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The European Union Summary Reporton antimicrobial resistance

in zoonotic and indicator bacteriafrom humans, animals and food for 2009

P.A. BeloeilUnit on Zoonoses Data CollectionWorkshop of EU RL AMR, Copenhagen, 4 April 2011

Collection of data on zoonoses, zoonotic agents, AMR and food-borne outbreaks in the EU

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ZCC(VLA)

Data on humans are collected through The European Surveillance System (TESSy)maintained by ECDC

Human AMR data available in 2009Methods (1)

• Clinical isolates of salmonellosis and campylobacteriosis

• Only S/I/R interpretation of ASTs

• Large panel of antimicrobials tested and reported

• Guidelines for AST method and interpretation differedo Mixture of disc diffusion, E-test and dilution

o Different thresholds used for interpretation

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Antimicrobial susceptibility testing guidelinesSalmonella

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Country No. reportedantimicrobials Guidelines

Austria 11 CLSI M100 breakpoints

Denmark 11 EUCAST epidemiological cut-offs (ECOFFS)

Estonia 11 CLSI

Germany 8 National + CLSI for NAL

Ireland 11 CLSI

Italy 11 CLSI

Latvia 6 CLSI

Lithuania 11 CLSI

Luxembourg 11 CLSI

Malta 4 Modified CLSI

Netherlands 8 EUCAST ECOFFS with EFSA modification for STR, CLSI for SSS

Romania 11 CLSI

Slovakia 8 CLSI

Slovenia 11 CLSI

Spain 11 CLSI

UK 11 National

Iceland 5 CLSI

Antimicrobial susceptibility testing guidelinesCampylobacter

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Country No. reportedantimicrobials Guidelines

Austria 4 National

Estonia 4 SRGA-M + CLSI M45-A

Italy 6 CLSI adapted to all antimicrobials

Lithuania 5 BSAC

Luxembourg 3 CA-SFM

Malta 2 CA-SFM

Netherlands 3 Not specified

Slovakia 3 CLSI

Slovenia 7 CA-SFM + CLSI

Spain 7 CA-SFM + CLSI

UK 7 BSAC + modified CLSI

Iceland 2 CLSI?

Human AMR data available in 2009Methods (2)

• Salmonella spp., S. Enteritidis and S. Typhimurium

o Results presented as % resistant isolates for each antimicrobial

o Three-year trends visualised for cefotaxime and ciprofloxacin

• Campylobacter, C. jejuni and C. coli

o Results presented as % resistant isolates for each antimicrobial

o Three-year trends visualised for ciprofloxacin and erythromycin

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Human AMR data available in 2009Results

• Salmonella

o 16 MSs and 1 non-MS reported AST data in Salmonella

o Numer of isolates representing 24% of reported salmonellosis cases in EU/EEA in 2009

High resistance for ampicillin, tetracyclines and sulphonamides, especially for S. Typhimurium (around 50%)

Low resistance (0-4%) for cefotaxime and ciprofloxacine, with the exception of countries using epidemiological cut-off values

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Cefotaxime resistance in S. Enteritidis from human samples, 2007-2009

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Countries that reported 0% resistance throughout this period are not shown: Germany and Luxembourg.

Countries that useEUCAST ECOFF (>0.5 mg/L) orsimilar standard (1 mg/L).

Countries that useCLSI breakpoint (≥64 mg/L)

Cefotaxime resistance in S. Typhimuriumfrom human samples, 2007-2009

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Countries that reported 0% resistance throughout this period are not shown: Luxembourg.

Countries that useEUCAST ECOFF (>0.5 mg/L) orsimilar standard (1 mg/L).

Countries that useCLSI breakpoint (≥64 mg/L).

Country that usesa national standard (>8 mg/L)

Human AMR data available in 2009Results

• Campylobacter

o 11 MSs and 1 non MS reported AST in Campylobacter

o Number of isolates representing 14% of reported Campylobacterinfection cases in EU/EEA in 2009

High resistance for ampicillin, ciprofloxacin and nalidixic acid

Low resistance (0-10%) for erythromycin

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Antimicrobial resistance in C. jejunifrom human samples, 2007-2009

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Direct comparisons between countries should be avoided due to use of different standards for testing:• Estonia (SRGA-M)• Netherlands (unspecified)• Spain (CLSI)

• UK (modified CLSI)

Ciprofloxacin

Erythromycin

Countries that reported 0% resistance throughout this period are not shown: Malta.

Human AMR data available in 2009Issues identified for human data

• Assessment of EU situation difficult when 2/5 and 3/5 MSs do not report AST data for Salmonella and Campylobacter, respectively

• Harmonisation needed on which guidelines to use when interpreting human data

• Many countries use disc diffusion for Campylobacterantimicrobial susceptibility testing though known problem with poor reproducibility

• International standards on breakpoints for several antimicrobials missing for Campylobacter 12

AMR data in animals and food in 2009Methods (1)

• Data mainly from fowl (Gallus gallus), pigs and cattle, and less data from meat thereofo 24 MSs + 2 non-MSs reported on AMR in Salmonella

o 16 MSs + 2 non-MSs reported on AMR in Campylobacter

o 12 MSs + 2 non-MSs reported on AMR in indicator E. coli

o 9 MSs + 1 non-MSs reported on AMR in indicator enterococci

• The number of MSs reporting quantitative data on AMR increased from 18 MSs to 24 MSs from 2004 to 2009

• Quantitative data were mainly reported as MICs

• Scarce quantitative disk diffusion data (only reported for Salmonella) were analysed in the qualitative chapter 13

AMR data in animals and food in 2009 Analyses

• Harmonised epidemiological cut-off values used for MICs

Epidemiological cut-off values ↔ Microbiological Resistance

• Analyses of trends over the years (in MS / in the EU)o Developments in the EU and in MSs

o Emerging resistance

• Spatial (geographical) distributions through maps

• EFSA is in a process of developing the analyses of AMR data at the Community level (supra-national)

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Presentation of AMR data

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2004 2005 2006 2007

% re

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Austria Czech Republic Denmark Greece

Hungary Lithuania Netherlands Poland

Slovakia Slovenia Spain UK

Country N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % Res N % ResGallus gallusAustria 78 0 28 0 78 0 28 0 78 1 28 14 78 0 28 0Czech Republic 31 6 25 4 234 0 31 0 25 0 234 0 30 0 25 4 234 0 234 0Denmark 18 17 13 8 18 6 10 20 18 6 13 0 18 0 10 10 18 17 13 0 18 11 10 10 18 0 13 0 18 0 20 0Estonia 11 0 11 18 11 45Finland 10 0 10 0 10 10 10 0France 132 4 132 2 132 4Greece 105 22 176 10 116 44 105 14 163 2 117 40 105 7 135 2 111 14Hungary 122 61 135 60 122 2 144 0 122 3 154 3 122 0 153 1Italy 136 49 136 19 136 43 136 3Lithuania 19 11 12 0 19 0 12 0 19 16 12 0Netherlands 52 21 164 26 52 10 164 4 52 25 164 40 52 2 164 13Poland 104 0 443 8 178 4 91 22 105 1 443 2 178 0 91 10 105 4 443 7 178 5 91 16 105 0 178 0Romania 81 35 28 4 21 5Slovakia 173 40 89 2 137 10 110 5 89 1 137 0 110 9 89 6 137 1 110 0 89 0 137 0Slovenia 31 6 29 0 26 8 33 12 31 0 29 0 26 0 33 0 32 9 29 0 25 0 33 3 25 0 33 0Spain 36 14 36 0 294 23 36 3 18 0 294 3 36 22 93 2 36 8 18 6 295 8Sweden 15 0 15 0 15 7 15 0United Kingdom 46 2 51 0 120 4 46 0 51 0 116 0 46 2 51 4 120 4Total (18 MSs) 435 25 1025 12 741 21 1457 18 436 5 931 2 751 7 1400 4 437 7 884 5 754 8 1196 13 245 0 91 0 402 0 53 0 36 8 128 1 141 1 991 5

Cefotaxime2004 2007

Tetracycline Chloramphenicol Ampicillin Ceftiofur2004 2005 2006 2004 2007 20052005 2006 2007 2004 2005 2006 20062007 2004 2005 20062007

% R = the number ofresistant isolatesfrom all reportingMSs over the numbertested

% R = the numberof resistantisolates over the number tested

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2005 2006 2007 2008 2009

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Austria Denmark Estonia France

Netherlands Spain Switzerland

AMR in indicator E. coli

Tetracycline - pigs

AMR data in animals and food in 2009 Main findings

• Microbiological Resistance to antimicrobials was commonly found in isolates of Salmonella, Campylobacter and indicator E. coli and enterococci from animals and food in the EU

• For many of the antimicrobials tested, there were large differencesin the occurrence of resistance in different MSs

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Czech Republic Germany Netherlands Poland Slovakia Spain

S. Enteritidis - Gallus gallus - Ciprofloxacin

Main findings (2)Fluoroquinolones

• In food and animal isolates, the highest occurrence of resistance to ciprofloxacin was noted in Salmonella isolates from fowl (Gallus gallus) and broiler meat, where moderate resistance rates were reported.

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Austria Czech Republic Denmark Finland France

Germany Italy Netherlands Spain Switzerland

C. jejuni - Gallus gallus - Ciprofloxacin

Main findings (2)Fluoroquinolones

• High resistance to fluoroquinolones was commonly observed in Campylobacter isolates from Gallus gallus and broiler meat, as well as from pigs and cattle.

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Main findings (3)Third-generation cephalosporins

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• Resistance to third-generation cephalosporins wasobserved in Salmonella and indicator E. coli isolates fromGallus gallus, pigs and cattle, and the meat derived fromthose species, but at low or very low levels in the EU.

Salmonella spp. MS-group level

• Gallus gallus 2% (0 - 12%)

• Pigs 0.7% (0 - 2%)

• Cattle 0.4% (0 - 0.9%)

Indicator E. coli MS-group level

• Gallus gallus 9% (0 - 26%)

• Pigs 2% (0 - 4%)

• Cattle 0.7% (0 - 4%)

Main findings (3)Macrolides

• Resistance to erythromycin was detected in Campylobacterisolates from Gallus gallus and poultry meat. The highest occurrence of resistance to erythromycin was in C. coli from pigs.

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France Germany Italy Netherlands

Norway Spain Switzerland

C. jejuni - Gallus gallus - Erythromycin

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Additional analyses

• Farm-to-Fork Analysiso Comparison between human and animal and food data difficult

due to use of clinical breakpoints vs. epidemiological cut-off (ECOFF) values

o Presenting resistance along the food chain: animal, food, human

• MRSAo Baseline survey on MRSA + “routine” monitoring

o Countries are encouraged to monitor and to report

• Third Generation Cephalosporin resistanceo Salmonella and indicator E. coli

o Data to be used in the framework of a mandate on ESBLs

Conclusions

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• First joint report on AMR ever published by ECDC and EFSA

• AMR commonly found in zoonotic bacteria from animals and food

• Low levels of clinical resistance to “CIA” in humans

• AMR to critically important antimicrobials in human medicine detected in Salmonella and Campylobactero High levels for fluoroquinoloneso Low levels for macrolides in Campylobactero Low levels for 3rd generation cephalosporins

• AMR varies among animal species

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In the 2010 EU-SR …

• Coordination meeting with ECDC on 11 March

• General structure similar to that of 2009 EU-SR

• Some enhancements are planned

o monophasic S. Typhimurium

o Statistical tests for trends

o Farm-to-fork analysis in broilers and pigs

o Analyses of isolate level data collected by pilot exercise(in depth presentation tomorrow)

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In the future…

• Integrated monitoring of antimicrobial resistance and antimicrobial consumption in humans and animals– ECDC, EFSA, EMA– Joint report is planned– Relationship between resistance and consumption– Discussions are on-going between Agencies and EC

• Enhancement of monitoring of resistance in animals– Indicator bacteria (mandatory)– Isolate level data needed

to account for co-resistance

Acknowledgements

• EFSA wishes to thank the MSs and non-MSs for providing the AMR data

• The Veterinary Laboratories Agency (VLA) is kindly acknowledged for analysing the 2009 AMR data

• ECDC is kindly acknowledged for providing for and analysing the AMR data in human isolates of Salmonellaand Campylobacter

• 2009 EU Summary Report on AMR to be published soon on www.efsa.europa.eu (zoonoses unit)

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Thank you for your attention!