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

Background

Urinary tract infections (UTIs) are among the most common bacterial infections. Despite this burden, there are few studies of the costs of UTIs. The objective of this study was to determine the costs of UTIs in women over 18 years of age who visit general practitioners in France.

Methods

The direct and indirect costs of clinical UTIs were estimated from societal, French National Health Insurance and patient perspectives. The study population was derived from a national cross-sectional survey entitled the Drug-Resistant Urinary Tract Infection (Druti). The Druti included every woman over 18 years of age who presented with symptoms of UTI and was conducted in France in 2012 and 2013 to estimate the annual incidence of UTIs due to antibiotic-resistant Enterobacteriaceae in women visiting general practitioners (GPs) for suspected UTIs.

Results

Of the 538 women included in Druti, 460 were followed over 8 weeks and included in the cost analysis. The mean age of the women was 46 years old. The median cost of care for one episode of a suspected UTI was €38, and the mean cost was €70. The annual societal cost was €58 million, and €29 million of this was reimbursed by the French National Health Insurance system. In 25 % of the cases, the suspected UTIs were associated with negative urine cultures. The societal cost of these suspected UTIs with negative urine cultures was €13.5 million. No significant difference was found between the costs of the UTIs due to antibiotic-resistant E. coli and those due to wild E. coli (p = 0.63).

Conclusion

In the current context in which the care costs are continually increasing, the results of this study suggests that it is possible to decrease the cost of UTIs by reducing the costs of suspected UTIs and unnecessary treatments, as well as limiting the use of non-recommended tests.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1620-2) contains supplementary material, which is available to authorized users.

The reliability of the McCabe score as a marker of co-morbidity in healthcare-associated infection point prevalence studies

This study aimed to ascertain the reliability of the McCabe score in a healthcare-associated infection point prevalence survey.   A 10 European Union Member States survey in 20 hospitals (n = 1912) indicated that there was a moderate level of agreement (κ = 0.57) with the score. The reliability of the application of the score could be increased by training data collectors, particularly with reference to the ultimately fatal criteria. This is important if the score is to be used to risk adjust data to drive infection prevention and control interventions.

A pilot validation in 10 European Union Member States of a point prevalence survey of healthcare-associated infections and antimicrobial use in acute hospitals in Europe, 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Surveillance of Occupational Blood and Body Fluid Exposures Among French Healthcare Workers in 2004

Objective.

To estimate the incidence rate of reported occupational blood and body fluid exposures among French healthcare workers (HCWs).

Design.

Prospective national follow-up of HCWs from January 1 to December 31, 2004.

Setting.

University hospitals, hospitals, clinics, local medical centers, and specialized psychiatric centers were included in the study on a voluntary basis.

Participants.

At participating medical centers, every reported blood and body fluid exposure was documented by the occupational practitioner in charge of the exposed HCW by use of an anonymous, standardized questionnaire.

Results.

A total of 375 medical centers (15% of French medical centers, accounting for 29% of hospital beds) reported 13,041 blood and body fluid exposures; of these, 9,396 (72.0%) were needlestick injuries. Blood and body fluid exposures were avoidable in 39.1% of cases (5,091 of 13,020), and 52.2% of percutaneous injuries (4,986 of 9,552) were avoidable (5.9% due to needle recapping). Of 10,656 percutaneous injuries, 22.6% occurred during an injection, 17.9% during blood sampling, and 16.6% during surgery. Of 2,065 splashes, 22.6% occurred during nursing activities, 19.1% during surgery, 14.1% during placement or removal of an intravenous line, and 12.0% during manipulation of a tracheotomy tube. The incidence rates of exposures were 8.9 per 100 hospital beds (95% confidence interval [CI], 8.7-9.0 exposures), 2.2 per 100 full-time—equivalent physicians (95% CI, 2.4-2.6 exposures), and 7.0 per 100 full-time—equivalent nurses (95% CI, 6.8-7.2 exposures). Human immunodeficiency virus serological status was unknown for 2,789 (21.4%) of 13,041 patients who were the source of the blood and body fluid exposures.

Conclusion.

National surveillance networks for blood and body fluid exposures help to better document their characteristics and risk factors and can enhance prevention at participating medical centers.

Large number of imported chikungunya cases in mainland France, 2014: a challenge for surveillance and response

During the summer of 2014, all the pre-requisites for autochthonous transmission of chikungunya virus are present in southern France: a competent vector, Aedes albopictus, and a large number of travellers returning from the French Caribbean islands where an outbreak is occurring. We describe the system implemented for the surveillance of chikungunya and dengue in mainland France. From 2 May to 4 July 2014, there were 126 laboratory-confirmed imported chikungunya cases in mainland France.

Acquisition of carbapenemase-producing Enterobacteriaceae by healthy travellers to India, France, February 2012 to March 2013

Healthy travellers to countries where carbapenemases-producing Enterobacteriaceae (CPE) are endemic might be at risk for their acquisition, even without contact with the local healthcare system. Here, we report the acquisition of CPE (two OXA-181, one New Delhi metallo-beta-lactamase 1 (NDM-1)) in three healthy travellers returning from India. The duration of CPE intestinal carriage was less than one month. The results indicate that healthy travellers recently returning from India might be considered as at risk for CPE carriage.

Benchmarking French regions according to their prevalence of healthcare-associated infections

OBJECTIVE

To propose an original method of benchmarking regions based on their prevalence of healthcare-associated infections (HAIs) and to identify regions with unusual results.

DESIGN

To study between-region variability with a three-level hierarchical logistic regression model and a Bayesian non-parametric method.

SETTING

French 2006 national HAIs point prevalence survey.

PARTICIPANTS

A total of 336 858 patients from 2289 healthcare facilities in 27 regions. Patients with an imported HAI (1% of the data, 20.7% of infected patients), facilities with <5 patients and patients who had at least one missing value for the variables taken into account were excluded (5.0% of patients).

MAIN OUTCOME MEASURE

Binary outcome variable indicates whether a given patient was infected.

RESULTS

Two clusters of regions were identified: one cluster of five regions had a lower adjusted prevalence than the other one of 22 regions, while no region with unusually high prevalence could be identified. Nevertheless, the degree of heterogeneity of odds ratios between facilities for facility-specific effects of use of invasive devices was more important in some regions than in others.

CONCLUSIONS

The adjusted regional prevalence of HAIs can serve as an adequate benchmark to identify regions with concerning results. Although no outlier regions were identified, the proposed approach could be applied to the data of the 2012 national survey to benchmark regional healthcare policies. The estimation of facility-specific effects of use of invasive devices may orient future regional action plans.

First cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infections in France, investigations and implications for the prevention of human-to-human transmission, France, May 2013

In May 2013, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection was diagnosed in an adult male in France with severe respiratory illness, who had travelled to the United Arab Emirates before symptom onset. Contact tracing identified a secondary case in a patient hospitalised in the same hospital room. No other cases of MERS-CoV infection were identified among the index case’s 123 contacts, nor among 39 contacts of the secondary case, during the 10-day follow-up period.

The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use

A standardised methodology for a combined point prevalence survey (PPS) on healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals developed by the European Centre for Disease Prevention and Control was piloted across Europe. Variables were collected at national, hospital and patient level in 66 hospitals from 23 countries. A patient-based and a unit-based protocol were available. Feasibility was assessed via national and hospital questionnaires. Of 19,888 surveyed patients, 7.1% had an HAI and 34.6% were receiving at least one antimicrobial agent. Prevalence results were highest in intensive care units, with 28.1% patients with HAI, and 61.4% patients with antimicrobial use. Pneumonia and other lower respiratory tract infections (2.0% of patients; 95% confidence interval (CI): 1.8–2.2%) represented the most common type (25.7%) of HAI. Surgical prophylaxis was the indication for 17.3% of used antimicrobials and exceeded one day in 60.7% of cases. Risk factors in the patient-based protocol were provided for 98% or more of the included patients and all were independently associated with both presence of HAI and receiving an antimicrobial agent. The patient-based protocol required more work than the unit-based protocol, but allowed collecting detailed data and analysis of risk factors for HAI and antimicrobial use.

Factors associated with the prevalence of antibiotic use for the treatment of hospital-acquired infections at 393 French hospitals: a regional variation analysis

OBJECTIVE

The present study investigated regional variations in antibiotic use for the treatment of hospital-acquired infections (HAIs) in France by means of a multilevel analysis, to identify targets for quality improvement.

METHODS

Data were obtained from the 2001 and 2006 French national point-prevalence surveys of HAIs and antibiotic use. The present study was conducted using data from 393 nonteaching public hospitals. Data included patient characteristics calculated at the hospital level (mean age and proportion of patients with the following: HAI, presence of a vascular catheter, presence of a urinary catheter, surgical procedure, and immunodeficiency) and hospital characteristics (size and presence of an intensive care unit). The regional effect was measured using a random intercept on a regional variable.

RESULTS

Overall, the prevalence of antibiotic use was 5.35% for both study years. The most commonly used antibiotics for HAIs were fluoroquinolones (2001, 1.33%; 2006, 1.35%) and combinations of penicillins with a β-lactamase inhibitor (2001, 0.92%; 2006, 1.02%). Mapping of antibiotic use showed wide variation between regions. The regional effect explained 3% of antibiotic variation in the unadjusted analysis. In the multivariable analysis, hospital size, high prevalence of patients with immunodeficiency, and infection characteristics explained 45% of the variability in antibiotic use. The regional effect was not retained in the final model.

CONCLUSION

The pattern of antibiotic use for HAIs differed over time, and regional variations were mostly explained by patient characteristics; there was no regional effect. Models that take data hierarchy into account are essential to better approach antibiotic use and develop relevant strategies for improvement.

Epidemiological trends in invasive aspergillosis in France: the SAIF network (2005-2007)

A prospective (2005-2007) hospital-based multicentre surveillance of EORTC/MSG-proven or probable invasive aspergillosis (IA) cases whatever the underlying diseases was implemented in 12 French academic hospitals. Admissions per hospital and transplantation procedures were obtained. Cox regression models were used to determine risk factors associated with the 12-week overall mortality. With 424 case-patients included, the median incidence/hospital was 0.271/10(3) admissions (range 0.072-0.910) without significant alteration of incidence and seasonality over time. Among the 393 adults (62% men, 56 years (16-84 years)), 15% had proven IA, 78% haematological conditions, and 92.9% had lung involvement. Acute leukaemia (34.6%) and allogeneic stem cell transplantation (21.4%) were major host factors, together with chronic lymphoproliferative disorders (21.6%), which emerged as a new high-risk group. The other risk host factors consisted of solid organ transplantation (8.7%), solid tumours (4.3%), systemic inflammatory diseases (4.6%) and chronic respiratory diseases (2.3%). Serum galactomannan tests were more often positive (≥69%) for acute leukaemia and allogeneic stem cell transplantation than for the others (<42%; p <10(-3)). When positive (n = 245), cultures mainly yielded Aspergillus fumigatus (79.7%). First-line antifungal therapy consisted of voriconazole, caspofungin, lipid formulations of amphotericin, or any combination therapy (52%, 14%, 8% and 19.9%, respectively). Twelve-week overall mortality was 44.8% (95% CI, 39.8-50.0); it was 41% when first-line therapy included voriconazole and 60% otherwise (p <0.001). Independent factors for 12-week mortality were older age, positivity for both culture and galactomannan and central nervous system or pleural involvement, while any strategy containing voriconazole was protective.

Emergence of carbapenemase-producing Enterobacteriaceae in France, 2004 to 2011

Emergence of carbapenemase-producing Enterobacteriaceae (CPE) is currently a major public health concern worldwide. This study showed that 53 episodes of CPE infection or colonisation have been notified by French healthcare facilities since 2004. A sharp increase in the number of notifications was observed in the last three years. Oxacillinase (OXA)-48 and Klebsiella pneumoniae carbapenemase (KPC) beta-lactamases were the most frequent enzymes reported in these episodes. The index cases in most episodes were patients with a history of hospitalisation abroad within the previous year. Around a third of the episodes (n=18) led to secondary transmission in hospitals but most of them were controlled due to reinforced measures. Reinforcement of screening and control measures at national level when there is cross-border transfer of patients, along with overall reinforcement of infection control and antimicrobial stewardship worldwide, is urgently needed to contain the spread of CPE.

Relationship between prevalence of device-associated infections and alcohol-based hand-rub consumption: a multi-level approach

Using a multi-level logistic regression model, we determined whether there was any relationship between alcohol-based hand-rub consumption and prevalence of device-associated infections (DAIs) in French healthcare facilities (HCFs). Two national databases were used: the 2006 French prevalence survey of nosocomial infections, and the 2006 French infection control indicator database which includes alcohol-based hand-rub consumption as an indicator (ICSHA: indicateur de consommation de solution hydro-alcoolique). Only patients with at least one medical device (urinary catheter, vascular catheter or tracheal tube) who were present in an HCF for at least two days were included in the analysis. A multi-level statistical analysis was performed to assess the joint effect of patient-level and hospital-level variables. In all, 814 HCFs, each with a minimum of 15 study patients, were included, giving a total of 53,459 patients. The overall prevalence of DAI was 6.7% (95% confidence interval: 6.4-6.9). The median value of ICSHA was 37.2%. There was no association between DAI prevalence and ICSHA, but all patient-level variables were associated with DAI prevalence. Patient-level variables explain 25% of the hospital-level variation in DAI prevalence, although 60% of this variation remains unexplained when both patient and hospital variables are included in the model. To further assess any association between DAI prevalence and hand hygiene, additional studies on hand hygiene practices specifically associated with invasive medical device manipulation are required.

Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009

An outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae type 2 was detected in September 2009 in two hospitals in a suburb south of Paris, France. In total, 13 KPC-producing K. pneumoniae type 2 cases (four with infections and nine with digestive-tract colonisations) were identified, including a source case transferred from a Greek hospital. Of the 13 cases, seven were secondary cases associated with use of a contaminated duodenoscope used to examine the source case (attack rate: 41%) and five were secondary cases associated with patient-to-patient transmission in hospital. All isolated strains from the 13 patients: (i) exhibited resistance to all antibiotics except gentamicin and colistin, (ii) were more resistant to ertapenem (minimum inhibitory concentration (MIC) always greater than 4 mg/L) than to imipenem (MIC: 1–8 mg/L, depending on the isolate), (iii) carried the blaKPC-2 and blaSHV12 genes and (iv) had an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern. These cases occurred in three hospitals: some were transferred to four other hospitals. Extended infection control measures implemented in the seven hospitals included: (i) limiting transfer of cases and contact patients to other wards, (ii) cohorting separately cases and contact patients, (iii) reinforcing hand hygiene and contact precautions and (iv) systematic screening of contact patients. Overall, 341 contact patients were screened. A year after the outbreak, no additional case has been identified in these seven hospitals. This outbreak emphasises the importance of rapid identification and notification of emerging highly resistant K. pneumoniae strains in order to implement reinforced control measures.

Investigation of a large outbreak of Clostridium difficile PCR-ribotype 027 infections in northern France, 2006-2007 and associated clusters in 2008-2009

In 2006 and 2007, a large outbreak of Clostridium difficile infections (CDIs) with PCR-ribotype 027 was identified in northern France. Overall, 38 healthcare facilities notified 529 CDIs over a 22-month period, including 281 laboratory-confirmed CDI 027 and 248 non-confirmed CDI 027 cases (incidence rate per 10,000 elective bed days: 1.63, range: 0.07 to 7.94). The cases occurred mainly in long-term care hospital facilities and nursing homes, near the border between France and Belgium. An active surveillance and prevention campaign was launched at the first epidemic peak including hygiene precautions for healthcare professionals, which supported healthcare facilities to improve care organisation. The outbreak was controlled at the end of 2007, but sporadic cases were identified until the end of 2009. A bundle of appropriate control measures may halt the spread of such outbreaks, provided that substantial human resources and financial support are available.

Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027. C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad. The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027.C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad.The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

Infection control measures to limit the spread of Clostridium difficile

Clostridium difficile-associated diarrhoea (CDAD) presents mainly as a nosocomial infection, usually after antimicrobial therapy. Many outbreaks have been attributed to C. difficile, some due to a new hyper-virulent strain that may cause more severe disease and a worse patient outcome. As a result of CDAD, large numbers of C. difficile spores may be excreted by affected patients. Spores then survive for months in the environment; they cannot be destroyed by standard alcohol-based hand disinfection, and persist despite usual environmental cleaning agents. All these factors increase the risk of C. difficile transmission. Once CDAD is diagnosed in a patient, immediate implementation of appropriate infection control measures is mandatory in order to prevent further spread within the hospital. The quality and quantity of antibiotic prescribing should be reviewed to minimise the selective pressure for CDAD. This article provides a review of the literature that can be used for evidence-based guidelines to limit the spread of C. difficile. These include early diagnosis of CDAD, surveillance of CDAD cases, education of staff, appropriate use of isolation precautions, hand hygiene, protective clothing, environmental cleaning and cleaning of medical equipment, good antibiotic stewardship, and specific measures during outbreaks. Existing local protocols and practices for the control of C. difficile should be carefully reviewed and modified if necessary.

Hepatitis B virus transmission from a nurse to a patient, France, 2005

Infection by the Hepatitis B virus (HBV), which is often asymptomatic at the acute phase, can progress to chronic liver disease, particularly when infection occurs early in life. Hepatitis B is mainly transmitted sexually or through blood or body fluids. Episodes of healthcare-associated transmission of HBV have been previously described [1-3]. Transmission of HBV results either from patient to patient through invasive healthcare procedures with improper disinfection of devices used between patient care or from a patient to a healthcare worker (HCW). Transmission can also take place from a chronically infected HCW to a patient. In those episodes, breaches in healthcare practices and standard precaution play a major role. Prevention of HBV transmission in healthcare settings also relies on the immunisation of HCW, which has been mandatory in France since 1991. HCW are considered immune if they have documented proof that they were vaccinated before 13 years of age, or if a positive anti-HBs antibody test is provided [4].

[Implementing a community surveillance network to monitor antimicrobial resistance: the Labville network]

BACKGROUND

In France, antimicrobial resistance monitoring is based on the contribution of many microbiological partners and networks, especially hospital laboratories. In order to complete this surveillance, the InVS implemented a network based on private-sector laboratories (PSL): the Labville network.

METHOD

Stratified by French region, 69 PSL were randomly selected. The microbiological analysis results, including anonymized individual patient data, are translated into an appropriate data format within an automated reading process. This data is then sent to InVS through a secure Internet connection.

RESULTS

The specifications of the automated system were defined according to a feasibility study conducted in 2003. The first stage of the project consisted in defining a global strategy for the reading of printed microbiological results. Then, the parameters were adapted for each PSL using a set of specific analysis over two to three weeks. After validation by InVS, the reading strategy was applied on to routinely printed results. The strategy was definitely validated after four month of a daily data transmission. The general approach needs to be adapted to each PSL and undergoes several adjustments. This long step of the project still requires microbiological expertise.

CONCLUSION

The automated data extraction process used for Labville project is innovating. It is not affected by the compatibility and diversity of computing systems and reduces the biologist's workload. The Labville network is a challenging project motivating future development of other electronic surveillance networks.

[Update on Clostridium difficile infections]

PURPOSE

Clostridium difficile is an anaerobic gram positive, spore-forming bacterium which is responsible for 15-25% of antibiotic-associated diarrhea and for more than 95% of pseudomembranous colitis (PMC). This paper will review the main knowledge on C. difficile-associated infections and their recent evolution.

CURRENT KNOWLEDGE AND KEY POINTS

Since 2003, outbreaks of severe C. difficile-associated diarrhea (CDAD) have been increasingly reported in Canada and the United States. This trend is assumed to be associated with the rapid emergence and spread of a specific clone of C. difficile belonging to PCR-ribotype 027 or North American Pulsotype 1, pulsotype (NAP1). This clone is characterized by the overproduction of toxins A and B and is positive for a third toxin named binary toxin. This clone has spread in UK, in Belgium, in the Netherlands, and, more recently, in France where it has been responsible for large outbreaks mainly in northern France.

FUTURE PROSPECTS AND PROJECTS

A systematic reporting of C. difficile incidence by health facilities should enable a better assessment of this pathology in France.

Update of Clostridium difficile-associated disease due to PCR ribotype 027 in Europe

Recent outbreaks of Clostridium difficile-associated diarrhoea (CDAD) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America, Japan and Europe. Definitions have been proposed by the European Centre of Disease Prevention and Control (ECDC) to identify severe cases of CDAD and to differentiate community-acquired cases from nosocomial CDAD (http://www.ecdc.europa.eu/documents/pdf/Cl_dif_v2.pdf). CDAD is mainly known as a healthcare-associated disease, but it is also increasingly recognised as a community-associated disease. The emerging strain is referred to as North American pulsed-field type 1 (NAP1) and PCR ribotype 027. Since 2005, individual countries have developed surveillance studies to monitor the spread of this strain. C. difficile type 027 has caused outbreaks in England and Wales, Ireland, the Netherlands, Belgium, Luxembourg, and France, and has also been detected in Austria, Scotland, Switzerland, Poland and Denmark. Preliminary data indicated that type 027 was already present in historical isolates collected in Sweden between 1997 and 2001.

Emergence of Clostridium difficile-associated disease in North America and Europe

The clinical spectrum of Clostridium difficile-associated disease (CDAD) ranges from diarrhoea to severe life-threatening pseudomembranous colitis. Although not always associated with previous antibiotic exposure, it is in the majority of cases. CDAD is recognised increasingly in a variety of animal species and in individuals previously not considered to be predisposed. C. difficile can be transmitted via personal contact or environmentally. The role of patients and healthcare workers who are symptom-free but colonised with C. difficile in the intestinal tract is unclear. C. difficile, with more than 150 PCR ribotypes and 24 toxinotypes, has a pathogenicity locus (PaLoc) with genes encoding enterotoxin A (tcdA) and cytotoxin B (tcdB). Genes for the binary toxin are located outside the PaLoc, but the role of this toxin is unclear. The recently completed genome sequence of C. difficile 630 revealed a large proportion of 11% of mobile genetic elements, mainly in the form of conjugative transposons. Diagnostic assays include tests for the detection of C. difficile products or genes and culture methods for isolation of a toxin-producing bacterium. Enzyme immunoassays to detect toxin in faeces are widely available, with varying sensitivities and specificities. Despite practical drawbacks and sensitivity less than 100%, the cell cytototoxicity assay is still considered to be the standard. Rapid diagnostic assays are available on a limited scale and require much improvement. Molecular tests enable the detection of carriers of toxigenic and non-toxigenic strains, as does culture. It is highly recommended to culture C. difficile from toxin-positive faeces samples and to store isolates for future characterisation and typing. The financial impact of CDAD on the healthcare system is substantial (5-15,000 euro/case in England and $1.1 billion/year in the USA). Assuming a European Union population of 457 million, the potential cost of CDAD can be estimated to be 3000 million euro/year, and is expected to almost double over the next four decades. In North America, increasing rates of CDAD have been reported in Canada and the USA since March 2003, involving a more severe course, higher mortality, increased risk of relapse and more complications. This increased virulence is presumably associated with higher levels of toxin production by fluoroquinolone-resistant strains belonging to PCR ribotype 027, pulsed-field gel electrophoresis (PFGE) type NAP1, REA (restriction endonuclease analysis) type BI and toxinotype III. In Europe, outbreaks of CDAD due to the new, highly virulent strain of C. difficile PCR ribotype 027, toxinotype III have been recognised in 75 hospitals in England, 16 hospitals in The Netherlands, 13 healthcare facilities in Belgium and nine healthcare facilities in France. These outbreaks are very difficult to control, and preliminary results from case-control studies indicate a correlation with fluoroquinolones and cephalosporins. Information concerning community-acquired cases of ribotype 027 is lacking, and data concerning its incidence in nursing homes are limited. European countries should first develop early-warning and response capabilities at a national level. Depending on the nature of the notifications received, countries should implement laboratory-based or patient-based surveillance systems in specific, targeted populations.

[Principles of an outbreak investigation in public health practice]

An outbreak (or epidemic) is a higher number of cases of a given disease in a given population and time interval. A timely investigation has for aim to identify the source and vehicle of the outbreak and provides unique opportunities to better understand its occurrence and the role of contributing risk factors to implement the most appropriate measures to control it and prevent further recurrences. The investigation of an outbreak is based on a multidisciplinary approach (clinical, epidemiological, environmental, and microbiological) with a descriptive and analytical (hypothesis testing) phase. In this article, we describe the methodological approach of a field outbreak investigation illustrated by examples taken from our experience. The investigation includes the following steps: establishing the existence of the outbreak; defining the disease; finding cases; describing cases by time, place, and person characteristics; establishing a hypothesis related to the mode of occurrence; testing the hypotheses; conducting an environmental investigation; conducting a microbiological investigation; controlling the outbreak, preventing further occurrences, and writing an investigation report to share experience with the public health and scientific community. The investigation of an outbreak is an evolving process: information gathered or conclusions made at a given stage must be fully used for following steps. The social, institutional, and political background associated with outbreaks usually makes their investigation complex and should be taken into account. The earlier the outbreak is detected and investigated in close relation with public health authorities, the greater will be the potential preventive impact of control measures.

Emergence of Clostridium difficile toxinotype III, PCR-ribotype 027-associated disease, France, 2006

On 27 March 2006, the Institut de Veille Sanitaire (InVS) was alerted to a cluster of Clostridium difficile associated disease (CDAD) in a healthcare facility in northern France

First cluster of C. difficile toxinotype III, PCR-ribotype 027 associated disease in France: preliminary report

On 27 March 2006, a cluster of cases of Clostridium difficile associated disease (CDAD) in a hospital in northern France (hospital A) was notified to the Institut de Veille Sanitaire

Les accidents d’exposition au sang chez les sages-femmes dans les maternités françaises

OBJECTIVE

Midwives appear to be the health care workers exposed to the highest rates of bloodborne injury. In this paper - based on a national survey - we describe the bloodborne injuries occurring in this profession.

MATERIAL AND METHOD

During the year 2003, 241 hospitals took part in a national survey of bloodborne injuries. Employees registered anonymous standardized reports of bloodborne events with the Occupational Medicine Unit. The data were processed by the coordination center for the fight against nosocomial infections (C. CLIN) which is in charge of the national analysis of all the events reported in this database.

RESULTS

169 of the 6973 bloodborne events reported during 2003 (2.4%), were signed by midwives or midwife students. The first three most frequent accidents reported were: ocular projections during childbirth, pricks when repairing episiotomy, pricks or cuts when handling soiled instruments.

CONCLUSION

Improving knowledge of risk as well as promotion of protection/prevention measures well adapted to this profession should be helpful in optimizing future attitudes.