the product. The factors significantly associated with a better compliance were the individual importance given to hand hygiene (HH); working in a healthcare facility, except in the situation "before an invasive technique"; medical profession "after patient contact"; paramedical profession "after contact with patient surroundings." Discussion: These results call for national actions to fight the most reported barriers and raise awareness on the importance of HH, especially before touching the patient.

Evolution of antibiotic treatments for healthcare-associated infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae in France.

BACKGROUND: Infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) remain a public health challenge. AIM: We traced the evolution of antibiotics prescribed for patients with ESBLE-healthcare associated infections (ESBLE-HAI) between 2012 and 2017, with a specific focus on treatments for lower urinary tract infections (LUTI). METHODS: We used the 2012 and 2017 French point prevalence survey data. Patients with ESBLE-HAI were defined as those diagnosed with at least one Enterobacteriaceae with ESBL production. Patients with LUTI caused by ESBLE (ESBLE-LUTI) were defined as those with LUTI as the reported infection site and diagnosed with ESBLE. We only analysed treatments intended for HAI. RESULTS: In 2017, more than half of treatments for ESBLE-HAIs were ß-lactams. While from 2012 to 2017 the proportion of carbapenem treatments decreased from 30% to 25%, penicillin treatments doubled. Among patients treated for ESBLE-LUTI, a larger proportion received a single antibiotic in 2017. The most frequently prescribed antibiotics for these infections were amoxicillin/clavulanic acid, nitrofurantoin and ofloxacin. More than one out of six treatments lasted for more than 7 days. Carbapenem use was halved between 2012 and 2017, and decreases were likewise observed for aminoglycosides. CONCLUSION: In accordance with French recommendations, comparison of the two most recent French point prevalence surveys showed an evolution in ESBLE-HAI treatment, especially for ESBLE-LUTI. However, treatment durations remained longer than recommended. Data from the 2022 survey should provide insights on the future evolution of prescription trends.

Systematic review of factors promoting behaviour change toward antibiotic use in hospitals.

BACKGROUND: Antimicrobial stewardship (AMS) programmes include actions to improve antibiotic use. OBJECTIVES: This study aimed to identify factors of AMS interventions associated with behaviour change toward antibiotic use in hospitals, applying behavioural sciences. DATA SOURCES: PubMed and Scopus online databases were searched. STUDY ELIGIBILITY CRITERIA: Studies published between January 2015 and December 2020 were included. The required study outcomes were as follows: effect of the intervention reported in terms of antibiotic consumption, antibiotic costs, appropriateness of prescription, duration of therapy, proportion of patients treated with antibiotics, or time to appropriate antibiotic therapy. PARTICIPANTS: Participants included health care professionals involved in antibiotic prescription and use in hospitals and patients receiving or susceptible to receiving antibiotics. INTERVENTIONS: Studies investigating AMS interventions in hospitals were included. METHODS: Risk of bias was determined using the integrated quality criteria for review of multiple study designs tool. A systematic review of AMS interventions was conducted using the behaviour change wheel to identify behaviour changes functions of interventions; and the action, actor, context, target, and time framework to describe how they are implemented. Relationships between intervention functions and the action, actor, context, target, and time domains were explored to deduce factors for optimal implementation. RESULTS: Among 124 studies reporting 123 interventions, 64% were effective in reducing antibiotic use or improving the quality of antibiotic prescription. In addition, 91% of the studies had a high risk of bias. The main functions retrieved in the effective interventions were enablement, environmental restructuring, and education. The most common subcategories were audit and feedback and real-time recommendation for enablement function, as well as material resources, human resources, and new tasks for environmental restructuring function. Most AMS interventions focused on prescriptions, targeted prescribers, and were implemented by pharmacists, infectious diseases specialists, and microbiologists. Interventions focusing on specific clinical situation were effective in 70% of cases. CONCLUSIONS: Knowledge of factors associated with behaviour changes will help address local barriers and enablers before implementing interventions.

How to measure hospital antibiotic consumption: comparison of two methods from data surveillance in France.

BACKGROUND: Antibiotic use (ABU) surveillance in healthcare facilities (HCFs) is essential to guide stewardship. Two methods are recommended: antibiotic consumption (ABC), expressed as the number of DDD/1000 patient-days; and prevalence of antibiotic prescription (ABP) measured through point prevalence surveys. However, no evidence is provided about whether they lead to similar conclusions. OBJECTIVES: To compare ABC and ABP regarding HCF ranking and their ability to identify outliers. METHODS: The comparison was made using 2012 national databases from the antibiotic surveillance network and prevalence study. HCF rankings according to each method were compared with Spearman's correlation coefficient. Analyses included the ABU from entire HCFs as well as according to type, clinical ward and by antibiotic class and specific molecule. RESULTS: A total of 1076 HCFs were included. HCF rankings were strongly correlated in the whole cohort. The correlation was stronger for HCFs with a higher number of beds or with a low or moderate proportion of acute care beds. ABU correlation between ABC or ABP was globally moderate or weak in specific wards. Furthermore, the two methods did not identify the same outliers, whichever HCF characteristics were analysed. Correlation between HCF ranking varied according to the antibiotic class. CONCLUSIONS: Both methods ranked HCFs similarly overall according to ABC or ABP; however, major differences were observed in ranking of clinical wards, antibiotic classes and detection of outliers. ABC and ABP are two markers of ABU that could be used as two complementary approaches to identify targets for improvement.

Pharmacists' role in antimicrobial stewardship and relationship with antibiotic consumption in hospitals: An observational multicentre study.

OBJECTIVES: Antimicrobial stewardship (AMS) teams around the world include pharmacists; however, their impact is relatively unknown. This study aimed to explore the relationship between pharmacists' actions and antibiotic consumption. METHODS: Hospital pharmacists involved in the French antibiotic consumption surveillance network (ATB-Raisin) were invited to participate in a retrospective observational multicentre study. Collected data were: the previous year's (2016) antibiotic consumption expressed in daily defined dose per 1000 patient-days; AMS measures, including pharmacist-specific actions; and use of a computerised prescription order entry (CPOE) system. Associations between antibiotic consumption and AMS measures were assessed by linear regression, after adjustment for hospital activities. RESULTS: Annual data for 2016 from 77 hospitals (7260000 bed-days in 24000 beds) were analysed. Pharmacists were involved in AMS programs in 73% of hospitals, and were the antibiotic advisor in 25%. Pharmaceutical review of prescriptions was organised in almost all hospitals (97%). The univariable analysis identified five measures associated with lower overall antibiotic consumption: CPOE use (if >80% of prescriptions or 100%), pharmaceutical review (if >80% of beds or 100%) and the antibiotic advisor being a pharmacist (P=0.04, P=0.004 and P=0.003, respectively). In the multivariable analysis, two explanatory variables were significantly and independently associated with a lower overall antibiotic consumption: the antibiotic advisor being a pharmacist and a pharmaceutical review covering all beds (-19.9% [-31.6%; -8.1%], P=0.002 and -18.3% [-34.0%; -2.6%], P=0.03, respectively). CONCLUSIONS: Antibiotic consumption was lower when the antibiotic advisor was a pharmacist and when the pharmaceutical team reviewed all prescriptions. These results highlight that actions initiated by pharmacists have a positive impact and should be supported.

Legal framework of antimicrobial stewardship in hospitals (LEASH): a European Society of Clinical Microbiology and Infectious Diseases (ESCMID) cross-sectional international survey.

Antimicrobial stewardship (AMS) is the cornerstone activity in the combat against antimicrobial resistance. In order to ensure sustainable deployment and development of AMS, a strategic and regulatory framework needs to be provided by national healthcare authorities. Experts from 32 European countries, Israel and Turkey were invited to participate in a cross-sectional internet-based survey from October 2016 to May 2017 on the legal framework and mandatory components (structures, activities) of AMS in hospitals, i.e. components required by legislation or regulations. We collected data from 25 countries and two regions (in countries with federal health administration). Laws regulating AMS existed in seven countries and one region. Other health ministry regulations were applicable in 13 countries and one region. National strategies and/or action plans approved by ministries of health were in place in 13 countries and one region. Conversely, five countries and one region had no regulation of AMS in hospitals. Funding for AMS in hospitals was provided in five countries and one region. Eight countries and one region reported mandatory AMS structures and activities complying with the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) structure, policy and practice indicators. In 10/27 cases, however, the mandatory AMS activities were not being fully carried out. The survey showed heterogeneous legal frameworks for AMS in hospitals, and in many countries it was even lacking. The situation may be critical in countries with poor control of antimicrobial use and resistance. Recent international initiatives calling on policy-makers to address the threat of antimicrobial resistance could yield improvement.

Higher third-generation cephalosporin prescription proportion is associated with lower probability of reducing carbapenem use: a nationwide retrospective study.

Background: The ongoing extended spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) pandemic has led to an increasing carbapenem use, requiring release of guidelines for carbapenem usage in France in late 2010. We sought to determine factors associated with changes in carbapenem use in intensive care units (ICUs), medical and surgical wards between 2009 and 2013. Methods: This ward-level multicentre retrospective study was based on data from French antibiotic and multidrug-resistant bacteria surveillance networks in healthcare facilities. Antibiotic use was expressed in defined daily doses per 1000 patient-days. Factors associated with the reduction in carbapenem use (yes/no) over the study period were determined from random-effects logistic regression model (493 wards nested within 259 healthcare facilities): ward characteristics (type, size…), ward antibiotic use (initial antibiotic use [i.e., consumption of a given antibiotic in 2009], initial antibiotic prescribing profile [i.e., proportion of a given antibiotic in the overall antibiotic consumption in 2009] and reduction in the use of a given antibiotic between 2009 and 2013) and regional ESBL-PE incidence rate in acute care settings in 2011. Results: Over the study period, carbapenem consumption in ICUs (n = 85), medical (n = 227) and surgical wards (n = 181) was equal to 73.4, 6.2 and 5.4 defined daily doses per 1000 patient-days, respectively. Release of guidelines was followed by a significant decrease in carbapenem use within ICUs and medical wards, and a slowdown in use within surgical wards. The following factors were independently associated with a higher probability of reducing carbapenem use: location in Eastern France, higher initial carbapenem prescribing profile and reductions in consumption of fluoroquinolones, glycopeptides and piperacillin/tazobactam. In parallel, factors independently associated with a lower probability of reducing carbapenem use were ICUs, ward size increase, wards of cancer centres, higher initial third-generation cephalosporin (3GC) prescribing profile and location in high-risk regions for ESBL-PE. Conclusions: Our study suggests that a decrease in 3GCs in the overall antibiotic use and the continuation of reduction in fluoroquinolone use, could allow reducing carbapenem use, given the well-demonstrated role of 3GCs and fluoroquinolones in the occurrence of ESBL-PE. Thus, antibiotic stewardship programs should target wards with higher 3GC prescription proportions to reduce them.

Identifying best practices across three countries: hospital antimicrobial stewardship in the United Kingdom, France, and the United States.

Rational antimicrobial use can be achieved through antimicrobial stewardship--a coordinated set of strategies designed to improve the appropriate use of antimicrobial agents. There are encouraging examples of antimicrobial stewardship programs from different parts of the world; however, the structure of these programs varies by hospital and country. In an effort to identify best practices in hospitals, we describe legislative requirements, antimicrobial stewardship program infrastructure, strategies and outcomes in 3 countries that have established programs--the United Kingdom, France, and the United States.

Antibiotics involved in the occurrence of antibiotic-resistant bacteria: a nationwide multilevel study suggests differences within antibiotic classes.

OBJECTIVES: To identify the antibiotics potentially the most involved in the occurrence of antibiotic-resistant bacteria from an ecological perspective in French healthcare facilities (HCFs). METHODS: This study was based on data from the French antimicrobial surveillance network (ATB-RAISIN, 2007-09). Antibiotics were expressed in defined daily doses per 1000 patient-days. Antibiotic-resistant bacteria were considered as count data adjusted for patient-days. These were third-generation cephalosporin (3GC)- and ciprofloxacin-resistant Escherichia coli, cefotaxime-resistant Enterobacter cloacae, methicillin-resistant Staphylococcus aureus and ceftazidime-, imipenem- and ciprofloxacin-resistant Pseudomonas aeruginosa. Three-level negative binomial regression models were built to take into account the hierarchical structure of data: level 1, repeated measures each year (count outcome, time, antibiotics); level 2, HCFs (type and size); and level 3, regions (geographical area). RESULTS: A total of 701 HCFs from 20 French regions and up to 1339 HCF-years were analysed. The use of ceftriaxone, but not of cefotaxime, was positively correlated with incidence rates of 3GC- and ciprofloxacin-resistant E. coli. In contrast, both 3GCs were positively correlated with the incidence rate of cefotaxime-resistant E. cloacae. Higher levels of use of ciprofloxacin and/or ofloxacin, but not of levofloxacin, were associated with higher incidence rates of 3GC- and ciprofloxacin-resistant E. coli, cefotaxime-resistant E. cloacae, methicillin-resistant S. aureus and ceftazidime- and ciprofloxacin-resistant P. aeruginosa. CONCLUSIONS: Our study suggests differences within antibiotic classes in promoting antibiotic resistance. We identified ceftriaxone, ciprofloxacin and ofloxacin as priority targets in public health strategies designed to reduce antibiotic use and antibiotic-resistant bacteria in French HCFs.

National multidrug-resistant bacteria (MDRB) surveillance in France through the RAISIN network: a 9 year experience.

BACKGROUND: In the mid-1990s, the prevalence rate of multidrug-resistant bacteria (MDRB) in French hospitals was high and control of MDRB spread then became a major priority in the national infection control programme (ICP). METHODS: To evaluate the impact of the ICP, a national coordination of MDRB surveillance was set up in 2002. Data were collected 3 months a year in healthcare facilities (HCFs) on a voluntary basis. All clinical specimens of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBLE) were prospectively included. Incidences per 1000 patient days (PDs) were calculated and trends in incidence from 2003 to 2010 were assessed. RESULTS: Participation in the surveillance increased from 478 HCFs in 2002 to 933 in 2010. In 2010, MRSA incidence was 0.40/1000 PDs: 1.14 in intensive care units (ICUs), 0.48 in acute care facilities (ACFs) and 0.27 in rehabilitation and long-term care facilities (RLTCFs). ESBLE incidence was 0.39/1000 PDs: 1.63 in ICUs, 0.46 in ACFs and 0.23 in RLTCFs. MRSA incidence significantly decreased from 0.72/1000 PDs in 2003 to 0.41/1000 PDs in 2010 (P<10(-3)); in contrast, ESBLE incidence significantly increased from 0.17/1000 PDs to 0.48/1000 PDs (P<10(-3)). The most prevalent ESBLE were Enterobacter aerogenes (34%) and Escherichia coli (25%) in 2003 and E. coli (60%) and Klebsiella pneumoniae (18%) in 2010. CONCLUSION: These results demonstrate the positive impact of the national ICP on MRSA rates. In contrast, ESBLE incidence, especially ESBL-producing E. coli, is increasing dramatically and represents a serious threat for hospitals and for the community that deserves specific control actions.

Antibiotic usage in south-western French hospitals: trends and association with antibiotic stewardship measures.

OBJECTIVES: French hospitals are urged by health authorities to develop antibiotic stewardship (ABS) programmes in order to improve antibiotic use and to decrease their consumption. We performed a longitudinal survey to describe ABS measures implementation and antibiotic use and to study relationships between ABS measures and trends in antibiotic use between 2005 and 2009. METHODS: Data on ABS, antibiotic use and activity were retrospectively collected by questionnaires sent to hospitals voluntarily participating in the south-western France network. ABS measures covered organization, resources, restrictive and persuasive actions. Antibiotic use was retrieved from pharmacy records and expressed as the number of defined daily doses/1000 patient-days according to national and WHO guidelines using 2009 defined daily dose values to monitor trends. Relationships between ABS measures and antibiotic use were studied by multivariate logistic regression. RESULTS: Between 2005 and 2009, the degree of implementation of ABS increased in the 74 participating hospitals. Antibiotic use remained stable, with variations according to hospital groups and antibiotic classes. In hospitals with more ABS measures, antibiotic use in general and fluoroquinolone use tended to remain stable or to decrease. Educational activities were associated with a decrease in fluoroquinolone use in the univariate analysis. In the multivariate analysis, practice audits and time dedicated by the antibiotic advisor were significantly associated with a decrease in total antibiotic use and fluoroquinolone use, respectively. CONCLUSIONS: This first longitudinal study, in 74 hospitals, showed that human resources and persuasive ABS measures, in the context of a multidisciplinary approach, are helpful in controlling total antibiotic and fluoroquinolone use.

Relationship between antibiotic consumption and antibiotic policy: an adjusted analysis in the French healthcare system.

OBJECTIVES: In France, the public reporting of antibiotic policies in hospitals has been mandatory since 2007. Consequently, all hospitals provide to the Ministry of Health an annual follow-up of antibiotic policy. This study aimed at identifying antibiotic policy measures related to a lower antibiotic consumption. METHODS: Data on antibiotic policy were extracted from the 2007 infection control indicator database in 977 acute hospitals providing antibiotic consumption data expressed in defined daily doses per 1000 patient-days (84% of all acute French hospitals). Policy data were collected using a standardized questionnaire including nine measures. From these measures, a composite score of 20 points and three policy sub-scores (organization, resource and action) were defined. Logistic regression analyses were performed using antibiotic consumption as dependent variables. Antibiotic consumption was categorized as low (≤ 75th percentile) or high (>75th percentile). All models were adjusted for hospital characteristics. RESULTS: Hospitals had an average score of 13.8 out of 20 points.The least common antibiotic policy measures were information technology support such as a computerized link between pharmacy, laboratory and wards (39%) and information technology support for prescription (33%). Multivariable analysis showed that a high resource score was significantly associated with lower antibiotic consumption. Among measures included in the resource score, information technology support for prescription was significantly associated with lower antibiotic consumption. The odds ratio was 0.55 (95% confidence interval 0.39-0.78). CONCLUSIONS: Information technology support for prescription could play an important role in controlling antibiotic consumption. Further investigations should study the type of computerized prescription system to implement in hospitals.

Antibiotic use in 530 French hospitals: results from a surveillance network at hospital and ward levels in 2007.

OBJECTIVES: Antibiotic use in French hospitals is among the highest in Europe. A study was carried out to describe antibiotic consumption for inpatients at hospital and at ward levels. METHODS: Data were voluntarily collected retrospectively by 530 hospitals accounting for approximately 40 million patient-days (PD) on the following: antibacterials for systemic use [J01 class of the WHO Anatomical Therapeutic Chemical (ATC) classification, defined daily doses (DDD) system, 2007], rifampicin and oral imidazole derivatives, expressed in number of DDD and number of PD in 2007. Consumption was expressed in DDD/1000 PD. RESULTS: Median antibiotic use ranged from 60 DDD/1000 PD in long-term care (LTC) and psychiatric hospitals to 633 DDD/1000 PD in teaching hospitals. Penicillins and beta-lactamase inhibitors combinations were the most frequently used antibiotics, accounting for 26% of total use in cancer hospitals to 40% in LTC/psychiatric hospitals. Glycopeptides and carbapenems were mostly used in cancer and teaching hospitals. Level of consumption and pattern of use differed according to clinical ward from 60 DDD/1000 PD in psychiatric wards up to 1466 DDD/1000 PD in intensive care units (ICUs). In medicine, surgery, ICU and rehabilitation wards, fluoroquinolones accounted for 13%-19% of the total use. CONCLUSIONS: This multicentre survey provided detailed information on antibiotic use in a large sample of hospitals and wards, allowing relevant comparisons and benchmarking. Analysis of consumption at the ward level should help hospitals to target practice audits to improve antibiotic use.