EARSS Annual Report 2002 - European Centre for Disease ...

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EARSS Annual Report 2002 - European Centre for Disease ...

EARSS Annual Report 2002

• The European Antimicrobial Resistance Surveillance System (EARSS), funded by DG SANCO

of the European Commission, is an international network of national surveillance systems which

collects comparable and validated antimicrobial susceptibility data for public health action.

EARSS performs on-going surveillance of antimicrobial susceptibility in Streptococcus

pneumoniae, Staphylococcus aureus, Escherichia coli, and Enterococcus faecalis/faecium

causing invasive infections and monitors variations of antimicrobial resistance over time and

from place to place.

• By December 2002, about 700 microbiological laboratories serving some 1100 hospitals from

28 countries had provided susceptibility data on about 120 000 invasive isolates.

• An interactive Website where up-to-date details can be found on country-specific resistance

levels for important groups of antibiotics is available at http://www.earss.rivm.nl.

Period of data collection: January 1999 – December 2002

This document was prepared by the EARSS Management Team, members of the Advisory Board,

and national representatives of EARSS, Bilthoven, The Netherlands, August 2003.

ISBN number: 90-6960-107-9


Funded by the European Commission under SI2.324194 (2001CVG4-011)

European Antimicrobial Resistance Surveillance System (EARSS)

Contractor

RIVM (Rijksinstituut voor Volksgezondheid en Milieu)

National Institute of Public Health and the Environment

EARSS thanks both the European Commission and the Dutch Ministry of Health, Welfare and

Sports for their financial support.

Neither the European Commission nor any person acting on its behalf is liable for the

consequences of any use made of this information.


CONTENTS 3

Contents

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

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

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

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

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

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

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

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

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

Chapter 4. Quality and comparability of antimicrobial susceptibility testing (AST)

among laboratories participating in EARSS in 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

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

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


4 CONTENTS

Appendix A. Country Summary Sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Explanation to the Country Summary Sheets

Austria……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Bulgaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Croatia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Czech Republic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Denmark……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Estonia……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Finland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

France……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

Germany……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

Hungary……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Iceland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

Ireland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78

Israel……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80

Italy……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

Luxembourg……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

Malta……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86

Netherlands……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Norway……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

Poland……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Portugal……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94

Romania……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Slovakia……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98

Slovenia……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100

Spain……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102

Sweden……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

United Kingdom……………………………………………………… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

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

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


Acknowledgement 5

Acknowledgements

May I take this opportunity to express my gratitude to all national representatives, national data

managers and participating laboratories for their enthusiasm and willingness to share the

antimicrobial susceptibility data, for their participation in the external quality control exercise and

for providing the background information requested by the laboratory hospital questionnaire.

I thank UK-NEQAS for their major role in preparing and organising the third successive external

quality assurance (EQA) exercise in close cooperation with the members of the EARSS EQA

committee. I would like to thank the various members of the EARSS Advisory Board and the

EARSS Management Team for sharing their expertise, for their contribution to this report and also

for making the activities organised within EARSS successful during the past year. Furthermore, I

would like to thank John Stelling for visiting many participating countries to give WHONET support

for EARSS and Bennie Bloemberg for his technical support in developing the country summary

sheets that are a substantial part of this report.

Finally, I would like to thank you all for your extremely professional collaborative effort to the

unique and well-functioning EARSS network, which now includes more than 700 laboratories in 28

countries. I look forward to continuing this fruitful cooperation for many years to come.

Hajo Grundmann

EARSS Project Leader

Department of Infectious Diseases Epidemiology

National Institute of Public Health and the Environment


6 Summary

Summary

The European Antimicrobial Resistance Surveillance System (EARSS) is an international network

funded by the Director General for Health and Consumer Protection (DG SANCO) of the European

Commission and the Dutch Ministry of Health, Welfare and Sports. It maintains a comprehensive

surveillance and information system that links national networks by providing comparable and

validated data on the prevalence and spread of major invasive bacteria with clinically and

epidemiologically relevant antimicrobial resistance in Europe.

EARSS collects routinely generated antimicrobial susceptibility testing (AST) data, provides spatial

trend analyses and makes up-to-date feedback available via an interactive Website at

http://www.earss.rivm.nl. Over 700 laboratories serving 1100 hospitals in 28 European countries

regularly submit routine data for major indicator pathogens (Streptococcus pneumoniae,

Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, and Escherichia coli). On the

basis of the 2002 laboratory/hospital questionnaire, the overall hospital catchment population of the

EARSS network is estimated at more than 100 million inhabitants in the European region, with

national coverage rates that range between 20% and 100% for individual countries. In 2002, 93% of

the eligible laboratories also participated in the annual external quality assurance (EQA) exercise,

which is jointly organised by EARSS, the United Kingdom External Quality Assurance Scheme (UK-

NEQAS) and the Centre Réfèrence des Antibiotiques (CRAB). Despite the different guidelines used

in various countries, the overall concordance of susceptibility results was of sufficient quality, which

shows that pooling and analysis of EARSS surveillance data render valid results for most pathogenspecific

susceptibility data.

For the last 4 years, the resistance showed a clear north–south gradient for penicillin non-susceptible

S. pneumoniae (PNSP), with high levels of macrolide co-resistance in several of the southern and

the northern countries. The dynamics of the global epidemic of methicillin-restistant S. aureus

(MRSA) has slowed down in the United Kingdom and Ireland, but it showed the fastest increasing

proportions in Germany and Austria between 1999 and 2002. Scandinavian countries have been

spared from this trend, but the Netherlands saw the beginning of a trend towards higher MRSA rates

in 2002. Vancomycin-resistant enterococci (VRE), with proportions less than 10% in most countries,

have been reported. The six countries that reported higher rates of VRE also had large MRSA

proportions, which suggests an epidemiological association. E. coli resistance to the

aminopenicillins is common in the European region; only Finland and Sweden report proportions of

less than 30%. Resistance of E. coli to third-generation cephalosporins remained less than 6% in

most countries. Greater proportions were noted for some eastern European countries that appeared

to have problems with extended spectrum beta-lactamase (ESBL)-producing strains. However, there

was a consistent and marked rise in fluoroquinolone-resistant E. coli in most European countries,

eight of which witnessed an 1.5-fold increase or more in only 2 years (2001 – 2002). This trend may

to be related to the widespread acceptance and use of newer fluoroquinolones with enhanced activity

against gram-positive pathogens. We predict that both hospital and community-acquired E. coli

infection may become a new challenge as a pathogen that will be difficult to treat in the European

region in the years to come.

EARSS has become an internationally accepted surveillance initiative, which provides meaningful

information about the status and trends of antimicrobial resistance in the European region. The

possible relationship between antimicrobial resistance and consumption will be explored in close


Summary 7

cooperation with European Surveillance of Antimicrobial Consumption (ESAC). We envision

EARSS serving as a platform for the detection and identification of clones with particular

importance to public health in terms of antimicrobial resistance and virulence properties.

The EARSS 2002 annual report would not have been possible without the financial support of DG

SANCO of the European Commission (SI2.324194/2001CVG4 – 011) and the Dutch Ministry of

Health, Welfare and Sports.


8 Annual report EARSS 2002

List of abbreviations and acronyms

AMR Antimicrobial resistance

ARMed Antibiotic resistance surveillance and control in the Mediterranean region

AST Antimicrobial susceptibility testing

BSAC British Society for Antimicrobial Chemotherapy

CA-SFM Comité de l’Ántibiogramme de la Société Française de Microbiologie

CRAB Centre National de Réfèrence des Antibiotiques

CRG Commissie Richtlijnen Gevoeligheidsbepalingen

CZECH Czech Republic antimicrobial susceptibility guideline

CSF Cerebrospinal fluid

DCFP Data check and feedback program

DEFS Data Entry & Feedback Software

DG SANCO Directorate General for Health and Consumer Protection

EARSS European Antimicrobial Resistance Surveillance System

EARSS-MT EARSS Management Team

ENSP Erythromycin nonsusceptible Streptococcus pneumoniae

EQA External Quality Assurance

ESAC European Surveillance of Antimicrobial Consumption

ESBL Extended-spectrum beta-lactamase

ESCMID European Society of Clinical Microbiology and Infectious Diseases

ESGARS ESCMID Study Group for Antimicrobial Resistance Surveillance

EUCAST European Committee on Antimicrobial Susceptibility Testing

FREC Fluoroquinoloneresistant Escherichia coli

HLAR HighLevel Aminoglycoside resistance

ICM Intersectoral Coordinating Mechanisms

ICU Intensive care unit

MENSURA Mesa Espanola de Normalización de la Sensibilidad y Resistencia a los

Antimicrobianos

MIC Minimal inhibitory concentration

MRSA Methicillin-resistant Staphylococcus aureus

NCCLS (American) National Committee for Clinical Laboratory Standards

PNSP Penicillin nonsusceptible Streptococcus pneumoniae

RIVM Rijksinstituut voor Volksgezondheid en Milieu

(National Institute for Public Health and the Environment)

SAR Self-medication with antibiotics and resistance

SRGA Swedish Reference Group for Antibiotics

UK-NEQAS United Kingdom National External Quality Assessment Scheme for

Microbiology

VRE Vancomycin-resistant enterococci

VRSA Vancomycin-resistant Staphylococcus aureus

WHO World Health Organization

WHONET WHO microbiology laboratory database software


The EARSS Network in 2002 9

The EARSS Network in 2002

Countries participating in EARSS in 2002

Austria AT

Belgium BE

Bulgaria BG

Croatia HR

Czech Republic CZ

Denmark DK

Estonia EE

Finland FI

France FR

Germany DE

Greece GR

Hungary HU

Iceland IS

Ireland IE

* UK data from England and Wales only.

EARSS Management Team in 2002

Israel IL

Italy IT

Luxembourg LU

Malta MT

Netherlands NL

Norway NO

Poland PL

Portugal PT

Romania RO

Slovakia SK

Slovenia SI

Spain ES

Sweden SE

United Kingdom UK*

Project leader: S. Bronzwaer (January to April 2002)

H. Grundmann (since March 2003)

Coordinator and International Data Manager P. Schrijnemakers

Epidemiologists N. Bruinsma and E. Tiemersma

Data Manager and Software Engineer J. Monen

Management Assistant C. Schinkel

Consultant Medical Microbiologist: J. Degener

E-mail: info.earss@rivm.nl

Post: National Institute for Public Health and the Environment (RIVM)

Antonie van Leeuwenhoeklaan 9

PO Box 1

3720 BA Bilthoven

The Netherlands

Phone: +31 30 274 4068

Fax: +31 30 274 4409

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


10 Annual report EARSS 2002

EARSS Advisory Board Members in 2002

Name On behalf of Country Profession

H. Mittermayer EARSS national representatives Austria Microbiologist

G. Cornaglia ESCMID Italy Microbiologist

F. Baquero ESGARS Spain Microbiologist

W. Hryniewicz EARSS national representatives Poland Microbiologist

O. Lyytikäinen EARSS national representatives Finland Epidemiologist

G. Kahlmeter EUCAST Sweden Microbiologist

K. Kristinsson EARSS national representatives Iceland Microbiologist

EARSS EQA Committee in 2002

P. Courvalin Unité des Agents Antibactériens, Institut Pasteur, France

G. Cornaglia Università degli Studi di Verona, Istituto de Microbiologia, Italy

J. Degener Department of Medical Microbiology, Groningen University Hospital, The

Netherlands

G. Kahlmeter Central Hospital Växjö, Sweden

J. Mouton Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

C. Walton Quality Assurance Laboratory, Central Public Health Laboratory, United

Kingdom

S. Bronzwaer Department of Infectious Diseases Epidemiology, RIVM, The Netherlands

P. Schrijnemakers Department of Infectious Diseases Epidemiology, RIVM, The Netherlands


Annual report EARSS 2002 11

EARSS National Representatives in 2002

Austria (AT) Estonia (EE) Ireland (IE) Netherlands (NL) Slovenia (SI)

H. Mittermayer P. Naaber D. O’ Flanagan E. Tiemersma M. Gubina

W. Koller O. Murphy A. de Neeling

Belgium (BE) Finland (FI) Iceland (IS) Norway (NO) Slovakia (SK)

H. Goossens O. Lyytikäinen K. Kristinsson A. Hoiby L. Langsadl

E. Hendrickx A. Nissinen E. Bjørløw

Bulgaria (BG) France (FR) Israel (IL) Poland (PL) Spain (ES)

B. Markova H. Aubry-Damon R. Raz W. Hryniewicz F. Baquero

P. Courvalin J. Campos

Croatia (HR) Germany (DE) Italy (IT) Portugal (PT) Sweden (SE)

S. Kalenic W. Witte G. Cornaglia M. Caniça B. Liljequist

A.Tambic U. Buchholz P. D’Ancona

Andrasevic

Czech Republic Greece (GR) Luxembourg (LU) Rumania (RO) United Kingdom

(CZ) N. Legakis R. Hemmer I. Codita (UK)

P. Urbaskova G. Vatopoulos A. Johnson

M. Wale

Denmark (DK) Hungary (HU) Malta (MT)

D. Monnet M. Füzi M. Borg

Other parties and representatives

WHO WHONET UK-NEQAS

P. Jenkins J. Stelling C.Walton


12 Annual report EARSS 2002

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

Contact Institute Country National URL

person surveillance

network

S. Metz Elisabethinen Hospital

Linz

Austria EARSS Austria

E. Hendrickx Scientific Institute of

Public Health

Belgium EARSS Belgium www.iph.fgov.be/

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

B. Markova Laboratory for Clinical

Microbiology, Sofia

S. Kalenic Clinical Hospital

Centre Zagreb

Croatia EARSS Croatia

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

Public Health Republic Laboratory for

Antibiotics

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

P. Naaber Tartu University Clinics Estonia EARSS Estonia

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

Program (SIRO)

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

for Antimicrobial

Resistance (FiRe)

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

V. Jarlier National Institut of France ONERBA

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

E.Varon Surveillance (InVS) Centre for

pneumococci

www.invs.sante.fr

U. Buchholz Robert Koch-Institute Germany EARSS Germany

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

& Epidemiology, Medical for the Surveillance of

School, Athens University, Antimicrobial Resistance

(WHONET Greece)

S. Vegh National Centre for

Epidemiology

Hungary EARSS Hungary www.antsz.hu

K. Kristinsson Landspitali University

Hospital

Iceland

S. Murchan National Disease

Surveillance Centre

Ireland EARSS Ireland www.ndsc.ie

R. Raz Ha’Emek Medical

Center

Israel EARSS Israel

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

A. Pantos Sanità resistenza.htm

O. Courteille National Service of

Infectious Diseases

Luxembourg EARSS Luxembourg

E. Scicluna Infection Control Unit,

St Luke’s Hospital

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


Annual report EARSS 2002 13

Contact Institute Country National URL

person surveillance

network

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

Public Health and surveillance in the

the Environment Netherlands

A. de Neeling Resistance

determination project

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

of Public Health MSIS

P. Grzesiowski National Institute

of Public Health

Poland OPTY www.cls.edu.pl/surveillance

M. Caniça National Institute of Portugal GEMVSA/EARSS

P. Lavado Health Dr. Ricardo Jorge Portugal

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

C. Balotescu Research and Development

in Microbiology and

Immunology Cantacuzino

L. Langsadl National Institute for

TB and Respiratory

Diseases

Slovakia EARSS-Slovakia www.nutarch.sk

J. Kolman Institute of Microbiology Slovenia EARSS Slovenia

M. Gubina and Immunology,

Medical Faculty, University

of Ljubljana

J. Oteo Instituto de Salud

Carlos III

Spain EARSS Spain

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

Liljequist Infectious Disease

Control

S. Cavendish Public Health United PHLS-AmSSU

Laboratory Service Kingdom


CHAPTER 1. Introduction 15

CHAPTER 1. Introduction

Antimicrobial resistance (AMR) challenges the effectiveness of successful treatment of bacterial

infections and is a public health issue with local, national and international dimensions. During the

‘Microbial Threat Conference’, held in September 1998 in Denmark, it was announced that

‘Effective European surveillance must have the agreement and active involvement of all

participants’ (‘the Copenhagen Recommendations’ [1]). In due course, the Directorate General for

Health and Consumer Protection (DG SANCO) of the European Commission funded the European

Antimicrobial Resistance Surveillance System (EARSS). EARSS’ mission is to maintain a

comprehensive surveillance and information system that links national networks by providing

comparable and validated data about the prevalence and spread of major invasive bacteria with

clinical and epidemiologically relevant AMR in Europe. In 2001, at a follow-up EU conference in

Visby, Sweden, it was concluded that all Member States of the European Union (EU) should join the

EARSS initiative as a minimum requirement of national surveillance programmes (‘the Visby

recommendations [2]’).

EARSS is co-ordinated by the Dutch National Institute of Public Health and the Environment

(RIVM), and since its beginning in 1999, it has steadily drawn in new participants from the

European countries. At present, around 700 laboratories serving almost 1100 hospitals in 28

European countries participate. They cover an estimated population of more than 100 million

inhabitants. The EARSS database contains AMR data on approximately 120 000 invasive isolates of

four genera (Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis/faecium, and

Escherichia coli). It is thus the most comprehensive public health effort that describes and analyses

geographic and secular trends in AMR worldwide.

EARSS has encouraged and helped sustain national surveillance efforts, and the network is the

perfect basis for an integrated public health approach for AMR containment in Europe. To this end,

EARSS operates in close collaboration with other EU- financed projects: European Surveillance of

Antimicrobial Consumption (ESAC), Self-medication with Antibiotics and Resistance (SAR) and

Antibiotic Resistance Surveillance and Control in the Mediterranean region (ARMed). There is a

close partnership between the European Society of Clinical Microbiology and Infectious Diseases

(ESCMID) and two of the society’s study groups, namely, the European Committee on

Antimicrobial Susceptibility Testing (EUCAST) and the ESCMID Study Group for Antimicrobial

Resistance Surveillance (ESGARS).

This report presents an overview of activities, innovations and results of the EARSS network.

Chapter 2 summarises the objectives and methodology. Chapters 3 and 4 present reference data

regarding the participating laboratories and hospitals and the results of the annual EQA exercise for

the year 2002. Chapter 5 gives an in-depth analysis on the situation of AMR in the European region.

Chapter 6 provides recommendations and lists possible future initiatives based on these results. The

appendixes contain detailed country summary sheets, tables with data and a technical section.

Results are based on data recorded from January 1999 - December 2002, if not otherwise indicated.


16 CHAPTER 1. Introduction

References

1. V. Thamdrup Rosdahl et al. Report from the invitational EU Conference on the microbial threat,

Copenhagen, Denmark, 9-10 September 1998.

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


CHAPTER 2. The EARSS objectives and methodology 17

CHAPTER 2. The EARRS objectives and methodology

The objectives

It is the public health purpose of EARSS to assist in the control of AMR; therefore, the following

objectives have been set:

• To collect comparable and validated AMR data

• To analyse trends in time and place (among various European countries)

• To provide official national AMR data that constitute a basis for policy decisions

• To provide feedback to ‘those who need to know’

• To provide information about clinically and epidemiologically relevant AMR and to evaluate

interventions.

Furthermore, EARSS aims are:

• To encourage the implementation, maintenance and improvement of national AMR surveillance

programmes to provide timely information for national policy decisions

• To link AMR data to factors influencing the emergence and spread of AMR, particularly to

antibiotic use data, in close cooperation with the European Surveillance of Antimicrobial

Consumption (ESAC)

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

At the start of the project, the task determined for EARSS was to collect routinely generated

antimicrobial susceptibility testing (AST) data from a limited number of invasive pathogens. The

pathogens that successively became objects of surveillance within EARSS were selected according

to epidemiological (community versus hospital acquisition) and ecological (transmission versus

selection) paradigms. At the same time, the focus was set on selected clinically and

epidemiologically relevant antibiotic resistance traits. The decision to collect routine data meant that

no changes to the regular diagnostic process were needed. Therefore, the participation of many

laboratories has become feasible, and this has facilitated the probing of a substantial part of the

population in the participating countries. Sampling of the pathogens was and is restricted to invasive

(blood culture and CSF) isolates, which are routinely tested for antimicrobial susceptibility in most

laboratories. Data collection started in 1999 for S. pneumoniae and S. aureus after a preparatory

phase in 1998. The surveillance has been extended to include E. coli and enterococci (E. faecium

and E. faecalis since 2001).

The methodology

Organisation of the EARSS network

Each participating country has appointed one or two national representatives. They are medical

microbiologists and/or infectious disease epidemiologists. Moreover, each country has a national data

manager. The main task of the national representatives is to connect the EARSS-specific activities of

the participating laboratories (data collection, reporting, questionnaire completion and EQA strain and

results distribution) with the EARSS central database, which is maintained and updated by the EARSS

Management Team (EARSS-MT). The national representatives also ensure that the laboratories

generate their AST data according to the EARSS protocols, as published in the 2001 EARSS manual.


18 CHAPTER 2. The EARSS objectives and methodology

Public

WHO 1

ESCMID 2

EUCAST 3

ESAC 4

ARMed 5

SAR 6

ICMs 7

LAB 1 LAB 2 LAB 3

National Management Team

National Representative Data Manager

EARSS Management Team

DG-SANCO

Dutch Ministry of Welfare

and Sport (co-funding)

National Advisory

Board

Advisory Board

Plenary Meeting

EQA Committee 8

Figure 1. Structure of the EARSS network

1 World Health Organisation, 2 European Society for Clinical Microbiology and Infectious Diseases, 3 European

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

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

coordinating mechanisms, 8 External Quality Assurance Committee

The main task of the national data manager is to collect, approve and forward resistance data each

quarter and to assist the national representative. Protocols for standardising the data collection have

been developed with professional help from the European Society of Clinical Microbiology and

Infectious Diseases (ESCMID) and WHO microbiology laboratory database software (WHONET).

To assess the quality and comparability of AST data, an EQA exercise is carried out every year in

collaboration with the UK-NEQAS and the Centre National de Réfèrence des Antibiotiques

(CRAB). EARSS contributes to the global strategy established by the World Health Organization

(WHO) for worldwide surveillance of drug resistance.

The national networks

It is the task of the national representatives to select participating laboratories/hospitals that cover at

least 20% of the total population. The various types of hospitals (university or tertiary care hospitals,

general or district hospitals, rehabilitation centres or nursing homes, and others), the different

geographic regions (urban/rural), and the socio-economic strata should be represented as well as

possible.

We collected reference information on the national networks with the 2002 laboratory/hospital

questionnaire. This questionnaire served three main purposes:

1. To collect denominator information for the estimation of incidence rates, i.e. the frequency with

which resistant bacteria were ascertained in a population. Unlike resistance proportions,

incidence rates may improve comparisons between hospitals, regions and countries.


CHAPTER 2. The EARSS objectives and methodology 19

2. To collect information about the representativeness of EARSS results to understand whether the

reported data should only be applied to regions or whether they can be generalised at the country

level.

3. To explore existing efforts and the potential interest among participating centres in improving an

infrastructure for the identification of clones with particular public health importance.

Collecting and processing antimicrobial susceptibility testing (AST) data

EARSS routinely collects susceptibility test results of invasive isolates and background information

about patients. Laboratories are asked only to report the first isolate from blood or cerebrospinal

fluid (CSF). According to the specifications of the EARSS exchange format (2001 EARSS manual),

the system requires the laboratory code, isolate sample number, isolate source, date of sample

collection, sex, month and year of birth, hospital code, hospital department, origin of patient (level

of care – ambulant, hospitalised, etc.), and the pathogen and antibiotic susceptibility testing results

as specified in the protocols. Furthermore, optional data are collected; they include clinical

diagnosis, other conditions, and susceptibility data for other antibiotics.

Laboratories

Participating laboratories can opt for one of two ways of submitting data: by e-mail or by sending

in conventional isolate record forms (paper). EARSS provides various free software tools for

electronic data handling, downloadable from the Website at www.earss.rivm.nl: (1) WHONET, the

microbiology laboratory software, revised for EARSS by John Stelling, and (2) Data Entry &

Feedback Software (DEFS), which was developed especially for EARSS. Laboratories are asked to

collect AST data on a routine basis and to forward them to the national representative or data

manager quarterly. Before submission, laboratories are asked to check their data for:

• Adherence to the EARSS protocol

• Microbiological consistency/plausibility

• Consistency with clinical sensitive (S), intermediate (I) and resistant (R) breakpoints as defined

by to the guideline used.

National representative and national data manager

At the national level, the national data manager, in consultation with the national representative,

processes the data. This is done in a stepwise procedure by:

• Recording data from all participating laboratories.

• Manual data entry if isolate record forms are used.

• Merging data from all participating laboratories into one single file.

• Removing duplicate reports. Only primary isolates per patient per quarter shall be reported.

• Converting data to EARSS exchange format (2001 EARSS manual).

• Revising data with the Data Check and Feedback Programme (DCFP)

• Approval of data by the national representative (adherence to EARSS protocol, check for

microbiological consistency, and check whether the S, I and R interpretations agree with the

minimal inhibitory concentrations (MICs) reported.

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

Feedback from EARSS

Accurate and timely feedback is essential for surveillance systems. Once they are made available to

EARSS-MT, data are analysed and returned in a standard feedback report to the national

representative. This feedback contains information on pathogens with important and unusual


20 CHAPTER 2. The EARSS objectives and methodology

resistance patterns (MRSA, PNSP, VRE), and contains information on the validity and completeness

of the data. Subsequently, the national representative is asked to confirm the correctness of the

results. With his/her approval, the data will be added to the EARSS database and will become

immediately available on the interactive EARSS Website at www.earss.rivm.nl, where they can be

accessed in various formats, such as tables, figures, and geographical maps.

Furthermore, the data from the EARSS database are used to prepare annual reports, newsletters and

publications that are disseminated to the participants, policy makers and a broader public.


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

CHAPTER 3. Results of the EARSS 2002 laboratory/hospital

questionnaire

Introduction

EARSS regularly receives routine AST results from approximately 700 laboratories in 28 European

countries. Reference information about the populations for which these laboratories provide their

services is essential for understanding the validity, i.e. representativeness and generalisability, of

EARSS data. A good to fair representation of the country’s situation with respect to antibiotic

resistance is needed to justify comparisons with other countries and to present sensible results. To

achieve this degree of comparability, EARSS aims to collect information on AST results for

populations that:

• Comprise at least 20% of the total national population

• Represent the different geographical and socio-economic strata

• Receive treatment in different types of hospitals (university hospital/tertiary care, district

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

In May 2003, the EARSS 2002 laboratory/hospital questionnaire was sent to all laboratories

participating in EARSS to collect information on the number and types of hospitals they serve, the

catchment population, size and occupancy rate of these institutions, and the frequency of bacterial

blood culture tests. The questionnaire also included eight questions about existing strain (clone)

identification systems (typing) and explored the interest of participating laboratories in contributing

to an international initiative for strain identification.

The EARSS-MT distributed the questionnaires to the national representatives, who forwarded them

to the participating laboratories. The information was required for the year 2002 only. Completed

questionnaires were returned to the national representatives, who forwarded the information to the

EARSS-MT. The EARSS-MT set up a database and carried out the descriptive analysis. Details of

the data analysis are given in the technical notes (Appendix B).

In this chapter, preliminary results of this exercise are presented and discussed. Detailed results for

each country are also presented in the country summary sheets (Table 1, Figures 1 and 2 of Appendix

A). More extensive and final information will be made available early next year.

Results and discussion

Participation

This preliminary investigation includes countries, laboratories and hospitals for which both

denominator data and AST results were available for 2002. In total, 306 of the 600 laboratories

(51%) and 416 of the 837 hospitals (50%) from 21 of the 27 countries that reported AST data to

EARSS in 2002 responded to the EARSS 2002 questionnaire (Figure 3.1). Three additional

countries (Austria, Denmark and Ireland) reported aggregated data, which unfortunately could not

be included in laboratory/hospital-specific analysis. However, the data provided by these countries

are included in Appendix A (country summary sheets).


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

Number of laboratories

Number of hospitals*

120

100

80

60

40

20

0

120

100

80

60

40

20

0

A

no denominator information

with denominator information

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

EARSS country code

B

no denominator information

with denominator information

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

EARSS country code

* see Appendix A for explanation on the number of hospitals

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

denominator data for 2002, by country


CHAPTER 3. Result of the EARSS 2002 laboratory/hospital questionnaire 23

Population coverage

Table 3.1 gives an overview of the laboratories and hospitals that had returned the requested

reference information by the time this report was written. Denominator data were hence available

for hospitals that provided health services for an estimated population of more than 85 million

people in 2002. This corresponds to an average coverage of 70% of the national population in these

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

information for the year 2002

Country Labs Labs Number Hospitals Hospitals Average Estimated Percentage Number

reporting providing of blood reporting providing annual catchment of of

to denominator culture to denominator occupancy population national blood

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

covered per 100 000

inhabitants

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

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

Czech

Republic

42 42 76 188 95 82 78 8 283 81 9.2

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

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

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

Germany 19 2 10 317 19 0 NA NA NA NA

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

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

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

Luxembourg 9 7 10 083 14 6 76 449 100 22.5

Malta 1 1 2 863 1 1 83 370 93 7.7

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

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

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

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

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

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

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

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

United

Kingdom

23 18 141 543 26 18 82 9 685 16 14.6

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

# NA, not available

see Appendix A for explanation on the number of hospitals

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

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

** Average, not total


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

countries. Almost complete coverage (> 90%) was achieved by eight of the 21 countries (Table 3.1).

The population coverage appears to be overestimated for some countries, possibly due to

overlapping catchment populations. This error may occur when hospitals are located within each

other’s vicinities and therefore draw patients from partly identical populations. The estimated

coverage of the total population was less than 20% for Spain (19%), Portugal (18%) and the United

Kingdom (16%). However, this underestimates the real coverage achieved by EARSS in these

countries, as catchment population data were not available for all participating hospitals. The

coverage would most likely have exceeded 20% if all hospitals participating in EARSS had been

included.

Hospital information

Figure 3.2 shows that secondary and tertiary care facilities in all countries except Malta were

represented. (Malta has only one public hospital, which provides both tertiary and secondary care).

The proportion of tertiary versus secondary care varied substantially among countries, which may

result in differences in case mix and may confound comparison of country AST results. However,

the definition of secondary and tertiary care may also vary from country to country, and assigning

unambiguous and comparable care levels to hospitals in various countries is presently not easily

achieved.

Percentage of hospitals

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

BG

(18)

CZ

(82)

EE

(7)

ES

(28)

*

FI

(12)

FR

(21)

HR

(15)

* Spain (ES) has one hospital of unknown type

General/secondary care

Figure 3.2. Types of hospitals per country in 2002

HU

(56)

IL

(5)

IS

(2)

LU

(6)

MT

(1)

NL

(18)

PL

(24)

EARSS country code (number of hospitals)

University/tertiary care

PT

(9)

RO

(8)

Other

SE

(57)

SI

(15)

SK

(14)

UK

(18)


CHAPTER 3. Result of the EARSS 2002 laboratory/hospital questionnaire 25

The average annual occupancy of hospitals was about 80% in most countries, and it varied from 61%

(the Netherlands) to 97% (Israel). Table 3.2 gives information on the hospitals providing

denominator data. In most of the countries, at least one hospital with a burn unit and/or facilities that

carry out solid organ/bone marrow transplantation reported to EARSS. The proportion of ICU beds

varied between 1.9% (Poland) and 8.6% (Czech Republic). Hospitals that care for burns, for

immunocompromised patients or for those who have had complex surgery are usually faced with

more infections requiring antibiotic treatment and consequently witness higher resistance rates.

Indeed, the incidences of MRSA and VRE were greater in hospitals performing complex operations

(1.5 versus 6.2 MRSA infections per 100 000 patient days, and 0.04 versus 0.2 VRE infections per

100 000 patient days, respectively; P < 0.05).

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

Country Hospitals Hospitals Hospitals Total Total Percentage Number Number Blood

with with number number of ICU of of blood culture

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

unit facilities beds total beds days sets* 1000 patient

days

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

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

Czech

Republic

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

United

Kingdom

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

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

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

# NA, not available

** Average, not total


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

Blood culture practice

As becomes clear from Tables 3.1 (number of blood culture sets per 100 000 inhabitants) and 3.2

(number of blood culture sets/1000 patient days), blood culturing practices vary among countries,

which was also shown by others [1,2]. The sampling frequency for blood cultures may bias the rates

of ascertaining blood stream infections. Variation in the numbers of blood culture sets per 100 000

inhabitants and per 1000 patient days suggests different practices in eastern and western Europe.

Relatively high rates (> 20 sets/1000 patient days) were reported by Spain, Finland, Israel,

Luxembourg, the Netherlands, Portugal, Sweden and the United Kingdom, whereas rates of less than

15 sets/1000 patient days were calculated for the other countries listed in Table 3.2, which were

mainly eastern European countries. Israel had much higher blood culturing rates than any other

country. Similar patterns exist for the number of blood culture sets/100 000 inhabitants (Table 3.1).

However, it is not expected that these differences in blood culture practice influence the comparison

of AMRs, as reported resistance proportions were independent of blood culture frequencies.

Incidence rates of nosocomial blood stream infections

Table 3.3 shows the incidence of MRSA and VRE blood stream infections. In general, incidence

rates are more relevant than resistance proportions as they provide patient-based risk estimates of

acquiring such blood stream infections in the respective national hospital care system. However, in

comparisons of incidence rates with resistance proportions, the ranking order by country remains by

and large unchanged as regards MRSA. This is a clear indication that EARSS resistance proportions

are good approximations of the incidence rates, and they supply useful information for comparing

country-specific resistance rates. Thus, the MRSA and VRE ranking order remains basically

unchanged (Chapter 5). There was little VRE incidence in most countries. However, confidence

intervals were large because few E. faecium isolates were reported. This is reflected in the relatively

high detection limits shown in Table 3.3. The highest rates were established for participating

hospitals in Israel and Croatia.

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

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

MRSA VRE

Bulgaria 1.36


CHAPTER 3. Result of the EARSS 2002 laboratory/hospital questionnaire 27

Laboratory information: typing

Most laboratories would welcome a standardised typing approach, a standardised nomenclature, and

a typing network for the identification of the emergence and spread of ‘EARSS-specific’ pathogens

in their countries. More laboratories were interested in such services for S. aureus and S. pneumoniae

(98%) than for E. faecium and E. coli (93%). Almost all laboratories (298 of 301; 98%) would

welcome a common database that could be queried for the existence, distribution and prevalence of

bacterial strains with important public health relevance (high resistance or virulence) in the

European region.

Conclusion

The EARSS 2002 laboratory/hospital questionnaire provided necessary insights into the

denominator population and sampling practice of the participating laboratories and hospitals. It was

a useful instrument for identifying the scope for future initiatives within the EARSS network. On a

sample basis (21 of 28 countries), it could be shown that EARSS supplies representative and robust

antimicrobial susceptibility data for European countries. The population coverage is adequate and

greater than 20% for most participant countries. Individual countries still differ in definition and

composition of tertiary and secondary care hospitals, which may introduce some minor flaws in

internal validity. Some countries could improve the geographical spread of EARSS laboratories by

inclusion of hospitals in areas that are not yet well represented (see country maps in the country

summary sheets). In comparisons of incidence rates with resistance proportions, the overall ranking

order by country remained unchanged. This indicates that EARSS resistance proportions represent

meaningful data and undoubtedly supply useful information for comparing country-specific

resistance rates. Moreover, EARSS participants would welcome standardised and international

typing approaches for the identification of bacterial strains with particular public health importance.

References

1. Ronveaux O, Jans B, Suetens C, Carsauw H. Epidemiology of nosocomial bloodstream infections

in Belgium, 1992-1996. Eur J Clin Microbiol Infect Dis 1998; 17: 695-700.

2. Bouza E, Pérez-Molina J, Muñoz P, Cooperative Group of the European Study Group on

Nosocomial Infections (ESGNI). Report of ESGNI-001 and ESGNI-002 studies. Bloodstream

infections in Europe. Clin Microbiol Infect 1999; 5(2S): 1-12.


CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing 29

CHAPTER 4. Quality and comparability of antimicrobial

susceptibility testing (AST) among laboratories

participating in EARSS in 2002

Introduction

The differences in methods and national guidelines among European laboratories may affect the

comparability of interpretative results based on clinical breakpoints. It is therefore indispensable that

laboratories participate in EQA schemes . In 2002 EARSS organised the third EQA exercise. Its aim

was to assess the quality and comparability of susceptibility results across countries and to compare

the results with respect to country-specific guidelines. This exercise is also crucial for determining

whether pooling and analysing the routinely collected antimicrobial surveillance data within the

EARSS network generates valid results.

Methods

In September 2002, UK-NEQAS distributed a set of five strains to the laboratories participating in

EARSS; S. aureus U2A1556, E. faecium U2A805, E. coli U2A1557, E. coli U2A1526 and S.

pneumoniae U2A1580, which were provided by CRAB. The laboratories were requested to report

methods and guidelines used for species identification, MIC determination (when performed) and

clinical susceptibility breakpoints (S, I and R). Results were considered ‘concordant’ if the reported

categorisation (S, I or R) agreed with the interpretation independently approved by three reference

laboratories.

Results and discussion

The offer of participation in the EQA was readily taken up by 642 of the 690 laboratories (93%) in

26 countries (Figure 4.1).

number of laboratories

120

100

80

60

40

20

0

Countries

Invited

Participation

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

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


30 CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing

The high response rate for this third successive EQA shows that the interest among laboratories to

compare their results with international standards has not abated (90% response rate in 2000, 91%

in 2001 and 93% in 2002) and shows a continuous commitment to quality.

Table 4.1 displays the different guidelines used by the laboratories of the various countries and

shows that most of the laboratories have adopted (American) National Committee for Clinical

Laboratory Standards (NCCLS) guidelines (71%).

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

Guideline used

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

AT 5 5

BE 1 83 10 94

BU 13 8 21

CZ 17 24 41

DK 2 3 5

EE 6 1 7

ES 1 34 1 36

FI 14 14

FR 55 55

GR 30 5 35

HR 24 24

HU 28 28

IE 2 12 7 21

IL 5 5

IS 2 2

IT 50 2 52

LU 9 9

MT 1 1

NL 7 16 2 25

PL 43 43

PT 22 2 24

RO 1 10 1 12

SE 1 23 1 25

SI 11 11

SK 12 1 13

UK 14 1 8 23

Total 16 57 17 7 1 451 25 57 631*

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

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


CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing 31

As Table 4.2 shows, the overall concordance of susceptibility results was excellent and matched the

intended results. This indicates that the routine susceptibility testing in the laboratories participating

in EARSS is extremely satisfactory. The results also show that the EARSS pooling and subsequent

analysis of the resistance surveillance data renders valid results for most of the pathogen-specific

susceptibility data. However, there is room for improvement.

The majority of laboratories identified the five distributed strains correctly at the species level. A

single strain (E. faecium U2A 805) was misidentified by 79 (13%) of the 627 laboratories. In most

of these cases (n = 55), it was identified as an E. casseliflavus or E. gallinarum. Commercial test kits

and automated methods that base species identification on substrate utilisation and biochemical

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

Pathogen Antimicrobial Intended result Overall concordance

(percentages)

S. aureus Species identification 100

U2A1556 Oxacillin and or methicillin R 94

Vancomycin S 99

S. pneumoniae Species identification 99

U2A1580 Oxacillin R 98

Penicillin-G I/R 98

Erythromycin R 95

Cefotaxime and or ceftriaxone S/I 89

Ciprofloxacin S 76

E. coli Species identification 98

U2A1557 Amoxicillin and or ampicillin I/R 98

Gentamicin S 99

Tobramycin S 99

Ciprofloxacin S 100

ESBL No 95

E. coli Species identification 100

U2A1526 Amoxicillin and or ampicillin R 100

Gentamicin R 99

Tobramycin R 99

Ciprofloxacin S 96

ESBL Yes 93

E. faecium Species identification 87

U2A805 Amoxicillin and or ampicillin R 98

Gentamicin HLR 98

Vancomycin R 90

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


32 CHAPTER 4. Quality and comparability of antimicrobal susceptibility testing

reaction are occasionally unable to distinguish accurately between E. faecium and other enterococci

of the gallinarum group. Additional testing for motility and pigmentation can discriminate more

reliably. This 13% misidentification of the E. faecium strain should alert the respective laboratories

to potential uncertainties in their speciation.

The oxacillin/methicillin resistance in S. aureus U2A1556 (mecA+ve) was not detected by 6% and

the resistance to vancomycin in E. faecium U2A805 was not noticed by 10% of the participating

laboratories. Considering the clinical, epidemiological, and infection control implications associated

with such strains, it appears critical to improve the identification of these relevant resistance

phenotypes.

The relatively low concordance in determining ciprofloxacin susceptibility in S. pneumoniae

U2A1580 can be explained by the facts that (1) the British Society for Antimicrobial Chemotherapy

(BSAC) and Swedish Reference Group for Antibiotics (SRGA) guidelines recommend always

reporting a ciprofloxacin test as I or R for S. pneumoniae and (2) some guidelines (e.g. NCCLS, or

Comité de l’Ántibiogramme de la Société Française de Microbiologie(CA-SFM)) do not give any

recommendations at all. This example illustrates that breakpoints may differ substantially for some

drug-bug combinations. In these cases, data interpreted (S, I, R) by the various countries should be

compared with caution. Therefore, EARSS strongly supports the EUCAST initiative to define

universal epidemiological breakpoints based on wild-type distributions for surveillance.

A complete and detailed report of the 2002 EQA results was distributed to all EARSS participants

in March 2003.

Conclusion

Despite the adherence to different guidelines by countries reporting to EARSS, most of the

susceptibility results were concordant. This finding underlines the facts that the overall comparison

of routine results generated in different laboratories throughout Europe is feasible for the species and

antibiotics tested.


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

CHAPTER 5. The antimicrobial resistance (AMR) situation in

Europe in 2002

Introduction

Approximately 10% of the entire burden of disease in European countries (which include new and

old member states of the European Community) can be attributed to infectious diseases. This

contrasts to many Asian, South American and African countries where 42% to 71% of the entire

disease burden is caused by communicable diseases [1]. The smaller proportion attributable to the

group of communicable diseases in Europe is the result of numerous economical and social

developments that have led to improvements in public health and clinical services. These include the

availability of successful antimicrobial therapy, which is an important factor. In contrast to other

pharmaceutical interventions, however, antibiotic treatment has a societal effect, as selection for

resistant pathogens is not confined to the individual receiving treatment, but by nature of the

infectious agents can expand into the community at large. It is this feature that makes AMR a health

issue for both clinical services and public health programmes.

During the last 4 years (1999–2002), EARSS has collected routine resistance data about disease

isolates of S. pneumoniae (n = 22 244), S. aureus (n = 53 264), E. coli (n = 35 565) and E.

faecium/faecalis (n = 9463). The EARSS database contained data on 120 536 isolates from some 700

laboratories serving around 1100 hospitals in 28 countries at the end of 2002. This chapter discusses

the current dimension and pertinent trends concerning AMR as related to the pathogens just mentioned

for the European region. Appendix A provides summary statistics for individual countries.

Results and discussion

Streptococcus pneumoniae

Streptococcus pneumoniae is the single most important cause of infections of the lower respiratory

tract (such as pneumonia) in adults and children. It is also the main cause of otitis media in children

and causes life-threatening meningitis in children and the elderly. Penicillin and other beta-lactam

antibiotics have been the mainstay of antipneumococcal therapy since the 1940s. However, a steady

decrease of penicillin susceptibility has been reported from many countries worldwide in the past

two decades.

In 2002, the EARSS network identified the largest proportions of penicillin non-susceptible S.

pneumoniae (PNSP, > 25%) in France, Israel, Poland, Romania and Spain. The smallest proportions

of PNSP were reported from the north of Europe, but also from more central European countries

such as Germany and Austria (Figure 5.1; Table 1 of Appendix C).

Even though the average proportion of PNSP was 11% for all the isolates reported in 2002, (Table

1 of Appendix C), the average proportion of isolates fully resistant (MIC ≥ 2 mg/L) to penicillin was

only 2%. However, large variations in the proportion of PNSP, from


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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT

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

Proportion PNSP

40%

35%

30%

25%

20%

15%

10%

5%

0%

AT (62)

BE (1014)

BG (18)

CZ (136)

DE (266)

DK (427)

ES (630)

FI (318)

Country (average number of isolates per year)

Figure 5.2. Streptococcus pneumoniae: invasive isolates non-susceptible to penicillin (PNSP) by year for countries

reporting to EARSS for 3 years or more, in alphabetical order

IE (220)

IS (44)

IT (178)

LU (25)

MT (12)

NL (769)

PT (138)

SE (807)

1999

2000

2001

2002

SI (99)

UK (480)


CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002 35

The frequency with which PNSP was reported to EARSS during the last 4 years remained relatively

stable for most of the countries (Austria, Belgium, Germany, Spain, Italy, the Netherlands, Sweden

and the United Kingdom), and showed an increase for the Czech Republic and Finland. In addition,

a decrease was observed for Slovenia and Ireland (P < 0.05). Due to the small sample size of

isolates, no conclusions concerning trends over time could be drawn for Bulgaria, Iceland,

Luxembourg and Malta (Figure 5.2).

EARSS identified a clear predominance of erythromycin non-susceptible isolates (ENSP) in

southwestern countries in 2002 (Figure 5.3). The greatest proportions of ENSP were found in

Belgium (34%), France (58%) and Italy (32%) and the smallest proportions of ENSP (≤ 5%) were

observed in the Czech Republic (4%), Denmark (5%), Estonia (0%), and Iceland (5%). Among the

Scandinavian countries, only Finland showed a steady increase in reduced erythromycin

susceptibility from 6% in 1999 to 13% in 2002 (Table 1 of Appendix C).

Figure 5.4 shows that a large part of the penicillin non-susceptible S. pneumoniae isolates are also

resistant to erythromycin in most countries. In fact, co-resistance is of dual public health importance.

Not only does it affect the clinical management of infections, co-resistance also means that each of

the antibiotic substances to which a pathogen has developed resistance independently facilitates the

success of co-resistant clones.

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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT


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

Proportion

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

*

IL (323)

ES (1782)

HU (88)

PT (216)

SI (228)

HR (104)

LU (90)

BE (4058)

IE (679)

IT (643)

Only penicillin non-susceptible

Co-resistant to penicillin

erythromycin

95% CI

Figure 5.4. Streptococcus pneumoniae: invasive isolates non- susceptible to both penicillin, and erythromycin (coresistant),

or penicillin only, shown by country for the period 1999 – 2002. (Only isolates that were tested for both

penicillin and erythromycin for the countries with at least 20 isolates reported in the period 1999–2002 were included)

Staphylococcus aureus

Staphylococcus aureus is the main cause of bone, joint and soft-tissue infections acquired in hospital

and in the community. It also causes blood stream infections and endocarditis, and it is a frequent

cause of food poisoning. S. aureus resistant to penicillinase-fast beta-lactam antibiotics such as

methicillin, oxacillin, cloxacillin, flucloxacillin, nafcillin and cephalosporins is commonly termed

MRSA (for methicillin-resistant S. aureus). S. aureus has become a notorious cause of hospitalacquired

infections and thrives in hospitals worldwide. Due to the multiresistant nature of MRSA,

glycopeptide antibiotics (vancomycin and teicoplanin) with inferior pharmacokinetic properties

have become the treatment of choice. In the last decade, there have been repeated reports of newly

emerging MRSA strains that cause difficult-to-treat community-acquired skin infections in the

United States.

Figure 5.5 displays the current proportions of MRSA in various European countries (Table 1 of

Appendix C). The reason why MRSA enjoys such heterogeneous success in Europe with resistance

proportions that vary 100-fold between countries is multifaceted. Successful epidemic clones

quickly exploit ecological opportunities. Any combination of a wide range of factors, such as

increased colonisation pressure brought about by imported cases, a habitual prescribing of antibiotics

in health care facilities, obstruction of early detection, inappropriate isolation precautions, patient

crowding, low staff-patient ratios and reduction in basic housekeeping performance can account for

the rapid spread of MRSA through regional or national health care systems.

BG (46)

UK (1072)

CZ (379)

FI (1206)

MT (34)

Country (total number of isolates)

*

IS (159)

DK (1282)

SE (2514)

AT (140)

NL (1997)

DE (790)

EE (37)


CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002 37

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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT

There has been a significant increase of MRSA (P < 0.05) in Austria, Belgium, Germany, and the

United Kingdom (Figure 5.6) during the last 4 years. Germany and Austria witnessed the quickest

expansion: from 8% to 19% and from 5% to 11%, respectively. The United Kingdom and Ireland

currently see more of a stabilisation of the fast rise that characterised the increase of MRSA

throughout the 1990s in the British Isles, and they have maintained levels below 45% in the last 2

years (2001 and 2002). The only consistent decrease was reported by Slovenia (from 21% in 2000

to 14% in 2002, P < 0.05), where public debate following a national prevalence study resulted in

increased awareness and nationwide education efforts for doctors in 2001. It appears that these

measures had the desired effect and brought MRSA rates down in 2002 for the second successive

year. In northern countries – Iceland, Denmark, Sweden, Finland and the Netherlands – the

proportion of MRSA remained less than 1%. Nonetheless, the Netherlands saw a slight, but

significant, increase in 2002 over the previous years (Figure 5.6).


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

Proportion MRSA

60%

50%

40%

30%

20%

10%

0%

AT (279)

BE (783)

BG (110)

CZ (919)

DE (915)

DK (623)

ES (1015)

FI (501)

GR (318)

Country (average number of isolates per year)

Figure 5.6. Staphylococcus aureus: invasive isolates resistant to methicillin (MRSA) by year for countries reporting to

EARSS for 3 years or more, in alphabetical order

Enterococci

Although not as virulent as the other indicator pathogens recorded by the EARSS initiative,

enterococci are common causes of urinary tract infections and a frequent component of intraabdominal

infections. They cause severe forms of endocarditis, and are hideous, opportunistic

pathogens in immunocompromised patients, where they cause septicaemia, meningitis and bone

infections. By nature relatively resistant to many antibiotics, enterococci were the first significant

human pathogens that reportedly developed resistance against third-line glycopeptide antibiotics

(vancomycin and teicoplanin). Ever since, vancomycin-resistant enterococci (VRE) have served as

a paradigm for the post-anti-microbial era [3].

The proportion of vancomycin-resistant E. faecium was reported above 10% in Ireland, Italy,

Greece, Croatia, and Romania in 2002, and it was between 5% and 10% in Germany, Austria, Czech

Republic and Israel (Figure 5.7; Table 1 of Appendix C). However, the European picture is

incomplete since EARSS does not yet receive data from Belgium, Denmark, Norway and the United

Kingdom, and very few isolates (< 10) were reported by Iceland, Romania and Slovakia.

High-level aminoglycoside-resistant E. faecalis appeared frequently in the European region in 2002.

Only Iceland reported a proportion of isolates less than 10%, and, for a few countries – Austria,

Finland, France, Luxembourg and Malta – the proportion was less than 20%. Bulgaria, Greece, and

Hungary reported the largest proportions of high-level aminoglycoside resistance (Figure 5.8; Table

1 of Appendix C).

IE (735)

IS (49)

IT (949)

LU (68)

MT (82)

NL (1352)

PT (396)

SE (1567)

1999

2000

2001

2002

SI (233)

UK (1340)


CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002 39

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT

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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT

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


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

Trends in resistance of hospital-acquired infections

The proportions of MRSA and VRE in 2002 are combined by country in Figure 5.9. Six countries

reported epidemic proportions of VRE (≥ 10%). All of them belong to the nine countries that also

reported the highest MRSA rates (> 35%). This suggests an intricate relation between MRSA and

VRE, which is most likely twofold. Empirical treatment decisions in situations where MRSA thrives

will frequently give preference to glycopeptide antibiotics and thereby bring about conditions that

favour the selection for glycopeptide-resistant enterococci. At the same time, the dissemination of

these predominantly nosocomial pathogens is supported by common ecological forces. The cocirculation

of these pathogens in the same populations is a reason for concern, as is highlighted by

recent reports of fully vancomycin-resistant MRSA (VRSA) in the USA, where co-infection of

patients with both VRE and MRSA led to conjugative transposition of the vancomycin resistance

genes from VRE to MRSA [4].

Escherichia coli

Escherichia coli is the most frequent gram-negative rod isolated from blood cultures in clinical

settings. It is the most frequent cause of community and hospital-acquired urinary tract infections; it

is associated with spontaneous and surgical peritonitis; it causes synergistic wound infections; and

it is one of the most important food-borne pathogens. Broad-spectrum penicillins such as ampicillin

and amoxicillin were the treatments of choice before beta-lactamases (mostly plasmid coded TEM1)

became an almost ubiquitous component of the genetic equipment of this species. Except for

Sweden and Finland, the proportion of E. coli isolates resistant to aminopenicillins was largest than

30% for all countries (Figure 5.10; Table 2 of Appendix C).

Proportion

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

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

Country

%MRSA

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

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

%VRE


CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002 41

Proportion aminopenicillin resistance

100

90

80

70

60

50

40

30

20

10

0

RO (28)

IL (864)

IE (735)

ES (2483)

PT (443)

FR (2493)

BG (134)

PL (134)

Country (total number of isolates)

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

SK (215)

DE (1025)

IT (564)

HR (490)

In most European countries, the proportions of isolates resistant to third-generation cephalosporins

remained at 6% or less in 2002. The greatest proportions of third-generation cephalosporin

resistance were found among some of the eastern European countries: Bulgaria (13%), Israel (8%)

and Romania (18%, Figure 5.11; Table 2 of Appendix C). Despite overall small proportions, there

is no reason for complacency, since resistance to third-generation cephalosporins in E. coli is

brought about by extremely successful, extended-spectrum beta-lactamases (ESBLs). These

resistance determinates are plasmid-coded and easily spread by conjugation, not only among

different strains of E. coli but also among different species of enterobacteriaceae. ESBLs are

potentially a serious impediment to the treatment of community and hospital E. coli infections in

Europe.

As shown in Figure 5.12, most European countries have attained proportions of fluoroquinolone

resistance of 10% or greater in 2002 (Table 2 of Appendix C). Within the 2 years since EARSS

started AMR surveillance for E. coli, 21 countries have provided complete AST data. Sixteen of

them witnessed an increase in fluoroquinolone resistance (Figure 5.13) and eight countries saw

fluoroquinolone resistance in 2002 increase to 1.5 times the resistance rates reported in 2001 or

more. The consistency of this finding reflects a worrying trend and might be the consequence of the

widespread acceptance and use of newer fluoroquinolones with enhanced activity against Grampositive

pathogens as a convenient alternative to other broad-spectrum antibiotics.

BE (1167)

GR (583)

HU (353)

CZ (1587)

SI (409)

MT (74)

LU (192)

NL (2421)

EE (65)

AT (414)

IS (79)

FL (1329)

SE (1753)


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

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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT

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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT


CHAPTER 5. The antimicrobial resistance (AMR) situation in Europe in 2002 43

Proportion fluoroquinolone resistance

25%

20%

15%

10%

5%

0%

AT (312)

BE (572)

BG (112)

CZ (1380)

DE (1127)

EE (53)

ES (2220)

FI (1306)

GR (578)

Country (average number of isolates per year)

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

HR (334)

Similar to third-generation cephalosporin resistance, the greatest proportions of gentamicin and

tobramycin resistance were found in eastern European countries, namely, Bulgaria , Romania and

Israel (>15%). They were still less than 1% in Finland and Sweden (Figure 5.14; Table 2 of

Appendix C). The greater resistance proportions in eastern Europe can be attributed to the frequent

administration of this antibiotic class in clinical settings. Aminoglycosides remain an inexpensive

alternative to other injectable drugs and are still employed as a single drug therapy in many

hospitals.

E. coli isolates with multiple resistance to third-generation cephalosporins, fluoroquinolones and

aminoglycosides are still scarce in Europe (0.74% for the period 1999–2002) and only occurred in

Bulgaria (14/211; 7%), Israel (85/1569; 5%) and Romania (4/26; 15%) in greater proportions.

HU (293)

IL (800)

IS (78)

LU (174)

MT (71)

NL (1974)

PL (113)

PT (344)

SE (2344)

2001

2002

SI (404)

SK (130)


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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT

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

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

No data

< 1%

1 – 5%

5 – 10%

10 – 25%

25 – 50%

> 50

LU MT


APPENDIX ‘Overview of activities in 2002’ 45

Conclusion

During the last 4 years, resistance proportions for S. pneumoniae have remained relatively stable in

the European region with high rates of PNSP in France, Spain, Poland and Romania and low levels

in northern and central parts of Europe. However, the proportions increased in Finland and the Czech

Republic. The alternative treatment with macrolides favoured in many countries has led to great

resistance in France, Spain, Italy, Belgium and Slovakia. The combined loss of susceptibility to both

penicillins and macrolides (co-resistance) may also become a growing issue in these countries. Since

there is increasing evidence of macrolide failure in pneumococci if the MICs are 4mg/L or greater,

high-dose treatment with beta-lactam antibiotics remains the saver treatment alternative in countries

where most PNSPs are of intermediate susceptibility.

For MRSA, the dynamics of the global epidemic has slowed down in the United Kingdom and

Ireland, whereas Germany and Austria showed the quickest increase of MRSA rates between 1999

and 2002. Scandinavian countries are still spared from this trend, but the Netherlands saw the

beginning of an increase in 2002. The proportions of vancomcyin-resistant enterococci have

remained small in most countries; however, a few reported large proportions. In all of them, MRSA

thrives and VRE outbreaks in hospitals are certainly favoured by increased glycopeptide

consumption. To control such outbreaks, it is incumbent to set up infection control procedures and

revise the guidelines for empirical glycopeptide use.

Of all “EARSS-specific” pathogens, E. coli showed the most worrying trends. Not only have betalactamases

become a constitutive genetic component of more than 50% of all invasive isolates

(rendering these strains resistant to ampicillin/amoxcicillin), but there was also a marked and

consistent increase in fluoroquinolone resistance in most countries (16 of 21) that reported E. coli

susceptibility data to EARSS. At the same time, third-generation cephalosporins have lost more and

more of their activity in countries where ESBL-producing strains are on the rise. Community and

hospital E. coli infections are likely to become increasingly difficult to treat and may pose a health

threat to patients in the European region.

References

1. World Development Report 1993, Oxford University Press, New York, USA.

2. Klugman KP. Bacteriological evidence of antibiotic failure in pneumococcal lower respiratory

tract infections. Eur Respir J 2002;36:3s-8s.

3. Cohen ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science

1992; 257:1050-5.

4. Sievert DM, Boulton ML, Stoltman G et al. Staphylococcus aureus resistant to vancomcyin –

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


CHAPTER 6. Conclusions and future initiatives 47

CHAPTER 6. Conclusions and future initiatives

Geographic variation in the proportions of antibiotic resistance in Europe has been a consistent

pattern over the years, and it seems to reflect the ecological differences encountered by the ‘EARSSspecific’

pathogens in various countries. To understand the driving forces behind this disparity,

EARSS did some original analysis and was able to correlate beta-lactam antibiotic consumption with

penicillin-non-susceptible S. pneumoniae (PNSP) for the EARSS participating countries in 2001 [1].

Since most of the PNSP isolates belong to eight frequently occurring serotypes and mainly originate

from infections of infants and toddlers, there is hope that invasive disease caused by resistant strains

could be controlled by conjugate vaccines that have recently been made available. It is incumbent,

however, to monitor the serotype distribution among invasive and resistant isolates once vaccines

become widely accepted. EARSS laboratories would be ideally suited to provide these services as

well as to determine the population effectiveness of such an intervention.

The largest variation in resistance proportions in the European region was observed for MRSA, and

it became apparent that the global MRSA epidemic continued to expand in many European countries

in 2002. Two features that have been noticed are worth mentioning. Firstly, countries that see an

epidemic rise in MRSA frequently witness a fast increase and spread in many hospitals, but MRSA

proportions appear to reach saturation levels after a couple of years. Secondly, European countries

with longstanding high MRSA rates maintained resistance proportions between 40% and 50%

(Portugal, Italy and Greece). It is not understood what limits this dissemination and determines the

national carrying capacity. Despite the relative uniformity of resistance proportions among

hyperendemic countries, some hospitals warrant attention since they see much higher MRSA rates

than the national average. To better understand the factors that drive the success of certain highly

prevalent clones, attention should be turned to hospitals with longstanding and extreme MRSA

figures. They represent ideal study sites for specific national and international investigations that

would potentially identify a set of common conductive ecological conditions.

Vancomycin-resistant enterococci (VRE) mainly belong to the species E. faecium and occur in

epidemic proportions in a few countries. Nevertheless, six countries reported proportions greater or

equal to 10% in 2002 compared to only 4 countries in 2001. It has been shown that invasive VRE

belong to hospital-associated strains, many of them phylogenetically related and carrying the esp

gene [2]. This means that appropriate methods of strain identification can potentially identify these

particularly important strains early enough to prevent hospital outbreaks, and EARSS will be able to

trace their regional and international dissemination with the use of spatial analysis.

In E. coli, aminopenicillin resistance continued to expand and the median resistance proportion

increased from 44.5% in 2001 to 48% in 2002. The same trend was recognised for third-generation

cephalosporins. The latter increase was mainly due to the spread of ESBL-producing strains in some

eastern European countries. The most rapid rise of resistance frequencies in 2002 was observed for

fluoroquinolone-resistant E. coli. Resistance increased in 16 of 21 countries; 8 of them observed

proportions that were at least 1.5 times greater in 2002 than in the previous year. It has been argued

that fluoroquinolone resistance mainly occurs in phylogenetically diverse subgroups other than very

virulent strains and may be derived from animal sources [3]. The exchange of strain-specific

information would enhance the ability of EARSS to characterise the nature of this threatening

development, which would be helpful in efforts to improve resistance surveillance.


48 CHAPTER 6. Conclusions and future initiatives

EARSS has become an internationally accepted surveillance organisation in the last 4 years. EARSS

provides meaningful information on the status and trends of AMR in the European region. However,

some obstacles have not entirely been overcome and remain to be addressed in the future to improve

on the accuracy and validity of the data. Susceptibility tests were originally devised and are routinely

used as guidance for therapeutic decision making in clinical services. The use of these routine

laboratory results for public health purposes has not been without controversy. The main concern is

that EARSS results are based on clinical breakpoints interpreted in S, I, and R categories. These

differ among laboratories depending on the various national guidelines used. Nonetheless, routine

EQA exercises performed annually throughout the EARSS network were able to demonstrate that

over 95% of the laboratories come to concordant results when the guidelines agreed on breakpoints

that clearly separate wild type from resistant bacteria. This means that most of the laboratories

satisfactorily identify micro-organisms that have acquired the ability to circumvent the effect of the

antibiotic to which they would normally be expected to be susceptible. The initiative taken by

EUCAST to harmonise the existing clinical breakpoints and define epidemiological cut off values

for surveillance [4] will certainly improve the completeness of conclusions drawn by EARSS.

The EARSS network with its 700 participating laboratories provides the ideal basis for further

epidemiological and ecological research towards a better understanding of the emergence and spread

of resistance in the European region. One property of the EARSS initiative has, in this respect, not

been exploited to its full potential: the capacity to process data based on strain-specific identification

of pathogens. Once this becomes possible, EARSS will not only provide a novel approach to

pertinent research questions, but value will be added to its role as a repository of knowledge for

informed policy decision. We envision EARSS becoming the platform for a warning system for the

detection and identification of pathogens and clones with particular public health importance in

terms of AMR and virulence properties. This becomes especially clear when one considers the

potentials of internet-based information exchange among the participating laboratories, which, after

all, are the centres of local expertise.

References

1. Bronzwaer SLAM, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, Kool JL,

Sprenger MJW, Degener JE, and participants in the European Antimicrobial Resistance

Surveillance System. A European Study on the Relationship between Antimicrobial Use and

Antimicrobial Resistance. Emerg Inf Dis 2002;8:278-82.

2. Willems RJ, Homan W, Top J, Santen-Verheuvel M van, Tribe D, Manzioros X, Gaillard C,

Vandenbroucke-Grauls CM, Mascini EM, Kregten van E, Embden JD van, Bonten MJ. Variant

esp gene as a marker of a distinct genetic lineage of vancomycin-resistant Enterococcus faecium

spreading in hospitals. Lancet 2001;357:853-5.

3. Johnson JR, Schee C van der, Kuskowski MA, Goessens W, Belkum A van. Phylogenetic

background and virulence profiles of fluoroquinolone-resistant Escherichia coli isolates from

the Netherlands. J Infect Dis 2002;186:1852-6.

4. Kahlmeter G, Brown DFJ, et al. European Harmonization of MIC breakpoints for antimicrobial

susceptibility testing of bacteria. J Antimicrob Chemother 2003;52:145-148.


APPENDIX A 49

Appendix A. Country Summary Sheets

In the following appendix, country-specific resistance information is presented together with

denominator data and the characteristics of the participating laboratories and hospitals.

Explanation to the country summary sheets:

Denominators: Table 1 and 2 and Figures 1 and 2 give an indication of the sample size and the

representativeness of the country-specific resistance data available to EARSS.

Table 1 displays results of the laboratories and hospitals that provided denominator data (i.e. that

responded to the questionnaire) and thus only includes the laboratories that reported AST results to

EARSS in 2002, and provided blood culture information and the hospitals that reported AST results

to EARSS in 2002, and provided their number of hospital beds. For details about the calculation of

the average annual occupancy rate, the estimated catchment population and the percentage of the

total population covered, we refer to the technical notes (Appendix B). If data were not available

this is stated as “na”.

Figure 1 gives and indication about the degree of specialisation of the participating hospitals, and

Figure 2 shows the geographic location of the laboratories reporting in 2002. The size of the dots in

the maps represents the number of laboratories in that location/town.

Dotsize

Number of labs 1 5 10 15

Antibiotic resistance 1999-2002: Table 3 provides information on the proportion of invasive

bacterial isolates not susceptible to the antibiotics or antibiotic classes mentioned in the EARSS

protocols. From the majority of all non-susceptible S. pneumoniae and S. aureus isolates we

received the corresponding MIC or Etest result, according to the EARSS protocols, however for

some of the non susceptible isolates this information is missing. The table also includes

erythromycin susceptibility for S. pneumoniae. Any interpretation of Table 3 should also take into

account the small sample size for E. faecium reported to EARSS.

Table 4 gives details about the origin of the isolate (patient, source and hospital department). The

abbreviations used in this table stand for; PNSP = pencillin non-susceptible S. pneumoniae, MRSA

= methicillin-resistant S. aureus, FREQ = fluoroquinolone-resistant E. coli, and VRE = vancomycin

resistant (I+R) E. faecalis or E. faecium. If the number of isolates in a certain category accounts for

less than 0.5% of the total number of isolates, the % total is set at 0 and the % resistance is not

shown.

Local variation: Figures 3 and 4 show national distribution in the proportions of PNSP and MRSA

by laboratory and by hospital, respectively.


50 APPENDIX A

For both Figures, a minimum of 5 isolates and at least 2 years of participation in EARSS for each

laboratory or hospital was required, before being included into the presentation. If an ‘X’ is

displayed at the end of a hospital code this means that the hospital code is not provided;

consequently, this can apply for one or more unknown hospitals.


APPENDIX A 51

Countries


52 APPENDIX A

Austria

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 10/46

Labs/Hosps providing denom.data *

0/0

Number of blood culture sets *

na

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population * 3500000

% total population covered *

43%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 9 53 9 156 0 0 0 0

2001 9 63 9 277 9 269 8 74

2002 9 71 10 404 9 417 9 166

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R .


APPENDIX A 53

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=187

n=837

n=623

n=176

n=62

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

Isolate source

Blood 86 3 100 9 100 9 100 1 100 6

CSF

Sex

14 0 0 . 0 . 0 . 0 .

Male 61 3 60 9 38 11 61 1 58 3

Female 39 1 40 7 62 7 39 0 42 12

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 13 0 11 18 8 15 23 3 35 14

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

Surgery 2 0 11 12 10 5 13 0 13 0

Other 29 4 28 6 24 9 23 0 19 0

Unknown 6 8 3 4 3 6 1 0 0 .

PNSP at laboratory level MRSA at hospital level

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

AT001

AT003

AT004

AT006

AT007

AT008

AT010

AT002

AT012

0/50

0/9

0/7

0/40

0/11

0/8

1/23

2/22

1/6

0 25 50 75 100

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

AT001K

AT001R

AT003B

AT003N

AT006H

AT006M

AT006N

AT008S

AT008T

AT010B

AT012D

AT012G

AT001S

AT010F

AT001E

AT001B

AT003G

AT007K

AT006S

AT012W

AT002A

AT006B

AT012H

0/22

0/7

0/5

0/6

0/5

0/5

0/11

0/7

0/12

0/18

0/11

0/8

1/60

2/51

3/69

2/38

2/36

8/129

6/79

3/31

15/81

4/7

4/7

0 25 50 75 100


54 APPENDIX A

Belgium

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 102/102

Labs/Hosps providing denom.data *

0/0

Number of blood culture sets *

na

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population *

na

% total population covered *

na

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 92 846 47 442 0 0 0 0

2000 90 909 42 657 0 0 0 0

2001 89 1093 47 940 23 226 0 0

2002 98 1210 48 1092 27 1184 0 0

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R 4 5


APPENDIX A 55

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=4058

n=3131

n=1143

n=0

n=0

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

Isolate source

Blood 94 14 100 24 100 13 . . . .

CSF

Sex

6 10 0 . 0 . . . . .

Male 56 14 58 25 43 14 . . . .

Female 43 14 40 23 56 11 . . . .

Unknown

Age (years)

1 11 2 21 1 27 . . . .

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

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

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

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

Unknown

Hospital department

0 . 2 27 0 . . . . .

ICU 13 13 15 33 10 10 . . . .

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

Surgery 2 18 11 25 8 9 . . . .

Other 26 14 23 27 50 14 . . . .

Unknown 25 15 20 23 1 25 . . . .

PNSP at laboratory level MRSA at hospital level

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

BE002 0/58

BE012 0/26

BE068 0/5

BE100 0/18

BE116 0/16

BE037 1/31

BE009

1/25

BE023

2/41

BE014

1/19

BE103

2/33

BE004

2/29

BE114

1/14

BE118

2/27

BE060

4/53

BE059

2/26

BE077

7/86

BE022

4/49

BE070

12/144

BE024

7/82

BE104

7/81

BE030

7/76

BE115

10/106

BE061

7/74

BE020

2/21

BE017

3/31

BE139

6/61

BE054

2/20

BE001

7/68

BE031

3/29

BE044

2/19

BE063

7/66

BE005

4/36

BE058

7/63

BE026

3/26

BE056

15/130

BE057

6/52

BE006

7/60

BE064

4/34

BE090

6/51

BE093

6/51

BE035

3/25

BE013

4/33

BE032

9/73

BE055

10/81

BE145

1/8

BE049

5/39

BE141

2/15

BE019

6/43

BE108

34/242

BE007

5/35

BE051

5/35

BE071

2/14

BE048

6/41

BE003

4/27

BE102

4/26

BE110

4/26

BE097

15/94

BE074

9/56

BE018

1/6

BE021

1/6

BE072

6/36

BE092

27/162

BE101

6/35

BE112

16/93

BE041

7/40

BE008

11/60

BE109

8/42

BE033

6/31

BE091

26/132

BE016

20/101

BE121

1/5

BE010

3/14

BE075

11/51

BE105

8/37

BE069

5/22

BE065

5/21

BE076

4/15

BE084

6/22

BE095

14/51

BE098

15/54

BE040

3/9

BE083

5/13

BE029

9/23

BE131

2/5

BE135

2/5

BE143

8/20

BE107

BE113

7/17

0 25 50 75 100

5/9

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

BE007X

BE002X

BE060X

BE057X

BE061X

BE014X

BE115X

BE012X

BE001X

BE024X

BE031X

BE004X

BE074X

BE030X

BE075X

BE041X

BE016X

BE063X

BE029X

BE008X

BE109X

BE005X

BE072X

BE114X

BE112X

BE058X

BE070X

BE077X

BE125X

BE006X

BE033X

BE003X

BE045X

BE019X

BE022X

BE040X

BE097X

BE056X

BE042X

BE032X

BE059X

BE017X

BE107X

BE026X

BE068X

BE018X

BE065X

2/37

10/95

12/111

4/30

24/178

4/28

10/68

2/12

16/91

21/119

7/39

2/11

33/178

10/53

8/38

19/90

29/134

42/185

10/43

28/118

8/33

6/24

7/28

4/16

19/74

11/42

66/247

32/118

5/18

26/93

11/39

7/24

8/27

20/66

19/62

5/16

92/263

28/76

6/15

23/52

9/20

15/30

3/6

9/17

3/5

9/12

6/8

0 25 50 75 100


56 APPENDIX A

Bulgaria

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 22/22

Labs/Hosps providing denom.data *

19/18

Number of blood culture sets *

15549

Number of hospital beds *

9168

Average annual occupancy rate *

76%

Estimated catchment population * 7621000

% total population covered *

100%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 8 13 16 111 0 0 0 0

2001 8 16 17 103 15 98 11 30

2002 11 25 21 116 20 135 16 42

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . 23 6 8

Penicillin I+R . 23 6 8

Macrolides I+R . 25 9 9

S. aureus Oxacillin/Methicillin R . 37 27 33

E. coli Aminopenicillins R . . 47 52

Aminoglycosides R . . 16 17

Fluoroquinolones R . . 8 14

3rd gen. Cephalosporins R . . 7 13

E. faecalis Aminopenicillins I+R . . 5 26

Aminoglycosides (high-level resistance) . . 30 63

Glycopeptides I+R . .


APPENDIX A 57

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=54

n=330

n=224

n=53

n=19

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

Isolate source

Blood 43 13 100 32 98 12 100 2 100 0

CSF

Sex

57 10 0 . 2 0 0 . 0 .

Male 63 15 60 30 48 17 72 3 58 0

Female 35 5 39 35 52 7 28 0 42 0

Unknown

Age (years)

2 0 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

7 0 6 40 2 40 6 0 16 0

ICU 15 0 18 58 10 4 21 0 53 0

Internal Medicine 43 17 40 23 45 8 42 0 21 0

Surgery 9 0 17 33 18 20 21 9 11 0

Other 33 11 25 28 27 15 17 0 16 0

Unknown 0 . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

BG013

BG016

BG003

BG007

0/7

1/9

1/7

2/8

0 25 50 75 100

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

BG014A

BG013A

BG004A

BG021A

BG003A

BG024A

BG005A

BG008A

BG007A

BG011A

BG001A

BG006A

BG009A

BG015A

0/10

1/23

1/10

2/12

10/35

3/10

4/13

9/28

6/17

6/15

42/100

0 25 50 75 100

9/16

3/5

6/6


58 APPENDIX A

Croatia

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 15/15

Labs/Hosps providing denom.data *

15/15

Number of blood culture sets *

34742

Number of hospital beds *

8533

Average annual occupancy rate *

91%

Estimated catchment population * 3775000

% total population covered *

86%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 10 20 14 149 13 182 7 33

2002 14 90 14 279 15 490 13 96

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . .


APPENDIX A 59

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=110

n=428

n=667

n=110

n=19

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

Isolate source

Blood 86 19 100 35 100 5 100 1 100 21

CSF

Sex

14 13 0 . 0 . 0 . 0 .

Male 65 18 69 34 42 7 65 0 74 21

Female 35 18 31 37 58 4 35 3 26 20

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 15 12 12 68 6 5 13 0 16 0

Internal Medicine 21 13 40 27 42 4 33 0 42 13

Surgery 1 100 13 69 3 10 9 0 0 .

Other 63 20 35 19 48 6 45 2 42 38

Unknown 0 . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

HR007

HR016

HR001

HR004

HR002

HR014

1/10

1/7

2/13

1/5

9/44

3/11

0 25 50 75 100

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

HR010A

HR014A

HR018A

HR009A

HR020A

HR002A

HR016A

HR011A

HR007A

HR004A

HR001A

HR005A

HR013A

HR012A

0/10

0/15

0/6

1/15

1/6

8/45

6/21

13/41

20/61

12/32

66/141

12/19

0 25 50 75 100

6/9

5/7


60 APPENDIX A

Czech Republic

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 42/95

Labs/Hosps providing denom.data *

42/82

Number of blood culture sets *

76188

Number of hospital beds *

44322

Average annual occupancy rate *

78%

Estimated catchment population * 8283000

% total population covered *

81%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 26 111 31 515 0 0 0 0

2001 32 154 39 1074 36 1176 34 461

2002 34 144 41 1168 40 1587 39 587

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R .


APPENDIX A 61

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=409

n=2757

n=2760

n=901

n=146

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

Isolate source

Blood 71 7 100 6 100 9 100 1 100 5

CSF

Sex

29 5 0 . 0 . 0 . 0 .

Male 62 7 59 6 42 12 62 1 57 6

Female 38 6 41 4 58 8 38 1 43 5

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 16 6 14 10 9 11 23 0 24 6

Internal Medicine 40 8 49 3 53 10 34 1 38 4

Surgery 2 22 13 9 10 8 15 2 8 9

Other 40 4 24 6 27 9 28 2 29 5

Unknown 1 0 0 . 0 . 0 . 1 100

PNSP at laboratory level MRSA at hospital level

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

CZ008

CZ013

CZ016

CZ019

CZ022

CZ024

CZ027

CZ030

CZ033

CZ036

CZ002

CZ006

CZ015

CZ031

CZ012

CZ009

CZ004

CZ023

CZ003

CZ005

CZ007

CZ021

CZ025

CZ026

CZ017

0/10

0/6

0/40

0/10

0/7

0/15

0/20

0/8

0/12

0/8

1/18

3/49

1/15

1/14

2/25

3/36

1/11

1/10

1/9

1/7

2/14

1/6

1/6

1/6

4/18

0 25 50 75 100

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

CZ002A

CZ007D

CZ007E

CZ009B

CZ011A

CZ012A

CZ012B

CZ012C

CZ012D

CZ013A

CZ015B

CZ017C

CZ017D

CZ019B

CZ022A

CZ022B

CZ023A

CZ025A

CZ027A

CZ027B

CZ028A

CZ028B

CZ029A

CZ030A

CZ031C

CZ031E

CZ031P

CZ032A

CZ038A

CZ039A

CZ040A

CZ009A

CZ026A

CZ015A

CZ004A

CZ005A

CZ036A

CZ037A

CZ014A

CZ016A

CZ007A

CZ019A

CZ021A

CZ006A

CZ008A

CZ034A

CZ017A

CZ031A

CZ020A

CZ031K

CZ017B

CZ018A

CZ024A

CZ033A

CZ035A

CZ031V

CZ042A

CZ003A

0/85

0/6

0/7

0/17

0/27

0/62

0/13

0/8

0/13

0/26

0/7

0/13

0/14

0/16

0/39

0/7

0/76

0/22

0/72

0/5

0/30

0/5

0/28

0/28

0/10

0/6

0/12

0/27

0/17

0/10

0/8

2/178

1/44

2/75

2/74

2/67

1/27

1/26

1/24

4/90

3/64

2/40

5/96

11/199

1/17

2/34

12/157

7/88

10/121

1/10

6/46

32/236

7/50

9/59

8/51

2/10

2/10

12/58

0 25 50 75 100


62 APPENDIX A

Denmark

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 5/35

Labs/Hosps providing denom.data *

0/35

Number of blood culture sets *

na

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population * 2490000

% total population covered *

46%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 5 718 0 0 0 0

2000 5 410 4 501 0 0 0 0

2001 5 506 4 520 0 0 0 0

2002 5 366 5 752 0 0 0 0

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R .


APPENDIX A 63

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=1282

n=2491

n=0

n=0

n=0

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

Isolate source

Blood 91 3 100 1 . . . . . .

CSF

Sex

9 2 0 . . . . . . .

Male 50 3 58 1 . . . . . .

Female 49 3 39 0 . . . . . .

Unknown

Age (years)

0 . 3 1 . . . . . .

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

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

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

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

Unknown

Hospital department

0 . 0 . . . . . . .

ICU 0 . 5 0 . . . . . .

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

Surgery 0 . 19 0 . . . . . .

Other 0 . 16 1 . . . . . .

Unknown 100 3 10 1 . . . . . .

PNSP at laboratory level MRSA at hospital level

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

DK016

DK014

DK005

DK009

DK002

5/265

8/317

5/130

12/277

13/293

0 25 50 75 100

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

DK005A

DK005B

DK008A

DK009A

DK009C

DK009D

DK009F

DK009G

DK014A

DK014B

DK014C

DK014E

DK014F

DK014G

DK014N

DK016B

DK016C

DK016D

DK016F

DK016G

DK016H

DK016A

DK009B

DK002E

DK002A

DK002B

DK014D

DK002F

0/117

0/62

0/50

0/64

0/15

0/27

0/30

0/5

0/34

0/107

0/71

0/16

0/11

0/12

0/87

0/97

0/62

0/23

0/22

0/31

0/12

1/388

4/421

1/100

2/199

3/271

1/53

2/90

0 25 50 75 100


64 APPENDIX A

Estonia

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 8/12

Labs/Hosps providing denom.data *

7/7

Number of blood culture sets *

4217

Number of hospital beds *

3021

Average annual occupancy rate *

75%

Estimated catchment population * 1416000

% total population covered *

100%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 5 20 6 79 4 52 4 21

2002 5 21 8 81 6 67 3 13

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . .


APPENDIX A 65

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=41

n=160

n=106

n=23

n=11

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

Isolate source

Blood 41 0 100 3 99 3 100 0 100 0

CSF

Sex

59 0 0 . 1 0 0 . 0 .

Male 66 0 54 5 33 6 43 0 82 0

Female 34 0 40 2 66 1 52 0 18 0

Unknown

Age (years)

0 . 6 0 1 0 4 0 0 .

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

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

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

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

Unknown

Hospital department

54 0 43 3 36 5 43 0 18 0

ICU 32 0 15 0 16 12 17 0 27 0

Internal Medicine 12 0 33 2 28 3 9 0 9 0

Surgery 2 0 14 4 12 0 22 0 18 0

Other 54 0 38 5 40 0 52 0 45 0

Unknown 0 . 1 0 4 0 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

EE001

EE002

EE006

0/12

0/16

0/6

0 25 50 75 100

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

EE001A

EE003R

EE006K

EE002M

EE002L

0/57

0/9

0/27

1/28

3/13

0 25 50 75 100


66 APPENDIX A

Finland

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 16/16

Labs/Hosps providing denom.data *

13/12

Number of blood culture sets *

121484

Number of hospital beds *

8880

Average annual occupancy rate *

86%

Estimated catchment population * 4242000

% total population covered *

82%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 14 242 13 316 0 0 0 0

2000 9 176 12 362 0 0 0 0

2001 13 425 13 606 14 1284 13 274

2002 15 453 15 721 15 1330 14 278

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R


APPENDIX A 67

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=1296

n=2005

n=2612

n=371

n=180

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

Isolate source

Blood 95 7 100 1 100 6 100 1 100 1

CSF

Sex

5 6 0 . 0 . 0 . 0 .

Male 56 5 61 1 35 5 62 0 62 0

Female 43 9 39 1 65 6 38 1 38 1

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 1 5 0 . 0 . 1 0

ICU 3 9 3 0 0 . 1 0 2 0

Internal Medicine 20 6 21 1 13 7 17 3 22 0

Surgery 5 3 13 1 13 9 13 0 10 0

Other 46 6 34 1 41 5 41 0 37 0

Unknown 26 9 29 1 32 5 29 0 29 2

PNSP at laboratory level MRSA at hospital level

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

FI008

FI00C

FI012

FI00H

FI005

FI001

FI015

FI017

FI003

FI002

FI004

FI014

FI009

FI011

FI010

0/38

1/88

1/60

4/110

3/79

6/110

3/41

3/38

6/70

35/405

2/22

4/40

5/49

5/47

6/39

0 25 50 75 100

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

FI001X

FI003A

FI004A

FI008A

FI009A

FI002A

FI00HA

FI005X

FI012A

FI011A

FI010A

FI00CA

FI014A

FI015A

0/110

0/104

0/63

0/55

0/54

1/323

1/143

2/143

1/71

1/69

1/57

3/121

2/56

2/44

0 25 50 75 100


68 APPENDIX A

France

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 21/21

Labs/Hosps providing denom.data *

21/21

Number of blood culture sets *

242938

Number of hospital beds *

18804

Average annual occupancy rate *

84%

Estimated catchment population *

na

% total population covered *

na

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 329 1337 21 1714 0 0 0 0

2002 296 580 * 21 1663 21 2495 21 467

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

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Only hospitals providing denominator data. The Observatoires Regionaux

du Pneumocoque (ORP) and the NRC involved in invasive pneumococcal

infections survey are nationwide distributed.

Pathogen Antimicrobial classes 1999 2000 2001 2002 *

S. pneumoniae Penicillin R . . 11 9

Penicillin I+R . . 47 53

Macrolides I+R . . 49 58

S. aureus Oxacillin/Methicillin R . . 33 33

E. coli Aminopenicillins R . . . 52

Aminoglycosides R . . . 4

Fluoroquinolones R . . . 8

3rd gen. Cephalosporins R . . .


APPENDIX A 69

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=1337 ** n=3377

n=2491

n=341

n=126

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

Isolate source

Blood 77 76 100 33 100 8 100 1 100 2

CSF

Sex

23 24 0 . 0 . 0 . 0 .

Male . . 61 33 44 10 67 0 55 0

Female . . 33 33 56 7 33 1 44 4

Unknown

Age (years)

. . 6 39 0 . 0 . 2 0

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

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

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

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

Unknown

Hospital department

0 0 0 . 0 . 0 . 0 .

ICU . . 23 39 13 9 32 0 18 0

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

Surgery . . 21 34 15 10 22 0 25 3

Other . . 26 26 42 7 28 1 37 2

Unknown

** for 2002

. . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

Data per laboratory were not transmitted

0 25 50 75 100

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

FR164A

FR095A

FR226A

FR126A

FR248A

FR121A

FR194A

FR362A

FR010A

FR208A

FR238A

FR252A

FR165A

FR105A

FR211A

FR138A

FR246A

FR120A

FR037A

FR046A

21/103

7/33

67/256

21/79

106/398

37/128

33/109

28/92

74/243

7/22

67/208

22/62

60/169

48/133

22/60

108/288

129/319

22/52

29/57

24/47

0 25 50 75 100


70 APPENDIX A

Germany

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 19/19

Labs/Hosps providing denom.data *

2/0

Number of blood culture sets *

10317

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population *

na

% total population covered *

na

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 23 417 25 1239 0 0 0 0

2000 18 204 19 890 0 0 0 0

2001 21 211 22 1220 21 1269 20 295

2002 16 232 18 1039 16 1026 13 282

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R


APPENDIX A 71

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=1064

n=4388

n=2253

n=422

n=138

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

Isolate source

Blood 93 2 100 14 100 13 100 1 100 4

CSF

Sex

7 3 0 . 0 . 0 . 0 .

Male 49 3 51 16 37 14 59 1 58 4

Female 38 2 35 13 50 13 33 1 39 4

Unknown

Age (years)

13 1 14 6 14 12 8 0 3 0

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

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

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

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

Unknown

Hospital department

1 0 1 16 0 . 1 0 1 0

ICU 17 4 19 26 11 13 26 0 28 8

Internal Medicine 48 1 44 10 53 11 39 1 35 2

Surgery 2 0 9 12 6 13 8 3 11 0

Other 21 3 17 12 22 16 22 1 23 0

Unknown 12 2 10 10 8 14 5 0 3 25

PNSP at laboratory level MRSA at hospital level

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

DE0102

DE0103

DE0301

DE0302

DE0306

DE0501

DE0702

DE0703

DE0901

DE1402

DE0803

DE1301

DE0902

DE0303

DE0905

DE0204

DE0802

DE0701

DE0101

DE1203

DE0801

0/93

0/6

0/12

0/135

0/47

0/47

0/14

0/14

0/26

0/5

1/158

1/75

2/84

1/41

1/40

4/116

1/26

1/18

2/33

4/26

3/18

0 25 50 75 100

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

DE0703X

DE0802X

DE1401X

DE0701X

DE1402X

DE0702X

DE1301X

DE0902X

DE1203X

DE0501X

DE0803X

DE0102X

DE0905X

DE0202X

DE0901X

DE0105X

DE0306X

DE0302X

DE0301X

DE0101X

DE0204X

DE0801X

DE0303X

0/85

0/56

0/14

3/123

2/61

2/44

11/224

10/190

17/276

8/123

55/670

13/143

23/195

10/79

13/81

5/30

56/329

128/690

31/145

20/91

160/552

7/22

23/63

0 25 50 75 100


72 APPENDIX A

Greece

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 36/36

Labs/Hosps providing denom.data *

0/0

Number of blood culture sets *

na

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population *

na

% total population covered *

na

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 19 192 0 0 0 0

2000 0 0 15 354 0 0 0 0

2001 0 0 25 356 26 619 25 304

2002 0 0 33 368 35 588 28 293

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . . . .

Penicillin I+R . . . .

Macrolides I+R . . . .

S. aureus Oxacillin/Methicillin R 30 51 39 44

E. coli Aminopenicillins R . . 46 46

Aminoglycosides R . . 5 7

Fluoroquinolones R . . 8 13

3rd gen. Cephalosporins R . . 5 6

E. faecalis Aminopenicillins I+R . . 8 4

Aminoglycosides (high-level resistance) . . 57 60

Glycopeptides I+R . . 10 16

E. faecium Aminopenicillins I+R . . 86 75

Aminoglycosides (high-level resistance) . . 45 52

Glycopeptides I+R . . 18 19


APPENDIX A 73

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=0

n=1270

n=1155

n=415

n=161

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

Isolate source

Blood . . 100 42 99 11 100 13 100 19

CSF

Sex

. . 0 . 1 0 0 . 0 .

Male . . 17 36 12 13 16 11 20 16

Female . . 11 38 22 7 16 9 14 23

Unknown

Age (years)

. . 71 45 65 12 68 14 66 19

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

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

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

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

Unknown

Hospital department

. . 96 43 95 11 96 13 97 19

ICU . . 16 68 3 17 44 19 43 26

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

Surgery . . 12 56 10 16 13 12 11 24

Other . . 6 17 2 5 1 0 1 0

Unknown . . 6 43 7 17 5 10 7 27

PNSP at laboratory level MRSA at hospital level

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

Not enough data per laboratory to provide a graph

0 25 50 75 100

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

GR026A

GR042A

GR024A

GR043A

GR044A

GR013A

GR015A

GR028A

GR007A

GR032A

GR030A

GR027A

GR047A

GR033A

GR001A

GR035A

GR018A

GR012A

GR039A

GR040A

GR014A

GR004A

GR005A

GR046A

0/9

1/13

1/7

2/10

9/39

6/24

8/32

21/62

13/36

4/11

23/63

16/43

23/60

36/91

20/45

16/35

7/15

26/53

14/28

147/277

68/115

7/10

33/47

5/7

0 25 50 75 100


74 APPENDIX A

Hungary

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 26/69

Labs/Hosps providing denom.data *

26/56

Number of blood culture sets *

19656

Number of hospital beds *

34569

Average annual occupancy rate *

78%

Estimated catchment population * 9312000

% total population covered *

92%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 14 36 18 301 18 264 17 121

2002 17 61 24 413 24 354 23 169

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . . 8 3

Penicillin I+R . . 22 23

Macrolides I+R . . 19 21

S. aureus Oxacillin/Methicillin R . . 5 9

E. coli Aminopenicillins R . . 40 45

Aminoglycosides R . . 4 6

Fluoroquinolones R . . 5 10

3rd gen. Cephalosporins R . .


APPENDIX A 75

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=97

n=714

n=585

n=255

n=32

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

Isolate source

Blood 67 26 100 7 97 8 100 2 100 0

CSF

Sex

33 16 0 . 3 0 0 . 0 .

Male 67 25 58 8 48 8 54 1 66 0

Female 30 21 40 6 51 8 45 3 34 0

Unknown

Age (years)

3 0 2 8 1 0 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 12 17 14 20 10 8 25 0 31 0

Internal Medicine 31 27 40 4 44 8 27 4 6 0

Surgery 2 0 11 10 8 9 10 0 28 0

Other 46 24 20 4 29 8 24 0 28 0

Unknown 8 13 16 5 10 5 14 6 6 0

PNSP at laboratory level MRSA at hospital level

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

HU005

HU016

HU019

HU006

HU007

HU009

HU020

HU013

0/5

0/5

4/21

2/9

2/8

2/8

2/7

0 25 50 75 100

3/5

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

HU002H

HU002X

HU005W

HU005Y

HU006C

HU007C

HU019D

HU020L

HU021A

HU014A

HU009B

HU019A

HU020A

HU006B

HU013A

HU016A

HU007B

HU015A

HU001U

HU005A

HU004Y

HU002R

HU009A

HU008C

HU021C

HU003A

0/14

0/5

0/6

0/6

0/5

0/6

0/10

0/12

0/46

1/25

1/23

4/88

2/43

1/21

1/21

2/38

1/13

1/12

2/22

3/29

1/9

1/8

8/54

1/5

2/8

5/16

0 25 50 75 100


76 APPENDIX A

Iceland

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 2/2

Labs/Hosps providing denom.data *

2/2

Number of blood culture sets *

8647

Number of hospital beds *

1139

Average annual occupancy rate *

92%

Estimated catchment population *

279000

% total population covered *

100%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 1 48 1 32 0 0 0 0

2000 1 36 1 40 0 0 0 0

2001 2 48 2 63 2 86 2 18

2002 2 43 2 59 2 83 2 25

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Iceland counts 9 hospitals that all report AST-results to EARSS. However,

only 2 of these are relevant to EARSS with respect to denominator informatio

because these are the main hospitals to provide acute and general care.

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R<


APPENDIX A 77

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=175

n=194

n=155

n=31

n=12

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

Isolate source

Blood 95 5 100 1 100 3 100 0 100 0

CSF

Sex

5 11 0 . 0 . 0 . 0 .

Male 52 4 61 1 47 5 58 0 42 0

Female 47 6 39 0 53 1 42 0 58 0

Unknown

Age (years)

1 0 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 5 13 3 0 0 . 0 . 0 .

Internal Medicine 7 0 10 0 9 7 3 0 8 0

Surgery 0 . 4 0 5 14 10 0 0 .

Other 26 7 20 3 5 0 3 0 8 0

Unknown 62 5 64 0 81 2 84 0 83 0

PNSP at laboratory level MRSA at hospital level

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

IS003

IS001

0/12

9/163

0 25 50 75 100

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

IS003A

IS001A

0/10

1/184

0 25 50 75 100


78 APPENDIX A

Ireland

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 22/22

Labs/Hosps providing denom.data *

21/43

Number of blood culture sets *

na

Number of hospital beds *

9643

Average annual occupancy rate *

85%

Estimated catchment population * 3500000

% total population covered *

90%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 10 154 11 511 0 0 0 0

2000 18 202 18 632 0 0 0 0

2001 21 246 19 798 0 0 0 0

2002 20 277 22 998 20 736 15 250

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R 3 5 2 2

Penicillin I+R 19 13 12 12

Macrolides I+R 14 12 12 13

S. aureus Oxacillin/Methicillin R 39 39 42 42

E. coli Aminopenicillins R . . . 61

Aminoglycosides R . . . 3

Fluoroquinolones R . . . 5

3rd gen. Cephalosporins R . . . 2

E. faecalis Aminopenicillins I+R . . . 8

Aminoglycosides (high-level resistance) . . . 39

Glycopeptides I+R . . . 2

E. faecium Aminopenicillins I+R . . . 89

Aminoglycosides (high-level resistance) . . . 17

Glycopeptides I+R . . . 11


APPENDIX A 79

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=879

n=2939

n=721

n=165

n=82

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

Isolate source

Blood 98 13 100 41 100 5 100 2 100 11

CSF

Sex

2 25 0 . 0 . 0 . 0 .

Male 54 14 62 42 42 5 65 2 62 8

Female 44 14 35 39 57 5 34 4 37 17

Unknown

Age (years)

2 5 3 32 1 0 1 0 1 0

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

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

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

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

Unknown

Hospital department

2 15 3 26 1 0 1 0 2 0

ICU 6 14 9 60 4 12 12 0 17 7

Internal Medicine 44 15 31 41 27 3 28 0 15 25

Surgery 2 11 14 55 8 4 12 5 7 0

Other 31 11 25 28 26 4 13 5 4 0

Unknown 17 14 21 39 36 7 35 3 57 11

PNSP at laboratory level MRSA at hospital level

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

IE-J

IE-T

IE-N

IE-Q

IE-A

IE-G

IE-R

IE-U

IE-E

IE-O

IE-K

IE-B

IE-L

IE-H

IE-D

IE-P

IE-W

IE-S

IE-F

IE-C

1/21

1/21

2/28

7/72

1/10

2/19

3/28

10/93

10/91

7/59

9/67

2/14

9/61

1/6

21/125

8/45

5/28

2/11

13/55

3/10

0 25 50 75 100

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

IE-AX

IE-JX

IE-VX

IE-RX

IE-HX

IE-BX

IE-TX

IE-SX

IE-WX

IE-OX

IE-KX

IE-QX

IE-LX

IE-NX

IE-EX

IE-GX

IE-CX

IE-PX

IE-DX

IE-UX

2/34

2/30

1/5

6/26

10/38

14/45

21/67

6/18

12/35

85/246

90/241

88/227

223/533

83/190

112/249

9/20

22/48

49/106

216/461

111/228

0 25 50 75 100


80 APPENDIX A

Israel

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 5/5

Labs/Hosps providing denom.data *

5/5

Number of blood culture sets *

118289

Number of hospital beds *

4409

Average annual occupancy rate *

97%

Estimated catchment population * 2430000

% total population covered *

40%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 5 170 5 381 5 741 5 184

2002 5 177 5 468 5 865 5 254

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . . 5 7

Penicillin I+R . . 40 38

Macrolides I+R . . 11 12

S. aureus Oxacillin/Methicillin R . . 39 38

E. coli Aminopenicillins R . . 62 62

Aminoglycosides R . . 17 16

Fluoroquinolones R . . 21 19

3rd gen. Cephalosporins R . . 9 8

E. faecalis Aminopenicillins I+R . .


APPENDIX A 81

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=347

n=849

n=1600

n=357

n=73

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

Isolate source

Blood 100 39 100 38 100 20 100 2 100 11

CSF

Sex

0 . 0 . 0 . 0 . 0 .

Male 58 35 60 38 43 24 57 1 55 10

Female 42 45 40 39 57 17 43 3 45 12

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

1 50 1 60 0 . 0 . 0 .

ICU 6 33 10 40 6 25 17 2 21 13

Internal Medicine 38 30 44 38 57 19 42 2 21 13

Surgery 2 14 13 45 11 30 8 0 11 0

Other 54 48 34 36 26 17 32 3 48 11

Unknown 0 . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

IL003

IL002

IL005

IL004

IL001

44/141

52/126

8/18

14/29

18/33

0 25 50 75 100

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

IL004A

IL001A

IL005A

IL003A

IL002A

14/79

15/84

13/45

51/123

233/518

0 25 50 75 100


82 APPENDIX A

Italy

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 56/56

Labs/Hosps providing denom.data *

0/0

Number of blood culture sets *

na

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population *

na

% total population covered *

na

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 41 177 56 1158 0 0 0 0

2000 36 116 48 456 0 0 0 0

2001 39 121 53 839 0 0 42 297

2002 50 296 53 1343 17 618 49 602

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R 2


APPENDIX A 83

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=710

n=3796

n=617

n=634

n=258

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

Isolate source

Blood 78 10 100 40 100 21 100 1 100 20

CSF

Sex

22 16 0 . 0 . 0 . 0 .

Male 55 13 58 41 27 18 57 1 58 18

Female 41 9 36 38 38 24 32 1 36 24

Unknown

Age (years)

4 12 6 47 35 21 11 1 7 18

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

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

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

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

Unknown

Hospital department

13 8 17 52 36 22 24 1 19 30

ICU 9 20 14 60 3 15 18 1 18 21

Internal Medicine 30 6 34 35 48 21 34 1 36 20

Surgery 1 11 12 51 6 26 13 2 15 15

Other 45 13 33 34 18 19 18 1 18 26

Unknown 15 13 7 41 24 23 16 0 12 16

PNSP at laboratory level MRSA at hospital level

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

IT004

IT017

IT027

IT028

IT030

IT032

IT040

IT047

IT051

IT061

IT065

IT078

IT079

IT080

IT037

IT059

IT031

IT046

IT054

IT007

IT009

IT019

IT034

IT042

IT070

IT005

IT036

IT091

IT014

IT077

IT024

IT067

IT015

IT038

IT025

IT060

IT021

IT029

IT035

IT003

IT008

IT072

IT012

IT044

0/7

0/11

0/5

0/9

0/9

0/7

0/10

0/9

0/5

0/20

0/8

0/15

0/13

0/5

1/23

1/19

2/35

1/16

1/16

1/11

1/11

3/28

1/9

2/18

1/9

2/16

2/16

1/8

2/15

2/15

1/7

1/7

3/19

2/12

2/11

5/27

2/10

1/5

3/15

4/19

10/41

3/11

2/5

6/14

0 25 50 75 100

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

IT006X

IT013X

IT028X

IT026X

IT007X

IT077X

IT023X

IT019X

IT044X

IT022X

IT024X

IT015X

IT002X

IT061X

IT047X

IT004X

IT080X

IT065X

IT010X

IT038X

IT029X

IT031X

IT056X

IT036X

IT062X

IT074X

IT042X

IT073X

IT050X

IT064X

IT075X

IT072X

IT008X

IT035X

IT041X

IT060X

IT045X

IT070X

IT059X

IT079X

IT021X

IT068X

IT052X

IT009X

IT027X

IT090X

IT067X

IT034X

IT051X

IT032X

IT016X

IT069X

IT088X

IT040X

IT054X

IT014X

IT025X

IT037X

IT030X

IT071X

IT066X

IT085X

IT049X

IT005X

IT012X

IT091X

IT011X

IT089X

IT017X

IT092X

IT046X

0/11

0/7

0/7

1/14

6/51

6/41

4/26

23/128

4/19

10/47

6/28

9/41

2/9

22/98

23/95

4/16

2/8

10/39

21/79

7/26

6/22

58/212

6/21

8/26

4/13

16/52

28/88

12/37

2/6

3/9

6/18

41/121

39/115

18/50

36/100

16/43

15/40

24/64

23/61

24/63

51/129

28/70

11/27

18/43

17/40

15/35

13/29

14/31

11/23

24/49

30/60

10/20

3/6

58/113

73/141

63/118

52/96

69/126

37/66

18/32

24/42

8/14

23/40

61/97

46/73

30/47

15/23

23/35

24/36

68/101

27/37

0 25 50 75 100


84 APPENDIX A

Luxembourg

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 9/14

Labs/Hosps providing denom.data *

7/6

Number of blood culture sets *

10083

Number of hospital beds *

1693

Average annual occupancy rate *

76%

Estimated catchment population *

449000

% total population covered *

100%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 1 9 1 25 0 0 0 0

2000 5 22 4 67 0 0 0 0

2001 8 41 8 85 8 193 7 31

2002 7 27 9 95 9 193 8 30

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R 11


APPENDIX A 85

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=99

n=272

n=348

n=45

n=10

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

Isolate source

Blood 85 18 100 17 100 7 100 0 100 0

CSF

Sex

15 7 0 . 0 . 0 . 0 .

Male 57 16 52 14 32 5 56 0 40 0

Female 43 16 42 21 53 5 40 0 50 0

Unknown

Age (years)

0 . 6 19 15 17 4 0 10 0

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

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

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

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

Unknown

Hospital department

0 . 6 20 15 17 4 0 10 0

ICU 17 12 10 27 8 4 38 0 30 0

Internal Medicine 22 18 24 17 29 10 11 0 10 0

Surgery 1 0 10 30 4 13 9 0 0 .

Other 27 11 19 16 24 4 22 0 40 0

Unknown 32 22 38 13 35 7 20 0 20 0

PNSP at laboratory level MRSA at hospital level

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

LU005

LU004

LU006

LU001

LU002

LU007

LU003

0/5

1/10

1/10

6/49

2/6

2/6

4/11

0 25 50 75 100

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

LU002W

LU006L

LU005I

LU004T

LU007Z

LU001E

LU006A

LU003S

0/7

0/10

1/10

4/28

6/40

22/105

3/14

9/41

0 25 50 75 100


86 APPENDIX A

Malta

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 1/1

Labs/Hosps providing denom.data *

1/1

Number of blood culture sets *

2863

Number of hospital beds *

846

Average annual occupancy rate *

83%

Estimated catchment population *

370000

% total population covered *

93%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 1 11 1 76 0 0 0 0

2001 1 12 1 83 1 67 1 13

2002 1 12 1 87 1 74 1 33

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R .


APPENDIX A 87

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=35

n=246

n=141

n=42

n=4

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

Isolate source

Blood 91 3 100 44 100 13 100 0 100 0

CSF

Sex

9 33 0 . 0 . 0 . 0 .

Male 71 4 60 49 43 20 62 0 25 0

Female 29 10 40 38 57 9 38 0 75 0

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 1 0 0 . 0 .

ICU 20 14 17 59 7 0 57 0 50 0

Internal Medicine 23 13 42 37 50 14 21 0 25 0

Surgery 0 . 20 50 19 19 14 0 25 0

Other 49 0 14 29 8 9 2 0 0 .

Unknown 9 0 8 68 16 13 5 0 0 .

PNSP at laboratory level MRSA at hospital level

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

MT001

2/35

0 25 50 75 100

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

MT001A

105/240

0 25 50 75 100


88 APPENDIX A

Netherlands

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 23/39

Labs/Hosps providing denom.data *

14/18

Number of blood culture sets *

93655

Number of hospital beds *

10644

Average annual occupancy rate *

61%

Estimated catchment population * 4564000

% total population covered *

28%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 21 762 20 1224 0 0 0 0

2000 23 740 24 1388 0 0 0 0

2001 20 723 21 1290 20 1864 14 275

2002 23 851 22 1501 22 2422 22 536

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R


APPENDIX A 89

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=3076

n=5403

n=3947

n=549

n=248

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

Isolate source

Blood 90 1 100 1 99 6 100 1 100 2

CSF

Sex

10 1 0 . 1 0 0 . 0 .

Male 54 1 57 1 46 7 61 1 58 2

Female 45 1 42 1 54 4 37 1 40 3

Unknown

Age (years)

1 3 1 0 0 . 1 0 2 0

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 1 0 0 .

ICU 5 2 7 1 5 10 19 0 10 0

Internal Medicine 11 1 12 0 13 6 14 1 8 10

Surgery 2 0 7 1 6 6 9 0 2 0

Other 21 2 21 1 12 6 16 1 12 0

Unknown 61 1 53 1 64 5 42 1 67 2

PNSP at laboratory level MRSA at hospital level

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

NL003

NL006

NL007

NL013

NL014

NL017

NL018

NL021

NL023

NL029

NL002

NL008

NL011

NL020

NL019

NL009

NL012

NL010

NL005

NL022

NL015

NL025

NL026

NL016

0/38

0/292

0/122

0/33

0/113

0/31

0/48

0/151

0/36

0/91

1/212

1/152

2/278

2/244

2/156

4/304

1/70

3/207

1/49

7/187

2/47

3/67

2/30

4/58

0 25 50 75 100

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

NL003A

NL005A

NL006A

NL006B

NL006C

NL009A

NL009F

NL009I

NL009K

NL010X

NL011A

NL011B

NL011C

NL011D

NL011E

NL011F

NL012A

NL012B

NL012C

NL013A

NL013B

NL016A

NL017A

NL021B

NL021C

NL026A

NL025A

NL022A

NL006D

NL029A

NL008A

NL002X

NL002A

NL020X

NL019X

NL023A

NL014X

NL007A

NL018A

NL022X

NL011X

NL021A

NL009Z

0/119

0/43

0/29

0/68

0/107

0/64

0/115

0/54

0/37

0/341

0/43

0/63

0/61

0/56

0/24

0/31

0/44

0/16

0/52

0/54

0/16

0/79

0/24

0/57

0/48

1/310

1/181

1/166

1/165

1/156

1/139

1/130

2/249

2/248

2/245

1/113

2/179

3/268

1/59

4/226

1/47

2/76

1/34

0 25 50 75 100


90 APPENDIX A

Norway

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 0/0

Labs/Hosps providing denom.data *

0/0

Number of blood culture sets *

na

Number of hospital beds *

na

Average annual occupancy rate *

na

Estimated catchment population *

na

% total population covered *

na

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 1 28 0 0 0 0 0 0

2000 1 388 0 0 0 0 0 0

2001 0 0 0 0 0 0 0 0

2002 0 0 0 0 0 0 0 0

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R


APPENDIX A 91

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=416

n=0

n=0

n=0

n=0

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

Isolate source

Blood 95 2 . . . . . . . .

CSF

Sex

5 0 . . . . . . . .

Male 47 3 . . . . . . . .

Female 52 1 . . . . . . . .

Unknown

Age (years)

1 20 . . . . . . . .

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

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

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

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

Unknown

Hospital department

0 . . . . . . . . .

ICU 0 . . . . . . . . .

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

Surgery 0 . . . . . . . . .

Other 0 . . . . . . . . .

Unknown 100 2 . . . . . . . .

PNSP at laboratory level MRSA at hospital level

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

NO032

9/416

0 25 50 75 100

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

Not enough data per hospital to provide a graph

0 25 50 75 100


92 APPENDIX A

Poland

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 24/24

Labs/Hosps providing denom.data *

24/24

Number of blood culture sets *

33634

Number of hospital beds *

14706

Average annual occupancy rate *

77%

Estimated catchment population * 8508000

% total population covered *

22%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 4 6 19 151 20 103 16 57

2002 7 10 21 186 22 135 19 56

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . .


APPENDIX A 93

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=16

n=337

n=226

n=83

n=30

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

Isolate source

Blood 69 18 100 20 99 10 100 0 100 3

CSF

Sex

31 20 0 . 1 0 0 . 0 .

Male 38 17 62 23 46 11 63 0 53 0

Female 63 20 38 13 54 9 37 0 47 7

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 13 0 12 38 8 16 13 0 27 0

Internal Medicine 56 22 51 17 54 11 47 0 23 14

Surgery 0 . 12 24 15 9 23 0 33 0

Other 31 20 24 12 23 6 17 0 17 0

Unknown 0 . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

Not enough data per laboratory to provide a graph

0 25 50 75 100

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

PL019A

PL008A

PL020A

PL017A

PL006A

PL011A

PL005A

PL012A

PL014A

PL022A

PL003A

PL002A

PL001A

PL013A

PL023A

0/20

1/14

1/10

2/19

3/22

5/34

6/38

1/6

5/30

5/21

12/50

6/23

3/9

3/7

0 25 50 75 100

8/9


94 APPENDIX A

Portugal

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 18/18

Labs/Hosps providing denom.data *

9/9

Number of blood culture sets *

25623

Number of hospital beds *

4309

Average annual occupancy rate *

76%

Estimated catchment population * 1841000

% total population covered *

18%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 12 119 13 369 0 0 0 0

2000 11 97 8 150 0 0 0 0

2001 16 155 16 521 13 418 12 185

2002 14 182 16 543 17 444 13 101

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R


APPENDIX A 95

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=553

n=1583

n=687

n=238

n=47

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

Isolate source

Blood 78 22 100 35 99 21 100 6 100 17

CSF

Sex

22 23 0 . 1 40 0 . 0 .

Male 61 20 62 34 45 25 55 5 55 23

Female 37 26 38 35 54 17 45 8 45 10

Unknown

Age (years)

2 30 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

14 31 10 23 8 4 10 4 17 13

ICU 5 23 11 54 6 24 18 2 13 17

Internal Medicine 21 17 26 37 29 21 20 10 11 0

Surgery 0 . 7 50 8 19 13 0 15 0

Other 68 24 54 27 55 21 48 8 60 25

Unknown 6 22 1 26 2 21 1 0 2 0

PNSP at laboratory level MRSA at hospital level

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

PT012

PT024

PT017

PT016

PT015

PT003

PT001

PT005

PT013

PT007

PT002

PT011

PT019

PT018

PT008

PT009

0/6

0/17

2/20

1/9

3/20

14/93

8/41

7/35

1/5

5/24

5/22

29/106

13/45

12/38

11/34

0 25 50 75 100

4/8

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

PT022A

PT004A

PT016A

PT011A

PT019A

PT015A

PT003A

PT018A

PT005A

PT012A

PT008A

PT007A

PT001A

PT002A

PT024A

PT017A

0/7

2/21

3/23

56/273

33/120

23/79

88/280

25/78

31/87

19/53

18/47

42/97

34/72

34/71

0 25 50 75 100

5/10

105/159


96 APPENDIX A

Romania

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 12/11

Labs/Hosps providing denom.data *

8/8

Number of blood culture sets *

10515

Number of hospital beds *

6201

Average annual occupancy rate *

87%

Estimated catchment population * 10243000

% total population covered *

46%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 0 0 0 0 0 0 0 0

2002 6 10 11 81 8 28 4 11

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . . . 10

Penicillin I+R . . . 50

Macrolides I+R . . . 10

S. aureus Oxacillin/Methicillin R . . . 36

E. coli Aminopenicillins R . . . 64

Aminoglycosides R . . . 19

Fluoroquinolones R . . . 21

3rd gen. Cephalosporins R . . . 18

E. faecalis Aminopenicillins I+R . . .


APPENDIX A 97

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=10

n=81

n=28

n=5

n=6

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

Isolate source

Blood 100 50 100 36 100 21 100 0 100 17

CSF

Sex

0 . 0 . 0 . 0 . 0 .

Male 60 33 62 28 64 33 40 0 17 100

Female 40 75 38 48 32 0 60 0 83 0

Unknown

Age (years)

0 . 0 . 4 0 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 6 60 0 . 0 . 0 .

ICU 0 . 2 100 4 0 0 . 0 .

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

Surgery 0 . 5 100 0 . 0 . 0 .

Other 50 40 56 33 75 19 40 0 0 .

Unknown 50 60 25 30 14 50 60 0 100 17

PNSP at laboratory level MRSA at hospital level

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

Not enough data per laboratory to provide a graph

0 25 50 75 100

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

Not enough data per hospital to provide a graph

0 25 50 75 100


98 APPENDIX A

Slovakia

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 14/14

Labs/Hosps providing denom.data *

14/14

Number of blood culture sets *

15207

Number of hospital beds *

11502

Average annual occupancy rate *

67%

Estimated catchment population * 5117000

% total population covered *

94%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 0 0 0 0 0 0 0 0

2001 4 6 7 37 8 45 6 17

2002 9 16 14 258 14 215 12 79

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . .


APPENDIX A 99

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=22

n=295

n=259

n=88

n=7

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

Isolate source

Blood 59 15 100 8 100 15 100 2 100 0

CSF

Sex

41 11 0 . 0 . 0 . 0 .

Male 45 0 59 9 43 15 48 2 57 0

Female 55 25 40 7 57 14 52 2 43 0

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 9 0 9 4 6 6 19 6 14 0

Internal Medicine 18 0 52 8 46 16 31 0 29 0

Surgery 5 0 13 11 15 13 11 0 14 0

Other 68 20 26 8 33 15 39 3 43 0

Unknown 0 . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

Not enough data per laboratory to provide a graph

0 25 50 75 100

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

SK001A

SK006A

SK011A

SK005A

SK004A

SK002A

SK003A

0/7

0/30

0/15

1/26

3/32

4/42

6/26

0 25 50 75 100


100 APPENDIX A

Slovenia

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 11/15

Labs/Hosps providing denom.data *

11/15

Number of blood culture sets *

28092

Number of hospital beds *

7960

Average annual occupancy rate *

73%

Estimated catchment population * 1933000

% total population covered *

100%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 7 40 10 154 0 0 0 0

2001 10 156 10 270 10 398 10 54

2002 11 101 11 276 11 409 9 45

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R .


APPENDIX A 101

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=297

n=700

n=807

n=72

n=27

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

Isolate source

Blood 92 20 100 18 100 10 100 0 100 0

CSF

Sex

8 17 0 . 0 . 0 . 0 .

Male 68 21 59 19 38 11 57 0 56 0

Female 32 18 41 16 62 9 43 0 44 0

Unknown

Age (years)

0 . 0 . 0 . 0 . 0 .

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 16 17 15 36 9 15 13 0 22 0

Internal Medicine 36 21 50 13 54 10 39 0 44 0

Surgery 1 0 13 33 6 10 10 0 7 0

Other 47 21 22 8 31 9 39 0 26 0

Unknown 0 . 0 . 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

SI009

SI001

SI006

SI004

SI008

SI003

SI010

SI007

SI002

3/22

17/108

1/5

13/56

4/17

9/38

7/28

2/7

3/10

0 25 50 75 100

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

SI006A

SI010A

SI003A

SI007A

SI008A

SI009A

SI001A

SI002A

SI004A

SI003B

SI005A

0/13

1/15

8/84

4/30

15/85

9/50

48/256

7/36

22/89

2/7

8/27

0 25 50 75 100


102 APPENDIX A

Spain

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 37/37

Labs/Hosps providing denom.data *

28/28

Number of blood culture sets *

136260

Number of hospital beds *

14043

Average annual occupancy rate *

82%

Estimated catchment population * 7714000

% total population covered *

19%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 0 0 0 0 0 0 0 0

2000 33 584 30 836 0 0 0 0

2001 36 649 35 1013 27 1967 26 371

2002 35 658 36 1196 28 2483 35 566

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R . 11 11 10

Penicillin I+R . 33 37 33

Macrolides I+R . 22 31 26

S. aureus Oxacillin/Methicillin R . 28 23 23

E. coli Aminopenicillins R . . 59 60

Aminoglycosides R . . 7 8

Fluoroquinolones R . . 17 19

3rd gen. Cephalosporins R . .


APPENDIX A 103

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=1891

n=3045

n=4439

n=776

n=160

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

Isolate source

Blood 94 34 100 25 100 18 100 1 100 3

CSF

Sex

6 37 0 . 0 . 0 . 0 .

Male 63 32 64 25 49 21 64 2 57 3

Female 37 38 35 22 51 15 35 0 41 3

Unknown

Age (years)

0 . 1 57 0 . 0 . 3 0

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

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

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

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

Unknown

Hospital department

2 40 2 16 1 17 1 0 0 .

ICU 8 29 14 37 4 21 25 1 14 0

Internal Medicine 32 32 33 26 35 19 24 1 25 0

Surgery 1 11 11 30 9 16 10 1 16 4

Other 57 37 40 18 51 18 40 1 45 6

Unknown 2 37 2 31 1 17 1 0 1 0

PNSP at laboratory level MRSA at hospital level

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

ES047

ES043

ES011

ES021

ES018

ES015

ES005

ES031

ES003

ES002

ES048

ES044

ES050

ES009

ES012

ES040

ES034

ES049

ES001

ES014

ES046

ES016

ES042

ES019

ES032

ES010

ES017

ES007

ES041

ES008

ES026

ES013

ES029

ES038

ES020

ES004

ES045

1/15

5/27

26/107

11/45

6/24

6/23

8/30

8/30

5/18

12/39

9/29

14/45

50/159

18/57

20/63

40/125

4/12

2/6

44/130

16/47

7/20

24/68

56/152

30/81

10/27

38/95

8/19

25/59

6/13

13/27

4/8

7/13

7/13

26/48

36/65

5/9

5/9

0 25 50 75 100

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

ES045A

ES005A

ES020A

ES013A

ES011A

ES015A

ES040A

ES048A

ES021A

ES047A

ES034A

ES043A

ES044A

ES018A

ES003A

ES016A

ES038A

ES032A

ES014A

ES031A

ES042A

ES017A

ES008A

ES007A

ES041A

ES001A

ES004A

ES012A

ES019A

ES009A

ES046A

ES002A

ES029A

ES049A

ES026A

0/12

4/79

2/38

4/70

6/102

2/24

6/53

9/73

12/90

7/51

2/14

9/61

14/87

5/31

6/35

26/139

25/131

9/47

7/36

15/71

23/103

13/56

27/115

31/120

33/127

45/163

19/68

29/103

69/217

55/171

4/12

25/74

25/63

41/87

104/172

0 25 50 75 100


104 APPENDIX A

Sweden

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 21/63

Labs/Hosps providing denom.data *

20/57

Number of blood culture sets *

176079

Number of hospital beds *

18447

Average annual occupancy rate *

88%

Estimated catchment population * 6276000

% total population covered *

71%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 24 805 24 1320 0 0 0 0

2000 19 803 19 1478 0 0 0 0

2001 20 788 21 1633 20 2800 20 671

2002 21 830 21 1836 21 3066 21 696

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R<


APPENDIX A 105

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=3226

n=6267

n=4687

n=825

n=350

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

Isolate source

Blood 97 2 100 1 100 4 100 0 100 0

CSF

Sex

3 2 0 . 0 . 0 . 0 .

Male 50 2 58 1 44 5 65 0 56 1

Female 47 2 38 1 51 4 29 0 39 0

Unknown

Age (years)

2 0 4 0 4 2 6 0 5 0

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

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

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

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

Unknown

Hospital department

0 . 0 . 0 . 0 . 0 .

ICU 9 3 7 1 4 3 8 0 10 0

Internal Medicine 42 2 44 0 41 5 33 0 36 0

Surgery 4 2 15 1 21 4 27 0 29 0

Other 44 2 33 1 34 5 31 0 24 1

Unknown 1 0 1 0 0 . 0 . 0 .

PNSP at laboratory level MRSA at hospital level

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

SE400

SE320

SE600

SE300

SE310

SE250

SE610

SE240

SE230

SE730

SE350

SE430

SE620

SE100

SE440

SE450

SE200

SE220

SE120

SE110

SE540

1/203

1/158

1/156

1/94

2/183

1/85

2/140

2/137

1/63

1/52

3/140

3/139

3/138

9/384

6/234

5/195

9/278

4/113

8/182

3/58

4/44

0 25 50 75 100

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

SE100C

SE110A

SE110B

SE200A

SE200B

SE200C

SE220A

SE220C

SE220D

SE230B

SE240A

SE240B

SE240C

SE250B

SE320B

SE320C

SE350B

SE350C

SE400A

SE400C

SE400D

SE430B

SE430C

SE430D

SE440B

SE440C

SE450A

SE450C

SE450D

SE450E

SE600C

SE610A

SE610B

SE610C

SE620B

SE620C

SE620D

SE730A

SE730B

SE730C

SE730D

SE730E

SE730F

SE310A

SE430A

SE350A

SE120A

SE440A

SE400B

SE230A

SE320A

SE600A

SE620A

SE540A

SE220B

SE100B

SE100A

SE250A

SE120B

SE450B

SE300A

0/37

0/102

0/36

0/263

0/147

0/63

0/118

0/29

0/13

0/25

0/156

0/27

0/65

0/77

0/32

0/17

0/31

0/35

0/243

0/50

0/5

0/15

0/15

0/35

0/67

0/62

0/171

0/50

0/50

0/30

0/29

0/197

0/65

0/98

0/11

0/49

0/10

0/24

0/19

0/23

0/6

0/23

0/53

1/337

1/218

1/196

2/315

2/291

1/124

1/105

2/171

3/251

3/247

1/80

1/51

4/185

14/567

3/120

1/37

1/32

6/130

0 25 50 75 100


106 APPENDIX A

United Kingdom

Denominators

Table 1.Reference data of 2002

Total

Labs/Hosps reporting to EARSS 23/26

Labs/Hosps providing denom.data *

18/18

Number of blood culture sets *

141543

Number of hospital beds *

13664

Average annual occupancy rate *

82%

Estimated catchment population * 9685000

% total population covered *

16%

* Based on labs/hospitals providing denominator data

University/tertiary care

General/secondary care

Other

Figure 1.Types of hospital in 2002

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

Year S. pneumoniae S. aureus

E. coli

Enterococci

Labs Isolates Labs Isolates Labs Isolates Labs Isolates

1999 22 240 23 653 0 0 0 0

2000 28 503 27 1495 0 0 0 0

2001 26 569 25 1518 0 0 0 0

2002 23 610 21 1703 0 0 0 0

Antibiotic resistance in 1999-2002

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

Figure 2.Geographic distribution of laboratories in 2002

Pathogen Antimicrobial classes 1999 2000 2001 2002

S. pneumoniae Penicillin R 4 4 3 3

Penicillin I+R 7 6 4 5

Macrolides I+R 15 18 13 13

S. aureus Oxacillin/Methicillin R 33 40 44 44

E. coli Aminopenicillins R . . . .

Aminoglycosides R . . . .

Fluoroquinolones R . . . .

3rd gen. Cephalosporins R . . . .

E. faecalis Aminopenicillins I+R . . . .

Aminoglycosides (high-level resistance) . . . .

Glycopeptides I+R . . . .

E. faecium Aminopenicillins I+R . . . .

Aminoglycosides (high-level resistance) . . . .

Glycopeptides I+R . . . .


APPENDIX A 107

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

Characteristic S. pneumoniae S. aureus E. coli

E. faecalis E. faecium

n=1922

n=5369

n=0

n=0

n=0

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

Isolate source

Blood 97 5 100 42 . . . . . .

CSF

Sex

3 4 0 . . . . . . .

Male 52 6 62 43 . . . . . .

Female 48 5 37 39 . . . . . .

Unknown

Age (years)

0 . 0 . . . . . . .

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

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

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

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

Unknown

Hospital department

2 9 2 23 . . . . . .

ICU 6 2 8 69 . . . . . .

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

Surgery 2 8 12 55 . . . . . .

Other 48 6 32 31 . . . . . .

Unknown 5 7 5 44 . . . . . .

PNSP at laboratory level MRSA at hospital level

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

UK016

UK004

UK034

UK022

UK007

UK032

UK015

UK012

UK025

UK023

UK026

UK008

UK038

UK001

UK002

UK010

UK017

UK031

UK027

UK030

UK033

UK009

UK011

UK020

UK005

UK037

UK044

0/15

1/99

1/66

1/58

6/259

3/125

1/37

3/94

2/60

4/98

1/22

2/40

6/117

3/56

3/55

2/35

8/136

3/51

4/60

5/69

3/38

1/11

4/41

6/55

22/186

3/16

4/20

0 25 50 75 100

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

UK030A

UK011A

UK001A

UK020A

UK025A

UK026A

UK005A

UK017A

UK044A

UK033A

UK002A

UK015A

UK016A

UK023A

UK034A

UK038B

UK007A

UK008A

UK010A

UK017B

UK012A

UK032A

UK037A

UK029A

UK031A

UK005B

UK022A

UK027A

UK004A

11/97

28/124

23/91

44/151

54/183

121/401

150/487

110/342

38/110

5/14

28/77

43/115

30/77

107/257

79/189

158/365

303/691

9/20

17/36

150/306

170/340

133/265

65/111

6/10

57/91

16/25

183/280

62/81

28/31

0 25 50 75 100


APPENDIX B 109

Appendix B. Technical Notes

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

Inclusion criteria

To be included in the analyses presented in Chapter 3, countries, laboratories and hospitals had to

provide both denominator data and AST results in 2002. Also, a laboratory had to indicate blood

culture frequencies and the number of hospital beds for each hospital served.

Denmark and Ireland reported aggregated data and were therefore not included in

laboratory/hospital-specific analysis in Chapter 3. However, the data provided by these countries are

included in Appendix A (country summary sheets).

Presentation of variables per country

Catchment population, number of beds, patient-days and number of blood culture sets were

aggregated by country.

Formulas

From each hospital, either hospital occupancy rate or the number of patient-days was required.

Occupancy rates could then be derived from patient-days, and vice versa.

Hospital occupancy rate was calculated if not provided or if the occupancy was considered

implausible (e.g. less than 25% or more than 125%). The following formula was used:

no. of patient-days / (no. of beds × 365).

The average occupancy rate per country was calculated as follows:

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

If the number of patient-days per hospital was not provided or if considered implausible (e.g. when

yielding a calculated occupancy rate of less than 25% or more than 125%), the value was estimated

according to the following formula:

no. of beds × annual occupancy rate × 365.

For calculation of the total catchment population, hospitals providing single speciality

(superregional) type of care (classified as other, e.g. oncology or psychiatric hospitals) were not

included because we considered this population as probably overlapping with the catchment

populations of the hospitals providing general care.

Population coverage per country was calculated using the following formula:

Σ(hospital catchment population)/total population

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

Detection limits for MRSA and VRE incidences (Table 3.3) were calculated in case of reported nulincidence

so that p < p upper limit of confidence interval as follows:

p < (1-p) n

at p=0.05, the detection limit is then given by

(1-p) n = 0.05


110 APPENDIX B

in which n is the number of isolates tested. After calculation of p, the detection limit for the incidence

rate can be calculated as follows:

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

Notes to Chapter 5

Inclusion criteria maps

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

Trend analysis

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

Aggregated data

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

national pneumococci surveillance system


APPENDIX C 111

Appendix C

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

na= not available

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

pneumococci surveillance system.


112 APPENDIX C

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

cephalosporins, fluoroquinolones, gentamicin and tobramycin.

Country Amino- 3rd generation Fluoroquinolones Gentamicin/ Tobramycin

penicillins cephalosporins Netilmicin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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