Monitoring procedures: networks and partners
Networks and partners generating RATB data
In France, surveillance of bacterial resistance to antibiotics relies on numerous partners and surveillance networks, coordinated under the auspices of Santé publique France. Focused on specific pathogens, surveillance relies on the voluntary participation of laboratories in healthcare facilities and community settings. The various data come from National Reference Centers, hospital or community-based surveillance networks, and alert systems such as the reporting of healthcare-associated infections. The landscape of antibiotic resistance surveillance is set to change significantly. Since February 3, 2017, Santé publique France has been tasked with leading national surveillance and prevention efforts for healthcare-associated infections (HAIs) and antibiotic resistance (decree of February 3, 2017) in collaboration with the Support Centers for HAI Prevention (CPias)—regional structures resulting from the reform of the CClin-Arlin network— the Regional Intervention Units (Cire) of Santé publique France, and the National Reference Centers (CNR). These national initiatives are now centered on the patient throughout their care journey and cover the three healthcare sectors: healthcare facilities (ES), medical-social facilities (EMS), and community care.
National Reference Centers
National Reference Centers for the control of communicable diseases are designated by order of the Ministry of Health for a period of several years, upon the recommendation of Santé publique France.
The general missions of the NRCs, defined by the decree of June 29, 2001, fall into four categories:
expertise in microbiology, the pathology of infectious agents, and their susceptibility to anti-infective agents,
contribution to epidemiological surveillance,
issuing alerts by immediately informing Santé publique France and the Ministry of Health of any findings that may have repercussions on the health status of the population,
advising public authorities, health safety agencies established by the Act of July 1, 1998, and healthcare professionals.
For the 2017–2022 period, the new network of National Reference Centers (NRCs) was designated by the Minister of Health via the decree of March 7, 2017 (Official Journal No. 0058, March 9, 2017). It lists 44 NRCs. Of these, 43 focus on specific pathogenic bacterial species. Their surveillance mission, which is based on the study of strains sent to them via a network of voluntary private and public laboratories, includes resistance to anti-infective agents. A 44th NRC is tasked with detecting and characterizing new resistance mechanisms: the NRC for Antibiotic Resistance. It collaborates with the other NRCs.
The CNRs and associated laboratories whose data were used for the website are:
CNR for Campylobacter and Helicobacter
CNR Escherichia coli and Shigella
CNR Gonococci
CNR Haemophilus influenzae
CNR Meningococci
CNR Mycobacteria and Mycobacterial Resistance to Antituberculosis Drugs
CNR Mycology and Antifungals
CNR Pneumococci
CNR Salmonella
CNR Staphylococci
CNR Streptococci
NRC Antibiotic Resistance.
Contact information for all NRCs is available in the thematic dossier "National Reference Centers."
Surveillance Networks
There are many such networks, each operating in different ways. Some monitor the incidence of resistant nosocomial bacterial infections (BMR-Raisin), others facilitate the sharing of bacterial resistance data based on a common methodological guide (Onerba networks), or collaborate with National Reference Centers by sending strains based on defined criteria (Regional Pneumococcal Observatories [ORP], Renago), and some consist of CNR collaborating laboratories (Salmonella, Campylobacter, etc.).
Surveillance Networks of the Network for Alert, Investigation, and Surveillance of Nosocomial Infections
Surveillance of multidrug-resistant bacteria (MDRB), combined with the prevention of their spread, is a major focus of the fight against nosocomial infections. The Network for Alert, Investigation, and Surveillance of Nosocomial Infections (Raisin) coordinates a network that contributes to the surveillance of antibiotic resistance in healthcare facilities: the Multidrug-Resistant Bacteria Surveillance Network (BMR-Raisin). This network is supported by Santé publique France, and its national coordination is delegated to the Coordination Center for the Fight Against Healthcare-Associated Infections (CPIias Ile-de-France). It compiles data collected from participating healthcare facilities across the five regions.
The BMR-Raisin network conducts prospective surveillance three months per year, focusing on methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL). The strains selected are those isolated from diagnostic samples taken from patients hospitalized for more than 24 hours; duplicates are excluded. With the creation of the CPias network, surveillance of antibiotic resistance in healthcare facilities is set to evolve significantly. In 2018, Santé publique France entrusted the national mission for the surveillance and prevention of bacterial antibiotic resistance in healthcare facilities to the CPias Grand Est and Nouvelle Aquitaine for a period of 5 years.
In parallel with annual or biannual surveillance networks, data on antibiotic resistance in the bacterial species most frequently isolated from nosocomial infections (Staphylococcus aureus, Enterobacteriaceae, Pseudomonas, Enterococcus, Acinetobacter) is collected during national prevalence surveys of nosocomial infections and antibiotic treatments in healthcare facilities (ENP), conducted in France every five years since 1996 to measure their frequency among these infections. The reports from these various surveys are available at the following URL: http://www.invs.sante.fr/enp. A new survey was conducted in May–June 2017; for the first time, it was carried out on a sample of 400 healthcare facilities representative of French healthcare facilities. The results of this survey will be available shortly.
Latest data and trends - S. aureusLatest data and trends - E. coli
Networks of the National Observatory on the Epidemiology of Bacterial Resistance to Antibiotics (Onerba)
Founded in 1997, the National Observatory for the Epidemiology of Bacterial Resistance to Antibiotics (Onerba) is a non-profit association under the 1901 law that currently brings together 16 bacterial resistance surveillance networks: - 3 networks of private medical testing laboratories - 11 networks of hospital laboratories, some of which specialize in monitoring multidrug-resistant bacteria - 1 network of veterinary laboratories - 1 network for monitoring pneumococci, which will be detailed further below.
As part of a collaboration between Santé publique France and ONERBA, the Azay-résistance, Réussir, and Ile-de-France networks provide the European EARS-Net (European Antimicrobial Resistance Surveillance Network) with resistance data on the main bacteria isolated from invasive infections in patients hospitalized in departments across France. Since 2014, ONERBA’s work has received joint financial support from the ANSM and Santé publique France.
Latest data and trends - S. aureus Latest data and trends - Enterococcus spp. Latest data and trends – E. coli Latest data and trends – Pseudomonas Latest data and trends – Klebsiella
Network of the National Reference Center for Pneumococci and Regional Pneumococcal Observatories (ORP)
Surveillance of Streptococcus pneumoniae resistance involves the National Reference Center for Pneumococci (CNRP) working with a network of 24 regional pneumococcal observatories (ORP), spread across the country and including both public and private laboratories. In 2015, 205 laboratories (including approximately 15% private clinical laboratories), serving about 70% of hospital admissions in internal medicine, participated in this surveillance. The CNRP also provides national data to the European EARS-net network. Since 2001, the CNRP’s efforts have focused on improving the comprehensiveness and representativeness of the collection of strains responsible for severe or so-called “invasive” pneumococcal infections (meningitis or bacteremia). This allows for a better estimate of the proportion of penicillin G-susceptibility-decreased (PSDP) pneumococcal strains and the proportion of strains resistant to erythromycin or fluoroquinolones. These are non-redundant strains, with duplicate samples excluded.
Latest data and trends - Streptococcus pneumoniae
Salmonella surveillance networks
Surveillance of antibiotic resistance in Salmonella integrates data on human Salmonella from the CNR Escherichia coli, Shigella, and Salmonella and non-human Salmonella collected through the Salmonella network led by the SEL unit ("Salmonella, E. coli, Listeria") unit of the Food Safety Laboratory (LSA) at the French Agency for Food, Environmental and Occupational Health & Safety (ANSES). In 1993 and 1997, and systematically since 2002, the Salmonella National Reference Center (CNR) has studied the resistance profile of a random sample of strains and the results of antibiotic susceptibility testing submitted to it by a network of over 1,000 private and hospital laboratories (1,185 in 2016). Latest data and trends - Salmonella enterica serotype Enteritidis Latest data and trends - Salmonella enterica serotype Typhimurium Latest data and trends - Salmonella enterica serotype 1,4,[5]:12:i:- (monophasic variant of S. Typhimurium)
Network of the National Reference Center for Shigella (CNR E. coli, Salmonella, Shigella)
National surveillance of Shigella resistance is based on collaboration between the National Reference Center for E. coli, Shigella, and Salmonella (CNR-ESS) and a network of clinical laboratories throughout the country that send their isolates to the CNR-ESS for confirmation and further typing, as well as to participate in epidemiological surveillance. Monitoring of trends in Shigella antibiotic resistance and the identification of resistance mechanisms are conducted in collaboration with the CNR-ESS.
Latest data and trends - Shigella
Surveillance of Campylobacter infections in humans in France
Since April 2002, surveillance of Campylobacter infections in France has been based on a network of clinical laboratories and hospital laboratories. Participating laboratories systematically screen for Campylobacter in all stool cultures and voluntarily send the strains they isolate to the National Reference Center (CNR) for Campylobacter and Helicobacter. Since 2013, the NRC has implemented a secure data system allowing laboratories that use the same methods as the NRC—notably species identification via MALDI-TOF mass spectrometry—to enter data directly online. These laboratories are expected to send one in ten strains to the NRC for quality control. For each strain received, the CNR performs species characterization and antibiotic susceptibility testing using the disk diffusion method. Since 2013, the antibiotics tested have been: ampicillin, erythromycin, gentamicin, ciprofloxacin, the amoxicillin/clavulanic acid combination, and tetracycline.
Latest data and trends - Campylobacter coliLatest data and trends - Campylobacter jejuni
Gonococcal Infection Surveillance Network (Renago)
Since 1986, surveillance of Neisseria gonorrhoeae infections has been conducted through the Renago network, which brings together the National Reference Center (CNR) for gonococci and volunteer public and private laboratories located throughout mainland France. Laboratories participating in microbiological surveillance send their gonococcal strains to the CNR, which monitors resistance to various antibiotics: penicillin G, ceftriaxone, cefixime, tetracycline, spectinomycin, azithromycin, and ciprofloxacin.
Until 2006, the primary indicator for monitoring antibiotic resistance was the proportion of strains resistant to ciprofloxacin, which was previously the first-line treatment for uncomplicated urethritis. Given the high rates of ciprofloxacin resistance among gonococci in recent years, the ANSM has recommended the use of injectable ceftriaxone as first-line therapy since 2005.
Since 2007, changes in the susceptibility of Neisseria gonorrhoeae to ceftriaxone (and to cefixime since 2008) have been used as the primary indicator for monitoring antibiotic resistance. To enable a comparison of surveillance data from the Rénago network with international data, taking into account the U.S. (GISP protocol) and European (Euro-GASP) criteria for decreased susceptibility or resistance, two MIC values are specified for ceftriaxone and cefixime (>0.125 and >0.25 mg/L). The criterion for defining resistance to ciprofloxacin adopted by this network is the U.S. and European criterion (MIC ≥ 1 mg/L); it is thus higher than that recommended by the Antibiogram Committee of the French Society of Microbiology (CA-SFM).
Latest data and trends - Neisseria gonorrhoeae
Mycobacterium tuberculosis Antibiotic Resistance Surveillance Network
Surveillance of Mycobacterium tuberculosis antibiotic resistance relies on the CNR Mycobacteria and Mycobacterial Resistance to Antituberculosis Drugs (CNR MyRMA) laboratory network established in 1992 (approximately 200 laboratories in 2017) and the AZAY-Mycobacteria network of university hospital laboratories, established in 1995 (36 university hospitals in 2016). The AZAY-Mycobacteria network monitors primary and secondary resistance to first-line antituberculosis drugs. The CNR-MyRMA network comprehensively monitors multidrug resistance. Since 2003, resistance to isoniazid and rifampicin has also been collected through mandatory reporting.
Latest data and trends - Mycobacterium tuberculosis
National Reference Center for Meningococci (CNRM) Network
Surveillance of meningococcal resistance relies on collaboration between the National Reference Center for Meningococci (CNRM) and nearly 700 clinical microbiology laboratories that regularly submit their isolates for confirmation and additional typing. This surveillance focuses primarily on antibiotics of therapeutic and/or prophylactic interest (beta-lactams, chloramphenicol, ciprofloxacin, and rifampicin). The results presented here concern strains isolated from invasive infections (meningitis and meningococcemia, which may be complicated by purpura fulminans). The CNR for Meningococci participates in the European IBD-labnet surveillance of invasive infections caused by Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae.
Latest data and trends - Neisseria meningitidis
European Antimicrobial Resistance Surveillance Network (EARS-Net)
Since January 2010, surveillance of antibiotic resistance in human health at the European level has been coordinated by the European Centre for Disease Prevention and Control (ECDC) through the European Antimicrobial Resistance Surveillance Network (EARS-Net). It monitors antibiotic resistance in seven bacterial species isolated from blood cultures and cerebrospinal fluid (blood cultures only for staphylococci and enterococci): Staphylococcus aureus and Streptococcus pneumoniae since 1999, Escherichia coli, Enterococcus faecalis, and Enterococcus faecium since 2001, Klebsiella pneumoniae and Pseudomonas aeruginosa since 2005, and Acinetobacter since 2012. Streptococcus pneumoniae is primarily a community-acquired bacterial species, whereas the other four are both community- and healthcare-associated. This surveillance system was established in 1999 under the auspices of the Netherlands (RIVM) with funding from the European Commission and was called the European Antimicrobial Resistance Surveillance System (EARSS).The French contribution to EARS-Net is provided by Santé publique France, the National Reference Center for Pneumococcus, and three networks of laboratories affiliated with the National Observatory for the Epidemiology of Bacterial Antibiotic Resistance (Onerba).
Antibiotic resistance in other bacterial species is monitored at the European level through networks dedicated to these species.
Tuberculosis Surveillance in Europe
Tuberculosis surveillance in Europe is coordinated by the ECDC (European Centre for Disease Prevention and Control). This surveillance has been conducted since January 1, 2008, in collaboration with the WHO Regional Office for Europe, as it covers the 53 countries in the WHO European Region (EU/EEA countries, the Balkans, and countries of the former USSR). The objectives of this surveillance are to support countries in the region in the fight against tuberculosis, in the prevention and control of the disease, and in monitoring drug resistance. They also aim to provide countries with expertise and information on epidemiological trends of the disease, scientific advances, and potential threats posed by tuberculosis. Prior to 2008, this surveillance was coordinated at the French Institute for Public Health Surveillance (InVS) through the EuroTB network from 1996 to the end of 2007. The EuroTB program facilitated the harmonization of recommendations, the standardization of surveillance methods across Europe, and improved coordination of international surveillance.France participates in this surveillance network by providing the ECDC annually with data on reported tuberculosis cases collected by Santé publique France (initial reports and treatment outcomes), as well as data on the resistance of Mycobacterium tuberculosis to antituberculosis drugs. This surveillance is based on the network of laboratories of the National Reference Center for Mycobacteria and Mycobacterial Resistance to Antituberculosis Drugs (CNR-MyRMA), established in 1992, and the AZAY-Mycobactéries network of university hospital laboratories, established in 1995. The AZAY-Mycobacteria network monitors primary and secondary resistance to first-line antituberculosis drugs. The CNR-MyRMA network comprehensively monitors multidrug resistance.
For more information:
Food and Waterborne Disease (FWD) Network (formerly the Enter-Net network)
The Food and Waterborne Disease (FWD) Network is a European surveillance network coordinated by the European Centre for Disease Prevention and Control (ECDC). It brings together microbiologists in charge of National Reference Centers (NRCs) and epidemiologists responsible for national surveillance in the 28 countries of the European Union, as well as Iceland, Liechtenstein, and Norway. By pooling national data from member states, it enables European surveillance of 21 foodborne infections and zoonoses, specifically infections caused by Salmonella (minor salmonellosis and typhoid and paratyphoid fevers), Shigella, Shiga toxin-producing Escherichia coli, Campylobacter, Listeria, and Yersinia.
France’s contribution to this European surveillance is based on the collaboration of Santé publique France with, in particular, the National Reference Center (NRC) for Escherichia coli, Shigella, and Salmonella and its associated laboratory, the NRC for Campylobacter and Helicobacter, and the NRC for Listeria.
European Invasive Bacterial Diseases Surveillance Network (EU-IBD)
The ECDC coordinates surveillance activities for the three bacterial agents of invasive infections: Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae (Surveillance of Haemophilus influenzae type b infection, Surveillance of Meningococcal disease, and Surveillance of Pneumococcal disease). This work is carried out by the IBD-LabNEt consortium in collaboration with the EMGM (The European Meningococcal and Haemophilus Disease Society).
About thirty countries contribute to this surveillance: European Invasive Bacterial Diseases Surveillance Network (EU-IBD)
France contributes to European surveillance of invasive Neisseria meningitidis infections by submitting:
epidemiological and bacteriological data from mandatory reporting and the CNR: these data are transmitted to the ECDC through the European surveillance system (TESSy),
MLST typing and antibiotic susceptibility data generated by the CNR and sent to the EMGM.
European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP)
At the European level, surveillance of gonococcal susceptibility has been coordinated by the ECDC (European Centre for Disease Prevention and Control) since 2009. Each year, strains isolated between September and November by laboratories in the 24 participating countries are either centralized and tested by an accredited laboratory (7 countries) or directly analyzed in the 17 countries meeting ECDC criteria, including France. Euro-GASP collects surveillance data on the susceptibility of Neisseria gonorrhoeae to ceftriaxone, cefixime, spectinomycin, azithromycin, and ciprofloxacin, as well as on β-lactamase production.
