En 2018, la surveillance de l’antibiorésistance pilotée par Santé publique France se rénove et concerne désormais les trois secteurs de soins : établissements de santé, établissements médico-sociaux et soins de ville. Quatre rapports de données de surveillances nationales ont été mis en ligne sur le site de Santé publique France et de nouveaux indicateurs, déclinés par territoire, sont accessibles sur la plateforme Web dynamique Géodes.
La surveillance de l’antibiorésistance regroupe la surveillance de la résistance aux antibiotiques et la surveillance des consommations d’antibiotiques. Pilotées par Santé publique France, ces surveillances s’intègrent dans la politique nationale de lutte contre l’antibiorésistance. Jusqu’en 2017 elles concernaient essentiellement les établissements de santé (ES) via la surveillance des bactéries multi-résistantes en ES (BMR-Raisin) et la surveillance des consommations d’antibiotiques en ES (ATB-Raisin). Elles concernent désormais les trois secteurs de soins : établissements de santé, établissements médico-sociaux et soins de ville.
Méthode
En ES :
Depuis 2018, pour assurer la surveillance de l’antibiorésistance, Santé publique France s’appuie sur la mission nationale SPARES « Surveillance et prévention de l’antibiorésistance en établissements de santé » portée par le CPias Grand-Est et le CPias Nouvelle Aquitaine.
Cette mission nationale développe depuis 2018 un recueil de données de résistances bactériennes issues des laboratoires de microbiologies des ES. La surveillance de la résistance aux antibiotiques repose encore pour 2018 sur la méthodologie BMR-Raisin ciblant les Staphylococcus aureus résistant à la méticilline et les entérobactéries productrices de bêta-lactamases à spectre étendu (EBLSE). Elle a concerné 1 053 ES en 2018.
Poursuivant la méthodologie du réseau ATB Raisin, Spares recueille (via l’outil Consores) les données de consommations d’antibiotiques en doses définies journalières (DDJ) pour 1 000 journées d’hospitalisation (JH) dans les ES volontaires. En 2018, 1 630 ES ont participé. Cet indicateur est décliné par famille d’antibiotiques, par territoire (région) et par type d’ES.
En ville et en Ehpad :
Depuis 2018, la mission nationale Primo « Surveillance et prévention de l’antibiorésistance et des infections associées aux soins, en soins de ville et en secteur médico-social » portée par le CPias Pays de La Loire et le CPias Grand-Est produit des indicateurs de résistance bactérienne aux antibiotiques dans ces 2 secteurs de soins.
Primo recueille en continu les données issues d’un réseau de laboratoires de biologie médicale (via l’outil MedQual-Ville) qui analysent quotidiennement des prélèvements réalisés chez des patients de ville (depuis 2008) ou hébergés en Ehpad non rattaché à un ES (depuis 2012). Ainsi, pour 2018, les résultats présentés ci-après sont basés sur plus de 400 000 antibiogrammes réalisés par 742 laboratoires dans 11 régions métropolitaines. Ils concernent principalement E. coli isolés de prélèvements urinaires.
La consommation d’antibiotiques en ville fait l’objet d’une surveillance spécifique produite en 2018 par Santé publique France sous forme de 2 indicateurs exprimés (1) en nombre de prescriptions et (2) en DDJ pour 1 000 habitants et par jour, élaborés à partir des données de remboursement de l’Assurance maladie (Système national des données de santé : SNDS). Ils incluent les prescriptions hospitalières honorées en officine de ville. Ces deux indicateurs ont été produits pour la période 2009-2018, sont déclinés par famille d’antibiotiques, par territoire (région et département) et par tranche d’âge (8) et sont accessibles sur la plateforme Géodes.
Des données de consommation d’antibiotiques en Ehpad devraient être disponibles en 2020 pour les Ehpad rattachés à un ES, à partir des données recueillies par la mission Spares et, pour les autres, par Santé publique France via le SNDS.
Résultats
En ES, l’incidence des cas d’infection par entérobactéries productrices de BLSE (EBLSE), mécanisme de résistance aux C3G le plus fréquent (environ 80 % des cas), a augmenté de 0,27 à 0,71 cas pour 1 000 JH entre 2008 et 2016. Depuis 2016, une baisse semble s’amorcer avec 0,67 cas en 2017 et 0,63 cas en 2018 pour 1 000 JH[ii].
La quantité d’antibiotiques consommée au regard de l’exposition possible des patients (journées d’hospitalisation) est de 288 doses pour 1 000 JH. La quantité d’antibiotiques consommée dépend du type d’activités cliniques : elle est 2 à 3 fois plus élevée dans les services de maladies infectieuses et en réanimation qu’en médecine ou chirurgie. En effet, les patients hospitalisés dans ces services ont plus souvent besoin d’antibiotiques pour leur traitement[iii].
Au cours de ces dernières années, la consommation de certains antibiotiques potentiellement générateurs de résistance bactérienne, a diminué : en particulier, celle des fluoroquinolones, des glycopeptides et de l’association amoxicilline/acide clavulanique.
En ville, après une hausse continue de 2,3% en 2012 à 4,3% en 2015, la résistance aux céphalosporines de 3e génération chez E coli est en baisse, passant de 3,8% en 2016 à 3,2% en 2018.
La résistance aux fluoroquinolones chez E. coli concernait 11 % des souches isolées en 2018 : elle est stable depuis 2012 (10,4 %)
En Ehpad, la résistance aux céphalosporines de 3e génération chez E. coli est plus élevée qu’en ville mais les évolutions sont similaires : après avoir augmenté de 8,0% en 2012 à 11,1% en 2015, elle est désormais en baisse pour atteindre 8,6% en 2018[iv].
Evolution du pourcentage de souches d’E. coli isolée d’urines productrice de BLSE [source : Primo, Données 2018]
En secteur de ville, la consommation globale des antibiotiques est estimée en 2018 à 22,5 DDJ ou 2,38 prescriptions pour 1 000 habitants et par jour.
Exprimée en DDJ, elle se stabilise, après une hausse entre 2014 et 2016 : 22,7 DDJ pour 1 000 habitants et par jour en 2009 vs 22,5 en 2018. Par ailleurs, elle augmente régulièrement avec l’âge chez l’adulte.
Exprimée en nombre de prescriptions, la consommation baisse de 15%, passant de 2,81 à 2,38 prescriptions pour 1 000 habitants et par jour de 2009 à 2018. Elle est la plus élevée chez les enfants <5 ans ; elle diminue nettement depuis 2009 chez les jeunes de moins de 15 ans et se stabilise chez les plus de 65 ans.
Prescription d’antibiotiques en secteur de ville dans quelques classes d’âges, 2009-2018 [source : Santé publique France, Données 2018]
Quel que soit l’indicateur, les niveaux de consommation varient d’une région à l’autre. Cependant, les écarts de consommation observés entre les régions de métropole ont peu varié depuis 2009.
– La baisse de prescription constatée au niveau national se retrouve dans toutes les régions.
– Ces résultats mettent également en évidence un report important des prescriptions et des consommations des céphalosporines en faveur des pénicillines à large spectre. L’utilisation des fluoroquinolones a également diminué.
Discussion
Les résultats 2018 de la surveillance de l’antibiorésistance en santé humaine sont encourageants.
Concernant la consommation, l’indicateur exprimé en nombre de prescription pour le secteur de ville permet une vision plus précise de la consommation d’antibiotiques en ville et suggère une évolution des pratiques médicales. En cohérence avec les recommandations de bonne pratique, l’augmentation de la consommation des bêta-lactamines et la diminution de la consommation de fluoroquinolones sont observées au cours de la période étudiée[v].En ES, la consommation d’antibiotiques amorce également une diminution depuis 2016. Cependant, selon les données en DDJ produites par l’ANSM et transmises à l’ECDC, la consommation des antibiotiques dans le secteur de ville demeure encore environ 30% supérieure à la moyenne européenne, plaçant la France au 4e rang des pays les plus consommateurs.
Côté résistance, après avoir augmenté de façon constante depuis le début des années 2000, la résistance chez E. coli aux céphalosporines de 3e génération semble également amorcer une diminution, dans les trois secteurs de la santé humaine. En Ehpad, les pourcentages de résistance sont le double de ceux observés en ville, se rapprochant des taux observés parmi les souches isolées en établissement de santé transmises à l’ECDC pour contribution de la France au réseau européen EARS-Net[vi]. L’incidence des K. pneumoniae et E. cloacae BLSE se stabilise en ES, suggérant le succès des efforts menés dans les ES contre la transmission croisée.
L’ensemble des résultats de surveillance 2018 en santé humaine sont à considérer plus largement dans une dynamique « one health » incluant les données de santé animale et de l’environnement pour des actions concertées dans ces différents secteurs[vii].
https://geodes.santepubliquefrance.fr/
[ii]https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/resistance-aux-antibiotiques/documents/rapport-synthese/bacteries-multiresistantes-en-etablissements-de-sante-en-2018-mission-nationale-spares-novembre-2019.-donnees-2018-du-reseau-bmr-raisin
[iii] https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/infections-associees-aux-soins/documents/rapport-synthese/surveillance-de-l-antibioresistance-en-etablissement-de-sante-resultats-2018.-partie-1-consommation-d-antibiotiques
[iv] https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/resistance-aux-antibiotiques/documents/rapport-synthese/surveillance-de-la-resistance-bacterienne-aux-antibiotiques-en-soins-de-ville-et-en-etablissements-pour-personnes-ages-dependantes.-annee-2018
[v] https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/infections-associees-aux-soins/documents/rapport-synthese/consommation-d-antibiotiques-en-secteur-de-ville-en-france-de-2009-a-2018.-synthese-des-indicateurs-mis-en-ligne-sur-geodes
[vi] https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/resistance-aux-antibiotiques/donnees/#tabs
[vii] https://www.santepubliquefrance.fr/maladies-et-traumatismes/infections-associees-aux-soins-et-resistance-aux-antibiotiques/resistance-aux-antibiotiques/documents/rapport-synthese/antibiotiques-et-resistance-bacterienne-une-menace-mondiale-des-consequences-individuelles
Contacts :
anne.berger-carbonne@santepubliquefrance.fr
philippe.cavalie@santepubliquefrance.fr
sylvie.maugat@santepubliquefrance.fr
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