Presentation from the 3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Networks, organised by the European Centre of Disease Prevention and Control - Stockholm, 11-13 February 2015

1. EARS-Net Ireland
ARHAI meeting, Stockholm,
10-13th February 2015
Stephen Murchan
Surveillance Scientist at the Health Protection Surveillance Centre, Dublin

2. Background
• Joined EARSS in 1999
• Population = 4,588,252 (2011 census)
• Complete population coverage since 2007
– 40 laboratories
– 58 acute hospitals
• 47 public
• 11 private
• Denominator data [include admissions, bed days
used (BDUs), blood cultures processed] on almost all
• Enhanced surveillance on ~50%
• EUCAST now predominant: just 6/40 still use CLSI

3. • Data collected and analysed quarterly
• Regular reports and feedback to labs/hospitals
• Supported by reference labs
– MRSA/ Pneumococcal typing/ CRE and other
resistant Gram –ves
Background

4. VRE (E. faecium), 2013:
A big problem in Ireland
Median = 6%
IE Rank =
1/30 (43%)
Next: CY, UK,
GR, PO =22-
23%
IE highest
since 2008

5. Reporting PNSP in Europe –
effect of using different
breakpoints/guidelines:
PNSP, 2013
Using oral bps
for CLSI and
non-men bps
for EUCAST
IE rank = 10/30
(20%)
Median = 12%

6. PNSP, 2013:
alternative scenario 1
Using non-men
bps for CLSI and
non-men bps
for EUCAST
IE = 9%

7. PNSP, 2013:
alternative scenario 2
If all CLSI and
using non-men
bps
IE = 0.3%

8. Invasive E. coli infections

9. 0%
5%
10%
15%
20%
25%
30%
35%
0
500
1000
1500
2000
2500
3000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014*
%Resistance
Numberofisolates
Year
Total E. coli %3GC-R %FQREC %GEN-R %GEN/TOB/AMK-R
AMR trends for E. coli

10. 0%
2%
4%
6%
8%
10%
12%
14%
16%
0
500
1000
1500
2000
2500
3000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014*
%3GC-R/ESBL+ve
Numberofisolates
Year
Total E. coli %3GC-R %ESBL+ve
3GC/ESBL trends for E. coli

11. 3GC-R E. coli, 2013
Median =
11%
IE Rank =
13/30 (12%)
Increased
from 17/28
(9%) in 2010

12. 0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
0
500
1000
1500
2000
2500
3000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014*
%MDRECO
Numberofisolates
Year
Total E. coli tested for MDR MDR ECO %MDR
MDR trends for E. coli

13. Invasive K. pneumoniae infections

14. 0%
5%
10%
15%
20%
25%
30%
0
50
100
150
200
250
300
350
400
2008 2009 2010 2011 2012 2013 2014*
%Resistance
Numberofisolates
Year
Total KPN %3GC-R %CIP/OFX-R %GEN/TOB/AMK-R %GEN-R
AMR trends for K. pneumoniae

15. 3GC/ESBL trends for K. pneumoniae
0%
5%
10%
15%
20%
25%
30%
0
50
100
150
200
250
300
350
400
2006 2007 2008 2009 2010 2011 2012 2013 2014*
%3GC-R/ESBL+ve
Numberofisolates
Year
Total KPN %3GC-R %ESBL+ve

16. 3GC-R K. pneumoniae, 2013
Median =
30%
IE Rank =
19/30 (21%)
Increased
from 23/29
(8%) in 2011
Big increase
in year since
2012

17. MDR K. pneumoniae, 2013
Median =
16.5%
IE Rank =
20/30 (8%)
Increased
from 24/29
(3%) in 2011
IE and UK
doubled in
last year
A3CG-R only

18. MDR K. pneumoniae –
an emerging problem in Ireland
• 138 isolates collected from 17 hospitals between
Jan 2011 and Jul 2013
• All ESBL-pos and resistant to CIP and GEN
• PCR: all harboured blaSHV and a blaCTX-M
• 15 resistant to ETP (7 to MEM): 5 confirmed CPE
– 4 KPC and 1 NDM/OXA-48
• 2 major clones (MLST/PFGE): ST1236/ST48 (45%
of isolates) and ST15/ST14 (20%)
• ST258 (4 isolates) = pandemic; KPC2
D. Morris, M. Cormican and colleagues, Antimicrobial Resistance and Microbial Ecology (ARME) laboratory,
National University of Ireland (NUI), Galway

19. 0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
0
50
100
150
200
250
300
350
400
2008 2009 2010 2011 2012 2013 2014*
%MDR
Numberofisolates
Year
Total KPN tested for MDRKP MDRKP %MDRKP
MDRKP trends (EARS-Net data)

20. MDRKP outbreak control team
Outbreak control team
Convened in October 2013
Recommendations regarding surveillance, screening, infection control including isolation,
antibiotic stewardship, education & training
Establish TASK FORCE
Prospective study
Carried out throughout 2014 to determine extent of the problem
All labs/hospitals participated
Case definition
The case definition for prospective reporting of MDRKP is:
The first isolate per patient per quarter of K. pneumoniae derived from any specimen
type (both infection and carriage) that are (1) ESBL‐producers and non‐susceptible to
both ciprofloxacin and gentamicin, or non‐susceptible to 3rd‐generation cephalosporins
and ciprofloxacin and gentamicin in cases where investigations for ESBLs are not
routinely carried out [MDRKP/Non-CRE] and/or (2) carbapenemase‐producers
[MDRKP/CRE].

21. 478 cases of MDRKP reported between Jan and Dec 2014
• 424 with MDRKP/Non-CRE phenotype
• 54 with MDRKP/CRE phenotype
– 36 KPC, 12 NDM and 6 OXA-48
• 403 from clinical samples (70% urines)
• 75 from screening samples
• 69% from acute hospitals
• 31% from GP or nursing homes
• 75% patients aged 57 years and over
• 59% inpatients isolated within 24 hrs: 12% were not (and 28% unknown!)
• By end of year, 43/58 (74%) of acute hospitals
*data correct as of 1st February 2015
MDRKP trends (Prospective study 2014)
0
10
20
30
40
50
60
70
Jan* Feb* Mar* Apr* May* Jun* Jul Aug Sep Oct Nov Dec
Numberofcases
Month
MDRKP/CRE MDRKP/Non-CRE

22. CRE from invasive infections (EARS-Net)
2011 2012 2013 Q1-3 2014 2011-Q3 2014
Total CRE 5 1 4 4 14
% CRE 1.6% 0.3% 1.2% 1.5% 1.1%
CPE 4 0 2 2 8
OXA-48 (3) OXA-48 (2) OXA-48 (1) OXA-48 (6)
KPC (1) KPC (1) KPC (2)
Non-CPE 1 1 2 2 6

23. CRE – the wider problem
2013 2014
KPC 14 44
OXA-48 29 17
NDM 3 17
IMP 1 2
IMI 1 0
VIM 0 2
TOTAL 48 82
Enzyme
0
5
10
15
20
25
30
35
40
45
50
KPC OXA-48 NDM IMP IMI VIM
Numberofisolates
Enzyme
2013 2014
0
10
20
30
40
50
60
70
80
90
2013 2014
Numberofisolates
Year
ESCO KLEB CITRO ENTER
Data courtesy of M. Cormican, E. McGrath and
colleagues at the CRE Reference Laboratory,
Galway University Hospital

26. 0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
0
50
100
150
200
250
300
350
400
2008 2009 2010 2011 2012 2013 2014*
%MDR
Numberofisolates
Year
Total KPN tested for MDRKP MDRKP %MDRKP
MDRKP trends (EARS-Net data)
A cause for hope: signs of a reduction in MDRKP in 2014 or
still too early to tell!

27. Thanks! Buíochas!
EARS-Net Steering Group: Ajay Oza, Belinda Hanahoe, Brian Carey, Brian O'Connell, Dearbhaile Morris,
Grainne Brennan, Margaret McIver, Martin Cormican, Robert Cunney, Sinead Kelly, Stephen Murchan
EARS-Net Participants: Agnes Szymanowska, Aine O'Callaghan, Ann McDermott, Anne Gilleece, Anne
MacLellan, Anne Marie Meenan, Annette Darcy, Bartley Cryan, Belinda Hanahoe, Binu Dinesh, Bob
McWade, Breda Boyle, Brendan Crowley, Brian Carey, Brian O'Connell, Bronagh O'Leary, Cara Wrenn,
Carmel Hooton, Carmel O'Reilly, Carol O’Connor, Carole Troy, Caroline Doherty, Cathal Collins, Cathal
O'Sullivan, Catherine Mahon, Colm Power, Dan Corcoran, Dave LeBlanc, Dearbhaile Morris, Deirbhile
Keady, Deirdre O'Brien, Donal Lanigan, Ed Smyth, Eddie McCullagh, Eithne McCarthy, Eleanor McNamara,
Eoghan O'Neill, Fidelma Fitzpatrick, Fiona Kenny, Frank Dennehy, Gabriela Dornikova, Grace O'Keeffe,
Grace O'Mahony, Grainne Bowens, Grainne Brennan, Hazel O'Connor, Helen McDermott, Hilary
Humphreys, Jackie Leavy, James Powell, Jean Wellwood, Jennifer Cleary, Jerome Fennell, John Flynn,
Karen Burns, Karen Logan, Kirsten Schaffer, Larry O'Neill, Lorraine Power, Louise Barry, Lynda Fenelon,
Maeve Doyle, Mairead O'Hanlon, Mairead Skally, Majella Sharkey, Margaret Bernard, Margaret Hannan,
Marianne Fraherk, Marianne Nolan, Martin Cormican, Mary Corcoran, Mary Coughlan, Mary Hickey, Mary
Kelleher, Mary Meehan, Maureen Lynch, Michael Mulhern, Michelle Dowling, Michelle Flanagan, Milada
Tavodova, Niall Wall, Niamh O'Flaherty, Niamh O'Sullivan, Niamh Purcell, Nuala O'Connell, Olive Murphy,
Paul Bennet, Philip Murphy, Ray Sheehan, Rebecca Rush, Regina Monahan, Richard Drew, Robert Cunney,
Rose Sexton, Rosemary Curran, Sandra Baldwin, Sarah Warner, Sinead Kelly, Siobhan Boothman, Susan
Kelly, Susan Knowles, Suzanne Chute, Suzanne Corcoran, Suzy Fitzgerald, Teck Wee Boo, Una Ni Riain, Una
Reidy, Ursula Fox, William Dibb
CRE Reference Laboratory, Galway University Hospital: Elaine McGrath, Martin Cormican
MDRKP Outbreak Control Team: Darina O’Flanagan, Dearbhaile Morris, Karen Burns, Martin Cormican,
Robert Cunney, Sinead Kelly, Stephen Murchan