Twenty years of antimicrobial resistance control programme in a regional multi hospital institution, with focus on emerging bacteria (VRE and CPE)

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.

Figures

Figure 1

Observed cases and predicted values (from segmented regression model) of monthly vancomycin-resistant Enterococcus (VRE) epidemic cases (infections and colonizations) in the Assistance Publique-Hôpitaux de Paris before (period 1) and after implementation of the institutional VRE infection control programme (periods 2 and 3). In period 1, measures to control cross transmission of endemic MDR such as MRSA were applied, in period 2, a specific strategy to control the spread of emerging MDR was instituted. In period 3, this strategy was maintained as routine.

Figure 2

Change in the incidence per 1,000 hospital days (HD) of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase producing enterobacteria (ESBL) in acute care hospitals.