Johan Struwe: Surveillance of Antimicrobial Resistance, antimicrobial use and health-care infection at the national level in Sweden

1. Surveillance of AMR, AMC and HAI
in Sweden
-National perspective
Dr. Johan Struwe
Public Health Agency of Sweden

2. Hospitals level/ health care workers
The Swedish Association of Local
Authorities and Regions;
An employer organization,
representing the regional
governments

3. Integrated annual surveillance report since 2000
https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/s/swedres-svarm-2018/

4. I Surveillance of AMR

5. 5
0
2000
4000
6000
8000
10000
12000
ESBL MRSA VRE ESBL-CARBA PNSP
2010 2011 2012 2013 2014 2015 2016 2017 2018
Source: Public Health Agency of Sweden
Number of cases
49/100 000
107/100 000
16/100 000
44/100 000
4/100 000
0,2/100 000 5/100 000 0,5/100 000 0,9/100 000
Surveillance systems for AMR I
Mandatory: Communicable diseases act
1/100 000

6. Surveillance systems for AMR II
Svebar
• A national automatized system for
– surveillance of resistance in bacteria and fungi
– automated early warning signals can be defined at laboratory and/ or national levels
• Development commissioned by the government.
A collaboration between diagnostic laboratories and PHAS
• Open since 2012, volontary.
21/ 26 laboratories participating, covering > 80 % population.
• Includes ”no growth” and ”mixed flora” results for
calculating denominators
• First reports (E. coli, K. pneumoniae and S. aureus in blood 2017)
– Published on PHAS website. Approved by laboratories before publication.
– https://www.folkhalsomyndigheten.se/smittskydd-beredskap/antibiotika-och-
antibiotikaresistens/resistensovervakning/svebar/rapporter-fran-svebar/rapporter-2017/
6

7. EW-filter
• National
• Lab-level
Terms
synonymized if
needed
Early database-(2 weeks w lab-id)
Daily AST-re-
sults
automatically
from all labs
Incoming files validated
New daily file
Reports
Long-term
Data-base
Day 14 are data anonymized
National operatorsLocal users
Early warnings sent by e-
mail and if extraordinary
telephone

8. .Sid
EARS-Net and CAESAR
-International AMR surveillance of invasive isolates
Source: WHO EURO CAESAR annual report 2019:
http://www.euro.who.int/__data/assets/pdf_file/0003/418863/53373-WHO-CAESAR-annual-report-2019.pdf?ua=1

9. GLASS
Global antimicrobial resistance
surveillance system
www.who.int/glass

10. .Sid
Laboratory AMR
surveillance
ESBLcarba (enterobacteriaceae)
All confirmed isolates are collected and subject to WGS.
Resistance genes are identified. Cluster analysis of relatedness.
ESBLcarba (acinetobacter)
All isolates resistant to meropenem are collected and subject o WGS.
Resistance genes are identified. Cluster analysis of relatedness.
Colistin resistant enterobacteriales verified by microdilution at reference lab
WGS for detection of mcr och and its´ variants. Cluster analysis of relatedness.
H. influenzae (cephalosporin-resistant)
Betalactam resistant isolates verified by microdilution at reference laboratory are
collected and analyzed by WGS for detection of mutations in the ftsI-gene and for
transmissible betalactamasegenes (blaTEM och blaROB) and other relevant genes.
Cluster analysis (SNPs) of relatedness.
MRSA
All isolates from clinical cases are collected, spa-typing and PVL-status (by PCR)
N. gonorrhoeae (ceftriaxome/cefixime MIC>0,125 and/or azitromycine MIC>256)
All isolates with MIC>0,125 mg/L for ceftriaxon or cefixim and/ or MIC>256
mg/mL for azitromycin are sent no national Neisseria reference and subject to
WGS, and MLST and NG-STAR including penA and 23S rRNA genes.
S. pneumonie (PcG MIC >=0,5)
Allisolates and their corresponding AST results are collected and are serotyped by
gel-diffusion and capsule swelling.
Vancomycin-resistant enterococci (VRE)
All confirmed isolates are collected and subject o WGS for van-type and plasmid
and/ or ribosomal resresistance to leinezolid Cluster analysis of relatedness.

11. II Surveillance of AMC

12. Surveillance of antibiotic consumption in hospitals
- National level
Data from e-health agency
Source: SWEDRES 2018

13. 0
1 000
2 000
3 000
4 000
5 000
6 000
7 000
Antalrecept
Recipes collected at a secondary hospital pharmacy
Source: SLL-data
2014
2015
2016
2017
Courtesy Annika Hahlin, Strama Stockholm
Surveillance of antibiotic consumption in hospitals
- Regional level

14. 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
Danderyd Norrtälje S:t Göran Södersjukhuet Södertälje Ersta Karolinska
Penicillin V + G
PcG PcV
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
2014
2015
2016
2017
Karolinska Södertälje S:t Göran Norrtälje Södersjukhuet Danderyd Ersta
Quinolones + cephalosporins
Kinoloner
Cefalosporiner
10%
8% 7% 6% 6% 5% 5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Piperacillin-tazobactam
2014
2015
2016
2017
Proportion out of total antibiotics, delivered DDD:s per
hospitals in Stockholm region 2014-2017
Source: SLL-data
8%
6%
4%
2% 2% 2% 2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Carbapenems
2014
2015
2016
2017
Courtesy Annika Hahlin, Strama Stockholm

15. .Sid
Surveillance of antibiotic prescriptions
Data from e-health agency
Open benchmarking at all levels (regions, municipalities, GP-practices, hospitals…)

16. III Surveillance of HAI

17. 1/ Infection tool
-surveillance of antibiotic prescriptions and treatment
of HAI at national level
Prescribers (so far
mainly hospitals
Monitoring, feedback
-rational ab use
-patient safety

18. .Sid
2/ Manual review by GTT of 88 638
randomly selected admissions 2013-2017

19. 0%
5%
10%
15%
20%
25%
30%
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Andel med VRI Andel med VRI av dem med multipla riskfaktorerProportion with HAI
3/ PPM; Prevalence of HAI 2008-2018
1-2 measures/ year, approx 75 hospitals, 20 000 beds
Over all proportion
with HAI
Proportion with HAI,
Multiple risk factors

20. 0,0 %
5,0 %
10,0 %
15,0 %
20,0 %
25,0 %
30,0 %
35,0 %
40,0 %
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Andel med CVK Andel med immunsuppression
Andel med KAD Andel med kirurgiskt ingrepp
Andel med mekanisk ventilation Andel med antibiotikabehandling
Proportion of patients with risk factors
for HAI during PPM
Central line
Urinary catheter
Mechanical ventilation
Immunosuppression
Surgical procedure
Antibiotic treatment

21. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Östergötland* (2419)
Stockholm (4010)
Halland (1054)
Norrbotten (675)
Dalarna (821)
Västmanland (831)
Gotland (258)
Jämtland Härjedalen (97)
Kalmar (531)
Västra Götaland (1009)
Kronoberg (596)
Blekinge (918)
Örebro (1625)
Västernorrland (845)
Värmland (1240)
Gävleborg (1262)
Skåne (4748)
Uppsala (1092)
Jönköping (1226)
Sörmland
Riket (22838)
2018 2017
Observational studies on compliance to basal
hygiene and dresscode
Percent correct in all 7 steps per region/ county

22. https://webbutik.skl.se/bilder/artiklar/pdf/5420.pdf?issuusl=ignore

23. 4/ HALT-
Health-caare
Associated
infections in Long-
Term care facilities

24. Reduced
need for
antibiotics
Prevention of
infections
Prevention of
bacterial spread
Data for action!
Raise awareness and commitment!
Rational use
of antibiotics
Evidence-based/
consensus
guidelines for
-treatment
-diagnosis
based on
prevailing AMR
situation
Situation
analyses;
national and
regional/local
surveillance
Resistance in
relevant pathogens
in relevant samples
Antibiotic use
Health-care
associated infections
Data for
action
Compliance to
guidelines
Open
benchmarking

25. Some recommended internationally available
protocols for surveillance
Antimicrobial resistance
• CAESAR
• http://www.euro.who.int/__data/assets/pdf_file/0005/293369/CAESAR-V2-Surveillance-Antimicrobial-
Resistance-2015-en.pdf
• GLASS
• www.who.int/glass
Antimicrobial use and/ or consumption
• ESAC-Net
• https://www.ecdc.europa.eu/en/about-us/partnerships-and-networks/disease-and-laboratory-networks/esac-
net
• WHO
• https://www.who.int/medicines/areas/rational_use/AMU_Surveillance/en/
Health-care associated infections
• Point prevalence surveys (PPS)
• ECDC
• https://www.ecdc.europa.eu/en/healthcare-associated-infections-acute-care-hospitals/surveillance-disease-
data/database

26. https://www.ecdc.europa.eu/sites/default/files/documents/AMR-indicators-joint-report-Oct-2017.pdf
Outcome indicators as regards surveillance
of antimicrobial resistance and
antimicrobial consumption

27. .Sid
Thank you!