French healthcare students and antibiotics: are they ready to promote their appropriate use?

Objectives: French healthcare students are required to carry out primary prevention interventions as part of the Healthcare Service by Healthcare Students (HSHS). The purpose of this study was to explore students' perceptions of preparedness to address the public's concerns about antibiotic use and how their perceptions changed after implementing their intervention. Methods: A questionnaire was sent twice during the 2020-2021 academic year to 920 multidisciplinary healthcare students (nursing, medicine, physiotherapy, pharmacy and midwifery students) enrolled in the HSHS in Franche-Comté (HSHS-FC). Results: This study included 870/920 students (94.6%). Medical and pharmacy students were the most concerned about the issue of antimicrobial resistance. Before enrollment in the HSHS-FC, 463 of the 870 students included (53.2%) reported having sufficient knowledge about antibiotics to lead preventive interventions, reaching 87.9% (58/66) for pharmacy students. Despite this relative lack of knowledge, 77.2% of students felt confident to promote the appropriate use of antibiotics in the healthcare service context. This rate ranged from 68.0% (17/25) for midwifery students to 93.9% (62/66) for pharmacy students. Irrespective of the topic of the intervention, students significantly improved their knowledge and ability to promote antibiotic use after training in the HSHS-FC. Conclusions: Theoretical prerequisites and a feeling of concern vary widely depending on the curriculum. The HSHS-FC promotes multidisciplinary collaboration and can contribute to improving students' knowledge. The support of an expert in antimicrobial resistance may be necessary to validate the content of the interventions proposed by the students.

Population structure of community-acquired extended-spectrum beta-lactamase producing Escherichia coli and methicillin resistant Staphylococcus aureus in a French region showed no difference between urban and rural areas.

Antimicrobial resistance is a global health issue and extended-spectrum ß-lactamase producing Escherichia coli (ESBL-Ec) and methicillin-resistant Staphylococcus aureus (MRSA) are of particular concern. Whole genome sequencing analysis of isolates from the community is essential to understand the circulation of those multidrug-resistant bacteria. Our main objective was to determine the population structure of clinical ESBL-Ec and MRSA isolated in the community setting of a French region. For this purpose, isolates were collected from 23 sites belonging to 6 private medical biology laboratories in the Bourgogne-Franche-Comté region. One hundred ninety ESBL-Ec and 67 MRSA were sequenced using the Illumina technology. Genomic analyses were performed to determine the bacterial typing, presence of antibiotic resistance genes, metal resistance genes as well as virulence genes. Analysis showed that ST131 was the major ESBL-Ec clone circulating in the region, representing 42.1% of the ESBL-Ec isolates. The blaCTX-M genes represented 98% of blaESBL with the majority being blaCTX-M-15 (53.9%). MRSA population consisted of mainly of CC8 (50.7%) and CC5 (38.8%) clonal complexes. Interestingly, we found a prevalence of 40% of the zinc resistance gene czrC in our MRSA population. We observed no differences in our ESBL-Ec or MRSA populations between urban and rural areas in our French region, suggesting no impact of population density or rural environment.

High prevalence of Pseudomonas aeruginosa carriage in residents of French and German long-term care facilities.

OBJECTIVES: To determine prevalence, incidence, and factors associated with Pseudomonas aeruginosa (PA) intestinal carriage in residents of long-term care facilities (LTCFs) and to understand the population structure of this pathogen in LTCFs from two European countries. METHODS: We assessed the prevalence of PA intestinal carriage and the incidence of acquisition by collecting fecal samples from 403 residents of 20 LTCFs. We collected 289 environmental samples from sinks and drinking water. Factors associated with carriage and acquisition of intestinal PA were identified. All PA isolates had their antibiotic phenotypic resistance profile determined and their genome sequenced, from which we assessed the population structure of the collection and identified resistance determinants. RESULTS: We found a high proportion of residents with PA intestinal carriage (51.6%) over the entire study period. Over the follow-up period, 28.6% of the residents acquired intestinal PA. Older age (OR, 1.29; 95% CI, 1.09-1.52; p = 0.002), urinary incontinence (OR, 2.56; 95% CI, 1.37-4.88; p = 0.003), and male sex (OR, 2.55; 95% CI, 1.05-6.18; p = 0.039) were associated with higher probability of carriage. Wheelchair usage (OR, 4.56; 95% CI, 1.38-15.05; p = 0.013) and a body mass index >25 (OR, 3.71; 95% CI, 1.17-11.82; p = 0.026) were associated with higher risk of PA acquisition. Population structure of our isolates was mainly non-clonal with 112 different STs among the 241 isolates. Most represented STs were high risk clones ST253 (n = 26), ST17 (n = 11), ST244 (n = 11), ST309 (n = 10), and ST395 (n = 10). Most PA isolates (86.3%) were susceptible to antibiotics, with no acquired genes conferring resistance to antipseudomonal agents. DISCUSSION: We found an unexpected high prevalence of PA intestinal carriage in LTCF residents mainly associated with individual-level factors. Our study revealed a polyclonal PA population structure suggesting that individual acquisition is more frequent than resident-to-resident transmission.

Do Contact Precautions Reduce the Incidence of Intensive Care Unit-Acquired Pseudomonas aeruginosa Infections? The DPCPYO (Detection and Contact Precautions for Patients With P. aeruginosa) Cluster-Randomized Crossover Trial.

BACKGROUND: The issue of contact precautions as contributory factors for reducing Pseudomonas aeruginosa (Pa) infections in intensive care units (ICUs) remains questioned. We evaluated the impact of the addition of contact precautions to standard precautions for Pa-positive patients on incidence of ICU-acquired Pa infections. METHODS: In this multicenter, cluster-randomized crossover trial, 10 French ICUs were randomly assigned (1:1) to sequence 0-1 (6-month control period [CP]/3-month washout period/6-month intervention period [IP]) or sequence 1-0 (6-month IP/3-month washout period/6-month CP). A surveillance screening program for Pa was implemented. Competing-risks regression models were built with death and discharge without the occurrence of ICU-acquired Pa infection (the primary outcome) as competing events. Models were adjusted for within-ICU correlation and patient- and ICU-level covariates. The Simpson diversity index (SDI) and transmission index (TI) of Pa isolates were derived from pulsed-field gel electrophoresis typing. RESULTS: Within recruited ICUs, the cumulative incidence and incidence rate of ICU-acquired Pa infections were 3.38% (55/1625) versus 3.44% (57/1658) and 3.31 versus 3.52 per 1000 patient-days at risk during the CP and IP, respectively. Multivariable models indicated that the intervention did not significantly change the cumulative incidence (subdistribution hazard ratio, .91; 95% confidence interval [CI], .49-1.67; P = .76) or rate (cause-specific hazard ratio, 1.36; 95% CI, .71-2.63; P = .36) of the primary outcome. SDI and TI did not significantly differ between CP and IP. CONCLUSIONS: The addition of contact precautions to standard precautions for Pa-positive patients with a surveillance screening program does not significantly reduce ICU-acquired Pa infections in non-outbreak situations. Clinical Trials Registration. ISRCTN92710225.

Perceptions of French healthcare students of vaccines and the impact of conducting an intervention in health promotion.

BACKGROUND: The perceptions of healthcare students of vaccines have been poorly explored and appropriate training strategies to address possible confidence gaps concerning vaccination for these future professionals is still a subject of debate. METHODS: A questionnaire to assess the perceptions of vaccination and the feeling of preparedness to address patient concerns was submitted to 874 multidisciplinary healthcare students enrolled in the French program "Service Sanitaire des Etudiants en Santé" (SSES). The evolution of their perceptions during the year and the impact of having performed a primary prevention intervention in the context of the SSES program were assessed. RESULTS: In total, 530 students of nursing (42.5%), medicine (31.5%), physiotherapy (11.3%), pharmacy (10.9%), and midwifery (3.8%) completed the questionnaires. Among them, 7.0% carried out an intervention within the topic "vaccination and hygiene" and 93.0% within another topic ("nutrition and physical activity" or "addiction"). A portion of the students showed traits of vaccine hesitancy, including specific concerns about side effects (61.5%) or the number of vaccines in the vaccination schedule (30.0%). They felt ill prepared to address vaccine-hesitant patients, with poor confidence of their knowledge about vaccines (52.5%), their ability to inform patients about the side effects (42.5%), the benefit/risk of adjuvants (51.7%), and the rules for introducing a new vaccine (51.9%). They showed significant differences in perception depending on their curriculum. Misconceptions and hesitancy concerning vaccines were significantly improved after the students had performed the primary prevention intervention, regardless of the topic. CONCLUSIONS: A portion of French healthcare students show traits of vaccine hesitancy, with significant differences depending on the courses attended. Programs of health promotion, such as the French SSES program, which includes a primary prevention intervention conducted by multidisciplinary groups of students, may improve the global confidence of healthcare students concerning vaccination.

Resistance to third-generation cephalosporins in Escherichia coli in the French community: The times they are a-changin'?

OBJECTIVES: Since the early 2000s, Escherichia coli resistance to third-generation cephalosporins (3GCs) has been increasing in all European countries, mainly due to the spread of extended spectrum ß-lactamases (ESBLs). Here we present a retrospective study that combines resistance of E. coli to 3GCs and quinolones with data on antibiotic use in the community in a region of Northeastern France. METHODS: Since 2012, an observational surveillance of antimicrobial resistance and antibiotic use in the community was conducted: data on antimicrobial resistance in E. coli isolates were collected from 11 private laboratories, and consumption data were collected from the three main healthcare insurances. RESULTS: A significant decrease in the prevalence of resistance to 3GCs (from 5.6% to 4.2%; P < 0.001), nalidixic acid (from 16.7% to 14.8%; P = 0.004) and ciprofloxacin (from 10.9% to 8.1%; P < 0.001) was reported between 2015 and 2017. Although total antibiotic consumption did not vary significantly between 2012 and 2017, a decrease in the consumption of 3GCs (-32.%; P < 0.001) and quinolones (-25.5%; P < 0.001) was observed. CONCLUSION: Here we report a decrease in the prevalence of E. coli isolates resistant to 3GCs and quinolones in outpatients in the context of significant decreasing consumption of these two antibiotic classes.

Molecular epidemiology of Pseudomonas aeruginosa isolated from infected ICU patients: a French multicenter 2012-2013 study.

Although Pseudomonas aeruginosa has a non-clonal epidemic population structure, recent studies have provided evidence of the existence of epidemic high-risk clones. The aim of this study was to assess the molecular epidemiology of P. aeruginosa isolates responsible for infections in French ICUs, regardless of resistance patterns. For a 1-year period, all non-duplicate P. aeruginosa isolated from bacteremia and pulmonary infections in ten adult ICUs of six French university hospitals were characterized by antimicrobial susceptibility testing and genotyping (MLST and PFGE). We identified ß-lactamases with an extended spectrum phenotypically and by sequencing. The 104 isolates tested were distributed in 46 STs, of which 7 epidemic high-risk (EHR) clones over-represented: ST111, ST175, ST235, ST244, ST253, ST308, and ST395. Multidrug-resistant (MDR) isolates mostly clustered in these EHR clones, which frequently spread within hospitals. Only one ST233 isolate produced the carbapenemase VIM-2. PFGE analysis suggests frequent intra-hospital cross-transmission involving EHR clones. For ST395 and ST308, we also observed the progression from wild-type to MDR resistance pattern within the same PFGE pattern. Molecular epidemiology of P. aeruginosa in French ICUs is characterized by high clonal diversity notably among antimicrobial susceptible isolates and the over-representation of EHR clones, particularly within MDR isolates, even though multidrug resistance is not a constant inherent trait of EHR clones.

Evaluation of the number of opportunities for hand hygiene in hospital: a new methodological approach.

OBJECTIVE: To assess the number of alcohol-based hand rubbing (ABHR) opportunities in different wards of a university hospital. MATERIALS AND METHODS: The amount of care procedures was measured in nine wards (4 medical wards, 4 surgical wards, 1 intensive care unit) over a two-year period. We converted the number of care procedures into a number of ABHR opportunities using the definition provided by the World Health Organization that takes in account the nature of the care procedure and the number of healthcare workers involved in. We compared these data with those obtained by other authors and the theoretical minimal number of ABHR opportunities defined by the French Ministry of Health. RESULTS: 1,252,671 care procedures (with a mean period of 734 days/department, 122,866 days of hospitalization and 21,905 patients) were converted into ABHR opportunities. The mean number of care procedures and ABHR per day and per patient was 6.1 and 35 for the medical departments, 7.6 and 49 for the surgery departments, 14.8 and 237 for the intensive care unit, respectively. CONCLUSION: Our methodological approach strengthens the results of previous observational studies. Here, we showed that the number of ABHR opportunities is far higher than that defined by the French Ministry of Health to measure the hand hygiene hospital endeavour.

Impact of a region wide antimicrobial stewardship guideline on urinary tract infection prescription patterns.

BACKGROUND: Fluoroquinolones are frequently prescribed for non complicated urinary tract infection treatments and have a negative ecological impact. We aimed to substitute them by antibiotics with narrower activity spectrum in order to preserve fluoroquinolone activity in complicated hospital infections. OBJECTIVE: To assess the impact of a multi-modal approach that combines the dispatching of antibiotic prescription guidelines and voluntary attendance at educational sessions on general practitioners' (GP) antibiotic prescription habits. SETTING: This study was led in Franche-Comté, a French eastern region, where GPs were given a guideline recommending a restricted use of fluoroquinolones for urinary tract infections. METHOD: Segmented regression analysis of interrupted time series was used to assess changes in antibiotic prescription. MAIN OUTCOME MEASURE: The antibiotic prescription data of nitrofurantoin, fosfomycin-trometamol and fluoroquinolones for women aged 15-65 years were obtained from the regional agency of health insurance. RESULTS: Twenty months after intervention, the number of nitrofurantoin and fosfomycintrometamol prescriptions increased by 36.8% (95% CI: 30.6-42.2) and 28.5% (95% CI: 22.9-35.4), respectively, while that of norfloxacin decreased by 9.1% (95% CI: -15.3 to -3.5). CONCLUSION: This study suggests that the dispatch of the guideline on urinary tract infection had a moderate impact on antibiotic prescriptions.

Tracking down antibiotic-resistant Pseudomonas aeruginosa isolates in a wastewater network.

The Pseudomonas aeruginosa-containing wastewater released by hospitals is treated by wastewater treatment plants (WWTPs), generating sludge, which is used as a fertilizer, and effluent, which is discharged into rivers. We evaluated the risk of dissemination of antibiotic-resistant P. aeruginosa (AR-PA) from the hospital to the environment via the wastewater network. Over a 10-week period, we sampled weekly 11 points (hospital and urban wastewater, untreated and treated water, sludge) of the wastewater network and the river upstream and downstream of the WWTP of a city in eastern France. We quantified the P. aeruginosa load by colony counting. We determined the susceptibility to 16 antibiotics of 225 isolates, which we sorted into three categories (wild-type, antibiotic-resistant and multidrug-resistant). Extended-spectrum ß-lactamases (ESBLs) and metallo-ß-lactamases (MBLs) were identified by gene sequencing. All non-wild-type isolates (n = 56) and a similar number of wild-type isolates (n = 54) were genotyped by pulsed-field gel electrophoresis and multilocus sequence typing. Almost all the samples (105/110, 95.5%) contained P. aeruginosa, with high loads in hospital wastewater and sludge (≥3×10(6) CFU/l or/kg). Most of the multidrug-resistant isolates belonged to ST235, CC111 and ST395. They were found in hospital wastewater and some produced ESBLs such as PER-1 and MBLs such as IMP-29. The WWTP greatly reduced P. aeruginosa counts in effluent, but the P. aeruginosa load in the river was nonetheless higher downstream than upstream from the WWTP. We conclude that the antibiotic-resistant P. aeruginosa released by hospitals is found in the water downstream from the WWTP and in sludge, constituting a potential risk of environmental contamination.