EARSS Annual Report 2007 - European Centre for Disease ......EARSS Annual Report 2007 The European Antimicrobial Resistance Surveillance System (EARSS), funded by the European Centre

EARSS Annual Report 2007

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 in 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 2007, over 900 microbiological laboratories serving more than 1400 hospitals from 31 countries had provided susceptibility data of more than 600,000 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 2007

This document was prepared by the EARSS Management Team, members of the Advisory Board, and national representatives of EARSS, Bilthoven, The Netherlands, October 2008.

ISBN: 978-90-6960-214-1

Table of contents Annual Report 2007

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

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

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

The EARSS network from January 2007 till August 2008 ..................................................................................................................13 I. Countries participating in EARSS ..............................................................................................................................13 II. EARSS national representatives per country .................................................................................................13 III. EARSS national data managers and contact persons ..........................................................................14 IV. EARSS advisory board members ................................................................................................................................ 16 V. Collaborating parties and representatives ..........................................................................................................16 VI. EARSS management team ....................................................................................................................................................17 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 ..............................................................................................................................................252.2.3. 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 2008 and beyond ...................................................................................................................................................272.3.1. Collection of antimicrobial susceptibility data .........................................................................272.3.2. The EARSS network .................................................................................................................................................272.3.3. EARSS in 2009 ................................................................................................................................................................27

Chapter 3. Results of the EARSS laboratory/hospital questionnaire 2007 ...............................................................293.1. Introduction ..................................................................................................................................................................................................293.2. Methods ............................................................................................................................................................................................................293.3. Results ................................................................................................................................................................................................................29

3.3.1. Participation ..............................................................................................................................................................................293.3.2. Population coverage ......................................................................................................................................................303.3.3. Hospital denominator information ...............................................................................................................323.3.4. Hospital characteristics ...............................................................................................................................................333.3.5. Laboratory denominator information ........................................................................................................343.3.6. Incidence rates for MRSA blood stream infections ................................................................35

3.4. Conclusions ..................................................................................................................................................................................................363.5. References .....................................................................................................................................................................................................37

Contents 3

Chapter 4. Antimicrobial resistance in Europe ...............................................................................................................................................394.1 Introduction and methods ..........................................................................................................................................................394.2. Streptococcus pneumoniae .......................................................................................................................................................39

4.2.1. Clinical and epidemiological importance ......................................................................................394.2.2. Streptococcus pneumoniae resistance trends: 1999-2007 ..........................................404.2.3. Serotypes ..................................................................................................................................................................................464.2.4. Conclusions ...........................................................................................................................................................................46

4.3. Staphylococcus aureus ...................................................................................................................................................................484.3.1. Clinical and epidemiological importance ......................................................................................484.3.2. Staphylococcus aureus resistance trends: 1999-2007 ......................................................494.3.3. MRSA by hospital department ......................................................................................................................504.3.4. Conclusions ...........................................................................................................................................................................53

4.4. Enterococci ...................................................................................................................................................................................................534.4.1. Clinical and epidemiological importance ......................................................................................534.4.2. Enterococcus faecalis resistance trends: 2001-2007 .........................................................544.4.3. Enterococcus faecium resistance trends: 2001-2007 ........................................................564.4.4. Conclusions ...........................................................................................................................................................................58

4.5. Escherichia coli ......................................................................................................................................................................................584.5.1. Clinical and epidemiological importance ......................................................................................584.5.2. Escherichia coli resistance trends: 2001-2007 .........................................................................594.5.3. Conclusions ...........................................................................................................................................................................62

4.6. Klebsiella pneumoniae ..................................................................................................................................................................684.6.1. Clinical and epidemiological importance ......................................................................................684.6.2. Klebsiella pneumoniae resistance in 2007 .....................................................................................684.6.3. Conclusions ...........................................................................................................................................................................71

4.7. Pseudomonas aeruginosa ..........................................................................................................................................................724.7.1. Clinical and epidemiological importance ......................................................................................724.7.2. Pseudomonas aeruginosa resistance in 2007 .............................................................................724.7.3. Conclusions ...........................................................................................................................................................................76

4.8. References .....................................................................................................................................................................................................77

Chapter 5. Conclusions and Recommendations ............................................................................................................................................81

4 Contents

Annex 1. Technical notes .......................................................................................................................................................................................................83 1.1. Technical Notes for table 1 of the Country Summary Sheets .........................................................83 1.2. Technical Notes for the MRSA incidence calculations in chapter 3 ......................................84 1.3. Technical Notes for chapter 4 ..................................................................................................................................................84

Annex 2. Country Summary Sheets ..........................................................................................................................................................................87 Austria ...............................................................................................................................................................................................................................88 Belgium ............................................................................................................................................................................................................................90 Bulgaria ............................................................................................................................................................................................................................92 Croatia ...............................................................................................................................................................................................................................94 Cyprus ................................................................................................................................................................................................................................96 Czech Republic ......................................................................................................................................................................................................98 Denmark ...................................................................................................................................................................................................................... 100 Estonia ........................................................................................................................................................................................................................... 102 Finland ........................................................................................................................................................................................................................... 104 France ............................................................................................................................................................................................................................. 106 Germany ...................................................................................................................................................................................................................... 108 Greece .............................................................................................................................................................................................................................110 Hungary ........................................................................................................................................................................................................................112 Iceland ............................................................................................................................................................................................................................114 Ireland .............................................................................................................................................................................................................................116 Israel ..................................................................................................................................................................................................................................118 Italy ................................................................................................................................................................................................................................... 120 Latvia .............................................................................................................................................................................................................................. 122 Lithuania ..................................................................................................................................................................................................................... 124 Luxembourg ........................................................................................................................................................................................................... 126 Malta ................................................................................................................................................................................................................................ 128 Netherlands .............................................................................................................................................................................................................. 130 Norway ......................................................................................................................................................................................................................... 132 Poland ............................................................................................................................................................................................................................. 134 Portugal ........................................................................................................................................................................................................................ 136 Romania ...................................................................................................................................................................................................................... 138 Slovenia ....................................................................................................................................................................................................................... 140 Spain ................................................................................................................................................................................................................................ 142 Sweden .......................................................................................................................................................................................................................... 144 Turkey ............................................................................................................................................................................................................................ 146 United Kingdom ............................................................................................................................................................................................... 148

Annex 3. Overview of antibiotic resistance in Europe, 2007 ............................................................................................... 151

Contents 5

Acknowledgements

EARSS…. still here!

Predictably, three main factors, (i) acceleration, (ii) facilitation, and (iii) lack of pharmaceutical response will be causing a critical decline of antimicrobial effectiveness within the next 10 years, which will result in widespread occurrence of untreatable (or next-to-untreatable) community as well as institutionally-acquired infections.

Acceleration is brought about by a couple of global economic and behavioural changes which substantially impact on the pattern of antimicrobial consumption worldwide. With the dramatic onslaught of the HIV/AIDS pandemic in most developing countries, recent patient generations have been brought up with the tacit conviction that microbes are one of the leading causes of disease. This has lead to an overwhelmingly changed pattern of health seeking behaviour especially in poorer societies. It explains the growing demand for antimicrobial chemotherapy, which, at the same time, is met by the availability of cheap generic compounds produced in emerging market communities. Thus, it will come as no surprise that there will be a massive increase in antimicrobial consumption at a time when patent protections for most antimicrobial compounds expire and the purchasing power in developing countries increases.

Changing dietary habits are driving the demand for meat and animal protein resulting in the expansion of intensive animal husbandry. By now, the national herd of large farm animals (mainly, pigs, veal calves, milk cows, and cattle) outnumbers the human population in many European countries. Yet antimicrobial consumption in industrial food animals is much higher than in the sector of human care. This relentless increase in antimicrobial use imposes a constant selection pressure on microorganisms that escape selective sweeps by evolutionary responses, setting the stage for an immediate and dramatic shift in the occurrence of AMR with a consecutive increase in the burden of disease caused by antimicrobial resistant pathogens in Europe and beyond.

Facilitation of resistance is due to extrinsic factors that are less predictable and fall in the same category as some of the threats mentioned above (emerging infections, zoonoses, bioterrorism and pandemic influenza). Facilitation will lead to a more rapid spread of AMR due to transmission and migration which could be the unwanted consequences of the unstable socio-political and physical environment in which we live. Civil unrest and the often extreme manifestations of recent climatic disturbances such as draught and flooding are disrupting human livelihoods, leading to crowding, food and water shortages. In their course, malnourishment and the lack of safe drinking water, per-sonal hygiene and migration are facilitating a speedy dissemination of AMR pathogens. Indeed, a worst case scenario would be an outbreak of pandemic flu which, under the present constellation of widespread AMR in hospitals, would likely be succeeded by a secondary epidemic of bacterial superinfections most notably MRSA acquired during treatment in overburdened hospitals that will struggle to maintain their hygienic standards.

The lack of new antimicrobial agents is highlighted by the exponential decline in the development of new classes of antimicrobials over the last six decades, whereby only a single new AM class has hit the market in the last ten years. A look into the research portfolio of large pharmaceutical companies is all but reassuring. This uncomfortable trend only supports the notion that no remedy for the deteriorating situation will arrive any time soon.

Acknowledgements 7

And it is for these reasons that EARSS is still here, confronting the public with an uncomfortable reality - the decline of antimicrobial effectiveness. 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 7th 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 spreading the gospel from Latin-America to China for WHONET and for EARSS.

Finally, I would like to thank you all for your extremely professional collaborative effort to this unique and well functioning network which now includes 917 laboratories in 31 countries. I look forward to continue this fruitful cooperation in 2009.

Hajo Grundmann Project leader EARSS ProjectCentre for Infectious Disease ControlNational Institute for Public Health and the Environment

8 Acknowledgements

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. Routine data for major indicator pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumonia and Pseudomonas aeruginosa) are quarterly submitted by over 900 laboratories serving more than 1400 hospitals in 31 European countries.Based on the denominator data reported through the laboratory/hospital questionnaire, the overall hospital catchment population of the EARSS network is estimated to include at least 25% of EU population; including accession countries and Israel, and 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.

The non-susceptibility profile of S. pneumoniae has a dynamic character. Although penicillin non-susceptibility (PNSP) is increasing in two countries, five countries are on the decrease, among those three countries showing the highest PNSP proportions in 2006. Erythromycin non-susceptibility is becoming more prevalent in quite a few countries, but against that, an equal number of countries is on the decrease. For dual non-susceptibility an increasing trend is observed, however Belgium and Spain show a decrease as they do for PNSP and ENSP.This year, 12 countries have reported serogroup information for S. pneumoniae isolates, and data from seven countries were included for analysis. Compared to 2006, changes were small. Serogroup 1, 14 and 19 are highly prevalent in most countries. MRSA is still an increasing problem all over Europe. In a number of low-endemic countries increasing MRSA proportions are found. In the high endemic countries, on the other hand, some countries seem to have stabilising MRSA proportions, and more important, more countries compared with previous years, showed a significant decrease. With the ongoing spread of clonal complex 17 in Europe, outbreaks of vancomycin resistant E. faecium continue to afflict more and more hospitals in various countries. The spread of these hospital-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 practitioners.The Europe-wide increase of resistance of Escherichia coli to all of the antimicrobial classes recorded by EARSS is a disturbing development with seemingly inexorable vigor. The highest resistance proportions have been reported for aminopenicillins and this can no longer be regarded as an useful option for empirical treatment now. For fluoroquinolones the situation becomes progressively dire. The speed with which fluoroquinolones loose their activity against E. coli is next to no other compound pathogen combination in the EARSS database. Combined resistance is a frequent occurrence, with co-resistance to 4 antimicrobial classes including 3rd generation cephalosporins already among the

Summary 9

4th most common resistance patterns encountered in invasive E. coli in Europe. In K. pneumoniae a high prevalence of resistant strains to 3rd generation cephalosporins, fluoroquinolones and aminoglycosides becomes evident in central and south-eastern Europe. Many of these 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. 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. For K. pneumoniae and P. aeruginosa trend analyses are not displayed yet, since we felt three years of data does not give sufficient estimates for solid and reliable trends.Combined 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 chemothera-py will predictably be a multi-resistant phenotype. 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.

10 Summary

List of abbreviations and acronyms

AMR Antimicrobial resistanceARMed 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 assessmentESAC 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-gene sequence 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

The EARSS network from January 2007 till August 2008

I. Countries participating in EARSS

Austria AT Italy ITBelgium BE Latvia LVBosnia and Herzegovina* BA Lithuania LTBulgaria BG Luxembourg LUCroatia HR Malta MTCyprus CY Netherlands NLCzech Republic CZ Norway NODenmark DK Poland PLEstonia EE Portugal PTFinland FI Romania ROFrance FR Slovenia SIGermany DE Spain ESGreece GR Sweden SEHungary HU Switzerland* CHIceland IS Turkey TRIreland IE United Kingdom UKIsrael IL

* Start delivering AST data per 2008

II. EARSS national representatives per country

Austria (AT)H. MittermayerW. Koller

Denmark (DK)R. SkovA. Hammerum

Iceland (IS)K. Kristinsson

Malta (MT)M. Borg

Spain (ES)F. Baquero J. Campos

Belgium (BE)H. GoossensE. Hendrickx

Estonia (EE)K. Kermes

Ireland (IE)R. CunneyO. Murphy

Netherlands (NL)N. van de SandeA. de Neeling

Sweden (SE)B. Liljequist

Bosnia and Herzegovina (BA)S. Uzunovic-Kamberovic

Finland (FI)O. LyytikäinenA. Hakanen

Israel (IL)R. Raz

Norway (NO)G. Skov Simonsen

Switzerland (CH)K. Mühlemann

Bulgaria (BG)B. Markova

France (FR)B. CoignardV. Jarlier

Italy (IT)A. PantostiP. D ‘Ancona

Poland (PL)W. Hryniewicz

Turkey (TR)D. Gür

Croatia (HR)S. KalenicA.Tambic-Andrasevic

Germany (DE)W. Witte

Latvia (LV)A. Balode

Portugal (PT)M. Caniça

United Kingdom (UK)A. Johnson, R. Hill(Eng & Wales) J. Wilson (Sct) L. Patterson (NIR)

Cyprus (CY)D. Bagatzouni

Greece (GR)A. TsakrisA. Vatopoulos

Lithuania (LT)V. JonaitieneL. Dagyte-Sileikiene

Romania (RO)A. Baicus

Czech Rep. (CZ)P. UrbaskovaH. Zemlickova

Hungary (HU)M. FüziA. Toth

Luxembourg (LU)R. Hemmer

Slovenia (SI)M. Mueller-PremruJ. Kolman

The EARSS network from January 2007 till August 2008 13

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

Contact person Institute Country National Surveillance Network

URL

S. Metz-Gercek 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

S. Uzunovic-Kamberovic

Canton Public Health Institute Zenica

Bosnia and Herzegovina

Y. Marteva-ProevskaB. Markova

“Alexandrovska”, Laboratory for Clinical Microbiology, Sofia

Bulgaria EARSS Bulgaria www.earss.online.bg

S. KalenicA. BudimirA. Tambic Andrasevic

Clinical Hospital Centre ZagrebUniversity Hospital for Infectious Diseases, 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

http://www.szu.cz/topics/diseasis-and-conditions/earss

A.M. HammerumR.L. 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

I. Noll 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

14 The EARSS network from January 2007 till August 2008


URL

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

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

V. 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

A. 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. OteoO. CuevasJ. Campos

Antibiotic Laboratory, Bacteriology, CNM. Instituto de Salud Carlos III

Spain EARSS Spain http://www.isciii.es/htdocs/en/index.jsp

B. Olsson-LiljequistL. GezeliusJ. Struwe

Swedish Institute for Infectious Disease Control

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

www.smittskydds institutet.se



URL

K. MühlemannA. Kronenberg

Institut für Infektions-krankheiten der Universität Bern

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

Name Representing InstituteDr. A. Balode all countries Paul Stradins Clinical University Hospital, Riga, LatviaProf. F. Baquero ESGARS Hospital Ramon y Cajal, Madrid, SpainDr. G. Cornaglia ESCMID University of Verona, ItalyProf. J. Degener all countries University Medical Centre Groningen, The NetherlandsProf. V. Jarlier all countries Groupe Hospitalier Pitié-Salpêtrière, Paris, FranceDr. G. Kahlmeter EUCAST Central Hospital Växjö, SwedenDr. J. Kolman all countries University Medical Centre Ljubljana, Slovenia Prof. A. Vatopoulos all countries National School of Public Health, Athens, GreeceDr. C. Suetens / Dr. O. Heuer ECDC ECDC, Stockholm, Sweden

V. Collaborating parties and representatives

ESCMID G. CornagliaESGARS F. BaqueroEUCAST G. KahlmeterWHO K. HollowayWHONET J. StellingCDC, USA F. Tenover (until October 2008) UK-NEQAS C. Walton


VI. EARSS management team

Project leader, Scientific coordinator H. Grundmann Project coordinator I. Roede (started May 2008)

N. van de Sande-Bruinsma

Epidemiologists M. de KrakerInternational Data Manager J. Monen 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 35 05Fax: +31 30 274 44 09

VII. EARSS related publications

Scientific papers in peer reviewed journalsEARSS 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; 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 Rela-tionship 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. Emerg 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 Antimicrob Chemother 2004; 54: 1045 – 1050.

• Tiemersma EW, Monnet DL, Bruinsma N, Skov R, Monen JCM, Grundmann H, and EARSS participants. Staphylococcus aureus bacteremia, Europe. Emerg 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, and Ferech M. Antibiotic Use and Resistance in Europe: The Relentless Strain on Non-Renewable Resources. Emerg Infect Dis 2008; in press.

• Borg M, Tiemersma E, Scicluna E, Van de Sande-Bruinsma N, De Kraker M, Monen J, Grundmann H. Prevalence of penicillin and erythromycin resistance amongst Streptococcus pneumoniae from invasive isolates reported by laboratories in the Southern and Eastern Mediterranean. Clinical Microbiology and Infection 2008; in press.

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• Urbášková P, Macková B, Jakubu V, Žemlicková H a CZ-EARSS. Resistance to clindamycin among 1373

Staphylococcus aureus isolates from blood. Zprávy CEM (Bulletin of the Centre of Epidemiology and Microbiology) 2006; 15(3-4):156-158, ISSN 1211-7358.

• Urbášková P, Macková B, Jakubu V, Žemlicková H a CZ-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.

• Urbášková P, Jakubu V, Žemlicková H a úcastníci CZ-EARSS. Antimicrobial resistance in seven invasive bacterial species monitored within EARSS in the Czech Republic (CR) from 2000 - 2006. CzMa JEP Prakticky 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. Eurosurveill 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; 89:367-71.

• 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.

Eurosurveill 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.• Vuopio-Varkila J, Lyytikäinen O. Mikä on avohoidon MRSA? Kansanterveys 2005;7:4.• Kainulainen K, Lyytikäinen O, Vuopio-Varkila J, Syrjälä H. Vankomysiinienterokokki (VRE) Suomessa.

Kansanterveys 2006;5-6:22-23.• Säilä P, Lyytikäinen O, Möttönen T, Nissinen A. Bakteerilääkeresistenssin seuranta Euroopassa: EARSS-tuloksia.

Kansanterveys 2007; 5-6:18-19.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. Eurosurveill 2002; 7: 87-93.

• Pantosti A, Boccia D, D’Ambrosio F, Recchia S, Orefici G, Moro ML, National Surveillance of Bacterial 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• Clarke P, Murchan S, Smyth EG, Humphreys H. Antimicrobial susceptibility of invasive isolates of Streptococcus

pneumoniae in Ireland. Clin Microbiol Infect. 2004 Jul;10(7):657-9.• 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(7): 480-3.

• Rossney AS, Lawrence MJ, Morgan PM, Fitzgibbon MM, Shore A, Coleman DC, Keane CT, O’Connell B. Epidemiological typing of MRSA isolates from blood cultures taken in Irish hospitals participating in the European Antimicrobial Resistance Surveillance System (1999-2003). Eur J Clin Microbiol 2006; 25: 79-89.

• Murchan S, Cunney R; Irish EARSS Steering Group. Rise in antimicrobial resistance in invasive isolates of Escherichia coli and Enterococcus faecium in Ireland. Euro Surveill. 2006 Apr 13;11(4):E060413.3.

Romania• Codita I. The global strategy for antimicrobial resistance containment, European Antimicrobial Resistance Surveil-

lance System (EARSS). Preparatory stages for integrating national surveillance of antimicrobial resistance in the European system. Viata medicala 2001; May: 2.

• Chifiriuc Mariana Carmen, Lixandru Mariana, Iordache Carmen, Bleotu Coralia, Larion Cristina, Olguta Dracea, Lazar Veronica, Antohe Felicia, Israil Anca Michaela. Internalization of Staphylococcus Aureus and Pseudomonas Aeruginosa Bacterial Cells By Non-Phagocytic, Epithelial Human Cells. Roum. Biotech. Lett. 2008; 13 (2), 3651-3658.

• Ani-Ioana Cotar, Sorin Dinu, Mariana-Carmen Balotescu Chifiriuc, Otilia Banu, Carmen Iordache, Cristina Larion, Marcela Bucur, Olguta Dracea, Veronica Lazar. Screening of molecular markers of quorum sensing in Pseudomonas aeruginosa strains isolated from clinical infections. Roum. Biotech. Lett. 2008; 13 (3): 3765-3771.

• Ani-Ioana Cotar, Sorin Dinu, Mariana-Carmen Balotescu Chifiriuc, Otilia Banu, Carmen Iordache, Mariana Lix-andru, Olguta Dracea, Marcela Bucur, Veronica Lazar. Molecular markers of quorum-sensing and virulence gene regulators in Staphylococcus aureus strains isolated from biofilm associated infections. Roum. Biotech. Lett. 2008; 13 (3) 3771-3778.

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; 2001 jun 22-23; Ljubljana. Ljubljana: Slovensko zdravniško društvo, Sekcija za klinično mikrobiologijo in hospitalne infekcije, 2001; 185-92.

• Kolman J, Gubina M, Mueller-Premru M, Lorenčič-Robnik S, Žohar-Čretnik T, Harlander T, Štrumbelj I, Kavčič M, Grmek-Košnik I, Tomič V, Ribič H, Fišer 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 Es-

cherichia 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 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-resistance 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.

• Oteo J, Cuevas O, Navarro C, Aracil B, Campos J; Spanish Group of The European Antimicrobial Resistance Surveillance System (EARSS). Trends in antimicrobial resistance in 3469 enterococci isolated from blood (EARSS experience 2001-06, Spain): increasing ampicillin resistance in Enterococcus faecium. J Antimicrob Chemother. 2007 59:1044-5.

• Oteo J, Campos J, Lázaro E, Cuevas O, et all. Increased Amoxicillin-Clavulanic Acid Resistance in Escheria coli Blood Isolates, Spain. Emerging Infectious Diseases 2008; 8: 1259-62.

• Oteo J, Garduño E, Bautista V, Cuevas O, Campos J; Spanish members of European Antimicrobial Resistance Surveillance System. Antibiotic-resistant Klebsiella pneumoniae in Spain: analyses of 718 invasive isolates from 35 hospitals and report of one outbreak caused by an SHV-12-producing strain. J Antimicrob Chemother. 2008;61:222-4.

• Pérez-Vázquez M, Vindel A, Marcos C, Oteo J, Cuevas J, Trincado P, Bautista V, Grundmann H, Campos J and the EARSS Spain spa-typing Group. Spread of invasive Spanish Staphylococcus aureus spa-type t067 associated with a high prevalence of the aminoglycoside-modifying enzyme gene ant (4´)-Ia and the efflux pumps genes msrA/msrB. J Antimicrob Chemother. 2008 accepted for publication.

United Kingdom• Johnson AP, Aucken HM, Cavendish S, Ganner M, Wale MC, Warner M et al. 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 et al. 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 in-volvement of all participants’ (‘the Copenhagen Recommendations’ [1]). 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 initiative as a minimum requirement of national surveillance programmes (‘the Visby recommendations’ [2]) and during the Rome conference convened by the EU Commission Directorate for Research and De-velopment 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 devel-opment of effective control strategies [3]. 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 2008, EARSS covers an estimated population of at least 120 million European citizens (25% of the European population; including accession countries and Israel), served by more than 1400 hos-pitals in 31 countries. The EARSS database contains AMR data on approximately 600,000 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, like the European Surveil-lance of Antimicrobial Consumption (ESAC). There is a close partnership between the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and two of the society’s sub-committees, namely, 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 in 2007. Chapter 2 summarises the objectives and operational strategy. Chapter 3 gives an overview of the results of the laboratory/hospital questionnaire 2008, through which information was collected on denominators and other relevant determinants of patient care. Chapter 4 provides a descriptive analysis of the situation of AMR in Europe. Chapter 5 presents the overall conclusions and recommendations

Chapter 1. Introduction 21

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 2007 (annex 3). Results are based on data recorded from January 1999 - December 2007, if not otherwise indicated.

References

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

2. 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.

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

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;• supports 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 epidemiological and ecological backgrounds and serve as markers for clinically and epidemiologically meaningful developments in antibiotic resistance. The decision to collect routine data, preferably according 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). 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

Chapter 2. EARSS objectives and operational strategy 23

microbiology laboratory database software (WHONET). To assess the quality and comparability of 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 were presented in the annual report from 2006. In 2007 the EQA exercise was carried out, but the results were not available in time to be presented in this report. These will be published later.

24 Chapter 2. EARSS objectives and operational strategy

A1 A A

National Management Team

EARSS Management Team

Data ManagerNational Representative

NationalAdvisoryBoard

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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 sponsor 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 onwards, and prolonged to

31 December 2009.10 DG-SANCO: Directorate-General for Health and Consumer Protection; funding until September 2006

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.

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 occur-rence of resistance patterns with particular public health importance (e.g. MRSA, GISA/VISA, 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. The annual plenary meeting of 2007/2008 will take place on 14 November, 2008, at The National School of Public Health in Athens, Greece. An update will be given on the situation of antimicrobial resistance in Europe, preliminary results of the EQA exercise 2007 will be presented, and the EARSS related projects, BURDEN (Burden of Resistance & Disease in European Nations) and the Spa-typing initiative EARSS/SeqNet.org will be on the program. The EARSS sister project ESAC is going to present a new initiative, and opportunities for cooperation with EARSS will be discussed; and in addition, two more new initiatives will be presented. Besides these topics, many other subjects considered to be of relevance for the audience will be discussed, such as the relationship between National campaigns and surveillance of antimicrobial resistance in Latin-America.

EARSS also organizes regular training sessions for data managers and reference laboratory personnel. In June 2008, the 3rd workshop for reference laboratory personnel was organized in cooperation with SeqNet.org, in Bilthoven, the Netherlands. In the ongoing EARSS/SeqNet initiative, broad collaboration between 26 European countries was achieved and clearly spa-typing allowed an easy aggregation of data generated in as many laboratories. For geographical display an interactive website based on a Google-map application was developed. Furthermore, an introduction was given into an unique MLVA technique that makes use of eight VNTRs scattered over the S. aureus genome. After the first rather technical day, the second day was more devoted to decisions concerning the future collaboration and new initiatives. Among others, it was agreed by all attendants that a second cross-


sectional study on invasive S. aureus shall be carried out in order to determine the dynamics of strain distribution over Europe. Finally, there was an open discussion about other bacterial pathogens for which similar initiatives should be encouraged.On June 4-5, 2009 the workshop will be organized for the data managers.

2.2.5 Linkage with other networksLaboratory protocols on the identification of fluoroquinolone resistance in Streptococcus pneumoniae 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. Momentarily, the EARSS advisory board and EUCAST are preparing a protocol for metallo-beta-lactamase detection. This protocol will be presented at the plenary meeting in 2008. EARSS and ESAC exchanged their surveillance data for the linking of resistance with the prescrip-tion of antimicrobial compounds in Europe (manuscript accepted, and will be published in the No-vember issue of Emerging Infectious Diseases). The pilot study resulting from the initiative on ‘Identifying the dominant strains of Staphylococcus aureus causing invasive infection in the European region’ was carried out and further expanded in collaboration with the SeqNet.org group (see 2.2.4 EARSS meetings).

2.3. EARSS in 2008 and beyond

2.3.1. Collection of antimicrobial susceptibility dataThis report includes AST data from the start of EARSS in 1999 up to December 2007; the results are described in Chapter 4 of this report. Data collected in 2008 are included in the interactive EARSS database which is regularly updated and accessible from the EARSS website (see www.rivm.nl/earss).


0

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s

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

2.3.2. The EARSS networkSince the beginning of EARSS in 1999, the coverage of the network has been extended from 13 countries in 1999, to 31 countries in 2007 (Figure 2.2). In addition to 26 of the 27 Member States, EARSS receives data from 2 of the 3 EEA/EFTA (Norway and Iceland) and 2 out of 3 candidate countries (Turkey and Croatia) and from Israel. It is the wish of ECDC that EARSS includes all member states, EEA/EFTA countries and candidate countries. One of the member states, Slovakia, was not able to deliver data in 2006 and 2007, but hopefully, this country will be included again soon. Liechtenstein and the Republic of Macedonia should also be included. Since the Republic of Mac-edonia only recently became a candidate country, there has not been contact yet, but it is intended to explore her participation this year. Liechtenstein will be approached as well.In 2008, we welcome two new countries starting reporting data to EARSS, Bosnia Herzegovina and Switzerland. Next to that there have also been very promising negotiations with Serbia and three oblasts of the Russian Federation. Recently, interest has been voiced by Belarus as well.Now that the network is almost complete at country level, the next focus of EARSS will be to assess the national coverage in each country and encourage improvement wherever necessary.

2.3.3. EARSS in 2009In November 2007, ECDC published a call for proposals for ‘Surveillance of antimicrobial resist-ance in Europe 2007-2009’. EARSS-MT at RIVM responded to this call. In December 2007, this proposal was supported awarding RIVM with the continuation of hosting EARSS for another two years, till the end of 2009. The transition of EARSS to Stockholm will be prepared by the EARSS-MT in cooperation with the Surveillance Unit of the ECDC.


Chapter 3. Results of the EARSS laboratory/hospital questionnaire 2007 29

Chapter 3. Results of the EARSS laboratory/hospital questionnaire 2007

3.1. Introduction

EARSS needs to address the timeliness and accuracy of denominator information. Therefore, a questionnaire has been forwarded to national representatives in 2008, and instead of having this questionnaire completed on a bi-annual basis, EARSS wishes to improve its estimates on the occurrence of blood stream infections with AMR bacteria by collecting denominator information such as hospital activity data and catchment populations annually, for better understanding of AMR rates across Europe. The denominator data collected in the questionnaire enables EARSS to approximate the incidence of antimicrobial resistance instead of relying on proportions. Incidences of antimicrobial resistance are a more direct measure of the risk of populations to develop BSIs with antimicrobial resistant bacteria, provided the data obtained are representative (2).Apart from denominator data, the questionnaire also collects reference information about the popu-lations for which laboratories provide their services. This information helps to understand the vali-dity, i.e. representativeness and general applicability of the antimicrobial resistance data collected by EARSS. It is crucial for interpretation of the results and helps to understand bias in antimicrobial resistance proportions between countries as reported by national EARSS partners. Antimicrobial resistance proportions may vary due to e.g. differences in blood sampling practices (1;4), differences in care-level (primary, secondary of tertiary hospitals) or differences in available specialties (3;5).

3.2. Methods

We sent out the EARSS questionnaire in April of this year. All EARSS national representatives distri-buted the digital Excel version or the paper version (translated if needed) to all participating labora-tories 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 participating hospital (both necessary for inclusion), the care-level (type) of hospital, the bed occupancy and the number of admissions. For the laboratory some other more qualitative questions about diagnostic habits were included as well, however these results will not be discussed in this report. The national representatives returned all completed questionnaires to EARSS-MT in May/June. Details of the inclusion criteria and data-analysis are given in Annex 1. Country-specific results were returned to the national representatives for confirmation and adapted where required. Thereafter data were processed in Excel and SAS. In this chapter results of the descriptive analysis are presented. Denominator data can also be found in the country-specific Country Summary Sheets (Table 1 and Figure 1 of Annex 2).

3.3. Results

3.3.1. ParticipationFor the first time, all countries participating in EARSS returned completed questionnaires, and 29/31 did so in digital format. In total, 456 of the 779 laboratories (59%) and 680 of the 1,293 hospitals (53%) reporting AST results in 2007 provided the necessary denominator data (Figure 3.1). Although more countries responded than last year, the overall proportion of laboratories and hospitals respon-

30 Chapter 3. Results of the EARSS laboratory/hospital questionnaire 2007

ding was lower than previous year (when respectively 94% of the countries, 63% of the laboratories and 59% of the hospitals responded). This is in part due to the low response in Greece, who contri-buted to the denominator data for the first time.

3.3.2. Population coverage This year’s response suggested that EARSS participating hospitals care for at least 120 million Eu-ropean citizens (25% of the EU population; including accession countries and Israel). This number does not include the catchment population for Austria, France and Luxemburg, since they were not able to provide this information for their national network. Moreover, the total number of inhabitants covered is based on the data from the returned questionnaires, since the response rate in the countries fluctuated between 7 and 100% (interquartile range 22%-88%) (Table 3.1), this suggests that 120 million is a conservative estimate. This is supported by the fact that last year’s estimate included 155 million European inhabitants, while the EARSS network expands year on year.On the other hand, some of the hospital catchment areas overlap, leading to overestimation in urban settings.

120 100 80 60 40 20 1400 160120100806040200

UKTRSISEROPTPLNONLMTLVLULTITISILIE

GRHRHU

FRFIESEEDKDECZCYBGBEAT

Number of laboratories Number of hospitalsEARSS country code

denominator information

no denominator information

A B

Figure 3.1. Number of laboratories (A) and hospitals (B) reporting AST data in 2007 and providing denominator data, per country. For Poland, the selection of labs is based on participation in 2006.

The above text illustrates how difficult it is to determine the exact coverage of a surveillance network like EARSS and emphasizes the importance of careful interpretation of the coverage figures. Esto-nia, Hungary, Iceland, Lithuania, and Slovenia reported total national coverage, Croatia, Ireland, and Malta reported near to complete national coverage (>90%). Germany, Greece and Italy had very low coverage, taking into account the proportion of hospitals responding to the questionnaire, the data still suggests that national coverage was lower than 20%, the preferred lower boundary with respect to national general applicability of EARSS results.

3.3.3. Hospital denominator informationThe total number of hospital beds for the hospitals reporting AST results and providing denominator


Table 3.1. Proportion of participating laboratories returning reports per country

Country code Hospitals providing

denominator data/reporting to

EARSS

Total number of

beds

Proportion of ICU

beds (%)

Annual occupancy

(%)

Median length of

stay (days)

IQR length of

stay (days)

Proportion of

population covered

(%)AT 123/135 47,364 5 70 5.0 4.4-6.2 naBE 23/105 11,342 4 77 7.7 6.7-8.6 31BG 18/20 7,443 8 75 6.4 5.4-7.1 63CY 5/5 1,277 10 101 5.7 5.3-7.2 54CZ 72/87 43,794 9 77 7.3 6.5-8.5 82DE 6/30 2,562 5 74 7.5 6.6-7.9 2DK 5/74 2,776 3 90 4.2 4-4.6 21EE 11/15 5,370 6 73 6.8 5.8-8 100ES 22/36 12,808 4 83 8.1 5.8-9.4 15FI 10/16 5,431 3 85 3.6 0.7-4.9 47FR 25/57 29,384 6 78 7.6 5.7-8.8 naGR 4/43 1,410 13 67 4.1 3.2-4.3 1HR 20/23 10,388 4 87 7.1 6.7-8.4 90HU 54/80 33,233 2 79 na 100IE 48/69 12,020 3 87 5.9 4.8-7.8 98IL 5/5 3,831 5 90 3.7 3.6-3.8 26IS 2/9 1,008 3 84 7.1 5.3-8.9 100IT 18/44 12,629 4 84 6.2 6-7.8 4LT 22/33 9,023 3 80 7.7 7.4-8.7 100LV 12/12 5,969 3 75 7.0 6.4-7.7 72MT 5/5 2,311 1 88 10.0 6.8-16.9 95NL 5/25 4,492 3 68 6.7 6.4-7.6 6NO 11/32 3,604 5 84 4.8 3.7-5.5 44PL 28/31 14,919 2 69 5.7 5.1-6.6 30PT 20/31 9,680 5 79 7.0 6-8.1 87RO 11/22 6,478 5 - 4SE 45/62 15,810 4 92 5.4 4.7-6.1 85SI 15/15 7,583 5 72 5.2 4.8-6.1 100TR 16/21 16,208 9 78 8.0 6.7-8.6 35UK 20/145 5623 2 81 6.0 4.1-14.3 7Total or median^ 680/1287 345,770 4^ 79^ 6.3^ 51^

ICU = intensive care unit; IQR = Interquartile range; na = not available.


data in the different countries ranged from 1,008 in Iceland to 47,364 in Austria, which reflects on the one hand the size of Iceland and on the other hand the high participation rate to EARSS and the high response rate to the questionnaire in Austria. The proportion of ICU beds over total hospital beds per country was similar, ranging from 1-13%, the absolute number of ICU beds for all participating hospitals in a country ranges from 20 (Malta) to 4,067 (Czech Republic). All hospitals that reported denominator information had an intensive care unit.The length of stay does not differ very much between European countries; the interquartile range was 5-7 days. Patients in Malta seem to stay longest (10 days), whereas patients in Finland and Israel were on average discharged after less than four days. Length of stay may be influenced by several factors, such as case mix, hospital policy, possibility of referral to a long term care facility, etc. In the-ory, increased length of stay may increase the risk of acquiring resistant strains through nosocomial transmission. However, EARSS resistance rates were independent from the median length of stay.

Table 3.2. Hospital characteristics for 2007

Country code Hospitals providing denominator data/

reporting to EARSS

Proportion of hospitals by level of care (%)Tertiary level Secondary level Primary level Other

AT 123/135 26 21 50 2BE 23/105 30 57 4 9BG 18/20 44 39 11 6CY 5/5 20 20 40 20CZ 72/87 33 39 28 0DE 6/30 17 50 33 0DK 5/74 40 40 20 0EE 11/15 36 45 18 0ES 22/36 50 41 9 0FI 10/16 90 10 0 0FR 25/57 88 12 0 0GR 4/43 50 25 25 0HR 20/23 35 40 10 15HU 54/80 37 31 17 15IE 48/69 19 48 15 19IL 5/5 80 20 0 0IS 2/9 100 0 0 0IT 18/44 67 28 6 0LT 22/33 32 41 23 5LV 12/12 50 8 25 17MT 5/5 20 0 20 60NL 5/25 60 20 20 0NO 11/32 27 45 27 0PL 28/31 4 71 18 7PT 20/31 60 30 0 10RO 11/22 30 60 10 0SE 45/62 22 44 33 0SI 15/15 13 47 20 20TR 16/21 100 0 0 0UK 20/145 15 40 35 10Total or median^ 680/1287 36^ 39^ 18^ 0^

Other = hospitals for a specific patient population, like a military hospital, or single specialty hospitals.


For hospitals in most countries the annual occupancy rate exceeded 70%. Cyprus reported the highest annual occupancy rate (101%). From the literature it is known that high bed occupancy, especially significant overcrowding, can increase the incidence of MRSA (6;7). However, EARSS data is too highly aggregated to test this hypothesis on the European level.

3.3.4. Hospital characteristicsBoth the size of a hospital and the level of specialisation can influence the proportion of resistance. As can be seen from Table 3.2 and Figure 3.2 the distribution of size and specialisation level of hospi-tals was quite different between the participating countries. This does not necessarily reflect different distributions of the origin of EARSS blood cultures per country, because not all hospitals contribute evenly to the EARSS database. On the other hand, this diversity can indicate differences in case-mix which may confound comparison of AST results between countries.The total amount of small hospitals (<200 beds) reporting to EARSS is low, compared to medium sized or large hospitals. As expected, countries approaching 100% population coverage tend to in-clude relatively more small hospitals than countries with lower population coverage. Next to that, most participating hospitals were either tertiary care or secondary care hospitals; the amount of pri-mary care hospitals was also low.The type of hospital and the size of a hospital do not correlate very well. For half of the countries university hospitals were also classified as large hospitals (having more than 500 beds), but for a

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hospitals > 500 beds Hospitals 201-500 beds Hospitals <=200 beds

EARSS country codes (responding/all hospitals)

Pro

porti

on o

f hos

pita

ls

BE

(23/

105)

AT (1

23/1

35)

BG

(18/

20)

CY

(5/5

)C

Z (7

2/87

)D

E (6

/30)

DK

(5/7

4)

EE

(11/

15)

ES

(22/

36)

FI (1

0/16

)FR

(25/

57)

GR

(4/4

3)H

R (2

0/23

)H

U (5

4/80

)IE

(48/

69)

IL (5

/5)

IS (2

/9)

IT (1

8/44

)LT

(22/

33)

LV (1

2/12

)M

T (5

/5)

NL

(5/2

5)N

O (1

1/32

)P

L (2

8/31

)

PT

(20/

31)

RO

(11/

22)

SE

(45/

62)

SI (

15/1

5)TR

(16/

21)

UK

(20/

145)

Figure 3.2. 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 2007.


third of the countries (Bulgaria, Finland, France, Greece, Israel, Iceland, Netherlands, Norway, Por-tugal, Turkey) there were more university hospitals than large hospitals; for the remaining countries (Belgium, Czech Republic, Denmark, Malta, Poland) there were more large hospitals than university hospitals. Although definitions of care level may differ from country to country, we believe that the WHO definitions that are used by EARSS, including a range of beds and a required number of spe-cialties, clearly distinguish between the different levels of care.

3.3.5. Laboratory denominator informationIn 2007, in total, 2,781,451 blood culture sets were processed in the EARSS laboratories responding to the questionnaire. As in previous years, the number of blood culture sets taken per 1000 patient

Table 3.3. Laboratory denominator information for 2007.

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

Median distance between the

laboratory and the hospital in

km

IQR of the median distance

AT 20/35 94,287 10.0 0.0 0-0BE 24/105 119,011 35.9 0.0 0-4BG 17/19 17,144 8.7 0.0 0-0CY 5/5 13,726 29.1 0.0 0-0CZ 46/48 153,193 11.4 2.0 0.1-25DE 6/13 30,882 15.8 2.5 0-32DK 5/15 78,609 47.2 13.0 0.1-55EE 11/11 21,031 12.6 4.0 0-25ES 21/36 153,809 40.3 0.0 0-0FI 12/16 159,812 50.3 1.0 0-45FR 25/57 465,630 56.1 na GR 3/43 10,034 29.8 0.0 0-0HR 19/20 57,999 20.5 0.1 0-2HU 17/26 39,659 9.4 25.0 2-45IE 39/42 180,025 45.5 na IL 5/5 158,733 113.9 0.0 0-0IS 2/2 12,298 40.7 57.0 47-290IT 16/42 102,949 38.5 0.6 0-10.5LT 13/13 17,754 4.1 13.5 1-60LU 4/6 13,256 na 0.0 0-0LV 12/12 15,019 9.2 0.0 0-0.2MT 1/1 4,911 11.9 2.0 0-2NL 9/21 95,801 40.1 0.1 0-13.5NO 9/13 66,549 55.2 3.0 0-55PL 27/30 59,700 12.8 0.0 0-0PT 20/22 110,357 46.5 0.0 0-0RO 10/14 12,361 na 1.0 0-8SE 21/21 254,638 48.7 30.0 0-50SI 10/10 45,953 23.6 1.9 0-33.5TR 16/21 143,205 35.6 0.0 0-0UK 11/55 73,116 36.2 10.0 0.3-30Total or median^ 456/779 2,781,451 35.6^ 0.9^

IQR, Interquartile range; na, not available.


days shows much higher rates in Israel (113.9), France (56.1), Finland (50.3) and Norway (55.2), than in Bulgaria (8.7), Czech Republic (11.4), Estonia (12.6), Lithuania (4.1), Latvia (9.2), Malta (11.9) and Poland (12.8). The median culturing frequency was 35.6 blood culture sets per 1000 patient days in 2007, and higher than in 2006 (29.6). As in 2002, 2004 and 2006 we again observed a tendency for higher culturing frequencies in Western European countries compared to Eastern European countries or the Baltic States (Table 3.3). However, there was no correlation between blood culturing rates and resistance proportions or incidences.In most countries the laboratories are located within the hospital or very close to the hospital. How-ever, in less densely populated countries like in Scandinavia or Iceland, laboratories are more often in distant locations. In these countries one laboratory often serves several hospitals. Larger distances between the laboratory and the hospital could make communication more difficult. On the other hand, modern communication tools can help to bridge this gap. Since the countries with the largest distances between the hospital and the laboratory, have the lowest resistance levels, we feel that dis-tance did not directly influence the resistance proportions as reported by EARSS.

3.3.6. Incidence rates for MRSA blood stream infectionsTable 3.4 shows the incidence of MRSA blood stream infections. In contrast to resistance proporti-ons, incidence rates provide patient-based risk estimates for the acquisition of MRSA bacteraemia. In the EARSS database, MRSA proportions and MRSA incidence rates correlate very well (Spearman rank correlation coefficient: 0.96, p<0.01) (Figure 3.3).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 the intended usefulness of information provided by this report. The median incidence, taking the countries’ calculated incidences into account was 3.5 MRSA bacteraemias per

Table 3.4. Incidence of MRSA per 100,000 patient days in 2007, 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 1.2 (1.0-1.4) IL 11.9 (10.3-13.6)BE 4.0 (3.2-4.9) IS <1.0#BG 0.8 (0.5-1.3) IT 7.7 (6.7-8.7)CY 10.3 (8.0-12.6) LT 0.8 (0.5-1.2)CZ 1.9 (1.7-2.2) LV 0.9 (0.5-1.5)DE 0.9 (0.4-1.9) MT 15.1 (12.2-17.9)DK <0.3# NL 0.7 (0.3-1.5)EE 1.3 (0.8-2.0) NO <0.3#ES 6.5 (5.9-7.3) PL naFI 0.3 (0.1-0.8) PT 24.4 (23.1-25.8)FR 7.1 (6.6-7.7) RO naGR 13.8 (11.0-16.5) SE 0.2 (0.1-0.4)HR 4.7 (4.1-5.4) SI 1.8 (1.3-2.5)HU 2.3 (1.8-2.8) TR 9.0 (8.2-9.7)IE 13.3 (12.4-14.2) UK 13.4 (12.0-14.8)

Median 3.5

na = not available; Romanian and Polish hospitals providing denominator and AST data did not report the number of patient days. # Denmark, Iceland and Norway did not report MRSA in 2007, therefore a detection limit for MRSA was calculated based on the number of patient days and the number of Staphylococcus aureus isolates reported over 2007 (see Annex 1).

100,000 patient days, which was equal to the incidence reported from 2006. Variation in incidence rates over countries and years of reporting may be the result of real variation in incidence, but 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) can also be of influence. Clearly, many other, partly unknown and undetermined factors may play a role in the dynamics of MRSA incidence.

3.4 Conclusions

Unfortunately, the response to this year’s laboratory/hospital questionnaire was lower than previous years. The fact that the frequency of the questionnaire changed from bi-annually to annually could be one of the reasons. On the other hand, for the first time, all countries responded to the questionnaire.In general, national population coverage is high and greater than 20% for most countries, which is considered adequate. The level of care and the size of the reporting hospital varied between coun-tries. Although assigning unambiguous and comparable levels of care to hospitals in different coun-tries 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. If lower blood culturing frequency is related to the selective sampling of patients whose empirical antibiotic therapy had failed, this would result in significant sample bias and lead to higher resistance proportions. However, overall, no correlation was found between blood culture frequency and resi-stance proportions. The resistance proportions as reported by EARSS were highly correlated with incidence. Although incidence provides a better estimate for risk, resistance proportions as presented in this report is an excellent approximation and supplies useful information when comparing the occurrence of resi-stance across Europe.Although for some countries national representativeness of the EARSS results seems to be low, ta-king into account the slim population coverage, we conclude that the resistance proportions provided by EARSS in 2007 have sufficient external validity.

00% 10% 20% 30% 40% 50% 60%

5

10

15

20

25

30

MRSA proportion

MR

SA

Inci

denc

e/ 1

00.0

00 p

atie

nt d

ays

Figure 3.3. MRSA incidences and proportions. The line is the calculated regression line with zero intercept.



3.5 References

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

2. Monnet DL, Frimodt-Moller N. Only percentage within species; neither incidence, nor prevalence: 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 summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004; 32: 470-485.

4. Tiemersma EW, Bronzwaer SL, Lyytikainen O, Degener JE, Schrijnemakers P, Bruinsma N et al. 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.

6. Clements A, Halton K, Graves N, Pettitt A, Morton A, Looke D, Whitby M. Overcrowding and understaffing in modern health-care systems: key determinants in meticillin-resistant Staphylococcus aureus transmission. Lancet Infect Dis 2008; 8: 427-34.

7. Borg M, Suda D, Scicluna E. Time-series analysis of the impact of bed occupancy rates on the incidence of methicillin-resistant Staphylococcus aureus infection in overcrowded general wards. Infect Control Hosp Epidemiol 2008; 29: 496-502.


Chapter 4. Antimicrobial resistance in Europe

4.1. Introduction and methods

This chapter provides an overview of the EARSS data in 2007 and the trends of antimicrobial resistance in Europe. For nine 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 resistance until 2007 will be described. To exclude possible bias in the trend analyses, a sensitivity analysis was done, per country, by using the complete dataset versus a subset from laboratories consistently reporting for all nine years (selected laboratories). If the trends in the subset and the complete dataset were discrepant, these trends were discussed in the text. However, if both datasets indicated the same trend, we indicate i) in the text, when significant trends were only identified in the subset, ii) in the graphs by an arrow with an asterisk, when significant trends were only identified in the complete 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 1.

4.2. Streptococcus pneumoniae

4.2.1. Clinical and epidemiological importance Streptococcus pneumoniae is a common cause of disease, especially among young children, elderly people and patients with compromised immune functions. The clinical spectrum ranges from upper airway infections such as sinusitis, and otitis media to pneumonia and invasive blood stream infec-tions and meningitis (1). Since S. pneumonia is the most common cause of pneumonia worldwide, morbidity and mortality are high and annually approximately 3 million people are estimated to die of pneumococcal infections. Pneumococci carry a variety of virulence factors that facilitate adherence and transcytosis of epithe-lial cells. The cell wall of pneumococci is coated with a viscous polysaccharide slime layer termed the capsule. This is the most important virulence factor, because it protects the bacteria from the adhesion of opsonising antibodies and the destruction by leucocytes (39). Capsular polysaccharides are highly divers and play an important 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 antimicrobial resistance (36;42).

Resistance mechanisms Beta-lactam antibiotics bind to cell wall synthesizing enzymes, so called 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 PBPs, which results in reduced affinity to this class of antibiotics. Alterations in PBPs occur in a stepwise fashion which causes different degrees of resistance proceeding from reduced susceptibility through low-level clinical resistance – conventionally termed intermediate* (I) to full clinical resist-

Chapter 4. Antimicrobial resistance in Europe 39

ance (R). Although intermediately 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 other beta-lactam compounds (10;14). Macrolide, Lincosamine and Streptogramin (MLS) antibiotics are chemically distinct, but all bind to a ribosomal subunit inhibiting the initiation of mRNA binding and thus act as protein synthesis inhibitors. 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 posttranscrip-tional modification of the 23S subunit of 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, lincosamines and streptogramin B, termed MLSB resistance (40;43). ii) The acquisition of a macrolide efflux system gene (mefE) results in the excretion of the antimicro-bial, and effectively reduces intracellular erythromycin, azithromycin and clarithromycin to subin-hibitory concentrations (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 lower airway infections caused by other pathogens, empirical treatment of community-acquired lower respiratory infections needs to be active against pneumococ-ci and should take the local prevalence of antimicrobial resistance into account. Habitual prescription of non-beta-lactam compounds is therefore typical in countries where penicillin resistance has been frequently reported. Such reactive prescribing increases the selection pressure for alternative anti-biotics such as macrolides and novel fluoroquinolones. It is therefore no surprise to see a dynamic antimicrobial resistance picture emerge in different European countries.

4.2.2. Streptococcus pneumoniae resistance trends: 1999-2007

Penicillin In 2007, 1,198 (10%) of the 11,606 S. pneumoniae isolates were non-susceptible for penicillin in 30 countries. Penicillin non-susceptibility shows a heterogeneous picture in Europe. Most northern countries had levels of non-susceptibility below 5%, but Belgium (9%, n=1511), Finland (13%, n=522), and Ireland (17%, n=435) reported relative high levels. High levels of PNSP, above 25%, were mainly reported from southern and eastern Europe: Cyprus (n=15), France (n=663), Israel (n=42), Poland (n=21), Romania (n=26) and Turkey (n=111).

The level of penicillin non-susceptibility in Finland and Turkey was rising significantly, and the pro-portion of fully resistant S. pneumoniae isolates was rising in Ireland, Slovenia and Turkey, although for Ireland and Turkey not confirmed by the data from laboratories reporting all nine years. The three countries with the highest levels of PNSP in 2006 (Spain, France and Israel) all show con-siderable decreasing rates now, all with more than 10% reduction of PNSP during the past years. In Belgium and France, the proportions PNSP continued to decrease, in Spain and the UK the decrease also holds for PRSP. In Israel, this year for the first time, the proportion of PNSP was decreasing significantly from 1999 to 2007 (Figure 4.1 and 4.4, Annex 3.1).

40 Chapter 4. Antimicrobial resistance in Europe

* Microorganisms are defined as intermediate by a level of antimicrobial activity with uncertain clinical effect. Occasion-ally, this can be overcome if antibiotics can be administered at a higher dose and/or are concentrated at the infected body site (From unpublished discussions between CEN and ISO for a new MIC dilution method 2005).

ErythromycinIn the EARSS database 11,014 (95%) S. pneumoniae isolates had susceptibility results for eryth-romycin in 2007. From the 29 countries reporting data, 1,708 (16%) isolates were reported non-susceptible to erythromycin. Where in 2006 five countries reported erythromycin non-susceptibility less than or equal to 5%, in 2007 this was only the case for Estonia (n=53) and Latvia (n=31). Eight countries had non-susceptibility proportions from 5-10%, 12 countries from 10-25% and 5 countries higher than 25% (Cyprus (n=15), Finland (n=522), France (n=663), Hungary (n=140) and Italy (n= 259)). Five countries showed a significant increase in erythromycin non-susceptibility; in Finland this increase was still very pronounced (6% in 1999 vs. 26% in 2007). The proportion of isolates non-susceptible to erythromycin in Spain and France continued to decrease, and now also Belgium, Croatia and the UK reported significant decreasing rates in this respect.Compared to 2006, when six countries reported over 30% erythromycin non-susceptibility in S. pneumoniae isolates, now three countries France (37%), Hungary (36%) and Italy (31%) are in this category (Figure 4.2 and 4.5, Annex 3.1.)

Dual non-susceptibility to penicillin and erythromycinFor 13 of the 29 countries, dual non-susceptibility remained below 5%, for eight countries the level of non-susceptibility was between 5-10% and six countries reported between 10-20% in 2007. The highest dual non-susceptibility was found in Cyprus (20%, n=15) and France (29%, n=663).Among the low-endemic countries, Norway and The Netherlands showed a continuously significant-ly increasing trend, although absolute and relative numbers of dual non-susceptible isolates are still


< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.1. Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2007. * 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 4.2. Streptococcus pneumoniae: proportion of invasive isolates resistant to erythromycin in 2007. * 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 4.3. Streptococcus pneumoniae: proportion of invasive isolates with dual non-susceptibility to erythromycin and penicillin in 2007. * These countries did not report any data or reported less than 10 isolates.


2001EE (39)

1999NO (504)

2004LV (35)

1999NL (830)

1999DE (186)

1999SE (904)

2000DK (757)

2000CZ (168)

1999UK (996)

2000AT (188)

2000LU (34)

1999BE (1274)

1999IS (44)

1999FI (426)

1999IT (237)

2002BG (31)

1999PT (156)

2000SI (151)

1999IE (320)

2001HR (97)

2000ES (682)

2001HU (115)

2003TR (116)

2001IL (203)

2001FR (863)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of i

sola

tes

repo

rted

per y

ear)

& y

ear o

f sta

rt su

rvei

llanc

e #

Intermediate resistant Fully resistant

0 5 10 15 20

% penicillin non-susceptible S. pneumoniae

25 30 35 40 45 50

Non-susceptible

*

*

*

Figure 4.4. Streptococcus pneumoniae: trends of penicillin non-susceptibility by country, 1999-2007. Only the coun-tries that reported 20 or more isolates per year were included. The arrows indicate the significant trends observed for the proportion of PNSP (black arrows) or full penicillin resistance (red arrows). The stars indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all nine years.# Either the first year of surveillance or the first year with 20 or more isolates were reported.


2000DK (757)

2000NL (685)

2001HR (66)

1999DE (147)

1999UK (919)

1999NO (370)

2000AT (156)

2003TR (103)

2001IL (198)

1999IE (283)

1999IS (42)

2000SI (142)

2000ES (657)

2001LU (34)

2004PT (187)

1999BE (1274)

1999FI (403)

1999IT (208)

2001HU (107)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of i

sola

tes

repo

rted

per y

ear)

#

19992000

50 10 15 20

% erythromycin resistant S. pneumoniae

25 30 35 40 45 50

2001200220032004200520062007

*

*2001FR (863)

2005LV (34)

1999SE (770)

2001EE (35)

2000CZ (162)

*

Figure 4.5. Streptococcus pneumoniae: trends of erythromycin non-susceptibility by country, 1999-2007. 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 nine years.# Either the first year of surveillance or the first year with 20 or more isolates were reported.


1999DE (147)

2004LV (29)

2001EE (32)

1999NO (370)

2000DK (757)

2000CZ (162)

1999SE (770)

2000NL (685)

1999UK (919)

2001HR (66)

1999IS (42)

2000AT (156)

2000SI (142)

2001LU (34)

1999BE (1274)

1999IT (208)

1999IE (283)

2001IL (198)

1999FI (403)

2000ES (657)

2004PT (187)

2005FR (555)

2001HU (107)

2003TR (103)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of i

sola

tes

repo

rted

per y

ear)

#

0 5 10 15 20

% dual non-susceptible S. pneumoniae

25 30 35 40 45 50

*

*

199920002001200220032004200520062007

*

Figure 4.6. Streptococcus pneumoniae: trends of dual non-susceptibility to penicillin and erythromycin by country, 1999-2007. 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 nine years.# Either the first year of surveillance or the first year with 20 or more isolates were reported.

very low. The same holds for Germany, showing an overall statistically significant increasing trend, however, only due to 4/110 (3.6%) resistant isolates in 2004, whereas in other years only one or none non-susceptible isolates were reported (nmean=147). This trend was not reported from the laboratories reporting all years, and clinical importance of this trend may be of less importance. For the countries with relatively high dual non-susceptibility levels, Belgium (n=1511) and Spain (n=846) showed a continuously, significantly decreasing trend: in Spain in fact dual non-susceptibil-ity halved from 2001 to 2007. Conversely, in Ireland (n=400), Finland (n=522) and Turkey (n=85), dual non susceptibility is on the rise, where for Ireland and Turkey this was only found in the overall data, not in the data from the selected laboratories (Figure 4.3, 4.6 and Annex 3.1).

4.2.3. SerotypesFor four years now, EARSS has collected serogroup information for S. pneumoniae. In 2007, twelve countries provided serogroup data. In the data from Belgium, Czech Republic, Iceland, and Slovenia more than 90% of all S. pneumoniae isolates had serogroup information, for Austria, Ireland and the United Kingdom these proportions were 39%, 53% and 69% respectively. As the serogroup informa-tion from these countries did not seem to be selectively reported for more resistant isolates, we report these data as well. For The Netherlands and Norway the serogroup information was confined to less than 6%, and Latvia, Cyprus and Germany reported less than 30 isolates; these data are therefore not shown. Serogroup information from 3,409 isolates was analyzed from seven countries, Austria, Belgium, Czech Republic, Ireland, Iceland, Slovenia and the United Kingdom. This does not reflect the sero-group distribution in Europe as a whole, as data from only seven countries are included in this analy-sis, of which Belgium and the UK each reported over 1000 isolates and are therefore overrepresented. With this in mind, comparing the included countries, the distribution of serotypes between countries as well as the resistance within serogroups varies considerably. However, compared to 2006, these changes were small. Serogroup 1 seemed to be the most prevalent one, followed by serogroups 19 and 14, with Slovenia showing a high proportion of serogroup 14 (17%) and a relatively low rate of serogroup 1 (6%). Iceland did not report isolates with serogroup 1, serogroup 4 was most prevalent (24%), while in other countries this serogroup is not very common (Table 4.1).

Resistance seems to be confined to few serogroups; for penicillin resistance these include 6, 9, 14, 19 and 23, and in a small degree 15; erythromycin resistance is also prevalent in serogroups 1 and 33. The high non-susceptibility in serogroup 14 can be ascribed to high erythromycin resistance in Ire-land (55%) and the UK (64%), and high dual resistance in Belgium (55%). In addition, in Belgium a unique high erythromycin resistance in serogroup 1 (32%) was found (Figure 4.7). Among the other serogroups, resistance to penicillin or erythromycin is rare; nevertheless these serogroups are also quite prevalent among invasive isolates. The new 13-valent conjugate vaccine covers all serogroups with penicillin resistance, but in contrast to the 23-valent vaccine, it does not cover serogroup 33 in which erythromycin resistance is quite common.

4.2.4. ConclusionsThe resistance profile of S. pneumoniae has a dynamic character. Although penicillin non-susceptibility is increasing in Finland and Turkey, five countries are on the decrease, among those three countries showing the highest PNSP proportions in 2006. This is most likely due to a decreasing selection pressure. Erythromycin non-susceptibility is becoming more prevalent in several countries, but against that, an equal number of countries is on the decrease. For dual non-susceptibility an increasing trend is observed, however Belgium and Spain show a decrease for dual as well as for PNSP and ENSP.



Tabl

e 4.

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

coun

try

in 2

007.

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=9

9)B

elgi

um

(n=1

504)

Cze

ch re

publ

ic(n

=194

)Ir

elan

d(n

=210

)Ic

elan

d(n

=38)

Slov

enia

(n=1

87)

Uni

ted

Kin

gdom

(n=1

177)

% 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

115

00

014

032

012

04

05

00

00

00

06

00

014

10

13

180

00

70

10

110

00

30

00

30

00

110

55

60

00

43

330

03

00

08

00

09

00

024

00

07

00

05

00

05

30

00

42

20

00

00

00

00

00

00

10

00

00

00

64

050

06

1036

66

018

08

00

188

033

07

714

148

08

07

90

00

90

00

30

00

80

00

110

00

40

00

70

20

81

00

04

00

04

00

03

140

00

00

03

00

06

14

19

120

017

53

356

1319

84

850

025

110

00

520

200

116

36

103

330

02

00

02

00

00

00

00

00

01

00

00

00

011

00

00

20

190

20

330

10

00

30

00

10

00

20

40

120

00

07

01

00

00

02

00

03

00

00

00

03

00

014

80

2538

76

3155

80

77

1421

5510

130

800

1719

3816

93

643

156

00

02

1319

102

00

01

00

03

00

03

200

201

00

018

20

00

23

30

50

00

40

00

00

00

413

00

30

00

193

00

011

849

166

918

011

84

2511

00

508

2013

138

27

220

00

00

00

00

20

00

20

00

00

00

10

00

10

00

222

050

03

00

03

00

04

130

08

00

06

180

03

30

323

20

00

512

106

90

00

68

00

50

00

924

60

66

16

331

010

00

10

620

10

00

20

00

00

00

10

100

02

00

0ot

her

714

00

70

43

60

00

77

70

00

00

60

00

55

05

tota

l10

03

65

100

318

710

03

51

100

109

810

00

135

100

1111

610

02

81

This year 12 countries have reported serogroup information, and data from seven countries were included for analysis. Compared to 2006, changes were small. From the overview of prevalent sero-types, it becomes evident that serogroup 1, 14 and 19 are highly prevalent in most countries. The UK and Ireland reported high resistance within serogroup 14; Belgium for serogroup 1, 14 and 19. The highest resistance proportions were identified in serogroups 1, 6, 9, 14, 19, 23, and 33, of which all but 33 are included in the new 13-conjugate vaccine.

4.3. Staphylococcus aureus

4.3.1. Clinical and epidemiological importanceStaphylococcus aureus is a gram-positive bacterium that colonizes the skin 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 rates (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.


Pro

porti

on

1 19 14 7 9 3 6 23 4 8

Serogroups

12 22 18 1115 5 other201033

14%

12%

10%

8%

6%

4%

2%

0%

Fully susceptible*

Single erythromycin resistance

Dual resistance

Single penicillin resistance

Figure 4.7. The distribution of serogroups and the resistance profile of S. pneumoniae isolates per serogroup in 2007. Only countries that reported serogroup information for more than 30 isolates were included in this figure. *Susceptible to at least penicillin and erythromycin.


Resistance mechanisms S. aureus acquires resistance to methicillin and all other beta-lactam antibiotics through expression of the exogenous mecA gene, that codes for a variant penicillin binding protein PBP2’ (PBP2a) with low affinity to beta-lactams, (21), thus preventing the drug induced inhibition of cell wall synthesis. The level of methicillin resistance (defined by its minimum inhibitory concentration, MIC) depends on the amount of PBP2’ 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 targets, 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.

4.3.2. Staphylococcus aureus resistance trends: 1999-2007

Beta-lactamsIn 2007, 31 countries reported AST results of 31,591 invasive S. aureus isolates to EARSS, of which 22% (n=7,115) were identified as MRSA. At least thirty-eight percent (n=2,736) of these MRSA isolates were confirmed by oxacillin MIC, PCR mecA-gene, or PBP2A-agglutination.MRSA proportions vary from 0% in the north to over 50% in southern European countries. Thirteen countries reported MRSA proportions equal or higher than 25%. Like previous years, all Mediter-ranean countries, Romania, the United Kingdom and Ireland were included in this category. In the UK, yet another year of decreasing MRSA proportions turned the increasing trend that prevailed until 2006 into a decrease, although this finding was not found by the subset analysis of laboratories that consistently provided data for the entire EARSS observation period (9 years). In France, Turkey and Slovenia, the MRSA proportions are still on the decrease and for the first time in 2007 propor-tions in Austria, Bulgaria and Italy also showed a significant decrease (not confirmed for the subset laboratories in Austria and Italy). Significant increases reported in 2006 continued in 2007 in Czech Republic, Hungary and Germany (Figure 4.8). Four countries had MRSA proportions over 40%, of which Portugal and Malta still show a continu-ing increase. In Greece, like last year, the subset laboratories showed a significant decrease, which was not confirmed by the overall trend. The same holds for an increase in Spain. These differences between the total and the subset laboratories are caused by changes in the national EARSS participa-tion over the years.In the northern part of Europe, MRSA rates are below 3%, except for the Baltic States (8%-9%). In Latvia, MRSA rates continue to decrease strongly, from 25% in 2004 to 8% in 2007. However, in the Netherlands, Finland and Denmark a significant increase was reported, although in Denmark not in the subset laboratories. The MRSA rates of Estonia, Iceland, Norway and Sweden remain relatively stable. In Belgium, the decrease of 2006 was maintained, although not (yet) reflected as statistically significant trend (Figure 4.9).

Glycopeptides/vancomycinOverall, four confirmed VISA’s and no VRSA were reported to the EARSS database in 2007. Vancomycin intermediate resistant S. aureus were reported by France (n=1), Ireland (n=1) and The Netherlands (n=2).

4.3.3. MRSA by hospital departmentS. aureus susceptibility data reported to EARSS originate from different hospital departments. Across the national EARSS networks, an average of 12% (min. 2%, max.26%) of the invasive S. aureus iso-lates was isolated from ICU patients. MRSA strains are more frequently isolated from ICU patients than non-ICU patients, and therefore country-specific differences in enrolment can be of influence on the comparability of the overall MRSA proportions. In 22 of 30 countries the MRSA proportions in ICU were higher compared to non-IC units; for twelve countries this difference was significant. In six countries, the MRSA proportions in ICU-isolates were lower than in the non-ICU isolates. Two countries had no MRSA isolates at all (Figure 4.10).In six countries, Croatia, Greece, Israel, Malta, Portugal, Turkey, the proportion of MRSA found among ICU patients was over 60%. Although in these counties, except for Malta, the MRSA pro-portions in ICUs were significantly higher compared to non-IC units, these high levels go together with high rates of MRSA, above 30%. However, high specialisation of ICU’s with very vulnerable patients could have been of influence.

4.3.4. ConclusionsMRSA is still an increasing problem all over Europe. In a number of low-endemic countries increasing MRSA proportions are found. In the high endemic countries, on the other hand, some countries seem


< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.8. Staphylococcus aureus: proportion of invasive isolates resistant to oxacillin (MRSA) in 2007. * These countries did not report any data or reported less than 10 isolates.


1999IS (57)

2000DK (978)

1999SE (1770)

1999NO (522)

1999NL (1401)

1999FI (679)

2004LV (138)

2000SI (310)

2001EE (123)

2000CZ (1289)

2000AT (1002)

2000BG (137)

2001PL (189)

2001HU (857)

1999LU (81)

1999DE (991)

1999BE (917)

2001FR (2855)

2000ES (1303)

2002RO (79)

2001IL (458)

2003TR (827)

1999IT (1119)

1999UK (2803)

2001HR (329)

1999IE (1041)

1999GR (541)

1999PT (836)

2003CY (54)

2000MT (92)

Cou

ntry

cod

e (a

vera

ge n

umbe

r of i

sola

tes

repo

rted

per y

ear)

& y

ear o

f sta

rt su

rvei

llanc

e #

0 10 20 30 40

% MRSA

50 60 70 80

**

199920002001200220032004200520062007

*

*

Figure 4.9. Staphylococcus aureus: trends of methicillin-resistance by country 1999-2007. 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 nine 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 n

on-IC

U/IC

U is

olat

es)

non-ICU ICU

0 10 20 30 40

% MRSA

50 60 70 80

Overall MRSA proportion

IS (62/1)

NO (722/54)

NL (589/116)

SE (2035/127)

FL (419/20)

LV (139/29)

SI (394/28)

AT (1312/171)

EE (157/48)

LT (185/54)

BG (110/11)

CZ (1204/431)

PL (171/14)

DE (760/85)

LU (21/8)

BE (629/133)

HU (946/221)

ES (1384/215)

FR (3577/631)

RO (20/9)

IL (412/38)

IT (585/102)

TR (907/217)

UK (3403/358)

HR (315/60)

IE (545/51)

CY (66/19)

GR (642/122)

PT (1229/148)

MT (77/18)

*

*

*

*

*

*

**

*

*

*

*

Figure 4.10. Staphylococcus aureus: proportion MRSA in ICU versus other hospital departments by country in 2007. Between brackets the number of isolates from non-ICU/ICU departments. The asterisks indicate a significant difference between the ICU and non-ICU MRSA proportions.

to have stabilizing MRSA proportions, and more important, more countries compared with previous years, show significantly decreasing trends. A decreasing MRSA trend was already seen in France, Slovenia and Turkey, but now we have also found decreasing trends in Austria, Bulgaria, Italy and Latvia and the United Kingdom. This indicates that improved control efforts can reverse the MRSA level in hospitals, even in high endemic countries.

4.4. Enterococci

4.4.1. Clinical and epidemiological importanceEnterococci belong to the resident 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;32). However, when the commensal relationship with the host is disrupted, enterococci can cause invasive diseases (25). Though not as virulent as other Gram-positive organisms, enterococci can cause a variety of clinical syndromes including endocarditis, bacteraemia, meningitis, wound and urinary tract infec-tions and are associated with peritonitis and intra-abdominal abscesses. In the USA, three to four nosocomial 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) (47). The emergence of E. faecalis and E. faecium was paralleled by the increases in glycopeptide and high-level aminoglycoside resistance, both important compounds for the treatment of human infections (42). 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 mechanismsEnterococci are intrinsically resistant to a broad range of antibiotics including cephalosporins, peni-cillins, sulphonamides and low concentrations of aminoglycosides (15). Patient safety in hospitals is challenged by the ability of enterococci to acquire additional resistance through the transfer of plas-mids and transposons and recombination or mutation (33).Beta-lactam antibiotics. By nature, enterococci have a low susceptibility to beta-lactam antibiotics – a consequence of their low-affinity PBPs. Complete penicillin resistance in E. faecalis is currently absent, though two possible mechanisms have been reported; i) the production of beta-lactamase (34) and ii) the overproduction and modification of penicillin-binding proteins (PBPs, 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 (42). 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 Europe, a closely related glycopeptide, avoparcin, has been widely utilized in the farming community as


< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.11. Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2007. * These countries did not report any data or reported less than 10 isolates.

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 glycopeptides (28). Five phenotypes have been identified of which three have clinical relevance; i) VanA with high-level resistance to both vancomycin and teicoplanin, and ii) VanB with a variable level of resistance to only vancomycin. (2;37) The VanA and VanB phenotypes, mostly found among E. faecalis and E. faecium, may be transferred by plasmids and conjugative transposition.

4.4.2. Enterococcus faecalis resistance trends: 2001-2007

High-level aminoglycosidesIn 2007, 28 countries reported AST results for invasive E. faecalis isolates (n=7,002). Only three countries reported less than 20 isolates, namely Luxembourg (n=9), Iceland (n=15) and Romania (n=4) (annex 3.3). The proportion of high-level aminoglycoside resistance varied between 13% in Iceland (n=15) and 67% in Germany (n=238). Figure 4.11 shows that Estonia (23% n=22), Finland (22% n=169), France (15%, n=1036), Iceland (13%, n=15), and Sweden (16%, n=632) reported resistance below 25%, whereas the majority of countries reported proportions of between 25% and 50%. Germany (67%, n=238) and Greece (65% n=523) were well over 50% (Figure 4.11, annex 3.3). During the EARSS surveillance period, this situation has been relatively constant. Since 2001, a significant increase was observed in Belgium, Czech Republic, Greece, Portugal and Spain. A sig-nificant decrease was only reported in Hungary. For this species, the proportions of resistance show considerable variation over time, probably due to occurrence of outbreaks (Figure 4.12).



2002FR (640)

2001FI (99)

2003SE (532)

2003EE (36)

2001BE (134)

2003TR (284)

2001BG (43)

2001NO (72)

2001AT (130)

2001HR (88)

2001NL (171)

2002IE (195)

2001IT (337)

2001PT (231)

2001IL (184)

2001ES (485)

2003HU (287)

2001PL (41)

2001CZ (496)

2001SI (69)

2004CY (41)

2001DE (96)

2001GR (317)

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% Aminoglycoside high level resistant Enterococcus faecalis

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Figure 4.12. Enterococcus faecalis: trends of high-level aminoglycoside resistance by country 2001-2007. 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.

4.4.3. Enterococcus faecium resistance trends: 2001-2007

Vancomycin In general, the number of invasive E. faecium isolates was low (n=4,561). Of the 31 countries that reported data, 7 reported less than 20 isolates in 2007 (Bulgaria, n=12; Cyprus, n=12; Iceland, n=14; Lithuania, n=18; Luxembourg, n=11; Malta, n=6; Romania, n=9). In 11 countries that reported more than 20 isolates, vancomycin resistance was less or equal to 1% or even absent. This contrasts to the 3 countries that reported more than 25% VREF isolates in 2007, namely Greece (37%, n=388), Ireland (33%, n=323) and Portugal (29%, n=158). (Figure 4.13, annex 3.3).Over the past 6 years, vancomycin resistance increased significantly in 6 countries, namely Germany, Greece, Ireland, Israel, Slovenia, and Turkey. In Slovenia vancomycin resistance had not been reported until 2005, but appeared in 2006 (6%, n=50) and 2007 (5%, n=65). 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 Croatia, Portugal and the United Kingdom. Over the past 5 years Croatia has shown a continuous decrease from 6% (n=32), which was already relatively low, in 2003 to 2% (n=51) in 2007. Portugal has shown a continuous decrease from 47% (n=103) in 2003 to 29% (n=158) in 2007. Italy first went up from 15% (n=80) in 2001 to a maximum of 24% (n=166) in 2003, but then the resistance proportion started to decrease gradually to 11% (n=254). A similar situation can be seen in Israel first up from 12% (n=42) in 2001 to 46% in 2005 (n=72), after which it gradually went down to 24% (n=51) in 2007 (Figure 4.14).


< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.13. Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2007. * These countries did not report any data or reported less than 10 isolates.


2004BE (44)

2001HU (45)

2005EE (28)

2001NO (48)

2001SE (239)

2001NL (207)

2002FR (191)

2001FI (111)

2001AT (136)

2001ES (134)

2003HR (36)

2001CZ (138)

2003SI (40)

2003TR (244)

2001DE (172)

2001IT (173)

2005UK (175)

2001IL (47)

2001GR (211)

2002IE (199)

2003PT (119)

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Figure 4.14. Enterococcus faecium: trends of vancomycin resistance by country 2001-2007. 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.

4.4.4. ConclusionsWith the ongoing spread of clonal complex 17 in Europe, outbreaks of vancomycin resistant E. faecium continues to afflict more and more hospitals in various countries. The spread of these hospital-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 practitioners and it is not difficult to predict that these problematic pathogens will continue to remain a challenge. It will be interesting to examine whether the decrease in resistance that is seen in some countries is the result of specific interventions, for instance in hospital hygiene.

4.5. Escherichia coli

4.5.1. 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;39).

Resistance mechanismsBeta-lactamases hydrolyse the beta-lactam ring of beta-lactam antibiotics, which is crucial for in-hibition 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 ESBL 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 spectrum of activity and enhance their hydrolyzing ability to include 3rd generation cephalosporins and monobactams. Many ESBLs can be inhibited by beta-lactamase inhibitors such as clavulanic acid, sulbactam, or tazobactam. More than 200 ESBL variants are known to date. Most of them be-long to four enzyme families TEM, SHV, CTX-M and OXA (an overview of identified ESBL types is given on http://www.lahey.org/studies/). In E. coli, over 90% of ESBL resistance was mediated through TEM variants. In the late 1990’s, new ESBLs of the CTX-M family emerged first in South America and soon after attained global importance. In contrast to conventional TEM, and SHV ES-BLs, CTX-M display a higher hydrolysing ability against cefotaxime than ceftazidime (hence their name). CMY-2, a plasmid encoded variant derived from the chromosomal ampC locus is still rare in Europe but frequent in the USA (43).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 fluoroquinolones 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 fluoroquinolones may also arise through changes in membrane porins or from genes regulating the activity of efflux pumps, resulting in lower mem-brane permeability and higher efflux, respectively (19). In recent years, the plasmid-mediated QNR mechanism, protecting DNA from quinolone binding, is of concern because of its frequent associa-tion with CTX-M and CMY-type enzymes inactivating third generation cephalosporins (40).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.

4.5.2. Escherichia coli resistance trends: 2001-2007EARSS began collecting AST results for invasive E. coli in 2001. In 2007, 46,524 isolates were reported from 30 countries.

AminopenicillinsAminopenicillin resistance in E. coli was highly prevalent in Europe; all countries reported resist-ance proportions above 30%. Still aminopenicillin resistance varied substantially between the coun-tries, three countries recorded resistance proportions below 40%, namely Sweden (33%, n=2,038), Finland (34%, n=1,516) and Norway (38%, n=1,712). Five countries recorded resistance proportions above 70%, namely Bulgaria (70%, n=127), Romania (77%, n=48), Cyprus (73%, n=108), Israel (70%, n=647) and Turkey (78%, n= 1,065) (Figure 4.18 annex 3.4). Aminopenicillin resistance also varied substantially over time, and from 2001 to 2007, it increased significantly in most countries (20 out of 29). (Figure 4.18)

Third generation cephalosporinsLess than half of the countries (13 of 31) reported less than 5% resistance against 3rd generation ce-phalosporins in 2007. This also varied substantially over time; from 2001 to 2007, 3rd generation ce-phalosporins resistance increased significantly in most countries (23 of 29). Moreover, 3rd generation cephalosporin resistance increasingly seems to affect countries with formerly very low resistance levels of around 1% in 2001 which are heading towards the 5% benchmark in 2007 (Figure 4.19). In 2007, three countries already reported levels of 20%, namely Bulgaria (23%, n=127), Romania (28%, n=57) and Turkey (40%, n= 1,068) (Figure 4.15).

Unfortunately, the EARSS database does not receive information that would allow for differential characterisation of resistance mechanisms. It is however expected that the rise in 3rd generation cephalosporin resistance is the result of fast dissemination of ESBLs in hospitals and the communi-ties.

FluoroquinolonesFluoroquinolone resistance has consistently and substantially increased over the past seven years all over Europe. In 2005 four countries had levels of 5% or less, in 2007 no country has maintained this level (Figure 4.16). In 2007 the lowest levels were reported in Estonia (7%, n=208), Norway (7%, n=1,651) and Finland (8%, n=1,949). At the same time, nine countries reported fluoroquinolone-resistant E. coli in excess of 30%, with three countries reporting resistance proportions above 35%: Malta (35%, n=117), Cyprus (40%, n=108) and Turkey (53%, n=1,062) (Figure 4.16, annex 3.4). Fluoroquinolone resistance increased significantly in all countries except Estonia (28 out of 29). The speed with which fluoroquinolones loose their activity against E. coli has been alarming for some time (Figure 4.20).

AminoglycosidesOnly 5 northern European countries reported not more than 5% resistance against aminoglycosides Sweden (2%, n=3,739), Finland (3%, n=1,859), Norway (3%, n=1,711), The Netherlands (5%, n=2,724) and Denmark (4%, n=3,019). Fourteen countries reported resistance between 5% and 10%. In the South and East, most countries reported 10% or more, with the highest percentages reported



< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

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Figure 4.16. Escherichia coli: proportion of invasive isolates with resistance to fluoroquinolones in 2007. * 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

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Figure 4.15. Escherichia coli: proportion of invasive isolates with resistance to third generation cephalosporins in 2007. * These countries did not report any data or reported less than 10 isolates.

by Malta (20%, n=117), Bulgaria (20%, n=127), Turkey (35%, n=1,073) and Romania (38%, n=58) (Figure 4.17, annex 3.4). Consistent with the increase of all other resistance proportions for E. coli, aminoglycoside resistance also increased in most countries (21 out of 29) (Figure 4.21).

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. For the fist time in 2007 only a minority (47%) of the Escherichia coli isolates tested by the laboratories participating in EARSS could be considered wild-type strains, i.e. displayed the original susceptibility to aminopenicillins, fluoroquinolones, 3rd generation cephalosporins, and aminoglycosides. Combined resistance to 3rd generation cephalosporins, fluoroquinolones and aminoglycosides was still below 2% in about half of the countries (17 of 31), but in Romania and Turkey combined resistance was already above 20% (Figure 4.22, annex 3.4). Again, the majority of countries (24 out of 29) showed a significant increase. Table 4.2 gives an overview of the most common phenotypes (single and combined resistance) based on the overall proportion from all 31 countries in 2007. In E. coli, single aminopenicillin resistance was the most frequent phenotype (31%), followed by dual resistance to aminopenicillins and fluoroquinolones (8.6%). Combined resistance to aminopenicillins, fluoroquinolones and aminoglycoside came third (3.2%), followed by resistance to all 4 antimicrobials reported to the EARSS (2.5%). NB1: 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.NB2: Table 4.2 shows four resistance combinations that are biologically implausible, (1) single cephalosporin resistance, (2) combined fluoroquinolone and cephalosporin resistance, (3) combined


< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

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Figure 4.17. Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2007. * These countries did not report any data or reported less than 10 isolates.

cephalosporin and aminoglycoside resistance, and (4) combined aminoglycoside, fluoroquinolone and cephalosporin and resistance; because these combinations cannot exist without the presence of aminopenicillin resistance. These implausible results reflect the amount of reporting error in the central database. Since it is represents less than 1% (0.33%) of total resistance reported, this small number is a good indicator for the overall quality of the EARSS data in this respect.

4.5.3. 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 33 to 78%. Aminopenicillins can therefore no longer be regarded as a useful option for empirical treat-ment. Irrespective of the high level of resistance, proportions continue to increase in most of the countries, including those with resistance well above 50%. For fluoroquinolones the situation be-comes progressively dire. Of the 29 countries providing data, 28 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 resistance 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.


Table 4.2. Overall resistance and resistance combinations among invasive Escherichia coli isolates tested against all four classes of drugs (according to the EARSS protocol) (n= 42,816) in Europe, 2007.

Resistance pattern Number % of totalFull susceptibility 20,002 46.7Single resistance (to indicated drug classes)Aminopenicillins 13,326 31.1Fluoroquinolones 1,084 2.53rd generation cephalosporins 35 0.1Aminoglycosides 98 0.2Resistance to two classes of antimicrobial drugsAminopenicillins + fluoroquinolones 3,682 8.6Aminopenicillins + 3rd generation cephalosporins 396 0.9Aminopenicillins + aminoglycosides 445 1.0Fluoroquinolones + 3rd generation cephalosporins 46 0.1Fluoroquinolones + aminoglycosides 127 0.33rd generation cephalosporins + aminoglycosides 12 0.03Resistance to three classes of antimicrobial drugsAminopenicillins + fluoroquinolones + aminoglycosides 1,348 3.2Aminopenicillins + fluoroquinolones + 3rd generation cephalosporins 948 2.2Aminoglycosides + fluoroquinolones + 3rd generation cephalosporins 62 0.1Aminopenicillins + aminoglycosides + 3rd generation cephalosporins 121 0.3Resistance to four classes of antimicrobial drugsAminopenicillins + fluoroquinolones + aminoglycosides + 3rd generation cephalosporins 1,084 2.5


2001SE (1889)

2005DK (2294)

2001NO (1237)

2001FI (1343)

2001IS (102)

2001NL (2289)

2001GR (920)

2001SI (572)

2001HR (578)

2001EE (134)

2001LU (205)

2002FR (5070)

2001AT (1517)

2001MT (87)

2001HU (808)

2001CZ (1894)

2001UK (1946)

2001DE (1042)

2001BE (1275)

2001PL (169)

2001ES (2943)

2001PT (905)

2002IT (872)

2001BG (147)

2002IE (1290)

2001IL (741)

2003TR (828)

2002RO (46)

2003CY (67)

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Figure 4.18. Escherichia coli: trends of aminopenicillin resistance by country, 2001-2007. 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 seven years.# Either the first year of surveillance or the first year with 20 or more isolates reported.


2001EE (138)

2001NO (1298)

2001IS (107)

2001FI (1637)

2001PL (169)

2001SE (3252)

2002FR (5138)

2001HR (578)

2001LU (205)

2001BE (1278)

2005DK (1517)

2001SI (572)

2001NL (2014)

2002IE (1277)

2001HU (818)

2001GR (995)

2001ES (2936)

2001CZ (1895)

2001DE (1043)

2001PT (864)

2001UK (1753)

2001AT (1516)

2002IT (870)

2003CY (67)

2001IL (886)

2001IL (88)

2003TR (843)

2002RO (50)

2001BG (154)

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Figure 4.19. Escherichia coli: trends of third generation cephalosporin resistance by country, 2001-2007. Only the countries that reported 20 isolates or more per year for at least 3 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 seven years.# Either the first year of surveillance or the first year with 20 or more isolates reported.


2001EE (129)

2005DK (1982)

2001FI (1601)

2001NO (1193)

2001NL (2224)

2001SE (3020)

2001PL (167)

2001HR (573)

2001SI (572)

2001IS (98)

2002FR (5172)

2001BE (1158)

2001UK (1916)

2002IE (1277)

2001GR (989)

2001AT (1506)

2001CZ (1894)

2001LU (204)

2001HU (786)

2001IL (888)

2001PT (845)

2001DE (1033)

2002RO (48)

2001ES (2937)

2001BG (151)

2002IT (851)

2003TR (838)

2003CY (67)

2001MT (88)

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Figure 4.20. Escherichia coli: trends of fluoroquinolone resistance by country, 2001-2007. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate significant trends. # Either the first year of surveillance or the first year with 20 or more isolates reported.


2001SE (2772)

2005DK (2341)

2001NO (1243)

2001FI (1507)

2001BE (973)

2001NL (2292)

2001LU (206)

2001EE (139)

2001PL (169)

2002FR (5214)

2001IS (107)

2001HR (578)

2001DE (1044)

2001CZ (1897)

2001SI (572)

2001GR (1001)

2001AT (1518)

2001UK (1945)

2002IE (1284)

2003CY (67)

2001HU (823)

2001ES (2943)

2001PT (906)

2001IL (890)

2002IT (851)

2002RO (50)

2003TR (839)

2001MT (88)

2001BG (154)

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Figure 4.21. Escherichia coli: trends of aminoglycoside resistance by country, 2001-2007. Only the countries that re-ported 20 isolates or more per year for at least 3 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 seven years.# Either the first year of surveillance or the first year with 20 or more isolates reported.


2001IS (98)

2001SE (2620)

2001NO (1146)

2001EE (127)

2001BE (908)

2001PL (166)

2005DK (1336)

2001FI (1466)

2001NL (1944)

2001HR (573)

2002FR (5092)

2001LU (200)

2002IE (1258)

2001ES (2928)

2001DE (1026)

2001AT (1493)

2001CZ (1891)

2001SI (572)

2001HU (777)

2002IT (829)

2001UK (1653)

2001GR (987)

2003CY (67)

2001IL (885)

2001PT (815)

2002RO (47)

2003MT (88)

2003TR (831)

2001BG (149)

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Figure 4.22. Escherichia coli: trends of combined resistance (resistant to fluoroquinolones, 3rd gen. cephalosporins and aminoglycosides) by country, 2001-2007. Only the countries that reported 20 isolates or more per year for at least 3 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 seven years.# Either the first year of surveillance or the first year with 20 or more isolates reported.


4.6. Klebsiella pneumoniae

4.6.1. 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 systems, such as diabetics, alcoholics, and hospitalized patients with indwelling devices. The most common 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 community-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 mechanismsSimilar to E. coli, K. pneumoniae can be resistant to multiple antibiotics, 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 resistant against aminopenicillins. Moreover, this organism readily acquires plasmid-mediated resistance determinants. Therefore, many novel ESBL 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 4.5 for further details (35).

4.6.2. Klebsiella pneumoniae resistance in 2007EARSS began collecting AST results for invasive K. pneumoniae in 2005. In 2007 1,0687 isolates were reported from 28 countries. Differences in resistance observed between 2005 and 2007 can be due to changes in susceptibility of K. pneumoniae, but are also related to the difference in the number of countries reporting (2005: 24, 2006: 30, 2007: 28), and to an increase of isolates reported per country.

Third generation cephalosporinsThird generation cephalosporin resistance varied substantially between countries. Ten countries (out of 29) reported resistance levels against 3rd generation cephalosporins less then 10%. Six Northern European countries reported proportions below 5%, Iceland (0%, n=27), Sweden (1%, n=649), Fin-land (1%, n=272), Norway (2%, n=320), Luxembourg (2%, n=47) and Estonia (3%, n=63). Eight countries, among which some (south)eastern European countries and Israel, reported 40% or more: Croatia (40%, n=279), Israel (44%, n=451), Latvia (44%, n=27), Turkey (44%, n=639), Czech Re-public (46%, n=1230), Bulgaria (55%, n=29), Greece (62%, n=972) and Romania (80%, n=30). (Figure 4.23, annex 3.5).

FluoroquinolonesFluoroquinolone resistance in Europe is rather heterogeneous; six countries recorded resistance against fluoroquinolones of 5% or below: Estonia (2%, n=56), Finland (1%, n=273), The Nether-lands (4%, n=478), Norway (5%, n=308), Poland (3%, n=32) and Iceland (0%, n=26) whereas four countries recorded resistance proportions of above 40%: Czech Republic (48%, n=1230), Greece (55%, n=968), Israel (42%, n=449) and Bulgaria (41%, n=29) (Figure 4.24, annex 3.5).


< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.23. Klebsiella pneumoniae: proportion of invasive isolates resistant to 3rd generation cephalosporins in 2007. * 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 4.24. Klebsiella pneumoniae: proportion of invasive isolates resistant to fluoroquinolones in 2007. * 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 4.25. Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2007. * 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 4.26. Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2007. * These countries did not report any data or reported less than 10 isolates.


AminoglycosidesLow resistance proportions were found in the northern part of Europe. Resistance proportions were 2% or less in Iceland (0%, n=27), Malta (0%, n=28), Norway (1%, n=320), Finland (1%, n=263), Estonia (2%, n=63) and Sweden (1%, n=647). Proportions above 40% were found in Bulgaria (59%, n=29), Czech Republic (43%, n=1230), Greece (54%, n=971) and Israel (46%, n=451) (Figure 4.25, annex 3.5).

CarbapenemsAlthough reporting of AST results for carbapenems is not obligatory in EARSS, 29 of the 30 coun-tries reported carbapenem susceptibility. In 2007, data were available for 62% of all isolates. Car-bapenem resistance is still absent in most countries. Four countries reported 1-5% resistance, Cyprus (3%, n=38), Italy (1%, n=360), Germany (2%, n=173), and Turkey (2%, n=539). Only Israel (22%, n=451) and Greece (42%, n=966) reported higher percentages. (29;44)Since carbapenems are regarded as reserve antibiotics with life-saving potential when isolates show resistance to other antibiotics (36) 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 4.26, annex 3.5).

Combined resistanceIn 2007, 68% of the Klebsiella pneumoniae isolates displayed susceptibility to fluoroquinolones, 3rd generation cephalosporins, and aminoglycosides. All other isolates were resistant to at least one of the other antibiotic classes as well. As shown in table 4.3, single resistance was rather rare; the most frequent pattern was combined resistance against all three classes recorded by EARSS (14%). Combined resistance above 10% was reported by Italy (18%, n=346), Slovenia (18%, n=170), Hun-garia (18%, n=314), Croatia (29%, n=274), Czech Republic (29%, n=1230), Bulgaria (34%, n=29), Cyprus (11%, n=38), Turkey (13%, n=636), Israel (35%, n=449) and Greece (43%, n=968).

4.6.3. ConclusionsIn K. pneumoniae a high prevalence of resistant strains to 3rd generation cephalosporins, fluoroquinolones and aminoglycosides became evident in central and south-eastern Europe. Many of these strains have combined resistance and the most frequent phenotype shows resistance to all three

Table 4.3. Overall resistance and resistance combinations among invasive Klebsiella pneumoniae isolates tested against all three classes of drugs (according to the EARSS protocol*) (n= 10,046) in Europe, 2007. Intrinsic resistance against aminopenicillins is excluded; therefore results for only 3 classes are illustrated. *Reporting of carbapenems susceptibility was not obligatory within EARSS in 2007.

Resistance pattern Number % of totalFull susceptibility* 6,871 68.4%Single resistance (to indicated drug classes)Fluoroquinolones 395 3.9%3rd generation cephalosporins 270 2.7%Aminoglycosides 130 1.3%Resistance to two classes of antimicrobial drugsFluoroquinolones + 3rd generation cephalosporins 160 1.6%Fluoroquinolones + aminoglycosides 342 3.4%3rd generation cephalosporins + aminoglycosides 428 4.3%Resistance to three classes of antimicrobial drugsFluoroquinolones + 3rd generation cephalosporins + aminoglycosides 1,450 14.4%


antimicrobial 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.

4.7. Pseudomonas aeruginosa

4.7.1. 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 mechanismsP. aeruginosa is intrinsically resistant to the majority of antimicrobial compounds due to its selective ability to exclude various molecules from penetrating its outer membrane. Acquired resistance in P. aeruginosa 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 fluoro-quinolones or aminoglycosides, ii) constitutional or inducible derepression of chromosomally coded AmpC beta-lactamase, iii) mutational loss of outer membrane proteins preventing the uptake of anti-microbial substances such as imipenem, iv) efficient efflux systems, that can confer resistance to be-ta-lactams, fluoroquinolones, tetracycline, chloramphenicol, trimethoprim and aminoglycosides, and v) plasmid-mediated expression of various beta-lactamases and aminoglycoside modifying enzymes that can confer resistance to carbapenems (metallo-beta-lactamases) and aminoglycosides (31;38).

4.7.2. Pseudomonas aeruginosa resistance in 2007EARSS 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, 6,467 isolates were reported by 29 countries and in 2007, 7,078 isolates were reported by 30 countries.

Piperacillin and Piperacillin/ TazobactamIn the EARSS database, the proportion of piperacillin resistance was higher than that for the piperacillin-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=30) 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 piperacillin and tazobactam only for a selection of isolates. Thirteen countries still reported resistance of less than 10%.The highest resistance proportions were reported from Greece (38%, n=797) and Poland (36%, n=67). The Czech Republic (n=510) and Croatia (n=189) both reported 30% piperacillin resistance (Figure 4.27, annex 3.6).


CeftazidimeOnly three countries reported ceftazidime resistance of 25% or more, namely Czech Republic (33%, n=517), Greece (40%, n=781), and Italy (25%, n=169). On the other hand, seven countries, mostly situated in the northern part of Europe still reported resistance proportions below 5%, namely Den-mark (2%, n=370), Iceland (0%, n=11), Lithuania (0%, n=21), Malta (3%, n=36), the Netherlands (4%, n=338), Norway (3%, n=105) and Sweden (4%, n=335) (Figure 4.28, annex 3.6).

FluoroquinolonesA third of the countries (11 of 30) reported 25% or more fluoroquinolone resistance for invasive P. aeruginosa isolates, and were mainly located in the south-eastern part of Europe. The Czech Republic (43%, n=517), Greece (50%, n=796), and Poland (40%, n=67) even reported 40% resistance or more. Low resistance levels (<5%) were only found in Iceland (0%, n=11) and The Netherlands (5%, n=337) (Figure 4.29 annex 3.6).

AminoglycosidesNine of 30 countries reported aminoglycoside resistance over 25%. Especially in the south-eastern European countries proportions were high and even over 40% in Greece (49%, n=799), Croatia (40%, n=189), and Poland (40%, n=67). Most northern European countries still report resistance levels of less than 5%: Iceland, Denmark, The Netherlands, Norway, Sweden, and the United Kingdom (Figure 4.30).

< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.27. Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillins in 2007. * 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 4.29. Pseudomonas aeruginosa: proportion of invasive isolates resistant to fluoroquinolones in 2007.* 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 4.28. Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2007. * 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 4.30. Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2007. * 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 map the overall distribution of carbapenem resistance without loosing too much valuable data (Figure 4.31).

Pseudomonas aeruginosa resistance proportions to carbapenems appear to be rather high all over Europe, as the majority of countries (20 of 30) reported more than 10% carbapenem resistance. The highest proportions of resistance were reported by the Czech Republic (36%, n=517), Greece (47%, n=798), and Lithuania (30%, n=20). All northern European countries still reported resistance below 10%; Denmark (2%, n=309), Finland (8%, n=180), Ireland (9%, n=160), Iceland (0%, n=11), The Netherlands (2%, n=298), Norway (9%, n=97), Sweden (7%, n=324), United Kingdom (10%, n=261). The eastern countries Latvia (6%, n=16) and Bulgaria (7%, n=14) also reported less than 10% carbapenem resistance, but the low number of isolates reported should be taken into account when interpreting the data (Figure 4.31, annex 3.6).

Combined resistanceP. aeruginosa isolates were often found to be multi-resistant (17.2%), i.e. being resistant to three or more antibiotics from the EARSS protocol. The most dominant phenotype in the EARSS database in the past 3 years 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

< 1% No data*

5 – 10% 10 – 25% 25 – 50% > 50

LU MT

1 – 5%

Figure 4.31. Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2007. * These countries did not report any data or reported less than 10 isolates.


to either carbapenems (4%) or fluoroquinolones (4%). As in 2006, the derepressed Amp-C phenotype with both piperacillin and ceftazidime resistance could be ascertained in only 1.7% of all resistant isolates.

4.7.3. 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.


4.8. References

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22. Huycke MM, Sahm DF, Gilmore MS. Multiple-drug resistant enterococci: the nature of the prob-lem and an agenda for the future. Emerg Infect Dis 1998;4:239-49.

23. Jacobs MR. In vivo veritas: in vitro macrolide resistance in systemic Streptococcus pneumoniae infections does result in clinical failure. Clin Infect Dis 2002;35:565-9.

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29. Marchaim D, Navon-Venezia S, Schwaber MJ, and Carmeli Y. Isolation of Imipenem-Resistant Enterobacter Species: Emergence of KPC-2 Carbapenemase, Molecular Characterization, Epide-miology, and Outcomes. Antimicrob Agents Chemother 2008;52(4): 1413–18. Published online 2008 January 28. doi: 10.1128/AAC.01103-07.

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33. Mundy LM, Sahm DF, Gilmore M. Relationships between enterococcal virulence and antimicro-bial resistance. Clin Microbiol Rev 2000;13:513-22.

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35. Paterson DL. Resistance in gram-negative bacteria: Enterobacteriaceae. Am J Infect Control 2006;34(5 Suppl 1).

36. Paterson DL, Ko WC, Von Gottberg A, Mohapatra S, Casellas JM, Goossens H et al. Internation-al prospective study of Klebsiella pneumoniae bacteremia: implications of extended-spectrum beta-lactamase production in nosocomial Infections. Ann Intern Med 2004;140:26-32.

37. Perichon B, Reynolds P, Courvalin P. VanD-type glycopeptide-resistant Enterococcus faecium BM4339. Antimicrob Agents Chemother 1997;41:2016-8.

38. Peterson LR. Squeezing the antibiotic balloon: the impact of antimicrobial classes on emerging resistance. Clin Microbiol Infect 2005;11 Suppl 5.

39. Reacher MH, Shah A, Livermore DM, Wale MC, Graham C, Johnson AP, Heine H, Monnicken-dam MA, Barker KF, James D, and George RC. Bacteraemia and antibiotic resistance of its pathogens reported in England and Wales between 1990 and 1998: trend analysis. BMJ 2000; 320:213-6.



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

41. 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.

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

43. 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.

44. Vatopoulos A. High rates of metallo-beta-lactamase-producing Klebsiella pneumoniae in Greece-a review of the current evidence. Euro Surveill 2008; 13(4)

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

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

47. 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.

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

49. 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 5. Conclusions and Recommendations 81

Chapter 5. Conclusions and Recommendations

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 quarter of the European Union population, with most countries covering between 20-100%. The comparabil-ity of MRSA incidence rates and proportions indicate that the resistance proportions as reported by EARSS are a good approximation of the incidence rates, when comparing the occurrence of resist-ance across Europe.

The non-susceptibility profile of S. pneumoniae has a dynamic character. Although penicillin non-susceptibility is increasing in two countries, five countries are on the decrease, among those three countries showing the highest PNSP proportions in 2006. Erythromycin non-susceptibility is becom-ing more prevalent in quite a few countries, but against that, an equal number of countries is on the decrease. For dual non-susceptibility an increasing trend is observed, however Belgium and Spain show a decrease as they do for PNSP and ENSP.This year 12 countries have reported serogroup information for S. pneumoniae isolates, and data from seven countries were included for analysis. Compared to 2006, changes were small. Serogroup 1, 14 and 19 are highly prevalent in most countries.

MRSA is still an increasing problem all over Europe, and it continues to spread in a number of low endemic countries. In the high endemic countries, on the other hand, some countries seem to have stabilizing MRSA proportions, and more important, more countries compared with previous years, showed a significant decrease.

With the ongoing spread of clonal complex 17 in Europe, outbreaks of vancomycin resistant E. faecium continue to afflict more and more hospitals in various countries. The spread of these hospital-adapted strains occurs on the background of high-level aminoglycoside resistance. The control of glycopeptide resistant enterococci therefore remains a formidable task for hospital infection control practitioners.

The Europe-wide increase of resistance of Escherichia coli to all of the antimicrobial classes record-ed by EARSS is a disturbing development with seemingly inexorable vigor. The highest resistance proportions have been reported for aminopenicillins and this can no longer be regarded as a useful option for empirical treatment now. For fluoroquinolones the situation becomes progressively dire. The speed with which fluoroquinolones loose their activity against E. coli is next to no other com-pound pathogen combination in the EARSS database.

Combined resistance 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. In 2007, participating laboratories in Europe reported for the first time that most of Escherichia coli (53%) had lost their original susceptibility to aminopenicillins, fluoro-quinolones, 3rd generation cephalosporins, and aminoglycosides and can no longer be regarded as wild-type strains.

In K. pneumoniae a high prevalence of resistant strains to 3rd generation cephalosporins, fluoroqui-nolones and aminoglycosides becomes evident in central and southeastern Europe. Many strains have combined resistance and the most frequent phenotype shows resistance to all three antimicro-

82 Chapter 6. Conclusions and Recommendations

bial 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.

Combined 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 sampled after prolonged exposure with antimicrobial chemotherapy will predictably be a multi-resistant phenotype.

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.

Annex 1. Technical Notes 83

Annex 1. Technical Notes

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 2007. 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 and ICU 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 population 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 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 specialities, mainly internal medicine, obstetrics-gynecology, pediatrics, and general surgery, or only general practice; limited laboratory services are available for general, but not for specialized pathological 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;

clinical services are highly differentiated by function; the hospital may have teaching activities; bed capacity 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 laboratory/hospital questionnaires were included that provided information on all variables needed for the spe-cific 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 3

In the case of linking of AST results with denominator information, only AST results from those hospitals 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 4

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 for 3 years 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 trends were discussed in the text. However, if both datasets indicated a similar trend, we included this;

84 Annex 1. Technical Notes

Annex 1. Technical Notes 85

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.

86 Annex 1. Technical Notes

Annex 2. Country Summary Sheets 87

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 1 and 2 and figure 1 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 2007 (i.e. that responded to the questionnaire) and thus only includes the laboratories that 1) reported AST results to EARSS in 2007, and 2) provided blood culture information; and the hospitals that 1) reported AST results to EARSS in 2007, 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 1). 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 2007.Figure 1 shows the geographic location of the laboratories reporting in 2007. 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 1999-2007Table 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 hospital department, and the proportion of resistance within the different groups, for the period 2006-2007.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 = vancomycin resistant E. faecalis or E. faecium, CRKP = 3rd generation cephalosporin resistant K. pneumoniae, 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. Both figures are based on data from 2006 and 2007, 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 2007, based on laboratories/hospitals providing denominator data

TotalLabs providing denom.data/reporting data to EARSS 20/35Hosps providing denom.data/reporting data to EARSS 123/135Number of blood culture sets 94,287Number of hospital beds 47,364Patient-days 12,043,355Average occupancy rate (%) 70%Median length of stay (days) 5Estimated catchment population na% total population covered naType of participating hospitals Regional/Tertiary 26% Provincial/Secondary 21% District/Primary 50%

Table 2. Number of laboratories and number of isolates reported for the period 2000-2007

Year S. pneumoniaeLabs Isolates

S. aureusLabs Isolates

E. coliLabs Isolates

EnterococciLabs Isolates

K. pneumoniaeLabs Isolates

P. aeruginosaLabs Isolates

2000 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 4052007 34 313 34 1503 34 2545 33 688 33 445 33 411

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

Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 2 <1 1 1 <1 <1 2

Penicillin I+R 2 4 1 9 5 5 5 5Macrolides I+R 5 10 9 14 12 15 12 13

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

Aminoglycosides R . 2 4 5 5 5 8 8Fluoroquinolones R . 7 10 14 17 19 22 263rd gen. Cephalosporins R . <1 1 2 3 4 7 9

E. faecalis Aminopenicillins I+R . 13 3 1 <1 1 2 2HL Aminoglycosides R . 35 27 33 23 28 29 30Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 86 84 85 85 84 89 82HL Aminoglycosides R . 13 21 22 22 28 21 28Glycopeptides R . 5 7 <1 <1 1 <1 2

K. pneumoniae Aminoglycosides R . . . . . 3 5 5Fluoroquinolones R . . . . . 11 8 123rd gen. Cephalosporins R . . . . . 6 6 8

P. aeruginosa Piperacillin R . . . . . 13 8 6Ceftazidime R . . . . . 7 9 5Carbapenems R . . . . . 10 15 12Aminoglycosides R . . . . . 6 9 8Fluoroquinolones R . . . . . 14 15 15

Figure 1. Geographic distribution of laboratories in 2007

AustriaGeneral Information about EARSS participating laboratories and hospitals

Antibiotic resistance from 2000 to 2007

88 Annex 2. Country Summary Sheets










2000 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 4052007 34 313 34 1503 34 2545 33 688 33 445 33 411


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 2 <1 1 1 <1 <1 2




E. faecalis Aminopenicillins I+R . 13 3 1 <1 1 2 2HL Aminoglycosides R . 35 27 33 23 28 29 30Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 86 84 85 85 84 89 82HL Aminoglycosides R . 13 21 22 22 28 21 28Glycopeptides R . 5 7 <1 <1 1 <1 2




AustriaGeneral Information about EARSS participating laboratories and hospitals


Table 4. Selected details on invasive isolates from the reporting period 2006 and 2007

Characteristic S. pneumo.n=604

S. aureusn=3140

E. colin=4994

E. faecalisn=800

E. faeciumn=471

K. pneumo.n=871

P. aeruginosan=805

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

Blood 94 4 100 9 100 24 100 0 100 1 100 7 100 13CSF 6 14 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 50 5 58 10 39 27 60 1 55 1 54 8 53 15Female 48 4 41 9 59 21 39 0 44 1 44 5 45 11Unknown 2 8 2 10 2 29 1 0 1 0 2 16 2 22

Age (years)0-4 8 15 2 3 2 8 4 0 1 0 3 0 1 85-19 4 4 2 1 1 19 1 0 1 0 1 0 1 020-64 37 5 35 9 27 25 33 0 42 2 34 10 36 1865 and over 51 4 61 10 71 24 62 0 57 1 63 6 61 11Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 12 3 10 17 7 28 16 2 25 1 12 14 15 22Internal Med. 52 4 50 8 54 22 41 0 36 1 43 5 34 13Surgery 2 18 10 17 9 18 11 0 11 0 14 8 10 9Other 33 7 28 6 29 27 29 0 25 3 29 7 39 12Unknown 1 0 1 13 1 23 2 0 2 0 2 0 2 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 : 87Minimum : 0.01st quartile : 0.0Median : 6.23rd quartile : 12.5Maximum : 39.6

no of labs : 31Minimum : 0.01st quartile : 0.0Median : 4.83rd quartile : 10.7Maximum : 20.0

Figure 3. Proportion (%) MRSA by hospital (2006 & 2007)

0 25 50 75 100

0/8AT003E0/22AT003G0/13AT005K0/20AT005Z0/7AT006O0/9AT007F0/17AT007W0/6AT008A0/8AT009R0/6AT009S0/5AT009W0/29AT010B0/18AT010H0/26AT012W0/12AT015M0/16AT015S0/5AT016G0/7AT022R0/5AT022S0/8AT023F0/5AT026Z0/21AT030F0/17AT030H0/13AT030V0/17AT030W0/5AT030X0/6AT032J0/5AT032R0/5AT036M0/25AT037P

1/68AT014R1/28AT026S1/27AT030G2/52AT010F1/21AT022B1/21AT029O1/20AT033F1/18AT011P1/18AT011W1/18AT024G1/17AT007V3/50AT021V5/83AT033D7/113AT016W4/62AT024V4/56AT015A3/41AT022L7/88AT001E2/25AT006N1/12AT009K4/47AT034E7/81AT019P10/115AT028R9/100AT006S14/146AT027L3/31AT017K15/148AT025K5/49AT035H2/19AT022K6/54AT001S1/9AT019L1/9AT032D14/118AT031W27/226AT002A7/58AT018M1/8AT003M15/120AT005I3/24AT023K17/127AT007K4/29AT001B1/7AT012D1/7AT012H8/55AT023S5/33AT024B

1/6AT005J1/6AT006B

5/28AT032G2/11AT005R2/11AT015W2/11AT017Z2/11AT021S

1/5AT005C2/10AT032V

10/37AT005L3/9AT008S

3/8AT005H21/53AT032B

Figure 2.Proportion (%) PNSP by laboratory (2006 & 2007)

0 25 50 75 100

0/19AT007

0/8AT011

0/6AT012

0/7AT014

0/20AT016

0/12AT018

0/24AT019

0/12AT021

0/26AT026

0/19AT030

0/10AT031

0/15AT032

0/5AT035

1/56AT001

1/24AT033

2/42AT005

1/20AT022

1/17AT015

2/32AT010

3/46AT028

2/27AT027

1/12AT024

3/34AT025

3/28AT006

4/37AT002

1/9AT008

1/8AT009

1/7AT034

1/6AT017

1/6AT029

1/5AT003



TotalLabs providing denom.data/reporting data to EARSS 24/105Hosps providing denom.data/reporting data to EARSS 23/105Number of blood culture sets 119,011Number of hospital beds 11,342Patient-days 3,112,184Average occupancy rate (%) 77%Median length of stay (days) 8Estimated catchment population 3,228,519% total population covered 31%Type of participating hospitals Regional/Tertiary 30% Provincial/Secondary 57% District/Primary 4%








2000 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 02007 105 1511 34 855 17 1460 20 245 0 0 0 0


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R 5 <1 <1 <1 <1 3 4 3



Aminoglycosides R . 4 6 5 5 4 6 5Fluoroquinolones R . 9 13 12 15 17 19 193rd gen. Cephalosporins R . 2 3 3 3 4 3 4

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

E. faecium Aminopenicillins I+R . 60 56 78 63 61 67 68HL Aminoglycosides R . <1 5 <1 11 22 19 23Glycopeptides R . <1 <1 <1 5 14 4 <1

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












2000 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 02007 105 1511 34 855 17 1460 20 245 0 0 0 0


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R 5 <1 <1 <1 <1 3 4 3




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

E. faecium Aminopenicillins I+R . 60 56 78 63 61 67 68HL Aminoglycosides R . <1 5 <1 11 22 19 23Glycopeptides R . <1 <1 <1 5 14 4 <1

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=1713

E. colin=2947

E. faecalisn=413

E. faeciumn=90

K. pneumo.n=0

P. aeruginosan=0


Blood 95 10 100 23 100 19 100 0 100 2 . . . .CSF 5 12 0 . 0 . 0 . 0 . . . . .

GenderMale 55 10 59 23 44 22 62 0 60 4 . . . .Female 44 9 39 23 56 17 37 1 39 0 . . . .Unknown 1 10 2 17 0 . 1 0 1 0 . . . .

Age (years)0-4 18 12 4 9 2 2 4 0 1 0 . . . .5-19 6 3 2 9 1 13 0 . 0 . . . . .20-64 33 7 34 16 29 17 27 1 43 3 . . . .65 and over 42 11 58 28 68 21 69 0 56 2 . . . .Unknown 0 . 1 33 0 . 0 . 0 . . . . .

Hospital dep.ICU 13 11 16 22 1 39 21 0 19 6 . . . .Internal Med. 36 9 37 27 4 29 37 1 34 3 . . . .Surgery 2 8 11 28 1 30 8 0 9 0 . . . .Other 28 11 26 18 4 17 27 0 28 0 . . . .Unknown 21 8 10 16 90 19 7 4 10 0 . . . .







0 25 50 75 100

1/15BE074X

5/46BE001X

14/113BE063X

4/31BE005X

4/31BE007X

4/28BE054X

12/82BE077X

10/60BE041X

11/65BE002X

9/53BE061X

20/115BE112X

10/55BE024X

11/58BE008X

4/21BE019X

22/115BE115X

14/68BE006X

16/77BE060X

2/9BE057X

31/132BE016X

15/60BE032X

14/52BE022X

38/134BE097X

43/131BE070X

20/59BE143X

15/38BE056X

8/20BE030X

16/19BE045X


0 25 50 75 100

0/13BE0020/5BE0050/31BE0230/29BE0350/27BE0510/16BE0640/6BE0650/6BE0810/16BE0830/13BE1000/9BE1370/18BE150

1/38BE0541/34BE0741/31BE0481/31BE1031/31BE1612/54BE1112/53BE0751/25BE0931/24BE0726/136BE1083/67BE0081/20BE0291/19BE0121/19BE0762/37BE0041/18BE1101/17BE0571/17BE1601/16BE1143/45BE0241/15BE0693/43BE0373/43BE0464/55BE0972/27BE0266/79BE0431/13BE1074/51BE0612/25BE0192/25BE0603/35BE0142/23BE1057/80BE0708/90BE0911/11BE0093/33BE0332/21BE0903/30BE0843/28BE0107/64BE01610/91BE0453/26BE0493/26BE1012/17BE0733/25BE0032/16BE0074/32BE02111/86BE0924/31BE0774/31BE1026/46BE0633/23BE0986/45BE0067/50BE0303/21BE1298/55BE0569/61BE11511/74BE0012/13BE0172/13BE11611/69BE1121/6BE0116/34BE0327/39BE1394/22BE0314/22BE1093/16BE1647/36BE1431/5BE1137/34BE0225/24BE0717/33BE104

4/18BE1667/30BE095











2000 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 312007 10 32 14 121 15 127 13 65 9 29 6 14


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R 23 6 8 9 22 30 7 9




E. faecalis Aminopenicillins I+R . 5 26 7 15 8 31 13HL Aminoglycosides R . 30 63 36 33 24 53 29Glycopeptides R . <1 <1 <1 2 <1 2 <1

E. faecium Aminopenicillins I+R . 50 71 60 59 96 97 100HL Aminoglycosides R . 33 83 60 62 56 79 75Glycopeptides R . <1 <1 <1 <1 <1 <1 <1




BulgariaGeneral Information about EARSS participating laboratories and hospitals












2000 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 312007 10 32 14 121 15 127 13 65 9 29 6 14






E. faecalis Aminopenicillins I+R . 5 26 7 15 8 31 13HL Aminoglycosides R . 30 63 36 33 24 53 29Glycopeptides R . <1 <1 <1 2 <1 2 <1





BulgariaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=280

E. colin=318

E. faecalisn=114

E. faeciumn=43

K. pneumo.n=84

P. aeruginosan=42


Blood 67 12 100 22 97 29 100 1 100 0 100 58 100 12CSF 33 10 0 . 3 38 0 . 0 . 0 . 0 .

GenderMale 64 8 60 24 45 37 63 0 56 0 61 57 57 8Female 36 18 40 19 54 23 37 2 44 0 39 61 43 17Unknown 0 . 0 . 1 50 0 . 0 . 0 . 0 .

Age (years)0-4 15 44 9 23 6 11 11 0 12 0 12 60 5 505-19 18 0 4 20 4 21 1 0 0 . 4 67 2 020-64 56 6 62 24 51 33 58 2 58 0 45 68 55 1365 and over 11 14 25 17 39 29 30 0 30 0 39 45 38 6Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 18 0 15 45 11 33 20 0 33 0 15 62 40 18Internal Med. 25 7 35 13 48 25 33 3 26 0 31 50 10 0Surgery 0 . 10 36 14 44 8 0 9 0 19 69 26 18Other 57 17 40 17 27 27 39 0 33 0 35 59 24 0Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/9BG013A

1/16BG030A

2/25BG023A

1/12BG002A

2/20BG017A

2/16BG001A

5/35BG003A

3/21BG005A

4/25BG011A

1/5BG029A

7/27BG018A

4/13BG027A

2/6BG021A

2/5BG026A

5/11BG006A

6/11BG009A

9/11BG015A


0 25 50 75 100

0/9BG013

0/5BG018

0/11BG023

1/5BG011

5/9BG003











2000 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 1702007 15 136 15 375 17 852 13 174 17 279 16 189


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . <1 <1 1 3 <1 <1 <1

Penicillin I+R . 15 19 20 17 17 18 18Macrolides I+R . 15 23 18 19 17 16 8

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

Aminoglycosides R . 6 7 7 6 5 6 6Fluoroquinolones R . 5 5 7 8 9 15 133rd gen. Cephalosporins R . 2 3 4 3 <1 1 3

E. faecalis Aminopenicillins I+R . 13 5 4 5 6 3 2HL Aminoglycosides R . 50 40 28 35 31 37 37Glycopeptides R . 3 <1 <1 <1 1 <1 <1

E. faecium Aminopenicillins I+R . 100 56 47 69 82 69 78HL Aminoglycosides R . 100 67 41 63 62 59 59Glycopeptides R . <1 22 6 3 6 3 2




CroatiaGeneral Information about EARSS participating laboratories and hospitals












2000 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 1702007 15 136 15 375 17 852 13 174 17 279 16 189


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . <1 <1 1 3 <1 <1 <1



Aminoglycosides R . 6 7 7 6 5 6 6Fluoroquinolones R . 5 5 7 8 9 15 133rd gen. Cephalosporins R . 2 3 4 3 <1 1 3

E. faecalis Aminopenicillins I+R . 13 5 4 5 6 3 2HL Aminoglycosides R . 50 40 28 35 31 37 37Glycopeptides R . 3 <1 <1 <1 1 <1 <1

E. faecium Aminopenicillins I+R . 100 56 47 69 82 69 78HL Aminoglycosides R . 100 67 41 63 62 59 59Glycopeptides R . <1 22 6 3 6 3 2




CroatiaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=766

E. colin=1628

E. faecalisn=265

E. faeciumn=85

K. pneumo.n=484

P. aeruginosan=359


Blood 95 18 100 37 100 14 100 0 100 2 100 38 100 26CSF 5 17 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 60 19 64 38 42 15 64 1 62 2 61 44 64 28Female 40 18 36 34 57 14 36 0 38 3 39 28 36 22Unknown 0 . 1 40 0 . 0 . 0 . 0 . 0 .


Hospital dep.ICU 10 33 17 65 6 17 11 0 21 0 16 49 23 25Internal Med. 18 24 39 27 40 15 34 1 44 0 31 23 26 20Surgery 0 . 12 72 4 16 12 0 5 0 11 55 17 18Other 72 15 31 20 50 13 42 0 31 8 43 40 34 34Unknown 1 0 0 . 0 . 1 0 0 . 0 . 0 .







0 25 50 75 100

0/8HR010A

1/16HR014A

1/11HR010H

3/25HR009A

2/11HR016A

3/14HR017A

19/73HR002A

18/58HR004A

17/52HR011A

15/43HR008A

9/22HR020A

63/152HR007A

78/185HR001A

9/21HR018A

17/32HR002C

5/9HR013A

6/10HR027A

14/19HR002B


0 25 50 75 100

0/5HR008

1/11HR005

1/10HR020

1/8HR017

1/7HR009

4/24HR007

21/123HR002

5/23HR001

2/7HR004

2/7HR013

2/7HR014

3/9HR010

2/6HR018



TotalLabs providing denom.data/reporting data to EARSS 5/5Hosps providing denom.data/reporting data to EARSS 5/5Number of blood culture sets 13,726Number of hospital beds 1,277Patient-days 471,767Average occupancy rate (%) 100%Median length of stay (days) 6Estimated catchment population 428,921% total population covered 54%Type of participating hospitals Regional/Tertiary 20% Provincial/Secondary 20% District/Primary 40%








2000 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 372007 4 15 4 85 5 108 3 63 4 38 3 52


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . <1 <1 <1 31 7

Penicillin I+R . . . <1 14 19 38 33Macrolides I+R . . . 33 <1 13 31 27

S. aureus Oxacillin/Methicillin R . . . 64 49 56 32 48E. coli Aminopenicillins R . . . 63 61 73 62 73

Aminoglycosides R . . . 11 11 14 10 11Fluoroquinolones R . . . 32 22 29 35 403rd gen. Cephalosporins R . . . 11 9 16 16 19

E. faecalis Aminopenicillins I+R . . . <1 3 3 5 2HL Aminoglycosides R . . . 43 77 71 44 61Glycopeptides R . . . <1 3 <1 <1 <1

E. faecium Aminopenicillins I+R . . . 100 100 80 43 92HL Aminoglycosides R . . . . 33 <1 14 33Glycopeptides R . . . <1 33 40 14 25




CyprusGeneral Information about EARSS participating laboratories and hospitals












2000 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 372007 4 15 4 85 5 108 3 63 4 38 3 52


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . <1 <1 <1 31 7

Penicillin I+R . . . <1 14 19 38 33Macrolides I+R . . . 33 <1 13 31 27



E. faecalis Aminopenicillins I+R . . . <1 3 3 5 2HL Aminoglycosides R . . . 43 77 71 44 61Glycopeptides R . . . <1 3 <1 <1 <1

E. faecium Aminopenicillins I+R . . . 100 100 80 43 92HL Aminoglycosides R . . . . 33 <1 14 33Glycopeptides R . . . <1 33 40 14 25




CyprusGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=147

E. colin=197

E. faecalisn=92

E. faeciumn=19

K. pneumo.n=64

P. aeruginosan=88


Blood 93 35 100 41 100 38 100 0 100 21 100 30 100 16CSF 7 50 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 68 37 65 38 48 40 63 0 68 15 58 35 72 16Female 32 33 35 49 51 36 36 0 32 33 42 22 28 16Unknown 0 . 0 . 1 0 1 0 0 . 0 . 0 .

Age (years)0-4 11 0 1 0 2 0 0 . 0 . 3 50 2 05-19 11 0 2 0 1 50 1 0 5 0 3 0 0 .20-64 14 0 15 27 9 28 17 0 11 50 14 33 22 1165 and over 14 75 18 52 25 37 26 0 37 14 22 14 13 18Unknown 50 50 64 44 63 40 55 0 47 22 58 35 64 18

Hospital dep.ICU 7 50 24 39 11 29 35 0 42 13 28 50 44 21Internal Med. 54 53 33 38 53 39 25 0 26 0 30 5 19 0Surgery 0 . 14 70 9 35 23 0 16 67 11 57 18 25Other 39 9 29 35 27 36 17 0 16 33 31 25 17 13Unknown 0 . 0 . 1 100 0 . 0 . 0 . 1 0







0 25 50 75 100

7/32CY003A

13/30CY002A

40/78CY001A


0 25 50 75 100

1/8CY004

7/11CY001











2000 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 4862007 41 205 47 1652 48 2407 47 816 48 1231 41 517


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 <1 2 <1 <1 <1




E. faecalis Aminopenicillins I+R . 3 2 4 <1 <1 2 3HL Aminoglycosides R . 38 39 44 43 45 43 49Glycopeptides R . 2 <1 <1 <1 <1 <1 1

E. faecium Aminopenicillins I+R . 67 73 80 81 92 90 91HL Aminoglycosides R . 33 35 48 43 69 74 79Glycopeptides R . 2 9 3 3 14 4 6




Czech RepublicGeneral Information about EARSS participating laboratories and hospitals












2000 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 4862007 41 205 47 1652 48 2407 47 816 48 1231 41 517


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 <1 2 <1 <1 <1




E. faecalis Aminopenicillins I+R . 3 2 4 <1 <1 2 3HL Aminoglycosides R . 38 39 44 43 45 43 49Glycopeptides R . 2 <1 <1 <1 <1 <1 1





Czech RepublicGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=3172

E. colin=4539

E. faecalisn=1099

E. faeciumn=410

K. pneumo.n=2355

P. aeruginosan=1002


Blood 82 4 100 13 100 24 100 1 100 5 100 40 99 34CSF 18 2 0 . 0 . 0 . 0 . 0 . 1 75

GenderMale 61 3 61 13 42 26 61 0 58 6 62 42 64 37Female 39 3 39 13 58 22 39 1 42 4 38 38 36 29Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .


Hospital dep.ICU 23 6 25 17 19 25 46 1 47 4 40 49 39 44Internal Med. 36 2 45 11 49 22 29 1 23 3 32 32 29 29Surgery 1 0 10 17 7 27 8 1 6 4 11 41 8 27Other 37 3 20 10 25 26 16 0 25 10 17 35 23 28Unknown 3 0 1 7 1 24 1 0 0 . 0 . 1 33







0 25 50 75 100

0/6CZ007D0/8CZ009B0/8CZ017C0/10CZ022B0/6CZ029A0/9CZ031F0/6CZ031Y0/8CZ037D0/13CZ045A0/14CZ047A

2/64CZ019A3/79CZ021A1/24CZ046A2/43CZ017B1/19CZ048A3/49CZ008A3/49CZ044A1/16CZ019B2/32CZ037A1/16CZ048B14/215CZ006A3/46CZ004A2/30CZ014A9/131CZ020A3/43CZ038A1/14CZ012C12/164CZ018A4/53CZ034A2/26CZ041A3/36CZ036A10/119CZ009A10/116CZ024A7/81CZ002A1/11CZ040A1/11CZ043C4/43CZ013A

3/29CZ012A11/105CZ016A4/35CZ011A13/113CZ027A4/33CZ032A9/70CZ035A5/38CZ030A4/30CZ022A8/60CZ026A13/97CZ017A1/7CZ034C3/21CZ039A

2/13CZ028A12/73CZ007A7/42CZ025A18/105CZ015A3/17CZ031J

9/46CZ049A3/14CZ012B3/14CZ031P8/36CZ042A

27/113CZ031A3/12CZ039B21/83CZ033A15/57CZ023A4/15CZ043B

2/7CZ049B22/76CZ003A

31/101CZ005A2/6CZ007E3/9CZ015B2/6CZ031K3/9CZ050A

5/11CZ031C8/16CZ007B


0 25 50 75 100

0/17CZ003

0/15CZ004

0/7CZ005

0/6CZ007

0/8CZ012

0/21CZ015

0/34CZ016

0/5CZ022

0/5CZ023

0/8CZ026

0/15CZ027

0/7CZ029

0/6CZ030

0/13CZ031

0/7CZ037

0/6CZ041

0/8CZ044

0/11CZ049

1/45CZ006

2/34CZ009

1/11CZ002

1/10CZ017

1/9CZ008

1/9CZ019

2/17CZ024

1/6CZ025



TotalLabs providing denom.data/reporting data to EARSS 5/15Hosps providing denom.data/reporting data to EARSS 5/74Number of blood culture sets 78,609Number of hospital beds 2,776Patient-days 882,398Average occupancy rate (%) 90%Median length of stay (days) 4Estimated catchment population 1,175,000% total population covered 21%Type of participating hospitals Regional/Tertiary 40% Provincial/Secondary 40% District/Primary 20%








2000 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 0 0 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 02007 15 1030 14 1315 12 3021 13 945 13 784 13 417


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 <1 <1 <1 <1 <1


S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 1 2 2 <1E. coli Aminopenicillins R . . . . . 39 41 43

Aminoglycosides R . . . . . 2 3 4Fluoroquinolones R . . . . . 5 7 93rd gen. Cephalosporins R . . . . . 1 2 3

E. faecalis Aminopenicillins I+R . . . . . . <1 2HL Aminoglycosides R . . . . . . . .Glycopeptides R . . . . . . <1 <1

E. faecium Aminopenicillins I+R . . . . . . 87 88HL Aminoglycosides R . . . . . . . .Glycopeptides R . . . . . . <1 <1

K. pneumoniae Aminoglycosides R . . . . . . 2 6Fluoroquinolones R . . . . . . 6 133rd gen. Cephalosporins R . . . . . . 4 10

P. aeruginosa Piperacillin R . . . . . . . 3Ceftazidime R . . . . . . . 2Carbapenems R . . . . . . . 2Aminoglycosides R . . . . . . . 1Fluoroquinolones R . . . . . . . 6


DenmarkGeneral Information about EARSS participating laboratories and hospitals












2000 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 0 0 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 02007 15 1030 14 1315 12 3021 13 945 13 784 13 417




S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 1 2 2 <1E. coli Aminopenicillins R . . . . . 39 41 43

Aminoglycosides R . . . . . 2 3 4Fluoroquinolones R . . . . . 5 7 93rd gen. Cephalosporins R . . . . . 1 2 3

E. faecalis Aminopenicillins I+R . . . . . . <1 2HL Aminoglycosides R . . . . . . . .Glycopeptides R . . . . . . <1 <1

E. faecium Aminopenicillins I+R . . . . . . 87 88HL Aminoglycosides R . . . . . . . .Glycopeptides R . . . . . . <1 <1


P. aeruginosa Piperacillin R . . . . . . . 3Ceftazidime R . . . . . . . 2Carbapenems R . . . . . . . 2Aminoglycosides R . . . . . . . 1Fluoroquinolones R . . . . . . . 6


DenmarkGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=2594

E. colin=5188

E. faecalisn=525

E. faeciumn=417

K. pneumo.n=922

P. aeruginosan=309


Blood 92 4 100 1 100 8 100 1 100 0 100 7 100 2CSF 8 3 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 49 4 31 1 46 9 66 1 58 0 59 9 63 2Female 51 3 19 1 54 7 34 1 42 1 41 4 37 4Unknown 0 . 49 2 0 . 0 . 0 . 0 . 0 .


Hospital dep.ICU 0 . 0 . 3 12 13 0 32 1 7 5 10 13Internal Med. 0 . 0 . 49 7 41 1 26 1 46 9 29 0Surgery 0 . 0 . 17 7 20 0 17 0 22 4 16 2Other 0 . 0 . 20 8 24 1 14 0 22 7 30 0Unknown 100 3 100 1 10 10 2 0 11 0 3 8 14 5







0 25 50 75 100

0/87DK002B0/51DK002F0/79DK003B0/23DK004B0/22DK004C0/42DK005A0/63DK005C0/45DK006A0/5DK006X0/21DK008A0/26DK009A0/6DK009F0/108DK009O0/34DK009P0/8DK010D0/33DK012B0/38DK012D0/39DK012E0/42DK013A0/60DK013B0/8DK013D0/5DK013X0/30DK014A0/62DK014B0/47DK014C0/7DK014E0/106DK014N0/65DK015A0/6DK015B0/5DK015C0/7DK015G0/7DK015X0/29DK016B0/13DK016C0/11DK016D0/10DK016F0/10DK016G0/5DK016H0/8DK016P0/11DK016Q0/16DK016X1/164DK016A1/102DK009B1/91DK004A1/85DK011A1/69DK014D3/198DK001A1/64DK010A1/44DK002E2/71DK002A5/160DK003C

2/46DK006B2/43DK012F1/20DK005B

6/93DK003A2/15DK006C

1/5DK011D


0 25 50 75 100

0/87DK015

1/96DK006

4/249DK014

2/86DK013

1/42DK001

6/206DK016

5/135DK004

4/108DK005

3/81DK007

5/130DK012

7/180DK009

4/84DK011

10/200DK003

12/215DK002











2000 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 10 167 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 432007 8 64 10 206 11 219 8 66 9 63 8 48


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . <1 <1 <1 <1 <1 <1 <1

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

S. aureus Oxacillin/Methicillin R . 5 1 4 5 2 3 9E. coli Aminopenicillins R <1 43 42 42 55 45 52 50

Aminoglycosides R <1 8 10 3 2 4 2 6Fluoroquinolones R <1 <1 5 5 6 5 7 73rd gen. Cephalosporins R <1 6 2 1 4 1 <1 1

E. faecalis Aminopenicillins I+R . 8 10 4 14 14 9 <1HL Aminoglycosides R . <1 50 22 32 50 35 23Glycopeptides R . <1 <1 <1 <1 <1 <1 <1


K. pneumoniae Aminoglycosides R . . . . . 8 9 2Fluoroquinolones R . . . . . <1 5 23rd gen. Cephalosporins R . . . . . 8 9 3



EstoniaGeneral Information about EARSS participating laboratories and hospitals












2000 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 10 167 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 432007 8 64 10 206 11 219 8 66 9 63 8 48


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . <1 <1 <1 <1 <1 <1 <1

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

S. aureus Oxacillin/Methicillin R . 5 1 4 5 2 3 9E. coli Aminopenicillins R <1 43 42 42 55 45 52 50

Aminoglycosides R <1 8 10 3 2 4 2 6Fluoroquinolones R <1 <1 5 5 6 5 7 73rd gen. Cephalosporins R <1 6 2 1 4 1 <1 1

E. faecalis Aminopenicillins I+R . 8 10 4 14 14 9 <1HL Aminoglycosides R . <1 50 22 32 50 35 23Glycopeptides R . <1 <1 <1 <1 <1 <1 <1


K. pneumoniae Aminoglycosides R . . . . . 8 9 2Fluoroquinolones R . . . . . <1 5 23rd gen. Cephalosporins R . . . . . 8 9 3



EstoniaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=360

E. colin=406

E. faecalisn=76

E. faeciumn=62

K. pneumo.n=110

P. aeruginosan=87


Blood 83 1 100 6 99 7 100 0 100 0 100 5 100 23CSF 17 0 0 . 1 0 0 . 0 . 0 . 0 .

GenderMale 65 1 55 7 36 10 57 0 55 0 57 5 62 22Female 34 0 43 5 63 5 41 0 42 0 42 7 38 24Unknown 1 0 2 43 1 0 3 0 3 0 1 0 0 .

Age (years)0-4 4 0 10 11 3 8 17 0 8 0 17 0 5 255-19 1 0 3 8 1 0 0 . 2 0 1 0 1 020-64 66 1 54 7 44 6 36 0 39 0 34 5 49 2865 and over 27 0 31 4 49 8 45 0 50 0 44 8 43 19Unknown 2 0 1 0 3 0 3 0 2 0 5 0 2 0

Hospital dep.ICU 43 2 26 11 18 4 36 0 37 0 29 3 57 28Internal Med. 28 0 36 1 42 4 22 0 27 0 27 10 13 27Surgery 2 0 10 3 7 15 3 0 5 0 6 0 6 20Other 27 0 27 11 33 10 39 0 31 0 37 5 24 10Unknown 0 . 1 0 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/5EE003R

0/18EE005P

0/7EE008V

0/7EE010N

0/5EE012P

1/48EE004P

1/40EE009K

1/36EE006K

4/88EE001A

2/27EE002L

14/76EE002M


0 25 50 75 100

0/21EE002

0/14EE004

0/8EE005

0/16EE006

0/18EE009

1/35EE001











2000 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 1632007 16 522 16 814 16 1949 16 400 15 273 14 183


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 1 2 2 <1 <1 2 1


S. aureus Oxacillin/Methicillin R 1 <1 <1 1 3 3 3 2E. coli Aminopenicillins R . 33 30 33 33 35 36 34

Aminoglycosides R . <1 <1 1 2 2 2 3Fluoroquinolones R . 5 6 5 7 7 8 83rd gen. Cephalosporins R . <1 <1 <1 2 2 2 2

E. faecalis Aminopenicillins I+R . 1 2 <1 <1 <1 <1 2HL Aminoglycosides R . 23 13 39 38 27 25 22Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 66 80 79 69 78 80 87HL Aminoglycosides R . <1 <1 4 12 1 16 19Glycopeptides R . <1 1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . 3 1 <1Fluoroquinolones R . . . . . 3 4 <13rd gen. Cephalosporins R . . . . . 2 <1 1



FinlandGeneral Information about EARSS participating laboratories and hospitals












2000 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 1632007 16 522 16 814 16 1949 16 400 15 273 14 183


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 1 2 2 <1 <1 2 1


S. aureus Oxacillin/Methicillin R 1 <1 <1 1 3 3 3 2E. coli Aminopenicillins R . 33 30 33 33 35 36 34

Aminoglycosides R . <1 <1 1 2 2 2 3Fluoroquinolones R . 5 6 5 7 7 8 83rd gen. Cephalosporins R . <1 <1 <1 2 2 2 2

E. faecalis Aminopenicillins I+R . 1 2 <1 <1 <1 <1 2HL Aminoglycosides R . 23 13 39 38 27 25 22Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 66 80 79 69 78 80 87HL Aminoglycosides R . <1 <1 4 12 1 16 19Glycopeptides R . <1 1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . 3 1 <1Fluoroquinolones R . . . . . 3 4 <13rd gen. Cephalosporins R . . . . . 2 <1 1



FinlandGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=1705

E. colin=3824

E. faecalisn=457

E. faeciumn=286

K. pneumo.n=500

P. aeruginosan=338


Blood 97 13 100 2 100 8 100 0 100 1 100 1 98 8CSF 3 9 0 . 0 . 0 . 0 . 0 . 2 13


Age (years)0-4 17 16 4 2 2 1 5 0 1 0 2 25 0 .5-19 3 7 4 1 1 11 2 0 2 0 1 0 2 020-64 46 12 45 2 31 8 28 0 36 0 29 1 28 1265 and over 34 12 48 3 66 8 65 0 60 1 68 1 70 7Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .








0 25 50 75 100

0/36FI008X

0/30FI009X

0/28FI00AA

0/82FI00CX

0/41FI00LX

0/60FI010X

0/36FI014A

0/26FI014X

1/202FI00EX

1/69FI003A

1/59FI012X

1/58FI011A

1/42FI017X

4/136FI00HX

24/621FI002X

5/116FI005X

3/50FI015X

1/13FI001X


0 25 50 75 100

0/11FI009

0/20FI00L

1/22FI014

1/16FI001

4/59FI005

3/43FI008

3/39FI015

2/21FI017

14/142FI00H

4/36FI012

46/326FI002

15/105FI00E

9/57FI011

7/43FI00C

8/49FI003

4/13FI00A

8/13FI010


Table 1.Reference data of 2007, based on laboratories/hospitals providing denominator data*

TotalLabs providing denom.data/reporting data to EARSS 25/57Hosps providing denom.data/reporting data to EARSS 25/57Number of blood culture sets 465,630

483,92 sdeb latipsoh fo rebmuN990,050,8 syad-tneitaP

%87 )%( etar ycnapucco egarevA8 )syad( yats fo htgnel naideMannoitalupop tnemhctac detamitsEanderevoc noitalupop latot %

Type of participating hospitals%88 yraitreT/lanoigeR %21 yradnoceS/laicnivorP %0 yramirP/tcirtsiD








2000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 21 1714 0 0 0 0 0 0 0 02002 0 0 21 1663 21 2495 21 467 0 0 0 02003 0 0 21 1708 21 2267 21 483 0 0 0 02004 0 0 50 3347 50 5678 47 882 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 10062007 168 663 57 4250 57 8115 56 1552 56 1194 56 1314


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . . 5 4 4

Penicillin I+R . . . . . 36 32 34Macrolides I+R . . . . . 41 36 37

S. aureus Oxacillin/Methicillin R . 33 33 29 29 27 27 26E. coli Aminopenicillins R . . 52 50 47 50 53 54

Aminoglycosides R . . 4 5 4 5 6 6Fluoroquinolones R . . 8 9 8 11 14 153rd gen. Cephalosporins R . . <1 <1 <1 1 2 2

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

E. faecium Aminopenicillins I+R . . 34 30 56 64 69 67HL Aminoglycosides R . . 10 23 21 24 30 30Glycopeptides R . . 2 <1 5 2 3 1



Figure 1. Geographic distribution of laboratories in 2007* Denominator data from one surveillance network, reporting all pathogens except S. pneumoniae )snegohtap rehto lla no gnitroper :thgir ,eainomuenp .S no gnitroper :tfel( )snegohtap rehto lla no gnitroper :thgir ,eainomuenp .S no gnitroper :tfel(

FranceGeneral Information about EARSS participating laboratories and hospitals


*

* First half of 2007


Table 1.Reference data of 2007, based on laboratories/hospitals providing denominator data*









2000 0 0 0 0 0 0 0 0 0 0 0 02001 0 0 21 1714 0 0 0 0 0 0 0 02002 0 0 21 1663 21 2495 21 467 0 0 0 02003 0 0 21 1708 21 2267 21 483 0 0 0 02004 0 0 50 3347 50 5678 47 882 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 10062007 168 663 57 4250 57 8115 56 1552 56 1194 56 1314


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . . 5 4 4

Penicillin I+R . . . . . 36 32 34Macrolides I+R . . . . . 41 36 37

S. aureus Oxacillin/Methicillin R . 33 33 29 29 27 27 26E. coli Aminopenicillins R . . 52 50 47 50 53 54

Aminoglycosides R . . 4 5 4 5 6 6Fluoroquinolones R . . 8 9 8 11 14 153rd gen. Cephalosporins R . . <1 <1 <1 1 2 2

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

E. faecium Aminopenicillins I+R . . 34 30 56 64 69 67HL Aminoglycosides R . . 10 23 21 24 30 30Glycopeptides R . . 2 <1 5 2 3 1



Figure 1. Geographic distribution of laboratories in 2007* Denominator data from one surveillance network, reporting all pathogens except S. pneumoniae (left: reporting on S. pneumoniae, right: reporting on all other pathogens)(left: reporting on S. pneumoniae, right: reporting on all other pathogens)

FranceGeneral Information about EARSS participating laboratories and hospitals


*

* First half of 2007



S. aureusn=8068

E. colin=14611

E. faecalisn=2143

E. faeciumn=543

K. pneumo.n=2124

P. aeruginosan=2306


Blood 67 33 100 26 100 14 100 0 100 2 100 8 100 13CSF 33 33 0 . 0 . 0 . 0 . 0 . 0 .



Hospital dep.ICU 0 . 16 26 9 17 24 0 21 1 15 18 30 21Internal Med. 100 33 35 28 28 15 27 0 27 2 31 6 24 11Surgery 0 . 15 26 12 15 17 0 18 3 17 10 12 12Other 0 . 33 25 50 13 31 0 33 2 37 5 33 9Unknown 0 . 1 28 1 16 1 0 1 0 1 7 1 11







0 25 50 75 100

3/24FR202A4/29FR084A4/29FR095A13/87FR164A15/93FR135A19/117FR362A38/227FR226A45/264FR248A

5/27FR145A18/94FR052A10/51FR120A49/246FR040A24/120FR134A20/99FR194A11/54FR401A10/47FR434A3/14FR208A61/283FR010A25/114FR213A43/195FR121A38/169FR165A11/47FR400A21/88FR126A66/272FR006A79/320FR238A36/145FR214A41/163FR260A28/110FR224A21/81FR037A80/308FR076A14/52FR046A79/292FR109A29/107FR211A87/318FR246A22/80FR276A51/185FR250A21/75FR237A177/621FR263A18/63FR008A79/273FR138A32/110FR105A44/149FR259A

21/68FR403A59/189FR064A103/329FR094A35/110FR009A121/378FR479A

44/132FR130A45/134FR067A

13/37FR193A19/54FR179A

21/54FR098A84/210FR249A

17/40FR015A11/25FR072A28/63FR055A


0 25 50 75 100

0/5FR0770/6FR1250/5FR1720/7FR2260/5FR400

1/14FR0011/11FR4731/10FR505

1/8FR0521/7FR253

4/25FR2141/6FR277

3/16FR0712/9FR0042/9FR2793/13FR4795/21FR0102/8FR0363/12FR2463/12FR270

9/34FR1944/15FR1373/11FR0382/7FR1004/14FR1312/7FR1672/7FR470

3/10FR0947/23FR1276/19FR26921/65FR1302/6FR0433/9FR0642/6FR0672/6FR1096/18FR2132/6FR2185/15FR476

9/26FR26512/33FR1086/16FR2633/8FR46711/29FR164

2/5FR2676/15FR999

5/12FR0063/7FR256

4/9FR1585/11FR232

7/14FR2733/6FR510

7/13FR0763/5FR0083/5FR0683/5FR1283/5FR2286/10FR2603/5FR442

5/7FR0407/9FR250

5/6FR142











2000 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 16 144 22 1106 22 1217 22 607 0 0 1 12005 15 119 17 826 17 961 17 569 12 105 12 1172006 14 84 18 796 18 851 16 529 14 148 12 1622007 10 72 12 853 12 977 12 648 10 173 11 198


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 1 <1 <1 <1 <1 1 <1


S. aureus Oxacillin/Methicillin R 12 16 18 18 20 21 20 16E. coli Aminopenicillins R 47 46 49 47 55 54 60 55

Aminoglycosides R 7 5 5 5 4 6 10 6Fluoroquinolones R 8 11 15 14 24 23 29 303rd gen. Cephalosporins R <1 <1 <1 <1 2 2 4 8

E. faecalis Aminopenicillins I+R <1 8 10 7 7 3 3 6HL Aminoglycosides R . 31 42 47 42 34 29 67Glycopeptides R <1 <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R 50 79 80 78 93 96 94 95HL Aminoglycosides R . 43 68 47 61 52 38 73Glycopeptides R <1 1 4 3 11 10 8 15


P. aeruginosa Piperacillin R . . . . <1 18 17 17Ceftazidime R . . . . <1 11 12 17Carbapenems R . . . . <1 25 17 22Aminoglycosides R . . . . <1 12 18 9Fluoroquinolones R . . . . <1 23 28 28


GermanyGeneral Information about EARSS participating laboratories and hospitals












2000 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 16 144 22 1106 22 1217 22 607 0 0 1 12005 15 119 17 826 17 961 17 569 12 105 12 1172006 14 84 18 796 18 851 16 529 14 148 12 1622007 10 72 12 853 12 977 12 648 10 173 11 198


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 1 <1 <1 <1 <1 1 <1



Aminoglycosides R 7 5 5 5 4 6 10 6Fluoroquinolones R 8 11 15 14 24 23 29 303rd gen. Cephalosporins R <1 <1 <1 <1 2 2 4 8

E. faecalis Aminopenicillins I+R <1 8 10 7 7 3 3 6HL Aminoglycosides R . 31 42 47 42 34 29 67Glycopeptides R <1 <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R 50 79 80 78 93 96 94 95HL Aminoglycosides R . 43 68 47 61 52 38 73Glycopeptides R <1 1 4 3 11 10 8 15


P. aeruginosa Piperacillin R . . . . <1 18 17 17Ceftazidime R . . . . <1 11 12 17Carbapenems R . . . . <1 25 17 22Aminoglycosides R . . . . <1 12 18 9Fluoroquinolones R . . . . <1 23 28 28


GermanyGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=1649

E. colin=1819

E. faecalisn=657

E. faeciumn=516

K. pneumo.n=320

P. aeruginosan=359


Blood 90 4 100 18 100 30 100 0 100 12 100 10 99 20CSF 10 0 0 . 0 . 0 . 0 . 0 . 1 0

GenderMale 50 4 63 16 50 32 65 1 59 12 56 9 60 21Female 50 4 36 21 50 27 35 0 41 12 44 10 39 17Unknown 0 . 1 20 0 . 0 . 0 . 0 . 1 67


Hospital dep.ICU 21 6 18 23 13 31 20 2 28 7 18 11 19 25Internal Med. 37 3 36 16 43 23 27 0 20 18 32 5 26 15Surgery 1 0 16 19 11 37 19 0 20 6 13 2 15 17Other 42 3 30 17 32 36 34 0 31 16 37 16 40 21Unknown 0 . 1 20 1 24 0 . 1 0 1 0 1 0







0 25 50 75 100

0/9DE0202A

0/16DE030101

0/5DE030107

0/7DE40202

1/18DE1401A

6/101DE401A

9/111DE0109A

1/12DE10701

17/186DE1602A

1/9DE40204

9/70DE10201

1/7DE401C

23/148DE1042A

5/31DE030110

27/166DE0906A

8/46DE1302A

12/67DE1301X

4/19DE030109

21/96DE120301

2/9DE030102

20/87DE1403A

3/11DE0105A

5/18DE40201

57/186DE0805A

28/91DE0701X

14/45DE100B

5/16DE030103

10/31DE030108

6/15DE401D


0 25 50 75 100

0/10DE0107

0/10DE0301

0/6DE0401

0/6DE1203

0/22DE1301

0/6DE1302

0/8DE1402

0/14DE1602

1/21DE0805

1/20DE0102

3/18DE0109

1/5DE1403











2000 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 8182007 0 0 41 806 43 1234 39 999 38 972 37 802


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . . . . .

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


Aminoglycosides R 4 4 7 6 6 7 7 9Fluoroquinolones R 4 9 13 12 12 12 14 193rd gen. Cephalosporins R 4 5 6 6 6 7 6 8

E. faecalis Aminopenicillins I+R 8 8 4 4 4 3 5 4HL Aminoglycosides R 52 57 60 52 59 54 58 65Glycopeptides R <1 7 13 7 4 4 5 7

E. faecium Aminopenicillins I+R 83 86 75 89 84 85 88 91HL Aminoglycosides R 25 45 52 40 52 34 35 44Glycopeptides R <1 15 19 18 20 37 42 37




GreeceGeneral Information about EARSS participating laboratories and hospitals












2000 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 8182007 0 0 41 806 43 1234 39 999 38 972 37 802


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . . . . .

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


Aminoglycosides R 4 4 7 6 6 7 7 9Fluoroquinolones R 4 9 13 12 12 12 14 193rd gen. Cephalosporins R 4 5 6 6 6 7 6 8

E. faecalis Aminopenicillins I+R 8 8 4 4 4 3 5 4HL Aminoglycosides R 52 57 60 52 59 54 58 65Glycopeptides R <1 7 13 7 4 4 5 7

E. faecium Aminopenicillins I+R 83 86 75 89 84 85 88 91HL Aminoglycosides R 25 45 52 40 52 34 35 44Glycopeptides R <1 15 19 18 20 37 42 37




GreeceGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=1632

E. colin=2477

E. faecalisn=1201

E. faeciumn=739

K. pneumo.n=1813

P. aeruginosan=1613


Blood . . 100 45 99 17 100 6 100 40 98 60 97 46CSF . . 0 . 1 15 0 . 0 . 2 77 3 76

GenderMale . . 12 49 9 17 9 7 11 44 9 57 9 38Female . . 7 44 10 15 5 8 9 51 7 58 4 38Unknown . . 81 45 81 17 85 6 80 38 84 60 87 49

Age (years)0-4 . . 3 41 4 17 5 12 6 49 4 66 3 555-19 . . 0 . 0 . 0 . 0 . 0 . 0 .20-64 . . 2 39 2 19 2 15 3 67 2 58 2 4565 and over . . 3 66 2 16 2 17 3 36 2 71 1 17Unknown . . 92 45 92 17 91 5 89 38 92 59 93 47

Hospital dep.ICU . . 13 69 3 26 33 8 31 39 43 84 44 57Internal Med. . . 67 39 78 16 47 4 47 42 37 35 38 38Surgery . . 11 64 11 21 15 4 16 34 15 58 15 46Other . . 3 40 3 1 1 0 1 44 2 38 1 8Unknown . . 5 35 5 19 4 18 5 35 3 40 2 36






0 25 50 75 100

2/15GR048X

2/11GR018X

3/14GR052X

9/38GR027X

3/12GR044X

25/99GR059X

3/11GR032X

13/45GR031X

5/17GR004X

11/34GR037X

2/6GR038X

5/15GR056X

14/38GR070X

17/46GR007X

10/27GR050X

10/26GR042X

12/30GR010X

2/5GR057X

4/10GR060X

2/5GR062X

18/44GR066X

10/24GR055X

6/14GR005X

13/30GR013X

11/25GR049X

23/52GR028X

45/100GR033X

12/25GR001X

68/138GR047X

3/6GR026X

89/178GR040X

4/8GR067X

22/43GR022X

47/88GR030X

46/84GR035X

8/14GR009X

23/40GR024X

21/35GR014X

6/10GR051X

60/93GR039X

11/17GR012X

11/16GR043X

28/40GR068X


0 25 50 75 100











2000 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 24 302 25 5462007 22 146 26 1199 25 1179 26 400 23 322 24 518


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . 8 3 3 <1 4 1 5



Aminoglycosides R . 4 6 8 10 9 12 11Fluoroquinolones R . 5 10 15 19 22 27 263rd gen. Cephalosporins R . <1 2 <1 3 4 5 5

E. faecalis Aminopenicillins I+R . 5 2 <1 2 1 3 2HL Aminoglycosides R . . 100 87 57 43 47 48Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 100 89 91 95 91 88 88HL Aminoglycosides R . . 100 96 80 64 67 53Glycopeptides R . <1 <1 <1 <1 <1 <1 <1




HungaryGeneral Information about EARSS participating laboratories and hospitals












2000 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 24 302 25 5462007 22 146 26 1199 25 1179 26 400 23 322 24 518


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . 8 3 3 <1 4 1 5




E. faecalis Aminopenicillins I+R . 5 2 <1 2 1 3 2HL Aminoglycosides R . . 100 87 57 43 47 48Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 100 89 91 95 91 88 88HL Aminoglycosides R . . 100 96 80 64 67 53Glycopeptides R . <1 <1 <1 <1 <1 <1 <1




HungaryGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=2326

E. colin=2238

E. faecalisn=717

E. faeciumn=104

K. pneumo.n=618

P. aeruginosan=1040


Blood 66 17 100 24 100 26 100 0 100 0 99 23 97 18CSF 34 26 0 . 0 . 0 . 0 . 1 0 3 10










0 25 50 75 100

0/8HU006B0/11HU006Y0/6HU007C0/5HU016D0/5HU024B

1/13HU022O2/24HU007B4/48HU024A2/22HU002G5/55HU022P21/219HU028A

3/27HU022I13/114HU019A4/35HU016A6/50HU027A2/16HU012G

1/7HU025H9/60HU009B

3/18HU004G9/54HU023B2/12HU023Y13/75HU023A16/88HU022A

1/5HU014A3/15HU023C4/20HU033O6/29HU001U24/113HU032A6/27HU006A2/9HU019D6/27HU020L2/9HU023F8/36HU034A17/73HU025A

2/8HU005Y3/12HU006W9/35HU025G

22/80HU023I33/115HU029V

6/20HU030A18/58HU033A

27/81HU019G4/12HU019H24/71HU026A

36/102HU009A22/57HU005A

2/5HU022E23/54HU020A

18/41HU023L4/9HU031A

16/34HU010G40/82HU023D4/8HU006C

7/11HU020C6/9HU002X

31/42HU022S


0 25 50 75 100

0/5HU012

0/6HU024

0/10HU026

0/15HU027

0/13HU028

1/22HU009

1/16HU006

5/44HU023

1/7HU034

2/10HU020

2/8HU033

15/53HU022

2/6HU025

10/26HU019

4/10HU032

8/18HU029

5/8HU005











2000 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 1 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 92007 2 42 2 64 2 105 1 29 2 27 1 11


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 2 <1 2 <1 <1 2


S. aureus Oxacillin/Methicillin R 3 <1 <1 <1 <1 <1 <1 <1E. coli Aminopenicillins R . 42 19 42 43 38 45 46

Aminoglycosides R . 4 1 2 <1 <1 7 6Fluoroquinolones R . 4 3 6 2 3 11 173rd gen. Cephalosporins R . <1 <1 1 <1 <1 <1 2

E. faecalis Aminopenicillins I+R . <1 <1 <1 <1 <1 7 <1HL Aminoglycosides R . 8 6 <1 5 <1 3 13Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

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

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

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


IcelandGeneral Information about EARSS participating laboratories and hospitals












2000 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 1 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 92007 2 42 2 64 2 105 1 29 2 27 1 11


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 2 <1 2 <1 <1 2


S. aureus Oxacillin/Methicillin R 3 <1 <1 <1 <1 <1 <1 <1E. coli Aminopenicillins R . 42 19 42 43 38 45 46

Aminoglycosides R . 4 1 2 <1 <1 7 6Fluoroquinolones R . 4 3 6 2 3 11 173rd gen. Cephalosporins R . <1 <1 1 <1 <1 <1 2

E. faecalis Aminopenicillins I+R . <1 <1 <1 <1 <1 7 <1HL Aminoglycosides R . 8 6 <1 5 <1 3 13Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

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

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

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


IcelandGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=121

E. colin=211

E. faecalisn=46

E. faeciumn=21

K. pneumo.n=40

P. aeruginosan=20


Blood 93 7 100 0 100 13 100 0 100 0 100 0 95 0CSF 7 0 0 . 0 . 0 . 0 . 0 . 5 0


Age (years)0-4 16 13 7 0 2 0 2 0 0 . 0 . 5 05-19 2 0 12 0 0 . 0 . 0 . 0 . 0 .20-64 44 7 40 0 33 11 33 0 33 0 30 0 45 065 and over 38 3 42 0 64 15 65 0 67 0 70 0 50 0Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 3 0 3 0 1 0 13 0 10 0 3 0 20 0Internal Med. 13 0 22 0 12 12 20 0 19 0 25 0 20 0Surgery 1 0 6 0 4 25 17 0 14 0 13 0 0 .Other 83 8 68 0 83 13 48 0 52 0 58 0 60 0Unknown 0 . 1 0 0 . 2 0 5 0 3 0 0 .







0 25 50 75 100

0/100IS001A

0/11IS003A


0 25 50 75 100

0/11IS003

6/83IS001











2000 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 1282007 33 435 41 1332 42 1750 37 598 31 237 29 172




S. aureus Oxacillin/Methicillin R 39 42 42 42 41 42 42 38E. coli Aminopenicillins R . . 62 61 65 67 69 65

Aminoglycosides R . . 3 4 5 7 7 10Fluoroquinolones R . . 5 10 12 17 21 213rd gen. Cephalosporins R . . 2 2 2 4 4 5

E. faecalis Aminopenicillins I+R . . 8 5 <1 4 5 2HL Aminoglycosides R . . 39 32 42 42 43 38Glycopeptides R . . 2 <1 1 3 3 3

E. faecium Aminopenicillins I+R . . 89 91 96 93 94 93HL Aminoglycosides R . . 17 54 56 52 44 36Glycopeptides R . . 11 19 22 31 36 33




IrelandGeneral Information about EARSS participating laboratories and hospitals












2000 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 1282007 33 435 41 1332 42 1750 37 598 31 237 29 172






E. faecalis Aminopenicillins I+R . . 8 5 <1 4 5 2HL Aminoglycosides R . . 39 32 42 42 43 38Glycopeptides R . . 2 <1 1 3 3 3

E. faecium Aminopenicillins I+R . . 89 91 96 93 94 93HL Aminoglycosides R . . 17 54 56 52 44 36Glycopeptides R . . 11 19 22 31 36 33




IrelandGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=2679

E. colin=3362

E. faecalisn=565

E. faeciumn=581

K. pneumo.n=435

P. aeruginosan=279


Blood 98 16 100 40 100 21 100 3 100 34 100 8 99 9CSF 2 37 0 . 0 . 0 . 0 . 0 . 1 0

GenderMale 56 16 63 39 44 25 58 3 60 36 61 7 59 8Female 44 18 36 43 56 18 41 3 40 31 38 9 40 11Unknown 0 . 1 26 1 18 0 . 0 . 1 33 1 0









0 25 50 75 100

0/13IE-AQZ

0/21IE-BCX

2/22IE-BBX

6/50IE-BPX

2/15IE-AFY

1/7IE-AEX

2/13IE-AKX

3/16IE-BSY

1/5IE-AHX

2/9IE-BAX

33/123IE-BXX

5/18IE-APX

6/20IE-BQZ

12/36IE-BOX

63/176IE-BIX

26/70IE-AZX

16/42IE-BTY

75/195IE-ALY

5/13IE-BJX

110/284IE-ARX

9/23IE-BDX

58/146IE-ABX

18/43IE-BGX

72/169IE-BWX

10/23IE-BLX

28/63IE-ACX

113/254IE-BEX

26/58IE-BFX

88/195IE-BNX

35/75IE-BHY

17/36IE-AUX

42/81IE-BYX

121/230IE-AYX

31/58IE-BKX

26/48IE-AJX

5/8IE-ASX

6/9IE-ADX


0 25 50 75 100

0/9IE-AP

0/13IE-BO

1/24IE-AQ

1/22IE-BG

1/16IE-AU

5/55IE-BW

3/27IE-AZ

4/35IE-BF

2/17IE-AJ

3/25IE-BY

2/16IE-BT

8/62IE-AY

5/36IE-AB

4/28IE-BP

8/47IE-BN

14/80IE-AL

10/57IE-AR

9/43IE-BE

2/9IE-AD

5/21IE-AC

11/45IE-BI

3/12IE-BD

14/56IE-BX

6/23IE-BH

4/13IE-BS

9/18IE-BK

3/5IE-AH











2000 0 0 0 0 0 0 0 0 0 0 1 12001 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 5 227 5 513 5 955 5 289 5 434 5 3502007 5 245 5 451 5 1035 5 274 5 451 5 313


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . 5 7 11 11 8 6 7




E. faecalis Aminopenicillins I+R . <1 4 2 3 1 1 1HL Aminoglycosides R . 24 44 43 46 43 43 40Glycopeptides R . <1 2 <1 1 <1 <1 <1



P. aeruginosa Piperacillin R <1 . . . . 13 20 15Ceftazidime R <1 . . . . 17 19 12Carbapenems R <1 . . . . 15 17 14Aminoglycosides R <1 . . . . 23 28 20Fluoroquinolones R <1 . . . . 25 32 26


IsraelGeneral Information about EARSS participating laboratories and hospitals












2000 0 0 0 0 0 0 0 0 0 0 1 12001 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 5 227 5 513 5 955 5 289 5 434 5 3502007 5 245 5 451 5 1035 5 274 5 451 5 313


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . 5 7 11 11 8 6 7




E. faecalis Aminopenicillins I+R . <1 4 2 3 1 1 1HL Aminoglycosides R . 24 44 43 46 43 43 40Glycopeptides R . <1 2 <1 1 <1 <1 <1



P. aeruginosa Piperacillin R <1 . . . . 13 20 15Ceftazidime R <1 . . . . 17 19 12Carbapenems R <1 . . . . 15 17 14Aminoglycosides R <1 . . . . 23 28 20Fluoroquinolones R <1 . . . . 25 32 26


IsraelGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=964

E. colin=1987

E. faecalisn=443

E. faeciumn=118

K. pneumo.n=885

P. aeruginosan=663


Blood 99 32 100 37 100 29 100 0 100 26 100 44 100 16CSF 1 100 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 58 31 63 37 42 36 61 0 57 15 58 47 57 18Female 41 34 37 35 58 24 38 1 43 41 41 39 43 14Unknown 1 0 0 . 0 . 1 0 0 . 1 50 0 .

Age (years)0-4 31 50 6 13 5 17 12 0 8 0 13 39 7 105-19 11 15 5 16 3 29 1 0 4 20 2 50 5 1820-64 26 21 33 26 28 28 22 0 32 29 30 41 39 1965 and over 30 29 54 47 63 30 64 1 54 30 54 46 47 14Unknown 1 29 1 56 1 28 1 0 1 0 1 82 2 30

Hospital dep.ICU 4 24 8 53 4 42 13 0 20 29 12 63 17 25Internal Med. 46 26 52 39 57 27 48 1 38 31 40 47 34 12Surgery 2 22 10 38 11 34 9 0 8 33 14 36 11 14Other 48 39 29 27 28 29 30 0 34 18 34 37 39 16Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

14/79IL001A

16/59IL005A

75/259IL003A

211/486IL002A

37/81IL004A


0 25 50 75 100

44/172IL002

6/23IL004

13/48IL001

54/163IL003

34/66IL005











2000 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 1832007 34 291 37 1059 14 1052 36 656 37 391 10 185


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 4 2 5 5 5 <1 4




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



P. aeruginosa Piperacillin R . . . . . . 23 20Ceftazidime R . . . . . . 20 25Carbapenems R . . . . . . 21 27Aminoglycosides R . . . . . . 30 27Fluoroquinolones R . . . . . . 36 35


ItalyGeneral Information about EARSS participating laboratories and hospitals












2000 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 1832007 34 291 37 1059 14 1052 36 656 37 391 10 185


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 4 2 5 5 5 <1 4




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





ItalyGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=2163

E. colin=1829

E. faecalisn=856

E. faeciumn=429

K. pneumo.n=687

P. aeruginosan=367


Blood 86 11 100 36 100 29 100 3 100 14 100 34 99 24CSF 14 13 0 . 0 . 0 . 0 . 0 . 1 20


Age (years)0-4 10 17 2 13 1 11 3 0 2 0 5 69 2 335-19 3 0 1 39 0 . 1 0 0 . 1 50 2 020-64 31 12 28 28 18 31 26 3 24 18 26 40 29 3965 and over 41 8 51 42 36 27 53 3 50 13 47 25 44 23Unknown 15 16 18 36 45 31 17 1 23 11 21 38 23 8





no of hospitals : 40Minimum : 16.01st quartile : 25.5Median : 34.53rd quartile : 45.1Maximum : 100



0 25 50 75 100

4/25IT077X

10/62IT010X

7/38IT015X

7/38IT065X

1/5IT012X

9/45IT024X

3/15IT044X

7/31IT064X

8/33IT001X

6/24IT071X

6/23IT050X

9/34IT072X

38/143IT037X

7/25IT060X

32/111IT019X

34/116IT061X

17/57IT016X

6/20IT028X

24/74IT031X

24/70IT070X

50/144IT009X

18/51IT045X

48/132IT008X

20/55IT069X

11/29IT035X

13/34IT067X

5/13IT036X

34/83IT034X

17/41IT004X

36/80IT075X

42/93IT047X

13/28IT049X

14/29IT052X

16/33IT059X

23/47IT074X

96/176IT005X

23/40IT076X

29/50IT006X

8/9IT042X

7/7IT039X


0 25 50 75 100

0/10IT005

0/12IT006

0/13IT028

0/12IT031

0/6IT045

0/21IT059

0/22IT067

0/6IT070

0/6IT074

0/5IT075

1/25IT072

2/38IT008

4/56IT037

1/14IT044

1/14IT047

1/14IT060

4/41IT019

1/10IT065

5/43IT009

1/8IT001

3/23IT030

7/39IT061

4/21IT024

2/10IT021

4/19IT034

3/14IT064

7/16IT003

5/9IT015











2000 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 162007 6 31 12 168 9 76 8 57 7 27 6 16


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . <1 <1 <1 <1

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

S. aureus Oxacillin/Methicillin R . . . . 25 20 18 8E. coli Aminopenicillins R . . . . . . 44 43

Aminoglycosides R . . . . . . 5 14Fluoroquinolones R . . . . . . 10 173rd gen. Cephalosporins R . . . . . . 6 14

E. faecalis Aminopenicillins I+R . . . . . . 9 30HL Aminoglycosides R . . . . . . 50 .Glycopeptides R . . . . . . <1 <1

E. faecium Aminopenicillins I+R . . . . . . 94 77HL Aminoglycosides R . . . . . . 73 <1Glycopeptides R . . . . . . <1 <1




LatviaGeneral Information about EARSS participating laboratories and hospitals












2000 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 162007 6 31 12 168 9 76 8 57 7 27 6 16


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . <1 <1 <1 <1

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

S. aureus Oxacillin/Methicillin R . . . . 25 20 18 8E. coli Aminopenicillins R . . . . . . 44 43


E. faecalis Aminopenicillins I+R . . . . . . 9 30HL Aminoglycosides R . . . . . . 50 .Glycopeptides R . . . . . . <1 <1

E. faecium Aminopenicillins I+R . . . . . . 94 77HL Aminoglycosides R . . . . . . 73 <1Glycopeptides R . . . . . . <1 <1




LatviaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=339

E. colin=136

E. faecalisn=64

E. faeciumn=49

K. pneumo.n=55

P. aeruginosan=32


Blood 88 0 100 13 100 14 100 0 100 0 100 40 100 9CSF 12 0 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 60 0 56 15 33 13 63 0 53 0 67 38 63 5Female 40 0 41 12 67 14 33 0 41 0 31 41 38 17Unknown 0 . 3 0 0 . 5 0 6 0 2 100 0 .

Age (years)0-4 3 0 10 0 3 0 13 0 16 0 20 55 28 05-19 1 0 5 0 1 0 5 0 0 . 0 . 9 3320-64 76 0 57 16 56 14 52 0 47 0 51 32 31 1065 and over 18 0 25 16 38 15 28 0 35 0 25 43 31 10Unknown 1 0 3 11 1 0 3 0 2 0 4 50 0 .

Hospital dep.ICU 47 0 21 13 19 19 28 0 41 0 38 52 34 9Internal Med. 9 0 26 10 21 10 25 0 12 0 11 17 16 0Surgery 0 . 9 23 4 20 5 0 10 0 4 50 3 0Other 44 0 44 14 56 13 41 0 35 0 45 36 47 13Unknown 0 . 1 0 0 . 2 0 2 0 2 0 0 .







0 25 50 75 100

0/29LV002A

0/7LV005A

0/9LV006A

0/8LV008A

4/52LV003A

8/89LV001A

8/69LV004A

4/26LV012A

1/6LV005B

12/26LV007A

8/10LV013A


0 25 50 75 100

0/24LV003

0/28LV004

0/6LV012











2000 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 142007 10 67 12 240 13 235 10 56 10 41 7 21


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . . . <1 1

Penicillin I+R . . . . . . 16 4Macrolides I+R . . . . . . <1 9

S. aureus Oxacillin/Methicillin R . . . . . . 12 9E. coli Aminopenicillins R . . . . . . 55 50


E. faecalis Aminopenicillins I+R . . . . . . 5 3HL Aminoglycosides R . . . . . . 50 41Glycopeptides R . . . . . . <1 <1

E. faecium Aminopenicillins I+R . . . . . . 75 100HL Aminoglycosides R . . . . . . 75 81Glycopeptides R . . . . . . <1 <1


P. aeruginosa Piperacillin R . . . . . . 21 5Ceftazidime R . . . . . . 31 <1Carbapenems R . . . . . . 21 30Aminoglycosides R . . . . . . 29 33Fluoroquinolones R . . . . . . 46 38


LithuaniaGeneral Information about EARSS participating laboratories and hospitals












2000 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 142007 10 67 12 240 13 235 10 56 10 41 7 21


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . . . . <1 1

Penicillin I+R . . . . . . 16 4Macrolides I+R . . . . . . <1 9

S. aureus Oxacillin/Methicillin R . . . . . . 12 9E. coli Aminopenicillins R . . . . . . 55 50


E. faecalis Aminopenicillins I+R . . . . . . 5 3HL Aminoglycosides R . . . . . . 50 41Glycopeptides R . . . . . . <1 <1

E. faecium Aminopenicillins I+R . . . . . . 75 100HL Aminoglycosides R . . . . . . 75 81Glycopeptides R . . . . . . <1 <1


P. aeruginosa Piperacillin R . . . . . . 21 5Ceftazidime R . . . . . . 31 <1Carbapenems R . . . . . . 21 30Aminoglycosides R . . . . . . 29 33Fluoroquinolones R . . . . . . 46 38


LithuaniaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=407

E. colin=403

E. faecalisn=60

E. faeciumn=26

K. pneumo.n=76

P. aeruginosan=34


Blood 78 5 100 10 99 11 100 0 100 0 100 25 97 27CSF 22 18 0 . 1 0 0 . 0 . 0 . 3 0

GenderMale 76 11 60 12 38 14 65 0 58 0 49 32 65 32Female 24 0 39 8 61 9 33 0 42 0 50 18 35 17Unknown 0 . 1 0 0 . 2 0 0 . 1 0 0 .

Age (years)0-4 10 10 3 0 3 0 18 0 19 0 3 0 15 05-19 6 0 9 0 3 15 3 0 4 0 8 17 6 5020-64 61 10 54 11 38 10 33 0 38 0 43 18 53 3365 and over 22 5 32 13 55 12 43 0 38 0 46 34 26 22Unknown 1 0 2 0 1 0 2 0 0 . 0 . 0 .

Hospital dep.ICU 47 13 24 12 20 10 27 0 35 0 32 29 35 17Internal Med. 30 3 33 11 34 4 35 0 35 0 26 5 15 0Surgery 1 0 12 17 6 13 10 0 0 . 13 40 9 33Other 21 5 31 5 38 18 28 0 31 0 28 33 41 43Unknown 0 . 0 . 2 0 0 . 0 . 1 0 0 .







0 25 50 75 100

0/7LT006A

0/10LT008A

0/9LT011A

0/7LT013B

5/86LT001A

2/24LT012A

2/24LT013A

5/58LT007A

5/47LT005A

1/9LT008C

7/56LT004A

1/6LT010A

3/17LT002A

6/26LT003A


0 25 50 75 100

0/9LT001

0/6LT002

0/7LT003

0/6LT011

1/18LT013

1/10LT004

1/9LT008

4/28LT007

1/5LT005



TotalLabs providing denom.data/reporting data to EARSS 4/6Hosps providing denom.data/reporting data to EARSS 0/6Number of blood culture sets 13,256Number of hospital beds naPatient-days naAverage occupancy rate (%) naMedian length of stay (days) naEstimated catchment population 430,965% total population covered 86%Type of participating hospitals Regional/Tertiary na Provincial/Secondary na District/Primary na








2000 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 232007 4 31 6 105 6 263 5 36 6 48 5 34


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 7 7 <1 6 7 5 3



Aminoglycosides R . 5 4 4 4 7 6 5Fluoroquinolones R . 4 9 12 18 19 20 223rd gen. Cephalosporins R . <1 <1 <1 <1 3 2 4

E. faecalis Aminopenicillins I+R . <1 <1 5 <1 <1 <1 <1HL Aminoglycosides R . 13 17 32 18 24 32 44Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . <1 60 100 50 36 75 73HL Aminoglycosides R . . 14 <1 <1 23 30 11Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . <1 2Fluoroquinolones R . . . . . . 6 83rd gen. Cephalosporins R . . . . . . 10 2

P. aeruginosa Piperacillin R . . . . . <1 9 16Ceftazidime R . . . . . <1 10 12Carbapenems R . . . . . <1 7 25Aminoglycosides R . . . . . <1 4 24Fluoroquinolones R . . . . . <1 10 38


LuxembourgGeneral Information about EARSS participating laboratories and hospitals




TotalLabs providing denom.data/reporting data to EARSS 4/6Hosps providing denom.data/reporting data to EARSS 0/6Number of blood culture sets 13,256Number of hospital beds naPatient-days naAverage occupancy rate (%) naMedian length of stay (days) naEstimated catchment population 430,965% total population covered 86%Type of participating hospitals Regional/Tertiary na Provincial/Secondary na District/Primary na








2000 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 232007 4 31 6 105 6 263 5 36 6 48 5 34


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 7 7 <1 6 7 5 3



Aminoglycosides R . 5 4 4 4 7 6 5Fluoroquinolones R . 4 9 12 18 19 20 223rd gen. Cephalosporins R . <1 <1 <1 <1 3 2 4

E. faecalis Aminopenicillins I+R . <1 <1 5 <1 <1 <1 <1HL Aminoglycosides R . 13 17 32 18 24 32 44Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . <1 60 100 50 36 75 73HL Aminoglycosides R . . 14 <1 <1 23 30 11Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . . <1 2Fluoroquinolones R . . . . . . 6 83rd gen. Cephalosporins R . . . . . . 10 2

P. aeruginosa Piperacillin R . . . . . <1 9 16Ceftazidime R . . . . . <1 10 12Carbapenems R . . . . . <1 7 25Aminoglycosides R . . . . . <1 4 24Fluoroquinolones R . . . . . <1 10 38


LuxembourgGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=182

E. colin=430

E. faecalisn=45

E. faeciumn=23

K. pneumo.n=68

P. aeruginosan=22


Blood 89 6 100 20 100 21 100 0 100 0 100 4 100 14CSF 11 0 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 62 0 58 20 34 20 47 0 35 0 35 4 36 0Female 38 15 33 25 52 22 38 0 26 0 49 6 59 23Unknown 0 . 9 6 14 20 16 0 39 0 16 0 5 0

Age (years)0-4 8 0 3 0 2 13 0 . 0 . 1 0 5 05-19 9 0 4 63 0 . 0 . 0 . 0 . 0 .20-64 45 4 34 16 24 16 29 0 39 0 37 8 32 1465 and over 26 7 40 18 55 23 58 0 57 0 41 4 59 15Unknown 11 17 19 26 18 22 13 0 4 0 21 0 5 0

Hospital dep.ICU 23 8 16 24 5 22 27 0 13 0 16 0 23 40Internal Med. 13 14 5 10 12 21 9 0 13 0 7 20 23 20Surgery 8 0 5 0 5 19 0 . 4 0 3 0 0 .Other 30 0 21 18 23 20 16 0 22 0 16 0 36 0Unknown 26 7 52 23 55 21 49 0 48 0 57 5 18 0







0 25 50 75 100

0/20LU004A

1/17LU003S

5/30LU001E

3/17LU006A

2/9LU003A

9/34LU001A

6/20LU007Z

4/13LU007A

6/18LU004T


0 25 50 75 100

1/33LU001

1/10LU004

1/6LU003











2000 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 512007 1 13 1 105 1 117 1 37 1 28 1 36


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 <1 <1 8 3 <1

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



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

E. faecium Aminopenicillins I+R . 100 33 33 43 25 14 40HL Aminoglycosides R . <1 <1 50 <1 <1 . .Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . 17 6 <1Fluoroquinolones R . . . . . 11 6 113rd gen. Cephalosporins R . . . . . 6 6 7



MaltaGeneral Information about EARSS participating laboratories and hospitals












2000 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 512007 1 13 1 105 1 117 1 37 1 28 1 36


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 <1 <1 8 3 <1

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



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

E. faecium Aminopenicillins I+R . 100 33 33 43 25 14 40HL Aminoglycosides R . <1 <1 50 <1 <1 . .Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . 17 6 <1Fluoroquinolones R . . . . . 11 6 113rd gen. Cephalosporins R . . . . . 6 6 7



MaltaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=195

E. colin=211

E. faecalisn=76

E. faeciumn=14

K. pneumo.n=60

P. aeruginosan=86


Blood 95 5 100 59 100 34 100 0 100 0 100 7 100 16CSF 5 0 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 53 0 67 61 38 46 49 0 50 0 50 7 56 19Female 47 10 32 58 61 26 47 0 50 0 50 7 44 13Unknown 0 . 2 0 0 . 4 0 0 . 0 . 0 .

Age (years)0-4 21 0 6 27 1 0 16 0 0 . 12 29 2 05-19 5 0 3 60 2 25 7 0 0 . 3 0 5 2520-64 30 15 40 54 28 27 29 0 50 0 40 8 38 2465 and over 37 0 51 67 68 38 47 0 50 0 45 0 55 11Unknown 7 0 1 0 1 0 1 0 0 . 0 . 0 .

Hospital dep.ICU 23 10 19 71 10 36 64 0 64 0 30 17 59 18Internal Med. 47 5 48 54 48 36 18 0 7 0 43 0 16 21Surgery 5 0 20 62 24 35 7 0 21 0 13 0 16 14Other 23 0 5 44 6 23 3 0 0 . 10 0 3 0Unknown 2 0 8 63 11 25 8 0 7 0 3 50 5 0







0 25 50 75 100

109/186MT001A

5/8MT001E


0 25 50 75 100

2/43MT001











2000 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 3302007 21 939 21 1469 21 2806 21 832 19 497 19 338



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

S. aureus Oxacillin/Methicillin R <1 <1 <1 1 1 <1 1 1E. coli Aminopenicillins R 37 39 39 44 43 48 47 49

Aminoglycosides R 2 2 2 3 3 4 3 5Fluoroquinolones R 3 5 5 7 7 10 11 133rd gen. Cephalosporins R <1 <1 <1 1 1 2 3 4

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

E. faecium Aminopenicillins I+R 33 64 23 30 42 61 73 83HL Aminoglycosides R . 4 11 19 20 40 50 62Glycopeptides R <1 2 1 <1 <1 <1 <1 <1




NetherlandsGeneral Information about EARSS participating laboratories and hospitals












2000 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 3302007 21 939 21 1469 21 2806 21 832 19 497 19 338



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

S. aureus Oxacillin/Methicillin R <1 <1 <1 1 1 <1 1 1E. coli Aminopenicillins R 37 39 39 44 43 48 47 49

Aminoglycosides R 2 2 2 3 3 4 3 5Fluoroquinolones R 3 5 5 7 7 10 11 133rd gen. Cephalosporins R <1 <1 <1 1 1 2 3 4

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

E. faecium Aminopenicillins I+R 33 64 23 30 42 61 73 83HL Aminoglycosides R . 4 11 19 20 40 50 62Glycopeptides R <1 2 1 <1 <1 <1 <1 <1




NetherlandsGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=3102

E. colin=5561

E. faecalisn=726

E. faeciumn=616

K. pneumo.n=819

P. aeruginosan=588


Blood 92 2 100 1 100 12 100 0 100 0 99 5 99 2CSF 8 2 0 . 0 . 0 . 0 . 1 0 1 0

GenderMale 53 1 59 2 47 14 68 0 60 1 53 7 66 1Female 46 2 39 1 51 10 29 0 40 0 46 4 34 3Unknown 1 4 2 0 2 11 3 0 0 . 0 . 0 .

Age (years)0-4 6 3 8 0 4 3 10 0 6 0 4 6 3 05-19 3 0 3 2 1 20 0 . 3 0 1 18 2 720-64 37 2 34 1 30 14 36 0 44 0 35 6 36 365 and over 53 1 52 1 63 11 51 1 47 1 60 5 59 1Unknown 1 5 2 0 2 12 3 0 0 . 0 . 0 .








0 25 50 75 100

0/140NL008X

0/11NL011A

0/19NL011D

0/5NL011E

0/18NL011F

0/59NL011X

0/42NL016X

0/42NL021A

0/45NL021B

0/22NL021C

0/179NL026A

0/180NL027A

0/61NL029A

0/137NL031X

0/22NL032X

1/177NL003A

1/165NL002X

3/412NL030X

3/268NL006X

1/84NL014X

3/243NL022X

1/58NL018X

3/125NL028X

2/76NL023X

2/65NL025X

7/192NL019X

1/26NL005X

1/25NL017X

9/202NL007A


0 25 50 75 100

0/98NL011

0/69NL014

0/83NL021

0/55NL023

0/31NL025

0/64NL028

1/121NL008

1/105NL022

1/101NL019

3/296NL030

2/146NL002

1/66NL003

1/66NL026

2/116NL031

1/57NL007

1/55NL027

4/205NL006

1/46NL018

1/35NL032

1/31NL005

1/22NL029

4/34NL017

5/42NL016











2000 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 962007 13 616 13 790 13 1713 13 416 13 320 13 105



Penicillin I+R <1 1 <1 <1 2 2 2 2Macrolides I+R 4 4 6 8 8 14 12 10

S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 <1 <1 <1E. coli Aminopenicillins R 26 27 29 34 32 34 35 38

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

E. faecalis Aminopenicillins I+R 3 3 4 4 <1 3 3 2HL Aminoglycosides R 11 42 30 38 27 32 33 34Glycopeptides R 1 1 3 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R 40 28 49 43 80 72 75 81HL Aminoglycosides R 33 40 14 14 25 44 45 52Glycopeptides R <1 <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R <1 <1 <1 <1 2 3 <1 <1Fluoroquinolones R <1 <1 <1 <1 <1 1 7 53rd gen. Cephalosporins R <1 <1 <1 <1 <1 2 2 2

P. aeruginosa Piperacillin R . . <1 <1 13 3 3 2Ceftazidime R 25 15 <1 <1 <1 3 5 3Carbapenems R <1 7 <1 <1 4 3 9 9Aminoglycosides R <1 <1 <1 <1 4 <1 1 2Fluoroquinolones R <1 9 <1 4 5 4 9 7


NorwayGeneral Information about EARSS participating laboratories and hospitals












2000 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 962007 13 616 13 790 13 1713 13 416 13 320 13 105



Penicillin I+R <1 1 <1 <1 2 2 2 2Macrolides I+R 4 4 6 8 8 14 12 10

S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 <1 <1 <1E. coli Aminopenicillins R 26 27 29 34 32 34 35 38

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

E. faecalis Aminopenicillins I+R 3 3 4 4 <1 3 3 2HL Aminoglycosides R 11 42 30 38 27 32 33 34Glycopeptides R 1 1 3 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R 40 28 49 43 80 72 75 81HL Aminoglycosides R 33 40 14 14 25 44 45 52Glycopeptides R <1 <1 <1 <1 <1 <1 <1 <1

K. pneumoniae Aminoglycosides R <1 <1 <1 <1 2 3 <1 <1Fluoroquinolones R <1 <1 <1 <1 <1 1 7 53rd gen. Cephalosporins R <1 <1 <1 <1 <1 2 2 2

P. aeruginosa Piperacillin R . . <1 <1 13 3 3 2Ceftazidime R 25 15 <1 <1 <1 3 5 3Carbapenems R <1 7 <1 <1 4 3 9 9Aminoglycosides R <1 <1 <1 <1 4 <1 1 2Fluoroquinolones R <1 9 <1 4 5 4 9 7


NorwayGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=1524

E. colin=3130

E. faecalisn=545

E. faeciumn=165

K. pneumo.n=583

P. aeruginosan=182


Blood 94 2 100 0 100 6 100 0 100 0 100 2 100 9CSF 6 1 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 8 2 4 2 2 10 2 0 1 0 1 0 2 335-19 2 0 3 0 1 6 1 0 0 . 1 17 3 020-64 40 1 35 0 26 6 24 0 32 0 29 2 29 1565 and over 50 2 57 0 72 6 72 0 67 0 68 1 67 7Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .








0 25 50 75 100

0/17NO101C

0/22NO101D

0/79NO102B

0/168NO103E

0/133NO104J

0/7NO104N

0/52NO105K

0/51NO106P

0/43NO106Q

0/87NO106S

0/22NO106T

0/6NO106U

0/78NO203C

0/34NO203D

0/94NO204E

0/22NO204H

0/55NO205I

0/72NO206O

0/47NO206P

0/13NO206Q

0/25NO304J

0/8NO304K

0/26NO402B

0/137NO403D

0/24NO403E

1/175NO101A

1/8NO402H


0 25 50 75 100

0/104NO103

0/48NO105

0/92NO204

0/18NO402

1/123NO206

1/119NO101

1/75NO205

1/44NO304

3/121NO104

5/192NO106

2/76NO102

3/95NO203

4/110NO403











2000 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 21 54 17 53 14 262006 4 9 24 174 26 206 21 68 15 42 16 372007 10 21 24 185 27 256 20 71 18 32 23 67


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . <1 30 19 <1 17 <1 10

Penicillin I+R . <1 30 19 <1 33 <1 29Macrolides I+R . <1 67 14 19 33 11 .



E. faecalis Aminopenicillins I+R . 5 12 <1 2 9 2 4HL Aminoglycosides R . 43 41 48 33 48 50 46Glycopeptides R . <1 <1 <1 <1 <1 <1 2

E. faecium Aminopenicillins I+R . 77 80 91 86 95 95 88HL Aminoglycosides R . 73 73 55 100 62 85 84Glycopeptides R . <1 <1 <1 <1 5 <1 <1




PolandGeneral Information about EARSS participating laboratories and hospitals












2000 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 21 54 17 53 14 262006 4 9 24 174 26 206 21 68 15 42 16 372007 10 21 24 185 27 256 20 71 18 32 23 67


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . <1 30 19 <1 17 <1 10

Penicillin I+R . <1 30 19 <1 33 <1 29Macrolides I+R . <1 67 14 19 33 11 .



E. faecalis Aminopenicillins I+R . 5 12 <1 2 9 2 4HL Aminoglycosides R . 43 41 48 33 48 50 46Glycopeptides R . <1 <1 <1 <1 <1 <1 2

E. faecium Aminopenicillins I+R . 77 80 91 86 95 95 88HL Aminoglycosides R . 73 73 55 100 62 85 84Glycopeptides R . <1 <1 <1 <1 5 <1 <1




PolandGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=359

E. colin=462

E. faecalisn=94

E. faeciumn=45

K. pneumo.n=74

P. aeruginosan=104


Blood 100 20 100 17 100 16 100 1 100 0 100 36 100 22CSF 0 . 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 43 15 59 21 41 21 54 2 53 0 58 42 63 25Female 57 24 40 13 59 13 45 0 47 0 42 29 37 18Unknown 0 . 1 0 0 . 1 0 0 . 0 . 1 0

Age (years)0-4 0 . 9 23 5 8 5 0 7 0 19 36 4 05-19 0 . 2 14 1 0 0 . 0 . 1 0 3 020-64 67 25 50 15 40 19 48 2 44 0 45 42 57 2465 and over 33 10 40 19 54 15 47 0 49 0 35 31 37 24Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .

Hospital dep.ICU 10 0 9 31 7 24 21 0 31 0 22 56 39 27Internal Med. 77 22 62 10 68 18 56 2 38 0 42 19 34 20Surgery 0 . 14 38 7 22 15 0 18 0 11 88 12 42Other 13 25 15 19 18 6 7 0 13 0 26 26 15 0Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .







0 25 50 75 100

0/37PL043A

0/6PL044A

0/5PL056A

1/11PL034A

2/20PL016A

3/26PL009A

1/8PL014A

3/23PL048A

2/15PL003A

4/28PL017A

1/7PL041A

4/25PL012A

4/23PL058A

2/11PL024A

3/15PL011A

1/5PL033A

2/9PL018A

3/11PL046A

2/7PL015A

11/34PL029A

4/11PL031A

7/14PL022A


0 25 50 75 100

1/6PL041

2/7PL043

2/6PL058











2000 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 1331 17 464 13 315 11 2662007 12 202 20 1383 20 1432 19 518 18 370 16 340



Penicillin I+R 29 25 20 20 27 17 17 16Macrolides I+R 11 . <1 . 20 19 21 23



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

E. faecium Aminopenicillins I+R . 76 79 88 83 92 76 93HL Aminoglycosides R . 23 33 55 66 68 53 49Glycopeptides R . 21 . 47 42 34 26 29

K. pneumoniae Aminoglycosides R . . . . . <1 13 11Fluoroquinolones R . . . . . <1 20 183rd gen. Cephalosporins R . . . . . . 21 17



PortugalGeneral Information about EARSS participating laboratories and hospitals


*

* Proportion not given, due to a very low number of isolates.











2000 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 1331 17 464 13 315 11 2662007 12 202 20 1383 20 1432 19 518 18 370 16 340



Penicillin I+R 29 25 20 20 27 17 17 16Macrolides I+R 11 . <1 . 20 19 21 23



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

E. faecium Aminopenicillins I+R . 76 79 88 83 92 76 93HL Aminoglycosides R . 23 33 55 66 68 53 49Glycopeptides R . 21 . 47 42 34 26 29

K. pneumoniae Aminoglycosides R . . . . . <1 13 11Fluoroquinolones R . . . . . <1 20 183rd gen. Cephalosporins R . . . . . . 21 17



PortugalGeneral Information about EARSS participating laboratories and hospitals


*

* Proportion not given, due to a very low number of isolates.



S. aureusn=2689

E. colin=2677

E. faecalisn=644

E. faeciumn=294

K. pneumo.n=648

P. aeruginosan=574


Blood 88 17 100 48 100 29 100 5 100 28 99 19 98 18CSF 12 19 0 . 0 . 0 . 0 . 1 0 2 0

GenderMale 61 15 63 48 46 33 56 4 58 30 61 21 60 18Female 39 20 37 48 54 25 44 5 42 24 38 14 40 17Unknown 0 . 0 . 0 . 0 . 0 . 1 25 0 .

Age (years)0-4 8 27 2 6 0 . 1 0 0 . 1 17 2 205-19 5 5 2 11 1 15 1 25 1 0 1 17 1 020-64 49 12 33 39 32 28 31 6 40 34 36 18 45 2065 and over 34 24 52 59 61 31 61 4 56 25 52 18 50 15Unknown 5 15 11 42 5 12 6 0 3 0 10 20 2 14

Hospital dep.ICU 5 17 9 60 4 32 14 2 14 25 10 18 17 27Internal Med. 10 24 23 56 20 28 21 6 23 25 20 24 16 16Surgery 0 . 9 64 5 33 10 0 15 14 12 14 9 14Other 85 16 58 41 68 28 55 5 49 33 58 18 58 15Unknown 0 . 0 . 3 29 0 . 0 . 0 . 0 .







0 25 50 75 100

0/15PT004A

6/38PT021A

37/204PT011A

4/20PT009A

33/102PT016A

44/126PT018A

43/115PT023A

103/236PT019A

14/31PT029A

38/82PT028A

67/140PT024A

82/156PT005A

112/210PT008A

41/76PT015A

211/378PT003A

103/184PT012A

213/357PT007A

77/122PT001A

58/84PT002A

6/7PT022A


0 25 50 75 100

0/7PT029

2/25PT017

5/59PT003

8/49PT002

1/6PT005

6/36PT018

16/88PT011

2/10PT008

15/75PT019

2/9PT001

2/5PT016

3/5PT028



TotalLabs providing denom.data/reporting data to EARSS 10/14Hosps providing denom.data/reporting data to EARSS 11/22Number of blood culture sets 12,361Number of hospital beds 6,478Patient-days naAverage occupancy rate (%) naMedian length of stay (days) naEstimated catchment population 779,796% total population covered 4%Type of participating hospitals Regional/Tertiary 30% Provincial/Secondary 60% District/Primary 10%








2000 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 11 83 9 41 9 28 5 32 2 32007 5 26 9 42 9 58 4 13 6 30 2 4


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . 10 23 11 22 10 23

Penicillin I+R . . 50 36 11 39 28 31Macrolides I+R . . 10 27 <1 31 25 20

S. aureus Oxacillin/Methicillin R . . 36 46 72 60 54 26E. coli Aminopenicillins R . . 50 70 79 78 85 77


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

E. faecium Aminopenicillins I+R . . 100 86 100 100 100 100HL Aminoglycosides R . . 80 63 100 70 80 67Glycopeptides R . . 17 <1 <1 <1 <1 <1


P. aeruginosa Piperacillin R . . . . . 61 33 25Ceftazidime R . . . . . 52 <1 <1Carbapenems R . . . . . 61 <1 <1Aminoglycosides R . . . . . 64 33 25Fluoroquinolones R . . . . . 64 33 25


RomaniaGeneral Information about EARSS participating laboratories and hospitals




TotalLabs providing denom.data/reporting data to EARSS 10/14Hosps providing denom.data/reporting data to EARSS 11/22Number of blood culture sets 12,361Number of hospital beds 6,478Patient-days naAverage occupancy rate (%) naMedian length of stay (days) naEstimated catchment population 779,796% total population covered 4%Type of participating hospitals Regional/Tertiary 30% Provincial/Secondary 60% District/Primary 10%








2000 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 11 83 9 41 9 28 5 32 2 32007 5 26 9 42 9 58 4 13 6 30 2 4


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . 10 23 11 22 10 23

Penicillin I+R . . 50 36 11 39 28 31Macrolides I+R . . 10 27 <1 31 25 20

S. aureus Oxacillin/Methicillin R . . 36 46 72 60 54 26E. coli Aminopenicillins R . . 50 70 79 78 85 77


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

E. faecium Aminopenicillins I+R . . 100 86 100 100 100 100HL Aminoglycosides R . . 80 63 100 70 80 67Glycopeptides R . . 17 <1 <1 <1 <1 <1


P. aeruginosa Piperacillin R . . . . . 61 33 25Ceftazidime R . . . . . 52 <1 <1Carbapenems R . . . . . 61 <1 <1Aminoglycosides R . . . . . 64 33 25Fluoroquinolones R . . . . . 64 33 25


RomaniaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=125

E. colin=96

E. faecalisn=17

E. faeciumn=24

K. pneumo.n=62

P. aeruginosan=7


Blood 42 26 100 45 89 31 100 0 100 0 100 87 100 0CSF 58 31 0 . 11 55 0 . 0 . 0 . 0 .

GenderMale 69 29 50 51 54 38 65 0 63 0 55 97 71 0Female 31 29 32 38 46 27 35 0 38 0 45 75 14 0Unknown 0 . 18 41 0 . 0 . 0 . 0 . 14 0

Age (years)0-4 13 71 16 65 23 27 41 0 38 0 66 98 71 05-19 5 0 4 0 7 57 0 . 8 0 8 40 0 .20-64 53 28 58 39 31 43 18 0 21 0 16 80 0 .65 and over 27 20 16 50 39 24 29 0 25 0 10 67 14 0Unknown 2 0 6 63 0 . 12 0 8 0 0 . 14 0

Hospital dep.ICU 2 100 19 46 4 50 0 . 0 . 8 100 0 .Internal Med. 13 14 10 85 22 29 24 0 38 0 21 69 0 .Surgery 0 . 13 50 1 100 6 0 8 0 3 100 0 .Other 80 32 30 43 73 33 65 0 54 0 68 90 100 0Unknown 5 0 28 29 0 . 6 0 0 . 0 . 0 .







0 25 50 75 100

0/6RO01BA

1/16RO01C

1/5RO01AA

1/5RO01CA

4/11RO01F

3/8RO01DA

3/8RO01HA

2/5RO01FA

5/10RO02A

6/10RO01A

9/11RO01D

10/11RO01B


0 25 50 75 100

1/8RO01C

2/8RO01E

7/24RO01A

3/8RO01B











2000 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 722007 10 195 10 422 10 851 9 183 10 170 9 88


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 2 2 2 5 4




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

E. faecium Aminopenicillins I+R . 64 69 83 76 93 86 92HL Aminoglycosides R . 50 62 82 56 47 54 63Glycopeptides R . <1 <1 <1 <1 <1 6 5




SloveniaGeneral Information about EARSS participating laboratories and hospitals












2000 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 722007 10 195 10 422 10 851 9 183 10 170 9 88


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R <1 <1 <1 2 2 2 5 4




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

E. faecium Aminopenicillins I+R . 64 69 83 76 93 86 92HL Aminoglycosides R . 50 62 82 56 47 54 63Glycopeptides R . <1 <1 <1 <1 <1 6 5




SloveniaGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=787

E. colin=1568

E. faecalisn=213

E. faeciumn=115

K. pneumo.n=315

P. aeruginosan=160


Blood 93 17 100 8 100 16 100 0 100 5 100 26 98 13CSF 7 21 0 . 0 . 0 . 0 . 0 . 3 25


Age (years)0-4 22 35 4 0 2 0 7 0 1 0 1 0 3 05-19 6 10 3 0 1 0 0 . 0 . 0 . 1 020-64 29 13 38 8 27 15 29 0 35 5 27 25 34 2265 and over 43 13 55 9 70 17 63 0 64 5 72 27 62 9Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 .








0 25 50 75 100

0/9SI001B

0/11SI001C

0/25SI002A

0/9SI003B

0/10SI004B

0/12SI010A

2/86SI004A

1/35SI009A

1/30SI007A

5/119SI003A

1/20SI011A

35/307SI001A

9/75SI008A

6/33SI005A

1/5SI006A


0 25 50 75 100

0/9SI011

3/25SI010

3/23SI002

7/49SI004

19/117SI001

3/17SI005

6/34SI008

12/51SI003

4/16SI009

7/18SI007











2000 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 4052007 35 860 35 1642 35 3678 35 885 33 618 35 448






E. faecalis Aminopenicillins I+R . 3 2 1 2 <1 2 1HL Aminoglycosides R . 32 37 36 36 36 36 42Glycopeptides R . <1 <1 <1 <1 <1 <1 <1





SpainGeneral Information about EARSS participating laboratories and hospitals












2000 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 4052007 35 860 35 1642 35 3678 35 885 33 618 35 448






E. faecalis Aminopenicillins I+R . 3 2 1 2 <1 2 1HL Aminoglycosides R . 32 37 36 36 36 36 42Glycopeptides R . <1 <1 <1 <1 <1 <1 <1





SpainGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=3125

E. colin=7019

E. faecalisn=1247

E. faeciumn=393

K. pneumo.n=1175

P. aeruginosan=830


Blood 95 24 100 25 100 29 100 0 100 3 100 10 100 13CSF 5 36 0 . 0 . 0 . 0 . 0 . 0 .


Age (years)0-4 13 28 3 8 2 10 5 0 6 0 4 18 2 65-19 5 12 3 11 1 8 2 0 2 0 1 23 1 920-64 40 21 35 20 28 24 30 0 33 3 34 9 38 1865 and over 40 29 57 30 67 33 60 0 58 3 58 9 57 11Unknown 1 20 2 17 1 14 3 0 1 0 2 21 2 7








0 25 50 75 100

2/29ES020A

7/61ES046A

11/85ES043A

2/15ES045A

6/45ES051A

13/82ES048A

16/95ES005A

22/128ES058A

9/52ES032A

9/48ES040A

23/120ES042A

28/145ES026A

12/58ES018A

28/130ES016A

5/23ES059A

38/172ES021A

17/76ES011A

45/194ES019A

11/46ES003A

24/94ES044A

6/23ES047A

9/34ES057A

28/100ES031A

23/82ES049A

29/102ES013A

22/76ES053A

9/31ES054A

29/96ES002A

38/123ES038A

39/123ES056A

29/89ES010A

6/18ES015A

46/136ES004A

37/102ES012A

48/129ES041A

35/93ES029A

31/70ES017A


0 25 50 75 100

1/15ES059

3/37ES019

1/11ES017

3/24ES043

1/7ES049

6/37ES020

3/18ES018

10/58ES050

11/63ES011

5/28ES046

16/89ES044

12/66ES040

5/27ES054

4/21ES057

14/72ES016

2/10ES051

13/60ES048

16/73ES038

13/55ES010

6/25ES012

34/129ES042

9/34ES002

8/29ES004

25/86ES021

15/51ES005

9/29ES032

21/66ES031

5/15ES029

4/12ES047

14/42ES053

26/74ES058

5/14ES026

26/66ES056

6/15ES003

4/9ES045

7/13ES015











2000 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 3002007 21 1028 21 2162 20 3745 21 932 20 649 20 343




S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 1 <1 <1E. coli Aminopenicillins R . 27 25 28 23 26 28 33

Aminoglycosides R . <1 <1 1 1 1 2 2Fluoroquinolones R . 4 5 7 8 6 8 103rd gen. Cephalosporins R . <1 <1 <1 <1 1 2 2

E. faecalis Aminopenicillins I+R . <1 1 <1 <1 <1 <1 <1HL Aminoglycosides R . . . 17 15 19 20 16Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 75 75 77 78 74 76 79HL Aminoglycosides R . . . 11 7 4 12 14Glycopeptides R . <1 <1 2 1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . 1 <1 1Fluoroquinolones R . . . . . 5 5 73rd gen. Cephalosporins R . . . . . 1 1 1

P. aeruginosa Piperacillin R . . . . . 9 <1 2Ceftazidime R . . . . . 5 6 4Carbapenems R . . . . . 18 5 7Aminoglycosides R . . . . . <1 <1 <1Fluoroquinolones R . . . . . 6 5 6


SwedenGeneral Information about EARSS participating laboratories and hospitals












2000 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 3002007 21 1028 21 2162 20 3745 21 932 20 649 20 343




S. aureus Oxacillin/Methicillin R <1 <1 <1 <1 <1 1 <1 <1E. coli Aminopenicillins R . 27 25 28 23 26 28 33

Aminoglycosides R . <1 <1 1 1 1 2 2Fluoroquinolones R . 4 5 7 8 6 8 103rd gen. Cephalosporins R . <1 <1 <1 <1 1 2 2

E. faecalis Aminopenicillins I+R . <1 1 <1 <1 <1 <1 <1HL Aminoglycosides R . . . 17 15 19 20 16Glycopeptides R . <1 <1 <1 <1 <1 <1 <1

E. faecium Aminopenicillins I+R . 75 75 77 78 74 76 79HL Aminoglycosides R . . . 11 7 4 12 14Glycopeptides R . <1 <1 2 1 <1 <1 <1

K. pneumoniae Aminoglycosides R . . . . . 1 <1 1Fluoroquinolones R . . . . . 5 5 73rd gen. Cephalosporins R . . . . . 1 1 1

P. aeruginosa Piperacillin R . . . . . 9 <1 2Ceftazidime R . . . . . 5 6 4Carbapenems R . . . . . 18 5 7Aminoglycosides R . . . . . <1 <1 <1Fluoroquinolones R . . . . . 6 5 6


SwedenGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=4129

E. colin=6960

E. faecalisn=1229

E. faeciumn=581

K. pneumo.n=1270

P. aeruginosan=559


Blood 98 2 100 1 100 9 100 0 100 0 100 1 100 6CSF 2 6 0 . 0 . 0 . 0 . 0 . 0 .










0 25 50 75 100

0/132SE100B0/30SE100C0/48SE110A0/15SE110B0/33SE120B0/8SE200D0/82SE220A0/51SE220B0/25SE220C0/10SE220D0/72SE230A0/22SE230B0/16SE240B0/32SE240C0/125SE250A0/43SE250B0/126SE300A0/120SE320A0/23SE320B0/14SE320C0/36SE350B0/58SE350C0/22SE400C0/34SE430D0/36SE440B0/38SE440C0/153SE450A0/15SE450C0/36SE450D0/56SE540A0/24SE600C0/32SE610B0/67SE610C0/135SE620A0/15SE620B0/41SE620C0/10SE620D0/26SE730B0/21SE730C0/9SE730D0/49SE730E0/45SE730F1/236SE310A1/233SE600A1/203SE120A1/135SE430A1/125SE440A1/121SE610A1/104SE200B2/200SE200A1/92SE240A2/128SE350A3/161SE400A2/92SE400B1/36SE200C10/275SE100A


0 25 50 75 100

0/74SE240

0/92SE430

1/105SE450

1/97SE310

1/97SE600

1/95SE610

1/90SE620

1/89SE350

3/217SE200

1/71SE300

1/71SE730

3/126SE440

2/77SE220

6/183SE100

4/117SE400

2/55SE230

5/97SE320

2/36SE110

8/135SE120

5/74SE250

4/23SE540











2000 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 14 889 14 583 14 456 13 3132007 11 111 16 1127 16 1075 16 774 16 639 15 420


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . 2 7 <1 5 11

Penicillin I+R . . . 13 23 24 18 28Macrolides I+R . . . 7 9 10 16 16



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

E. faecium Aminopenicillins I+R . . . 75 81 87 87 91HL Aminoglycosides R . . . 55 58 60 70 69Glycopeptides R . . . 4 3 5 4 8




TurkeyGeneral Information about EARSS participating laboratories and hospitals












2000 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 14 889 14 583 14 456 13 3132007 11 111 16 1127 16 1075 16 774 16 639 15 420


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R . . . 2 7 <1 5 11

Penicillin I+R . . . 13 23 24 18 28Macrolides I+R . . . 7 9 10 16 16



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

E. faecium Aminopenicillins I+R . . . 75 81 87 87 91HL Aminoglycosides R . . . 55 58 60 70 69Glycopeptides R . . . 4 3 5 4 8




TurkeyGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=1921

E. colin=1946

E. faecalisn=695

E. faeciumn=652

K. pneumo.n=1093

P. aeruginosan=732


Blood 80 21 100 35 99 51 100 0 100 6 100 44 100 30CSF 20 33 0 . 1 50 0 . 0 . 0 . 0 .

GenderMale 69 22 59 37 56 54 53 1 51 7 56 45 62 31Female 30 27 40 33 43 48 46 0 48 5 42 41 37 28Unknown 1 0 1 29 1 26 1 0 1 14 3 54 0 .

Age (years)0-4 22 38 10 25 6 21 10 0 12 11 21 57 13 305-19 17 19 8 27 5 33 4 0 4 4 7 36 7 2420-64 40 17 53 38 52 53 45 1 46 6 46 40 48 2965 and over 22 24 29 36 38 54 40 0 38 4 25 41 32 32Unknown 0 . 1 40 0 . 1 0 0 . 0 . 1 0

Hospital dep.ICU 5 36 17 64 10 63 28 1 34 6 20 56 27 45Internal Med. 11 26 21 20 19 52 15 0 17 7 16 31 14 18Surgery 6 25 12 60 12 54 15 0 12 4 12 53 15 39Other 78 22 49 25 57 47 42 0 37 6 52 41 43 21Unknown 0 . 0 . 3 55 0 . 0 . 0 . 1 25







0 25 50 75 100

11/69TR010A

9/55TR005A

8/45TR016A

26/140TR008A

16/84TR006A

30/121TR015A

35/135TR007A

77/273TR001A

19/61TR014A

20/64TR011A

26/80TR012A

103/221TR003A

92/197TR004A

65/137TR002A

3/6TR0010A

63/110TR009A

73/121TR013A


0 25 50 75 100

0/5TR010

2/14TR006

3/19TR003

1/6TR005

1/6TR013

2/9TR002

10/45TR008

4/16TR011

6/22TR004

9/32TR001

8/24TR015

3/8TR009











2000 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 3532007 50 1744 55 4811 20 2393 18 435 18 394 19 370


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R 4 3 3 1 <1 2 <1 2




E. faecalis Aminopenicillins I+R . . . . . 2 3 4HL Aminoglycosides R . . . . . 47 52 31Glycopeptides R . . . . . 2 1 2

E. faecium Aminopenicillins I+R . . . . . 84 78 82HL Aminoglycosides R . . . . . 53 18 35Glycopeptides R . . . . . 33 18 21




United KingdomGeneral Information about EARSS participating laboratories and hospitals












2000 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 3532007 50 1744 55 4811 20 2393 18 435 18 394 19 370


Pathogen Antimicrobial classes 2000 2001 2002 2003 2004 2005 2006 2007S. pneumoniae Penicillin R 4 3 3 1 <1 2 <1 2




E. faecalis Aminopenicillins I+R . . . . . 2 3 4HL Aminoglycosides R . . . . . 47 52 31Glycopeptides R . . . . . 2 1 2

E. faecium Aminopenicillins I+R . . . . . 84 78 82HL Aminoglycosides R . . . . . 53 18 35Glycopeptides R . . . . . 33 18 21




United KingdomGeneral Information about EARSS participating laboratories and hospitals




S. aureusn=8807

E. colin=4295

E. faecalisn=618

E. faeciumn=300

K. pneumo.n=623

P. aeruginosan=519


Blood 98 3 100 39 100 19 100 2 100 19 100 12 100 8CSF 2 8 0 . 0 . 0 . 0 . 0 . 0 .

GenderMale 50 3 62 40 46 22 60 1 61 23 58 13 62 8Female 49 4 37 36 54 16 39 2 39 13 41 10 37 8Unknown 2 9 1 31 1 16 0 . 0 . 1 25 0 .

Age (years)0-4 7 5 3 12 2 6 7 5 7 5 5 3 4 55-19 4 3 2 14 1 12 2 0 2 0 1 20 4 2020-64 34 2 30 29 25 19 32 3 37 28 29 11 32 1465 and over 36 5 44 47 72 19 60 1 54 16 65 13 60 4Unknown 19 3 20 42 0 . 0 . 0 . 1 0 0 .

Hospital dep.ICU 4 1 8 50 0 . 0 . 0 . 0 . 0 .Internal Med. 26 3 26 39 0 . 0 . 0 . 0 . 0 .Surgery 1 0 8 44 0 . 0 . 0 . 0 . 0 .Other 39 4 35 33 0 . 0 . 0 . 0 . 0 .Unknown 29 4 22 41 100 19 100 2 100 19 100 12 100 8







0 25 50 75 100

0/6UK033A0/12UK047D

1/27UK007C1/18UK050X

3/36UK078C1/10UK055X

1/9UK078B4/34UK055A

3/20UK057X8/47UK053X

3/16UK044B3/15UK013C4/20UK053A

8/34UK003A4/17UK076D

3/12UK049X7/28UK054X

35/133UK054A25/95UK066A

9/33UK076A49/173UK059A2/7UK046X2/7UK066X27/94UK053D19/66UK043B38/132UK056A25/86UK052A19/65UK031A23/78UK001A60/201UK043A34/112UK045X22/72UK017A4/13UK044C134/432UK045A35/111UK064A23/71UK020A13/39UK046A5/15UK047C17/51UK070X13/39UK077A11/33UK081A86/257UK013A97/283UK026A15/43UK049A39/110UK090A8/22UK042X79/217UK038C57/155UK084A7/19UK044D9/24UK081B101/269UK007A32/85UK057A5/13UK010A56/143UK023A60/153UK069A43/108UK011A66/165UK012A2/5UK038E4/10UK084B120/297UK051A120/294UK017B114/278UK068B82/199UK070A38/91UK068X18/43UK048A37/88UK060A72/171UK007B38/90UK008A22/52UK064X3/7UK058A45/104UK015A29/66UK059B227/516UK047A65/147UK044A8/18UK052X50/110UK047X34/74UK032A25/54UK070B7/15UK056X15/32UK015B54/115UK050A35/74UK032B11/23UK004A67/139UK083A130/267UK005A39/80UK047B

5/10UK022A5/10UK042A10/20UK051B18/36UK059X10/20UK063X13/26UK069X29/57UK063A45/88UK051X35/68UK068A23/44UK013B50/94UK080A

4/7UK007F7/12UK045B

3/5UK003B71/111UK078A

17/25UK027A7/10UK060X

4/5UK045C9/10UK038X

14/15UK084E


0 25 50 75 100

0/41UK0010/73UK0170/30UK0270/24UK0330/39UK0440/36UK0520/67UK0530/20UK0550/27UK0560/51UK0570/64UK0660/63UK070

1/73UK0631/71UK0323/194UK0451/60UK0042/114UK0124/210UK0471/48UK0201/42UK0031/42UK0781/40UK0421/37UK0501/36UK0313/104UK0152/69UK0131/34UK0113/99UK0641/31UK0601/29UK0492/58UK0544/97UK0389/198UK0073/56UK0084/71UK0693/53UK0232/34UK0461/17UK0816/100UK0053/49UK04810/160UK0437/108UK0597/107UK0681/15UK0763/43UK0903/40UK0102/23UK0269/103UK051

5/40UK0842/10UK077


Annex 3. Overview of antibiotic resistance in Europe, 2007 151

Annex 3. Overview of antibiotic resistance in Europe, 2007

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 non-susceptible isolates, including 95% confidence intervals (95CI) reported per country in 2007.

Country No SPNisolates testedfor PEN/ERY

%PNSP (95CI)

%PRSP (95CI)

%ENSP(95CI)

%single PEN

(95CI)

%single ERY

(95CI)

%DUAL (95CI)

AT 313/257 5 (3-8) 2 (1-4) 13 (9-18) 2 (1-5) 10 (7-14) 3 (0-0)BE 1511/1511 9 (8-11) 3 (2-4) 25 (22-27) 3 (2-4) 18 (16-20) 7 (0-0)BG 32/30 16 (6-34) 9 (2-26) 17 (6-35) 3 (0-19) 3 (0-19) 13 (0-0)CY 15/15 33 (13-61) 7 (0-34) 27 (9-55) 13 (2-42) 7 (0-34) 20 (0-0)CZ 205/205 4 (2-8) 0 (0-2) 5 (3-10) 3 (1-7) 4 (2-8) 1 (0-0)DE 72/63 3 (0-11) 0 (0-6) 8 (3-18) 3 (1-12) 8 (3-18) 0 (0-7)DK 1030/1030 3 (2-5) 0 (0-1) 6 (5-8) 2 (2-4) 5 (4-7) 1 (0-0)EE 64/53 0 (0-7) 0 (0-7) 2 (0-11) 0 (0-8) 2 (0-11) 0 (0-8)ES 860/846 22 (20-25) 8 (6-10) 18 (16-21) 11 (9-14) 7 (6-9) 11 (0-0)FI 522/522 13 (10-16) 1 (1-3) 26 (22-30) 4 (2-6) 16 (13-20) 9 (0-0)FR 663/663 34 (31-38) 4 (3-6) 37 (33-41) 6 (4-8) 8 (6-11) 29 (0-0)HR 136/101 18 (12-26) 1 (0-5) 8 (4-15) 13 (7-21) 5 (2-12) 3 (0-0)HU 146/140 23 (16-30) 5 (2-10) 36 (28-44) 4 (2-9) 17 (12-25) 19 (0-0)IE 435/400 17 (14-21) 6 (4-9) 17 (13-21) 10 (7-13) 9 (6-12) 8 (0-0)IL 245/244 29 (24-36) 7 (5-12) 14 (10-19) 21 (16-27) 5 (3-9) 9 (0-0)IS 42/42 7 (2-21) 2 (0-14) 17 (8-32) 2 (0-14) 12 (4-26) 5 (0-0)IT 291/259 15 (11-20) 4 (2-7) 31 (26-37) 7 (5-11) 24 (19-29) 8 (0-0)LT 67/64 4 (1-13) 1 (0-9) 9 (4-20) 2 (0-10) 6 (2-16) 3 (0-0)LU 31/31 6 (1-23) 3 (0-19) 23 (10-42) 0 (0-14) 16 (6-34) 6 (0-0)LV 31/31 0 (0-14) 0 (0-14) 0 (0-14) 0 (0-14) 0 (0-14) 0 (0-14)MT 13/13 0 (0-28) 0 (0-28) 8 (0-38) 0 (0-28) 8 (0-38) 0 (0-28)NL 939/781 2 (1-3) 0 (0-1) 7 (5-9) 1 (0-2) 6 (4-8) 1 (0-0)NO 616/602 2 (1-3) 0 (0-1) 10 (7-12) 1 (1-2) 9 (7-12) 0 (0-0)PL 21/0 29 (12-52) 10 (2-32) PT 202/201 16 (12-22) 0 (0-2) 23 (17-29) 4 (2-9) 11 (7-16) 12 (0-0)RO 26/25 31 (15-52) 23 (10-44) 20 (8-41) 16 (5-37) 4 (0-22) 16 (0-0)SE 1028/925 3 (2-4) 0 (0-1) 5 (4-7) 2 (1-3) 4 (3-6) 1 (0-0)SI 195/194 17 (12-23) 4 (2-8) 17 (12-23) 10 (7-16) 11 (7-16) 6 (0-0)TR 111/85 28 (20-37) 11 (6-18) 16 (10-26) 15 (9-25) 2 (0-9) 14 (0-0)UK 1744/1681 4 (3-5) 2 (1-2) 10 (8-11) 2 (2-3) 8 (7-9) 2 (0-0)Total 11,606/11,014 10 2 16 4 9 6

152 Annex 3. Overview of antibiotic resistance in Europe, 2007

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 2007.

Country No SAU isolates %MRSA 95CIAT 1503 9 (8-11)BE 855 23 (21-26)BG 121 13 (8-21)CY 85 48 (37-59)CZ 1652 13 (11-15)DE 853 16 (14-19)DK 1315 1 (0-2)EE 206 9 (5-14)ES 1642 25 (23-28)FI 814 2 (1-3)FR 4250 26 (24-27)GR 806 48 (45-52)HR 375 38 (33-43)HU 1199 23 (21-26)IE 1332 38 (35-41)IL 451 33 (29-38)IS 64 0 (0-7)IT 1059 34 (31-37)LT 240 9 (6-13)LU 105 21 (14-30)LV 168 8 (5-14)MT 105 52 (42-62)NL 1469 1 (1-2)NO 790 0 (0-1)PL 185 15 (10-21)PT 1383 48 (46-51)RO 42 26 (14-42)SE 2162 1 (0-1)SI 422 8 (6-11)TR 1127 34 (32-37)UK 4811 36 (34-37)Total 31,591 22


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 2007.

High level aminoglycoside resistant E. faecalis

Vancomycin resistantE. faecium

Country No %R (95CI) No %R (95CI)AT 170 30 (23-38) 259 2 (1-5)BE 178 26 (20-34) 42 0 (0-10)BG 51 29 (18-44) 12 0 (0-30)CY 51 61 (46-74) 12 25 (7-57)CZ 578 49 (45-54) 229 6 (4-10)DE 238 67 (60-73) 274 15 (11-20)DK - - 334 1 (0-2)EE 22 23 (9-46) 31 0 (0-14)ES 648 42 (38-46) 218 2 (1-6)FI 169 22 (16-29) 163 1 (0-4)FR 1036 15 (13-17) 322 1 (0-3)GR 523 65 (60-69) 388 37 (32- 42)HR 122 37 (28-46) 51 2 (0-12)HU 341 48 (43-54) 59 0 (0-8)IE 247 38 (32-44) 323 33 (27-38)IL 212 40 (34-47) 51 24 (13-38)IS 15 13 (2-42) 14 0 (0-27)IT 345 39 (34-44) 254 11 (7-15)LT 37 41 (25-58) 18 0 (0-22)LU 9 44 (15-77) 11 0 (0-32)LV - - 30 0 (0-14)MT - - 6 0 (0-48)NL 252 38 (32-44) 328 0 (0-2)NO 162 34 (27-42) 97 0 (0-5)PL 46 46 (31-61) 25 0 (0-17)PT 349 41 (36-47) 158 29 (22-37)RO 4 50 (9-91) 9 0 (0-37)SE 632 16 (13-19) 279 0 (0-2)SI 118 50 (41-59) 65 5 (1-14)TR 386 29 (25-34) 368 8 (5-11)UK 61 31 (20-44) 131 21 (15-30)Total 7,002 35 4,561 10


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 2007.

Aminopenicillins Fluoroquinolones Third gen. Cephalosporines

Aminoglycosides Multi-resistance*

Country No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI) No %R (95CI)AT 2542 53 ( 51-55) 2531 26 ( 24-27) 2525 9 (8-10) 2541 8 (7-9) 2510 3 (2-3)BE 1446 57 ( 55-60) 1393 19 ( 17-21) 1451 4 (3-5) 1091 5 (4-6) 1074 1 (1-2)BG 127 70 ( 61-78) 127 35 ( 27-44) 127 23 (16-31) 127 20 (13-28) 127 9 (5-15)CY 108 73 ( 64-81) 108 40 ( 31-50) 108 19 (12-27) 108 11 (6-19) 108 6 (2-12)CZ 2407 56 ( 54-58) 2406 24 ( 22-26) 2407 7 (6-9) 2407 7 (6-8) 2406 2 (2-3)DE 975 55 ( 52-58) 972 30 ( 27-33) 974 8 (6-10) 975 6 (5-8) 970 2 (1-3)DK 2876 43 ( 41-45) 2818 9 ( 8-10) 1756 3 (2-4) 3019 4 (3-4) 1720 1 (1-2)EE 215 50 ( 43-57) 208 7 ( 4-11) 217 1 (0-4) 216 6 (3-10) 203 0 (0-3)ES 3672 62 ( 60-63) 3659 30 ( 29-32) 3665 7 (7-8) 3678 10 (9-11) 3646 2 (2-3)FI 1516 34 ( 32-36) 1949 8 ( 7-9) 1948 2 (1-2) 1859 3 (2-4) 1858 1 (1-2)FR 8068 54 ( 53-55) 7984 15 ( 14-16) 7840 2 (2-3) 8078 6 (5-6) 7730 1 (1-1)GR 1166 48 ( 45-51) 1227 19 ( 17-21) 1232 8 (6-9) 1234 9 (7-10) 1227 3 (2-4)HR 852 51 ( 47-54) 852 13 ( 11-16) 852 3 (2-4) 852 6 (5-8) 852 1 (1-2)HU 1169 54 ( 51-57) 1167 26 ( 24-29) 1146 5 (4-7) 1177 11 (9-13) 1138 3 (2-4)IE 1748 65 ( 63-68) 1741 21 ( 19-23) 1740 5 (4-7) 1745 10 (8-11) 1728 1 (1-2)IL 647 70 ( 66-74) 1034 30 ( 27-33) 1032 14 (12-17) 1035 17 (14-19) 1031 8 (6-10)IS 104 46 ( 36-56) 90 17 ( 10-26) 105 2 (0-7) 105 6 (2-13) 90 0 (0-5)IT 1049 58 ( 55-61) 977 32 ( 29-35) 943 11 (9-14) 978 14 (12-16) 868 5 (4-7)LT 234 50 ( 43-57) 232 9 ( 6-14) 235 7 (4-11) 235 12 (9-17) 232 3 (1-6)LU 263 50 ( 44-56) 263 22 ( 17-27) 260 4 (2-8) 260 5 (3-9) 260 2 (1-5)LV 76 43 ( 32-55) 76 17 ( 10-28) 76 14 (8-25) 76 14 (8-25) 76 5 (2-14)MT 116 54 ( 45-64) 117 35 ( 27-44) 117 13 (8-21) 117 20 (13-28) 117 10 (6-18)NL 2789 49 ( 47-51) 2725 13 ( 11-14) 2546 4 (3-5) 2724 5 (4-6) 2469 1 (1-2)NO 1712 38 ( 36-41) 1651 7 ( 6-8) 1713 2 (2-3) 1711 3 (2-4) 1650 1 (0-1)PL 256 56 ( 50-62) 256 13 ( 9-18) 256 2 (1-5) 256 6 (3-10) 256 1 (0-3)PT 1432 59 ( 56-61) 1387 30 ( 27-32) 1350 10 (8-11) 1429 12 (11-14) 1328 6 (5-7)RO 48 77 ( 62-87) 57 28 ( 17-42) 57 28 (17-42) 58 38 (26-52) 56 21 (12-35)SE 2038 33 ( 31-35) 3716 10 ( 9-11) 3743 2 (2-3) 3739 2 (2-3) 3711 1 (0-1)SI 851 49 ( 46-53) 851 17 ( 15-20) 851 4 (3-6) 851 7 (5-9) 851 2 (1-4)TR 1065 78 ( 76-81) 1062 53 ( 50-56) 1068 40 (37-43) 1073 35 (33-38) 1058 23 (20-25)UK 2105 55 ( 53-57) 2140 18 ( 16-20) 1828 9 (8-11) 2037 7 (6-9) 1722 4 (3-5)Total 43,672 55 45,776 22 44,168 9 45,791 10 43,072 4

* 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 2007

Aminopenicillins Fluoro quinolones 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 443 98 (95-99) 445 12 ( 9- 16) 440 8 (6-11) 445 5 (4-8) 306 0 (0-2) 440 4 (3-7)

BG 29 97 (80-100) 29 41 ( 24- 61) 29 55 (36-73) 29 59 (39-76) 27 0 (0-16) 29 34 (19-54)

CY 38 100 (89-100) 38 24 ( 12- 41) 38 32 (18-49) 38 13 (5-29) 38 3 (0-15) 38 11 (3-26)

CZ 1230 96 (94-97) 1230 48 ( 46- 51) 1230 46 (43-49) 1230 43 ( 41-46) 287 0 (0-2) 1230 29 (27-32)

DE 173 96 (92-98) 173 9 ( 6- 15) 173 6 (3-11) 173 6 (3-11) 173 2 (0-5) 173 3 (1-7)

DK 752 100 (99-100) 733 13 ( 11- 16) 492 10 (8-13) 782 6 (4-8) 93 0 (0-5) 483 6 (4-8)

EE 62 94 (84-98) 56 2 ( 0- 11) 63 3 (1-12) 63 2 (0-10) 48 0 (0-9) 56 0 (0-8)

ES 618 96 (94-97) 617 17 ( 14- 20) 613 10 (7-12) 618 9 (7-12) 570 0 (0-1) 612 5 (4-8)

FI 203 96 (91-98) 273 1 ( 0- 3) 272 1 (0-4) 263 1 (0-3) 251 0 (0-2) 263 0 (0-2)

FR 1186 99 (99-100) 1175 14 ( 12- 16) 1161 10 (8-12) 1186 11 (9-13) 1057 0 (0-1) 1149 9 (7-11)

GR 909 95 (94-96) 968 55 ( 52- 58) 972 62 (59-65) 971 54 (51-57) 966 42 (39-46) 968 43 (40-46)

HR 279 99 (97-100) 274 34 ( 28- 40) 279 40 (34-46) 279 38 (33-44) 278 0 (0-2) 274 29 (24-35)

HU 319 100 (98-100) 320 22 ( 18- 27) 317 25 (21-30) 319 29 (24-34) 309 0 (0-2) 314 18 (14-23)

IE 237 98 (95-99) 230 17 ( 12- 22) 236 8 (5-12) 237 10 (6-14) 174 0 (0-3) 230 4 (2-8)

IL 299 95 (92-97) 449 42 ( 37- 47) 451 44 (39-48) 451 46 (42-51) 451 22 (18-26) 449 35 (30-39)

IS 27 89 (70-97) 26 0 ( 0- 16) 27 0 (0-16) 27 0 (0-16) 26 0 (0-16) 26 0 (0-16)

IT 361 91 (87-93) 370 27 ( 23- 32) 367 35 (30-40) 371 25 (21-30) 360 1 (0-3) 346 18 (14-22)

LT 41 98 (86-100) 39 8 ( 2- 22) 41 27 (15-43) 41 37 (23-53) 41 0 (0-11) 39 3 (0-15)

LU 48 85 (72-93) 48 8 ( 3- 21) 47 2 (0-13) 47 2 (0-13) 19 0 (0-21) 47 0 (0-9)

LV 27 96 (79-100) 26 27 ( 12- 48) 27 44 (26-64) 27 22 (9-43) 27 0 (0-16) 26 8 (1-27)

MT 28 100 (85-100) 28 11 ( 3- 29) 28 7 (1-25) 28 0 (0-15) 28 0 (0-15) 28 0 (0-15)

NL 495 100 (99-100) 478 4 ( 3- 7) 422 7 (5-10) 487 5 (4-8) 336 0 (0-1) 411 3 (1-5)

NO 320 100 (98-100) 308 5 ( 3- 8) 320 2 (1-4) 320 1 (0-2) 274 0 (0-2) 308 0 (0-2)

PL 32 78 (60- 90) 32 3 ( 0- 18) 32 34 (19-53) 32 31 (17-50) 13 0 (0-28) 32 0 (0-13)

PT 370 99 (98-100) 366 18 ( 15- 23) 345 17 (13-21) 370 11 (8-15) 57 0 (0-8) 343 7 (5-10)

RO 18 100 (78- 99) 30 23 ( 11- 43) 30 80 (61-92) 30 80 (61-92) 23 0 (0-18) 30 23 (11-43)

SE 343 80 (75- 84) 645 7 ( 5- 9) 649 1 (1-3) 647 1 (0-2) 525 0 (0-1) 644 0 (0-1)

SI 170 99 (95-100) 170 26 ( 20- 34) 170 28 (21-35) 170 24 (18-31) 145 0 (0-3) 170 18 (13-25)

TR 637 98 (96-99) 638 23 ( 20- 27) 639 44 (41-48) 637 26 (22-29) 539 2 (1-4) 636 13 (10-16)

UK 352 97 (95-99) 346 12 ( 9- 16) 327 13 (9-17) 364 9 (6-12) 302 0 (0-2) 314 7 (5-11)

Total 10,046 96 10,560 18 10,237 23 10,682 20 7,743 2 10,108 11

* 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 2007.

Piperacillin +/- Tazobactam

Ceftazidime Carbapenems Fluoroquinolones Aminoglycosides

Country No %R(95CI) No %R(95CI) No %R(95CI) No %R(95CI) No %R(95CI)AT 410 6 (4-8) 377 5 (3-8) 408 12 (9-15) 374 14 (11-18) 385 8 (6-11)BG 14 14 (3-44) 14 21 (6-51) 14 7 (0-36) 14 14 (3-44) 14 29 (10-58)CY 52 29 (18-43) 52 13 (6-26) 52 19 (10-33) 51 18 (9-31) 52 23 (13-37)CZ 510 30 (26-34) 517 33 (29-37) 517 36 (32-40) 517 43 (38-47) 470 34 (30-38)DE 196 17 (12-24) 193 17 (12-23) 197 22 (16-28) 196 22 (16-29) 197 9 (6-14)DK 349 3 (2-6) 370 2 (1-5) 309 2 (1-5) 386 6 (4-9) 417 1 (0-3)EE 45 9 (3-22) 45 7 (2-19) 45 18 (9-33) 45 9 (3-22) 45 7 (2-19)ES 445 8 (6-11) 447 10 (7-13) 441 15 (12-19) 448 25 (21-29) 447 15 (12-19)FI 178 7 (4-12) 183 5 (3-10) 180 8 (5-14) 182 11 (7-17) 183 8 (5-13)FR 1168 11 (10-13) 1257 7 (5-8) 1302 14 (12-16) 1291 24 (21-26) 1245 18 (16-21)GR 797 38 (35-42) 781 40 (36-43) 798 47 (43-50) 796 50 (46-53) 799 49 (46-53)HR 189 30 (24-37) 185 14 (9-19) 189 26 (20-33) 188 30 (23-37) 189 40 (33-48)HU 489 11 (9-15) 514 9 (7-12) 507 19 (15-22) 512 22 (19-26) 518 26 (22-30)IE 170 6 (3-11) 165 5 (3-10) 160 9 (5-15) 170 18 (12-24) 168 10 (6-15)IL 312 15 (11-19) 307 12 (9-16) 313 14 (11-19) 313 26 (21-31) 313 20 (16-25)IS 11 0 (0-32) 11 0 (0-32) 11 0 (0-32) 11 0 (0-32) 11 0 (0-32)IT 184 20 (14-26) 169 25 (19-33) 184 27 (21-34) 184 35 (28-42) 183 27 (21-34)LT 20 5 (0-27) 21 0 (0-19) 20 30 (13-54) 21 38 (19-61) 21 33 (15-57)LU 32 16 (6-34) 34 12 (4-28) 8 25 (4-64) 34 35 (20-54) 34 24 (11-42)LV 16 31 (12-59) 16 13 (2-40) 16 6 (0-32) 16 13 (2-40) 16 31 (12-59)MT 36 11 (4-27) 36 3 (0-16) 36 11 (4-27) 36 11 (4-27) 36 8 (2-24)NL 311 2 (1-5) 338 4 (2-7) 298 2 (1-5) 337 5 (3-8) 338 3 (2-6)NO 97 2 (0-8) 105 3 (1-9) 97 9 (5-17) 103 7 (3-14) 105 2 (0-7)PL 67 36 (25-49) 66 23 (14-35) 67 22 (13-35) 67 40 (29-53) 67 40 (29-53)PT 336 14 (10-18) 339 16 (12-20) 323 15 (11-19) 335 19 (15-24) 340 16 (12-20)RO 4 0 (0-69) 3 0 (0-69) 4 0 (0-60) 4 25 (1-78) 4 25 (1-78)SE 260 2 (0-4) 335 4 (3-7) 324 7 (5-11) 271 6 (4-10) 342 0 (0-1)SI 88 13 (7-22) 88 7 (3-15) 88 19 (12-29) 88 17 (10-27) 88 10 (5-19)TR 413 24 (20-28) 415 23 (19-27) 420 28 (23-32) 418 25 (21-29) 373 24 (20-29)UK 332 5 (3-9) 320 7 (5-11) 261 10 (7-14) 353 9 (6-13) 350 5 (3-8)Total 6,875 18 7,055 16 6,997 21 7,078 27 7,114 22


Documents

EARSS Annual Report 2007 - European Centre for Disease ......EARSS Annual Report 2007 The European Antimicrobial Resistance Surveillance System (EARSS), funded by the European Centre