EARS-Net data on Antimicrobial Resistance in Ireland, Q

EARS-Net data on antimicrobial resistance in Ireland Quarter 1-4 2018 4th April 2019

EARS-Net data on Antimicrobial Resistance in Ireland, Q1-4 2018
KEY POINTS, 2018 Increasing numbers of invasive infections in recent years due to the following pathogens: P. aeruginosa (54% since 2015), S. pneumoniae (up 50% since 2015), K. pneumoniae (up 35% since 2014), E. coli (up 20% since 2014), S. aureus (up 10% since 2014) The emergence of carbapenemase-producing strains of K. pneumoniae, E. coli and other enterobacteriaceae (CPE) in recent years is cause for a concern: a national CPE public health emergency was declared in November 2017 Escherichia coli The proportion of invasive infections caused by 3rd generation cephalosporin-resistant and extended-spectrum beta-lactamase (ESBL)-producing E. coli have increased to 12.9% and 11.6%, respectively, their highest levels to date; the proportion multi-drug (MDR*) resistant E. coli is also at its highest level (6.2%) Three isolates were found to be carbapenemase-producers (CPE) Staphylococcus aureus/ MRSA The proportion of S. aureus bloodstream infections (BSIs) that were meticillin-resistant (MRSA) decreased to12.2%, the lowest level to date * Note: Definition of MDR has changed to “combined resistance to 3GCs, fluoroquinolones and aminoglycosides” EARS-Net data on Antimicrobial Resistance in Ireland, Q

KEY POINTS, 2018 (continued)
Klebsiella pneumoniae The proportions of invasive infections caused by fluoroquinolone- and multi-drug (MDR*) resistant K. pneumoniae have increased to 18.4% and 8.3%, respectively, the highest proportions to date The proportion of invasive infections caused by extended-spectrum beta-lactamase (ESBL)-producing K. pneumoniae increased to 16.9%, the highest level since 2013 Four isolates were found to be carbapenemase-producers (3 OXA-48-type and one OXA-131/282) Enterococcus faecium/ VREfm (vancomycin-resistant E. faecium) The proportion of E. faecium BSI that are vancomycin-resistant (i.e. VREfm) increased to 40.2% Ireland had the 2nd highest proportion of VREfm in Europe in 2017 Acinetobacter spp. No MDR isolate was reported * Note: Definition of MDR has changed to “combined resistance to 3GCs, fluoroquinolones and aminoglycosides” EARS-Net data on Antimicrobial Resistance in Ireland, Q

Why do surveillance of antimicrobial resistance?
Surveillance data provides information for action: timely data collection, validation, analysis, feedback and reporting therefore very important Monitor trends over time: Emergence and spread of AMR phenotypes Inform policy makers Effect of interventions, e.g. following introduction of vaccine EARS-Net data on Antimicrobial Resistance in Ireland, Q

EARS-Net (previously known as EARSS)
Established as European Antimicrobial Resistance Surveillance System (or EARSS) in 1998 by EC DG-SANCO organised by Dutch public health institute (RIVM) = Europe-wide co-ordination HPSC in Ireland Transferred to ECDC in 2010 Name changed to EARS-Net An international network of national surveillance systems with laboratories and hospitals from 29 EU/EEA countries participating in 2016 Aims to collect comparable & reliable antimicrobial resistance (AMR) data for public health action EARS-Net data on Antimicrobial Resistance in Ireland, Q

EARS-Net Objectives Collect comparable, representative and accurate AMR data Analyse temporal and spatial trends of AMR in Europe Provide timely AMR data for policy decisions Encourage the implementation, maintenance and improvement of AMR surveillance programmes Support national systems in their efforts to improve diagnostic accuracy by offering an annual External Quality Assessment (EQA) EARS-Net data on Antimicrobial Resistance in Ireland, Q

EARS-Net case definition
EARS-Net collects antimicrobial resistance data on the first invasive isolate (specimen types indicated below) per patient per year for eight key pathogens (arranged in order of frequency reported): Escherichia coli (blood or CSF) Staphylococcus aureus (blood only) Enterococcus faecium (blood only) Klebsiella pneumoniae (blood or CSF) Streptococcus pneumoniae (blood or CSF) Enterococcus faecalis (blood only) Pseudomonas aeruginosa (blood or CSF) Acinetobacter spp. (blood or CSF) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Data collected by EARS-Net
Routinely-generated data from laboratories on key antibiotics for eight pathogens under surveillance Qualitative, i.e. RIS data (interpretations only) Quantitative, i.e. MIC/Etest results in mg/l* *especially important for pneumococci/penicillin and cefotaxime Reference laboratory data Serotypes on pneumococci Confirmation on K. pneumoniae/E. coli isolates that are carbapenemase-producing CRE EARS-Net data on Antimicrobial Resistance in Ireland, Q

Data Management Nationally Data stored in WHONET format (a freeware from WHO, which is versatile for collecting, storing and analysing AMR data) and in an Access database at HPSC Locally WHONET files* LIMS files*, that can be translated to WHONET via BacLink software Excel template* Isolate Record Forms *all electronic files should be encrypted before being sent to HPSC by EARS-Net data on Antimicrobial Resistance in Ireland, Q

Participation in EARS-Net
Between 2015 and 2017, a number of laboratories suspended their participation in EARS-Net due to resource issues but coverage of the Irish population has remained in excess of 95% since 2007. EARS-Net coverage for the past 8 years: % % % % % % %* % *Approaching 100% (99.7%) Note: estimated population coverage by EARS-Net in other EU/EEA countries varies considerably from <20% to 100% EARS-Net data on Antimicrobial Resistance in Ireland, Q

Data Management EUCAST vs CLSI (situation as of Q4 2018) 35 labs have now adopted EUCAST guidelines = 94% of all isolates 3 labs still use CLSI Note: one lab now sends all positive blood cultures to another lab, hence one lab few than previously Data collection in 2018 carried out using: WHONET – 24 labs – representing 89% of data LIMS file – 2 labs – 4% of data Excel – 3 labs – 4% of data Paper forms – 9 labs – 3% of data EARS-Net data on Antimicrobial Resistance in Ireland, Q

Important changes to definitions in 2018
First isolate of each pathogen per patient per year (i.e. no longer “per quarter”, which was the original EARSS definition) Multi-drug resistance for E. coli and K. pneumoniae = co-resistance to 3rd generation cephalosporins, fluoroquinolones and aminoglycosides EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive infections of Escherichia coli
Key messages The numbers of invasive E. coli infections increased by 20% between 2014 and 2018 Resistance to 3rd-generation cephalosporins and ESBL-production among invasive E. coli isolates have continued to increase, reaching their highest levels to date in 2018: 12.9% and 11.6%, respectively Multi-drug resistance also increased to its highest level at 6.2% The number of invasive E. coli isolates that are carbapenemase producers (CPE) has remained stable with three cases reported in 2018 (all with the OXA-48-type enzyme) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive Escherichia coli infections
3GC, 3rd-generation cephalosporins (include cefotaxime, ceftazidime); ESBL, extended-spectrum beta-lactamase; MDR, multi-drug resistance (defined as combined resistance to 3GCs, fluoroquinolones and aminoglycosides) *Note all isolates tested EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in E. coli invasive infections showing percentage
resistance to 3rd-generation cephalosporins (3GC), fluoroquinolones and aminoglycosides EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in E. coli invasive infections showing percentage 3GC-resistance and ESBL-positivity 3GC, 3rd-generation cephalosporins (e.g. cefotaxime, ceftazidime); ESBL, extended-spectrum beta-lactamase EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of 3rd-generation cephalosporin resistant E. coli in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 18/30 (12.0%) EU/EEA: 14.9% (population-weighted mean) 2017 trends 8 countries 1 country EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in E. coli invasive infections with percentage multi-drug resistance Note: MDR, multidrug resistance (defined as combined resistance to 3GCs, fluoroquinolones and aminoglycosides) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Carbapenemase-producing E. coli
CP-ECO, carbapenemase-producing E. coli EARS-Net data on Antimicrobial Resistance in Ireland, Q

Resistance to 3 or more antimicrobial groups: Ireland ranked 16th of 30 countries in 2016 Ireland has one of the lowest proportions of isolates that are fully susceptible to all 5 antimicrobial groups EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of multi-drug resistant (MDR) E. coli in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 Note: MDR defined as combined resistance to 3GCs, fluoroquinolones and aminoglycosides IE rank: 15/30 (5.7%) EU/EEA: 6.3% (population-weighted mean) 2017 trends 5 countries 2 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Staphylococcus aureus bloodstream infections
Key messages The numbers of S. aureus bloodstream infections (BSI) have increased by 10% between 2014 and 2018 In 2018, there were 147 cases of meticillin-resistant S. aureus (MRSA) BSI: this is the lowest annual number to date The proportion of all S. aureus BSI due to MRSA decreased to 12.4%, the lowest level to date By contrast, there has been an increase in meticillin-susceptible S. aureus (MSSA) with 1,039 cases reported in 2018, the highest to date EARS-Net data on Antimicrobial Resistance in Ireland, Q

Staphylococcus aureus bloodstream infections
EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in S. aureus bloodstream infections showing %MRSA

Distribution of MRSA in EARS-Net countries in 2017
Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 11/30 (16.3%) EU/EEA: 16.9% (population-weighted mean) 2017 trends 2 countries 9 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of MRSA in EARS-Net countries in 2017

Trends in S. aureus bloodstream infections:
Rates per 1,000 Patient Days vs Proportions *Rate per 1,000 Patient Days (or Bed Days Used) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive infections of Klebsiella pneumoniae
Key messages The numbers of invasive K. pneumoniae infections have increased by 35% between 2014 and 2018 ESBL-production among invasive K. pneumoniae isolates increased to 16.9% in 2018, reaching its highest level since 2013 (22.4%) Fluoroquinolone and multi-drug resistance have increased to their highest levels to date at 18.4% and 8.3%, respectively The number of invasive K. pneumoniae isolates that are carbapenemase producers (CPE) has remained stable with four cases reported in 2018 (3 OXA-48-type and one OXA-181/232) Still relatively low levels of resistance in Ireland compared to other countries but signs that increasing EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive Klebsiella pneumoniae infections
3GC, 3rd-generation cephalosporins (include cefotaxime, ceftazidime); ESBL, extended-spectrum beta-lactamase; MDR, multi-drug resistance (defined as combined resistance to 3GCs, fluoroquinolones and aminoglycosides) *Note all isolates tested EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in K. pneumoniae invasive infections showing percentage resistance to 3rd-generation cephalosporins, fluoroquinolones and aminoglycosides 3GC, 3rd-generation cephalosporins EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in K. pneumoniae invasive infections with percentage 3GC-resistance and ESBL-positivity EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of 3rd-generation cephalosporin-resistant K. pneumoniae in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 22/30 (14.6%) Median = 31.2% 2017 trends 7 countries 3 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in carbapenemase-producing K. pneumoniae
Year N CP-KPN Enzyme 2011 4 3x OXA-48; 1x KPC 2012 2013 2 Both OXA-48 2014 1x OXA-48; 1x KPC 2015 6 5x OXA-48; 1x KPC 2016 3x KPC; 1x OXA-48 2017 All OXA-48 2018 3x OXA-48; 1x OXA-181/232 CP-KPN, carbapenemase-producing K. pneumoniae EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in K. pneumoniae invasive infections with percentage 3GC- and carbapenem-resistance 3GC, 3rd-generation cephalosporins EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of carbapenem-resistant K. pneumoniae in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 13/30 (0.2%) EU/EEA: 7.2% (population-weighted mean) 2017 trends 3 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in K. pneumoniae invasive infections with % multi-drug resistance (MDR) Note: MDR, multidrug resistance (defined as combined resistance to 3GCs, fluoroquinolones and aminoglycosides) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of multi-drug resistant (MDR) K. pneumoniae in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 Note: MDR defined as combined resistance to 3GCs, fluoroquinolones and aminoglycosides IE rank: 22/30 (5.9%) EU/EEA: 15.8% (population-weighted mean) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Resistance to 4 or more antimicrobial groups: Ireland ranked 21st of 30 countries in 2016 Ireland has one of the lowest proportions of invasive K. pneumoniae isolates that are MDR EARS-Net data on Antimicrobial Resistance in Ireland, Q

bloodstream infections
Enterococcus faecium bloodstream infections Key messages Although vancomycin-resistant E. faecium (VREfm; or VRE) BSI has decreased from 45.9% in 2015 to 40.2% in 2017, Ireland still has the 2nd highest proportion of VREfm in Europe EARS-Net data on Antimicrobial Resistance in Ireland, Q

Enterococcus faecium bloodstream infections
*Not all isolates tested; VREfm, vancomycin-resistant E. faecium; HLG, high-level gentamicin; MDR, multi-drug resistant (defined as resistant to ampicillin, high-level gentamicin and vancomycin) VAN, vancomycin; EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in E. faecium bloodstream infections showing % vancomycin resistance VREfm, vancomycin-resistant E. faecium EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of vancomycin-resistant E. faecium (VREfm) in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 2/30 (38.2%) EU/EEA: 14.9% (population-weighted mean) 2017 trends 10 countries 2 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive infections of Pseudomonas aeruginosa
Key messages The numbers of invasive P. aeruginosa infections have increased by 54% between 2015 and 2018 Multi-drug resistance among invasive P. aeruginosa infections decreased to 3.1% in 2018, its lowest level to date EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive P. aeruginosa infections
MDR, Multi-drug resistant (defined as resistance to three or more of the 5 required antibiotics/antibiotic classes: piperacillin-tazobactam, ceftazidime, carbapenems, fluoroquinolones and aminoglycosides) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in P. aeruginosa invasive infections with % multi-drug resistance (MDR) MDR, multi-drug resistance (defined as resistance to three or more of the 5 required antibiotics/antibiotic classes: piperacillin-tazobactam, ceftazidime, carbapenems, fluoroquinolones and aminoglycosides) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of multi-drug resistant P. aeruginosa in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 19/30 (7.6%) EU/EEA: 13.3% (population-weighted mean) 2017 trends 0 countries 4 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive infections of Streptococcus pneumoniae
Key message The numbers of invasive S. pneumoniae infections have increased by 50% between 2015 and 2018 Penicillin non-susceptibility among invasive S. pneumoniae infections increased to 20% in 2018, its highest level since 2008 EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive Streptococcus pneumoniae infections
NS, non-susceptible; HLR, high-level resistant; Int, intermediate-level resistance; R, Resistant EARS-Net data on Antimicrobial Resistance in Ireland, Q

Trends in S. pneumoniae bloodstream infections showing %PNSP
PNSP, penicillin-non-susceptible S. pneumoniae; I, intermediate; R, high-level resistant

Distribution of penicillin non-susceptible S. pneumoniae in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of S. pneumoniae with penicillin non-susceptibility and erythromycin-resistant in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 EARS-Net data on Antimicrobial Resistance in Ireland, Q

Enterococcus faecalis bloodstream infections
Key messages High-level gentamicin resistance among E. faecalis bloodstream infections (BSI) decreased to 23% in 2018, the lowest level to date No linezolid-resistant E. faecalis was reported in 2018 In 2017, one linezolid-resistant isolate was confirmed as optrA gene-positive EARS-Net data on Antimicrobial Resistance in Ireland, Q

Enterococcus faecalis bloodstream infections
*Not all isolates tested; VREfa, vancomycin-resistant E. faecalis; HLG, high-level gentamicin VAN, vancomycin; EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of high-level gentamicin-resistant E. faecalis in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 14/28 (30.8%) EU/EEA: 30.2% (population-weighted mean) 2017 trends 0 countries 8 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive infections of
Acinetobacter spp. Key messages No multi-drug resistance (MDR) among invasive Acinetobacter spp. infections was reported in Ireland in 2018; only 3 MDR Acinetobacter spp. infections have been identified since surveillance began in 2013, including one in 2017 that was also a carbapenemase-producer (OXA-23/51) MDR Acinetobacter spp. is a major problem in Southern and Eastern European countries, with 8 countries reporting proportions in excess of 70% in 2017 EARS-Net data on Antimicrobial Resistance in Ireland, Q

Invasive Acinetobacter spp. infections
MDR, Multi-drug resistant [defined as resistance to: carbapenems (imipenem/meropenem), fluoroquinolones and aminoglycosides] EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of multi-drug resistant Acinetobacter spp. in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 20/26 (1.7%) EU/EEA: 28.4% (population-weighted mean) 2017 trends 4 countries 3 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Distribution of carbapenem-resistant Acinetobacter spp. in EARS-Net countries in 2017 Map downloaded from ECDC’s Surveillance Atlas on 02/04/2018 IE rank: 19/27 (6.3%) EU/EEA: 33.4% (population-weighted mean) 2017 trends 5 countries 2 countries EARS-Net data on Antimicrobial Resistance in Ireland, Q

Other non-EARS-Net pathogens

Invasive Group A streptococcal (iGAS) infections

Candida (and other yeasts) from bloodstream infections
Case definition: First isolate of each Candida spp. from blood per patient per year 22 laboratories reported 197 cases from 188 patients in 29 acute hospitals (note: 9 patients each had 2 different Candida spp.) No data on candidaemia were received from 16 laboratories: at least three of which (in tertiary hospitals) did not participate in this surveillance activity in 2018 No C. auris reported in 2018 The majority of cases (57%) were from tertiary hospitals Majority of cases (77%) occurred on day 3 or later after admission* *where admission date provided EARS-Net data on Antimicrobial Resistance in Ireland, Q

Breakdown of Candida spp. isolated from blood-stream infections in patients in Irish hospitals, 2018 EARS-Net data on Antimicrobial Resistance in Ireland, Q

Acknowledgements All microbiology laboratories for their continued support for EARS-Net and for providing data for this report EARS-Net Steering Group Microbiology team at HPSC Irish Pneumococcal Reference Laboratory National Carbapenemase-Producing Enterobacteriaceae Reference Laboratory Service (CPEaRLS) EARS-Net at ECDC, Stockholm, Sweden for providing the European data and maps EARS-Net data on Antimicrobial Resistance in Ireland, Q

Additional slides EARS-Net data on Antimicrobial Resistance in Ireland, Q

Monitoring trends over time: changing epidemiology

Monitoring trends over time: changing epidemiology (continued)

Breakdown of EARS-Net pathogens by age and sex in 2018

Breakdown of Denominator data & EARS-Net pathogens by origin (hospital type), 2018 Other hospital type = single speciality hospitals (e.g. maternity, orthopaedic) EARS-Net data on Antimicrobial Resistance in Ireland, Q

Possible association of EARS-Net pathogens with current hospital admission, 2018 EARS-Net data on Antimicrobial Resistance in Ireland, Q

EARS-Net data on Antimicrobial Resistance in Ireland, Q

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