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SURVEILLANCE REPORT Antimicrobial resistance surveillance in Europe 2009 www.ecdc.europa.eu

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SURVEILLANCE REPORT

Antimicrobial resistance

surveillance in Europe

2009

www.ecdc.europa.eu

Antimicrobial resistance

surveillance in Europe

Annual report of the European Antimicrobial Resistance Surveillance Network (EARS-Net)

2009

ii

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Suggested citation for full report:European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2009. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). Stockholm: ECDC; 2010.

Cover picture © istockphoto

ISBN 978-92-9193-227-6

doi 10.2900/35994

© European Centre for Disease Prevention and Control, 2010.

Reproduction is authorised, provided the source is acknowledged.

iii

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Contents

Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Countries participating in EARS-Net 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

National institutions/organisations participating in EARS-Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

2 Escherichia coli and Staphylococcus aureus: bad news and good news. Analysis of data from laboratories reporting continuously from 2002 to 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

2.1 Methods of analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

2.2 Limitations of the analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

2.3 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

3 External Quality Assessment Exercise (EQA) 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

3.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

3.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

3.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

4 EARS-Net laboratory/hospital denominator data 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.3 Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.4 Population coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.5 Hospital denominator information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.6 Hospital characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.7 Laboratory denominator information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

4.8 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

5 Antimicrobial resistance in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

5.1 Streptococcus pneumoniae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5.2 Staphylococcus aureus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

5.3 Enterococci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

5.4 Escherichia coli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

5.5 Klebsiella pneumoniae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

5.6 Pseudomonas aeruginosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

5.7 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Annex 1: Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Annex 2: Country summary sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

List of tables

2.1: Average numbers of Escherichia coli and Staphylococcus aureus isolates per country reported yearly from 2002 to 2009 by laboratories participating continuously in EARSS/EARS-Net during this time interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63.1: Escherichia coli (9448): Minimum inhibitory concentration (MIC) and intended results reported by reference laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.2: Klebsiella pneumoniae (9449): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.3: Streptococcus pneumoniae (9450): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.4: Pseudomonas aeruginosa (9451): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.5: Pseudomonas aeruginosa (9452): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.6: Staphylococcus aureus (9453): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134.1: Hospital denominator data for 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174.2: Hospital characteristics for 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174.3: Laboratory denominator information for 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.1: Number of invasive S. pneumoniae isolates and proportion of penicillin-non-susceptible (PNSP), penicillin-resistant (PRSP), macrolide non-susceptible (MNSP), single penicillin (PEN), single macrolides (MACR) and dual non-susceptible (DUAL) isolates, including 95% confidence intervals (95% CI), reported per country in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265.2: Distribution of single penicillin, single macrolides and dual penicillin-macrolides non-susceptibility, among the most common serogroups reported per country in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265.3: Number of invasive S. aureus isolates and proportion resistant to meticillin (MRSA) and rifampin (RIF), including 95% confidence intervals (95% CI), reported per country in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295.4: Number of invasive E. faecalis and E. faecium isolates and proportion of high-level aminoglycoside-resistant E. faecalis and vancomycin-resistant E. faecium (%R), including 95% confidence intervals (95% CI), reported per country in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .345.5: Number of invasive E. coli isolates and proportion aminopenicillins, third-generation cephalosporins, fluoroquinolones, aminoglycosides and multiresistance (%R), including 95% confidence intervals (95% CI), reported per country in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . .395.6: Number of invasive E. coli isolates resistant to third-generation cephalosporins (CREC) and proportion of ESBL positive among these isolates, as ascertained by the participating laboratories in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395.7: Overall resistance and resistance combinations among invasive Escherichia coli isolates tested against aminopenicillins, fluoroquinolones, third-generation cephalosporins and aminoglycosides (n= 42 898) in Europe, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405.8: Number of invasive K. pneumoniae isolates and proportion of fluoroquinolones, third-generation cephalosporins, aminoglycosides and multiresistance (%R), including 95% confidence intervals (95% CI), reported per country in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555.9: Number of invasive K. pneumoniae isolates resistant to third-generation cephalosporins (CRKP) and proportion of ESBL positive among these isolates, as ascertained by the participating laboratories in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555.10: Overall resistance and resistance combinations among invasive Klebsiella pneumoniae isolates tested against fluoroquinolones, third-generation cephalosporins and aminoglycosides (n= 10 952) in Europe, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565.11: Number of invasive P. aeruginosa isolates and proportion of piperacillin±tazobactam, fluoroquinolones, ceftazidime, aminoglycosides, carbapenems and multiresistance (%R), including 95% confidence intervals (95% CI), reported per country in 2009 . . . . . . . . . .685.12: Overall resistance and resistance combinations among invasive Pseudomonas aeruginosa isolates tested against at least three antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems (n= 8 376) in Europe, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

List of figures

2.1: Yearly number of bloodstream infections caused by Escherichia coli and Staphylococcus aureus. EARSS/EARS-Net 2002–2009 (22 countries/198 laboratories) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72.2: Proportion of third-generation cephalosporin-resistant Escherichia coli (CREC) and meticillin-resistant Staphylococcus aureus (MRSA). EARSS/EARS-Net 2002–2009 (22 countries/198 laboratories) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72.3: Combined resistance (R) of Escherichia coli to aminopenicillins, third-generation cephalosporins, fluoroquinolones and aminoglycosides. EARSS/EARS-Net 2002–2009 (22 countries/198 laboratories) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73.1: Proportion of participating laboratories returning reports per country, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.2: Adherence to guidelines: number of laboratories per country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.1: Number of laboratories and hospitals reporting AMR and/or denominator data in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

4.2: Proportion of small, medium and large hospitals per country, based on the number of beds, for all hospital reporting both antimicrobial resistance data and denominator data in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.1: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215.2: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to macrolides in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225.3: Streptococcus pneumoniae: proportion of invasive isolates with dual non-susceptibility to penicillin and macrolides in 2009 . . . . . . . . . . . . . . . .225.4: Streptococcus pneumoniae: trend of penicillin non-susceptibility by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235.5: Streptococcus pneumoniae: trend of macrolides non-susceptibility by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .245.6: Streptococcus pneumoniae: trend of dual non-susceptibility (penicillin and macrolides) by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.7: Distribution of serogroups and the resistance profile of S. pneumoniae isolates per serogroup in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275.8: Staphylococcus aureus: proportion of invasive isolates resistant to meticillin (MRSA) in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295.9: Staphylococcus aureus: trend of meticillin-resistance (MRSA) by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .305.10: Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .325.11: Enterococcus faecalis: trends of high-level aminoglycoside resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335.12: Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .345.13: Enterococcus faecium: trends of vancomycin resistance by country 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355.14: Escherichia coli: proportion of third-generation cephalosporin resistance in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405.15: Escherichia coli: proportion of invasive isolates with resistance to fluoroquinolones in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415.16: Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415.17: Escherichia coli: trends of aminopenicillin resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425.18: Escherichia coli: trends of third-generation cephalosporin resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435.19: Escherichia coli: trends of fluoroquinolone resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445.20: Escherichia coli: trends of aminoglycoside resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455.21: Escherichia coli: trends of combined resistance (resistant to fluoroquinolones, third-generation cephalosporins and aminoglycosides) by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465.22: Klebsiella pneumoniae: proportion of invasive isolates resistant to third-generation cephalosporins in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .495.23: Klebsiella pneumoniae: proportion of invasive isolates resistant to fluoroquinolones in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .495.24: Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505.25: Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505.26: Klebsiella pneumoniae: trend of third-generation cephalosporins resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515.27: Klebsiella pneumoniae: trend of fluoroquinolones resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525.28: Klebsiella pneumoniae: trend of aminoglycosides resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535.29: Klebsiella pneumoniae: trend of multiresistance (third-generation cephalosporins, fluoroquinolones and aminoglycosides) by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545.30: Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillin±tazobactam in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595.31: Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595.32: Pseudomonas aeruginosa: proportion of invasive isolates resistant to fluoroquinolones in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .605.33: Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .605.34: Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615.35: Pseudomonas aeruginosa: trend of piperacillin±tazobactam resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .625.36: Pseudomonas aeruginosa: trend of ceftazidime resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635.37: Pseudomonas aeruginosa: trend of fluoroquinolones resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .645.38: Pseudomonas aeruginosa: trend of aminoglycosides resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655.39: Pseudomonas aeruginosa: trend of carbapenems resistance by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .665.40: Pseudomonas aeruginosa: trend of multiresistance (R to three or more antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems) by country, 2006–2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

AMR Antimicrobial resistance

AmpC Ampicillinase C

ARMed Antibiotic resistance surveillance and control in the Mediterranean region

AST Antimicrobial susceptibility testing

BSAC British Society for Antimicrobial Chemotherapy

BSI Bloodstream infections

CC Clonal complex

CMY Cephamycinase

CLSI Clinical and Laboratory Standards Institute

CREC Third-generation cephalosporin-resistant E. coli

CRKP Third-generation cephalosporin-resistant K. pneumoniae

CSF Cerebrospinal fluid

DCFP Data Check and Feedback Programme

DEFS Data Entry & Feedback Software

DG SANCO Directorate-General for Health and Consumer Protection

DIN Deutsche Industrie Norm (German)

DNA Deoxyribonucleic acid

EARSS European Antimicrobial Resistance Surveillance System

EARS-Net European Antimicrobial Resistance Surveillance Network

ECDC European Centre for Disease Prevention and Control

ENSP Erythromycin non-susceptible Streptococcus pneumoniae

EU European Union

EQA External quality assessment

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 Fluoroquinolone-resistant E. coli

GISA Glycopeptide intermediate-resistant Staphylococcus aureus

GRC Commissie Richtlijnen Gevoeligheidsbepalingen (Dutch)

ICU Intensive care unit

IMP Imipenemase

KPC Klebsiella pneumoniae carbapenemase

MIC Minimum inhibitory concentration

MLS Macrolide, lincosamide and streptogramin

MNSP Macrolide non-susceptible S. pneumoniae

MRSA Meticillin-resistant Staphylococcus aureus

NDM-1 New Delhi metallo-beta-lactamase 1

NRL National reference laboratories

NWGA Norwegian Working Group on Antimicrobials

OXA Oxacillinase gene

PBP Penicillin-binding protein

PCV Pneumococcal conjugate vaccine

PNSP Penicillin-non-susceptible Streptococcus pneumoniae

PRSP Penicillin-resistant Streptococcus pneumoniae

RNA Ribonucleic acid

SeqNet European Network of Laboratories for Sequence Based Typing of Microbial Pathogens

SFM Comité de l’Antibiogramme de la Société Française de Microbiologie (French)

SIR Sensitive, intermediate, resistant

SHV Sulfhydryl-variable extended-spectrum beta-lactamase gene

Spa-typing S. aureus protein A-gene sequence typing

SRGA Swedish Reference Group for Antibiotics

TESSy The European Surveillance System (at ECDC)

TEM Temoneira extended-spectrum beta-lactamase gene

UK NEQAS United Kingdom National External Quality Assessment Scheme for Microbiology

VISA Vancomycin-intermediate Staphylococcus aureus

VIM Verona integron-encoded metallo-beta-lactamase

VRE Vancomycin-resistant enterococci

VREF Vancomycin-resistant Enterococcus faecalis

VRSA Vancomycin-resistant Staphylococcus aureus

WHO World Health Organization

WHONET WHO microbiology laboratory database software

Abbreviations and acronyms

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Countries participating in EARS-Net 2010

Participating countriesNon participating countries

AT

BE

BG

CY

CZ

DE

DK

EE

ES

FI

FR

EL

HU

IE

IS

IT

LT

LU

LV

MT

NL

NO

PL

PT

RO

SE

SI

UK

AT AustriaBE BelgiumBG BulgariaCY CyprusCZ Czech RepublicDE GermanyDK DenmarkEE EstoniaEL GreeceES Spain

FI FinlandFR FranceHU HungaryIE IrelandIS IcelandIT ItalyLT LithuaniaLU LuxembourgLV LatviaMT Malta

NL NetherlandsNO NorwayPL PolandPT PortugalRO RomaniaSE SwedenSI SloveniaUK United Kingdom

As of 1 January 2010, only EU and EEA Member States can report data to EARS-Net. Antimicrobial resistance surveillance data from five countries previously participating in EARSS (Bosnia-Herzegovina, Croatia, Israel, Switzerland and Turkey) are therefore not included in this report.

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Austria

Federal Ministry of HealthMedical University ViennaElisabethinen Hospital, Linz www.elisabethinen.or.at

Belgium

Scientific Institute of Public Healthwww.iph.fgov.be

University of Antwerp

Bulgaria

Alexander University Hospital, SofiaNational Center of Infectious and Parasitic Diseases

Cyprus

Nicosia General Hospital

Czech Republic

National Institute of Public HealthNational Reference Laboratory for Antibiotics

Denmark

Statens Serum Institut, Danish Study Group for Antimicrobial Resistance Surveillance (DANRES)www.danmap.org

Estonia

Health BoardEast-Tallinn Central HospitalTartu University Hospital

Finland

National Institute for Health and Welfare, Finnish Hospital Infection Program (SIRO)www.thl.fi/siro

Finnish Study Group for Antimicrobial Resistance (FiRe)www.finres.fi

France

Pitié-Salpêtrière HospitalNational Institute for Public Health Surveillancewww.invs.sante.fr

French National Observatory for the Epidemiology of Bacterial Resistance to Antimicrobials (ONERBA): Azay-Résistance, Île-de-France and Réussir networkswww.onerba.org

National Reference Centre for Pneumococci (CNRP)

Germany

Robert Koch Institute

Greece

Hellenic Pasteur InstituteNational School of Public Health

National and Kapodistrian University of Athens, Medical School www.mednet.gr/whonet

Hungary

National Centre for Epidemiologywww.antsz.hu

Ireland

Health Protection Surveillance Centre (HPSC)www.hpsc.ie

Iceland

National University Hospital of Iceland Centre for Health Security and Infectious Disease Control

Italy

National Institute of Public Healthwww.simi.iss.it/antibiotico_resistenza.htm

Latvia

Paul Stradins Clinical University HospitalState Agency ‘Infectology Centre of Latvia’

Lithuania

National Public Health Surveillance LaboratoryInstitute of Hygiene

Luxembourg

National Health LaboratoryMicrobiology Lab, Luxembourg’s Hospital Centre

Malta

Hospital of Malta

Netherlands

National Institute for Public Health and the Environment

Norway

University Hospital of North NorwayNorwegian Institute of Public HealthSt. Olav University Hospital, Trondheim

Poland

National Medicines Institute

Portugal

National Institute of Health Dr. Ricardo Jorge www.insarj.pt

Ministry of HealthDirectorate-General of Health

Romania

National Institute of Research and Development for Microbiology and Immunology ‘Cantacuzino’Institute of Public Health

National institutions/organisations participating in EARS-Net

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Slovenia

National Institute of Public HealthUniversity of Ljubljana

Spain

Health Institute Carlos lll www.isciii.es/htdocs/en/index.jsp

National Centre of Epidemiology

Sweden

Swedish Institute for Infectious Disease Controlwww.smittskyddsinstitutet.se

United Kingdom

Health Protection Agencywww.hpa.org.uk

Health Protection ScotlandPublic Health Agency Northern Ireland

1

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

This is the first Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net) after the transition of the European Antimicrobial Resistance Surveillance System (EARSS) to the European Centre of Disease Prevention and Control (ECDC) by 1 January 2010. This report represents the continuation of the series of highly valued EARSS Annual Reports pub-lished by the network since 2001.

During the last decade, antimicrobial resistance has moved steadily to a more and more prominent position on the public health agenda in Europe. The surveillance of antimicrobial resistance conducted previously by EARSS, and currently by EARS-Net, has played an impor-tant role to provide documentation of the occurrence and spread of antimicrobial resistance, and to increase awareness of the problem at the political level, among public health officials and in the scientific community.

Based on the antimicrobial resistance data reported to EARS-Net by 28 countries in 2009, and on the results of trend analyses including EARSS data from previous years, the resistance situation in Europe displays large variation depending on pathogen type, antimicrobial substance and geographic region.

In 2009, the most concerning resistance results come from the rapidly decreasing susceptibility of invasive Escherichia coli to basically all antimicrobial agents included in the EARS-Net surveillance except carbap-enems, and from the high prevalence of resistance in Klebsiella pneumoniae to third-generation cepha-losporins, fluoroquinolone and aminoglycosides. In half of the reporting countries, the proportion of multire-sistant K. pneumoniae isolates (combined resistance to third-generation cephalosporins, fluoroquinolones and aminoglycosides) is above 10%, and a few countries are now also reporting high proportions of resistance to carbapenems. These antibiotics have been widely used in many countries due to the increasing rate of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae with a consequent impact on the emergence of carbapenemase production (VIM, KPC and NDM-1), especially in K. pneumoniae.

The highest resistance proportions in E. coli were reported for aminopenicillins ranging up to 66%. Irrespective of the high level of resistance, proportions continue to increase even in countries already pre-senting resistance levels well above 50%. Resistance to third-generation cephalosporins in E. coli has also increased significantly during the last four years in more than half of the reporting countries. This resistance is directly linked to the high proportions (85–100%) of ESBL positives among the resistant isolates in countries reporting on ESBL in 2009.

Other trends in the occurrence of resistance reported to EARS-Net bring hope that national efforts on infection control and efforts targeted at containment of resistance may in some cases bring the development of resistance to a halt, or even reverse undesirable resistance trends, as exemplified by the development for meticillin-resist-ant Staphylococcus aureus (MRSA). Even though the proportion of MRSA among Staphylococcus aureus is still above 25% in 10 out of 28 countries, the occurrence of MRSA is stabilising or decreasing in some countries and a sustained decrease was observed in Austria, France, Ireland, Latvia and UK.

Furthermore, the United Kingdom has shown a consist-ent reduction of resistant proportions in K. pneumoniae for all the antibiotic classes under surveillance, and in a few countries (Greece, Germany, Italy and France) the efforts to control glycopeptide resistance in Enterococcus faecium seem to be successful and result-ing in a continuous decrease of proportions of resistant isolates. Meanwhile, high-level aminoglycoside resist-ance in Enterococcus faecalis seems to stabilise at a relatively high level. The majority of countries reported proportions of resistant isolates between 30% and 50%.

For Streptococcus pneumoniae, non-susceptibility to penicillin is generally stable in Europe and non-suscep-tibility to macrolides has declined in six countries while no country reported increasing trends. For Pseudomonas aeruginosa, high proportions of resistance to fluoroqui-nolones, carbapenems and combined resistance have been reported by many countries, especially in southern and eastern Europe.

For several antimicrobial and pathogen combinations, e.g. fluoroquinolone resistance in E. coli, K. pneumoniae, P. aeruginosa and for MRSA, a north to south gradient is evident in Europe. In general, lower resistance propor-tions are reported in the north and higher proportions in the south of Europe likely reflecting differences in infection control practices, presence or absence of legis-lation regarding prescription of antimicrobials and other factors known to influence the occurrence of resist-ance. However, for K. pneumoniae, increasing trends of resistance to specific antibiotic classes and of multire-sistance have been observed also in northern European countries, like Denmark and Norway, with a traditionally prudent approach to the antibiotic use.

In addition to the regular trend analysis and situation overview, this 2009 EARS-Net report features a new focus chapter providing in-depth analysis for E. coli and MRSA. These analyses are based exclusively on data from laboratories reporting consistently over several years. The in-depth analysis confirms a consistent rise in multidrug resistance and reveals a steady and sig-nificant decline of antimicrobial susceptibility in E. coli

Summary

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

over several years. For MRSA, the observed decline likely reflects the efficacy of infection control measures at hospital level, and may even leave some hope for the success of containment strategies in other areas.

In conclusion, the data reported to EARS-Net for 2009 by the participating countries provide a knowledge baseline on the occurrence of antimicrobial resistance in Europe and document the unfortunate and steadily diminishing antimicrobial treatment options for major bacterial pathogens.

3

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

The European Antimicrobial Resistance Surveillance Network (EARS-Net) is a European-wide network of national surveillance systems, providing European refer-ence data on antimicrobial resistance for public health purposes. The network is coordinated and funded by the European Centre for Disease Prevention and Control (ECDC).

The surveillance of antimicrobial resistance within the EU is carried out in agreement with Decision No 2119/98/EC of the European Parliament and of the Council of 24 September 1998 and Regulation (EC) No 851/2004 of the European Parliament and of the Council of 21 April 2004 establishing a European Centre for Disease Prevention and Control.

The coordination of EARS-Net (former EARSS) was trans-ferred from the Dutch National Institute for Public Health and the Environment (RIVM) to ECDC in January 2010. At the same time, EU Member States were requested to nominate disease-specific contact points for antimicro-bial resistance. Five non-EU Member States previously participating in EARSS (Bosnia-Herzegovina, Croatia, Israel, Switzerland and Turkey) had to be detached from the network.

At ECDC, the management and coordination of EARS-Net is carried out by the Section for Antimicrobial Resistance and Healthcare-associated Infections. Scientific guid-ance and support to the coordination of the network is provided by the EARS-Net Coordination Group (previous EARSS Advisory Board), composed of experts selected among the nominated disease-specific contact points and experts selected from other organisations involved in surveillance of antimicrobial resistance.

EARS-Net consists of national antimicrobial resist-ance surveillance networks in Europe and conducts surveillance of antimicrobial susceptibility in seven major invasive pathogens of public health importance: Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Enterococcus faecalis, Enterococcus faecium, Klebsiella pneumoniae and Pseudomonas aeruginosa.

The national networks systematically collect data from clinical laboratories in their own countries. At present, EARS-Net includes over 900 public health laboratories serving over 1 400 hospitals in Europe. The national net-works upload data to a central database at ECDC (The European Surveillance System – TESSy).

EARS-Net maintains an interactive database at the ECDC website (www.ecdc.europa.eu) and publishes annual reports on the occurrence of antimicrobial resistance in Europe. This constitutes an important source of infor-mation on antimicrobial resistance for policymakers, scientists, doctors and the public.

1 Introduction

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

The results presented in this focus chapter are based on data from laboratories (n=198) that participated to EARS-Net and previously EARSS from 2002 to 2009, and reported continuously during the period on suscep-tibility of Escherichia coli and Staphylococcus aureus to selected antimicrobial agents. The long-standing contribution of these laboratories to the surveillance of antimicrobial resistance allow for accurate compari-son of proportions of resistant isolates and number of reported infections over time. Thus, results presented in this focus chapter may be slightly different from results obtained from the full group of laboratories reporting to EARS-Net and previously to EARSS.

Key points• A significant decline of antimicrobial susceptibil-

ity was observed for E. coli between 2002 and 2009, with a concomitant increase of reported bloodstream infections of 71%.

• S. aureus showed a different tendency, with a significant decrease of the proportion of meticil-lin resistance (MRSA) and an increase of 34% in the number of reported bloodstream infections.

• The trends observed for E. coli could suggest an incremental burden of disease caused by this microorganism, and the simultaneous decline of antimicrobial susceptibility is a serious public health concern.

• The reduction of the MRSA proportion and the relative containment of the number of S. aureus infections could result from efficacy of infec-tion control measures at hospital level in some countries. However, efforts to reduce MRSA occurrence should remain a priority, irrespective of decreasing trends.

Escherichia coli and Staphylococcus aureus are the most frequent causes of bloodstream infections (BSI). The temporal trends of resistance and the trends in the inci-dence of BSI caused by these microorganisms, observed through the EARSS/EARS-Net data, are described for the period 2002–2009.

The antimicrobial susceptibility of E. coli BSI isolates shows an alarming Europe-wide decline as previously reported by EARSS [1]. Increasing resistance in E. coli

and combined resistance of invasive and non-invasive isolates is reported in several national European surveil-lance reports [2–6]. At the same time, the proportion of MRSA has showed a significant decrease in many European countries. The numbers of BSI caused by MRSA, as reported by the mandatory surveillance sys-tem in England, decreased by 56% between 2004 and 2008 [7], and in France a significant decrease in the occurrence of MRSA was reported in 2008 [8] A similar reduction of the rate of healthcare-associated invasive MRSA infections has been observed at population level in the United States [9].

A total of 198 laboratories in 22 countries reported con-tinuously from 2002 to 2009. The number of laboratories per country ranged between 1 (Iceland and Malta) and 33 (Czech Republic) (Table 2.1). Considering the whole group of selected laboratories, the reported number of E. coli BSI, increased by 71% from 10 688 in 2002 to 18 240 in 2009. In the same period, S. aureus BSI showed a 34% increase from 7 855 to 10 503 (Figure 2.1); this increase was observed in most but not all countries (Table 2.1).

During this interval, the proportion of third-generation cephalosporin-resistant E. coli increased significantly from 1.7% to 8% (p < 0.001) and the proportion of MRSA decreased from 21.5% to 19.7% (p < 0.001) (Figure 2.2). The trends of resistance proportions at country level were consistent with those of the whole group of 198 laboratories in 18 countries out of 22 for E. coli and in seven countries out of 22 for S. aureus.

Combined resistance in E. coli (defined as resistance to two, three and four antibiotic classes reported to EARS-Net) showed a significant increase (Figure 2.3) (p  <  0.001) and became a frequent phenotype in most countries, whereby single resistance diminished from 37.1% in 2002 and 35.8% in 2009 (p < 0.001). The pro-portion of isolates susceptible to all four antibiotic classes decreased from 51.4% in 2002 to 41.7% in 2009 (p < 0.001).

The decline of antimicrobial activity in E. coli was evi-dent both through the observed increase of combined resistance and through the reduction of full suscepti-bility to the antimicrobials included in the analysis. In the same time period and considering the same data source, a significant decrease of meticillin resistance was observed for S. aureus. For this species, the number of BSI increased less (+34%) than for E. coli BSI (+71%).

2 Escherichia coli and Staphylococcus aureus: bad news and good news. Analysis of data from laboratories reporting continuously from 2002 to 2009

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Importantly, most of the rise (38% of 71%) in E. coli BSI appeared to be due to isolates resistant to two or more antibiotics. Furthermore, the increase in the number of BSI was similar for meticillin-susceptible S. aureus (MSSA, 37%) and for fully susceptible E. coli (39%).

Despite the possible limitations of the presented results (see section 2.2), the trends of third-generation cepha-losporins and combined resistance are relevant findings that deserve further consideration. According to the results, it appears that, during the study period, the emergence and spread of combined resistance is the main factor that influences the decline of antimicrobial activity against E. coli. In the period 2002–2009, only an increase of combined resistance with a concurrent rela-tive reduction of the proportion of single resistance was observed. The resistant subpopulation with the largest relative growth in the period 2002–2009 was the resist-ance to all the four antibiotic classes under surveillance: this pattern increased more than fivefold from 0.6% to 3.4%. This trend suggests that inside the subpopula-tion of resistant isolates there was a continuous relative growth of combined resistance possibly caused by the addition of resistance traits to strains that were already resistant to at least one among the considered antibiotic classes. This trend may be explained by the spread of multidrug-resistant plasmids, which also contain genes for extended-spectrum beta-lactamase (ESBL) produc-tion [10].

The growing number of E. coli BSI indicates an increas-ing burden of disease caused by this microorganism. A similar trend in the number of reported cases of E. coli BSI has been observed in England, Wales and Northern Ireland by the national voluntary surveillance scheme, in the period 2004–2008. The increase (38%) observed by

the British surveillance system is greater than the 16% increase in all BSI reported in the country during the same time period [11].

In conclusion, the reported data show a significant increase of antimicrobial resistance in E. coli invasive isolates and an overall increase in BSI caused by this microorganism. This is a serious public health concern since, if the increasing trend of antimicrobial resist-ance and the spread of ESBL are not contained, the use of carbapenems will increase favouring the emergence of carbapenemase-producing enterobacteria. This has been already observed for Klebsiella pneumoniae in Greece, Israel and Cyprus [1].

At the same time, S. aureus showed a relatively smaller increase in the number of reported BSI, but a significant decrease in the proportion of MRSA overall in EARSS/EARS-Net. This could be the result of the public health efforts targeted at containment of MRSA in several European countries and in the US. Even though an over-all decreasing trend for MRSA is evident in Europe, not all countries contribute to this result. Efforts to reduce MRSA occurrence should remain a priority irrespective of decreasing trends.

In this perspective, coordinated international surveil-lance is particularly important in order to obtain accurate knowledge of the occurrence and spread of antimicrobial resistance and to enable planning of public health inter-ventions aimed at prevention and control of the problem.

2.1 Methods of analysis• Data for E. coli and S. aureus BSIs were extracted

from the EARSS/EARS-Net database for laboratories

Table 2.1: Average numbers of Escherichia coli and Staphylococcus aureus isolates per country reported yearly from 2002 to 2009 by laboratories participating continuously in EARSS/EARS-Net during this time interval

Country Number of laboratoriesNumber of E. coli isolates average per year

(2002–2009)Number of S. aureus isolates average per year

(2002–2009)

Austria 10 802 630Belgium 9 646 343Bulgaria 7 96 82Czech Republic 33 1 837 1 290Estonia 5 142 125Finland 5 849 381France 12 1 583 1 018Germany 2 156 121Greece 22 829 472Hungary 14 446 526Iceland 1 97 56Ireland 15 1 086 961Italy 3 237 166Luxemburg 4 176 80Malta 1 104 96Netherlands 4 291 238Norway 7 975 467Portugal 8 559 574Slovenia 9 572 321Spain 19 1 973 835Sweden 3 578 331United Kingdom 5 641 373

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Figure 2.1: Yearly number of bloodstream infections caused by Escherichia coli and Staphylococcus aureus. EARSS/EARS-Net 2002–2009 (22 countries/198 laboratories)

Figure 2.2: Proportion of third-generation cephalosporin-resistant Escherichia coli (CREC) and meticillin-resistant Staphylococcus aureus (MRSA). EARSS/EARS-Net 2002–2009 (22 countries/198 laboratories)

Figure 2.3: Combined resistance (R) of Escherichia coli to aminopenicillins, third-generation cephalosporins, fluoroquinolones and aminoglycosides. EARSS/EARS-Net 2002–2009 (22 countries/198 laboratories)

E. coli

S. aureus

No. b

lood

stre

am in

fect

ions

5000

10000

15000

20000

20092008200720062005200420032002

Third-generation cephalosporin-resistant E. coli

MRSA

Perc

ent r

esis

tant

isol

ates

am

ong

spec

ies

0

5

10

15

20

25

20092008200720062005200420032002

R to two antimicrobial classes

R to three antimicrobial classes

R to four antimicrobial classes

Perc

ent i

sola

tes

0

2

4

6

8

10

12

20092008200720062005200420032002

Only laboratories reporting susceptibility results for specific antimicrobials continuously during the period 2002–2009 are included in the analysis.

Only laboratories reporting susceptibility results for specific antimicrobials continuously during the period 2002–2009 are included in the analysis.

Only laboratories reporting susceptibility results for specific antimicrobials continuously during the period 2002–2009 are included in the analysis.

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

reporting susceptibility results continuously dur-ing the period 2002–2009 for aminopenicillin, fluoroquinolones, third-generation cephalosporin and aminoglycosides in E. coli and for oxacillin in S. aureus. Countries with no laboratory participating for the entire period or with small amount of data (less than 20 isolates per microorganism and per year) were not included in the analysis. Only the first isolate per patient, microorganism and year was included.

• The number of BSI caused by E. coli and S. aureus and the proportions of third-generation cephalosporin resistant E. coli and of MRSA were calculated for each year of the period 2002–2009. Three additional anti-biotic classes (aminopenicillins, aminoglycosides and fluoroquinolones) were also considered for E. coli to assess the patterns of combined resistance of this pathogen.

• The significance of the temporal trends for resistance proportions was evaluated by the Cochran-Armitage test for trend.

2.2 Limitations of the analysis• Even considering a stable group of laboratories, it is

still possible that a change in the population coverage of these laboratories has occurred over time.

• The different trends observed for E. coli and S. aureus could also be explained by ascertainment bias leading to higher reporting of E. coli infections and caused by an increase of empirical treatment failures triggering delayed diagnostic procedures (blood culture).

• The indicator used to monitor the resistance trend was the SIR (sensitive, intermediate, resistant) inter-pretation, since the actual MIC (minimum inhibitory concentration) values are not systematically made available by participating laboratories. Reporting MIC instead of the SIR interpretation – defined by clinical breakpoints – would improve the monitor-ing of dynamic and subtle changes of antimicrobial susceptibility.

2.3 References

1. RIVM. EARSS annual report 2008. Bilthoven: Rij ksinstituut voor Volksgezondheid en Milieu; 2009.

2. DANMAP 2008. Jensen VJ, Hammerum A (eds). Consumption of anti-microbial agents and occurrence of antimicrobial resistance in bac-teria from food animals, food and humans in Denmark. Copenhagen: National Food Institute, Technical University of Denmark; 2009.

3. Health Protection Agency. Antimicrobial Resistance and Prescribing in England, Wales and Northern Ireland, 2008. London: Health Protection Agency; 2008.

4. NORM/NORM-VET 2009. Norström M, Simonsen GS (eds). Usage of Antimicrobial Agents and Occurrence of Antimicrobial Resistance in Norway. Tromsø/Oslo; 2010.

5. RIVM, SWAB. NethMap 2009. Consumption of antimicrobial agents and antimicrobial resistance among medically important bacteria in the Netherlands.

6. SWEDRES 2009. Dohnhammar U, Olsson-Liljequist B (eds). A Report on Swedish Antimicrobial Utilisation and Resistance in Human Medicine. Swedish Strategic Programme against Antibiotic Resistance (STRAMA). Stockholm: Swedish Institute for Infectious Disease Control; 2010.

7. Pearson A, Chronias A, Murray M. Voluntary and mandatory surveil-lance for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) bacteraemia in England. J Antimicrob Chemother. 2009;64(Suppl 1):i11-7.

8. Anonymous. Recent trends in antimicrobial resistance among Streptococcus pneumoniae and Staphylococcus aureus isolates: the French experience. Euro Surveill. 13 Nov 2008;13(46).

9. Kallen AJ, Mu Y, Bulens S et al. Health care-associated invasive MRSA infections, 2005–2008. JAMA 2010;304(6):641-648.

10. Coque TM, Baquero F, Canton R. Increasing prevalence of ESBL-producing Enterobacteriaceae in Europe. Euro Surveill 20 Nov 2008;13(47).

11. HPA. Escherichia coli bacteraemia in England, Wales, and Northern Ireland, 2004 to 2008. London: Health Protection Agency, 2009.

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

3.1. IntroductionSince 2000, EARSS has been organising external quality assessment (EQA) exercises of antimicrobial suscepti-bility testing in collaboration with UK NEQAS (United Kingdom National External Quality Assessment Service). UK NEQAS is based at the Health Protection Agency, in London, and is a non-profit organisation with more than 35 years experience with external quality assessment in different countries (www.ukneqasmicro.org.uk).

The rationale of these EQA exercises is:

• to assess the ability of participating laboratories to identify antimicrobial resistance of clinical and public health importance;

• to determine the accuracy of susceptibility test results reported by individual laboratories; and

• to decide on the overall comparability of routinely col-lected test results between laboratories and countries and thus provide the means for justifying the pooling and comparison of antimicrobial susceptibility test (AST) data across Europe.

The external quality assessment exercise, held in the second half of 2009, was open to all countries partici-pating in EARSS in 2009, including Bosnia-Herzegovina, Croatia, Israel and Turkey. A panel of six strains was included in the exercise. The strains were characterised and tested in two reference laboratories (Addenbrooke’s Hospital, Cambridge, and City Hospital, Birmingham). Both reference laboratories confirmed MICs and interpreted the results according to frequently used breakpoint criteria such as CLSI and EUCAST, as indi-cated in each of the species’ chapters.

3.2. ResultsStrain panels were distributed to 886 participating laboratories, who were asked to report the clinical sus-ceptibility categorisation – susceptible, intermediate and resistant (S, I, R) – according to the guideline used. The laboratories returned 775 (87%) reports, which is equivalent to the return rate of previous years. Turkey was not able to perform the tests, due to difficulties related to the shipment of strains. Figure 3.1 shows the proportion of participating laboratories returning reports per country.

All results were collected via the UK NEQAS internet website. Results were analysed and considered ‘con-cordant’ if the reported categorisation agreed with the interpretation of the reference laboratories.

For the determination of AST results, laboratories used automated methods (35%), disc diffusion tests (33%),

or combined methods (23%). For species identifica-tion, 60% used automated and 40% used conventional methods.

The majority of laboratories applied CLSI guidelines (68%), and some countries used national guidelines, e.g. France (SFM), UK (BSAC), and Sweden (SRGA). The use of EUCAST guidelines was mainly reported by labo-ratories that utilise automated diagnostic test systems already calibrated for EUCAST breakpoints. However, the UK, Sweden, the Netherlands, Germany, France and Norway have been implementing EUCAST breakpoints in their national MIC breakpoint recommendations as harmonised breakpoints have been agreed, and in addition have adjusted the interpretation of their disk diffusion methods accordingly. Harmonisation efforts between the different national guideline committees have accomplished a satisfactory degree of agreement and, therefore, previous discrepancies between differ-ent guidelines have become less significant. Figure 3.2 shows the adherence to (inter)national guidelines by number of laboratories per country.

3.2.1. Specimen 9448 Escherichia coli

This specimen consisted of an Escherichia coli with CTX-M-14 ESBL production. Unlike most TEM- and SHV-derived ESBLs, CTX-M enzymes are more active against cefotaxime than ceftazidime. This organism should clearly be interpreted as resistant to cefotaxime (MIC ≥ 128 mg/L) using EUCAST (S ≤ 1, R > 2 mg/L), and CLSI (S ≤ 8, R ≥ 64 mg/L) guidelines. With ceftazidime (MIC 2 mg/L) the isolate appears intermediate by EUCAST guidelines (S ≤ 1, I 2–8, R > 8 mg/L) and susceptible by standard CLSI guidelines (S ≤ 8, I 16, R ≥ 32 mg/L). However, current EUCAST expert rules recommend that ESBL-producing isolates are reported resistant if they appear intermediate in routine tests and intermedi-ate if they appear susceptible. Resistance should be reported if CLSI ESBL screening methods are used as recommended.

Detection of reduced susceptibility to cefotaxime and ceftriaxone was not a problem and < 1% participants reported the organism susceptible to these agents. With ceftazidime, reports of intermediate (15%) and suscep-tible (6%) were more common. A large majority (98%) of participants testing for ESBLs correctly reported the organism ESBL-positive.

This organism was susceptible to piperacillin+tazobactam in MIC tests (MIC 2–4 mg/L). Despite some reports of clinical efficacy, there has been considerable debate about whether ESBL-producing strains from seri-ous infections should be reported susceptible to beta-lactamase inhibitor combinations when they appear susceptible in routine tests. While the majority

3 External Quality Assessment Exercise (EQA) 2009

10

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Figure 3.1: Proportion of participating laboratories returning reports per country, 2009

Figure 3.2: Adherence to guidelines*: number of laboratories per country

0 20 40 60 80 100

UKTRSISEROPTPL

NONLMTLVLULTITISILIE

HUHRFRFI

ESELEEDKDECZCYBGBEBAAT

No results

Results

Coun

try

code

Number of laboratories

0 10 20 30 40 50 60 70 80

UKSISEROPTPL

NONLMTLVLULTITISILIE

HUHRFRFI

ESELEEDKDECZCYBUBEBAAT

COMB

CRG

DIN

EUCAST

FIRE

NCCLS

NWGA

SFM

SRGA

Other

BSAC

Coun

try

code

Number of laboratories

BSAC, British Society for Antimicrobial Chemotherapy; CRG, (Dutch) Commissie Richtlijnen Gevoeligheidsbepalingen; DIN, Deutsche Industrie Norm; EUCAST, European Committee on Antimicrobial Susceptibility Testing; NCCLS/CLSI, (American) Clinical and Laboratory Standards Institute; NWGA, Norwegian Working Group on Antimicrobials; SFM, Comité de l’Antibiogramme de la Société Française de Microbiologie; SRGA, Swedish Reference Group for Antibiotics. BSAC, CRG, DIN, NWGA, SFM and SRGA have implemented EUCAST breakpoints for MIC determinations and have adjusted the interpretation of their disk diffusions accordingly.The external quality assessment exercise was open to all countries participating in EARSS in 2009.BA = Bosnia-Herzegovina; HR = Croatia; IL = Israel.

The external quality assessment exercise was open to all countries participating in EARSS in 2009.BA = Bosnia-Herzegovina; HR = Croatia; IL = Israel; TR = Turkey.

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

of participants (71%) reported the organism suscepti-ble to piperacillin+tazobactam, significant proportions reported intermediate (9%) or resistant (20%).

In reference tests, this organism was resistant to gen-tamicin, highly variable in susceptibility to tobramycin (reference MICs 4 to > 128 mg/L) and susceptible to amikacin. It is likely that this reflects production of an ANT (2’’) enzyme, expression of which can be variable. EUCAST expert rules suggest that such isolates should be reported resistant to tobramycin if they appear inter-mediate. While 99% participants reported the organism gentamicin resistant and 98% amikacin susceptible, for tobramycin, 30%, 28% and 42% were reporting resistant, intermediate and susceptible, respectively (Table 3.1).

3.2.2. Specimen 9449 Klebsiella pneumoniae

This organism is a Klebsiella pneumoniae with a high-level beta-lactamase production; not only penicillin resistant, but also reduced susceptibility to beta-lacta-mase inhibitor combinations. Piperacillin+tazobactam MICs of 64 to ≥ 128 mg/L for this organism indicate resist-ance by EUCAST breakpoints and intermediate/resistant by CLSI breakpoints. Among participants, 70% reported the organism resistant, 25% intermediate and 5% sus-ceptible. ESBL production was incorrectly reported by 9% participants and this was frequently associated with incorrect reporting of resistance to cefotaxime, ceftriax-one and ceftazidime by these participants (Table 3.2).

3.2.3. Specimen 9450 Streptococcus pneumoniae

This organism is a Streptococcus pneumoniae with reduced susceptibility to penicillin (MIC 0.25 mg/L). For S. pneumoniae with no mechanism of resistance to penicillin, MICs are ≤ 0.06 mg/L. EUCAST guidelines divide reduced susceptibility to penicillin into interme-diate (penicillin MIC 0.12–2 mg/L) and resistant (MIC > 2 mg/L) categories. However, the interpretation of sus-ceptibility to penicillin depends on whether the isolate is from a patient with meningitis or other infections (most commonly pneumonia). Strains with intermediate sus-ceptibility are treatable with the high doses of penicillin, ampicillin or amoxicillin routinely used to treat pneumo-nia. Hence such strains may be reported susceptible in this situation. Patients with meningitis caused by strains with intermediate susceptibility to penicillin are unlikely to respond to therapy, and hence such strains should be reported as resistant in this situation.

Overall, 92% participants reported resistance in the oxacillin screening test for penicillin resistance. A fur-ther 3% reported the isolate intermediate to oxacillin, although the oxacillin screening test does not distin-guish penicillin intermediate and resistant isolates and published guidelines do not include an intermediate category.

The participants’ results for penicillin will include those that only screened for reduced susceptibility with

oxacillin discs, those that screened with oxacillin and confirmed with a penicillin MIC, and those that tested with other methods. Overall, 76% reported the isolate as being of intermediate susceptibility to penicillin, with a further 8% reporting the isolate resistant. Susceptibility reported to clinicians for this organism – if isolated from cases of meningitis or pneumonia – indicates that many participants do interpret test results to suit the clinical situation. Eighty-five per cent reported the isolate as resistant when the isolate was from a case of meningitis and 70% as susceptible when the isolate was from a case of pneumonia, but significant numbers of participants interpreted the organism as intermediate in susceptibil-ity to penicillin irrespective of whether the isolate was from meningitis (11% reported intermediate) or from pneumonia (26% reported intermediate). However, it is recognised that some local reporting guidelines may recommend categorisation of pneumonia isolates with intermediate penicillin susceptibility as intermediate, with the note that the isolate is susceptible if the patient is treated with a high dose.

With EUCAST, breakpoints for ciprofloxacin wild type organisms such as this (MIC 1 mg/L) are reported inter-mediate in susceptibility to ciprofloxacin, reflecting the uncertain outcome of therapy. CLSI do not give cipro-floxacin breakpoints for S. pneumoniae. This uncertainty was reflected in the high discrepancy rate in reporting for this agent (69% susceptible, 27% intermediate and 4% resistant) (Table 3.3).

3.2.4. Specimen 9451 Pseudomonas aeruginosa

This organism is a Pseudomonas aeruginosa with borderline resistance to piperacillin+tazobactam (MIC 32–64 mg/L) but susceptible to ceftazidime, a susceptibility profile seen with some beta-lactamase-producing strains. This organism produces the PSE-4 (CARB-1) beta-lactamase. The borderline resistance to piperacillin+tazobactam was reflected in the variation in susceptibility reported by participants, with 49% reporting susceptible, 12% intermediate and 39% resist-ant. The different categorisation largely relates to the breakpoint differences between EUCAST (susceptible ≤  16  mg/L, resistant > 16 mg/L) and CLSI (susceptible ≤ 64 mg/L, resistant ≥ 128 mg/L) (Table 3.4).

3.2.5. Specimen 9452 Pseudomonas aeruginosa

This organism is a Pseudomonas aeruginosa resistant to gentamicin and susceptible to other reference agents tested. Some laboratories experienced problems with piperacillin+tazobactam testing in that overall 14% participants reported the isolate intermediate and 2% resistant. The reason for the problems is not obvious as the isolate was clearly susceptible in reference tests (Table 3.5).

3.2.6. Specimen 9453 Staphylococcus aureus

This organism is a meticillin-resistant Staphylococcus aureus (EMRSA-6) and most participants correctly reported resistance. There was no significant difference

12

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Table 3.1: Escherichia coli (9448): Minimum inhibitory concentration (MIC) and intended results reported by reference laboratories and the overall concordance of the participating laboratories

Antibiotic agentMIC range ref. lab. Intended interpretation

from to EUCAST/CLSI Overall concordance (%)

Amikacin 1 1 S 98Amoxicillin NT* - R 93Ampicillin > 128 > 128 R 100Cefotaxime 128 > 128 R 97Ceftazidime 2 2 R (expert rule) 80Ceftriaxone > 128 > 128 R 99Ciprofloxacin 64 128 R 100ESBL positive 98Gentamicin 32 64 R 99Imipenem 0.12 0.12 S 100Meropenem ≤ 0.03 ≤ 0.03 S 99Piperacillin ≥ 128 ≥ 128 R 99Piperacillin+tazobactam 2 4 S 71Tobramycin 4 > 128 I-R/S-I-R

* Not tested, result inferred from ampicillin.

Table 3.2: Klebsiella pneumoniae (9449): Minimal inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories

Antibiotic agentMIC range ref. lab. Intended interpretation

from to EUCAST/CLSI Overall concordance (%)

Amikacin 64 64 R 97Ampicillin/amoxicillin 128 ≥ 128 R 100Cefotaxime 0.12 0.5 S 92Ceftazidime 0.12 0.25 S 93Ceftriaxone 0.5 0.5 S 93Ciprofloxacin 0.015 0.03 S 100ESBL - - negative 91Gentamicin 64 128 R 99Imipenem 0.12 0.12 S 99Meropenem ≤ 0.03 ≤ 0.03 S 99Piperacillin 64 ≥ 128 I/R 99Piperacillin+tazobactam 64 128 I/R 95Tobramycin 16 128 R 99

Table 3.3: Streptococcus pneumoniae (9450): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories

Antibiotic agentMIC range ref. lab. Intended interpretation

from to EUCAST/CLSI Overall concordance (%)

Cefotaxime 0.06 0.12 S 98 Meningitis - - S 96 Pneumonia - - S 99Ceftriaxone 0.06 0.12 S 98 Meningitis - - S 95 Pneumonia - - S 98Ciprofloxacin 1 1 I/- 27Clindamycin 0.12 0.12 S 99Erythromycin 0.12 0.25 S 99Oxacillin - - R 92Penicillin 0.25 0.25 I 76 Meningitis - - R 85 Pneumonia - - S 70

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Table 3.6: Staphylococcus aureus (9453): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories

Antibiotic agentMIC range ref. lab. Intended interpretation

from to EUCAST/CLSI Overall concordance (%)

Cefoxitin 8 16 R 95Ciprofloxacin 0.5 0.5 S 95Erythromycin 4 ≥ 128 I/R 93Fucidic acid 0.06 0.12 S 100Gentamicin 0.25 0.50 S 99Methicillin NT* R 97Oxacillin 8 32 R 94Penicillin 1 4 R 99Rifampicin 0.004 0.008 S 99Teicoplanin 1 1 S 99Tetracycline 64 64 R 97Vancomycin 1 2 S 99

* Not tested, result inferred from oxacillin and cefoxitin.

Table 3.4: Pseudomonas aeruginosa (9451): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories

Antibiotic agentMIC range ref. lab. Intended interpretation

from to EUCAST/CLSI Overall concordance (%)

Amikacin 1 8 S 100Ceftazidime 1 2 S 98Ciprofloxacin 0.12 0.5 S 100Gentamicin 1 4 S 97Imipenem 1 2 S 99Meropenem 0.5 2 S 99Piperacillin+tazobactam 32 64 R/S 39Tobramycin 0.5 1 S 99

Table 3.5: Pseudomonas aeruginosa (9452): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and the overall concordance of the participating laboratories

Antibiotic agentMIC range ref. lab. Intended interpretation

from to EUCAST/CLSI Overall concordance (%)

Amikacin 1 4 S 99Ceftazidime 1 2 S 99Ciprofloxacin 0.12 0.25 S 100Gentamicin 16 64 R 99Imipenem 1 2 S 99Meropenem 0.5 2 S 99Piperacillin+tazobactam 4 8 S 84Tobramycin 0.5 1 S 99

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

in reliability of detection of meticillin resistance in tests with oxacillin (94% participants reported resistance) and cefoxitin (95% participants reported resistance).

About a third of participants reported a result for meti-cillin (97% resistant) but it may be that oxacillin or cefoxitin were actually tested. Erythromycin reference MICs were very variable (4 to > 128 mg/L), probably because resistant colonies of this organism grew slowly. MICs in this range indicate resistance by EUCAST break-points and intermediate/resistant by CLSI breakpoints; 93% participants reported the organism resistant and only 6% intermediate (Table 3.6).

3.3 ConclusionsIn this eighth EARSS EQA exercise, participation of laboratories was high. The results show that rou-tinely reported results, as collected by EARSS in most instances, have sufficient accuracy to provide good estimates of overall resistance prevalence and trends. The overall concordance was high, except in case of bor-derline susceptibility, when various guidelines reveal remaining discrepancies in routine susceptibility testing, and when a breakpoint was recently changed. The latter was found for penicillin susceptibility of Streptococcus pneumoniae in relation to the source of the isolate, where the isolate was regularly reported non-susceptible for pneumonia. Furthermore, differences in interpretation of results were found for piperacillin+tazobactam (as frequently noted previously).

EARSS Management Team would like to thank UK NEQAS for Microbiology, the reference laboratories, the mem-bers of the Advisory Board, the country coordinators for the swift distribution of the strains, and all the partici-pating laboratories for their excellent response rate.

15

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

4.1 IntroductionFor correct interpretation of the EARS-Net data on anti-microbial resistance, accurate background information is important. Therefore, laboratory and hospital and denominator data are collected and presented in this chapter.

4.2 MethodsQuestionnaires, in Microsoft Excel files, were sent to the EARS-Net contact points at the beginning of June 2010. The contact points distributed the questionnaires to the participating laboratories and hospitals in their country. Information was collected on the total number of blood culture sets processed in the laboratories, and the number of hospital beds for each participating hospital, the type of hospital, the bed occupancy and the number of admissions. The national data managers received the completed questionnaires, compiled them and produced the final format suitable for uploading in the European Surveillance System (TESSy). Laboratories have been defined as reporting denominator data if they have pro-vided the number of blood culture sets performed for one or for more than one hospital; hospitals have been defined as reporting denominator data if they have pro-vided the number of beds.

4.3 ParticipationFifteen out of 28 countries reporting antimicrobial resistance results returned hospital denominator data while 14 countries returned laboratory denominator data. Considering the responding countries, 219 of the 307 laboratories (71.3%) and 606 of the 871 hospitals (69.6%) reporting antimicrobial susceptibility results for the 15 countries in 2009, also provided denominator data (Figures 4.1–4.2, Tables 4.1–4.3). Some denomina-tor data of laboratories and hospitals not participating to antimicrobial resistance surveillance, or reporting zero cases, have been included in Figure 4.1, but were not included in the analysis.

4.4 Population coverage The population coverage of antimicrobial resistance data at country level is not reported for 2009 because of the low number of countries submitting denominator data and because of possible limitations in the use of the data on population coverage:

• laboratories/hospitals reporting antimicrobial sus-ceptibility data do not always provide denominator data and this could give a biased figure of the country population coverage since it can be calculated only for laboratories/hospitals with denominator data; and

• laboratories and hospitals cluster in big cities and, for this reason, some of the catchment areas overlap. This could lead to double counts, which could artifi-cially increase the estimated coverage.

The coverage at European level possibly increased in 2009 compared to the previous year since the number of reporting laboratories increased from 825 in 2008 to 916 in 2009. A high coverage at country level is very impor-tant to properly describe the country profile and it also allows a more accurate calculation of the culture rate and the MRSA incidence rate. Calculation of the MRSA incidence rate (not included in the 2009 report) would be based on the assumption that each hospital is served by one laboratory. Therefore, in cases where the labora-tory denominator data is referring to a specific hospital (with patient days available), calculation of the culture rate for that hospital is possible. Similarly, having AMR data referring to a specific hospital (with patient days available) would enable calculation the MRSA rate for that hospital.

However, looking into the available data, this assump-tion seems not always correct. Some hospitals are served by more than one laboratory; it occurs mainly in UK (where the hospital code often refers to a trust instead of a single hospital), but there are examples also in Ireland and Hungary. The implication of the relation ‘one hospital to more than one laboratory’ is that, if one hospital is reported in the AMR and denominator data while only one of the laboratories serving this hospital is reported, then the culture rate and the MRSA incidence rate will be underestimated.

4.5 Hospital denominator informationThe total number of hospital beds for the hospitals reporting AMR results and providing denominator data in different countries ranged from 1 274 in Malta to 143 433 in France, reflecting the size of the country as well as the rate of participation to EARS-Net and the rate of response to the questionnaires. The proportion of ICU beds over total hospital beds shows wide variation according with the country, ranging from 1% in UK to 9% in Cyprus. The median length of stay was 6.6 days with a minimum in UK (3.4 days) and a maximum in Malta (12.7 days). The annual occupancy rate was 75% or higher in 10 out of 15 countries (Table 4.1).

4.6 Hospital characteristicsBoth the size of a hospital and the level of specialisa-tion can influence the proportion of resistance. As can be seen from Table 4.2 and Figure 4.2, the distribu-tion of size and specialisation level of hospitals varied

4 EARS-Net laboratory/hospital denominator data 2009

16

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Figure 4.1: Number of laboratories and hospitals reporting AMR and/or denominator data in 2009

0 50 100 150 200 250 300 350 400

UK

SI

PT

PL

MT

LV

LT

IT

IE

HU

FR

EE

DE

CY

BG

Denominator information only

AMR information only

AMR and denominator information

Coun

try

code

Number of hospitals

0 50 100 150 200 250

UK

SI

PT

PL

MT

LV

LT

IT

IE

HU

FR

EE

DE

CY

BG

Denominator information only

AMR information only

AMR and denominator information

Coun

try

code

Number of laboratories

A)

B)

17

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Table 4.1: Hospital denominator data for 2009

CountryHospitals reporting (denominator/AMR

data)Total number of beds

Proportion of ICU beds (%)

Annual occupancy rate (%)

Median length of stay (days)

IQR length of stay (days)

Bulgaria (20/22) 9 326 8 77 6.3 5.4–6.9Cyprus (5/5) 1 313 9 72 5.5 5.4–5.7Estonia (13/14) 4 989 6 75 6.4 5.1–7.0France (231*/242) 143 433 5 83 7.7 6.4–9.2Germany (47/173) 18 897 6 73 7.1 6.7–9.1Hungary (62/65) 40 749 2 76 7.8 6.5–9.6Ireland (52/71) 12 175 3 87 5.8 4.6–7.1Italy (25/25) 15 358 5 84 - -Latvia (11/12) 5 251 2 68 6.8 5.6–7.4Lithuania (22/30) 9 792 4 75 7.0 6.3–8.1Malta (3/3) 1 274 5 85 12.7 5.4–38.6Poland (30/30) 15 045 2 70 5.5 4.4–6.2Portugal (23/25) 10 885 5 79 7.3 5.5–8.6Slovenia (12/12) 6 559 5 79 5.4 4.8–6.2United Kingdom (50/142) 60 775 1 74 3.4 2.7–6.1

* 178 hospitals in France reported data for a six-month period.

Table 4.3: Laboratory denominator information for 2009

CountryLaboratories reporting

(denominator/AMR data)Number of hospitals* Total number of blood culture sets

Number of blood culture sets per 1000 patient days

Bulgaria (18/20) 20 19 855 7.5Cyprus (5/5) 5 12 991 37.6Estonia (9/11) 11 11 691 10.7Germany (6/17) 28 38 466 14.7Hungary (26/27) 60 83 624 7.8Ireland (37/43) 51 184 985 47.8Italy (25/25) 25 125 577 26.8Latvia (10/12) 10 7 859 6.2Lithuania (12/13) 20 15 618 6.1Malta (1/1) 3 4 879 12.4Poland (30/30) 30 82 521 21.6Portugal (21/22) 23 158 902 50.7Slovenia (9/9) 12 46 040 24.2United Kingdom (10/72) 10 95 017 45.2

* Number of hospitals served by laboratories reporting denominator data.

Table 4.2: Hospital characteristics for 2009

CountryHospitals reporting

(denominator/AMR data)Proportion of hospitals by level of care (%)

Tertiary level Secondary level Primary level Other Unknown

Bulgaria (20/22) 50 35 5 10 0Cyprus (5/5) 20 20 40 20 0Estonia (13/14) 31 38 23 0 8France (231/242) 22 78 0 0 0Germany (47/173) 23 32 30 15 0Hungary (62/65) 50 29 15 6 0Ireland (52/71) 17 52 12 17 2Italy (25/25) 68 28 4 0 0Latvia (11/12) 36 55 0 0 9Lithuania (22/30) 41 55 5 0 0Malta (3/3) 33 33 0 33 0Poland (30/30) 13 77 10 0 0Portugal (23/25) 57 26 4 13 0Slovenia (12/12) 17 50 17 17 0United Kingdom (50/142) 6 20 6 18 50

Primary level or district hospital = has few specialties, limited laboratory services; bed capacity ranges from 30 to 200 beds. Secondary level, or provincial hospital = highly differentiated by function with five to 10 clinical specialties; bed capacity ranging from 200 to 800 beds. Tertiary level or central/regional hospital = highly specialised staff and technical equipment; clinical services are highly differentiated by function; may have teaching activities; bed capacity ranges from 300 to 1500 beds. Other = hospitals for a specific patient population, like a military hospital, or hospitals with any single specialty, like a burns unit. Unknown = not available.

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

considerably between the reporting countries. This does not necessarily reflect different distributions of the ori-gin of EARS-Net blood cultures per country, because not all hospitals contribute evenly to the EARS-Net database. On the other hand, this diversity can indicate differences in case-mix, which may confound compari-son of AMR results between countries.

The type of hospital and the size of hospital are not always linked and it is not rare, especially in small coun-tries, that university hospitals have less than 500 beds.

4.7 Laboratory denominator informationIn 2009, the number of blood culture sets processed in the EARS-Net laboratories responding to the question-naire was 888 025. The median culturing frequency was 18.2 blood culture sets per 1 000 patient days in 2009. The highest rate was reported by Portugal (50.7) and the lowest by Lithuania (6.1). For the majority of the reporting countries, only minor changes in the number of blood culture sets taken per 1 000 patient days (Table 4.3) was observed when comparing 2008 data to 2009. The most significant change was observed for the UK and may originate from the increasing number of report-ing hospitals (10 in 2008 and 20 in 2009).

The BSIs ascertainment is strongly linked to the blood culture rate. Therefore, the very wide range of culture rate observed in the countries providing denominator

data could have implications on inter-country com-parison of both the incidence rate of infections, which could be underestimated in some countries, and of the proportion of resistance. In particular, the proportion of resistance could be overestimated if there is a frequent use of empiric therapy also for invasive infections, and if the cultures are more likely to be performed in patients not responding to the empiric treatment.

4.8 ConclusionsIn summary, the situation as assessed from denomina-tor data reported in 2009 is similar to 2008, with only few changes. For future improvement of the denominator data collection and analysis, it is important to address the following issues:

• increase the number of countries reporting denomina-tor data;

• increase the number of hospital and laboratories par-ticipating within countries;

• improve the data quality for the variable HospitalId (unique identifier for the hospital within each labora-tory); and

• improve the estimation of the coverage of the EARS-Net surveillance, e.g. by using estimations done at the national level based on knowledge of the country-specific situation.

Figure 4.2: Proportion of small, medium and large hospitals per country, based on the number of beds, for all hospital reporting both antimicrobial resistance data and denominator data in 2009

0 20 40 60 80 100

UK (50/142)

SI (12/12)

PT (23/25)

PL (30/30)

MT (3/3)

LV (11/12)

LT (22/30)

IT (25/25)

IE (52/71)

HU (62/65)

FR (231/242)

EE (13/14)

DE (47/173)

CY (5/5)

BG (20/22)

Small hospitals (≤ 200 beds)

Medium hospitals (201–500 beds)

Large hospitals (> 500 beds)

Coun

try

code

s (re

spon

ding

/all

hosp

itals

pro

vidi

ng A

MR

data

)

Proportion of hospitals

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

5.1 Streptococcus pneumoniae5.1.1 Clinical and epidemiological importance

Streptococcus pneumoniae is a common cause of dis-ease, especially among young children, elderly people and patients with compromised immune functions. The clinical spectrum ranges from upper airway infections, such as sinusitis, and otitis media to pneumonia and invasive bloodstream infections and meningitis. Since S. pneumoniae is the most common cause of pneumonia worldwide, morbidity and mortality are high and annu-ally approximately 3 million people are estimated to die of pneumococcal infections.

Pneumococci carry a variety of virulence factors that facilitate adherence and transcytosis of epithelial cells. The cell wall of pneumococci is coated with a viscous polysaccharide slime layer termed the capsule. This is the most important virulence factor because it protects the bacteria from the adhesion of opsonising antibodies and the destruction by leucocytes. Capsular polysac-charides are highly diverse and play an important role in immune evasion. Around 80 different serotypes have been described. The serotype distribution varies with age, disease and geographical region. Interestingly, serotypes most frequently involved in pneumococcal disease or colonisation in infants are also most fre-quently associated with antimicrobial resistance.

5.1.2 Resistance mechanisms

Beta-lactam antibiotics bind to cell wall synthesising enzymes, so called penicillin-binding proteins (PBPs) and interfere with the biosynthesis and remodelling of the bacterial cell wall during cell growth and division. The mechanism of penicillin resistance in S. pneumo-niae consists of alterations in PBPs, which results in reduced affinity to this class of antibiotics. Alterations in PBPs occur in a stepwise fashion that causes dif-ferent degrees of resistance proceeding from reduced susceptibility through low-level clinical resistance – conventionally termed intermediate1 (I) to full clinical resistance (R). Although intermediately resistant strains are clearly less susceptible than sensitive strains, in absence of meningitis, infections with these strains are often successfully treated with high doses of penicillin or other beta-lactam compounds.

Macrolide, lincosamine and streptogramin (MLS) antibiotics are chemically distinct, but all bind to a ribosomal subunit inhibiting the initiation of mRNA binding and thus act as protein synthesis inhibitors. In

1 Microorganisms are defined as intermediate by a level of antimicrobial activity with uncertain clinical effect. Occasionally, this can be overcome if antibiotics can be administered at a higher dose and/or are concentrated at the infected body site.

S. pneumoniae two resistance mechanisms against MLS antibiotics have been reported:

• The acquisition of an erythromycin ribosomal meth-ylation gene (erm) results in a post-transcriptional modification of the 23S subunit of ribosomal RNA, which blocks the binding of the macrolide to the ribosome. Once expression of the gene is induced, this often results in high-level resistance (MICs >  128  mg/L) to macrolide, lincosamines and strepto-gramin B, termed MLSB resistance.

• The acquisition of a macrolide efflux system gene (mefE) results in the excretion of the antimicrobial, and effectively reduces intracellular erythromycin, azithromycin and clarithromycin to subinhibitory con-centrations. In contrast to beta-lactam resistance, macrolide resistance via these mechanisms (particu-larly for MLSB ) provides very high MICs, and cannot be overcome by increasing the dosages of antibiotics.

Since S. pneumoniae is the most frequent cause of community-acquired pneumonia and cannot clinically be easily distinguished from lower airway infections caused by other pathogens, empirical treatment of com-munity-acquired lower respiratory infections needs to be active against pneumococci and should take the local prevalence of antimicrobial resistance into account. Habitual prescription of non-beta-lactam compounds is therefore typical in countries where penicillin resistance has been frequently reported. Such reactive prescribing increases the selection pressure for alternative antibiot-ics such as macrolides and novel fluoroquinolones. It is therefore no surprise to see a dynamic antimicrobial resistance picture emerge in different European coun-tries. At the same time, the existence of frequent dual beta-lactam/macrolides resistance, particularly among children’s serotypes, assures that in practice the use of drugs of any of these families will increase resistance for the members of the other one, and so the extended use of macrolides has been considered as a major driver for the increase in beta-lactam resistance.

Even though a certain small decrease in penicillin resistance was detected in some countries before the introduction of the PCV7 vaccine, the widespread use of this vaccine is probably an important factor that may have influenced the decrease in antibiotic resistance levels, eliminating the infections (and more importantly, the children’s carriage) of frequent ‘classic’ resistant serotypes, 14, 6B, 19F and 23F, all of them covered by PCV7. The distribution of serotypes detected in this 2009 report (almost identical to that of 2008) includes serotypes 1 (15%), 19A (12%), 7F (11%), 3 (8%), 12F (7%), 6A (6%), 14 (5%). Even though a limited number of coun-tries have provided serotyping data, ad hoc studies in other EU countries, like France, Spain, Greece, Norway

5 Antimicrobial resistance in Europe

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

and Portugal, confirm the current generality of this pat-tern. This shift indicates the effect of the PCV7 vaccine, selecting the non-vaccine serotypes, and more impor-tantly the serotype 19A. In fact the ‘classic diversity pattern’ of well-adapted types of S. pneumoniae clones in children has been maintained, being these clones ‘disguised’ under the PCV7-non-covered 19A capsule type. At least 10 non-19A serotypes had a 19A capsular switch. Eventually, the introduction of PCV13 vaccine (covering 19A) will produce a new reduction in antibiotic resistance in S. pneumoniae.

5.1.3 Results

Penicillin

• Twenty-seven countries reported 11 055 isolates of which 828 were non-susceptible to penicillin; 344 of the 828 non-susceptible isolates were identified as resistant. One country did not report (Greece) and one country reported less than 10 isolates (Malta), there-fore, no data displayed on the maps.

• Proportion of non-susceptibility was: below 1% in three countries, 1–5% in nine countries, 5–10% in two countries, 10–25% in seven countries and 25–50% in five countries (Figure 5.1, Table 5.1).

• Trends in the 2006–2009 period have been calculated for 22 countries. Three countries (Bulgaria, Ireland and Luxembourg) reported a significant increas-ing trend with proportions of non-susceptibility to penicillin, which, in 2009, were 37%, 20% and 19%, respectively. In one of these countries, the trends are significant also when considering only data from labo-ratories consistently reporting all four years (Figure 5.4).

• Significant decreasing trends have been observed for Belgium2, France and Spain with proportions of non-susceptibility to penicillin of < 1%, 27% and 22%, respectively, in 2009. In two of these countries the trend is significant also when considering only data from laboratories consistently reporting all four years (Figure 5.4).

Macrolides

• Twenty-seven countries reported 10 934 isolates of which 1 469 were non-susceptible to macrolides. One country (Malta) reported less than 10 isolates (no data displayed in maps).

• Proportion of non-susceptibility was: 1–5% in seven countries, 5–10% in four countries, 10–25% in 10 countries and 25–50% in five countries (Figure 5.2, Table 5.1).

2 The proportion of Streptococcus pneumoniae non-susceptible to penicillin reported by Belgium dropped from 8% in 2008 to < 1% in 2009. This is largely due to the fact that the clinical breakpoints (CLSI) used to determine SIR have changed. The laboratory that performs all the susceptibility tests started using the new CLSI clinical breakpoints in the beginning of 2009. During the entire EARS-Net surveillance, the same method of susceptibility testing has been used, only clinical breakpoints have changed.

• Trends in the 2006–2009 period have been calculated for 22 countries. No country reported a significant increasing trend (Figure 5.5).

• Significant decreasing trends have been observed for six countries. In four of these countries the trends are significant also when considering only data from labo-ratories consistently reporting all four years (Figure 5.5). In 2009, these six countries reported the fol-lowing proportion of resistance to macrolides: 1–5% in one case (United Kingdom), 5–10% in two cases (Netherlands and Norway), 10–25% in two cases (Belgium and Italy) and 25–50% in one case (France).

Dual non-susceptibility (penicillin and macrolides)

• Twenty-seven countries reported 10 577 isolates tested for penicillin and macrolides. In 2009, 5% of isolates had dual non-susceptibility to these two anti-biotic classes. One country (Malta) reported less than 10 isolates (therefore not included in Figure 5.3).

• Proportion of dual non-susceptibility was: below 1% in seven countries, 1–5% in seven countries, 5–10% in three countries, 10–25% in seven countries and 25–50% in two countries (Figure 5.3, Table 5.1).

• Trends for 2006–2009 were calculated for 22 coun-tries. A significant increase was observed for Ireland reporting 12% dual non-susceptibility in 2009. A significant decreasing trend has been observed for Belgium (proportion of dual non-susceptibility in 2009 was < 1%) (Figure 5.6).

Serogroups

• Six countries reported 2 959 S. pneumoniae iso-lates with identification of the serotype/serogroup (Table 5.2).

• In 2009 data, the serogroup 1 was the most prevalent (16% of total), followed by serogroups 19 and 7 (both 11% of total), serogroup 3 (8%), serogroup 12 (7%) and serogroups 6, 14, 9 and 22 (all at 5%) (Figure 5.7, Table 5.2).

• Dual non-susceptibility has been mainly retrieved in serogroups 14, 19, 6, 9 and 23. Single non-suscepti-bility to penicillin in serogroups 14, 9, 19 and 6. Single non-susceptibility to macrolides in serogroups 1, 19, 14, 6, 33, 15, 9, 23, 11, 3 and 12 (Figure 5.7, Table 5.2).

5.1.4 Conclusions

In 2009, the proportion of non-susceptibility to penicillin remained generally stable in Europe with three countries reporting significant increasing trends and other three reporting significant decreasing trends. Fourteen of 26 countries reported proportions of non-susceptibility below 10%. The proportion of non-susceptibility to mac-rolides declined significantly in six countries while no country reported increasing trends. Nevertheless, 14 countries out of 25 reported proportion of non-suscep-tibility above 10%.

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

The dual non-susceptibility to penicillin and macrolides was above 10% in eight countries out of 25 countries reporting more than 10 isolates.

The highest proportions of non-susceptibility of S. pneu-moniae to penicillin and/or macrolides were reported by countries of southern and eastern Europe, with Finland as the only northern exception.

So far, the serogroup data reported to EARS-Net should not be regarded as representative for Europe in general; only six countries reported more than 30 isolates with serogroup information and more than 60% of results were provided by Belgium. The serogroup distribution reported in 2009 is similar to the previous year. Most non-susceptible isolates belong to few serogroups, especially serogroups 1, 19, 14, 6 and 9. The serogroup 14, which is particularly important in relation to penicil-lin resistance, was the most frequent serogroup only in Ireland (12%) (Figure 5.7, Table 5.2).

Figure 5.1: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Figure 5.2: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to macrolides in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Figure 5.3: Streptococcus pneumoniae: proportion of invasive isolates with dual non-susceptibility to penicillin and macrolides in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Figure 5.4: Streptococcus pneumoniae: trend of penicillin non-susceptibility by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 5 10 15 20 25 30 35 40

BG (>)

FR (<*)

ES (<)

IE (>*)

LU (>*)

PT

SI

FI

HU

LT

IT

AT

CZ

DK

SE

UK

DE

NO

NL

EE

BE (<)

IS 2006200720082009

Coun

try c

ode

% penicilllin non-susceptibility

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Figure 5.5: Streptococcus pneumoniae: trend of macrolides non-susceptibility by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 5 10 15 20 25 30 35 40

FI

FR (<)

BG

BE (<)

PT

IT (<*)

ES

HU

SI

IE

LU

AT

DE

LT

NO (<)

NL (<*)

CZ

UK (<)

DK

SE

IS

EE 2006200720082009

Coun

try c

ode

% macrolides non-susceptibility

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Figure 5.6: Streptococcus pneumoniae: trend of dual non-susceptibility (penicillin and macrolides) by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively.* 0% resistance for all four years.

0 5 10 15 20 25 30

FR

BG

IE (>)

PT

ES

FI

SI

HU

LU

IT

LT

AT

UK

NO

CZ

DK

DE

NL

SE

BE (<)

IS

EE* 2006200720082009

Coun

try c

ode

% Dual non-susceptibility

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Table 5.1: Number of invasive S. pneumoniae isolates and proportion of penicillin-non-susceptible (PNSP), penicillin-resistant (PRSP), macrolide non-susceptible (MNSP), single penicillin (PEN), single macrolides (MACR) and dual non-susceptible (DUAL) isolates, including 95% confidence intervals (95% CI), reported per country in 2009

CountryNumber of isolates

tested for (PEN/MACR/both)

%PNSP (95%CI)

%PRSP (95%CI)

%MNSP (95%CI)

%single PEN (95%CI)

%single MACR (95%CI)

%DUAL (95%CI)*

Austria 352/319/294 4.5 (3–7) 2.6 (1–5) 13.8 (10–18) 2.7 (1–5) 12.9 (9–17) 1.7 (1–4)Belgium 1 885/1 885/1 885 0.3 (0–1) 0.2 (0–1) 23.1 (21–25) 0.1 (0–0) 23.0 (21–25) 0.2 (0–0)Bulgaria 27/26/26 37.0 (19–58) 22.2 (9–42) 26.9 (12–48) 23.1 (9–44) 11.5 (2–30) 15.4 (4–35)Cyprus 11/11/11 36.4 (11–69) 18.2 (2–52) 36.4 (11–69) 9.1 (0–41) 9.1 (0–41) 27.3 (6–61)Czech Republic 297/297/297 4.4 (2–7) 0.7 (0–2) 4.7 (3–8) 3.0 (1–6) 3.4 (2–6) 1.3 (0–3)Denmark 996/996/996 3.5 (2–5) 0.7 (0–1) 4.2 (3–6) 2.9 (2–4) 3.2 (2–5) 1.0 (0–2)Estonia 82/63/63 1.2 (0–7) 0.0 (0–4) 1.6 (0–9) 1.6 (0–9) 1.6 (0–9) 0.0 (0–6)Finland 652/679/643 12.9 (10–16) 1.7 (1–3) 27.7 (24–31) 2.8 (2–4) 17.9 (15–21) 10.0 (8–13)France 826/826/826 26.8 (24–30) 5.9 (4–8) 27.0 (24–30) 3.5 (2–5) 3.8 (3–5) 23.2 (20–26)Germany 328/339/323 2.4 (1–5) 0.6 (0–2) 8.3 (6–12) 1.5 (1–4) 7.4 (5–11) 0.9 (0–3)Hungary 143/134/134 11.9 (7–18) 2.8 (1–7) 19.4 (13–27) 5.2 (2–10) 14.2 (9–21) 5.2 (2–10)Iceland 35/35/35 0.0 (0–10) 0.0 (0–10) 2.9 (0–15) 0.0 (0–10) 2.9 (0–15) 0.0 (0–10)Ireland 356/336/336 19.9 (16–24) 6.2 (4–9) 17.3 (13–22) 7.7 (5–11) 5.4 (3–8) 11.9 (9–16)Italy 202/191/178 5.9 (3–10) 3.0 (1–6) 21.5 (16–28) 1.7 (0–5) 16.3 (11–23) 3.9 (2–8)Latvia 30/30/30 0.0 (0–12) 0.0 (0–12) 3.3 (0–17) 0.0 (0–12) 3.3 (0–17) 0.0 (0–12)Lithuania 46/44/44 8.7 (2–21) 6.5 (1–18) 6.8 (1–19) 6.8 (1–19) 4.5 (1–15) 2.3 (0–12)Luxembourg 64/61/59 18.8 (10–30) 10.9 (5–21) 16.4 (8–28) 6.8 (2–16) 11.9 (5–23) 5.1 (1–14)Malta 7/8/7 14.3 (0–58) 0.0 (0–41) 12.5 (0–53) 0.0 (0–41) 0.0 (0–41) 14.3 (0–58)Netherlands 572/679/505 1.4 (1–3) 0.2 (0–1) 5.0 (3–7) 0.6 (0–2) 4.8 (3–7) 0.6 (0–2)Norway 554/545/545 2.2 (1–4) 0.4 (0–1) 5.7 (4–8) 0.9 (0–2) 4.4 (3–6) 1.3 (1–3)Poland 68/62/62 29.8 (18–43) 29.8 (18–43) 16.1 (8–27) 8.8 (3–18) 1.5 (0–8) 14.7 (7–25)Portugal 237/237/237 18.1 (13–24) 18.1 (13–24) 22.4 (17–28) 7.2 (4–11) 11.4 (8–16) 11.0 (7–16)Romania 17/16/16 29.4 (10–56) 11.8 (1–36) 25.0 (7–52) 6.3 (0–30) 0.0 (0–21) 25.0 (7–52)Slovenia 213/213/213 17.4 (13–23) 1.4 (0–4) 17.8 (13–24) 10.8 (7–16) 11.3 (7–16) 6.6 (4–11)Spain 708/697/697 22.0 (19–25) 8.3 (6–11) 19.4 (16–23) 11.8 (9–14) 9.2 (7–12) 10.2 (8–13)Sweden 1 058/1 008/1 005 3.3 (2–5) 2.5 (2–4) 4.1 (3–5) 2.8 (2–4) 3.5 (2–5) 0.6 (0–1)United Kingdom 1 300/1 252/1 166 2.8 (2–4) 1.0 (1–2) 4.2 (3–5) 1.5 (1–2) 2.7 (2–4) 1.4 (1–2)

* Dual non-susceptibility defined as being non-susceptible to penicillin and macrolides.

Table 5.2: Distribution of single penicillin, single macrolides and dual penicillin-macrolides non-susceptibility, among the most common serogroups reported per country in 2009

Ser

ogro

ups

Belgium Czech Republic Iceland Ireland Slovenia United Kingdom

Nu

mb

er

% s

ing

le P

EN

% s

ing

le M

AC

R

% D

UA

L

Nu

mb

er

% s

ing

le P

EN

% s

ing

le M

AC

R

% D

UA

L

Nu

mb

er

% s

ing

le P

EN

% s

ing

le M

AC

R

% D

UA

L

Nu

mb

er

% s

ing

le P

EN

% s

ing

le M

AC

R

% D

UA

L

Nu

mb

er

% s

ing

le P

EN

% s

ing

le M

AC

R

% D

UA

L

Nu

mb

er

% s

ing

le P

EN

% s

ing

le M

AC

R

% D

UA

L

1 368 0 48 0 28 0 0 0 1 0 0 0 13 0 0 0 25 4 0 0 28 0 0 03 125 0 1 0 24 0 4 0 1 0 0 0 18 0 6 0 33 0 0 0 23 4 0 04 42 0 0 0 20 0 5 0 0 0 0 0 11 0 0 0 9 0 0 0 6 0 0 05 115 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 06 71 0 30 1 18 0 6 0 3 0 0 0 22 5 5 45 16 13 13 13 18 0 6 07 202 0 0 0 24 0 0 0 4 0 0 0 32 0 3 0 9 0 0 0 41 0 0 08 42 0 2 0 14 0 0 0 0 0 0 0 9 0 0 0 1 0 0 0 26 4 0 49 49 0 22 0 28 25 4 0 9 0 0 0 20 15 0 20 21 29 5 0 11 0 9 010 40 0 3 0 11 0 0 0 0 0 0 0 1 0 0 0 2 0 0 0 2 0 0 011 24 0 17 0 2 0 0 0 1 0 0 0 5 0 20 0 3 0 0 0 13 0 8 012 193 0 2 0 0 0 0 0 0 0 0 0 4 0 0 0 1 0 0 0 7 0 0 014 37 0 65 3 26 4 8 12 6 0 17 0 33 27 36 24 28 21 61 18 11 0 64 915 38 0 39 0 3 0 0 0 0 0 0 0 11 0 9 0 3 0 0 0 7 0 0 1418 16 0 0 0 6 0 0 0 0 0 0 0 16 13 0 0 5 0 0 0 1 0 0 019 201 1 64 0 16 6 25 0 4 0 0 0 32 6 3 28 21 29 5 24 41 2 7 020 5 0 0 0 3 0 0 0 1 0 0 0 3 0 0 0 0 0 0 0 0 0 0 022 88 0 0 0 7 0 0 0 0 0 0 0 15 0 0 0 2 0 0 0 25 4 0 023 49 0 20 0 23 0 0 4 2 0 0 0 20 0 0 5 11 0 9 9 8 13 0 033 36 0 64 0 1 0 0 0 1 0 0 0 7 0 0 0 6 0 17 0 9 0 11 0other 139 0 9 0 12 0 0 0 0 0 0 0 10 20 0 10 9 0 11 11 14 7 0 0Total/average

1 880 0 23 0 266 3 4 2 33 0 3 0 283 7 6 12 206 10 12 7 291 2 5 1

Only countries reporting more that 30 isolates were presented.

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Figure 5.7: Distribution of serogroups and the resistance profile of S. pneumoniae isolates per serogroup in 2009

Only countries that reported serogroup information for more than 30 isolates were included in the figure.* Susceptible to at least penicillin and macrolides.** Non-susceptible to penicillin and macrolides.

0 2 4 6 8 10 12 14 16

Other

20

18

11

10

33

15

4

8

23

5

22

9

14

6

12

3

7

19

1

Single macrolides non-susceptible

Dual non-susceptible**

Single penicillin non-susceptible

Fully susceptible*

Sero

grou

ps

Proportion

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

5.2 Staphylococcus aureus5.2.1 Clinical and epidemiological importance

Staphylococcus aureus is a gram-positive bacterium that colonises the skin of about 30% of healthy humans. Although mainly a harmless coloniser, S. aureus can cause severe infection. Its oxacillin-resistant form (meticillin-resistant S. aureus, MRSA) is the most impor-tant cause of antibiotic-resistant healthcare-associated infections worldwide. Since healthcare-associated MRSA infections add to the number of infections caused by meticillin-susceptible S. aureus, a high incidence of MRSA adds to the overall burden of infections caused by this species in hospitals. Moreover, infections with MRSA may result in prolonged hospital stay and in higher mortality rates, owing mainly to the increased toxicity and limited effectiveness of alternative treat-ment regimens. MRSA is currently the most commonly identified antibiotic-resistant pathogen in hospitals in many parts of the world, including Europe, the Americas, North Africa and the Middle- and Far East.

5.2.2 Resistance mechanisms

S. aureus acquires resistance to meticillin and all other beta-lactam antibiotics through expression of the exog-enous mecA gene, that codes for a variant penicillin binding protein PBP2’ (PBP2a) with low affinity to beta-lactams, thus preventing the drug induced inhibition of cell wall synthesis. The level of meticillin resistance, defined by its MIC, depends on the amount of PBP2’ production, which is influenced by various genetic fac-tors. Resistance levels of mecA-positive strains can thus range from phenotypically susceptible to highly resistant. Upon challenge with meticillin, a population of a heterogeneously resistant MRSA strain may quickly be outgrown by a subpopulation of highly resistant variants.

5.2.3 Results

Beta-lactams

• Twenty-eight countries reported 30 680 isolates of which 5 965 were identified as meticillin-resistant Staphylococcus aureus (MRSA).

• Proportion of MRSA was: below 1% in two countries, 1–5% in five countries, 5–10% in two countries, 10–25% in nine countries, 25–50% in nine countries and above 50% in one country (Figure 5.8, Table 5.3).

• Trends in the 2006–2009 period have been calculated for 28 countries. Significant decreasing trends have been observed for eight countries. In six of these coun-tries the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.9). In 2009, these eight countries reported the following proportion of MRSA: 5–10% in two cases (Austria and Latvia), 10–25% in two cases (Bulgaria and France) and 25–50% in four cases (Greece, Ireland, Romania and UK).

• One country (Czech Republic) reported a significant increasing trend of MRSA proportion (Figure 5.9) which, in 2009, was 15%.

Rifampin

• Twenty-five countries reported 21 190 isolates of which 203 were identified as resistant to rifampin. Seventeen countries reported at least one resistant isolate. Most resistant isolates (159) were also MRSA. The proportion of rifampin resistance was 3.7% among the MRSA isolates and 0.3% among the MSSA isolates.

• Proportion of resistance was: below 1% in 17 coun-tries, 1–5% in six countries, 5–10% in one country, 10–25% in one country (Table 5.3).

5.2.4 Conclusions

The proportion of MRSA is stabilising or decreasing in most European countries. Eight countries reported decreasing trends while only one reported an increas-ing trend. The countries showing a more evident and sustained decrease of MRSA proportion are: Austria, France, Ireland, Latvia and UK. Although these signals provide reasons for optimism, MRSA should remain a public health priority, since the proportion of MRSA is still above 25% in 10 out of 28 countries, mainly in southern Europe and on the British Isles.

The occurrence of resistance to rifampin, which is rec-ommended in combination with other antimicrobials to treat various staphylococcal infections, is still very low in most European countries.

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Figure 5.8: Staphylococcus aureus: proportion of invasive isolates resistant to meticillin (MRSA) in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Table 5.3: Number of invasive S. aureus isolates and proportion resistant to meticillin (MRSA) and rifampin (RIF), including 95% confidence intervals (95% CI), reported per country in 2009

CountryMeticillin Rifampin

N % MRSA (95%CI) N % RIF (95%CI)

Austria 1 739 6.3 (5–8) 1 677 0.2 (0–1)Belgium 949 21.1 (19–24) 0 -Bulgaria 221 15.8 (11–21) 137 2.9 (1–7)Cyprus 89 32.6 (23–43) 89 0.0 (0–4)Czech Republic 1 695 14.6 (13–16) 716 1.3 (1–2)Denmark 1 395 2.1 (1–3) 1 395 0.1 (0–1)Estonia 213 3.3 (1–7) 63 0.0 (0–6)Finland 978 1.9 (1–3) 934 0.0 (0–0)France 4 720 22.8 (22–24) 4 519 1.2 (1–2)Germany 1 885 18.5 (17–20) 1 152 0.5 (0–1)Greece 996 40.4 (37–43) 0 -Hungary 1 068 29.0 (26–32) 287 2.4 (1–5)Iceland 59 0.0 (0–6) 0 -Ireland 1 261 26.8 (24–29) 1 051 0.4 (0–1)Italy 978 37.4 (34–41) 908 5.5 (4–7)Latvia 186 9.1 (5–14) 159 0.6 (0–3)Lithuania 254 11.0 (7–16) 164 0.0 (0–2)Luxembourg 113 13.3 (8–21) 72 0.0 (0–5)Malta 86 58.1 (47–69) 86 0.0 (0–4)Netherlands 1 035 1.0 (0–2) 861 0.0 (0–0)Norway 907 0.3 (0–1) 262 0.0 (0–1)Poland 506 20.2 (17–24) 259 1.2 (0–3)Portugal 1 824 49.1 (47–51) 828 3.5 (2–5)Romania 45 35.6 (22–51) 45 15.6 (6–29)Slovenia 424 10.1 (7–13) 395 0.5 (0–2)Spain 1 715 25.9 (24–28) 1 614 0.5 (0–1)Sweden 2 456 1.0 (1–1) 1 608 0.1 (0–0)United Kingdom 2 883 27.8 (26–29) 1 909 0.6 (0–1)

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Figure 5.9: Staphylococcus aureus: trend of meticillin-resistance (MRSA) by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50 60 70 80

MT

PT

EL (<)

IT

RO (<*)

CY

HU

UK (<)

IE (<)

ES

FR (<)

BE

PL

DE

BG (<*)

CZ (>)

LU

LT

SI

LV (<)

AT (<)

EE

DK

FI

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NO

IS 2006200720082009

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% MRSA

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

5.3 Enterococci

5.3.1 Clinical and epidemiological importance

Enterococci belong to the normal bacterial flora of the gastrointestinal tract of humans, other mammals, birds and reptiles. Enterococci are regarded harmless com-mensals, and are even believed to have positive effects on a number of gastrointestinal and systemic conditions. However, when the commensal relationship with the host is disrupted, enterococci can cause invasive diseases. Recently, the recognition of high risk clones as those of the polyclonal subcluster CC17 in Enterococcus faecium, suggests that some particular strains can act as true pathogens, and not only as opportunistic commensals. Enterococci can cause a variety of clinical syndromes, including endocarditis, bacteraemia, meningitis, wound and urinary tract infections and are associated with peritonitis and intra-abdominal abscesses. In the United States, three to four nosocomial bloodstream infections per 10 000 hospital discharges are caused by entero-cocci, and contribute to patient mortality as well as additional hospital stay.

The vast majority (around 80%) of clinical enterococcal infections in humans are caused by Enterococcus faeca-lis, whereas E. faecium accounts for the majority of the remaining 20%. Epidemiological data collected over the last two decades have documented the emergence of enterococci, and in particular E. faecium, as important nosocomial pathogens, which is seen as the expansion of a major hospital adapted polyclonal subcluster CC17, but also in E. faecalis CC2 and CC9, which are also iso-lated from farm animals. The emergence of particular clones and clonal complexes of E. faecalis and E. fae-cium was paralleled by increases in glycopeptide and high-level aminoglycoside resistance. These two antimi-crobial groups represent the few remaining therapeutic options for treatment of human infections caused by E. faecium when resistance has emerged against penicil-lins. Besides the fact that infections caused by resistant enterococci are difficult to treat, they are highly tena-cious and thus easily disseminate in the hospital setting.

5.3.2 Resistance mechanisms

Enterococci are intrinsically resistant to a broad range of antibiotics including cephalosporins, sulphonamides and low concentrations of aminoglycosides. Patient safety in hospitals is challenged by the ability of ente-rococci to acquire additional resistance through the transfer of plasmids and transposons and recombination or mutation.

Beta-lactam antibiotics – By nature, enterococci have low susceptibility to many beta-lactam antibiotics – a consequence of their low-affinity PBPs. Two possible mechanisms of resistance of enterococci to beta-lactams have been reported: the production of beta-lactamase, which is an extremely rare finding; and the overpro-duction and modification of penicillin-binding proteins (PBPs, particularly PBP5) that causes high-level peni-cillin resistance in E. faecium. Complete penicillin resistance in E. faecalis is currently absent; therefore,

the first choice for treatment of infections caused by this microorganism is still an aminopenicillin such as ampi-cillin. In E. faecium, ampicillin-resistance has increased significantly during the last years due to the wide dis-semination of ampicillin-resistant strains belonging to the polyclonal subcluster CC17.

Aminoglycosides – In addition to the intrinsic mecha-nism of low-level resistance, which causes a low uptake of the drug, enterococci have acquired genes conferring high-level resistance to aminoglycosides. High-level resistance to streptomycin can be mediated by single mutations within a protein of the 30S ribosomal subu-nit, the target of aminoglycoside activity. In addition, different aminoglycoside-modifying enzymes have been identified, targeting eight different aminoglycosides.

Glycopeptides – Vancomycin resistance in enterococci was first encountered in France and England but showed the most dramatic increase in the United States and was attributed to the widespread use of vancomycin in US hospitals. Whereas vancomycin consumption was less pronounced in Europe, a closely related glycopeptide, avoparcin, was widely used as growth promoter in ani-mal husbandry from the late-1970s until it was banned in the EU by 1998. Glycopeptide resistance is due to the synthesis of modified cell wall precursors that show a decreased affinity for glycopeptides. Five pheno-types have been identified of which two have clinical relevance: VanA, with high-level resistance to both van-comycin and teicoplanin; and VanB, with a variable level of resistance to only vancomycin. The VanA and VanB phenotypes, mostly found among E. faecalis and E. fae-cium, may be transferred by plasmids and conjugative transposition.

5.3.3 Results E. faecalis

High-level aminoglycosides

• Twenty-six countries reported 6 950 isolates of which 2 484 were high-level resistant to aminoglycosides.

• Three countries reported resistance proportions above 50% (Cyprus, Greece and Hungary), and the majority of countries (18 of 26) reported resistant proportions between 50% and 30%. Among five countries report-ing proportions below 30%, the lowest proportions were reported by Sweden (18.6%), France (18.0%) and Iceland (15.4%) (Figure 5.10 and Table 5.4).

• Nineteen of 26 countries reported more than 20 iso-lates per year since 2006 and were included in the trend analysis for the period 2006–2009. During the past four years, a significant increase was observed for three of 19 countries. Only for Cyprus, the increas-ing trend was significant, when considering data from laboratories reporting consistently for all four years (Figure 5.11).

• Two countries (Germany and Ireland) reported signifi-cant decreasing trends of high-level aminoglycosides resistance. The decreasing trend was significant only for Ireland when considering data from laboratories reporting consistently for all four years (Figure 5.11).

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

5.3.4 Results E. faecium

Vancomycin

• Twenty-eight countries reported 4 945 isolates of which 451 were resistant to vancomycin. Only two countries (Malta and Romania) reported less than 10 isolates (thus not shown in Figure 5.12).

• Three countries reported resistance proportions above 25% (Ireland, Luxembourg and Greece) and five countries reported resistant proportions between 10% and 25%, while the majority of countries (18 of 26) reported resistant proportions below 10%. Several countries reported even below 1% (Bulgaria, Estonia, Finland, France, Norway, Romania and Sweden) (Figure 5.12 and Table 5.4).

• Nineteen of 28 countries reported more than 20 iso-lates per year since 2006 and were included in the trend analysis for the period 2006–2009. During the past four years, a significant increase was observed only for Austria; however, the increasing trend was not significant when considering data from laboratories reporting consistently for all four years (Figure 5.13).

• Four countries (Greece, Germany, Italy and France) reported significant decreasing trends of vancomycin resistance. Considering data from laboratories report-ing consistently for all four years, the decreasing trend was significant for Greece and Italy (Figure 5.13).

5.3.5 Conclusions

High-level aminoglycoside resistance in E. faecalis seems stable in Europe but at a relatively high level. The majority of countries reported proportions of resistant isolates between 30% and 50%, however, a consistent decrease was reported by Germany and Ireland.

The occurrence of vancomycin resistance in E. faecium seems also to stabilise in Europe, although fluctuations may arise from hospitals outbreaks, e.g. related to the continuing dissemination of strains belonging to the pol-yclonal subcluster CC17. This may, however, not reflect the overall trend or the situation in hospitals, which have remained unaffected.

In some countries (Greece, Germany, Italy and France) the efforts to control glycopeptide-resistant enterococci seem to be successful and resulting in a continuous decrease of proportions of resistant isolates, and sev-eral countries reported resistant proportions below 1%.

Figure 5.10: Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.11: Enterococcus faecalis: trends of high-level aminoglycoside resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50 60 70 80

CY (>)

EL

HU

IT (>*)

CZ

SI

EE

ES (>*)

DE (<*)

UK

BG

NO

PT

IE (<)

AT

NL

BE

SE

FR 2006200720082009

Coun

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% aminoglycoside high-level resistance

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Figure 5.12: Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Table 5.4: Number of invasive E. faecalis and E. faecium isolates and proportion of high–level aminoglycoside–resistant E. faecalis and vancomycin–resistant E. faecium (%R), including 95% confidence intervals (95% CI), reported per country in 2009

CountryHigh-level aminoglycoside resistant E. faecalis Vancomycin-resistant E. faecium

N % R (95% CI) N % R (95% CI)

Austria 252 31.0 (25–37) 310 4.2 (2–7)Belgium 150 23.3 (17–31) 67 4.5 (1–13)Bulgaria 53 35.8 (23–50) 26 0.0 (0–13)Cyprus 65 66.2 (53–77) 15 13.3 (2–40)Czech Republic 626 46.8 (43–51) 209 5.7 (3–10)Denmark 52 32.7 (20–47) 348 1.7 (1–4)Estonia 23 43.5 (23–66) 40 0.0 (0–9)Finland 0 - 243 0.0 (0–2)France 1 298 18.0 (16–20) 591 0.8 (0–2)Germany 450 39.6 (35–44) 408 6.1 (4–9)Greece 547 61.2 (57–65) 435 26.9 (23–31)Hungary 368 50.5 (45–56) 76 1.3 (0–7)Iceland 26 15.4 (4–35) 25 8.0 (1–26)Ireland 260 34.2 (28–40) 386 37.8 (33–43)Italy 136 49.3 (41–58) 188 4.3 (2–8)Latvia 26 38.5 (20–59) 22 18.2 (5–40)Lithuania 31 48.4 (30–67) 19 10.5 (1–33)Luxembourg 32 28.1 (14–47) 14 35.7 (13–65)Malta 0 - 6 0.0 (0–46)Netherlands 190 30.5 (24–38) 207 1.0 (0–3)Norway 252 35.7 (30–42) 101 0.0 (0–4)Poland 163 38.7 (31–47) 85 1.2 (0–6)Portugal 420 34.3 (30–39) 217 22.6 (17–29)Romania 17 35.3 (14–62) 9 0.0 (0–34)Slovenia 115 44.3 (35–54) 69 4.3 (1–12)Spain 735 42.9 (39–47) 342 2.6 (1–5)Sweden 597 18.6 (16–22) 221 0.5 (0–2)United Kingdom 66 37.9 (26–51) 266 12.8 (9–17)

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Figure 5.13: Enterococcus faecium: trends of vancomycin resistance by country 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.** 0% resistance for all four years.

0 10 20 30 40 50

IE

EL (<)

PT

UK

DE (<*)

CZ

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IT (<)

SI

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

5.4 Escherichia coli5.4.1 Clinical and epidemiological importance

Escherichia coli is the most frequent gram-negative rod isolated from blood cultures in clinical settings. It is the most frequent cause of bacteremia, community and hospital-acquired urinary tract infections, is associated with spontaneous and surgical peritonitis and with skin and soft tissue infections due to multiple microorgan-isms, causes neonatal meningitis and is one of the most important foodborne pathogens worldwide.

5.4.2 Resistance mechanisms

Beta-lactamases hydrolyse the beta-lactam ring of beta-lactam antibiotics, which is crucial for inhibition of PBPs in bacteria. In E. coli, resistance to broad-spectrum penicillins such as ampicillin or amoxicillin is usually conferred by plasmid coded beta-lactamases mainly of the TEM type and to a lesser extend of the SHV type, whereby TEM-1 accounts for up to 60% of aminopeni-cillin resistance. In 1982 the first ESBL was identified during a hospital outbreak of Klebsiella pneumoniae in Germany. It was soon understood that single or multi-ple amino acid substitutions in the basic structure of SHV or TEM enzymes can alter their spectrum of activity and enhance their hydrolysing ability to include third-generation cephalosporins (in this report referring to: cefotaxime, ceftriaxone, ceftazidime) and monobactams. Most ESBLs can be inhibited by beta-lactamase inhibi-tors such as clavulanic acid, sulbactam or tazobactam. More than 200 ESBL variants are known to date. Most of them belong to four enzyme families TEM, SHV, CTX-M and OXA (an overview of identified ESBL types is given on http://www.lahey.org/studies/). Until 2000, over 90% of ESBL resistance was mediated through TEM or VHS variants. In the late 1980s, new ESBLs of the CTX-M family emerged first in South America and, during early 2000s, attained global importance. In contrast to con-ventional TEM, and SHV ESBLs, most CTX-Ms display a higher hydrolysing ability against cefotaxime than ceftazidime (hence their name). An important part of this global success is due to the wide dissemination of particular plasmids or bacterial clones producing ESBL (e.g. CTX-M15). Other enzymes affecting the susceptibil-ity to third-generation cephalosporins include plasmid encoded variants from the chromosomal AmpC beta-lactamases. CMY-2 is the most widespread enzyme belonging to this group, which is still less common in E. coli in Europe but frequent in the United States. An important threat that will require close surveillance in the future is the development of carbapenem-resistance in E coli, mediated by metallo-beta-lactamases (as VIM or IMP enzymes, or the emerging NDM enzyme) and serin-beta-lactamases (as KPC enzymes), providing resistance to virtually all available beta-lactam agents.

Fluoroquinolones interact with DNA gyrase and topoisomerase IV, which are enzymes that regulate conformational changes in the bacterial chromosome

during replication and transcription. This interaction leads to irreversible inhibition of the enzyme activity followed by DNA fragmentation and eventually to cell death. Resistance to fluoroquinolones arises through stepwise mutations in the coding regions of the gyrase subunits (gyrA and gyrB) and DNA topoisomerase IV (parC). Accumulation of mutations in several of these genes increases the MIC in a stepwise manner. Low-level resistance to fluoroquinolones may also arise through changes in outer membrane porins or from upregula-tion of efflux pumps, resulting in lower outer membrane permeability and higher efflux, respectively. In recent years, several plasmid-mediated quinolone resistance mechanisms have also been identified, including the Qnr proteins, which protect DNA topoisomerases from quinolone binding, the AAC6’-Ib-cr enzyme, which inactivates some fluoroquinolones by acetylation, and the QepA efflux pump, which effluxes hydrophilic qui-nolones. These mechansims are of concern because of transferability and their frequent association with CTX-M and CMY-type enzymes inactivating third-gener-ation cephalosporins.

Aminoglycosides block protein synthesis by binding to the ribosomes, which are involved in the translation of RNA into proteins, and are also able to damage the outer membrane of gram-negative rods. Resistance to aminoglycosides can be due to targeted modification (methylation) of the large ribosomal subunit, which excludes aminoglycoside molecules, or by aminogly-coside modifying enzymes that acetylate, adenylate or phosphorylate their target molecules and thereby neu-tralise the biologic effect of aminoglycosides.

5.4.3 Results

Aminopenicillins

• Twenty-eight countries reported 47 318 isolates of which 25 254 were resistant to aminopenicillins.

• The majority of countries (19 of 28) reported resistance proportions from 50% to 66.5%. Among nine countries reporting proportions below 50%, the lowest pro-portions were reported by Sweden (33.2 %), Finland (36.4 %) and Norway (37.2 %) (Table 5.5). Trends for the period 2006–2009 were calculated for 28 countries. During the past four years, a significant increase was observed in 10 of 28 countries. In seven of these coun-tries, the trends were significant also when considering only data from laboratories reporting consistently for all four years (Figure 5.17). Among the 10 countries with increasing trends, four countries reported propor-tion of resistance to aminopenicillin higher than 60% even though these countries were already at relatively high levels, five countries reported between 60% and 50%, and one country reported below 50%.

• Two countries (Austria and Estonia) reported significant decreasing trends of resistance to ami-nopenicillin, although both countries were already at relatively low levels (Figure 5.17).

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Third-generation cephalosporins

• Twenty-eight countries reported 49 720 isolates of which 3 657 were resistant to third-generation cephalosporins.

• Nine of 28 countries reported third-generation cephalosporins resistance higher than 10% and the proportions ranged up to 19.2%. Among the 19 coun-tries reporting less than 10% resistance, the lowest proportions were reported by Iceland (1.8%), Estonia (2.2%) and Norway (2.3%) (Table 5.5 and Figure 5.14).

• Trends for the period the 2006–2009 were calculated for 28 countries. During the past four years, a signifi-cant increase was observed in more than half (16 of 28) of the countries. In 15 of these, the trends were significant also when considering only data from laboratories reporting consistently for all four years (Figure 5.18). Among the 16 countries with increasing trends for 2006–2009, five countries reported propor-tions of resistance to third-generation cephalosporins above 10%, nine countries reported between 10% and 5%, and two countries reported below 5%.

• Only one country reported a decreasing trend in resist-ance to third-generation cephalosporins, however the trend was not significant when considering only data from laboratories reporting consistently for all four years.

Extended-spectrum beta-lactamase (ESBL)

• Among E. coli isolates resistant to third-genera-tion cephalosporins, a large proportion has been ascertained as ESBL positive by the participating laboratories in 2009. Twelve of 13 countries reported proportions of ESBL production between 85% and 100% among isolates resistant to third-generation cephalosporins (Table 5.6).

Fluoroquinolones

• Twenty-eight countries reported 48 054 isolates of which 9 488 were resistant to fluoroquinolones.

• The majority of countries (16 of 28) reported resistant proportions higher than 20%, ranging up to 43.4%. Seven countries reported between 20% and 10%. Among five countries reporting below 10%, the low-est proportions of resistant isolated were reported by Iceland (7.1%), Sweden (8.2 %) and Estonia (8.3%) (Table 5.5 and Figure 5.15).

• Trends in the period 2006–2009 were calculated for 28 countries. A significant increase was observed for seven countries. In six of these countries the trends were significant also when considering only data from laboratories reporting consistently all four years (Figure 5.19).

• Among the seven countries with increasing trends for 2006–2009, two reported proportions of resistance to fluoroquinolones above 30%, two reported between 30% and 20%, and three countries reported below 20%.

• Only two countries (Austria and Germany) reported significant decreasing trends in resistance to fluoro-quinolones (Figure 5.19).

Aminoglycosides

• Twenty-eight countries reported 50 699 isolates of which 3 983 were resistant to aminoglycosides.

• Eleven of 28 countries reported proportions of resist-ance higher than 10%, ranging up to 21.4%. Eleven countries reported between 10% and 5%. Among six countries reporting below 5%, the lowest proportions of resistant isolated were reported by Norway (3.3%), Finland (2.8%) and Sweden (2.5%) (Table 5.5 and Figure 5.16).

• Trends in the period 2006–2009 were calculated for 28 countries. A significant increase in the proportion of isolates resistant to aminoglycosides was observed for 10 countries. Among these, five countries reported proportions higher than 10%, one country reported between 10% and 5%, and four countries reported below 5%.

• For two countries (Austria and Romania) the propor-tions of resistance to aminoglycosides significantly decreased over the last four years. For Austria, the trend was significant also when considering only data from laboratories consistently reporting for all four years (Figure 5.20).

Combined resistance (aminopenicillins, third-generation

cephalosporins, fluoroquinolones and aminoglycosides)

• In 2009, 28 countries reported 42 898 isolates tested for aminopenicillins, third-generation cephalosporins, fluoroquinolones and aminoglycosides. Fifty-seven per cent of these isolates were resistant to one or more of the four considered antibiotic classes.

• In nine countries, the proportion of multiresistant iso-lates (resistance to third-generation cephalosporins, fluoroquinolones and aminoglycosides) was higher than 5%, between 5% and 1% in 14 countries, and below 1% in four countries (Table 5.7 and Figure 5.21).

• Trends in the period 2006–2009 were calculated for 28 countries. A significant increase in proportions of multiresistant isolates was observed for 12 countries. In 10 of these countries the trends were significant also when considering only data from laboratories reporting consistently for all four years (Figure 5.21). Among the 12 countries with significantly increasing proportions of multiresistant isolates, four countries reported above 5%, eight countries reported between 5% and 1%, whereas no country reported below 1%. No country had a significantly decreasing trend of pro-portions of multiresistance in E. coli in 2006–2009.

• The most frequent resistance phenotypes in E. coli were single aminopenicillin resistance (33.3%), fol-lowed by dual resistance to aminopenicillins and fluoroquinolones (8.7%). Combined resistance to all four antimicrobials was reported for 3.3% of the iso-lates and combined resistance to aminopenicillins,

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SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

fluoroquinolones and aminoglycosides was 3.2% (Table 5.7).

5.4.4 Conclusions

The remarkable and constant Europe-wide decline of antimicrobial susceptibility in E. coli observed during recent years continued in 2009. Resistance in E. coli shows increasing trends in several countries and for both multiresistance and for single antimicrobials under surveillance.

The highest proportions of resistance in E. coli were reported for aminopenicillins ranging up to 66.5%. Irrespective of the high level of resistance, proportions continue to increase in several countries, including those already presenting resistance well above 50%.

The proportion of third-generation cephalosporins resistance reported for E. coli has increased signifi-cantly during the last four years in more than half of the reporting countries. Among isolates resistant to third-generation cephalosporins, a high proportion (85–100%) was identified as ESBL positive. These data indicate that ESBL production is highly prevalent in third-generation cephalosporin-resistant E. coli in European hospitals.

Fluoroquinolone resistance in E. coli continues the increase as in previous years. Although the number of countries showing an increasing trend over the last four years was reduced compared to 2008, the situation becomes progressively dire and more than half of the countries are reporting resistance proportions higher than 20%.

Ten countries had significant increases in the propor-tion of isolates resistant to aminoglycosides and five of these countries reported proportions higher than 10%. This indicates that aminoglycosides resistance is increasing even among the countries already reporting higher levels of resistance.

The most frequent resistance phenotypes in E. coli were single aminopenicillin resistance (33.3%), followed by dual resistance to aminopenicillins and fluoroquinolones (8.7%). Combined resistance to all four antimicrobials was reported for 3.3% of the isolates and combined resistance to aminopenicillins, fluoroquinolones and aminoglycosides was 3.2%. Resistance to third-gener-ation cephalosporins was associated with resistance to aminoglycosides in almost half of the cases and to fluo-roquinolones in approximate 75% of the cases. These results indicate that the loss of antimicrobial suscepti-bility in E. coli requires close surveillance.

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Table 5.5: Number of invasive E. coli isolates and proportion aminopenicillins, third-generation cephalosporins, fluoroquinolones, aminoglycosides and multiresistance (%R), including 95% confidence intervals (95% CI), reported per country in 2009

CountryAminopenicillins Fluoroquinolones Third-gen. cephalosporins Aminoglycosides Multiresistance*

N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)

Austria 2 605 48.6 (47–51) 2 616 20.5 (19–22) 2 597 7.5 (7–9) 2 619 6.1 (5–7) 2 588 2.2 (2–3)Belgium 1 607 55.9 (53–58) 1 504 19.9 (18–22) 1 596 6.5 (5–8) 1 195 7.3 (6–9) 1 175 1.6 (1–3)Bulgaria 181 66.3 (59–73) 193 28.0 (22–35) 193 19.2 (14–25) 194 18.0 (13–24) 192 7.3 (4–12)Cyprus 136 66.2 (58–74) 136 43.4 (35–52) 136 14.0 (9–21) 136 9.6 (5–16) 136 5.1 (2–10)Czech Republic 2 759 60.6 (59–62) 2 758 23.2 (22–25) 2 759 9.8 (9–11) 2 742 9.0 (8–10) 2 741 3.0 (2–4)Denmark 3 531 42.9 (41–45) 3 406 13.2 (12–14) 2 705 6.2 (5–7) 3 530 4.4 (4–5) 2 634 1.4 (1–2)Estonia 319 38.2 (33–44) 302 8.3 (5–12) 319 2.2 (1–4) 320 3.8 (2–6) 301 0.7 (0–2)Finland 1 906 36.4 (34–39) 2 223 9.2 (8–10) 2 176 2.8 (2–4) 2 033 2.8 (2–4) 1 984 1.5 (1–2)France 8 436 55.5 (54–57) 8 353 18.6 (18–19) 8 449 6.7 (6–7) 8 448 8.2 (8–9) 8 350 3.0 (3–3)Germany 2 158 56.1 (54–58) 2 786 23.4 (22–25) 2 759 8.2 (7–9) 2 796 8.4 (7–9) 2 745 3.2 (3–4)Greece 1 694 50.9 (48–53) 1 806 23.4 (21–25) 1 815 10.1 (9–12) 1 828 14.5 (13–16) 1 806 6.4 (5–8)Hungary 1 047 59.8 (57–63) 1 046 30.5 (28–33) 1 052 12.9 (11–15) 1 056 15.9 (14–18) 1 042 9.8 (8–12)Iceland 109 49.5 (40–59) 99 7.1 (3–14) 110 1.8 (0–6) 110 7.3 (3–14) 99 0.0 (0–4)Ireland 1 987 66.5 (64–69) 2 005 21.7 (20–24) 1 986 6.5 (5–8) 2 009 8.8 (8–10) 1 976 2.4 (2–3)Italy 764 63.4 (60–67) 863 36.2 (33–39) 687 17.0 (14–20) 863 12.5 (10–15) 687 5.5 (4–8)Latvia 86 43.0 (32–54) 85 23.5 (15–34) 86 11.6 (6–20) 86 12.8 (7–22) 85 5.9 (2–13)Lithuania 291 58.4 (53–64) 295 14.6 (11–19) 293 7.8 (5–12) 297 15.2 (11–20) 291 3.8 (2–7)Luxembourg 298 57.0 (51–63) 300 25.7 (21–31) 300 8.3 (5–12) 300 9.3 (6–13) 300 4.3 (2–7)Malta 159 54.7 (47–63) 159 30.8 (24–39) 159 15.1 (10–22) 159 21.4 (15–29) 159 12.6 (8–19)Netherlands 2 359 45.1 (43–47) 2 377 11.0 (10–12) 2 368 4.3 (3–5) 2 389 4.4 (4–5) 2 339 1.4 (1–2)Norway 1 845 37.2 (35–39) 1 830 8.7 (7–10) 1 846 2.3 (2–3) 1 841 3.3 (3–4) 1 827 0.7 (0–1)Poland 487 64.7 (60–69) 567 23.1 (20–27) 584 9.1 (7–12) 595 7.1 (5–9) 546 1.8 (1–3)Portugal 1 919 58.3 (56–61) 1 973 27.7 (26–30) 1 912 9.2 (8–11) 2 038 10.8 (9–12) 1 885 5.5 (4–7)Romania 12 83.3 (52–98) 53 22.6 (12–36) 53 17.0 (8–30) 80 12.5 (6–22) 53 15.1 (7–28)Slovenia 783 53.8 (50–57) 783 18.9 (16–22) 783 6.6 (5–9) 783 10.5 (8–13) 783 4.6 (3–6)Spain 3 821 64.7 (63–66) 3 810 31.5 (30–33) 3 821 11.3 (10–12) 3 820 13.0 (12–14) 3 809 4.5 (4–5)Sweden 2 195 33.2 (31–35) 1 596 8.2 (7–10) 4 233 2.8 (2–3) 4 121 2.5 (2–3) 1 529 0.7 (0–1)United Kingdom 3 824 61.6 (60–63) 4 130 18.0 (17–19) 3 943 9.4 (8–10) 4 311 7.4 (7–8) 3 616 4.0 (3–5)

* Multiresistance defined as being resistant to third-generation cephalosporins, fluoroquinolones and aminoglycosides.

Table 5.6: Number of invasive E. coli isolates resistant to third-generation cephalosporins (CREC) and proportion of ESBL positive among these isolates, as ascertained by the participating laboratories in 2009

CountryNumber of

laboratoriesNumber of CREC %ESBL

Austria 24 86 94.2Belgium 4 14 92.9Bulgaria 12 37 94.6Cyprus 5 19 100Czech Republic 42 270 85.6France 38 316 64.9Ireland 25 117 85.5Lithuania 8 23 100Netherlands 6 40 90Poland 16 53 89Portugal 15 122 91.8Sloveni 7 52 92.3Spain 33 432 90.7

Only data from laboratories consistently reporting the ESBL test results for all isolates identified as resistant to third-generation cephalosporins and from countries with at least 10 of such isolates were selected for the analysis.

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Figure 5.14: Escherichia coli: proportion of third-generation cephalosporin resistance in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Table 5.7: Overall resistance and resistance combinations among invasive Escherichia coli isolates tested against aminopenicillins, fluoroquinolones, third-generation cephalosporins and aminoglycosides (n= 42 898) in Europe, 2009

Resistance pattern Number % of total

Fully susceptible 18 622 43.4Single resistance (to indicated drug classes)Aminopenicillins 14 292 33.3Fluoroquinolones 908 2.1Aminoglycosides 86 0.2Resistance to two classes of antimicrobial drugsAminopenicillins + fluoroquinolones 3 718 8.7Aminopenicillins + third-generation cephalosporins 640 1.5Aminopenicillins + aminoglycosides 555 1.3Fluoroquinolones + aminoglycosides 40 0.1Resistance to three classes of antimicrobial drugsAminopenicillins + fluoroquinolones + aminoglycosides 1 387 3.2Aminopenicillins + third-generation cephalosporins + fluoroquinolones 1 123 2.6Aminopenicillins + third-generation cephalosporins + aminoglycosides 132 0.3Resistance to four classes of antimicrobial drugsAminopenicillins + third-generation cephalosporins + fluoroquinolones + aminoglycosides 1 395 3.3

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Figure 5.15: Escherichia coli: proportion of invasive isolates with resistance to fluoroquinolones in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Figure 5.16: Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.17: Escherichia coli: trends of aminopenicillin resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

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Figure 5.18: Escherichia coli: trends of third-generation cephalosporin resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

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Figure 5.19: Escherichia coli: trends of fluoroquinolone resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

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Figure 5.20: Escherichia coli: trends of aminoglycoside resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

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Figure 5.21: Escherichia coli: trends of combined resistance (resistant to fluoroquinolones, third-generation cephalosporins and aminoglycosides) by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 5 10 15 20 25 30

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5.5 Klebsiella pneumoniae5.5.1 Clinical and epidemiological importance

Bacteria of the genus Klebsiella are frequent colonisers of the gastrointestinal tract in humans but may also be found on skin, in the oropharynx and upper airways in hospitalised individuals. Klebsiella pneumoniae is asso-ciated with opportunistic infections in individuals with impaired immune defences, such as diabetics, alcohol-ics and hospitalised patients with indwelling devices. The most common sites of infection are the urinary and the respiratory tract. Organisms can spread rapidly, from the gastrointestinal tract of patients and via the hands of hospital personnel to other patients, leading to nosocomial outbreaks. K. pneumoniae is the second most frequent cause of gram-negative bloodstream infections after Escherichia coli. The mortality rates of pneumonia caused by K. pneumoniae can be high even when appropriate antibiotic treatment is given, however, also depends on the severity of the underlying condition.

5.5.2 Resistance mechanisms

Similar to E. coli, K. pneumoniae can be resistant to multiple antibiotics, and resistance traits are frequently acquired through plasmids. However, in contrast to E. coli, K. pneumoniae has a chromosomally encoded SHV beta-lactamase and is thus intrinsically resistant against aminopenicillins. Moreover, this organism read-ily acquires plasmid-mediated resistance determinants. Many novel ESBL variants were initially identified in K. pneumoniae and were only subsequently found in E. coli. Since the resistance mechanisms do not signifi-cantly differ from those described for E. coli, readers should refer to the E. coli chapter for further details. Carbapenems have been widely used in many coun-tries due to the increasing rate of ESBL-producing Enterobacteriaceae with a consequent impact on the emergence of resistance to these antibiotics, especially in K. pneumoniae. KPC carbapenemase-producing clones of K. pneumoniae have been observed in the United States, Greece and Israel, while plasmids encoding the VIM metallo-carbapenemase are frequent in K. pneu-moniae in Greece. Recently, a new type of plasmidic carbapenemase, the New Delhi metallo-beta-lactamase 1 (NDM-1), has been observed in patients returning from the Indian subcontinent.

5.5.3 Results

Third-generation cephalosporins

• Twenty-eight countries reported 11 665 isolates of which 3 214 were resistant to third-generation cephalosporins.

• Proportion of resistance was: below 1% in two countries, 1–5% in three countries, 5–10% in three countries, 10–25% in seven countries, 25–50% in seven countries and above 50% in six countries (Figure 5.22, Table 5.8).

• Trends in the 2006–2009 period have been calcu-lated for 24 countries. A significant increase has

been observed for nine countries. In eight of these, the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.26). In 2009, the nine countries with increasing trends reported the following proportion of resistance to third-generation cephalosporins: 10–25% in three cases (Denmark, Estonia and France), 25–50% in three cases (Hungary, Luxembourg and Portugal) and above 50% in three cases (Czech Republic, Greece and Latvia).

• Two countries (Malta and the United Kingdom) reported significant decreasing trends of proportions of resist-ance to third-generation cephalosporins (Figure 5.26) which, in 2009, were 0% and 7%, respectively.

Extended-spectrum beta-lactamase (ESBL)

• Sixteen countries have been included in the analysis of ESBL proportion for K. pneumoniae. Only data from laboratories consistently reporting ESBL test results for all isolates identified as resistant to third-gener-ation cephalosporins and from countries with at least 10 of such isolates were selected for the analysis.

• The proportion of K. pneumoniae isolates resistant to third-generation cephalosporins and ESBL produc-ers, as ascertained by the participating laboratories, ranged between 73% and 100%. Proportion of ESBL producers was: 70–80% in three countries, 80–90% in four countries and above 90% in nine countries (Table 5.9).

Fluoroquinolones

• Twenty-eight countries reported 11 344 isolates of which 3 203 were resistant to fluoroquinolones.

• Proportion of resistance was: below 1% in one coun-try, 1–5% in four countries, 5–10% in three countries, 10–25% in 10 countries, 25–50% in eight countries and above 50% in two countries (Figure 5.23, Table 5.8).

• Trends in the 2006–2009 period have been calcu-lated for 23 countries. A significant increase has been observed for 11 countries. In 10 of these countries the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.27). In 2009, the 11 countries with increasing trends reported the following proportion of resistance to fluoroquinolones: 10–25% in four cases (Denmark, Estonia, France and Spain), 25–50% in five cases (Bulgaria, Cyprus, Hungary, Lithuania and Portugal) and above 50% in two cases (Czech Republic and Greece).

• Two countries (Ireland and the United Kingdom) reported significant decreasing trends of proportions of resistance to fluoroquinolones (Figure 5.27) which, in 2009, were 11% and 6%, respectively.

Aminoglycosides

• Twenty-eight countries reported 11 922 isolates of which 2 787 were resistant to aminoglycosides.

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• Proportion of resistance was: below 1% in three coun-tries, 1–5% in four countries, 5–10% in five countries, 10–25% in seven countries, 25–50% in six countries and above 50% in three countries (Figure 5.24, Table 5.8).

• Trends in the 2006–2009 period have been calcu-lated for 24 countries. A significant increase has been observed for 11 countries. In 10 of these countries the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.28). In 2009, the 11 countries with increasing trends reported the following proportion of resist-ance to aminoglycosides: 1–5% in one case (Norway), 5–10% in one case (Denmark), 10–25% in four cases (Estonia, France, Luxembourg and Portugal), 25–50% in three cases (Czech Republic, Hungary and Latvia) and above 50% in two cases (Greece and Lithuania).

• Two countries (Malta and the United Kingdom) reported significant decreasing trends of proportions of resistance to aminoglycosides (Figure 5.28) which, in 2009, were 0% and 5%, respectively.

Combined resistance (third-generation cephalosporins,

fluoroquinolones and aminoglycosides)

• Twenty-eight countries reported 10 952 isolates tested for third-generation cephalosporins, fluoroquinolo-nes and aminoglycosides. In 2009, 35% of isolates were resistant to one or more of the three consid-ered antibiotic classes. The most frequent pattern of resistance was the multiresistance (R to all three anti-biotic classes) (19%). More than 90% of the isolates resistant to third-generation cephalosporins were also resistant to either fluoroquinolones or aminogly-cosides and two thirds were resistant to both these classes (Table 5.10).

• Proportion of multiresistance was: below 1% in four countries, 1–5% in six countries, 5–10% in four countries, 10–25% in nine countries, 25–50% in four countries and above 50% in one country (Table 5.8).

• Trends in the 2006–2009 period have been calculated for 23 countries. A significant increase of multire-sistance has been observed for 13 countries. In 10 of these countries the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.29). In 2009, the 13 countries with increasing trends reported the follow-ing proportion of multiresistance: below 1% in one case (Sweden), 1–5% in two cases (Norway and Spain), 5–10% in two cases (Denmark and Estonia), 10–25% in three cases (Latvia, France and Portugal), 25–50% in four cases (Bulgaria, Czech Republic, Hungary and Lithuania) and above 50% in one case (Greece).

• One country (the United Kingdom) reported a significant decreasing trend of proportions of multire-sistance (Figure 5.29), which, in 2009, was 3%.

Carbapenems

• Twenty-seven countries reported 10 573 isolates of which 738 were resistant to carbapenems. Most of

the resistant isolates (708) were identified in Greece; other 12 countries reported at least one resistant isolate.

• Proportion of resistance was: 43.5% in Greece, 17.0% in Cyprus, 1.3% in Italy, 1.2% in Belgium and below 1% in the other 23 reporting countries (Figure 5.25).

5.5.4 Conclusions

The antimicrobial resistance of K. pneumoniae is a wor-risome problem in Europe. In 2009, many countries reported high proportions and increasing trends of resistance to third-generation cephalosporins, fluo-roquinolones and aminoglycosides. Greece and Cyprus have also reported high proportions of resistance to carbapenems; proportions of resistance to these agents above 1% have been observed so far in Belgium and Italy.

Two thirds of the countries reported proportions of resistance to third-generation cephalosporins and fluoroquinolones higher than 10%. Proportions of mul-tiresistance (R to third-generation cephalosporins, fluoroquinolones and aminoglycosides) above 10% have been reported by half of the countries.

The majority of isolates resistant to third-generation cephalosporins were resistant also to fluoroquinolones and aminoglycosides. Increasing trends of resistance to specific antibiotic classes and of multiresistance have been observed also in northern European countries, like Denmark and Norway, with a traditionally prudent approach to the antibiotic use.

Only the United Kingdom has shown a consistent reduc-tion of resistance proportion of K. pneumoniae for all the antibiotic classes under surveillance. Decreasing trends for specific antibiotic classes were also observed for Ireland and Malta.

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Figure 5.23: Klebsiella pneumoniae: proportion of invasive isolates resistant to fluoroquinolones in 2009

Figure 5.22: Klebsiella pneumoniae: proportion of invasive isolates resistant to third-generation cephalosporins in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.24: Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Figure 5.25: Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.26: Klebsiella pneumoniae: trend of third-generation cephalosporins resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

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Figure 5.27: Klebsiella pneumoniae: trend of fluoroquinolones resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

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Figure 5.28: Klebsiella pneumoniae: trend of aminoglycosides resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50 60 70 80

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Figure 5.29: Klebsiella pneumoniae: trend of multiresistance (third-generation cephalosporins, fluoroquinolones and aminoglycosides) by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50 60

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Table 5.8: Number of invasive K. pneumoniae isolates and proportion of fluoroquinolones, third-generation cephalosporins, aminoglycosides and multiresistance (%R), including 95% confidence intervals (95% CI), reported per country in 2009

CountryFluoroquinolones Third-gen. cephalosporins Aminoglycosides Multiresistance*

N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)

Austria 604 8.4 (6–11) 615 7.6 (6–10) 618 3.6 (2–5) 599 2.5 (1–4)Belgium 142 13.4 (8–20) 142 14.8 (9–22) 142 9.9 (5–16) 142 2.8 (1–7)Bulgaria 95 48.4 (38–59) 95 69.5 (59–79) 95 65.3 (55–75) 95 38.9 (29–49)Cyprus 53 43.4 (30–58) 53 41.5 (28–56) 53 18.9 (9–32) 53 17.0 (8–30)Czech Republic 1 415 54.3 (52–57) 1 415 52.1 (49–55) 1 394 47.2 (45–50) 1 394 35.3 (33–38)Denmark 791 16.2 (14–19) 623 11.2 (9–14) 822 7.2 (6–9) 600 6.8 (5–9)Estonia 58 19.0 (10–31) 58 17.2 (9–29) 60 15.0 (7–27) 56 8.9 (3–20)Finland 375 3.2 (2–6) 367 1.4 (0–3) 349 1.1 (0–3) 341 0.6 (0–2)France 1 352 24.0 (22–26) 1 378 18.7 (17–21) 1 378 19.6 (18–22) 1 352 15.5 (14–17)Germany 479 14.8 (12–18) 471 13.2 (10–17) 478 9.6 (7–13) 470 7.2 (5–10)Greece 1 626 65.6 (63–68) 1 634 68.7 (66–71) 1 644 60.3 (58–63) 1 625 54.0 (52–56)Hungary 355 33.2 (28–38) 359 38.4 (33–44) 361 40.4 (35–46) 354 28.8 (24–34)Iceland 26 0.0 (0–13) 27 0.0 (0–13) 27 0.0 (0–13) 26 0.0 (0–13)Ireland 315 10.8 (8–15) 314 11.1 (8–15) 316 11.1 (8–15) 313 5.1 (3–8)Italy 299 20.4 (16–25) 272 37.1 (31–43) 309 19.4 (15–24) 254 12.6 (9–17)Latvia 44 34.1 (20–50) 44 54.5 (39–70) 44 43.2 (28–59) 44 22.7 (11–38)Lithuania 67 37.3 (26–50) 67 56.7 (44–69) 68 55.9 (43–68) 66 34.8 (24–48)Luxembourg 28 21.4 (8–41) 28 25.0 (11–45) 28 17.9 (6–37) 28 14.3 (4–33)Malta 38 2.6 (0–14) 38 0.0 (0–9) 38 0.0 (0–9) 38 0.0 (0–9)Netherlands 393 4.1 (2–7) 400 5.5 (3–8) 397 3.3 (2–6) 380 1.1 (0–3)Norway 392 5.6 (4–8) 396 2.8 (1–5) 394 3.0 (2–5) 391 1.5 (1–3)Poland 139 32.4 (25–41) 143 49.0 (41–57) 150 29.3 (22–37) 133 15.0 (9–22)Portugal 537 27.6 (24–32) 556 27.5 (24–31) 564 20.4 (17–24) 532 14.5 (12–18)Romania 18 11.1 (1–35) 18 55.6 (31–78) 26 30.8 (14–52) 18 11.1 (1–35)Slovenia 168 28.6 (22–36) 168 33.9 (27–42) 168 28.0 (21–35) 168 23.2 (17–30)Spain 627 15.8 (13–19) 628 11.1 (9–14) 628 9.2 (7–12) 627 4.8 (3–7)Sweden 248 1.6 (0–4) 701 1.7 (1–3) 676 0.4 (0–1) 235 0.9 (0–3)United Kingdom 660 5.8 (4–8) 655 7.2 (5–9) 695 5.5 (4–7) 618 3.1 (2–5)

* Multiresistance defined as being resistant to third-generation cephalosporins, fluoroquinolone and aminoglycosides.

Table 5.9: Number of invasive K. pneumoniae isolates resistant to third-generation cephalosporins (CRKP) and proportion of ESBL positive among these isolates, as ascertained by the participating laboratories in 2009

CountryNumber of

laboratoriesNumber of CRKP %ESBL

Austria 16 40 87.5Bulgaria 10 66 98.5Cyprus 4 22 86.4Czech Republic 44 737 79.9Estonia 4 10 100Spain 20 70 85.7France 27 89 80.9Ireland 12 32 78.1Italy 7 47 91.5Lithuania 9 38 97.4Latvia 5 17 94.1Netherlands 4 11 72.7Poland 12 70 92.9Portugal 11 92 90.2Romania 3 10 100Slovenia 7 57 96.5

Only data from laboratories consistently reporting ESBL test results for all isolates identified as resistant to third-generation cephalosporins and from countries with at least 10 of such isolates were selected for the analysis.

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Table 5.10: Overall resistance and resistance combinations among invasive Klebsiella pneumoniae isolates tested against fluoroquinolones, third-generation cephalosporins and aminoglycosides (n= 10 952) in Europe, 2009

Resistance pattern Number % of total

Fully susceptible 7 108 64.9Single resistance (to indicated drug classes)Fluoroquinolones 409 3.7Third-generation cephalosporins 241 2.2Aminoglycosides 135 1.2Resistance to two classes of antimicrobial drugsThird-generation cephalosporins + fluoroquinolones 477 4.4Third-generation cephalosporins + aminoglycosides 320 2.9Fluoroquinolones + aminoglycosides 150 1.4Resistance to three classes of antimicrobial drugsthird-generation cephalosporins + fluoroquinolones + aminoglycosides 2 112 19.3

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5.6 Pseudomonas aeruginosa5.6.1 Clinical and epidemiological importance

Pseudomonas aeruginosa is a non-fermenting gram-neg-ative bacterium that is ubiquitously present in aquatic environments in nature. It is an opportunistic pathogen for plants, animals and humans, and is a major and dreaded cause of infection among hospitalised patients with localised or systemic impairment of immune defences, being a common cause of hospital-acquired pneumonia (including ventilator-associated pneumo-nia), bloodstream and urinary tract infections. Because of its ubiquitous presence, its enormous versatility and intrinsic tolerance to many detergents, disinfectants and antimicrobial compounds, it is difficult to control P. aer-uginosa in hospitals and institutional environments. Moreover, P. aeruginosa is a frequent cause of skin infections such as folliculitis and otitis externa in recrea-tional and competitive swimmers. In patients with cystic fibrosis, P. aeruginosa causes the most important bac-terial complication leading to chronic colonisation and intermittent exacerbations ranging from bronchiolitis to acute respiratory distress syndrome. Finally, P. aerugi-nosa is a common pathogen found in burns units, and in these locations it is almost impossible to eradicate colo-nising strains by classical infection control procedures.

5.6.2 Resistance mechanism

P. aeruginosa is intrinsically resistant to the majority of antimicrobial compounds due to its selective ability to exclude various molecules from penetrating its outer membrane. The antibiotic classes that remain active include the fluoroquinolones, the aminoglycosides, some beta-lactams (piperacillin, ceftazidime, carbapen-ems) and colistin. Acquired resistance in P. aeruginosa is caused by one or more of several mechanisms:

• mutational modification of antibiotic targets, such as gyrase, topoisomerase or ribosomal proteins, which confer resistance to fluoroquinolones or aminoglyco-sides, respectively;

• mutational derepression of the chromosomally coded AmpC beta-lactamase;

• mutational loss of outer membrane proteins prevent-ing the uptake of antimicrobial substances such as carbapenems;

• mutational upregulation of efflux systems, that can confer resistance to beta-lactams, fluoroquinolones and aminoglycosides; and

• acquisition of plasmid-mediated resistance genes coding for various beta-lactamases and aminoglyco-side modifying enzymes that can confer resistance to various beta-lactams including carbapenems (e. g. metallo-beta-lactamases) and aminoglycosides.

5.6.3 Results

Piperacillin±tazobactam

• Twenty-eight countries reported 8 028 isolates of which 1 306 were resistant to piperacillin±tazobactam.

• Proportion of resistance was: 1–5% in six countries, 5–10% in four countries, 10–25% in 12 countries and 25–50% in six countries (Figure 5.30, Table 5.11).

• Trends in the 2006–2009 period have been cal-culated for 21 countries. A significant increase has been observed for France and Hungary that, in 2009, reported a proportion of resistance to piperacillin±tazobactam of 21% and 19%, respectively. A significant decreasing trend has been observed for Greece (proportion of resistance in 2009 was 33%) (Figure 5.35).

Ceftazidime

• Twenty-eight countries reported 7 937 isolates of which 1 171 were resistant to ceftazidime; one country (Romania) reported less than 10 isolates and, there-fore, it was not included in the map.

• Proportion of resistance was: 1–5% in four countries, 5–10% in eight countries, 10–25% in 12 countries and 25–50% in three countries (Figure 5.31, Table 5.11).

• Trends in the 2006–2009 period have been calcu-lated for 21 countries. A significant increase has been observed for France and Hungary, which, in 2009, reported a proportion of resistance to ceftazidime of 17% and 12%, respectively. A significant decreasing trend has been observed for Portugal (proportion of resistance in 2009 was 13%) but the trend significance disappears when considering only data from laborato-ries consistently reporting all four years (Figure 5.36).

Fluoroquinolones

• Twenty-eight countries reported 8 253 isolates of which 1 884 were resistant to fluoroquinolones.

• Proportion of resistance was: 1–5% in one country, 5–10% in five countries, 10–25% in 13 countries and 25–50% in nine countries (Figure 5.32, Table 5.11).

• Trends in the 2006–2009 period have been calcu-lated for 20 countries. A significant increase has been observed for Hungary (proportion of resistance in 2009 was 27%). A significant decreasing trend has been observed for Germany, Ireland and Norway, which, in 2009, reported a proportion of resistance to fluoroquinolones of 17%, 9% and 3%, respectively. In two of these countries (Ireland and Norway) the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.37).

Aminoglycosides

• Twenty-eight countries reported 8 223 isolates of which 1 437 were resistant to aminoglycosides.

• Proportion of resistance was: below 1% in four coun-tries, 1–5% in four countries, 5–10% in six countries, 10–25% in seven countries and 25–50% in seven countries (Figure 5.33, Table 5.11).

• Trends in the 2006–2009 period have been calculated for 21 countries. Three countries (Hungary, Malta and Spain) reported a significant increasing trend (Fig

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5.38) with proportions of resistance to aminoglyco-sides of 29%, 21% and 19%, respectively, in 2009.

• Significant decreasing trends have been observed for five countries. In three of these the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure  5.38). In 2009, these five countries reported the following proportion of resistance to aminoglyco-sides: 1–5% in one case (the United Kingdom), 5–10% in one case (Germany), 10–25% in one case (Portugal) and 25–50% in two cases (Greece and Poland).

Carbapenems

• Twenty-eight countries reported 8 129 isolates of which 1 541 were resistant to carbapenems.

• Proportion of resistance was: below 1% in one coun-try, 1–5% in two countries, 5–10% in nine countries, 10–25% in 10 countries, 25–50% in five countries and above 50% in one country (Figure 5.34, Table 5.11).

• Trends in the 2006–2009 period have been calculated for 20 countries. Three countries (France, Hungary and Italy) reported a significant increasing trend with proportions of resistance to carbapenems, which, in 2009, were 17%, 27% and 31%, respectively. In two of these countries (Hungary and Italy) the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.39).

• Significant decreasing trends have been observed for Austria, Czech Republic and Germany, with propor-tions of resistance to carbapenems of 9%, 29% and 11%, respectively, in 2009. In one of these countries (Austria) the trend is significant also when consider-ing only data from laboratories consistently reporting all four years (Figure 5.39).

Combined resistance (piperacillin±tazobactam,

ceftazidime, fluoroquinolones, aminoglycosides and

carbapenems)

• Twenty-eight countries reported 8 376 isolates tested for at least three antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolo-nes, aminoglycosides and carbapenems. In 2009, 33% of isolates were resistant to one or more of the five considered antibiotic classes while 16% were resistant to three or more. The most frequent pattern was the resistance to all five antibiotic classes (5%) (Table 5.12).

• Proportion of multiresistance (R to at least three of the five considered antibiotic classes) was: below 1% in one country, 1–5% in seven countries, 5–10% in four countries, 10–25% in 11 countries and 25–50% in five countries (Table 5.11).

• Trends in the 2006–2009 period have been calculated for 21 countries. Significant increasing trends of mul-tiresistance have been observed for four countries. In three of these countries the trends are significant also when considering only data from laboratories

consistently reporting all four years (Figure 5.40). In 2009, these four countries (France, Hungary, Malta and Spain) reported proportion of multiresistance between 10% and 25%.

• Significant decreasing trends of multiresistance have been observed for four countries. In two of these the trends are significant also when considering only data from laboratories consistently reporting all four years (Figure 5.40). In 2009, these four countries reported the following proportion of multiresistance: 1–5% in one case (Ireland), 5–10% in one case (Germany), 10–25% in one case (Portugal) and 25–50% in one case (Greece).

5.6.4 Conclusions

High proportions of resistance of P. aeruginosa to antimicrobials have been reported by many countries especially in southern and eastern Europe. The com-bined resistance is also frequent with 16% of isolates resistant to at least three antibiotic classes (multire-sistance) and with 5% of isolates resistant to all five antibiotic classes under surveillance. Despite the high proportions of resistance, the situation appears to be generally stable in Europe with few countries reporting significant increasing or decreasing trends of resist-ance. The countries with increasing trends of resistance to specific antibiotic classes or of multiresistance are: France, Hungary, Italy, Malta and Spain. In 2009, Greece reported the highest proportion of multiresistance (40%) although a significant decreasing trend was observed from 2006 to 2009.

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Figure 5.31: Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2009

Figure 5.30: Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillin±tazobactam in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.32: Pseudomonas aeruginosa: proportion of invasive isolates resistant to fluoroquinolones in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

Figure 5.33: Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.34: Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2009

LuxembourgMalta

Non-visible countries

10% to < 25%25% to < 50%≥ 50% No data reported or less than 10 isolatesNot included

< 1%1% to < 5%5% to < 10%

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Figure 5.35: Pseudomonas aeruginosa: trend of piperacillin±tazobactam resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

MT

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Figure 5.36: Pseudomonas aeruginosa: trend of ceftazidime resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

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Figure 5.37: Pseudomonas aeruginosa: trend of fluoroquinolones resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

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Figure 5.38: Pseudomonas aeruginosa: trend of aminoglycosides resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

EL (<)

IT

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Figure 5.39: Pseudomonas aeruginosa: trend of carbapenems resistance by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

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Figure 5.40: Pseudomonas aeruginosa: trend of multiresistance (R to three or more antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems) by country, 2006–2009

Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.

0 10 20 30 40 50

EL (<)

CZ

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Table 5.11: Number of invasive P. aeruginosa isolates and proportion of piperacillin±tazobactam, fluoroquinolones, ceftazidime, aminoglycosides, carbapenems and multiresistance (%R), including 95% confidence intervals (95% CI), reported per country in 2009

Country

Piperacillin± tazobactam

Fluoroquinolones Ceftazidime Aminoglycosides Carbapenems Multiresistance*

N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)

Austria 512 6.4 (4–9) 512 12.9 (10–16) 483 6.0 (4–9) 509 7.9 (6–11) 513 8.8 (6–12) 516 6.0 (4–8)Belgium 104 6.7 (3–13) 134 15.7 (10–23) 134 6.0 (3–11) 105 9.5 (5–17) 134 9.0 (5–15) 134 5.2 (2–10)Bulgaria 36 33.3 (19–51) 36 33.3 (19–51) 35 22.9 (10–40) 33 33.3 (18–52) 34 23.5 (11–41) 36 27.8 (14–45)Cyprus 62 17.7 (9–30) 62 12.9 (6–24) 62 17.7 (9–30) 62 4.8 (1–13) 61 8.2 (3–18) 62 11.3 (5–22)Czech Republic 574 27.9 (24–32) 575 41.4 (37–46) 575 29.0 (25–33) 575 32.2 (28–36) 575 28.9 (25–33) 575 30.8 (27–35)Denmark 373 1.9 (1–4) 411 5.4 (3–8) 311 3.5 (2–6) 428 0.7 (0–2) 347 2.9 (1–5) 415 1.7 (1–3)Estonia 40 12.5 (4–27) 43 18.6 (8–33) 43 7.0 (1–19) 42 9.5 (3–23) 29 17.2 (6–36) 43 7.0 (1–19)Finland 229 6.6 (4–11) 233 10.7 (7–15) 233 4.7 (2–8) 224 4.5 (2–8) 229 7.9 (5–12) 233 3.9 (2–7)France 1 156 21.0 (19–23) 1 204 24.8 (22–27) 1 085 16.8 (15–19) 1 159 19.0 (17–21) 1 219 17.4 (15–20) 1 220 16.8 (15–19)Germany 284 13.0 (9–18) 285 17.2 (13–22) 284 10.9 (8–15) 284 7.4 (5–11) 283 10.6 (7–15) 285 7.4 (5–11)Greece 1 084 32.7 (30–36) 1 080 45.4 (42–48) 1 074 33.7 (31–37) 1 090 41.3 (38–44) 1 095 44.0 (41–47) 1 077 40.2 (37–43)Hungary 505 18.8 (15–22) 513 26.5 (23–31) 516 11.6 (9–15) 516 29.1 (25–33) 516 26.6 (23–31) 516 20.7 (17–24)Iceland 16 12.5 (2–38) 16 12.5 (2–38) 16 6.3 (0–30) 16 0.0 (0–21) 16 0.0 (0–21) 16 0.0 (0–21)Ireland 235 4.3 (2–8) 236 9.3 (6–14) 232 6.0 (3–10) 235 6.4 (4–10) 224 8.5 (5–13) 236 3.8 (2–7)Italy 185 24.3 (18–31) 193 42.0 (35–49) 164 16.5 (11–23) 151 36.4 (29–45) 188 30.9 (24–38) 195 27.7 (22–35)Latvia 18 16.7 (4–41) 17 11.8 (1–36) 18 16.7 (4–41) 18 22.2 (6–48) 14 7.1 (0–34) 18 11.1 (1–35)Lithuania 20 20.0 (6–44) 21 33.3 (15–57) 21 14.3 (3–36) 21 19.0 (5–42) 21 19.0 (5–42) 21 19.0 (5–42)Luxembourg 35 14.3 (5–30) 35 11.4 (3–27) 35 14.3 (5–30) 35 8.6 (2–23) 33 15.2 (5–32) 35 14.3 (5–30)Malta 58 36.2 (24–50) 58 22.4 (13–35) 58 29.3 (18–43) 58 20.7 (11–33) 58 20.7 (11–33) 58 19.0 (10–31)Netherlands 233 3.0 (1–6) 230 7.0 (4–11) 228 4.4 (2–8) 230 1.3 (0–4) 234 3.0 (1–6) 234 2.1 (1–5)Norway 161 3.7 (1–8) 162 2.5 (1–6) 164 4.9 (2–9) 165 0.0 (0–2) 166 5.4 (3–10) 165 1.8 (0–5)Poland 151 29.8 (23–38) 149 25.5 (19–33) 121 21.5 (15–30) 143 27.3 (20–35) 142 25.4 (18–33) 152 22.4 (16–30)Portugal 535 17.0 (14–20) 517 20.5 (17–24) 536 12.5 (10–16) 536 11.9 (9–15) 520 16.3 (13–20) 536 13.8 (11–17)Romania 11 36.4 (11–69) 11 36.4 (11–69) 8 37.5 (9–76) 11 45.5 (17–77) 11 54.5 (23–83) 11 36.4 (11–69)Slovenia 93 18.3 (11–28) 93 15.1 (8–24) 93 10.8 (5–19) 91 14.3 (8–23) 93 17.2 (10–26) 93 12.9 (7–21)Spain 539 8.2 (6–11) 544 25.0 (21–29) 544 7.7 (6–10) 543 19.2 (16–23) 540 16.1 (13–19) 544 14.0 (11–17)Sweden 224 2.2 (1–5) 259 6.6 (4–10) 317 6.9 (4–10) 321 0.3 (0–2) 326 7.7 (5–11) 330 1.2 (0–3)United Kingdom 555 3.1 (2–5) 624 7.1 (5–9) 547 5.5 (4–8) 622 1.3 (1–3) 508 8.1 (6–11) 620 1.9 (1–3)

* Multiresistance defined as being resistant to three or more antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems.

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Table 5.12: Overall resistance and resistance combinations among invasive Pseudomonas aeruginosa isolates tested against at least three antibiotic classes among piperacillin±tazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems (n= 8 376) in Europe, 2009

Resistance pattern Number % of total

Fully susceptible (to the tested drugs) 5 588 66.7Resistance to one class of antimicrobial drugsFluoroquinolones 350 4.2Carbapenems 309 3.7Aminoglycosides 101 1.2Ceftazidime 83 1Piperacillin(±tazobactam) 72 0.9Resistance to two classes of antimicrobial drugsFluoroquinolones + aminoglycosides 185 2.2Piperacillin(±tazobactam) + ceftazidime 147 1.8Fluoroquinolones + carbapenems 93 1.1Piperacillin(±tazobactam) + fluoroquinolones 27 0.3Piperacillin(±tazobactam) + carbapenems 26 0.3Piperacillin(±tazobactam) + aminoglycosides 21 0.3Aminoglycosides + carbapenems 16 0.2Ceftazidime + carbapenems 16 0.2Fluoroquinolones + ceftazidime 11 0.1Ceftazidime + aminoglycosides 5 0.1Resistance to three classes of antimicrobial drugsFluoroquinolones + aminoglycosides + carbapenems 165 2Piperacillin(±tazobactam) + fluoroquinolones + aminoglycosides 83 1Piperacillin(±tazobactam) + ceftazidime + carbapenems 62 0.7Piperacillin(±tazobactam) + fluoroquinolones + ceftazidime 39 0.5Fluoroquinolones + ceftazidime + aminoglycosides 36 0.4Piperacillin(±tazobactam) + fluoroquinolones + carbapenems 19 0.2Fluoroquinolones + ceftazidime + carbapenems 16 0.2Piperacillin(±tazobactam) + aminoglycosides + carbapenems 12 0.1Piperacillin(±tazobactam) + ceftazidime + aminoglycosides 9 0.1Ceftazidime + aminoglycosides + carbapenems 9 0.1Resistance to four classes of antimicrobial drugsPiperacillin(±tazobactam) + fluoroquinolones + aminoglycosides + carbapenems 139 1.7Fluoroquinolones + ceftazidime + aminoglycosides + carbapenems 100 1.2Piperacillin(±tazobactam) + fluoroquinolones + ceftazidime + aminoglycosides 96 1.1Piperacillin(±tazobactam) + fluoroquinolones + ceftazidime + carbapenems 94 1.1Piperacillin(±tazobactam) + ceftazidime + aminoglycosides + carbapenems 18 0.2Resistance to five classes of antimicrobial drugsPiperacillin(±tazobactam) + fluoroquinolones + ceftazidime + aminoglycosides + carbapenems 429 5.1

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5.7 References

• Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46:1-24.

• Arthur M, Molinas C, Depardieu F, Courvalin P. Characterization of Tn1546, a Tn3-related transposon conferring glycopeptide resist-ance by synthesis of depsipeptide peptidoglycan precursors in Enterococcus faecium BM4147. J Bacteriol 1993;175:117-27.

• Banerjee SN, Emori TG, Culver DH, Gaynes RP, Jarvis WR, Horan T et al. Secular trends in nosocomial primary bloodstream infections in the United States, 1980–1989. National Nosocomial Infections Surveillance System. Am J Med 1991;91:86S-9S.

• Benyacoub J, Czarnecki-Maulden GL, Cavadini C, Sauthier T, Anderson RE, Schiff rin EJ et al. Supplementation of food with Enterococcus faecium (SF68) stimulates immune functions in young dogs. J Nutr 2003;133:1158-62.

• Berger-Bachi B, Rohrer S. Factors infl uencing methicillin resistance in staphylococci. Arch Microbiol 2002;178:165-71.

• Chow JW. Aminoglycoside resistance in enterococci. Clin Infect Dis 2000;31:586-9.

• Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bac-teremia: a meta-analysis. Clin Infect Dis 2003;36:53-9.

• DiazGranados CA, Jernigan JA. Impact of vancomycin resistance on mortality among patients with neutropenia and enterococcal blood-stream infection. J Infect Dis 2005;191:588-95.

• Diekema DJ, Pfaller MA, Schmitz FJ, Smayevsky J, Bell J, Jones RN et al. Survey of infections due to Staphylococcus species: frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, Latin America, Europe, and the Western Pacifi c region for the SENTRY Antimicrobial Surveillance Program, 1997–1999. Clin Infect Dis 2001;32 Suppl 2:S114-32.

• Evans AS BP. Bacterial infections of humans, epidemiology and con-trol. New York: Plenum Medical Book Company; 1991. p. 525-46.

• Fluit AC, Jones ME, Schmitz FJ, Acar J, Gupta R, Verhoef J. Antimicrobial susceptibility and frequency of occurrence of clinical blood isolates in Europe from the SENTRY antimicrobial surveillance program, 1997 and 1998. Clin Infect Dis 2000;30:454-60.

• Fontana R, Ligozzi M, Pittaluga F, Satta G. Intrinsic penicillin resist-ance in enterococci. Microb Drug Resist 1996;2:209-13.

• Franz CM, Holzapfel WH, Stiles ME. Enterococci at the crossroads of food safety? Int J Food Microbiol 1999;47:1-24.

• Garau J. Role of beta-lactam agents in the treatment of community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2005;24:83-99.

• Gold HS, Moellering RC Jr. Antimicrobial-drug resistance. N Engl J Med 1996;335:1445-53.

• Hausdorff WP, Bryant J, Kloek C, Paradiso PR, Siber GR. The con-tribution of specifi c pneumococcal serogroups to diff erent disease manifestations: implications for conjugate vaccine formulation and use, part II. Clin Infect Dis 2000;30:122-40.

• Hausdorff WP, Bryant J, Paradiso PR, Siber GR. Which pneumo-coccal serogroups cause the most invasive disease: implications for conjugate vaccine formulation and use, part I. Clin Infect Dis 2000;30:100-21.

• Hausdorff WP, Siber G, Paradiso PR. Geographical diff erences in invasive pneumococcal disease rates and serotype frequency in young children. Lancet 2001;357:950-2.

• Hawkey PM. Mechanisms of quinolone action and microbial response. J Antimicrob Chemother 2003;51 Suppl 1:29-35.

• Herwaldt LA. Control of methicillin-resistant Staphylococcus aureus in the hospital setting. Am J Med 1999;106:11S-8S; discussion 48S-52S.

• Hiramatsu K, Cui L, Kuroda M, Ito T. The emergence and evolution of methicillin-resistant Staphylococcus aureus. Trends Microbiol 2001;9:486-93.

• Huycke MM, Sahm DF, Gilmore MS. Multiple-drug resistant entero-cocci: the nature of the problem and an agenda for the future. Emerg Infect Dis 1998;4:239-49.

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

• Jacobs MR. Worldwide trends in antimicrobial resistance among common respiratory tract pathogens in children. Pediatr Infect Dis J 2003;22(8 Suppl):S109-19.

• Jett BD, Huycke MM, Gilmore MS. Virulence of enterococci. Clin Microbiol Rev 1994;7:462-78.

• Karchmer AW. Nosocomial bloodstream infections: organisms, risk factors, and implications. Clin Infect Dis 2000;31 Suppl 4:S139-43.

• Kumarasamy KK, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597-602.

• Landry SL, Kaiser DL, Wenzel RP. Hospital stay and mortality attrib-uted to nosocomial enterococcal bacteremia: a controlled study. Am J Infect Control 1989;17:323-9.

• Leclercq R, Courvalin P. Resistance to glycopeptides in enterococci. Clin Infect Dis 1997;24:545-54; quiz 555-6.

• Marchaim D, Navon-Venezia S, Schwaber MJ, and Carmeli Y. Isolation of imipenem-resistant Enterobacter species: Emergence of KPC-2 carbapenemase, molecular characterization, epidemiology, and outcomes. Antimicrob Agents Chemother 2008;52(4): 1413–18. Published online 2008 January 28. doi: 10.1128/AAC.01103-07.

• McCormick AW, Whitney CG, Farley MM, Lynfi eld R, Harrison LH, Bennett NM et al. Geographic diversity and temporal trends of anti-microbial resistance in Streptococcus pneumoniae in the United States. Nat Med 2003;9:424-30.

• McGowan JE. Resistance in nonfermenting gram-negative bacteria: multidrug resistance to the maximum. Am J Infect Control 2006;34(5 Suppl 1).

• Mitra AK, Rabbani GH. A double-blind, controlled trial of bio-fl orin (Streptococcus faecium SF68) in adults with acute diarrhea due to Vibrio cholerae and enterotoxigenic Escherichia coli. Gastroenterology 1990;99:1149-52.

• Mundy LM, Sahm DF, Gilmore M. Relationships between entero-coccal virulence and antimicrobial resistance. Clin Microbiol Rev 2000;13:513-22.

• Murray BE. Beta-lactamase-producing enterococci. Antimicrob Agents Chemother 1992;36:2355-9.

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

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

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

• Peterson LR. Squeezing the antibiotic balloon: the impact of anti-microbial classes on emerging resistance. Clin Microbiol Infect 2005;11 Suppl 5.

• Reacher MH, Shah A, Livermore DM, Wale MC, Graham C, Johnson AP, et al. Bacteraemia and antibiotic resistance of its pathogens reported in England and Wales between 1990 and 1998: trend analy-sis. BMJ 2000;320:213-6.

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

• Strahilevitz J, Jacoby GA, Hooper DC, Robicsek A. Plasmid-mediated quinolone resistance: a multifaceted threat. Clin Microbiol Rev. 2009;22:664-89.

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

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

• Sturenburg E, Mack D. Extended-spectrum beta-lactamases: impli-cations for the clinical microbiology laboratory, therapy, and infec-tion control. J Infect 2003;47:273-95.

• Vatopoulos A. High rates of metallo-beta-lactamase-producing Klebsiella pneumoniae in Greece – a review of the current evidence. Euro Surveill 2008; 13(4) pii 8023.

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

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

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

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

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

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Annex 1:

Technical notes

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Technical notes for chapter 4

Number of blood culture sets

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

Patient days

If patient days were not available at hospital level, these were calculated by:

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

Type of hospitals

Since hospital categorisation was always intricate, more specific definitions from WHO have been implemented to make the categorisation of hospitals easier.

Primary level, often referred to as a district hospital or first-level referral: A hospital with few specialities, mainly internal medicine, obstetrics-gynecology, pae-diatrics, and general surgery, or only general practice; limited laboratory services are available for general, but not for specialised pathological analysis; the bed capac-ity ranges from 30 to 200 beds.

Secondary level, often referred to as provincial hospital: A hospital highly differentiated by function with five to 10 clinical specialities; bed capacity ranging from 200 to 800 beds.

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

Averaged variables

Annual occupancy rate and length of stay were averaged per country. In these totals only laboratory/hospital questionnaires that provided information on all vari-ables needed for the specific formula were included.

Technical notes for chapter 5

Resistance trend analysis

Resistance trends were calculated for the last four years. To determine significant trends over time, the Cochrane-Armitage test was used, excluding countries reporting less than 20 isolates per year. To exclude pos-sible biases in the trend analyses, a sensitivity analysis was done, per country, to determine the sensitivity of the trend analysis for using the complete dataset, versus a subset from laboratories reporting all four years. In the graphs, trends were indicated in the following way:

• using ‘<*’ if decreasing or ‘>*’ if increasing when sig-nificant trends were only identified in the complete dataset; and

• using ‘<’ if decreasing or ‘>’ if increasing when a sig-nificant trend was detected in both the subset and the complete dataset.

European maps showing resistance levels

To be included in the maps of Europe displaying the resistance proportions per country, for all drug-bug com-binations under surveillance by EARS-Net, a country had to report results for at least 10 isolates.

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Annex 2:

Country summary sheets

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Explanation to the country summary sheets

General information about EARS-Net participating laboratories and hospitals

Table 1 gives the number of laboratories and isolates reported by year and by pathogen under EARS-Net sur-veillance for the period 2002–2009.

Antibiotic resistance 2002–2009

Table 2 provides information on the proportion of inva-sive bacterial isolates non-susceptible (I+R) or resistant (R) to the antibiotics or antibiotic classes mentioned in the EARSS protocols. When interpreting the results in Table 2, always check the number of isolates provided in Table 1.

Demographic characteristics

Table 3 gives the proportional distribution of the iso-lates reported by source, gender, age, and hospital department, and the proportion of resistance within the different groups, for the period 2008–2009.

The abbreviations used in this table stand for: PNSP = penicillin-non-susceptible S. pneumoniae; MRSA = meticillin-resistant S. aureus; FREC = fluoroquinolone-resistant E. coli; VRE = vancomycin-resistant E. faecalis or E. faecium; CRKP = third-generation cephalosporin resistant K. pneumoniae; and CRPA = carbapenem-resistant P. aeruginosa.

If the number of isolates in a certain category accounts for less than 0.5% of the total number of isolates, the % total is set at 0 and the % resistance is not shown.

PNSP at laboratory level/MRSA, FREC and CRKP at hospital level

Figures 1, 2, 3 and 4 show the local variation in the pro-portions of PNSP by laboratory and of MRSA, FREC and CRKP by hospital. These figures are based on data from 2008 and 2009, only including the laboratories and hos-pitals that reported at least five isolates in these two years. The total number of laboratories or hospitals, the minimum, maximum, median, first and third quartile of the proportion of resistance is displayed in a box in the figures.

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Austria

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 10 80 11 456 10 479 10 181 - - - -2003 20 163 20 871 21 985 19 327 - - - -2004 28 257 30 1 453 31 1 862 28 604 - - - -2005 31 298 32 1 481 33 2 058 30 568 7 89 8 772006 32 293 33 1 640 33 2 483 33 699 30 434 31 4052007 35 322 34 1 577 34 2 545 33 688 33 445 33 4112008 38 380 38 1 899 38 2 985 38 864 38 583 38 5102009 38 379 38 1 794 38 2 625 36 825 37 622 36 525

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 1 1 <1 <1 2 <1 3Penicillin RI 1 9 5 5 5 5 5 5Macrolides RI 10 13 13 15 13 13 12 14Staphylococcus aureusOxacillin/Meticillin R 12 15 14 14 9 11 8 6Escherichia coliAminopenicilins R 33 41 46 49 53 53 50 49Aminoglycosides R 4 5 6 6 8 8 7 6Fluoroquinolones R 10 14 17 19 22 26 23 20Third-gen. cephalosporins R 1 2 3 4 7 9 7 8Enterococcus faecalisAminopenicilins RI 3 1 <1 1 2 2 2 1HL Gentamicin R 29 33 23 29 29 30 21 31Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 84 85 85 85 89 82 91 88HL Gentamicin R 21 22 22 30 21 28 19 31Vancomycin R 7 <1 <1 1 <1 2 2 4Klebsiella pneumoniaeAminoglycosides R - - - 3 5 5 6 4Fluoroquinolones R - - - 11 8 13 12 8Third-gen. cephalosporins R - - - 6 6 8 8 8Pseudomonas aeruginosaPiperacillin R - - - 13 8 6 8 6Ceftazidime R - - - 7 9 5 6 6Carbapenems R - - - 10 15 12 11 9Aminoglycosides R - - - 6 9 9 8 8Fluoroquinolones R - - - 14 15 15 12 13

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Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=719

S. aureusn=3 633

E. colin=5 591

E. faecalisn=1 020

E. faeciumn=644

K. pneumoniaen=1 194

P. aeruginosan=1 020

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 97 4 100 7 100 22 100 0 100 3 100 8 100 10CSF 3 15 - - <1 25 - - - - 0 0 <1 0GenderMale 57 6 58 8 41 25 62 1 58 4 56 10 58 11Female 42 3 41 6 58 19 37 0 41 2 44 5 40 9Unknown 1 0 1 16 1 13 1 0 1 0 1 17 1 7Age (years)0–4 8 7 2 5 2 6 4 0 1 0 2 8 1 75–19 4 4 2 3 1 19 1 0 1 0 <1 0 1 520–64 41 5 37 10 28 21 36 0 42 2 34 10 35 1665 and over 47 4 58 12 70 21 59 0 56 2 63 6 63 9Unknown <1 0 <1 25 <1 29 0 0 <1 0 - - - -Hospital departmentICU 15 7 12 18 7 24 18 1 27 2 12 12 17 18Internal med. 50 4 48 9 54 19 39 0 33 2 41 6 33 9Surgery 2 7 11 17 8 18 13 0 13 1 12 7 10 6Other 30 5 28 8 28 24 28 0 24 2 31 8 37 12Unknown 2 2 2 7 2 21 3 0 3 5 3 0 3 3

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

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Labo

rato

ry c

odes

0 25 50 75 100

AT028 (8/32)

AT020 (1/5)

AT023 (1/5)

AT031 (2/14)

AT021 (2/15)

AT012 (2/17)

AT009 (2/17)

AT025 (4/47)

AT008 (1/14)

AT019 (1/22)

AT016 (1/23)

AT001 (2/48)

AT024 (1/26)

AT005 (2/61)

AT006 (1/35)

AT010 (1/36)

AT002 (1/47)

AT041 (0/10)

AT017 (0/11)

AT037 (0/8)

AT022 (0/11)

AT003 (0/19)

AT026 (0/26)

AT015 (0/11)

AT042 (0/7)

AT014 (0/5)

AT034 (0/12)

AT033 (0/15)

AT018 (0/12)

AT030 (0/18)

AT027 (0/29)

AT036 (0/6)

AT035 (0/5)

AT007 (0/28)

AT032 (0/10)

AT011 (0/6)

Hosp

ital c

odes

0 25 50 75 100AT032G (6/19)AT020N (2/7)AT032V (2/8)

AT032B (7/29)AT005J (1/5)

AT005H (1/6)AT020W (10/66)AT031W (17/113)AT027L (24/168)

AT021S (2/14)AT033F (4/31)AT017T (2/16)AT022M (1/8)

AT023S (7/56)AT024B (4/32)AT001B (4/34)AT024G (4/34)

AT006S (11/99)AT011P (2/18)

AT032J (1/9)AT033D (10/98)

AT009K (1/10)AT002A (23/232)

AT018M (7/75)AT005S (1/11)

AT025K (13/143)AT019P (9/103)AT034E (6/69)AT009S (1/12)AT005R (1/12)AT012H (1/13)

AT040A (3/40)AT007K (9/124)AT003G (2/28)

AT001E (5/71)AT010F (4/58)

AT035H (4/67)AT007W (1/17)

AT041E (1/17)AT017K (2/35)AT016G (1/18)

AT005I (8/146)AT008S (1/19)AT006N (1/19)

AT028R (5/100)AT021V (3/60)AT010H (1/21)AT010B (1/22)

AT016W (3/92)AT023K (1/31)

AT042B (1/33)AT001S (2/71)AT026S (1/37)AT011W (1/37)AT005Z (1/38)AT012W (1/38)AT024V (2/79)AT005L (1/44)AT015A (1/45)AT037P (1/47)AT014R (1/66)AT007V (0/8)AT030V (0/6)AT032R (0/9)

AT030H (0/14)AT012D (0/19)AT022K (0/19)AT005K (0/25)AT042T (0/20)

AT023E (0/9)AT30UE (0/12)AT022B (0/24)

AT022S (0/7)AT023F (0/6)

AT009R (0/18)AT015S (0/18)AT036B (0/7)AT030L (0/5)AT010R (0/6)

AT008B (0/12)AT026Z (0/12)AT007F (0/15)AT032E (0/5)

AT012Z (0/13)AT036H (0/8)AT022L (0/23)AT009W (0/8)AT030F (0/26)AT030G (0/28)AT030W (0/23)

AT005U (0/8)AT022R (0/5)

AT029O (0/9)AT015M (0/7)AT032D (0/7)AT015W (0/6)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 36Minimum 0First quartile 0Median 0Third quartile 5.8Maximum 25

N hospitals 96Minimum 0First quartile 0Median 3.9Third quartile 9.2Maximum 31.6

Austria

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Hosp

ital c

odes

0 25 50 75 100AT022A (3/6)

AT005N (5/10)AT005C (3/6)

AT005H (10/21)AT006O (6/13)AT003M (4/9)

AT005I (102/231)AT012T (3/7)

AT005S (8/19)AT005U (3/8)

AT010R (6/16)AT032P (4/11)

AT037P (19/53)AT005J (5/14)

AT011W (15/45)AT036M (2/6)AT022B (5/16)AT012D (7/23)

AT035H (32/107)AT017K (18/61)

AT030G (11/38)AT023E (4/14)

AT027L (82/289)AT042B (10/36)

AT033D (38/137)AT005Z (14/52)

AT017T (4/15)AT018M (27/107)

AT012H (2/8)AT026Z (4/16)

AT029O (6/25)AT007K (40/169)AT002A (47/200)

AT30UE (3/13)AT022K (5/22)AT032G (7/31)AT020N (7/31)

AT019P (22/98)AT001E (34/153)AT022L (14/64)

AT020W (20/92)AT031W (33/152)

AT021S (3/14)AT007W (6/28)

AT005R (3/14)AT001S (28/131)AT030F (19/89)

AT011P (7/33)AT025K (69/326)AT006S (23/110)AT041E (22/109)

AT008M (1/5)AT015M (3/15)AT011G (2/10)

AT015A (18/92)AT012W (8/41)AT030W (8/41)AT014R (15/78)AT007F (4/21)

AT021V (10/53)AT028R (43/232)

AT042T (5/27)AT015W (5/28)

AT023S (17/98)AT030H (6/35)AT033F (9/53)

AT026S (14/83)AT008A (2/12)AT019L (2/12)

AT040A (11/66)AT008S (5/31)AT016G (4/25)AT007V (6/38)

AT034E (12/76)AT003G (5/32)AT009W (2/13)AT010B (9/59)AT005K (5/33)AT032R (2/14)

AT016W (21/154)AT001B (6/44)AT036B (3/25)AT010F (8/67)AT005L (8/69)AT010H (4/35)AT015S (2/18)

AT036H (2/18)AT024V (12/112)

AT006N (1/10)AT032D (1/10)AT022R (1/10)

AT024G (4/42)AT023K (5/55)

AT024B (4/46)AT032B (3/36)AT032V (2/24)AT009S (1/13)AT012Z (1/14)

AT009R (1/22)AT022S (0/9)AT024U (0/9)

AT009K (0/10)AT023F (0/6)

AT030V (0/23)AT023G (0/5)

Hosp

ital c

odes

0 25 50 75 100AT005C (7/7)AT005S (2/5)AT030G (2/6)AT040A (3/11)

AT018M (5/22)AT030V (1/5)

AT033F (2/11)AT019P (3/17)

AT005I (12/75)AT020W (5/33)AT005K (2/14)AT033D (5/36)

AT024G (1/8)AT007K (3/26)

AT003G (1/9)AT005Z (1/9)

AT001E (3/29)AT015A (1/10)

AT024V (2/22)AT030F (1/12)AT011W (1/13)

AT002A (4/53)AT016W (2/27)AT035H (2/28)AT005L (1/14)

AT006S (3/46)AT034E (1/20)AT027L (3/64)AT025K (3/69)AT031W (1/30)AT028R (1/51)AT005H (0/5)

AT014R (0/10)AT001B (0/7)

AT022L (0/10)AT036B (0/5)AT017K (0/16)AT032G (0/6)

AT001S (0/26)AT024B (0/5)AT008S (0/5)AT029O (0/7)

AT023S (0/19)AT037P (0/7)AT007V (0/8)

AT042B (0/23)AT012W (0/5)AT041E (0/14)AT009K (0/6)AT010B (0/12)AT032B (0/11)

AT020N (0/12)AT023K (0/18)AT021V (0/14)AT026S (0/11)AT042T (0/9)AT012D (0/5)AT010F (0/11)AT017T (0/5)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 105Minimum 0First quartile 14.3Median 20Third quartile 26.7Maximum 50

N hospitals 59Minimum 0First quartile 0Median 3.3Third quartile 11.1Maximum 100

82

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Belgium

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 98 1 210 48 1 092 27 1 184 23 205 - - - -2003 107 1 488 47 1 133 24 1 326 16 146 - - - -2004 95 1 443 49 1 227 25 1 601 18 228 - - - -2005 97 1 539 41 1 048 25 1 592 19 223 - - - -2006 98 1 427 33 858 21 1 632 22 267 - - - -2007 105 1 511 34 855 17 1 460 20 245 - - - -2008 101 1 647 38 906 16 1 430 19 236 - - - -2009 101 1 885 34 949 18 1 610 14 227 8 142 8 136

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 3 4 3 <1 <1Penicillin RI 14 12 9 12 10 9 8 <1Macrolides RI 34 34 33 31 31 25 24 23Staphylococcus aureusOxacillin/Meticillin R 28 30 33 31 22 23 21 21Escherichia coliAminopenicilins R 47 50 50 53 54 57 55 56Aminoglycosides R 6 5 5 4 6 5 4 7Fluoroquinolones R 13 12 15 17 19 19 17 20Third-gen. cephalosporins R 3 3 3 4 3 4 4 6Enterococcus faecalisAminopenicilins RI <1 1 2 <1 <1 <1 3 1HL Gentamicin R 20 17 22 26 30 26 30 23Vancomycin R <1 1 <1 <1 <1 1 <1 1Enterococcus faeciumAminopenicilins RI 56 78 63 61 67 68 76 90HL Gentamicin R 5 <1 11 22 19 23 17 32Vancomycin R <1 <1 5 14 4 <1 5 4Klebsiella pneumoniaeAminoglycosides R - - - - - - - 10Fluoroquinolones R - - - - - - - 13Third-gen. cephalosporins R - - - - - - - 15Pseudomonas aeruginosaPiperacillin R - - - - - - - 7Ceftazidime R - - - - - - - 6Carbapenems R - - - - - - - 9Aminoglycosides R - - - - - - - 10Fluoroquinolones R - - - - - - - 16

83

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=3 532

S. aureusn=1 855

E. colin=2 828

E. faecalisn=335

E. faeciumn=126

K. pneumoniaen=142

P. aeruginosan=134

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 96 4 100 21 100 19 100 1 100 5 99 15 100 9CSF 4 7 - - <1 0 - - - - 1 0 - -GenderMale 53 4 61 22 46 20 63 1 55 7 58 16 66 6Female 46 5 38 19 53 17 34 0 41 2 41 14 34 15Unknown 1 0 1 13 1 6 2 0 4 0 1 0 - -Age (years)0–4 19 11 4 8 2 5 4 0 3 0 6 22 3 05–19 5 3 2 9 1 13 1 0 - - - - 1 020–64 34 6 34 21 29 16 29 0 37 2 31 18 25 1265 and over 41 11 58 32 68 18 66 1 59 6 63 12 72 8Unknown - - 1 20 <1 50 0 0 1 0 - - - -Hospital departmentICU 14 9 15 34 3 17 23 0 22 4 - - - -Internal med. 34 9 34 24 10 16 34 1 31 3 - - - -Surgery 2 10 10 30 2 18 9 0 6 0 - - - -Other 30 9 26 26 14 15 24 0 26 5 - - - -Unknown 21 8 16 23 71 17 11 1 15 10 100 15 100 9

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

84

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100BE065 (2/6)BE127 (2/8)

BE143 (7/31)BE095 (7/35)BE029 (2/11)

BE158 (1/6)BE129 (1/8)

BE069 (2/17)BE084 (3/28)BE076 (1/10)BE071 (2/21)

BE098 (4/43)BE152 (1/11)

BE006 (4/44)BE012 (2/23)

BE097 (5/60)BE112 (6/74)

BE023 (3/37)BE016 (5/63)BE109 (1/13)

BE045 (7/99)BE161 (3/43)

BE019 (2/29)BE057 (1/15)BE137 (1/15)

BE026 (1/16)BE014 (2/32)

BE070 (5/90)BE118 (2/36)BE166 (1/18)

BE056 (4/75)BE154 (1/19)

BE046 (3/58)BE009 (1/20)BE022 (2/41)BE091 (4/88)BE116 (1/22)

BE104 (2/44)BE092 (5/115)BE001 (3/69)BE074 (2/48)BE060 (1/24)BE011 (1/24)

BE043 (4/98)BE035 (1/25)BE005 (1/27)BE003 (1/31)BE093 (1/32)BE004 (1/34)BE114 (1/34)

BE077 (1/36)BE090 (1/36)BE061 (2/76)

BE108 (4/154)BE113 (1/40)

BE063 (1/42)BE032 (1/48)BE008 (1/54)BE075 (1/58)BE030 (1/67)BE115 (1/68)BE111 (1/102)BE105 (0/38)BE072 (0/19)BE007 (0/20)BE021 (0/56)BE017 (0/16)

BE049 (0/37)BE139 (0/51)BE125 (0/9)

BE051 (0/29)BE031 (0/22)BE037 (0/28)BE054 (0/47)BE110 (0/28)BE024 (0/61)BE073 (0/9)

BE103 (0/27)BE107 (0/17)

BE171 (0/7)BE048 (0/33)BE157 (0/16)BE010 (0/15)BE146 (0/28)

BE087 (0/5)BE160 (0/14)BE044 (0/5)

BE033 (0/23)BE081 (0/11)BE159 (0/13)BE102 (0/29)BE101 (0/35)

BE100 (0/20)BE164 (0/29)BE064 (0/23)

BE018 (0/9)BE083 (0/25)

BE153 (0/6)

Hosp

ital c

odes

0 25 50 75 100

BE143A (24/55)

BE125A (3/8)

BE152A (7/19)

BE056A (6/19)

BE019A (7/23)

BE032A (25/84)

BE029A (5/17)

BE070A (35/125)

BE024A (18/68)

BE006A (16/62)

BE012A (6/25)

BE007A (5/21)

BE097A (17/74)

BE061A (25/113)

BE115A (18/87)

BE002A (12/58)

BE112A (24/119)

BE139A (10/50)

BE074A (16/80)

BE016A (26/132)

BE008A (23/121)

BE045A (9/52)

BE063A (16/105)

BE005A (3/20)

BE164A (2/14)

BE022A (5/38)

BE060A (4/31)

BE111A (3/27)

BE054A (3/45)

BE077A (6/93)

BE030A (1/31)

BE048A (0/10)

BE041A (0/15)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 98Minimum 0First quartile 0Median 2.9Third quartile 6.7Maximum 33.3

N hospitals 33Minimum 0First quartile 14.3Median 20.2Third quartile 26.5Maximum 43.6

Belgium

85

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

BE077A (43/136)

BE005A (18/64)

BE063A (60/239)

BE012A (19/76)

BE070A (34/140)

BE139A (32/133)

BE061A (47/212)

BE112A (48/265)

BE008A (55/316)

BE016A (43/266)

BE007A (13/86)

BE097A (52/345)

BE022A (18/124)

BE006A (18/166)

BE032A (22/227)

BE164A (1/29)

Hosp

ital c

odes

0 25 50 75 100

BE115A (7/26)

BE008A (5/22)

BE092A (7/34)

BE077A (1/12)

BE042A (1/13)

BE016A (0/14)

BE006A (0/10)

BE003A (0/11)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 16Minimum 3.4First quartile 14.8Median 17.8Third quartile 24.6Maximum 31.6

N hospitals 8Minimum 0First quartile 0Median 8Third quartile 21.7Maximum 26.9

86

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Bulgaria

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 11 25 21 116 20 135 16 42 - - - -2003 13 22 20 157 20 158 16 49 - - - -2004 13 32 22 170 20 167 16 75 - - - -2005 16 43 26 160 23 203 21 95 15 34 9 342006 11 29 23 159 20 196 19 98 15 55 13 312007 10 32 14 121 15 127 13 65 9 29 6 142008 13 29 21 160 22 147 18 70 11 49 10 232009 10 27 20 221 17 194 16 92 12 95 11 36

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 8 9 22 30 7 9 21 22Penicillin RI 8 14 22 33 7 16 21 37Macrolides RI 9 11 17 8 15 17 4 27Staphylococcus aureusOxacillin/Meticillin R 33 31 23 29 28 13 25 16Escherichia coliAminopenicilins R 52 54 64 69 64 70 65 66Aminoglycosides R 17 22 20 24 28 20 31 18Fluoroquinolones R 14 19 24 29 26 35 32 28Third-gen. cephalosporins R 13 18 22 28 29 23 29 19Enterococcus faecalisAminopenicilins RI 26 7 15 8 31 13 8 16HL Gentamicin R 63 36 33 24 53 29 44 36Vancomycin R <1 <1 2 <1 2 <1 <1 <1Enterococcus faeciumAminopenicilins RI 71 60 59 96 97 100 93 96HL Gentamicin R 83 60 62 56 79 75 84 65Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Klebsiella pneumoniaeAminoglycosides R - - - 53 60 59 59 65Fluoroquinolones R - - - 26 24 41 52 48Third-gen. cephalosporins R - - - 50 60 55 73 69Pseudomonas aeruginosaPiperacillin R - - - 50 33 14 48 33Ceftazidime R - - - 45 13 21 55 23Carbapenems R - - - 38 14 7 17 24Aminoglycosides R - - - 53 42 29 48 33Fluoroquinolones R - - - 47 17 14 36 33

87

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=56

S. aureusn=381

E. colin=339

E. faecalisn=101

E. faeciumn=54

K. pneumoniaen=144

P. aeruginosan=57

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 63 34 100 20 99 30 100 0 100 0 100 71 100 21CSF 38 19 - - 1 0 - - - - - - - -GenderMale 63 26 61 21 48 36 67 0 48 0 65 71 74 17Female 38 33 39 18 52 23 33 0 52 0 35 71 26 33Unknown - - 0 100 - - - - - - - - - -Age (years)0–4 13 41 10 34 7 12 11 0 16 0 13 67 8 185–19 9 10 5 14 4 20 1 0 1 0 4 82 2 020–64 58 14 57 24 48 27 50 1 49 0 47 68 60 1865 and over 18 30 28 23 41 26 37 0 31 0 36 56 30 33Unknown 1 33 <1 20 1 50 <1 0 4 0 - - - -Hospital departmentICU 15 16 15 40 11 31 20 0 35 0 20 73 32 31Internal med. 31 20 35 15 47 20 34 1 18 0 24 47 16 5Surgery 2 0 12 38 12 35 11 0 13 0 19 70 16 19Other 51 23 38 23 29 29 35 0 35 0 37 67 36 23Unknown - - - - <1 50 - - - - - - - -

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

88

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

BG003 (3/5)

BG029 (3/6)

BG017 (2/10)

BG005 (1/8)

BG023 (0/5)

Hosp

ital c

odes

0 25 50 75 100

BG022A (4/9)

BG005A (8/21)

BG018A (14/38)

BG001A (7/20)

BG006A (6/20)

BG009A (3/10)

BG027A (3/10)

BG003A (4/25)

BG007A (6/42)

BG029A (1/7)

BG021A (3/25)

BG002A (2/17)

BG017A (7/70)

BG013A (1/12)

BG011A (1/13)

BG023A (1/21)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 5Minimum 0First quartile 12.5Median 20Third quartile 50Maximum 60

N hospitals 16Minimum 4.8First quartile 10.9Median 15.1Third quartile 32.5Maximum 44.4

Bulgaria

89

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

BG002A (5/7)

BG006A (9/17)

BG027A (3/6)

BG007A (14/32)

BG017A (19/44)

BG021A (4/10)

BG001A (8/26)

BG018A (12/45)

BG023A (7/27)

BG005A (6/24)

BG003A (4/22)

BG011A (3/18)

BG014A (1/6)

BG009A (1/10)

BG013A (2/25)

Hosp

ital c

odes

0 25 50 75 100

BG006A (15/17)

BG002A (6/7)

BG021A (15/18)

BG011A (7/10)

BG017A (18/27)

BG018A (14/21)

BG001A (8/13)

BG007A (9/16)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 15Minimum 8First quartile 16.7Median 26.7Third quartile 43.8Maximum 71.4

N hospitals 8Minimum 56.3First quartile 64.1Median 68.3Third quartile 84.5Maximum 88.2

90

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Cyprus

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2003 1 3 1 28 1 19 1 28 - - - -2004 1 7 3 39 4 46 3 38 - - - -2005 4 16 5 54 5 75 3 40 4 9 4 82006 5 13 5 62 5 90 4 48 4 26 4 372007 4 15 4 85 5 109 3 63 4 39 3 522008 4 14 5 92 4 119 5 85 5 62 5 432009 4 11 5 89 5 136 5 80 5 53 5 62

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R - <1 <1 <1 31 7 21 18Penicillin RI - <1 14 19 38 33 43 36Macrolides RI - 33 <1 13 31 27 29 36Staphylococcus aureusOxacillin/Meticillin R - 64 49 56 34 48 46 33Escherichia coliAminopenicilins R - 63 61 72 62 72 58 66Aminoglycosides R - 11 11 13 10 11 10 10Fluoroquinolones R - 32 22 29 35 39 45 43Third-gen. cephalosporins R - 11 9 16 16 18 19 14Enterococcus faecalisAminopenicilins RI - <1 3 3 5 2 16 32HL Gentamicin R - 43 77 71 44 61 65 66Vancomycin R - <1 3 <1 <1 <1 1 <1Enterococcus faeciumAminopenicilins RI - 100 100 80 43 92 60 80HL Gentamicin R - - 33 <1 14 33 10 13Vancomycin R - <1 33 40 14 25 20 13Klebsiella pneumoniaeAminoglycosides R - - - 11 12 13 21 19Fluoroquinolones R - - - 22 12 23 23 43Third-gen. cephalosporins R - - - 33 27 31 35 42Pseudomonas aeruginosaPiperacillin R - - - 13 27 31 23 18Ceftazidime R - - - 38 24 15 9 18Carbapenems R - - - 13 11 19 19 8Aminoglycosides R - - - 13 11 25 21 5Fluoroquinolones R - - - 13 27 23 38 13

91

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=25

S. aureusn=181

E. colin=255

E. faecalisn=140

E. faeciumn=25

K. pneumoniaen=115

P. aeruginosan=104

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 96 42 100 39 100 44 100 1 100 16 100 38 100 13CSF 4 0 - - - - - - - - - - - -GenderMale 64 38 67 40 55 45 68 0 64 19 57 34 59 16Female 36 44 32 36 45 43 31 2 36 11 37 40 34 9Unknown - - 1 50 <1 100 1 0 - - 6 71 8 0Age (years)0–4 10 13 2 10 3 0 1 0 4 0 4 57 5 05–19 6 20 2 27 2 44 0 0 2 0 2 0 1 020–64 15 33 18 36 13 39 17 0 11 33 23 45 24 1065 and over 9 57 21 53 27 50 28 1 39 9 28 33 25 12Unknown 59 30 56 46 57 34 54 1 45 28 43 30 46 19Hospital departmentICU 6 40 19 42 9 35 30 0 38 19 31 49 41 18Internal med. 65 31 35 46 54 38 29 0 25 14 27 20 20 10Surgery - - 13 58 6 42 19 0 21 25 11 35 14 26Other 29 26 33 38 30 37 22 3 16 22 31 34 26 4Unknown - - <1 100 1 50 - - - - - - 1 0

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

92

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

CY001 (7/14)

Hosp

ital c

odes

0 25 50 75 100

CY002A (25/45)

CY001A (40/105)

CY004A (3/9)

CY003A (3/19)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 1Minimum 50First quartile 50Median 50Third quartile 50Maximum 50

N hospitals 4Minimum 15.8First quartile 24.6Median 35.7Third quartile 46.8Maximum 55.6

Cyprus

93

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

CY002A (35/68)

CY003A (18/37)

CY001A (51/126)

CY004A (7/18)

CY005A (2/6)

Hosp

ital c

odes

0 25 50 75 100

CY005A (5/10)

CY002A (10/21)

CY004A (2/5)

CY001A (25/64)

CY003A (2/15)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 5Minimum 33.3First quartile 38.9Median 40.5Third quartile 48.6Maximum 51.5

N hospitals 5Minimum 13.3First quartile 39.1Median 40Third quartile 47.6Maximum 50

94

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Czech Republic

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 34 144 41 1 168 40 1 587 39 587 - - - -2003 32 204 45 1 387 43 1 766 44 630 - - - -2004 37 162 45 1 444 44 1 966 41 660 - - - -2005 39 195 47 1 553 47 2 234 45 758 37 478 36 2572006 39 172 47 1 527 47 2 176 45 697 45 1 130 43 4902007 41 205 47 1 653 48 2 407 47 816 48 1 230 41 5172008 40 244 47 1 715 46 2 738 44 883 45 1 493 42 5682009 41 297 46 1 695 45 2 759 44 835 45 1 415 45 575

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 2 <1 <1 <1 <1 <1Penicillin RI 8 2 6 4 2 4 3 4Macrolides RI 4 2 4 2 3 5 3 5Staphylococcus aureusOxacillin/Meticillin R 6 6 9 13 12 13 14 15Escherichia coliAminopenicilins R 45 45 47 50 56 56 60 61Aminoglycosides R 6 5 5 6 8 7 9 9Fluoroquinolones R 10 13 16 20 23 24 26 23Third-gen. cephalosporins R 1 1 2 2 5 7 10 10Enterococcus faecalisAminopenicilins RI 2 4 <1 <1 2 3 2 <1HL Gentamicin R 39 44 43 45 43 49 49 47Vancomycin R <1 <1 <1 <1 <1 1 <1 <1Enterococcus faeciumAminopenicilins RI 73 80 81 92 90 91 94 98HL Gentamicin R 35 48 43 69 74 79 75 65Vancomycin R 9 3 3 14 4 6 8 6Klebsiella pneumoniaeAminoglycosides R - - - 36 38 43 42 47Fluoroquinolones R - - - 38 47 48 52 54Third-gen. cephalosporins R - - - 32 35 46 48 52Pseudomonas aeruginosaPiperacillin R - - - 21 29 30 27 28Ceftazidime R - - - 40 30 33 44 29Carbapenems R - - - 31 33 36 29 29Aminoglycosides R - - - 28 30 34 45 32Fluoroquinolones R - - - 45 47 43 46 41

95

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=540

S. aureusn=3 410

E. colin=5 494

E. faecalisn=1 275

E. faeciumn=443

K. pneumoniaen=2 908

P. aeruginosan=1 139

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 85 3 100 14 100 25 100 0 100 7 100 50 99 29CSF 15 6 - - <1 6 - - - - <1 27 1 50GenderMale 56 3 61 14 43 28 64 0 59 8 60 53 63 30Female 44 6 39 15 57 22 36 0 41 5 40 45 37 27Unknown - - - - 0 100 - - - - - - - -Age (years)0–4 11 7 4 3 3 6 4 1 1 0 3 26 3 135–19 6 3 3 3 1 12 1 0 1 0 1 32 2 2620–64 51 4 44 11 33 19 45 1 50 10 42 49 44 3765 and over 32 4 49 13 63 22 50 0 47 4 54 43 51 28Unknown <1 0 <1 0 <1 0 - - - - <1 20 <1 0Hospital departmentICU 23 4 22 16 17 23 41 0 43 3 38 52 41 38Internal med. 38 4 47 10 51 20 30 0 23 5 34 37 28 26Surgery 2 7 11 13 8 20 10 1 6 1 10 46 7 27Other 35 5 20 8 24 21 20 0 28 16 17 43 23 28Unknown 2 6 1 16 <1 22 <1 0 <1 100 <1 48 1 31

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

96

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

CZ018 (2/5)

CZ040 (1/8)

CZ025 (1/8)

CZ030 (1/8)

CZ047 (1/8)

CZ027 (3/26)

CZ013 (1/9)

CZ023 (2/18)

CZ014 (1/14)

CZ042 (1/17)

CZ033 (1/19)

CZ015 (1/22)

CZ006 (2/55)

CZ044 (1/31)

CZ016 (1/60)

CZ024 (0/26)

CZ007 (0/20)

CZ003 (0/10)

CZ036 (0/6)

CZ009 (0/17)

CZ041 (0/5)

CZ008 (0/11)

CZ031 (0/15)

CZ002 (0/9)

CZ049 (0/12)

CZ019 (0/6)

CZ004 (0/16)

CZ017 (0/19)

CZ026 (0/9)

CZ029 (0/11)

CZ037 (0/9)

Hosp

ital c

odes

0 25 50 75 100CZ012C (7/7)

CZ050A (17/28)CZ049B (3/6)

CZ023A (27/56)CZ012A (14/36)

CZ005A (40/113)CZ007B (5/15)CZ044C (4/14)

CZ012B (2/7)CZ034A (14/52)CZ049A (7/26)CZ043B (3/12)

CZ033A (16/65)CZ034C (4/17)

CZ051A (2/9)CZ003A (19/88)

CZ041A (9/43)CZ031K (2/10)

CZ024A (27/143)CZ008A (8/43)CZ025A (8/44)CZ042A (8/45)CZ048A (8/45)CZ037D (3/17)

CZ007A (16/96)CZ031A (11/67)CZ031P (3/19)

CZ026A (10/64)CZ009A (18/130)CZ015A (16/118)

CZ013A (9/68)CZ031V (1/8)CZ043C (1/8)CZ031J (2/16)CZ034B (1/8)

CZ018A (27/223)CZ035A (7/58)CZ044A (5/47)CZ031C (1/10)

CZ006A (20/204)CZ004A (7/76)

CZ020A (10/113)CZ002A (6/71)CZ015B (1/12)

CZ016A (9/109)CZ011A (3/37)

CZ017A (8/99)CZ032A (3/38)

CZ027A (10/131)CZ029A (3/40)CZ039B (1/14)CZ037A (2/30)CZ019A (3/45)CZ039A (1/15)CZ038A (1/16)CZ040A (1/17)CZ022A (2/41)CZ028A (2/41)

CZ030A (4/84)CZ031F (1/21)

CZ014A (2/46)CZ021A (3/90)CZ007D (0/11)

CZ009B (0/20)CZ046A (0/15)CZ017B (0/30)CZ036A (0/29)

CZ047A (0/8)CZ037C (0/6)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 31Minimum 0First quartile 0Median 0Third quartile 11.1Maximum 40

N hospitals 69Minimum 0First quartile 6.7Median 12.5Third quartile 20Maximum 100

Czech Republic

97

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100CZ017C (4/5)

CZ007B (19/36)CZ036A (30/60)

CZ012C (8/17)CZ034C (4/9)

CZ039B (16/37)CZ007E (3/7)

CZ049B (11/26)CZ031C (5/12)

CZ002A (77/185)CZ017B (26/65)CZ028A (35/89)CZ033A (26/71)CZ025A (24/70)

CZ051A (6/18)CZ043B (2/6)

CZ041A (20/61)CZ009A (57/174)

CZ034A (15/47)CZ035A (26/82)CZ038A (17/54)

CZ031K (5/16)CZ027A (57/183)CZ049A (23/74)

CZ031F (9/29)CZ011A (14/47)

CZ023A (33/112)CZ037C (5/17)CZ050A (5/17)

CZ031Y (2/7)CZ031P (7/25)

CZ021A (38/136)CZ044A (20/72)CZ048B (14/51)

CZ026A (31/113)CZ005A (38/144)

CZ046A (24/91)CZ017A (29/111)

CZ039A (8/31)CZ044C (11/43)

CZ031J (8/33)CZ018A (56/238)CZ004A (30/131)

CZ006A (90/396)CZ042A (32/144)

CZ031A (20/91)CZ022A (23/105)CZ007A (24/115)CZ008A (19/92)

CZ048A (9/45)CZ009B (1/5)

CZ024A (32/163)CZ012B (4/22)

CZ019A (19/110)CZ037D (6/35)

CZ016A (28/173)CZ007D (3/19)

CZ015A (30/199)CZ012A (6/40)

CZ013A (18/122)CZ003A (13/90)

CZ037A (7/50)CZ030A (20/148)

CZ040A (1/8)CZ014A (13/105)CZ032A (14/114)

CZ020A (9/88)CZ031V (1/11)

CZ047A (4/45)CZ029A (4/70)

CZ034B (0/5)CZ015B (0/9)

CZ047B (0/15)

Hosp

ital c

odes

0 25 50 75 100CZ031K (15/17)

CZ012C (5/6)CZ043B (10/12)

CZ031J (12/15)CZ050A (10/13)CZ044C (13/17)

CZ025A (30/40)CZ007B (21/28)CZ011A (25/34)CZ047A (13/18)

CZ009A (147/219)CZ042A (34/52)

CZ034C (7/11)CZ021A (40/63)CZ007A (24/38)CZ028A (20/32)CZ048A (17/28)CZ046A (23/38)

CZ031V (3/5)CZ007E (3/5)

CZ023A (22/38)CZ035A (48/83)

CZ027A (68/120)CZ037D (5/9)

CZ038A (16/29)CZ037A (12/22)

CZ006A (119/221)CZ019A (31/58)CZ036A (14/27)CZ004A (31/60)CZ049A (22/43)

CZ031C (5/10)CZ012A (12/24)CZ002A (6/12)

CZ005A (68/138)CZ018A (107/220)

CZ041A (14/29)CZ024A (41/85)

CZ003A (42/88)CZ017B (16/34)

CZ031F (7/15)CZ022A (13/28)CZ009B (14/31)CZ013A (14/32)

CZ034A (19/44)CZ012B (3/7)

CZ033A (23/56)CZ016A (24/59)CZ049B (6/15)CZ048B (8/21)

CZ031A (20/54)CZ039B (4/11)

CZ008A (12/40)CZ020A (25/84)

CZ044A (5/17)CZ017A (18/67)CZ030A (7/27)

CZ026A (14/56)CZ029A (6/24)CZ032A (5/24)CZ015A (8/45)CZ014A (8/49)CZ031P (2/15)

CZ039A (0/10)CZ034B (0/8)CZ047B (0/5)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 73Minimum 0First quartile 17.1Median 26.4Third quartile 31.9Maximum 80

N hospitals 66Minimum 0First quartile 38.1Median 50Third quartile 60.7Maximum 88.2

98

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Denmark

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 5 366 5 752 - - - - - - - -2003 5 606 5 671 - - - - - - - -2004 15 1 188 15 1 436 - - - - - - - -2005 14 1 081 15 1 350 5 1 283 - - - - - -2006 15 872 15 1 279 11 2 723 11 711 11 607 - -2007 15 1 030 14 1 315 12 3 021 13 927 13 784 13 4172008 15 934 15 1 295 14 3 283 14 1 005 14 793 14 4202009 15 996 15 1 395 14 3 532 14 1 100 14 822 14 429

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 <1 <1 <1 <1Penicillin RI 4 3 3 4 4 3 3 4Macrolides RI 5 5 5 6 6 6 7 4Staphylococcus aureusOxacillin/Meticillin R <1 <1 1 2 2 <1 2 2Escherichia coliAminopenicilins R - - - 40 42 43 43 43Aminoglycosides R - - - 2 3 4 4 4Fluoroquinolones R - - - 5 7 9 10 13Third-gen. cephalosporins R - - - 1 2 3 4 6Enterococcus faecalisAminopenicilins RI - - - - <1 2 2 1HL Gentamicin R - - - - - - 37 33Vancomycin R - - - - <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI - - - - 87 88 88 88HL Gentamicin R - - - - - - 61 52Vancomycin R - - - - <1 <1 <1 2Klebsiella pneumoniaeAminoglycosides R - - - - 2 6 7 7Fluoroquinolones R - - - - 6 13 16 16Third-gen. cephalosporins R - - - - 4 10 9 11Pseudomonas aeruginosaPiperacillin R - - - - - 3 2 2Ceftazidime R - - - - - 2 3 4Carbapenems R - - - - - 2 1 3Aminoglycosides R - - - - - 1 1 <1Fluoroquinolones R - - - - - 6 3 5

99

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=1 930

S. aureusn=2 690

E. colin=6 424

E. faecalisn=926

E. faeciumn=692

K. pneumoniaen=1 243

P. aeruginosan=687

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 93 3 100 2 100 12 100 0 100 1 100 10 99 2CSF 7 3 - - <1 0 - - - - <1 0 1 0GenderMale 24 3 62 2 49 14 71 0 58 0 59 12 61 2Female 24 3 38 1 51 9 29 0 41 2 41 7 39 2Unknown 52 4 - - <1 100 <1 0 <1 0 - - - -Age (years)0–4 8 4 3 1 1 6 2 0 1 0 1 3 2 05–19 2 1 3 1 1 3 1 0 2 5 1 5 2 920–64 38 3 40 1 29 11 33 0 45 0 35 10 31 465 and over 52 4 54 1 69 9 64 0 52 1 63 8 65 1Unknown - - <1 0 <1 0 - - - - - - - -Hospital departmentICU - - 2 2 3 15 12 0 32 1 5 8 8 12Internal med. - - 19 1 44 9 42 0 24 0 44 9 29 0Surgery - - 7 2 17 8 19 0 18 1 22 8 13 3Other - - 6 1 21 11 22 1 18 1 24 9 30 1Unknown 100 4 65 1 15 12 5 0 7 2 5 11 20 2

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

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Labo

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0 25 50 75 100

DK002 (12/258)

DK012 (6/134)

DK001 (2/46)

DK015 (4/101)

DK005 (4/103)

DK007 (3/81)

DK009 (4/163)

DK016 (7/196)

DK013 (3/85)

DK004 (4/128)

DK014 (5/209)

DK003 (4/191)

DK006 (2/102)

DK010 (1/60)

DK011 (1/73)

Hosp

ital c

odes

0 25 50 75 100DK012B (2/7)DK007D (1/5)

DK002X (2/25)DK002E (3/41)

DK005B (2/30)DK004B (1/17)DK012D (1/18)

DK002B (6/119)DK007A (3/63)DK014B (2/49)DK006B (2/57)DK013A (2/68)DK015A (2/69)DK009A (1/39)DK002F (1/40)

DK001A (5/212)DK014D (1/59)DK005A (1/59)DK003A (1/60)DK003B (1/62)DK007B (1/64)DK014Y (1/65)

DK002A (1/84)DK003C (2/169)DK009B (2/253)

DK016A (1/151)DK016C (0/15)DK010B (0/6)

DK006C (0/10)DK015G (0/6)

DK006A (0/85)DK008A (0/19)

DK004A (0/106)DK004C (0/24)

DK016G (0/6)DK014N (0/92)DK016B (0/41)DK015C (0/16)DK005X (0/6)DK011A (0/76)DK013D (0/5)DK016F (0/9)DK015B (0/5)DK012F (0/11)

DK010D (0/18)DK014E (0/5)

DK016D (0/15)DK015X (0/14)DK014C (0/36)DK014A (0/34)DK012E (0/16)DK013B (0/42)DK004X (0/7)

DK010A (0/44)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 15Minimum 1.4First quartile 2.1Median 3.6Third quartile 4Maximum 5

N hospitals 54Minimum 0First quartile 0Median 0Third quartile 2.6Maximum 28.6

Denmark

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100DK001A (50/191)

DK002F (36/149)

DK015B (2/9)

DK014N (17/98)

DK002A (37/227)

DK015A (31/192)

DK004B (20/129)

DK005A (30/198)

DK003C (68/460)

DK014C (10/68)

DK006X (16/110)

DK014B (10/69)

DK013A (13/97)

DK006A (8/60)

DK016A (49/369)

DK011A (26/196)

DK015G (9/72)

DK013B (15/126)

DK006C (2/17)

DK008A (8/70)

DK009B (48/428)

DK006B (15/135)

DK012F (16/145)

DK012B (7/65)

DK002B (28/261)

DK014Y (17/159)

DK003A (17/164)

DK013D (2/21)

DK012D (11/116)

DK004A (19/209)

DK003B (19/211)

DK016C (7/81)

DK005B (13/159)

DK014D (13/174)

DK016D (4/55)

DK009A (15/213)

DK016B (11/158)

DK004C (11/167)

DK002E (9/145)

DK012E (6/117)

DK007B (3/59)

DK016F (2/42)

DK007A (3/77)

DK016G (1/26)

DK011D (1/27)

DK014A (1/67)

DK007D (0/11)

DK009G (0/10)

DK009H (0/5)

Hosp

ital c

odes

0 25 50 75 100

DK004B (8/19)

DK002F (12/29)

DK002A (12/58)

DK001A (28/137)

DK008A (1/7)

DK005B (4/30)

DK016B (3/23)

DK016F (1/8)

DK002B (8/64)

DK004A (5/42)

DK014Y (4/36)

DK009B (13/148)

DK002E (2/23)

DK014N (3/38)

DK014D (4/52)

DK014B (2/28)

DK005A (3/43)

DK016A (7/111)

DK012D (1/17)

DK004C (2/38)

DK009A (2/46)

DK015A (1/35)

DK014C (0/18)

DK013A (0/12)

DK016D (0/9)

DK014A (0/14)

DK014A (0/14)

DK012E (0/17)

DK013B (0/20)

DK012F (0/36)

DK011D (0/5)

DK015G (0/11)

DK016C (0/11)

DK012B (0/9)

DK011A (0/38)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 49Minimum 0First quartile 7Median 10.7Third quartile 13.4Maximum 26.2

N hospitals 34Minimum 0First quartile 0Median 6.6Third quartile 12.5Maximum 42.1

102

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Estonia

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 5 21 8 82 6 67 3 13 - - - -2003 8 26 9 98 9 98 6 27 - - - -2004 6 40 9 104 10 167 5 63 - - - -2005 7 53 8 141 10 156 7 66 7 38 5 382006 8 52 9 154 9 215 8 85 6 47 6 432007 8 64 10 206 11 219 8 66 9 63 8 482008 10 66 11 185 11 267 11 86 10 72 8 412009 8 82 11 213 11 320 8 72 7 60 6 43

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 <1 <1 <1 <1Penicillin RI <1 <1 <1 2 2 <1 5 1Macrolides RI <1 10 6 <1 3 2 4 2Staphylococcus aureusOxacillin/Meticillin R <1 4 5 2 3 9 4 3Escherichia coliAminopenicilins R 42 42 55 45 52 50 47 38Aminoglycosides R 10 3 2 4 2 6 5 4Fluoroquinolones R 5 5 6 5 7 7 7 8Third-gen. cephalosporins R 2 1 4 1 <1 1 5 2Enterococcus faecalisAminopenicilins RI 10 4 14 14 9 <1 9 9HL Gentamicin R 50 22 32 50 35 23 27 43Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 33 75 79 83 84 94 85 90HL Gentamicin R 67 50 79 74 78 89 75 79Vancomycin R <1 <1 <1 <1 <1 <1 3 <1Klebsiella pneumoniaeAminoglycosides R - - - 8 9 2 15 15Fluoroquinolones R - - - <1 5 2 7 19Third-gen. cephalosporins R - - - 8 9 3 12 17Pseudomonas aeruginosaPiperacillin R - - - 27 12 9 18 13Ceftazidime R - - - 18 7 7 13 7Carbapenems R - - - 38 29 18 30 17Aminoglycosides R - - - 28 8 7 17 10Fluoroquinolones R - - - 14 10 9 18 19

103

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=147

S. aureusn=398

E. colin=554

E. faecalisn=79

E. faeciumn=79

K. pneumoniaen=127

P. aeruginosan=69

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 85 3 100 4 99 8 100 0 100 1 100 14 100 25CSF 15 0 - - 1 0 - - - - - - - -GenderMale 60 2 59 3 39 9 59 0 46 0 57 16 57 26Female 40 3 39 4 60 7 41 0 53 2 43 11 43 23Unknown - - 2 17 1 0 - - 1 0 - - - -Age (years)0–4 6 4 10 5 3 2 17 0 10 0 16 5 4 255–19 3 0 4 6 3 5 <1 0 2 0 1 0 5 3320–64 55 1 48 4 40 7 31 0 41 1 38 9 46 3365 and over 27 1 29 5 48 7 45 0 45 0 43 14 45 20Unknown 8 3 8 1 6 5 6 0 2 0 2 0 1 0Hospital departmentICU 37 1 23 6 17 7 29 0 39 0 30 11 55 31Internal med. 25 2 33 2 41 5 25 0 16 0 28 14 12 17Surgery 2 0 11 2 6 14 8 0 8 0 6 6 6 9Other 36 1 33 6 35 7 37 0 38 1 36 6 27 25Unknown <1 0 <1 0 <1 0 <1 0 - - - - - -

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

104

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Labo

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0 25 50 75 100

EE006 (2/15)

EE004 (1/25)

EE002 (1/36)

EE005 (0/14)

EE009 (0/10)

EE011 (0/6)

EE001 (0/35)

Hosp

ital c

odes

0 25 50 75 100

EE003R (5/10)

EE001A (5/89)

EE006K (1/27)

EE002M (2/66)

EE005P (1/34)

EE004P (1/51)

EE011L (0/11)

EE010N (0/13)

EE002L (0/44)

EE008V (0/16)

EE009K (0/31)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 7Minimum 0First quartile 0Median 0Third quartile 4Maximum 13.3

N hospitals 11Minimum 0First quartile 0Median 2Third quartile 3.7Maximum 50

Estonia

105

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

EE011L (4/17)

EE002L (1/6)

EE006K (9/78)

EE008V (2/18)

EE004P (8/73)

EE003R (1/14)

EE002M (7/102)

EE001A (7/141)

EE009K (1/32)

EE005P (1/52)

EE010N (0/8)

EE012P (0/7)

Hosp

ital c

odes

0 25 50 75 100

EE009K (5/17)

EE006K (3/14)

EE004P (3/16)

EE005P (1/7)

EE001A (4/33)

EE002M (2/21)

EE002L (0/13)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 12Minimum 0First quartile 2.5Median 7Third quartile 11.3Maximum 23.5

N hospitals 7Minimum 0First quartile 9.5Median 14.3Third quartile 21.4Maximum 29.4

106

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Finland

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 15 454 15 721 15 1 330 14 278 - - - -2003 16 517 16 727 15 1 450 15 266 - - - -2004 17 548 17 883 17 1 749 17 336 - - - -2005 17 543 17 790 17 1 924 17 340 14 175 13 1082006 15 501 15 894 15 1 875 15 348 14 228 14 1622007 16 547 16 814 16 1 949 16 400 15 273 14 1832008 15 643 15 923 15 2 111 15 381 12 288 12 1752009 20 688 20 978 20 2 224 20 506 20 375 18 233

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 2 2 <1 <1 2 1 <1 2Penicillin RI 6 10 8 7 12 13 11 13Macrolides RI 14 20 20 20 24 25 24 28Staphylococcus aureusOxacillin/Meticillin R <1 1 3 3 3 2 3 2Escherichia coliAminopenicilins R 30 33 33 35 36 34 35 36Aminoglycosides R <1 1 2 2 2 3 4 3Fluoroquinolones R 6 5 7 7 8 8 9 9Third-gen. cephalosporins R <1 1 2 2 2 2 2 3Enterococcus faecalisAminopenicilins RI 2 <1 <1 <1 <1 2 <1 <1HL Gentamicin R 13 39 39 27 25 22 13 -Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 80 79 69 78 80 87 87 87HL Gentamicin R <1 4 12 1 16 19 15 -Vancomycin R 1 <1 <1 <1 <1 <1 <1 <1Klebsiella pneumoniaeAminoglycosides R - - - 3 1 <1 1 1Fluoroquinolones R - - - 3 4 <1 2 3Third-gen. cephalosporins R - - - 2 <1 1 2 1Pseudomonas aeruginosaPiperacillin R - - - 8 8 7 8 7Ceftazidime R - - - 5 3 5 5 5Carbapenems R - - - 15 8 9 6 8Aminoglycosides R - - - 11 8 8 6 4Fluoroquinolones R - - - 16 17 11 15 11

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=1 294

S. aureusn=1 901

E. colin=4 332

E. faecalisn=475

E. faeciumn=398

K. pneumoniaen=655

P. aeruginosan=404

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 96 12 100 2 100 9 100 0 100 0 100 2 97 7CSF 4 9 - - <1 13 - - - - <1 0 3 8GenderMale 56 11 62 3 36 11 71 0 60 0 56 1 64 7Female 44 13 38 2 64 8 29 0 40 0 44 2 36 8Unknown 1 0 1 16 1 13 1 0 1 0 1 17 1 7Age (years)0–4 15 15 4 2 2 2 5 0 2 0 2 14 <1 255–19 4 9 5 2 1 7 1 0 1 0 1 0 1 820–64 49 9 44 2 31 7 30 0 38 0 31 2 29 1265 and over 33 10 48 2 66 8 63 0 58 0 67 1 69 7Unknown <1 0 <1 100 <1 0 <1 0 - - - - - -Hospital departmentICU 1 8 2 5 1 8 3 0 4 0 2 0 4 19Internal med. 8 9 12 2 8 6 10 0 11 0 9 2 8 6Surgery 2 4 5 3 4 8 8 0 10 0 5 1 6 7Other 29 10 20 2 22 7 18 0 16 0 21 2 18 10Unknown 61 11 61 2 65 8 60 0 60 1 63 1 65 8

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

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Labo

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0 25 50 75 100

FI003 (11/60)

FI008 (5/28)

FI014 (8/46)

FI021 (4/25)

FI00A (5/32)

FI011 (9/61)

FI002 (55/391)

FI017 (5/41)

FI00L (2/17)

FI009 (4/36)

FI005 (8/76)

FI020 (7/72)

FI018 (1/11)

FI00H (10/113)

FI010 (6/68)

FI012 (4/47)

FI00E (8/99)

FI00C (2/26)

FI015 (1/37)

FI019 (0/8)

Hosp

ital c

odes

0 25 50 75 100

FI020X (11/86)

FI012X (3/60)

FI005X (5/124)

FI00AA (1/25)

FI010X (3/92)

FI011X (1/32)

FI00LX (1/33)

FI014A (1/34)

FI017X (2/77)

FI011A (1/41)

FI002X (13/542)

FI021X (1/54)

FI015X (1/57)

FI00EX (1/155)

FI003X (0/45)

FI00AX (0/20)

FI019X (0/23)

FI014X (0/28)

FI008X (0/28)

FI003A (0/41)

FI018X (0/23)

FI009X (0/81)

FI00CX (0/53)

FI00HX (0/147)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 20Minimum 0First quartile 8.7Median 10.8Third quartile 15.2Maximum 18.3

N hospitals 24Minimum 0First quartile 0Median 1.8Third quartile 3.1Maximum 12.8

Finland

109

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

FI018X (8/46)

FI014X (9/73)

FI019X (5/41)

FI011X (9/74)

FI002X (154/1348)

FI00EX (27/287)

FI00AA (4/43)

FI020X (9/97)

FI00CX (12/130)

FI00LX (9/99)

FI017X (18/201)

FI003X (11/123)

FI021X (10/115)

FI005X (21/267)

FI00HX (29/376)

FI015X (9/127)

FI010X (14/226)

FI003A (7/117)

FI00AX (2/36)

FI012X (6/117)

FI009X (7/139)

FI008X (4/105)

FI014A (2/66)

FI011A (2/79)

Hosp

ital c

odes

0 25 50 75 100

FI00EX (3/50)

FI017X (1/30)

FI002X (5/215)

FI00HX (1/57)

FI008X (0/8)

FI019X (0/6)

FI003X (0/13)

FI009X (0/32)

FI015X (0/15)

FI00AX (0/10)

FI005X (0/33)

FI003A (0/14)

FI00CX (0/35)

FI011X (0/14)

FI020X (0/27)

FI012X (0/20)

FI021X (0/18)

FI00LX (0/13)

FI014X (0/15)

FI011A (0/16)

FI010X (0/14)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 24Minimum 2.5First quartile 5.8Median 8.8Third quartile 9.4Maximum 17.4

N hospitals 21Minimum 0First quartile 0Median 0Third quartile 0Maximum 6

110

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

France

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 - - 21 1 664 21 2 495 21 467 - - - -2003 - - 21 1 710 21 2 266 20 468 - - - -2004 - - 50 3 355 50 5 678 46 871 - - - -2005 195 632 50 3 484 50 6 056 47 1 023 49 838 48 9932006 97 371 50 3 824 50 6 718 50 1 152 50 963 47 1 0062007 168 663 57 4 265 57 8 093 56 1 545 56 1 187 56 1 3052008 127 557 56 4 380 56 7 993 54 1 555 54 1 138 54 1 2252009 225 826 54 4 727 54 8 451 54 1 969 52 1 378 32 1 221

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R - - - 5 4 4 7 6Penicillin RI - - - 36 32 34 30 27Macrolides RI - - - 41 36 37 31 27Staphylococcus aureusOxacillin/Meticillin R 33 29 29 27 27 26 24 23Escherichia coliAminopenicilins R 52 50 47 50 53 54 54 55Aminoglycosides R 4 5 4 5 6 6 7 8Fluoroquinolones R 8 9 8 11 14 15 16 19Third-gen. cephalosporins R <1 <1 <1 1 2 2 4 7Enterococcus faecalisAminopenicilins RI 5 3 1 <1 1 1 <1 1HL Gentamicin R 15 16 17 15 16 15 18 18Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 34 30 56 64 69 67 68 63HL Gentamicin R 10 23 21 24 30 30 30 38Vancomycin R 2 <1 5 3 3 1 <1 <1Klebsiella pneumoniaeAminoglycosides R - - - 5 7 11 17 20Fluoroquinolones R - - - 7 9 14 21 24Third-gen. cephalosporins R - - - 4 6 10 15 19Pseudomonas aeruginosaPiperacillin R - - - 15 11 11 14 21Ceftazidime R - - - 9 6 7 8 17Carbapenems R - - - 14 12 14 14 17Aminoglycosides R - - - 22 16 18 15 19Fluoroquinolones R - - - 27 23 24 22 25

111

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=1 383

S. aureusn=9 096

E. colin=15 838

E. faecalisn=2 431

E. faeciumn=944

K. pneumoniaen=2 516

P. aeruginosan=2 442

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 69 29 100 24 100 17 100 0 100 1 100 17 100 16CSF 31 26 - - - - - - - - - - - -GenderMale 55 26 61 23 47 20 64 0 60 1 58 20 60 16Female 44 31 38 24 51 15 35 0 38 0 40 14 39 15Unknown <1 20 2 22 2 17 2 0 2 0 2 5 1 26Age (years)0–4 25 35 4 12 2 4 3 0 3 0 2 14 2 55–19 11 16 3 9 1 8 1 0 1 0 1 18 2 1420–64 32 26 41 19 35 13 39 0 44 2 45 14 48 1965 and over 32 39 52 34 61 14 56 0 51 1 51 9 48 11Unknown <1 25 <1 40 <1 9 <1 0 <1 11 <1 56 <1 17Hospital departmentICU - - 17 28 9 15 24 0 24 2 15 24 29 23Internal med. 73 33 34 28 29 14 28 0 26 1 30 9 24 11Surgery - - 15 26 12 15 17 0 17 2 16 15 12 14Other - - 32 24 49 13 29 0 32 2 36 6 32 10Unknown 27 27 2 23 2 16 2 0 1 0 3 14 2 10

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

112

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100FR064 (6/7)FR198 (3/5)FR104 (3/5)

FR479 (16/31)FR403 (3/6)FR142 (3/6)FR028 (3/6)

FR214 (14/32)FR041 (3/7)

FR271 (6/14)FR493 (3/7)FR226 (3/7)FR244 (3/7)FR224 (3/7)

FR194 (4/10)FR035 (2/5)FR235 (2/5)

FR131 (4/10)FR230 (2/5)FR274 (2/5)

FR125 (4/10)FR130 (6/16)

FR116 (3/8)FR999 (4/11)

FR263 (14/39)FR467 (11/31)

FR277 (2/6)FR219 (2/6)FR020 (3/9)FR079 (2/6)FR260 (3/9)

FR246 (13/39)FR270 (2/6)

FR109 (13/40)FR269 (12/37)

FR514 (3/10)FR076 (6/20)

FR006 (10/34)FR071 (4/14)

FR094 (11/40)FR249 (3/11)

FR010 (11/43)FR008 (2/8)

FR499 (5/20)FR047 (2/8)

FR164 (6/25)FR213 (4/17)FR476 (4/18)

FR232 (2/9)FR186 (4/18)FR108 (4/19)

FR228 (1/5)FR470 (2/10)FR077 (2/10)

FR241 (1/5)FR492 (1/5)FR466 (1/5)FR032 (1/5)

FR036 (4/22)FR167 (3/17)FR279 (2/12)FR265 (2/12)

FR148 (1/6)FR505 (1/6)FR490 (1/6)

FR137 (4/26)FR100 (1/7)FR037 (1/7)FR088 (1/7)FR150 (1/7)FR251 (1/8)

FR250 (1/8)FR043 (1/9)

FR022 (1/10)FR473 (1/11)FR519 (0/6)FR120 (0/8)FR112 (0/5)FR162 (0/5)FR172 (0/6)FR025 (0/6)FR306 (0/6)FR009 (0/8)

Hosp

ital c

odes

0 25 50 75 100FR179A (38/80)FR208A (15/34)

FR260A (55/150)FR046A (16/45)FR098A (18/52)

FR479A (119/365)FR259A (48/152)

FR130A (120/387)FR067A (48/160)

FR120A (19/64)FR193A (13/45)

FR009A (32/114)FR064A (57/204)

FR015A (14/51)FR037A (10/37)FR055A (14/54)

FR194A (31/120)FR224A (26/101)FR052A (73/285)FR246A (39/154)

FR006A (125/510)FR214A (16/66)FR434A (22/91)

FR076A (73/306)FR250A (46/195)FR121A (47/203)

FR400A (9/39)FR276A (23/100)FR249A (42/183)FR109A (60/262)

FR008A (8/35)FR403A (13/57)

FR138A (75/329)FR237A (20/88)FR126A (20/88)FR213A (26/115)

FR094A (63/283)FR263A (134/603)

FR134A (23/107)FR135A (14/66)

FR238A (75/359)FR145A (10/50)

FR248A (46/237)FR072A (17/88)

FR362A (22/115)FR211A (8/43)

FR165A (32/174)FR105A (22/124)FR010A (54/320)FR226A (85/504)

FR040A (48/290)FR095A (6/37)

FR164A (40/251)FR401A (7/50)

FR084A (6/46)FR202A (3/25)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 83Minimum 0First quartile 16.7Median 25.6Third quartile 40Maximum 85.7

N hospitals 56Minimum 12First quartile 19.7Median 23Third quartile 27.2Maximum 47.5

France

113

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100FR179A (6/10)

FR046A (13/34)FR259A (74/248)

FR064A (103/405)FR015A (28/115)

FR138A (141/599)FR165A (77/330)

FR479A (127/548)FR055A (22/96)

FR006A (202/909)FR095A (11/50)

FR248A (71/323)FR105A (69/320)FR246A (67/314)

FR076A (113/546)FR237A (43/208)FR098A (36/177)FR052A (92/480)FR213A (56/293)FR362A (51/270)

FR109A (116/622)FR084A (15/81)

FR164A (63/358)FR094A (78/445)FR401A (20/118)FR037A (16/95)

FR126A (42/250)FR010A (80/488)FR263A (82/501)

FR040A (64/398)FR224A (34/214)FR214A (19/120)

FR009A (36/240)FR249A (46/317)FR403A (18/127)

FR193A (13/92)FR121A (41/305)FR120A (20/151)FR208A (10/76)

FR260A (36/275)FR434A (32/248)FR276A (28/220)FR134A (34/268)FR072A (18/147)FR202A (16/131)FR400A (15/127)FR211A (14/122)

FR130A (64/564)FR067A (36/321)FR238A (56/519)FR226A (73/695)FR250A (45/434)FR194A (19/196)FR135A (10/120)

FR008A (10/122)FR145A (4/56)

Hosp

ital c

odes

0 25 50 75 100FR138A (102/197)FR226A (96/225)

FR046A (5/16)FR095A (4/13)FR193A (5/19)

FR246A (12/46)FR213A (11/47)

FR179A (10/43)FR121A (13/59)FR403A (7/34)FR015A (3/16)

FR259A (12/67)FR064A (8/47)FR165A (13/79)FR055A (4/25)FR214A (4/25)FR120A (3/20)FR134A (4/27)

FR164A (1/7)FR084A (2/14)

FR479A (12/88)FR248A (11/84)

FR263A (22/178)FR009A (3/25)FR401A (5/42)FR224A (2/18)

FR037A (1/9)FR006A (17/154)

FR105A (8/73)FR238A (5/47)FR126A (3/31)

FR010A (4/49)FR076A (6/84)FR249A (2/28)FR434A (1/19)

FR094A (4/79)FR250A (2/50)FR052A (1/29)FR362A (1/31)

FR040A (1/46)FR202A (0/11)FR208A (0/8)FR211A (0/17)FR237A (0/13)FR135A (0/14)

FR276A (0/20)FR130A (0/43)FR072A (0/8)

FR109A (0/80)FR400A (0/11)

FR260A (0/29)FR145A (0/8)

FR008A (0/9)FR067A (0/30)FR194A (0/15)

FR098A (0/10)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 56Minimum 7.1First quartile 12.7Median 16.4Third quartile 21Maximum 60

N hospitals 56Minimum 0First quartile 0Median 11Third quartile 16.2Maximum 51.8

114

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Germany

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 17 248 18 1 067 16 1 068 14 290 . . . .2003 17 175 20 920 19 997 17 347 . . . .2004 16 145 22 1 107 22 1 217 22 606 . .2005 15 119 17 827 17 961 17 569 12 105 12 1172006 15 85 18 799 18 850 16 529 14 148 12 1622007 11 75 12 853 12 977 12 648 10 173 11 1972008 11 209 14 1 090 14 1 615 13 451 11 235 11 1672009 16 346 17 1 894 17 2 803 17 952 15 479 16 287

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 1 <1 <1 <1Penicillin RI 1 1 1 4 5 3 5 2Macrolides RI 14 11 13 17 12 8 10 8Staphylococcus aureusOxacillin/Meticillin R 18 18 20 21 20 16 19 18Escherichia coliAminopenicilins R 50 47 55 54 60 55 55 56Aminoglycosides R 5 5 4 6 10 6 7 8Fluoroquinolones R 15 14 24 23 29 30 23 23Third-gen. cephalosporins R <1 <1 2 2 4 8 5 8Enterococcus faecalisAminopenicilins RI 10 7 7 3 3 7 <1 3HL Gentamicin R 42 47 42 34 29 67 39 40Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 80 78 93 96 94 95 95 94HL Gentamicin R 68 47 61 52 38 73 35 45Vancomycin R 4 3 11 10 8 15 6 6Klebsiella pneumoniaeAminoglycosides R - - - 10 12 6 10 10Fluoroquinolones R - - - 6 12 9 15 15Third-gen. cephalosporins R - - - 7 14 6 11 13Pseudomonas aeruginosaPiperacillin R - - - 18 17 17 9 13Ceftazidime R - - - 11 12 17 8 11Carbapenems R - - - 25 17 22 11 11Aminoglycosides R - - - 12 18 9 10 7Fluoroquinolones R - - - 23 28 28 22 17

115

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=527

S. aureusn=2 974

E. colin=4 396

E. faecalisn=816

E. faeciumn=583

K. pneumoniaen=706

P. aeruginosan=450

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 93 3 100 19 100 24 100 0 100 6 100 13 99 10CSF 7 5 - - <1 0 - - - - <1 0 1 33GenderMale 36 3 43 19 30 28 49 1 48 6 43 13 46 10Female 29 5 24 18 37 21 21 0 28 5 28 9 24 13Unknown 35 3 33 20 32 22 31 0 24 8 28 15 30 10Age (years)0–4 11 6 2 5 2 3 3 0 3 2 3 9 3 105–19 3 4 2 9 1 22 1 0 1 24 1 25 2 1920–64 38 2 35 17 29 26 38 0 46 10 33 16 37 2265 and over 48 2 60 21 69 22 57 0 50 8 63 9 58 12Unknown <1 0 <1 7 <1 16 <1 0 <1 0 0 0 <1 100Hospital departmentICU 21 3 20 25 14 23 26 1 37 7 20 10 21 23Internal med. 46 2 42 17 49 20 35 0 24 9 38 8 31 11Surgery 2 0 12 21 8 26 12 0 13 5 12 7 12 13Other 27 3 22 17 25 29 25 0 25 15 28 18 33 18Unknown 4 0 4 21 4 18 3 0 1 4 2 8 2 9

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

116

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

DE0909 (2/13)

DE0111 (1/9)

DE1203 (1/11)

DE0102 (2/35)

DE0110 (7/162)

DE0911 (3/76)

DE0107 (1/29)

DE0301 (1/39)

DE0202 (0/5)

DE1303 (0/5)

DE0401 (0/18)

DE0908 (0/26)

DE0907 (0/82)

DE0402 (0/8)

DE1302 (0/6)

Hosp

ital c

odes

0 25 50 75 100DE011067 (3/5)

DE090902 (3/5)DE011037 (11/19)DE090814 (4/7)DE011068 (4/7)DE091119 (5/11)

DE030102 (5/11)DE011063 (4/9)

DE130307 (7/16)DE011015 (3/7)

DE091125 (7/17)DE091108 (2/5)

DE090806 (13/34)DE091127 (4/11)

DE090714 (5/15)DE011005 (3/9)

DE030108 (13/41)DE030109 (11/36)DE011020 (11/36)DE090713 (3/10)

DE090905 (13/44)DE090803 (4/14)DE011066 (4/14)DE091122 (7/25)DE011045 (5/18)DE011042 (3/11)DE0401B (3/11)

DE090808 (3/11)DE091134 (3/11)

DE091126 (7/26)DE090710 (4/15)DE011085 (4/15)

DE090903 (5/19)DE030110 (11/42)

DE090706 (10/39)DE090707 (8/32)

DE011058 (3/12)DE011016 (5/20)DE011031 (4/16)DE011014 (6/24)DE091132 (8/33)

DE090716 (17/72)DE030101 (8/34)DE011025 (6/26)DE091133 (5/22)DE011022 (4/18)DE011004 (4/18)DE011034 (4/18)DE090715 (4/19)

DE120301 (28/135)DE090709 (9/44)

DE130320 (1/5)DE070103 (3/15)DE091102 (3/15)DE091101 (4/20)

DE090801 (10/51)DE011024 (7/36)DE030103 (4/21)DE090901 (3/16)DE011021 (6/32)

DE090705 (17/91)DE011038 (7/39)DE011012 (3/17)DE090812 (1/6)

DE091129 (2/12)DE040202 (1/6)DE091107 (1/6)

DE090906 (2/12)DE090704 (5/30)DE090708 (6/36)DE090701 (10/61)

DE011003 (3/19)DE130201 (7/45)DE091143 (2/13)DE091135 (2/13)

DE070101 (17/113)DE011062 (2/14)DE011026 (2/15)DE090804 (1/8)DE011010 (3/26)DE011101 (9/79)DE011006 (1/9)DE011029 (1/9)DE011061 (1/9)

DE0102A (17/169)DE010701 (4/43)DE070102 (1/11)

DE040204 (1/11)DE011017 (2/22)DE011007 (2/23)

DE0401A (11/127)DE040201 (1/12)DE011018 (1/12)DE011028 (1/12)DE090718 (1/13)DE011001 (1/13)

DE011083 (3/40)DE091105 (1/14)DE091131 (1/14)DE0102B (1/15)

DE090802 (1/15)DE091120 (1/15)DE091117 (2/33)

DE2020 (3/52)DE011044 (0/12)DE011086 (0/12)DE011039 (0/14)

DE0401D (0/7)DE091106 (0/14)

DE40202 (0/5)DE090819 (0/12)

DE091116 (0/7)DE090807 (0/10)

DE091114 (0/5)DE011041 (0/6)DE091110 (0/5)

DE030107 (0/6)DE011087 (0/7)DE010702 (0/7)DE091112 (0/5)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 15Minimum 0First quartile 0Median 2.6Third quartile 5.7Maximum 15.4

N hospitals 120Minimum 0First quartile 8.7Median 18.7Third quartile 26.8Maximum 60

Germany

117

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100DE011006 (6/11)DE091119 (4/8)

DE030107 (8/17)DE011005 (6/13)DE030106 (3/7)DE011002 (3/7)DE011032 (3/7)

DE011101 (54/131)DE030108 (13/33)

DE070103 (7/18)DE011007 (12/32)DE090707 (6/16)

DE090713 (10/28)DE091135 (13/38)

DE090719 (3/9)DE090709 (28/86)

DE011066 (14/43)DE011016 (10/31)

DE120301 (49/152)DE011001 (8/26)DE091105 (8/26)DE011021 (17/56)DE091101 (10/33)DE011017 (9/30)

DE011045 (10/34)DE011020 (20/70)DE011083 (14/49)DE130320 (4/14)DE091106 (4/14)DE090710 (7/25)

DE070101 (42/151)DE011085 (5/18)DE091133 (6/22)

DE011014 (13/48)DE090704 (7/26)DE090714 (4/15)DE011004 (4/15)

DE030101 (19/72)DE011003 (6/23)DE090819 (6/23)DE011037 (8/31)

DE011026 (10/39)DE090701 (22/86)DE030109 (16/63)

DE011027 (2/8)DE011067 (2/8)

DE011019 (4/16)DE130307 (3/12)DE091120 (7/28)DE090718 (3/12)

DE0401B (3/12)DE130201 (13/53)DE091102 (7/29)

DE090903 (6/25)DE011034 (8/34)

DE090716 (34/146)DE011063 (3/13)DE091127 (3/13)

DE011022 (12/52)DE090906 (8/35)DE0102A (58/254)DE090705 (13/57)

DE030102 (5/22)DE011062 (7/31)

DE091132 (9/40)DE090902 (2/9)

DE011024 (13/60)DE090708 (11/51)DE011025 (10/47)

DE0401A (23/109)DE090801 (16/76)DE090806 (5/24)

DE2020 (8/39)DE090706 (9/44)DE091143 (4/20)DE091108 (3/15)DE091121 (2/10)DE011088 (1/5)

DE011010 (9/46)DE091126 (8/41)DE091125 (5/27)

DE011068 (4/22)DE091122 (9/51)DE011018 (4/23)DE011012 (7/41)DE090904 (1/6)DE011087 (1/6)

DE010703 (2/12)DE011031 (6/36)DE011039 (3/18)

DE030110 (13/78)DE040204 (3/19)

DE011015 (2/13)DE011042 (6/39)

DE090803 (3/20)DE090905 (12/80)

DE090901 (7/47)DE030103 (5/34)DE011086 (3/21)

DE040202 (3/22)DE091104 (2/15)DE011061 (4/31)DE091134 (1/8)

DE091107 (2/16)DE090715 (6/49)DE091117 (3/25)DE091131 (3/27)DE011044 (1/9)

DE091129 (2/18)DE040201 (3/27)DE010701 (9/83)DE011038 (4/39)DE010702 (2/22)DE011029 (2/23)

DE090802 (2/31)DE090807 (1/17)

DE011009 (0/5)DE011028 (0/14)DE090808 (0/7)

DE011041 (0/9)DE090804 (0/7)

Hosp

ital c

odes

0 25 50 75 100DE011079 (3/5)

DE090713 (3/5)

DE011034 (3/6)

DE011024 (3/7)

DE011038 (2/8)

DE090901 (2/9)

DE2020 (2/10)

DE090709 (3/16)

DE011015 (1/6)

DE030108 (1/6)

DE090803 (1/6)

DE090701 (2/12)

DE011012 (1/6)

DE091131 (1/6)

DE090806 (2/12)

DE090905 (3/20)

DE011025 (1/7)

DE090715 (1/7)

DE090906 (1/7)

DE0102A (5/36)

DE090707 (1/8)

DE120301 (5/41)

DE090801 (1/9)

DE090716 (2/19)

DE011083 (1/10)

DE011020 (1/10)

DE070101 (2/24)

DE011101 (3/40)

DE090705 (1/14)

DE030109 (0/8)

DE090710 (0/5)

DE091105 (0/6)

DE090708 (0/5)

DE090802 (0/7)

DE011001 (0/6)

DE0401A (0/20)

DE030103 (0/9)

DE040201 (0/6)

DE011031 (0/10)

DE011022 (0/7)

DE011007 (0/5)

DE130201 (0/10)

DE030110 (0/10)

DE011021 (0/11)

DE030101 (0/13)

DE0401D (0/7)

DE090706 (0/5)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 121Minimum 0First quartile 16.7Median 22.8Third quartile 27.8Maximum 54.5

N hospitals 47Minimum 0First quartile 0Median 10.5Third quartile 16.7Maximum 60

118

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Greece

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 - - 33 368 35 588 28 292 - - - -2003 - - 34 682 35 1 076 32 621 - - - -2004 - - 35 610 39 1 131 34 565 - - - -2005 - - 35 682 35 1 140 34 737 33 774 33 6992006 - - 42 828 41 1 253 39 949 38 841 38 8182007 - - 41 819 43 1 234 39 999 38 972 37 8022008 - - 46 907 44 1 462 42 992 41 1 093 42 9202009 - - 48 1 025 49 1 831 47 1 190 47 1 649 47 1 123

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R - - - - - - - -Penicillin RI - - - - - - - -Macrolides RI - - - - - - - -Staphylococcus aureusOxacillin/Meticillin R 44 45 44 42 43 48 41 40Escherichia coliAminopenicilins R 45 44 46 46 46 48 50 51Aminoglycosides R 7 6 6 7 7 9 15 14Fluoroquinolones R 13 12 12 12 14 19 22 23Third-gen. cephalosporins R 6 6 6 7 6 8 10 10Enterococcus faecalisAminopenicilins RI 4 4 4 3 5 4 3 4HL Gentamicin R 60 52 59 54 57 65 52 61Vancomycin R 13 7 4 4 5 7 7 6Enterococcus faeciumAminopenicilins RI 75 89 84 85 88 91 85 86HL Gentamicin R 52 40 52 34 35 44 52 63Vancomycin R 19 18 20 37 42 37 28 27Klebsiella pneumoniaeAminoglycosides R - - - 60 54 54 55 60Fluoroquinolones R - - - 54 50 55 64 66Third-gen. cephalosporins R - - - 61 58 62 66 69Pseudomonas aeruginosaPiperacillin R - - - 30 39 38 34 33Ceftazidime R - - - 27 34 40 37 34Carbapenems R - - - 39 48 47 49 44Aminoglycosides R - - - 40 47 49 48 41Fluoroquinolones R - - - 39 45 50 48 45

119

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=.

S. aureusn=1 855

E. colin=3 252

E. faecalisn=1 341

E. faeciumn=803

K. pneumoniaen=2 714

P. aeruginosan=2 011

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood - - 100 41 99 23 100 6 100 27 98 67 95 45CSF - - - - 1 0 - - - - 2 77 5 72GenderMale - - 8 38 6 23 6 4 9 28 6 59 6 38Female - - 4 36 8 19 4 2 7 25 4 63 3 48Unknown - - 88 41 86 23 90 7 84 28 90 68 91 47Age (years)0–4 - - 3 41 3 17 4 9 5 38 6 74 4 505–19 - - <1 0 <1 0 <1 0 - - <1 0 <1 020–64 - - 2 33 2 14 1 6 3 46 2 52 2 4065 and over - - 2 54 2 23 3 5 3 33 2 56 2 24Unknown - - 93 43 92 17 92 6 90 30 91 64 92 46Hospital departmentICU - - 14 65 4 24 35 10 32 34 46 87 44 58Internal med. - - 67 37 77 16 46 4 48 31 36 39 38 33Surgery - - 12 58 11 24 14 4 14 24 13 62 14 44Other - - 3 33 3 5 1 2 2 32 3 32 1 20Unknown - - 5 43 5 15 3 10 4 26 2 40 2 27

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

120

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Hosp

ital c

odes

0 25 50 75 100GR057X (7/7)

GR062X (7/10)

GR072X (8/12)

GR039X (37/58)

GR012X (15/25)

GR004X (9/15)

GR011X (7/12)

GR014X (26/45)

GR060X (4/7)

GR001X (28/50)

GR038X (7/13)

GR005X (11/21)

GR071X (3/6)

GR026X (7/14)

GR024X (18/37)

GR059X (27/57)

GR037X (35/75)

GR022X (7/15)

GR050X (13/28)

GR030X (43/93)

GR042X (17/37)

GR040X (90/202)

GR007X (26/59)

GR068X (18/41)

GR043X (29/67)

GR033X (19/45)

GR051X (8/19)

GR032X (7/17)

GR070X (13/32)

GR052X (2/5)

GR049X (8/21)

GR008X (8/21)

GR015X (17/46)

GR010X (15/42)

GR031X (25/72)

GR075X (25/73)

GR013X (18/57)

GR009X (2/7)

GR047X (32/118)

GR055X (3/12)

GR028X (14/58)

GR027X (11/49)

GR035X (16/75)

GR044X (2/10)

GR066X (7/35)

GR018X (3/19)

GR048X (0/13)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N hospitals 47Minimum 0First quartile 34.2Median 43.9Third quartile 52.4Maximum 100

Greece

No data reported

121

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100GR049X (14/27)

GR072X (5/12)

GR013X (21/56)

GR037X (22/63)

GR055X (24/70)

GR018X (14/41)

GR007X (16/48)

GR032X (9/27)

GR059X (24/78)

GR039X (15/51)

GR012X (11/39)

GR040X (76/271)

GR070X (12/43)

GR033X (19/72)

GR044X (12/46)

GR075X (31/120)

GR030X (37/147)

GR015X (27/108)

GR004X (5/20)

GR024X (20/82)

GR005X (14/58)

GR014X (22/93)

GR038X (13/55)

GR047X (64/276)

GR042X (15/65)

GR001X (25/119)

GR035X (28/138)

GR028X (49/254)

GR043X (14/74)

GR022X (3/16)

GR060X (2/12)

GR008X (6/36)

GR068X (7/43)

GR009X (2/13)

GR027X (18/117)

GR066X (6/42)

GR051X (3/22)

GR050X (10/76)

GR031X (14/112)

GR010X (5/44)

GR062X (2/18)

GR071X (2/22)

GR048X (2/22)

GR052X (4/46)

GR026X (2/25)

GR011X (1/26)

GR057X (0/5)

Hosp

ital c

odes

0 25 50 75 100

GR015X (101/117)

GR005X (51/61)

GR007X (52/63)

GR068X (84/104)

GR026X (12/15)

GR057X (4/5)

GR012X (52/66)

GR024X (44/56)

GR033X (47/60)

GR040X (253/324)

GR031X (104/135)

GR014X (62/81)

GR050X (35/48)

GR022X (8/11)

GR001X (74/102)

GR043X (65/90)

GR037X (83/117)

GR039X (139/197)

GR010X (41/59)

GR030X (112/164)

GR013X (11/17)

GR072X (10/16)

GR011X (10/16)

GR035X (78/127)

GR059X (36/59)

GR071X (3/5)

GR048X (10/17)

GR075X (45/78)

GR049X (8/14)

GR042X (8/14)

GR070X (23/45)

GR038X (4/8)

GR032X (4/8)

GR047X (66/141)

GR018X (5/12)

GR055X (11/29)

GR051X (4/11)

GR027X (33/91)

GR028X (28/81)

GR008X (2/8)

GR044X (2/8)

GR004X (2/10)

GR066X (2/10)

GR062X (1/6)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 47Minimum 0First quartile 14.3Median 23.2Third quartile 28Maximum 51.9

N hospitals 44Minimum 16.7First quartile 48.4Median 62.5Third quartile 76.8Maximum 86.3

122

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Hungary

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 17 61 24 416 24 354 23 169 - - - -2003 20 134 27 858 27 842 25 279 - - - -2004 26 143 30 1 020 28 967 26 366 - - - -2005 23 133 28 1 083 27 1 046 27 476 21 314 24 5072006 23 151 27 1 127 26 1 135 25 453 24 302 25 5462007 22 146 26 1 199 25 1 179 26 400 23 322 24 5182008 22 166 26 1 181 25 1 057 21 428 23 369 25 5132009 22 143 26 1 068 25 1 057 27 444 24 361 25 518

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 3 3 <1 4 1 5 8 3Penicillin RI 23 24 16 21 18 23 27 12Macrolides RI 21 25 25 32 19 36 32 19Staphylococcus aureusOxacillin/Meticillin R 9 15 17 20 25 23 23 29Escherichia coliAminopenicilins R 45 49 55 51 53 54 59 60Aminoglycosides R 6 8 10 9 12 11 13 16Fluoroquinolones R 10 15 19 22 27 26 26 30Third-gen. cephalosporins R 2 <1 3 4 5 5 9 13Enterococcus faecalisAminopenicilins RI 2 <1 2 1 3 2 3 2HL Gentamicin R 100 87 57 43 47 48 53 51Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 89 91 95 91 88 88 96 97HL Gentamicin R 100 96 80 64 67 53 62 70Vancomycin R <1 <1 <1 <1 <1 <1 3 1Klebsiella pneumoniaeAminoglycosides R - - - 26 20 29 36 40Fluoroquinolones R - - - 21 13 22 33 33Third-gen. cephalosporins R - - - 28 20 25 35 38Pseudomonas aeruginosaPiperacillin R - - - 10 9 11 13 19Ceftazidime R - - - 10 8 9 11 12Carbapenems R - - - 18 16 19 26 27Aminoglycosides R - - - 32 23 26 26 29Fluoroquinolones R - - - 28 21 24 26 27

123

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=309

S. aureusn=2 249

E. colin=2 091

E. faecalisn=716

E. faeciumn=147

K. pneumoniaen=728

P. aeruginosan=1 010

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 71 22 100 26 100 28 100 0 100 2 99 37 98 26CSF 29 14 - - - - - - - - 1 40 2 25GenderMale 82 21 89 26 84 30 93 0 93 1 91 38 90 26Female 18 16 11 23 16 22 7 0 7 10 9 26 10 31Unknown 1 0 1 16 1 13 1 0 1 0 1 17 1 7Age (years)0–4 12 36 2 8 2 7 4 0 5 0 9 35 4 135–19 5 22 2 8 1 23 2 0 1 0 2 32 2 2820–64 55 18 48 21 41 23 46 0 49 1 44 33 50 2465 and over 29 18 49 23 56 25 48 0 44 0 45 26 44 18Unknown - - <1 0 <1 0 - - - - - - - -Hospital departmentICU 26 20 18 30 12 23 31 0 36 0 27 38 39 24Internal med. 19 16 28 18 29 20 20 0 14 0 19 22 12 13Surgery 2 24 12 28 7 26 11 0 12 0 11 28 12 19Other 44 22 30 17 41 25 28 0 28 2 33 27 27 22Unknown 9 21 12 18 11 25 11 0 9 0 10 34 10 19

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

124

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

HU006 (3/6)

HU005 (2/5)

HU025 (7/18)

HU027 (4/11)

HU024 (2/6)

HU029 (9/30)

HU032 (5/19)

HU028 (2/8)

HU019 (5/23)

HU009 (5/31)

HU022 (10/70)

HU034 (1/10)

HU002 (1/11)

HU026 (1/13)

HU020 (1/16)

HU033 (0/8)

HU023 (0/7)

Hosp

ital c

odes

0 25 50 75 100

HU022S (21/34)

HU005A (37/66)

HU008F (4/8)

HU033A (55/128)

HU020A (18/42)

HU012G (11/27)

HU009A (59/152)

HU020C (3/8)

HU006A (11/30)

HU029V (65/206)

HU023I (18/59)

HU007B (10/33)

HU023D (26/86)

HU009B (14/52)

HU007C (4/15)

HU004G (5/19)

HU035A (12/46)

HU023A (7/29)

HU019G (14/63)

HU022I (26/129)

HU001Q (1/5)

HU031A (1/5)

HU034A (13/69)

HU028A (32/181)

HU022P (7/40)

HU025A (14/82)

HU002M (1/6)

HU016G (1/6)

HU019H (1/6)

HU026A (16/97)

HU027A (7/45)

HU006B (6/39)

HU019A (17/111)

HU032A (15/119)

HU002G (4/32)

HU020L (4/32)

HU024A (5/44)

HU005J (2/19)

HU006W (0/5)

HU034C (0/6)

HU022A (0/8)

HU001R (0/5)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 17Minimum 0First quartile 9.1Median 21.7Third quartile 33.3Maximum 50

N hospitals 42Minimum 0First quartile 15.4Median 20Third quartile 30.5Maximum 61.8

Hungary

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

HU009A (72/138)

HU022S (21/46)

HU005A (13/31)

HU028A (68/184)

HU020C (4/11)

HU002B (2/6)

HU032A (38/115)

HU019G (20/61)

HU025A (33/103)

HU029V (58/197)

HU034A (21/74)

HU009B (13/47)

HU020A (12/44)

HU033A (27/100)

HU022I (70/260)

HU023D (11/41)

HU006B (6/24)

HU031A (2/8)

HU034C (2/8)

HU027A (15/63)

HU026A (11/51)

HU023A (5/24)

HU024A (8/42)

HU019A (17/92)

HU002G (6/33)

HU023I (6/37)

HU006A (4/25)

HU007B (4/25)

HU020L (4/35)

HU012G (2/19)

HU022P (2/20)

HU016D (1/12)

HU035A (2/28)

HU004G (1/16)

HU005J (0/6)

HU001R (0/5)

Hosp

ital c

odes

0 25 50 75 100

HU031A (6/8)

HU009A (22/35)

HU007B (9/16)

HU012G (5/9)

HU020A (7/13)

HU022S (7/13)

HU032A (45/92)

HU002G (9/19)

HU029V (43/101)

HU023D (5/12)

HU033A (13/34)

HU034A (11/29)

HU028A (31/96)

HU005A (7/23)

HU027A (3/11)

HU023A (3/12)

HU025A (9/37)

HU019A (4/19)

HU004G (1/5)

HU026A (4/22)

HU023I (2/12)

HU022I (4/25)

HU019G (1/10)

HU009B (1/10)

HU005J (0/8)

HU035A (0/9)

HU024A (0/5)

HU020L (0/5)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 36Minimum 0First quartile 16Median 25Third quartile 30.7Maximum 52.2

N hospitals 28Minimum 0First quartile 16.3Median 28.9Third quartile 48.1Maximum 75

126

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Iceland

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 2 43 2 60 2 83 2 25 - - - -2003 2 35 2 64 2 100 2 22 - - - -2004 2 54 2 55 2 119 1 27 - - - -2005 2 37 2 78 2 130 2 31 2 22 1 132006 2 52 2 57 2 130 2 40 2 13 1 92007 2 42 2 65 2 105 1 29 2 27 1 112008 2 46 2 63 2 123 2 17 1 24 2 72009 2 35 2 59 2 111 2 51 2 27 2 16

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 2 <1 2 <1 <1 2 <1 <1Penicillin RI 5 9 17 8 6 7 9 <1Macrolides RI 5 20 8 17 10 17 22 3Staphylococcus aureusOxacillin/Meticillin R <1 <1 <1 <1 <1 <1 2 <1Escherichia coliAminopenicilins R 19 42 43 38 45 46 44 50Aminoglycosides R 1 2 <1 <1 7 6 7 7Fluoroquinolones R 3 6 2 3 12 17 6 7Third-gen. cephalosporins R <1 1 <1 <1 <1 2 <1 2Enterococcus faecalisAminopenicilins RI <1 <1 <1 <1 7 <1 <1 <1HL Gentamicin R 6 <1 5 <1 3 13 30 15Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 29 57 63 80 56 57 43 68HL Gentamicin R <1 <1 13 <1 14 14 43 36Vancomycin R <1 <1 <1 <1 <1 <1 <1 8Klebsiella pneumoniaeAminoglycosides R - - - <1 <1 <1 4 <1Fluoroquinolones R - - - <1 <1 <1 8 <1Third-gen. cephalosporins R - - - <1 <1 <1 4 <1Pseudomonas aeruginosaPiperacillin R - - - 8 <1 <1 <1 -Ceftazidime R - - - 8 <1 <1 <1 6Carbapenems R - - - 8 <1 <1 <1 <1Aminoglycosides R - - - <1 <1 <1 <1 <1Fluoroquinolones R - - - <1 <1 <1 <1 13

127

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=81

S. aureusn=122

E. colin=214

E. faecalisn=36

E. faeciumn=32

K. pneumoniaen=51

P. aeruginosan=23

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 96 5 100 1 100 7 100 0 100 6 100 2 100 0CSF 4 0 - - <1 0 - - - - - - - -GenderMale 51 2 61 1 44 9 78 0 50 13 53 0 74 0Female 49 8 39 0 56 4 22 0 50 0 47 4 26 0Unknown 1 0 1 16 1 13 1 0 1 0 1 17 1 7Age (years)0–4 22 9 5 0 4 3 4 0 1 0 - - 2 05–19 3 0 9 0 1 0 - - 1 0 - - - -20–64 38 9 40 1 31 9 29 0 26 5 37 2 27 065 and over 38 7 46 0 64 6 67 0 71 2 63 0 71 3Unknown - - <1 0 - - - - - - - - - -Hospital departmentICU 3 0 4 0 2 0 12 0 12 0 3 0 7 0Internal med. 8 4 16 0 9 6 16 0 10 0 16 0 16 0Surgery <1 0 6 0 4 12 8 0 10 0 8 0 2 0Other 64 9 49 0 61 8 41 0 48 5 71 1 71 3Unknown 25 7 25 0 25 3 23 0 21 0 3 0 4 0

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

128

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Labo

rato

ry c

odes

0 25 50 75 100

IS001 (4/71)

IS003 (0/10)

Hosp

ital c

odes

0 25 50 75 100

IS001A (1/100)

IS003A (0/16)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 2Minimum 0First quartile 0Median 2.8Third quartile 5.6Maximum 5.6

N hospitals 2Minimum 0First quartile 0Median 0.5Third quartile 1Maximum 1

Iceland

129

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Hosp

ital c

odes

0 25 50 75 100

IS001A (14/183)

IS001G (0/6)

IS001C (0/10)

IS001B (0/8)

Hosp

ital c

odes

0 25 50 75 100

IS001A (1/48)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 4Minimum 0First quartile 0Median 0Third quartile 3.8Maximum 7.7

N hospitals 1Minimum 2.1First quartile 2.1Median 2.1Third quartile 2.1Maximum 2.1

130

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Ireland

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 20 277 22 998 20 736 15 250 - - - -2003 24 363 26 1 108 26 978 21 348 - - - -2004 28 399 38 1 286 37 1 235 29 418 - - - -2005 31 397 38 1 360 39 1 424 33 502 15 42 11 292006 32 406 38 1 347 39 1 638 32 550 28 211 23 1282007 33 435 41 1 332 42 1 750 37 598 31 237 29 1722008 35 442 38 1 242 41 1 875 37 685 33 307 29 1912009 34 356 41 1 261 41 2 012 38 671 37 316 30 236

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 2 3 3 3 3 6 6 6Penicillin RI 12 12 10 11 16 17 23 20Macrolides RI 13 12 14 12 16 17 17 17Staphylococcus aureusOxacillin/Meticillin R 42 42 41 42 42 38 33 27Escherichia coliAminopenicilins R 62 61 65 67 69 65 67 66Aminoglycosides R 3 4 5 7 7 10 9 9Fluoroquinolones R 5 10 12 17 21 21 23 22Third-gen. cephalosporins R 2 2 2 4 4 5 6 6Enterococcus faecalisAminopenicilins RI 8 5 <1 4 5 2 <1 3HL Gentamicin R 39 32 42 42 43 38 31 34Vancomycin R 2 <1 1 3 3 3 3 <1Enterococcus faeciumAminopenicilins RI 89 91 96 93 94 93 95 93HL Gentamicin R 17 54 56 52 44 36 27 38Vancomycin R 11 19 22 31 36 33 35 38Klebsiella pneumoniaeAminoglycosides R - - - 5 9 10 9 11Fluoroquinolones R - - - 3 16 17 11 11Third-gen. cephalosporins R - - - 7 9 8 11 11Pseudomonas aeruginosaPiperacillin R - - - 7 7 6 5 4Ceftazidime R - - - 10 6 5 4 6Carbapenems R - - - 11 9 9 6 8Aminoglycosides R - - - 7 9 10 6 6Fluoroquinolones R - - - 14 17 18 16 9

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Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=797

S. aureusn=2 503

E. colin=3 861

E. faecalisn=578

E. faeciumn=776

K. pneumoniaen=619

P. aeruginosan=399

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 96 22 100 30 100 22 100 2 100 36 100 11 99 8CSF 4 19 - - <1 0 - - - - - - 1 0GenderMale 57 21 63 30 45 27 61 1 57 38 58 11 59 9Female 43 22 37 30 55 18 39 3 43 34 42 11 41 6Unknown <1 0 <1 50 <1 25 <1 0 - - - - - -Age (years)0–4 16 19 6 13 3 3 8 0 4 7 6 11 4 05–19 4 9 4 11 1 5 1 4 2 28 1 25 3 2820–64 37 12 40 31 32 17 37 3 43 38 41 11 37 1165 and over 42 18 50 49 62 20 53 2 51 28 52 8 56 6Unknown <1 14 <1 43 <1 16 <1 0 <1 33 <1 33 <1 0Hospital departmentICU 3 13 4 53 3 20 6 0 10 31 3 9 7 13Internal med. 17 16 15 43 15 17 14 1 7 30 9 6 11 12Surgery 2 22 7 49 7 19 7 3 6 18 8 2 6 10Other 28 15 17 28 22 12 15 1 9 22 19 6 17 9Unknown 50 15 57 38 54 21 58 3 67 34 61 12 60 7

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

132

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Labo

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odes

0 25 50 75 100

IE-64 (4/5)

IE-43 (5/8)

IE-76 (2/5)

IE-73 (3/8)

IE-31 (9/26)

IE-30 (5/15)

IE-58 (9/27)

IE-70 (5/15)

IE-61 (5/16)

IE-46 (9/29)

IE-44 (4/13)

IE-62 (4/13)

IE-6 (8/29)

IE-63 (2/8)

IE-48 (4/17)

IE-4 (11/49)

IE-18 (2/9)

IE-74 (1/5)

IE-47 (4/20)

IE-10 (16/84)

IE-34 (10/55)

IE-49 (3/18)

IE-72 (1/6)

IE-25 (7/42)

IE-32 (4/25)

IE-15 (8/50)

IE-20 (4/26)

IE-50 (9/60)

IE-1 (6/48)

IE-2 (4/32)

IE-60 (2/19)

Hosp

ital c

odes

0 25 50 75 100IE-30 (19/38)

IE-62 (10/21)

IE-70 (19/40)

IE-58 (26/56)

IE-29 (74/163)

IE-48 (30/72)

IE-52 (4/10)

IE-75 (2/5)

IE-53 (3/8)

IE-34 (42/113)

IE-51 (7/20)

IE-33 (9/26)

IE-20 (47/139)

IE-43 (5/15)

IE-10 (30/94)

IE-1 (58/185)

IE-15 (50/164)

IE-2 (61/204)

IE-72 (5/17)

IE-13 (9/31)

IE-4 (39/136)

IE-26 (4/14)

IE-32 (15/53)

IE-50 (50/181)

IE-35 (3/11)

IE-6 (13/48)

IE-11 (12/46)

IE-47 (15/58)

IE-31 (11/44)

IE-21 (5/20)

IE-38 (2/8)

IE-73 (4/17)

IE-44 (9/39)

IE-36 (2/9)

IE-64 (4/18)

IE-12 (8/37)

IE-61 (4/19)

IE-74 (5/26)

IE-60 (7/38)

IE-49 (3/17)

IE-18 (3/19)

IE-76 (1/7)

IE-46 (7/68)

IE-59 (2/23)

IE-63 (1/16)

IE-79 (0/7)

IE-77 (0/22)

IE-57 (0/28)

IE-71 (0/9)

IE-80 (0/5)

IE-65 (0/9)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 31Minimum 10.5First quartile 16.7Median 22.4Third quartile 33.3Maximum 80

N hospitals 51Minimum 0First quartile 18.4Median 27.1Third quartile 33.8Maximum 50

Ireland

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Hosp

ital c

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0 25 50 75 100IE-53 (3/5)

IE-35 (14/30)IE-32 (31/84)IE-30 (20/58)

IE-80 (3/9)IE-58 (34/108)

IE-71 (4/13)IE-29 (58/191)

IE-6 (30/101)IE-20 (61/212)IE-62 (13/47)IE-43 (8/29)

IE-44 (25/91)IE-26 (12/44)IE-51 (12/45)

IE-34 (44/169)IE-15 (52/212)IE-1 (65/279)

IE-10 (27/116)IE-73 (10/43)IE-21 (12/52)

IE-4 (36/159)IE-72 (8/36)

IE-47 (24/108)IE-74 (11/51)IE-75 (5/24)

IE-68 (1/5)IE-2 (59/299)IE-70 (11/56)IE-31 (19/98)IE-33 (7/38)IE-61 (9/50)IE-76 (3/17)

IE-36 (8/47)IE-52 (4/24)

IE-57 (1/6)IE-48 (22/138)

IE-38 (4/26)IE-12 (12/78)

IE-50 (28/183)IE-63 (3/23)IE-60 (9/71)IE-13 (9/80)IE-11 (7/79)

IE-46 (3/35)IE-18 (4/50)IE-65 (1/13)

IE-49 (0/16)IE-77 (0/22)IE-64 (0/8)

IE-59 (0/26)IE-37 (0/13)IE-67 (0/8)

Hosp

ital c

odes

0 25 50 75 100

IE-4 (16/44)

IE-32 (3/10)

IE-20 (8/37)

IE-2 (10/62)

IE-15 (7/56)

IE-31 (1/8)

IE-10 (3/24)

IE-30 (1/8)

IE-58 (1/8)

IE-34 (2/17)

IE-60 (1/10)

IE-11 (1/14)

IE-18 (1/14)

IE-50 (2/32)

IE-48 (1/16)

IE-1 (2/62)

IE-77 (0/5)

IE-46 (0/5)

IE-29 (0/28)

IE-72 (0/5)

IE-47 (0/13)

IE-73 (0/6)

IE-26 (0/5)

IE-12 (0/6)

IE-13 (0/10)

IE-44 (0/8)

IE-36 (0/5)

IE-6 (0/14)

IE-57 (0/5)

IE-49 (0/6)

IE-74 (0/5)

IE-21 (0/21)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 53Minimum 0First quartile 15.3Median 20Third quartile 27.3Maximum 60

N hospitals 32Minimum 0First quartile 0Median 1.6Third quartile 12.5Maximum 36.4

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Italy

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 51 300 53 1 343 17 618 49 602 - - - -2003 44 293 46 1 480 17 923 44 634 - - - -2004 37 271 42 1 225 14 645 40 576 - - - -2005 38 331 41 1 479 16 1 195 40 714 38 344 - -2006 34 269 38 1 164 13 910 35 650 32 321 12 1832007 34 298 38 1 167 14 1 052 36 656 37 391 10 1852008 27 194 30 939 14 957 31 580 27 331 11 1682009 21 216 23 987 9 863 22 509 22 313 10 195

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 2 5 5 5 <1 4 3 3Penicillin RI 11 13 14 9 7 15 10 6Macrolides RI 32 37 29 31 33 31 26 21Staphylococcus aureusOxacillin/Meticillin R 38 39 40 37 38 33 34 37Escherichia coliAminopenicilins R 48 52 53 55 56 58 62 63Aminoglycosides R 6 10 9 11 8 14 14 13Fluoroquinolones R 21 25 28 28 27 32 38 36Third-gen. cephalosporins R 3 6 5 8 7 11 16 17Enterococcus faecalisAminopenicilins RI 6 4 4 4 4 4 13 20HL Gentamicin R 38 39 36 38 38 39 47 49Vancomycin R <1 2 2 3 3 2 2 3Enterococcus faeciumAminopenicilins RI 79 80 78 77 86 73 64 60HL Gentamicin R 37 44 39 36 48 53 49 52Vancomycin R 19 24 21 19 18 11 6 4Klebsiella pneumoniaeAminoglycosides R - - - 8 26 25 28 19Fluoroquinolones R - - - 11 23 27 28 20Third-gen. cephalosporins R - - - 20 33 35 39 37Pseudomonas aeruginosaPiperacillin R - - - - 23 20 20 24Ceftazidime R - - - - 20 25 24 16Carbapenems R - - - - 21 27 33 31Aminoglycosides R - - - - 30 27 30 36Fluoroquinolones R - - - - 36 35 36 42

135

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=378

S. aureusn=1 908

E. colin=1 770

E. faecalisn=618

E. faeciumn=403

K. pneumoniaen=552

P. aeruginosan=349

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 90 7 100 36 100 37 100 2 100 5 100 38 99 32CSF 10 16 - - <1 0 - - - - <1 50 1 40GenderMale 39 11 43 37 31 43 47 3 37 7 41 47 33 34Female 23 8 28 40 34 32 29 1 35 5 25 36 26 31Unknown 38 5 30 30 35 37 24 2 28 3 34 28 42 30Age (years)0–4 11 12 2 16 2 8 3 0 2 3 5 65 1 305–19 3 10 1 22 <1 31 1 6 <1 0 1 50 1 1320–64 30 12 26 28 17 31 23 3 23 16 25 36 24 4165 and over 35 9 46 43 35 27 46 2 43 13 43 27 39 24Unknown 21 13 25 40 46 32 27 2 31 16 26 31 34 23Hospital departmentICU 6 9 11 56 4 28 18 3 13 18 12 52 15 39Internal med. 31 11 34 35 35 25 29 2 29 14 28 29 14 17Surgery 2 13 10 42 7 27 10 2 11 15 10 34 6 34Other 39 11 17 27 14 34 15 2 15 17 16 34 7 24Unknown 23 11 28 38 40 33 28 2 32 13 35 27 58 27

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

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odes

0 25 50 75 100

IT034 (8/24)

IT024 (3/14)

IT047 (1/5)

IT059 (4/22)

IT044 (2/11)

IT077 (1/6)

IT065 (1/7)

IT009 (1/9)

IT061 (3/65)

IT008 (1/23)

IT037 (2/55)

IT019 (1/31)

IT005 (0/9)

IT028 (0/5)

IT072 (0/13)

IT021 (0/7)

IT067 (0/13)

IT064 (0/9)

IT060 (0/17)

IT031 (0/6)

Hosp

ital c

odes

0 25 50 75 100

IT0035 (15/27)

IT0037 (96/175)

IT0074 (12/23)

IT0042 (19/37)

IT0034 (67/144)

IT0060 (19/42)

IT0005 (25/56)

IT0072 (24/54)

IT0064 (9/21)

IT0008 (18/44)

IT0067 (39/98)

IT0049 (15/39)

IT0075 (15/41)

IT0047 (34/93)

IT0052 (13/37)

IT0031 (40/115)

IT0061 (58/180)

IT0045 (13/41)

IT0001 (19/62)

IT0065 (10/33)

IT0050 (6/20)

IT0059 (35/118)

IT0009 (15/54)

IT0079 (6/22)

IT0070 (10/40)

IT0076 (3/14)

IT0019 (30/162)

IT0077 (5/29)

IT0028 (3/18)

IT0044 (3/19)

IT0069 (2/13)

IT0024 (1/36)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 20Minimum 0First quartile 0Median 4Third quartile 17.4Maximum 33.3

N hospitals 32Minimum 2.8First quartile 26.1Median 33.5Third quartile 43.7Maximum 55.6

Italy

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Hosp

ital c

odes

0 25 50 75 100

IT0049 (29/47)

IT0034 (142/303)

IT0075 (37/89)

IT0005 (36/91)

IT0067 (52/132)

IT0009 (37/102)

IT0059 (84/238)

IT0070 (21/60)

IT0019 (90/264)

IT0008 (36/109)

IT0037 (40/126)

IT0001 (18/62)

IT0035 (13/45)

IT0047 (15/72)

IT0045 (3/16)

IT0079 (0/14)

Hosp

ital c

odes

0 25 50 75 100

IT0072 (12/12)

IT0077 (9/9)

IT0074 (8/8)

IT0052 (8/8)

IT0060 (12/14)

IT0049 (17/22)

IT0047 (27/35)

IT0076 (7/10)

IT0075 (14/29)

IT0042 (8/17)

IT0064 (4/10)

IT0005 (8/21)

IT0019 (23/64)

IT0031 (18/52)

IT0050 (3/10)

IT0001 (7/24)

IT0045 (2/8)

IT0059 (6/26)

IT0067 (4/20)

IT0035 (1/5)

IT0009 (5/29)

IT0037 (4/31)

IT0024 (1/8)

IT0065 (1/17)

IT0061 (1/46)

IT0044 (0/8)

IT0070 (0/6)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 16Minimum 0First quartile 29Median 34.5Third quartile 39.5Maximum 61.7

N hospitals 27Minimum 0First quartile 17.2Median 34.6Third quartile 77.1Maximum 100

138

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Latvia

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 - - - - - - - - - - - -2003 - - - - - - - - - - - -2004 4 17 7 87 - - - - - - - -2005 5 36 7 127 - - - - - - - -2006 7 37 11 172 10 62 10 56 6 28 9 162007 6 31 12 169 9 76 8 57 7 27 6 162008 3 18 12 164 10 90 9 51 11 40 6 112009 7 30 12 188 9 86 8 48 10 44 7 18

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R - - <1 <1 <1 <1 6 <1Penicillin RI - - <1 <1 <1 <1 6 <1Macrolides RI - - 7 3 3 <1 <1 3Staphylococcus aureusOxacillin/Meticillin R - - 26 20 19 8 12 9Escherichia coliAminopenicilins R - - - - 44 43 48 43Aminoglycosides R - - - - 5 14 10 13Fluoroquinolones R - - - - 10 17 14 24Third-gen. cephalosporins R - - - - 6 14 11 12Enterococcus faecalisAminopenicilins RI - - - - 9 30 5 12HL Gentamicin R - - - - 50 - 27 38Vancomycin R - - - - <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI - - - - 94 77 90 82HL Gentamicin R - - - - 73 <1 78 79Vancomycin R - - - - <1 <1 7 18Klebsiella pneumoniaeAminoglycosides R - - - - 25 22 52 43Fluoroquinolones R - - - - 26 27 45 34Third-gen. cephalosporins R - - - - 36 44 58 55Pseudomonas aeruginosaPiperacillin R - - - - 17 31 30 17Ceftazidime R - - - - 29 13 36 17Carbapenems R - - - - 13 6 40 7Aminoglycosides R - - - - 47 31 44 22Fluoroquinolones R - - - - 33 13 45 12

139

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=48

S. aureusn=350

E. colin=175

E. faecalisn=46

E. faeciumn=52

K. pneumoniaen=84

P. aeruginosan=24

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 94 2 100 11 100 19 100 0 100 12 100 56 100 21CSF 6 0 - - - - - - - - - - - -GenderMale 56 4 48 12 35 16 61 0 46 8 61 55 79 26Female 44 0 51 9 65 20 39 0 54 14 39 58 21 0Unknown - - <1 0 - - - - - - - - - -Age (years)0–4 3 20 9 4 6 0 12 0 12 0 19 63 18 05–19 4 0 4 5 3 10 3 0 - - 1 0 5 3320–64 74 0 54 15 50 17 49 0 43 2 46 45 43 1765 and over 18 0 29 17 38 18 33 0 41 10 31 49 32 17Unknown 1 0 3 12 3 40 4 0 5 20 2 67 2 0Hospital departmentICU 62 0 23 19 23 31 33 0 54 11 35 59 45 12Internal med. 7 0 28 11 22 12 20 0 13 0 11 20 11 0Surgery 2 0 8 22 6 17 4 0 8 0 7 70 2 0Other 30 2 39 13 49 12 42 0 24 0 46 47 43 21Unknown - - 1 0 <1 0 2 0 1 0 1 0 - -

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

140

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Labo

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ry c

odes

0 25 50 75 100

LV003 (0/9)

LV004 (0/29)

Hosp

ital c

odes

0 25 50 75 100

LV013A (16/18)

LV007A (4/15)

LV006A (1/9)

LV002A (2/21)

LV001A (10/112)

LV003A (3/48)

LV004A (1/63)

LV009A (0/8)

LV005A (0/21)

LV012A (0/27)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 2Minimum 0First quartile 0Median 0Third quartile 0Maximum 0

N hospitals 10Minimum 0First quartile 0Median 7.6Third quartile 11.1Maximum 88.9

Latvia

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Hosp

ital c

odes

0 25 50 75 100

LV001A (14/32)

LV006A (1/5)

LV004A (8/43)

LV002A (2/12)

LV012A (3/21)

LV003A (5/47)

LV008A (0/5)

LV005A (0/5)

Hosp

ital c

odes

0 25 50 75 100

LV002A (11/16)

LV001A (16/24)

LV004A (7/13)

LV013A (2/5)

LV003A (2/6)

LV012A (0/5)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 8Minimum 0First quartile 5.3Median 15.5Third quartile 19.3Maximum 43.8

N hospitals 6Minimum 0First quartile 33.3Median 46.9Third quartile 66.7Maximum 68.8

142

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Lithuania

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 - - - - - - - - - - - -2003 - - - - - - - - - - - -2004 - - - - - - - - - - - -2005 - - - - - - - - - - - -2006 9 35 13 167 11 171 8 30 8 35 7 142007 10 67 12 240 13 235 10 56 10 41 7 212008 11 48 12 278 12 304 10 67 11 54 7 212009 10 46 13 258 13 297 11 57 12 68 8 21

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R - - - - <1 1 <1 7Penicillin RI - - - - 16 4 2 9Macrolides RI - - - - <1 9 6 7Staphylococcus aureusOxacillin/Meticillin R - - - - 13 9 11 11Escherichia coliAminopenicilins R - - - - 55 50 54 58Aminoglycosides R - - - - 15 12 12 15Fluoroquinolones R - - - - 12 9 14 15Third-gen. cephalosporins R - - - - 5 7 6 8Enterococcus faecalisAminopenicilins RI - - - - 5 3 5 3HL Gentamicin R - - - - 50 41 33 48Vancomycin R - - - - <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI - - - - 75 100 88 95HL Gentamicin R - - - - 75 81 78 64Vancomycin R - - - - <1 <1 <1 11Klebsiella pneumoniaeAminoglycosides R - - - - 26 37 41 56Fluoroquinolones R - - - - 3 8 23 37Third-gen. cephalosporins R - - - - 23 27 36 57Pseudomonas aeruginosaPiperacillin R - - - - 21 5 14 20Ceftazidime R - - - - 31 <1 10 14Carbapenems R - - - - 21 30 24 19Aminoglycosides R - - - - 29 33 38 19Fluoroquinolones R - - - - 46 38 35 33

143

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=48

S. aureusn=350

E. colin=175

E. faecalisn=46

E. faeciumn=52

K. pneumoniaen=84

P. aeruginosan=24

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 94 2 100 11 100 19 100 0 100 12 100 56 100 21CSF 6 0 - - - - - - - - - - - -GenderMale 56 4 48 12 35 16 61 0 46 8 61 55 79 26Female 44 0 51 9 65 20 39 0 54 14 39 58 21 0Unknown - - <1 0 - - - - - - - - - -Age (years)0–4 3 20 9 4 6 0 12 0 12 0 19 63 18 05–19 4 0 4 5 3 10 3 0 - - 1 0 5 3320–64 74 0 54 15 50 17 49 0 43 2 46 45 43 1765 and over 18 0 29 17 38 18 33 0 41 10 31 49 32 17Unknown 1 0 3 12 3 40 4 0 5 20 2 67 2 0Hospital departmentICU 62 0 23 19 23 31 33 0 54 11 35 59 45 12Internal med. 7 0 28 11 22 12 20 0 13 0 11 20 11 0Surgery 2 0 8 22 6 17 4 0 8 0 7 70 2 0Other 30 2 39 13 49 12 42 0 24 0 46 47 43 21Unknown - - 1 0 <1 0 2 0 1 0 1 0 - -

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

144

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Labo

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odes

0 25 50 75 100

LT013 (3/26)

LT007 (1/16)

LT001 (0/17)

LT004 (0/11)

LT011 (0/8)

Hosp

ital c

odes

0 25 50 75 100

LT005A (15/60)

LT004A (16/64)

LT010A (1/5)

LT002A (2/16)

LT012A (4/37)

LT003A (3/34)

LT013A (3/42)

LT007A (6/87)

LT001A (7/109)

LT013B (0/12)

LT008C (0/5)

LT011A (0/16)

LT013C (0/6)

LT008A (0/15)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 5Minimum 0First quartile 0Median 0Third quartile 6.3Maximum 11.5

N hospitals 14Minimum 0First quartile 0Median 7Third quartile 12.5Maximum 25

Lithuania

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Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

LT001A (34/118)

LT001B (3/12)

LT012A (3/14)

LT003A (6/36)

LT002A (3/20)

LT004A (10/75)

LT013A (10/80)

LT005A (6/63)

LT013D (1/11)

LT007A (6/90)

LT008A (1/16)

LT011A (1/17)

LT010A (1/19)

LT013C (0/5)

LT013B (0/10)

Hosp

ital c

odes

0 25 50 75 100

LT011A (7/10)

LT007A (7/11)

LT012A (6/10)

LT004A (10/18)

LT013A (3/6)

LT003A (3/6)

LT001A (14/31)

LT005A (4/10)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 15Minimum 0First quartile 5.9Median 9.5Third quartile 16.7Maximum 28.8

N hospitals 8Minimum 40First quartile 47.6Median 52.8Third quartile 61.8Maximum 70

146

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Luxembourg

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 9 33 9 97 9 193 8 30 - - - -2003 7 54 8 95 8 227 7 41 - - - -2004 6 36 7 96 7 216 5 28 - - - -2005 5 47 5 83 5 188 5 31 - - 1 12006 5 31 5 77 5 167 4 42 4 21 4 232007 6 48 6 117 6 275 5 37 6 52 5 362008 6 59 5 117 6 303 5 61 6 52 4 332009 6 67 6 113 6 301 5 54 3 28 6 35

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 7 <1 6 7 5 3 5 11Penicillin RI 22 15 11 12 5 6 11 19Macrolides RI 25 28 33 24 26 24 14 16Staphylococcus aureusOxacillin/Meticillin R 15 21 16 13 19 20 9 13Escherichia coliAminopenicilins R 43 49 49 49 46 49 56 57Aminoglycosides R 4 4 4 7 6 5 8 9Fluoroquinolones R 9 12 18 19 20 21 22 26Third-gen. cephalosporins R <1 <1 <1 3 2 4 6 8Enterococcus faecalisAminopenicilins RI <1 5 <1 <1 <1 <1 3 10HL Gentamicin R 17 32 18 24 32 44 17 28Vancomycin R <1 <1 <1 <1 <1 <1 3 10Enterococcus faeciumAminopenicilins RI 60 100 50 36 75 67 76 93HL Gentamicin R 14 <1 <1 23 30 10 21 29Vancomycin R <1 <1 <1 <1 <1 <1 5 36Klebsiella pneumoniaeAminoglycosides R - - - - <1 4 13 18Fluoroquinolones R - - - - 6 12 12 21Third-gen. cephalosporins R - - - - 10 2 19 25Pseudomonas aeruginosaPiperacillin R - - - <1 9 15 3 14Ceftazidime R - - - <1 10 11 3 14Carbapenems R - - - <1 7 20 25 15Aminoglycosides R - - - <1 4 22 6 9Fluoroquinolones R - - - <1 10 36 15 11

147

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=120

S. aureusn=230

E. colin=603

E. faecalisn=78

E. faeciumn=36

K. pneumoniaen=80

P. aeruginosan=41

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 98 15 100 11 100 24 100 6 100 17 98 22 100 17CSF 3 33 - - <1 50 - - - - 3 0 - -GenderMale 51 11 49 8 35 25 53 10 36 23 39 19 61 16Female 38 20 30 16 47 23 32 4 33 25 41 27 34 21Unknown 11 15 22 12 19 25 15 0 31 0 20 13 5 0Age (years)0–4 12 10 3 11 2 5 3 0 2 0 1 0 2 05–19 5 11 4 29 <1 20 - - - - - - - -20–64 40 8 40 10 28 16 35 1 31 7 39 19 35 2265 and over 40 20 47 19 64 21 59 3 64 7 51 12 62 12Unknown 2 13 6 24 6 24 3 0 2 0 9 0 2 0Hospital departmentICU 12 8 11 14 7 14 27 0 22 5 13 15 9 33Internal med. 15 20 13 22 20 16 14 0 7 0 5 13 9 17Surgery 3 0 6 17 4 16 4 0 2 0 3 0 - -Other 26 9 22 15 20 22 18 0 29 0 19 24 18 8Unknown 43 15 48 15 48 20 37 6 39 14 59 10 64 14

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

148

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

LU003 (9/28)

LU001 (6/51)

LU004 (1/9)

LU007 (1/11)

LU006 (1/14)

LU002 (0/7)

Hosp

ital c

odes

0 25 50 75 100

LU002A (2/7)

LU003A (4/24)

LU003S (5/32)

LU004A (1/9)

LU004T (1/10)

LU001A (3/32)

LU007Z (2/22)

LU001E (3/36)

LU006A (3/39)

LU007A (1/15)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 6Minimum 0First quartile 7.1Median 10.1Third quartile 11.8Maximum 32.1

N hospitals 10Minimum 6.7First quartile 8.3Median 9.7Third quartile 15.6Maximum 28.6

Luxembourg

149

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

LU002W (5/14)

LU003S (23/71)

LU002A (4/13)

LU004A (6/21)

LU001A (28/104)

LU003A (18/68)

LU004T (5/22)

LU007A (7/31)

LU001E (18/89)

LU006A (21/111)

LU007Z (8/53)

Hosp

ital c

odes

0 25 50 75 100

LU001E (8/19)

LU001A (4/16)

LU003S (2/11)

LU006A (3/19)

LU007Z (0/6)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 11Minimum 15.1First quartile 20.2Median 26.5Third quartile 30.8Maximum 35.7

N hospitals 5Minimum 0First quartile 15.8Median 18.2Third quartile 25Maximum 42.1

150

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Malta

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 1 12 1 87 1 74 1 33 - - - -2003 1 9 1 121 1 91 1 26 - - - -2004 1 18 1 94 1 91 1 41 - - - -2005 1 13 1 77 1 85 1 38 1 18 1 452006 1 31 1 90 1 94 1 53 1 32 1 512007 1 13 1 105 1 117 1 37 1 28 1 362008 1 17 1 108 1 128 1 32 1 36 1 312009 1 8 1 86 1 159 1 36 1 38 1 58

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 8 3 <1 24 <1Penicillin RI <1 <1 <1 15 7 <1 47 14Macrolides RI 25 38 25 46 45 8 35 13Staphylococcus aureusOxacillin/Meticillin R 43 43 56 56 67 52 56 58Escherichia coliAminopenicilins R 43 39 48 51 56 54 52 55Aminoglycosides R 8 18 20 7 15 20 22 21Fluoroquinolones R 12 24 36 31 32 35 34 31Third-gen. cephalosporins R 3 2 4 1 4 13 21 15Enterococcus faecalisAminopenicilins RI <1 5 <1 3 2 3 <1 5HL Gentamicin R 17 29 44 32 - - - -Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 33 33 43 25 14 40 60 75HL Gentamicin R <1 50 <1 <1 - - - -Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Klebsiella pneumoniaeAminoglycosides R - - - 17 6 <1 <1 <1Fluoroquinolones R - - - 11 6 11 8 3Third-gen. cephalosporins R - - - 6 6 7 <1 <1Pseudomonas aeruginosaPiperacillin R - - - 22 47 11 45 36Ceftazidime R - - - 11 30 3 33 29Carbapenems R - - - 18 20 11 30 21Aminoglycosides R - - - 16 8 8 23 21Fluoroquinolones R - - - 44 24 11 19 22

151

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=24

S. aureusn=194

E. colin=287

E. faecalisn=57

E. faeciumn=11

K. pneumoniaen=74

P. aeruginosan=88

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 92 41 100 57 100 32 100 0 100 0 100 0 97 25CSF 8 0 - - - - - - - - - - 3 0GenderMale 42 30 70 60 47 36 67 0 64 0 62 0 65 26Female 58 43 30 50 53 28 33 0 36 0 36 0 35 19Unknown - - - - - - - - - - 1 0 - -Age (years)0–4 18 9 9 39 3 0 11 0 4 0 9 15 3 05–19 4 20 5 38 2 14 3 0 4 0 2 0 5 1720–64 33 8 40 49 27 28 39 0 43 0 43 5 41 2565 and over 42 14 46 62 68 33 46 0 48 0 46 0 51 17Unknown 3 0 1 25 <1 0 0 0 - - 1 0 - -Hospital departmentICU 23 7 17 60 8 25 60 0 52 0 20 10 52 26Internal med. 39 6 44 49 42 31 17 0 28 0 43 2 23 14Surgery 3 50 19 60 22 34 13 0 11 0 18 0 11 20Other 23 15 11 49 14 21 5 0 4 0 14 0 9 5Unknown 12 14 9 56 14 32 6 0 4 0 5 13 5 9

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

152

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

MT001 (9/24)

Hosp

ital c

odes

0 25 50 75 100

MT001A (102/179)

MT001E (5/10)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 1Minimum 37.5First quartile 37.5Median 37.5Third quartile 37.5Maximum 37.5

N hospitals 2Minimum 50First quartile 50Median 53.5Third quartile 57Maximum 57

Malta

153

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

MT001F (4/9)

MT001E (14/32)

MT001A (73/245)

Hosp

ital c

odes

0 25 50 75 100

MT001A (0/74)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 3Minimum 29.8First quartile 29.8Median 43.8Third quartile 44.4Maximum 44.4

N hospitals 1Minimum 0First quartile 0Median 0Third quartile 0Maximum 0

154

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Netherlands

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 23 892 23 1 550 22 2 427 22 530 - - - -2003 24 891 23 1 422 23 2 133 23 480 - - - -2004 22 758 22 1 339 21 2 111 22 444 - - - -2005 23 815 23 1 407 23 2 201 23 563 16 301 16 2102006 22 1 006 23 1 636 22 2 905 23 776 18 458 19 3302007 21 940 21 1 471 21 2 801 21 827 19 497 19 3382008 17 723 16 1 191 16 2 283 17 632 15 463 15 3452009 17 746 16 1 035 16 2 398 16 522 15 408 15 235

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 <1 <1 <1 <1Penicillin RI 1 1 2 1 1 2 2 1Macrolides RI 7 5 8 11 8 7 7 5Staphylococcus aureusOxacillin/Meticillin R <1 1 1 <1 <1 2 <1 <1Escherichia coliAminopenicilins R 40 45 43 48 47 49 48 45Aminoglycosides R 2 3 3 4 3 5 6 4Fluoroquinolones R 5 7 7 10 11 13 14 11Third-gen. cephalosporins R 1 1 1 2 3 4 5 4Enterococcus faecalisAminopenicilins RI 3 4 3 3 5 5 <1 2HL Gentamicin R 39 29 37 38 28 38 34 31Vancomycin R <1 1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 21 30 42 61 73 83 86 89HL Gentamicin R 4 20 20 40 50 62 53 76Vancomycin R 2 <1 <1 <1 <1 <1 <1 <1Klebsiella pneumoniaeAminoglycosides R - - - 5 4 5 7 3Fluoroquinolones R - - - 6 4 4 7 4Third-gen. cephalosporins R - - - 4 4 7 8 6Pseudomonas aeruginosaPiperacillin R - - - 4 2 2 6 3Ceftazidime R - - - 5 5 4 6 4Carbapenems R - - - 5 2 2 6 3Aminoglycosides R - - - 7 4 3 4 1Fluoroquinolones R - - - 9 9 5 8 7

155

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=1 282

S. aureusn=2 111

E. colin=4 614

E. faecalisn=530

E. faeciumn=372

K. pneumoniaen=862

P. aeruginosan=579

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 94 2 100 1 100 13 100 0 100 1 99 7 98 5CSF 6 0 - - <1 15 - - - - 1 13 2 11GenderMale 50 2 57 1 47 16 63 0 62 1 57 7 69 5Female 47 1 39 1 49 9 32 1 38 0 43 6 31 5Unknown 3 0 3 0 4 15 5 0 - - - - - -Age (years)0–4 7 2 9 1 4 3 9 0 7 0 4 7 3 35–19 3 1 3 1 1 18 1 0 3 0 1 21 2 1020–64 38 1 35 1 30 11 37 0 42 1 37 6 36 465 and over 49 1 50 1 61 10 49 0 46 1 58 5 60 3Unknown 3 2 3 0 4 11 4 0 2 0 <1 0 <1 100Hospital departmentICU 6 1 8 2 6 11 21 0 26 0 10 9 16 8Internal med. 18 2 17 1 20 11 13 1 9 0 18 3 17 4Surgery 3 1 9 2 7 9 9 0 5 2 9 8 10 4Other 22 2 22 1 20 13 22 0 21 1 21 7 18 3Unknown 51 1 44 1 47 8 35 1 40 1 42 4 39 2

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

156

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

NL005 (3/35)

NL022 (3/42)

NL014 (4/68)

NL119 (2/43)

NL113 (3/83)

NL027 (1/28)

NL026 (1/36)

NL031 (1/126)

NL002 (1/159)

NL003 (0/27)

NL112 (0/27)

NL033 (0/52)

NL029 (0/36)

NL007 (0/56)

NL021 (0/37)

NL034 (0/5)

NL131 (0/49)

NL030 (0/157)

NL036 (0/31)

NL023 (0/69)

NL132 (0/40)

NL101 (0/40)

NL025 (0/31)

Hosp

ital c

odes

0 25 50 75 100NL101C (1/5)

NL014A (1/8)NL002A (1/13)NL101A (1/19)

NL033A (1/28)NL132A (2/57)NL030A (1/31)NL119A (2/86)NL131A (1/49)NL104B (1/55)NL023B (1/64)NL025A (1/68)NL026A (1/78)NL002B (1/87)NL007A (1/97)NL021A (0/19)NL113B (0/14)

NL003A (0/81)NL033B (0/15)NL005A (0/21)NL101B (0/13)NL112A (0/8)

NL002C (0/63)NL113C (0/23)

NL026B (0/79)NL0033 (0/13)NL031C (0/52)

NL101D (0/9)NL030F (0/40)NL014C (0/43)NL031B (0/60)NL030D (0/21)NL026C (0/15)NL023A (0/10)NL014B (0/40)NL030I (0/40)NL113D (0/18)

NL007C (0/92)NL030B (0/21)NL021B (0/24)NL021C (0/13)NL031A (0/13)

NL023D (0/27)NL036B (0/35)NL030C (0/21)NL113A (0/53)

NL030G (0/32)NL131B (0/9)

NL131C (0/10)NL112B (0/30)NL030J (0/10)

NL029A (0/72)NL030E (0/52)NL030H (0/51)NL005B (0/15)NL027A (0/80)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 23Minimum 0First quartile 0Median 0Third quartile 3.6Maximum 8.6

N hospitals 56Minimum 0First quartile 0Median 0Third quartile 1.1Maximum 20

Netherlands

157

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100NL027A (4/11)NL101D (7/23)

NL101C (2/7)NL026B (20/78)

NL002A (9/41)NL033B (12/56)

NL007A (31/154)NL003A (28/140)

NL030C (12/60)NL033A (12/61)

NL113B (7/39)NL113E (3/17)

NL014C (15/86)NL132A (27/155)NL036B (12/69)

NL007C (18/109)NL022X (32/197)NL029A (26/167)

NL021C (5/33)NL112B (9/60)

NL005B (7/49)NL030J (5/35)

NL030F (22/154)NL030I (16/116)NL023D (8/62)

NL119A (19/149)NL112A (4/32)NL021A (3/24)NL131B (2/16)

NL023A (4/34)NL113D (6/51)

NL031C (17/147)NL036A (1/9)

NL030D (10/90)NL031B (20/189)

NL025A (9/87)NL021B (3/30)NL131C (3/30)

NL014B (8/80)NL030A (8/82)

NL002C (17/180)NL030E (15/159)

NL005A (5/53)NL113A (11/124)

NL002B (17/199)NL101A (5/60)NL031A (3/37)NL104B (7/87)NL113C (3/41)

NL026C (1/14)NL023B (8/114)NL030B (4/61)

NL030G (6/94)NL030H (7/123)

NL0033 (1/18)NL026A (4/89)

NL131A (4/91)NL101B (0/26)NL014A (0/8)

Hosp

ital c

odes

0 25 50 75 100

NL026C (2/7)

NL023B (4/20)

NL007A (6/34)

NL026A (3/17)

NL132A (3/20)

NL023D (1/8)

NL003A (4/33)

NL027A (4/35)

NL112B (1/9)

NL007C (4/37)

NL014B (2/21)

NL002B (5/53)

NL026B (2/22)

NL002C (3/36)

NL022X (6/75)

NL101B (1/14)

NL030I (1/16)

NL119A (2/32)

NL025A (1/22)

NL014C (1/23)

NL031B (1/37)

NL031C (0/25)

NL030G (0/9)

NL030B (0/8)

NL113D (0/9)

NL030F (0/14)

NL030E (0/25)

NL101A (0/9)

NL005B (0/11)

NL104B (0/16)

NL002A (0/9)

NL030A (0/10)

NL023A (0/5)

NL0033 (0/5)

NL033A (0/9)

NL113A (0/15)

NL033B (0/5)

NL131C (0/8)

NL031A (0/5)

NL113B (0/11)

NL036B (0/14)

NL030H (0/14)

NL131A (0/10)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 59Minimum 0First quartile 8.5Median 11.8Third quartile 17.4Maximum 36.4

N hospitals 43Minimum 0First quartile 0Median 0Third quartile 9.5Maximum 28.6

158

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Norway

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 11 453 11 502 11 1 119 11 177 4 29 4 272003 11 512 11 506 11 1 179 11 192 4 46 4 252004 11 600 11 516 11 1 212 11 235 4 51 4 272005 11 606 11 553 11 1 331 11 304 11 193 11 972006 12 601 12 734 12 1 574 12 349 12 263 12 962007 13 616 13 794 13 1 713 13 416 13 320 13 1052008 13 576 13 837 13 1 799 13 403 13 349 13 1482009 12 554 12 909 12 1 846 12 478 12 396 12 166

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 <1 <1 <1 <1Penicillin RI <1 <1 2 2 2 2 2 2Macrolides RI 6 8 8 14 12 10 7 6Staphylococcus aureusOxacillin/Meticillin R <1 <1 <1 <1 <1 <1 <1 <1Escherichia coliAminopenicilins R 29 34 32 34 35 38 38 37Aminoglycosides R <1 <1 <1 2 2 3 3 3Fluoroquinolones R 2 2 4 5 5 7 7 9Third-gen. cephalosporins R <1 <1 <1 <1 1 2 3 2Enterococcus faecalisAminopenicilins RI 4 4 <1 3 3 2 2 <1HL Gentamicin R 30 38 27 32 33 34 29 36Vancomycin R 3 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 49 43 80 72 75 81 78 76HL Gentamicin R 14 14 25 44 45 52 54 38Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Klebsiella pneumoniaeAminoglycosides R <1 <1 2 3 <1 <1 1 3Fluoroquinolones R <1 <1 <1 1 7 5 4 6Third-gen. cephalosporins R <1 <1 <1 2 2 2 2 3Pseudomonas aeruginosaPiperacillin R <1 <1 13 3 3 2 6 4Ceftazidime R <1 <1 <1 3 5 3 4 5Carbapenems R <1 <1 4 3 9 9 7 5Aminoglycosides R <1 <1 4 <1 1 2 <1 <1Fluoroquinolones R <1 4 5 4 9 7 3 2

159

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=1 128

S. aureusn=1 743

E. colin=3 616

E. faecalisn=616

E. faeciumn=211

K. pneumoniaen=745

P. aeruginosan=312

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 97 2 100 0 100 8 100 0 100 0 100 2 100 6CSF 3 9 - - - - - - - - - - <1 0GenderMale 48 2 63 0 45 10 74 0 59 0 60 3 69 6Female 52 2 37 0 55 6 26 0 41 0 40 1 30 6Unknown <1 0 <1 0 <1 9 <1 0 - - 0 0 1 0Age (years)0–4 7 2 4 1 2 4 2 3 1 0 1 7 2 275–19 3 0 3 0 1 4 1 0 <1 0 1 6 2 820–64 41 1 35 0 26 7 23 0 31 0 27 3 27 865 and over 49 2 57 0 71 5 74 0 68 0 71 1 69 5Unknown <1 0 <1 0 <1 33 <1 0 - - - - - -Hospital departmentICU 10 2 7 0 5 7 9 0 15 0 7 4 10 15Internal med. 53 1 42 0 46 5 40 0 34 0 41 1 41 5Surgery 4 3 17 0 17 7 21 0 22 0 20 2 12 6Other 30 2 31 0 30 6 28 0 28 0 30 2 34 4Unknown 3 1 3 1 2 4 2 0 2 0 2 3 2 15

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

160

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

NO101 (13/159)

NO502 (1/32)

NO103 (3/108)

NO402 (1/36)

NO204 (2/108)

NO104 (2/109)

NO102 (1/64)

NO106 (2/151)

NO206 (1/108)

NO205 (0/26)

NO403 (0/87)

NO304 (0/34)

NO203 (0/90)

NO105 (0/16)

Hosp

ital c

odes

0 25 50 75 100

NO101A (4/176)

NO402B (1/49)

NO101C (1/50)

NO206P (1/54)

NO403D (1/147)

NO106S (0/46)

NO304J (0/38)

NO403E (0/22)

NO106U (0/10)

NO203X (0/34)

NO204I (0/36)

NO105K (0/26)

NO104J (0/144)

NO204H (0/7)

NO106T (0/21)

NO106Q (0/29)

NO106P (0/94)

NO101D (0/32)

NO206O (0/69)

NO203C (0/84)

NO502I (0/15)

NO106V (0/11)

NO203D (0/36)

NO103E (0/163)

NO206Q (0/7)

NO304K (0/6)

NO502L (0/5)

NO502D (0/6)

NO402H (0/17)

NO502H (0/32)

NO205I (0/34)

NO102B (0/123)

NO204E (0/97)

NO502K (0/8)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 14Minimum 0First quartile 0Median 1.4Third quartile 2.8Maximum 8.2

N hospitals 34Minimum 0First quartile 0Median 0Third quartile 0Maximum 2.3

Norway

161

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Hosp

ital c

odes

0 25 50 75 100

NO106V (7/29)

NO402H (8/51)

NO106U (1/8)

NO105K (9/77)

NO101D (9/78)

NO106S (8/73)

NO106P (19/179)

NO102B (24/232)

NO403D (29/296)

NO206O (15/161)

NO103E (35/378)

NO502I (2/22)

NO101A (22/255)

NO206P (8/102)

NO104J (20/255)

NO106T (4/52)

NO204E (18/243)

NO402B (8/108)

NO502H (4/56)

NO203C (12/170)

NO204I (5/75)

NO203X (3/45)

NO403E (4/71)

NO304M (1/22)

NO203D (4/91)

NO206Q (2/46)

NO101C (5/122)

NO106Q (2/59)

NO304J (1/71)

NO205I (1/88)

NO502K (0/19)

NO502L (0/15)

NO502D (0/11)

NO304K (0/21)

NO205N (0/7)

NO204H (0/6)

NO104N (0/6)

Hosp

ital c

odes

0 25 50 75 100

NO106T (2/7)

NO102B (3/40)

NO105K (1/15)

NO101C (1/18)

NO206P (1/19)

NO104J (4/81)

NO203D (1/22)

NO206O (1/28)

NO203C (1/42)

NO403D (1/49)

NO103E (1/64)

NO106U (0/5)

NO402B (0/20)

NO403E (0/11)

NO204E (0/57)

NO106Q (0/12)

NO101D (0/18)

NO304J (0/18)

NO203X (0/8)

NO206Q (0/8)

NO502H (0/15)

NO106P (0/31)

NO106S (0/18)

NO101A (0/64)

NO204I (0/20)

NO106V (0/8)

NO205I (0/10)

NO502I (0/8)

NO502L (0/5)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 37Minimum 0First quartile 3.4Median 7.1Third quartile 9.3Maximum 24.1

N hospitals 29Minimum 0First quartile 0Median 0Third quartile 3.6Maximum 28.6

162

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Poland

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 7 10 21 186 22 135 19 56 - - - -2003 11 16 24 166 25 124 16 64 - - - -2004 11 16 30 262 29 192 23 52 - - - -2005 6 6 30 198 30 176 21 54 17 53 14 262006 4 9 24 174 26 206 21 68 15 42 16 372007 10 22 24 185 27 256 20 71 18 32 23 672008 34 84 15 99 14 84 11 26 11 19 8 222009 20 68 30 551 29 625 28 267 25 151 27 153

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 30 19 <1 17 <1 10 12 30Penicillin RI 30 19 <1 33 <1 29 13 30Macrolides RI 67 14 19 33 11 - 50 16Staphylococcus aureusOxacillin/Meticillin R 23 19 19 24 20 15 12 20Escherichia coliAminopenicilins R 52 50 45 56 55 56 54 65Aminoglycosides R 11 10 5 7 11 6 7 7Fluoroquinolones R 11 7 9 20 20 13 20 23Third-gen. cephalosporins R 6 4 5 5 4 2 2 9Enterococcus faecalisAminopenicilins RI 12 <1 2 9 2 4 6 <1HL Gentamicin R 41 48 33 48 50 46 29 39Vancomycin R <1 <1 <1 <1 <1 2 <1 <1Enterococcus faeciumAminopenicilins RI 80 91 86 95 95 88 78 98HL Gentamicin R 73 55 100 62 85 84 67 75Vancomycin R <1 <1 <1 5 <1 <1 <1 1Klebsiella pneumoniaeAminoglycosides R - - - 57 36 31 26 29Fluoroquinolones R - - - 34 29 3 32 32Third-gen. cephalosporins R - - - 66 38 34 37 49Pseudomonas aeruginosaPiperacillin R - - - 50 43 36 32 30Ceftazidime R - - - 31 42 21 27 21Carbapenems R - - - 27 30 18 14 25Aminoglycosides R - - - 56 46 40 27 27Fluoroquinolones R - - - 31 41 37 13 26

163

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=141

S. aureusn=605

E. colin=651

E. faecalisn=157

E. faeciumn=94

K. pneumoniaen=162

P. aeruginosan=164

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 74 16 100 19 99 23 100 0 100 1 99 48 98 24CSF 26 31 - - 1 25 - - - - 1 0 2 0GenderMale 56 22 57 19 38 29 54 0 57 0 60 48 57 27Female 42 17 40 19 59 19 42 0 36 3 35 46 37 18Unknown 2 33 3 11 3 10 4 0 6 0 5 50 7 27Age (years)0–4 16 32 9 14 6 6 5 0 8 0 13 50 5 135–19 9 21 3 16 1 5 1 0 1 50 1 33 3 1120–64 49 17 49 21 43 18 43 1 46 1 47 49 50 2865 and over 26 14 38 20 48 18 50 0 42 0 37 46 38 20Unknown 1 33 1 6 2 23 2 0 3 0 2 57 4 23Hospital departmentICU 20 12 17 36 17 22 21 0 32 2 34 62 41 30Internal med. 39 15 38 12 41 16 31 1 19 0 20 33 15 20Surgery 1 50 13 31 10 18 19 0 16 3 14 60 11 22Other 39 25 26 13 25 13 17 0 20 0 25 38 19 7Unknown 1 67 7 24 7 24 11 0 13 0 8 36 14 32

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

164

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

PL033 (5/7)

PL003 (2/5)

PL041 (3/12)

PL019 (1/5)

PL024 (1/14)

PL058 (1/20)

PL018 (0/10)

PL034 (0/7)

PL036 (0/5)

Hosp

ital c

odes

0 25 50 75 100

PL0126 (19/33)

PL0023 (9/19)

PL0029 (3/8)

PL0130 (8/22)

PL0031 (4/12)

PL0035 (4/12)

PL0033 (10/33)

PL0131 (6/21)

PL0018 (5/18)

PL0011 (7/28)

PL0052 (3/13)

PL0058 (4/21)

PL0043 (3/17)

PL0012 (4/24)

PL0124 (4/26)

PL0014 (5/33)

PL0046 (1/7)

PL0044 (1/9)

PL0041 (4/38)

PL0024 (2/20)

PL0003 (5/58)

PL0048 (1/22)

PL0019 (1/23)

PL0132 (0/9)

PL0009 (0/7)

PL0025 (0/6)

PL0005 (0/15)

PL0015 (0/9)

PL0006 (0/12)

PL0056 (0/16)

PL0057 (0/6)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 9Minimum 0First quartile 0Median 7.1Third quartile 25Maximum 71.4

N hospitals 31Minimum 0First quartile 0Median 15.2Third quartile 28.6Maximum 57.6

Poland

165

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

PL0005 (9/17)

PL0126 (13/33)

PL0130 (9/23)

PL0019 (8/23)

PL0131 (5/15)

PL0132 (2/6)

PL0011 (3/10)

PL0043 (8/27)

PL0012 (7/24)

PL0035 (8/31)

PL0014 (10/39)

PL0018 (6/26)

PL0048 (6/26)

PL0023 (3/13)

PL0044 (2/9)

PL0029 (9/50)

PL0041 (7/39)

PL0024 (7/43)

PL0003 (7/45)

PL0056 (4/28)

PL0058 (6/42)

PL0006 (2/16)

PL0031 (1/8)

PL0015 (1/9)

PL0057 (1/10)

PL0124 (2/24)

Hosp

ital c

odes

0 25 50 75 100

PL0019 (6/6)

PL0126 (9/10)

PL0023 (5/6)

PL0011 (10/13)

PL0029 (20/27)

PL0006 (4/6)

PL0035 (5/13)

PL0003 (4/14)

PL0130 (3/12)

PL0014 (0/7)

PL0024 (0/6)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 26Minimum 8.3First quartile 14.3Median 23.1Third quartile 30Maximum 52.9

N hospitals 11Minimum 0First quartile 25Median 66.7Third quartile 83.3Maximum 100

166

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Portugal

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 14 185 16 544 17 444 13 101 - - - -2003 12 95 22 1 033 21 792 18 398 - - - -2004 14 166 23 1 063 19 761 19 410 - - - -2005 13 202 19 1 153 19 1 171 17 405 1 1 - -2006 15 183 17 1 306 18 1 331 17 464 13 315 11 2662007 12 202 20 1 383 20 1 432 19 518 18 370 16 3402008 14 260 20 1 557 21 1 625 20 588 21 543 19 4672009 17 237 20 1 824 20 2 040 19 675 20 564 18 536

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 <1 <1 <1 18Penicillin RI 20 20 27 17 17 16 18 18Macrolides RI <1 - 20 19 21 23 22 22Staphylococcus aureusOxacillin/Meticillin R 38 45 46 47 48 48 53 49Escherichia coliAminopenicilins R 58 53 58 58 59 59 58 58Aminoglycosides R 9 9 13 12 12 12 14 11Fluoroquinolones R 23 26 27 29 28 30 29 28Third-gen. cephalosporins R 6 7 8 12 10 10 10 9Enterococcus faecalisAminopenicilins RI 2 4 5 <1 2 4 4 7HL Gentamicin R 25 34 29 38 41 41 43 34Vancomycin R 6 3 6 5 5 4 4 4Enterococcus faeciumAminopenicilins RI 79 88 83 92 76 93 86 91HL Gentamicin R 33 55 66 68 53 49 28 49Vancomycin R <1 47 42 34 26 29 24 23Klebsiella pneumoniaeAminoglycosides R - - - <1 13 11 19 20Fluoroquinolones R - - - <1 20 18 22 28Third-gen. cephalosporins R - - - - 21 17 26 28Pseudomonas aeruginosaPiperacillin R - - - - 15 14 17 17Ceftazidime R - - - - 19 16 16 13Carbapenems R - - - - 21 15 18 16Aminoglycosides R - - - - 17 16 11 12Fluoroquinolones R - - - - 21 19 23 21

167

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=497

S. aureusn=3 380

E. colin=3 550

E. faecalisn=844

E. faeciumn=394

K. pneumoniaen=1 089

P. aeruginosan=950

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 92 18 100 51 100 28 100 4 100 23 100 27 100 17CSF 8 13 - - <1 0 - - - - - - <1 100GenderMale 56 18 62 49 46 33 57 4 53 19 57 28 58 20Female 44 18 38 53 54 24 43 5 47 28 43 25 42 13Unknown <1 0 <1 100 - - - - - - <1 50 - -Age (years)0–4 9 31 3 15 1 7 2 2 1 20 2 43 2 75–19 5 17 2 18 1 15 1 4 1 8 2 18 2 1220–64 43 14 34 38 34 25 30 5 39 32 36 24 41 1865 and over 37 19 50 58 56 31 57 4 50 28 48 23 48 17Unknown 5 30 11 46 7 21 10 5 8 28 12 22 8 15Hospital departmentICU 6 21 9 58 5 32 15 4 15 22 11 27 17 25Internal med. 15 16 24 56 22 29 22 6 19 32 18 30 15 15Surgery <1 14 8 63 5 30 10 2 13 20 11 18 9 19Other 78 19 54 40 64 27 50 5 51 33 57 22 56 15Unknown 1 22 4 55 3 30 2 2 2 38 3 15 3 21

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

168

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

rato

ry c

odes

0 25 50 75 100

PT026 (4/8)

PT005 (7/18)

PT016 (3/12)

PT024 (3/13)

PT008 (5/24)

PT003 (12/60)

PT028 (1/5)

PT017 (2/11)

PT011 (12/67)

PT018 (8/46)

PT002 (9/55)

PT019 (14/97)

PT001 (3/24)

PT015 (1/8)

PT029 (3/42)

Hosp

ital c

odes

0 25 50 75 100

PT022A (17/21)

PT005A (115/176)

PT007A (351/541)

PT028A (29/47)

PT002A (110/184)

PT016A (70/123)

PT008A (129/231)

PT031B (47/86)

PT019A (155/307)

PT012A (118/234)

PT015A (45/90)

PT003A (164/342)

PT018A (34/73)

PT031D (37/82)

PT029A (31/72)

PT023A (72/169)

PT001A (57/135)

PT026A (19/46)

PT027A (6/15)

PT031C (5/14)

PT006A (36/107)

PT011A (50/179)

PT021A (13/56)

PT009A (5/29)

PT031A (3/20)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 15Minimum 7.1First quartile 14.4Median 18.2Third quartile 23.1Maximum 50

N hospitals 25Minimum 15First quartile 40Median 46.6Third quartile 55.8Maximum 81

Portugal

169

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

PT022A (13/25)

PT025A (5/11)

PT005A (30/67)

PT016A (34/96)

PT001A (49/139)

PT029A (40/114)

PT003A (199/616)

PT031B (27/86)

PT007A (131/424)

PT002A (60/218)

PT028A (22/80)

PT006A (53/197)

PT018A (24/94)

PT008A (20/79)

PT019A (65/274)

PT012A (34/145)

PT021A (15/64)

PT015A (24/105)

PT031D (24/106)

PT011A (68/301)

PT026A (13/58)

PT023A (38/181)

PT031A (2/10)

PT027A (7/38)

PT009A (1/11)

PT031C (0/11)

Hosp

ital c

odes

0 25 50 75 100

PT028A (21/30)

PT001A (27/43)

PT009A (3/6)

PT031B (15/37)

PT026A (6/16)

PT012A (17/47)

PT031D (9/29)

PT015A (8/27)

PT005A (12/41)

PT007A (47/162)

PT031C (2/7)

PT008A (6/22)

PT002A (8/33)

PT029A (5/21)

PT011A (33/139)

PT021A (6/28)

PT003A (30/151)

PT019A (15/82)

PT006A (10/68)

PT023A (4/32)

PT018A (2/25)

PT016A (1/29)

PT027A (0/6)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 26Minimum 0First quartile 22.6Median 25.4Third quartile 32.3Maximum 52

N hospitals 23Minimum 0First quartile 18.3Median 27.3Third quartile 36.2Maximum 70

170

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Romania

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 6 10 10 80 8 28 4 11 - - - -2003 5 26 9 85 9 50 5 12 - - - -2004 4 9 15 95 12 48 4 9 - - - -2005 5 18 13 93 13 84 7 14 1 3 2 232006 8 29 11 83 9 41 9 28 5 32 2 32007 5 27 9 42 9 63 5 14 6 30 2 42008 4 14 5 39 4 58 4 16 3 6 3 82009 3 17 5 45 6 80 5 26 3 26 3 22

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 10 21 11 22 10 22 54 12Penicillin RI 50 33 11 39 28 33 69 29Macrolides RI 10 29 <1 31 25 19 27 25Staphylococcus aureusOxacillin/Meticillin R 36 46 71 60 54 26 33 36Escherichia coliAminopenicilins R 50 70 79 78 85 76 55 83Aminoglycosides R 15 21 33 14 41 35 24 13Fluoroquinolones R 20 14 21 9 41 27 27 23Third-gen. cephalosporins R 18 19 23 17 41 27 24 17Enterococcus faecalisAminopenicilins RI <1 <1 29 <1 <1 25 10 12HL Gentamicin R 40 25 <1 50 15 50 22 35Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 100 86 100 100 100 100 100 100HL Gentamicin R 80 63 100 70 80 67 50 56Vancomycin R 17 <1 <1 <1 <1 <1 <1 <1Klebsiella pneumoniaeAminoglycosides R - - - 100 91 80 60 31Fluoroquinolones R - - - 33 34 23 20 11Third-gen. cephalosporins R - - - 100 94 80 50 56Pseudomonas aeruginosaPiperacillin R - - - 61 33 25 25 36Ceftazidime R - - - 52 <1 <1 13 38Carbapenems R - - - 61 <1 <1 13 55Aminoglycosides R - - - 64 33 25 38 45Fluoroquinolones R - - - 64 33 25 25 36

171

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=30

S. aureusn=84

E. colin=105

E. faecalisn=27

E. faeciumn=15

K. pneumoniaen=22

P. aeruginosan=19

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 63 63 100 35 100 25 100 0 100 0 100 55 95 39CSF 37 18 - - - - - - - - - - 5 0GenderMale 53 63 35 38 46 23 56 0 53 13 59 62 53 40Female 47 29 18 33 54 26 44 0 47 0 41 44 37 43Unknown - - 48 33 - - - - - - - - 11 0Age (years)0–4 22 66 24 57 20 19 27 0 35 0 60 96 16 05–19 12 11 11 23 7 43 2 0 8 0 7 50 4 10020–64 44 34 41 51 37 20 33 0 28 11 22 58 10 8065 and over 20 21 12 53 33 20 34 0 18 0 10 44 6 33Unknown 2 33 13 47 3 18 5 0 11 0 - - 63 45Hospital departmentICU 1 50 9 66 5 20 6 0 8 0 8 71 22 82Internal med. 5 13 8 50 20 20 20 0 25 0 17 60 - -Surgery - - 7 61 3 17 2 0 3 0 2 100 6 100Other 82 38 42 48 68 23 59 0 46 3 71 85 51 20Unknown 12 29 34 42 3 14 13 0 18 8 1 0 20 40

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

172

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Labo

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odes

0 25 50 75 100

ROROU (5/6)

RO01A (5/17)

Hosp

ital c

odes

0 25 50 75 100

RO001D (4/7)

RO01DX (5/11)

RO001B (4/9)

RO01BX (3/7)

RO000X (4/12)

RO001A (3/13)

RO01AX (1/7)

RO001I (0/9)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 2Minimum 29.4First quartile 29.4Median 56.4Third quartile 83.3Maximum 83.3

N hospitals 8Minimum 0First quartile 18.7Median 38.1Third quartile 44.9Maximum 57.1

Romania

173

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Hosp

ital c

odes

0 25 50 75 100

RO00UX (13/30)

RO001C (6/19)

RO01AX (1/7)

RO001A (2/20)

RO014A (0/6)

RO01BX (0/7)

RO01CX (0/8)

Hosp

ital c

odes

0 25 50 75 100

RO001B (6/7)

RO001C (2/7)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 7Minimum 0First quartile 0Median 10Third quartile 31.6Maximum 43.3

N hospitals 2Minimum 28.6First quartile 28.6Median 57.1Third quartile 85.7Maximum 85.7

174

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Slovenia

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 11 101 11 276 11 409 9 45 - - - -2003 11 172 11 299 11 401 10 76 - - - -2004 10 166 11 347 11 573 9 91 - - - -2005 11 208 11 349 11 657 11 119 10 78 8 382006 11 167 11 365 11 717 10 145 10 145 10 722007 10 195 10 422 10 851 9 183 10 170 9 882008 10 209 10 418 10 874 10 196 9 157 10 952009 9 213 9 424 9 783 9 184 9 168 9 93

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 2 2 2 5 4 3 1Penicillin RI 19 15 25 11 19 17 15 17Macrolides RI 10 9 11 11 13 17 16 18Staphylococcus aureusOxacillin/Meticillin R 14 13 12 10 7 8 7 10Escherichia coliAminopenicilins R 43 41 40 42 44 49 49 54Aminoglycosides R 3 2 5 4 7 7 7 10Fluoroquinolones R 12 11 12 12 15 17 17 19Third-gen. cephalosporins R 1 <1 1 2 2 4 4 7Enterococcus faecalisAminopenicilins RI <1 <1 <1 1 1 <1 <1 <1HL Gentamicin R 50 49 37 46 40 50 40 44Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 69 83 76 93 86 92 96 94HL Gentamicin R 62 82 56 47 54 63 57 58Vancomycin R <1 <1 <1 <1 6 5 13 4Klebsiella pneumoniaeAminoglycosides R - - - 17 19 24 23 28Fluoroquinolones R - - - 14 21 26 25 29Third-gen. cephalosporins R - - - 19 24 28 26 34Pseudomonas aeruginosaPiperacillin R - - - 21 18 13 21 18Ceftazidime R - - - 11 8 7 14 11Carbapenems R - - - 13 6 19 16 17Aminoglycosides R - - - 18 15 10 13 14Fluoroquinolones R - - - 29 21 17 24 15

175

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=422

S. aureusn=842

E. colin=1 657

E. faecalisn=235

E. faeciumn=145

K. pneumoniaen=325

P. aeruginosan=188

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 93 16 100 9 100 18 100 0 100 9 100 30 99 16CSF 7 21 - - <1 0 - - - - - - 1 50GenderMale 59 16 62 9 41 21 59 0 59 11 55 34 70 18Female 41 16 38 8 59 16 41 0 41 7 45 26 30 12Unknown - - - - - - - - - - - - - -Age (years)0–4 21 30 4 1 3 2 7 0 1 0 3 15 2 05–19 5 7 3 4 1 4 <1 0 - - 1 40 2 1420–64 35 12 38 9 30 15 30 0 39 9 31 30 38 2365 and over 39 15 55 12 67 16 63 0 59 3 65 26 58 10Unknown <1 0 <1 25 <1 29 <1 0 <1 0 - - - -Hospital departmentICU 9 15 10 15 7 17 11 0 21 0 13 45 15 24Internal med. 38 13 46 8 52 14 38 0 31 1 42 18 35 9Surgery 1 11 11 21 6 16 15 0 14 2 15 32 16 25Other 52 20 33 7 35 16 35 0 33 14 30 30 34 12Unknown - - 0 0 - - - - - - - - - -

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

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0 25 50 75 100

SI011 (7/16)

SI009 (4/12)

SI007 (7/24)

SI002 (5/23)

SI003 (7/44)

SI008 (4/27)

SI001 (24/174)

SI004 (4/30)

SI010 (7/57)

SI005 (0/15)

Hosp

ital c

odes

0 25 50 75 100

SI008A (14/79)

SI001A (41/335)

SI005A (3/31)

SI007A (3/34)

SI003A (7/128)

SI009A (2/50)

SI002A (2/53)

SI004A (1/43)

SI001B (0/6)

SI001C (0/17)

SI011A (0/25)

SI010A (0/20)

SI004B (0/5)

SI003B (0/13)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 10Minimum 0First quartile 13.3Median 15.4Third quartile 29.2Maximum 43.8

N hospitals 14Minimum 0First quartile 0Median 3Third quartile 8.8Maximum 17.7

Slovenia

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Hosp

ital c

odes

0 25 50 75 100

SI001B (13/37)

SI007A (15/56)

SI005A (13/64)

SI008A (23/120)

SI003A (49/256)

SI001A (105/549)

SI001C (7/39)

SI004A (16/92)

SI002A (16/101)

SI009A (22/142)

SI004B (2/19)

SI011A (9/91)

SI010A (5/57)

SI003B (1/30)

Hosp

ital c

odes

0 25 50 75 100

SI003B (6/10)

SI001C (6/11)

SI011A (6/13)

SI003A (29/73)

SI001A (39/113)

SI008A (5/26)

SI001B (1/7)

SI004A (2/19)

SI005A (1/11)

SI009A (1/16)

SI002A (0/17)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 14Minimum 3.3First quartile 10.5Median 17.7Third quartile 19.2Maximum 35.1

N hospitals 11Minimum 0First quartile 9.1Median 19.2Third quartile 46.2Maximum 60

178

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Spain

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 35 658 36 1 196 29 2 484 35 566 - - - -2003 35 656 36 1 391 29 2 650 36 608 - - - -2004 36 684 36 1 527 36 3 471 36 710 - - - -2005 34 740 34 1 337 34 2 997 35 623 14 56 13 702006 35 625 35 1 483 35 3 364 34 755 33 564 32 4052007 35 862 35 1 645 35 3 678 35 885 33 618 35 4482008 31 695 32 1 505 32 3 626 32 1 002 30 639 32 5482009 32 708 33 1 715 33 3 821 33 1 093 32 628 33 544

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 10 7 9 9 8 8 7 8Penicillin RI 33 32 29 25 27 22 23 22Macrolides RI 26 27 27 23 22 18 22 19Staphylococcus aureusOxacillin/Meticillin R 23 24 26 27 25 25 27 26Escherichia coliAminopenicilins R 60 58 60 62 64 62 63 65Aminoglycosides R 8 7 7 10 9 10 11 13Fluoroquinolones R 19 21 25 28 28 30 33 31Third-gen. cephalosporins R 2 4 7 8 7 7 9 11Enterococcus faecalisAminopenicilins RI 2 1 2 <1 2 1 3 3HL Gentamicin R 37 36 36 36 36 42 41 43Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 59 64 66 67 73 79 79 83HL Gentamicin R 16 11 17 16 21 40 35 38Vancomycin R 1 3 2 3 3 2 1 3Klebsiella pneumoniaeAminoglycosides R - - - 4 7 9 9 9Fluoroquinolones R - - - 11 8 17 15 16Third-gen. cephalosporins R - - - 7 9 10 12 11Pseudomonas aeruginosaPiperacillin R - - - 4 9 8 8 8Ceftazidime R - - - 6 7 10 11 8Carbapenems R - - - 17 12 15 13 16Aminoglycosides R - - - 4 11 15 18 19Fluoroquinolones R - - - 14 19 25 23 25

179

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=1 402

S. aureusn=3 220

E. colin=7 420

E. faecalisn=1 463

E. faeciumn=631

K. pneumoniaen=1 267

P. aeruginosan=1 087

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 97 22 100 26 100 32 100 0 100 2 100 12 100 15CSF 3 21 - - <1 0 - - - - - - - -GenderMale 59 22 65 26 51 36 61 0 60 3 58 12 68 16Female 38 23 33 28 47 28 36 0 38 1 39 11 30 12Unknown 3 10 2 19 2 31 3 0 2 0 3 16 2 4Age (years)0–4 14 36 4 7 3 9 8 0 6 0 5 19 3 25–19 4 13 3 9 1 13 1 0 1 10 1 16 1 820–64 40 22 37 20 29 24 31 0 35 4 34 10 37 1965 and over 40 29 55 32 66 30 57 0 57 2 58 10 58 12Unknown 2 22 1 19 1 18 3 0 1 0 3 10 2 6Hospital departmentICU 8 24 12 32 5 30 21 0 16 3 12 15 23 26Internal med. 25 27 35 28 29 30 26 0 29 3 29 8 28 12Surgery 1 24 9 32 7 26 10 0 14 0 9 12 7 21Other 64 26 42 20 58 26 41 0 39 2 49 11 40 8Unknown 2 26 2 25 1 29 1 0 2 0 1 11 1 7

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

180

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

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0 25 50 75 100

ES013 (3/5)

ES003 (9/19)

ES051 (4/10)

ES032 (15/38)

ES053 (14/36)

ES017 (5/13)

ES002 (16/43)

ES056 (20/55)

ES016 (9/28)

ES060 (8/26)

ES031 (21/73)

ES021 (22/86)

ES012 (12/48)

ES049 (3/12)

ES004 (9/38)

ES010 (13/55)

ES057 (7/30)

ES048 (14/60)

ES019 (14/63)

ES005 (13/61)

ES059 (4/19)

ES046 (6/34)

ES058 (15/85)

ES042 (20/118)

ES044 (14/86)

ES015 (3/23)

ES038 (8/76)

ES018 (2/21)

ES011 (7/75)

ES043 (3/36)

ES029 (1/15)

ES047 (0/15)

Hosp

ital c

odes

0 25 50 75 100

ES017A (41/86)

ES056A (54/134)

ES049A (32/80)

ES029A (19/52)

ES002A (40/110)

ES057A (13/36)

ES012A (47/138)

ES059A (13/39)

ES041A (50/162)

ES060A (49/166)

ES019A (71/242)

ES004A (44/160)

ES031A (55/204)

ES013A (28/106)

ES053A (19/72)

ES018A (14/54)

ES010A (22/88)

ES005A (23/94)

ES038A (33/141)

ES058A (31/137)

ES015A (4/18)

ES011A (14/65)

ES016A (13/61)

ES044A (23/122)

ES003A (5/27)

ES042A (17/96)

ES032A (9/54)

ES048A (13/82)

ES047A (8/54)

ES046A (6/47)

ES051A (5/40)

ES021A (20/173)

ES043A (8/78)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 32Minimum 0First quartile 16.6Median 23.5Third quartile 34.3Maximum 60

N hospitals 33Minimum 10.3First quartile 18.5Median 25Third quartile 30.9Maximum 47.7

Spain

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odes

0 25 50 75 100

ES015A (17/37)

ES047A (26/61)

ES056A (161/391)

ES017A (39/99)

ES003A (47/121)

ES031A (154/399)

ES059A (58/157)

ES004A (104/294)

ES016A (45/128)

ES043A (69/198)

ES048A (60/174)

ES060A (87/255)

ES041A (75/225)

ES012A (82/246)

ES019A (183/552)

ES049A (36/109)

ES010A (92/280)

ES044A (97/300)

ES002A (93/297)

ES013A (35/113)

ES038A (99/323)

ES053A (37/123)

ES005A (100/334)

ES046A (26/90)

ES051A (27/94)

ES042A (127/444)

ES058A (81/293)

ES018A (64/236)

ES032A (43/160)

ES021A (107/404)

ES029A (26/113)

ES057A (28/136)

ES011A (47/232)

Hosp

ital c

odes

0 25 50 75 100

ES043A (18/56)

ES013A (9/30)

ES012A (8/34)

ES031A (13/65)

ES060A (12/68)

ES002A (10/62)

ES016A (2/14)

ES021A (7/52)

ES057A (3/23)

ES056A (10/77)

ES004A (5/42)

ES059A (3/26)

ES005A (5/48)

ES044A (8/77)

ES038A (5/54)

ES042A (8/88)

ES053A (3/33)

ES046A (2/32)

ES019A (1/16)

ES010A (2/35)

ES047A (1/18)

ES041A (3/57)

ES018A (2/38)

ES058A (4/84)

ES049A (1/30)

ES011A (1/39)

ES029A (0/8)

ES051A (0/17)

ES015A (0/9)

ES032A (0/21)

ES017A (0/12)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 33Minimum 20.3First quartile 28.7Median 32.9Third quartile 35.2Maximum 45.9

N hospitals 31Minimum 0First quartile 4.8Median 9.1Third quartile 13.5Maximum 32.1

182

SURVEILLANCE REPORTAntimicrobial resistance surveillance in Europe 2009

Sweden

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 21 830 21 1 837 21 3 066 21 695 - - - -2003 21 919 21 1 855 21 3 350 21 850 - - - -2004 21 955 21 1 906 21 3 372 21 856 - - - -2005 21 1 025 21 1 774 21 3 241 21 821 18 282 17 1492006 21 996 21 1 968 20 3 539 21 884 20 621 18 3002007 21 1 032 21 2 163 20 3 749 21 932 20 649 20 3432008 21 1 219 21 2 410 20 4 032 21 1 059 20 826 20 3152009 19 1 061 19 2 459 18 4 245 19 967 18 705 18 338

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R <1 <1 <1 <1 <1 <1 <1 2Penicillin RI 2 5 3 4 2 3 2 3Macrolides RI 6 5 5 6 5 5 6 4Staphylococcus aureusOxacillin/Meticillin R <1 <1 <1 1 <1 <1 <1 1Escherichia coliAminopenicilins R 25 29 23 26 28 33 32 33Aminoglycosides R <1 1 1 1 2 2 2 2Fluoroquinolones R 5 7 8 6 8 10 10 8Third-gen. cephalosporins R <1 <1 <1 1 2 2 2 3Enterococcus faecalisAminopenicilins RI 1 <1 <1 <1 <1 <1 <1 <1HL Gentamicin R - 17 16 19 20 16 20 19Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1Enterococcus faeciumAminopenicilins RI 75 77 78 74 76 79 82 76HL Gentamicin R - 11 7 4 12 14 25 24Vancomycin R <1 2 1 <1 <1 <1 2 <1Klebsiella pneumoniaeAminoglycosides R - - - 1 <1 1 1 <1Fluoroquinolones R - - - 5 5 6 7 2Third-gen. cephalosporins R - - - 1 1 1 2 2Pseudomonas aeruginosaPiperacillin R - - - 9 <1 2 1 2Ceftazidime R - - - 5 6 4 5 7Carbapenems R - - - 18 5 7 4 8Aminoglycosides R - - - <1 <1 <1 <1 <1Fluoroquinolones R - - - 6 5 6 5 7

183

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=2 271

S. aureusn=4 865

E. colin=5 176

E. faecalisn=1 283

E. faeciumn=554

K. pneumoniaen=1 526

P. aeruginosan=605

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 98 3 100 1 100 10 100 0 100 1 100 2 100 6CSF 2 3 - - - - - - - - <1 0 - -GenderMale 50 2 62 1 45 12 70 0 57 1 60 2 68 6Female 50 3 38 1 55 7 30 0 43 1 40 2 32 6Unknown - - <1 0 - - - - - - - - - -Age (years)0–4 5 5 4 1 1 3 5 0 3 0 2 4 2 115–19 2 4 4 0 1 6 1 0 1 0 1 0 2 1220–64 41 2 33 1 25 10 24 0 31 2 24 3 26 865 and over 51 3 60 1 73 7 69 0 65 1 73 1 70 6Unknown <1 0 <1 13 <1 0 - - - - <1 0 - -Hospital departmentICU 7 2 6 1 4 8 6 0 10 2 4 2 7 13Internal med. 44 3 41 1 40 7 34 0 35 0 38 2 42 7Surgery 4 2 16 1 20 8 24 0 27 1 25 1 14 5Other 44 3 37 1 36 9 36 0 28 1 33 2 37 5Unknown <1 0 <1 0 <1 33 <1 0 <1 0 <1 20 <1 33

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

184

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Labo

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0 25 50 75 100

SE110 (5/54)

SE250 (6/90)

SE540 (2/34)

SE100 (12/231)

SE230 (2/56)

SE310 (3/99)

SE240 (3/105)

SE120 (5/192)

SE220 (1/42)

SE200 (6/260)

SE450 (2/89)

SE620 (3/136)

SE300 (1/47)

SE610 (2/111)

SE350 (2/113)

SE320 (1/86)

SE430 (1/94)

SE600 (1/98)

SE400 (1/123)

SE730 (0/76)

SE440 (0/135)

Hosp

ital c

odes

0 25 50 75 100SE540A (2/54)

SE200B (4/144)SE350B (1/40)SE600C (1/45)

SE600A (5/250)SE620A (3/166)SE100B (3/187)SE250B (1/66)SE110A (1/76)

SE200A (3/228)SE320A (2/153)SE120A (3/233)SE310A (3/258)SE220A (1/94)SE350C (1/98)

SE350A (1/134)SE240A (1/135)SE250A (1/150)

SE100A (2/302)SE430A (1/157)SE450A (1/160)SE320B (0/44)SE230B (0/30)SE440B (0/52)SE200C (0/32)SE320C (0/20)SE220C (0/11)SE120B (0/23)

SE440A (0/136)SE620D (0/14)SE730E (0/26)SE230A (0/83)SE730F (0/86)SE450B (0/29)SE100C (0/50)SE730B (0/22)SE730C (0/17)SE400C (0/31)

SE610A (0/176)SE300A (0/74)SE200D (0/7)

SE620C (0/36)SE440C (0/42)SE110B (0/36)SE730D (0/17)SE610C (0/81)

SE400B (0/112)SE450D (0/39)SE430D (0/48)

SE400A (0/140)SE220B (0/64)SE610B (0/37)SE240C (0/53)SE240B (0/30)SE620B (0/32)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 21Minimum 0First quartile 1.2Median 2.2Third quartile 3Maximum 9.3

N hospitals 55Minimum 0First quartile 0Median 0Third quartile 1.1Maximum 3.7

Sweden

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Hosp

ital c

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0 25 50 75 100SE220C (6/22)

SE100C (8/36)

SE100A (52/235)

SE610B (6/31)

SE100B (38/208)

SE250A (19/106)

SE240C (7/40)

SE250B (10/61)

SE240B (3/19)

SE230A (9/62)

SE220A (18/128)

SE320B (11/87)

SE110A (13/105)

SE110B (4/33)

SE350A (10/89)

SE620B (6/56)

SE240A (12/116)

SE440C (6/60)

SE430D (8/83)

SE610A (12/126)

SE120A (33/360)

SE220D (1/11)

SE540A (4/44)

SE400A (21/231)

SE730B (1/11)

SE430A (26/294)

SE300A (12/136)

SE730F (6/71)

SE320A (23/280)

SE220B (6/75)

SE450D (6/79)

SE440A (24/340)

SE620A (13/194)

SE310A (13/209)

SE730C (1/17)

SE450B (5/85)

SE120B (2/34)

SE620C (4/71)

SE450A (13/237)

SE400B (8/146)

SE440B (4/89)

SE400C (3/68)

SE730E (1/26)

SE320C (3/79)

SE350C (3/82)

SE610C (2/60)

SE620D (0/24)

SE350B (0/64)

SE230B (0/20)

SE730D (0/20)

Hosp

ital c

odes

0 25 50 75 100SE620B (2/11)

SE730E (1/6)

SE110B (1/9)

SE240B (1/10)

SE220C (1/11)

SE310A (5/87)

SE400B (1/26)

SE400A (2/54)

SE100A (4/108)

SE250B (1/27)

SE120A (3/82)

SE230A (1/30)

SE200B (2/61)

SE200A (2/78)

SE350A (1/46)

SE320A (1/55)

SE430A (1/59)

SE100B (1/61)

SE450A (0/48)

SE610A (0/58)

SE430D (0/11)

SE540A (0/21)

SE350C (0/26)

SE400C (0/9)

SE230B (0/8)

SE220B (0/19)

SE730F (0/18)

SE100C (0/10)

SE300A (0/24)

SE450D (0/11)

SE620C (0/16)

SE120B (0/8)

SE250A (0/44)

SE440C (0/10)

SE240C (0/9)

SE110A (0/25)

SE450B (0/25)

SE220A (0/40)

SE240A (0/28)

SE200C (0/15)

SE610C (0/33)

SE620A (0/46)

SE610B (0/10)

SE440B (0/26)

SE440A (0/51)

SE350B (0/16)

SE220D (0/5)

SE320B (0/12)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 50Minimum 0First quartile 5.6Median 9Third quartile 12.4Maximum 27.3

N hospitals 48Minimum 0First quartile 0Median 0Third quartile 3.3Maximum 18.2

186

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United Kingdom

General information about EARS-Net participating laboratories

Antibiotic resistance from 2002 to 2009

Table 1: Number of laboratories and number of isolates reported for the period 2002–2009

YearS. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosaLabs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates

2002 23 617 21 1 588 20 1 958 - - - - - -2003 50 1 334 51 3 548 19 2 253 - - - - - -2004 54 1 059 54 3 562 20 2 091 - - - - - -2005 53 1 375 58 3 971 23 2 359 27 591 23 420 25 4382006 51 1 514 55 4 132 26 2 438 22 547 22 404 24 3532007 50 1 785 55 4 865 20 2 374 18 435 18 382 19 3702008 51 1 223 55 3 355 15 2 456 14 274 15 350 14 3452009 59 1 396 69 2 977 28 4 712 26 712 27 725 26 639

Table 2: Proportion (%) of antibiotic non-susceptible isolates

Pathogens by antimicrobial classes 2002 2003 2004 2005 2006 2007 2008 2009

Streptococcus pneumoniaePenicillin R 3 1 <1 2 <1 2 1 1Penicillin RI 6 5 3 4 3 4 5 3Macrolides RI 13 13 13 11 12 10 6 4Staphylococcus aureusOxacillin/Meticillin R 47 44 44 44 42 36 31 28Escherichia coliAminopenicilins R 52 55 53 56 57 55 61 62Aminoglycosides R 3 4 6 8 7 7 7 7Fluoroquinolones R 7 11 14 17 20 18 15 18Third-gen. cephalosporins R 2 3 3 6 8 9 7 9Enterococcus faecalisAminopenicilins RI - - - 2 3 4 2 2HL Gentamicin R - - - 47 52 31 42 38Vancomycin R - - - 2 1 2 4 2Enterococcus faeciumAminopenicilins RI - - - 84 78 82 83 91HL Gentamicin R - - - 53 18 35 7 38Vancomycin R - - - 33 18 21 28 13Klebsiella pneumoniaeAminoglycosides R - - - 6 8 9 6 5Fluoroquinolones R - - - 12 13 12 7 6Third-gen. cephalosporins R - - - 12 11 13 7 7Pseudomonas aeruginosaPiperacillin R - - - 2 1 5 2 3Ceftazidime R - - - 3 3 7 4 5Carbapenems R - - - 9 6 10 6 8Aminoglycosides R - - - 3 3 5 3 1Fluoroquinolones R - - - 8 8 9 8 7

187

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Demographic characteristics

Table 3: Selected details on invasive isolates from the reporting period 2008 and 2009

Characteristic

S. pneumoniaen=2 477

S. aureusn=6 233

E. colin=6 500

E. faecalisn=572

E. faeciumn=354

K. pneumoniaen=953

P. aeruginosan=759

% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA

Isolate sourceBlood 99 4 100 29 100 17 100 2 100 17 100 7 100 8CSF 1 3 - - - - - - - - - - - -GenderMale 52 4 61 31 46 19 62 3 54 13 61 8 64 6Female 47 4 38 27 53 15 38 1 44 21 38 6 35 11Unknown 1 0 1 14 <1 35 - - 3 22 <1 0 <1 0Age (years)0–4 9 4 4 14 3 7 8 2 6 21 4 6 4 75–19 4 4 2 13 1 9 1 0 3 30 1 12 3 1820–64 36 3 35 32 26 16 31 3 39 29 31 10 31 1265 and over 39 5 49 47 70 16 60 2 51 16 63 10 63 6Unknown 12 3 10 42 <1 20 <1 100 - - <1 0 - -Hospital departmentICU 5 3 7 56 - - - - - - - - - -Internal med. 24 4 26 41 - - - - - - - - - -Surgery 1 3 8 50 - - - - - - - - - -Other 36 4 34 34 - - - - - - - - - -Unknown 34 4 25 35 100 16 100 2 100 22 100 9 100 8

PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.

188

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Labo

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odes

0 25 50 75 100UK038 (4/11)

UK084 (6/37)UK042 (3/31)UK005 (4/42)UK093 (3/34)UK043 (8/95)UK044 (3/36)UK033 (2/27)UK099 (5/69)UK100 (1/14)

UK076 (3/43)UK011 (2/31)

UK020 (2/36)UK053 (2/36)UK032 (4/75)UK091 (2/38)UK023 (2/39)UK064 (3/60)

UK031 (1/21)UK081 (1/21)UK055 (1/23)UK012 (4/92)UK017 (2/55)

UK090 (2/55)UK045 (4/115)UK008 (1/29)UK054 (2/59)UK056 (1/32)UK066 (1/34)UK070 (1/35)UK098 (1/38)UK068 (2/77)UK059 (2/79)UK015 (1/43)

UK007 (3/147)UK047 (2/105)

UK069 (1/55)UK101 (1/62)UK051 (1/71)

UK092 (0/31)UK049 (0/11)UK077 (0/17)UK060 (0/12)UK097 (0/18)UK050 (0/18)UK001 (0/31)

UK052 (0/20)UK004 (0/29)UK048 (0/16)UK094 (0/40)

UK080 (0/9)UK027 (0/16)UK058 (0/14)UK063 (0/37)UK010 (0/18)UK057 (0/26)UK102 (0/14)

UK096 (0/30)UK078 (0/33)UK046 (0/32)

Hosp

ital c

odes

0 25 50 75 100UK094X (6/6)

UK090X (17/17)UK058X (5/6)UK004A (5/7)

UK043B (16/26)UK065X (3/5)

UK084E (10/17)UK043C (4/7)

UK081A (10/19)UK038C (3/6)

UK049A (10/21)UK044C (8/17)

UK083A (62/137)UK060A (16/36)UK048A (12/28)

UK066A (9/21)UK080A (36/85)UK070A (16/38)

UK078A (62/149)UK043A (57/137)

UK045B (2/5)UK070B (4/10)

UK031A (17/43)UK063A (9/23)UK072A (5/13)

UK032B (13/34)UK084B (7/19)

UK045A (47/130)UK051X (46/129)UK077A (16/45)UK017A (11/31)

UK050A (12/34)UK069A (19/54)UK051A (27/77)

UK008A (14/40)UK068B (45/129)UK005A (38/111)

UK047A (66/193)UK044A (49/144)

UK070X (25/74)UK084A (26/77)UK056X (31/92)

UK017B (38/113)UK044D (6/18)UK057X (12/37)

UK069X (34/105)UK059B (9/28)UK052A (8/25)

UK063X (16/51)UK052X (9/29)

UK027A (12/39)UK068X (57/186)

UK011A (17/56)UK049X (10/33)

UK047X (82/271)UK032A (15/50)UK048X (15/50)UK054A (11/37)

UK059X (32/111)UK054X (18/63)

UK081B (4/14)UK046A (5/18)

UK076A (26/94)UK053D (11/40)UK020A (12/45)UK056A (17/64)

UK064X (30/117)UK045X (43/168)

UK050X (11/43)UK007B (21/83)

UK015B (4/16)UK026B (19/80)UK012A (14/60)UK023A (16/69)UK026A (19/83)UK091X (21/94)UK015A (6/27)UK047B (2/9)

UK060X (4/18)UK064A (9/42)UK097X (6/28)

UK007A (24/115)UK057A (6/29)

UK099X (28/140)UK007C (1/5)

UK053X (8/41)UK044B (2/11)

UK066X (10/55)UK093X (19/106)

UK033X (10/57)UK046X (3/18)UK102X (7/42)UK059A (7/43)

UK096X (10/62)UK076D (5/32)UK026C (5/33)UK001A (5/33)

UK098X (11/74)UK090A (10/68)

UK055A (2/14)UK092X (7/57)UK055X (4/35)UK010A (3/28)

UK101X (16/154)UK078C (3/34)UK078B (2/23)UK100X (2/25)UK072X (1/25)

Figure 1: Proportion (%) of penicillin-non-susceptible S. pneumonia by laboratory (2008–2009)

Figure 2: Proportion (%) of meticillin-resistant S. aureus by hospital (2008–2009)

N laboratories 60Minimum 0First quartile 0Median 2.7Third quartile 5.3Maximum 36.4

N hospitals 108Minimum 4First quartile 21.1Median 30.3Third quartile 36.5Maximum 100

United Kingdom

189

Antimicrobial resistance surveillance in Europe 2009SURVEILLANCE REPORT

Hosp

ital c

odes

0 25 50 75 100

UK003X (19/40)

UK007X (9/20)

UK094X (16/40)

UK043X (37/105)

UK026X (35/128)

UK020X (20/74)

UK005X (28/105)

UK012X (86/390)

UK099X (82/383)

UK042X (19/90)

UK092X (32/157)

UK101X (79/391)

UK100X (11/55)

UK011X (42/225)

UK097X (16/91)

UK015X (171/982)

UK027X (24/143)

UK096X (25/149)

UK093X (3/18)

UK102X (14/86)

UK031X (8/52)

UK017X (70/455)

UK091X (37/251)

UK038X (22/151)

UK098X (31/221)

UK032X (71/630)

UK008X (16/143)

UK033X (19/171)

UK023X (51/572)

UK001X (9/124)

UK090X (1/58)

Hosp

ital c

odes

0 25 50 75 100

UK038X (2/15)

UK032X (18/147)

UK012X (5/44)

UK097X (1/9)

UK020X (1/11)

UK102X (2/22)

UK101X (7/77)

UK091X (5/55)

UK026X (3/33)

UK042X (1/15)

UK027X (1/19)

UK099X (3/61)

UK017X (3/66)

UK096X (1/25)

UK092X (1/25)

UK015X (6/156)

UK033X (1/31)

UK098X (0/19)

UK008X (0/16)

UK011X (0/31)

UK023X (0/43)

UK090X (0/5)

UK100X (0/14)

Figure 3: Proportion (%) of fluoroquinolone-resistant E. coli by hospital (2008–2009)

Figure 4: Proportion (%) of third-generation cephalosporin-resistant K. pneumoniae by hospital (2008–2009)

N hospitals 31Minimum 1.7First quartile 14.6Median 17.4Third quartile 22.1Maximum 47.5

N hospitals 23Minimum 0First quartile 0Median 4.9Third quartile 9.1Maximum 13.3

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