Bacterial resistance to Antibiotics represents a major public health problem.
The epidemiology of enteric bacteria including E.coli is changing rapidly due to global spread of a resistance mechanism called extended spectrum beta-lactamase (ESBL), responsible for resistance to almost all penicillins and cephalosporins, and associated with 75% resistance to quinolones, 67% to cotrimoxazole, and 30 to 50% to aminoglycosides.
The main phenomena causing this problem include:
– Selection pressure by antibiotics, due to their use in humans or animals;
– Hand-borne transmission via the digestive reservoir (feces);
– Easy spread of a resistance mechanism in Enterobacteriaceae due to transferable genetic information (plasmid).
This situation is even more worrying since the pharmaceutical industry invests little in research on new antibiotics. Several studies have reported a recent increase in morbidity and mortality due to therapeutic deadlock related to resistance.
In Nice, epidemiological data from the Hospital and the main city microbiology laboratories show that 4 to 12% of E.coli bacteria found in urine samples are now classified as ESBL which reflects national data. In countries where there is no control of antibiotics use, and the level of hygiene is precarious, 40 to 60% of strains are multi-resistant. Our PACA (Provence Alpes Côte d’Azur) region is particularly exposed and vulnerable because of tourism and its location as the nations’ Southern border.
These strains are often identified in the hospital setting but the majority of carrier-patients are found within the community and have major risk factors: age, recent antibiotic use, diabetes, kidney failure or recurrent urinary tract infections and travel in high risk endemic areas.
Awareness of this epidemic is lacking both among the community and in hospital settings. Microbiological diagnosis of ESBL is explicitly codified but certain medical laboratories are not aware of the necessity to rapidly report resistance mechanisms. This has led us to organize a warning system for physicians in charge of ESBL-infected or carrier patients. Practitioners often feel helpless when confronted with an antibiotic susceptibility test calling for unfamiliar patient management. Patient Information on how to limit the spread of these germs is also still rare.
Carbapenems are the antibiotics advocated in case of ESBL. However, the necessary but unfortunately often excessive use of carbapenem antibiotics in health care facilities or severe conditions currently leads to the emergence of resistance mechanisms, the carbapenemases, posing a major therapeutic problem. This is furthermore complicated by the need to apply hygiene measures and drastic isolation.
In this context, we organized a collaborative regional network of 6 city hospitals: Nice University Hospital, outpatient clinics and private practices of the PACA East (Provence Alpes Côte d’Azur) region, and major medical laboratories. This multidisciplinary network (infectious disease physicians, microbiologists, hygienists, pharmacists) named Réso Infectio PACA Est, decided to pool its epidemiological data and to standardize its microbiological diagnosis procedures, therapeutic protocols and information transmission. A common tool to treat ESBL-patients was created, the ESBL TOOL-KIT.
The “ESBL TOOl-KIT” includes:
– A patient information sheet for carriers of multi-drug resistant (MDR) bacteria , developed by AzurClin and CCLIN.
– Treatment protocols including a version for outpatients and another for hospitalized patients. ESBL management guidelines are also available on the SPILF website since June 2014.
– A check-list of procedures to be carried out by the patient’s attending physician. One is intended for ambulatory care and includes the telephone number of the hospital infectious disease specialist, another is intended for healthcare institutions.
– A standard letter template providing information to the patient’s physician.
All healthcare partners thus take part in a common procedure: once the microbiological diagnosis is established, the patient’s attending physician is alerted and is offered the tool kit.
– To this day, very few countries have published guidelines or reference treatment for ESBL infections (French recommendations on urinary tract infections treatment, including ESBL, were only published on 01.06.2014 by the French Society for Infectious Diseases: (SPILF).
– All health professionals involved follow the same procedure: once the microbiological diagnosis is established, the physician in charge of the patient is alerted and provided with the ESBL Tool-KIT.
A study in 2012 in Nice University Hospital of showed improvement in the management of ESBL patients in terms of processing information to the physician and applying hygiene measures and quality of treatment. The ESBL-TOOLKIT also proved to be effective in applying the accurate ICD-code and thus justifying the daily cost increase of an ESBL-infected patient due to isolation and hygiene measures. Another study in outpatient clinics and private practices in the community showed that GPs’ use of the ESBL-TOOLKIT improved antibiotic use and prescriptions.
These results have encouraged us to create this internet version of the ESBL TOOL-KIT to make it available to all health professionals and also to patients in order to provide them with information concerning hygiene measures.
This approach meets the objectives of quality and safety of care, and is in line with the French national alert plan on Antibiotics and its three strategic themes: improving patient management, preserving the effectiveness of existing antibiotics and promoting research.