Antimicrobial resistance surveillance in Europe

Antimicrobial resistancesurveillance in EuropeAnnual report of the European AntimicrobialResistance Surveillance Network (EARS-Net)2011

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTThe European Centre for Disease Prevention and Control (ECDC) wishesto thank all EARS-Net participating laboratories and hospitals in theMember States for providing data for this report.Furthermore, all EARS-Net participants and National EpidemiologicalContact Points are acknowledged for facilitating data transferand providing valuable comments for this report. The ECDC’s staffmembers Silvia Sarbu and Dana Ursut, and WHONET representativeJohn Stelling are acknowledged for data management and providingtechnical support to the participating countries.ECDC’s staff members Liselotte Diaz Högberg and Ole Heuer areacknowledged for the preparation of the report, and Christine Waltonat UK NEQAS is acknowledged for her contribution to Annex 1. Inaddition, the ECDC wishes to thank EARS-Net Coordination groupmembers Christian Giske, Hajo Grundmann, Vincent Jarlier, GunnarKahlmeter, Jolanta Miciuleviciene, Jos Monen, Gian Maria Rossolini,Gunnar Skov Simonsen, Nienke van de Sande-Bruinsma and HelenaZemlickova for providing valuable comments and scientific adviceduring the production of the report.Suggested citation for full report:European Centre for Disease Prevention and Control. Antimicrobialresistance surveillance in Europe 2011. Annual Report of theEuropean Antimicrobial Resistance Surveillance Network (EARS-Net).Stockholm: ECDC; 2012.Cover picture © istockphotoISSN 1831-9491ISBN 978-92-9193-398-3doi 10.2900/6551© European Centre for Disease Prevention and Control, 2012.Reproduction is authorised, provided the source is acknowledged.ii

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011ContentsList of tables ................................................................................................................................................... ivList of figures ................................................................................................................................................. ivAbbreviations and acronyms ...................................................................................................................... viNational institutions/organisations participating in EARS-Net ........................................................ viiSummary ........................................................................................................................................................... 11 Introduction ................................................................................................................................................... 32 Data collection and analysis .................................................................................................................... 52.1 Data analysis ............................................................................................................................................... 62.2 Interpretation of the results .......................................................................................................................... 63 Demographic characteristics of cases of invasive gram-negative infections in Europe. . . . . . . . . . . 93.1. Introduction ................................................................................................................................................ 93.2. Material and methods .................................................................................................................................. 93.3 Results ....................................................................................................................................................... 103.4 Discussion .................................................................................................................................................. 114 Antimicrobial resistance in Europe ........................................................................................................ 134.1 Escherichia coli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134.2 Klebsiella pneumoniae ................................................................................................................................ 234.3 Pseudomonas aeruginosa ........................................................................................................................... 344.4 Streptococcus pneumoniae ......................................................................................................................... 474.5 Staphylococcus aureus ................................................................................................................................. 554.6 Enterococci ................................................................................................................................................ 59References ...................................................................................................................................................... 69Annex 1 External quality assessment (EQA) exercise 2011 ................................................................ 69Annex 2 EARS-Net laboratory/hospital denominator data 2011 ........................................................ 75Country summary sheets ............................................................................................................................. 81iii

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011SummaryThe results presented in this report are based on antimicrobialresistance data from invasive isolates reportedto EARS-Net by 29 EU/EEA countries in 2012 (data referringto 2011), and on trend analyses of EARSS/EARS-Netdata reported by the participating countries during theperiod 2008 to 2011.The results show a general Europe-wide increase of antimicrobialresistance in the gram-negative pathogensunder surveillance (Escherichia coli, Klebsiella pneumoniaeand Pseudomonas aeruginosa), whereas theoccurrence of resistance in the gram-positive pathogens(Streptococcus pneumoniae, Staphylococcus aureus,Enterococcus faecium and Enterococcus faecalis) appearsto be stabilising or even decreasing in some countries.For most pathogen–antimicrobial combinations, largeinter-country variations are evident.In 2011, the most alarming evidence of increasingantimicrobial resistance in Europe came from data oncombined resistance (resistance to third-generationcephalosporins, fluoroquinolones and aminoglycosides)in E. coli and in K. pneumoniae. For both of these pathogens,more than one third of the reporting countries hadsignificantly increasing trends of combined resistanceover the last four years.The high and increasing percentage of combined resistanceobserved for K. pneumoniae means that for somepatients with life-threatening infections, only a fewtherapeutic options remain available, e.g. carbapenems.However since 2010, carbapenem-resistance hasincreased in a number of countries, further aggravatingthe situation. For P. aeruginosa, combined resistanceis also common, with 15% of the isolates resistantto at least three of the antimicrobial classes undersurveillance. The seemingly unimpeded increase ofantimicrobial resistance in the major gram-negativepathogens will unavoidably lead to loss of therapeutictreatment options.In parallel, other trends of antimicrobial resistancereported to EARS-Net indicate that national effortson infection control and containment of resistance areeffective, as illustrated by the trends for meticillinresistantS. aureus (MRSA), antimicrobial-resistant S.pneumoniae and antimicrobial-resistant enterococci,for which the situation appears generally stable or evenimproving in some countries. For MRSA, these observationsare consistent with reports from the nationalsurveillance programmes of some Member States andrecent scientific studies on the results of infection controlefforts. Large inter-country variations can be notedfor S. pneumoniae, but non-susceptibility to commonlyused antimicrobials has remained relatively stable inEurope during recent years, and this observation wasconfirmed by the 2011 data.High-level aminoglycoside resistance in E. faecalisseems stable in Europe and several countries whichpreviously reported relatively high levels of resistancenow have decreasing trends. Likewise, the occurrenceof vancomycin-resistance in E. faecium is stabilising ordecreasing.For several antimicrobial–pathogen combinations, e.g.fluoroquinolone-resistance in E. coli, K. pneumoniae, P.aeruginosa and for MRSA, a north-to-south gradient isevident in Europe. In general, lower resistance percentagesare reported in the north and higher percentagesin the south of Europe. These geographical differencesmay reflect differences in infection control practices andantimicrobial use in the reporting countries. Prudent useof antimicrobial agents and comprehensive infectioncontrol measures should be cornerstones of effectiveprevention and control efforts aimed at reducing theselection and transmission of antimicrobial-resistantbacteria1

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT2

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011isolates of the same bacterial species from other sites,i.e. urinary tract infections, pneumonia, wound infections,etc.Case ascertainment of patients with bloodstream infections(BSIs) is strongly linked to diagnostic habits andthe frequency with which blood cultures are taken.Therefore, variations in blood culture frequency (nondifferentialsampling) result in an increasing uncertaintywhen comparing resistance percentages between differenthospitals and countries. Extrapolations of EARS-Netdata as a measure of BSI incidence could thereforeunderestimate the true value in countries with low bloodculture frequency.Differential sampling can occur if blood cultures are typicallyonly performed after empirical treatment showsno adequate therapeutic response. Predictably, thiswill lead to an overestimation of the percentage resistanceby not including susceptible BSI isolates from thedenominator.For detailed information on national blood culture frequency,see Annex 2.Laboratory routines and capacityThe use of guidelines for clinical breakpoints variesbetween countries in Europe, and in some instanceseven between laboratories in the same country. As aresult the interpretation of AST results may vary, atleast for resistance mechanisms producing MICs closeto the breakpoints. In addition, the use of microbiologicalbreakpoints may change over time, when breakpointprotocols are updated or changed. As data on quantitativemeasures (i.e. zone diameters in disk diffusiontests or MIC values) are not provided by all participatinglaboratories, only the reported S, I, and R results areconsidered for the analyses.The ability of the laboratory to identify the microorganismand its associated antimicrobial susceptibilitypattern may differ. All laboratories providing data forEARS-Net are offered participation in an annual ExternalQuality Assessment (EQA) exercise to assess the reliabilityof the laboratory test results.For more information on the EARS-Net EQA and laboratoryperformance, see Annex 1.7

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT8

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20113 Demographic characteristics of cases ofinvasive gram-negative infections in EuropeExperiences from EARSS/EARS-Net 2005–20113.1 IntroductionGram-negative bacteria (GNB) are a frequent cause ofserious infections including bloodstream infections(BSIs) 1 . Antimicrobial-resistant GNB have become animportant clinical and public health issue, having asignificant impact on morbidity, mortality and healthrelatedcosts 2–6 . Trends reported from EARSS/EARS-Nethave shown a continuous increase in the percentages ofantimicrobial-resistant GNB in many countries, indicatingthat the rise of resistant GNB in Europe is becominga serious public health problem that requires urgent andconcerted action. Antibiotic treatment options for multidrug-resistantGNB are often very limited and finding anappropriate drug is an increasing challenge since veryfew new antibiotics are expected to enter the market asthe older classes lose their efficacy 7 .An understanding of the risk factors associated withantimicrobial-resistant GNB is essential to guide interpretationof surveillance data and design effectivecontrol programmes, as antimicrobial-resistant GNB arereported to vary depending on geography, origin of isolateand type of population under surveillance 8–12 . Datafrom EARSS/EARS-Net provide an important source ofinformation on GNB in Europe, including informationfrom over 471 000 GNB isolates from 29 EU/EEA countriescollected over seven years. Traditionally, data fromEARS-Net are presented by their temporal and spatialaspects and are not routinely analysed by the demographiccharacteristics of the cases. The exception isthe country summary sheets provided in the annualEARS-Net report presenting isolates by age group, genderand hospital department. However, annual nationaldata in most cases do not cover a sufficient number ofisolates to determine any significant differences in datastratified by major demographic characteristics.Here we used pooled EARSS/EARS-Net data from 2005to 2011 to describe general demographic characteristicsof GNB infection cases reported to the network,and investigated demographic differences in resistanceto major antimicrobial classes and for combined resistance.This provides previously unpublished informationon antimicrobial-resistant GNB epidemiology in Europe.3.2 Material and methodsData for the three GNB included in EARS-Net (Klebsiellapneumoniae, Escherichia coli and Pseudomonas aeruginosa)reported from 2005 to 2011 were extractedfrom the EARS-Net (formerly EARSS) database at ECDC.Data were analysed by bacterial species and stratifiedaccording to patient’s age, gender, admission status andhospital department type. For age, data were groupedin four age strata: 0 to 4 years; 5 to 19 years; 20 to 64years and 65 years or older. Gender strata were femaleand male. Admission status was stratified accordingto reported inpatient and outpatient status at the timethe isolates were obtained. Hospital department typewas stratified as intensive care units (ICUs) (for isolatesreported obtained from patients in adult or paediatricICUs) and other, non-ICU departments (includingpatients from internal medicine, paediatric, surgery,oncology, obstetrics/gynaecology, emergency, urology,infectious disease and other departments).Reporting completeness differed for the variables. Ageinformation was missing for 7% of all cases, with onecountry (Greece) providing age information for less thanhalf of the cases; gender information was missing for 7%of all cases with one country (Greece) providing genderinformation for less than half of their cases; admissionstatus was missing for 15% of all cases with threecountries (Finland, Iceland and Ireland) providing thisinformation for less than half of their cases; and informationon hospital department was missing for 26% ofthe cases with six countries (Belgium, Finland, Ireland,Luxembourg, Netherlands and United Kingdom) reportinghospital department for less than half of their cases.Significant differences in selected demographic characteristicsbetween two groups were determined byChi 2 -test, and a p-value < 0.05 was considered statisticallysignificant.Mean percentages of AMR during the study periodincluding a 95% confidence interval (CI) were calculatedper bacterial species for the total number of isolates,as well as for each demographic characteristic includedin the study. For E. coli and K. pneumoniae, resistanceto third-generation cephalosporins and combinedresistance (i.e. resistance to fluoroquinolones, thirdgenerationcephalosporins and aminoglycosides) wereincluded, and for P. aeruginosa resistance to carbapenemsand combined resistance (i.e. resistance to threeor more of piperacillin±tazobactam, fluoroquinolones,ceftazidime, aminoglycosides and carbapenems) wereincluded in the analysis.9

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT3.3 ResultsGeneral demographic characteristics ofreported isolatesA total of 471 596 invasive isolates were included in thestudy, of which E. coli were the majority, accounting for344 700 (73%) isolates, followed by K. pneumoniae at74 985 isolates (16%) and 51 911 (11%) P. aeruginosa isolates.The number of isolates for which information onage and gender was missing was higher for K. pneumoniaeand P. aeruginosa than E. coli.As shown in Table 3.1, the age distribution was skewedtowards the elderly population (aged 65 years or older)for all included bacterial species. The highest percentageof isolates from the elderly was reported for E. coli(64%) and this was also the bacterium with the lowestpercentage of isolates from young children (0 to 4years). Escherichia coli were more frequent in femaleswhereas K. pneumoniae and P. aeruginosa were morefrequent in males.Inpatients represented the majority of cases for all bacteria,but the percentage was significantly lower for E.coli compared to the other two GNB (p

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Among inpatients, isolates from ICU patients were significantlymore likely to be resistant to the studiedantimicrobial classes than isolates from other departments(non-ICU patients). The differences in resistancepercentage between ICU and non-ICU patients were lessprominent for E. coli than K. pneumoniae and P. aeruginosa,but were significant for all three bacteria (Tables3.2, 3.3).3.4 DiscussionThis study is based on a unique dataset containing informationfrom a large number of GNB isolates collectedfrom 29 European countries over a seven-year period.For the first time, we present the demographic characteristicsof cases of invasive GNB infection as reportedto EARSS/EARS-Net, highlighting differences in theepidemiological data linked to the isolates of E. coli, K.pneumoniae and P. aeruginosa in Europe.The rank order of the bacteria included in this study wassimilar to that which has been reported elsewhere 4,13–15with the majority (70%) of the isolates being E. coli.There was a significant difference between the demographicprofile of cases with E. coli BSI and cases withBSI caused by K. pneumoniae or P. aeruginosa; a higherpercentage of isolates from the elderly, a majority offemale patients and a lower percentage of isolates frominpatients and from ICU patients. Although data fromEARSS/EARS-Net do not provide sufficient informationto determine the origin of the infection, these resultsmay partly be explained by previously reported differencesin the aetiology of invasive E. coli infections and ofK. pneumoniae and P. aeruginosa infections. In severalstudies, E. coli has more frequently been associated withcommunity-acquired BSI than other GNB 16 and was moreoften associated with a urinary tract source 17 , especiallyin female patients 18 . This is in contrast to observationsfor invasive isolates of K. pneumoniae and P. aeruginosaTable 3.2: Percentage (%) of isolates resistant to third-generation cephalosporins (3GC R) and combined resistance(combined R) (resistance to fluoroquinolones, third-generation cephalosporins and aminoglycosides) for all cases andper demographic characteristic in invasive isolates of E. coli and K. pneumoniae reported to EARSS/EARS-Net duringthe period 2005–2011 (95% CI given in parenthesis)E. coli K. pneumoniae3GC R Combined R 3GC R Combined RAll cases 6.7 (6.6-6.8) 2.9 (2.8-2.9) 35.3 (33.5-37.2) 17.5 (17.2-17.8)Age0 to 4 years 5.5 (5.0-6.1) 1.5 (1.2-1.8) 35.3 (33.5-37.2) 15.4 (14.0-16.8)5 to 19 years 5.7 (4.9-6.5) 2.1 (1.6-2.7) 24.5 (21.4-27.8) 13.6 (11.2-16.3)20 to 64 years 6.6 (6.4-6.7) 2.8 (2.7-2.9) 23.1 (22.5-23.6) 15.7 (15.2-16.2)65 years or older 6.5 (6.4-6.6) 2.7 (2.7-2.8) 17.0 (16.7-17.4) 11.0 (10.6-11.1)GenderMale 7.9 (7.7-8.0) 3.4 (3.3-3.5) 22.3 (21.9-22.7) 14.6 (14.2-15.0)Female 5.4 (5.3-5.5) 2.2 (2.1-2.2) 17.8 (17.3-18.3) 11.1 (10.7-11.5)Admission statusInpatient 7.1 (7.0-7.2) 3.0 (3.0-3.1) 29.0 (28.7-29.4) 20.0 (19.7-20.4)Outpatient 5.1 (4.9-5.3) 2.1 (2.0-2.3) 8.2 (7.5-9.0) 5.0 (4.4-5.6)Hospital departmentICU 9.8 (9.4-10.2) 3.9 (3.6-4.1) 51.7 (50.9-52.5) 37.1 (36.3-37.9)Other department 6.4 (6.4-6.5) 2.8 (2.7-2.9) 18.9 (18.6-19.2) 12.3 (12.0-12.6)Table 3.3: Percentage (%) resistance to carbapenems and combined resistance (resistance to three or more antibioticclasses among piperacillin–tazobactam, ceftazidime, aminoglycosides and carbapenems) for all cases and perdemographic characteristic in invasive isolates of P. aeruginosa reported to EARSS/EARS-Net during the period2005–2011 (95% CI given in parenthesis)P. aeruginosaCarbapenem RCombined resistanceAll cases 18.8 (18.5-19.1) 15.6 (15.3-15.9)Age0 to 4 years 17.2 (15.3-19.3) 11.4 (9.7-13.0)5 to 19 years 17.1 (14.5-19.8) 11.1 (9.0-13.3)20 to 64 years 19.7 (19.1-20.4) 15.5 (15.0-16.0)65 years or older 11.5 (11.1-11.9) 9.5 (9.2-9.9)GenderMale 15.5 (15.1-15.9) 12.5 (12.1-12.9)Female 14.8 (14.3-15.4) 11.6 (11.1-12.1)Admission statusInpatient 20.8 (20.4-21.2) 17.5 (17.2-17.9)Outpatient 6.7 (5.8-7.7) 4.4 (3.7-5.1)Hospital departmentICU 32.5 (31.7-33.3) 27.9 (27.1-28.7)Other department 14.1 (13.7-14.5) 11.5 (11.2-11.8)11

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTwhich have been reported to originate more frequentlyfrom healthcare-associated infections and from patientsin ICU 14 where BSIs with GNB often originate from therespiratory or gastrointestinal tract 17–20 .For all GNB and all resistance types included in thestudy, isolates from inpatients had higher resistancelevels than those from outpatients, and isolatesfrom ICU patients had significantly higher resistancepercentages than isolates from patients from otherdepartments. These results are hardly surprising andsupport previous conclusions highlighting risk factorsfor transmission of resistant bacteria in the hospitalenvironment. High antibiotic pressure, frequent use ofinvasive devices and the challenge of maintaining a highstandard of infection control all contribute to increasethe risk of patients acquiring a healthcare-associatedinfection with resistant bacteria 20 .Our results also revealed age- and gender-related differencesbetween resistance percentages. While thesedifferences were less prominent for E. coli than K. pneumoniaeand P. aeruginosa, they could be noted for allthree bacteria. Interestingly, the age group where resistancepercentages were the highest differed betweenbacteria. For K. pneumoniae and P. aeruginosa, resistancepercentages were lower in isolates from the elderly(age ≥65 years) than in those from other age groups,whereas for E. coli resistance percentages were higheramong isolates from adults and the elderly than fromchildren. These differences are difficult to explain, butmay be attributed to differences in the types of infectioncaused by the bacteria as well as age-related differencesin risk factors such as antimicrobial use and exposure tothe healthcare environment. A more in-depth analysisincluding additional clinical information is required inorder to properly determine the role of the patient’s agein resistance percentages for the different bacteria.EARS-Net inclusion criteria address some of thepotential threats to data validity by only accepting informationfrom invasive isolates and by excluding duplicatereports from the same patient and year. By pooling informationfrom a seven-year period, the large number ofobservations allowed for analysis of data by differentdemographic strata. However, pooling national surveillancedata to provide European estimates will increasethe risk of bias caused by inter-country differences inpopulation coverage, methods for data collection andspecimen processing. As the population coverage for thecountries participating in EARS-Net varies considerably,individual countries will contribute differently to thecrude European estimate. In addition, the percentageof missing information for the demographic variablesdiffered both between countries and between bacteria.The percentages of isolates missing information on ageand gender were considerably higher for K. pneumoniaeand P. aeruginosa than for E. coli. Although this maypartly influence the observed differences in age andgender distribution between the bacteria, it is unlikelythat it would fully explain the observed demographicdifferences.In conclusion, documenting population-specific differencesin resistance percentages and trends is importantto enable identification of high-risk groups and to formulatepolicies on screening, prevention and control ofAMR. Data from EARSS/EARS-Net indicate that there aresignificant differences in the demographic profiles ofcases with invasive GNB infections in Europe, both forthe GNB involved, and for the percentages of resistanceto important antimicrobials including combined resistance.However, due to the ecological nature of EARSS/EARS-Net data, our results should be interpreted withcaution, and we encourage additional studies based ondata with more extensive clinical information to furtherexplore these differences.Providing representative population estimates is achallenge for any surveillance system 21,22 . The EARSS/12

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20114 Antimicrobial resistance in Europe4.1 Escherichia coli4.1.1 Clinical and epidemiological importanceEscherichia coli is the gram-negative rod most frequentlyisolated from blood cultures. It is the mostfrequent cause of bacteraemia, community- and hospital-acquiredurinary tract infections, is associated withspontaneous and post-surgical peritonitis and with skinand soft tissue infections of polymicrobial aetiology,causes neonatal meningitis and is one of the leadingcausative agents in food-borne infections worldwide.4.1.2 Resistance mechanismsIn E. coli, resistance to beta-lactams is mostly due toproduction of beta-lactamases, which hydrolyse thebeta-lactam ring of beta-lactam antimicrobials, whichis crucial for inhibition of the penicillin-binding protein(PBP) targets. Resistance to broad-spectrum penicillins,such as ampicillin or amoxicillin, is usually conferred byplasmid coded beta-lactamases mainly of the TEM typeand to a lesser extent of the SHV type, (whereby TEM-1accounts for up to 60% of aminopenicillin resistance),while resistance to third-generation cephalosporinsis mostly conferred by extended-spectrum beta-lactamases(ESBLs). The first ESBLs spreading in E. coli werevariants of the TEM or SHV enzymes in which single ormultiple aminoacid substitutions expand their hydrolysingability to include third-generation cephalosporins(in this report referring to cefotaxime, ceftriaxone andceftazidime), fourth-generation cephalosporins andmonobactams. During the past decade, however, theseenzymes have largely been replaced by the CTX-M-typeESBLs, which are now the most common ESBLs in E. coli.Most ESBLs can be inhibited by beta-lactamase inhibitorssuch as clavulanic acid, sulbactam or tazobactam.More than 250 ESBL variants are known to date. Animportant factor in their global dominance is the widedissemination of particular plasmids or bacterial clonesproducing CTX-M-type ESBLs (e.g. CTX-M-15). Otherenzymes affecting the susceptibility to third-generationcephalosporins include plasmid-encoded variantsderived from some chromosomal AmpC-type beta-lactamases.CMY-2 is the most widespread enzyme belongingto this group, which is still less common than ESBLs in E.coli in Europe, but frequently seen in the United States.An important threat that will require close surveillancein the future is the emergence of carbapenem resistancein E. coli, mediated by metallo-beta-lactamases (such asthe VIM or IMP enzymes, or the emerging NDM enzyme)or serine-carbapenemases (such as the KPC enzymes),providing resistance to most or all available beta-lactamFigure 4.1: Escherichia coli: percentage (%) of invasive isolates with resistance to third-generation cephalosporins bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta13

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011agents. Another growing family of ESBLs comprises theOXA-type enzymes that confer resistance to ampicillinand cefalotin and are characterised by their high hydrolyticactivity against oxacillin and cloxacillin and the factthat they are poorly inhibited by clavulanic acid. Thisfamily also includes some enzymes with carbapenemaseactivity (e.g. OXA-48), which have recently emerged inE. coli and other enterobacteriaceae and confer reducedsusceptibility to carbapenems and resistance to penicillins,but not to the expanded-spectrum cephalosporins.Increasingly common is also the finding of E. coli strainswhich produce multiple beta-lactamases.Fluoroquinolones interact with DNA gyrase andtopoisomerase IV, which are enzymes that regulateconformational changes in the bacterial chromosomeduring replication and transcription. This interactionleads to the irreversible inhibition of the enzyme activityfollowed by DNA fragmentation and eventually to celldeath. Resistance to fluoroquinolones arises throughstepwise mutations in the coding regions of the gyrasesubunits (gyrA and gyrB) and DNA topoisomerase IV(parC). Accumulation of mutations in several of thesegenes increases the MIC in a stepwise manner. Low-levelresistance to fluoroquinolones may also arise throughchanges in outer membrane porins or from upregulationof efflux pumps, resulting in lower outer membranepermeability and higher efflux, respectively. In recentyears, several plasmid-mediated quinolone resistancemechanisms have also been identified, including theQnr proteins, which protect DNA topoisomerases fromquinolone binding, the AAC(6’)-Ib-cr enzyme, whichinactivates some fluoroquinolones by acetylation, andthe QepA efflux pump, which effluxes hydrophilic quinolones.These mechanisms are a concern becausethis type of resistance is transferable and because oftheir frequent association with CTX-M and CMY-typeenzymes inactivating third-generation cephalosporins.Additionally they are believed to increase the risk ofchromosomal mutations.Aminoglycosides block protein synthesis by bindingto the ribosomes, which are involved in the translationof RNA into proteins, and are also able to damagethe outer membrane of gram-negative rods. Resistanceto aminoglycosides can be due to targeted modification(methylation) of the large ribosomal subunit,which excludes aminoglycoside molecules, or byaminoglycoside-modifying enzymes that acetylate,adenylate or phosphorylate their target molecules andthereby neutralise the biological effect of aminoglycosides.Of particular concern is ArmA 16S that conferspan-resistance to aminoglycosides, and is frequentlyaccompanying carbapenemases.4.1.3 ResultsAminopenicillins• For 2011, 28 countries reported 57 920 isolates,of which 32 110 (55.4%) were resistant toTable 4.1: Escherichia coli: number and percentage of invasive isolates resistant to aminopenicillins, third-generationcephalosporins, fluoroquinolones, aminoglycosides and combined resistance*, including 95% confidence intervals(95% CI), by country, EU/EEA countries, 2011CountryAminopenicillins Third-gen. cephalosporins Fluoroquinolones Aminoglycosides Combined resistanceN %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)Austria 3 148 50.3 (49-52) 3 160 9.1 (8-10) 3 162 22.3 (21-24) 3 144 7.4 (7-8) 3 121 2.6 (2-3)Belgium 3 507 58.7 (57-60) 3 985 6.0 (5-7) 3 549 21.5 (20-23) 3 831 9.3 (8-10) 3 331 1.4 (1-2)Bulgaria 152 60.5 (52-68) 179 22.9 (17-30) 179 30.2 (24-37) 179 17.3 (12-24) 179 10.1 (6-15)Cyprus 134 77.6 (70-84) 138 36.2 (28-45) 137 47.4 (39-56) 138 23.9 (17-32) 137 18.2 (12-26)Czech Republic 2 683 60.7 (59-63) 2 684 11.4 (10-13) 2 682 23.5 (22-25) 2 674 8.8 (8-10) 2 667 3.7 (3-4)Denmark 3 638 47.9 (46-50) 2 532 8.5 (7-10) 3 583 14.1 (13-15) 3 638 6.4 (6-7) 2 529 3.0 (2-4)Estonia 0 . 90 12.2 (6-21) 312 9.9 (7-14) 314 4.8 (3-8) 89 1.1 (0-6)Finland 1 826 36.3 (34-39) 2 419 5.1 (4-6) 2 420 10.8 (10-12) 2 420 5.3 (4-6) 2 419 2.7 (2-3)France 8 784 55.1 (54-56) 8 479 8.2 (8-9) 8 694 17.9 (17-19) 8 742 7.9 (7-8) 8 428 2.6 (2-3)Germany 3 638 52.3 (51-54) 3 642 8.0 (7-9) 3 636 23.7 (22-25) 3 645 7.6 (7-9) 3 631 3.6 (3-4)Greece 1 297 54.5 (52-57) 1 435 14.9 (13-17) 1 433 26.6 (24-29) 1 434 16.8 (15-19) 1 431 10.8 (9-13)Hungary 991 64.7 (62-68) 1 224 15.1 (13-17) 1 213 31.2 (29-34) 1 226 14.8 (13-17) 1 209 8.3 (7-10)Iceland 129 48.1 (39-57) 130 6.2 (3-12) 121 14.0 (8-22) 129 6.2 (3-12) 120 0.8 (0-5)Ireland 2 118 69.5 (68-72) 2 166 9.0 (8-10) 2 153 22.9 (21-25) 2 158 10.2 (9-12) 2 148 3.6 (3-4)Italy 1 530 67.1 (65-69) 1 870 19.8 (18-22) 1 899 40.5 (38-43) 1 985 18.3 (17-20) 1 745 10.3 (9-12)Latvia 130 54.6 (46-63) 132 15.9 (10-23) 131 16.8 (11-24) 132 11.4 (7-18) 131 9.2 (5-15)Lithuania 383 47.8 (43-53) 385 7.0 (5-10) 381 12.9 (10-17) 382 9.7 (7-13) 378 2.4 (1-4)Luxembourg 353 52.1 (47-57) 353 8.2 (6-12) 353 24.1 (20-29) 354 8.2 (6-12) 353 2.8 (1-5)Malta 219 53.0 (46-60) 219 12.8 (9-18) 219 32.0 (26-39) 219 15.5 (11-21) 219 9.6 (6-14)Netherlands 4 425 48.5 (47-50) 4 408 5.7 (5-6) 4 427 14.3 (13-15) 4 431 7.8 (7-9) 4 400 2.2 (2-3)Norway 2 617 39.1 (37-41) 2 523 3.6 (3-4) 2 505 9.0 (8-10) 2 470 4.1 (3-5) 2 259 1.2 (1-2)Poland 934 62.0 (59-65) 938 11.7 (10-14) 1 141 27.3 (25-30) 1 171 8.4 (7-10) 902 4.0 (3-5)Portugal 1 963 56.5 (54-59) 1 901 11.3 (10-13) 1 917 27.2 (25-29) 1 962 16.1 (14-18) 1 891 7.5 (6-9)Romania 22 68.2 (45-86) 91 22.0 (14-32) 46 30.4 (18-46) 46 19.6 (9-34) 46 10.9 (4-24)Slovakia 608 68.6 (65-72) 738 31.0 (28-35) 737 41.9 (38-46) 738 17.9 (15-21) 737 12.9 (11-16)Slovenia 1 002 53.9 (51-57) 1 002 8.8 (7-11) 1 002 20.7 (18-23) 1 002 9.8 (8-12) 1 002 4.1 (3-6)Spain 5 592 65.6 (64-67) 5 600 12.0 (11-13) 5 597 34.5 (33-36) 5 603 14.8 (14-16) 5 594 4.9 (4-6)Sweden 1 023 34.8 (32-38) 3 939 3.0 (3-4) 3 295 7.9 (7-9) 3 203 3.7 (3-4) 2 844 1.0 (1-1)United Kingdom 5 074 62.8 (61-64) 5 182 9.6 (9-10) 5 564 17.5 (17-19) 5 661 8.2 (7-9) 5 005 3.6 (3-4)* Combined resistance defined as being resistant to third-generation cephalosporins, fluoroquinolones and aminoglycosides.15

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTTable 4.2: Escherichia coli: number of invasive isolatesresistant to third-generation cephalosporins (3GCREC)and percentage of extended spectrum beta-lactamase(ESBL)-positive among these isolates, as ascertainedby the participating laboratories, EU/EEA countries,2011CountryNumber oflaboratoriesNumber of3GCREC%ESBLAustria 27 237 91.1Bulgaria 12 30 93.3Czech Republic 42 305 89.5Denmark 3 45 71.1Estonia 5 11 100France 16 99 83.8Germany 12 190 92.1Hungary 9 44 100Ireland 26 189 82Latvia 5 21 90.5Lithuania 8 27 100Luxembourg 5 29 96.6Poland 33 98 85.7Portugal 14 159 97.5Slovakia 7 154 83.1Slovenia 9 88 94.3Spain 26 381 88.5Only data from laboratories consistently reporting the ESBL test results for allisolates identified as resistant to third-generation cephalosporins and fromcountries with at least 10 of such isolates were selected for the analysis.aminopenicillins. The number of isolates with relevantAST information reported per country ranged from 22to 8 784 (Table 4.1).• The percentages of resistant isolates in the reportingcountries ranged from 34.8% (Sweden) to 77.6%(Cyprus). Seven countries reported 25-50%, while theremaining 21 countries reported resistant percentagesabove 50% (Table 4.1).• Trends for the period 2008–2011 were calculatedfor 27 countries. Significantly increasing trendswere observed for eight countries (Belgium, Cyprus,Denmark, Greece, Hungary, Italy, Spain and Sweden).For Belgium, Italy and Sweden the trends were not significantwhen considering only data from laboratoriesreporting consistently for all four years (Figure 4.4).• Significantly decreasing trends were observed for twocountries (Germany and Lithuania); however, thesetrends were not significant when considering onlylaboratories reporting consistently for all four years(Figure 4.4).Third-generation cephalosporins• For 2011, 29 countries reported 61 544 isolates, ofwhich 5 619 (9.1%) were resistant to third-generationcephalosporins. The number of isolates with relevantAST information reported per country ranged from 90to 8 479 (Table 4.1).• The percentages of resistant isolates in the reportingcountries ranged from 3.0% (Sweden) to 36.2%(Cyprus). Two countries reported resistance percentagesbelow 5%, 13 countries reported 5-10%,12 countries reported 10-25%, and two countriesreported above 25% (Table 4.1 and Figure 4.5).• Trends for the period 2008–2011 were calculatedfor 28 countries. Significant increasing trends wereobserved in 18 of 28 countries. For three countries(Italy, the Netherlands, and Poland), the trends didnot remain significant when considering only datafrom laboratories reporting consistently for all fouryears (Figure 4.5).• None of the 28 reporting countries had decreasingtrends of resistance to third-generation cephalosporinsover the last four years (Figure 4.5).Extended-spectrum beta-lactamase (ESBL)• Among E. coli isolates resistant to third-generationcephalosporins, a large percentage was ascertainedas ESBL-positive by the participating laboratoriesin 2011. Fourteen of 17 countries reported between85% and 100% ESBL-positive isolates among isolatesresistant to third-generation cephalosporins (Table4.2).Fluoroquinolones• For 2011, 29 countries reported 62 488 isolates ofwhich 13 075 (20.9%) were resistant to fluoroquinolones.The number of isolates with relevant ASTinformation reported by the countries ranged from 46to 8 694 (Table 4.1).• The percentages of resistant isolates in the reportingcountries ranged from 7.9% (Sweden) to 47.4%(Cyprus). Three countries reported resistance percentagesbelow 10%, 15 countries reported 10-25% and 11countries reported above 25% (Table 4.1 and Figure4.2)• Trends for the period 2008–2011 were calculated for28 countries. Significantly increasing trends wereobserved for 11 countries. For Italy and Poland, thesetrends were not significant when considering onlydata from laboratories reporting consistently duringall four years (Figure 4.6).• Significantly decreasing trends were observed forthe Czech Republic and Sweden; however, the trendsfor these two countries were not significant whenconsidering only data from laboratories reporting consistentlyfor all four years (Figure 4.6).Aminoglycosides• For 2011, 29 countries reported 63 031 isolates ofwhich 5 867 (9.3%) were resistant to aminoglycosides.The number of isolates with relevant AST informationreported by the countries ranged from 46 to 8 742(Table 4.1).• The percentages of resistant isolates in the reportingcountries ranged from 3.7% (Sweden) to 23.9%(Cyprus). Three countries reported resistance percentagesbelow 5%, 14 countries reported 5-10%, 12countries reported above 10% (Table 4.1 and Figure4.3).• Trends for the period 2008–2011 were calculated for28 countries. Significantly increasing trends were16

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Table 4.3: Escherichia coli: overall resistance and resistance combinations among invasive isolates tested againstaminopenicillins, fluoroquinolones, third-generation cephalosporins and aminoglycosides (n=54 338), EU/EEAcountries, 2011Resistance pattern Number of isolates % of totalFully susceptible 22 586 41.6Single resistance (to indicated drug classes)Total (all single resistance) 19 293 35.5Aminopenicillins 17 954 33Fluoroquinolones 1 236 2.3Aminoglycosides 103 0.2Resistance to two classes of antimicrobial drugsTotal (all two classes combinations) 6 457 11.9Aminopenicillins + fluoroquinolones 4 610 8.5Aminopenicillins + third-generation cephalosporins 964 1.8Aminopenicillins + aminoglycosides 797 1.5Fluoroquinolones + aminoglycosides 86 0.2Resistance to three classes of antimicrobial drugsTotal (all three classes combinations) 3 864 7.1Aminopenicillins + fluoroquinolones + aminoglycosides 1 867 3.4Aminopenicillins + third-generation cephalosporins + fluoroquinolones 1 796 3.3Aminopenicillins + third-generation cephalosporins + aminoglycosides 201 0.4Resistance to four classes of antimicrobial drugsAminopenicillins + third-generation cephalosporins + fluoroquinolones + aminoglycosides 2 138 3.9Only data from isolates tested against all four antimicrobial classes were included in the analysis.observed for 11 countries. For Belgium, Hungary, Italyand Portugal the trends did remain significant whenconsidering only data from laboratories consistentlyreporting for all four years (Figure 4.7).• A significantly decreasing trend of aminoglycosideresistance was observed only for one country(Bulgaria) (Figure 4.7).Carbapenems• For 2011, 28 countries reported 59 326 isolates, ofwhich 25 (0.04%) were resistant to carbapenems.The number of isolates with relevant AST informationreported by the countries ranged from 1 to 8 503.Eleven countries reported one or more resistantisolate(s) in 2011. The majority of the resistant isolates(10 isolates; 40%) were reported by Greece.Combined resistance• For 2011, 29 countries reported 58 945 E. coli isolatestested for resistance to third-generation cephalosporins,fluoroquinolones and aminoglycosides. Thenumber of isolates with relevant AST informationreported by the countries ranged from 46 to 8 428(Table 4.1).• The percentage of isolates with combined resistanceto third-generation cephalosporins, fluoroquinolonesand aminoglycosides) reported by the countriesranged from 0.8% (Iceland) to 18.2% (Cyprus). Onecountry reported a resistance percentage below 1%,18 countries reported 1–5%, four countries reported5–10%, and six countries reported above 10% (Table4.1 and Figure 4.8).• Trends for the period 2008–2011 were calculated for28 countries. Significantly increasing trends wereobserved for 13 countries. For Belgium, Italy, theNetherlands and Poland, the trends did not remain significantwhen considering only data from laboratoriesreporting consistently for all four years (Figure 4.8).• Significantly decreasing trends were observed forBulgaria and Malta. For Bulgaria, the trend did notremain significant when considering only data fromlaboratories reporting consistently for all four years.• More detailed information on the most frequent resistancephenotypes in E. coli is presented in Table 4.3.4.1.4 Discussion and conclusionsAntimicrobial resistance in E. coli requires close attentionas the percentages of isolates resistant to commonlyused antimicrobials continue to increase throughoutEurope. Especially worrisome is the increase of resistanceto third-generation cephalosporins and combinedresistance to at least three antimicrobial classes, forwhich many countries reported significantly increasingtrends during the period 2008–2011.Although EARS-Net data on ESBL production remainincomplete, a large percentage of third-generationcephalosporin-resistant E. coli was reported as ESBLpositive.Presence of ESBL production and combinedresistance is a serious public health concern since itseverely limits the number of treatment alternatives forpatients with life-threatening infections. In addition,increasing combined resistance and spread of ESBLmay lead to increased use of carbapenems, favouringthe further dissemination of carbapenemase-producingEnterobacteriaceae (CPE).Prudent antimicrobial use and comprehensive infectioncontrol measures should be the cornerstones ofinterventions aiming to prevent selection and transmissionof resistant bacteria, including E. coli. A recent riskassessment on the spread of CPE published by ECDCin 2011 emphasises that the use of standard precautions,especially adherence to hand hygiene policies,is fundamental to prevent transmission of any multidrug-resistantorganisms, not only CPE, in healthcaresettings 23 .17

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.5: Escherichia coli: trends of invasive isolates with resistance to third-generation cephalosporins, by country,EU/EEA countries, 2008–2011SENO (>)FI (>)NL (>*)2008200920102011BEIS (>)LTDE (>)FR (>)LUDK (>)SI (>)IE (>)Country codeAT (>)UK (>)PTCZPL (>*)ES (>)EE (>)MTEL (>)HU (>)LVIT (>*)ROBGCY (>)0 5 10 15 20 25 30 35 40% third-generation cephalosporin resistanceCountries not reporting data for all four years (Slovakia) were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends,respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.19

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.6: Escherichia coli: trends of invasive isolates with resistance to fluoroquinolones, by country, EU/EEAcountries, 2008–2011SE ()2008200920102011LTIS (>)DK (>)NLLVUKFR (>)SI (>)BE (>)Country codeATIECZ ()PTPL (>*)BGROHU (>)MTES (>)IT (>*)CY0 10 20 30 40 50% fluoroquinolone resistanceCountries not reporting data for all four years (Slovakia) were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends,respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.20

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.7: Escherichia coli: trends of invasive isolates with resistance to aminoglycosides, by country, EU/EEAcountries, 2008–2011SE (>)NOEEFI (>)2008200920102011ISDK (>)ATDENL (>)FR (>)UKLUPLCountry codeCZBE (>*)LTSIIELVHU (>*)ES (>)MTPT (>*)ELBG (*)ROCY (>)0 5 10 15 20 25 30 35% aminoglycoside resistanceCountries not reporting data (Slovakia) for all four years were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends,respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.21

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.8: Escherichia coli: trends of invasive isolates with combined resistance (resistant to fluoroquinolones, thirdgenerationcephalosporins and aminoglycosides), by country, EU/EEA countries, 2008–2011ISSEEENO2008200920102011BE (>*)NL (>*)LTATFR (>)FI (>)LUDK (>)DECountry codeUKIE (>)CZPL (>*)SI (>)ES (>)PTHU (>)LVMT ()ROCY (>)0 5 10 15 20% combined resistanceCountries not reporting data for all four years (Slovakia) were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends,respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.22

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20114.2 Klebsiella pneumoniae4.2.1 Clinical and epidemiological importanceBacteria of the genus Klebsiella are frequent colonisersof the gastrointestinal tract in humans, but may also befound on skin, in the oropharynx and upper airways inhospitalised individuals. Klebsiella pneumoniae is associatedwith opportunistic infections in individuals withimpaired immune systems, such as diabetic, alcoholicand hospitalised patients with indwelling devices. Themost common sites of infection are the urinary tractand the respiratory tract. Organisms such as K. pneumoniaecan spread rapidly, from the gastrointestinaltract of patients and via the hands of hospital personnelto colonise other patients, leading to nosocomialoutbreaks. Klebsiella pneumoniae is the second mostfrequent cause of gram-negative bloodstream infectionsafter Escherichia coli. The mortality rates of pneumoniacaused by K. pneumoniae can be high even when appropriateantimicrobial treatment is given. However, thisalso depends on the severity of the underlying condition.4.2.2 Resistance mechanismsSimilar to E. coli, K. pneumoniae can be resistant to multipleantimicrobials, and resistance traits are frequentlyacquired through plasmids. However, in contrast to E.coli, K. pneumoniae has a chromosomally encoded SHVbeta-lactamase and is thus intrinsically resistant to aminopenicillins.Moreover, this organism readily acquiresplasmid-mediated resistance determinants. Many novelESBL variants were initially identified in K. pneumoniaeand were only subsequently found in E. coli. Since theresistance mechanisms do not differ significantly fromthose described for E. coli, readers should refer to the E.coli section (4.1, above) for further details. Carbapenemshave been widely used in many countries due to theincreasing rate of ESBL-producing Enterobacteriaceaewith a consequent impact on the emergence ofresistance to these antimicrobials, especially in K. pneumoniae.KPC carbapenemase-producing clones of K.pneumoniae have been observed in the United States,Greece, Italy and Israel, and similar strains are nowspreading in several European countries while plasmidsencoding the VIM metallo-carbapenemase are frequentin K. pneumoniae in Greece. A new type of plasmidic carbapenemase,the New Delhi metallo-beta-lactamase 1(NDM-1), has been observed in patients returning fromthe Indian subcontinent. The bla OXA-48 gene codes for anoxacillinase (OXA-48) that causes resistance to penicillinand reduces susceptibility to carbapenems, but not toexpanded-spectrum cephalosporins. The level of resistanceis often low and such strains are thus frequentlymissed in laboratories using automated AST systems. Acombination of OXA-48-like enzymes with ESBLs suchas CTX-M15 can occur in Klebsiella spp. and can resultin a highly drug-resistant phenotype. Single clones withsuch combinations have caused hospital outbreaks inseveral European countries.Figure 4.9: Klebsiella pneumoniae: percentage (%) of invasive isolates with resistance to third-generationcephalosporins, by country, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta23

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT4.2.3 ResultsThird-generation cephalosporins• For 2011, 29 countries reported 15 052 K. pneumoniaeisolates of which 4 538 (30.1%) were resistant to thirdgenerationcephalosporins. The number of isolateswith relevant AST information reported by the countriesranged from 25 to 1 665.• The percentages of isolates reported as resistantranged from 2.3% (Sweden) to 81.0% (Bulgaria). Threecountries reported resistance percentages below 5%,four countries reported 5–10%, six countries reported10–25%, 10 countries reported 25–50%, and six countriesreported above 50% (Figure 4.9, Table 4.4).• Trends for the period 2008–2011 were calculated for25 countries. Significantly increasing trends wereobserved for 10 countries. For Italy, the trend did notremain significant when considering only data fromlaboratories reporting consistently for all four years(Figure 4.14).• None of the reporting countries had significantlydecreasing trends of resistance to third-generationcephalosporins (Figure 4.14).Extended-spectrum beta-lactamase (ESBL)• Nineteen countries were included in the calculationof ESBL percentages for K. pneumoniae. Datawere only included from laboratories reporting ESBLtest results for all isolates identified as resistant tothird-generation cephalosporins, and only from countrieswith at least 10 of such isolates.• The percentage of K. pneumoniae isolates found tobe resistant to third-generation cephalosporins andascertained by the participating laboratories as ESBLproducers, ranged from 65.2% to 100%. The percentagesof isolates ascertained as ESBL producers werereported by 19 countries (Table 4.5).Fluoroquinolones• For 2011, 29 countries reported 15 329 isolates, ofwhich 4 668 (30.5%) were resistant to fluoroquinolones.The number of isolates with relevant ASTinformation reported per country ranged from 10 to1 683 (Table 4.4).• The percentage of isolates found to be resistantranged from 1.9% (Sweden) to 72.2% (Greece). Fivecountries reported resistance percentages below 5%,two countries reported 5-10, seven countries reported10–25%, eight countries reported 25–50%, and sevencountries reported above 50% (Figure 4.10, Table 4.4).• Trends for the period 2008–2011 were calculated for25 countries. Significantly increasing trends wereobserved for 10 countries. For Luxembourg, the trendwas not significant when considering only data fromlaboratories reporting consistently for all four years(Figure 4.15).Figure 4.10: Klebsiella pneumoniae: percentage (%) of invasive isolates with resistance to fluoroquinolones, bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta24

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011• Significantly decreasing trends were observed for twocountries (Denmark and Sweden) (Figure 4.15).Aminoglycosides• For 2011, 29 countries reported 15 367 isolates, ofwhich 4 020 (26.2%) were resistant to aminoglycosides.The number of isolates with relevant ASTinformation reported per country ranged from 10 to1 688.• The percentages of resistant isolates reported bythe countries ranged from zero (Iceland) to 71.7%(Bulgaria). Five countries reported resistant percentagesbelow 5%, seven countries reported 5–10%, fourcountries reported 10–25%, eight countries reported25–50%, and five countries reported above 50%(Figure 4.11, Table 4.4).• Trends for the period 2008–2011 were calculated for25 countries. Significantly increasing trends wereobserved for six countries (Greece, Hungary, Italy,France, Malta and Portugal). For Italy, the trend wasnot significant when considering only data fromlaboratories reporting consistently for all four years(Figure 4.16).• None of the reporting countries had significantlydecreasing trends of aminoglycoside resistance.Carbapenems• For 2011, 28 countries reported 14 594 isolates, ofwhich 1 323 (9.1%) were resistant to carbapenems.The number of isolates with relevant AST informationreported by the countries ranged from 10 to 1 640.Fifteen countries reported one or more resistantisolate(s) in 2011. The majority of the resistant isolates(1 115 isolates; 84.3%) were reported by Greece,followed by Italy (164 isolates; 26.7%) and Cyprus (13isolates; 15.7%).• The percentage of isolates resistant to carbapenemsreported by the countries ranged from zero (13countries) to 68.2% (Greece). Twenty-three countriesreported resistance percentages below 1%, two countriesreported 1–5%, one country reported 10–25%,and two countries reported above 25% (Figure 4.12and Table 4.4).• Trends for the period 2008–2011 were calculated for22 countries (Figure 4.17). Significantly increasingtrends were observed for three countries (Greece,Hungary and Italy).• Significantly decreasing trends were only observed forNorway. This trend was not significant when includingonly data from laboratories reporting consistentlythroughout the period.Figure 4.11: Klebsiella pneumoniae: percentage (%) of invasive isolates with resistance to aminoglycosides, bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta25

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTCombined resistance• For 2011, 29 countries reported 14 532 isolates testedfor susceptibility to third-generation cephalosporins,fluoroquinolones and aminoglycosides. The numberof isolates with relevant AST information reported percountry ranged from 10 to 1 647.• The percentages of isolates with combined resistanceto third-generation cephalosporins, fluoroquinolonesand aminoglycosides reported by the countriesranged from zero (Iceland) to 64.1% (Greece). Threecountries reported resistance percentages below 1%,eight countries reported 1–5%, two countries reported5–10%, four countries reported 10–25%, ten countriesreported 25–50%, and two countries reported above50% (Figure 4.13, Table 4.4).• Trends for the period 2008–2011 were calculatedfor 25 countries. Significantly increasing trends ofcombined resistance were observed for 10 countries(Figure 4.18).• A significantly decreasing trend was only observedfor the United Kingdom. This trend was not significantwhen considering only data from laboratories reportingconsistently for all four years (Figure 4.18).• More detailed information on the most frequent resistancephenotypes in K. pneumoniae is presented inTable 4.6.4.2.4 Discussion and conclusionAntimicrobial resistance in K. pneumoniae is a publichealth concern of increasing importance in Europe.Resistance to third-generation cephalosporins increasedsignificantly in several countries during the period2008–2011. Combined resistance is common andincreasing in several European countries, with 22.3% ofthe isolates in 2011 resistant to at least three antimicrobialclasses.Similar to reports for E. coli, ESBL production among K.pneumoniae with resistance to third-generation cephalosporinswas very common. Besides the beta-lactams,ESBL producers are also commonly resistant to otherantimicrobial classes, complicating the treatment ofserious infections caused by these bacteria.Further diminishing the available options for antimicrobialtreatment is the increasing percentage ofcarbapenem-resistant K. pneumoniae in some Europeancountries. This situation is of particular concern as thecarbapenems are among the few effective antimicrobialsavailable for the treatment of infections caused bymultidrug-resistant K. pneumoniae.Although information on carbapenemase production isvery limited in EARS-Net, data from scientific publicationsand enhanced surveillance established by someTable 4.4: Klebsiella pneumoniae: number and percentage (%) of invasive isolates with resistance to third-generationcephalosporins, fluoroquinolones, aminoglycosides, carbapenems and combined resistance*, including 95%confidence intervals (95%CI), by country, EU/EEA countries, 2011CountryThird-gen. cephalosporins Fluoroquinolones Aminoglycosides Carbapenems Combined resistanceN %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)Austria 795 13.3 (11-16) 797 16.6 (14-19) 790 7.2 (6-9) 610 0.2 (0-1) 785 4.1 (3-6)Belgium 668 13.6 (11-16) 663 14.9 (12-18) 608 8.1 (6-11) 646 0.3 (0-1) 587 4.9 (3-7)Bulgaria 121 81.0 (73-88) 121 51.2 (42-60) 120 71.7 (63-80) 116 0.0 (0-3) 120 45.8 (37-55)Cyprus 83 41.0 (30-52) 83 36.1 (26-47) 83 27.7 (18-39) 83 15.7 (9-25) 83 25.3 (16-36)Czech Republic 1 287 48.3 (45-51) 1 287 52.8 (50-56) 1 283 44.7 (42-48) 1 193 0.1 (0-0) 1 283 36.0 (33-39)Denmark 637 11.1 (9-14) 888 11.6 (10-14) 908 5.8 (4-8) 589 0.0 (0-1) 633 4.9 (3-7)Estonia 43 39.5 (25-56) 91 22.0 (14-32) 90 12.2 (6-21) 73 0.0 (0-5) 42 19.0 (9-34)Finland 319 3.4 (2-6) 319 3.8 (2-6) 319 1.9 (1-4) 318 0.0 (0-1) 319 1.9 (1-4)France 1 654 25.3 (23-28) 1 683 28.0 (26-30) 1 688 23.6 (22-26) 1 640 0.0 (0-0) 1 647 19.5 (18-21)Germany 519 12.5 (10-16) 519 14.1 (11-17) 518 8.9 (7-12) 512 0.0 (0-1) 518 6.9 (5-9)Greece 1 665 75.8 (74-78) 1 635 72.2 (70-74) 1 649 69.0 (67-71) 1 636 68.2 (66-70) 1 630 64.1 (62-66)Hungary 431 53.1 (48-58) 420 51.0 (46-56) 430 53.0 (48-58) 413 1.9 (1-4) 417 46.0 (41-51)Iceland 26 7.7 (1-25) 24 4.2 (0-21) 26 0.0 (0-13) 0 . 24 0.0 (0-14)Ireland 304 7.6 (5-11) 303 8.9 (6-13) 304 7.6 (5-11) 302 0.3 (0-2) 303 3.3 (2-6)Italy 627 45.9 (42-50) 597 45.7 (42-50) 661 34.6 (31-38) 615 26.7 (23-30) 566 32.9 (29-37)Latvia 65 38.5 (27-51) 63 38.1 (26-51) 65 33.8 (23-47) 65 0.0 (0-6) 63 33.3 (22-46)Lithuania 137 60.6 (52-69) 137 54.7 (46-63) 137 55.5 (47-64) 19 0.0 (0-18) 137 43.1 (35-52)Luxembourg 48 35.4 (22-51) 48 33.3 (20-48) 48 29.2 (17-44) 48 0.0 (0-7) 48 27.1 (15-42)Malta 52 13.5 (4-24) 52 13.5 (6-26) 52 9.6 (3-21) 52 3.8 (0-13) 52 3.8 (0-13)Netherlands 720 8.1 (6-10) 728 7.3 (6-9) 729 8.1 (6-10) 722 0.3 (0-1) 720 4.3 (3-6)Norway 421 2.9 (1-5) 427 3.5 (2-6) 426 2.8 (1-5) 443 0.0 (0-1) 374 0.8 (0-2)Poland 278 59.7 (54-66) 369 57.7 (53-63) 383 47.5 (42-53) 376 0.5 (0-2) 259 37.1 (31-43)Portugal 616 35.4 (32-39) 617 36.3 (33-40) 619 31.5 (28-35) 580 0.3 (0-1) 614 20.8 (18-24)Romania 25 44.0 (24-65) 10 30.0 (7-65) 10 50.0 (19-81) 10 0.0 (0-31) 10 30.0 (7-65)Slovakia 463 68.0 (64-72) 462 70.6 (66-75) 463 66.1 (62-70) 432 0.7 (0-2) 462 62.1 (58-67)Slovenia 232 30.2 (24-37) 232 35.3 (29-42) 232 22.0 (17-28) 232 0.0 (0-2) 232 19.8 (15-26)Spain 1 145 13.4 (11-15) 1 145 17.0 (15-19) 1 145 10.5 (9-12) 1 144 0.3 (0-1) 1 145 8.3 (7-10)Sweden 736 2.3 (1-4) 624 1.9 (1-3) 602 1.7 (1-3) 900 0.0 (0-0) 545 0.7 (0-2)United Kingdom 935 5.3 (4-7) 985 4.6 (3-6) 979 4.3 (3-6) 825 0.4 (0-1) 914 2.1 (1-3)* Combined resistance defined as being resistant to third-generation cephalosporins, fluoroquinolone and aminoglycosides.26

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011EU Member States indicate an increase in the spreadof carbapenemase-producing Enterobacteriaceae (CPE)in Europe in recent years, with reports of travel-relatedcases, autochthonous cases and outbreaks. ECDC issuedtwo risk assessments targeting CPE during 2011 23,24 ,emphasising the need for implementation of infectioncontrol measures such as active patient screening andadditional hygiene precautions for the care of CPEpositivepatients. In addition, countries are encouragedto develop national guidance on how to stop the spreadof CPE within their country, and to actively report casesof CPE by making confirmed cases notifiable to nationalpublic health authorities. These interventions wouldnot only target CPE but also affect the general spreadof AMR.Table 4.5: Klebsiella pneumoniae: number of invasiveisolates resistant to third-generation cephalosporins(3GCRKP) and percentage (%) extended-spectrum betalactamase(ESBL)-positive among these isolates, asascertained by participating laboratories, by country,EU/EEA countries, 2011CountryNumber oflaboratoriesNumber of3GCRKP%ESBLAustria 24 57 75.4Bulgaria 11 53 96.2Czech Republic 44 621 87.3Denmark 3 10 80Estonia 4 17 100France 24 114 98.2Germany 10 40 97.5Hungary 9 91 100Ireland 13 23 65.2Italy 7 40 100Latvia 5 22 90.9Lithuania 9 83 100Luxembourg 4 17 82.4Netherlands 9 26 92.3Poland 32 151 96Portugal 14 135 93.3Slovakia 4 176 90.3Slovenia 8 70 98.6Spain 24 89 86.5Only data from laboratories consistently reporting ESBL test results for allisolates identified as resistant to third-generation cephalosporins and fromcountries with at least 10 of such isolates were selected for the analysis.Table 4.6: Klebsiella pneumoniae: overall resistance and resistance combinations among invasive isolates testedagainst fluoroquinolones, third-generation cephalosporins and aminoglycosides (n=14 532), by country, EU/EEAcountries, 2011Resistance pattern Number of isolates % of totalFully susceptible 9 239 63.6Single resistance (to indicated drug classes)Total (all single resistance) 987 6.8Fluoroquinolones 517 3.6Third-generation cephalosporins 338 2.3Aminoglycosides 132 0.9Resistance to two classes of antimicrobial drugsTotal (all two classes combinations) 1 065 7.3Third-generation cephalosporins + fluoroquinolones 567 3.9Third-generation cephalosporins + aminoglycosides 299 2.1Fluoroquinolones + aminoglycosides 199 1.4Resistance to three classes of antimicrobial drugsThird-generation cephalosporins + fluoroquinolones + aminoglycosides 3 241 22.3Only data from isolates tested against all three antimicrobial classes were included in the analysis.27

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.14: Klebsiella pneumoniae: trends of invasive isolates with resistance to third-generation cephalosporins, bycountry, EU/EEA countries, 2008–2011SENOFI (>)UK2008200920102011IEISNLDKMT (>)DEAT (>)ESCountry codeFR (>)SIPT (>)LULVEE (>)CYIT (>*)CZHU (>)LT (>)EL (>)BG0 20 40 60 80 100% third-generation cephalosporin resistanceCountries not reporting data for all four years (Belgium and Slovakia) and countries reporting relevant AST data for 19 isolates or fewer per year (Poland and Romania)were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends, respectively. The asterisks indicate significant trends inthe overall data that were not supported by data from laboratories consistently reporting for all four years.29

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.15: Klebsiella pneumoniae: trends of invasive isolates with resistance to fluoroquinolones, by country, EU/EEA countries, 2008–2011SE ()FR (>)LU (>*)SI (>)CYPT (>)LVIT (>)HU (>)BGCZLT (>)EL (>)0 10 20 30 40 50 60 70 80% fluoroquinolone resistanceCountries not reporting data for all four years (Belgium and Slovakia) and countries reporting relevant AST data for 19 isolates or fewer per year (Poland and Romania)were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends, respectively. The asterisks indicate significant trends inthe overall data that were not supported by data from laboratories consistently reporting for all four years.30

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.16: Klebsiella pneumoniae: trends of invasive isolates with resistance to aminoglycosides, by country, EU/EEAcountries, 2008–2011ISSEFINO2008200920102011UKDKATIENLDEMT (>)ESCountry codeEESIFR (>)CYLUPT (>)LVIT (>*)CZHU (>)LTEL (>)BG0 10 20 30 40 50 60 70 80% aminoglycoside resistanceCountries not reporting data for all four years (Belgium and Slovakia) and countries reporting relevant AST data for 19 isolates or fewer per year (Poland and Romania)were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends, respectively. The asterisks indicate significant trends inthe overall data that were not supported by data from laboratories consistently reporting for all four years.31

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.17: Klebsiella pneumoniae: trends of invasive isolates with resistance to carbapenems, by country, EU/EEAcountries, 2008–2011LVEEBG2008200920102011SIFRSEDKFINO ()MTCYIT (>)EL (>)0 10 20 30 40 50 60 70 80% carbapenem resistanceCountries not reporting data for all four years (Belgium, Iceland and Slovakia) and countries reporting relevant AST data for 19 isolates or fewer per year (Lithuania,Luxembourg, Poland and Romania) were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trend, respectively. Theasterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.32

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.18: Klebsiella pneumoniae: trends of invasive isolates with combined resistance (third-generationcephalosporins, fluoroquinolones and aminoglycosides), by country, EU/EEA countries, 2008–2011ISSENOFI2008200920102011UK ()Country codeEE (>)FR (>)SIPT (>)CYLU (>)IT (>)LVCZ (>)LT (>)BGHU (>)EL (>)0 10 20 30 40 50 60 70 80% combined resistanceCountries not reporting data for all four years (Belgium and Slovakia) and countries reporting relevant AST data for 19 isolates or fewer per year (Poland and Romania)were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends inthe overall data that were not supported by data from laboratories consistently reporting for all four years.33

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT4.3 Pseudomonas aeruginosa4.3.1 Clinical and epidemiological importancePseudomonas aeruginosa is a non-fermenting gramnegativebacterium that is ubiquitous in aquaticenvironments in nature. It is an opportunistic pathogenfor plants, animals and humans, and is a major anddreaded cause of infection in hospitalised patients withlocalised or systemic impairment of immune defences,being a common cause of hospital-acquired pneumonia(including ventilator-associated pneumonia), bloodstreamand urinary tract infections. Because of itsubiquity, its enormous versatility and intrinsic toleranceto many detergents, disinfectants and antimicrobialcompounds, it is difficult to control P. aeruginosa inhospitals and institutional environments. Moreover, P.aeruginosa is a frequent cause of skin infections suchas folliculitis and otitis externa among recreational andcompetitive swimmers. In patients with cystic fibrosis, P.aeruginosa causes severe bacterial complication leadingto chronic colonisation and intermittent exacerbation ofthe condition with, for example, bronchiolitis and acuterespiratory distress syndrome. Finally, P. aeruginosa iscommonly found in burn units, and in these locations itis almost impossible to eradicate colonising strains withclassic infection control procedures.4.3.2 Resistance mechanismPseudomonas aeruginosa is intrinsically resistant tothe majority of antimicrobial agents due to its selectiveability to exclude various molecules from penetrating itsouter membrane. The antimicrobial classes that remainactive include some fluoroquinolones (e.g. ciprofloxacinand levofloxacin), aminoglycosides (e.g. gentamicin,tobramycin and amikacin), some beta-lactams (piperacillin–tazobactam,ceftazidime, cefepime, imipenem,doripenem and meropenem) and colistin. Resistance ofP. aeruginosa to these agents can be acquired throughone or more of several mechanisms:• mutational modification of antimicrobial targets suchas topoisomerases or ribosomal proteins, whichconfer resistance to fluoroquinolones and aminoglycosides,respectively;• mutational derepression of the chromosomallycoded AmpC beta-lactamase, that can confer resistanceto penicillins and cephalosporins active againstPseudomonas spp., and which is not inhibited bytazobactam;• mutational loss of outer membrane proteins preventingthe uptake of antimicrobial agents such ascarbapenems;Table 4.7: Pseudomonas aeruginosa: number and percentage (%) of invasive isolates with resistance topiperacillin(±tazobactam), ceftazidime fluoroquinolones, aminoglycosides, carbapenems and combined resistance*,including 95% confidence intervals, by country, EU/EEA countries, 2011Piperacillin±CountrytazobactamCeftazidime Fluoroquinolones Aminoglycosides CarbapenemsCombinedresistance*N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)Austria 528 13.6 (11-17) 498 10.6 (8-14) 511 18.6 (15-22) 535 13.3 (11-16) 538 13.6 (11-17) 537 10.6 (8-14)Belgium 376 15.4 (12-19) 417 8.9 (6-12) 397 21.2 (17-26) 332 14.2 (11-18) 459 10.7 (8-14) 417 11.0 (8-14)Bulgaria 43 23.3 (12-39) 39 30.8 (17-48) 47 29.8 (17-45) 48 33.3 (20-48) 48 29.2 (17-44) 48 25.0 (14-40)Cyprus 51 19.6 (10-33) 51 23.5 (13-37) 51 13.7 (6-26) 51 15.7 (7-29) 51 43.1 (29-58) 51 19.6 (10-33)Czech Republic 448 22.1 (18-26) 448 20.3 (17-24) 448 33.9 (30-39) 448 24.1 (20-28) 448 13.2 (10-17) 448 21.2 (18-25)Denmark 405 5.4 (3-8) 402 5.2 (3-8) 403 6.9 (5-10) 404 2.2 (1-4) 403 5.5 (3-8) 404 3.2 (2-5)Estonia 3 0.0 (0-71) 4 0.0 (0-60) 16 6.3 (0-30) 14 0.0 (0-23) 12 8.3 (0-38) 12 0.0 (0-26)Finland 164 14.0 (9-20) 168 8.3 (5-14) 185 14.6 (10-21) 221 3.6 (2-7) 221 10.4 (7-15) 185 5.9 (3-10)France 1 572 22.5 (20-25) 1 466 16.0 (14-18) 1 554 27.0 (25-29) 1 598 21.0 (19-23) 1 622 20.0 (18-22) 1 621 18.9 (17-21)Germany 386 14.8 (11-19) 386 9.1 (6-12) 385 18.2 (14-22) 386 11.7 (9-15) 386 9.8 (7-13) 387 7.2 (5-10)Greece 923 31.1 (28-34) 930 37.4 (34-41) 933 38.8 (36-42) 935 37.8 (35-41) 900 54.0 (51-57) 935 38.4 (35-42)Hungary 599 10.7 (8-13) 604 11.9 (9-15) 599 20.4 (17-24) 605 17.9 (15-21) 604 21.2 (18-25) 604 12.3 (10-15)Iceland 17 5.9 (0-29) 17 5.9 (0-29) 16 6.3 (0-30) 17 0.0 (0-20) 17 5.9 (0-29) 17 5.9 (0-29)Ireland 172 2.9 (1-7) 181 4.4 (2-9) 179 6.1 (3-11) 181 3.9 (2-8) 180 6.1 (3-11) 181 3.3 (1-7)Italy 233 21.9 (17-28) 303 16.2 (12-21) 318 26.1 (21-31) 279 20.4 (16-26) 316 20.6 (16-25) 313 17.3 (13-22)Latvia 11 9.1 (0-41) 11 9.1 (0-41) 12 25.0 (5-57) 12 25.0 (5-57) 12 8.3 (0-38) 12 8.3 (0-38)Lithuania 30 13.3 (4-31) 29 20.7 (8-40) 30 16.7 (6-35) 30 13.3 (4-31) 30 20.0 (8-39) 30 10.0 (2-27)Luxembourg 32 15.6 (5-33) 32 9.4 (2-25) 32 18.8 (7-36) 32 15.6 (5-33) 32 15.6 (5-33) 32 15.6 (5-33)Malta 42 23.8 (11-38) 42 11.9 (4-26) 42 19.0 (9-35) 42 33.3 (18-48) 42 23.8 (11-38) 42 23.5 (11-38)Netherlands 391 6.4 (4-9) 434 4.6 (3-7) 434 7.1 (5-10) 434 4.6 (3-7) 431 3.5 (2-6) 434 3.0 (2-5)Norway 142 4.9 (2-10) 146 3.4 (1-8) 147 5.4 (2-10) 147 0.0 (0-2) 148 4.1 (2-9) 148 1.4 (0-5)Poland 191 31.4 (25-39) 142 23.2 (17-31) 194 30.4 (24-37) 191 33.5 (27-41) 184 24.5 (18-31) 194 25.8 (20-33)Portugal 522 19.0 (16-23) 526 15.2 (12-19) 516 25.6 (22-30) 526 15.2 (12-19) 505 19.8 (16-24) 525 16.2 (13-20)Romania 6 66.7 (22-96) 8 62.5 (24-91) 8 75.0 (35-97) 9 66.7 (30-93) 9 66.7 (30-93) 9 66.7 (30-93)Slovakia 264 41.3 (35-47) 248 25.0 (20-31) 264 58.7 (53-65) 264 50.8 (45-57) 249 30.5 (25-37) 265 39.6 (34-46)Slovenia 118 12.7 (7-20) 118 7.6 (4-14) 118 9.3 (5-16) 118 7.6 (4-14) 118 23.7 (16-32) 118 10.2 (5-17)Spain 833 6.4 (5-8) 836 8.9 (7-11) 838 24.2 (21-27) 839 18.7 (16-22) 839 16.3 (14-19) 839 12.6 (10-15)Sweden 289 4.2 (2-7) 378 5.3 (3-8) 344 5.8 (4-9) 234 0.9 (0-3) 390 7.7 (5-11) 379 1.8 (1-4)United Kingdom 557 4.3 (3-6) 578 4.8 (3-7) 585 6.2 (4-8) 590 3.4 (2-5) 540 5.6 (4-8) 587 2.6 (1-4)* Combined resistance defined as being resistant to three or more antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosidesand carbapenems.34

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011• mutational upregulation of efflux systems, that canconfer resistance to beta-lactams, fluoroquinolonesand aminoglycosides; and• acquisition of plasmid-mediated resistance genescoding for various beta-lactamases and aminoglycoside-modifyingenzymes that can confer resistanceto various beta-lactams including carbapenems (e.g.metallo-beta-lactamases) and aminoglycosides, orcoding for rRNA ribosomal methylases that can conferhigh-level resistance to all aminoglycosides.4.3.3 ResultsPiperacillin (± tazobactam)• For 2011, 29 countries reported 9 348 isolates, ofwhich 1 538 (16.5%) were resistant to piperacillin(±tazobactam). The number of isolates with relevantAST information reported per country ranged from 3 to1 572. Two countries (Estonia and Romania) reportedfewer than 10 isolates and are thus not shown inFigure 4.19.• The percentages of resistant isolates reported bythe countries ranged from zero (Estonia) to 66.7%(Romania). Five countries reported resistance percentageslower than 5%, five countries reported 5–10%, 15countries reported 10–25%, three countries reported25–50%, and one country reported above 50% (Figure4.19 and Table 4.7).• Trends for the period 2008–2011 were calculated for23 countries. Significantly increasing trends wereobserved for six countries (Austria, Denmark, Finland,France, Sweden and United Kingdom). For Finland, thetrend was not significant when considering only datafrom laboratories reporting consistently throughoutthe period (Figure 4.25).• Significantly decreasing trends were observed forthree countries (Bulgaria, Hungary and Malta). ForBulgaria and Hungary, the trends were not significantwhen considering only data from laboratories reportingconsistently throughout the period (Figure 4.25).Ceftazidime• For 2011, 29 countries reported 9 442 isolates, ofwhich 1 338 (14.2%) were resistant to ceftazidime.The number of isolates with relevant AST informationreported per country ranged from 4 to 1 466. Twocountries (Estonia and Romania) reported fewer than10 isolates and are thus not included in Figure 4.20.• The percentages of resistant isolates reported bythe countries ranged from zero (Estonia) to 62.5%(Romania). Five countries reported resistance percentageslower than 5%, 10 countries reported 5–10%, 10countries reported 10–25%, three countries reported25–50%, and one country reported above 50% (Figure4.20, Table 4.7).Figure 4.19: Pseudomonas aeruginosa: percentage (%) of invasive isolates with resistance to piperacillin±tazobactam,by country, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta35

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT• Trends for the period 2008–2011 were calculated for23 countries. Significantly increasing trends wereobserved for Austria and France (Figure 4.26).• Significantly decreasing trends were observed for theCzech Republic and Malta (Figure 4.26).Fluoroquinolones• For 2011, 29 countries reported 9 606 isolates, ofwhich 2 159 (22.5%) were resistant to fluoroquinolones.The number of isolates with relevant ASTinformation reported per country ranged from 8 to1 554. One country (Romania) reported fewer than 10isolates and is thus not included in Figure 4.21.• The percentages of resistant isolates reported bythe countries ranged from 5.4% (Norway) to 75.0%(Romania). Nine countries reported resistance percentagesof 5–10%, 10 countries reported 10–25%,eight countries reported 25–50%, and two countriesreported above 50% (Figure 4.21, Table 4.7).• Trends for the period 2008–2011 were calculated for21 countries. Significantly increasing trends wereobserved for three countries (Austria, Denmark andFrance). For France, the trend was not significant whenincluding only data from laboratories reporting consistentlyfor all four years (Figure 4.27).• Significantly decreasing trends were observed forseven countries (Czech Republic, Cyprus, Greece,Hungary, Ireland, Italy and Slovenia). For Hungary andItaly, the trends were not significant when consideringonly data from laboratories reporting consistently forall four years (Figure 4.27).Aminoglycosides• For 2011, 29 countries reported 9 522 isolates, ofwhich 1 690 (17.7%) were resistant to aminoglycosides.The number of isolates with relevant AST informationreported per country ranged from 9 to 1 598. Onecountry (Romania) reported fewer than 10 isolates andis thus not included in Figure 4.22).• The percentage of resistant isolates reported by thecountries ranged from zero (Estonia, Iceland andNorway) to 66.7% (Romania). Four countries reportedresistance percentages lower than 1%, five countriesreported 1–5%, one country reported 5–10%, 12countries reported 10–25%, five countries reported25–50%, and two countries reported above 50%(Figure 4.22, Table 4.7).• Trends for the period 2008–2011 were calculated for23 countries. Significantly increasing trends wereobserved for three countries (Austria, France andPortugal). For France and Portugal, the trends werenot significant when considering only data fromlaboratories reporting consistently for all four years(Figure 4.28).Figure 4.20: Pseudomonas aeruginosa: percentage (%) of invasive isolates with resistance to ceftazidine, by country,EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta36

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011• Significantly decreasing trends were observed forfour countries (Czech Republic, Greece, Hungary, andItaly). For Italy, the trend was not significant whenconsidering only data from laboratories reporting consistentlyfor all four years (Figure 4.28).Carbapenems• For 2011, 29 countries reported 9 734 isolates, ofwhich 1 807 (18.6%) were resistant to carbapenems.The number of isolates with relevant AST informationreported per country ranged from 9 to 1 622. Onecountry (Romania) reported fewer than 10 isolates andis thus not included in Figure 4.23.• The percentages of resistant isolates reported bythe countries ranged from 3.5% (the Netherlands)to 66.7% (Romania). Two countries reported resistancepercentages of 1–5%, eight countries reported5–10%, 14 countries reported 10–25%, three countriesreported 25–50%, and two countries reportedabove 50% (Figure 4.23 and Table 4.7).• Trends for the period 2008–2011 were calculated for22 countries. Significantly increasing trends wereobserved for five countries (Austria, Cyprus, Denmark,Greece and France). For Greece, the trend was not significantwhen considering only data from laboratoriesreporting consistently for all four years (Figure 4.29).• Significantly decreasing trends were observed for fourcountries (Hungary, Italy, the Czech Republic, and theNetherlands). For Hungary, Italy and the Netherlands,the trends were not significant when considering onlydata from laboratories reporting consistently for allfour years (Figure 4.29).Combined resistance (piperacillin±tazobactam, ceftazidime,fluoroquinolones, aminoglycosides andcarbapenems)• For 2011, 29 countries reported 9 774 isolates testedfor susceptibility to at least three antimicrobialclasses among piperacillin±tazobactam, ceftazidime,fluoroquinolones, aminoglycosides and carbapenems.The number of isolates with relevant AST informationreported per country ranged from 9 to 1 621 (Table4.7).• In 2011, 34.7% of the isolates were resistant to oneor more of the five considered antimicrobial classes,while 15.3% were resistant to three or more. The mostcommon pattern was resistance to all five antimicrobialclasses (4.6%) (Table 4.8).• The percentages of isolates with combined resistance,i.e. resistant (R) to at least three of the five consideredantimicrobial classes, were below 1% in one country,1–5% in six countries, 5–10% in four countries,10–25% in 13 countries, 25–50% in four countries andabove 50% in one country (Figure 4.24, Table 4.7).• Trends for the period 2008–2011 were calculated for22 countries. Significantly increasing trends of combinedresistance were observed for three countries(Austria, Denmark and France). For France, the trendFigure 4.21: Pseudomonas aeruginosa: percentage (%) of invasive isolates with resistance to fluoroquinolones, bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta37

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTwas not significant when including only data fromlaboratories consistently reporting for all four years(Figure 4.30).• Significantly decreasing trends of combined resistancewere observed for four countries (the CzechRepublic, Greece, Hungary, and Italy). For Italy, thetrend was not significant when including only datafrom laboratories consistently reporting for all fouryears (Figure 4.30).4.3.4 Discussion and conclusionsIn 2011, high percentages of resistance in P. aeruginosaisolates were reported, especially by countries insouthern and eastern Europe. Combined resistance wascommon; 15.3% of the isolates were resistant to at leastthree antimicrobial classes and 4.6% of the isolateswere resistant to all five antimicrobial classes undersurveillance. Pseudomonas aeruginosa carries intrinsicresistance to a number of antimicrobial classes and anyadditional acquired resistance severely limits the therapeuticoptions for treatment of serious infections.Pseudomonas aeruginosa is recognised as a major causeof healthcare-associated infection, and in data reportedfrom HAI-Net ICU surveillance, this pathogen was one ofthe most commonly isolated bacteria in pneumonia andbloodstream infections in European ICUs in 2009 25 .Although EARS-Net reports high percentages of resistancein P. aeruginosa isolates for 2011, the situationappears generally stable in Europe with few countriesreporting significantly increasing or decreasing trendsof resistance to the antimicrobial agents under surveillance.However, due to its ubiquitous nature andpotential virulence, P. aeruginosa is a challengingpathogen to control in healthcare settings. Prudent antimicrobialuse and high standards of infection control areessential to prevent the situation from deteriorating.Table 4.8: Pseudomonas aeruginosa: overall resistance and resistance combinations among invasive isolatestested against at least three antimicrobial classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones,aminoglycosides and carbapenems (n=9 774), EU/EEA countries, 2011Resistance pattern Number of isolates % of totalFully susceptible (to tested antimicrobials) 6 379 65.3Single resistance (to indicated drug classes)Total (all single resistance types) 1 208 12.4Fluoroquinolones 430 4.4Carbapenems 436 4.5Aminoglycosides 162 1.7Ceftazidime 78 0.8Piperacillin(±tazobactam) 102 1Resistance to two classes of antimicrobialsTotal (all two classes combinations) 696 7.1Fluoroquinolones + aminoglycosides 211 2.2Piperacillin (±tazobactam) + ceftazidime 199 2Fluoroquinolones + carbapenems 103 1.1Piperacillin (±tazobactam) +fluoroquinolones 33 0.3Piperacillin (±tazobactam) + carbapenems 38 0.4Piperacillin (±tazobactam) + aminoglycosides 33 0.3Aminoglycosides +carbapenems 33 0.3Ceftazidime + carbapenems 17 0.2Fluoroquinolones + ceftazidime 20 0.2Ceftazidime + aminoglycosides 9 0.1Resistance to three classes of antimicrobialsTotal (all three classes combinations) 520 5.3Fluoroquinolones + aminoglycosides + carbapenems 181 1.9Piperacillin (±tazobactam) + fluoroquinolones +aminoglycosides 112 1.1Piperacillin (±tazobactam) + ceftazidime + carbapenems 66 0.7Piperacillin (±tazobactam) + fluoroquinolones + ceftazidime 51 0.5Fluoroquinolones + ceftazidime + carbapenems 18 0.2Fluoroquinolones +ceftazidime +aminoglycosides 29 0.3Piperacillin (±tazobactam) + aminoglycosides + carbapenems 14 0.1Piperacillin (±tazobactam) + ceftazidime +aminoglycosides 15 0.2Ceftazidime + aminoglycosides + carbapenems 10 0.1Piperacillin (±tazobactam) + fluoroquinolones + carbapenems 24 0.2Resistance to four classes of antimicrobialsTotal (all four classes combinations) 522 5.3Piperacillin (±tazobactam) + fluoroquinolones + aminoglycosides + carbapenems 146 1.5Fluoroquinolones + ceftazidime + aminoglycosides + carbapenems 130 1.3Piperacillin (±tazobactam) + fluoroquinolones + ceftazidime + aminoglycosides 123 1.3Piperacillin (±tazobactam) + fluoroquinolones + ceftazidime + carbapenems 94 1Piperacillin (±tazobactam) + ceftazidime + aminoglycosides + carbapenems 29 0.3Resistance to five classes of antimicrobialsPiperacillin (±tazobactam) + fluoroquinolones + ceftazidime + aminoglycosides + carbapenems 449 4.638

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.22: Pseudomonas aeruginosa: proportion (%) of invasive isolates with resistance to aminoglycosides, bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMaltaFigure 4.23: Pseudomonas aeruginosa: percentage (%) of invasive isolates with resistance to carbapenems, bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta39

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.24: Pseudomonas aeruginosa: percentage (%) of invasive isolates with combined resistance (resistance tothree or more antimicrobial classes among piperacillin (±tazobactam), ceftazidime, fluoroquinolones, aminoglycosidesand carbapenems), by country, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta40

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.25: Pseudomonas aeruginosa: trends of invasive isolates with resistance to piperacillin±tazobactam, bycountry, EU/EEA countries, 2008–2011IESE (>)UK (>)NO2008200920102011DK (>)ESNLHU ()Country codeFI (>*)DELUPTCYITMT ()BG ( and < indicate significant increasing and decreasing trends, respectively. The asterisks indicatesignificant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.41

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.26: Pseudomonas aeruginosa: trends of invasive isolates with resistance to ceftazidime, by country, EU/EEAcountries, 2008–2011NOIENLUK2008200920102011DKSESIFIESDELUCountry codeAT (>)HUMT ()ITCZ ( and < indicate significant increasing and decreasing trends, respectively.42

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.28: Pseudomonas aeruginosa: trends of invasive isolates with resistance to aminoglycosides, by country, EU/EEA countries, 2008–2011NOSEDKUK2008200920102011FIIENLSIDEAT (>)LT (*)LUCYHU (

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.29: Pseudomonas aeruginosa: trends of invasive isolates with resistance to carbapenems, by country, EU/EEAcountries, 2008–2011NL ()2008200920102011UKIESEDEFICZ ()Country codeESPTFR (>)LTIT (*)0 10 20 30 40 50 60% carbapenem resistanceCountries not reporting data for all four years (Belgium and Slovakia) and countries reporting relevant AST data for 19 isolates or fewer per year (Estonia, Iceland,Latvia, Luxembourg and Romania) were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends, respectively. Theasterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.** For Czech Republic there is a decreasing trend, but the drop in 2010 was caused by the adoption of the new EUCAST breakpoints.45

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.30: Pseudomonas aeruginosa: trends of invasive isolates with combined resistance (resistant to three or moreantibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems),by country, EU/EEA countries, 2008–2011NOSEUK2008200920102011NLDK (>)IEFIDELTSICountry codeAT (>)HU (

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20114.4 Streptococcus pneumoniae4.4.1 Clinical and epidemiological importanceStreptococcus pneumoniae is a common cause of disease,especially among young children, elderly peopleand patients with compromised immune functions. Theclinical spectrum ranges from upper airway infections,such as sinusitis, and otitis media to pneumonia andinvasive bloodstream infections and meningitis. SinceS. pneumoniae is the most common cause of pneumoniaworldwide, morbidity and mortality are high and annuallyapproximately 3 million people are estimated to dieof pneumococcal infections.Pneumococci carry a variety of virulence factors thatfacilitate adherence and transcytosis of epithelial cells.The cell wall of pneumococci is coated with a viscouspolysaccharide slime layer termed the capsule. This isthe most important virulence factor because it protectsthe bacteria from the adhesion of opsonising antibodiesand the destruction by leucocytes. Capsular polysaccharidesare highly diverse and play an important rolein immune evasion. To date, 93 different serotypes havebeen described. The serotype distribution varies withage, disease and geographical region. Interestingly,serotypes most frequently involved in pneumococcal diseaseor colonisation in infants are also most frequentlyassociated with AMR. However, serotype replacementdue to increased use of the pneumococcal conjugatevaccine (PCV) might change this over time.4.4.2 Resistance mechanismsBeta-lactam antimicrobials bind to cell wall synthesisingenzymes, so-called penicillin-binding proteins (PBPs),and interfere with the biosynthesis and remodelling ofthe bacterial cell wall during cell growth and division.The mechanism of penicillin resistance in S. pneumoniaeconsists of alterations in PBPs, which result in reducedaffinity to this class of antimicrobial. Alterations inPBPs are due to a continuous mutation process thatcauses different degrees of resistance proceeding fromreduced susceptibility through low-level clinical resistance– conventionally termed intermediate i (I) – to fullclinical resistance (R). Intermediately resistant strainsare clearly less susceptible than susceptible strains.However, in the absence of meningitis, infections withintermediately resistant strains are often successfullytreated with high doses of benzyl-penicillin oraminopenicillins.Macrolide, lincosamide and streptogramin (MLS) antimicrobialsare chemically distinct, but all bind to aribosomal subunit inhibiting the initiation of mRNA bindingand thus act as protein synthesis inhibitors. Thereare two predominant resistance mechanisms againstMLS antimicrobials in S. pneumoniae:iMicroorganisms are defined as intermediate by a level ofantimicrobial activity with uncertain clinical effect. Occasionally, thiscan be overcome if antibiotics can be administered at a higher doseand/or are concentrated at the infected body site.Table 4.9: Streptococcus pneumoniae: number of invasive isolates tested for penicillin and macrolides susceptibility,percentage (%) being penicillin-non-susceptible (PNSP), penicillin-resistant (PRSP), macrolide-non-susceptible(MNSP), single penicillin-resistant (PENR), single macrolide-resistant (MACR) and non-susceptible to penicillin andmacrolides, including 95% confidence intervals, by country, EU/EEA countries, 2011CountryNumber of isolatestested for (PEN/MACR/both)%PNSP(95%CI)%PRSP(95%CI)%MNSP(95%CI)%single PEN(95%CI)%single MACR(95%CI)%DUAL(95%CI)Austria 405/373/355 3.0 (2-5) 1.7 (1-4) 11.5 (8-15) 0.8 (0-2) 9.6 (7-13) 2.3 (1-4)Belgium 1829/1829/1829 0.8 (0-1) 0.8 (0-1) 26.0 (24-28) 0.2 (0-1) 25.4 (23-27) 0.6 (0-1)Bulgaria 33/30/30 21.2 (9-39) 21.2 (9-39) 13.3 (4-31) 10.0 (2-27) 0.0 (0-12) 13.3 (4-31)Cyprus 12/12/12 25.0 (5-57) 25.0 (5-57) 25.0 (5-57) 8.3 (0-38) 8.3 (0-38) 16.7 (2-48)Czech Republic 316/316/316 3.8 (2-7) 0.0 (0-1) 3.5 (2-6) 1.9 (1-4) 1.6 (1-4) 1.9 (1-4)Denmark 896/896/896 4.8 (3-6) 0.2 (0-1) 5.1 (4-7) 1.8 (1-3) 2.1 (1-3) 3.0 (2-4)Estonia 51/45/42 2.0 (0-10) 2.0 (0-10) 2.2 (0-12) 2.4 (0-13) 2.4 (0-13) 0.0 (0-8)France 1413/1413/1413 23.8 (22-26) 0.1 (0-1) 26.0 (24-28) 5.1 (4-6) 7.3 (6-9) 18.8 (17-21)Germany 347/353/343 1.7 (1-4) 0.3 (0-2) 7.9 (5-11) 1.2 (0-3) 8.2 (5-12) 0.0 (0-1)Hungary 139/129/129 11.5 (7-18) 5.8 (3-11) 14.7 (9-22) 3.9 (1-9) 6.2 (3-12) 8.5 (4-15)Iceland 32/32/32 9.4 (2-25) 6.3 (1-21) 21.9 (9-40) 0.0 (0-11) 12.5 (4-29) 9.4 (2-25)Ireland 324/310/310 19.4 (15-24) 6.2 (4-9) 18.4 (14-23) 5.5 (3-9) 4.8 (3-8) 13.5 (10-18)Italy 174/266/162 6.9 (4-12) 6.3 (3-11) 27.4 (22-33) 2.5 (1-6) 24.7 (18-32) 4.3 (2-9)Latvia 40/46/38 12.5 (4-27) 10.0 (3-24) 0.0 (0-8) 13.2 (4-28) 0.0 (0-9) 0.0 (0-9)Lithuania 48/41/41 18.8 (9-33) 2.1 (0-11) 26.8 (14-43) 4.9 (1-17) 9.8 (3-23) 17.1 (7-32)Luxembourg 50/52/50 8.0 (2-19) 2.0 (0-11) 15.4 (7-28) 2.0 (0-11) 10.0 (3-22) 6.0 (1-17)Malta 8/10/8 50.0 (25-73) 10.0 (2-71) 12.5 (0-53) 0.0 (0-71) 0.0 (0-71) 12.5 (0-53)Netherlands 1067/1200/978 1.1 (1-2) 0.3 (0-1) 4.5 (3-6) 0.7 (0-1) 4.2 (3-6) 0.3 (0-1)Norway 619/570/567 3.4 (2-5) 0.0 (0-1) 4.2 (3-6) 1.9 (1-3) 2.6 (1-4) 1.4 (1-3)Poland 165/135/134 18.2 (13-25) 4.2 (2-9) 26.7 (19-35) 3.7 (1-8) 11.9 (7-19) 14.9 (9-22)Portugal 439/417/402 10.5 (8-14) 8.4 (6-11) 14.9 (12-19) 5.5 (3-8) 9.2 (7-12) 5.2 (3-8)Romania 36/18/18 61.1 (43-77) 61.1 (43-77) 44.4 (22-69) 16.7 (4-41) 0.0 (0-19) 44.4 (22-69)Slovak Republic 26/25/25 7.7 (1-25) 3.8 (0-20) 12.0 (3-31) 4.0 (0-20) 8.0 (1-26) 4.0 (0-20)Slovenia 252/251/251 12.3 (9-17) 0.8 (0-3) 24.3 (19-30) 6.4 (4-10) 18.3 (14-24) 6.0 (3-10)Spain 736/746/720 30.2 (27-34) 9.8 (8-12) 24.8 (22-28) 13.2 (11-16) 8.3 (6-11) 16.9 (14-20)Sweden 1013/963/963 3.5 (2-5) 3.2 (2-4) 5.2 (4-7) 1.7 (1-3) 3.2 (2-5) 2.0 (1-3)United Kingdom 1324/1263/1126 5.4 (4-7) 0.8 (0-1) 5.9 (5-7) 2.7 (2-4) 2.5 (2-4) 3.6 (3-5)47

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT• The acquisition of an erythromycin ribosomal methylationgene (erm) results in a post-transcriptionalmodification of the 23S subunit of ribosomal RNA,which blocks the binding of the macrolide to theribosome. Once expression of the gene is induced,this often results in high-level resistance (MICs > 128mg/L) to macrolides, lincosamide and streptograminB, termed MLS B resistance.• The acquisition of a macrolide efflux system gene(mef(E)) results in the excretion of the antimicrobial,and effectively reduces intracellular erythromycin,azithromycin and clarithromycin to subinhibitory concentrations.In contrast to beta-lactam resistance,macrolide resistance via these mechanisms (particularlyfor MLS B ) provides very high MICs, and cannot beovercome by increasing the dosages of antimicrobials.The two fluoroquinolones with acknowledged clinicalactivity against pneumococci are levofloxacin and moxifloxacin.Resistance to fluoroquinolones is mediatedby the mutations in ParC (subunit of topoisomerase IV)and/or GyrA (subunit of DNA gyrase/topoisomerase IV).Additionally, resistance may be conferred by efflux.Since S. pneumoniae is the most frequent cause ofcommunity-acquired pneumonia and cannot clinicallybe easily distinguished from lower airway infectionscaused by other pathogens, empirical treatment ofcommunity-acquired lower respiratory infections needsto be active against pneumococci and should take thelocal prevalence of AMR into account. Prescription ofnon-beta-lactam compounds is therefore typical incountries where penicillin non-susceptibility has beenfrequently reported. Such prescribing patterns increasethe selection pressure for alternative antimicrobialssuch as macrolides and fluoroquinolones. It is thereforeno surprise to see a dynamic AMR picture emergein different European countries. At the same time, theexistence of frequent dual beta-lactam/macrolide resistance,particularly among serotypes commonly found inchildren, means that in practice the use of agents fromeither of these classes will result in increasing percentagesof resistance to the other class and frequent use ofmacrolides has been considered as a major driver for theincrease in beta-lactam resistance.Even though a certain small decrease in penicillin resistancehad been detected in some countries before theintroduction of the PCV, the widespread use of this vaccineis an important factor that may have influenced thedecrease in AMR levels, eliminating the infections (andmore importantly, the children’s carriage) of frequent‘classic’ resistant serotypes – 14, 6B, 19F and 23F – allof them covered by the PCV.Figure 4.31: Streptococcus pneumoniae: percentage (%) of invasive isolates non-susceptible to penicillin (PNSP), bycountry, EU/EEA countries 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta48

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20114.4.3 ResultsPenicillin• For 2011, 27 countries reported 11 788 isolates, ofwhich 1 039 (8.8%) were non-susceptible to penicillinand 268 of these non-susceptible isolates were identifiedas resistant. Greece and Finland did not reportdata for 2011 and Malta reported fewer than 10 isolates(accordingly no data from these countries aredisplayed in Figure 4.31).• For 2011, the number of reported S. pneumoniae isolateswith relevant AST information for penicillin(penicillins or oxacillin) ranged between 8 (Malta) and1 829 (Belgium) (Table 4.9).• The percentage of isolates reported as non-susceptiblewas below 1% in one country, 1–5% in eightcountries, 5–10% in five countries, 10–25% in ninecountries, 25–50% in three countries and above 50%in one country (Figure 4.31 and Table 4.9).• Trends for the period 2008–2011 were calculatedfor 22 countries. Four countries (Denmark, Estonia,Lithuania and Sweden) had significantly increasingtrends (Figure 4.35).• Significantly decreasing trends were observed for fourcountries (Belgium* i , Portugal, Hungary, and France).For France and Portugal, the trends did not remain significantwhen considering only data from laboratoriesreporting consistently for all four years (Figure 4.35).Macrolides• For 2011, 27 countries reported 11 739 isolates, ofwhich 1 713 (14.6%) were non-susceptible to macrolidesand 1 658 of these non-susceptible isolateswere identified as resistant (14.1% of total isolates).• The number of reported S. pneumoniae isolates withrelevant AST information for macrolides (erythromycin,clarithromycin or azitromycin) ranged between 10(Malta) and 1 829 (Belgium) (Table 4.9).• The percentage of isolates reported as non-susceptibleranged from zero (Latvia) to 44.4% (Romania), andwas reported below 5% in five countries, 5–10% infour countries, 10–25% in 11 countries, and 25–50% inseven countries (Figure 4.32, Table 4.9).iThe percentage of Streptococcus pneumoniae non-susceptible topenicillin reported by Belgium dropped from 8% in 2008 to < 1% in2009. This is largely due to the fact that the clinical breakpoints(CLSI) used to determine SIR have changed. These new CLSIguidelines started to be used in the beginning of 2009.Figure 4.32: Streptococcus pneumoniae: percentage (%) of invasive isolates non-susceptible to macrolides by country,EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta49

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT• Trends for the period 2008–2011 were calculated for21 countries. Significantly increasing trends wereobserved for Lithuania, Slovenia and Spain. For Spain,the trend did not remain significant when consideringonly data from laboratories reporting consistentlythroughout the period (Figure 4.36).• Significantly decreasing trends were observed forthree countries (Hungary, Norway and Portugal)(Figure 4.36).Non-susceptibility to penicillins and macrolides• For 2011, 27 countries reported 11 184 isolates testedfor both penicillin and macrolides, of which 652 (5.8%)isolates were non-susceptible to both antimicrobialclasses. One country (Malta) reported fewer than 10isolates and is therefore not included in Figure 4.33.• The number of reported S. pneumoniae isolates withrelevant AST information for both penicillins and macrolidesranged between 8 (Malta) and 1 829 (Belgium)(Table 4.9).• Percentages of non-susceptibility to penicillin andmacrolides ranged from zero (Estonia, Germany andLatvia) to 44.4% (Romania), and were reported below1% in five countries, 1–5% in eight countries, 5–10% infive countries 10–25% in eight countries, and 25–50%in one country (Figure 4.33 and Table 4.9).• Trends for 2008–2011 were calculated for 21 countries.A significant increase was observed for four countries(Denmark, Lithuania, Spain and Sweden) (Figure 4.37).• Significantly decreasing trends were observed for fivecountries (Belgium, Germany, Hungary, France andPortugal) (Figure 4.37).Fluoroquinolones• For 2011, 24 countries reported susceptibility data forfluoroquinolones in 7 275 isolates (58% of all reportedS. pneumoniae isolates). Among them, 4.8% wereresistant to fluoroquinolones. Forty fluoroquinoloneresistantisolates were also penicillin-non-susceptible.Serogroups• Fifteen countries reported 3 855 S. pneumoniae isolateswith identification of the serotype/serogroup.Cyprus, Germany, Poland, Romania and Slovakiareported fewer than 30 isolates with serotype/serogroupinformation and are hence not included in theanalysis.• In 2011, serogroups 1 and 19 were the most prevalentserogroups (accounting for 14% and 13% of the isolates,respectively), followed by serogroup 7 (12%)and serogroup 3 (9%). This serogroup distribution issimilar to the one reported by EARS-Net in 2010.Figure 4.33: Streptococcus pneumoniae: percentage (%) of invasive isolates non-susceptible to penicillins andmacrolides by country, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta50

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011• Among the most commonly reported serogroups,dual non-susceptibility to both penicillin and macrolideswas mainly observed in serogroups 19, 14, 6,15 and 9 (by order of decreasing percentage). Singlenon-susceptibility to penicillin was most common inserogroups 19, 14, 9 and 23, and single non-susceptibilityto macrolides was most common in serogroups19, 1, 14 and 6 (Figure 4.34).4.4.4 Discussion and conclusionsAlthough large inter-country variations can be noted,the overall percentages of S. pneumoniae with nonsusceptibilityto commonly used antimicrobials reportedto EARS-Net have remained relatively stable in Europeduring recent years. The lowest percentages of S. pneumoniaewith non-susceptibility to penicillin and/ormacrolides were reported by countries in central andnorthern Europe. Geographical differences in reportedpercentages of resistant S. pneumoniae have beenshown, in several studies, to be associated with differencesin antimicrobial consumption, both on individualand population levels 26 . A previous ecological studylinking data collected by the former EARSS with nationaldata on antimicrobial consumption, supported thisassumption 27 . In addition, differences in serotype distributionsand local dominance of specific clones may alsoinfluence national estimates 25 .It is important to note that the differences and changesin clinical breakpoints used for determining penicillinsusceptibility in S. pneumoniae might introduce biaswhen comparing national data reported to EARS-Net, butalso when interpreting trends in countries that changedclinical breakpoints during the observation period.Similar surveillance artefacts have been reported fromthe United States when S. pneumoniae data were analysedwith new breakpoints 28 .Although the number of countries reporting data onserotype distribution to EARS-Net is increasing, dataremain incomplete. However, data reported for 2011support previous observations that most penicillin nonsusceptibleisolates belong to a few serogroups. MostEU/EEA Member States have, in recent years, implementedroutine immunisation for children with themultivalent PCV 29 . As a limited number of S. pneumoniaeserotypes are responsible for a considerable percentageof serious pneumococcal infections in both adultsand children, introduction of PCV is likely to change theepidemiology of invasive pneumococcal disease in manyEuropean countries.Figure 4.34: Distribution of serogroups and associated resistance profiles per serogroup, 2011Serogroups119731262214952381543310111820OtherFully susceptible*Single penicillin non-susceptibleSingle macrolides non-susceptibleDual non-susceptibility**0 2 4 6 8 10 12 14 16Proportion (%)Only countries that reported serogroup information for more than 30 isolates were included in the figure.* Susceptible to at least penicillin and macrolides.** Non-susceptible to penicillin and macrolides.51

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.35: Streptococcus pneumoniae: trends of invasive isolates with non-susceptibility to penicillin, by country,EU/EEA countries, 2008–2011BE**NLDE2008200920102011EEATNOSE (>)CZDK (>)UKCountry codeITLUISPT ( and < indicate significant increasing and decreasing trends, respectively. The asterisksindicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.** The percentage of Streptococcus pneumoniae non-susceptible to penicillin reported by Belgium dropped from 8% in 2008 to < 1% in 2009. This is largely due to thefact that the clinical breakpoints (CLSI) used to determine SIR have changed. These new CLSI guidelines began to be used in the beginning of 2009.52

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.36: Streptococcus pneumoniae: trends of invasive isolates with non-susceptibility to macrolides, by country,EU/EEA countries, 2008–2011EECZNO ()IT0 5 10 15 20 25 30 35% macrolide non-susceptibilityCountries not reporting data for all four years (Finland, Greece and Slovakia) and countries only reporting relevant AST data for 19 isolates or fewer per year (Cyprus,Latvia, Malta, Poland and Romania) were excluded from the analysis. The symbols > and < indicate significant increasing and decreasing trends, respectively.The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.53

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.37: Streptococcus pneumoniae: trends of invasive isolates with non-susceptibility to penicillins andmacrolides, by country, EU/EEA countries, 2008–2011EEDE ()UKCountry codeITPT ()FR ( and < indicate significant increasing and decreasing trends, respectively.54

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20114.5 Staphylococcus aureus4.5.1 Clinical and epidemiological importanceStaphylococcus aureus is a gram-positive organismthat colonises the skin of about 30% of healthyhumans. Although mainly a harmless coloniser, S.aureus can cause severe infection. Its oxacillin-resistantform (meticillin-resistant S. aureus, MRSA) has beenthe most important cause of antimicrobial-resistanthealthcare-associated infections worldwide. Sincehealthcare-associated MRSA infections add to the numberof infections caused by meticillin-susceptible S.aureus, a high incidence of MRSA adds to the overallburden of infections caused by S. aureus in hospitals.Moreover, infections with MRSA may result in prolongedhospital stay and in higher mortality, owing mainly to theinferior effectiveness of alternative treatment regimens.MRSA is still the most commonly identified antimicrobial-resistantpathogen in hospitals in many parts of theworld, including Europe, the Americas, North Africa andthe Middle- and Far East.4.5.2 Resistance mechanismsStaphylococcus aureus acquires resistance to meticillinand all other beta-lactam antimicrobials throughexpression of exogenous mecA gene that code for a variantpenicillin-binding protein PBP2’ (PBP2a) with lowaffinity for beta-lactams, thus preventing the inhibitionby beta-lactams of cell wall synthesis. A new mec genehas been discovered, mecC (formerly called mecA lga251 ).The level of meticillin resistance, as defined by the MICdepends on the amount of PBP2’ production, which isinfluenced by various genetic factors. Resistance levelsof mec-positive strains can thus range from phenotypicallysusceptible to highly resistant. Upon challenge withbeta-lactam antimicrobials, a population of a heterogeneouslyresistant MRSA strain may quickly be outgrownby a sub-population of highly resistant variants.For rifampicin, the mechanism of resistance is mutationin the rpoB-gene, leading to production of RNA polymerasewith low affinity for rifampicin and other rifamycins.Such resistance easily occurs with rifampicin monotherapy,for which reason the drug should only be used incombination therapy.Resistance to fluoroquinolones is mediated by the mutationsin ParC or ParE (subunits of topoisomerase IV)and/or GyrA (subunit of DNA gyrase/topoisomerase IV).Additionally, resistance may be conferred by efflux.The most common mechanism of linezolid resistanceis mutation in the 23S rRNA target site. A more recentmechanism is nonmutational and involves acquisition ofa natural resistance gene, cfr (chloramphenicol–florfenicolresistance). The cfr gene has been found primarily inplasmids that can be spread horizontally. The product ofthe cfr gene is a methyltransferase that catalyses methylationof the 23S rRNA gene.Table 4.10: Staphylococcus aureus: number and percentage (%) of invasive isolates resistant to meticillin (MRSA) andrifampicin, including 95% confidence intervals, by country, EU/EEA countries, 2011CountryMeticillinRifampicinNumber of isolates tested % MRSA (95%CI) Number of isolates tested % rifampicin-resistant (95%CI)Austria 1 966 7.4 (6-9) 1 850 0.3 (0-1)Belgium 1 744 17.4 (16-19) 1 014 0.6 (0-1)Bulgaria 214 22.4 (17-29) 162 14.2 (9-21)Cyprus 113 41.6 (32-51) 113 0.0 (0-3)Czech Republic 1 555 14.5 (13-16) 782 1.8 (1-3)Denmark 1 452 1.2 (1-2) 1 452 0.1 (0-0)Estonia 116 1.7 (0-6) 3 0.0 (0-71)France 4 716 20.1 (19-21) 4 278 1.0 (1-1)Germany 2 388 16.1 (15-18) 1 656 0.7 (0-1)Greece 784 39.2 (36-43) 0 .Hungary 1 156 26.2 (24-29) 570 0.4 (0-1)Iceland 71 2.8 (0-10) 3 0.0 (0-71)Ireland 1 057 23.7 (21-26) 835 1.0 (0-2)Italy 1 261 38.2 (36-41) 970 4.3 (3-6)Latvia 192 9.9 (6-15) 186 0.5 (0-3)Lithuania 278 5.4 (3-9) 158 0.6 (0-2)Luxembourg 127 20.5 (14-29) 90 0.0 (0-4)Malta 130 49.2 (41-59) 130 0.8 (0-4)Netherlands 1 801 1.4 (1-2) 1 581 0.4 (0-1)Norway 1 223 0.3 (0-1) 446 0.0 (0-1)Poland 860 24.3 (21-27) 135 27.4 (20-36)Portugal 1 307 54.6 (52-57) 1 092 1.7 (1-3)Romania 107 50.5 (41-60) 101 7.9 (3-15)Slovakia 560 25.9 (22-30) 478 1.3 (0-3)Slovenia 464 7.1 (5-10) 443 0.5 (0-2)Spain 1 950 22.5 (21-24) 1 826 0.5 (0-1)Sweden 3 099 0.8 (1-1) 2 456 0.2 (0-1)United Kingdom 3 408 13.6 (13-15) 1777 0.6 (0-1)55

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.39: Staphylococcus aureus: trends of invasive isolates resistant to meticillin (MRSA), by country, EU/EEAcountries, 2008–2011NOSEDKNL2008200920102011EEISLTSIATLVUK (

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 20114.6 Enterococci4.6.1 Clinical and epidemiological importanceEnterococci belong to the normal bacterial flora of thegastrointestinal tract of humans, other mammals, birdsand reptiles. Enterococci are regarded harmless commensals,and are even believed to have positive effectson a number of gastrointestinal and systemic conditions.However, when the commensal relationship withthe host is disrupted, enterococci can cause invasivediseases. Recently, the recognition of high-risk clonessuggests that some particular strains can act as truepathogens, and not only as opportunistic commensals.Enterococci can cause a variety of infections, includingendocarditis, bloodstream infections, and urinary tractinfections, and are associated with peritonitis and intraabdominalabscesses. In the United States, three to fournosocomial bloodstream infections per 10 000 hospitaldischarges are caused by enterococci, and contribute topatient mortality as well as additional hospital stay.The vast majority of clinical enterococcal infections inhumans are caused by Enterococcus faecalis and E. faecium.Epidemiological data collected over the last twodecades have documented the emergence of enterococcias important nosocomial pathogens, exemplifiedby the expansion of a major hospital-adapted polyclonalsubcluster CC17 in E. faecium, and by CC2 and CC9 in E.faecalis. The latter clones have even been isolated fromfarm animals. The emergence of particular clones andclonal complexes of E. faecalis and E. faecium was paralleledby increases in resistance to glycopeptides andhigh-level resistance to aminoglycosides. These twoantimicrobial classes represent the few remaining therapeuticoptions for treatment of human infections causedby E. faecium when resistance has emerged againstpenicillins. Besides the fact that infections caused byresistant strains are difficult to treat, enterococci arehighly tenacious and thus easily disseminate in the hospitalsetting.4.6.2 Resistance mechanismsEnterococci are intrinsically resistant to a broad rangeof antimicrobials including cephalosporins, sulphonamidesand low concentrations of aminoglycosides.Patient safety in hospitals is challenged by the ability ofenterococci to acquire additional resistance through thetransfer of plasmids and transposons and recombinationor mutation.Beta-lactam antimicrobialsBy nature, enterococci have low susceptibility to manybeta-lactam antimicrobials as a consequence of theirlow-affinity PBPs. Two possible mechanisms of resistanceof enterococci to beta-lactams have been reported:the production of beta-lactamase, which is an extremelyrare finding, and the overproduction and modificationof PBPs, particularly PBP5, that causes high-levelpenicillin resistance in E. faecium. Resistance to aminopenicillinis currently rare in E. faecalis. Therefore, theTable 4.11: Total number of invasive isolates and percentages (%) of high-level aminglycoside-resistant E. faecalis andvancomycin-resistant E. faecium, including 95% confidence intervals, by country, EU/EEA countries, 2011CountryHigh-level aminoglycoside resistant E. faecalisVancomycin-resistant E. faeciumNumber of isolates % R (95% CI) Number of isolates % R (95% CI)Austria 327 30.9 (26-36) 354 4.5 (3-7)Belgium 335 18.2 (14-23) 215 7.0 (4-11)Bulgaria 62 30.6 (20-44) 39 0.0 (0-9)Cyprus 54 18.5 (9-31) 17 0.0 (0-20)Czech Republic 556 46.2 (42-50) 211 7.6 (4-12)Denmark 45 31.1 (18-47) 615 1.3 (1-3)Estonia 32 19.1 (6-43) 15 0.0 (0-25)Finland 0 . 169 1.2 (0-4)France 955 20.0 (18-23) 569 1.4 (1-3)Germany 578 41.0 (37-45) 535 11.4 (9-14)Greece 653 37.4 (34-41) 424 23.1 (19-27)Hungary 461 48.6 (44-53) 120 0.8 (0-5)Iceland 19 0.0 (0-18) 13 0.0 (0-25)Ireland 244 29.9 (24-36) 347 34.9 (30-40)Italy 330 50.0 (44-56) 236 4.2 (2-8)Latvia 34 26.5 (13-44) 22 9.1 (1-29)Lithuania 48 43.8 (29-59) 26 7.7 (1-25)Luxembourg 27 44.4 (25-65) 24 4.2 (0-21)Malta 0 . 14 0.0 (0-23)Netherlands 363 33.3 (28-38) 481 1.0 (0-2)Norway 115 21.7 (15-30) 165 1.8 (0-5)Poland 190 48.4 (41-56) 202 8.4 (5-13)Portugal 403 29.8 (25-35) 208 20.2 (15-26)Romania 0 . 12 0.0 (0-26)Slovakia 188 49.5 (42-57) 101 4.0 (1-10)Slovenia 125 36.0 (28-45) 83 0.0 (0-4)Spain 917 39.3 (36-43) 542 1.5 (1-3)Sweden 707 19.2 (16-22) 353 0.0 (0-1)United Kingdom 75 16.0 (9-26) 302 8.9 (6-13)59

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTfirst choice for treatment of infections caused by thismicroorganism is still an aminopenicillin such as ampicillin.In E. faecium, ampicillin-resistance has increasedsignificantly in recent years not the least due to the widedissemination of ampicillin-resistant strains belongingto the polyclonal subcluster CC17.AminoglycosidesIn addition to the intrinsic mechanism of low-level resistanceto aminoglycosides, which causes a low uptake ofthe drug, enterococci have acquired genes conferringhigh-level resistance to aminoglycosides. High-levelresistance to streptomycin can be mediated by singlemutations within a protein of the 30S ribosomal subunit,the target of aminoglycoside activity. In addition,different aminoglycoside-modifying enzymes have beenidentified, targeting eight different aminoglycosides. Thebi-functional APH(2’’)/AAC(6’) enzyme confers high-levelresistance to all aminoglycosides except streptomycinand is now widespread across Europe. With high-levelresistance, any synergistic effect between beta-lactamsand glycopeptides is lost.GlycopeptidesVancomycin resistance in enterococci was first reportedin France and England, but showed the most dramaticincrease in the United States and was attributed to thewidespread use of vancomycin in US hospitals. Whilevancomycin consumption was lower in Europe, a closelyrelated glycopeptide, avoparcin, had been widelyused as a growth promoter in animal husbandry sincethe late 1970s until it was banned in the EU by 1998.Glycopeptide-resistance is due to the synthesis of modifiedcell wall precursors that show a decreased affinityfor glycopeptides. Six phenotypes have been identifiedof which two have clinical relevance: VanA, with highlevelresistance to vancomycin and a variable level ofresistance to teicoplanin; and VanB, with a variablelevel of resistance in most cases to vancomycin only.The VanA and VanB phenotypes, mostly found among E.faecalis and E. faecium, may be transferred by plasmidsand through conjugative transposition.4.6.3 Results4.6.3.2 E. faecalisHigh-level aminoglycoside-resistance• For 2011, 26 countries reported 7 843 isolates, ofwhich 2 642 (33.7%) had high-level resistance to gentamicin.The number of isolates reported per countryranged from 19 to 955 (Table 4.11).• The percentages of high-level aminoglycoside-resistancereported by the countries ranged from zero(Iceland) to 50.0% (Italy). One country reported resistancepercentages below 1%, seven countries reported10–25%, and eighteen reported 25–50%. No countryreported a percentage above 50% (Figure 4.40 andTable 4.11).Figure 4.40: Enterococcus faecalis: percentage (%) of invasive isolates with high-level resistance to aminoglycosides, bycountry, EU/EEA countries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta60

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011• Twenty countries have reported more than 20 isolatesper year since 2008 and were thus included in thetrend analysis for the period 2008–2011. Significantlyincreasing trends were observed for two countries(Austria and Luxembourg) (Figure 4.42).• Five countries (Belgium, Cyprus, Greece, Portugal, andthe United Kingdom) have had significantly decreasingtrends of high-level aminoglycoside-resistance forthe past four years (Figure 4.42).4.6.3.3 E. faeciumVancomycin• For 2011, 29 countries reported 6 414 isolates, ofwhich 467 (7.3%) were resistant to vancomycin. Thenumber of isolates with relevant AST informationreported per country ranged from 12 to 481. Only onecountry (Estonia) reported fewer than 10 isolates andis thus not shown in Figure 4.41).• The percentages of vancomycin-resistant isolatesreported by the countries ranged from zero (Bulgaria,Cyprus, Estonia, Iceland, Malta, Romania, Slovenia,and Sweden) to 34.9% (Ireland). Nine countriesreported resistance percentages below 1%, ten countriesreported 1-5%, six countries reported 5-10%,three countries reported 10-25%, and one countryreported above 25% (Figure 4.41 and Table 4.11).• Twenty countries have reported more than 20 isolatesper year since 2008 and were thus included in thetrend analysis for the period 2008–2011. Significantlyincreasing trends were observed only for Germany;however, this trend was not significant when consideringonly data from laboratories reporting consistentlyfor all four years (Figure 4.43).• Significantly decreasing trends of vancomycin resistancewere observed for four countries (Greece,Sweden, Slovenia and the United Kingdom). ForGreece and United Kingdom the trend did not remainsignificant when considering only data from laboratoriesreporting consistently for all four years (Figure4.43).4.6.4 Discussion and conclusionsHigh-level aminoglycoside-resistance in E. faecalisseems stable in Europe, but at a generally high levelwith the majority of countries reporting percentages ofresistant isolates between 25% and 50%. Several countries(Belgium, Cyprus, Greece, Portugal, and UnitedKingdom), which previously reported relatively high levelsof resistance now have decreasing trends. Likewise,the occurrence of vancomycin-resistance in E. faecium isstabilising or decreasing throughout Europe.Despite these stable trends, high levels of antimicrobialresistant enterococci remain a major infection controlchallenge in Europe.Figure 4.41: Enterococcus faecium: percentage (%) of invasive isolates resistant to vancomycin, by country, EU/EEAcountries, 2011< 1%1% to < 5%5% to < 10%10% to < 25%25% to < 50%≥ 50%No data reported or less than 10 isolatesNot includedNon-visible countriesLiechtensteinLuxembourgMalta61

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure 4.42: Enterococcus faecalis: trends of invasive isolates with high-level resistance to aminoglycosides, bycountry, EU/EEA countries, 2008–2011UK (

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 4.43: Enterococcus faecium: trends of invasive isolates with resistance to vancomycin, by country, EU/EEAcountries, 2008–2011BGSE (

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT64

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Five years of nosocomial Gramnegativebacteremia in a general intensive care unit: epidemiology,antimicrobial susceptibility patterns, and outcomes. Int J Infect Dis2006;10(4):320-5.19. Gardiner DF, Scholand SJ, Babinchak T. Mortality and gramnegativerod bacteraemia in the intensive care unit. J Hosp Infect2006;62(4):453-7.20. Bereket W, Hemalatha K, Getenet B, Wondwossen T, Solomon A,Zeynudin A. Update on bacterial nosocomial infections. Eur Rev MedPharmacol Sci 2012;16(8):1039-44.21. Fluit AC, van der Bruggen JT, Aarestrup FM, Verhoef J, Jansen WT.Priorities for antibiotic resistance surveillance in Europe. ClinMicrobiol Infect 2006;12(5):410-7.22. Grundmann H, Klugman KP, Walsh T, Ramon-Pardo P, Sigauque B,Khan W. A framework for global surveillance of antibiotic resistance.Drug Resist Updat 2011;14(2):79-87.23. European Centre for Disease Prevention and Control. Riskassessment on the spread of carbapenemase-producingEnterobacteriaceae (CPE) through patient transfer between healthcarefacilities, with special emphasis on cross-border transfer.Stockholm: ECDC; 2011.24. European Centre for Disease Prevention and Control. Updated riskassessment on the spread of NDM and its variants within Europe.Stockholm: ECDC; 2011.25. European Centre for Disease Prevention and Control. AnnualEpidemiological Report 2011. Reporting on 2009 surveillance dataand 2010 epidemic intelligence data. Stockholm: ECDC; 2011.26. Lynch JP 3rd, Zhanel GG. Streptococcus pneumoniae: epidemiologyand risk factors, evolution of antimicrobial resistance, and impactof vaccines. Curr Opin Pulm Med 2010;16(3):217-25.27. Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W,Veldhuijzen IK, et al. A European study on the relationship betweenantimicrobial use and antimicrobial resistance. Emerg Infect Dis2002;8(3):278-82.28. CDC. Effects of new penicillin susceptibility breakpoints forStreptococcus pneumoniae — United States, 2006-2007. MMWRMorb Mort Wkly Rep 2008;57(50):1353-5.29. EUVAC-Net. Pneumococcal vaccination (PCV) overview in Europeancountries. [Internet]. Available from http://www.euvac.net/graphics/euvac/vaccination/pcv.html30. Johnson AP, Davies J, Guy R, Abernethy J, Sheridan E, Pearson A, etal. Mandatory surveillance of methicillin-resistant Staphylococcusaureus (MRSA) bacteraemia in England: the first 10 years.J Antimicrob Chemother 2012;67(4):802-9.31. Anonymous. Recent trends in antimicrobial resistance amongStreptococcus pneumoniae and Staphylococcus aureus isolates: theFrench experience. Euro Surveill 2008;13(46). pii: 19035.32. de Kraker ME, Davey PG, Grundmann H; BURDEN study group.Mortality and hospital stay associated with resistant Staphylococcusaureus and Escherichia coli bacteremia: estimating the burden ofantibiotic resistance in Europe. PLoS Med 2011;8(10):e1001104.33. Rampling A, Wiseman S, Davis L, Hyett AP, Walbridge AN, PayneGC, et al. Evidence that hospital hygiene is important in the controlof methicillin-resistant Staphylococcus aureus. J Hosp Infect2001;49(2):109-16.34. Thompson DS, Workman R, Strutt M. Decline in the rates of methiicillin-resistantStaphlococcus aureus acquisition and bacteraemiain a general intensive care unit between 1996 and 2008. J HospInfect 2009;71(4):314-9.35. Vos MC, Behrendt MD, Melles DC, Mollema FP, de Groot W, ParlevlietG, et al. 5 years of experience implementing a methicillin-resistantStaphylococcus aureus search and destroy policy at the largestuniversity medical center in the Netherlands. Infect Control HospEpidemiol 2009;30(10):977-84.36. Ellington MJ, Hope R, Livermore DM, Kearns AM, Henderson K,Cookson BD, et al. Decline of EMRSA-16 amongst methicillinresistantStaphylococcus aureus causing bacteraemias in the UKbetween 2001 and 2007. J Antimicrob Chemother 2010;65(3):446-8.65

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Annex 1 External quality assessment (EQA)2011IntroductionSince 2000, EARSS/EARS-Net have organised annualexternal quality assessments (EQA) for antimicrobialsusceptibility testing in collaboration with UK NEQAS(United Kingdom National External Quality AssessmentService). UK NEQAS is based at the Health ProtectionAgency in London, and is a non-profit organisation withmore than 35 years of experience in external qualityassessment in different countries (www.ukneqasmicro.org.uk).The purposes of the EARS-Net EQA are:• to assess the ability of participating laboratories toidentify antimicrobial resistance of clinical and publichealth importance;• to determine the accuracy of susceptibility test resultsreported by individual laboratories;• to estimate the overall comparability of routinely collectedtest results between laboratories and countriesacross Europe.The strains used for the 2011 EQA were compatiblewith species under surveillance at ECDC, namelyStreptococcus pneumoniae, Staphylococcus aureus,Escherichia coli, Klebsiella pneumoniae, Pseudomonasaeruginosa and Enterococcus faecium. The referenceMICs of strains were each tested in two of three laboratories:Addenbrookes Hospital, Cambridge (UK),University Hospital of Wales, Cardiff (UK) and CityHospital, Birmingham (UK). Reference laboratories confirmedMICs and results were interpreted according tothe most frequently used breakpoint criteria (EUCASTand CLSI), as indicated in the summary for each speciesoutlined below.ResultsSix strains were distributed to 908 laboratories connectedto EARS-Net. The laboratories were asked toreport the identification of each organism and clinicalsusceptibility characterisation – susceptible, intermediateor resistant (S, I, R) – according to the guidelineused. The return rate was similar to that in previousyears; 817 laboratories (90%) returned reports. FigureA1.1 shows the number of participating laboratories andthe number returning results per country. Participants’results were analysed and considered ‘concordant’ if thereported categorisation agreed with the interpretationof the MICs determined in the reference laboratories.Figure A1.1: Number of participating laboratories returning EQA reports 2011, per countryCountryAustriaBelgiumBosnia & HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIcelandIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsNorwayPolandPortugalRomaniaSloveniaSpainSwedenTurkeyUnited KingdomResultsNo results0 20 40 60 80 100 120Number of laboratoriesThe external quality assessment exercise was open to all countries participating in EARSS in 2011.69

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFor the determination of AST results, laboratories usedautomated methods (42%), disc diffusion tests (34%), ora combination of methods (16%). For species identification,56% used automated and 44% used conventionalmethods. Increased use of conventional methods was toa large extent associated with identification of S. pneumoniaeand E. faecium.Forty-seven percent of laboratories used CLSI guidelines;this represented a significant reduction from theprevious year when 66% used CLSI guidelines. Nationalguidelines are commonly followed in some countries,e.g. SFM (France), BSAC (UK), SRGA (Sweden), CRG(Netherlands) and DIN (Germany). EUCAST guidelineswere reported to be used by 281 (35%) laboratories,an increase of 174 laboratories since the previous year(n=107). However, the BSAC, SRGA, CRG, DIN, SFM andNWGA have been implementing EUCAST breakpointsin their national MIC breakpoint recommendations asharmonised breakpoints have been agreed, and haveFigure A1.2: Guidelines reported to be used by laboratories: number of laboratories per country, 2011CountryAustriaBelgiumBosnia & HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIcelandIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsNorwayPolandPortugalRomaniaSloveniaSpainSwedenTurkeyUnited KingdomBSACCOMBCRGDINEUCASTCLSINWGAOtherSFMSRGA0 20 40 60 80 100Number of laboratoriesBSAC: British Society for Antimicrobial Chemotherapy; CRG: (Dutch) Commissie Richtlijnen Gevoeligheidsbepalingen; DIN: Deutsche Industrie Norm; EUCAST:European Committee on Antimicrobial Susceptibility Testing; CLSI: Clinical and Laboratory Standards institute; NWGA: Norwegian Working Group on Antimicrobials;SFM: Société Française de Microbiologie; SRGA: Swedish Reference Group for Antimicrobials. Laboratories specifying ‘other’ indicates did they did not use any ofthe specified guidelines above. Where more than one guideline was used to cover certain antimicrobial/organism combinations laboratories could select combined(COMB) as the guideline.Table A1.1: Escherichia coli (0270): Minimum inhibitory concentration (MIC) and intended results reported by thereference laboratories and the overall concordance of the participating laboratoriesAntibiotic agentMIC range (mg/L) ref. lab.Intended interpretationfrom to EUCAST/CLSI Overall concordance (%)Amikacin 4 8 S 69Amoxicillin NT* R 99Ampicillin ≥128 ≥128 R 100Cefotaxime ≥128 ≥128 R 100Ceftazidime 16 64 R 95Ceftriaxone ≥128 ≥128 R 100Ciprofloxacin 64 ≥128 R 100Gentamicin 32 ≥128 R 100Imipenem 0.06 0.12 S 99Meropenem 0.016 0.03 S 100Piperacillin* R 99Piperacillin–tazobactam 8 16 S/I 56Tobramycin 32 64 R 100ESBL** Positive 100* Not tested, reference MICs were participants’ results.** ESBL: Extended-spectrum beta-lactamaseS: susceptible; R: resistant; I: intermediate.70

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011adjusted the interpretation of their disc diffusion methodsaccordingly. Therefore, a combined total of some48% of laboratories used EUCAST breakpoints. FigureA1.2 shows the adherence to (inter)national guidelinesby number of laboratories per country.Specimen 0270 Escherichia coliThis specimen consisted of an Escherichia coli witha CTX-M-15 ESBL. There were no problems detectingresistance to cephalosporins or in identifying that theorganism was an ESBL-producer.Reference MICs of piperacillin–tazobactam were 8–16mg/L (fixed concentration of 4 mg/L tazobactam), sosusceptibility was borderline and interpreted as susceptibleor intermediate by EUCAST breakpoints andsusceptible by CLSI breakpoints. Results of participantswere also variable, with 32.7% reporting piperacillin–tazobactam-susceptible,23.7% intermediate and ahigher than expected rate (43.6%) reporting resistant.The percentage of participants reporting susceptible orintermediate was similar for those using EUCAST-basedbreakpoints (57% of 356 laboratories) and those usingCLSI breakpoints (59.2% of 341 laboratories). Thoseusing automated methods were more likely to reportresistance (63.1% of 225 participants) than those usingMIC methods (55.3% of 103), multiple methods (44.6%of 94) or disc diffusion methods (24.5% of 310). Currentguidelines from both EUCAST and CLSI recommendreporting β-lactamase inhibitor combinations ‘as found’in routine tests. Despite this, for participants where dataare available, some laboratories edited susceptible testresults to intermediate or resistant, or edited intermediatetest results to resistant (in total around 34% ofparticipants using disc diffusion methods, 24% usingMIC methods and 9% using automated methods).Reference MICs of amikacin were 4–8 mg/L, which isslightly raised compared with typical susceptible isolates,but interpreted as susceptible by both EUCASTand CLSI breakpoints. The isolate was reportedsusceptible by 61.8% participants, intermediate by31.6% and resistant by 6.6% (Table A1.1).Specimen 0271 Klebsiella pneumoniaeThis specimen consisted of a Klebsiella pneumoniaewhich produces both a KPC carbapenemase and an SHV-12 ESBL.Although the organism is a carbapenemase producer,reference carbapenem MICs by the ISO broth microdilutionmethod were low, 0.5–1 mg/L for imipenem, whichwould be reported susceptible by both EUCAST and CLSI,and 4 mg/L for meropenem, which would be reportedintermediate by EUCAST breakpoints and resistant byCLSI breakpoints. Most participants, however, reportedreduced susceptibility to imipenem (6.3% susceptible,19.3% intermediate and 74.4% resistant) and to meropenem(6.4% susceptible, 9.5% intermediate and 84.1%resistant). MICs reported by participants were very variable,from 0.12 to 256 mg/L with a mode of 8 mg/L forimipenem and 0.5–128 mg/L with a mode of 2 mg/L formeropenem. The reason for the highly variable carbapenemMICs is unclear, but repeat MICs by the ISO brothmicrodilution method in one of the reference laboratoriesafter the distribution were 16 mg/L for imipenemand 32 mg/L for meropenem, suggesting that there mayhave been variation in the strain, which would inevitablyresult in variable reporting.Detection of ESBLs may be required for epidemiologicalpurposes and the presence of a carbapenemase inaddition to an ESBL in this isolate makes detection ofthe SHV-12 ESBL problematic. With this isolate, clavulanicacid synergy tests were difficult to interpretas there was only slight reduction in third- generationcephalosporin MICs, depending on the cephalosporintested, and resistance mediated by carbapenemasescan also be marginally affected by clavulanate. Amongparticipants, 54.2% reported the presence of an ESBL.Reporting of susceptibility to β-lactam agents other thancarbapenems was not an issue as reference MICs wereuniformly high.Table A1.2: Klebsiella pneumoniae (0271): Minimum inhibitory concentration (MIC) and intended results reported bythe reference laboratories and the overall concordance of the participating laboratoriesAntibiotic agentMIC range (mg/L) ref. lab.Intended interpretationfrom to EUCAST/CLSI Overall concordance (%)Amikacin 16 16 S/I/R 100Amoxicillin ≥128 I/R 100Ampicillin ≥128 ≥128 R 100Cefotaxime ≥128 ≥128 R 100Ceftazidime ≥128 ≥128 R 100Ceftriaxone ≥128 ≥128 R 100Ciprofloxacin ≥128 ≥128 R 100Gentamicin 1 1 S 87Imipenem 1 1 S 10Meropenem 4 4 I/R 94Piperacillin* R 100Piperacillin–tazobactam ≥128 ≥128 R 100Tobramycin ≥128 ≥128 R 99ESBL** Positive 57* Not tested, reference MICs were participants’ results.** ESBL: Extended-spectrum beta-lactamaseS: susceptible; R: resistant; I: intermediate.71

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTAminoglycoside susceptibility was typical of an organismproducing AAC(6’)I in that it was resistant totobramycin (MIC ≥128 mg/L), susceptible to gentamicin(MIC 1 mg/L) and borderline to amikacin (MIC 16 mg/L;intermediate by EUCAST breakpoints and susceptibleby CLSI breakpoints). EUCAST expert rules note thatacquired AAC(6’)I may not confer phenotypic resistanceto amikacin despite modification of amikacin, and thatsuch organisms should be reported intermediate evenif they appear susceptible. There were no significantproblems with tobramycin and only 1.2% of participantsreported the organism susceptible to amikacin, themajority (89.8%) reporting resistance. For gentamicin,88.7% of participants reported the isolate as susceptible,8.1% as intermediate and 3.2% as resistant (TableA1.2).Specimen 0272 Streptococcus pneumoniaeThis specimen consisted of a Streptococcus pneumoniaewith reduced susceptibility to penicillin (MIC 0.5 mg/L).For S. pneumoniae with no mechanism of resistance topenicillin, MICs are ≤0.06 mg/L. However, the interpretationof susceptibility to penicillin depends on whetherthe isolate is from a patient with pneumonia, meningitisor other infections. Strains with intermediate susceptibility(EUCAST MIC 0.06–2 mg/L, CLSI MIC 0.06–4 mg/L)are treatable with the high doses of penicillin, ampicillinor amoxicillin routinely used to treat pneumonia. Hencesuch strains may be reported susceptible in this situation.Patients with meningitis caused by strains withintermediate susceptibility to penicillin are unlikely torespond to therapy, and hence such strains should bereported as resistant in this situation. Participants wereasked to give the interpretations that would be reportedif the isolate was from a case of pneumonia and if theisolate was from a case of meningitis.Overall, 90.8% participants reported resistance in theoxacillin screening test for penicillin resistance. An additional4.6% reported oxacillin intermediate althoughthere is no intermediate category for the oxacillinscreening test. There were no problems in detectingreduced susceptibility to oxacillin in reference tests bythe EUCAST and CLSI methods.The participants’ results for penicillin without a siteof infection cannot be interpreted because guidelinebreakpoints relate to the site of infection. However, forpenicillin without a site of infection 69.8% designatedthe isolate as being of intermediate susceptibility topenicillin, with a further 6.7% reporting the isolateresistant and 23.5% susceptible. Susceptibility reportedto clinicians indicates variable practice in that some participantsdo not interpret test results to suit the clinicalsituation, as only 86.4% reported the isolate resistant ifthe isolate was from a case of meningitis and only 76.1%Table A1.3: Streptococcus pneumoniae (0272): Minimum inhibitory concentration (MIC) and intended results reportedby the reference laboratories and the overall concordance of the participating laboratoriesAntibiotic agentMIC range (mg/L) ref. lab.Intended interpretationfrom to EUCAST/CLSI Overall concordance (%)CefotaximeMeningitis S -Pneumonia 0.25 0.25S/- 95Other S/- 99Non-meningitis - -Ceftriaxone99Meningitis S -Pneumonia 0.25 0.25S/- 96Other S/- 99Non-meningitis -/S -Ciprofloxacin 0.5 1 I/no interpretation 35Clindamycin 0.12 0.12 S 98Erythromycin 32 > 128 R 96PenicillinMeningitis R -Pneumonia 0.5 0.5S/- 86Other I/- 73Non-meningitis -/S -S: susceptible; R: resistant; I: intermediate.Table A1.4: Enterococcus faecium (0273): Minimum inhibitory concentration (MIC) and intended results reported by thereference laboratories and the overall concordance of the participating laboratoriesAntibiotic agentMIC range (mg/L) ref. lab.Intended interpretationfrom to EUCAST/CLSI Overall concordance (%)Amoxicillin NT* R 89Ampicillin 16 32 R 98High-level gentamicin 4 4 S (not high-level resistance) 74Teicoplanin 0.5 1 S 98Vancomycin 8 16 R/I 79* Not tested, result inferred from ampicillin result.S: susceptible; R: resistant; I: intermediate.72

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011reported susceptible if the isolate was from a case ofpneumonia. Significant numbers of participants interpretedthe isolate as intermediate in susceptibility topenicillin irrespective of whether the isolate was frommeningitis (8.1% reported intermediate) or from pneumonia(20.8% reported intermediate). These differenceswill partly relate to national differences in reportingpractices.Resistance to cefotaxime and ceftriaxone is rare inS. pneumoniae and a high percentage of participantsreported the isolate susceptible to these agents whateverthe source of the infection.Ciprofloxacin is not the fluoroquinolone of choice fortreatment of infections with S. pneumoniae. EUCAST categorisewild-type isolates as intermediate and CLSI donot include breakpoints in current tables. Only aroundhalf the participants tested this organism against ciprofloxacinand, contrary to guidelines, 55.4% of thosetesting ciprofloxacin reported the isolate susceptible(Table A1.3).Specimen 0273 Enterococcus faeciumThis specimen consisted of an Enterococcus faecium withvanB-mediated resistance to vancomycin.Vancomycin MICs can be low for VanB strains, as inthis case (MICs 8–16 mg/L), and the isolate would beinterpreted as resistant by EUCAST breakpoints butintermediate by CLSI breakpoints. The borderline susceptibilitymakes detection of reduced susceptibilitymore difficult, particularly with disc diffusion methodswhere the difference in zone diameter between susceptibleand resistant isolates may be small and resistancemay be seen only as small colonies inside zone edges,or ‘fuzzy’ zone edges after 24 hours incubation, in contrastwith the sharp zone edges seen with susceptibleisolates. Reduced susceptibility to vancomycin wasdetected by only 92% of participants (8.6% intermediate,83.4% resistant).Gentamicin mono-therapy is ineffective against enterococci.There is, however, synergism between gentamicinand β-lactam agents against enterococci without mechanismsconferring high-level gentamicin resistance(usually production of the bi-functional enzyme APH(2’’)/AAC(6’)). Overall, 24.7% of participants incorrectlyreported this isolate as high-level gentamicin-resistant.Previously, similar errors have been related to theerroneous use of lower content gentamicin discs thanspecified in disc diffusion method guidelines; this mayalso explain the incorrect results for 2011.This organism is resistant to ampicillin and amoxicillinwith EUCAST breakpoints. CLSI specifies that susceptibilityof enterococci to amoxicillin should be inferredfrom the ampicillin susceptibility, so the organismTable A1.5: Pseudomonas aeruginosa (0274): Minimum inhibitory concentration (MIC) and intended results reported bythe reference laboratories and the overall concordance of the participating laboratoriesAntibiotic agentMIC range (mg/L) ref. lab.Intended interpretationfrom to EUCAST/CLSI Overall concordance (%)Amikacin 1 4 S 94Ceftazidime 1 2 S 98Ciprofloxacin 0.12 0.5 S 99Gentamicin 16 ≥128 R* 99Imipenem 1 2 S 99Meropenem 0,5 2 S 98Piperacillin–tazobactam 4 8 S 83Tobramycin 0.5 1 S 99* Reference MICs covered the range of susceptible to resistant by both EUCAST and CLSI.S: susceptible; R: resistant; I: intermediate.Table A1.6: Staphylococcus aureus (0275): Minimum inhibitory concentration (MIC) and intended results reported bythe reference laboratories and the overall concordance of the participating laboratoriesAntibiotic agentMIC range (mg/L) ref. lab.Intended interpretationfrom to EUCAST/CLSI Overall concordance (%)Cefoxitin 8 16 R 95Ciprofloxacin 0.5 0.5 S 98Clindamycin 0.12 0.12 dissociated resistance 75Erythromycin 8 64 R 92Fusidic acid 0.06 0.12 S 99Gentamicin 0.25 0.5 S/no interpretation 98Meticillin NT* R 99Oxacillin 8 32 R 96Penicillin 1 4 R 100Rifampicin 0.004 0.008 S 100Teicoplanin 1 1 S 100Tetracycline 64 64 R 98Vancomycin 1 2 S 99* Not tested, result inferred from oxacillin and cefoxitin results.S: susceptible; R: resistant; I: intermediate.73

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTshould also be reported resistant to ampicillin andamoxicillin by CLSI guidelines. Overall, 98.8% of participantsreported resistance to ampicillin. Only one thirdof participants reported susceptibility results for amoxicillinand of these only 84.2% reported resistance, with7.9% reporting intermediate and another 7.9% reportingsusceptible (Table A1.4).Specimen 0274 Pseudomonas aeruginosaThis specimen consisted of a Pseudomonas aeruginosaresistant to gentamicin and susceptible to other referenceagents tested.Some laboratories experienced problems with piperacillin–tazobactamtesting in that overall 6.2% ofparticipants reported the isolate intermediate and 5.7%resistant. The reason for the problems is not obvious asthe isolate was clearly susceptible in reference tests byboth MIC and disc diffusion methods (Table A1.5).Specimen 0275 Staphylococcus aureusThis specimen consisted of a meticillin-resistantStaphylococcus aureus with dissociated resistance toclindamycin.Testing for meticillin resistance still causes problems insome laboratories as only 95.2% reported resistance tocefoxitin and 95% to oxacillin.As seen with previous distributions of organisms withdissociated resistance, there were significant discrepanciesin reporting susceptibility to clindamycin,with 74.2% reporting resistant, 1.8% intermediate and24.0% susceptible. In staphylococci, most resistanceto macrolide, lincosamide and streptogramin type B(MLS B ) antimicrobials is mediated by the erm genes andis induced by erythromycin, clarithromycin and azithromycin,but not by clindamycin (dissociated resistanceor MLS B -inducible resistance). Hence inducible strainsare resistant to erythromycin but not to clindamycinin susceptibility tests. Strains with MLS B -constitutiveresistance are resistant to both agents.There has been debate about whether staphylococciwith inducible resistance (erythromycin-resistant,clindamycin-susceptible) should be reported resistantas inducible strains segregate clindamycin-resistantmutants, which may be selected during therapy. EUCASTexpert rules indicate that such strains should either bereported as resistant to clindamycin or reported as susceptiblewith a warning of possible clinical failure duringtreatment with clindamycin due to selection of constitutivelyresistant mutants. EUCAST also states that theuse of clindamycin is best avoided for severe infectionscaused by isolates with dissociated resistance. CLSIsuggest that such strains should be reported resistantbut that a comment may be added that clindamycin maystill be effective in some patients. Inducible clindamycinresistance is detected in disc diffusion tests witha clindamycin disc placed adjacent to an erythromycindisc; strains with inducible resistance show flattening ofthe clindamycin zone adjacent to the erythromycin disc(Table A1.6).ConclusionsThe response to the 2011 EARS-Net EQA was very goodwith a high return rate and very few late responders.Performance was generally very good and consistentwith that seen in previous EQA. Problems, where experienced,were related to borderline susceptibility andwhen guidelines revealed remaining discrepancies inroutine susceptibility testing.ECDC would like to thank UK NEQAS, the reference laboratories,the members of the EARS-Net CoordinationGroup and the country coordinators for the swift distributionof the strains, and all the participating laboratoriesfor their efforts and timely response to the assessment.74

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Annex 2 EARS-Net laboratory/hospitaldenominator data 2011IntroductionFor correct interpretation of the EARS-Net data on antimicrobialresistance, accurate background informationis important. Therefore, laboratory and hospital denominatordata are collected and presented in this Annex.MethodsQuestionnaires (Microsoft Excel files) were sent to theEARS-Net contact points in May 2012. The contact pointsdistributed the questionnaires to the participating laboratoriesand hospitals in their country. Information wascollected on the total number of blood culture sets processedin the laboratories, and the number of hospitalbeds for each participating hospital, the type of hospital,the bed occupancy and the number of admissions. Thenational data managers received the completed questionnaires,compiled them and produced the final formatsuitable for uploading to The European SurveillanceSystem (TESSy). Laboratories were defined as reportingdenominator data if they provided the number ofblood culture sets performed for one or more hospitals.Hospitals were defined as reporting denominator data ifthey provided the number of beds.Organisation of health care systems and affiliationbetween laboratories and hospitals differsconsiderably between countries, which might influencedata comparability. For countries submitting denominatordata for a small percentage of hospitals and/orlaboratories contributing data to EARS-Net, the reportedfigures might not be representative for the overall countryprofile.ParticipationSixteen of the 29 countries reporting AMR data alsoreturned hospital and laboratory denominator datareferring to 2011, while for eight countries, hospitaland laboratory denominator data referring to 2010 wereavailable and included in the analysis. In total, 1 012(70 %) of the 1 445 hospitals and 477 (61 %) of the 784laboratories reporting AST results for the 24 countries,also provided denominator data (Figures A2.1, A2.2 andTables A2.1–A2.3). Some denominator data for laboratoriesand hospitals not reporting AMR data, or reportingzero cases, have been included in Figure A2.1, but werenot included in other parts of the analysis.Population coverageData on population coverage for AMR data at countrylevel are not reported because of the inherentlimitations of these data. Not all laboratories/hospitalsreporting AST data also provide denominator data, andthis would introduce bias into the calculation of countrypopulation coverage since only laboratories/hospitalsTable A2.1: Hospital denominator data for 2010 or 2011 (using latest available data)CountryHospitals reporting(denominator/AMRdata)Total number of bedsProportion of ICUbeds (%)Annual occupancyrate (%)Median length ofstay (days)IQR length of stay(days)Austria* (140/142) 54 743 5 67 4.7 4.1-5.4Bulgaria (21/22) 9 474 8 76 6.1 5.4-6.6Cyprus (5/5) 1 316 10 77 5.3 5.1-5.4Czech Republic (68/76) 38 911 11 70 7.2 6.1-8.3Denmark (5/69) 3 254 82 3.2 2.8-3.6Estonia* (10/11) 4 472 4 76 6.3 5.1-7.1France (260/264) 156 586 5 81 7.4 6.2-8.8Germany (46/189) 18 296 7 76 6.9 6.5-7.9Hungary (66/73) 51 240 2 74 8.5 7.1-9.4Ireland (53/59) 12 265 3 87 5.5 4.6-6.8Italy* (31/35) 10 249 83 .-.Latvia* (11/12) 5 135 3 71 6.1 4.1-6.8Lithuania (21/25) 10 734 4 74 7.1 6.0-8.8Malta (3/3) 1 157 6 87 5.3 4.8-45.0Netherlands* (37/55) 14 886 67 5.2 4.9-5.6Norway* (14/49) 4 347 5 84 4.4 4.0-4.7Poland (41/58) 20 432 2 71 5.0 4.0-6.0Portugal (21/21) 9 680 6 79 7.1 5.7-7.9Romania (5/5) 2 964 6 85 6.2 5.7-6.4Slovakia (21/21) 11 354 9 70 6.9 6.2-7.9Slovenia* (15/15) 7 265 6 71 5.8 4.8-6.5Spain* (39/49) 24 571 4 79 .-.Sweden (46/66) 15 882 4 91 4.7 4.1-5.2United Kingdom (33/121) 11 561 2 79 4.4 2.9-7.7* Data from 2010.75

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFigure A2.1: Number of hospitals (A) and laboratories (B) reporting AMR and/or denominator data in 2010 or 2011(using latest available data)A)CountryAustria*BulgariaCyprusCzech RepublicDenmarkEstonia*FranceGermanyHungaryIrelandItaly*Latvia*LithuaniaMaltaNetherlands*Norway*PolandPortugalRomaniaSlovakiaSlovenia*Spain*SwedenUnited KingdomAMR and denominator informationAMR information onlyDenominator information only0 50 100 150 200 250 300Number of hospitalsB)CountryAustria*BulgariaCyprusCzech RepublicDenmarkEstonia*FranceGermanyHungaryIrelandItaly*Latvia*LithuaniaMaltaNetherlands*Norway*PolandPortugalRomaniaSlovakiaSlovenia*Spain*SwedenUnited KingdomAMR and denominator informationAMR information onlyDenominator information only0 50 100 150 200 250 300Number of laboratories* Denominator data from 2010.76

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011reporting denominator data can be included. Secondly,laboratories and hospitals cluster in big cities and, forthis reason, some of the catchment areas overlap. Thiscould lead to double counts, which would artificiallyincrease the estimated coverage.Hospital denominatorinformationThe total number of hospital beds for hospitals reportingboth AMR and denominator data in differentcountries ranged from 1 157 in Malta to 156 586 in France,reflecting the size of the country as well as the rate ofparticipation to EARS-Net and the rate of response to thequestionnaires.The percentage of ICU beds over total hospital bedsshows wide variation by country, ranging from 2 % inHungary, Poland and the United Kingdom to 11 % in theCzech Republic. The overall median length of stay in hospitalwas 5.9 days with the lowest median in Denmark(3.2 days) and the highest in Hungary (8.5 days). Theannual occupancy rate was 75 % or higher in 15 out of 24countries (Table A2.1).Hospital characteristicsBoth the size of a hospital and the level of specialisationmay influence the occurrence of antimicrobial resistancein the hospital. As can be seen from Table A2.2 and FigureA2.2, the distribution of size and specialisation level ofhospitals varied considerably between the reportingcountries. This does not necessarily reflect differentdistributions of the origin of EARS-Net blood culturesper country, as not all hospitals contribute evenly to theEARS-Net database. On the other hand, this diversitycan indicate differences in case-mix, which may confoundcomparison of AMR results between countries.The type of hospital and the size of hospital are notalways linked and it is not rare, especially in smallercountries, that university hospitals have fewer than 500beds.Laboratory denominatorinformationIn 2010/2011 (latest available data), the number of bloodculture sets processed in the EARS-Net laboratoriesresponding to the questionnaire was 3 278 850. Themedian culturing frequency was 28.3 blood culture setsper 1 000 patient days. The highest rate was reportedby Italy (91.3) and the lowest by Lithuania (5.5). Forthe majority of the reporting countries, there are onlyminor changes in the number of blood culture sets takenper 1 000 patient days (Table A2.3) when comparing2009/2010 (latest available data) data with 2010/2011(latest available data). The highest total number ofblood culture sets was reported by France (881 270) followedby Sweden (352 450).Figure A2.2: Percentage of small, medium and large hospitals per country, based on the number of beds, for allhospitals reporting both antimicrobial resistance data and denominator data in 2010 or 2011 (using latest availabledata)CountryAustria* (140/142)Bulgaria (21/22)Cyprus (5/5)Czech Republic (68/76)Denmark (5/69)Estonia* (10/11)France (260/264)Germany (46/189)Hungary (66/73)Ireland (53/59)Italy* (31/35)Latvia* (11/12)Lithuania (21/25)Malta (3/3)Netherlands* (37/55)Norway* (14/49)Poland (41/58)Portugal (21/21)Romania (5/5)Slovakia (21/21)Slovenia* (15/15)Spain* (39/49)Sweden (46/66)United Kingdom (33/121)Large hospitals(> 500 beds)Medium-sized hospitals(201–500 beds)Small hospitals(≤ 200 beds)0 20 40 60 80 100* Denominator data from 2010.Percentage hospital type77

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTTable A2.2: Hospital characteristics for 2010 or 2011 (using latest available data)CountryHospitals reporting(denominator/AMR data)Proportion of hospitals by level of care (%)Tertiary level Secondary level Primary level Other UnknownAustria* (140/142) 8 24 39 29 0Bulgaria (21/22) 52 33 5 10 0Cyprus (5/5) 20 20 40 20 0Czech Republic (68/76) 34 34 29 3 0Denmark (5/69) 40 40 0 0 20Estonia* (10/11) 0 50 20 30 0France (260/264) 22 77 0 0 1Germany (46/189) 33 30 28 7 0Hungary (66/73) 50 26 14 11 0Ireland (53/59) 17 55 11 17 0Italy* (31/35) 16 16 0 0 0Latvia* (11/12) 45 18 9 27 0Lithuania (21/25) 48 38 10 5 0Malta (3/3) 33 33 0 33 0Netherlands* (37/55) 8 73 19 0 0Norway* (14/49) 36 36 29 0 0Poland (41/58) 29 66 0 5 0Portugal (21/21) 57 33 5 5 0Romania (5/5) 80 20 0 0 0Slovakia (21/21) 67 0 5 29 0Slovenia* (15/15) 13 47 20 13 7Spain* (39/49) 56 38 5 0 0Sweden (46/66) 17 39 43 0 0United Kingdom (33/121) 27 27 24 6 9* Data from 2010.Primary level or district hospital = has few specialties, limited laboratory services; bed capacity ranges from 30 to 200 beds. Secondary level, or provincial hospital= highly differentiated by function with five to 10 clinical specialties; bed capacity ranging from 200 to 800 beds. Tertiary level or central/regional hospital = highlyspecialised staff and technical equipment; clinical services are highly differentiated by function; may have teaching activities; bed capacity ranges from 300 to 1500beds. Other = hospitals for a specific patient population, like a military hospital, or hospitals with any single specialty, like a burns unit.Unknown = not available.Table A2.3: Laboratory denominator information for 2010 or 2011 (using latest available data)CountryLaboratories reporting(denominator/AMR data)Number of hospitals Total number of blood culture setsNumber of blood culture sets per1000 patient daysAustria* (36/39) 127 178 672 14.1Bulgaria (20/20) 21 19 642 7.5Cyprus (5/5) 5 13 513 36.5Czech Republic (44/46) 68 144 615 14.5Denmark (4/13) 4 79 269 81Estonia* (10/11) 11 20 593 16.6France (52/263) 52 881 270 61Germany (11/19) 37 69 259 16.5Hungary (24/31) 54 87 980 7.8Ireland (38/40) 53 180 995 46.7Italy* (30/35) 30 209 974 91.3Latvia* (11/11) 11 12 726 9.6Lithuania (10/10) 21 15 920 5.5Malta (1/1) 3 8 796 24Netherlands* (13/22) 28 99 034 38.3Norway* (9/15) 14 62 532 46.7Poland (41/45) 41 125 330 23.4Portugal (18/18) 21 122 744 43.8Romania (5/5) 5 27 252 29.5Slovakia (11/11) 21 60 922 20.9Slovenia* (10/10) 14 50 480 27Spain* (39/41) 39 308 872 43.4Sweden (18/18) 46 352 450 67.1United Kingdom (17/55) 26 146 763 48.1* Data from 2010.78

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Discussion and conclusionsIn summary, the situation for most countries as assessedfrom denominator data reported to EARS-Net in 2011appears stable and similar to 2010. This indicates thatbased on EARS-Net data the comparison of resistancepercentages over time remains valid.The BSIs ascertainment is strongly linked to the bloodculture rate. Therefore, the wide range in blood culturerates observed in the countries providing denominatordata has implications for inter-country comparisonsof both the incidence rate of infections, which couldbe underestimated in some countries, and of the percentageof resistance. In particular, the percentage ofresistance could be overestimated if blood cultures arenot systematically performed before starting empirictherapy and if blood cultures are more likely to be performedin patients not responding to initial empirictreatment.For future improvement of the denominator data collectionand analysis, a further increase in the numberof countries reporting denominator data, as well asan increased number of hospital and laboratoriesparticipating within countries, would be desirable.Furthermore, an improved estimation of the coverageof the EARS-Net surveillance, e.g. by using estimationsdone at the national level based on knowledge of thecountry-specific situation, would also be desirable.79

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Country summary sheets81

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORT82

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Explanation to the countrysummary sheetsGeneral information about EARS-Netparticipating laboratories and hospitalsTable 1 gives the number of laboratories and isolatesreported by year and by pathogen under EARSS/EARS-Net surveillance for the period 2003–2011.Antibiotic resistance 2003–2011Table 2 provides information on the proportion of invasivebacterial isolates non-susceptible (I+R) or resistant(R) to the antibiotics or antibiotic classes mentioned inthe EARSS/EARS-Net protocols. When interpreting theresults in Table 2, always check the number of isolatesprovided in Table 1.PNSP at laboratory level/MRSA, FREC and3GCRKP at hospital levelFigures 1, 2, 3 and 4 show the local variation in the percentageof PNSP by laboratory and of MRSA, FREC and3GCRKP by hospital. These figures are based on datafrom 2010 and 2011, only including the laboratories andhospitals that reported at least five isolates in these twoyears. The total number of laboratories or hospitals, theminimum, maximum, median, first and third quartile ofthe proportion of resistance is displayed in a box in thefigures.Demographic characteristicsTable 3 gives the proportional distribution of the isolatesreported by source, gender, age, and hospitaldepartment, and the percentage of resistance within thedifferent groups, for the period 2010–2011.The abbreviations used in this table stand for:PNSP = penicillin-non-susceptible S. pneumoniae;MRSA = meticillin-resistant S. aureus;FREC = fluoroquinolone-resistant E. coli;VRE = vancomycin-resistant E. faecalis or E. faecium;3GCRKP = third-generation cephalosporin-resistantK. pneumoniae; andCRPA = carbapenem-resistant P. aeruginosa.If the number of isolates in a certain category accountsfor less than 0.5% of the total number of isolates, the %total is set at

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTAustriaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 20 163 20 871 21 985 19 327 - - - -2004 28 257 30 1 453 31 1 862 28 604 - - - -2005 31 298 32 1 481 33 2 058 30 568 7 89 8 772006 32 293 33 1 640 33 2 483 33 699 30 434 31 4052007 35 322 34 1 577 34 2 545 33 688 33 445 33 4112008 38 380 38 1 899 38 2 985 38 864 38 583 38 5102009 38 379 38 1 794 38 2 625 36 825 37 622 36 5252010 35 375 39 1 840 39 2 937 39 944 39 722 39 5042011 39 438 40 1 982 40 3 174 40 894 40 799 40 544Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 1 1

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 97 3 100 7 100 22 100 1 100 4 100 13 100 14CSF 3 4 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTAustriaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesAT016 (0/12)AT022 (0/10)AT038 (0/7)AT019 (0/25)AT015 (0/18)AT009 (0/8)AT033 (0/11)AT042 (0/6)AT021 (0/17)AT030 (0/35)AT018 (0/26)AT023 (0/16)AT003 (0/14)AT032 (0/5)AT002 (0/37)AT034 (0/9)AT031 (0/17)AT036 (0/9)AT037 (0/35)AT014 (0/6)AT026 (0/29)AT005 (1/64)AT001 (1/37)AT007 (1/35)AT006 (2/48)AT012 (1/22)AT028 (2/37)AT024 (1/14)AT010 (2/27)AT027 (3/33)AT017 (1/10)AT025 (4/34)AT020 (1/8)AT041 (2/12)AT043 (3/7)N laboratories 35Minimum 0First quartile 0Median 0Third quartile 5.4Maximum 42.90 25 50 75 100Hospital codesAT30UE (0/13)AT030G (0/21)AT022R (0/8)AT006N (0/32)AT036B (0/9)AT022Z (0/6)AT042B (0/35)AT007E (0/8)AT001B (0/31)AT015M (0/11)AT008S (0/7)N hospitals 111Minimum 0First quartile 0Median 3.7Third quartile 11.1Maximum 37.5AT036D (0/5)AT022B (0/29)AT043H (0/8)AT010R (0/9)AT030F (0/29)AT015S (0/24)AT005J (0/6)AT009S (0/13)AT030V (0/7)AT009R (0/21)AT007V (0/6)AT019L (0/7)AT008B (0/7)AT011P (0/7)AT007W (0/21)AT009W (0/16)AT022S (0/7)AT036U (0/8)AT016G (0/16)AT032R (0/11)AT009K (0/17)AT006M (0/9)AT030W (0/17)AT043G (0/13)AT040A (0/19)AT010L (0/11)AT006O (0/9)AT010F (0/60)AT030L (0/5)AT030H (0/9)AT022A (0/5)AT043W (0/14)AT015A (0/29)AT003M (0/16)AT005S (0/13)AT022K (0/17)AT037P (1/98)AT014R (1/75)AT001E (1/63)AT016W (2/104)AT007K (3/136)AT005L (1/33)AT012T (1/33)AT005Z (1/28)AT019P (4/107)AT011W (2/49)AT021S (1/23)AT005I (4/93)AT017K (2/45)AT026S (3/66)AT012W (2/39)AT022L (1/19)AT005R (1/18)AT020N (1/17)AT010H (1/17)AT003G (2/34)AT028R (6/96)AT005H (1/16)AT001S (3/48)AT023S (5/77)AT010B (1/15)AT026Z (1/15)AT035H (4/57)AT024V (6/79)AT023K (2/26)AT005K (2/23)AT036H (1/11)AT021V (6/65)AT024G (2/21)AT029O (2/20)AT025K (14/139)AT033D (6/57)AT032V (2/18)AT006B (1/9)AT033F (3/26)AT019T (3/26)AT038M (4/34)AT041E (4/33)AT006S (13/105)AT023F (1/8)AT002A (25/195)AT015W (1/7)AT023E (1/7)AT032J (1/7)AT020W (16/108)AT017T (4/27)AT018M (14/92)AT031W (12/78)AT007F (2/13)AT012D (3/19)AT018S (1/6)AT012H (1/6)AT032E (1/6)AT027L (30/166)AT043J (2/11)AT024B (6/30)AT034E (12/59)AT038B (11/37)AT005N (2/6)AT032D (3/8)0 25 50 75 100% penicillin non-susceptible % MRSA86

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesAT008K (0/5)AT001W (0/8)AT008A (0/5)AT032H (0/6)AT009S (1/26)AT008S (1/21)AT024G (3/53)AT007W (1/16)AT007F (1/16)AT006O (1/16)AT003G (2/30)AT010L (2/27)N hospitals 117Minimum 0First quartile 13.2Median 20Third quartile 28.6Maximum 60AT30UE (2/27)AT032D (1/13)AT015S (3/38)AT010R (2/22)AT032V (2/22)AT005L (6/65)AT012T (4/40)AT032R (1/10)AT023K (6/57)AT023S (12/112)AT010B (8/74)AT021V (7/64)AT022S (1/9)AT036B (1/9)AT024V (10/85)AT034E (11/90)AT021S (2/16)AT006B (5/38)AT007V (6/43)AT010H (6/42)AT036D (1/7)AT009K (2/14)AT019L (2/14)AT026S (15/104)AT017T (6/41)AT028R (30/204)AT005K (8/53)AT015A (10/63)AT005Z (8/49)AT043J (2/12)AT005R (3/18)AT024B (9/54)AT026Z (4/24)AT030N (1/6)AT016G (6/34)AT011W (13/73)AT033F (7/39)AT022B (5/28)AT043H (2/11)AT007K (30/162)AT042B (14/72)AT041E (20/102)AT019T (9/46)AT040A (6/30)AT036H (5/25)AT038B (13/65)AT007E (2/10)AT030L (1/5)AT010F (19/94)AT016W (30/142)AT025K (54/256)AT006S (39/184)AT012W (11/52)AT033D (28/130)AT020N (8/37)AT030V (5/23)AT001E (23/105)AT001B (8/36)AT022A (2/9)AT015M (3/13)AT005S (7/30)AT001S (29/123)AT017K (15/63)AT003M (5/21)AT030W (7/29)AT018M (29/118)AT027L (67/270)AT009W (2/8)AT005H (10/40)AT020W (29/113)AT030F (21/81)AT015W (4/15)AT014R (26/96)AT012D (7/25)AT038M (19/67)AT032P (2/7)AT035H (29/101)AT002A (72/250)AT019P (37/127)AT043G (7/24)AT030G (12/41)AT005J (5/17)AT037P (46/155)AT030Z (4/13)AT029O (7/22)AT023F (3/9)AT006N (3/9)AT022L (18/52)AT023E (9/26)AT031W (35/101)AT005I (69/198)AT009R (8/23)AT011P (9/24)AT012H (6/16)AT018S (3/8)AT022K (8/20)AT043W (8/20)AT006M (10/24)AT030H (7/16)AT005C (5/11)AT022R (6/12)AT023G (3/6)AT003L (3/6)AT005N (5/9)AT015U (3/5)0 25 50 75 100Hospital codesAT010R (0/5)AT016G (0/13)AT005H (0/6)AT005S (0/5)AT022K (0/5)AT042B (0/19)AT006N (0/8)AT022A (0/5)N hospitals 75Minimum 0First quartile 0Median 10Third quartile 20Maximum 60AT020N (0/13)AT023K (0/10)AT023E (0/5)AT029O (0/5)AT006B (0/7)AT022L (0/14)AT009R (0/11)AT021S (0/6)AT032P (0/5)AT043J (0/7)AT007V (0/9)AT032V (0/9)AT032R (0/8)AT007E (0/5)AT033F (0/10)AT001S (1/36)AT025K (2/69)AT041E (1/20)AT031W (2/40)AT010F (1/16)AT026S (1/15)AT024V (1/14)AT005Z (1/13)AT006S (5/64)AT007K (3/38)AT015A (1/12)AT027L (7/82)AT016W (4/42)AT023S (2/21)AT005L (1/10)AT001B (1/10)AT010B (1/10)AT017K (2/19)AT028R (7/66)AT022B (1/9)AT001E (4/36)AT020W (5/44)AT018M (3/26)AT011W (4/34)AT005R (1/8)AT021V (2/15)AT037P (4/28)AT014R (2/13)AT034E (2/12)AT017T (1/6)AT002A (14/78)AT012T (2/11)AT015M (1/5)AT003M (1/5)AT043W (1/5)AT033D (9/39)AT038B (2/8)AT005K (2/8)AT024G (2/8)AT038M (4/15)AT035H (7/26)AT005I (20/73)AT011P (3/10)AT030F (2/6)AT003G (4/11)AT019T (4/11)AT019P (20/53)AT005C (2/5)AT001W (2/5)AT009K (4/9)AT009W (3/6)AT040A (3/5)0 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance87

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTBelgiumGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 107 1488 47 1 133 24 1 326 16 146 - - - -2004 95 1 443 49 1 227 25 1 601 18 228 - - - -2005 97 1 539 41 1 048 25 1 592 19 223 - - - -2006 98 1 427 33 858 21 1 632 22 267 - - - -2007 105 1 511 34 855 17 1 460 20 245 - - - -2008 101 1 647 38 906 16 1 430 19 236 - - - -2009 101 1 885 34 949 18 1 610 14 227 8 142 8 1362010 97 1 797 40 1 088 23 1 966 22 323 14 145 15 1302011 91 1 829 50 1 771 43 4 039 46 754 44 676 43 460Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 96 0 100 19 100 22 100 0 100 6 100 13 99 9CSF 4 15 - - 0 0 - - - - 0 0 1 20GenderMale 55 1 59 19 47 26 63 0 58 6 58 13 62 9Female 44 1 40 18 53 18 37 0 42 5 42 14 38 9Unknown 1 2

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTBelgiumFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesBE114 (0/24)BE047 (0/25)BE166 (0/18)BE109 (0/5)BE090 (0/17)BE030 (0/50)BE072 (0/24)BE107 (0/29)BE033 (0/24)BE001 (0/50)N laboratories 94Minimum 0First quartile 0Median 0Third quartile 0Maximum 5.6BE130 (0/38)BE024 (0/70)BE061 (0/49)BE022 (0/46)BE081 (0/9)BE164 (0/29)BE011 (0/10)BE093 (0/20)BE054 (0/46)BE170 (0/7)BE003 (0/35)BE065 (0/9)BE097 (0/78)BE102 (0/25)BE043 (0/74)BE060 (0/23)BE077 (0/68)BE139 (0/58)BE026 (0/22)BE032 (0/36)BE046 (0/59)BE108 (0/156)BE129 (0/13)BE063 (0/40)BE092 (0/90)BE029 (0/17)BE057 (0/16)BE100 (0/17)BE023 (0/35)BE084 (0/32)BE007 (0/16)BE049 (0/49)BE051 (0/36)BE161 (0/33)BE073 (0/9)BE091 (0/86)BE141 (0/13)BE031 (0/17)BE083 (0/17)BE103 (0/33)BE002 (0/22)BE146 (0/44)BE113 (0/74)BE018 (0/15)BE160 (0/18)BE101 (0/27)BE159 (0/16)BE004 (0/54)BE037 (0/31)BE110 (0/39)BE152 (0/16)BE116 (0/40)BE104 (0/45)BE137 (0/28)BE087 (0/30)BE064 (0/8)BE056 (0/109)BE125 (0/10)BE112 (0/96)BE071 (0/20)BE105 (0/39)BE098 (0/26)BE035 (0/23)BE014 (0/29)BE008 (1/88)BE111 (1/82)BE016 (1/78)BE075 (1/67)BE115 (1/55)BE143 (1/52)BE021 (1/52)BE045 (1/53)BE070 (2/94)BE044 (1/45)BE095 (1/42)BE074 (1/40)BE019 (1/38)BE006 (1/35)BE118 (1/30)BE048 (1/22)BE017 (1/21)BE154 (1/21)BE069 (1/20)BE012 (1/18)0 25 50 75 100Hospital codesBE0071 (0/11)BE0751 (1/30)BE0771 (3/86)BE0031 (3/43)BE1581 (2/25)BE0601 (6/63)BE1151 (10/100)BE0721 (1/10)BE1141 (1/10)BE0921 (11/108)BE0911 (5/46)BE0611 (16/132)BE0451 (8/64)BE1301 (7/55)BE0301 (2/15)BE1121 (10/73)BE1611 (1/7)BE1111 (9/62)BE0631 (13/87)BE0371 (3/20)BE0191 (2/13)BE0741 (13/84)BE0081 (19/122)BE1391 (12/75)BE0561 (17/103)BE0841 (3/18)BE0011 (7/42)BE0161 (21/125)BE0241 (14/78)BE0481 (2/11)BE0121 (7/38)BE0971 (25/134)BE0021 (9/47)BE1431 (11/56)BE1641 (6/29)BE0061 (9/43)BE0541 (12/57)BE0571 (6/26)BE1091 (7/30)BE1571 (3/12)BE0221 (15/58)BE1521 (2/7)BE0701 (35/120)BE0842 (13/42)BE0321 (24/77)BE1701 (11/35)BE1601 (6/18)BE1291 (19/54)BE1021 (11/31)BE0171 (8/22)BE0511 (8/22)BE1361 (8/22)BE0331 (16/43)BE1251 (4/9)BE1161 (6/13)BE0291 (8/17)BE0401 (8/17)N hospitals 57Minimum 0First quartile 13.3Median 17.9Third quartile 29.2Maximum 47.10 25 50 75 100% penicillin non-susceptible % MRSA90

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesBE0011 (9/121)BE0321 (29/240)BE1391 (27/173)BE0541 (15/94)BE1121 (38/231)BE0031 (13/78)BE0751 (10/57)BE1291 (24/131)BE0221 (29/157)BE0061 (18/95)BE0511 (16/80)BE0601 (24/120)BE0331 (13/63)BE0971 (64/309)BE0611 (44/213)BE1141 (5/24)BE0721 (14/67)BE1111 (38/181)BE0291 (13/62)BE0371 (12/57)BE1571 (8/38)BE0301 (4/19)BE0071 (19/88)BE0921 (36/167)BE0451 (35/161)BE0631 (56/253)BE0842 (25/113)BE1161 (15/66)BE1251 (9/38)BE0701 (54/220)BE0081 (82/327)BE1361 (25/98)BE0771 (36/140)BE0161 (76/296)BE0441 (43/166)BE0121 (26/97)BE1601 (12/44)BE1091 (21/76)BE0911 (45/163)BE0841 (9/32)BE1641 (23/74)BE1581 (34/102)N hospitals 42Minimum 7.4First quartile 20Median 21.1Third quartile 25.5Maximum 33.30 25 50 75 100Hospital codesBE0371 (0/9)BE0011 (0/11)BE0061 (0/12)BE1251 (0/5)BE0751 (0/10)BE1121 (0/11)BE1641 (0/5)BE0842 (0/17)BE0841 (0/5)BE0221 (0/9)BE1601 (0/10)BE0561 (1/35)BE0611 (1/30)BE1111 (1/26)BE1391 (1/25)BE0241 (1/17)BE0451 (2/29)BE0911 (3/42)BE0171 (1/13)BE0321 (1/12)BE0161 (1/11)BE1161 (1/9)BE0331 (1/8)BE0721 (1/8)BE0541 (2/16)BE0971 (5/37)BE1361 (1/7)BE1291 (5/34)BE1581 (5/33)BE0441 (4/26)BE0631 (3/19)BE0031 (3/19)BE0601 (3/18)BE0081 (8/48)BE0701 (4/21)BE1091 (2/10)BE0511 (3/12)BE1021 (2/7)BE0771 (6/19)BE0921 (11/34)BE1151 (19/53)BE1571 (2/5)BE0291 (4/10)N hospitals 43Minimum 0First quartile 0Median 11.1Third quartile 16.7Maximum 400 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance91

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTBulgariaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 13 22 20 157 20 158 16 49 - - - -2004 13 32 22 170 20 167 16 75 - - - -2005 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 142008 13 29 21 160 22 147 18 70 11 49 10 232009 10 27 20 221 17 194 16 92 12 95 11 362010 13 22 20 200 21 153 16 108 15 127 11 422011 16 33 19 214 19 179 16 117 15 121 12 48Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 9 22 30 7 9 21 22 18 21Penicillin RI 14 22 33 7 16 21 37 18 21Macrolides RI 11 17 8 15 17 4 27 25 13Staphylococcus aureusOxacillin/Meticillin R 31 23 29 28 13 25 16 19 22Escherichia coliAminopenicilins R 54 64 69 64 70 65 66 72 61Aminoglycosides R 22 20 24 28 20 31 18 16 17Fluoroquinolones R 19 24 29 26 35 32 28 33 30Third-gen. cephalosporins R 18 22 28 29 23 29 19 25 23Carbapenems R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 64 20 100 21 98 32 100 0 100 0 98 79 97 30CSF 36 20 - - 2 17 - - - - 2 50 3 33GenderMale 56 23 64 22 54 34 63 0 61 0 65 78 60 31Female 44 17 35 17 46 28 37 0 39 0 35 78 40 28Unknown - - 1 67 0 0 - - - - - - - -Age (years)0–4 15 38 3 42 2 20 3 0 5 0 9 91 8 295–19 11 33 4 24 2 14 1 0 3 0 2 100 1 020–64 42 17 42 21 35 32 45 0 48 0 32 85 40 3365 and over 24 15 30 22 42 33 35 0 26 0 23 68 30 7Unknown 9 0 21 14 19 30 16 0 18 0 34 74 21 58Hospital departmentICU 18 10 19 34 17 44 22 0 32 0 19 79 34 52Internal med. 24 15 38 11 47 25 31 0 16 0 21 51 17 7Surgery - - 11 35 10 42 13 0 19 0 13 94 9 0Other 58 25 32 20 26 31 33 0 32 0 46 86 40 28Unknown - - 0 0 - - 1 0 - - 1 67 - -PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.93

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTBulgariaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 4Minimum 14.3First quartile 21.4Median 28.6Third quartile 28.6Maximum 28.6BG014A (0/5)BG002A (0/10)N hospitals 19Minimum 0First quartile 5.6Median 17.8Third quartile 33.3Maximum 64.1BG016 (1/7)BG013A (1/22)BG017A (4/71)BG011A (1/18)BG003A (2/20)BG007A (5/35)BG013 (2/7)BG001A (4/26)Laboratory codesHospital codesBG018A (3/18)BG005A (8/45)BG029A (1/5)BG003 (2/7)BG021A (8/32)BG022A (4/15)BG004A (4/12)BG009A (2/6)BG026A (5/14)BG017 (2/7)BG027A (4/11)BG008A (3/5)BG006A (25/39)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA94

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)BG029A (0/7)BG013A (1/19)N hospitals 15Minimum 0First quartile 14.3Median 26.3Third quartile 36.8Maximum 58.3BG013A (2/8)N hospitals 10Minimum 25First quartile 66.7Median 82.1Third quartile 86.7Maximum 95.7BG026A (2/18)BG018A (8/16)BG014A (1/7)BG009A (4/6)BG018A (6/31)BG022A (1/5)BG021A (51/67)BG021A (6/27)BG017A (42/52)Hospital codesBG001A (5/19)BG027A (4/14)Hospital codesBG007A (10/12)BG007A (10/31)BG026A (5/6)BG005A (7/20)BG003A (7/19)BG011A (13/15)BG017A (24/54)BG006A (22/25)BG006A (15/27)BG011A (7/12)BG001A (22/23)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance95

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 83 25 100 37 100 45 100 2 100 0 98 38 98 36CSF 17 75 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTCyprusFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 2Minimum 28.6First quartile 28.6Median 28.6Third quartile 28.6Maximum 28.6CY004A (2/7)N hospitals 5Minimum 28.6First quartile 33.3Median 35.8Third quartile 38.3Maximum 50CY001 (4/14)CY003A (8/24)Laboratory codesHospital codesCY002A (19/53)CY001A (46/120)CY002 (2/7)CY005A (4/8)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA98

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTCzech RepublicGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 32 204 45 1 387 43 1 766 44 630 - - - -2004 37 162 45 1444 44 1 966 41 660 - - - -2005 39 195 47 1 553 47 2 234 45 758 37 478 36 2572006 39 172 47 1 527 47 2 176 45 697 45 1 130 43 4902007 41 205 47 1 653 48 2 407 47 816 48 1 230 41 5172008 40 244 47 1 715 46 2 738 44 883 45 1 493 42 5682009 41 297 46 1 695 45 2 759 44 835 45 1 415 45 5752010 41 288 44 1 593 43 2 484 41 759 44 1 264 41 5112011 42 316 46 1 555 45 2 696 44 767 44 1 287 42 448Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 86 4 100 14 100 23 100 0 100 6 99 48 100 15CSF 14 5 - - 0 0 - - - - 1 41 0 0GenderMale 60 3 62 14 43 27 65 1 64 6 60 50 62 15Female 40 6 38 15 57 20 35 0 36 7 40 46 38 14Unknown - - - - - - - - - - - - - -Age (years)0–4 5 3 5 1 2 9 4 2 2 0 1 39 1 175–19 5 0 2 1 1 20 1 0 2 14 1 60 2 1620–64 47 5 41 13 29 21 39 0 48 10 42 51 42 1865 and over 42 5 52 17 68 25 56 1 49 2 56 46 54 13Hospital departmentICU 25 5 26 17 19 26 46 0 38 1 42 56 49 19Internal med. 37 4 43 14 50 22 26 1 18 5 31 40 23 7Surgery 1 0 8 14 5 23 6 0 7 8 7 39 5 13Other 32 5 23 10 26 23 22 0 37 12 20 47 23 15Unknown 5 6 0 21 0 0 0 0 - - 0 75 - -PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.101

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTCzech RepublicFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesCZ004 (0/7)CZ030 (0/13)CZ003 (0/11)CZ032 (0/15)CZ019 (0/9)CZ037 (0/11)CZ011 (0/9)CZ026 (0/5)CZ041 (0/8)CZ024 (0/19)CZ036 (0/10)CZ051 (0/5)CZ023 (0/15)CZ044 (1/34)CZ016 (2/54)CZ017 (1/27)CZ009 (1/26)CZ027 (1/24)CZ018 (1/23)CZ049 (1/21)CZ013 (1/20)CZ031 (1/20)CZ006 (3/57)CZ042 (1/19)CZ015 (1/16)CZ029 (1/16)CZ033 (2/30)CZ007 (1/14)CZ002 (1/10)CZ047 (1/9)CZ005 (1/5)CZ014 (2/7)N laboratories 32Minimum 0First quartile 0Median 3.8Third quartile 5.8Maximum 28.60 25 50 75 100Hospital codesCZ031J (0/18)CZ029A (0/32)CZ036A (0/35)CZ034B (0/5)CZ021A (2/86)CZ030A (2/53)CZ011A (1/25)CZ026A (3/72)CZ038A (1/20)CZ044A (3/52)CZ009B (1/17)CZ048A (1/17)CZ028A (4/57)CZ013A (4/52)CZ002A (7/86)CZ047A (1/12)CZ009A (11/133)CZ034A (5/58)CZ017A (8/87)CZ004A (6/59)CZ022A (4/37)CZ020A (10/92)CZ032A (8/73)CZ024A (16/140)CZ031A (6/52)CZ016A (10/86)CZ007A (10/82)CZ015A (16/125)CZ019A (6/46)CZ006A (30/216)CZ035A (7/50)CZ047B (1/7)CZ044C (3/20)CZ033A (11/66)CZ037A (5/30)CZ027A (22/128)CZ018A (31/171)CZ039A (2/11)CZ040A (3/16)CZ051A (4/21)CZ003A (15/78)CZ012B (2/10)CZ041A (7/34)CZ014A (11/51)CZ050A (5/23)CZ012C (2/9)CZ008A (8/35)CZ005A (26/113)CZ017B (7/30)CZ039B (4/17)CZ023A (8/33)CZ049A (9/37)CZ037D (6/24)CZ012A (8/32)CZ037C (2/7)CZ025A (14/48)CZ007D (3/10)CZ042A (9/29)CZ031P (3/9)CZ015B (2/6)CZ031C (3/8)CZ034C (6/15)CZ007B (5/12)CZ031F (5/8)N hospitals 64Minimum 0First quartile 8.3Median 14.6Third quartile 23.2Maximum 62.50 25 50 75 100% penicillin non-susceptible % MRSA102

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesCZ015B (0/6)CZ030A (9/164)CZ031V (1/10)CZ040A (1/10)CZ047A (4/37)CZ012A (4/33)CZ020A (10/81)CZ032A (20/159)CZ038A (8/60)CZ011A (5/36)CZ031P (5/35)CZ037A (8/56)CZ031F (3/20)CZ015A (33/209)CZ014A (12/75)CZ003A (20/123)CZ017A (19/112)CZ051A (5/29)CZ019A (17/98)CZ047B (4/23)CZ037D (8/44)CZ007A (20/109)CZ029A (15/82)CZ016A (40/214)CZ033A (16/85)CZ017B (14/73)CZ022A (12/61)CZ039A (8/40)CZ028A (16/80)CZ031Y (1/5)CZ050A (5/24)CZ026A (18/86)CZ048A (3/14)CZ013A (21/94)CZ004A (20/89)CZ044A (14/62)CZ006A (100/443)CZ037C (6/25)CZ041A (15/62)CZ007D (5/20)CZ036A (16/63)CZ023A (14/54)CZ009A (36/136)CZ049A (20/74)CZ031A (23/85)CZ012B (6/22)CZ024A (63/225)CZ018A (63/216)CZ021A (42/143)CZ035A (15/50)CZ039B (9/30)CZ005A (47/152)CZ042A (27/87)CZ034A (10/32)CZ027A (65/201)CZ002A (67/205)CZ008A (30/89)CZ031J (14/40)CZ031C (5/13)CZ034B (3/7)CZ031K (4/9)CZ007B (11/24)CZ025A (28/61)CZ049B (5/9)CZ007E (4/7)CZ012C (11/18)N hospitals 67Minimum 0First quartile 17Median 22.3Third quartile 30Maximum 63.6CZ034C (7/11)0 25 50 75 100Hospital codesCZ032A (2/29)CZ037D (1/8)CZ015A (7/41)CZ014A (7/39)CZ037A (3/14)CZ019A (7/32)CZ048A (2/9)CZ030A (7/29)CZ020A (15/59)CZ029A (10/33)CZ008A (9/29)CZ007A (11/35)CZ031P (4/12)CZ044A (8/24)CZ031F (4/12)CZ005A (33/89)CZ034B (3/8)CZ051A (4/10)CZ044C (6/15)CZ039B (2/5)CZ031A (25/62)CZ018A (66/159)CZ016A (25/60)CZ012B (3/7)CZ049A (13/30)CZ006A (77/178)CZ035A (32/73)CZ021A (8/18)CZ028A (22/46)CZ034A (17/35)CZ024A (63/127)CZ039A (4/8)CZ012A (6/12)CZ017A (36/71)CZ017B (24/47)CZ041A (10/19)CZ033A (44/81)CZ031K (6/11)CZ004A (22/40)CZ027A (72/131)CZ025A (25/45)CZ003A (40/72)CZ022A (18/32)CZ002A (25/43)CZ009B (10/17)CZ009A (106/175)CZ036A (22/36)CZ031C (8/13)CZ049B (8/13)CZ013A (20/32)CZ043C (5/8)CZ047A (12/19)CZ042A (23/35)CZ034C (4/6)CZ026A (50/71)CZ007B (18/25)CZ038A (19/26)CZ023A (28/38)CZ050A (16/20)CZ011A (12/15)CZ031J (14/17)CZ012C (15/17)N hospitals 62Minimum 6.9First quartile 37.1Median 49.8Third quartile 61.1Maximum 88.20 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance103

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTDenmarkGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 5 606 5 671 - - - - - - - -2004 15 1 188 15 1 436 - - - - - - - -2005 14 1 081 15 1 350 5 1 283 - - - - - -2006 15 872 15 1 279 11 2 723 11 711 11 607 - -2007 15 1 030 14 1 315 12 3 021 13 927 13 784 13 4172008 15 934 15 1 295 14 3 283 14 1 005 14 793 14 4202009 15 996 15 1 395 14 3 532 14 1 100 14 822 14 4292010 15 954 15 1 362 14 3 418 14 1 112 14 799 14 3762011 13 896 13 1 452 12 3 642 12 1 197 12 910 12 407Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 93 4 100 1 100 14 100 0 100 2 100 11 99 4CSF 7 4 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTDenmarkFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesDK005 (0/8)DK012 (1/101)DK015 (1/70)DK016 (4/183)DK011 (2/71)DK013 (2/63)DK009 (6/189)DK002 (11/275)DK006 (9/224)DK014 (12/242)DK001 (3/47)DK003 (11/172)DK010 (2/30)DK007 (4/57)DK004 (9/118)N laboratories 15Minimum 0First quartile 2.2Median 4Third quartile 6.4Maximum 7.60 25 50 75 100Hospital codesDK016X (0/9)DK014A (0/26)DK016F (0/8)DK014X (0/14)DK007B (0/82)DK016P (0/5)DK016Q (0/9)DK007X (0/6)DK014B (0/44)DK014D (0/78)DK011X (0/5)DK012F (0/52)DK011A (0/96)DK012E (0/42)DK002E (0/20)DK013A (0/50)DK008A (0/19)DK015X (0/39)DK013B (0/65)DK015C (0/31)DK009X (0/12)DK009A (0/41)DK004X (0/23)DK016D (0/8)DK012D (0/46)DK012B (0/35)DK016C (0/13)DK014Y (0/38)DK003B (0/30)DK005A (0/63)DK014E (0/5)DK011D (0/5)DK016A (1/153)DK009B (2/260)DK004A (1/98)DK002A (1/86)DK014N (1/80)DK016B (1/61)DK006A (1/60)DK015A (1/57)DK003A (1/56)DK014C (1/56)DK001A (4/208)DK006B (1/52)DK005B (1/43)DK002X (2/86)DK003C (4/164)DK002F (1/36)DK002B (4/112)DK006X (1/25)DK007A (2/42)DK004B (1/15)DK004C (1/12)N hospitals 53Minimum 0First quartile 0Median 0Third quartile 1.8Maximum 8.30 25 50 75 100% penicillin non-susceptible % MRSA106

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesDK014I (0/7)DK006C (0/11)DK016C (3/65)DK007B (4/69)DK016D (4/62)DK016F (3/44)DK008A (5/71)DK016B (13/178)DK014D (19/256)DK012B (7/84)DK011D (2/23)DK012E (12/134)DK003B (15/154)DK013B (15/153)DK007A (8/78)DK006A (15/141)DK015G (5/45)DK012F (17/151)DK015C (5/42)DK012D (18/151)DK006B (16/129)DK009A (27/216)DK014B (24/188)DK004A (29/224)DK011A (31/236)DK002E (16/120)DK015A (23/172)DK003A (20/147)DK004C (17/121)DK009B (55/391)DK002A (48/319)DK002B (54/352)DK003C (95/580)DK016A (61/368)DK016G (4/24)DK015B (1/6)DK014C (32/190)DK002F (25/146)DK013A (18/103)DK005B (25/141)DK014A (14/78)DK005A (26/133)DK004B (15/69)DK014N (23/101)DK001A (68/259)N hospitals 45Minimum 0First quartile 9Median 12.8Third quartile 16.6Maximum 26.30 25 50 75 100Hospital codesDK015G (0/8)DK016C (0/9)DK008A (0/14)DK002E (0/21)DK016F (0/8)DK016D (0/11)DK003B (0/9)DK016G (0/6)DK015C (0/5)DK012E (0/22)DK012F (1/24)DK009A (2/48)DK009B (6/119)DK002A (4/73)DK012B (1/17)DK016A (5/81)DK016B (2/30)DK004B (1/15)DK015A (3/42)DK004A (3/40)DK011A (4/52)DK014A (2/23)DK014C (6/52)DK011D (1/8)DK002B (12/87)DK014D (9/51)DK014B (8/45)DK001A (29/143)DK002F (8/38)DK012D (7/31)DK004C (5/22)DK014N (9/32)DK014Y (2/5)N hospitals 33Minimum 0First quartile 0Median 6.7Third quartile 13.8Maximum 400 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance107

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTEstoniaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 8 26 9 98 9 98 6 27 - - - -2004 6 40 9 104 10 167 5 63 - - - -2005 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 482008 10 66 11 185 11 267 11 86 10 72 8 412009 8 82 11 213 11 320 8 72 7 60 6 432010 10 64 9 152 11 317 8 66 9 82 8 432011 9 54 11 121 11 315 8 77 6 91 6 17Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 97 2 100 1 100 9 100 0 100 0 100 25 98 19CSF 3 0 - - 0 0 - - - - - - 2 0GenderMale 57 3 57 1 38 13 70 0 56 0 50 21 52 25Female 43 0 43 2 62 7 30 0 44 0 50 29 48 12Unknown - - - - 0 0 - - - - - - - -Age (years)0–4 7 0 6 0 3 6 13 0 - - 5 0 2 05–19 3 25 2 0 2 0 4 0 - - 2 0 4 020–64 65 1 49 0 41 11 39 0 52 0 48 31 43 1365 and over 24 0 43 3 53 9 41 0 48 0 46 23 52 25Unknown - - 0 0 - - 2 0 - - - - - -Hospital departmentICU 30 3 20 6 15 12 26 0 41 0 35 33 33 22Internal med. 36 2 37 0 46 5 20 0 15 0 28 26 28 20Surgery 1 0 5 0 6 11 9 0 7 0 7 22 2 100Other 34 0 38 0 33 13 43 0 37 0 30 16 37 10Unknown - - - - 0 100 2 0 - - - - - -PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.109

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTEstoniaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)EE002 (0/12)N laboratories 7Minimum 0First quartile 0Median 0Third quartile 9.1Maximum 12.5EE005X (0/29)N hospitals 9Minimum 0First quartile 0Median 0Third quartile 0Maximum 5.7EE010X (0/9)EE011 (0/11)EE011X (0/9)EE001 (0/19)EE003X (0/7)Laboratory codesEE006 (0/11)Hospital codesEE002X (0/5)EE009X (0/28)EE004 (0/34)EE004X (0/60)EE009 (1/11)EE001X (1/76)EE005 (1/8)EE006X (2/35)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA110

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)EE011X (1/28)N hospitals 10Minimum 3.6First quartile 5.5Median 10.4Third quartile 11.8Maximum 27.8EE005X (0/5)N hospitals 6Minimum 0First quartile 11.4Median 33.8Third quartile 50Maximum 50EE001X (8/150)EE005X (3/55)EE002X (5/44)EE008X (2/27)EE001X (7/26)EE010X (1/10)Hospital codesEE002X (8/74)Hospital codesEE004X (11/27)EE004X (12/103)EE006X (10/85)EE009X (3/6)EE009X (3/21)EE006X (5/10)EE003X (5/18)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance111

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFinlandGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 16 517 16 727 15 1 450 15 266 - - - -2004 17 548 17 883 17 1 749 17 336 - - - -2005 17 543 17 790 17 1 924 17 340 14 175 13 1082006 15 501 15 894 15 1 875 15 348 14 228 14 1622007 16 547 16 814 16 1 949 16 400 15 273 14 1832008 15 643 15 923 15 2 111 15 381 12 288 12 1752009 20 688 20 978 20 2 224 20 506 20 375 18 2332010 20 622 20 1 094 20 2 551 20 521 20 401 20 2812011 - - - - 17 2 470 16 375 17 319 16 221Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 2

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae* S. aureus* E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 97 14 100 2 100 10 100 0 100 0 100 4 99 10CSF 3 10 - - 0 0 - - - - 0 0 1 29GenderMale 55 15 63 2 38 14 69 0 62 0 54 5 62 12Female 45 13 37 3 62 8 31 0 38 1 46 2 38 7Age (years)0–4 16 25 4 0 2 6 7 0 2 0 1 25 1 05–19 3 11 4 0 1 8 1 0 1 0 1 0 2 3620–64 44 11 39 2 27 9 24 0 32 0 26 4 29 1565 and over 37 14 53 3 70 10 68 0 65 1 72 3 67 7Hospital departmentICU 0 0 2 0 0 9 0 0 2 0 1 17 2 27Internal med. 6 3 6 1 5 8 3 0 6 0 4 4 5 15Surgery 2 5 1 7 2 0 4 0 2 6 2 18Other 21 8 17 2 16 11 11 0 7 0 16 4 11 2Unknown 73 17 73 2 77 10 84 0 81 1 78 4 80 10* Data only for 2010.PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.113

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFinlandFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)No data reported for 2011 No data reported for 2011114

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)FI021X (11/205)FI008X (6/108)N hospitals 20Minimum 5.4First quartile 6.3Median 9.4Third quartile 11.9Maximum 14.7FI00CX (0/49)FI008X (0/13)N hospitals 19Minimum 0First quartile 0Median 3.7Third quartile 6.3Maximum 12.1FI017X (11/195)FI00AX (0/9)FI010X (5/87)FI021X (0/35)FI018X (4/68)FI010X (0/15)FI00EX (16/236)FI017X (0/23)FI012X (10/143)FI009X (0/12)FI014X (12/169)FI002X (5/185)FI00CX (24/320)FI003X (1/35)Hospital codesFI003X (25/267)FI00LX (7/74)Hospital codesFI020X (3/82)FI019X (1/24)FI020X (55/525)FI011X (1/23)FI015X (12/106)FI009X (9/79)FI014X (1/21)FI002X (157/1330)FI00HX (3/61)FI005X (28/234)FI012X (1/16)FI00AX (7/58)FI015X (1/16)FI011X (20/164)FI00LX (1/13)FI00HX (57/459)FI00EX (5/47)FI019X (21/143)FI005X (4/33)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance115

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFranceGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 403 1 389 21 1 710 21 2 266 20 468 - - - -2004 403 515 50 3 355 50 5 678 46 871 - - - -2005 195 632 50 3 484 50 6 056 47 1 023 49 838 48 9932006 97 371 50 3 824 50 6 718 50 1 152 50 963 47 1 0062007 168 663 57 4 265 57 8 093 56 1 545 56 1 187 56 1 3052008 127 557 56 4 380 56 7 993 54 1 555 54 1 138 54 1 2252009 225 826 54 4 727 54 8 451 54 1 969 52 1 378 32 1 2212010 181 1 127 56 4 883 56 9 028 54 1 970 56 1 542 36 1 1912011 255 1 413 52 4 740 52 8 790 46 2 163 52 1 691 52 1 634Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R - - 5 4 4 7 6

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates from the reporting period 2009 and 2010CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 68 24 100 21 100 18 100 0 100 1 100 22 100 19CSF 32 28 - - - - - - - - - - - -GenderMale 55 26 63 21 48 20 67 0 64 1 61 23 65 18Female 45 25 35 21 51 16 32 0 35 2 37 20 34 20Unknown - - 2 10 2 15 1 0 1 0 2 13 1 19Age (years)0–4 21 28 4 9 2 7 5 0 2 30 2 19 2 45–19 9 13 3 3 1 9 1 0 1 0 1 38 2 1220–64 36 23 40 14 34 18 36 0 45 1 47 24 49 2365 and over 34 30 52 28 63 18 58 0 51 1 50 19 47 16Unknown - - 0 0

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTFranceFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesFR257 (0/5)FR144 (0/6)FR201 (0/5)FR129 (0/5)FR460 (0/7)FR050 (0/9)FR069 (0/6)FR521 (0/9)FR054 (0/7)FR125 (0/15)FR188 (0/5)FR146 (0/6)FR133 (0/5)FR450 (0/12)N laboratories 140Minimum 0First quartile 14.3Median 23.1Third quartile 33.3Maximum 80FR306 (0/5)FR492 (0/5)FR473 (0/10)FR528 (1/11)FR170 (1/11)FR098 (1/10)FR004 (1/10)FR465 (1/10)FR160 (1/10)FR043 (1/9)FR022 (1/9)FR066 (1/8)FR239 (1/8)FR162 (2/16)FR232 (2/15)FR100 (1/7)FR015 (1/7)FR020 (2/14)FR024 (1/7)FR217 (1/7)FR434 (1/7)FR235 (1/7)FR052 (5/34)FR142 (2/13)FR507 (2/13)FR224 (3/19)FR249 (4/24)FR488 (1/6)FR418 (1/6)FR062 (1/6)FR148 (1/6)FR116 (5/29)FR175 (3/17)FR076 (9/51)FR479 (10/56)FR260 (5/28)FR198 (2/11)FR277 (2/11)FR241 (2/11)FR040 (7/37)FR172 (2/10)FR105 (1/5)FR506 (1/5)FR271 (3/15)FR218 (1/5)FR270 (1/5)FR524 (1/5)FR254 (2/10)FR112 (1/5)FR462 (1/5)FR107 (1/5)FR514 (3/14)FR208 (3/14)FR167 (5/23)FR079 (2/9)FR131 (3/13)FR234 (3/13)FR164 (7/30)FR009 (5/21)FR149 (3/12)FR999 (2/8)FR251 (3/12)FR498 (4/16)FR174 (2/8)FR269 (15/59)FR010 (13/50)FR467 (12/45)FR126 (3/11)FR094 (21/76)FR064 (5/18)FR263 (26/92)FR137 (13/46)FR038 (4/14)FR194 (6/21)FR403 (2/7)FR063 (2/7)FR032 (2/7)FR071 (9/31)FR153 (5/17)FR250 (5/17)FR505 (3/10)FR518 (3/10)FR196 (3/10)FR470 (4/13)FR109 (15/48)FR213 (10/32)FR246 (17/54)FR496 (6/19)FR028 (3/9)FR121 (2/6)FR214 (14/42)FR274 (4/12)FR219 (2/6)FR400 (2/6)FR051 (3/9)FR414 (2/6)FR476 (19/57)FR108 (18/53)FR266 (8/23)FR067 (6/17)FR228 (5/14)FR279 (5/14)FR490 (5/14)FR186 (7/19)FR230 (3/8)FR238 (3/8)FR138 (3/8)FR127 (20/50)FR037 (2/5)FR135 (2/5)FR120 (8/19)FR130 (11/26)FR036 (6/14)FR248 (3/7)FR493 (3/7)FR502 (3/7)FR068 (4/8)FR252 (3/6)FR096 (3/6)FR115 (3/6)FR240 (8/15)FR006 (10/18)FR140 (4/7)FR276 (4/7)FR077 (3/5)FR072 (4/5)0 25 50 75 100Hospital codesFR164A (39/380)FR145A (3/27)FR095A (6/52)FR193A (5/41)FR076A (45/304)FR134A (15/99)FR249A (29/188)FR226A (83/533)FR248A (29/183)FR208A (4/25)FR010A (48/295)FR084A (6/36)FR109A (46/276)FR403A (9/54)FR202A (5/28)FR072A (7/38)FR052A (36/193)FR055A (3/16)FR362A (10/53)FR434A (17/90)FR179A (12/63)FR138A (74/376)FR401A (11/55)FR126A (16/80)FR214A (56/275)FR040A (49/239)FR165A (57/272)FR006A (128/607)FR130A (81/381)FR094A (77/359)FR263A (147/679)FR250A (46/209)FR238A (66/298)FR224A (15/66)FR121A (42/182)FR194A (23/99)FR135A (10/43)FR105A (31/131)FR213A (27/113)FR037A (11/46)FR246A (88/361)FR400A (11/45)FR067A (33/135)FR015A (4/16)FR276A (31/122)FR008A (15/58)FR259A (45/167)FR120A (24/89)FR237A (32/115)FR009A (39/139)FR479A (113/398)FR260A (36/125)FR064A (56/192)FR098A (22/70)FR046A (12/36)FR531A (14/23)N hospitals 56Minimum 10.3First quartile 17.3Median 21.2Third quartile 24.4Maximum 60.90 25 50 75 100% penicillin non-susceptible % MRSA118

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesFR276A (23/268)FR434A (21/236)FR250A (41/446)FR145A (7/72)FR531A (4/41)FR208A (8/81)FR037A (8/79)FR130A (63/614)FR194A (24/232)FR238A (59/568)FR126A (15/143)FR072A (10/94)FR362A (15/135)FR009A (35/307)FR224A (20/167)FR008A (22/183)FR249A (36/298)FR202A (17/136)FR134A (26/206)FR067A (34/266)FR400A (20/142)FR010A (65/460)FR226A (111/776)FR179A (23/159)FR120A (32/219)FR213A (51/332)FR135A (18/115)FR193A (16/99)FR040A (67/406)FR109A (87/527)FR094A (96/555)FR260A (47/271)FR084A (13/71)FR052A (84/454)FR246A (127/643)FR164A (121/612)FR138A (148/746)FR098A (33/161)FR076A (106/507)FR263A (192/901)FR121A (55/257)FR214A (119/550)FR403A (29/134)FR259A (52/234)FR401A (25/112)FR015A (16/70)FR064A (101/432)FR006A (253/1071)FR095A (17/71)FR105A (79/324)FR165A (140/561)FR248A (80/316)FR237A (52/200)FR479A (141/542)FR055A (15/55)FR046A (19/44)N hospitals 56Minimum 8.6First quartile 11.7Median 16.3Third quartile 21.6Maximum 43.20 25 50 75 100Hospital codesFR276A (0/10)FR008A (0/18)FR055A (0/7)FR434A (0/20)FR400A (0/19)FR072A (0/6)FR202A (0/8)FR224A (0/16)FR246A (1/95)FR164A (2/59)FR362A (1/23)FR194A (2/35)FR052A (4/70)FR120A (2/26)FR076A (9/111)FR010A (2/24)FR237A (2/23)FR260A (2/22)FR067A (3/33)FR084A (2/20)FR006A (19/181)FR259A (7/61)FR249A (3/26)FR098A (1/8)FR214A (17/131)FR130A (8/59)FR064A (11/81)FR250A (5/35)FR208A (1/7)FR109A (13/88)FR238A (11/70)FR094A (17/107)FR105A (18/97)FR531A (2/10)FR126A (5/24)FR193A (4/19)FR401A (9/42)FR479A (24/104)FR248A (28/118)FR135A (5/19)FR095A (5/18)FR179A (11/39)FR165A (50/166)FR121A (19/63)FR145A (4/13)FR403A (14/45)FR009A (10/32)FR213A (17/52)FR138A (70/203)FR040A (23/66)FR015A (5/14)FR134A (7/19)FR263A (101/253)FR046A (4/10)FR226A (103/245)FR037A (11/26)N hospitals 56Minimum 0First quartile 7.9Median 14.3Third quartile 29.2Maximum 42.30 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance119

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTGermanyGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 17 175 20 920 19 997 17 347 - - - -2004 16 145 22 1 107 22 1 217 22 606 - - 1 12005 15 119 17 827 17 961 17 569 12 105 12 1172006 15 85 18 799 18 850 16 529 14 148 12 1622007 11 75 12 853 12 977 12 648 10 173 11 1972008 11 209 14 1 090 14 1 615 13 451 11 235 11 1672009 16 346 17 1 893 17 2 803 17 952 15 479 16 2872010 16 363 17 1 980 17 3 024 16 1 009 15 478 15 3152011 18 359 19 2 388 19 3 650 17 1 231 17 519 17 389Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 94 3 100 18 100 24 100 0 100 10 99 12 99 11CSF 6 2 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTGermanyFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesDE0907 (0/94)DE0202 (0/6)DE1001 (0/31)DE1101 (0/7)DE1304 (0/23)DE0107 (0/30)DE1303 (0/26)DE0401 (0/22)DE0110 (2/157)DE0911 (3/111)DE0908 (2/51)DE0102 (2/40)DE0402 (1/18)DE1302 (1/13)DE0301 (3/35)DE0111 (5/32)N laboratories 16Minimum 0First quartile 0Median 0.6Third quartile 5.3Maximum 15.60 25 50 75 100Hospital codesDE010703 (0/7)DE070102 (0/6)DE091133 (0/8)DE011044 (0/12)DE100127 (0/5)DE090717 (0/5)DE100109 (0/10)DE100110 (0/9)DE100103 (0/8)DE011007 (0/27)DE091106 (0/23)DE030107 (0/8)DE011027 (0/9)DE130404 (0/11)N hospitals 144Minimum 0First quartile 9.1Median 16.7Third quartile 25Maximum 83.3DE011062 (1/26)DE040202 (1/25)DE010701 (3/67)DE011028 (1/20)DE070103 (1/20)DE011086 (2/40)DE011018 (1/16)DE100128 (1/16)DE091104 (1/16)DE040204 (1/15)DE011039 (1/14)DE090715 (2/27)DE030103 (2/27)DE0102A (13/172)DE091105 (2/26)DE011066 (2/25)DE0401A (12/145)DE0102B (1/12)DE090832 (1/12)DE091135 (3/36)DE011003 (2/23)DE011041 (1/11)DE0401D (1/11)DE091120 (3/31)DE011081 (1/10)DE030101 (4/37)DE100113 (1/9)DE011022 (4/36)DE011045 (3/26)DE090708 (5/43)DE011020 (6/50)DE110101 (7/58)DE091119 (1/8)DE011019 (1/8)DE091129 (3/24)DE091114 (1/8)DE0401C (1/8)DE011010 (6/47)DE090707 (4/31)DE070101 (16/124)DE011005 (2/15)DE090704 (2/15)DE091132 (6/45)DE091143 (2/15)DE011032 (1/7)DE011026 (4/28)DE100131 (1/7)DE090716 (15/104)DE011068 (3/20)DE091107 (2/13)DE011004 (4/26)DE011021 (10/65)DE090719 (2/13)DE011031 (4/26)DE120301 (20/129)DE091117 (5/32)DE011083 (14/89)DE091146 (3/18)DE011024 (6/36)DE100108 (1/6)DE011029 (2/12)DE030110 (1/6)DE030801 (1/6)DE090706 (6/34)DE2020 (11/62)DE090710 (4/22)DE011087 (2/11)DE011101 (30/165)DE100101 (5/27)DE090819 (3/16)DE091126 (6/32)DE091134 (3/16)DE090718 (9/47)DE090701 (14/70)DE091121 (1/5)DE100136 (5/25)DE030109 (7/34)DE090807 (4/19)DE011012 (8/38)DE011063 (4/19)DE091108 (3/14)DE090713 (6/28)DE090709 (14/65)DE100107 (2/9)DE010702 (2/9)DE011037 (6/27)DE090814 (3/13)DE030108 (8/34)DE030102 (5/21)DE011038 (15/61)DE090705 (21/84)DE100119 (2/8)DE130307 (12/48)DE091116 (3/12)DE011061 (4/16)DE011085 (11/44)DE011016 (2/8)DE090806 (12/47)DE130403 (20/75)DE011042 (7/26)DE130320 (7/26)DE091101 (12/44)DE040201 (10/36)DE091131 (7/25)DE100129 (2/7)DE100120 (2/7)DE011025 (8/27)DE090812 (3/10)DE091145 (3/10)DE091125 (12/39)DE011017 (4/13)DE091122 (11/35)DE090833 (6/19)DE090803 (8/25)DE090905 (3/9)DE090901 (3/9)DE0401B (3/9)DE090906 (3/9)DE090714 (7/21)DE011014 (7/20)DE130201 (51/143)DE090801 (19/52)DE130312 (20/53)DE090804 (13/31)DE100111 (5/11)DE090802 (7/13)DE011088 (4/7)DE011050 (3/5)DE011079 (17/26)DE011058 (5/6)0 25 50 75 100% penicillin non-susceptible % MRSANote. Individual laboratories may serve a large number of hospitals over awide geographical area within Germany.122

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesDE090717 (0/6)DE011041 (0/8)DE090814 (0/6)DE011015 (0/12)DE100103 (1/16)DE011088 (1/16)DE100110 (1/16)DE011029 (2/30)DE090803 (2/26)DE090807 (2/25)DE090706 (3/37)DE100102 (1/12)DE011028 (2/23)DE091114 (1/11)DE030107 (1/11)N hospitals 154Minimum 0First quartile 16.3Median 22.7Third quartile 29.4Maximum 61.1DE091117 (6/61)DE100138 (2/20)DE011079 (1/9)DE090812 (1/9)DE040204 (4/32)DE130320 (5/39)DE090718 (10/77)DE011039 (5/38)DE100106 (2/15)DE011026 (4/30)DE091145 (2/15)DE090901 (4/30)DE0401B (2/14)DE090704 (4/28)DE100111 (1/7)DE011022 (10/69)DE010701 (22/151)DE011062 (7/48)DE011032 (2/13)DE091116 (2/13)DE091122 (15/97)DE100108 (3/19)DE130307 (4/25)DE040202 (7/43)DE030103 (10/60)DE090804 (3/18)DE091126 (10/60)DE090833 (7/41)DE091131 (6/35)DE091143 (4/23)DE100109 (4/23)DE100136 (7/40)DE090715 (10/57)DE100131 (3/17)DE100119 (2/11)DE011045 (6/33)DE0401A (37/200)DE090806 (11/59)DE011003 (6/32)DE130403 (29/147)DE100107 (2/10)DE011068 (5/25)DE030110 (1/5)DE100132 (1/5)DE011031 (11/54)DE011038 (16/78)DE091133 (8/39)DE091104 (6/29)DE011021 (11/53)DE090906 (5/24)DE090713 (4/19)DE091106 (8/38)DE070103 (4/19)DE011012 (10/47)DE091120 (12/56)DE091129 (12/55)DE090802 (7/32)DE100128 (2/9)DE100129 (2/9)DE011006 (2/9)DE091105 (13/58)DE011018 (5/22)DE091108 (5/22)DE011017 (8/35)DE090719 (6/26)DE040201 (15/64)DE011020 (20/84)DE011087 (5/21)DE090705 (21/88)DE010703 (7/29)DE100101 (14/58)DE090819 (11/45)DE011010 (15/61)DE091121 (3/12)DE090905 (2/8)DE100113 (3/12)DE100120 (5/20)DE011081 (3/12)DE091101 (13/51)DE090801 (23/90)DE091125 (10/39)DE090707 (8/31)DE011024 (25/96)DE091132 (18/69)DE090708 (16/61)DE011083 (44/167)DE011086 (12/45)DE090701 (23/86)DE090709 (30/110)DE030109 (15/55)DE010702 (9/33)DE120301 (42/154)DE011042 (11/40)DE011007 (12/43)DE011004 (9/32)DE091147 (4/14)DE130312 (18/63)DE090716 (49/171)DE070101 (61/212)DE030102 (9/31)DE011061 (10/34)DE130201 (35/119)DE090832 (5/17)DE090710 (8/27)DE091135 (19/64)DE011025 (14/47)DE2020 (15/50)DE030101 (18/60)DE011027 (3/10)DE091146 (9/30)DE0102B (3/10)DE011063 (7/23)DE0102A (96/301)DE011085 (17/52)DE100112 (3/9)DE011066 (16/48)DE011067 (5/15)DE090820 (2/6)DE030108 (13/38)DE011014 (13/38)DE011005 (12/35)DE090714 (9/26)DE110101 (25/68)DE011044 (3/8)DE130404 (5/13)DE011101 (100/257)DE011102 (2/5)DE091138 (2/5)DE011050 (2/5)DE011001 (4/10)DE091112 (5/12)DE011037 (19/45)DE011016 (9/20)DE091134 (5/11)DE091107 (5/11)DE070102 (7/14)DE0401C (3/6)DE091119 (7/13)DE011019 (11/18)0 25 50 75 100Hospital codesDE040202 (0/5)DE100128 (0/5)DE091129 (0/6)DE030109 (0/9)DE011063 (0/6)DE011014 (0/6)DE011012 (0/6)N hospitals 70Minimum 0First quartile 0Median 6.5Third quartile 16Maximum 57.1DE090706 (0/6)DE011024 (0/15)DE011007 (0/6)DE011066 (0/6)DE011004 (0/10)DE011038 (0/8)DE091126 (0/7)DE011044 (0/5)DE091105 (0/11)DE090705 (0/7)DE091106 (0/5)DE090804 (0/5)DE090718 (0/7)DE011022 (0/10)DE030108 (0/7)DE030101 (0/15)DE090719 (0/5)DE030103 (0/13)DE090833 (0/5)DE090802 (0/6)DE011042 (0/10)DE090715 (0/9)DE091131 (0/7)DE011025 (0/6)DE090906 (0/7)DE0401A (2/39)DE011083 (1/19)DE0102A (3/51)DE120301 (2/28)DE090801 (1/14)DE090701 (1/13)DE090806 (1/12)DE011031 (1/10)DE130312 (2/20)DE011062 (1/9)DE011021 (1/8)DE130307 (1/8)DE091101 (1/8)DE100101 (1/7)DE110101 (2/14)DE011086 (1/7)DE011017 (1/7)DE090708 (1/7)DE011020 (2/13)DE090716 (3/19)DE070101 (4/25)DE040201 (2/12)DE011005 (1/5)DE2020 (2/10)DE070103 (1/5)DE011010 (2/10)DE091135 (1/5)DE090819 (1/5)DE090709 (4/19)DE130403 (8/35)DE091122 (3/13)DE091132 (2/8)DE130201 (4/16)DE011101 (25/81)DE091134 (2/5)DE091125 (3/6)DE011058 (4/8)DE091133 (4/7)0 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance123

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTGreeceGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 - - 34 682 35 1 076 32 621 - - - -2004 - - 35 610 39 1 131 34 565 - - - -2005 - - 35 682 35 1 140 34 737 33 774 33 6992006 - - 42 828 41 1 253 39 949 38 841 38 8182007 - - 41 819 43 1 234 39 999 38 972 37 8022008 - - 46 907 44 1 462 42 992 41 1 093 42 9202009 - - 48 1 025 49 1 831 47 1 190 47 1 649 47 1 1232010 - - 44 902 45 1 549 43 1 105 40 1 703 42 1 0142011 - - 39 826 37 1 437 36 1 122 38 1 671 35 948Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R - - - - - - - - -Penicillin RI - - - - - - - - -Macrolides RI - - - - - - - - -Staphylococcus aureusOxacillin/Meticillin R 45 44 42 43 48 41 40 39 39Escherichia coliAminopenicilins R 44 46 46 46 48 50 51 52 55Aminoglycosides R 6 6 7 7 9 15 14 16 17Fluoroquinolones R 12 12 12 14 19 22 23 24 27Third-gen. cephalosporins R 6 6 7 6 8 10 10 14 15Carbapenems R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood - - 100 39 100 25 100 5 100 23 97 75 97 48CSF - - - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTGreeceFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)No data reportedGR009X (0/5)GR052X (1/8)GR043X (3/18)GR018X (3/17)GR062X (4/18)GR027X (12/50)GR050X (8/31)GR026X (7/27)GR047X (33/122)GR031X (20/72)GR035X (15/53)GR030X (29/88)GR010X (4/12)GR038X (3/9)GR005X (10/29)GR051X (7/19)GR037X (29/78)GR001X (20/53)N hospitals 40Minimum 0First quartile 28Median 38.9Third quartile 51Maximum 77.8Hospital codesGR028X (20/53)GR024X (25/66)GR055X (4/10)GR015X (20/50)GR075X (25/62)GR040X (81/192)GR042X (7/16)GR068X (17/38)GR070X (9/20)GR039X (35/74)GR013X (9/18)GR049X (15/30)GR014X (27/52)GR041X (25/48)GR007X (33/63)GR048X (7/13)GR033X (27/49)GR012X (18/32)GR071X (4/7)GR032X (11/17)GR004X (6/9)GR059X (7/9)0 25 50 75 100% MRSA126

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesGR026X (0/27)GR010X (1/15)GR027X (13/130)GR051X (2/16)GR052X (3/24)GR038X (4/28)GR009X (1/7)GR050X (14/87)GR068X (6/37)GR004X (1/6)GR064X (1/6)GR048X (4/23)GR071X (4/23)GR018X (8/45)GR042X (7/39)GR032X (6/33)GR011X (8/39)GR012X (11/50)GR047X (71/315)GR001X (28/123)GR024X (35/152)GR062X (4/17)GR028X (20/84)GR035X (35/145)GR041X (33/133)GR033X (21/80)GR030X (38/140)GR070X (6/22)GR015X (26/93)GR043X (14/50)GR060X (4/14)GR075X (37/127)GR031X (30/101)GR014X (32/107)GR037X (28/85)GR040X (89/268)GR005X (26/74)GR013X (9/24)GR055X (6/14)GR049X (9/21)GR059X (3/7)GR039X (34/77)GR007X (17/36)N hospitals 43Minimum 0First quartile 16.7Median 23.5Third quartile 29.7Maximum 47.20 25 50 75 100Hospital codesGR011X (3/13)GR051X (2/7)GR052X (2/6)GR055X (7/15)GR018X (10/20)GR038X (7/14)GR047X (93/159)GR033X (48/82)GR049X (18/30)GR027X (102/170)GR062X (8/13)GR028X (51/81)GR070X (14/21)GR035X (75/108)GR001X (63/89)GR048X (25/35)GR012X (43/60)GR005X (49/65)GR039X (154/204)GR031X (100/132)GR075X (92/121)GR026X (32/42)GR030X (183/238)GR014X (157/201)GR010X (31/39)GR007X (44/55)GR068X (81/101)GR024X (94/117)GR013X (9/11)GR041X (118/144)GR050X (55/67)GR040X (380/459)GR043X (54/65)GR032X (13/15)GR015X (79/91)GR037X (211/243)N hospitals 36Minimum 23.1First quartile 60Median 75.4Third quartile 80.3Maximum 86.80 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance127

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTHungaryGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 20 134 27 858 27 842 25 279 - - - -2004 26 143 30 1 020 28 967 26 366 - - - -2005 23 133 28 1 083 27 1 046 27 476 21 314 24 5072006 23 151 27 1 127 26 1 135 25 453 24 302 25 5462007 22 146 26 1 199 25 1 179 26 400 23 322 24 5182008 22 166 26 1 181 25 1 057 21 428 23 369 25 5132009 22 143 26 1 068 25 1 057 27 444 24 361 25 5182010 27 140 30 1 224 29 1 385 29 591 29 514 28 6362011 27 139 28 1 156 30 1 227 28 582 27 432 29 606Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 3

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 67 11 100 28 100 34 100 0 100 1 98 49 97 23CSF 33 18 - - - - - - - - 2 57 3 19GenderMale 54 10 57 28 43 36 57 0 56 2 56 54 57 25Female 44 18 41 28 56 33 41 0 42 0 43 42 40 21Unknown 2 0 2 33 1 19 2 0 2 0 1 86 3 16Age (years)0–4 9 20 1 6 3 12 4 0 4 0 7 48 5 185–19 6 18 2 5 1 22 1 0 1 0 1 60 2 1220–64 48 15 45 26 38 33 39 0 46 1 43 50 49 2765 and over 36 8 52 31 58 36 57 0 48 2 48 48 45 20Unknown

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTHungaryFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesHU024 (0/10)HU035 (0/10)HU040 (0/12)HU039 (0/5)HU020 (0/7)HU019 (0/8)HU009 (1/22)HU022 (3/43)HU002 (1/9)HU034 (2/15)HU041 (1/7)HU029 (4/25)HU033 (2/10)HU028 (2/10)HU026 (1/5)HU006 (2/8)HU032 (7/28)HU027 (2/7)HU005 (2/7)HU025 (4/10)N laboratories 20Minimum 0First quartile 0Median 13.8Third quartile 22.5Maximum 400 25 50 75 100Hospital codesHU034C (0/11)HU002Y (0/14)HU038X (0/12)HU025A (4/94)HU034A (5/71)HU024A (7/60)HU020L (1/8)HU002M (1/8)HU019A (17/123)HU022Y (1/7)HU027A (3/20)HU002L (1/6)HU022P (8/41)HU037A (2/10)HU041A (15/69)HU006W (2/9)HU002G (7/30)HU035A (18/74)HU009B (9/35)HU028A (38/145)HU006B (5/19)HU038I (4/15)HU022I (39/143)HU026A (24/87)HU012G (13/47)HU040A (34/121)HU001Q (2/7)HU019H (3/10)HU032A (49/162)HU001P (4/13)HU033A (48/135)HU009A (55/154)HU031A (4/11)HU029V (93/250)HU005A (21/56)HU020A (20/53)HU007C (6/14)HU020C (3/7)HU008F (3/7)HU039A (22/49)HU007B (16/34)HU012P (10/19)HU004G (5/9)HU038A (14/25)HU006A (9/16)HU022S (9/14)N hospitals 46Minimum 0First quartile 16.7Median 27.4Third quartile 37.5Maximum 64.30 25 50 75 100% penicillin non-susceptible % MRSA130

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesHU002L (0/7)HU001R (0/10)HU009B (1/16)HU034C (1/12)HU022P (2/18)HU004G (1/7)HU038X (1/6)HU032X (1/6)HU038A (3/18)HU002G (5/28)HU037A (1/5)HU012P (4/19)HU019A (25/114)HU024A (20/91)HU020L (4/18)HU027A (12/48)HU006B (2/8)HU020C (2/8)HU038I (3/12)HU026A (13/47)HU022I (84/298)HU002M (4/14)HU006A (9/31)HU012G (9/31)HU029V (78/265)HU040A (28/95)HU034A (28/89)HU019H (2/6)HU002D (2/6)HU031A (3/9)HU007C (2/6)HU001P (2/6)HU033A (43/128)HU039A (23/66)HU025A (52/149)HU020A (17/46)HU041A (29/77)HU006W (2/5)HU016D (2/5)HU032A (59/146)HU035A (32/75)HU007B (20/41)HU005A (22/45)HU028A (102/208)HU027L (3/6)HU009A (96/174)HU022S (8/14)HU006R (3/5)N hospitals 48Minimum 0First quartile 21.5Median 29.2Third quartile 37.3Maximum 600 25 50 75 100Hospital codesHU024A (0/10)HU019A (0/18)HU034A (1/14)HU040A (3/22)HU022I (2/11)HU002G (2/9)HU026A (3/13)HU041A (7/27)HU007B (5/18)HU027A (2/7)HU033A (19/42)HU009A (19/42)HU039A (10/21)HU025A (32/64)HU031A (4/8)HU029V (63/126)HU006A (8/15)HU032A (68/127)HU001P (14/26)HU020A (6/11)HU004G (5/9)HU035A (20/34)HU032X (3/5)HU001R (3/5)HU005A (11/18)HU028A (99/154)HU012G (6/9)HU012P (35/40)N hospitals 28Minimum 0First quartile 24.5Median 50Third quartile 57.2Maximum 87.50 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance131

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTIcelandGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 2 35 2 64 2 100 2 22 - - - -2004 2 54 2 55 2 119 1 27 - - - -2005 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 65 2 105 1 29 2 27 1 112008 2 46 2 63 2 123 2 17 1 24 2 72009 2 35 2 59 2 111 2 51 2 27 2 162010 2 37 2 65 2 104 2 31 2 27 2 122011 2 32 2 71 2 130 2 32 2 26 2 17Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 90 5 100 2 100 13 100 0 100 3 100 6 100 3CSF 10 29 - - - - - - - - - - - -GenderMale 65 7 63 2 45 15 50 0 66 5 57 7 72 5Female 35 8 38 2 55 10 50 0 34 0 43 4 28 0Age (years)0–4 12 38 5 0 2 0 3 0 3 0 - - 3 05–19 3 0 4 0 1 0 - - 3 0 - -20–64 43 3 44 3 37 14 35 0 48 0 51 4 52 065 and over 42 3 46 2 60 12 62 0 45 8 49 8 45 8Hospital departmentICU 6 0 3 0

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTIcelandFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 2Minimum 6.6First quartile 6.6Median 9.5Third quartile 12.5Maximum 12.5N hospitals 2Minimum 0First quartile 0Median 1.4Third quartile 2.8Maximum 2.8IS001 (4/61)IS003A (0/21)Laboratory codesHospital codesIS003 (1/8)IS001A (3/109)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA134

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)N hospitals 4Minimum 0First quartile 0Median 6.5Third quartile 20.8Maximum 28.6N hospitals 2Minimum 0First quartile 0Median 3.3Third quartile 6.7Maximum 6.7IS001G (0/5)IS003A (0/5)IS001B (0/10)Hospital codesHospital codesIS001A (24/185)IS001A (3/45)IS001C (2/7)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance135

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTIrelandGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 24 363 26 1 108 26 978 21 348 - - - -2004 28 399 38 1 286 37 1 235 29 418 - - - -2005 31 397 38 1 360 39 1 424 33 502 15 42 11 292006 32 406 38 1 347 39 1 638 32 550 28 211 23 1282007 33 435 41 1 332 42 1 750 37 598 31 237 29 1722008 35 442 38 1 242 41 1 875 37 685 33 307 29 1912009 34 356 41 1 261 41 2 012 38 671 37 316 30 2362010 32 310 39 1 207 40 2 121 38 670 34 318 30 2192011 32 324 39 1 057 38 2 167 36 608 34 304 28 181Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 3 3 3 3 6 6 6 5 6Penicillin RI 12 10 11 16 17 23 20 18 19Macrolides RI 12 14 12 16 17 17 17 16 18Staphylococcus aureusOxacillin/Meticillin R 42 41 42 42 38 33 27 24 24Escherichia coliAminopenicilins R 61 65 67 69 65 67 66 67 70Aminoglycosides R 4 5 7 7 10 9 9 10 10Fluoroquinolones R 10 12 17 21 21 23 22 23 23Third-gen. cephalosporins R 2 2 4 4 5 6 6 8 9Carbapenems R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 97 19 100 24 100 23 100 2 100 37 100 8 99 6CSF 3 13 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTIrelandFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)IE-60 (0/17)IE-18 (0/6)IE-15 (2/34)N laboratories 27Minimum 0First quartile 12.7Median 16.7Third quartile 30.8Maximum 44.4IE-49 (0/21)IE-65 (0/11)IE-37 (0/8)IE-21 (0/17)IE-63 (0/5)IE-77 (0/15)N hospitals 50Minimum 0First quartile 17.3Median 24.4Third quartile 31.3Maximum 57.1IE-32 (2/24)IE-59 (1/35)IE-48 (2/20)IE-43 (1/19)IE-46 (6/56)IE-49 (1/8)IE-71 (1/8)IE-57 (2/15)IE-10 (9/71)IE-64 (1/7)IE-60 (9/52)IE-46 (2/15)IE-11 (9/51)IE-4 (19/103)IE-61 (1/7)IE-48 (14/74)IE-15 (29/153)IE-2 (6/41)IE-76 (2/10)IE-79 (2/10)IE-1 (6/40)IE-12 (7/31)IE-31 (2/13)IE-6 (12/53)IE-18 (5/22)Laboratory codesIE-50 (7/45)IE-65 (1/6)IE-34 (11/55)Hospital codesIE-36 (4/17)IE-50 (35/145)IE-44 (9/37)IE-34 (30/123)IE-20 (34/139)IE-35 (2/8)IE-30 (4/19)IE-2 (48/192)IE-1 (39/152)IE-44 (3/14)IE-33 (7/27)IE-31 (11/41)IE-6 (4/15)IE-73 (5/17)IE-4 (9/33)IE-29 (38/128)IE-32 (11/37)IE-25 (10/34)IE-10 (28/91)IE-61 (5/16)IE-58 (4/13)IE-80 (5/16)IE-30 (11/35)IE-62 (5/16)IE-52 (6/19)IE-70 (9/28)IE-20 (10/30)IE-62 (5/15)IE-74 (12/36)IE-43 (2/6)IE-47 (13/37)IE-47 (6/16)IE-38 (4/11)IE-58 (16/41)IE-70 (5/12)IE-13 (10/25)IE-51 (4/8)IE-74 (4/9)0 25 50 75 100IE-26 (8/14)IE-81 (4/7)0 25 50 75 100% penicillin non-susceptible % MRSA138

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesIE-57 (0/24)IE-77 (0/23)IE-37 (0/8)IE-59 (0/23)IE-51 (3/35)IE-65 (3/25)IE-72 (1/8)IE-73 (6/47)IE-46 (4/31)IE-11 (13/98)IE-80 (4/29)IE-2 (46/330)IE-68 (1/7)IE-18 (5/31)IE-13 (14/86)IE-67 (2/12)IE-10 (28/167)IE-30 (13/76)IE-49 (3/17)IE-60 (23/119)IE-48 (30/154)IE-50 (37/188)IE-44 (15/74)IE-70 (13/64)IE-21 (7/34)IE-38 (6/29)IE-81 (4/19)IE-76 (4/19)IE-47 (23/107)IE-33 (11/51)IE-74 (22/99)IE-61 (10/44)IE-35 (6/26)IE-63 (4/17)IE-34 (43/182)IE-12 (18/75)IE-31 (25/102)IE-1 (69/277)IE-64 (2/8)IE-32 (29/116)IE-15 (62/244)IE-52 (11/42)IE-26 (9/34)IE-43 (14/51)IE-20 (70/251)IE-6 (26/89)IE-4 (48/157)IE-62 (17/54)IE-36 (14/43)IE-53 (4/12)IE-40 (2/6)IE-27 (2/6)IE-29 (79/218)IE-79 (7/19)IE-58 (41/101)IE-71 (13/30)IE-23 (3/6)N hospitals 57Minimum 0First quartile 16.3Median 21.5Third quartile 26.5Maximum 500 25 50 75 100Hospital codesIE-32 (0/11)IE-47 (0/14)IE-80 (0/7)IE-30 (0/11)IE-48 (0/16)IE-31 (0/9)IE-33 (0/5)IE-6 (0/10)IE-50 (0/20)IE-13 (0/8)IE-73 (0/7)IE-12 (0/10)IE-21 (0/11)IE-29 (1/31)IE-1 (3/57)IE-74 (1/16)IE-60 (1/14)IE-10 (2/20)IE-44 (1/10)IE-34 (4/38)IE-11 (1/9)IE-2 (6/53)IE-15 (6/50)IE-58 (2/15)IE-20 (7/51)IE-18 (2/12)IE-4 (5/28)IE-71 (1/5)IE-46 (2/7)IE-81 (3/5)N hospitals 30Minimum 0First quartile 0Median 5.8Third quartile 12Maximum 600 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance139

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTItalyGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 44 293 46 1 480 17 923 44 634 - - - -2004 37 271 42 1 225 14 645 40 576 - - - -2005 38 331 41 1 479 16 1 195 40 714 38 344 - -2006 34 269 38 1 164 13 910 35 650 32 321 12 1832007 34 298 38 1 167 14 1 052 36 656 37 391 10 1852008 27 194 30 939 14 957 31 580 27 331 11 1682009 21 216 23 987 9 863 22 509 22 313 10 1952010 33 323 35 1 886 23 2 623 35 1 106 34 739 23 5172011 29 294 31 1 372 21 2 098 31 841 30 688 21 355Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 5 5 5

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 88 8 100 37 100 40 100 2 100 4 98 46 98 21CSF 12 8 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTItalyFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)IT024 (0/15)IT028 (0/6)N laboratories 18Minimum 0First quartile 0Median 6.5Third quartile 7.7Maximum 50IT0071 (1/25)IT0001 (6/44)IT0024 (7/46)IT0019 (24/125)N hospitals 42Minimum 4First quartile 26.3Median 35.7Third quartile 43.4Maximum 64.9IT0059 (29/147)IT086 (0/5)IT0088 (8/39)IT0064 (16/76)IT037 (0/52)IT0077 (10/47)IT0025 (11/49)IT0015 (5/22)IT090 (0/24)IT0067 (49/186)IT0028 (9/33)IT064 (1/23)IT0045 (14/50)IT0092 (23/74)IT091 (2/34)IT0072 (39/125)IT004E (12/37)IT0061 (71/217)IT019 (1/16)IT0047 (9/26)IT004B (7/20)Laboratory codesIT004 (2/31)IT061 (2/31)Hospital codesIT0049 (17/48)IT0042 (16/45)IT0022 (43/120)IT004D (9/25)IT004A (11/30)IT022 (1/15)IT004F (14/38)IT0023 (30/81)IT072 (2/30)IT0090 (22/59)IT0031 (19/49)IT089 (2/28)IT0060 (22/55)IT0070 (29/71)IT004G (34/81)IT060 (2/26)IT0085 (33/76)IT0074 (32/73)IT085 (3/12)IT0091 (78/158)IT0052 (26/52)IT042 (2/8)IT004C (6/12)IT0037 (65/130)IT0034 (40/70)IT077 (2/6)IT0086 (39/65)IT0040 (46/74)IT034 (7/14)IT0035 (59/93)IT0089 (87/134)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA142

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)IT0047 (9/44)IT0001 (16/56)IT0061 (71/248)N hospitals 32Minimum 20.5First quartile 36Median 39.8Third quartile 47.3Maximum 62.6IT0061 (3/84)IT004G (2/21)IT004C (1/8)IT0059 (6/45)N hospitals 42Minimum 3.6First quartile 27.8Median 48.1Third quartile 63.5Maximum 80.3IT004G (58/192)IT0023 (6/29)IT0037 (100/294)IT0070 (54/157)IT0024 (2/9)IT0072 (6/26)IT0070 (4/17)IT0035 (55/154)IT004E (6/25)IT0059 (105/292)IT0072 (59/164)IT0086 (7/26)IT004F (5/18)IT0028 (2/7)IT004C (15/41)IT0035 (14/44)IT004D (26/68)IT0090 (51/133)IT0025 (12/34)IT0090 (5/14)IT0088 (16/44)IT0023 (58/151)IT0085 (12/30)Hospital codesIT0019 (107/275)IT0086 (44/112)IT004F (33/83)IT0089 (105/264)IT004B (27/67)IT0092 (61/145)Hospital codesIT0031 (10/22)IT0042 (10/22)IT0034 (16/34)IT0091 (41/87)IT0019 (26/53)IT0089 (21/42)IT0074 (3/6)IT0047 (9/18)IT0091 (101/238)IT0067 (72/169)IT004E (70/156)IT0034 (63/140)IT0085 (61/129)IT0015 (9/19)IT0042 (35/71)IT0049 (35/69)IT004A (35/68)IT0025 (73/140)IT0040 (33/59)IT0075 (17/30)IT0088 (67/107)0 25 50 75 100IT004A (5/10)IT0037 (34/66)IT0067 (22/41)IT0022 (15/25)IT004B (12/20)IT0015 (14/23)IT0040 (40/63)IT0064 (21/33)IT004D (13/20)IT0001 (18/27)IT0060 (6/9)IT0077 (24/35)IT0049 (30/42)IT0052 (18/25)IT0075 (27/36)IT0071 (13/17)IT0092 (57/71)0 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance143

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTLatviaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2004–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2004 4 17 7 87 - - - - - - - -2005 5 36 7 127 - - - - - - - -2006 7 37 11 172 10 62 10 56 6 28 9 162007 6 31 12 169 9 76 8 57 7 27 6 162008 3 18 12 164 10 90 9 51 11 40 6 112009 7 30 12 188 9 86 8 48 10 44 7 182010 4 38 10 155 8 98 8 61 8 64 6 212011 5 51 11 197 9 132 8 59 9 65 4 12Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R -

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 73 5 100 12 100 16 100 0 100 11 98 46 97 13CSF 27 19 - - 0 0 - - - - 2 100 3 0GenderMale 55 2 53 13 32 21 51 0 51 9 53 43 39 15Female 45 17 47 10 68 14 49 0 49 14 47 50 61 10Age (years)0–4 13 40 8 4 8 6 8 0 2 0 16 33 9 05–19 1 100 4 7 2 0 1 0 - - 2 100 - -20–64 58 2 47 14 41 15 43 0 49 14 49 52 42 2965 and over 27 5 40 9 49 19 47 0 47 10 33 43 48 0Unknown - - 1 100 0 0 - - 2 0 1 0 - -Hospital departmentICU 57 5 23 19 25 28 38 0 67 13 43 61 48 19Internal med. 9 29 41 11 27 15 24 0 16 14 19 40 33 9Surgery - - 8 15 4 44 8 0 9 0 4 40 6 0Other 19 13 20 9 27 7 19 0 7 0 18 35 9 0Unknown 14 9 8 0 17 8 11 0 2 0 16 30 3 0PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.145

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTLatviaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 4Minimum 0First quartile 1.2Median 3.7Third quartile 30.3Maximum 55.6LV009A (0/5)N hospitals 11Minimum 0First quartile 0Median 5.9Third quartile 14.4Maximum 16.7LV001 (0/7)LV006A (0/5)LV005A (0/18)LV008A (0/6)LV004 (1/41)LV002A (1/25)Laboratory codesHospital codesLV003A (2/34)LV012A (2/23)LV003 (1/20)LV013A (1/7)LV004A (14/97)LV002 (5/9)LV001A (19/117)LV011A (1/6)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA146

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)LV005A (0/7)N hospitals 6Minimum 0First quartile 0Median 8Third quartile 18.2Maximum 34.7LV003A (1/7)N hospitals 5Minimum 14.3First quartile 36.1Median 40Third quartile 44.4Maximum 63.3LV002A (0/14)LV004A (13/36)LV003A (2/58)Hospital codesHospital codesLV012A (4/10)LV012A (2/16)LV002A (8/18)LV004A (14/77)LV001A (17/49)LV001A (31/49)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance147

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTLithuaniaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2006–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2006 9 35 13 167 11 171 8 30 8 35 7 142007 10 67 12 240 13 235 10 56 10 41 7 212008 11 48 12 278 12 304 10 67 11 54 7 212009 10 46 13 258 13 297 11 57 12 68 8 212010 9 40 11 257 10 333 10 59 9 81 8 312011 8 48 10 279 10 385 9 74 10 137 6 30Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R - - -

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 92 18 100 10 100 13 100 0 100 8 99 56 100 23CSF 8 0 - - - - - - - - 1 100 - -GenderMale 70 11 54 9 37 16 65 0 54 15 60 60 67 20Female 30 27 45 11 62 12 35 0 46 0 40 52 33 30Unknown - - 1 0 0 0 - - - - - - - -Age (years)0–4 26 26 4 5 4 15 10 0 8 0 6 85 2 05–19 5 25 6 0 2 7 1 0 6 33 1 100 2 020–64 51 14 44 8 38 18 35 0 32 13 39 52 45 3065 and over 18 6 45 13 56 10 54 0 54 4 54 56 52 19Unknown - - 1 0 0 0 - - - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTLithuaniaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)LT004 (0/7)N laboratories 6Minimum 0First quartile 0Median 8Third quartile 26.7Maximum 37.5LT002A (0/14)N hospitals 13Minimum 0First quartile 3.8Median 7.7Third quartile 16.7Maximum 50LT009F (0/8)LT013B (0/17)LT005 (0/5)LT011A (1/26)LT012A (1/21)LT007 (1/13)LT007A (4/82)Laboratory codesHospital codesLT001A (11/142)LT013 (2/24)LT013A (4/33)LT005A (10/69)LT001 (4/15)LT004A (11/66)LT003A (4/19)LT013D (2/6)LT011 (6/16)LT001B (3/6)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA150

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)LT013C (0/9)N hospitals 14Minimum 0First quartile 6.5Median 12.9Third quartile 18.2Maximum 23.5LT013A (6/19)N hospitals 9Minimum 31.6First quartile 47.6Median 56.8Third quartile 57.9Maximum 100LT005A (4/106)LT012A (1/16)LT007A (8/20)LT009F (2/31)LT005A (10/21)LT007A (7/99)LT013B (1/13)LT009F (3/6)Hospital codesLT013A (11/101)LT002A (3/20)Hospital codesLT001A (25/44)LT004A (8/51)LT003A (12/21)LT002F (1/6)LT012A (11/19)LT001B (2/11)LT003A (6/31)LT004A (32/39)LT011A (4/19)LT011A (12/12)LT001A (42/179)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance151

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTLuxembourgGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 7 54 8 95 8 227 7 41 - - - -2004 6 36 7 96 7 216 5 28 - - - -2005 5 47 5 83 5 188 5 31 - - 1 12006 5 31 5 77 5 167 4 42 4 21 4 232007 6 48 6 117 6 275 5 37 6 52 5 362008 6 59 5 117 6 303 5 61 6 52 4 332009 6 67 6 113 6 301 5 54 3 28 6 352010 6 50 6 134 6 354 6 70 6 59 6 322011 5 52 5 127 5 354 5 76 4 48 5 32Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 87 10 100 18 100 25 100 4 100 17 98 18 97 13CSF 13 8 - - - - - - - - 2 50 3 0GenderMale 54 9 63 15 42 25 72 4 65 23 58 21 55 17Female 46 11 37 24 58 25 28 4 33 0 42 16 45 7Unknown - - - - - - - - 2 100 - - - -Age (years)0–4 3 0 2 0 1 11 4 0 2 0 6 50 2 05–19 3 33 4 20 1 0 1 0 2 0 - - 2 020–64 45 11 37 15 26 22 30 7 30 29 27 38 19 865 and over 49 8 57 21 72 27 65 3 65 13 67 8 78 14Hospital departmentICU 12 25 12 32 6 24 16 0 20 0 12 23 17 9Internal med. 8 13 8 23 8 28 8 0 2 0 7 0 5 0Surgery 4 0 6 25 11 26 8 0 9 25 15 25 5 33Other 36 14 40 11 35 25 38 0 46 29 37 25 38 13Unknown 40 3 33 20 40 24 30 13 24 9 28 10 36 13PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.153

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTLuxembourgFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)LU007 (0/9)N laboratories 5Minimum 0First quartile 6.3Median 6.3Third quartile 7.7Maximum 20.7LU003C (1/13)N hospitals 7Minimum 7.7First quartile 10Median 16.7Third quartile 22.5Maximum 22.5LU001A (4/40)LU001 (2/32)LU003B (1/6)Laboratory codesLU006 (1/16)Hospital codesLU004A (3/18)LU007A (7/36)LU004 (1/13)LU006A (9/40)LU003 (6/29)LU003A (23/102)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA154

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)LU003D (0/10)N hospitals 9Minimum 0First quartile 21.4Median 25.5Third quartile 26.1Maximum 38.1LU007A (1/14)N hospitals 5Minimum 7.1First quartile 10Median 14.3Third quartile 23.4Maximum 60LU003B (1/8)LU006A (28/131)LU001A (2/20)LU004A (22/88)Hospital codesLU001A (26/102)Hospital codesLU006A (2/14)LU007A (22/85)LU003A (11/47)LU003A (63/241)LU004B (5/14)LU003B (3/5)LU003C (8/21)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance155

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTMaltaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 1 9 1 121 1 91 1 26 - - - -2004 1 18 1 94 1 91 1 41 - - - -2005 1 13 1 77 1 85 1 38 1 18 1 452006 1 31 1 90 1 94 1 53 1 32 1 512007 1 13 1 105 1 117 1 37 1 28 1 362008 1 17 1 108 1 128 1 32 1 36 1 312009 1 8 1 85 1 158 1 36 1 38 1 582010 1 11 1 108 1 192 1 37 1 57 1 422011 1 11 1 130 1 220 1 53 1 52 1 42Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTMaltaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 1Minimum 16.7First quartile 16.7Median 16.7Third quartile 16.7Maximum 16.7N hospitals 3Minimum 42.9First quartile 42.9Median 48.6Third quartile 60Maximum 60MT001E (3/7)Laboratory codesMT001 (2/12)Hospital codesMT001A (107/220)MT001F (6/10)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA158

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)N hospitals 3Minimum 27.8First quartile 27.8Median 32.5Third quartile 50Maximum 50N hospitals 3Minimum 0First quartile 0Median 12.5Third quartile 16.7Maximum 16.7MT001E (10/36)MT001E (0/6)Hospital codesMT001A (114/351)Hospital codesMT001A (12/96)MT001F (12/24)MT001F (1/6)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance159

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTNetherlandsGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 24 891 23 1 422 23 2 133 23 480 - - - -2004 22 758 22 1 339 21 2 111 22 444 - - - -2005 23 815 23 1 407 23 2 201 23 563 16 301 16 2102006 22 1 006 23 1 636 22 2 905 23 776 18 458 19 3302007 21 940 21 1 471 21 2 801 21 827 19 497 19 3382008 17 723 16 1 191 16 2 283 17 632 15 463 15 3452009 17 746 16 1 035 16 2 398 16 522 15 408 15 2352010 22 971 21 1 565 21 3 422 20 834 20 647 21 3762011 25 1 289 23 1 815 23 4 436 23 1 108 23 729 23 434Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 94 1 100 1 100 14 100 0 100 1 99 8 99 3CSF 6 3 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTNetherlandsFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesNL005 (0/23)NL112 (0/70)NL139 (0/48)NL119 (0/68)NL132 (0/77)NL131 (0/121)NL030 (0/76)NL125 (0/72)NL111 (1/98)NL134 (1/94)NL141 (1/78)NL007 (1/71)NL031 (2/123)NL026 (1/60)NL113 (3/164)NL145 (2/107)NL002 (3/149)NL126 (2/87)NL101 (2/84)NL023 (2/77)NL104 (1/19)NL014 (5/47)N laboratories 22Minimum 0First quartile 0Median 1.3Third quartile 2Maximum 10.60 25 50 75 100Hospital codesNL125B (0/21)NL014X (0/6)NL030C (0/19)NL030A (0/27)NL023B (0/25)NL026C (0/16)NL131E (0/5)N hospitals 63Minimum 0First quartile 0Median 0Third quartile 2Maximum 12.5NL113A (0/105)NL125C (0/27)NL030D (0/53)NL113B (0/27)NL007B (0/11)NL118A (0/48)NL139B (0/43)NL118C (0/70)NL139D (0/13)NL134B (0/13)NL007C (0/21)NL112X (0/48)NL014G (0/41)NL113E (0/9)NL101B (0/14)NL132A (0/106)NL030B (0/15)NL113C (0/28)NL030F (0/28)NL030G (0/35)NL030I (0/24)NL139C (0/6)NL145B (0/29)NL111C (0/36)NL111D (0/30)NL125A (0/20)NL119A (1/135)NL145A (1/127)NL002A (1/116)NL112A (1/98)NL101A (1/96)NL131A (1/89)NL131B (1/88)NL007A (1/83)NL030E (1/78)NL126A (1/74)NL031A (1/68)NL030H (1/66)NL026A (1/66)NL104A (2/101)NL126B (3/148)NL111B (1/48)NL134A (3/143)NL141A (4/182)NL002B (2/83)NL031B (2/75)NL005A (1/37)NL023A (2/74)NL026B (2/62)NL113D (1/31)NL007X (3/80)NL118B (1/25)NL111A (1/23)NL014V (1/19)NL131X (1/10)NL131F (1/8)0 25 50 75 100% penicillin non-susceptible % MRSA162

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesNL007B (0/18)NL026C (1/18)NL030A (5/73)NL118B (9/128)NL014V (4/53)NL111A (4/51)NL113E (4/49)N hospitals 64Minimum 0First quartile 10.4Median 13.7Third quartile 17.1Maximum 28.6NL014G (11/133)NL111D (6/70)NL104A (17/191)NL031A (13/141)NL002B (18/195)NL113C (10/102)NL118C (20/199)NL145A (28/272)NL030D (13/126)NL002A (25/240)NL007C (2/19)NL030G (12/105)NL134A (26/222)NL126B (35/296)NL134X (1/8)NL113B (12/95)NL030H (24/187)NL139C (4/31)NL131A (24/186)NL131X (5/38)NL118A (17/129)NL023B (12/91)NL113A (37/278)NL112A (25/187)NL031B (28/206)NL113D (20/145)NL111C (18/129)NL023A (22/155)NL119A (42/287)NL126A (15/102)NL005A (20/130)NL134B (4/26)NL112X (23/149)NL125C (14/89)NL101A (34/216)NL139D (9/54)NL131E (1/6)NL145B (13/77)NL132A (51/301)NL111B (22/129)NL125B (7/41)NL007A (18/105)NL139B (16/93)NL131B (37/214)NL125A (8/45)NL030C (13/72)NL030F (16/88)NL030E (40/210)NL007X (24/125)NL026A (21/109)NL141A (56/278)NL131F (6/29)NL030I (17/75)NL030B (15/65)NL014X (4/17)NL026B (28/99)NL101B (8/28)0 25 50 75 100Hospital codesNL145B (0/8)NL030E (0/31)NL030D (0/22)NL131X (0/7)NL125B (0/10)NL030F (0/11)NL031A (0/26)NL113D (0/28)NL030G (0/17)NL030A (0/12)NL126B (0/43)NL118B (0/17)NL014V (0/8)NL113E (0/6)NL030C (0/6)NL026A (0/26)NL005A (0/9)NL007B (0/6)NL023B (0/7)NL014G (0/19)NL134B (0/5)NL125A (0/5)NL113B (0/12)NL139B (0/14)NL030B (0/12)NL101A (0/43)NL023A (1/36)NL113A (1/32)NL145A (2/44)NL118A (1/21)NL113C (1/14)NL131B (3/40)NL031B (3/39)NL126A (1/13)NL026B (2/24)NL112A (3/35)NL125C (2/21)NL141A (5/52)NL118C (3/30)NL002B (3/30)NL112X (3/29)NL002A (6/56)NL030H (3/28)NL111A (1/9)NL134A (7/62)NL119A (6/53)NL007A (4/34)NL030I (1/8)NL007X (3/23)NL111C (3/22)NL111B (4/29)NL007C (1/7)NL104A (5/31)NL111D (2/12)NL139D (1/6)NL131A (9/40)NL132A (12/53)N hospitals 57Minimum 0First quartile 0Median 4.5Third quartile 10.7Maximum 22.60 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance163

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTNorwayGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 11 512 11 506 11 1 179 11 192 4 46 4 252004 11 600 11 516 11 1 212 11 235 4 51 4 272005 11 606 11 553 11 1 331 11 304 11 193 11 972006 12 601 12 734 12 1 574 12 349 12 263 12 962007 13 616 13 794 13 1 713 13 416 13 320 13 1052008 13 576 13 837 13 1 799 13 403 13 349 13 1482009 12 554 12 909 12 1 846 12 478 12 396 12 1662010 15 576 15 1 050 15 2 277 15 563 15 479 15 1682011 17 622 17 1 223 17 2 620 17 588 17 450 17 148Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 96 4 100 0 100 9 100 0 100 2 100 2 99 2CSF 4 2 - - 0 0 - - - - 0 0 1 50GenderMale 51 4 64 0 46 12 74 0 61 2 58 2 67 2Female 49 3 36 0 54 6 26 0 39 0 42 3 33 3Unknown - - 0 0

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTNorwayFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)NO402 (0/29)NO401 (0/9)N laboratories 17Minimum 0First quartile 1.1Median 2.4Third quartile 5.9Maximum 6.8NO206O (0/74)NO502K (0/19)NO304J (0/35)NO501B (0/12)NO203D (0/15)N hospitals 47Minimum 0First quartile 0Median 0Third quartile 0Maximum 6.7NO103X (0/9)NO404 (0/26)NO404F (0/23)NO502L (0/16)NO106V (0/38)NO105 (0/49)NO501E (0/20)NO403E (0/23)NO402B (0/37)NO203 (1/89)NO206Q (0/8)NO106T (0/25)NO501 (1/56)NO106S (0/46)NO502D (0/15)NO105K (0/82)NO104 (2/93)NO106U (0/13)NO204E (0/126)NO203C (0/85)Laboratory codesNO403 (2/84)NO101 (3/123)NO204 (4/161)Hospital codesNO101D (0/59)NO304M (0/6)NO102B (0/82)NO401A (0/15)NO204M (0/11)NO502I (0/20)NO103E (0/125)NO203K (0/21)NO102 (1/27)NO203X (0/10)NO206P (0/49)NO501F (0/6)NO301 (3/61)NO404G (0/16)NO304K (0/7)NO501G (0/16)NO502 (3/51)NO104J (0/184)NO106P (0/54)NO304 (2/34)NO401C (0/14)NO501C (0/16)NO106Q (0/57)NO106 (9/137)NO101A (1/219)NO301A (1/102)NO502H (1/99)NO206 (6/91)NO204I (1/87)NO501A (1/55)NO403D (3/148)NO103 (5/74)NO101C (1/48)NO402H (1/15)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA166

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesNO501F (0/16)NO204L (0/17)NO103X (0/20)NO501E (0/34)NO204N (0/7)NO501G (0/36)NO203X (0/10)NO501A (2/122)NO106Q (3/136)NO304J (3/90)NO106S (2/59)NO502I (2/57)NO204I (5/131)NO106U (1/26)NO101C (6/131)NO501C (2/38)NO106T (4/64)NO403E (6/90)NO104J (29/409)NO101D (7/96)NO501B (3/40)NO404F (4/51)NO204M (3/37)NO401C (2/24)NO103E (29/342)NO106V (10/117)NO403D (28/323)NO206O (11/121)NO203K (5/55)NO404G (1/11)NO401A (3/32)NO502L (3/31)NO502H (14/133)NO106P (12/108)NO105K (22/195)NO204E (31/270)NO502K (3/26)NO101A (32/269)NO203C (24/193)NO304M (2/16)NO206P (12/96)NO402H (8/62)NO206Q (3/23)NO304K (2/15)NO301A (33/243)NO203D (3/22)NO402B (15/103)NO102B (27/184)NO502D (5/34)N hospitals 49Minimum 0First quartile 3.8Median 8.5Third quartile 11.5Maximum 14.70 25 50 75 100Hospital codesNO106S (0/11)NO101D (0/12)NO403E (0/15)NO206P (0/19)NO106P (0/15)NO304K (0/6)NO106T (0/9)NO106V (0/12)NO206O (0/39)NO301A (0/45)NO502I (0/6)NO106Q (0/15)NO105K (0/26)NO304J (0/12)NO501B (0/6)NO204I (0/35)NO204M (0/5)NO501G (0/6)NO204E (0/56)NO402H (0/19)NO206Q (0/7)NO204L (0/5)NO403D (0/57)NO501E (0/6)NO102B (1/40)NO103E (2/76)NO502H (1/36)NO203C (1/34)NO104J (2/59)NO501A (1/26)NO101C (1/25)NO402B (2/24)NO501C (1/11)NO101A (8/69)NO203K (1/7)NO502K (1/6)N hospitals 36Minimum 0First quartile 0Median 0Third quartile 2.9Maximum 16.70 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance167

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTPolandGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 11 16 24 166 25 124 16 64 - - - -2004 11 16 30 262 29 192 23 52 - - - -2005 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 22 24 185 27 256 20 71 18 32 23 672008 34 84 15 99 14 84 11 26 11 19 8 222009 21 71 30 551 29 625 28 267 25 151 27 1532010 26 76 35 527 35 771 32 286 33 246 29 1692011 41 166 45 868 45 1 188 44 484 45 391 35 199Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 19

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 83 21 100 20 100 27 100 0 100 8 99 50 98 24CSF 17 18 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTPolandFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)PL138 (0/6)PL107 (0/8)N laboratories 20Minimum 0First quartile 15.6Median 21.1Third quartile 28.6Maximum 50PL0120 (0/10)PL0118 (0/33)PL0143 (0/30)PL0122 (0/7)PL0141 (0/16)N hospitals 44Minimum 0First quartile 7.6Median 15.7Third quartile 25Maximum 92.6PL150 (1/14)PL0136 (0/10)PL0148 (1/40)PL148 (1/13)PL0109 (2/61)PL0123 (2/46)PL110 (3/22)PL0108 (1/15)PL0121 (2/28)PL123 (3/17)PL0138 (6/74)PL0131 (1/12)PL0103 (2/20)PL143 (3/15)PL0139 (2/19)PL0107 (6/55)PL119 (1/5)PL0105 (6/52)PL0132 (1/8)PL126 (2/10)PL0149 (1/8)PL0137 (4/31)Laboratory codesPL134 (1/5)PL118 (2/9)PL116 (4/16)Hospital codesPL0150 (3/23)PL0124 (5/33)PL0106 (6/37)PL00 (1/6)PL0134 (1/6)PL0127 (3/18)PL0115 (6/34)PL121 (2/8)PL0130 (9/50)PL0101 (12/66)PL147 (2/7)PL0112 (12/58)PL0113 (4/19)PL117 (2/7)PL0104 (2/9)PL0110 (9/36)PL105 (2/7)PL0117 (3/12)PL0116 (17/68)PL0102 (6/21)PL102 (2/5)PL0119 (7/23)PL0114 (29/77)PL127 (3/7)PL0129 (2/5)PL0147 (32/79)PL106 (3/6)PL0135 (9/20)PL0133 (6/13)PL101 (3/6)PL0126 (32/67)PL0142 (25/27)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA170

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)PL0132 (0/7)PL0133 (0/7)PL0139 (2/25)PL0108 (3/21)N hospitals 41Minimum 0First quartile 17.6Median 22.8Third quartile 34.3Maximum 63.6PL0121 (0/6)PL0127 (0/6)PL0138 (0/11)N hospitals 31Minimum 0First quartile 25Median 46.2Third quartile 58.3Maximum 87.9PL0149 (2/13)PL0149 (1/14)PL0101 (8/50)PL0118 (7/43)PL0123 (7/43)PL0142 (1/8)PL0106 (1/6)PL0143 (16/94)PL0143 (3/16)PL0124 (5/29)PL0109 (13/74)PL0148 (14/79)PL0123 (2/8)PL0110 (2/7)PL0141 (4/22)PL0133 (2/6)PL0113 (9/47)PL0107 (21/107)PL0134 (4/19)PL0124 (2/6)PL0103 (4/10)PL0129 (4/19)PL0117 (2/5)Hospital codesPL0119 (3/14)PL0136 (4/18)PL0102 (8/36)PL0110 (26/114)PL0127 (11/48)PL0117 (4/16)PL0137 (12/48)Hospital codesPL0115 (15/36)PL0137 (5/11)PL0114 (6/13)PL0107 (15/32)PL0126 (10/20)PL0150 (6/23)PL0141 (4/8)PL0121 (16/61)PL0105 (11/40)PL0114 (13/47)PL0131 (10/20)PL0130 (32/59)PL0116 (25/90)PL0116 (13/23)PL0103 (10/33)PL0112 (24/70)PL0138 (23/65)PL0101 (11/19)PL0113 (7/12)PL0147 (21/58)PL0109 (11/18)PL0115 (24/66)PL0130 (31/73)PL0126 (37/85)PL0118 (4/6)PL0120 (4/6)PL0135 (8/18)PL0119 (9/11)PL0106 (18/39)PL0135 (5/6)PL0131 (13/27)PL0120 (7/12)PL0105 (7/8)PL0142 (14/22)PL0112 (51/58)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance171

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTPortugalGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 12 95 22 1 033 21 792 18 398 - - - -2004 14 166 23 1 063 19 761 19 410 - - - -2005 13 202 19 1 153 19 1 171 17 405 1 1 - -2006 15 183 17 1 306 18 1 331 17 464 13 315 11 2662007 12 202 20 1 383 20 1 432 19 518 18 370 16 3402008 14 260 20 1 557 21 1 625 20 588 21 543 19 4672009 17 237 20 1 824 20 2 040 19 675 20 564 18 5362010 12 156 18 1 633 19 1 980 19 621 19 596 19 5482011 17 455 18 1 507 18 1 963 18 684 18 619 18 526Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 96 11 100 54 100 27 100 3 100 22 99 32 99 18CSF 4 24 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTPortugalFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)PT005 (0/10)PT026 (0/9)N laboratories 19Minimum 0First quartile 0Median 10.3Third quartile 16.7Maximum 36.4PT021A (0/32)PT031A (11/54)N hospitals 22Minimum 0First quartile 41.1Median 53.5Third quartile 61.9Maximum 67.7PT029A (8/28)PT022 (0/9)PT011A (71/210)PT016 (0/12)PT030A (18/44)PT021 (0/5)PT026A (23/56)PT002 (0/11)PT003A (102/223)PT003 (1/61)PT024A (11/23)PT031 (3/91)PT001A (87/176)Laboratory codesPT024 (4/49)PT029 (3/29)PT012 (1/9)Hospital codesPT027A (27/53)PT031B (120/231)PT031D (72/131)PT023A (90/160)PT001 (8/58)PT019A (162/286)PT018 (1/7)PT016A (83/141)PT007 (4/26)PT012A (102/169)PT027 (1/6)PT022A (13/21)PT011 (15/85)PT019 (16/80)PT007A (291/456)PT031C (29/45)PT002A (53/82)PT008 (8/27)PT005A (107/164)PT030 (4/11)PT008A (105/155)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA174

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)PT031A (3/19)PT021A (13/81)N hospitals 22Minimum 15.8First quartile 23.3Median 26.8Third quartile 33Maximum 37.3PT021A (1/17)PT023A (3/49)N hospitals 21Minimum 5.9First quartile 15.3Median 27.8Third quartile 34.6Maximum 66.7PT030A (15/78)PT008A (3/25)PT024A (39/190)PT016A (5/39)PT011A (66/294)PT011A (14/99)PT019A (65/279)PT003A (19/124)PT026A (12/50)PT031C (3/15)PT003A (123/508)PT029A (8/34)PT023A (62/255)PT022A (4/15)Hospital codesPT016A (27/108)PT022A (12/47)PT007A (160/569)PT001A (45/151)Hospital codesPT031B (25/93)PT031A (5/18)PT024A (14/47)PT031B (79/253)PT031D (75/239)PT005A (9/30)PT019A (32/101)PT031C (8/25)PT026A (4/12)PT029A (37/112)PT031D (44/127)PT002A (46/137)PT030A (7/17)PT027A (21/62)PT001A (31/59)PT008A (31/87)PT012A (18/34)PT012A (62/174)PT007A (126/229)PT005A (44/118)PT027A (6/9)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance175

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTRomaniaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 5 26 9 85 9 50 5 12 - - - -2004 4 9 15 95 12 48 4 9 - - - -2005 5 18 13 93 13 84 7 14 1 3 2 232006 8 29 11 83 9 41 9 28 5 32 2 32007 5 27 9 42 9 63 5 14 6 30 2 42008 4 14 5 39 4 58 4 16 3 6 3 82009 3 17 6 48 7 90 5 27 4 27 4 242010 2 13 5 47 5 35 2 19 3 17 5 102011 3 36 4 107 3 91 3 31 4 25 3 9Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 21 11 22 10 22 54 24 31 61Penicillin RI 33 11 39 28 33 69 29 31 61Macrolides RI 29

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates from the reporting period 2009 and 2010CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 57 46 100 47 99 27 100 0 100 0 100 55 100 68CSF 43 62 - - 1 100 - - - - - - - -GenderMale 57 50 69 45 54 42 75 0 73 0 60 56 74 79Female 41 55 29 53 46 11 25 0 27 0 38 56 26 40Unknown 2 100 2 33 - - - - - - 2 0 - -Age (years)0–4 12 50 5 63 1 0 11 0 64 0 26 91 32 505–19 12 50 5 13 4 33 - - 5 0 7 67 11 10020–64 10 0 54 45 51 25 36 0 14 0 10 25 21 5065 and over 22 64 10 44 35 29 18 0 - - 10 50 21 75Unknown 43 62 25 56 9 43 36 0 18 0 48 40 16 100Hospital departmentICU - - 1 100 - - - - - - - - 16 100Internal med. - - 5 57 6 0 - - - - 5 0 11 0Surgery - - 1 0 - - - - 5 0 5 100 11 100Other 57 46 58 42 53 33 64 0 77 0 40 71 47 56Unknown 43 62 35 56 41 25 36 0 18 0 50 43 16 100PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.177

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTRomaniaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 2Minimum 40.9First quartile 40.9Median 49.6Third quartile 58.3Maximum 58.3RO001D (2/5)N hospitals 5Minimum 40First quartile 40.5Median 52Third quartile 53.7Maximum 62.5RO01A (9/22)RO001A (30/74)Laboratory codesHospital codesRO002A (13/25)RO001E (22/41)RO01E (14/24)RO001B (5/8)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA178

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)N hospitals 4Minimum 24.3First quartile 25.9Median 28.8Third quartile 36.4Maximum 42.9N hospitals 3Minimum 33.3First quartile 33.3Median 40Third quartile 91.7Maximum 91.7RO002A (8/33)RO001D (2/6)RO001A (8/29)Hospital codesHospital codesRO001E (8/20)RO001D (3/10)RO001B (11/12)RO001E (3/7)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance179

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSlovakiaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 14 27 16 269 16 239 10 75 - - - -2004 9 17 15 289 15 310 12 82 - - - -2005 4 8 12 147 13 134 8 46 - - - -2006 - - - - - - - - - - - -2007 - - - - - - - - - - - -2008 - - - - - - - - - - - -2009 - - - - - - - - - - - -2010 - - - - - - - - - - - -2011 7 26 11 565 11 738 11 302 11 463 11 265Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 4 24

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 65 6 100 26 99 42 100 0 100 4 97 68 98 30CSF 35 11 - - 1 57 - - - - 3 83 2 50GenderMale 50 0 61 25 47 52 63 0 61 5 62 75 57 31Female 50 15 39 27 53 33 37 0 39 3 38 57 43 30Age (years)0–4 15 0 8 9 6 9 8 0 4 0 9 74 12 175–19 4 0 3 14 3 47 2 0 3 42 4 3020–64 50 0 47 25 37 45 44 0 59 3 43 71 53 3565 and over 31 25 42 32 54 43 47 0 37 5 45 65 31 29Hospital departmentICU 31 13 14 30 12 37 28 0 29 0 22 79 28 51Internal med. 27 0 52 26 40 44 34 0 30 0 31 61 22 13Surgery - - 10 36 10 45 12 0 9 11 10 65 8 35Other 42 9 21 19 35 41 26 0 32 9 36 67 40 27Unknown - - 3 28 3 36 2 0 1 0 2 75 2 0PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.181

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSlovakiaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)N laboratories 2Minimum 0First quartile 0Median 7.1Third quartile 14.3Maximum 14.3SKSK15F (0/9)SKSK15G (0/7)N hospitals 20Minimum 0First quartile 16.7Median 25Third quartile 29.8Maximum 54.2SKSK16A (4/36)SKSK15I (4/25)SKSK10A (3/18)SK005 (0/6)SKSK10B (2/12)SKSK15H (1/5)SKSK09A (11/51)SKSK15E (3/13)Laboratory codesHospital codesSKSK08A (15/63)SKSK07A (16/61)SKSK04A (7/26)SKSK15C (10/37)SKSK12A (3/11)SKSK15B (19/69)SK008 (1/7)SKSK11A (9/28)SKSK15A (4/11)SKSK06A (13/34)SKSK10C (8/18)SKSK05A (13/24)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA182

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)SKSK10B (4/22)SKSK11A (13/49)N hospitals 18Minimum 18.2First quartile 31.4Median 38.4Third quartile 49Maximum 56.9SKSK15E (2/5)SKSK12A (7/16)N hospitals 17Minimum 40First quartile 53.7Median 64.5Third quartile 70Maximum 89.7SKSK05A (9/32)SKSK08A (11/24)SKSK15E (2/7)SKSK10B (7/15)SKSK16A (16/51)SKSK15I (22/41)SKSK08A (16/45)SKSK16A (12/20)SKSK15A (4/11)SKSK10A (10/16)SKSK15G (3/8)SKSK15F (5/8)Hospital codesSKSK15I (24/64)SKSK07A (35/89)Hospital codesSKSK07A (40/62)SKSK04A (16/24)SKSK15F (2/5)SKSK15G (4/6)SKSK10A (11/27)SKSK05A (21/30)SKSK12A (9/22)SKSK04A (25/51)SKSK15C (14/20)SKSK09A (29/57)SKSK15B (32/43)SKSK15B (40/74)SKSK09A (32/40)SKSK15C (31/57)SKSK06A (37/43)SKSK06A (33/58)SKSK11A (35/39)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance183

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSloveniaGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 11 172 11 299 11 401 10 76 - - - -2004 10 166 11 347 11 573 9 91 - - - -2005 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 882008 10 209 10 418 10 874 10 196 9 157 10 952009 10 253 10 471 10 893 10 198 10 189 10 1072010 10 232 10 476 10 952 10 196 10 196 10 952011 10 253 10 464 10 1 002 10 208 10 232 10 118Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 2 2 2 5 4 3 1

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 94 14 100 10 100 20 100 0 100 1 98 26 98 22CSF 6 11 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSloveniaFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)SI011 (0/23)N laboratories 10Minimum 0First quartile 10.5Median 11.5Third quartile 17.4Maximum 30.8SI002A (0/38)SI003B (0/20)N hospitals 15Minimum 0First quartile 2.5Median 11.1Third quartile 13.3Maximum 18.2SI005 (2/20)SI010A (0/21)SI008 (4/38)SI003A (3/119)SI004A (3/85)SI010 (3/28)SI011A (2/40)Laboratory codesSI004 (10/90)SI007 (2/17)Hospital codesSI001B (1/13)SI004C (1/9)SI005A (6/49)SI001 (24/165)SI001A (44/354)SI001C (3/23)SI002 (4/23)SI009A (6/45)SI003 (10/55)SI008A (12/72)SI007A (7/41)SI009 (8/26)SI004B (2/11)0 25 50 75 1000 25 50 75 100% penicillin non-susceptible % MRSA186

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)SI004C (1/18)SI010A (7/59)N hospitals 15Minimum 5.6First quartile 15.8Median 19.6Third quartile 23.4Maximum 30.7SI011A (0/9)N hospitals 11Minimum 0First quartile 8.7Median 14.3Third quartile 36.8Maximum 54.5SI009A (2/24)SI011A (16/116)SI004B (6/38)SI008A (2/23)SI002A (21/133)SI002A (2/16)SI001C (8/48)SI004A (6/44)SI004A (36/199)Hospital codesSI003A (55/280)Hospital codesSI001B (3/21)SI003B (8/39)SI007A (2/12)SI008A (23/109)SI001A (31/137)SI001A (118/558)SI005A (18/77)SI001C (7/19)SI001B (10/42)SI003A (50/100)SI009A (41/163)SI007A (23/75)SI005A (6/11)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance187

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSpainGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 35 656 36 1 391 29 2 650 36 608 - - - -2004 36 684 36 1 527 36 3 471 36 710 - - - -2005 34 740 34 1 337 34 2 997 35 623 14 56 13 702006 35 625 35 1 483 35 3 364 34 755 33 564 32 4052007 35 862 35 1 645 35 3 678 35 885 33 618 35 4482008 31 695 32 1 505 32 3 626 32 1 002 30 639 32 5482009 32 708 33 1 715 33 3 821 33 1 093 32 628 33 5442010 41 862 41 1 986 41 5 696 41 1 467 41 1 161 41 7492011 40 763 40 1 965 40 5 605 39 1 478 40 1 145 40 839Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 7 9 9 8 8 7 8 10 10Penicillin RI 32 29 25 27 22 23 22 30 30Macrolides RI 27 27 23 22 18 22 19 27 25Staphylococcus aureusOxacillin/Meticillin R 24 26 27 25 25 27 26 25 22Escherichia coliAminopenicilins R 58 60 62 64 62 63 65 65 66Aminoglycosides R 7 7 10 9 10 11 13 14 15Fluoroquinolones R 21 25 28 28 30 33 31 33 34Third-gen. cephalosporins R 4 7 8 7 7 9 11 12 12Carbapenems R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 92 30 100 24 100 34 100 0 100 1 99 12 98 17CSF 8 32 - -

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSpainFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesES047 (1/15)ES062 (6/64)ES005 (7/61)ES016 (1/8)ES010 (5/35)ES057 (2/13)ES059 (7/31)ES043 (5/22)ES042 (18/79)ES011 (13/54)ES044 (11/43)ES054 (28/108)ES032 (6/23)ES021 (16/61)ES026 (4/15)ES058 (18/67)ES064 (20/73)ES012 (8/27)ES048 (18/60)ES049 (3/10)ES065 (7/23)ES019 (12/39)ES046 (12/38)ES041 (6/19)ES060 (8/24)ES018 (5/15)ES031 (26/78)ES029 (8/23)ES038 (24/68)ES020 (10/28)ES004 (13/34)ES056 (18/45)ES015 (4/10)ES017 (5/12)ES053 (23/55)ES051 (3/7)ES002 (13/29)ES061 (51/113)ES063 (18/38)ES003 (15/27)N laboratories 40Minimum 6.7First quartile 24.8Median 30.2Third quartile 37Maximum 55.60 25 50 75 100Hospital codesES0043 (1/29)ES0046 (1/26)ES020A (1/13)ES048A (3/35)ES046A (3/32)ES0042 (5/47)ES015A (1/8)ES0061 (14/101)ES0044 (7/46)N hospitals 82Minimum 3.4First quartile 18Median 23.5Third quartile 30.6Maximum 66.7ES0063 (7/46)ES021A (13/85)ES032A (2/13)ES0020 (2/13)ES0048 (6/38)ES0049 (6/37)ES043A (5/30)ES0018 (6/36)ES0051 (2/12)ES0038 (11/63)ES058A (12/68)ES0041 (11/61)ES0053 (22/122)ES0032 (4/22)ES0060 (10/54)ES005A (5/27)ES061A (24/128)ES010A (7/37)ES005 (4/21)ES0021 (15/78)ES060A (17/86)ES051A (3/15)ES031A (22/110)ES0062 (19/92)ES053A (13/62)ES054A (17/80)ES047A (5/23)ES0026 (17/77)ES0010 (8/36)ES042A (12/53)ES0019 (19/83)ES0064 (11/48)ES0058 (14/58)ES004 (21/86)ES019A (28/114)ES0056 (17/67)ES013A (11/42)ES044A (10/38)ES038A (14/53)ES064A (9/34)ES0054 (20/75)ES018A (8/30)ES002 (11/40)ES063A (11/40)ES011A (12/43)ES0057 (7/25)ES004A (18/63)ES0015 (2/7)ES0059 (7/24)ES003 (5/17)ES016A (9/30)ES012A (15/50)ES062A (19/62)ES003A (5/16)ES0031 (24/76)ES056A (18/57)ES041A (20/63)ES0011 (14/44)ES0013 (15/46)ES026A (28/84)ES0012 (15/45)ES057A (6/18)ES017A (13/37)ES0029 (11/31)ES0017 (10/27)ES065A (28/73)ES002A (15/39)ES0065 (33/84)ES0047 (2/5)ES029A (15/36)ES049A (13/31)ES059A (11/24)ES032B (4/6)0 25 50 75 100% penicillin non-susceptible % MRSA190

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesES021B (0/6)ES0026 (17/96)ES026A (23/118)ES020A (1/5)ES064A (29/134)ES0011 (40/181)ES065A (34/151)ES0015 (5/22)ES0064 (33/143)ES013A (16/65)ES060A (33/134)ES058A (41/165)ES062A (51/204)ES011A (44/167)ES0010 (35/131)ES038A (49/182)ES0021 (68/239)ES029A (20/69)ES032A (25/86)ES048A (33/113)ES019A (94/317)ES0065 (35/118)ES0013 (18/60)ES0018 (42/139)ES041A (35/115)ES0012 (43/140)ES0062 (59/192)ES010A (38/123)ES015A (9/29)ES054A (111/354)ES018A (39/124)ES0053 (74/235)ES0046 (24/76)ES0032 (26/80)ES061A (93/280)ES0048 (47/141)ES0043 (43/128)ES043A (43/128)ES005 (39/116)ES0019 (109/324)ES005A (47/138)ES057A (29/85)ES042A (86/251)ES0060 (40/116)ES002 (48/139)ES021A (86/249)N hospitals 83Minimum 0First quartile 29.7Median 34.1Third quartile 39.2Maximum 75ES0061 (109/314)ES0058 (60/171)ES046A (19/54)ES016A (36/102)ES003A (30/85)ES063A (27/76)ES0041 (46/129)ES053A (57/159)ES031A (84/232)ES0049 (22/60)ES0042 (106/289)ES004 (61/164)ES002A (63/169)ES0038 (68/180)ES0059 (40/104)ES0044 (58/149)ES0063 (47/120)ES059A (40/102)ES0054 (132/335)ES003 (30/76)ES047A (17/43)ES044A (65/162)ES004A (72/177)ES0031 (82/200)ES032B (7/17)ES012A (56/135)ES0057 (30/72)ES0017 (31/74)ES0029 (24/57)ES0051 (13/29)ES017A (26/58)ES051A (18/39)ES049A (25/53)ES056A (114/241)ES0056 (104/212)ES0047 (7/14)ES051E (12/16)0 25 50 75 100Hospital codesES0011 (0/22)ES046A (0/22)ES0048 (0/30)ES015A (0/7)ES005 (0/20)ES0032 (0/12)ES051E (0/6)ES064A (0/16)N hospitals 78Minimum 0First quartile 3.8Median 6.7Third quartile 15.2Maximum 40ES051A (0/8)ES0051 (0/10)ES032A (0/16)ES029A (0/8)ES057A (0/10)ES017A (0/7)ES0064 (0/22)ES0057 (0/6)ES0053 (1/41)ES063A (1/31)ES0021 (1/27)ES0018 (1/26)ES048A (1/25)ES0058 (2/47)ES011A (1/22)ES0012 (1/21)ES012A (1/21)ES019A (1/20)ES004A (1/20)ES0041 (1/19)ES002 (1/18)ES0010 (1/18)ES041A (2/35)ES0026 (2/34)ES053A (2/34)ES0013 (1/16)ES0049 (1/15)ES0063 (3/45)ES010A (1/15)ES0059 (1/15)ES002A (2/30)ES061A (8/119)ES059A (1/14)ES049A (1/14)ES005A (2/26)ES058A (3/34)ES0065 (2/22)ES042A (5/53)ES065A (2/19)ES0054 (6/56)ES062A (8/73)ES026A (3/27)ES0015 (1/9)ES0017 (1/9)ES021A (3/26)ES0061 (16/134)ES054A (8/64)ES0019 (1/8)ES038A (6/40)ES056A (7/46)ES0044 (7/46)ES0062 (11/72)ES013A (3/19)ES044A (7/42)ES0043 (5/29)ES003A (3/17)ES060A (8/43)ES031A (14/72)ES016A (2/10)ES018A (4/19)ES0046 (4/18)ES003 (3/13)ES043A (7/29)ES0056 (11/45)ES0042 (11/40)ES0060 (7/25)ES004 (10/33)ES0031 (15/46)ES0038 (22/59)ES0029 (2/5)0 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance191

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSwedenGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 21 919 21 1 855 21 3 350 21 850 - - - -2004 21 955 21 1 906 21 3 372 21 856 - - - -2005 21 1025 21 1 774 21 3 241 21 821 18 282 17 1492006 21 996 21 1 968 20 3 539 21 884 20 621 18 3002007 21 1 032 21 2 163 20 3 749 21 932 20 649 20 3432008 21 1 219 21 2 410 20 4 032 21 1 059 20 826 20 3152009 19 1 063 19 2 460 18 4 247 19 967 18 706 18 3382010 19 1 008 19 2 867 18 4 846 18 1 038 18 878 18 3772011 18 1 015 18 3 113 17 5 253 18 1 239 17 966 17 412Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 98 4 100 1 100 9 100 0 100 0 100 2 100 6CSF 2 5 - - 0 0 - - - - - - - -GenderMale 53 4 63 1 50 12 73 0 61 0 60 3 69 6Female 47 3 37 1 50 6 27 0 39 0 40 1 31 6Age (years)0–4 3 5 4 0 1 8 3 0 2 0 1 0 2 145–19 2 3 3 1 1 12 1 0 2 0 1 8 3 820–64 40 3 30 1 23 12 23 0 29 0 25 3 25 765 and over 54 4 63 1 73 8 72 0 65 0 72 2 69 6Unknown 1 5 1 0 2 8 1 0 1 0 1 0 1 13Hospital departmentICU 6 3 4 1 3 8 6 0 12 0 4 6 5 15Internal med. 36 3 34 0 32 7 28 0 24 0 27 2 32 5Surgery 3 7 12 0 15 10 20 0 26 0 21 0 13 3Other 49 4 44 1 39 10 40 0 34 0 39 3 44 6Unknown 6 3 7 1 11 7 7 0 4 0 9 2 6 12PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistantEnterococcus; 3GCRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenem-resistant P. aeruginosa.193

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTSwedenFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesSE540 (0/15)SE230 (0/48)SE600 (1/92)SE450 (1/79)SE240 (1/71)SE110 (1/64)SE250 (1/56)SE320 (2/92)SE730 (2/87)SE440 (3/122)SE610 (2/79)SE350 (3/102)SE620 (3/91)SE120 (9/263)SE400 (5/125)SE200 (6/134)SE310 (5/76)SE430 (4/58)SE100 (22/319)N laboratories 19Minimum 0First quartile 1.4Median 2.5Third quartile 4Maximum 6.90 25 50 75 100Hospital codesSE440B (0/54)SE350B (0/73)SE610B (0/51)SE100E (0/251)SE400B (0/117)SE730E (0/44)SE250B (0/73)SE220B (0/72)SE310A (0/70)SE230B (0/12)SE400X (0/37)SE600C (0/34)SE610A (0/194)SE730C (0/28)SE620A (0/163)SE450C (0/23)SE730F (0/91)SE610C (0/97)SE350C (0/113)SE200C (0/47)SE220C (0/22)SE100C (0/52)SE450D (0/38)SE730B (0/30)SE730D (0/17)SE620B (0/18)SE100G (0/16)SE110B (0/38)SE400C (0/28)SE110A (0/86)SE240C (0/40)SE440C (0/33)SE120B (0/40)SE100I (0/11)SE220A (0/126)SE620D (0/12)SE620C (0/61)SE200B (0/166)SE450B (0/11)SE200D (0/7)SE600A (1/282)SE120A (1/282)SE320A (1/194)SE430A (1/193)SE440A (1/174)SE200A (2/255)SE230A (1/116)SE310B (2/211)SE100B (2/199)SE450A (2/161)SE250A (2/150)SE100D (3/223)SE350A (2/147)SE400A (2/129)SE100A (6/368)SE240A (3/136)SE320B (1/42)SE100F (1/38)SE540A (2/62)SE430D (2/55)SE240B (1/25)N hospitals 61Minimum 0First quartile 0Median 0Third quartile 0.8Maximum 40 25 50 75 100% penicillin non-susceptible % MRSA194

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)Hospital codesSE100D (0/10)SE620B (0/41)SE240C (1/47)SE610B (1/39)SE730B (1/38)SE440B (3/102)SE450C (1/33)SE730C (2/50)SE320A (6/125)SE100C (1/20)SE450A (15/287)SE730D (2/37)SE450B (2/35)SE220B (1/17)SE240B (1/17)SE440C (4/67)SE610C (5/83)SE240A (7/112)SE200C (4/60)SE350C (5/75)SE230B (1/15)SE610A (9/135)SE620C (6/88)SE730E (5/69)SE310B (19/255)SE730F (12/159)SE200B (19/243)SE440A (22/279)SE110A (14/176)SE540A (7/88)SE400B (18/224)SE400C (8/95)SE620A (19/224)SE320B (3/35)SE120A (5/55)SE350A (11/120)SE430D (8/85)SE350B (7/69)SE450D (7/65)SE230A (5/44)SE430A (39/338)SE110B (8/68)SE400A (33/279)SE100B (14/115)SE200A (41/318)SE200D (2/15)SE310A (5/35)SE220A (34/201)SE220C (9/53)SE620D (3/17)SE100E (2/11)SE100A (27/137)SE120B (3/10)N hospitals 53Minimum 0First quartile 5.9Median 7.8Third quartile 11.4Maximum 300 25 50 75 100Hospital codesSE620A (0/44)SE450B (0/11)SE220A (0/46)SE240C (0/19)SE440B (0/12)SE450D (0/17)SE310B (0/57)SE450C (0/8)SE430D (0/12)SE400C (0/9)SE250A (0/44)SE730E (0/11)SE350B (0/17)SE320B (0/21)SE620B (0/5)SE230A (0/32)SE100E (0/6)SE610A (0/47)SE610C (0/20)SE730C (0/10)SE440C (0/19)SE110B (0/9)SE100A (0/38)SE440A (0/53)SE220C (0/11)SE350A (0/45)SE200C (0/10)SE220B (0/7)SE100D (0/7)SE250B (0/29)SE730F (0/36)SE310A (0/25)SE610B (0/8)SE200A (2/97)SE350C (1/34)SE200B (2/60)SE320A (2/60)SE430A (2/59)SE540A (1/24)SE400B (2/45)SE400X (1/21)SE240A (2/40)SE450A (4/73)SE100B (1/18)SE400A (4/70)SE110A (2/35)SE620C (1/16)SE120A (1/13)SE730D (1/6)N hospitals 49Minimum 0First quartile 0Median 0Third quartile 3.3Maximum 16.70 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance195

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTUnited KingdomGeneral information about EARS-Net participating laboratoriesTable 1: Annual number of reporting laboratories and number of reported isolates, 2003–2011YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates2003 50 1 334 51 3 548 19 2 253 - - - - - -2004 54 1 059 54 3 562 20 2 091 - - - - - -2005 53 1 375 58 3 971 23 2 359 27 591 23 420 25 4382006 51 1 514 55 4 132 26 2 438 22 547 22 404 24 3532007 50 1 785 55 4 865 20 2 374 18 435 18 382 19 3702008 51 1 223 55 3 355 15 2 456 14 274 15 350 14 3452009 59 1 396 69 2 977 28 4 712 26 712 27 725 26 6392010 50 1 459 55 2 730 29 5 389 28 651 28 840 28 5882011 53 1 513 53 3 430 29 5 971 28 723 28 1 007 28 599Antibiotic resistance from 2003 to 2011Table 2: Annual percentage (%) of antimicrobial non-susceptible and resistant isolates, 2003–2011Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010 2011Streptococcus pneumoniaePenicillin R 1

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Demographic characteristicsTable 3: Selected details on invasive isolates reported for 2010 and 2011CharacteristicS. pneumoniae S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % 3GCRKP % total % CRPAIsolate sourceBlood 99 4 100 17 100 17 100 2 100 10 100 7 100 6CSF 1 7 - - - - - - - - - - - -GenderMale 51 4 61 18 48 20 65 0 63 8 59 8 61 6Female 48 4 39 16 52 15 35 3 37 12 41 6 39 6Unknown 1 0

Antimicrobial resistance surveillance in Europe 2011SURVEILLANCE REPORTUnited KingdomFigure 1: S. pneumoniae: percentage (%) of invasiveisolates with penicillin non-susceptibility by laboratory(2010–2011)Figure 2: S. aureus: percentage (%) of invasive isolateswith resistance to meticillin (MRSA) by hospital(2010–2011)Laboratory codesUK059 (0/56)UK096 (0/51)UK054 (0/27)UK023 (0/38)UK091 (0/101)UK102 (0/11)UK033 (0/20)UK046 (0/24)UK011 (0/28)UK026 (0/27)UK097 (0/48)UK042 (0/25)UK027 (0/22)UK101 (1/105)UK093 (1/85)UK051 (1/77)UK094 (1/56)UK015 (2/107)UK017 (1/53)UK008 (1/53)UK099 (3/143)UK004 (1/45)UK092 (2/84)UK069 (1/42)UK052 (1/34)UK007 (4/129)UK100 (1/25)UK020 (2/49)UK049 (1/24)UK047 (5/91)UK001 (1/18)UK012 (4/72)UK043 (4/68)UK053 (2/34)UK064 (4/65)UK066 (2/32)UK057 (2/31)UK055 (1/15)UK098 (4/59)UK090 (2/28)UK045 (7/93)UK078 (6/75)UK050 (4/50)UK056 (1/12)UK010 (1/12)UK068 (11/119)UK063 (3/24)UK032 (7/56)UK076 (5/38)UK048 (4/25)UK084 (6/35)UK075 (2/10)N laboratories 52Minimum 0First quartile 0.5Median 3.6Third quartile 7Maximum 200 25 50 75 100Hospital codesUK027X (0/33)UK017X (0/74)UK053X (0/13)UK032X (0/75)UK072A (0/19)UK015X (0/168)UK008X (0/32)UK047B (0/5)UK090X (0/41)N hospitals 92Minimum 0First quartile 9Median 15.9Third quartile 26.5Maximum 100UK020X (0/26)UK052A (1/34)UK055A (1/32)UK045X (3/91)UK001X (1/30)UK066A (2/41)UK026X (7/128)UK050A (5/81)UK092X (9/138)UK096X (7/94)UK049A (3/40)UK102X (9/103)UK054A (7/80)UK033X (9/102)UK052X (1/11)UK053D (6/63)UK064A (13/135)UK091X (20/205)UK078C (2/20)UK044B (1/9)UK004X (13/116)UK097X (10/82)UK045A (26/209)UK098X (16/126)UK012X (10/76)UK055X (2/15)UK066X (2/15)UK100X (9/67)UK059A (17/125)UK003X (3/22)UK084B (1/7)UK072X (1/7)UK059X (10/65)UK049X (4/26)UK093X (28/180)UK051A (19/122)UK046X (5/32)UK101X (45/279)UK048X (3/18)UK099X (39/224)UK068B (52/295)UK050X (5/28)UK047X (21/116)UK063A (8/44)UK069X (11/58)UK051X (11/57)UK068X (32/164)UK044D (3/15)UK064X (15/75)UK056X (2/10)UK075A (11/54)UK048A (11/53)UK047A (57/273)UK063X (4/19)UK044C (2/9)UK056A (24/107)UK054X (9/36)UK083A (23/91)UK084A (27/104)UK044A (24/91)UK076D (4/15)UK057A (11/41)UK069A (23/82)UK076A (14/47)UK057X (4/13)UK078A (42/130)UK079A (3/9)UK078B (2/6)UK046A (10/28)UK077A (14/37)UK081A (5/13)UK080A (17/41)UK011A (9/10)UK043X (16/17)UK094X (24/25)UK023A (5/5)UK017B (24/24)UK023B (6/6)UK008A (12/12)UK032A (8/8)UK007A (13/13)UK015A (7/7)UK007B (12/12)0 25 50 75 100% penicillin non-susceptible % MRSA100% meticillin resistance rates for isolates of S. aureus reflect reporting ofMRSA only.198

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2011Figure 3: E. coli: percentage (%) of invasive isolateswith resistance to fluoroquinolones by hospital(2010–2011)Figure 4: K. pneumoniae: percentage (%) of invasiveisolates with resistance to third-generationcephalosporins by hospital (2010–2011)UK023X (42/429)UK004X (17/169)UK090X (25/246)N hospitals 29Minimum 9.8First quartile 13.3Median 17.2Third quartile 21.2Maximum 49UK023X (0/52)UK003X (0/12)UK017X (1/86)N hospitals 25Minimum 0First quartile 2.8Median 6.6Third quartile 9.4Maximum 83.3UK001X (13/124)UK093X (46/434)UK033X (1/47)UK017X (47/423)UK008X (1/37)UK098X (61/499)UK032X (3/109)UK032X (88/664)UK004X (1/36)UK008X (31/231)UK020X (1/29)UK033X (36/266)UK027X (1/25)UK097X (43/290)UK026X (70/451)UK092X (2/40)UK100X (29/183)UK096X (2/35)Hospital codesUK020X (32/195)UK092X (68/396)UK011X (49/275)Hospital codesUK098X (5/78)UK015X (12/182)UK101X (11/157)UK015X (201/1102)UK102X (44/233)UK091X (104/545)UK012X (83/405)UK003X (31/147)UK012X (3/42)UK026X (8/110)UK093X (6/81)UK042X (4/49)UK101X (164/775)UK097X (3/32)UK042X (58/273)UK096X (59/270)UK099X (190/826)UK007X (19/78)UK027X (42/155)UK094X (66/191)UK043X (51/104)UK102X (5/49)UK091X (18/174)UK099X (12/116)UK011X (8/46)UK100X (7/39)UK094X (5/6)0 25 50 75 1000 25 50 75 100% fluoroquinolone resistance % third-generation cephalosporin resistance199