Antimicrobial Resistance PDF

SURVEILLANCE REPORT
Antimicrobial resistance
surveillance in Europe
2010
www.ecdc.europa.eu
Antimicrobial resistance
surveillance in Europe
Annual report of the European Antimicrobial
Resistance Surveillance Network (EARS-Net)
2010
ii
SURVEILLANCE REPORT Antimicrobial resistance surveillance in Europe 2010
Revised December 2011
This edition has been revised to correct a number of errors.
The changes affect Figures 5.31 (Estonia and Romania), 5.32
(Estonia), 5.33 (Estonia and Romania) and 5.34 (Estonia).
Estonia has been added to the listed countries showing a decrease
in MRSA: pages 1, 30.
Greece has been added as showing a significant decrease in
vancomycin-resistant E faecium: page 34.
Table 5.8a has been added.
Suggested citation for full report:
European Centre for Disease Prevention and Control. Antimicrobial
resistance surveillance in Europe 2010. Annual Report of the
European Antimicrobial Resistance Surveillance Network (EARS-Net).
Stockholm: ECDC; 2011.
Cover picture istockphoto
ISSN 1831-9491
ISBN 978-92-9193-323-5
doi 10.2900/14911
European Centre for Disease Prevention and Control, 2011.
Reproduction is authorised, provided the source is acknowledged.
Coordination
This report of the European Centre for Disease Prevention and Control
(ECDC) was coordinated by Ole Heuer.
Contributing authors
Ole Heuer, Anna-Pelagia Magiorakos, Marianne Gunell, Assimoula
Economopoulou, Paula Bianca Blomquist, Derek Brown, Christine Walton,
Nita Patel and Dominique Monnet.
Data analysis
Carlo Gagliotti, Carl Suetens, Jolanta Griskeviciene
Acknowledgements
The EARS-Net Coordination group members: Christian Giske, Hajo
Grundmann, Vincent Jarlier, Gunnar Kahlmeter, Jolanta Miciuleviciene,
Gian Maria Rossolini, Gunnar Skov Simonsen, Nienke van de Sande-
Bruinsma and Helena Zemlickova are acknowledged for providing valuable
comments and scientific advice during the production of the report.
All EARS-Net participants and National Epidemiological Contact Points are
acknowledged for providing valuable comments for this report.
All EARS-Net participating laboratories and hospitals in the Member
States are acknowledged for providing data for this report.
John Stelling, Silvia Sarbu and Catalin Albu are acknowledged for data
management and providing helpdesk support to the participating
countries.
iii
Antimicrobial resistance surveillance in Europe 2010 SURVEILLANCE REPORT
Contents
Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Countries participating in EARS-Net 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
National institutions/organisations participating in EARS-Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
2 Carbapenem-resistant Klebsiella pneumoniae and Pseudomonas aeruginosa.
Analysis of data from laboratories reporting continuously from 2005 to 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
2.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
2.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3 External Quality Assessment Exercise (EQA) 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
3.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
3.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
3.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4 EARS-Net laboratory/hospital denominator data 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.3 Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.4 Population coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.5 Hospital denominator information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.6 Hospital characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.7 Laboratory denominator information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.8 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
5 Antimicrobial resistance in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
5.1 Streptococcus pneumoniae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
5.2 Staphylococcus aureus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.3 Enterococci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.4 Escherichia coli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.5 Klebsiella pneumoniae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
5.6 Pseudomonas aeruginosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Annex 1: Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Annex 2: Country summary sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
iv
List of tables
2.1: Numbers of laboratories reporting continuously and average numbers of K. pneumoniae and P. aeruginosa isolates reported per
country per year to EARSS/EARS-Net during 20052010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
3.1: Klebsiella pneumoniae (0243): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories
and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2: Escherichia coli (0244): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories and
the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.3: Streptococcus pneumoniae (0245): Minimum inhibitory concentration (MIC) and intended results reported by the reference
laboratories and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.4: Enterococcus faecium (0246): Minimum inhibitory concentration (MIC) and intended results reported by the reference laboratories
and the overall concordance of the participating laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.5: Pseudomonas aeruginosa (0247): Minimum inhibitory concentration (MIC) and intended results reported by the reference
3.6: Staphylococcus aureus (0248): Minimum inhibitory concentration (MIC) and intended results reported by the reference
4.1: Hospital denominator data for 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.2: Hospital characteristics for 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.3: Laboratory denominator information for 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5.1: Number and proportion of invasive S. pneumoniae isolates penicillin-non-susceptible (PNSP), penicillin-resistant (PRSP),
macrolide-non-susceptible (MNSP), single penicillin (PEN), single macrolides (MACR) and non-susceptible to penicillin and macrolides
isolates, including 95 % confidence intervals (95 % CI), reported per country in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
5.2: Distribution of single penicillin, single macrolides and non-susceptibility to penicillin and macrolides, among the most common
serogroups reported per country in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
5.3: Number and proportion of invasive S. aureus isolates resistant to meticillin (MRSA) and rifampin (RIF), including 95 % confidence
intervals (95 % CI), reported per country in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.4: Number of invasive E. faecalis and E. faecium isolates and proportion of high-level aminoglycoside-resistant E. faecalis and
vancomycin-resistant E. faecium (%R), including 95 % confidence intervals (95 % CI), reported per country in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.5: Number and proportion of invasive E. coli isolates resistant to aminopenicillins, third-generation cephalosporins, fluoroquinolo-
nes and aminoglycosides, and multiresistant (%R), including 95 % confidence intervals (95 % CI), reported per country in 2010 . . . . . . . . . . . . . . . . . . 38
5.6: Number of invasive E. coli isolates resistant to third-generation cephalosporins (CREC) and proportion of ESBL-positive (% ESBL)
among these isolates, as ascertained by the participating laboratories in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5.7: Overall resistance and resistance combinations among invasive E. coli isolates tested against aminopenicillins, fluoroquinolones,
third-generation cephalosporins and aminoglycosides (n = 49 847) in Europe, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.8: Number and proportion of invasive K. pneumoniae isolates resistant to fluoroquinolones, third-generation cephalosporins,
aminoglycosides and multiresistant (%R), including 95 % confidence intervals (95 % CI), reported per country in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.8a: Number and proportion of invasive K. pneumoniae isolates resistant to carbapenems and confidence intervals (95% CI) per
country in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.9: Number of invasive K. pneumoniae isolates resistant to third-generation cephalosporins (CRKP) and proportion ESBL-positive
(% ESBL) among these isolates, as ascertained by the participating laboratories in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.10: Overall resistance and resistance combinations among invasive K. pneumoniae isolates tested against fluoroquinolones, third-
generation cephalosporins and aminoglycosides (n = 12 665) in Europe, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.11: Number and proportion of invasive P. aeruginosa isolates resistant to piperacillintazobactam, fluoroquinolones, ceftazidime,
aminoglycosides, carbapenems and multiresistant (%R), including 95 % confidence intervals (95 % CI), reported per country in 2010 . . . . . . . . . . . 63
5.12: Overall resistance and resistance combinations among invasive Pseudomonas aeruginosa isolates tested against at least three
antibiotic classes among piperacillintazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems (n= 8 485) in
Europe, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
List of figures
1.1: Organisation of EARS-Net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
2.1: Percentage of EARS-Net participating laboratories employing interpretive criteria from various breakpoint committees for
antimicrobial susceptibility testing in 2010. Only data for laboratories returning EQA data for K. pneumoniae and P. aeruginosa are included . . . . .6
2.2: Klebsiella pneumoniae: Percentage of invasive isolates resistant to carbapenems reported to EARSS/EARS-Net by year,
20052010 (18 countries;140 laboratories) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
2.3: Pseudomonas aeruginosa: Percentage of invasive isolates resistant to carbapenems reported to EARSS/EARS-Net by year,
20052010 (18 countries;168 laboratories). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.1: Number of participating laboratories returning reports, per country, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
v
3.2: Adherence to guidelines: number of laboratories per country, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1: Number of hospitals (A) and laboratories (B) reporting AMR and/or denominator data in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4.2: Proportion of small, medium and large hospitals per country, based on the number of beds, for all hospital reporting both
antimicrobial resistance data and denominator data in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
5.1: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
5.2: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to macrolides in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
5.3: Streptococcus pneumoniae: proportion of invasive isolates with non-susceptibility to penicillin and macrolides in 2010 . . . . . . . . . . . . . . . . . . . . . . 25
5.4: Streptococcus pneumoniae: trends of non-susceptibility to penicillin by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.5: Streptococcus pneumoniae: trends of non-susceptibility to macrolides by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.6: Streptococcus pneumoniae: trends of non-susceptibility to penicillin and macrolides by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
5.7: Distribution of serogroups and the resistance profile of S. pneumoniae isolates per serogroup in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5.8: Staphylococcus aureus: proportion of invasive isolates resistant to meticillin (MRSA) in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.9: Staphylococcus aureus: trend of resistance to meticillin (MRSA) by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.10: Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
5.11: Enterococcus faecalis: trends of high-level resistance to aminoglycosides by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.12: Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.13: Enterococcus faecium: trends of resistance to vancomycin by country 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.14: Escherichia coli: proportion of invasive isolates with resistance to third-generation cephalosporins in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5.15: Escherichia coli: proportion of invasive isolates with resistance to fluoroquinolones in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
5.16: Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.17: Escherichia coli: trends of resistance to aminopenicillin by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.18: Escherichia coli: trends of resistance to third-generation cephalosporins by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
5.19: Escherichia coli: trends of resistance to fluoroquinolones by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.20: Escherichia coli: trends of resistance to aminoglycosides by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
5.21: Escherichia coli: trends of combined resistance (resistant to fluoroquinolones, third-generation cephalosporins and
aminoglycosides) by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.22: Klebsiella pneumoniae: proportion of invasive isolates resistant to third-generation cephalosporins in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
5.23: Klebsiella pneumoniae: proportion of invasive isolates resistant to fluoroquinolones in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.24: Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.25: Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.26: Klebsiella pneumoniae: trends of resistance to third-generation cephalosporins by country, 20072010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.27: Klebsiella pneumoniae: trends of resistance to fluoroquinolones by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.28: Klebsiella pneumoniae: trends of resistance to aminoglycosides by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.29: Klebsiella pneumoniae: trends of resistance to carbapenems by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
5.30: Klebsiella pneumoniae: trend of multiresistance (third-generation cephalosporins, fluoroquinolones and aminoglycosides) by
country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.31: Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillintazobactam in 2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.32: Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
5.33: Pseudomonas aeruginosa: proportion of invasive isolates resistant to fluoroquinolones in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.34: Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
5.35: Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.36: Pseudomonas aeruginosa: trend of resistance to piperacillintazobactam by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
5.37: Pseudomonas aeruginosa: trend of resistance to ceftazidime by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.38: Pseudomonas aeruginosa: trend of resistance to fluoroquinolones by country, 20072010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
5.39: Pseudomonas aeruginosa: trend of resistance to aminoglycosides by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.40: Pseudomonas aeruginosa: trend of resistance to carbapenems by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
5.41: Pseudomonas aeruginosa: trend of combined resistance (R to three or more antimicrobial classes among
piperacillintazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems) by country, 20072010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
vii
AMR Antimicrobial resistance
AmpC Ampicillinase C
AST Antimicrobial susceptibility testing
BSAC British Society for Antimicrobial
Chemotherapy
BSI Bloodstream infections
CC Clonal complex
CLSI Clinical and Laboratory Standards Institute
CMY Cephamycinase
CNSE Carbapenem-non-susceptible
Enterobacteriaceae
CPE Carbapenemase-producing
Enterobacteriaceae
CREC Third-generation cephalosporin-resistant
Escherichia coli
CRG Commissie Richtlijnen
Gevoeligheidsbepalingen (Dutch)
CRKP Third-generation cephalosporin-resistant
Klebsiella pneumoniae
CSF Cerebrospinal fluid
DIN Deutsche Industrie Norm (German)
DNA Deoxyribonucleic acid
EARSS European Antimicrobial Resistance
Surveillance System
EARS-Net European Antimicrobial Resistance
Surveillance Network
ECDC European Centre for Disease Prevention
and Control
EU European Union
EQA External quality assessment
ESAC European Surveillance of Antimicrobial
Consumption
ESBL Extended-spectrum beta-lactamase
ESCMID European Society of Clinical Microbiology
and Infectious Diseases
ESGARS ESCMID Study Group for Antimicrobial
Resistance Surveillance
EUCAST European Committee on Antimicrobial
Susceptibility Testing
FREC Fluoroquinolone-resistant Escherichia coli
ICU Intensive care unit
IMP Imipenemase
KPC Klebsiella pneumoniae carbapenemase
MIC Minimum inhibitory concentration
MLS Macrolide, lincosamide and streptogramin
MNSP Macrolide non-susceptible Streptococcus
pneumoniae
MRSA Meticillin-resistant Staphylococcus aureus
NDM New Delhi metallo-beta-lactamase
NRL National reference laboratories
NWGA Norwegian Working Group on
Antimicrobials
OXA Oxacillinase gene
PBP Penicillin-binding protein
PCV Pneumococcal conjugate vaccine
PNSP Penicillin-non-susceptible Streptococcus
pneumoniae
PRSP Penicillin-resistant Streptococcus
pneumoniae
RNA Ribonucleic acid
SFM Comit de lAntibiogramme de la Socit
Franaise de Microbiologie (French)
SIR Sensitive, intermediate, resistant
SHV Sulfhydryl-variable extended-spectrum
beta-lactamase gene
SRGA Swedish Reference Group for Antibiotics
TESSy The European Surveillance System (at
ECDC)
TEM Temoneira extended-spectrum beta-
lactamase gene
UK NEQAS United Kingdom National External Quality
Assessment Scheme for Microbiology
VISA Vancomycin-intermediate Staphylococcus
aureus
VIM Verona integron-encoded
metallo-beta-lactamase
VRE Vancomycin-resistant enterococci
WHO World Health Organization
WHONET WHO microbiology laboratory database
software
Abbreviations and acronyms
viii
Countries participating in EARS-Net 2010
Participating countries
Non participating countries
AT
BE
BG
CY
CZ
DE
DK
EE
ES
FI
FR
EL
HU
IE
IS
IT
LT
LU
LV
MT
NL
NO
PL
PT
RO
SE
SI
UK
AT Austria
BE Belgium
BG Bulgaria
CY Cyprus
CZ Czech Republic
DE Germany
DK Denmark
EE Estonia
EL Greece
ES Spain
FI Finland
FR France
HU Hungary
IE Ireland
IS Iceland
IT Italy
LT Lithuania
LU Luxembourg
LV Latvia
MT Malta
NL Netherlands
NO Norway
PL Poland
PT Portugal
RO Romania
SE Sweden
SI Slovenia
UK United Kingdom
As of 1 January 2010, only EU and EEA Member States can report data to EARS-Net. Antimicrobial resistance surveillance data from five countries previously
participating in EARSS (Bosnia-Herzegovina, Croatia, Israel, Switzerland and Turkey) are therefore not included in this report.
ix
Austria
Federal Ministry of Health
Medical University Vienna
Elisabethinen Hospital, Linz
www.elisabethinen.or.at
Belgium
Scientific Institute of Public Health
www.iph.fgov.be
University of Antwerp
Bulgaria
Alexander University Hospital, Sofia
National Center of Infectious and Parasitic Diseases
Cyprus
Nicosia General Hospital
Czech Republic
National Institute of Public Health
www.szu.cz
National Reference Laboratory for Antibiotics
Denmark
Statens Serum Institut, Danish Study Group for
Antimicrobial Resistance Surveillance (DANRES)
www.danmap.org
Estonia
Health Board
East-Tallinn Central Hospital
Tartu University Hospital
Finland
National Institute for Health and Welfare, Finnish
Hospital Infection Program (SIRO)
www.thl.fi/siro
Finnish Study Group for Antimicrobial Resistance (FiRe)
www.finres.fi
France
Piti-Salptrire Hospital
National Institute for Public Health Surveillance
www.invs.sante.fr
French National Observatory for the Epidemiology of
Bacterial Resistance to Antimicrobials (ONERBA): Azay-
Rsistance, le-de-France and Russir networks
www.onerba.org
National Reference Centre for Pneumococci (CNRP)
Germany
Robert Koch Institute
www.rki.de
Greece
Hellenic Pasteur Institute
National School of Public Health
National and Kapodistrian University of Athens, Medical
School
www.mednet.gr/whonet
Hungary
National Centre for Epidemiology
www.antsz.hu
Ireland
Health Protection Surveillance Centre (HPSC)
www.hpsc.ie
Iceland
National University Hospital of Iceland
Centre for Health Security and Infectious Disease
Control
Italy
www.simi.iss.it/antibiotico_resistenza.htm
Latvia
Paul Stradins Clinical University Hospital
State Agency Infectology Centre of Latvia
Lithuania
National Public Health Surveillance Laboratory
Institute of Hygiene
Luxembourg
National Health Laboratory
Microbiology Laboratory, Luxembourgs Hospital Centre
Malta
Mater Dei Hospital, BKara
Netherlands
National Institute for Public Health and the Environment
Norway
University Hospital of North Norway
Norwegian Institute of Public Health
St. Olav University Hospital, Trondheim
Poland
National Medicines Institute
National Reference Centre for Antimicrobial Resistance
and Surveillance
National institutions/organisations
participating in EARS-Net
x
Portugal
National Institute of Health Dr. Ricardo Jorge
www.insarj.pt
Ministry of Health
Directorate-General of Health
Romania
National Institute of Research and Development for
Microbiology and Immunology Cantacuzino
Institute of Public Health
Slovenia
University of Ljubljana
Spain
Health Institute Carlos lll
www.isciii.es
National Centre of Microbiology
Sweden
Swedish Institute for Communicable Disease Control
www.smi.se
United Kingdom
Health Protection Agency
www.hpa.org.uk
Health Protection Scotland
Public Health Agency Northern Ireland
1
This report is based on antimicrobial resistance data
reported to EARS-Net by 28 countries in 2010 and trend
analyses including EARSS data from previous years. The
data show that the Europe-wide increase of antimicro-
bial resistance observed in Escherichia coli during recent
years is continuing unimpeded. The highest resistance
proportions in E. coli were reported for aminopenicil-
lins ranging up to 83 %. Despite the already high level
of resistance the increase continues even in countries
presenting resistance well above 50 %. The percentage
of third-generation cephalosporin resistance reported
among E. coli isolates has increased significantly over
the last four years in half of the reporting countries,
while a decreasing trend was observed in only one
country. This resistance is directly linked to the high
proportions (65100 %) of ESBL-positives among cepha-
losporin-resistant E. coli isolates reported in 2010.
A high frequency of multi-drug resistant Klebsiella pneu-
moniae was observed in southern, central and eastern
Europe. In half of the reporting countries, the propor-
tion of multiresistant K. pneumoniae isolates (combined
resistance to third-generation cephalosporins, fluoro-
quinolones and aminoglycosides) was above 10 % and
five countries show an increasing trend of carbapenem-
resistant K. pneumoniae. Carbapenems have been
widely used in many countries due to the increasing rate
of extended-spectrum beta-lactamase (ESBL) produc-
ing Enterobacteriaceae with a consequent impact on the
emergence of carbapenemase production (VIM, KPC and
NDM-1).
Other trends in the occurrence of resistance reported to
EARS-Net bring hope that national efforts on infection
control and efforts targeted at containment of resistance
may in some cases bring the development of resistance
to a halt, or even reverse undesirable resistance trends,
as exemplified by the development for meticillin-resist-
ant Staphylococcus aureus (MRSA). Even though the
proportion of MRSA among S. aureus is still above 25 %
in eight out of 28 countries, the occurrence of MRSA is
stabilising or decreasing in some countries and a sus-
tained decrease has been observed in Austria, Cyprus,
Estonia, France, Greece, Ireland and the UK.
Furthermore, the United Kingdom has shown a consist-
ent reduction of resistant proportions in K. pneumoniae
for all antimicrobial classes under surveillance, and
in a few countries (Germany, Greece, Italy and the
UK) the efforts to control glycopeptide resistance in
Enterococcus faecium seem to be successful and result-
ing in a continuous decrease of proportions of resistant
isolates. Meanwhile, high-level aminoglycoside resist-
ance in Enterococcus faecalis is stabilising in Europe at
a level of 2550 %.
For Streptococcus pneumoniae, non-susceptibility
to penicillin remains generally stable in Europe and
non-susceptibility to macrolides has declined in five
countries while an increasing trend was observed in only
one country. For Pseudomonas aeruginosa, high propor-
tions of resistance to fluoroquinolones, carbapenems
and combined resistance have been reported by many
countries, especially in southern and eastern Europe.
For several antimicrobial and pathogen combinations,
e.g. fluoroquinolone resistance in E. coli, K. pneumo-
niae, P. aeruginosa and for MRSA, a north to south
gradient is evident in Europe. In general, lower resist-
ance proportions are reported in the north and higher
proportions in the south of Europe. This is likely to be
a reflection of differences in infection control practices,
presence or absence of legislation regarding prescrip-
tion of antimicrobial drugs. However, for K. pneumoniae,
increasing trends of resistance to specific antimicrobial
classes and of multiresistance have also been observed
in northern European countries, like Denmark and
Norway, which traditionally have a prudent approach to
antimicrobial use.
In addition to the regular trend analysis and situation
overview, this 2010 EARS-Net report contains a focus
chapter providing in-depth analysis for carbapenem-
resistant K. pneumoniae and P. aeruginosa. Results
from susceptibility testing to carbapenems for these
two pathogens reported since 2005, reveal a sig-
nificant decrease of susceptibility to carbapenems in
invasive K. pneumoniae over the period 20052010.
Carbapenems are some of the few effective antimicro-
bials for the treatment of infections caused by bacteria
that produce extended-spectrum beta-lactamases and
thus resistance to carbapenems leaves very few thera-
peutic options available.
Based on EARS-Net data, the antimicrobial resistance
situation in Europe displays large variation depending
on pathogen type, antimicrobial substance and geo-
graphical region. Besides evidence of stabilisation of the
situation for some pathogens (e.g. MRSA) in a number
of countries, the data show the unimpeded decline of
antimicrobial susceptibility in other major pathogens
(e.g. E.coli) and the alarming emergence of carbapenem
resistance in K. pneumonia, leading to an unfortunate
loss of antimicrobial treatment options.
Summary
2
Figure 1.1: Organisation of EARS-Net
National Laboratories
National Epidemiological Contact Points
Disease Experts Data Managers
European Antimicrobial Resistance
Surveillance Network (EARS-Net)
at
European Centre for Disease
Prevention and Control (ECDC)
National Advisory
Board
EARS-Net
Coordination Group
EUCAST
ESCMID
ESAC-Net
HAI-Net
WHO
3
This is the second Annual Report of the European
Antimicrobial Resistance Surveillance Network (EARS-
Net) published by European Centre of Disease Prevention
and Control (ECDC). The report represents the continua-
tion of a series of highly valued EARSS Annual Reports
published by the network since 2001. The results pre-
sented in this report are based on data submitted from
over 900 laboratories serving more than 1400 hospitals
in 26 EU Member States, Norway and Iceland.
Surveillance of antimicrobial resistance within the EU
is carried out in agreement with Decision No 2119/98/
EC of the European Parliament and of the Council of 24
September 1998 and Regulation (EC) No 851/2004 of the
European Parliament and of the Council of 21 April 2004
establishing a European Centre for Disease Prevention
and Control.
The antimicrobial resistance surveillance data col-
lected previously by EARSS and currently by EARS-Net,
play an important role in documenting the occurrence
and spread of antimicrobial resistance in Europe, and
contribute to raising awareness of the problem at the
political level, among public health officials, in the sci-
entific community and in the general public.
In the present report, results referring to 2010 and trend
analyses including data from previous years are pre-
sented and discussed in Chapter 5. This years focus
chapter (Chapter 2) is on carbapenem-resistant K. pneu-
moniae and P. aeruginosa. Country-specific information
is provided in Annex 2.
About EARS-Net
The European Antimicrobial Resistance Surveillance
Network (EARS-Net) is a European-wide network of
national surveillance systems, providing European refer-
ence data on the occurrence of antimicrobial resistance.
EARS-Net is the largest publicly funded surveillance sys-
tem for antimicrobial resistance in Europe.
The management and coordination of EARS-Net was
transferred from the Dutch National Institute for Public
Health and the Environment (RIVM) to the European
Centre for Disease Prevention and Control in January
2010. At ECDC, the management and coordination of
EARS-Net is carried out by the Surveillance Section
in collaboration with the Disease Programme for
Antimicrobial Resistance and Healthcare-associated
Infections.
Scientific guidance and support to the coordination of
the network is provided by the EARS-Net Coordination
Group (see Figure 1.1), composed of experts selected
from among the nominated disease-specific contact
points and experts from other organisations involved
in surveillance of antimicrobial resistance. EARS-Net
activities are coordinated in close collaboration with
two other major surveillance networks: the European
Surveillance of Antimicrobial Consumption Network
(ESAC-Net) and the Healthcare-associated Infections
Surveillance Network (HAI-Net). EARS-Net collaborates
with the European Society of Clinical Microbiology and
Infectious Diseases (ESCMID), in particular with the
societys subcommittee, the European Committee on
Antimicrobial Susceptibility Testing (EUCAST).
Data for EARS-Net are provided by a network of national
surveillance systems in the participating countries. The
national surveillance systems collect data from clinical
laboratories on antimicrobial susceptibility of seven bac-
terial pathogens of public health importance in humans:
Streptococcus pneumoniae, Staphylococcus aureus,
Escherichia coli, Enterococcus faecalis, Enterococcus
faecium, Klebsiella pneumoniae and Pseudomonas
aeruginosa. The majority of countries participating in
EARS-Net even collect and report denominator data on
laboratory/hospital activity and patient characteristics.
The data from national surveillance systems are
uploaded by national data managers to a central data-
base at ECDC (The European Surveillance System,
TESSy). After uploading, each country approves its own
data and the results are made available from the ECDC
website. EARS-Net maintains an interactive database at
the ECDC website
i
and publishes annual reports on the
occurrence of antimicrobial resistance in Europe.
i http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/Pages/
index.aspx
1 Introduction
5
2.1 Introduction
The increase of carbapenem resistance in Gram-negative
bacteria has become an exceedingly important clinical
and public health issue in recent years. Carbapenems
are some of the few effective antimicrobials for the
treatment of infections caused by bacteria that pro-
duce extended-spectrum beta-lactamases and so
resistance to carbapenems leaves very few therapeu-
tic options
1
. Although carbapenem resistance in both
Klebsiella pneumoniae and Pseudomonas aeruginosa
can result through various mechanisms of resistance
2
,
the emergence and spread of carbapenemases, a group
of clinically important beta-lactamases, especially in
members of Enterobacteriaceae family
14
, has made the
surveillance of carbapenem resistance and carbapen-
emases in Gram-negative bacteria imperative.
Key points
A significant decrease in susceptibility to carbap-
enems in invasive K. pneumoniae isolates was
observed in Europe from 2005 to 2010. During the
same period, no significant change in suscepti-
bility to carbapenems in invasive P. aeruginosa
isolates was observed.
A marked heterogeneity was observed with
regard to the interpretive criteria being used by
clinical microbiology laboratories for reporting
susceptibility testing results. Harmonised use
of breakpoints would substantially increase the
comparability of data.
Carbapenem resistance can result through vari-
ous mechanisms, including the production of
carbapenemases. Confirming the presence of
carbapenemases in Enterobacteriaceae, would
allow a closer surveillance of the spread of car-
bapenemase-producing Enterobacteriaceae (CPE)
in Europe.
Carbapenemase enzymes that can efficiently hydro-
lyse most beta-lactams, including carbapenems
1,3

have emerged and spread among all members of
the Enterobacteriaceae family worldwide
46
. Though
the exact prevalence of carbapenemase-producing
Enterobacteriaceae (CPE) in healthcare facilities and
in the community in Europe is not known, publications
from Member States indicate that CPE are endemic in
certain countries in Europe
7,8
. Although some of the
most widespread types of carbapenemases found in
Enterobacteriaceae are K. pneumoniae carbapenemase
(KPC) and Verona integron-encoded metallo-beta-lacta-
mase (VIM)
813
, other carbapenemases like OXA-48
9,14

and New Delhi metallo-beta-lactamase (NDM)
15,16
have
also emerged. Variants of NDM carbapenemase, such as
NDM-2, have recently been reported from countries in
the north of Africa
17
.
The emergence and spread of CPE has been identi-
fied as a public health threat, especially since recent
studies on CPE
18,19
and carbapenem-non-susceptible
Enterobacteriaceae (CNSE)
20,21
have shown that infec-
tion or colonisation is associated with higher in-hospital
mortality.
Results from testing the susceptibility of K. pneumo-
niae and P. aeruginosa to carbapenems have been
reported to EARSS/EARS-Net by participating clinical
microbiological laboratories since 2005. Susceptibility
to carbapenems reported to EARS-Net is based on the
results of testing against either imipenem or mero-
penem. The choice of which breakpoint committees
interpretive criteria is used for the interpretation of
minimum inhibitory concentrations (MIC) as either sus-
ceptible (S), intermediate (I) or resistant (R), is at the
discretion of each clinical microbiology laboratory.
In general, however, EARS-Net encourages the use of
EUCAST breakpoints.
Because of the public health impact of infections caused
by CPE, it is important to follow the trends of carbap-
enem resistance in Europe. Confirming the presence
of carbapenemases in bacteria and understanding the
extent of the reservoir in Europe is a prerequisite for tar-
geted intervention to control the spread.
Although carbapenem susceptibility results are avail-
able from EARS-Net reports, it is important to note that
these only provide resistance profiles with no further
characterisation of resistance mechanisms. The results
may therefore be useful for the surveillance of carbap-
enem resistance in Gram-negative bacteria, but may
not be useful for following the occurrence of carbap-
enemases. Performance of phenotypic and molecular
testing for screening and confirmation of the presence of
carbapenemases would add a significant and important
layer of information to the existing data.

2 Carbapenem-resistant Klebsiella
pneumoniae and Pseudomonas aeruginosa
Analysis of data from laboratories reporting continuously
from 2005 to 2010
6
2.2 Methods
Results of testing susceptibility to carbapenems of
invasive K. pneumoniae and P. aeruginosa isolates
causing blood stream infections (BSI) and infections
of cerebrospinal fluid (CSF) were extracted from the
EARSS/EARS-Net database for 20052010. A trend anal-
ysis was performed using the Cochran-Armitage test for
trend for both K. pneumoniae and P. aeruginosa.
The following data were also extracted from the EARSS/
EARS-Net database with regard to reporting of carbap-
enem resistance of K. pneumoniae and P. aeruginosa
isolates from 2005 to 2010:
the number of countries reporting to EARSS/EARS-Net
annually for these organisms,
the number of clinical microbiology laboratories
reporting to EARSS/EARS-Net per country per year,
the number of clinical microbiology laboratories in
each country that have reported their results continu-
ously during the period (some countries may report
through one central laboratory),
the total number of laboratories using the interpretive
criteria of various breakpoint committees as reported
by EARS-Net laboratories participating in the 2010
EARS-Net External Quality Assessment (EQA) exercise
(see Figure 3.2).
2.3 Results
Number of participating countries
Twenty-one countries reported results to EARSS for K.
pneumoniae and 22 reported for P. aeruginosa, in 2005;
this number had increased to 28 for both organisms by
2010. Eighteen countries reported continuously for the
two pathogens throughout the period 20052010. Trend
Figure 2.1: Percentage of EARS-Net participating laboratories employing interpretive criteria from various breakpoint
committees for antimicrobial susceptibility testing in 2010. Only data for laboratories returning EQA data for K.
pneumoniae and P. aeruginosa are included
%

l
a
b
s

p
a
r
t
i
c
p
a
t
i
n
g
0
10
20
30
40
50
60
70
80
Other SRGA SFM NWGA EUCAST DIN CRG CLSI COMB BSAC
Data: UKNEQAS 2010
BSAC: British Society of Antimicrobial Chemotherapy; COMB: Combination; CLSI: Clinical Laboratory Standards Institute; CRG: Commissie Richtlijnen
Gevoeligheidsbepalingen; DIN: Deutsches Institut fr Normung; EUCAST: European Committee for Antimicrobial Susceptibility Testing; NWGA: Norwegian Working
Group on Antibiotics; SFM: Socit Franaise de Microbiologie; SRGA: Swedish Reference Group for Antibiotics.
Figure 2.2: Klebsiella pneumoniae: Percentage of carbapenem-resistant invasive isolates reported to EARSS/EARS-Net
by year, 20052010 (18 countries; 140 laboratories)
P
e
r
c
e
n
t
a
g
e
5
10
15
20
2010 2009 2008 2007 2006 2005
Only laboratories that continuously reported susceptibility results for carbapenems during the period 20052010 are included in the analysis.
7
analyses for 20052010 presented in this chapter for
both K. pneumoniae and P. aeruginosa are based only on
data from the laboratories reporting continuously during
the period (Table 2.1).
Participation of clinical microbiology
laboratories
There has been an overall increase of 56 % (366 to 570)
and 69 % (312 to 526) in the total numbers of clinical
microbiology laboratories reporting K. pneumoniae and
P. aeruginosa isolates, respectively, from 2005 to 2010.
Number of continuously reporting laboratories
The numbers of laboratories continuously reporting sus-
ceptibility results for K. pneumoniae and P. aeruginosa
isolates throughout the period 20052010, were 140 and
168, respectively. The number of continuously reporting
laboratories per country and the average number of iso-
lates per year and country can be seen in Table 2.1.
Use of various interpretive criteria by
participating laboratories
The distribution of the interpretive criteria used by all
laboratories that participated in the EARS-Net EQA in
June 2010 is shown in Figure 2.1. Data from this EQA
showed that 66 % of participating laboratories used
guidelines from the Clinical Laboratory Standards
Institute (CLSI) and 14 % used those from the European
Committee on Antimicrobial Susceptibility Testing
(EUCAST); making the interpretive criteria provided by
these the two breakpoint committees the most widely
used.
Trends in resistance
Between 2005 and 2010, a total of 140 laboratories from
18 countries continuously reported results on the sus-
ceptibility to carbapenems of invasive K. pneumoniae
isolates. During this period, the number of laboratories
reporting continuously per country ranged from one
laboratory in the Czech Republic, Iceland, Malta and
Sweden, to 33 laboratories in France. Trend analy-
sis was performed only on the results from these 140
laboratories.
Results from this analysis show that in Europe the
proportion of K. pneumoniae isolates resistant to car-
bapenems increased from 8 % to 15 % between 2005 and
2010. This increase was found to be highly significant
(p < 0.001) (Figure 2.2) but this is mainly due to a sub-
stantial increase in a few countries.
For more detailed trends of carbapenem resistance in K.
pneumoniae per country for 20072010, please refer to
chapter 5, figure 5.29.
Pseudomonas aeruginosa
A total of 168 laboratories from 18 countries continu-
ously reported results on susceptibility of invasive P.
aeruginosa isolates to carbapenems between 2005 and
2010. The number of laboratories continuously reporting
per country, ranged from one each in Bulgaria, Iceland
and Malta to 24 in Greece. Trend analysis was performed
only on the results from these 168 laboratories.
Results from this analysis show that in Europe the
proportion of P. aeruginosa isolates resistant to carbap-
enems was 22 % in 2005, increased to 24 % in 2008,
and decreased to 22 % in 2010. Trend analysis on these
data showed no significant change over the study period
(p < 0.49) (Figure 2.3).
For more detailed trends of carbapenem resistance in P.
aeruginosa per country for 2007 2010, please refer to
chapter 5, figure 5.40.
2.4 Discussion
Results from the analyses in this report show that car-
bapenem resistance is significantly increasing among K.
pneumoniae invasive isolates in Europe. Reports from
Figure 2.3: Pseudomonas aeruginosa: Percentage of carbapenem-resistant invasive isolates reported to EARSS/EARS-
Net by year, 20052010 (18 countries; 168 laboratories).
P
e
r
c
e
n
t
a
g
e
0
5
10
15
20
25
2010 2009 2008 2007 2006 2005
Only laboratories that continuously reported susceptibility results for carbapenems during the period 20052010 are included in the analysis.
8
Table 2.1: Numbers of laboratories reporting continuously and average numbers of K. pneumoniae and P. aeruginosa
isolates reported per country per year to EARSS/EARS-Net during 20052010
Country
K. pneumoniae P. aeruginosa
Number of laboratories* Average number of isolates per year Number of laboratories* Average number of isolates per year
Austria 7 336 8 396
Bulgaria 2 61 1 29
Cyprus 2 43 2 41
Czech Republic 1 654 30 485
Estonia 4 46 5 39
Finland 7 270 6 185
France 33 1 060 20 1 153
Greece 25 1 161 24 887
Hungary 15 351 16 530
Iceland 1 20 1 11
Ireland 8 189 9 154
Malta 1 35 1 44
Netherlands 5 392 4 288
Norway 7 292 9 125
Slovenia 7 75 8 82
Spain 10 569 9 456
Sweden 1 403 7 260
United Kingdom 4 396 9 355
Total 140 168
* In some countries, data from several laboratories may be reported to EARS-Net from one central laboratory.
Member States showing similar susceptibility results
and an increasing number of reports documenting the
spread of CPE have given rise to the suspicion that
susceptibility of Enterobacteriaceae to carbapenems
is decreasing across Europe. The proportion of carbap-
enem-resistant P. aeruginosa, which is already high at
22 %, showed no significant increase. The increase in
resistance to carbapenems in K. pneumoniae, as well as
the high level of resistance in P. aeruginosa, constitutes
a serious public health concern, since few therapeutic
options are available for the treatment of carbapenem-
resistant infections.
When making inferences based on the available data on
carbapenem-resistant P. aeruginosa and K. pneumoniae,
a number of limitations regarding detection and testing
should be taken into consideration. One of the diffi-
culties of accurately detecting carbapenem resistance
is that it may be the result of a variety of mechanisms
of resistance, including the presence of outer mem-
brane porin protein loss, increased activity of efflux
pumps, the production of extended-spectrum beta-
lactamases or AmpC beta-lactamases in combination
with porin loss and last, but not least, the production
of carbapenemases
2,8
. Furthermore, even with routine
antimicrobial susceptibility testing, CPE can demon-
strate significant variation in their carbapenem MICs,
even falling within the susceptibility range as defined by
either the CLSI
22
or EUCAST
23
, despite a recent reduction
of the susceptibility breakpoints for carbapenems and
Enterobacteriaceae by CLSI
24
. Moreover, certain testing
methods, such as automatic testing, have been shown
to not always distinguish between Enterobacteriaceae
that produce carbapenemases and those that carry
other mechanisms of resistance (e.g. ESBLs and/or porin
loss)
8,25
. Another issue affecting the comparability of
susceptibility testing results is the marked heterogene-
ity of the breakpoints used by laboratories in Europe.
As shown in Figure 2.1, the most commonly used break-
points are those from CLSI, followed by EUCAST, but
interpretive criteria from a number of other committees
are also followed. While the effect of this heterogeneity
on the susceptibility results and trends presented here
are not explored, it can be argued that in order to obtain
fully comparable results, harmonisation of the use of
breakpoints and interpretive criteria for all reporting
laboratories is needed.
The increased morbidity, mortality and overall public
health impact of infections with carbapenemase-pro-
ducing bacteria calls for action to prevent the spread of
these bacteria and resistance mechanisms in Europe.
Data on carbapenem resistant bacteria is available
through existing surveillance systems; however, in the
absence of data on the mechanisms of resistance in
these bacteria, the real prevalence of carbapenemase-
producing bacteria remains unknown. Having this
information would provide better understanding of the
extent of the reservoir in Europe, which is a prerequisite
for designing and implementing targeted interventions
to control the spread.
In support of this, a recent ECDC risk assessment on
the spread of CPE through patient transfer between
healthcare facilities, with special emphasis on
cross-border transfer
6
suggests that the elements nec-
essary to curb the spread of CPE include surveillance
data, prompt detection of carbapenem resistance in
Enterobacteriaceae, and confirmation of the production
of carbapenemases in these bacteria
6,8
.
9
References
1. Paterson DL, Bonomo RA. Extended-spectrum beta-lactamases: a
clinical update. Clin Microbiol Rev. 2005 Oct;18(4):657-86.
2. Miriagou V, Cornaglia G, Edelstein M, Galani I, Giske CG,
Gniadkowski M, et al. Acquired carbapenemases in Gram-negative
bacterial pathogens: detection and surveillance issues. Clinical
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3. Queenan AM, Bush K. Carbapenemases: the versatile beta-lactama-
ses. Clin Microbiol Rev. 2007 Jul;20(3):440-58, table of contents.
4. Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneu-
moniae carbapenemase-producing bacteria. Lancet Infect Dis. 2009
Apr;9(4):228-36.
5. Bush K, Jacoby GA. Updated Functional Classifcation of {beta}-
Lactamases. Antimicrob Agents Chemother. 2010 March 1,
2010;54(3):969-76.
6. European Centre for Disease Prevention and Control. Risk assess-
ment on the spread of CPE through patient transfer between health-
care facilities. Stockholm: ECDC 2011.
7. Vatopoulos A. High rates of metallo-beta-lactamase-producing
Klebsiella pneumoniae in Greece--a review of the current evidence.
Euro Surveill. 2008 Jan 24;13(4).
8. Grundmann H, Livermore DM, Giske CG, Canton R, Rossolini GM,
Campos J, et al. Carbapenem-non-susceptible Enterobacteriaceae
in Europe: conclusions from a meeting of national experts. Euro
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9. Poirel L, Ros A, Carrr A, Fortineau N, Carricajo A, Berthelot P, et
al. Cross-border transmission of OXA-48-producing Enterobacter
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Chemotherapy. 2011 May 1, 2011;66(5):1181-2.
10. Levast M, Poirel L, Carrr A, Deiber M, Decroisette E, Mallaval F-O,
et al. Transfer of OXA-48-positive carbapenem-resistant Klebsiella
pneumoniae from Turkey to France. Journal of Antimicrobial
Chemotherapy. 2011.
11. Galan-Sanchez F, Marin-Casanova P, Aznar-Marin P, Foncubierta
E, Garca-Martos P, Garca-Tapia A, et al. Detection of OXA-48-
encoding plasmid in a clinical strain of Enterobacter cloacae iso-
lated in Spain. 21st European Congress of Clinical Microbiology
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12. Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneu-
moniae carbapenemase-producing bacteria. Lancet Infect Dis. 2009
Apr;9(4):228-36.
13. Walsh TR. Clinically signifcant carbapenemases: an update. Curr
Opin Infect Dis. 2008 Aug;21(4):367-71.
14. Carrer A, Poirel L, Yilmaz M, Akan OA, Feriha C, Cuzon G, et al. Spread
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Agents and Chemotherapy. [Jour]. 2010;54(3):1369-73.
15. Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F,
Balakrishnan R, et al. Emergence of a new antibiotic resist-
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Sep;10(9):597-602.
16. Struelens MJ, Monnet DL, Magiorakos AP, Santos OConnor
F, Giesecke J. New Delhi metallo-beta-lactamase 1-producing
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17. Kaase M, Nordmann P, Wichelhaus TA, Gatermann SG, Bonnin RA,
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18. Gasink LB, Edelstein PH, Lautenbach E, Synnestvedt M, Fishman
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of imipenem-resistant Enterobacter species: emergence of
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20. Borer A, Saidel-Odes L, Riesenberg K, Eskira S, Peled N, Nativ
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10
11
3.1 Introduction
Since 2000, EARSS/EARS-Net have organised external
quality assessment (EQA) exercises of antimicrobial
susceptibility testing in collaboration with UK NEQAS
(United Kingdom National External Quality Assessment
Service). UK NEQAS is based at the Health Protection
Agency in London, and is a non-profit organisation with
more than 35 years of experience in external quality
assessment in different countries (www.ukneqasmicro.
org.uk).
The purpose of the EARS-Net EQA exercises is:
to assess the ability of participating laboratories to
identify antimicrobial resistance of clinical and public
health importance;
to determine the accuracy of susceptibility test results
reported by individual laboratories;
to estimate the overall comparability of routinely col-
lected test results between laboratories and countries
across Europe.
The EQA exercise conducted in 2010 was open to all 28
countries participating in EARS-Net. In addition, the
EQA was offered to previous EARSS participants includ-
ing Bosnia-Herzegovina, Croatia, Turkey and Israel.
A panel of six strains (S. pneumoniae, S. aureus, E. coli,
K. pneumoniae, P. aeruginosa and E. faecium) resem-
bling resistance phenotypes of bacterial species under
surveillance by EARS-Net was included in the exercise.
The strains were characterised and tested in two refer-
ence laboratories (Addenbrookes Hospital, Cambridge,
UK and City Hospital, Birmingham, UK). Both reference
laboratories confirmed MICs and interpreted the results
according to frequently used breakpoint criteria such as
CLSI and EUCAST, as indicated in each of the species
chapters.
3.2 Results
The six strains were distributed to 873 laboratories con-
nected to EARS-Net. The laboratories were asked to
report the identification of each organism and clinical
susceptibility characterisation susceptible, intermedi-
ate and resistant (S, I, R) according to the guidelines
used. The return rate was similar to previous years; 766
laboratories (88 %) returned reports. Figure 3.1 shows
the number of participating laboratories returning
results per country. Participants results were analysed
3 External quality assessment exercise
(EQA) 2010
Figure 3.1: Number of participating laboratories returning reports per country, 2010
0 20 40 60 80 100
United Kingdom
Turkey
Sweden
Spain
Slovenia
Romania
Portugal
Poland
Norway
Netherlands
Malta
Luxembourg
Lithuania
Latvia
Italy
Ireland
Iceland
Hungary
Greece
Germany
France
Finland
Estonia
Denmark
Czech Republic
Cyprus
Croatia
Bulgaria
Bosnia & Herzegovina
Belgium
Austria
No results
Results
C
o
u
n
t
r
y
Number of laboratories
The external quality assessment exercise was open to all countries participating in EARSS in 2010.
12
Figure 3.2: Adherence to guidelines: number of laboratories per country, 2010
0 20 40 60 80 100
United Kingdom
Turkey
Sweden
Spain
Slovenia
Romania
Portugal
Poland
Norway
Netherlands
Malta
Luxembourg
Lithuania
Latvia
Italy
Ireland
Iceland
Hungary
Greece
Germany
France
Finland
Estonia
Denmark
Czech Republic
Cyprus
Croatia
Bulgaria
Bosnia & Herzegovina
Belgium
Austria
COMB
CRG
DIN
EUCAST
CLSI
NWGA
SFM
SRGA
Other
BSAC
C
o
u
n
t
r
y
BSAC: British Society for Antimicrobial Chemotherapy; CRG: (Dutch) Commissie Richtlijnen Gevoeligheidsbepalingen; DIN: Deutsche Industrie Norm; EUCAST:
European Committee on Antimicrobial Susceptibility Testing; CLSI: Clinical and Laboratory Standards institute; NWGA: Norwegian Working Group on Antimicrobials;
SFM: Socit Franaise de Microbiologie; SRGA: Swedish Reference Group for Antibiotics. Laboratories specifying other indicates did they did not use any of the
specified guidelines above. Where more than one guideline was used to cover certain antimicrobial/organism combinations laboratories could select combined
(COMB) as the guideline.
and considered concordant if the reported categori-
sation agreed with the interpretation of the reference
laboratories.
For the determination of AST results, laboratories used
automated methods (42 %), disc diffusion tests (34 %)
or combined methods (14 %). For species identification
laboratories used automated (52 %) or conventional
methods (46 %). Increased use of conventional methods
was associated with identification of the S. pneumoniae
and E. faecium.
The majority of laboratories applied CLSI guidelines
(66 %), and some countries used national guidelines,
e.g. France (SFM), United Kingdom (BSAC), and Sweden
(SRGA). EUCAST guidelines were reported by 107 (14 %)
laboratories. However, the United Kingdom, Sweden, the
Netherlands, Germany, France and Norway have been
implementing EUCAST breakpoints in their national
MIC breakpoint recommendations, as harmonised
breakpoints have been agreed, and their disc diffu-
sion method has been adjusted accordingly. Therefore,
a combined total of some 29 % of laboratories used
EUCAST breakpoints. Figure 3.2 shows the adherence to
(inter)national guidelines by number of laboratories per
country.
3.2.1 Specimen 0243 Klebsiella pneumoniae
This specimen consisted of a Klebsiella pneumoniae with
plasmid-mediated CIT-type (CMY-like enzymes derived
from C. freundii) AmpC beta-lactamase production.
Reporting of susceptibility to cephalosporins by partici-
pants was very variable (cefotaxime S 20.1 %, I 18.5 %,
R 61.4 %; ceftriaxone S 16.1 %, I 24.6 %, R 59.3 %;
ceftazidime S 2.8 %, I 22.9 %, R 74.3 %). MICs of cepha-
losporins included in reference tests (cefotaxime 416
mg/L, ceftriaxone > 32 mg/L, ceftazidime 32 mg/L) were
all in the resistant range with current EUCAST and CLSI
breakpoints, although cefotaxime MICs were border-
line. CLSI breakpoints for Enterobacteriaceae tested
against cefotaxime, ceftriaxone and ceftazidime were
significantly reduced in January 2010. It is likely that
many laboratories have not yet implemented the new
breakpoints in their systems and according to old CLSI
13
recommendations it would have been correct to report
bacteria with MICs of 4 or 8 mg/L as sensitive to cefotax-
ime if the isolate did not have a class A ESBL. Reports of
susceptible to cefotaxime, ceftriaxone and ceftazidime
were returned by significantly fewer participants follow-
ing EUCAST-related guidelines (4.0 % of 199, 3.4 % of
58 and 0.5 % of 210, respectively) than participants fol-
lowing CLSI guidelines (27.1 % of 431, 18.1 % of 221 and
3.7 % of 488, respectively).
As seen with the E. coli with plasmid-mediated AmpC
beta-lactamase distributed in the EARSS EQA distribu-
tion in 2009 (specimen 9011), reports that the organism
was an ESBL-producer were not uncommon: 22.4 % of
the participants incorrectly reported the presence of an
ESBL. Synergy between third-generation cephalosporins
and clavulanate was not seen in reference tests and
some participants may have reported the presence of an
ESBL simply because ESBLs are the most common mech-
anism of resistance to third-generation cephalosporins
in K. pneumoniae. However, AmpC-mediated resistance
in K. pneumoniae is not rare and reflects acquisition of
a plasmid-mediated form of the enzyme. AmpC enzymes
do have an extended spectrum of activity and it has
been argued that the established definition of an ESBL,
based mainly on activity against third-generation cepha-
losporins and inhibited by clavulanate, is unreasonably
narrow. Some participants may have used an extended
definition of an ESBL when giving results for the ESBL
test, although this extended definition is controversial
and not widely accepted.
Isolates with plasmid-mediated AmpC beta-lacta-
mase are typically resistant to third-generation
cephalosporins, cefuroxime, penicillin+clavulanate com-
binations, and cefoxitin, but susceptible to cefepime,
cefpirome and carbapenems. They are negative in ESBL
confirmation tests, but synergy is seen with cepha-
losporinboronic acid or cephalosporincloxacillin
tests.
High discrepancy rates were also seen with piperacil-
lintazobactam, 70.9 % of participants reporting the
organism susceptible, 17.4 % intermediate and 11.7 %
resistant. However, it is important to notice that pipera-
cillintazobactam is an extremely difficult substance
to test, and therefore it is difficult to correctly classify
isolates that are borderline. In reference MIC tests, the
organism appeared borderline susceptible/intermediate
to piperacillintazobactam (MIC 816 mg/L). There is
little clinical evidence on whether infections caused by
K. pneumoniae with plasmid-mediated AmpC are treat-
able with piperacillintazobactam when the producers
appear susceptible in vitro, and response will probably
depend on the type and amount of AmpC produced.
Results should, however, be viewed with considerable
caution and it may be that some participants edited
results from susceptible to intermediate or resistant
on this basis. There were no significant problems with
susceptibility testing of this organism against other ref-
erence agents (Table 3.1).
Table 3.1: Klebsiella pneumoniae (0243): Minimum inhibitory concentration (MIC) and intended results reported by the
reference laboratories and the overall concordance of the participating laboratories
Antibiotic agent
MIC range (mg/L) ref. lab. Intended interpretation
from to EUCAST/CLSI Overall concordance (%)
Amikacin 1 2 S 99
Amoxicillin NT* R 100
Ampicillin 128 >128 R 99
Cefotaxime 4 16 R 61
Ceftazidime 32 32 R 74
Ceftriaxone >32 >32 R 59
Ciprofloxacin 16 32 R 99
Gentamicin 0.25 0.5 S 99
Imipenem 0.12 0.12 S 99
Meropenem 0.016 0.03 S 99
Piperacillin** R 79
Piperacillintazobactam 8 16 S 71
Tobramycin 0.5 1 S 98
ESBL Negative 78
* Not tested, result inferred from ampicillin result.
** Not tested, reference MICs were participants results.
S: susceptible; R: resistant; I: intermediate.
14
Table 3.2: Escherichia coli (0244): Minimum inhibitory concentration (MIC) and intended results reported by the
Antibiotic agent
Amikacin 8 16 S 51
Ampicillin 16 128 R 96
Cefotaxime 0.03 0.12 S 99
Ceftazidime 0.12 0.25 S 99
Ceftriaxone 0.125 0.25 S 99
Ciprofloxacin 0.004 0.016 S 99
Gentamicin 16 32 R 93
Imipenem 0.06 0.12 S 99
Meropenem 0.016 0.016 S 99
Piperacillin** S 66
Piperacillintazobactam 2 2 S 99
Tobramycin 32 64 R 98
ESBL Negative 99
** Not tested, reference MICs were participants results.
Table 3.3: Streptococcus pneumoniae (0245): Minimum inhibitory concentration (MIC) and intended results reported by
the reference laboratories and the overall concordance of the participating laboratories
Antibiotic agent
Cefotaxime 99
Meningitis <0.004 <0.004 S 99
Non-meningitis S 99
Ceftriaxone 99
Meningitis <0.04 <0.04 S 99
Non-meningitis S 99
Ciprofloxacin >32 >32 R 95
Clindamycin 0.032 0.064 S 97
Erythromycin 16 16 R 96
Penicillin 98
Meningitis 0.015 0.015 S 99
Non-meningitis S 95
3.2.2 Specimen 0244 Escherichia coli
This specimen consisted of an Escherichia coli with
low-level penicillinase production and borderline sus-
ceptibility to amikacin.
Reference MICs of ampicillin and amoxicillin both varied
from 16 to 128 mg/L (resistant by EUCAST guidelines,
intermediateresistant by CLSI guidelines) and most par-
ticipants reported resistance to both agents (amoxicillin
89 % resistant, ampicillin 96 % resistant). No reference
MIC results are available for piperacillin alone but the
majority of participants reporting an MIC gave results in
the range 416 mg/L (susceptible by EUCAST and CLSI
breakpoints). Among participants, 65.7 % reported sus-
ceptible, 19.3 % intermediate and 15.0 % resistant.
The organism is borderline in susceptibility to amikacin
(MIC 816 mg/L) and would be reported susceptible/
intermediate by EUCAST guidelines and susceptible by
CLSI guidelines. This was reflected in the variable sus-
ceptibility reported by participants (51.4 % susceptible,
31.7 % intermediate, 16.9 % resistant) (Table 3.2).
3.2.3 Specimen 0245 Streptococcus
pneumoniae
This specimen consisted of a Streptococcus pneumoniae
resistant to ciprofloxacin and erythromycin but suscep-
tible to other reference agents tested. There were no
significant problems in susceptibility testing with any of
the reference agents.
Participants were asked if they would use a norfloxacin
screening test with this isolate: 185 participants reported
that they used a 10g disc and all correctly reported the
isolate resistant to this agent. Some 768 participants,
following a variety of guidelines, reported a disc content
value for ciprofloxacin with this specimen; 454 indi-
cated that they used a content of 1g and 313 used 5g.
However, only 429 participants reported a test result.
The results for participants using a disc content of 1g
were: 11 susceptible, 4 intermediate and 137 resistant;
and for those using a disc content of 5g were: 4 suscep-
tible, 3 intermediate and 269 resistant (Table 3.3).
15
3.2.4 Specimen 0246 Enterococcus faecium
This specimen consisted of an Enterococcus faecium
with vanA-mediated resistance to vancomycin and
teicoplanin.
Resistance to vancomycin was obvious and was detected
by 99.6 % of participants. It is common for teicoplanin
MICs to be lower than vancomycin MICs with VanA iso-
lates. The teicoplanin MIC of 8 mg/L is recognised as
resistant with EUCAST breakpoints (S 2, R > 2 mg/L) but
as borderline susceptible with CLSI breakpoints (S 8,
R 32 mg/L). The borderline susceptibility was reflected
in the results returned by participants (7.7 % susceptible,
14.2 % intermediate, 78.1 % resistant). The proportion
of participants reporting teicoplanin susceptible was
much lower with EUCAST-related methods (1 % of 196
participants) than with the CLSI method (10.7 % of 457
participants). Disc diffusion tests with glycopeptides
can be problematic as isolates with borderline resist-
ance may give zone diameters very close to breakpoints.
In order to improve test reliability, some guidelines rec-
ommend incubation for a full 24 hours before reporting
isolates as susceptible, and resistance may be seen only
as small colonies inside zone edges, or fuzzy zone
edges in contrast with the sharp zone edges seen with
susceptible isolates.
Gentamicin mono-therapy is ineffective against entero-
cocci. There is, however, synergism between gentamicin
and beta-lactam agents against enterococci without
mechanisms conferring high-level gentamicin resistance
(usually production of the bi-functional enzyme APH(2)/
AAC(6)). Overall, 20.9 % of participants incorrectly
reported this isolate high-level gentamicin resistant.
This error has been related to the erroneous use of lower
content gentamicin discs than specified in disc diffusion
method guidelines (Table 3.4).
3.2.5 Specimen 0247 Pseudomonas aeruginosa
This specimen consisted of a Pseudomonas aeruginosa
with borderline susceptibility to piperacillintazo-
bactam and tobramycin.
The piperacillintazobactam MIC was 32 mg/L, which
is interpreted as resistant by EUCAST guidelines and
susceptible by CLSI guidelines. As is often the case
with borderline susceptibility, this was reflected in
varied results from participants: 56.6 % reported the
organism resistant, 3.9 % intermediate and 39.5 %
susceptible. The percentage of participants reporting
piperacillintazobactam susceptible was much lower
with the EUCAST-related methods (23.2 % of 211 par-
ticipants) than with the CLSI method (47.4 % of 492
participants).
In reference tests on aminoglycoside agents MICs were
variable. This did not affect categorisation of suscep-
tibility to amikacin and gentamicin and discrepancy
rates were low. Reference MICs of tobramycin (432
mg/L) covered the range of susceptible to resistant by
both EUCAST and CLSI guidelines, and it is likely that
the organism produces an aminoglycoside-modifying
enzyme with low activity against tobramycin. However,
only 4.7 % of participants reported the organism sus-
ceptible, with 32.5 % reporting intermediate and 62.8 %
resistant (Table 3.5).
Table 3.4: Enterococcus faecium (0246): Minimum inhibitory concentration (MIC) and intended results reported by the
Antibiotic agent
Ampicillin 64 64 R 99
High-level gentamicin 4 4 S (not high-level resistance) 79
Teicoplanin 8 8 R/S 78
Vancomycin 64 >128 R 99
Table 3.5: Pseudomonas aeruginosa (0247): Minimum inhibitory concentration (MIC) and intended results reported by
Antibiotic agent
Amikacin 1 8 S 99
Ceftazidime 2 2 S 99
Ciprofloxacin 0.12 0.5 S 99
Gentamicin 32 >128 R 99
Imipenem 1 2 S 97
Meropenem 1 2 S 95
Piperacillintazobactam 32 32 R/S 57
Tobramycin 4 32 S/I/R *
* Reference MICs covered the range of susceptible to resistant by both EUCAST and CLSI.
16
3.2.6 Specimen 0248 Staphylococcus aureus
This specimen consisted of a Staphylococcus aureus,
sequence type 239, resistant to multiple agents. There
were no significant problems with susceptibility test-
ing of this organism against the reference agents (Table
3.6).
3.3 Conclusions
The response to this ninth EARSS/EARS-Net EQA exercise
by the participating laboratories was good, with a high
return rate and very few late responders. Performance
was generally very good and consistent with that seen in
previous EQA exercises. Problems, where experienced,
were related to borderline susceptibility and when
guidelines revealed remaining discrepancies in routine
susceptibility testing.
ECDC would like to thank UK NEQAS, the reference labora-
tories, the members of the EARS-Net Coordination Group
and the country coordinators for the swift distribution
of the strains, and all the participating laboratories for
their efforts and timely response to the exercise.
Table 3.6: Staphylococcus aureus (0248): Minimum inhibitory concentration (MIC) and intended results reported by
Antibiotic agent
Cefoxitin 128 >128 R 99
Ciprofloxacin 32 32 R 98
Clindamycin >128 >128 R 99
Erythromycin >128 >128 R 100
Fusidic acid 0.06 0.12 S 99
Gentamicin >128 >128 R 99
Meticillin NT* R 98
Oxacillin >128 >128 R 99
Penicillin 32 64 R 99
Rifampicin 0.004 0.008 S 99
Teicoplanin 1 2 S 99
Tetracycline >128 >128 R 98
Vancomycin 1 2 S 98
* Not tested, result inferred from oxacillin and cefoxitin results.
17
4.1 Introduction
For correct interpretation of the EARS-Net data on anti-
microbial resistance, accurate background information
is important. Therefore, laboratory and hospital denomi-
nator data are collected and presented in this chapter.
4.2 Methods
Questionnaires (Microsoft Excel files) were sent to
the EARS-Net contact points by June 2011. The con-
tact points distributed the questionnaires to the
participating laboratories and hospitals in their country.
Information was collected on the total number of blood
culture sets processed in the laboratories, and the
number of hospital beds for each participating hospital,
the type of hospital, the bed occupancy and the number
of admissions. The national data managers received the
completed questionnaires, compiled them and produced
the final format suitable for uploading to the European
Surveillance System (TESSy). Laboratories were defined
as reporting denominator data if they provided the
number of blood culture sets performed for one or more
hospitals. Hospitals were defined as reporting denomi-
nator data if they provided the number of beds.
4.3 Participation
Eighteen of the 28 countries reporting antimicrobial
resistance results also returned hospital and labora-
tory denominator data referring to 2010, while for two
countries, hospital and laboratory denominator data
referring to 2009 was available and included in the
analysis. In total, 391 of the 658 laboratories (59.4 %)
and 833 of the 1 173 hospitals (71.0 %) reporting antimi-
crobial susceptibility results for the 20 countries, also
provided denominator data (Figures 4.14.2, and Tables
4.14.3). Some denominator data for laboratories and
hospitals not reporting antimicrobial resistance data, or
reporting zero cases, have been included in Figure 4.1,
but were not included in other parts of the analysis.
4.4 Population coverage
Data on population coverage for antimicrobial resist-
ance data at country level is not reported because of the
inherent limitations of these data. Not all laboratories/
hospitals reporting antimicrobial susceptibility data pro-
vide denominator data, and this will bias the calculation
of country population coverage since only laboratories/
hospitals reporting denominator data can be included.
Secondly, laboratories and hospitals cluster in big cit-
ies and, for this reason, some of the catchment areas
overlap. This could lead to double counts, which would
artificially increase the estimated coverage.
4 EARS-Net laboratory/hospital denominator
data 2010
Table 4.1: Hospital denominator data for 2010
Country
Hospitals reporting
(denominator/AMR
data)
Total number of beds
Proportion of ICU
beds (%)
Annual occupancy
rate (%)
Median length of
stay (days)
IQR length of stay
(days)
Austria* (128/149) 49 761 6 70 4.7 4.2-5.6
Bulgaria (21/22) 10 028 8 74 6.1 5.4-6.6
Cyprus (5/5) 1 333 10 73 5.3 5.3-5.4
Czech Republic (64/72) 37 682 10 71 7.1 6.1-7.9
Estonia (10/11) 4 630 4 77 6.5 5.9-9.0
France (193/202) 124 914 5 83 7.6 6.4-9.2
Germany (45/166) 16 161 5 76 6.8 6.3-7.8
Hungary (67/73) 44 998 2 75 8.3 7.1-10.0
Ireland (55/60) 12 016 3 87 5.6 4.6-7.1
Italy (25/41) 6 946 7 84 - -
Latvia (11/12) 5 135 3 71 6.1 4.1-6.8
Lithuania (22/26) 10 094 4 73 6.9 6.2-8.2
Malta (3/3) 1 273 5 83 11.9 5.4-38.8
Norway (14/49) 4 347 5 84 4.4 4.0-4.7
Poland (33/39) 16 390 2 76 5.5 4.7-6.4
Portugal* (23/25) 10 885 5 79 7.3 5.5-8.6
Romania (6/6) 2 322 8 92 6.6 5.6-6.9
Slovenia (15/15) 7 265 6 71 5.8 4.8-6.5
Spain (39/49) 24 571 4 79 - -
United Kingdom (57/134) 28 182 2 83 5.2 2.9-7.2
* Data from 2009.
18
0 50 100 150 200 250
United Kingdom
Spain
Slovenia
Romania
Portugal*
Poland
Norway
Malta
Lithuania
Latvia
Italy
Ireland
Hungary
Germany
France
Estonia
Czech Republic
Cyprus
Bulgaria
Austria*
Denominator information only
AMR information only
AMR and denominator information
C
o
u
n
t
r
y
Figure 4.1: Number of hospitals (A) and laboratories (B) reporting AMR and/or denominator data in 2010
0 50 100 150 200 250 300 350 400
United Kingdom
Spain
Slovenia
Romania
Portugal*
Poland
Norway
Malta
Lithuania
Latvia
Italy
Ireland
Hungary
Germany
France
Estonia
Czech Republic
Cyprus
Bulgaria
Austria*
Denominator information only
AMR information only
AMR and denominator information
C
o
u
n
t
r
y
Number of hospitals
A)
B)
* Denominator data from 2009
19
4.5 Hospital denominator
information
The total number of hospital beds for hospitals reporting
both AMR and denominator data in different countries
ranged from 1 273 in Malta to 124 914 in France, reflect-
ing the size of the country as well as the rate of
participation to EARS-Net and the rate of response to the
questionnaires. The proportion of ICU beds over total
hospital beds shows wide variation by country, ranging
from 2 % in Hungary, Poland and the United Kingdom,
to 10 % in Cyprus and the Czech Republic. The overall
median length of stay in hospital was 6.3 days with the
lowest median in Norway (4.4 days) and the highest in
Malta (11.9 days). The annual occupancy rate was 75 % or
higher in 13 out of 20 countries (Table 4.1).
4.6 Hospital characteristics
Both the size of a hospital and the level of specialisation
may influence the occurrence of antimicrobial resistance
in the hospital. As can be seen from Table 4.2 and Figure
4.2, the distribution of size and specialisation level of
hospitals varied considerably between the reporting
countries. This does not necessarily reflect different
distributions of the origin of EARS-Net blood cultures
per country, as not all hospitals contribute evenly to the
EARS-Net database. On the other hand, this diversity
can indicate differences in case-mix, which may con-
found comparison of AMR results between countries.
The type of hospital and the size of hospital are not
always linked and it is not rare, especially in smaller
countries, that university hospitals have fewer than 500
beds.
4.7 Laboratory denominator
information
In 2010, the number of blood culture sets processed in
the EARS-Net laboratories responding to the question-
naire was 2 027 480. The median culturing frequency
was 23.8 blood culture sets per 1 000 patient days. The
highest rate was reported by Italy (70.7) and the low-
est by Lithuania (6.4). For the majority of the reporting
countries, there are only minor changes in the number
of blood culture sets taken per 1 000 patient days (Table
4.3) when comparing 2009 data with 2010. However, in
Estonia and Latvia, the total number of blood culture
sets almost doubled from 2009 to 2010, while the United
Kingdom reported an even more substantial increase
accompanied by an increase in the number of report-
ing hospitals. The highest total number of blood culture
sets was reported by Spain (308 872) followed by the
United Kingdom (215 502).
4.8 Conclusions
In summary, the situation for most countries as assessed
from denominator data reported to EARS-Net in 2010
appears stable and similar to 2009. This indicates that
Figure 4.2: Proportion of small, medium and large hospitals per country, based on the number of beds, for all hospital
reporting both antimicrobial resistance data and denominator data in 2010
0 20 40 60 80 100
United Kingdom (57/134)
Spain (39/49)
Slovenia (15/15)
Romania (6/6)
Portugal* (23/25)
Poland (33/39)
Norway (14/49)
Malta (3/3)
Lithuania (22/26)
Latvia (11/12)
Italy (25/41)
Ireland (55/60)
Hungary (67/73)
Germany (45/166)
France (193/202)
Estonia (10/11)
Czech Republic (64/72)
Cyprus (5/5)
Bulgaria (21/22)
Austria* (128/149)
C
o
u
n
t
r
y
Small hospitals
( 200 beds)
Medium-sized hospitals
(201500 beds)
Large hospitals
(> 500 beds)
* Denominator data from 2009
20
the comparison of occurrence of resistance over time
based on EARS-Net data remains feasible, and the
increasing number of countries reporting denominator
data is encouraging.
The BSIs ascertainment is strongly linked to the blood
culture rate. Therefore, the wide range in culture rate
observed in the countries providing denominator data
will have implications for inter-country comparison of
both the incidence rate of infections, which could be
underestimated in some countries, and of the proportion
of resistance. In particular, the proportion of resistance
could be overestimated if there is a frequent use of
empiric therapy also for invasive infections, and if the
cultures are more likely to be performed in patients not
responding to the empiric treatment.
For future improvement of the denominator data col-
lection and analysis, a further increase of the number
of countries reporting denominator data, as well as
an increased number of hospital and laboratories
participating within countries, would be desirable.
Furthermore, an improved estimation of the coverage
of the EARS-Net surveillance, e.g. by using estimations
done at the national level based on knowledge of the
country-specific situation, would also be desirable.
Table 4.3: Laboratory denominator information for 2010
Country
Laboratories reporting
(denominator/AMR data)
Number of hospitals* Total number of blood culture sets
Number of blood culture sets per
1000 patient days
Austria* (36/38) 120 158 529 13.1
Bulgaria (20/21) 21 19 090 7
Cyprus (5/5) 5 14 207 40
Czech Republic (42/45) 62 145 548 15.2
Estonia (10/11) 11 20 593 15.7
France (27/202) 27 289 724 46.5
Germany (10/17) 37 44 101 12.1
Hungary (29/32) 64 84 846 7.3
Ireland (36/41) 51 176 917 46.1
Italy (22/35) 22 119 221 70.7
Latvia (11/11) 11 12 726 9.6
Lithuania (10/11) 22 17 356 6.4
Malta (1/1) 3 6 328 16.4
Norway (9/15) 14 62 532 46.7
Poland (33/35) 33 93 059 20.5
Portugal* (21/22) 23 158 902 50.7
Romania (4/6) 4 28 947 37.3
Slovenia (10/10) 14 50 480 27
Spain (39/41) 39 308 872 43.4
United Kingdom (16/59) 26 215 502 46.1
* Data from 2009.
Table 4.2: Hospital characteristics for 2010
Country
Hospitals reporting
(denominator/AMR data)
Proportion of hospitals by level of care (%)
Tertiary level Secondary level Primary level Other Unknown
Austria* (128/149) 8 23 44 26 0
Bulgaria (21/22) 52 33 5 10 0
Cyprus (5/5) 20 20 40 20 0
Czech Republic (64/72) 38 36 25 0 2
Estonia (10/11) 0 50 20 30 0
France (193/202) 28 72 0 0 0
Germany (45/166) 24 47 24 4 0
Hungary (67/73) 45 30 16 9 0
Ireland (55/60) 17 50 13 17 2
Italy (25/41) 0 8 0 0 92
Latvia (11/12) 45 18 9 27 0
Lithuania (22/26) 45 41 14 0 0
Malta (3/3) 33 33 0 33 0
Norway (14/49) 36 36 29 0 0
Poland (33/39) 39 61 0 0 0
Portugal* (23/25) 57 26 4 13 0
Romania (6/6) 50 17 0 0 33
Slovenia (15/15) 13 47 20 13 7
Spain (39/49) 56 38 5 0 0
United Kingdom (57/134) 37 23 16 18 7
* Data from 2009.
Primary level or district hospital = has few specialties, limited laboratory services; bed capacity ranges from 30 to 200 beds. Secondary level, or provincial hospital
= highly differentiated by function with five to 10 clinical specialties; bed capacity ranging from 200 to 800 beds. Tertiary level or central/regional hospital = highly
specialised staff and technical equipment; clinical services are highly differentiated by function; may have teaching activities; bed capacity ranges from 300 to 1500
beds. Other = hospitals for a specific patient population, like a military hospital, or hospitals with any single specialty, like a burns unit.
Unknown = not available.
21
5.1 Streptococcus pneumoniae
5.1.1 Clinical and epidemiological importance
Streptococcus pneumoniae is a common cause of dis-
ease, especially among young children, elderly people
and patients with compromised immune functions. The
clinical spectrum ranges from upper airway infections,
such as sinusitis, and otitis media to pneumonia and
invasive bloodstream infections and meningitis. Since
S. pneumoniae is the most common cause of pneumonia
worldwide, morbidity and mortality are high and annu-
ally approximately 3 million people are estimated to die
of pneumococcal infections.
Pneumococci carry a variety of virulence factors that
facilitate adherence and transcytosis of epithelial cells.
The cell wall of pneumococci is coated with a viscous
polysaccharide slime layer termed the capsule. This is
the most important virulence factor because it protects
the bacteria from the adhesion of opsonising antibodies
and the destruction by leucocytes. Capsular polysac-
charides are highly diverse and play an important role
in immune evasion. Around 80 different serotypes have
been described. The serotype distribution varies with
age, disease and geographical region. Interestingly,
serotypes most frequently involved in pneumococcal
disease or colonisation in infants are also most fre-
quently associated with antimicrobial resistance.
5.1.2 Resistance mechanisms
Beta-lactam antibiotics bind to cell wall synthesising
enzymes, so-called penicillin-binding proteins (PBPs),
and interfere with the biosynthesis and remodelling of
the bacterial cell wall during cell growth and division.
The mechanism of penicillin resistance in S. pneumoniae
consists of alterations in PBPs, which result in reduced
affinity with this class of antibiotics. Alterations in PBPs
are due to a continuous mutation process that causes
different degrees of resistance proceeding from reduced
susceptibility through low-level clinical resistance
conventionally termed intermediate
i
(I) to full clinical
resistance (R). Although intermediately resistant strains
are clearly less susceptible than sensitive strains, in the
absence of meningitis, infections with these strains are
often successfully treated with high doses of penicillin
or other beta-lactam compounds.
Macrolide, lincosamide and streptogramin (MLS)
antibiotics are chemically distinct, but all bind to a
ribosomal subunit inhibiting the initiation of mRNA bind-
ing and thus act as protein synthesis inhibitors. In S.
i Microorganisms are defined as intermediate by a level of antimicro-
bial activity with uncertain clinical effect. Occasionally, this can be
overcome if antibiotics can be administered at a higher dose and/or
are concentrated at the infected body site.
pneumoniae two resistance mechanisms against MLS
antibiotics have been reported:
The acquisition of an erythromycin ribosomal meth-
ylation gene (erm) results in a post-transcriptional
modification of the 23S subunit of ribosomal RNA,
which blocks the binding of the macrolide to the
ribosome. Once expression of the gene is induced,
this often results in high-level resistance (MICs > 128
mg/L) to macrolide, lincosamide and streptogramin B,
termed MLS
B
resistance.
The acquisition of a macrolide efflux system gene
(mef(E)) results in the excretion of the antimicrobial,
and effectively reduces intracellular erythromycin,
azithromycin and clarithromycin to subinhibitory con-
centrations. In contrast to beta-lactam resistance,
macrolide resistance via these mechanisms (particu-
larly for MLS
B
) provides very high MICs, and cannot be
overcome by increasing the dosages of antibiotics.
Since S. pneumoniae is the most frequent cause of
community-acquired pneumonia and cannot clinically be
easily distinguished from lower airway infections caused
by other pathogens, empirical treatment of community-
acquired lower respiratory infections needs to be active
against pneumococci and should take the local preva-
lence of antimicrobial resistance into account. Habitual
prescription of non-beta-lactam compounds is therefore
typical in countries where penicillin resistance has been
frequently reported. Such reactive prescribing increases
the selection pressure for alternative antibiotics such as
macrolides and novel fluoroquinolones. It is therefore
no surprise to see a dynamic antimicrobial resistance
picture emerge in different European countries. At the
same time, the existence of frequent dual beta-lactam/
macrolides resistance, particularly among serotypes
commonly found in children, assures that in practice the
use of drugs from either of these classes will increase
resistance for the members of the other one, and so the
extended use of macrolides has been considered as a
major driver for the increase in beta-lactam resistance.
Even though a certain small decrease in penicillin resist-
ance had been detected in some countries before the
introduction of the PCV7 vaccine, the widespread use
of this vaccine is an important factor that may have
influenced the decrease in antibiotic resistance levels,
eliminating the infections (and more importantly, the
childrens carriage) of frequent classic resistant sero-
types, 14, 6B, 19F and 23F, all of them covered by PCV7.
The distribution of serotypes in 2010 had slight changes
to that for 2009, and includes serotypes 19A (13.2 %), 1
(12.7 %), 7F (11.3 %), 3 (8.4 %), 12F (5.8 %), 22 (5.5 %) and
6 (5.3 %). Even though only a limited number of coun-
tries have provided serotyping data, ad hoc studies in
other EU countries, like France, Spain, Greece, Norway
5 Antimicrobial resistance in Europe
22
and Portugal, confirm the current generality of this pat-
tern. This shift indicates the effect of the PCV7 vaccine,
selecting the non-vaccine serotypes, and more impor-
tantly the serotype 19A. In fact the classic diversity
pattern of well adapted types of S. pneumoniae clones
in children has been maintained, being these clones
disguised under the PCV7-non-covered 19A capsule
type. At least 10 non-19A serotypes had a 19A capsular
switch. Eventually, the introduction of PCV13 vaccine
(covering 19A) will probably produce a new reduction in
antibiotic resistance in S. pneumoniae.
5.1.3 Results
Penicillin
Twenty-seven countries reported 11 389 isolates of
which 1 056 (9.27 %) were non-susceptible to peni-
cillin; 418 of the 1 056 non-susceptible isolates were
identified as resistant. Greece did not report and
Malta reported fewer than 10 isolates (accordingly no
data are displayed on the maps for these countries)
(Figure 5.1).
The proportion of isolates reported as non-suscep-
tible was: below 1 % in one country, 15 % in nine
countries, 510 % in three countries, 1025 % in 10
countries and 2550 % in four countries (Figure 5.1,
Table 5.1).
Trends for the period 20072010 were calculated for
22 countries. Two countries (Spain and Norway) had
a significant increasing trend with proportions of
non-susceptibility to penicillin in 2010 of 29.8 %, and
3.7 % respectively. These trends were, however, not
significant when considering only data from labora-
tories reporting consistently for all four years (Figure
5.4).
Significant decreasing trends were observed for
five countries: Belgium
i
, the United Kingdom, Italy,
Hungary, and France, with proportions of non-sus-
ceptibility to penicillin of 0.4 %, 3.1 %, 9.2 %, 15 %,
and 27.6 % respectively in 2010. In three of these
countries, (Belgium, Hungary and France) the trends
remained significant even when considering only the
data from laboratories reporting consistently for all
four years (Figure 5.4).
Macrolides
Twenty-seven countries reported 11 439 isolates of
which 1 778 (15.5 %) were non-susceptible to mac-
rolides (Figure 5.2).
The proportion of isolates reported as non-susceptible
ranged from 0.0 % (Lithuania) to 54.5 % (Cyprus), and
was reported as under 5 % in six countries, 510 %
in four countries, 1025 % in ten countries (including
i The proportion of Streptococcus pneumoniae non-susceptible to
penicillin reported by Belgium dropped from 8% in 2008 to < 1% in
2009. This is largely due to the fact that the clinical breakpoints
(CLSI) used to determine SIR have changed. The laboratory that
performs all the susceptibility tests started using the new CLSI
clinical breakpoints in the beginning of 2009. During the entire
EARS-Net surveillance, the same method of susceptibility testing has
been used, only clinical breakpoints have changed.
Figure 5.1: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to penicillin (PNSP) in 2010
Luxembourg
Liechtenstein
Malta
Non-visible countries
to
to
No data reported or less than 10 isolates
Not included
to
to
23
Bulgaria with exactly 25 %), 2550 % in six countries
and over 50 % in one country (Figure 5.2, Table 5.1).
22 countries. Spain, which reported a proportion of
non-susceptibility of 26.7 % in 2010, had a significant
increasing trend, which remained significant even
when considering only data from laboratories report-
ing consistently throughout the period 20072010
(Figure 5.5).
Significant decreasing trends were observed for five
countries: Denmark, France, Hungary, Norway and the
United Kingdom, with proportions of non-susceptibil-
ity to macrolides of 4.2 %, 30.0 %, 24.1 %, 3.8 %, and
4.7 % respectively in 2010. In all these countries, the
trends were significant even when including only data
from laboratories reporting consistently for all four
years (Figure 5.5).
Non-susceptibility to penicillin and macrolides
Twenty-seven countries reported 10 959 isolates
tested for penicillin and macrolides. In 2010, 676
(6.2 %) of these isolates were non-susceptible to both
these antibiotic classes. One country (Malta) reported
fewer than 10 isolates (therefore it is not included in
Figure 5.3).
Proportions of non-susceptibility to penicillin and
macrolides ranged from 0.0 % (Estonia, Lithuania) to
36.4 % (Cyprus), and were reported below 1 % in six
countries, 15 % in eight countries (including Bulgaria
with exactly 5 %), 510 % in five countries 1025 % in
six countries, and 2550 % in two countries (Figure
5.3, Table 5.1).
Trends for 20072010 were calculated for 22 coun-
tries. A significant increase was observed for Ireland
and Spain, which in 2010 reported 12.4 % and 17.2 %,
respectively. For Spain the trend was significant even
when including only laboratories reporting for all four
years. A significant decreasing trend was observed
for three countries (Belgium, France and Hungary)
which reported non-susceptibility to penicillin and
macrolides proportions of 22.7 %, 9.8 %, and 0.3 %,
respectively, in 2010. The trends for these three coun-
tries remained significant even when considering
only the data from laboratories reporting consistently
throughout the period 20072010 (Figure 5.6).
Serogroups
Six countries reported 2 852 S. pneumoniae isolates
with identification of the serotype / serogroup (Table
5.2).
In 2010, serogroups 19 and 1 were the most prevalent
(each accounting for 13 % of the isolates), followed
by serogroup 7 (11 %), serogroup 3 (8 %), serogroup
12 (6 %) as well as serogroups 22 and 6 (both at 5 %)
(Figure 5.7, Table 5.2).
Non-susceptibility to penicillin and macrolides has
been mainly observed in serogroups 19, 6, 14, 15,
9, and 7; (order of decreasing proportion). Single
Table 5.1: Number and proportion of invasive S. pneumoniae isolates penicillin-non-susceptible (PNSP), penicillin-
resistant (PRSP), macrolide non-susceptible (MNSP), single penicillin (PEN), single macrolides (MACR) and
non-susceptible to penicillin and microlides isolates, including 95% confidence intervals (95% CI), reported per
country in 2010
Country
Number of isolates
tested for (PEN/
MACR/both)
%PNSP
(95%CI)
%PRSP
(95%CI)
%MNSP
(95%CI)
%single PEN
(95%CI)
%single MACR
(95%CI)
%DUAL
(95%CI)*
Austria 351/323/310 4.0 (2-7) 2.3 (1-4) 10.5 (7-14) 2.6 (1-5) 8.4 (6-12) 1.9 (1-4)
Belgium 1 797/1 797/1 797 0.4 (0-1) 0.4 (0-1) 24.8 (23-27) 0.1 (0-0) 24.5 (23-27) 0.3 (0-1)
Bulgaria 22/20/20 18.2 (5-40) 18.2 (5-40) 25.0 (9-49) 10.0 (1-32) 20.0 (6-44) 5.0 (0-25)
Cyprus 12/11/11 41.7 (15-72) 33.3 (10-65) 54.5 (23-83) 0.0 (0-28) 18.2 (2-52) 36.4 (11-69)
Czech Republic 288/288/288 4.9 (3-8) 0.0 (0-1) 6.3 (4-10) 3.1 (1-6) 4.5 (2-8) 1.7 (1-4)
Denmark 954/954/954 3.6 (2-5) 0.1 (0-1) 4.2 (3-6) 2.0 (1-3) 2.6 (2-4) 1.6 (1-3)
Estonia 64/45/45 1.6 (0-8) 1.6 (0-8) 4.4 (1-15) 2.2 (0-12) 4.4 (1-15) 0.0 (0-8)
Finland 611/607/596 14.2 (12-17) 1.3 (1-3) 27.5 (24-31) 3.5 (2-5) 16.4 (14-20) 11.1 (9-14)
France 1 127/1 127/1 127 27.6 (25-30) 0.2 (0-1) 30.0 (27-33) 4.9 (4-6) 7.3 (6-9) 22.7 (20-25)
Germany 354/358/349 3.7 (2-6) 0.3 (0-2) 9.2 (6-13) 1.7 (1-4) 7.2 (5-10) 2.0 (1-4)
Hungary 140/133/133 15.0 (10-22) 5.7 (2-11) 24.1 (17-32) 5.3 (2-11) 14.3 (9-21) 9.8 (5-16)
Iceland 37/37/37 5.4 (1-18) 2.7 (0-14) 10.8 (3-25) 0.0 (0-9) 5.4 (1-18) 5.4 (1-18)
Ireland 310/290/290 18.1 (14-23) 4.8 (3-8) 15.5 (12-20) 6.6 (4-10) 3.1 (1-6) 12.4 (9-17)
Italy 229/297/222 9.2 (6-14) 5.2 (3-9) 29.0 (24-34) 3.2 (1-6) 21.6 (16-28) 6.3 (3-10)
Latvia 37/38/37 5.4 (1-18) 5.4 (1-18) 5.3 (1-18) 2.7 (0-14) 2.7 (0-14) 2.7 (0-14)
Lithuania 39/35/34 12.8 (4-27) 7.7 (2-21) 0.0 (0-10) 14.7 (5-31) 0.0 (0-10) 0.0 (0-10)
Luxembourg 46/47/46 13.0 (5-26) 4.3 (1-15) 19.1 (9-33) 6.5 (1-18) 13.0 (5-26) 6.5 (1-18)
Malta 09/11/09 22.2 (3-60) 11.1 (0-48) 18.2 (2-52) 22.2 (3-60) 11.1 (0-48) 0.0 (0-34)
Netherlands 753/898/681 2.0 (1-3) 0.3 (0-1) 6.0 (5-8) 1.3 (1-2) 5.6 (4-8) 0.9 (0-2)
Norway 575/547/546 3.7 (2-6) 0.3 (0-1) 3.8 (2-6) 2.9 (2-5) 3.1 (2-5) 0.7 (0-2)
Poland 75/71/70 24.0 (15-35) 24.0 (15-35) 39.4 (28-52) 1.4 (0-8) 17.1 (9-28) 21.4 (13-33)
Portugal 156/156/156 14.7 (10-21) 14.7 (10-21) 21.8 (16-29) 4.5 (2-9) 11.5 (7-18) 10.3 (6-16)
Romania 13/11/11 30.8 (9-61) 30.8 (9-61) 36.4 (11-69) 0.0 (0-28) 9.1 (0-41) 27.3 (6-61)
Slovenia 232/232/232 15.5 (11-21) 0.4 (0-2) 17.2 (13-23) 9.1 (6-14) 10.8 (7-15) 6.5 (4-10)
Spain 862/862/862 29.8 (27-33) 29.8 (27-33) 26.7 (24-30) 12.6 (10-15) 9.5 (8-12) 17.2 (15-20)
Sweden 960/955/907 3.8 (3-5) 2.3 (1-3) 4.0 (3-5) 2.2 (1-3) 2.5 (2-4) 1.7 (1-3)
United Kingdom 1 336/1 289/1 189 3.1 (2-4) 0.7 (0-1) 4.7 (4-6) 1.3 (1-2) 2.9 (2-4) 1.7 (1-3)
24
non-susceptibility to penicillin in serogroups 19, 9,
14, 23; and single non-susceptibility to macrolides in
serogroups 19, 1, 14, 33, 6, 15, 9, 23, 7, 11, 10, and 3
5.1.4 Conclusions
In 2010, the proportion of S. pneumoniae isolates that
were non-susceptible to penicillin remained generally
stable in Europe with two countries reporting increasing
trends and five reporting decreasing trends. Thirteen of
27 countries reported proportions of non-susceptibility
below 10 %. The proportion of S. pneumoniae non-
susceptible to macrolides declined significantly in five
countries while one country had an increasing trend.
Nevertheless, 10 of 27 countries reported proportions
of non-susceptibility below 10 %. The non-susceptibility
to both penicillin and macrolides was above 10 % in 19
countries out of 27. The lowest proportions of S. pneu-
moniae non-susceptible to penicillin and/or macrolides
were reported by countries of central and northern
Europe, with Finland as the only northern exception.
So far, the serogroup data reported to EARS-Net should
not be regarded as representative for Europe in gen-
eral; only six countries reported 2 852 S. pneumoniae
isolates with serogroup identification. The serogroup
distribution reported in 2010 is similar to the previous
year. Most non-susceptible isolates belong to few sero-
groups, especially serogroups 1, 19, 7 and 3.
Figure 5.2: Streptococcus pneumoniae: proportion of invasive isolates non-susceptible to macrolides in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
25
Figure 5.3: Streptococcus pneumoniae: proportion of invasive isolates with non-susceptibility to penicillin and
macrolides in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
Table 5.2: Distribution of single penicillin (PEN), single macrolides (MACR) and non-susceptibility to penicillin-
macrolides (DUAL), among the most common serogroups reported per country in 2010
S
e
r
o
g
r
o
u
p
s
Belgium Czech Republic Iceland Ireland Slovenia United Kingdom
N
u
m
b
e
r
%

s
i
n
g
l
e

P
E
N
%

s
i
n
g
l
e

M
A
C
R
%

D
U
A
L
N
u
m
b
e
r
%

s
i
n
g
l
e

P
E
N
%

s
i
n
g
l
e

M
A
C
R
%

D
U
A
L
N
u
m
b
e
r
%

s
i
n
g
l
e

P
E
N
%

s
i
n
g
l
e

M
A
C
R
%

D
U
A
L
N
u
m
b
e
r
%

s
i
n
g
l
e

P
E
N
%

s
i
n
g
l
e

M
A
C
R
%

D
U
A
L
N
u
m
b
e
r
%

s
i
n
g
l
e

P
E
N
%

s
i
n
g
l
e

M
A
C
R
%

D
U
A
L
N
u
m
b
e
r
%

s
i
n
g
l
e

P
E
N
%

s
i
n
g
l
e

M
A
C
R
%

D
U
A
L
1 271 0 54 0 36 0 0 0 1 0 0 0 5 20 0 0 17 0 0 0 42 0 0 2
3 122 0 0 0 47 0 2 0 4 0 0 0 13 0 0 0 36 0 0 0 17 0 6 0
4 28 0 0 0 14 0 0 0 2 0 0 0 8 0 0 0 13 0 0 0
5 88 1 0 0
6 68 0 34 0 23 0 9 9 3 0 0 0 23 4 0 39 16 6 0 25 19 0 5 0
7 223 0 1 0 14 0 7 0 4 0 0 0 19 0 0 5 15 0 0 0 48 0 0 0
8 55 0 0 0 5 0 0 0 28 4 0 7 3 0 0 0 21 0 0 0
9 40 0 18 0 27 11 4 0 3 0 0 0 21 38 5 10 21 0 0 0 8 0 0 0
10 38 0 8 0 7 0 0 0 3 0 0 0 5 0 0 0 6 0 0 0
11 24 0 17 0 7 0 0 0 1 0 0 0 7 0 0 0 3 0 0 0 2 0 0 0
12 150 0 2 0 4 0 0 0 8 0 0 0 5 0 0 0
14 34 0 56 0 15 0 13 13 5 0 40 0 14 7 29 50 33 15 67 15 1 0 0 0
15 49 0 51 4 5 0 0 0 9 11 11 22 7 0 0 14 6 0 0 33
18 11 0 0 0 3 0 0 0 2 0 0 0 8 0 0 0 6 0 17 0 3 0 0 0
19 260 0 59 1 17 24 12 6 7 0 0 29 28 0 7 29 23 39 4 22 37 3 3 0
20 4 0 0 0 3 0 0 0 6 17 0 0 1 0 0 0 3 0 0 0
22 104 0 1 0 5 0 0 0 1 0 0 0 20 0 0 0 4 0 0 0 20 0 0 0
23 31 0 23 0 21 5 5 0 2 0 0 0 10 0 0 0 16 25 0 0 8 0 0 0
33 51 0 65 0 3 0 33 0 1 0 0 0 8 0 0 0 5 0 20 0 8 0 13 0
other 142 0 11 1 11 9 0 0 1 0 0 0 17 18 0 0 0 33 0 0 22 9 5 0
Total 1793 0 25 0 267 3 4 2 37 0 5 5 255 7 3 12 224 9 11 7 276 1 2 1
Only countries reporting more that 30 isolates were presented.
26
Figure 5.4: Streptococcus pneumoniae: trends of non-susceptibility to penicillin by country, 20072010
Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trends, respectively. The
asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.
0 5 10 15 20 25 30 35 40
ES (>*)
FR (<)
BG
IE
SI
HU (<)
PT
FI
LU
LT
IT (<*)
IS
CZ
AT
SE
DE
NO (>*)
DK
UK (<*)
NL
EE
BE (<)
C
o
u
n
t
r
y

c
o
d
e
% penicilllin non-susceptibility
2008
2009
2010
2007
27
Figure 5.5: Streptococcus pneumoniae: trends of non-susceptibility to macrolides by country, 20072010
Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trends, respectively.
0 5 10 15 20 25 30 35 40
FR (<)
IT
FI
ES (>)
BG
BE
HU (<)
PT
LU
SI
IE
IS
AT
DE
CZ
NL
UK (<)
EE
DK (<)
SE
NO (<)
LT
C
o
u
n
t
r
y

c
o
d
e
% macrolide non-susceptibility
2008
2009
2010
2007
28
Figure 5.6: Streptococcus pneumoniae: trends of non-susceptibility to penicillin and macrolides by country, 20072010
The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.
0 5 10 15 20 25 30
FR (<)
ES (>)
IE (>*)
FI
PT
HU (<)
LU
SI
IT
IS
BG
DE
AT
CZ
UK
SE
DK
NL
NO
BE (<)
EE
LT
C
o
u
n
t
r
y

c
o
d
e
% Non-susceptibility to penicillin and macrolides
2008
2009
2010
2007
29
Figure 5.7: Distribution of serogroups and the resistance profile of S. pneumoniae isolates per serogroup in 2010
Only countries that reported serogroup information for more than 30 isolates were included in the figure.
* Susceptible to at least penicillin and macrolides.
** Non-susceptible to penicillin and macrolides.
0 2 4 6 8 10 12 14 16
Other
20
18
11
10
4
33
15
5
23
14
8
9
6
22
12
3
7
1
19
Single macrolides non-susceptible
Dual non-susceptible**
Single penicillin non-susceptible
Fully susceptible*
S
e
r
o
g
r
o
u
p
s
Proportion (%)
30
5.2 Staphylococcus aureus
Staphylococcus aureus is a Gram-positive bacterium that
colonises the skin of about 30 % of healthy humans.
Although mainly a harmless coloniser, S. aureus can
cause severe infection. Its oxacillin-resistant form
(meticillin-resistant S. aureus, MRSA) is the most impor-
tant cause of antibiotic-resistant healthcare-associated
infections worldwide. Since healthcare-associated MRSA
infections add to the number of infections caused by
meticillin-susceptible S. aureus, a high incidence of
MRSA adds to the overall burden of infections caused
by this species in hospitals. Moreover, infections with
MRSA may result in prolonged hospital stay and in
higher mortality rates, owing mainly to the increased
toxicity and limited effectiveness of alternative treat-
ment regimens. MRSA is currently the most commonly
identified antibiotic-resistant pathogen in hospitals in
many parts of the world, including Europe, the Americas,
North Africa and the Middle- and Far East.
S. aureus acquires resistance to meticillin and all
other beta-lactam antibiotics through expression of
the exogenous mecA gene, that codes for a variant
penicillin-binding protein PBP2 (PBP2a) with low affin-
ity to beta-lactams, thus preventing the drug-induced
inhibition of cell wall synthesis. The level of meticillin
resistance, as defined by MIC, depends on the amount of
PBP2 production which is influenced by various genetic
factors. Resistance levels of mecA-positive strains can
thus range from phenotypically susceptible to highly
resistant. Upon challenge with beta-lactam antibiotics,
a population of a heterogeneously resistant MRSA strain
may quickly be outgrown by a subpopulation of highly
resistant variants.
5.2.3 Results
Beta-lactams
Twenty-eight countries reported 31 854 isolates of
which 5 555 (17.4 %) were identified as meticillin-
resistant S. aureus (MRSA), with proportions ranging
from 0.5 % to 52.2 % in the reporting countries.
The proportion of isolates that were found to be MRSA
was below 1 % in three countries, 15 % in four coun-
tries, 510 % in one country, 1025 % in 12 countries,
2550 % in seven countries and above 50 % in one
country (Figure 5.8, Table 5.3).
Trends for the period 20072010 were calculated
for 28 countries (Figure 5.9). Significant decreasing
trends were observed for seven countries, even when
considering only data from laboratories consistently
reporting throughout all four years (Figure 5.9). In
2010, these seven countries reported the following
proportions of MRSA: 05 % in one country (Estonia),
510 % in one country case (Austria), 1025 % in three
countries cases (the UK, France, and Ireland) and
2550 % in two countries cases (Cyprus and Greece).
Four countries (Italy, Hungary, Germany, and Slovenia)
reported a significant increasing trend of MRSA pro-
portions (Figure 5.9). The increasing trend remained
significant for three of these countries (Hungary,
Germany, and Slovenia) when looking only at data
from laboratories that reported consistently through-
out the 20072010 period.
Rifampin
Twenty-seven countries reported 22 949 isolates
of which 196 (0.9 %) were identified as resistant
to rifampin, and 22 of these countries reported at
least one resistant isolate. Sixty-five percent of the
rifampin-resistant isolates were also MRSA. The pro-
portion of rifampin resistance was 3.0 % among the
MRSA isolates and 0.4 % among the MSSA isolates.
The proportion of isolates that were resistant was
below 1 % in 21 countries, 15 % in four countries,
510 % in one country, 1025 % in one country (Table
5.3).
Fluoroquinolones
Twenty-six countries reported susceptibility data
for at least one fluoroquinolone in 20 683 isolates.
Among them, 4 825 (23.3 %) were non-susceptible to
fluoroquinolones. Eighteen percent (3 747/20 558) of
all S. aureus isolates reported were non-susceptible
to both meticillin and fluoroquinolones. Eighty-nine
percent of the MRSA (3 747/4 203) were resistant to
fluoroquinolones.
Various fluoroquinolones were tested: ciprofloxacin
(n=13 829), levofloxacin (n=6 484), norfloxacin
(n=364). The number of isolates tested against at
least one of these agents was 20 683.
Linezolid
Twenty-six countries reported susceptibility data for
18 527 isolates of S. aureus, of which 23 (0.1 %) were
non-susceptible.
5.2.4 Conclusions
The proportion of S. aureus isolates found to be MRSA
is stabilising or decreasing in most European countries.
Seven countries reported decreasing trends while four
reported an increasing trend. The countries showing
a more evident and sustained decrease of MRSA pro-
portion are Austria, Cyprus, Estonia, France, Ireland,
Latvia and the UK. Although these observations provide
reasons for optimism, MRSA remains a public health pri-
ority, as the proportion of MRSA is still above 25 % in
eight out of 28 countries, mainly in southern and east-
ern Europe. The occurrence of resistance to rifampin,
which is recommended in combination with other anti-
microbials to treat various staphylococcal infections,
remains low in most European countries.
31
Figure 5.8: Staphylococcus aureus: proportion of invasive isolates resistant to meticillin (MRSA) in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
Table 5.3: Number and proportion of invasive S. aureus isolates resistant to meticillin (MRSA) and rifampin (RIF),
including 95% confidence intervals (95% CI), reported per country in 2010
Country
Meticillin Rifampin
Number of isolates tested % MRSA (95%CI) Number of isolates tested % RIF (95%CI)
Austria 1 813 7.4 (6-9) 1 736 0.2 (0-1)
Belgium 1 057 20.5 (18-23) 246 0.8 (0-3)
Bulgaria 200 19.0 (14-25) 123 7.3 (3-13)
Cyprus 99 32.3 (23-42) 99 0.0 (0-4)
Czech Republic 1 593 13.5 (12-15) 591 1.5 (1-3)
Denmark 1 362 1.3 (1-2) 1 362 0.7 (0-1)
Estonia 145 0.7 (0-4) 33 0.0 (0-11)
Finland 1 094 2.3 (1-3) 1 006 0.3 (0-1)
France 4 859 21.6 (20-23) 4 594 1.1 (1-1)
Germany 1 980 20.9 (19-23) 1 303 0.7 (0-1)
Greece 867 39.2 (36-43) 0 -
Hungary 1 224 30.2 (28-33) 427 0.9 (0-2)
Iceland 65 1.5 (0-8) 1 0.0 (0-98)
Ireland 1 207 23.9 (21-26) 973 0.5 (0-1)
Italy 1 766 36.5 (34-39) 1 798 3.2 (2-4)
Latvia 153 13.7 (9-20) 150 0.7 (0-4)
Lithuania 255 14.1 (10-19) 204 0.0 (0-2)
Luxembourg 104 17.3 (11-26) 62 1.6 (0-9)
Malta 108 48.1 (38-58) 108 0.0 (0-3)
Netherlands 1 564 1.2 (1-2) 1 305 0.2 (0-1)
Norway 1 047 0.6 (0-1) 383 0.3 (0-1)
Poland 526 13.1 (10-16) 213 0.9 (0-3)
Portugal 718 52.2 (49-56) 334 0.6 (0-2)
Romania 46 39.1 (25-55) 45 13.3 (5-27)
Slovenia 476 12.0 (9-15) 457 0.2 (0-1)
Spain 1 986 25.3 (23-27) 1 827 0.5 (0-1)
Sweden 2 856 0.5 (0-1) 1 854 0.1 (0-0.3)
United Kingdom 2 684 21.6 (20-23) 1 715 0.3 (0-1)
32
Figure 5.9: Staphylococcus aureus: trends of resistance to meticillin (MRSA) by country, 20072010
0 10 20 30 40 50 60
PT
MT
EL (<)
RO
IT (>*)
CY (<)
HU (>)
ES
IE (<)
FR (<)
UK (<)
DE (>)
BE
BG
LU
LT
LV
CZ
PL
SI (>)
AT (<)
FI
IS
DK
NL
EE (<)
NO
SE
C
o
u
n
t
r
y

c
o
d
e
% MRSA
2008
2009
2010
2007
33
5.3 Enterococci
Enterococci belong to the normal bacterial flora of
the gastrointestinal tract of humans, other mammals,
birds and reptiles. Enterococci are regarded harmless
commensals, and are even believed to have positive
effects on a number of gastrointestinal and systemic
conditions. However, when the commensal relation-
ship with the host is disrupted, enterococci can cause
invasive diseases. Recently, the recognition of high
risk clones such as those of the polyclonal subcluster
CC17 in Enterococcus faecium, suggests that some par-
ticular strains can act as true pathogens, and not only
as opportunistic commensals. Enterococci can cause
a variety of clinical syndromes, including endocardi-
tis, bacteraemia, meningitis, wound and urinary tract
infections and are associated with peritonitis and intra-
abdominal abscesses. In the United States, three to four
nosocomial bloodstream infections per 10 000 hospital
discharges are caused by enterococci, and contribute to
patient mortality as well as additional hospital stay.
The vast majority (around 80 %) of clinical enterococcal
infections in humans are caused by Enterococcus fae-
calis, while E. faecium accounts for the majority of the
remaining 20 %. Epidemiological data collected over the
last two decades have documented the emergence of
Enterococci as important nosocomial pathogens, exem-
plified by the expansion of a major hospital-adapted
polyclonal subcluster CC17 in E. faecium, and by CC2 and
CC9 E. faecalis. The latter clones have even been isolated
from farm animals. The emergence of particular clones
and clonal complexes of E. faecalis and E. faecium was
paralleled by increases in resistance to glycopeptides
and high-level aminoglycosides. These two antimicro-
bial groups represent the few remaining therapeutic
options for treatment of human infections caused by E.
faecium when resistance has emerged against penicil-
lins. Besides the fact that infections caused by resistant
enterococci are difficult to treat, they are highly tena-
cious and thus easily disseminate in the hospital setting.
Enterococci are intrinsically resistant to a broad range
of antibiotics including cephalosporins, sulphonamides
and low concentrations of aminoglycosides. Patient
safety in hospitals is challenged by the ability of ente-
rococci to acquire additional resistance through the
transfer of plasmids and transposons and recombination
or mutation.
Beta-lactam antibiotics By nature, enterococci have
low susceptibility to many beta-lactam antibiotics as
a consequence of their low-affinity PBPs. Two possible
mechanisms of resistance of enterococci to beta-lactams
have been reported: the production of beta-lactamase,
which is an extremely rare finding; and the overproduc-
tion and modification of PBPs, particularly PBP5, that
causes high-level penicillin resistance in E. faecium.
Complete penicillin resistance in E. faecalis is cur-
rently absent; therefore, the first choice for treatment
of infections caused by this microorganism is still an
aminopenicillin such as ampicillin. In E. faecium, amp-
icillin-resistance has increased significantly during the
last years not the least due to the wide dissemination of
ampicillin-resistant strains belonging to the polyclonal
subcluster CC17.
Aminoglycosides In addition to the intrinsic mecha-
nism of low-level resistance, which causes a low uptake
of the drug, enterococci have acquired genes conferring
high-level resistance to aminoglycosides. High-level
resistance to streptomycin can be mediated by single
mutations within a protein of the 30S ribosomal subu-
nit, the target of aminoglycoside activity. In addition,
different aminoglycoside-modifying enzymes have been
identified, targeting eight different aminoglycosides.
Glycopeptides Vancomycin resistance in enterococci
was first encountered in France and England but showed
the most dramatic increase in the United States and
was attributed to the widespread use of vancomycin in
US hospitals. Whereas vancomycin consumption was
less pronounced in Europe, a closely related glycopep-
tide, avoparcin, was widely used as growth promoter
in animal husbandry from the late-1970s until it was
banned in the EU by 1998. Glycopeptide resistance is
due to the synthesis of modified cell wall precursors
that show a decreased affinity for glycopeptides. Six
phenotypes have been identified of which two have clin-
ical relevance: VanA, with high-level resistance to both
vancomycin and teicoplanin; and VanB, with a variable
level of resistance to only vancomycin. The VanA and
VanB phenotypes, mostly found among E. faecalis and
E. faecium, may be transferred by plasmids and through
conjugative transposition.
5.3.3 Results E. faecalis
High-level aminoglycosides
Twenty-five countries reported 7 533 isolates of which
2 600 (34.5 %) had high-level resistance to gentamicin.
The majority of the countries (21 of 25) reported resist-
ant proportions between 50 % and 20 %. Belgium,
Iceland, Sweden and France reported proportions
below 20 % and only one country (Hungary) reported
resistance proportions above 50 % (Figure 5.10 and
Table 5.4).
Twenty of 26 countries have reported more than 20
isolates per year since 2007 and were included in the
trend analysis for the period 20072010. During the
past four years, a significant increase was observed
only for Italy. The trend for Italy remained significant
when including only data from laboratories reporting
consistently for all four years (Figure 5.11).
Five countries (Germany, Greece, Portugal, Cyprus
and Belgium) reported significant decreasing trends
of high-level aminoglycoside resistance. These trends
were, however, significant only for Greece, Cyprus
and Belgium when considering data from laboratories
reporting consistently for all four years (Figure 5.11).
34
5.3.4 Results E. faecium
Vancomycin
which 410 (7.4 %) were resistant to vancomycin. Only
one country (Luxembourg) reported fewer than 10 iso-
lates (thus it is not shown in Figure 5.12).
One country reported resistance proportions above
25 % (Ireland, with 38.7 %) and five countries reported
resistant proportions between 10 % and 25 %,
while the majority of countries (22 of 28) reported
resistant proportions below 10 %. Eight of these
countries even reported below 1 % (Sweden, Cyprus,
Estonia, Bulgaria, Finland, Malta, Romania and the
Netherlands) (Figure 5.12 and Table 5.4).
Twenty of 28 countries have reported more than 20
isolates per year since 2007 and were included in the
trend analysis for the period 20072010. During the
past four years, a significant increase was observed
only for Latvia. However, the increasing trend was not
significant when considering data from laboratories
Four countries (Greece, the UK, Germany, and Italy)
reported significant decreasing trends of vancomycin
resistance. Considering data from laboratories report-
ing consistently for all four years, the decreasing trend
was only significant for Greece and Italy (Figure 5.13).
5.3.5 Conclusions
High-level aminoglycoside resistance in E. faecalis seems
stable in Europe but at a relatively high level of resist-
ance. The majority of countries reported proportions of
resistant isolates between 25 % and 50 %. However, a
consistent decrease was reported by Germany, Greece,
Portugal, Cyprus and Belgium. Only for Italy was a sig-
nificantly increasing trend observed.
The occurrence of vancomycin resistance in E. faecium
seems to continue to decrease in Europe. In some
countries (Greece, Germany, Italy and UK) the efforts
to control glycopeptide-resistant enterococci are obvi-
ously successful and resulting in a continuous decrease
of proportions of resistant isolates, only one country
reported resistance above 25 %, while most of the coun-
tries reported resistant proportions below 5 %.
Figure 5.10: Enterococcus faecalis: proportion of invasive isolates with high-level resistance to aminoglycosides in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
35
Figure 5.11: Enterococcus faecalis: trends of high-level resistance to aminoglycosides by country, 20072010
0 10 20 30 40 50 60 70 80
HU
IT (>)
CZ
DE (<*)
SI
EL (<)
LT
BG
ES
UK
NO
PT (<*)
NL
AT
IE
EE
CY (<)
BE (<)
FR
SE
C
o
u
n
t
r
y

c
o
d
e
% gentamicin high-level resistance
2008
2009
2010
2007
36
Figure 5.12: Enterococcus faecium: proportion of invasive isolates resistant to vancomycin in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
Table 5.4: Number of invasive E. faecalis and E. faecium isolates and proportion of high-level aminoglycoside-resistant
E. faecalis and vancomycin-resistant E. faecium (%R), including 95% confidence intervals (95% CI), reported per
country in 2010
Country
High-level aminoglycoside resistant E. faecalis Vancomycin-resistant E. faecium
Number of isolates % R (95% CI) Number of isolates % R (95% CI)
Austria 312 32.1 (27-38) 354 4.0 (2-7)
Belgium 187 18.2 (13-24) 79 2.5 (0-9)
Bulgaria 76 40.8 (30-53) 23 0.0 (0-15)
Cyprus 67 23.9 (14-36) 23 0.0 (0-15)
Czech Republic 571 48.0 (44-52) 188 4.8 (2-9)
Denmark 44 36.4 (22-52) 501 1.8 (1-3)
Estonia 22 27.3 (11-50) 23 0.0 (0-15)
Finland 0 - 239 0.0 (0-2)
France 1 409 17.7 (16-20) 540 1.1 (0-2)
Germany 457 46.8 (42-52) 437 8.5 (6-11)
Greece 620 42.6 (39-47) 435 22.5 (19-27)
Hungary 486 51.0 (46-56) 105 1.9 (0-7)
Iceland 15 13.3 (2-40) 16 6.3 (0-30)
Ireland 268 28.7 (23-35) 382 38.7 (34-44)
Italy 380 49.7 (45-55) 412 3.9 (2-6)
Latvia 38 47.4 (31-64) 23 13.0 (3-34)
Lithuania 29 41.4 (24-61) 24 8.3 (1-27)
Luxembourg 4 25.0 (1-81) 9 11.1 (0-48)
Malta 0 - 12 0.0 (0-26)
Netherlands 298 33.6 (28-39) 365 0.5 (0-2)
Norway 218 33.9 (28-41) 135 1.5 (0-5)
Poland 158 36.1 (29-44) 102 7.8 (3-15)
Portugal 184 33.7 (27-41) 67 23.9 (14-36)
Romania 0 - 10 0.0 (0-31)
Slovenia 137 43.1 (35-52) 59 1.7 (0-9)
Spain 959 40.8 (38-44) 471 1.5 (1-3)
Sweden 533 15.2 (12-19) 293 0.0 (0-1)
United Kingdom 61 39.3 (27-53) 250 10.4 (7-15)
37
Figure 5.13: Enterococcus faecium: trends of resistance to vancomycin by country 20072010
The asterisks indicate significant trends in the overall data that were not supported by data from laboratories consistently reporting for all four years.
** Data for Ireland showed a significant increasing trend only for data from laboratories which reported continuously for the last four years.
0 5 10 15 20 25 30 35 40
IE**
PT
EL (<)
LV (>*)
UK (<*)
DE (<*)
CZ
AT
IT (<)
BE
HU
DK
SI
ES
NO
FR
NL
FI
SE
EE
C
o
u
n
t
r
y

c
o
d
e
% vancomycin resistance
2008
2009
2010
2007
38
5.4 Escherichia coli
Escherichia coli is the most frequent Gram-negative
rod isolated from blood cultures in clinical settings. It
is the most frequent cause of bacteraemia, community
and hospital-acquired urinary tract infections, is associ-
ated with spontaneous and surgical peritonitis and with
skin and soft tissue infections due to multiple micro-
organisms, causes neonatal meningitis and is one of
the leading causative agents in food-borne infections
worldwide.
Beta-lactamases hydrolyse the beta-lactam ring of beta-
lactam antibiotics, which is crucial for inhibition of PBPs
in bacteria. In E. coli, resistance to broad-spectrum
penicillins such as ampicillin or amoxicillin is usually
conferred by plasmid coded beta-lactamases mainly
of the TEM type and to a lesser extent of the SHV type,
(whereby TEM-1 accounts for up to 60% of aminopeni-
cillin resistance), while resistance to third generation
cephalosporins is mostly conferred by extended spec-
trum beta-lactamases (ESBLs). In 1982 the first ESBL was
identified during a hospital outbreak of Klebsiella pneu-
moniae in Germany. It was soon understood that single
or multiple amino acid substitutions in the basic struc-
ture of SHV or TEM enzymes can alter their spectrum of
activity and enhance their hydrolysing ability to include
third-generation cephalosporins (in this report referring
to cefotaxime, ceftriaxone and ceftazidime) and mono-
bactams. Most ESBLs can be inhibited by beta-lactamase
inhibitors such as clavulanic acid, sulbactam or tazo-
bactam. More than 200 ESBL variants are known to date.
Most of them belong to four enzyme families: TEM, SHV,
CTX-M and OXA (an overview of identified ESBL types is
given on http://www.lahey.org/studies/). Until 2000,
over 90 % of ESBL resistance was mediated through
TEM or SHV variants. In the late 1980s, new ESBLs of
the CTX-M family emerged first in South America and,
during early 2000s, received global attention. In con-
trast to conventional TEM and SHV ESBLs, most CTX-Ms
(CefoTaximase Munich) display a higher hydrolysing
ability against cefotaxime than ceftazidime (hence their
name). An important part of this global success is due
to the wide dissemination of particular plasmids or
bacterial clones producing ESBL (e.g. CTX-M15). Other
enzymes affecting the susceptibility to third-generation
cephalosporins include plasmid encoded variants from
the chromosomal AmpC beta-lactamases. CMY-2 is the
most widespread enzyme belonging to this group, which
is still less common than ESBL in E. coli in Europe but
frequent in the United States. An important threat that
will require close surveillance in the future is the devel-
opment of carbapenem-resistance in E. coli, mediated by
metallo-beta-lactamases (such as VIM or IMP enzymes,
or the emerging NDM enzyme) and serine-beta-lacta-
mases (such as KPC enzymes), providing resistance
to virtually all available beta-lactam agents. Another
Table 5.5: Number and proportion of invasive E. coli isolates resistant to aminopenicillins, third-generation
cephalosporins, fluoroquinolones, aminoglycosides and multiresistant (%R), including 95% confidence intervals (95%
CI), reported per country in 2010
Country
Aminopenicillins Fluoroquinolones Third-gen. cephalosporins Aminoglycosides Multiresistance*
N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)
Austria 2 928 50.6 (49-52) 2 925 20.9 (19-22) 2 922 7.3 (6-8) 2 915 6.5 (6-7) 2 889 2.0 (2-3)
Belgium 1 957 56.9 (55-59) 1 782 21.5 (20-24) 1 952 5.2 (4-6) 1 584 5.6 (5-7) 1 562 1.0 (1-2)
Bulgaria 142 71.8 (64-79) 151 33.1 (26-41) 153 24.8 (18-32) 152 15.8 (10-23) 150 8.0 (4-14)
Cyprus 137 62.0 (53-70) 138 42.8 (34-51) 139 20.1 (14-28) 138 15.9 (10-23) 138 8.7 (5-15)
Czech Republic 2 481 59.3 (57-61) 2 481 22.7 (21-24) 2 482 10.4 (9-12) 2 449 8.5 (7-10) 2 447 3.4 (3-4)
Denmark 3 412 45.8 (44-47) 3 166 13.7 (13-15) 2 408 7.6 (7-9) 3 412 5.8 (5-7) 2 403 2.4 (2-3)
Estonia 259 37.5 (32-44) 263 8.4 (5-12) 309 5.5 (3-9) 269 5.6 (3-9) 255 2.0 (1-5)
Finland 2 165 33.8 (32-36) 2 550 9.2 (8-10) 2 509 3.7 (3-5) 2 356 3.8 (3-5) 2 315 1.9 (1-3)
France 9 017 54.6 (54-56) 9 007 17.5 (17-18) 9 022 7.2 (7-8) 9 025 7.2 (7-8) 9 000 2.9 (3-3)
Germany 3 022 54.4 (53-56) 3 017 24.8 (23-26) 3 015 8.4 (7-9) 3 021 8.7 (8-10) 3 009 3.6 (3-4)
Greece 1 474 52.3 (50-55) 1 516 24.4 (22-27) 1 507 14.2 (12-16) 1 530 16.5 (15-18) 1 490 9.5 (8-11)
Hungary 1 328 65.3 (63-68) 1 367 36.6 (34-39) 1 383 19.5 (17-22) 1 384 21.2 (19-23) 1 366 15.4 (14-17)
Iceland 100 46.0 (36-56) 95 10.5 (5-19) 104 3.8 (1-10) 104 2.9 (1-8) 95 1.1 (0-6)
Ireland 2 121 66.8 (65-69) 2 117 22.9 (21-25) 2 119 7.7 (7-9) 2 118 9.9 (9-11) 2 112 3.0 (2-4)
Italy 2 288 64.2 (62-66) 2 436 39.2 (37-41) 2 419 21.0 (19-23) 2 609 15.5 (14-17) 2 395 10.5 (9-12)
Latvia 98 50.0 (40-60) 97 14.4 (8-23) 98 12.2 (6-20) 98 11.2 (6-19) 97 6.2 (2-13)
Lithuania 329 55.9 (50-61) 333 13.5 (10-18) 333 8.7 (6-12) 331 14.5 (11-19) 331 5.4 (3-8)
Luxembourg 47 57.4 (42-72) 49 26.5 (15-41) 48 4.2 (1-14) 52 19.2 (10-33) 47 2.1 (0-11)
Malta 192 44.3 (37-52) 192 34.4 (28-42) 192 15.6 (11-22) 192 22.4 (17-29) 192 13.5 (9-19)
Netherlands 3 404 47.6 (46-49) 3 409 13.6 (12-15) 3 387 5.1 (4-6) 3 408 7.2 (6-8) 3 371 1.8 (1-2)
Norway 2 268 38.2 (36-40) 2 267 8.7 (8-10) 2 275 3.7 (3-5) 2 246 4.3 (4-5) 2 236 1.4 (1-2)
Poland 616 60.2 (56-64) 691 25.8 (23-29) 744 7.5 (6-10) 704 9.1 (7-11) 661 3.2 (2-5)
Portugal 862 54.3 (51-58) 808 23.8 (21-27) 814 6.6 (5-9) 865 9.5 (8-12) 785 3.9 (3-6)
Romania 23 82.6 (61-95) 33 24.2 (11-42) 34 20.6 (9-38) 33 12.1 (3-28) 32 6.3 (1-21)
Slovenia 941 48.0 (45-51) 952 19.3 (17-22) 952 6.6 (5-8) 952 8.8 (7-11) 952 3.8 (3-5)
Spain 5 696 64.5 (63-66) 5 696 32.8 (32-34) 5 696 12.1 (11-13) 5 696 14.2 (13-15) 5 696 5.5 (5-6)
Sweden 1 727 34.7 (32-37) 2 130 10.8 (9-12) 3 883 2.6 (2-3) 3 665 2.7 (2-3) 1 925 0.9 (1-1)
United Kingdom 4 429 62.3 (61-64) 4 815 17.3 (16-18) 4 547 9.0 (8-10) 4 929 8.3 (8-9) 4 192 4.0 (3-5)
* Multiresistance defined as resistance to aminopenicillins, third-generation cephalosporins, fluoroquinolones and aminoglycosides.
39
growing family of ESBLs is the OXA- type enzymes that
confer resistance to ampicillin and cephalothin and are
characterised by their high hydrolytic activity against
oxacillin and cloxacillin and the fact that they are poorly
inhibited by clavulanic acid.
Fluoroquinolones interact with DNA gyrase and
topoisomerase IV, which are enzymes that regulate
conformational changes in the bacterial chromosome
during replication and transcription. This interaction
leads to irreversible inhibition of the enzyme activity
followed by DNA fragmentation and eventually to cell
death. Resistance to fluoroquinolones arises through
stepwise mutations in the coding regions of the gyrase
subunits (gyrA and gyrB) and DNA topoisomerase IV
(parC). Accumulation of mutations in several of these
genes increases the MIC in a stepwise manner. Low-level
resistance to fluoroquinolones may also arise through
changes in outer membrane porins or from upregula-
tion of efflux pumps, resulting in lower outer membrane
permeability and higher efflux, respectively. In recent
years, several plasmid-mediated quinolone resistance
mechanisms have also been identified, including the
Qnr proteins, which protect DNA topoisomerases from
quinolone binding, the AAC(6)-Ib-cr enzyme, which
inactivates some fluoroquinolones by acetylation, and
the QepA efflux pump, which effluxes hydrophilic qui-
nolones. These mechanisms are a concern because
of transferability and their frequent association with
CTX-M and CMY-type enzymes inactivating third-gener-
ation cephalosporins.
Aminoglycosides block protein synthesis by binding to
the ribosomes, which are involved in the translation
of RNA into proteins, and are also able to damage the
outer membrane of Gram-negative rods. Resistance to
aminoglycosides can be due to targeted modification
(methylation) of the large ribosomal subunit, which
excludes aminoglycoside molecules, or by aminogly-
coside modifying enzymes that acetylate, adenylate or
phosphorylate their target molecules and thereby neu-
tralise the biologic effect of aminoglycosides.
Table 5.6: Number of invasive E. coli isolates
resistant to third-generation cephalosporins (CREC)
and proportion of ESBL-positive (%ESBL) among
these isolates, as ascertained by the participating
laboratories in 2010
Country
Number of
laboratories
Number of CREC %ESBL
Austria 30 139 89.9
Bulgaria 12 35 91.4
Czech Republic 40 257 87.5
France 40 361 64.8
Germany 12 184 92.9
Ireland 26 133 82
Italy 1 23 100
Lithuania 7 20 95
Poland 20 56 87.5
Portugal 8 34 88.2
Slovenia 9 63 90.5
Spain 41 690 91.3
Only data from laboratories consistently reporting the ESBL test results for all
isolates identified as resistant to third-generation cephalosporins and from
countries with at least 10 of such isolates were selected for the analysis.
Figure 5.14: Escherichia coli: proportion of invasive isolates with resistance to third-generation cephalosporins in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
40
5.4.3 Results
Aminopenicillins
which 28 961 (54.2 %) were resistant to aminopenicil-
lins, and the proportions of resistant isolates in the
reporting countries ranged from 33.8 % to 82.6 %.
The majority of countries (21 of 28) reported resist-
ance proportions from 45.8 % to 66.8 %. Among nine
countries reporting proportions below 50 %, the low-
est proportions were reported by Finland (33.8 %),
Sweden (34.7 %) and Estonia (37.5 %) (Table 5.5).
28 countries. During the past four years, a significant
increase was observed in six of 28 countries. In two of
these countries, the trends were still significant when
considering only data from laboratories reporting con-
sistently for all four years (Figure 5.17).
Among the six countries with increasing trends,
four countries reported proportions of resistance to
aminopenicillin in 2010 of between 60 % and 70 %,
while two countries reported resistance proportions
between 50 % and 60 %.
Two countries (Austria and Estonia) reported
significant decreasing trends of resistance to ami-
nopenicillin, with resistance proportions in 2010 of
50.6 % and 37.5 % respectively (Figure 5.17).
Third-generation cephalosporins
which 4 705 (8.5 %) were resistant to third-generation
cephalosporins, and the proportions of resistant iso-
lates in the reporting countries ranged from 2.6 % to
24.8 %.
Ten of 28 countries reported resistance to third-gen-
eration cephalosporins in more than 10 % of isolates.
Among the 18 countries reporting less than 10 %
resistance, the lowest proportions were reported by
Sweden (2.6 %), Norway (3.7 %), and Finland (3.7 %)
(Table 5.5 and Figure 5.14).
28 countries. During the past four years, a significant
increase was observed in half (14 of 28) of the coun-
tries. In 11 of these, the trends were still significant
ing consistently for all four years (Figure 5.18). Among
the 14 countries with increasing trends for 20072010,
one country reported resistance to third-generation
cephalosporins in more than 20 % of isolates, four
countries reported between 10 % and 20 %, seven
reported between 5 % and 10 %, and two reported
below 5 % (Table 5.5).
Two countries (Portugal and Austria) reported
decreasing trends of resistance to third-generation
cephalosporins. However, only for Portugal was the
trend still significant when considering only data from
laboratories reporting consistently for all four years.
Figure 5.15: Escherichia coli: proportion of invasive isolates with resistance to fluoroquinolones in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
41
Extended-spectrum beta-lactamase (ESBL)
Among E. coli isolates resistant to third-generation
cephalosporins, a large proportion was ascertained
as ESBL-positive by the participating laboratories in
2010. Ten of 12 countries reported between 85 % and
100 % ESBL-positive isolates among isolates resistant
to third-generation cephalosporins (Table 5.6).
Fluoroquinolones
which 11 295 (20.7 %) were resistant to fluoroquinolo-
nes, and the proportions of resistant isolates in the
reporting countries ranged from 8.4 % to 42.8 %.
The majority of countries (16 of 28) reported resist-
ant proportions higher than 20 %. Nine countries
reported between 10 % and 20 %, while three coun-
tries reported below 10 %; Estonia (8.4 %), Norway
(8.7 %), and Finland (9.2 %) (Table 5.5 and Figure 5.15).
28 countries. A significant increase was observed for
eight countries. In five of these countries the trends
were still significant when considering only data from
laboratories reporting consistently during all four
years (Figure 5.19).
Among the eight countries with increasing trends for
20072010, two reported proportions of resistance to
fluoroquinolones above 30%, three reported between
20 % and 30 %, and three countries reported below
20 % (Table 5.5).
Only two countries (Austria and Germany) reported
significant decreasing trends in resistance to fluoro-
quinolones, with resistance proportions of 20.9 % and
24.8 % respectively in 2010 (Figure 5.19).
Aminoglycosides
which 4 911 (8.7 %) were resistant to aminoglycosides,
and the proportions of resistant isolates in the report-
ing countries ranged from 2.7 % to 22.4 %.
Eleven of 28 countries reported proportions of resist-
ant isolates higher than 10 %, and 13 countries
reported between 5 % and 10 %. The lowest propor-
tions (below 5 %) of resistant isolates were reported
by Sweden (2.7 %), Iceland (2.9 %), Finland (3.8 %) and
Norway (4.3 %) (Table 5.5 and Figure 5.16).
28 countries. A significant increase in the proportion
of isolates resistant to aminoglycosides was observed
for ten countries. Among these, four countries
reported proportions higher than 10 %, five coun-
tries reported between 5 % and 10 %, and one country
reported below 5 % (Figure 5.20).
For three countries (Austria, Romania and Portugal)
the proportions of resistance to aminoglycosides
has decreased significantly over the last four years.
For Portugal, the trend remained significant when
considering only data from laboratories consistently
reporting for all four years (Figure 5.20).
Figure 5.16: Escherichia coli: proportion of invasive isolates with resistance to aminoglycosides in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
42
Table 5.7: Overall resistance and resistance combinations among invasive E. coli isolates tested against
aminopenicillins, fluoroquinolones, third-generation cephalosporins and aminoglycosides (n= 49 847) in Europe, 2010
Resistance pattern Number of isolates % of total
Fully susceptible 21 264 42.7
Single resistance (to indicated drug classes)
Aminopenicillins 16 244 32.6
Fluoroquinolones 1 138 2.3
Aminoglycosides 118 0.2
Resistance to two classes of antimicrobial drugs
Aminopenicillins + fluoroquinolones 4 276 8.6
Aminopenicillins + third-generation cephalosporins 804 1.6
Aminopenicillins + aminoglycosides 686 1.4
Fluoroquinolones + aminoglycosides 88 0.2
Resistance to three classes of antimicrobial drugs
Aminopenicillins + fluoroquinolones + aminoglycosides 1 571 3.2
Aminopenicillins + third-generation cephalosporins + fluoroquinolones 1 531 3.1
Aminopenicillins + third-generation cephalosporins + aminoglycosides 132 0.3
Resistance to four classes of antimicrobial drugs
Aminopenicillins + third-generation cephalosporins + fluoroquinolones + aminoglycosides 1 995 4.0
Combined resistance (aminopenicillins, third-generation
cephalosporins, fluoroquinolones and aminoglycosides)
In 2010, 28 countries reported 49 847 isolates tested
for aminopenicillins, third-generation cephalosporins,
fluoroquinolones and aminoglycosides. Of these iso-
lates, 57.3 % were resistant to one or more of these
four antibiotic classes.
The proportion of multiresistant isolates (resistance
to third-generation cephalosporins, fluoroquinolones
and aminoglycosides) was higher than 10 % in three
countries, between 5 % and 10 % in seven countries,
between 1 % and 5 % in seventeen countries, and
below 1 % in one country (Table 5.5 and Figure 5.21).
28 countries. A significant increase in proportions of
multiresistant isolates was observed for 10 countries.
In six of these countries the trends remained signifi-
cant when considering only data from laboratories
Among the 10 countries with significantly increasing
proportions of multiresistant isolates over the period
20072010, four countries reported above 5 % and six
countries reported between 1 % and 5 %. One country
(Austria) had a decreasing trend of proportions of mul-
tiresistance in E. coli in 20072010, yet this was not
significant when considering only the data from labo-
ratories reporting throughout all four years.
The most frequent resistance phenotypes in E. coli
were single aminopenicillin resistance (32.6 %), fol-
lowed by combined resistance to aminopenicillins
and fluoroquinolones (8.6 %). Combined resistance
to all four antimicrobials was reported for 4 % of the
isolates and combined resistance to aminopenicil-
lins, fluoroquinolones and aminoglycosides was 3.2 %
(Table 5.7).
5.4.4 Conclusions
The remarkable and constant Europe-wide decline of
antimicrobial susceptibility in E. coli observed during
recent years continued in 2010. Resistance in E. coli
is increasing in several countries; both multiresist-
ance and resistance to the single antimicrobials under
surveillance.
The highest proportions of resistant E. coli were
reported for aminopenicillins ranging up to 82.6 %.
Irrespective of the high level of resistance, proportions
continue to increase in several countries. The proportion
of reported E. coli isolates resistant to third-generation
cephalosporins has increased significantly during the
last four years in half of the reporting countries and has
decreased in only one country. Among these isolates
resistant to third-generation cephalosporins, a high
proportion (65100 %) was identified as ESBL-positive.
These data indicate that ESBL production is highly prev-
alent in third-generation cephalosporin-resistant E. coli
in European hospitals.
Fluoroquinolone resistance in E. coli continues to
increase as in previous years. The situation becomes
progressively dire and more than half of the countries
are reporting resistance proportions higher than 20 %.
In two countries, however, a decreasing resistance trend
has been observed.
Ten countries had significant increases in the propor-
tion of isolates resistant to aminoglycosides and four of
these countries reported proportions higher than 10 %.
This indicates that resistance to aminoglycosides is
increasing even among the countries already reporting
high levels of resistance.
Combined resistance to all four antimicrobials was
reported in 4% of the isolates and combined resist-
ance to aminopenicillins, fluoroquinolones and
aminoglycosides was 3.2 %. These results show that
antimicrobial susceptibility in E. coli requires continued
close surveillance.
43
Figure 5.17: Escherichia coli: trends of resistance to aminopenicillin by country, 20072010
0 20 40 60 80 100
RO
BG
IE
HU (>)
ES (>)
IT (>*)
UK (>*)
CY
PL
CZ (>*)
LU
BE
LT
FR
DE
PT
EL (>*)
AT (<*)
LV
SI
NL
IS
DK
MT
NO
EE (<)
SE
FI
C
o
u
n
t
r
y

c
o
d
e
% aminopenicillin resistance
2008
2009
2010
2007
44
Figure 5.18: Escherichia coli: trends of resistance to third-generation cephalosporins by country, 20072010
0 5 10 15 20 25 30
BG
IT (>*)
RO
CY
HU (>)
MT
EL (>)
LV
ES (>)
CZ (>)
UK
LT
DE (>*)
IE (>)
DK (>)
PL (>*)
AT (<*)
FR (>)
PT (<)
SI (>)
EE
BE (>)
NL
LU
IS
FI (>)
NO (>)
SE
C
o
u
n
t
r
y

c
o
d
e
% third-generation cephalosporin resistance
2008
2009
2010
2007
45
Figure 5.19: Escherichia coli: trends of resistance to fluoroquinolones by country, 20072010
0 10 20 30 40 50
CY
IT (>*)
HU (>)
MT
BG
ES
LU
PL (>*)
DE
EL (>)
RO
PT (<)
IE
CZ
BE (>*)
AT (<)
SI
FR (>)
UK
LV
DK (>)
NL
LT
SE
IS
FI
NO (>)
EE
C
o
u
n
t
r
y

c
o
d
e
% uoroquinolone resistance
2008
2009
2010
2007
46
Figure 5.20: Escherichia coli: trends of resistance to aminoglycosides by country, 20072010
0 5 10 15 20 25 30 35 40
MT
HU (>)
LU (>*)
EL (>)
CY
BG
IT
LT
ES (>)
RO (<*)
LV
IE
PT (<)
PL
SI (>)
DE (>*)
CZ
UK
NL (>)
FR (>)
AT (<*)
DK (>)
BE
EE
NO (>)
FI
IS
SE
C
o
u
n
t
r
y

c
o
d
e
% aminoglycoside resistance
2008
2009
2010
2007
47
Figure 5.21: Escherichia coli: trends of combined resistance (resistant to fluoroquinolones, third-generation
cephalosporins and aminoglycosides) by country, 20072010
0 5 10 15 20 25
HU (>)
MT
IT (>*)
EL (>)
CY
BG
RO
LV
ES (>)
LT
UK
PT
SI
DE (>*)
CZ
PL (>*)
IE (>)
FR (>)
DK (>)
LU
AT (<*)
EE
FI
NL
NO (>*)
IS
BE
SE
C
o
u
n
t
r
y

c
o
d
e
% combined resistance
2008
2009
2010
2007
48
5.5 Klebsiella pneumoniae
Bacteria of the genus Klebsiella are frequent colonisers
of the gastrointestinal tract in humans but may also be
found on skin, in the oropharynx and upper airways in
hospitalised individuals. Klebsiella pneumoniae is asso-
ciated with opportunistic infections in individuals with
impaired immune systems, such as diabetics, alcoholics
and hospitalised patients with indwelling devices. The
most common sites of infection are the urinary and the
respiratory tract. Organisms can spread rapidly, from
the gastrointestinal tract of patients and via the hands
of hospital personnel to colonise other patients, leading
to nosocomial outbreaks. K. pneumoniae is the second
most frequent cause of Gram-negative bloodstream
infections after Escherichia coli. The mortality rates
of pneumonia caused by K. pneumoniae can be high
even when appropriate antibiotic treatment is given.
However, this also depends on the severity of the under-
lying condition.
Similar to E. coli, K. pneumoniae can be resistant to
multiple antibiotics, and resistance traits are frequently
acquired through plasmids. However, in contrast to
E. coli, K. pneumoniae has a chromosomally encoded
SHV beta-lactamase and is thus intrinsically resist-
ant against aminopenicillins. Moreover, this organism
readily acquires plasmid-mediated resistance determi-
nants. Many novel ESBL variants were initially identified
in K. pneumoniae and were only subsequently found
in E. coli. Since the resistance mechanisms do not
significantly differ from those described for E. coli,
readers should refer to the E. coli chapter for further
details. Carbapenems have been widely used in many
countries due to the increasing rate of ESBL-producing
Enterobacteriaceae with a consequent impact on the
emergence of resistance to these antibiotics, espe-
cially in K. pneumoniae. KPC carbapenemase-producing
clones of K. pneumoniae have been observed in the
United States and Greece and similar strains are now
spreading in several European countries while plasmids
encoding the VIM metallo-carbapenemase are frequent
in K. pneumoniae in Greece. Recently, a new type of
plasmidic carbapenemase, the New Delhi metallo-beta-
lactamase 1 (NDM-1), has been observed in patients
returning from the Indian subcontinent, while the OXA-
48 gene, which codes for an oxacillinase and causes
resistance to penicillin and reduces susceptibility to car-
bapenems but not to cephalosporins, is thus frequently
missed in laboratories using automated AST systems. A
combination of OXA-48 with ESBLs such as CTX-M15 can
occur in Klebsiella and can bring about an extensively
drug-resistant phenotype. Single clones with these
combinations have caused hospital outbreaks in several
European countries.
Figure 5.22: Klebsiella pneumoniae: proportion of invasive isolates resistant to third-generation cephalosporins in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
49
5.5.3 Results
Third-generation cephalosporins
which 3 635 (27.5 %) were resistant to third-generation
cephalosporins.
The proportions of isolates found to be resistant
ranged from 1.7 % (Sweden) to 75.6 % (Bulgaria).
Among the 28 countries, four countries reported pro-
portions below 5 %, four countries reported 510 %,
10 countries reported 1025 %, five countries reported
2550 %, and five countries reported above 50 %
for 25 countries (Figure 5.26). A significant increase
was observed for nine countries. In seven of these
(Austria, France, Estonia, Finland, Greece, Hungary
and Lithuania), the trends were still significant when
None of the countries reported a significant decreasing
trend of proportions of resistance to third-generation
cephalosporins (Figure 5.26).
Extended-spectrum beta-lactamase (ESBL)
Fifteen countries were included in the calculation
of ESBL proportions for K. pneumoniae. Data were
only included from laboratories reporting ESBL test
results for all isolates identified as resistant to
third-generation cephalosporins, and only from coun-
tries with at least 10 of such isolates.
The proportion of K. pneumoniae isolates resistant
to third-generation cephalosporins and ESBL produc-
ers, as ascertained by the participating laboratories,
ranged from 59.3 % to 100 %. The proportion of ESBL
producers was under 75 % in one country, 7585 % in
two countries, 8595 % in six countries, and above
95 % in six countries (Table 5.9).
Fluoroquinolones
Twenty-eight countries reported 13 013 iso-
lates of which 3 706 (28.5 %) were resistant to
fluoroquinolones.
The proportion of isolates found to be resistant
ranged from 0.0 % (Iceland) to 70.9 % (Greece). One
country reported below 1 %, two countries 15 %, five
countries 510 %, ten countries 1025 % (including
Estonia and Slovenia with exactly 25 %), 2550 % in
six countries, and above 50 % in four countries (Figure
5.23, Table 5.8).
23 countries. A significant increase was observed for
eleven countries. In nine of these countries (Austria,
Cyprus, Czech Republic, Estonia, France, Greece,
Hungary, Lithuania and Norway) the trends were still
significant when considering only data from labora-
tories which reported consistently for all four years
(Figure 5.27).
Figure 5.23: Klebsiella pneumoniae: proportion of invasive isolates resistant to fluoroquinolones in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
50
Three countries (Ireland, Sweden and the United
Kingdom) reported significant decreasing trends of
proportions of resistance to fluoroquinolones (Figure
5.27). However, only for Ireland did the trend maintain
its significance when taking into account only data
from laboratories that reported consistently through-
out the period 20072010.
Aminoglycosides
which 3 108 (23.1 %) were resistant to aminoglycosides.
Proportions of isolates found to be resistant ranged
from 0.0 % (Iceland) to 70.6 % (Romania), and were
reported as below 5 % in six countries, 510 % in six
countries, 1025 % in six countries, 2550 % in five
countries and above 50 % in five countries (Figure
5.24, Table 5.8).
25 countries (Figure 5.28). A significant increase was
observed for nine countries. In all of these countries
(Czech Republic, Estonia, Finland, France, Greece,
Hungary, Latvia, Malta and Portugal), the trends were
significant even when considering only data from lab-
oratories reporting consistently for all four years.
One country (United Kingdom) reported a significant
decreasing trend of proportions of isolates resist-
ant to aminoglycosides (Figure 5.28) which remained
significant when looking only at laboratories report-
ing consistently throughout the 20072010 period. In
2010 the proportion of resistance to aminoglycosides
in the UK was 4.9 %.
Carbapenems
which 990 (8.0 %) were resistant to carbapenems. The
majority of the resistant isolates (828; 83.6 %) were
identified in Greece, 111 in Italy, 27 in Hungary and
11 in Cyprus. Twelve countries reported one or more
resistant isolate(s) in 2010.
The proportion of isolates resistant to carbapenems
was 49.1 % in Greece, 16.4 % in Cyprus, 15.2 % in Italy,
5.5 % in Hungary, 1.7 % in Portugal, and below 1 % in
the rest of the reporting countries (Figure 5.25).
23 countries (Figure 5.29). A significant increase was
observed for five countries (Austria, Cyprus, Greece,
Hungary and Italy). For all of these countries, the
trends were significant even when considering only
four years. For Austria, Hungary and Italy, the increase
occurred mainly during the last year (20092010).
One country (Germany) had a significant decreasing
trend of proportions of isolates resistant to carbap-
enems (Figure 5.29). However, this trend was not
significant when including only data from labora-
tories reporting consistently throughout the period
20072010.
Figure 5.24: Klebsiella pneumoniae: proportion of invasive isolates resistant to aminoglycosides in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
51
Combined resistance (third-generation cephalosporins,
fluoroquinolones and aminoglycosides)
Twenty-eight countries reported 12 665 isolates tested
for susceptibility to third-generation cephalosporins,
fluoroquinolones and aminoglycosides. In 2010, 35 %
of isolates were resistant to one or more of the three
considered antibiotic classes. The most frequent pat-
tern of resistance (19 %) was multiresistance (resistant
(R) to all three antibiotic classes) (Table 5.10).
Proportions of multiresistance ranged from 0.0 %
(Iceland) to 57.4 % (Greece), and was reported as
below 1 % in three countries, 15 % in eight countries,
510 % in three countries, 1025 % in seven countries,
2550 % in six countries and above 50 % in one coun-
try (Table 5.8).
25 countries. A significant increase of multiresistance
was observed for nine countries. In seven of these
countries (Czech Republic, Estonia, France, Greece,
Hungary, Latvia, and Lithuania), the trends were
significant even when considering only data from
laboratories reporting consistently for all four years
(Figure 5.30).
Two countries (United Kingdom and Austria) reported
a significant decreasing trend of proportions of mul-
tiresistance (Figure 5.30), with 2010 proportions of
3.6 % and 1.8 %, respectively. Both these trends were
significant even when looking only at data from labo-
ratories reporting throughout the 20072010 period.
5.5.4 Conclusions
Antimicrobial resistance in K. pneumoniae is a pub-
lic health concern of increasing importance in Europe.
In 2010, a high frequency of multidrug-resistant K.
pneumoniae (combined resistance to third-generation
cephalosporins, fluoroquinolones and aminoglycosides)
was evident in southern, central and eastern Europe.
In two thirds of the reporting countries, the propor-
tions of resistance to third-generation cephalosporins
and fluoroquinolones was higher than 10 %, and more
than one third of the countries reported proportions
higher than 25 %. The majority of isolates resistant to
third-generation cephalosporins were also resistant to
fluoroquinolones and aminoglycosides, which indicates
that combined resistance was common. Proportions of
multiresistance above 10 % were reported by half of the
countries.
The occurrence of carbapenem-resistant K. pneumoniae
has increased dramatically in a number of countries. In
2009, carbapenem resistance in K. pneumoniae was only
established in Greece. In 2010, in addition to Greece,
an increasing trend of carbapenem-resistant K. pneu-
moniae was also observed in Austria, Cyprus, Hungary
and Italy. This increasing trend is a particularly worry-
ing phenomenon as carbapenems are some of the few
effective antimicrobials available for the treatment of
infections caused by bacteria producing extended-spec-
trum beta-lactamases and resistance to carbapenems
leaves very few therapeutic options.
Figure 5.25: Klebsiella pneumoniae: proportion of invasive isolates resistant to carbapenems in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
52
Figure 5.26: Klebsiella pneumoniae: trends of resistance to third-generation cephalosporins by country, 20072010
0 10 20 30 40 50 60 70 80
BG
EL (>)
LV
LT (>)
CZ
IT (>*)
HU (>)
CY
SI
FR (>)
EE (>)
PT
DE (>*)
AT (>)
MT
DK
ES
UK
IE
NL
LU
FI (>)
IS
NO
SE
C
o
u
n
t
r
y

c
o
d
e
% third-generation cephalosporin resistance
2008
2009
2010
2007
53
Figure 5.27: Klebsiella pneumoniae: trends of resistance to fluoroquinolones by country, 20072010
0 10 20 30 40 50 60 70 80
EL (>)
CZ (>)
LV
BG
HU (>)
CY (>)
IT (>*)
LT (>)
EE (>)
SI
PT (>*)
FR (>)
AT (>)
MT
DE
ES
DK
LU
IE (<)
UK (<*)
NO (>)
NL
SE (<*)
FI
IS
C
o
u
n
t
r
y

c
o
d
e
2008
2009
2010
2007
54
Figure 5.28: Klebsiella pneumoniae: trends of resistance to aminoglycosides by country, 20072010
0 10 20 30 40 50 60 70 80
BG
EL (>)
LV (>)
LT
HU (>)
CZ (>)
IT
EE (>)
SI
PT (>)
CY
FR (>)
MT (>)
DE
ES
IE
NL
LU
DK
AT
UK (<)
FI (>)
NO
SE
IS
C
o
u
n
t
r
y

c
o
d
e
2008
2009
2010
2007
55
Figure 5.29: Klebsiella pneumoniae: trends of resistance to carbapenems by country, 20072010
Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The
0 10 20 30 40 50
EL (>)
CY (>)
IT (>)
HU (>)
PT
AT (>)
SI
NL
SE
CZ
FR
UK
BG
DE (<*)
DK
EE
ES
FI
IE
LT
LV
MT
NO
C
o
u
n
t
r
y

c
o
d
e
% carbapenem resistance
2008
2009
2010
2007
56
Figure 5.30: Klebsiella pneumoniae: trends of combined resistance (third-generation cephalosporins, fluoroquinolones
and aminoglycosides) by country, 20072010
Only countries that reported 20 isolates or more per year were included. The symbols > and < indicate significant increasing and decreasing trend, respectively. The
0 10 20 30 40 50 60
EL (>)
LV (>)
BG
HU (>)
CZ (>)
LT (>)
IT (>*)
CY
SI
EE (>)
FR (>)
PT (>*)
DE
DK
MT
ES
NL
UK (<)
LU
IE
AT (<)
FI
NO
SE
IS
C
o
u
n
t
r
y

c
o
d
e
2008
2009
2010
2007
57
Table 5.8: Number and proportion of invasive K. pneumoniae isolates resistant to fluoroquinolones, third-generation
cephalosporins, aminoglycosides and multiresistant (%R), including 95% confidence intervals (95% CI), reported per
country in 2010
Country
Fluoroquinolones Third-gen. cephalosporins Aminoglycosides Multiresistance*
N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)
Austria 720 18.2 (15-21) 720 12.6 (10-15) 720 5.6 (4-7) 716 1.8 (1-3)
Belgium 144 12.5 (8-19) 143 12.6 (8-19) 133 2.3 (0-6) 132 0.8 (0-4)
Bulgaria 126 52.4 (43-61) 127 75.6 (67-83) 127 68.5 (60-76) 126 43.7 (35-53)
Cyprus 67 38.8 (27-51) 67 34.3 (23-47) 67 19.4 (11-31) 67 19.4 (11-31)
Czech Republic 1 263 55.1 (52-58) 1 263 48.2 (45-51) 1 245 46.7 (44-49) 1 244 35.9 (33-39)
Denmark 673 11.3 (9-14) 559 10.6 (8-13) 799 6.1 (5-8) 557 5.4 (4-8)
Estonia 64 25.0 (15-37) 81 17.3 (10-27) 66 25.8 (16-38) 63 15.9 (8-27)
Finland 401 2.5 (1-5) 397 4.0 (2-6) 372 3.8 (2-6) 368 1.4 (0-3)
France 1 527 21.8 (20-24) 1 542 17.8 (16-20) 1 542 17.7 (16-20) 1 527 14.8 (13-17)
Germany 478 14.9 (12-18) 478 12.8 (10-16) 478 10.5 (8-14) 478 7.5 (5-10)
Greece 1 676 70.9 (69-73) 1 686 74.6 (72-77) 1 687 61.7 (59-64) 1 668 57.4 (55-60)
Hungary 504 42.9 (38-47) 512 45.9 (42-50) 514 47.9 (43-52) 502 37.8 (34-42)
Iceland 24 0.0 (0-14) 27 3.7 (0-19) 27 0.0 (0-13) 24 0.0 (0-14)
Ireland 318 8.2 (5-12) 318 8.5 (6-12) 318 6.9 (4-10) 318 2.2 (1-4)
Italy 696 38.5 (35-42) 701 46.5 (43-50) 735 29.1 (26-33) 685 26.3 (23-30)
Latvia 63 52.4 (39-65) 64 54.7 (42-67) 64 54.7 (42-67) 63 49.2 (36-62)
Lithuania 80 36.3 (26-48) 81 50.6 (39-62) 81 51.9 (40-63) 80 32.5 (22-44)
Luxembourg 33 9.1 (2-24) 33 6.1 (1-20) 32 6.3 (1-21) 32 3.1 (0-16)
Malta 57 15.8 (7-28) 57 12.3 (5-24) 57 12.3 (5-24) 57 5.3 (1-15)
Netherlands 644 7.0 (5-9) 641 7.2 (5-9) 644 6.5 (5-9) 638 3.8 (2-6)
Norway 476 7.4 (5-10) 479 2.1 (1-4) 471 1.7 (1-3) 468 1.1 (0-2)
Poland 221 33.0 (27-40) 232 39.7 (33-46) 231 31.2 (25-38) 209 23.0 (17-29)
Portugal 211 23.7 (18-30) 215 15.8 (11-21) 231 19.5 (15-25) 204 10.3 (6-15)
Romania 17 29.4 (10-56) 17 70.6 (44-90) 17 70.6 (44-90) 17 23.5 (7-50)
Slovenia 196 25.0 (19-32) 196 22.4 (17-29) 196 23.0 (17-29) 196 17.9 (13-24)
Spain 1 161 13.6 (12-16) 1 161 10.2 (9-12) 1 161 8.7 (7-10) 1 161 4.7 (4-6)
Sweden 405 4.7 (3-7) 700 1.7 (1-3) 642 1.2 (1-2) 364 0.8 (0-2)
United Kingdom 768 7.4 (6-10) 743 9.7 (8-12) 797 4.9 (4-7) 701 3.6 (2-5)
* Multiresistance defined as being resistant to third-generation cephalosporins, fluoroquinolone and aminoglycosides.
Table 5.9: Number of invasive K. pneumoniae isolates
resistant to third-generation cephalosporins (CRKP)
and proportion ESBL-positive (% ESBL) among
these isolates, as ascertained by the participating
laboratories in 2010
Country
Number of
laboratories
Number of CRKP %ESBL
Austria 27 73 78.1
Bulgaria 13 77 100
Czech Republic 43 609 86.4
France 19 65 87.7
Germany 6 32 96.9
Ireland 12 27 59.3
Italy 10 69 81.2
Latvia 5 15 93.3
Lithuania 7 35 100
Netherlands 6 13 92.3
Poland 21 92 98.9
Portugal 7 22 90.9
Romania 3 12 100
Slovenia 5 44 97.7
Spain 32 119 88.2
Only data from laboratories consistently reporting ESBL test results for all
isolates identified as resistant to third-generation cephalosporins and from
countries with at least 10 of such isolates were included in the analysis.
Table 5.8a: Number and proportion of invasive
K.pneumoniae isolates resistant to carbapenems and
confidence intervals (95% CI) per country in 2010
Country
Carbapenems
N %R (95%CI)
Austria 509 0.6 (0-2)
Belgium 116 0.0 (0-3)
Bulgaria 126 0.0 (0-3)
Cyprus 67 16.4 (8-27)
Czech Republic 1103 0.1 (0-1)
Denmark 491 0.0 (0-1)
Estonia 66 0.0 (0-5)
Finland 391 0.0 (0-1)
France 1432 0.1 (0-0)
Germany 464 0.0 (0-1)
Greece 1687 49.1 (47-51)
Hungary 491 5.5 (4-8)
Iceland 13 0.0 (0-25)
Ireland 301 0.0 (0-1)
Italy 731 15.2 (13-18)
Latvia 63 0.0 (0-6)
Lithuania 43 0.0 (0-8)
Luxembourg 33 0.0 (0-11)
Malta 57 0.0 (0-6)
Netherlands 640 0.3 (0-1)
Norway 448 0.0 (0-1)
Poland 238 0.0 (0-2)
Portugal 116 1.7 (0-6)
Romania 14 0.0 (0-23)
Slovenia 195 0.5 (0-3)
Spain 1161 0.0 (0-0)
Sweden 655 0.3 (0-1)
United Kingdom 677 0.1 (0-1)
58
Table 5.10: Overall resistance and resistance combinations among invasive K. pneumoniae isolates tested against
fluoroquinolones, third-generation cephalosporins and aminoglycosides (n= 12 665) in Europe, 2010
Fully susceptible 8 297 65.5
Single resistance (to indicated drug classes)
Fluoroquinolones 478 3.8
Third-generation cephalosporins 297 2.3
Third-generation cephalosporins + fluoroquinolones 552 4.4
Third-generation cephalosporins + aminoglycosides 270 2.1
Third-generation cephalosporins + fluoroquinolones + aminoglycosides 2 452 19.4
59
5.6 Pseudomonas aeruginosa
Pseudomonas aeruginosa is a non-fermenting Gram-
negative bacterium that is ubiquitous in aquatic
environments in nature. It is an opportunistic patho-
gen for plants, animals and humans, and is a major and
dreaded cause of infection among hospitalised patients
with localised or systemic impairment of immune
defences, being a common cause of hospital-acquired
pneumonia (including ventilator-associated pneumonia),
bloodstream and urinary tract infections. Because of its
ubiquity, its enormous versatility and intrinsic tolerance
to many detergents, disinfectants and antimicrobial
compounds, it is difficult to control P. aeruginosa in
hospitals and institutional environments. Moreover, P.
aeruginosa is a frequent cause of skin infections such
as folliculitis and otitis externa among recreational and
competitive swimmers. In patients with cystic fibrosis, P.
aeruginosa causes severe bacterial complication leading
to chronic colonisation and intermittent exacerbation of
the condition with, for example, bronchiolitis and acute
respiratory distress syndrome. Finally, P. aeruginosa is
commonly found in burns units, and in these locations it
is almost impossible to eradicate colonising strains with
classic infection control procedures.
5.6.2 Resistance mechanism
P. aeruginosa is intrinsically resistant to the major-
ity of antimicrobial compounds due to its selective
ability to exclude various molecules from penetrating
its outer membrane. The antibiotic classes that remain
active include some fluoroquinolones (e.g. ciprofloxacin
and levofloxacin), aminoglycosides (e.g. gentamicin,
tobramicin and amikacin), some beta-lactams (pip-
eracillintazobactam, ceftazidime, cefipime and
carbapenems) and colistin. Resistance in P. aeruginosa
is acquired through one or more of several mechanisms:
mutational modification of antibiotic targets such as
topoisomerases or ribosomal proteins, which confer
resistance to fluoroquinolones and aminoglycosides,
respectively;
mutational derepression of the chromosomally
coded AmpC beta-lactamase, that can confer resist-
ance to penicillins and cephalosporins active against
pseudomonas;
mutational loss of outer membrane proteins prevent-
ing the uptake of antimicrobial substances such as
carbapenems;
mutational upregulation of efflux systems, that can
confer resistance to beta-lactams, fluoroquinolones
and aminoglycosides; and
acquisition of plasmid-mediated resistance genes
coding for various beta-lactamases and aminoglyco-
side-modifying enzymes that can confer resistance
to various beta-lactams including carbapenems (e.g.
metallo-beta-lactamases) and aminoglycosides.
Figure 5.31: Pseudomonas aeruginosa: proportion of invasive isolates resistant to piperacillintazobactam in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
60
5.6.3 Results
Piperacillintazobactam
Twenty-eight countries reported 8 203 iso-
lates of which 1 322 (16.1 %) were resistant to
piperacillintazobactam. One country reported fewer
than 10 isolates and was therefore excluded from the
map (Figure 5.31).
from 1.1 % (Sweden) to 62.5 % (Romania) and were
reported less than 5 % in five countries, 510 % in
seven countries, 1025 % in eleven countries, 2550 %
in four countries and above 50 % in one country (Figure
5.31, Table 5.11).
22 countries. A significant increase in resistance was
observed for France, which in 2010 reported a propor-
tion of resistance to piperacillintazobactam of 20.3 %.
This increasing trend remained significant even when
including only data from laboratories reporting con-
sistently throughout the period 20072010 (Figure
5.36).
Ceftazidime
which 1 103 (13.6 %) were resistant to ceftazidime. One
country (Estonia) reported fewer than 10 isolates and
therefore was not included in the map (Figure 5.32).
from 0.0 % (Luxembourg) to 60.0 % (Romania), and
was reported as less than 5 % in seven countries,
510 % in nine countries, 1025 % in nine countries
and 2550 % in two countries, and over 50 % in one
country. (Figure 5.32, Table 5.11).
for 22 countries. A significant increasing trend was
observed for France, which in 2010 reported a propor-
tion of resistance to ceftazidime of 12.7 %. This trend
remained significant even when including only data
from laboratories reporting consistently throughout
the period 20072010. A significant decreasing trend
was observed for the Czech Republic, Italy, Portugal
and Germany (where proportions of resistance in 2010
were 28.5 %, 17.7 %, 12.0 % and 8.1 % respectively).
However, this trend remained significant only for the
Czech Republic and Italy when including only data
from laboratories reporting consistently throughout
the four years (Figure 5.37).
Fluoroquinolones
Twenty-eight countries reported 8 434 isolates of which
1 878 (22.3 %) were resistant to fluoroquinolones.
from 4.3 % (Netherlands) to 55.6 % (Romania) and was
reported as less than 5 % in two countries, 510 % in
four countries, 1025 % in sixteen countries, 2550 %
in five countries, and above 50 % in one country
Figure 5.32: Pseudomonas aeruginosa: proportion of invasive isolates resistant to ceftazidime in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
61
for 21 countries. No country reported a significant
increase in proportions of resistance to fluoroquinolo-
nes. A significant decreasing trend was observed for
Greece, Germany, Ireland and Slovenia, which in 2010
reported proportions of fluoroquinolone resistance
of 45.7 %, 18.4 %, 10.6 % and 9.5 %, respectively. In
three of these countries (Greece, Ireland and Slovenia)
the trends were significant even when including only
four years (Figure 5.38).
Aminoglycosides
which 1 485 (17.8 %) were resistant to aminoglycosides.
from 0.0 % (Iceland) to 50.0 % (Romania), and was
reported as below 1 % in three countries, 15 % in
five countries, 510 % in two countries, 1025 % in
eleven countries (including Austria with exactly 10 %),
2550 % in six countries and exactly 50 % in one coun-
try (Figure 5.34, Table 5.11).
Trends for the period 20072010 were calculated for 22
countries. One country (Malta) reported a significant
increasing trend with a proportion of aminoglycoside
resistance of 31.0 % in 2010 (Figure 5.39). This increas-
ing trend remained significant even when examining
data from laboratories which reported consistently
throughout the 20072010 period.
Significant decreasing trends were observed for four
countries (Greece, Lithuania, Cyprus and the UK). For
all of these, the trends remained significant even when
sistently for all four years (Figure 5.39). In 2010, these
four countries reported the following proportions of
resistance to aminoglycosides: Greece with 41.8 %,
Lithuania with 12.9 %, Cyprus with 10.4 %, and the UK
with 1.9 %.
Carbapenems
which 1 510 (17.9 %) were resistant to carbapenems.
from 0.0 % (Iceland) to 70.0 % (Romania) and was
reported as below 1 % in one country, 15 % in five
countries, 510 % in four countries, 1025 % in thir-
teen countries, 2550 % in four countries and above
50 % in one country (Figure 5.35, Table 5.11).
22 countries. Two countries (Hungary and France)
reported a significant increasing trend with propor-
tions of resistance to carbapenems in 2010 of 24.9 %
and 17.8 %, respectively. However, this increasing
trend remained significant only in Hungary when
Figure 5.33: Pseudomonas aeruginosa: proportion of invasive isolates resistant to fluoroquinolones in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
62
Figure 5.34: Pseudomonas aeruginosa: proportion of invasive isolates resistant to aminoglycosides in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
Significant decreasing trends were observed for
Greece, Italy, the Czech Republic, Germany and Norway,
with proportions of resistance to carbapenems in 2010
under 5 % in Norway, 1025 % in Germany, the Czech
Republic and Italy, and over 40 % in Greece. In the
Czech Republic and Norway, the trend is still significant
ing consistently all four years (Figure 5.40). Combined
resistance (piperacillintazobactam, ceftazidime, fluo-
roquinolones, aminoglycosides and carbapenems)
Twenty-eight countries reported 8 485 isolates tested
for susceptibility to at least three antibiotic classes
among piperacillintazobactam, ceftazidime, fluo-
roquinolones, aminoglycosides and carbapenems.
In 2010, 33 % of the isolates were resistant to one
or more of the five considered antibiotic classes,
while 15 % were resistant to three or more. The most
common pattern was resistance to all five antibiotic
classes (5.2 %) (Table 5.12).
Proportions of multiresistance (resistant (R) to at least
three of the five considered antibiotic classes) were:
below 1 % in two countries, 15 % in five countries
(including two countries with exactly 5 %), 510 %
in eight countries, 1025 % in nine countries and
2550 % in four countries (including Romania with
exactly 50 %) (Table 5.11).
22 countries. Significant increasing trends of multire-
sistance were observed for two countries (Malta and
France), which in 2010 reported proportions of mul-
tiresistance of 28.6 % and 14.7 % respectively (Figure
5.41).
Significant decreasing trends of multiresistance have
been observed for three countries (Greece, Italy and
Germany), which in 2010 reported proportions of mul-
tiresistance of 42.5 %, 20.8 %, and 9.5 %, respectively.
Only for Greece did the trend remain significant when
including only data from laboratories consistently
reporting all four years (Figure 5.41).
5.6.4 Conclusions
High proportions of resistance of P. aeruginosa to
antimicrobials have been reported by many countries
especially in southern and eastern Europe. Combined
resistance is also common with 15 % of the isolates
resistant to at least three antimicrobial classes (multire-
sistance) and with 5 % of the isolates resistant to all five
antimicrobial classes under surveillance. Despite the
high proportions of resistance, the situation appears
generally stable in Europe with few countries reporting
significant increasing or decreasing trends of resistance
to different antimicrobial agents.
63
Figure 5.35: Pseudomonas aeruginosa: proportion of invasive isolates resistant to carbapenems in 2010
Luxembourg
Liechtenstein
Malta
to
to
Not included
to
to
Table 5.11: Number and proportion of invasive P. aeruginosa isolates resistant to piperacillintazobactam,
fluoroquinolones, ceftazidime, aminoglycosides, carbapenems and multiresistant (%R), including 95% confidence
intervals (95% CI), reported per country in 2010
Country
Piperacillin
tazobactam
Fluoroquinolones Ceftazidime Aminoglycosides Carbapenems Multiresistance*
N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI) N %R (95%CI)
Austria 503 8.7 (6-12) 500 15.6 (13-19) 461 7.6 (5-10) 500 10.0 (8-13) 473 14.4 (11-18) 503 8.5 (6-11)
Belgium 121 11.6 (6-19) 121 12.4 (7-20) 120 6.7 (3-13) 94 13.8 (8-22) 130 4.6 (2-10) 121 5.0 (2-10)
Bulgaria 41 14.6 (6-29) 42 21.4 (10-37) 37 18.9 (8-35) 42 19.0 (9-34) 42 31.0 (18-47) 42 14.3 (5-29)
Cyprus 48 18.8 (9-33) 47 17.0 (8-31) 48 16.7 (7-30) 48 10.4 (3-23) 48 29.2 (17-44) 48 14.6 (6-28)
Czech Republic 510 27.6 (24-32) 510 40.8 (36-45) 509 28.5 (25-33) 510 32.4 (28-37) 510 16.5 (13-20) 510 29.4 (25-34)
Denmark 361 3.9 (2-6) 360 6.1 (4-9) 358 2.8 (1-5) 375 1.3 (0-3) 356 3.1 (2-5) 360 1.9 (1-4)
Estonia 7 14.3 (0-58) 9 11.1 (0-48) 8 12.5 (0-53) 9 11.1 (0-48) 41 22.0 (11-38) 9 11.1 (0-48)
Finland 270 7.0 (4-11) 280 11.1 (8-15) 281 2.8 (1-6) 270 4.1 (2-7) 275 9.8 (7-14) 281 5.3 (3-9)
France 1 125 20.3 (18-23) 1 181 22.8 (20-25) 1 009 12.7 (11-15) 1 121 18.6 (16-21) 1 186 17.8 (16-20) 1191 14.7 (13-17)
Germany 315 15.6 (12-20) 315 18.4 (14-23) 309 8.1 (5-12) 315 10.2 (7-14) 311 12.5 (9-17) 315 9.5 (7-13)
Greece 998 38.9 (36-42) 985 45.7 (43-49) 967 40.2 (37-43) 994 41.8 (39-45) 999 43.1 (40-46) 981 42.5 (39-46)
Hungary 596 13.8 (11-17) 629 26.7 (23-30) 635 10.6 (8-13) 634 29.0 (26-33) 635 24.9 (22-28) 636 17.8 (15-21)
Iceland 12 8.3 (0-38) 12 16.7 (2-48) 12 8.3 (0-38) 12 0.0 (0-26) 12 0.0 (0-26) 12 8.3 (0-38)
Ireland 218 8.3 (5-13) 218 10.6 (7-15) 216 6.0 (3-10) 219 4.6 (2-8) 216 6.5 (4-11) 219 5.0 (3-9)
Italy 429 21.2 (17-25) 467 31.0 (27-35) 407 17.7 (14-22) 467 23.3 (20-27) 509 22.0 (18-26) 467 20.8 (17-25)
Latvia 21 19.0 (5-42) 21 19.0 (5-42) 21 9.5 (1-30) 21 28.6 (11-52) 21 14.3 (3-36) 21 9.5 (1-30)
Lithuania 31 6.5 (1-21) 31 16.1 (5-34) 31 9.7 (2-26) 31 12.9 (4-30) 30 26.7 (12-46) 31 9.7 (2-26)
Luxembourg 25 8.0 (1-26) 25 20.0 (7-41) 25 0.0 (0-14) 25 8.0 (1-26) 25 8.0 (1-26) 25 8.0 (1-26)
Malta 42 35.7 (22-52) 42 23.8 (12-39) 42 14.3 (5-29) 42 31.0 (18-47) 42 23.8 (12-39) 42 28.6 (16-45)
Netherlands 374 4.3 (2-7) 375 4.3 (2-7) 372 2.7 (1-5) 376 2.4 (1-4) 371 2.7 (1-5) 375 1.1 (0-3)
Norway 163 3.1 (1-7) 165 3.6 (1-8) 162 2.5 (1-6) 167 0.6 (0-3) 168 1.2 (0-4) 167 0.6 (0-3)
Poland 163 29.4 (23-37) 158 27.8 (21-36) 151 21.9 (16-29) 145 29.7 (22-38) 167 24.6 (18-32) 163 23.3 (17-31)
Portugal 215 16.7 (12-22) 203 21.2 (16-27) 216 12.0 (8-17) 216 13.9 (10-19) 203 16.3 (11-22) 217 13.8 (10-19)
Romania 8 62.5 (24-91) 9 55.6 (21-86) 10 60.0 (26-88) 10 50.0 (19-81) 10 70.0 (35-93) 10 50.0 (19-81)
Slovenia 95 14.7 (8-23) 95 9.5 (4-17) 95 5.3 (2-12) 93 8.6 (4-16) 89 19.1 (12-29) 95 9.5 (4-17)
Spain 749 6.4 (5-8) 749 24.8 (22-28) 749 7.5 (6-10) 749 18.2 (15-21) 749 17.8 (15-21) 749 12.3 (10-15)
Sweden 272 1.1 (0-3) 317 6.3 (4-10) 311 2.9 (1-5) 278 0.0 (0-1) 337 4.5 (3-7) 329 0.3 (0-2)
United Kingdom 491 3.9 (2-6) 568 6.7 (5-9) 533 4.9 (3-7) 575 1.9 (1-3) 493 6.5 (4-9) 566 2.1 (1-4)
* Multiresistance defined as being resistant to three or more antibiotic classes among piperacillintazobactam, ceftazidime, fluoroquinolones, aminoglycosides and
carbapenems.
64
Figure 5.36: Pseudomonas aeruginosa: trends of resistance to piperacillintazobactam by country, 20072010
0 10 20 30 40 50
EL
MT
PL
CZ
IT
FR (>)
CY
PT
DE
SI
HU
AT
IE
LU
FI
LT
ES
NL
DK
UK
NO
SE
C
o
u
n
t
r
y

c
o
d
e
% piperacillintazobactam resistance
2008
2009
2010
2007
65
Figure 5.37: Pseudomonas aeruginosa: trends of resistance to ceftazidime by country, 20072010
0 10 20 30 40 50
EL
CZ (<)
PL
IT (<)
CY
MT
FR (>)
PT (<*)
HU
LT
DE (<*)
AT
ES
IE
SI
UK
SE
FI
DK
NL
NO
LU
C
o
u
n
t
r
y

c
o
d
e
% ceftazidime resistance
2008
2009
2010
2007
66
Figure 5.38: Pseudomonas aeruginosa: trends of resistance to fluoroquinolones by country, 20072010
0 10 20 30 40 50
EL (<)
CZ
IT
HU
ES
MT
FR
PT
LU
DE (<*)
CY
LT
AT
FI
IE (<)
SI (<)
UK
SE
DK
NL
NO
C
o
u
n
t
r
y

c
o
d
e
2008
2009
2010
2007
67
Figure 5.39: Pseudomonas aeruginosa: trends of resistance to aminoglycosides by country, 20072010
0 10 20 30 40 50
EL (<)
CZ
MT (>)
PL
HU
IT
FR
ES
PT
LT (<)
CY (<)
DE
AT
SI
LU
IE
FI
NL
UK (<)
DK
NO
SE
C
o
u
n
t
r
y

c
o
d
e
2008
2009
2010
2007
68
Figure 5.40: Pseudomonas aeruginosa: trends of resistance to carbapenems by country, 20072010
** For Czech Republic there is a decreasing trend, but the drop in 2010 was caused by the adoption of the new EUCAST breakpoints.
0 10 20 30 40 50
EL (<*)
CY
LT
HU (>)
PL
MT
IT (<*)
EE
SI
FR (>*)
ES
CZ** (<)
PT
AT
DE (<*)
FI
UK
IE
SE
DK
NL
NO (<)
C
o
u
n
t
r
y

c
o
d
e
% carbapenem resistance
2008
2009
2010
2007
69
Figure 5.41: Pseudomonas aeruginosa: trends of combined resistance (R to three or more antibiotic classes among
piperacillintazobactam, ceftazidime, fluoroquinolones, aminoglycosides and carbapenems) by country, 20072010
0 10 20 30 40 50
EL (<)
CZ
MT (>)
PL
IT (<*)
HU
FR (>*)
CY
PT
ES
LT
DE (<*)
SI
AT
LU
FI
IE
UK
DK
NL
NO
SE
C
o
u
n
t
r
y

c
o
d
e
2008
2009
2010
2007
70
Table 5.12: Overall resistance and resistance combinations among invasive Pseudomonas aeruginosa isolates
tested against at least three antibiotic classes among piperacillintazobactam, ceftazidime, fluoroquinolones,
aminoglycosides and carbapenems (n= 8 485) in Europe, 2010
Fully susceptible (to the tested drugs) 5 684 67
Resistance to one class of antimicrobial drugs
Fluoroquinolones 351 4.1
Carbapenems 300 3.5
Ceftazidime 115 1.4
Piperacillin(tazobactam) 60 0.7
Piperacillin(tazobactam) + ceftazidime 138 1.6
Fluoroquinolones + carbapenems 88 1
Piperacillin(tazobactam) + fluoroquinolones 30 0.4
Piperacillin(tazobactam) + carbapenems 29 0.3
Piperacillin(tazobactam) + aminoglycosides 23 0.3
Aminoglycosides + carbapenems 17 0.2
Ceftazidime + carbapenems 17 0.2
Fluoroquinolones + ceftazidime 8 0.1
Ceftazidime + aminoglycosides 4 0
Fluoroquinolones + aminoglycosides + carbapenems 168 2
Piperacillin(tazobactam) + fluoroquinolones + aminoglycosides 74 0.9
Piperacillin(tazobactam) + ceftazidime + carbapenems 49 0.6
Piperacillin(tazobactam) + fluoroquinolones + ceftazidime 35 0.4
Fluoroquinolones + ceftazidime + aminoglycosides 32 0.4
Piperacillin(tazobactam) + fluoroquinolones + carbapenems 19 0.2
Fluoroquinolones + ceftazidime + carbapenems 18 0.2
Piperacillin(tazobactam) + aminoglycosides + carbapenems 12 0.1
Piperacillin(tazobactam) + ceftazidime + aminoglycosides 9 0.1
Ceftazidime + aminoglycosides + carbapenems 4 0
Resistance to four classes of antimicrobial drugs
Piperacillin(tazobactam) + fluoroquinolones + aminoglycosides + carbapenems 145 1.7
Fluoroquinolones + ceftazidime + aminoglycosides + carbapenems 115 1.4
Piperacillin(tazobactam) + fluoroquinolones + ceftazidime + aminoglycosides 81 1
Piperacillin(tazobactam) + fluoroquinolones + ceftazidime + carbapenems 61 0.7
Piperacillin(tazobactam) + ceftazidime + aminoglycosides + carbapenems 23 0.3
Resistance to five classes of antimicrobial drugs
Piperacillin(tazobactam) + fluoroquinolones + ceftazidime + aminoglycosides + carbapenems 445 5.2
71
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72
73
Annex 1:
Technical notes
73
75
Technical notes for chapter 4
Number of blood culture sets
The total number of blood culture sets was defined as
the number of blood samples, not the number of patients
sampled.
Patient days
If patient days were not available at hospital level, these
were calculated by:
Number of beds * (annual occupancy / 100) * 365
Type of hospitals
Since hospital categorisation was always intricate, more
specific definitions from WHO have been implemented
to make the categorisation of hospitals easier.
Primary level, often referred to as a district hospital
or first-level referral: A hospital with few specialities,
mainly internal medicine, obstetrics-gynecology, pae-
diatrics, and general surgery, or only general practice;
limited laboratory services are available for general, but
not for specialised pathological analysis; the bed capac-
ity ranges from 30 to 200 beds.
Secondary level, often referred to as provincial hospital:
A hospital highly differentiated by function with five to
10 clinical specialities; bed capacity ranging from 200 to
800 beds.
Tertiary level, often referred to as central, regional or
tertiary-level hospital: A hospital with highly specialised
staff and technical equipment, e.g., cardiology, ICU and
specialised imaging units; clinical services are highly
differentiated by function; the hospital may have teach-
ing activities; bed capacity ranges from 300 to 1 500
beds. A fourth category was for hospitals with a single
specialty.
Averaged variables
Annual occupancy rate and length of stay were averaged
per country. In these totals only laboratory/hospital
questionnaires that provided information on all vari-
ables needed for the specific formula were included.
Technical notes for chapter 5
Resistance trend analysis
Resistance trends were calculated for the last four years.
To determine significant trends over time, the Cochrane
Armitage test was used, excluding countries reporting
fewer than 20 isolates per year. To exclude possible
biases in the trend analyses, a sensitivity analysis was
done, per country, to determine the sensitivity of the
trend analysis for using the complete dataset, versus a
subset from laboratories reporting all four years. In the
graphs, trends were indicated in the following way:
using <* if decreasing or >* if increasing when sig-
nificant trends were only identified in the complete
dataset; and
using < if decreasing or > if increasing when a sig-
nificant trend was detected in both the subset and the
complete dataset.
European maps showing resistance levels
To be included in the maps of Europe displaying the
resistance proportions per country, for all pathogen
antimicrobial combinations under surveillance by
EARS-Net, a country had to report results for at least 10
isolates.
77
Annex 2:
Country summary sheets
77
79
Explanation to the country
summary sheets
General information about EARS-Net
participating laboratories and hospitals
Table 1 gives the number of laboratories and isolates
reported by year and by pathogen under EARS-Net sur-
veillance for the period 20032010.
Antibiotic resistance 20032010
Table 2 provides information on the proportion of inva-
sive bacterial isolates non-susceptible (I+R) or resistant
(R) to the antibiotics or antibiotic classes mentioned in
the EARSS protocols. When interpreting the results in
Table 2, always check the number of isolates provided
in Table 1.
Demographic characteristics
Table 3 gives the proportional distribution of the iso-
lates reported by source, gender, age, and hospital
department, and the proportion of resistance within the
different groups, for the period 20092010.
The abbreviations used in this table stand for:
PNSP = penicillin-non-susceptible S. pneumoniae;
MRSA = meticillin-resistant S. aureus;
FREC = fluoroquinolone-resistant E. coli;
VRE = vancomycin-resistant E. faecalis or E. faecium;
CRKP = third-generation cephalosporin-resistant
K. pneumoniae; and
CRPA = carbapenem-resistant P. aeruginosa.
If the number of isolates in a certain category accounts
for less than 0.5% of the total number of isolates, the %
total is set at <1.
PNSP at laboratory level/MRSA, FREC and CRKP
at hospital level
Figures 1, 2, 3 and 4 show the local variation in the pro-
portions of PNSP by laboratory and of MRSA, FREC and
CRKP by hospital. These figures are based on data from
2009 and 2010, only including the laboratories and hos-
pitals that reported at least five isolates in these two
years. The total number of laboratories or hospitals, the
minimum, maximum, median, first and third quartile of
the proportion of resistance is displayed in a box in the
figures.
80
Austria
General information about EARS-Net participating laboratories
Antibiotic resistance from 2003 to 2010
Table 1: Number of laboratories and number of isolates reported for the period 20032010
Year
S. pneumoniae S. aureus E. coli Enterecocci K. pneumoniae P. aeruginosa
Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates Labs Isolates
2003 20 163 20 871 21 985 19 327 - - - -
2004 28 257 30 1453 31 1862 28 604 - - - -
2005 31 298 32 1481 33 2058 30 568 7 89 8 77
2006 32 293 33 1640 33 2483 33 699 30 434 31 405
2007 35 322 34 1577 34 2545 33 688 33 445 33 411
2008 38 380 38 1899 38 2985 38 864 38 583 38 510
2009 38 379 38 1794 38 2625 36 825 37 622 36 525
2010 35 375 39 1840 39 2937 39 944 39 722 39 504
Table 2: Proportion (%) of antibiotic non-susceptible isolates
Pathogens by antimicrobial classes 2003 2004 2005 2006 2007 2008 2009 2010
Streptococcus pneumoniae
Penicillin R 1 1 <1 <1 2 <1 3 2
Penicillin RI 9 5 5 5 5 5 5 4
Macrolides RI 13 13 15 13 13 12 14 11
Staphylococcus aureus
Oxacillin/Meticillin R 15 14 14 9 11 8 6 7
Escherichia coli
Aminopenicilins R 41 46 49 53 53 50 49 51
Aminoglycosides R 5 6 6 8 8 7 6 6
Fluoroquinolones R 14 17 19 22 26 23 20 21
Third-gen. cephalosporins R 2 3 4 7 9 7 8 7
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Enterococcus faecalis
Aminopenicilins RI 1 <1 1 2 2 2 1 2
HL Gentamicin R 33 23 29 29 30 21 31 32
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
Enterococcus faecium
Aminopenicilins RI 85 85 85 89 82 91 88 92
HL Gentamicin R 22 22 30 21 28 19 31 42
Vancomycin R <1 <1 1 <1 2 2 4 4
Aminoglycosides R - - 3 5 5 6 4 6
Fluoroquinolones R - - 11 8 13 12 8 18
Third-gen. cephalosporins R - - 6 6 8 8 8 13
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 13 8 6 8 6 9
Ceftazidime R - - 7 9 5 6 6 8
Carbapenems R - - 10 15 12 11 9 14
81
Table 3: Selected details on invasive isolates from the reporting period 2009 and 2010
Characteristic
S. pneumoniae
n=703
S. aureus
n=3 552
E. coli
n=5 541
E. faecalis
n=1 083
E. faecium
n=664
K. pneumoniae
n=1 335
P. aeruginosa
n=986
% total % PNSP % total % MRSA % total % FREC % total % VRE % total % VRE % total % CRKP % total % CRPA
Isolate source
Blood 97 4 100 7 100 21 100 1 100 4 100 10 100 11
CSF 3 13 - - <1 67 - - - - <1 33 <1 0
Gender
Male 56 5 58 7 41 25 61 1 60 5 54 13 59 11
Female 44 3 41 6 58 18 38 0 39 3 45 7 39 12
Unknown <1 0 1 13 1 29 1 0 1 0 1 10 1 21
Age (years)
04 6 5 1 4 1 6 3 0 1 0 1 18 1 0
519 4 3 2 7 1 11 <1 0 1 0 1 0 1 0
2064 41 4 33 5 26 20 31 1 36 5 32 12 31 16
65 and over 49 4 64 8 72 21 66 0 62 4 66 10 67 10
Hospital department
ICU 19 7 10 9 8 25 15 1 27 6 13 13 16 18
Internal med. 50 4 47 6 54 19 39 1 34 3 41 9 34 9
Surgery 2 0 9 14 6 18 9 1 11 4 9 12 9 9
Other 27 4 29 6 28 24 31 0 25 4 33 11 37 13
Unknown 2 0 5 4 4 18 6 0 4 4 5 3 4 5
PNSP: penicillin-non-susceptible S. pneumoniae; MRSA: meticillin-resistant S. aureus; FREC: fluoroquinolone-resistant E. coli; VRE: vancomycin-resistant
Enterococcus; CRKP: third-generation cephalosporin-resistant K. pneumoniae; CRPA: carbapenems-resistant P. aeruginosa.
82
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
AT0/1 (2]11
AT008 (1]6
AT028 (6]37
AT031 (2]13
AT012 (2]1/
AT02/ (2]20
AT025 (/]/3
AT027 (2]23
AT023 (1]12
AT021 (1]1/
AT016 (1]19
AT010 (2]38
AT019 (1]26
AT006 (1]/1
AT001 (1]//
AT005 (1]65
AT003 (0]22
AT017 (0]1/
AT01/ (0]6
AT022 (0]8
AT007 (0]35
AT002 (0]36
AT009 (0]13
AT015 (0]18
AT030 (0]22
AT036 (0]9
AT0/2 (0]6
AT037 (0]20
AT018 (0]11
AT020 (0]7
AT033 (0]9
AT03/ (0]5
AT026 (0]25
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
AT038 (7]18
AT038M (/]11
AT032v (2]7
AT005I (1]5
AT005C (1]5
AT027L (27]155
AT02/ (6]35
AT033F (3]19
AT017T (6]/1
AT007F (2]1/
AT018M (11]80
AT031w (10]77
AT03/L (8]62
AT0326 (1]8
AT023F (1]8
AT021S (2]16
AT032L (1]8
AT006S (11]89
AT010 (2]17
AT002A (2/]206
AT015w (1]9
AT0320 (1]9
AT020w (8]75
AT032 (2]19
AT020I (1]10
AT0330 (8]83
AT005K (2]21
AT0/1L (2]21
AT010h (2]21
AT02/v (7]7/
AT009S (1]11
AT026S (/]/6
AT025K (12]139
AT008S (1]13
AT011P (1]13
AT0036 (2]27
AT02/6 (2]29
AT029U (1]15
AT005l (7]111
AT021v (/]66
AT026Z (1]17
AT001 (2]35
AT0166 (1]18
AT017K (2]/2
AT010F (3]66
AT001L (3]71
AT007w (1]2/
AT028k (/]98
AT023K (1]25
AT019P (/]102
AT006I (1]27
AT023S (2]55
AT001S (2]55
AT012w (1]28
AT005Z (1]31
AT037P (2]63
AT005L (1]33
AT01/k (2]66
AT007K (3]135
AT016w (2]103
AT035h (1]56
AT010k (0]7
AT030w (0]19
AT010L (0]6
AT0306 (0]26
AT015S (0]21
AT30uL (0]11
AT022A (0]5
AT030v (0]7
AT032} (0]7
AT015M (0]9
AT0/2T (0]11
AT022S (0]7
AT0/2 (0]/3
AT012T (0]21
AT011w (0]//
AT036h (0]9
AT005h (0]12
AT015A (0]/0
AT036u (0]7
AT005S (0]9
AT022 (0]2/
AT023L (0]8
AT030h (0]11
AT009k (0]22
AT009w (0]1/
AT0120 (0]19
AT007v (0]9
AT005k (0]11
AT0116 (0]5
AT022K (0]16
AT012h (0]11
AT003M (0]10
AT022k (0]5
AT032k (0]13
AT009K (0]9
AT032P (0]6
AT022L (0]19
AT012Z (0]8
AT006M (0]7
AT030L (0]5
AT0/0A (0]17
AT030Z (0]5
AT036 (0]13
AT030F (0]28
AT019L (0]6
AT008 (0]10
Figure 1: Proportion (%) of penicillin-non-susceptible
S.pneumoniae by laboratory (20092010)
Figure 2: Proportion (%) of meticillin-resistant
S.aureus by hospital (20092010)
N laboratories 33
Minimum 0
First quartile 0
Median 0
Third quartile 8.3
Maximum 18.2
N hospitals 107
Minimum 0
First quartile 0
Median 3.6
Third quartile 9.5
Maximum 38.9
Austria
83
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
AT015u (/]5
AT006M (6]12
AT005I (/]8
AT023L (9]19
AT005C (/]9
AT030L (3]7
AT030Z (/]10
AT005l (76]191
AT005h (11]28
AT011P (8]21
AT0116 (3]8
AT009w (/]11
AT022K (6]18
AT006 (2]6
AT022A (2]6
AT006U (5]15
AT012h (/]12
AT005S (9]27
AT01/k (23]7/
AT029U (9]29
AT0306 (12]39
AT005} (/]13
AT035h (32]105
AT038M (8]27
AT037P (26]88
AT032P (2]7
AT020I (10]35
AT008K (2]7
AT030h (8]28
AT022k (3]11
AT006I (3]11
AT012w (11]/2
AT022L (16]62
AT033F (11]/3
AT0330 (35]137
AT0120 (6]2/
AT015M (3]12
AT017K (13]5/
AT011w (15]63
AT009k (5]21
AT002A (58]2//
AT027L (61]266
AT001L (26]11/
AT020w (23]101
AT006S (31]137
AT031w (2/]109
AT019P (2/]11/
AT018M (23]111
AT030w (6]29
AT026Z (6]29
AT007K (32]156
AT025K (52]258
AT0236 (1]5
AT0166 (5]25
AT030v (/]20
AT007F (3]15
AT015A (15]75
AT030F (15]76
AT0/2 (11]56
AT038 (5]26
AT001S (23]121
AT005Z (9]/8
AT007w (5]27
AT0/1L (19]109
AT028k (35]205
AT021v (11]67
AT0326 (3]19
AT0/0A (5]32
AT021S (2]13
AT017T (8]53
AT010h (5]3/
AT0/2T (2]1/
AT022 (3]21
AT007L (1]7
AT0036 (5]35
AT02/v (1/]99
AT026S (13]92
AT016w (20]1/5
AT010F (10]7/
AT023S (13]97
AT032 (2]15
AT032v (3]23
AT005K (5]39
AT001 (5]39
AT005k (2]16
AT012Z (1]8
AT30uL (2]16
AT036h (2]17
AT03/L (10]87
AT005L (7]62
AT010k (2]19
AT019L (1]10
AT022S (1]10
AT036 (2]20
AT008S (3]31
AT02/6 (5]52
AT010L (2]21
AT003M (1]11
AT008A (1]11
AT02/ (5]57
AT012T (2]23
AT010 (6]70
AT0320 (1]12
AT009K (1]1/
AT015w (1]17
AT007v (2]35
AT015S (1]23
AT023K (2]/8
AT0360 (0]7
AT009S (0]18
AT032k (0]1/
h
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p
l
a

c
c
d
c
s
0 25 50 75 100
AT038M (3]9
AT0/0A (2]6
AT005S (2]6
AT0306 (2]6
AT0036 (3]10
AT011P (2]7
AT037P (3]11
AT009K (2]8
AT02/6 (2]8
AT035h (5]23
AT019P (5]23
AT02/v (3]1/
AT005l (1/]67
AT018M (/]22
AT005k (1]6
AT020w (7]//
AT005K (2]13
AT033F (2]15
AT007K (/]32
AT03/L (2]16
AT015A (2]16
AT016w (/]3/
AT002A (10]88
AT005Z (1]9
AT030F (1]9
AT027L (7]6/
AT0330 (3]28
AT017T (1]10
AT005L (1]11
AT001L (3]38
AT006S (/]52
AT031w (2]31
AT025K (/]63
AT017K (1]16
AT021v (1]17
AT010F (1]20
AT011w (1]2/
AT028k (1]61
AT0/1L (0]18
AT001 (0]7
AT023S (0]2/
AT001S (0]33
AT0166 (0]8
AT0120 (0]5
AT006I (0]6
AT005} (0]5
AT021S (0]5
AT015M (0]6
AT029U (0]8
AT032 (0]8
AT0/2 (0]2/
AT007v (0]7
AT01/k (0]7
AT010 (0]8
AT012w (0]6
AT023K (0]1/
AT008S (0]6
AT036 (0]7
AT026S (0]10
AT032P (0]5
AT020I (0]1/
AT005h (0]5
AT009k (0]8
AT0/2T (0]5
AT022L (0]13
Figure 3: Proportion (%) of fluoroquinolone-resistant
E.coli by hospital (20092010)
Figure 4: Proportion (%) of third-generation
cephalosporin-resistant K.pneumoniae by hospital
(20092010)
N hospitals 111
Minimum 0
First quartile 12.8
Median 20
Third quartile 28.6
Maximum 80
N hospitals 65
Minimum 0
First quartile 0
Median 6.3
Third quartile 15.4
Maximum 33.3
84
Belgium
Year
2003 107 1488 47 1133 24 1326 16 146 - - - -
2004 95 1443 49 1227 25 1601 18 228 - - - -
2005 97 1539 41 1048 25 1592 19 223 - - - -
2006 98 1427 33 858 21 1632 22 267 - - - -
2007 105 1511 34 855 17 1460 20 245 - - - -
2008 101 1647 38 906 16 1430 19 236 - - - -
2009 101 1885 34 949 18 1610 14 227 8 142 8 136
2010 97 1797 40 1088 23 1966 22 323 14 145 15 130
Penicillin R <1 <1 3 4 3 <1 <1 <1
Penicillin RI 12 9 12 10 9 8 <1 <1
Macrolides RI 34 33 31 31 25 24 23 25
Escherichia coli
Carbapenems R - - - - - - - <1
Aminopenicilins RI 1 2 <1 <1 <1 3 1 2
HL Gentamicin R 17 22 26 30 26 30 23 18
Vancomycin R 1 <1 <1 <1 1 <1 1 <1
HL Gentamicin R <1 11 22 19 23 17 32 30
Vancomycin R <1 5 14 4 <1 5 4 3
Aminoglycosides R - - - - - - 10 2
Fluoroquinolones R - - - - - - 13 13
Third-gen. cephalosporins R - - - - - - 15 13
Carbapenems R - - - - - - 1 <1
Piperacillin R - - - - - - 7 12
Ceftazidime R - - - - - - 6 7
Carbapenems R - - - - - - 9 5
Aminoglycosides R - - - - - - 10 14
Fluoroquinolones R - - - - - - 16 12
85
Characteristic
S. pneumoniae
n=3 682
S. aureus
n=2 006
E. coli
n=3 286
E. faecalis
n=389
E. faecium
n=146
K. pneumoniae
n=285
P. aeruginosa
n=264
Isolate source
Blood 96 0 100 21 100 21 100 1 100 3 100 14 100 7
CSF 4 8 - - <1 0 - - - - <1 0 <1 0
Gender
Male 55 0 62 22 46 24 64 1 56 5 57 13 68 4
Female 44 0 37 19 53 18 35 0 42 2 42 15 32 13
Unknown 1 0 1 7 <1 40 1 0 1 0 <1 0 - -
Age (years)
04 17 1 4 16 2 11 3 0 1 0 5 13 3 0
519 5 1 2 9 1 26 <1 0 - - - - 2 0
2064 37 0 34 17 30 17 28 0 33 2 29 15 25 9
65 and over 41 0 59 24 67 23 68 1 64 4 65 13 71 6
Unknown - - - - - - 1 0 1 0 - - - -
Hospital department
ICU 7 1 1 4 1 37 7 0 7 0 - - - -
Internal med. 15 0 2 16 1 27 10 3 10 0 - - - -
Surgery 1 0 1 27 <1 29 3 0 1 0 - - - -
Other 15 0 5 16 1 67 5 0 7 0 - - - -
Unknown 63 0 91 21 97 20 75 0 76 5 100 14 100 7
86
L
a
b
c
r
a
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c
r
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c
c
d
c
s
0 25 50 75 100
L109 (1]5
L15/ (1]21
L0// (1]27
L095 (1]31
L0/8 (1]3/
L1/3 (1]3/
L118 (1]39
L063 (1]/7
L008 (1]69
L0/3 (1]85
L033 (0]2/
L161 (0]36
L100 (0]2/
L006 (0]/8
L05/ (0]/8
L069 (0]1/
L016 (0]76
L026 (0]18
L019 (0]33
L110 (0]32
L1/6 (0]//
L157 (0]6
L092 (0]103
L061 (0]56
L060 (0]27
L057 (0]1/
L159 (0]29
L056 (0]10/
L017 (0]17
L101 (0]/2
L160 (0]23
L16/ (0]38
L129 (0]15
L001 (0]62
L1/1 (0]6
L021 (0]61
L137 (0]21
L105 (0]//
L005 (0]16
L00/ (0]/8
L018 (0]19
L087 (0]20
L081 (0]10
L035 (0]20
L012 (0]16
L102 (0]3/
L076 (0]6
L051 (0]29
L002 (0]2/
L02/ (0]70
L01/ (0]31
L153 (0]5
L071 (0]25
L032 (0]39
L139 (0]57
L0/9 (0]/5
L111 (0]9/
L113 (0]55
L115 (0]60
L070 (0]8/
L073 (0]12
L083 (0]26
L029 (0]13
L11/ (0]28
L0/7 (0]17
L130 (0]38
L090 (0]27
L10/ (0]/5
L023 (0]3/
L011 (0]12
L103 (0]28
L152 (0]1/
L003 (0]3/
L107 (0]2/
L125 (0]15
L116 (0]33
L0/6 (0]53
L112 (0]95
L077 (0]/5
L007 (0]1/
L031 (0]21
L030 (0]6/
L06/ (0]19
L08/ (0]31
L097 (0]69
L091 (0]88
L098 (0]36
L093 (0]31
L072 (0]23
L065 (0]10
L037 (0]30
L009 (0]10
L0/5 (0]/8
L07/ (0]50
L022 (0]/6
L010 (0]8
L075 (0]59
L108 (0]1/8
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
L1361 (5]11
L0291 (11]27
L1/31 (19]55
L1601 (3]9
L0701 (/1]12/
L0191 (5]16
L0321 (26]8/
L16/1 (/]1/
L1521 (/]1/
L0221 (1/]52
L02/1 (17]67
L0051 (3]12
L0061 (18]77
L0611 (26]118
L0121 (9]/1
L0971 (21]97
L1391 (16]7/
L0081 (2/]119
L0161 (2/]123
L0021 (12]62
L1121 (17]88
L07/1 (17]95
L0071 (3]17
L0571 (3]17
L0/51 (9]52
L0631 (1/]91
L0031 (3]20
L1611 (1]7
L1301 (7]55
L05/1 (5]/3
L0561 (1]9
L0/81 (2]19
L1111 (3]30
L1151 (10]115
L0301 (2]26
L0771 (6]107
N laboratories 98
Minimum 0
First quartile 0
Median 0
Third quartile 0
Maximum 20
N hospitals 36
Minimum 5.6
First quartile 14.6
Median 19.8
Third quartile 27.7
Maximum 45.5
Belgium
87
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
L0051 (9]22
L0721 (5]1/
L0121 (25]81
L0771 (/2]1//
L1601 (6]21
L16/1 (10]36
L0//1 (23]90
L1361 (15]62
L0631 (5/]226
L0161 (62]260
L0701 (68]287
L0611 (51]22/
L0291 (13]62
L0081 (68]339
L1391 (30]152
L0221 (29]150
L0971 (57]309
L1121 (/1]2/6
L0061 (31]187
L0071 (12]82
L0031 (5]39
L0321 (28]2/9
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
L0291 (/]10
L1151 (1/]53
L0921 (7]3/
L0081 (9]/9
L0//1 (1]11
L0611 (1]11
L0771 (1]12
L0/21 (1]13
L0031 (1]17
L0161 (0]1/
L1391 (0]1/
L0061 (0]22
L1601 (0]5
L1121 (0]8
L02/1 (0]6
(20092010)
N hospitals 22
Minimum 11.2
First quartile 18.4
Median 23.2
Third quartile 27.8
Maximum 40.9
N hospitals 15
Minimum 0
First quartile 0
Median 7.7
Third quartile 18.4
Maximum 40.0
88
Bulgaria
Year
2003 13 22 20 157 20 158 16 49 - - - -
2004 13 32 22 170 20 167 16 75 - - - -
2005 16 43 26 160 23 203 21 95 15 34 9 34
2006 11 29 23 159 20 196 19 98 15 55 13 31
2007 10 32 14 121 15 127 13 65 9 29 6 14
2008 13 29 21 160 22 147 18 70 11 49 10 23
2009 10 27 20 221 17 194 16 92 12 95 11 36
2010 13 22 20 200 21 153 16 108 15 127 11 42
Penicillin R 9 22 30 7 9 21 22 18
Penicillin RI 14 22 33 7 16 21 37 18
Macrolides RI 11 17 8 15 17 4 27 25
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 36 33 24 53 29 44 36 41
Vancomycin R <1 2 <1 2 <1 <1 <1 <1
HL Gentamicin R 60 62 56 79 75 84 65 71
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 50 33 14 48 33 15
Ceftazidime R - - 45 13 21 55 23 19
Carbapenems R - - 38 14 7 17 24 31
89
Characteristic
S. pneumoniae
n=49
S. aureus
n=421
E. coli
n=344
E. faecalis
n=143
E. faecium
n=49
K. pneumoniae
n=222
P. aeruginosa
n=76
Isolate source
Blood 65 34 100 17 99 31 100 0 100 0 100 73 97 27
CSF 35 18 - - 1 0 - - - - <1 0 3 50
Gender
Male 59 28 65 19 48 34 66 0 67 0 64 68 64 22
Female 41 30 35 13 52 27 34 0 33 0 36 81 36 37
Unknown - - <1 100 - - - - - - - - - -
Age (years)
04 18 44 5 45 2 17 7 0 10 0 13 83 11 25
519 4 50 4 25 2 0 1 0 4 0 3 83 - -
2064 45 23 47 14 43 32 44 0 47 0 36 73 51 23
65 and over 24 25 32 19 41 30 37 0 27 0 29 70 25 21
Unknown 8 25 12 12 13 32 11 0 12 0 20 68 13 60
Hospital department
ICU 14 14 17 27 13 30 22 0 43 0 22 76 29 50
Internal med. 27 31 41 9 49 26 30 0 10 0 19 42 18 7
Surgery - - 9 32 10 42 13 0 16 0 18 90 11 25
Other 59 31 33 18 28 33 36 0 31 0 41 79 42 22
90
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
6003 (3]6
6017 (3]9
6013 (2]7
6005 (1]6
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
600/A (/]8
6022A (/]9
6026A (3]8
6027A (5]15
6006A (9]28
6001A (7]26
6005A (9]37
6018A (6]28
6009A (2]10
6021A (5]32
6003A (/]27
6023A (2]1/
6007A (5]/2
6013A (1]1/
6017A (5]78
6011A (1]20
6002A (0]1/
6029A (0]6
N laboratories 4
Minimum 16.7
First quartile 22.6
Median 31
Third quartile 41.7
Maximum 50
N hospitals 18
Minimum 0
First quartile 7.1
Median 17.8
Third quartile 32.1
Maximum 50
Bulgaria
91
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
6027A (5]9
6006A (15]27
6007A (1/]29
6005A (8]19
6011A (6]18
6021A (6]20
6017A (16]5/
6023A (6]21
6001A (7]26
6009A (2]8
6018A (8]3/
6003A (5]22
6026A (1]8
6013A (2]29
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
6001A (20]23
6011A (12]1/
6026A (6]7
6006A (22]26
6017A (37]50
6021A (29]/1
6007A (10]16
6018A (13]23
6009A (2]5
6013A (0]5
(20092010)
N hospitals 14
Minimum 6.9
First quartile 23.5
Median 29.1
Third quartile 42.1
Maximum 55.6
N hospitals 10
Minimum 0
First quartile 56.5
Median 72.4
Third quartile 85.7
Maximum 87.0
92
Cyprus
Year
2003 1 3 1 28 1 19 1 28 - - - -
2004 1 7 3 39 4 46 3 38 - - - -
2005 4 16 5 54 5 75 3 40 4 9 4 8
2006 5 13 5 62 5 90 4 48 4 26 4 37
2007 4 15 4 85 5 109 3 63 4 39 3 52
2008 4 14 5 92 4 119 5 85 5 62 5 43
2009 4 11 5 89 5 136 5 80 5 53 5 62
2010 4 12 5 99 5 139 5 91 4 67 5 48
Penicillin R <1 <1 <1 31 7 21 18 33
Penicillin RI <1 14 19 38 33 43 36 42
Macrolides RI 33 <1 13 31 27 29 36 55
Escherichia coli
Carbapenems R <1 <1 <1 <1 2 <1 <1 <1
Aminopenicilins RI <1 3 3 5 2 16 32 6
HL Gentamicin R 43 77 71 44 61 65 66 24
Vancomycin R <1 3 <1 <1 <1 1 <1 <1
HL Gentamicin R - 33 <1 14 33 10 13 <1
Vancomycin R <1 33 40 14 25 20 13 <1
Carbapenems R - - <1 <1 3 10 17 16
Piperacillin R - - 13 27 31 23 18 19
Ceftazidime R - - 38 24 15 9 18 17
Carbapenems R - - 13 11 19 19 8 29
93
Characteristic
S. pneumoniae
n=23
S. aureus
n=188
E. coli
n=274
E. faecalis
n=133
E. faecium
n=38
K. pneumoniae
n=120
P. aeruginosa
n=109
Isolate source
Blood 91 38 100 32 100 43 100 0 100 5 99 38 99 18
CSF 9 50 - - - - - - - - 1 0 1 0
Gender
Male 74 41 64 34 46 53 62 0 63 8 56 37 60 20
Female 26 33 34 30 53 35 37 0 37 0 43 37 34 14
Unknown - - 2 25 1 0 1 0 - - 2 50 6 14
Age (years)
04 4 100 8 20 3 11 4 0 5 0 6 0 7 13
519 13 33 2 0 1 50 1 0 - - 2 0 - -
2064 17 75 23 32 16 51 27 0 37 0 35 33 28 19
65 and over 30 29 39 42 45 48 49 0 50 5 38 48 40 18
Unknown 35 25 28 25 34 35 20 0 8 33 19 39 24 15
Hospital department
ICU 4 100 16 35 10 48 44 0 47 11 32 53 39 31
Internal med. 70 25 47 30 62 44 26 0 16 0 32 26 25 11
Surgery - - 14 46 7 50 12 0 11 0 13 31 10 9
Other 26 67 22 27 20 36 18 0 24 0 23 36 25 4
Unknown - - 1 50 1 33 - - 3 0 - - 2 50
94
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
C002 (3]7
C001 (/]10
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
C00/A (/]11
C001A (35]100
C002A (19]56
C003A (3]17
N laboratories 2
Minimum 40
First quartile 40
Median 41.4
Third quartile 42.9
Maximum 42.9
N hospitals 4
Minimum 17.6
First quartile 25.8
Median 34.5
Third quartile 35.7
Maximum 36.4
Cyprus
95
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
C003A (16]3/
C001A (65]150
C002A (30]70
C00/A (5]13
C005A (2]7
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
C001A (26]56
C002A (15]38
C003A (3]1/
C005A (1]9
(20092010)
N hospitals 5
Minimum 28.6
First quartile 38.5
Median 42.9
Third quartile 43.3
Maximum 47.1
N hospitals 4
Minimum 11.1
First quartile 16.3
Median 30.5
Third quartile 43
Maximum 46.4
96
Czech Republic
Year
2003 32 204 45 1387 43 1766 44 630 - - - -
2004 37 162 45 1444 44 1966 41 660 - - - -
2005 39 195 47 1553 47 2234 45 758 37 478 36 257
2006 39 172 47 1527 47 2176 45 697 45 1130 43 490
2007 41 205 47 1653 48 2407 47 816 48 1230 41 517
2008 40 244 47 1715 46 2738 44 883 45 1493 42 568
2009 41 297 46 1695 45 2759 44 835 45 1415 45 575
2010 41 288 44 1593 43 2484 41 759 44 1264 41 511
Penicillin R <1 2 <1 <1 <1 <1 <1 <1
Macrolides RI 2 4 2 3 5 3 5 6
Escherichia coli
Carbapenems R - - <1 <1 <1 <1 <1 <1
Aminopenicilins RI 4 <1 <1 2 3 2 <1 8
HL Gentamicin R 44 43 45 43 49 49 47 48
Vancomycin R <1 <1 <1 <1 1 <1 <1 <1
HL Gentamicin R 48 43 69 74 79 75 65 54
Vancomycin R 3 3 14 4 6 8 6 5
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 21 29 30 27 28 28
Ceftazidime R - - 40 30 33 44 29 28
Carbapenems R - - 31 33 36 29 29 16
97
Characteristic
S. pneumoniae
n=585
S. aureus
n=3 288
E. coli
n=5 239
E. faecalis
n=1 196
E. faecium
n=397
K. pneumoniae
n=2 678
P. aeruginosa
n=1 085
Isolate source
Blood 87 5 100 14 100 23 100 0 100 5 100 50 99 23
CSF 13 4 - - <1 9 - - - - <1 18 1 50
Gender
Male 56 3 61 14 43 27 65 0 63 6 61 52 62 25
Female 44 7 39 14 57 20 35 0 37 4 39 47 38 20
Unknown - - - - <1 100 - - - - - - - -
Age (years)
04 6 6 4 0 2 5 3 0 2 0 2 26 1 8
519 5 4 2 1 1 29 1 0 1 0 1 50 2 35
2064 48 5 41 12 31 21 41 1 46 9 43 53 45 26
65 and over 42 5 53 17 66 24 55 0 51 2 54 49 51 20
Unknown - - <1 0 <1 0 - - - - <1 20 <1 0
Hospital department
ICU 25 3 25 16 20 25 46 0 44 1 41 56 47 25
Internal med. 37 5 44 15 49 22 27 0 19 4 34 44 25 17
Surgery 1 17 9 15 6 24 7 1 7 0 8 54 6 29
Other 32 4 22 10 25 24 19 0 31 13 17 47 21 24
Unknown 4 12 1 30 <1 25 <1 0 - - 1 65 1 33
98
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
CZ018 (2]9
CZ01/ (2]13
CZ0/0 (1]8
CZ013 (2]17
CZ002 (1]9
CZ0/7 (1]9
CZ015 (2]21
CZ030 (1]12
CZ023 (2]2/
CZ027 (2]26
CZ0/9 (1]16
CZ006 (3]50
CZ031 (1]20
CZ016 (2]/5
CZ033 (1]23
CZ017 (1]29
CZ0// (1]/2
CZ007 (0]17
CZ011 (0]7
CZ009 (0]18
CZ029 (0]19
CZ019 (0]8
CZ008 (0]6
CZ032 (0]9
CZ02/ (0]2/
CZ0/1 (0]8
CZ003 (0]11
CZ0/8 (0]5
CZ0/2 (0]22
CZ036 (0]10
CZ00/ (0]8
CZ026 (0]9
CZ037 (0]10
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
CZ012C (7]8
CZ03/C (6]13
CZ050A (12]26
CZ007 (7]16
CZ0/9 (2]5
CZ0/3 (2]5
CZ023A (20]50
CZ012A (12]33
CZ005A (33]100
CZ031P (/]13
CZ015 (3]10
CZ0//C (5]21
CZ0070 (2]9
CZ0/1A (9]/1
CZ008A (9]/3
CZ003A (20]96
CZ031K (2]10
CZ03/ (1]5
CZ012 (2]11
CZ037A (/]22
CZ025A (9]51
CZ0370 (/]23
CZ0/2A (6]35
CZ031F (2]12
CZ033A (10]61
CZ007A (13]82
CZ039 (3]19
CZ0/9A (5]32
CZ018A (28]182
CZ02/A (21]139
CZ03/A (8]56
CZ031v (1]7
CZ0/0A (2]15
CZ032A (7]53
CZ015A (16]123
CZ031A (8]62
CZ0/8A (5]39
CZ027A (15]117
CZ051A (2]16
CZ01/A (7]56
CZ006A (27]218
CZ009A (17]1//
CZ026A (8]68
CZ013A (7]6/
CZ039A (2]19
CZ017 (3]29
CZ011A (3]29
CZ016A (10]98
CZ037C (1]10
CZ022A (/]/0
CZ017A (9]9/
CZ031} (2]21
CZ00/A (7]82
CZ020A (8]96
CZ029A (3]37
CZ019A (3]//
CZ035A (3]/6
CZ002A (/]80
CZ028A (2]56
CZ030A (2]61
CZ0//A (1]/5
CZ036A (0]35
CZ009 (0]18
CZ038A (0]17
CZ0/6A (0]11
CZ021A (0]95
N laboratories 33
Minimum 0
First quartile 0
Median 2.4
Third quartile 8.3
Maximum 22.2
N hospitals 66
Minimum 0
First quartile 10
Median 13.3
Third quartile 20
Maximum 87.5
Czech Republic
99
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
CZ012C (11]16
CZ03/C (9]16
CZ025A (27]53
CZ0/9 (8]18
CZ031C (3]7
CZ007 (13]31
CZ039 (11]29
CZ036A (22]59
CZ017 (20]59
CZ051A (10]30
CZ002A (66]213
CZ033A (17]56
CZ050A (6]20
CZ027A (58]19/
CZ031A (29]99
CZ009A (/0]138
CZ0/2A (33]115
CZ007L (2]7
CZ035A (18]6/
CZ011A (9]32
CZ039A (8]29
CZ021A (/7]171
CZ031K (3]11
CZ037C (7]26
CZ03/A (11]/1
CZ0//A (10]38
CZ031} (11]/2
CZ0//C (6]23
CZ023A (22]85
CZ0/1A (16]63
CZ006A (98]/0/
CZ005A (/2]17/
CZ0/6A (10]/2
CZ017A (28]118
CZ0/9A (16]68
CZ038A (12]51
CZ026A (20]87
CZ028A (17]7/
CZ018A (52]227
CZ00/A (27]120
CZ0370 (10]/5
CZ03/ (2]9
CZ02/A (/3]196
CZ031P (8]38
CZ031F (5]2/
CZ031 (1]5
CZ007A (22]111
CZ022A (12]61
CZ013A (22]113
CZ008A (16]83
CZ016A (32]171
CZ003A (20]107
CZ012 (5]28
CZ019A (19]112
CZ0/7 (2]13
CZ037A (8]52
CZ01/A (13]88
CZ012A (5]35
CZ015A (28]203
CZ0/8A (7]51
CZ0070 (2]15
CZ031v (2]16
CZ029A (10]86
CZ0/7A (/]38
CZ032A (13]13/
CZ0/0A (1]11
CZ020A (6]86
CZ030A (9]1//
CZ015 (0]11
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
CZ0/3C (7]8
CZ050A (13]15
CZ031} (12]1/
CZ011A (19]23
CZ007 (25]31
CZ007L (/]5
CZ0/3 (/]5
CZ012C (8]10
CZ023A (30]39
CZ0/6A (18]2/
CZ038A (22]31
CZ031K (12]17
CZ013A (19]27
CZ03/C (8]12
CZ036A (1/]21
CZ0/2A (27]/1
CZ0/7A (13]20
CZ0//C (11]17
CZ009A (130]203
CZ021A (1/]22
CZ025A (25]/0
CZ031v (3]5
CZ0070 (3]5
CZ012A (11]19
CZ027A (66]11/
CZ003A (/8]83
CZ051A (/]7
CZ002A (8]1/
CZ0/1A (13]23
CZ022A (18]32
CZ037A (12]22
CZ028A (19]35
CZ019A (28]53
CZ006A (107]206
CZ0/8A (15]29
CZ035A (/3]8/
CZ0/9A (22]/3
CZ00/A (26]51
CZ039 (6]12
CZ009 (9]18
CZ026A (33]70
CZ0/9 (7]15
CZ007A (20]/3
CZ02/A (/2]91
CZ018A (83]182
CZ033A (26]59
CZ016A (25]57
CZ0370 (3]7
CZ005A (/9]115
CZ012 (/]10
CZ03/A (18]/5
CZ017A (23]59
CZ017 (12]33
CZ0//A (5]1/
CZ029A (1/]/0
CZ031F (6]18
CZ031A (16]/9
CZ031P (5]17
CZ030A (6]21
CZ03/ (2]7
CZ020A (15]56
CZ008A (11]/7
CZ015A (7]38
CZ032A (5]29
CZ01/A (6]/9
CZ039A (1]10
(20092010)
N hospitals 69
Minimum 0
First quartile 18.7
Median 23.5
Third quartile 28.6
Maximum 68.8
N hospitals 66
Minimum 10
First quartile 40
Median 52.4
Third quartile 65
Maximum 87.5
100
Denmark
Year
2003 5 606 5 671 - - - - - - - -
2004 15 1188 15 1436 - - - - - - - -
2005 14 1081 15 1350 5 1283 - - - - - -
2006 15 872 15 1279 11 2723 11 711 11 607 - -
2007 15 1030 14 1315 12 3021 13 927 13 784 13 417
2008 15 934 15 1295 14 3283 14 1005 14 793 14 420
2009 15 996 15 1395 14 3532 14 1100 14 822 14 429
2010 15 954 15 1362 14 3418 14 1112 14 799 14 376
Penicillin R <1 <1 <1 <1 <1 <1 <1 <1
Oxacillin/Meticillin R <1 1 2 2 <1 2 2 1
Escherichia coli
Aminopenicilins R - - 40 42 43 43 43 46
Carbapenems R - - <1 <1 <1 <1 <1 <1
Aminopenicilins RI - - - <1 2 2 1 <1
HL Gentamicin R - - - . . 37 33 36
Vancomycin R - - - <1 <1 <1 <1 <1
Aminopenicilins RI - - - 87 88 88 88 93
HL Gentamicin R - - - . . 61 52 74
Vancomycin R - - - <1 <1 <1 2 2
Aminoglycosides R - - - 2 6 7 7 6
Fluoroquinolones R - - - 6 13 16 16 11
Third-gen. cephalosporins R - - - 4 10 9 11 11
Carbapenems R - - - <1 <1 <1 <1 <1
Piperacillin R - - - - 3 2 2 4
Ceftazidime R - - - - 2 3 4 3
Carbapenems R - - - - 2 1 3 3
Aminoglycosides R - - - - 1 1 <1 1
Fluoroquinolones R - - - - 6 3 5 6
101
Characteristic
S. pneumoniae
n=1 950
S. aureus
n=2 757
E. coli
n=6 572
E. faecalis
n=950
E. faecium
n=849
K. pneumoniae
n=1 182
P. aeruginosa
n=703
Isolate source
Blood 93 4 100 2 100 13 100 0 100 2 100 11 99 3
CSF 7 3 - - <1 29 - - - - <1 0 1 0
Gender
Male 23 4 63 2 49 16 72 0 60 1 59 13 64 3
Female 25 3 37 1 51 11 28 0 40 2 41 8 36 3
Unknown 51 4 - - <1 33 <1 33 <1 0 <1 0 - -
Age (years)
04 5 2 4 2 2 10 3 0 1 0 2 10 2 0
519 2 0 3 3 1 8 1 0 2 7 1 7 1 13
2064 40 3 39 2 28 16 30 0 42 2 34 13 31 5
65 and over 53 4 54 2 70 13 66 1 55 2 63 10 66 2
Hospital department
ICU - - <1 8 3 18 13 1 29 2 4 19 7 13
Internal med. - - 7 1 40 13 40 0 22 0 43 10 31 1
Surgery - - 2 0 15 11 18 1 17 2 21 10 13 3
Other - - 5 1 22 14 23 0 20 3 26 9 28 4
Unknown 100 4 85 2 20 14 7 0 11 2 7 18 21 1
102
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
0K002 (15]282
0K007 (5]98
0K015 (/]83
0K010 (2]/2
0K001 (2]//
0K00/ (6]139
0K003 (8]192
0K005 (2]57
0K012 (/]119
0K006 (/]139
0K016 (5]19/
0K01/ (6]23/
0K013 (2]80
0K009 (3]17/
0K011 (1]73
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
0K002X (2]16
0K002L (3]3/
0K00/ (1]18
0K002 (6]108
0K005 (2]/2
0K007A (3]67
0K00/C (1]23
0K013A (2]/9
0K01/ (2]/9
0K009A (1]36
0K001A (6]226
0K002F (1]/1
0K003C (3]151
0K016 (1]5/
0K003 (1]56
0K01/0 (1]61
0K003A (1]65
0K009 (/]268
0K01/C (1]68
0K01/I (1]85
0K00/A (1]10/
0K010 (0]6
0K005X (0]6
0K002A (0]95
0K012 (0]18
0K00/X (0]9
0K01/L (0]8
0K006A (0]77
0K016F (0]12
0K0120 (0]/1
0K016C (0]13
0K016A (0]139
0K005A (0]6/
0K006 (0]/8
0K012L (0]/0
0K0100 (0]16
0K006C (0]8
0K011A (0]93
0K012F (0]36
0K007 (0]70
0K015A (0]71
0K015C (0]23
0K008A (0]21
0K010A (0]2/
0K01/A (0]37
0K0156 (0]6
0K013 (0]57
0K016 (0]9
0K015X (0]7
0K0160 (0]9
0K01/ (0]38
N laboratories 15
Minimum 1.4
First quartile 2.6
Median 3.5
Third quartile 4.8
Maximum 5.3
N hospitals 51
Minimum 0
First quartile 0
Median 0
Third quartile 2
Maximum 12.5
Denmark
103
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
0K001A (6/]265
0K002F (31]1/1
0K015 (3]15
0K005A (32]163
0K01/I (18]92
0K00/ (2/]12/
0K002A (50]276
0K013A (16]89
0K016A (62]360
0K015A (29]176
0K006X (13]83
0K01/C (2/]156
0K013 (21]137
0K003C (73]509
0K0096 (1]7
0K011A (31]218
0K002L (16]115
0K009 (56]/03
0K0120 (17]130
0K01/A (10]77
0K00/A (26]201
0K002 (/1]318
0K01/ (21]166
0K003A (18]1/8
0K006 (13]108
0K00/C (18]152
0K012 (12]105
0K015C (5]/5
0K005 (15]137
0K0156 (/]38
0K012F (17]167
0K0110 (3]30
0K003 (19]199
0K009A (21]220
0K006A (7]7/
0K01/0 (19]211
0K008A (5]75
0K016 (11]165
0K0160 (3]/8
0K007 (3]59
0K0166 (1]22
0K012L (5]110
0K007A (3]77
0K016C (1]71
0K006C (0]6
0K0070 (0]11
0K0130 (0]10
0K016F (0]/7
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
0K002F (10]3/
0K005 (3]12
0K001A (32]1/1
0K00/ (5]23
0K01/I (8]39
0K00/C (6]31
0K0120 (/]22
0K002 (8]6/
0K002A (9]80
0K005A (2]18
0K01/ (5]50
0K01/0 (5]52
0K009A (/]/8
0K011A (/]50
0K009 (9]125
0K008A (1]1/
0K015A (3]/2
0K01/A (1]1/
0K016 (1]18
0K012F (1]30
0K016A (3]91
0K00/A (1]37
0K01/C (1]/0
0K016F (0]8
0K012L (0]16
0K012 (0]15
0K002L (0]19
0K015C (0]7
0K016C (0]12
0K0160 (0]10
0K0156 (0]6
(20092010)
N hospitals 48
Minimum 0
First quartile 7.8
Median 12.1
Third quartile 15.4
Maximum 24.2
N hospitals 31
Minimum 0
First quartile 0
Median 7.1
Third quartile 12.5
Maximum 29.4
104
Estonia
Year
2003 8 26 9 98 9 98 6 27 - - - -
2004 6 40 9 104 10 167 5 63 - - - -
2005 7 53 8 141 10 156 7 66 7 38 5 38
2006 8 52 9 154 9 215 8 85 6 47 6 43
2007 8 64 10 206 11 219 8 66 9 63 8 48
2008 10 66 11 185 11 267 11 86 10 72 8 41
2009 8 82 11 213 11 320 8 72 7 60 6 43
2010 10 64 9 152 11 317 8 66 9 82 8 42
Penicillin R <1 <1 <1 <1 <1 <1 <1 2
Penicillin RI <1 <1 2 2 <1 5 1 2
Macrolides RI 10 6 <1 3 2 4 2 4
Oxacillin/Meticillin R 4 5 2 3 9 4 3 <1
Escherichia coli
Third-gen. cephalosporins R 1 4 1 <1 1 5 2 6
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 4 14 14 9 <1 9 9 14
HL Gentamicin R 22 32 50 35 23 27 43 27
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 50 79 74 78 89 75 79 67
Vancomycin R <1 <1 <1 <1 <1 3 <1 <1
Fluoroquinolones R - - <1 5 2 7 19 25
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 27 12 9 18 13 14
Ceftazidime R - - 18 7 7 13 7 13
Carbapenems R - - 38 29 18 30 17 22
105
Characteristic
S. pneumoniae
n=146
S. aureus
n=358
E. coli
n=565
E. faecalis
n=72
E. faecium
n=63
K. pneumoniae
n=139
P. aeruginosa
n=70
Isolate source
Blood 92 1 100 2 99 8 100 0 100 0 100 17 99 20
CSF 8 0 - - 1 0 - - - - - - 1 0
Gender
Male 58 1 57 2 37 11 64 0 44 0 51 23 57 25
Female 42 2 42 3 62 7 36 0 56 0 49 12 43 13
Unknown - - 1 0 1 0 - - - - - - - -
Age (years)
04 8 9 8 0 2 0 17 0 3 0 9 8 1 0
519 3 0 4 7 2 8 3 0 . . 2 0 6 0
2064 61 1 49 1 38 10 33 0 46 0 40 18 39 11
65 and over 28 0 39 4 58 7 46 0 51 0 49 19 54 29
Unknown - - <1 0 - - 1 0 - - - - - -
Hospital department
ICU 29 0 24 5 16 6 28 0 51 0 34 23 41 31
Internal med. 28 2 33 3 47 6 24 0 8 0 32 16 21 20
Surgery 1 0 7 0 4 21 11 0 6 0 7 10 3 0
Other 42 2 37 1 33 12 36 0 35 0 27 13 34 8
Unknown - - - - - - 1 0 - - - - - -
106
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
LL005 (1]1/
LL002 (1]35
LL006 (0]11
LL011 (0]5
LL00/ (0]30
LL009 (0]8
LL001 (0]35
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LL003k (3]5
LL006K (1]13
LL005P (1]21
LL002M (1]31
LL001X (1]/2
LL001A (1]55
LL00/P (0]23
LL00/X (0]29
LL002X (0]5
LL002L (0]21
LL005X (0]19
LL006X (0]16
LL011X (0]5
LL010X (0]7
LL009X (0]20
LL010I (0]11
LL011L (0]7
LL008v (0]11
LL009K (0]13
N laboratories 7
Minimum 0
First quartile 0
Median 0
Third quartile 2.9
Maximum 7.1
N hospitals 19
Minimum 0
First quartile 0
Median 0
Third quartile 2.4
Maximum 60
Estonia
107
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LL011L (3]10
LL003X (2]7
LL008v (2]7
LL009X (2]11
LL006K (6]35
LL010X (1]7
LL006X (/]3/
LL00/X (6]52
LL003k (1]11
LL001A (5]77
LL002M (/]63
LL008X (1]16
LL001X (5]80
LL00/P (2]35
LL005X (1]30
LL005P (1]32
LL011X (0]1/
LL009K (0]16
LL012P (0]5
LL002X (0]10
LL010I (0]6
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LL009K (3]6
LL00/P (2]7
LL006X (2]7
LL001X (7]26
LL00/X (/]15
LL001A (/]21
LL006K (1]6
LL002X (1]19
LL005X (0]5
LL002M (0]10
(20092010)
N hospitals 21
Minimum 0
First quartile 3.1
Median 6.3
Third quartile 14.3
Maximum 30
N hospitals 10
Minimum 0
First quartile 5.3
Median 22.9
Third quartile 28.6
Maximum 50
108
Finland
Year
2003 16 517 16 727 15 1450 15 266 - - - -
2004 17 548 17 883 17 1749 17 336 - - - -
2005 17 543 17 790 17 1924 17 340 14 175 13 108
2006 15 501 15 894 15 1875 15 348 14 228 14 162
2007 16 547 16 814 16 1949 16 400 15 273 14 183
2008 15 643 15 923 15 2111 15 381 12 288 12 175
2009 20 688 20 978 20 2224 20 506 20 375 18 233
2010 20 622 20 1094 20 2551 20 521 20 401 20 281
Penicillin R 2 <1 <1 2 1 <1 2 1
Penicillin RI 10 8 7 12 13 11 13 14
Macrolides RI 20 20 20 24 25 24 28 28
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI <1 <1 <1 <1 2 <1 <1 <1
HL Gentamicin R 39 39 27 25 22 13 - -
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 4 12 1 16 19 15 - -
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
Aminoglycosides R - - 3 1 <1 1 1 4
Fluoroquinolones R - - 3 4 <1 2 3 2
Third-gen. cephalosporins R - - 2 <1 1 2 1 4
Carbapenems R - - <1 <1 <1 <1 <1 <1
Carbapenems R - - 15 8 9 6 8 10
109
Characteristic
S. pneumoniae
n=1 263
S. aureus
n=2 072
E. coli
n=4 773
E. faecalis
n=541
E. faecium
n=482
K. pneumoniae
n=764
P. aeruginosa
n=504
Isolate source
Blood 96 14 100 2 100 9 100 0 100 0 100 3 98 9
CSF 4 11 - - <1 13 - - - - <1 0 2 8
Gender
Male 54 13 62 2 37 13 70 0 61 0 54 4 61 10
Female 46 14 38 2 63 7 30 0 39 0 46 2 39 7
Age (years)
04 15 24 3 1 2 5 6 0 2 0 1 20 1 20
519 4 8 4 0 1 5 1 0 2 0 1 0 2 27
2064 46 11 39 2 28 9 27 0 32 0 28 4 27 13
65 and over 35 13 53 3 69 9 65 0 63 0 70 2 70 7
Hospital department
ICU 1 13 1 0 1 4 1 0 2 0 <1 0 2 18
Internal med. 6 7 6 1 5 10 4 0 7 0 4 0 5 0
Surgery <1 50 2 3 1 8 2 0 5 0 2 7 2 20
Other 22 12 16 3 16 9 15 0 10 0 15 4 9 4
Unknown 71 14 74 2 77 9 78 0 76 0 80 3 81 10
110
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
Fl003 (13]53
Fl002 (7/]339
Fl01/ (9]/2
Fl011 (12]59
Fl005 (11]68
Fl00h (16]100
Fl021 (6]/3
Fl017 (/]30
Fl00C (5]/9
Fl008 (2]27
Fl00L (6]85
Fl009 (2]33
Fl010 (2]38
Fl020 (7]1/3
Fl018 (1]21
Fl012 (1]50
Fl00A (0]28
Fl019 (0]21
Fl015 (0]22
Fl00L (0]12
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Fl020X (22]235
Fl00LX (1]26
Fl005X (5]131
Fl012X (2]56
Fl01/X (2]62
Fl021X (2]107
Fl011X (1]66
Fl009X (1]70
Fl010X (1]71
Fl002X (5]/66
Fl00CX (1]121
Fl00LX (1]1/0
Fl00hX (0]1/1
Fl00AX (0]/5
Fl008X (0]31
Fl015X (0]/0
Fl019X (0]57
Fl003X (0]86
Fl017X (0]81
Fl018X (0]/0
N laboratories 20
Minimum 0
First quartile 3.4
Median 7.2
Third quartile 16.1
Maximum 24.5
N hospitals 20
Minimum 0
First quartile 0
Median 0.9
Third quartile 2.5
Maximum 9.4
Finland
111
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Fl019X (12]99
Fl00LX (9]77
Fl018X (10]86
Fl00hX (/3]388
Fl002X (133]1263
Fl003X (26]2/9
Fl011X (16]15/
Fl00AX (9]9/
Fl020X (33]3/8
Fl00LX (21]2/3
Fl017X (1/]16/
Fl009X (13]157
Fl01/X (12]1/5
Fl005X (22]275
Fl00CX (23]290
Fl021X (1/]21/
Fl010X (12]19/
Fl012X (8]13/
Fl015X (6]102
Fl008X (3]97
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Fl00LX (/]/7
Fl019X (1]15
Fl005X (2]38
Fl01/X (1]25
Fl002X (8]203
Fl00hX (2]56
Fl011X (1]31
Fl020X (2]69
Fl008X (0]16
Fl017X (0]25
Fl00AX (0]19
Fl021X (0]38
Fl010X (0]22
Fl015X (0]6
Fl009X (0]25
Fl00CX (0]63
Fl003X (0]35
Fl00LX (0]11
Fl012X (0]20
(20092010)
N hospitals 20
Minimum 3.1
First quartile 7.2
Median 8.6
Third quartile 10.5
Maximum 12.1
N hospitals 19
Minimum 0
First quartile 0
Median 0
Third quartile 3.9
Maximum 8.5
112
France
Year
2003 - - 21 1710 21 2266 20 468 - - - -
2004 - - 50 3355 50 5678 46 871 - - - -
2005 195 632 50 3484 50 6056 47 1023 49 838 48 993
2006 97 371 50 3824 50 6718 50 1152 50 963 47 1006
2007 168 663 57 4265 57 8093 56 1545 56 1187 56 1305
2008 127 557 56 4380 56 7993 54 1555 54 1138 54 1225
2009 225 826 54 4727 54 8451 54 1969 52 1378 32 1221
2010 181 1127 56 4883 56 9028 54 1970 56 1542 36 1191
Penicillin R - - 5 4 4 7 6 <1
Penicillin RI - - 36 32 34 30 27 28
Macrolides RI - - 41 36 37 31 27 30
Escherichia coli
Third-gen. cephalosporins R <1 <1 1 2 2 4 7 7
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 3 1 <1 1 1 <1 1 <1
HL Gentamicin R 16 17 15 16 15 18 18 18
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 23 21 24 30 30 30 38 41
Vancomycin R <1 5 3 3 1 <1 <1 1
Carbapenems R . . <1 <1 <1 <1 <1 <1
Piperacillin R - - 15 11 11 14 21 20
Ceftazidime R - - 9 6 7 8 17 13
Carbapenems R - - 14 12 14 14 17 18
113
Characteristic
S. pneumoniae
n=1 953
S. aureus
n=9 579
E. coli
n=17 360
E. faecalis
n=2 788
E. faecium
n=1 131
K. pneumoniae
n=2 920
P. aeruginosa
n=2 405
Isolate source
Blood 66 27 100 22 100 18 100 0 100 1 100 18 100 18
CSF 34 29 - - - - - - - - - - - -
Gender
Male 55 27 62 22 47 20 65 0 60 1 59 21 62 17
Female 45 28 37 22 51 16 33 0 38 0 40 14 38 18
Unknown <1 0 2 22 2 16 2 0 2 0 1 13 <1 60
Age (years)
04 24 31 5 10 2 6 4 0 2 0 2 23 2 9
519 9 14 3 6 1 11 1 0 1 0 1 29 2 13
2064 35 22 39 16 34 18 37 0 45 1 47 22 50 22
65 and over 32 34 53 29 62 19 57 0 51 1 50 14 45 13
Unknown - - <1 0 <1 25 <1 0 <1 0 <1 0 <1 0
Hospital department
ICU - - 13 23 8 21 19 0 26 2 15 36 27 25
Internal med. - - 34 24 26 20 30 0 27 0 28 17 22 14
Surgery - - 14 20 10 18 15 0 14 1 15 24 14 19
Other - - 35 20 51 17 31 0 31 1 36 10 32 14
Unknown 100 27 4 21 5 17 5 0 2 0 6 13 5 9
114
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
Fk252 (/]5
Fk2/0 (7]11
Fk2// (5]8
Fk035 (3]5
Fk058 (3]5
Fk0/1 (/]7
Fk06/ (5]10
Fk999 (/]8
Fk/93 (5]10
Fk028 (/]8
Fk/03 (3]6
Fk/96 (3]6
Fk130 (9]18
Fk186 (10]23
Fk127 (17]/1
Fk217 (2]5
Fk276 (2]5
Fk125 (/]10
Fk/18 (2]5
Fk230 (2]5
Fk/66 (2]5
Fk266 (2]5
Fk21/ (17]/3
Fk108 (17]//
Fk27/ (3]8
Fk271 (9]2/
Fk175 (/]11
Fk/70 (/]11
Fk131 (5]1/
Fk213 (11]31
Fk263 (21]63
Fk066 (2]6
Fk219 (2]6
Fk22/ (/]12
Fk507 (2]6
Fk277 (2]6
Fk505 (2]6
Fk126 (2]6
Fk/76 (17]53
Fk071 (6]19
Fk153 (/]13
Fk/90 (3]10
Fk235 (3]10
Fk/98 (3]10
Fk109 (13]//
Fk518 (2]7
Fk/00 (2]7
Fk037 (2]7
Fk279 (/]1/
Fk079 (2]7
Fk25/ (2]7
Fk2/9 (7]26
Fk2/6 (13]/9
Fk51/ (5]19
Fk09/ (17]65
Fk120 (5]20
Fk19/ (/]16
Fk077 (2]8
Fk196 (2]8
Fk137 (17]72
Fk/67 (10]/3
Fk/99 (3]13
Fk0/0 (7]31
Fk008 (2]9
Fk010 (12]5/
Fk167 (3]1/
Fk16/ (7]33
Fk269 (10]/9
Fk190 (1]5
Fk020 (2]10
Fk228 (1]5
Fk250 (3]16
Fk116 (3]16
Fk208 (2]11
Fk/79 (9]50
Fk/9/ (1]6
Fk0/7 (1]6
Fk162 (1]6
Fk076 (7]//
Fk519 (1]7
Fk528 (1]7
Fk150 (1]7
Fk036 (2]15
Fk251 (1]8
Fk1/2 (1]8
Fk270 (1]8
Fk0/3 (1]9
Fk009 (1]10
Fk2/1 (1]10
Fk232 (1]11
Fk022 (1]11
Fk260 (1]12
Fk/73 (1]1/
Fk088 (0]5
Fk/92 (0]5
Fk172 (0]7
Fk067 (0]6
Fk306 (0]6
Fk201 (0]6
Fk160 (0]7
Fk025 (0]5
Fk02/ (0]5
Fk038 (0]5
Fk/65 (0]5
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Fk531A (9]13
Fk0/6A (16]/0
Fk098A (22]62
Fk260A (/9]1/6
Fk208A (11]33
Fk179A (27]85
Fk/79A (11/]359
Fk067A (/6]150
Fk259A (/7]159
Fk009A (3/]120
Fk120A (23]83
Fk2/6A (97]355
Fk130A (11/]/23
Fk06/A (53]201
Fk250A (55]21/
Fk276A (31]122
Fk213A (30]119
Fk22/A (18]7/
Fk121A (//]183
Fk037A (11]/6
Fk008A (10]/2
Fk015A (11]/7
Fk135A (10]/3
Fk193A (5]22
Fk006A (1/2]626
Fk237A (2/]108
Fk238A (76]3/3
Fk263A (1/2]6/3
Fk055A (7]32
Fk138A (76]362
Fk202A (5]2/
Fk126A (15]73
Fk0/0A (53]258
Fk105A (26]127
Fk09/A (65]319
Fk052A (58]286
Fk095A (7]35
Fk076A (6/]322
Fk13/A (18]92
Fk2/8A (25]131
Fk/00A (8]/2
Fk109A (57]300
Fk19/A (22]116
Fk2/9A (31]172
Fk/03A (11]63
Fk/01A (8]/6
Fk072A (13]75
Fk21/A (22]131
Fk362A (18]108
Fk195A (/]2/
Fk010A (/8]296
Fk165A (25]155
Fk226A (88]555
Fk/3/A (13]88
Fk1/5A (5]37
Fk16/A (5/]/02
Fk08/A (6]/5
N laboratories 104
Minimum 0
First quartile 16.3
Median 26.7
Third quartile 36.9
Maximum 80
N hospitals 57
Minimum 13.3
First quartile 19
Median 21.9
Third quartile 25.7
Maximum 69.2
France
115
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Fk0/6A (21]/1
Fk06/A (118]/15
Fk055A (20]71
Fk095A (1/]52
Fk105A (83]320
Fk015A (3/]132
Fk2/8A (/8]187
Fk237A (51]200
Fk259A (6/]25/
Fk006A (283]112/
Fk/79A (12/]5/1
Fk138A (1/8]657
Fk21/A (72]325
Fk165A (82]375
Fk2/6A (138]6/1
Fk193A (10]/7
Fk076A (112]532
Fk052A (116]576
Fk16/A (127]6/1
Fk09/A (98]500
Fk/03A (27]138
Fk098A (30]15/
Fk263A (171]925
Fk109A (106]586
Fk121A (/9]276
Fk213A (58]338
Fk08/A (1/]82
Fk260A (/7]278
Fk/01A (17]103
Fk362A (//]272
Fk0/0A (72]//6
Fk135A (18]115
Fk067A (/2]282
Fk126A (23]158
Fk179A (10]70
Fk22/A (30]217
Fk008A (18]133
Fk010A (58]/3/
Fk202A (18]135
Fk120A (23]17/
Fk072A (21]160
Fk13/A (27]209
Fk130A (72]598
Fk009A (3/]285
Fk2/9A (36]302
Fk250A (55]/68
Fk195A (6]53
Fk19/A (2/]216
Fk276A (26]23/
Fk226A (75]699
Fk/00A (15]1//
Fk238A (58]567
Fk037A (8]79
Fk/3/A (2/]239
Fk1/5A (7]70
Fk531A (1]17
Fk208A (3]73
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Fk138A (102]220
Fk037A (11]26
Fk226A (97]2/6
Fk213A (17]53
Fk009A (8]25
Fk193A (/]13
Fk0/6A (3]10
Fk/03A (11]39
Fk1/5A (3]11
Fk135A (5]19
Fk015A (6]23
Fk121A (17]70
Fk13/A (5]21
Fk263A (//]193
Fk095A (2]10
Fk055A (/]21
Fk165A (18]95
Fk105A (17]96
Fk/79A (18]10/
Fk126A (/]2/
Fk120A (3]21
Fk2/6A (13]98
Fk179A (5]39
Fk010A (6]/7
Fk238A (7]57
Fk0/0A (6]/9
Fk006A (25]207
Fk21/A (8]67
Fk076A (11]93
Fk22/A (2]17
Fk06/A (7]62
Fk195A (1]10
Fk2/8A (6]63
Fk08/A (2]21
Fk259A (6]66
Fk/01A (3]38
Fk250A (3]/3
Fk09/A (6]101
Fk130A (3]52
Fk16/A (2]38
Fk362A (2]/0
Fk052A (3]67
Fk2/9A (1]2/
Fk260A (1]25
Fk109A (3]87
Fk067A (1]37
Fk098A (0]9
Fk276A (0]11
Fk237A (0]1/
Fk/3/A (0]21
Fk072A (0]7
Fk/00A (0]16
Fk008A (0]1/
Fk531A (0]6
Fk19/A (0]23
Fk202A (0]9
(20092010)
N hospitals 57
Minimum 4.1
First quartile 12
Median 16.5
Third quartile 21.5
Maximum 51.2
N hospitals 56
Minimum 0
First quartile 4.3
Median 11.9
Third quartile 21.4
Maximum 46.4
116
Germany
Year
2003 17 175 20 920 19 997 17 347 - - - -
2004 16 145 22 1107 22 1217 22 606 - - 1 1
2005 15 119 17 827 17 961 17 569 12 105 12 117
2006 15 85 18 799 18 850 16 529 14 148 12 162
2007 11 75 12 853 12 977 12 648 10 173 11 197
2008 11 209 14 1090 14 1615 13 451 11 235 11 167
2009 16 346 17 1893 17 2803 17 952 15 479 16 287
2010 16 363 17 1980 17 3024 16 1009 15 478 15 315
Penicillin R <1 <1 <1 1 <1 <1 <1 <1
Macrolides RI 11 13 17 12 8 10 8 9
Escherichia coli
Third-gen. cephalosporins R <1 2 2 4 8 5 8 8
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 7 7 3 3 7 <1 3 <1
HL Gentamicin R 47 42 34 29 67 39 40 47
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 47 61 52 38 73 35 45 45
Vancomycin R 3 11 10 8 15 6 6 8
Carbapenems R - - 2 <1 2 <1 <1 <1
Piperacillin R - <1 18 17 17 9 13 16
Ceftazidime R - <1 11 12 17 8 11 8
Carbapenems R - <1 25 17 22 11 11 13
Aminoglycosides R - <1 12 18 9 10 7 10
Fluoroquinolones R - <1 23 28 28 22 17 18
117
Characteristic
S. pneumoniae
n=682
S. aureus
n=3 865
E. coli
n=5 803
E. faecalis
n=1 106
E. faecium
n=845
K. pneumoniae
n=949
P. aeruginosa
n=594
Isolate source
Blood 91 3 100 20 100 24 100 0 100 7 99 13 99 12
CSF 9 3 - - <1 8 - - - - 1 29 1 13
Gender
Male 35 3 42 19 31 28 48 1 47 6 44 15 48 11
Female 30 4 24 20 37 22 24 0 29 7 31 10 24 16
Unknown 35 3 34 20 32 22 28 0 23 10 26 13 28 8
Age (years)
04 8 4 2 3 1 9 2 0 3 5 3 8 2 0
519 2 7 1 4 1 24 <1 0 1 0 <1 0 1 13
2064 37 4 27 17 22 28 26 1 35 7 28 18 29 19
65 and over 52 2 69 22 76 23 71 0 62 8 69 11 68 9
Unknown - - - - <1 0 - - - - - - - -
Hospital department
ICU 24 2 18 22 13 25 22 1 42 7 19 20 22 21
Internal med. 51 3 47 20 55 21 45 0 29 7 43 9 37 8
Surgery 3 0 12 22 7 27 11 0 11 3 11 9 10 10
Other 20 4 21 17 22 31 21 0 18 10 24 18 27 10
Unknown 2 0 1 20 3 27 2 0 1 0 3 4 4 14
118
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
0L0111 (5]29
0L1302 (1]15
0L0102 (3]/9
0L0301 (2]35
0L0911 (6]123
0L0/02 (1]21
0L0908 (1]/9
0L0110 (2]165
0L130/ (0]1/
0L0/01 (0]18
0L0107 (0]37
0L0907 (0]9/
0L0202 (0]5
0L1303 (0]20
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
0L011079 (12]1/
0L130312 (16]27
0L090833 (7]1/
0L09071/ (8]19
0L0/01C (2]5
0L0110/2 (7]18
0L091125 (13]3/
0L091127 (/]11
0L011037 (9]25
0L090803 (9]26
0L091122 (1/]/1
0L011063 (/]12
0L09081/ (5]15
0L011005 (3]9
0L091119 (5]15
0L030102 (3]9
0L011016 (5]15
0L090901 (2]6
0L130307 (12]37
0L011068 (6]19
0L090806 (19]61
0L130201 (33]108
0L130/03 (1/]/6
0L090905 (7]23
0L091108 (3]10
0L090903 (3]10
0L01101/ (6]20
0L0/01 (3]10
0L090801 (15]53
0L01100/ (5]18
0L011038 (11]/0
0L130320 (6]22
0L090706 (9]33
0L090808 (3]11
0L030109 (9]33
0L091126 (13]/8
0L09080/ (7]26
0L090710 (7]26
0L011012 (7]26
0L011021 (11]/1
0L090906 (2]8
0L090802 (3]12
0L011025 (7]28
0L090709 (1/]57
0L090705 (25]102
0L030110 (5]21
0L09113/ (5]21
0L030108 (9]38
0L090713 (/]17
0L0/0201 (7]30
0L090716 (22]95
0L090707 (9]/0
0L01102/ (7]32
0L091116 (3]1/
0L011085 (7]33
0L090701 (15]71
0L091132 (11]53
0L091102 (3]15
0L011022 (/]20
0L011015 (1]5
0L011020 (10]50
0L090812 (2]10
0L011006 (2]10
0L091133 (5]26
0L0911/3 (/]21
0L091101 (8]/2
0L090719 (2]11
0L09110/ (2]11
0L0110/5 (/]23
0L030801 (1]6
0L011101 (27]163
0L091131 (/]25
0L070103 (3]19
0L120301 (19]125
0L011010 (5]33
0L011031 (3]20
0L090718 (6]/0
0L011066 (3]20
0L090807 (3]20
0L011003 (3]20
0L070101 (16]110
0L090708 (6]/2
0L030103 (3]21
0L011029 (1]7
0L091110 (1]7
0L091135 (/]29
0L091107 (2]15
0L091129 (3]23
0L09070/ (/]31
0L011026 (2]16
0L091121 (1]8
0L0/0202 (2]17
0L2020 (7]62
0L011083 (9]80
0L0102A (19]170
0L030101 (/]37
0L011061 (1]10
0L011087 (1]10
0L010702 (1]10
0L090715 (2]22
0L091120 (3]33
0L0/01A (1/]155
0L011062 (1]12
0L011017 (2]25
0L091105 (2]28
0L0102 (1]1/
0L091117 (3]51
0L0/020/ (1]17
0L010701 (3]56
0L011007 (1]25
0L011086 (1]26
0L090832 (0]7
0L0110// (0]10
0L011018 (0]9
0L011039 (0]12
0L0/010 (0]8
0L091128 (0]5
0L011027 (0]5
0L011028 (0]13
0L091106 (0]22
0L0110/1 (0]8
0L090819 (0]1/
0L09111/ (0]9
0L091112 (0]6
0L011001 (0]11
0L011102 (0]6
0L030107 (0]6
0L070102 (0]8
N laboratories 14
Minimum 0
First quartile 0
Median 1.6
Third quartile 5.7
Maximum 17.2
N hospitals 128
Minimum 0
First quartile 10.4
Median 19.1
Third quartile 27.3
Maximum 85.7
Germany
Note. Individual laboratories may serve a large number of hospitals over a
wide geographical area within Germany.
119
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
0L070102 (6]9
0L011102 (3]5
0L011019 (11]19
0L011037 (19]/2
0L011016 (13]29
0L030108 (16]37
0L091119 (6]1/
0L011005 (10]2/
0L011006 (7]17
0L011007 (16]39
0L011101 (108]266
0L090813 (2]5
0L030106 (2]5
0L130312 (10]27
0L091135 (23]66
0L011066 (17]/9
0L011025 (16]/8
0L09111/ (3]9
0L011058 (2]6
0L011032 (3]9
0L030107 (/]12
0L130201 (3/]106
0L090707 (8]25
0L011001 (7]22
0L011067 (/]13
0L011021 (1/]/6
0L090710 (8]27
0L091106 (10]3/
0L091101 (16]55
0L120301 (/6]159
0L011068 (6]21
0L011020 (23]81
0L090709 (31]111
0L0102A (82]295
0L011083 (36]130
0L090819 (13]/7
0L0110// (3]11
0L01100/ (6]22
0L091132 (18]67
0L090906 (9]3/
0L01101/ (10]38
0L090716 (/1]156
0L011085 (11]/2
0L091125 (11]/3
0L030109 (15]59
0L090801 (21]83
0L011027 (2]8
0L091105 (15]60
0L090832 (2]8
0L09113/ (3]12
0L091121 (/]16
0L0110/5 (8]32
0L011087 (3]12
0L070101 (/5]183
0L01102/ (18]7/
0L091102 (7]29
0L091120 (13]5/
0L010702 (6]25
0L030102 (6]25
0L030103 (11]/6
0L091127 (3]13
0L09071/ (6]26
0L090806 (12]53
0L091133 (9]/0
0L090705 (17]76
0L090719 (/]18
0L011061 (6]27
0L0102 (2]9
0L090708 (13]59
0L090701 (22]100
0L010703 (6]28
0L011003 (7]33
0L130320 (7]33
0L090905 (7]33
0L011038 (12]57
0L011063 (/]19
0L091129 (10]/9
0L0/0201 (11]5/
0L090902 (1]5
0L011078 (1]5
0L091116 (2]10
0L090903 (1]5
0L091108 (/]20
0L091112 (2]10
0L011026 (6]30
0L130/03 (1/]71
0L011017 (6]31
0L011010 (8]/2
0L130307 (/]21
0L030101 (13]69
0L090802 (6]32
0L091131 (8]/3
0L2020 (9]/9
0L09070/ (6]33
0L011062 (8]//
0L090715 (12]67
0L011022 (11]63
0L0/01 (/]23
0L0/020/ (5]29
0L0/01A (31]182
0L091122 (17]100
0L091126 (11]65
0L011088 (2]12
0L011086 (7]/2
0L090713 (3]19
0L0911/3 (5]32
0L011012 (7]/5
0L011031 (7]/5
0L090718 (8]52
0L091107 (3]20
0L090812 (1]7
0L011028 (2]1/
0L090706 (5]38
0L010701 (16]122
0L090803 (/]31
0L0/0202 (5]39
0L090833 (3]2/
0L011081 (1]8
0L091117 (6]53
0L09110/ (3]27
0L011029 (3]28
0L070103 (2]21
0L0110/2 (/]/3
0L090901 (2]23
0L011039 (2]2/
0L09080/ (1]12
0L030110 (2]26
0L090807 (2]31
0L011015 (1]18
0L011018 (1]19
0L0110/1 (0]11
0L090808 (0]7
0L030801 (0]5
0L011009 (0]5
0L09081/ (0]7
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
0L011079 (5]8
0L091135 (3]5
0L091125 (2]5
0L091120 (2]6
0L091132 (2]6
0L011058 (2]6
0L011086 (3]9
0L090901 (2]7
0L011020 (3]12
0L011038 (2]8
0L011101 (20]85
0L0110/2 (2]9
0L090709 (/]19
0L090819 (1]5
0L011005 (1]5
0L090905 (2]10
0L130/03 (3]16
0L090801 (2]11
0L070101 (/]23
0L090833 (1]6
0L091122 (1]6
0L011012 (1]6
0L090806 (3]18
0L2020 (2]13
0L130201 (3]20
0L090708 (1]7
0L011015 (1]7
0L090707 (1]7
0L091101 (1]7
0L090701 (2]1/
0L090803 (1]8
0L0102A (5]/9
0L011010 (1]10
0L011031 (1]10
0L091131 (1]10
0L011021 (1]11
0L090716 (2]22
0L01102/ (1]15
0L011083 (1]17
0L120301 (2]/0
0L030108 (0]6
0L011017 (0]6
0L090705 (0]12
0L030103 (0]12
0L130312 (0]5
0L0/0201 (0]9
0L090715 (0]10
0L011001 (0]5
0L090706 (0]6
0L030109 (0]12
0L011025 (0]5
0L0/010 (0]5
0L011022 (0]11
0L091105 (0]16
0L09070/ (0]5
0L0110// (0]5
0L011062 (0]5
0L0/01A (0]35
0L01100/ (0]6
0L090802 (0]8
0L011007 (0]9
0L030101 (0]16
0L130320 (0]5
0L090906 (0]9
(20092010)
N hospitals 135
Minimum 0
First quartile 16.9
Median 22.2
Third quartile 27.8
Maximum 66.7
N hospitals 64
Minimum 0
First quartile 0
Median 10.1
Third quartile 19.4
Maximum 62.5
120
Greece
Year
2003 - - 34 682 35 1076 32 621 - - - -
2004 - - 35 610 39 1131 34 565 - - - -
2005 - - 35 682 35 1140 34 737 33 774 33 699
2006 - - 42 828 41 1253 39 949 38 841 38 818
2007 - - 41 819 43 1234 39 999 38 972 37 802
2008 - - 46 907 44 1462 42 992 41 1093 42 920
2009 - - 48 1025 49 1831 47 1190 47 1649 47 1123
2010 - - 44 902 45 1549 43 1105 40 1703 42 1014
Penicillin R - - - - - - - -
Penicillin RI - - - - - - - -
Macrolides RI - - - - - - - -
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 52 59 54 57 65 52 61 43
Vancomycin R 7 4 4 5 7 7 6 3
HL Gentamicin R 40 52 34 35 44 52 63 53
Vancomycin R 18 20 37 42 37 28 27 23
Carbapenems R - - 28 33 42 37 44 49
Piperacillin R - - 30 39 38 34 33 39
Ceftazidime R - - 27 34 40 37 34 40
Carbapenems R - - 39 48 47 49 44 43
121
Characteristic
S. pneumoniae
n=.
S. aureus
n=1 863
E. coli
n=3 322
E. faecalis
n=1 372
E. faecium
n=870
K. pneumoniae
n=3 320
P. aeruginosa
n=2 094
Isolate source
Blood - - 100 40 100 24 100 5 100 25 97 71 97 43
CSF - - - - <1 7 - - - - 3 89 3 68
Gender
Male - - 8 35 8 23 6 3 9 25 5 65 6 38
Female - - 4 34 8 17 4 0 7 31 4 57 4 32
Unknown - - 88 41 84 25 89 5 84 24 91 73 90 44
Age (years)
04 - - 6 36 7 21 9 9 8 20 8 79 6 43
519 - - - - <1 14 - - - - <1 0 <1 0
2064 - - 3 25 3 12 1 0 3 33 2 44 2 22
65 and over - - 3 31 5 29 3 0 3 26 3 57 3 27
Unknown - - 88 41 86 24 86 4 86 25 88 72 89 45
Hospital department
ICU - - 13 51 6 31 31 10 33 30 46 91 47 56
Internal med. - - 73 37 77 23 51 2 49 24 37 53 39 34
Surgery - - 10 52 10 32 14 3 15 15 13 68 12 34
Other - - 3 28 4 8 2 0 3 17 4 35 2 18
Unknown - - 2 48 3 16 2 7 1 20 1 41 1 6
122
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
6k0/8X (6]8
6k022X (6]8
6k072X (5]7
6k032X (12]18
6k012X (15]2/
6k00/X (10]16
6k071X (5]9
6k0/1X (25]/6
6k038X (7]13
6k059X (2/]/5
6k039X (25]50
6k001X (2/]51
6k070X (1/]30
6k007X (26]56
6k068X (17]37
6k01/X (18]/0
6k0/0X (87]195
6k033X (22]50
6k028X (25]61
6k02/X (33]81
6k055X (6]15
6k062X (/]10
6k037X (39]98
6k030X (33]83
6k0/9X (11]28
6k010X (9]23
6k015X (26]69
6k026X (10]27
6k013X (19]52
6k066X (/]11
6k005X (9]25
6k0/2X (10]28
6k050X (13]38
6k051X (8]25
6k0/3X (17]5/
6k075X (17]56
6k0/7X (39]132
6k031X (21]73
6k0//X (2]7
6k060X (2]7
6k027X (11]39
6k009X (2]9
6k035X (15]68
6k008X (2]11
6k018X (1]18
N hospitals 45
Minimum 5.6
First quartile 32
Median 39.8
Third quartile 47.1
Maximum 75
Greece
No data reported
123
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
6k072X (/]7
6k0/9X (11]21
6k007X (16]33
6k059X (20]/8
6k066X (6]16
6k013X (17]/6
6k005X (2/]67
6k055X (16]/5
6k022X (3]9
6k039X (23]7/
6k037X (19]6/
6k075X (32]108
6k0//X (10]3/
6k032X (10]3/
6k0/0X (81]277
6k060X (6]21
6k001X (32]120
6k01/X (26]98
6k0/1X (2/]92
6k033X (20]79
6k009X (3]12
6k035X (33]135
6k012X (11]/5
6k051X (5]21
6k0/3X (1/]59
6k068X (9]38
6k02/X (//]191
6k030X (27]12/
6k00/X (5]23
6k0/7X (65]305
6k018X (10]/8
6k0/8X (5]2/
6k015X (22]110
6k070X (7]35
6k028X (/5]235
6k062X (2]11
6k038X (7]39
6k011X (6]3/
6k0/2X (9]52
6k027X (19]120
6k031X (15]107
6k050X (12]97
6k052X (/]3/
6k010X (/]3/
6k008X (2]17
6k071X (/]36
6k026X (2]35
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
6k015X (109]12/
6k037X (168]196
6k005X (66]79
6k0/1X (81]97
6k01/X (1/0]171
6k068X (7/]93
6k0/0X (3/0]/29
6k0/3X (63]80
6k031X (10/]133
6k033X (50]65
6k072X (10]13
6k02/X (9/]123
6k001X (81]106
6k026X (25]33
6k013X (15]20
6k022X (6]8
6k032X (6]8
6k0/9X (20]27
6k010X (56]77
6k007X (29]/0
6k039X (165]228
6k012X (/5]63
6k070X (2/]3/
6k0/2X (7]10
6k050X (39]57
6k030X (130]190
6k075X (58]89
6k0/8X (22]3/
6k035X (81]126
6k011X (10]16
6k018X (9]15
6k059X (2/]/2
6k071X (5]9
6k038X (5]9
6k0/7X (78]155
6k062X (5]10
6k028X (56]112
6k027X (55]132
6k055X (11]28
6k0//X (2]8
6k00/X (1]6
(20092010)
N hospitals 47
Minimum 5.7
First quartile 18.2
Median 23.8
Third quartile 29.6
Maximum 57.1
N hospitals 41
Minimum 16.7
First quartile 60
Median 72.4
Third quartile 76.9
Maximum 87.9
124
Hungary
Year
2003 20 134 27 858 27 842 25 279 - - - -
2004 26 143 30 1020 28 967 26 366 - - - -
2005 23 133 28 1083 27 1046 27 476 21 314 24 507
2006 23 151 27 1127 26 1135 25 453 24 302 25 546
2007 22 146 26 1199 25 1179 26 400 23 322 24 518
2008 22 166 26 1181 25 1057 21 428 23 369 25 513
2009 22 143 26 1068 25 1057 27 444 24 361 25 518
2010 27 140 30 1224 29 1385 29 591 29 514 28 636
Penicillin R 3 <1 4 1 5 8 3 6
Penicillin RI 24 16 21 18 23 27 12 15
Macrolides RI 25 25 32 19 36 32 19 24
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI <1 2 1 3 2 3 2 1
HL Gentamicin R 87 57 43 47 48 53 51 51
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 96 80 64 67 53 62 70 62
Vancomycin R <1 <1 <1 <1 <1 3 1 2
Carbapenems R . . <1 <1 <1 <1 <1 5
Piperacillin R - - 10 9 11 13 19 14
Ceftazidime R - - 10 8 9 11 12 11
Carbapenems R - - 18 16 19 26 27 25
125
Characteristic
S. pneumoniae
n=283
S. aureus
n=2 292
E. coli
n=2 413
E. faecalis
n=848
E. faecium
n=181
K. pneumoniae
n=871
P. aeruginosa
n=1 151
Isolate source
Blood 73 13 100 30 100 34 100 0 100 2 99 43 97 26
CSF 27 16 - - - - - - - - 1 14 3 14
Gender
Male 61 14 63 29 49 36 66 0 61 3 60 46 63 27
Female 38 13 36 30 51 33 33 0 38 0 39 38 34 25
Unknown 1 0 1 47 1 17 2 0 1 0 <1 67 2 14
Age (years)
04 8 13 2 10 2 7 3 0 4 0 7 46 5 12
519 7 19 1 6 1 23 1 0 1 0 1 42 1 20
2064 52 14 46 28 39 34 41 0 49 2 46 42 49 30
65 and over 33 12 51 33 57 35 55 0 47 1 46 44 45 23
Hospital department
ICU 27 13 19 37 13 32 35 0 41 3 30 46 39 32
Internal med. 18 15 21 29 22 29 18 0 13 0 15 32 9 17
Surgery 1 0 9 35 6 29 6 0 4 0 7 37 9 13
Other 39 10 33 23 41 31 26 0 22 3 29 41 24 22
Unknown 14 22 17 33 19 49 14 0 20 0 20 51 18 27
126
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
hu006 (3]6
hu005 (3]7
hu025 (6]16
hu028 (3]11
hu019 (3]12
hu029 (6]28
hu035 (1]6
hu026 (1]6
hu032 (3]20
hu02/ (1]8
hu009 (2]26
hu03/ (1]17
hu022 (3]56
hu002 (0]12
hu020 (0]11
hu033 (0]7
hu0/0 (0]8
hu027 (0]5
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
hu022S (17]26
hu038A (1/]25
hu033A (6/]133
hu006A (18]39
hu00/6 (5]11
hu007 (13]29
hu005A (26]59
hu039A (9]21
hu020A (21]/9
hu009A (70]16/
hu029v (93]252
hu0126 (16]//
hu007C (6]17
hu0/0A (19]5/
hu020C (3]9
hu0196 (3]9
hu009 (1/]/2
hu008F (2]7
hu035A (22]8/
hu026A (25]96
hu022P (11]/3
hu032A (3/]133
hu019h (2]8
hu0/1A (7]28
hu001 (3]12
hu028A (/5]190
hu005} (3]13
hu022l (32]139
hu031A (1]5
hu019A (22]120
hu006 (3]18
hu022 (1]7
hu02/A (6]/3
hu03/A (10]78
hu001k (1]8
hu0026 (/]3/
hu027A (/]35
hu002M (1]10
hu025A (9]90
hu006w (1]11
hu020L (1]1/
hu002 (0]6
hu03/C (0]12
hu037A (0]5
N laboratories 18
Minimum 0
First quartile 0
Median 13.8
Third quartile 25
Maximum 50
N hospitals 44
Minimum 0
First quartile 13.4
Median 25.3
Third quartile 36.6
Maximum 65.4
Hungary
127
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
hu009A (115]186
hu022S (22]36
hu005A (20]37
hu028A (118]252
hu033A (/2]110
hu032A (56]1/7
hu025A (/8]128
hu0/1A (1/]39
hu0160 (2]6
hu007 (1/]/2
hu020C (2]6
hu020A (12]37
hu03/A (3/]108
hu0/0A (1/]/5
hu035A (22]71
hu022l (81]262
hu029v (77]253
hu026A (15]50
hu006 (2]7
hu009 (8]3/
hu006A (12]53
hu02/A (11]50
hu039A (6]29
hu037A (1]5
hu002M (1]5
hu022 (1]5
hu0126 (/]22
hu03/C (2]11
hu020L (5]28
hu027A (11]65
hu001 (1]6
hu038A (3]18
hu031A (2]13
hu019A (15]115
hu0026 (3]27
hu022P (2]18
hu0196 (1]10
hu00/6 (1]12
hu001k (0]12
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
hu007C (/]6
hu0126 (6]10
hu005A (8]1/
hu032A (65]117
hu039A (5]9
hu001P (6]11
hu028A (98]181
hu006A (8]16
hu001k (/]8
hu009A (16]32
hu029v (61]132
hu007 (9]20
hu027A (/]9
hu025A (18]/8
hu033A (16]/3
hu0026 (5]15
hu035A (6]23
hu03/A (6]2/
hu020A (2]8
hu0/1A (3]13
hu022l (/]20
hu031A (1]5
hu026A (3]23
hu0/0A (1]11
hu019A (1]17
hu005} (0]6
hu02/A (0]8
hu009 (0]5
(20092010)
N hospitals 39
Minimum 0
First quartile 16.9
Median 23.5
Third quartile 33.3
Maximum 61.8
N hospitals 28
Minimum 0
First quartile 20
Median 37.4
Third quartile 52.1
Maximum 66.7
128
Iceland
Year
2003 2 35 2 64 2 100 2 22 - - - -
2004 2 54 2 55 2 119 1 27 - - - -
2005 2 37 2 78 2 130 2 31 2 22 1 13
2006 2 52 2 57 2 130 2 40 2 13 1 9
2007 2 42 2 65 2 105 1 29 2 27 1 11
2008 2 46 2 63 2 123 2 17 1 24 2 7
2009 2 35 2 59 2 111 2 51 2 27 2 16
2010 2 37 2 65 2 104 2 31 2 27 2 12
Penicillin R <1 2 <1 <1 2 <1 <1 3
Penicillin RI 9 17 8 6 7 9 <1 5
Macrolides RI 20 8 17 10 17 22 3 11
Oxacillin/Meticillin R <1 <1 <1 <1 <1 2 <1 2
Escherichia coli
Aminoglycosides R 2 <1 <1 7 6 7 7 3
Third-gen. cephalosporins R 1 <1 <1 <1 2 <1 2 4
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI <1 <1 <1 7 <1 <1 <1 <1
HL Gentamicin R <1 5 <1 3 13 30 15 13
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R <1 13 <1 14 14 43 36 13
Vancomycin R <1 <1 <1 <1 <1 <1 8 6
Aminoglycosides R - - <1 <1 <1 4 <1 <1
Fluoroquinolones R - - <1 <1 <1 8 <1 <1
Third-gen. cephalosporins R - - <1 <1 <1 4 <1 4
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 8 <1 <1 <1 13 8
Ceftazidime R - - 8 <1 <1 <1 6 8
Carbapenems R - - 8 <1 <1 <1 <1 <1
Aminoglycosides R - - <1 <1 <1 <1 <1 <1
Fluoroquinolones R - - <1 <1 <1 <1 13 17
129
Characteristic
S. pneumoniae
n=72
S. aureus
n=124
E. coli
n=194
E. faecalis
n=41
E. faecium
n=41
K. pneumoniae
n=54
P. aeruginosa
n=28
Isolate source
Blood 96 3 100 1 99 9 100 0 100 7 100 2 100 0
CSF 4 0 - - 1 0 - - - - - - - -
Gender
Male 53 3 62 1 46 11 76 0 56 13 57 3 71 0
Female 47 3 38 0 54 7 24 0 44 0 43 0 29 0
Age (years)
04 15 18 3 0 4 0 5 0 - - - - 4 0
519 4 0 4 0 2 0 - - 2 0 - - - -
2064 43 0 40 2 30 16 32 0 37 7 39 0 32 0
65 and over 38 0 53 0 64 6 63 0 61 8 61 3 64 0
Hospital department
ICU 3 0 2 0 2 33 10 0 10 0 - - 4 0
Internal med. 15 9 25 0 20 3 15 0 10 0 15 0 25 0
Surgery - - 5 0 3 17 10 0 15 0 4 0 7 0
Other 78 2 67 1 73 10 63 0 59 13 80 2 61 0
Unknown 4 0 1 0 3 0 2 0 7 0 2 0 4 0
130
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
lS003 (1]10
lS001 (1]62
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lS001A (1]100
lS003A (0]18
N laboratories 2
Minimum 1.6
First quartile 1.6
Median 5.8
Third quartile 10
Maximum 10
N hospitals 2
Minimum 0
First quartile 0
Median 0.5
Third quartile 1
Maximum 1
Iceland
131
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lS001A (16]165
lS001 (0]7
lS001C (0]7
lS0016 (0]8
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lS001A (1]/8
(20092010)
N hospitals 4
Minimum 0
First quartile 0
Median 0
Third quartile 4.8
Maximum 9.7
N hospitals 1
Minimum 2.1
First quartile 2.1
Median 2.1
Third quartile 2.1
Maximum 2.1
132
Ireland
Year
2003 24 363 26 1108 26 978 21 348 - - - -
2004 28 399 38 1286 37 1235 29 418 - - - -
2005 31 397 38 1360 39 1424 33 502 15 42 11 29
2006 32 406 38 1347 39 1638 32 550 28 211 23 128
2007 33 435 41 1332 42 1750 37 598 31 237 29 172
2008 35 442 38 1242 41 1875 37 685 33 307 29 191
2009 34 356 41 1261 41 2012 38 671 37 316 30 236
2010 32 310 39 1207 40 2121 38 670 34 318 30 219
Penicillin R 3 3 3 3 6 6 6 5
Penicillin RI 12 10 11 16 17 23 20 18
Macrolides RI 12 14 12 16 17 17 17 16
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 5 <1 4 5 2 <1 3 2
HL Gentamicin R 32 42 42 43 38 31 34 29
Vancomycin R <1 1 3 3 3 3 <1 <1
HL Gentamicin R 54 56 52 44 36 27 38 39
Vancomycin R 19 22 31 36 33 35 38 39
Carbapenems R - - <1 <1 <1 <1 <1 <1
Carbapenems R - - 11 9 9 6 8 6
133
Characteristic
S. pneumoniae
n=666
S. aureus
n=2 468
E. coli
n=4 122
E. faecalis
n=571
E. faecium
n=768
K. pneumoniae
n=632
P. aeruginosa
n=440
Isolate source
Blood 97 20 100 25 100 22 100 1 100 38 100 10 99 8
CSF 3 5 - - <1 11 - - - - - - 1 0
Gender
Male 54 18 64 26 45 26 59 0 57 40 55 11 55 7
Female 46 20 36 25 55 19 41 0 43 36 45 9 45 8
Unknown - - - - <1 0 <1 100 - - - - - -
Age (years)
04 12 21 9 7 3 4 10 0 3 13 4 18 4 6
519 4 8 4 10 1 8 1 0 2 20 1 0 3 31
2064 37 15 38 21 30 19 35 1 41 50 45 9 36 11
65 and over 47 22 49 33 65 25 54 1 54 32 49 10 57 4
Unknown - - - - <1 0 - - - - - - - -
Hospital department
ICU 4 8 3 37 3 24 4 0 7 33 3 0 6 12
Internal med. 13 23 12 39 13 26 13 0 7 38 8 6 12 6
Surgery 1 29 6 30 6 25 5 0 5 31 4 8 6 7
Other 30 16 21 17 23 17 18 1 12 29 19 4 15 13
Unknown 53 20 58 24 55 23 60 1 69 41 67 12 61 6
134
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
lL/3 (7]12
lL30 (3]9
lL70 (/]13
lL62 (/]13
lL/6 (5]17
lL/8 (/]1/
lL7/ (2]7
lL20 (9]32
lL/7 (6]22
lL/ (11]/1
lL25 (9]35
lL// (3]12
lL65 (2]9
lL2 (7]37
lL58 (3]16
lL3/ (8]/6
lL73 (1]6
lL31 (3]18
lL10 (12]7/
lL61 (2]13
lL6 (2]13
lL50 (7]58
lL1 (/]38
lL32 (3]29
lL60 (1]16
lL15 (2]33
lL18 (0]7
lL/9 (0]12
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lL52 (9]15
lL58 (32]58
lL70 (21]/3
lL26 (5]11
lL30 (15]35
lL33 (12]30
lL13 (9]25
lL62 (6]17
lL7/ (12]35
lL3/ (39]115
lL51 (5]15
lL79 (2]6
lL29 (50]152
lL61 (6]19
lL/8 (23]73
lL// (11]36
lL38 (/]1/
lL/7 (1/]50
lL1 (50]179
lL10 (25]91
lL35 (3]11
lL32 (11]/3
lL11 (15]61
lL50 (/0]166
lL15 (39]162
lL73 (/]17
lL20 (33]1//
lL31 (9]/1
lL2 (/1]192
lL/3 (5]2/
lL6 (11]53
lL/ (2/]118
lL6/ (3]15
lL80 (2]13
lL18 (/]26
lL12 (6]/0
lL72 (1]7
lL60 (6]/6
lL76 (1]9
lL63 (1]13
lL71 (1]1/
lL21 (1]17
lL/6 (3]62
lL/9 (1]21
lL59 (1]36
lL77 (0]19
lL65 (0]9
lL37 (0]5
lL36 (0]12
lL57 (0]2/
N laboratories 28
Minimum 0
First quartile 13.7
Median 18.8
Third quartile 28.3
Maximum 58.3
N hospitals 50
Minimum 0
First quartile 13
Median 23.8
Third quartile 32.9
Maximum 60
Ireland
135
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lL23 (3]5
lL53 (/]10
lL29 (68]195
lL58 (37]108
lL6 (29]86
lL79 (5]15
lL26 (16]/9
lL36 (15]/7
lL35 (7]22
lL71 (7]23
lL21 (13]/3
lL20 (68]230
lL62 (1/]/8
lL75 (2]7
lL/ (/6]168
lL81 (3]11
lL32 (27]100
lL// (25]93
lL/3 (15]57
lL30 (15]57
lL3/ (/8]185
lL15 (60]237
lL1 (70]287
lL61 (9]39
lL76 (/]18
lL10 (29]131
lL/7 (2/]118
lL33 (8]/0
lL50 (/0]202
lL31 (17]89
lL38 (5]27
lL12 (1/]76
lL52 (5]29
lL72 (5]29
lL51 (8]/8
lL7/ (1/]8/
lL68 (1]6
lL63 (3]18
lL70 (10]63
lL80 (3]19
lL60 (1/]92
lL/8 (22]1/9
lL6/ (1]7
lL2 (/3]30/
lL73 (6]/7
lL13 (9]76
lL11 (10]93
lL18 (5]/7
lL/9 (2]22
lL/6 (2]30
lL57 (1]20
lL67 (0]12
lL59 (0]2/
lL37 (0]12
lL77 (0]2/
lL65 (0]16
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lL59 (3]8
lL20 (8]37
lL/ (8]39
lL71 (1]5
lL80 (1]5
lL18 (2]11
lL/6 (1]6
lL31 (1]6
lL2 (10]66
lL15 (8]60
lL10 (3]23
lL3/ (3]28
lL32 (1]11
lL58 (1]12
lL60 (1]1/
lL1 (3]58
lL/9 (0]6
lL21 (0]23
lL/7 (0]1/
lL50 (0]23
lL11 (0]11
lL30 (0]7
lL26 (0]5
lL/3 (0]5
lL29 (0]25
lL// (0]12
lL13 (0]9
lL/8 (0]12
lL6 (0]1/
lL12 (0]6
lL73 (0]6
lL36 (0]5
lL7/ (0]11
(20092010)
N hospitals 56
Minimum 0
First quartile 14.5
Median 19.9
Third quartile 28
Maximum 60
N hospitals 33
Minimum 0
First quartile 0
Median 0
Third quartile 15.2
Maximum 37.5
136
Italy
Year
2003 44 293 46 1480 17 923 44 634 - - - -
2004 37 271 42 1225 14 645 40 576 - - - -
2005 38 331 41 1479 16 1195 40 714 38 344 - -
2006 34 269 38 1164 13 910 35 650 32 321 12 183
2007 34 298 38 1167 14 1052 36 656 37 391 10 185
2008 27 194 30 939 14 957 31 580 27 331 11 168
2009 21 216 23 987 9 863 22 509 22 313 10 195
2010 33 323 35 1886 23 2623 35 1106 34 739 23 517
Penicillin R 5 5 5 <1 4 3 3 5
Penicillin RI 13 14 9 7 15 10 6 9
Macrolides RI 37 29 31 33 31 26 21 29
Escherichia coli
Carbapenems R - - - - <1 <1 <1 <1
HL Gentamicin R 39 36 38 38 39 47 49 50
Vancomycin R 2 2 3 3 2 2 3 2
HL Gentamicin R 44 39 36 48 53 49 52 59
Vancomycin R 24 21 19 18 11 6 4 4
Carbapenems R - - - 1 1 2 1 15
Piperacillin R - - - 23 20 20 24 21
Ceftazidime R - - - 20 25 24 16 18
Carbapenems R - - - 21 27 33 31 22
137
Characteristic
S. pneumoniae
n=431
S. aureus
n=2 744
E. coli
n=3 299
E. faecalis
n=956
E. faecium
n=600
K. pneumoniae
n=973
P. aeruginosa
n=697
Isolate source
Blood 90 8 100 37 100 38 100 2 100 4 98 44 98 24
CSF 10 7 - - <1 27 - - - - 2 56 2 27
Gender
Male 47 8 54 39 44 46 58 3 54 4 54 49 58 24
Female 39 9 36 37 46 33 34 1 35 4 37 42 34 25
Unknown 14 3 10 24 10 34 8 1 11 3 9 21 8 25
Age (years)
04 8 6 2 25 1 8 4 0 1 0 3 45 1 20
519 2 0 1 13 1 21 <1 0 1 0 1 50 <1 67
2064 24 5 22 27 17 36 18 2 19 3 22 44 20 37
65 and over 41 6 47 41 44 38 51 2 47 3 45 48 41 17
Unknown 24 15 28 39 37 42 28 3 33 6 28 37 37 25
Hospital department
ICU 6 8 7 41 4 42 13 2 13 4 13 57 17 35
Internal med. 21 9 34 38 30 38 32 2 28 5 30 47 26 19
Surgery 2 13 8 42 11 42 10 2 10 3 11 35 10 16
Other 35 10 17 29 25 39 13 2 18 3 16 34 15 19
Unknown 35 5 34 37 30 36 31 3 32 4 30 43 31 28
138
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
lT03/ (9]25
lT077 (2]6
lT0/2 (2]7
lT059 (2]1/
lT02/ (2]15
lT089 (1]1/
lT091 (1]15
lT00/ (2]31
lT072 (2]32
lT019 (1]17
lT06/ (1]18
lT061 (3]71
lT037 (1]53
lT067 (0]13
lT0// (0]5
lT090 (0]13
lT021 (0]7
lT028 (0]5
lT060 (0]26
lT022 (0]7
lT031 (0]7
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lT0089 (/5]68
lT0035 (35]53
lT00/0 (30]/7
lT0037 (102]167
lT0086 (25]/3
lT003/ (8/]160
lT00/C (6]12
lT00// (3]6
lT0091 (39]79
lT0085 (20]//
lT007/ (20]/5
lT00/6 (3/]81
lT0070 (1/]35
lT0031 (/2]108
lT0075 (7]18
lT00/2 (15]39
lT0052 (21]55
lT0072 (51]136
lT0022 (23]62
lT0023 (17]/6
lT0060 (21]57
lT00/F (1/]38
lT00/A (11]30
lT00/0 (9]25
lT00/7 (23]65
lT00/ (7]20
lT00/L (12]37
lT0092 (10]31
lT0061 (73]230
lT00/5 (15]/8
lT0065 (5]16
lT0090 (9]33
lT0059 (35]13/
lT0028 (9]35
lT006/ (13]53
lT0067 (/1]169
lT0001 (2/]101
lT00/9 (6]29
lT0019 (27]152
lT0088 (3]18
lT0077 (6]/1
lT0079 (1]7
lT0071 (1]16
lT002/ (3]55
N laboratories 21
Minimum 0
First quartile 0
Median 5.6
Third quartile 7.1
Maximum 36
N hospitals 44
Minimum 5.5
First quartile 25.9
Median 36.8
Third quartile 43.2
Maximum 66.2
Italy
139
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lT0088 (37]55
lT00/2 (2/]/1
lT0075 (3/]60
lT00/0 (20]37
lT00/A (35]68
lT00/9 (21]/3
lT0085 (31]65
lT003/ (1/0]301
lT00/L (70]156
lT0092 (31]73
lT0089 (62]1/6
lT0091 (53]127
lT00/ (27]67
lT00/F (33]83
lT0023 (30]76
lT0067 (52]132
lT0086 (22]57
lT00/0 (26]68
lT0090 (2/]65
lT00/C (15]/1
lT0035 (28]78
lT0019 (107]30/
lT0070 (26]79
lT0059 (98]301
lT0037 (88]276
lT00/6 (58]192
lT0001 (3/]118
lT0072 (23]88
lT00/7 (18]88
lT0079 (0]1/
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
lT0071 (11]11
lT0060 (16]16
lT0077 (15]15
lT0022 (12]12
lT007/ (6]6
lT0052 (18]18
lT0092 (36]/3
lT006/ (16]22
lT0075 (32]/6
lT0072 (17]26
lT00/0 (13]20
lT00/9 (18]28
lT00/ (12]20
lT00/7 (18]30
lT00/A (5]10
lT0090 (/]8
lT0001 (25]51
lT0088 (10]21
lT003/ (16]3/
lT0085 (7]16
lT0031 (2/]59
lT0091 (1/]36
lT0035 (7]21
lT0019 (16]52
lT0070 (2]7
lT00/F (5]18
lT0037 (11]/0
lT00/2 (5]19
lT00/L (6]25
lT00/0 (5]21
lT0067 (5]22
lT0086 (3]1/
lT0028 (1]5
lT002/ (2]11
lT0089 (2]1/
lT0023 (2]1/
lT0059 (5]37
lT00/C (1]8
lT00/6 (2]21
lT0061 (2]67
lT0065 (0]6
(20092010)
N hospitals 30
Minimum 0
First quartile 32.9
Median 39.4
Third quartile 46.5
Maximum 67.3
N hospitals 41
Minimum 0
First quartile 22.7
Median 40.7
Third quartile 65
Maximum 100
140
Latvia
Year
2004 4 17 7 87 - - - - - - - -
2005 5 36 7 127 - - - - - - - -
2006 7 37 11 172 10 62 10 56 6 28 9 16
2007 6 31 12 169 9 76 8 57 7 27 6 16
2008 3 18 12 164 10 90 9 51 11 40 6 11
2009 7 30 12 188 9 86 8 48 10 44 7 18
2010 4 38 10 155 8 98 8 61 8 64 6 21
Penicillin R - <1 <1 <1 <1 6 <1 5
Penicillin RI - <1 <1 <1 <1 6 <1 5
Macrolides RI - 7 3 3 <1 <1 3 5
Oxacillin/Meticillin R - 26 20 19 8 12 9 14
Escherichia coli
Aminopenicilins R - - - 44 43 48 43 50
Carbapenems R - - - <1 <1 <1 2 <1
HL Gentamicin R - - - 50 - 27 38 47
Vancomycin R - - - <1 <1 <1 <1 <1
HL Gentamicin R - - - 73 <1 78 79 83
Vancomycin R - - - <1 <1 7 18 13
Carbapenems R - - - <1 <1 3 <1 <1
Piperacillin R - - - 17 31 30 17 19
Ceftazidime R - - - 29 13 36 17 10
Carbapenems R - - - 13 6 40 7 14
141
Characteristic
S. pneumoniae
n=67
S. aureus
n=339
E. coli
n=182
E. faecalis
n=64
E. faecium
n=45
K. pneumoniae
n=108
P. aeruginosa
n=35
Isolate source
Blood 79 4 100 11 100 19 100 0 100 16 98 54 97 12
CSF 21 0 - - - - - - - - 2 100 3 0
Gender
Male 52 0 50 13 28 25 59 0 51 9 55 54 60 14
Female 48 6 50 10 72 16 41 0 49 23 45 55 40 7
Age (years)
04 7 20 8 4 5 10 13 0 7 0 22 50 11 0
519 - - 2 0 4 13 - - - - 1 100 - -
2064 69 2 47 16 46 19 41 0 56 12 46 58 49 18
65 and over 24 0 40 8 42 17 45 0 33 20 31 52 37 8
Unknown - - 2 13 2 75 2 0 4 50 - - 3 0
Hospital department
ICU 58 0 21 13 25 30 36 0 64 21 37 75 54 16
Internal med. 4 33 36 10 24 14 16 0 11 20 13 36 17 0
Surgery 3 0 9 20 6 36 6 0 11 0 6 67 3 0
Other 18 0 26 13 24 19 30 0 11 0 26 50 23 13
Unknown 16 9 9 0 21 5 13 0 2 0 19 30 3 0
142
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
Lv003 (1]17
Lv00/ (0]36
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Lv013A (5]5
Lv007A (3]7
Lv001A (19]110
Lv00/A (7]88
Lv003A (3]//
Lv012A (1]22
Lv011A (0]5
Lv005A (0]18
Lv006A (0]6
Lv009A (0]6
Lv002A (0]23
N laboratories 2
Minimum 0
First quartile 0
Median 2.9
Third quartile 5.9
Maximum 5.9
N hospitals 11
Minimum 0
First quartile 0
Median 4.5
Third quartile 17.3
Maximum 100
Latvia
143
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Lv001A (13]37
Lv002A (2]7
Lv00/A (12]5/
Lv012A (3]17
Lv003A (/]5/
Lv005A (0]8
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Lv001A (29]38
Lv002A (12]20
Lv00/A (9]20
Lv012A (2]8
Lv003A (1]9
(20092010)
N hospitals 6
Minimum 0
First quartile 7.4
Median 19.9
Third quartile 28.6
Maximum 35.1
N hospitals 5
Minimum 11.1
First quartile 25
Median 45
Third quartile 60
Maximum 76.3
144
Lithuania
Year
2006 9 35 13 167 11 171 8 30 8 35 7 14
2007 10 67 12 240 13 235 10 56 10 41 7 21
2008 11 48 12 278 12 304 10 67 11 54 7 21
2009 10 46 13 258 13 297 11 57 12 68 8 21
2010 9 40 11 257 10 333 10 59 9 81 8 31
Penicillin R - - - <1 1 <1 7 8
Penicillin RI - - - 16 4 2 9 13
Macrolides RI - - - <1 9 6 7 <1
Oxacillin/Meticillin R - - - 13 9 11 11 14
Escherichia coli
Aminopenicilins R - - - 55 50 54 58 56
Carbapenems R - - - <1 <1 <1 <1 <1
HL Gentamicin R - - - 50 41 33 48 41
Vancomycin R - - - <1 <1 <1 <1 <1
HL Gentamicin R - - - 75 81 78 64 87
Vancomycin R - - - <1 <1 <1 11 8
Carbapenems R - - - <1 <1 <1 <1 <1
Piperacillin R - - - 21 5 14 20 6
Ceftazidime R - - - 31 <1 10 14 10
Carbapenems R - - - 21 30 24 19 27
145
Characteristic
S. pneumoniae
n=85
S. aureus
n=509
E. coli
n=628
E. faecalis
n=72
E. faecium
n=43
K. pneumoniae
n=148
P. aeruginosa
n=51
Isolate source
Blood 94 11 100 13 100 14 100 0 100 9 100 53 100 24
CSF 6 0 - - <1 33 - - - - - - - -
Gender
Male 68 3 54 12 39 16 69 0 53 17 59 53 63 25
Female 31 27 44 14 61 12 29 0 47 0 41 53 37 21
Unknown 1 0 1 0 <1 33 1 0 - - - - - -
Age (years)
04 25 14 5 4 5 10 14 0 14 0 11 88 4 0
519 6 20 8 5 2 8 - - 5 0 1 100 2 0
2064 49 10 45 10 39 19 33 0 37 6 39 49 39 35
65 and over 20 6 41 19 54 11 53 0 44 16 49 48 55 18
Unknown - - 1 0 <1 0 - - - - 1 100 - -
Hospital department
ICU 48 5 21 10 20 17 26 0 35 20 40 64 43 23
Internal med. 20 18 43 12 37 9 36 0 19 0 27 40 27 21
Surgery 1 0 10 13 7 9 6 0 5 50 11 44 2 0
Other 29 16 25 16 35 18 29 0 40 0 20 57 25 31
Unknown 1 0 1 0 1 14 3 0 2 0 2 33 2 0
146
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
LT013 (5]27
LT011 (1]9
LT001 (1]15
LT007 (0]10
LT00/ (0]9
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LT001 (3]7
LT0130 (2]5
LT005A (16]59
LT00/A (1/]66
LT003A (7]33
LT013A (3]28
LT001A (11]113
LT007A (5]80
LT012A (1]23
LT011A (1]26
LT013 (0]15
LT008A (0]5
LT006A (0]5
LT002A (0]13
LT009F (0]5
LT013C (0]5
N laboratories 5
Minimum 0
First quartile 0
Median 6.7
Third quartile 11.1
Maximum 18.5
N hospitals 16
Minimum 0
First quartile 0
Median 5.3
Third quartile 21.2
Maximum 42.9
Lithuania
147
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LT001A (36]13/
LT003A (9]37
LT011A (3]17
LT00/A (8]6/
LT008A (1]8
LT002A (3]2/
LT013A (10]82
LT0130 (1]9
LT005A (8]77
LT012A (1]10
LT001 (1]13
LT007A (5]92
LT009F (0]19
LT013C (0]6
LT013 (0]11
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LT011A (15]16
LT012A (9]13
LT001A (21]32
LT00/A (7]13
LT007A (6]12
LT003A (5]12
LT005A (6]17
LT013A (3]10
(20092010)
N hospitals 15
Minimum 0
First quartile 5.4
Median 11.1
Third quartile 12.5
Maximum 26.9
N hospitals 8
Minimum 30
First quartile 38.5
Median 51.9
Third quartile 67.4
Maximum 93.8
148
Luxembourg
Year
2003 7 54 8 95 8 227 7 41 - - - -
2004 6 36 7 96 7 216 5 28 - - - -
2005 5 47 5 83 5 188 5 31 - - 1 1
2006 5 31 5 77 5 167 4 42 4 21 4 23
2007 6 48 6 117 6 275 5 37 6 52 5 36
2008 6 59 5 117 6 303 5 61 6 52 4 33
2009 6 67 6 113 6 301 5 54 3 28 6 35
2010 6 47 5 104 3 56 4 21 4 33 4 25
Penicillin R <1 6 7 5 3 5 11 4
Penicillin RI 15 11 12 5 6 11 19 13
Macrolides RI 28 33 24 26 24 14 16 19
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 5 <1 <1 <1 <1 3 10 18
HL Gentamicin R 32 18 24 32 44 17 28 25
Vancomycin R <1 <1 <1 <1 <1 3 10 <1
HL Gentamicin R <1 <1 23 30 10 21 29 40
Vancomycin R <1 <1 <1 <1 <1 5 36 11
Aminoglycosides R - - - <1 4 13 18 6
Carbapenems R - - - <1 <1 <1 <1 <1
Piperacillin R - - <1 9 15 3 14 8
Ceftazidime R - - <1 10 11 3 14 <1
Carbapenems R - - <1 7 20 25 15 8
Aminoglycosides R - - <1 4 22 6 9 8
149
Characteristic
S. pneumoniae
n=110
S. aureus
n=217
E. coli
n=349
E. faecalis
n=50
E. faecium
n=23
K. pneumoniae
n=61
P. aeruginosa
n=58
Isolate source
Blood 93 16 100 15 99 26 100 8 100 26 95 16 100 12
CSF 7 25 - - 1 50 - - - - 5 0 - -
Gender
Male 55 16 59 12 45 26 68 9 52 33 54 15 67 13
Female 45 16 41 20 55 26 32 6 48 18 46 14 33 11
Age (years)
04 9 20 2 0 2 0 2 0 - - 2 0 2 0
519 4 0 2 40 <1 0 - - 4 0 - - - -
2064 41 13 39 8 28 27 22 9 22 20 28 18 28 25
65 and over 46 20 57 20 69 26 76 8 74 29 70 14 71 7
Hospital department
ICU 4 75 7 33 1 50 4 0 - - 11 14 9 0
Internal med. 3 0 3 17 1 0 2 0 - - 2 0 - -
Surgery 1 0 3 17 1 33 2 0 4 0 11 0 2 100
Other 16 11 27 14 5 25 12 0 26 17 26 6 22 0
Unknown 76 15 60 14 93 26 80 10 70 31 49 23 67 15
150
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
Lu003 (11]30
Lu001 (5]/0
Lu007 (1]9
Lu006 (1]13
Lu00/ (0]13
Lu002 (0]5
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Lu002A (2]8
Lu003A (1/]65
Lu006A (5]32
Lu00/A (3]21
Lu001A (7]72
Lu007A (1]15
N laboratories 6
Minimum 0
First quartile 0
Median 9.4
Third quartile 12.5
Maximum 36.7
N hospitals 6
Minimum 6.7
First quartile 9.7
Median 15
Third quartile 21.5
Maximum 25
Luxembourg
151
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Lu002 (3]6
Lu001A (28]105
Lu003A (18]68
Lu00/A (16]62
Lu002A (/]16
Lu006A (1/]61
Lu007A (7]31
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Lu006A (3]8
Lu001A (6]36
Lu003A (0]9
(20092010)
N hospitals 7
Minimum 22.6
First quartile 23
Median 25.8
Third quartile 26.7
Maximum 50
N hospitals 3
Minimum 0
First quartile 0
Median 16.7
Third quartile 37.5
Maximum 37.5
152
Malta
Year
2003 1 9 1 121 1 91 1 26 - - - -
2004 1 18 1 94 1 91 1 41 - - - -
2005 1 13 1 77 1 85 1 38 1 18 1 45
2006 1 31 1 90 1 94 1 53 1 32 1 51
2007 1 13 1 105 1 117 1 37 1 28 1 36
2008 1 17 1 108 1 128 1 32 1 36 1 31
2009 1 8 1 85 1 158 1 36 1 38 1 58
2010 1 11 1 108 1 192 1 37 1 57 1 42
Penicillin R <1 <1 8 3 <1 24 <1 11
Penicillin RI <1 <1 15 7 <1 47 14 22
Macrolides RI 38 25 46 45 8 35 13 18
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 1 <1
Aminopenicilins RI 5 <1 3 2 3 <1 5 <1
HL Gentamicin R 29 44 32 - - - - -
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 50 <1 <1 - - - - -
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
Aminoglycosides R - - 17 6 <1 <1 <1 12
Third-gen. cephalosporins R - - 6 6 7 <1 <1 12
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 22 47 11 45 36 36
Ceftazidime R - - 11 30 3 33 29 14
Carbapenems R - - 18 20 11 30 21 24
153
Characteristic
S. pneumoniae
n=16
S. aureus
n=193
E. coli
n=350
E. faecalis
n=55
E. faecium
n=18
K. pneumoniae
n=95
P. aeruginosa
n=100
Isolate source
Blood 100 19 100 53 100 33 100 0 100 0 100 7 95 23
CSF - - - - <1 0 - - - - - - 5 0
Gender
Male 50 13 68 56 50 37 62 0 72 0 55 8 67 22
Female 50 25 32 47 50 28 38 0 28 0 45 7 33 21
Age (years)
04 6 0 6 67 2 0 11 0 6 0 5 0 4 0
519 - - 2 25 <1 0 2 0 - - 4 0 5 20
2064 44 0 38 45 27 31 33 0 67 0 34 16 33 30
65 and over 50 38 53 58 70 34 55 0 28 0 57 4 58 19
Hospital department
ICU 13 0 7 43 2 43 29 0 33 0 13 0 31 39
Other - - 2 100 4 64 2 0 - - 5 0 1 0
Unknown 88 21 91 53 94 31 69 0 67 0 82 9 68 15
154
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
MT001 (3]16
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
MT001F (/]6
MT001L (5]9
MT001A (93]178
N laboratories 1
Minimum 18.8
First quartile 18.8
Median 18.8
Third quartile 18.8
Maximum 18.8
N hospitals 3
Minimum 52.2
First quartile 52.2
Median 55.6
Third quartile 66.7
Maximum 66.7
Malta
155
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
MT001F (8]16
MT001L (10]31
MT001A (96]303
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
MT001F (1]5
MT001A (6]86
(20092010)
N hospitals 3
Minimum 31.7
First quartile 31.7
Median 32.3
Third quartile 50
Maximum 50
N hospitals 2
Minimum 7
First quartile 7
Median 13.5
Third quartile 20
Maximum 20
156
Netherlands
Year
2003 24 891 23 1422 23 2133 23 480 - - - -
2004 22 758 22 1339 21 2111 22 444 - - - -
2005 23 815 23 1407 23 2201 23 563 16 301 16 210
2006 22 1006 23 1636 22 2905 23 776 18 458 19 330
2007 21 940 21 1471 21 2801 21 827 19 497 19 338
2008 17 723 16 1191 16 2283 17 632 15 463 15 345
2009 17 746 16 1035 16 2398 16 522 15 408 15 235
2010 22 971 21 1565 21 3422 20 834 20 647 21 376
Penicillin R <1 <1 <1 <1 <1 <1 <1 <1
Oxacillin/Meticillin R 1 1 <1 <1 2 <1 <1 1
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 4 3 3 5 5 <1 2 3
HL Gentamicin R 29 37 38 28 38 34 31 34
Vancomycin R 1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 20 20 40 50 62 53 76 65
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
Carbapenems R - - <1 <1 <1 <1 <1 <1
157
Characteristic
S. pneumoniae
n=1 325
S. aureus
n=2 599
E. coli
n=5 786
E. faecalis
n=770
E. faecium
n=572
K. pneumoniae
n=1 041
P. aeruginosa
n=605
Isolate source
Blood 93 2 100 1 100 13 100 0 100 1 100 6 98 3
CSF 7 0 - - <1 18 - - - - <1 20 2 10
Gender
Male 52 2 59 1 49 16 70 0 63 1 55 9 70 3
Female 48 1 41 1 51 9 30 0 37 0 45 4 30 2
Age (years)
04 4 3 5 0 2 7 4 0 3 0 2 5 2 10
519 2 0 2 3 1 17 1 0 2 0 1 10 1 0
2064 41 2 34 1 27 13 27 0 38 0 30 7 31 4
65 and over 52 1 59 1 70 12 68 0 57 1 67 6 66 2
Hospital department
ICU 9 2 11 3 9 12 18 0 43 1 11 16 19 6
Internal med. 11 1 12 0 18 12 13 0 12 0 17 2 16 4
Surgery 3 7 7 2 5 12 6 0 4 0 5 4 7 0
Other 46 1 33 1 32 13 30 0 22 1 28 6 24 1
Unknown 30 2 38 1 36 13 33 0 20 1 39 6 34 2
158
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
IL10/ (1]20
IL1/5 (2]51
IL01/ (2]62
IL1/1 (1]36
IL119 (2]73
IL126 (1]37
IL113 (/]165
IL101 (2]88
IL026 (1]/6
IL13/ (1]55
IL031 (2]125
IL007 (1]68
IL002 (2]157
IL023 (1]8/
IL005 (0]28
IL132 (0]80
IL131 (0]7/
IL107 (0]6
IL112 (0]63
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
IL101C (1]5
IL01/v (1]17
IL031 (1]19
IL1130 (1]29
IL13/A (2]77
IL023 (1]/1
IL1/1A (2]86
IL002 (2]87
IL126A (1]//
IL132A (2]107
IL119A (3]161
IL10/ (1]55
IL10/A (1]58
IL1/5A (1]59
IL101A (1]65
IL031A (1]68
IL026A (2]139
IL126 (1]76
IL030L (1]76
IL007A (1]87
IL131A (1]95
IL112A (1]106
IL007 (0]11
IL13/ (0]7
IL002C (0]30
IL002A (0]58
IL131 (0]19
IL01/6 (0]15
IL113C (0]33
IL030A (0]32
IL118 (0]12
IL101 (0]21
IL0230 (0]17
IL01/C (0]1/
IL0300 (0]/2
IL023A (0]30
IL113A (0]106
IL030F (0]19
IL031C (0]52
IL112X (0]11
IL030h (0]68
IL113 (0]28
IL030C (0]2/
IL113L (0]6
IL007C (0]113
IL030l (0]29
IL118C (0]38
IL131C (0]10
IL112 (0]30
IL0306 (0]30
IL1010 (0]9
IL026 (0]27
IL01/ (0]18
IL1/5 (0]12
IL030 (0]17
IL005A (0]37
N laboratories 19
Minimum 0
First quartile 0
Median 1.8
Third quartile 2.7
Maximum 5
N hospitals 56
Minimum 0
First quartile 0
Median 0
Third quartile 1.6
Maximum 20
Netherlands
159
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
IL026 (10]27
IL1010 (7]23
IL101C (2]7
IL030l (16]68
IL030C (13]71
IL030F (19]105
IL1/1A (25]1/1
IL031 (16]91
IL132A (53]305
IL007A (21]128
IL126A (8]/9
IL007C (20]128
IL112 (9]60
IL0230 (6]/0
IL030 (10]67
IL119A (/3]29/
IL01/X (1]7
IL01/C (6]/2
IL1130 (17]121
IL101A (23]16/
IL113 (12]87
IL030L (28]205
IL112A (29]219
IL026A (2/]18/
IL1/5 (3]23
IL13/ (2]16
IL005A (12]99
IL118C (12]101
IL002A (13]112
IL031C (17]1/7
IL126 (17]1/8
IL113L (5]/5
IL01/ (/]36
IL023A (9]82
IL113A (30]281
IL0306 (13]123
IL113C (10]95
IL01/6 (5]/9
IL131A (18]179
IL131C (3]30
IL0300 (12]123
IL002C (9]9/
IL131 (/]/2
IL1/5A (12]126
IL002 (18]189
IL101 (/]/3
IL031A (13]1/1
IL13/A (10]109
IL030h (1/]171
IL10/ (7]87
IL023 (9]117
IL112X (3]/1
IL118 (5]70
IL01/v (3]/3
IL10/A (6]93
IL030A (/]62
IL007 (0]20
IL01/A (0]5
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
IL132A (11]/7
IL10/A (/]21
IL1/1A (5]30
IL131A (5]30
IL002A (/]27
IL126A (1]7
IL023 (2]16
IL007C (5]//
IL007A (/]36
IL01/ (1]9
IL112 (1]9
IL1/5A (2]19
IL118C (2]19
IL002 (/]/2
IL13/A (3]37
IL112A (3]39
IL026A (3]/1
IL119A (/]61
IL101 (1]16
IL002C (1]20
IL113A (1]33
IL030A (0]10
IL030C (0]5
IL10/ (0]16
IL031 (0]2/
IL030l (0]6
IL0306 (0]15
IL007 (0]6
IL030h (0]19
IL01/C (0]9
IL0230 (0]5
IL113 (0]17
IL118 (0]1/
IL01/6 (0]8
IL131 (0]5
IL126 (0]23
IL101A (0]28
IL01/v (0]8
IL031A (0]26
IL0300 (0]17
IL113C (0]11
IL131C (0]8
IL030F (0]13
IL030L (0]31
IL005A (0]8
IL1130 (0]2/
IL031C (0]25
IL023A (0]18
IL030 (0]10
(20092010)
N hospitals 58
Minimum 0
First quartile 9.5
Median 11.6
Third quartile 14.9
Maximum 37
N hospitals 49
Minimum 0
First quartile 0
Median 0
Third quartile 10.5
Maximum 23.4
160
Norway
Year
2003 11 512 11 506 11 1179 11 192 4 46 4 25
2004 11 600 11 516 11 1212 11 235 4 51 4 27
2005 11 606 11 553 11 1331 11 304 11 193 11 97
2006 12 601 12 734 12 1574 12 349 12 263 12 96
2007 13 616 13 794 13 1713 13 416 13 320 13 105
2008 13 576 13 837 13 1799 13 403 13 349 13 148
2009 12 554 12 909 12 1846 12 478 12 396 12 166
2010 15 576 15 1050 15 2277 15 563 15 479 15 168
Penicillin R <1 <1 <1 <1 <1 <1 <1 <1
Penicillin RI <1 2 2 2 2 2 2 4
Macrolides RI 8 8 14 12 10 7 6 4
Oxacillin/Meticillin R <1 <1 <1 <1 <1 <1 <1 <1
Escherichia coli
Aminoglycosides R <1 <1 2 2 3 3 3 4
Third-gen. cephalosporins R <1 <1 <1 1 2 3 2 4
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 4 <1 3 3 2 2 <1 <1
HL Gentamicin R 38 27 32 33 34 29 36 34
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 14 25 44 45 52 54 38 57
Vancomycin R <1 <1 <1 <1 <1 <1 <1 1
Aminoglycosides R <1 2 3 <1 <1 1 3 2
Fluoroquinolones R <1 <1 1 7 5 4 6 7
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Piperacillin R <1 13 3 3 2 6 4 3
Ceftazidime R <1 <1 3 5 3 4 5 2
Carbapenems R <1 4 3 9 9 7 5 1
Aminoglycosides R <1 4 <1 1 2 <1 <1 <1
161
Characteristic
S. pneumoniae
n=1 129
S. aureus
n=1 954
E. coli
n=4 097
E. faecalis
n=727
E. faecium
n=236
K. pneumoniae
n=875
P. aeruginosa
n=334
Isolate source
Blood 97 3 100 0 100 9 100 0 100 1 100 2 100 3
CSF 3 6 - - <1 0 - - - - <1 0 <1 100
Gender
Male 49 4 65 1 45 11 76 0 61 1 59 3 69 3
Female 51 2 35 0 55 7 24 0 39 0 41 1 30 4
Unknown <1 0 <1 0 <1 67 <1 0 <1 100 <1 0 <1 0
Age (years)
04 5 6 3 0 2 6 3 0 2 20 1 0 1 0
519 2 0 4 1 1 4 <1 0 1 0 1 0 2 0
2064 41 2 34 1 26 10 24 0 33 1 29 5 27 4
65 and over 51 4 59 0 72 8 72 0 64 0 69 1 70 3
Hospital department
ICU 9 4 7 1 5 13 9 0 14 0 7 0 8 12
Internal med. 37 3 34 1 36 8 34 0 28 0 31 3 30 4
Surgery 4 0 13 0 13 11 17 0 16 0 17 3 13 5
Other 47 3 43 0 44 8 37 0 41 2 43 3 47 1
Unknown 4 0 3 0 2 5 3 0 2 0 2 0 3 0
162
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
IU502 (3]5/
IU301 (1]19
IU103 (5]101
IU101 (6]133
IU106 (6]1/0
IU102 (2]/7
IU/02 (1]28
IU20/ (/]1/1
IU501 (1]36
IU30/ (1]37
IU206 (2]97
IU/03 (1]7/
IU105 (0]26
IU10/ (0]92
IU203 (0]10/
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
IU501A (1]2/
IU/02 (1]/2
IU101C (1]/6
IU/030 (3]159
IU20/l (1]79
IU101A (2]198
IU1010 (0]/6
IU206U (0]78
IU20/L (0]103
IU206 (0]8
IU10/} (0]155
IU103X (0]10
IU106v (0]31
IU203K (0]10
IU106 (0]/2
IU2030 (0]27
IU/02h (0]18
IU106u (0]13
IU106T (0]19
IU203C (0]80
IU102 (0]115
IU106S (0]36
IU502L (0]10
IU30/} (0]32
IU203X (0]/3
IU103L (0]133
IU502l (0]26
IU/03L (0]17
IU502h (0]7/
IU105K (0]37
IU106P (0]76
IU301A (0]/5
IU502K (0]16
IU5020 (0]12
IU206P (0]/0
IU5016 (0]5
IU501L (0]12
IU20/M (0]7
IU501C (0]9
N laboratories 15
Minimum 0
First quartile 1.4
Median 2.8
Third quartile 4.5
Maximum 5.6
N hospitals 39
Minimum 0
First quartile 0
Median 0
Third quartile 0
Maximum 4.2
Norway
163
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
IU/02h (12]58
IU102 (36]251
IU30/M (2]15
IU/02 (13]99
IU106v (11]86
IU1010 (10]83
IU101A (33]275
IU301A (12]102
IU206P (13]112
IU106P (1/]129
IU501 (2]19
IU203C (16]15/
IU105K (9]89
IU502L (3]30
IU/030 (30]312
IU103L (33]363
IU20/L (19]232
IU502l (/]50
IU203K (2]25
IU10/} (23]293
IU2030 (5]6/
IU501C (1]15
IU106T (/]61
IU206U (11]168
IU502K (2]3/
IU20/l (8]1/0
IU203X (3]55
IU502h (6]11/
IU20/M (1]20
IU30/K (1]20
IU106S (2]/6
IU/03L (3]71
IU5020 (1]27
IU501A (2]57
IU101C (/]125
IU106 (3]97
IU206 (1]3/
IU30/} (1]78
IU5016 (0]12
IU501L (0]11
IU501F (0]6
IU103X (0]21
IU20/I (0]10
IU20/L (0]9
IU106u (0]18
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
IU502K (1]5
IU106T (2]11
IU2030 (1]13
IU101A (5]69
IU10/} (5]79
IU102 (2]/8
IU206U (1]2/
IU101C (1]27
IU103L (2]65
IU203C (1]3/
IU206 (0]8
IU502h (0]35
IU30/} (0]15
IU/03L (0]1/
IU106P (0]32
IU301A (0]19
IU106u (0]8
IU106v (0]1/
IU30/K (0]5
IU/02 (0]23
IU501A (0]17
IU20/l (0]/0
IU502L (0]8
IU502l (0]11
IU106S (0]10
IU1010 (0]12
IU106 (0]13
IU20/L (0]5
IU206P (0]18
IU20/L (0]67
IU/02h (0]8
IU105K (0]12
IU203X (0]9
IU/030 (0]63
(20092010)
N hospitals 45
Minimum 0
First quartile 3.5
Median 6.6
Third quartile 10.4
Maximum 20.7
N hospitals 34
Minimum 0
First quartile 0
Median 0
Third quartile 3.1
Maximum 20
164
Poland
Year
2003 11 16 24 166 25 124 16 64 - - - -
2004 11 16 30 262 29 192 23 52 - - - -
2005 6 6 30 198 30 176 21 54 17 53 14 26
2006 4 9 24 174 26 206 21 68 15 42 16 37
2007 10 22 24 185 27 256 20 71 18 32 23 67
2008 34 84 15 99 14 84 11 26 11 19 8 22
2009 21 71 30 551 29 625 28 267 25 151 27 153
2010 26 76 35 527 35 771 32 286 33 246 29 169
Penicillin R 19 <1 17 <1 10 12 30 24
Penicillin RI 19 <1 33 <1 29 13 30 24
Macrolides RI 14 19 33 11 . 50 19 39
Escherichia coli
Carbapenems R - <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI <1 2 9 2 4 6 <1 3
HL Gentamicin R 48 33 48 50 46 29 39 36
Vancomycin R <1 <1 <1 <1 2 <1 <1 <1
HL Gentamicin R 55 100 62 85 84 67 75 65
Vancomycin R <1 <1 5 <1 <1 <1 1 8
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 50 43 36 32 30 29
Ceftazidime R - - 31 42 21 27 21 22
Carbapenems R - - 27 30 18 14 25 25
165
Characteristic
S. pneumoniae
n=132
S. aureus
n=1 032
E. coli
n=1 258
E. faecalis
n=312
E. faecium
n=187
K. pneumoniae
n=375
P. aeruginosa
n=309
Isolate source
Blood 88 26 100 17 99 25 100 0 100 5 99 43 98 25
CSF 12 31 - - 1 22 - - - - 1 40 2 14
Gender
Male 58 24 58 16 39 31 55 0 57 5 61 43 59 27
Female 40 30 40 18 58 21 43 0 40 5 36 43 37 22
Unknown 2 33 2 9 3 6 2 0 4 0 3 40 4 27
Age (years)
04 9 58 7 8 4 9 7 0 5 0 7 29 3 13
519 6 13 3 10 1 8 2 0 2 100 2 25 4 33
2064 51 19 45 15 42 25 40 0 48 4 49 41 51 32
65 and over 31 32 42 21 49 26 48 0 40 3 38 51 33 18
Unknown 3 25 3 7 4 20 3 0 5 0 4 38 9 10
Hospital department
ICU 27 14 19 24 20 25 27 0 29 0 33 61 36 33
Internal med. 21 29 14 14 18 22 9 0 5 0 11 23 3 0
Surgery 2 0 7 24 6 39 14 0 15 4 18 46 7 18
Other 44 34 44 12 43 23 33 0 30 11 30 33 38 19
Unknown 7 22 15 20 13 26 16 0 20 5 8 28 16 28
166
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
PL033 (/]5
PL116 (3]7
PL105 (2]6
PL0/1 (3]10
PL118 (1]5
PL126 (1]6
PL058 (1]11
PL02/ (1]12
PL1/8 (0]5
PL110 (0]12
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
PL0023 (9]19
PL0126 (3/]7/
PL0012 (/]9
PL0018 (5]13
PL0031 (/]12
PL0035 (/]12
PL0113 (2]6
PL0033 (10]33
PL0130 (12]/7
PL0011 (5]21
PL0131 (6]26
PL0052 (3]13
PL0115 (3]1/
PL0058 (/]20
PL0119 (2]11
PL0108 (1]6
PL0112 (5]31
PL001/ (5]33
PL0116 (6]/0
PL0101 (/]28
PL0137 (2]1/
PL01/9 (1]7
PL012/ (7]5/
PL0105 (/]31
PL0103 (1]9
PL011/ (2]20
PL002/ (2]20
PL0106 (2]20
PL0123 (2]22
PL00/1 (3]3/
PL0003 (/]/6
PL0110 (1]13
PL0138 (2]32
PL01/8 (1]17
PL00/8 (1]21
PL0019 (1]23
PL0109 (1]31
PL0121 (0]15
PL0006 (0]12
PL0107 (0]20
PL0118 (0]12
PL0122 (0]6
PL0005 (0]15
PL013/ (0]5
PL0056 (0]13
PL01/1 (0]9
PL0015 (0]9
PL0025 (0]6
PL0132 (0]10
N laboratories 10
Minimum 0
First quartile 8.3
Median 18.3
Third quartile 33.3
Maximum 80
N hospitals 49
Minimum 0
First quartile 3.2
Median 11.1
Third quartile 21.4
Maximum 47.4
Poland
167
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
PL0005 (9]17
PL0131 (13]28
PL0126 (32]7/
PL0130 (27]67
PL00/3 (/]11
PL0019 (8]23
PL0138 (9]26
PL0115 (9]26
PL0106 (7]21
PL0116 (12]37
PL0102 (/]13
PL0011 (3]10
PL0012 (/]1/
PL0132 (2]7
PL0112 (11]/0
PL0110 (1/]5/
PL0035 (8]31
PL001/ (10]39
PL0018 (6]2/
PL0137 (6]25
PL00/8 (5]21
PL0023 (3]13
PL0118 (5]23
PL01/9 (1]5
PL0109 (7]35
PL0121 (6]30
PL0103 (3]16
PL0101 (5]27
PL0029 (7]39
PL0107 (10]60
PL0123 (1]6
PL002/ (7]/3
PL0003 (5]31
PL0058 (6]39
PL00/1 (5]3/
PL01/8 (6]/1
PL0056 (/]28
PL0057 (1]7
PL012/ (6]/5
PL0105 (3]23
PL0108 (1]8
PL0031 (1]8
PL01/1 (2]16
PL0006 (2]16
PL0113 (3]25
PL0015 (1]9
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
PL0019 (6]6
PL0105 (7]8
PL0023 (5]6
PL0119 (9]11
PL0112 (23]29
PL0011 (8]11
PL0029 (18]25
PL0126 (15]21
PL0006 (/]6
PL0113 (5]8
PL0101 (6]10
PL0109 (7]12
PL0003 (/]9
PL0137 (3]7
PL01/1 (2]5
PL0035 (5]13
PL0103 (2]6
PL0130 (10]33
PL0123 (2]7
PL0115 (5]18
PL012/ (1]6
PL011/ (1]6
PL0131 (0]9
PL002/ (0]6
PL001/ (0]7
PL01/9 (0]9
PL0107 (0]15
PL0138 (0]7
PL0121 (0]5
PL0116 (0]7
(20092010)
N hospitals 46
Minimum 11.1
First quartile 14.7
Median 20.9
Third quartile 30
Maximum 52.9
N hospitals 30
Minimum 0
First quartile 0
Median 39.2
Third quartile 71.4
Maximum 100
168
Portugal
Year
2003 12 95 22 1 033 21 792 18 398 - - - -
2004 14 166 23 1 063 19 761 19 410 - - - -
2005 13 202 19 1 153 19 1 171 17 405 1 1 - -
2006 15 183 17 1 306 18 1 331 17 464 13 315 11 266
2007 12 202 20 1 383 20 1 432 19 518 18 370 16 340
2008 14 260 20 1 557 21 1 625 20 588 21 543 19 467
2009 17 237 20 1 824 20 2 040 19 675 20 564 18 536
2010 12 156 18 1 633 19 1 980 19 621 19 596 19 548
Penicillin R <1 <1 <1 <1 <1 <1 18 15
Penicillin RI 20 27 17 17 16 18 18 15
Macrolides RI - 20 19 21 23 22 22 22
Escherichia coli
3rd gen. Cephalosporins R 7 8 12 10 10 10 9 10
Carbapenems R - - - - <1 <1 <1 <1
Aminopenicilins RI 4 5 <1 2 4 4 7 17
HL Gentamicin R 34 29 38 41 41 43 34 39
Vancomycin R 3 6 5 5 4 4 4 2
HL Gentamicin R 55 66 68 53 49 28 49 53
Vancomycin R 47 42 34 26 29 24 23 23
Aminoglycosides R - - <1 13 11 19 20 27
3rd gen. Cephalosporins R - - - 21 17 26 28 28
Carbapenems R - - - - <1 <1 <1 1
Piperacillin R - - - 15 14 17 17 18
Ceftazidime R - - - 19 16 16 13 12
Carbapenems R - - - 21 15 18 16 16
Note. The data in this Country Report were updated after the analyses were completed for the main report.
169
Characteristic
S. pneumoniae
n=393
S. aureus
n=3 457
E. coli
n=3 894
E. faecalis
n=833
E. faecium
n=405
K. pneumoniae
n=1 136
P. aeruginosa
n=1 054
Isolate source
Blood 93 17 100 51 100 28 100 3 100 23 100 28 99 16
CSF 7 17 - - <1 11 - - - - <1 67 1 0
Gender
Male 58 17 62 50 44 31 56 3 54 19 55 28 59 19
Female 41 17 38 53 56 25 44 2 45 27 45 28 41 13
Unknown <1 0 <1 0 <1 18 <1 0 <1 100 <1 0 - -
Age (years)
04 8 19 5 17 2 10 4 3 2 0 3 31 2 5
519 6 22 2 13 1 17 1 0 2 29 1 27 2 18
2064 43 16 31 41 33 24 28 3 41 21 39 27 42 14
65 and over 43 17 59 61 62 30 65 3 56 25 54 29 53 18
Unknown 1 0 3 49 2 23 2 0 - - 3 30 1 21
Hospital department
ICU 2 25 8 60 4 23 16 5 17 20 12 35 17 21
Internal med. 10 11 24 61 19 30 18 3 14 29 15 25 17 17
Surgery <1 0 9 63 5 33 12 2 17 26 10 21 9 19
Other 88 17 58 44 70 27 53 2 52 21 63 28 57 14
Unknown - - 1 50 1 24 1 0 - - 1 33 <1 0
170
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
PT001 (/]1/
PT005 (/]1/
PT008 (5]23
PT02/ (/]19
PT003 (9]/7
PT011 (15]81
PT019 (15]85
PT015 (1]8
PT018 (3]28
PT002 (2]37
PT029 (1]2/
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
PT022A (26]38
PT007A (321]508
PT005A (99]163
PT002A (10/]172
PT031 (112]196
PT016A (82]1/7
PT012A (119]215
PT008A (115]210
PT031C (18]3/
PT019A (160]310
PT023A (97]191
PT026A (26]53
PT001A (71]1/5
PT015A (26]5/
PT02/A (11]23
PT0310 (73]153
PT003A (172]393
PT027A (17]/0
PT029A (2/]6/
PT006A (16]/9
PT011A (63]205
PT031A (9]/6
PT021A (6]/7
N laboratories 11
Minimum 4.2
First quartile 10.7
Median 18.5
Third quartile 21.7
Maximum 28.6
N hospitals 23
Minimum 12.8
First quartile 42.5
Median 49.1
Third quartile 55.8
Maximum 68.4
Portugal
Note. The data in this Country Report were updated after the analyses were
completed for the main report.
171
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
PT005A (/0]90
PT025A (/]10
PT022A (13]39
PT002A (81]255
PT008A (32]10/
PT015A (18]59
PT001A (/9]161
PT012A (52]171
PT003A (20/]691
PT016A (38]129
PT007A (135]/67
PT031 (62]216
PT0310 (68]2/0
PT006A (20]72
PT029A (29]110
PT027A (17]65
PT031C (6]26
PT021A (18]78
PT011A (67]292
PT031A (5]23
PT026A (11]5/
PT023A (/6]238
PT019A (52]270
PT02/A (/]3/
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
PT007A (100]188
PT001A (20]//
PT031A (5]11
PT012A (16]36
PT005A (17]51
PT026A (5]15
PT015A (5]15
PT0310 (29]100
PT031C (/]1/
PT031 (21]77
PT002A (/]17
PT029A (5]22
PT022A (2]9
PT021A (5]23
PT011A (26]129
PT003A (35]178
PT006A (3]21
PT027A (1]9
PT023A (5]/6
PT019A (6]62
PT016A (2]/0
PT008A (1]23
(20092010)
N hospitals 24
Minimum 11.8
First quartile 23
Median 28.5
Third quartile 30.5
Maximum 44.4
N hospitals 22
Minimum 4.3
First quartile 14.3
Median 23.1
Third quartile 33.3
Maximum 53.2
172
Romania
Year
2003 5 26 9 85 9 50 5 12 - - - -
2004 4 9 15 95 12 48 4 9 - - - -
2005 5 18 13 93 13 84 7 14 1 3 2 23
2006 8 29 11 83 9 41 9 28 5 32 2 3
2007 5 27 9 42 9 63 5 14 6 30 2 4
2008 4 14 5 39 4 58 4 16 3 6 3 8
2009 3 17 6 48 7 90 5 27 4 27 4 24
2010 2 13 5 47 5 35 2 19 3 17 5 10
Penicillin R 21 11 22 10 22 54 24 31
Penicillin RI 33 11 39 28 33 69 29 31
Macrolides RI 29 <1 31 25 19 27 33 36
Escherichia coli
Carbapenems R <1 3 <1 3 <1 <1 <1 <1
Aminopenicilins RI <1 29 <1 <1 25 10 13 <1
HL Gentamicin R 25 <1 50 15 50 22 42 -
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 63 100 70 80 67 50 71 -
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
Carbapenems R - - <1 <1 <1 <1 <1 <1
Piperacillin R - - 61 33 25 25 31 63
Ceftazidime R - - 52 <1 <1 13 30 60
Carbapenems R - - 61 <1 <1 13 46 70
173
Characteristic
S. pneumoniae
n=30
S. aureus
n=93
E. coli
n=88
E. faecalis
n=24
E. faecium
n=17
K. pneumoniae
n=34
P. aeruginosa
n=23
Isolate source
Blood 57 29 100 37 100 20 100 0 100 0 100 68 96 59
CSF 43 31 - - - - - - - - - - 4 0
Gender
Male 50 33 63 34 53 28 58 0 71 0 56 68 57 69
Female 50 27 35 42 47 12 42 0 29 0 44 67 43 40
Unknown - - 1 0 - - - - - - - - - -
Age (years)
04 30 44 20 37 11 20 21 0 65 0 47 94 26 17
519 13 50 9 25 1 100 - - - - 9 67 9 100
2064 40 8 53 41 43 16 46 0 35 0 29 40 43 60
65 and over 17 40 18 29 44 23 33 0 - - 15 40 22 80
Hospital department
ICU - - 5 100 5 25 4 0 6 0 6 0 35 88
Internal med. - - 9 38 11 0 4 0 - - 9 33 9 0
Surgery - - 4 0 - - - - - - 6 100 - -
Other 100 30 77 36 82 24 92 0 94 0 79 74 57 46
Unknown - - 4 0 2 0 - - - - - - - -
174
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
kU01L (2]6
kU01A (5]22
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
kU001 (6]12
kU0010 (6]12
kU001L (2]5
kU001A (1/]/1
kU002A (3]10
kU001l (0]9
N laboratories 2
Minimum 22.7
First quartile 22.7
Median 28
Third quartile 33.3
Maximum 33.3
N hospitals 6
Minimum 0
First quartile 30
Median 37.1
Third quartile 50
Maximum 50
Romania
175
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
kU0010 (5]1/
kU001C (3]13
kU002A (3]16
kU001A (5]36
kU01/A (0]6
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
kU001 (15]16
kU001C (2]5
kU0010 (3]9
(20092010)
N hospitals 5
Minimum 0
First quartile 13.9
Median 18.8
Third quartile 23.1
Maximum 35.7
N hospitals 3
Minimum 33.3
First quartile 33.3
Median 40
Third quartile 93.8
Maximum 93.8
176
Slovenia
Year
2003 11 172 11 299 11 401 10 76 - - - -
2004 10 166 11 347 11 573 9 91 - - - -
2005 11 208 11 349 11 657 11 119 10 78 8 38
2006 11 167 11 365 11 717 10 145 10 145 10 72
2007 10 195 10 422 10 851 9 183 10 170 9 88
2008 10 209 10 418 10 874 10 196 9 157 10 95
2009 10 253 10 471 10 893 10 198 10 189 10 107
2010 10 232 10 476 10 952 10 196 10 196 10 95
Penicillin R 2 2 2 5 4 3 1 <1
Penicillin RI 15 25 11 19 17 15 15 16
Macrolides RI 9 11 11 13 17 16 17 17
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI <1 <1 1 1 <1 <1 <1 2
HL Gentamicin R 49 37 46 40 50 40 43 43
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 82 56 47 54 63 57 56 66
Vancomycin R <1 <1 <1 6 5 13 4 2
Carbapenems R . . <1 <1 <1 <1 <1 <1
Piperacillin R - - 21 18 13 21 16 15
Ceftazidime R - - 11 8 7 14 8 5
Carbapenems R - - 13 6 19 16 15 19
177
Characteristic
S. pneumoniae
n=485
S. aureus
n=947
E. coli
n=1 845
E. faecalis
n=264
E. faecium
n=130
K. pneumoniae
n=385
P. aeruginosa
n=196
Isolate source
Blood 92 15 100 11 100 19 100 0 100 3 99 26 98 17
CSF 8 13 - - <1 0 - - - - 1 100 2 33
Gender
Male 59 16 61 11 42 21 61 0 60 3 61 30 69 20
Female 41 14 39 10 58 17 39 0 40 4 39 22 31 10
Age (years)
04 22 15 3 4 2 2 3 0 2 0 3 10 3 0
519 3 7 2 0 1 0 - - - - 1 20 1 0
2064 36 16 37 10 27 20 29 0 48 5 34 29 37 29
65 and over 39 15 58 12 70 19 68 0 50 2 63 27 60 10
Hospital department
ICU 14 14 10 16 10 19 11 0 22 0 19 45 21 33
Internal med. 38 16 43 9 47 18 38 0 28 0 40 14 33 6
Surgery 1 33 12 23 6 24 20 0 18 4 15 34 18 23
Other 47 15 35 7 37 19 30 0 32 7 25 29 28 13
178
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
Sl009 (6]18
Sl011 (6]23
Sl007 (/]20
Sl003 (9]/8
Sl010 (8]/9
Sl002 (/]25
Sl008 (/]28
Sl001 (25]175
Sl00/ (7]82
Sl005 (1]17
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Sl008A (15]8/
Sl005A (7]//
Sl001C (3]19
Sl001A (52]35/
Sl007A (5]/1
Sl00/ (2]17
Sl009A (5]/6
Sl001 (1]10
Sl00/A (/]78
Sl011A (2]/6
Sl002A (2]/7
Sl003A (/]122
Sl010A (0]16
Sl00/C (0]6
Sl003 (0]17
N laboratories 10
Minimum 5.9
First quartile 14.3
Median 16.2
Third quartile 20
Maximum 33.3
N hospitals 15
Minimum 0
First quartile 3.3
Median 10
Third quartile 14.7
Maximum 17.9
Slovenia
179
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Sl001 (15]//
Sl009A (37]162
Sl007A (12]53
Sl008A (25]12/
Sl003A (55]276
Sl001A (98]525
Sl005A (13]70
Sl002A (21]121
Sl00/A (32]193
Sl011A (17]103
Sl003 (5]33
Sl00/ (5]33
Sl010A (7]56
Sl001C (/]35
Sl00/C (1]17
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
Sl003 (/]8
Sl003A (35]75
Sl001C (6]15
Sl001A (36]128
Sl011A (/]16
Sl005A (2]9
Sl00/A (8]38
Sl008A (3]27
Sl009A (2]19
Sl007A (1]10
Sl001 (1]13
Sl002A (0]18
Sl00/ (0]5
(20092010)
N hospitals 15
Minimum 5.9
First quartile 15.2
Median 17.4
Third quartile 20.2
Maximum 34.1
N hospitals 13
Minimum 0
First quartile 10
Median 21.1
Third quartile 28.1
Maximum 50
180
Spain
Year
2003 35 656 36 1391 29 2650 36 608 - - - -
2004 36 684 36 1527 36 3471 36 710 - - - -
2005 34 740 34 1337 34 2997 35 623 14 56 13 70
2006 35 625 35 1483 35 3364 34 755 33 564 32 405
2007 35 862 35 1645 35 3678 35 885 33 618 35 448
2008 31 695 32 1505 32 3626 32 1002 30 639 32 548
2009 32 708 33 1715 33 3821 33 1093 32 628 33 544
2010 41 862 41 1986 41 5696 41 1467 41 1161 41 749
Penicillin R 7 9 9 8 8 7 8 10
Penicillin RI 32 29 25 27 22 23 22 30
Macrolides RI 27 27 23 22 18 22 19 27
Escherichia coli
Carbapenems R <1 <1 <1 <1 <1 <1 <1 <1
Aminopenicilins RI 1 2 <1 2 1 3 3 1
HL Gentamicin R 36 36 36 36 42 41 43 41
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 11 17 16 21 40 35 38 27
Vancomycin R 3 2 3 3 2 1 3 1
Carbapenems R . . <1 <1 <1 <1 <1 <1
Ceftazidime R - - 6 7 10 11 8 7
Carbapenems R - - 17 12 15 13 16 18
181
Characteristic
S. pneumoniae
n=1 570
S. aureus
n=3 701
E. coli
n=9 506
E. faecalis
n=1 746
E. faecium
n=813
K. pneumoniae
n=1 789
P. aeruginosa
n=1 289
Isolate source
Blood 95 27 100 26 100 32 100 0 100 2 99 11 99 17
CSF 5 20 - - <1 19 - - - - 1 0 1 17
Gender
Male 57 26 63 26 51 36 61 0 60 2 58 11 68 18
Female 39 27 34 26 46 28 35 1 37 1 38 10 30 16
Unknown 4 16 3 24 3 38 3 0 3 0 4 15 2 7
Age (years)
04 13 39 5 12 4 9 13 0 5 0 8 10 4 9
519 4 23 3 8 1 21 1 0 1 13 1 7 2 17
2064 41 19 34 19 27 29 30 1 34 3 33 11 35 21
65 and over 40 30 58 32 67 35 54 0 59 2 57 11 59 15
Unknown 2 23 1 23 1 22 2 0 <1 0 1 0 <1 20
Hospital department
ICU 12 25 10 24 6 35 17 0 18 2 12 14 23 28
Internal med. 31 26 51 29 41 37 40 0 52 3 42 10 45 15
Surgery 1 24 9 30 7 29 11 1 14 1 10 15 9 18
Other 55 27 29 20 46 28 31 0 15 0 36 9 24 11
Unknown 1 23 1 27 <1 19 1 0 <1 0 <1 0 <1 0
182
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
LS003 (15]26
LS017 (5]11
LS061 (28]63
LS063 (6]1/
LS065 (6]15
LS053 (17]//
LS002 (13]3/
LS056 (21]55
LS0/1 (3]8
LS020 (7]19
LS00/ (15]/1
LS013 (2]6
LS060 (6]19
LS032 (12]38
LS06/ (11]35
LS018 (7]23
LS031 (29]96
LS0/9 (2]7
LS016 (10]36
LS029 (6]22
LS059 (7]26
LS012 (11]/1
LS019 (1/]5/
LS0/8 (13]52
LS021 (18]7/
LS015 (/]17
LS05/ (11]/7
LS010 (11]/7
LS057 (/]18
LS0/3 (5]23
LS0/6 (6]29
LS058 (15]7/
LS026 (1]5
LS038 (13]69
LS0/2 (19]103
LS0// (13]76
LS062 (5]30
LS005 (11]75
LS051 (1]7
LS011 (9]66
LS0/7 (1]25
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LS017A (38]90
LS029A (29]70
LS059A (18]/6
LS0/9A (26]67
LS065A (28]73
LS002A (39]105
LS056A (/5]123
LS012A (39]11/
LS057A (1/]/2
LS026A (28]8/
LS0/1A (/8]153
LS062A (19]62
LS019A (73]2/5
LS063A (11]/0
LS06/A (9]3/
LS011A (23]91
LS018A (1/]56
LS013A (22]88
LS060A (/2]170
LS00/A (/0]162
LS016A (22]91
LS003A (7]29
LS053A (22]9/
LS031A (/9]211
LS005A (18]80
LS058A (32]1/5
LS010A (19]87
LS0//A (21]97
LS038A (28]131
LS05/A (17]80
LS0/2A (19]92
LS061A (2/]128
LS051A (6]35
LS0/7A (9]55
LS032A (6]/2
LS0/3A (9]6/
LS015A (2]15
LS021A (18]166
LS0/8A (7]71
LS020A (1]13
LS0/6A (/]55
N laboratories 41
Minimum 4
First quartile 20.7
Median 26.9
Third quartile 36.6
Maximum 57.7
N hospitals 41
Minimum 7.3
First quartile 20.7
Median 24.2
Third quartile 31.4
Maximum 42.2
Spain
183
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LS032 (8]15
LS056A (206]//8
LS017A (/9]109
LS0/7A (29]72
LS0/9A (/6]116
LS012A (10/]267
LS00/A (12/]319
LS031A (167]//8
LS059A (63]172
LS0/6A (30]8/
LS0//A (10/]292
LS063A (27]76
LS016A (81]230
LS0/3A (83]237
LS051A (25]72
LS015A (17]/9
LS002A (107]317
LS003A (/9]1/6
LS0/1A (77]231
LS061A (93]280
LS005A (95]287
LS053A (7/]225
LS0/8A (61]192
LS019A (188]595
LS0/2A (1/2]/50
LS05/A (111]35/
LS021A (139]/5/
LS010A (81]266
LS018A (75]265
LS038A (99]35/
LS060A (72]258
LS032A (/5]177
LS058A (78]308
LS013A (29]115
LS062A (51]20/
LS029A (36]1//
LS057A (/0]162
LS011A (72]298
LS065A (3/]151
LS06/A (29]13/
LS020A (1]5
LS026A (23]118
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
LS0/3A (12]5/
LS013A (7]3/
LS060A (15]75
LS003A (3]18
LS016A (/]2/
LS0//A (13]81
LS031A (17]107
LS056A (13]86
LS059A (/]27
LS018A (6]/2
LS021A (7]53
LS05/A (8]6/
LS057A (3]2/
LS0/2A (12]97
LS002A (7]59
LS012A (/]3/
LS026A (3]27
LS062A (8]73
LS038A (7]6/
LS065A (2]19
LS058A (6]70
LS00/A (3]/0
LS061A (8]119
LS005A (3]/8
LS019A (2]33
LS0/1A (/]67
LS053A (2]//
LS0/8A (1]25
LS0/9A (1]26
LS063A (1]31
LS010A (1]32
LS011A (1]/1
LS017A (0]12
LS0/6A (0]32
LS032A (0]31
LS051A (0]16
LS06/A (0]16
LS0/7A (0]10
LS015A (0]1/
LS029A (0]15
(20092010)
N hospitals 42
Minimum 19.5
First quartile 25.4
Median 33
Third quartile 35.6
Maximum 53.3
N hospitals 40
Minimum 0
First quartile 3.2
Median 9.5
Third quartile 13.7
Maximum 22.2
184
Sweden
Year
2003 21 919 21 1855 21 3350 21 850 - - - -
2004 21 955 21 1906 21 3372 21 856 - - - -
2005 21 1025 21 1774 21 3241 21 821 18 282 17 149
2006 21 996 21 1968 20 3539 21 884 20 621 18 300
2007 21 1032 21 2163 20 3749 21 932 20 649 20 343
2008 21 1219 21 2410 20 4032 21 1059 20 826 20 315
2009 19 1063 19 2460 18 4247 19 967 18 706 18 338
2010 19 1008 19 2865 18 4846 18 1038 18 878 18 377
Penicillin R <1 <1 <1 <1 <1 <1 2 2
Oxacillin/Meticillin R <1 <1 1 <1 <1 <1 1 <1
Escherichia coli
Carbapenems R . . <1 <1 <1 <1 <1 <1
Aminopenicilins RI <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 17 16 19 20 16 20 19 15
Vancomycin R <1 <1 <1 <1 <1 <1 <1 <1
HL Gentamicin R 11 7 4 12 14 25 24 22
Vancomycin R 2 1 <1 <1 <1 2 <1 <1
Aminoglycosides R - - 1 <1 1 1 <1 1
Carbapenems R . . <1 <1 <1 <1 <1 <1
Piperacillin R - - 9 <1 2 1 2 1
Aminoglycosides R - - <1 <1 <1 <1 <1 <1
185
Characteristic
S. pneumoniae
n=2 020
S. aureus
n=5 313
E. coli
n=3 728
E. faecalis
n=1 235
E. faecium
n=514
K. pneumoniae
n=1 402
P. aeruginosa
n=663
Isolate source
Blood 98 4 100 1 100 10 100 0 100 0 100 2 100 6
CSF 2 3 - - <1 0 - - - - <1 0 - -
Gender
Male 52 4 63 1 48 13 71 0 61 0 61 2 71 5
Female 48 3 37 1 52 6 29 0 39 0 39 1 29 8
Age (years)
04 4 5 4 0 1 16 4 0 3 0 1 0 2 21
519 1 7 3 1 1 4 1 0 2 0 1 0 2 7
2064 38 4 31 1 24 13 23 0 28 1 24 3 24 7
65 and over 56 3 62 1 74 9 73 0 68 0 74 1 72 5
Unknown <1 0 <1 0 <1 25 <1 0 - - <1 0 - -
Hospital department
ICU 5 4 4 1 3 11 5 0 12 2 3 5 5 17
Internal med. 35 4 33 0 31 7 27 0 24 0 29 1 32 7
Surgery 3 5 12 1 16 10 18 0 23 0 21 0 13 2
Other 54 3 47 1 43 11 44 0 37 0 41 2 47 4
Unknown 3 2 4 0 7 7 5 0 4 0 5 3 4 17
186
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
SL250 (/]/1
SL110 (5]61
SL/30 (5]76
SL100 (1/]226
SL2/0 (/]77
SL310 (/]79
SL5/0 (1]20
SL120 (7]166
SL620 (5]130
SL200 (10]283
SL230 (2]63
SL610 (3]109
SL600 (2]9/
SL350 (2]119
SL/50 (1]70
SL320 (1]88
SL//0 (1]113
SL/00 (0]131
SL730 (0]7/
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
SL5/0A (3]52
SL2/0 (1]25
SL320 (1]/1
SL600A (5]26/
SL200 (3]170
SL620A (3]171
SL350 (1]61
SL120A (/]261
SL250A (2]1/6
SL200A (3]229
SL250 (1]80
SL230A (1]93
SL220A (1]101
SL100 (2]211
SL350C (1]125
SL2/0A (1]125
SL350A (1]150
SL/50A (1]151
SL/00A (1]15/
SL320A (1]159
SL310A (1]187
SL100A (1]350
SL110 (0]/5
SL110A (0]7/
SL/50 (0]10
SL120 (0]32
SL//0C (0]31
SL620C (0]5/
SL/00 (0]123
SL100L (0]97
SL7300 (0]19
SL220 (0]6/
SL/30A (0]172
SL610A (0]179
SL730C (0]17
SL200C (0]/0
SL610C (0]76
SL730L (0]3/
SL2/0C (0]51
SL/50C (0]23
SL230 (0]28
SL/300 (0]51
SL/00C (0]35
SL2000 (0]5
SL100C (0]/2
SL1006 (0]16
SL620 (0]19
SL320C (0]13
SL6200 (0]19
SL220C (0]20
SL//0A (0]156
SL310 (0]86
SL610 (0]/8
SL/500 (0]/3
SL730 (0]23
SL730F (0]88
SL600C (0]30
SL1000 (0]82
SL//0 (0]/9
N laboratories 19
Minimum 0
First quartile 1.4
Median 3.5
Third quartile 5.2
Maximum 9.8
N hospitals 59
Minimum 0
First quartile 0
Median 0
Third quartile 0.8
Maximum 5.8
Sweden
187
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
SL310 (9]29
SL220A (25]91
SL220C (7]26
SL310A (/]15
SL100L (1]5
SL2000 (2]11
SL200C (/]22
SL5/0A (/]23
SL200A (20]119
SL320 (7]/2
SL100A (13]90
SL230A (10]73
SL/00A (29]250
SL200 (12]105
SL/30A (37]333
SL120A (18]163
SL//0C (7]68
SL110A (13]136
SL100 (7]7/
SL620C (7]79
SL/300 (6]68
SL110 (/]/6
SL/00 (18]209
SL320A (13]155
SL120 (1]12
SL620A (16]19/
SL/500 (6]7/
SL100C (1]1/
SL6200 (2]28
SL610C (1]15
SL730L (2]30
SL//0A (19]300
SL320C (2]33
SL730C (1]18
SL730F (/]76
SL/00C (/]78
SL620 (2]/2
SL/50A (11]2/8
SL610A (1]23
SL230 (1]2/
SL//0 (/]10/
SL/50C (1]33
SL220 (1]37
SL/50 (1]/0
SL730 (0]12
SL1000 (0]5
SL610 (0]7
SL2/0A (0]16
SL7300 (0]16
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
SL110 (1]10
SL110A (2]2/
SL220C (1]12
SL/00 (2]/1
SL/00A (3]63
SL310A (2]5/
SL2/0A (1]28
SL/30A (2]60
SL250 (1]31
SL100 (1]33
SL200A (2]7/
SL/50A (1]/8
SL320A (1]52
SL120A (1]52
SL200 (1]65
SL230 (0]8
SL5/0A (0]16
SL620C (0]19
SL620 (0]6
SL2000 (0]5
SL100A (0]71
SL/500 (0]11
SL230A (0]26
SL200C (0]8
SL//0 (0]25
SL220A (0]/7
SL620A (0]/2
SL350A (0]/9
SL730F (0]29
SL100C (0]5
SL2/0C (0]15
SL320 (0]18
SL120 (0]5
SL610C (0]26
SL610A (0]53
SL/50 (0]13
SL/300 (0]10
SL350 (0]17
SL220 (0]12
SL730C (0]8
SL//0C (0]11
SL250A (0]/6
SL610 (0]6
SL/50C (0]8
SL730L (0]10
SL/00C (0]9
SL310 (0]25
SL350C (0]26
SL//0A (0]/8
(20092010)
N hospitals 49
Minimum 0
First quartile 4.8
Median 8.3
Third quartile 11.6
Maximum 31
N hospitals 49
Minimum 0
First quartile 0
Median 0
Third quartile 1.9
Maximum 10
188
United Kingdom
Year
2003 50 1334 51 3548 19 2253 - - - - - -
2004 54 1059 54 3562 20 2091 - - - - - -
2005 53 1375 58 3971 23 2359 27 591 23 420 25 438
2006 51 1514 55 4132 26 2438 22 547 22 404 24 353
2007 50 1785 55 4865 20 2374 18 435 18 382 19 370
2008 51 1223 55 3355 15 2456 14 274 15 350 14 345
2009 59 1396 69 2977 28 4712 26 712 27 725 26 639
2010 50 1459 55 2730 29 5389 28 651 28 840 28 588
Penicillin R 1 <1 2 <1 2 1 1 <1
Macrolides RI 13 13 11 12 10 6 4 5
Escherichia coli
Carbapenems R - - - <1 <1 <1 <1 <1
Aminopenicilins RI - - 2 3 4 2 2 6
HL Gentamicin R - - 47 52 31 42 38 39
Vancomycin R - - 2 1 2 4 2 1
Aminopenicilins RI - - 84 78 82 83 91 84
HL Gentamicin R - - 53 18 35 7 38 31
Vancomycin R - - 33 18 21 28 13 10
Carbapenems R - - <1 <1 <1 1 <1 <1
189
Characteristic
S. pneumoniae
n=2 636
S. aureus
n=5 567
E. coli
n=8 945
E. faecalis
n=779
E. faecium
n=516
K. pneumoniae
n=1 398
P. aeruginosa
n=1 001
Isolate source
Blood 99 3 100 25 100 18 100 2 100 12 100 9 100 7
CSF 1 6 - - - - - - - - - - - -
Gender
Male 52 3 61 26 47 20 62 1 57 8 59 9 62 6
Female 47 3 38 23 53 16 38 2 41 16 41 7 38 10
Unknown 1 0 1 29 <1 23 <1 0 2 20 <1 33 <1 25
Age (years)
04 7 3 5 9 2 10 11 0 6 3 3 20 3 12
519 4 4 3 9 1 10 2 0 2 9 1 8 2 6
2064 45 2 39 19 26 17 26 3 38 18 31 7 29 10
65 and over 44 4 52 32 71 18 61 1 52 8 65 9 64 6
Unknown 1 5 1 15 <1 0 1 0 2 8 <1 0 1 0
Hospital department
ICU 5 1 3 34 - - - - - - - - - -
Internal med. 17 4 11 35 - - - - - - - - - -
Surgery 1 3 3 31 - - - - - - - - - -
Other 30 3 21 25 - - - - - - - - - -
Unknown 48 3 62 22 100 18 100 2 100 12 100 9 100 7
190
L
a
b
c
r
a
l
c
r
y

c
c
d
c
s
0 25 50 75 100
uK08/ (8]36
uK031 (1]8
uK0/9 (1]10
uK076 (3]32
uK032 (6]67
uK057 (2]26
uK090 (2]28
uK100 (2]30
uK056 (2]30
uK055 (1]15
uK0/7 (/]6/
uK053 (2]39
uK010 (1]20
uK06/ (3]66
uK0/3 (3]66
uK078 (3]66
uK068 (/]96
uK093 (3]81
uK099 (5]1/1
uK011 (1]29
uK00/ (1]29
uK092 (2]70
uK066 (1]35
uK0/5 (3]107
uK007 (/]1/9
uK008 (1]/5
uK091 (2]95
uK020 (1]53
uK101 (2]122
uK098 (1]70
uK012 (1]73
uK051 (1]73
uK015 (1]76
uK081 (0]6
uK070 (0]6
uK023 (0]15
uK09/ (0]7/
uK102 (0]21
uK0/6 (0]27
uK027 (0]18
uK0// (0]11
uK069 (0]/7
uK017 (0]50
uK063 (0]3/
uK096 (0]59
uK097 (0]39
uK059 (0]72
uK052 (0]29
uK05/ (0]/5
uK001 (0]23
uK058 (0]9
uK0/2 (0]8
uK050 (0]3/
uK0/8 (0]17
uK080 (0]6
uK077 (0]9
uK033 (0]26
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
uK008A (15]15
uK090X (17]17
uK00/A (5]5
uK09/X (13]1/
uK0/3 (5]6
uK023X (/]5
uK017 (31]/1
uK020A (7]10
uK007A (20]29
uK0/3A (17]25
uK032A (15]23
uK007 (19]30
uK011A (11]18
uK031A (3]5
uK08/L (6]12
uK0//C (6]12
uK010A (5]10
uK027A (7]15
uK032 (6]13
uK0/6A (10]2/
uK0//0 (6]15
uK070X (15]39
uK081A (5]13
uK077A (16]/2
uK083A (38]101
uK081 (3]8
uK079A (3]8
uK015A (3]8
uK080A (17]/6
uK0/8X (12]33
uK052X (9]25
uK076A (23]66
uK056X (27]79
uK078A (50]1/9
uK023A (6]18
uK08/ (6]18
uK069X (30]95
uK0//A (31]99
uK090A (8]26
uK08/A (25]82
uK069A (16]53
uK057A (9]30
uK05/X (18]62
uK001A (2]7
uK068X (5/]193
uK051X (28]102
uK063X (12]//
uK063A (6]22
uK0/7X (60]227
uK06/X (28]111
uK075A (7]28
uK0760 (6]2/
uK057X (8]33
uK056A (16]66
uK053X (7]29
uK0/8A (6]25
uK0/7A (37]157
uK099X (56]253
uK068 (/0]188
uK0/9X (7]33
uK059X (19]92
uK066X (10]/9
uK0// (2]10
uK0/6X (/]20
uK097X (1/]72
uK0/9A (5]26
uK050X (7]38
uK0/5X (30]16/
uK093X (36]199
uK098X (2/]1/0
uK078 (2]12
uK091X (3/]208
uK0/5A (21]131
uK05/A (7]/5
uK051A (11]72
uK059A (11]73
uK00/X (8]55
uK033X (17]118
uK101X (/3]301
uK100X (9]6/
uK096X (1/]102
uK066A (3]22
uK102X (12]95
uK055A (2]19
uK06/A (8]78
uK092X (13]132
uK072X (2]2/
uK0530 (2]29
uK078C (1]25
uK055X (1]31
uK050A (1]/5
uK072A (0]10
uK052A (0]20
N laboratories 57
Minimum 0
First quartile 0
Median 1.6
Third quartile 4.5
Maximum 22.2
N hospitals 93
Minimum 0
First quartile 17.1
Median 27.3
Third quartile 38.1
Maximum 100
United Kingdom
100% meticillin resistance rates for isolates of S. aureus reflect reporting of
MRSA only.
191
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
uK003X (33]71
uK09/X (53]131
uK0/3X (62]158
uK007X (1/]39
uK027X (39]157
uK099X (176]771
uK101X (165]799
uK0/2X (/7]232
uK026X (5/]267
uK020X (36]18/
uK012X (72]375
uK092X (65]355
uK102X (33]187
uK015X (177]102/
uK091X (86]50/
uK011X (/1]2/5
uK096X (/7]282
uK097X (3/]22/
uK100X (21]1/0
uK098X (62]/58
uK032X (8/]6//
uK001X (15]117
uK017X (52]/08
uK008X (30]2/5
uK093X (26]226
uK033X (18]208
uK023X (30]3/9
uK090X (6]1/3
h
c
s
p
l
a

c
c
d
c
s
0 25 50 75 100
uK09/X (5]5
uK003X (3]5
uK011X (5]33
uK012X (6]/7
uK097X (3]26
uK093X (/]35
uK091X (1/]129
uK099X (12]121
uK102X (/]/1
uK100X (3]31
uK026X (7]7/
uK101X (1/]1/9
uK0/2X (3]36
uK032X (10]131
uK020X (2]30
uK015X (10]155
uK027X (1]19
uK098X (3]58
uK096X (2]/0
uK092X (2]/3
uK033X (2]/5
uK008X (1]3/
uK017X (2]72
uK023X (0]32
(20092010)
N hospitals 28
Minimum 4.2
First quartile 12.9
Median 17.2
Third quartile 20.5
Maximum 46.5
N hospitals 24
Minimum 0
First quartile 5.1
Median 8.9
Third quartile 11.1
Maximum 100
HOW TO OBTAIN EU PUBLICATIONS
Free publications:
via EU Bookshop (http://bookshop.europa.eu);
at the European Commissions representations or delegations. You can
obtain their contact details on the Internet (http://ec.europa.eu) or by
sending a fax to +352 2929-42758.
Priced publications:
via EU Bookshop (http://bookshop.europa.eu).
Priced subscriptions (e.g. annual series of the Official Journal of the European
Union and reports of cases before the Court of Justice of the European Union):
via one of the sales agents of the Publications Office of the European
Union(http://publications.europa.eu/others/agents/index_en.htm).
European Centre for Disease
Prevention and Control (ECDC)
Postal address:
ECDC, 171 83 Stockholm, Sweden
Visiting address:
Tomtebodavgen 11a, Solna, Sweden
Phone +46 (0)8 58 60 1000
Fax +46 (0)8 58 60 1001
www.ecdc.europa.eu
An agency of the European Union
www.europa.eu
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