Post on 26-May-2020
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Project No. 115737
ND4BB COMBACTE-MAGNET
Combatting Bacterial Resistance in Europe
Deliverable Report
WP2: D2.3: Results of systematic reviews
Due date 13.01.2017
Delivery date 16.01.2017
Deliverable type1 Report
Dissemination level1 PU
Description of Work Version Date
V2.0 29June2016
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Lead contributors
Evelina Tacconelli (7-EKUT) Evelina.Tacconelli@med.uni-tuebingen.de Jesús Rodrigues Baño (9-SAS) jesusrb@us.es
Andreas Voss (8-RUNMC) andreas.voss@radboudumc.nl
Frangiscos Sifakis (1-AZ) Frangiscos.Sifakis@astrazeneca.com
Other contributors María Núñez-Núñez (9-SAS)
María Dolores Navarro (9-SAS)
Virginia Palomo (9-SAS)
Remco Schrijver (8-RUNMC)
Nithya Babu Rajendran (7-EKUT)
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TABLE OF CONTENTS
1. Summary.......................................................................................................................................... 5
2. Surveillance Systems for Antimicrobial Resistance and Healthcare-Associated Infections in Europe (SUSPIRE): A Systematic Review ................................................................................................. 6
Introduction ............................................................................................................................................. 6
Methods .................................................................................................................................................. 7
Results ..................................................................................................................................................... 8
3. A systematic review of SURVeillance programs for Antimicrobial resistance In Livestock and meat thereof in the European Union (SURVAIL) ................................................................................... 67
Introduction ........................................................................................................................................... 67
Materials and Methods ......................................................................................................................... 67
Results ................................................................................................................................................... 68
4. EpideMiology and control measures of outBreaks due to Antibiotic-Resistant orGanisms in EurOpe (EMBARGO): a systematic review protocol .............................................................................. 78
Introduction ........................................................................................................................................... 78
Materials and Methods ......................................................................................................................... 79
Results ................................................................................................................................................... 81
5. Discussion .................................................................................................................................... 103
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ABBREVIATIONS
AMR Antimicrobial resistance ARB Antimicrobial-resistant bacteria CI Cumulative incidence CR Carbapenem resistance CR-AB Carbapenem-resistant / carbapenemase-producing Acinetobacter baumannii CR-EC Carbapenem-resistant / carbapenemase-producing Escherichia coli CR-KP Carbapenem-resistant / carbapenemase-producing Klebsiella pneumoniae CR-PA Carbapenem-resistant / carbapenemase-producing Pseudomonas aeruginosa CZ-AB Ceftazidime-resistant Acinetobacter baumannii CZ-EC Ceftazidime-resistant Escherichia coli CZ-PA Ceftazidime-resistant Pseudomonas aeruginosa ECDC European Centre for Disease Control and Prevention EEA European Economic Area EFSA European Food Safety Authority EFTA European Free Trade Association EMA European Medicines Agency ESBL Extended-spectrum beta-lactamase ESBL-KP ESBL producing-Klebsiella pneumoniae ESBL-AB ESBL producing - Acinetobacter baumannii ESBL-EC ESBL producing - Escherichia coli ESBL-PA ESBL producing -Pseudomonas aeruginosa ESCMID European Society of Clinical Microbiology and Infectious Diseases ESICM European Society of Intensive Care Medicine EU European Union EUCAST European Committee on Antimicrobial Susceptibility Testing EUCIC European Committee on Infection Control GN Gram Negative GISA Glycopeptide Intermediate Staphylococcus aureus HAI Health-care associated infection HCF Healthcare facilities ID Incidence density IEA International Epidemiological Association ISID International Society for Infectious Diseases MDR Multi-drug resistant MRSA Methicilin Resistant Staphylococcus aureus MS Member States PRISMA Preferred Reporting Items for Systematic Reviews and Meta-analyses RT Real time VRE Vancomycin Resistant Enterococci VRSA Vancomycin Resistant Staphylococcus aureus WHO World Health Organization
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1. Summary
Surveillance of healthcare-associated infections and antimicrobial resistance are essential to
providing the evidence for development and monitoring of appropriate antibiotic guidelines and
stewardship, public health interventions, infection control policies, and therapeutic or preventive
research and development. In order to define areas for improvement of surveillance, the EPI-Net
consortium performed two systematic reviews focused on the current status of surveillance systems
in humans (SUSPIRE) and in animals and food (SURVAIL) in European countries. Given that current
surveillance systems do not include data from outbreaks, a third review (EMBARGO) was conducted
and it focused on major epidemiological characteristics of bacterial outbreaks caused by
antimicrobial-resistant strains in European countries. The SUSPIRE review summarises the
characteristics of 56 national and international surveillance systems in Europe. Key results from this
study indicate substantial weaknesses and heterogeneity among national surveillance systems,
particularly for antimicrobial surveillance, with insufficient reporting of relevant epidemiological,
clinical, and health outcome data. The SURVAIL review reports data from 15 national and
international surveillance systems and shows the lack of coordination between human and
animal/food data in case of antibiotic resistance surveillance. Finally, the EMBARGO review reports
epidemiological data on 430 oubreaks and highlights high risk settings (e.g., neonatal intensive care
units, immunocompromised patients) and microorganisms associated with significant clinical burden
(e.g., carbapenem-resistant gram-negative).
The detailed objectives, methodologies, results and conclusions drawn from these reviews are
presented individually in this deliverable report.
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2. Surveillance Systems for Antimicrobial Resistance and Healthcare-
Associated Infections in Europe (SUSPIRE): A Systematic Review
Authors
María Núñez-Núñez, María Dolores Navarro, Virginia Palomo, Nithya Babu Rajendran, Panagiota
Gkolia, María Dolores del Toro, Andreas Voss, Mike Sharland, Frangiscos Sifakis , Evelina Tacconelli,
Jesús Rodríguez-Baño
(Study protocol under review for publication)
Introduction
Surveillance of healthcare-associated infection (HAI) and antimicrobial resistance (AMR) are key parts
of all public health efforts to reduce the spread of antimicrobial-resistant pathogens and have been
traditionally used in healthcare systems to detect new patterns of resistance and outbreaks,
prioritise resources, define local guidelines, and provide therapeutic and infection control feedback
(Zingg et al., 2015). More recently, surveillance data are being increasingly used for benchmarking
and public reporting (Haustein et al., 2011). However, methodological heterogeneity and inadequate
control of confounders and data quality significantly lower the applicability of data from existing
surveillance systems for these purposes. In 2008, the European Centre for Disease Control and
Prevention (ECDC) reviewed the surveillance protocols/modules implemented by national or regional
networks for the purpose of HAI surveillance in European Union countries (ECDC, 2008) and
emphasised the presence of significant heterogeneity. Subsequently, in 2009, the European Council
recommended the establishment and/or strengthening of active surveillance systems at national or
regional level (EU council, 2009). As part of this effort, the ECDC implemented two major projects: in
2008 the HAI-net, a network of national/regional networks collecting surveillance data across
Europe, including specific modules on surgical site infections (SSIs), infections in intensive care units
(ICUs), Clostridium difficile and point prevalence surveys (PPS) in acute care and long term care
facilities, and in 2010 the European Antimicrobial Resistance Surveillance (EARS)-net. The
establishment of these networks has substantially reduced the differences in reporting among the
European countries and ECDC provides regular, standardised outcome measures of HAIs amd AMR
rates in Europe. However, very little information is available on the situation of surveillance systems
reporting national data at a local level.
The objectives of this review were to catalogue all active surveillance systems in European countries
or regions and to define methodology and indicators used for reporting HAIs and AMR rates.
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Methods
A systematic scientific and grey literature search and review of surveillance systems for HAI and/or
AMR developed by official institutions in European countries/regions or endorsed by them was
performed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)
guideline (Shamseer et al., 2015) was followed.
Information sources and searching strategies
Three strategies were applied. First, a systematic search of peer-reviewed literature (PubMed,
EMBASE and Scopus) and references from the retrieved articles was done. Second, a comprehensive
search of grey literature, including Google search engine and targeted websites of ministries of
health, healthcare services, institutes of public health, ECDC, World Health Organization (WHO),
scientific societies in the field e.g. the European Society of Clinical Microbiology and Infectious
Diseases (ESCMID); the International Society for Infectious Diseases (ISID); the International
Epidemiological Association (IEA); the European Society of Intensive Care Medicine (ESICM) and the
European Respiratory Society (ERS) was performed. The search strategy used for grey literature
included the combination of the following terms in English and the local languages in European
countries: "Antimicrobial resistance" AND/OR "Hospital-associated" OR "Hospital-acquired" OR
"Nosocomial" AND "Surveillance" AND "epidemiology" OR "prevalence" OR "incidence". The time
period was until October 31, 2016. Third, national representatives of the European Committee on
Infection Control (EUCIC) of ESCMID were consulted.
Eligibility criteria
We targeted 32 European countries, including the 28 European Union member states and 4 countries
from the European Free Trade Association (EFTA) Iceland, Liechtenstein, Norway and Switzerland. A
HAI or AMR surveillance system was defined as a structured and systematic procedure to measure
the prevalence or incidence of HAI and/or AMR, performed continuously or periodically, with a
defined methodology and specified indicators. The surveillance systems were included if fulfilling the
following criteria: data were reported for at least one year from 2006; the methodology used was
publicly available for review; human data from European countries were included; and the system
was promoted or endorsed by a regional, national or transnational official health organisation or
scientific society. Surveillance systems referring their methodology to transnational systems (like
those promoted by ECDC) were included if protocols were publicly available.
The following surveillance systems were excluded for this review: systems exclusively
declaring/notifying individual cases of a specific disease or pathogen (e.g., compulsory reporting of
individual cases without denominators); systems providing only animal, environmental or food data
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(included in the second review in this deliverable report); surveillance data promoted by private
companies; studies not including continuous or periodic surveillance; and outbreaks reports
(included in the third review in this deliverable report). Potentially eligible surveillance systems for
which the methodology was not publicly available were excluded. Regional systems using the same
methodology as national systems were also excluded from the analyses to avoid duplicities.
Three independent reviewers (MNN, MDN and NBR) performed a two-step selection process. Titles
and abstracts of the retrieved documents were initially assessed and non-relevant documents
excluded. For data from grey literature, executive summaries, table of contents and documents
(whichever was available) were screened. The full text of potentially eligible documents were then
obtained and assessed for relevance or duplication against predefined selection criteria. When
available, national experts were contacted to clarify protocol details.
Data extraction
Data extraction was performed using a tailored, pilot-tested electronic data extraction form. Periodic
quality controls were performed and disagreements resolved by review and consensus with other co-
authors (JRB, ET and PG).
The data collected included: objective of the surveillance system, population covered, modality of
reporting, quality audit, and dates of the information available. For systems reporting AMR: type of
sampling, type of infections, pathogens, antibiotics tested, patients’s clinical data and outcome. For
systems reporting HAIs in intensive care units (ICUs): target device related-infections (central line-
associated bloodstream infections [CLABSI], ventilator-associated pneumonia [VAP] and catheter-
associated urinary tract infection [CAUTI]) and relevant patients’s clinical data and outcome. For
systems reporting surgical site infections: data on type of interventions (coronary artery bypass
grafting [CABG], cardiac valve replacement [CVAL], cholecystectomy [CHOL], colon surgery [COLO],
caesarean section [CSEC], hip prosthesis [HPRO], knee prosthesis [KPRO] and laminectomy [LAM]),
antibiotic prophylaxis, and procedure indicators were extracted. Variables for which information was
not specified or was not available were noted down as “not reported/unknown”.
We did not seek ethical approval for this study because data collected is not linked to individuals.
Results
Using the three search strategies, 112 surveillance activities from 27 countries/regions were
identified. After reviewing the available data, 52 systems, plus the transnational systems from ECDC
and WHO, were finally included (Figure 1 and Table 1). The main reasons for exclusion were: no
public access or availability of data on methodology; regional systems using national-wide prescribed
methodologies; mandatory reporting of cases for specific infections/pathogens without
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denominators; and surveillance activities not primarily intended for HAI/AMR. According to the study
protocol no surveillance systems could be reported for the following 12 countries (38%): Bulgaria,
Cyprus, Czech Republic, Estonia, Iceland, Latvia, Liechtenstein, Luxembourg, Malta, Poland, Romania
and Slovenia.
The general features of the surveillance systems for which data extraction was performed are shown
in Table 2. The coverage of the systems was international for 4, national for 35 and regional for 17.
The majority of the systems included all age groups (96%) in inpatient setting (40%) or inpatient and
outpatient settings (40%). The majority of the HAI surveillance systems targeted ICUs (67%) and
surgical departments (67%) and a very few nursing homes (3%). External quality audits were applied
or recommended in 16 systems (25%) and local quality assessments were used in 8 (14%).
Surveillance of HAI in intensive care units (ICUs)
A description of key features and indicators used in surveillance of HAI in ICU patients is provided in
Table 3. Overall, 32 systems plus one international system were included. The most frequent
surveillance metric for device related-infections was density of incidence (60% for CLABSI, 53% for
VAP and CAUTI) Individual risk factors were included in 17 systems (53%)and 11 (34%) of them
reported a severity score such as APACHE. As outcome measures, 13 systems (41%) reported ICU-
mortality and 2 (6%) included the length of ICU stay.
Surveillance of surgical site infections (SSI)
The features of the 32 systems for SSI plus the ECDC programme are shown in Table 4. The data were
stratified according to the NNIS risk index in 16 national or regional systems (50%). Urgent
procedures were included in 15 (47%) and data on antibiotic prophylaxis were collected in 14 (44%).
Among the systems reporting type of procedures, the most common were colon surgery, hip
prosthesis and knee prosthesis. Data on procedure indicators such as checklist were included in 47%
of the surveillance systems. No system included data on environmental cleaning in operating
theatres.
Surveillance systems for antimicrobial resistance
Forty surveillance systems from 19 countries and 4 international systems were included in our review
(see Table 5). The source of data was laboratory-based in the majority of the systems (36, 90%). Only
7 (16%) report patients’ data. A policy to avoid duplicates for laboratory-based data was specified in
23 systems (58%). The case definition included pathogens isolated from clinical samples in 21
systems (53%) both infections and colonisations. Nine (23%) systems included only patients with
infection due to resistant pathogens. Twenty-two systems (55%) applied the resistance breakpoints
recommended by EUCAST (in 11 28%, CLSI were also included).
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Overall, the most frequent indicator used in the reporting was the proportion of resistant isolates
among 100 isolates (29 systems 63%). Sixteen (40%) systems reported incidence rates (either
cumulative or density). Potential predisposing factors for resistance were collected in 19 (43%)
systems, with antibiotic use being the most frequently reported (88%). No outcome data were
collected.
Most frequently targeted pathogens were Streptococcus pneumoniae (75%), Staphylococcus aureus
(98%), Enterococcus faecalis (80%), Escherichia coli (93%), Klebsiella species (90%), Pseudomonas
aeruginosa (88%), and Acinetobacter baumannii (85%). Clostridium difficile was included in 50% of
the surveillance systems. Most frequently reported resistance bacteria were MRSA (83%), VRE (78%),
cephalosporin-resistant E. coli or K. pneumoniae (73%), cephalosporin-resistant P. aeruginosa (70%),
carbapenem-resistant P. aeruginosa (68%), carbapenem-resistant E. coli or K. pneumoniae (65%) and
carbapenem-resistant A. baumannii (63%). The specimens and antimicrobials tested for resistance by
microorganisms are shown in Tables 6 and 7 and figure 2.
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Figure 1. Flow diagram of the systematic review
Iden
tific
atio
n Sources identified through database
searches
Google search
engine
Targeted websites
Consultation with
experts
Scre
enin
g
Potentially relevant records
Records excluded with reasons:
- Privately funded - No public access from primary sources - Reference centres/ quality registers - Statutory notifications/ passive surveillance - Only animal - Outbreaks
Objective not clear/ public data limited
Inclu
ded
Surveillance systems included N=56
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Table 1. Surveillance activities in EU/EAA identified and classified according to the study criteria.
Country System
s included System
s excluded
Austria Austrian Nosocom
ial Infection Surveillance System
Austrian surveillance of nosocomial infections in Neonatal Care
1 National Reference Centre for Nosocom
ial infection and Antimicrobial Resistance
Epidemiologisches m
eldesystem/national reference centres 3,4
Belgium
Scientific Institute of Public Health (IPH) - Institut Scientifique de Santé Publique
Croatia Intersectoral Coordination M
echanism for the Control of AM
R Croatian Institute of Public Health
2 Cyprus
National antim
icrobial resistance surveillance system2
Czech Republic
SZU-Statni zdravotni Listav
2
Denmark
Hospital-acquired infections database Danish m
icrobiology database 5
Danish integrated antimicrobial resistance m
onitoring and research programm
e North Denm
ark region microbiological bacteraem
ia research database2
Com
pulsory notification of MRSA
4 Estonia
National institute for health developm
ent 2
Finland Finnish hospital infection program
National infectious diseases register
Finnish study group for antimicrobial resistance
France
l’Observatoire National de l’Epidém
iologie de la Résistance Bactérienne aux Antibiotiques Enquête nationale de prévalence des infections associées aux soins et des traitem
ents antibiotiques en EHPAD1
Réseau d’Alerte, d’Investigation et de Surveillance des Infections Nosocom
iales Centre de coordination de la lutte contre les infections nosocom
iales (C.CLIN) 1
(HAI) Institut de vieille sanitaire 1
Germany
Krankenhaus infektions surveillance system
National reference centre for Streptococci 3
Antibiotic resistance surveillance Com
pulsory notification of MRSA, carbapenem
-resistant or carbapenemase-
producing Acinetobacter spp. Enterobacteriaceae 4 Surveillance of antibiotic use and resistance in ICU
Statutory notification of m
ultidrug-resistant bacteria4
Antibiotika resistenz monitoring in N
iedersachsen
German netw
ork for antimicrobial resistance surveillance
Greece Greek system
for the surveillance of antimicrobial resistance
Procrustes, compulsory notification of bacteraem
ia due to AMR 4
Greek national reference centre for Neisseria gonorrhoeae 3
National Salmonella and Shigella Reference Centre 3
Hungary National Nosocom
ial Surveillance System
Iceland
Landlknisem
btti, Directorate of Health / EPI_ICE 2
Ireland Health Protection Surveillance Centre
Italy
Sorveglianza regionale delle infezioni in terapia intensiva National reference centre for Neisseria
Sorveglianza prospettica delle infezioni nosocomiali nella Unità di Terapia Intensiva
Laboratory-based surveillance of invasive infections 3 Sistem
a nazionale di sorveglianza delle infezioni del sito chirurgico
Margherita PRO
SAFE
Antibiotico resistenza - Istituto Superiore di Sanitá
Sorveglianza dell’antibioticoresistenza e uso di antibiotici sistemici in Em
ilia-Romagna
Sorveglianza antibiotico resistenza Toscana
M
icronet
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Latvia
Infectology Centre Department of Epidem
iological Safety and Public Health (DESPH) 2 Centre for Disease Prevention and Control (CDPC) 2
Liechtenstein
Lithuania
Healthcare-associated infections epidemiological surveillance*
National public health surveillance laboratory and Institute of hygiene Vilnus 2 Luxem
burg
Centre de Recherche Public de la Santé 2 M
alta
Mater Dei Hospital 2
The N
etherlands
Preventie van ziekenhuisinfecties door surveillance* Kinderdagverblijven infectieziekten surveillance systeem
5 Surveillance netw
ork for infectious diseases in nursing homes*
Compulsory notification of M
RSA4
Infectious disease surveillance and information system
for antibiotic resistance Surveillance of antim
icrobial resistance in the Netherlands 5
Norw
ay Nasjonalt Folkehelseinstitutt (FHI) / The Norw
egian Institute of Public Health (NIPH): Healthcare Asssociated Infections m
odule for SSI (NOIS-SSI); Antim
icrobial drug Resistance m
odule (NORM
)
Norwegian Arthroplasty Register 3
Norwegian Hip Fracture Register 3
Norwegian Surveillance System
for Comm
unicable Diseases (MSIS) 4
Portugal Antibiotic Resistance Surveillance Program
in Portugal
Poland
Active Supervision of nosocomial infections Program
2 National M
edicines Institute 2 National reference centre for diagnosis of bacterial infections of the central nervous system
3 Rom
ania
Sentinel Surveillance System of Nosocom
ial Infections and AMR
2
Slovakia Slovak national antim
icrobial resistance surveillance system
EPIS, Epidemiology inform
ation system 2
National reference centre for Salmonella
3 Slovenia
National Institute of Public Health, University of Ljubljana 2
Spain
Sistema de Vigilancia, prevención y control de IRAS en Principado de Asturias
Red Nacional de Vigilancia epidemiológica (RENAVE) 1
Sistema de Vigilancia Nosocom
ial de Galicia Program
a de Vigilancia y control de microorganism
os multirresistentes 4
Vigilancia de les Infeccions nosocomials als Hospitals de Cataluya (VIN
CAT) Spanish national nosocom
ial infection surveillance network 2
Programa Integral de Prevención, control de las Infecciones relacionadas con la Asistencia
Sanitaria y Uso apropiado de los Antimicrobianos en Andalucía (PIRASO
A)
Plan INOZ - Infekzio Nosocom
ialak Zaintzeko eta Kontrolatzeko del País Vasco
Vigilancia de las Infecciones Relacionadas con la Asistencia Sanitaria de Madrid (VIRAS)
Sistem
a de Vigilancia epidemiológica de Canarias
Estudio nacional de vigilancia de Infección nososcom
ial en servicios de medicina intensiva
(ENVIN-UCI)
Estudio de Prevalencia de las Infecciones Nosocomiales en España (EPIN
E)
Sweden
Swedish surveillance of antim
icrobial resistance ICU STRAM
A Program 2
Annual resistance monitoring and quality control program
me
Bi-annual point-prevelance surveillance of HAI*
Mandatory/voluntary notification of infections 4
National reference laboratory for pathogenic Neisseria
3
Switzerland
SWISSNO
SO
Mandatory notification of carbapenem
ase-producing Enterobacteriaceae4
Comm
unity-associated methicillin-resistant Staphylococcus aureus (CA-M
RSA) surveillance system
Hygiène hospitalière prévention et contrôle de l'infection* Sw
iss centre for antibiotic resistance
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United
Kingdom
Healthcare Infection Centre
The Pan Celtic Network 1
Public Health England (Healthcare Protection Agency: inactive) Health Protection Scotland W
elsh Healthcare Associated Infections Programm
e
ECDC Healthcare-Associated Infections Surveillance Netw
ork
European Antim
icrobial Resistance Surveillance Network
WHO
Central Asian and Eastern European Surveillance of Antim
icrobial Resistance Global Antim
icrobial Resistance Surveillance System
* Systems exclusively declaring/notifying individual cases of a specific disease or pathogen (e.g., com
pulsory reporting of individual cases without denom
inators); systems providing only anim
al, environmental or
food data; surveillance data promoted by private com
panies; studies not including continuous or periodic surveillance; and outbreaks reports are not display in this table.
NR/ UNK= Not reported / Unknown; HAI: Healthcare Associated Infections; AM
R: Antimicrobial Resistance
1. Data included in other surveillance systems
2. Not public access or data available from prim
ary sources
3. Reference centers / Quality registers
4. Statutory notification/ passive surveillance
5. Currently not intended for HAI / AMR surveillance / does not m
eet all eligible criteria
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Table 2. Main characteristics of 56 surveillance system
s reporting healthcare-associated infections and antimicrobial resistance
Country Coverage
Acronym N
ame
Focus Data source
Age Frequence of reporting
Modality of reporting
Quality
Audits Year of info used
Austria
National ANISS
Austrian nosocomial infection surveillance system
HAI
Inpatients All ages
Yearly Pooled data
External, voluntary
2012, 2014-2016
National NRZ
National reference centre for nosocomial infection
and antimicrobial resistance
AMR
Inpatients and outpatients
All ages Yearly
Pooled data External, voluntary
2014-2016
Belgium
National W
IV-ISSP Scientific institute of public health (IPH) - institut scientifique de santé publique
HAI+AMR
Laboratory All ages
Yearly Individual HCF and pooled data
Not specified 2011
Croatia National
ISKRA Intersectoral coordination m
echanism for the control
of AMR
AMR
Laboratory All ages
Yearly Pooled data
Not specified 2014
Denmark
National HAIBA
Hospital-acquired infections database HAI
Inpatients All ages
Weekly
Individual HCF data Not specified
2015, 2016
National DANM
AP Danish integrated antim
icrobial resistance monitoring
and research programm
e AM
R Inpatients and outpatients
All ages Yearly
Pooled data External, voluntary
2014-2016
Finland
National SIRO
Finnish hospital infection program
HAI
Inpatients All ages
Yearly Pooled data
External, voluntary
2006, 2011, 2014, 2016
National FIRE
Finnish study group for antimicrobial resistance
AMR
Inpatients and outpatients
All ages Yearly
Pooled data External, voluntary
2014-2016
France
National O
NERBA L’O
bservatoire national de l’epidémiologie de la
résistance bactérienne aux antibiotiques AM
R Inpatients and outpatients
All ages Yearly
Not specified Local
2015
National RAISIN
Réseau d’alerte, d’investigation et de surveillance des infections nosocom
iales HAI
Inpatients All ages
Yearly Com
parative data with
other HCF Not specified
2009
Germany
National KISS
Krankenhaus infektions surveillance system
HAI+AMR
Inpatients and outpatients
All ages Yearly
Pooled data Not specified
2010, 2012-2016
National ARS
Antibiotic resistance surveillance AM
R Inpatients and outpatients
All ages Yearly
Pooled data External, voluntary
2015, 2016
National SARI
Surveillance of antibiotic use and resistance in ICU
AMR
Inpatients All ages
Yearly Pooled data
Not specified 2009,2016
Regional ARM
IN
Antibiotika resistenz monitoring in niedersachsen
AMR
Inpatients and outpatients
All ages Yearly
Pooled data Not specified
2015, 2016
National GENARS
German netw
ork for antimicrobial resistance
surveillance AM
R Laboratory
All ages Not specified
Pooled data Not specified
2002, 2007
Greece National
GSSAR Greek system
for the surveillance of antimicrobial
resistance AM
R Inpatients
All ages Yearly
Comparative data w
ith other HCF
External, voluntary
2015, 2016
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Hungary National
NNSR National nosocom
ial surveillance system
HAI+AMR
Inpatients All ages
Mixed
Pooled data Not specified
2010 Ireland
National HPSC
Health propection surveillance centre HAI+AM
R Not specified
All ages M
ixed Pooled data
Not specified 2014, 2016
Italy
Regional SITIER
Sorveglianza regionale delle infezioni in terapia intensiva HAI+AM
R Inpatients
All ages RT
Comparative data
with other HCF
Not specified 2013
National SNICh
Sistema nazionale di sorveglianza delle infezioni del sito
chirurgico HAI+AM
R Inpatients
All ages Yearly
Comparative data
with other HCF
Local, com
pulsory 2014
National SPIN-UTI
Sorveglianza prospettica delle infezioni nosocomiali nella
Unità di Terapia Intensiva HAI+AM
R Inpatients
All ages Yearly
Pooled data Not specified
2009, 2013, 2015
National M
argherita M
argherita PROSAFE
HAI+AMR
Inpatients All ages
Yearly Com
parative data w
ith other HCF Local
2014
National AR-ISS
Antibiotico resistenza - Istituto superiore di sanitá AM
R Laboratory
All ages M
ixed Com
parative data w
ith other HCF External, voluntary
2013
Regional LAB
Sorveglianza dell’antibioticoresistenza e uso di antibiotici sistem
ici in Emilia-Rom
agna AM
R Inpatients and outpatients
All ages Yearly
Comparative data
with other HCF
Local 2003 - 2014
Regional SART
Sorveglianza antibiotico resistenza Toscana AM
R Inpatients and outpatients
All ages Not specified
Pooled data Not specified
2015
National M
icronet M
icronet AM
R Laboratory
All ages Not specified
Pooled data Not specified
2007 Lithuania
National HAI E.S.LI
Healthcare-associated infections epidemiological
surveillance HAI
Inpatients All ages
Yearly Pooled data
Not specified 2015,2016
Netherlands
National PREZIES
Preventie van ziekenhuisinfecties door surveillance HAI
Inpatients All ages
Yearly Pooled data
Not specified 2015,2016
National SNIV
Surveillance network for infectious diseases in nursing
homes
HAI Inpatients
Only adults
Yearly Pooled data
Not specified 2014-2016
National ISIS-AR
Infectious disease surveillance and information system
for antibiotic resistance
AMR
Inpatients and outpatients
All ages Q
uarterly Pooled data
Not specified 2012, 2015, 2016
Norw
ay National
FHI Nasjonalt Folkehelseinstitutt: Healthcare Asssociated Infections m
odule for SSI (NOIS-SSI); Antim
icrobial drug Resistance m
odule (NORM
)
HAI+AMR
Not specified All ages
Yearly Com
parative data w
ith other HCF Not specified
2014
Portugal National
ARSIP Antibiotic resistance surveillance program
in Portugal HAI+AM
R Inpatients and outpatients
All ages Not specified
Comparative data
with other HCF
Not specified 2014
Slovakia National
SNARS Slovak national antim
icrobial resistance surveillance system
AMR
Inpatients and outpatients
All ages Yearly
Pooled data External, com
pulsory 2016
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Spain
Regional SVPCIPA
Sistema de vigilancia, prevención y control de IRAS en
principado de Asturias HAI+AM
R Inpatients
All ages Yearly
Individual HCF data
Not specified 2011
Regional SVIN
Sistema de vigilancia nosocom
ial de Galicia HAI+AM
R Inpatients and outpatients
All ages M
onthly Com
parative data w
ith other HCF Local
2000
Regional VIN
CAT Vigilancia de les Infeccions nosocom
ials als hospitals de Cataluya
HAI+AMR
Inpatients All ages
Yearly Com
parative data w
ith other HCF Not specified
2015
Regional PIRASOA
Programa Integral de Prevención, control de las Infecciones
relacionadas con la Asistencia Sanitaria y Uso apropiado de los Antim
icrobianos (PIRASOA)
HAI+AMR
Inpatients and outpatients
All ages Q
uarterly Com
parative data w
ith other HCF Not specified
2014
National ENVIN
-UCI Estudio nacional de vigilancia de Infección nososcom
ial en servicios de m
edicina intensiva HAI+AM
R Inpatients and outpatients
All ages Yearly
Individual HCF data
Not specified 2014
National EPINE
Estudio de prevalencia de las infecciones nosocomiales en
España HAI
Inpatients All ages
Yearly Com
parative data w
ith other HCF External
2015
Regional IN
OZ
Infekzio nosocomialak zaintzeko eta kontrolatzeko del País
Vasco HAI
Inpatients All ages
Not specified Individual HCF data
Not specified 2016
Regional VIRAS
Vigilancia de las Infecciones relacionadas con la asistencia sanitaria de M
adrid HAI
Inpatients All ages
Yearly Individual HCF data
Not specified 2012
Regional SVE Canarias
Sistema de Vigilancia epidem
iológica de Canarias HAI
Inpatients and outpatients
All ages Yearly
Pooled data Not specified
2014
Sweden
National RESNET
Annual resistance monitoring and quality control program
me
AMR
Not specified Not specified
Yearly Pooled data
Not specified 2014, 2016
National SVEBAR
Swedish surveillance of antim
icrobial resistance AM
R Inpatients and outpatients
All ages Yearly
Pooled data External, com
pulsory 2016
Switzerland
National SW
ISSNOSO
SW
ISSNOSO
HAI
Inpatients All ages
Yearly Pooled data
Local, com
pulsory 2015, 2016
Regional HPCI
Hygiène hospitalière prévention et contrôle de l'infection HAI+AM
R Inpatients and outpatients
All ages Not specified
Not specified Not specified
2016
National ANRESIS
Swiss centre for antibiotic resistance
AMR
Inpatients and outpatients
All ages Yearly
Pooled data External, voluntary
2015, 2016
Regional CA-M
RSA CA-M
RSA surveillance system
AMR
Inpatients and outpatients
All ages Not specified
Pooled data Not specified
2006,2012, 2016
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United
Kingdom
Regional W
HAIP W
elsh healthcare associated infections programm
e HAI+AM
R Inpatients and outpatients
All ages M
onthly Com
parative data with
other HCF Not specified
2016
Regional HPS
Health protection Scotland HAI+AM
R Inpatients
All ages Q
uarterly Com
parative data with
other HCF External
2015
Regional PHE
Public health England HAI+AM
R Laboratory
All ages M
ixed Individual HCF data
Not specified 2014
Regional HISC/HPA
Healthcare infection centre/healthcare protection agency
HAI+AMR
Laboratory All ages
Not specified Pooled data
Local 2008
ECDC Transnational
HAINET
Healthcare-Associated Infections Surveillance Netw
ork HAI+AM
R Laboratory
All ages M
ixed Pooled data (country)
External 2015 ICU; 2012 SSI
Transnational EARSNET
European Antimicrobial Resistance Surveillance
Network
AMR
Not specified All ages
Yearly Pooled data (country)
External 2015
WHO
Transnational
CAESAR Central Asian and Eastern European Surveillance of Antim
icrobial Resistance AM
R Inpatients and outpatients
All ages Not specified
Comparative data w
ith other HCF
External, voluntary
2015
Transnational GLASS
Global Antimicrobial Resistance Surveillance
System
AMR
Laboratory All ages
Yearly Com
parative data with
other HCF Local, com
pulsory 2015
*HCF= Healthcare facilities.
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Table 3. Main characteristics of 33 surveillance system
s for healthcare-associated infections in intensive care units
Country System
Risk factors others than invasive procedures
Clinical outcomes
CLABSI indicators VAP indicators
CAUTI indicators
Austria ANISS
Antibiotic use, comorbidities, severity score, previous
hospitalisations M
ortality ID, UR
ID, UR ID, UR
Belgium
WIV-ISSP
Comorbidities, severity score
Not specified ID, CI, UR
ID, CI, UR ID, CI
Denmark
HAIBA Not specified
Not specified ID
Not specified ID
Finland SIRO
Antibiotic use, com
orbidities M
ortality ID
Not specified Not specified
France RAISIN
Not specified Not specified
Not specified Not specified
Not specified Germ
any KISS
Antibiotic use M
ortality ID, UR
ID, UR ID, UR
Hungary NNSR
Not specified Not specified
Not specified Not specified
Not specified Ireland
HPSC Antibiotic use
Mortality
ID, UR ID, UR
ID, UR Italy
SITIER Antibiotic use, com
orbidities, severity score, previous hospitalisations
Mortality, length of
stay ID, UR
ID, UR ID
SPIN-UTI Antibiotic use, severity score, previous hospitalisations
Mortality
ID, UR ID, UR
ID, UR M
argherita Antibiotic use, severity score, previous hospitalisations
Mortality
ID, UR ID, UR
ID, UR SNICh
Not specified Not specified
Not specified Not specified
Not specified Lithuania
HAI E.S.LI Antibiotic use, severity score, previous hospitalisations.
Mortality
ID, CA ID, CA
ID, CA N
etherlands PREZIES
Antibiotic use, comorbidities
Mortality
CI Not specified
Not specified SNIV
Antibiotic use M
ortality Not specified
ID ID
Norw
ay FHI
Not specified Not specified
Not specified Not specified
Not specified Portugal
ARSIP Not specified
Not specified Not specified
Not specified Not specified
Spain
SVPCIPA Not specified
Not specified ID, UR
ID, UR ID, UR
SVIN Severity score
Not specified ID, UR
ID, UR Not specified
VINCAT
Comorbidities, severity score, length of stay
Not specified ID, CI, UR
ID, CI, UR ID, CI, UR
PIRASOA Antibiotic use, com
orbidities, severity score, length of stay, antibiotic use
Mortality
ID, CI, UR ID, CI, UR
ID, CI, UR
ENVIN-UCI
Antibiotic use, comorbidities, severity score, length of
stay, antibiotic use M
ortality ID, CI, UR
ID, CI, UR ID, CI, UR
INO
Z Com
orbidities, Severity score Not specified
ID, UR ID, UR
ID, UR SVE Canarias
Not specified Not specified
Not specified Not specified
Not specified VIRAS
Not specified Not specified
Not specified Not specified
Not specified EPINE
Not specified Not specified
Not specified Not specified
Not specified
Switzerland
HPCI Not specified
Not specified ID, CI
Not specified Not specified
SWISSNO
SO
Not specified Not specified
Not specified Not specified
Not specified
United
Kingdom
WHAIP
Not specified Not specified
ID, UR ID, UR
ID, UR
HPS Com
orbidities, severity score M
ortality, length of stay
ID, UR ID, UR
ID, UR PHE
Not specified Not specified
Not specified Not specified
Not specified HISC/HPA
Not specified Not specified
Not specified Not specified
Not specified ECDC
HAINET
Antibiotic use, comorbidities, severity score, previous
hospitalisations M
ortality, length of stay
ID, UR ID, UR
ID, UR
CLABSI: Central line-associated bloodstream
infection VAP: Ventilator-associated pneum
onia CAUTI: Catheter-associated urinary tract infections ID: Incidence density CI: Cum
ulative incidence UR: Utilisation rate
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Table 4. Main characteristics of 33 surveillance system
s for surgical site infections
Country System
N
NIS Risk Index
Include urgent procedures
Data on antibiotic prophylaxis
Peri- operative checklist
CABG CVAL
CHOL
COLO
CSEC
HPRO
KPRO
LAM
Austria ANISS
Yes Yes
Yes PO
ST-op
Belgium
WIV-ISSP
Yes Yes
Yes PO
ST-op
Denmark
HAIBA Not specified
Not specified Not specified
Not specified
Finland SIRO
Yes
Yes Yes
POST-op
France RAISIN
Yes Not specified
Yes Not specified
Germany
KISS Yes
Yes Not specified
Not specified
Hungary NNSR
Not specified Not specified
Not specified Not specified
Ireland HPSC
Not specified Not specified
Not specified Not specified
Italy
SNICh Yes
Yes Yes
Not specified
SITIER Not specified
Not specified Not specified
Not specified
SPIN-UTI Not specified
Not specified Not specified
Not specified
Margherita
Not specified Not specified
Not specified Not specified
Lithuania HAI E.S.LI
Yes Yes
Yes Not specified
Netherlands
PREZIES Yes
Yes Yes
POST-op
SNIV Not specified
Not specified Not specified
Not specified
Norw
ay FHI
Yes Yes
Yes PO
ST-op
Portugal ARSIP
Not specified Not specified
Not specified Not specified
Spain
SVPCIPA Not specified
Not specified Not specified
POST-op
VINCAT
Yes Yes
Yes PO
ST-op
PIRASOA Yes
Yes Not specified
PRE+POST-op
INO
Z Not specified
Not specified Not specified
PRE-op
VIRAS Not specified
Not specified Not specified
PRE-op
SVIN Not specified
Not specified Not specified
Not specified
SVE Canarias Not specified
Not specified Not specified
Not specified
EPINE Not specified
Not specified Not specified
Not specified
ENVIN-UCI
Not specified Not specified
Not specified Not specified
Switzerland
SWISSNO
SO
Yes Yes
Yes PO
ST-op
HPCI Not specified
Not specified Not specified
Not specified
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United Kingdom
WHAIP
Yes Yes
Not specified PRE+PO
ST-op
HPS Yes
Yes Yes
PRE+POST-op
PHE Yes
Yes Yes
POST-op
HISC/HPA Yes
Yes Yes
PRE+POST-op
ECDC HAIN
ET Yes
Yes Yes
POST-op
PRE-op: Preoperative checklist, POST-op: Post-operative checklist, PRE+PO
ST-op: Pre- and post- operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHO
L: cholecystectomy.
COLO
: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO
: knee prosthesis. LAM: lam
inectomy.
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Table 5. Characteristics of 44 surveillance systems reporting antim
icrobial resistance
Country Acronym
Source of data
Duplicates policy
Type of sam
pling
Resistance definition criteria
Indicator Patients’ risk factors
Streptococcus pneumoniae
Staphylococcus aureus
Enterococcus faecalis
Enterococcus faecium
Escherichia coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Acinetobacter baumannii
Clostridium difficile
Austria NRZ
Laboratory Yes
Infection EUCAST or CLSI
Prev Not specified
Belgium
WIV-ISSP
Laboratory Not specified
Infection + colonisation
Not specified CI
Antibiotic use, comorbidities
Croatia ISKRA
Laboratory Yes
Infection + colonisation
EUCAST Not specified
Not specified
Denmark
DANMAP
Laboratory Yes
Infection + colonisation
EUCAST or CLSI Prev, CI 1, %
Infection Not specified
Finland FIRE
Laboratory Yes
Infection EUCAST
Prev Not specified
France O
NERBA Laboratory
Yes Infection
Local Not specified
Not specified
Germany
KISS Laboratory+cases
Yes Infection + colonisation
Local Prev, CI, ID, %
Infection Invasive procedures, Antibiotic use
ARS Laboratory
Yes Not specified
EUCAST or CLSI or Local
Prev Not specified
SARI Laboratory
Yes Not specified
EUCAST or CLSI or Local
Prev, ID Antibiotic use
ARMIN
Laboratory
Yes Not specified
EUCAST or CLSI or Local
Prev Not specified
GENARS Laboratory
Not specified
Not specified Local
Prev Not specified
Greece GSSAR
Laboratory Yes
Not specified CLSI
Prev Not specified
Hungary NNSR
Not specified Not specified
Not specified EUCAST or CLSI
Not specified Not specified
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Ireland HPSC
Laboratory+cases Yes
Infection EUCAST
Prev, ID, %
Infection Previous hospitalisations, ICU stay
Italy
SITIER Laboratory
Not specified
Infection Not specified
Prev, CI, %
Infection Invasive procedures
SNICh Laboratory
Not specified
Infection Not specified
CI Antibiotic use
SPIN-UTI Laboratory
Not specified
Infection + colonisation
Not specified Prev, ID
Invasive procedures, antibiotic use, com
orbidities, previous hospitalisation
Margherita
Laboratory Yes
Infection Not specified
Prev, %
Infection Invasive procedures, antibiotic use, com
orbidities, previous hospitalisation
AR-ISS Laboratory
Yes Not specified
EUCAST Prev, Prev
Not specified
LAB Laboratory
Yes Infection + colonisation
EUCAST Prev, Prev, ID
Not specified
SART Laboratory
Yes Infection + colonisation
EUCAST Prev, Prev
Antibiotic use, lenght of stay, com
orbidities
Micronet
Laboratory Not specified
Infection + colonisation
Not specified Prev
Not specified
Netherlands
ISIS-AR Laboratory
Yes Infection + colonisation
EUCAST Prev
Not specified
Norw
ay FHI
Laboratory+cases Yes
Not specified EUCAST
Prev, Prev Antibiotic use
Portugal ARSIP
Laboratory Not specified
Infection Not specified
Not specified Not specified
Slovakia SNARS
Laboratory Yes
Infection + colonisation
EUCAST or CLSI Prev
Not specified
Spain
SVPCIPA Laboratory
Not specified
Infection + colonisation
Not specified ID
Not specified
SVIN Laboratory
Not specified
Infection Not specified
Not specified Antibiotic use
VINCAT
Laboratory Yes
Infection + colonisation
Not specified Not specified
Antibiotic use
PIRASOA Laboratory
Yes Infection + colonisation
EUCAST or CLSI ID
Invasive procedures, antibiotic use
ENVIN-UCI
Laboratory Not specified
Infection + colonisation
EUCAST or CLSI ID
Antibiotic use
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Sweden
RESNET Laboratory
Not specified
Not specified EUCAST
Prev Not specified
SVEBAR Laboratory
Not specified
Infection + colonisation
EUCAST Prev
Not specified
Switzerland
HPCI Laboratory+cases
Not specified
Infection + colonisation
EUCAST CI, ID
Not specified
ANRESIS Laboratory
Yes Infection + colonisation
EUCAST or CLSI Prev
Not specified
CA-MRSA
Cases Not specified
Infection + colonisation
EUCAST %
Infection Invasive procedures, antibiotic use, com
orbidities, previous hospitalisation, other *
United Kingdom
WHAIP
Laboratory Not specified
Infection + colonisation
Not specified CI
Not specified
HPS Cases
Yes Infection + colonisation
Not specified CI, Prev
Antibiotic use
PHE Cases
Yes Infection + colonisation
Not specified Prev, CI, ID
Invasive procedures, antibiotic use
HISC/HPA Laboratory
Not specified
Not specified Not specified
Not specified Not specified
ECDC
EARSNET Laboratory
Yes Infection
EUCAST or CLSI Prev
Invasive procedures, antibiotic use, com
orbidities, previous hospitalisation, other **
HAINET
Laboratory Yes
Infection EUCAST
Prev, CI, ID Invasive procedures, antibiotic use, com
orbidities, previous hospitalisation
WHO
GLASS Laboratory
Yes Infection + colonisation
EUCAST or CLSI Prev
Not specified
CAESAR Laboratory
Yes Infection + colonisation
EUCAST or CLSI Prev, CI
Not specified
CI: cumulative incidence of resistant isolate/cases. ID: incidence density of resistant isolates/cases. Prev: prevalence
1. Only reported for m
ethicillin-resistant S. aureus.
* Other predisposing factors registered: contacts, travels, substance abuse, and sexual preferences
**Other predisposing factors registered: exposure to colonised patients
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Table 6. Key antibiotics tested and type of sampling reported for gram
-positive pathogens in 40 surveillance systems (ECDC and W
HO not included)
Streptococcus pneumoniae
Staphylococcus aureus Enterococcus faecalis/ Enterococcus faecium
Country Acronym
Type of sam
ple PEN
LVX or M
FX CTX or CRO
AZM
, CLR or ERY
Type of sample
OXA
FQ
LNZ
VAN GEN
or TO
B
Type of sample
AMP
VAN
GEH
Austria NRZ
Blood, CSF, respiratory
√ √
√ √
All √
√ √
√ √
Blood √
√ √
Belgium
WIV-ISSP
Not specified
Blood, CSF
√
√
Blood, CSF
√ √
Croatia ISKRA
Blood, CSF, respiratory
√ √
√
Blood, CSF √
√ √
√ √
Blood, CSF √
√ √
Denmark
DANMAP
Blood, CSF √
√ All
√
√
Blood
√ √
Finland FIRE
All √
√ √
√ All
√ √
All
√ √
France
ONERBA
Not specified
Not specified
Not specified
Germany
KISS Not specified
Not specified √
Not specified
√
ARS All*
√ √
√ √
All* √
√ √
√ √
All* √
√ √
SARI Not specified
√ √
√ √
Not specified √
√ √
√ ?
UNK √
√
ARMIN
All
√ √
√ √
All √
√ √
√ √
All √
√ √
GENARS All*
√ √
√ √
All* √
√ √
√ √
All* √
√ √
Greece GSSAR
All* √
√ √
√ All*
√ √
√ √
√ All*
√ √
√ Hungary
NNSR Blood, CSF
All √
√
All
√
Ireland HPSC
Blood, CSF √
Blood, CSF
√
Blood, CSF
√ √
√
Italy
SITIER Not specified
Not specified √
√
Not specified √
√
SNICh Not specified
Surgical site √
√
Surgical site √
√
SPIN-UTI Not specified
Not specified √
Not specified
Margherita
Not specified √
Not specified
√
Not specified
√
AR-ISS
Blood, CSF √
√
√ Blood, CSF
√ √
√
√ Blood, CSF
√ √
LAB
All √
√ √
√ All
√
All
√ √
SART
Blood √
√ √
√ Blood
√ √
√ √
Blood
√ √
M
icronet All*
√ √
√ √
All* √
√ √
√ √
All* √
√ √
Netherlands
ISIS-AR All*
√ √
√ √
All* √
√ √
√ √
All* √
√ √
Norw
ay FHI
Blood, CSF √
√ √
√ All
√ √
√ √
Blood
√ √
√ Portugal
ARSIP Not specified
Not specified
Not specified
Slovakia SNARS
All* √
√ √
√ All*
√ √
√ √
√ All*
V √
√
Spain
SVPCIPA Not specified
Blood
Not specified
SVIN Not specified
Not specified
Not specified
VINCAT
Not specified
Blood
Not specified
PIRASOA
Not specified
Blood
Not specified
√
ENVIN
-UCI All
√
√
All √
√
All √
√
Sweden
RESNET Not specified
Not specified
Not specified
SVEBAR All*
√ √
√ √
All* √
√ √
√ √
All* V
√ √
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Switzerland
HPCI Not specified
Blood √
Blood
√
ANRESIS All*
√ √
√ √
All* √
√ √
√ √
All* V
√ √
CA-MRSA
Not specified
All
√
Not specified
United Kingdom
WHAIP
Not specified
Blood
√
Blood
√ HPS
Blood, respiratory
√ √
√ √
Blood, respiratory
√ √
√ √
Blood, respiratory
√ √
√
PHE Respiratory specim
en
Blood
√
Blood
√
HISC/HPA Not specified
√
Blood √
Not specified
√ √
PEN: peniclllin. FQ: fluoroquinolones. CTX: cefotaxim
e or ceftriaxone. MACR: m
acrolydes. OXA: oxacillin. LNZ: linezolid. VAN: vancom
ycin. GEN: gentamicin. GHLR: gentam
icin, high level resistance. TOB: tobram
ycin.
AMP: am
picillin.
√: Yes. Blank cell : not specified.
CSF: cerebrospinal fluid
*Any clinically relevant or routinely cultured pathogens/antibiotics
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Table 7. Key antibiotics tested and type of sampling reported for gram
-negative pathogens in 40 surveillance systems (ECDC and W
HO not included)
Escherichia coli/ Klebsiella pneumoniae
Pseudomonas aeruginosa
Acinetobacter baumannii
Country Acronym
Type of sam
ple AM
P or AM
X
AMC
TZP FEP, CTX, CAZ or CRO
ERT M
EM
or IPM
AMK,
GEN
or TO
B
CIP, LVX, M
FX or O
FX
COL
Type of sam
ple FEP or CAZ
TZP M
EM
or IPM
AMK,
GEN
or TO
B
CIP, LVX, M
FX or O
FX
COL
Type of sam
ple M
EM
or IPM
COL
AMK,
GEN
or TO
B
TGC SU
L
Austria NRZ
Urinary, blood, CSF
√ √
√ √
√ √
√ √
M
ixed √
√ √
√ √
√ Blood, CSF
√ √
√ √
√
Belgium
WIV-ISSP
Blood
√
√ √
√
Blood √
√ √
√ Blood
√ √
Croatia
ISKRA Blood, CSF
√ √
√ √
√ √
√ √
√ Blood, CSF
√ √
√ √
√ √
Blood, CSF √
√ √
√
Denmark
DANMAP
Blood, urine
√
√
√ √
√
Blood
√ √
√ √
√
Not specified
Finland FIRE
All √
√ √
√
√ √
√
All √
√ √
√ √
All
√
√
France
ONERBA
All
All
All
Germany
KISS Not specified
√ √
√ √
√ √
√
Not specified
√ √
√
√
Not specified
√
ARS All*
√ √
√ √
√ √
√ √
√ All*
√ √
√ √
√ √
All* √
√ √
√ √
SARI Not specified
√ √
√ √
√
√ √
Not specified
√ √
√ √
√
Not specified
√
√ √
√
ARMIN
All
√ √
√ √
√
√ √
All
√ √
√ √
√ √
All √
√ √
GENARS All*
√ √
√ √
√ √
√ √
√ All*
√ √
√ √
√ √
All* √
√ √
√ √
Greece GSSAR
All* √
√ √
√ √
√ √
√ √
All* √
√ √
√ √
√ All*
√ √
√ √
√ Hungary
NNSR All
√
√ √
All
√
√
All √
Ireland HPSC
Blood, CSF
√
√
√
√ √
Blood, CSF
√ √
√
√
Blood, CSF √
√
Italy
SITIER Not specified
√
√
√ √
Not specified
√
√
√
Not specified
√ √
SNICh Not specified
Surgical site
√
Surgical site
SPIN-UTI Not specified
√
√ √
Not specified
Not specified
√
Margherita
Not specified
Not specified
√
√
Not specified
√
AR-ISS Blood, CSF
√ √
√ √
√ √
√ √
Blood, CSF
√ √
√ √
√
Blood, CSF
LAB All
√ √
√ √
√ √
√ √
? All
√ √
√ √
√ √
All √
√ √
SART Blood
√ √
√ √
√ √
√ √
√ Blood
√ √
√ √
√ √
Blood √
√ √
Micronet
All* √
√ √
√ √
√ √
√ √
All* √
√ √
√ √
√ All*
√ √
√ √
√
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Netherlands
ISIS-AR All*
√ √
√ √
√ √
√ √
√ All*
√ √
√ √
√ √
All* √
√ √
√ √
Norw
ay FHI
All √
√ √
√ √
√ √
√ √
Not specified
√ √
√ √
√ √
Not specified
√ √
√ √
Portugal ARSIP
Not specified
Not specified
Not specified
Slovakia SNARS
All* √
√ √
√ √
√ √
√ √
All* √
√ √
√ √
√ All*
√ √
√ √
√
Spain
SVPCIPA Not specified
Blood
Not specified
SVIN Not specified
Not specified
Not specified
VINCAT
Blood
Not specified
Not specified
PIRASOA Blood
√
Blood
Not specified
ENVIN-UCI
All
√
√
All √
√ √
√
√ All
Sw
eden RESNET
Not specified
Not specified
Not specified
SVEBAR All*
√ √
√ √
√ √
√ √
√ All*
√ √
√ √
√ √
All* √
√ √
√ √
Switzerland
HPCI Blood
√
√ √
Not specified
Not specified
ANRESIS All*
√ √
√ √
√ √
√ √
√ All*
√ √
√ √
√ √
All* √
√ √
√ √
CA-MRSA
Not specified
Not specified
Not specified
United Kingdom
WHAIP
Blood
Not specified
Not specified
HPS All
√ √
√ √
√ √
√ √
√ All
√ √
√ √
√ √
All √
√ √
√
PHE Blood
Not specified
Blood
HISC/HPA Blood
Not specified
Not specified
AMP: Am
picillin. AMX: am
oxicillin. AMC: am
oxicillin/clavulanate; TZP: Piperacillin/tazobactam. FEP: cefepim
e. CTX: cefotaxime. CAZ: ceftazidim
e. CRO: ceftriaxone. ERT: ertapenem
. MEM
: meropenem
. IPM:
imipenem
. AMK: am
ikacin. GEN: gentamicin. TO
B: tobramycin. CIP: ciprofloxacin. LVX: levofloxacin. M
FX: moxifloxacin. O
FX: ofloxacin. COL: colistin. TGC: tigecycline. SUL: sulbactam
.
√=Yes. Blank cell = not specified. CSF: cerebrospinal fluid. *Any clinically relevant or routinely cultured pathogens/antibiotics
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Figure 2A. National surveillance systems in European countries reporting MRSA and VRE (ECDC and
WHO not included)
Country System/ institution
Austria NRZ
Belgium WIV-ISSP
Croatia ISKRA
Denmark DANMAP
Finland FIRE
Germany KISS ARS SARI ARMIN GENARS
Greece GSSAR
Hungary NNSR
Ireland HPSC
Italy SITIER SNICh Margherita AR-ISS LAB SART Micronet
Netherlands ISIS-AR
Norway FHI
Slovakia SNARS
Spain PIRASOA ENVIN-UCI
Sweden SVEBAR
Switzerland HPCI ANRESIS
United Kingdom
HPS PHE HISC/HPA
Country System/ Institution
Austria
NRZ
Belgium
WIV-ISSP
Croatia
ISKRA
Denmark
DANMAP
Finland
FIRE
Germany
KISS ARS SARI ARMIN GENARS
Greece
GSSAR
Hungary
NNSR
Ireland
HPSC
Italy
SITIER SNICh SPIN-UTI Margherita AR-ISS LAB SART Micronet
Netherlands
ISIS-AR
Norway
FHI
Slovakia
SNARS
Spain
ENVIN-UCI
Sweden
SVEBAR
Switzerland
HPCI ANRESIS CA-MRSA
United Kingdom
WHAIP HPS PHE HISC/HPA
MRSA
VRE
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Figure 2B. National surveillance system
s in European countries reporting colistin-resistant E. coli/K. pneumoniae, P. aeruginosa, A. baum
annii (ECDC and
WHO
not included)
Carbapenem-resistant
A. baumannii
Country System
/ institution Austria
NRZ Belgium
W
IV-ISSP Croatia
ISKRA Denm
ark
DANM
AP Finland
FIRE Germ
any
KISS
ARS
SARI
ARM
IN
GENARS Greece
GSSAR Hungary
NNSR Ireland
HPSC Italy
SITIER
SPIN-UTI
AR-ISS
LAB
SART
Micronet
Netherlands
ISIS-AR N
orway
FHI Slovakia
SNARS Sw
eden
SVEBAR
Switzerland
HPCI
ANRESIS U
nited Kingdom
HPS
Country System
/ institution Austria
NRZ Belgium
W
IV-ISSP Croatia
ISKRA Denm
ark
DANM
AP Finland
FIRE Germ
any
KISS
ARS
SARI
ARM
IN
GENARS Greece
GSSAR Hungary
NNSR Ireland
HPSC Italy
SITIER
Margherita
AR-ISS
LAB
SART
M
icronet N
etherlands
ISIS-AR
Norw
ay
FHI
Slovakia
SNARS
Spain
ENVIN-UCI
Sweden
SVEBAR Sw
itzerland
ANRESIS
United
Kingdom
HPS
Country System
/ institution Austria
NRZ Belgium
W
IV-ISSP Croatia
ISKRA Finland
FIRE Germ
any
KISS
ARS
SARI
ARM
IN
GENARS
Greece
GSSAR
Hungary
NNSR
Ireland
HPSC
Italy
SITIER
SPIN-UTI
M
argherita
LAB
SART
Micronet
Netherlands
ISIS-AR N
orway
FHI Slovakia
SNARS Sw
eden
SVEBAR
Switzerland
ANRESIS U
nited Kingdom
HPS
Carbapenem-resistant
E. coli/K. pneumoniae
Carbapenem
-resistant P. aeruginosa
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Figure 2C. National surveillance systems in European countries reporting cephalosporin-resistant E. coli/K. pneumoniae and P. aeruginosa (ECDC and WHO not included)
Country System/ institution
Austria NRZ
Belgium WIV-ISSP
Croatia ISKRA
Denmark DANMAP
Finland FIRE
Germany KISS ARS SARI ARMIN GENARS
Greece GSSAR
Hungary NNSR
Ireland HPSC
Italy SITIER SNICh Margherita AR-ISS LAB SART Micronet
Netherlands ISIS-AR
Norway FHI
Slovakia SNARS
Spain ENVIN-UCI
Sweden SVEBAR
Switzerland ANRESIS
United Kingdom
HPS
Country System/ institution
Austria NRZ
Belgium WIV-ISSP
Croatia ISKRA
Denmark DANMAP
Finland FIRE
Germany KISS ARS SARI ARMIN GENARS
Greece GSSAR
Hungary NNSR
Ireland HPSC
Italy SITIER SPIN-UTI AR-ISS LAB SART Micronet
Netherlands ISIS-AR
Norway FHI
Slovakia SNARS
Spain PIRASOA
Sweden SVEBAR
Switzerland ANRESIS
United Kingdom
HPS
Cephalosporin-resistant E. coli/K. pneumoniae
Cephalosporin-resistant P. aeruginosa
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Figure 2D. National surveillance system
s in European countries reporting colistin-resistant E.coli/K. pneumoniae, P. aeruginosa, A. baum
annii (ECDC and W
HO not included)
Colistin-resistant A. baum
annii
Country System
/ institution
Croatia
ISKRA
Germany
ARS
GENARS Greece
GSSAR Italy
SART
Micronet
Netherlands
ISIS-AR
Norway
FHI Slovakia
SNARS Sw
eden
SVEBAR
Switzerland
ANRESIS United Kingdom
HPS
Country System
/ institution
Austria
NRZ
Belgium
WIV-ISSP
Croatia
ISKRA
Germany
ARS
ARMIN
GENARS Greece
GSSAR Italy
SITIER
LAB
SART
Micronet
Netherlands
ISIS-AR
Norway
FHI Slovakia
SNARS Spain
ENVIN-UCI
Sweden
SVEBAR Sw
itzerland
ANRESIS
United Kingdom
HPS
Country System
/ institution
Austria
NRZ
Belgium
WIV-ISSP
Croatia
ISKRA
Germany
ARS
ARMIN
GENARS Greece
GSSAR Italy
SITIER
LAB
SART
Micronet
Netherlands
ISIS-AR
Norway
FHI Slovakia
SNARS Sw
eden
SVEBAR
Switzerland
ANRESIS United Kingdom
HPS
Colistin-resistant E.coli/K. pneum
oniae
Colistin-resistant P. aeruginosa
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• National • AMR, voluntary participation • Inpatients and outpatients, all ages • Number of participating hospitals:
139
•
Source of data Laboratory Clinical status Infection Duplicates policy Yes Resistance definition EUCAST or CLSI Metrics and dissemination Prevalence. Yearly, pooled data. Quality Assessment External, voluntary
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae
Blood, CSF, respiratory PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN
GEN or TOB
Enterococcus faecalis/ Enterococcus faecium Blood AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae
Urinary, blood, CSF
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ
Pseudomonas aeruginosa Mixed FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii Blood, CSF MEM or IPM
COL AG TGC SUL
NRZ
National reference centre for nosocomial infection and antimicrobial resistance
ANISS
Austrian nosocomial infection surveillance system
• National • HAI, voluntary participaton • Inpatients, all ages • Number of participating hospitals:
60 • :
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG:GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
NRZ
The Austrian strategy
Total population: 9 million
NNIS Risk Index Yes Include urgent procedures Yes Data on antibiotic prophylaxis Yes Peri- operative checklist POST-op Interventions CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Risk factors Antibiotic use, comorbidities, severity score, previous hospitalizations Clinical outcomes Mortality Metrics and dissemination Incidence density, device utilisation rate.
Quality Assessment:
External, voluntary
SSI CLABSI
VAP CAUTI
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneumonia. CAUTI: Catheter-associated urinary tract infections SSI: surgical site infection. POST-op: Post-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
Dissemination: Yearly, pooled
data
ANISS
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NNIS Risk Index Yes Include urgent procedures Yes Data on antibiotic prophylaxis Yes Peri- operative checklist POST-op Interventions CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Source of data Laboratory Clinical status Infection+colonisation Metrics and dissemination CI. Yearly, individual HCF and pooled data
Risk factors Comorbidities, severity score Metrics Incidence density and cumulative incidence , device utilisation rate.
SSI CLABSI
VAP CAUTI
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus Blood, CSF OXA VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium Blood, CSF AMP VAN
Escherichia coli/ Klebsiella pneumoniae Blood AMC CG ERT
MEM or IPM
Pseudomonas aeruginosa Blood FEP or CAZ
TZP MEM or IPM
COL
Acinetobacter baumannii Blood MEM or IPM
COL
• National • AMR+HAI, voluntary participation • Laboratory, all ages • Number of participating labs:
138
CI: cumulative incidence. HCF: healthcare facilities. FEP: cefepime. CAZ: ceftazidime. OXA: oxacillin. VAN: vancomycin. GEN: gentamicin. TOB: tobramycin. AMP: Ampicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin.
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneumonia. CAUTI: Catheter-associated urinary tract infections SSI: surgical site infection. POST-op: Post-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
The Belgian strategy
Total population: 11 million
WIV-ISSP Scientific institute of public health (IPH) –
Institut scientifique de santé publique
Dissemination: Yearly,
individual HCF and pooled
data
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Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST Dissemination Yearly, pooled data
• National • AMR, voluntary participation • Laboratory, all ages • Number of participating hospitals:
38
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone. CG:FEP/CTX/CAZ/CRO. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG:GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. SUL: sulbactam.
ISKRA
Intersectoral coordination mechanism for the control of AMR
The Croatian strategy
Total population: 4 million
Pathogens under surveillance
Specimen source Antibiotics
Streptococcu pneumoniae
Blood, CSF, respiratory PEN
LVX or MFX
MAC
Staphylococcus aureus Blood, CSF OXA FQ LNZ VAN
GEN or TOB
Enterococcus faecalis/ Enterococcus faecium Blood, CSF AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae
Blood, CSF AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa Blood, CSF
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii Blood, CSF
MEM or IPM
COL AG SUL
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Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST or CLSI Metrics and dissemination Prevalence and CI1. Yearly, pooled data. Quality Assessment External, voluntary
Metrics and dissemination Incidence density. Weekly, individual HCF data
CLABSI CAUTI
Pathogens under surveillance Specimen source Antibiotics
Streptococcus pneumoniae Blood, CSF PEN MAC
Staphylococcus aureus All OXA LNZ
Enterococcus faecalis/ Enterococcus faecium Blood AMP VAN
Escherichia coli/ Klebsiella pneumoniae Blood, urine
AMP or AMX
CG ERT MEM or IPM FQ
Pseudomonas aeruginosa Blood FEP or CAZ TZP MEM
or IPM AG FQ
CI: cumulative incidence (reported only for MRSA). PEN: peniclllin. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. AMP: Ampicillin. VAN: vancomycin. AMX: amoxicillin. CG: cefepime (FEP)/cefotaxime/ceftazidime (CAZ)/ceftriaxone. ERT: ertapenem. MEM: meropenem. IPM: imipenem. FQ: ciprofloxacin/levofloxacin /moxifloxacin /ofloxacin. TZP: Piperacillin/tazobactam. AG: gentamicin/tobramycin/amikacin.
CLABSI: Central line-associated bloodstream infection. CAUTI: Catheter-associated urinary tract. HCF: healthcare facilities.
The Danish strategy
Total population: 6 million
• National • HAI, voluntary participation • Inpatients, all ages • Number of participating hospitals:
312
• National • AMR, voluntary participation • Inpatients and outpatients, all ages • Number of participating labs: 10
Departments of clinical microbiology
DANMAP
Danish integrated antimicrobial resistance monitoring and research programme
DANMAP
HAIBA
HAIBA
Hospital-acquired infections database
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NNIS Risk Index Yes Include urgent procedures Yes Data on antibiotic prophylaxis Yes Peri- operative checklist POST-op Interventions CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Source of data Laboratory Clinical status Infection Duplicates policy Yes Resistance definition EUCAST Metrics and dissemination Prevalence. Yearly, pooled data. Quality Assessment External, voluntary
Risk factors Antibiotic use, comorbidities Clinical outcomes Mortality Metrics Incidence density.
Quality Assessment:
External, voluntary
SSI CLABSI
Pathogens under surveillance Specimen source Antibiotics
Streptococcus pneumoniae All PEN LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ
Enterococcus faecalis/ Enterococcus faecium All AMP VAN
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG MEM or IPM
AG FQ
Pseudomonas aeruginosa All FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All MEM or IPM
AG
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone. CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. AMP: Ampicillin. VAN: vancomycin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam. MEM: meropenem. IPM: imipenem. . AG: gentamicin/ tobramycin/ amikacin. COL: colistin.
CLABSI: Central line-associated bloodstream infection. SSI: surgical site infection. POST-op: Post-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
The Finnish strategy
Total population: 6 million
SIRO
Finnish hospital infection program
• National • HAI, voluntary participation • Inpatients, all ages • Number of participating hospitals:
258
• National • AMR, voluntary participation • Inpatients and outpatients, all ages • Number of participating labs:
28
FIRE
Finnish study group for antimicrobial resistance
Dissemination: Yearly, pooled
data
FIRE
SIRO
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NNIS Risk Index Yes Data on antibiotic prophylaxis Yes Interventions
CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Dissemination Yearly, comparative with other HCF Quality assessment External, voluntary
Source of data Laboratory Clinical status Infection Duplicates policy Yes Resistance definition Local Dissemination Yearly.
RAISIN
Réseau d’alerte, d’investigation et de surveillance des infections nosocomiales
• National • HAI, voluntary participation • Inpatients, all ages • Number of participating
labs/hospitals: Not specified • :
The French strategy
Total population: 65 million
• National • AMR, voluntary participation • Inpatients and outpatients, all ages • Number of participating
labs/hospitals: Not specified •
ONERBA
L’Observatoire national de l’epidémiologie de la résistance bactérienne aux antibiotiques
SSI
ONERBA
RAISIN
SSI: surgical site infection. HCF: healthcare facilities. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
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The German strategy
Total population: 81 million
• N
ational •
AMR+HAI, voluntary participation
• Inpatients, all ages
• N
umber of hospitals: 1482
• N
ational •
AMR, voluntary participation
• Inpatients and outpatients, all ages
• N
umber of hospitals: 100
ARS Antibiotic resistance
surveillance
• N
ational •
AMR, voluntary participation
• Inpatients, all ages
• N
umber of hospitals: 100
SARI Surveillance of antibiotic use and resistance in ICU
• N
ational, Inactive •
AMR, voluntary participation
• Laboratory, all ages
GENARS Germ
an network for
antimicrobial resistance surveillance
KISS Krankenhaus infektions
surveillance system
• Regional
• AM
R, voluntary participation •
Inpatients and outpatients, all ages •
Num
ber of labs: 13
ARMIN
Antibiotika resistenz m
onitoring in niedersachsen
NN
IS Risk Index
Yes Include urgent procedures
Yes Interventions CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Risk factors Antibiotic use Clinical outcom
es M
ortality M
etrics and dissemination
Incidence density, device utlisation rate
SSI
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneum
onia. CAUTI: Catheter-associated urinary tract infections
SSI: surgical site infection. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacem
ent. CHOL: cholecystectom
y. COLO
: colon surgery. CSEC: caesarean section. HPRO
: hip prosthesis. KPRO: knee prosthesis. LAM
: laminectom
y. Dissemination:
Yearly, pooled data
CLABSI VAP
CAUTI
KISS
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ARS
SARI
KISS
Source of data Laboratory Duplicates policy Yes Resistance definition EUCAST or CLSI or Local Risk factors Not specified Metrics and dissemination Prevalence. Yearly, pooled data. Quality Assessment External, voluntary
Source of data Laboratory Duplicates policy Yes Resistance definition EUCAST or CLSI or Local Risk factors Antibiotic use Metrics and dissemination Prevalence, ID. Yearly, pooled data.
Source of data Laboratory+charts Clinical status Infection+colonisation Duplicates policy Yes Resistance definition Local Risk factors Invasive procedures, Antibiotic use Metrics and dissemination Prevalence, ID, CI. Yearly, pooled data.
ID: incidence density: CI: cumulative incidence. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG:GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG TGC SUL
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae
Not specified PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus Not specified OXA FQ LNZ VAN
Enterococcus faecalis/ Enterococcus faecium
Not specified AMP VAN
Escherichia coli/ Klebsiella pneumoniae
Not specified
AMP or AMX
AMC TZP CG MEM or IPM
AG FQ
Pseudomonas aeruginosa
Not specified
FEP or CAZ
TZP MEM or IPM
AG FQ
Acinetobacter baumannii
Not specified
MEM or IPM
AG TGC SUL
Pathogens under surveillance
Specimen source Antibiotics
Staphylococcus aureus Not specified OXA
Enterococcus faecalis/ Enterococcus faecium
Not specified VAN
Escherichia coli/ Klebsiella pneumoniae
Not specified
AMP or AMX
AMC TZP CG ERT MEM or IPM
FQ
Pseudomonas aeruginosa
Not specified
FEP or CAZ
TZP MEM or IPM
FQ
Acinetobacter baumannii
Not specified
MEM or IPM
COL
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ARMIN
GENARS
Source of data Laboratory Duplicates policy Yes Resistance definition EUCAST or CLSI or Local Metrics and dissemination Prevalence. Yearly, pooled data.
Source of data Laboratory Resistance definition Local Metrics and dissemination Prevalence. Pooled data.
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG MEM or IPM
AG FQ
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG TGC SUL
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG:GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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Source of data Laboratory Duplicates policy Yes Resistance definition CLSI Metrics and dissemination Prevalence. Yearly, comparative data with other HCF Quality Assessment External, voluntary
• National • AMR, voluntary participation • Inpatients, all ages • Number of participating hospitals:
52
GSSAR
Greek system for the surveillance of antimicrobial resistance
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN
GEN or TOB
Enterococcus faecalis/ Enterococcus faecium
All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae
All AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG TGC SUL
The Greek strategy
Total population: 11 million
HCF: healthcare facilities. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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Resistance definition EUCAST or CLSI Dissemination Not specified. Mixed, pooled data
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus All OXA VAN
Enterococcus faecalis/ Enterococcus faecium All VAN
Escherichia coli/ Klebsiella pneumoniae All CG ERT MEM or IPM
Pseudomonas aeruginosa All FEP or CAZ
MEM or IPM
Acinetobacter baumannii All MEM or IPM
• National • AMR+HAI, voluntary participation • Inpatients, all ages • Number of participating
labs/hospitals: Not specified
OXA: oxacillin. VAN: vancomycin. CG: cefepime (FEP)/cefotaxime/ceftazidime (CAZ)/ceftriaxone. ERT: ertapenem. MEM: meropenem. IPM: imipenem.
NNSR
National nosocomial surveillance system
The Hungarian strategy
Total population: 10 million
NNIS Risk Index Not specified Include urgent procedures Not specified Data on antibiotic prophylaxis Not specified Peri- operative checklist Not specified Interventions CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Dissemination Mixed, pooled data Quality Assessment Not specified
SSI
SSI: surgical site infection. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
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Source of data Laboratory+charts Clinical status Infection Duplicates policy Yes Resistance definition EUCAST Risk factors Previous hospitalisations, ICU stay Metrics and dissemination Prevalence and ID. Mixed, pooled data
Risk factors Antibiotic use Clinical outcomes Mortality Metrics and dissemination Incidence density, utlisation rate. Mixed, pooled data
CLABSI VAP
CAUTI
Pathogens under surveillance Specimen source Antibiotics
Streptococcus pneumoniae Blood, CSF PEN
Staphylococcus aureus Blood, CSF OXA
Enterococcus faecalis/ Enterococcus faecium Blood, CSF AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae Blood, CSF
AMP or AMX
CG MEM or IPM AG FQ
Pseudomonas aeruginosa Blood, CSF FEP or CAZ TZP MEM
or IPM FQ
Acinetobacter baumannii Blood, CSF MEM or IPM AG
ID: incidence density.PEN: peniclllin. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. AMP: Ampicillin. VAN: vancomycin. AMX: amoxicillin. CG: cefepime (FEP)/cefotaxime/ceftazidime (CAZ)/ceftriaxone. ERT: ertapenem. MEM: meropenem. IPM: imipenem. FQ: ciprofloxacin/levofloxacin /moxifloxacin /ofloxacin. TZP: Piperacillin/tazobactam. AG: gentamicin/tobramycin/amikacin.
CLABSI: Central line-associated bloodstream infection. CAUTI: Catheter-associated urinary tract. VAP: Ventilator-associated pneumonia.
• National • AMR+HAI, voluntary participation • All ages • Number of participating
labs/hospitals: Not specified
HPSC
Health propection surveillance centre
The Irish strategy
Total population: 5 million
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The Italian strategy
•
National
• AM
R, voluntary participation •
Laboratory, all ages •
Num
ber of participating labs: 51
AR-ISS
Antibiotico resistenza - Istituto superiore di sanitá
• Regional
• AM
R, voluntary participation •
Inpatients+outpatients, all ages •
Num
ber of participating hospitals: 59
LAB
Sorveglianza dell’antibioticoresistenza e uso di antibiotici sistem
ici in Emilia-Rom
agna
• Regional
• AM
R, voluntary participation •
Inpatients+outpatients, all ages •
Num
ber of participating labs: 14
SART
Sorveglianza antibiotico resistenza Toscana •
National, inactive
• AM
R, voluntary participation •
Laboratory, all ages
M
ICRONET
Total population: 60 million
• N
ational •
AMR+HAI, voluntary participation
• Inpatients, all ages
• N
umber of participating hospitals:
98
SN
ICh Sistem
a nazionale di sorveglianza delle infezioni del sito chirurgico
• N
ational •
AMR+HAI, voluntary participation
• Inpatients, all ages
• N
umber of participating hospitals:
23
SPIN-U
TI Sorveglianza prospettica delle infezioni
nosocomiali nella U
nità di Terapia Intensiva
• N
ational •
AMR+HAI, voluntary participation
• Inpatients, all ages
• N
umber of participating hospitals:
256
M
ARGHERITA M
argherita PROSAFE
• Regional
• AM
R+HAI, voluntary participation •
Inpatients, all ages •
Num
ber of participating hospitals: 142
SITIER
Sorveglianza regionale delle infezioni in terapia intensiva
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SITIER
MARGHERITA
SPIN-U
TI
Risk factors Antibiotic use, severity score, previous hospitalisations Clinical outcom
es M
ortality M
etrics and dissemination
Incidence density, utlisation rate. Yearly, pooled data
Risk factors Antibiotic use, severity score, previous hospitalisations Clinical outcom
es M
ortality M
etrics and dissemination
Incidence density, utlisation rate. Yearly, comparative data
with other HCF
Quality Assessm
ent Local
Risk factors Antibiotic use, com
orbidities, severity score, previous hospitalisations Clinical outcom
es M
ortality, length of stay M
etrics and dissemination
Incidence density, utlisation rate. RT, comparative data w
ith other HCF
SNICh
NN
IS Risk Index
Yes Include urgent procedures
Yes Data on antibiotic prophylaxis
Yes Peri- operative checklist
Not specified Interventions CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Yearly, comparative
data with other HCF
Quality Assessm
ent
Local, compulsory
SSI
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneum
onia. CAUTI: Catheter-associated urinary tract infections. HCF: healthcare facilities. RT: real-tim
e SSI: surgical site infection. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacem
ent. CHOL:
cholecystectomy. CO
LO: colon surgery. CSEC: caesarean section. HPRO
: hip prosthesis. KPRO: knee prosthesis.
LAM: lam
inectomy.
CLABSI VAP
CAUTI
CLABSI VAP
CAUTI
CLABSI VAP
CAUTI
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AR-ISS
SNICh
SPIN-UTI
Source of data Laboratory Duplicates policy Yes Resistance definition EUCAST Metrics and dissemination Prevalence. Mixed, comparative data with other HCF Quality Assessment External, voluntary
Source of data Laboratory Clinical status Infection Risk factors Antibiotic use Metrics and dissemination CI. Yearly, comparative data with other HCF Quality Assessment Local, compulsory
Source of data Laboratory Clinical status Infection+colonisation Risk factors Invasive procedures, antibiotic use, comorbidities, previous hospitalisation Metrics and dissemination Prevalence, ID. Yearly, pooled data
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae Blood, CSF PEN
CTX or CRO
MAC
Staphylococcus aureus Blood, CSF OXA FQ VAN
GEN or TOB
Enterococcus faecalis/ Enterococcus faecium
Blood, CSF AMP VAN
Escherichia coli/ Klebsiella pneumoniae
Blood, CSF AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ
Pseudomonas aeruginosa Blood, CSF
FEP or CAZ
TZP MEM or IPM
AG FQ
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus Surgical site OXA VAN
Enterococcus faecalis/ Enterococcus faecium Surgical site AMP VAN
Pseudomonas aeruginosa Surgical site FEP or CAZ
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus Not specified OXA
Escherichia coli/ Klebsiella pneumoniae Not specified CG ERT MEM
or IPM
Pseudomonas aeruginosa Not specified FEP or CAZ
Acinetobacter baumannii Not specified MEM or IPM
CI: cumulative incidence. ID: incidence density. HCF: healthcare facilities. RT: real-time. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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MARGHERITA
LAB
SART
Source of data Laboratory+charts Clinical status Infection Duplicates policy Yes Risk factors Invasive procedures, antibiotic use, comorbidities, previous hospitalisation Metrics and dissemination Prevalence. Yearly, comparative data with other HCF Quality Assessment Local
Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST Metrics and dissemination Prevalence. Yearly, comparative data with other HCF Quality Assessment Local
Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST Risk factors Antibiotic use, length of stay, comorbidities Metrics and dissemination Prevalence, ID. Pooled data
CI: cumulative incidence. ID: incidence density. HCF: healthcare facilities. RT: real-time. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
Pathogens under surveillance Specimen source Antibiotics
Streptococcus pneumoniae Not specified PEN
Staphylococcus aureus Not specified OXA
Enterococcus faecalis/ Enterococcus faecium Not specified VAN
Pseudomonas aeruginosa Not specified FEP or CAZ
MEM or IPM
Acinetobacter baumannii Not specified MEM or IPM
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA
Enterococcus faecalis/ Enterococcus faecium
All AMP
Escherichia coli/ Klebsiella pneumoniae
All AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae Blood PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus Bloodv OXA FQ LNZ VAN
Enterococcus faecalis/ Enterococcus faecium Blood AMP VAN
Escherichia coli/ Klebsiella pneumoniae Blood
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa Blood
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii Blood
MEM or IPM
COL AG
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SITIER
MICRONET
Source of data Laboratory Clinical status Infection Risk factors Invasive procedures Metrics and dissemination Prevalence, CI. RT, comparative data with other HCF
Source of data Laboratory+charts Clinical status Infection+colonisation Metrics and dissemination Prevalence. Pooled data
CI: cumulative incidence. ID: incidence density. HCF: healthcare facilities. RT: real-time. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus Not specified OXA VAN
Enterococcus faecalis/ Enterococcus faecium Not specified AMP VAN
Escherichia coli/ Klebsiella pneumoniae Not specified AMC CG ERT MEM
or IPM
Pseudomonas aeruginosa Not specified FEP or CAZ
MEM or IPM
Acinetobacter baumannii Not specified MEM or IPM COL
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG TGC SUL
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NNIS Risk Index Yes Include urgent procedures Yes Data on antibiotic prophylaxis Yes Interventions CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Risk factors Antibiotic use, severity score, previous hospitalizations Clinical outcomes Mortality Metrics Incidence density, cumulative incidence
Dissemination:
Yearly, pooled data
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneumonia. CAUTI: Catheter-associated urinary tract infections SSI: surgical site infection. POST-op: Post-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
The Lithuanian strategy
Total population: 3 million
HAI E.S.LI
Healthcare-associated infections epidemiological surveillance
• National • HAI, voluntary participation • Inpatients, all ages • Number of participating hospitals: 103
SSI
CLABSI VAP
CAUTI
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The Dutch strategy
Total population: 17 million
• National • AMR, voluntary participation • Inpatients+outpatients, all ages • Number of participating labs: 37
ISIS-AR
Infectious disease surveillance and information system for antibiotic resistance
• National • HAI, voluntary participation • Inpatients, all ages • Number of participating hospitals:
43
PREZIES
Preventie van ziekenhuisinfecties door surveillance
• National • HAI, voluntary participation • Inpatients, only adults • Number of participating nursing
homes: 38
SNIV
Surveillance network for infectious diseases in nursing homes
NNIS Risk Index Yes Include urgent procedures Yes Data on antibiotic prophylaxis Yes Peri- operative checklist POST-op Interventions CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Risk factors Antibiotic use, comorbidities Clinical outcomes Mortality Metrics Cumulative incidence
SSI CLABSI
Dissemination: Yearly, pooled
data
PREZIES
Risk factors Antibiotic use Clinical outcomes Mortality Metrics and dissemination Incidence density. Yearly, pooled data
CLABSI VAP
CAUTI
SNIV
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneumonia. CAUTI: Catheter-associated urinary tract infections SSI: surgical site infection. POST-op: Post-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
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Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST Metrics and dissemination Prevalence. Weekly, pooled data
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN
GEN or TOB
Enterococcus faecalis/ Enterococcus faecium
All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae
All AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG TGC SUL
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
ISIS-AR
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The Norwegian strategy
Total population: 5 million
NNIS Risk Index Yes Include urgent procedures Yes Data on antibiotic prophylaxis Yes Peri- operative checklist POST-op Intervention CABG CVAL CHOL COLO CSEC HPRO KPRO LAM
Dissemination Yearly, comparative
data with other HCF
• National • AMR+HAI, voluntary participation • All ages • Number of participating
labs/hospitals: Not specified
FHI Nasjonalt Folkehelseinstitutt: Healthcare
Asssociated Infections module for SSI (NOIS-SSI); Antimicrobial drug Resistance module
(NORM)
SSI: surgical site infection. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacement. CHOL: cholecystectomy. COLO: colon surgery. CSEC: caesarean section. HPRO: hip prosthesis. KPRO: knee prosthesis. LAM: laminectomy.
Source of data Laboratory+charts Clinical status Not specified Duplicates policy Yes Resistance definition EUCSAT Risk factors Antibiotic use Metrics and dissemination Prevalence. Yearly, comparative data with other HCF Quality Assessment Not specified
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae Blood, CSF PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN
Enterococcus faecalis/ Enterococcus faecium
Blood AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae
All AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa
Not specified
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii
Not specified
MEM or IPM
COL AG TGC
SSI
HCF: healthcare facilities. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline.
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The Portugese strategy
Total population: 10 million
• National • AMR+HAI, voluntary participation • Inpatients+outpatients, all ages • Number of participating
labs/hospitals: Not specified
ARSIP
Antibiotic resistance surveillance program in Portugal
Source of data Laboratory Clinical status Infection Dissemination Comparative data with other HCF
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The Slovak strategy
Total population: 5 million
Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST or CLSI Metrics and dissemination Prevalence. Yearly, pooled data Quality Assessment External, compulsory
• National • AMR, voluntary participation • Inpatients+outpatients, all ages • Number of participating labs: 40
SNARS
Slovak national antimicrobial resistance surveillance system
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN
GEN or TOB
Enterococcus faecalis/ Enterococcus faecium
All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae
All AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All
FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All
MEM or IPM
COL AG TGC SUL
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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The Spanish strategy
•
National
• HAI, voluntary participation
• Inpatients, all ages
• N
umber of participating
labs/hospitals: Not specified
EPINE
Estudio de prevalencia de las infecciones nosocom
iales en España
• N
ational •
AMR+HAI, voluntary participation
• Inpatients+outpatients, all ages
• N
umber of participating
labs/hospitals: Not specified
EN
VIN-UCI
Estudio nacional de vigilancia de Infección nososcom
ial en servicios de medicina
intensiva
• Regional
• HAI, voluntary participation
• Inpatients, all ages
• N
umber of participating
labs/hospitals: Not specified
IN
OZ
Infekzio nosocomialak zaintzeko eta
kontrolatzeko del País Vasco
• Regional
• HAI, voluntary participation
• Inpatients+outpatients, all ages
• N
umber of participating
labs/hospitals: Not specified
SVE Canarias
Sistema de Vigilancia epidem
iológica de Canarias
• Regional
• AM
R+HAI, voluntary participation •
Inpatients, all ages •
Num
ber of participating labs/hospitals: Not specified
VIN
CAT Vigilancia de les Infeccions nosocom
ials als hospitals de Cataluya
• Regional
• AM
R+HAI, voluntary participation •
Inpatients, all ages •
Num
ber of participating labs/hospitals: N
ot specified
SVPCIPA
Sistema de vigilancia, prevención y control
de IRAS en principado de Asturias
• Regional
• AM
R+HAI, voluntary participation •
Inpatients+outpatients, all ages •
Num
ber of participating labs/hospitals: Not specified
PIRASOA
Programa Integral de Prevención, control de
las Infecciones relacionadas con la Asistencia Sanitaria y Uso apropiado de los
Antimicrobianos
• Regional
• AM
R+HAI, voluntary participation •
Inpatients+outpatients, all ages •
Num
ber of participating labs/hospitals: N
ot specified
SVIN
Sistema de vigilancia nosocom
ial de Galicia
• Regional
• HAI, voluntary participation
• Inpatients, all ages
• N
umber of participating
labs/hospitals: Not specified
VIRAS
Vigilancia de las Infecciones relacionadas con la asistencia sanitaria de M
adrid
Total population: 46 million
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VIRAS EN
VIN-UCI
Risk factors Antibiotic use, com
orbidities, severity score, length of stay, antibiotic use. Clinical outcom
es M
ortality M
etrics and dissemination
ID,CI,UR. Yearly, individual HCF data
CLABSI VAP
CAUTI
CLABSI: Central line-associated bloodstream infection. VAP: Ventilator-associated pneum
onia. CAUTI: Catheter-associated urinary tract infections
ID: Incidence density. CI: Cumulative incidence. UR: Utilisation rate. HCF: Healthcare facilities
SSI: surgical site infection. PRE-op: PRE-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacem
ent. CHOL: cholecystectom
y. COLO
: colon surgery. CSEC: caesarean section. HPRO
: hip prosthesis. KPRO: knee prosthesis. LAM
: laminectom
y.
SVIN
Risk factors Severity score M
etrics and dissemination
ID,UR. Monthly, com
parative data with other HCF
CLABSI VAP
Peri- operative checklist
PRE-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Yearly, individual HCF data
SSI
SVPCIPA
Metrics
ID, UR. Peri- operative checklist
PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Yearly, individual HCF data SSI
CLABSI VAP
CAUTI
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VIN
CAT
Risk factors Com
orbidities, severity score, length of stay M
etrics ID,CI,UR.
CLABSI VAP
CAUTI
NN
IS Risk Index
Yes Include urgent procedures
Yes Data on antibiotic prophylaxis
Yes Peri- operative checklist
PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
SSI
Dissemination
Yearly, comparative data w
ith other HCF
PIRASOA
Risk factors Antibiotic use, com
orbidities, severity score, length of stay, antibiotic use. Clinical outcom
es M
ortality M
etrics ID,CI,UR.
CLABSI VAP
CAUTI
NN
IS Risk Index
Yes Include urgent procedures
Yes Peri- operative checklist
PRE+PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
SSI
Dissemination
Quarterly, com
parative data with other
HCF
INO
S
Risk factors Com
orbidities, severity score Clinical outcom
es M
ortality M
etrics ID, UR.
CLABSI VAP
CAUTI
Peri- operative checklist
PRE-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
SSI
Dissemination
Individual HCF data
CLABSI: Central line-associated bloodstream
infection VAP: Ventilator-associated pneum
onia CAUTI: Catheter-associated urinary tract infections ID: Incidence density CI: Cum
ulative incidence UR: Utilisation rate HCF: Healthcare facilities SSI: surgical site infection PRE-op: PRE-operative checklist PO
ST-op: POST-operative
checklist CABG: Coronary artery bypass grafting CVAL: cardiac valve replacem
ent CHO
L: cholecystectomy
COLO
: colon surgery CSEC: caesarean section HPRO
: hip prosthesis KPRO
: knee prosthesis LAM
: laminectom
y
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ENVIN-UCI
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN CTX or CRO
Staphylococcus aureus All OXA VAN
Enterococcus faecalis/ Enterococcus faecium All AMP VAN
Escherichia coli/ Klebsiella pneumoniae All CG FQ
Pseudomonas aeruginosa All FEP or CAZ
TZP MEM or IPM
FQ COL
Source of data Laboratory Clinical status Infection+colonisation Resistance definition EUCAST+CLSI Risk factors Antibiotic use Metrics and dissemination Incidence density. Yearly, individual HCF data
PIRASOA
Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST+CLSI Risk factors Invasive procedures, antibiotic use Metrics and dissemination Incidence density. Quarterly, comparative data with other HCF
Pathogens under surveillance
Specimen source Antibiotics
Enterococcus faecalis/ Enterococcus faecium Not specified VAN
Escherichia coli/ Klebsiella pneumoniae Blood CG
SVPCIPA
SVIN
VINCAT
Source of data Laboratory Clinical status Infection+colonisation Metrics and dissemination Incidence density. Yearly, individual HCF data
Source of data Laboratory Clinical status Infection Risk factors Antibiotic use Dissemination Monthly, comparative data with other HCF Quality Assessment Local
Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Risk factors Antibiotic use Dissemination Yearly, comparative data with other HCF
HCF: Healthcare facilities. PEN: peniclllin. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone. CG:FEP/CTX/CAZ/CRO. OXA: oxacillin. VAN: vancomycin. AMP: Ampicillin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. TZP: Piperacillin/tazobactam. MEM: meropenem. IPM: imipenem. COL: colistin.
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• National • AMR, voluntary participation • Inpatients and outpatients, all ages • Number of participating labs: 25
•
Source of data Laboratory Clinical status Infection+colonisation Resistance definition EUCAST Metrics and dissemination Prevalence. Yearly, pooled data. Quality Assessment External, compulsory
The Swedish strategy
Total population: 10 million
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All MEM or IPM
COL AG TGC SUL
SVEBAR
Swedish surveillance of antimicrobial resistance
SVEBAR
• National • AMR, voluntary participation • Number of participating labs: 24
RESNET
Annual resistance monitoring and quality control programme
Source of data Laboratory Resistance definition EUCAST Metrics and dissemination Prevalence. Yearly, pooled data.
RESNET
PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG: GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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• N
ational •
AMR, voluntary participation
• Inpatients and outpatients, all ages
• N
umber of participating labs: 19
•
The Swiss strategy
Total population: 8 million
AN
RESIS Sw
iss centre for antibiotic resistance
• Regional
• AM
R, voluntary participation •
Inpatients and outpatients, all ages •
Num
ber of participating labs/hospitals: N
ot specified •
: •
CA-M
RSA CA-M
RSA surveillance system
• N
ational •
HAI, voluntary participation •
Inpatients, all ages •
Num
ber of participating hospitals: 165
SW
ISSNO
SO
• Regional
• AM
R+HAI, voluntary participation •
Inpatients+outpatients, all ages •
Num
ber of participating labs/hospitals: N
ot specified
HPCI
Hygiène hospitalière prévention et contrôle de l'infection
SWISSN
OSO
HPCI M
etrics and dissemination
ID,CI. Not specified NN
IS Risk Index
Yes Include urgent procedures
Yes Data on antibiotic prophylaxis
Yes Peri- operative checklist
POST-op
Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Yearly, pooled data Q
uality Assessment
Local, com
pulsory
CLABSI
SSI
SSI: surgical site infection. POST-op: PO
ST-operative checklist. CABG: Coronary artery bypass grafting. CVAL: cardiac valve replacem
ent. CHOL: cholecystectom
y. COLO
: colon
surgery. CSEC:
caesarean section.
HPRO:
hip prosthesis.
KPRO:
knee prosthesis.
LAM:
laminectom
y. CLABSI: Central line-associated bloodstream
infection. ID: Incidence density. CI: Cumulative incidence.
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ANRESIS
CA-MRSA
Source of data Laboratory Clinical status Infection+colonisation Duplicates policy Yes Resistance definition EUCAST or CLSI Metrics and dissemination Prevalence. Yearly, pooled data Quality Assessment External voluntary
Source of data Charts Clinical status Infection+colonisation Resistance definition EUCAST Risk factors Invasive procedures, antibiotic use, comorbidities, previous hospitalisation, others (contact, travel, substance use, sexual preference) Metrics and dissemination % infections Pooled data
HPCI
Source of data Laboratory+charts Clinical status Infection+colonisation Duplicates policy Not specified Resistance definition EUCAST Metrics and dissemination CI, ID. Not specified
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae All PEN LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus All OXA FQ LNZ VAN GEN or TOB
Enterococcus faecalis/ Enterococcus faecium All AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All MEM or IPM
COL AG TGC SUL
Pathogens under surveillance
Specimen source Antibiotics
Staphylococcus aureus Blood OXA
Enterococcus faecalis/ Enterococcus faecium Blood VAN
Escherichia coli/ Klebsiella pneumoniae Blood CG ERT
MEM or IPM
Pathogens under surveillance
Specimen source Antibiotics
Staphylococcus aureus Blood OXA
ID: Incidence density: CI: Cumulative incidence. PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG:GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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• Regional • AMR+HAI, voluntary participation • Inpatients and outpatients, all ages • Number of participating hospitals:
86 • :
•
The British strategy
Total population: 65 million
WHAIP
Welsh healthcare associated infections programme
• Regional • AMR+HAI, voluntary participation • Inpatients, all ages • Number of participating
labs/hospitals: Not specified • :
•
HPS
Health protection Scotland
• Regional • AMR+HAI, voluntary participation • Laboratory , all ages • Number of participating hospitals:
26
HISC/HPA
Healthcare infection centre/healthcare protection agency
• Regional • AMR+HAI, voluntary participation • Laboratory, all ages • Number of participating
labs/hospitals: Not specified • : •
PHE
Public health England
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PHE
NN
IS Risk Index
Yes Include urgent procedures
Yes Data on antibiotic prophylaxis
Yes Peri- operative checklist
PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Mixed, individual HCF data
CLABSI: Central line-associated bloodstream
infection VAP: Ventilator-associated pneum
onia CAUTI: Catheter-associated urinary tract infections ID: Incidence density UR: Utilisation rate HCF: Healthcare facilities SSI: surgical site infection PRE-op: PRE-operative checklist PO
ST-op: POST-operative
checklist CABG: Coronary artery bypass grafting CVAL: cardiac valve replacem
ent CHO
L: cholecystectomy
COLO
: colon surgery CSEC: caesarean section HPRO
: hip prosthesis KPRO
: knee prosthesis LAM
: laminectom
y
WHAIP
Metrics
ID,UR N
NIS Risk Index
Yes Include urgent procedures
Yes Peri- operative checklist
PRE+PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Monthly, com
parative data with other
HCF
HPS
Risk factors Com
orbidities, severity score Clinical outcom
es M
ortality, length of stay M
etrics ID,UR N
NIS Risk Index
Yes Include urgent procedures
Yes Data on antibiotic prophylaxis
Yes Peri- operative checklist
PRE+PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Quarterly, com
parative data with
other HCF Q
uality Assessment
External
HISC/HPA
NN
IS Risk Index
Yes Include urgent procedures
Yes Data on antibiotic prophylaxis
Yes Peri- operative checklist
PRE+PO
ST-op Intervention CABG
CVAL CHO
L CO
LO
CSEC HPRO
KPRO
LAM
Dissemination
Pooled data
CLABSI VAP
CAUTI
SSI
SSI
SSI SSI
CLABSI VAP
CAUTI
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WHAIP
PHE
Source of data Laboratory Clinical status Infection+colonisation Metrics and dissemination CI. Monthly, comparative data with other HCF
Source of data Charts Clinical status Infection+colonisation Duplicates policy Yes Risk factors Invasive procedures, antibiotic use Metrics and dissemination CI,DI, Prevalence. Mixed, individual HCF data
HPS
HISC/HPA
Source of data Charts Clinical status Infection+colonisation Duplicates policy Yes Risk factors Antibiotic use Metrics and dissemination CI, Prevalence. Quarterly, comparative data with other HCF Quality Assessment External
Source of data Laboratory Dissemination Pooled data Quality Assessment Local
Pathogens under surveillance
Specimen source Antibiotics
Streptococcus pneumoniae
Blood, respiratory PEN
LVX or MFX
CTX or CRO
MAC
Staphylococcus aureus Blood, respiratory OXA FQ LNZ VAN
Enterococcus faecalis/ Enterococcus faecium
Blood, respiratory AMP VAN GEH
Escherichia coli/ Klebsiella pneumoniae All
AMP or AMX
AMC TZP CG ERT MEM or IPM
AG FQ COL
Pseudomonas aeruginosa All FEP or CAZ
TZP MEM or IPM
AG FQ COL
Acinetobacter baumannii All MEM or IPM
COL AG TGC
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus Blood
OXA
Enterococcus faecalis/ Enterococcus faecium
Blood VAN
Pathogens under surveillance Specimen source Antibiotics
Streptococcus pneumoniae Not specified PEN
Staphylococcus aureus Blood OXA
Enterococcus faecalis/ Enterococcus faecium Blood VAN GEH
Pathogens under surveillance Specimen source Antibiotics
Staphylococcus aureus Blood OXA
Enterococcus faecalis/ Enterococcus faecium Blood GEN or
TOB
CI: Cumulative incidence. ID: Incidence density HCF: Healthcare facilities.PEN: peniclllin. CIP: ciprofloxacin. LVX: levofloxacin. MFX: moxifloxacin. OFX: ofloxacin. FQ: CIP/LVX/MFX/OFX. FEP: cefepime. CTX: cefotaxime. CAZ: ceftazidime. CRO: ceftriaxone.CG:FEP/CTX/CAZ/CRO. MAC: macrolides (erythromycin/ clarithromycin). OXA: oxacillin. LNZ: linezolid. VAN: vancomycin. GEN: gentamicin. GHLR: gentamicin, high level resistance. TOB: tobramycin. AMK: amikacin. AG:GEN/TOB/AMK. AMP: Ampicillin. AMX: amoxicillin. AMC: amoxicillin/clavulanate; TZP: Piperacillin/tazobactam.. ERT: ertapenem. MEM: meropenem. IPM: imipenem. COL: colistin. TGC: tigecycline. SUL: sulbactam.
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References
1. Cassini A, Plachouras D, Eckmanns T, et al. Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study. PLoS Med. 2016 Oct 18;13(10):e1002150.
2. European com-mission. Action plan against the rising threats from Antimicrobial Resistance. Communication from the commission to the European parliament and the council. Brussels, September 2011. Available at: http://ec.europa.eu/dgs/health_consumer/docs/communication_amr_2011_748_es.pdf
3. ECDC/EMEA Joint technical report. The bacterial challenge: time to react. ref. EMEA/576176/2009. Stockholm, September 2009. ISBN 978-92-9193-193-4. doi 10.2900/2518.
4. Zingg W, Holmes A, Dettenkofer M, et al. Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. Lancet Infect Dis. 2015 Feb;15(2):212-24. doi: 10.1016/S1473-3099(14)70854-0. Epub 2014 Nov 11.
5. Haustein T, Gastmeier P, Holmes A, Lucet JC, Shannon RP, Pittet D, Harbarth S. Use of benchmarking and public reporting for infection control in four high-income countries. Lancet Infect Dis 2011;11:471-81.
6. European Centre for Disease Prevention and Control: Annual Epidemiological Report on Communicable Diseases in Europe 2008. Stockholm, European Centre for Disease Prevention and Control, 2008. Available at: http://ecdc.europa.eu/en/publications/publications/0812_sur_annual_epidemiological_report_2008.pdf.
7. Council Recommendation of 9 June 2009 on patient safety, including the prevention and control of healthcare associated infections (2009/C 151/01). Available at: http://ec.europa.eu/health/patient_safety/docs/council_2009_en.pdf.
8. Shamseer L, Moher D, Clarke M et al, PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 2015;349:g7647 doi: 10.1136/bmj.g7647.
9. Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D. Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clin Infect Dis. 2014 Jul 1;59(1):96-105.
10. Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015 Jul;158(1):66-77.
11. Helmick RA, Knofsky ML, Braxton CC, Subramanian A, Byers P, Lan CK, Awad SS. Mandated self-reporting of ventilator-associated pneumonia bundle and catheter-related bloodstream infection bundle compliance and infection rates. JAMA Surg. 2014 Oct;149(10):1003-7.
12. Zarb P, Coignard B, Griskeviciene J, Muller A, Vankerckhoven V, Weist K, Goossens M, Vaerenberg S, Hopkins S, Catry B, Monnet D, Goossens H, Suetens C; National Contact Points for the ECDC pilot point prevalence survey.; Hospital Contact Points for the ECDC pilot point prevalence survey. The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use. Euro Surveill. 2012 Nov 15;17(46). pii: 20316.
13. de Kraker ME, Stewardson AJ, Harbarth S. Will 10 Million People Die a Year due to Antimicrobial Resistance by 2050? PLoS Med. 2016 Nov 29;13(11):e1002184.
14. van Mourik MS, Troelstra A, van Solinge WW, Moons KG, Bonten MJ. Automated surveillance for healthcare-associated infections: opportunities for improvement. Clin Infect Dis. 2013 Jul;57(1):85-93.
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3. A systematic review of SURVeillance programs for Antimicrobial resistance In Livestock and meat thereof in the European Union (SURVAIL) Authors
Remco Schrijver, Jesús Rodríguez-Baño, Nithya Babu Rajendran, Evelina Tacconelli, Andreas
Voss
Introduction
Antibiotics usage in animal production has been associated with resistance in humans,
although bacteria and antibiotics of veterinary and human interest differ deeply. Depending
on the aim, veterinary surveillance programmes may not necessarily include bacteria for
human interest, though such information might be very valuable. The “one-health concept”
clearly underlines the importance of connecting human and animal data on antibiotic
resistance to antibiotics. However at the moment, to the best of our knowledge, there is no
comprehensive information on this connection.
The aim of this study was to describe national and international surveillance programs and
networks collecting multi-annual data on antimicrobial resistance of bacterial isolates from
livestock and meat and compare the antibiotics and bacteria monitored with the antibiotics
and bacteria relevant for human health.
Materials and Methods
Surveillance systems including data from livestock and meat were identified through
systematic search of peer-reviewed (PubMed, EMBASE and Scopus) and grey literature
(Google search engine and targeted websites of public health institutions and scientific
societies). The following terms were used for the searches: “antimicrobial resistance” or
“antimicrobial susceptibility” combined with “livestock”, “cattle”, “bulls”, “calves”, “veal
calves”, “pigs”, “fatteners”, “poultry” (“chicken and “turkey”), “broilers” and geographical
(Europe). Time period was limited to the last 10 years. A three-step screening strategy was
used: 1. text words contained in the title, abstract and the index (MESH) terms in PubMed
along with title searches; 2. keywords and index terms across all other included databases;
and 3. The reference lists of all identified reports and articles were searched for additional
studies. No language restriction was applied. Additionally, data was obtained through
consulation with national authorities in European Union (EU) member states (MS) or
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representatives of national as well as European organisations active in AMR recording in
animals and food.
Results
International AMR monitoring programmes in Europe
Table 1 summarises the characterisitcs of the following international AMR surveillance
systems for animals and food.
• Harmonised monitoring and reporting of AMR in zoonotic and commensal bacteria: an
initiative of the European commission which mandates and recommends the surveillance of
specific bacterial species and antibiotic combinations in its member states under the
Decision 2013/652/EU.
• EASSA, European Antimicrobial Susceptibility Surveillance in Animals: a voluntary
programme – coordinated by the Centre Européen d’Etudes pour la Santé Animale (CEESA)-
examining the antimicrobial susceptibility of zoonotic and commensal bacteria in healthy
food animals.
• Vetpath: a voluntary programme, coordinated by CEESA, examining the antimicrobial
susceptibility of disease-causing bacterial pathogens in animals.
National antimicrobial monitoring programmes
Besides the mandatory AMR reporting, several MS have undertaken other AMR surveillance
activities, particularly for animal bacteria. Table 2 presents the characteristics of national
antimicrobial monitoring programmes in Europe, including thoss which adhere to mandatory
EU monitoring by Decision 2013/652/EU (Figure 1, Table 2).
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Table 1. International antimicrobial-resistance monitoring programmes in Europe Programme Target bacteria Animals and
derived meat Origin of samples
Susceptibility tests
Breakpoints Laboratories
Harmonised monitoring and reporting of AMR in EU
Salmonella spp Campylobacter jejuni Campylobacter coli Escherichia coli Enterococcus faecalis Enterococcus. faecium ESBL- or AmpC- or carbapenemase-producing Salmonella spp. and E. coli
Bovines, pigs, poultry
(broilers, laying hens,
fattening turkeys)
farm, slaughterhouse,
retail
dilution tests, diffusion tests
epidemiological cutoff values
(ECOFFs)
National laboratories
EASSA
beef cattle, slaughter pigs,
broiler chickens
intestinal samples taken at
slaughter microdilution
clinical breakpoints
(CLSI) or epidemiological
breakpoints (EFSA/EUCAST)
National laboratories
Salmonella spp. Campylobacter Enterococcus spp E. coli
VetPath
Staphylococcus. aureus E. coli Pasteurella multocida Mannheimia haemolytica Histophilus somni Actinobacillus pleuropneumoniae Haemophilus parasuis Bordetella bronchiseptica Streptococcus suis Streptococcus uberis
cattle, pigs
lung samples or nasopharyngeal
/nasal swabs, mastitis samples
microdilution clinical
breakpoints (CLSI)
Central laboratory
Figure 1A. European countries with national antimicrobial-resistance monitoring programmes in
animals and food
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Figure 1B. Main characteristics of national antim
icrobial-resistance monitoring program
mes in Europe
Austria
Surveillance programm
e AURES Target bacteria, anim
als and food In accordance w
ith EU regulations
Suceptibility tests and read-outs M
icrodilution. ECOFF follow
ing EUCAST standards
Belgium
Surveillance institution CO
DA-CERVA, Veterinary and agrochem
ical research centre Target bacteria Salm
onella spp., C. jejuni, C. coli,E. coli m
ethicillin-resistant S. aureus (MRSA),
comm
ensal enterococci Target anim
als and food Cattle, pigs, poultry and m
eat and meat
products Suceptibility tests and read-outs M
icrodilution. ECOFF follow
ing EUCAST standards
Denmark
Surveillance programm
e DANM
AP, Danish integrated antim
icrobial resistance monitoring and
research programm
e Target bacteria, anim
als and food In accordance w
ith EU regulations
Suceptibility tests and read-outs M
icrodilution. ECOFF and EUCAST clinical
breakpoints
Germany
1. Surveillance programm
e DARLink, Germ
an antimicrobial
situation in the food chain Target bacteria Salm
onella spp. Cam
pylobacter spp. verotoxin-form
ing E. coli(VTEC) comm
ensal E. coli M
RSA Suceptibility tests and read-outs M
icrodilution. ECOFF
2. Surveillance programm
e GERM
Vet, German national
monitoring program
me
Target bacteria E. coli, Klebsiella pneum
oniae E. faecalis, E. faecium
, S. aureus Streptococcus agalactiae, Streptococcus dysgalactiae, S. uberis, M
. haemolytica
Pasteurella haemolytica, A. pleuropneum
oniae B. bronchiseptica Target anim
als and food Cattle, pigs, chickens and non-m
eat producing anim
als (clinical samples)
Suceptibility tests and read-outs M
icrodilution. CLSI clinical breakpoints
Finland
Surveillance programm
e FINRES-Vet, Finnish veterinary antim
icrobial resistance m
onitoring and consumption of
antimicrobial agents
Target bacteria, animals and food
In accordance with EU
regulations. Veterninary pathogens (from
clinical samples) additional
Suceptibility tests and read-outs Dilution. ECO
FF
France
Surveillance programm
e RESAPATH, French surveillance netw
ork for antim
icrobial resistance in pathogenic bacteria of anim
al origin Target bacteria Arcanobacterium
, Corynebacterium spp.
Salmonella spp., Klebsiella spp.
Pasteurella spp., Pseudomonas spp.
E. coli, Enterococcus spp. Streptococcus spp., S. aureus Staphylococcus hyicus Actinobacillus pleuropneum
oniae Clostridum
perfringens O
rnithobacterium tracheale
Target animals and food
Cattle, pigs, and poultry (clinical samples)
Suceptibility tests and read-outs Disk diffusuion. Resistance follow
ing antibiogram
comm
ittee of the French society of m
icrobiology (CA-SFM) guidelines.
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Figure 1C. Main characteristics of national antim
icrobial-resistance monitoring program
mes in Europe
Netherlands
Surveillance programm
e M
ARAN, M
onitoring of antim
icrobial resistance and antibiotic usage in anim
als in Netherlands Target bacteria ESBL- producing Salm
onella spp. and E. coli, carbapenem
ase-producing Enterobacteriaceae, M
RSA, colistin-resistant E. coli Suceptibility tests and read-outs M
icrodilution. ECOFF follow
ing EUCAST standards
Norw
ay Surveillance program
me
NORM
-Vet Target bacteria, anim
als and food In accordance w
ith EU regulations
Suceptibility tests and read-outs M
icrodilution. ECOFF follow
ing EUCAST standards
Spain Surveillance program
me
VAV, Veterinary Antim
icrobial Resistance Surveillance Netw
ork Target bacteria Salm
onella, Campylobacter,
E. coli, enterococci,S.aureus Target anim
als and food Healthy and infected anim
als Suceptibility tests and read-outs M
icrodilution and agar diffusion.
Sweden
Surveillance programm
e SVARM
, Swedish veterinary
antimicrobial resistance m
onitoring program
me
Target bacteria Salm
onella, Campylobacter,
E. coli, enterococci, carbapenemase-producing
Enterobacteriaceae, Pasteurella spp., A. pleuropneum
oniae, Brachyspira hyodysenteriae, M
. haemolytica, Bibersteinia trehalosi
Target animals and food
Healthy and infected farm anim
als Suceptibility tests and read-outs M
icrodilution. ECOFF follow
ing EUCAST standards
United kingdom
Surveillance institution VARSS, Veterinary antibiotic resistance and sales surveillance program
me
Target bacteria Salm
onella, Campylobacter,
E. coli, enterococci, P. m
ultocida, Histophilus somnus,
A. pleuropneumonia, Trueperella pyogenes,
M. haem
olytica, B. trehalosi, S. dysgalactiae, S. uberis, S. aureus, Klebsiella pneum
oniae, Pseudom
onas aeruginosa, Brachyspira hyodysenteriae Target anim
als and food Cattle, pigs, poultry, and sheeps (healthy and infected) Suceptibility tests and read-outs M
icrodilution and agar diffusion. ECOFF and
human clinical breakpoints
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Table 2. Microorganism
s tested in 15 antimicrobial-resistance surveillance program
mes in livestock
Gram-positive bacteria
Resistance risk for humans
Surveillance in Geographical areas
Cattles Pigs
Poultry Food (m
eat) Staphylococcus aureus
Methicillin resistance (M
RSA); vancomycin-interm
ediate resistance and resistance (VISA/VRSA)
Yes Yes
Yes Yes
EU,DE, FI, SE, UK
Enterococcus faecalis Vancom
ycin resistance (VRE) Yes
DE
Enterococcus faecium
Yes
DE
Streptococcus pneumoniae
Penicillin resistance
Streptococcus suis
EU, UK
Streptococcus agalactiae
Yes
DE, FI
Streptococcus uberis
Yes
EU, DE, FR, UK
Streptococcus dysgalactiae
Yes
DE, FI, FR, UK
Gram-negative bacteria
Resistance risk for humans
Surveillance in Geographical areas
Cattles Pigs
Poultry Food (m
eat)
Acinetobacter baumannii
Ceftazidime and carbapenem
Actinobacillus pleuropneum
oniae
Yes
EU,DE, SE
Bordetella bronchiseptica
Yes
Yes
EU
Campylobacter
Fluroquinolone and macrolide resistance
Yes Yes
Yes Yes
EU
Escherichia coli ESBL (third-generation cephalosporin resistance); carbapenem
resistance; ciprofloxacine resistance
Yes Yes
Yes Yes
EU,DE, FI, FR, SE
Haemophilus parasuis
Yes
EU
Histophilus somnus
Yes
EU
Klebsiella ESBL (third-generation cephalosporin resistance); carbapenem
resistance
Yes
DE, FR
Mannheim
ia haemolytica
Yes
EU, DE, FR
Pasteurella haemolytica
Yes
DE
Pasteurella multocida
Yes
Yes
EU,DE, FR, SE, UK
Pseudomonas aeruginosa
Carbapenem resistance
Salmonella
ESBL (third-generation cephalosporin resistance)
EU, FR
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Table 3. Antibiotics included in 15 antimicrobial-resistance surveillance program
mes in livestock
ATC Codes ATC Vet codes
Therapeutic group Antibiotics intended for veterinary use (ATC Vet)
Antibiotics intended for human
use (ATC) Antibiotics in veterinary/food
surveillance programm
es Geographical areas
J01CA Q
J01CA Penicillins w
ith extended spectrum
Ampicillin
Ampicillin
Ampicillin
EU,DE, FI, FR, SE, UK Am
oxicillin Am
oxicillin Am
oxicillin EU,FR,
Penicillin
Penicillin EU,DE, FI, SE, UK
Temocillin
Temocillin
Temocillin
EU
Oxacillin
Oxacillin
FI
J01D Q
J01D
Cephalosporin 1st generation
Cefalexin Cefalexin
Cefalexin FR
Cefalotin
Cefalotin FI, FR, SE
Cephalosporin 2nd generation
Cefoxitin
Cefoxitin EU, FI, FR
Cefuroxim
e Cefuroxim
e FR
Cephalosporin 3nd generation
Cefoperazone
Cefoperazone DE,FR
Cefotaxime
Cefotaxime
Cefotaxime
EU,DE, FI, SE
Cefpodoxime
Cefpodoxime
UK
Ceftazidime
Ceftazidime
FR Ceftiofur
Ceftiofur
EU,DE, FR, SE
Cephalosporin 4th generation
Cefquinome
Cefquinom
e DE,FR
Cefepim
e Cefepim
e EU, FR
Ertapenem
Ertapenem
EU, FR
Im
ipenem
Imipenem
EU
M
eropenem
Meropenem
EU
J01GB Q
J01G Am
inoglycosides Gentam
icin
Gentamicin
EU, FI, FR, SE
Kanamycin
Kanamycin
EU, FI, FR, SE Neom
ycin
Neomycin
FI, FR, SE, UK
J01A Q
01A Tetracyclines
Doxycyclin Doxycyclin
Doxycyclin DE, FR, UK
Tetracycline Tetracycline
Tetracycline EU,DE, FI, FR, SE, UK
Tigecycline
Tigecycline EU
J01B Q
01B Am
phenicols Chloram
phenicol
Chloramphenicol
EU, FI, FR, SE Florfenicol
Florfenicol
EU,DE, FI, FR, SE, UK
J01E Q
J01E Trim
ethoprim derivatives
Trimethoprim
Trimethoprim
EU, FI, FR, SE
Sulfamethoxazole and
trimethoprim
Sulfamethoxazole
EU,DE, FI, SE, UK
J01FA Q
J01F M
acrolides
Apramycin
Apramycin
Apramycin
FR, UK Azithrom
ycin Azithrom
ycin Azithrom
ycin EU
Erthromycin
Erthromycin
Erthromycin
FI, FR, SE, UK Pristinam
ycin
Pristinamycin
FR Streptom
ycin Streptom
ycin Streptom
ycin EU,DE, FI, FR, SE, UK
Spiramycin
Spiramycin
Spiramycin
FR Tulathrom
ycin Tulathrom
ycin Tulathrom
ycin EU,DE
Tylosin
Tylosin FR, UK
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J01FF Q
J01F Lincosam
ides
Clindamycin
Clindamycin
EU, FI, SE Lincom
ycin Lincom
ycin Lincom
ycin FR, UK
Pirilimycin
Pirilim
ycin DE
J01FG02 Q
J01FG02 Streptogram
ins Q
uinupristin/dalfopristin Q
uinupristin/dalfopristin Q
uinupristin/dalfopristin EU,DE
J01MA
QJ01M
A Fluoroquinolones
Ciprofloxacin Ciprofloxacin
Ciprofloxacin EU,FI,SE
Danofloxacin
Danofloxacin EU, FR
Difloxacin
Difloxacin FR
Enrofloxacin
Enrofloxacin EU,DE, FR, SE, UK
Levofloxacin
Levofloxacin
Marbofloxacin
M
arbofloxacin EU,DE, FR
J01MB
QJ01M
O
ther quinolones Flum
equin
Flumequin
FR Nalidixic acid
Nalidixic acid
EU,DE, FI, FR, SE
J01XB Q
J01XB Polym
yxins Colistin
Colistin
EU,SE
Vancomycin
Vancomycin
EU,DE J01XC01
QJ01XC01
Steriod antimicrobials
Fusidic acid Fusidic acid
Fusidic acid EU, FI, SE
J01XX04
Spectinom
ycin
Spectinomycin
EU,DE, FR, UK
Pleuorom
utilins Tiam
ulin
Tiamulin
EU,DE J01XX08
QJ01XX08
Other antim
icrobials Linezolid
Linezolid Linezolid
EU J04AM
Antibioitcs specific for TB
Rifampicin
Rifampicin
EU, FR D06AX09
QD06AX09
Topical use M
upirocin M
upirocin M
upirocin EU
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References
1. A. de Jong, V. Thomas, S. Simjee, K.Godinho, B. Schiessl, U.Klein, P.Butty, M.Valle, H. Marion and T. R. Shryock. Pan-European monitoring of susceptibility to human-use antimicrobial agents in enteric bacteria isolated from healthy food-producing animals. Antimicrob Chemother 2012; 67: 638–651
2. A de Jong et al; Pan-European resistance monitoring programmes encompassing food-borne bacteria and target pathogens of food-producing and companion animals. International Journal of Antimicrobial Agents 41 (2013) 403– 409
3. A de Jong et al; Antimicrobial susceptibility monitoring of respiratory tract pathogens isolated from diseased cattle and pigs across Europe: The VetPath study. Veterinary Microbiology 172 (2014) 202–215 (VetPath Study)
4. A. de Jong, H. Moyaert, and S. Simjee. Antimicrobial susceptibility testing of foodborne bacteria related to national and international resistance-monitoring programmes. In: Antimicrobial Food Packaging; chapter 9; 117 ev. 2016. ISBN 978-0-12-800723-5
5. ARSIA, 2013. Antibiogrammes. Rapport d’activité et résultats de l’ARSIA. ARSIA esbl. http://www.arsia.be/?page_id=3991#
6. AURES 2014. Austrian report on antimicrobial resistance . http://www.ages.at/en/topics/ages-topics/antibiotika-resistenzen/aures-berichte/#downloads
7. BVL, 2016. GERMVET. Resistenzsituation bei klinisch wichtigen tierpathogenen Bakterien 2012/2013. ISBN 978-3-319-31696-3. http://www.bvl.bund.de/DE/09_Untersuchungen/01_Aufgaben/03_Nationales%20Resistenz-Monitoring/untersuchungen_NatResistenzmonitoring_node.html
8. DARLink; German Antimicrobial Resistance Situation in the Food Chain –2009 Federal Institute for Risk Assessment (2013) ISBN 3-938163-98-4. http://www.bfr.bund.de/cm/350/german-antimicrobial-resistance-situation-in-the-food-chain-2009.pdf
9. DGZ, Diergezondheidszorg Vlaanderen. Antibiotica resistentie evolutie 2012-2015. http://www.dgz.be/publicatie/antibioticaresistentie-evolutie-2012-2015
10. ECDC/EMEA JOINT TECHNICAL REPORT. 2009 The bacterial challenge: time to react A call to narrow the gap between multidrug-resistant bacteria in the EU and the development of new antibacterial agents. EMEA doc. ref. EMEA/576176/2009 ISBN 978-92-9193-193-4. doi 10.2900/2518
11. ECDC/EFSA/EMA, 2015. ECDC (European Centre for Disease Prevention and Control), EFSA (European Food Safety Authority) and EMA (European Medicines Agency). 2015. ECDC/EFSA/EMA first joint report on the integrated analysis of the consumption of antimicrobial agents and occurrence of antimicrobial resistance in bacteria from humans and food-producing animals. Stockholm/Parma/London: ECDC/EFSA/EMA, 2015. EFSA Journal 2015;13(1):4006, 114 pp. doi:10.2903/j.efsa.2015.4006
12. EFSA, 2012. Technical specifications on the harmonised monitoring and reporting of antimicrobial resistance in Salmonella, Campylobacter and indicator Escherichia coli and Enterococcus spp. bacteria transmitted through food EFSA Journal 2012;10(6):2742
13. EFSA (European Food Safety Authority) and ECDC (European Centre for Disease Prevention and Control), 2016. The European Union summary report on antimicrobial resistance in zoonotic and indicator bacteria from humans, animals and food in 2014. EFSA Journal 2016;14(2):4380, 207 pp. doi:10.2903/j.efsa.2016.4380
14. El Garch F., De Jong A., Simjee S., Moyaer H, Klein U., Ludwig C., Marion H., Haag-Diergarten S., Richard-Mazet A, Thomas V, Siegwart E. Monitoring of antimicrobial susceptibility of respiratory tract pathogens isolated from diseased cattle and pigs across Europe, 2009–2012: VetPath results .Vet. Microbiol. (2016), http://dx.doi.org/10.1016/j.vetmic.2016.04.009
15. FAVV-AFSCA, 2015. Trends in 2012-2013. Report on zoonotic agents in Belgium. http://www.coda-cerva.be/images/pdf/Report%20on%20Zoonotic%20agents%20in%20Belgium_2012_2013.pdf
16. FINRES-Vet 2007-2009, Finnish Veterinary Antimicrobial Resistance Monitoring and Consumption of Antimicrobial Agents, Finnish Food Safety Authority Evira, Helsinki, Finland, ISSN 1797-299X. https://www.evira.fi/en/animals/animal-health-and-diseases/animal-medication/monitoring-of-antibiotic-resistance/
17. FVO, 2016a. Final report of an audit carried out in Denmark from 15 September to 22 September in order to evaluate the monitoring and reporting of antimicrobial resistance in zoonotic and
Deliverable Report WP2 : D2.3
ND4BB COMBACTE-MAGNET Deliverable Report dated 16Jan2017 Page 76
commensal bacteria in certain foodproducing animal populations and food. DG(SANTE) 2015-7383 – MR.
18. FVO, 2016b. Final report of an audit carried out in Denmark from 10 November to 20 November in order to evaluate the monitoring and reporting of antimicrobial resistance in zoonotic and commensal bacteria in certain foodproducing animal populations and food. DG(SANTE) 2015-7404 – MR.
19. GERMAP, Antibiotika-Resistenz und -Verbrauch. Bundesamt für Verbraucherschutz und Lebensmittelsicherheit; 1st ed.(2011). ISBN 978-3-00-031622. http://www.bvl.bund.de/DE/09_Untersuchungen/01_Aufgaben/03_Nationales%20Resistenz-Monitoring/untersuchungen_NatResistenzmonitoring_node.html
20. K. Supre et al; Antimicrobial susceptibility and distribution of inhibition zone diameters of bovine mastitis pathogens in Flanders, Belgium. Veterinary Microbiology 171 (2014) 374–381
21. Lourdes Garcia-Migura et al; Antimicrobial resistance of zoonotic and commensal bacteria in Europe: The missing link between consumption and resistance in veterinary medicine. Veterinary Microbiology 170 (2014) 1–9
22. MARAN 2014. Monitoring of Antimicrobial Resistance and Antibiotic Usage in Animals in the Netherlands in 2014. http://www.wageningenur.nl/upload_mm/2/2/2/0ab4b3f5-1cf0-42e7-a460-d67136870ae5_NethmapMaran2015.pdf
23. Miguel A. Moreno, Lucas Dominguez, Tirushet Teshager, Inmaculada A. Herrero, M. Concepcion Porrero. The VAV Network Antibiotic resistance monitoring: the Spanish programme. Int J Antimicrobial Agents 14 (2000) 285–290
24. Moyaert H, De Jong A, Simjee S, Thomas V. Antimicrobial resistance monitoring projects for zoonotic and indicator bacteria of animal origin: Common aspects and differences between EASSA and EFSA. Veterinary Microbiology 171 (2014) 279–283
25. NORM/NORM-VET 2013. Usage of Antimicrobial Agents and Occurrence of Antimicrobial Resistance in Norway. Tromsø / Oslo 2014. ISSN:1502-2307 (print) / 1890-9965 (electronic). http://www.vetinst.no/Publikasjoner/NORM-NORM-VET
26. Noyes NR et al. Mannheimia haemolytica in Feedlot Cattle: Prevalence of Recovery and Associations with Antimicrobial Use, Resistance, and Health Outcomes. J Vet Intern Med 2015;29:705–713 (USA paper)
27. P. Silley, S. Simjee , S. Schwarz. Surveillance and monitoring of antimicrobial resistance and antibiotic consumption in humans and animals. Rev. sci. tech. Off. int. Epiz., 2012, 31 (1), 105-120
28. Peter Silley, Anno de Jong, Shabbir Simjee, Valérie Thomas. Harmonisation of resistance monitoring programmes in veterinary medicine: an urgent need in the EU? International Journal of Antimicrobial Agents 37 (2011) 504–512
29. Rene Hendriksen et al; Prevalence of antimicrobial resistance among bacterial pathogens isolated from cattle in different European countries: 2002–2004 Acta Veterinaria Scandinavica 2008, 50:28 (ARBAO-II Study)
30. RESAPATH, 2016. French surveillance network for antimicrobial resistance in pathogenic bacteria of animal origin. Annual Report 2014. ANSES.
31. Rui Figueiredo et al; Antimicrobial Resistance and Extended-Spectrum b-Lactamases of Salmonella enterica Serotypes Isolated from Livestock and Processed Food in Portugal: An Update. Foodborne pathogens and disease Volume 12, Number 2, 201
32. Silley P, De Jong A, Simjee S, Thomas V. 2011. Harmonisation of resistance monitoring programmes in veterinary medicine: an urgent need in the EU? International Journal of Antimicrobial Agents 37 (2011) 504–512
33. Stefan Schwarz. The BfT-GermVet monitoring program – Aims and basics. Berl.Münch.Tierärztl.Wochenschr. 120, Heft 9/10, 357–362 (2007)
34. Strauss R, Muchl R, Metz-Gercek S, Sagl M, Allerberger F, Hrabcik H, Mittermayer H. AURES – the first Austrian report on antimicrobial resistance – perspective of the human sector. Euro Surveill. 2007;12(50):pii=3329. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3329
35. SVARM 2014. Consumption of antibiotics and occurrence of antibiotic resistance in Sweden. Solna/Uppsala ISSN 1650-6332. http://www.sva.se/om-sva/publikationer/antibiotikaresistens?lid=32744
Deliverable Report WP2 : D2.3
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36. V.Thomas, A. de Jong, H. Moyaert, S. Simjee, F.El Garch, I.Morrissey, H.Marion, M. Vallé. Antimicrobial susceptibility monitoring of mastitis pathogens isolated from acute cases of clinical mastitis in dairy cows across Europe:VetPath results. International Journal of Antimicrobial Agents 46 (2015) 13–20
37. UK-VARSS 2014. Uk Veterinary Antibiotic Resistance and Sales Surveillance Report. http://webarchive.nationalarchives.gov.uk/20140909112428/http://www.vmd.defra.gov.uk/pharm/antibiotic_salesdata.aspx
38. Urdahl AM, Bergsjø B, Hofshagen M, Nordström M, Lium B. The surveillance programme for methicillin resistant Staphylococcus aureus in pigs in Norway in 2014. Surveillance programmes for terrestrial and aquatic animals in Norway. Annual report 2014. Oslo: Norwegian Veterinary Institute 2014
39. VAV 2005; Veterinary monitoring of antimicrobial resistance in Spain. 12th Report. 2005. https://www.visavet.es/en/research/networks/vav.php
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4. EpideMiology and control measures of outBreaks due to Antibiotic-
Resistant orGanisms in EurOpe (EMBARGO): a systematic review protocol
Authors
Nithya Babu Rajendran, Beryl Primrose Gladstone, Jesús Rodríguez-Baño, Frangiscos Sifakis, Andreas
Voss, Yehuda Carmeli, Francesco Robert Burkert, Panagiota Gkolia, and Evelina Tacconelli
(Study protocol published in BMJ Open 2016)
Introduction
The genetic capabilities of bacteria and indiscriminate use of antibiotics have resulted in the wide-
spread development of resistance, hindering the effectiveness of antibiotic therapy (Wright, 2007,
Davies and Davies, 2010, Tacconelli et al., 2009, Brown and Wright; 2016, Schroeder et al,2016).
Notably, resistance to single antibiotics has further progressed into multi-drug resistance which
advantageously protects bacterial pathogens against several commonly used therapeutic agents.
Multidrug resistances are rapidly evolving in several bacterial species: most predominant and
difficult-to-deal-with multi-drug resistant (MDR) organisms include methicillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum beta-
lactamase (ESBL)-producing Escherichia coli, and MDR-Pseudomonas aeruginosa, Acinetobacter
baumannii and Klebsiella pneumoniae (Nikaido, 2009, Alekshun and Levi, 2007, Munita et al., 2015,
McGowan, 2006).
In the 2011-2012 point-prevalence survey conducted by the European Centre for Disease Prevention
and Control (ECDC), methicillin resistance was reported in 41% of invasive S. aureus isolates,
vancomycin resistance in 10% of enterococci isolates, third-generation cephalosporin resistance in
33% of all Enterobacteriaceae isolates, and carbapenem resistance in 8% of Enterobacteriaceae, 32%
of P. aeruginosa, and 81% of A. baumannii isolates (ECDC, 2013). Mortality from antimicrobial
resistance was estimated at 50,000 deaths per year in the US and Europe alone (Teilannt et al.,
2015).
A well-recognized tool in the strategy to contain antibiotic resistance is surveillance (Williams and
Heymann, 1998, Williams and Ryan, 1998, Roca et al., 2015, Grundmann et al., 2011).Based on the
information gathered, surveillance data on antimicrobial resistance drive clinical decision making on
empiric therapy and infection prevention policy (O'Brien and Stelling, 2011). Overall, surveillance
enables improved patient outcome at the local level, while guiding public health policy-making and
interventions at the national level, and helps identify emerging threats on a global scale.
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The objective of the systematic review was to systematically review the past and ongoing outbreaks
of target antimicrobial resistant bacteria (ARB) in order to map and characterise the epidemiological
aspects of outbreaks due to ARB and infection control measures in European countries, analyse
effectiveness of infection control measures or bundles of measures to control the outbreaks and
assess the quality of outbreak studies.
Materials and Methods
Target ARB: MRSA, vancomycin-resistant S. aureus (VRSA), vancomycin-resistant Enterococcus
faecalis and Enterococcus faecium (VRE), EBSL (extended-spectrum beta-lactamase)-producing E. coli
(ESBL-EC), K. pneumoniae (ESBL-KP), A. baumannii (ESBL-AB), and P. aeruginosa (ESBL-PA),
carbapenem-resistant/carbapenemase-producing E. coli (CR-EC), K. pneumoniae (CR-KP),
A. baumannii (CR-AB), and P. aeruginosa (CR-PA) and ceftazidime-resistant E. coli (CZ-EC),
K. pneumoniae (CZ-KP), A. baumannii (CZ-AB), and P. aeruginosa (CZ-PA).
No restriction was applied regarding languages, countries and settings. Since the definition of what
an ESBL producer is, has changed overtime, we included the following definitions for ESBL: 1)
resistant to ceftazidime and/or ceftriaxone (the two may have different detection at different
locations and may have changed over time) 2) phenotypic confirmation (e.g. using beta-lactamase
inhibitor combination). 3) gene identification (likely to exist initially only in single isolates, and more
recently for larger number of strains). Due to the high heterogeneity in defining carbapenemase
production, carbapenems resistance and MDR strains, the definitions reported by the authors were
used and accounted for during the data analysis. Infection rate was defined as the number of
patients infected with an ARB on the number of patients tested positive for ARB during the outbreak.
Study design: systematic review of the literature. Types of studies: all studies regardless of their
design reporting either an outbreak or a sentinel case, irrespective of it resulting in an outbreak,
were included. Outbreaks were searched for at least 10 years after the first one or until endemicity is
established. Endemicity was defined as a prevalence of an ARB higher than 5% in surveillance
programs or large scale reports in the relevant geographical area or worldwide. An outbreak was
defined as an unusual or unexpected increase of cases of infection due to ARB, already isolated with
or without molecular analysis of strains.
Inclusion criteria: reports an outbreak or a single case report of the target ARB, reports the detection
of the ARB using standard laboratory techniques for the period studied, and reports the time of
detection of the outbreak or availability of this information with the corresponding author.
Exclusion criteria: diagnostic studies, reviews, conference abstracts and study protocols.
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Study setting: all settings including clinic, hospitals, health care facilities and community and all
population groups including elderly, immuno-compromised, and children.
Screening strategy: eligibility of the resulting articles from the initial search based on title and
abstract screening were assessed by two reviewers and discrepancies sorted out. The reasons for
exclusion of articles were noted down. The full texts of the resulting eligible articles were carefully
read through to extract and enter the data onto a standardised pre-formatted data sheet by two
reviewers. The databases were cross verified to find any discrepancies and inconsistencies were
discussed among the study team and sorted out by consensus.
Data extraction: the following data were extracted: article related variables: name of the author,
email of the corresponding author, institute, country, year of publication, title of the article, journal:
outbreak / sentinel case - related general variables: time of data collection, study design, sampling,
study setting (hospital based, other health care facilities, community based..) population profile
(immuno-compromised, elderly, children, etc); socio-demographic characteristics: age, sex; ARB
specific characteristics: laboratory test used to confirm isolation, type of sample tested (serum,
throat swab, rectal swab, etc), type of infection or colonisation; outbreak specific characteristics:
how outbreak was detected (routine surveillance, clinical samples, etc.), how many patients were
screened, how many were positive, how many patients were infected and how many were colonized,
date of sentinel case, date of first infection control intervention, number of cases before the
intervention, date of last case, endemicity, duration of outbreak, country and city/region of the
outbreak, any mode of spread reported, clonality (clonal vs polyclonal/plasmid/gene), control
measures.
Data synthesis and analysis: data were synthesized for each ARB and linked chronologically and
spatially. For each outbreak report, case rate was calculated as the proportion of the population
screened who are positive (colonisations and/or infections). Attack rate as the proportion of
population screened who develop an infection; and infection rate as the proportion of positively
screened individuals who develop an infection. Pooled estimates of case rate, attack rate and
infection rate were estimated based on random effects models of meta-analysis with Freeman-Tukey
Double Arcsine Transformation for variance stability using STATA’s metaprop command. Outbreak
characteristics as well as infection control measures were studied and effectiveness of infection
control measures studied using logistic regression models. The outbreak numbers were further
standardised per 1 million country population. .
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Results
Overall 2647 abstracts and 923 papers were read in detail. According to the study´s inclusion criteria
data from 430 outbreaks (1976-2014) were extracted. The 430 outbreaks were reported from 22
countries; Western Europe (52%), Northern Europe (14%), Eastern Europe (5%), Southwest Europe
(22%) and Southeast Europe (6%). The majority of the outbreaks were published between 1990 and
2010 (84%) as detailed in Table 1 and involved mainly hospitals (386/418, 92%). The UK (18%)
reported the highest number of outbreaks followed by France (14%), Spain (11%), Germany (9%) and
Italy (9%). Standardised number of outbreaks by the latest country population is reported in Table 2
and Figure 1. The majority of published outbreaks were caused by MRSA (45%), followed by VRE
(13%), ESBL KP (12%), CR-AB (9.3%) and CR-KP (8%). Among the European countries, MRSA outbreaks
were reported from Western and Northern European regions (54% vs 28%) while those due to CR-KP
(16% vs 4%), CR-AB(19% vs 5%), CR-PA (6% vs 1%) and ESBL-KP (14% vs 11%) from Eastern,
Southwest and Southeast Europe.
The majority of outbreaks were monocentric (88%) although in 53 outbreaks more than one centre
was involved (range, 2-40), mainly in Western and Northern European countries. Among the 61
outbreaks reporting the age distribution, individuals were on an average 58 years old (IQR: 44 – 66;
range: 0 – 102) and the gender ratio (based on 86 outbreaks) was 33% females (IQR: 20 – 45; range: 0
– 100). Majority of the outbreaks were reported from ICUs (46%) followed by surgical (25%) and
neonatal (14%) settings (Table 4). Community onset outbreaks were more frequently due to MRSA
(15%) and ESBL-EC outbreaks (11%), while CR-GN outbreaks were more often reported from ICUs.
The duration of outbreaks was on an average (median), 274 days (inter quartile range: 114 – 602
days). Table 6 and Figure 2 present the duration according to the type of ARB.
The overall as well as ARB specific case rates, attack rates and infection rates have been presented in
Table 7. Screening of staff and relatives was reported in 26.5% and 6.5% of the overall outbreaks.
Screening of staff (14.4% vs 4.8%) and relatives (3.5% vs 0.7%) were more often reported from
Western and Northern Europe for MRSA outbreaks.
Staff personnel were screened in 114 outbreaks and on an average, 65 staff (IQR: 35 – 152; range: 0 –
459) were screened per outbreak; 3 tested positive (IQR: 1 – 7; range: 0 – 223) and number of staff
with an infection caused by ARB ranged from 0 to 8. Relatives of patients were screened in 28
outbreaks and on an average, 6 individuals (IQR: 4 – 16; range: 3 – 68) were screened per outbreak; 2
tested positive (IQR: 1 – 3; range: 0 – 37) and number of relatives with an infection caused by ARB
ranged from 0 to 8 (median: 0; IQR: 0 – 1).
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The attack rate in hospital staff was lower compared to that among patients (00.0% vs 4.4%). Attack
rate was also different among ARB: a lower attack rate was observed among VRE outbreaks (0.63%)
while MRSA, ESBL-KP, ESBL-EC had higher attack rates (>=4%) except for a single CZ-PA outbreak
reporting an attack rate of 32.7%. (p=0.006)
Table 9 presents the distribution of the various types of infections according to ARB. Blood stream
infections (33%), respiratory tract infections (16%), urinary tract infections (16%), and wound
infections (12%) were the type of infections more commonly reported in the outbreaks. Considering
the primary ARB involved in the outbreak, skin (83%) and wound infections (67%) were more often
MRSA infections, while ventilator associated pneumonia were more commonly reported in CR-AB
outbreaks (63%).
The majority of the hospitals (70%) provided information about infection control measures used to
control the outbreak. One hundred and thirty studies reported clinical and/or microbiological details
of the outbreaks without mentioning any infection control measures (30%). The distribution of the
various infection control measures reported is presented in Table 10. Targeted screening, isolation
and hand washing were the most frequently reported infection control measures.
Post-outbreak endemicity was reported in 25 studies (5.8%). High endemicity rate was associated
with CR-KP (26%), CZ-EC (33%) and CZ-PA (36%). A bundle approach (at least 2 infection control
measures introduced) was significantly associated with controlling the outbreak (p =0.03)
Analyses were undertaken to determine factors associated with longer duration of outbreak using
logistic regression. All the outbreaks with duration longer than the overall median duration in our
systematic review (274 days) were labelled as longer. 193/395 outbreaks with data available on
outbreak duration were defined as unsuccessfully contained. The ARB distribution among the
unsuccessful was as follows: CR-AB (19), CR-EC (1), CR-KP (14), CR-PA (8), CZ-PA (8), ESBL-AB (1),
ESBL-EC (7), ESBL-KP (29), ESBL-PA (1), GISA (1), MRSA (83), VRE (23). The ARB distribution was not
very different between the two groups (p=0.48). The results are presented in Table 11. Univariate
analysis showed that hospital-wide outbreaks (OR=2.49 (1.33 – 4.66), p=0.004)) and those involving
urinary tract infections (UTI) (OR=2.58 (1.42 - 4.68)) were significantly longer and more difficult to
contain. This result was confirmed after adjusted multivariate regression.
Among the infection control measures, targeted screening and ward closure were significantly
associated with the duration of the outbreak. Outbreaks implementing targeted screening and ward
closure were 46% and 54% less likely to be of a longer duration respectively.
Mandatory reporting of outbreaks due to ARB: Out of the 32 European Union and European Free
Trade Association nations, Germany, Hungary, the Netherlands, Norway and Sweden have an
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outbreak-specific surveillance programme implemented. Germany (since 2011), Hungary (2010) and
Norway (2005) mandate the reporting of nosocomial outbreaks, irrespective of the causative
organism, from hospitals and healthcare centres, while in Sweden the surveillance programme based
on an automated outbreak detection system (2009) targets penicillin-resistant Streptococcus
pneumoniae, MRSA, VRE, and ESBL/carbapenemase-producing Enterobacteriaceae in community and
healthcare facilities. Interestingly, in the Netherlands, incidence of MRSA clusters outside hospitals
(community) must be reported to the national public health agency as part of the national
surveillance agenda (since 2008). Hospital outbreaks due to any pathogen are reported voluntarily to
the outbreak surveillance programme, SO-ZI/AMR, since 2012. All countries, excepting Germany,
provide outbreak data stratified by resistant pathogens. The characteristics of these surveillance
programmes and the number of outbreaks reported by these systems are described in tables 12 and
13.
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Table 1. Outbreak period and associated frequencies (published reports)
Frequency of outbreaks (percentage) in European regions
Period of outbreak Western Northern Eastern Southwest Southeast Total
1976 -1999 112 24 9 30 5 180
(50.22) (38.71) (39.13) (31.58) (18.52) (41.86)
2000 - 2009 83 34 13 48 15 193
(37.22) (54.84) (56.52) (50.53) (55.56) (44.88)
2010 - 2014 28 4 1 17 7 57
(12.56) (6.45) (4.35) (17.89) (25.93) (13.26)
Total 223 62 23 95 27 430
Table 2. Outbreak numbers in correlation with total population according to published reports
Country Total population*
Number of outbreaks
Standardised outbreak rate (published reports) per million population
ARB most frequently associated with published outbreak
Bulgaria 7098000 1 0,14 CRGN Slovakia 5429000 1 0,18 CRGN Austria 8570000 2 0,23 MRSA, ESBLGN Poland 38593000 15 0,39 VRE Belgium 11372000 5 0,44 ESBLGN Germany 80682000 40 0,5 MRSA Hungary 9821000 6 0,61 MRSA Italy 59801000 39 0,65 CRGN Croatia 4225000 3 0,71 ESBLGN Portugal 10304000 8 0,78 MRSA France 64668000 61 0,94 ESBLGN, MRSA Slovenia 2069000 2 0,97 MRSA Latvia 1956000 2 1,02 CRGN, ESBLGN Spain 46065000 48 1,04 CRGN United Kingdom
65111000 79 1,21 MRSA
Netherlands 16980000 24 1,41 MRSA Switzerland 8379000 12 1,43 MRSA Denmark 5691000 9 1,58 MRSA Sweden 9852000 19 1,93 MRSA Greece 10919000 22 2,01 CRGN Finland 5524000 14 2,53 MRSA Norway 5272000 18 3,41 MRSA
*Population as per the latest census as provided by the UN statistics
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Figure 1. Outbreak etiology by country inhabitants according to published reports
0
0.5
1
1.5
2
2.5
3
3.5
4
0
10
20
30
40
50
60
70
80
90
Num
ber o
f out
brea
ks
Carbapenem-resistant GN Cefatzidime-resistant GN ESBL-GN
VRE GISA MRSA
Frequency per million
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CR-AB
Country Frequency Percentage Belgium 1 2,5 Bulgaria 1 2,5 Croatia 1 2,5 Finland 1 2,5 France 6 15,0 Germany 2 5,0 Greece 4 10,0 Italy 11 27,5 Latvia 1 2,5 Poland 1 2,5 Spain 9 22,5 UK 2 5,0 Total 40 100
CR-EC
Country Frequency Percentage France 1 50 Greece 1 50 Total 2 100
CR-KP
Country Frequency Percentage France 5 14,3 Germany 4 11,4 Greece 7 20,0 Italy 9 25,7 Norway 1 2,9 Portugal 1 2,9 Spain 6 17,1 UK 2 5,7 Total 35 100
CR-PA
Country Frequency Percentage France 1 7,7 Germany 1 7,7 Greece 3 23,1 Italy 2 15,4 Netherlands 1 7,7 Slovakia 1 7,7 Spain 3 23,1 UK 1 7,7 Total 13 100
CZ-AB
Country Frequency Percentage Netherlands 1 100 Total 1 100
CZ-EC
Country Frequency Percentage Germany 1 33,3 Sweden 1 33,3 UK 1 33,3 Total 3 100
CZ-PA
Country Frequency Percentage Denmark 1 9,1 France 5 45,5 Germany 1 9,1 Greece 2 18,2 Italy 1 9,1 Spain 1 9,1 Total 11 100
Table 3A. Outbreaks stratified by countries (alphabetical order) and antibiotic-resistant bacteria
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ESBL-AB
Country Frequency Percentage Belgium 1 100 Total 1 100
ESBL-EC
Country Frequency Percentage Finland 1 5,3 France 3 15,8 Italy 1 5,3 Netherlands 1 5,3 Norway 1 5,3 Poland 1 5,3 Spain 1 5,3 Sweden 4 21,1 Switzerland 1 5,3 UK 5 26,3 Total 19 100
ESBL-KP
Country Frequency Percentage Austria 1 2,0 Belgium 1 2,0 Croatia 2 3,9 Denmark 2 3,9 France 12 23,5 Germany 3 5,9 Greece 2 3,9 Hungary 1 2,0 Italy 4 7,8 Latvia 1 2,0 Netherlands 3 5,9 Norway 1 2,0 Poland 4 7,8 Portugal 1 2,0 Spain 7 13,7 Sweden 2 3,9 UK 4 7,8 Total 51 100
ESBL-PA
Country Frequency Percentage Italy 1 100 Total 1 100
VRE
Country Frequency Percentage Belgium 1 1,8 Finland 1 1,8 France 10 17,9 Germany 11 19,6 Greece 1 1,8 Hungary 1 1,8 Italy 2 3,6 Netherlands 3 5,4 Poland 6 10,7 Spain 6 10,7 Sweden 3 5,4 Switzerland 2 3,6 UK 9 16,1 Total 56 100
MRSA
Country Frequency Percentage Austria 1 0,5 Belgium 1 0,5 Denmark 6 3,1 Finland 11 5,7 France 15 7,7 Germany 17 8,8 Greece 2 1,0 Hungary 4 2,1 Italy 8 4,1 Netherlands 15 7,7 Norway 15 7,7 Poland 3 1,5 Portugal 6 3,1 Slovenia 2 1,0 Spain 15 7,7 Sweden 9 4,6 Switzerland 9 4,6 UK 55 28,4 Total 194 100
GISA
Country Frequency Percentage France 3 100 Total 3 100
Table 3B. Outbreaks stratified by countries (alphabetical order) and antibiotic-resistant bacteria
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Table 3C. Outbreaks stratified by countries and antibiotic-resistant bacteria – a com
prehensive overview
Country CR-AB
CR-EC CR-KP
CR-PA CZ-AB
CZ-EC CZ-KP
CZ-PA ESBL-AB
ESBL-EC ESBL-KP
ESBL-PA VRE
MRSA
GISA Total
Austria
1
1
2 Belgium
1
1
1
1
1
5 Bulgaria
1
1
Croatia 1
2
3 Denm
ark
1
2
6
9 Finland
1
1
1 11
14
France 6
1 5
1
5
3 12
10
15 3
61 Germ
any 2
4
1
1
1
3
11
17
40 Greece
4 1
7 3
2
2
1 2
22
Hungary
1
1
4
6 Italy
11
9 2
1
1
4 1
2 8
39
Latvia 1
1
2 Netherlands
1
1
1
3
3 15
24
Norway
1
1
1
15
18
Poland 1
1 4
6
3
15 Portugal
1
1
6
8
Slovakia
1
1 Slovenia
2
2
Spain 9
6
3
1
1 7
6
15
48 Sw
eden
1
4 2
3
9
19 Sw
itzerland
1
2
9
12 UK
2
2 1
1
5
4
9 55
79
Total 40
2 35
13 1
3 0
11 1
19 51
1 56
194 3
430
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Table 4. Distribution of 430 outbreaks based on the hospital setting
Outbreak setting Number of outbreaks (%) Day care 1 (0,24) Elderly home 1 (0,24) Rehabilitation Center 1 (0,24) Emergency 2 (0,48) Trauma care 3 (0,72) Dermatology 5 (1,2) Obst. & Gyn 6 (1,44) Transplantation 10 (2,4) Burns Unit 10 (2,4) Cardiology 13 (3,13) Pediatric 19 (4,57) Hematology 36 (8,65) Nephrology 43 (10,34) Medical 49 (11,78) Hospital wide 57 (13,7) Neonatal 59 (14,18) Surgical 103 (24,76) ICU 192 (46,15)
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Table 5. Outbreaks by antibiotic-resistant bacteria, type of setting – num
bers and percentage
Setting \ ARO
CR-AB CR-EC
CR-KP CR-PA
CZ-AB CZ-EC
CZ-PA ESBL-AB
ESBL-EC ESBL-KP
ESBL-PA GISA
MRSA
VRE Surgery
9%
1%
13%
3%
1%
2%
17%
1%
46%
8%
Medicine
14%
2%
20%
4%
4%
2%
12%
35%
6%
N
eonatal 3%
2%
10%
20%
58%
7%
Pediatric
11%
5%
5%
16%
37%
26%
Hospital wide
11%
2%
11%
7%
2%
18%
2%
33%
16%
ICU
17%
1%
14%
4%
1%
1%
4%
1%
2%
17%
1%
1%
29%
10%
Burns U
nit 10%
10%
10%
10%
10%
50%
Hem
atology 6%
8%
6%
3%
6%
3%
6%
11%
53%
Elderly 8%
17%
17%
33%
25%
Nephrology
7%
9%
2%
5%
14%
26%
37%
Cardiology
8%
31%
38%
23%
Transplantation
20%
10%
20%
30%
20%
Setting \ ARO
CR-AB CR-EC
CR-KP CR-PA
CZ-AB CZ-EC
CZ-PA ESBL-AB
ESBL-EC ESBL-KP
ESBL-PA GISA
MRSA
VRE Total
Surgery 9
1 13
3
1
2
18
1 47
8 103
Medicine
7 1
10 2
2
1 6
17 3
49 N
eonatal 2
1
6
12
34
4 59
Pediatric
2
1 1
3
7
5 19
Hospital wide
6 1
6 4
1 10
1
19 9
57 ICU
32
1 27
7 1
1 7
1 4
33 1
2 55
20 192
Burns Unit
1
1
1 1
1
5
10 Hem
atology 2
3
2
1 2
1
2
4
19 36
Elderly 1
2
2
4
3 12
Nephrology
3
4 1
2 6
11 16
43 Cardiology
1
4
5 3
13 Transplantation
2
1 2
3 2
10
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Table 6. Duration of outbreaks according to antibiotic-resistant bacteria
ARB Number of studies reporting duration
Duration of outbreak in days
Median (Inter quartile range) Range ESBL-AB 1 539
CZ-PA 11 519 ( 151 - 609 ) 61 - 1614 CR-PA 13 395 ( 151 - 882 ) 15 - 1096 CR-EC 1 365
ESBL-KP 48 345 ( 153 - 609.5 ) 30 - 1460 ESBL-PA 1 303
VRE 47 274 ( 153 - 730 ) 11 - 1553 CR-AB 39 267 ( 132 - 546 ) 32 - 1461 CZ-AB 1 243
ESBL-EC 15 242 ( 37 - 638 ) 1 - 1399 MRSA 176 228 ( 91 - 516.5 ) 3 - 1825 CR-KP 35 182 ( 65 - 390 ) 5 - 1095 CZ-EC 2 137 ( 122 - 152 ) 122 - 152 GISA 3 91 ( 50 - 378 ) 50 - 378
Total 393 274 ( 114 - 602 ) 1 - 1825
Figure 2. Duration of outbreaks according to antibiotic-resistant bacteria
GISA
CZEC
CRKP
MRSA
ESBLE
CZAB
CRAB
VRE
ESBLPA
ESBLKP
CREC
CRPA
CZPA
ESBLAB
0
100
200
300
400
500
600
700
800
900
1000
Med
ian
(IQR)
dur
atio
n of
out
brea
k in
day
s
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Table 7. Case and Infection rates according to antibiotic-resistant bacteria
ARB Case rate (%) Attack rate (%) Infection rate (%) n pooled estimate* n pooled estimate* n pooled estimate*
ESBL-AB 1 88.89 ( 56.50 - 98.01 ) ESBL-KP 3 15.18 ( 1.91 - 37.36 ) 3 4.66 ( 1.26 - 9.88 ) 26 74.69 ( 55.32 - 90.36 ) CR-PA 2 9.44 ( 8.13 - 10.83 ) 1 2.10 ( 1.02 - 4.26 ) 8 68.38 ( 45.29 - 87.90 ) CR-KP 3 5.91 ( 1.42 - 12.76 ) 3 3.69 ( 0.61 - 8.69 ) 1 59.59 ( 47.23 - 71.45 ) CR-AB 2 7.23 ( 4.92 - 9.92 ) 2 3.85 ( 2.17 - 5.94 ) 26 58.25 ( 49.68 - 66.60 ) MRSA 31 14.92 ( 11.54 - 18.62 ) 19 6.31 ( 3.23 - 10.20 ) 99 54.91 ( 48.30 - 61.45 ) CZ-PA 2 77.29 ( 69.11 - 84.58 ) 1 32.65 ( 21.21 - 46.62 ) 4 54.77 ( 26.62 - 81.43 ) CR-EC 1 54.55 ( 28.01 - 78.73 ) GISA 21 52.38 ( 32.37 - 71.66 ) ESBL-EC 2 33.27 ( 24.15 - 43.03 ) 2 3.98 ( 0.69 - 9.15 ) 8 49.45 ( 17.35 - 81.77 ) VRE 12 15.63 ( 9.73 - 22.59 ) 9 0.63 ( 0.04 - 1.66 ) 35 20.21 ( 13.06 - 28.34 ) CZ-EC 1 47.73 ( 33.75 - 62.06 ) Overall 58 16.55 ( 13.52 - 19.80 ) 40 4.37 ( 2.75 - 6.29 ) 230 52.76 47.58 - 57.90 )
*pooled estimate derived from random effects meta-analysis using Wilson score method only for categories where more than one estimate is available
Table 8. Case and Infection rates among staff personnel according to antibiotic-resistant bacteria
ARB Case rate (%) Attack rate (%) Infection rate (%) n pooled estimate* n pooled estimate* n pooled estimate*
MRSA 36 5.26 ( 3.58 - 7.20 ) 28 0.00 ( 0.00 - 0.08 ) 58 0.00 ( 0.00 - 1.21 ) ESBL-KP 1 0.00 ( 0.00 - 11.35 ) 1 0.00 ( 0.00 - 11.35 ) 1 0.00 ( 0.00 - 1.10 ) ESBL-EC 1 6.45 ( 1.79 - 20.72 ) CZ-EC CZ-PA CR-AB 2 0.00 ( 0.00 - 4.25 ) CR-PA 1 1.82 ( 0.50 - 6.39 ) VRE 2 1.03 ( 0.06 - 2.70 ) CR-KP GISA 1 2.04 ( 0.36 - 10.69 ) CR-EC ESBL-AB Overall 44 4.39 ( 2.99 - 6.00 ) 29 0.00 ( 0.00 - 0.07 ) 59 0.00 ( 0.00 - 1.10 )
*pooled estimate derived from random effects meta-analysis using Wilson score method only for categories where more than one estimate is available
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Table 9. Type of infections according to antibiotic-resistant bacteria (in numbers and percentages)
Type of infections \ARB CR-AB
CR-EC CR-KP
CR-PA CZ-AB
CZ-EC CZ-PA
ESBL-AB ESBL-EC
ESBL-KP ESBL-PA
GISA M
RSA VRE
Total Blood stream
infection 23
1 19
6
1 4
4
17
2 47
16 140
Urinary tract infection
8 1
10 4
1
4
6 7
1 2
15 8
67
Respiratory tract infection 15
1 13
2
5
1
10
1 19
2 69
Skin infection 3
1
29
2 35
Wound infection
5 1
3
1
1
1 2
1
34 2
51
Surgical site infection 4
3
2
4
5
18
Meningitis
3
1
1 1
1 1
8
Ventilator-ssociated infection 10
1
2
1
2
16
Type of infections \ARB CR-AB
CR-EC CR-KP
CR-PA CZ-AB
CZ-EC CZ-PA
ESBL-AB ESBL-EC
ESBL-KP ESBL-PA
GISA M
RSA VRE
Blood stream infection
16%
1%
14%
4%
1%
3%
3%
12%
1%
34%
11%
U
rinary tract infection 12%
1%
15%
6%
1%
6%
9%
10%
1%
3%
22%
12%
Respiratory tract infection
22%
1%
19%
3%
7%
1%
14%
1%
28%
3%
Skin infection 9%
3%
83%
6%
W
ound infection 10%
2%
6%
2%
2%
2%
4%
2%
67%
4%
Surgical site infection
22%
17%
11%
22%
28%
M
eningitis 38%
13%
13%
13%
13%
13%
Ventilator-ssociated infection
63%
6%
13%
6%
13%
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Table 10 A. Infection control measures applied during the outbreak according to antibiotic-resistant bacteria (in num
bers)
ARB Hand
washing
Room
isolation ATBS
Ward
closure U
niversal screening
Targeted screening
Environental screening
Cohorting personnel
Education Cohorting patients
Decolonisation Total
CR-AB
24 21
8 16
18 6
20 10
14 13
6 31
CR-EC 1
1 1
1
2
1 1
1
2 CR-KP
19 18
8 3
21 11
9 3
11 13
2 31
CR-PA 6
6 3
7
1 6
1 4
3 1
9 CZ-AB
1
1
CZ-EC
CZ-PA 1
1 3
1
2
1
7 ESBL-AB
ESBL-EC 3
1 2
2 2
3 4
1 3
3 3
10 ESBL-KP
7 9
1 2
8 13
14 1
3 8
7 25
ESBL-PA
GISA 2
2
1
1 1
1
1
2 M
RSA 61
72 2
23 65
106 55
18 29
46 96
138 VRE
17 18
16 3
8 17
19 7
14 20
3 44
Total
142 149
44 49
131 160
129 43
81 107
120 300
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Table 10 B. Infection control measures applied during the outbreak according to antibiotic-resistant bacteria (in percentages)
ARB Hand
washing
Room
isolation ATBS
Ward
closure U
niversal screening
Targeted screening
Environental screening
Cohorting personnel
Education Cohorting patients
Decolonisation
CR-AB 77%
68%
26%
52%
58%
19%
65%
32%
45%
42%
19%
CR-EC 50%
50%
50%
50%
100%
50%
50%
50%
CR-KP 61%
58%
26%
10%
68%
35%
29%
10%
35%
42%
6%
CR-PA 67%
67%
33%
78%
11%
67%
11%
44%
33%
11%
CZ-AB 100%
CZ-EC
CZ-PA 14%
14%
43%
14%
29%
14%
ESBL-AB
ESBL-EC 30%
10%
20%
20%
20%
30%
40%
10%
30%
30%
30%
ESBL-KP 28%
36%
4%
8%
32%
52%
56%
4%
12%
32%
28%
ESBL-PA
GISA 100%
100%
50%
50%
50%
50%
50%
MRSA
44%
52%
1%
17%
47%
77%
40%
13%
21%
33%
70%
VRE 39%
41%
36%
7%
18%
39%
43%
16%
32%
45%
7%
Total 47%
50%
15%
16%
44%
53%
43%
14%
27%
36%
40%
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Table 11. Outbreak characteristics associated with longer duration of outbreak (duration longer than the overall median (> 274 days)) – logistic regression analyses
Factors Univariate Multivariate
OR (95% CI) p-value Adjusted OR (95% CI)
p-value
Outbreak setting ICU 0.73 ( 0.49 - 1.08 ) 0.11 0.73 ( 0.47 - 1.14 ) 0.17 Surgery 0.75 ( 0.47 - 1.19 ) 0.23 Medicine 1.13 ( 0.6 - 2.11 ) 0.71 Hospital wide 2.49 ( 1.33 - 4.66 ) 0.004 1.87 ( 0.96 - 3.64 ) 0.07 Type of infection involved Bloodstream infection 0.96 ( 0.63 - 1.45 ) 0.83 Urinary tract infection 2.58 ( 1.42 - 4.68 ) 0.002 2.62 ( 1.40 - 4.89 ) 0.003 Respiratory tract infection 1.27 ( 0.74 - 2.18 ) 0.38 Ventilator associated pneumonia 0.6 ( 0.21 - 1.68 ) 0.33
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Table 12. Main characterisitics of surveillance program
mes m
onitoring outbreaks in Europe
Country System
/institution Active since
Surveillance structure
Target resistance
Setting O
utbreak definition Resistance definition
Demographic
s O
utcome
Control m
easures to tackle outbreaks
Acronym
Nam
e
Germany
RKI Robert Koch Institute
2011
Mandatory
notification of nosocom
ial outbreaks
Any Healthcare facilities
Two or m
ore epidemiologically-
linked nosocomial infections
Not specified
Not specified M
ortality Not specified
Hungary NNSR
National nosocomial
surveillance system
2010
Mandatory
notification of nosocom
ial outbreaks
Any Healthcare facilities
Not specified Not specified
Not specified Not specified
Not specified
Netherlands
RIVM
Dutch National Institute for Public Health and the Environm
ent
2008
Mandatory
notification of clusters due to M
RSA
MRSA
Comm
unity Not specified
Not specified
Age, gender Not specified
Not specified
Netherlands
SO-ZI/AM
R
Signaling Consultation of Hospital acquired Infections and AntiM
icrobial Resistance
2012
Voluntary notification of outbreaks due to resistant+ susceptible pathogens
Any Hospitals
Not specified Not specified
Not specified Not specified
Not specified
Norw
ay VESUV
Web-based outbreak
alert system
2005
Mandatory
notification of outbreaks due to resistant+ susceptible pathogens
Any Healthcare facilities
(1) number of cases of an
infectious disease which clearly
exceeds the expected level within
a given time and area, or (2) ⩾
2 cases of the sam
e infectious diseases w
here a comm
on source is suspected
Not specified
Not specified M
ortality Yes
Sweden
CASE/ Sm
iNet
Computer Assisted
Search for Epidem
ics/ Swedish
national electronic surveillance system
2009
Automated
outbreak detection based on m
andatory notification of diseases due to susceptible and resistant pathogens
PNSP, MRSA,
VRE, ESBL/carbapenem
ase-producing Enterobacteriaceae
Comm
unity+ healthcare facilities
Two or m
ore cases of a disease Not specified
Age, gender Not specified
Not specified
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Table 13. Comparision of antibiotic-resistant bacteria outbreaks reported annually: peer-reviewed vs surveillance system reports
Germany
MRSA 2012 2013 2014 2015 1
RKI 19
VRE 2012 2013 2014 2015 1
RKI 2
ESBL-EC 2012 2013 2014 2015
RKI 7
ESBL-KP 2012 2013 2014 2015
RKI 6
CR-KP 2012 2013 2014 2015
1
RKI
Hungary
MRSA 2010 2011 2012 2013 2014 2015
NNSR 6 3 1 9 1
VRE 2010 2011 2012 2013 2014 2015
NNSR
2 2 2
ESBL-KP 2010 2011 2012 2013 2014 2015
NNSR 3 8 5
1
Netherlands
MRSA 2008 2009 2010 2011 2012 2013 2014 2015
1
RIVM (community) 4 16 14 6 2 11 3 11
SO-ZI/AMR (hospitals)
4 10 19 22
VRE 2012 2013 2014 2015 *Years considered according to surveillance commencement
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SO-ZI/AMR 7 11 14 16
ESBL-EC 2012 2013 2014 2015
1
SO-ZI/AMR
2
ESBL-KP 2012 2013 2014 2015
SO-ZI/AMR 3 4 1 2
Norway MRSA 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
1 2 1 1 1 1 1
VESUV
9 10 9 4 12 8 10 10
VRE 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
VESUV
1 1 1 2 4 1
ESBL-EC 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
VESUV
2 2 4
CR-KP 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
1
VESUV
ESBL-KP 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
1
VESUV
*Years considered according to surveillance commencement
Sweden
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MRSA 2009 2010 2011 2012 2013 2014 2015
CASE
25 30 20 13
VRE 2009 2010 2011 2012 2013 2014 2015
CASE
2 3 5 10 13 12
ESBL-KP 2009 2010 2011 2012 2013 2014 2015
1
CASE
*Years considered according to surveillance commencement
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References
1. Wright GD. The antibiotic resistome: the nexus of chemical and genetic diversity. Nat Rev Microbiol 2007;5(3):175-86.doi: 10.1038/nrmicro1614.
2. Davies J, Davies D. Origins and evolution of antibiotic resistance. Microbiol Mol Biol Rev 2010;74(3):417-33.doi: 10.1128/MMBR.00016-10.
3. Tacconelli E, De Angelis G, Cataldo MA, et al. Antibiotic usage and risk of colonization and infection with antibiotic-resistant bacteria: a hospital population-based study. Antimicrob Agents Chemother 2009;53(10):4264-9.doi: 10.1128/AAC.00431-09|.
4. Brown ED, Wright GD. Antibacterial drug discovery in the resistance era. Nature 2016;529(7586):336-43.doi: 10.1038/nature17042.
5. Schroder W, Sommer H, Gladstone BP, et al. Gender differences in antibiotic prescribing in the community: a systematic review and meta-analysis. J Antimicrob Chemother 2016;71(7):1800-6.doi: 10.1093/jac/dkw054.
6. Nikaido H. Multidrug resistance in bacteria. Annu Rev Biochem 2009;78:119-46.doi: 10.1146/annurev.biochem.78.082907.145923.
7. Alekshun MN, Levy SB. Molecular mechanisms of antibacterial multidrug resistance. Cell 2007;128(6):1037-50.doi: 10.1016/j.cell.2007.03.004.
8. Munita JM, Bayer AS, Arias CA. Evolving resistance among Gram-positive pathogens. Clin Infect Dis 2015;61 (Suppl 2):S48-57.doi: 10.1093/cid/civ523.
9. McGowan JE, Jr. Resistance in nonfermenting gram-negative bacteria: multidrug resistance to the maximum. Am J Infect Control 2006;34(5 Suppl 1):S29-37; discussion S64-73.doi: 10.1016/j.ajic.2006.05.226.
10. European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals 2011-2012. Stockholm:ECDC, 2013. http://ecdc.europa.eu/en/publications/surveillance_reports/Pages/index.aspx (accessed 08 June 2016).
11. Teillant A, Gandra S, Barter D, et al. Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study. Lancet Infect Dis 2015;15(12):1429-37.doi: 10.1016/S1473-3099(15)00270-4.
12. O'Neill J. Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. Review on Antimicrobial Resistance 2014: http://amr-review.org/Publications (accessed 15 June 2016).
13. Williams RJ, Heymann DL. Containment of antibiotic resistance. Science 1998;279(5354):1153-4.doi: 10.1126/science.279.5354.1153.
14. Williams RJ, Ryan MJ. Surveillance of antimicrobial resistance--an international perspective. BMJ 1998;317(7159):651.doi: http://dx.doi.org/10.1136/bmj.317.7159.651.
15. Roca I, Akova M, Baquero F, et al. The global threat of antimicrobial resistance: science for intervention. New Microbes New Infect 2015;6:22-9.doi: 10.1016/j.nmni.2015.02.007.
16. Grundmann H, Klugman KP, Walsh T, et al. A framework for global surveillance of antibiotic resistance. Drug Resist Updat 2011;14(2):79-87.doi: 10.1016/j.drup.2011.02.007.
17. O'Brien TF, Stelling J. Integrated Multilevel Surveillance of the World's Infecting Microbes and Their Resistance to Antimicrobial Agents. Clin Microbiol Rev 2011;24(2):281-95.doi: 10.1128/CMR.00021-10.
18. O'Neill J. Tackling drug-resistant infections globally: final report and recommendations. Review on Antimicrobial Resistance 2016. http://amr-review.org/Publications (accessed 15 June 2016).
19. ND4BB COMBACTE-MAGNET. http://www.combacte.com/COMBACTE-MAGNET/About (accessed 20 June 2016).
20. Kostyanev T, Bonten MJ, O'Brien S, et al. The Innovative Medicines Initiative's New Drugs for Bad Bugs programme: European public-private partnerships for the development of new strategies to tackle antibiotic resistance. J Antimicrob Chemother 2016;71(2):290-5.doi: 10.1093/jac/dkv339.
21. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.doi: 10.1186/2046-4053-4-1.
22. Tacconelli E, Cataldo MA, Dancer SJ, et al. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients. Clin Microbiol Infect 2014;20 (Suppl 1):1-55.doi: 10.1111/1469-0691.12427.
Deliverable Report WP2 : D2.3
ND4BB COMBACTE-MAGNET Deliverable Report dated 16Jan2017 Page 102
23. Rawat D, Nair D. Extended-spectrum beta-lactamases in Gram Negative Bacteria. J Glob Infect Dis 2010;2(3):263-74.doi: 10.4103/0974-777X.68531.
24. Paterson DL, Bonomo RA. Extended-spectrum beta-lactamases: a clinical update. Clin Microbiol Rev 2005;18(4):657-86.doi: 10.1128/CMR.18.4.657-686.2005.
25. Stone SP, Cooper BS, Kibbler CC, et al. The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection. Lancet Infect Dis 2007;7(4):282-8.doi: 10.1016/S1473-3099(07)70082-8.
26. Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Archives of Public Health. 2014;72:39. doi:10.1186/2049-3258-72-39.
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5. Discussion
(The following statements are partly extracted from the paper “Improved Surveillance is Essential for
Control of Antimicrobial Resistance: A Call to Action” from the EPI-Net group, currently under revision
for publication).
Surveillance is essential to all aspects of HAI and AMR management. It provides the necessary
information to develop and monitor therapy guidelines, antibiotic formularies, antibiotic stewardship
programmes, public health interventions, infection control policies, and antimicrobial and vaccine
development. The key role played by surveillance starts with the development of algorithms for
empiric antibiotic therapy and of stewardship programmes. Indeed, active monitoring of AMR is
essential to effective antibiotic stewardship supporting appropriate antimicrobial use that optimises
patients´ clinical outcomes while minimising unintended consequences of antibiotics, including
toxicity and the emergence of resistance. Knowledge of up-to-date surveillance data improves public
health not only at the local level (clinical outcomes for patients) but also globally (hospital and
community AMR rates). Moreover, data from global surveillance systems provide information on
new and worrisome AMR trends and allow policymakers at national and international level to design
new strategies to counter the threat.
European surveillance data are publicly available from the ECDC as well as from many national
cohorts. EARS-Net, the largest publicly funded AMR surveillance system in Europe, was established in
1998 by the European Commission and from 2010 has been coordinated and funded by the ECDC.20
This network, which significantly improved the quality of surveillance data in Europe, provides yearly
reference data on AMR. As AMR has emerged as a significant threat, many national surveillance
systems have also been implemented in Europe.
Our systematic reviews show that limitations of these national surveillance systems can be grouped
into three categories: (1) structural problems, (2) lab-based surveillance issues, and (3) lack of
coordination with animal and food surveillance systems. Structural problems are manifold. In
general, the national surveillance efforts in Europe are still fragmented and heterogeneous.
Numerous local and national systems for HAI and AMR data collection have different goals and little
or no coordination, harmonisation, or information sharing with international networks. Lack of
standardisation of epidemiological definitions, samples and data collected, settings included,
microbiological testing methods (including susceptibility testing), and data sharing policies are
potential obstacles to reliable and informative collaborative surveillance. Almost half of the systems
do not report if European Committee on Antimicrobial Susceptibility Testing (EUCAST) or Clinical &
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Laboratory Standards Institute (CLSI) guidelines are used to define resistance, and a clear definition
of AMR is provided for only one-third of the systems. Although point-prevalence surveys and lab-
based surveillance can provide comprehensive information, publication of these results often
appears years after data collection, limiting their utility in clinical, institutional, and regulatory
decision-making and in targeting of resources and research priorities. Only 7% of the surveillance
systems in Europe provide real-time access to resistance data.
Inherent limitations of the methods used also challenge adequate interpretation of the data.
Laboratory-based systems have a number of specific limitations. First, the microbiological results
reported usually have no associated relevant epidemiological, clinical, or outcome data. Thus, these
systems provide no information on identification of at-risk patient populations, types of infections,
sources (community-onset versus healthcare-associated versus truly hospital-acquired), treatment
failure, or real burden of disease associated with HAIs and AMR. Second, genetic typing and
characterisation is not routinely included for all relevant isolates or mechanisms of resistance; this
testing would facilitate determination of whether AMR trends are caused by spread of resistant
strains or by transfer of resistance determinants among different strains and species. Third, sample
collection may introduce biases that result in lack of external validity, inability to measure impact of
HAIs or AMR within an institution or a community, and failure to predict upcoming trends. Difference
in the frequency and distribution of sampling among physicians, institutions, and countries and the
inclusion of screening isolates rather than only clinical isolates undermine the representatives of the
data. In many settings, sample collection is more likely for more severe infections or ones for which
first-line treatment has failed. In these cases, AMR rates may be inflated, and use of these data may
lead to inappropriate choice of therapy, more resistance, and increased health care costs. In
contrast, underreporting of HAIs and AMR may occur if samples are not routinely collected, and
reliance on laboratory-based surveillance underestimates the incidence of clinically relevant HAIs. In
addition, because samples are collected only from affected sites in patients (and probably just a
subset of those), laboratory-based surveillance based on only clinical samples is not like to be useful
as an early-warning system for emerging pathogens and resistance mechanisms, which are more
likely to be first detected as colonisation in samples such as sputum or urine.
High-quality surveillance of AMR in animals and in the food chain is essential to understanding and
predicting AMR trends and mechanisms in humans, but current surveillance in these areas is also
inadequate. In their recent report exploring associations between consumption of antimicrobials and
AMR in humans and food-producing animals,the ECDC, EFSA, and EMA emphasised major limitations
of the available evidence and highlighted the need for enhanced combined surveillance.Few
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European countries have implemented national AMR surveillance programmes in animals or food,
and these systems have limited goals. They were set up to monitor resistance mainly in Salmonella,
C. jejuni, and E. coli as required by the European Commission’s mandate, and only a very few monitor
resistance in Klebsiella and S. aureus. Our systematic reviews show that even where such systems
have been established, the lack of coordination with human AMR surveillance systems limits the
data’s applicability to humans. Data collection in animals is directed mainly towards treatment of
disease and less towards detection of resistance to either veterinary or human drugs. The data
largely cover veterinary pathogens and antibiotics, so, while there is some overlap with human
disease, they are difficult to interpret with regard to human health or are not at all relevant.
Furthermore, surveillance in animals and food suffer from the same structural problems as human
surveillance systems, namely fragmentation, lack of standardisation and coordination, and reporting
delays. Results from food surveillance are usually not released publicly and can be difficult to obtain
from regulators because they are considered commercially sensitive.
The impact on patient care
The limitations of current surveillance systems significantly affect patients’ care and outcomes.
Inadequate, delayed reporting of surveillance data can lead to suboptimal empiric prescribing and
overprescribing that may jeopardise the outcome for the individual, increase risk of transmission
among hospitalised patients and in the community, and further drive the cycle of AMR development.
In a recent meta-analysis of 27 studies, the rate of inappropriate antibiotic therapy in patients with
severe infections ranged from 14% to 78%, and more than half of the studies had an inappropriate
prescribing rate of more than 50%. Successful empiric therapy of bacterial infections requires
knowledge of the likely microorganism and related susceptibility patterns. Surveillance should thus
provide up-to-date information to the clinician to determine a patient’s risk for resistance in a
specific setting. Increasing globalisation (which includes refugee movements, international travel,
and medical tourism) requires that geographic and temporal changes in AMR be closely monitored
and available in a timely manner. New molecular tests should also be included to increase
understanding of traceability and spread of new AMR threats. Furthermore, an ideal surveillance
system would correlate these data with demographic and clinical data. Surveillance data should be
easily accessible and continuously updated, and detect the emergence and spread of previously
uncommon or completely novel types of resistance.
In addition to the deleterious effects on patient treatment, inadequate surveillance data may also
hamper efforts in other areas. Lack of adequate surveillance data can place susceptible hospital
patients and individuals in the community at risk when infection control measures needed to stop
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the spread of AMR are delayed or incorrectly targeted. Results that lack external validity can limit
understanding of AMR and complicate implementation of agricultural, food industry, and
environmental regulations to reduce animal, food, and water transmission. Inferences drawn from
inaccurate or incomplete surveillance data may lead academia and industry in sub-optimal allocation
of research and development resources, including toward the promising translational approach.
The way forward
Under the pressure of increasing AMR, several initiatives have been launched in Europe in the last
few years to address the limitations of current surveillance systems. The European Surveillance of
Veterinary Antimicrobial Consumption (ESVAC) project of the EMA, which since 2009 has collected
and reported data on sales of veterinary antimicrobials, has recently announced their strategy for
improved surveillance over the next 5 years. ESVAC’s goals include expansion of data collection to all
EEA countries (bolstered by a new regulatory requirement), transition to ongoing annual reporting,
standardisation and harmonisation of data collection, automation of data analysis and presentation,
database linkage, and integration of animal, food, and human data.
The Central Asian and Eastern European Surveillance of Antimicrobial Resistance (CAESAR) network
is a joint initiative of the WHO Regional Office for Europe, the European Society of Clinical
Microbiology and Infectious Diseases, and the Dutch National Institute for Public Health and the
Environment. CAESAR is a network of national AMR surveillance systems and includes all countries of
the WHO European Region that are not part of the EARS-Net. The second annual CAESAR report was
published in November 2016. Currently, 20 countries are participating in CAESAR and six have
submitted national surveillance data to the CAESAR database.
The European Survey on Carbapenemase-Producing Enterobacteriaceae (EuSCAPE) project was
funded by the ECDC in 2013 with the goal to reduce gaps in the diagnostic capacity and
heterogeneity of national surveillance and reporting standards in Europe. The network recently
completed a multicenter study of carbapenemase-producing Enterobacteriaceae prevalence in
European countries and demonstrated that challenges in the establishment of continent-wide
enhanced sentinel AMR surveillance can be overcome.
EPI-net was launched in 2015 to contribute to the improvement of HAI and AMR surveillance in
Europe. The project is one of the four pillars of the COMBACTE consortium (LAB-net, CLIN-net, STAT-
net, and EPI-net) within the New Drugs for Bad Bugs (ND4BB) programme. ND4BB is a joint
undertaking of the European Commission and the European Federation of Pharmaceutical Industries
and Associations under the Innovative Medicines Initiative with the objective to accelerateof the
development and patient access to new medications addressing the AMR crisis in Europe. The major
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innovation of this new project is the creation of a network of representatives from all sectors
involved in surveillance (including stakeholders, public health, academia, and pharmaceutical
industry) to build consensus and drive funding without duplicating efforts. This deliverable
summarizes the first step of the network with the production of a database including all active
surveillance programmes in humans, animals, and food to identify strengths, limitations, areas for
mitigation or improvement, and possible linkages. Concomitantly, short-term goals include the
testing and implementation of semiautomated surveillance systems in different European countries
to test feasibility and data sensitivity. Long-term goals include a central data repository that for the
first time will include different sources of automated surveillance data (ND4BB clinical trials, national
networks, and pharmaceutical companies) and produce standardised indicators with real-time data
access and evaluation of the cost-effectiveness of connected sentinel laboratories for human and
animal data.
A call to action
Timely and targeted dissemination of surveillance data ought to be an essential component of efforts
to combat the AMR threat. Development of a reliable, comprehensive, and sustainable HAI and AMR
surveillance network is critical to adequately support stakeholders and physicians involved in
patients’ care. It requires the involvement of national and international medical and veterinary
societies, environmental advocates, health care systems, academia, the pharmaceutical industry, and
governments. High-quality surveillance data collection, timely analysis, and wide dissemination will
enable a variety of stakeholders to commit the resources and take the actions necessary to combat
the spread of AMR. No country or professional group can achieve this goal without more extensive
collaboration. Such collaboration will ultimately reduce the burden of disease from HAIs and AMR
and provide both health and economic benefits in Europe and worldwide.
The incessant tide of threats posed by HAIs and AMR cannot be stemmed without improving
surveillance systems. Two short-term priorities are urgent in our opinion: (1) agreement at the
European level on goals of AMR surveillance and on definitions and standardised measures to be
applied at the national level to increase comparability of data and feasibility international projects
and (2) agreement on data sharing among European countries. These achievements would allow
increased and simplified data transmission and thus definitively contribute to the development of
automated systems for AMR alerts that could have a significant impact on the effectiveness of
infection control measures in European countries. Long-term goals must include (1) development of
automated linkage of routine surveillance data with other existing databases containing relevant
clinical data (such as treatments and outcomes) and epidemiological data to provide large integrated
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patient-level datasets and to enable definition of the burden of AMR infections in different patients
settings and population communities, (2) enhancement of surveillance systems of AMR in animals
and the food chain, and (3) connection among surveillance systems in humans, animals, and the food
chain, including agreement on key human and veterinary pathogens and key antibiotics to be
monitored and periodic update of these based on AMR trends. These goals cannot be achieved
without increased dedicated financial resources and active involvement of policy makers.
Conclusions
This era of escalating AMR presents an urgent need for improvements in surveillance to streamline
empiric therapy, drive antimicrobial stewardship and infection control measures, and inform
development of new drugs and vaccines. Without such improvements, it will be difficult—almost
impossible—to significantly reduce the medical and economic burdens imposed by AMR. New
initiatives like EPI-net can directly counter the existing inadequacies of surveillance systems, such as
fragmentation, heterogeneity, and time lag, and support their advancement