antimicrobial resistance and antimicrobial consumption in ... · eu/eea, 2013 & 2016...

Antimicrobial resistance and antimicrobial consumption in Europe

Dominique L. Monnet, on behalf of ECDC Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Programme

Vilnius, 28 November 2017

• An agency of the European Union, located in Stockholm, Sweden

• Founded in 2005; nearly 300 employees in 2015

• Mandate to ‘identify, assess and communicate current and emerging threats to human health from communicable diseases’

• European Union (EU) (28) and European Economic Area (EEA) (3) = 31 countries with a total of more than 500 million people

ECDC – European Centre for Disease Prevention and Control

www.ecdc.europa.eu

Antimicrobial Resistance and Healthcare- Associated Infections (ARHAI) Networks

• European Antimicrobial Resistance

Surveillance Network (EARS-Net) (formerly EARSS, integrated in January 2010)

• European Surveillance of

Antimicrobial Consumption

Network (ESAC-Net) (formerly ESAC, integrated in July 2011)

• Healthcare-Associated Infections

surveillance Network (HAI-Net) (formerly HELICS / IPSE, integrated in July 2008)

www.ecdc.europa.eu

AMR Antimicrobial resistance

Several, inter-related compartments of healthcare, (i.e. patients in primary care, hospitals, nursing homes and long-term care facilities), food animals, food, environment

Many types of human infections, i.e. respiratory tract, urinary tract, skin and soft tissue, bloodstream, surgical site, related to medical devices, etc.)

Many bacteria/microorganisms

Many antimicrobials and mechanisms of resistance

Antimicrobial resistance: what does it really mean?

Patients with infections due to resistant bacteria!

https://antibiotic.ecdc.europa.eu/en/patient-stories

each year in the EU/EEA

attributable to

5 multidrug-resistant bacteria

4 main healthcare-associated infections (HAIs)

Burden of antimicrobial resistance (AMR) for the EU/EEA

Update: 2018

Source: ECDC, 2009. In: http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf

25 000 deaths

Source: ECDC, 2015.

Photo: Luis García

Hospitals Food animals

Photo: US Dept. of Agriculture

http://upload.wikimedia.org/wikipedia/commons/0/05/Hospital_Universitario_La_Paz_(Madrid)_02.jpg

2nd Joint Interagency Antimicrobial Consumption and Resistance Analysis (JIACRA) Report

ECDC/EFSA/EMA second 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

Humans + Animals = One Health

Source: ECDC, EFSA & EMA, 2017. EFSA Journal, 27 July 2017. http://onlinelibrary.wiley.com/doi/10.2903/j.efsa.2017.4872/epdf


Biomass-corrected antimicrobial consumption in humans and animals, EU/EEA, 2014

Humans: 124 mg/kg (range: 50 – 182 mg/kg)

Animals: 152 mg/kg (range: 3 – 419 mg/kg)

* Humans: community consumption only


Biomass-corrected consumption of selected antimicrobial groups in humans and animals, EU/EEA, 2014

* Humans: community consumption only

3rd- and 4th-generation cephalosporins Fluoroquinolones and other quinolones

Humans

Animals

Source: EFSA Journal, 27 July 2017.

Joint Interagency Antimicrobial Consumption and Resistance Analysis (JIACRA): example

Each dot represent one country.

Poultry

Quinolone consumption and probability of resistance to quinolones in Campylobacter jejuni from poultry, EU/EEA, 2014

OR = 2.71 [1.57 – 5.63], p < 0.001

Community

Source: ESAC-Net, 2017.

Sweden

Finland

The symbols and indicate a significant increasing or decreasing trend for the period 2012-2016, respectively.

Defined daily doses (DDD) per 1000 inh. and per day

Packages per 1000 inh. and per day

* Total care data, including the hospital sector.

† Reimbursement data (i.e. not including consumption without a prescription and other non-reimbursed courses).

Consumption of antibiotics for systemic use (ATC group J01) in the community, EU/EEA, 2012-2016

Norway

Spain

Greece

Luxembourg

Sweden

Denmark

Estonia

Finland

Streptococcus pneumoniae: percentage of invasive isolates not susceptible to macrolides; EU/EEA, 2015

Source: EARS-Net, 2016 The symbols and indicate a significant increasing or decreasing trend for the period 2012-2015, respectively.

These trends were calculated on laboratories that consistently reported during this period.

Update with 2016 data: 15 Nov. 2017

Escherichia coli: percentage of invasive isolates resistant to third-generation cephalosporins; EU/EEA, 2015



Escherichia coli: percentage of invasive isolates resistant to fluoroquinolones; EU/EEA, 2015




Joint Interagency Antimicrobial Consumption and Resistance Analysis (JIACRA): Results of partial least square path modeling (PLS-PM) of fluoroquinolone consumption and fluoroquinolone-resistant Escherichia coli

H

R Strep.

pneumoniae

R Strep.

pyogenes

R Haem.

influenzae

R Salmonella

R Campylo-

bacter

R E. coli

R E. coli

HA-MRSA

CA-MRSA

LA-MRSA

(mostly

CC398)

R E. coli

R Salmonella

R Campylo-

bacter

R

Enterobacter

R

Klebsiella

pneumoniae

Clostridium

difficile

R

Pseudomonas

aeruginosa

R

Acinetobacter

baumannii

Compartments of antimicrobial resistance

Photo: Luis García

Hospitals

http://upload.wikimedia.org/wikipedia/commons/0/05/Hospital_Universitario_La_Paz_(Madrid)_02.jpg

Comparing the burden of healthcare-associated infections (HAIs) with other infectious diseases (BCoDE project 2015)

Source: *Cassini A, et al. PLoS Med 2016;13(10):e1002150 (18 October 2016) ** Cassini A, et al. PLoS Med (submitted).

Healthcare-associated infections account for twice the burden of 31 other infectious diseases

Burden of HAIs – 2011-2012 * Burden of 5 top ranking infectious diseases from BCoDE 2009-2013 **

HA, Healthcare-associated; DALYs: Disability-Adjusted Life Years

Healthcare- associated infections

Community-acquired infections

Antimicrobial resistance

Healthcare-associated infections, antimicrobial resistance: Overlapping, but not identical

Antimicrobial resistance

Staphylococcus aureus: % of invasive isolates with resistance to meticillin (MRSA), EU/EEA, 2013 & 2016

Source: EARS-Net, 2017. The symbols and indicate a significant increasing or decreasing trend for the period 2013-2016, respectively. These trends were calculated on laboratories that consistently reported during this period.

2013

2016

Klebsiella pneumoniae: % of invasive isolates with combined resistance* EU/EEA, 2013 & 2016 *Third-generation cephalosporins, fluoroquinolones and aminoglycosides


2013

2016

Klebsiella pneumoniae: % of invasive isolates with resistance to carbapenems EU/EEA, 2013 & 2016


2013

2016

Source: EARS-Net and CAESAR, 2017. *European Health Information Gateway (https://gateway.euro.who.int/en/)

E. coli K. pneumoniae

Enerobacteriaceae: carbapenem resistance (%), Europe*, 2016

Carbapenem-resistant infections: a challenge for appropriate patient therapy

Courtesy: C. Giske. Karolinska University Hospital, Stockholm, Swede.n Photo: www.microbiologie.info.

https://storify.com/EAAD_EU/patient-stories

Mohammed (United Kingdom)


Humans

Carbapenem consumption and probability of resistance to carbapenems in invasive Klebsiella pneumoniae from humans, EU/EEA, 2015

OR = 1.23 [95% CI: 1.08 – 1.42], p = 0.002

Each dot represent one country.

Joint Interagency Antimicrobial Consumption and Resistance Analysis (JIACRA): example

Source: ESAC-Net, 2017. The symbols and indicate a significant increasing or decreasing trend for the period 2012-2016, respectively.

Consumption of last-line antibiotics in the hospital sector, EU/EEA, 2012-2016 Carbapenems (DDD per 1000 inh. and per day)

Polymyxins (mainly colistin) (DDD per 1000 inh. and per day)

* Cyprus and Romania:

total care data, including consumption in the community. These data were not used to calculate the EU/EEA population-weighted average.

(a) Finland: data include

consumption in remote primary healthcare centres and nursing homes.

(b) Portugal: data relate to public hospitals only.

Greece

Slovakia

Italy

Romania

Malta

Hungary Slovenia

Denmark

Bulgaria

Ireland

France

Bulgaria

Latvia

Hungary

Lithuania

Slovakia

Romania Estonia

Croatia

Malta Cyprus

Portugal (b)

Source: EARS-Net, 2017

2016

Klebsiella pneumoniae: % of invasive isolates with combined resistance to carbapenems and colistin, EU/EEA, 2016

All isolates tested for carbapenem susceptibility were included in the denominator to limit the effect of sequential testing.

Source: Douka E, et al. Int J Antimicrob Agents 2015;48:533-6.

Outbreak of pandrug-resistant VIM-1 Providencia stuartii, Sept.-Nov. 2011

Examples

• Mycobacterium chimaera cardiovascular infections linked to heater-cooler devices

• Candida auris infection

• optrA (transferable oxazolidinone and chloramphenicol resistance)

Modern medicine: not possible without effective antibiotics

Care of preterm babies

Intensive care

Organ transplant

Hip / knee replacement

Cancer chemotherapy

Prudent use of antimicrobial agents (only when needed, correct dose, correct dose intervals, correct duration)

Infection prevention and control (hand hygiene, screening, isolation)

New antimicrobial agents (with a novel mechanism of action, research, development)

Main actions to prevent and control antimicrobial resistance (AMR)

EU One Health Action Plan against Antimicrobial Resistance (29 June 2017)

https://ec.europa.eu/health/amr/action_eu_en

EU Guidelines for the prudent use of antimicrobials in human health (June 2017)

https://ec.europa.eu/health/amr/action_eu_en

• Based on Council Recommendation of 15 November 2001 on the prudent use of antimicrobial agents in human medicine (2002/77/EC)

• Reports (observations, conclusions, suggestions, examples of best practice)

• 23 EU Member States and 1 EU enlargement country (see map)

• 5 follow-up visits (Greece × 2 and Hungary × 2, Malta)

• 2018: 6 visits*

jointly with DG SANTE/F5, in a One Health perspective

Country visits to discuss antimicrobial resistance (AMR) issues, 2006-2017 As of 28 November 2017

Done

Planned (invitation received)

Discussed

Jointly with DG SANTE/F

*

*

*

*

Source: ECDC, 2017.

ECDC rapid risk assessments

http://ecdc.europa.eu/en/publications/risk_assessment/Pages/default.aspx?p=2

https://ecdc.europa.eu/en/publications-data/directory-online-resources-prevention-and-control-antimicrobial-resistance-amr

Source: ECDC, 2015. http://www.ecdc.europa.eu/en/healthtopics/Healthcare-associated_infections/guidance-infection-prevention-control/Pages/guidance-prevention-control-infections-caused-by-multidrug-resistant-bacteria-and-healthcare-associated-infections.aspx

Infection prevention and control measures and tools to prevent entry of carbapenem-resistant Enterobacteriaceae (CRE) into healthcare settings: ECDC guidance

• Core measures

• Profile for ”at risk” patients who require supplemental measures

• Preliminary supplemental measures (at admission, for ”at risk” patients)

• Supplemental measures (for confirmed CRE-positive patients)

Source: Magiorakos et al. Antimicrob Resist Infect Control (15 November 2017).

https://antibiotic.ecdc.europa.eu

A forward look into 2018

Burden of antimicrobial resistance (AMR) for the EU/EEA (Q2 2018)

Annual update on AMR and antimicrobial consumption in

humans in the EU/EEA (November 2018)

ECDC point prevalence surveys of HAIs, AMR

and antimicrobial use in European acute care hospitals and in long-term care facilities, 2016-2017 (ECDC publications, November 2018)

Launch of project on whole genome sequencing (WGS)-based surveillance of carbapenem- and/or colistin-resistant Enterobacteriaceae (EURGen-Net)

18 November 2017

E-mail: [email protected] Website: http://antibiotic.ecdc.europa.eu Facebook: EAAD.EU Twitter: @EAAD_EU (#EAAD) Global Twitter: #AntibioticResistance

EU event, Brussels, 15 November 2017

13-19 NOVEMBER 2017

antimicrobial resistance and antimicrobial consumption in ... · eu/eea, 2013 & 2016...

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