EARSS Annual Report 2002 - European Centre for …ecdc.europa.eu/sites/portal/files/media/en/healthtopics/... · EARSS Annual Report 2002 ... CA-SFM Comité de l’Ántibiogramme

EARSS Annual Report 2002

• The European Antimicrobial Resistance Surveillance System (EARSS), funded by DG SANCOof the European Commission, is an international network of national surveillance systems whichcollects comparable and validated antimicrobial susceptibility data for public health action.

• EARSS performs on-going surveillance of antimicrobial susceptibility in Streptococcuspneumoniae, Staphylococcus aureus, Escherichia coli, and Enterococcus faecalis/faeciumcausing invasive infections and monitors variations of antimicrobial resistance over time andfrom place to place.

• By December 2002, about 700 microbiological laboratories serving some 1100 hospitals from28 countries had provided susceptibility data on about 120 000 invasive isolates.

• An interactive Website where up-to-date details can be found on country-specific resistancelevels for important groups of antibiotics is available at http://www.earss.rivm.nl.

Period of data collection: January 1999 – December 2002

This document was prepared by the EARSS Management Team, members of the Advisory Board,and national representatives of EARSS, Bilthoven, The Netherlands, August 2003.

ISBN number: 90-6960-107-9

Funded by the European Commission under SI2.324194 (2001CVG4-011)European Antimicrobial Resistance Surveillance System (EARSS)

Contractor RIVM (Rijksinstituut voor Volksgezondheid en Milieu)National Institute of Public Health and the Environment

EARSS thanks both the European Commission and the Dutch Ministry of Health, Welfare andSports for their financial support.

Neither the European Commission nor any person acting on its behalf is liable for theconsequences of any use made of this information.

Contents

Acknowledgements………………………………………………………................................................................................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

List of abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

List of acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

The EARSS network in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

EARSS National Representatives in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Chapter 2. The EARRS objectives and methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Chapter 3. Results of the EARSS 2002 laboratory/hospital questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Chapter 4. Quality and comparability of antimicrobial susceptibility testing (AST) among laboratories participating in EARSS in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Chapter 5. The antimicrobial resistance (AMR) situation in Europe in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Chapter 6. Conclusions and future initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

CONTENTS 3

Appendix A. Country Summary Sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49Explanation to the Country Summary SheetsAustria……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54Bulgaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Croatia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58Czech Republic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Denmark……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62Estonia……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64Finland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66France……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68Germany……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72Hungary……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74Iceland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Ireland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78Israel……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80Italy……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82Luxembourg……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84Malta……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Netherlands……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88Norway……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Poland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Portugal……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94Romania……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96Slovakia……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98Slovenia……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100Spain……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102Sweden……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104United Kingdom……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

Appendix B. Technical notes……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

Appendix C. Antimicrobial susceptibility data………………………………….. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

4 CONTENTS

Acknowledgements

May I take this opportunity to express my gratitude to all national representatives, national datamanagers and participating laboratories for their enthusiasm and willingness to share theantimicrobial susceptibility data, for their participation in the external quality control exercise andfor providing the background information requested by the laboratory hospital questionnaire.

I thank UK-NEQAS for their major role in preparing and organising the third successive externalquality assurance (EQA) exercise in close cooperation with the members of the EARSS EQAcommittee. I would like to thank the various members of the EARSS Advisory Board and theEARSS Management Team for sharing their expertise, for their contribution to this report and alsofor making the activities organised within EARSS successful during the past year. Furthermore, Iwould like to thank John Stelling for visiting many participating countries to give WHONET supportfor EARSS and Bennie Bloemberg for his technical support in developing the country summarysheets that are a substantial part of this report.

Finally, I would like to thank you all for your extremely professional collaborative effort to theunique and well-functioning EARSS network, which now includes more than 700 laboratories in 28countries. I look forward to continuing this fruitful cooperation for many years to come.

Hajo Grundmann EARSS Project LeaderDepartment of Infectious Diseases EpidemiologyNational Institute of Public Health and the Environment

Acknowledgement 5

Summary

The European Antimicrobial Resistance Surveillance System (EARSS) is an international networkfunded by the Director General for Health and Consumer Protection (DG SANCO) of the EuropeanCommission and the Dutch Ministry of Health, Welfare and Sports. It maintains a comprehensivesurveillance and information system that links national networks by providing comparable andvalidated data on the prevalence and spread of major invasive bacteria with clinically andepidemiologically relevant antimicrobial resistance in Europe.

EARSS collects routinely generated antimicrobial susceptibility testing (AST) data, provides spatialtrend analyses and makes up-to-date feedback available via an interactive Website athttp://www.earss.rivm.nl. Over 700 laboratories serving 1100 hospitals in 28 European countriesregularly submit routine data for major indicator pathogens (Streptococcus pneumoniae,Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, and Escherichia coli). On thebasis of the 2002 laboratory/hospital questionnaire, the overall hospital catchment population of theEARSS network is estimated at more than 100 million inhabitants in the European region, withnational coverage rates that range between 20% and 100% for individual countries. In 2002, 93% ofthe eligible laboratories also participated in the annual external quality assurance (EQA) exercise,which is jointly organised by EARSS, the United Kingdom External Quality Assurance Scheme (UK-NEQAS) and the Centre Réfèrence des Antibiotiques (CRAB). Despite the different guidelines usedin various countries, the overall concordance of susceptibility results was of sufficient quality, whichshows that pooling and analysis of EARSS surveillance data render valid results for most pathogen-specific susceptibility data.

For the last 4 years, the resistance showed a clear north–south gradient for penicillin non-susceptibleS. pneumoniae (PNSP), with high levels of macrolide co-resistance in several of the southern andthe northern countries. The dynamics of the global epidemic of methicillin-restistant S. aureus(MRSA) has slowed down in the United Kingdom and Ireland, but it showed the fastest increasingproportions in Germany and Austria between 1999 and 2002. Scandinavian countries have beenspared from this trend, but the Netherlands saw the beginning of a trend towards higher MRSA ratesin 2002. Vancomycin-resistant enterococci (VRE), with proportions less than 10% in most countries,have been reported. The six countries that reported higher rates of VRE also had large MRSAproportions, which suggests an epidemiological association. E. coli resistance to theaminopenicillins is common in the European region; only Finland and Sweden report proportions ofless than 30%. Resistance of E. coli to third-generation cephalosporins remained less than 6% inmost countries. Greater proportions were noted for some eastern European countries that appearedto have problems with extended spectrum beta-lactamase (ESBL)-producing strains. However, therewas a consistent and marked rise in fluoroquinolone-resistant E. coli in most European countries,eight of which witnessed an 1.5-fold increase or more in only 2 years (2001 – 2002). This trend mayto be related to the widespread acceptance and use of newer fluoroquinolones with enhanced activityagainst gram-positive pathogens. We predict that both hospital and community-acquired E. coliinfection may become a new challenge as a pathogen that will be difficult to treat in the Europeanregion in the years to come.

EARSS has become an internationally accepted surveillance initiative, which provides meaningfulinformation about the status and trends of antimicrobial resistance in the European region. Thepossible relationship between antimicrobial resistance and consumption will be explored in close

6 Summary

cooperation with European Surveillance of Antimicrobial Consumption (ESAC). We envisionEARSS serving as a platform for the detection and identification of clones with particularimportance to public health in terms of antimicrobial resistance and virulence properties.

The EARSS 2002 annual report would not have been possible without the financial support of DGSANCO of the European Commission (SI2.324194/2001CVG4 – 011) and the Dutch Ministry ofHealth, Welfare and Sports.

Summary 7

8 Annual report EARSS 2002

List of abbreviations and acronyms

AMR Antimicrobial resistance ARMed Antibiotic resistance surveillance and control in the Mediterranean regionAST Antimicrobial susceptibility testingBSAC British Society for Antimicrobial ChemotherapyCA-SFM Comité de l’Ántibiogramme de la Société Française de MicrobiologieCRAB Centre National de Réfèrence des AntibiotiquesCRG Commissie Richtlijnen GevoeligheidsbepalingenCZECH Czech Republic antimicrobial susceptibility guidelineCSF Cerebrospinal fluidDCFP Data check and feedback programDEFS Data Entry & Feedback SoftwareDG SANCO Directorate General for Health and Consumer ProtectionEARSS European Antimicrobial Resistance Surveillance SystemEARSS-MT EARSS Management TeamENSP Erythromycin nonsusceptible Streptococcus pneumoniaeEQA External Quality AssuranceESAC European Surveillance of Antimicrobial Consumption ESBL Extended-spectrum beta-lactamaseESCMID European Society of Clinical Microbiology and Infectious DiseasesESGARS ESCMID Study Group for Antimicrobial Resistance SurveillanceEUCAST European Committee on Antimicrobial Susceptibility TestingFREC Fluoroquinoloneresistant Escherichia coliHLAR HighLevel Aminoglycoside resistanceICM Intersectoral Coordinating MechanismsICU Intensive care unitMENSURA Mesa Espanola de Normalización de la Sensibilidad y Resistencia a los

AntimicrobianosMIC Minimal inhibitory concentrationMRSA Methicillin-resistant Staphylococcus aureusNCCLS (American) National Committee for Clinical Laboratory Standards PNSP Penicillin nonsusceptible Streptococcus pneumoniaeRIVM Rijksinstituut voor Volksgezondheid en Milieu

(National Institute for Public Health and the Environment)SAR Self-medication with antibiotics and resistanceSRGA Swedish Reference Group for AntibioticsUK-NEQAS United Kingdom National External Quality Assessment Scheme for

MicrobiologyVRE Vancomycin-resistant enterococciVRSA Vancomycin-resistant Staphylococcus aureusWHO World Health OrganizationWHONET WHO microbiology laboratory database software

The EARSS Network in 2002 9

* UK data from England and Wales only.

EARSS Management Team in 2002

Project leader: S. Bronzwaer (January to April 2002) H. Grundmann (since March 2003)

Coordinator and International Data Manager P. Schrijnemakers Epidemiologists N. Bruinsma and E. TiemersmaData Manager and Software Engineer J. MonenManagement Assistant C. SchinkelConsultant Medical Microbiologist: J. Degener

E-mail: [email protected]: National Institute for Public Health and the Environment (RIVM)

Antonie van Leeuwenhoeklaan 9PO Box 13720 BA BilthovenThe Netherlands

Phone: +31 30 274 4068Fax: +31 30 274 4409

For general information and direct access to the EARSS database, see www.earss.rivm.nl

The EARSS Network in 2002

Countries participating in EARSS in 2002Austria ATBelgium BEBulgaria BGCroatia HRCzech Republic CZDenmark DKEstonia EEFinland FIFrance FRGermany DEGreece GRHungary HUIceland ISIreland IE

Israel ILItaly ITLuxembourg LUMalta MTNetherlands NLNorway NOPoland PLPortugal PTRomania ROSlovakia SKSlovenia SISpain ESSweden SEUnited Kingdom UK*

EARSS Advisory Board Members in 2002

Name On behalf of Country ProfessionH. Mittermayer EARSS national representatives Austria MicrobiologistG. Cornaglia ESCMID Italy MicrobiologistF. Baquero ESGARS Spain MicrobiologistW. Hryniewicz EARSS national representatives Poland MicrobiologistO. Lyytikäinen EARSS national representatives Finland EpidemiologistG. Kahlmeter EUCAST Sweden MicrobiologistK. Kristinsson EARSS national representatives Iceland Microbiologist

EARSS EQA Committee in 2002

P. Courvalin Unité des Agents Antibactériens, Institut Pasteur, FranceG. Cornaglia Università degli Studi di Verona, Istituto de Microbiologia, ItalyJ. Degener Department of Medical Microbiology, Groningen University Hospital, The

Netherlands G. Kahlmeter Central Hospital Växjö, SwedenJ. Mouton Canisius Wilhelmina Hospital, Nijmegen, The Netherlands C. Walton Quality Assurance Laboratory, Central Public Health Laboratory, United

KingdomS. Bronzwaer Department of Infectious Diseases Epidemiology, RIVM, The NetherlandsP. Schrijnemakers Department of Infectious Diseases Epidemiology, RIVM, The Netherlands


Annual report EARSS 2002 11

EARSS National Representatives in 2002

Austria (AT) Estonia (EE) Ireland (IE) Netherlands (NL) Slovenia (SI)H. Mittermayer P. Naaber D. O’ Flanagan E. Tiemersma M. GubinaW. Koller O. Murphy A. de Neeling

Belgium (BE) Finland (FI) Iceland (IS) Norway (NO) Slovakia (SK)H. Goossens O. Lyytikäinen K. Kristinsson A. Hoiby L. Langsadl E. Hendrickx A. Nissinen E. Bjørløw

Bulgaria (BG) France (FR) Israel (IL) Poland (PL) Spain (ES)B. Markova H. Aubry-Damon R. Raz W. Hryniewicz F. Baquero

P. Courvalin J. Campos

Croatia (HR) Germany (DE) Italy (IT) Portugal (PT) Sweden (SE)S. Kalenic W. Witte G. Cornaglia M. Caniça B. LiljequistA.Tambic U. Buchholz P. D’AnconaAndrasevic

Czech Republic Greece (GR) Luxembourg (LU) Rumania (RO) United Kingdom(CZ) N. Legakis R. Hemmer I. Codita (UK)P. Urbaskova G. Vatopoulos A. Johnson

M. Wale

Denmark (DK) Hungary (HU) Malta (MT)D. Monnet M. Füzi M. Borg

Other parties and representatives

WHO WHONET UK-NEQASP. Jenkins J. Stelling C.Walton


EARSS data collection (national data managers or contact persons of national networks)

Contact Institute Country National URL

person surveillance

network

S. Metz Elisabethinen Hospital Austria EARSS Austria

Linz

E. Hendrickx Scientific Institute of Belgium EARSS Belgium www.iph.fgov.be/

Public Health

H. Velinov “Alexandrovska”, Bulgaria EARSS Bulgaria earss.online.bg

B. Markova Laboratory for Clinical

Microbiology, Sofia

S. Kalenic Clinical Hospital Croatia EARSS Croatia

Centre Zagreb

V. Jakubu National Institute of Czech National Reference www.szu.cz/cem/earss/czeanj.htm

Public Health Republic Laboratory for

Antibiotics

D. L. Monnet Statens Serum Institute Denmark DANMAP www.ssi.dk

P. Naaber Tartu University Clinics Estonia EARSS Estonia

T. Möttönen (KTL) National Public Health Finland Finnish Hospital Infection

Program (SIRO)

A. Nissinen (FiRe) Institute (KTL) Finnish Study Group www.ktl.fi/siro

for Antimicrobial www.mmm.fi/extras/fire/index.html

Resistance (FiRe)

V. Jarlier National Institut of France ONERBA

L. Gutmann and Public Health National Reference www.onerba.org

E.Varon Surveillance (InVS) Centre for www.invs.sante.fr

pneumococci

U. Buchholz Robert Koch-Institute Germany EARSS Germany

A. Vatopoulos Department of Hygiene Greece The Greek System www.mednet.gr/whonet/

& Epidemiology, Medical for the Surveillance of

School, Athens University, Antimicrobial Resistance

(WHONET Greece)

S. Vegh National Centre for Hungary EARSS Hungary www.antsz.hu

Epidemiology

K. Kristinsson Landspitali University Iceland

Hospital

S. Murchan National Disease Ireland EARSS Ireland www.ndsc.ie

Surveillance Centre

R. Raz Ha’Emek Medical Israel EARSS Israel

Center

F. D’Ancona Istituto Superiore di Italy AR-ISS www.simi.iss.it/antibiotico_

A. Pantos Sanità resistenza.htm

O. Courteille National Service of Luxembourg EARSS Luxembourg

Infectious Diseases

E. Scicluna Infection Control Unit, Malta EARSS Malta www.slh.gov.mt/icut

St Luke’s Hospital

Annual report EARSS 2002 13

Contact Institute Country National URL

person surveillance

network

A. Bosman National Institute of Netherlands Electronic laboratory www.isis.rivm.nl

Public Health and surveillance in the

the Environment Netherlands

A. de Neeling Resistance

determination project

E. Bjorlow Norwegian Institute Norway NORM www.fhi.no

of Public Health MSIS

P. Grzesiowski National Institute Poland OPTY www.cls.edu.pl/surveillance

of Public Health

M. Caniça National Institute of Portugal GEMVSA/EARSS

P. Lavado Health Dr. Ricardo Jorge Portugal

L. Codita National Institute for Romania EARSS-Romania Not yet active for EARSS

C. Balotescu Research and Development

in Microbiology and

Immunology Cantacuzino

L. Langsadl National Institute for Slovakia EARSS-Slovakia www.nutarch.sk

TB and Respiratory

Diseases

J. Kolman Institute of Microbiology Slovenia EARSS Slovenia

M. Gubina and Immunology,

Medical Faculty, University

of Ljubljana

J. Oteo Instituto de Salud Spain EARSS Spain

Carlos III

B. Olsson- Swedish Institute for Sweden SMI-ResNet www.smittskyddsinstitutet.se

Liljequist Infectious Disease

Control

S. Cavendish Public Health United PHLS-AmSSU

Laboratory Service Kingdom

CHAPTER 1. Introduction

Antimicrobial resistance (AMR) challenges the effectiveness of successful treatment of bacterialinfections and is a public health issue with local, national and international dimensions. During the‘Microbial Threat Conference’, held in September 1998 in Denmark, it was announced that‘Effective European surveillance must have the agreement and active involvement of allparticipants’ (‘the Copenhagen Recommendations’ [1]). In due course, the Directorate General forHealth and Consumer Protection (DG SANCO) of the European Commission funded the EuropeanAntimicrobial Resistance Surveillance System (EARSS). EARSS’ mission is to maintain acomprehensive surveillance and information system that links national networks by providingcomparable and validated data about the prevalence and spread of major invasive bacteria withclinical and epidemiologically relevant AMR in Europe. In 2001, at a follow-up EU conference inVisby, Sweden, it was concluded that all Member States of the European Union (EU) should join theEARSS initiative as a minimum requirement of national surveillance programmes (‘the Visbyrecommendations [2]’).

EARSS is co-ordinated by the Dutch National Institute of Public Health and the Environment(RIVM), and since its beginning in 1999, it has steadily drawn in new participants from theEuropean countries. At present, around 700 laboratories serving almost 1100 hospitals in 28European countries participate. They cover an estimated population of more than 100 millioninhabitants. The EARSS database contains AMR data on approximately 120 000 invasive isolates offour genera (Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis/faecium, andEscherichia coli). It is thus the most comprehensive public health effort that describes and analysesgeographic and secular trends in AMR worldwide.

EARSS has encouraged and helped sustain national surveillance efforts, and the network is theperfect basis for an integrated public health approach for AMR containment in Europe. To this end,EARSS operates in close collaboration with other EU- financed projects: European Surveillance ofAntimicrobial Consumption (ESAC), Self-medication with Antibiotics and Resistance (SAR) andAntibiotic Resistance Surveillance and Control in the Mediterranean region (ARMed). There is aclose partnership between the European Society of Clinical Microbiology and Infectious Diseases(ESCMID) and two of the society’s study groups, namely, the European Committee onAntimicrobial Susceptibility Testing (EUCAST) and the ESCMID Study Group for AntimicrobialResistance Surveillance (ESGARS).

This report presents an overview of activities, innovations and results of the EARSS network.Chapter 2 summarises the objectives and methodology. Chapters 3 and 4 present reference dataregarding the participating laboratories and hospitals and the results of the annual EQA exercise forthe year 2002. Chapter 5 gives an in-depth analysis on the situation of AMR in the European region.Chapter 6 provides recommendations and lists possible future initiatives based on these results. Theappendixes contain detailed country summary sheets, tables with data and a technical section.Results are based on data recorded from January 1999 - December 2002, if not otherwise indicated.

CHAPTER 1. Introduction 15

References

1. V. Thamdrup Rosdahl et al. Report from the invitational EU Conference on the microbial threat,Copenhagen, Denmark, 9-10 September 1998.

2. Progress Report on Antimicrobial Resistance, Visby, Sweden, June 2001.

16 CHAPTER 1. Introduction

CHAPTER 2. The EARRS objectives and methodology

The objectives

It is the public health purpose of EARSS to assist in the control of AMR; therefore, the followingobjectives have been set:• To collect comparable and validated AMR data • To analyse trends in time and place (among various European countries) • To provide official national AMR data that constitute a basis for policy decisions• To provide feedback to ‘those who need to know’• To provide information about clinically and epidemiologically relevant AMR and to evaluate

interventions.

Furthermore, EARSS aims are:• To encourage the implementation, maintenance and improvement of national AMR surveillance

programmes to provide timely information for national policy decisions• To link AMR data to factors influencing the emergence and spread of AMR, particularly to

antibiotic use data, in close cooperation with the European Surveillance of AntimicrobialConsumption (ESAC)

• To initiate, foster and complement scientific research in Europe in the field of AMR.

At the start of the project, the task determined for EARSS was to collect routinely generatedantimicrobial susceptibility testing (AST) data from a limited number of invasive pathogens. Thepathogens that successively became objects of surveillance within EARSS were selected accordingto epidemiological (community versus hospital acquisition) and ecological (transmission versusselection) paradigms. At the same time, the focus was set on selected clinically andepidemiologically relevant antibiotic resistance traits. The decision to collect routine data meant thatno changes to the regular diagnostic process were needed. Therefore, the participation of manylaboratories has become feasible, and this has facilitated the probing of a substantial part of thepopulation in the participating countries. Sampling of the pathogens was and is restricted to invasive(blood culture and CSF) isolates, which are routinely tested for antimicrobial susceptibility in mostlaboratories. Data collection started in 1999 for S. pneumoniae and S. aureus after a preparatoryphase in 1998. The surveillance has been extended to include E. coli and enterococci (E. faeciumand E. faecalis since 2001).

The methodology

Organisation of the EARSS networkEach participating country has appointed one or two national representatives. They are medicalmicrobiologists and/or infectious disease epidemiologists. Moreover, each country has a national datamanager. The main task of the national representatives is to connect the EARSS-specific activities ofthe participating laboratories (data collection, reporting, questionnaire completion and EQA strain andresults distribution) with the EARSS central database, which is maintained and updated by the EARSSManagement Team (EARSS-MT). The national representatives also ensure that the laboratoriesgenerate their AST data according to the EARSS protocols, as published in the 2001 EARSS manual.

CHAPTER 2. The EARSS objectives and methodology 17

The main task of the national data manager is to collect, approve and forward resistance data eachquarter and to assist the national representative. Protocols for standardising the data collection havebeen developed with professional help from the European Society of Clinical Microbiology andInfectious Diseases (ESCMID) and WHO microbiology laboratory database software (WHONET).To assess the quality and comparability of AST data, an EQA exercise is carried out every year incollaboration with the UK-NEQAS and the Centre National de Réfèrence des Antibiotiques(CRAB). EARSS contributes to the global strategy established by the World Health Organization(WHO) for worldwide surveillance of drug resistance.

The national networksIt is the task of the national representatives to select participating laboratories/hospitals that cover atleast 20% of the total population. The various types of hospitals (university or tertiary care hospitals,general or district hospitals, rehabilitation centres or nursing homes, and others), the differentgeographic regions (urban/rural), and the socio-economic strata should be represented as well aspossible.

We collected reference information on the national networks with the 2002 laboratory/hospitalquestionnaire. This questionnaire served three main purposes:1. To collect denominator information for the estimation of incidence rates, i.e. the frequency with

which resistant bacteria were ascertained in a population. Unlike resistance proportions,incidence rates may improve comparisons between hospitals, regions and countries.

18 CHAPTER 2. The EARSS objectives and methodology

Figure 1. Structure of the EARSS network 1 World Health Organisation, 2 European Society for Clinical Microbiology and Infectious Diseases, 3 European

Committee on Antimicrobial Susceptibility Testing, 4 European Surveillance of Antimicrobial Consumption, 5 Antibiotic

Resistance in Mediterranean countries, 6 Self-medication of antimicrobial and resistance levels in Europe, 7 Intersectoral

coordinating mechanisms, 8 External Quality Assurance Committee

National Management Team

National Representative Data Manager

EARSS Management Team

DG-SANCO

National AdvisoryBoard

Advisory Board

Plenary Meeting

EQA Committee8

WHO1

ESCMID2

EUCAST3

ESAC4

ARMed5

SAR6

LAB 1 LAB 2 LAB 3

Dutch Ministry of Welfareand Sport (co-funding)

Public

ICMs7

2. To collect information about the representativeness of EARSS results to understand whether thereported data should only be applied to regions or whether they can be generalised at the countrylevel.

3. To explore existing efforts and the potential interest among participating centres in improving aninfrastructure for the identification of clones with particular public health importance.

Collecting and processing antimicrobial susceptibility testing (AST) dataEARSS routinely collects susceptibility test results of invasive isolates and background informationabout patients. Laboratories are asked only to report the first isolate from blood or cerebrospinalfluid (CSF). According to the specifications of the EARSS exchange format (2001 EARSS manual),the system requires the laboratory code, isolate sample number, isolate source, date of samplecollection, sex, month and year of birth, hospital code, hospital department, origin of patient (levelof care – ambulant, hospitalised, etc.), and the pathogen and antibiotic susceptibility testing resultsas specified in the protocols. Furthermore, optional data are collected; they include clinicaldiagnosis, other conditions, and susceptibility data for other antibiotics.

LaboratoriesParticipating laboratories can opt for one of two ways of submitting data: by e-mail or by sendingin conventional isolate record forms (paper). EARSS provides various free software tools forelectronic data handling, downloadable from the Website at www.earss.rivm.nl: (1) WHONET, themicrobiology laboratory software, revised for EARSS by John Stelling, and (2) Data Entry &Feedback Software (DEFS), which was developed especially for EARSS. Laboratories are asked tocollect AST data on a routine basis and to forward them to the national representative or datamanager quarterly. Before submission, laboratories are asked to check their data for: • Adherence to the EARSS protocol• Microbiological consistency/plausibility• Consistency with clinical sensitive (S), intermediate (I) and resistant (R) breakpoints as defined

by to the guideline used.

National representative and national data managerAt the national level, the national data manager, in consultation with the national representative,processes the data. This is done in a stepwise procedure by:• Recording data from all participating laboratories.• Manual data entry if isolate record forms are used. • Merging data from all participating laboratories into one single file.• Removing duplicate reports. Only primary isolates per patient per quarter shall be reported. • Converting data to EARSS exchange format (2001 EARSS manual). • Revising data with the Data Check and Feedback Programme (DCFP)• Approval of data by the national representative (adherence to EARSS protocol, check for

microbiological consistency, and check whether the S, I and R interpretations agree with theminimal inhibitory concentrations (MICs) reported.

• Data transfer to EARSS-MT on a quarterly basis.

Feedback from EARSSAccurate and timely feedback is essential for surveillance systems. Once they are made available toEARSS-MT, data are analysed and returned in a standard feedback report to the nationalrepresentative. This feedback contains information on pathogens with important and unusual

CHAPTER 2. The EARSS objectives and methodology 19

resistance patterns (MRSA, PNSP, VRE), and contains information on the validity and completenessof the data. Subsequently, the national representative is asked to confirm the correctness of theresults. With his/her approval, the data will be added to the EARSS database and will becomeimmediately available on the interactive EARSS Website at www.earss.rivm.nl, where they can beaccessed in various formats, such as tables, figures, and geographical maps.

Furthermore, the data from the EARSS database are used to prepare annual reports, newsletters andpublications that are disseminated to the participants, policy makers and a broader public.

20 CHAPTER 2. The EARSS objectives and methodology

CHAPTER 3. Results of the EARSS 2002 laboratory/hospital questionnaire

Introduction

EARSS regularly receives routine AST results from approximately 700 laboratories in 28 Europeancountries. Reference information about the populations for which these laboratories provide theirservices is essential for understanding the validity, i.e. representativeness and generalisability, ofEARSS data. A good to fair representation of the country’s situation with respect to antibioticresistance is needed to justify comparisons with other countries and to present sensible results. Toachieve this degree of comparability, EARSS aims to collect information on AST results forpopulations that:• Comprise at least 20% of the total national population• Represent the different geographical and socio-economic strata• Receive treatment in different types of hospitals (university hospital/tertiary care, district

hospital/general care, and long-term care/other).

In May 2003, the EARSS 2002 laboratory/hospital questionnaire was sent to all laboratoriesparticipating in EARSS to collect information on the number and types of hospitals they serve, thecatchment population, size and occupancy rate of these institutions, and the frequency of bacterialblood culture tests. The questionnaire also included eight questions about existing strain (clone)identification systems (typing) and explored the interest of participating laboratories in contributingto an international initiative for strain identification.

The EARSS-MT distributed the questionnaires to the national representatives, who forwarded themto the participating laboratories. The information was required for the year 2002 only. Completedquestionnaires were returned to the national representatives, who forwarded the information to theEARSS-MT. The EARSS-MT set up a database and carried out the descriptive analysis. Details ofthe data analysis are given in the technical notes (Appendix B).

In this chapter, preliminary results of this exercise are presented and discussed. Detailed results foreach country are also presented in the country summary sheets (Table 1, Figures 1 and 2 of AppendixA). More extensive and final information will be made available early next year.

Results and discussion

Participation This preliminary investigation includes countries, laboratories and hospitals for which bothdenominator data and AST results were available for 2002. In total, 306 of the 600 laboratories(51%) and 416 of the 837 hospitals (50%) from 21 of the 27 countries that reported AST data toEARSS in 2002 responded to the EARSS 2002 questionnaire (Figure 3.1). Three additionalcountries (Austria, Denmark and Ireland) reported aggregated data, which unfortunately could notbe included in laboratory/hospital-specific analysis. However, the data provided by these countriesare included in Appendix A (country summary sheets).

CHAPTER 3. Result of the EARSS 2002 laboratory/hospital questionnaire 21

Figure 3.1A, B. Numbers of laboratories (A) and hospitals (B) reporting AST results to EARSS and numbers providing

denominator data for 2002, by country

22 CHAPTER 3. Result of the EARSS 2002 laboratory/hospital questionnaire

0

20

40

60

80

100

120

AT BE BG CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LU MT NL PL PT RO SE SI SK UKEARSS country code

Num

ber

of l

abor

ator

ies

0

20

40

60

80

100

120

AT BE BG CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LU MT NL PL PT RO SE SI SK UK

EARSS country code

Num

ber

of h

ospi

tals

*

no denominator information

with denominator information

A

no denominator information

with denominator information

B

* see Appendix A for explanation on the number of hospitals

Population coverage Table 3.1 gives an overview of the laboratories and hospitals that had returned the requestedreference information by the time this report was written. Denominator data were hence availablefor hospitals that provided health services for an estimated population of more than 85 millionpeople in 2002. This corresponds to an average coverage of 70% of the national population in these


Table 3.1. Representativeness of EARSS data, based on the laboratories and hospitals that provided denominator

information for the year 2002

Country Labs Labs Number Hospitals Hospitals Average Estimated Percentage Number

reporting providing of blood reporting providing annual catchment of of

to denominator culture to denominator occupancy population national blood

EARSS data sets EARSS ¶ data ¶ rate, % (x1000) population cultures

covered per 100 000

inhabitants

Bulgaria 22 19 15 549 22 18 76 7 621 100 2.0

Croatia 15 15 34 742 15 15 91 3 775 86 9.2

Czech 42 42 76 188 95 82 78 8 283 81 9.2

Republic

Estonia 8 7 4 217 12 7 75 1 416 100 3.0

Finland 16 13 121 484 16 12 86 4 242 82 28.6

France 21 21 242 938 21 21 84 NA# NA NA

Germany 19 2 10 317 19 0 NA NA NA NA

Hungary 26 26 19 656 69 56 78 9 312 92 2.1

Iceland 2 2 8 647 2* 2 92 279 100 31.0

Israel 5 5 118 289 5 5 97 2 430 40 48.7

Luxembourg 9 7 10 083 14 6 76 449 100 22.5

Malta 1 1 2 863 1 1 83 370 93 7.7

Netherlands 23 14 93 655 39 18 61 4 564 28 22.2

Poland 24 24 33 634 24 24 77 8 508 22 4.0

Portugal 18 9 25 623 18 9 76 1 841 18 13.9

Romania 12 8 10 515 11 8 87 10 243 46 1.0

Slovakia 14 14 15 207 14 14 67 5 117 94 3.0

Slovenia 11 11 28 092 15 15 73 1 933 100 14.5

Spain 37 28 136 260 37 28 82 7 714 19 17.7

Sweden 21 20 176 079 63 57 88 6 276 71 28.1

United 23 18 141 543 26 18 82 9 685 16 14.6

Kingdom

Total 332 306 1 315 265 501 416 79** 93 664 70 14.1**

# NA, not available

¶ see Appendix A for explanation on the number of hospitals

*Iceland counts nine hospitals that all report AST results to EARSS. However, only two of these are relevant to EARSS with respect to denominator

information because they are the main hospitals providing acute and general care

** Average, not total

countries. Almost complete coverage (> 90%) was achieved by eight of the 21 countries (Table 3.1).The population coverage appears to be overestimated for some countries, possibly due tooverlapping catchment populations. This error may occur when hospitals are located within eachother’s vicinities and therefore draw patients from partly identical populations. The estimatedcoverage of the total population was less than 20% for Spain (19%), Portugal (18%) and the UnitedKingdom (16%). However, this underestimates the real coverage achieved by EARSS in thesecountries, as catchment population data were not available for all participating hospitals. Thecoverage would most likely have exceeded 20% if all hospitals participating in EARSS had beenincluded.

Hospital informationFigure 3.2 shows that secondary and tertiary care facilities in all countries except Malta wererepresented. (Malta has only one public hospital, which provides both tertiary and secondary care).The proportion of tertiary versus secondary care varied substantially among countries, which mayresult in differences in case mix and may confound comparison of country AST results. However,the definition of secondary and tertiary care may also vary from country to country, and assigningunambiguous and comparable care levels to hospitals in various countries is presently not easilyachieved.

Figure 3.2. Types of hospitals per country in 2002


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BG(18)

CZ(82)

EE(7)

ES(28)

FI(12)

FR(21)

HR(15)

HU(56)

IL(5)

IS(2)

LU(6)

MT(1)

NL(18)

PL(24)

PT(9)

RO(8)

SE(57)

SI(15)

SK(14)

UK(18)

EARSS country code (number of hospitals)

Perc

enta

ge o

f hos

pita

ls

OtherUniversity/tertiary careGeneral/secondary care

*

* Spain (ES) has one hospital of unknown type

The average annual occupancy of hospitals was about 80% in most countries, and it varied from 61%(the Netherlands) to 97% (Israel). Table 3.2 gives information on the hospitals providingdenominator data. In most of the countries, at least one hospital with a burn unit and/or facilities thatcarry out solid organ/bone marrow transplantation reported to EARSS. The proportion of ICU bedsvaried between 1.9% (Poland) and 8.6% (Czech Republic). Hospitals that care for burns, forimmunocompromised patients or for those who have had complex surgery are usually faced withmore infections requiring antibiotic treatment and consequently witness higher resistance rates.Indeed, the incidences of MRSA and VRE were greater in hospitals performing complex operations(1.5 versus 6.2 MRSA infections per 100 000 patient days, and 0.04 versus 0.2 VRE infections per100 000 patient days, respectively; P < 0.05).


Table 3.2. Information about hospitals with denominator data available for the year 2002

Country Hospitals Hospitals Hospitals Total Total Percentage Number Number Blood

with with number number of ICU of of blood culture

burn transplant of beds of ICU beds/ patient culture sets per

unit facilities beds total beds days sets* 1000 patient

days

Bulgaria 18 3 3 9 168 782 9 2 356 099 15 454 6.56

Croatia 15 1 2 8 533 376 4 2 825 852 34 742 12.29

Czech 82 4 12 44 322 3812 9 12 436 030 76 188 6.13

Republic

Estonia 7 0 2 3 021 222 7 599 577 4 177 6.97

Finland 12 2 2 8 880 226 3 2 748 433 119 193 43.37

France 21 NA# 11 18 804 1045 6 5 783 830 242 938 42.00

Hungary 56 1 1 34 569 900 3 8 346 323 13 749 1.65

Iceland 2 1 0 1 139 27 2 340 230 8 647 25.42

Israel 5 2 3 4 409 179 4 1 574 809 118 289 75.11

Luxembourg 6 0 1 1 693 115 7 458 535 9 237 20.14

Malta 1 1 1 846 33 4 308 683 2 863 9.27

Netherlands 18 1 4 10 644 321 3 2 360 807 85 340 36.15

Poland 24 0 0 14 706 280 2 4 115 371 33 634 8.17

Portugal 9 0 2 4 309 179 4 829 938 17 949 21.63

Romania 8 5 0 6 201 425 7 2 006 236 10 461 5.21

Slovakia 14 0 6 11 502 574 5 2 780 024 15 207 5.47

Slovenia 15 3 1 7 960 422 5 2 116 299 28 092 13.27

Spain 28 1 7 14 043 513 4 4 048 014 136 260 33.66

Sweden 57 NA 3 18 447 573 3 2 579 638 82 762 32.08

United 18 0 7 13 664 384 3 3 383 394 102 685 30.35

Kingdom

Total 416 25 68 236 860 11 388 5** 61 998 122 1 157 867 18.68**

* Includes only laboratories that serve hospitals for which the number of patient days was reported or could be calculated

# NA, not available

** Average, not total

Blood culture practice As becomes clear from Tables 3.1 (number of blood culture sets per 100 000 inhabitants) and 3.2(number of blood culture sets/1000 patient days), blood culturing practices vary among countries,which was also shown by others [1,2]. The sampling frequency for blood cultures may bias the ratesof ascertaining blood stream infections. Variation in the numbers of blood culture sets per 100 000inhabitants and per 1000 patient days suggests different practices in eastern and western Europe.Relatively high rates (> 20 sets/1000 patient days) were reported by Spain, Finland, Israel,Luxembourg, the Netherlands, Portugal, Sweden and the United Kingdom, whereas rates of less than15 sets/1000 patient days were calculated for the other countries listed in Table 3.2, which weremainly eastern European countries. Israel had much higher blood culturing rates than any othercountry. Similar patterns exist for the number of blood culture sets/100 000 inhabitants (Table 3.1).However, it is not expected that these differences in blood culture practice influence the comparisonof AMRs, as reported resistance proportions were independent of blood culture frequencies.

Incidence rates of nosocomial blood stream infectionsTable 3.3 shows the incidence of MRSA and VRE blood stream infections. In general, incidencerates are more relevant than resistance proportions as they provide patient-based risk estimates ofacquiring such blood stream infections in the respective national hospital care system. However, incomparisons of incidence rates with resistance proportions, the ranking order by country remains byand large unchanged as regards MRSA. This is a clear indication that EARSS resistance proportionsare good approximations of the incidence rates, and they supply useful information for comparingcountry-specific resistance rates. Thus, the MRSA and VRE ranking order remains basicallyunchanged (Chapter 5). There was little VRE incidence in most countries. However, confidenceintervals were large because few E. faecium isolates were reported. This is reflected in the relativelyhigh detection limits shown in Table 3.3. The highest rates were established for participatinghospitals in Israel and Croatia.

Table 3.3. Estimated incidence rates of nosocomial bloodstream infections/100 000 patient days in 2002*

* Only isolates from hospitals with available denominator information were included in the calculation

# NA, not available

** Incidence is lower than the detection limit at p=0.05 calculated with the available numbers of isolates and patient-days (see Appendix B).


Country Incidence rate (per 100, 000 patient-days)

MRSA VRE

Bulgaria 1.36 <0.11**

Croatia 3.64 0.14

Czech Republic 0.54 0.06

Estonia 0.17 <0.32

Finland 0.22 0.04

France 9.44 0.03

Hungary 0.34 <0.03

Iceland <0.86 <0.72

Israel 11.37 0.19

Luxembourg 2.62 <0.54

Malta 11.99 <0.61

Country Incidence rate (per 100, 000 patient-days)

MRSA VRE

Netherlands 0.25 <0.13

Poland 1.04 <0.07

Portugal 14.10 <0.30

Romania 1.00 0.05

Slovakia 0.79 <0.08

Slovenia 1.80 <0.13

Spain 5.61 0.02

Sweden 0.47 0.04

United Kingdom 14.48 NA#

Total 3.20 0.03

Laboratory information: typingMost laboratories would welcome a standardised typing approach, a standardised nomenclature, anda typing network for the identification of the emergence and spread of ‘EARSS-specific’ pathogensin their countries. More laboratories were interested in such services for S. aureus and S. pneumoniae(98%) than for E. faecium and E. coli (93%). Almost all laboratories (298 of 301; 98%) wouldwelcome a common database that could be queried for the existence, distribution and prevalence ofbacterial strains with important public health relevance (high resistance or virulence) in theEuropean region.

Conclusion

The EARSS 2002 laboratory/hospital questionnaire provided necessary insights into thedenominator population and sampling practice of the participating laboratories and hospitals. It wasa useful instrument for identifying the scope for future initiatives within the EARSS network. On asample basis (21 of 28 countries), it could be shown that EARSS supplies representative and robustantimicrobial susceptibility data for European countries. The population coverage is adequate andgreater than 20% for most participant countries. Individual countries still differ in definition andcomposition of tertiary and secondary care hospitals, which may introduce some minor flaws ininternal validity. Some countries could improve the geographical spread of EARSS laboratories byinclusion of hospitals in areas that are not yet well represented (see country maps in the countrysummary sheets). In comparisons of incidence rates with resistance proportions, the overall rankingorder by country remained unchanged. This indicates that EARSS resistance proportions representmeaningful data and undoubtedly supply useful information for comparing country-specificresistance rates. Moreover, EARSS participants would welcome standardised and internationaltyping approaches for the identification of bacterial strains with particular public health importance.

References

1. Ronveaux O, Jans B, Suetens C, Carsauw H. Epidemiology of nosocomial bloodstream infectionsin Belgium, 1992-1996. Eur J Clin Microbiol Infect Dis 1998; 17: 695-700.

2. Bouza E, Pérez-Molina J, Muñoz P, Cooperative Group of the European Study Group onNosocomial Infections (ESGNI). Report of ESGNI-001 and ESGNI-002 studies. Bloodstreaminfections in Europe. Clin Microbiol Infect 1999; 5(2S): 1-12.


CHAPTER 4. Quality and comparability of antimicrobialsusceptibility testing (AST) among laboratoriesparticipating in EARSS in 2002

Introduction

The differences in methods and national guidelines among European laboratories may affect thecomparability of interpretative results based on clinical breakpoints. It is therefore indispensable thatlaboratories participate in EQA schemes . In 2002 EARSS organised the third EQA exercise. Its aimwas to assess the quality and comparability of susceptibility results across countries and to comparethe results with respect to country-specific guidelines. This exercise is also crucial for determiningwhether pooling and analysing the routinely collected antimicrobial surveillance data within theEARSS network generates valid results.

Methods

In September 2002, UK-NEQAS distributed a set of five strains to the laboratories participating inEARSS; S. aureus U2A1556, E. faecium U2A805, E. coli U2A1557, E. coli U2A1526 and S.pneumoniae U2A1580, which were provided by CRAB. The laboratories were requested to reportmethods and guidelines used for species identification, MIC determination (when performed) andclinical susceptibility breakpoints (S, I and R). Results were considered ‘concordant’ if the reportedcategorisation (S, I or R) agreed with the interpretation independently approved by three referencelaboratories.

Results and discussionThe offer of participation in the EQA was readily taken up by 642 of the 690 laboratories (93%) in26 countries (Figure 4.1).

CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing 29

0

20

40

60

80

100

120

Countries

num

ber o

f lab

orat

orie

s

Invited

Participation

AT BE BG CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LU MT NL PL PT RO SE SI SK UK

Figure 4.1. Participation in the 2002 external quality assurance (EQA) exercise

The high response rate for this third successive EQA shows that the interest among laboratories tocompare their results with international standards has not abated (90% response rate in 2000, 91%in 2001 and 93% in 2002) and shows a continuous commitment to quality.

Table 4.1 displays the different guidelines used by the laboratories of the various countries andshows that most of the laboratories have adopted (American) National Committee for ClinicalLaboratory Standards (NCCLS) guidelines (71%).

30 CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing

Table 4.1. The usage of guidelines by number of laboratories per country

Guideline used

Country BSAC CA-SFM CZECH CRG MENSURA NCCLS SRGA Other Total

AT 5 5

BE 1 83 10 94

BU 13 8 21

CZ 17 24 41

DK 2 3 5

EE 6 1 7

ES 1 34 1 36

FI 14 14

FR 55 55

GR 30 5 35

HR 24 24

HU 28 28

IE 2 12 7 21

IL 5 5

IS 2 2

IT 50 2 52

LU 9 9

MT 1 1

NL 7 16 2 25

PL 43 43

PT 22 2 24

RO 1 10 1 12

SE 1 23 1 25

SI 11 11

SK 12 1 13

UK 14 1 8 23

Total 16 57 17 7 1 451 25 57 631*

Percentage (3%) (9%) (3%) (1%) (0.2%) (71%) (4%) (9%)

*In total, 642 laboratories participated; 11 laboratories did not mention the guideline used

As Table 4.2 shows, the overall concordance of susceptibility results was excellent and matched theintended results. This indicates that the routine susceptibility testing in the laboratories participatingin EARSS is extremely satisfactory. The results also show that the EARSS pooling and subsequentanalysis of the resistance surveillance data renders valid results for most of the pathogen-specificsusceptibility data. However, there is room for improvement.

The majority of laboratories identified the five distributed strains correctly at the species level. Asingle strain (E. faecium U2A 805) was misidentified by 79 (13%) of the 627 laboratories. In mostof these cases (n = 55), it was identified as an E. casseliflavus or E. gallinarum. Commercial test kitsand automated methods that base species identification on substrate utilisation and biochemical

CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing 31

Table 4.2. Intended results and overall concordance for the EARSS protocol antibiotics

Pathogen Antimicrobial Intended result Overall concordance

(percentages)

S. aureus Species identification 100

U2A1556 Oxacillin and or methicillin R 94

Vancomycin S 99

S. pneumoniae Species identification 99

U2A1580 Oxacillin R 98

Penicillin-G I/R 98

Erythromycin R 95

Cefotaxime and or ceftriaxone S/I 89

Ciprofloxacin S 76

E. coli Species identification 98

U2A1557 Amoxicillin and or ampicillin I/R 98

Gentamicin S 99

Tobramycin S 99

Ciprofloxacin S 100

ESBL No 95

E. coli Species identification 100

U2A1526 Amoxicillin and or ampicillin R 100

Gentamicin R 99

Tobramycin R 99

Ciprofloxacin S 96

ESBL Yes 93

E. faecium Species identification 87

U2A805 Amoxicillin and or ampicillin R 98

Gentamicin HLR 98

Vancomycin R 90

ESBL, Extended-spectrum beta lactamase; HLR, High Level Resistance; I, intermediate; R, resistant; S, sensitive

reaction are occasionally unable to distinguish accurately between E. faecium and other enterococciof the gallinarum group. Additional testing for motility and pigmentation can discriminate morereliably. This 13% misidentification of the E. faecium strain should alert the respective laboratoriesto potential uncertainties in their speciation.

The oxacillin/methicillin resistance in S. aureus U2A1556 (mecA+ve) was not detected by 6% andthe resistance to vancomycin in E. faecium U2A805 was not noticed by 10% of the participatinglaboratories. Considering the clinical, epidemiological, and infection control implications associatedwith such strains, it appears critical to improve the identification of these relevant resistancephenotypes.

The relatively low concordance in determining ciprofloxacin susceptibility in S. pneumoniaeU2A1580 can be explained by the facts that (1) the British Society for Antimicrobial Chemotherapy(BSAC) and Swedish Reference Group for Antibiotics (SRGA) guidelines recommend alwaysreporting a ciprofloxacin test as I or R for S. pneumoniae and (2) some guidelines (e.g. NCCLS, orComité de l’Ántibiogramme de la Société Française de Microbiologie(CA-SFM)) do not give anyrecommendations at all. This example illustrates that breakpoints may differ substantially for somedrug-bug combinations. In these cases, data interpreted (S, I, R) by the various countries should becompared with caution. Therefore, EARSS strongly supports the EUCAST initiative to defineuniversal epidemiological breakpoints based on wild-type distributions for surveillance.

A complete and detailed report of the 2002 EQA results was distributed to all EARSS participantsin March 2003.

Conclusion

Despite the adherence to different guidelines by countries reporting to EARSS, most of thesusceptibility results were concordant. This finding underlines the facts that the overall comparisonof routine results generated in different laboratories throughout Europe is feasible for the species andantibiotics tested.

32 CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing

CHAPTER 5. The antimicrobial resistance (AMR) situation inEurope in 2002

Introduction

Approximately 10% of the entire burden of disease in European countries (which include new andold member states of the European Community) can be attributed to infectious diseases. Thiscontrasts to many Asian, South American and African countries where 42% to 71% of the entiredisease burden is caused by communicable diseases [1]. The smaller proportion attributable to thegroup of communicable diseases in Europe is the result of numerous economical and socialdevelopments that have led to improvements in public health and clinical services. These include theavailability of successful antimicrobial therapy, which is an important factor. In contrast to otherpharmaceutical interventions, however, antibiotic treatment has a societal effect, as selection forresistant pathogens is not confined to the individual receiving treatment, but by nature of theinfectious agents can expand into the community at large. It is this feature that makes AMR a healthissue for both clinical services and public health programmes.

During the last 4 years (1999–2002), EARSS has collected routine resistance data about diseaseisolates of S. pneumoniae (n = 22 244), S. aureus (n = 53 264), E. coli (n = 35 565) and E.faecium/faecalis (n = 9463). The EARSS database contained data on 120 536 isolates from some 700laboratories serving around 1100 hospitals in 28 countries at the end of 2002. This chapter discussesthe current dimension and pertinent trends concerning AMR as related to the pathogens just mentionedfor the European region. Appendix A provides summary statistics for individual countries.

Results and discussion

Streptococcus pneumoniae Streptococcus pneumoniae is the single most important cause of infections of the lower respiratorytract (such as pneumonia) in adults and children. It is also the main cause of otitis media in childrenand causes life-threatening meningitis in children and the elderly. Penicillin and other beta-lactamantibiotics have been the mainstay of antipneumococcal therapy since the 1940s. However, a steadydecrease of penicillin susceptibility has been reported from many countries worldwide in the pasttwo decades.

In 2002, the EARSS network identified the largest proportions of penicillin non-susceptible S.pneumoniae (PNSP, > 25%) in France, Israel, Poland, Romania and Spain. The smallest proportionsof PNSP were reported from the north of Europe, but also from more central European countriessuch as Germany and Austria (Figure 5.1; Table 1 of Appendix C).

Even though the average proportion of PNSP was 11% for all the isolates reported in 2002, (Table1 of Appendix C), the average proportion of isolates fully resistant (MIC ≥ 2 mg/L) to penicillin wasonly 2%. However, large variations in the proportion of PNSP, from <1% in Estonia and Malta to53% in France (Table 1 of Appendix C) and variations in the proportion of fully penicillin resistantisolates, which ranged between 0% and 10% (Spain), were found between countries. So far, there isno evidence of bacteriological failure of penicillins active against intermediate susceptible strains[2]. This means that pneumococcal infections other than meningitis should still respond to high oralor intravenous doses of amoxicillin or high intravenous doses of penicillin.

CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002 33

34 CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Figure 5.1. Streptococcus pneumoniae: invasive isolates non-susceptible to penicillin (PNSP) in 2002.

Figure 5.2. Streptococcus pneumoniae: invasive isolates non-susceptible to penicillin (PNSP) by year for countriesreporting to EARSS for 3 years or more, in alphabetical order

Country (average number of isolates per year)

0%

5%

10%

15%

20%

25%

30%

35%

40%

AT (6

2)

BE (1

014)

BG (1

8)

CZ (1

36)

DE (2

66)

DK (4

27)

ES (6

30)

FI (3

18)

IE (2

20)

IS (4

4)

IT (1

78)

LU (2

5)

MT

(12)

NL (7

69)

PT (1

38)

SE (8

07)

SI (9

9)

UK (4

80)

Prop

ortio

n PN

SP

1999

20002001

2002

The frequency with which PNSP was reported to EARSS during the last 4 years remained relativelystable for most of the countries (Austria, Belgium, Germany, Spain, Italy, the Netherlands, Swedenand the United Kingdom), and showed an increase for the Czech Republic and Finland. In addition,a decrease was observed for Slovenia and Ireland (P < 0.05). Due to the small sample size ofisolates, no conclusions concerning trends over time could be drawn for Bulgaria, Iceland,Luxembourg and Malta (Figure 5.2).

EARSS identified a clear predominance of erythromycin non-susceptible isolates (ENSP) insouthwestern countries in 2002 (Figure 5.3). The greatest proportions of ENSP were found inBelgium (34%), France (58%) and Italy (32%) and the smallest proportions of ENSP (≤ 5%) wereobserved in the Czech Republic (4%), Denmark (5%), Estonia (0%), and Iceland (5%). Among theScandinavian countries, only Finland showed a steady increase in reduced erythromycinsusceptibility from 6% in 1999 to 13% in 2002 (Table 1 of Appendix C).

Figure 5.4 shows that a large part of the penicillin non-susceptible S. pneumoniae isolates are alsoresistant to erythromycin in most countries. In fact, co-resistance is of dual public health importance.Not only does it affect the clinical management of infections, co-resistance also means that each ofthe antibiotic substances to which a pathogen has developed resistance independently facilitates thesuccess of co-resistant clones.


Figure 5.3. Streptococcus pneumoniae: invasive isolates non-susceptible to erythromycin (ENSP) in 2002.

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Staphylococcus aureus Staphylococcus aureus is the main cause of bone, joint and soft-tissue infections acquired in hospitaland in the community. It also causes blood stream infections and endocarditis, and it is a frequentcause of food poisoning. S. aureus resistant to penicillinase-fast beta-lactam antibiotics such asmethicillin, oxacillin, cloxacillin, flucloxacillin, nafcillin and cephalosporins is commonly termedMRSA (for methicillin-resistant S. aureus). S. aureus has become a notorious cause of hospital-acquired infections and thrives in hospitals worldwide. Due to the multiresistant nature of MRSA,glycopeptide antibiotics (vancomycin and teicoplanin) with inferior pharmacokinetic propertieshave become the treatment of choice. In the last decade, there have been repeated reports of newlyemerging MRSA strains that cause difficult-to-treat community-acquired skin infections in theUnited States.

Figure 5.5 displays the current proportions of MRSA in various European countries (Table 1 ofAppendix C). The reason why MRSA enjoys such heterogeneous success in Europe with resistanceproportions that vary 100-fold between countries is multifaceted. Successful epidemic clonesquickly exploit ecological opportunities. Any combination of a wide range of factors, such asincreased colonisation pressure brought about by imported cases, a habitual prescribing of antibioticsin health care facilities, obstruction of early detection, inappropriate isolation precautions, patientcrowding, low staff-patient ratios and reduction in basic housekeeping performance can account forthe rapid spread of MRSA through regional or national health care systems.


Figure 5.4. Streptococcus pneumoniae: invasive isolates non- susceptible to both penicillin, and erythromycin (co-resistant), or penicillin only, shown by country for the period 1999 – 2002. (Only isolates that were tested for bothpenicillin and erythromycin for the countries with at least 20 isolates reported in the period 1999–2002 were included)

Prop

ortio

n

Only penicillin non-susceptible

95% CI

Co-resistant to penicillinerythromycin

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

IL (3

23)

ES (1

782)

HU (8

8)

PT (2

16)

SI (2

28)

HR (1

04)

LU (9

0)

BE (4

058)

IE (6

79)

IT (6

43)

BG (4

6)

UK (1

072)

CZ (3

79)

FI (1

206)

MT

(34)

IS (1

59)

DK (1

282)

SE (2

514)

AT (1

40)

NL (1

997)

DE (7

90)

EE (3

7)

Country (total number of isolates)

*

*

There has been a significant increase of MRSA (P < 0.05) in Austria, Belgium, Germany, and theUnited Kingdom (Figure 5.6) during the last 4 years. Germany and Austria witnessed the quickestexpansion: from 8% to 19% and from 5% to 11%, respectively. The United Kingdom and Irelandcurrently see more of a stabilisation of the fast rise that characterised the increase of MRSAthroughout the 1990s in the British Isles, and they have maintained levels below 45% in the last 2years (2001 and 2002). The only consistent decrease was reported by Slovenia (from 21% in 2000to 14% in 2002, P < 0.05), where public debate following a national prevalence study resulted inincreased awareness and nationwide education efforts for doctors in 2001. It appears that thesemeasures had the desired effect and brought MRSA rates down in 2002 for the second successiveyear. In northern countries – Iceland, Denmark, Sweden, Finland and the Netherlands – theproportion of MRSA remained less than 1%. Nonetheless, the Netherlands saw a slight, butsignificant, increase in 2002 over the previous years (Figure 5.6).


Figure 5.5. Staphylococcus aureus: invasive isolates resistant to methicillin (MRSA) in 2002

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

EnterococciAlthough not as virulent as the other indicator pathogens recorded by the EARSS initiative,enterococci are common causes of urinary tract infections and a frequent component of intra-abdominal infections. They cause severe forms of endocarditis, and are hideous, opportunisticpathogens in immunocompromised patients, where they cause septicaemia, meningitis and boneinfections. By nature relatively resistant to many antibiotics, enterococci were the first significanthuman pathogens that reportedly developed resistance against third-line glycopeptide antibiotics(vancomycin and teicoplanin). Ever since, vancomycin-resistant enterococci (VRE) have served asa paradigm for the post-anti-microbial era [3].

The proportion of vancomycin-resistant E. faecium was reported above 10% in Ireland, Italy,Greece, Croatia, and Romania in 2002, and it was between 5% and 10% in Germany, Austria, CzechRepublic and Israel (Figure 5.7; Table 1 of Appendix C). However, the European picture isincomplete since EARSS does not yet receive data from Belgium, Denmark, Norway and the UnitedKingdom, and very few isolates (< 10) were reported by Iceland, Romania and Slovakia.

High-level aminoglycoside-resistant E. faecalis appeared frequently in the European region in 2002.Only Iceland reported a proportion of isolates less than 10%, and, for a few countries – Austria,Finland, France, Luxembourg and Malta – the proportion was less than 20%. Bulgaria, Greece, andHungary reported the largest proportions of high-level aminoglycoside resistance (Figure 5.8; Table1 of Appendix C).


Figure 5.6. Staphylococcus aureus: invasive isolates resistant to methicillin (MRSA) by year for countries reporting toEARSS for 3 years or more, in alphabetical order


AT (2

79)

BE (7

83)

BG (1

10)

CZ (9

19)

DE (9

15)

DK (6

23)

ES (1

015)

FI (5

01)

GR (3

18)

IE (7

35)

IS (4

9)

IT (9

49)

LU (6

8)

MT

(82)

NL (1

352)

PT (3

96)

SE (1

567)

SI (2

33)

UK (1

340)

Prop

ortio

n M

RSA

1999

20002001

2002

0%

10%

20%

30%

40%

50%

60%


< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Figure 5.7. Enterococcus faecium: invasive isolates resistant to vancomycin in 2002

Figure 5.8. Enterococcus faecalis: invasive isolates with high-level aminoglycoside (gentamicin) resistance in 2002

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Trends in resistance of hospital-acquired infections The proportions of MRSA and VRE in 2002 are combined by country in Figure 5.9. Six countriesreported epidemic proportions of VRE (≥ 10%). All of them belong to the nine countries that alsoreported the highest MRSA rates (> 35%). This suggests an intricate relation between MRSA andVRE, which is most likely twofold. Empirical treatment decisions in situations where MRSA thriveswill frequently give preference to glycopeptide antibiotics and thereby bring about conditions thatfavour the selection for glycopeptide-resistant enterococci. At the same time, the dissemination ofthese predominantly nosocomial pathogens is supported by common ecological forces. The co-circulation of these pathogens in the same populations is a reason for concern, as is highlighted byrecent reports of fully vancomycin-resistant MRSA (VRSA) in the USA, where co-infection ofpatients with both VRE and MRSA led to conjugative transposition of the vancomycin resistancegenes from VRE to MRSA [4].

Escherichia coliEscherichia coli is the most frequent gram-negative rod isolated from blood cultures in clinicalsettings. It is the most frequent cause of community and hospital-acquired urinary tract infections; itis associated with spontaneous and surgical peritonitis; it causes synergistic wound infections; andit is one of the most important food-borne pathogens. Broad-spectrum penicillins such as ampicillinand amoxicillin were the treatments of choice before beta-lactamases (mostly plasmid coded TEM1)became an almost ubiquitous component of the genetic equipment of this species. Except forSweden and Finland, the proportion of E. coli isolates resistant to aminopenicillins was largest than30% for all countries (Figure 5.10; Table 2 of Appendix C).


Figure 5.9. Staphylococcus aureus: invasive isolates resistant to methicillin (MRSA) and vancomycin-resistant E.

faecium (VRE) by country (both reporting MRSA and VRE) in 2002

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Prop

ortio

n

GR MT IE IL IT PT HR RO FR BG ES PL DE LU SI AT HU SK CZ EE NL FI SE IS

%VRE

%MRSA

Country

Figure 5.10. Escherichia coli: invasive isolates resistant to aminopenicillins in 2002

In most European countries, the proportions of isolates resistant to third-generation cephalosporinsremained at 6% or less in 2002. The greatest proportions of third-generation cephalosporinresistance were found among some of the eastern European countries: Bulgaria (13%), Israel (8%)and Romania (18%, Figure 5.11; Table 2 of Appendix C). Despite overall small proportions, thereis no reason for complacency, since resistance to third-generation cephalosporins in E. coli isbrought about by extremely successful, extended-spectrum beta-lactamases (ESBLs). Theseresistance determinates are plasmid-coded and easily spread by conjugation, not only amongdifferent strains of E. coli but also among different species of enterobacteriaceae. ESBLs arepotentially a serious impediment to the treatment of community and hospital E. coli infections inEurope.

As shown in Figure 5.12, most European countries have attained proportions of fluoroquinoloneresistance of 10% or greater in 2002 (Table 2 of Appendix C). Within the 2 years since EARSSstarted AMR surveillance for E. coli, 21 countries have provided complete AST data. Sixteen ofthem witnessed an increase in fluoroquinolone resistance (Figure 5.13) and eight countries sawfluoroquinolone resistance in 2002 increase to 1.5 times the resistance rates reported in 2001 ormore. The consistency of this finding reflects a worrying trend and might be the consequence of thewidespread acceptance and use of newer fluoroquinolones with enhanced activity against Gram-positive pathogens as a convenient alternative to other broad-spectrum antibiotics.


Country (total number of isolates)

RO (2

8)

IL (8

64)

IE (7

35)

ES (2

483)

PT (4

43)

FR (2

493)

BG (1

34)

PL (1

34)

SK (2

15)

DE (1

025)

IT (5

64)

HR (4

90)

BE (1

167)

GR (5

83)

HU (3

53)

CZ (1

587)

SI (4

09)

MT

(74)

LU (1

92)

NL (2

421)

EE (6

5)

AT (4

14)

IS (7

9)

FL (1

329)

SE (1

753)

Prop

ortio

n am

inop

enic

illin

resi

stan

ce

0

10

20

30

40

50

60

70

80

90

100


Figure 5.11. Escherichia coli: invasive isolates resistant to third-generation cephalosporins in 2002

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Figure 5.12. Escherichia coli: invasive isolates resistant to fluoroquinolones in 2002

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Figure 5.13. Escherichia coli: invasive isolates resistant to fluoroquinolones by country in 2001 and 2002

Similar to third-generation cephalosporin resistance, the greatest proportions of gentamicin andtobramycin resistance were found in eastern European countries, namely, Bulgaria , Romania andIsrael (>15%). They were still less than 1% in Finland and Sweden (Figure 5.14; Table 2 ofAppendix C). The greater resistance proportions in eastern Europe can be attributed to the frequentadministration of this antibiotic class in clinical settings. Aminoglycosides remain an inexpensivealternative to other injectable drugs and are still employed as a single drug therapy in manyhospitals.

E. coli isolates with multiple resistance to third-generation cephalosporins, fluoroquinolones andaminoglycosides are still scarce in Europe (0.74% for the period 1999–2002) and only occurred inBulgaria (14/211; 7%), Israel (85/1569; 5%) and Romania (4/26; 15%) in greater proportions.



Prop

ortio

n flu

oroq

uino

lone

resi

stan

ce

2001

2002

0%

5%

10%

15%

20%

25%

AT (3

12)

BE (5

72)

BG (1

12)

CZ (1

380)

DE (1

127)

EE (5

3)

ES (2

220)

FI (1

306)

GR (5

78)

HR (3

34)

HU (2

93)

IL (8

00)

IS (7

8)

LU (1

74)

MT

(71)

NL (1

974)

PL (1

13)

PT (3

44)

SE (2

344)

SI (4

04)

SK (1

30)


< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Figure 5.14a. Escherichia coli: invasive isolates resistant to gentamicin/netilmicin in 2002

Figure 5.14b. Proportion of Escherichia coli: invasive isolates resistant to tobramycin in 2002

< 1%No data

1 – 5%5 – 10%10 – 25%25 – 50%> 50

LU MT

Conclusion

During the last 4 years, resistance proportions for S. pneumoniae have remained relatively stable inthe European region with high rates of PNSP in France, Spain, Poland and Romania and low levelsin northern and central parts of Europe. However, the proportions increased in Finland and the CzechRepublic. The alternative treatment with macrolides favoured in many countries has led to greatresistance in France, Spain, Italy, Belgium and Slovakia. The combined loss of susceptibility to bothpenicillins and macrolides (co-resistance) may also become a growing issue in these countries. Sincethere is increasing evidence of macrolide failure in pneumococci if the MICs are 4mg/L or greater,high-dose treatment with beta-lactam antibiotics remains the saver treatment alternative in countrieswhere most PNSPs are of intermediate susceptibility.

For MRSA, the dynamics of the global epidemic has slowed down in the United Kingdom andIreland, whereas Germany and Austria showed the quickest increase of MRSA rates between 1999and 2002. Scandinavian countries are still spared from this trend, but the Netherlands saw thebeginning of an increase in 2002. The proportions of vancomcyin-resistant enterococci haveremained small in most countries; however, a few reported large proportions. In all of them, MRSAthrives and VRE outbreaks in hospitals are certainly favoured by increased glycopeptideconsumption. To control such outbreaks, it is incumbent to set up infection control procedures andrevise the guidelines for empirical glycopeptide use.

Of all “EARSS-specific” pathogens, E. coli showed the most worrying trends. Not only have beta-lactamases become a constitutive genetic component of more than 50% of all invasive isolates(rendering these strains resistant to ampicillin/amoxcicillin), but there was also a marked andconsistent increase in fluoroquinolone resistance in most countries (16 of 21) that reported E. colisusceptibility data to EARSS. At the same time, third-generation cephalosporins have lost more andmore of their activity in countries where ESBL-producing strains are on the rise. Community andhospital E. coli infections are likely to become increasingly difficult to treat and may pose a healththreat to patients in the European region.

References

1. World Development Report 1993, Oxford University Press, New York, USA.2. Klugman KP. Bacteriological evidence of antibiotic failure in pneumococcal lower respiratory

tract infections. Eur Respir J 2002;36:3s-8s.3. Cohen ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science

1992; 257:1050-5.4. Sievert DM, Boulton ML, Stoltman G et al. Staphylococcus aureus resistant to vancomcyin –

United States, 2002. MMWR 2002;51:565-7.

APPENDIX ‘Overview of activities in 2002’ 45

CHAPTER 6. Conclusions and future initiatives

Geographic variation in the proportions of antibiotic resistance in Europe has been a consistentpattern over the years, and it seems to reflect the ecological differences encountered by the ‘EARSS-specific’ pathogens in various countries. To understand the driving forces behind this disparity,EARSS did some original analysis and was able to correlate beta-lactam antibiotic consumption withpenicillin-non-susceptible S. pneumoniae (PNSP) for the EARSS participating countries in 2001 [1].Since most of the PNSP isolates belong to eight frequently occurring serotypes and mainly originatefrom infections of infants and toddlers, there is hope that invasive disease caused by resistant strainscould be controlled by conjugate vaccines that have recently been made available. It is incumbent,however, to monitor the serotype distribution among invasive and resistant isolates once vaccinesbecome widely accepted. EARSS laboratories would be ideally suited to provide these services aswell as to determine the population effectiveness of such an intervention.

The largest variation in resistance proportions in the European region was observed for MRSA, andit became apparent that the global MRSA epidemic continued to expand in many European countriesin 2002. Two features that have been noticed are worth mentioning. Firstly, countries that see anepidemic rise in MRSA frequently witness a fast increase and spread in many hospitals, but MRSAproportions appear to reach saturation levels after a couple of years. Secondly, European countrieswith longstanding high MRSA rates maintained resistance proportions between 40% and 50%(Portugal, Italy and Greece). It is not understood what limits this dissemination and determines thenational carrying capacity. Despite the relative uniformity of resistance proportions amonghyperendemic countries, some hospitals warrant attention since they see much higher MRSA ratesthan the national average. To better understand the factors that drive the success of certain highlyprevalent clones, attention should be turned to hospitals with longstanding and extreme MRSAfigures. They represent ideal study sites for specific national and international investigations thatwould potentially identify a set of common conductive ecological conditions.

Vancomycin-resistant enterococci (VRE) mainly belong to the species E. faecium and occur inepidemic proportions in a few countries. Nevertheless, six countries reported proportions greater orequal to 10% in 2002 compared to only 4 countries in 2001. It has been shown that invasive VREbelong to hospital-associated strains, many of them phylogenetically related and carrying the espgene [2]. This means that appropriate methods of strain identification can potentially identify theseparticularly important strains early enough to prevent hospital outbreaks, and EARSS will be able totrace their regional and international dissemination with the use of spatial analysis.

In E. coli, aminopenicillin resistance continued to expand and the median resistance proportionincreased from 44.5% in 2001 to 48% in 2002. The same trend was recognised for third-generationcephalosporins. The latter increase was mainly due to the spread of ESBL-producing strains in someeastern European countries. The most rapid rise of resistance frequencies in 2002 was observed forfluoroquinolone-resistant E. coli. Resistance increased in 16 of 21 countries; 8 of them observedproportions that were at least 1.5 times greater in 2002 than in the previous year. It has been arguedthat fluoroquinolone resistance mainly occurs in phylogenetically diverse subgroups other than veryvirulent strains and may be derived from animal sources [3]. The exchange of strain-specificinformation would enhance the ability of EARSS to characterise the nature of this threateningdevelopment, which would be helpful in efforts to improve resistance surveillance.

CHAPTER 6. Conclusions and future initiatives 47

EARSS has become an internationally accepted surveillance organisation in the last 4 years. EARSSprovides meaningful information on the status and trends of AMR in the European region. However,some obstacles have not entirely been overcome and remain to be addressed in the future to improveon the accuracy and validity of the data. Susceptibility tests were originally devised and are routinelyused as guidance for therapeutic decision making in clinical services. The use of these routinelaboratory results for public health purposes has not been without controversy. The main concern isthat EARSS results are based on clinical breakpoints interpreted in S, I, and R categories. Thesediffer among laboratories depending on the various national guidelines used. Nonetheless, routineEQA exercises performed annually throughout the EARSS network were able to demonstrate thatover 95% of the laboratories come to concordant results when the guidelines agreed on breakpointsthat clearly separate wild type from resistant bacteria. This means that most of the laboratoriessatisfactorily identify micro-organisms that have acquired the ability to circumvent the effect of theantibiotic to which they would normally be expected to be susceptible. The initiative taken byEUCAST to harmonise the existing clinical breakpoints and define epidemiological cut off valuesfor surveillance [4] will certainly improve the completeness of conclusions drawn by EARSS.

The EARSS network with its 700 participating laboratories provides the ideal basis for furtherepidemiological and ecological research towards a better understanding of the emergence and spreadof resistance in the European region. One property of the EARSS initiative has, in this respect, notbeen exploited to its full potential: the capacity to process data based on strain-specific identificationof pathogens. Once this becomes possible, EARSS will not only provide a novel approach topertinent research questions, but value will be added to its role as a repository of knowledge forinformed policy decision. We envision EARSS becoming the platform for a warning system for thedetection and identification of pathogens and clones with particular public health importance interms of AMR and virulence properties. This becomes especially clear when one considers thepotentials of internet-based information exchange among the participating laboratories, which, afterall, are the centres of local expertise.

References

1. Bronzwaer SLAM, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, Kool JL,Sprenger MJW, Degener JE, and participants in the European Antimicrobial ResistanceSurveillance System. A European Study on the Relationship between Antimicrobial Use andAntimicrobial Resistance. Emerg Inf Dis 2002;8:278-82.

2. Willems RJ, Homan W, Top J, Santen-Verheuvel M van, Tribe D, Manzioros X, Gaillard C,Vandenbroucke-Grauls CM, Mascini EM, Kregten van E, Embden JD van, Bonten MJ. Variantesp gene as a marker of a distinct genetic lineage of vancomycin-resistant Enterococcus faeciumspreading in hospitals. Lancet 2001;357:853-5.

3. Johnson JR, Schee C van der, Kuskowski MA, Goessens W, Belkum A van. Phylogeneticbackground and virulence profiles of fluoroquinolone-resistant Escherichia coli isolates fromthe Netherlands. J Infect Dis 2002;186:1852-6.

4. Kahlmeter G, Brown DFJ, et al. European Harmonization of MIC breakpoints for antimicrobialsusceptibility testing of bacteria. J Antimicrob Chemother 2003;52:145-148.

48 CHAPTER 6. Conclusions and future initiatives

Appendix A. Country Summary Sheets

In the following appendix, country-specific resistance information is presented together withdenominator data and the characteristics of the participating laboratories and hospitals.

Explanation to the country summary sheets:

Denominators: Table 1 and 2 and Figures 1 and 2 give an indication of the sample size and therepresentativeness of the country-specific resistance data available to EARSS.

Table 1 displays results of the laboratories and hospitals that provided denominator data (i.e. thatresponded to the questionnaire) and thus only includes the laboratories that reported AST results toEARSS in 2002, and provided blood culture information and the hospitals that reported AST resultsto EARSS in 2002, and provided their number of hospital beds. For details about the calculation ofthe average annual occupancy rate, the estimated catchment population and the percentage of thetotal population covered, we refer to the technical notes (Appendix B). If data were not availablethis is stated as “na”.

Figure 1 gives and indication about the degree of specialisation of the participating hospitals, andFigure 2 shows the geographic location of the laboratories reporting in 2002. The size of the dots inthe maps represents the number of laboratories in that location/town.

Dotsize

Number of labs 1 5 10 15

Antibiotic resistance 1999-2002: Table 3 provides information on the proportion of invasivebacterial isolates not susceptible to the antibiotics or antibiotic classes mentioned in the EARSSprotocols. From the majority of all non-susceptible S. pneumoniae and S. aureus isolates wereceived the corresponding MIC or Etest result, according to the EARSS protocols, however forsome of the non susceptible isolates this information is missing. The table also includeserythromycin susceptibility for S. pneumoniae. Any interpretation of Table 3 should also take intoaccount the small sample size for E. faecium reported to EARSS.

Table 4 gives details about the origin of the isolate (patient, source and hospital department). Theabbreviations used in this table stand for; PNSP = pencillin non-susceptible S. pneumoniae, MRSA= methicillin-resistant S. aureus, FREQ = fluoroquinolone-resistant E. coli, and VRE = vancomycinresistant (I+R) E. faecalis or E. faecium. If the number of isolates in a certain category accounts forless than 0.5% of the total number of isolates, the % total is set at 0 and the % resistance is notshown.

Local variation: Figures 3 and 4 show national distribution in the proportions of PNSP and MRSAby laboratory and by hospital, respectively.

APPENDIX A 49

For both Figures, a minimum of 5 isolates and at least 2 years of participation in EARSS for eachlaboratory or hospital was required, before being included into the presentation. If an ‘X’ isdisplayed at the end of a hospital code this means that the hospital code is not provided;consequently, this can apply for one or more unknown hospitals.

50 APPENDIX A

APPENDIX A 51

Countries

52 APPENDIX A

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 10/46

Labs/Hosps providing denom.data 0/0

Number of blood culture sets na

Number of hospital beds na

Average annual occupancy rate naAverage annual occupancy rate

Estimated catchment population 3500000

% total population covered 43%

Table 2.Number of laboratories and number of isolates reported for the period 1999-2002

Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 9 53 9 156 0 0 0 0

2001 9 63 9 277 9 269 8 74

2002 9 71 10 404 9 417 9 166

Table 3.Proportion of antibiotic non-susceptible isolates in percent

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . <1 <1 <1

Penicillin I+R . 2 3 1

Macrolides I+R . 4 10 10

S. aureus Oxacillin/Methicillin R . 5 8 11

E. coli Aminopenicillins R . . 35 33

Aminoglycosides R . . 1 4

Fluoroquinolones R . . 8 10

3rd gen. Cephalosporins R . . <1 1

E. faecalis Aminopenicillins I+R . . 10 3

Aminoglycosides (high-level resistance) . . 35 17

Glycopeptides I+R . . <1 <1

E. faecium Aminopenicillins I+R . . 86 83


Glycopeptides I+R . . 5 8

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

Figure 2.Geographic distribution of laboratories in 2002

AustriaDenominators

Antibiotic resistance in 1999-2002

* Based on labs/hospitals providing denominator data

*

*

*

*

*

*

APPENDIX A 53

Table 4.Details on the origin of invasive isolates (1999-2002)

Characteristic S. pneumoniae

n=187

S. aureus

n=837

E. coli

n=623

E. faecalis

n=176

E. faecium

n=62

%total %PNSP %total %MRSA %total %FREC %total %VRE %total %VRE

Isolate source

Blood 86 3 100 9 100 9 100 1 100 6

CSF 14 0 0 . 0 . 0 . 0 .

Sex

Male 61 3 60 9 38 11 61 1 58 3

Female 39 1 40 7 62 7 39 0 42 12

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 10 6 3 4 2 0 4 0 5 0

5-19 4 0 3 0 2 7 2 0 2 0

20-64 40 0 36 9 34 10 44 0 55 12

65 and over 47 3 58 9 61 9 50 1 39 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 13 0 11 18 8 15 23 3 35 14

Internal Medicine 50 1 46 7 55 9 41 0 32 5

Surgery 2 0 11 12 10 5 13 0 13 0

Other 29 4 28 6 24 9 23 0 19 0

Unknown 6 8 3 4 3 6 1 0 0 .

PNSP at laboratory level MRSA at hospital levelFigure 4.Proportion (%) MRSA by hospital (1999-2002)

0 25 50 75 100

0/22AT001K

0/7AT001R

0/5AT003B

0/6AT003N

0/5AT006H

0/5AT006M

0/11AT006N

0/7AT008S

0/12AT008T

0/18AT010B

0/11AT012D

0/8AT012G

1/60AT001S

2/51AT010F

3/69AT001E

2/38AT001B

2/36AT003G

8/129AT007K

6/79AT006S

3/31AT012W

15/81AT002A

4/7AT006B

4/7AT012H

Figure 3.Proportion (%) PNSP by laboratory (1999-2002)

0 25 50 75 100

0/50AT001

0/9AT003

0/7AT004

0/40AT006

0/11AT007

0/8AT008

1/23AT010

2/22AT002

1/6AT012

54 APPENDIX A


Total






Estimated catchment population na

% total population covered na


Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 92 846 47 442 0 0 0 0

2000 90 909 42 657 0 0 0 0

2001 89 1093 47 940 23 226 0 0

2002 98 1210 48 1092 27 1184 0 0



S. pneumoniae Penicillin R 4 5 <1 <1

Penicillin I+R 13 16 13 14

Macrolides I+R 31 34 35 34

S. aureus Oxacillin/Methicillin R 23 21 23 28




3rd gen. Cephalosporins R . . 2 3

E. faecalis Aminopenicillins I+R . . . .

Aminoglycosides (high-level resistance) . . . .

Glycopeptides I+R . . . .

E. faecium Aminopenicillins I+R . . . .





Other



BelgiumDenominators



*

*

*

*

*

*

APPENDIX A 55



n=4058

S. aureus

n=3131

E. coli

n=1143

E. faecalis

n=0

E. faecium

n=0


Isolate source

Blood 94 14 100 24 100 13 . . . .

CSF 6 10 0 . 0 . . . . .

Sex

Male 56 14 58 25 43 14 . . . .

Female 43 14 40 23 56 11 . . . .

Unknown 1 11 2 21 1 27 . . . .

Age (years)

0-4 19 17 4 11 3 0 . . . .

5-19 5 5 3 4 1 0 . . . .

20-64 29 10 33 19 29 13 . . . .

65 and over 47 16 59 29 67 13 . . . .

Unknown 0 . 2 27 0 . . . . .

Hospital department

ICU 13 13 15 33 10 10 . . . .

Internal Medicine 34 14 31 19 31 11 . . . .

Surgery 2 18 11 25 8 9 . . . .

Other 26 14 23 27 50 14 . . . .

Unknown 25 15 20 23 1 25 . . . .


0 25 50 75 100

2/37BE007X

10/95BE002X

12/111BE060X

4/30BE057X

24/178BE061X

4/28BE014X

10/68BE115X

2/12BE012X

16/91BE001X

21/119BE024X

7/39BE031X

2/11BE004X

33/178BE074X

10/53BE030X

8/38BE075X

19/90BE041X

29/134BE016X

42/185BE063X

10/43BE029X

28/118BE008X

8/33BE109X

6/24BE005X

7/28BE072X

4/16BE114X

19/74BE112X

11/42BE058X

66/247BE070X

32/118BE077X

5/18BE125X

26/93BE006X

11/39BE033X

7/24BE003X

8/27BE045X

20/66BE019X

19/62BE022X

5/16BE040X

92/263BE097X

28/76BE056X

6/15BE042X

23/52BE032X

9/20BE059X

15/30BE017X

3/6BE107X

9/17BE026X

3/5BE068X

9/12BE018X

6/8BE065X


0 25 50 75 100

0/58BE0020/26BE0120/5BE0680/18BE1000/16BE116

1/31BE0371/25BE0092/41BE0231/19BE0142/33BE1032/29BE0041/14BE1142/27BE1184/53BE0602/26BE0597/86BE0774/49BE02212/144BE0707/82BE0247/81BE1047/76BE03010/106BE1157/74BE0612/21BE0203/31BE0176/61BE1392/20BE0547/68BE0013/29BE0312/19BE0447/66BE0634/36BE0057/63BE0583/26BE02615/130BE0566/52BE0577/60BE0064/34BE0646/51BE0906/51BE0933/25BE0354/33BE0139/73BE03210/81BE0551/8BE1455/39BE0492/15BE1416/43BE01934/242BE1085/35BE0075/35BE0512/14BE0716/41BE0484/27BE0034/26BE1024/26BE11015/94BE0979/56BE0741/6BE0181/6BE0216/36BE07227/162BE0926/35BE10116/93BE1127/40BE04111/60BE0088/42BE1096/31BE03326/132BE09120/101BE0161/5BE121

3/14BE01011/51BE0758/37BE105

5/22BE0695/21BE065

4/15BE0766/22BE08414/51BE09515/54BE098

3/9BE0405/13BE0839/23BE029

2/5BE1312/5BE1358/20BE143

7/17BE1075/9BE113

56 APPENDIX A


Total



Number of blood culture sets 15549

Number of hospital beds 9168

Average annual occupancy rate 76%Average annual occupancy rate




Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 8 13 16 111 0 0 0 0

2001 8 16 17 103 15 98 11 30

2002 11 25 21 116 20 135 16 42



S. pneumoniae Penicillin R . 23 6 8










Glycopeptides I+R . . <1 4






Other



BulgariaDenominators



*

*

*

*

*

*

APPENDIX A 57



n=54

S. aureus

n=330

E. coli

n=224

E. faecalis

n=53

E. faecium

n=19


Isolate source

Blood 43 13 100 32 98 12 100 2 100 0

CSF 57 10 0 . 2 0 0 . 0 .

Sex

Male 63 15 60 30 48 17 72 3 58 0

Female 35 5 39 35 52 7 28 0 42 0

Unknown 2 0 0 . 0 . 0 . 0 .

Age (years)

0-4 13 43 11 40 12 11 9 0 5 0

5-19 15 13 5 28 3 14 0 . 0 .

20-64 52 4 58 32 48 9 47 4 74 0

65 and over 13 14 19 28 34 13 38 0 5 0

Unknown 7 0 6 40 2 40 6 0 16 0

Hospital department

ICU 15 0 18 58 10 4 21 0 53 0


Surgery 9 0 17 33 18 20 21 9 11 0

Other 33 11 25 28 27 15 17 0 16 0

Unknown 0 . 0 . 0 . 0 . 0 .


0 25 50 75 100

0/10BG014A

1/23BG013A

1/10BG004A

2/12BG021A

10/35BG003A

3/10BG024A

4/13BG005A

9/28BG008A

6/17BG007A

6/15BG011A

42/100BG001A

9/16BG006A

3/5BG009A

6/6BG015A


0 25 50 75 100

0/7BG013

1/9BG016

1/7BG003

2/8BG007

58 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 10 20 14 149 13 182 7 33

2002 14 90 14 279 15 490 13 96



S. pneumoniae Penicillin R . . <1 <1

Penicillin I+R . . 15 19

Macrolides I+R . . 15 23

S. aureus Oxacillin/Methicillin R . . 32 37







Glycopeptides I+R . . 3 <1






Other



CroatiaDenominators



*

*

*

*

*

*

APPENDIX A 59



n=110

S. aureus

n=428

E. coli

n=667

E. faecalis

n=110

E. faecium

n=19


Isolate source

Blood 86 19 100 35 100 5 100 1 100 21

CSF 14 13 0 . 0 . 0 . 0 .

Sex

Male 65 18 69 34 42 7 65 0 74 21

Female 35 18 31 37 58 4 35 3 26 20

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 38 19 5 15 8 0 12 0 11 50

5-19 6 29 4 13 1 22 4 0 11 50

20-64 35 15 50 36 35 7 35 0 42 13

65 and over 20 18 42 38 56 4 50 2 37 14

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 15 12 12 68 6 5 13 0 16 0


Surgery 1 100 13 69 3 10 9 0 0 .

Other 63 20 35 19 48 6 45 2 42 38

Unknown 0 . 0 . 0 . 0 . 0 .


0 25 50 75 100

0/10HR010A

0/15HR014A

0/6HR018A

1/15HR009A

1/6HR020A

8/45HR002A

6/21HR016A

13/41HR011A

20/61HR007A

12/32HR004A

66/141HR001A

12/19HR005A

6/9HR013A

5/7HR012A


0 25 50 75 100

1/10HR007

1/7HR016

2/13HR001

1/5HR004

9/44HR002

3/11HR014

60 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 26 111 31 515 0 0 0 0

2001 32 154 39 1074 36 1176 34 461

2002 34 144 41 1168 40 1587 39 587



















Other



Czech RepublicDenominators



*

*

*

*

*

*

APPENDIX A 61



n=409

S. aureus

n=2757

E. coli

n=2760

E. faecalis

n=901

E. faecium

n=146


Isolate source

Blood 71 7 100 6 100 9 100 1 100 5

CSF 29 5 0 . 0 . 0 . 0 .

Sex

Male 62 7 59 6 42 12 62 1 57 6

Female 38 6 41 4 58 8 38 1 43 5

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 14 9 5 5 5 2 5 0 5 0

5-19 8 0 3 5 1 6 1 0 4 0

20-64 49 7 45 6 34 10 46 1 49 7

65 and over 30 7 47 5 60 10 47 1 41 5

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 16 6 14 10 9 11 23 0 24 6


Surgery 2 22 13 9 10 8 15 2 8 9

Other 40 4 24 6 27 9 28 2 29 5

Unknown 1 0 0 . 0 . 0 . 1 100


0 25 50 75 100

0/85CZ002A0/6CZ007D0/7CZ007E0/17CZ009B0/27CZ011A0/62CZ012A0/13CZ012B0/8CZ012C0/13CZ012D0/26CZ013A0/7CZ015B0/13CZ017C0/14CZ017D0/16CZ019B0/39CZ022A0/7CZ022B0/76CZ023A0/22CZ025A0/72CZ027A0/5CZ027B0/30CZ028A0/5CZ028B0/28CZ029A0/28CZ030A0/10CZ031C0/6CZ031E0/12CZ031P0/27CZ032A0/17CZ038A0/10CZ039A0/8CZ040A2/178CZ009A

1/44CZ026A2/75CZ015A2/74CZ004A2/67CZ005A1/27CZ036A1/26CZ037A1/24CZ014A4/90CZ016A3/64CZ007A2/40CZ019A5/96CZ021A11/199CZ006A1/17CZ008A2/34CZ034A

12/157CZ017A7/88CZ031A10/121CZ020A

1/10CZ031K6/46CZ017B32/236CZ018A7/50CZ024A

9/59CZ033A8/51CZ035A

2/10CZ031V2/10CZ042A12/58CZ003A


0 25 50 75 100

0/10CZ008

0/6CZ013

0/40CZ016

0/10CZ019

0/7CZ022

0/15CZ024

0/20CZ027

0/8CZ030

0/12CZ033

0/8CZ036

1/18CZ002

3/49CZ006

1/15CZ015

1/14CZ031

2/25CZ012

3/36CZ009

1/11CZ004

1/10CZ023

1/9CZ003

1/7CZ005

2/14CZ007

1/6CZ021

1/6CZ025

1/6CZ026

4/18CZ017

62 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 5 718 0 0 0 0

2000 5 410 4 501 0 0 0 0

2001 5 506 4 520 0 0 0 0

2002 5 366 5 752 0 0 0 0






S. aureus Oxacillin/Methicillin R 1 <1 <1 <1

E. coli Aminopenicillins R . . . .

Aminoglycosides R . . . .

Fluoroquinolones R . . . .

3rd gen. Cephalosporins R . . . .









Other



DenmarkDenominators



*

*

*

*

*

*

<

APPENDIX A 63



n=1282

S. aureus

n=2491

E. coli

n=0

E. faecalis

n=0

E. faecium

n=0


Isolate source

Blood 91 3 100 1 . . . . . .

CSF 9 2 0 . . . . . . .

Sex

Male 50 3 58 1 . . . . . .

Female 49 3 39 0 . . . . . .

Unknown 0 . 3 1 . . . . . .

Age (years)

0-4 8 6 2 0 . . . . . .

5-19 2 10 3 1 . . . . . .

20-64 40 3 40 0 . . . . . .

65 and over 50 3 54 1 . . . . . .

Unknown 0 . 0 . . . . . . .

Hospital department

ICU 0 . 5 0 . . . . . .

Internal Medicine 0 . 50 1 . . . . . .

Surgery 0 . 19 0 . . . . . .

Other 0 . 16 1 . . . . . .

Unknown 100 3 10 1 . . . . . .


0 25 50 75 100

0/117DK005A

0/62DK005B

0/50DK008A

0/64DK009A

0/15DK009C

0/27DK009D

0/30DK009F

0/5DK009G

0/34DK014A

0/107DK014B

0/71DK014C

0/16DK014E

0/11DK014F

0/12DK014G

0/87DK014N

0/97DK016B

0/62DK016C

0/23DK016D

0/22DK016F

0/31DK016G

0/12DK016H

1/388DK016A

4/421DK009B

1/100DK002E

2/199DK002A

3/271DK002B

1/53DK014D

2/90DK002F


0 25 50 75 100

5/265DK016

8/317DK014

5/130DK005

12/277DK009

13/293DK002

64 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 5 20 6 79 4 52 4 21

2002 5 21 8 81 6 67 3 13



S. pneumoniae Penicillin R . . <1 <1

Penicillin I+R . . <1 <1

Macrolides I+R . . 5 <1




Fluoroquinolones R . . <1 5



Aminoglycosides (high-level resistance) . . <1 50







Other



EstoniaDenominators



*

*

*

*

*

*

APPENDIX A 65



n=41

S. aureus

n=160

E. coli

n=106

E. faecalis

n=23

E. faecium

n=11


Isolate source

Blood 41 0 100 3 99 3 100 0 100 0

CSF 59 0 0 . 1 0 0 . 0 .

Sex

Male 66 0 54 5 33 6 43 0 82 0

Female 34 0 40 2 66 1 52 0 18 0

Unknown 0 . 6 0 1 0 4 0 0 .

Age (years)

0-4 7 0 10 19 7 0 22 0 9 0

5-19 10 0 7 0 2 0 0 . 0 .

20-64 27 0 34 0 31 0 17 0 36 0

65 and over 2 0 6 0 25 4 17 0 36 0

Unknown 54 0 43 3 36 5 43 0 18 0

Hospital department

ICU 32 0 15 0 16 12 17 0 27 0


Surgery 2 0 14 4 12 0 22 0 18 0

Other 54 0 38 5 40 0 52 0 45 0

Unknown 0 . 1 0 4 0 0 . 0 .


0 25 50 75 100

0/57EE001A

0/9EE003R

0/27EE006K

1/28EE002M

3/13EE002L


0 25 50 75 100

0/12EE001

0/16EE002

0/6EE006

66 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 14 242 13 316 0 0 0 0

2000 9 176 12 362 0 0 0 0

2001 13 425 13 606 14 1284 13 274

2002 15 453 15 721 15 1330 14 278



S. pneumoniae Penicillin R <1 <1 1 2



S. aureus Oxacillin/Methicillin R <1 1 <1 <1


Aminoglycosides R . . <1 <1


3rd gen. Cephalosporins R . . <1 <1





Aminoglycosides (high-level resistance) . . <1 <1




Other



FinlandDenominators



*

*

*

*

*

*

APPENDIX A 67



n=1296

S. aureus

n=2005

E. coli

n=2612

E. faecalis

n=371

E. faecium

n=180


Isolate source

Blood 95 7 100 1 100 6 100 1 100 1

CSF 5 6 0 . 0 . 0 . 0 .

Sex

Male 56 5 61 1 35 5 62 0 62 0

Female 43 9 39 1 65 6 38 1 38 1

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 12 13 3 0 3 0 5 0 2 0

5-19 5 6 6 0 1 4 1 0 3 0

20-64 51 6 44 1 32 4 35 1 49 0

65 and over 32 6 45 1 64 7 59 0 46 1

Unknown 0 . 1 5 0 . 0 . 1 0

Hospital department

ICU 3 9 3 0 0 . 1 0 2 0


Surgery 5 3 13 1 13 9 13 0 10 0

Other 46 6 34 1 41 5 41 0 37 0

Unknown 26 9 29 1 32 5 29 0 29 2


0 25 50 75 100

0/110FI001X

0/104FI003A

0/63FI004A

0/55FI008A

0/54FI009A

1/323FI002A

1/143FI00HA

2/143FI005X

1/71FI012A

1/69FI011A

1/57FI010A

3/121FI00CA

2/56FI014A

2/44FI015A


0 25 50 75 100

0/38FI008

1/88FI00C

1/60FI012

4/110FI00H

3/79FI005

6/110FI001

3/41FI015

3/38FI017

6/70FI003

35/405FI002

2/22FI004

4/40FI014

5/49FI009

5/47FI011

6/39FI010

68 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 329 1337 21 1714 0 0 0 0

2002 296 580 21 1663 21 2495 21 467



S. pneumoniae Penicillin R . . 11 9




E. coli Aminopenicillins R . . . 52

Aminoglycosides R . . . 4

Fluoroquinolones R . . . 8

3rd gen. Cephalosporins R . . . <1

E. faecalis Aminopenicillins I+R . . . 5

Aminoglycosides (high-level resistance) . . . 15

Glycopeptides I+R . . . <1

E. faecium Aminopenicillins I+R . . . 34


Glycopeptides I+R . . . 2



Other



Only hospitals providing denominator data. The Observatoires Regionauxdu Pneumocoque (ORP) and the NRC involved in invasive pneumococcalinfections survey are nationwide distributed.

FranceDenominators



*

*

*

*

*

*

*

* Two first quarters of 2002 for pneumococci surveillance, aggregated data.

*

* Two first quarters of 2002 for pneumococci surveillance

APPENDIX A 69



n=1337

S. aureus

n=3377

E. coli

n=2491

E. faecalis

n=341

E. faecium

n=126


Isolate source

Blood 77 76 100 33 100 8 100 1 100 2

CSF 23 24 0 . 0 . 0 . 0 .

Sex

Male . . 61 33 44 10 67 0 55 0

Female . . 33 33 56 7 33 1 44 4

Unknown . . 6 39 0 . 0 . 2 0

Age (years)

0-4 36 47 3 12 2 2 5 0 3 0

5-19 7 4 3 8 1 3 1 0 2 0

20-64 26 18 44 28 41 9 44 1 45 4

65 and over 31 30 50 41 55 8 50 1 50 0

Unknown 0 0 0 . 0 . 0 . 0 .

Hospital department

ICU . . 23 39 13 9 32 0 18 0

Internal Medicine . . 30 35 30 9 18 2 20 0

Surgery . . 21 34 15 10 22 0 25 3

Other . . 26 26 42 7 28 1 37 2

Unknown . . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

**

** for 2002

Figure 4.Proportion (%) MRSA by hospital (1999-2002)

0 25 50 75 100

21/103FR164A

7/33FR095A

67/256FR226A

21/79FR126A

106/398FR248A

37/128FR121A

33/109FR194A

28/92FR362A

74/243FR010A

7/22FR208A

67/208FR238A

22/62FR252A

60/169FR165A

48/133FR105A

22/60FR211A

108/288FR138A

129/319FR246A

22/52FR120A

29/57FR037A

24/47FR046A


0 25 50 75 100

Data per laboratory were not transmitted

70 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 23 417 25 1239 0 0 0 0

2000 18 204 19 890 0 0 0 0

2001 21 211 22 1220 21 1269 20 295

2002 16 232 18 1039 16 1026 13 282



S. pneumoniae Penicillin R <1 <1 1 <1
















Other



GermanyDenominators



*

*

*

*

*

*

APPENDIX A 71



n=1064

S. aureus

n=4388

E. coli

n=2253

E. faecalis

n=422

E. faecium

n=138


Isolate source

Blood 93 2 100 14 100 13 100 1 100 4

CSF 7 3 0 . 0 . 0 . 0 .

Sex

Male 49 3 51 16 37 14 59 1 58 4

Female 38 2 35 13 50 13 33 1 39 4

Unknown 13 1 14 6 14 12 8 0 3 0

Age (years)

0-4 9 4 3 5 2 0 2 0 3 0

5-19 3 7 2 8 1 13 0 . 1 0

20-64 43 3 39 13 27 14 39 2 46 2

65 and over 44 1 55 15 70 13 58 0 50 6

Unknown 1 0 1 16 0 . 1 0 1 0

Hospital department

ICU 17 4 19 26 11 13 26 0 28 8


Surgery 2 0 9 12 6 13 8 3 11 0

Other 21 3 17 12 22 16 22 1 23 0

Unknown 12 2 10 10 8 14 5 0 3 25


0 25 50 75 100

0/85DE0703X

0/56DE0802X

0/14DE1401X

3/123DE0701X

2/61DE1402X

2/44DE0702X

11/224DE1301X

10/190DE0902X

17/276DE1203X

8/123DE0501X

55/670DE0803X

13/143DE0102X

23/195DE0905X

10/79DE0202X

13/81DE0901X

5/30DE0105X

56/329DE0306X

128/690DE0302X

31/145DE0301X

20/91DE0101X

160/552DE0204X

7/22DE0801X

23/63DE0303X


0 25 50 75 100

0/93DE0102

0/6DE0103

0/12DE0301

0/135DE0302

0/47DE0306

0/47DE0501

0/14DE0702

0/14DE0703

0/26DE0901

0/5DE1402

1/158DE0803

1/75DE1301

2/84DE0902

1/41DE0303

1/40DE0905

4/116DE0204

1/26DE0802

1/18DE0701

2/33DE0101

4/26DE1203

3/18DE0801

72 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 19 192 0 0 0 0

2000 0 0 15 354 0 0 0 0

2001 0 0 25 356 26 619 25 304

2002 0 0 33 368 35 588 28 293



S. pneumoniae Penicillin R . . . .

Penicillin I+R . . . .

Macrolides I+R . . . .














Other



GreeceDenominators



*

*

*

*

*

*

APPENDIX A 73



n=0

S. aureus

n=1270

E. coli

n=1155

E. faecalis

n=415

E. faecium

n=161


Isolate source

Blood . . 100 42 99 11 100 13 100 19

CSF . . 0 . 1 0 0 . 0 .

Sex

Male . . 17 36 12 13 16 11 20 16

Female . . 11 38 22 7 16 9 14 23

Unknown . . 71 45 65 12 68 14 66 19

Age (years)

0-4 . . 0 . 0 . 0 . 0 .

5-19 . . 1 0 0 . 0 . 0 .

20-64 . . 1 38 2 14 1 0 1 0

65 and over . . 1 41 2 17 3 9 2 0

Unknown . . 96 43 95 11 96 13 97 19

Hospital department

ICU . . 16 68 3 17 44 19 43 26

Internal Medicine . . 60 35 79 10 38 6 39 8

Surgery . . 12 56 10 16 13 12 11 24

Other . . 6 17 2 5 1 0 1 0

Unknown . . 6 43 7 17 5 10 7 27


0 25 50 75 100

0/9GR026A

1/13GR042A

1/7GR024A

2/10GR043A

9/39GR044A

6/24GR013A

8/32GR015A

21/62GR028A

13/36GR007A

4/11GR032A

23/63GR030A

16/43GR027A

23/60GR047A

36/91GR033A

20/45GR001A

16/35GR035A

7/15GR018A

26/53GR012A

14/28GR039A

147/277GR040A

68/115GR014A

7/10GR004A

33/47GR005A

5/7GR046A


0 25 50 75 100

Not enough data per laboratory to provide a graph

74 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 14 36 18 301 18 264 17 121

2002 17 61 24 413 24 354 23 169



















Other



HungaryDenominators



*

*

*

*

*

*

APPENDIX A 75



n=97

S. aureus

n=714

E. coli

n=585

E. faecalis

n=255

E. faecium

n=32


Isolate source

Blood 67 26 100 7 97 8 100 2 100 0

CSF 33 16 0 . 3 0 0 . 0 .

Sex

Male 67 25 58 8 48 8 54 1 66 0

Female 30 21 40 6 51 8 45 3 34 0

Unknown 3 0 2 8 1 0 0 . 0 .

Age (years)

0-4 11 36 3 11 4 0 2 0 9 0

5-19 9 0 3 0 2 17 2 0 0 .

20-64 49 21 52 7 42 8 55 1 44 0

65 and over 30 28 42 8 52 8 42 3 47 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 12 17 14 20 10 8 25 0 31 0


Surgery 2 0 11 10 8 9 10 0 28 0

Other 46 24 20 4 29 8 24 0 28 0

Unknown 8 13 16 5 10 5 14 6 6 0


0 25 50 75 100

0/14HU002H

0/5HU002X

0/6HU005W

0/6HU005Y

0/5HU006C

0/6HU007C

0/10HU019D

0/12HU020L

0/46HU021A

1/25HU014A

1/23HU009B

4/88HU019A

2/43HU020A

1/21HU006B

1/21HU013A

2/38HU016A

1/13HU007B

1/12HU015A

2/22HU001U

3/29HU005A

1/9HU004Y

1/8HU002R

8/54HU009A

1/5HU008C

2/8HU021C

5/16HU003A


0 25 50 75 100

0/5HU005

0/5HU016

4/21HU019

2/9HU006

2/8HU007

2/8HU009

2/7HU020

3/5HU013

76 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 1 48 1 32 0 0 0 0

2000 1 36 1 40 0 0 0 0

2001 2 48 2 63 2 86 2 18

2002 2 43 2 59 2 83 2 25



S. pneumoniae Penicillin R< <1 <1 <1 2



S. aureus Oxacillin/Methicillin R <1 3 <1 <1





E. faecalis Aminopenicillins I+R . . <1 <1








Other



Iceland counts 9 hospitals that all report AST-results to EARSS. However,only 2 of these are relevant to EARSS with respect to denominator informatiobecause these are the main hospitals to provide acute and general care.

IcelandDenominators



*

*

*

*

*

*

APPENDIX A 77



n=175

S. aureus

n=194

E. coli

n=155

E. faecalis

n=31

E. faecium

n=12


Isolate source

Blood 95 5 100 1 100 3 100 0 100 0

CSF 5 11 0 . 0 . 0 . 0 .

Sex

Male 52 4 61 1 47 5 58 0 42 0

Female 47 6 39 0 53 1 42 0 58 0

Unknown 1 0 0 . 0 . 0 . 0 .

Age (years)

0-4 22 8 10 0 3 0 6 0 8 0

5-19 3 0 13 0 2 0 0 . 0 .

20-64 41 3 37 0 31 4 19 0 8 0

65 and over 34 7 40 1 65 3 74 0 83 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 5 13 3 0 0 . 0 . 0 .


Surgery 0 . 4 0 5 14 10 0 0 .

Other 26 7 20 3 5 0 3 0 8 0

Unknown 62 5 64 0 81 2 84 0 83 0


0 25 50 75 100

0/10IS003A

1/184IS001A


0 25 50 75 100

0/12IS003

9/163IS001

78 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 10 154 11 511 0 0 0 0

2000 18 202 18 632 0 0 0 0

2001 21 246 19 798 0 0 0 0

2002 20 277 22 998 20 736 15 250



S. pneumoniae Penicillin R 3 5 2 2







3rd gen. Cephalosporins R . . . 2

E. faecalis Aminopenicillins I+R . . . 8








Other



IrelandDenominators



*

*

*

*

*

*

APPENDIX A 79



n=879

S. aureus

n=2939

E. coli

n=721

E. faecalis

n=165

E. faecium

n=82


Isolate source

Blood 98 13 100 41 100 5 100 2 100 11

CSF 2 25 0 . 0 . 0 . 0 .

Sex

Male 54 14 62 42 42 5 65 2 62 8

Female 44 14 35 39 57 5 34 4 37 17

Unknown 2 5 3 32 1 0 1 0 1 0

Age (years)

0-4 15 17 5 14 2 7 3 0 5 0

5-19 5 7 4 12 1 0 2 0 1 100

20-64 37 10 40 37 32 6 48 4 46 11

65 and over 41 16 48 51 64 5 47 1 45 11

Unknown 2 15 3 26 1 0 1 0 2 0

Hospital department

ICU 6 14 9 60 4 12 12 0 17 7


Surgery 2 11 14 55 8 4 12 5 7 0

Other 31 11 25 28 26 4 13 5 4 0

Unknown 17 14 21 39 36 7 35 3 57 11


0 25 50 75 100

2/34IE-AX

2/30IE-JX

1/5IE-VX

6/26IE-RX

10/38IE-HX

14/45IE-BX

21/67IE-TX

6/18IE-SX

12/35IE-WX

85/246IE-OX

90/241IE-KX

88/227IE-QX

223/533IE-LX

83/190IE-NX

112/249IE-EX

9/20IE-GX

22/48IE-CX

49/106IE-PX

216/461IE-DX

111/228IE-UX


0 25 50 75 100

1/21IE-J

1/21IE-T

2/28IE-N

7/72IE-Q

1/10IE-A

2/19IE-G

3/28IE-R

10/93IE-U

10/91IE-E

7/59IE-O

9/67IE-K

2/14IE-B

9/61IE-L

1/6IE-H

21/125IE-D

8/45IE-P

5/28IE-W

2/11IE-S

13/55IE-F

3/10IE-C

80 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 5 170 5 381 5 741 5 184

2002 5 177 5 468 5 865 5 254











E. faecalis Aminopenicillins I+R . . <1 4








Other



IsraelDenominators



*

*

*

*

*

*

APPENDIX A 81



n=347

S. aureus

n=849

E. coli

n=1600

E. faecalis

n=357

E. faecium

n=73


Isolate source

Blood 100 39 100 38 100 20 100 2 100 11

CSF 0 . 0 . 0 . 0 . 0 .

Sex

Male 58 35 60 38 43 24 57 1 55 10

Female 42 45 40 39 57 17 43 3 45 12

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 38 57 9 31 5 4 12 0 11 13

5-19 13 25 6 13 2 25 1 0 10 14

20-64 24 18 33 34 26 17 27 4 22 0

65 and over 25 38 52 45 67 21 60 1 58 14

Unknown 1 50 1 60 0 . 0 . 0 .

Hospital department

ICU 6 33 10 40 6 25 17 2 21 13


Surgery 2 14 13 45 11 30 8 0 11 0

Other 54 48 34 36 26 17 32 3 48 11

Unknown 0 . 0 . 0 . 0 . 0 .


0 25 50 75 100

14/79IL004A

15/84IL001A

13/45IL005A

51/123IL003A

233/518IL002A


0 25 50 75 100

44/141IL003

52/126IL002

8/18IL005

14/29IL004

18/33IL001

82 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 41 177 56 1158 0 0 0 0

2000 36 116 48 456 0 0 0 0

2001 39 121 53 839 0 0 42 297

2002 50 296 53 1343 17 618 49 602



S. pneumoniae Penicillin R 2 <1 4 2
















Other



ItalyDenominators



*

*

*

*

*

*

APPENDIX A 83



n=710

S. aureus

n=3796

E. coli

n=617

E. faecalis

n=634

E. faecium

n=258


Isolate source

Blood 78 10 100 40 100 21 100 1 100 20

CSF 22 16 0 . 0 . 0 . 0 .

Sex

Male 55 13 58 41 27 18 57 1 58 18

Female 41 9 36 38 38 24 32 1 36 24

Unknown 4 12 6 47 35 21 11 1 7 18

Age (years)

0-4 13 6 3 16 2 0 4 0 6 7

5-19 4 8 2 14 1 20 1 0 1 0

20-64 37 16 33 33 16 17 27 0 28 19

65 and over 34 10 46 44 45 23 44 2 46 19

Unknown 13 8 17 52 36 22 24 1 19 30

Hospital department

ICU 9 20 14 60 3 15 18 1 18 21


Surgery 1 11 12 51 6 26 13 2 15 15

Other 45 13 33 34 18 19 18 1 18 26

Unknown 15 13 7 41 24 23 16 0 12 16


0 25 50 75 100

0/11IT006X0/7IT013X0/7IT028X

1/14IT026X6/51IT007X

6/41IT077X4/26IT023X

23/128IT019X4/19IT044X10/47IT022X6/28IT024X9/41IT015X2/9IT002X22/98IT061X

23/95IT047X4/16IT004X2/8IT080X10/39IT065X21/79IT010X7/26IT038X6/22IT029X58/212IT031X

6/21IT056X8/26IT036X4/13IT062X16/52IT074X

28/88IT042X12/37IT073X

2/6IT050X3/9IT064X6/18IT075X41/121IT072X39/115IT008X

18/50IT035X36/100IT041X


51/129IT021X28/70IT068X11/27IT052X

18/43IT009X17/40IT027X15/35IT090X

13/29IT067X14/31IT034X

11/23IT051X24/49IT032X

30/60IT016X10/20IT069X3/6IT088X

58/113IT040X73/141IT054X

63/118IT014X52/96IT025X69/126IT037X


61/97IT005X46/73IT012X30/47IT091X

15/23IT011X23/35IT089X24/36IT017X68/101IT092X

27/37IT046X


0 25 50 75 100

0/7IT004

0/11IT017

0/5IT027

0/9IT028

0/9IT030

0/7IT032

0/10IT040

0/9IT047

0/5IT051

0/20IT061

0/8IT065

0/15IT078

0/13IT079

0/5IT080

1/23IT037

1/19IT059

2/35IT031

1/16IT046

1/16IT054

1/11IT007

1/11IT009

3/28IT019

1/9IT034

2/18IT042

1/9IT070

2/16IT005

2/16IT036

1/8IT091

2/15IT014

2/15IT077

1/7IT024

1/7IT067

3/19IT015

2/12IT038

2/11IT025

5/27IT060

2/10IT021

1/5IT029

3/15IT035

4/19IT003

10/41IT008

3/11IT072

2/5IT012

6/14IT044

84 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 1 9 1 25 0 0 0 0

2000 5 22 4 67 0 0 0 0

2001 8 41 8 85 8 193 7 31

2002 7 27 9 95 9 193 8 30



S. pneumoniae Penicillin R 11 <1 7 7











E. faecium Aminopenicillins I+R . . <1 60





Other



LuxembourgDenominators



*

*

*

*

*

*

APPENDIX A 85



n=99

S. aureus

n=272

E. coli

n=348

E. faecalis

n=45

E. faecium

n=10


Isolate source

Blood 85 18 100 17 100 7 100 0 100 0

CSF 15 7 0 . 0 . 0 . 0 .

Sex

Male 57 16 52 14 32 5 56 0 40 0

Female 43 16 42 21 53 5 40 0 50 0

Unknown 0 . 6 19 15 17 4 0 10 0

Age (years)

0-4 13 15 10 23 3 0 2 0 10 0

5-19 5 40 3 0 1 0 2 0 10 0

20-64 41 12 40 14 22 1 36 0 10 0

65 and over 40 18 43 20 59 7 56 0 60 0

Unknown 0 . 6 20 15 17 4 0 10 0

Hospital department

ICU 17 12 10 27 8 4 38 0 30 0


Surgery 1 0 10 30 4 13 9 0 0 .

Other 27 11 19 16 24 4 22 0 40 0

Unknown 32 22 38 13 35 7 20 0 20 0


0 25 50 75 100

0/7LU002W

0/10LU006L

1/10LU005I

4/28LU004T

6/40LU007Z

22/105LU001E

3/14LU006A

9/41LU003S


0 25 50 75 100

0/5LU005

1/10LU004

1/10LU006

6/49LU001

2/6LU002

2/6LU007

4/11LU003

86 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 1 11 1 76 0 0 0 0

2001 1 12 1 83 1 67 1 13

2002 1 12 1 87 1 74 1 33




Penicillin I+R . 9 8 <1







E. faecalis Aminopenicillins I+R . . 8 <1








Other



MaltaDenominators



*

*

*

*

*

*

APPENDIX A 87



n=35

S. aureus

n=246

E. coli

n=141

E. faecalis

n=42

E. faecium

n=4


Isolate source

Blood 91 3 100 44 100 13 100 0 100 0

CSF 9 33 0 . 0 . 0 . 0 .

Sex

Male 71 4 60 49 43 20 62 0 25 0

Female 29 10 40 38 57 9 38 0 75 0

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 43 0 7 24 8 18 7 0 0 .

5-19 6 0 8 11 3 25 0 . 25 0

20-64 34 8 41 37 23 18 36 0 50 0

65 and over 17 17 44 61 65 11 57 0 25 0

Unknown 0 . 0 . 1 0 0 . 0 .

Hospital department

ICU 20 14 17 59 7 0 57 0 50 0


Surgery 0 . 20 50 19 19 14 0 25 0

Other 49 0 14 29 8 9 2 0 0 .

Unknown 9 0 8 68 16 13 5 0 0 .


0 25 50 75 100

105/240MT001A


0 25 50 75 100

2/35MT001

88 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 21 762 20 1224 0 0 0 0

2000 23 740 24 1388 0 0 0 0

2001 20 723 21 1290 20 1864 14 275

2002 23 851 22 1501 22 2422 22 536



S. pneumoniae Penicillin R <1 <1 <1 <1

Penicillin I+R 1 1 <1 1


S. aureus Oxacillin/Methicillin R <1 <1 <1 <1













Other



NetherlandsDenominators



*

*

*

*

*

*

APPENDIX A 89



n=3076

S. aureus

n=5403

E. coli

n=3947

E. faecalis

n=549

E. faecium

n=248


Isolate source

Blood 90 1 100 1 99 6 100 1 100 2

CSF 10 1 0 . 1 0 0 . 0 .

Sex

Male 54 1 57 1 46 7 61 1 58 2

Female 45 1 42 1 54 4 37 1 40 3

Unknown 1 3 1 0 0 . 1 0 2 0

Age (years)

0-4 9 2 9 1 4 1 10 0 6 0

5-19 3 2 4 0 1 2 2 0 2 0

20-64 36 1 37 1 30 8 40 1 41 3

65 and over 52 1 50 1 64 5 47 1 50 2

Unknown 0 . 0 . 0 . 1 0 0 .

Hospital department

ICU 5 2 7 1 5 10 19 0 10 0


Surgery 2 0 7 1 6 6 9 0 2 0

Other 21 2 21 1 12 6 16 1 12 0

Unknown 61 1 53 1 64 5 42 1 67 2


0 25 50 75 100

0/119NL003A

0/43NL005A

0/29NL006A

0/68NL006B

0/107NL006C

0/64NL009A

0/115NL009F

0/54NL009I

0/37NL009K

0/341NL010X

0/43NL011A

0/63NL011B

0/61NL011C

0/56NL011D

0/24NL011E

0/31NL011F

0/44NL012A

0/16NL012B

0/52NL012C

0/54NL013A

0/16NL013B

0/79NL016A

0/24NL017A

0/57NL021B

0/48NL021C

1/310NL026A

1/181NL025A

1/166NL022A

1/165NL006D

1/156NL029A

1/139NL008A

1/130NL002X

2/249NL002A

2/248NL020X

2/245NL019X

1/113NL023A

2/179NL014X

3/268NL007A

1/59NL018A

4/226NL022X

1/47NL011X

2/76NL021A

1/34NL009Z


0 25 50 75 100

0/38NL003

0/292NL006

0/122NL007

0/33NL013

0/113NL014

0/31NL017

0/48NL018

0/151NL021

0/36NL023

0/91NL029

1/212NL002

1/152NL008

2/278NL011

2/244NL020

2/156NL019

4/304NL009

1/70NL012

3/207NL010

1/49NL005

7/187NL022

2/47NL015

3/67NL025

2/30NL026

4/58NL016

90 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 1 28 0 0 0 0 0 0

2000 1 388 0 0 0 0 0 0

2001 0 0 0 0 0 0 0 0

2002 0 0 0 0 0 0 0 0



S. pneumoniae Penicillin R <1 <1 . .

Penicillin I+R <1 2 . .

Macrolides I+R . . . .

S. aureus Oxacillin/Methicillin R . . . .













Other



NorwayDenominators



*

*

*

*

*

*

APPENDIX A 91



n=416

S. aureus

n=0

E. coli

n=0

E. faecalis

n=0

E. faecium

n=0


Isolate source

Blood 95 2 . . . . . . . .

CSF 5 0 . . . . . . . .

Sex

Male 47 3 . . . . . . . .

Female 52 1 . . . . . . . .

Unknown 1 20 . . . . . . . .

Age (years)

0-4 5 5 . . . . . . . .

5-19 2 0 . . . . . . . .

20-64 44 3 . . . . . . . .

65 and over 48 2 . . . . . . . .

Unknown 0 . . . . . . . . .

Hospital department

ICU 0 . . . . . . . . .

Internal Medicine 0 . . . . . . . . .

Surgery 0 . . . . . . . . .

Other 0 . . . . . . . . .

Unknown 100 2 . . . . . . . .


0 25 50 75 100

Not enough data per hospital to provide a graph


0 25 50 75 100

9/416NO032

92 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 4 6 19 151 20 103 16 57

2002 7 10 21 186 22 135 19 56



S. pneumoniae Penicillin R . . <1 30

Penicillin I+R . . <1 30

Macrolides I+R . . <1 67














Other



PolandDenominators



*

*

*

*

*

*

APPENDIX A 93



n=16

S. aureus

n=337

E. coli

n=226

E. faecalis

n=83

E. faecium

n=30


Isolate source

Blood 69 18 100 20 99 10 100 0 100 3

CSF 31 20 0 . 1 0 0 . 0 .

Sex

Male 38 17 62 23 46 11 63 0 53 0

Female 63 20 38 13 54 9 37 0 47 7

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 13 0 14 15 11 0 11 0 20 0

5-19 6 100 3 44 3 17 4 0 3 0

20-64 56 11 54 21 40 14 37 0 60 6

65 and over 25 25 29 16 46 8 48 0 17 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 13 0 12 38 8 16 13 0 27 0


Surgery 0 . 12 24 15 9 23 0 33 0

Other 31 20 24 12 23 6 17 0 17 0

Unknown 0 . 0 . 0 . 0 . 0 .


0 25 50 75 100

0/20PL019A

1/14PL008A

1/10PL020A

2/19PL017A

3/22PL006A

5/34PL011A

6/38PL005A

1/6PL012A

5/30PL014A

5/21PL022A

12/50PL003A

6/23PL002A

3/9PL001A

3/7PL013A

8/9PL023A


0 25 50 75 100


94 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 12 119 13 369 0 0 0 0

2000 11 97 8 150 0 0 0 0

2001 16 155 16 521 13 418 12 185

2002 14 182 16 543 17 444 13 101



S. pneumoniae Penicillin R <1 <1 <1 <1


Macrolides I+R 9 11 . .














Other



PortugalDenominators



*

*

*

*

*

*

APPENDIX A 95



n=553

S. aureus

n=1583

E. coli

n=687

E. faecalis

n=238

E. faecium

n=47


Isolate source

Blood 78 22 100 35 99 21 100 6 100 17

CSF 22 23 0 . 1 40 0 . 0 .

Sex

Male 61 20 62 34 45 25 55 5 55 23

Female 37 26 38 35 54 17 45 8 45 10

Unknown 2 30 0 . 0 . 0 . 0 .

Age (years)

0-4 13 50 3 11 1 22 2 0 2 0

5-19 5 16 3 24 2 18 2 25 0 .

20-64 42 15 46 30 38 21 36 4 53 24

65 and over 26 16 38 46 51 24 51 8 28 8

Unknown 14 31 10 23 8 4 10 4 17 13

Hospital department

ICU 5 23 11 54 6 24 18 2 13 17


Surgery 0 . 7 50 8 19 13 0 15 0

Other 68 24 54 27 55 21 48 8 60 25

Unknown 6 22 1 26 2 21 1 0 2 0


0 25 50 75 100

0/7PT022A

2/21PT004A

3/23PT016A

56/273PT011A

33/120PT019A

23/79PT015A

88/280PT003A

25/78PT018A

31/87PT005A

19/53PT012A

18/47PT008A

42/97PT007A

34/72PT001A

34/71PT002A

5/10PT024A

105/159PT017A


0 25 50 75 100

0/6PT012

0/17PT024

2/20PT017

1/9PT016

3/20PT015

14/93PT003

8/41PT001

7/35PT005

1/5PT013

5/24PT007

5/22PT002

29/106PT011

13/45PT019

12/38PT018

11/34PT008

4/8PT009

96 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 0 0 0 0 0 0 0 0

2002 6 10 11 81 8 28 4 11



S. pneumoniae Penicillin R . . . 10

Penicillin I+R . . . 50

Macrolides I+R . . . 10

S. aureus Oxacillin/Methicillin R . . . 36





E. faecalis Aminopenicillins I+R . . . <1


Glycopeptides I+R . . . <1






Other



RomaniaDenominators



*

*

*

*

*

*

APPENDIX A 97



n=10

S. aureus

n=81

E. coli

n=28

E. faecalis

n=5

E. faecium

n=6


Isolate source

Blood 100 50 100 36 100 21 100 0 100 17

CSF 0 . 0 . 0 . 0 . 0 .

Sex

Male 60 33 62 28 64 33 40 0 17 100

Female 40 75 38 48 32 0 60 0 83 0

Unknown 0 . 0 . 4 0 0 . 0 .

Age (years)

0-4 40 50 25 40 21 17 0 . 83 0

5-19 20 0 25 5 18 100 20 0 0 .

20-64 40 75 38 48 36 0 40 0 17 100

65 and over 0 . 6 40 25 0 40 0 0 .

Unknown 0 . 6 60 0 . 0 . 0 .

Hospital department

ICU 0 . 2 100 4 0 0 . 0 .

Internal Medicine 0 . 12 20 7 0 0 . 0 .

Surgery 0 . 5 100 0 . 0 . 0 .

Other 50 40 56 33 75 19 40 0 0 .

Unknown 50 60 25 30 14 50 60 0 100 17


0 25 50 75 100

Not enough data per hospital to provide a graph


0 25 50 75 100


98 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 4 6 7 37 8 45 6 17

2002 9 16 14 258 14 215 12 79



S. pneumoniae Penicillin R . . <1 19

Penicillin I+R . . <1 19















Other



SlovakiaDenominators



*

*

*

*

*

*

APPENDIX A 99



n=22

S. aureus

n=295

E. coli

n=259

E. faecalis

n=88

E. faecium

n=7


Isolate source

Blood 59 15 100 8 100 15 100 2 100 0

CSF 41 11 0 . 0 . 0 . 0 .

Sex

Male 45 0 59 9 43 15 48 2 57 0

Female 55 25 40 7 57 14 52 2 43 0

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 23 40 5 7 3 0 6 0 29 0

5-19 9 0 2 14 2 0 7 0 0 .

20-64 50 0 46 7 39 16 43 5 43 0

65 and over 18 25 46 10 56 15 44 0 29 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 9 0 9 4 6 6 19 6 14 0


Surgery 5 0 13 11 15 13 11 0 14 0

Other 68 20 26 8 33 15 39 3 43 0

Unknown 0 . 0 . 0 . 0 . 0 .


0 25 50 75 100

0/7SK001A

0/30SK006A

0/15SK011A

1/26SK005A

3/32SK004A

4/42SK002A

6/26SK003A


0 25 50 75 100


100 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 7 40 10 154 0 0 0 0

2001 10 156 10 270 10 398 10 54

2002 11 101 11 276 11 409 9 45



















Other



SloveniaDenominators



*

*

*

*

*

*

APPENDIX A 101



n=297

S. aureus

n=700

E. coli

n=807

E. faecalis

n=72

E. faecium

n=27


Isolate source

Blood 92 20 100 18 100 10 100 0 100 0

CSF 8 17 0 . 0 . 0 . 0 .

Sex

Male 68 21 59 19 38 11 57 0 56 0

Female 32 18 41 16 62 9 43 0 44 0

Unknown 0 . 0 . 0 . 0 . 0 .

Age (years)

0-4 24 27 4 0 4 3 15 0 4 0

5-19 6 21 4 4 2 11 1 0 0 .

20-64 39 16 40 15 34 11 29 0 33 0

65 and over 31 19 52 22 59 10 54 0 63 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 16 17 15 36 9 15 13 0 22 0


Surgery 1 0 13 33 6 10 10 0 7 0

Other 47 21 22 8 31 9 39 0 26 0

Unknown 0 . 0 . 0 . 0 . 0 .


0 25 50 75 100

0/13SI006A

1/15SI010A

8/84SI003A

4/30SI007A

15/85SI008A

9/50SI009A

48/256SI001A

7/36SI002A

22/89SI004A

2/7SI003B

8/27SI005A


0 25 50 75 100

3/22SI009

17/108SI001

1/5SI006

13/56SI004

4/17SI008

9/38SI003

7/28SI010

2/7SI007

3/10SI002

102 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 33 584 30 836 0 0 0 0

2001 36 649 35 1013 27 1967 26 371

2002 35 658 36 1196 28 2483 35 566



S. pneumoniae Penicillin R . 11 11 10
















Other



SpainDenominators



*

*

*

*

*

*

APPENDIX A 103



n=1891

S. aureus

n=3045

E. coli

n=4439

E. faecalis

n=776

E. faecium

n=160


Isolate source

Blood 94 34 100 25 100 18 100 1 100 3

CSF 6 37 0 . 0 . 0 . 0 .

Sex

Male 63 32 64 25 49 21 64 2 57 3

Female 37 38 35 22 51 15 35 0 41 3

Unknown 0 . 1 57 0 . 0 . 3 0

Age (years)

0-4 17 55 4 4 3 8 10 0 16 4

5-19 3 20 4 11 2 9 2 0 3 20

20-64 38 26 39 23 29 16 32 1 29 2

65 and over 40 34 51 29 66 20 56 1 52 2

Unknown 2 40 2 16 1 17 1 0 0 .

Hospital department

ICU 8 29 14 37 4 21 25 1 14 0


Surgery 1 11 11 30 9 16 10 1 16 4

Other 57 37 40 18 51 18 40 1 45 6

Unknown 2 37 2 31 1 17 1 0 1 0


0 25 50 75 100

0/12ES045A

4/79ES005A

2/38ES020A

4/70ES013A

6/102ES011A

2/24ES015A

6/53ES040A

9/73ES048A

12/90ES021A

7/51ES047A

2/14ES034A

9/61ES043A

14/87ES044A

5/31ES018A

6/35ES003A

26/139ES016A

25/131ES038A

9/47ES032A

7/36ES014A

15/71ES031A

23/103ES042A

13/56ES017A

27/115ES008A

31/120ES007A

33/127ES041A

45/163ES001A

19/68ES004A

29/103ES012A

69/217ES019A

55/171ES009A

4/12ES046A

25/74ES002A

25/63ES029A

41/87ES049A

104/172ES026A


0 25 50 75 100

1/15ES047

5/27ES043

26/107ES011

11/45ES021

6/24ES018

6/23ES015

8/30ES005

8/30ES031

5/18ES003

12/39ES002

9/29ES048

14/45ES044

50/159ES050

18/57ES009

20/63ES012

40/125ES040

4/12ES034

2/6ES049

44/130ES001

16/47ES014

7/20ES046

24/68ES016

56/152ES042

30/81ES019

10/27ES032

38/95ES010

8/19ES017

25/59ES007

6/13ES041

13/27ES008

4/8ES026

7/13ES013

7/13ES029

26/48ES038

36/65ES020

5/9ES004

5/9ES045

104 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 24 805 24 1320 0 0 0 0

2000 19 803 19 1478 0 0 0 0

2001 20 788 21 1633 20 2800 20 671

2002 21 830 21 1836 21 3066 21 696



S. pneumoniae Penicillin R< <1 <1 <1 <1



S. aureus Oxacillin/Methicillin R <1 <1 <1 <1


Aminoglycosides R . . <1 <1











Other



SwedenDenominators



*

*

*

*

*

*

APPENDIX A 105



n=3226

S. aureus

n=6267

E. coli

n=4687

E. faecalis

n=825

E. faecium

n=350


Isolate source

Blood 97 2 100 1 100 4 100 0 100 0

CSF 3 2 0 . 0 . 0 . 0 .

Sex

Male 50 2 58 1 44 5 65 0 56 1

Female 47 2 38 1 51 4 29 0 39 0

Unknown 2 0 4 0 4 2 6 0 5 0

Age (years)

0-4 4 1 4 1 1 2 7 0 3 0

5-19 2 0 4 0 1 3 1 0 1 0

20-64 44 2 34 1 24 7 23 0 29 1

65 and over 50 3 58 1 74 4 68 0 67 0

Unknown 0 . 0 . 0 . 0 . 0 .

Hospital department

ICU 9 3 7 1 4 3 8 0 10 0


Surgery 4 2 15 1 21 4 27 0 29 0

Other 44 2 33 1 34 5 31 0 24 1

Unknown 1 0 1 0 0 . 0 . 0 .


0 25 50 75 100

0/37SE100C0/102SE110A0/36SE110B0/263SE200A0/147SE200B0/63SE200C0/118SE220A0/29SE220C0/13SE220D0/25SE230B0/156SE240A0/27SE240B0/65SE240C0/77SE250B0/32SE320B0/17SE320C0/31SE350B0/35SE350C0/243SE400A0/50SE400C0/5SE400D0/15SE430B0/15SE430C0/35SE430D0/67SE440B0/62SE440C0/171SE450A0/50SE450C0/50SE450D0/30SE450E0/29SE600C0/197SE610A0/65SE610B0/98SE610C0/11SE620B0/49SE620C0/10SE620D0/24SE730A0/19SE730B0/23SE730C0/6SE730D0/23SE730E0/53SE730F1/337SE310A1/218SE430A1/196SE350A2/315SE120A2/291SE440A1/124SE400B1/105SE230A2/171SE320A3/251SE600A3/247SE620A1/80SE540A1/51SE220B4/185SE100B14/567SE100A3/120SE250A1/37SE120B1/32SE450B

6/130SE300A


0 25 50 75 100

1/203SE400

1/158SE320

1/156SE600

1/94SE300

2/183SE310

1/85SE250

2/140SE610

2/137SE240

1/63SE230

1/52SE730

3/140SE350

3/139SE430

3/138SE620

9/384SE100

6/234SE440

5/195SE450

9/278SE200

4/113SE220

8/182SE120

3/58SE110

4/44SE540

106 APPENDIX A


Total









Year S. pneumoniae

Labs Isolates

S. aureus

Labs Isolates

E. coli

Labs Isolates

Enterococci

Labs Isolates

1999 22 240 23 653 0 0 0 0

2000 28 503 27 1495 0 0 0 0

2001 26 569 25 1518 0 0 0 0

2002 23 610 21 1703 0 0 0 0



S. pneumoniae Penicillin R 4 4 3 3
















Other



United KingdomDenominators



*

*

*

*

*

*

APPENDIX A 107



n=1922

S. aureus

n=5369

E. coli

n=0

E. faecalis

n=0

E. faecium

n=0


Isolate source

Blood 97 5 100 42 . . . . . .

CSF 3 4 0 . . . . . . .

Sex

Male 52 6 62 43 . . . . . .

Female 48 5 37 39 . . . . . .

Unknown 0 . 0 . . . . . . .

Age (years)

0-4 13 5 4 7 . . . . . .

5-19 5 3 3 16 . . . . . .

20-64 31 5 36 36 . . . . . .

65 and over 50 5 55 50 . . . . . .

Unknown 2 9 2 23 . . . . . .

Hospital department

ICU 6 2 8 69 . . . . . .

Internal Medicine 40 5 43 40 . . . . . .

Surgery 2 8 12 55 . . . . . .

Other 48 6 32 31 . . . . . .

Unknown 5 7 5 44 . . . . . .


0 25 50 75 100

11/97UK030A

28/124UK011A

23/91UK001A

44/151UK020A

54/183UK025A

121/401UK026A

150/487UK005A

110/342UK017A

38/110UK044A

5/14UK033A

28/77UK002A

43/115UK015A

30/77UK016A

107/257UK023A

79/189UK034A

158/365UK038B

303/691UK007A

9/20UK008A

17/36UK010A

150/306UK017B

170/340UK012A

133/265UK032A

65/111UK037A

6/10UK029A

57/91UK031A

16/25UK005B

183/280UK022A

62/81UK027A

28/31UK004A


0 25 50 75 100

0/15UK016

1/99UK004

1/66UK034

1/58UK022

6/259UK007

3/125UK032

1/37UK015

3/94UK012

2/60UK025

4/98UK023

1/22UK026

2/40UK008

6/117UK038

3/56UK001

3/55UK002

2/35UK010

8/136UK017

3/51UK031

4/60UK027

5/69UK030

3/38UK033

1/11UK009

4/41UK011

6/55UK020

22/186UK005

3/16UK037

4/20UK044

Appendix B. Technical Notes

Notes to Chapter 3 and Country Summary Sheets (Appendix A)

Inclusion criteriaTo be included in the analyses presented in Chapter 3, countries, laboratories and hospitals had toprovide both denominator data and AST results in 2002. Also, a laboratory had to indicate bloodculture frequencies and the number of hospital beds for each hospital served.Denmark and Ireland reported aggregated data and were therefore not included inlaboratory/hospital-specific analysis in Chapter 3. However, the data provided by these countries areincluded in Appendix A (country summary sheets).

Presentation of variables per countryCatchment population, number of beds, patient-days and number of blood culture sets wereaggregated by country.

FormulasFrom each hospital, either hospital occupancy rate or the number of patient-days was required.Occupancy rates could then be derived from patient-days, and vice versa.Hospital occupancy rate was calculated if not provided or if the occupancy was consideredimplausible (e.g. less than 25% or more than 125%). The following formula was used:

no. of patient-days / (no. of beds × 365). The average occupancy rate per country was calculated as follows:

[Σ(occupancy rate × no. of beds)/ Σ(no. of beds)]

If the number of patient-days per hospital was not provided or if considered implausible (e.g. whenyielding a calculated occupancy rate of less than 25% or more than 125%), the value was estimatedaccording to the following formula:

no. of beds × annual occupancy rate × 365.

For calculation of the total catchment population, hospitals providing single speciality(superregional) type of care (classified as other, e.g. oncology or psychiatric hospitals) were notincluded because we considered this population as probably overlapping with the catchmentpopulations of the hospitals providing general care.

Population coverage per country was calculated using the following formula:Σ(hospital catchment population)/total population

The total population of mid 2002 was obtained from the CIA World Fact book.

Detection limits for MRSA and VRE incidences (Table 3.3) were calculated in case of reported nul-incidence so that p < p upper limit of confidence interval as follows:

p < (1-p)n

at p=0.05, the detection limit is then given by (1-p)n = 0.05

APPENDIX B 109

in which n is the number of isolates tested. After calculation of p, the detection limit for the incidencerate can be calculated as follows:

detection limit = n/patient-days × 100 000 × p

Notes to Chapter 5

Inclusion criteria mapsTo be coloured in the maps a country had to report at least 10 isolates of a specific pathogen in 2002.

Trend analysisTrend analysis over the years was calculated using the Cochran-Armitage test (p ≤ 0.05).

Aggregated dataFor S. pneumoniae France provided aggregated AST data of the first two quarters of 2002 from theirnational pneumococci surveillance system

110 APPENDIX B

Appendix C

Table 1. The total number of isolates (N) and the proportion (%), PNSP, ENSP, MRSA, VRE and High level

aminoglycoside (gentamicicn)-resistant E. faecalis (HLAR) by country in 2002.

Country S. pneumoniae S. pneumoniae S. aureus E. faecium E. faecalis

N %PNSP N %ENSP N %MRSA N %VRE N %HLAR

AT 71 1% 59 10% 404 11% 40 8% 47 17%

BE 1210 14% 1210 34% 1092 28% na na na na

BG 25 8% 23 9% 116 33% 14 0% 27 63%

CZ 144 8% 141 4% 1168 6% 82 9% 505 39%

DE 232 1% 206 14% 1039 19% 68 6% 43 47%

DK 366 4% 360 5% 752 1% na na na na

EE 21 0% 17 0% 81 1% 3 0% 10 50%

ES 658 33% 615 26% 1196 23% 97 4% 421 37%

FI 427 7% 411 13% 721 1% 86 1% 30 13%

FR* 580 53% 580 58% 1663 33% 123 2% 339 15%

GR na na na na 368 44% 68 19% 128 60%

HR 90 19% 84 23% 279 37% 18 22% 78 40%

HU 61 23% 57 21% 413 9% 19 0% 16 100%

IE 277 12% 226 13% 998 42% 81 11% 51 39%

IL 177 38% 171 12% 468 38% 31 10% 185 44%

IS 43 5% 43 5% 59 0% 7 0% 18 6%

IT 296 11% 250 32% 1343 38% 178 21% 296 38%

LU 27 22% 23 22% 95 15% 8 0% 12 17%

MT 12 0% 12 25% 87 43% 3 0% 30 17%

NL 851 1% 728 7% 1501 1% 186 2% 135 33%

PL 10 30% 9 67% 186 23% 15 0% 41 42%

PT 182 20% na na 543 38% 13 0% 32 25%

RO 10 50% 10 10% 81 36% 6 17% 5 40%

SE 830 2% 683 6% 1836 1% 181 1% na na

SI 101 19% 96 10% 276 14% 13 0% 32 50%

SK 16 19% 14 29% 258 9% 4 0% 68 34%

UK 610 5% 362 13% 1703 44% na na na na

Total 6747 11% 5816 17% 18726 22% 1344 7% 2549 36%

na= not available

* For S. pneumoniae France provided aggregated AST data of the two first quarters of 2002 from their national

pneumococci surveillance system.

APPENDIX C 111

Table 2. The total number of E. coli isolates (N) and the proportion resistant to amoxicillin/ampicillin, 3rd generation

cephalosporins, fluoroquinolones, gentamicin and tobramycin.

Country Amino- 3rd generation Fluoroquinolones Gentamicin/ Tobramycin

penicillins cephalosporins Netilmicin

N %R N %R N %R N %R N %R

AT 414 33% 416 1% 413 10% 415 3% 210 5%

BE 1167 47% 1181 3% 952 13% 828 6% 151 6%

BG 134 52% 135 13% 135 14% 131 17% 46 24%

CZ 1587 45% 1585 1% 1586 10% 1587 4% 1384 5%

DE 1025 50% 1022 1% 1026 15% 1022 5% 379 3%

EE 65 38% 65 2% 61 5% 67 10% 1 0%

ES 2483 60% 2474 2% 2477 19% 2473 7% 2116 5%

FI 1329 26% 1310 1% 1329 6% 522 1% 1194 1%

FR 2493 52% 2495 1% 2491 8% 2495 4% 1668 5%

GR 583 46% 581 6% 586 13% 587 5% 517 5%

HR 490 47% 490 3% 490 5% 490 7% 2 0%

HU 353 45% 350 2% 328 10% 352 5% 286 6%

IE 735 62% 732 2% 721 5% 726 3% 67 2%

IL 864 62% 861 8% 862 19% 862 15% 561 16%

IS 79 33% 82 0% 74 3% 82 1% 2 0%

IT 564 48% 614 3% 617 21% 611 6% na na

LU 192 42% 192 1% 159 10% 193 4% 130 1%

MT 74 43% 74 3% 74 12% 74 7% 54 4%

NL 2421 39% 2040 1% 2238 5% 1951 2% 1663 2%

PL 134 52% 130 6% 133 11% 132 10% 1 100%

PT 443 58% 442 6% 396 23% 443 8% 273 4%

RO 28 64% 28 18% 28 21% 28 18% 15 7%

SE 1753 25% 3062 0% 2414 5% 2279 0% 770 0%

SI 409 43% 409 1% 409 12% 409 3% 74 3%

SK 215 51% 214 2% 214 14% 215 3% 164 2%

Total 20034 46% 20984 2% 20213 11% 18974 5% 11728 4%

112 APPENDIX C

Documents

EARSS Annual Report 2002 - European Centre for …ecdc.europa.eu/sites/portal/files/media/en/healthtopics/... · EARSS Annual Report 2002 ... CA-SFM Comité de l’Ántibiogramme