Coordinated surveillance of the multi drug resistant organisms in a French University Hospital: Results since 2013

Abstract

Introduction The control of the cross-transmission of multi drug resistant organisms (MDRO) is a major concern in the healthcare centers. That is the purpose of one of the axes of the French national program of prevention of healthcare-associated infections (Propias). To adapt the recommendations, a French multicenter university hospital started a coordinated and standardized surveillance of MDRO since 2013. The objective of the study is to know the global incidence rate of MDROs and to follow this rate along time. Methods An active standardized surveillance of MDRO was carried out in a university hospital of about 6000 beds. The methodology was based on the French national MDRO's surveillance network (BMR-RAISIN). All methicillin resistant Staphylococcus aureus (MRSA), and extended spectrum beta-lactamase Enterobacteriaceae (ESBLE) detected in clinical specimen performed between April 1, and June 30, in 2013, 2015, and 2017, in the hospitalized patients (in conventional ward or week hospitalization) were included. Screening for colonization and environment samples were excluded. To describe the population with MDROs, we collected data on patient characteristics, specimen sample site, acquired or imported, infection or colonization, ESBLE species, resistance profile for certain antibiotics markers. To calculate the incidence rates, the number of hospitalization days was collected for each period of surveillance. Results For the 3 surveillance periods, a total of 1191 MDRO were included, distributed in 989 ESBLEs (93.04%) and 202 MRSAs (16.96%). The main ESBLE species were Escherichia coli (41.6%), Klebsiella pneumoniae (31.6%) and Enterobacter cloacae (11.4%). The proportion of E. coli decreased along time to the detriment of the other Enterobacteriaceae species, in particular for imported ESBLE (P = 0.0304), while the time evolution was not statistically significant for acquired ESBLEs (P = 0.0555). There were 506 acquired MDROs (42.5%) and 651 imported (54.7%). The most frequent sample types were urine samples (N = 608, 52.9%), respiratory specimens (N = 185, 16.1%) and bloodstream specimens (N = 123, 10.7%). MDROs were responsible of 786 infections among the 1108 for which the information was available (70.9%). Fifteen ESBLEs among 952 were imipenem-resistant (1.6%), and 54 among 868 were ertapenem-resistant (6.2%). The proportion of ertapenem resistant ESBLE was 2-fold increased between 2013 and 2017, from 4.3% to 8.4% (P = 0.06). A 20% > decreased of the incidence rate of MRSA was observed between 2013 and 2017: from 0.25/1000 hospitalization-days in 2013, to 0.17 in 2015, and 0.20 in 2017. This decrease was higher in imported MRSA group. A 62.7% > increased of the ESBLE incidence rate was observed, from 0.83/1000 hospitalization-days in 2013 and 2015 to 1.35 in 2017. This increase was observed both for the imported and acquired ESBLE but was higher for the imported ones. Conclusions The implementation of this surveillance allowed the University hospital to know its global incidence rate of MRSA and ESBLE, and to propose straightaway coordinated prevention measures. We observed over the 3 periods of surveillance a decrease in the MRSA incidence and an increase in the ESBLE incidence. These results are coherent with the national network data. We observed also an increase in the proportion of ertapenem-resistant ESBLE. These data should be construed in the light of the change of the national epidemiology of the antibiotic resistance in Enterobacteriaceae, and particularly the increasing number of episodes of carbapenem-producing Enterobacteriaceae which the university hospital have to manage. These data suggest that a strengthening of campaigns of preventing MDROs cross transmission. Appropriate antibiotic use might also help to limit de diffusion of MDRO in hospital and community.