Antimicrobial Resistance (AMR) in Ireland

1. Infectious Diseases Workshop:
15th
November 2017
Dr Karen Burns
Consultant Clinical Microbiologist
HPSC, Dublin
Antimicrobial Resistance (AMR) in
Ireland

2. Presentation Outline
• Microbiology refresher in two slides
• Making sense of the alphabet soup
• Key AMR trends in Ireland
• National response – where to next?
(C) K Burns HPSC November 2017 2

3. Gram positive cocci
1. Staphylococci - clusters
2. Streptococci - chains
3. Enterococci - chains
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(C) K Burns HPSC November 2017

4. Gram negative bacilli
• Enterobacteriaceae:
– E. coli
– Klebsiella pneumoniae
– Proteus mirabilis
– Enterobacter cloacae
– Citrobacter freundii
• Pseudomonas aeruginosa
• Acinetobacter baumanii 4
(C) K Burns HPSC November 2017

5. Making sense of the alphabet soup
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(C) K Burns HPSC November 2017

6. Existing AMR surveillance systems in Ireland
• European Antimicrobial Resistance Surveillance
Network (EARS-Net)
– AMR trends in key pathogens causing bloodstream
infections (BSI)
– 99% population coverage in 2016 & coverage >95%
since 2004
• CRE surveillance
– Mandatory notification of invasive infection (BSI)
– Voluntary enhanced: 2011 – 2016
– Mandatory enhanced: 2017 onwards
In Ireland, the terms CRE & CPE are used interchangeably, where we refer to CRE, we are specifically
targeting carbapenemase producers – ID Regulations refers to CRE – CPE becoming more widely-used
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(C) K Burns HPSC November 2017

7. BSI surveillance – tip of the iceberg
Bloodstream infections
Non-invasive infections
UTI, SSI, pneumonia etc.
Asymptomatic
colonisation/carriage
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(C) K Burns HPSC November 2017

8. Key AMR trends in S. aureus causing BSI
• Approximately 1,100
cases/year
• Reduction in proportion that
are MRSA
• BSI rates: MRSA declining
MSSA increasing
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
0
200
400
600
800
1000
1200
1400
1600
Proportionofisolates
Numberofisolates
Year
MRSA MSSA %MRSA
Total number of S. aureus (MRSA and MSSA) bloodstream isolates and
proportion (%) MRSA from acute hospitals (public & private) by year,
2004 to 2017 † 2017 provisional (unvalidated) data to the end of Q2
Data courtesy of S Murchan, HPSC
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0
200
400
600
800
1000
1200
1400
1600
Rateper1,000beddaysused
Numberofisolates
Year
MRSA MSSA MRSA rate MSSA rate
Total number of S. aureus (MRSA and MSSA) bloodstream isolates, and
MRSA and MSSA rates (per 1,000 bed days used) from acute hospitals (public
& private) by year, 2004 to 2017 † 2017 provisional (unvalidated) data to
the end of Q2
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9. Key AMR trends in Enterococcus faecium causing BSI
• Approximately 400 cases/year
• High proportion that are VRE
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0
50
100
150
200
250
300
350
400
450
500
%VREfm
Numberofisolates
Year
VREfm VSEfm %VREfm
Total number of E. faecium bloodstream isolates, and VRE proportions from
acute hospitals (public & private) by year, 2004 to 2017 † 2017 provisional
(unvalidated) data to the end of Q2
Data courtesy of S Murchan, HPSC
VREfm isolates Europe 2016 (Source: EARS-Net at ECDC; map accessed
via www.ecdc.europa.eu 13/10/17) 9

10. Key AMR trends in E. coli causing BSI
• Approximately 3000 cases/year
• Increase in proportions that are
ESBL positive and that are MDR
Data courtesy of S Murchan, HPSC
0%
2%
4%
6%
8%
10%
12%
14%
0
500
1000
1500
2000
2500
3000
3500
%3GC-R/ESBL+ve
Numberofisolates
Year
Total E. coli %3GC-R %ESBL+ve
Total number of E. coli bloodstream isolates and proportions of
3GC-resistant and ESBL-producing isolates from acute hospitals (public &
private) by year, 2004 to 2017† 2017 provisional (unvalidated) data to the
end of Q2
3GC, 3rd
-Generation Cephalosporin
0%
2%
4%
6%
8%
10%
12%
14%
16%
0
500
1000
1500
2000
2500
3000
3500
%MDRECO
Numberofisolates Year
Total E. coli tested for MDR MDR ECO %MDR
Total number of E. coli bloodstream isolates and proportions of MDR isolates
from acute hospitals (public & private) by year, 2004 to 2017 † 2017
provisional (unvalidated) data to the end of Q2
MDR, Multi-drug resistant E. coli
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11. Key AMR trends in K. pneumoniae
• Approximately 400 BSI cases/year
• Increasing proportion that produce
ESBLs and that are multi-drug
resistant (MDRKP)
Data courtesy of S Murchan, HPSC
0%
2%
4%
6%
8%
10%
12%
14%
0
50
100
150
200
250
300
350
400
450
500
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017†
%MDRKP
Numberofisolates
Year
Total KPN tested for MDRKP MDRKP %MDRKP
Number of MDRKP bloodstream isolates MDRKP proportions from
acute hospitals (public & private) by year, 2006 to 2017
† 2017 provisional (unvalidated) data to the end of Q2
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12. Key AMR trends in K. pneumoniae
• 2014 – 2016: MDRKP
mandatory enhanced
surveillance (all isolates –
screening, colonising and
infection) -> 1,449 reported
from 88% of acute hospitals,
LTCF and primary care
• 195% increase in proportion of
MDRKP that were also
carbapenem resistant (CRE)
from 2015 to 2016
Data courtesy of S Murchan, HPSC
0%
2%
4%
6%
8%
10%
12%
14%
0
50
100
150
200
250
300
350
400
450
500
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017†
%MDRKP
Numberofisolates
Year
Total KPN tested for MDRKP MDRKP %MDRKP
Number of MDRKP bloodstream isolates MDRKP proportions from
acute hospitals (public & private) by year, 2006 to 2017
† 2017 provisional (unvalidated) data to the end of Q2
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13. Rectal swab: Klebsiella pneumoniae
ANTIMICROBIAL RESULT
Amoxicillin RESISTANT
Co-amoxiclav RESISTANT
Cefuroxime RESISTANT
Cefotaxime RESISTANT
Ceftazidime RESISTANT
Piperacillin/tazobactam RESISTANT
Aztreonam RESISTANT
Meropenem RESISTANT
Ciprofloxacin RESISTANT
Gentamicin RESISTANT
Tobramycin RESISTANT
Amikacin SUSCEPTIBLE
Tigecycline RESISTANT
Colistin SUSCEPTIBLE
Multi-drug resistant
K. pneumoniae (MDR-KP)
ESBL & carbapenemase
producing
OXA-48 CRE confirmed
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14. The story starts in 2009
• First case reported from mid-west – KPC
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15. CRE in mid-west of Ireland
Two outbreaks – KPC in 2011 (n=9) & NDM in 2014 (n=10)
Almost 9,500 screening swabs performed in 2015
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16. Not only from the mid-west…
The arrival of OXA-48 – A game changer
Jan – Aug 2015
Source: NCPEARL 16
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17. Major OXA-48 outbreak in a tertiary Dublin
Hospital: Media 2016/17
Irish Independent 10/01/17
The Herald 12/10/16
Irish Times 31/01/17
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18. Reference laboratory data –
A useful tool to validate reporting to voluntary surveillance
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19. Voluntary surveillance = under-reporting
107 in 2016 versus 283 confirmed by reference lab
Source: HPSC19
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20. Transition from voluntary to mandatory reporting (n=39)
• Jan – June 2017: 234 isolates reported by 24 labs
• 15 labs reported no carbapenemases
http://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/strategyforthecontrolofantimicrobialresistanceinirelandsari/carbapenemresistantenterobacter
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21. Jan – June 2017
• Inpatients in 29 hospitals: n=182; 78%
– Incomplete reporting of data on patient isolation
– Where reported, 91% isolated within 24 hours of lab
result
– Incomplete reporting of data on antimicrobials for
suspected CRE infection (55% of inpatient cases)
– Where reported, 70% had required treatment
• Outpatients: n=20
• LTCF residents: n=23 – Outbreaks in LTCF also
• Primary care (GP) patients: n=9 21
(C) K Burns HPSC November 2017

22. Outbreaks
• Five additional acute hospital outbreaks in 2017
Source: HPSC
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23. Launch of Ireland’s AMR NAP 25/10/17
• Minister Simon Harris declared
CPE to constitute a national
public health emergency on
25/10/17
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(C) K Burns HPSC November 2017

24. Conclusion
• Ireland is an EU leader in EARS-Net participation
• Great strides made in AMR trends for S. aureus
• AMR in bacteria normally carried in the bowel
(Enterobacteriaceae >> enterococci) is the major threat to
public health
• Surveillance is important information for action, but just
one element in addressing the CRE/CPE issue:
– Communication – inter-facility, inter-professional and
with patients/residents & families
– Screening and access to results
– Infrastructure that supports prevention – IT & physical
– Antimicrobial stewardship – hospital, GP, LTCF
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(C) K Burns HPSC November 2017

25. Thank you for your attention
karen.burns1@hse.ie
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