1. 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, November, 2011

2. 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

3. 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.

4. 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 laboratories serving approx 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

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

6. 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

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

8. 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

9. 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

10. E. Coli - 3rd gen cephalosporin resistance 2007-2010
3rd gen cephalosporin resistance in E. coli increased significantly in 14 of 28 countries
Decreasing trends 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.

11. 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

12. 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
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.

13. 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
57% of the isolates were resistant to at least one of the four antimicrobials
4% of the isolates were resistant all four antimicrobials

14. 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%

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

16. Klebsiella pneumoniae – 3rd gen cephalosporin resistance, 2007-2010
3dr gen cephalosporin resistance increased significantly in 9 of 25 countries
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

17. 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

18. 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

19. 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

20. 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)

21. EARS-Net Annual Report 2010
Available at the ECDC website under “publications”:
Direct ink:
...or Google: EARS-Net

22. EARS-Net interactive database AMR results available 1998 -2010

23. 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

24. For reflection: Antimicrobial Consumption
Total consumption of antibiotics for systemic use expressed in DDD per 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