EARS-Net results 2011 Ole Heuer Surveillance Section European Centre for Disease Prevention and Control Joint Annual Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Networks, Warsaw, Poland, 23-25 November, 2011

EARS-Net The European Antimicrobial Resistance Surveillance Network (EARS-Net) is a network of national networks engaged in surveillance of antimicrobial resistance The management and coordination of EARS-Net (former EARSS) was transferred from RIVM (NL) to ECDC by January 1st, 2010

Countries participating in EARS-Net in 2011 Not updated As of January 1st, 2010, five non-EU Member States previously participating in EARSS (Bosnia-Herzegovina, Croatia, Israel, Switzerland and Turkey) had to be detached from the network.

EARS-Net Surveillance of antimicrobial resistance in bacterial isolates from BSI and CSF from humans Data reported by 26 EU Member States + Norway and Iceland EARS-Net data originate from over 900 laboratories serving approx 1400 hospitals in Europe Includes 7 selected bacterial pathogens of public health importance                       Streptococcus pneumoniae Staphylococcus aureus Enterococcus faecalis   Enterococcus faecium   Escherichia coli Klebsiella pneumoniae Pseudomonas auruginosa EARS-Net provides data from the “top of the iceberg” of AMR in humans

EARS-Net results …A look at selected results from 2011 EARS-Net AMR data collection (Data referring to 2010) and trend analysis 2007-2010

Meticillin-resistant Staphylococcus aureus (MRSA) In 2010, MRSA proportions were stabilising or even decreasing in most European countries MRSA remains a public health priority. The proportion of MRSA is still above 25% in 8 out of 28 countries

Trends for MRSA 2007-2010 Seven countries (Austria, Cyprus, Estonia, France, Greece, Ireland and the UK) had decreasing trends for MRSA 2007-2010 Increasing trend for MRSA 2007-2010 was observed in four countries (Germany, Hungary, Italy and Slovenia)

Enterococcus faecium - vancomycin resistance, 2007-2010 Overall 7.4% of E. faecium isolates were resistant to vancomycin A significant decrease was observed in 4 countries (Greece, Germany, Italy and UK) Increase observed for 2 countries (Ireland and Latvia) Efforts to control glycopeptide resistance seem to be successful and resulting in stabilisation or continuous decrease

E. Coli - 3rd gen cephalosporin resistance, 2010 Overall 8.5% of the E. coli isolates were resistant to 3rd gen cephalosporins in 2010 Resistant proportions ranged from 2.6% (Sweden) to 24.8% (Bulgaria) ….this may not look dramatic, but the situation is evolving in a dramatic way. If we look at trends…next

E. Coli - 3rd gen cephalosporin resistance 2007-2010 3rd gen cephalosporin resistance in E. coli increased significantly in 14 of 28 countries 2007-2010 Decreasing trends 2007-2010 were observed only for Portugal and Austria 11 of the14 had significant increase even when considering only labs reporting consistently during the last 4 years. As indicated here… the two countries having a decrease, are not among the high level countries, this again means that some of the increase is taking place in countries who are already in the higher level.

E. Coli – ESBL, 2010 High proportions (65–100 %) of the third-generation cephalosporin resistant E. coli isolates were ascertained as ESBL-positive by the participating laboratories in 2010

E. coli - fluoroquinolone resistance, 2010 Overall 21% of the isolates were resistant to fluoroquinolones 8 countries reported resistance proportions higher than 25% An increasing trend was observed for 8 countries 2007-2010 Decreasing trend for 2 countries (Austria and Germany) E. coli is the most frequent cause of bacteraemia caused by Gram-negative bacteria, as well as community and hospital-acquired urinary tract infections. It is also one of the most common foodborne pathogens worldwide.

E. coli – Combined resistance*, 2007-2010 *resistance to aminopenicillins, 3rd gen cephalosporins, fluoroquinolones and aminoglycosides Combined resistance in E. coli increased significantly in 10 of 28 countries 2007-2010 57% of the isolates were resistant to at least one of the four antimicrobials 4% of the isolates were resistant all four antimicrobials

Klebsiella pneumoniae – 3rd gen cephalosporin resistance Over all 27.5% of the isolates were resistant to 3rd gen cephalosporins Large variation across Europe 10 countries >25% 5 countries > 50%

Klebsiella pneumoniae – ESBL, 2010 The proportion of 3dr gen cephalosporin resistant isolates assessed by the laboratories as ESBL ranged from 75-100% in 14 of 15 countries

Klebsiella pneumoniae – 3rd gen cephalosporin resistance, 2007-2010 3dr gen cephalosporin resistance increased significantly in 9 of 25 countries 2007-2010 Non of the countries had decreasing trends High proportions of resistance in 1/3 of the countries and sharp increasing trends for countries already at high level

Klebsiella pneumoniae - Combined resistance*, 2010 * Resistance to 3rd gen cephalosporins, fluoroquinolones and aminoglycosides 35% of the isolates were resistant to at least one of the antimicrobials 19% of the isolates were resistant to all three antimicrobials. This was even the most frequent resistance pattern. Combined resistance leaves few treatment options - carbapenems Source: EARS-Net, 2011

Klebsiella pneumoniae – resistance to carbapenems 2009 2010   Klebsiella is now starting to show resistance to carbapenems a last-line class of antibiotics: carbapenems. Carbapenems have been widely used in many countries due to the increasing rate of ESBL–producing Enterobacteriaceae, with a consequent impact on the emergence of resistance to these antibiotics, especially in Klebsiella.   In 2009, most of the EU was green, meaning very few Klebsiella infections were resistant to carbapenems. Our new data for 2010 shows carbapenem resistance in this bacterium emerging as a problem in several EU countries Source: EARS-Net, 2011

K. pneumoniae - carbapenem resistance 2007-2010 Overall, 8% of the K. pneumoniae isolates were resistant to carbapenems Carbapenem resistance increased significantly in 5 of 23 countries 2007– 2010 One country (Germany) had a decreasing trend of carbapenem resistance

Conclusions - based on EARS-Net data on AMR in 2010 and trends 2007-2010 Good news : MRSA is stabilising or even decreasing in several countries Aminoglycoside and vancomycin resistance in enterococci is stabilising or continues to decline (few exceptions) Non-susceptibility to penicillin and macrolides in Streptococcus remains stable. High but stable multiresistance in P. aeruginosa Bad news: 3rd gen cephalosporin resistance and multidrug resistance (3-4 antimicrobials) continues a sharp and widespread increase in E. coli and Klebsiella Sad News: Increasing resistance to last line antimicrobials – carbapenem resistance is becoming more frequent in more countries (Carbapenems: .. session 2…and session 7)

EARS-Net Annual Report 2010 Available at the ECDC website under “publications”: http://ecdc.europa.eu/en/Pages/home.aspx Direct ink: http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=774 ...or Google: EARS-Net

EARS-Net interactive database AMR results available 1998 -2010 http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/database/Pages/database.aspx

Thank you for your attention! Thank you! to National EARS-Net representatives and all staff involved in data collection at Laboratories and Hospitals in the countries Thank you for your attention! Not updated

For reflection: Antimicrobial Consumption Total consumption of antibiotics for systemic use expressed in DDD per 1 000 inhabitants and per day in 2009 AB consumption map resembles many of the antimicrobial resistance maps Many factors e.g. infection control affects antimicrobial resistance Combined use of data: AMR, AB consumption and HAI data (ARHAI data linkage …session 13) Infection control practises Data source: ESAC 2010 For Cyprus and Lithuania: total consumption (both community and hospital sector). For Spain: reimbursement data that do not include over-the-counter sales without a prescription. Source: ESAC, 2010