Objectives: Epidemiological surveillance is one critical approach to estimate and fight the burden of antibiotic resistance (AR). Here we summarise the characteristics of surveillance systems devoted to the surveillance of AR worldwide and published in the literature. Methods: We performed a systematic review of the literature available on PubMed from January 2007 to July 2019 (12.5 years). The keywords (‘surveillance system’ OR ‘laboratory-based surveillance’ OR ‘syndromic surveillance’ OR ‘sentinel surveillance’ OR ‘integrated surveillance’ OR ‘population-based surveillance’) AND (‘antibiotic resistance’ OR ‘antimicrobial resistance’) were used. This research was completed with AR monitoring systems available on websites. Results: We identified 71 AR surveillance systems described by 90 publications from 35 countries, including 64 (90.1%) national and 7 (9.9%) multinational surveillance systems. Two regions accounted for ∼72% of systems: European region (37; 52.1%) and Region of the Americas (14; 19.7%). Fifty-three focused on AR surveillance in humans, 12 studied both humans and animals, and 6 focused only on animals. The two most common bacterial species reported were Staphylococcus aureus (42; 59.2%) and Escherichia coli (39; 54.9%). Of the 71 AR surveillance systems, 20 (28.2%) used prevalence as an indicator, 3 (4.2%) used incidence and 7 (9.9%) used both. Methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus spp., S. aureus and Streptococcus pneumoniae, penicillin-resistant S. pneumoniae, and extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant E. coli and Klebsiella pneumoniae were monitored. Conclusions: Our results showed heterogeneous surveillance systems. A ‘One Health’ approach is needed to monitor AR, with reference to the WHO Global Action Plan.

In our institution, between January 2010 and December 2017, 15 140 peripherally inserted central catheters (PICCs) were inserted in 12 314 patients. Using time-series analysis to evaluate the annual historical trend (AHT), we observed a significant increase in bloodstream infections (BSIs; AHT = 24; p < 0.001) and associated deaths (AHT = 3; p 0.02) in patient with PICCs. The risk of experiencing a BSI was significantly higher in patients with PICCs (odds ratio = 9.6; 95% confidence interval, 9.08-10.18; p < 0.001). To reduce PICC-related BSIs and their related mortality, it is important to limit the overuse of PICCs and to implement a 'no PICC' policy by limiting the insertion of PICCs to situations without other available options. (C) 2020 The Author(s). Published by Elsevier Ltd.

La surmortalité causée par la résistance aux antibiotiques est un problème actuel de santé publique. Des études basées sur des modèles mathématiques ont été réalisées pour tenter d’estimer cette surmortalité, mais ces modèles sont approximatifs et sujets à controverse. Au sein de notre laboratoire, nous avons mis en place un système de surveillance hebdomadaire de la mortalité due à la résistance bactérienne. L’objectif de ce travail est d’évaluer le véritable impact de la résistance bactérienne sur la mortalité au sein de nos hôpitaux. Nous avons réalisé une étude rétrospective cas-témoins entre janvier 2014 et janvier 2018. Les données analysées sont issues du service médical de l’information de l’hôpital et de notre logiciel de surveillance. Les données de résistance aux antibiotiques clés ainsi que l’évaluation du nombre de bactéries DTR ont été recueillis pour chacun des deux groupes pour les 10 bactéries les plus fréquemment isolées dans les hémocultures. Les facteurs de risque d’acquisition de ces souches ont été évalués par régression logistique. Le logiciel R a été utilisé pour les statistiques. Nous avons reçu un total de 375 165 hémocultures dont 36813 (9,81 %) étaient positives correspondant à 11946 patients. Parmi eux, 1715 (14,35 %) patients sont décédés. Le nombre d’infections polymicrobiennes était plus élevé dans le groupe des décès (9,4 %) que dans le groupe contrôle (6,8 %) (p = 0,004). Les bactéries à Gram négatif représentaient 72,2 % des co-infections dans le groupe décès contre 48,6 % dans le groupe contrôle. Les facteurs de risque associés à la mortalité étaient l’âge > 60 ans, le sexe masculin, un long séjour à l’hôpital et l’acquisition nosocomiale. La prévalence de la résistance à la ceftriaxone (24 % vs 14,2 % ; p < 0,001) et à la ciprofloxacine (31,3 % versus 21,8 % ; p = 0,009) étaient significativement plus élevée dans le groupe des décès pour Escherichia coli. Pour Klebsiella pneumoniae, la prévalence de la résistance à l’imipénème était plus élevée (2,2 % vs 0,4 % ; p = 0,05). Pour Pseudomonas aeruginosa, le taux de résistance à l’imipénème (35,5 % vs 18,9 % ; p = 0,007) et la ciprofloxacine (26,2 % vs 13,8 % ; p = 0,01) était statistiquement significatifs. Il n’existait pas de différence en terme de résistance pour les bactériémies causées par les bactéries à Gram positifs analysés entre les deux groupes. Sur les 9078 patients analysés, 26 (0,28 %) étaient infectés par une souche DTR (13 cas dans chaque groupes). P. aeruginosa était l’espèce la plus rencontrée avec ce phénotype (12 ; 46,15 %), suivie d’Acinetobacter baumannii (7 ; 26,9 %). Pour ces souches, la colistine restait l’antibiotique de 2e ligne le plus actif, suivi de la tigécycline et de l’amikacine. Le taux de résistance de certains antibiotiques clés était plus important dans le groupe des patients décédés que dans le groupe des patients survivants. Ces antibiotiques sont essentiellement ceux utilisés en traitement empirique, suggérant que dans certains cas, celui-ci n’est pas adapté. Le recueil des traitements reçus par les patients est en cours. Le nombre de souches DTR dans les deux groupes étaient par contre très faible, suggérant que l’utilisation d’antibiothérapie de 1ere ligne est possible dans la grande majorité des cas. Dans tous les cas, il existait une alternative thérapeutique.

Acute undifferentiated fever (AUF) is frequently observed in tropical settings, but diagnosing the cause of AUF is often a challenge for local physicians and the physicians treating returning travellers. We conducted a case-control study in central Vietnam in 2016. A total of 378 febrile adult patients (AUFs) with a fever for <= 21 days, no evidence of localized infection and negative screening tests for dengue and malaria, and 384 afebrile adult patients (Controls) were prospectively enrolled. Whole blood, plasma, eschar swab, throat swab and urine specimens were collected and analysed. Quantitative PCR and RT-PCR were used to test for 55 bacteria, viruses and their subtypes. Serological tests were also used to test for rickettsial agents. The most common aetiology was influenza virus (20.9% in AUFs vs. 0% in Controls), followed by rickettsial agents (mainly Orientia tsutsugamushi and Rickettsia typhi) (10.8% vs. 0.3%), dengue virus (7.7% vs. 0.5%), Leptospira (4.8% vs. 0.8%), adenovirus (4.8% vs. 1.0%), and enterovirus (2.1% vs. 0%) (p < .05). The real proportion of dengue in AUF cases was underestimated because patients with dengue-positive rapid diagnosis tests were excluded from the study. The emerging agent Rickettsia felis, which had not been previously observed in Vietnam, was detected in this study. In total, 216 patients (57.1%) were given causative diagnoses, comprising 143 (66.2%) monoinfections and 73 (33.8%) coinfections. The infections caused by these agents should be considered in clinical practice and further studies. Additionally, agents susceptible to doxycycline were detected in 15.6% of AUFs; thus, this drug should be included in the panel used to treat AUF patients.

In 2009, the European Centre for Disease Prevention and Control (ECDC) estimated that multidrug-resistant (MDR) bacterial infections were responsible for 25,000 extra-deaths per year. In 2015, another report estimated that 12,500 extra-deaths were attributable to MDR bacteria every year in France. Recently, the United Nations claimed that resistance to antimicrobials was a global scourge, forecasting 10 million deaths in 2050. Surprisingly, our antibiotic resistance surveillance system in Marseille, France, did not allowed us to observe similar trends. We herein compared our data on extremely drug-resistant (XDR)/pandrug-resistant (PDR) patient extra-deaths to evaluations and predictions from these reports. First, we retrospectively collect and analyze antibiotic resistance data produced by our settings between November 2009 and March 2015 to look for 30-day deaths attributable to XDR/PDR strains belonging to 11 bacterial species/genus. In parallel, we performed a PubMed literature search to look for articles published prior to July 2016 and describing human deaths due to PDR strains. Overall, 35,723 patients were infected by at least one bacterial species/genus of interest and 85 by XDR/PDR strains. Of these patients, only one death was attributable to a XDR bacterial infection in a patient with strong comorbidities and two consecutive septic shocks. Our literature review shows that only four articles described human deaths due to PDR bacteria. All together, these data allowed us to conclude that there is a large discrepancy between the real count of deaths attributable to XDR/PDR bacteria and alarmist predictions.

There is a growing disconnect between catastrophic information and observed reality. This catastrophism has taken over the popular and scientific press at even the highest levels and is fueled by predictive models the value of which has never been confirmed [[1]Raoult D. Alice's living croquet theory.Int J Antimicrob Agents. 2016; 47: 249Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. Thus, for 30 years we have been lurching from one infectious disease health warning to another—including H7N9, Middle East respiratory syndrome and Ebola—while the actual record of infectious disease evolution shows a significant decrease. Over recent decades, antibiotic resistance has become the new worldwide fear, and multidrug-resistant (MDR) bacterial strains have been assumed to cause thousands of human deaths every year around the world [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar]. A report from 2015 estimated that MDR infections will lead to ten million extra human deaths worldwide by 2050 [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar]. However, we observed that the antibiotic resistance of clinical bacterial strains isolated in our hospitals, which belonged to 11 bacterial species of clinical interest, did not significantly change from 2001 to 2015 [[3]Rolain J.M. Abat C. Jimeno M.T. Fournier P.E. Raoult D. Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. Given the aforementioned predictions, estimations and our observations, we recently decided to perform a 7-year analysis of the antibiotic-resistance test results obtained in our hospitals to determine the true impact of extensively drug-resistant (XDR) bacterial strains (those susceptible to fewer than two generic antibiotics) on the mortality of patients hospitalized in our facility [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar]. Focusing our analysis on ten bacterial species and genera of particular interest, we finally concluded that no human deaths were attributable to XDR bacterial infections over the 7-year period, and that only one human death was due to an XDR bacterial strain in our hospital in 2002 [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar]. Comparing our observations to the estimations and predictions mentioned above [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar], we clearly identified that the reality in terms of antibiotic resistance is totally different to that which is reported, and that empirical data are urgently needed, as recently supported by Abat et al. [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar]. Empirical observations that would truly enable us to quantify the number of deaths due to therapeutic impasses and a lack of antibiotic solutions are currently nonexistent. According to the 'Alice's living croquet' theory, which states that it is impossible to predict the future amongst living things [[1]Raoult D. Alice's living croquet theory.Int J Antimicrob Agents. 2016; 47: 249Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar], we strongly believe that it is not possible to predict antibiotic resistance epidemiology. The first example proving this is that of methicillin-resistant Staphylococcus aureus (MRSA). Although methicillin and oxacillin are still used to treat patients infected with S. aureus, we are currently facing an unexplained worldwide decrease in the levels of MRSA strains, which is clearly not the result of screening and isolation strategies developed to control MRSA in hospital settings [[3]Rolain J.M. Abat C. Jimeno M.T. Fournier P.E. Raoult D. Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. Another good example is that of Streptococcus pneumoniae infections. Pneumococcal infections have long been treated using penicillin, which has resulted in the dramatic decrease of worldwide mortality from pneumococcal pneumonia, dropping from 20–40% to only 5% over the last few decades, and was part of the reason for the dramatic decrease in the number of deaths due to lower respiratory infections over the years. However, only a very small proportion of the pneumococcal strains that are currently isolated worldwide are resistant to penicillin [[3]Rolain J.M. Abat C. Jimeno M.T. Fournier P.E. Raoult D. Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar], and the reason for this phenomenon remains unclear. Moreover, predicting the number of deaths directly attributable to MDR bacterial strains is more complex than expected. Firstly, the definition of MDR remains unclear and changes depending on the author [[2]Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar]. Secondly, extra MDR deaths are directly related to the time patients spend in hospital and the departments to which they were admitted. Indeed, a patient hospitalized for a long stay in an intensive care unit (ICU) is more likely to be infected by MDR bacterial strains, but will also have more chance of dying in hospital because of the comorbidities that brought them to the ICU [[3]Rolain J.M. Abat C. Jimeno M.T. Fournier P.E. Raoult D. Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. Hence, if a patient infected by an MDR dies in an ICU, it is clearly impossible to determine whether or not the MDR bacterial strain is responsible for the death. For all these reasons, we think that it is crucial to urgently collect and analyse clinical antibiotic resistance data to determine the real increases and decreases in antibiotic resistance, and to use this information to make good public health decisions. Inadequate prescriptions should thus be evaluated, as it is expected that prescribing a compound considered inactive in vitro is less likely to be efficient on patients [[4]Gutiérrez-Gutiérrez B. Salamanca E. de Cueto M. Hsueh P.R. Viale P. Paño-Pardo J.R. et al.Effect of appropriate combination therapy on mortality of patients with bloodstream infections due to carbapenemase-producing Enterobacteriaceae (INCREMENT): a retrospective cohort study.Lancet Infect Dis. 2017; 17: 726-734Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar]. By doing so, a huge amount of money could be saved and allocated to better purposes, including the development of new antibiotic drugs, improved management of patients infected with antibiotic-resistant bacterial strains and implementation of laboratory hospital data-based antibiotic resistance monitoring systems to detect and monitor antibiotic resistance in hospital settings [2Abat C. Rolain J.M. Dubourg G. Fournier P.E. Chaudet H. Raoult D. Evaluating the clinical burden and mortality attributable to antibiotic resistance: the disparity of empirical data and simple model estimations.Clin Infect Dis. 2017; 65: S58-S63Crossref PubMed Scopus (31) Google Scholar, 3Rolain J.M. Abat C. Jimeno M.T. Fournier P.E. Raoult D. Do we need new antibiotics?.Clin Microbiol Infect. 2016; 22: 408-415Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. Finally, antibiotic stewardship programmes must be implemented to adapt prescriptions to the local epidemiology and to the microbiologic results [4Gutiérrez-Gutiérrez B. Salamanca E. de Cueto M. Hsueh P.R. Viale P. Paño-Pardo J.R. et al.Effect of appropriate combination therapy on mortality of patients with bloodstream infections due to carbapenemase-producing Enterobacteriaceae (INCREMENT): a retrospective cohort study.Lancet Infect Dis. 2017; 17: 726-734Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar, 5Pulcini C. Mohrs S. Beovic B. Gyssens I. Theuretzbacher U. Cars O. et al.Forgotten antibiotics: a follow-up inventory study in Europe, the USA, Canada and Australia.Int J Antimicrob Agents. 2017; 49: 98-101Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] in order to avoid the predicted disasters. All authors report no conflicts of interest relevant to this commentary.

Klein et al. (1) report that global antibiotic consumption increased by 65% over the 2000–2015 period, with a 114% increase in low- and middle-income countries (LMICs). The authors conclude that global antibiotic consumption must be decreased to reduce the threat of antibiotic resistance, although reduction efforts must take into account the limitations in antibiotic access in LMICs and consider local and global resistance patterns. Considering the data from the 2016 Global Burden of Disease study (2), the worldwide mortality attributable to infectious agents dramatically decreased from ∼13 million deaths in 1990 to ∼10 million deaths in 2016. This decrease was mainly driven by the yearly decline of mortality caused by antibiotic-susceptible bacterial infections, including lower … [↵][1]1To whom correspondence should be addressed. Email: philippe.gautret{at}club-internet.fr. [1]: #xref-corresp-1-1

Rickettsia felis is a common emerging pathogen in sub-Saharan Africa. Comparing dynamics of morbidities due to malaria and R. felis infections in two Senegalese villages, we found a strong and significant correlation between them. Malaria morbidity is strongly decreasing because of the implementation of long-lasting insecticidal nets, so we hypothesize that the same measure may decrease the R. felis infections.

Food-borne infections are major causes of public health concern in developing and developed countries. During the past decade, the Institut Hospitalo-Universitaire Méditerranée Infection has conducted or been involved in multiple investigations that aimed at identifying the sources and strains responsible for food-borne diseases and therefore at improving the understanding, diagnosis, prevention and control of these infections. Investigations were conducted in the Mediterranean area and in sub-Saharan Africa on more than 15 food-borne agents, 17 food products and 14 antibiotic resistance-associated genes. Multiple sources, including unexpected ones, and pathogens, including emerging ones, were involved. Travelling in developing countries and zoonoses are major contributors to food-borne infections, while food-borne transmission of resistance-associated genes is increasingly reported. However, risk factors and pathogens associated with food-borne infections likely remain untapped and must be more extensively investigated, monitored and regularly reassessed. Diagnostic tests based on new technologies and real-time surveillance tools based on microbiology laboratory data are promising approaches to detect known food-borne infections and decipher new ones. Studies of the microbiota and its relationships with dietary patterns are also worth being conducted.

Klein et al. (1) report that global antibiotic consumption increased by 65% over the 2000–2015 period, with a 114% increase in low- and middle-income countries (LMICs). The authors conclude that global antibiotic consumption must be decreased to reduce the threat of antibiotic resistance, although reduction efforts must take into account the limitations in antibiotic access in LMICs and consider local and global resistance patterns.Considering the data from the 2016 Global Burden of Disease study (2), the worldwide mortality attributable to infectious agents dramatically decreased from ∼13 million deaths in 1990 to ∼10 million deaths in 2016. This decrease was mainly driven by the yearly decline of mortality caused by antibiotic-susceptible bacterial infections, including lower … [↵][1]1To whom correspondence should be addressed. Email: philippe.gautret{at}club-internet.fr. [1]: #xref-corresp-1-1

To the Editor, We read with interest the work presented by Cahill et al 1 in which the authors evaluate the impact of antibiotic prophylaxis to prevent bactaeremia and infective endocarditis in patients undergoing dental procedures. The analysis was performed based on 36 studies, including 21 bacteraemia studies, five case controls and cohort studies and 10 time trend studies. It is generally well established that dental cares cause bacteraemia and that most …

The new director of WHO has set up a programme, recently outlined in The Lancet Infectious Diseases,1Burki T WHO Director-General shortlist chosen.Lancet Infect Dis. 2017; 17: 267-268Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar which reflects more synchronisation with current European social fears than the more urgent problems that we face. Indeed, worries about antibiotic resistance and global warming are more predictions than realities. From our point of view, the most urgent need is to develop new insecticides to fight vector-borne diseases, especially those transmitted by lice and mosquitoes. In human history, lice have been at the origin of many of the most serious human pandemics—typhus, trench fever, louse-borne relapsing fever, and probably plague pandemics—that have been responsible for millions of human deaths. Lice are beginning to show substantial resistance to permethrin,2Durand R Bouvresse S Berdjane Z Izri A Chosidow O Clark JM Insecticide resistance in head lice: clinical, parasitological and genetic aspects.Clin Microbiol Infect. 2012; 18: 338-344Summary Full Text Full Text PDF PubMed Scopus (83) Google Scholar and currently up to 30% of head lice are resistant to this insecticide.2Durand R Bouvresse S Berdjane Z Izri A Chosidow O Clark JM Insecticide resistance in head lice: clinical, parasitological and genetic aspects.Clin Microbiol Infect. 2012; 18: 338-344Summary Full Text Full Text PDF PubMed Scopus (83) Google Scholar The recently discovered ability of head lice to vectorise diseases as body lice3Sangare AK Boutellis A Drali R et al.Detection of Bartonella quintana in African body and head lice.Am J Trop Med Hyg. 2014; 91: 294-301Crossref PubMed Scopus (35) Google Scholar poses a very substantial threat to humanity because such infections are not controlled in any countries, including the richest. Mosquitoes also represent an important problem in all countries. One of the greatest successes in strategies to control infectious diseases in recent years in tropical countries, especially in Africa, has been the massive distribution of permethrin-impregnated mosquito nets. Thus, this strategy has contributed heavily to the prevention of millions of deaths for malaria worldwide, with a 37·4% decrease in the number of deaths from 1·2 million in 2005 to 730 000 in 2015.4GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4080) Google Scholar Unfortunately, there has been a very substantial increase in the resistance of anopheles to permethrin in tropical countries, which is likely to lead to a return of malaria, as was observed after the banning of dichlorodiphenyltrichloroethane in the 1970s. Moreover, pesticides are essential in many countries for agricultural use, and have made it possible to feed growing populations of human beings worldwide. Finally, they have a crucial economic role by supporting economic sectors, and have improved our living conditions by reducing the pest populations such as those of mosquitoes and cockroaches.5Enserink M Hines PJ Vignieri SN Wigginton NS Yeston JS The pesticide paradox.Science. 2013; 341: 728-729Crossref PubMed Scopus (77) Google Scholar In practice, during the 20th and 21st centuries, insecticides have saved the lives of tens of millions of people worldwide. Therefore, resistance to insecticides is more important and urgent risk than antibiotic resistance and global warming. Caution should be exercised around insecticide-denigrating campaigns, since the effects of insecticides on human beings remain to be proved. We declare no competing interests.

Staphylococcus saprophyticus is one of the leading causes of urinary tract infections (UTI). In December 2014, our surveillance system identified an abnormal increase in S. saprophyticus causing UTIs in four university hospitals in Marseille, indicating a suspected community S. saprophyticus UTI outbreak. This was detected by our surveillance system BALYSES (Bacterial real-time Laboratory-based Surveillance System). S. saprophyticus/ Escherichia coli UTI ratio increased three-fold from 0.0084 in 2002 to 0.025 in December 2015 in Marseille with an abnormal peak in December 2014, and with an annual estimated ratio trend of 5.10−6 (p-value < 10−3). Matrix-Assisted Laser Desorption Ionisation-Time of Flight Mass Spectrometry (MALDI-TOF MS) spectral analysis of strains was used to analyse strains cluster expansion, comparing strains from Marseille to those from Nice during the same period. MALDI-TOF MS spectral analysis revealed a geographical restricted clonal expansion of the strains clusters in Marseille as compared to Nice. Our finding suggests (i) a geographically restricted expansion of a specific S. saprophyticus strain clusters circulating in Marseille, and (ii) MALDI-TOF MS can be used as a cost-effective tool to investigate an outbreak.

We describe the implementation of an automated infectious disease surveillance system that uses data collected from 210 microbiologic laboratories throughout the Provence-Alpes-Côte d’Azur region in France. Each week, these facilities report bacterial species that have been isolated from patients in their area. An alarm is triggered whenever the case count for a bacterial species infection exceeds 2 SDs of the historical mean for that species at the participating laboratory. At its inception in July 2013, the system monitored 611 bacterial species. During July 1, 2013–March 20, 2016, weekly analyses of incoming surveillance data generated 34 alarms signaling possible infectious disease outbreaks; after investigation, 14 (41%) of these alarms resulted in health alerts declared by the regional health authority. We are currently improving the system by developing an Internet-based surveillance platform and extending our surveillance to include more laboratories in the region.