Setting
AP-HP is a public health institution administering 38 teaching hospitals (23 acute care and 15 rehabilitation/long-term care hospitals, spread over Paris, suburbs and surrounding counties), totalizing 23,000 beds (10% of all public hospital beds in France) and serving 11.6 millions of inhabitants. AP-HP admits approximately 1 million inpatients per year, employs 19,000 physicians, 18,500 nurses and 29,800 assistant nurses. Local administrators and medical committees manage AP-HP hospitals, but decisions on large investments and medical developments are taken by the central administration. A local infection control team (ICT) is in charge of prevention and surveillance of HAI in each hospital but actions of foremost importance for the whole institution, e.g. MDR control programme, are coordinated centrally by a multidisciplinary infection control team (infectious disease physician, bacteriologist, epidemiologist and nurse)[
2].
MDR control programme
In 1993, AP-HP launched a long-term programme to survey and control MDR. Each step of the programme was implemented gradually in every AP-HP hospitals and supported by a strong commitment of AP-HP central and local administration. This implementation was included as incentive in evaluation process within the institution (quality indicator).
The 1
st step (1993) was bundle measures to control cross transmission of MRSA, whose incidence was at that time higher in France than in other European countries, and extended-spectrum ß-lactamase producing enterobacteria (ESBL): identification of MDR carriers by passive and active surveillance, barrier precautions, training and feedback [
2].
The 2nd step was a large campaign (2001-2002) promoting the use of alcohol-based hand rub solution (ABHRS). This campaign provided pedagogical material to the local ICT (ready to use slide sets, 200,000 brochures, 14,000 posters). Importantly, AP-HP's General Director urged all administrators, head of departments and chief nurses to support the implementation of the campaign.
The 3rd step (2006) was a specific strategy to quickly control the spread of emerging MDR (vancomycin resistant enterococci, VRE; carbapenemase producing enterobacteria, CPE). Indeed, from August 2004 to December 2005, the monthly number of VRE cases increased significantly [
3] and the 1st outbreak of CPE [
4] occurred in AP-HP hospitals. In response to this worrying situation, an institutional "emerging MDR programme" was designed: (a) quickly reporting every new VRE/CPE case (defined as infected or colonized patient) to the AP-HP central infection control team (CICT), (b) stopping transfers to other units of the hospital or to other hospitals of the cases and of the contact patients, defined as any patient hospitalized in the same unit during the same period of time as a VRE/CPE case, (c) screening contact patients for VRE/CPE carriage (rectal swabbing) extended to those already transferred from the involved unit, and maintained this screening until the outbreak was controlled, i.e. after all VRE/CPE patients have been discharged and after a period of at least three months without new case, (d) identifying discharged VRE/CPE cases and contact patients when readmitted and (e) cohorting patients in 3 distinct areas with dedicated nursing staffs: "VRE/CPE case patients" section, "Contact patients" section, "VRE/CPE-free patients" section for newly admitted patients with no previous contact with the case patients [
4]. To stimulate the efforts made by the local infection control teams and administrators, the CICT (a) followed the number of new VRE/CPE cases, and difficulties in programme implementation, (b) visited regularly the hospitals to help the local teams in applying the programme and (c) regularly disseminated results within hospitals and central administration.
In 2008, based on the analysis of the 1
st VRE/CPE events [
5], ICTs were advised to screen every patient transferred from a foreign hospital for VRE/CPE.
Finally, a 4 years lasting campaign was launched in 2006 to decrease antibiotics consumption and, consequently, the selection pressure on MDR: (a) identifying a physician in each hospital as "antibiotic referent" in charge of implementing antibiotic policy, (b) providing teaching material to these referents (slide sets, 40,000 brochures, 15,000 posters), (c) stimulation by the General Director (see above). This campaign was based on 10 teasing messages: treat only bacterial infections, know when to say "no" to antibiotics, know when to stop antibiotics, treat only infection and no colonization, use antibiotics wisely, know to say "no" to antibiotic associations, re-evaluate antibiotic prescription after 2 days, prevent infections, limit invasive devices, prevent cross transmission.