EARSS Annual Report The European Antimicrobial Resistance Surveillance System

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EARSS Annual Report 2005 The European Antimicrobial Resistance Surveillance System (EARSS), funded by DG SANCO of the European Commission, is an international network of national surveillance systems which collects comparable and validated antimicrobial susceptibility data for public health action. EARSS performs continuous surveillance of antimicrobial susceptibility for seven major bacterial pathogens Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa causing invasive infections and monitors variations of antimicrobial resistance over time and place. In December 2005, over 900 microbiological laboratories serving some 1400 hospitals from 32 countries had provided susceptibility data of almost 400,000 invasive isolates. An interactive website is available at www.rivm.nl/earss, where up-to-date details can be found on country-speciﬁc resistance levels for important groups of antibiotics. Period of data collection: January 1999 – December 2005 This document was prepared by the EARSS Management Team, members of the Advisory Board, and national representatives of EARSS, Bilthoven, The Netherlands, October 2006. ISBN-10: 90-6960-159-1 ISBN-13: 978-90-6960-159-5 Contents 3 Table of contents Annual Report 2005 A word of thanks ............................................................................................................................................................................................................................................ 7 Summary .................................................................................................................................................................................................................................................................. 9 List of abbreviations and acronyms ................................................................................................................................................................................... 11 The EARSS network from January 2005 till August 2006 .................................................................................................................. 13 I. Countries participating in EARSS .............................................................................................................................. 13 II. EARSS national representatives per country ................................................................................................ 13 III. EARSS national data managers and contact persons of national networks ............ 14 IV. EARSS advisory board members in 2005.......................................................................................................... 16 V. Collaborating parties and representatives .......................................................................................................... 16 VI. EARSS management team .................................................................................................................................................... 16 VII. EARSS related publications ................................................................................................................................................ 17 Chapter 1. Introduction ................................................................................................................................................................................................................. 21 Chapter 2. EARSS objectives and operational strategy ...................................................................................................................... 23 2.1. Objectives ...................................................................................................................................................................................................... 23 2.2. The EARSS network and operational strategy ................................................................................................ 23 2.2.1. Organisation of the EARSS network .................................................................................................... 23 2.2.2. The national networks ............................................................................................................................................. 24 2.2.3. Collecting and processing antimicrobial susceptibility testing (AST) results .................................................................................................................................................. 25 2.2.4. EARSS meetings ............................................................................................................................................................ 26 2.2.5 Linkage with other networks ........................................................................................................................... 26 2.3. EARSS in 2006 and beyond ................................................................................................................................................... 26 2.3.1. Collection of antimicrobial susceptibility data ......................................................................... 26 2.3.2. The EARSS network ................................................................................................................................................. 27 2.3.3. Upcoming EARSS meetings ........................................................................................................................... 27 2.3.4. New initiatives .................................................................................................................................................................. 27 Chapter 3. The status of Quality Assessment for Antimicrobial susceptibility testing in Europe. 3.1. Introduction ................................................................................................................................................................................................. 29 3.2. Methods ............................................................................................................................................................................................................ 29 3.3. Results ................................................................................................................................................................................................................ 29 3.4. Conclusions ................................................................................................................................................................................................. 32 3.5. Acknowledgements ............................................................................................................................................................................ 33 4 Contents Chapter 4. Antimicrobial resistance in Europe .............................................................................................................................................. 35 4.1 Introduction ................................................................................................................................................................................................. 35 4.2. Streptococcus pneumoniae ......................................................................................................................................................... 35 4.2.1. Clinical and epidemiological importance ........................................................................................ 35 4.2.2. Streptococcus pneumoniae resistance trends: 1999-2005 .......................................... 36 4.2.3. Serotypes .................................................................................................................................................................................. 38 4.2.4 Conclusions ........................................................................................................................................................................... 42 4.3. Staphylococcus aureus .................................................................................................................................................................. 43 4.3.1. Clinical and epidemiological importance ........................................................................................ 43 4.3.2. Staphylococcus aureus resistance trends: 1999-2005 ...................................................... 44 4.3.3. MRSA by hospital department ..................................................................................................................... 46 4.3.4. Conclusions ........................................................................................................................................................................... 46 4.4. Enterococci ................................................................................................................................................................................................... 46 4.4.1. Clinical and epidemiological importance ........................................................................................ 46 4.4.2. Enterococcus faecalis resistance trends: 2001-2005 ........................................................ 48 4.4.3. Enterococcus faecium resistance trends: 2001-2005 ........................................................ 49 4.4.4. Conclusions ........................................................................................................................................................................... 51 4.5. Escherichia coli ...................................................................................................................................................................................... 51 4.5.1. Clinical and epidemiological importance ........................................................................................ 51 4.5.2. Escherichia coli resistance trends: 2001-2005 ......................................................................... 53 4.5.3. Conclusions ........................................................................................................................................................................... 61 4.6. Klebsiella pneumoniae .................................................................................................................................................................. 62 4.6.1. Clinical and epidemiological importance ........................................................................................ 62 4.6.2. Klebsiella pneumoniae resistance in 2005 ..................................................................................... 62 4.6.3. Conclusions ........................................................................................................................................................................... 66 4.7. Pseudomonas aeruginosa .......................................................................................................................................................... 66 4.7.1. Clinical and epidemiological importance ........................................................................................ 66 4.7.2. Pseudomonas aeruginosa resistance in 2005 ............................................................................. 66 4.7.3. Conclusions ........................................................................................................................................................................... 71 Chapter 5. Conclusions and Recommendations ............................................................................................................................................ 73 Contents 5 Annex 1. Annex 2. Technical notes on data analysis ................................................................................. 79 Country Summary Sheets ............................................................................................ 81 Austria ......................................................................................................................... 82 Belgium ....................................................................................................................... 84 Bulgaria ........................................................................................................................ 86 Croatia ......................................................................................................................... 88 Cyprus ......................................................................................................................... 90 Czech Republic ........................................................................................................... 92 Denmark ...................................................................................................................... 94 Estonia ......................................................................................................................... 96 Finland ......................................................................................................................... 98 France ........................................................................................................................ 100 Germany .................................................................................................................... 102 Greece ........................................................................................................................ 104 Hungary ..................................................................................................................... 106 Iceland ....................................................................................................................... 108 Ireland ........................................................................................................................ 110 Israel .......................................................................................................................... 112 Italy ............................................................................................................................ 114 Latvia ......................................................................................................................... 116 Luxembourg .............................................................................................................. 118 Malta .......................................................................................................................... 120 Netherlands ................................................................................................................ 122 Norway ...................................................................................................................... 124 Poland ........................................................................................................................ 126 Portugal ..................................................................................................................... 128 Romania .................................................................................................................... 130 Slovakia ..................................................................................................................... 132 Slovenia ..................................................................................................................... 134 Spain .......................................................................................................................... 136 Sweden ...................................................................................................................... 138 United Kingdom ........................................................................................................ 140 Overview tables of antibiotic resistance in Europe ................................................... 142 Annex 3. A word of thanks 7 A word of thanks The successful introduction of sulpha drugs and penicillin in the 1940’s heralded an era of drug discovery reminiscent only of a freshly unearthed gold ﬁeld. Numerous derivatives from over twenty distinct antibiotic classes had been licensed in the 15 years between 1945 and 1960 alone. And in the decades that followed, demographic and economic improvements in Europe and Northern America lead to a decline in infectious diseases as one of the major health threats in this part of the world. But many of these achievements are increasingly threatened. Since the 1990’s, only a single class of antibacterial compounds have become available for therapeutic use in humans (oxazolidinones). At the same time antimicrobial resistance clearly became an emerging problem, threatening the previous advances of modern medicine. The consequences of this disquieting development have still not been appreciated to its full extent at a time when international, national and non-governmental agencies trust that market forces and worldwide demand will redirect the ﬂow of investment and scientiﬁc initiative. It is therefore critical to realise that antimicrobial effectiveness, widely accepted as a common good, cannot be taken for granted and that antimicrobial substances are increasingly attaining the status of non-renewable resources. What is even more surprising is that the scientiﬁc community lacks a precise understanding of the impact of this problem on public health in terms of mortality, morbidity and economic loss. Before being able to estimate what effect antimicrobial resistance has on healthy life expectancy, it is necessary to have comparable resistance surveillance data for wide geographical regions. We are therefore deeply indebted to all the national representatives and national data managers from 32 European countries, and the 900 participating laboratories willing to keep up their enthusiasm to share antimicrobial susceptibility data throughout the European region and to the European Commission and Dutch Ministry of Welfare and Sports who, during the last seven years, have maintained the ﬁnancial support that made EARSS the largest publicly funded surveillance network on antimicrobial resistance worldwide. I would also like to thank all members of the EARSS Advisory Board and the EARSS Management Team for sharing their expertise, for their contribution to this report and also for making the activities organised within EARSS again successful during the past year. Furthermore I would like to thank John Stelling for his ever altruistic contribution and the many visits to participating countries to give support on WHONET for EARSS and Bennie Bloemberg for his technical support in developing the country summary sheets that are a substantial part of this report. Finally, I would like to thank the European Centre for Disease Prevention and Control (ECDC) for their success in earmarking the funding, which will allow us to continue our collaborative effort of this well-functioning network for yet another year. With conﬁdence I look forward to the important future work with all of you…. Hajo Grundmann Project leader EARSS Project Department of Infectious Diseases Epidemiology National Institute of Public Health and the Environment Summary 9 Summary The European Antimicrobial Resistance Surveillance System (EARSS) is an international initiative funded by the Director General for Health and Consumer Protection (DG SANCO) of the European Commission and the Dutch Ministry of Health, Welfare and Sports. It maintains a comprehensive surveillance and information system that links national networks by providing comparable and validated data on the prevalence and spread of major invasive bacteria with clinically and epidemiologically relevant antimicrobial resistance in Europe. EARSS collects routinely generated antimicrobial susceptibility (AST) data, provides spatial trend analyses and makes timely feedback available via an interactive website at www.rivm.nl/earss. Routine data for major indicator pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumonia and Pseudomonas aeruginosa) are regularly submitted by over 900 laboratories serving around 1400 hospitals in 32 European countries. By the end of 2005 two new countries joined the EARSS initiative, Lithuania and Turkey. Based on a previous laboratory/hospital questionnaire, the overall hospital catchment population of the EARSS network is estimated to include over 100 million inhabitants in the European region, with national coverage rates that ranged between 20-100% for individual countries. In 2005, information on the laboratory demands for external quality assessment (EQA) was collected by questionnaire. Several countries do not have formal agreements on national or international quality assessment schemes in place. Among the international providers of EQA the British UK-NEQAS scheme was most frequently named by countries. Alternatively, different national schemes are in place, either alone or in combination with one of the international programs. Importantly, the majority of laboratories that participate in EARSS utilise some type of EQA, demonstrating their commitment to diagnostic accuracy. In Europe the proportion of antibiotic resistant S. pneumoniae keeps changing with decreasing penicillin-resistance in some highly endemic countries and with continuous loss of susceptibility against penicillin and erythromycin in others. The main resistance phenotypes in pneumococci are conﬁned to few serogroups, all of which are included in the currently promoted conjugate vaccines. This suggests that vaccination, especially in young children, may represent an effective additional means of controlling antibiotic resistance in pneumococcal disease in Europe. The increase of MRSA is consistent throughout Europe and includes countries with high, medium and low baseline MRSA endemicity. At the same time it appears that the MRSA pandemic is not an irreversible secular trend as two European countries (Slovenia and France) succeeded in constantly reducing the proportion of MRSA among S. aureus blood stream infections over the past ﬁve or six years. The speed with which ﬂuoroquinolones loose their activity against E. coli is next to no other compound pathogen combination in the EARSS database. Combined resistance is a frequent occurrence, with co-resistance to three antimicrobial classes including third generation cephalosporins already among the four most common resistance patterns encountered in invasive E. coli in Europe, and undeniably these resistance traits are on the increase as well. In K. pneumoniae a high prevalence of resistant strains to third generation cephalosporins, ﬂuoroquinolones and aminoglycosides becomes evident in Eastern and Southeastern Europe. Combined resistance is the dominant threat imposed by invasive P. aeruginosa. Our data suggest that the same geographical gradient exists for all gramnegative pathogens and shows that lower resistance prevails in the Northwest with increasing resistance towards the Southeast of Europe. 10 Summary It appears that the overall threat imposed on European communities by the increasing loss of antimicrobial effectiveness continues unabated with the same speed as has been previously described by our network. This is shown most convincingly among the pathogens that are frequently transmitted in health care settings (MRSA and VRE) and for antimicrobial compounds that are available for oral administration and hence preferred in ambulatory care (aminopenicillins, macrolides, and ﬂuoroquinolones). The growing availability of third-line antimicrobial drugs as oral formulations is in this context a matter of concern and underscores the need of locally or nationally advised prescribing practices for both ambulatory and hospital-based care. List of abbreviations and acronyms 11 List of abbreviations and acronyms AMR ARMed AST CC CSF DCFP DEFS DG-SANCO DNA EARSS EARSS-ibis EARSS-MT EARSS-NR ENSP EU EQA ESAC ESBL ESCMID ESGARS EUCAST GISA HLAR ICU IPSE MIC MLS MLST MRSA NRL OXA PBP PCV PFGE PNSP RIVM RNA SeqNet.org Spa-typing SHV UK-NEQAS VISA VRE VREF VRSA WHO WHONET Antimicrobial resistance Antibiotic resistance surveillance and control in the Mediterranean region Antimicrobial susceptibility testing Clonal complex Cerebrospinal ﬂuid Data Check and Feedback Programme Data Entry & Feedback Software Directorate General for Health and Consumer Protection Deoxyribonucleic Acid European Antimicrobial Resistance Surveillance System EARSS internet based information system EARSS Management Team EARSS National Representatives Erythromycin non-susceptible Streptococcus pneumoniae European Union External quality assurance European Surveillance of Antimicrobial Consumption Extended-spectrum beta-lactamase European Society of Clinical Microbiology and Infectious Diseases ESCMID Study Group for Antimicrobial Resistance Surveillance European Committee on Antimicrobial Susceptibility Testing Glycopeptide intermediate resistant Staphylococcus aureus High level aminoglycoside resistance Intensive care unit Improving Patient Safety in Europe Minimal inhibitory concentration Macrolide-Lincosamide-Streptogramin Multi Locus Sequence Typing Methicillin-resistant Staphylococcus aureus National reference laboratories Oxacillinase gene Penicillin binding protein Pneumococcal conjugate vaccine Pulsed Field Gel Electrophoresis Penicillin nonsusceptible Streptococcus pneumoniae Rijksinstituut voor Volksgezondheid en Milieu (National Institute for Public Health and the Environment) Ribonucleic Acid European Network of Laboratories for Sequence Based Typing of Microbial Pathogens S. aureus protein A sequence typing Sulfhydryl Variable gene United Kingdom National External Quality Assessment Scheme for Microbiology Vancomycin intermediate resistant Staphylococcus aureus Vancomycin resistant enterococci Vancomycin resistant Enterococcus faecalis Vancomycin resistant Staphylococcus aureus World Health Organization WHO microbiology laboratory database software The EARSS network from January 2005 till August 2006 13 The EARSS network from January 2005 till August 2006 I. Countries participating in EARSS AT BE BG HR CY CZ DK EE FI FR DE GR HU IS IE IL Italy Latvia Lithuania* Luxembourg Malta Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Turkey* United Kingdom IT LV LT LU MT NL NO PL PT RO SK SI ES SE TR UK Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Israel * regular reporting commences in 2006 II. EARSS national representatives per country Estonia (EE) P. Naaber Finland (FI) O. Lyytikäinen A. Nissinen France (FR) B. Coignard V. Jarlier Germany (DE) W. Witte K. Heckenbach Iceland (IS) K. Kristinsson Israel (IL) R. Raz Italy (IT) A. Pantosti P. D ‘Ancona Latvia (LV) A. Balode Netherlands (NL) E. Tiemersma A. de Neeling Norway (NO) A. Hoiby G. Simonsen Poland (PL) W. Hryniewicz Portugal (PT) M. Caniça Spain (ES) F. Baquero J. Campos Sweden (SE) B. Liljequist Turkey (TR) D. Gür United Kingdom (UK) A. Johnson, R. Hill (England & Wales) H. Hughes (Northern Ireland) A. Eastaway (Scotland) Austria (AT) H. Mittermayer W. Koller Belgium (BE) H. Goossens E. Hendrickx Bulgaria (BG) B. Markova Croatia (HR) S. Kalenic A.Tambic Andrasevic Cyprus (CY) D. Bagatzouni Czech Rep. (CZ) P. Urbaskova Denmark (DK) D. Monnet R. Skov Greece (GR) A. Tsakris A. Vatopoulus Hungary (HU) M. Füzi Ireland (IE) R. Cunney O. Murphy Lithuania (LT) J. Miciuleviciene Luxembourg (LU) R. Hemmer Malta (MT) M. Borg Romania (RO) I. Codita Slovakia (SK) L. Langsadl Slovenia (SI) M. Mueller-Premru J. Kolman 14 The EARSS network from January 2005 till August 2006 III. EARSS national data managers and contact persons of national networks Contact person S. Metz E. Hendrickx J. Verhaegen M. Struelens D. Piérard H. Goossens Y. Marteva-Proevska B. Markova S. Kalenic D. PieridouBagatzouni V. Jakubu B. Mackova P. Urbaskova D. Monnet R. Skov M. Kaltoft K. Kermes M. Ivanova T. Möttönen (KTL) A. Nissinen (FiRe) Institute Elisabethinen Hospital Linz Scientiﬁc Institute of Public Health Catholic University of Leuven Free University of Brussels Free University of Brussels University of Antwerp “Alexandrovska”, Laboratory for Clinical Microbiology, Soﬁa Clinical Hospital Centre Zagreb Nicosia General Hospital Medical and Public Health Services National Institute of Public Health Statens Serum Institut Country Austria Belgium National Surveillance Network EARSS Austria EARSS Belgium www.iph.fgov.be URL Bulgaria EARSS Bulgaria earss.online.bg Croatia Cyprus EARSS Croatia EARSS/ARMed Cyprus Czech Republic Denmark National Reference Labo- www.szu.cz/cem/ ratory for Antibiotics earss/czeanj.htm Danish Study Group for Antimicrobial Resistance Surveillance (DANRES) DANMAP EARSS Estonia Finnish Hospital Infection Program (SIRO) Finnish Study Group for Antimicrobial Resistance (FiRe) ONERBA National Reference Centre for pneumococci www.ssi.dk (for DANMAP reports, see: www. danmap.org) Tartu University Clinics Rakvere Hospital National Public Health Institute (KTL) Estonia Finland www.ktl.ﬁ/siro www.ktl.ﬁ/extras/ﬁre/ index.html www.onerba.org D. Trystram/Y. Pean/H. Chardon France L. Gutmann E. Varon S. Maugat National institute of Public Health Surveillance (InVS) A. Vatopoulos Department of Microbiol- Greece ogy, National School of Public Health Z. Vegh L. Helgadottir S. Murchan R. Raz H. Edelstein R. Colodner F. D’Ancona A. Pantosti National Centre for Epidemiology Landspitali University Hospital Health Protection Surveillance Centre Ha’Emek Medical Centre Hungary Iceland Ireland Israel www.invs.sante.fr The Greek System for www.mednet.gr/ the Surveillance of whonet Antimicrobial Resistance (WHONET Greece) EARSS Hungary www.antsz.hu EARSS Ireland EARSS Israel www.hpsc.ie Istituto Superiore di Sanità Italy AR-ISS www.simi.iss.it/ antibiotico_ resistenza.htm The EARSS network from January 2005 till August 2006 15 Contact person A. Balode J. Miciuleviciene L. Dagyte-Sileikiene O. Courteille V. Karremans P. Kirpach E. Scicluna H. van Vliet Institute Pauls Stradins Clinical University Hospital National Public Health Investigation Centre Microbiology Lab, Luxembourg’s Hospital Centre Infection Control Unit, St. Luke’s Hospital National Institute of Public Health and the Environment Country Latvia Lithuania Luxembourg National Surveillance Network EARSS Latvia EARSS Lithuania EARSS Luxembourg URL www.nvstc.lt Malta Netherlands EARSS Malta Electronic laboratory surveillance in the Netherlands (ISIS) Resistance surveillance project EARSS The Netherlands NORM www.slh.gov.mt/ ICUnit www.isis.rivm.nl A. de Neeling E. Bosch G. Simonsen F. Width Gran P. Grzesiowski M. Caniça P. Lavado I. Codita C. Balotescu J. Kolman M. Mueller-Premru L. Langsadl J. Oteo J. Campos B. Olsson-Liljequist L. Gezelius University Hospital of North Norway/ National Institute of Public Health St. Olav University Hospital Trondheim National Institute of Public Health National Institute of Health Dr. Ricardo Jorge National Institute for Research and Development in Microbiology and Immunology Cantacuzino University Medical Centre Ljubljana Institute of Microbiology and Immunology, Medical Faculty, University of Ljubljana National Institute for TB and Respiratory Diseases Instituto de Salud Carlos III Swedish Institute for Infectious Disease Control Norway Poland Portugal Romania OPTY ARSIP/EARSS Portugal EARSS Romania www.insarj.pt Slovenia EARSS Slovenia Slovakia Spain Sweden EARSS Slovakia EARSS Spain Electronic laboratory surveillance in Sweden (ResNet), Resistance surveillance project EARSS Sweden ARMed/EARSS Turkey www.nutarch.sk www.smittskyddsinstitutet.se D. Gür M. Lillie J. Shah Hacettepe University School of Medicine Children’s Hospital Clinical Microbiology laboratory Health Protection Agency Communicable Disease Surveillance network Turkey http://www.slh.gov. mt/ armed/default1.asp United Kingdom UK EARSS Collaborating Group www.hpa.org.uk 16 The EARSS network from January 2005 till August 2006 IV. EARSS advisory board members in 2005 Name Dr. A. Balode Prof. F. Baquero Dr. G. Cornaglia Prof. J. Degener Prof. V. Jarlier Dr. G. Kahlmeter Dr. J. Kolman Prof. A. Vatopoulos Representing all countries ESGARS ESCMID all countries all countries EUCAST all countries all countries Institute Paul Stradins Clinical University Hospital, Riga, Latvia Hospital Ramon y Cajal, Madrid, Spain University of Verona, Italy University Medical Centre Groningen, The Netherlands Groupe Hospitalier Pitié-Salpêtrière, Paris, France Central Hospital Växjö, Sweden University Medical Centre Ljubljana, Slovenia National School of Public Health, Athens, Greece V. Collaborating parties and representatives G. Cornaglia F. Baquero G. Kahlmeter K. Holloway J. Stelling C. Walton ESCMID ESGARS EUCAST WHO WHONET UK-NEQAS VI. EARSS management team Project leader, Scientiﬁc coordinator Project coordinator Epidemiologists International Data Manager Assistant Data Manager Management Assistant E-mail: Post: H. Grundmann E. Tiemersma N. van de Sande-Bruinsma M. de Kraker J. Monen E. Bosch C. Schinkel info.earss@rivm.nl National Institute for Public Health and the Environment (RIVM) Antonie van Leeuwenhoeklaan 9 PO Box 1 3720 BA Bilthoven The Netherlands +31 30 274 36 79 +31 30 274 44 09 Phone: Fax: The EARSS network from January 2005 till August 2006 17 VII. EARSS related publications Scientiﬁc papers in peer reviewed journals EARSS management team • Bronzwaer SL, Cars O, Buchholz U, Molstad S, Goettsch W, Veldhuijzen IK, Kool JL, Sprenger MJ, Degener JE. European Antimicrobial Resistance Surveillance System. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 2002; 8: 278-82. Bronzwaer S, Buchholz U, Courvalin P, Snell J, Cornaglia G, de Neeling A, Aubry-Damon H, Degener J; EARSS participants. Comparability of antimicrobial susceptibility test results from 22 European countries and Israel: an external quality assurance exercise of the European Antimicrobial Resistance Surveillance System (EARSS) in collaboration with the United Kingdom National External Quality Assurance Scheme (UK NEQAS). J Antimicrob Chemother 2002; 50: 953-64. Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, Kool JL, Sprenger MJW, Degener JE, and participants in the European Antimicrobial Resistance Surveillance System A European Study on the Relationship between Antimicrobial Use and Antimicrobial Resistance. Emerg Infect Dis 2002; 6: 278-282. Tiemersma EW, Bronzwaer SL, Lyytikäinen O, Degener JE, Schrijnemakers P, Bruinsma N, Monen J, Witte W, Grundmann H, and EARSS Participants. Methicillin-resistant Staphylococcus aureus in Europe, 1999–2002. Emerging Infect Dis 2004; 10: 1627-1634. Bruinsma N, Kristinsson K, Bronzwaer S, Schrijnemakers P, Degener J, Tiemersma E, Hryniewicz W, Monen J, Grundmann H, and the EARSS participants. Trends of penicillin and erythromycin resistance among invasive Streptococcus pneumoniae in Europe. J Antimicrobial Chemother 2004; 54: 1045-1050. Tiemersma EW, Monnet DL, Bruinsma N, Skov R, Monen JCM, Grundmann H, and EARSS participants. Staphylococcus aureus bacteremia, Europe. Emerging Infect Dis 2005; 11: 1798-9. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of methicillin- resistant Staphylococcus aureus as a public health threat. The Lancet 2006; 368: 874-885. Foster KR, Grundmann H. Do we need to put society ﬁrst? The potential for tragedy in antimicrobial resistance. PloS Medicine 2006; 3: 29. Goossens H, Ferech M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005; 9459: 579-587. Budimir A, Duerenberg RH, Plecko V, Vink C, Kalenic S, Stobberingh E. Molecular characterization of methicillin-resistant Staphylococcus aureus bloodstream isolates from Croatia. J Antimicrob Chemother, 2006; 57:331334. Urbaskova P, Mackova B, Jakubu V, Zemlickova H a CZ-EARSS, Resistance to clindamycin among 1373 Staphylococcus aureus isolates from blood, Zprávy CEM (Bulletin of the Centre of Epidemiology and Microbiology) 2006; 15(3-4):156-158, ISSN 1211-7358 Urbaskova P, Mackova B, Jakubu V, Zemlickova H a CZ-EARSS, Antimicrobial resistance surveillance in invasive Staphylococcus aureus isolates within EARSS, Zprávy CEM (Bulletin of the Centre of Epidemiology and Microbiology) 2006; 15(5): 200-203, ISSN 1211-7358 Lõivukene K, Kermes K, Sepp E, Adamson V, Mitt P, Kallandi Ü, Otter K, Naaber P. The surveillance of antimicrobial resistance of invasive pathogens: Estonian experience. Eurosurveillance monthly 2006; 11; Issues 1-3: 47-49 Lõivukene K, Kermes K, Sepp E, Adamson V, Mitt P, Jürna M, Mägi H, Kallandi Ü, Otter K, Naaber P. The comparison of susceptibility of gram-negative invasive and nosocomial pathogens in Estonian hospitals. Antonie van Leeuwenhoek. 2006; 89: 367-371 Lõivukene K, Sepp E, Adamson V, Kallandi Ü, Otter K, Naaber P. Importance and antimicrobial susceptibility of Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae in intensive care units. Estonian study compared with other European data. Scand J Infect Dis, in press. • • • • • • • Belgium • Croatia • Czech Republic • • Estonia • • • 18 The EARSS network from January 2005 till August 2006 Finland • • • • • • • Italy • Moro ML, Pantosti A, Boccia D, e il gruppo EARSS-Italia. Sorveglianza dell’antibiotico-resistenza in infezioni invasive da Streptococcus pneumoniae e Staphylococcus aureus: il progetto EARSS in Italia (Aprile 1999- Aprile 2000). Ann Ig 2002; 14: 361-371. Boccia D, Pantosti A, D’Ancona F, Giannitelli S, Monaco M, Salmaso S. Antimicrobial resistance in Italy: preliminary results from the AR-ISS project. Eurosurveillance 2002; 7: 87-93. Pantosti A, Boccia D, D’Ambrosio F, Recchia S, Oreﬁci G, Moro ML, National Surveillance of Bacterial Meningitis, and The EARSS-Italia Study. Inferring the potential success of pneumococcal vaccination in Italy: serotypes and antibiotic resistance of Streptococcus pneumoniae isolates from invasive diseases. Microb Drug Resist 2003; 9: S61-S68. Fokas S, D’Ancona F, Boccia D, Pantosti A, Giannitelli S, Meduri FR, Salmaso S per il gruppo di studio AR-ISS. L’antibioticoresistenza in Italia: il progetto AR-ISS. Risultati del primo anno di attività e prospettive per il futuro. Not Ist Super Sanità 2003; 16: 11-14. Boccia D, Spila Alegiani S, Pantosti A, Moro ML, Traversa G. The geographic relationship between the use of antimicrobial drugs and the pattern of resistance for Streptococcus pneumoniae in Italy. Eur J Pharmacol 2004; 60: 115-119. Stampone L, Del Grosso M, Boccia D, Pantosti A. Clonal spread of a vancomycin-resistant Enterococcus faecium strain among bloodstream-infecting isolates in Italy. J Clin Microbiol 2005; 43: 1575-1580. Monaco M, Camilli R, D’Ambrosio F, Del Grosso M, Pantosti A. Evolution of erythromycin resistance in Streptococcus pneumoniae in Italy. J Antimicrob Chemother 2005; 55: 256-259. Boccia D, D’Ancona F, Salmaso S, Monaco M, Del Grosso M, D’Ambrosio F. Giannitelli S, Lana S, Fokas S, Pantosti A e il Gruppo AR-ISS. Antibiotico-resistenza in Italia: un anno di attività del progetto di sorveglianza AR-ISS. Ann Ig 2005; 17: 95-110. Murphy OM, Murchan S, Whyte D, Humphreys H, Rossney A, Clarke P, Cunney R, Keane C, Fenelon LE, O’Flanagan D. Impact of the European Antimicrobial Resistance Surveillance System on the development of a national programme to monitor resistance in Staphylococcus aureus and Streptococcus pneumoniae in Ireland, 1999-2003. Eur J Clin Microbiol Infect Dis 2005; 24: 480-3. Rossney AS, Lawrence MJ, Morgan PM, Fitzgibbon MM, Shore A, Coleman DC, Keane CT, O’Connell B. Epidemiological typing of MRSA isolates from blood cultures taken in Irish hospitals participating in the European Antimicrobial Resistance Surveillance System (1999-2003). Eur J Clin Microbiol Infect Dis 2006; 25: 79-89. Codita I. The global strategy for antimicrobial resistance containment, European Antimicrobial Resistance Surveillance System (EARSS). Preparatory stages for integrating national surveillance of antimicrobial resistance in the European system. Viata medicala 2001; May: 2. Lyytikäinen O, Möttönen T, Nissinen A. Mikrobilääkeresistenssin seuranta Euroopassa: EARSS-tuloksia 2002. Kansanterveys 2003; 10: 13-14. Lyytikäinen O, Möttönen T, Nissinen A. Mikrobilääkeresistenssin seuranta Euroopassa: EARSS-tuloksia 2002. Sairaalahygienialehti 2003; 6: 282-283. Lyytikäinen O, Nissinen A. Mikrobilääkeresistentit sairaalainfektioiden aiheuttajat meillä ja muualla. Sairaala 2004; 3: 14-15. Lyytikäinen O, Agthe N, Virolainen-Julkunen A, Vuopio-Varkila J. MRSA-tilanne yhä huonontunut – nyt myös vaikeissa yleisinfektioissa. Kansanterveys 2004; 7: 9. Lyytikäinen O, Agthe N, Virolainen-Julkunen A, Vuopio-Varkila A. MRSA cases continue to increase in Finland. Eurosurveillance weekly 16 September 2004. Virolainen-Julkunen A, Vuopio-Varkila J, Huovinen P, Lyytikäinen O, Ruutu P. Lisämääräraha MRSA:n torjuntaan. Kansanterveys 2005; 2-3: 7-8. Lyytikäinen O. Onko Suomen MRSA-tilanteen huononeminen pysähtynyt? Kansanterveys 2005; 7: 3-4. • • • • • • • Ireland • • Romania • The EARSS network from January 2005 till August 2006 19 Slovenia • Kolman J, Gubina M, Mueller-Premru M, So�an M, Cyetkovski L, Koren S. Slovenski rezultati ob�utljivosti bakterij Staphylococcus aureus in Streptococcus pneumoniae iz hemokultur in likvorjev, zbrani v okviru projekta EARSS. In: Mueller-Premru M, Gubina M, editors. Mikrobi in antibiotiki 2001. Zbornik predavanj Mikrobiološki simpozij z mednarodno udeležbo; 2001 jun 22-23; Ljubljana. Ljubljana: Slovensko zdravnisko društvo, Sekcija za klinicno mikrobiologijo in hospitalne infekcije 2001; 185-92. Kolman J, Gubina M, Mueller-Premru M, Loren�i�-Robnik S, Žohar-�retnik T, Harlander T, Štrumbelj I, Kav�i� M, Grmek-Košnik I, Tomi� V, Ribi� H, Fišer J, Merljak L, Piltaver-Vajdec I. Sodelovanje Slovenije v evropskem projektu EARSS - prikaz rezultatov deleža MRSA - izolatov iz hemokultur. Isis 2003; 12: 30-33. Kolman J, Gubina M. Trendi ob�utljivosti invazivnih izolatov bakerije Staphylococcus aureus v Sloveniji in Evropi - rezultati projekta EARSS. Med Razgl 2004; 43: 11-17. Kolman J, Gubina M. Sodelovanje Slovenije v projektu EARSS. Med Razgl 2006; 45 (Suppl 2): 3-10. Oteo J, Campos J, Baquero F and the Spanish EARSS Group. Antibiotic resistance in 1962 invasive isolates of Escherichia coli in 27 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2001). J Antimicrob Chemother 2002; 50: 945-952. Oteo J, Cruchaga S, Campos J, Saez JA, Baquero F, y miembros espanoles del grupo “European Antimicrobial Resistance Surveillance System. Antibiotic resistance in blood isolates of Staphylococcus aureus in 31 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2000)]. Medicina Clinica 2002; 119: 361-5. Oteo J, Cruchaga S, Campos J, Saez JA, Baquero F, y miembros espanoles del grupo “European Antimicrobial Resistance Surveillance System. Antibiotic resistance in 622 Streptococcus pneumoniae isolated from blood and cerebrospinal ﬂuid in 33 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2000)]. Enfermedades Infecciosas y Microbiologia Clinica 2003; 21: 12-9. Oteo J, Campos J, Cruchaga S, Baquero G, Lázaro E, Madurga M, de Abajo FJ, Baquero F and the Spanish EARSS Group. Increase of resistance to macrolides in invasive Streptococcus pneumoniae in Spain (2000-2001). Clin Microbiol Infect 2004; 12: 851-854. Oteo J, Baquero F, Vindel A, Campos J and the Spanish EARSS Group. Antibiotic resistance in 3113 blood isolates of Staphylococcus aureus in 40 Spanish hospitals participating in the European Antimicrobial Resistance Surveillance System (2000-2002). J Antimicrob Chemother 2004; 53: 1033-1038. Oteo J, Lázaro E, de Abajo FJ, Campos J, and Spanish EARSS Group. Trends in antimicrobial resistance in 1,968 invasive Streptococcus pneumoniae strains isolated in Spanish hospitals (2001-2003): Decreasing penicillin-resistance in children’s isolates. J Clin Microbiol 2004; 42: 5571-5577. Oteo J, Lázaro E, de Abajo FJ, Baquero F, Campos J and the Spanish EARSS Group. Antimicrobial-resistant invasive Escherichia coli, Spain. Emerg Infect Dis 2005, 11: 546-553. Johnson AP, Aucken HM, Cavendish S, Ganner M, Wale MC, Warner M et al. Dominance of EMRSA-15 and -16 among MRSA causing nosocomial bacteraemia in the UK: analysis of isolates from the European Antimicrobial Resistance Surveillance System (EARSS). J Antimicrob Chemother 2001; 48: 143-144. Johnson AP, Lamagni TL, Wale M, Cavendish S, Bishop L, Alhaddad N et al. Susceptibility to moxiﬂoxacin of pneumococci isolated in English hospitals participating in the European Antimicrobial Resistance Surveillance System (EARSS) in 2003. Int J Antimicrob Agents 2005; 25: 539-541. • • • • Spain • • • • • • United Kingdom • • Chapter 1. Introduction 21 Chapter 1. Introduction Antimicrobial resistance (AMR) threatens the effectiveness of successful treatment of infections and is a public health issue with local, national, and global dimensions. Antimicrobial resistance thus can result in increased morbidity, disease burden, and mortality. Surveillance of antimicrobial resistance proportions provides data that are needed to raise the awareness to the problem and instigate necessary interventions. At the ‘Microbial Threat Conference’, held in September 1998 in Denmark, it was concluded that an ‘Effective European surveillance should be in place and must have the agreement and active involvement of all participants’ (‘the Copenhagen Recommendations’ [1]). This conference led to the foundation of the European Antimicrobial Resistance Surveillance System (EARSS), funded by the Directorate General for Health and Consumer Protection (DG SANCO) of the European Commission and the Dutch Ministry of Health, Welfare and Sports. Since 1999, it has been the remit of EARSS to maintain a comprehensive surveillance and information system that links national networks by providing comparable and validated data about the prevalence and spread of major invasive bacteria with clinical and epidemiologically relevant AMR in Europe. In 2001, at a follow-up EU conference in Visby, Sweden, it was concluded that all Member States of the European Union (EU) shall join the EARSS initiative as a minimum requirement of national surveillance programmes (‘the Visby recommendations’ [2]) and during the Rome conference convened by the EU Commission Directorate for Research and Development in November 2003, is was made clear that linking antimicrobial resistance with microbial ecology and improving the knowledge about its costs to European societies is essential for the development of effective control strategies [3]. EARSS is co-ordinated by the Dutch National Institute of Public Health and the Environment (RIVM). Ever since the start of EARSS, the number of participants has increased. By the beginning of 2006, EARSS covers an estimated population of more than a 100 million inhabitants served by about 1400 hospitals in 32 countries. The EARSS database contains AMR data on approximately 400,000 invasive isolates of Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. It is thus the most comprehensive public health effort that describes and analyses geographic and secular trends in AMR worldwide. EARSS operates in close collaboration with other EU-ﬁnanced projects: European Surveillance of Antimicrobial Consumption (ESAC), and Antibiotic Resistance Surveillance and Control in the Mediterranean region (ARMed). There is a close partnership between the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and two of the society’s sub committees, namely, the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and the ESCMID Study Group for Antimicrobial Resistance Surveillance (ESGARS). This report presents an overview of activities, innovations and results of the EARSS network from January 2005 till August 2006. Chapter 2 summarises the objectives and operational strategy. Chapter 3 describes the situation on External Quality Assessment of Antimicrobial Susceptibility Testing in Europe. Chapter 4 provides a descriptive analysis of the situation of AMR in the European region. Chapter 5 presents the overall conclusions and recommendations based on these results. The annexes contain a technical section (Annex 1), detailed country summary sheets (Annex 2) and overview 22 Chapter 1. Introduction tables of antibiotic resistance in Europe in 2005 (Annex 3). Results are based on data recorded from January 1999 - December 2005, if not otherwise indicated. References 1. Thamdrup Rosdahl V and Borge Pederson K. Report from the invitational EU Conference on the microbial threat, Copenhagen, Denmark, 9-10 September 1998. 2. Progress Report on Antimicrobial Resistance, Visby, Sweden: Social Styrelsen, the Swedish National Board of Health and Welfare, June 2001. Available at http://www.sos.se/FULLTEXT/123/2001-123-68/2001-123-68.pdf. 3. Report from the European Conference on the Role of Research in Combating Antibiotic Resistance, 2003. Clin Microbiol Infect 2004; 10: 473 – 497. Chapter 2. EARSS objectives and operational strategy 23 Chapter 2. EARSS objectives and operational strategy 2.1. Objectives It is the remit of EARSS to maintain a comprehensive surveillance and information system that links national networks by providing comparable and validated data on the prevalence and spread of major invasive bacteria with clinically and epidemiologically relevant antimicrobial resistance in Europe. Thus, EARSS aims to: • Collect comparable and validated AMR data; • Analyse trends in time and place • Provide timely AMR data that constitute a basis for policy decisions • Provide feedback to ‘those who need to know’ • Encourage the implementation, maintenance and improvement of national AMR surveillance programmes • Supports national systems in their efforts to improve diagnostic accuracy at every level of the surveillance chain • Link AMR data to factors inﬂuencing the emergence and spread of AMR, such as antibiotic use data • Initiate, foster and complement scientiﬁc research in Europe in the ﬁeld of AMR. EARSS collects routine antimicrobial susceptibility test (AST) results of invasive (blood culture and CSF) isolates of Streptococcus pneumoniae, Staphylococcus aureus, (both since 1999), Enterococcus faecalis and E. faecium, Escherichia coli (since 2001), and Klebsiella pneumoniae and Pseudomonas aeruginosa (since 2005). These pathogens were selected because they have different epidemiological and ecological backgrounds and serve as markers for clinically and epidemiologically meaningful developments in antibiotic resistance. The decision to collect routine data, preferably according to the internet-accessible EARSS protocols, means that no changes to the regular diagnostic process are needed. In this way, the participation of many laboratories in many countries has become feasible. 2.2. The EARSS network and operational strategy 2.2.1. Organisation of the EARSS network Each participating country has appointed one or two national representatives. They are medical microbiologists and/or infectious diseases epidemiologists (see Table II, page 13). Moreover, each country has a national data manager (see Table III, pages 14-15). The main task of the national representatives is to coordinate the EARSS-speciﬁc activities of the participating laboratories (data collection, reporting, questionnaire completion and EQA strain and results distribution) and to communicate with the EARSS Management Team (EARSS-MT). The national representatives also encourage the laboratories to generate their AST data according to the EARSS protocols, as published in the EARSS Manual 2005 (downloadable from the ofﬁcial EARSS website at www.rivm.nl/earss). The main tasks of the national data manager are to collect, approve and forward resistance data each quarter to the international data manager maintaining the EARSS central database and to assist the national representative. Protocols for standardising the data collection have been developed with professional help from the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and WHO microbiology laboratory database software (WHONET). To assess the quality and comparability 24 Chapter 2. EARSS objectives and operational strategy LAB 1 A1 ICMs2 PUBLIC LAB 2 A LAB 3 A National Advisory Board National Management Team National Representative B1 Data Manager PUBLIC WHO3 ESCMID4 EUCAST5 ESAC6 ARMed7 ESGARS8 Advisory Board EARSS Management Team Plenary Meeting C1 C Dutch Ministry of Health, Welfare and Sport DG-SANCO Figure 2.1. Structure of the EARSS network. 1 Reporting lines are indicated with arrows. The most important reporting lines are further clariﬁed with letters (A-C): A. Participating laboratories collect data and report the data to the national data manager, who checks the data. Messages from the national level and from EARSS-MT, including new protocols, questionnaires and reports, are forwarded by the national representative to the participating laboratories. B. Once checked, the national data manager forwards the data to EARSS-MT, where the data is again checked and a feedback report is produced which is sent to the national representative. EARSS-MT awaits approval of the data by the national representative before the results are added to the EARSS database and thus become visible at the interactive website and published in the annual report. Messages from EARSS-MT, including new protocols, questionnaires and reports, are always directed to the national representatives who shall forward the information to the relevant parties in their own country. (NB: the annual plenary meeting brings together EARSS-MT and all national representatives). C. Ofﬁcial reports are forwarded for ﬁnal approval to DG Sanco and the Dutch Ministry of Welfare and Sports (considering a 45 days term) before they become ofﬁcial reports of the EARSS network. 2 ICMs: Intersectoral Co-operating Mechanisms 3 WHO: World Health Organisation 4 ESCMID: European Society on Clinical Microbiology and Infectious Diseases 5 EUCAST: European Committee on Antimicrobial Susceptibility Testing 6 ESAC: European Surveillance on Antimicrobial Consumption 7 ARMed: Antibiotic Resistance Surveillance and Control in the Mediterranean Region 8 ESGARS: ESCMID Study Group for Antimicrobial Resistance 9 European Centre for Disease Prevention and Control of AST data, regular EQA exercises are carried out in collaboration with UK-NEQAS. In 2005, no EQA exercise was organized because of budgetary constraints, but the next EQA exercise is now being prepared for February 2007. 2.2.2. The national networks It is the task of the national representatives to select participating laboratories/hospitals that cover at least 20% of the total population and serve various types of institutions (university or tertiary care hospitals, general or district hospitals, rehabilitation centres or nursing homes, and others). Different geographic regions (urban/rural), and the socio-economic strata should be included in a demographically representative manner. Chapter 2. EARSS objectives and operational strategy 25 2.2.3. Collecting and processing antimicrobial susceptibility testing (AST) results EARSS collects susceptibility test results of invasive isolates and background information about patients. Laboratories are asked to report the ﬁrst isolate per patient from blood or CSF per reporting quarter, including speciﬁc information on the bacterial isolate, host, institution and laboratory that submits the results. Data shall be reported according to the speciﬁcations of the EARSS exchange format. AST results are generated and reported as speciﬁed by standard EARSS protocols. Furthermore, optional data are collected such as clinical diagnosis, other conditions, and facultative susceptibility data for additional antibiotics. More information about data collection and protocols can be found in the EARSS Manual 2005, which can be downloaded from the ofﬁcial EARSS website at www.rivm.nl/earss. Laboratories Participating laboratories can opt for one of two ways of submitting data: electronically or by sending in conventional isolate record forms (on paper). EARSS provides various free software tools for electronic data handling, downloadable from the website at www.rivm.nl/earss: (1) WHONET, the microbiology laboratory software, adapted for EARSS by John Stelling, and (2) Data Entry & Feedback Software (DEFS), which was developed as an exclusive EARSS tool. Laboratories are asked to collect AST data on a routine basis and to forward them to the national representative or data manager quarterly. Before submission, laboratories are asked to check their data for: • Adherence to the EARSS protocol • Microbiological consistency/plausibility • Consistency with clinical breakpoints, sensitive (S), intermediate (I) and resistant (R) breakpoints as deﬁned by the speciﬁc guideline used. National representative and national data manager At the national level, the national data manager, in consultation with the national representative, processes the data. This is done in a stepwise fashion: • Recording data from all participating laboratories and manual data entry if isolate record forms are used. • Merging data from all participating laboratories into one single ﬁle. • Converting data to EARSS exchange format (EARSS Manual 2005). • Revising data with the Data Check and Feedback Programme (DCFP). • Approval of data by the national representative (adherence to EARSS protocol). • Data transfer to EARSS-MT at the end of each quarter (March, June, September and December). International data manager at EARSS-MT After receiving the data from the national data manager, the ﬁles are examined by the international data manager of EARSS-MT. This process involves the following steps: • Checking the data format • Inspection of the contents of the ﬁles • Removing duplicate reports • Determining resistance proportions • Identiﬁcation of unusual or rare results • Compilation of a feedback report summarizing the results • After approval by the national representative, data are added to the database, and the results are made public on the EARSS website at www.rivm.nl/earss. 26 Chapter 2. EARSS objectives and operational strategy Feedback from EARSS-MT Once data become available to EARSS-MT, they are processed and returned in a standard feedback report to the national representative in order to obtain conﬁrmation and ﬁnal approval of validity and completeness of the data. This feedback step also informs the national representatives of the occurrence of resistance patterns with particular public health importance (MRSA, PNSP, VRE, GISA and ESBLs). Subsequently, the national coordinator is asked to conﬁrm the correctness of the results. With his/her approval, the data will be added to the EARSS database and will become immediately available on the interactive EARSS website at www.rivm.nl/earss, where they can be displayed in various downloadable formats, such as tables, ﬁgures, and maps. The data from the EARSS database are used to prepare annual reports, newsletters and publications that are disseminated to the participants, the scientiﬁc community, policy makers and a broader public. 2.2.4. EARSS meetings EARSS organizes annual meetings for all national representatives to inform them on the progress of EARSS and discuss future initiatives. The annual plenary meeting was held from 23-25 November 2005 in cooperation with EUCAST in Rome, Italy, and in collaboration with our Italian representative Dr. Annalisa Pantosti. An update was given on the situation of antimicrobial resistance in Europe. The results of laboratory/hospital questionnaire 2005, including factors potentially inﬂuencing resistance proportions were discussed. The latest results on S. pneumoniae serotyping were shown and deligates were updated on the EARSS - internet based information system (EARSS-ibis). Besides the plenary meeting, EARSS organizes training sessions for data managers and reference laboratory staff. Data managers workshops are organized bi-annually. In June 2006, the 4th data managers workshop was organized in Bilthoven, the Netherlands, in which theoretical and practical aspects of data management were discussed, focussing on data analysis and feedback at national level. A workshop for reference laboratory personnel on molecular typing of S. aureus using the spa method was organized in October 2005 in Muenster, Germany, in cooperation with SeqNet.org. 2.2.5 Linkage with other networks Laboratory protocols on the identiﬁcation of ﬂuoroquinolone resistance in Streptococcus pneumoniae as well as the clinically and epidemiologically relevant resistance patterns for the two new species (Klebsiella pneumoniae and Pseudomonas aeruginosa) were devised in cooperation with EUCAST. EARSS and ESAC exchanged their surveillance data for the linking of resistance with the prescription of antimicrobial compound in Europe (manuscript in preparation). Collaboration with IPSE resulted in the integration of a new web-accessible communication platform for hospital infection control practitioners (NEWS site) with the EARSS-ibis tool. A new initiative on ‘Identifying the dominant strains of Staphylococcus aureus causing invasive infection in the European region’ was based on a formal agreement (see 2.3.4 Typing initiatives) for collaboration with the previously established SeqNet.org group. 2.3. EARSS in 2006 and beyond 2.3.1. Collection of antimicrobial susceptibility data Data for 2006 will be presented in the EARSS annual report 2006, to be published in autumn 2007. The most recent version of the database includes data reported in 2006 and can be accessed interactively at the EARSS website (see www.rivm.nl/earss). Results up to and including 2005 are described in Chapter 4 and are the focus of his report. Chapter 2. EARSS objectives and operational strategy 27 1000 # labs per year 900 800 number of laboratories # countries per year 35 30 25 20 15 10 5 0 number of countries 700 600 500 400 300 200 100 0 1999 2000 2001 2002 year 2003 2004 2005 Figure 2.2. Number of laboratories (left axis) and countries (right axis) participating in EARSS by year. 2.3.2. The EARSS network Two new countries (Lithuania and Turkey) joined the EARSS initiative in 2005. Both countries started reporting in 2006 on a regular basis. The number of laboratories continued to increase in 2005. 2.3.3. Upcoming EARSS meetings The next plenary meeting will be organized on the 10th and 11th of May, 2007. The meeting will focus on exploitation of interventions based on EARSS data and the future of EARSS with ECDC. 2.3.4. New initiatives Early warning and response systems (EARSS-ibis) The EARSS-ibis system is accessible on the internet (see www.rivm.nl/earss) since 2005. The EARSS-ibis system enables users (mainly microbiologists) to report on bacterial pathogens with unexpected antimicrobial resistance, virulence or transmissibility. The EARSS-ibis system can be used within a country as well as internationally. To facilitate the use of EARSS-ibis as a national tool, it is possible to use the national languages. Eleven languages have been made already available with the help of the EARSS National Representatives. Typing initiatives Through its grant agreement for action (no. 2003212) the European Antimicrobial Resistance Surveillance System (EARSS) is committed to improve the understanding of the spread of antimicrobial resistance by identifying the expansion of clones of particular public health importance (i.e. with special resistance, transmissibility or virulence) through common typing approaches. Since 2004, EARSS has collected S. pneumoniae serotype data next to the AST results. By now, 10 countries have made serotype data available for this species. An analysis of the serotype data available is presented in chapter 4 of this report (page 38). 28 Chapter 2. EARSS objectives and operational strategy For S. aureus, EARSS undertook a European-wide consultation of scientiﬁc experts in the ﬁeld of molecular typing and stakeholders including the National Reference Laboratories (NRL) and the EARSS National Representatives (EARSS-NR) in 2004. As a result of this consultation, sequencebased typing approaches were identiﬁed as the most reliable method, since DNA sequencing utilises the genetic code, a common and biological meaningful language. Sequence-based typing allows for unambiguous clone designation, unequivocal comparisons, and real time quality control. A comparison of the different sequence-based approaches (MLST, spa-typing) with the most frequently used typing technique (PFGE) identiﬁed spa-sequence typing of S. aureus as the most promising technique in terms of ease, costs, discriminatory ability and excellent concordance with the other two (29). With the wide availability of sequencing capacity at NRLs and user-friendly software that allows for automatic strain identiﬁcation and on-line quality control, the means for easy communication and international comparison of typing information are available for spa-sequence typing. A central database at http://www.ridom.de/spaserver/ has been established where information of spa-types, like their frequencies, their relation to MLST sequence types and epidemiological information is freely available. This is established and maintained by the SeqNet.org initiative on behalf of all users (http://www.seqnet.org). During two workshops in Muenster, Germany in fall 2004 and fall 2005 (the 2005 workshop was funded by EARSS) laboratory experts from 28 European countries were trained in all aspects of spa-sequence typing (DNA puriﬁcation, ampliﬁcation, sequencing, editing and submitting). At the EARSS Annual Plenary Meeting that took place in November 2005 in Rome, a decision was supported by all EARSS-NRs to pilot an initiative of “Identifying the dominant Staphylococcus aureus strains causing invasive infections in the European region” using the spa-sequence typing approach for isolates submitted by the EARSS participating hospitals. Thereby, each EARSS participating laboratory shall submit the ﬁrst 5 successive MSSA isolates and the ﬁrst 5 successive MRSA isolates from individual patients with invasive infection per hospital they serve. Collection of isolates started on the 1st of September 2006. The duration of the sampling shall be six months ending on the 28th of February 2007. More information about this joint EARSS/Seqnet.org initiative can be found in the protocol manual at www.rivm.nl/earss. Data collection on two new pathogens Since November 2004, EARSS participants are encouraged to report antimicrobial susceptibility data for Klebsiella pneumoniae and Pseudomonas aeruginosa. In 2005 about 5000 isolates of K. pneumoniae and 4000 isolates of P. aeruginosa from 24 and 23 countries respectively, were already reported to the EARSS database during this ﬁrst year of data collection. This reﬂects not only the availability of AST data for these two important pathogens but also the enthusiasm of the participating laboratories to expand the EARSS information base for public health purposes. Standard protocols were devised together with EUCAST and the EARSS Advisory Board. The ﬁrst results of 2005 are published in chapter 4 of this report (pages 62 and 66, respectively). Chapter 3. The status of Quality Assessment in Antimicrobial susceptibility testing in Europe 29 Chapter 3. The status of Quality Assessment in Antimicrobial susceptibility testing in Europe 3.1. Introduction External Quality Assessment (EQA) plays a crucial role in the evaluation of diagnostic accuracy, reﬂecting the validity of reporting and thus directly inﬂuences the quality i.e. effectiveness of treatment and patient care. EQA is also an educational tool that allows laboratories to monitor, evaluate and improve their own performance, which ultimately improves local, national and international standards. At the same time EQA is a requirement for surveillance networks as it reﬂects the quality and thus the comparability of test results from different laboratories. With this in mind, EARSS has carried out EQA once yearly by sending out six strains belonging to ﬁve bacterial species for antimicrobial susceptibility testing. The results were convincing and demonstrated that for the bacteria and antimicrobials addressed by the EARSS program, the comparability of routine AST data from the different countries participating in EARSS was satisfactory for surveillance purposes. However, it is important to remember that the EARSS EQA is not in a strict sense an EQA, since the EQA strains are given special attention by the participating laboratories. The results do not necessarily reﬂect routine diagnostic procedures in many of the laboratories for bacteria and antimicrobials not part of the program. We advocate that laboratories should routinely subscribe to one of the national and or international EQA schemes. By signing up for one of the international programs, the laboratory is given the opportunity to compare its proﬁciency on a grander scale. By means of a questionnaire we explored, at country level, what kind of EQA schemes are already in place in the European countries, and how EARSS National Representatives envisage the implementation or improvements of EQA in their country. 3.2. Methods All National Representatives of the countries currently participating in EARSS (n=32) were sent a questionnaire with questions on national opportunities for EQA in bacteriology in general and AST in particular and on their opinion on how EQA should be organised in the future. EQA was deﬁned as; the regular documentation and assessment of and feedback on performance of a sizable number of laboratories by an independent external institution designed to evaluate quality of diagnostic performance and to demonstrate a continuous commitment to quality. All completed questionnaires were collected at the RIVM and processed by EARSS-MT. 3.3. Results Current EQA situation in Europe. Twenty-seven of 32 countries returned a completed questionnaire. Four countries reported that they did not have a formal, mandatory EQA scheme (Austria, Cyprus, Portugal and Turkey). In Cyprus and Portugal this was attributed to the absence of ﬁnancial support. Austria and Turkey indicated that there was a need for organisational support. Italy has mandatory EQA, but there is no national scheme since the organization of EQA has been devolved to the regions. Six countries reported that they had national schemes, 9 that they used international schemes 30 Chapter 3. The status of Quality Assessment in Antimicrobial susceptibility testing in Europe Table 3.1. Information on the current EQA schemes in the EARSS countries that returned the EQA questionnaire (n=26) Austria Cyprus Portugal Turkey Belgium Bulgaria France Germany Italy Spain United Kingdom Estonia Iceland Ireland Israel Latvia Lithuania Luxembourg Slovenia Sweden Croatia Czech Republic Denmark Finland Hungary Norway Poland X X X X # X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X * * * X X X X X X X * X X X X X X X X X X X X X X X X Question/Country National EQA scheme International EQA scheme No EQA scheme Reason why no EQA No ﬁnancial support No scientiﬁc support No organizational support Other reason Who pays for EQA Government/ministry Nat. Microbiological Society International body Local laboratory *WHO/CDC EQA scheme # Italy has no national EQA scheme, but a mandatory EQA at the regional level. and 7 participated in both national and an international schemes (Table 3.1). Table 3.2 shows the different EQA schemes in the various countries. In general all EARSS laboratories participate in their respective national EQA schemes. In ten countries, laboratories subscribed to the UK-NEQAS scheme, 4 participated in WHO/CDC EQAS and another 4 participated in the Labquality scheme provided by a Finish institute. The costs of EQA were fully covered by the respective governments in Belgium, Norway and France, (Table 3.1), but were entirely borne by the participating laboratories in 12 of 22 responding countries. Four countries participated in the WHO-CDC scheme. Only laboratories in Spain were supported ﬁnancially by a national professional organisation. EQA in the future. All agreed that EQA should be part of a regular scheme and of the every-day workﬂow in diagnostic laboratories. Moreover, organisation and logistics should be in the hands of an independent agency. The majority of countries also agreed that EQA should be mandatory and reﬂect an agreed national diagnostic standard (Table 3.3). Although bacteriological identiﬁcation and antimicrobial susceptibility testing were given priority, typing, serology, and nucleic acid-based tests were also regarded as important components of future EQA schemes (Table 3.3). There were further suggestions that mentioned microscopic examination of micro organisms, antigen testing of difﬁcult organisms, and critical resistance to be added to the EQA programme. But there were also replies arguing that “no single EQA can cover all areas of diagnostic microbiology” and advocated an a la carte content of EQA depending on the diagnostic activities the individual laboratory needs to assess. Country UK NEQAS WHO/CDC EQAS UK NEQAS Labquality (Finland) Labquality: Blood culture WHO/CDC EQAS Y NEQAS scheme 32/50 ALL 7/10 ALL 1/25 ALL ALL 1/5 3/29 - International EQA scheme Distribution frequency ID pathogen Belgium Y Y N Y Varies Y Y Y Y Y ALL ALL ALL 20/25 ALL ALL ALL 14/15 ALL ALL 2 strains every month: Y + 3 only ID 2 strains every 6 months Y ALL National EQA scheme EQA Microbiology ID pathogen Y Participation EARSS labs? ALL Participation EARSS labs? - Bulgaria BULSTAR-EQA Croatia WHO/CDC EQAS Czech Republic Denmark EHK-Externí hodnoceni kvality DANRES-M Estonia - Distribution frequency 4 strains every 4 months 5 strains every 6 months 2-4 strains every 6 months 2 strains every 3 months 10 strains every 12 months 1-3 strains every 1-3 Y months 2 strains every 3 months Y - Finland France UK NEQAS Afssaps-CQN Germany INSTANDe.V1 Table 3.2. Different EQA schemes executed by country Hungary QualiCont Iceland - 1-3 strains every 6 months 5 strains every 6 months 3 strains every 4 months 3 strains every 6-8 months depends on scheme 2 stains every month 2 strains every month: + 3 only ID Ireland Israel - - The whole NEQAS scheme Y Latvia - - UK NEQAS and EQUALIS (Sweden) UK NEQAS UK NEQAS General Bacteriology + Antimicrobial susceptibility Labquality (Finland) Lithuania Luxembourg Norway depends on ﬁnancial possibilities of hospital Labquality (Finland) 5-7 strains every month EEQA (ISP B-1050 Bruxelles) 4 strains every 4 months UK NEQAS Gram stain, ID, sus- ALL ceptibility testing Y 1/13 All microorganisms ALL ? of 10 Y Y 1 of ? ALL Chapter 3. The status of Quality Assessment in Antimicrobial susceptibility testing in Europe Poland Bacteriological EQAS (NIPH2) POLMICRO Slovenia - 4 specimen3 every 3 months 4-5 strains every 3-4 months UK NEQAS - CDC/WHO EQAS Labquality (Finland) UK NEQAS Spain Control Calidad SEIMC UK NEQAS 4 strains every year 2-3 strains every 6 months 2 strains every month: + 3 only ID 2 strains every month - Y - ALL - 31 Sweden United 1-2 strains every Y ALL Kingdom month 1 Gesellschaft zur Förderung der Qualitätssicherung in medizinischen Laboratorien 2 Norwegian Institute of Public Health 3 Simulated clinical material 32 Chapter 3. The status of Quality Assessment in Antimicrobial susceptibility testing in Europe Table 3.3. Answers to the questionnaire (n=27) regarding the needs of a future EQA Question Should EQA be part of regular scheme/routine workﬂow Should an Independent agency carry out the EQA? Should EQA be mandatory and reﬂect nat. diag. standards EQA shall include; Identiﬁcation of organisms Susceptibility testing Typing Serology Nucleic acid-based tests Other Information with strains; Clinical info on the case Source of the isolate Sampling procedure Epidemiological info Other Different levels of EQA Number that agreed 27 26 25 26 27 26 24 24 3 27 27 25 26 3 20 First priority 25 25 5 12 11 24 25 13 7 - There was broad agreement on the accompanying information of the EQA strains. Clinical information and the isolate source were regarded crucial. Information on the sampling procedure and information on the epidemiology were by some regarded as important (Table 3.3). Several asked that the information provided should be realistic and commented that under normal circumstances it is unlikely that very much epidemiological information will be provided. Others asked that basic demographic data such as age and gender of source patients be given. Opinions on the frequency of EQA and the number of isolates per shipment, varied widely between countries. Eight countries indicated that they prefer to receive samples every month, but the requested number of isolates per shipment varied between 1 and 5. Most of these countries participate in the UK-NEQAS scheme, where a monthly schedule is today standard. Seventeen countries preferred quarterly, half year or yearly distributions; the number of preferred strains per shipment ranged between 2 and 6. Most countries (n=20) agreed that there should be different EQA schemes for routine diagnostic laboratories and reference laboratories. Five preferred no difference in levels. Again the issue of a la carte designed EQA appeared in some responses. Since general bacteriology and AST distributions probably apply to all laboratories, these abilities should be principally assessed in EQA. However, it should be possible for labs to indicate which speciﬁc tests they do not perform routinely (as in the UK-NEQAS scheme). 3.4. Conclusions The EARSS questionnaire on EQA provided us with a better understanding of the availability and practices of EQA in Europe. It became evident that a few countries do not have any formal arrangements for mandatory EQA. This was mainly due to lack of ﬁnancial or organisational support. Laboratories in twenty-two countries participate in regular EQA for diagnostic bacteriology. Almost half of them (n=10) participate in the UK-NEQAS scheme, 4 participated in WHO/CDC EQAS and another 4 participated in the Labquality scheme provided from Finland. Alternatively, national schemes were used, either alone or in combination with one of the international schemes. The majo- Chapter 3. The status of Quality Assessment in Antimicrobial susceptibility testing in Europe 33 rity of laboratories participating in EARSS also participated in the EQA scheme available in that country. The information provides a useful insight into the existing structures and may facilitate the next steps towards a sustainable and comparable EQA structure in Europe. 3.5. Acknowledgements We would like to thank Gunnar Kahlmeter and Derek Brown from EUCAST and Christine Walton and Vivienne James from UK-NEQAS and the EARSS Advisory Board for their expertise in putting together the questionnaire. Furthermore we would like to explicitly thank the EARSS National Representatives for completing this questionnaire. Chapter 4. Antimicrobial resistance in Europe 35 Chapter 4. Antimicrobial resistance in Europe 4.1 Introduction This chapter provides an overview of the EARSS data 2005 and the trends of antimicrobial resistance in Europe. For seven years EARSS has been collecting antimicrobial susceptibility data of invasive isolates with clinical and epidemiological importance. For each pathogen the clinical and epidemiological relevance, major resistance mechanisms, the data and trends of antimicrobial resistance until 2005 will be described. Information on the statistical methods and the inclusion criteria for the different analyses and ﬁgures can be found in Annex 1. 4.2. Streptococcus pneumoniae 4.2.1. Clinical and epidemiological importance Streptococcus pneumoniae is a common cause of disease, especially among young children, elderly people and patients with immunodeﬁciencies. The clinical spectrum ranges from upper airway infections such as sinusitis, and otitis media to pneumonia and invasive disease meningitis, and sepsis (1). Since S. pneumoniae is the most common cause of pneumonia worldwide, morbidity and mortality are high and annually approximately 3 million people die of pneumococcal infections (50). These casualties are frequently associated with economic inequalities and about one third of these are children under the age of ﬁve. Pneumococci carry a wide variety of virulence factors that facilitate adherence and invasiveness of host tissues. The cell wall of pneumococcal cells is coated with a viscous slime layer termed the polysaccharide capsule. This is the most important virulence factor, because it protects the bacteria from destruction by leucocytes (45). Capsular polysaccharides are highly divers and play an important role in immune evasion. Around 80 different serotypes have been described. The serotype distribution varies with age, disease and geographical region (17-19). Interestingly, serotypes most frequently involved in pneumococcal disease in infants are also most frequently associated with antimicrobial resistance (42;48). Resistance mechanisms. Beta-lactam antibiotics bind to cell wall synthesizing enzymes, penicillinbinding proteins (PBPs) and interfere with the biosynthesis and remodelling of the bacterial cell wall during cell growth and division. The mechanism of penicillin resistance in S. pneumoniae consists of alterations in PBPs, which results in reduced afﬁnity to this class of antibiotics. Alterations in PBPs develop in a stepwise fashion which causes different degrees of resistance proceeding from low-level resistance – conventionally termed intermediate* (I) to full clinical resistance (R). Although intermediately resistant strains are clearly less susceptible than sensitive strains, in absence of meninigitis, infections with these strains are often successfully treated with high doses of penicillin or alternative beta-lactam compounds (11, 15). Macrolide, Lincosamide and Streptogramin (MLS) antibiotics are chemically distinct, but all bind to the ribosomal 50S subunit. In S. pneumoniae two resistance mechanisms against MLS antibiotics have been reported: i) The acquisition of an erythromycin ribosomal methylation gene (erm) results * 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 (From unpublished discussions between CEN and ISO for a new MIC dilution method 2005). 36 Chapter 4. Antimicrobial resistance in Europe in a posttranscriptional modiﬁcation of the 23S ribosomal RNA, which blocks the binding of the macrolide to the ribosome. Once expression of the gene is induced, this often results in high-level resistance (MIC>128 mg/L) to macrolide, lincosamides and streptogramin B, termed MLSB resistance (46;49). ii) The acquisition of a macrolide efﬂux system gene (mefE) results in pumping of the antimicrobial out of the cell via an efﬂux system, and is effective against erythromycin, azithromycin and clarithromycin (25). In contrast to beta-lactam resistance, macrolide resistance via these mechanisms is absolute, and cannot be overcome by increasing the dosages of antibiotics (24). Since S. pneumoniae is the most frequent cause of community-acquired pneumonia and can clinically not easily be distinguished from airway infections caused by other pathogens, empirical treatment of community-acquired lower respiratory infections needs to be active against pneumococci and should take the local prevalence of antimicrobial resistance into account. Reports on widespread beta-lactam resistance therefore engender the habitual prescription of non-beta-lactam compounds in countries where penicillin resistance has been frequently reported. Such reactive prescribing increases the selection pressure for alternative antibiotics such as macrolides and novel ﬂuoroquinolones. It is therefore no surprise to see a dynamic antimicrobial resistance picture emerge in different European countries. 4.2.2. Streptococcus pneumoniae resistance trends: 1999-2005 Penicillin In 2005, 29 countries reported AST results of invasive S. pneumoniae isolates to EARSS (n=10,741). Large differences in PNSP were reported between the countries, varying between 1% in the Netherlands (n=802), 36% in France (n=632) and 39% in Romania (n=18) (Figure 4.1, Annex 3.1). No consistent trends were observed over time. Several countries reported a signiﬁcant increase like Sweden (from 1.5% in 1999 to 3.6% in 2005), Iceland (from 2.1% in 1999 to 8.11% in 2005) and Bulgaria (from 8% in 2002 to 32.6% in 2005) whereas Spain (from 32.5% in 1999 to 25.6% in 2005), Ireland (from 19.5% in 2000 to 11.1% in 2005), Belgium (from 13.5% in 1999 to 11.8% in 2005), and the UK (from 7.4% in 1999 to 3.9% in 2005) reported a decrease in the proportion of PNSP. In Belgium and the UK this decrease is mainly caused by a signiﬁcant drop in full penicillin resistance (Figure 4.4). Erythromycin In 2005, the majority of countries reported between 10% and 25% of erythromcyin resistance. Only Estonia, Czech Republic, Sweden, Denmark and Bulgaria still reported resistance levels below 10% (Figure 4.2, Annex 3.1). Until 2000, The Netherlands, Austria, Norway, Germany, Finland also reported levels below 10%, but in these countries proportions have increased signiﬁcantly in the last ﬁve years (NL 11%, AT 15%, NO 16%, DE 17% and FI 20%, Figure 4.5). Only in the UK erythromycin resistance seems to decrease. Dual resistance to penicillin and erythromycin Dual resistance still remained below 5% for most of the countries, but has reached high levels in France (32%, n=632) and Romania (31%, n=31%) (Figure 4.3). On the positive side, the UK reported a signiﬁcant drop from 3.3% in 1999 to 1.2% in 2005. Finland where erythromycin resistance had steadily increased over the entire EARSS surveillance period, dual resistance also went up from 1.4% in 1999 to 4.9% in 2005 (Figure 4.6). For most of the remaining countries no signiﬁcant changes in dual resistance were observed. Chapter 4. Antimicrobial resistance in Europe 37 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU MT Figure 4.1. Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2005. No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU MT Figure 4.2. Streptococcus pneumoniae: proportion of invasive isolates resistant to erythromycin (ENSP) in 2005. 38 Chapter 4. Antimicrobial resistance in Europe No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU MT Figure 4.3. Streptococcus pneumoniae: proportion of invasive isolates with dual resistance to erythromycin and penicillin in 2005. 4.2.3. Serotypes Since 2004 serogroup/serotype information is collected by EARSS. In 2005, serotype information was provided by 8 countries (Austria, Belgium, Bulgaria, Czech republic, Denmark, Iceland, Slovenia and the United Kingdom). The data are presented in table 4.1. Austria and Bulgaria could only provide serotype information for a small number of isolates and are therefore not presented in the table. The distribution of serotypes as well as the resistance within serogroups varies between countries. The relative high proportion of erythromycin resistance in serogroup 1 in Belgium (21%) was not seen in any other country and may indicate the dissemination of a single clone. Figure 4.6a illustrates the distribution of serogroups for all isolates reported in 2005. The illustration may, however, not reﬂect the true serogroup distribution in Europe as a whole, as Belgium, Denmark and the UK reported more than 1000 isolates and may cause some distortion due to overrepresentation. However, some salient features become visible; penicillin resistance is conﬁned to only ﬁve serogroups (14, 9, 19, 6 and 23) and entirely absent from the most frequent serogroup, serogroup 1. Erythromycin resistance is especially high in serogroup 14, and moderately high in 9, 19, 6 and 33. Importantly, all serogroups that comprise resistant isolates are included in the 7-valent conjugate vaccine, with as exception the relatively rare serotype 33. It can be therefore expected that the introduction of this vaccine into the ofﬁcially recommended childhood vaccination programs in many European countries will have a sizeable impact on the control of antimicrobial resistance in S. pneumoniae. Chapter 4. Antimicrobial resistance in Europe 39 1999 NL (790) 2001 EE (32) 1999 NO (443) 2000 CZ (162) 1999 SE (874) 1999 UK (816) 2000 DK(693) 1999 DE (218) 2000 AT (150) 1999 FI (403) 1999 IS (43) 1999 IT (225) 2000 SI (141) 1999 IE (291) 2000 LU (36) 1999 BE (1218) 1999 PT (145) 2001 HR (86) 2001 HU (92) 2000 ES (661) 2002 BG (31) 2001 IL (190) 0 5 10 15 20 25 Intermediate resistant Fully resistant Country code (average number of isolates reported per year) & year of start surveillance 30 35 40 % penicillin non-susceptible S. pneumoniae Figure 4.4. Streptococcus pneumoniae: trends of penicillin non-susceptibility by country, 1999-2005. Only the countries that reported 20 or more isolates per year for at least 3 years were included. The arrows indicate the signiﬁcant trends observed for the proportion of PNSP (black arrows) or only full penicillin resistance (red arrows). 40 Chapter 4. Antimicrobial resistance in Europe EE (26) 1999 CZ (154) 2000 2001 2002 SE (724) 2003 2004 DK (693) 2005 BG (27) NL (652) SI (129) Country code (average number of isolates reported per year) UK (734) IE (251) AT (123) IL (184) NO (290) DE (170) IS (40) HR (65) FI (373) ES (633) LU (34) IT (198) BE (1218) HU (84) 0 5 10 15 20 25 30 35 40 % erythromycin resistant S. pneumoniae Figure 4.5. Streptococcus pneumoniae: trends of erythromycin resistance by country, 1999-2005. Only the countries that reported 20 or more isolates per year for at least 3 years were included. The arrows indicate statistically signiﬁcant trends. Chapter 4. Antimicrobial resistance in Europe 41 2001 EE (26) 2000 CZ (154) 2000 DK (693) 1999 SE (724) 2000 NL (652) 1999 UK (734) 1999 NO (290) 2000 AT (123) 1999 IE (251) 1999 DE (170) 2000 SI (129) 1999 FI (373) 1999 IT (198) 2002 BG (27) 1999 IS (40) 1999 BE (1218) 2001 HR (65) 2001 IL (184) 2001 LU (37) 2000 ES (633) 2001 HU (84) 0 5 10 15 20 % dual resistance 25 30 35 1999 2000 2001 2002 2003 2004 2005 Country code (average number of isolates reported per year) & year start surveillance 40 Figure 4.6. Streptococcus pneumoniae: trends of dual resistance to penicillin (intermediate and resistant) and erythromycin by country, 1999-2005. Only the countries that reported 20 or more isolates per year for at least 3 years were included. The arrows indicate statistically signiﬁcant trends. 42 Chapter 4. Antimicrobial resistance in Europe Table 4.1. Distribution of single penicillin (pnsp), single erythromycin (ensp) and dual penicillin-erythromycin resistance (dual) among the most common S. pneumoniae serogroups reported to EARSS per country in 2005. Only countries reporting serogroup information for more than 30 isolates were presented. Belgium (n=1536) Serogroups Czech Republic ( n=180) Denmark (n=1081) Iceland (n=35) Slovenia (n=207) United Kingdom (n=1182) % of total % ENSP % PNSP % of total % of total % of total % of total % of total % ENSP % ENSP % ENSP % ENSP % ENSP % PNSP % PNSP % PNSP % PNSP % PNSP % dual % dual % dual % dual % dual 1 3 4 5 6 7 8 9 11 12 14 15 18 19 20 22 23 33 other total 14 0 21 0 6 0 0 0 5 1 1 0 4 0 1 0 8 5 53 6 6 0 1 1 4 0 1 0 8 5 45 7 1 0 19 5 1 0 0 0 13 8 39 41 2 13 25 4 3 0 2 0 9 8 52 11 0 0 0 0 3 0 0 0 8 4 8 11 1 0 76 0 5 1 3 4 100 3 23 3 0 15 0 9 0 1 0 9 0 4 0 6 0 8 20 0 0 11 5 1 0 7 0 9 0 1 0 1 0 6 10 0 22 3 3 0 0 0 0 6 0 0 0 5 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 5 0 0 0 0 0 0 0 na na na na na na na na na na na na na na na na na na na 1 0 1 0 3 0 0 1 14 2 42 10 0 0 0 0 0 11 2 5 0 0 0 0 4 0 0 1 7 0 0 0 0 2 0 0 0 0 0 1 99 100 99 100 89 97 100 88 79 98 51 60 100 86 100 100 98 84 90 6 6 11 0 6 9 0 3 3 0 23 0 6 14 0 3 11 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 38 13 0 0 0 0 0 40 0 0 0 0 0 0 0 9 15 22 11 0 5 8 1 10 0 2 16 0 2 4 1 1 4 1 0 0 0 0 0 0 0 0 0 0 11 11 11 0 0 0 0 0 0 25 15 0 0 0 0 16 29 13 0 0 0 29 14 29 0 0 0 0 0 0 29 0 0 0 100 0 8 8 13 0 0 5 0 0 7 0 2 0 0 0 8 4 5 4 2 2 8 1 1 9 16 7 1 0 6 2 0 0 15 1 58 1 0 0 2 0 0 9 2 8 2 0 0 3 0 0 7 4 0 1 0 0 4 2 0 3 11 9 100 1 na 90 100 9 100 4 100 na: not available 4.2.4. Conclusions The proportion PNSP keeps changing in the European region. It appears that in countries that reported high endemic prevalence in the previous years the situation improves. The reduction of full penicillin resistance may be the result of ﬁtness trade-offs, in absence of extreme selection pressures. More unambiguous was the increase of erythromycin resistance observed in several countries. In contrast to this widespread observation, in the UK, Belgium and Hungary this trend has been reversed and a consistent decrease of S. pneumoniae resistant to erythromycin could be observed. The distribution of serogroups/serotypes reported to EARSS indicate that resistance is mainly conﬁned to few serogroups, all of which are part of the currently available conjugate vaccines. Vaccination, especially in young children may represent an effective additional means of controlling antibiotic resistance in pneumococcal disease in Europe. Up to now, universal infant PCV immunization policy has been implemented in Luxembourg and will be introduced in Norway, the UK and the Netherlands in the course of 2006 with many countries following suit (6). To monitor the effect of these interventions, surveillance of the serotype distribution becomes even more urgent. % dual 0 0 0 0 1 0 0 3 0 0 1 0 0 3 0 0 1 0 0 1 Chapter 4. Antimicrobial resistance in Europe 43 14% 12% 10% 8% 6% 4% Fully susceptible Single erythromycin resistance Dual resistance Single penicillin resistance Proportion 2% 0% 1 14 9 19 4 6 3 23 7 8 18 22 12 5 11 20 33 15 oth Serogroups Figure 4.6a. The distribution of serogroups and the resistance proﬁle (single penicillin, single erythromycin and dual penicillin-erythromycin resistance) per serogroup of S. pneumoniae isolates in the EARSS database, in 2005. Only countries that reported serogroup information for more than 30 isolates (Belgium, Czech Republic, Denmark, Iceland, Slovenia and the United Kingdom) were included in this ﬁgure. * Susceptible at least to penicillin & erythromycin. 4.3. Staphylococcus aureus 4.3.1. Clinical and epidemiological importance Staphylococcus aureus is a gram-positive bacterium that colonizes the skin of about 30% of healthy humans. Although mainly a harmless coloniser, S. aureus can cause severe infection. Its oxacillin-resistant form (methicillin-resistant S. aureus, MRSA) is the most important cause of antibiotic-resistant health care-associated infections worldwide (28). Since health care-associated MRSA infections add to the number of infections caused by methicillin-susceptible S. aureus, a high incidence of MRSA adds to the overall burden of infections caused by this species in hospitals (21). Moreover, infections with MRSA may result in prolonged hospital stay and in higher mortality rates (8), owing mainly to the increased toxicity and limited effectiveness of alternative treatment regimens. MRSA is currently the most commonly identiﬁed antibiotic-resistant pathogen in hospitals in many parts of the world, including Europe, the Americas, North Africa and the Middle- and Far-East. Resistance mechanisms. Beta-lactam antibiotics. S. aureus acquires resistance to methicillin and all other beta-lactam antibiotics through expression of the exogenous mecA gene, that codes for a variant penicillin binding protein PBP2’ (PBP2a) with low afﬁnity to beta-lactams, (22), thus preventing the drug induced inhibition of cell wall synthesis. The level of methicillin resistance (deﬁned by its minimum inhibitory concentration, MIC) depends on the amount of PBP2’ production, which is inﬂuenced by various genetic factors. Resistance levels of mecA-positive strains can thus range from phenotypically susceptible to highly resistant (5). Upon challenge with methicillin, a population of a heterogeneously resistant MRSA strain may quickly be outgrown by a subpopulation of highly resistant variants. Glycopeptide antibiotics include vancomycin and teicoplanin. Both are very large molecules that through binding to the terminal amino acid residues (D-alanyl-D-alanine) of the peptide side chains in the growing peptidoglycan polymers inhibit the cross linking essential for cell wall stability. It is 44 Chapter 4. Antimicrobial resistance in Europe No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.7. Staphylococcus aureus: proportion of invasive isolates resistant to oxacillin (MRSA) in 2005. MT estimated that to block cell wall synthesis effectively, the glycopeptide antibiotic has to penetrate about 20 peptidoglycan layers, all with free D-alanyl-D-alanine targets, without being ‘trapped’, and this together with a poor penetration into infected tissues, limits the therapeutic effects of glycopeptides. Cell wall thickening of S. aureus thus increases its ability to resist vancomycin, and in S. aureus most strains with reduced vancomycin susceptibility have a markedly thicker cell wall (22). Vancomycin resistance is far more prevalent among enterococci, owing to different genetic resistance determinants. 4.3.2. Staphylococcus aureus resistance trends: 1999-2005 Beta-lactams Of the 30 countries reporting AST results of invasive S. aureus isolates to EARSS in 2005 (n=27,095), 7 reported MRSA proportions below 3%. The prevalence in these, mainly northern countries, Iceland, Norway, Sweden and Estonia, remained relatively stable over time with MRSA proportions of 0%, 1%, 1% and 2% in 2005 respectively (Figure 4.8, Annex 3.2). However, a signiﬁcant increase was observed for the Netherlands (from 0.34% to 0.93%), Denmark (from 0.28% to 1.70%) and Finland (0.95% to 2.91%) since 1999 (Figure 4.8). Four countries, namely the Czech Republic, Slovakia, Hungary and Germany, which still reported less than 10% MRSA until 2001, saw in the last four years MRSA rates soaring (CZ 13%, SK 19%, HU 19% and DE 21% in 2005, Figure 4.8). By and large, central European countries reported resistance proportions below 25%, whereas all Southern countries reported higher levels of which eight had MRSA proportions over 40% (Figure 4.7, Annex 3.2). However, optimistic trends appear to be Chapter 4. Antimicrobial resistance in Europe 45 1999 IS (56) 1999 NO (416) 1999 NL (1358) 1999 SE (1686) 1999 DK (850) 2001 EE (101) 1999 FI (629) Country code (average number of isolates reported per year) & year of surveillance start 2000 SI (283) 2000 CZ (1190) 1999 LU (78) 2000 AT (813) 2001 SK (200) 2001 HU (624) 1999 DE (1045) 2001 PL (192) 2000 ES (1043) 2001 FR (2383) 2000 BG (136) 1999 BE (934) 1999 IT (1130) 2001 HR (307) 2001 IL (448) 1999 IE (956) 1999 GR (463) 1999 UK (2346) 1999 PT (690) 2000 MT (90) 2003 CY (40) 2003 RO (85) 0 10 20 30 40 % MRSA 50 60 70 1999 2000 2001 2002 2003 2004 2005 80 Figure 4.8. Staphylococcus aureus: trends of methicillin-resistance by country 1999-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate signiﬁcant trends. 46 Chapter 4. Antimicrobial resistance in Europe emerging as well. Two countries, Slovenia and France, show a consistent decrease over the past ﬁve to six years (SI from 21% in 1999 to 10% in 2005 and FR from 33% in 2001 to 27% in 2005, Figure 4.8). These improvements support the notion that MRSA is not an irreversible development but may be dealt with by appropriate long term control efforts. An apparent decrease in Italy is explained by consecutive changes among the enrolled laboratories during the last ﬁve years and unfortunately does not reﬂect a true trend. 4.3.3. MRSA by hospital department It is well known that MRSA strains are more frequently isolated from ICU patients than non-ICU patients. This is supported by the EARSS database: for the majority of countries, the proportion MRSA was higher among ICU patients, except for most low-endemic countries. In some countries like Poland, Bulgaria, Croatia, Greece, the UK, Cyprus and Romania the proportion of MRSA found among ICU patients was over 60%. Although potentially due to selective sampling, the ﬁgures remain concerning, as it seems that ICU infection control procedures should be improved. As an exception Finland reported a relative low number of MRSA, but had a disproportionate high MRSA rate among ICU patients. At the same time, MRSA proportions signiﬁcantly increased during the last two years. This observation could be consistent with outbreaks limited to ICU facilities in this country. France, Israel, Ireland, Portugal and Malta also reported very similar MRSA proportions for ICU patients and patients from the other departments. This homogeneity may indicate similar exposure proﬁles such as high utilisation rates of intravascular devices in non-ICU patients. As illustrated in ﬁgure 4.9, average MRSA proportion per country were by and large independent of the relative proportion of MRSA among the subgroups (ICU vs. non-ICU patients), mainly because the numbers of ICU isolates were much smaller. 4.3.4. Conclusions Within the last seven years no less than twelve countries reported a signiﬁcant increase in the proportion of MRSA. This trend was largely consistent throughout Europe and included low, medium as well as high endemic countries. At the same time it appears that this is not part of an irreversible secular trend as two European countries (Slovenia and France) succeeded in constantly reducing the proportion of MRSA among Staphylococcus aureus blood stream infections over the past ﬁve or six years. 4.4. Enterococci 4.4.1. Clinical and epidemiological importance Enterococci belong to the residential ﬂora of the gastrointestinal tract of humans, other mammals, birds and reptiles. Under normal circumstances they are harmless commensals, and are even believed to have positive effects on a number of gastrointestinal and systemic conditions (4;14;33). However, when the commensal relationship with the host is disrupted, enterococci can cause invasive disease (27). Though not as virulent as other gram-positive organisms, enterococci can cause a variety of clinical syndromes including endocarditis, bacteremia, meningitis, wound and urinary tract infections and are associated with peritonitis and intra-abdominal abscesses. In the USA, three to four nosocomial bloodstream infections per 10,000 hospital discharges are caused by enterococci (3), and contribute to patient mortality as well as additional hospital stay (30). The vast majority of clinical enterococcal infections in humans are caused by Enterococcus faecalis in around 80% of clinical isolates and Enterococcus faecium in most of the remainder (23). Epide- Chapter 4. Antimicrobial resistance in Europe 47 IS (73/4) NL (913/152) NO (484/17) SE (1670/104) DK (1308/42) EE (107/34) FI (768/22) SI (315/34) AT (1297/174) CZ (1217/336) LU (73/10) Country code (number of non-ICU/ICU isolates) HU (434/93) SK (126/21) LV (91/34) DE (671/198) PL (170/27) ES (1143/194) FR (2867/609) BE (876/172) BG (139/21) HR (293/61) IT (1244/187) IL (494/50) GR (565/116) IE (1297/63) UK (3602/360) PT (1039/114) MT( 66/12) CY (42/12) RO (77/6) 0 10 20 30 40 % MRSA 50 non-ICU ICU Overall MRSA proportion 60 70 80 Figure 4.9. Staphylococcus aureus: proportion MRSA in ICU versus other hospital departments and the overall MRSA proportion, by country in 2005. Between brackets the number of isolates from non-ICU/ICU departments. 48 Chapter 4. Antimicrobial resistance in Europe miological data collected over the last two decades have documented the emergence of enterococci, and in particular E. faecium, as important nosocomial pathogens, which is seen as the expansion of a major hospital adapted clonal complex (CC17) (47). The emergence of E. faecalis and E. faecium was paralleled by the increase glycopeptide and high-level aminoglycoside resistance both including important compounds for the treatment of human infections (43). Besides the fact that infections with these resistant enterococci are difﬁcult to treat, Enterococci are highly tenacious and thus disseminate and spread between patients in the hospital setting easily. Resistance mechanisms. Enterococci are intrinsically resistant to a broad range of antibiotics including cephalosporins, penicillinase-fast penicillins, sulphonamides and low concentrations of aminoglycosides (16). Patient safety in hospitals is challenged by the ability of enterococci to acquire additional resistance through transfer of plasmids and transposons, recombination, or mutation (34). Beta-lactam antibiotics. By nature, enterococci have a low susceptibility to beta-lactam antibiotics – a consequence of intrinsically low-afﬁnity PBPs. Complete penicillin resistance in E. faecalis is currently absent, though two possible mechanisms have been reported; i) the production of betalactamase (35) and ii) the overproduction and modiﬁcation of penicillin-binding proteins (PBPs, particularly PBP5) (13). Aminoglycosides. In addition to the intrinsic mechanism of low-level resistance, reducing the ability of the enterococcal uptake of the drug, enterococci have acquired genes conferring high level resistance to aminoglycosides (43). High-level resistance to streptomycin can be mediated by single mutations within a protein of the 30S ribosomal subunit, the target of aminoglycoside activity (7). In addition, different aminoglycoside-modifying enzymes have been identiﬁed, targeting 8 different aminoglycosides (7). 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 (9). Whereas vancomycin consumption was less pronounced in Europe, another glycopeptide, avoparcin, has been widely utilized in the farming community as growth promoter in animal husbandry from the late-1970s until it was banned in 1998. Glycopeptide resistance is due to the synthesis of modiﬁed cell wall precursors that show a decreased afﬁnity for glycopeptides (31). Five phenotypes have been identiﬁed of which three have clinical relevance; i) VanA with high-level resistance to both vancomycin and teicoplanin, ii) VanB with a variable level of resistance to only vancomycin, iii) VanC with intrinsic low-level resistance to vancomycin and teicoplanin, (2), (38). The VanA and VanB phenotypes, mostly found among E. faecalis and E. faecium, may be transferred by plasmids and conjugative transposition. 4.4.2. Enterococcus faecalis resistance trends: 2001-2005 High-level aminoglycosides In 2005, 26 countries reported AST results for invasive E. faecalis isolates (n= 5,216). Only two countries reported less than 20 isolates, namely Luxembourg (n=17) and Romania (n=4) (Annex 3.3).The proportion of high level aminoglycoside resistance varied between none in Iceland (n=20) and 54% in Greece (n=448). Figure 4.10 shows that apart from Iceland, only three other countries: France (15%, n=767), Sweden (19%, n=492) and Bulgaria; (24%, n=55) reported resistance below 25%, whereas the majority were between 25% and 50% (Figure 4.10, Annex 3.3). During the EARSS surveillance period, this situation did not change substantially. Since 2001, a signiﬁcant increase was only observed in the Netherlands (from 28% to 38%), Czech Republic (from Chapter 4. Antimicrobial resistance in Europe 49 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU MT Figure 4.10. Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2005. 38% to 45%) and Estonia (from 22% in 2003 to 50% in 2005) and a decrease was only reported in Hungary (from 87% in 2003 to 40% in 2005) (Figure 4.11). In the Netherlands this increase was not observed for the subgroup of laboratories that reported data for all years. 4.4.3. Enterococcus faecium resistance trends: 2001-2005 Vancomycin In general, the number of AST results reported for invasive E. faecium isolates is low (n=2,855). As a result, four of the 26 countries reported less than 20 isolates in 2005 (Iceland; n=9, Luxembourg; n=14, Romania; n=10, and Slovakia; n=3). In half of the countries that reported more than 20 isolates, vancomycin resistance was less or equal to 1% or even absent in 8 countries. This contrasts to 5 countries which reported more than 25% of VREF in 2005, which were Greece (37%; n=227), Ireland (31%; n=220), Israel (46%; n=71), Portugal (34%; n=95) and the UK (33%, n=224) (Figure 4.12, Annex 3.3). Over the past 4 years, vancomycin resistance increased signiﬁcantly in 5 countries (Germany, Czech Republic, Ireland, Greece and Israel) (Figure 4.13). The rapid expansion of E. faecium in these countries is typically the result of institutional outbreaks. It does thus not represent the situation for hospitals that have remained unaffected. Indeed in the Czech Republic and Israel most VREF originated from one institution. The high proportion of VREF in Portugal showed a signiﬁcant decrease from the high level reported in 2003. However from a single laboratory, high proportions of VREF were persistently reported ever since, in 2003 (67%, n=54), 2004 (76%, n=43) and 2005 (67%, n=37). As the number of isolates reported to the EARSS central database from this laboratory decreased, the overall proportion 50 Chapter 4. Antimicrobial resistance in Europe 2002 FR (485) 2003 SE (488) 2001 BG (40) 2001 BE (114) 2001 FI (75) 2001 AT (99) Country code (average number of isolates reported per year) & year start surveillance* 2001 HR (70) 2001 NO (48) 2001 DE (79) 2001 ES (434) 2001 PT (194) 2001 NL (135) 2001 IT (322) 2002 SK (50) 2003 HU (159) 2002 IE (169) 2001 IL (175) 2001 CZ (476) 2001 SI (54) 2001 PL (39) 2003 EE (36) 2001 GR (235) 0 10 20 30 40 50 60 70 80 2001 2002 2003 2004 2005 90 High level aminoglycoside resistant E. faecalis Figure 4.11. Enterococcus faecalis: trends of high-level aminoglycoside resistance by country 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. * Either the ﬁrst year of surveillance or the ﬁrst year with 20 or more isolates reported. Chapter 4. Antimicrobial resistance in Europe 51 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.12. Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2005. MT of VREF in Portugal decreased as well (Figure 4.13), which may explain the overall reduction of VREF in this country. 4.4.4. Conclusions With the ongoing spread of CC 17 in Europe outbreaks of vancomycin resistant E. faecium continues to afﬂict more and more hospitals in various countries. The spread of these hospital-adapted strains occurs on the background of high-level aminoglycoside resistance. The control of glycopeptide resistant Enterococci remains a formidable task for hospital infection control practitioners and it is not difﬁcult to predict that these problematic pathogens will continue to remain a challenge. 4.5. Escherichia coli 4.5.1. 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 community and hospital-acquired urinary tract infections, is associated with spontaneous and surgical peritonitis, causes synergistic wound infections and is one of the most important food-borne pathogens worldwide (10;12;40). Resistance mechanisms. Beta-lactamases hydrolyse the beta-lactam ring of beta-lactam antibiotics, which is crucial for their inhibition of PBPs in bacteria. In E. coli resistance to broad-spectrum penicillins such as ampicillin or amoxicillin is conferred by plasmid coded beta-lactamases of the SHV and TEM type, whereby TEM-1 accounts for up to 60% of aminopenicillins resistance. In 1982 52 Chapter 4. Antimicrobial resistance in Europe 2001 FI (98) 2001 2002 2003 2004 2005 2003 HU (50) 2002 NO (35) 2003 SI (29) Country code (average number of isolates reported per year) & year of start surveillance* 2001 NL (166) 2001 SE (219) 2001 AT (96) 2002 FR (150) 2001 ES (110) 2003 HR (32) 2001 DE (139) 2001 CZ (111) 2001 IT (156) 2002 IE (154) 2003 PT (101) 2001 GR (147) 2001 IL (42) 0 10 20 30 40 50 60 70 80 % Vancomycin resistant E. faecium Figure 4.13. Enterococcus faecium: trends of vancomycin resistance by country 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. * Either the ﬁrst year of surveillance or the ﬁrst year with 20 or more isolates reported. Chapter 4. Antimicrobial resistance in Europe 53 the ﬁrst ESBL was identiﬁed during a hospital outbreak of Klebsiella pneumoniae in Germany. It was soon understood that single or multiple amino acid substitutions in the basic structure of SHV or TEM enzymes can alter their activity spectrum and enhance their hydrolyzing ability to include third generation cephalosporins and monobactams. Many ESBLs can be inhibited by beta-lactamase inhibitors such as clavulanic acid, sulbactam, or tazobactam. More than 200 ESBL variants are known to date. Most of them belong to three enzyme families TEM, SHV, and OXA (26). In E. coli, over 90% of ESBL resistance is mediated through TEM variants. Newly emerging ESBLs are CTX-M, and lately CMY-2, a plasmid encoded variant derived from the chromosomal AmpC locus (44). Fluoroquinolones interact with DNA gyrase and topoisomerase IV which are enzymes that regulate conformational changes in bacterial DNA during replication and transcription. This leads to irreversible inhibition of DNA strand separation and eventually to cell death. Resistance to quinolones arises through stepwise mutations in the coding regions of the gyrase subunits (gyrA and gyrB) and DNA topoisomerase IV (parC). Accumulation of mutations in several of these genes increases the MIC in a stepwise manner. Low-level resistance to quinolones may also arise through changes in membrane porins or in genes regulating the activity of efﬂux pumps, resulting in lower membrane permeability and higher efﬂux of ﬂuoroquinolones, respectively (20). In recent years, the plasmid-mediated QNR mechanism, protecting DNA from quinolone binding, is of concern because of its frequent association with CTX-M and CMY-type enzymes inactivating third generation cephalosporins(41). Aminoglycosides block protein synthesis by binding to the ribosomes or by disruption of the outer membrane of gram-negative rods. Resistance to aminoglycosides is brought about by target modiﬁcation of the large ribosomal subunit which excludes aminoglycoside molecules or by aminoglycoside modifying enzymes that acetylate, adenylate or phosphorylate their target molecules and thereby neutralize the biologic effect of aminoglycosides. 4.5.2. Escherichia coli resistance trends: 2001-2005 Aminopenicillins Aminopenicillin resistance in E. coli is highly prevalent in Europe and this substance can no longer be regarded as a useful option for empirical treatment. Of the 29 countries reporting AST results of invasive E.coli isolates to EARSS (n=36,134), resistance proportions were above 30% in all countries (n=29) except for Sweden (26%). Still aminopenicillin resistance varies substantially between countries, from 26% in Sweden to 77% in Romania (Figure 4.17. Annex 3.4). It also varied substantially over time; from 2001 to 2005, aminopenicillin resistance increased signiﬁcantly in 14 countries. Third generation cephalosporins Most countries (18 of 29) report less than 5% resistance against third generation cephalosporins in 2005. However this seemingly comfortable situation is no reason for complacency as resistance is rising in 23 of 28 countries with signiﬁcant trends identiﬁed for 15. Moreover third generation cephalosporin resistance seems to take-off rather quickly even in countries with formerly very low resistance from levels around 1% in 2001 to around 3% in 2005, and it only seems a matter of time before more and more countries will report levels of more than 5% (Figure 4.14). Five countries already reported levels of 10% or more in 2005, namely Bulgaria (28%, n=203), Cyprus (16%, n=74), Portugal (12%, n=1076), and Romania (16%, n=80) (Figure 4.18). Unfortunately, the EARSS database does not receive sufﬁcient information about the presence of ESBLs in the resistant strains to understand the detailed nature of this increasing problem. 54 Chapter 4. Antimicrobial resistance in Europe No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU MT Figure 4.14. Escherichia coli: proportion of invasive isolates with resistance to third generation cephalosporins in 2005. No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.15. Escherichia coli: proportion of invasive isolates with resistance to ﬂuoroquinolones in 2005. MT Chapter 4. Antimicrobial resistance in Europe 55 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.16. Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2005. MT Fluoroquinolones Fluoroquinolone resistance has consistently and substantially increased over the past ﬁve years all over Europe. Few countries have maintained levels at 5% or below, like Denmark (5%; n=758), Estonia (5%; n=151), Iceland (3%; n=117), and Norway (5%; n=1217) (Figure 4.19). At the same time the number of countries reporting ﬂuoroquinolone-resistant E. coli above 25% have doubled within a year between 2004 and 2005 and now comprise six countries: Bulgaria (29%, n=196), Cyprus (29%, n=72), Spain (28%, n=2993), Italy (28%,n=1094), Malta (30%, n=87) and Portugal (29%, n=1086) (Figure 4.15, Annex 3.4). Of the 28 countries providing data, 25 showed a clear increase in resistance, and in 19 this trend was signiﬁcant. The speed with which ﬂuoroquinolones loose their activity against E. coli is next to no other compound pathogen combination under study by EARSS (Figure 4.19). Aminoglycosides The proportions of aminoglycoside resistance were quite evenly distributed over the lowest categories; resistance below 5% was reported by 9 countries, between 5% and 10% was reported by 13 and between 10% and 25% was reported by 7 countries, with the highest percentage reported by Bulgaria (24%, n=203) (Figure 4.16, Annex 3.4). Similar to the other resistance phenotypes under surveillance for E. coli, aminoglycoside resistance also witnessed an increase in numerous countries (16 out of 28) whereby 12 showed signiﬁcant trends (Figure 4.20). For Spain the increase in the last year was due to laboratories that only started reporting since 2005; no increase in aminoglycoside resistance could be detected looking at Spanish laboratories that reported for all ﬁve years, therefore no signiﬁcant trend was reported. 56 Chapter 4. Antimicrobial resistance in Europe SE (1829) 2001 NO (977) FI (1286) IS (97) SI (487) EE (102) HR (483) GR (816) NL (2066) Country code (average number of isolates reported per year) AT (1121) LU (201) MT (81) HU (569) FR (3997) CZ (1742) BE (1172) DE (1105) IT (822) UK (1875) PL (145) PT (714) SK (175) ES (2713) IL (739) IE (1090) BG (145) CY (46) RO (49) 0 10 20 30 40 50 60 70 80 2002 2003 2004 2005 % aminonpenicillin resistance Figure 4.17. Escherichia coli: trends of aminopenicillin resistance by country, 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate signiﬁcant trends. Chapter 4. Antimicrobial resistance in Europe 57 IS (103) 2001 HR (483) NO (1061) MT (82) SE (3096) EE (107) FR (4068) SI (488) DE (1107) Country code (average number of isolates reported per year) FI (1528) HU (585) CZ (1742) NL (1780) LU (202) BE (1177) IE (1073) AT (1123) PL (144) UK (1734) GR (897) ES (2706) SK (175) IT (842) IL (844) PT (688) CY (46) RO (51) BG (151) 0 5 10 15 20 25 30 35 40 2002 2003 2004 2005 % 3rd gen. cephalosporin resistance Figure 4.18. Escherichia coli: trends of third generation cephalosporin resistance by country, 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate signiﬁcant trends. 58 Chapter 4. Antimicrobial resistance in Europe IS (95) 2001 NO (1044) EE (100) SE (2836) FI (1476) RO (38) HR (477) NL (2000) FR (3284) Country code (average number of isolates reported per year) SI (488) GR (889) SK (187) BE (1031) UK (1823) IE (859) LU (196) AT (1110) HU (553) PL (142) CZ (1744) IL (845) DE (1093) ES (2708) IT (655) BG (148) CY (27) PT (647) MT (82) 0 5 10 15 20 % fluoroquinolone resistance 25 30 35 40 2002 2003 2004 2005 Figure 4.19. Escherichia coli: trends of ﬂuoroquinolone resistance by country, 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate signiﬁcant trends. Chapter 4. Antimicrobial resistance in Europe 59 IS (103) 2001 SE (2428) NO (985) FI (1378) NL (2095) SI (488) EE (108) BE (922) HR (483) Country code (average number of isolates reported per year) FR (4123) AT (1122) DE (1108) CZ (1746) MT (82) GR (904) HU (585) IE (1081) PL (145) LU (203) SK (189) UK (1900) ES (2712) IT (818) PT (717) CY (46) RO (50) IL (848) BG (152) 0 5 10 15 20 25 30 35 40 2002 2003 2004 2005 % aminoglycoside resistance Figure 4.20. Escherichia coli: trends of aminoglycoside resistance by country, 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate signiﬁcant trends. 60 Chapter 4. Antimicrobial resistance in Europe 2001 IS (95) 2001 MT (82) 2001 HR (477) 2001 NO (979) 2001 BE (838) 2001 SE (2281) 2001 DE (1084) 2002 FR (4050) 2001 NL (1709) Country code (average number of isolates reported per year) 2001 EE (98) 2001 CZ (1741) 2002 IE (1053) 2001 SI (488) 2001 AT (1099) 2001 FI (1322) 2001 HU (548) 2001 LU (194) 2001 GR (886) 2001 UK (1647) 2001 ES (2699) 2002 RO (46) 2001 PL (140) 2001 SK (175) 2002 IT (813) 2003 CY (46) 2001 IL (843) 2001 PT (628) 2001 BG (146) 0 5 10 15 20 % multi resistance 25 30 35 2001 2002 2003 2004 2005 40 Figure 4.21. Escherichia coli: trends of combined resistance (resistant to ﬂuoroquinolones, third generation cephalosporins, and aminoglycosides) by country, 2001-2005. Only the countries that reported 20 isolates or more per year for at least 3 years were included. The arrows indicate signiﬁcant trends. Chapter 4. Antimicrobial resistance in Europe 61 Combined resistance It is not surprising that the overall increase of single compound resistance in E. coli is paralleled by a concomitant spread of phenotypes with combined resistance. Although combined resistance to third generation cephalosporins, ﬂuoroquinolones and aminoglycosides was still below 2% in most countries (20 of 29) (Figure 4.21, Annex 3.4), 18 witnessed an increase, which in 13 countries was signiﬁcant and unlikely due to random ﬂuctuations. Table 4.2 gives an overview over the most common phenotypes (single and combine resistance) based on the average proportions reported from all 29 countries in 2005. In E. coli, single aminopenicillins resistance was the most frequently phenotype (33%), followed by the dual combination of aminopenicillins with ﬂuoroquinolones (8%). The triple combination, aminopenicillins, ﬂuoroquinolones and aminoglycoside came third (3%), followed by resistance to all four antimicrobials reported to EARSS (2.2%). Please note that other compounds like trimethoprim, sulphamethoxazole, nitrofurantoin, tetracyclins etc. are not taken into account, as reporting of AST results for these substances is not obligatory in EARSS. Table 4.2. Overall resistance and resistance combinations among invasive Escherichia coli isolates tested against all four classes of drugs (according to the EARSS protocol) (n=33,730) in Europe, 2005. The ﬁgures represent averages of the country percentages. Resistance pattern Single resistance (to indicated drug classes) Aminopenicillins Fluoroquinolones Third generation cephalosporins Aminoglycosides Resistance to two or more classes of antimicrobial drugs Aminopenicillins + ﬂuoroquinolones Aminopenicillins + third generation cephalosporins Aminopenicillins + aminoglycosides Fluoroquinolones + aminoglycosides Aminopenicillins + ﬂuoroquinolones + aminoglycosides Aminopenicillins + ﬂuoroquinolones + third generation cephalosporins Aminopenicillins + aminoglycosides + third generation cephalosporins Aminopenicillins + ﬂuoroquinolones + aminoglycosides + Third generation cephalosporins 2.2 7.9 1.1 1.1 0.2 2.8 1.4 0.6 32.9 1.7 0.0 0.2 Average (%) 4.5.3. Conclusions The Europe-wide increase of resistance of Escherichia coli to all of the antimicrobial classes recorded by EARSS is a disturbing development with seemingly inexorable vigor. The highest resistance proportions have been reported for aminopenicillins ranging between 26 to 77%. Irrespective of this high level, resistance continues to increase in most of the countries, including those with proportions well above 60%. For ﬂuoroquinolones the situation becomes progressively dire. Of the 28 countries providing data, 25 showed a clear increase in ﬂuoroquinolone 62 Chapter 4. Antimicrobial resistance in Europe resistance, and in 19 this trend could not be explained by random ﬂuctuations. The speed with which ﬂuoroquinolones loose their activity against E. coli is next to no other compound pathogen combination in the EARSS database. Combined resistance is a frequent occurrence, with co-resistance to 4 antimicrobial classes including third generation cephalosporins already among the fourth most common resistance patterns encountered in invasive E. coli in Europe, and undeniably these resistance traits are on the increase as well. 4.6. Klebsiella pneumoniae 4.6.1. Clinical and epidemiological importance Bacteria of the genus Klebsiella are frequent colonizers of the gastrointestinal tract in humans but may also be found on skin, in the oro-pharynx and upper airways in hospitalized individuals. K. pneumoniae is associated with opportunistic infections in individuals with impaired immune systems, such as diabetics, alcoholics, and hospitalized patients with indwelling devices. The most common sites of infection are the urinary and the respiratory tract. Organisms can spread rapidly, from the gastrointestinal tract of patients and via the hands of hospital personnel to other patients, leading to nosocomial outbreaks. Klebsiella pneumoniae is the second most frequent cause of gram-negative blood stream infections after Escherichia coli. The mortality rate for Klebsiella pneumoniae community-acquired pneumoniae depends on the severity of the underlying condition and can be as high as 50%, even when appropriate antibiotic treatment is given. Resistance 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 TEM beta-lactamase and is thus intrinsically resistance against aminopenicillins. Moreover, this organism readily acquires plasmid-mediated resistance determinants. Therefore, many novel ESBL variants were initially identiﬁed in K. pneumoniae and are only subsequently found in E. coli. Since resistance mechanisms do not signiﬁcantly differ from those describe for E. coli, the reader is referred to the previous chapter for further detail (36). 4.6.2. Klebsiella pneumoniae resistance in 2005 EARSS began collecting AST results for invasive K. pneumoniae in 2005 and already 4,942 isolates were reported from 24 countries in this ﬁrst year alone. Third generation cephalosporins Third generation cephalosporin resistance is rather heterogeneous across Europe. Some counties report proportions below 5%, Finland (2%, n=175), France (4%, n=824), Norway (1%, n=174), The Netherlands (4%, n=256) and Sweden (1%, n=281), whereas some Eastern European countries and Israel report 25% or more: Bulgaria (50%, n=34), Croatia (46%, n=112), Cyprus (33%, n=9), Czech republic (32%, n=478), Greece (61%, n=469), Hungary (31%, n=140), Israel (38%, n=125) and Poland (66%, n=53) (Figure 4.22, annex 3.5). Fluoroquinolones Fluoroquinolone resistance in Europe has a similar geographical pattern as third generation cephalosporins; the lowest proportions can be found in the northern part of Europe: Estonia (0%, n=35, Finland (3%, n=155) , Ireland (3%, n=40), Iceland (0%, n=21), Norway (1%, n=172) and Sweden (5%, n=265) and the higher proportions in Eastern and Southern Europe: Bulgaria (26%, n=34), Czech republic (38%, n=478), Greece (54%, n=772), and Israel (30%, n=331) (Figure 4.23, Annex Chapter 4. Antimicrobial resistance in Europe 63 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU MT Figure 4.22. Klebsiella pneumoniae: proportion of invasive isolates resistant to third generation cephalosporins in 2005. No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.23. Klebsiella pneumoniae: proportion of invasive isolates resistant to ﬂuoroquinolones in 2005. MT 64 Chapter 4. Antimicrobial resistance in Europe No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.24. Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2005. MT number 3.5). Aminoglycosides A very similar pattern as for third generation cephalosporins and ﬂuoroquinolones can be found for aminoglycosides although low resistance proportions are also found in the middle European country Austria and the Southern European country Spain. Resistance proportions are below 5% in Austria (3%, n=89), Finland (3%,n=150), Ireland (5%, n=42) The Netherlands (5%, n=300), Norway (2%, n=174), Spain (4%, n=56), and Sweden (1%, n=279), and above 25% in Bulgaria (53%, n=34), Croatia (38%, n=112), Czech Republic (36%, n=477), Greece (60%, n=773), Hungary (30%, n=142), Israel (36%, n=331), and Poland (57%, n=53) (Figure 4.24, Annex 3.5). Carbapenems Carbapenems were reported voluntarily according to the routine procedures in place in participating laboratories from 22 of the 23 countries reporting on K. pneumoniae and therefore data were available for 67% of all isolates. Carbapenem resistance is still below 1% in most countries. Only Germany (2%, n=110) and Greece (28%, n=773) reported higher percentages reﬂecting the high number of ICU isolates in Greece. Most guidelines use breakpoints that are not designed to detect metallo-beta-lactamases and therefore our data do not capture the prevalence of these resistance determinants in Europe. ESGARS has developed a new protocol which may become part of the EARSS recommendation pending a decision at the annual plenary meeting. Since carbapenems are regarded as reserve antibiotics with life-saving potential when isolates show resistance to other antibiotics (37) it is important to monitor the susceptibility of this important group which may become increasingly threatened by the dissemination of metallo-beta-lactamases (Figure 4.25, Annex 3.5). Chapter 4. Antimicrobial resistance in Europe 65 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.25. Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2005. MT Table 4.3. Overall resistance and resistance combinations among invasive Klebsiella pneumoniae isolates tested against all four classes of drugs (according to the EARSS protocol) (n=4,610) in Europe, 2005. Intrinsic resistance against aminopenicillins is excluded; therefore results for only 3 classes are illustrated. The ﬁgures are averages of country percentages. Resistance pattern Overall resistance (to indicated drug classes) Fluoroquinolones Third generation cephalosporins Aminoglycosides (Carbapenems) Single resistance (to indicated drug classes) Fluoroquinolones Third generation cephalosporins Aminoglycosides Resistance to two or more classes of antimicrobial drugs Fluoroquinolones + third generation cephalosporins Fluoroquinolones + aminoglycosides Third generation cephalosporins + aminoglycosides Fluoroquinolones + third generation cephalosporins + aminoglycosides 2.9% 4.2% 5.9% 9.6% 3.1% 2.9% 1.6% 15.1% 20.0% 18.0% 1.4% Average (% ) 66 Chapter 4. Antimicrobial resistance in Europe Combined resistance In 2005, only 70% of the Klebsiella pneumoniae isolates displayed wild-type susceptibility (resistant to aminopenicillins only). All other isolates were resistant to at least one of the other antibiotic classes as well. As shown in table 4.3, single resistance is rather rare; the most frequent pattern is combined resistance against all four classes recorded by EARSS (10%). This suggests that the majority of invasive isolates carry multi-resistance plasmids coding for a combination of resistance determinants. 4.6.3. Conclusions In K. pneumoniae a high prevalence of resistant strains to third generation cephalosporins, ﬂuoroquinolones and aminoglycosides becomes evident in Eastern and Southeastern Europe. Many of these strains have combined resistance and the most frequent phenotype shows resistance to all three antimicrobial classes recorded by EARSS. Carbapenems seem to be still effective in most countries except Greece where the emergence of metallo-beta-lactamases jeopardizes the effectiveness of this reserve antibiotic. It will be necessary to closely monitor the effectiveness of carbapenems and make sure that its value is not put at stake through irresponsible prescribing in hospitals and ambulant care. 4.7. Pseudomonas aeruginosa 4.7.1. Clinical and epidemiological importance Pseudomonas aeruginosa is a non-fermenting gram-negative bacterium that is ubiquitously present in aquatic environments in nature. It is an opportunistic pathogen for plants, animals and humans, and is a major and dreaded cause of infection among patients with localized and systemic immune defects. Because of its ubiquitous presence, its enormous versatility and intrinsic tolerance to many detergents, disinfectants and antimicrobial compounds is difﬁcult to control P. aeruginosa in hospitals and institutional environments. Moreover, P. aeruginosa is a frequent cause for skin infections such as folliculitis and otitis externa in recreational and competitive swimmers. It causes the most important bacterial complication in patients with cystic ﬁbrosis leading to chronic colonization and intermittent exacerbations ranging from bronchiolitis to acute lung syndrome. Finally, P. aeruginosa is a common pathogen found in burns units and in these locations almost impossible to eradicate by classical infection control procedures. Resistance mechanisms. P. aeruginosa is intrinsically resistant to the majority of antimicrobial compounds due to its selective ability to exclude various molecules from penetrating its outer membrane. Acquired resistance in P. aeruginosa is caused by one or more of ﬁve mechanisms: i) mutational modiﬁcation of antibiotic target sites such as gyrase, topoisomerase or ribosomal proteins which confer resistance to ﬂuoroquinolones or aminoglycosides, ii) constitutional or inducible derepression of chromosomally coded AmpC beta-lactamase, iii) mutational loss of outer membrane proteins preventing the uptake of antimicrobial substances such as imipenem, iv) efﬁcient efﬂux systems, that can confer resistance to beta-lactams, ﬂuoroquinolones, tetracycline, chloramphenicol, trimethoprim and aminoglycosides, and v) plasmid-mediated expression of various beta-lactamases that can confer resistance to carbapenems (metallo-beta-lactamases) and aminoglycosides (32;39). 4.7.2. Pseudomonas aeruginosa resistance in 2005 EARSS began collecting AST results for invasive P. aeruginosa in 2005 and already 3,887 isolates were reported from 23 countries in this ﬁrst year alone. Chapter 4. Antimicrobial resistance in Europe 67 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.26. Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillin in 2005. MT Piperacillin The proportion of piperacillin resistance was higher than that for the piperacillin-tazobactam combination owing to the fact that the beta-lactamase inhibitor, although not effective against the AmpC beta-lactamase, has some residual inhibitory effect on P. aeruginosa. In Figure 4.26 the resistance is shown for the combined formulation or piperacillin alone where only these data were available. Of the 23 countries reporting AST results of invasive P. aeruginosa isolates, 7 countries reported resistance proportions below 10%, namely Spain (4%, n=70), Finland (8%, n=108), Ireland (7%, n=28), Iceland (8%, n=13), the Netherlands (4%, n=184), Norway (3%, n=75) and the UK (2%, n=349). The highest resistance were reported from Bulgaria (50%, n=34), Poland (50%, n=26) and Romania (61%, n=23) (Figure 4.26, Annex 3.6). Ceftazidime The most Northern European countries have ceftazidime resistance proportions below 5% . Austria (7%, n=76), France (9%, n=905), the Netherlands (5%, n=209), Spain (6%, n=70) and Croatia (6%, n=71) report proportion just over 5%. In all other countries, resistance proportions are higher than 10% with some Eastern European countries (BG, CY, CZ) reporting rates of more than 25%: Bulgaria (45%, n=33) , Cyprus (38%, n=8), Czech Republic (40%, n=257), Greece (27%, n=662), Poland (31%, n=26) and Romania (52%, n=23) (Figure 4.27, Annex number 3.6). Fluoroquinolones Ten (of 23) countries reported more than 25% ﬂuoroquinolone resistance for invasive P. aeruginosa isolates, of which Bulgaria (47%, n=34), Czech Republic (45%, n=245), Malta (44%, n=45) and Romania (64%, n=22) reported even more then 40% resistance. Low resistance levels (<5%) were only found in Iceland (0%, n=13) and Norway (4%, n=89) (Figure 4.28, Annex 3.6). 68 Chapter 4. Antimicrobial resistance in Europe No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.27. Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2005. MT No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.28. Pseudomonas aeruginosa: proportion of invasive isolates resistant to ﬂuoroquinolones in 2005. MT Chapter 4. Antimicrobial resistance in Europe 69 No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.29. Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2005. MT No data < 1% 1 – 5% 5 – 10% 10 – 25% 25 – 50% > 50 LU Figure 4.30. Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2005. MT 70 Chapter 4. Antimicrobial resistance in Europe Table 4.4. Overall resistance and resistance combinations among invasive Pseudomonas aeruginosa isolates tested against all ﬁve classes of drugs (as mentioned in the EARSS protocol) (n=3,197) in Europe, 2005. The ﬁgures are averages of country percentages. Resistance pattern Single resistance (to indicated drug classes) Piperacillin +/- tazobactam Ceftazidime Carbapenems Fluoroquinolones Aminoglycosides Resistance to two classes of antimicrobial drugs Piperacillin +/- tazobactam + ceftazidime Piperacillin +/- tazobactam + carbapenems Piperacillin +/- tazobactam + ﬂuoroquinolones Piperacillin +/- tazobactam + aminoglycosides Ceftazidime + carbapenems Ceftazidime + ﬂuoroquinolones Ceftazidime + aminoglycosides Carbapenems + ﬂuoroquinolones Carbapenems + aminoglycosides Fluoroquinolones + aminoglycosides Resistance to three classes of antimicrobial drugs Piperacillin +/- tazobactam + ceftazidime + carbapenems Piperacillin +/- tazobactam + ceftazidime + ﬂuoroquinolones Piperacillin +/- tazobactam + ceftazidime + aminoglycosides Piperacillin +/- tazobactam + ﬂuoroquinolones + aminoglycosides Piperacillin +/- tazobactam + carbapenems + ﬂuoroquinolones Piperacillin +/- tazobactam + carbapenems + aminoglycosides Ceftazidime + carbapenems + ﬂuoroquinolones Ceftazidime + carbapenems + aminoglycosides Ceftazidime + ﬂuoroquinolones + aminoglycosides Carbapenems + ﬂuoroquinolones + aminoglycosides Resistance to four or more classes of antimicrobial drugs Piperacillin +/- tazobactam + ceftazidime + carbapenems + ﬂuoroquinolones Piperacillin +/- tazobactam + ceftazidime + carbapenems + aminoglycosides Piperacillin +/- tazobactam + ceftazidime + ﬂuoroquinolones + aminoglycosides Piperacillin +/- tazobactam + carbapenems + ﬂuoroquinolones + aminoglycosides ceftazidime + carbapenems + ﬂuoroquinolones + aminoglycosides Piperacillin +/- tazobactam + ceftazidime + carbapenems + ﬂuoroquinolones + aminoglycosides 0.8 0.7 1.3 2.1 1.0 7.4 1.4 0.6 0.2 1.5 0.1 0.3 0.0 0.0 0.5 1.2 0.8 0.3 0.2 0.6 0.1 0.3 0.1 0.9 0.5 2.1 1.0 1.6 4.0 3.9 1.7 Average (% ) Chapter 4. Antimicrobial resistance in Europe 71 Aminoglycosides Aminoglycoside resistance proportions varied largely between countries, with proportions of less than 1 % in north western Europe: Iceland (n=13), Norway (n=89) and Sweden (n=149) all report 0%. Levels were well over 25% in Eastern Europe: Croatia (35%, n=72), Czech Republic (28% n=230), Estonia (28% n=36), Greece (40%, n=696), Hungary (32% n=238) and Romania (64%, n=22) (Figure 4.29, Annex 3.6). Carbapenems Countries differ in the reporting routine for carbapenems. Some hardly or never test for meropenem (Austria, Spain, France, Malta, Sweden), whereas other mainly test for imipenem susceptibility (Czech Republic, Estonia, Finland, Ireland, Iceland). We took a pragmatic approach and combined the AST results for both drugs. With this restriction in mind, we were thus able to draw up the overall distribution carbapenem resistance without loosing too much of valuable data (see ﬁgure 4.28). Pseudomonas aeruginosa resistance proportions appear to be rather high all over Europe. The only two countries which report proportions of less than 5% are the Netherlands (5%, n=187) and Norway (4%, n=80). In south eastern Europe, Poland and Estonia, resistance proportions where over 25%: Bulgaria (38%, n=32), Estonia (38%, n=37), Greece (39%, n=698), Poland (27%, n=26) and Romania (61%, n=23) (Figure 4.30, Annex 3.6). Combined resistance As expected, P. aeruginosa isolates were often found to be multi-resistant. In our database, the dominant phenotype in Europe in 2005 combined resistance to all the ﬁve classes of antimicrobials recorded by EARSS (7.4%). The second and third most common pattern consisted of single resistance phenotypes to either carbapenems or ﬂuoroquinolones (4.0 and 3.9% respectively) (Table 4.4). A clear AmpC phenotype with both piperacillin and ceftazidime resistance was surprisingly rare (only 0.8% of all resistant isolates). This may be due to selective uptake or hydrolysation kinetics of the two substances and poses the question if laboratories report susceptibility to either of the substances when an AmpC phenotype has been clearly identiﬁed - which could be misleading for clinicians. 4.7.3. Conclusions Combined resistance is the dominant threat imposed by invasive P. aeruginosa in Europe. Since resistance in P. aeruginosa emerges readily during antibiotic treatment, the time when blood cultures are taken is crucial as any isolate collected after prolonged exposure with antimicrobial chemotherapy will predictably be a multi-resistant phenotype. Assuming the diagnostic habits in Europe are comparable the picture that our data suggest is that the geographical gradient observed for all other gram-negative pathogens namely lower resistance in the Northwest and increasing resistance towards the Southeast also holds for P. aeruginosa. Chapter 5. Conclusions and Recommendations 73 Chapter 5. Conclusions and Recommendations In Europe the proportion Streptococcus pneumoniae that is not susceptible to penicillin (PNSP) keeps changing. It appears that in countries which reported high endemic prevalence in previous years the situation has improved. The reduction of full penicillin resistance may be the result of ﬁtness trade-offs, in absence of extreme selection pressures. More obvious was the increase of erythromycin resistance observed in most countries. In contrast to this widespread observation, in the UK, Belgium and Hungary this trend appears to have been reversed and the beginning of a decrease of S. pneumoniae resistant to erythromycin could be observed. The distribution of serogroups/serotypes reported to EARSS indicate that resistance is mainly conﬁned to few serogroups, all of which are included in the currently promoted conjugate vaccines. This suggests that vaccination, especially in young children, may represent an effective additional means of controlling antibiotic resistance in pneumococcal disease in Europe. Up to now, universal infant PCV immunization policy has been implemented in Luxembourg and the Netherlands and will be introduced in Norway and the UK in due course, with many countries following soon. To monitor the effect of these interventions, surveillance of the serotype distribution becomes ever more important. For Staphylococcus aureus no less than twelve countries reported a signiﬁcant increase in the proportion of MRSA within the last seven years. This trend was largely consistent throughout Europe and included countries with low, medium as well as high baseline MRSA endemicity. At the same time it appears that the MRSA pandemic is not an irreversible secular trend as two European countries (Slovenia and France) succeeded in constantly reducing the proportion of MRSA among Staphylococcus aureus blood stream infections over the past ﬁve or six years through rigorously implementing containment programs. With the ongoing spread of clonal complex 17 in Europe, outbreaks of vancomycin resistant E. faecium continues to afﬂict more and more hospitals in various countries. The spread of these hospital-adapted strains occurs on the background of high-level aminoglycoside resistance. The control of glycopeptide resistant enterococci remains a formidable task for hospital infection control practitioners and it is not difﬁcult to predict that these problematic pathogens will continue to remain an expanding challenge. The Europe-wide increase of resistance of Escherichia coli to all antimicrobial classes recorded by EARSS is a disturbing development with seemingly inexorable vigor. The highest resistance proportions have been reported for aminopenicillins ranging between 26 to 77%. Irrespective of this high level, resistance continues to increase in most of the countries, including those with proportions well above 60%. For ﬂuoroquinolones, the situation becomes progressively dire. Of the 28 countries providing data, 25 showed a clear increase in ﬂuoroquinolone resistance, and in 19 this trend is signiﬁcant i.e. is unlikely due to random ﬂuctuations. The speed with which ﬂuoroquinolones loose their activity against E. coli is next to no other compound pathogen combination in the EARSS database. Combined resistance is a frequent occurrence, with co-resistance to four antimicrobial classes including third generation cephalosporins already among the four most common resistance patterns encountered in invasive E. coli in Europe, and undeniably these resistance traits are on the increase as well. 74 Chapter 5. Conclusions and Recommendations In Klebsiella pneumoniae a high prevalence of resistant strains to third generation cephalosporins, ﬂuoroquinolones and aminoglycosides becomes evident in Eastern and Southeastern Europe. Many of these strains have combined resistance and the most frequent phenotype shows resistance to all three antimicrobial classes recorded by EARSS. Carbapenems seem to be still effective in most countries except for Greece, where the emergence of metallo-beta-lactamases jeopardizes the effectiveness of this class of reserve antibiotics. It will be necessary to closely monitor the effectiveness of carbapenems as it is clear that with increasing prevalence of multi-resistant phenotypes more of these antibiotics will be prescribed in the future. It is therefore important to reemphasize the importance of good microbiological diagnostic services to make sure that the value of these third-line drugs is not put at stake through irresponsible prescribing in hospitals and especially in ambulant care, for which oral carbapenems have been made available. Combined resistance is the dominant threat imposed by invasive Pseudomonas aeruginosa in Europe. Since resistance in P. aeruginosa emerges readily during antibiotic treatment, the time when blood cultures are taken is crucial as any isolate collected after prolonged exposure with antimicrobial chemotherapy will predictably have a multi-resistant phenotype. Assuming the diagnostic habits in Europe are comparable, the picture that our data suggest is that the same geographical gradient observed for all other gram-negative pathogens, namely lower resistance in the Northwest and increasing resistance towards the Southeast, also holds for P. aeruginosa. It appears that the overall threat imposed on European communities by the increasing loss of antimicrobial effectiveness continues unabated with the same speed as has been previously described by our network. This is shown most convincingly among the pathogens that are frequently transmitted in health care settings (MRSA and VRE) and for antimicrobial compounds that are available for oral administration and hence preferred in ambulatory care (aminopenicillins, macrolides, and ﬂuoroquinolones). 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Pneumococcal conjugate vaccines in Europe, Berlin, Germany, 23-25 August 2000. Report of a European advisory board meeting. Vaccine 2001;19(25-26):3347-54. 43. Shepard BD, Gilmore MS. Antibiotic-resistant enterococci: the mechanisms and dynamics of drug introduction and resistance. Microbes Infect 2002;4(2):215-24. 44. Sturenburg E, Mack D. Extended-spectrum beta-lactamases: implications for the clinical microbiology laboratory, therapy, and infection control. J Infect 2003;47(4):273-95. 45. Watson DA, Musher DM. A brief history of the pneumococcus in biomedical research. Semin Respir Infect 1999;14(3):198-208. 46. Weisblum B. Insights into erythromycin action from studies of its activity as inducer of resistance. Antimicrob Agents Chemother 1995;39(4):797-805. 47. Willems RJ, Top J, van Santen M, Robinson DA, Coque TM, Baquero F et al. Global spread of vancomycin-resistant Enterococcus faecium from distinct nosocomial genetic complex. Emerg Infect Dis 2005;11(6):821-8. 48. Wuorimaa T, Kayhty H. Current state of pneumococcal vaccines. Scand J Immunol 2002;56(2): 111-29. 49. 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(3):183-8. Annex 1. Technical Notes 79 Annex 1. Technical Notes on data analysis 1.1. Technical Notes for table 1 of the Country Summary Sheets Inclusion criteria To be included in the analyses presented in table 1 of the country summary sheets (Annex 1), countries, laboratories and hospitals had to provide both denominator data and AST results in 2004. Necessary details for inclusion were information on blood culture frequencies for laboratories and the number of beds for hospitals. Ranges The ranges given by speciﬁc laboratories for occupancy rate, number of sets collected per patient, or number of blood culture bottles per set were averaged (e.g. 1 to 3 = 2). Added up variables Number of blood culture sets, number of hospital beds (total, ICU and psychiatry or long term care beds), number of patient-days, catchment population, and type of hospitals were added up by country. Number of blood culture sets The total number of bottles per set was deﬁned as the number of bottles used per blood sample (and not per patient). If the number of blood culture sets was not available at laboratory level, it was calculated by: Total number of blood culture bottles / Total number of bottles per set Patient-days If patient-days were not available at hospital level, these were calculated by: Number of beds * (Annual occupancy / 100) * 365 Catchment population & Percentage of the total population covered. The total catchment population was the sum of the catchment populations of university and general hospitals. Hospitals providing only a speciﬁc type of care (classiﬁed as 3=other, e.g. oncology or psychiatric hospitals) were not included as we considered this population as probably overlapping with the catchment populations of the other hospitals. The percentage of population covered was then calculated by dividing the total catchment population by the estimated national population, which we derived from the CIA factbook available from the internet at www.cia.gov/cia/publications/factbook/. If the percentage of population covered exceeded 100%, this was set at 100%. Averaged variables Annual occupancy rate and length of stay were averaged per country. In these totals only laboratory/hospital questionnaires were included that provided information on all variables needed for the speciﬁc formula. 80 Annex 2. Country Summary Sheets Annual occupancy rate The average annual occupancy per country was calculated as: [ ∑( Annual occupancy / 100 * Number of beds) / ∑(Number of beds) ] * 100 Length of stay The median length of stay per country was determined, since the values of the hospital-speciﬁc lengths of stay had a skewed distribution for some countries. 1.2 Technical notes for chapter 4 Resistance trend analysis To determine signiﬁcant trends over time, the Cochrane Armitage test was used, excluding countries reporting less than 20 isolates per year. In addition, at least three years of data had to be reported by country to be included in the analysis. To exclude possible biases in the trend analyses, a sensitivity analysis was done to determine the sensitivity of the trend analysis for using the complete dataset versus only the subgroup selection. When trends were inﬂuenced signiﬁcantly by the differences in the composition of laboratories over the years this was indicated in the text. Annex 2.Country Summary Sheets 81 Annex 2. Country Summary Sheets In the following appendix, country-speciﬁc resistance information is presented together with denominator data and the characteristics of the participating laboratories and hospitals. Explanation to the country summary sheets General information about EARSS participating laboratories and hospitals Table 1 and 2 and ﬁgure 1 give an indication of the sample size and the representativeness of the country-speciﬁc resistance data available to EARSS. Table 1 displays results of the laboratories and hospitals that provided denominator data in 2004 (i.e. that responded to the questionnaire) and thus only includes the laboratories that 1) reported AST results to EARSS in 2004, and 2) provided blood culture information and the hospitals that 1) reported AST results to EARSS in 2004, and 2) provided their number of hospital beds. For details about the calculation of the average annual occupancy rate, the estimated catchment population and the percentage of the total population covered, we refer to the technical notes (Annex 2). If data were not available this is stated as “na”. Table 2 gives the number of laboratories and isolates reported by year and by pathogen under EARSS surveillance for the period 1999 to 2005. Figure 1 shows the geographic location of the laboratories reporting in 2005. The size of the dots in the maps represents the number of laboratories in that area: Dot Number of labs 1 5 10 15 Antibiotic resistance 1999-2005 Table 3 provides information on the proportion of invasive bacterial isolates non-susceptible (I+R) or resistant (R) to the antibiotics or antibiotic classes mentioned in the EARSS protocols. When interpreting Table 3 always check the number of isolates the proportions are based on given in Table 2. Demographic characteristics Table 4 gives the proportional distribution of the isolates reported by source, gender, age, and hospital department, and the proportion of resistance within the different groups, for the period 2004 and 2005. The abbreviations used in this table stand for; PNSP = penicillin non-susceptible S. pneumoniae, MRSA = methicillin resistant S. aureus, FREC = ﬂuoroquinolone resistant E. coli, VRE = vancomycin resistant E. faecalis or E. faecium, CRKP = 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 at hospital level Figures 2 and 3 show the local variation in the proportions of PNSP and MRSA by laboratory and by hospital, respectively. Both ﬁgures are based on data from 2004 and 2005, only including the laboratories and hospitals that reported at least 5 isolates in these 2 years. The total number of laboratories or hospitals, the minimum, maximum, median, 1st and third quartile of the proportion of resistance is displayed in a box in the Figures. If an ‘X’ is displayed at the end of a hospital code this means that the hospital code is not provided; consequently, this can compass one or more unknown hospitals. 82 Annex 2. Country Summary Sheets Austria General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2005, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 13/31 104/130 38,915 38,432 10,606,105 na na 5,740,000 70% 14% 69% 16% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 9 8 10 19 27 30 0 63 53 80 162 250 290 S. aureus Labs Isolates 0 10 9 11 20 30 32 0 382 278 455 871 1419 1471 E. coli Labs Isolates 0 0 0 0 8 260 10 479 21 985 31 1862 33 2059 Enterococci Labs Isolates 0 0 6 10 19 28 30 0 0 67 181 327 604 568 K. pneumoniae Labs Isolates 0 0 0 0 0 0 7 0 0 0 0 0 0 89 P. aeruginosa Labs Isolates 0 0 0 0 0 0 8 0 0 0 0 0 0 77 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 <1 2 5 18 . . . . . . . . . . . . . . . . . . 2001 2 4 10 8 35 2 7 <1 13 35 <1 86 13 5 . . . . . . . . 2002 <1 1 9 12 33 4 10 1 3 27 <1 84 21 7 . . . . . . . . 2003 1 9 14 15 41 5 14 2 1 33 <1 85 22 <1 . . . . . . . . 2004 1 5 12 14 46 5 17 3 <1 23 <1 85 22 <1 . . . . . . . . 2005 <1 5 15 13 48 5 19 4 1 28 <1 84 28 1 3 11 6 13 7 10 6 14 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 83 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=540 n=2890 n=3903 data 2005, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=819 %tot %VRE 100 0 61 37 1 4 1 38 57 0 0 . 0 1 0 0 0 0 0 . n=332 %tot %VRE 100 0 54 43 3 2 2 42 55 0 1 . 2 0 0 0 0 1 1 . n=88 %tot %CRKP 100 0 52 48 0 0 1 50 49 0 6 . 7 5 . . 0 7 5 . P. aeruginosa n=77 %tot %CRPA 100 0 68 32 0 1 1 44 53 0 10 . 10 12 . 0 0 15 7 . 15 16 7 0 0 Austria providing denominator data Isolate source Blood 94 5 CSF 6 10 Labs providing denom.data/ Gender data to EARSS reporting Male 55 Hosps providing denom.data/ 4 Female 43 6 reporting data to EARSS Unknown 2 Number of blood culture sets 0 Age (years) Number of hospital beds 0-4 9 6 Patient-days 5-19 4 4 Average occupancy rate (%) 20-64 4 Median length of stay 39 (days) 65 and catchment population 6 over 47 Estimated Unknown 1 0 % total population covered Hospital dep. Type of participating hospitals ICU 13 6 University/Tertiary 100 Total 14 0 . 56 43 1 2 2 39 57 0 100 0 18 . 20 17 32 5 17 18 18 . 13/31 15 38 12 104/130 61 13 38,9151 38,432 8 10,606,1052 3 na1 13 28 na 15 69 5,740,000 . 70%0 12 20 20 19 1 28 1 10 0 17 14%7 Internal Med. 55 4 50 12 57 17 41 0 34 1 48 7 42 General/Secondary 69% Surgery 1 0 11 19 10 17 15 Figure 0 Geographic distribution 17 laboratories in 2005 17 0 7 19 Other 16% 1. of Other 29 6 25 12 24 20 25 0 20 1 22 5 18 Unknown 1 14 number of isolates reported for the period 1999-2005 2 11 2 23 1 0 1 0 3 0 4 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 9 63 10 382 0 0 0 0 0 0 0 0 2001 8 53 9 278 8 260 6 67 0 0 0 0 2002 10 80 11 455 10 479 10 181 0 0 0 0 2003 19 162 20 871 21 985 19 327 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 27 250 30 1419 31 1862 28 604 0 0 0 0 AT003M 0/6 2005 30 290 no of32 1471: 24 33 2059 568 7 no of hospitals 89 77 AT005S 0/9 30 AT001 0/49 labs :8 74 AT005U 0/6 AT005Z 0/18 Minimum : 0.0 Minimum : 0.0 AT006B 0/9 AT003 0/9 AT006M 0/6 : 1st quartile : 0.0 Antibiotic resistance from 1st quartile 2005 0.0 1999 to AT007F 0/10 AT008S 0/9 Median : 3.3 Median : 8.5 AT005 0/47 AT010F 0/49 Table 3. Proportion of antibiotic non-susceptible isolates in:percent AT010H 0/5 3rd quartile 9.5 3rd quartile : 17.9 AT011W 0/7 AT007 0/15 AT014R 0/50 Maximum : 26.7 Maximum : 100 Pathogen Antimicrobial classes 1999 2000 2002 2003 2004 2005 AT015A 2001 0/29 AT015W 0/6 AT008 0/8 AT016G 0/16 S. pneumoniae Penicillin R . <1 AT022L 0/28 2 <1 1 1 <1 AT022M 0/5 AT012 0/18 AT022Z Penicillin I+R . 2 AT023G 0/7 4 1 9 5 5 0/5 AT024G 0/22 AT014 0/8 AT026Z Macrolides I+R . 5 AT032A 0/7 10 9 14 12 15 0/6 AT032E 0/5 AT017 3/73 S. aureus 0/5 Oxacillin/Methicillin R . 18 AT006S 8 12 15 14 13 AT026S 1/24 AT033F 1/21 E. coli Aminopenicillins R . . AT012W 35 33 41 46 48 AT024 0/11 1/20 AT023S 2/34 1/16 Aminoglycosides R . . AT005K 2 4 5 5 5 AT006N 1/16 AT026 0/17 AT001S 4/62 Fluoroquinolones R . . AT001B 72/30 10 14 17 19 AT010B 1/15 AT031 0/21 AT016W 8/120 AT001E 3rd gen. Cephalosporins R . . AT005H <15/69 1 2 3 4 1/13 AT028 1/39 AT024V 4/51 E. faecalis Aminopenicillins I+R . . AT021V 13 4/44 3 1 <1 1 PNSP at laboratory level MRSA at hospital level HL Aminoglycosides R AT027 1/25 Glycopeptides R AT002 2/36 E. faecium Aminopenicillins I+R AT006 2/33 HL Aminoglycosides R AT022 1/15 Glycopeptides R AT032 K. pneumoniae 1/11 Aminoglycosides R AT015 1/10 Fluoroquinolones R AT025 6/50 3rd gen. Cephalosporins R P. aeruginosa Piperacillin R AT010 4/29 Ceftazidime R AT029 1/7 Carbapenems R AT033 2/13 Aminoglycosides R AT018 4/15 Fluoroquinolones R 0 25 50 AT016 1/25 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . AT025K AT005L AT008T AT007K AT017Z AT031W AT033D AT005R AT005I AT015S AT022B AT009W AT021S AT022R AT029O AT018M AT003G AT017K AT028R AT022K AT007W AT011P AT027L AT032U AT035H AT034E AT005N AT024B AT002A AT007V AT023K AT032B AT020W AT005C AT032G AT019P 35 <1 86 13 5 . . . . . . . . 0 16/172 5/48 3/26 20/165 1/8 17/132 7/54 2/15 24/168 1/7 3/20 2/12 1/6 1/6 4/24 16/94 4/23 5/28 19/106 2/11 2/10 2/10 34/170 1/5 6/30 3/14 2/8 15/60 76/272 4/13 4/13 11/35 12/37 27 <1 84 21 7 . . . . . . . . 25 33 <1 85 22 <1 . . . . . . . 3/7 5/11 . 50 23 <1 85 22 <1 . . . . . . . . 75 28 <1 84 28 1 3 11 6 13 7 10 6 7/7 14 100 84 Annex 2. Country Summary Sheets Belgium General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 36/100 35/100 187,005 16,815 4,626,468 77% 8 3,046,147 29% 26% 74% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 92 90 89 98 107 95 97 846 909 1093 1210 1488 1443 1539 S. aureus Labs Isolates 47 42 47 48 47 49 41 442 657 941 1092 1133 1227 1048 E. coli Labs Isolates 0 0 0 0 23 226 27 1184 24 1326 25 1601 25 1592 Enterococci Labs Isolates 0 0 19 23 16 18 19 0 0 42 205 146 228 224 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 4 13 31 23 . . . . . . . . . . . . . . . . . . 2000 5 16 34 21 . . . . . . . . . . . . . . . . . . 2001 <1 13 35 23 53 4 9 2 <1 20 <1 60 <1 <1 . . . . . . . . 2002 <1 14 34 28 47 6 13 3 <1 20 <1 56 5 <1 . . . . . . . . 2003 <1 12 34 29 50 5 12 3 1 17 1 78 <1 <1 . . . . . . . . 2004 <1 9 33 33 50 5 15 3 2 22 <1 63 11 5 . . . . . . . . 2005 3 12 31 31 53 4 17 4 <1 26 <1 61 22 14 . . . . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 85 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=2982 n=2275 n=2794 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=363 %tot %VRE 100 0 61 37 2 6 1 29 64 0 0 . 0 0 0 0 0 0 0 . n=85 %tot 100 0 55 41 4 5 0 32 64 0 %VRE 9 . 11 6 33 0 . 4 13 . n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Belgium providing denominator data Isolate source Blood 96 11 CSF 4 11 Labs providing denom.data/ Gender data to EARSS reporting Male 53 Hosps providing denom.data/ 11 Female 46 10 reporting data to EARSS Unknown 2 Number of blood culture sets 12 Age (years) Number of hospital beds 0-4 20 15 Patient-days 5-19 6 5 Average occupancy rate (%) 20-64 6 Median length of stay 32 (days) 65 and catchment population over 42 13 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 13 11 University/Tertiary 100 Total 32 0 . 59 41 1 4 2 32 60 1 100 0 16 . 16 16 21 8 10 16 16 . 36/100 32 42 33 35/100 57 12 187,0051 16,815 8 4,626,4683 6 77%1 26 26 8 39 71 3,046,147 16 29%0 17 40 21 24 0 25 5 . . . 26%2 Internal Med. 32 10 35 30 19 31 0 29 4 . . . General/Secondary 74%7 Surgery 2 4 12 34 31 8 Figure 0 Geographic distribution of laboratories in 2005 2 0 . . . Other 0%2 1. Other 31 11 28 31 9 17 25 0 35 13 . . . Unknown 21 11 number of isolates reported for the period 1999-2005 8 31 80 15 12 0 8 29 . . . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 92 846 47 442 0 0 0 0 0 0 0 0 2000 90 909 42 657 0 0 0 0 0 0 0 0 2001 89 1093 47 941 23 226 19 42 0 0 0 0 2002 98 1210 48 1092 27 1184 23 205 0 0 0 0 2003 107 1488 47 1133 24 1326 16 146 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 95 1443 49 1227 25 1601 18 228 0 0 0 0 BE004 0/41 BE057A 1/21 2005 BE005 0/14 97 1539 no of41 1048: 89 25 1592 19 224 0 no of hospitals 0 0 BE010 0/28 labs :0 39 BE012 0/8 BE061A 13/110 BE017 0/10 Minimum : 4.8 Minimum : 0.0 BE020 0/7 BE077A 9/69 BE035 0/20 : 1st quartile : 25.0 BE051 0/25 Antibiotic resistance from 1st quartile 2005 4.4 1999 to BE075A 5/35 BE059 0/13 Median : 10.0 Median : 32.8 BE076 0/21 BE022A 9/49 BE105 0/19 Table 3. Proportion of antibiotic non-susceptible isolates in:percent BE107 0/8 3rd quartile 13.8 3rd quartile : 48.1 BE116 0/5 BE060A 17/91 BE137 0/11 Maximum : 40.0 Maximum : 100 BE156 14/73 Pathogen 0/9 Antimicrobial classes 1999 2000 BE003A 2001 2002 2003 2004 2005 BE164 0/5 BE024 1/50 1/5 BE037A BE075 1/50 S. pneumoniae Penicillin R 4 5 <1 <1 <1 <1 3 BE049 1/34 BE037 1/29 BE112A 29/131 BE048 1/27 BE084 1/24 Penicillin I+R 13 16 BE019A 13 14 12 9 12 8/32 BE021 2/45 BE023 2/44 44/170 BE063 2/41 Macrolides I+R 31 34 BE074A 35 34 34 33 31 BE001 3/60 BE041A 22/82 BE101 1/20 BE009 1/18 S. aureus Oxacillin/Methicillin R 23 21 BE005A 23 28 29 33 31 BE090 2/36 7/26 BE026 2/35 BE077 2/33 20/74 BE115 4/66 E. coli Aminopenicillins R . . BE006A 53 47 50 50 53 BE022 2/32 BE016A 33/118 BE055 1/15 BE100 1/14 Aminoglycosides R . . BE063A 4 6 5 5 4 21/70 BE097 5/63 BE061 4/50 BE071 1/12 Fluoroquinolones R . . BE097A 9 13 39/125 12 15 17 BE072 1/12 BE103 2/24 BE115A 27/85 BE008 6/70 BE057 3/33 3rd gen. Cephalosporins R . . BE001A 2 3 22/69 3 3 4 BE102 1/11 BE040 1/10 BE064 2/20 E. faecalis Aminopenicillins I+R . . BE002A <1 <1 20/61 1 2 <1 BE070 9/88 PNSP at laboratory level MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa BE045 BE091 BE002 BE030 BE033 BE069 BE032 BE003 BE109 BE016 BE056 BE029 BE031 BE046 BE074 BE114 BE108 BE014 BE104 BE139 BE019 BE043 BE006 BE013 BE092 BE060 BE112 BE093 BE007 BE143 BE054 BE073 BE081 BE161 BE098 BE118 BE150 BE044 BE110 BE152 BE065 BE095 BE083 6/57 9/85 5/46 8/72 1/9 2/17 5/42 3/25 3/25 7/58 7/58 1/8 2/16 3/24 5/40 2/16 20/157 4/31 8/62 9/66 4/29 14/94 6/39 3/19 22/138 6/36 12/72 7/37 5/26 6/31 5/25 1/5 2/10 5/24 9/42 3/14 3/14 2/9 4/17 5/19 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R 2/6 9/23 2/5 Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . BE058A BE143A BE030A BE114A BE029A BE056A BE026A BE008A BE007A BE032A BE054A BE024A BE070A BE072A BE012A BE014A BE040A BE152A BE154A 20 <1 60 <1 <1 . . . . . . . . 0 25 20 <1 56 5 <1 . . . . . . . . 5/15 14/42 18/51 17 1 11/27 78 17/41 24/57 <1 3/7 <1 51/118 12/27 . 39/81 . 3/6 . 34/67 85/159 . 5/9 . . . . 50 22 <1 63 11 5 . . . . . 4/6 10/14 . 12/16 . . 75 5/6 26 <1 61 22 14 . . . . . . . 6/6 . 100 86 Annex 2. Country Summary Sheets Bulgaria General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 23/23 23/24 23,063 10,703 2,630,314 82% 7 5,778,683 77% 35% 48% 17% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 8 8 11 13 13 16 0 13 16 25 22 32 43 S. aureus Labs Isolates 0 16 17 21 20 22 26 0 111 103 116 157 169 160 E. coli Labs Isolates 0 0 0 0 15 98 20 135 20 158 20 167 23 203 Enterococci Labs Isolates 0 0 11 16 16 16 21 0 0 30 42 49 75 95 K. pneumoniae Labs Isolates 0 0 0 0 0 0 15 0 0 0 0 0 0 34 P. aeruginosa Labs Isolates 0 0 0 0 0 0 9 0 0 0 0 0 0 34 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 23 23 25 37 . . . . . . . . . . . . . . . . . . 2001 6 6 9 27 48 15 8 7 5 30 <1 50 33 <1 . . . . . . . . 2002 8 8 9 33 52 17 14 13 26 63 <1 71 83 <1 . . . . . . . . 2003 9 14 11 31 54 22 19 18 7 36 <1 60 60 <1 . . . . . . . . 2004 22 22 17 24 64 20 24 22 15 33 2 59 62 <1 . . . . . . . . 2005 30 33 8 31 69 24 29 28 8 24 <1 96 56 <1 53 26 50 50 45 38 53 47 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 87 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=75 n=329 n=359 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=116 %tot %VRE 100 0 61 39 0 11 1 50 38 0 1 . 1 0 . 0 0 2 0 . n=49 %tot 100 0 63 37 0 16 2 47 35 0 %VRE 0 . 0 0 . 0 0 0 0 . n=34 %tot %CRKP 100 0 74 26 0 6 3 56 35 0 50 . 52 44 . 50 100 58 33 . P. aeruginosa n=32 %tot %CRPA 100 0 59 41 0 6 0 56 38 0 38 . 47 23 . 0 . 28 58 . 36 25 0 54 . Bulgaria providing denominator data Isolate source Blood 63 30 CSF 37 Labs providing denom.data/ 25 Gender data to EARSS reporting Male 53 Hosps providing denom.data/ 28 Female 47 29 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 9 57 Patient-days 5-19 5 0 Average occupancy rate (%) 20-64 Median length of stay 57 (days) 26 65 and over 28 29 Estimated catchment population Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 19 29 University/Tertiary 100 Total 27 0 . 62 38 0 10 5 56 29 0 98 2 26 43 31 21 . 12 25 27 28 . 23/23 29 53 24 23/24 47 . 23,0630 10,703 25 2,630,3147 20 82%2 28 46 7 28 45 5,778,683 . 77%0 14 44 12 39 15 0 24 0 15 60 34 35% Internal Med. 36 30 38 16 46 18 40 2 16 0 29 30 13 General/Secondary 48% Surgery 1 0 14 40 13 35 11 Figure 0 Geographic distribution 21 laboratories in 2005 16 0 43 13 Other 17% 1. of Other 44 27 34 27 29 30 34 0 43 0 35 67 41 Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 8 13 16 111 0 0 0 0 0 0 0 0 2001 8 16 17 103 15 98 11 30 0 0 0 0 2002 11 25 21 116 20 135 16 42 0 0 0 0 2003 13 22 20 157 20 158 16 49 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 13 32 22 169 20 167 16 75 0 0 0 0 2005 16 43 no of26 160: 6 23 203 21 95 15 no of hospitals 34 34 BG014A 0/6 labs :9 19 Minimum : 0.0 Minimum : 0.0 : 1st quartile : 16.7 BG030A 0/5 Antibiotic resistance from 1st quartile 200511.1 1999 to BG007 0/5 Median : 18.3 Median : 27.1 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 44.4 3rd quartile : 40.0 BG013A 2/19 Maximum : 50.0 Maximum : 50.0 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 1/7 BG022A S. pneumoniae Penicillin R . 23 6 8 9 22 30 2/12 Penicillin I+R . 23BG027A 6 8 14 22 33 BG013 1/9 Macrolides I+R . 25BG007A 9 9 11 17 8 4/20 S. aureus Oxacillin/Methicillin R . 37 27 33 31 24 31 6/29 E. coli Aminopenicillins R . .BG018A 48 52 54 64 69 Aminoglycosides R . .BG003A 15 22 20 24 5/2317 BG023 1/6 Fluoroquinolones R . . 8 14 19 24 29 BG023A 6/24 3rd gen. Cephalosporins R . . 7 13 18 22 28 13/48 E. faecalis Aminopenicillins I+R . .BG001A 5 26 7 15 8 PNSP at laboratory level MRSA at hospital level BG003 E. faecium K. pneumoniae BG011 P. aeruginosa BG024 0 HL Aminoglycosides R Glycopeptides R 2/10 Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R 4/9 Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R 3/6 Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 .BG020A . .BG024A .BG009A . BG002A . .BG021A .BG011A . .BG005A .BG006A . BG029A . 0 30 <1 50 33 <1 . . . . . . . . 63 36 3/11 <1 <1 3/11 71 60 83 3/9 60 <1 <1 3/8 . . 4/10 . . . . 7/17 . . 6/14 . . . 11/24 . . . 3/6 . . 25 50 33 2 59 62 <1 . . . . . . . . 75 24 <1 96 56 <1 53 26 50 50 45 38 53 47 100 88 Annex 2. Country Summary Sheets Croatia General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 15/15 15/16 44,013 8,431 2,780,926 90% 8 3,600,000 80% 27% 73% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 10 14 12 12 15 0 0 20 90 88 103 129 S. aureus Labs Isolates 0 0 14 14 14 13 17 0 0 149 279 360 392 354 E. coli Labs Isolates 0 0 0 0 13 182 15 490 16 570 14 535 16 638 Enterococci Labs Isolates 0 0 7 13 11 11 11 0 0 33 96 101 115 120 K. pneumoniae Labs Isolates 0 0 0 0 0 0 14 0 0 0 0 0 0 112 P. aeruginosa Labs Isolates 0 0 0 0 0 0 10 0 0 0 0 0 0 72 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 <1 15 15 32 51 6 5 2 13 50 3 100 100 <1 . . . . . . . . 2002 <1 19 23 37 47 7 5 3 5 40 <1 56 67 22 . . . . . . . . 2003 1 20 18 37 46 7 7 4 4 28 <1 47 41 6 . . . . . . . . 2004 3 17 19 38 45 6 8 3 5 35 <1 69 63 3 . . . . . . . . 2005 <1 17 17 37 46 5 9 <1 6 31 1 82 62 6 38 18 46 25 6 24 35 34 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 89 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=232 n=746 n=1171 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=171 %tot %VRE 100 0 63 36 1 8 6 43 43 0 1 . 1 0 0 0 10 0 0 . n=64 %tot 100 0 64 36 0 6 0 47 47 0 %VRE 5 . 2 9 . 25 . 7 0 . n=112 %tot %CRKP 100 0 64 36 0 24 0 42 34 0 46 . 50 38 . 70 . 38 37 . P. aeruginosa n=72 %tot %CRPA 100 0 63 38 0 3 3 49 46 0 24 . 22 26 . 50 0 26 21 . 20 17 46 20 . Croatia providing denominator data Isolate source Blood 97 16 CSF 3 33 Labs providing denom.data/ Gender data to EARSS reporting Male 59 Hosps providing denom.data/ 18 Female 41 15 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 22 22 Patient-days 5-19 8 Average occupancy rate (%) 11 20-64 Median length of stay 41 (days) 13 65 and catchment population over 30 20 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 15 9 University/Tertiary 100 Total 38 0 . 63 37 0 3 4 46 47 0 100 0 8 . 10 7 . 4 0 9 8 . 15/15 38 41 38 15/16 59 . 44,0130 8,431 12 2,780,9265 21 90%1 35 37 8 43 57 3,600,000 . 80%0 17 59 6 16 0 14 0 14 50 28 27%8 Internal Med. 22 24 38 26 37 8 35 0 48 6 21 21 33 General/Secondary 73% Surgery 1 50 13 70 14 17 Figure 0 Geographic distribution 13 laboratories in 2005 11 0 43 18 Other 0%3 1. of Other 63 16 32 27 53 9 32 2 27 6 52 55 21 Unknown 0 . number of isolates reported for the period 1999-2005 0 . 0 . 0 . 0 . 0 . 0 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2001 10 20 14 149 13 182 7 33 0 0 0 0 2002 14 90 14 279 15 490 13 96 0 0 0 0 2003 12 88 14 360 16 570 11 101 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 12 103 13 392 14 535 11 115 0 0 0 0 2005 15 129 no of17 354: 9 16 638 11 120 14 no of 112 72 labs hospitals 10 17 : HR010H 1/13 Minimum : 7.7 Minimum : 0.0 HR004 0/12 : 1st quartile : 19.1 Antibiotic resistance from 1st quartile 200511.5 1999 to HR014A 2/18 Median : 20.8 Median : 30.0 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 27.3 3rd quartile : 50.0 1/8 HR017A Maximum : 75.0 Maximum : 100 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 HR005 1/15 S. pneumoniae Penicillin R . .HR009A <1 <1 1 3 <1 6/37 Penicillin I+R . . 15 19 20 17 17 HR011A 13/68 Macrolides I+R . . 15 23 18 19 17 HR002 12/104 S. aureus Oxacillin/Methicillin R . .HR016A 32 37 37 38 37 2/10 E. coli Aminopenicillins R . . 51 47 46 45 46 7/24 HR007 4/22 Aminoglycosides R . .HR010A 6 7 7 6 5 Fluoroquinolones R . .HR013A 5 5 7 8 9 3/10 3rd gen. Cephalosporins R . . 2 3 4 3 <1 6/20 HR001 5/24 E. faecalis Aminopenicillins I+R . .HR018A 13 5 4 5 6 PNSP at laboratory level MRSA at hospital level HR010 E. faecium HR014 K. pneumoniae HR009 P. aeruginosa HR011 0 HL Aminoglycosides R Glycopeptides R 3/12 Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R 3/11 Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin3/8 R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 6/8 . . . . . . . . . . . . . 100 . HR002A . .HR004A . HR001A . .HR020A . .HR007A .HR008A . .HR027A . HR024B . 0 50 3 100 100 <1 . . . . . . . . 25 40 26/82 <1 56 27/83 67 22 . . . . . . . . 75 28 <1 47 41 86/184 6 4/8. . .86/160 . 3/5 . . 3/5 . . 50 35 <1 69 63 3 . . . . . . . . 75 31 1 82 62 6 38 18 46 25 6 24 35 5/5 34 100 90 Annex 2. Country Summary Sheets Cyprus General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 4/5 5/5 6,369 1,153 313,037 74% 5 800,000 100% 20% 80% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 0 0 1 1 4 0 0 0 0 3 7 16 S. aureus Labs Isolates 0 0 0 0 1 3 5 0 0 0 0 28 39 54 E. coli Labs Isolates 0 0 0 0 0 0 0 0 1 19 4 46 5 74 Enterococci Labs Isolates 0 0 0 0 1 3 3 0 0 0 0 28 38 40 K. pneumoniae Labs Isolates 0 0 0 0 0 0 4 0 0 0 0 0 0 9 P. aeruginosa Labs Isolates 0 0 0 0 0 0 4 0 0 0 0 0 0 8 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 . . . . . . . . . . . . . . . . . . . . . . 2002 . . . . . . . . . . . . . . . . . . . . . . 2003 <1 <1 33 64 63 11 32 11 <1 43 <1 100 . <1 . . . . . . . . 2004 <1 14 <1 49 61 11 22 9 3 77 3 100 33 33 . . . . . . . . 2005 <1 19 13 56 73 14 29 16 3 71 <1 80 <1 40 11 22 33 13 38 13 13 13 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 91 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=23 n=93 n=118 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=70 %tot 100 0 60 40 0 0 0 1 9 90 %VRE 1 . 0 4 . . . 0 0 2 n=8 %tot 100 0 63 38 0 0 0 13 13 75 %VRE 38 . 20 67 . . . 100 0 33 n=9 %tot %CRKP 100 0 78 22 0 0 0 0 11 89 33 . 29 50 . . . . 100 25 P. aeruginosa n=8 %tot %CRPA 100 0 88 13 0 0 0 0 25 75 13 . 14 0 . . . . 0 17 0 0 50 0 . Cyprus providing denominator data Isolate source Blood 70 19 CSF 30 Labs providing denom.data/ 14 Gender data to EARSS reporting Male 57 Hosps providing denom.data/ 23 Female 43 10 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 9 0 Patient-days 5-19 9 Average occupancy rate (%) 50 20-64 4 0 Median length of stay (days) 65 and catchment population 0 over 4 Estimated Unknown 74 18 % total population covered Hospital dep. Type of participating hospitals ICU 4 0 University/Tertiary 100 Total 53 0 . 66 34 0 4 2 6 8 80 51 56 . 100 0 26 . 37 16 0 0 33 31 31 26 4/5 50 48 5/5 6,3692 1,153 0 313,0373 50 74%3 33 11 5 57 800,000 11 57 100% 72 18 65 40 17 0 13 0 33 0 25 20%8 Internal Med. 70 19 35 45 52 26 37 0 25 50 56 40 38 General/Secondary 80% Surgery 0 . 16 60 33 27 Figure 0 Geographic distribution of laboratories in 2005 50 25 0 . 25 Other 0%5 1. Other 26 17 30 50 33 23 19 8 13 100 11 100 13 Unknown 0 . 0 . 2 0 0 . 0 . 0 . 0 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 2000 0 0 0 0 2001 0 0 0 0 2002 0 0 0 0 2003 1 3 1 28 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 1 7 3 39 2005 4 16 no of labs 5 54: 3 Minimum : 16.7 : Antibiotic resistance from 1st quartile 200516.7 1999 to Median : 18.2 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 20.0 Maximum : 20.0 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 0 0 1 4 5 S. pneumoniae CY003 1/6 S. aureus E. coli CY001 E. faecalis Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R 2/11 Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R 1/5 Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 1 28 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 46 3 38 0 0 0 0 74 3 40 4 no of hospitals 9 8 :4 5 Minimum : 16.7 1st quartile : 33.3 Median : 33.3 CY005A 1/6 3rd quartile : 50.0 Maximum : 63.2 2000 2001 2002 2003 2004 2005 . . . <1 <1 <1 . . . <1 14 19 . . . 33 <1 13 .CY003A . . 4/12 64 49 56 . . . 63 61 73 . . . 11 11 14 . . . 32 22 29 . . . 11 9 16 .CY004A . . 2/6 <1 3 3 MRSA at hospital level E. faecium K. pneumoniae CY002 P. aeruginosa . . . . .CY002A . . . . .CY001A . . . 0 . . . . . . . . . . . . . 25 . . . . . . . . . . . . . 0 43 <1 100 . <1 6/12 . . . . . . . . 50 77 3 100 33 33 . . . . . 36/57 . . . 75 71 <1 80 <1 40 11 22 33 13 38 13 13 13 100 92 Annex 2. Country Summary Sheets Czech Republic General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2005, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 48/48 82/82 127,520 44,180 12,365,539 79% 8 9,298,105 91% 27% 67% 6% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 26 32 34 32 37 39 0 111 154 144 204 162 194 S. aureus Labs Isolates 0 31 39 41 45 45 47 0 515 1074 1168 1387 1444 1553 E. coli Labs Isolates 0 0 0 0 36 1176 40 1587 43 1766 44 1966 47 2234 Enterococci Labs Isolates 0 0 34 39 44 41 45 0 0 461 587 630 660 758 K. pneumoniae Labs Isolates 0 0 0 0 0 0 37 0 0 0 0 0 0 478 P. aeruginosa Labs Isolates 0 0 0 0 0 0 36 0 0 0 0 0 0 257 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 <1 4 1 4 . . . . . . . . . . . . . . . . . . 2001 <1 7 2 6 42 6 8 2 3 38 2 67 33 2 . . . . . . . . 2002 <1 8 4 6 45 6 10 1 2 39 <1 73 35 9 . . . . . . . . 2003 <1 2 2 6 45 5 13 1 4 44 <1 80 48 3 . . . . . . . . 2004 2 6 4 9 47 5 16 2 <1 43 <1 81 43 3 . . . . . . . . 2005 <1 4 2 13 50 6 20 2 <1 45 <1 92 69 14 36 38 32 21 40 31 28 45 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 93 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=356 n=2997 n=4198 data 2005, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=1101 %tot %VRE 100 0 64 36 0 4 1 44 50 0 0 . 0 0 . 0 0 0 0 . n=317 %tot %VRE 100 0 53 47 0 1 1 52 46 0 10 . 8 13 . 0 0 13 7 . n=478 %tot %CRKP 99 1 60 40 0 5 1 42 51 0 32 75 35 29 . 35 20 35 30 . P. aeruginosa n=257 %tot %CRPA 99 1 63 37 0 8 2 43 47 0 31 50 34 27 . 5 33 33 34 . 41 22 26 29 . Czech Republic providing denominator data Isolate source Blood 83 5 CSF 17 5 Labs providing denom.data/ Gender data to EARSS reporting Male 65 Hosps providing denom.data/ 4 Female 35 6 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 9 0 Patient-days 5-19 6 5 Average occupancy rate (%) 20-64 5 Median length of stay 54 (days) 65 and catchment population 6 over 31 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 24 4 University/Tertiary 100 Total 11 0 . 60 40 0 4 3 44 49 0 100 0 18 . 21 16 . 4 15 17 19 . 48/48 11 41 10 82/82 59 . 127,5200 44,180 2 12,365,5392 3 79%1 10 32 8 13 65 9,298,105 . 91%0 21 17 16 21 38 0 34 2 32 39 37 27% Internal Med. 43 6 49 9 54 19 32 0 24 6 40 26 30 General/Secondary 67% Surgery 2 0 12 12 17 10 Figure 0 Geographic distribution 11 laboratories in 2005 8 0 19 7 Other 6%8 1. of Other 31 4 18 9 22 15 20 0 34 23 17 44 26 Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 26 111 31 515 0 0 0 0 0 0 0 0 2001 32 154 39 1074 36 1176 34 461 0 0 0 0 2002 34 144 41 1168 40 1587 39 587 0 0 0 0 2003 32 204 45 1387 43 1766 44 630 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 37 162 45 1444 44 1966 41 660 0 0 0 0 CZ007D 0/8 2005 39 194 no of47 1553: 28 47 2234 758 37 no of 478 257 CZ003 0/5 CZ009B 0/14 45 labs hospitals 36 66 : CZ025A 0/31 CZ029A 0/14 Minimum : 0.0 CZ004 0/7 Minimum : 0.0 0/7 CZ031F : 1st quartile : 3.2 CZ031K 0/10 Antibiotic resistance from 1st quartile 2005 0.0 1999 to CZ005 0/5 CZ032A 0/25 Median : 0.0 Median : 8.6 CZ037D 0/10 Table 3. Proportion of antibiotic non-susceptible isolates in:percent CZ006 0/28 0/8 CZ040C 3rd quartile 8.1 3rd quartile : 16.7 CZ045A 0/21 Maximum : 33.3 Maximum : 80.0 0/23 CZ012 Pathogen 0/13 Antimicrobial classes 1999 2000 CZ046A 2001 2002 2003 2004 2005 0/6 CZ048B CZ049A 0/14 CZ013 0/5 S. pneumoniae Penicillin R . <1 CZ004A <1 <1 <1 2 <1 1/54 CZ002A 2/82 CZ014 0/7 1/40 Penicillin I+R . 4 CZ019A 7 8 2 6 4 CZ037A 1/31 CZ038A 1/30 CZ015 0/16 Macrolides I+R . 1 CZ006A 2 4 2 4 2 6/173 CZ009A 6/151 CZ016 4/72 S. aureus 0/32 Oxacillin/Methicillin R . 4 CZ007A 6 6 6 9 13 CZ027A 4/70 CZ019 0/6 CZ022A 2/33 E. coli Aminopenicillins R . . CZ036A 42 45 45 47 50 2/33 CZ021A 6/94 CZ022 0/16 Aminoglycosides R . . CZ047A 61/15 6 5 5 6 CZ044A 3/44 CZ023 0/8 CZ024A 10/142 Fluoroquinolones R . . CZ026A 84/56 10 13 16 20 CZ043B 1/14 CZ027 0/12 3rd gen. Cephalosporins R . . CZ040A 2 1/13 1 1 2 2 CZ008A 2/25 CZ029 0/6 CZ017B 3/37 E. faecalis Aminopenicillins I+R . . CZ015B 3 1/11 2 4 <1 <1 PNSP at laboratory level MRSA at hospital level HL Aminoglycosides R Glycopeptides R CZ036 0/6 E. faecium 0/6 Aminopenicillins I+R CZ046 HL Aminoglycosides R CZ009 1/21 Glycopeptides R CZ025 1/15 K. pneumoniae 1/14 Aminoglycosides R CZ007 CZ002 1/11 Fluoroquinolones R CZ017 2/18 3rd gen. Cephalosporins R CZ049 1/7Piperacillin R P. aeruginosa CZ024 2/13 Ceftazidime R CZ044 1/5 Carbapenems R CZ031 4/14 Aminoglycosides R CZ037 2/6 Fluoroquinolones R 0 25 50 CZ032 0/6 CZ030 0/11 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . CZ022B CZ030A CZ031J CZ034A CZ020A CZ016A CZ015A CZ012A CZ018A CZ012B CZ031P CZ031A CZ017C CZ028A CZ035A CZ011A CZ041A CZ023A CZ013A CZ014A CZ017A CZ033A CZ012C CZ019B CZ047B CZ042A CZ003A CZ031Y CZ005A CZ039B CZ039A CZ031N 38 2 67 33 2 . . . . . . . . 0 1/11 4/44 1/11 3/30 11/109 10/99 10/96 2/19 24/224 1/9 2/17 10/84 4/32 1/8 10/69 5/30 6/36 10/58 7/39 2/11 22/114 15/77 1/5 2/10 1/5 7/32 39 <1 73 35 9 . . . . . 21/76 . 2/7 . . 42/115 7/17 44 <1 80 48 3 . . . . . . . 5/10 . 50 25 43 <1 81 43 3 . . . . . . . . 75 4/5 45 <1 92 69 14 36 38 32 21 40 31 28 45 100 94 Annex 2. Country Summary Sheets Denmark General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2005, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 15/15 na na na na na na 5,150,000* 95%* na na na Figure 1. Geographic distribution of laboratories in 2005 * Except for E. coli : 1,940,000 (36%). Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 5 5 5 5 15 14 0 410 506 366 606 1188 1081 S. aureus Labs Isolates 5 4 4 5 5 15 15 718 501 520 752 671 1436 1350 E. coli Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 5 1283 Enterococci Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . <1 . . . . . . . . . . . . . . . . . . 2000 <1 4 5 <1 . . . . . . . . . . . . . . . . . . 2001 <1 3 5 <1 . . . . . . . . . . . . . . . . . . 2002 <1 4 5 <1 . . . . . . . . . . . . . . . . . . 2003 <1 3 5 <1 . . . . . . . . . . . . . . . . . . 2004 <1 3 5 1 . . . . . . . . . . . . . . . . . . 2005 <1 4 6 2 39 2 5 1 . . . . . . . . . . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 95 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=2269 n=2786 n=758 data 2005, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=0 %tot . . . . . . . . . . %VRE . . . . . . . . . . n=0 %tot . . . . . . . . . . %VRE . . . . . . . . . . n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Denmark providing denominator data Isolate source Blood 92 4 CSF 8 5 Labs providing denom.data/ Gender data to EARSS reporting Male 49 Hosps providing denom.data/ 3 Female 51 4 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 8 5 Patient-days 5-19 3 3 Average occupancy rate (%) 20-64 3 Median length of stay 37 (days) 65 and catchment population 4 over 53 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 0 . University/Tertiary 100 Total 1 0 . 60 37 3 4 3 37 56 0 2 1 1 100 0 5 . 5 4 . 0 0 7 4 . 15/15 44 56 na na0 na 1 na1 1 na1 1 28 na 2 70 5,150,000* * . 95%0 4 2 9 . . . . . . . na3 Internal Med. 0 . 38 1 49 5 . . . . . . . General/Secondary na Surgery 0 . 15 3 20 3 . Figure 1. Geographic distribution of laboratories in 2005 . . . . . . Other na Other 0 . 1 28 5 . . . . . . . * Except for15 coli : 1,940,000 (36%). E. Unknown 100 4 number of isolates reported for the period 1999-2005 29 1 0 . . . . . . . . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 5 718 2000 5 410 4 501 2001 5 506 4 520 2002 5 366 5 752 2003 5 606 5 671 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 15 1188 15 1436 2005 14 1081 no of15 1350: 14 labs DK006 2/111 Minimum : 1.8 : Antibiotic resistance from 1st quartile 2005 2.6 1999 to Median : 3.6 DK015 2/107 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 4.2 Maximum : 6.7 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 0 0 0 0 5 S. pneumoniae DK016 DK007 2/96 7/271 S. aureus DK005 E. coli DK014 3/112 8/278 DK012 6/170 E. faecalis DK011 3/80 Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . <1 . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 0 0 0 0 0 0 0 DK001A 0/226 1283 0 0 0 no of hospitals 0 0 DK002A 0/86 :0 51 DK002B 0/109 Minimum : 0.0 DK002F 0/34 1st quartile : 0.0 DK005A 0/67 Median : 0.0 DK006A 0/66 DK006B 0/53 3rd quartile : 1.9 DK006C 0/17 Maximum : 16.7 0/20 2000 DK008A 2001 2002 2003 2004 2005 DK009A 0/32 <1 DK009C 0/5<1 <1 <1 <1 <1 0/6 DK009D 4 DK009F 0/16 3 4 3 3 4 DK009G 0/5 5 DK010D 0/7 5 5 5 5 6 DK011D 0/7 <1 DK012A 0/8<1 <1 <1 1 2 . DK012C 0/5 . . . . 39 DK012F 0/46 DK013A . DK013D 0/37 . . . . 2 0/7 . DK014A 0/21 . . . . 5 DK014N 0/65 . DK015A 0/85 . . . . 1 DK015C 0/9 . DK016B 0/55 . . . . . MRSA at hospital level DK004 E. faecium DK003 6/158 11/280 K. pneumoniae DK001 2/48 P. aeruginosa DK002 DK013 4/90 17/272 DK009 13/194 . . . . . . . . . . . . . DK016C DK016D DK016F DK016G DK016H DK004A DK003C DK016A DK010A DK003B DK009B DK013B DK014C DK005B DK011A DK003A DK004B DK014B DK002E DK014D DK004C DK012D DK010B DK012B DK012E 0/22 0/15 0/12 0/22 0/10 1/101 2/189 2/175 1/79 1/78 3/217 1/69 1/54 1/48 2/82 3/98 1/31 4/116 2/54 2/51 2/31 3/46 1/14 3/34 . . . . . . . . . . . . . 4/24 . . . . . . . . . . . . . 50 . . . . . . . . . . . . . 75 . . . . . . . . . . . . . 100 . . . . . . . . . . . . . 0 0 25 96 Annex 2. Country Summary Sheets Estonia General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 10/10 12/13 6,127 4,995 1,326,411 73% 7 1,300,000 100% 33% 67% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 5 5 8 6 7 0 0 20 21 26 40 53 S. aureus Labs Isolates 0 0 6 8 9 9 8 0 0 79 81 98 104 141 E. coli Labs Isolates 0 0 0 0 4 52 6 67 9 98 10 166 10 156 Enterococci Labs Isolates 0 0 4 3 6 5 7 0 0 21 13 27 63 66 K. pneumoniae Labs Isolates 0 0 0 0 0 0 7 0 0 0 0 0 0 38 P. aeruginosa Labs Isolates 0 0 0 0 0 0 5 0 0 0 0 0 0 38 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 <1 <1 5 5 43 8 <1 6 8 <1 <1 63 63 <1 . . . . . . . . 2002 <1 <1 <1 1 42 10 5 2 10 50 <1 33 67 <1 . . . . . . . . 2003 <1 <1 10 4 42 3 5 1 4 22 <1 75 50 <1 . . . . . . . . 2004 <1 <1 6 5 55 2 6 4 14 32 <1 79 79 <1 . . . . . . . . 2005 <1 2 <1 2 45 4 5 1 14 50 <1 83 74 <1 8 <1 8 27 18 38 28 14 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 97 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=93 n=245 n=306 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=79 %tot 100 0 62 37 1 18 1 35 41 5 %VRE 0 . 0 0 0 0 0 0 0 0 n=41 %tot 100 0 46 49 5 20 5 44 29 2 %VRE 0 . 0 0 0 0 0 0 0 0 n=37 %tot %CRKP 100 0 46 46 8 16 0 46 38 0 8 . 12 6 0 17 . 6 7 . P. aeruginosa n=37 %tot %CRPA 100 0 73 24 3 5 8 41 46 0 38 . 41 33 0 0 67 73 6 . 36 0 . 55 . Estonia providing denominator data Isolate source Blood 78 1 CSF 22 0 Labs providing denom.data/ Gender data to EARSS reporting Male 57 Hosps providing denom.data/ 2 Female 42 0 reporting data to EARSS Unknown 1 Number of blood culture sets 0 Age (years) Number of hospital beds 0-4 9 0 Patient-days 5-19 6 0 Average occupancy rate (%) 20-64 2 Median length of stay 47 (days) 65 and catchment population 0 over 32 Estimated Unknown 5 0 % total population covered Hospital dep. Type of participating hospitals ICU 31 3 University/Tertiary 100 Total 3 0 . 58 40 2 10 6 50 29 5 4 2 0 98 2 6 0 8 5 0 0 0 5 8 8 10/10 36 62 12/13 6,1272 4,995 0 1,326,4115 0 73%3 5 43 7 3 45 1,300,000 0 100%4 21 2 17 10 32 0 24 0 32 8 59 33% Internal Med. 25 0 31 5 36 5 18 0 12 0 22 0 11 General/Secondary 67% Surgery 4 0 12 0 7 6 Figure 0 Geographic distribution of laboratories in 2005 12 0 0 . 0 Other 0%9 1. Other 39 0 36 3 38 5 43 0 51 0 46 12 30 Unknown 1 0 . 1 0 1 0 0 . 0 . 0 Table 2. Number of laboratories 0 number of isolates reported for the period 1999-2005 and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2001 5 20 6 79 4 52 4 21 0 0 0 0 2002 5 21 8 81 6 67 3 13 0 0 0 0 2003 8 26 9 98 9 98 6 27 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 6 40 9 104 10 166 5 63 0 0 0 0 2005 7 53 no of labs 8 141: 5 10 156 7 66 7 no of hospitals 38 38 :5 9 Minimum : 0.0 Minimum : 0.0 EE002L 0/14 : 1st quartile : 0.0 Antibiotic resistance from 1st quartile 2005 0.0 1999 to Median : 0.0 Median : 0.0 EE001 0/27 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 0.0 3rd quartile : 2.9 Maximum : 10.0 Maximum : 8.3 Pathogen Antimicrobial classes 1999 2000 EE003R 2001 2002 2003 2004 2005 0/8 S. pneumoniae Penicillin R . . <1 <1 <1 <1 <1 Penicillin I+R . . <1 <1 <1 <1 2 Macrolides I+R . . EE004P 0/275 <1 10 6 <1 EE002 S. aureus 0/27 Oxacillin/Methicillin R . . 5 1 4 5 2 E. coli Aminopenicillins R . . 43 42 42 55 45 Aminoglycosides R . . EE005P 0/128 10 3 2 4 Fluoroquinolones R . . <1 5 5 6 5 3rd gen. Cephalosporins R . . 6 2 1 4 1 EE005 E. faecalis 0/5 Aminopenicillins I+R . . EE009K 0/258 10 4 14 14 PNSP at laboratory level MRSA at hospital level E. faecium EE006 0/14 K. pneumoniae P. aeruginosa EE009 1/10 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . EE010N . . . EE001A . . . EE006K . . EE002M . . 0 <1 <1 0/7 63 63 <1 2/70 . . . 2/33 . . . 4/48 . . 25 50 <1 33 67 <1 . . . . . . . . 50 22 <1 75 50 <1 . . . . . . . . 32 <1 79 79 <1 . . . . . . . . 75 50 <1 83 74 <1 8 <1 8 27 18 38 28 14 100 98 Annex 2. Country Summary Sheets Finland General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 15/17 15/17 158,679 10,561 3,257,496 86% 5 4,531,969 87% 27% 73% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 14 9 13 15 16 17 16 242 176 425 453 490 508 525 S. aureus Labs Isolates 13 12 13 15 16 17 17 316 362 606 721 727 882 790 E. coli Labs Isolates 0 0 0 0 14 1284 15 1330 15 1450 17 1749 17 1924 Enterococci Labs Isolates 0 0 13 14 15 17 17 0 0 274 278 266 336 341 K. pneumoniae Labs Isolates 0 0 0 0 0 0 14 0 0 0 0 0 0 175 P. aeruginosa Labs Isolates 0 0 0 0 0 0 13 0 0 0 0 0 0 108 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 4 6 <1 . . . . . . . . . . . . . . . . . . 2000 <1 5 8 1 . . . . . . . . . . . . . . . . . . 2001 1 9 12 <1 33 <1 5 <1 1 23 <1 66 <1 <1 . . . . . . . . 2002 2 6 14 <1 30 <1 6 <1 2 13 <1 80 <1 1 . . . . . . . . 2003 2 10 20 1 33 1 5 <1 <1 39 <1 79 4 <1 . . . . . . . . 2004 <1 8 20 3 33 2 7 2 <1 38 <1 69 12 <1 . . . . . . . . 2005 <1 7 20 3 35 2 7 2 <1 27 <1 78 1 <1 3 3 2 8 5 15 11 16 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 99 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=1033 n=1672 n=3396 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=422 %tot %VRE 100 0 65 35 0 6 0 31 63 0 0 . 0 0 . 0 . 0 0 . n=210 %tot %VRE 100 0 59 41 0 2 1 38 60 0 0 . 0 0 . 0 0 0 0 . n=175 %tot %CRKP 100 0 49 51 0 2 2 37 59 0 2 . 2 2 . 33 0 3 1 . P. aeruginosa n=99 %tot %CRPA 99 1 68 32 0 1 1 39 59 0 15 0 10 25 . 0 0 18 14 . 40 29 0 30 5 Finland providing denominator data Isolate source Blood 96 8 CSF 4 2 Labs providing denom.data/ Gender data to EARSS reporting Male 55 Hosps providing denom.data/ 8 Female 45 8 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 15 11 Patient-days 5-19 4 Average occupancy rate (%) 15 20-64 6 Median length of stay 49 (days) 65 and catchment population 8 over 32 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 1 8 University/Tertiary 100 Total 3 0 . 61 39 0 5 5 43 47 0 100 0 7 . 8 7 . 1 6 7 8 . 15/17 4 35 2 15/17 65 . 158,6790 10,561 4 3,257,4962 2 86%1 3 31 5 3 66 4,531,969 . 87%0 3 9 13 7 0 3 0 1 0 5 27%1 Internal Med. 7 7 14 4 10 4 12 0 11 0 17 0 7 General/Secondary 73% Surgery 1 0 7 5 5 9 Figure 0 Geographic distribution 11 laboratories in 2005 17 0 0 5 Other 0%4 1. of Other 36 8 28 2 32 8 28 0 27 0 21 3 27 Unknown 55 7 number of isolates reported for the period 1999-2005 49 3 53 7 44 0 43 0 50 3 56 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 14 242 13 316 0 0 0 0 0 0 0 0 2000 9 176 12 362 0 0 0 0 0 0 0 0 2001 13 425 13 606 14 1284 13 274 0 0 0 0 2002 15 453 15 721 15 1330 14 278 0 0 0 0 2003 16 490 16 727 15 1450 15 266 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 17 508 17 882 17 1749 17 336 0 0 0 0 2005 16 525 no of17 790: 16 17 1924 17 341 14 no of 175 108 FI008X 0/40 labs hospitals 13 19 : FI012 1/42 Minimum : 0.0 Minimum : 2.4 : 1st quartile : 0.0 FI00AA 0/29 Antibiotic resistance from 1st quartile 2005 4.4 1999 to FI001 2/64 Median : 7.8 Median : 2.2 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 9.5 3rd quartile : 4.0 FI00CX 0/104 Maximum : 26.3 Maximum : 9.7 FI00C 2/49 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 FI012X 0/33 S. pneumoniae Penicillin R <1 <1 1 2 2 <1 <1 FI00E 4/96 Penicillin I+R 4 5 FI014A 0/479 6 10 8 7 Macrolides I+R 6 8 FI017X 0/55 12 14 20 20 20 FI003 2/43 S. aureus Oxacillin/Methicillin R <1 1 <1 <1 1 3 3 2/165 FI017 2/34 E. coli Aminopenicillins R . . FI00EX 33 30 33 33 35 Aminoglycosides R . . FI00HX <1 <1 1 2 2 2/163 FI00H 9/142 Fluoroquinolones R . . 5 6 5 7 7 FI011A 1/58 3rd gen. Cephalosporins R . . <1 <1 <1 2 2 FI00L 2/26 1/46 E. faecalis Aminopenicillins I+R . . FI012A 1 2 <1 <1 <1 PNSP at laboratory level MRSA at hospital level HL Aminoglycosides R Glycopeptides R FI011 3/36 E. faecium Aminopenicillins I+R FI002 25/279 HL Aminoglycosides R Glycopeptides R FI014 K. pneumoniae 3/33 Aminoglycosides R Fluoroquinolones R FI005 5/50 3rd gen. Cephalosporins R P. aeruginosa 3/29 Piperacillin R FI015 Ceftazidime R FI010 6/37 Carbapenems R Aminoglycosides R FI00A 5/19 Fluoroquinolones R 0 25 50 FI008 4/51 . . . . . . . . . . . . . 75 100 . FI008A . . FI003A . FI015X . FI002X . . FI005X . FI001X . . FI010X . FI00LX . FI009X . 0 23 1/31 <1 2/54 66 <1 2/52 <1 19/492 . 4/101 . . 2/43 . . 5/62 . 3/35 . 6/62 . 25 13 <1 80 <1 1 . . . . . . . . 50 39 <1 79 4 <1 . . . . . . . . 38 <1 69 12 <1 . . . . . . . . 75 27 <1 78 1 <1 3 3 2 8 5 15 11 16 100 100 Annex 2. Country Summary Sheets France General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total 26/50 50/50 213,456 29,009 8,149,296 77% 6 na na 34% 60% 6% Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other Figure 1. Geographic distribution of laboratories in 2005 (left: reporting on S. pneumoniae, right: reporting on all other pathogens) Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 329 296 403 403 195 S. aureus Labs Isolates 0 0 21 21 21 50 50 0 0 1714 1663 1708 3347 3483 E. coli Labs Isolates 0 0 0 0 0 0 21 2495 21 2267 50 5678 50 6056 Enterococci Labs Isolates 0 0 0 21 21 50 47 0 0 0 467 483 882 1023 K. pneumoniae Labs Isolates 0 0 0 0 0 0 49 0 0 0 0 0 0 839 P. aeruginosa Labs Isolates 0 0 0 0 0 0 48 0 0 0 0 0 0 993 0 0 1337 1132 1389 515* 632** Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 11 47 49 33 . . . . . . . . . . . . . . . . . . 2002 8 48 53 33 52 4 8 <1 5 2003 . 43 48 29 50 5 9 <1 3 2004 . 39 45 29 47 4 8 <1 1 2005 5 36 41 27 50 5 11 1 <1 15 <1 64 24 2 5 7 4 15 9 14 22 27 Antibiotic resistance from 1999 to 2005 * First half of 2004 ** First half of 2005 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 15 <1 34 10 2 . . . . . . . . 16 <1 30 23 <1 . . . . . . . . 17 <1 56 21 5 . . . . . . . . Annex 2.Country Summary Sheets 101 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=2469 n=6830 n=11668 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=1472 %tot %VRE 100 0 63 34 2 3 1 37 58 1 0 . 0 0 0 0 0 0 0 0 n=355 %tot %VRE 100 0 62 35 3 3 2 40 54 1 3 . 4 3 0 0 0 3 4 0 n=824 %tot %CRKP 100 0 58 39 2 3 1 43 52 0 4 . 5 3 0 4 9 6 3 . P. aeruginosa n=984 %tot %CRPA 100 0 60 38 2 2 2 43 53 0 14 . 14 14 24 0 14 20 10 . France providing denominator data Isolate source Blood 77 48 CSF 23 Labs providing denom.data/ 46 Gender data to EARSS reporting Male 54 Hosps providing denom.data/ 33 Female 45 41 reporting data to EARSS Unknown 1 Number of blood culture sets 33 Age (years) Number of hospital beds 0-4 29 60 Patient-days 5-19 6 Average occupancy rate (%) 26 20-64 Median length of stay 30 (days) 37 65 and catchment population over 34 49 Estimated Unknown 1 90 % total population covered Hospital dep. Type of participating hospitals ICU 0 . University/Tertiary 100 Total 28 0 . 60 37 3 3 3 40 53 1 100 0 10 . 11 9 6 3 5 9 10 . 26/50 27 44 30 50/50 53 23 213,4563 29,009 14 8,149,2963 7 77%1 20 33 6 36 62 na 32 na0 17 30 12 25 0 23 4 15 8 25 24 34%9 Internal Med. 100 36 35 30 31 10 30 0 32 2 35 4 29 11 General/Secondary 60% Surgery 0 . 15 29 12 11 17 Figure 0 Geographic distribution 16 laboratories in 2005 15 4 2 14 14 Other 6% 1. of S. reporting on3 other 32 all pathogens)10 Other 0 . 32 25 48 9 29 (left: reporting on 30pneumoniae, right: 35 0 5 Unknown 0 . number of isolates reported for the period 1999-2005 0 . 0 . 0 . 0 . 0 . 0 . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2001 329 1337 21 1714 0 0 0 0 0 0 0 0 2002 296 1132 21 1663 21 2495 21 467 0 0 0 0 2003 403 1389 21 1708 21 2267 21 483 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 403 515* 50 3347 50 5678 50 882 0 0 0 0 FR263A 2005FR249 0/13 195 632** no of50 3483: 46 50 6056 4738/422 1023 49 no of 839 993 FR095A 5/38 labs hospitals 48 52 : 0/8 FR467 FR164A 12/74 1/7 Minimum : 9.0 FR038 Minimum : 0.0* First half of 2004 ** First half of 2005 FR401A 12/71 FR043 1/7 : 1st quartile : 24.4 Antibiotic resistance from 1st quartile 200528.6 1999 to FR138A 29/159 1/7 FR162 Median : 38.8 Median : 29.0 FR211A 6/31 Table 3. Proportion of antibiotic non-susceptible isolates in:percent FR175 1/5 FR040A 28/136 3rd quartile 44.4 3rd quartile : 33.3 FR449 1/5 FR145A 4/19 Maximum : 80.0 Maximum : 50.0 FR130 3/14 21/97 Pathogen Antimicrobial classes 1999 2000 FR126A 2001 2002 2003 2004 2005 PNSP at laboratory level MRSA at hospital level S. pneumoniae FR010 FR269 FR040 FR138 FR402 S. aureus FR051 E. coli FR065 FR137 FR213 FR238 FR271 FR094 FR219 FR263 E. faecalis FR006 FR024 FR056 FR060 FR071 FR232 FR267 FR276 FR498 K. pneumoniae FR067 FR186 FR479 FR250 FR254 P. aeruginosa FR009 FR167 FR188 FR499 FR120 FR139 FR277 FR020 FR492 Penicillin R 2/8 8/31 Penicillin I+R 2/7 2/7 Macrolides I+R 2/7 2/7 Oxacillin/Methicillin R 2/6 Aminopenicillins R 2/6 4/12 Aminoglycosides R 2/6 5/15 Fluoroquinolones R 3/9 3/8 3rd gen. Cephalosporins R 3/8 Aminopenicillins I+R 2/5 2/5 HL Aminoglycosides R 2/5 2/5 Glycopeptides R 2/5 Aminopenicillins I+R 2/5 2/5 HL Aminoglycosides R 2/5 4/10 Glycopeptides 3/7 R 3/7 Aminoglycosides R 4/9 Fluoroquinolones R 3/6 4/8 3rd gen. Cephalosporins R 4/7 4/7 Piperacillin R 3/5 6/10 Ceftazidime R 3/5 Carbapenems R 6/10 Aminoglycosides R Fluoroquinolones R 25 50 2/9 . . . . . . . . . . . . . . . . . . . . . . 100 . . . . . . . . . . . . . . . . . . . . . . E. faecium FR125 4/6 4/5 4/5 FR076A FR134A FR213A FR248A FR226A FR015A FR098A FR165A FR193A FR202A FR094A FR037A FR194A FR252A FR208A FR250A FR008A FR084A FR010A FR246A FR362A FR135A FR121A FR105A FR067A FR191A FR224A FR400A FR064A FR009A FR238A FR260A FR259A FR237A FR055A FR249A FR403A FR109A FR276A FR479A FR046A FR120A FR402A 11 47 49 33 . . . . . . . . . . . . . . . . . . 0 75/329 26/111 27/115 78/324 78/315 7/28 17/68 44/168 9/34 7/26 90/331 24/87 12/43 19/68 9/32 53/186 23/80 12/41 81/276 83/282 35/116 27/88 62/202 43/140 48/156 18/56 31/95 16/49 56/169 33/99 102/306 62/182 52/149 30/84 22/61 66/182 24/64 108/282 33/85 65/161 22/54 22/53 8 48 53 33 52 4 8 <1 5 . 43 48 29 50 5 9 <1 3 16 <1 30 23 <1 . . . . . . . 3/6 . . 39 45 29 47 4 8 <1 1 17 <1 56 21 5 . . . . . . . . 75 5 36 41 27 50 5 11 1 <1 15 <1 64 24 2 5 7 4 15 9 14 22 27 100 15 <1 34 10 2 . . . . . . . . 0 75 25 50 102 Annex 2. Country Summary Sheets Germany General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 8/23 20/60 29,561 12,127 2,707,154 74% 8 12,410,500 15% 35% 65% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 23 18 21 17 17 16 15 417 204 211 248 175 143 130 S. aureus Labs Isolates 25 19 22 18 20 22 17 1239 890 1220 1066 919 1106 874 E. coli Labs Isolates 1 166 1 180 21 1269 16 1068 19 997 22 1217 17 1016 Enterococci Labs Isolates 1 1 20 14 17 22 17 44 28 294 290 347 607 597 K. pneumoniae Labs Isolates 0 0 0 0 0 0 12 0 0 0 0 0 0 113 P. aeruginosa Labs Isolates 0 0 0 0 0 0 12 0 0 0 0 0 0 127 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 2 7 8 36 5 4 <1 <1 . <1 40 . <1 . . . . . . . . 2000 <1 2 10 12 47 7 8 <1 <1 . <1 50 . <1 . . . . . . . . 2001 1 4 17 16 46 5 11 <1 8 31 <1 79 43 1 . . . . . . . . 2002 <1 1 14 18 49 5 15 <1 10 42 <1 80 68 4 . . . . . . . . 2003 <1 1 11 18 47 5 14 <1 7 47 <1 78 47 3 . . . . . . . . 2004 <1 1 13 20 55 4 24 2 7 42 <1 93 61 11 . . . . . . . . 2005 <1 5 17 21 54 6 23 2 3 34 <1 96 49 10 9 5 6 17 11 24 13 22 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 103 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=273 n=1980 n=2203 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=734 %tot %VRE 100 0 63 37 0 4 1 43 51 0 0 . 0 0 . 0 0 1 0 . n=454 %tot %VRE 100 0 60 40 0 2 2 52 44 0 10 . 10 9 . 11 38 12 7 . n=112 %tot %CRKP 99 1 58 42 0 3 1 47 49 0 6 0 6 6 . 0 0 11 2 . P. aeruginosa n=127 %tot %CRPA 96 4 69 31 0 7 3 48 42 0 23 40 16 40 . 0 25 36 13 . 45 15 18 18 0 Germany providing denominator data Isolate source Blood 96 3 CSF 4 0 Labs providing denom.data/ Gender data to EARSS reporting Male 60 Hosps providing denom.data/ 4 Female 37 1 reporting data to EARSS Unknown 3 Number of blood culture sets 0 Age (years) Number of hospital beds 0-4 13 9 Patient-days 5-19 3 0 Average occupancy rate (%) 20-64 2 Median length of stay 35 (days) 65 and catchment population 2 over 49 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 25 3 University/Tertiary 100 Total 20 0 . 63 36 1 3 2 40 55 0 100 0 24 . 28 20 13 2 20 29 22 29 8/23 22 47 18 20/60 52 17 29,5611 12,127 2 2,707,1542 10 74%1 19 33 8 22 63 12,410,500 . 15%1 22 27 17 22 33 0 44 8 27 3 24 35% Internal Med. 38 3 38 18 41 19 26 0 20 5 33 0 26 General/Secondary 65% Surgery 1 0 11 23 26 10 Figure 1 Geographic distribution of laboratories in 2005 9 3 7 13 9 Other 0%8 1. Other 32 3 22 16 28 32 26 1 24 22 33 14 40 Unknown 3 6 19 6 17 5 0 2 0 0 . 1 Table 2. Number of laboratories 0 number of isolates reported for the period 1999-2005 and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 23 417 25 1239 1 166 1 44 0 0 0 0 2000 18 204 19 890 1 180 1 28 0 0 0 0 2001 21 211 22 1220 21 1269 20 294 0 0 0 0 2002 17 248 18 1066 16 1068 14 290 0 0 0 0 2003 17 175 20 919 19 997 17 347 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 16 143 22 1106 22 1217 22 607 0 0 0 0 DE70101 2/57 2005 15 130 no of17 874: 15 17 1016 17 597 12 no of 113 127 labs hospitals 12 38 : DE0206 0/21 DE1301X 4/80 Minimum : 3.5 Minimum : 0.0 DE20601 3/39 : 1st quartile : 11.4 Antibiotic resistance from 1st quartile 2005 0.0 1999 to DE10701 3/34 DE0302 0/28 Median : 0.0 Median : 21.1 Table 3. Proportion of antibiotic non-susceptible isolates in:percent DE0206X 3/32 3rd quartile 5.6 3rd quartile : 34.4 DE0109A 13/134 Maximum : 7.1 Maximum : 66.7 Pathogen 0/20 Antimicrobial classes 1999 2000 DE20602 2001 1/10 2002 2003 2004 2005 DE0306 DE0105A 7/69 S. pneumoniae Penicillin R <1 <1 1 <1 <1 <1 <1 DE30110 2/18 DE0805 0/14 Penicillin I+R 2 2 DE1401A 4 10/88 1 1 1 5 Macrolides I+R 7 10 DE30101 17 4/33 14 11 13 17 DE0905 0/6 DE10702 2/16 S. aureus Oxacillin/Methicillin R 8 12 DE130101 16 1/8 18 18 20 21 E. coli Aminopenicillins R 36 47 DE40201 46 3/24 49 47 55 54 DE1301 0/27 18/125 Aminoglycosides R 5 7 DE10201 5 5 5 4 6 DE1602A 23/150 Fluoroquinolones R 4 8 DE202A 11 14 24 23 4/21 15 DE1401 0/6 36/180<1 3rd gen. Cephalosporins R <1 <1 DE1403A <1 <1 2 2 DE0905X 5/24 DE1403 E. faecalis 0/5 Aminopenicillins I+R <1 <1 DE1302A 8 10 7 7 3 19/89 PNSP at laboratory level MRSA at hospital level DE1602 0/8 E. faecium DE0107 DE0301 1/30 1/20 K. pneumoniae DE1302 1/18 DE0102 P. aeruginosa DE0105 2/32 1/15 DE0109 1/14 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . <1 40 . <1 . . . . . . . . 75 100 . DE0906A DE306U <1 DE30109 50 DE1203A . DE306F DE100B <1 DE160101 . DE306P DE30102 . DE30103 . DE10202 DE0805A . DE306H . DE40202 . DE30108 DE300D . DE30107 . DE30105 0 31 <1 79 43 1 . . . . . . . . 42 <1 4/17 80 15/60 9/35 68 43/148 4 3/9 . 5/15 11/32 . 10/29 . . . . . . 25 34/150 3/13 47 <1 78 47 3 . . 3/7 . 55/127 . 5/11 . 5/11 15/32 . . . 50 8/14 3/5 42 <1 93 61 11 . . . . . . . 4/6 . 75 34 <1 96 49 10 9 5 6 17 11 24 13 22 100 104 Annex 2. Country Summary Sheets Greece General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 29/39 30/39 89,267 10,504 2,781,858 86% 4 8,067,261 75% 30% 57% 13% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 S. aureus Labs Isolates 19 15 25 33 34 35 35 192 363 360 368 666 609 681 E. coli Labs Isolates 0 0 16 395 26 619 35 588 35 1076 39 1131 35 1140 Enterococci Labs Isolates 0 12 25 28 32 34 34 0 197 304 293 623 566 737 K. pneumoniae Labs Isolates 0 0 0 0 0 0 33 0 0 0 0 0 0 774 P. aeruginosa Labs Isolates 0 0 0 0 0 0 33 0 0 0 0 0 0 699 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . 31 . . . . . . . . . . . . . . . . . . 2000 . . . 50 42 4 4 4 8 52 <1 83 25 <1 . . . . . . . . 2001 . . . 39 47 4 9 5 8 57 7 86 45 15 . . . . . . . . 2002 . . . 44 45 7 13 6 4 60 13 75 52 19 . . . . . . . . 2003 . . . 45 44 6 12 6 4 52 7 89 40 18 . . . . . . . . 2004 . . . 44 46 6 12 6 4 59 4 84 52 20 . . . . . . . . 2005 . . . 42 46 7 12 7 3 54 4 85 34 37 60 54 61 30 27 39 40 39 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 105 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=0 n=1290 n=2255 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=898 %tot %VRE 100 0 9 6 85 0 0 1 2 97 4 . 5 5 4 . . 0 0 4 n=404 %tot %VRE 100 0 14 10 76 0 0 4 3 93 30 . 29 38 29 . . 44 31 29 n=774 %tot %CRKP 98 2 9 7 84 0 0 2 1 96 60 83 43 52 63 . . 50 36 61 P. aeruginosa n=698 %tot %CRPA 97 3 10 5 85 1 0 2 2 96 37 88 51 44 37 75 . 33 36 39 51 24 43 17 23 Greece providing denominator data Isolate source Blood . CSF . Labs providing denom.data/ Gender data to EARSS reporting Male . Hosps providing denom.data/ Female . reporting data to EARSS Unknown . Number of blood culture sets Age (years) Number of hospital beds 0-4 . Patient-days 5-19 Average occupancy rate. (%) 20-64 . Median length of stay (days) 65 and catchment population over . Estimated Unknown . % total population covered Hospital dep. Type of participating hospitals ICU . University/Tertiary . . . . . . . . . . 100 Total 43 0 . 12 6 83 0 0 1 2 97 100 0 12 . 12 7 13 23 . 20 15 12 29/39 49 10 54 30/39 14 42 89,267 76 10,504 . 2,781,8581 . 86%0 57 42 69 8,067,2612 42 96 75% . 16 68 17 36 6 31 34 49 84 47 30%3 Internal Med. . . 66 35 78 10 44 3 50 30 34 32 39 General/Secondary 57% Surgery . . 13 58 13 22 16 Figure 3 Geographic distribution 15 laboratories in 2005 14 21 56 12 Other 13% 1. of Other . . 3 29 2 8 1 9 2 29 2 43 1 Unknown . . number of isolates reported for the period 1999-2005 3 51 3 10 3 4 3 27 1 0 2 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 19 192 2000 0 0 15 363 2001 0 0 25 360 2002 0 0 33 368 2003 0 0 34 666 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 0 0 35 609 2005 0 0 35 681 PNSP at laboratory level 0 16 26 35 35 39 35 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 1999 . . . 31 . . . . . . . . . . . . . . . . . . 75 100 S. aureus E. coli E. faecalis 0 0 0 0 0 0 0 395 12 197 0 0 0 0 619 25 304 0 0 0 0 588 28 293 0 0 0 0 1076 32 623 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 1131 34 566 0 0 0 0 GR060A 0/5 34 1140 737 33 no of 774 699 hospitals 33 36 : GR057A 1/13 Minimum : 0.0 GR035A 6/39 1st quartile : 26.6 GR028A 5/26 Median : 41.8 GR048A 3/15 3rd quartile : 50.9 GR027A 7/31 Maximum : 90.9 2000 2001 2002 2003 2004 2005 GR026A 7/30 . GR059A . . . . . 19/76 13/49 . GR013A . . . . . GR042A 4/15 . GR051A . . . . . 4/14 50 GR018A 39 44 5/16 45 44 42 42 GR015A 47 45 6/18 44 46 46 GR038A 2/6 4 GR050A 4 7 7/21 6 6 7 4 GR043A 9 13 12 12 12 9/24 18/45 4 GR037A 5 6 6 6 7 GR049A 10/25 8 GR001A 8 4 4 4 3 31/71 MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa 52 <1 83 25 <1 . . . . . . . . GR004A GR022A GR005A GR009A GR024A GR014A GR030A GR040A GR047A GR007A GR039A GR031A GR044A GR055A GR068A GR033A GR032A 57 7 86 45 15 . . . . . . . . 0 25 60 13 75 52 19 . . . . . . . . 7/16 7/16 0 52 7 13/29 6/1389 6/1340 35/72 18 51/104 . 65/131 58/111 . 23/44 . 42/77 . 5/9 . . . . 50 59 4 84 52 20 . . . . 5/8 . 18/28 . 12/17 . 34/46 . 75 54 4 85 34 37 60 54 61 30 27 39 40 10/11 39 100 106 Annex 2. Country Summary Sheets Hungary General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 10/32 30/76 12,116 17,034 4,331,778 76% 7 10,000,000 100% 10% 80% 10% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 * S. pneumoniae Labs Isolates 0 0 14 17 20 26 22 0 0 36 61 134 143 86 S. aureus Labs Isolates 0 0 18 24 27 30 26 0 0 301 413 858 1020 527 E. coli Labs Isolates 0 0 0 0 18 264 24 354 27 842 28 967 25 513 Enterococci Labs Isolates 0 0 17 23 25 26 25 0 0 121 169 279 366 238 K. pneumoniae Labs Isolates 0 0 0 0 0 0 21 0 0 0 0 0 0 143 P. aeruginosa Labs Isolates 0 0 0 0 0 0 23 0 0 0 0 0 0 238 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 8 22 19 5 46 4 5 <1 5 . <1 100 . <1 . . . . . . . . 2002 3 23 21 9 45 6 10 2 2 100 <1 89 100 <1 . . . . . . . . 2003 3 24 25 15 49 8 15 <1 <1 87 <1 91 96 <1 . . . . . . . . 2004 <1 16 25 17 55 10 19 3 2 57 <1 95 80 <1 . . . . . . . . 2005 * 2 22 37 19 50 7 20 2 2 40 <1 91 65 <1 30 25 31 12 11 17 32 27 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa * First half year of 2005. Annex 2.Country Summary Sheets 107 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=229 n=1547 n=1369 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=486 %tot %VRE 100 0 67 33 0 3 1 46 49 0 0 . 0 0 . 0 0 0 0 . n=105 %tot %VRE 100 0 73 27 0 3 1 56 40 0 0 . 0 0 . 0 0 0 0 . n=140 %tot %CRKP 97 3 65 34 1 6 1 41 52 0 31 50 30 35 0 63 100 38 22 . P. aeruginosa n=231 %tot %CRPA 96 4 73 27 0 3 2 52 42 0 17 22 18 14 . 25 60 13 20 . 17 11 13 26 16 Hungary providing denominator data Isolate source Blood 67 16 CSF 33 Labs providing denom.data/ 22 Gender data to EARSS reporting Male 77 Hosps providing denom.data/ 18 Female 23 21 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 12 44 Patient-days 5-19 5 Average occupancy rate (%) 18 20-64 Median length of stay 55 (days) 17 65 and catchment population over 28 11 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 22 24 University/Tertiary 100 Total 18 0 . 67 33 0 2 2 49 47 0 100 0 20 . 22 16 . 4 29 18 21 . 10/32 19 62 15 30/76 37 . 12,1160 17,034 11 4,331,7782 3 76%1 19 40 7 17 57 10,000,000 . 100%0 17 25 12 25 33 0 30 0 32 44 47 10% Internal Med. 19 14 29 16 30 19 20 0 17 0 21 17 12 General/Secondary 80% Surgery 1 33 13 26 17 11 Figure 0 Geographic distribution of laboratories in 2005 16 0 9 54 10 Other 10%6 1. Other 46 18 22 13 35 21 18 0 25 0 19 22 18 Unknown 12 15 19 13 17 15 18 0 11 0 19 23 13 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2001 14 36 18 301 18 264 17 121 0 0 0 0 2002 17 61 24 413 24 354 23 169 0 0 0 0 2003 20 134 27 858 27 842 25 279 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 26 143 30 1020 28 967 26 366 0 0 0 0 HU002R 0/5 25 2005 * 22 86 no of26 527: 17 25 513 238 21 no of 143 238 labs hospitals 23 44 : HU006 0/12 0/6 HU004G Minimum : 0.0 Minimum : 0.0 HU005W 0/14 0/7 HU007C : 1st quartile : 5.7 Antibiotic resistance from 1st quartile 200512.5 1999 to HU013 0/5 0/5 HU010D Median : 20.0 Median : 13.2 Table 3. Proportion of antibiotic non-susceptible isolates in:percent HU015A 0/22 3rd quartile 25.0 3rd quartile : 27.1 HU016A 0/31 HU016 0/7 Maximum : 80.0 Maximum : 80.0 Pathogen Antimicrobial classes 1999 2000 HU016G 2001 2002 2003 2004 2005 * 0/5 0/7 HU022O S. pneumoniae Penicillin R . . HU004Z 8 3 3 <1 2 HU028 0/16 4/121 1/23 Penicillin I+R . . HU007B 22 23 24 16 22 HU006A 1/14 HU019 1/8 Macrolides I+R . . HU030A 19 2/25 21 25 25 37 HU027A S. aureus Oxacillin/Methicillin R . . HU022P 5 4/47 9 15 17 19 HU022 6/47 3/34 E. coli Aminopenicillins R . . HU028A 46 1/11 45 49 55 50 HU022A 8/67 HU005 1/7Aminoglycosides R . . HU009B 4 6/50 6 8 10 7 Fluoroquinolones R . . HU023C 5 2/16 10 15 19 20 HU027 1/7 HU024A 4/32 3rd gen. Cephalosporins R . . HU032A <1 14/111 2 <1 3 2 HU021A 6/46 HU023 3/15 E. faecalis Aminopenicillins I+R . . HU008V 5 13/98 2 <1 2 2 PNSP at laboratory level MRSA at hospital level HU026 E. faecium HU029 HU020 K. pneumoniae HU009 HU021 P. aeruginosa HU014 HU032 HU025 * First half year of 2005. 0 HL Aminoglycosides R 1/5 Glycopeptides R Aminopenicillins I+R 5/25 HL Aminoglycosides R 3/14 Glycopeptides R Aminoglycosides R 3/12 Fluoroquinolones R 3/10 3rd gen. Cephalosporins R Piperacillin R 3/6 Ceftazidime R 5/9 Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 4/5 . . . . . . . . . . . . . 100 . HU023B HU019A . HU019D HU020A . HU014A . HU009A HU023A . HU020L HU023D . HU026A . HU001U HU008B . HU023L HU006B . HU013A . HU008C HU017A . HU031A HU005A . HU020C . HU001W 0 . <1 100 . <1 . . . . . . . . 4/30 10/71 1/6 75 100 87 <1 <1 10/56 89 91 8/43 16/69 100 96 16/68 3/12 <1 <1 10/38 . . 14/52 3/11 . . 4/13 . 15/47 . 7/20 . 7/20 . . 4/11 . 28/70 . . 9/22 12/28 . . 3/7 . . 25 50 57 <1 95 80 <1 . . . . . . . . 75 12/15 40 <1 91 65 <1 30 25 31 12 11 17 32 27 100 108 Annex 2. Country Summary Sheets Iceland General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 2/2 2/2 10,430 1,042 304,252 80% 7 300,000 100% 50% 50% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 1 1 2 2 2 2 2 48 36 48 43 35 54 37 S. aureus Labs Isolates 1 1 2 2 2 2 2 32 40 63 60 64 55 77 E. coli Labs Isolates 0 0 0 0 2 86 2 83 2 100 2 119 2 130 Enterococci Labs Isolates 0 0 2 2 2 1 2 0 0 18 25 22 27 31 K. pneumoniae Labs Isolates 0 0 0 0 0 0 2 0 0 0 0 0 0 22 P. aeruginosa Labs Isolates 0 0 0 0 0 0 1 0 0 0 0 0 0 13 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 2 3 <1 . . . . . . . . . . . . . . . . . . 2000 <1 8 11 3 . . . . . . . . . . . . . . . . . . 2001 <1 6 8 <1 42 4 4 <1 <1 8 <1 40 <1 <1 . . . . . . . . 2002 2 5 5 <1 19 1 3 <1 <1 6 <1 29 <1 <1 . . . . . . . . 2003 <1 9 20 <1 42 2 6 1 <1 <1 <1 57 <1 <1 . . . . . . . . 2004 2 17 8 <1 43 <1 2 <1 <1 5 <1 63 13 <1 . . . . . . . . 2005 <1 8 17 <1 38 <1 3 <1 <1 <1 <1 80 <1 <1 <1 <1 <1 8 8 8 <1 <1 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 109 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=91 n=132 n=230 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=40 %tot 100 0 53 48 0 3 0 28 70 0 %VRE 0 . 0 0 . 0 . 0 0 . n=17 %tot 100 0 53 47 0 6 0 18 76 0 %VRE 0 . 0 0 . 0 . 0 0 . n=22 %tot %CRKP 100 0 55 45 0 0 0 36 64 0 0 . 0 0 . . . 0 0 . P. aeruginosa n=13 %tot %CRPA 100 0 62 38 0 0 0 15 85 0 8 . 13 0 . . . 0 9 . . . 0 9 0 Iceland providing denominator data Isolate source Blood 98 13 CSF 2 0 Labs providing denom.data/ Gender data to EARSS reporting Male 53 Hosps providing denom.data/ 8 Female 47 19 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 23 19 Patient-days 5-19 2 0 Average occupancy rate (%) 20-64 7 Median length of stay 31 (days) 65 and catchment population over 44 15 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 5 0 University/Tertiary 100 Total 0 0 . 61 38 1 5 9 38 47 1 100 0 3 . 2 3 . 10 0 5 1 . 2/2 0 43 0 57 2/2 0 10,4300 1,042 0 304,2524 0 80%2 0 29 7 0 300,000 65 0 100%0 8 0 0 20 0 29 0 5 0 0 50%3 Internal Med. 10 11 18 0 11 0 28 0 18 0 18 0 0 General/Secondary 50% Surgery 0 . 11 0 5 5 Figure 0 Geographic distribution of laboratories in 2005 6 0 5 0 8 Other 0%9 1. Other 78 15 60 0 75 3 45 0 47 0 73 0 85 Unknown 7 0 number of isolates reported for the period 1999-2005 2 0 3 0 3 0 0 . 0 . 8 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 1 48 1 32 2000 1 36 1 40 2001 2 48 2 63 2002 2 43 2 60 2003 2 35 2 64 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 2 54 2 55 2005 2 37 no of labs 2 77: 2 Minimum : 0.0 : Antibiotic resistance from 1st quartile 2005 0.0 1999 to Median : 7.5 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 15.0 Maximum : 15.0 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 2 2 2 2 2 S. pneumoniae IS003 0/11 S. aureus E. coli E. faecalis Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R 12/80 Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 <1 2 3 <1 . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 86 2 18 0 0 0 0 83 2 25 0 0 0 0 100 2 22 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 119 1 27 0 0 0 0 130 2 31 2 no of hospitals 22 13 :1 2 Minimum : 0.0 1st quartile : 0.0 Median : 0.0 3rd quartile : 0.0 Maximum : 0.0 2000 2001 2002 2003 2004 2005 <1 <1 2 <1 2 <1 8 6 5 9 17 8 11 IS001A 0/119 8 5 20 8 17 3 <1 <1 <1 <1 <1 . 42 19 42 43 38 . 4 1 2 <1 <1 . 4 3 6 2 3 . <1 <1 1 <1 <1 . <1 <1 <1 <1 <1 MRSA at hospital level E. faecium IS001 K. pneumoniae P. aeruginosa . . . . . . . . . . . . . IS003A 8 <1 40 <1 <1 0/13 . . . . . . . . 0 25 6 <1 29 <1 <1 . . . . . . . . 50 <1 <1 57 <1 <1 . . . . . . . . 0 5 <1 63 13 <1 . . . . . . . . 75 <1 <1 80 <1 <1 <1 <1 <1 8 8 8 <1 <1 100 110 Annex 2. Country Summary Sheets Ireland General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 35/39 57/66 131,867 13,262 4,136,385 85% 6 3,920,000 98% 19% 54% 26% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 10 18 21 20 24 28 31 154 202 246 277 363 399 397 S. aureus Labs Isolates 11 18 19 22 26 38 38 511 632 798 998 1108 1286 1360 E. coli Labs Isolates 0 0 0 0 0 0 20 736 26 978 37 1235 39 1424 Enterococci Labs Isolates 0 0 0 15 21 29 33 0 0 0 250 348 418 502 K. pneumoniae Labs Isolates 0 0 0 0 0 0 15 0 0 0 0 0 0 42 P. aeruginosa Labs Isolates 0 0 0 0 0 0 11 0 0 0 0 0 0 29 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 3 19 14 39 . . . . . . . . . . . . . . . . . . 2000 5 13 12 39 . . . . . . . . . . . . . . . . . . 2001 2 12 12 42 . . . . . . . . . . . . . . . . . . 2002 2 12 13 42 62 3 5 2 8 39 2 89 17 11 . . . . . . . . 2003 3 12 12 42 61 4 10 2 5 32 <1 91 54 19 . . . . . . . . 2004 3 10 14 41 65 5 12 2 <1 42 1 96 56 22 . . . . . . . . 2005 3 11 12 42 67 7 17 4 4 42 3 93 52 31 5 3 7 7 10 11 7 14 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 111 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=796 n=2646 n=2624 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=510 %tot %VRE 100 0 58 41 1 9 1 34 55 0 2 . 1 3 0 0 0 3 2 . n=401 %tot %VRE 100 0 53 47 0 3 1 42 53 0 27 . 27 27 . 8 67 32 23 . n=42 %tot %CRKP 100 0 64 36 0 2 2 21 74 0 7 . 7 7 . 100 0 0 6 . P. aeruginosa n=27 %tot %CRPA 100 0 52 48 0 4 0 48 44 4 11 . 7 15 . 0 . 23 0 0 100 0 100 0 7 Ireland providing denominator data Isolate source Blood 99 11 CSF 1 13 Labs providing denom.data/ Gender data to EARSS reporting Male 55 Hosps providing denom.data/ 12 Female 44 9 reporting data to EARSS Unknown 1 Number of blood culture sets 10 Age (years) Number of hospital beds 0-4 16 13 Patient-days 5-19 4 6 Average occupancy rate (%) 20-64 8 Median length of stay 36 (days) 65 and catchment population over 43 12 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 4 10 University/Tertiary 100 Total 42 0 . 61 38 1 6 3 39 51 0 100 0 15 . 18 12 . 2 5 16 15 12 35/39 42 42 41 57/66 57 35 131,8670 13,262 14 4,136,3854 9 85%1 32 32 6 54 62 3,920,000 . 98%1 4 51 17 6 0 8 12 0 . 4 19%3 Internal Med. 15 10 13 46 14 10 11 0 7 21 17 14 7 General/Secondary 54% Surgery 2 11 7 49 12 7 Figure 3 Geographic distribution 10 laboratories in 2005 6 15 0 4 Other 26%7 1. of Other 27 8 15 32 19 8 15 1 7 10 19 0 30 Unknown 51 12 60 42 56 18 60 3 71 32 55 9 56 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 10 154 11 511 0 0 0 0 0 0 0 0 2000 18 202 18 632 0 0 0 0 0 0 0 0 2001 21 246 19 798 0 0 0 0 0 0 0 0 2002 20 277 22 998 20 736 15 250 0 0 0 0 2003 24 363 26 1108 26 978 21 348 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 28 399 38 1286 37 1235 29 418 0 0 0 0 IE-ASX 0/5 33 2005 31 397 no of38 1360: 27 39 1424 502 15 no of hospitals 11 38 42 29 IE-AD 0/10 labs : IE-BPX 2/49 Minimum : 0.0 Minimum : 0.0 IE-BS 0/6 IE-BBX 1/24 : 1st quartile : 27.8 Antibiotic resistance from 1st quartile 2005 5.9 1999 to IE-AFY 1/12 IE-BY 1/33 Median : 10.5 Median : 40.3 Table 3. Proportion of antibiotic non-susceptible isolates in:percent IE-BCX 1/11 3rd quartile 15.2 3rd quartile : 46.4 IE-BW 2/41 IE-AQZ 3/23 Maximum : 25.0 Maximum : 69.2 Pathogen Antimicrobial classes 1999 2000 IE-AEX 2001 2002 2003 2004 2005 IE-AL 4/75 1/6 IE-BAX 3/15 S. pneumoniae2/37 Penicillin R 3 5 2 2 3 3 3 IE-BF IE-BQZ 2/10 Penicillin I+R 19 13 IE-BDX 12 12 12 10 11 IE-BL 1/17 5/18 4/14 IE-AC 1/15 Macrolides I+R 14 12 IE-APX 12 13 12 14 12 IE-ACX 16/55 IE-AU 1/12 Oxacillin/Methicillin R S. aureus 39 39 IE-BOX 42 427/23 42 41 42 IE-BB 1/12 Aminopenicillins R E. coli . . IE-BHY . 6217/55 61 65 67 IE-AQ 2/21 Aminoglycosides R . . IE-BRX . 3 2/6 4 5 7 IE-BWX 58/165 IE-AB 4/40 Fluoroquinolones R . . IE-ARX . 5 12 17 109/276 10 27/68 IE-BN 4/39 3rd gen. Cephalosporins R . . IE-BFX . 2 2 2 4 IE-ABX 60/151 IE-BG 2/19 Aminopenicillins I+R E. faecalis . . IE-BXX . 8 5 <1 4 51/125 PNSP at laboratory level MRSA at hospital level IE-AR IE-AY IE-AZ E. faecium IE-AH IE-BX IE-BI K. pneumoniae IE-BE IE-BH IE-BP P. aeruginosa IE-BO IE-BK IE-BT IE-BD 8/69 8/67 Glycopeptides 0 HL Aminoglycosides R R 3/25 Aminopenicillins I+R 1/8 HL Aminoglycosides R 5/38 Glycopeptides R 7/53 Aminoglycosides R 5/33 Fluoroquinolones R 3/19 3rd gen. Cephalosporins R 5/25 Piperacillin R 4/19 Ceftazidime R 3/14 Carbapenems R 5/23 Aminoglycosides R 2/8 Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . IE-AHX IE-ALY IE-AKX IE-BIX IE-AZX IE-AJX IE-BGX IE-BEX IE-BTY IE-AYX IE-BYX IE-BLX IE-ADX IE-BJX IE-BNX IE-BKX IE-AUX IE-BSY . . . . . . . . . . . . . 0 25 39 2 89 17 11 . . . . . . . . 10/24 71/167 32 42 <1 1 3/7 96 68/157 91 27/61 54 56 9/20 19 22 19/42 134/292 . . 13/28 . . 120/257 56/117 . . 12/25 . . 4/8 . . 5/10 .111/205 . 33/53 . . 27/43 9/13 . . 50 75 42 3 93 52 31 5 3 7 7 10 11 7 14 100 112 Annex 2. Country Summary Sheets Israel General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 5/5 5/5 131,998 4,187 1,520,982 99% 4 2,230,000 35% 60% 40% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 5 5 5 5 5 0 0 170 177 180 190 235 S. aureus Labs Isolates 0 0 5 5 5 5 5 0 0 381 468 369 475 546 E. coli Labs Isolates 0 0 0 0 5 741 5 865 5 774 5 916 5 943 Enterococci Labs Isolates 0 0 5 5 5 5 5 0 0 184 254 244 288 296 K. pneumoniae Labs Isolates 0 0 0 0 0 0 4 0 0 0 0 0 0 331 P. aeruginosa Labs Isolates 0 0 0 0 0 0 4 0 0 0 0 0 0 215 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 5 40 11 39 68 16 21 9 <1 24 <1 46 33 12 . . . . . . . . 2002 7 38 12 38 68 16 19 8 4 44 2 50 42 10 . . . . . . . . 2003 11 38 14 43 62 14 20 9 2 43 <1 48 38 8 . . . . . . . . 2004 11 37 12 39 63 16 23 10 3 46 1 65 18 8 . . . . . . . . 2005 8 33 15 41 66 15 23 10 1 43 <1 87 20 46 36 30 38 13 17 15 23 25 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 113 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=425 n=1021 n=1852 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=469 %tot %VRE 100 0 52 48 0 13 1 23 62 0 1 . 1 0 . 0 0 1 1 . n=111 %tot %VRE 100 0 54 46 0 11 2 32 56 0 32 . 37 27 . 0 0 46 32 . n=330 %tot %CRKP 100 0 61 39 0 15 2 32 51 1 38 . 44 29 . 41 60 38 36 100 P. aeruginosa n=215 %tot %CRPA 100 0 60 38 1 7 3 42 47 2 15 . 17 13 0 0 0 19 16 0 24 9 11 19 . Israel providing denominator data Isolate source Blood 100 35 CSF 0 . Labs providing denom.data/ Gender data to EARSS reporting Male 58 Hosps providing denom.data/ 39 Female 41 30 reporting data to EARSS Unknown 1 Number of blood culture sets 0 Age (years) Number of hospital beds 0-4 40 51 Patient-days 5-19 9 Average occupancy rate (%) 18 20-64 Median length of stay 27 (days) 27 65 and catchment population over 24 24 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 6 36 University/Tertiary 100 Total 40 0 . 61 39 1 9 4 33 52 1 100 0 23 . 29 19 . 3 37 21 24 . 5/5 41 39 39 61 5/5 50 131,9980 4,187 26 1,520,9825 19 99%1 30 28 4 51 65 2,230,000 50 35%0 9 46 35 10 4 16 56 13 43 18 60%3 Internal Med. 39 24 53 45 62 22 51 0 40 34 38 45 34 General/Secondary 40% Surgery 1 0 8 41 10 27 9 Figure 0 Geographic distribution 15 laboratories in 2005 8 11 23 13 Other 0% 1. of Other 54 44 30 30 25 21 30 1 35 23 35 35 35 Unknown 0 . 0 . 0 . 0 . 1 100 0 . 0 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 2000 0 0 0 0 2001 5 170 5 381 2002 5 177 5 468 2003 5 180 5 369 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 5 190 5 475 2005 5 235 no of labs 5 546: 5 Minimum : 31.7 : Antibiotic resistance from 1st quartile 200533.3 1999 to Median : 33.6 IL001 13/41 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 35.7 Maximum : 40.7 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 5 5 5 5 5 S. pneumoniae IL004 S. aureus E. coli IL002 E. faecalis Penicillin R Penicillin I+R Macrolides I+R 8/24 Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R 51/152 Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R 55/154 Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R 22/54 Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 741 5 184 0 0 0 0 865 5 254 0 0 0 0 774 5 244 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 916 5 288 0 0 0 0 943 5 296 4 no of 331 215 hospitals :4 5 Minimum : 17.7 1st quartile : 25.3 Median : 31.0 IL004A 17/96 3rd quartile : 34.6 Maximum : 49.1 2000 2001 2002 2003 2004 2005 . 5 7 11 11 8 . 40 38 38 37 33 . 11 12 14 12 15 19/75 . IL005A 39 38 43 39 41 . 68 68 62 63 66 . 16 16 14 16 15 . 21 19 20 23 23 . 9 8 9 10 10 . IL001A <1 426/84 2 3 1 MRSA at hospital level E. faecium IL003 K. pneumoniae P. aeruginosa IL005 . . . . . IL003A . . . . . IL002A . . . 0 24 <1 46 33 12 . . . . . . . . 25 44 2 50 42 10 . . . . . . . . 64/185 0 43 <1 48 38 8 . . . . . 285/581 . . . 50 46 1 65 18 8 . . . . . . . . 75 43 <1 87 20 46 36 30 38 13 17 15 23 25 100 114 Annex 2. Country Summary Sheets Italy General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 24/43 25/45 91,337 15,998 3,602,565 68% 7 6,445,066 11% 16% 76% 8% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 41 36 39 50 43 37 37 177 116 121 296 282 267 319 S. aureus Labs Isolates 56 48 53 53 46 42 41 1158 456 839 1343 1465 1219 1431 E. coli Labs Isolates 0 0 0 0 0 0 17 618 17 923 14 645 16 1195 Enterococci Labs Isolates 0 0 42 49 44 40 40 0 0 297 602 634 576 714 K. pneumoniae Labs Isolates 0 0 0 0 0 0 38 0 0 0 0 0 0 344 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 2 13 29 41 . . . . . . . . . . . . . . . . . . 2000 <1 11 28 44 . . . . . . . . . . . . . . . . . . 2001 4 9 39 41 . . . . 3 31 1 69 18 15 . . . . . . . . 2002 2 11 32 38 48 6 21 3 6 38 <1 79 37 19 . . . . . . . . 2003 5 13 37 39 52 10 25 6 4 39 2 80 44 24 . . . . . . . . 2004 5 14 28 40 53 9 28 5 4 36 2 78 39 21 . . . . . . . . 2005 5 9 31 37 55 11 28 8 4 38 3 77 36 19 8 11 20 . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 115 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=586 n=2650 n=1737 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=850 %tot %VRE 100 0 52 31 17 2 0 23 47 28 2 . 3 2 1 0 . 6 1 2 n=358 %tot %VRE 100 0 55 30 15 1 0 24 42 33 20 . 21 19 17 0 . 18 19 23 n=343 %tot %CRKP 100 0 33 26 41 5 1 25 39 30 20 . 22 18 19 75 50 23 15 14 P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Italy providing denominator data Isolate source Blood 88 10 CSF 12 Labs providing denom.data/ 21 Gender data to EARSS reporting Male 47 Hosps providing denom.data/ 16 Female 31 6 reporting data to EARSS Unknown 22 Number of blood culture sets 9 Age (years) Number of hospital beds 0-4 9 13 Patient-days 5-19 4 Average occupancy rate (%) 14 20-64 8 Median length of stay 27 (days) 65 and catchment population over 39 12 Estimated Unknown 22 13 % total population covered Hospital dep. Type of participating hospitals ICU 6 12 University/Tertiary 100 Total 38 0 . 49 30 21 1 1 24 46 28 100 0 28 . 27 23 33 4 . 33 27 27 24/43 41 29 38 25/45 30 34 91,337 41 15,998 23 3,602,5651 16 68%0 30 20 7 43 36 6,445,066 38 42 11% 12 59 29 19 3 13 26 13 35 . 16%5 Internal Med. 35 11 38 35 44 24 33 3 29 14 31 16 . General/Secondary 76% Surgery 2 0 12 38 10 27 10 Figure 1 Geographic distribution 15 laboratories in 2005 15 19 23 . Other 8% 1. of Other 47 11 20 26 17 38 19 3 23 19 20 26 . Unknown 10 15 18 45 23 28 19 2 20 26 20 6 . Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 41 177 56 1158 0 0 0 0 0 0 0 0 2000 36 116 48 456 0 0 0 0 0 0 0 0 2001 39 121 53 839 0 0 42 297 0 0 0 0 2002 50 296 53 1343 17 618 49 602 0 0 0 0 2003 43 282 46 1465 17 923 44 634 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 37 267 42 1219 14 645 40 576 0 0 0 0 IT044X 0/11 40 2005 37 319 no of41 1431: 31 16 1195 714 38 no of 344 0 IT016 0/10 labs hospitals :0 45 IT038X 1/12 IT038 0/7 Minimum : 0.0 Minimum : 0.0 IT062X 6/43 IT024X 7/43 : 1st quartile : 25.0 IT062 0/16 Antibiotic resistance from 1st quartile 2005 5.6 1999 to IT010X 4/23 Median : 13.2 Median : 38.6 IT072 0/15 Table 3. Proportion of antibiotic non-susceptible isolates in:percent IT064X 3/16 3rd quartile 16.7 3rd quartile : 46.4 IT001X 4/20 IT019 1/37 Maximum : 33.3 Maximum : 63.1 1/5 Pathogen Antimicrobial classes 1999 2000 IT077X 2001 2002 2003 2004 2005 IT022 1/29 IT019X 35/162 S. pneumoniae Penicillin R 2 <1 IT067X 4 5 5 5 15/642 IT037 3/64 8/34 Penicillin I+R 13 11 IT050X 9 11 13 14 9 IT009 1/18 IT022X 20/80 IT035 1/14 16/64 Macrolides I+R 29 28 IT049X 39 32 37 28 31 IT034X 24/91 IT065 1/13 S. aureus Oxacillin/Methicillin R 41 44 IT065X 41 38 39 40 37 7/25 IT070 1/12 IT060X E. coli Aminopenicillins R . . IT072X . 48 10/32 52 53 55 10/31 IT040 1/10 Aminoglycosides R . . IT037X . 6 69/196 10 9 11 IT030 2/19 IT030X 39/103 Fluoroquinolones R . . IT070X . 21 25 28 28 35/92 IT028 1/8 35/91 . . IT009X . 3 6 5 8 IT047 1/8 3rd gen. Cephalosporins R IT059X 35/91 34/88 IT008 7/53 E. faecalis Aminopenicillins I+R . . IT061X 3 6 4 4 4 PNSP at laboratory level MRSA at hospital level IT060 IT064 3/21 1/7 E. faecium IT059 IT021 IT031 IT034 K. pneumoniae IT045 IT006 IT067 P. aeruginosa IT005 IT061 IT052 IT024 IT049 IT003 0 HL Aminoglycosides R Glycopeptides R 2/14 Aminopenicillins I+R 3/20 HL 2/13 Aminoglycosides R Glycopeptides R 1/6 4/24 Aminoglycosides R 1/6 Fluoroquinolones R 2/11 3rd gen. Cephalosporins R 3/16 Piperacillin R 3/16 Ceftazidime R 9/40 Carbapenems R 2/8 4/13 Aminoglycosides R 2/6 Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . IT008X IT028X IT075X IT052X IT076X IT021X IT036X IT042X IT031X IT016X IT071X IT006X IT003X IT004X IT040X IT047X IT005X IT014X IT017X IT045X IT074X IT035X 31 1 69 18 15 . . . . . . . . 0 25 38 <1 79 37 19 . . . . . . . . 69/178 8/20 18/42 29/66 39 36 2 2 12/27 80 78 5/11 5/11 44 39 11/24 24 21 18/39 31/67 . . 13/28 16/33. . 5/10 . . 7/14 60/120 . . 53/105 86/167 . . 30/57 .6/11 . . 35/64 . 39/66 41/65 . . 50 75 38 3 77 36 19 8 11 20 . . . . . 100 116 Annex 2. Country Summary Sheets Latvia General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 6/7 9/9 9,395 4,603 1,276,513 79% 8 1,801,593 78% 44% 33% 22% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 0 0 0 4 5 0 0 0 0 0 17 36 S. aureus Labs Isolates 0 0 0 0 0 7 7 0 0 0 0 0 87 125 E. coli Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Enterococci Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 . . . . . . . . . . . . . . . . . . . . . . 2002 . . . . . . . . . . . . . . . . . . . . . . 2003 . . . . . . . . . . . . . . . . . . . . . . 2004 <1 <1 7 25 . . . . . . . . . . . . . . . . . . 2005 <1 <1 3 20 . . . . . . . . . . . . . . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 117 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=53 n=212 n=0 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=0 %tot . . . . . . . . . . %VRE . . . . . . . . . . n=0 %tot . . . . . . . . . . %VRE . . . . . . . . . . n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Latvia providing denominator data Isolate source Blood 79 0 CSF 21 0 Labs providing denom.data/ Gender data to EARSS reporting Male 70 Hosps providing denom.data/ 0 Female 30 0 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 2 0 Patient-days 5-19 9 0 Average occupancy rate (%) 20-64 0 Median length of stay 66 (days) 65 and catchment population 0 over 21 Estimated Unknown 2 0 % total population covered Hospital dep. Type of participating hospitals ICU 79 0 University/Tertiary 100 Total 22 0 . 61 38 0 11 6 51 31 1 27 15 . . . . 9/9 . 9,395 . . . . . . . . . . . 6/7 4,603 4 1,276,513 . 8 79% . 24 8. 28 1,801,593 . 33 78% . 27 40 . . . . . . . . 44% . Internal Med. 9 0 33 16 . . . . . . . . General/Secondary 33% . Surgery 0 . 7 43 . . Figure 1. Geographic distribution of laboratories in 2005 . . . . . . Other 22% . Other 11 0 33 10 . . . . . . . . . Unknown 0 . number of isolates reported for the period 1999-2005 0 . . . . . . . . . . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 2000 0 0 0 0 2001 0 0 0 0 2002 0 0 0 0 2003 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 4 17 7 87 2005 5 36 no of labs 7 125: 3 Minimum : 0.0 : Antibiotic resistance from 1st quartile 2005 0.0 1999 to Median : 0.0 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 0.0 Maximum : 0.0 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 0 0 0 0 0 S. pneumoniae LV002 0/6 S. aureus E. coli LV003 E. faecalis 0/10 Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 0 0 0 0 0 0 0 0 0 0 0 no of hospitals 0 0 :0 6 Minimum : 0.0 1st quartile : 0.0 LV002A 0/20 Median : 15.6 3rd quartile : 28.8 Maximum : 57.1 2000 2001 2002 2003 2004 2005 . . . . <1 <1 . . . . <1 <1 LV006A 0/14 . . . . 7 3 . . . . 25 20 . . . . . . . . . . . . .LV003A . 4/29 . . . . . . . . . . . . . . . . MRSA at hospital level E. faecium K. pneumoniae LV004 0/32 P. aeruginosa . .LV004A . . . . LV001A . . . . .LV007A . . 0 . . . . . . . . . . . . . 8/46 . . . . . . 19/66 . . . . . . . 50 . . . . . . . . . . . . . 16/28 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . 0 25 118 Annex 2. Country Summary Sheets Luxembourg General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 5/6 6/8 10,445 1,771 513,009 79% 5 474,000 100% 0% 67% 33% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 1 5 8 7 7 6 5 9 22 41 27 48 36 43 S. aureus Labs Isolates 1 4 8 9 8 7 5 25 67 85 95 95 96 83 E. coli Labs Isolates 0 0 0 0 8 193 9 193 8 227 7 216 5 188 Enterococci Labs Isolates 0 0 7 8 7 5 5 0 0 31 30 41 28 31 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 11 22 33 16 . . . . . . . . . . . . . . . . . . 2000 <1 14 26 18 . . . . . . . . . . . . . . . . . . 2001 7 12 23 20 44 5 4 <1 <1 13 <1 <1 . <1 . . . . . . . . 2002 7 22 22 15 43 4 9 <1 <1 17 <1 60 14 <1 . . . . . . . . 2003 <1 15 30 21 49 4 12 <1 5 32 <1 100 <1 <1 . . . . . . . . 2004 6 11 33 16 49 4 18 <1 <1 18 <1 50 <1 <1 . . . . . . . . 2005 7 12 24 13 49 7 19 3 <1 24 <1 36 23 <1 . . . . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 119 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=79 n=179 n=404 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=41 %tot 100 0 59 41 0 7 0 41 51 0 %VRE 0 . 0 0 . 0 . 0 0 . n=18 %tot 100 0 94 6 0 6 0 33 61 0 %VRE 0 . 0 0 . 0 . 0 0 . n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Luxembourg providing denominator data Isolate source Blood 99 12 CSF 1 0 Labs providing denom.data/ Gender data to EARSS reporting Male 56 Hosps providing denom.data/ 11 Female 44 11 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 8 17 Patient-days 5-19 10 Average occupancy rate (%) 13 20-64 6 Median length of stay 39 (days) 65 and catchment population over 43 15 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 18 7 University/Tertiary 100 Total 15 0 . 49 51 0 4 4 42 49 0 100 0 18 . 20 17 . 0 . 18 18 . 5/6 15 40 14 59 6/8 . 10,4450 1,771 0 513,0092 38 79%0 9 30 5 18 474,000 68 . 100%0 16 4 11 11 27 0 39 0 . . . 0% Internal Med. 24 11 25 20 34 18 27 0 6 0 . . . General/Secondary 67% Surgery 5 0 10 17 12 7 Figure 0 Geographic distribution of laboratories in 2005 6 0 . . . Other 33%8 1. Other 30 13 22 15 23 26 27 0 39 0 . . . Unknown 23 17 number of isolates reported for the period 1999-2005 27 15 24 15 12 0 11 0 . . . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 1 9 1 25 2000 5 22 4 67 2001 8 41 8 85 2002 7 27 9 95 2003 7 48 8 95 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 6 36 7 96 2005 5 43 no of labs 5 83: 5 Minimum : 0.0 : Antibiotic resistance from 1st quartile 2005 0.0 1999 to Median : 5.3 LU004 0/9 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 17.1 Maximum : 22.2 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 8 9 8 7 5 S. pneumoniae LU007 S. aureus E. coli 0/6 LU003 E. faecalis 1/19 Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R 6/35 Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R 2/9 Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 11 22 33 16 . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 193 7 31 0 0 0 0 193 8 30 0 0 0 0 227 7 41 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 216 5 28 0 0 0 0 188 5 31 0 no of hospitals 0 0 :0 5 Minimum : 9.3 1st quartile : 13.0 Median : 16.7 LU003S 4/43 3rd quartile : 19.2 Maximum : 27.3 2000 2001 2002 2003 2004 2005 <1 7 7 <1 6 7 14 12 22 15 11 12 26 23 22 30 33 24 18 LU001E 20 9/69 15 21 16 13 . 44 43 49 49 49 . 5 4 4 4 7 . 4 9 12 18 19 . <1 <1 <1 <1 3 3/18 .LU006K <1 <1 5 <1 <1 MRSA at hospital level E. faecium LU001 K. pneumoniae P. aeruginosa LU006 . . . . . LU007Z . . . . . LU004T . . . 0 13 <1 <1 . <1 . . . . . . . . 5/26 17 <1 60 14 <1 . . . . . 3/11 . . . 0 25 32 <1 100 <1 <1 . . . . . . . . 50 18 <1 50 <1 <1 . . . . . . . . 75 24 <1 36 23 <1 . . . . . . . . 100 120 Annex 2. Country Summary Sheets Malta General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 1/1 4/4 4,329 1,034 307,677 81% 8 380,000 95% 25% 25% 50% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 1 1 1 1 1 1 0 11 12 12 9 18 13 S. aureus Labs Isolates 0 1 1 1 1 1 1 0 76 83 87 122 94 78 E. coli Labs Isolates 0 0 0 0 1 67 1 74 1 91 1 92 1 87 Enterococci Labs Isolates 0 0 1 1 1 1 1 0 0 13 33 26 42 38 K. pneumoniae Labs Isolates 0 0 0 0 0 0 1 0 0 0 0 0 0 18 P. aeruginosa Labs Isolates 0 0 0 0 0 0 1 0 0 0 0 0 0 45 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 <1 9 36 36 . . . . . . . . . . . . . . . . . . 2001 <1 8 18 54 27 10 15 <1 8 8 <1 100 <1 <1 . . . . . . . . 2002 <1 <1 25 43 43 8 12 3 <1 17 <1 33 <1 <1 . . . . . . . . 2003 <1 <1 38 43 39 18 24 2 5 29 <1 33 50 <1 . . . . . . . . 2004 <1 <1 25 56 47 20 35 4 <1 44 <1 43 <1 <1 . . . . . . . . 2005 8 15 46 55 49 7 30 1 3 32 <1 25 <1 <1 17 11 6 22 11 18 16 44 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 121 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=31 n=172 n=178 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=68 %tot 100 0 53 47 0 7 3 43 47 0 %VRE 0 . 0 0 . 0 0 0 0 . n=12 %tot 100 0 50 50 0 8 8 17 67 0 %VRE 0 . 0 0 . 0 0 0 0 . n=18 %tot %CRKP 100 0 56 44 0 6 6 44 44 0 6 . 10 0 . 0 0 13 0 . P. aeruginosa n=45 %tot %CRPA 100 0 64 36 0 4 2 53 40 0 18 . 24 6 . 0 0 29 6 . 28 0 0 0 0 Malta providing denominator data Isolate source Blood 84 8 CSF 16 0 Labs providing denom.data/ Gender data to EARSS reporting Male 65 Hosps providing denom.data/ 0 Female 35 18 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 23 14 Patient-days 5-19 6 0 Average occupancy rate (%) 20-64 0 Median length of stay 29 (days) 65 and catchment population 8 over 42 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 19 0 University/Tertiary 100 Total 56 0 . 63 37 0 11 5 38 45 1 55 58 . 100 0 33 . 37 28 . 0 33 34 34 . 1/1 48 52 4/4 4,3290 1,034 47 307,6774 44 81%2 48 28 8 65 380,000 66 100 95%0 20 65 10 35 60 0 42 0 6 0 64 25% Internal Med. 42 0 44 50 46 31 12 0 42 0 39 14 22 General/Secondary 25% Surgery 3 100 17 62 28 41 16 Figure 0 Geographic distribution 28 laboratories in 2005 8 0 0 7 Other 50% 1. of Other 19 17 10 61 5 11 3 0 8 0 11 0 4 Unknown 16 9 47 12 27 9 0 0 . 17 0 2 Table 2. Number of laboratories 0 number of isolates reported for the period 1999-2005 and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 2000 1 11 1 76 2001 1 12 1 83 2002 1 12 1 87 2003 1 9 1 122 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 1 18 1 94 2005 1 13 no of labs 1 78: 1 Minimum : 6.5 : Antibiotic resistance from 1st quartile 2005 6.5 1999 to Median : 6.5 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 6.5 Maximum : 6.5 Pathogen Antimicrobial classes 1999 PNSP at laboratory level 0 0 1 1 1 1 1 S. pneumoniae S. aureus E. coli MT001 E. faecalis 2/31 Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . . . . . . . . . . 75 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67 1 13 0 0 0 0 74 1 33 0 0 0 0 91 1 26 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 92 1 42 0 0 0 0 87 1 38 1 no of hospitals 18 45 :1 2 Minimum : 42.9 1st quartile : 42.9 Median : 50.0 3rd quartile : 57.1 Maximum : 57.1 2000 2001 2002 2003 2004 2005 <1 <1 <1 <1 <1 8 9 8 <1 <1 <1 15 36MT001E 18 25 25 46 3/7 38 36 54 43 43 56 55 . 27 43 39 47 49 . 10 8 18 20 7 . 15 12 24 35 30 . <1 3 2 4 1 . 8 <1 5 <1 3 MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa . . . . . .MT001A . . . . . . . 0 8 <1 100 <1 <1 . . . . . . . . 25 17 <1 33 <1 <1 . . . . . . . . 50 29 <1 33 50 <1 . . . . . . . . 92/161 0 44 <1 43 <1 <1 . . . . . . . . 75 32 <1 25 <1 <1 17 11 6 22 11 18 16 44 100 122 Annex 2. Country Summary Sheets Netherlands General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 13/22 18/39 123,924 11,976 2,299,079 59% 7 8,142,254 50% 33% 67% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 21 23 20 23 24 21 23 762 740 723 860 886 754 802 S. aureus Labs Isolates 20 24 21 22 22 22 23 1224 1388 1290 1502 1363 1336 1401 E. coli Labs Isolates 0 0 12 1312 20 1864 22 2427 23 2143 21 2112 23 2199 Enterococci Labs Isolates 0 8 14 22 23 22 23 0 81 275 536 482 455 565 K. pneumoniae Labs Isolates 0 0 0 0 0 0 16 0 0 0 0 0 0 301 P. aeruginosa Labs Isolates 0 0 0 0 0 0 16 0 0 0 0 0 0 210 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 1 . <1 . . . . . . . . . . . . . . . . . . 2000 <1 1 4 <1 37 2 3 <1 <1 . <1 33 . <1 . . . . . . . . 2001 <1 <1 5 <1 39 2 5 <1 2 28 <1 64 4 2 . . . . . . . . 2002 <1 1 7 <1 39 2 5 <1 3 33 <1 23 11 1 . . . . . . . . 2003 <1 1 5 1 44 3 7 1 4 23 1 30 19 <1 . . . . . . . . 2004 <1 2 7 1 43 3 7 1 3 37 <1 42 20 <1 . . . . . . . . 2005 <1 1 11 <1 48 4 10 2 3 38 <1 61 40 <1 5 6 4 4 5 5 7 9 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 123 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=1556 n=2737 n=4003 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=564 %tot %VRE 100 0 62 34 5 9 7 35 49 0 0 . 0 0 0 0 0 0 0 . n=380 %tot %VRE 100 0 62 38 0 9 3 40 48 0 0 . 0 0 . 0 0 0 1 . n=256 %tot %CRKP 99 1 60 40 0 4 1 37 58 0 4 50 4 4 . 0 67 5 2 . P. aeruginosa n=187 %tot %CRPA 99 1 70 30 1 4 3 35 58 0 5 0 5 4 0 0 17 5 5 . 13 0 13 0 3 Netherlands providing denominator data Isolate source Blood 91 1 CSF 9 1 Labs providing denom.data/ Gender data to EARSS reporting Male 52 Hosps providing denom.data/ 1 Female 46 1 reporting data to EARSS Unknown 2 Number of blood culture sets 9 Age (years) Number of hospital beds 0-4 9 3 Patient-days 5-19 5 2 Average occupancy rate (%) 20-64 1 Median length of stay 39 (days) 65 and catchment population 1 over 47 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 8 1 University/Tertiary 100 Total 1 0 . 59 39 2 9 6 36 48 0 100 0 8 . 9 7 9 2 10 10 8 . 13/22 1 47 1 18/39 49 0 123,9243 11,976 2 2,299,0794 1 59%4 1 31 7 1 60 8,142,254 . 50%0 9 2 10 25 0 18 0 13 13 21 33%7 Internal Med. 17 3 17 1 18 9 12 0 7 0 6 0 10 General/Secondary 67% Surgery 2 0 9 1 6 7 Figure 0 Geographic distribution of laboratories in 2005 4 0 6 0 4 Other 0%6 1. Other 22 2 22 1 19 13 23 0 27 1 14 5 12 Unknown 51 42 1 49 7 34 0 43 0 61 3 52 Table 2. Number of laboratories 1 number of isolates reported for the period 1999-2005 and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 21 762 20 1224 0 0 0 0 0 0 0 0 2000 23 740 24 1388 12 1312 8 81 0 0 0 0 2001 20 723 21 1290 20 1864 14 275 0 0 0 0 2002 23 860 22 1502 22 2427 22 536 0 0 0 0 2003 24 886 22 1363 23 2143 23 482 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 21 754 22 1336 21 2112 22 455 0 0 0 0 NL006X 0/86 23 2005 23 802 no of23 1401: 24 23 2199 565 16 no of 301 210 NL002 0/63 labs hospitals 16 38 : NL008A 0/55 Minimum : 0.0 Minimum : 0.0 NL003 0/73 NL008X 0/36 : 1st quartile : 0.0 Antibiotic resistance from 1st quartile 2005 0.0 1999 to NL009A 0/21 Median : 1.2 Median : 0.0 NL006 0/61 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 0/6 NL009K 3rd quartile 2.6 3rd quartile : 1.8 NL009Z 0/8 NL008 0/66 Maximum : 5.9 Maximum : 8.0 Pathogen Antimicrobial classes 1999 2000 NL011D 2001 2002 2003 2004 2005 0/10 NL014 0/56 NL011E 0/10 S. pneumoniae Penicillin R <1 <1 <1 <1 <1 <1 <1 NL011F 0/18 NL017 0/35 Penicillin I+R 1 1 NL011X 0/115 <1 1 1 2 1 NL018 0/26 Macrolides I+R . 4 NL012A 0/28 5 7 5 7 11 NL012C 0/36 NL019 S. aureus 0/79 Oxacillin/Methicillin R <1 <1 NL016A 0/42 <1 <1 1 1 <1 E. coli Aminopenicillins R . 37 NL018X 0/43 39 39 44 43 48 NL020 0/90 Aminoglycosides R . 2 NL020X 0/1142 2 3 3 4 NL028 0/62 NL021A 0/35 Fluoroquinolones R . 3 NL021B 0/29 5 5 7 7 10 NL011 1/167 3rd gen. Cephalosporins R . <1 NL021C 0/21 <1 <1 1 1 2 NL027 1/87 NL023A 0/71 E. faecalis Aminopenicillins I+R . <1 NL026A 0/2222 3 4 3 3 PNSP at laboratory level MRSA at hospital level NL009 NL021 1/84 1/73 1/72 1/70 1/51 E. faecium NL025 NL023 NL015 NL016 1/40 K. pneumoniae NL005 NL007 1/38 1/30 P. aeruginosa 4/79 NL022 NL012 NL026 NL029 3/52 4/68 2/34 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . NL028X NL029A <1 NLVUMC 33 NL002A . NL015A NL022X <1 NL019X . NL003A NL027A . NL025X . NL007A NL014X . NL025A . NL009F . NL011A NL017X . NL005A . NL009I 0 28 <1 0/24 64 1/130 1/95 4 3/252 2 3/200 3/176 . 3/167 . 1/53 2/101 . 2/96 . 2/90 . 1/35 1/34 . 1/27 . 2/39 . 2/25 0/125 0/60 33 <1 23 11 1 . . . . . . . . 25 50 23 1 30 19 <1 . . . . . . . . 37 <1 42 20 <1 . . . . . . . . 75 38 <1 61 40 <1 5 6 4 4 5 5 7 9 100 124 Annex 2. Country Summary Sheets Norway General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 6/8 8/31 45,369 3,479 867,115 92% 5 1,763,000 38% 25% 75% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 10 10 10 10 10 10 10 280 396 391 421 484 562 569 S. aureus Labs Isolates 9 10 10 10 10 10 10 270 362 364 460 471 482 501 E. coli Labs Isolates 9 629 10 847 10 879 10 1026 10 1071 10 1099 10 1238 Enterococci Labs Isolates 10 10 10 10 10 10 10 76 106 144 172 190 222 288 K. pneumoniae Labs Isolates 3 2 3 3 3 3 10 15 21 19 28 38 37 174 P. aeruginosa Labs Isolates 2 3 3 3 3 3 10 8 6 11 21 23 19 90 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 2 9 <1 27 <1 2 <1 <1 23 <1 19 <1 <1 <1 <1 <1 . <1 <1 <1 13 2000 <1 1 4 <1 25 <1 2 <1 3 11 2 36 33 <1 <1 <1 <1 . 20 <1 <1 <1 2001 <1 1 4 <1 26 <1 1 <1 3 42 <1 30 40 <1 <1 <1 <1 . <1 <1 <1 9 2002 <1 <1 6 <1 27 <1 2 <1 4 30 3 50 14 <1 <1 <1 <1 <1 <1 <1 <1 <1 2003 <1 <1 7 <1 33 <1 2 <1 4 38 <1 46 14 <1 <1 <1 <1 <1 <1 <1 <1 4 2004 <1 1 8 <1 32 <1 4 <1 <1 27 <1 77 25 <1 3 <1 <1 13 <1 6 5 5 2005 <1 2 16 <1 33 2 5 <1 3 32 <1 73 44 <1 2 1 1 3 3 4 <1 4 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 125 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=1131 n=983 n=2316 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=376 %tot %VRE 100 0 74 25 1 1 0 19 80 0 0 . 0 0 0 0 . 0 0 . n=84 %tot 100 0 62 37 1 0 0 27 73 0 %VRE 0 . 0 0 0 . . 0 0 . n=211 %tot %CRKP 100 0 57 42 1 1 0 23 75 0 1 . 0 1 50 33 . 2 0 . P. aeruginosa n=98 %tot %CRPA 99 1 66 30 4 4 2 29 65 0 4 0 2 3 50 50 0 4 2 . 14 3 6 0 33 Norway providing denominator data Isolate source Blood 95 2 CSF 5 2 Labs providing denom.data/ Gender data to EARSS reporting Male 46 Hosps providing denom.data/ 3 Female 52 1 reporting data to EARSS Unknown 2 Number of blood culture sets 6 Age (years) Number of hospital beds 0-4 9 2 Patient-days 5-19 3 3 Average occupancy rate (%) 20-64 2 Median length of stay 39 (days) 65 and catchment population 2 over 49 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 9 2 University/Tertiary 100 Total 1 0 . 58 40 1 3 3 34 59 0 100 0 5 . 6 3 11 3 0 6 4 . 6/8 0 45 1 54 8/31 7 45,3691 3,479 3 867,1152 0 92%1 1 26 5 0 71 1,763,000 . 38%0 5 0 6 6 0 15 0 7 0 7 25%5 Internal Med. 53 1 47 1 47 4 45 0 26 0 35 1 38 General/Secondary 75% Surgery 4 2 17 1 19 4 19 Figure 0 Geographic distribution 23 laboratories in 2005 31 0 0 17 Other 0% 1. of Other 30 3 29 1 26 6 27 0 26 0 33 0 35 Unknown 3 3 4 3 0 2 0 1 0 2 20 3 Table 2. Number of laboratories 3 number of isolates reported for the period 1999-2005 and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 10 280 9 270 9 629 10 76 3 15 2 8 2000 10 396 10 362 10 847 10 106 2 21 3 6 2001 10 391 10 364 10 879 10 144 3 19 3 11 2002 10 421 10 460 10 1026 10 172 3 28 3 21 2003 10 484 10 471 10 1071 10 190 3 38 3 23 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 10 562 10 482 10 1099 10 222 3 37 3 19 2005 10 569 no of10 501: 10 10 1238 288 10 no of 174 90 NO104N 0/8 10 labs hospitals 10 23 : Minimum : 0.0 NO103 0/123 Minimum : 0.0 NO105K 0/49 : 1st quartile : 0.0 Antibiotic resistance from 1st quartile 2005 0.8 1999 to Median : 2.0 Median : 0.0 NO106P 0/34 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 2.8 3rd quartile : 0.8 NO106Q 0/29 NO304 0/64 Maximum : 3.4 Maximum : 12.5 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 NO106S 0/27 S. pneumoniae Penicillin R <1 <1 <1 <1 <1 <1 <1 Penicillin I+R 2 1NO106T 0/131 <1 <1 1 2 NO204 1/133 Macrolides I+R 9 4NO203C 0/534 6 7 8 16 S. aureus Oxacillin/Methicillin R <1 <1NO203D 0/36 <1 <1 <1 <1 <1 NO106 2/151 E. coli Aminopenicillins R 27 25 26 27 33 32 33 NO204H 0/19 Aminoglycosides R <1 <1 <1 <1 <1 <1 2 NO205I 0/68 Fluoroquinolones R 2 2 1 2 2 4 5 NO105 1/57 3rd gen. Cephalosporins R <1 <1NO205M 0/7 <1 <1 <1 <1 <1 E. faecalis Aminopenicillins I+R <1 3NO205X 0/103 4 4 <1 3 PNSP at laboratory level MRSA at hospital level NO206 3/135 E. faecium NO205 2/84 K. pneumoniae NO403 4/145 P. aeruginosa NO203 3/93 NO104 5/146 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 23 <1 19 <1 <1 <1 <1 <1 . <1 <1 <1 13 75 100 11NO206O 2NO206Q 36 NO304J 33 NO304M <1 NO403E <1 <1 NO104J <1NO103E .NO204E 20NO403D <1 NO206P <1 NO206X <1 0 42 0/68 <1 0/5 30 40 0/13 <1 0/23 <1 1/130 <1 1/118 <1 1/71. <1 2/131 <1 1/32 <1 9 0/21 1/8 30 3 50 14 <1 <1 <1 <1 <1 <1 <1 <1 <1 25 50 38 <1 46 14 <1 <1 <1 <1 <1 <1 <1 <1 4 27 <1 77 25 <1 3 <1 <1 13 <1 6 5 5 75 32 <1 73 44 <1 2 1 1 3 3 4 <1 4 100 126 Annex 2. Country Summary Sheets Poland General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 36/36 36/36 51,924 20,421 5,311,381 71% 7 11,452,915 30% 19% 81% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 4 7 11 11 6 0 0 6 10 16 16 6 S. aureus Labs Isolates 0 0 19 21 24 30 30 0 0 151 186 166 262 197 E. coli Labs Isolates 0 0 0 0 20 103 22 135 25 124 29 192 30 176 Enterococci Labs Isolates 0 0 16 19 16 23 20 0 0 57 56 64 52 53 K. pneumoniae Labs Isolates 0 0 0 0 0 0 17 0 0 0 0 0 0 53 P. aeruginosa Labs Isolates 0 0 0 0 0 0 14 0 0 0 0 0 0 26 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 <1 <1 <1 15 58 5 9 7 5 43 <1 77 73 <1 . . . . . . . . 2002 30 30 67 23 52 11 11 6 12 41 <1 80 73 <1 . . . . . . . . 2003 19 19 14 19 50 10 7 4 <1 48 <1 91 55 <1 . . . . . . . . 2004 <1 <1 19 19 45 5 9 5 2 33 <1 86 100 <1 . . . . . . . . 2005 17 33 33 24 56 7 20 5 9 48 <1 95 60 5 57 34 66 50 31 27 56 31 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 127 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=22 n=459 n=363 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=78 %tot 100 0 63 37 0 1 0 47 51 0 %VRE 0 . 0 0 . 0 . 0 0 . n=27 %tot 100 0 56 44 0 15 0 48 37 0 %VRE 4 . 7 0 . 0 . 8 0 . n=53 %tot %CRKP 100 0 66 34 0 21 0 45 34 0 66 . 66 67 . 91 . 71 44 . P. aeruginosa n=26 %tot %CRPA 100 0 54 46 0 19 0 38 42 0 27 . 21 33 . 20 . 30 27 . 40 40 0 14 . Poland providing denominator data Isolate source Blood 73 13 CSF 27 0 Labs providing denom.data/ Gender data to EARSS reporting Male 64 Hosps providing denom.data/ 7 Female 36 13 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 23 0 Patient-days 5-19 5 0 Average occupancy rate (%) 20-64 8 Median length of stay 55 (days) 65 and catchment population over 18 25 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 5 0 University/Tertiary 100 Total 22 0 . 58 42 0 9 3 49 38 0 100 0 14 . 13 14 . 3 0 12 18 . 36/36 24 41 19 36/36 58 . 51,9240 20,421 12 5,311,3819 7 71%1 24 44 7 22 46 11,452,915 . 30%0 12 53 17 10 0 26 14 23 83 38 19%6 Internal Med. 36 25 44 13 51 14 42 0 33 0 34 44 19 General/Secondary 81% Surgery 0 . 15 35 15 18 24 Figure 0 Geographic distribution 17 laboratories in 2005 26 0 67 15 Other 0% 1. of Other 59 0 28 15 28 11 22 0 15 0 25 85 27 Unknown 0 . 0 . 0 . 1 0 0 . 2 0 0 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 2000 0 0 0 0 2001 4 6 19 151 2002 7 10 21 186 2003 11 16 24 166 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) 2004 11 16 30 262 2005 6 6 30 197 PNSP at laboratory level 0 0 20 22 25 29 30 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 1999 . . . . . . . . . . . . . . . . . . . . . . 75 100 S. aureus E. coli E. faecalis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 103 16 57 0 0 0 0 135 19 56 0 0 0 0 124 16 64 0 0 0 0 Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 192 23 52 0 0 0 0 176 53 17 no of hospitals 14 31 53 26 PL004A 0/7 20 : PL006A 0/13 Minimum : 0.0 1st quartile : 0.0 0/6 PL007A Median : 14.3 0/9 PL008A 3rd quartile : 36.8 PL009A 0/18 Maximum : 80.0 2000 PL033A 2001 2002 2003 2004 2005 0/7 . PL045A 0/5 <1 30 19 <1 17 . PL048A 0/10 <1 30 19 <1 33 1/44 . PL017A <1 67 14 19 33 1/21 . PL005A 15 23 19 19 24 PL043A 1/15 . 58 52 50 45 56 PL014A 1/9 . PL013A 5 1/8 11 10 5 7 . PL019A 9 1/8 11 7 9 20 . PL012A 7 6 4 5 5 2/14 1/7 . PL020A 5 12 <1 2 9 MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa . PL024A PL046A . PL011A . PL016A . PL023A . PL002A . PL003A . PL001A PL041A . PL018A . PL015A . PL022A . PL031A . PL035A . PL010A 0 43 <1 77 73 <1 . . . . . . . . 1/6 2/10 0 41 48 <1 <1 3/12 80 91 10/36 73 55 2/7 <1 <1 11/38 . 12/35 . . 7/19 . 4/10 . . 3/7 . . 4/8 . . 19/38 . 4/8. 3/6. . . . 25 50 33 <1 86 100 <1 . . . . . . . . 75 4/5 48 <1 95 60 5 57 34 66 50 31 27 56 31 100 128 Annex 2. Country Summary Sheets Portugal General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 23/23 23/23 72,145 10,527 2,388,639 79% 8 8,840,081 83% 17% 57% 26% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 12 11 16 14 12 14 13 119 97 155 184 95 166 202 S. aureus Labs Isolates 13 8 16 16 22 23 19 369 150 521 543 1033 1063 1153 E. coli Labs Isolates 0 0 0 0 13 418 17 444 21 792 19 761 19 1171 Enterococci Labs Isolates 0 0 12 13 18 19 17 0 0 185 101 398 410 405 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 17 9 37 . . . . . . . . . . . . . . . . . . 2000 <1 29 11 25 . . . . . . . . . . . . . . . . . . 2001 <1 25 . 32 54 6 18 3 5 30 5 76 23 21 . . . . . . . . 2002 <1 20 <1 38 58 9 23 6 2 25 6 79 33 .* . . . . . . . . 2003 <1 20 . 45 53 9 26 7 4 34 3 88 55 47 . . . . . . . . 2004 <1 27 20 46 58 13 27 8 5 29 6 83 66 42 . . . . . . . . 2005 <1 17 19 47 58 12 29 12 <1 38 5 92 68 34 . . . . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa * Proportion not given, due to a very low number of isolates. Annex 2.Country Summary Sheets 129 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=368 n=2216 n=1805 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=583 %tot %VRE 100 0 55 45 0 1 1 36 55 6 5 . 4 7 . 0 0 5 6 11 n=199 %tot %VRE 100 0 54 45 1 2 2 36 56 4 38 . 40 37 0 50 0 47 35 14 n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Portugal providing denominator data Isolate source Blood 89 21 CSF 11 Labs providing denom.data/ 20 Gender data to EARSS reporting Male 64 Hosps providing denom.data/ 18 Female 36 28 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 13 35 Patient-days 5-19 5 Average occupancy rate (%) 35 20-64 Median length of stay 41 (days) 15 65 and catchment population over 35 18 Estimated Unknown 7 40 % total population covered Hospital dep. Type of participating hospitals ICU 3 33 University/Tertiary 100 Total 46 0 . 62 38 0 2 2 38 47 10 100 0 28 . 34 24 . 4 15 24 33 16 23/23 47 45 45 23/23 55 . 72,1450 10,527 6 2,388,6391 17 79%1 38 35 8 58 57 8,840,081 39 83%5 9 52 38 15 3 17 29 . . . 17%5 Internal Med. 17 13 26 53 27 33 28 5 20 26 . . . General/Secondary 57% Surgery 1 25 8 56 29 9 Figure 8 Geographic distribution of laboratories in 2005 8 25 . . . Other 26%6 1. Other 76 22 45 37 61 26 45 7 52 49 . . . Unknown 2 44 number of isolates reported for the period 1999-2005 12 55 2 21 4 0 3 17 . . . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 12 119 13 369 0 0 0 0 0 0 0 0 2000 11 97 8 150 0 0 0 0 0 0 0 0 2001 16 155 16 521 13 418 12 185 0 0 0 0 2002 14 184 16 543 17 444 13 101 0 0 0 0 2003 12 95 22 1033 21 792 18 398 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 14 166 23 1063 19 761 19 410 0 0 0 0 2005 13 202 no of19 1153: 12 19 1171 405 0 no of hospitals 0 0 PT024A 0/6 17 labs :0 23 PT005 1/8 Minimum : 0.0 Minimum : 12.5 PT009A 1/13 : 1st quartile : 28.7 Antibiotic resistance from 1st quartile 200515.7 1999 to Median : 22.3 Median : 39.4 PT004A 2/16 Table 3. Proportion6/45 antibiotic non-susceptible isolates in:percent of PT002 3rd quartile 30.7 3rd quartile : 50.0 1/5 PT027A Maximum : 50.0 Maximum : 83.3 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 PT006A 5/19 S. pneumoniae Penicillin R <1 <1 <1 <1 <1 <1 <1 PT003 9/61 52/181 Penicillin I+R 17 29 PT011A 25 20 20 27 17 Macrolides I+R 9 11 PT023A . <112/39 . 20 19 PT019 10/60 S. aureus Oxacillin/Methicillin R 37 25 PT016A 32 38 26/75 45 46 47 E. coli Aminopenicillins R . . 54 58 53 58 58 PT015A 28/80 PT001 6/34 Aminoglycosides R . . 6 9 9 13 12 PT021A 5/14 Fluoroquinolones R . . 18 23 26 27 29 PT024 4/19 3rd gen. Cephalosporins R . . PT022A 3 6 9/25 7 8 12 65/165 E. faecalis Aminopenicillins I+R . . PT003A 5 2 4 5 <1 PNSP at laboratory level MRSA at hospital level HL 16/68 Aminoglycosides R Glycopeptides R E. faecium Aminopenicillins I+R PT016 2/8 HL Aminoglycosides R Glycopeptides R PT018 7/25 K. pneumoniae Aminoglycosides R Fluoroquinolones R PT008 5/15 3rd gen. Cephalosporins R P. aeruginosa Piperacillin R PT017 Ceftazidime R 5/11 Carbapenems R Aminoglycosides R PT009 3/6 Fluoroquinolones R * Proportion not given, due to a very low number of isolates. 75 0 25 50 PT011 . . . . . . . . . . . . . 100 . PT005A . PT018A . PT019A . PT028A . PT008A . . PT017A . PT001A . PT012A . PT007A . PT002A . PT025A . 0 30 5 76 23 21 . . . . . . . . 25 25 6 79 33 .* . . . . . . . . 55/132 34 23/55 29 3 6 88 83 120/274 55 66 48/97 47 42 52/105 . . 29/58 . . 75/143 . . .81/149 . . 228/395 . . . 105/164 . . . . 50 75 5/6 38 5 92 68 34 . . . . . . . . 100 130 Annex 2. Country Summary Sheets Romania General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 13/20 16/20 15,122 12,317 3,551,512 90% 7 12,500,000 56% 75% 13% 13% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 0 0 6 4 4 5 0 0 0 10 22 9 18 S. aureus Labs Isolates 0 0 0 10 9 15 13 0 0 0 80 85 92 83 E. coli Labs Isolates 0 0 0 0 0 0 8 28 9 50 12 46 13 80 Enterococci Labs Isolates 0 0 0 4 5 4 7 0 0 0 11 12 9 14 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 2 0 0 0 0 0 0 23 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 . . . . . . . . . . . . . . . . . . . . . . 2002 10 50 10 36 50 15 20 18 <1 40 <1 100 80 17 . . . . . . . . 2003 23 36 27 46 70 21 14 19 <1 25 <1 86 63 <1 . . . . . . . . 2004 11 11 <1 72 79 30 17 22 29 <1 <1 100 100 <1 . . . . . . . . 2005 22 39 31 61 77 14 8 16 <1 50 <1 100 70 <1 . . . 61 52 61 64 64 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 131 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=27 n=175 n=116 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=11 %tot 100 0 73 27 0 27 0 27 45 0 %VRE 0 . 0 0 . 0 . 0 0 . n=12 %tot 100 0 67 33 0 50 0 8 33 8 %VRE 0 . 0 0 . 0 . 0 0 0 n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=23 %tot %CRPA 87 13 30 35 35 0 30 0 0 70 70 0 71 38 75 . 43 . . 69 83 . 100 43 43 Romania providing denominator data Isolate source Blood 59 25 CSF 41 Labs providing denom.data/ 36 Gender data to EARSS reporting Male 52 Hosps providing denom.data/ 29 Female 41 36 reporting data to EARSS Unknown 7 Number of blood culture sets 0 Age (years) Number of hospital beds 0-4 22 67 Patient-days 5-19 22 Average occupancy rate (%) 17 20-64 Median length of stay 26 (days) 14 65 and catchment population over 26 14 Estimated Unknown 4 % total population covered 100 Hospital dep. Type of participating hospitals ICU 4 0 University/Tertiary 100 Total 67 0 . 64 36 0 29 11 41 15 5 94 6 12 0 9 13 0 11 33 11 7 0 13/20 71 47 60 16/20 52 . 15,1222 12,317 70 24 3,551,512 37 90%8 69 40 7 69 26 12,500,000 88 56%3 10 71 0 18 0 33 0 . . 26 75%9 Internal Med. 0 . 11 47 19 5 18 0 8 0 . . 0 General/Secondary 13% Surgery 0 . 10 78 10 0 Figure 1. Geographic distribution of laboratories in 2005 . 0 . . . 13 Other 13%9 Other 89 33 50 66 60 16 45 0 33 0 . . 30 Unknown 7 0 number of isolates reported for the period 1999-2005 19 74 3 0 18 0 25 0 . . 30 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2001 0 0 0 0 0 0 0 0 0 0 0 0 2002 6 10 10 80 8 28 4 11 0 0 0 0 2003 4 22 9 85 9 50 5 12 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 4 9 15 92 12 46 4 9 0 0 0 0 2005 5 18 no of13 83: 1 13 80 7 14 0 no of hospitals 0 23 labs :2 9 : 42.9 Minimum : 33.3 RO08BX 3/7 Minimum : 1st quartile : 50.0 Antibiotic resistance from 1st quartile 200533.3 1999 to Median : 33.3 Median : 67.6 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 33.3 3rd quartile : 72.7 Maximum : 33.3 Maximum : 92.9 Pathogen Antimicrobial classes 1999 2000 RO01BX 2001 2002 2003 2004 2005 13/27 S. pneumoniae Penicillin R . . . 10 23 11 22 Penicillin I+R . . . 50 36 11 39 Macrolides I+R . .RO01AX . 10 27 <1 31 8/16 S. aureus Oxacillin/Methicillin R . . . 36 46 72 61 E. coli Aminopenicillins R . . . 50 70 79 77 6/9 30 Aminoglycosides R . .RO02AX . 15 21 14 Fluoroquinolones R . . . 20 14 17 8 3rd gen. Cephalosporins R . . . 18 19 22 16 RO01A 5/15 23/34 E. faecalis Aminopenicillins I+R . .RO01FX . <1 <1 29 <1 PNSP at laboratory level MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . .RO01EX . . .RO06AX . . .RO01CX . . RO01DX . . 0 . . . . . . . . . . . . . 40 <1 100 80 17 . . . . . . . . 25 25 <1 86 63 <1 . . . . . . . . 50 <1 <1 5/7 100 100 <1 8/11 . . . 13/17 . . . . . 75 50 <1 100 70 <1 . . . 61 52 61 26/28 64 64 100 132 Annex 2. Country Summary Sheets Slovakia General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 13/15 20/23 21,035 12,673 2,548,517 68% 7 5,400,000 100% 65% 35% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 * S. pneumoniae Labs Isolates 0 0 4 9 14 9 4 0 0 6 16 27 17 8 S. aureus Labs Isolates 0 0 7 14 16 15 12 0 0 37 259 269 289 147 E. coli Labs Isolates 0 0 0 0 8 45 14 215 16 239 15 310 13 134 Enterococci Labs Isolates 0 0 6 12 10 12 8 0 0 17 79 75 82 46 K. pneumoniae Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P. aeruginosa Labs Isolates 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 . . . . . . . . . . . . . . . . . . . . . . 2001 <1 <1 20 5 36 2 16 7 <1 58 <1 67 50 <1 . . . . . . . . 2002 19 19 29 8 49 4 14 2 4 34 <1 75 75 <1 . . . . . . . . 2003 4 11 <1 13 54 6 20 <1 <1 35 <1 92 60 <1 . . . . . . . . 2004 24 29 33 19 62 11 24 7 7 37 <1 91 45 9 . . . . . . . . 2005 * <1 <1 40 19 59 7 14 8 7 40 <1 100 33 <1 . . . . . . . . S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa * First half year of 2005. Annex 2.Country Summary Sheets 133 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=25 n=436 n=440 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=113 %tot %VRE 100 0 64 36 0 11 1 50 37 1 0 . 0 0 . 0 0 0 0 0 n=14 %tot 100 0 79 21 0 0 0 64 36 0 %VRE 7 . 9 0 . . . 11 0 . n=0 %tot %CRKP . . . . . . . . . . . . . . . . . . . . P. aeruginosa n=0 %tot %CRPA . . . . . . . . . . . . . . . . . . . . . . . . . Slovakia providing denominator data Isolate source Blood 68 24 CSF 32 Labs providing denom.data/ 13 Gender data to EARSS reporting Male 56 Hosps providing denom.data/ 7 Female 44 36 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 24 17 Patient-days 5-19 12 Average occupancy rate (%) 33 20-64 9 Median length of stay 44 (days) 65 and catchment population over 20 40 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 12 0 University/Tertiary 100 Total 19 0 . 65 35 0 8 3 50 38 0 100 0 21 . 26 18 . 8 40 17 25 20 13/15 17 41 23 20/23 59 . 21,0350 12,673 19 2,548,5176 27 68%2 16 37 7 22 54 5,400,000 . 100%1 12 26 24 27 0 7 0 . . . 65%8 Internal Med. 28 0 42 17 46 20 21 0 14 0 . . . General/Secondary 35% Surgery 0 . 8 27 33 15 Figure 0 Geographic distribution of laboratories in 2005 29 0 . . . Other 0%9 1. Other 60 33 38 18 36 19 36 0 50 14 . . . Unknown 0 . number of isolates reported for the period 1999-2005 0 . 1 33 0 . 0 . . . . Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 0 0 0 0 0 0 0 0 0 0 0 0 2001 4 6 7 37 8 45 6 17 0 0 0 0 2002 9 16 14 259 14 215 12 79 0 0 0 0 2003 14 27 16 269 16 239 10 75 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 9 17 15 289 15 310 12 82 0 0 0 0 2005 * 4 8 no of12 147: 1 13 134 8 46 0 no of hospitals 0 0 labs :0 18 SK009A 2/31 Minimum : 6.5 Minimum : 0.0 : 1st quartile : 15.4 Antibiotic resistance from 1st quartile 2005 0.0 1999 to SK002D 1/12 Median : 0.0 Median : 20.0 Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 0.0 3rd quartile : 25.0 SK003A 3/23 Maximum : 0.0 Maximum : 42.9 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 * SK007A 9/67 S. pneumoniae Penicillin R . . <1 19 4 24 <1 Penicillin I+R . . SK006A <1 19 11 29 <1 6/39 Macrolides I+R . . 20 29 <1 33 40 3/19 S. aureus Oxacillin/Methicillin R . . SK013A 5 8 13 19 19 E. coli Aminopenicillins R . . SK002B 36 49 54 62 59 5/31 Aminoglycosides R . . 2 4 6 11 7 1/6 Fluoroquinolones R . . SK016A 16 14 20 24 14 3rd gen. Cephalosporins R . . SK002A 7 <1 7 8 6/30 2 SK002 E. faecalis 0/6 Aminopenicillins I+R . . <1 4 <1 7 7 PNSP at laboratory level MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa * First half year of 2005. 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . SK010C . SK015A . . SK004A . SK008A . . SK014A . SK012A . . SK005A . SK001A . 0 SK010A 58 <1 67 50 <1 . . . . . . . . 34 <1 75 1/5 75 6/28<1 . 4/16 . . 9/34 . 5/16 . . . . 25 1/5 5/25 12/29 3/7 35 <1 92 60 <1 . . . . . . . . 50 37 <1 91 45 9 . . . . . . . . 75 40 <1 100 33 <1 . . . . . . . . 100 134 Annex 2. Country Summary Sheets Slovenia General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 11/11 14/14 36,276 7,604 2,047,687 74% 6 2,000,000 100% 21% 79% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 7 10 11 11 10 11 0 40 156 101 172 166 208 S. aureus Labs Isolates 0 10 10 11 11 11 11 0 154 270 276 299 347 349 E. coli Labs Isolates 0 0 0 0 10 398 11 409 11 401 11 573 11 657 Enterococci Labs Isolates 0 0 10 9 10 9 11 0 0 54 45 76 91 119 K. pneumoniae Labs Isolates 0 0 0 0 0 0 10 0 0 0 0 0 0 78 P. aeruginosa Labs Isolates 0 0 0 0 0 0 8 0 0 0 0 0 0 38 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 <1 23 12 21 . . . . . . . . . . . . . . . . . . 2001 <1 20 18 20 44 2 8 <1 <1 35 <1 64 50 <1 . . . . . . . . 2002 <1 19 10 14 43 3 12 1 <1 50 <1 69 62 <1 . . . . . . . . 2003 2 15 9 13 41 2 11 <1 <1 49 <1 83 82 <1 . . . . . . . . 2004 2 25 11 12 40 5 12 1 <1 37 <1 76 56 <1 . . . . . . . . 2005 2 11 11 10 42 4 12 2 1 46 <1 93 47 <1 17 14 19 21 11 13 18 29 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 135 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=374 n=696 n=1230 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=146 %tot %VRE 100 0 65 35 0 4 0 27 68 0 0 . 0 0 . 0 . 0 0 . n=64 %tot 100 0 64 36 0 3 0 41 56 0 %VRE 0 . 0 0 . 0 . 0 0 . n=78 %tot %CRKP 99 1 46 54 0 10 5 33 51 0 19 0 25 14 . 0 50 27 15 . P. aeruginosa n=38 %tot %CRPA 100 0 63 37 0 3 3 39 55 0 13 . 13 14 . 0 0 13 14 . 0 23 33 6 . Slovenia providing denominator data Isolate source Blood 91 18 CSF 9 9 Labs providing denom.data/ Gender data to EARSS reporting Male 59 Hosps providing denom.data/ 14 Female 41 22 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 17 38 Patient-days 5-19 5 0 Average occupancy rate (%) 20-64 9 Median length of stay 36 (days) 65 and catchment population over 42 18 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 10 13 University/Tertiary 100 Total 11 0 . 61 39 0 4 4 38 54 0 100 0 12 . 13 12 . 0 0 11 13 . 11/11 13 37 8 14/14 63 . 36,2760 7,604 0 2,047,6872 7 74%1 9 30 6 14 67 2,000,000 . 100%0 11 17 13 10 0 20 0 10 25 16 21%7 Internal Med. 38 13 44 8 53 12 48 0 38 0 27 19 34 General/Secondary 79% Surgery 2 33 11 26 16 13 Figure 0 Geographic distribution 18 laboratories in 2005 19 0 14 8 Other 0%4 1. of Other 51 21 34 8 36 12 29 0 23 0 45 20 42 Unknown 0 . 0 . 0 . 0 . 0 . 0 . 0 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 7 40 10 154 0 0 0 0 0 0 0 0 2001 10 156 10 270 10 398 10 54 0 0 0 0 2002 11 101 11 276 11 409 9 45 0 0 0 0 2003 11 172 11 299 11 401 10 76 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 10 166 11 347 11 573 9 91 0 0 0 0 2005 11 208 no of11 349: 10 11 657 11 119 10 no of hospitals 78 38 labs :8 14 SI003B 0/9 Minimum : 0.0 SI005 0/7 Minimum : 0.0 : 1st quartile : 0.0 Antibiotic resistance from 1st quartile 2005 7.3 1999 to Median : 19.7 Median : 7.2 0/5 SI004B Table 3. Proportion of antibiotic non-susceptible isolates in:percent 3rd quartile 22.2 3rd quartile : 11.1 SI003 2/32 Maximum : 27.8 Maximum : 19.7 Pathogen Antimicrobial classes 1999 2000 2001 2002 2003 2004 2005 SI005A 0/28 S. pneumoniae Penicillin R . <1 <1 <1 2 2 2 Penicillin I+R . 23 SI010A 0/21 20 19 15 25 11 SI010 4/55 Macrolides I+R . 12 18 10 9 11 11 S. aureus Oxacillin/Methicillin R . 21 SI011A 0/17 20 14 13 12 10 SI007 1/9 Aminopenicillins R E. coli . . 44 43 41 40 42 Aminoglycosides R . . SI009A 2 3 2 5 4 1/33 Fluoroquinolones R . . 8 12 11 12 12 SI001 30/155 2/32 3rd gen. Cephalosporins R . . SI007A <1 1 <1 1 2 E. faecalis Aminopenicillins I+R . . <1 <1 <1 <1 1 PNSP at laboratory level MRSA at hospital level SI011 E. faecium SI004 K. pneumoniae SI008 P. aeruginosa SI002 SI009 0 HL Aminoglycosides R 2/10 Glycopeptides R Aminopenicillins I+R 12/55 HL Aminoglycosides R Glycopeptides R Aminoglycosides R 4/18 Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R 3/11 Ceftazidime R Carbapenems R 5/18 Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . SI003A SI001B SI006A SI002A SI001A SI004A SI008A 35 8/98 50 <1 <1 64 1/10 69 50 62 2/20 <1 <1 . . 2/18 . . . . 38/273 . . . . 11/71 . . . 12/61 . . . 25 0 49 <1 83 82 <1 . . . . . . . . 50 37 <1 76 56 <1 . . . . . . . . 75 46 <1 93 47 <1 17 14 19 21 11 13 18 29 100 136 Annex 2. Country Summary Sheets Spain General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 24/37 25/37 157,994 13,258 4,526,911 77% 7 6,587,249 16% 40% 60% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 0 33 36 35 35 36 34 0 584 649 658 655 682 740 S. aureus Labs Isolates 0 30 35 36 36 36 34 0 836 1013 1196 1391 1526 1337 E. coli Labs Isolates 0 0 0 0 27 1967 29 2484 29 2650 36 3471 34 2997 Enterococci Labs Isolates 0 0 26 35 36 36 34 0 0 371 566 608 710 622 K. pneumoniae Labs Isolates 0 0 0 0 0 0 14 0 0 0 0 0 0 56 P. aeruginosa Labs Isolates 0 0 0 0 0 0 13 0 0 0 0 0 0 70 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 . . . . . . . . . . . . . . . . . . . . . . 2000 11 33 22 28 . . . . . . . . . . . . . . . . . . 2001 11 37 31 23 59 7 17 <1 3 32 <1 49 15 2 . . . . . . . . 2002 10 33 26 23 60 8 19 2 2 37 <1 59 16 1 . . . . . . . . 2003 7 32 27 24 58 7 21 4 1 36 <1 64 11 3 . . . . . . . . 2004 9 29 27 26 60 7 25 7 2 36 <1 66 17 2 . . . . . . . . 2005 9 25 23 27 62 10 28 8 <1 36 <1 67 16 3 4 11 7 4 6 17 4 14 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 137 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=1422 n=2863 n=6459 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=1062 %tot %VRE 100 0 65 35 0 7 1 30 60 2 0 . 0 0 . 0 0 0 0 0 n=269 %tot %VRE 100 0 64 36 0 10 0 29 60 1 2 . 2 3 . 0 . 6 1 0 n=56 %tot %CRKP 100 0 61 39 0 4 0 36 61 0 7 . 9 5 . 0 . 5 9 . P. aeruginosa n=70 %tot %CRPA 97 3 71 29 0 4 0 44 50 1 15 100 14 25 . 0 . 26 11 0 30 8 25 8 0 Spain providing denominator data Isolate source Blood 95 27 CSF 5 22 Labs providing denom.data/ Gender data to EARSS reporting Male 64 Hosps providing denom.data/ 25 Female 36 30 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 15 40 Patient-days 5-19 5 8 Average occupancy rate (%) 20-64 Median length of stay 39 (days) 23 65 and over 40 28 Estimated catchment population Unknown 1 18 % total population covered Hospital dep. Type of participating hospitals ICU 8 26 University/Tertiary 100 Total 27 0 . 66 34 0 4 3 38 55 1 100 0 27 . 30 23 . 8 11 25 29 0 24/37 27 51 26 25/37 49 . 157,9940 13,258 7 4,526,9113 10 77%1 21 29 7 33 66 6,587,249 12 16%1 12 37 28 22 0 11 7 11 17 33 40%5 Internal Med. 28 30 35 27 30 29 25 0 28 3 36 5 19 General/Secondary 60% Surgery 1 20 10 41 25 10 Figure 0 Geographic distribution of laboratories in 2005 14 0 9 0 11 Other 0%6 1. Other 60 26 42 21 58 25 41 0 44 2 45 8 36 Unknown 3 21 number of isolates reported for the period 1999-2005 2 24 1 33 2 0 3 0 0 . 1 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 0 0 0 0 0 0 0 0 0 0 0 0 2000 33 584 30 836 0 0 0 0 0 0 0 0 2001 36 649 35 1013 27 1967 26 371 0 0 0 0 2002 35 658 36 1196 29 2484 35 566 0 0 0 0 2003 35 655 36 1391 29 2650 36 608 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 36 682 36 1526 36 3471 36 710 0 0 0 0 ES020A 1/34 1/14 2005ES047 34 740 no of34 1337: 35 34 2997 34 622 14 no of hospitals 13 37 56 70 labs : ES013A 4/76 ES015 3/24 Minimum : 2.9 Minimum : 7.1 ES051A 4/65 ES043 5/31 : 1st quartile : 20.0 Antibiotic resistance from 1st quartile 200521.0 1999 to ES015A 2/16 ES019 4/23 Median : 28.6 Median : 25.8 Table 3. Proportion of 7/38 antibiotic non-susceptible isolates in:percent ES046A 8/64 ES048 3rd quartile 35.2 3rd quartile : 31.1 ES005A 13/85 Maximum : 52.2 Maximum : 43.9 ES040 20/103 Pathogen Antimicrobial classes 1999 2000 ES040A 2001 2002 2003 2004 2005 12/74 ES012 4/20 3/16 S. pneumoniae Penicillin R . 11 ES045A 11 10 7 9 9 ES044 12/59 ES047A 4/20 Penicillin I+R . 33 37 33 32 29 25 ES011 21/100 ES048A 18/90 ES046 4/19 Macrolides I+R . 22 ES021A 31 26 27 27 23 31/150 ES056 15/68 12/5623 S. aureus Oxacillin/Methicillin R . 28 ES002A 23 24 26 27 ES042 26/110 ES018A 8/37 E. coli Aminopenicillins R . . ES009A 59 60 58 60 62 ES021 20/82 21/90 ES010 12/46 25/106 Aminoglycosides R . . ES044A 7 8 7 7 10 ES050 31/118 45/181 Fluoroquinolones R . . ES019A 17 19 21 25 28 ES053 13/48 ES011A 13/52 3rd gen. Cephalosporins R . . ES054A <1 2 4 7 8 ES005 7/25 18/72 2/7 32/124 ES017 E. faecalis Aminopenicillins I+R . . ES053A 3 2 1 2 <1 PNSP at laboratory level MRSA at hospital level ES009 ES013 ES045 ES038 E. faecium ES020 ES031 ES008 ES002 K. pneumoniae ES054 ES018 ES016 P. aeruginosa ES003 ES007 ES004 ES051 ES049 ES032 0 HL Aminoglycosides R 3/10 Glycopeptides R 4/13 11/35 Aminopenicillins I+R 15/46 HL Aminoglycosides R 21/64 Glycopeptides R 6/18 9/26 Aminoglycosides R 31/88 Fluoroquinolones R 5/14 3rd gen. Cephalosporins R 11/28 6/15 Piperacillin R 12/29 Ceftazidime R 5/12 Carbapenems R4/9 Aminoglycosides R 8/16 Fluoroquinolones R12/23 25 50 10/34 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . ES043A ES004A ES008A ES032A ES003A ES042A ES016A ES038A ES056A ES031A ES041A ES010A ES012A ES029A ES017A ES049A ES007A ES026A 32 <1 49 15 2 . . . . . . . . 0 37 36 11/40 <1 <1 21/74 14/49 59 64 14/48 16 11 33/113 26/89 1 3 31/103 . 37/119 . . 18/54 . . 49/143 . 28/80 . . 37/95 19/47 . . 29/71 . . 45/109 . . 29/70 29/66 . . 25 50 23/85 36 <1 66 17 2 . . . . . . . . 75 36 <1 67 16 3 4 11 7 4 6 17 4 14 100 138 Annex 2. Country Summary Sheets Sweden General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2005, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 20/21 45/59 188,291 17,285 4,971,229 83% 5 6,388,281 71% 18% 82% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 24 19 20 21 21 21 21 805 803 788 830 917 955 1017 S. aureus Labs Isolates 24 19 20 21 21 21 21 1320 1478 1633 1836 1855 1906 1774 E. coli Labs Isolates 0 0 0 0 20 2800 21 3066 21 3350 21 3373 21 3240 Enterococci Labs Isolates 0 0 20 21 21 21 21 0 0 671 696 850 856 821 K. pneumoniae Labs Isolates 0 0 0 0 0 0 18 0 0 0 0 0 0 281 P. aeruginosa Labs Isolates 0 0 0 0 0 0 17 0 0 0 0 0 0 149 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 <1 1 6 <1 . . . . . . . . . . . . . . . . . . 2000 <1 2 3 <1 . . . . . . . . . . . . . . . . . . 2001 <1 3 5 <1 27 <1 4 <1 <1 . <1 75 . <1 . . . . . . . . 2002 <1 2 6 <1 25 <1 5 <1 1 . <1 75 . <1 . . . . . . . . 2003 <1 5 4 <1 28 1 7 <1 <1 17 <1 77 11 2 . . . . . . . . 2004 <1 3 5 <1 23 1 8 <1 <1 15 <1 78 7 1 . . . . . . . . 2005 <1 4 6 1 26 1 6 1 <1 19 <1 74 4 <1 1 5 1 9 5 18 <1 6 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 139 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=1972 n=3680 n=6372 data 2005, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=1159 %tot %VRE 100 0 71 29 0 6 1 23 70 0 0 . 0 0 . 0 0 0 0 . n=513 %tot %VRE 100 0 61 39 0 2 1 31 65 0 1 . 0 2 . 0 0 1 1 . n=281 %tot %CRKP 100 0 58 42 0 2 1 20 76 0 1 . 1 2 . 17 0 4 0 . P. aeruginosa n=57 %tot %CRPA 100 0 65 35 0 2 4 19 75 0 18 . 16 20 . 0 50 18 16 . 50 21 0 14 . Sweden providing denominator data Isolate source Blood 97 3 CSF 3 3 Labs providing denom.data/ Gender data to EARSS reporting Male 51 Hosps providing denom.data/ 4 Female 49 3 reporting data to EARSS Unknown 0 . Number of blood culture sets Age (years) Number of hospital beds 0-4 6 8 Patient-days 5-19 2 3 Average occupancy rate (%) 20-64 3 Median length of stay 40 (days) 65 and catchment population 3 over 52 Estimated Unknown 0 . % total population covered Hospital dep. Type of participating hospitals ICU 8 1 University/Tertiary 100 Total 1 0 . 63 37 0 4 4 32 60 0 100 0 7 . 8 6 . 2 13 9 6 . 20/21 1 47 1 45/59 53 . 188,2910 17,285 1 4,971,2291 0 83%1 1 24 5 1 74 6,388,281 . 71%0 6 0 5 7 0 8 5 6 0 11 18%4 Internal Med. 43 3 42 1 40 6 35 0 36 0 30 1 25 General/Secondary 82% Surgery 4 3 16 1 19 8 23 Figure 0 Geographic distribution 27 laboratories in 2005 27 1 0 16 Other 0% 1. of Other 45 4 36 1 37 8 35 0 28 1 36 3 49 Unknown 0 . number of isolates reported for the period 1999-2005 0 . 0 . 0 . 0 . 0 . 0 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 24 805 24 1320 0 0 0 0 0 0 0 0 2000 19 803 19 1478 0 0 0 0 0 0 0 0 2001 20 788 20 1633 20 2800 20 671 0 0 0 0 2002 21 830 21 1836 21 3066 21 696 0 0 0 0 2003 21 917 21 1855 21 3350 21 850 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 21 955 21 1906 21 3373 21 856 0 0 0 0 SE100C 0/23 2005 21 1017 no of21 1774: 21 21 3240 21 821 18 no of 281 149 SE110 0/39 SE110A 0/67 labs hospitals 17 56 : SE110B 0/10 Minimum : 0.0 Minimum : 0.0 SE120A 0/172 SE350 0/98 : 1st quartile : 0.0 SE120B 0/26 Antibiotic resistance from 1st quartile 2005 1.2 1999 to SE200A 0/166 Median : 3.2 Median : 0.0 SE200B 0/121 Table 3. Proportion of antibiotic non-susceptible isolates in:percent SE730 0/56 3rd quartile 5.0 3rd quartile : 0.7 SE200C 0/58 SE220A 0/73 Maximum : 9.3 Maximum : 5.8 Pathogen 1/123 Antimicrobial classes 1999 2000 SE220C 2001 2002 2003 2004 2005 SE400 0/17 0/6 SE220D S. pneumoniae Penicillin R <1 <1 SE230A 0/71 <1 <1 <1 <1 <1 SE610 1/86 SE230B 0/24 Penicillin I+R 1 2 SE240A 0/95 3 2 5 3 4 SE240B 0/24 SE310 1/83 Macrolides I+R 6 3 SE240C 0/45 5 6 4 5 6 SE250B 0/59 SE620 S. aureus 2/104 Oxacillin/Methicillin R <1 <1 SE300A 0/121 <1 <1 <1 <1 1 SE320B 0/25 E. coli Aminopenicillins R . . SE320C 0/11 27 25 28 23 26 SE450 2/93 SE350B 0/35 Aminoglycosides R . . SE350C 0/68 <1 <1 1 1 1 SE400C 0/24 SE430 2/69 Fluoroquinolones R . . SE430D 0/31 4 5 7 8 6 SE440A 0/126 SE220 2/68 3rd gen. Cephalosporins R . . SE440B 0/46 <1 <1 <1 <1 1 SE440C 0/33 SE450C 0/19 SE120 E. faecalis 5/157 Aminopenicillins I+R . . SE450D 0/17 <1 1 <1 <1 <1 PNSP at laboratory level MRSA at hospital level SE250 SE600 SE320 SE100 3/85 2/53 4/96 11/242 E. faecium K. pneumoniae SE230 2/40 SE240 4/79 SE540 P. aeruginosa 1/19 SE200 SE440 SE300 11/208 9/120 5/54 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . SE600C SE610B SE620A SE620B SE620C SE620D SE730A SE730B SE730C SE730D SE730E SE730F SE400A SE450A SE320A SE610A SE310A SE400B SE250A SE600A SE610C SE430A SE540A SE350A SE100A SE120C SE100B 0/13 0/23 0/147 0/7 0/38 0/10 0/40 0/15 0/16 0/7 0/18 0/66 1/153 1/143 1/115 1/106 2/171 1/82 1/71 2/119 1/54 3/136 1/43 2/80 7/236 1/29 7/121 . <1 75 . <1 . . . . . . . . . <1 75 . <1 . . . . . . . . 25 50 17 <1 77 11 2 . . . . . . . . 0 15 <1 78 7 1 . . . . . . . . 75 19 <1 74 4 <1 1 5 1 9 5 18 <1 6 100 140 Annex 2. Country Summary Sheets United Kingdom General Information about EARSS participating laboratories and hospitals Table 1. Reference data of 2004, based on laboratories/hospitals providing denominator data Total Labs providing denom.data/ reporting data to EARSS Hosps providing denom.data/ reporting data to EARSS Number of blood culture sets Number of hospital beds Patient-days Average occupancy rate (%) Median length of stay (days) Estimated catchment population % total population covered Type of participating hospitals University/Tertiary General/Secondary Other 20/57 21/89 168,733 12,684 2,804,193 81% 5 4,102,967 7% 14% 86% 0% Figure 1. Geographic distribution of laboratories in 2005 Table 2. Number of laboratories and number of isolates reported for the period 1999-2005 Year 1999 2000 2001 2002 2003 2004 2005 S. pneumoniae Labs Isolates 22 28 26 23 50 54 53 242 512 573 617 1334 1058 1373 S. aureus Labs Isolates 23 27 25 21 51 54 58 659 1492 1517 1703 3521 3560 3967 E. coli Labs Isolates 0 0 0 0 20 1424 20 1958 19 2253 20 2091 23 2359 Enterococci Labs Isolates 0 0 0 0 0 0 27 0 0 0 0 0 0 598 K. pneumoniae Labs Isolates 0 0 0 0 0 0 23 0 0 0 0 0 0 425 P. aeruginosa Labs Isolates 0 0 0 0 0 0 25 0 0 0 0 0 0 438 Antibiotic resistance from 1999 to 2005 Table 3. Proportion of antibiotic non-susceptible isolates in percent Pathogen S. pneumoniae Antimicrobial classes Penicillin R Penicillin I+R Macrolides I+R Oxacillin/Methicillin R Aminopenicillins R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R Fluoroquinolones R 1999 4 7 14 33 . . . . . . . . . . . . . . . . . . 2000 4 6 18 39 . . . . . . . . . . . . . . . . . . 2001 3 5 13 44 51 3 6 1 . . . . . . . . . . . . . . 2002 3 6 13 44 52 3 7 2 . . . . . . . . . . . . . . 2003 1 5 13 43 55 4 11 3 . . . . . . . . . . . . . . 2004 <1 3 13 44 53 6 14 3 . . . . . . . . . . . . . . 2005 2 4 11 44 56 8 17 6 2 47 2 84 53 33 6 12 12 2 3 9 3 8 S. aureus E. coli E. faecalis E. faecium K. pneumoniae P. aeruginosa Annex 2.Country Summary Sheets 141 Demographic characteristics Table 4. Selected details on invasive isolates from the reporting period 2004 and 2005 Characteristic S. pneumo. S. E. coli K. General Information aboutaureus EARSS participating E. faecalis laboratoriesE. faecium and hospitalspneumo. n=2431 n=7527 n=4096 data 2004, based on %MRSA %tot Table 1. Reference %tot of%PNSP %tot laboratories/hospitals%FREC n=314 %tot %VRE 100 0 64 36 0 9 1 33 57 0 2 . 2 1 . 0 0 2 2 . n=224 %tot %VRE 100 0 57 43 0 6 5 36 53 0 33 . 32 34 . 62 58 38 24 . n=300 %tot %CRKP 100 0 59 41 0 5 2 32 60 0 12 . 13 11 . 6 17 15 11 . P. aeruginosa n=358 %tot %CRPA 99 1 64 36 0 4 3 34 60 0 9 50 10 8 . 0 40 16 5 . . . . . 9 United Kingdom providing denominator data Isolate source Blood 98 4 CSF 2 4 Labs providing denom.data/ Gender data to EARSS reporting Male 52 Hosps providing denom.data/ 4 Female 47 3 reporting data to EARSS Unknown 1 Number of blood culture sets 8 Age (years) Number of hospital beds 0-4 13 1 Patient-days 5-19 5 8 Average occupancy rate (%) 20-64 3 Median length of stay 36 (days) 65 and catchment population 4 over 42 Estimated Unknown 3 1 % total population covered Hospital dep. Type of participating hospitals ICU 4 6 University/Tertiary 100 Total 44 0 . 62 37 1 4 3 37 52 4 100 0 16 . 19 13 . 7 7 18 15 . 20/57 45 44 41 21/89 55 37 168,7330 12,684 23 2,804,1933 15 81%1 36 26 5 52 69 4,102,967 46 7%0 9 64 . 0 . 0 . 0 . 0 14%0 Internal Med. 22 4 28 44 . 0 . 0 . 0 . 0 General/Secondary 86%0 Surgery 1 0 10 53 . 0 Figure 1. Geographic distribution of laboratories in 2005 . 0 . 0 . 0 Other 0%0 Other 38 3 40 37 0 . 0 . 0 . 0 . 0 Unknown 35 4 number of isolates reported for the period 1999-2005 13 42 100 16 100 2 100 33 100 12 100 Table 2. Number of laboratories and MRSA = Methicillin Resistant S. aureus Enterococci YearPNSP = Penicillin Non-Susceptible S. pneumonia aureus S. pneumoniae S. E. coli VRE = Vancomycin Resistant Enterococcus CRKP = 3rd gen. Cephalosporine Resistant K. pneumoniae Labs Isolates Labs Isolates Labs Isolates Labs Isolates FREC = Fluoroquinolone Resistant E. coli K. pneumoniae P. aeruginosa CRPA = Carbapenem Resistant P. aeruginosa Labs Isolates Labs Isolates 1999 22 242 23 659 0 0 0 0 0 0 0 0 2000 28 512 27 1492 0 0 0 0 0 0 0 0 2001 26 573 25 1517 20 1424 0 0 0 0 0 0 2002 23 617 21 1703 20 1958 0 0 0 0 0 0 2003 50 1334 51 3521 19 2253 0 0 0 0 0 0 Figure 2. Proportion (%) PNSP by laboratory (2004 & 2005) Figure 3. Proportion (%) MRSA by hospital (2004 & 2005) 2004 54 1058 54 3560 20 2091 0 0 0 0 0 0 UK007E 0/7 UK022 0/53 UK030A 2/84 2005 53 1373 no of58 3967: 52 23 2359 27 6/53 598 23 no of 425 438 UK030 0/39 UK055A labs hospitals 25 84 : UK078C 3/22 UK031 0/25 UK007C 3/20 Minimum : 0.0 Minimum : 0.0 UK069B 4/23 UK041 0/16 UK043B 8/38 : 1st quartile : 33.8 Antibiotic resistance from 1st quartile 2005 0.0 1999 to UK042 0/30 UK078B 3/14 UK064A 10/40 Median : 3.6 Median : 44.2 UK044 0/11 UK045A 95/372 Table 3. Proportion of antibiotic non-susceptible isolates in:percent UK081A 5/19 UK048 0/17 3rd quartile 5.3 3rd quartile : 53.0 UK060A 21/75 UK049 0/20 UK003B 2/7 Maximum : 28.6 Maximum : 80.0 UK012B UK050 Pathogen 0/39 Antimicrobial classes 1999 2000 2002 2/7 2003 2004 2005 UK054A 2001 34/119 UK053 0/29 UK043A 18/62 UK084E 4/13 UK054 0/33 S. pneumoniae Penicillin R 4 4 UK053D 3 3 32/101 1 <1 2 UK046A 16/49 UK057 0/28 UK038E UK059 0/40 Penicillin I+R 7 6 UK045B 5 6 5/15 5 3 4 3/9 UK081B 12/35 UK063 0/29 UK017A 26/75 UK078 0/24 Macrolides I+R 14 18 UK066A 13 13 35/99 13 13 11 UK027A 33/90 UK045 1/87 UK052A 21/57 35/92 S. aureus 1/74 Oxacillin/Methicillin R 33 39 UK057A 44 44 43 44 44 UK017 UK001A 26/68 UK007 3/205 UK013C 5/13 UK017B 104/266 E. coli Aminopenicillins R . . UK056A 51 52 55 53 56 UK051 1/63 52/133 UK070A 94/239 UK027 1/46 UK068B 120/301 Aminoglycosides R . . UK013A 3 3 4 6 8 UK008 1/45 62/153 UK007A 94/231 UK020 1/38 53/130 Fluoroquinolones R . . UK044A 6 7 11 14 17 UK055 1/37 UK038A 3/7 UK045C 3/7 UK068 2/71 116/270 3rd gen. Cephalosporins R . . UK026A 1 2 3 3 6 UK003A 7/16 UK033 1/30 UK084A 56/127 UK056 1/29 UK008A 19/43 19/43 E. faecalis 1/27 Aminopenicillins I+R . . UK069A . . . . 2 UK046 UK010A 16/36 PNSP at laboratory level MRSA at hospital level E. faecium K. pneumoniae P. aeruginosa UK038 UK013 UK010 UK015 UK026 UK069 UK070 UK023 UK003 UK047 UK032 UK005 UK012 UK066 UK084 UK001 UK060 UK052 UK004 UK011 UK081 UK043 UK064 UK090 UK077 3/79 2/48 1/23 4/90 1/22 2/44 2/43 3/64 1/20 6/120 4/79 7/132 6/113 1/18 3/47 2/30 2/29 1/14 4/52 2/24 2/23 4/45 4/45 0 HL Aminoglycosides R Glycopeptides R Aminopenicillins I+R HL Aminoglycosides R Glycopeptides R Aminoglycosides R Fluoroquinolones R 3rd gen. Cephalosporins R Piperacillin R Ceftazidime R Carbapenems R Aminoglycosides R 3/20 4/14 Fluoroquinolones R 25 50 . . . . . . . . . . . . . 75 100 . . . . . . . . . . . . . UK020A UK015A UK063A UK077A UK049A UK038C UK047A UK005A UK011A UK007B UK059A UK068A UK015B UK047B UK032B UK070B UK032A UK059B UK023A UK013B UK051A UK058A UK050A UK078A UK022A UK072A UK031A UK083A UK007D UK033A UK041A UK042A UK048A UK080A UK004A UK005B UK047C UK012A UK090A UK084B . . . . . . . . . . . . . 0 25 . . . . . . . . . . . . . 30/67 55/122 25/55 16/35 27/59 128/275 202/428 157/332 18/38 62/130 42/88 33/69 46/94 78/157 48/96 48/93 61/118 51/97 81/153 17/32 164/306 6/11 69/124 73/130 150/263 4/7 29/50 25/43 3/5 3/5 18/30 3/5 . . . . . . . . . . . . . 50 . . . . . . . . . . 12/18 . 24/36 10/14 10/14 . 5/7 106/142 36/48 . 8/10 75 47 2 84 53 33 6 12 12 2 3 9 3 8 100 142 Annex 3. Overview of antibiotic resistance in Europe, 2005 Annex 3. Overview of antibiotic resistance in Europe, 2005 Annex 3.1. The number (No) of invasive S. pneumoniae (SPN) isolates, and the proportion penicillin non-susceptible (PNSP), erythromycin non-susceptible (ENSP), single penicillin (PEN), single erythromycin (ERY) and dual resistant isolates, including 95% conﬁdence intervals (95CI) reported per country in 2005. Country No SPN isolates tested for PEN/ ERY 290/ 255 1539/ 1539 43/ 37 16/ 16 194/ 191 130/ 120 1081/ 1081 53/ 41 740/ 733 525/ 427 632/ 632 129/ 65 86/ 81 397/ 375 235/ 233 37/ 36 319/ 276 43/ 42 36/ 34 13/ 13 802/ 641 569/ 347 6/ 6 202/ 201 18/ 13 1017/ 924 208/ 208 8/ 5 1373/ 1328 10741/9900 % PNSP (95CI) 5 (3-9) 12 (10-14) 33 (20-49) 19 (5-46) 4 (2-8) 5 (2-10) 4 (3-6) 2 (0-11) 25 (22-28) 7 (5-9) 36 (33-40) 17 (11-25) 22 (14-33) 11 (8-15) 33 (27-40) 8 (2-23) 9 (6-13) 12 (4-26) 0 (0-12) 15 (3-46) 1 (1-2) 2 (1-4) 33 (6-76) 17 (12-23) 39 (18-64) 4 (3-5) 11 (7-16) 0 (1-40) 4 (3-5) 10 % PRSP (95 CI) 1 (0-3) 3 (2-4) 30 (18-46) 0 (1-24) 0 (0-2) 0 (0-4) 1 (0-2) 0 (0-8) 9 (7-12) 1 (0-2) 5 (3-7) 0 (0-4) 2 (0-9) 3 (1-5) 8 (5-13) 0 (0-12) 5 (3-8) 7 (2-20) 0 (0-12) 8 (0-38) 0 (0-1) 1 (0-2) 17 (1-64) 1 (0-4) 22 (7-48) 0 (0-1) 2 (1-5) 0 (1-40) 2 (1-2) 2 % ENSP (95CI) 15 (11-20) 31 (29-34) 8 (2-23) 13 (2-40) 2 (1-6) 17 (11-25) 6 (5-7) 0 (0-11) 23 (20-26) 20 (17-24) 41 (38-45) 17 (9-29) 37 (27-49) 12 (9-16) 15 (11-21) 17 (7-33) 31 (25-37) 24 (13-40) 3 (0-17) 46 (20-74) 11 (8-13) 16 (12-20) 33 (6-76) 19 (14-25) 31 (10-61) 6 (4-7) 11 (7-16) 40 (7-83) 11 (10-13) 18 %Single PEN(95CI) 3 (1-6) 3 (2-4) 30 (16-47) 6 (0-32) 3 (1-7) 1 (0-5) 4 (3-5) 2 (0-14) 11 (9-14) 1 (1-3) 4 (3-6) 14 (7-25) 5 (2-13) 8 (5-11) 23 (18-29) 0 (0-12) 4 (2-7) 0 (0-10) 0 (0-13) 15 (3-46) 0 (0-1) 1 (0-3) 17 (1-64) 6 (4-11) 23 (6-54) 3 (2-4) 7 (4-12) 0 (2-54) 3 (2-4) 4 %Single ERY(95CI) 13 (9-17) 23 (21-25) 0 (0-12) 0 (1-24) 2 (0-5) 13 (8-21) 5 (4-7) 0 (0-11) 10 (8-12) 15 (12-19) 9 (7-12) 8 (3-18) 21 (13-32) 9 (6-13) 5 (3-9) 8 (2-24) 25 (20-30) 12 (4-26) 3 (0-17) 46 (20-74) 10 (8-12) 14 (11-18) 17 (1-64) 8 (5-13) 0 (1-28) 5 (4-7) 8 (5-12) 40 (7-83) 10 (9-12) 11 % DUAL (95CI) 2 (1-5) 9 (7-10) 8 (2-23) 13 (2-40) 1 (0-3) 3 (1-9) 1 (0-1) 0 (0-11) 13 (11-16) 5 (3-8) 32 (28-36) 9 (4-20) 16 (9-26) 3 (1-5) 11 (7-16) 8 (2-24) 6 (4-10) 12 (4-26) 0 (0-13) 0 (1-28) 1 (0-2) 1 (1-4) 17 (1-64) 10 (7-16) 31 (10-61) 1 (0-2) 3 (1-7) 0 (2-54) 1 (1-2) 10 AT BE BG CY CZ DE DK EE ES FI FR HR HU IE IL IS IT LU LV MT NL NO PL PT RO SE SI SK UK Total Annex 3. Overview of antibiotic resistance in Europe, 2005 143 Annex 3.2. The number (No) of invasive Staphylococcus aureus (SAU) isolates, and the proportion resistant to methicillin (MRSA) including 95% conﬁdence intervals (95CI) reported per country in 2005. Country AT BE BG CY CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LU LV MT NL NO PL PT RO SE SI SK UK Total No SAU isolates 1471 1048 160 54 1553 874 1350 141 1337 790 3483 681 354 527 1360 546 77 1431 83 125 78 1401 501 197 1153 83 1774 349 147 3967 27095 % MRSA 13% 31% 31% 56% 13% 21% 2% 2% 27% 3% 27% 42% 37% 19% 42% 41% 0% 37% 13% 20% 55% 1% 1% 24% 47% 61% 1% 10% 19% 44% 25 95CI (12-15) (29-34) (24-38) (41-69) (11-15) (19-24) (1-3) (1-7) (25-30) (2-4) (26-29) (38-46) (32-43) (16-23) (39-44) (37-46) (0-6) (35-40) (7-23) (14-28) (43-66) (1-2) (0-2) (19-31) (44-50) (50-72) (1-2) (7-14) (13-27) (42-45) 144 Annex 3. Overview of antibiotic resistance in Europe, 2005 Annex 3.3. The number (No) of invasive E. faecalis and E. faecium isolates, and the proportion high level aminoglycoside resistant E. faecalis, and vancomcyin resistant E. faecium (%R) including 95% conﬁdence intervals (95CI) reported per country in 2005. High level aminoglycoside resistant E. faecalis Country AT BE BG CZ DE EE ES FI FR GR HR HU IE IL IS IT LU NL NO PL PT RO SE SI SK UK Total No 149 136 55 423 97 42 473 133 767 448 86 192 240 207 20 433 17 216 119 33 288 4 492 89 25 32 5216 %R (95CI) 28 (21-36) 26 (19-35) 24 (14-37) 45 (40-50) 34 (25-44) 50 (34-66) 36 (32-40) 27 (20-36) 15 (13-18) 54 (49-58) 31 (22-42) 40 (33-47) 42 (36-49) 43 (36-50) 0 (0-20) 38 (34-43) 24 (8-50) 38 (32-45) 32 (24-41) 48 (31-66) 38 (32-44) 50 (9-91) 19 (15-22) 46 (36-57) 40 (22-61) 47 (30-65) 34 Vancomycin resistant E. faecium No 171 43 28 211 256 23 141 94 194 227 34 46 220 71 9 193 14 188 57 20 95 10 253 30 3 224 2855 %R (95CI) 1 (0-5) 14 (6-29) 0 (0-15) 14 (10-19) 10 (7-14) 0 (0-18) 3 (1-8) 0 (0-5) 2 (1-6) 37 (31-44) 6 (1-21) 0 (0-10) 31 (25-38) 46 (35-59) 0 (1-37) 19 (14-25) 0 (1-27) 1 (0-3) 0 (0-8) 5 (0-27) 34 (25-44) 0 (1-34) 1 (0-3) 0 (0-14) 0 (3-69) 33 (27-40) 14 Annex 3. Overview of antibiotic resistance in Europe, 2005 145 Annex 3.4. The number of invasive Escherichia coli isolates (No), and the proportion aminopenicillins, third generation cephalosporins, ﬂuoroquinolones, aminoglycosides and multi-resistance (%R) including 95% conﬁdence intervals (95CI) reported per country in 2005. Aminopenicillins Country AT BE BG CY CZ DE DK EE ES FI FR GR HR HU IE IL IS IT LU MT NL NO PL PT RO SE SI SK UK Total No 2050 1579 189 74 2234 1014 1283 151 2995 1519 5722 1039 637 510 1422 824 128 1176 188 87 2137 1233 176 1171 79 1904 656 97 1987 Fluoroquinolones third Cephalosporins 2046 1577 203 74 2233 1012 957 155 2997 1918 5835 1139 637 510 1404 938 130 1191 188 87 1890 1236 176 1076 80 3198 657 97 1892 4 (3-5) 4 (3-5) 28 (22-35) 16 (9-27) 2 (2-3) 2 (1-3) 1 (1-2) 1 (0-5) 8 (7-9) 2 (1-2) 1 (1-2) 7 (6-9) 1 (0-2) 2 (1-4) 4 (3-5) 10 (8-12) 0 (0-4) 8 (7-10) 3 (1-7) 1 (0-7) 2 (2-3) 1 (0-2) 5 (2-9) 12 (10-14) 16 (9-27) 1 (1-2) 2 (1-3) 8 (4-16) 6 (5-8) Aminoglycosides Multi-resistance* % R (95CI) 1 (1-2) 0 (0-1) 16 (12-22) 4 (1-13) 1 (1-2) 0 (0-1) 1 (0-2) 1 (0-4) 3 (2-3) 1 (1-2) 0 (0-1) 2 (2-3) 0 (0-1) 2 (1-3) 1 (1-2) 6 (5-8) 0 (0-4) 4 (3-6) 2 (0-5) 0 (0-5) 1 (0-1) 0 (0-1) 3 (1-7) 8 (6-9) 3 (0-10) 0 (0-1) 1 (1-3) 3 (1-9) 2 (2-3) % R (95CI) No 48 (46-51) 53 (50-55) 69 (62-75) 73 (61-82) 50 (48-52) 54 (51-57) 39 (36-42) 45 (37-53) 62 (60-64) 35 (33-37) 50 (49-51) 46 (43-49) 46 (42-49) 50 (45-54) 67 (64-69) 66 (62-69) 38 (29-47) 55 (52-58) 49 (42-56) 49 (39-60) 48 (46-50) 33 (31-36) 56 (49-64) 58 (55-61) 77 (66-86) 26 (24-28) 42 (38-46) 59 (48-69) 56 (54-58) 2049 1461 196 72 2233 1012 758 151 2993 1743 6028 1136 637 468 1411 942 117 1094 188 87 2139 1217 176 1086 75 3035 657 132 2127 % R (95CI) No 19 (18-21) 17 (15-19) 29 (22-36) 29 (19-41) 20 (19-22) 23 (21-26) 5 (3-6) 5 (2-11) 28 (27-30) 7 (6-9) 11 (10-12) 12 (10-14) 9 (7-11) 20 (16-24) 17 (15-19) 23 (20-26) 3 (1-9) 28 (26-31) 19 (13-25) 30 (21-41) 10 (9-11) 5 (4-6) 20 (14-27) 29 (27-32) 8 (3-17) 6 (5-7) 12 (10-15) 14 (9-22) 17 (15-19) % R (95CI) No 2053 1274 203 74 2234 1014 1283 156 2996 1760 6056 1140 637 513 1414 943 130 1097 188 87 2187 1236 175 1170 80 3188 657 134 2055 % R (95CI) No 5 (5-7) 4 (3-5) 24 (18-30) 14 (7-24) 6 (5-7) 6 (5-8) 2 (1-3) 4 (2-9) 10 (9-11) 2 (2-3) 5 (4-5) 7 (6-9) 5 (3-7) 7 (5-10) 7 (6-9) 15 (12-17) 1 (0-5) 11 (10-13) 7 (4-12) 7 (3-15) 4 (3-5) 2 (1-3) 7 (4-13) 12 (11-15) 14 (7-24) 1 (1-2) 4 (3-6) 7 (4-14) 8 (7-10) 2036 1207 196 72 2233 1006 587 150 2992 1575 5808 1136 637 466 1392 937 117 1090 188 87 1882 1213 175 1039 75 2991 657 97 1689 34261 50 35420 15 35533 4 36134 6 33730 2 * Multi-resistance was deﬁned as being resistant to ﬂuoroquinolones, third generation cephalosporins, and aminoglycosides irrespective of aminopenicillins susceptibility 146 Annex 3. Overview of antibiotic resistance in Europe, 2005 Annex 3.5. The number of invasive Klebsiella pneumoniae isolates (No), and the proportion aminopenicillins, third generation cephalosporins, ﬂuoroquinolones, aminoglycosides, carbapenems and multi-resistance (%R) including 95% conﬁdence intervals (95CI) reported per country in 2005. Aminopenicillins Coun- No try AT BG CY CZ DE EE ES FI FR GR HR HU IE IL IS IT MT NL NO PL SE SI UK 89 31 9 476 112 37 56 100 792 640 111 141 42 296 22 324 17 301 173 53 145 78 364 Fluoroquinolones Third generation Cephalosporins %R (95CI) 11 (6-20) 26 (14-45) 22 (4-60) 38 (34-43) 5 (2-12) 0 (0-11) 11 (4-23) 3 (1-8) 7 (6-9) 54 (51-58) 18 (12-27) 25 (18-33) 3 (0-15) 30 (25-36) 0 (0-19) 11 (8-15) 11 (2-36) 6 (3-9) 1 (0-5) 34 (22-48) 5 (2-8) 14 (8-24) 12 (9-16) No 88 34 9 478 112 37 56 175 824 774 112 140 42 330 22 243 18 256 174 53 281 78 300 %R (95CI) 6 (2-13) 50 (33-67) 33 (9-69) 32 (28-37) 6 (3-13) 8 (2-23) 7 (2-18) 2 (1-6) 4 (3-6) 61 (57-64) 46 (36-55) 31 (24-40) 7 (2-21) 38 (33-43) 0 (0-18) 20 (16-24) 6 (0-29) 4 (2-7) 1 (0-5) 66 (52-78) 1 (0-4) 19 (12-30) 12 (9-17) Aminoglycosides Carbapenems No 89 34 9 477 112 38 56 150 838 773 112 142 42 331 22 318 18 300 174 53 279 78 395 %R (95CI) 3 (1-10) 53 (35-70) 11 (1-49) 36 (32-41) 9 (5-16) 8 (2-22) 4 (1-13) 3 (1-7) 5 (4-7) 60 (56-63) 38 (29-47) 30 (23-39) 5 (1-17) 36 (31-42) 0 (0-18) 8 (6-12) 17 (4-42) 5 (3-8) 2 (1-6) 57 (42-70) 1 (0-4) 17 (10-27) 6 (4-9) No 80 30 9 44 110 26 54 131 753 773 112 133 26 331 21 0 18 230 159 33 16 44 275 %R (95CI) 0 (0-6) 0 (0-14) 0 (1-37) 0 (0-10) 2 (0-7) 0 (0-16) 0 (0-8) 0 (0-4) 0 (0-1) 28 (25-31) 0 (0-4) 0 (0-3) 0 (0-16) 0 (0-2) 0 (0-19) 0 (1-22) 0 (0-2) 1 (0-4) 0 (0-13) 0 (0-24) 0 (0-10) 0 (0-2) Multi-resistance* No 87 34 9 477 111 37 56 130 824 772 110 123 40 330 21 317 18 255 172 53 263 78 280 %R (95CI) 1 (0-7) 21 (9-38) 11 (1-49) 17 (14-21) 3 (1-8) 0 (0-12) 4 (1-13) 2 (1-7) 2 (1-4) 46 (42-49) 15 (9-23) 22 (15-30) 0 (0-11) 24 (20-29) 0 (0-19) 3 (1-6) 0 (0-22) 2 (1-5) 0 (0-3) 26 (16-41) 0 (0-2) 12 (6-21) 6 (3-9) % R (95CI) No 94 (87-98) 97 (81-100) 100 (63-99) 98 (97-99) 95 (88-98) 92 (77-98) 82 (69-91) 95 (88-98) 98 (97-99) 95 (93-97) 99 (94-100) 100 (97-100) 98 (86-100) 98 (96-99) 100 (82-100) 87 (83-91) 88 (62-98) 98 (95-99) 98 (94-99) 96 (86-99) 64 (56-72) 96 (88-99) 96 (94-98) 88 34 9 478 113 38 56 155 838 772 110 126 40 331 21 318 18 290 172 53 265 78 372 Total 4409 95 4775 22 4436 24 4840 23 3408 7 4597 15 * Multi-resistance was deﬁned as being resistant to ﬂuoroquinolones, third generation cephalosporins, and aminoglycosides irrespective of aminopenicillins susceptibility Annex 3. Overview of antibiotic resistance in Europe, 2005 147 Annex 3.6. The number of invasive Pseudomonas aeruginosa isolates (No), and the proportion piperacillin (+/- tazobactam), ceftazidime, carbapenems, ﬂuoroquinolones, aminoglycosides resistance (%R) including 95% conﬁdence intervals (95CI) reported per country in 2005. Piperacillin+/Tazobactam Country AT BG CY CZ DE EE ES FI FR GR HR HU IE IL IS MT NL NO PL RO SE SI UK Total No 77 34 8 257 126 37 70 108 929 698 72 226 28 213 13 45 184 75 26 23 22 38 349 3658 13 (7-23) 50 (33-67) 13 (1-53) 21 (16-26) 17 (11-25) 27 (14-44) 4 (1-13) 8 (4-16) 15 (12-17) 30 (27-34) 25 (16-37) 12 (9-18) 7 (1-25) 13 (9-18) 8 (0-38) 22 (12-37) 4 (2-9) 3 (0-10) 50 (30-70) 61 (39-80) 9 (2-31) 21 (10-38) 2 (1-4) 19 Ceftazidime Carbapenems Fluoroquinolones Aminoglycosides % R (95CI) 6 (2-15) 53 (35-70) 13 (1-53) 28 (22-34) 13 (8-21) 28 (15-45) 4 (1-13) 11 (6-19) 22 (19-24) 40 (36-44) 35 (24-47) 32 (27-39) 7 (1-25) 23 (18-30) 0 (1-28) 16 (7-30) 7 (4-11) 0 (0-5) 56 (35-75) 64 (41-82) 0 (0-3) 18 (8-35) 3 (2-6) 21 % R (95CI) No 76 33 8 257 123 38 70 108 905 662 71 237 29 168 13 45 209 89 26 23 149 38 376 3753 % R (95CI) No 7 (2-15) 45 (29-63) 38 (10-74) 40 (34-46) 11 (6-18) 18 (8-35) 6 (2-15) 5 (2-11) 9 (7-11) 27 (24-31) 6 (2-15) 11 (7-15) 10 (3-28) 17 (12-23) 8 (0-38) 11 (4-25) 5 (3-9) 3 (1-10) 31 (15-52) 52 (31-73) 5 (2-10) 11 (3-26) 3 (2-6) 16 77 32 8 257 127 37 70 99 984 698 72 231 27 215 13 45 187 80 26 23 57 38 358 3761 % R (95CI) No 10 (5-20) 38 (22-56) 13 (1-53) 31 (26-37) 24 (17-32) 38 (23-55) 17 (10-28) 15 (9-24) 14 (12-17) 39 (35-42) 24 (15-35) 17 (13-23) 11 (3-30) 15 (11-21) 8 (0-38) 18 (9-33) 5 (2-9) 4 (1-11) 27 (12-48) 61 (39-80) 18 (9-30) 13 (5-29) 9 (7-13) 20 77 34 8 256 125 37 70 96 985 694 71 181 29 215 13 45 200 89 26 22 133 38 412 3856 % R (95CI) No 13 (7-23) 47 (30-65) 13 (1-53) 45 (39-52) 19 (13-27) 14 (5-30) 14 (7-25) 16 (9-25) 27 (24-29) 39 (36-43) 34 (23-46) 26 (20-33) 14 (5-33) 25 (20-32) 0 (1-28) 44 (30-60) 9 (6-14) 4 (1-12) 31 (15-52) 64 (41-82) 6 (3-12) 29 (16-46) 8 (6-11) 24 77 34 8 230 127 36 70 100 971 696 72 238 28 215 13 45 210 89 25 22 149 38 394 3887