Transcript EARSS in Ireland, 2007

Antimicrobial resistance
surveillance in Ireland
Results of invasive
Streptococcus pneumoniae infection
(blood/CSF) surveillance (2009Q1-4)
**** Data as of 14/04/2010 ****
Ireland is a member of the European Antimicrobial Resistance
Surveillance System (EARSS)
EARSS S. pneumoniae:
Objective and case definition
Objective:

To determine the proportions of S. pneumoniae isolates from
blood and/or CSF that are resistant/non-susceptible to:
◦
Penicillin (including intermediate and high-level resistance)
◦
Erythromycin
◦
Fluoroquinolones (e.g. Ciprofloxacin, moxifloxacin, norfloxacin)
Case definition:

EARSS collects data on the first invasive isolate (from
blood/CSF) of S. pneumoniae per patient per quarter
Caveats in interpreting EARSS data

Care must be exercised when interpreting the raw
figures, i.e. increases in numbers of isolates, as the
numbers of laboratories reporting to EARSS has
increased over the years

EARSS data does not distinguish clinically significant
isolates from contaminants

If a resistant isolate is identified subsequent to a
susceptible one within the same quarter, then that
isolate is not counted (and similarly if susceptible
isolates is identified subsequent to resistant one)
For further information on antimicrobial resistance
and EARSS in Ireland, including quarterly and annual
reports, plus reference/ resource material on the
individual pathogens under surveillance, see:
http://www.ndsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/EuropeanAntimic
robialResistanceSurveillanceSystemEARSS/
Antibiotic codes and abbreviations:
CTX, Ciprofloxacin
ERY, Erythromycin
OXA, Oxacillin
TCY, Tetracycline
CRO, Ceftriaxone
NOR, Norfloxacin
PEN, Penicillin
VAN, Vancomycin
SPN, Streptococcus pneumoniae
PNSP, Penicillin-Non-Susceptible S. pneumoniae
PSSP, Penicillin-Susceptible S. pneumoniae
PEN-HLR, Penicillin High-level Resistant (MIC, ≥2mg/L)
PEN-I, Penicillin Intermediate Resistant (MIC, 0.1-1mg/L)
The latest CLSI guidelines (2008) distinguish
between:
Non-meningitis
[Susceptible (S) ≤2 mg/L, Intermediate (I) 4 mg/L,
Resistant (R) ≥8 mg/L]
and
Meningitis breakpoints (S ≤0.06 mg/L, R ≥0.12 mg/L)
for iv/parenteral penicillin and recommend that blood isolates
should be reported using both sets of breakpoints.
EARSS recommends using the old breakpoints [S ≤0.06 mg/L,
I 0.12-1.0 mg/L, R (or HLR), ≥2 mg/L], corresponding with the
new oral CLSI breakpoints, for surveillance purposes and to
avoid any confusion with interpretation of historic data
***Penicillin and cefotaxime/ceftriaxone MICs should be
submitted on all pneumococcal isolates reported***
Numbers and proportions of S. pneumoniae/
PNSP from invasive infection with 95%
confidence Intervals (CI), 1999-2009*
Time
period
1999
Number
Number
Number
of labs of S. pneumoniae of PNSP
12
157
30
%PNSP
(95%CI)
19.1 (13.0-25.3)
2000
19
201
27
13.4 (8.7-18.1)
2001
20
245
30
12.2 (8.1-16.3)
2002
23
278
32
11.5 (7.8-15.3)
2003
28
364
43
11.8 (8.5-15.1)
2004
41
400
41
10.3 (7.3-13.2)
2005
42
401
47
11.7 (8.6-14.9)
2006
42
407
64
15.7 (12.2-19.3)
2007
44
438
76
17.4 (13.8-20.9)
2008
42
445**
103
23.1 (19.2-27.1)
2009
44
356
72
20.2 (16.1-24.4)
2009Q1
44
137
38
27.7 (20.2-35.2)
2009Q2
44
92
16
17.4 (9.6-25.1)
2009Q3
44
40
8
20.0 (7.6-32.4)
2009Q4
44
87
10
11.5 (4.8-18.2)
* Data for 2009 provisional up to the end of Q4;
** Excludes 2 isolates with no susceptibility results
PNSP trends among invasive isolates of
S. pneumoniae, 1999-2009*
500
12 19
20
23
28
41
42
42
44
42 44
44 44 44 44
450
40%
35%
400
350
25%
300
250
20%
200
15%
150
10%
100
5%
50
0
0%
Time period
Total S.pneumoniae
PNSP
%PNSP
* Data for 2009 provisional up to the end of Q4;
Number of laboratories participating by year-end and quarter are indicated above the bars
%PNSP
Number of isolates
30%
PNSP trends among invasive isolates of
S. pneumoniae, 1999-2009*
500
12 19 20 23
28 41
42
42
44
42
44
44 44 44 44
450
40%
35%
400
350
25%
300
250
20%
200
15%
150
10%
100
5%
50
0
0%
Time period
Total S.pneumoniae
PNSP
%PNSP
%Pen-I
* Data for 2009 provisional up to the end of Q4;
Number of laboratories participating by year-end and quarter are indicated above the bars
%Pen-HLR
%PNSP
Number of isolates
30%
New CLSI guidelines for interpreting penicillin
susceptibility among pneumococci

72 PNSP isolates: 72 from blood and one from CSF
[Note: MICs not available for 3 isolates; plus one with MIC
>=0.12mg/L]

Data interpreted according to both meningitis and nonmeningitis breakpoints following latest CLSI guidelines:
◦ 69 isolates (with MICs) were resistant to penicillin by
meningitis breakpoints (MIC, ≥0.12 mg/L)
◦ Of 68 isolates (with MICs; and excluding CSF isolate), one
was resistant (MIC, ≥8mg/L), 4 were intermediately
resistant (MIC, 4mg/L) and 63 were susceptible (MIC,
≤2mg/L) by non-meningitis breakpoints†
†One
isolate was reported with an MIC of >1mg/L and could not be interpreted correctly
Penicillin MIC distribution:
Latest CLSI non-meningitis breakpoints
100
90
Number of isolates
80
70
60
50
40
30
20
10
ND*
<=.001
.004
.006
<=.008
.008
.012
.016
.023
<=.03
.03
.032
.047
<=.06
.06
.064
.094
.125
.19
.25
.38
.5
.75
1
1.5
2
3
4
6
>1
0
ND
Penicillin MIC (mg/L)
S
I
R
ND, Not Determined; S, ≤2mg/L; I, 4mg/L; R, ≥8mg/L
No Penicillin MICs available for 18 isolates (3x Oxa-NS, 6x Oxa-S, 9x Pen-S)
?
Penicillin MIC distribution:
Latest CLSI meningitis breakpoints
100
90
Number of isolates
80
70
60
50
40
30
20
10
ND*
<=.001
.004
.006
<=.008
.008
.012
.016
.023
<=.03
.03
.032
.047
<=.06
.06
.064
.094
.125
.19
.25
.38
.5
.75
1
>1
1.5
2
3
4
6
0
ND
Penicillin MIC (mg/L)
S
R
ND, Not Determined; S, ≤0.06mg/L; R, ≥0.12mg/L
No Penicillin MICs available for 18 isolates (3x Oxa-NS, 6x Oxa-S, 9x Pen-S)
Penicillin MIC distribution:
Latest CLSI oral (=old) breakpoints
100
90
Number of isolates
80
70
60
50
40
30
20
10
ND*
<=.001
.004
.006
<=.008
.008
.012
.016
.023
<=.03
.03
.032
.047
<=.06
.06
.064
.094
.125
.19
.25
.38
.5
.75
1
>1
1.5
2
3
4
6
0
ND
Penicillin MIC (mg/L)
S
NS
I
ND, Not Determined; S, ≤0.06mg/L; I, 0.12-1mg/L; R, ≥2mg/L
No Penicillin MICs available for 18 isolates (3x Oxa-NS, 6x Oxa-S, 9x Pen-S)
R
Erythromycin resistance trends among
invasive isolates of S. pneumoniae, 1999-2009*
450
12 19
20 23
28
41
42
42 44
42 44
44
44 44 44
400
35%
30%
25%
300
250
20%
200
15%
150
10%
100
5%
50
0
0%
Time period
Total S.pneumoniae tested
Ery-R
%Ery-R
* Data for 2009 provisional up to the end of Q4;
Number of laboratories participating by year-end and quarter are indicated above the bars
%Ery-R
Number of isolates
350
Susceptibility data for invasive S. pneumoniae
isolates reported in 2009Q1-4 (n=356)
400
20.2%
17.3%
2.6%
Number of isolates
350
300
10.5%
250
200
0.0%
150
100
6.1%
50
0
OXA/PEN
Non-susceptible*
ERY
NOR
CTX/CRO
Antibiotic
Resistant
Intermediate
* No MIC available to determine level of penicillin susceptibility
TCY
Susceptible
VAN
No data
Resistance profiles of S. pneumoniae
isolates, 2009Q1-4
Pen
Ery
Number of
isolates
S
ND
15
S
S
251
S
R
18
NS
ND
0
NS
S
2
NS
R
1
I
ND
3
I
I
S
R
19
29
R
ND
2
R
S
6
R
R
Total
10
356
Pen-S Susceptible (MIC <0.1 mg/L)
Pen-NS Non-Susceptible (No MIC available)
Pen-I
Intermediate-resistant (MIC 0.1-1.0 mg/L)
Pen-R
High-level resistant (MIC ≥2.0 mg/L)
Ery-ND Not determined
Of the 72 of 356
pneumococcal isolates that
were identified as PNSP:
•49 were Pen-I (13.8%)
•20 were Pen-HLR (5.6%)
•3 were Pen-NS (0.8%)
Of isolates tested against both
Pen and Ery (n=336),
40, or 11.9%, were nonsusceptible to both (2008,
10.3%)
Age and sex of invasive S. pneumoniae
isolates, 2009Q1-4
Age Group
Sex
(yrs)
male
female
unknown
TOTAL
<2y
17
11
2-64
65+
92
86
70
79
1
163
165
Total
195
160
1
356
28
Pneumococcal serotype data
(n=300 of 356 isolates; 84%), 2009Q1-4
60
Number of isolates
50
40
30
20
10
ND
14*
7F*
19A*
3*
18C*
6B*
22F*
9V*
1*
23F*
19F*
4*
8*
9N*
33F*
6A
11A*
15B*
12F*
15A
23A
35B
20*
15C
16F
5*
6C
10A*
18B
23B
24F
28A
31
34
38
NT
0
Pen-HLR
Serotype
Pen-I
Pen-S
Pen-ND
* Serotypes included in PPV23;
serotypes in PCV7; ND, Not determined (not referred for serotyping);
NT, Non-Typable
Serotype data provided by Pneumococcal Serotyping Project, RCSI/Beaumont Hospital; Children’s
University Hospital, Temple Street and HPSC
Pneumococcal serotype data by age group,
2009Q1-4
60
Number of isolates
50
40
30
20
10
ND
14*
7F*
19A*
3*
18C*
6B*
22F*
9V*
1*
23F*
19F*
4*
8*
9N*
33F*
6A
11A*
15B*
12F*
15A
23A
35B
20*
15C
16F
5*
6C
10A*
18B
23B
24F
28A
31
34
38
NT
0
Serotype
<2 years
* Serotypes included in PPV23;
NT, Non-Typable
2-64 years
65+ years
serotypes in PCV7; ND, Not determined (not referred for serotyping);
Pneumococcal serotype data and coverage
among patient age groups by vaccines,
2009Q1-4: All isolates (PSSP & PNSP)
Age Group
All ages
<2 years
PCV7
PPV23
123 of 300
270 of 300
3460.0%
75.8%
15 of 27
55.6%
≥65 years
118 of 136
86.8%
PCV7 recommended for children <2 years (=target population);
PPV23 recommended for adults ≥65 years and other at risk groups
but not children <2 years
PCV7 was introduced into routine childhood vaccination schedule in
Ireland in September 2008
PCV7, 7-valent Pneumococcal Conjugate Vaccine; PPV23, 23-valent Pneumococcal Polysaccharide Vaccine
Pneumococcal serotype data and coverage
among patient age groups by vaccines,
2009Q1-3: PNSP isolates only
Age Group
All ages
<2 years
PCV7
PPV23
46 of 57
52 of 57
80.7%
91.2%
7 of 8
87.5%
≥65 years
28 of 30
93.3%
PCV7 recommended for children <2 years (=target population);
PPV23 recommended for adults ≥65 years and other at risk groups
but not children <2 years
PCV7 was introduced into routine childhood vaccination schedule in
Ireland in September 2008
PCV7, 7-valent Pneumococcal Conjugate Vaccine; PPV23, 23-valent Pneumococcal Polysaccharide Vaccine
PNSP isolates, 2009Q1-4: data by serotype
and age
SEROTYPE
NO SEROTYPE
14**
6B**
9V**
19A*
19F**
35B
6A
18C**
23F**
TOTAL
From patient aged
<2yrs 2-64yrs 65+yrs
6
9
2
3
15
3
2
4
4
5
1
3
2
1
2
2
1
2
2
1
1
1
8
25
39
TOTAL
15
20
9
9
6
5
3
2
2
1
72
* Serotypes covered by both PCV7 and PPV23; ** Serotypes
covered by PPV23 only; Serotypes 6A and 35B are not covered by
either vaccine
Rates of invasive S. pneumoniae infection
(or invasive pneumococcal disease, IPD), 1999-2009
Year
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Number Number of labs
of reports
by year-end
157
12
201
19
245
20
278
23
364
28
400
41
401
42
407
42
438
44
447
42
356
44
Population covered
(% of total*)
1,776,783 (49)
2,585,384 (66)
3,016,246 (77)
3,172,934 (81)
3,486,311 (89)
4,155,051 (98)
4,155,051 (98)
4,155,051 (98)
4,155,051 (98)
4,155,051 (98)
4,155,051 (100)
Rate/100,000
population (95%CI)
8.8 (7.5-10.3)
7.8 (6.7-8.9)
8.1 (7.1-9.2)
8.8 (7.8-9.9)
10.4 (9.4-11.6)
9.6 (8.7-10.6)
9.7 (8.7-10.6)
9.8 (8.9-10.8)
10.5 (9.6-11.6)
10.8 (9.8-11.8)
8.6 (7.7-9.5)
Rate for 1999 calcuated using the 1996 ROI census (Total population = 3,626,087)
Rates for 2000-2003 calcuated using the 2002 ROI census (Total population = 3,917,203)
Rates for 2004-2009 calcuated using the 2006 ROI census (Total population = 4,239,848)
* % of total population covered estimated using Acute Public Hospital Activity Data from the HSE's
Business Intelligence Unit, Corporate Planning and Corporate Performance
95%CI, 95% confidence interval
Age distribution of patients with invasive
PNSP and PSP infection in 2008
60
Number of isolates
50
40
30
20
10
0
Age Group
PNSP
PSP
Age-specific incidence rates of invasive
PNSP and PSP infection in 2008
80
70
60
ASIR
50
40
30
20
10
0
PNSP
Age Group
PSP
ASIR, Age-Specific Incidence Rate (per 100,000 population)
TOTAL
Age and sex distribution of patients with
invasive PNSP infection in 2008
14
Number of isolates
12
10
8
6
4
2
0
Age Group
female
male
Age and sex-specific incidence rates of
invasive PNSP infection in 2008
70
60
ASIR
50
40
30
20
10
0
Age Group
female
male
ASIR, Age-Specific Incidence Rate (per 100,000 population)
TOTAL
Age and sex distribution of patients with
invasive PSP bacteraemia in 2008
40
Number of isolates
35
30
25
20
15
10
5
0
Age Group
female
male
Age and sex-specific incidence rates of
invasive PSP bacteraemia in 2008
100
80
ASIR
60
40
20
0
Age Group
female
male
ASIR, Age-Specific Incidence Rate (per 100,000 population)
TOTAL
Age-specific incidence rates* of IPD in 2008
70
450
400
60
50
300
250
40
200
30
150
20
100
10
50
0
0
<1
1-4
5-9
10-14 15-44 45-64 65-74 75-79
Age Group
Number of patients
* Using age groups from UK study by Gungabissoon et al (2005)
ASIR, Age-Specific Incidence Rate (per 100,000 population)
80+
ASIR
TOTAL
ASIR
Number of isolates
350
Mean, median, mode and range of ages of
patients with invasive S. pneumoniae (PNSP
and PSP) infection in 2008
PNSP
PSP
SPN
n
103
342
447
n with age
103
342
447
50.9y
50.3y
50.2y
60y (52-65y)
58y (52-61y)
58y (53-61y)
Mode
0y
0y
0y
Range
0-96y
0-95y
0-96y
Mean
Median (95%CI)
Sex distribution of patients with invasive
S. pneumoniae (PNSP and PSP) infection
in 2008
PNSP
PSP
SPN
57
206
265
55.3%
60.4%
59.3%
46
135
182
%female
44.7%
39.6%
40.7%
m/f ratio
1.24
1.53
1.46
z-test
1.09
3.93
4.00
P-value
0.28
<0.0001
<0.0001
No. male
%male
No. female
In patients with laboratory-confirmed invasive S. pneumoniae infection in
2008, males were approximately 1.5-times more likely to get an infection
(1.2-times for PNSP; 1.5-times for PSP) than females. Although these
findings were significant (P<0.0001) for S. pneumoniae overall (SPN) and
PSP, they were not significant for PNSP (P=0.28)
Distribution of PNSP in EARSS countries
in 2008
Map downloaded from http://www.rivm.nl/earss/database/ on 24/08/2009
Distribution of PNSP in EARSS countries
in 2007
Map downloaded from http://www.rivm.nl/earss/database/ on 26/08/2008
Distribution of penicillin-HLR in EARSS
countries in 2008
HLR, high-level resistant (MIC to pencillin ≥2mg/L)
Map downloaded from http://www.rivm.nl/earss/database/ on 24/08/2009
Distribution of penicillin-HLR in EARSS
countries in 2007
HLR, high-level resistant (MIC to pencillin ≥2mg/L)
Map downloaded from http://www.rivm.nl/earss/database/ on 26/08/2008
Distribution of erythromycin resistance in
EARSS countries in 2008
Map downloaded from http://www.rivm.nl/earss/database/ on 24/08/2009
Distribution of erythromycin resistance in
EARSS countries in 2007
Map downloaded from http://www.rivm.nl/earss/database/ on 26/08/2008
Distribution of penicillin (PNSP) and
erythromycin co-resistance in S. pneumoniae
in EARSS countries in 2008
Map downloaded from http://www.rivm.nl/earss/database/ on 24/08/2009
Distribution of penicillin (PNSP) and
erythromycin co-resistance in S. pneumoniae
in EARSS countries in 2007
Map downloaded from http://www.rivm.nl/earss/database/ on 26/08/2008