EARSS Annual Report 2006 - nsih.be · EARSS performs on-going surveillance of antimicrobial susceptibility for Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Enterococcus

EARSS Annual Report 2006

The European Antimicrobial Resistance Surveillance System (EARSS), funded by the European Centre for Disease Prevention and Control (ECDC) of the European Commission, the Dutch Ministry of Health, Welfare and Sports, and the Dutch National Institute for Public Health and the Environment, is an international network of national surveillance systems which collects comparable and validated antimicrobial susceptibility data for public health action.

EARSS performs on-going surveillance of antimicrobial susceptibility for Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Enterococcus faecalis/faecium, Klebsiella pneumonia and Pseudomonas aeruginosa causing invasive infections and monitors variations of antimicrobial resistance over time and place.

In December 2006, over 800 microbiological laboratories serving more than 1300 hospitals from 31 countries had provided susceptibility data of more than 500,000 invasive isolates. An interactive website is available at www.rivm.nl/earss, where up-to-date details can be found on country-specific resistance levels for important groups of antibiotics.

Period of data collection: January 1999 – December 2006

This document was prepared by the EARSS Management Team, members of the Advisory Board, and national representatives of EARSS, Bilthoven, The Netherlands, October 2007.

ISBN-13: 978-90-6960-183-0

Table of contents Annual Report 2006

Acknowledgements ....................................................................................................................................................................................................................................7

Summary ..................................................................................................................................................................................................................................................................9

List of abbreviations and acronyms ................................................................................................................................................................................... 11

The EARSS network from January 2006 till August 2007 ..................................................................................................................13 I. Countries participating in EARSS ..............................................................................................................................13 II. EARSS national representatives per country .................................................................................................13 III. EARSS national data managers and contact persons of national networks ............14 IV. EARSS advisory board members in 2006 .......................................................................................................... 16 V. Collaborating parties and representatives ..........................................................................................................16 VI. EARSS management team ....................................................................................................................................................16 VII. EARSS related publications ................................................................................................................................................17

Chapter 1. Introduction .................................................................................................................................................................................................................21References ....................................................................................................................................................................................................................22

Chapter 2. EARSS objectives and operational strategy ......................................................................................................................232.1. Objectives ......................................................................................................................................................................................................232.2. The EARSS network and operational strategy ................................................................................................23

2.2.1. Organisation of the EARSS network ....................................................................................................232.2.2. The national networks ..............................................................................................................................................242.2.3. Collecting and processing antimicrobial susceptibility testing (AST) results ..................................................................................................................................................252.2.4. EARSS meetings ............................................................................................................................................................262.2.5 Linkage with other networks ...........................................................................................................................26

2.3. EARSS in 2007 and beyond ...................................................................................................................................................272.3.1. Collection of antimicrobial susceptibility data .........................................................................272.3.2. The EARSS network .................................................................................................................................................272.3.3. EARSS in 2008 ................................................................................................................................................................27

2.4. References .....................................................................................................................................................................................................28

Chapter 3. External Quality Assessment Exercise .....................................................................................................................................293.1. Introduction ..................................................................................................................................................................................................293.2. Results ................................................................................................................................................................................................................29

3.2.1. Specimen 8563 Escherichia coli ................................................................................................................303.2.2. Specimen 8564 Klebsiella pneumoniae ............................................................................................323.2.3. Specimen 8565 Enterococcus faecium ...............................................................................................323.2.4. Specimen 8566 Streptococcus pneumoniae .................................................................................333.2.5. Specimen 8567 Pseudomonas aeruginosa ....................................................................................343.2.6. Specimen 8568 Pseudomonas aeruginosa ....................................................................................35

3.3. Conclusions ..................................................................................................................................................................................................35

Contents 3

Chapter 4. Results of the EARSS laboratory/hospital questionnaire 2006 ...............................................................374.1. Introduction ..................................................................................................................................................................................................374.2. Methods ............................................................................................................................................................................................................374.3. Results ................................................................................................................................................................................................................37

4.3.1. Participation ..............................................................................................................................................................................374.3.2. Population coverage ......................................................................................................................................................384.3.3. Hospital denominator information ...............................................................................................................384.3.4. Hospital characteristics ...............................................................................................................................................414.3.5. Laboratory denominator information ........................................................................................................424.3.6. Incidence rates for MRSA blood stream infections ................................................................43

4.4. Conclusions ..................................................................................................................................................................................................444.5. References .....................................................................................................................................................................................................44

Chapter 5. Antimicrobial resistance in Europe ...............................................................................................................................................455.1 Introduction and methods ..........................................................................................................................................................455.2. Streptococcus pneumoniae .......................................................................................................................................................45

5.2.1. Clinical and epidemiological importance ......................................................................................455.2.2. Streptococcus pneumoniae resistance trends: 1999-2006 ..........................................465.2.3. Serotypes ..................................................................................................................................................................................525.2.4. Conclusions ...........................................................................................................................................................................54

5.3. Staphylococcus aureus ...................................................................................................................................................................545.3.1. Clinical and epidemiological importance ......................................................................................545.3.2. Staphylococcus aureus resistance trends: 1999-2006 ......................................................555.3.3. MRSA by hospital department ......................................................................................................................565.3.4. Conclusions ...........................................................................................................................................................................57

5.4. Enterococci ...................................................................................................................................................................................................595.4.1. Clinical and epidemiological importance ......................................................................................595.4.2. Enterococcus faecalis resistance trends: 2001-2006 .........................................................605.4.3. Enterococcus faecium resistance trends: 2001-2006 ........................................................625.4.4. Conclusions ...........................................................................................................................................................................62

5.5. Escherichia coli .......................................................................................................................................................................................645.5.1. Clinical and epidemiological importance ......................................................................................645.5.2. Escherichia coli resistance trends: 2001-2006 .........................................................................645.5.3. Conclusions ...........................................................................................................................................................................68

5.6. Klebsiella pneumoniae ..................................................................................................................................................................685.6.1. Clinical and epidemiological importance ......................................................................................685.6.2. Klebsiella pneumoniae resistance in 2006 .....................................................................................685.6.3. Conclusions ...........................................................................................................................................................................77

5.7. Pseudomonas aeruginosa ............................................................................................................................................................775.7.1. Clinical and epidemiological importance ......................................................................................775.7.2. Pseudomonas aeruginosa resistance in 2006 .............................................................................785.7.3. Conclusions ...........................................................................................................................................................................82

5.8. References .....................................................................................................................................................................................................83

Chapter 6. Conclusions and Recommendations ............................................................................................................................................87

4 Contents

Annex 1. Technical notes .......................................................................................................................................................................................................89 Annex 2. Country Summary Sheets ..........................................................................................................................................................................93 Austria ...............................................................................................................................................................................................................................94 Belgium ............................................................................................................................................................................................................................96 Bulgaria ............................................................................................................................................................................................................................98 Croatia ........................................................................................................................................................................................................................... 100 Cyprus ............................................................................................................................................................................................................................ 102 Czech Republic .................................................................................................................................................................................................. 104 Denmark ...................................................................................................................................................................................................................... 106 Estonia ........................................................................................................................................................................................................................... 108 Finland ............................................................................................................................................................................................................................110 France ..............................................................................................................................................................................................................................112 Germany .......................................................................................................................................................................................................................114 Greece .............................................................................................................................................................................................................................116 Hungary ........................................................................................................................................................................................................................118 Iceland ........................................................................................................................................................................................................................... 120 Ireland ............................................................................................................................................................................................................................ 122 Israel ................................................................................................................................................................................................................................. 124 Italy ................................................................................................................................................................................................................................... 126 Latvia .............................................................................................................................................................................................................................. 128 Lithuania ..................................................................................................................................................................................................................... 130 Luxembourg ........................................................................................................................................................................................................... 132 Malta ................................................................................................................................................................................................................................ 134 Netherlands .............................................................................................................................................................................................................. 136 Norway ......................................................................................................................................................................................................................... 138 Poland ............................................................................................................................................................................................................................. 140 Portugal ........................................................................................................................................................................................................................ 142 Romania ...................................................................................................................................................................................................................... 144 Slovenia ....................................................................................................................................................................................................................... 146 Spain ................................................................................................................................................................................................................................ 148 Sweden .......................................................................................................................................................................................................................... 150 Turkey ............................................................................................................................................................................................................................ 152 United Kingdom ............................................................................................................................................................................................... 154

Annex 3. Overview of antibiotic resistance in Europe, 2006 ............................................................................................... 157

Contents 5

Acknowledgements

Antimicrobial resistance is a multifaceted threat to the health of the European population. It has become evident that the ongoing pandemic varies extensively in different European regions and that differential utilisation of antimicrobials and infection control strategies are largely to blame. However, it cannot be denied that all European countries are seeing a steady loss of antimicrobial effectiveness and that this trend may only become more pronounced if other facilitating factors such as increasing antimicrobial use in emerging market communities, travel and migration, and poten-tial global threats such as pandemic influenza, are coming to bear on these already strained medical resources. Rather than providing rocket science, the annual EARSS report provides year on year a reliable source of information of antimicrobial resistance in the Member States of the European Union and beyond and thus provides policy makers, public health experts and the public with a crucial understanding and helps prioritising antimicrobial resistance in the arena of competing public health threats.I would therefore like to take this opportunity to express my gratitude to all national representatives, national data managers and participating laboratories for their enthusiasm and willingness to share the antimicrobial susceptibility data, for their participation in the external quality control exercise and for providing the denominator information requested by the laboratory hospital questionnaire in 2007.I thank UK-NEQAS for their major role in preparing and organising the 6th successive external QA exercise. I would also like to thank the different members of the EARSS Advisory Board and the EARSS Management Team for sharing their expertise, for their contribution to this report and also for making the activities organised within EARSS again successful during the past year. Furthermore I would like to thank John Stelling for visiting many participating countries and opening the roads to the Russian Federation and Serbia by providing support on WHONET for EARSS.Finally I would like to thank you all for your extremely professional collaborative effort to the unique and well functioning EARSS network which now includes over 800 laboratories in 31 countries. I look forward to continue this fruitful cooperation for the years to come.

Hajo Grundmann Project leader EARSS ProjectCentre for Infectious Disease Control, Epidemiology and SurveillanceNational Institute for Public Health and the Environment

Acknowledgements 7

Summary

The European Antimicrobial Resistance Surveillance System (EARSS) is an international initia-tive funded by the European Centre for Disease Prevention and Control (ECDC) of the European Union, the Dutch Ministry of Health, Welfare and Sports and the Dutch National Institute of Public Health and the Environment (RIVM). It maintains a comprehensive surveillance and information system that links national networks by providing comparable and validated data on the prevalence and spread of major invasive bacteria with clinically and epidemiologically relevant antimicrobial resistance in Europe.EARSS collects routinely generated antimicrobial susceptibility (AST) data, provides spatial trend analyses and makes timely feedback available via an interactive website at www.rivm.nl/earss. Rou-tine data for major indicator pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Ente-rococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumonia and Pseudomonas aeruginosa) are quarterly submitted by over 800 laboratories serving more than 1300 hospitals in 31 European countries.In 2006, 83% of the EARSS laboratories participated in the sixth External Quality Assurance ex-ercise (EQA), jointly organised by EARSS and the United Kingdom External Quality Assurance Scheme (UK-NEQAS). It could be concluded that routinely reported results as collected by EARSS have sufficient accuracy to provide good estimates of overall resistance prevalences and trends. The EQA exercise does, however, also indicate the need for further calibration and standardisation of methods in European routine susceptibility testing.Based on the denominator data reported through the laboratory/hospital questionnaire, the overall hospital catchment population of the EARSS network is estimated to include around one third of the inhabitants of the European region, with national coverage rates between 20-100% for most countries. The comparability of MRSA incidence rates and proportions indicates that the resistance proportions as reported by EARSS are a good approximation of the incidence rates, and comparison of resistance proportions between countries thus provides useful information.

Penicillin resistance in S. pneumoniae has a dynamic character; in some countries it stabilised, where-as in others rising and falling resistance proportions were identified. Erythromycin resistance showed a more uniform picture; either resistance remained at the same medium level, or an increase could be identified. Dual resistance was still a minor problem in most countries. In 2006, more countries than before reported serogroup information for their S. pneumoniae isolates. The resistant isolates all belonged to the same few serogroups as reported in 2005 and are almost all covered by the 7-valent vaccine.In general, MRSA proportions in Europe were high, especially in the southern European countries. Although quite a few countries still showed increasing trends, four countries realized a decrease, of which Slovenia and France had reported this positive trend already for the past six years. This indicates that improved control efforts can still have a large impact on the spread of MRSA in the hospital.The susceptibility of E. coli for aminopenicillins, fluoroquinolones, 3rd generation cephalosporins and aminoglycosides is diminishing in almost all countries and especially the increasing level of fluoroquinolone resistance in Europe is alarming. In parallel, the combined resistance of these inva-sive isolates is increasing and almost 18% of the isolates already exhibits resistance to two or more classes of antimicrobials.The reporting of susceptibility results for K. pneumoniae was taken on board by more countries and more laboratories in 2006. The data showed that high levels of resistance to 3rd generation ce-

Summary 9

phalosporins, fluoroquinolones and aminoglycosides exist, especially in the southern and eastern European countries. The most frequent phenotype identified showed resistance to all three of these classes. The effectiveness of carbapenems needs to be closely monitored to make sure its value is not put at stake through irresponsible prescribing.Almost one fifth of the invasive P. aeruginosa isolates had a multi-resistant phenotype (resistant to three or more antibiotics from the EARSS protocol), these rates were especially high in the more southern countries.In conclusion, the data that EARSS has gathered over the years bring an unpleasant, but important message: Antimicrobial resistance is becoming a larger public health problem year after year and only a concerted effort might turn the tide, like in Slovenia and France for MRSA.

10 Summary

List of abbreviations and acronyms

AMR Antimicrobial resistance ARMed Antibiotic resistance surveillance and control in the Mediterranean regionAST Antimicrobial susceptibility testingCC Clonal Complex CSF Cerebrospinal fluidDCFP Data Check and Feedback ProgrammeDEFS Data Entry & Feedback SoftwareDG-SANCO Directorate General for Health and Consumer ProtectionDNA Deoxyribonucleic AcidEARSS European Antimicrobial Resistance Surveillance SystemEARSS-ibis EARSS internet based information systemEARSS-MT EARSS Management TeamEARSS-NR EARSS National RepresentativesECDC European Centre for Disease Prevention and ControlENSP Erythromycin nonsusceptible Streptococcus pneumoniaeEU European UnionEQA 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 TestingGISA Glycopeptide intermediate resistant Staphylococcus aureusHLAR High level aminoglycoside resistanceICU Intensive care unitIPSE Improving Patient Safety EuropeMIC Minimum inhibitory concentration MLS Macrolide-Lincosamide-StreptograminMLST Multi Locus Sequence TypingMRSA Methicillin-resistant Staphylococcus aureusNRL National reference laboratoriesOXA Oxacillinase genePBP Penicillin binding proteinPCV Pneumococcal conjugate vaccinPFGE Pulsed Field Gel ElectrophoresisPNSP Penicillin nonsusceptible Streptococcus pneumoniaePRSP Penicillin resistant Streptococcus pneumoniaeRIVM Rijksinstituut voor Volksgezondheid en Milieu

(National Institute for Public Health and the Environment)RNA Ribonucleic AcidSeqNet.org European Network of Laboratories for Sequence Based Typing of Microbial PathogensSpa-typing S. aureus protein A typingUK-NEQAS United Kingdom National External Quality Assessment Scheme for MicrobiologyVISA Vancomycin intermediate Staphylococcus aureusVRE Vancomycin resistant enterococciVREF Vancomycin resistant Enterococcus faecalisVRSA Vancomycin resistant Staphylococcus aureusWHO World Health OrganizationWHONET WHO microbiology laboratory database software

List of abbreviations and acronyms 11 11

The EARSS network from January 2006 till August 2007

I. Countries participating in EARSS

Austria AT Italy IT

Belgium BE Latvia LV

Bulgaria BG Lithuania LT

Croatia HR Luxembourg LU

Cyprus CY Malta MT

Czech Republic CZ Netherlands NL

Denmark DK Norway NO

Estonia EE Poland PL

Finland FI Portugal PT

France FR Romania RO

Germany DE Slovenia SI

Greece GR Spain ES

Hungary HU Sweden SE

Iceland IS Turkey TR

Ireland IE United Kingdom UK

Israel IL

II. EARSS national representatives per country

Austria (AT)H. MittermayerW. Koller

Belgium (BE)H. GoossensE. Hendrickx

Bulgaria (BG)B. Markova

Croatia (HR)S. KalenicA.Tambic Andrasevic

Cyprus (CY)D. Bagatzouni

Czech Rep. (CZ)P. Urbaskova

Denmark (DK)D. MonnetR. Skov

Estonia (EE)K. Kermes

Finland (FI)O. LyytikäinenA. Hakanen

France (FR)B. CoignardV. Jarlier

Germany (DE)W. Witte K. Heckenbach

Greece (GR)A. TsakrisA. Vatopoulus

Hungary (HU)M. Füzi

Ireland (IE)D. IgoeO. Murphy

Iceland (IS)K. Kristinsson

Israel (IL)R. Raz

Italy (IT)A. PantostiP. D ‘Ancona

Latvia (LV)A. Balode

Lithuania (LT)V. Jonaitiene

Luxembourg (LU)R. Hemmer

Malta (MT)M. Borg

Netherlands (NL)E. Tiemersma A. de Neeling

Norway (NO)A. HoibyG. Simonsen

Poland (PL)W. Hryniewicz

Portugal (PT)M. Caniça

Romania (RO)I. Codita*A. Baicus

Slovenia (SI)M. Mueller-PremruJ. Kolman

Spain (ES)F. Baquero J. Campos

Sweden (SE)B. Liljequist

Turkey (TR)D. Gür

United Kingdom (UK)A. Johnson, R. Hill(England & Wales)

H. Hughes(Northern Ireland)A. Eastaway(Scotland)

* In 2006

The EARSS network from January 2006 till August 2007 13 13

III. EARSS national data managers and contact persons of national networks

Contact person Institute Country National Surveillance Network

URL

S. Metz Elisabethinen Hospital Linz

Austria EARSS Austria www.elisabethinen.or.at

E. Hendrickx

J. Verhaegen

M. StruelensD. PiérardH. Goossens

Scientific Institute of Public HealthCatholic University of LeuvenFree University of BrusselsFree University of BrusselsUniversity of Antwerp

Belgium EARSS Belgium www.iph.fgov.be

Y. Marteva-ProevskaB. Markova

“Alexandrovska”, Laboratory for Clinical Microbiology, Sofia

Bulgaria EARSS Bulgaria www.earss.online.bg

S. KalenicA. Budimir

Clinical Hospital Centre Zagreb

Croatia EARSS Croatia

D. Pieridou-Bagatzouni

Nicosia General Hospital Nicosia

Cyprus EARSS/ARMed Cyprus

V. JakubuH. ZemlickovaP. Urbaskova

National Institute of Public Health

Czech Republic

National Reference Laboratory for Antibiotics

www.szu.cz/cem/earss/czeanj.htm

D. MonnetR. SkovS.S. OlsenL. LambertsenJ.J. Christensen

Statens Serum Institut Denmark Danish Study Group for Antimicrobial Resistance Surveillance (DANRES)DANMAP

www.ssi.dk (for DANMAP reports, see: www.danmap.org)

K. KermesM. Ivanova

Tartu University ClinicsRakvere Hospital

Estonia EARSS Estonia

T. Möttönen (KTL)

A. Hakanen (KTL & FiRe)

National Public Health Institute (KTL)

Finland Finnish Hospital Infection Program (SIRO)Finnish Study Group for Antimicrobial Resistance (FiRe)

www.ktl.fi/siro

www.ktl.fi/extras/fire/index.html

D. TrystramY. PeanH. ChardonL. Gutmann E. VaronS. Maugat National institute of Public

Health Surveillance (InVS)

France ONERBA

National Reference Centre for pneumococci

www.onerba.org

www.invs.sante.fr

K. Heckenbach Robert Koch Institute Germany EARSS GermanyA. VatopoulosM. Polemis

Department of Microbiology, National School of Public Health

Greece The Greek System for the Surveillance of Antimicrobial Resistance (WHONET Greece)

www.mednet.gr/whonet

Z. Vegh National Centre for Epidemiology

Hungary EARSS Hungary www.antsz.hu

L. Helgadottir Landspitali University Hospital

Iceland

S. Murchan Health Protection Surveillance Centre

Ireland EARSS Ireland www.hpsc.ie

R. RazH. EdelsteinR. Colodner

Ha’Emek Medical Centre Israel EARSS Israel

14 The EARSS network from January 2006 till August 2007The EARSS network from January 2006 till August 2007

Contact person Institute Country National Surveillance Network

URL

F. D’AnconaA. Pantosti

Istituto Superiore di Sanità Italy AR-ISS www.simi.iss.it/antibiotico_ resistenza.htm

A. BalodeK. Aksenoka

Pauls Stradins Clinical University Hospital

Latvia EARSS Latvia

V. JonaitienėL. Dagyte-Sileikiene

National Public Health Investigation Centre

Lithuania EARSS Lithuania

O. CourteilleV. KarremansP. Kirpach

Microbiology Lab, Luxembourg’s Hospital Centre

Luxembourg EARSS Luxembourg

E. Scicluna Infection Control Unit, St. Luke’s Hospital

Malta EARSS Malta www.slh.gov.mt/ICUnit

N. van de Sande

A. de Neeling

A. Haenen

National Institute of Public Health and the Environment

Netherlands Electronic laboratory surveillance in the Netherlands (ISIS)Resistance surveillance project EARSS The Netherlands

www.isis.rivm.nl

G. Simonsen

F. Width Gran

Arne Høiby

University Hospital of North Norway/ National Institute of Public HealthSt. Olav University Hospital TrondheimNorwegian Insitute of Public health

Norway NORM

P. Grzesiowski National Institute of Public Health

Poland OPTY

M. CaniçaP. Lavado

National Institute of Health Dr. Ricardo Jorge

Portugal ARSIP/EARSS Portugal www.insarj.pt

A. BaicusC. Balotescu

National Institute for Research and Development in Microbiology and Immunology Cantacuzino

Romania EARSS Romania

J. Kolman

M. Mueller-Premru

University Medical Centre LjubljanaInstitute of Microbiology and Immunology, Medical Faculty, University of Ljubljana

Slovenia EARSS Slovenia

J. OteoJ. Campos

Instituto de Salud Carlos III

Spain EARSS Spain

B. Olsson-LiljequistL. GezeliusJ. Struwe

Swedish Institute for Infectious Disease Control

Sweden Electronic laboratory surveillance in Sweden (ResNet), Resistance surveillance project EARSS Sweden

www.smittskyddsinstitutet.se

D. Gür Hacettepe UniversitySchool of MedicineChildren’s HospitalClinical Microbiology laboratory

Turkey ARMed/EARSS Turkey www.slh.gov.mt/armed/default1.asp

M. Lillie Health Protection Agency Communicable Disease Surveillance network

United Kingdom

UK EARSS Collaborating Group

www.hpa.org.uk


IV. EARSS advisory board members in 2006

Name Representing Institute

Dr. A. Balode all countries Paul Stradins Clinical University Hospital, Riga, Latvia

Prof. F. Baquero ESGARS Hospital Ramon y Cajal, Madrid, Spain

Dr. G. Cornaglia ESCMID University of Verona, Italy

Prof. J. Degener all countries University Medical Centre Groningen, The Netherlands

Prof. V. Jarlier all countries Groupe Hospitalier Pitié-Salpêtrière, Paris, France

Dr. G. Kahlmeter EUCAST Central Hospital Växjö, Sweden

Dr. J. Kolman all countries University Medical Centre Ljubljana, Slovenia

Prof. A. Vatopoulos all countries National School of Public Health, Athens, Greece

Dr. P. Tull ECDC ECDC, Stockholm, Sweden

V. Collaborating parties and representatives

ESCMID G. Cornaglia

ESGARS F. Baquero

EUCAST G. Kahlmeter

WHO K. Holloway

WHONET J. Stelling

CDC, USA T. Webber

UK-NEQAS C. Walton

VI. EARSS management team

Project leader, Scientific coordinator H. Grundmann

Project coordinator E. Tiemersma

Epidemiologists N. van de Sande-Bruinsma M. de Kraker

International Data Manager J. Monen

Management Assistant C. Schinkel

E-mail: [email protected]

Post: National Institute for Public Health and the Environment (RIVM)Antonie van Leeuwenhoeklaan 9PO Box 13720 BA BilthovenThe Netherlands

Phone: +31 30 274 44 25

Fax: +31 30 274 44 09


VII. EARSS related publications

Scientific papers in peer reviewed journals

EARSS management team

• Bronzwaer SL, Cars O, Buchholz U, Molstad S, Goettsch W, Veldhuijzen IK, Kool JL, Sprenger MJ, Degener JE. European Antimicrobial Resistance Surveillance System. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 2002; 8: 278-82.

• Bronzwaer S, Buchholz U, Courvalin P, Snell J, Cornaglia G, de Neeling A, Aubry-Damon H, Degener J, and EARSS participants. Comparability of antimicrobial susceptibility test results from 22 European countries and Israel: an external quality assurance exercise of the European Antimicrobial Resistance Surveillance System (EARSS) in collaboration with the United Kingdom National External Quality Assurance Scheme (UK NEQAS). J Antimicrob Chemother 2002; 50: 953-64.

• Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, Kool JL, Sprenger MJW, Degener JE, and participants in the European Antimicrobial Resistance Surveillance System. A European Study on the Relationship between Antimicrobial Use and Antimicrobial Resistance. Emerg Infect Dis 2002; 6: 278-282.

• Tiemersma EW, Bronzwaer SL, Lyytikäinen O, Degener JE, Schrijnemakers P, Bruinsma N, Monen J, Witte W, Grundmann H, and EARSS Participants. Methicillin-resistant Staphylococcus aureus in Europe, 1999–2002. Emerging Infect Dis 2004; 10: 1627-1634.

• Bruinsma N, Kristinsson K, Bronzwaer S, Schrijnemakers P, Degener J, Tiemersma E, Hryniewicz W, Monen J, Grundmann H, and the EARSS participants. Trends of penicillin and erythromycin resistance among invasive Streptococcus pneumoniae in Europe. J Antimicrobial Chemother 2004; 54: 1045-1050.

• Tiemersma EW, Monnet DL, Bruinsma N, Skov R, Monen JCM, Grundmann H, and EARSS participants. Staphylococcus aureus bacteremia, Europe. Emerging Infect Dis 2005; 11: 1798-9.

• Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of methicillin- resistant Staphylococcus aureus as a public health threat. The Lancet 2006; 368: 874-885.

• Foster KR, Grundmann H. Do we need to put society first? The potential for tragedy in antimicrobial resistance.PloS Medicine 2006; 3: 29.

• Van de Sande-Bruinsma N, Grundmann, H, Verloo D, Tiemersma E, Monen J, Goossens H, Ferech M, and the EARSS and ESAC participants. Antibiotic Use and Resistance in Europe: The Relentless Strain on Non-Renewable Resources. Emerg Infect Dis. Under review.

Belgium

• Goossens H, Ferech M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005; 9459: 579-587.

Croatia

• Budimir A, Duerenberg RH, Plecko V, Vink C, Kalenic S, Stobberingh E. Molecular characterization of methicillin-resistant Staphylococcus aureus bloodstream isolates from Croatia. J Antimicrob Chemother 2006; 57:331-334.

Czech Republic

• Urbá�ková P, Macková �, Jakubu V, �emlicková H a C�-EARSS. Resistance to clindamycin among �3�3�ková P, Macková �, Jakubu V, �emlicková H a C�-EARSS. Resistance to clindamycin among �3�3ková P, Macková �, Jakubu V, �emlicková H a C�-EARSS. Resistance to clindamycin among �3�3 Staphylococcus aureus isolates from blood, Zprávy CEM (Bulletin of the Centre of Epidemiology and Microbiology) 2006; 15(3-4):156-158, ISSN 1211-7358

• Urbá�ková P, Macková �, Jakubu V, �emlicková H a C�-EARSS. Antimicrobial resistance surveillance in invasive Staphylococcus aureus isolates within EARSS, Zprávy CEM (Bulletin of the Centre of Epidemiology and Microbiology) 2006; 15(5): 200-203, ISSN 1211-7358

• Urbá�ková P, Jakubu V, �emlicková H a �castn�ci C�-EARSS. Antimicrobial resistance in seven invasive�ková P, Jakubu V, �emlicková H a �castn�ci C�-EARSS. Antimicrobial resistance in seven invasiveková P, Jakubu V, �emlicková H a �castn�ci C�-EARSS. Antimicrobial resistance in seven invasive bacterial species monitored within EARSS in the Czech Republic (CR) from 2000 - 2006. CzMa JEP Praktický lékar No. 1, 2007.

Estonia

• Lõivukene K, Kermes K, Sepp E, Adamson V, Mitt P, Kallandi Ü, Otter K, Naaber P. The surveillance of antimicrobial resistance of invasive pathogens: Estonian experience. Eurosurveillance monthly 2006; 11; Issues 1-3: 47-49.


• Lõivukene K, Kermes K, Sepp E, Adamson V, Mitt P, Jürna M, Mägi H, Kallandi Ü, Otter K, Naaber P. The comparison of susceptibility of gram-negative invasive and nosocomial pathogens in Estonian hospitals. Antonie van Leeuwenhoek 2006; 89: 367-371.

• Lõivukene K, Sepp E, Adamson V, Kallandi Ü, Otter K, Naaber P. Importance and antimicrobial susceptibility of Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae in intensive care units. Estonian study compared with other European data. Scand J Infect Dis 2006; 38: 1001-1008.

Finland

• Lyytikäinen O, Möttönen T, Nissinen A. Mikrobilääkeresistenssin seuranta Euroopassa: EARSS-tuloksia 2002. Kansanterveys 2003; 10: 13-14.

• Lyytikäinen O, Möttönen T, Nissinen A. Mikrobilääkeresistenssin seuranta Euroopassa: EARSS-tuloksia 2002. Sairaalahygienialehti 2003; 6: 282-283.

• Lyytikäinen O, Nissinen A. Mikrobilääkeresistentit sairaalainfektioiden aiheuttajat meillä ja muualla. Sairaala 2004; 3: 14-15.

• Lyytikäinen O, Agthe N, Virolainen-Julkunen A, Vuopio-Varkila J. MRSA-tilanne yhä huonontunut – nyt myös vaikeissa yleisinfektioissa. Kansanterveys 2004; 7: 9.

• Lyytikäinen O, Agthe N, Virolainen-Julkunen A, Vuopio-Varkila A. MRSA cases continue to increase in Finland. Eurosurveillance weekly 16 September 2004.

• Virolainen-Julkunen A, Vuopio-Varkila J, Huovinen P, Lyytikäinen O, Ruutu P. Lisämääräraha MRSA:n torjuntaan. Kansanterveys 2005; 2-3: 7-8.

• Lyytikäinen O. Onko Suomen MRSA-tilanteen huononeminen pysähtynyt? Kansanterveys 2005; 7: 3-4.

Italy

• Moro ML, Pantosti A, Boccia D, e il gruppo EARSS-Italia. Sorveglianza dell’antibiotico-resistenza in infezioni invasive da Streptococcus pneumoniae e Staphylococcus aureus: il progetto EARSS in Italia (Aprile 1999-Aprile 2000). Ann Ig 2002; 14: 361-371.

• Boccia D, Pantosti A, D’Ancona F, Giannitelli S, Monaco M, Salmaso S. Antimicrobial resistance in Italy: preliminary results from the AR-ISS project. Eurosurveillance 2002; 7: 87-93.

• Pantosti A, �occia D, D’Ambrosio F, Recchia S, Orefici G, Moro ML, National Surveillance of �acterial Meningitis, and The EARSS-Italia Study. Inferring the potential success of pneumococcal vaccination in Italy: serotypes and antibiotic resistance of Streptococcus pneumoniae isolates from invasive diseases. Microb Drug Resist 2003; 9: S61-S68.

• Fokas S, D’Ancona F, Boccia D, Pantosti A, Giannitelli S, Meduri FR, Salmaso S, per il gruppo di studio AR-ISS. L’antibioticoresistenza in Italia: il progetto AR-ISS. Risultati del primo anno di attività e prospettive per il futuro. Not Ist Super Sanità 2003; 16: 11-14.

• Boccia D, Spila Alegiani S, Pantosti A, Moro ML, Traversa G. The geographic relationship between the use of antimicrobial drugs and the pattern of resistance for Streptococcus pneumoniae in Italy. Eur J Pharmacol 2004; 60: 115-119.

• Stampone L, Del Grosso M, Boccia D, Pantosti A. Clonal spread of a vancomycin-resistant Enterococcus faecium strain among bloodstream-infecting isolates in Italy. J Clin Microbiol 2005; 43: 1575-1580.

• Monaco M, Camilli R, D’Ambrosio F, Del Grosso M, Pantosti A. Evolution of erythromycin resistance in Streptococcus pneumoniae in Italy. J Antimicrob Chemother 2005; 55: 256-259.

• Boccia D, D’Ancona F, Salmaso S, Monaco M, Del Grosso M, D’Ambrosio F, Giannitelli S, Lana S, Fokas S, Pantosti A e il Gruppo AR-ISS. Antibiotico-resistenza in Italia: un anno di attività del progetto di sorveglianza AR-ISS. Ann Ig 2005; 17: 95-110.

Ireland

• Murphy OM, Murchan S, Whyte D, Humphreys H, Rossney A, Clarke P, Cunney R, Keane C, Fenelon LE, O’Flanagan D. Impact of the European Antimicrobial Resistance Surveillance System on the development of a national programme to monitor resistance in Staphylococcus aureus and Streptococcus pneumoniae in Ireland, 1999-2003. European Journal of Clinical Microbiology and Infectious Diseases 2005; 24: 480-3.


• Rossney AS, Lawrence MJ, Morgan PM, Fitzgibbon MM, Shore A, Coleman DC, Keane CT, O’Connell B. Epi-demiological typing of MRSA isolates from blood cultures taken in Irish hospitals participating in the European Antimicrobial Resistance Surveillance System (1999-2003). European Journal of Clinical Microbiology and Infectious Diseases 2006; 25: 79-89.

Romania

• Codita I. The global strategy for antimicrobial resistance containment, European Antimicrobial Resistance Sur-veillance System (EARSS). Preparatory stages for integrating national surveillance of antimicrobial resistance in the European system. Viata medicala 2001; May: 2.

Slovenia

• Kolman J, Gubina M, Mueller-Premru M, Sočan M, Cyetkovski L, Koren S. Slovenski rezultati občutljivosti bakterij Staphylococcus aureus in Streptococcus pneumoniae iz hemokultur in likvorjev, zbrani v okviru projekta EARSS. In: Mueller-Premru M, Gubina M, editors. Mikrobi in antibiotiki 2001. Zbornik predavanj Mikrobiološki simpozij z mednarodno udeležbo; 200� jun 22-23; Ljubljana. Ljubljana: Slovensko zdravnisko društvo, Sekcija za klinično mikrobiologijo in hospitalne infekcije 2001; 185-92.

• Kolman J, Gubina M, Mueller-Premru M, Lorenčič-Robnik S, �ohar-Čretnik T, Harlander T, Štrumbelj I, Kavčič M, Grmek-Ko�nik I, Tomič V, Ribič H, Fi�er J, Merljak L, Piltaver-Vajdec I. Sodelovanje Slovenije v evropskem projektu EARSS - prikaz rezultatov deleža MRSA - izolatov iz hemokultur. Isis 2003; 12: 30-33.

• Kolman J, Gubina M. Trendi občutljivosti invazivnih izolatov bakerije Staphylococcus aureus v Sloveniji in Evropi - rezultati projekta EARSS. Med Razgl 2004; 43: 11-17.

• Kolman J, Gubina M. Sodelovanje Slovenije v projektu EARSS. Med Razgl 2006; 45 (Suppl 2): 3-10.

Spain

• Oteo J, Campos J, Baquero F and the Spanish EARSS Group. Antibiotic resistance in 1962 invasive isolates of Escherichia coli in 27 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2001). J Antimicrob Chemother 2002; 50: 945-952.

• Oteo J, Cruchaga S, Campos J, Saez JA, Baquero F, y miembros espanoles del grupo “European Antimicrobial Resistance Surveillance System. Antibiotic resistance in blood isolates of Staphylococcus aureus in 31 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2000)]. Medicina Clinica 2002; 119: 361-5.

• Oteo J, Cruchaga S, Campos J, Saez JA, Baquero F, y miembros espanoles del grupo “European Antimicrobial Resistance Surveillance System. Antibiotic resistance in 622 Streptococcus pneumoniae isolated from blood and cerebrospinal fluid in 33 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2000)]. Enfermedades Infecciosas y Microbiologia Clinica 2003; 21: 12-9.

• Oteo J, Campos J, Cruchaga S, Baquero G, Lázaro E, Madurga M, de Abajo FJ, Baquero F and the Spanish EARSS Group. Increase of resistance to macrolides in invasive Streptococcus pneumoniae in Spain (2000-2001). Clin Microbiol Infect 2004; 12: 851-854.

• Oteo J, Baquero F, Vindel A, Campos J and the Spanish EARSS Group. Antibiotic resistance in 3113 blood isolates of Staphylococcus aureus in 40 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2000-2002). J Antimicrob Chemother 2004; 53: 1033-1038.

• Oteo J, Lázaro E, de Abajo FJ, Campos J, and Spanish EARSS Group. Trends in antimicrobial resistance in 1,968 invasive Streptococcus pneumoniae strains isolated in Spanish hospitals (2001-2003): Decreasing penicillin-re-sistance in children’s isolates. J Clin Microbiol 2004; 42: 5571-5577.

• Oteo J, Lázaro E, de Abajo FJ, Baquero F, Campos J and the Spanish EARSS Group. Antimicrobial-resistant invasive Escherichia coli, Spain. Emerg Infect Dis 2005, 11: 546-553.

United Kingdom

• Johnson AP, Aucken HM, Cavendish S, Ganner M, Wale MC, Warner M, Livermore DM, Cookson BD, UK-EARSS. Dominance of EMRSA-15 and -16 among MRSA causing nosocomial bacteraemia in the UK: analysis of isolates from the European Antimicrobial Resistance Surveillance System (EARSS). J Antimicrob Chemother 2001; 48: 143-144.

• Johnson AP, Lamagni TL, Wale M, Cavendish S, Bishop L, Alhaddad N, Warner M, Livermore DM, Duckworth G, George RC. Susceptibility to moxifloxacin of pneumococci isolated in English hospitals participating in the European Antimicrobial Resistance Surveillance System (EARSS) in 2003. Int J Antimicrob Agents 2005; 25: 539-541.


Chapter 1. Introduction

Antimicrobial resistance (AMR) threatens the effectiveness of successful treatment of infections and is a public health issue with local, national, and global dimensions. Antimicrobial resistance can result in increased morbidity, disease burden, and mortality. Surveillance of antimicrobial resistance proportions provides data that are needed to raise the awareness to the problem and instigate neces-sary interventions.

At the ‘Microbial Threat Conference’, held in September 1998 in Denmark, it was concluded that an ‘Effective European surveillance should be in place and must have the agreement and active involvement of all participants’ (‘the Copenhagen Recommendations’ [3]). This conference led to the foundation of the European Antimicrobial Resistance Surveillance System (EARSS), funded by the Directorate General for Health and Consumer Protection (DG SANCO) of the European Commis-sion, the Dutch Ministry of Health, Welfare and Sports and the Dutch National Institute for Public Health and the Environment. Since 1999, it has been the remit of EARSS to maintain a comprehen-sive surveillance and information system that links national networks by providing comparable and validated data about the prevalence and spread of major invasive bacteria with clinical and epide-miologically relevant AMR in Europe. In 2001, at a follow-up EU conference in Visby, Sweden, it was concluded that all Member States of the European Union (EU) shall join the EARSS initia-tive as a minimum requirement of national surveillance programmes (‘the Visby recommendations’ [1]) and during the Rome conference convened by the EU Commission Directorate for Research and Development in November 2003, is was made clear that linking antimicrobial resistance with microbial ecology and improving the knowledge about its costs to European societies is essential for the development of effective control strategies [2]. From September 2006 onwards, EARSS was co-financed by ECDC from the European Union.

EARSS is co-ordinated by the Dutch National Institute of Public Health and the Environment (RIVM). Ever since the start of EARSS, the number of participants has increased. By the beginning of 2007, EARSS covers an estimated population of over 150 million inhabitants (which is about one-third of the European population) served by more than 1200 hospitals in 31 countries. The EARSS data-base contains AMR data on approximately 500,000 invasive isolates of Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. It is thus the most comprehensive public health effort that describes and analyses geographic and secular trends in AMR worldwide.

EARSS operates in close collaboration with other EU-financed projects: European Surveillance of Antimicrobial Consumption (ESAC), and Antibiotic Resistance Surveillance and Control in the Mediterranean region (ARMed). There is a close partnership between the European Society of Clini-cal Microbiology and Infectious Diseases (ESCMID) and two of the society’s sub committees, name-ly, the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and the ESCMID Study Group for Antimicrobial Resistance Surveillance (ESGARS).

This report presents an overview of activities, innovations and results of the EARSS network from January 2006 till August 2007. Chapter 2 summarises the objectives and operational strategy. Chap-ter 3 describes the results of the 2007 External Quality Assessment exercise. Chapter 4 gives an overview of the first results of the laboratory/hospital questionnaire 2006, through which information

Chapter 1. Introduction 21

was collected on denominators and other relevant determinants of patient care. Chapter 5 provides a descriptive analysis of the situation of AMR in Europe. Chapter 6 presents the overall conclusions and recommendations based on these results. The annexes contain a technical section (annex 1), detailed country summary sheets (annex 2) and overview tables of antibiotic resistance in Europe in 2006 (annex 3). Results concerning AMR are based on data recorded from January 1999 - December 2006, if not otherwise indicated.

References

1. Progress Report on Antimicrobial Resistance, Visby, Sweden: Social Styrelsen, the Swed-ish National Board of Health and Welfare, June 2001. Available at http://www.sos.se/FULL-TEXT/123/2001-123-68/2001-123-68.pdf.

2. Report from the European Conference on the Role of Research in Combating Antibiotic Resi-stance, 2003. Clin Microbiol Infect 2004; 10: 473 – 497.

3. Thamdrup Rosdahl V, Borge Pederson K. Report from the invitational EU Conference on the microbial threat, Copenhagen, Denmark, 9-10 September 1998.

22 Chapter 1. Introduction

Chapter 2. EARSS objectives and operational strategy

2.1. Objectives

It is the remit of EARSS to maintain a comprehensive surveillance and information system that links national networks by providing comparable and validated data on the prevalence and spread of major invasive bacteria with clinically and epidemiologically relevant antimicrobial resistance in Europe. Thus, EARSS aims to:• collect comparable and validated AMR data;• analyse trends in time and place; • provide timely AMR data that constitute a basis for policy decisions; • provide feedback to ‘those who need to know’;• encourage the implementation, maintenance and improvement of national AMR surveillance

programmes;• support national systems in their efforts to improve diagnostic accuracy at every level of the

surveillance chain;• link AMR data to factors influencing the emergence and spread of AMR, such as antibiotic use

data; and• initiate, foster and complement scientific research in Europe in the field of AMR.EARSS collects routine antimicrobial susceptibility test (AST) results of invasive (blood culture and CSF) isolates of Streptococcus pneumoniae, Staphylococcus aureus (both since 1999), Enterococcus faecalis and E. faecium, Escherichia coli (since 2001), Klebsiella pneumoniae and Pseudomonas aeruginosa (both since 2005). These pathogens were selected because they have different epide-miological and ecological backgrounds and serve as markers for clinically and epidemiologically meaningful developments in antibiotic resistance. The decision to collect routine data, preferably ac-cording to the internet-accessible EARSS protocols, means that no changes to the regular diagnostic process are needed. In this way, the participation of many laboratories in many countries has become feasible.

2.2. The EARSS network and operational strategy

2.2.1. Organisation of the EARSS networkEach participating country has appointed one or two national representatives. They are medical microbiologists and/or infectious diseases epidemiologists (see table II, page 13). Moreover, each country has a national data manager (see table III, pages 14-15). The main task of the national repre-sentatives is to coordinate the EARSS-specific activities of the participating laboratories in their own country (data collection, reporting, questionnaire completion and EQA strain and results distribution) and to communicate with the EARSS Management Team (EARSS-MT). The national representa-tives also encourage the laboratories to generate their AST data according to the EARSS protocols, as published in the EARSS Manual 2005 (downloadable from the EARSS website at www.rivm.nl/earss). The main tasks of the national data manager are to collect, approve and forward resistance data each quarter to the international data manager maintaining the EARSS central database and to assist the national representative. Protocols for standardising the data collection have been developed with professional help from the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and WHO microbiology laboratory database software (WHONET). To assess the quality and comparability of

Chapter 2. EARSS objectives and operational strategy 23 23

AST data, regular EQA exercises are carried out in collaboration with UK-NEQAS. The results of the EQA exercise carried out in the spring of 2007 are presented in Chapter 3 of this report. 2.2.2. The national networksIt is the task of the national representatives to select participating laboratories/hospitals that cover at least 20% of the total population and serve various types of institutions (university or tertiary care hospitals, general or district hospitals, rehabilitation centres or nursing homes, and others). Different geographic regions (urban/rural), and the socio-economic strata should be included in a demographi-cally representative manner.

24 Chapter 2. EARSS objectives and operational strategyChapter 2. EARSS objectives and operational strategy

A1 A A

National Management Team

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Figure 2.1. Structure of the EARSS network.1 Reporting lines are indicated with arrows. The most important reporting lines are further clarified with letters (A-C):

A. Participating laboratories collect data and report the data to the national data manager, who checks the data. Messages from the national level and from EARSS-MT, including new protocols, questionnaires and reports, are forwarded by the national representative to the participating laboratories. B. Once checked, the national data manager forwards the data to EARSS-MT, where the data is again checked and a feedback report is produced which is sent to the national representative. EARSS-MT awaits approval of the data by the national representative before the results are added to the EARSS database and thus become visible at the interactive website and published in the annual report. Messages from EARSS-MT, including new protocols, questionnaires and reports, are always directed to the national representatives who shall forward the information to the relevant parties in their own country. (NB: the annual plenary meeting brings together EARSS-MT and all national representatives). C. Official reports are forwarded for final approval to DG-SANCO (until September 2006), respectively ECDC (from September 2006 onwards) and the Dutch Ministry of Welfare and Sports (considering a 45 days term) which are the main sponsors of the EARSS project, before they become official reports of the EARSS network.

2 ICMs: Intersectoral Co-operating Mechanisms3 WHO: World Health Organisation4 ESCMID: European Society on Clinical Microbiology and Infectious Diseases5 EUCAST: European Committee on Antimicrobial Susceptibility Testing6 ESAC: European Surveillance on Antimicrobial Consumption7 ARMed: Antibiotic Resistance Surveillance and Control in the Mediterranean Region8 ESGARS: ESCMID Study Group for Antimicrobial Resistance9 ECDC: European Centre for Disease Prevention and Control; funding from September 2006 onwards10 DG-SANCO: Directorate-General for Health and Consumer Protection; funding until September 2006

2.2.3. Collecting and processing antimicrobial susceptibility testing (AST) resultsEARSS collects susceptibility test results of invasive isolates and background information about patients. Laboratories are asked to report the first isolate from blood or CSF per reporting quarter, including specific information on the bacterial isolate, host, institution and laboratory that submits the results. Data shall be reported according to the specifications of the EARSS exchange format. AST results are generated and reported as specified by standard EARSS protocols. Furthermore, optional data are collected such as clinical diagnosis, other conditions, and facultative susceptibility data for additional antibiotics. More information about data collection and protocols can be found in the EARSS Manual 2005, which can be downloaded from the official EARSS website at www.rivm.nl/earss.

Laboratories Participating laboratories can opt for one of two ways of submitting data: electronically or by sub-mitting conventional isolate record forms (on paper). EARSS provides various free software tools for electronic data handling, downloadable from the website at www.rivm.nl/earss: (1) WHONET, the microbiology laboratory software, adapted for EARSS by John Stelling, and (2) Data Entry & Feedback Software (DEFS), which was developed as an exclusive EARSS tool. Laboratories are asked to collect AST data on a routine basis and to forward these to the national representative or data manager quarterly. Before submission, laboratories are asked to check their data for: • adherence to the EARSS protocol;• microbiological consistency/plausibility;• consistency with clinical breakpoints, sensitive (S), intermediate (I) and resistant (R)

breakpoints as defined by the specific 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 fashion:• recording data from all participating laboratories and manual data entry if isolate record forms

are used;• merging data from all participating laboratories into one single file;• converting data to EARSS exchange format (EARSS Manual 2005); • revising data with a data check programme, such as DCFP, which is part of the WHONET

programme, or DEFS;• approval of data by the national representative (adherence to EARSS protocol);• data transfer to EARSS-MT at the end of each quarter (March, June, September and December).

International data manager at EARSS-MTAfter receiving the data from the national data manager, the files are examined by the international data manager of EARSS-MT. This process involves the following steps:• checking the data format;• inspection of the contents of the files; • removing duplicate reports;• determining resistance proportions;• identification of unusual or rare results;• compilation of a feedback report summarizing the results, to be confirmed by the national

representative in writing.


After approval by the national representative, data are added to the database, and the results are made public on the EARSS website at www.rivm.nl/earss.

Feedback from EARSS-MT Once data become available to EARSS-MT, they are processed and returned in a standard feedback report to the national representative in order to obtain confirmation and final approval of validity and completeness of the data. This feedback step also informs the national representatives of the oc-currence of resistance patterns with particular public health importance (e.g. MRSA, GISA, PNSP, VRE). Subsequently, the national coordinator is asked to confirm the correctness of the results. With his/her approval, the data will be added to the EARSS database and will become immediately avail-able on the interactive EARSS website at www.rivm.nl/earss, where they can be displayed in various downloadable formats, such as tables, figures, and maps. The data from the EARSS database are used to prepare annual reports, newsletters and publications that are disseminated to the participants, the scientific community, policy makers and a broader public.

2.2.4. EARSS meetings EARSS organizes annual meetings for all national representatives to inform them on the progress of EARSS and discuss future initiatives. In contrast to former meetings, the annual plenary meeting of 2006/2007 was organized in spring, from 9 to 11 May 2007 at ECDC in Stockholm, Sweden. An update was given on the situation of antimicrobial resistance in Europe, preliminary results of the EQA exercise 200� were presented, the influence of EARSS in the creation of national surveillance networks was exemplified by the Austrian national representative, and the usefulness of EARSS data to the scientific community was discussed in several presentations. EARSS sister projects such as ARMed, ESAC and EUCAST discussed their results and cooperation with EARSS. Besides these topics, many other subjects considered to be of relevance for the audience were discussed, such as identification of ES�Ls, newly emerging resistance like MRSA in animal husbandry, and, using an example from the Pan American Health Organisation’s AMR surveillance system, alternative approaches of external assessment of diagnostic quality were discussed.EARSS also organizes regular training sessions for data managers and reference laboratory staff. In March 2007, the 2nd workshop for reference laboratory staff was organized in cooperation with SeqNet.org in Bilthoven, the Netherlands. The ongoing EARSS/SeqNet initiative was discussed, in which per country about 200 S. aureus isolates (50% MRSA) are typed using the spa typing method and epidemiological background information is collected.

2.2.5 Linkage with other networksLaboratory protocols on the identification of fluoroquinolone resistance in Streptococcus pneumo-niae as well as the clinically and epidemiologically relevant resistance patterns for the two new species (Klebsiella pneumoniae and Pseudomonas aeruginosa) were devised in cooperation with EUCAST. EARSS and ESAC exchanged their surveillance data for the linking of resistance with the prescription of antimicrobial compounds in Europe (manuscript submitted). Collaboration with IPSE resulted in the integration of a web-accessible communication platform for hospital infection control practitioners (NEWS site) with the EARSS-ibis tool. The initiative on ‘Identifying the domi-nant strains of Staphylococcus aureus causing invasive infection in the European region’ was based on a formal agreement (see 2.3.4 Typing initiatives) for collaboration with the previously established SeqNet.org group.


2.3. EARSS in 2007 and beyond

2.3.1. Collection of antimicrobial susceptibility dataThis report includes AST data from the start of EARSS in 1999 up to December 2006; the results are described in Chapter 5 of this report. Data collected in 2007 are included in the interactive EARSS database which is regularly updated and accessible from the EARSS website (see www.rivm.nl/earss).

2.3.2. The EARSS networkTwo new countries (Lithuania and Turkey) joined the EARSS initiative in 2005. Both countries started reporting in 2006. As Turkey had been participating in the ARMed project, data for 2003 to 2005 were retrospectively added to the EARSS database. Unfortunately, Slovakia was not able to continue its longstanding contribution to the EARSS network due to decreasing financial commit-ments and dropped out in 2006. The main decrease in the number of participating laboratories was due to defaulting laboratories in France. This decline was explained by decreasing participation of the national network that is dedicated to Streptococcus pneumoniae.

2.3.3. EARSS in 2008In March 2007, the EARSS network was evaluated by an international and independent team of pub-lic health specialists. The evaluation team (consisting of an epidemiologist, a clinician and a micro-biologist) rated EARSS as an important project with excellent links to participating laboratories. The evaluation team concluded that the aims set by the EARSS annual plenary meeting in Warsaw 2003 were largely achieved. Some of the achievements have, however, not had their full bearing and the expected impact on the network. For example, the installation of the EARSS-ibis system that although built and functioning, is not yet utilised by EARSS participants. It was also remarked that efforts should be undertaken to link available antimicrobial utilisation data with resistance rates. The


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Figure 2.2. Number of laboratories (right axis) and countries (left axis) participating in EARSS by year.

modelling of antimicrobial resistance dynamics, so far attempted for S. pneumoniae (1), could also be improved. The visit of the ECDC evaluation team was preceded by an inquiry about the useful-ness of EARSS addressing the State Epidemiologists (SE), National Epidemiological Contact Points (NEP; EARSS national representatives being epidemiologists by training) and National Laboratory contact Points (NLP; EARSS national representatives being medical microbiologists). The main out-come of this exercise is given in table 2.1. It is envisaged that EARSS will continue to exist after the end of its contract period with ECDC (ex-tended until 31 December 2007) and a call for proposal has been published to this effect.

2.4 References

1. Bruinsma N, Kristinsson KG, Bronzwaer S, Schrijnemakers P, Degener J, Tiemersma E, Hrynie-wicz W, Monen J, Grundmann H, European Antimicrobial Resistance Surveillance System (EARSS). Trends of penicillin and erythromycin resistance among invasive Streptococcus pneu-moniae in Europe. J Antimicrob Chemother. 2004 Dec;54(6):1045-50.


Table 2.1. Response of State Epidemiologists (SE), National Epidemiological Contact Points (NEP) and National Laboratory contact Points (NLP) to ECDC questionnaire investigating the usefulness of EARSS.

SE NEP NLP

Number invited 14 9 41Responded to questionnaire 93% 67% 75%Questions: Answered affirmative:Network provides more detailed analysis or information about AMR in the countries than is regularly produced at national level

50% 14% 71%

Protocols, guidelines or procedures from EARSS are used 79% 86% 97%Information produced by EARSS is used in the country 93% 100% 97%Laboratories participated in laboratory training?* n.a. n.a. 29%Data in EARSS database are used n.a. 100% 81%EARSS website provides useful information for EARSS members

86% 100% 100%

EARSS contributes to improvements in national AMR surveillance

79% 57% n.a.

EARSS contributes to short or long term improvements in national public health prevention and control policies /activities

64% 57% n.a.

Participation to EARSS led to improvement in protocols or procedures for sampling

43%** 14% n.a.

EARSS increased national coverage of strains sent to reference laboratories

n.a. n.a. 81%

EARSS improved competence of public health and reference laboratories

n.a. n.a. 77%

EARSS contributes to improved use of methods for detection or characterization of microbes

n.a. n.a. 81%

EARSS has led to public health interventions 64%^ 0^^ n.a.

n.a., not available;* all participating laboratories rated the training as useful.** 29% of SE answered ‘unknown’ to this question^ 21% of SE answered ‘unknown’ to this question^^ 14% of NEP answered ‘unknown’ to this question

Chapter 3. External Quality Assessment Exercise 29 29

Chapter 3. External Quality Assessment Exercise

3.1. Introduction

Since 2000, EARSS has been organizing external quality assessment (EQA) exercises of antibiotic susceptibility testing in collaboration with UK NEQAS (United Kingdom National External Quality Assessment Scheme). UK NEQAS is based at the Health Protection Agency – Colindale, London (UK) and is a non-profit organization with more than 30 years experience with external quality as-sessment in different countries (www.ukneqasmicro.org.uk).

The rationale of these EQA exercises is, i) to assess the ability of participating laboratories to identify antimicrobial resistance of clinical

and public health importance, ii) to determine the accuracy of quantitative susceptibility test results reported by individual labora-

tories and iii) to decide on the overall comparability of routinely collected test results between laboratories and

countries and thus provide the means for justifying the pooling and comparison of antimicrobial susceptibility test (AST) data across Europe.

The latest EQA held in the first quarter of 200� consisted of 6 strains provided by the Health Protec-tion Agency. The strains were characterized and tested by the Addenbrookes Hospital in Cambridge (UK) and the Antibiotic Resistance Monitoring and Reference Laboratory (ARMRL) in London (UK). Both reference laboratories interpreted the results according to different breakpoint criteria of CLSI and BSAC, as indicated in each of the species’ chapters.

3.2. Results

The strains were distributed to 889 laboratories participating in EARSS (in 2005) by UK-NEQAS and the laboratories were asked to report the clinical susceptibility categorization (S, I, R) according to the guideline used. Results were analyzed and considered ‘concordant’ if the reported categori-zation agreed with the interpretation of the reference laboratory. In table 3.1 the proportion of parti-cipating laboratories (n=741) returning reports is shown by country. The overall response rate was lower than in previous years (83%). It was the first time that results could only be reported via the internet website, which could have led to this lower response rate. There are still countries where not all laboratories have internet access. Belgium is a country in which more than 100 laboratories participate in EARSS, and always has a very high response rate. This year, unfortunately there was a distribution problem, caused by the local UK NEQAS distributor of the strains, which led to a lower response rate.

Overall, half of the participants used automated methods to identify the different strains. However, only a quarter of the participating laboratories identified the S. pneumoniae strain with an automated identification method. In figure 3.� the different methods used for the detection of antimicrobial susceptibility per country are shown. A third of the laboratories used a disc method, and 23% used automated MIC determi-nation. Another third of the laboratories used various methods (=multi) to determine antimicriobial

30 Chapter 3. External Quality Assessment ExerciseChapter 3. External Quality Assessment Exercise

susceptibility. The adherence to national or international guidelines by number of laboratories per country is shown in figure 3.2. Over the years the majority of laboratories has been using CLSI (68%).

3.2.1. Specimen 8563 Escherichia coliThis organism was susceptible to all reference agents tested except ampicillin, amoxicillin and piper-acillin (table 3.2). This is a common resistance phenotype in E. coli in Europe (33% of the isolates reported to EARSS in 2005) and is usually mediated by the TEM-1 b-lactamase. Nearly all partici-pants (99%) have correctly identified this E. coli strain. Of 646 participants that tested susceptibi-lity to ampicillin 97.5% reported resistance. Smaller numbers of participants tested amoxicillin and piperacillin, but incorrect reports were more common with only 89.3% and 81.4% reporting resi-stance respectively. Among the laboratories that used an automated method for their susceptibility

Table 3.1. Proportion of participating laboratories returning reports per country

Country Number of EQA samples sent

Number of returned reports

Percentage returned reports

Austria (AT) 36 35 97Belgium (BE)* 98 66 67Bulgaria (BU) 26 22 85Cyprus (CY) 5 3 60Czech Republic (CZ) 50 45 90Germany (DE) 22 19 86Denmark (DK) 15 12 80Estonia (EE) 11 11 100Spain (ES) 42 33 79Finland (FI) 14 11 79France (FR) 57 50 88Greece (GR) 46 32 70Croatia (HR) 27 24 89Hungary (HU) 26 24 92Ireland (IE) 44 35 80Israel (IL) 5 5 100Iceland (IS) 2 2 100Italy (IT) 50 41 82Lithuania (LT) 13 13 100Luxembourg (LU) 7 6 86Latvia (LV) 13 13 100Malta (MT) 1 1 100Netherlands (NL) 25 18 72Norway (NO) 11 10 91Poland (PL) 74 71 96Portugal (PT) 24 20 83Romania (RO) 37 31 84Sweden (SE) 22 20 91Slovenia (SI) 12 11 92Turkey (TR) 15 14 93United Kingdom (UK) 59 43 73

Total 889 741 83

* The low number of responders in Belgium is caused by a distribution problem.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Not specified Multi E-test MIC Disc Break Auto

AT BE BG CY CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LT LU LV MT NL NO PL PT RO SE SI TR UK

Country

Met

hod

of a

ntim

icro

bial

sus

cept

ibili

ty

Figure 3.1. Methods used for the detection of antimicrobial susceptibility per country.Multi, more than one method; disc, disc diffusion; break, breakpoints; auto, automated system.

0

10

20

30

40

50

60

70

80

SRGAOther/ Combination SFM NWGA CLSI DIN CRG BSAC

AT BE BG CY CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LT LU LV MT NL NO PL PT RO SE SI TR UK

Country

Num

ber

of la

bora

torie

s

Figure 3.2. Adherence to guidelines: number of laboratories per country.BSAC, British Society for Antimicrobial Chemotherapy; CRG, Commissie Richtlijnen Gevoeligheidsbepalingen; DIN, Deutsche Industrie Norm; NCCLS/CLSI, (American) National Committee for Clinical Laboratory Standards; NWGA, Norwegian Working Group on Antimicrobials; SFM, Comité de l’Antibiogramme de la Société Française de Microbiologie; SRGA, Swedish Reference Group for Antibiotics.


testing, the lowest proportion of piperacillin resistance was reported (�5%). There were no signifi-cant problems in susceptibility testing of other agents, with >97% participants correctly reporting the organism susceptible to other reference agents tested (table 3.2).

3.2.2. Specimen 8564 Klebsiella pneumoniaeThis organism produces an SHV-3 extended spectrum beta-lactamase (ESBL). SHV enzymes are the most common ESBLs found in K. pneumoniae. The ESBL confers resistance to all the b-lactam agents tested other than carbapenems (table 3.3). The strain was correctly identified by the vast ma-jority of laboratories (95%). Some of the laboratories that used a conventional method (n=20) did not further specify the Klebsiella species. Ceftazidime MICs were 32/64 mg/L, which was clearly resi-stant, and reports other than resistant (92.5%) or intermediate (6.7%) were uncommon. Cefotaxime MICs were lower (8-16 mg/L) and intermediate reports were more common (14.7%) although most laboratories reported resistance (83.7%). Results for ceftriaxone were similar to cefotaxime, with 10.2% intermediate reports and most laboratories reporting resistance (85.8%). Piperacillin/tazobac-tam MICs (64/128 mg/L) were borderline intermediate/resistant depending on the guideline followed and most reports were intermediate (26.7%) or resistant (70.5%). Among those participants that re-ported the result of an ESBL test, 98.4% reported a positive result (table 3.3). The organism was borderline susceptible to gentamicin, low level resistant to amikacin and resi-stant to tobramycin. This pattern of resistance to aminoglycosides is seen with strains producing the AAC(6’) aminglycoside modifying enzyme, although the enzyme is uncommon and has not been confirmed in this strain. The borderline susceptibility to gentamicin and amikacin was reflected in the reports by participants in that there was a fairly even spread of reports of susceptible, interme-diate and resistant for the organism. The laboratories that used a disc method to determine amikacin susceptibility reported the highest level of amikacin resistance (58%, compared to 39% overall), with tobramycin, 98% reported resistance (table 3.3).

3.2.3. Specimen 8565 Enterococcus faeciumThis organism contains the vanB resistance element, conferring resistance to vancomycin but not teicoplanin (table 3.4). Species identification was better performed by laboratories using automa-

Table 3.2. Escherichia coli (8673): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories.

Antibiotic agent MIC ref. labBSAC

MIC ref. labCLSI

Intended Interpretation [BSAC/CLSI)

Overall concordance

Amikacin 2 3 S 97%Ampicillin >128 >128 R 99%Ceftazidime 0.25 0.5 S 99%Cefotaxime 0.06 0.06 S 99%Ceftriaxone 0.094 0.125 S 99%Ciprofloxacin 0.015 0.015 S 100%Gentamicin 0.5 1 S 99%Imipenem 0.12 0.12 S 100%Meropenem <0,03 <0.03 S 100%Piperacillin >256 >256 R 81%Pip-Taz 1 2 S 98%Tobramycin 1.5 1.5 S 98%ESBL Neg. Neg. Neg. 99%

Neg., negative; ref. lab, reference laboratory


ted methods (97%) compared to conventional methods (90%). The lower concordance obtained via conventional methods was due to the fact that some of these laboratories did not further specify the species (n=11), but also because other species were reported (n=26). Resistance to vancomycin was reported by 97.8% of participants, and 96.8% concordantly reported the organism susceptible to tei-coplanin. High level gentamicin resistance was detected by 99% of participants (table 3.4).

3.2.4. Specimen 8566 Streptococcus pneumoniaeThe organism has reduced susceptibility to penicillin (MIC 0.5 mg/L). Overall, 97.8% participants reported resistance in the oxacillin screening test for reduced susceptibility to penicillin. The scree-ning test detects isolates with penicillin MIC >0.06mg/L (table 3.5). The results for penicillin did not only include the laboratories that screened with oxacillin and confirmed with a penicillin MIC, but also the results without confirmation and results from other methods were included. Overall, 58.9% concordantly reported the isolate as being of intermediate susceptibility to penicillin, with a further 38.7% that reported the isolate penicillin resistant.

Table 3.3. Klebsiella pneumoniae (8564): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories.


MIC ref. labCLSI

Intended Interpretation BSAC

Intended Interpretation CLSI

Overall concordance

Amikacin 32 48 R R 39%Ampicillin >128 >128 R R 100%Ceftazidime 32 64 R R 93%Cefotaxime 8 16 R R 84%Ceftriaxone 48 32 R R 86%Ciprofloxacin 128 64 R R 99%Gentamicin S/I S/I 72%

ref. Lab (1) 2 4ref. Lab (2) 4 8

Imipenem 0.25 0.5 S S 100%Meropenem 0.12 0.12 S S 99%Piperacillin >256 >256 R R 100%Piperacillin/Tazobactam

R I/R

ref. Lab (1) 128 64ref. Lab (2) >256 >256

Tobramycin 32 32 R R 98%ESBL Pos Pos Pos Pos 98%

Pos., positive; ref. lab, reference laboratory

Table 3.4. Enterococcus faecium (8565): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories.


MIC ref. labCLSI

Intended Interpretation BSAC/CLSI

Overall concordance

Ampicillin 64 64 R 100%High level Genta-micin

>512 >512 R 99%

Teicoplanin 0.5 0.5 S 97%Vancomycin >128 >128 R 98%


Participants were asked if they would use a norfloxacin screening test with this isolate; �49 partici-pants reported use of a �0ug disc and 32 used another unspecified method.Compared with fully susceptible strains MIC values for cefotaxime (0.25 mg/L) and ceftriaxone (0.25 mg/L) were increased (albeit still below the breakpoint). This may explain the lower concor-dance rates for cefotaxime (74.2%) and ceftriaxone (86.2%) (table 3.5).

3.2.5. Specimen 8567 Pseudomonas aeruginosaThis strain had reduced susceptibility to several b-lactam agents. Ceftazidime MICs were increased compared to wild type strains but still susceptible. Hence the high discrepancy rates (58.0% suscep-tible, 30.3% intermediate, 11.7% resistant) were not unexpected (table 3.6). Ceftazidim susceptibility was most often reported by laboratories using a disc method (73%). Piperacillin-tazobactam MICs of 64 mg/L will be interpreted as susceptible, intermediate or resistant depending on the guideline followed and reports were largely in line with breakpoints used. Overall, 53.0% reported susceptible, 13.8% intermediate and 33.2% resistant to piperacillin-tazobactam. There was >94% concordance in reports for other reference agents tested (table 3.6).

Table 3.5. Streptococcus pneumoniae (8566): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories.

Antibioticagent

MIC ref. labBSAC

MIC ref. labCLSI

Intended Interpretation BSAC/ CLSI

Overall concordance

Cefotaxime S/I* 74% (S)ref. Lab (1) 0.25 0.25ref. Lab (2) 0.75 1.5

Ceftriaxone 0.25 0.25 S 86%Ciprofloxacin >32 >32 R 97%Clindamycin >256 >256 R 86%Erythromycin 32 32 R 97%Oxacillin(screen disc)

- - R 98%

Penicillin 0.5 0.5 I 59%

Ref. lab, reference laboratory

Table 3.6. Pseudomonas aeruginosa (8567) : Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories.

Antibioticagent

MIC ref. labBSAC

MIC ref. labCLSI

Intended Interpretation BSAC

Intended Interpretation CLSI

Overall concordance

Amikacin 2 4 S S 95%Ceftazidime 8 8 S S 58%Ciprofloxacin 64 64 R R 99%Gentamicin >128 >128 R R 99%Imipenem 16 >16 R R 98%Meropenem 16 >16 R R 99%Tobramycin 128 >128 R 98%



3.2.6. Specimen 8568 Pseudomonas aeruginosaThis organism was susceptible to all reference agents tested (table 3.7). Overall concordance for non-b-lactam agents was >94%. For b-lactam agents there were more discrepancies, with concordance ranging from 83.1% for ceftazidime to 93.4% for meropenem. Laboratories that used an automated method or MIC test for their susceptibility testing of b-lactam agents, had a higher concordance with the reference laboratories than laboratories that used other methods.

3.3 Conclusions

This sixth EARSS EQA exercise has again illustrated that routinely reported results as collected by EARSS in most instances have sufficient accuracy to provide good estimates of overall resistance prevalences and trends. The EQA exercise does, however, also indicate the need for further calibra-tion and standardisation of methods in European routine susceptibility testing. EARSS MT would like to thank UK NEQAS, the reference laboratories, the members of the Advisory board, the country coordinators for the swift distribution of the strains, and all the participating laboratories.

Table 3.7. Pseudomonas aeruginosa (8568): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories.

Antibioticagent

MIC ref. labBSAC

MIC ref. labCLSI

Intended Interpretation BSAC/ CLSI

Overall concordance

Amikacin 1 4 S 97%Ceftazidime 1 2 S 83%Ciprofloxacin 0.25 0.5 S 97%Gentamicin 0.25 1 S 94%Imipenem I/S 83%

ref. Lab (1) 2 4ref. Lab (2) 8 8

Meropenem 0.25 0.25 S 93%Piperacillin/Tazobactam

2 2 S 89%

Tobramycin 0.25 0.25 S 99%


Chapter 4. Results of the EARSS laboratory/hospital questionnaire 2006

4.1. Introduction

In 2007, the fourth bi-annual questionnaire collecting laboratory and hospital background informa-tion was sent out to all laboratories participating in EARSS. The main purpose of this and former questionnaires was to collect updated denominator information. This information enables calcula-tion of incidence rates of antimicrobial resistance, next to proportions. Incidences of antimicrobial resistance are a more direct measure of the impact of antimicrobial resistance in a specific country, provided the data obtained are representative (2).Apart from denominator data, the questionnaire also collects reference information about the popula-tions for which laboratories provide their services. This information helps to understand the validity, i.e. representativeness and generalisability of the antimicrobial resistance data collected by EARSS. It is crucial for interpretation of the results and helps to understand differences in antimicrobial re-sistance proportions between countries as reported by EARSS. Antimicrobial resistance proportions may vary due to e.g. differences in blood sampling practices (1; 4), in case-mix (which is a determi-nant of hospital type) and available specialties (3; 5).

4.2. Methods

At the EARSS Plenary Meeting in May 2007 in Stockholm, it was decided to send out a new labo-ratory/hospital questionnaire. All EARSS national representatives received the questionnaire at the end of May. They distributed the digital Excel version or the paper version (translated if needed) to all participating laboratories in their country. Information was collected on the total number of blood culture sets processed in the laboratories and the number of hospital beds for each participat-ing hospital (both necessary for inclusion), the type of hospital and its specialties, the bed occupancy and the number of admissions. The national representatives returned all completed questionnaires to EARSS-MT. Details of the inclusion criteria and data-analysis are given in annex �. Country-specific results were returned to the national representatives for confirmation and adapted where required. In this chapter results of the descriptive analysis are discussed. Some of the results can also be found in the country-specific Country Summary Sheets (table � and figure � of annex 2).

4.3. Results

4.3.1. ParticipationCompleted questionnaires were received from 29 of 31 countries (94%) participating in EARSS, almost all in digital format (28 countries). In these participating countries, 483 of the 764 laboratories (63%) and 728 of the 1185 hospitals (61%) reporting AST results over 2006 provided the neces-sary denominator data (figure 4.�). The response is thus comparable to the response in 2005 (when respectively 93% of the countries, 64% of the laboratories and 61% of the hospitals participated), and higher than in 2003 (responses were 78%, 51% and 50%, respectively).

Chapter 4. Results of the EARSS laboratory/hospital questionnaire 2006 37 37

4.3.2. Population coverage The response suggested that EARSS participating hospitals care for at least 155 million European citizens (32% of the EU population; including accession countries and Israel). Bulgaria, Estonia, Finland, Iceland, Malta, and Slovenia reported total national coverage and Denmark, Ireland and Lithuania reported near to complete national coverage (>90%).However, coverage is certainly overestimated since catchment populations overlap in many coun-tries. On the other hand, coverage may be underestimated: for several countries only a small part of the hospitals participating in EARSS returned denominator data (table 4.1) and the calculated catch-ment population was only based on those responding hospitals. Thus, with few exceptions (Germany, Italy and Turkey) EARSS most likely collects information on AST results from at least 20% of the national population in all EARSS countries.

4.3.3. Hospital denominator informationThe total number of hospital beds for the hospitals reporting AST results and providing denominator data in the different countries ranged from 1,118 in Malta to 44,270 in Austria. The proportion of

38 Chapter 4. Results of the EARSS laboratory/hospital questionnaire 2006Chapter 4. Results of the EARSS laboratory/hospital questionnaire 2006

120 100 80 60 40 20 1400 120100806040200

UK

TR

SI

SE

RO

PT

PL

NO

NL

MT

LV

LU

LT

IT

IS

IL

IE

HR

FR

FI

ES

EE

DK

DE

CZ

CY

BG

BE

AT

Number of laboratories Number of hospitalsEARSS country code

denominator information

no denominator information

A B

Figure 4.1. Number of laboratories (A) and hospitals (B) reporting AST data in 2006 with or without providing denomi-nator data, per country.

ICU beds over total hospital beds per country was similar, ranging from 2-10%, which is a slightly broader range than that reported from former questionnaires. The proportion of psychiatry or long term care beds over total hospital beds per country had a wider range from 0-39% and is similar to the range reported for 2004. In table 4.1, the annual occupancy rate and the median length of stay per hospital are displayed as well. For most countries the annual occupancy rate exceeded 70%. Israel reported the highest annual occupancy rate. From the patient days and the number of admissions we derived the average length of stay per hospital, and determined the median length of stay per country. The length of stay in the different countries was quite similar and ranged from 3.5 to 9.7 days; being shortest in the United Kingdom and longest in Malta.


Table 4.1. Hospital denominator data for 2006*

Country code

Hosps providing denominator

data/reporting to EARSS

Total number of beds

Proportion of ICU

beds (%)

Proportion of P/LTC beds (%)

Annual occupancy

rate (%)

Median length of stay (days)

IQR length of stay (days)

Proportion of population covered (%)

AT 124/136 44,270 5 2 69 5.0 4.5-5.6 87BE 46/101 22,575 4 10 75 7.7 7.1-8.4 56BG 25/25 11,451 7 4 78 6.4 5.9-7.1 100CY 5/5 1,291 10 4 73 4.8 4.6-5.9 54CZ 68/87 43,992 9 12 78 7.6 6.8-8.9 81DE 22/31 14,633 4 4 83 8.0 7.3-9.2 2DK 30/71 10,519 3 8 88 4.7 4.1-5.7 94EE 13/13 5,523 7 21 76 6.5 6.1-7.1 100ES 27/36 16,684 4 6 83 7.7 7.0-9.9 19FI 14/15 11,031 2 9 86 4.8 0.9-5.5 100FR 16/128 20,965 6 18 78 8.2 6.7-10.1 n.a.HR 21/22 11,352 5 6 87 6.9 6.8-8.8 90IE 54/67 12,572 3 3 87 5.9 4.6-7.6 98IL 5/5 3,846 5 7 100 3.8 3.1-3.9 44IS 5/9 1,214 3 39 82 8.8 5.7-10.0 100IT 23/40 14,054 4 4 81 6.4 5.9-7.2 10LT 15/26 7,345 3 13 80 7.8 6.5-8.7 94LU 5/5 1,734 7 8 77 5.6 4.9-5.6 68LV 11/14 6,129 2 0 77 7.3 6.5-7.8 47MT 2/3 1,118 4 16 86 9.7 5.8-13.6 100NL 23/30 14,674 4 5 67 6.8 6.3-7.4 69NO 15/34 5,296 3 17 87 4.8 4.0-6.2 42PL 28/31 14,962 2 4 73 5.7 5.1-7.0 34PT 20/20 10,066 5 2 78 7.3 5.6-8.8 82RO 8/12 5,683 5 1 85 6.8 5.8-8.7 36SE 45/58 16,741 4 5 89 5.3 4.6-6.1 76SI 15/15 7,382 5 3 75 5.8 5.0-7.4 100TR 14/14 13,314 8 4 64 8.3 5.6-9.9 19UK 29/129 14,660 3 4 80 3.5 2.5-5.2 31

Total or median^

728/1,185 365,076 4^ 5^ 80^ 6.5^ 72^

ICU, intensive care unit; P/LTC, psychiatry or long term care facilities; IQR, Interquartile range; na, not available.

Length of stay may be influenced by several factors, such as case mix or hospital policy; in theory, increasing length of stay may increase the risk of acquiring nosocomial resistant strains. However, EARSS resistance rates were independent from the median length of stay.


Table 4.2. Hospital characteristics for 2006*

Country code

Hosps providing denom. data/reporting to

EARSS

Proportion of hospitals by level of care (%)**

Proportion of hospitals with specialists units (%)***

Tertiary level

Secondary level

Primary level

Other# Neonatal intensive

care

Burns Trans-plant

Hema-tology

Any of these

AT 124/136 24 24 52 0 12 2 3 7 15BE 46/101 35 54 11 0 26 2 15 46 48BG 25/25 64 20 4 12 40 16 16 36 72CY 5/5 20 20 40 20 40 40 0 40 60CZ 68/87 38 38 24 0 47 6 12 15 50DE 22/31 45 36 18 0 36 18 32 27 55DK 30/71 43 27 30 0 30 10 23 33 40EE 13/13 31 38 31 0 31 8 8 23 38ES 27/36 52 41 7 0 52 19 33 81 85FI 14/15 57 36 7 0 86 14 14 64 86FR 16/128 100 0 0 0 56 13 81 63 88HR 21/22 48 38 10 5 52 19 14 57 76IE 54/67 17 30 33 20 30 6 13 28 48IL 5/5 60 20 20 0 100 40 20 100 100IS 5/9 40 0 60 0 40 20 20 20 40IT 23/40 39 57 0 4 65 13 30 65 83LT 15/26 53 27 20 0 33 7 13 27 47LU 5/5 60 40 0 0 20 0 20 80 80LV 11/14 64 9 18 9 45 18 9 9 55MT 2/3 50 0 50 0 50 50 50 50 50NL 23/30 43 43 13 0 43 0 26 48 65NO 15/34 20 40 40 0 47 7 0 40 53PL 28/31 4 68 21 7 29 0 11 29 50PT 20/20 60 15 20 5 65 15 20 35 80RO 8/12 100 0 0 0 50 25 13 38 75SE 45/58 22 49 29 0 44 9 7 51 58SI 15/15 20 47 20 13 27 20 7 40 53TR 14/14 100 0 0 0 93 36 86 100 100UK 29/129 62 28 10 0 52 17 17 62 79

Total or median^

728/1,185 45^ 30^ 20^ 0^ 44^ 14^ 15^ 40^ 58^

*na, not available** for NO, RO and UK level of care was unknown for 1 hospital.*** for BE, DE, ES, FI, HR, IE, IT, NO, and UK, not all hospitals are included in the calculation of proportions as infor-mation about some specialties in a minority of hospitals was missing.# Other; other type of hospital than university, general hospital, or primary hospital, like a military hospital, or hospitals with any single specialty, like a burns unit.

4.3.4. Hospital characteristicsMost hospitals from countries that reported denominator information had intensive care units. In table 4.2 more characteristics of the hospitals in the different countries can be found. The proportions of types of hospital and types of specialized units varied between countries. All of the Israeli and Turkish hospitals participating in EARSS housed at least a haematology department, and all partici-pating hospitals in Israel also had a neonatal intensive care unit. In contrast, only 15% of the Austrian hospitals reporting to EARSS provided at least one type of specialist care, which is also reflected in the relatively high participation of small hospitals (see figure 4.2) providing secondary level of care. In general, countries approaching 100% population coverage tend to include relatively more small hospitals than countries with lower population coverage. Although differences in hospital characteristics not necessarily reflect differences in origin of EARSS blood cultures because hospitals may not evenly contribute to the EARSS database, it could result in differences in case-mix and may confound comparison of AST results between countries. The fact that definitions of care level may differ from country to country, complicates this picture even more. This year, we defined the level of care more specifically by including a description of the type of care provided as well as a range of beds. In figure 4.2, we also classified the hospitals according to size. The intertertile range for number of beds of all hospitals providing denominator data was determined and used as a classifier. In this figure, this range was the same as identified for 2004. Again differ-ences were found between countries.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hospitals > 500 beds Hospitals 301-500 beds Hospitals <=300 beds

EARSS country codes (responding/all hospitals)

Pro

port

ion

of h

ospi

tals

AT

(12

4/13

6)

BE

(46

/101

)

BG

(25

/25)

CY

(5/

5)

CZ

(68

/87)

DE

(22

/31)

DK

(30

/71)

EE

(13

/13)

ES

(27

/36)

FI (

14/1

5)

FR

(16

/128

)

HR

(21

/22)

IE (

54/6

7)

IL (

5/5)

IS (

5/9)

IT (

23/4

0)

LT (

15/2

6)

LU (

5/5)

LV (

11/1

4)

MT

(2/

3)

NL

(23/

30)

NO

(15

/34)

PL

(28/

31)

PT

(20

/20)

RO

(8/

12)

SE

(45

/58)

SI (

15/1

5)

TR

(14

/14)

UK

(29

/129

)

Figure 4.2. The proportion of small, medium and large hospitals per country, based on the intertertile range of number of beds, for all hospitals reporting both AST data and providing denominator data in 2006.

In most countries, all participating hospitals were publicly funded. In Austria (10%), Belgium (51%), Czech Republic (18%), Germany (43%), Finland (7%), Ireland (9%), Italy (5%), and Luxemburg (20%) a substantial part were private hospitals.

4.3.5. Laboratory denominator informationIn 2006, in total, 2,899,852 blood culture sets were processed in the EARSS laboratories responding to the questionnaire. The number of blood culture sets taken per 1000 patient days shows a much higher culturing rate in Israel (104.6), Finland (51.3) and Denmark (51.2), than in Romania (3.5). The median culturing frequency was 29.6 blood culture sets per 1000 patient days in 2006. Like in 2002 and 2004, the number of blood culture sets per 1000 patient days was highest in Is-rael. This could be related to the high level of specialization of the Israeli hospitals participating in EARSS (see table 4.2.). In contrast, the number of blood culture sets processed per 1000 patient days remained very low in Romania. The calculated blood culture rate for Austria was low compared to other central European countries, which is probably due to the practice of blood culturing commonly

Table 4.3. Laboratory denominator information for 2004.

Country code Labs providing denominator data/reporting to EARSS

Total number of blood culture sets

Number of blood culture sets per 1,000 patient days

AT 15/33 72,396 6.9BE 46/101 220,036 35.4BG 24/24 43,551 13.4CY 5/5 9,458 27.4CZ 48/48 148,292 12.6DE 10/17 71,715 18.9DK 8/15 187,623 51.2EE 10/10 15,796 10.4ES 25/36 201,440 43.1FI 14/15 176,805 51.3FR 16/125 300,210 50.2HR 20/20 52,722 14.3IE 34/39 166,994 45.1IL 5/5 148,569 104.6IS 2/2 11,793 34.8IT 24/40 132,837 29.6LT 10/13 13,234 4.1LU 5/5 11,633 24.2LV 11/11 15,409 9.3MT 1/1 5,406 15.4NL 17/23 145,074 41.5NO 10/12 97,717 45.4PL 28/30 29,582 7.0PT 20/20 84,851 29.7RO 8/12 7,668 3.5SE 21/21 221,513 40.6SI 11/11 38,610 19.1TR 14/14 124,830 33.8UK 21/56 144,088 38.1

Total or median^ 483/764 2,899,852 29.6^


executed in the hospitals: the blood culturing rate for Austria is in most instances based on the pro-portion of swabs that arrive in the laboratories, since many hospitals culture their blood samples at the wards and only send positive cultures to the laboratory, the blood culturing rate as reported by the laboratories is low.As in 2002 and in 2004, we again observed a tendency for higher culturing frequencies in western European countries compared to eastern European countries (table 4.3). However, there was no cor-relation between blood culturing rates and resistance proportions or incidences.

4.3.6. Incidence rates for MRSA blood stream infectionsTable 4.4 shows the incidence of MRSA blood stream infections. In contrast to resistance propor-tions, incidence rates provide patient-based risk estimates for the acquisition of health care-associ-ated MRSA bacteraemia. In the EARSS database, MRSA proportions and MRSA incidence rates correlate very well (Spearman rank correlation coefficient: 0.9, p<0.05).The comparability of MRSA proportions and incidence rates indicate that the resistance proportions as reported by EARSS (Chapter 5) are a good approximation of the incidence rates, and comparison of countries thus provides useful information. The median incidence taking the countries’ calculated incidences into account was 3.8 MRSA bacteraemias per 100,000 patient days, which was slightly lower than the incidence reported in 2004 (3.9). Variation in incidence rates over countries and years of reporting may be the result of various underlying factors, such as changes in blood culturing rate, changes in case-mix (the set of hospitals responding to the questionnaire in a country may vary over years), and real variation in incidence. Clearly, many other, partly unknown and undetermined fac-tors may play a role in the dynamics of MRSA incidence.

Table 4.4. Incidence of MRSA per 100,000 patient days in 2006, specified per country.

Country code Incidence of MRSA per 100,000 patient days (95% confidence interval)

Country code Incidence of MRSA per 100,000 patient days(95% confidence interval)

AT 1.5 (1.3 - 1.8) IT 7.2 (6.5 - 8.1)BE 3.8 (3.2 - 4.4) LT 0.8 (0.5- 1.3)BG 1.4 (1.1 - 1.8) LU 3.1 (1.9 - 4.9)CY 5.8 (3.8 - 8.2) LV 1.8 (1.3 - 2.5)CZ 1.6 (1.4 - 1.8) MT 17.0 (14.3 - 19.4)DE 1.1 (0.8 - 1.6) NL 0.5 (0.3 - 0.8)DK 0.2 (0.1 - 0.5) NO <0.2#EE 0.3 (0.1 - 0.8) PL 1.0 (0.7 - 1.3)ES 6.3 (5.7 - 6.9) PT 26.9 (25.4 - 28.4)FI 0.8 (0.6 - 1.2) RO n.a.FR 8.6 (8.0 - 9.3) SE 0.3 (0.2 - 0.5)HR 4.6 (4.0 - 5.3) SI 1.3 (0.9 - 1.9)IE 14.6 (13.7 - 15.5) TR 9.4 (8.6 - 10.3)IL 14.1 (12.7 - 15.7) UK 12.5 (11.6 - 13.4)IS <0.9# Median 3.8

n.a, not available; the Romanian hospitals providing denominator and AST data did not report the number of patient days.# Iceland and Norway did not report MRSA in 2006, therefore a detection limit for MRSA was calculated based on the number of patient days and the number of Staphylococcus aureus isolates reported over 2006 (see annex 2).


4.4. Conclusions

As in 2004, the response to this years’ laboratory/hospital questionnaire was high, which validates the applicability of the results presented in this chapter to all EARSS laboratories and hospitals.In general, national population coverage is high and greater than 20%, which is considered adequate. Hospital characteristics varied between countries, particularly the distribution of types of hospitals and the proportion of hospitals providing specialist care. Although assigning unambiguous and com-parable levels of care to hospitals in different countries is complicated, this variation could indicate a difference in case mix between countries, which may confound resistance rates.As reported before, there was large variation in the frequency of blood culturing over the countries. In theory, blood culturing frequency may be related to resistance proportions, as a low frequency of taking blood cultures may lead to an overestimation of resistance rates. However, no correlation be-tween these determinants was found. On the contrary, resistance proportions were highly correlated with the resistance incidence rates. Resistance proportions thus are useful to compare countries, although resistance incidence rates might be more relevant in terms of estimating the impact of the resistance problem. In conclusion, the resistance proportions provided by EARSS in 2006 seem valid and comparable between countries. Nevertheless, denominator data remains important for under-standing differences in antimicrobial resistance proportions between countries.

4.5. References

1. Bouza E, Pérez-Molina J, Munoz P. Report of ESGNI-001 and ESGNI-002 studies. Bloodstream infections in Europe. Clinical Microbiology and Infections 1999: 2S1-2S12.

2. Monnet DL, Frimodt-Moller N. Only percentage within species; neither incidence, nor prev-alence: demographic information and representative surveillance data are urgently needed to estimate the burden of antimicrobial resistance. Int J Antimicrob Agents 2004; 24: 622-3; author reply 623-4.

3. NNIS system. National Nosocomial Infections Surveillance (NNIS) System Report, data sum-mary from January 1992 through June 2004, issued October 2004. American Journal of Infection Control 2004; 32: 470-485.

4. Tiemersma EW, Bronzwaer SL, Lyytikainen O, Degener JE, Schrijnemakers P, Bruinsma, Skov R, Monen JC, Grundmann H. Methicillin-resistant Staphylococcus aureus in Europe, 1999-2002. Emerg Infect Dis 2004; 10: 1627-34.

5. Voss A, Milatovic D, Wallrauch-Schwarz C, Rosdahl VT, Braveny I. Methicillin-resistant Staphylococcus aureus in Europe. Eur J Clin Microbiol Infect Dis 1994; 13: 50-5.


Chapter 5. Antimicrobial resistance in Europe

5.1 Introduction and methods

This chapter provides an overview of the EARSS data in 2006 and the trends of antimicrobial re-sistance in Europe. For eight years, EARSS has been collecting antimicrobial susceptibility data of invasive isolates with clinical and epidemiological importance. For each pathogen the clinical and epidemiological relevance, major resistance mechanisms, the data and trends of antimicrobial resist-ance until 2006 will be described. To exclude possible biases in the trend analyses, a sensitivity analysis was done, per country, to determine the sensitivity of the trend analysis for using the complete dataset versus a subset from laboratories reporting all years (selected laboratories). If the trends in the subset and the complete da-taset were contradictive, these trends were discussed in the text. However, if both datasets indicated a similar trend, we included this; i) in the text, when significant trends were only identified in the subset of data, ii) in the graphs by an arrow with asterisk, when significant trends were only identified in the com-plete dataset, iii) in the graphs by an arrow when a significant trend was detected in both the subset and the com-plete dataset.More information on the statistical methods and the inclusion criteria for the different analyses and figures can be found in annex �.

5.2. Streptococcus pneumoniae

5.2.1. Clinical and epidemiological importance Streptococcus pneumoniae is a common cause of disease, especially among young children, elderly people and patients with immunodeficiencies. The clinical spectrum ranges from upper airway infec-tions such as sinusitis and otitis media, to pneumonia and invasive disease meningitis, and sepsis (1). Since S. pneumonia is the most common cause of pneumonia worldwide, morbidity and mortality are high and annually approximately 3 million people die of pneumococcal infections (50). Pneumococci carry a wide variety of virulence factors that facilitate adherence to and invasiveness of host tissues. The cell wall of pneumococcal cells is coated with a viscous slime layer termed the polysaccharide capsule. This is the most important virulence factor, because it protects the bacteria from destruction by leucocytes (43). Capsular polysaccharides are highly diverse and play an im-portant role in immune evasion. Around 80 different serotypes have been described. The serotype distribution varies with age, disease and geographical region (16-18). Interestingly, serotypes most frequently involved in pneumococcal disease in infants are also most frequently associated with an-timicrobial resistance (40;46).

Resistance mechanisms. Beta-lactam antibiotics bind to cell wall synthesizing enzymes, penicillin-binding proteins (PBPs) and interfere with the biosynthesis and remodelling of the bacterial cell wall during cell growth and division. The mechanism of penicillin resistance in S. pneumoniae consists of alterations in P�Ps, which results in reduced affinity to this class of antibiotics. Alterations in P�Ps develop in a stepwise fashion which causes different degrees of resistance proceeding from low-level resistance – conventionally termed intermediate (I) to full clinical resistance (R). Although interme-

Chapter 5. Antimicrobial resistance in Europe 45 45

diately resistant strains are clearly less susceptible than sensitive strains, in absence of meninigitis, infections with these strains are often successfully treated with high doses of penicillin or alternative beta-lactam compounds (10;14). Macrolide, Lincosamide and Streptogramin (MLS) antibiotics are chemically distinct, but all bind to the ribosomal 50S subunit. In S. pneumoniae two resistance mechanisms against MLS antibiotics have been reported: i) The acquisition of an erythromycin ribosomal methylation gene (erm) results in a posttranscriptional modification of the 23S ribosomal RNA, which blocks the binding of the macrolide to the ribosome. Once expression of the gene is induced, this often results in high-level resistance (MICs>128 mg/L) to macrolide, lincosamides and streptogramin B, termed MLSB resist-ance (44;4�). ii) The acquisition of a macrolide efflux system gene (mefE) results in pumping of the antimicrobial drug out of the cell via an efflux system, and is effective against erythromycin, azithro-mycin and clarithromycin (24). In contrast to beta-lactam resistance, macrolide resistance via these mechanisms is absolute, and cannot be overcome by increasing the dosages of antibiotics (23). Since S. pneumoniae is the most frequent cause of community-acquired pneumonia and can clini-cally not easily be distinguished from airway infections caused by other pathogens, empirical treat-ment of community-acquired lower respiratory infections needs to be active against pneumococci and should take the local prevalence of antimicrobial resistance into account. Reports on widespread beta-lactam resistance therefore engender the habitual prescription of non-beta-lactam compounds in countries where penicillin resistance has been frequently reported. Such reactive prescribing in-creases the selection pressure for alternative antibiotics such as macrolides and novel fluoroquinolo-nes. It is therefore no surprise to see a dynamic antimicrobial resistance picture emerge in different European countries.

5.2.2. Streptococcus pneumoniae resistance trends: 1999-2006

Penicillin In 2006, 950 of the 10,351 S. pneumoniae isolates were non-susceptible to penicillin in 30 countries. Penicillin non-susceptibility shows a heterogeneous picture in Europe, although most northern coun-tries had levels of non-susceptibility below 5%, Belgium (10%, n=1,427), Finland (12%, n=493) and Ireland (16%, n=406) reported relative high levels. In southern Europe, on the other hand, Bulgaria (n=29), Italy (n=260) and Malta (n=30) reported a relatively low level of 7% penicillin non-suscep-tible S. pneumoniae isolates, while Cyprus (n=13), France (n=371), Israel (n=223), Romania (n=29) and Spain (n=624) reported a proportion of more than 25% PNSP.

The level of penicillin non-susceptibility in Finland (PNSP), Italy (PNSP), Slovenia (PRSP) and Sweden (PNSP and PRSP) was significantly rising, although for Italy, when taking into account the selected laboratories, only a borderline significant rising trend could be detected. Decreasing trends were detected in Belgium (PNSP), France (PNSP), Spain (PNSP and PRSP) and the UK (PNSP and PRSP). (figure 5.� and 5.4, annex 3.�)

ErythromycinIn the EARSS database, 9,665 S. pneumoniae isolates had susceptibility results for erythromycin in 2006 (93% of all isolates). From the 30 countries reporting data, 1,584 isolates were reported non-susceptible to erythromycin. Five countries spread over North-, East- and Central-Europe reported erythromycin non-susceptibility below 5%. Most countries, however, had resistance proportions be-tween �0 and 25%. Of these �6 countries, five showed a significant increase in erythromycin resist-ance. Especially in Finland (1999: 6%, n=214; 2006: 24%, n=493) and Turkey (2003: 7%, n=105;

46 Chapter 5. Antimicrobial resistance in EuropeChapter 5. Antimicrobial resistance in Europe


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.1. Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2006. * These countries did not report any data or reported less than 10 isolates.

2006: 16%, n=90) this increase was pronounced. The proportion of isolates resistant to erythromycin in Spain was significantly decreasing. �elgium (3�%, n=�,42�), Cyprus (3�%, n=�3), France (36%, n=370), Italy (32%, n=233), Luxemburg (36%, n=22) and Malta (47%, n=30) reported over 30% erythromycin resistance in S. pneumoniae isolates in 2006. Promisingly, the erythromycin resistance in France was significantly decreasing (200�: 49%, n=�,33�; 2006: 36%, n=3�0) (figure 5.2 and 5.5, annex 3.1.)

Dual resistance to penicillin and erythromycinFor 16 of the 30 countries, dual resistance remained below 5%, for eight countries the level of resist-ance was between 5-10% and four countries reported between 10-20% in 2006. The highest dual resistance was found in France (26%, n=370) and Cyprus (23%, n=13). Among the low endemic countries, UK showed a continuously, significantly decreasing trend, on the other hand the dual resistance in The Netherlands has tripled in seven years time. Of the coun-tries with resistance levels between 5-10%, Belgium showed a drop in 2003 that remained present up till 2006. In Finland the dual resistance has been on the rise for a few years now and has almost doubled from 2005 to 2006 (from 5%, n=632; to 9%, n=491). Dual resistance in Ireland seems to be increasing, although this was only found in the overall data, not in the data from the selected labora-tories. Spain, one of the countries with a relatively high proportion of dual resistance, has reported a persistent significantly decreasing trend. For Italy the dual resistance seemed to be decreasing as well, although this was only found significant for the selected laboratories. In Israel dual resistance seemed to increase, but again this was only significant for the selected laboratories (figure 5.3, 5.6 and annex 3.1.).


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.2. Streptococcus pneumoniae: proportion of invasive isolates resistant to erythromycin in 2006. * These countries did not report any data or reported less than 10 isolates.

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.3. Streptococcus pneumoniae: proportion of invasive isolates with dual resistance to erythromycin and penicillin in 2006. * These countries did not report any data or reported less than 10 isolates.


*

2004LV (30)

1999NO (490)

1999NL (817)

2001EE(656)

1999SE (889)

2000CZ (163)

1999UK (902)

2000DK (718)

2000LU (34)

2000AT (170)

1999DE (200)

1999IT (230)

1999IS (44)

2002BG (30)

1999BE (1244)

1999FI (414)

1999IE (306)

1999PT (150)

2001HU (110)

2001HR (91)

2003TR (117)

2000SI (144)

2000ES (656)

2001FR (896)

2001IL (196)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of

isol

ates

rep

orte

d pe

r ye

ar)

& y

ear

of s

tart

sur

veill

ance

#

Intermediate resistant

Fully resistant

0 5 10 15 20

% penicillin non-susceptible S. pneumoniae

25 30 35 40 45 50

Non-susceptible*

*

*

Figure 5.4. Streptococcus pneumoniae: trends of penicillin non-susceptibility by country, 1999-2006. Only the countries that reported 20 or more isolates per year were included. The arrows indicate the significant trends observed for the pro-portion of PNSP (black arrows) or full penicillin resistance (red arrows). The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all eight years. # Either the first year of surveillance or the first year with 20 or more isolates reported.


2001EE (29)

1999SE (751)

2000CZ (156)

2000DK (718)

2000NL (671)

1999IS (42)

1999UK (824)

1999DE (157)

1999NO (341)

2000AT (141)

2000SI (134)

1999IE (268)

2003TR (108)

2001HR (61)

2001IL (190)

2001HU (101)

2004PT (182)

2000ES (630)

1999FI (388)

1999BE (1244)

1999IT (202)

2001LU (35)

2001FR (896)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of

isol

ates

rep

orte

d pe

r ye

ar)

#

1999

2000

0 5 10 15 20

% erythromycin resistant S. pneumoniae

25 30 35 40 45 50

2001

2002

2003

2004

2005

2006

*

*

*

Figure 5.5. Streptococcus pneumoniae: trends of erythromycin resistance by country, 1999-2006. Only the countries that reported 20 or more isolates per year were included. The arrows indicate statistically significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all eight years. # Either the first year of surveillance or the first year with 20 or more isolates reported.


2001EE (29)

1999NO (341)

1999SE (751)

2000DK (718)

2000NL (671)

2000CZ (156)

1999DE (157)

1999UK (824)

2000AT (141)

1999IS (42)

2001LU (35)

1999IT (202)

2000SI (134)

1999IE (268)

1999BE (1244)

2001HR (61)

2003TR (108)

1999FI (388)

2001HU (101)

2004PT (182)

2000ES (630)

2001IL (190)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of

isol

ates

rep

orte

d pe

r ye

ar)

& y

ear

of s

tart

sur

veill

ance

#

0 5 10 15 20

% dual resistance

25 30 35 40 45 50

*

1999

2000

2001

2002

2003

2004

2005

2006

Figure 5.6. Streptococcus pneumoniae: trends of dual resistance to penicillin (intermediate and resistant) and erythromycin by country, 1999-2006. Only the countries that reported 20 or more isolates per year were included. The arrows indicate statistically significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all eight years. # Either the first year of surveillance or the first year with 20 or more isolates reported.

5.2.3. SerotypesFor three years, EARSS has now collected serogroup information for S. pneumoniae. In 2006, eleven countries provided serogroup data. In the data from Belgium, Czech republic, Denmark, Iceland, and Slovenia more than 90% of all S. pneumoniae isolates had serogroup information. For Austria, Ireland and the United Kingdom these proportions were 40%, 15% and 77%, respectively. Since the serogroup information from these countries did not seem to be selectively reported for more resist-ant isolates, we report these data as well. For Bulgaria, Germany and The Netherlands the serogroup information was confined to less than 8% of the isolates and this data is therefore not shown. (table 5.1)The distribution of serotypes as well as the resistance within serogroups varies considerably between countries. Nevertheless, serogroup 1 and 14 seemed to be highly prevalent in almost all countries. In Belgium and the UK most different serogroups were found, respectively 30 and 28. In Ireland and Iceland, both islands and especially Iceland relatively small and isolated, respectively, only 15 and �4 different serogroups were detected. In Iceland serogroup 23 is mostly identified, whereas in other countries this serogroup is not very common.The high erythromycin resistance in serogroup 1, which is exclusive for Belgium, was already iden-tified in 2005 and is still present. The high dual resistance of 46% in serogroup �4 is also mostly pronounced in Belgium.

Figure 5.7 illustrates the distribution of serogroups for all isolates reported in 2006. The illustration does not reflect the serogroup distribution in Europe as a whole, as only eleven countries reported serogroup information and Belgium, Denmark and the UK each reported around 1000 isolates and are therefore overrepresented in this graph.Interestingly, resistance seems to be confined to few serogroups; for penicillin resistance these in-clude 14, 9, 19, 6 and 23, erythromycin resistance is also prevalent in serogroups 1 and 33. Among the other serogroups, resistance to penicillin or erythromycin is rare, nevertheless these serogroups


0%

2%

4%

6%

8%

10%

12%

14%

Serogroups

Pro

port

ion

1 14 9 19 3 6 7 23 4 8 18 12 22 15 33 5 11 10 20 oth

Fully susceptible*

Single erythromycin resistance

Dual resistance

Single penicillin resistance

Figure 5.7. The distribution of serogroups and the resistance profile (single erythromycin, single penicillin or dual resistance) per serogroup of S. pneumoniae isolates in the EARSS database, in 2006. Only countries that reported serogroup information for more than 30 isolates (Austria, Belgium, Czech Republic, Denmark, Ireland, Iceland, Slovenia and the United Kingdom) were included in this figure. * Susceptible to at least penicillin and erythromycin.


Tabl

e 5.

1. D

istri

butio

n of

sing

le p

enic

illin

, sin

gle

eryt

hrom

ycin

and

dua

l pen

icill

in-e

ryth

rom

ycin

resis

tanc

e am

ong

the

mos

t com

mon

sero

grou

ps r

epor

ted

to E

AR

SS p

er c

oun-

try

in 2

006.

Onl

y co

untr

ies r

epor

ting

mor

e th

an 3

0 iso

late

s wer

e pr

esen

ted.

Serogroups

Aus

tria

(n=8

6)B

elgi

um

(n=1

420)

Cze

ch re

publ

ic(n

=155

)D

enm

ark

(n=8

71)

Irel

and

(n=5

7)Ic

elan

d(n

=51)

Slov

enia

(n=1

57)

Uni

ted

Kin

gdom

(n=1

161)

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

% of total

% PNSP

% ENSP

% dual

116

00

013

035

05

00

0na

11

011

00

06

00

010

00

015

00

03

80

00

80

10

130

00

na2

20

90

00

60

00

190

00

50

00

414

00

04

02

07

00

0na

00

011

00

012

00

07

00

07

00

05

10

00

40

00

0-

--

na0

00

0-

--

0-

--

0-

--

00

00

67

033

177

945

125

00

0na

34

411

170

5012

00

173

020

208

26

77

60

00

80

20

30

00

na0

00

50

00

100

00

40

00

60

00

82

00

04

00

08

08

0na

00

05

00

00

--

-2

00

06

01

09

814

140

72

469

1310

55

na10

30

1183

00

1233

00

842

178

94

42

102

050

02

04

04

00

0na

170

04

00

00

--

-0

--

-1

00

011

10

100

51

011

02

00

0na

70

00

--

-0

--

-1

00

01

00

012

20

00

30

00

20

00

na0

00

0-

--

0-

--

0-

--

42

00

1415

038

010

642

4610

00

0na

434

19

2080

08

010

00

1546

2113

141

622

150

--

-2

77

34

00

17na

00

02

00

04

00

01

00

01

00

018

20

00

30

00

30

00

na5

00

50

00

20

00

30

00

40

20

196

00

011

762

107

00

0na

60

47

00

02

00

08

3333

177

09

820

0-

--

00

00

10

00

na0

00

0-

--

0-

--

10

00

10

00

220

--

-3

00

21

00

0na

00

04

00

02

00

05

00

02

00

023

70

330

63

75

60

110

na4

00

70

00

220

00

60

00

613

30

331

00

01

050

00

--

-na

013

02

00

02

00

02

330

01

00

0ot

her

0-

--

40

52

70

00

na0

00

0-

--

20

00

30

013

33

30

tota

l10

01

141

100

224

710

01

21

na3

51

100

127

510

04

82

100

138

510

02

101

are also quite prevalent among invasive isolates. The 7-valent conjugate vaccine covers all sero-groups with penicillin resistance, but in contrast to the 23-valent vaccine, it does not cover serogroup 1 and 33 in which erythromycin resistance is quite common.

5.2.4. ConclusionsThe resistance profile of S. pneumoniae has a dynamic character. Although penicillin resistance is still increasing in Sweden and Finland, in most countries penicillin resistance is quite stable or even on the decrease. This might be due to a decreasing selection pressure. Erythromycin resistance, however, is becoming more prevalent in quite a few countries, independent of the national resistance level. Nevertheless, in Spain and France a significant decrease in erythromycin resistance of S. pneu-moniae isolates could be observed.This year more countries have reported serogroup information, although for some countries the pro-portion of isolates with typing information was still very low. From the overview of prevalent sero-types, it becomes evident that serogroup 1 and 14 are highly prevalent in most countries. The highest proportions of resistance were identified in serogroups 6, 9, �4, �9, 23, �, 33, of which the first five are represented in the 7-conjugate vaccine and all seven in the 23-valent vaccine. Belgium reported distinctive resistance within serogroup 1 and 14. Since McCormick et al. (29) showed that the vari-ation in antimicrobial resistance of S. pneumoniae isolates is best explained by differential selection pressure for resistance, rather than by the spread of specific clones, this could be related to high con-sumption of penicillin and erythromycin in this region.

5.3. Staphylococcus aureus

5.3.1. Clinical and epidemiological importanceStaphylococcus aureus is a gram-positive bacterium that colonizes the anterior nares of about 30% of healthy humans. Although mainly a harmless coloniser, S. aureus can cause severe infection. Its oxacillin-resistant form (methicillin-resistant S. aureus, MRSA) is the most important cause of antibiotic-resistant health care-associated infections worldwide (26). Since health care-associated MRSA infections add to the number of infections caused by methicillin-susceptible S. aureus, a high incidence of MRSA adds to the overall burden of infections caused by this species in hospitals (20). Moreover, infections with MRSA may result in prolonged hospital stay and in higher mortality (7), owing mainly to the increased toxicity and limited effectiveness of alternative treatment regimens. MRSA is currently the most commonly identified antibiotic-resistant pathogen in hospitals in many parts of the world, including Europe, the Americas, North Africa and the Middle- and Far-East.

Resistance mechanisms S. aureus acquires resistance to methicillin and all other beta-lactam anti-biotics through the horizontal transfer of a large gene cassette termed SCCmec and the expression of its mecA gene, that codes for a variant penicillin binding protein P�P2’ (P�P2a) with low affinity to beta-lactams, (2�). The level of methicillin resistance (defined by its minimum inhibitory concen-tration, MIC) depends on the amount of P�P2’ production, which is influenced by various genetic factors. Resistance levels of mecA-positive strains can thus range from phenotypically susceptible to highly resistant (5). Upon challenge with methicillin, a population of a heterogeneously resistant MRSA strain may quickly be outgrown by a subpopulation of highly resistant variants.

Glycopeptide antibiotics include vancomycin and teicoplanin. Both are very large molecules that through binding to the terminal amino acid residues (D-alanyl-D-alanine) of the peptide side chains



in the growing peptidoglycan polymers inhibit the cross linking essential for cell wall stability. It is estimated that to block cell wall synthesis effectively, the glycopeptide antibiotic has to penetrate about 20 peptidoglycan layers, all with free D-alanyl-D-alanine residues, without being ‘trapped’, and this together with a poor penetration into infected tissues, limits the therapeutic effects of glyco-peptides. Cell wall thickening of S. aureus thus increases its ability to resist vancomycin, and in S. aureus most strains with reduced vancomycin susceptibility have a markedly thicker cell wall (21). Vancomycin resistance is far more prevalent among enterococci, owing to different genetic resist-ance determinants.

5.3.2. Staphylococcus aureus resistance trends: 1999-2006

Beta-lactamsIn 2006, 31 countries reported AST results of 29,552 invasive S. aureus isolates to EARSS, of which almost a quarter (n=�,03�) were identified as MRSA isolates. From the EARSS database it is known that at least half (n=3,9��) of these MRSA isolates were confirmed by oxacillin MIC, PCR mecA-gene, or PBP2A-agglutination.Almost half of the countries (n=15) reported MRSA proportions higher than 25%. Like previous years, all southern countries, the United Kingdom and Ireland could be included in this category. With a statistically significant and continuing increasing trend Hungary went from �9% (n=�083) in 2005, to more than 25% (n=1127) MRSA in 2006. In France the MRSA proportions are still on the decrease and this year the MRSA proportions in Cyprus and Turkey show a significant decrease as well. An apparent decrease in Italy is explained by consecutive changes among the enrolled laborato-ries during the last six years and unfortunately does not reflect a true trend. Six countries had propor-tions of over 40%, of which Portugal and Malta showed a significant increase and Greece and Ireland reported relatively stable MRSA proportions. MRSA rates in the UK stabilised in the last few years and seemed to decline in 2006. In two high endemic countries sensitivity analysis identified contra-dictory trends: In Greece only the selected laboratories showed a significant decrease, which was not confirmed by the overall trend, while in Spain the selected laboratories reported a significant increas-ing trend, when overall no trend could be detected. These differences are caused by changes in the national EARSS networks over the years. In central Europe, most countries have MRSA proportions between �-22%. Slovenia reported a significant decreasing trend, the MRSA proportions changed from 10% (n=349) in 2005 to 7% (n=365) in 2006. In Austria the MRSA proportions seem to de-crease as well, however this was only found for the selected laboratories. The MRSA proportions in the Czech Republic and Germany seem to stabilise, although this is not indicated in the trends yet.In the northern part of Europe, MRSA rates are still below 4%. However, the increase identified in The Netherlands and Finland last year, still continues. In Denmark the overall increase was not confirmed by the selected laboratories and was therefore not included in the figure. The MRSA rates of Estonia, Iceland, Norway and Sweden remain relatively stable. For the first time the MRSA proportions in �elgium seem to decrease, however no significant trend can be discerned as yet (figure 5.8, 5.9).

Glycopeptides/vancomycinOverall, nine VISAs and one confirmed VRSA were reported to the EARSS database in 2006. Five countries reported vancomycin intermediate resistant S. aureus: Austria (n=1), Belgium (n=2), France (n=1), Ireland (n=1) and United Kingdom (n=4). Austria also reported one invasive S. aureus isolate resistant to vancomycin, with an MIC that was only slightly above the clinical CLSI breakpoint of 16 mg/l. All of these VISA/VRSA isolates were confirmed by NRL.

5.3.3. MRSA by hospital departmentS. aureus susceptibility data reported to EARSS come from different hospital departments. Across the national EARSS networks, 5-36% of the invasive S. aureus isolates are isolated from ICU pa-tients. MRSA strains are more frequently isolated from ICU patients than non-ICU patients, and therefore country-specific differences in enrolment of isolates from ICU patients could confound the comparability of the overall MRSA proportions.In 27 of 30 countries the MRSA proportions in ICU were higher and in thirteen countries this differ-ence was significant. However, the overall effect of ICU-specific MRSA rates remained negligible (figure 5.�0) and this is due to the low number of isolates originating from the ICU. In some countries, Croatia (n=317), Greece (n=693), Ireland (n=543), Malta (n=64), Turkey (n=674), the proportion of MRSA found among ICU patients was over 60%. This high level seems to be restricted to the ICU and could be due to an overrepresentation of isolates from highly specialized ICU’s with very vulnerable patients. However, in Malta the problem does not seem to be restricted to the ICU; the proportion MRSA in non-ICU isolates is also very high.In three countries, Belgium, Lithuania and Romania, the MRSA proportions in ICU-isolates were lower than in the non-ICU isolates.

5.3.4. ConclusionsMRSA is still an increasing problem all over Europe, it continues to spread in high, medium as well as low endemic countries. Nevertheless, some of the high endemic countries seem to have stabilizing MRSA proportions. Next to that, there have been promising trends in France and Slovenia already for


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.8. Staphylococcus aureus: proportion of invasive isolates resistant to oxacillin (MRSA) in 2006. * These countries did not report any data or reported less than 10 isolates.


1999IS (64)

1999NL (1591)

1999SE (1967)

1999NO (558)

1999DK (1032)

2001EE (94)

2000SI (294)

1999FI (756)

2000AT (930)

2004LV (55)

2000CZ (1237)

1999LU (89)

2001PL (162)

2001HU (686)

1999BE (1057)

1999DE (1149)

2000ES (1255)

2000BG (139)

2001FR (2248)

2003CY (26)

2001HR (275)

1999IT (1288)

2003TR (429)

2001IL (393)

1999UK (2916)

1999IE (1149)

1999GR (581)

2002RO (61)

1999PT (877)

2000MT (90)

Cou

ntry

cod

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isol

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rep

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& y

ear

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tart

sur

veill

ance

#

0 10 20 30 40

% MRSA

50 60 70 80 90

*

1999

2000

2001

2002

2003

2004

2005

2006

Figure 5.9. Staphylococcus aureus: trends of methicillin-resistance by country 1999-2006. Only the countries that reported 20 isolates or more per year and reported at least three years were included. The arrows indicate significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all eight years. # Either the first year of surveillance or the first year with 20 or more isolates reported.


Cou

ntry

cod

e (n

umbe

r of

non

-IC

U/IC

U is

olat

es)

non-ICU

ICU

0 10 20 30 40

% MRSA

50 60 70 80

Overall MRSA proportion

IS (54/3)

NO (674/51)

SE (1845/121)

NL (646/129)

EE (108/44)

FI (489/24)

SI (327/38)

AT (1469/156)

LT (122/45)

CZ (1147/363)

LV (126/42)

LU (37/21)

PL (156/18)

DE (569/204)

BE (636/138)

HU (916/205)

ES (1271/187)

FR (3144/641)

BG (128/31)

CY (45/17)

HR (317/74)

TR (674/118)

IT (769/141)

IL (473/38)

UK (2746/347)

IE (543/62)

GR (693/95)

PT (1205/96)

RO (42/14)

MT (64/20)

*

*

*

**

*

*

**

*

**

*

Figure 5.10. Staphylococcus aureus: proportion MRSA in ICU versus other hospital departments by country in 2006. �etween brackets the number of isolates from non-ICU/ICU departments. The stars indicate a significant difference between the ICU and non-ICU MRSA proportions.

the past six years, and now we have also found decreasing MRSA trends in Cyprus and Turkey. This indicates that improved control efforts can still reverse the increasing MRSA problem in hospitals, even in high endemic countries.

5.4. Enterococci

5.4.1. Clinical and epidemiological importanceEnterococci belong to the residential flora of the gastrointestinal tract of humans, other mammals, birds and reptiles. Under normal circumstances they are harmless commensals, and are even believed to have positive effects on a number of gastrointestinal and systemic conditions (4;13;31). However, when the commensal relationship with the host is disrupted, enterococci can cause invasive disease (25). Though not as virulent as other gram-positive organisms, enterococci can cause a variety of clinical syndromes including endocarditis, bacteremia, meningitis, wound and urinary tract infec-tions and are associated with peritonitis and intraabdomial abscesses. In the USA, three to four no-socomial bloodstream infections per 10,000 hospital discharges are caused by enterococci (3), and contribute to patient mortality as well as additional hospital stay (27).The vast majority of clinical enterococcal infections in humans are caused by Enterococcus faecalis in around 80% of clinical isolates and Enterococcus faecium in most of the remainder (22). Epide-miological data collected over the last two decades have documented the emergence of enterococci, and in particular E. faecium, as important nosocomial pathogens, which is seen as the expansion of a major hospital adapted clonal lineage (CC17) (45). The emergence of E. faecalis and E. faecium was paralleled by the increase glycopeptide and high-level aminoglycoside resistance both both impor-tant compounds for the treatment of human infections (41). Besides the fact that infections with these resistant enterococci are difficult to treat, they are highly tenacious and thus disseminate and spread between patients in the hospital setting easily.

Resistance mechanisms. Enterococci are intrinsically resistant to a broad range of antibiotics including cephalosporins, penicillinase-fast penicillins, sulphonamides and low concentrations of aminoglycosides (15). Patient safety in hospitals is challenged by the ability of enterococci to acquire additional resistance through transfer of plasmids and transposons, recombination, or mutation (32).Beta-lactam antibiotics. By nature, enterococci have a low susceptibility to beta-lactam antibiotics – a consequence of intrinsically low-affinity P�Ps. Complete penicillin resistance in E. faecalis is currently absent, though two possible mechanisms have been reported; i) the production of beta-lactamase (33) and ii) the overproduction and modification of penicillin-binding proteins (P�Ps, particularly PBP5) (12).Aminoglycosides. In addition to the intrinsic mechanism of low-level resistance, which causes a low uptake of the drug, enterococci have acquired genes conferring high level resistance to aminogly-cosides (41). High-level resistance to streptomycin can be mediated by single mutations within a protein of the 30S ribosomal subunit, the target of aminoglycoside activity (6). In addition, different aminoglycoside-modifying enzymes have been identified, targeting 8 different aminoglycosides (6). Glycopeptides. Vancomycin resistance in enterococci was first encountered in France and England but showed the most dramatic increase in the United States and was attributed to the widespread use of vancomycin in US hospitals (8). Whereas vancomycin consumption was less pronounced in Eu-rope, a closely related glycopeptide, avoparcin, has been widely utilized in the farming community as growth promoter in animal husbandry from the late-1970s until it was banned in 1998. Glycopeptide resistance is due to the synthesis of modified cell wall precursors that show a decreased affinity for


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.11. Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2006. * These countries did not report any data or reported less than 10 isolates.

glycopeptides (28). Five phenotypes have been identified of which three have clinical relevance; i) VanA with high-level resistance to both vancomycin and teicoplanin, ii) VanB with a variable level of resistance to only vancomycin, iii) VanC with intrinsic low-level resistance to vancomycin and teicoplanin, (2;36). The VanA and VanB phenotypes, mostly found among E. faecalis and E. faecium, may be transferred by plasmids and conjugative transposition.

5.4.2. Enterococcus faecalis resistance trends: 2001-2006

High-level aminoglycosidesIn 2006, 29 countries reported AST results for invasive E. faecalis isolates (n= 6,510). Only two countries reported less than 20 isolates, namely Lithuania (n=14) and Romania (n=13) (annex 3.3).The proportion of high level aminoglycoside resistance varied between 3% in Iceland (n=31) and 58% in Greece (n=523). Figure 5.10 shows that only Iceland (3%, n=31), France (16%, n=868), Swe-den (20%, n=561) and Romania, (15%, n=13) reported resistance below 25%, whereas the majority of countries reported proportions of between 25% and 50% (figure 5.��, annex 3.3). During the EARSS surveillance period, this situation did not change substantially. Since 2001, a significant increase was only observed in �elgium (from 20% to 30%), and Portugal (from 30% to 4�%). A decrease was only reported in Hungary (from 8�% in 2003 to 4�% in 2006) (figure 5.�2) and Turkey (from 39% in 2003 to 29% in 2006; p=0.057).



2001AT (123)

2001BG (42)

2001BE (127)

2004CY (37)

2001CZ (482)

2001DE (72)

2003EE (39)

2001FI (87)

2001ES (458)

2002FR (561)

2001HR (82)

2001GR (283)

2003HU (273)

2001IL (179)

2002IE (184)

2001IT (336)

2001NO (58)

2001NL (157)

2001PL (41)

2001PT (211)

2003SE (507)

2003TR (258)

2001SI (61)

Cou

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(ye

ar)

#

0 10 20 30 40

% Aminoglycoside high level resistant Enterococcus faecalis

50 60 70 80 90

2001

2002

2003

2004

2005

2006

Figure 5.12. Enterococcus faecalis:trends of high-level aminoglycoside resistance by country 2001-2006. Only the countries that reported 20 isolates or more per year were included. # Either the first year of surveillance or the first year with 20 or more isolates reported.

5.4.3. Enterococcus faecium resistance trends: 2001-2006

Vancomycin In general, the number of invasive E. faecium isolates was low (n=3,662). Of the 31 countries that reported data, 7 reported less than 20 isolates in 2006 (Cyprus, n=7; Iceland, n=7; Lithuania, n=8; Luxembourg, n=12; Latvia, n=19; Malta, n=8; Romania, n=13). In half of the countries that reported more than 20 isolates, vancomycin resistance was less or equal to 1% or even absent in 8 countries. This contrasts to the 4 countries that reported more than 25% VREF isolates in 2006, namely Greece (42%, n=35�), Ireland (36%, n=258), Israel (28%, n=6�), and Portugal (26%, n=�36). (figure 5.�3, annex 3.3).Over the past 5 years, vancomycin resistance increased significantly in 5 countries, namely Germany, Greece, Ireland, Israel and Slovenia. In Slovenia vancomycin resistance had been absent until 2005, but started to appear in 2006 (6%, n=50). The rapid expansion of E. faecium in these countries is typically the result of institutional outbreaks. It does thus not represent the situation for hospitals that have remained unaffected. A decrease in vancomycin resistance was observed in Austria and Portu-gal. In the past 4 years Portugal has shown a continuous decrease from 47% (n=103) in 2003 to 26% (n=�36) in 2006 (figure 5.�4). 5.4.4. ConclusionsWith the ongoing spread of clonal complex 17 in Europe outbreaks of vancomycin resistant E. fae-cium continues to afflict more and more hospitals in various countries. The spread of these hospi-tal-adapted strains occurs on the background of high-level aminoglycoside resistance. The control of glycopeptide resistant enterococci remains a formidable task for hospital infection control prac-titioners and it is not difficult to predict that these problematic pathogens will continue to remain a challenge.


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.13. Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2006. * These countries did not report any data or reported less than 10 isolates.


2001AT (115)

2004BG (27)

2004BE (44)

2004CZ (123)

2001DE (154)

2001ES (121)

2002FR (164)

2001FI (102)

2001GR (181)

2003HU (56)

2003HR (33)

2001IL (46)

2002IE (174)

2001IT (160)

2001NO (40)

2001NL (186)

2003PT (110)

2001SE (233)

2003TR (213)

2003SI (34)

Cou

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cod

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rep

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d by

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(ye

ar)

#

% Vancomycin resistant Enterococcus faecalis

2001

2002

2003

2004

2005

2006

0 5 10 15 20 25 30 35 40 45 50

Figure 5.14. Enterococcus faecium: trends of vancomycin resistance by country 2001-2006. Only the countries that reported 20 isolates or more per year were included. # Either the first year of surveillance or the first year with 20 or more isolates reported.

5.5. Escherichia coli

5.5.1. Clinical and epidemiological importanceEscherichia coli is the most frequent gram-negative rod isolated from blood cultures in clinical set-tings. It is the most frequent cause of community and hospital-acquired urinary tract infections, is as-sociated with spontaneous and surgical peritonitis, causes neonatal meningitis and synergistic wound infections and is one of the most important food-borne pathogens worldwide (9;11;38).

Resistance mechanisms. Beta-lactamases hydrolyse the beta-lactam ring of beta-lactam antibiot-ics, which is crucial for their inhibition of PBPs in bacteria. In E. coli resistance to broad-spectrum penicillins such as ampicillin or amoxicillin is conferred by plasmid coded beta-lactamases of the SHV and TEM type, whereby TEM-1 accounts for up to 60% of aminopenicillin resistance. In 1982 the first ES�L was identified during a hospital outbreak of Klebsiella pneumoniae in Germany. It was soon understood that single or multiple amino acid substitutions in the basic structure of SHV or TEM enzymes can alter their activity spectrum and enhance their hydrolyzing ability to include 3rd

generation cephalosporins and monobactams. Many ESBLs can be inhibited by beta-lactamase in-hibitors such as clavulanic acid, sulbactam, or tazobactam. More than 200 ESBL variants are known to date. Most of them belong to three enzyme families TEM, SHV, and OXA (an overview of identi-fied ES�L types is given on http://www.lahey.org/studies/). In E. coli, over 90% of ESBL resistance was mediated through TEM variants. Newly emerging ESBLs were CTX-M, and lately CMY-2, a plasmid encoded variant derived from the chromosomal ampC locus (42).Fluoroquinolones interact with DNA gyrase and topoisomerase IV which are enzymes that regulate conformational changes in bacterial DNA during replication and transcription. This leads to irrevers-ible inhibition of DNA strand separation and eventually to cell death. Resistance to quinolones arises through stepwise mutations in the coding regions of the gyrase subunits (gyrA and gyrB) and DNA topoisomerase IV (parC). Accumulation of mutations in several of these genes increases the MIC in a stepwise manner. Low-level resistance to quinolones may also arise through changes in membrane porins or from genes regulating the activity of efflux pumps, resulting in lower membrane perme-ability and higher efflux of fluoroquinolones, respectively (�9). In recent years, the plasmid-mediated QNR mechanism, protecting DNA from quinolone binding, is of concern because of its frequent as-sociation with CTX-M and CMY-type enzymes inactivating third generation cephalosporins(39).Aminoglycosides block protein synthesis by binding to the ribosomes, which are involved in the translation of RNA into proteins or by disruption of the outer membrane of gram-negative rods. Resistance to aminoglycosides is brought about by targeted modification of the large ribosomal subunit which excludes aminoglycoside molecules or by aminoglycoside modifying enzymes that acetylate, adenylate or phosphorylate their target molecules and thereby neutralize the biologic effect of aminoglycosides.

5.5.2. Escherichia coli resistance trends: 2001-2006

AminopenicillinsAminopenicillin resistance in E. coli was highly prevalent in Europe; of the 31 countries reporting AST results of invasive E. coli isolates to EARSS (n= 40,348 in 2006), resistance proportions were above 40% in all countries except for Sweden (28%, n=2,038), Norway (35%, n=1,573) and Fin-land (36%, n=1,460). Still aminopenicillin resistance varied substantially between the countries with proportions above 40%, from 44% in Latvia (n=62) to 88% in Romania (n=3�) (figure 5.�8 annex 3.4). It also varied substantially over time; from 2001 to 2006, aminopenicillin resistance increased significantly in more than the half of countries (�� of 28).


Third generation cephalosporinsMost countries (18 of 31) reported less than 5% resistance against 3rd generation cephalosporins in 2006. This also varied substantially over time; from 2001 to 2006, 3rd generation cephalosporins resistance increased significantly in most countries (�9 of 28). In Estonia and Croatia the resist-ance against 3rd generation cephalosporins decreased significantly. Moreover, 3rd generation cepha-losporin resistance seems to take-off more quickly in countries with formerly very low resistance levels of around 1% in 2001 to around 4% in 2006. It only seems a matter of time before more countries report levels of over 5%. Five countries already reported levels of 10% or more in 2006, namely Bulgaria (29%, n=196), Cyprus (16%, n=90), Israel (13%, n=940), Romania (41%, n=37) and Turkey (33%, n=88�) (figure 5.�5 and 5.�9, annex 3.4).

Unfortunately, the EARSS database does not receive information about the different ESBLs in the resistant strains to understand the detailed nature of this increasing problem.

FluoroquinolonesFluoroquinolone resistance has consistently and substantially increased over the past five years all over Europe. In 2005, four countries had levels of 5% or less, but in 2006 only Norway has main-tained this level (5%, n=�,4�9) (figure 5.20). At the same time, eleven countries reported fluoroqui-nolone-resistant E. coli above 25%, with four countries reporting resistance proportions above 30%: Cyprus (35%, n=89), Romania (44%, n=39), Malta (32%, n=97) and Turkey (48%, n=883) (figure 5.�6, annex 3.4). Fluoroquinolone resistance increased significantly in nearly all countries (26 of 28). The speed with which fluoroquinolones loose their activity against E. coli is alarming (figure 5.20).


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.15. Escherichia coli: proportion of invasive isolates with resistance to third generation cephalosporins in 2006. * These countries did not report any data or reported less than 10 isolates.


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.16. Escherichia coli: proportion of invasive isolates with resistance to fluoroquinolones in 2006. * These countries did not report any data or reported less than 10 isolates.

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.17. Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2006. * These countries did not report any data or reported less than 10 isolates.

AminoglycosidesStill 7 northern European countries reported less than 5% resistance against aminoglycosides, 13 countries reported resistance between 5% and 10%. In the South and East of Europe, most countries reported 10% or more, with the highest percentages reported by Bulgaria (28%, n=194) and Romania (4�%, n=4�) (figure 5.��, annex 3.4). Similar to the other resistance phenotypes under surveillance for E. coli, aminoglycoside resistance also increased in numerous countries (17 out of 28) whereby �6 showed significantly increasing trends (figure 5.2�).

Combined resistanceIt is not surprising that the overall increase of single compound resistance in E. coli is paralleled by a concomitant spread of phenotypes with combined resistance. In 2006 only 48% of the Escherichia coli isolates could be considered wild-type strains, i.e. displayed susceptibility for aminopenicillins, fluoroquinolones, 3rd generation cephalosporins, and aminoglycosides. Although combined resist-ance to 3rd generation cephalosporins, fluoroquinolones and aminoglycosides was still below 2% in most countries (�8 of 3�) (figure 5.22, annex 3.4), the majority of countries (�9 out of 28) did show a significant increase. For Italy a significant increase was found in the selected laboratories only, whereas a slight, non-significant increase was seen in the overall data, therefore no significant trend was reported.Table 5.2 gives an overview of the most common phenotypes (single and combined resistance) based on an overall proportion for all 31 countries in 2006. In E. coli, single aminopenicillin resistance was the most frequent phenotype (32%), followed by dual resistance to aminopenicillins and fluoro-quinolones (8.4%). Combined resistance to aminopenicillins, fluoroquinolones and aminoglycoside came third (3.1%), followed by resistance to all 4 antimicrobials reported to EARSS (2.1%).


Table 5.2. Overall resistance and resistance combinations among invasive Escherichia coli isolates tested against all four classes of drugs (according to the EARSS protocol) (n=39,520) in Europe, 2006.

Resistance pattern Number % of total

Full susceptibility 18,900 47.7Single resistance (to indicated drug classes)Aminopenicillins 12,583 31.8Fluoroquinolones 871 2.23rd generation cephalosporins 28 0.1Aminoglycosides 116 0.3Resistance to two classes of antimicrobial drugsAminopenicillins + fluoroquinolones 3,326 8.4Aminopenicillins + 3rd generation cephalosporins 303 0.8Aminopenicillins + aminoglycosides 409 1.0Fluoroquinolones + 3rd generation cephalosporins 28 0.1Fluoroquinolones + aminoglycosides 101 0.3Resistance to three classes of antimicrobial drugsAminopenicillins + fluoroquinolones + aminoglycosides 1,226 3.1Aminopenicillins + fluoroquinolones + 3rd generation cephalosporins 674 1.7Aminoglycosides + fluoroquinolones + 3rd generation cephalosporins 33 0.1Aminopenicillins + aminoglycosides + 3rd generation cephalosporins 99 0.3Resistance to four classes of antimicrobial drugsAminopenicillins + fluoroquinolones + aminoglycosides + 33rd generation cephalosporins 813 2.1

NB: Other compounds, including trimethoprim, sulphamethoxazole, nitrofurantoin and tetracyclin, are not taken into account, as reporting of AST results for these substances is not obligatory within EARSS.

5.5.3. ConclusionsThe Europe-wide increase of resistance of Escherichia coli to all of the antimicrobial classes re-corded by EARSS is a disturbing development with seemingly inexorable vigor. The highest resistance proportions have been reported for aminopenicillins ranging between 28 to 88%. Aminopenicillins can therefore no longer be regarded as a useful option for empirical treatment. Irrespective of the high level of resistance, proportions continue to increase in most of the countries, including those with resistance well above 60%. For fluoroquinolones the situation becomes pro-gressively dire. Of the 28 countries providing data 26 displayed a trend over time that could not be explained by random fluctuations. The speed with which fluoroquinolones loose their activity against E. coli is next to no other compound pathogen combination in the EARSS database. Combined resist-ance is a frequent occurrence, with co-resistance to 4 antimicrobial classes including 3rd generation cephalosporins already among the 4th most common resistance patterns encountered in invasive E. coli in Europe and undeniably these resistance traits are on the increase as well.

5.6. Klebsiella pneumoniae

5.6.1. Clinical and epidemiological importanceBacteria of the genus Klebsiella are frequent colonizers of the gastrointestinal tract in humans but may also be found on skin, in the oro-pharynx and upper airways in hospitalized individuals. K. pneumoniae is associated with opportunistic infections in individuals with impaired immune sys-tems, such as diabetics, alcoholics, and hospitalized patients with indwelling devices. The most com-mon sites of infection are the urinary and the respiratory tract. Organisms can spread rapidly, from the gastrointestinal tract of patients and via the hands of hospital personnel to other patients, leading to nosocomial outbreaks. Klebsiella pneumoniae is the second most frequent cause of gram-negative blood stream infections after Escherichia coli. The mortality rates for Klebsiella pneumoniae com-munity-acquired pneumoniae depends on the severity of the underlying condition and can be as high as 50%, even when appropriate antibiotic treatment is given.

Resistance mechanisms. Similar to E. coli, K. pneumoniae can be resistant to multiple antibiot-ics, and resistance traits are frequently acquired through plasmids. However, in contrast to E. coli, K. pneumoniae has a chromosomally encoded TEM beta-lactamase and is thus intrinsically resist-ant against aminopenicillins. Moreover, this organism readily acquires plasmid-mediated resistance determinants. Therefore, many novel ES�L variants were initially identified in K. pneumoniae and are only subsequently found in E. coli. Since resistance mechanisms do not significantly differ from those described for E. coli, the reader is referred to paragraph 5.5. for further details (34).

5.6.2. Klebsiella pneumoniae resistance in 2006EARSS began collecting AST results for invasive K. pneumoniae in 2005. In 2006 9,374 isolates were reported from 30 countries. Differences in resistance observed between 2005 and 2006 can be due to changes in susceptibility of K. pneumoniae, but are also related to the increase in the number of countries reporting (2005, 24; 2006, 30), and to an increase of isolates reported per country.



2001SE (1864)

2001SI (526)

2001FI (1315)

2001NO (1158)

2001IS (102)

2001LU (196)

2001GR (880)

2001NL (2205)

2002FR (4470)

2001EE (121)

2001HR (532)

2001HU (748)

2001AT (1346)

2001PL (155)

2001BE (1246)

2001MT (84)

2002IT (836)

2001CZ (1809)

2001PT (817)

2001UK (1919)

2003CY (57)

2001DE (1051)

2001BG (150)

2001ES (2821)

2001IL (755)

2002RO (46)

2003TR (769)

2002IE (1198)

Cou

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year

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% aminopenicillin resistance

2001

2002

2003

2004

2005

2006

0 10 20 30 40 50 60 70 80 90

*

Figure 5.18. Escherichia coli: trends of aminopenicillin resistance by country, 2001-2006. Only the countries that reported 20 isolates or more per year were included. The arrows indicate significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all six years. # Either the first year of surveillance or the first year with 20 or more isolates reported.# Either the first year of surveillance or the first year with 20 or more isolates reported.

70 Chapter 5. Antimicrobial resistance in Europe

2001IS (108)

2001NO (1229)

2001HR (532)

2001EE (124)

2001SI (526)

2001SE (3170)

2001FI (1586)

2001LU (196)

2001NL (1925)

2001BE (1250)

2002FR (3832)

2001MT (85)

2002IE (1184)

2001PL (154)

2001DE (1052)

2001GR (956)

2001CZ (1810)

2001HU (764)

2001AT (1347)

2001UK (1741)

2002IT (855)

2001ES (2815)

2001PT (783)

2003CY (57)

2001IL (860)

2002RO (49)

2003TR (787)

2001BG (158)

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year

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% 3rd gen. cephalosporin resistance

2001

2002

2003

2004

2005

2006

0 5 10 15 20 25 30 35 40 45 50

*

Figure 5.19. Escherichia coli: trends of third generation cephalosporin resistance by country, 2001-2006. Only the countries that reported 20 isolates or more per year for at least 4 years were included. The arrows indicate significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all six years. # Either the first year of surveillance or the first year with 20 or more isolates reported.


2001NO (1117)

2001FI (1543)

2001SE (2904)

2001EE (116)

2001NL (2140)

2001IS (99)

2002FR (4610)

2001GR (950)

2001BE (1118)

2001HR (527)

2001SI (526)

2001UK (1879)

2001LU (191)

2002IE (1184)

2001PL (153)

2001BG (155)

2001CZ (1809)

2001AT (1336)

2001HU (723)

2001PT (754)

2001IL (862)

2002IT (826)

2001ES (2816)

2001MT (84)

2001DE (1040)

2003TR (782)

2002RO (47)

2003CY (57)

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2001

2002

2003

2004

2005

2006

0 5 10 15 20 25 30 35 40 45 50

Figure 5.20. Escherichia coli: trends of fluoroquinolone resistance by country, 200�-2006. Only the countries that reported 20 isolates or more per year for at least 4 years were included. The arrows indicate significant trends. # Either# Either the first year of surveillance or the first year with 20 or more isolates reported.


2001SE (2611)

2001EE (126)

2001FI (1448)

2001NO (1165)

2001BE (954)

2001NL (2220)

2001HR (532)

2001LU (197)

2001UK (2894)

2001SI (526)

2002FR (4641)

2001GR (963)

2001IS (107)

2002IT (825)

2002IE (1192)

2001ES (2820)

2001CZ (1812)

2001AT (1347)

2003CY (57)

2001PT (819)

2001PL (155)

2001DE (1053)

2001HU (764)

2001IL (864)

2001MT (85)

2002RO (48)

2001BG (159)

2003TR (521)

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2001

2002

2003

2004

2005

2006

0 5 10 15 20 25 30 35 40 45 50

*

*

*

Figure 5.21. Escherichia coli: trends of aminoglycoside resistance by country, 2001-2006. Only the countries that re-ported 20 isolates or more per year for at least 4 years were included. The arrows indicate significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all six years. # Either the first year of surveillance or the first year with 20 or more isolates reported.# Either the first year of surveillance or the first year with 20 or more isolates reported.


2001EE (115)

2001SE (2439)

2001NO (1062)

2001IS (99)

2002IE (1163)

2001HR (527)

2001BE (880)

2001FI (1401)

2001NL (1856)

2001SI (526)

2002FR (4565)

2001LU (190)

2001CZ (1805)

2001ES (2808)

2001DE (1032)

2002IT (821)

2001UK (1641)

2001GR (947)

2001AT (1324)

2001MT (84)

2001PL (151)

2001HU (717)

2003CY (57)

2001IL (859)

2001PT (730)

2002RO (45)

2003TR (774)

2001BG (153)

Cou

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% multi resistance

2001

2002

2003

2004

2005

2006

0 5 10 15 20 25 30 35 40 45 50

**

Figure 5.22. Escherichia coli: trends of combined resistance (resistant to fluoroquinolones, 3rd gen. cephalosporins and aminoglycosides) by country, 2001-2006. Only the countries that reported 20 isolates or more per year for at least 4 years were included. The arrows indicate significant trends. The asterisks indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all six years. # Either the first year of surveillance or the first year with 20 or more isolates reported.


Third generation cephalosporinsThird generation cephalosporin resistance varied substantially between countries, from 0% in Iceland (n=13) to 91% in Romania (n=31). However, due to the low number of isolates, these proportions may be not very representative. More than half of the countries (17 out of 30) reported resistance levels against 3rd generation cephalosporins of more than 10%. Six Northern European countries reported proportions below 5%, Denmark (4%, n=430), Finland (1%, n=228), Iceland (0%, n=13), Norway (2%, n=263), The Netherlands (4%, n=397) and Sweden (1%, n=621). Seven countries, among which some (south)eastern European countries and Israel, reported 35% or more: Bulgaria (60%, n=55), Latvia (36%, n=28), Greece (58%, n=841), Israel (44%, n=430), Poland (38%, n=42), Romania (94%, n=3�) and Turkey (43%, n=450) (figure 5.23, annex 3.5). In comparison with 2005, 13 out of 24 countries reported a higher resistance percentage in 2006.

FluoroquinolonesFluoroquinolone resistance in Europe is rather heterogeneous; five countries recorded resistance against fluoroquinolones of 5% or below: Estonia (5%, n=4�), Finland (4%, n=228), Lithuania (3%, n=35) and Iceland (0%, n=12) whereas six countries recorded resistance proportions of above 25%: Latvia (26%, n=27), (Czech republic (47, n=1124), Greece (50%, n=840), Israel (41%, n=429), Po-land (29%, n=42) and Romania (33, n=30). (figure 5.24, annex 3.5). In comparison with 2005, �� out of 24 countries reported a higher resistance percentage in 2006.

AminoglycosidesLow resistance proportions were found in the northern part of Europe and in Austria. Resistance proportions were 5% or less in Austria (5%, n=433), Denmark (2%, n=606), Finland (1%, n=222), Iceland (0%, n=13), Luxembourg (0%, n=21), The Netherlands (4%, n=446), Norway (0%, n=263) and Sweden (0%, n=620). Proportions above 35% were found in eastern and southeastern Euro-pean countries: Bulgaria (60%, n=55), Czech Republic (38%, n=1125), Greece (54%, n=841), Israel (46%, n=430), Poland (36%, n=42) and Romania (9�, n=32). (figure 5.25, annex 3.5). Compared to 2005, 13 out of 24 countries reported a higher resistance percentage in 2006.

CarbapenemsAlthough reporting of AST results for carbapenems is not obligatory in EARSS, 29 of the 30 coun-tries reported data about carbapenems susceptibility. In 2006, data were available for 62% of all iso-lates. Carbapenem resistance is still below 1% in most countries. Only Israel (11%, n=429), Greece (32%, n=837) and Turkey (3%, n=425) reported higher percentages. Since carbapenems are regarded as reserve antibiotics with life-saving potential when isolates show resistance to other antibiotics (35) it is important to monitor the susceptibility of this important group. Carbapenem resistance seems to be compromised in the Mediterranean countries due to the occurrence of metallo-beta-lactamases particularly among isolates from ICU patients (figure 5.26, annex 3.5).

Combined resistanceIn 2006, 70.1% of the Klebsiella pneumoniae isolates displayed susceptibility for fluoroquinolones, 3rd generation cephalosporins, and aminoglycosides (resistance against aminopenicillins was not taken in account). All other isolates were resistant to at least one of the other antibiotic classes as well. As shown in table 5.3, single resistance was rather rare; the most frequent pattern was combined resistance against all three classes recorded by EARSS (12%). In the countries with carbapenem resistance above �%, about one third (34%) of the isolates resistant against fluoroquinolones, 3rd

generation cephalosporins, and aminoglycosides was also resistant against carbapenems.


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.23. Klebsiella pneumoniae: proportion of invasive isolates resistant to 3rd generation cephalosporins in 2006. * These countries did not report any data or reported less than 10 isolates.

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.24. Klebsiella pneumoniae: proportion of invasive isolates resistant to fluoroquinolones in 2006. * These countries did not report any data or reported less than 10 isolates.


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.25. Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2006. * These countries did not report any data or reported less than 10 isolates.

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.26. Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2006. * These countries did not report any data or reported less than 10 isolates.


5.6.3. ConclusionsIn K. pneumoniae a high prevalence of resistant strains to 3rd generation cephalosporins, fluoroqui-nolones and aminoglycosides becomes evident in eastern and southeastern Europe. Many of these strains have combined resistance and the most frequent phenotype shows resistance to all three an-timicrobial classes recorded by EARSS. Carbapenems seem to be still effective in most countries. It will be necessary to closely monitor the effectiveness of carbapenems and make sure that its value is not put at stake through irresponsible prescribing in hospitals and ambulant care.

5.7. Pseudomonas aeruginosa

5.7.1. Clinical and epidemiological importancePseudomonas aeruginosa is a non-fermenting gram-negative bacterium that is ubiquitously present in aquatic environments in nature. It is an opportunistic pathogen for plants, animals and humans, and is a major and dreaded cause of infection among patients with localized and systemic immune defects. Because of its ubiquitous presence, its enormous versatility and intrinsic tolerance to many detergents, disinfectants and antimicrobial compounds is difficult to control P. aeruginosa in hospi-tals and institutional environments. Moreover, P. aeruginosa is a frequent cause for skin infections such as folliculitis and otitis externa in recreational and competitive swimmers. It causes the most important bacterial complication in patients with cystic fibrosis leading to chronic colonization and intermittent exacerbations ranging from bronchiolitis to acute lung syndrome. Finally, P. aeruginosa is a common pathogen found in burns units and in these locations almost impossible to eradicate by classical infection control procedures.

Resistance mechanisms. P. aeruginosa is intrinsically resistant to the majority of antimicrobial com-pounds due to its selective ability to exclude various molecules from penetrating its outer membrane. Acquired resistance in P. auruginosa is caused by one or more of five mechanisms: i) mutational modification of antibiotic target sites such as gyrase, topoisomerase or ribosomal proteins which confer resistance to fluoroquinolones or aminoglycosides, ii) constitutional or inducible derepres-sion of chromosomally coded AmpC beta-lactamase, iii) mutational loss of outer membrane proteins

Table 5.3. Overall resistance and resistance combinations among invasive Klebsiella pneumoniae isolates tested against all four classes of drugs (according to the EARSS protocol*) (n=8,746) in Europe, 2006. Intrinsic resistance against aminopenicillins is excluded; therefore results for only 3 classes are illustrated. *Reporting of carbapenems susceptibility was not obligatory within EARSS in 2006.


Full susceptibility* 6,130 70.1%Single resistance (to indicated drug classes)Fluoroquinolones 358 4.1%3rd generation cephalosporins 217 2.5%Aminoglycosides 134 1.5%Resistance to two classes of antimicrobial drugsFluoroquinolones + 3rd generation cephalosporins 281 3.2%Fluoroquinolones + aminoglycosides 198 2.3%3rd generation cephalosporins + aminoglycosides 406 4.6%Resistance to three classes of antimicrobial drugsFluoroquinolones + 3rd generation cephalosporins + aminoglycosides 1,027 11.7%


preventing the uptake of antimicrobial substances such as imipenem, iv) efficient efflux systems, that can confer resistance to beta-lactams, fluoroquinolones, tetracycline, chloramphenicol, trimethoprim and aminoglycosides, and v) plasmid-mediated expression of various beta-lactamases that can confer resistance to carbapenems (metallo-beta-lactamases) and aminoglycosides (30;37).

5.7.2. Pseudomonas aeruginosa resistance in 2006EARSS began collecting AST results for invasive P. aeruginosa in 2005 and already 3,887 isolates were reported from 23 countries in this first year alone. In 2006, 6,6�4 isolates were reported by 29 countries.

PiperacillinIn the EARSS database, the proportion of piperacillin resistance was higher than that for the pip-eracillin-tazobactam combination owing to the fact that the beta-lactamase inhibitor (tazobactam), although not effective against the AmpC beta-lactamase, has some residual inhibitory effect on P. aeruginosa. All countries (n=29) reported susceptibility to piperacillin-tazobactam with or without susceptibility results for piperacillin for the vast majority of P. aeruginosa isolates, except for the Czech Republic and Iceland, which report piperacillin for all isolates and the combination of pip-eracillin and tazobactam only for a selection of isolates. Eleven countries still reported resistance of less than 10%.The highest resistance proportions were reported from Greece (39%, n=813), Croatia (38%, n=��8), Malta (4�%, n=45) and Poland (43%, n=3�)(figure 5.2�, annex 3.6).

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.27. Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillins in 2006. * These countries did not report any data or reported less than 10 isolates.


CeftazidimeOnly six countries, mostly situated in the eastern part of Europe, reported ceftazidime resistance above 25%, namely Czech republic (31%, n=485), Greece (34%, n=800), Latvia (31%, n=13), Lithuania (29%, n=14), Malta (30%, n=50) and Poland (42%, n=36). Of the last three countries the number of isolates was very low, this should be taken into account when interpreting the figures. On the other hand, only five countries, mostly situated in the northwestern part of Europe reported resist-ance proportions below 5%, namely Finland (3%, n=161)), Iceland (0%, n=9), the Netherlands (5%, n=325), Norway (5%, n=96) and the United Kingdom (3%, n=288). The central and southern part of Europe reported resistance proportions varying between 6% in France (n=952) and 24% in Turkey (n=305) and Cyprus (n=3�) (figure 5.28, annex 3.6). FluoroquinolonesTwelve (of 29) countries reported more than 25% fluoroquinolone resistance for invasive P. aeru-ginosa isolates, and were mainly located in the south-eastern part of Europe. The Czech Republic (48%, n=486), Greece (45%, n=814), Lithuania (46%, n=13) and Poland (41%, n=37) even reported more then 40% resistance. Low resistance levels (≤5%) were only found in Iceland (0%, n=9) and Sweden (5%, n=24�) (figure 5.29 annex 3.6.).

AminoglycosidesSimilarly as for fluoroquinolone resistance, �� of 29 countries reported aminoglycoside resistance of over 25%. Especially in the eastern European countries proportions were high and even over 40% in Bulgaria (42%, n=31), Greece (47%, n=815), Croatia (47%, n=169), Latvia (47%, n=15) and Poland (46%, n=37). Most northern European countries still report resistance levels of less than 5%: Iceland, Luxembourg, The Netherlands, Norway, Sweden, and the United Kingdom (figure 5.30).

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.28. Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2006. * These countries did not report any data or reported less than 10 isolates.


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.29. Pseudomonas aeruginosa: proportion of invasive isolates resistant to fluoroquinolones in 2006. * These countries did not report any data or reported less than 10 isolates.

< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.30. Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2006. * These countries did not report any data or reported less than 10 isolates.


< 1%

No data*

5 – 10%

10 – 25% 25 – 50%

> 50

LU MT

1 – 5%

Figure 5.31. Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2006. * These countries did not report any data or reported less than 10 isolates.

CarbapenemsCountries differ in the reporting routine for carbapenems. Some hardly or never test for meropenem (France, Malta, Spain, Sweden), whereas others hardly test for imipenem susceptibility (Finland, Czech Republic, Iceland, Ireland, The Netherlands). We took a pragmatic approach and combined the AST results for both drugs. With this restriction in mind, we were able to draw up the overall distribution of carbapenem resistance without loosing too much valuable data (see figure 5.3�).

Pseudomonas aeruginosa resistance proportions to carbapenems appear to be rather high all over Europe. Except for the northern European countries, Finland (8%, n=158), Ireland (9%, n=119), Iceland (0%, n=9), The Netherlands (2%, n=290), Norway (9%, n=85), Sweden (5%, n=235), United Kingdom (6%, n=258) and the more central countries Slovenia (6%, n=72) and Luxembourg (7%, n=14), all countries reported more than 10% carbapenem resistance. Czech Republic (33%, n=485), Estonia (29%, n=42), Greece (48%, n=815), Poland (30%, n=37) and Turkey (33%, n=312) even reported resistance of more then 25% carbapenem resistance. (figure 5.3�, annex 3.6.).

Combined resistanceAs expected, P. aeruginosa isolates were often found to be multi-resistant (18%), i.e. being resistant to 3 of more antibiotics from the EARSS protocol. In the EARSS database, the dominant phenotype in Europe in 2006 was combined resistance to all the five classes of antimicrobials recorded by EARSS (6%). The second and third most common pattern consisted of single resistance phenotypes to either carbapenems (4%) or fluoroquinolones (4%) (table 5.4).


Table 5.4. Resistance combinations among invasive Pseudomonas aeruginosa isolates tested against all five classes of drugs (as mentioned in the EARSS protocol) (n=5,470) in Europe, 2006.


Single resistance (to indicated drug classes)Piperacillin +/- tazo (PIPT) 51 0.9Ceftazidime (CEFT) 47 0.9Carbapenems (CARB) 227 4.2Fluoroquinolones (FLUO) 235 4.3Aminoglycosides (AMINO) 104 1.9Resistance to two classes of antimicrobial drugsPIPT + CEFT 94 1.7PIPT + CARB 14 0.3PIPT + FLUO 17 0.3PIPT + AMINO 19 0.4CEFT + CARB 10 0.2CEFT + FLUO 11 0.2CEFT + AMINO 6 0.1CARB + FLUO 60 1.1CARB + AMINO 33 0.6FLUO + AMINO 187 3.4Resistance to three classes of antimicrobial drugsPIPT + CEFT + CARB 35 0.6PIPT + CEFT + FLUO 28 0.5PIPT + CEFT + AMINO 8 0.2PIPT + FLUO + AMINO 97 1.8PIPT + CARB + FLUO 9 0.2PIPT + CARB + AMINO 11 0.2CEFT + CARB + FLUO 12 0.2CEFT + CARB + AMINO 5 0.1CEFT + FLUO + AMINO 37 0.7CARB + FLUO + AMINO 106 1.9Resistance to four or more classes of antimicrobial drugsPIPT + CEFT + CARB + FLUO 48 0.9PIPT + CEFT + CARB + AMINO 20 0.4PIPT + CEFT + FLUO + AMINO 65 1.2PIPT + CARB + FLUO + AMINO 118 2.2CEFT + CARB + FLUO + AMINO 54 1.0PIPT + CEFT + CARB + FLUO + AMINO 339 6.2

5.7.3. ConclusionsCombined resistance is the dominant threat imposed by invasive P. aeruginosa on Europe. Since resistance in P. aeruginosa emerges readily during antibiotic treatment, the time when blood cultures are taken is crucial as any isolate collected after prolonged exposure with antimicrobial chemo-therapy will predictably be a multi-resistant phenotype. Assuming the diagnostic habits in Europe are comparable the picture that our data suggest is that the geographical gradient observed for all other gram-negative pathogens namely lower resistance in the Northwest and increasing resistance towards the Southeast also holds for P. aeruginosa.


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38. Reacher, M. H., Shah, A., Livermore, D. M., Wale, M. C., Graham, C., Johnson, A. P., Heine, H., Monnickendam, M. A., Barker, K. F., James, D., and George, R. C. Bacteraemia and antibiotic resistance of its pathogens reported in England and Wales between 1990 and 1998: trend analy-sis. BMJ 320, 213-6. 2000.

39. Rodriguez-Martinez JM, Poirel L, Pascual A, Nordmann P. Plasmid-mediated quinolone resist-ance in Australia. Microb Drug Resist 2006;12:99-102.



40. Schmitt HJ. Pneumococcal conjugate vaccines in Europe, Berlin, Germany, 23-25 August 2000. Report of a European advisory board meeting. Vaccine 2001;19:3347-54.

41. Shepard BD, Gilmore MS. Antibiotic-resistant enterococci: the mechanisms and dynamics of drug introduction and resistance. Microbes Infect 2002;4:215-24.

42. Sturenburg E, Mack D. Extended-spectrum beta-lactamases: implications for the clinical micro-biology laboratory, therapy, and infection control. J Infect 2003;47:273-95.

43. Watson DA, Musher DM. A brief history of the pneumococcus in biomedical research. Semin Respir Infect 1999;14:198-208.

44. Weisblum B. Insights into erythromycin action from studies of its activity as inducer of resist-ance. Antimicrob Agents Chemother 1995;39:797-805.

45. Willems RJ, Top J, van Santen M, Robinson DA, Coque TM, Baquero F et al. Global spread of vancomycin-resistant Enterococcus faecium from distinct nosocomial genetic complex. Emerg Infect Dis 2005;11:821-8.

46. Wuorimaa T, Kayhty H. Current state of pneumococcal vaccines. Scand J Immunol 2002;56:111-29.

47. Zhong P, Cao Z, Hammond R, Chen Y, Beyer J, Shortridge VD et al. Induction of ribosome meth-ylation in MLS-resistant Streptococcus pneumoniae by macrolides and ketolides. Microb Drug Resist 1999;5:183-8.

Chapter 6. Conclusions and Recommendations 87 87

Chapter 6. Conclusions and Recommendations

In March 2007, the EARSS network was evaluated by an international and independent team of public health specialists and was rated as an important project with excellent links to participating laboratories. The evaluation team concluded that the aims set by the EARSS annual plenary meeting in Warsaw, 2003 were largely achieved. It is envisaged that EARSS will continue to exist beyond 2007 and a call for proposal has been published to this effect.

In 2006, 83% of the EARSS laboratories participated in the sixth External Quality Assurance ex-ercise (EQA), jointly organised by EARSS and the United Kingdom External Quality Assurance Scheme (UK-NEQAS). It could be concluded that routinely reported results as collected by EARSS have sufficient accuracy to provide good estimates of overall resistance prevalences and trends. The EQA exercise does, however, also indicate the need for further calibration and standardisation of methods in European routine susceptibility testing.

Based on the denominator data reported through the laboratory/hospital questionnaire, the overall hospital catchment population of the EARSS network is estimated to include around one third of the inhabitants of the European region, with national coverage rates between 20-100% for most countries. The comparability of MRSA incidence rates and proportions indicate that the resistance proportions as reported by EARSS are a good approximation of the incidence rates, and comparison of resistance proportions between countries thus provides useful information.

The resistance profile of S. pneumoniae has a dynamic character. Although penicillin resistance is still increasing in Sweden and Finland, in most countries penicillin resistance is quite stable or even on the decrease, which might be the result of decreasing selection pressure. Erythromycin resistance, however, is becoming more prevalent in quite a few countries, independent of the national resist-ance level. In contrast, two southern European countries (Spain and France) reported a significant decrease in erythromycin resistance.Although still far from complete, EARSS now gives more insight into serogroup information, as more countries have provided data this year. Serogroup 1 and 14 are highly prevalent in most coun-tries. The highest proportions of resistance were identified in serogroups 6, 9, �4, �9, 23, �, 33, of which the first five are represented in the �-conjugate vaccine and all seven in the 23-valent vaccine. Compared to other countries, Belgium reported distinctive resistance within serogroups 1 and 14. Since McCormick et al.(29) showed that the variation in antimicrobial resistance of S. pneumoniae isolates is best explained by differential selection pressure for resistance, rather than by the spread of specific clones, this could be related to high consumption of penicillin and erythromycin in this region.

MRSA is still an increasing problem all over Europe. Increasing proportions of S. aureus bloodstream infections being methicillin-resistant were reported from high, medium as well as low endemic coun-tries. Nevertheless, some of the high endemic countries seem to have stabilizing MRSA proportions. There have been promising trends in France and Slovenia already for six years, and now we have also found decreasing MRSA trends in Cyprus and Turkey. This indicates that improved control efforts can still reverse the increasing MRSA problem in hospitals, even in high endemic countries.

88 Chapter 6. Conclusions and RecommendationsChapter 6. Conclusions and Recommendations

Increasing proportions of VRE were reported for various countries, which most probably relates to the ongoing spread of clonal complex 17, causing outbreaks in increasing numbers of hospitals. The spread of these hospital-adapted strains occurs on the background of high-level aminoglycoside re-sistance. It is and will remain a major challenge to hospital infection control practitioners to control the spread of glycopeptide resistant enterococci within and between hospitals.

The Europe-wide increase of resistance of Escherichia coli to all of the antimicrobial classes recorded by EARSS is still ongoing. The highest resistance proportions have been reported for aminopenicil-lins ranging between 28 to 88% and aminopenicillins no longer should be used for empirical treat-ment. Despite already high levels of resistance, proportions continue to increase in most countries, including those with resistance well above 60%. Especially fluoroquinolone susceptibility quickly diminishes: of the 28 countries providing data 26 displayed a statistically increasing trend over time. Indeed, the speed with which fluoroquinolones loose their activity against E. coli is higher than any other drug-bug combination present in the EARSS database. Combined resistance frequently oc-curs, with co-resistance to four antimicrobial classes including 3rd generation cephalosporins already ranking 4th when listing the most common resistance patterns. The trends reported by EARSS are certainly worrisome as few treatment options remain available to treat patients infected by these dif-ficult-to-treat strains, and the situation will most probably only deteriorate in the coming years.

With respect to Klebsiella pneumoniae, a high prevalence of resistant strains to 3rd generation ce-phalosporins, fluoroquinolones and aminoglycosides was reported from eastern and southeastern Europe, which is consistent with the data reported for 2005. Many strains have combined resistance and the most frequent phenotype shows resistance to all three antimicrobial classes recorded by EARSS. Carbapenems seem to be still effective in most countries, although some countries in the Mediterranean region reported significant resistance rates probably due to the occurrence of metallo-beta-lactamases, particularly among isolates from ICU patients. Since carbapenems are regarded as reserve antibiotics with life-saving potential when isolates show resistance to other antibiotics it is very important that these drugs are sensibly and restrictively prescribed in hospitals and ambulant care.

Combined resistance is the dominant threat imposed by invasive P. aeruginosa. Since resistance in P. aeruginosa emerges readily during antibiotic treatment, the time when blood cultures are taken is crucial as any isolate collected after prolonged exposure with antimicrobial chemotherapy will predictably be a multi-resistant phenotype. Assuming the diagnostic habits in Europe are comparable the picture that our data suggest is that the geographical gradient observed for all other gram-negative pathogens namely lower resistance in the Northwest and increasing resistance towards the Southeast also holds for P. aeruginosa.

From the data collected by EARSS between 1999 and 2006, we conclude that antimicrobial resist-ance is becoming a larger public health problem year after year. Specific problems might require specific solutions, but most of the resistance problems discussed in this report will only come to grips when using the input of different disciplines in concerted efforts, as is demonstrated by the promising decline of MRSA proportions in Slovenia and France.

Annex 1. Technical Notes 89 89

Annex 1. Technical Notes on data analysis

1.1. Technical Notes for table 1 of the Country Summary Sheets

Inclusion criteria To be included in the analyses presented in table 1 of the country summary sheets (annex 2), coun-tries, laboratories and hospitals had to provide both denominator data and AST results in 2006. Nec-essary details for inclusion were information on blood culture frequencies for laboratories and the number of beds for hospitals.

Cumulative variables Number of blood culture sets, number of hospital beds (total, ICU and psychiatry or long term care beds), number of patient-days, catchment population, and type of hospitals were added up by country.

Number of blood culture sets The Total number of blood culture sets was defined as the number of blood samples, not the number of patients sampled.

Patient-daysIf patient-days were not available at hospital level, these were calculated by:

Number of beds * (Annual occupancy / 100) * 365

Catchment population & Percentage of the total population coveredThe total catchment population was the sum of the catchment populations of primary, secondary and tertiary level care hospitals. Hospitals providing only a specific type of care (classified as 4=other, e.g. oncology or psychiatric hospitals) were not included as we considered this population as prob-ably overlapping with the catchment populations of the other hospitals. The percentage of population covered was then calculated by dividing the total catchment popula-tion by the estimated national population, which we derived from the CIA factbook available from https://www.cia.gov/library/publications/the-world-factbook/index.html. Some NRs (from Austria, Croatia, Denmark, Ireland, Latvia, Malta) were able to provide the national catchment population for all EARSS hospitals, in that case this number was used instead of the number derived from the questionnaire data.If the percentage of population covered exceeded 100%, this was reduced to 100%.

Type of hospitalsSince hospital categorisation was always intricate, we now supplied more specific definitions from WHO that hopefully made categorising the hospitals easier.Primary level, often referred to as a district hospital or first-level referral: A hospital has few spe-cialities, mainly internal medicine, obstetrics-gynecology, pediatrics, and general surgery, or only general practice; limited laboratory services are available for general, but not for specialized patho-logical analysis; the bed capacity ranges from 30 to 200 beds.Secondary level, often referred to as provincial hospital: A hospital highly differentiated by function with five to ten clinical specialities; bed capacity ranging from 200-800 beds.

Tertiary level, often referred to as central, regional or tertiary-level hospital: A hospital with highly specialized staff and technical equipment, e.g., cardiology, ICU and specialized imaging units; clini-cal services are highly differentiated by function; the hospital may have teaching activities; bed ca-pacity ranges from 300 to 1,500 beds.A fourth category was for hospitals with a single specialty.

Averaged variablesAnnual occupancy rate and length of stay were averaged per country. In these totals only labora-tory/hospital questionnaires were included that provided information on all variables needed for the specific formula.

Annual occupancy rateThe average annual occupancy per country was calculated as:

[ ∑(Annual occupancy / 100 * Number of beds) / ∑(Number of beds) ] * 100

Length of stayThe median length of stay per country was determined, since the values of the hospital-specific lengths of stay had a skewed distribution for most countries.

1.2 Technical Notes for the MRSA incidence calculations in chapter 4

In the case of linking of AST results with denominator information only AST results from those hos-pitals that also provided denominator information were included.Detection limits for MRSA incidences were calculated in case of reported nul-incidence so that

alpha < Pupper limit of confidence interval as follows:alpha < (1- Pupper limit of confidence interval)n

where P stands for the chance of finding a resistant S. aureus in one cultureand n stands for the total number of S. aureus cultures

For alpha = 0.05, the detection limit is then given by :(1 - Pupper limit of confidence interval)n =0.05

After calculation of Pupper limit of confidence interval, the detection limit for the incidence rate can be cal-culated as follows: Detection limit = n/patient-days * 100,000* Pupper limit of confidence interval

1.3. Technical Notes for chapter 5

Resistance trend analysisTo determine significant trends over time, the Cochrane Armitage test was used, excluding countries reporting less than 20 isolates per year. In addition, for E. coli, enterococci, S. pneumoniae and S. aureus at least 3 years of data had to be reported by country to be included in the analysis. To exclude possible biases in the trend analyses, a sensitivity analysis was done, per country, to determine the sensitivity of the trend analysis for using the complete dataset versus a subset from laboratories reporting all years. If the trends in the subset and the complete dataset were contradictive, these

90 Annex 1. Technical NotesAnnex 1. Technical Notes

Annex 1. Technical Notes 91 91

trends were discussed in the text. However, if both datasets indicated a similar trend, we included this; i) in the text, when significant trends were only identified in the subset of data, ii) in the graphs by an arrow with asterisk, when significant trends were only identified in the com-

plete dataset, iii) in the graphs by an arrow when a significant trend was detected in both the subset and the com-

plete dataset.

European maps with resistance levelsTo be included in the maps of Europe displaying the resistance proportions per country, for all drug-bug combinations under surveillance by EARSS, a country had to report AST results for at least 10 isolates in 2006.

Annex 2. Country Summary Sheets 93 93

Annex 2. Country Summary Sheets

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

Explanation to the country summary sheets

General information about EARSS participating laboratories and hospitalsTable � and 2 and figure � give an indication of the sample size and the representativeness of the country-specific resistance data available to EARSS.Table 1 displays results of the laboratories and hospitals that provided denominator data in 2006 (i.e. that responded to the questionnaire) and thus only includes the laboratories that 1) reported AST results to EARSS in 2006, and 2) provided blood culture information and the hospitals that 1) reported AST results to EARSS in 2006, and 2) provided their number of hospital beds. For details about the calculation of the average annual occupancy rate, the estimated catchment population and the percentage of the total population covered, we refer to the technical notes (annex 2). If data were not available this is stated as “na”.Table 2 gives the number of laboratories and isolates reported by year and by pathogen under EARSS surveillance for the period 1999 to 2006.Figure 1 shows the geographic location of the laboratories reporting in 2006. The size of the dots in the maps represents the number of laboratories in that area:

Dot Number of labs 1 5 10 15

Antibiotic resistance 1999-2006Table 3 provides information on the proportion of invasive bacterial isolates non-susceptible (I+R) or resistant (R) to the antibiotics or antibiotic classes mentioned in the EARSS protocols. When in-terpreting table 3 always check the number of isolates the proportions are based on given in table 2.

Demographic characteristicsTable 4 gives the proportional distribution of the isolates reported by source, gender, age, and hos-pital department, and the proportion of resistance within the different groups, for the period 2005-2006.The abbreviations used in this table stand for; PNSP = penicillin non-susceptible S. pneumoniae, MRSA = methicillin resistant S. aureus, FREC = fluoroquinolone resistant E. coli, VRE = vancomy-cin resistant E. faecalis or E. faecium, CRKP = 3rd generation cephalosporin resistant K. pneumo-niae, and CRPA = carbapenem resistant P. aeruginosa. If the number of isolates in a certain category accounts for less than 0.5% of the total number of isolates, the % total is set at 0 and the % resistance is not shown.

PNSP at laboratory level / MRSA at hospital level Figures 2 and 3 show the local variation in the proportions of PNSP and MRSA by laboratory and by hospital, respectively. �oth figures are based on data from 2005 and 2006, only including the labora-tories and hospitals that reported at least 5 isolates in these 2 years. The total number of laboratories or hospitals, the minimum, maximum, median, 1st and 3rd quartile of the proportion of resistance is displayed in a box in the figures. If an ‘X’ is displayed at the end of a hospital code this means that the hospital code is not provided; consequently, this can compass one or more unknown hospitals.

Table 1.Reference data of 2006, based on laboratories/hospitals providing denominator data

TotalLabs providing denom.data/reporting data to EARSS 15/33Hosps providing denom.data/reporting data to EARSS 124/136Number of blood culture sets 72,396Number of hospital beds 44,270Patient-days 8,748,276Average occupancy rate (%) 69%Median length of stay (days) 5Estimated catchment population 7,125,800% total population covered 87%Type of participating hospitals Regional/Tertiary 24% Provincial/Secondary 24% District/Primary 52%

Table 2. Number of laboratories and number of isolates reported for the period 1999-2006

Year S. pneumoniaeLabs Isolates

S. aureusLabs Isolates

E. coliLabs Isolates

EnterococciLabs Isolates

K. pneumoniaeLabs Isolates

P. aeruginosaLabs Isolates

1999 0 0 0 0 0 0 0 0 0 0 0 02000 9 63 10 382 0 0 0 0 0 0 0 02001 8 53 9 278 8 260 6 67 0 0 0 02002 10 80 11 455 10 479 10 181 0 0 0 02003 19 162 20 871 21 985 19 327 0 0 0 02004 27 250 30 1419 31 1862 28 604 0 0 0 02005 30 290 32 1471 33 2059 30 568 7 89 8 772006 32 291 33 1637 33 2483 33 699 30 434 31 405

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

Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . <1 2 <1 1 1 <1 <1

Penicillin I+R . 2 4 1 9 5 5 5Macrolides I+R . 5 10 9 14 12 15 12

S. aureus Oxacillin/Methicillin R . 18 8 12 15 14 13 9E. coli Aminopenicillins R . . 35 33 41 46 48 53

Aminoglycosides R . . 2 4 5 5 5 8Fluoroquinolones R . . 7 10 14 17 19 223rd gen. Cephalosporins R . . <1 1 2 3 4 7

E. faecalis Aminopenicillins I+R . . 13 3 1 <1 1 2HL Aminoglycosides R . . 35 27 33 23 28 29Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 86 84 85 85 84 89HL Aminoglycosides R . . 13 21 22 22 28 21Glycopeptides R . . 5 7 <1 <1 1 <1

K. pneumoniae Aminoglycosides R . . . . . . 3 5Fluoroquinolones R . . . . . . 11 83rd gen. Cephalosporins R . . . . . . 6 6

P. aeruginosa Piperacillin R . . . . . . 13 8Ceftazidime R . . . . . . 7 9Carbapenems R . . . . . . 10 15Aminoglycosides R . . . . . . 6 9Fluoroquinolones R . . . . . . 14 15

Figure 1. Geographic distribution of laboratories in 2006

AustriaGeneral Information about EARSS participating laboratories and hospitals

Antibiotic resistance from 1999 to 2006

94 Annex 2. Country Summary Sheets

Table 4. Selected details on invasive isolates from the reporting period 2005 and 2006

Characteristic S. pneumo.n=581

S. aureusn=3108

E. colin=4512

E. faecalisn=803

E. faeciumn=383

K. pneumo.n=519

P. aeruginosan=474

%tot %PNSP %tot %MRSA %tot %FREC %tot %VRE %tot %VRE %tot %CRKP %tot %CRPAIsolate source

Blood 93 5 100 11 100 21 100 0 100 1 100 6 100 14CSF 7 10 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 52 4 56 12 38 25 61 0 55 1 54 7 51 15Female 46 6 42 11 60 18 38 1 43 0 43 4 46 13Unknown 2 9 2 11 2 27 1 0 2 0 3 7 3 21

Age (years)0-4 9 13 2 7 2 5 3 0 2 0 3 0 2 115-19 4 9 2 3 1 19 1 0 1 0 1 0 1 020-64 38 4 37 12 28 22 38 0 39 1 34 8 37 1965 and over 48 4 59 11 70 21 58 1 57 1 62 5 60 12Unknown 1 0 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 12 7 11 19 7 23 17 2 24 0 12 10 15 18Internal Med. 54 3 51 10 55 19 41 0 36 1 46 4 35 15Surgery 2 10 11 18 9 17 12 0 15 0 12 9 11 10Other 31 8 26 9 27 25 29 0 25 2 29 7 38 13Unknown 1 0 1 13 1 21 1 0 0 . 2 0 1 0

Demographic characteristics

PNSP at laboratory level MRSA at hospital level

PNSP = Penicillin Non-Susceptible S. pneumonia MRSA = Methicillin Resistant S. aureus FREC = Fluoroquinolone Resistant E. coliVRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae CRPA = Carbapenem Resistant P. aeruginosa

no of hospitals : 85Minimum : 0.01st quartile : 0.0Median : 8.33rd quartile : 15.8Maximum : 42.9

no of labs : 29Minimum : 0.01st quartile : 0.0Median : 0.03rd quartile : 8.3Maximum : 25.0

Figure 3. Proportion (%) MRSA by hospital (2005 & 2006)

0 25 50 75 100

0/7AT003E0/5AT003M0/15AT005K0/5AT005S0/20AT005Z0/5AT006O0/15AT007F0/5AT008B0/9AT009R0/23AT010B0/9AT010H0/23AT012W0/11AT015M0/10AT016G0/8AT021S0/6AT022R0/5AT022S0/6AT023F0/32AT026S0/6AT026Z0/12AT030F0/8AT030G0/6AT030V0/5AT030X0/5AT032A0/17AT033F

1/63AT014R2/58AT010F5/130AT016W1/22AT003G1/22AT006N1/20AT024G4/73AT033D3/54AT001S5/89AT006S3/51AT015A1/16AT011W1/16AT015S3/47AT021V1/15AT022B2/29AT022L6/80AT001E1/12AT009K4/45AT005L2/22AT007W15/163AT025K7/75AT018M1/10AT008S6/57AT024V16/141AT031W4/35AT034E13/112AT028R

1/8AT008T3/24AT029O21/164AT007K3/23AT007V3/22AT001B22/159AT005I1/7AT030W5/33AT023S2/13AT005H2/13AT009W3/19AT011P27/171AT027L9/55AT035H1/6AT012D2/12AT015W1/6AT019L4/23AT017K3/17AT032G2/11AT017Z

12/61AT019P1/5AT006B1/5AT008H

52/242AT002A10/45AT024B

3/13AT022K3/12AT005R

3/11AT030H2/7AT032V

7/23AT023K12/35AT032B

3/8AT005N2/5AT005J

3/7AT005C

Figure 2.Proportion (%) PNSP by laboratory (2005 & 2006)

0 25 50 75 100

0/51AT001

0/15AT007

0/8AT009

0/10AT011

0/12AT012

0/10AT014

0/16AT019

0/5AT021

0/18AT022

0/14AT024

0/27AT026

0/25AT027

0/5AT030

0/12AT031

0/12AT032

0/5AT034

0/8AT035

1/37AT025

1/30AT016

2/46AT005

2/36AT028

1/12AT015

3/33AT010

2/19AT033

1/8AT003

5/39AT006

6/36AT002

3/16AT018

2/8AT029











1999 92 846 47 442 0 0 0 0 0 0 0 02000 90 909 42 657 0 0 0 0 0 0 0 02001 89 1093 47 941 23 226 19 42 0 0 0 02002 98 1210 48 1092 27 1184 23 205 0 0 0 02003 107 1488 47 1133 24 1326 16 146 0 0 0 02004 95 1443 49 1227 25 1601 18 228 0 0 0 02005 97 1539 41 1048 25 1592 19 224 0 0 0 02006 98 1427 33 858 21 1632 22 267 0 0 0 0


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R 4 5 <1 <1 <1 <1 3 4

Penicillin I+R 13 16 13 14 12 9 12 10Macrolides I+R 31 34 35 34 34 33 31 31

S. aureus Oxacillin/Methicillin R 23 21 23 28 29 33 31 22E. coli Aminopenicillins R . . 53 47 50 50 53 54

Aminoglycosides R . . 4 6 5 5 4 6Fluoroquinolones R . . 9 13 12 15 17 193rd gen. Cephalosporins R . . 2 3 3 3 4 3

E. faecalis Aminopenicillins I+R . . <1 <1 1 2 <1 <1HL Aminoglycosides R . . 20 20 17 22 26 30Glycopeptides R . . <1 <1 1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 60 56 78 63 61 67HL Aminoglycosides R . . <1 5 <1 11 22 19Glycopeptides R . . <1 <1 <1 5 14 4

K. pneumoniae Aminoglycosides R . . . . . . . .Fluoroquinolones R . . . . . . . .3rd gen. Cephalosporins R . . . . . . . .

P. aeruginosa Piperacillin R . . . . . . . .Ceftazidime R . . . . . . . .Carbapenems R . . . . . . . .Aminoglycosides R . . . . . . . .Fluoroquinolones R . . . . . . . .


BelgiumGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1906

E. colin=3015

E. faecalisn=395

E. faeciumn=91

K. pneumo.n=0

P. aeruginosan=0


Blood 95 11 100 27 100 18 100 0 100 9 . . . .CSF 5 13 0 . 0 . 0 . 0 . . . . .

GenderMale 53 11 59 27 44 19 62 0 59 9 . . . .Female 45 11 40 27 56 18 36 0 37 6 . . . .Unknown 2 10 1 14 0 . 2 0 3 33 . . . .

Age (years)0-4 20 16 4 10 2 7 4 0 3 0 . . . .5-19 6 3 2 5 1 14 1 0 0 . . . . .20-64 31 7 34 21 28 18 27 0 37 6 . . . .65 and over 43 12 58 33 69 19 69 0 59 11 . . . .Unknown 0 . 1 22 0 . 0 . 0 . . . . .

Hospital dep.ICU 13 12 16 29 2 32 22 0 24 9 . . . .Internal Med. 34 10 36 31 4 20 35 0 34 6 . . . .Surgery 2 0 12 34 1 29 7 0 2 0 . . . .Other 29 13 27 18 3 9 26 0 27 8 . . . .Unknown 23 11 9 27 91 18 11 0 12 18 . . . .




no of hospitals : 57Minimum : 6.51st quartile : 15.6Median : 23.63rd quartile : 34.4Maximum : 100



0 25 50 75 100

2/31BE001X1/15BE074X4/55BE061A2/24BE008X

1/10BE057A1/8BE057X6/47BE112X4/30BE032X4/30BE077X7/52BE063X5/37BE061X6/42BE077A7/48BE060A2/13BE005X5/32BE041X5/31BE006X5/31BE024X3/18BE007X8/45BE003A4/22BE002X11/60BE097X15/79BE115X1/5BE054X2/10BE075A7/33BE001A5/23BE063A9/40BE041A3/13BE019A13/55BE060X

14/56BE016A7/27BE115A5/19BE022A4/15BE056X

16/57BE112A2/7BE019X

12/40BE006A25/80BE074A7/22BE029A21/66BE070X

11/33BE002A3/9BE007A2/6BE114A21/61BE016X9/26BE143A21/59BE097A10/28BE022X

23/57BE008A10/24BE030A

13/29BE024A13/29BE143X

14/30BE056A6/12BE005A

20/37BE032A42/77BE070A

8/14BE030X7/9BE014A

8/8BE045X


0 25 50 75 100

0/6BE0050/12BE0090/5BE0110/9BE0120/5BE0130/21BE0350/25BE0510/15BE0720/15BE1370/8BE160

1/35BE0231/32BE0541/31BE0101/28BE0041/26BE0602/50BE0241/24BE0481/23BE0643/62BE0753/60BE0082/38BE0022/37BE0221/18BE0762/35BE0491/17BE1052/31BE1033/46BE0461/14BE0693/39BE0261/13BE0833/38BE0634/48BE0611/12BE1003/35BE0373/34BE0213/34BE0902/22BE0841/11BE1565/53BE0166/62BE0304/41BE0746/61BE0972/20BE0072/20BE0333/30BE1439/88BE0913/29BE10915/143BE1082/19BE11411/101BE0452/18BE0031/9BE1071/9BE1111/9BE1643/26BE05711/95BE0702/17BE0292/16BE1022/16BE1504/31BE0194/31BE0777/54BE0567/54BE1393/23BE1612/15BE07313/96BE0433/22BE0719/66BE1155/35BE0983/21BE10111/73BE00116/106BE0928/53BE1045/32BE0937/44BE006

7/41BE0323/17BE11011/61BE1122/11BE017

7/35BE0141/5BE0652/10BE129

3/14BE1183/14BE1662/9BE116

4/17BE0312/6BE0444/12BE152

10/25BE095











1999 0 0 0 0 0 0 0 0 0 0 0 02000 8 13 16 111 0 0 0 0 0 0 0 02001 8 16 17 103 15 98 11 30 0 0 0 02002 11 25 21 116 20 135 16 42 0 0 0 02003 13 22 20 157 20 158 16 49 0 0 0 02004 13 32 22 169 20 167 16 75 0 0 0 02005 16 43 26 160 23 203 21 95 15 34 9 342006 11 29 23 159 20 196 19 98 15 55 13 31


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . 23 6 8 9 22 30 7




E. faecalis Aminopenicillins I+R . . 5 26 7 15 8 31HL Aminoglycosides R . . 30 63 36 33 24 53Glycopeptides R . . <1 <1 <1 2 <1 2

E. faecium Aminopenicillins I+R . . 50 71 60 59 96 97HL Aminoglycosides R . . 33 83 60 62 56 79Glycopeptides R . . <1 <1 <1 <1 <1 <1




BulgariaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=319

E. colin=387

E. faecalisn=125

E. faeciumn=59

K. pneumo.n=89

P. aeruginosan=60


Blood 54 26 100 29 98 27 100 1 100 0 100 56 100 27CSF 46 18 0 . 2 50 0 . 0 . 0 . 0 .

GenderMale 60 19 63 31 54 37 62 0 59 0 64 56 57 32Female 40 28 37 26 45 16 38 2 41 0 36 56 43 19Unknown 0 . 0 . 1 33 0 . 0 . 0 . 0 .

Age (years)0-4 7 60 11 38 7 4 13 0 12 0 9 63 3 05-19 14 0 3 36 4 27 1 0 2 0 3 100 2 020-64 57 20 58 28 46 31 57 1 53 0 53 62 63 2165 and over 22 31 28 28 43 28 30 0 34 0 35 42 32 42Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 25 17 16 58 14 31 18 0 29 0 16 64 35 33Internal Med. 26 26 33 14 43 20 33 2 25 0 27 42 10 17Surgery 0 . 10 42 13 45 11 0 10 0 22 60 20 8Other 49 23 41 27 29 28 38 0 36 0 35 61 35 33Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/11BG007A

0/5BG014A

0/5BG022A

1/17BG030A

1/13BG013A

2/25BG023A

2/12BG005A

3/15BG027A

5/22BG003A

4/15BG011A

9/33BG001A

9/28BG018A

3/9BG024A

4/11BG029A

3/8BG021A

4/10BG002A

5/10BG020A

12/21BG006A

4/7BG012A

7/12BG009A

4/6BG026A

11/13BG015A


0 25 50 75 100

0/8BG013

0/12BG023

0/6BG030

2/7BG003

3/9BG011











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 10 20 14 149 13 182 7 33 0 0 0 02002 14 90 14 279 15 490 13 96 0 0 0 02003 12 88 14 360 16 570 11 101 0 0 0 02004 12 103 13 392 14 535 11 115 0 0 0 02005 15 129 17 354 16 638 11 120 14 112 10 722006 14 116 17 391 17 780 16 178 15 205 15 170


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . <1 <1 1 3 <1 <1

Penicillin I+R . . 15 19 20 17 17 18Macrolides I+R . . 15 23 18 19 17 16

S. aureus Oxacillin/Methicillin R . . 32 37 37 38 37 36E. coli Aminopenicillins R . . 51 47 46 45 46 51

Aminoglycosides R . . 6 7 7 6 5 6Fluoroquinolones R . . 5 5 7 8 9 153rd gen. Cephalosporins R . . 2 3 4 3 <1 1

E. faecalis Aminopenicillins I+R . . 13 5 4 5 6 3HL Aminoglycosides R . . 50 40 28 35 31 37Glycopeptides R . . 3 <1 <1 <1 1 <1

E. faecium Aminopenicillins I+R . . 100 56 47 69 82 69HL Aminoglycosides R . . 100 67 41 63 62 59Glycopeptides R . . <1 22 6 3 6 3




CroatiaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=745

E. colin=1413

E. faecalisn=228

E. faeciumn=68

K. pneumo.n=317

P. aeruginosan=242


Blood 98 18 100 37 100 12 100 1 100 4 100 38 100 24CSF 2 20 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 60 18 64 41 42 13 59 1 69 4 62 44 66 26Female 40 17 35 30 58 12 41 0 31 5 38 29 34 22Unknown 0 . 1 50 0 . 0 . 0 . 0 . 0 .


Hospital dep.ICU 12 14 18 64 7 10 14 0 19 0 15 46 22 28Internal Med. 22 24 42 22 39 13 37 1 40 4 27 25 27 20Surgery 0 . 12 73 3 25 13 0 6 0 11 35 18 26Other 66 16 28 25 51 12 36 1 35 8 47 44 33 25Unknown 0 . 0 . 0 . 1 0 0 . 0 . 0 .







0 25 50 75 100

0/6HR010A

2/24HR010H

3/35HR009A

1/8HR016A

2/15HR014A

13/64HR004A

11/47HR011A

2/8HR017A

4/14HR002C

7/21HR018A

22/64HR002A

15/38HR008A

5/12HR020A

72/171HR001A

8/19HR013A

90/171HR007A

7/12HR027A

6/9HR002B


0 25 50 75 100

0/5HR017

0/6HR020

1/15HR005

1/11HR004

15/110HR002

3/20HR007

5/25HR001

3/12HR010

2/8HR013

2/7HR014

3/7HR009

3/7HR018

5/7HR011



TotalLabs providing denom.data/reporting data to EARSS 5/5Hosps providing denom.data/reporting data to EARSS 5/5Number of blood culture sets 9,458Number of hospital beds 1,291Patient-days 345,646Average occupancy rate (%) 73%Median length of stay (days) 5Estimated catchment population 428,921% total population covered 54%Type of participating hospitals Regional/Tertiary 20% Provincial/Secondary 20% District/Primary 40%








1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 0 0 0 0 0 0 0 0 0 02002 0 0 0 0 0 0 0 0 0 0 0 02003 1 3 1 28 1 19 1 28 0 0 0 02004 1 7 3 39 4 46 3 38 0 0 0 02005 4 16 5 54 5 74 3 40 4 9 4 82006 5 13 5 62 5 90 4 48 4 26 4 37


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . . . <1 <1 <1 31

Penicillin I+R . . . . <1 14 19 38Macrolides I+R . . . . 33 <1 13 31

S. aureus Oxacillin/Methicillin R . . . . 64 49 56 32E. coli Aminopenicillins R . . . . 63 61 73 62

Aminoglycosides R . . . . 11 11 14 10Fluoroquinolones R . . . . 32 22 29 353rd gen. Cephalosporins R . . . . 11 9 16 16

E. faecalis Aminopenicillins I+R . . . . <1 3 3 5HL Aminoglycosides R . . . . 43 77 71 44Glycopeptides R . . . . <1 3 <1 <1

E. faecium Aminopenicillins I+R . . . . 100 100 80 43HL Aminoglycosides R . . . . . 33 <1 14Glycopeptides R . . . . <1 33 40 14




CyprusGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=116

E. colin=161

E. faecalisn=76

E. faeciumn=12

K. pneumo.n=35

P. aeruginosan=44


Blood 76 27 100 43 100 32 100 0 100 25 100 29 100 11CSF 24 29 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 66 32 67 42 48 42 63 0 75 22 66 30 66 14Female 34 20 33 45 50 24 36 0 25 33 34 25 34 7Unknown 0 . 0 . 2 0 1 0 0 . 0 . 0 .

Age (years)0-4 7 0 3 0 4 0 0 . 0 . 3 0 0 .5-19 14 25 3 25 2 33 0 . 0 . 3 0 0 .20-64 3 0 10 33 14 23 7 0 8 100 0 . 11 065 and over 7 50 12 43 19 27 18 0 25 0 14 20 11 0Unknown 69 30 71 48 62 38 75 0 67 25 80 32 77 15

Hospital dep.ICU 3 0 25 55 12 37 21 0 25 0 26 22 25 0Internal Med. 55 38 29 32 49 38 28 0 25 0 34 17 27 0Surgery 0 . 12 71 6 22 30 0 42 40 11 50 27 25Other 41 17 34 33 32 21 21 0 8 100 29 40 20 22Unknown 0 . 0 . 1 100 0 . 0 . 0 . 0 .







0 25 50 75 100

1/9CY005A

2/8CY004A

6/17CY003A

11/24CY002A

30/58CY001A


0 25 50 75 100

2/8CY003

2/7CY002

4/10CY001











1999 0 0 0 0 0 0 0 0 0 0 0 02000 26 111 31 515 0 0 0 0 0 0 0 02001 32 154 39 1074 36 1176 34 461 0 0 0 02002 34 144 41 1168 40 1587 39 587 0 0 0 02003 32 204 45 1387 43 1766 44 630 0 0 0 02004 37 162 45 1444 44 1966 41 660 0 0 0 02005 39 194 47 1553 47 2234 45 758 37 478 36 2572006 39 172 47 1520 47 2165 45 695 45 1125 43 486


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . <1 <1 <1 <1 2 <1 <1




E. faecalis Aminopenicillins I+R . . 3 2 4 <1 <1 2HL Aminoglycosides R . . 38 39 44 43 45 43Glycopeptides R . . 2 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 67 73 80 81 92 90HL Aminoglycosides R . . 33 35 48 43 69 74Glycopeptides R . . 2 9 3 3 14 4




Czech RepublicGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=3073

E. colin=4366

E. faecalisn=1060

E. faeciumn=392

K. pneumo.n=1603

P. aeruginosan=742


Blood 79 3 100 13 100 22 100 0 100 9 100 34 99 32CSF 21 1 0 . 0 . 0 . 0 . 0 . 1 75

GenderMale 62 3 60 12 42 25 62 0 56 8 62 36 62 35Female 38 4 40 13 58 19 38 0 44 11 38 31 38 27Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .


Hospital dep.ICU 27 3 23 18 17 25 42 0 38 1 38 45 38 43Internal Med. 38 4 48 11 52 21 31 0 25 7 35 24 32 25Surgery 1 0 10 16 8 23 9 0 7 4 11 32 7 25Other 33 2 18 10 23 19 18 0 30 22 16 31 23 27Unknown 1 0 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/8CZ007D0/12CZ009B0/12CZ014A0/15CZ029A0/8CZ031F0/23CZ032A0/5CZ034B0/6CZ034C0/6CZ037D0/11CZ040A0/5CZ040C0/22CZ045A0/26CZ046A0/14CZ047A0/8CZ048A0/13CZ048B

1/53CZ019A1/30CZ037A7/188CZ006A2/44CZ004A2/42CZ038A3/55CZ026A2/36CZ036A1/16CZ022B6/89CZ021A

8/102CZ027A3/38CZ017B3/37CZ008A1/12CZ015B4/48CZ030A7/83CZ002A

5/53CZ034A12/123CZ009A18/178CZ018A7/67CZ007A12/113CZ020A11/99CZ016A2/18CZ019B4/36CZ025A14/121CZ024A5/43CZ044A5/42CZ013A4/32CZ022A1/8CZ031K8/61CZ035A5/37CZ011A5/36CZ049A14/99CZ015A1/7CZ028A

4/24CZ012A3/18CZ031P1/6CZ043C

9/51CZ023A4/22CZ017C22/118CZ031A19/99CZ017A6/31CZ041A1/5CZ007E3/15CZ031J

4/19CZ039A3/14CZ012B2/9CZ012C

20/83CZ033A2/8CZ031Y

5/19CZ043B20/75CZ003A

11/36CZ042A2/6CZ031C2/6CZ050A

3/8CZ039B4/10CZ007B

45/107CZ005A


0 25 50 75 100

0/11CZ002

0/9CZ003

0/8CZ004

0/10CZ007

0/7CZ008

0/28CZ009

0/9CZ012

0/5CZ013

0/7CZ014

0/16CZ015

0/36CZ016

0/13CZ017

0/15CZ022

0/5CZ023

0/6CZ026

0/14CZ027

0/6CZ029

0/5CZ030

0/5CZ032

0/6CZ037

0/7CZ041

0/5CZ044

0/5CZ046

1/34CZ006

1/13CZ049

1/9CZ019

3/19CZ024

3/16CZ031

2/8CZ025











1999 0 0 5 718 0 0 0 0 0 0 0 02000 5 410 4 501 0 0 0 0 0 0 0 02001 5 506 4 520 0 0 0 0 0 0 0 02002 5 366 5 752 0 0 0 0 0 0 0 02003 5 606 5 671 0 0 0 0 0 0 0 02004 15 1188 15 1436 1 1 0 0 0 0 0 02005 14 1081 15 1350 5 1283 0 0 0 0 0 02006 15 872 15 1279 11 2723 11 727 11 607 0 0


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . <1 <1 <1 <1 <1 <1 <1


S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 1 2 2E. coli Aminopenicillins R . . . . . <1 39 41

Aminoglycosides R . . . . . <1 2 3Fluoroquinolones R . . . . . . 5 73rd gen. Cephalosporins R . . . . . <1 1 2

E. faecalis Aminopenicillins I+R . . . . . . . <1HL Aminoglycosides R . . . . . . . .Glycopeptides R . . . . . . . <1

E. faecium Aminopenicillins I+R . . . . . . . 87HL Aminoglycosides R . . . . . . . .Glycopeptides R . . . . . . . <1

K. pneumoniae Aminoglycosides R . . . . . . . 2Fluoroquinolones R . . . . . . . 63rd gen. Cephalosporins R . . . . . . . 4

P. aeruginosa Piperacillin R . . . . . . . .Ceftazidime R . . . . . . . .Carbapenems R . . . . . . . .Aminoglycosides R . . . . . . . .Fluoroquinolones R . . . . . . . .


*

* Except for E. coli, K. pneumoniae and enterococci: 3971,000 (73%)

DenmarkGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=2629

E. colin=3128

E. faecalisn=132

E. faeciumn=83

K. pneumo.n=430

P. aeruginosan=0


Blood 92 4 100 2 100 6 100 1 100 0 100 4 . .CSF 8 6 0 . 0 . 0 . 0 . 0 . . .

GenderMale 47 4 31 2 45 7 68 1 61 0 60 5 . .Female 53 4 19 1 55 5 32 0 39 0 40 2 . .Unknown 0 . 50 2 0 . 0 . 0 . 0 . . .

Age (years)0-4 9 3 4 1 2 4 1 0 0 . 2 0 . .5-19 3 4 3 1 1 0 0 . 0 . 1 0 . .20-64 37 3 38 2 30 8 23 0 34 0 36 7 . .65 and over 52 5 56 2 68 6 76 1 66 0 62 2 . .Unknown 0 . 0 . 0 . 0 . 0 . 0 . . .

Hospital dep.ICU 0 . 2 2 3 8 10 0 29 0 9 0 . .Internal Med. 0 . 21 1 53 6 43 2 30 0 45 3 . .Surgery 0 . 8 3 20 6 23 0 36 0 21 3 . .Other 0 . 8 1 24 6 23 0 5 0 24 7 . .Unknown 100 4 62 2 0 . 0 . 0 . 1 33 . .







0 25 50 75 100

0/85DK002A0/82DK002B0/38DK002F0/75DK005A0/61DK006A0/15DK008A0/47DK009A0/15DK009F0/5DK009G0/8DK010B0/86DK011A0/7DK012A0/41DK013A0/22DK014A0/99DK014B0/57DK014C0/79DK014N0/60DK015A0/10DK015C0/60DK016B0/17DK016C0/18DK016D0/11DK016F0/24DK016G0/7DK016H1/193DK001A1/84DK003B1/71DK013B3/210DK009B1/52DK006B3/148DK016A1/49DK012F1/45DK002E4/172DK003C2/86DK004A2/78DK010A1/30DK012B2/50DK014D1/23DK004C2/45DK005B2/44DK012D1/20DK004B7/112DK003A

4/33DK012E2/14DK006C

1/6DK011D


0 25 50 75 100

0/43DK001

0/104DK006

2/85DK015

3/105DK005

2/69DK007

8/259DK014

7/226DK016

8/228DK003

3/71DK013

9/173DK009

4/76DK011

8/147DK004

8/145DK012

18/221DK002











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 1 1 0 0 0 0 0 02001 5 20 6 79 4 52 4 21 0 0 0 02002 5 21 8 81 6 67 3 13 0 0 0 02003 8 26 9 98 9 98 6 27 0 0 0 02004 6 40 9 104 10 166 5 63 0 0 0 02005 7 53 8 141 10 156 7 66 7 38 5 382006 8 52 9 154 9 215 8 85 6 47 6 43


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . <1 <1 <1 <1 <1 <1

Penicillin I+R . . <1 <1 <1 <1 2 2Macrolides I+R . . 5 <1 10 6 <1 3

S. aureus Oxacillin/Methicillin R . . 5 1 4 5 2 3E. coli Aminopenicillins R . <1 43 42 42 55 45 52

Aminoglycosides R . <1 8 10 3 2 4 2Fluoroquinolones R . <1 <1 5 5 6 5 73rd gen. Cephalosporins R . <1 6 2 1 4 1 <1

E. faecalis Aminopenicillins I+R . . 8 10 4 14 14 9HL Aminoglycosides R . . <1 50 22 32 50 35Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 63 33 75 79 83 84HL Aminoglycosides R . . 63 67 50 79 74 78Glycopeptides R . . <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . 8 9Fluoroquinolones R . . . . . . <1 53rd gen. Cephalosporins R . . . . . . 8 9



EstoniaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=295

E. colin=349

E. faecalisn=84

E. faeciumn=54

K. pneumo.n=84

P. aeruginosan=79


Blood 78 2 100 3 99 6 100 0 100 0 100 8 100 33CSF 22 0 0 . 1 0 0 . 0 . 0 . 0 .


Age (years)0-4 9 0 10 7 3 9 18 0 11 0 18 7 5 255-19 4 0 4 0 1 0 0 . 6 0 0 . 5 5020-64 56 3 51 2 47 4 33 0 37 0 38 6 48 5365 and over 27 0 31 3 46 7 46 0 43 0 40 12 39 10Unknown 5 0 3 0 2 13 2 0 4 0 4 0 3 0

Hospital dep.ICU 33 6 26 5 19 7 37 0 35 0 25 5 57 36Internal Med. 29 0 32 0 42 4 20 0 19 0 24 10 9 14Surgery 3 0 11 0 8 14 4 0 6 0 6 0 5 25Other 34 0 31 4 31 6 38 0 41 0 45 11 29 35Unknown 1 0 1 0 0 . 1 0 0 . 0 . 0 .







0 25 50 75 100

0/5EE003R

0/39EE004P

0/15EE005P

0/33EE009K

0/7EE010N

1/31EE006K

2/48EE002M

4/93EE001A

1/15EE002L


0 25 50 75 100

0/22EE002

0/8EE004

0/8EE005

0/17EE006

1/30EE001

1/14EE009











1999 14 242 13 316 0 0 0 0 0 0 0 02000 9 176 12 362 0 0 0 0 0 0 0 02001 13 425 13 606 14 1284 13 274 0 0 0 02002 15 453 15 721 15 1330 14 278 0 0 0 02003 16 490 16 727 15 1450 15 266 0 0 0 02004 17 508 17 882 17 1749 17 336 0 0 0 02005 16 525 17 790 17 1924 17 341 14 175 13 1082006 15 493 15 891 15 1875 15 348 14 228 14 163


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R <1 <1 1 2 2 <1 <1 2


S. aureus Oxacillin/Methicillin R <1 1 <1 <1 1 3 3 3E. coli Aminopenicillins R . . 33 30 33 33 35 36

Aminoglycosides R . . <1 <1 1 2 2 2Fluoroquinolones R . . 5 6 5 7 7 83rd gen. Cephalosporins R . . <1 <1 <1 2 2 2

E. faecalis Aminopenicillins I+R . . 1 2 <1 <1 <1 <1HL Aminoglycosides R . . 23 13 39 38 27 25Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 66 80 79 69 78 80HL Aminoglycosides R . . <1 <1 4 12 1 16Glycopeptides R . . <1 1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . 3 1Fluoroquinolones R . . . . . . 3 43rd gen. Cephalosporins R . . . . . . 2 <1



FinlandGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1681

E. colin=3618

E. faecalisn=431

E. faeciumn=217

K. pneumo.n=403

P. aeruginosan=257


Blood 96 10 100 3 100 8 100 0 100 0 100 1 98 10CSF 4 8 0 . 0 . 0 . 0 . 0 . 2 17


Age (years)0-4 16 14 4 3 2 1 7 0 2 0 1 17 0 .5-19 4 8 5 3 1 11 1 0 2 0 2 0 2 020-64 48 8 43 3 31 6 29 0 41 0 30 2 34 1665 and over 33 9 48 4 66 9 62 0 54 1 67 1 64 8Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 1 0 3 7 1 9 7 0 4 0 3 0 6 33Internal Med. 10 14 15 2 10 4 14 0 12 0 14 2 9 17Surgery 2 0 7 7 4 11 10 0 12 0 10 0 7 11Other 42 10 31 2 35 7 29 0 29 0 27 1 26 12Unknown 45 8 44 3 49 9 39 0 43 1 47 2 51 6







0 25 50 75 100

0/64FI008X

0/24FI00AA

0/94FI00CX

0/65FI012X

0/61FI014A

0/19FI017X

2/192FI00EX

1/55FI003A

1/44FI00LX

5/159FI00HX

4/119FI005X

2/56FI011A

2/48FI010X

24/542FI002X

2/32FI001X

4/53FI009X

5/54FI015X


0 25 50 75 100

0/9FI009

0/21FI00L

2/49FI001

3/48FI003

3/48FI005

7/100FI00E

4/57FI008

2/24FI014

28/299FI002

16/152FI00H

1/9FI017

4/32FI015

5/39FI012

7/49FI00C

6/42FI011

4/24FI010

4/16FI00A


Table 1.Reference data of 2006, based on laboratories/hospitals providing denominator data*

TotalLabs providing denom.data/reporting data to EARSS 16/53Hosps providing denom.data/reporting data to EARSS 16/50Number of blood culture sets 300,210

569,02sdeblatipsohforebmuN344,489,5syad-tneitaP

%87)%(etarycnapuccoegarevA8)syad(yatsfohtgnelnaideMannoitalupoptnemhctacdetamitsEanderevocnoitalupoplatot%

Type of participating hospitals%001yraitreT/lanoigeR%0yradnoceS/laicnivorP%0yramirP/tcirtsiD








1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 329 1337 21 1714 0 0 0 0 0 0 0 02002 296 1132 21 1663 21 2495 21 467 0 0 0 02003 403 1389 21 1708 21 2267 21 483 0 0 0 02004 403 515 50 3347 50 5678 50 882 0 0 0 02005 195 632 50 3483 50 6056 47 1023 49 839 48 9932006 97 371 50 3818 50 6718 50 1154 50 963 47 1006


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . 11 8 . . 5 4


S. aureus Oxacillin/Methicillin R . . 33 33 29 29 27 27E. coli Aminopenicillins R . . . 52 50 47 50 53

Aminoglycosides R . . . 4 5 4 5 6Fluoroquinolones R . . . 8 9 8 11 143rd gen. Cephalosporins R . . . <1 <1 <1 1 2

E. faecalis Aminopenicillins I+R . . . 5 3 1 <1 1HL Aminoglycosides R . . . 15 16 17 15 16Glycopeptides R . . . <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . . 34 30 56 64 69HL Aminoglycosides R . . . 10 23 21 24 30Glycopeptides R . . . 2 <1 5 2 3



Figure 1. Geographic distribution of laboratories in 2006* Denominator data from one surveillance network, reporting all pathogens except S. pneumoniae )snegohtaprehtollanognitroper:thgir,eainomuenp.Snognitroper:tfel( )snegohtaprehtollanognitroper:thgir,eainomuenp.Snognitroper:tfel(

FranceGeneral Information about EARSS participating laboratories and hospitals


*

* First half of 2006




S. aureusn=7301

E. colin=12655

E. faecalisn=1694

E. faeciumn=415

K. pneumo.n=1787

P. aeruginosan=1988


Blood 77 48 100 27 100 12 100 0 100 3 100 5 100 13CSF 23 46 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 29 60 3 10 2 3 3 0 2 0 2 2 2 35-19 6 26 3 8 1 8 1 0 1 0 1 4 2 1420-64 30 37 40 19 34 12 37 0 44 3 42 7 44 1865 and over 34 49 53 35 63 13 59 0 53 2 54 4 52 10Unknown 1 90 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 0 . 17 28 9 16 26 0 24 2 14 10 28 21Internal Med. 100 35 35 28 30 12 29 0 29 3 34 4 28 9Surgery 0 . 16 27 12 15 17 0 18 5 17 6 14 13Other 0 . 32 25 48 11 28 0 28 2 34 4 31 9Unknown 0 . 1 25 1 16 1 0 1 0 0 . 0 .







0 25 50 75 100

1/16FR84A5/29FR202A10/56FR194A6/32FR095A22/114FR362A54/279FR248A101/520FR263A16/81FR164A21/104FR135A25/119FR213A23/108FR134A58/272FR040A58/269FR226A20/89FR126A71/312FR076A43/188FR165A7/30FR145A47/201FR121A14/59FR401A

15/59FR098A72/283FR010A6/23FR191A10/38FR193A61/230FR138A88/328FR094A12/44FR120A83/301FR246A30/108FR224A39/140FR259A9/32FR252A105/361FR238A7/24FR084A57/194FR250A39/130FR105A22/73FR008A26/85FR037A54/176FR260A35/113FR009A44/141FR067A86/275FR109A26/83FR276A59/182FR064A

18/53FR046A16/47FR400A

124/349FR479A5/14FR208A8/22FR109B30/80FR237A8/21FR179A26/68FR403A

10/25FR015A19/47FR211A

86/202FR249A30/67FR055A


0 25 50 75 100

0/7FR2261/14FR249

1/9FR0431/8FR162

1/6FR1752/12FR4671/6FR473

1/5FR0361/5FR1731/5FR4491/5FR5031/5FR507

3/14FR1272/9FR1313/13FR476

10/41FR2695/20FR0102/8FR0382/8FR2322/8FR2792/8FR5059/35FR194

3/11FR2703/11FR271

2/7FR0408/28FR1302/7FR2142/7FR2192/7FR4025/17FR2638/27FR1376/20FR213

2/6FR0042/6FR0512/6FR0653/9FR0712/6FR2462/6FR267

5/14FR0944/11FR999

3/8FR1386/16FR2383/8FR492

2/5FR0062/5FR0242/5FR0602/5FR1254/10FR276

3/7FR0203/7FR498

6/13FR4793/6FR0565/10FR0673/6FR1867/14FR273

6/11FR1674/7FR2547/12FR108

3/5FR0093/5FR1586/10FR1643/5FR1886/10FR499

8/13FR2504/6FR0684/6FR1204/6FR277

7/9FR1424/5FR139











1999 23 417 25 1239 1 166 1 44 0 0 0 02000 18 204 19 890 1 180 1 28 0 0 0 02001 21 211 22 1220 21 1269 20 294 0 0 0 02002 17 248 18 1066 16 1068 14 290 0 0 0 02003 17 175 20 919 19 997 17 347 0 0 0 02004 16 143 22 1106 22 1217 22 607 0 0 0 02005 15 119 17 826 17 961 17 569 12 105 12 1172006 13 83 17 775 17 834 15 520 14 146 12 162


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R <1 <1 1 <1 <1 <1 <1 1


S. aureus Oxacillin/Methicillin R 8 12 16 18 18 20 21 20E. coli Aminopenicillins R 36 47 46 49 47 55 54 61

Aminoglycosides R 5 7 5 5 5 4 6 10Fluoroquinolones R 4 8 11 15 14 24 23 293rd gen. Cephalosporins R <1 <1 <1 <1 <1 2 2 4

E. faecalis Aminopenicillins I+R <1 <1 8 10 7 7 3 3HL Aminoglycosides R . . 31 42 47 42 34 29Glycopeptides R <1 <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R 40 50 79 80 78 93 96 94HL Aminoglycosides R . . 43 68 47 61 52 37Glycopeptides R <1 <1 1 4 3 11 10 8




GermanyGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1601

E. colin=1787

E. faecalisn=599

E. faeciumn=484

K. pneumo.n=249

P. aeruginosan=279


Blood 92 5 100 21 99 26 100 0 100 9 99 11 97 20CSF 8 0 0 . 1 11 0 . 0 . 1 0 3 22

GenderMale 57 4 64 20 49 28 61 0 59 9 56 10 66 16Female 40 5 35 21 51 24 39 0 40 9 44 12 34 28Unknown 3 0 1 33 1 18 0 . 1 33 0 . 0 .


Hospital dep.ICU 26 8 24 25 19 28 33 0 46 8 26 11 25 34Internal Med. 40 5 38 17 43 21 27 0 19 10 35 3 27 12Surgery 1 0 14 22 9 29 13 1 11 2 9 9 10 21Other 33 2 23 20 29 32 27 0 23 15 29 21 37 17Unknown 0 . 1 22 1 13 1 0 1 0 1 0 1 0







0 25 50 75 100

0/9DE0202A

0/13DE30101

2/41DE1301X

1/16DE20601

1/14DE10701

1/14DE40201

3/31DE401A

14/132DE0109A

2/18DE30110

1/8DE30109

7/55DE0105A

17/130DE10201

2/12DE0206X

6/36DE1401A

48/272DE0906A

1/5DE20602

28/135DE1602A

38/169DE1403A

12/52DE120301

20/84DE1302A

24/95DE100B

2/6DE40202

54/152DE0805A

3/8DE10202

2/5DE10702

4/10DE202A

2/5DE40204

10/22DE30108

6/13DE30103

5/9DE401D


0 25 50 75 100

0/13DE0107

0/8DE0206

0/13DE0302

0/5DE1203

0/14DE1301

0/5DE1401

0/7DE1602

1/33DE0102

1/27DE0805

1/15DE1302

2/28DE0109

1/12DE0105

1/11DE0301

1/10DE1403



TotalLabs providing denom.data/reporting data to EARSS naHosps providing denom.data/reporting data to EARSS naNumber of blood culture sets naNumber of hospital beds naPatient-days naAverage occupancy rate (%) naMedian length of stay (days) naEstimated catchment population na% total population covered naType of participating hospitals Regional/Tertiary na Provincial/Secondary na District/Primary na








1999 0 0 19 192 0 0 0 0 0 0 0 02000 0 0 15 363 16 395 12 197 0 0 0 02001 0 0 25 360 26 619 25 304 0 0 0 02002 0 0 33 368 35 588 28 293 0 0 0 02003 0 0 34 666 35 1076 32 623 0 0 0 02004 0 0 35 609 39 1131 34 566 0 0 0 02005 0 0 35 681 35 1140 34 737 33 774 33 6992006 0 0 42 826 41 1253 39 948 38 841 38 818


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . . . . . . .

Penicillin I+R . . . . . . . .Macrolides I+R . . . . . . . .

S. aureus Oxacillin/Methicillin R 31 50 39 44 45 44 42 43E. coli Aminopenicillins R . 42 47 45 44 46 46 46

Aminoglycosides R . 4 4 7 6 6 7 7Fluoroquinolones R . 4 9 13 12 12 12 143rd gen. Cephalosporins R . 4 5 6 6 6 7 6

E. faecalis Aminopenicillins I+R . 8 8 4 4 4 3 5HL Aminoglycosides R . 52 57 60 52 59 54 58Glycopeptides R . <1 7 13 7 4 4 5

E. faecium Aminopenicillins I+R . 83 86 75 89 84 85 88HL Aminoglycosides R . 25 45 52 40 52 34 35Glycopeptides R . <1 15 19 18 20 37 42




GreeceGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1507

E. colin=2386

E. faecalisn=1102

E. faeciumn=578

K. pneumo.n=1615

P. aeruginosan=1513


Blood . . 100 43 100 13 100 5 100 40 98 59 97 42CSF . . 0 . 0 . 0 . 0 . 2 72 3 79

GenderMale . . 11 44 9 14 8 5 12 41 9 48 10 47Female . . 6 44 11 10 5 7 9 58 7 52 5 46Unknown . . 83 42 79 14 86 5 79 38 85 61 86 43

Age (years)0-4 . . 2 43 2 20 3 10 2 46 2 66 1 415-19 . . 0 . 0 . 0 . 0 . 0 . 0 .20-64 . . 1 40 2 22 1 7 2 64 2 54 2 4265 and over . . 2 66 1 15 2 5 3 47 2 50 1 32Unknown . . 95 42 94 13 94 5 92 39 94 59 95 44

Hospital dep.ICU . . 14 64 3 18 35 4 28 43 46 83 47 53Internal Med. . . 67 36 78 12 44 5 50 41 35 32 37 31Surgery . . 12 62 12 21 15 4 16 34 15 55 13 46Other . . 3 29 2 4 1 0 2 36 2 36 1 18Unknown . . 4 37 4 9 4 15 4 35 2 40 2 31






0 25 50 75 100

0/6GR018X0/5GR032X0/6GR048X

2/24GR035A1/8GR057A

1/7GR018A2/11GR042A

1/5GR044X2/9GR051A

4/17GR027A13/53GR059X4/16GR013X2/8GR052X

5/19GR027X12/43GR059A

5/17GR050X4/13GR026A4/13GR028A5/16GR007X10/31GR013A11/34GR037X3/9GR010X6/18GR015A9/27GR037A6/18GR042X2/6GR048A3/9GR055X3/9GR056X

18/49GR033X10/27GR031X6/16GR001X3/8GR004A9/24GR066X5/13GR050A

2/5GR004X2/5GR009A

5/12GR049X5/12GR070X36/85GR040X3/7GR005X3/7GR009X6/14GR043A

5/11GR005A35/77GR040A24/52GR030A16/34GR014A14/29GR028X17/35GR039A27/55GR047A9/18GR007A3/6GR026X19/38GR030X31/62GR047X9/18GR049A

12/23GR014X20/37GR001A

5/9GR031A5/9GR043X9/16GR033A23/40GR024X

29/49GR035X6/10GR051X

13/21GR022X9/14GR068X

24/35GR039X12/17GR068A5/7GR012X

11/14GR055A9/9GR032A


0 25 50 75 100



TotalLabs providing denom.data/reporting data to EARSS naHosps providing denom.data/reporting data to EARSS naNumber of blood culture sets naNumber of hospital beds naPatient-days naAverage occupancy rate (%) naMedian length of stay (days) naEstimated catchment population na% total population covered naType of participating hospitals Regional/Tertiary na Provincial/Secondary na District/Primary na








1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 14 36 18 301 18 264 17 121 0 0 0 02002 17 61 24 413 24 354 23 169 0 0 0 02003 20 134 27 858 27 842 25 279 0 0 0 02004 26 143 30 1020 28 967 26 366 0 0 0 02005 23 133 28 1083 27 1046 27 476 21 314 24 5072006 23 151 27 1127 26 1135 25 453 24 301 25 545


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . 8 3 3 <1 4 1



Aminoglycosides R . . 4 6 8 10 9 12Fluoroquinolones R . . 5 10 15 19 22 273rd gen. Cephalosporins R . . <1 2 <1 3 4 5

E. faecalis Aminopenicillins I+R . . 5 2 <1 2 1 3HL Aminoglycosides R . . . 100 87 57 43 47Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 100 89 91 95 91 88HL Aminoglycosides R . . . 100 96 80 64 67Glycopeptides R . . <1 <1 <1 <1 <1 <1




HungaryGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=2210

E. colin=2038

E. faecalisn=785

E. faeciumn=121

K. pneumo.n=611

P. aeruginosan=1028


Blood 67 16 100 23 100 24 100 0 100 0 99 24 97 17CSF 33 26 0 . 0 . 0 . 0 . 1 33 3 16










0 25 50 75 100

0/9HU002G0/7HU005W0/6HU006Y0/8HU007C0/9HU012G

1/20HU015A2/35HU004Z1/17HU006B2/32HU006A10/143HU028A1/13HU004G5/63HU022P4/47HU027A3/33HU016A4/43HU024A2/20HU007B

6/53HU023B3/23HU020L3/22HU023C1/7HU025H15/99HU022A6/39HU008V2/13HU022O

2/12HU006W2/12HU025G17/96HU019A8/45HU021A16/89HU023A10/53HU009B7/36HU030A26/133HU032A13/66HU026A3/15HU033O

3/13HU019D14/55HU025A7/27HUXXXX

3/11HU013A11/40HU019G7/25HU001U

29/96HU009A21/65HU023D10/30HU014A6/18HU033A

18/52HU005A27/77HU029V

2/5HU019H26/65HU023L

10/24HU017A25/60HU020A24/56HU023I

4/9HU005Y6/13HU020C

3/6HU008B12/24HU031A

13/25HU010G4/6HU002X

24/32HU022S6/7HU001W


0 25 50 75 100

0/21HU009

0/6HU016

0/6HU024

0/14HU028

1/10HU026

4/33HU023

1/6HU033

2/11HU006

10/55HU022

3/12HU027

6/23HU029

5/19HU019

4/13HU020

3/8HU021

2/5HU002

2/5HU013

3/7HU025

4/8HU032

3/5HU005











1999 1 48 1 32 0 0 0 0 0 0 0 02000 1 36 1 40 0 0 0 0 0 0 0 02001 2 48 2 63 2 86 2 18 0 0 0 02002 2 43 2 60 2 83 2 25 0 0 0 02003 2 35 2 64 2 100 2 22 0 0 0 02004 2 54 2 55 2 119 2 27 0 0 0 02005 2 37 2 78 2 130 2 31 2 22 1 132006 2 52 2 57 2 130 2 40 2 13 1 9


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R <1 <1 <1 2 <1 2 <1 <1


S. aureus Oxacillin/Methicillin R <1 3 <1 <1 <1 <1 <1 <1E. coli Aminopenicillins R . . 42 19 42 43 38 45

Aminoglycosides R . . 4 1 2 <1 <1 7Fluoroquinolones R . . 4 3 6 2 3 113rd gen. Cephalosporins R . . <1 <1 1 <1 <1 <1

E. faecalis Aminopenicillins I+R . . <1 <1 <1 <1 <1 7HL Aminoglycosides R . . 8 6 <1 5 <1 3Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 40 29 57 63 80 56HL Aminoglycosides R . . <1 <1 <1 13 <1 14Glycopeptides R . . <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . <1 <1Fluoroquinolones R . . . . . . <1 <13rd gen. Cephalosporins R . . . . . . <1 <1

P. aeruginosa Piperacillin R . . . . . . 8 <1Ceftazidime R . . . . . . 8 <1Carbapenems R . . . . . . 8 <1Aminoglycosides R . . . . . . <1 <1Fluoroquinolones R . . . . . . <1 <1


IcelandGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=135

E. colin=238

E. faecalisn=52

E. faeciumn=16

K. pneumo.n=35

P. aeruginosan=22


Blood 96 7 100 0 100 7 100 0 100 0 100 0 100 5CSF 4 0 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 19 18 7 0 3 0 4 0 6 0 0 . 0 .5-19 3 0 12 0 1 0 0 . 0 . 0 . 0 .20-64 38 6 37 0 32 8 29 0 25 0 37 0 14 065 and over 39 3 43 0 63 7 67 0 69 0 63 0 86 5Unknown 0 . 1 0 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 2 0 5 0 2 0 15 0 19 0 6 0 9 0Internal Med. 9 0 16 0 7 19 25 0 19 0 17 0 5 0Surgery 1 0 11 0 4 0 10 0 6 0 6 0 5 0Other 81 8 67 0 85 7 46 0 56 0 71 0 77 6Unknown 7 0 1 0 2 0 4 0 0 . 0 . 5 0







0 25 50 75 100

0/124IS001A

0/8IS003A


0 25 50 75 100

0/13IS003

6/76IS001











1999 10 154 11 511 0 0 0 0 0 0 0 02000 18 202 18 632 0 0 0 0 0 0 0 02001 21 246 19 798 0 0 0 0 0 0 0 02002 20 277 22 998 20 736 15 250 0 0 0 02003 24 363 26 1108 26 978 21 348 0 0 0 02004 28 399 38 1286 37 1235 29 418 0 0 0 02005 31 397 38 1360 39 1424 33 502 15 42 11 292006 32 406 38 1347 39 1638 32 550 28 211 23 128


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R 3 5 2 2 3 3 3 3


S. aureus Oxacillin/Methicillin R 39 39 42 42 42 41 42 42E. coli Aminopenicillins R . . . 62 61 65 67 69

Aminoglycosides R . . . 3 4 5 7 7Fluoroquinolones R . . . 5 10 12 17 213rd gen. Cephalosporins R . . . 2 2 2 4 4

E. faecalis Aminopenicillins I+R . . . 8 5 <1 4 5HL Aminoglycosides R . . . 39 32 42 42 43Glycopeptides R . . . 2 <1 1 3 3

E. faecium Aminopenicillins I+R . . . 89 91 96 93 94HL Aminoglycosides R . . . 17 54 56 52 44Glycopeptides R . . . 11 19 22 31 36




IrelandGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=2707

E. colin=3032

E. faecalisn=568

E. faeciumn=478

K. pneumo.n=241

P. aeruginosan=146


Blood 99 13 100 42 100 19 100 3 100 34 100 8 100 10CSF 1 14 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 58 12 62 42 43 22 59 1 54 38 61 9 55 10Female 42 16 38 42 56 17 40 5 46 29 38 7 42 10Unknown 1 20 1 30 1 19 0 . 0 . 1 50 2 0

Age (years)0-4 15 15 6 17 3 3 8 0 4 5 6 7 1 05-19 5 8 3 6 1 2 1 0 2 27 2 33 1 020-64 37 12 38 33 33 18 34 5 38 43 35 8 42 1665 and over 44 15 53 53 62 21 56 2 56 30 57 7 55 5Unknown 0 . 0 . 1 26 0 . 0 . 0 . 1 0








0 25 50 75 100

0/9IE-AFY

0/5IE-BMX

1/11IE-BCX

4/43IE-BPX

3/25IE-BBX

1/8IE-AEX

3/22IE-AQZ

3/17IE-APX

2/9IE-ASX

8/28IE-BOX

4/13IE-AKX

9/27IE-BDX

22/64IE-AZX

45/130IE-BXX

5/14IE-BAX

5/14IE-BSY

64/175IE-BIX

24/65IE-ACX

107/278IE-ARX

28/70IE-BHY

2/5IE-BRX

69/168IE-BWX

75/182IE-ALY

63/152IE-ABX

5/12IE-BQZ

32/74IE-BFX

18/41IE-BGX

21/45IE-BTY

54/112IE-BYX

99/200IE-BNX

19/38IE-AUX

139/278IE-BEX

4/8IE-BJX

122/235IE-AYX

23/42IE-AJX

17/29IE-BLX

32/51IE-BKX

6/8IE-ADX


0 25 50 75 100

0/8IE-AP

0/10IE-BB

0/22IE-BG

0/12IE-BL

2/33IE-BF

1/14IE-AD

1/14IE-AU

1/13IE-BO

2/25IE-BY

3/34IE-AZ

4/39IE-BW

2/19IE-AQ

2/19IE-BH

9/69IE-AL

9/68IE-AY

6/45IE-BN

7/47IE-BE

6/39IE-AB

2/13IE-AJ

9/58IE-AR

2/12IE-AC

9/52IE-BI

2/11IE-BS

3/16IE-BT

10/48IE-BX

6/28IE-BP

3/8IE-BD

6/13IE-BK











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 5 170 5 381 5 741 5 184 0 0 0 02002 5 177 5 468 5 865 5 254 0 0 0 02003 5 180 5 369 5 774 5 244 0 0 0 02004 5 190 5 475 5 917 5 288 0 0 0 02005 5 235 5 547 5 943 5 296 4 331 4 2152006 5 223 5 511 5 947 5 286 5 430 5 346


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . 5 7 11 11 8 6




E. faecalis Aminopenicillins I+R . . <1 4 2 3 1 1HL Aminoglycosides R . . 24 44 43 46 43 42Glycopeptides R . . <1 2 <1 1 <1 <1





IsraelGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1058

E. colin=1887

E. faecalisn=440

E. faeciumn=138

K. pneumo.n=760

P. aeruginosan=561


Blood 99 34 100 40 100 25 100 0 100 38 100 41 100 16CSF 1 100 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 62 38 60 40 38 31 54 0 57 38 58 44 57 17Female 38 28 39 41 61 21 45 1 43 37 42 37 42 16Unknown 0 . 1 38 0 . 0 . 0 . 0 . 1 0

Age (years)0-4 36 52 6 15 6 9 11 0 9 0 14 41 6 115-19 11 14 5 16 2 27 1 0 1 50 2 50 5 1520-64 27 18 33 28 29 25 22 0 36 49 30 39 42 1965 and over 25 33 55 53 63 26 65 1 53 37 52 41 45 15Unknown 1 40 1 50 0 . 1 0 1 0 1 89 1 13

Hospital dep.ICU 5 32 8 42 4 37 11 2 17 54 11 53 17 25Internal Med. 40 24 53 47 59 24 51 0 39 39 38 45 35 9Surgery 1 17 9 37 9 32 8 0 7 20 14 30 11 14Other 53 42 30 30 28 24 29 0 36 31 37 38 37 20Unknown 0 . 0 . 0 . 0 . 1 100 0 . 0 .







0 25 50 75 100

18/69IL005A

24/78IL001A

29/90IL004A

81/247IL003A

275/574IL002A


0 25 50 75 100

44/157IL002

7/22IL004

16/49IL001

55/153IL003

34/77IL005











1999 41 177 56 1158 0 0 0 0 0 0 0 02000 36 116 48 456 0 0 0 0 0 0 0 02001 39 121 53 839 0 0 42 297 0 0 0 02002 50 296 53 1343 17 618 49 602 0 0 0 02003 43 282 46 1465 17 923 44 634 0 0 0 02004 37 267 42 1219 14 645 40 576 0 0 0 02005 37 319 41 1431 16 1195 40 714 38 344 0 02006 33 260 37 1104 13 910 35 650 32 321 12 183


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R 2 <1 4 2 5 5 5 <1


S. aureus Oxacillin/Methicillin R 41 44 41 38 39 40 37 38E. coli Aminopenicillins R . . . 48 52 53 55 56


E. faecalis Aminopenicillins I+R . . 3 6 4 4 4 4HL Aminoglycosides R . . 31 38 39 36 38 38Glycopeptides R . . 1 <1 2 2 3 3



P. aeruginosa Piperacillin R . . . . . . . 23Ceftazidime R . . . . . . . 20Carbapenems R . . . . . . . 21Aminoglycosides R . . . . . . . 30Fluoroquinolones R . . . . . . . 36


ItalyGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=2535

E. colin=1946

E. faecalisn=939

E. faeciumn=368

K. pneumo.n=663

P. aeruginosan=183


Blood 87 8 100 38 100 28 100 3 100 18 100 26 99 21CSF 13 9 0 . 0 . 0 . 0 . 0 . 1 50


Age (years)0-4 10 12 2 15 1 0 2 0 1 0 6 76 2 675-19 4 4 1 23 0 . 0 . 0 . 1 60 1 020-64 29 9 25 31 18 33 27 5 25 22 23 31 26 3465 and over 40 6 52 43 37 25 52 3 54 19 42 20 44 24Unknown 16 9 20 36 43 28 18 1 20 13 29 21 28 4








0 25 50 75 100

0/7IT044X1/7IT038X4/28IT065X

5/31IT062X14/85IT010X7/42IT024X

5/27IT050X4/21IT077X4/20IT001X8/38IT022X5/23IT064X

32/131IT019X25/92IT061X

21/74IT067X8/28IT060X

15/48IT072X8/24IT071X

21/59IT049X34/95IT070X19/53IT016X62/172IT037X57/153IT008X37/99IT034X

24/61IT045X36/91IT030X27/68IT059X2/5IT014X52/129IT009X28/69IT031X12/29IT069X10/24IT028X13/31IT004X28/65IT052X

37/83IT075X5/11IT021X51/112IT047X

40/75IT035X80/143IT005X

7/12IT042X29/48IT076X

31/49IT006X40/63IT074X

7/7IT039X


0 25 50 75 100

0/9IT016

0/9IT035

0/12IT044

0/9IT062

0/11IT065

0/29IT067

0/8IT070

0/8IT074

0/5IT075

0/6IT077

1/38IT019

1/24IT072

1/19IT022

4/68IT037

2/32IT030

1/15IT059

1/15IT064

2/25IT009

4/49IT008

1/12IT028

1/11IT031

1/10IT021

2/20IT034

2/16IT005

4/29IT061

2/14IT006

2/14IT047

1/7IT052

2/13IT060

1/5IT045

2/9IT024

5/13IT003











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 0 0 0 0 0 0 0 0 0 02002 0 0 0 0 0 0 0 0 0 0 0 02003 0 0 0 0 0 0 0 0 0 0 0 02004 4 17 7 87 0 0 0 0 0 0 0 02005 5 36 7 126 0 0 0 0 0 0 0 02006 7 37 11 171 10 62 10 56 6 28 9 16


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . . . . <1 <1 <1

Penicillin I+R . . . . . <1 <1 <1Macrolides I+R . . . . . 7 3 3

S. aureus Oxacillin/Methicillin R . . . . . 25 20 18E. coli Aminopenicillins R . . . . . . . 44

Aminoglycosides R . . . . . . . 5Fluoroquinolones R . . . . . . . 103rd gen. Cephalosporins R . . . . . . . 6

E. faecalis Aminopenicillins I+R . . . . . . . 9HL Aminoglycosides R . . . . . . . 50Glycopeptides R . . . . . . . <1

E. faecium Aminopenicillins I+R . . . . . . . 94HL Aminoglycosides R . . . . . . . 73Glycopeptides R . . . . . . . <1




LatviaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=297

E. colin=60

E. faecalisn=37

E. faeciumn=19

K. pneumo.n=28

P. aeruginosan=16


Blood 84 0 100 19 100 10 100 0 100 0 100 36 100 13CSF 16 0 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 67 0 59 22 33 10 62 0 42 0 82 35 69 0Female 33 0 40 14 67 10 32 0 53 0 14 25 31 40Unknown 0 . 1 0 0 . 5 0 5 0 4 100 0 .

Age (years)0-4 3 0 8 0 2 0 11 0 21 0 18 60 13 05-19 4 0 4 0 2 0 5 0 0 . 0 . 19 3320-64 71 0 57 19 50 10 49 0 47 0 61 29 38 1765 and over 19 0 28 26 47 11 35 0 32 0 21 33 31 0Unknown 3 0 2 40 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 71 0 26 25 18 0 30 0 32 0 46 46 38 17Internal Med. 7 0 30 15 28 6 30 0 26 0 4 0 6 0Surgery 0 . 7 35 3 50 3 0 11 0 4 0 6 0Other 22 0 37 15 50 13 38 0 32 0 46 31 50 13Unknown 0 . 1 0 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/25LV002A

0/14LV006A

1/10LV012A

6/49LV003A

1/8LV005B

8/63LV004A

17/79LV001A

19/39LV007A


0 25 50 75 100

0/5LV002

0/17LV003

0/40LV004











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 0 0 0 0 0 0 0 0 0 02002 0 0 0 0 0 0 0 0 0 0 0 02003 0 0 0 0 0 0 0 0 0 0 0 02004 0 0 0 0 0 0 0 0 0 0 0 02005 0 0 0 0 0 0 0 0 0 0 0 02006 9 32 13 167 11 171 8 30 8 35 7 14


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . . . . . . <1

Penicillin I+R . . . . . . . 16Macrolides I+R . . . . . . . <1

S. aureus Oxacillin/Methicillin R . . . . . . . 12E. coli Aminopenicillins R . . . . . . . 55

Aminoglycosides R . . . . . . . 15Fluoroquinolones R . . . . . . . 123rd gen. Cephalosporins R . . . . . . . 5

E. faecalis Aminopenicillins I+R . . . . . . . 5HL Aminoglycosides R . . . . . . . 50Glycopeptides R . . . . . . . <1

E. faecium Aminopenicillins I+R . . . . . . . 75HL Aminoglycosides R . . . . . . . 75Glycopeptides R . . . . . . . <1




LithuaniaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=167

E. colin=171

E. faecalisn=22

E. faeciumn=8

K. pneumo.n=35

P. aeruginosan=14


Blood 63 10 100 12 99 12 100 0 100 0 100 23 93 23CSF 38 25 0 . 1 0 0 . 0 . 0 . 7 0

GenderMale 75 21 63 18 39 15 64 0 63 0 34 25 71 30Female 25 0 37 2 60 11 36 0 38 0 63 23 29 0Unknown 0 . 1 0 1 0 0 . 0 . 3 0 0 .

Age (years)0-4 6 50 4 0 4 0 27 0 25 0 6 0 21 05-19 6 0 13 0 5 13 5 0 0 . 9 0 0 .20-64 72 17 54 13 39 12 36 0 38 0 46 19 50 4365 and over 16 0 28 17 53 13 27 0 38 0 40 36 29 0Unknown 0 . 1 0 0 . 5 0 0 . 0 . 0 .

Hospital dep.ICU 63 20 27 11 16 11 23 0 50 0 26 33 29 25Internal Med. 19 0 32 15 38 2 32 0 25 0 23 13 14 0Surgery 0 . 13 19 8 8 0 . 0 . 23 38 14 0Other 19 17 28 6 37 25 45 0 25 0 26 11 43 33Unknown 0 . 0 . 1 0 0 . 0 . 3 0 0 .







0 25 50 75 100

0/7LT008A

0/6LT011A

0/5LT012A

1/21LT007A

2/36LT001A

1/9LT013A

2/17LT005A

5/26LT004A

3/9LT002A

5/15LT003A


0 25 50 75 100

1/7LT004

4/9LT007











1999 1 9 1 25 0 0 0 0 0 0 0 02000 5 22 4 67 0 0 0 0 0 0 0 02001 8 41 8 85 8 193 7 31 0 0 0 02002 7 27 9 95 9 193 8 30 0 0 0 02003 7 48 8 95 8 227 7 41 0 0 0 02004 6 36 7 96 7 216 5 28 0 0 0 02005 5 43 5 83 5 188 5 31 0 0 1 12006 4 22 5 77 5 167 4 42 4 21 4 23


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R 11 <1 7 7 <1 6 7 5



Aminoglycosides R . . 5 4 4 4 7 6Fluoroquinolones R . . 4 9 12 18 19 203rd gen. Cephalosporins R . . <1 <1 <1 <1 3 2

E. faecalis Aminopenicillins I+R . . <1 <1 5 <1 <1 <1HL Aminoglycosides R . . 13 17 32 18 24 32Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . <1 60 100 50 36 75HL Aminoglycosides R . . . 14 <1 <1 23 30Glycopeptides R . . <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . . <1Fluoroquinolones R . . . . . . . 63rd gen. Cephalosporins R . . . . . . . 10

P. aeruginosa Piperacillin R . . . . . . <1 9Ceftazidime R . . . . . . <1 10Carbapenems R . . . . . . <1 7Aminoglycosides R . . . . . . <1 4Fluoroquinolones R . . . . . . <1 10


LuxembourgGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=160

E. colin=355

E. faecalisn=47

E. faeciumn=26

K. pneumo.n=21

P. aeruginosan=15


Blood 97 10 100 16 100 19 100 0 100 0 100 10 100 7CSF 3 0 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 60 5 54 16 37 22 57 0 81 0 48 0 47 0Female 40 15 46 16 62 18 43 0 19 0 52 18 47 14Unknown 0 . 0 . 0 . 0 . 0 . 0 . 7 0

Age (years)0-4 9 17 4 0 1 20 0 . 4 0 0 . 7 05-19 12 0 6 50 1 50 0 . 0 . 0 . 0 .20-64 45 3 41 9 28 14 30 0 31 0 62 8 27 065 and over 34 18 49 19 70 21 70 0 65 0 38 13 67 10Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 22 0 19 16 12 20 36 0 31 0 33 0 20 0Internal Med. 28 11 16 15 25 20 17 0 15 0 19 25 27 25Surgery 6 0 9 7 9 16 6 0 8 0 5 0 0 .Other 22 7 23 22 23 25 21 0 35 0 19 0 40 0Unknown 23 20 32 16 31 15 19 0 12 0 24 20 13 0







0 25 50 75 100

0/20LU004A

2/20LU003S

4/30LU001E

2/13LU007Z

1/6LU004T

2/11LU006K

2/9LU003A

9/34LU001A

4/13LU007A


0 25 50 75 100

0/7LU004

2/31LU001

2/17LU003

2/6LU006











1999 0 0 0 0 0 0 0 0 0 0 0 02000 1 11 1 76 0 0 0 0 0 0 0 02001 1 12 1 82 1 65 1 12 0 0 0 02002 1 12 1 87 1 74 1 33 0 0 0 02003 1 9 1 121 1 91 1 26 0 0 0 02004 1 18 1 94 1 91 1 41 0 0 0 02005 1 13 1 77 1 85 1 38 1 18 1 452006 1 30 1 90 1 94 1 53 1 32 1 51


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . <1 <1 <1 <1 <1 8 3

Penicillin I+R . 9 8 <1 <1 <1 15 7Macrolides I+R . 36 18 25 38 25 46 47



E. faecalis Aminopenicillins I+R . . 9 <1 5 <1 3 2HL Aminoglycosides R . . 9 17 29 44 32 .Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 100 33 33 43 25 14HL Aminoglycosides R . . <1 <1 50 <1 <1 .Glycopeptides R . . <1 <1 <1 <1 <1 <1




MaltaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=167

E. colin=179

E. faecalisn=78

E. faeciumn=13

K. pneumo.n=50

P. aeruginosan=95


Blood 93 10 100 62 100 31 100 0 100 0 100 6 100 19CSF 7 0 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 21 11 8 46 3 0 6 0 8 0 6 0 2 05-19 2 0 5 56 2 33 5 0 8 0 4 0 4 2520-64 35 13 35 58 31 31 33 0 23 0 44 14 46 2765 and over 35 7 51 67 64 33 54 0 62 0 46 0 47 11Unknown 7 0 1 100 1 0 1 0 0 . 0 . 0 .








0 25 50 75 100

4/9MT001E

98/155MT001A


0 25 50 75 100

4/43MT001











1999 21 762 20 1224 0 0 0 0 0 0 0 02000 23 740 24 1388 12 1312 8 81 0 0 0 02001 20 723 21 1290 20 1864 14 275 0 0 0 02002 23 860 22 1502 22 2427 22 536 0 0 0 02003 24 886 22 1363 23 2143 23 482 0 0 0 02004 22 755 22 1336 21 2112 22 455 0 0 0 02005 23 802 23 1402 23 2203 23 566 16 301 16 2102006 22 1005 23 1633 22 2910 23 778 18 459 19 330


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R <1 <1 <1 <1 <1 <1 <1 <1

Penicillin I+R 1 1 <1 1 1 2 1 1Macrolides I+R . 4 5 7 5 7 11 8

S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 1 1 <1 1E. coli Aminopenicillins R . 37 39 39 44 43 48 47

Aminoglycosides R . 2 2 2 3 3 4 3Fluoroquinolones R . 3 5 5 7 7 10 113rd gen. Cephalosporins R . <1 <1 <1 1 1 2 3

E. faecalis Aminopenicillins I+R . <1 2 3 4 3 3 5HL Aminoglycosides R . . 28 33 23 37 38 28Glycopeptides R . <1 <1 <1 1 <1 <1 <1

E. faecium Aminopenicillins I+R . 33 64 23 30 42 61 73HL Aminoglycosides R . . 4 11 19 20 40 50Glycopeptides R . <1 2 1 <1 <1 <1 <1




NetherlandsGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=3035

E. colin=4979

E. faecalisn=733

E. faeciumn=476

K. pneumo.n=653

P. aeruginosan=477


Blood 92 1 100 1 100 11 100 0 100 1 100 4 99 3CSF 8 1 0 . 0 . 0 . 0 . 0 . 1 0

GenderMale 52 1 58 1 45 12 63 0 58 1 56 4 70 2Female 45 1 38 1 49 9 31 0 42 0 44 3 30 5Unknown 3 7 4 0 5 10 6 0 0 . 0 . 0 .

Age (years)0-4 7 2 9 0 4 2 12 0 9 0 4 0 4 05-19 5 2 5 1 4 12 5 0 3 0 1 33 3 1420-64 37 1 35 1 30 13 35 0 43 0 37 3 38 365 and over 50 1 49 1 60 10 45 1 45 1 59 4 55 3Unknown 1 5 2 0 3 12 3 0 0 . 0 . 0 .








0 25 50 75 100

0/76NL002A

0/71NL002X

0/55NL008A

0/71NL008X

0/31NL011A

0/25NL011D

0/10NL011E

0/25NL011F

0/112NL011X

0/13NL012A

0/19NL012C

0/18NL016A

0/20NL016X

0/17NL020X

0/38NL021A

0/37NL021B

0/26NL021C

0/35NL023A

0/208NL026A

0/126NL028X

0/121NL029A

0/68NL031X

0/6NL032X

0/24NLVUMC

1/211NL006X

1/193NL003A

1/192NL027A

2/186NL030X

1/86NL014X

3/235NL022X

1/53NL025X

1/49NL018X

1/45NL015A

6/223NL019X

8/215NL007A

1/26NL017X

2/37NL023X

1/17NL005A

1/13NL005X


0 25 50 75 100

0/136NL002

0/59NL003

0/32NL005

0/178NL011

0/64NL014

0/79NL019

0/24NL020

0/79NL021

0/40NL025

0/66NL027

0/63NL028

0/5NL032

1/168NL006

1/103NL008

2/146NL030

1/60NL023

1/59NL031

1/52NL007

1/45NL015

1/33NL012

1/33NL018

2/65NL026

3/95NL022

1/29NL017

3/56NL029

3/38NL016











1999 11 306 10 291 10 689 11 79 4 20 3 92000 11 419 11 398 11 922 11 110 3 22 4 92001 11 425 11 411 11 966 11 155 4 26 4 202002 11 451 11 502 11 1119 11 177 4 29 4 272003 11 512 11 503 11 1179 11 192 4 46 4 252004 11 598 11 514 11 1212 11 235 4 51 4 272005 11 606 11 551 11 1331 11 304 11 193 11 972006 12 601 12 734 12 1574 12 349 12 263 12 96



Penicillin I+R 2 <1 1 <1 <1 2 2 2Macrolides I+R 9 4 4 6 8 8 14 12

S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 <1 <1 <1E. coli Aminopenicillins R 27 26 27 29 34 32 34 35

Aminoglycosides R <1 <1 <1 <1 <1 <1 2 2Fluoroquinolones R 2 2 1 2 2 4 5 53rd gen. Cephalosporins R <1 <1 <1 <1 <1 <1 <1 1

E. faecalis Aminopenicillins I+R 2 3 3 4 4 <1 3 3HL Aminoglycosides R 23 11 42 30 38 27 32 33Glycopeptides R <1 1 1 3 <1 <1 <1 <1

E. faecium Aminopenicillins I+R 19 40 28 49 43 80 72 75HL Aminoglycosides R <1 33 40 14 14 25 44 45Glycopeptides R <1 <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R <1 <1 <1 <1 <1 2 3 <1Fluoroquinolones R <1 <1 <1 <1 <1 <1 1 73rd gen. Cephalosporins R <1 <1 <1 <1 <1 <1 2 2

P. aeruginosa Piperacillin R . . . <1 <1 13 3 3Ceftazidime R <1 25 15 <1 <1 <1 3 5Carbapenems R <1 <1 7 <1 <1 4 3 9Aminoglycosides R <1 <1 <1 <1 <1 4 <1 1Fluoroquinolones R 13 <1 9 <1 4 5 4 9


NorwayGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1285

E. colin=2696

E. faecalisn=479

E. faeciumn=130

K. pneumo.n=456

P. aeruginosan=172


Blood 94 2 100 0 100 5 100 0 100 0 100 2 99 6CSF 6 3 0 . 0 . 0 . 0 . 0 . 1 0


Age (years)0-4 10 2 4 2 2 10 1 0 1 0 1 17 2 335-19 3 3 3 0 1 6 1 0 0 . 0 . 3 020-64 37 2 34 0 26 6 22 0 32 0 28 3 30 865 and over 50 2 60 0 71 4 76 0 68 0 70 1 65 5Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .








0 25 50 75 100

0/89NO102B

0/9NO104N

0/43NO105K

0/50NO106P

0/36NO106Q

0/67NO106S

0/22NO106T

0/59NO203C

0/38NO203D

0/23NO204H

0/63NO205I

0/5NO205M

0/66NO206O

0/31NO206P

0/10NO206Q

0/26NO304J

0/7NO304M

0/148NO403D

0/21NO403E

1/142NO103E

1/131NO104J

1/91NO101A

1/83NO204E


0 25 50 75 100

0/48NO101

0/96NO103

0/53NO105

1/135NO206

1/123NO204

1/76NO102

1/51NO304

2/88NO205

4/171NO106

4/109NO203

5/126NO104

6/131NO403











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 4 6 19 151 20 103 16 57 0 0 0 02002 7 10 21 186 22 135 19 56 0 0 0 02003 11 16 24 166 25 124 16 64 0 0 0 02004 11 16 30 262 29 192 23 52 0 0 0 02005 6 6 30 198 30 176 20 53 17 53 14 262006 4 9 24 174 26 205 21 68 15 42 16 37


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . <1 30 19 <1 17 <1

Penicillin I+R . . <1 30 19 <1 33 <1Macrolides I+R . . <1 67 14 19 33 11



E. faecalis Aminopenicillins I+R . . 5 12 <1 2 9 2HL Aminoglycosides R . . 43 41 48 33 48 50Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 77 80 91 86 95 95HL Aminoglycosides R . . 73 73 55 100 60 85Glycopeptides R . . <1 <1 <1 <1 5 <1




PolandGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=372

E. colin=381

E. faecalisn=81

E. faeciumn=40

K. pneumo.n=95

P. aeruginosan=63


Blood 100 13 100 22 100 20 100 0 100 3 100 54 100 29CSF 0 . 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 13 0 7 15 8 3 2 0 15 0 17 63 13 135-19 0 . 4 13 1 0 0 . 0 . 1 0 2 020-64 53 13 49 23 43 20 47 0 50 5 46 64 48 3365 and over 33 20 40 23 49 23 51 0 35 0 36 38 38 29Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 0 . 12 56 6 33 21 0 35 7 26 76 33 43Internal Med. 73 18 59 14 62 22 52 0 38 0 38 31 30 32Surgery 0 . 13 37 7 29 16 0 10 0 14 77 14 22Other 27 0 16 13 25 10 10 0 18 0 21 55 22 7Unknown 0 . 0 . 0 . 1 0 0 . 1 0 0 .







0 25 50 75 100

0/9PL005A

0/6PL034A

0/18PL048A

0/7PL058A

1/32PL043A

1/18PL009A

1/11PL011A

1/10PL014A

2/15PL012A

5/35PL017A

4/26PL016A

2/12PL024A

1/5PL019A

2/7PL001A

2/7PL018A

11/31PL003A

4/11PL041A

5/12PL046A

10/22PL029A

14/30PL022A

5/10PL002A

3/5PL015A

5/6PL031A


0 25 50 75 100

1/6PL043











1999 12 119 13 369 0 0 0 0 0 0 0 02000 11 97 8 150 0 0 0 0 0 0 0 02001 16 155 16 521 13 418 12 185 0 0 0 02002 14 184 16 543 17 444 13 101 0 0 0 02003 12 95 22 1033 21 792 18 398 0 0 0 02004 14 166 23 1063 19 761 19 410 0 0 0 02005 13 202 19 1153 19 1171 17 405 1 1 0 02006 15 183 17 1306 18 1330 17 464 13 315 11 266



Penicillin I+R 17 29 25 20 20 27 17 17Macrolides I+R 9 11 . <1 . 20 19 21



E. faecalis Aminopenicillins I+R . . 5 2 4 5 <1 2HL Aminoglycosides R . . 30 25 34 29 38 41Glycopeptides R . . 5 6 3 6 5 5

E. faecium Aminopenicillins I+R . . 76 79 88 83 92 76HL Aminoglycosides R . . 23 33 55 66 68 53Glycopeptides R . . 21 <1 47 42 34 26

K. pneumoniae Aminoglycosides R . . . . . . <1 13Fluoroquinolones R . . . . . . <1 203rd gen. Cephalosporins R . . . . . . . 21



PortugalGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=2459

E. colin=2376

E. faecalisn=596

E. faeciumn=231

K. pneumo.n=303

P. aeruginosan=251


Blood 88 16 100 47 100 28 100 5 100 29 99 21 100 21CSF 12 22 0 . 0 . 0 . 0 . 1 0 0 .

GenderMale 66 16 63 47 45 33 56 5 57 34 61 23 61 19Female 34 19 37 47 55 25 44 6 43 22 39 17 39 23Unknown 0 . 0 . 0 . 0 . 0 . 1 0 0 .

Age (years)0-4 10 25 2 9 1 14 1 0 1 50 1 50 1 675-19 4 27 2 13 1 20 1 17 1 0 1 0 1 020-64 46 12 36 38 33 26 34 5 36 39 37 21 45 2465 and over 34 18 51 58 61 31 60 5 59 25 45 21 51 16Unknown 5 30 9 44 3 8 4 0 3 0 16 20 2 40

Hospital dep.ICU 4 18 9 52 5 38 15 4 16 25 13 15 19 21Internal Med. 15 17 27 56 24 28 26 5 20 21 20 31 17 21Surgery 1 0 9 60 5 29 9 6 10 9 9 29 7 11Other 79 17 55 40 63 28 50 5 53 37 57 17 57 22Unknown 1 67 1 54 3 30 0 . 1 50 0 . 0 .







0 25 50 75 100

0/10PT004A

3/25PT021A

50/192PT011A

29/91PT016A

32/85PT023A

39/98PT018A

4/10PT022A

72/171PT005A

46/107PT024A

105/236PT019A

44/98PT015A

68/151PT008A

96/204PT003A

107/189PT001A

50/88PT028A

91/160PT012A

207/363PT007A

119/178PT002A


0 25 50 75 100

5/62PT003

3/30PT001

6/49PT002

1/7PT005

13/79PT019

4/22PT018

16/76PT011

4/19PT017

4/14PT008

2/7PT024

3/6PT016

3/6PT028











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 0 0 0 0 0 0 0 0 0 02002 6 10 10 80 8 28 4 11 0 0 0 02003 4 22 9 85 9 50 5 12 0 0 0 02004 4 9 15 92 12 46 4 9 0 0 0 02005 5 18 13 92 13 83 7 14 1 3 2 232006 8 29 10 78 8 39 9 26 5 32 2 3


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . . 10 23 11 22 10

Penicillin I+R . . . 50 36 11 39 28Macrolides I+R . . . 10 27 <1 31 25

S. aureus Oxacillin/Methicillin R . . . 36 46 72 60 55E. coli Aminopenicillins R . . . 50 70 79 78 87


E. faecalis Aminopenicillins I+R . . . <1 <1 29 <1 <1HL Aminoglycosides R . . . 40 25 <1 50 15Glycopeptides R . . . <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . . 100 86 100 100 100HL Aminoglycosides R . . . 80 63 100 70 77Glycopeptides R . . . 17 <1 <1 <1 <1


P. aeruginosa Piperacillin R . . . . . . 61 33Ceftazidime R . . . . . . 52 <1Carbapenems R . . . . . . 61 <1Aminoglycosides R . . . . . . 64 33Fluoroquinolones R . . . . . . 64 33


RomaniaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=170

E. colin=115

E. faecalisn=17

E. faeciumn=23

K. pneumo.n=34

P. aeruginosan=26


Blood 36 35 100 58 88 17 100 0 100 0 100 94 88 61CSF 64 30 0 . 12 43 0 . 0 . 0 . 12 0

GenderMale 53 32 52 61 45 27 59 0 65 0 59 95 35 56Female 43 35 36 57 54 15 41 0 35 0 41 93 35 33Unknown 4 0 12 45 1 0 0 . 0 . 0 . 31 75

Age (years)0-4 15 71 26 66 17 5 35 0 48 0 76 96 12 05-19 11 20 6 50 5 33 0 . 0 . 9 67 27 4320-64 40 26 48 51 43 27 18 0 13 0 6 100 0 .65 and over 30 21 15 65 33 18 35 0 30 0 9 100 0 .Unknown 4 50 5 67 2 0 12 0 9 0 0 . 62 69

Hospital dep.ICU 2 100 12 57 10 17 0 . 13 0 15 100 23 83Internal Med. 6 33 11 61 20 17 12 0 17 0 3 100 0 .Surgery 0 . 8 79 8 11 6 0 9 0 6 100 12 100Other 81 34 48 57 58 24 65 0 48 0 76 92 38 30Unknown 11 0 21 49 3 0 18 0 13 0 0 . 27 43







0 25 50 75 100

6/23RO01C

18/33RO01F

10/18RO02A

12/21RO01A

18/28RO01B

9/13RO06A

12/14RO01D


0 25 50 75 100

1/5RO01C

9/28RO01A











1999 0 0 0 0 0 0 0 0 0 0 0 02000 7 40 10 154 0 0 0 0 0 0 0 02001 10 156 10 270 10 398 10 54 0 0 0 02002 11 101 11 276 11 409 9 45 0 0 0 02003 11 172 11 299 11 401 10 76 0 0 0 02004 10 166 11 347 11 573 9 91 0 0 0 02005 11 208 11 349 11 657 11 119 10 78 8 382006 11 167 11 365 11 717 10 145 10 145 10 72


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . <1 <1 <1 2 2 2 5



Aminoglycosides R . . 2 3 2 5 4 7Fluoroquinolones R . . 8 12 11 12 12 153rd gen. Cephalosporins R . . <1 1 <1 1 2 2

E. faecalis Aminopenicillins I+R . . <1 <1 <1 <1 1 1HL Aminoglycosides R . . 35 50 49 37 46 40Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 64 69 83 76 93 86HL Aminoglycosides R . . 50 62 82 56 47 54Glycopeptides R . . <1 <1 <1 <1 <1 6




SloveniaGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=714

E. colin=1374

E. faecalisn=184

E. faeciumn=80

K. pneumo.n=223

P. aeruginosan=110


Blood 91 15 100 9 100 14 100 0 100 4 99 23 99 8CSF 9 9 0 . 0 . 0 . 0 . 1 0 1 0


Age (years)0-4 15 38 3 0 2 0 4 0 1 0 4 0 3 05-19 6 5 3 8 1 0 1 0 0 . 2 40 2 020-64 36 8 38 8 29 12 26 0 34 4 26 25 35 865 and over 43 12 55 9 68 15 70 0 65 4 69 22 60 9Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 9 11 10 15 6 14 13 0 16 0 11 29 16 0Internal Med. 40 13 48 7 55 13 46 0 35 0 42 18 37 10Surgery 1 0 12 17 5 15 13 0 18 7 13 14 9 30Other 50 16 31 6 35 15 28 0 31 8 35 28 37 5Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/9SI001B

0/9SI003B

0/6SI004B

0/14SI010A

3/83SI004A

1/26SI007A

1/21SI002A

1/21SI011A

7/120SI003A

2/33SI009A

2/32SI005A

1/12SI006A

35/269SI001A

9/58SI008A


0 25 50 75 100

0/6SI006

1/14SI005

3/25SI008

2/16SI009

7/50SI003

19/135SI001

9/59SI004

5/32SI010

3/19SI002

2/10SI007

2/9SI011











1999 0 0 0 0 0 0 0 0 0 0 0 02000 33 584 30 836 0 0 0 0 0 0 0 02001 36 649 35 1013 27 1967 26 371 0 0 0 02002 35 658 36 1196 29 2484 35 566 0 0 0 02003 35 655 36 1391 29 2650 36 608 0 0 0 02004 36 682 36 1526 36 3471 36 710 0 0 0 02005 34 740 34 1337 34 2997 35 623 14 56 13 702006 35 624 35 1483 35 3364 34 755 33 564 32 405


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . 11 11 10 7 9 9 8




E. faecalis Aminopenicillins I+R . . 3 2 1 2 <1 2HL Aminoglycosides R . . 32 37 36 36 36 36Glycopeptides R . . <1 <1 <1 <1 <1 <1





SpainGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=2820

E. colin=6353

E. faecalisn=1061

E. faeciumn=316

K. pneumo.n=618

P. aeruginosan=459


Blood 96 26 100 26 100 28 100 0 100 3 100 9 100 12CSF 4 34 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 13 35 4 4 3 11 6 0 9 0 4 25 2 05-19 5 12 3 10 1 7 1 0 1 0 1 14 2 020-64 41 24 36 21 29 24 30 0 30 5 33 10 41 1665 and over 40 27 56 32 67 31 61 0 59 2 59 7 54 10Unknown 1 8 1 14 1 9 3 0 1 0 3 28 1 0








0 25 50 75 100

0/33ES020A

8/64ES046A

6/47ES051A

12/72ES013A

3/17ES015A

4/22ES045A

12/66ES058A

32/169ES019A

16/82ES048A

10/51ES040A

20/101ES005A

23/108ES042A

20/90ES044A

36/159ES021A

15/66ES011A

10/43ES018A

22/93ES043A

11/45ES003A

24/98ES053A

17/67ES016A

12/45ES032A

28/101ES004A

11/37ES008A

40/131ES038A

19/62ES054A

39/127ES056A

24/78ES002A

25/77ES017A

42/129ES026A

34/103ES049A

4/12ES057A

46/136ES041A

33/92ES012A

26/72ES010A

13/34ES031A

7/18ES007A

33/73ES029A


0 25 50 75 100

0/8ES017

1/14ES019

1/13ES012

3/26ES043

7/47ES048

4/24ES046

5/28ES016

16/82ES040

15/76ES050

10/47ES020

19/88ES011

12/55ES010

2/9ES049

16/71ES044

5/21ES018

2/8ES008

2/8ES013

3/12ES029

13/52ES038

14/56ES054

12/45ES053

32/118ES042

9/31ES005

21/69ES056

25/81ES021

6/19ES015

20/63ES031

11/34ES002

7/19ES003

7/19ES045

10/27ES004

5/12ES007

18/42ES058

11/22ES032

4/8ES051

4/6ES026











1999 24 805 24 1320 0 0 0 0 1 1 0 02000 19 803 19 1478 0 0 0 0 0 0 0 02001 20 788 20 1633 20 2800 20 671 0 0 0 02002 21 830 21 1836 21 3066 21 696 0 0 0 02003 21 917 21 1855 21 3350 21 850 0 0 0 02004 21 955 21 1906 21 3373 21 856 0 0 0 02005 21 1017 21 1774 21 3241 21 821 18 282 17 1492006 21 993 21 1967 20 3539 21 884 20 621 18 300




S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 <1 1 <1E. coli Aminopenicillins R . . 27 25 28 23 26 28

Aminoglycosides R . . <1 <1 1 1 1 2Fluoroquinolones R . . 4 5 7 8 6 83rd gen. Cephalosporins R . . <1 <1 <1 <1 1 2

E. faecalis Aminopenicillins I+R . . <1 1 <1 <1 <1 <1HL Aminoglycosides R . . . . 17 15 19 20Glycopeptides R . . <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . . 75 75 77 78 74 76HL Aminoglycosides R . . . . 11 7 4 12Glycopeptides R . . <1 <1 2 1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . 1 <1Fluoroquinolones R <1 . . . . . 5 53rd gen. Cephalosporins R <1 . . . . . 1 1

P. aeruginosa Piperacillin R . . . . . . 9 <1Ceftazidime R . . . . . . 5 6Carbapenems R . . . . . . 18 5Aminoglycosides R . . . . . . <1 <1Fluoroquinolones R . . . . . . 6 5


SwedenGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=3741

E. colin=6280

E. faecalisn=1145

E. faeciumn=555

K. pneumo.n=903

P. aeruginosan=292


Blood 97 3 100 1 100 7 100 0 100 1 100 1 100 7CSF 3 2 0 . 0 . 0 . 0 . 0 . 0 .



Hospital dep.ICU 6 1 6 1 4 7 6 0 8 2 5 0 8 22Internal Med. 44 3 43 1 40 6 35 0 35 0 37 2 39 7Surgery 5 2 15 1 19 8 23 0 26 1 26 1 12 0Other 45 3 36 1 37 8 35 0 31 1 32 2 41 7Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/124SE100B0/29SE100C0/55SE110A0/5SE110B0/170SE120A0/33SE120B0/169SE200A0/81SE220A0/24SE220B0/26SE220C0/8SE220D0/67SE230A0/20SE230B0/83SE240A0/13SE240B0/33SE240C0/98SE250A0/46SE250B0/118SE300A0/19SE320B0/14SE320C0/42SE350B0/66SE350C0/21SE400C0/32SE430D0/123SE440A0/38SE440B0/33SE440C0/15SE450C0/21SE450D0/17SE600C0/30SE610B0/141SE620A0/5SE620B0/40SE620C0/5SE620D0/40SE730A0/15SE730B0/16SE730C0/22SE730E0/50SE730F1/144SE450A1/137SE600A1/115SE320A1/109SE200B3/202SE310A1/62SE610C2/121SE610A2/109SE350A3/163SE400A1/50SE540A1/45SE200C3/128SE430A2/79SE400B

12/249SE100A1/9SE120C


0 25 50 75 100

0/93SE350

0/49SE600

0/103SE610

1/83SE430

1/54SE730

2/104SE450

2/98SE310

2/98SE620

3/131SE400

5/209SE200

4/156SE120

2/75SE220

2/74SE240

2/49SE230

9/214SE100

3/69SE250

6/131SE440

2/39SE110

5/94SE320

5/63SE300

2/24SE540











1999 0 0 0 0 0 0 0 0 0 0 0 02000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 0 0 0 0 0 0 0 0 0 02002 0 0 0 0 0 0 0 0 0 0 0 02003 11 117 11 749 12 719 10 370 0 0 0 02004 11 149 11 703 11 765 11 476 0 0 0 02005 10 103 10 760 10 782 10 551 3 13 2 52006 12 98 14 794 14 888 14 581 14 452 13 313


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R . . . . 2 7 <1 5

Penicillin I+R . . . . 13 23 24 18Macrolides I+R . . . . 7 9 10 16

S. aureus Oxacillin/Methicillin R . . . . 43 40 35 36E. coli Aminopenicillins R . . . . 68 68 75 72

Aminoglycosides R . . . . 28 27 27 28Fluoroquinolones R . . . . 38 43 44 483rd gen. Cephalosporins R . . . . 26 28 31 33

E. faecalis Aminopenicillins I+R . . . . 10 23 8 10HL Aminoglycosides R . . . . 39 31 30 29Glycopeptides R . . . . 1 1 <1 <1

E. faecium Aminopenicillins I+R . . . . 75 81 87 87HL Aminoglycosides R . . . . 55 58 60 70Glycopeptides R . . . . 4 3 5 4




TurkeyGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=1554

E. colin=1659

E. faecalisn=610

E. faeciumn=519

K. pneumo.n=463

P. aeruginosan=317


Blood 82 21 100 36 99 46 100 0 100 4 100 43 100 33CSF 18 25 0 . 1 47 0 . 0 . 0 . 0 .

GenderMale 65 18 57 38 55 50 52 0 50 5 52 44 66 35Female 35 27 42 34 44 41 46 0 49 3 45 40 33 28Unknown 0 . 1 17 1 22 1 0 1 0 3 57 1 33

Age (years)0-4 24 25 13 23 6 20 12 0 13 9 21 62 13 355-19 18 22 7 23 5 26 4 0 5 8 7 35 7 2620-64 39 18 51 40 52 48 44 1 45 3 46 42 44 3265 and over 18 24 27 39 36 50 39 0 36 3 25 31 34 35Unknown 1 0 1 30 1 67 1 0 1 0 0 . 2 20

Hospital dep.ICU 9 22 15 69 8 56 24 1 30 6 19 52 26 58Internal Med. 10 20 20 19 18 48 13 0 15 1 14 27 12 11Surgery 4 11 12 61 9 47 18 0 14 3 11 51 16 43Other 76 22 52 27 62 44 45 0 41 4 55 42 45 20Unknown 0 . 0 . 3 53 0 . 0 . 1 33 1 50







0 25 50 75 100

0/15TR015A

14/77TR006A

10/54TR005A

43/200TR007A

2/9TR014A

21/94TR010A

41/180TR008A

91/265TR001A

35/80TR011A

14/32TR012A

88/177TR002A

55/108TR009A

97/179TR004A

47/84TR013A


0 25 50 75 100

1/18TR010

2/14TR006

1/6TR007

2/12TR011

4/21TR004

1/5TR009

13/62TR008

2/9TR002

9/30TR001

6/17TR005











1999 22 242 23 659 0 0 0 0 0 0 0 02000 28 512 27 1492 0 0 0 0 0 0 0 02001 26 573 25 1517 20 1424 0 0 0 0 0 02002 23 617 21 1703 20 1958 0 0 0 0 0 02003 50 1334 51 3521 19 2253 0 0 0 0 0 02004 54 1058 54 3560 20 2091 0 0 0 0 0 02005 53 1373 58 3967 23 2359 27 598 23 425 25 4382006 51 1510 55 3996 26 2444 22 547 22 410 24 353


Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 2006S. pneumoniae Penicillin R 4 4 3 3 1 <1 2 <1




E. faecalis Aminopenicillins I+R . . . . . . 2 3HL Aminoglycosides R . . . . . . 47 52Glycopeptides R . . . . . . 2 1

E. faecium Aminopenicillins I+R . . . . . . 84 78HL Aminoglycosides R . . . . . . 53 18Glycopeptides R . . . . . . 33 18




United KingdomGeneral Information about EARSS participating laboratories and hospitals





S. aureusn=7963

E. colin=4282

E. faecalisn=651

E. faeciumn=393

K. pneumo.n=596

P. aeruginosan=616


Blood 98 3 100 43 100 18 100 2 100 26 100 12 100 8CSF 2 6 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 52 3 63 44 45 22 61 2 57 28 59 12 61 8Female 48 3 36 42 55 15 39 1 43 24 41 11 39 8Unknown 1 10 1 36 0 . 0 . 0 . 0 . 0 .

Age (years)0-4 10 1 3 18 2 4 8 4 7 31 5 3 4 05-19 5 3 2 15 2 9 1 0 4 47 1 17 3 2420-64 30 3 28 35 26 19 32 1 36 34 30 14 33 1465 and over 34 5 41 52 70 19 59 2 54 19 64 11 59 4Unknown 22 3 25 42 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 4 5 9 60 0 . 0 . 0 . 0 . 0 .Internal Med. 24 4 27 43 0 . 0 . 0 . 0 . 0 .Surgery 1 0 10 50 0 . 0 . 0 . 0 . 0 .Other 39 3 37 37 0 . 0 . 0 . 0 . 0 .Unknown 32 3 18 43 100 18 100 2 100 26 100 12 100 8







0 25 50 75 100

0/5UK012B0/21UK030A0/6UK033A0/6UK044B0/9UK047D

1/16UK078C3/36UK007C

5/52UK055A1/10UK007E

11/57UK064A6/30UK003A1/5UK043C1/5UK044C

27/117UK054A6/26UK081A

38/157UK043A19/77UK043B2/8UK044D3/12UK078B

6/23UK013C3/11UK069B23/82UK017A

127/428UK045A10/32UK081B31/99UK066A

2/6UK007F36/104UK053D

19/53UK049A47/127UK056A15/40UK077A39/103UK060A105/276UK026A124/324UK013A23/60UK052A24/62UK020A19/49UK046A116/299UK068B47/121UK059A32/81UK001A59/149UK084A22/55UK031A62/153UK044A125/307UK017B96/234UK070A

11/26UK010A35/82UK057A104/240UK007A101/232UK038C31/71UK011A4/9UK003B4/9UK038A26/58UK068A53/117UK015A5/11UK058A

88/190UK007B40/83UK070B28/57UK013B142/289UK051A30/61UK008A70/141UK023A43/86UK022A5/10UK038E218/429UK047A28/55UK027A

27/52UK063A11/21UK051B9/17UK004A7/13UK045B47/87UK059B139/256UK005A6/11UK042A49/89UK083A114/207UK012A59/107UK090A78/141UK047B

38/67UK015B70/123UK050A12/21UK048A

46/79UK032B58/97UK032A50/83UK080A

13/21UK041A10/16UK047C47/75UK069A7/11UK045C69/108UK078A

7/10UK005B5/6UK047F

6/7UK084E6/6UK084B


0 25 50 75 100

0/35UK0010/33UK0110/82UK0170/17UK0220/41UK0270/15UK0300/28UK0310/10UK0410/50UK0420/16UK0440/28UK0490/25UK0520/35UK0530/30UK0550/23UK0560/36UK0570/31UK0661/84UK0322/118UK0451/52UK0591/49UK0041/48UK0541/48UK0631/45UK0502/81UK0686/214UK0071/34UK0331/33UK0782/65UK0703/94UK0384/124UK0155/152UK0473/85UK0131/25UK0602/46UK0201/23UK0483/64UK0691/21UK0266/123UK0056/122UK0124/79UK0513/59UK0233/57UK0082/37UK0037/121UK043

2/27UK0461/12UK0775/55UK0642/21UK0813/31UK0105/47UK090

6/47UK084


Annex 3. Overview of antibiotic resistance in Europe, 2006 157 157

Annex 3. Overview of antibiotic resistance in Europe, 2006

Annex 3.1. The number (No) of invasive S. pneumoniae (SPN) isolates, and the proportion penicillin non-susceptible (PNSP), penicillin resistant (PRSP), erythromycin non-susceptible (ENSP), single penicillin (PEN), single erythromycin (ERY) and dual resistant isolates, including 95% confidence intervals (95CI) reported per country in 2006.

Country No. SPN isolates tested for PEN/ERY

%PNSP(95CI)

%PRSP(95CI)

%ENSP(95CI)

%singlePEN (95CI)

%singleERY (95CI)

% DUAL(95CI)

AT 291/250 5 (3-8) 1 (0-3) 12 (9-17) 3 (1-6) 11 (7-15) 2 (1-4)BE 1,427/1,427 10 (8-12) 4 (3-6) 31 (29-34) 2 (2-3) 24 (22-26) 7 (6-9)BG 29/19 7 (1-24) 7 (1-24) 16 (4-40) 5 (0-28) 11 (2-35) 5 (0-28)CY 13/13 38 (15-68) 31 (10-61) 31 (10-61) 15 (3-46) 8 (0-38) 23 (6-54)CZ 172/172 2 (1-6) 1 (0-4) 3 (1-7) 1 (0-5) 2 (0-5) 1 (0-5)DE 83/77 5 (2-13) 1 (0-7) 12 (6-22) 4 (1-12) 10 (5-20) 1 (0-8)DK 872/872 4 (3-5) 0 (0-1) 6 (4-7) 3 (2-4) 5 (4-7) 1 (0-2)EE 52/40 2 (0-12) 0 (0-9) 3 (0-15) 3 (0-15) 3 (0-15) 0 (0-11)ES 624/612 27 (24-31) 8 (6-10) 22 (18-25) 15 (12-18) 9 (7-11) 13 (10-16)FI 493/491 12 (9-15) 2 (1-3) 24 (21-29) 3 (2-5) 15 (12-19) 9 (7-12)FR 371/370 32 (27-37) 4 (2-7) 36 (31-41) 6 (4-9) 10 (7-14) 26 (22-31)HR 116/37 18 (12-27) 0 (0-4) 16 (7-33) 8 (2-23) 8 (2-23) 8 (2-23)HU 151/144 18 (12-25) 1 (0-5) 19 (14-27) 8 (4-14) 10 (6-16) 10 (6-16)IE 406/391 16 (12-20) 3 (2-6) 16 (13-20) 8 (6-11) 9 (6-12) 7 (5-11)IL 223/221 35 (29-42) 6 (4-11) 17 (13-23) 19 (15-25) 2 (1-5) 15 (11-21)IS 52/51 6 (2-17) 0 (0-9) 10 (4-22) 4 (1-15) 8 (3-20) 2 (0-12)IT 260/233 7 (4-10) 1 (0-3) 32 (26-38) 3 (2-7) 28 (23-35) 3 (2-7)LT 32/28 16 (6-34) 0 (0-13) 0 (0-15) 11 (3-29) 0 (0-15) 0 (0-15)LU 22/22 5 (0-25) 5 (0-25) 36 (18-59) 0 (0-18) 32 (15-55) 5 (0-25)LV 37/36 0 (0-12) 0 (0-12) 3 (0-16) 0 (0-12) 3 (0-16) 0 (0-12)MT 30/30 7 (1-24) 3 (0-19) 47 (29-65) 3 (0-19) 43 (26-62) 3 (0-19)NL 1005/783 1 (1-2) 1 (0-1) 8 (7-11) 0 (0-1) 7 (6-9) 1 (0-2)NO 601/479 2 (1-3) 0 (0-2) 12 (9-15) 1 (0-2) 11 (9-15) 1 (0-2)PL 9/9 0 (0-37) 0 (0-37) 11 (1-49) 0 (0-37) 11 (1-49) 0 (0-37)PT 183/182 17 (12-24) 0 (0-3) 21 (16-28) 5 (3-10) 9 (6-15) 12 (8-18)RO 29/28 28 (13-47) 10 (3-28) 25 (11-45) 11 (3-29) 7 (1-25) 18 (7-38)SE 993/942 2 (1-3) 1 (0-2) 5 (3-6) 2 (1-3) 5 (3-6) 0 (0-1)SI 167/165 19 (13-25) 5 (2-10) 13 (8-19) 13 (9-20) 7 (4-13) 5 (3-10)TR 98/90 18 (12-28) 5 (2-12) 16 (9-25) 9 (4-17) 7 (3-14) 9 (4-17)UK 1,510/1,451 3 (2-4) 1 (0-2) 12 (10-13) 2 (1-2) 10 (9-12) 1 (1-2)

Total 10,351/9,665 9 2 15 4 11 5

158 Annex 3. Overview of antibiotic resistance in Europe, 2006Annex 3. Overview of antibiotic resistance in Europe, 2006

Annex 3.2. The number (No) of invasive S. aureus (SAU) isolates, and the proportion resistant to methicillin (MRSA) including 95% confidence intervals (95CI) reported per country in 2006.

Country No SAU isolates %MRSA 95CI

AT 1,637 9 (8-11)BE 858 22 (19-25)BG 159 28 (22-36)CY 62 32 (21-45)CZ 1,520 12 (11-14)DE 775 20 (17-23)DK 1,279 2 (1-3)EE 154 3 (1-8)ES 1,483 25 (23-28)FI 891 3 (2-5)FR 3,818 27 (25-28)GR 826 43 (39-46)HR 391 36 (32-41)HU 1,127 25 (23-28)IE 1,347 42 (40-45)IL 511 39 (35-44)IS 57 0 (0-8)IT 1,104 38 (36-41)LT 167 12 (8-18)LU 77 19 (12-30)LV 171 18 (13-25)MT 91 67 (56-76)NL 1,633 1 (1-2)NO 734 0 (0-1)PL 174 20 (14-26)PT 1,306 48 (45-51)RO 78 55 (43-66)SE 1,967 1 (1-1)SI 365 7 (5-10)TR 794 36 (33-40)UK 3,996 42 (41-44)

Total 29,552 24


Annex 3.3. The number (No) of invasive E. faecalis and E. faecium isolates, and the proportion high level aminoglycoside resistant E. faecalis, and vancomycin resistant E. faecium (%R) including 95% confidence intervals (95CI) reported per country in 2006.

High level aminoglycoside resistant E. faecalis

Vancomycin resistantE. faecium

Country No %R (95CI) No %R (95CI)

AT 242 29 (23-35) 212 0 (0-3)BE 189 30 (23-37) 48 4 (1-15)BG 51 53 (39-67) 31 0 (0-14)CY 40 45 (30-61) 7 14 (1-58)CZ 509 43 (39-47) 181 4 (2-8)DE 52 29 (18-43) 237 8 (5-13)DK 0 - 83 0 (0-6)EE 48 35 (23-51) 31 0 (0-14)ES 575 36 (32-40) 175 3 (1-7)FI 150 25 (18-32) 123 1 (0-5)FR 868 16 (14-19) 221 3 (1-7)GR 523 58 (53-62) 351 42 (37-48)HR 142 37 (29-46) 34 3 (0-17)HU 408 47 (42-52) 45 0 (0-10)IE 246 43 (36-49) 258 36 (31-43)IL 197 42 (35-49) 67 28 (18-41)IS 31 3 (0-19) 7 0 (0-44)IT 405 38 (33-43) 175 18 (13-24)LT 14 50 (24-76) 8 0 (0-40)LU 25 32 (16-54) 12 0 (0-30)LV 30 50 (32-68) 19 0 (0-21)MT 0 - 8 0 (0-40)NL 268 28 (23-34) 288 1 (0-3)NO 107 33 (24-43) 68 0 (0-7)PL 48 50 (35-65) 20 0 (0-20)PT 298 41 (35-46) 136 26 (19-34)RO 13 15 (3-46) 13 0 (0-28)SE 561 20 (17-24) 302 0 (0-2)SI 95 40 (30-51) 50 6 (2-18)TR 285 29 (24-35) 283 4 (2-7)UK 90 52 (41-63) 169 18 (12-25)

Total 6,510 35 3,662 11


Annex 3.4. The number of invasive E. coli isolates (No), and the proportion aminopenicillins, third generation cephalosporins, fluoroquinolones, aminoglycosides and multi-resistance (%R) including 95% confidence intervals (95CI) reported per country in 2006.

Aminopenicillins Fluoroquinolones Third gen. Cepha-losporines

Aminoglycosides Multi-resistance*

Country No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI)

AT 2469 53 (51-55) 2,463 22 (20-24) 2,471 7 (6-8) 2,474 8 (7-9) 2,450 3 (2-4)BE 1618 54 (52-57) 1,554 19 (17-21) 1,615 3 (2-4) 1,112 6 (5-7) 1,090 1 (1-2)BG 177 64 (56-71) 191 26 (20-33) 196 29 (22-36) 194 28 (22-35) 189 16 (11-22)CY 90 62 (51-72) 89 35 (25-46) 90 16 (9-25) 90 10 (5-19) 89 7 (3-15)CZ 2,144 56 (54-58) 2,133 23 (21-25) 2,149 5 (4-6) 2,142 8 (7-10) 2,125 1 (1-2)DE 832 61 (57-64) 830 29 (26-32) 831 4 (3-6) 833 10 (8-12) 829 2 (1-3)DK 2,722 41 (39-43) 2,370 7 (6-8) 1,839 2 (2-3) 2,721 3 (2-4) 1,700 1 (0-1)EE 215 52 (45-59) 198 7 (4-11) 213 0 (0-3) 215 2 (1-6) 196 0 (0-2)ES 3,363 64 (62-65) 3,360 28 (26-30) 3,362 7 (6-8) 3,363 9 (8-10) 3,357 2 (1-2)FI 1,460 36 (34-39) 1,875 8 (7-10) 1,873 2 (1-3) 1,795 2 (2-3) 1,794 1 (1-2)FR 6,363 53 (52-54) 6,627 14 (13-15) 6,717 2 (2-2) 6714 6 (6-7) 6,626 1 (1-1)GR 1,199 46 (43-48) 1,250 14 (13-17) 1,251 6 (5-8) 1,253 7 (6-9) 1,250 2 (1-3)HR 780 51 (47-54) 776 15 (13-18) 777 1 (1-3) 777 6 (4-8) 776 1 (0-2)HU 1,125 53 (50-56) 1,071 27 (24-29) 1,128 5 (4-6) 1,130 12 (11-14) 1,063 3 (2-4)IE 1,632 69 (67-71) 1,621 21 (19-23) 1,627 4 (3-5) 1,634 7 (6-9) 1,606 1 (0-1)IL 835 66 (62-69) 945 27 (24-30) 940 13 (11-15) 945 17 (14-19) 938 8 (6-10)IS 128 45 (36-54) 121 11 (6-18) 130 0 (0-4) 130 7 (3-13) 121 0 (0-4)IT 896 56 (52-59) 852 27 (24-30) 910 7 (6-9) 853 8 (6-10) 852 2 (1-4)LT 167 55 (47-63) 171 12 (8-18) 171 5 (2-9) 171 15 (10-21) 171 1 (0-5)LU 167 46 (38-54) 167 20 (14-27) 167 2 (0-6) 167 6 (3-11) 167 2 (0-6)LV 62 44 (31-57) 60 10 (4-21) 62 6 (2-16) 62 5 (1-14) 60 2 (0-10)MT 97 56 (45-66) 97 32 (23-42) 97 4 (1-11) 97 14 (8-23) 97 4 (1-11)NL 2,897 47 (45-49) 2,836 11 (10-12) 2,647 3 (3-4) 2,837 3 (3-4) 2,585 1 (1-2)NO 1,573 35 (32-37) 1,479 5 (4-6) 1,573 1 (1-2) 1,570 2 (1-3) 1,475 0 (0-1)PL 205 55 (48-62) 205 20 (15-27) 205 4 (2-8) 204 11 (7-16) 204 3 (1-7)PT 1,329 59 (56-62) 1290 28 (25-30) 1,258 10 (8-12) 1,329 12 (10-14) 1,237 7 (6-8)RO 33 88 (71-96) 39 44 (28-60) 38 42 (27-59) 41 41 (27-58) 36 31 (17-48)SE 2,038 28 (27-30) 3,244 8 (7-9) 3,539 2 (1-2) 3,521 2 (1-2) 3,226 0 (0-1)SI 717 44 (41-48) 717 15 (13-18) 717 2 (1-3) 717 7 (5-9) 717 1 (0-2)TR 874 72 (69-75) 883 48 (44-51) 887 33 (30-36) 887 28 (25-31) 881 17 (15-20)UK 2,141 57 (55-59) 2,155 20 (18-22) 1,772 8 (6-9) 2,076 7 (6-8) 1,613 2 (2-3)

Total 40,348 52 41,669 18 41,252 5 42,054 7 39,520 2

* Multi-resistance was defined as being resistant to fluoroquinolones, third generation cephalosporins and aminoglycosides irrespective of aminopenicillin susceptibility


Annex 3.5. The number of invasive K. pneumoniae isolates (No), and the proportion aminopenicillins, third generation cephalosporins, fluoroquinolones, aminoglycosides and multi-resistance (%R) including 95% confidence intervals (95CI) reported per country in 2006.

Aminopenicillins Fluoroquinolones Third gen.

Cephalos-

porins

Aminoglycosides Carbapenemen Multi-resistance*

Country No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI)

AT 432 95 (93-97) 432 8 (6-11) 431 6 (4-9) 433 5 (3-7) 269 0 (0-2) 429 2 (1-4)BG 53 98 (89-100) 55 24 (14-37) 55 60 (46-73) 55 60 (46-73) 47 0 (0-9) 55 22 (12-35)CY 26 100 (84-100) 26 12 (3-31) 26 27 (12-48) 26 12 (3-31) 26 0 (0-16) 26 12 (3-31)CZ 1125 99 (98-100) 1124 47 (44-50) 1125 35 (32-37) 1125 38 (35-41) 15 0 (0-25) 1124 20 (18-23)DE 145 93 (87-96) 145 12 (8-19) 145 14 (9-21) 146 12 (8-19) 145 0 (0-3) 144 5 (2-10)DK 607 97 (95-98) 527 6 (4-9) 430 4 (2-6) 606 2 (1-4) 44 0 (0-10) 401 1 (0-2)EE 47 100 (91-100) 41 5 (1-18) 47 9 (3-21) 46 9 (3-22) 26 0 (0-16) 40 3 (0-15)ES 560 96 (94-97) 563 8 (6-11) 562 9 (7-12) 564 7 (5-9) 468 0 (0-1) 561 1 (0-2)FI 180 95 (90-98) 228 4 (2-8) 228 1 (0-3) 222 1 (0-4) 214 0 (0-2) 222 1 (0-4)FR 896 99 (98-100) 938 9 (7-11) 963 6 (5-8) 962 7 (5-9) 831 0 (0-1) 938 4 (3-5)GR 771 96 (94-97) 840 50 (46-53) 841 58 (54-61) 841 54 (50-57) 837 33 (30-36) 840 38 (35-41)HR 205 100 (98-100) 205 23 (18-30) 205 34 (28-41) 205 33 (26-40) 204 0 (0-2) 205 18 (13-24)HU 300 100 (98-100) 272 13 (10-18) 300 20 (16-25) 300 20 (15-25) 284 0 (0-2) 271 11 (7-15)IE 211 96 (92-98) 203 16 (11-22) 199 9 (5-14) 211 9 (5-13) 147 0 (0-3) 191 2 (1-6)IL 399 99 (97-100) 429 41 (36-46) 430 44 (39-49) 430 46 (42-51) 429 11 (8-15) 429 33 (28-37)IS 13 92 (62-100) 12 0 (0-30) 13 0 (0-28) 13 0 (0-28) 12 0 (0-30) 12 0 (0-30)IT 305 89 (85-92) 308 23 (19-28) 320 33 (28-38) 308 26 (22-32) 305 1 (0-4) 307 17 (13-22)LT 34 94 (79-99) 35 3 (0-17) 35 23 (11-41) 35 26 (13-44) 32 0 (0-13) 35 3 (0-17)LU 20 90 (67-98) 18 6 (0-29) 21 10 (2-32) 21 0 (0-19) 2 0 (0-80) 18 0 (0-22)LV 26 85 (64-95) 27 26 (12-47) 28 36 (19-56) 28 25 (11-45) 26 0 (0-16) 27 7 (1-26)MT 33 100 (87-100) 33 6 (1-22) 33 6 (1-22) 33 6 (1-22) 33 0 (0-13) 33 0 (0-13)NL 456 98 (97-99) 441 4 (3-7) 397 4 (2-6) 446 4 (2-6) 329 0 (0-2) 387 1 (0-3)NO 262 94 (91-97) 248 7 (4-11) 263 2 (0-4) 263 0 (0-2) 221 0 (0-3) 248 0 (0-2)PL 42 90 (76-97) 42 29 (16-45) 42 38 (24-54) 42 36 (22-52) 17 0 (0-23) 42 24 (13-40)PT 314 99 (97-100) 310 20 (15-25) 303 21 (16-26) 314 13 (10-18) - 298 8 (6-12)RO 29 100 (85-100) 30 33 (18-53) 33 94 (78-99) 33 91 (75-98) 33 0 (0-13) 30 30 (15-50)SE 315 69 (64-74) 558 5 (4-7) 621 1 (1-3) 620 0 (0-1) 3 0 (0-69) 558 0 (0-1)SI 145 97 (92-99) 145 21 (15-29) 145 24 (18-32) 145 19 (13-27) 117 0 (0-4) 145 15 (10-22)TR 443 97 (94-98) 450 23 (20-28) 450 43 (38-48) 452 28 (24-33) 425 3 (2-5) 448 10 (7-13)UK 377 99 (97-100) 381 13 (10-16) 296 11 (8-15) 378 8 (6-12) 286 0 (0-2) 282 8 (5-12)

Total 8,771 96 9,066 21 8,987 22 9,303 19 5,827 6 8,746 12

* Multi-resistance was defined as being resistant to fluoroquinolones, third generation cephalosporins and aminoglycosides irrespective of aminopenicillin susceptibility

Annex 3.6. The number of invasive Pseudomonas aeruginosa isolates (No), and the proportion piperacillin (+/- tazobactam), ceftazidime, carbapenems, fluoroquinolones and aminoglycosides resistance (%R) including 95% confidence intervals (95CI) reported per country in 2006.

Piperacillin +/- Tazobactam

Ceftazidime Carbapenems Fluoroquinolones Amino-glycosides

Country No %R(95CI) No %R(95CI) No %R(95CI) No %R(95CI) No %R(95CI)

AT 401 8 (6-11) 369 9 (6-12) 397 15 (12-19) 372 14 (11-18) 399 9 (7-13)BG 30 33 (18-53) 30 13 (4-32) 28 14 (5-34) 30 17 (6-35) 31 42 (25-61)CY 37 27 (14-44) 37 24 (12-42) 36 11 (4-27) 37 27 (14-44) 37 11 (4-26)CZ 480 29 (25-33) 485 31 (26-35) 485 33 (28-37) 486 48 (43-52) 451 30 (26-34)DE 162 17 (12-24) 162 12 (7-18) 162 17 (11-24) 161 20 (14-27) 162 18 (12-25)EE 41 12 (5-27) 41 7 (2-21) 42 29 (16-45) 41 10 (3-24) 40 8 (2-21)ES 404 9 (6-12) 400 7 (5-10) 389 12 (9-15) 402 19 (15-23) 405 11 (8-14)FI 161 7 (4-13) 161 3 (1-7) 158 8 (4-13) 162 17 (12-24) 161 8 (5-14)FR 943 11 (9-14) 952 6 (5-8) 1,004 12 (10-14) 995 23 (20-26) 984 16 (14-19)GR 813 39 (36-43) 800 34 (31-38) 815 48 (44-51) 814 45 (42-49) 815 47 (44-51)HR 170 38 (30-45) 166 11 (7-18) 170 25 (19-32) 170 35 (28-42) 169 47 (40-55)HU 510 9 (7-12) 543 8 (6-11) 532 16 (13-20) 372 20 (16-25) 544 23 (19-27)IE 127 7 (3-13) 123 6 (3-12) 119 9 (5-16) 127 17 (11-24) 127 9 (5-16)IL 345 19 (15-24) 283 19 (15-24) 346 17 (13-22) 344 31 (27-37) 346 27 (23-33)IS 9 0 (0-37) 9 0 (0-37) 9 0 (0-37) 9 0 (0-37) 9 0 (0-37)IT 183 23 (18-30) 173 20 (14-27) 183 21 (16-28) 182 34 (27-41) 183 30 (24-37)LT 14 21 (6-51) 13 31 (10-61) 14 21 (6-51) 13 46 (20-74) 14 29 (10-58)LU 22 9 (2-31) 20 10 (2-33) 14 7 (0-36) 20 10 (2-33) 23 4 (0-24)LV 12 17 (3-49) 14 29 (10-58) 16 13 (2-40) 15 33 (13-61) 15 47 (22-73)MT 45 47 (32-62) 50 30 (18-45) 50 20 (11-34) 50 22 (12-36) 51 8 (3-20)NL 304 2 (1-5) 325 5 (3-8) 290 2 (1-5) 313 8 (5-12) 328 4 (2-7)NO 91 3 (1-10) 96 5 (2-12) 85 9 (4-18) 92 9 (4-17) 95 1 (0-7)PL 37 43 (28-60) 36 42 (26-59) 37 30 (16-47) 37 41 (25-58) 37 46 (30-63)PT 232 15 (11-20) 264 19 (15-25) 251 21 (16-26) 266 21 (16-26) 266 17 (13-22)RO 3 33 (2-87) 2 0 (0-80) 3 0 (0-69) 3 33 (2-87) 3 33 (2-87)SE 237 0 (0-3) 297 6 (3-9) 235 5 (2-8) 247 5 (3-9) 300 0 (0-2)SI 72 18 (10-29) 72 8 (3-18) 72 6 (2-14) 72 21 (12-32) 71 15 (8-26)TR 310 28 (24-34) 305 24 (20-30) 312 33 (28-38) 304 29 (24-34) 282 33 (28-39)UK 311 1 (0-3) 288 3 (2-6) 258 6 (4-10) 331 8 (5-11) 326 3 (2-6)

Total 6,506 17 6,516 15 6,512 20 6,467 25 6,674 21


Documents

EARSS Annual Report 2006 - nsih.be · EARSS performs on-going surveillance of antimicrobial susceptibility for Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Enterococcus