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Original article
Three years of antibiotic consumption evaluation in French nursing homes Trois ans de consommations d’antibiotiques en établissements d’hébergement pour personnes âgées dépendantes A. Marquet a,∗ , S. Thibaut a , E. LePabic a , J.F. Huon a,b , F. Ballereau a,b a
Centre ressource en antibiologie, hôpital Saint-Jacques, MedQual, CHU de Nantes, 85, rue Saint-Jacques, 44093 Nantes cedex 01, France b EA 3826, thérapeutiques cliniques et expérimentales des infections, université de Nantes, Nantes, France Received 20 October 2014; received in revised form 28 April 2015; accepted 18 May 2015
Abstract Objectives. – We had for aim to assess antibiotic consumption and to better understand their use in nursing homes so as to target messages on relevant practice procedures sent to prescribers. Design. – The MedQual network asked nursing homes with in-house pharmacies to participate in a retrospective collection of yearly antibiotic consumption data with an Excel® spread sheet according to the Health Ministry recommendations. Results. – Fifty-two nursing homes participated in 2011, 2012, and 74 in 2013, accounting for 10% of the Pays de la Loire region’s nursing homes and 15% of beds. The medians of total antibiotic consumption in daily-defined dose for 1000 patient-days were respectively 39 (32.4–49.0), 39.3 (34.4–52.9), and 44.8 (33.6–55.4). There was no significant difference between 2011 and 2013. Penicillins (J01C) were the most commonly used class with a median of 25.7 [IQ 18.8; 33.8] in 2011 and 30.4 [IQ 23.6; 41.3] in 2013. Quinolones (J01M) were the second most commonly used class with a median of 4.6 [IQ 2.9; 5.9] in 2011 and 3.8 [IQ 2.3; 6.5] in 2013, followed by the other beta-lactams (J01D) with a median of 2.5 [IQ 1.7; 4.5] in 2011 and 2,8 [IQ 1.7; 3.8] in 2013. Conclusion. – The monitoring of antibiotic consumption in nursing homes in the Pays de la Loire Region since 2011 has allowed identifying inappropriate use and helped improve practices. No increase of overall consumption was observed in nursing homes but the distribution according to antibiotic class changed. The current objective is to extend this monitoring and to send personalized messages to prescribers. © 2015 Elsevier Masson SAS. All rights reserved. Keywords: Antibiotic; Nursing home; Penicillin
Résumé Objectifs. – Suivre la consommation des antibiotiques afin de mieux en connaître l’utilisation dans les établissements d’hébergement pour personnes âgées dépendantes (EHPAD) et de cibler les messages à adresser aux prescripteurs. Méthodes. – Depuis 2011, MedQual propose aux EHPAD dont l’approvisionnement est assuré par une pharmacie à usage intérieur, de participer à un recueil rétrospectif annuel des consommations antibiotiques à l’aide d’un tableau Excel® adapté à la région, selon les recommandations du ministère de la Santé. Résultats. – Cinquante-deux EHPAD en 2011 et 2012, et 74 en 2013, représentant environ 10 % des établissements de la région et 15 % des lits, ont participé au recueil des données de consommation d’antibiotiques. Les médianes de la consommation globale d’antibiotiques sur ces 3 ans, exprimée en doses définies journalières pour 1000 journées d’hospitalisation, sont respectivement de 39 (32,4–49,0), 39,3 (34,4–52,9) et 44,8 (33,6–55,4). Il n’y pas de différence significative entre 2011 et 2013. Les pénicillines (J01C) restent la classe la plus consommée avec une médiane de 25,7 [IQ 18,8 ; 33,8] en 2011 à 30,4 [IQ 23,6 ; 41,3] en 2013. Les quinolones (J01M) représentent la deuxième classe avec une médiane de 4,6 [IQ 2,9 ; 5,9] en 2011 et 3,8 [IQ 2,3 ; 6,5] en 2013 devant les autres bêtalactamines (J01D) : 2,5 [IQ 1,7 ; 4,5] en 2011 et 2,8 [IQ 1,7 ; 3,8] en 2013.
∗
Corresponding author. E-mail address: [email protected] (A. Marquet).
http://dx.doi.org/10.1016/j.medmal.2015.05.006 0399-077X/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Marquet A, et al. Three years of antibiotic consumption evaluation in French nursing homes. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.05.006
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Conclusion. – Le suivi de la consommation d’antibiotiques en EHPAD permet de repérer les situations d’usage inapproprié et d’accompagner les mesures d’amélioration. Il n’a pas été observé d’augmentation de la consommation totale mais la répartition entre les classes d’antibiotiques a évolué. L’objectif à terme est d’étendre ce dispositif et de véhiculer des messages individualisés aux prescripteurs. © 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Antibiotiques ; EHPAD ; Pénicillines
1. Introduction The management of dependent elderly patients has become a major public health issue due to the aging of the French population. France remains one of the countries with the greatest consumption of antibiotics in community and healthcare facilities [1]. The French population is aging and therefore requirements for accommodation are increasing [2]. Age-related frailty and living in an institution are risk factors for infection [3] and account for the exposure of elderly patients to antibiotics. The systematic monitoring of antibiotic consumption is neither proposed nor performed in nursing homes (NHs) in France, contrary to what is proposed in healthcare institutions by the ATB-RAISIN (French antibiotic network) [4]. Only prevalence studies of antibiotic consumption on a given day were conducted at a national and regional level in France, with results ranging from 3.9 to 6% [5–12]. MedQual, the resource center for antibiotic use, has extended its actions to NHs since 2011, to promote the regional policy of antibiotic stewardship. The objective of our study was to monitor the consumption of antibiotics in NHs longitudinally, to assess the trends and document the most frequently prescribed agents. 2. Materials and methods The yearly retrospective collection of antibiotic consumption data has been performed since 2011 in NHs of the Pays de la Loire region supplied by an in-house pharmacy (IHP), because inventory management and/or prescription and pharmaceutical analysis software facilitate access to data. The antibiotic consumption in day-care institutions and sheltered housing is excluded from the collection. NHs participate on a voluntary basis. Data were collected from Excel® spreadsheets according to the Ministry of Health recommendations, adapted to a yearly retrospective collection in the region [13] for 2011 and 2012. In 2013, the e-tool ConsoRes® designed by the regional coordination center for the control of nosocomial infections in Eastern France (CClin East), was implemented by MedQual in Pays de la Loire healthcare institutions. This allows monitoring J01 class systemic antibiotics of the Anatomical Therapeutic Chemical classification system (ATC). Seven antibiotics administered orally were more closely monitored: amoxicillin, amoxicillin/clavulanic acid, ofloxacin, norfloxacin, sulfamethoxazole/trimethoprim, nitrofurantoin, and third-generation cephalosporins (C3G). The NHs are classified according to their administrative subdivision and category defined by the number of beds: less than 80 beds, from
81 to 160 beds, and 161 beds and more. The medians were compared with a Mann-Whitney test (nonparametric test) and Student’s t test (nonparametric test) (P < 0.05). 3. Results 3.1. Representativeness Fifty-two NHs, supplied by an IHP, participated in the collection of antibiotic consumption data in 2011 and 2012, and 74 in 2013. Table 1 is a list of NHs for which consumption data were analyzed, approximately 10% of NHs in the Pays de la Loire region and 12% of total number of beds. 3.2. Antibiotic consumption The median regional consumption of antibiotics, expressed in DDD/1000PD, was respectively 39, 39.3, and 44.8 from 2011 to 2013. No significant difference was observed between 2011 and 2013 (P > 0.05). The first 3 classes (median expressed in DDD/1000PD) of the most consumed antibiotics were penicillins (J01C) [25.7 (2011), 28.9 (2012) and 30.4 (2013)], quinolones (J01M) [4.7 (2011), 4 (2012), 3.8 (2013)] DDD/1000PD, and class of macrolides and related (J01F) [3.2 (2011), 2.6 (2012), 2.7 (2013)]. A significant difference was observed only for the class of penicillins (Table 2) with a decrease of 15.4% between 2011 and 2013. A significant increase in consumption was noted for amoxicillin/clavulanic acid per os (P < 0.05) among the 7 closely monitored antibiotics (Table 3) considered as important antibiotics concerning the emergence of resistance (amoxicillin/clavulanic acid, third-generation cephalosporins, and fluoroquinolones). Comparisons between region administrative sub-divisions were made (Table 4). There was no difference in antibiotic consumption among the Loire Atlantique (44), Maine et Loire (49), Mayenne (53), Sarthe (72), and Vendée (85) subdivisions for each year. The antibiotic consumption increased in the sub-divisions, (P > 0.05) except for Vendée. NHs consumed less between 2011 and 2013, but not significantly so (P = 0.36). We also analyzed the data according to nursing homes’ number of beds (Table 5). No significant difference was observed. 4. Discussion The management of dependent elderly patients has become a major public health issue due to the aging French population. A total of 1.17 million of elderly were dependent (7.8% of
Please cite this article in press as: Marquet A, et al. Three years of antibiotic consumption evaluation in French nursing homes. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.05.006
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Table 1 Nursing homes representativeness. Représentativité des EHPAD participants par année.
2011 2012 2013
NB nursing homes
% Nursing home region
% Nursing home/IHP region
NB beds
% Beds for the region
52 52 74
9.1 9.1 13.0
58.4 58.4 83.1
6413 6410 7053
14.9 14.9 16.4
NB nursing homes: number of nursing homes participating in the study; % nursing home region: representativeness compared to the total number of nursing homes in the Pays de la Loire region; % nursing home/IHP region: representativeness compared to the total number of nursing homes with an IHP; NB beds: total number of beds in all nursing homes; % beds region: representativeness compared to the total number of beds in all nursing homes, in the Pays de la Loire region. Table 2 Total antimicrobial consumption, median and interquartiles. Consommation globale d’antibiotiques, médiane et IQ. Median 2011
2012
2013
n
52
52
74
Penicillins Cephalosporins, penems, monobactams Sulfamides Macrolides, lincosamides, streptogramins Aminosides Quinolones Other antibiotics Total IQ
25.70 2.54 0.49 3.22 0.00 4.58 1.50 39.01 32.4–49.0
28.85 2.73 0.64 2.58 0.00 4.04 1.05 39.34 34.4–52.9
30.36 2.75 0.72 2.74 0.00 3.78 1.49 44.84 33.6–55.4
P (2011–2013)
< 0.05 NS NS NS NS NS NS NS
IQ: interquartile; n: number of nursing home participating in the study; NS: non significant.
individuals 60 years of age or more) in January 2012, in France. The number of dependent elderly patients is forecasted to reach 2.3 million in 2060. Nine percent of people 75 years of age or more live in a NH [14]. A French national infection prevention program was implemented for the health and social sector in 2011; one of its items was the implementation of a document analyzing infectious risks (French acronym Dari) in which antibiotic stewardship was encouraged. [5] Monitoring antibiotic prescriptions, bacterial resistance, and infections is crucial to increase the awareness of prescribers and promote preventive actions in all European countries [6]. No such monitoring has been proposed in NHs so far, in France; this is also true for other European countries [6]. Only prevalence surveys have been carried out at a European [9] and French [15] level. The reported prevalence in these studies was variable.
The European surveillance of antimicrobial consumption group (ESAC) conducted a prevalence survey between April and May 2013 in 19 European countries, in 1181 long-term care units. NHs accounted for 64.5% of the sample. France did not participate in the second edition of the HALT study (Healthcareassociated infections and antimicrobial use in long-term care facilities). The rate of NH patients with an antibiotic prescription was 4.4%. Penicillins (J01C) accounted for 29.3% of prescriptions (J01C), 19.8% were other antibiotics (J01X), and 16% were quinolones (J01M) [12]. Our study results were different concerning the consumption of other antibiotics with on average only 4% of the total antibiotic consumption. We were not able to demonstrate any significant difference among administrative sub-divisions or according to NH number of beds. The results were mainly due to a significant
Table 3 Targeted antibiotics. Antibiotiques suivis.
Amoxicillin PO Amoxicillin/clavulanic acid PO Ceftriaxon IV Cotrimoxazole PO Norfloxacin 400 mg PO Ofloxacin 200 mg PO C3G PO Nitrofurantoin
2011
2012
2013
P (2011–2013)
9.52 13.62 0.99 0.49 1.72 1.06 0.90 0.61
11.77 15.39 0.96 0.59 1.41 0.77 1.20 0.52
12.96 15.20 1.20 0.58 1.04 0.73 0.68 0.38
NS < 0.05 NS NS NS NS NS NS
PO: per os.
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Table 4 Total antibiotic consumption for the Pays de la Loire region sub-divisions. Consommation globale d’antibiotiques par département de la région des Pays de la Loire. 2011
2012
2013
P (2011–2013)
32.7 30.2–41.2 15
45.4 35.5–53.1 14
42.7 37.6–51.5 17
NS
41.5 36.2–45.5 5
45.2 35.8–56.1 8
47.6 36.7–60.1 21
NS
49.1 33.8–53.2 11
37.9 37.1–51.5 9
49.5 41.7–74.8 12
NS
36.8 32.0–45.8 11
39.4 32.9–58.8 11
38.3 32.1–68.9 15
NS
41.8 39.0–56.4 10
37.6 31.9–43.0 10
37.3 29.1–48.9 9
NS
44 Median IQ n 49 Median IQ n 53 Median IQ n 72 Median IQ n 85 Median IQ n
Table 5 Total antibiotic consumption in relation to nursing home capacity. Consommation globale d’antibiotiques par capacité des EHPAD de la région des Pays de la Loire.
0–80 Median IQ n 81–160 Median IQ n 161 and more Median IQ n
2011
2012
2013
P (2011–2013)
33.0 28.4–46.9 24
35.4 30.9–50.4 25
44.6 33.1–55.2 41
NS
42.2 36.0–53.0 15
51.8 40.6–59.5 15
45.0 37.5–60.1 26
NS
41.5 38.3–45.5 13
43.6 37.4–46.9 12
44.5 39.1–48.6 7
NS
increase in the number of participating NHs. The increasing participation was due to an improved accuracy of data collection in NHs with the implementation of the ConsoRes® web tool. The 2011 and 2012 consumption was expressed for all NH activity and not for each NH unit. We were able to improve the accuracy of data collection with the new e-tool. It will be interesting to compare the 2013 and 2014 consumption to show the impact of this system. We compared NH data with Pays de la Loire healthcare institution data (a cohort of 39 institutions) and found that NHs accounted for 11% of overall antibiotic consumption (Table 6). But NHs did not follow the same trend as healthcare institutions (Pays de la Loire) that were decreasing their antibiotic consumption (P > 0.05). Fluoroquinolones are beginning to be less frequently used than other antibiotics, such as amoxicillin/clavulanic acid, although the difference is not significant. However, it is difficult to predict the long-term consequences of this qualitative change
in prescription, both in terms of bacterial resistance [16,17] and safety; this will require close monitoring over time. The next step of this study will be to work also with NHs without an IHP. This may be achieved via a partnership with the Healthcare Insurance to have access to data for these institutions. The longitudinal monitoring of antibiotic consumption ultimately aims at educating prescribers on the optimal use of antibiotics for NH residents, and at supporting remedial Table 6 Total antimicrobial consumption for nursing homes and hospitals from 2011 to 2013 (median expressed in DDD/1000PD). Consommation globale d’antibiotiques pour les EHPAD et les établissements de santé des Pays de la Loire de 2011 à 2013 (médiane en DDJ/1000PD).
Median number of healthcare institutions Median number of nursing homes
2011
2012
2013
323.9 39.0
320.6 39.3
321.1 44.8
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measures that can be adapted to the number of beds and/or location of the NH according to supplied data. Specific studies with the objective of documenting indications for antibiotics used in NHs should usefully complement this monitoring. 5. Conclusion Studying antibiotic consumption in NHs remains infrequent in France and Europe. Only prevalence surveys have been conducted. We did not find any French publications on a permanent monitoring of antibiotic consumption in this type of structure. The use of antibiotics for nursing home residents is common and sometimes inappropriate. The main contribution of this monitoring is to know which antibiotics are used in NHs and to follow their consumption trend to understand how they are used in NHs, and to help prescribers use them optimally in the risk group of elderly patients. Even if the nursing home is considered as home for residents, prescribing an individual antibiotic therapy impacts on the whole community, particularly with the emergence of bacterial resistance. Participation of authors A. Marquet collected and processed the data, and wrote the article. E. Lepabic processed the data. S. Thibault, J.-F. Huon, and F. Ballereau proofread the article. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements We would like to thank all nursing homes having participated in this study and especially their pharmacists. References [1] Agence nationale de sécurité des médicaments et des produits de santé. Évolution des consommations d’antibiotiques en France entre 2000 et 2013 : nouveau rapport d’analyse de l’ANSM; 2014 [Dernière consultation le 31/03/2015] www.ansm.sante.fr [2] Institut national de la statistique et des études économiques. Évolution de la population jusqu’en 2012. Disponible sur www.insee.fr. [Dernière consultation le 30/07/2014].
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[3] Nicolle ALE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin microbiol Rev 1996;9(1): 1–17. [4] Institut de veille sanitaire. Surveillance des consommations antibiotiques et des résistances bactériennes dans les établissements de santé (avril 2014). Disponible sur www.invs.sante.fr. [Dernière consultation le 31/07/2014]. [5] Circulaire interministérielle no DGS/2012/118 du 15 mars 2012 relative à la mise en œuvre du programme national de prévention des infections dans le secteur médico-social 2011/2013 (15 mai 2012). [6] Chami K, Gavazzi G, de Wazières B, Lejeune B, Piette F, et al. Prévalence des infections dans les établissements d’hébergement pour personnes âgées dépendantes : analyse régionale, enquête PRIAM, France, 2006–2007. Bull Epidemiol Hebd 2009;31–32:349–52. [7] Moro ML, Jans B, Cookson B, Fabry J. The burden of healthcare-associated infections in European long-term care facilities. Infect Control Hosp Epidemiol 2010;31(Suppl. 1):S59–62. [8] Institut national de veille sanitaire [Dernière consultation le 31/07/2014] Enquête de prévalence des infections en établissements d’hébergement de personnes âgées dépendantes; 2010. [9] McClean P, Hughes C, Tunney M, Goossens H, Jans B. Antimicrobial prescribing in European nursing homes. J Antimicrob Chemother 2011;66(7):1609–16. [10] European surveillance of antimicrobial consumption. Results from the national survey of characteristics of nursing homes. 2009. Disponible sur http://www.esac.eu. [Dernière consultation le 30/07/2014]. [11] European Centre for disease prevention control. Ears-net result 2011; 2011 [Dernière consultation le 31/03/2015] www.ecdc.europa.eu [12] European Centre for disease prevention control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities; 2013 [Dernière consultation le 31/03/2015] www.ecdc.europa.eu [13] Ministère de la Santé. Guide pour une méthode de calcul des consommations d’antibiotiques dans les établissements de santé et en ville; 2006 [Dernière consultation le 4 août 2014] www.sante.gouv.fr [14] Institut national de la statistique et des études économiques. Tableau de l’économie. 100–101; 2014 [Dernière consultation le 31/07/2014] www.insee.fr [15] Boivin Y, Talon D, Leroy J, Floret N, Gbaguidi-Haore H, Bertrand X. Antibiotic prescription in nursing homes for dependent elderly people: a cross-sectional study in Franche-Comté. Med Mal Infect 2013;(43): 163–9. [16] Thibaut S, Caillon J, Marquet A, Grandjean G, Potel G, Ballereau F. Epidemiology of third-generation cephalosporin-resistant communityacquired Enterobacteria isolated from elderly patients. Med Mal Infect 2014;44(2):57–62. [17] Van der Mee-Marquet N, Savoyen P, Domelier-Valentin AS, Mourens C, Quentin R, Réseau des Hygiénistes du Centre Study Group. CTX-M-type fluoroquinolone-resistant Escherichia coli: analysis of the colonization of residents and inanimate surfaces 1 year after a first case of urinary tract infection at a nursing home in France. Infect Control Hosp Epidemiol 2010;31(9):968–70, http://dx.doi.org/10.1086/655835.
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Original article
Three years of antibiotic consumption evaluation in French nursing homes Trois ans de consommations d’antibiotiques en établissements d’hébergement pour personnes âgées dépendantes A. Marquet a,∗ , S. Thibaut a , E. LePabic a , J.F. Huon a,b , F. Ballereau a,b a
Centre ressource en antibiologie, hôpital Saint-Jacques, MedQual, CHU de Nantes, 85, rue Saint-Jacques, 44093 Nantes cedex 01, France b EA 3826, thérapeutiques cliniques et expérimentales des infections, université de Nantes, Nantes, France Received 20 October 2014; received in revised form 28 April 2015; accepted 18 May 2015
Abstract Objectives. – We had for aim to assess antibiotic consumption and to better understand their use in nursing homes so as to target messages on relevant practice procedures sent to prescribers. Design. – The MedQual network asked nursing homes with in-house pharmacies to participate in a retrospective collection of yearly antibiotic consumption data with an Excel® spread sheet according to the Health Ministry recommendations. Results. – Fifty-two nursing homes participated in 2011, 2012, and 74 in 2013, accounting for 10% of the Pays de la Loire region’s nursing homes and 15% of beds. The medians of total antibiotic consumption in daily-defined dose for 1000 patient-days were respectively 39 (32.4–49.0), 39.3 (34.4–52.9), and 44.8 (33.6–55.4). There was no significant difference between 2011 and 2013. Penicillins (J01C) were the most commonly used class with a median of 25.7 [IQ 18.8; 33.8] in 2011 and 30.4 [IQ 23.6; 41.3] in 2013. Quinolones (J01M) were the second most commonly used class with a median of 4.6 [IQ 2.9; 5.9] in 2011 and 3.8 [IQ 2.3; 6.5] in 2013, followed by the other beta-lactams (J01D) with a median of 2.5 [IQ 1.7; 4.5] in 2011 and 2,8 [IQ 1.7; 3.8] in 2013. Conclusion. – The monitoring of antibiotic consumption in nursing homes in the Pays de la Loire Region since 2011 has allowed identifying inappropriate use and helped improve practices. No increase of overall consumption was observed in nursing homes but the distribution according to antibiotic class changed. The current objective is to extend this monitoring and to send personalized messages to prescribers. © 2015 Elsevier Masson SAS. All rights reserved. Keywords: Antibiotic; Nursing home; Penicillin
Résumé Objectifs. – Suivre la consommation des antibiotiques afin de mieux en connaître l’utilisation dans les établissements d’hébergement pour personnes âgées dépendantes (EHPAD) et de cibler les messages à adresser aux prescripteurs. Méthodes. – Depuis 2011, MedQual propose aux EHPAD dont l’approvisionnement est assuré par une pharmacie à usage intérieur, de participer à un recueil rétrospectif annuel des consommations antibiotiques à l’aide d’un tableau Excel® adapté à la région, selon les recommandations du ministère de la Santé. Résultats. – Cinquante-deux EHPAD en 2011 et 2012, et 74 en 2013, représentant environ 10 % des établissements de la région et 15 % des lits, ont participé au recueil des données de consommation d’antibiotiques. Les médianes de la consommation globale d’antibiotiques sur ces 3 ans, exprimée en doses définies journalières pour 1000 journées d’hospitalisation, sont respectivement de 39 (32,4–49,0), 39,3 (34,4–52,9) et 44,8 (33,6–55,4). Il n’y pas de différence significative entre 2011 et 2013. Les pénicillines (J01C) restent la classe la plus consommée avec une médiane de 25,7 [IQ 18,8 ; 33,8] en 2011 à 30,4 [IQ 23,6 ; 41,3] en 2013. Les quinolones (J01M) représentent la deuxième classe avec une médiane de 4,6 [IQ 2,9 ; 5,9] en 2011 et 3,8 [IQ 2,3 ; 6,5] en 2013 devant les autres bêtalactamines (J01D) : 2,5 [IQ 1,7 ; 4,5] en 2011 et 2,8 [IQ 1,7 ; 3,8] en 2013.
∗
Corresponding author. E-mail address: [email protected] (A. Marquet).
http://dx.doi.org/10.1016/j.medmal.2015.05.006 0399-077X/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Marquet A, et al. Three years of antibiotic consumption evaluation in French nursing homes. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.05.006
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A. Marquet et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Conclusion. – Le suivi de la consommation d’antibiotiques en EHPAD permet de repérer les situations d’usage inapproprié et d’accompagner les mesures d’amélioration. Il n’a pas été observé d’augmentation de la consommation totale mais la répartition entre les classes d’antibiotiques a évolué. L’objectif à terme est d’étendre ce dispositif et de véhiculer des messages individualisés aux prescripteurs. © 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Antibiotiques ; EHPAD ; Pénicillines
1. Introduction The management of dependent elderly patients has become a major public health issue due to the aging of the French population. France remains one of the countries with the greatest consumption of antibiotics in community and healthcare facilities [1]. The French population is aging and therefore requirements for accommodation are increasing [2]. Age-related frailty and living in an institution are risk factors for infection [3] and account for the exposure of elderly patients to antibiotics. The systematic monitoring of antibiotic consumption is neither proposed nor performed in nursing homes (NHs) in France, contrary to what is proposed in healthcare institutions by the ATB-RAISIN (French antibiotic network) [4]. Only prevalence studies of antibiotic consumption on a given day were conducted at a national and regional level in France, with results ranging from 3.9 to 6% [5–12]. MedQual, the resource center for antibiotic use, has extended its actions to NHs since 2011, to promote the regional policy of antibiotic stewardship. The objective of our study was to monitor the consumption of antibiotics in NHs longitudinally, to assess the trends and document the most frequently prescribed agents. 2. Materials and methods The yearly retrospective collection of antibiotic consumption data has been performed since 2011 in NHs of the Pays de la Loire region supplied by an in-house pharmacy (IHP), because inventory management and/or prescription and pharmaceutical analysis software facilitate access to data. The antibiotic consumption in day-care institutions and sheltered housing is excluded from the collection. NHs participate on a voluntary basis. Data were collected from Excel® spreadsheets according to the Ministry of Health recommendations, adapted to a yearly retrospective collection in the region [13] for 2011 and 2012. In 2013, the e-tool ConsoRes® designed by the regional coordination center for the control of nosocomial infections in Eastern France (CClin East), was implemented by MedQual in Pays de la Loire healthcare institutions. This allows monitoring J01 class systemic antibiotics of the Anatomical Therapeutic Chemical classification system (ATC). Seven antibiotics administered orally were more closely monitored: amoxicillin, amoxicillin/clavulanic acid, ofloxacin, norfloxacin, sulfamethoxazole/trimethoprim, nitrofurantoin, and third-generation cephalosporins (C3G). The NHs are classified according to their administrative subdivision and category defined by the number of beds: less than 80 beds, from
81 to 160 beds, and 161 beds and more. The medians were compared with a Mann-Whitney test (nonparametric test) and Student’s t test (nonparametric test) (P < 0.05). 3. Results 3.1. Representativeness Fifty-two NHs, supplied by an IHP, participated in the collection of antibiotic consumption data in 2011 and 2012, and 74 in 2013. Table 1 is a list of NHs for which consumption data were analyzed, approximately 10% of NHs in the Pays de la Loire region and 12% of total number of beds. 3.2. Antibiotic consumption The median regional consumption of antibiotics, expressed in DDD/1000PD, was respectively 39, 39.3, and 44.8 from 2011 to 2013. No significant difference was observed between 2011 and 2013 (P > 0.05). The first 3 classes (median expressed in DDD/1000PD) of the most consumed antibiotics were penicillins (J01C) [25.7 (2011), 28.9 (2012) and 30.4 (2013)], quinolones (J01M) [4.7 (2011), 4 (2012), 3.8 (2013)] DDD/1000PD, and class of macrolides and related (J01F) [3.2 (2011), 2.6 (2012), 2.7 (2013)]. A significant difference was observed only for the class of penicillins (Table 2) with a decrease of 15.4% between 2011 and 2013. A significant increase in consumption was noted for amoxicillin/clavulanic acid per os (P < 0.05) among the 7 closely monitored antibiotics (Table 3) considered as important antibiotics concerning the emergence of resistance (amoxicillin/clavulanic acid, third-generation cephalosporins, and fluoroquinolones). Comparisons between region administrative sub-divisions were made (Table 4). There was no difference in antibiotic consumption among the Loire Atlantique (44), Maine et Loire (49), Mayenne (53), Sarthe (72), and Vendée (85) subdivisions for each year. The antibiotic consumption increased in the sub-divisions, (P > 0.05) except for Vendée. NHs consumed less between 2011 and 2013, but not significantly so (P = 0.36). We also analyzed the data according to nursing homes’ number of beds (Table 5). No significant difference was observed. 4. Discussion The management of dependent elderly patients has become a major public health issue due to the aging French population. A total of 1.17 million of elderly were dependent (7.8% of
Please cite this article in press as: Marquet A, et al. Three years of antibiotic consumption evaluation in French nursing homes. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.05.006
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Table 1 Nursing homes representativeness. Représentativité des EHPAD participants par année.
2011 2012 2013
NB nursing homes
% Nursing home region
% Nursing home/IHP region
NB beds
% Beds for the region
52 52 74
9.1 9.1 13.0
58.4 58.4 83.1
6413 6410 7053
14.9 14.9 16.4
NB nursing homes: number of nursing homes participating in the study; % nursing home region: representativeness compared to the total number of nursing homes in the Pays de la Loire region; % nursing home/IHP region: representativeness compared to the total number of nursing homes with an IHP; NB beds: total number of beds in all nursing homes; % beds region: representativeness compared to the total number of beds in all nursing homes, in the Pays de la Loire region. Table 2 Total antimicrobial consumption, median and interquartiles. Consommation globale d’antibiotiques, médiane et IQ. Median 2011
2012
2013
n
52
52
74
Penicillins Cephalosporins, penems, monobactams Sulfamides Macrolides, lincosamides, streptogramins Aminosides Quinolones Other antibiotics Total IQ
25.70 2.54 0.49 3.22 0.00 4.58 1.50 39.01 32.4–49.0
28.85 2.73 0.64 2.58 0.00 4.04 1.05 39.34 34.4–52.9
30.36 2.75 0.72 2.74 0.00 3.78 1.49 44.84 33.6–55.4
P (2011–2013)
< 0.05 NS NS NS NS NS NS NS
IQ: interquartile; n: number of nursing home participating in the study; NS: non significant.
individuals 60 years of age or more) in January 2012, in France. The number of dependent elderly patients is forecasted to reach 2.3 million in 2060. Nine percent of people 75 years of age or more live in a NH [14]. A French national infection prevention program was implemented for the health and social sector in 2011; one of its items was the implementation of a document analyzing infectious risks (French acronym Dari) in which antibiotic stewardship was encouraged. [5] Monitoring antibiotic prescriptions, bacterial resistance, and infections is crucial to increase the awareness of prescribers and promote preventive actions in all European countries [6]. No such monitoring has been proposed in NHs so far, in France; this is also true for other European countries [6]. Only prevalence surveys have been carried out at a European [9] and French [15] level. The reported prevalence in these studies was variable.
The European surveillance of antimicrobial consumption group (ESAC) conducted a prevalence survey between April and May 2013 in 19 European countries, in 1181 long-term care units. NHs accounted for 64.5% of the sample. France did not participate in the second edition of the HALT study (Healthcareassociated infections and antimicrobial use in long-term care facilities). The rate of NH patients with an antibiotic prescription was 4.4%. Penicillins (J01C) accounted for 29.3% of prescriptions (J01C), 19.8% were other antibiotics (J01X), and 16% were quinolones (J01M) [12]. Our study results were different concerning the consumption of other antibiotics with on average only 4% of the total antibiotic consumption. We were not able to demonstrate any significant difference among administrative sub-divisions or according to NH number of beds. The results were mainly due to a significant
Table 3 Targeted antibiotics. Antibiotiques suivis.
Amoxicillin PO Amoxicillin/clavulanic acid PO Ceftriaxon IV Cotrimoxazole PO Norfloxacin 400 mg PO Ofloxacin 200 mg PO C3G PO Nitrofurantoin
2011
2012
2013
P (2011–2013)
9.52 13.62 0.99 0.49 1.72 1.06 0.90 0.61
11.77 15.39 0.96 0.59 1.41 0.77 1.20 0.52
12.96 15.20 1.20 0.58 1.04 0.73 0.68 0.38
NS < 0.05 NS NS NS NS NS NS
PO: per os.
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Table 4 Total antibiotic consumption for the Pays de la Loire region sub-divisions. Consommation globale d’antibiotiques par département de la région des Pays de la Loire. 2011
2012
2013
P (2011–2013)
32.7 30.2–41.2 15
45.4 35.5–53.1 14
42.7 37.6–51.5 17
NS
41.5 36.2–45.5 5
45.2 35.8–56.1 8
47.6 36.7–60.1 21
NS
49.1 33.8–53.2 11
37.9 37.1–51.5 9
49.5 41.7–74.8 12
NS
36.8 32.0–45.8 11
39.4 32.9–58.8 11
38.3 32.1–68.9 15
NS
41.8 39.0–56.4 10
37.6 31.9–43.0 10
37.3 29.1–48.9 9
NS
44 Median IQ n 49 Median IQ n 53 Median IQ n 72 Median IQ n 85 Median IQ n
Table 5 Total antibiotic consumption in relation to nursing home capacity. Consommation globale d’antibiotiques par capacité des EHPAD de la région des Pays de la Loire.
0–80 Median IQ n 81–160 Median IQ n 161 and more Median IQ n
2011
2012
2013
P (2011–2013)
33.0 28.4–46.9 24
35.4 30.9–50.4 25
44.6 33.1–55.2 41
NS
42.2 36.0–53.0 15
51.8 40.6–59.5 15
45.0 37.5–60.1 26
NS
41.5 38.3–45.5 13
43.6 37.4–46.9 12
44.5 39.1–48.6 7
NS
increase in the number of participating NHs. The increasing participation was due to an improved accuracy of data collection in NHs with the implementation of the ConsoRes® web tool. The 2011 and 2012 consumption was expressed for all NH activity and not for each NH unit. We were able to improve the accuracy of data collection with the new e-tool. It will be interesting to compare the 2013 and 2014 consumption to show the impact of this system. We compared NH data with Pays de la Loire healthcare institution data (a cohort of 39 institutions) and found that NHs accounted for 11% of overall antibiotic consumption (Table 6). But NHs did not follow the same trend as healthcare institutions (Pays de la Loire) that were decreasing their antibiotic consumption (P > 0.05). Fluoroquinolones are beginning to be less frequently used than other antibiotics, such as amoxicillin/clavulanic acid, although the difference is not significant. However, it is difficult to predict the long-term consequences of this qualitative change
in prescription, both in terms of bacterial resistance [16,17] and safety; this will require close monitoring over time. The next step of this study will be to work also with NHs without an IHP. This may be achieved via a partnership with the Healthcare Insurance to have access to data for these institutions. The longitudinal monitoring of antibiotic consumption ultimately aims at educating prescribers on the optimal use of antibiotics for NH residents, and at supporting remedial Table 6 Total antimicrobial consumption for nursing homes and hospitals from 2011 to 2013 (median expressed in DDD/1000PD). Consommation globale d’antibiotiques pour les EHPAD et les établissements de santé des Pays de la Loire de 2011 à 2013 (médiane en DDJ/1000PD).
Median number of healthcare institutions Median number of nursing homes
2011
2012
2013
323.9 39.0
320.6 39.3
321.1 44.8
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measures that can be adapted to the number of beds and/or location of the NH according to supplied data. Specific studies with the objective of documenting indications for antibiotics used in NHs should usefully complement this monitoring. 5. Conclusion Studying antibiotic consumption in NHs remains infrequent in France and Europe. Only prevalence surveys have been conducted. We did not find any French publications on a permanent monitoring of antibiotic consumption in this type of structure. The use of antibiotics for nursing home residents is common and sometimes inappropriate. The main contribution of this monitoring is to know which antibiotics are used in NHs and to follow their consumption trend to understand how they are used in NHs, and to help prescribers use them optimally in the risk group of elderly patients. Even if the nursing home is considered as home for residents, prescribing an individual antibiotic therapy impacts on the whole community, particularly with the emergence of bacterial resistance. Participation of authors A. Marquet collected and processed the data, and wrote the article. E. Lepabic processed the data. S. Thibault, J.-F. Huon, and F. Ballereau proofread the article. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements We would like to thank all nursing homes having participated in this study and especially their pharmacists. References [1] Agence nationale de sécurité des médicaments et des produits de santé. Évolution des consommations d’antibiotiques en France entre 2000 et 2013 : nouveau rapport d’analyse de l’ANSM; 2014 [Dernière consultation le 31/03/2015] www.ansm.sante.fr [2] Institut national de la statistique et des études économiques. Évolution de la population jusqu’en 2012. Disponible sur www.insee.fr. [Dernière consultation le 30/07/2014].
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[3] Nicolle ALE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin microbiol Rev 1996;9(1): 1–17. [4] Institut de veille sanitaire. Surveillance des consommations antibiotiques et des résistances bactériennes dans les établissements de santé (avril 2014). Disponible sur www.invs.sante.fr. [Dernière consultation le 31/07/2014]. [5] Circulaire interministérielle no DGS/2012/118 du 15 mars 2012 relative à la mise en œuvre du programme national de prévention des infections dans le secteur médico-social 2011/2013 (15 mai 2012). [6] Chami K, Gavazzi G, de Wazières B, Lejeune B, Piette F, et al. Prévalence des infections dans les établissements d’hébergement pour personnes âgées dépendantes : analyse régionale, enquête PRIAM, France, 2006–2007. Bull Epidemiol Hebd 2009;31–32:349–52. [7] Moro ML, Jans B, Cookson B, Fabry J. The burden of healthcare-associated infections in European long-term care facilities. Infect Control Hosp Epidemiol 2010;31(Suppl. 1):S59–62. [8] Institut national de veille sanitaire [Dernière consultation le 31/07/2014] Enquête de prévalence des infections en établissements d’hébergement de personnes âgées dépendantes; 2010. [9] McClean P, Hughes C, Tunney M, Goossens H, Jans B. Antimicrobial prescribing in European nursing homes. J Antimicrob Chemother 2011;66(7):1609–16. [10] European surveillance of antimicrobial consumption. Results from the national survey of characteristics of nursing homes. 2009. Disponible sur http://www.esac.eu. [Dernière consultation le 30/07/2014]. [11] European Centre for disease prevention control. Ears-net result 2011; 2011 [Dernière consultation le 31/03/2015] www.ecdc.europa.eu [12] European Centre for disease prevention control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities; 2013 [Dernière consultation le 31/03/2015] www.ecdc.europa.eu [13] Ministère de la Santé. Guide pour une méthode de calcul des consommations d’antibiotiques dans les établissements de santé et en ville; 2006 [Dernière consultation le 4 août 2014] www.sante.gouv.fr [14] Institut national de la statistique et des études économiques. Tableau de l’économie. 100–101; 2014 [Dernière consultation le 31/07/2014] www.insee.fr [15] Boivin Y, Talon D, Leroy J, Floret N, Gbaguidi-Haore H, Bertrand X. Antibiotic prescription in nursing homes for dependent elderly people: a cross-sectional study in Franche-Comté. Med Mal Infect 2013;(43): 163–9. [16] Thibaut S, Caillon J, Marquet A, Grandjean G, Potel G, Ballereau F. Epidemiology of third-generation cephalosporin-resistant communityacquired Enterobacteria isolated from elderly patients. Med Mal Infect 2014;44(2):57–62. [17] Van der Mee-Marquet N, Savoyen P, Domelier-Valentin AS, Mourens C, Quentin R, Réseau des Hygiénistes du Centre Study Group. CTX-M-type fluoroquinolone-resistant Escherichia coli: analysis of the colonization of residents and inanimate surfaces 1 year after a first case of urinary tract infection at a nursing home in France. Infect Control Hosp Epidemiol 2010;31(9):968–70, http://dx.doi.org/10.1086/655835.
Please cite this article in press as: Marquet A, et al. Three years of antibiotic consumption evaluation in French nursing homes. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.05.006