Antimicrobial Susceptibility Studies
Resistance surveillance program report for selected European nations (2011)

https://doi.org/10.1016/j.diagmicrobio.2013.10.008Get rights and content

Abstract

In the European component of the Regional Resistance Surveillance study for 2011, a total of 21 countries were monitored for antimicrobial resistance patterns including Belgium, Bulgaria (BU), Croatia, Czech Republic, France (F), Germany (GE), Greece (GR), Ireland (IR), Israel (IS), Italy (IT), Poland (PO), Portugal (PT), Romania (RO), Russia (RU), Slovakia (SK), Slovenia, Spain, Sweden (SW), Turkey (T), Ukraine, and United Kingdom. Results from testing 12,572 strains (100 [BU] to 1535 [F] per nation) were interpreted by contemporary published breakpoints. Samples from 47 hospitals were reference tested against agents such as amikacin (AMK), cefoperazone/sulbactam (C/S), colistin (COL), levofloxacin, linezolid (LZD), tigecycline (TIG), vancomycin (VAN), and 21 others. Among Staphylococcus aureus, LZD (MIC90, 2 μg/mL), TIG (MIC90, 0.12 μg/mL), and VAN (MIC90, 1 μg/mL) exhibited complete coverage and methicillin resistance rates among nations (average, 31%) ranged from 0.9% (SW) to 60.0–60.2% (PT, SK). Seven LZD-resistant coagulase-negative staphylococci (only 1.1% resistance overall) were noted in 5 nations, and a Staphylococcus simulans strain (MIC, 8 μg/mL from RO) had L3 mutations (N130D, G152A, F147S, A157R); also 6 LZD-resistant enterococci were detected in 3 countries (GE, IR, T). VAN-resistant enterococci (10% overall; 84% VanA) were found in 14 countries, highest in GE and IR (23.0%). The ESBL phenotype rate for Escherichia coli was 20.1% (range, 0.9% [SW] to 70.0–89.7% [BU, RU]), best inhibited by COL (100.0% S), TIG (100.0%), AMK (83.3–94.1%), C/S (81.0%), and carbapenems (>99.0%; resistant strains in IS and T). Klebsiella spp. had greater ESBL rates (45.7% overall, range 2.5–100.0%), as well as carbapenem resistance (8.3% overall, greatest in BU, GR, IS, IT, PO, RO, RU, T). Non-fermentative Gram-negative bacilli (Pseudomonas aeruginosa, Acinetobacter [ACB]) were generally less susceptible, except against COL (99.2–99.6% S) and TIG (95.0% inhibited at ≤2 μg/mL; ACB only). The following carbapenemases were detected: VIM-1 (2 countries); IMP-1 (1 from T); KPC-2 or -3 (2 countries); VIM-4 (1 from PO), NDM-1 (2 in RO; 2 centers); and OXA-48 or -162 (5 from T; 2 centers). European surveillance sampling demonstrates a wide array of resistant isolates, less prevalent among Gram-positive cocci that remain inhibited by several available agents. However, beta-lactamase–mediated mechanisms have spread widely among Gram-negative bacilli, especially across the Eastern and Southern European nations, severely limiting infection chemotherapy and necessitating escalated antimicrobial stewardship.

Introduction

Bacterial strains resistant to commonly used β-lactams, fluoroquinolones, and other antimicrobial agents remain a significant challenge to successful chemotherapy in both developed and developing nations (Rice, 2012). β-lactamase–mediated resistances among Gram-negative bacilli (Bonnet, 2004, Castanheira et al., 2008, Castanheira et al., 2011, Kumarasamy et al., 2010, Rolain et al., 2010) and the expansion of Gram-positive resistant species (methicillin-resistant Staphylococcus aureus [MRSA], vancomycin [VAN]–resistant enterococci [VRE], multidrug-resistant [MDR] Streptococcus pneumoniae) present the most critical compromises to favorable patient outcomes (Sader et al., 2010, Sader et al., 2011, Woodford and Livermore, 2009).

To address these concerns, a structured antimicrobial surveillance program was organized for 2011 to 1) sample key pathogens by nation in the European area, especially Eastern areas; 2) use reference quantitative susceptibility testing methods (Clinical and Laboratory Standards Institute [CLSI]) in a central monitoring laboratory design; and 3) offer a wide range of tested antimicrobials, usually more than 20 agents. These program results can then be compared to other regional or national surveillance programs that utilize available “non-reference” (convenience samples), often commercial categorical (not quantitative) results (Bolmstrom et al., 2002, Castanheira et al., 2008, Castanheira et al., 2011, Flamm et al., 2013, Rodloff et al., 2008, Sader et al., 2010, Sader et al., 2011). The categorical susceptible breakpoint definitions may vary as well as the quality/accuracy of the method (Clinical and Laboratory Standards Institute (CLSI), 2013, EUCAST, 2013); therefore, structured programs such as this Regional Resistance Surveillance (RRS) Study offers expanded, validating information for other programs such as the European Antimicrobial Resistance Surveillance Network (EARS-Net) (2011) of the European Antimicrobial Resistance Surveillance System especially for Eastern Europe and Mediterranean nations.

In the European component of RRS, 21 nations were monitored in 2011 (12,572 isolates), enabling comparison of numerous drugs to that data generated by the EARS-Net (2011) and other published program information.

Section snippets

Nations and organisms monitored

A total of 21 countries (47 sites, 97–492 strains/site) were sampled with a target of ≥200 isolates of specific species per nation. The organisms were isolated from a wide variety of clinical infection types/sites including respiratory tract (26.3%), acute bacterial skin and skin structure (17.2%), and bacteremias (26.3%). The countries (sample size) were: Belgium (492), Bulgaria (BU; 100), Croatia (200), Czech Republic (447), France (F; 1535), Germany (GE; 756), Greece (GR; 418), Ireland (IR;

Antimicrobial profiles of Gram-positive pathogens (Table 1)

S. aureus isolates (2413; 31.3% MRSA overall) exhibited complete (100.0%) susceptibility to LZD (MIC50/90, 1/2 μg/mL), teicoplanin (MIC50/90, ≤2/≤2 μg/mL; data not shown), TIG (MIC50/90, 0.06/0.12 μg/mL), and VAN (MIC50/90, 1/1 μg/mL). Highest MRSA rates (≥50.0%) occurred in Eastern nations (PO, RO, RU, SK, Ukraine) and PT, range 50.0–60.0%. Rarer non-susceptibility to daptomycin (0.1%; strains from Croatia, GE, GR, and T), doxycycline (0.7–5.7%), and trimethoprim/sulfamethoxazole (TMP/SMX;

Conclusions

In this study, resistances in Gram-positive pathogens across Europe remain common, particularly among S. aureus (MRSA) and CoNS, but some agents still have high potencies (LZD, daptomycin, and glycopeptides) (Bolmstrom et al., 2002, Flamm et al., 2013, Sader et al., 2011). Enterococcal resistance (VRE at 9.2–10.1%) was rare for LZD and daptomycin and not increasing, but some isolates were detected confirming epidemic clones emerging in some institutions (Mendes et al., 2010). Ceftriaxone

Acknowledgments

The co-authors wish to thank the other participants/sites for contributing the isolates and especially University Hospital Antwerp, Antwerp, Belgium (Dr H. Goossens); Alexander University Hospital, Sofia, BU (Dr B. Markova); Clinical Hospital Center, Zagreb, Croatia (Dr V. Plecko); University Hospital, Brno, Czech Republic (Dr M. Hanslianova); Meir Medical Center, Kfar Saba, IS (Dr Y. Paitan); Rambam Medical Center, Haifa, IS (Dr H. Sprecher); National Medicines Institute, Warsaw, PO (Drs W.

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