Ines Noll

Increasing Occurrence of Multidrug-Resistance in Acinetobacter baumannii Isolates From Four German University Hospitals, 2002-2006

Background:Acinetobacter baumannii can cause severeinfections, mainly in critically ill inpatients. Treatment iscomplicated by multidrug-resistance (MDR). In Germany, todate, little is known on the extent of MDR in A. baumanniiisolated from inpatients in German hospitals and potentialfactors influencing the emergence of MDR.Materials and Methods:We retrospectively analysed thedata of A. baumannii isolates from the inpatients of fourGerman university hospitals, tested for antimicrobial resistancewith the broth dilution method between 2002 and2006. We defined MDR as resistance to three or more classesof recommended drugs. After calculating the proportions ofMDR in A. baumannii isolates, we investigated the associationbetween MDR in A. baumannii and year of pathogenisolation, hospital, ward type, specimen and demographics.We performed descriptive analysis and multivariable logisticregression. Additionally, proportions of in vitro drug effectivenessagainst multidrug-resistant and non-multidrugresistantA. baumannii isolates were determined.Results:MDR was found in 66 of 1,190 (5.6%)A. baumannii isolates and increased from 2.1% in 2002 to7.9% in 2006. The highest proportions of MDR were foundin hospital A (8.9%), in intensive care units (7.3%), inisolates from blood (7.6%) and in male patients aged60 years or older (6.6%). In multivariable analysis, thechance of MDR in A. baumannii isolates increased with thesuccessive years of pathogen isolation (odds ratio [OR] 1.3,95% confidence interval [CI] 1.1–1.5) and there was ahigher risk of MDR in A. baumannii in intensive care units(OR 1.8, 95% CI 1.1–2.9). The lowest in vitro antibioticresistance was found in meropenem, imipenem and ampicillin/sulbactam, with 33, 37 and 39% for multidrugresistantand 0.4, 1 and 3% in non-multidrug-resistantA. baumannii isolates, respectively.Conclusions:The increase of MDR in A. baumannii isolatesfrom 2002 to 2006 in four hospitals suggests that cliniciansin Germany may expect a rising proportion of MDR inA. baumannii isolates among inpatients. The antimicrobialsusceptibility testing of A. baumannii isolates against recommendeddrugs, combined with in-house antimicrobial resistancesurveillance, is needed to ensure appropriate treatment.

MRSA-surveillance in Germany: data from the Antibiotic Resistance Surveillance System (ARS) and the mandatory surveillance of MRSA in blood

Data from the German Antibiotic Resistance Surveillance system (ARS) and statutory notification of methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures are presented. ARS is a voluntary laboratory-based surveillance system providing resistance data of all clinical pathogens and sample types from hospitals and ambulatory care. Statutory notification includes MRSA detected in blood and cerebrospinal fluid by microbiological laboratories. Resistance data from 2008 to 2010 and MRSA-bacteraemia incidences from 2010 are presented. From 2008 to 2010, resistance data from 70,935 Staphylococcus aureus isolates were transferred to the national health institution. MRSA proportions in hospitals and outpatient care account for 19.2% and 10.6%, respectively. In hospital care high proportions of MRSA were found in nephrological, geriatric, neurological general wards and surgical ICUs (49.4%, 45.8%, 34.2%, and 27.0%, respectively), while in community outpatient care urological practices (29.2%) account for the highest values. In both healthcare settings urinary tract samples stand out with high proportions of MRSA (hospitals, 32.9%; outpatients, 20.5%). In 2010, 3900 cases of MRSA bacteraemia were reported, accounting for an incidence of MRSA bacteraemia of 4.8/100,000 inhabitants/year. Stratification by federal states shows considerable regional differences (range, 1.0–8.3/100,000 inhabitants/year). Vulnerable areas in hospitals and outpatient care have been pointed out as subjects for further inquiries.

A Survey of Outpatient Antibiotic Prescribing for Cystitis

BACKGROUND In view of the currently increasing rates of antibiotic resistance, we studied the factors that affect the prescribing of specific antibiotics for uncomplicated cystitis in outpatient care. METHODS A nationwide cross-sectional survey of physicians in private practice in various specialties (internal medicine, general medicine, surgery, obstetrics/gynecology, child and adolescent medicine, otorhinolaryngology, dermatology, urology) was carried out in 2008. The sample was derived from the German state directories of medical specialists. RESULTS 1810 (60%) of the physicians surveyed reported that they made decisions about antibiotic treatment every day, with uncomplicated urinary tract infection as the most common diagnosis (715 physicians). The antibiotics that they prescribed most commonly for it were cotrimoxazole (61%) and fluoroquinolones (21%). The following factors were significantly associated with a preference for fluoroquinolones: being a gynecologist (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.27-0.80), location of practice in the former East Germany (OR 2.01, CI 1.16-3.46), a treatment strategy incorporating a switch from empirical to targeted treatment (OR 1.72, CI 1.02-2.90), and the stated intention of avoiding inconvenience to the patient (OR 2.14, CI 1.25-3.68). DISCUSSION Fluoroquinolones are no longer recommended as the drug of first choice for uncomplicated urinary tract infections because of the development of resistance, but are still commonly prescribed for it. ARS (Antibiotic Resistance Surveillance in Germany) publishes current regional and patient-group-specific resistance rates to promote good clinical practice and improve prescribing behavior.

Antibiotic-resistant E. coli in uncomplicated community-acquired urinary tract infection

BACKGROUND Routine urine culture testing is not recommended for uncomplicated urinary tract infections (UTIs). As a result, the antibiotic resistance patterns or the organisms causing UTIs are not adequately reflected in routine data. We studied the sensitivity of Escherichia coli (E. coli) to trimethoprim (TMP) and to cotrimoxazole (i.e., trimethoprim/sulfamethoxazole, TMP/SMX) in community-acquired UTI and compared the findings with the resistance data of the Antimicrobial Resistance Surveillance System (ARS). METHODS General practitioners and internists in private practice prospectively recruited all of their adult patients with symptoms of a urinary tract infection from May 2015 to February 2016. Urine specimens from all patients were tested (including urine culture testing and antibiotic susceptibility) and infections were defined as uncomplicated or complicated UTIs. RESULTS 1245 participants from 58 medical practices were enrolled in the study. Pathogenic organisms were found in the urine of 877 patients, of whom 74.5% had E. coli infections. Among the E.-coli-positive UTIs, 52.4% were classified as uncomplicated and 47.6% as complicated. The prevalence of E. coli that was resistant to TMP and to TMP/SMX in uncomplicated UTIs was 15.2% and 13.0%, respectively, compared to 25.3% and 24.4%, respectively, from all UTIs in ARS in 2015. Study participants who had previously taken antibiotics had the highest prevalence of E. coli resistance (30.9%), followed by those who had two or more UTIs within the past six months (28.9%). CONCLUSION E. coli with resistance to TMP was significantly less prevalent among the study patients with uncomplicated UTIs than in the routine data of the ARS. Accordingly, TMP should still be considered as an option for the treatment of uncomplicated UTIs. TMP/SMX is considered the agent of second choice because of its side effects. Surveillance systems based on routine data do not yield a representative sample for the evaluation of the resistance situation in patients with uncomplicated UTIs.

Carbapenem non-susceptibility of Klebsiella pneumoniae isolates in hospitals from 2011 to 2016, data from the German Antimicrobial Resistance Surveillance (ARS)

BackgroundCarbapenem resistance in Klebsiella pneumoniae is of significant public health concern and recently spread across several countries. We investigated the extent of carbapenem non-susceptibility in K. pneumoniae isolates in Germany.MethodsWe analysed 2011–2016 data from the German Antimicrobial Resistance Surveillance (ARS) System, which contains routine data of antimicrobial susceptibility testing from voluntarily participating German laboratories. Klebsiella pneumoniae isolates tested resistant or intermediate against an antibiotic were classified as non-susceptible.ResultsWe included 154,734 isolates from 655 hospitals in the analysis. Carbapenem non-susceptibility in K. pneumoniae isolates was low in Germany 0.63% (95% CI 0.51–0.76%). However, in continuously participating hospitals the number of K. pneumoniae isolates almost doubled and we found evidence for a slowly increasing trend for non-susceptibility (OR = 1.20 per year, 95% CI 1.09–1.33, p < 0.001). Carbapenem non-susceptibility was highest among isolates from patients aged 20–39 in men but not in women. Moreover, carbapenem non-susceptibility was more frequently reported for isolates from tertiary care, specialist care, and prevention and rehabilitation care hospitals as well as from intensive care units. Co-resistance of carbapenem non-susceptible isolates against antibiotics such as tigecycline, gentamicin, and co-trimoxazole was common. Co-resistance against colistin was 13.3% (95% CI 9.8–17.9%) in carbapenem non-susceptible isolates.ConclusionCarbapenem non-susceptibility in K. pneumoniae isolates in Germany is still low. However, it is slowly increasing and in the light of the strong increase of K. pneumoniae isolates over the last year this poses a significant challenge to public health. Continued surveillance to closely monitor trends as well as infection control and antibiotic stewardship activities are necessary to preserve treatment options.

Survey zur ärztlichen Verschreibung von Antibiotika: Ergebnisse zur akuten Zystitis in der ambulanten Versorgung

BACKGROUND In view of the currently increasing rates of antibiotic resistance, we studied the factors that affect the prescribing of specific antibiotics for uncomplicated cystitis in outpatient care. METHODS A nationwide cross-sectional survey of physicians in private practice in various specialties (internal medicine, general medicine, surgery, obstetrics/gynecology, child and adolescent medicine, otorhinolaryngology, dermatology, urology) was carried out in 2008. The sample was derived from the German state directories of medical specialists. RESULTS 1810 (60%) of the physicians surveyed reported that they made decisions about antibiotic treatment every day, with uncomplicated urinary tract infection as the most common diagnosis (715 physicians). The antibiotics that they prescribed most commonly for it were cotrimoxazole (61%) and fluoroquinolones (21%). The following factors were significantly associated with a preference for fluoroquinolones: being a gynecologist (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.27-0.80), location of practice in the former East Germany (OR 2.01, CI 1.16-3.46), a treatment strategy incorporating a switch from empirical to targeted treatment (OR 1.72, CI 1.02-2.90), and the stated intention of avoiding inconvenience to the patient (OR 2.14, CI 1.25-3.68). DISCUSSION Fluoroquinolones are no longer recommended as the drug of first choice for uncomplicated urinary tract infections because of the development of resistance, but are still commonly prescribed for it. ARS (Antibiotic Resistance Surveillance in Germany) publishes current regional and patient-group-specific resistance rates to promote good clinical practice and improve prescribing behavior.