AMR surveillance in Europe: Historical background and future outlook

Hajo Grundmann, University Medical Centre Groningen, The Netherlands

Sources of funding and COI

Staphylococcus aureus Reference Laboratory (SRL) Network: ECDC framework service contract 09/033

UK MRSA INVESTIGATION NETWORK: UK CRC MRC/Wellcome Trust

European Survey on Carbapenemase-Producing Enterobacteriaceae (EuSCAPE): ECDC framework service contract 12/055

COI none to declare

Overview

• Surveillance of antibiotic resistance

• Historical context

• Ingredients for success

• How to address the challenges of the future?

Surveillance of antibiotic resistance

Definition: Surveillance

‘ The ongoing systematic collection, analysis of health data

essential to the planning, implementation, and evaluation, of

public health practice, …

Alexander Langmuir 1963

The ecological landscapes of AMR surveillance

Patients Antibiotic Exposure

Microbiota

The Nemesis of good surveillance in Antibiotic resistance

Ambition

Perfection

Conflicting demands

Historical context

The Golden age of AMR surveillance Year Name Country

1986 NNIS USA

1989 ISS IS

1990 CDSC/PHLS Eng & Wales

1994 STRAMA SE

1995 DANMAP DK

1996 ICARE USA

MITRA/MENSUR ES

ENARE EU

Alexander Project 5 countries

1997 CARB FR

SENTRY USA/8 countries

MYSTIC How many countries ?

ARM/WHO-NET WHO

1998 WHO-NET Greece GR

ISGAR IT

EARSS EU

The Golden age of AMR surveillance Year Name Country

1986 NNIS USA

1989 ISS IS

1990 CDSC/PHLS Eng & Wales

1994 STRAMA SE

1995 DANMAP DK

1996 ICARE USA

MITRA/MENSUR ES

ENARE EU

Alexander Project 5 countries

1997 CARB FR

SENTRY USA/8 countries

MYSTIC How many countries ?

ARM/WHO-NET WHO

1998 WHO-NET Greece GR

ISGAR IT

EARSS EU

Philosophy of EARSS

“Simplicity is the name of the game”

Heterogeneity between laboratories and regions

Health care system

Hospital mix

Disease patterns

Diagnostic habits

Susceptibility testing

Sceptic view:

“…it is doubtful if national rates of resistance have any comparative

value at all.”

Surveillance of antimicrobial resistance – what, how and

whither ?

R. Bax, R. Bywater, G. Cornaglia, H. Goossens, et al

Clin Microbiol Infect Dis 2001, 7: 316-325

Resumeé:

Ingredients for success

The six conditions for successful AMR surveillance

legal support

economic viability

partnership

acceptability

validity & comparability

representativeness

The six conditions for successful AMR surveillance (1)

Legal support

EARSS = European Antimicrobial Resistance Surveillance System

Recommended by the Visby declaration 1998

endorsed by European Parliament and the Council Legislation 2119/98/EC and Commission Decision 2000/96/EC

The six conditions for successful AMR surveillance (2)

Economic viability

EARSS funding by ECDC and the Dutch Ministry of Welfare and Sports

at an annual cost of EURO 668.458

The six conditions for successful AMR surveillance (3)

Partnership = Devolution

network of network approach

clear data ownership

support network development

support data management

support microbiological protocols

Datamanagers workshop 2003

WHO – NET support

The six conditions for successful AMR surveillance (4)

Acceptability = Restriction

routine data

indicator pathogens

invasive isolates

indicator antibiotics (class resistance)

reporting proportions

The six conditions for successful AMR surveillance (5)

Validity & Comparability

standard protocols

defined endpoints (S,I,R, EUCAST, CLSI)

routine internal quality control

regular external quality assurance exercises

EARSS - EUCAST added value

and lost of good wine and dine…..

EARSS 2008 917 Laboratories

1587 Hospitals

>100 million citizens

33 countries

EARSS- database

EARSS- database

EARSS- database

How to address the challenges of the future ?

European structured surveys

Staphylococcal Reference Laboratory Working Group

Structured survey 1 (2006)

Structured survey 2 (2011, supported through ECDC tender)

European Survey on Carbapenemase-producing

Enterobacteriaceae (EuSCAPE, 2013 – 2014, supported through

ECDC tender)

Conclusions • Population level surveillance of Antibiotic resistance in Europe was

successful for many good reasons

• EARS-net continues to provide ever more meaningful data about

the spread of clinically relevant antibiotic resistance through

Europe

• ECDC is well prepared to take on novel challenges by embracing

advanced approaches that will increasingly help understand

contain the dissemination of antibiotic resistant bacteria through

communities and patient populations.

Thanks University Medical Center Groningen

Tjibbe Donker

Corinna Glasner

Alex Friedrich

Sanger Centre

Matt Holden

Sandra Reuters

Julian Parkhill

University of Bath

Ed Feil

Santiago Castillo-Ramirez

Imperial College London

David Aanesen

Brian Spratt

European Centers for Disease Prevention and Control (ECDC)

Ole Heuer, Lotta Diaz Högberg

Marc Struelens

Barbara Albiger, Dominique Monnet

The EARSS management team

Paul Schrijnemakers

Nienke van der Sande Bruinsma

Edine Timmermans

Carola Schinkel

WHO-Net

John Stelling

Tom O’Brian

UK NEQAS

Christine Walton

Vivienne James

EUCAST

Gunnar Kahlmeter

Derek Brown

All national representatives & data mangers