European Surveillance of Antibiotic Resistance (ESAR)

A Study of the European Society of Biomodulation and Chemotherapy

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The denominator for the total of all the strains of potential Alert organisms is shown for each ESAR centre in Table 1. The Centres in Aberdeen, Bratislava NCI and Warsaw accumulate data from many hospitals around them whereas Leipzig (University Hospital) and Bratislava NCI deal only with smaller, single units. The two centres in Bratislava are Cancer specialist centres.

The high percentage of alert organisms in Warsaw and Bratislava St Elizabeth (BSE) probably reflect Warsaws function as a reference laboratory and St Elizabeths function as a tertiary referral cancer centre.

The distribution of organisms tested for Alert status is remarkably similar between the centres (Table 2).

Aberdeen and BSE had the lowest proportion from ICU, 12.8% and 4.8% respectively, increasing to a maximum of 50.5% at BNCI.

All Campylobacter, Salmonella and Shigella came from Aberdeen. Almost all Citrobacter and most Acinetobacter came from Bratislava NCI suggesting outbreaks of these organisms. No enterococci Alerts were isolated in Aberdeen but Leipzig had twice the number of E.faecalis than any other laboratory, comprising 30.1% of all its Alerts. 16.8% of BSE Alerts were E.cloacae and 31.2% E.coli (double the rate of any other centre). In Warsaw 25.7% of all its alerts were E.faecium, comprising over half of all strains. Haemophilus type B still seems a problem at NCI with 24 isolates (1.5%). NCI had double the rate for P.mirabilis of all other centres at 5.4% and also P.aeruginosa at 32.3%. Overall P.aeruginosa was the most common Alert (603 strains) followed by E.coli (414) and S.aureus (402).

Aberdeen which is in the middle of an MRSA epidemic provided almost ¾ of all the MRSA strains and at 61.9% had treble the incidence (as a proportion of all Alert organisms) of Warsaw, the next highest.

Glycopeptide resistant Staphylococci (even coagulase negative) were rare although there were low levels of Group A streptococci from Aberdeen, NCI and Warsaw, Group B from NCI and Group G from Aberdeen.

Warsaw was the only centre with S.pneumoniae greater than 2.5% at 12.9%.

Up to 30% of Alerts were from surveillance cultures (Leipzig) but only 2.3% in Warsaw (Table 3). The mean was 15.8%. Overall 73% were aquired in hospital and, the great majority of the rest, in the community. Only Leipzig had significant acquisition abroad (31.8%).

18.6% of Alerts were from LRTI, 34.9% from UTI and 21.9% from skin or wounds (Table 4). Less than 10% of the latter were catheter related with as expected, BSE had over twice the rate for these. Only 4.1% were from blood culture isolates which formed a particularly high proportion of Warsaw’s Alert isolates (17.9%), reflecting its National referene laboraotry status.

A slight male sex preponderance existed in each centre except BSE. where two-thirds of alert organisms came from female patients. Only a minority of patients had undergone an operation with the exception of Leipzig (approximately 50%). Alert organisms documented by discipline showed only one significant difference: a ten fold greater number coming from haematology/oncology in BSE than any other centre.

Prior antibiotic therapy had been given in 74% of all patients where this data was available (1785) and the percentage ranged from 70.7 in NCI to 86.1 in Leipzig.

Underlying diseases were present in almost 90% of patients in each centre with neoplasms being the most common (21.3%) ranging from 3.8% in Warsaw to 78.6% at BSE. Next followed diseases of the respiratory system (12.4%), genitourinary system (12.2%), circulatory system (11.7%) and digestive system (8.4%). There were marked variations in the distribution of these between the various centres.

Where data was available (1674 patients). 67.5% of patients had identifiable risk factors ranging from 49.2% in Warsaw to 91.7% in Leipzig.

These ranged from vascular catheters (26.2%) to urinary catheters (10.8%) and chemotherapy 4.8%. This will form the subject of another report by V. Krcmery.

The three non-specialist centres have low rates of Alert organisms (1.4 –4.1% of the Denominator). The two specialist centres (Warsaw, a national reference laboratory and Bratislava St Elizabeth, a cancer referral centre) have much higher rates at 9.8 and 25.5% respectively. These reflect the more likely referral of multiply-resistant organisms to a reference laboratory and the predisposition of cancer patients to infection as shown by the analysis of underlying diseases and risk factors. The number of infections related to vascular catheters and manifesting as bacteraemia were lower than expected, given the patient mix but the high proportion of hospital aquired infections and prior antibiotic exposure is well described.

The low prevalence of resistant pneumococci may reflect a lack of community isolates, the main Alert organisms being MRSA, Pseudomonas aeruginosa and Enterbacteriaceae, all most often nosocomial pathogens with the exception of E.coli UTI.

Some outbreaks were identified such as the MRSA outbreak (Type 15), running now for over 2 years in Aberdeen. It is possible that there are outbreaks also in NCI, Leipzig, BSE and Warsaw, infact in all the centres and this will be investigated along with possible reasons such as epidemic strains, antibiotic use or infection control problems.

There was little evidence of importation of Alert organisms from abroad with the exception of Leipzig (? Source) nor of the latest scare, glycopeptide resistance in Staphylococci.

In some ways the data is re-assuring but it must be remembered that these Alert organisms are just the tip of the iceberg, reflecting the most worrying of resistant developments of the time. In addition, the great majority of them seem to be causing clinical infection, very frequently in very ill patients with associated high mortality (data still being processed).

In the second year of the project we will collect available data on antibiotic use and infection control aspects of each hospital and address each of the possible outbreaks identified in each centre:

In addition there will be further refining of the data and detailed analysis of the resistant phenotypes for new resistant mechanisms and relationship to antibiotic use.

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