Emerging extensively drug resistant bacteria (EXDR) in a French University Hospital in 2016: Description of incident cases and evaluation of five years trend

Introduction Emerging extensively drug resistant bacteria (eXDR), including Carbapenem-Producing Enterobacteriaceae (CPE) and Vancomycin-Resistant Enterococci faecium (VRE), represent a major world health emergency over the last ten years. About CPE, in France, 2376 episodes were reported from 2009 to 2015, their incidence increased from 10 episodes in 2009 to 942 episodes in 2015 (based on National Public Health Institute); the most common CPE is Klebsiella pneumoniae (58% of CPE episodes). The proportion of foreign-related episodes decreased from 80% in 2009 to 42% in 2015. The objective is to describe eXDR incident cases at Lyon University Hospitals (LUH, France) in 2016 and to evaluate eXDR 5 years trend. Methods eXDR surveillance was implemented at all hospitals from LUH (5362 beds) between 01/01/2016 to 31/12/2016. Population included all hospitalized patients. The infection control unit was informed by the microbiology laboratory for each eXDR identification. A case was defined as a patient with eXDR isolation in clinical sample or in rectal swab (including index or secondary cases, colonization or infection cases, whatever the anatomic site). An index case and the secondary cases possibly generated determined an episode. A contact patient was a patient who received care by the same healthcare team as a case. Demographic data, type of case (index/secondary, infection/colonization, foreign link), and bacteriological data were collected and analyzed; eXDR trend was evaluated since 2012. Results In 2016, 79 eXDR cases were identified (equally distributed between CPE and VRE); among them, 47 were index cases (episodes). Concerning index cases, 61.7% of them were men and mean age was 62.7 ± 18.8 years (range 11–103 years). On average, 16.1% of the episodes lead to secondary cases, which represented 32.6% of all the cases. Regarding CPE species, 35% of them were represented by Klebsiella pneumoniae , followed by Enterobacter cloacae (30%), Citrobacter freundii (12%) and Escherichia coli (10%); 27.7% of cases were infected with eXDR, 70.2% were colonized. For 42.5% of the index cases, a link with foreign countries was identified (65% of them were represented by CPE). About CPE resistance mechanism, OXA-48 represented 62% of the cases, followed by VIM (25%), NDM (5%) and OXA-29 (3%); for VRE, the main mechanism of resistance was VanA (54%). In previous years of surveillance, 11 cases in 2012, 12 in 2013, 32 in 2014, 61 in 2015 and 79 in 2016 were identified. In summary, in our university hospital, a significant eXDR increase from 2012 to 2016 has been observed. According to the “National Action Program for the Prevention of Healthcare-Associated Infections” (2015), two objectives must be reached: proportion of episodes with secondary cases  Conclusions eXDR augmentation trend observed in the last 5 years in our university hospital is in line with the national one; this increase is due to the strong antibiotics utilization in human medicine, animal nutrition and agriculture since many decades, and only to a lesser extent to the improvement of diagnostic tools. To prevent eXDR spreading and cross-transmission, a constant effort must be devoted to: fight against antibiotic resistance, identify patients at risk of infection or colonization by eXDR, apply isolation measures and contact precautions, track and screen all carrier patients and their contacts.