1
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Grohs P, Vilfaillot A, Zahar JR, Barbut F, Frange P, Casetta A, Moulin V, Lawrence C, Baune P, Bourgeois C, Bouffier A, Laussucq C, Sienzonit L, Picard S, Podglajen I, Kassis-Chikhani N. Faecal carriage of multidrug-resistant bacteria and associated risk factors: results from a point prevalence study. J Antimicrob Chemother 2022; 77:2667-2678. [PMID: 36031727 DOI: 10.1093/jac/dkac289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/01/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Since 2003, incidences of carbapenemase-producing Gram-negative bacilli (CP-GNB) and vancomycin-resistant Enterococcus faecium (VRE) have steadily increased in France. We therefore conducted a point prevalence study to estimate carriage rates of CP-GNB, VRE and ESBL-producing Enterobacterales (ESBL-PE) and associated risk factors. METHODS Between September 2019 and January 2020, all inpatients hospitalized on a given day in 11 teaching hospitals in the Paris urban area were eligible. Patient interviews and rectal swab screening results were recorded by dedicated nurses. The swabs were plated onto selective chromogenic media and processed using the GeneXpert® system. RESULTS Of 2396 patients, 364 (15.2%) yielded at least one multiresistant bacterial isolate, including 29 CP-GNB carriers (1.2%), 13 VRE carriers (0.5%) and 338 ESBL-PE carriers (14%). In 15 patients (4.4% of ESBL-PE carriers and 36.6% of CP-GNB/VRE carriers), concomitant CP-GNB/VRE and ESBL-PE carriage was observed. In 7/29 CP-GNB and 7/13 VRE carriers, carbapenemase production and vanA in the screening samples was only detected with Xpert® tests. The OXA-48 gene was predominant in 13/34 CP-GNB isolates from 29 carriers. From the 338 ESBL-PE carriers, 372 isolates were recovered, mainly Escherichia coli (61.2%). Among 379 children, 1.1% carried a CP-GNB/VRE strain, and 12.4% carried an ESBL strain. Previous hospitalization outside mainland France, previous antimicrobial treatment and previous ESBL-PE carriage were the main risk factors associated with CP-GNB and/or VRE carriage. CONCLUSIONS The low CP-GNB and VRE prevalence likely reflects the French policy to limit intrahospital spread of CP-GNB and VRE strains.
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Affiliation(s)
- Patrick Grohs
- Laboratoire de microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Aurélie Vilfaillot
- Unité de Recherche Clinique, Hôpital Européen Georges Pompidou, Paris, France.,INSERM Centre d'Investigation Clinique 1418 (CIC1418), Paris, France
| | - Jean Ralph Zahar
- Equipe Opérationnelle en Hygiène, Hôpitaux Avicenne, Bobigny/Jean Verdier, Bondy/René Muret, Sevran, France
| | - Frédéric Barbut
- Equipe Opérationnelle en Hygiène, Hôpital St Antoine, Paris, France
| | - Pierre Frange
- Equipe Opérationnelle en Hygiène, Laboratoire de microbiologie clinique, Hôpital Necker - Enfants malades, Paris, France
| | - Anne Casetta
- Equipe Opérationnelle en Hygiène, Hôpital Cochin, Paris, France
| | - Véronique Moulin
- Equipe Opérationnelle en Hygiène, Hôpitaux Corentin Celton/Vaugirard, Issy-les-Moulineaux, France
| | - Christine Lawrence
- Equipe Opérationnelle en Hygiène, GHU Paris-Saclay site R, Poincaré, APHP, Garches, France
| | - Patricia Baune
- Equipe Opérationnelle en Hygiène, Hôpital Paul Brousse, Villejuif, France
| | - Cléo Bourgeois
- Unité de Recherche Clinique, Hôpital Européen Georges Pompidou, Paris, France.,INSERM Centre d'Investigation Clinique 1418 (CIC1418), Paris, France
| | - Axel Bouffier
- Unité de Recherche Clinique, Hôpital Européen Georges Pompidou, Paris, France.,INSERM Centre d'Investigation Clinique 1418 (CIC1418), Paris, France
| | - Claudine Laussucq
- Laboratoire de microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Lydia Sienzonit
- Laboratoire de microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Simon Picard
- Laboratoire de microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Isabelle Podglajen
- Laboratoire de microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Najiby Kassis-Chikhani
- Equipe Opérationnelle en Hygiène, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
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2
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Roux J, Nekkab N, Colomb-Cotinat M, Astagneau P, Crépey P. Time-series modelling for the quantification of seasonality and forecasting antibiotic-resistant episodes: application to carbapenemase-producing Enterobacteriaceae episodes in France over 2010-20. J Antimicrob Chemother 2021; 76:226-232. [PMID: 32929455 DOI: 10.1093/jac/dkaa388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/17/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) cause resistant healthcare-associated infections that jeopardize healthcare systems and patient safety worldwide. The number of CPE episodes has been increasing in France since 2009, but the dynamics are still poorly understood. OBJECTIVES To use time-series modelling to describe the dynamics of CPE episodes from August 2010 to December 2016 and to forecast the evolution of CPE episodes for the 2017-20 period. METHODS We used time series to analyse CPE episodes from August 2010 to November 2016 reported to the French national surveillance system. The impact of seasonality was quantified using seasonal-to-irregular ratios. Seven time-series models and three ensemble stacking models (average, convex and linear stacking) were assessed and compared with forecast CPE episodes during 2017-20. RESULTS During 2010-16, 3559 CPE episodes were observed in France. Compared with the average yearly trend, we observed a 30% increase in the number of CPE episodes in the autumn. We noticed a 1 month lagged seasonality of non-imported episodes compared with imported episodes. Average stacking gave the best forecasts and predicted an increase during 2017-20 with a peak up to 345 CPE episodes (95% prediction interval = 124-1158, 80% prediction interval = 171-742) in September 2020. CONCLUSIONS The observed seasonality of CPE episodes sheds light on potential factors associated with the increased frequency of episodes, which need further investigation. Our model predicts that the number of CPE episodes will continue to rise in the coming years in France, mainly due to local dissemination, associated with bacterial carriage by patients in the community, which is becoming an immediate challenge with regard to outbreak control.
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Affiliation(s)
- Jonathan Roux
- Univ Rennes, EHESP, REPERES (Pharmacoepidemiology and health services research) - EA 7449, Rennes, France
| | - Narimane Nekkab
- Laboratoire MESuRS, Conservatoire National des Arts et Métiers, Paris, France.,Institut Pasteur, Cnam, Unité PACRI, Paris, France
| | | | - Pascal Astagneau
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.,Centre de prévention des infections associées aux soins, Paris, France
| | - Pascal Crépey
- Univ Rennes, EHESP, REPERES (Pharmacoepidemiology and health services research) - EA 7449, Rennes, France
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3
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Nekkab N, Crépey P, Astagneau P, Opatowski L, Temime L. Assessing the role of inter-facility patient transfer in the spread of carbapenemase-producing Enterobacteriaceae: the case of France between 2012 and 2015. Sci Rep 2020; 10:14910. [PMID: 32913244 PMCID: PMC7483561 DOI: 10.1038/s41598-020-71212-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/31/2020] [Indexed: 11/09/2022] Open
Abstract
The spread of carbapenemase-producing Enterobacteriaceae (CPE) in healthcare settings is a major public health threat that has been associated with cross-border and local patient transfers between healthcare facilities. Since the impact of transfers on spread may vary, our study aimed to assess the contribution of a patient transfer network on CPE incidence and spread at a countrywide level, with a case study of France from 2012 to 2015. Our results suggest a transition in 2013 from a CPE epidemic sustained by internationally imported episodes to an epidemic sustained by local transmission events through patient transfers. Incident episodes tend to occur within close spatial distance of their potential infector. We also observe an increasing frequency of multiple spreading events, originating from a limited number of regional hubs. Consequently, coordinated prevention and infection control strategies should focus on transfers of carriers of CPE to reduce regional and inter-regional transmission.
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Affiliation(s)
- Narimane Nekkab
- Laboratoire MESuRS, Conservatoire National Des Arts Et Métiers, Paris, France. .,Unité PACRI, Institut Pasteur, Conservatoire National Des Arts Et Métiers, Paris, France. .,EHESP, REPERES (Recherche en pharmaco-épidémiologie et recours aux soins) - EA 7449, University Rennes, Rennes, France.
| | - Pascal Crépey
- EHESP, REPERES (Recherche en pharmaco-épidémiologie et recours aux soins) - EA 7449, University Rennes, Rennes, France
| | - Pascal Astagneau
- Centre régional de prévention Des Infections associées Aux Soins (CPias), Paris, France.,INSERM, Institut Pierre Louis D'Epidémiologie Et de Santé Publique, Sorbonne Université, 75013, Paris, France
| | - Lulla Opatowski
- UMR 1181, «Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases» (B2PHI), University Versailles Saint Quentin en Yvelines, Saint Quentin en Yvelines, France.,Pharmacoepidemiology and Infectious Diseases Unit, Institut Pasteur, Paris, France.,Inserm UMR 1181 (B2PHI), Paris, France
| | - Laura Temime
- Laboratoire MESuRS, Conservatoire National Des Arts Et Métiers, Paris, France.,Unité PACRI, Institut Pasteur, Conservatoire National Des Arts Et Métiers, Paris, France
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4
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Hereng O, Dinh A, Salomon J, Davido B. Evaluation in general practice of the patient's feelings about a recent hospitalization and isolation for a multidrug-resistant infection. Am J Infect Control 2019; 47:1077-1082. [PMID: 31047690 DOI: 10.1016/j.ajic.2019.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/14/2019] [Accepted: 03/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Isolation precautions used against multidrug-resistant (MDR) organisms are responsible for many emotional side effects. We evaluated patient's feeling after a hospitalization for an MDR infection. METHODS We conducted a qualitative study that included 11 interviews from August 2017 to June 2018. We used phenomenology and verbatim transcription analysis was performed using NVivo software. Patients reported mainly negative feelings. Among them, 4 main themes were expressed: a desire to "be free from carriage," self-questioning regarding its nosocomial origin, the reduction of the therapeutic arsenal, and the expression of many fears especially relapse. RESULTS For most of the participants (n = 6/11), the type of bacteria that colonized their digestive tract was precisely known including the MDR characteristics of the infection. Participants were convinced that the infection was strongly linked to the hospital and considered it as nosocomial that led to anxiety, especially regarding the origin of the infection and the absence of formal source of infection. CONCLUSIONS MDR infections are negatively impacting patient's lived experience even after hospital discharge, partly owing to prior implementation of isolation precautions. We need to improve communication between specialists and general practitioners to reassure the patient and his surroundings regarding the anxiety resulting from such hospitalization.
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5
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Decousser JW, Woerther PL, Soussy CJ, Fines-Guyon M, Dowzicky MJ. The tigecycline evaluation and surveillance trial; assessment of the activity of tigecycline and other selected antibiotics against gram-positive and gram-negative pathogens from France collected between 2004 and 2016. Antimicrob Resist Infect Control 2018; 7:68. [PMID: 29876099 PMCID: PMC5977734 DOI: 10.1186/s13756-018-0360-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/21/2018] [Indexed: 01/25/2023] Open
Abstract
Background A high level of antibiotic consumption in France means antimicrobial resistance requires rigorous monitoring. The Tigecycline Evaluation and Surveillance Trial (T.E.S.T.) is a global surveillance study that monitors the in vitro activities of tigecycline and a panel of marketed antimicrobials against clinically important Gram-positive and Gram-negative isolates. Methods Annually clinically relevant strains were prospectively included in the survey through a national network of hospital-based laboratories. MICs were determined locally by broth microdilution using CLSI guidelines. Antimicrobial susceptibility was assessed using European Committee on Antimicrobial Susceptibility Testing breakpoints. Results Thirty-three centres in France collected 26,486 isolates between 2004 and 2016. Enterococcus species were highly susceptible (≥94.4%) to linezolid, tigecycline and vancomycin. Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA), were susceptible (≥99.9%) to tigecycline, vancomycin and linezolid. Between 2004 and 2016, 27.7% of S. aureus isolates were MRSA, decreasing from 28.0% in 2013 to 23.5% in 2016. Susceptibility of Streptococcus pneumoniae isolates was 100% to vancomycin, and > 99.0% to levofloxacin, linezolid and meropenem; 3.0% were penicillin-resistant S. pneumoniae (100% susceptibility to vancomycin and linezolid). Escherichia coli isolates were highly susceptible (> 98.0%) to meropenem, tigecycline and amikacin. The rate of extended-spectrum β-lactamase (ESBL) positive E. coli increased from 2004 (3.0%), but was stable from 2012 (23.1%) to 2016 (19.8%). Susceptibility of Klebsiella pneumoniae isolates was 99.4% to meropenem and 96.5% to amikacin. The proportion of ESBL-positive K. pneumoniae isolates increased from 2004 (7.5%) to 2012 (33.3%) and was highest in 2016 (43.6%). A. baumannii was susceptible to meropenem (81.0%) and amikacin (74.9%); none of the 6.2% of isolates identified as multidrug-resistant (MDR) was susceptible to any agents with breakpoints. P. aeruginosa isolates were most susceptible to amikacin (88.5%), and MDR rates were 13.6% in 2013 to 4.0% in 2016; susceptibility of MDR isolates was no higher than 31.4% to amikacin. Conclusions Rates of MRSA decreased slowly, while rates of ESBL-positive E. coli and K. pneumoniae increased from 2004 to 2016. Susceptibility of Gram-positive isolates to vancomycin, tigecycline, meropenem and linezolid was well conserved, as was susceptibility of Gram-negative isolates to tigecycline and meropenem. The spread of MDR non-fermentative isolates must be carefully monitored.
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6
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Gautier G, Guillard T, Podac B, Bercot B, Vernet-Garnier V, de Champs C. Detection of different classes of carbapenemases: Adaptation and assessment of a phenotypic method applied to Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii, and proposal of a new algorithm. J Microbiol Methods 2018; 147:26-35. [PMID: 29486226 DOI: 10.1016/j.mimet.2018.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/22/2018] [Accepted: 02/22/2018] [Indexed: 10/18/2022]
Abstract
A new phenotypic method for detecting carbapenemases has been adapted (assembling of two MAST® kits, including one that contains faropenem to which a temocillin disk has been added) then assessed using 101 bacterial strains (Enterobacteriaceae with assays on Pseudomonas aeruginosa and Acinetobacter baumannii) including 62 which produce genetically identified carbapenemases. Concerning Carbapenemase-Producing Enterobacteriaceae (CPE), there is 100% sensitivity for Klebsiella pneumoniae carbapenemase (KPC, Ambler class A) and OXA-48 (Ambler class D), and 91% for metallo-beta-lactamase (MBL, Ambler class B), with a 97% sensitivity for all carbapenemases, with a specificity of 100%. The test is also efficient for detecting Pseudomonas aeruginosa carbapenemases (sensitivity between 82 and 100% and 100% specificity). The major innovation is the combined use of faropenem and temocillin for reliable detection (excellent performance with 100% sensitivity and specificity) of OXA-48. This study has led to the development of a new algorithm to detect the different classes of carbapenemases, for first-line diagnosis, by combining this modified MAST® test with immunochromatographic methods and molecular biology techniques.
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Affiliation(s)
- Guillaume Gautier
- Bacteriology-Virology-Hygiene Department, Bacteriology Unit, Robert Debré University Hospital, avenue du général Koenig, 51092 Reims Cedex, France; Medical Biology Laboratory, Microbiology Department, Bacteriology Unit, William Morey General Hospital, 4 rue capitaine Drillien, 71321 Chalon-sur-Saône Cedex, France.
| | - Thomas Guillard
- Bacteriology-Virology-Hygiene Department, Bacteriology Unit, Robert Debré University Hospital, avenue du général Koenig, 51092 Reims Cedex, France; Research Unit EA 4687 SFR Cap-Santé (FED 4231), Acquired Resistance in Enterobacteriaceae, Reims Champagne-Ardenne University, 51 rue Cognacq-Jay, 51095 Reims Cedex, France.
| | - Bianca Podac
- Medical Biology Laboratory, Microbiology Department, Bacteriology Unit, William Morey General Hospital, 4 rue capitaine Drillien, 71321 Chalon-sur-Saône Cedex, France.
| | - Béatrice Bercot
- AP-HP, Saint-Louis-Lariboisière-Fernand-Widal Hospital Group, Laboratory of Bacteriology, associated for the National Reference Center for gonococci, 1 avenue Claude Vellefaux, 75010 Paris, France; IAME, UMR 1137, INSERM, Paris Diderot University, 16 rue Henri Huchard, 75890 Paris Cedex 18, France.
| | - Véronique Vernet-Garnier
- Bacteriology-Virology-Hygiene Department, Bacteriology Unit, Robert Debré University Hospital, avenue du général Koenig, 51092 Reims Cedex, France; Research Unit EA 4687 SFR Cap-Santé (FED 4231), Acquired Resistance in Enterobacteriaceae, Reims Champagne-Ardenne University, 51 rue Cognacq-Jay, 51095 Reims Cedex, France.
| | - Christophe de Champs
- Bacteriology-Virology-Hygiene Department, Bacteriology Unit, Robert Debré University Hospital, avenue du général Koenig, 51092 Reims Cedex, France; Research Unit EA 4687 SFR Cap-Santé (FED 4231), Acquired Resistance in Enterobacteriaceae, Reims Champagne-Ardenne University, 51 rue Cognacq-Jay, 51095 Reims Cedex, France.
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7
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Potron A, Bernabeu S, Cuzon G, Pontiès V, Blanchard H, Seringe E, Naas T, Nordmann P, Dortet L. Analysis of OXA-204 carbapenemase-producing Enterobacteriaceae reveals possible endoscopy-associated transmission, France, 2012 to 2014. Euro Surveill 2017; 22:17-00048. [PMID: 29233256 PMCID: PMC5727592 DOI: 10.2807/1560-7917.es.2017.22.49.17-00048] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OXA-48-like beta-lactamase producing bacteria are now endemic in several European and Mediterranean countries. Among this carbapenemase family, the OXA-48 and OXA-181 variants predominate, whereas other variants such as OXA-204 are rarely reported. Here, we report the molecular epidemiology of a collection of OXA-204-positive enterobacterial isolates (n = 29) recovered in France between October 2012 and May 2014. This study describes the first outbreak of OXA-204-producing Enterobacteriaceae in Europe, involving 12 isolates of an ST90 Escherichia coli clone and nine isolates of an ST147 Klebsiella pneumoniae clone. All isolates co-produced the cephalosporinase CMY-4, and 60% of them co-produced the extended-spectrum beta-lactamase CTX-M-15. The blaOXA-204 gene was located on a 150-kb IncA/C plasmid, isolated from various enterobacterial species in the same patient, indicating a high conjugative ability of this genetic vehicle.
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Affiliation(s)
- Anaïs Potron
- National Reference Centre for Antibiotic Resistance, (division of carbapenemase-producing Enterobacteriaceae), Le Kremlin-Bicêtre, France,Department of Bacteriology, University Hospital of Besançon, Université of Franche-Comté, Besançon, France
| | - Sandrine Bernabeu
- National Reference Centre for Antibiotic Resistance, (division of carbapenemase-producing Enterobacteriaceae), Le Kremlin-Bicêtre, France,Bacteriology-Hygiene Unit, Assistance Publique/Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France,EA7361 “Structure, Dynamic, Function and Expression of Broad Spectrum beta-Lactamases”, Paris-Sud University, LabEx Lermit, Faculty of Medicine, Le Kremlin-Bicêtre, France,Joint Research Unit EERA “Evolution and Ecology of Resistance to Antibiotics,” Institut Pasteur-APHP-Université Paris-Sud, Paris, France
| | - Gaëlle Cuzon
- National Reference Centre for Antibiotic Resistance, (division of carbapenemase-producing Enterobacteriaceae), Le Kremlin-Bicêtre, France,Bacteriology-Hygiene Unit, Assistance Publique/Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France,EA7361 “Structure, Dynamic, Function and Expression of Broad Spectrum beta-Lactamases”, Paris-Sud University, LabEx Lermit, Faculty of Medicine, Le Kremlin-Bicêtre, France,Joint Research Unit EERA “Evolution and Ecology of Resistance to Antibiotics,” Institut Pasteur-APHP-Université Paris-Sud, Paris, France
| | - Valérie Pontiès
- Santé Publique France, The French Public Health Agency, Saint-Maurice, France
| | - Hervé Blanchard
- Regional Coordinating Centre for Nosocomial Infection Control (C-CLIN Paris Nord), Paris, France
| | - Elise Seringe
- Regional Coordinating Centre for Nosocomial Infection Control (C-CLIN Paris Nord), Paris, France
| | - Thierry Naas
- National Reference Centre for Antibiotic Resistance, (division of carbapenemase-producing Enterobacteriaceae), Le Kremlin-Bicêtre, France,Bacteriology-Hygiene Unit, Assistance Publique/Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France,EA7361 “Structure, Dynamic, Function and Expression of Broad Spectrum beta-Lactamases”, Paris-Sud University, LabEx Lermit, Faculty of Medicine, Le Kremlin-Bicêtre, France,Joint Research Unit EERA “Evolution and Ecology of Resistance to Antibiotics,” Institut Pasteur-APHP-Université Paris-Sud, Paris, France
| | - Patrice Nordmann
- Emerging Antibiotic Resistance Unit, Medical and Molecular Microbiology, Department of Medicine, University of Fribourg, Fribourg, Switzerland,Institut National de la Santé et de la Recherche Médicale (INSERM) European Unit (LEA Paris, IAME, France), University of Fribourg, Switzerland,National Reference Centre for Emerging Antibiotic Resistance, Fribourg, Switzerland,Institute for Microbiology, University hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent Dortet
- National Reference Centre for Antibiotic Resistance, (division of carbapenemase-producing Enterobacteriaceae), Le Kremlin-Bicêtre, France,Bacteriology-Hygiene Unit, Assistance Publique/Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France,EA7361 “Structure, Dynamic, Function and Expression of Broad Spectrum beta-Lactamases”, Paris-Sud University, LabEx Lermit, Faculty of Medicine, Le Kremlin-Bicêtre, France,Joint Research Unit EERA “Evolution and Ecology of Resistance to Antibiotics,” Institut Pasteur-APHP-Université Paris-Sud, Paris, France
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8
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Mellouk FZ, Bakour S, Meradji S, Al-Bayssari C, Bentakouk MC, Zouyed F, Djahoudi A, Boutefnouchet N, Rolain JM. First Detection of VIM-4-Producing Pseudomonas aeruginosa and OXA-48-Producing Klebsiella pneumoniae in Northeastern (Annaba, Skikda) Algeria. Microb Drug Resist 2017; 23:335-344. [DOI: 10.1089/mdr.2016.0032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Fatma Zohra Mellouk
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), UM 63, CNRS 7278, IRD 198, INSERM 1095, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille-Université, Marseille, France
- Laboratoire de Biochimie et de Microbiologie Appliquée, Département de Biochimie, Université Badji Mokhtar-Annaba, Annaba, Algérie
| | - Sofiane Bakour
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), UM 63, CNRS 7278, IRD 198, INSERM 1095, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille-Université, Marseille, France
| | - Sameh Meradji
- Laboratoire de Biochimie et de Microbiologie Appliquée, Département de Biochimie, Université Badji Mokhtar-Annaba, Annaba, Algérie
| | - Charbel Al-Bayssari
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), UM 63, CNRS 7278, IRD 198, INSERM 1095, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille-Université, Marseille, France
| | | | - Fatiha Zouyed
- Laboratoire central d'EPH EL Hadjar, Annaba, Algérie
| | | | - Nafissa Boutefnouchet
- Laboratoire de Biochimie et de Microbiologie Appliquée, Département de Biochimie, Université Badji Mokhtar-Annaba, Annaba, Algérie
| | - Jean Marc Rolain
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), UM 63, CNRS 7278, IRD 198, INSERM 1095, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille-Université, Marseille, France
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9
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Molecular epidemiology of carbapenemase-producing Enterobacteriaceae in a primary care hospital in Japan, 2010–2013. J Infect Chemother 2017; 23:224-229. [DOI: 10.1016/j.jiac.2016.12.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 12/12/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
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10
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Popescu C, Popescu GA, Dorobăț O, Rafilă A, Tănase D, Mikula C, Weissensteiner G, Huhulescu S. OXA-48-Carbapenemase-Producing Klebsiella pneumoniae infections - the first cases diagnosed in Romanian National Institute of Infectious Diseases. REV ROMANA MED LAB 2017. [DOI: 10.1515/rrlm-2017-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
We report first description of clinical cases of OXA-48 carbapenemase-producing Klebsiella pneumoniae originating from patients hospitalized in the most important Infectious Diseases Hospital from Romania, between December 2012 and March 2013. All strains were isolated from patients who were previously admitted in surgical wards. None of the patients had been admitted in a hospital outside of Romania.
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Affiliation(s)
- Cristina Popescu
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Gabriel Adrian Popescu
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Olga Dorobăț
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Alexandru Rafilă
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Diana Tănase
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Claudia Mikula
- Austrian Agency for Health and Food Safety, Vienna, Austria
- Institute for Medical Microbiology and Hygiene, Graz, Austria
| | - Gudrun Weissensteiner
- Austrian Agency for Health and Food Safety, Vienna, Austria
- Institute for Medical Microbiology and Hygiene, Graz, Austria
| | - Steliana Huhulescu
- Austrian Agency for Health and Food Safety, Vienna, Austria
- Institute for Medical Microbiology and Hygiene, Vienna, Austria
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Nosocomial Outbreak of OXA-48-Producing Klebsiella pneumoniae in a Chinese Hospital: Clonal Transmission of ST147 and ST383. PLoS One 2016; 11:e0160754. [PMID: 27490695 PMCID: PMC4973971 DOI: 10.1371/journal.pone.0160754] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 07/25/2016] [Indexed: 02/05/2023] Open
Abstract
Background In China, the spread and outbreak of OXA-48-producing Enterobacteriaceae remains largely unknown. Methods OXA-48-producing isolates were analyzed for genetic relatedness by pulsed-field gel electrophoresis (PFGE), antimicrobial susceptibility by E-test, and sequence type (ST) by multilocus sequence typing. S1-PFGE and southern blotting were used for plasmid profiling, and PCR and subsequent sequencing were performed to determine the genetic environment of blaOXA-48 gene. Results In total, 37 non-duplicated OXA-48-producing K. pneumoniae (OXAKp) isolates were recovered. From December 2013 to August 2014, an outbreak was observed at a respiratory ICU. The 37 isolates of K. pneumoniae were categorized into four PFGE types (A, B, C, and D). The predominant strains associated with the outbreak were strains with PFGE type A and B, which belonged to ST383 and ST147, respectively. Plasmid sequencing revealed that the blaOXA-48-carrying plasmid is 69,069 bp in length and belongs to the IncL/M incompatibility group. Sequence analysis revealed that the IS1999 element was located upstream of the blaOXA-48 gene and was truncated by IS1R. Conclusions In this study, the dissemination and outbreak of OXAKp isolates were clonal, and ST147 and ST383 K. pneumoniae were the predominant clones that were associated with the outbreak. Meanwhile, the horizontal transfer of plasmids potentially mediate the spread of blaOXA-48 gene between different K. pneumoniae strains.
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Molecular Characterization of Carbapenem-Nonsusceptible Enterobacterial Isolates Collected during a Prospective Interregional Survey in France and Susceptibility to the Novel Ceftazidime-Avibactam and Aztreonam-Avibactam Combinations. Antimicrob Agents Chemother 2015; 60:215-21. [PMID: 26482307 DOI: 10.1128/aac.01559-15] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/13/2015] [Indexed: 11/20/2022] Open
Abstract
An interregional surveillance program was conducted in the northwestern part of France to determine the prevalence of carbapenem-nonsusceptible Enterobacteriaceae (CNSE) isolates and their susceptibility to ceftazidime-avibactam and aztreonam-avibactam combinations. Nonduplicate CNSE clinical isolates were prospectively collected from six hospitals between June 2012 and November 2013. MICs of ceftazidime and aztreonam, alone or combined with a fixed concentration of avibactam (4 μg/ml), and those of carbapenems (comparator agents) were determined. MICs of ertapenem in combination with phenylalanine arginine-naphthylamide dihydrochloride (PAβN) were also determined to assess active efflux. Genes encoding carbapenemases, plasmid-mediated AmpC enzymes, extended-spectrum β-lactamases (ESBLs), and major outer membrane proteins (OMPs) were amplified and sequenced. OMPs were also extracted for SDS-PAGE analysis. Among the 139 CNSE isolates, mainly Enterobacter spp. and Klebsiella pneumoniae, 123 (88.4%) were ertapenem nonsusceptible, 12 (8.6%) exhibited reduced susceptibility to all carbapenems, and 4 Proteeae isolates (2.9%) were resistant to imipenem. Carbapenemase production was detected in only two isolates (producing OXA-48 and IMI-3). In contrast, OMP deficiency, in association with AmpCs and/or ESBLs (mainly CTX-M-9, SHV-12, and CTX-M-15), was largely identified among CNSE isolates. The ceftazidime-avibactam and aztreonam-avibactam combinations exhibited potent activity against CNSE isolates (MIC50/MIC90, 1/1 μg/ml and 0.5/0.5 μg/ml, respectively) compared to that of ceftazidime and aztreonam alone (MIC50/MIC90, 512/512 μg/ml and 128/512 μg/ml, respectively). This study reveals the in vitro activity of ceftazidime-avibactam and aztreonam-avibactam combinations against a large collection of porin-deficient enterobacterial isolates that are representative of the CNSE recovered in the northern part of France.
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13
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Bassetti M, Pecori D, Sibani M, Corcione S, De Rosa FG. Epidemiology and Treatment of MDR Enterobacteriaceae. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0065-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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14
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Delory T, Seringe E, Antoniotti G, Novakova I, Goulenok C, Paysant I, Boyer S, Carbonne A, Naas T, Astagneau P. Prolonged delay for controlling KPC-2-producing Klebsiella pneumoniae outbreak: the role of clinical management. Am J Infect Control 2015; 43:1070-5. [PMID: 26174583 DOI: 10.1016/j.ajic.2015.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 05/12/2015] [Accepted: 05/12/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak. METHODS An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method. RESULTS The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members. CONCLUSION Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.
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Affiliation(s)
- T Delory
- Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France
| | - E Seringe
- Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France.
| | | | - I Novakova
- Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France
| | | | - I Paysant
- Groupe Générale de Santé, Paris, France
| | - S Boyer
- Groupe Générale de Santé, Paris, France; Laboratoire Bactériologie Novescia, Paris, France
| | - A Carbonne
- Office of Quality and Safety in Care, Direction Générale de l'Offre de Soins-Bureau PF2-Ministère de la Santé, des affaires sociales et du droit des femmes, Paris, France
| | - T Naas
- Department of Bacteriology, APHP, Laboratoire de Bactériologie-Virologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France; Centre National de Référence de la résistance aux antibiotiques, Le Kremlin Bicêtre, France; EA7361, Faculté de Médecine, Université Paris Sud, France
| | - P Astagneau
- Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France; Department of Epidemiology, Ecole des Hautes Etudes en Santé Publique/Universités Sorbonne Paris Cité, Paris, France
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Arnaud I, Maugat S, Jarlier V, Astagneau P. Ongoing increasing temporal and geographical trends of the incidence of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in France, 2009 to 2013. Euro Surveill 2015; 20:30014. [DOI: 10.2807/1560-7917.es.2015.20.36.30014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 08/13/2015] [Indexed: 11/20/2022] Open
Abstract
Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are a major focus of multidrug-resistant organisms (MRO) surveillance programmes in France. To describe the temporal and geographical trends of these pathogens, we conducted an epidemiological study based on data extracted from the nationwide MRO surveillance network from 2009 to 2013. During this time, the incidence of ESBL-E infections in French hospitals increased by 73%, from 0.35 to 0.60 per 1,000 patient days (PD) (p < 0.001) and ESBL-E bacteraemia by 77%, from 0.03 to 0.05 per 1,000 PD (p < 0.001). The incidence of ESBL-E infections was higher in intensive-care units (1.62 to 2.44 per 1,000 PD (p < 0.001)) than in recovery and long-term care facilities (0.20 to 0.31 per 1,000 PD (p < 0.001)). Escherichia coli was the most frequent extended-spectrum beta-lactamase-producing (ESBL) pathogen, representing 59% (26,238/44,425) of all ESBL isolates, followed by Klebsiella pneumoniae (20%; 8,856/44,425) in 2013. The most frequent infection was urinary tract infection, for all species. The incidence of ESBL-E varied by region but showed an upward trend overall. Reinforcement of control measures for halting the spread of such MRO is crucial.
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Affiliation(s)
- Isabelle Arnaud
- Regional Coordinating Centre for Healthcare-Associated Infections Control (CClin Paris – Nord), Paris, France
| | - Sylvie Maugat
- French Institute for Public Health Surveillance (Institut de Veille Sanitaire, InVS), Saint Maurice, France
| | - Vincent Jarlier
- AP-HP (Assistance Publique - Hôpitaux de Paris), Paris, France
| | - Pascal Astagneau
- Regional Coordinating Centre for Healthcare-Associated Infections Control (CClin Paris – Nord), Paris, France
- École des hautes études en santé publique (EHESP) Sorbonne Paris Cité University, Paris, France
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Pailhoriès H, Lemarié C, Kempf M, Mahaza C, Joly-Guillou ML, Eveillard M. Retrospective detection of the hidden spread of OXA-48-producing Klebsiella pneumoniae in a French teaching hospital. J Infect 2015; 71:407-9. [DOI: 10.1016/j.jinf.2015.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/09/2015] [Indexed: 11/16/2022]
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17
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Control of emerging extensively drug-resistant organisms (eXDRO) in France: a survey among infection preventionists from 286 healthcare facilities. Eur J Clin Microbiol Infect Dis 2015; 34:1615-20. [PMID: 25957988 DOI: 10.1007/s10096-015-2396-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
Abstract
We performed a multicenter survey in May-June 2012 to assess strategies in preventing the spread of emerging extensively drug-resistant organisms (eXDRO), including glycopeptide-resistant enterococci and carbapenemase-producing Enterobacteriaceae, in a convenient sample of French healthcare facilities (HCFs). The collected data included organization and measures to: (1) identify patients at risk for carrying eXDRO, (2) investigate and control sporadic cases or outbreaks, and (3) describe prior 2010-2012 episodes with one or more colonized patients. Of the 286 participating HCFs, 163 (57 %) and 134 (47 %) reported having a specific procedure to detect repatriates or patients hospitalized in foreign countries within the last year, respectively. Among the 97 HCFs with prior at-risk patient management experience, contact precautions, hospitalization in a single room, and screening for eXDRO carriage were quasi-systematically performed (n = 92/97, 95 %). The alleged time between admission and alert ranged from 24 to 48 h after the patient's admission; 203 (71 %) HCFs recommended obtaining three successive negative screening samples to declare a patient free of eXDRO colonization. During the last two years, 64 HCFs (23 %) had to manage at least one eXDRO case, with a total of 20 outbreaks with more than one secondary case. This first national survey shows that French HCFs were not totally ready to control eXDRO spread in 2012. Their previous experiences and capacities in controlling eXDRO outbreaks are quite heterogeneous from one hospital to another. Further researches are needed in order to understand the constraints in applying national guidance.
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18
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Lepelletier D, Berthelot P, Lucet JC, Fournier S, Jarlier V, Grandbastien B. French recommendations for the prevention of 'emerging extensively drug-resistant bacteria' (eXDR) cross-transmission. J Hosp Infect 2015; 90:186-95. [PMID: 25986165 DOI: 10.1016/j.jhin.2015.04.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/07/2015] [Indexed: 11/15/2022]
Abstract
Controlling the spread of multi- or extensively drug-resistant bacteria (MDR or XDR) includes a dual strategy for reducing antibiotic prescriptions and preventing their spread from patient carriers. Standard precautions are applicable to all health professionals caring for any patients; additional barrier precautions (isolation) are recommended for patients carrying transmissible infectious diseases or MDR bacteria in sporadic or epidemic situations. Moreover, additional precautions may be required for populations at particular risk of infection or colonization by emerging XDR (eXDR), defined in our country as carbapenemase-producing Enterobacteriaceae and vancomycin-resistant enterococci. Our ability to detect and identify eXDR carriers early and ensure their follow-up, through effective communication between all those involved, is a significant challenge for controlling their spread. Thus, the French High Committee for Public Health has updated and standardized all French existing recommendations concerning the prevention of the cross-transmission of these bacteria, and these recommendations are summarized in this review. The recommendations are based on scientific and operational knowledge up to 2013. Different preventive strategies are recommended for patients found to be carrying eXDR and those who are considered to be at risk of having eXDR because of a history of contact. The local context, the experience of the infection control team, the different times at which detection of eXDR takes place (during admission, hospitalization, etc.) and the epidemiological situation (sporadic cases, clusters, outbreaks, widespread epidemic) must be included in risk assessments that in turn inform the control measures that should be applied in each clinical circumstance.
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Affiliation(s)
- D Lepelletier
- Unité de Gestion du risque Infectieux, Service de Bactériologie-Hygiène Hospitalière, CHU Nantes, Nantes, France; Université de Nantes, EA 3826, UFR Médecine, Nantes, France.
| | - P Berthelot
- Unité d'Hygiène Inter-Hospitalière, Service des Maladies Infectieuses et Laboratoire des Agents Infectieux et Hygiène, CHU St-Etienne, St Etienne, France
| | - J-C Lucet
- Unité Hospitalière de Lutte contre l'Infection Nosocomiale, GH Bichat - Claude Bernard, AP-HP, Paris, France
| | | | - V Jarlier
- Laboratoire de Bactériologie, Hôpital La Pitié-Salpêtrière, AP-HP, Paris, France; CLIN central de l'AP-HP, Paris, France
| | - B Grandbastien
- Unité de Lutte contre les Infections Nosocomiales, Service du Risque Infectieux, des Vigilances et d'Infectiologie, CHRU Lille, Lille, France
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Compain F, Decré D, Frazier I, Ramahefasolo A, Lavollay M, Carbonnelle E, Rostane H, Tackin A, Berger-Carbonne A, Podglajen I. Carbapenemase-producing bacteria in patients hospitalized abroad, France. Emerg Infect Dis 2015; 20:1246-8. [PMID: 24963645 PMCID: PMC4073856 DOI: 10.3201/eid2007.131638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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20
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Semin-Pelletier B, Cazet L, Bourigault C, Juvin ME, Boutoille D, Raffi F, Hourmant M, Blancho G, Agard C, Connault J, Corvec S, Caillon J, Batard E, Lepelletier D. Challenges of controlling a large outbreak of OXA-48 carbapenemase-producing Klebsiella pneumoniae in a French university hospital. J Hosp Infect 2015; 89:248-53. [PMID: 25601745 DOI: 10.1016/j.jhin.2014.11.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
Abstract
A large outbreak of OXA-48 carbapenemase-producing Klebsiella pneumoniae at Nantes University Hospital was investigated. The index case had no history of travel or hospitalization abroad and had been hospitalized in the internal medicine department for more than one month when the epidemic strain was isolated from a urine sample in June 2013. Seventy-two secondary cases were detected by weekly screening for gastrointestinal colonization during the two phases of the outbreak from June to October 2013 (33 cases) and from November 2013 to August 2014 (39 cases). Spread of the epidemic strain was attributed to the proximity of, and staff movement between, the infectious diseases (32 cases) and the internal medicine (26 cases) departments; 14 secondary cases were also observed in the renal transplant department following the transfer of an exposed patient from the infectious diseases department. Most of the patients (90%) were colonized and no death was linked to the epidemic strain. More than 3000 contact patients were reviewed and 6000 rectal swabs were performed. Initial control measures failed to control the outbreak owing to the late detection of the index case. The late implementation of three successive cohort units, the large number of transfers between wards, and the frequent readmission of cases contributed to the incomplete success of control measures.
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Affiliation(s)
- B Semin-Pelletier
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France
| | - L Cazet
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France
| | - C Bourigault
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France
| | - M E Juvin
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France
| | - D Boutoille
- Infectious Diseases Department, Nantes University Hospital, Nantes, France; University of Nantes, EA 3826, UFR Medicine School, Nantes, France
| | - F Raffi
- Infectious Diseases Department, Nantes University Hospital, Nantes, France
| | - M Hourmant
- Renal Transplant Department, Nantes University Hospital, Nantes, France
| | - G Blancho
- Renal Transplant Department, Nantes University Hospital, Nantes, France
| | - C Agard
- Internal Medicine Department, Nantes University Hospital, Nantes, France
| | - J Connault
- Renal Transplant Department, Nantes University Hospital, Nantes, France
| | - S Corvec
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France; University of Nantes, EA 3826, UFR Medicine School, Nantes, France
| | - J Caillon
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France; University of Nantes, EA 3826, UFR Medicine School, Nantes, France
| | - E Batard
- University of Nantes, EA 3826, UFR Medicine School, Nantes, France; Emergency Department, Nantes University Hospital, Nantes, France
| | - D Lepelletier
- Bacteriology and Hygiene Department, Nantes University Hospital, Nantes, France; University of Nantes, EA 3826, UFR Medicine School, Nantes, France.
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21
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Pantel A, Marchandin H, Prère MF, Boutet-Dubois A, Brieu-Roche N, Gaschet A, Davin-Regli A, Sotto A, Lavigne JP. Faecal carriage of carbapenemase-producing Gram-negative bacilli in hospital settings in southern France. Eur J Clin Microbiol Infect Dis 2014; 34:899-904. [PMID: 25532506 DOI: 10.1007/s10096-014-2298-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/07/2014] [Indexed: 12/22/2022]
Abstract
The emergence of carbapenemase-producing Gram-negative bacilli is a worldwide problem. To date, no study has evaluated the prevalence of faecal carriage of carbapenemase-producing and carbapenem-resistant Gram-negative bacilli (CR GNB) in France. From 1 February to 30 April 2012, we conducted a prospective, multicentre study in three University Hospitals and four General Hospitals in the south of France. The carriage of carbapenemase-producing Enterobacteriaceae (CPE) and other CR GNB was screened by both cultivation on chromID® CARBA and chromID® OXA-48 media (bioMérieux) and molecular tools [multiplex polymerase chain reaction (PCR) and NucliSENS EasyQ® KPC (bioMérieux)]. The genetic relationship between isolates was assessed by rep-PCR (DiversiLab, bioMérieux) or multilocus sequence typing (MLST). The prevalences of CR GNB and carbapenemase-producing bacteria were 2.4 % (27/1,135) and 0.4 % (n = 5), respectively. Two strains corresponded to OXA-23-producing Acinetobacter baumannii and belonged to the widespread sequence type (ST) 2/international clone II, whereas one strain was an ST15 OXA-48-producing Klebsiella pneumoniae. Two OXA-48-producers were detected exclusively by PCR. This first French study revealed the very low dissemination of carbapenemase-producing bacteria in patients attending hospitals in southern France during a non-outbreak situation. However, the increasing description of epidemic cases in this area must reinforce the use of hygiene procedures to prevent diffusion of these multidrug-resistant microorganisms.
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Affiliation(s)
- A Pantel
- Service de Microbiologie, CHU Carémeau, Place du Professeur Robert Debré, Nîmes, France
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22
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Zahar JR, Lesprit P. Management of multidrug resistant bacterial endemic. Med Mal Infect 2014; 44:405-11. [PMID: 25169940 DOI: 10.1016/j.medmal.2014.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/16/2014] [Accepted: 07/16/2014] [Indexed: 11/18/2022]
Abstract
The fight against multi-drug resistant Gram-negative bacilli (MDRGNB), especially extended-spectrum β-lactamase producing Enterobacteriaceae, is about to be lost in our country. The emergence of new resistance mechanisms to carbapenems in these Enterobacteriaceae exposes patients to a risk of treatment failure without any other therapeutic options. This dramatic situation is paradoxical because we are well aware of the 2 major factors responsible for this situation: 1) MDRO cross-transmission, associated with a low compliance to standard precautions, especially hand hygiene, and 2) overexposure of patients to antibiotics. The implementation of a "search and isolate" policy, which was justified to control the spread of some MDRO that remained rare in the country, was not associated with a better adherence to standard precautions. The antibiotic policy and the measures implemented to control antibiotic consumptions have rarely been enforced and have shown inconsistent results. Notably, no significant decrease of antibiotic consumption has been observed. There is no excuse for these poor results, because some authors evaluating the effectiveness of programs for the control of MDRO have reported their positive effects on antimicrobial resistance without any detrimental effects. It is now urgent to deal with the 2 major factors by establishing an educational and persuasive program with quantified and opposable objectives. Firstly, we have to improve the observance of hand hygiene above 70%. Secondly, we have to define and reach a target for the reduction of antibiotic consumption both in community and in hospital settings.
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Affiliation(s)
- J-R Zahar
- Unité de prévention et de lutte contre les infections nosocomiales, université d'Angers, centre hospitalo-universitaire d'Angers, 4, rue Larrey, 49000 Angers, France.
| | - P Lesprit
- Infectiologie transversale, laboratoire de biologie, hôpital Foch, 92151 Suresnes, France
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Savard P, Perl TM. Combating the spread of carbapenemases in Enterobacteriaceae: a battle that infection prevention should not lose. Clin Microbiol Infect 2014; 20:854-61. [PMID: 24980472 DOI: 10.1111/1469-0691.12748] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The emergence of carbapenemases in Enterobacteriaceae has raised global concern among the scientific, medical and public health communities. Both the CDC and the WHO consider carbapenem-resistant Enterobacteriaceae (CRE) to constitute a significant threat that necessitates immediate action. In this article, we review the challenges faced by laboratory workers, infection prevention specialists and clinicians who are confronted with this emerging infection control issue.
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Affiliation(s)
- P Savard
- Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montréal, QC, Canada; Medical Microbiology and Infectious Diseases Department, Centre Hospitalier Universitaire de Montréal, Hôpital St-Luc, Montréal, QC, Canada
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Liapis E, Pantel A, Robert J, Nicolas-Chanoine MH, Cavalié L, van der Mee-Marquet N, de Champs C, Aissa N, Eloy C, Blanc V, Guyeux C, Hocquet D, Lavigne JP, Bertrand X. Molecular epidemiology of OXA-48-producing Klebsiella pneumoniae in France. Clin Microbiol Infect 2014; 20:O1121-3. [PMID: 24942039 DOI: 10.1111/1469-0691.12727] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/11/2014] [Accepted: 06/15/2014] [Indexed: 11/27/2022]
Abstract
We characterized 53 OXA-48-producing Klebsiella pneumoniae (OXA-48-Kp) isolated between 2011 and 2013 in 21 French hospitals. All the isolates were genotyped using MLST and PFGE and the population structure of the species was determined by a nucleotide-based analysis of the entire K. pneumoniae MLST database. Most of the OXA-48-Kp isolates also produced CTX-M-15 and remained susceptible to imipenem and meropenem. The isolates were distributed into 20 STs, of which five were dominant (ST15, ST101, ST147, ST395 and ST405). All the OXA-48-Kp clustered in the major clade of K. pneumoniae KpI.
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Affiliation(s)
- E Liapis
- Service d'Hygiène Hospitalière, UMR 6249 Chrono-environnement, Centre Hospitalier Régional Universitaire, Université de Franche-Comté, Besançon, France
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Pantel A, Boutet-Dubois A, Jean-Pierre H, Marchandin H, Sotto A, Lavigne JP. French regional surveillance program of carbapenemase-producing Gram-negative bacilli: results from a 2-year period. Eur J Clin Microbiol Infect Dis 2014; 33:2285-92. [PMID: 25037867 DOI: 10.1007/s10096-014-2189-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
In February 2011, the CARB-LR group was created as a sentinel laboratory-based surveillance network to control the emergence of carbapenem-resistant Gram-negative bacilli (CR GNB) in a French Southern Region. We report the epidemiological results of a 2-year study. All the Gram-negative bacilli isolates detected in the different labs (hospital and community settings) of a French Southern Region and with reduced susceptibility to ertapenem and/or imipenem were characterised with regard to antibiotic resistance, bla genes content, repetitive sequence-based polymerase chain reaction (rep-PCR) profiles and multilocus sequence typing (MLST). A total of 221 strains were analysed. Acinetobacter baumannii was the most prevalent carbapenemase-producing bacteria, with a majority of OXA-23 producers (n = 37). One isolate co-produced OXA-23 and OXA-58 enzymes. Klebsiella pneumoniae was the most frequent carbapenemase-producing Enterobacteriaceae (CPE) (OXA-48 producer: n = 29, KPC producer: n = 1), followed by Escherichia coli (OXA-48 producer: n = 8, KPC producer: n = 1) and Enterobacter cloacae (OXA-48 producer, n = 1). One isolate of Pseudomonas aeruginosa produced a VIM-1 carbapenemase. A clonal diversity of carbapenemase-producing K. pneumoniae and E. coli was noted with different MLSTs. On the other hand, almost all OXA-23-producing A. baumannii strains belonged to the widespread ST2/international clone II. The link between the detection of CR GNB and a foreign country was less obvious, suggesting the beginning of a local cross-transmission. The number of CR GNB cases in our French Southern Region has sharply increased very recently due to the diffusion of OXA-48 producers.
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Affiliation(s)
- A Pantel
- Service de Microbiologie, CHU Carémeau, Place du Professeur Robert Debré, Nîmes Cedex 09, 30029, France
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Fournier S, Monteil C, Lepainteur M, Richard C, Brun-Buisson C, Jarlier V, Ap-Hp Outbreaks Control Group C. Long-term control of carbapenemase-producing Enterobacteriaceae at the scale of a large French multihospital institution: a nine-year experience, France, 2004 to 2012. ACTA ACUST UNITED AC 2014; 19. [PMID: 24852956 DOI: 10.2807/1560-7917.es2014.19.19.20802] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In 2009, following the occurrence of several outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), a programme for controlling the spread of CPE was implemented in the 38 hospitals of the Assistance Publique-Hôpitaux de Paris, a 21,000-bed institution. This programme included recommendations to isolate, and screen for CPE, patients previously hospitalised abroad, and bundled measures to control cross transmission (barrier precautions, dedicated staff and screening of contact patients). From 2004 to 2012, 140 CPE index cases were identified, 17 leading to outbreaks. After application of the programme, in spite of an increase in the number of CPE index cases epidemiologically linked with a recent stay or hospitalisation abroad, the proportion of cases followed by outbreaks, which was 40% (4/10) before 2009, decreased to 10% (13/130) (p=0.02), and the proportion of secondary cases among all CPE cases decreased from 69% (22/32) to 23% (38/168), (p<0.001). The number of secondary cases varied significantly depending on the speed and strength of the measures implemented around the CPE index case: quick (within two days of patient admission at the hospital) setting of nursing staff dedicated to the patient, quick setting of simple barrier precautions, or delayed measures of control (p=0.001). A sustained and coordinated strategy can lead to control CPE at the level of a large regional multi-hospital institution in a country where CPE are at an emerging stage.
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Affiliation(s)
- S Fournier
- Infection Control Team, Direction de la Politique Medicale, Assistance Publique-Hopitaux de Paris, Paris, France
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Janvier F, Delacour H, Tessé S, Larréché S, Sanmartin N, Ollat D, Rapp C, Mérens A. Faecal carriage of extended-spectrum β-lactamase-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas. Eur J Clin Microbiol Infect Dis 2014; 33:1719-23. [PMID: 24807441 DOI: 10.1007/s10096-014-2141-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/24/2014] [Indexed: 11/28/2022]
Abstract
The aim of this study was to assess the faecal carriage of carbapenemase-producing enterobacteria (CPE) and extended-spectrum β-lactamase (ESBL)-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas. During a period of 1 year, 83 rectal swabs collected in French soldiers at admission were screened for multidrug-resistant enterobacteria with a chromogenic medium. ESBL detection was performed with the double-disc synergy test in the absence or presence of cloxacillin. The genotypic characterisation of resistance mechanisms, sequence typing and phylotyping was performed by polymerase chain reaction (PCR) and sequencing with bacterial DNA extracted from isolates. No CPE was detected. Eleven ESBL Escherichia coli isolates belonging to four phylogenetic groups were detected, including ten CTX-M-15 and one CTX-M-14. The overall gut colonisation with ESBL-producing bacteria (13.25 %) was 6-fold higher than that reported in soldiers in the suburbs of Paris in 2009. ESBL faecal carriage was particularly high (34.48 %) in soldiers repatriated from Afghanistan (risk ratio = 18.62; p = 0.0001). This study highlights the importance of systematic additional contact precautions and CPE/ESBL screening in soldiers repatriated from overseas in French hospitals.
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Affiliation(s)
- F Janvier
- Service de Microbiologie et Hygiène hospitalière, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France,
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Munier E, Bénet T, Nicolle MC, Oltra L, Ricanet-Delannoy A, Comte B, Vanhems P. Health care workers travelling abroad: investigation of carbapenemase-producing enterobacteriaceae infection possibly acquired overseas. Am J Infect Control 2014; 42:85-6. [PMID: 24388474 DOI: 10.1016/j.ajic.2013.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/19/2013] [Indexed: 11/13/2022]
Affiliation(s)
- Elodie Munier
- Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Thomas Bénet
- Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Marie-Christine Nicolle
- Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Luc Oltra
- Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Brigitte Comte
- Department of Geriatrics, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Philippe Vanhems
- Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; Epidemiology and Public Health Group, University of Lyon, University of Lyon 1, Lyon, France.
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Impact of a program combining pre-authorization requirement and post-prescription review of carbapenems: an interrupted time-series analysis. Eur J Clin Microbiol Infect Dis 2013; 32:1599-604. [PMID: 23839593 DOI: 10.1007/s10096-013-1918-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/23/2013] [Indexed: 10/26/2022]
Abstract
The objective of this study was to assess the impact on carbapenems use of a program combining pre-authorization requirement and systematic post-prescription review of carbapenems prescriptions. The program was implemented in a 1,230-bed teaching tertiary hospital. Monthly carbapenems consumption was analyzed using a controlled interrupted time-series method and compared to that of vancomycin before and after implementation of the intervention. Compared to the pre-intervention period (14 monthly points), a significant and sustained decrease of carbapenems consumption [1.66 defined daily doses (DDD)/1,000 patient-days; p = 0.048] was observed during the intervention period (12 monthly points), despite an increasing trend in incidence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) isolates (0.02/1,000 patient-days per month; p = 0.093). As expected, vancomycin consumption was unaffected by the intervention. A total of 337 prescriptions were reviewed in the intervention period; most were microbiologically documented (81.3%; ESBL-PE: 39.2%). Three of four (76.6%) carbapenems prescriptions were modified within a median [interquartile range] of 2 [1; 4] days, either after infectious disease physician (IDP) advice (48.4%) or by ward physicians (28.2%). Most changes included de-escalating (52.2%) or reducing the planned duration (22.2%), which resulted in a median duration of treatment of only 3 [2; 7] days. The median length of stay and mortality rate were not influenced by the intervention. This reasonably practicable antimicrobial stewardship program including controlled delivery and systematic reevaluation of carbapenems prescriptions was able to reduce their use in our hospital, despite a rising ESBL-PE incidence.
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Characterization of a new blaOXA-48-carrying plasmid in Enterobacteriaceae. Antimicrob Agents Chemother 2013; 57:4064-7. [PMID: 23733457 DOI: 10.1128/aac.02550-12] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this work, we characterized a new, 160-kb, blaOXA-48-harboring IncL/M-type plasmid isolated from a Klebsiella pneumoniae strain from France. Moreover, we report the transfer of a 60-kb OXA-48-encoding plasmid from Klebsiella pneumoniae to other Enterobacteriaceae in two patients.
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Ruppé E, Andremont A. Causes, consequences, and perspectives in the variations of intestinal density of colonization of multidrug-resistant enterobacteria. Front Microbiol 2013; 4:129. [PMID: 23755045 PMCID: PMC3664761 DOI: 10.3389/fmicb.2013.00129] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 05/06/2013] [Indexed: 11/17/2022] Open
Abstract
The intestinal microbiota is a complex environment that hosts 1013 to 1014 bacteria. Among these bacteria stand multidrug-resistant enterobacteria (MDRE), which intestinal densities can substantially vary, especially according to antibiotic exposure. The intestinal density of MDRE and their relative abundance (i.e., the proportion between the density of MDRE and the density of total enterobacteria) could play a major role in the infection process or patient-to-patient transmission. This review discusses the recent advances in understanding (i) what causes variations in the density or relative abundance of intestinal colonization, (ii) what are the clinical consequences of these variations, and (iii) what are the perspectives for maintaining these markers at low levels.
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Affiliation(s)
- Etienne Ruppé
- Laboratoire de Bactériologie, AP-HP, Hôpitaux Paris Nord Val de Seine site Bichat-Claude Bernard, Paris, France
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Bushnell G, Mitrani-Gold F, Mundy LM. Emergence of New Delhi metallo-β-lactamase type 1-producing Enterobacteriaceae and non-Enterobacteriaceae: global case detection and bacterial surveillance. Int J Infect Dis 2013; 17:e325-33. [DOI: 10.1016/j.ijid.2012.11.025] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 11/08/2012] [Accepted: 11/10/2012] [Indexed: 01/01/2023] Open
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Ruppé E, de Lastours V. Entérobactéries résistantes aux antibiotiques et microbiote intestinal : la face cachée de l’iceberg. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0459-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fournier S, Brun-Buisson C, Jarlier V. Twenty years of antimicrobial resistance control programme in a regional multi hospital institution, with focus on emerging bacteria (VRE and CPE). Antimicrob Resist Infect Control 2012; 1:9. [PMID: 22958336 PMCID: PMC3436665 DOI: 10.1186/2047-2994-1-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/13/2012] [Indexed: 11/20/2022] Open
Abstract
Background Assistance Publique-Hôpitaux de Paris (APHP), the largest public health care institution in France (38 hospitals, 23,000 beds, serving 11.6 millions inhabitants) launched in 1993 a long term programme to control and survey multidrug resistant bacteria (MDR). Findings AP-HP MDR programme consisted in successive waves of actions: bundle measures to survey and control cross transmission of MRSA and extended-spectrum betalactamase producing enterobacteria (ESBL) in 1993, large campaign to promote the use of alcohol-based hand rub solution (ABHRS) in 2001, specific strategy to quickly control the spread of emerging MDR (vancomycin resistant Enterococcus, VRE; carbapenemase producing enterobacteria, CPE) in 2006, large campaign to decrease antibiotics consumption in 2006. Following this programme, the ABHRS consumption dramatically increased, the antibiotic consumption decreased by 10%, the incidence of MRSA, including MRSA bacteraemia, decreased by 2/3, all VRE and CPE events were rapidly controlled. However, the incidence of ESBL, mainly Klebsiella pneumoniae and Escherichia coli, that remained low and stable until 2003 increased markedly afterwards, justifying adapting our programme in the future. Conclusion A sustained and coordinated strategy can lead to control multidrug resistant bacteria at the level of a large multihospital institution.
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Affiliation(s)
- Sandra Fournier
- Direction de la Politique Médicale, Assistance publique-Hôpitaux de Paris (AP-HP), Paris, France.
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Lepelletier D, Andremont A, Grandbastien B. Risk of highly resistant bacteria importation from repatriates and travelers hospitalized in foreign countries: about the French recommendations to limit their spread. J Travel Med 2011; 18:344-51. [PMID: 21896099 DOI: 10.1111/j.1708-8305.2011.00547.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Didier Lepelletier
- Unité de Gestion du Risque Infectieux, Service de Bactériologie-Hygiène, Centre Hospitalier Universitaire de Nantes Université de Nantes, EA 3826, UFR Médecine, Nantes, France.
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