EPI-Net One Health reporting guideline for antimicrobial consumption and resistance surveillance data: a Delphi approach

Strategic and standardised approaches to analysis and reporting of surveillance data are essential to inform antimicrobial resistance (AMR) mitigation measures, including antibiotic policies. Targeted guidance on linking full-scale AMR and antimicrobial consumption (AMC)/antimicrobial residues (AR) surveillance data from the human, animal, and environmental sectors is currently needed. This paper describes the initiative whereby a multidisciplinary panel of experts (56 from 20 countries-52 high income, 4 upper middle or lower income), representing all three sectors, elaborated proposals for structuring and reporting full-scale AMR and AMC/AR surveillance data across the three sectors. An evidence-supported, modified Delphi approach was adopted to reach consensus among the experts for dissemination frequency, language, and overall structure of reporting; core elements and metrics for AMC/AR data; core elements and metrics for AMR data. The recommendations can support multisectoral national and regional plans on antimicrobials policy to reduce resistance rates applying a One Health approach.

Country data on AMR in Kuwait in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review AMR in Kuwait and initiatives underway addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rise in AMR within Kuwait and to improve patient outcomes.

Methods

National initiatives to address AMR, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from a clinician in Kuwait were sought to contextualize this information.

Conclusions

In Kuwait there have been some initiatives addressing AMR such as annual campaigns for proper use of antibiotics. Antibiotic use is high but there appears to be a low understanding in the general public about their appropriate use. However, there is legislation in place prohibiting over-the-counter purchase of antibiotics. Only international guidelines for CA-RTIs are used. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Kuwait, could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical patient outcomes.

Country data on AMR in Russia in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial reistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review AMR in Russia and any initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rise in AMR within Russia and to improve patient outcomes.

Methods

National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from both a local clinician and a local clinical microbiologist were sought to contextualize this information.

Conclusions

Russia launched a national strategy in 2017 to prevent the spread of AMR and the WHO reports that as of 2020–21, it is being implemented and actively monitored. Reports suggest outpatient antibiotic use of antibiotics is high and that non-prescription access and self-medication are very common. Antibiotic susceptibility studies in Russia include PeHASus, a multicentre epidemiological study focusing on susceptibilities of community-acquired respiratory pathogens and international studies such as Survey of Antibiotic Resistance (SOAR), Antimicrobial Testing Leadership and Surveillance (ATLAS) and SENTRY Antimicrobial Surveillance Program. International guidelines are used to support the development of local guidelines in Russia, and for the common CA-RTIs Russian clinicians use of several country-specific local antibiotic prescribing guidelines. A standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Russia, could make guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Country data on AMR in Saudi Arabia in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review AMR in Saudi Arabia and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize a further rise in AMR within Saudi Arabia and improve patient outcomes.

Methods

National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from a clinician in Saudi Arabia were sought to contextualize this information.

Conclusions

Various initiatives are underway in Saudi Arabia, including a National Action Plan for AMR, which was published in 2017. However, AMR is rising and knowledge about appropriate antibiotic use seems to be lacking among physicians and the general public. Various international guidelines are utilized by clinicians in Saudi Arabia, but a more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Saudi Arabia could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Country data on AMR in India in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review the current situation with respect to AMR in India and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize further rises in AMR and to improve patient outcomes.

Methods

National AMR initiatives, antibiotic use and prescribing in India, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information.

Conclusions

Many initiatives have been launched since AMR was recognized as a national priority and organizations such as the Indian Academy of Paediatrics and the Global Antibiotic Resistance Partnership have worked to build awareness. The Indian Ministry of Health and Family Welfare published a 5 year national action plan on AMR. However, the burden of infectious disease and consumption of antibiotics in India is high. There have been national surveillance studies generating local data along with international studies such as Survey of Antibiotic Resistance (SOAR) and Antimicrobial Testing Leadership and Surveillance (ATLAS). For common RTIs, clinicians use a range of international and national guidelines. However, a more standardized inclusive approach to developing local guidelines, using up-to-date local surveillance data from community-acquired infections, could make guidelines more locally relevant. This would encourage more appropriate antibiotic prescribing and improve adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Country data on AMR in Brazil in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review the situation with respect to AMR in Brazil and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize any further rises in AMR within Brazil and to improve patient outcomes.

Methods

National initiatives to address AMR, antibiotic use and prescribing in Brazil, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infections (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines for CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, along with local antibiotic availability.

Conclusions

In Brazil there have been some initiatives addressing AMR such as the National Action Plan for AMR, established in 2018. Antibiotic consumption in Brazil is high but a ban on over-the-counter sales of antibiotics has led to a decrease in consumption. Local antibiotic susceptibility testing needs to be increased and the Survey of Antibiotic Resistance (SOAR) study in Brazil will provide useful data for pathogens causing CA-RTIs. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Brazil, could make guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical outcomes for patients.

Country data on AMR in Mexico in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review AMR in Mexico and initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rises in AMR and to improve patient outcomes.

Methods

National AMR initiatives in Mexico, antibiotic use and prescribing, and availability of susceptibility data, particularly the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used in Mexico for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, along with local antibiotic availability. Insights from a local clinician were sought to contextualize this information.

Conclusions

The Mexican national AMR strategy was published in 2018. This comprised similar objectives to the Global Action Plan from the World Health Assembly (2015) and was compulsory, requiring full compliance from members of the National Health System. Historically, antibiotic consumption in Mexico has been high, however, between 2000 and 2015, consumption fell, in sharp contrast to the majority of countries. Mexico lacks a national surveillance network for AMR, however there are several ongoing global surveillance studies providing local antibiotic susceptibility data. International and local antibiotic prescribing guidelines for CA-RTIs are used. A more standardized inclusive approach in developing local guidelines, using up-to-date local surveillance data of isolates from community-acquired infections, could make guideline use more locally relevant. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development in Mexico and improve patient outcomes.

Country data on AMR in Vietnam in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicines and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review the current situation with respect to AMR in Vietnam and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize any further rises in AMR within Vietnam and improve patient outcomes.

Methods

National initiatives to address AMR in Vietnam, antibiotic use and prescribing, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines for CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from clinicians in Vietnam were sought to contextualize this information.

Conclusions

In Vietnam there have been some initiatives addressing AMR; Vietnam was the first country in the Western Pacific Region to develop a national action plan to combat AMR, which according to the WHO is being implemented. Vietnam also has one of the highest rates of AMR in Asia due, in part, to the overuse of antimicrobial drugs, both in the animal health sector and in humans in both hospitals and the community. In addition, despite a 2005 law requiring antibiotic prescription, there is unrestricted access to over-the-counter antibiotics. Several global surveillance studies provide antibiotic susceptibility data for CA-RTI pathogens in Vietnam including Survey of Antibiotic Resistance (SOAR) and SENTRY (small isolate numbers only). For management of the common CA-RTIs in Vietnam there are several country-specific local antibiotic prescribing guidelines and in addition, there is a range of international guidelines referred to, but these may have been created based on pathogen resistance patterns that might be very different to those in Vietnam. Expert clinician opinion confirms the high resistance rates among common respiratory pathogens. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Vietnam, could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical outcomes for patients.

Country data on AMR in Pakistan in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review the current situation with respect to AMR in Pakistan and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize any further rises in AMR and improve patient outcomes.

Methods

National AMR initiatives, antibiotic use and prescribing in Pakistan, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information.

Conclusions

Pakistan is active in developing initiatives to address AMR such as compiling a National Action Plan. However, antibiotic consumption is high and although there is legislation in place prohibiting over-the-counter purchase of antibiotics, this is still possible. Healthcare professionals use local and international antibiotic prescribing guidelines for CA-RTIs when managing patients. As highlighted by the clinical microbiologist’s expert comments, surveillance of AMR in locally prevalent microorganisms is lacking. A more standardized inclusive approach in developing local guidelines, using up-to-date local surveillance data of isolates from community-acquired infections, could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical outcomes for patients.

Relevance of the Consensus Principles for Appropriate Antibiotic Prescribing in 2022

Background

In the late 1990s, as a response to rising antimicrobial resistance (AMR), an independent multinational, interdisciplinary group was formed specifically targeting primary care antibiotic prescribing for community-acquired respiratory tract infections (CA-RTIs). The group comprised senior clinicians from Canada, Israel, Spain, Sweden, UK and USA. The group’s objectives were to provide recommendations for antibiotic stewardship in the community because, whilst it was widely accepted that inappropriate antibiotic use was contributing to AMR, it remained difficult to change prescribing behaviour. The group aimed to identify principles underlying appropriate antibiotic prescribing and guideline formulation to reduce morbidity from CA-RTIs, limit therapeutic failure and, importantly, curb AMR emergence. The group published a report in 2002, which has become known as the Consensus Principles.

Objectives

(i) To consider the relevance of the Consensus Principles in 2022 by reviewing current global approaches to rising AMR. A wide range of factors, such as antibiotic overuse, most recently seen in COVID-19 patients, are still driving rising AMR even though there has been a high-level international response to the AMR threat; and (ii) as an introduction to this Supplement, which reports the findings of analyses of how AMR is being addressed in nine disparate countries (Brazil, India, Kuwait, Mexico, Pakistan, Russia, Saudi Arabia, Türkiye and Vietnam). Understanding how these initiatives are being pursued in different countries helps identify areas where more information is needed.

Conclusions

Adherence to the Consensus Principles remains as important now as it was in 2002. Achieving appropriate antibiotic prescribing is a vital objective in order that the right patient receives the right antibiotics at the right time to ensure optimal clinical outcomes while at the same time helping to limit further increases in AMR.

Country data on AMR in Türkiye in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

BACKGROUND

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

OBJECTIVES

To review AMR in Türkiye and initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rise in AMR within Türkiye and to improve patient outcomes.

METHODS

National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media, acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from both a local clinician and local clinical microbiologist were sought to contextualize this information.

CONCLUSIONS

Türkiye developed an antibiotic stewardship programme, The Rational Drug Use National Action Plan 2014-2017, prioritizing appropriate antibiotic prescription in the community. Public campaigns discouraging inappropriate antibiotic use were also initiated. Türkiye has a high level of antibiotic resistance and a high level of consumption, however, in 2015 over-the-counter antibiotic sales were prohibited, resulting in a declining trend in overall consumption. There is still a need for physician education on current developments in antibiotic use. Several ongoing global surveillance studies provide antibiotic susceptibility data in Türkiye. Clinicians in Türkiye use several country-specific guidelines for common CA-RTIs plus a range of international guidelines. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data on isolates from community-acquired infections in Türkiye, could make guideline use more relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcome.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Turkey: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Turkey.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 179 S. pneumoniae and 239 H. influenzae isolates were collected. Few (27.9%) pneumococci were penicillin susceptible by CLSI oral or EUCAST low-dose breakpoints, but by EUCAST high-dose or CLSI IV breakpoints 84.4% were susceptible. The most active antibiotics (excluding penicillin IV) by CLSI breakpoints were fluoroquinolones (98.9% of isolates susceptible), ceftriaxone (83.2%), amoxicillin (78.8%) and amoxicillin/clavulanic acid (78.8%). Pneumococcal susceptibility to amoxicillin and amoxicillin/clavulanic acid was lower using EUCAST low-dose breakpoints (49.7%), although susceptibility increased when using EUCAST high-dose (57.0%-58.1%) and PK/PD (78.8%-87.7%) breakpoints. Twenty-three H. influenzae isolates were β-lactamase positive, with 11 characterized as β-lactamase negative and ampicillin resistant following EUCAST criteria and 5 by CLSI criteria. Generally antibiotic susceptibility was high using CLSI breakpoints: ≥92.9% for all antibiotics except ampicillin (87% by CLSI and EUCAST breakpoints) and trimethoprim/sulfamethoxazole (67.4% and 72% by CLSI and EUCAST breakpoints, respectively). Susceptibility using EUCAST breakpoints (where these are published) was similar, except for cefuroxime (oral) with 3.8% of isolates susceptible. PK/PD breakpoints indicated low susceptibility to macrolides (5.9%-10%) and cefaclor (13%). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Antibiotic susceptibility of S. pneumoniae was generally low, which is in keeping with evidence of inappropriate and high antibiotic use in Turkey. H. influenzae susceptibility was high. These data are important for empirical therapy of CA-RTIs.

White Paper: Bridging the gap between human and animal surveillance data, antibiotic policy and stewardship in the hospital sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks

BACKGROUND

Antimicrobial surveillance and antimicrobial stewardship (AMS) are essential pillars in the fight against antimicrobial resistance (AMR), but practical guidance on how surveillance data should be linked to AMS activities is lacking. This issue is particularly complex in the hospital setting due to structural heterogeneity of hospital facilities and services. The JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks have joined efforts to formulate a set of target actions for linking surveillance data with AMS activities.

METHODS

A scoping review of the literature was carried out addressing research questions on three areas: (i) AMS leadership and accountability; (ii) antimicrobial usage and AMS; (iii) AMR and AMS. Consensus on the target actions was reached through a RAND-modified Delphi process involving over 40 experts in different fields from 18 countries.

RESULTS

Evidence was retrieved from 51 documents. Initially 38 targets were proposed, differentiated as essential or desirable according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for 32 targets. Following a second consultation, 27 targets were approved, 11 were deleted and 4 were suggested for rephrasing, leading to a final approved list of 34 target actions in the form of a practical checklist.

CONCLUSIONS

This White Paper provides a pragmatic and flexible tool to guide the development of calibrated hospital-surveillance-based AMS interventions. The strength of this tool is that it is a comprehensive perspective that takes into account the hospital patient case-mix and the related epidemiology, which ultimately drives antimicrobial usage, and the feasibility in low-resource settings.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Latin America (Argentina, Chile and Costa Rica): data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Argentina, Chile and Costa Rica.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 170 S. pneumoniae and 218 H. influenzae isolates were collected at five centres in Argentina, Chile and Costa Rica in 2015-17. Small S. pneumoniae isolate numbers from Costa Rica (n = 2) meant that these could only be included in the penicillin susceptibility analysis; they were excluded from further country analyses. Around one-third of pneumococcal isolates from Argentina and two-thirds from Chile were non-susceptible to penicillin by CLSI oral or EUCAST low-dose IV breakpoints, but most (≥89%) were susceptible by CLSI IV or EUCAST high-dose breakpoints. Amongst pneumococci from Argentina, about 80% or more were susceptible to most other antibiotics except cefaclor (all breakpoints), cefixime (PK/PD breakpoints), cefuroxime (EUCAST breakpoints) and trimethoprim/sulfamethoxazole (CLSI and PK/PD breakpoints). S. pneumoniae isolates from Chile showed significantly lower susceptibility (P < 0.05) using CLSI breakpoints compared with those from Argentina for many of the antibiotics tested. Among isolates of H. influenzae from Latin America, more than 90% were susceptible to amoxicillin/clavulanic acid (high dose), cefixime, cefpodoxime, ceftriaxone and fluoroquinolones, irrespective of the breakpoints used. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Antibiotic susceptibility of H. influenzae isolates was generally high in the Latin American countries studied; however, susceptibility profiles varied for S. pneumoniae by country and depending on the breakpoints used, especially for cefaclor. These factors are important in decision making for empirical therapy of bacterial infections.

Results from the Survey of Antibiotic Resistance (SOAR) 2016-17 in Ukraine: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2016-17 from Ukraine.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 177 viable clinical isolates, including 78 S. pneumoniae and 99 H. influenzae, were collected. Overall, ∼98% of S. pneumoniae isolates were susceptible to penicillin by CLSI IV or EUCAST high-dose breakpoints and 73.1% were susceptible by CLSI oral or EUCAST low-dose IV breakpoints. Susceptibility rates of 76.9%-100% were observed for most antibiotics by all breakpoints except trimethoprim/sulfamethoxazole (41%-69.2%) and cefaclor, which showed the greatest difference between breakpoints: 0% by EUCAST, 28.2% by PK/PD and 73.1% by CLSI. All S. pneumoniae isolates were susceptible to amoxicillin/clavulanic acid by CLSI and PK/PD breakpoints. H. influenzae isolates were almost all β-lactamase negative (90.9%). One isolate was β-lactamase negative and ampicillin resistant (BLNAR) by CLSI and four isolates were BLNAR by EUCAST criteria. Susceptibility of isolates was high (≥90.9%) by CLSI breakpoints for all antibiotics tested except trimethoprim/sulfamethoxazole (61.6%). Susceptibility using EUCAST breakpoints was similar for ampicillin (90.9%) and amoxicillin/clavulanic acid (95%) but was low for cefuroxime (oral), where only 10.1% of isolates were susceptible. All S. pneumoniae and H. influenzae isolates were susceptible to the fluoroquinolones by all breakpoints. Susceptibility to ceftriaxone was also 100% for H. influenzae and ≥91% for S. pneumoniae isolates by all breakpoints. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Antibiotic susceptibility in these respiratory tract pathogens was generally high in Ukraine. These data are important for empirical therapy choices in the treatment of CA-RTIs.

Results from the Survey of Antibiotic Resistance (SOAR) 2016-18 in Vietnam, Cambodia, Singapore and the Philippines: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates collected from community-acquired respiratory tract infections (CA-RTIs) in 2016-18 in four Asian countries.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

In total, 260 S. pneumoniae and 258 H. influenzae isolates were tested. Pneumococci from Vietnam (n = 161) were the least susceptible, with rates of susceptibility >90% for fluoroquinolones by CLSI breakpoints, ∼60% for amoxicillin, amoxicillin/clavulanic acid and ceftriaxone but <14% for most other agents. Pneumococcal isolates from Cambodia (n = 48) and Singapore (n = 34) showed susceptibilities ranging from ∼30% for trimethoprim/sulfamethoxazole and oral penicillin to 100% for fluoroquinolones. Among isolates of H. influenzae from Cambodia (n = 30), the Philippines (n = 59) and Singapore (n = 80), rates of susceptibility using CLSI breakpoints were >90% for amoxicillin/clavulanic acid, cephalosporins [except cefaclor in Singapore (77.5%)], macrolides and fluoroquinolones; for isolates from Vietnam (n = 89) the rates of susceptibility were >85% only for amoxicillin/clavulanic acid (95.5%), ceftriaxone (100%) and macrolides (87.6%-89.9%). Susceptibility to other antibiotics ranged from 7.9% (trimethoprim/sulfamethoxazole) to 57.3%-59.6% (fluoroquinolones) and 70.8% (cefixime). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. A limitation of the study was the small sample sizes and only one or two sites participating per country; however, since susceptibility data are scarce in some of the participating countries any information concerning antibiotic susceptibility is of value.

CONCLUSIONS

Antibiotic susceptibility varied across countries and species, with isolates from Vietnam demonstrating the lowest susceptibility. Knowledge of resistance patterns can be helpful for clinicians when choosing empirical therapy options for CA-RTIs.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-18 in Tunisia, Kenya and Morocco: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of community-acquired respiratory tract infection (CA-RTI) isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2015-18 from Tunisia, Kenya and Morocco.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

S. pneumoniae isolates from Tunisia (n = 79), Kenya (n = 44) and Morocco (n = 19) and H. influenzae isolates (n = 74) from Tunisia only were collected and analysed. Low antibiotic susceptibility was observed in S. pneumoniae from Tunisia, with >90% susceptible only to the fluoroquinolones (all breakpoints), penicillin (CLSI IV and EUCAST high-dose) and ceftriaxone (CLSI, EUCAST high-dose and PK/PD breakpoints). In addition, isolate susceptibility in Kenya was >90% to amoxicillin and amoxicillin/clavulanic acid (CLSI and PK/PD breakpoints). Antibiotic activity was highest in Morocco, where ≥89.5% of pneumococci were susceptible to most antibiotics, excluding trimethoprim/sulfamethoxazole (68.4% by CLSI or PK/PD and 79%-84.2% by EUCAST), macrolides (79%-84.2% by all breakpoints) and cefaclor (0% by EUCAST and 52.6% by PK/PD). The majority (≥86.5%) of H. influenzae isolates from Tunisia were susceptible to most antibiotics by all available breakpoints, except ampicillin and amoxicillin (almost one-third were β-lactamase positive), trimethoprim/sulfamethoxazole (51.4%-56.8%), cefaclor (1.4% by PK/PD), cefuroxime (4.1% by EUCAST), macrolides (1.4%-2.7% by PK/PD) and cefdinir (66.2% by PK/PD). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Low antibiotic susceptibility was observed in S. pneumoniae from Tunisia, but susceptibility was higher in isolates from Kenya and highest in those from Morocco. H. influenzae from Tunisia were highly susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in the Middle East (Kuwait, Lebanon and Saudi Arabia): data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Kuwait, Lebanon and Saudi Arabia.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 139 S. pneumoniae isolates were collected from four centres in Kuwait, Lebanon and Saudi Arabia in 2015-17 and 55 H. influenzae isolates were collected and analysed from Saudi Arabia over the same time period. Pneumococci from all three countries were commonly non-susceptible to penicillin based on CLSI oral or low-dose IV penicillin using EUCAST breakpoints (39% in Kuwait to 57.1% in Lebanon) but by CLSI IV and EUCAST high-dose breakpoints most isolates were susceptible (∼90% in Kuwait and Saudi Arabia, and 100% in Lebanon). Isolates from Lebanon were highly susceptible to most other antibiotics (>90%) except cefaclor, oral cefuroxime and cefpodoxime (EUCAST breakpoints only). Overall, susceptibility was significantly lower in Kuwait and Saudi Arabia than Lebanon. Although all H. influenzae isolates (Saudi Arabia only) were β-lactamase negative, 3.6% and 12.7% were ampicillin resistant by CLSI and EUCAST breakpoints, respectively. Otherwise susceptibility was high in H. influenzae. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Relatively low antibiotic susceptibility was observed in S. pneumoniae from Kuwait and Saudi Arabia in contrast to Lebanon, where rates of susceptibility were generally higher. Isolates of H. influenzae from Saudi Arabia were susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Pakistan: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of community-acquired respiratory tract infection (CA-RTI) isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2015-17 from Pakistan.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 94 S. pneumoniae and 122 H. influenzae isolates were collected. Susceptibility to penicillin was noted in 23.4% of the S. pneumoniae isolates by CLSI oral/EUCAST low-dose IV breakpoints, although by CLSI IV and EUCAST high-dose breakpoints all isolates were characterized as susceptible. Susceptibility to trimethoprim/sulfamethoxazole (10.6%), macrolides (33%) and cefaclor (28.7%) was low but higher susceptibility was observed to ceftriaxone (100%), amoxicillin and amoxicillin/clavulanic acid (98.9%), cefuroxime (oral, 97.9%), cefpodoxime (96.8%), fluoroquinolones (93.6%-96.8%) and cefdinir (76.6%) by CLSI breakpoints. However, using EUCAST breakpoints, susceptibility to cefpodoxime (70.2%) and cefuroxime (oral, 61.7%) was reduced. H. influenzae isolates were almost all β-lactamase negative (96.7%). Using CLSI breakpoints, ≥93.4% of isolates were susceptible to all antibiotics tested except fluoroquinolones (75.4%-77.1%) and trimethoprim/sulfamethoxazole (41%). The proportion of isolates susceptible using EUCAST breakpoints was similar or identical for penicillins, trimethoprim/sulfamethoxazole and the cephalosporins that have EUCAST breakpoints; the proportion of isolates susceptible using EUCAST breakpoints was similar or identical to that using CSLI breakpoints except for cefuroxime (oral), where only 1.6% of isolates were considered susceptible. Susceptibility of H. influenzae to fluoroquinolones was also lower by EUCAST breakpoints (33.6%-34.4%). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Antibiotic susceptibility in these important respiratory tract pathogens varied in Pakistan based on different breakpoints. These data are important for empirical therapy choices in the treatment of CA-RTIs.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Russia

Objectives

To determine antibiotic susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from Russia.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

A total of 279 S. pneumoniae and 279 H. influenzae were collected. Overall, 67.0% of S. pneumoniae were penicillin susceptible by CLSI oral/EUCAST and 93.2% by CLSI intravenous (iv) breakpoints. All were fluoroquinolone susceptible, with amoxicillin, amoxicillin/clavulanic acid and ceftriaxone susceptibility ≥92.8% by CLSI and PK/PD breakpoints. Isolates showed lower susceptibility to cefuroxime, cefaclor, macrolides and trimethoprim/sulfamethoxazole by CLSI criteria: 85.0%, 76.7%, 68.8% and 67.7%, respectively. Generally, susceptibility was slightly lower by EUCAST criteria, except for cefaclor, for which the difference in susceptibility was much greater. Penicillin-resistant isolates had low susceptibility (≤60%) to all agents except fluoroquinolones. All 279 H. influenzae were ceftriaxone susceptible, 15.4% were β-lactamase positive and ≥97.5% were amoxicillin/clavulanic acid susceptible (CLSI, EUCAST and PK/PD breakpoints). Four isolates were fluoroquinolone non-susceptible by current EUCAST criteria. A major discrepancy was found with azithromycin susceptibility between CLSI (99.3%) and EUCAST and PK/PD (2.2%) breakpoints. Trimethoprim/sulfamethoxazole was poorly active (62.7% susceptible).

Conclusions

Susceptibility to penicillin (oral), macrolides and trimethoprim/sulfamethoxazole was low in S. pneumoniae from Russia. However, isolates were fully susceptible to fluoroquinolones and ≥92.8% were susceptible to amoxicillin, amoxicillin/clavulanic acid and ceftriaxone. Isolates of H. influenzae only showed reduced susceptibility to ampicillin, cefaclor, clarithromycin and trimethoprim/sulfamethoxazole. Some differences were detected between CLSI, EUCAST and PK/PD breakpoints, especially with cefaclor, cefuroxime and macrolides. These data suggest further efforts are required to harmonize international breakpoints.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Greece

Objectives

To determine antimicrobial susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from patients with community-acquired respiratory tract infections in Greece.

Methods

MICs were determined by CLSI broth microdilution and susceptibility assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

A total of 99 S. pneumoniae and 52 H. influenzae isolates were collected. Overall, 36.4% of S. pneumoniae were penicillin susceptible by CLSI oral/EUCAST and 88.9% by CLSI intravenous (iv) breakpoints. All were fluoroquinolone susceptible with ≥94% of isolates also susceptible to amoxicillin, amoxicillin/clavulanic acid and ceftriaxone by CLSI and PK/PD breakpoints. Trimethoprim/sulfamethoxazole, cefuroxime, cefaclor and macrolides were less active, with rates of susceptibility of 83.8%, 69.7%, 50.5% and 49.5%, respectively, by CLSI. Generally susceptibility was the same or slightly lower by EUCAST, but the cefaclor difference was much greater. Among H. influenzae, 15.4% of isolates were β-lactamase positive. Susceptibility to amoxicillin/clavulanic acid, ceftriaxone, cefuroxime and the fluoroquinolones was seen in >95% of isolates by CLSI criteria. Susceptibility to azithromycin was seen in 94.2% of isolates using CLSI breakpoints, but clarithromycin susceptibility was lower (61.5%). However, susceptibility to both macrolides was seen in <5% of isolates by PK/PD and EUCAST criteria. Susceptibility to trimethoprim/sulfamethoxazole was seen in 71.2% of isolates.

Conclusions

Owing to the high prevalence of macrolide resistance among S. pneumoniae and the reduced activity of clarithromycin against H. influenzae, it appears that these agents are not appropriate as monotherapy for community-acquired pneumonia in Greece. Amoxicillin/clavulanic acid, on the other hand, maintained excellent in vitro activity and, as opposed to the similarly effective fluoroquinolones, is safe to use in paediatric patients.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Ukraine and the Slovak Republic

Objectives

To determine antibiotic susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from Ukraine and the Slovak Republic.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

S. pneumoniae isolates collected in Ukraine (n = 100) showed susceptibility rates ≥97% for amoxicillin, amoxicillin/clavulanic acid, penicillin [intravenous (iv) non-meningitis] and fluoroquinolones, between 83% and 86% for oral penicillin, macrolides and cefaclor, and 75% for trimethoprim/sulfamethoxazole. Susceptibility was substantially lower in the Slovak Republic (n = 95). All isolates were susceptible to the fluoroquinolones, but susceptibility to penicillin, amoxicillin, amoxicillin/clavulanic acid, cefuroxime and trimethoprim/sulfamethoxazole varied between 61% and 64%, with only 44% of isolates susceptible to the macrolides. Susceptibility of H. influenzae was more homogeneous, with susceptibility to amoxicillin/clavulanic acid, ceftriaxone, cefuroxime, azithromycin and the fluoroquinolones seen in >90% of isolates by CLSI criteria in both countries. Much greater variability was seen across breakpoints, especially for azithromycin, cefaclor and cefuroxime. The β-lactamase rate was 5.1% (5/98) in the Slovak Republic and 7.3% (7/96) in Ukraine, but the Slovak Republic also had a relatively high rate of β-lactamase-negative-ampicillin-resistant (BLNAR) isolates (7.1%; 7/98).

Conclusions

The variability found across these two neighbouring countries illustrates the need to monitor and publish national and local resistance patterns. This information is not only critical for effective empirical therapy but can also be used to help shape and support antimicrobial stewardship efforts in order to limit antibiotic resistance.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Bulgaria, Romania, Serbia and Croatia

Objectives

To determine antibiotic susceptibility of isolates of Streptococcus pneumoniae (n = 573) and Haemophilus influenzae (n = 345) collected in 2014-16 from Bulgaria, Romania, Serbia and Croatia.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

Among S. pneumoniae, susceptibility was generally lowest in Romania and Serbia and highest in Bulgaria. Rates of susceptibility to penicillin (CLSI oral or EUCAST) were 22.3% and 21.8% in Romania and Serbia respectively, 57% in Croatia and 86.6% in Bulgaria. Similarly, macrolide susceptibility using CLSI/EUCAST breakpoints was low in Romania and Serbia (∼28% and 34.5%, respectively), higher in Croatia (55.9%) and highest in Bulgaria (∼75%). Only fluoroquinolones were active against all isolates in all four countries. Susceptibility was higher and variability across countries less pronounced for H. influenzae. Susceptibility by CLSI criteria to amoxicillin/clavulanic acid, azithromycin, cefuroxime, ceftriaxone and fluoroquinolones was ≥98% in all countries. Ampicillin susceptibility ranged from 85.3% in Romania to 100% in Bulgaria. Much greater variability was seen across breakpoints. Susceptibility to azithromycin and cefuroxime using CLSI criteria was ≥98% in all four countries, but was 0%-1% by EUCAST criteria.

Conclusions

The variability in antimicrobial susceptibility using different breakpoints makes it difficult for clinicians to interpret antimicrobial resistance data, and efforts should be made to harmonize breakpoints. The variability found across the four neighbouring countries demonstrates the need to monitor and publish national and local resistance patterns. These findings provide information critical for the selection of appropriate antimicrobial agents for the treatment of S. pneumoniae and H. influenzae.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in the Czech Republic

Objectives

To determine the antibiotic susceptibility of isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from patients with community-acquired respiratory infections in the Czech Republic.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

S. pneumoniae isolates (n = 200) showed high rates of susceptibility (>95%) to amoxicillin, amoxicillin/clavulanic acid, penicillin [intravenous (iv) non-meningitis], ceftriaxone, cefuroxime and the fluoroquinolones using CLSI breakpoints. Susceptibility to cefaclor and trimethoprim/sulfamethoxazole was 94%-94.5%, to penicillin (oral) 91.5% and to the macrolides 89.5%. Susceptibility of H. influenzae (n = 197) to amoxicillin/clavulanic acid, ceftriaxone, cefuroxime, azithromycin and the fluoroquinolones was ≥98% by CLSI criteria. Rates of susceptibility to the remaining agents were ≥75% except for clarithromycin at 37.1%. Great variability was seen across breakpoints, especially for the macrolides, cefaclor and cefuroxime (oral), 98.0% of H. influenzae showing susceptibility to the latter by CLSI criteria, 69.5% by PK/PD and 1.5% by EUCAST standards. The β-lactamase rate was 13.7% with no β-lactamase-negative-ampicillin-resistant (BLNAR) isolates by CLSI criteria.

Conclusions

Antibiotic resistance among the two major respiratory pathogens remained low in the Czech Republic. These findings support local clinicians in continuing the historically restrictive use of antibiotics in the Czech Republic, with selection of narrower-spectrum agents for the empirical therapy of community-acquired respiratory tract infections. This highlights one of the great benefits of continuous surveillance of antimicrobial resistance: knowledge of current local resistance patterns reduces the need to choose broad-spectrum agents that contribute to increasing resistance worldwide.

Results from the Survey of Antibiotic Resistance (SOAR) 2002-09 in Turkey

OBJECTIVES

To investigate changes in antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae from the Survey of Antibiotic Resistance (SOAR) in community-acquired respiratory tract infections (CA-RTIs) between 2002 and 2009 in Turkey.

METHODS

Previously published SOAR data were used for this analysis. MICs were determined using Etest(®) gradient strips or disc diffusion. Susceptibility against a range of antimicrobial agents was assessed using CLSI breakpoints.

RESULTS

A total of 900 S. pneumoniae isolates were analysed: 2002-03 (n = 75), 2004-05 (n = 301) and 2007-09 (n = 524). Four antibiotics were tested consistently throughout and three showed a statistically significant decrease in susceptibility (P < 0.0001): penicillin (74.7% susceptible in 2002-03; 67.8% in 2004-05; and 47.2% in 2007-09); cefaclor (85.3% in 2002-03; 78.7% in 2004-05; and 53.5% in 2007-09) and clarithromycin (85.3% in 2002-03; 82.7% in 2004-05; and 61.9% in 2007-09). Susceptibility to amoxicillin/clavulanic acid did not significantly change (100% in 2002-03; 98.7% in 2004-05; and 97.7% in 2007-09). A total of 930 H. influenzae isolates were analysed: 2002-03 (n = 133), 2004-05 (n = 379) and 2007-09 (n = 418). Four antibiotics were also consistently tested: ampicillin, amoxicillin/clavulanic acid, clarithromycin and cefaclor. All showed >90% susceptibility, but only cefaclor susceptibility significantly reduced (P < 0.0001) over time (99.2% in 2002-03; 96.3% in 2004-05; and 90.4% in 2007-09).

CONCLUSIONS

In S. pneumoniae from Turkey, there has been a clear statistically significant reduction in susceptibility to key antibiotics since 2002, but not to amoxicillin/clavulanic acid (or amoxicillin). However, susceptibility in H. influenzae remained stable. Continued surveillance is required to monitor future changes in antibiotic susceptibility for CA-RTI bacteria.

Results from the Survey of Antibiotic Resistance (SOAR) 2011-13 in Turkey

OBJECTIVES

Data are presented from the Survey of Antibiotic Resistance (SOAR) for respiratory tract infection pathogens collected in 2011-13 from Turkey.

METHODS

MICs were determined using Etest(®). Susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) interpretive criteria.

RESULTS

Rates of antibiotic susceptibility were very low among 333 isolates of Streptococcus pneumoniae tested: penicillin 38% using CLSI (oral) and EUCAST breakpoints; erythromycin 51% using CLSI and EUCAST criteria; and cefuroxime 64.6% using CLSI and PK/PD and 46.9% using EUCAST. Of the isolates, >90% were susceptible to amoxicillin/clavulanic acid, ceftriaxone (except using EUCAST criteria: 76%), levofloxacin and high-dose intravenous penicillin. Among 339 Haemophilus influenzae isolates, 6.8% were β-lactamase positive while 9.1% were β-lactamase negative but ampicillin resistant (BLNAR) by CLSI (14.7% by EUCAST) criteria. Amoxicillin/clavulanic acid susceptibility was ∼90% by CLSI (with or without BLNAR adjustment, EUCAST and high-dose PK/PD) but lower, at 82.9%, by EUCAST with BLNAR adjustment. Levofloxacin susceptibility was 96% using all three breakpoints. Dramatic differences in rates of susceptibility, depending on the breakpoints used, were seen for cefaclor [94% by CLSI (86.4% BLNAR adjusted), 23% by PK/PD] and cefuroxime [97% by CLSI (89.1% BLNAR adjusted), 85% by PK/PD, 15% by EUCAST (13.0% BLNAR adjusted)]. Streptococcus pyogenes (n = 222) and Moraxella catarrhalis (n = 40) isolates remained highly susceptible to amoxicillin/clavulanic acid, cephalosporins and levofloxacin, with only erythromycin susceptibility dropping below 95% for S. pyogenes.

CONCLUSIONS

Overall, amoxicillin/clavulanic acid and levofloxacin were the most active antibiotics based on all three breakpoints against these pathogens. Although susceptibility was not universally low in Turkey, high resistance rates were found in S. pneumoniae and, when using PK/PD and EUCAST breakpoints, in other respiratory pathogens.

Results from the Survey of Antibiotic Resistance (SOAR) 2011-13 in the Gulf States

OBJECTIVES

To provide surveillance data on the susceptibility of community-acquired respiratory tract isolates from four Gulf and Near East countries from 2011 to 2013.

METHODS

MICs were determined using Etests(®) for all antibiotics evaluated except erythromycin, where testing was by disc diffusion. Susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

Seven hundred and twenty-six respiratory isolates comprising 265 isolates of Streptococcus pneumoniae, 125 isolates of Streptococcus pyogenes and 336 isolates of Haemophilus influenzae were collected from Bahrain, Lebanon, Oman and the United Arab Emirates (UAE). Among S. pneumoniae, susceptibility to penicillin was low in the UAE and Bahrain. Macrolide susceptibility was ∼45%-60% in the UAE and Oman but higher in Lebanon (73.7%) and Bahrain (84%-85%). Penicillin susceptibility using CLSI intravenous breakpoints was >85% in all countries. Antibiotic susceptibility of S. pneumoniae was lower in UAE and Oman. Among S. pyogenes isolates, resistance to erythromycin was highest in Oman (31.6%) but <20% in the other countries. In H. influenzae, susceptibility to most antibiotics was high, except for ampicillin in Lebanon (70.2%) and amoxicillin in Oman (95.4%). Lebanon also had a high percentage (14.9%) of β-lactamase-positive isolates with non-susceptibility to ampicillin. Amoxicillin/clavulanic acid susceptibility was >95% in all countries. Use of EUCAST versus CLSI breakpoints demonstrated profound differences for cefaclor and cefuroxime in S. pneumoniae and H. influenzae, with EUCAST showing lower susceptibility.

CONCLUSIONS

There was considerable variability in susceptibility among countries in the same region. Thus, continued surveillance is necessary to track future changes in antibiotic resistance.

Results from the Survey of Antibiotic Resistance (SOAR) 2012-14 in Thailand, India, South Korea and Singapore

OBJECTIVES

To provide susceptibility data for community-acquired respiratory tract isolates of Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae and Moraxella catarrhalis collected in 2012-14 from four Asian countries.

METHODS

MICs were determined using Etest(®) for all antibiotics except erythromycin, which was evaluated by disc diffusion. Susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. For macrolide/clindamycin interpretation, breakpoints were adjusted for incubation in CO2 where available.

RESULTS

Susceptibility of S. pneumoniae was generally lower in South Korea than in other countries. Penicillin susceptibility assessed using CLSI oral or EUCAST breakpoints ranged from 21.2% in South Korea to 63.8% in Singapore. In contrast, susceptibility using CLSI intravenous breakpoints was much higher, at 79% in South Korea and ∼95% or higher elsewhere. Macrolide susceptibility was ∼20% in South Korea and ∼50%-60% elsewhere. Among S. pyogenes isolates (India only), erythromycin susceptibility (∼20%) was lowest of the antibiotics tested. In H. influenzae antibiotic susceptibility was high except for ampicillin, where susceptibility ranged from 16.7% in South Korea to 91.1% in India. South Korea also had a high percentage (18.1%) of β-lactamase-negative ampicillin-resistant isolates. Amoxicillin/clavulanic acid susceptibility for each pathogen (PK/PD high dose) was between 93% and 100% in all countries except for H. influenzae in South Korea (62.5%).

CONCLUSIONS

Use of EUCAST versus CLSI breakpoints had profound differences for cefaclor, cefuroxime and ofloxacin, with EUCAST showing lower susceptibility. There was considerable variability in susceptibility among countries in the same region. Thus, continued surveillance is necessary to track future changes in antibiotic resistance.

Results from the Survey of Antibiotic Resistance (SOAR) 2011-14 in the Democratic Republic of Congo, Ivory Coast, Republic of Senegal and Kenya

OBJECTIVES

To assess antibiotic susceptibility of community-acquired respiratory tract isolates from Ivory Coast, Kenya, Democratic Republic of Congo (DRC) and Senegal in 2011-14.

METHODS

Bacterial isolates were collected and MICs determined using Etest(®) for all antibiotics except erythromycin, for which testing was by disc diffusion. Susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. For macrolide interpretation, CLSI breakpoints were adjusted for incubation in CO2.

RESULTS

Susceptibility to penicillin (using CLSI oral or EUCAST breakpoints) was low among isolates of Streptococcus pneumoniae from the DRC and Kenya (17.4% and 19%, respectively) but higher among isolates from the Ivory Coast (70%) and Senegal (85.7%). Penicillin susceptibility using CLSI iv breakpoints was higher in all countries, but still only 69.6% in the DRC. Macrolide susceptibility (based on CLSI erythromycin disc diffusion breakpoints) was also low in Kenya (∼65%) but 87%-100% elsewhere. Haemophilus influenzae were only collected in the DRC and Senegal, with β-lactamase prevalence of 39% and 4%, respectively. Furthermore, β-lactamase-negative ampicillin-resistant (BLNAR) isolates were found in DRC (four isolates, 17%), but only two isolates were found in Senegal (by EUCAST definition). Amoxicillin/clavulanic acid in vitro susceptibility was 73.9% in the DRC and 100% in Senegal based on CLSI breakpoints, but this reduced to 65.2% in the DRC when BLNAR rates were considered. Clarithromycin susceptibility was >95% in both countries.

CONCLUSIONS

There was considerable variability in antibiotic susceptibility among the African countries participating in the surveillance programme. Thus, continued surveillance is necessary to track future changes in antibiotic resistance. Use of EUCAST versus CLSI breakpoints showed profound differences for cefaclor and ofloxacin against S. pneumoniae, with EUCAST showing lower susceptibility.

Antibiotic susceptibility in Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes in Pakistan: a review of results from the Survey of Antibiotic Resistance (SOAR) 2002-15

OBJECTIVES

To investigate changes in the antibiotic susceptibility of Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes from the Survey of Antibiotic Resistance (SOAR) in community-acquired respiratory tract infections (CA-RTIs) between 2002 and 2015 in Pakistan.

METHODS

This is a review based on previously published studies from 2002-03, 2004-06 and 2007-09 and also new data from 2014-15. Susceptibility was determined by Etest(®) or disc diffusion according to CLSI and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 706 isolates from CA-RTIs comprising 381 S. pneumoniae, 230 H. influenzae and 95 S. pyogenes were collected between 2002 and 2015 and tested against a range of antibiotics. Antibiotic resistance in S. pneumoniae rose steeply from 2002 to 2009, with isolates non-susceptible to penicillin and macrolides increasing from 10% to 34.1% and from 13%-14% to 29.7%, respectively. Susceptibility to amoxicillin/clavulanic acid (and by inference amoxicillin) remained between 99.4% and 100% from 2002 to 2015. Over the years, the prevalence of susceptibility to cefuroxime was 98%-100% among S. pneumoniae. Resistance in S. pneumoniae to some older antibiotics between 2007 and 2009 was high (86.8% for trimethoprim/sulfamethoxazole and 57.2% for tetracycline). Between 2002 and 2015, ampicillin resistance (β-lactamase-positive strains) among H. influenzae has remained low (between 2.6% and 3.2%) and almost unchanged over the years (H. influenzae was not tested during 2004-06). For S. pyogenes isolates, macrolide resistance reached 22%; however, susceptibility to penicillin, amoxicillin/clavulanic acid and cefuroxime remained stable at 100%.

CONCLUSIONS

In S. pneumoniae from Pakistan, there has been a clear reduction in susceptibility to key antibiotics since 2002, but not to amoxicillin/clavulanic acid (amoxicillin) or cefuroxime. However, susceptibility in H. influenzae has remained stable. Local antibiotic susceptibility/resistance data are essential to support informed prescribing for CA-RTIs and other infections.

Results from the Survey of Antibiotic Resistance (SOAR) 2009-11 and 2013-14 in China

OBJECTIVES

To compare antibiotic susceptibility of community-acquired respiratory bacteria in China during 2009-11 and 2013-14.

METHODS

Susceptibility was determined by Etest(®) (bioMérieux) or disc diffusion according to CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints, except for azithromycin where Etest(®) breakpoints (in CO2 incubation) were used in place of standard CLSI breakpoints. Statistical significance of differences in susceptibility across time periods was evaluated using Fisher's exact test.

RESULTS

During 2009-11, 434 Streptococcus pneumoniae, 307 Haemophilus influenzae and 140 Moraxella catarrhalis were collected from eight centres and during 2013-14, 208 S. pneumoniae, 185 H. influenzae and 80 M. catarrhalis were collected from five centres. Penicillin-non-susceptible isolates remained stable at ∼66% over both time periods but susceptibility decreased significantly for amoxicillin/clavulanic acid (or amoxicillin) and cefaclor. For H. influenzae, the proportion of β-lactamase-positive isolates and β-lactamase-negative ampicillin-resistant strains (CLSI definition) was higher in 2013-14 (25.4% and 7.0%, respectively) than in 2009-11 (16.3% and 3.6%, respectively), with decreased ampicillin and cephalosporin susceptibility. By 2009-11 and 2013-14, only amoxicillin/clavulanic acid (amoxicillin), levofloxacin, penicillin (intravenously) and chloramphenicol inhibited >70% of S. pneumoniae. During 2013-14, M. catarrhalis showed increasing resistance, with cefaclor and levofloxacin susceptibility decreasing significantly. However, amoxicillin/clavulanic acid, cefuroxime and levofloxacin continued to inhibit >90% of isolates.

CONCLUSIONS

On the whole, antimicrobial susceptibility decreased in China between 2009-11 and 2013-14. In 2013-14, amoxicillin/clavulanic acid, levofloxacin and chloramphenicol were the most active antibacterial agents tested against community-acquired respiratory pathogens when assessed by CLSI, EUCAST or PK/PD breakpoints. Resistance to other antibacterials in China was generally high. Our data demonstrate the need to harmonize breakpoints for these pathogens.

Results from the Survey of Antibiotic Resistance (SOAR) 2009-11 in Vietnam

OBJECTIVES

To investigate the susceptibility of respiratory tract infection pathogens collected between 2009 and 2011 from the SOAR study in Vietnam.

METHODS

MICs were determined using Etest(®) and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

Two hundred and eighty-nine Streptococcus pneumoniae and 195 Haemophilus influenzae were collected from 11 centres. Overall, 4.8% of S. pneumoniae were penicillin susceptible (CLSI oral and EUCAST breakpoints). Using CLSI intravenous breakpoints, 86.9% were penicillin susceptible. Susceptibility to high-dose amoxicillin/clavulanic acid (or amoxicillin) using PK/PD breakpoints, cefuroxime (using CLSI or PK/PD breakpoints), cefaclor (CLSI breakpoint) and azithromycin (CLSI breakpoint) was 96.9%, 18.7%, 8% and 4.2%, respectively. Ofloxacin susceptibility was 93.4% by CLSI but 0% by EUCAST. All S. pneumoniae were fully vancomycin susceptible. S. pneumoniae from children were significantly less susceptible to most antimicrobials than those from the elderly. For ofloxacin, however, the reverse was true.Among H. influenzae isolates, 40.5% produced β-lactamase and 13.8% were β-lactamase negative but ampicillin resistant (BLNAR) by CLSI. H. influenzae were highly susceptible (97.4%) in vitro to amoxicillin/clavulanic acid and also to ceftriaxone by CLSI and PK/PD breakpoints but not EUCAST breakpoints. However, BLNAR isolates should be considered clinically resistant, with susceptibility reduced to 84.1%. With EUCAST breakpoints, amoxicillin/clavulanic acid susceptibility was lower, at 63.1%. Azithromycin susceptibility was 79.5% (CLSI).

CONCLUSIONS

Resistance to antibacterials in Vietnam was high, with amoxicillin/clavulanic acid being the most active agent. Ceftriaxone was highly active against H. influenzae while ofloxacin appeared highly active against S. pneumoniae using CLSI but not by EUCAST breakpoints. Ongoing surveillance through SOAR will further assist in understanding susceptibility trends over time.

Results from the Survey of Antibiotic Resistance (SOAR) 2011-13 in Ukraine

OBJECTIVES

To determine the antibiotic susceptibility of respiratory isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2011-13 from Ukraine.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 134 isolates of S. pneumoniae and 67 of H. influenzae were collected from eight sites in Ukraine. Overall, 87.3% of S. pneumoniae were penicillin susceptible by CLSI oral breakpoints and 99.3% by CLSI iv breakpoints. Susceptibility to amoxicillin/clavulanic acid (amoxicillin), ceftriaxone and levofloxacin was 100% by CLSI and PK/PD breakpoints. Cephalosporin and macrolide susceptibility was ≥95.5% and 88.1%, respectively using CLSI breakpoints. Trimethoprim/sulfamethoxazole was essentially inactive against pneumococci. Of the 67 H. influenzae tested, 4.5% were β-lactamase positive and all H. influenzae were fully susceptible to amoxicillin/clavulanic acid, ceftriaxone, ciprofloxacin, cefixime and levofloxacin (all breakpoints). Cefuroxime susceptibility was 100% by CLSI but 73.1% by EUCAST and PK/PD breakpoints. A discrepancy was found in macrolide susceptibility between CLSI (∼100% susceptible), EUCAST (22%-43% susceptible) and PK/PD (0%-22% susceptible) breakpoints. Trimethoprim/sulfamethoxazole was poorly active (59.7% susceptible).

CONCLUSIONS

Generally, antibiotic resistance was low in respiratory pathogens from Ukraine. However, only amoxicillin/clavulanic acid (amoxicillin), ceftriaxone and levofloxacin were fully active against both species. Trimethoprim/sulfamethoxazole was the least active, particularly against S. pneumoniae. Some susceptibility differences were apparent between CLSI, EUCAST and PK/PD breakpoints, especially with macrolides against H. influenzae. These data suggest that further efforts are required to harmonize these international breakpoints. Future studies are warranted to monitor continued low resistance levels in Ukraine compared with other parts of Eastern Europe.