Anna-Pelagia Magiorakos

Public Health Risks of Enterobacterial Isolates Producing Extended-Spectrum β-Lactamases or AmpC β-Lactamases in Food and Food-Producing Animals: An EU Perspective of Epidemiology, Analytical Methods, Risk Factors, and Control Options

The blaESBL and blaAmpC genes in Enterobacteriaceae are spread by plasmid-mediated integrons, insertion sequences, and transposons, some of which are homologous in bacteria from food animals, foods, and humans. These genes have been frequently identified in Escherichia coli and Salmonella from food animals, the most common being blaCTX-M-1, blaCTX-M-14, and blaCMY-2. Identification of risk factors for their occurrence in food animals is complex. In addition to generic antimicrobial use, cephalosporin usage is an important risk factor for selection and spread of these genes. Extensive international trade of animals is a further risk factor. There are no data on the effectiveness of individual control options in reducing public health risks. A highly effective option would be to stop or restrict cephalosporin usage in food animals. Decreasing total antimicrobial use is also of high priority. Implementation of measures to limit strain dissemination (increasing farm biosecurity, controls in animal trade, and other general postharvest controls) are also important.

Use of colistin-containing products within the European Union and European Economic Area (EU/EEA): development of resistance in animals and possible impact on human and animal health.

Since its introduction in the 1950s, colistin has been used mainly as a topical treatment in human medicine owing to its toxicity when given systemically. Sixty years later, colistin is being used as a last-resort drug to treat infections caused by multidrug-resistant (MDR) Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae (e.g., Escherichia coli, Klebsiella pneumoniae), for which mortality can be high. In veterinary medicine, colistin has been used for decades for the treatment and prevention of infectious diseases. Colistin has been administered frequently as a group treatment for animal gastrointestinal infections caused by Gram-negative bacteria within intensive husbandry systems. Given the ever-growing need to retain the efficacy of antimicrobials used to treat MDR infections in humans, the use of colistin in veterinary medicine is being re-evaluated. Despite extensive use in veterinary medicine, there is limited evidence for the development of resistance to colistin and no evidence has been found for the transmission of resistance in bacteria that have been spread from animals to humans. Since surveillance for colistin resistance in animals is limited and the potential for such transmission exists, there is a clear need to reinforce systematic monitoring of bacteria from food-producing animals for resistance to colistin (polymyxins). Furthermore, colistin should only be used for treatment of clinically affected animals and no longer for prophylaxis of diseases, in line with current principles of responsible use of antibiotics.

The rise of carbapenem resistance in Europe: just the tip of the iceberg?

The European Antimicrobial Resistance Surveillance Network (EARS-Net) collects data on carbapenem resistance from invasive bacterial infections. Increasing percentages of carbapenem resistance in K. pneumoniae isolates were reported from progressively more countries in Europe between 2005 and 2010. A trend analysis showed increasing trends for Greece, Cyprus, Hungary and Italy (p < 0.01). EARS-Net collects data on invasive bacterial isolates, which likely correspond to a fraction of the total number of infections. Increasing reports of community cases suggest that dissemination of carbapenem-resistant K. pneumoniae has penetrated into the community. Good surveillance and infection control measures are urgently needed to contain this spread.

European Antibiotic Awareness Day: a five-year perspective of Europe-wide actions to promote prudent use of antibiotics.

Following the European Union (EU) Council Recommendation on prudent use of antimicrobial agents in human medicine in 2001, and the success of national campaigns, i.e. Belgium and France, the European Centre for Disease Prevention and Control (ECDC) decided to establish the European Antibiotic Awareness Day (EAAD) on 18 November as platform to support national campaigns across Europe. This article provides an overview of EAAD tools, materials, and activities developed during the first five years. It shows that EAAD has been successful due to good cooperation between ECDC and national institutions, strong political and stakeholder support and evidence-based development of campaign materials. EAAD has provided a platform for pre-existing national campaigns and encouraged similar campaigns to develop where neither political support had been secured, nor financial support had been available. As a result, participating countries have continuously expressed strong support for ECDC to continue its work on EAAD. This has been endorsed by a steadily increasing number of countries participating and the growing interest of varied professional and stakeholder organisations. We conclude that EAAD should continue to act as catalyst for discussion and as mechanism to raise awareness of the public and prescribers about prudent use of antibiotics.

The role and utilisation of public health evaluations in Europe: a case study of national hand hygiene campaigns

BackgroundEvaluations are essential to judge the success of public health programmes. In Europe, the proportion of public health programmes that undergo evaluation remains unclear. The European Centre for Disease Prevention and Control sought to determine the frequency of evaluations amongst European national public health programmes by using national hand hygiene campaigns as an example of intervention.MethodsA cohort of all national hand hygiene campaigns initiated between 2000 and 2012 was utilised for the analysis. The aim was to collect information about evaluations of hand hygiene campaigns and their frequency. The survey was sent to nominated contact points for healthcare-associated infection surveillance in European Union and European Economic Area Member States.ResultsThirty-six hand hygiene campaigns in 20 countries were performed between 2000 and 2012. Of these, 50% had undergone an evaluation and 55% of those utilised the WHO hand hygiene intervention self-assessment tool. Evaluations utilised a variety of methodologies and indicators in assessing changes in hand hygiene behaviours pre and post intervention. Of the 50% of campaigns that were not evaluated, two thirds reported that both human and financial resource constraints posed significant barriers for the evaluation.ConclusionThe study identified an upward trend in the number of hand hygiene campaigns implemented in Europe. It is likely that the availability of the internationally-accepted evaluation methodology developed by the WHO contributed to the evaluation of more hand hygiene campaigns in Europe. Despite this rise, hand hygiene campaigns appear to be under-evaluated. The development of simple, programme-specific, standardised guidelines, evaluation indicators and other evidence-based public health materials could help promote evaluations across all areas of public health.

Antimicrobial resistance surveillance in Europe: regional pooling of national data from a small number of sites can be misleading

We read with interest the results of the European component of theRegionalResistanceSurveillancestudyreportedbyJonesandcolleaguesintheir online article on October 14, 2013 ( Jones et al., 2013). This articlepresents antimicrobial susceptibility test results from a collection ofEuropean bacterial isolates with centralised determination of MICs for alarge panel of antibiotics, followed by interpretation according to 2international breakpoint de finitions. The authors suggest that the resultscan be used to validate results from national and regional antimicrobialresistance surveillance programs, such as the European AntimicrobialResistance Surveillance Network (EARS-Net) ( ECDC, 2013).Unfortunately, 2 important factors were not taken into account bythe authors, which preclude the use of their results for validationpurposes or to properly reflect the heterogeneous resistance situationin Europe. Firstly, the results were based on pooled data from only 47hospitals in 21 countries. Secondly, the authors mentioned largevariations in resistance percentages between countries, but theseinter-country differences were neither thoroughly presented, nordiscussed. As a consequence, the pooled estimates could be subject tobias due to poor representativeness and might not reflect the truepicture of antimicrobial resistance in Europe.Results from EARS-Net, based on routine microbiological data fromapproximately 1300 hospitals in Eu rope, have repeatedly shown thatdifferencesinantimicrobialresistancepercentagesbetweencountriesaresubstantial. As an example, the national percentage of invasive Klebsiellapneumoniae isolates resistant to third-generation cephalosporins variedbetween 2% and 75% among the 30 Europe an countries that participatedin EARS-Net in 2012. Similar significant inter-country differences can befound for many antimicrobial-microorganism combinations in thepublicly available on-line EARS-Net database ( ECDC, 2014).As the authors state in their conclusions, antimicrobial resistancesurveillance programs should be more widely supported to monitoremerging resistance trends and follow the impact of structuredinterventions at national, regional, and local levels. Moreover,although European readers may be tempted to use the data providedby the European component of the Regional Resistance Surveillancestudy to update their guidelines for empiric therapy of infectedpatients, due to the aforementioned limitations, much caution shouldbe exercised in doing so. While national antimicrobial resistance dataremain essential to describe the magnitude and trends in antimicro-bial resistance in and between European countries, large variationsmay exist even within 1 single country (Carbonne et al., 2013;SWEDRES-SVARM, 2013; ECDC, 2013). It is, therefore, necessary forhospitals and physicians to be familiar with their local surveillancedataandusethemasabasisforthecreationoflocal guidelinesaswellas for empiric antimicrobial treatment of infections.The Regional Resistance Surveillance study is indeed complemen-tary to other surveillance programs such as EARS-Net and should, inprinciple, provide additional, useful information. This goal, however,is only partially achieved by this study due to the small number ofparticipating sites and the fact that the pooled data at the regionallevel provide misleading information on antimicrobial resistanceacross Europe.Conflicts of interestWe declare no conflict of interest.Liselotte Diaz HogbergAnna-Pelagia MagiorakosOle E. HeuerDominique L. MonnetEuropean Centre for Disease Prevention and ControlTomtebodavagen 11a, 171 83 Stockholm, SwedenE-mail address: liselotte.diaz-hogberg@ecdc.europa.euhttp://dx.doi.org/10.1016/j.diagmicrobio.2014.03.015References

Association of national and hospital factors to hospitals' alcohol-based handrub consumption in Europe: Results of the European PROHIBIT study

OBJECTIVES Hand hygiene is considered the most effective way to reduce the transmission of (multidrug-resistant) organisms and to prevent healthcare-associated infections. Hand rubbing with alcohol-based handrub (AHR) has become the reference standard for hand hygiene. Data on AHR consumption are easy to obtain and can serve as an approximation for hand hygiene compliance. As described earlier, AHR consumption varies among European hospitals. In the current study the role of various hospital and country indicators for AHR consumption is analysed. METHODS As part of the European Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project hospital-based data on infection prevention and control (IPC) structure and organization and hospital-wide AHR consumption were obtained from acute care hospitals. National indicators such as income, public health expenditure, national hand hygiene campaigns, IPC training and the six Hofstede dimensions were identified. Univariable and multivariable linear regression analyses using generalized linear models were performed to estimate the association between AHR consumption and indicators at both hospital and country levels. RESULTS Data from 232 hospitals from 22 European countries were analysed. Multivariate risk factor analysis showed independent associations between AHR consumption and private and university-affiliated hospitals (multiplicative effect, 95% CI: 1.76, 1.21-2.55; and 1.39, 1.17-1.64, respectively), high-income countries (3.61, 2.94-4.43), and countries offering national curricula for the training of IPC nurses (3.77, 2.32-6.13). However, no cultural dimension was independently associated with AHR consumption. CONCLUSION Country indicators such as high-income, national training on IPC, and hospital type and status are positively associated with AHR consumption in Europe.

Health-care-associated infections – Authors' reply

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