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 are:
- The selection pressure by antibiotics, in their use in humans or animals;
- The hand transmission via the digestive reservoir (feces);
- Easy spread of resistance mechanism in Enterobacteria due to transferable genetic information (plasmid).
- Information on epidemiological data
- A leaflet “MRB” (Multidrug resistant bacteria-leaflet) for the patient explaining the problematic as well as hygiene measures (according to CCLIN-recommendations)
- Different therapeutic protocols for hospital use and outpatient clinic use
- A checklist edited for outpatient clinic use describing actions to be taken by the physician who takes care of an ESBL- patient with contact details and telephone number of the University "Department of Infectious Diseases" or its referent for further information.
- A checklist edited for hospital use
- A sample letter for the attending physician
- Strengthening the effectiveness of ESBL-patient management
- Preserving effectiveness of existing antibiotics
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 impasses 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 now are classified as ESBL which corresponds to national data. In countries where there is no control of the use of antibiotics, 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 opening to the south.
These strains are often revealed in the hospital but the majority of carrier-patients are in the city with major risk factors such as: age, recent antibiotic use, diabetes, kidney failure or recurrent urinary tract infections and travelling in high risk endemic areas.
The awareness of this epidemic is insufficient both in the city and the hospital. The microbiological diagnosis is explicitly ESBL-codified but some medical laboratories are not aware of the necessity to report resistance mechanisms rapidly. Therefore we saw the necessity of organizing an alarm system for the physician in charge of an ESBL-patient. As for the practitioners themselves they often feel helpless facing an antibiogram not allowing a usual care of their patients. Patient information on how to limit the spread of these germs is also still rare.
Carbapenem antibiotics are the referenced antibiotic for ESBL. The necessary but unfortunately often excessive use of carbapenem antibiotics in health care facilities or severe pathologies 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, the University Hospital of Nice, outpatientclinics and private offices of the PACA East (Provence Alpes Côte d’Azur) region, and major medical laboratories. This multidisciplinary network (infectious disease doctors, microbiologists, hygienists, pharmacists) named Réso Infectio PACA Est, decided to share its epidemiological data and to standardize its microbiological diagnosis measures, therapeutic protocols and information transmission. Therefore a shared tool to treat ESBL-patients was created, the ESBL TOOL-KIT.
The "ESBL TOOl-KIT" includes:
Until today no guidelines or reference treatment for ESBL infections have been published in almost all countries (French recommendations on urinary tract infections treatment, including ESBL, were published only on 01.06.2014 by the SPILF)
All health actors involved follow the same organization procedure: once the microbiological diagnosis is established, the doctor in charge of the patient is alerted and provided with the ESBL Tool-KIT.
A study in 2012 at the University Hospital of Nice 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-patient due to isolation and hygiene measures. Another study in outpatient clinics and private offices in the city showed that the GP’s 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 making it available to all health professionals and also to patients in order to provide information about hygiene measures.
This approach meets the objective of quality and safety of care, and is conclusive with the French national alert plan on Antibiotics and its three strategic axes: