More needs to be done to tackle the spread of antimicrobial resistance

Effective infection control and the prudent use of antibiotics are key to controlling the spread of resistant bacteria in Europe's hospitals, argue ECDC's Andrea Ammon and Dominique Monnet.

The global rise of antibiotic resistant bacteria, Carbapenemase-producing Enterobacteriaceae, or CPE is alarming and is an increasing threat to patient safety, in Europe and globally, resulting in higher healthcare costs, prolonged hospital stays, treatment failures and sometimes death.

CPE produce an enzyme - a carbapenemase - that make them resistant to carbapenems, a major last-line class of antibiotics to treat infections with multidrug-resistant Gram-negative bacteria, including Enterobacteriaceae such as Klebsiella pneumoniae.

There are only few remaining treatment options for patients infected with CPE which are limited to combination therapy and to older antibiotics such as polymyxins (e.g., colistin).


And some countries with high prevalence of CPE already report large numbers of infections with Enterobacteriaceae showing both carbapenem and polymyxin resistance, an indication that the options for effective antibiotic treatment of these infections are further limited.

In 2012, we launched the 'European Survey on Carbapenamase-Producing Enterobacteriaceae' (EuSCAPE) project with the aim of gathering data on the occurrence of CPE in Europe and build laboratory capacity for their diagnosis and for surveillance.

At the start of the project, the level of spread of CPE and the capacity of European countries for their containment was mapped with a self-assessment by national experts in each country. It was followed by laboratory capacity building, an external quality assessment and the collection and characterisation of CPE isolates in European hospitals.

In 2015, after completion of the project, another self-assessment by national experts was conducted to re-assess CPE spread, as well as improvements in the capacity for containment of CPE in these countries.

The results were published on the occasion of the eighth European Antibiotic Awareness Day, showing that, since 2013, the occurrence and spread of CPE continued to worsen in European countries.
There were, however, improvements in the capacity and ability to detect CPE and to identify the various carbapenemase genes in all the participating countries.

Thirteen countries (34 per cent) reported inter-regional spread of or an endemic situation for CPE in 2015, compared to six countries (15 per cent) in 2013. Furthermore, the self-assessment showed the more frequent reporting and rapid spread of two specific types of CPE (OXA-48- and NDM-producing Enterobacteriaceae) in European hospitals in 2015 compared with 2013.

For OXA-48-producing Enterobacteriaceae, four countries had reported regional spread and only one country had reported an endemic situation in 2013, while in 2015, three countries reported regional spread, four reported inter-regional spread and two reported an endemic situation.

Similarly for NDM-producing Enterobacteriaceae, only two countries had reported sporadic hospital outbreaks in 2013, while in 2015 six countries reported sporadic hospital outbreaks and seven countries reported regional and inter-regional spread.

The current spread of CPE represents a challenge for adequate delivery of healthcare and is a threat to the safety of many European patients.

The cornerstones of effective prevention and control of CPE are the establishment of a dedicated national surveillance system, based on the notification of cases to health authorities, supported by reference laboratory confirmation and identification as well as infection control measures.

Since 2013, many European countries have developed dedicated national surveillance systems for CPE and designated reference laboratories.

Some countries have also implemented mandatory laboratory participation in surveillance, or mandatory reporting of all CPE cases in an attempt to control the increasing their spread. However, not all European countries have implemented these measures.

Specific infection control measures, combined with prudent use of antibiotics, are key to controlling the spread of CPE in European hospitals.

Failing this, Europe will rapidly face many hospital outbreaks of extensively drug-resistant (XDR), or even pandrug-resistant (i.e. totally resistant), Enterobacteriaceae.