Bacterial resistance to antibiotics in France : a public health priority

H. Aubry-Damon 1, J. Carlet 2, P. Courvalin 3, J.C. Desenclos 1 , J. Drucker 1 , D. Guillemot 4 , V. Jarlier 5, B. Régnier 6 , B. Schlemmer 71. Institut de Veille Sanitaire, Département des Maladies Infectieuses, Saint-Maurice, France
2 .Service de réanimation polyvalente, Hôpital St Joseph, Paris, France
3. Centre National de Référence des mécanismes de résistance, Institut Pasteur, Paris, France
4. INSERM unité 21, Villejuif, France
5. Laboratoire de Bactériologie et Hygiène, groupe hospitalier Pitié Salpétrière, Paris, France
6. Service de réanimation des maladies infectieuses, groupe hospitalier Bîchat-Claude Bernard, Paris, France
7. Service de réanimation médicale, Centre Hospitalier Universitaire Saint-Louis, Paris, France

For a few years, France has been faced to a rapid spread of antimicrobial resistance in hospitals and in general practice despite the many recommendations issued to solve this problem. In 1999, the Institut de Veille Sanitaire conducted a collective expertise followed by a national consultation gathering all national health professionals involved in antimicrobial resistance. This consultation ended with proposals in the perspective of a national plan of actions to control antimicrobial resistance presented to the French Ministry of Health.

The spread of antimicrobial resistance in France has been a major concern for a few years, whether in general practice or in hospitals. We are observing a clonal and rapid spread of methicillin resistant Staphylococcus aureus (MRSA) in hospitals (over a 7-year period the incidence of isolation of MRSA susceptible to gentamicin and with heterogeneous susceptibility to methicillin has steadily increased to represent in 1998, depending on hospitals, 46.8% to 94.4 % of the MRSA strains (1). In general practice, the rate of Streptococcus pneumomiae strains with diminished susceptibility to penicillin G raised considerably from 4.9% in 1988 to 48% in 1997 as well as the rate of therapeutic failures of infections caused by these bacteria, notably ENT infections in children (2,3) .

Many recommendations have been issued in the fields of surveillance and the prevention of infectious disease transmission since 1996 (4-10), but few have prompted action, because health professionals concerned have been inadequately informed. In 1998, a report on antibiotics issued by the Observatoire National des Prescriptions et Consommations des Médicaments (ONPCM; National Observatory for Prescriptions and Medicines Consumption) showed that antibiotic sales in general practice in France were increasing by 2.6 % per year in value, and that half of them were for the treatment for respiratory infections mainly of viral origin (11). Following the publication of this report, and upon request from the State Secretary for Health and Social Action, national experts in consultation with health professionals developed proposals for a national action plan to control antimicrobial resistance. This article focuses on the proposals related to human medicine. Actions set up since then will be presented in a Euroroundup (12)

An original consultation

In 1999 the Réseau National de Santé Publique (Institut de Veille Sanitaire (InVS) since 1999) launched a national consultation in order to define the terms of reference for a coordinated scheme for the control of antimicrobial resistance. This consultation was made in two stages. Proposals were developed by groups of experts. The proposals were presented for consultation to health professionals in human and animal health, from the public and private sectors, concerned in the use and the manufacture of antibiotics and in resistance control.

Fifty-five French experts who had attended a European conference on antimicrobial resistance in Copenhagen in 1998 (13) formed three multidisciplinary groups to elaborate proposals for action on the following subjects: surveillance of bacterial resistance to antibiotics and surveillance of their consumption in humans and animals, the control and prevention of resistance, and the promotion of research on resistance. In parallel, active bibliographical research was carried out. Documentary resources as well as national validated recommendations not yet issued at the time (9,10) were made available to each expert.

In January 1999, the work of the thematic groups was presented during a seminar open to all professionals, institutions, and organizations related to human and veterinary health and concerned with bacterial resistance to antibiotics. At the end of January 1999, after validation, the proposals were presented in a report to the Ministry of Health as part of a national plan of actions to control antimicrobial resistance (14).

Proposals for a national plan

All the proposals were matched with orientation elements for the elaboration of this plan (table).

Table. Basis for the development of a national plan

 

Actions

Type of actions

Level

Surveillance

a. monitoring

Regulations, Developing tools *

National, international, hospital, community

b. sentinel network

Regulations, Developing tools *

Experimental, community

c. alert

Regulations

National, hospital, community

d. ONPCM

Regulations

National, hospital, community

e. COM.MED

Regulations

Local, hospitalier

Control

a. distribution / hospital

Educating population,  Health care staff training, Developing tools *

National, hospitalier

b. distribution / community

Educating population,  Health care staff training, Regulations

National, community

c. good practice / hospitals

Health care staff training,  Regulations, Developing tools *

National, hospital

d. good practice / community

Educating population, Health care staff training,  Regulations, Developing tools *

National, community

* Developing tools (methods and standardisation of monitoring, information systems, prescription guides, diagnosis and therapeutic tests …)

From surveillance…

In term of surveillance, six proposals were issued. Two were to reinforce and/or improve existing facilities or agencies (14) for the surveillance of resistance in humans – reinforcing existing networks and national reference centres, extending the role of the ONPCM in hospitals and registering the task of the Medicines Committee (COM.MED) as regulations. The third was to create a sentinel network for laboratories and corresponding practitioners, the fourth to set up an alert procedure when new resistances emerge, to work alongside statutory notifications of nosocomial infections, the fifth to develop incentive measures (reinvestment, accreditation, contracts of objectives), and the sixth to improve collaboration between doctors and veterinarians for the surveillance of resistance in bacterial zoonoses.

… to resistance control

As far as resistance control is concerned, the emphasis for hospitals is to follow recommendations published previously (6) and to apply the programme of the National Nosocomial Infections Committee (CTIN-CCLIN, Comité Technique National des Infections Nosocomiales et des Centres de Coordination de la Lutte contre les Infections Nosocomiales) set up in 1992 to prevent the spread of multiresistant bacteria in hospitals (4,5). As for general practice, it has been proposed to follow existing recommendations (10) and to promote the use of a rapid diagnosis test for streptococcal tonsillitis in doctors’ practices. Control of the advertising of antibiotics has also been proposed. In the face of the transmission of resistant pathogenic bacteria in very young children kept in nurseries (unlike other European countries, in France children aged 3 to 4 months may attend such facilities) it is recommended to encourage alternatives that could delay placement in day nurseries until children are 18 months old, when the risks are lower, and to reinforce hygiene standards in such facilities.

Initial training and continuous education of all health professionals and informing patients and their families (through active communication, adapted to the community and echoed by health professionals) must be reinforced to ensure that the proposed measures are understood and followed

Research

Three proposals related to research have been written up for publication by Guillemot D, Courvalin P, and the members of the French Working Group ‘Promote research to control bacterial resistance’ :

– promote pharmacoclinical, pharmacoepidemiological (exposure of populations…), socioeconomic (social and financial costs …), and public health (impact in terms of mortality, morbidity…) research as well as research on the strategies regarding the use of antibiotics and the new anti-infectious approaches

– support fundamental microbiological research on the emergence of resistance and the process of resistance transmission.

– promote research on rapid diagnosis tests of detection/prediction of resistance.

Conclusion

Since the publication of this report in January 1999 (14), several measures have been taken to inform practitioners and the population about appropriate use of antibiotics in hospital and in the community, and to control advertising of antibiotics. The control of nosocomial infections is now subject to a national plan. Measures to enable control to be reinforced are under way as is an evaluation system (12).

Beside these national initiatives, France takes part in European projects such as European Antimicrobial Resistance Surveillance System (EARSS), Enter-net (whose two objectives are to collect standardized data on the antimicrobial resistance patterns of salmonella and to facilitate the study of resistance mechanisms on a collection of representative strains of multidrug resistant salmonella), and EUROTB (improved surveillance of tuberculosis by encouraging countries to collect and to analyze national data on drug resistance with standardized methods). France also takes part in HELICS III (Hospitals in Europe Link for Infection Control through Surveillance, phase 3), a programme for the development of a European network for monitoring and making harmonised recommendations in the field of nosocomial infections. One of its five priority areas for development is the monitoring of antibiotic resistance and use of antibiotics.

To date, many measures, statutory or organisational, have been taken to control antimicrobial resistance in the community and in hospitals. National partners and institutions involved in this fight are numerous. The adoption of a national plan against antimicrobial resistance gathering all participants would improve the efficiency of all these measures and actions.


References

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