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. Session 7: MS experiences
Recent resistance development in Germany
Ines Noll
Robert Koch Institute | Nosocomial Infections, Surveillance of Antimicrobial
Resistance and Consumption
3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-
Associated Infections (ARHAI) Networks
Stockholm, 11-13 February 2015

2. 3rd Joint Meeting of ARHAI Networks, Stockholm February 2015
1. Overview of recent trends in German data
reported to EARS-Net
2. Supplementary data on national trends
3. Description of the action taken in response to these findings
4. Outlook to the future
2
Overview

3. Microorganism x antimicrobial class
2010 2011 2012 2013 trend mean 2013 trend
Staphylococcus aureus
Oxacillin/Meticillin R 20.9 16.1 15.4 12.8 18.0
Enterococcus faecalis
HL Gentamicin R 46.8 41.0 35.6 39.3 30.9
Enterococcus faecium
Vancomycin R 8.5 11.4 16.2 14.5 8.9
Streptococcus pneumoniae
Penicillin RI 3.7 1.7 5.2 7.0 nd
Macrolides RI 9.2 7.9 7.4 10.7 nd
German EARS-Net results EU/EEA
3rd Joint Meeting of ARHAI Networks, Stockholm February 2015
Gram-positives
3
Recent Trends in Germany

4. Microorganism x antimicrobial class
2010 2011 2012 2013 trend mean 2013 trend
Escherichia coli
Aminoglycosides R 8.7 7.6 7.1 7.0 9.9
Fluoroquinolones R 24.8 23.7 21.1 22.1 22.5
3rd gen. Cephalosporins R 8.4 8.0 8.8 10.8 12.6
Carbapenems R 0.0 0.0 0.0 0.1 0.2
combined resistance 3.6 3.6 3.2 2.7 4.6
Klebsiella pneumoniae
Aminoglycosides R 10.5 8.9 8.3 9.6 24.5
Fluoroquinolones R 14.9 14.1 13.7 14.8 29.2
3rd gen. Cephalosporins R 12.8 12.5 13.0 16.0 30.0
Carbapenems R 0.0 0.0 0.0 0.7 8.3
combined resistance 7.5 6.9 6.2 6.9 20.9
German EARS-Net results EU/EEA
3rd Joint Meeting of ARHAI Networks, Stockholm February 2015
Gram-negatives: Enterobacteriaceae
4
Recent Trends in Germany

5. Microorganism x antimicrobial class
2010 2011 2012 2013 trend mean 2013 trend
Pseudomonas aeruginosa
Piperacillin R 15.6 14.8 15.5 18.4 16.2
Ceftazidime R 8.1 9.1 9.6 10.0 12.2
Carbapenems R 12.5 9.8 10.7 15.3 17.6
Aminoglycosides R 10.2 11.7 10.6 7.6 15.9
Fluoroquinolones R 18.4 18.2 19.6 16.3 20.0
combined resistance 9.5 7.2 8.4 9.2 13.0
Acinetobacter spp.
Aminoglycosides R - - 5.9 6.4 -
Fluoroquinolones R - - 8.3 9.8 -
Carbapenems R - - 6.6 9.2 -
combined resistance - - 4.2 5.2 -
German EARS-Net results EU/EEA
3rd Joint Meeting of ARHAI Networks, Stockholm February 2015
Gram-negatives: P. aeruginosa, Acinetobacter spp.
5
Recent Trends in Germany

6. 3rd Joint Meeting of ARHAI Networks, Stockholm February 2015
Antimicrobial Resistance Surveillance (ARS) System
• established in 2008 – co-ordinated by the Robert Koch Institute
• laboratory-based – voluntary participation
• data collection:
– all bacterial species from any kind of sample site
– from hospital care as well as from outpatient care institutions
• data submission via electronic interface on a daily / weekly basis
once a year: data feedback to labs for approval
• reports and feedback via interactive database (public access) on ARS website
• coverage (2013):
– hospitals: 418 out of 1,996 (= 21 percent), practices: 6,920
• limitations
– no clinical information
– regional representativeness not yet achieved
6
German Surveillance System

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Trends 2010 – 2013
• comparing 3 sectors of care
– intensive care units
– general wards
– outpatient care
• examples
– MRSA
– E. coli / K. pneumoniae - Cefotaxime
• calculation
– isolates from all kinds of sample sites excluding screenings
– copy-strain-elimination: first isolate /patient /year
– adjustment for longitudinal analysis:
inclusion of hospitals /practices with continuous data for the period 2010-2013
7
Supplementary data

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Additional data: MRSA
No. of isolates 2010 – 2013: 9,974
No. of isolates 2010 – 2013: 9,956 No. of isolates 2010 – 2013: 72,568
No. of isolates 2010 – 2013: 72,311

9. 3rd Joint Meeting of ARHAI Networks, Stockholm February 2015 9
Additional data: E. coli
No. of isolates 2010 – 2013: 171,162
No. of isolates 2010 – 2013: 140,584No. of isolates 2010 – 2013: 16,092
No. of isolates 2010 – 2013: 14,621

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Additional data: K. pneumoniae
No. of isolates 2010 – 2013: 31,980
No. of isolates 2010 – 2013: 18,629No. of isolates 2010 – 2013: 2,407
No. of isolates 2010 – 2013: 4,690

11. 3rd Joint Meeting of ARHAI Networks, Stockholm February 2015
Amendment of Protection against Infection Act, 2011
• Heads of hospitals and institutions for outpatient surgery
– are obliged to continuously record and evaluate
• nosocomial infections and the appearance of pathogens with special resistances and multiple
resistances (since 2001)
• antimicrobial consumption (new)
– are in charge of hospital hygiene and have to care that hygiene regulations are according
to scientific knowledge i.e. in line with recommendations by the
Commission for Hospital Hygiene and Infection Prevention (KRINKO)
Commission for Antiinfectives, Resistance and Therapy (ART)
latest recommendations by KRINKO (selection):
• Hygiene measures for infection or colonization with multidrug-resistant gram-negative bacilli
(2012) | Update to the epidemiological situation (2014)
• Prevention and control of MRSA in medical and long term care facilities (2014)
• Hygiene regulations by federal states: requirements for adequate staffing of hospitals
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Action: legislation

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mandatory notification
• MRSA in blood and cerebrospinal fluid (since 2009)
• nosocomial outbreaks (notifiable to local health services since 2001,
mandatory data submission to national level / RKI since 2012)
• in preparation:
mandatory notification of
– carbapenem-resistance in Gram-negative bacteria
– VRE from blood cultures
– MRSA from skin and tissue-infections
– Clostridium difficile infections
participation in surveillance systems is voluntary!
• Antimicrobial Resistance Surveillance ARS (laboratories)
• Antimicrobial Consumption Surveillance AVS (hospital pharmacies)
• Surveillance of Nosocomial Infections KISS (hospitals, hospital departments)
12
Action: surveillance

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Regional Networks for prevention and control of MRSA / MDR
• established since 2010 in all 16 federal states
to improve the implementation of prevention and control strategies
• co-ordinated by the regional public health services
• participants
– hospitals, nursing homes, ambulatory nursing services and patient transportation services
– microbiological laboratories
– professional associations and health insurances
• goals – activities
– to collect regional data on AMR, antimicrobial consumption, prevalence of MDR etc., to
evaluate the regional situation and to define goals and activities
– to improve communication between all parties
– to support further education and professional development
– to promote quality standards (certificates for hospitals / nursing homes)
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Action: regional networks

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biggest AMR challenges in the coming 5-10 years?
• multi-drug resistance in gram-negative bacteria
limited treatment options – potential to spread
How can we best meet these on a both national and European
level? – surveillance perspective only
• Integrated surveillance of antimicrobial resistance and consumption (hospitals and
practices/clinics)
• Antibiotic stewardship programmes (hospitals and practices/clinics)
• AMR surveillance in outpatient care:
evaluation of routine data – representativeness for community-acquired infections?
• as a complement to EARS-Net:
Tracing the spread of MDR clones on a national and international level
• Outbreaks: rapid availability of state-of-the-art typing methods to local laboratories
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Outlook to the future