Antibiotic resistance is a constantly evolving phenomenon. In France, Santé publique France is closely monitoring four emerging trends based on data from reports of healthcare-associated infections.

Colistin-resistant Enterobacteriaceae carrying the mcr-1 gene

Plasmid-mediated colistin resistance (mcr-1 gene) in Enterobacteriaceae was first detected in China in late 2015. This resistance is still emerging in France and worldwide. It poses a public health risk because colistin is one of the few antibiotics still effective against carbapenemase-producing Enterobacteriaceae (CPE) strains—the primary emerging Highly Resistant Bacteria (HRB). Its plasmid-mediated nature allows it to be very easily transferred between bacteria.

To limit the spread of this new resistance mechanism in humans, an alert was issued by the Directorate General for Health and the Directorate General for Healthcare Provision to all French healthcare facilities on September 9, 2016. It includes recommendations from the National Reference Center for Antibiotic Resistance regarding the detection of strains carrying the mcr-1 gene, and from Santé publique France regarding measures to be implemented in response to cases. An advisory opinion from the High Council for Public Health was published in October 2016 and updated in May 2017 to supplement these initial recommendations. The BHRe recommendations published in 2013 apply to patients carrying mcr-1 enterobacteria.

This new resistance mechanism is subject to enhanced monitoring in France by all involved partners.

Learn more: colistin-resistant Enterobacteriaceae

Carbapenemase-producing Enterobacteriaceae (CPE)

Carbapenemase-producing Enterobacteriaceae (CPE) are highly antibiotic-resistant and emerging bacteria (BHRe). Carbapenemases lead to partial or total ineffectiveness of carbapenem-class antibiotics, which are treatments of last resort. The emergence and subsequent spread of CPEs thus risks creating genuine therapeutic dead ends, which could ultimately jeopardize the major advances of modern medicine. In France, the first case involving CPEs was reported to Santé publique France in 2004. An increase in cases involving CPEs reported to the Health Surveillance Institute has been observed since 2009. Since then, recommendations have been issued calling for screening of all hospitalized patients who have been hospitalized in a foreign country, the implementation of strict hygiene measures, and screening efforts around patients infected with or colonized by CPB. Specific surveillance has also been established to monitor the emergence of these BHRe. Carbapenemase-producing Enterobacteriaceae (CPE) remain rare in France compared to other countries, but the situation calls for the utmost vigilance. However, regions bordering countries with high CPE prevalence or healthcare facilities treating many patients from countries with high incidence rates must be particularly vigilant.

Public Health France regularly publishes reports on outbreaks involving carbapenemase-producing Enterobacteriaceae in France.

Learn more: carbapenemase-producing Enterobacteriaceae

Imipenem-resistant Acinetobacter baumannii (ABRI)

A. baumannii is naturally resistant to many antibiotics, such as aminopenicillins, first- and second-generation cephalosporins, and ertapenem. It can also acquire other resistances, such as resistance to imipenem, which can transform this opportunistic pathogen with low virulence into an infectious agent often responsible for outbreaks of nosocomial infections that are difficult to control. The first reports of healthcare-associated infections caused by imipenem-resistant Acinetobacter baumannii were recorded in 2003 in northern France and then in 2004 in the southwest. The number of reports has been rising sharply in France since 2009. Despite the biases associated with this data source, this increase calls for the utmost vigilance.

Learn more: Imipenem-resistant Acinetobacter baumannii

Glycopeptide-resistant enterococci (GRE)

Glycopeptide-resistant enterococci (GRE), resistant to vancomycin and/or teicoplanin, emerged in the mid-1980s. Glycopeptide-resistant Enterococcus faecium are highly antibiotic-resistant and emerging bacteria (HARB). Since 2004, they have been responsible for outbreaks in several French healthcare facilities and are subject to very strict control measures, defined by an advisory opinion from the Technical Committee on Nosocomial and Healthcare-Associated Infections, to limit their spread.

In 2016, Santé publique France published a review of epidemiological data from reports of nosocomial infections caused by glycopeptide-resistant Enterococci in healthcare facilities.

Learn more: glycopeptide-resistant enterococci

Epidemic Monitoring Tool

As part of the Raisin initiative, a computer tool has been developed by Santé publique France. It is made available to healthcare facilities, ARLins, and CClins to assist in monitoring outbreaks of BHRe, ABRI, Clostridium difficile, and other microorganisms. This user-friendly tool can be adapted to different types of outbreaks, used at the local, regional, or interregional levels, and easily modified. It takes the form of an Excel® file that automatically generates multiple outbreak curves, a summary table, and an outbreak report. It includes a table for tracking cases and contacts. This tool is freely downloadable.

Once the data has been entered, it is important to ensure that it is properly anonymized if it is to be shared outside of healthcare facilities.