The EUCAST and EARSS/EARS-Net experience in Europe

The EUCAST and EARSS/EARS-Net experience in Europe Riga, BARN-meeting 2011 by Barbro Olsson Liljequist SMI, Stockholm, Sweden

B Olsson-Liljequist, SMI, Sweden

EUCAST, the European breakpoint committee Major achievement: Common guidelines and breakpoints for AST now implemented in Europe

B Olsson-Liljequist, SMI, Sweden

Breakpoint committees 2001, determining clinical MIC breakpoints

Committee

Country

BSAC

United Kingdom

Yes

CA-SFM

France

Yes

CLSI

USA

Yes

CRG

The Netherlands

No

DIN

Germany

No

NWGA

Norway

No

SRGA

Sweden

Yes

B Olsson-Liljequist, SMI, Sweden

Disk test?

Breakpoint committees 2010, determining clinical MIC breakpoints

Committee

Country

Disk test?

EUCAST*

Europe

Yes

CLSI

USA

Yes

B Olsson-Liljequist, SMI, Sweden

EUCAST and CLSI are different; reasons why we need European breakpoints in Europe

• • • • • • • • •

EUCAST Profession together with regulatory authorities Funded by ESCMID, ECDC and national breakpoint committees Industry consultative role Decision by consensus Five meetings per year EUCAST=EMEA brpt committee Clinical breakpoints and ECOFFs Rationale for decisions published Documents in public domain and free of charge

• • • • • • • •

CLSI Industry, the profession Funded by industry and sales of output Industry part of decision process Decision by vote Two meetings per year CLSI technical standing with FDA Clinical breakpoints Rationale for decisions not published Documents for sale

B Olsson-Liljequist, SMI, Sweden

EUCAST General committee representatives on EUCAST Steering committee 2002 - 2012 General Committee reps on Steering Committe: • Czech Republic • Greece • Russia 2004-05 • Spain • Italy • Poland • Finland • ISC • Estonia 2010-11 • Austria

• • • • • •

National breakpoint committees (permanent members): Germany France Norway Sweden The Netherlands The UK

B Olsson-Liljequist, SMI, Sweden

Setting breakpoints • For existing drugs

– harmonisation of Euopean brekpoints finalised – review of existing breakpoints • Altered indications • Change in target organisms • New resistance mechanisms • New drug in class • New clinical experience • Change in dosing or administration

• For new drugs (with EMA)

B Olsson-Liljequist, SMI, Sweden

Methods for susceptibility testing • Phenotypic test methods

based on antimicrobial activity (MIC) and breakpoints

– MIC-determination (broth, agar, Etest, M.I.C.E.), disk diffusion, automated systems (Vitek, Phoenix, Microscan, …) – Predicts susceptibility and resistance – Quantifiable

• Genotypic test methods

based on the detection of a resistance gene or its product – mecA, vanA, vanB, ….PBP2, … betalactamase detection…. – Predicts resistance, not susceptibility – Not quantifiable

• By deduction – ”expert rules”

– If mecA-positive then report betalactam antibiotics R If ESBL-positive, then report betalactam antibiotics R !? Some rules predict susceptibility, others resistance – Not quantifiable B Olsson-Liljequist, SMI, Sweden

EUCAST guidelines also for disk diffusion

B Olsson-Liljequist, SMI, Sweden

B Olsson-Liljequist, SMI, Sweden

B Olsson-Liljequist, SMI, Sweden

EUCAST disk diffusion method Updates April and December 2010

• Based on – – – – – –

MH medium 0.5 MF inoculum 16-20h incubation Most disk contents same as CLSI Most control strains same as CLSI Control ranges same as CLSI (unless different medium or disk)

• Extensive database of MIC v Zone diameters available • Significant differences to CLSI – Calibrated to EUCAST MIC breakpoints – Some disk contents lower – MH-F for fastidious organisms (instead of HTM and Sheep blood) B Olsson-Liljequist, SMI, Sweden

Enterobacteriaceae v. gentamicin 768

40

256

35

192 128

No of isolates

30

96 64

25

48

20

32 24

15

16 8

10

6

5

2 1,5

0 6

7

8

9

10 11 13 15 16 17 19 20 21 22 23 24 25 26 Inhibition zone diameter (mm)

B Olsson-Liljequist, SMI, Sweden

1 0,75

National strategies and joint decisions on AST are needed!

NAC

National Antimicrobial Committee Chairperson, scientific secretary, educational officer + representatives of laboratories, societies, reference laboratories (5 – 6 reps) B Olsson-Liljequist, SMI, Sweden

National Antimicrobial Committees tasks • Subcommittee on Antimicrobial susceptibility testing – – – – –

Strategy at national level Implementation of breakpoints, methods, and QA Education Liaison and consultation with EUCAST Liaisonsin AMR-surveillance (ECDC, EARS-Net, …)

• Antimicrobial Policies • Antimicrobial Resistance Surveillance • Antimicrobial Consumption and Policies B Olsson-Liljequist, SMI, Sweden

EUCAST breakpoints and NACs EUCAST: France Germany Norway Sweden The Netherlands The UK

Decisions for 2010/11: Denmark Belgium Austria Estonia Ireland Finland Scotland Wales Switzerland Spain Hungary

Discussion: Greece Italy Turkey Israel Poland

Portugal, Czeck republic, Slovakia, Croatia, Slovenia, Serbia, B Olsson-Liljequist, SMI, Sweden Rumania, Latvia, Lithuania, Russia.

EUCAST Website www.eucast.org Open access No login B Olsson-Liljequist, SMI, Sweden

B Olsson-Liljequist, SMI, Sweden

EARSS/EARS-Net in Europe EARSS 1998-2009: Initiation and constant progress to provide timely and accurate antibiotic resistance data for action, run by RIVM, Bilthoven, Holland EARS-Net 2010 and onwards: European surveillance system for AMR in invasive isolates; network of networks supervised by ECDC, Stockholm, Sweden

B Olsson-Liljequist, SMI, Sweden

Development of EARSS Number of countries

35

SE

EE

LV

LT

30 25 20 15 10 5

19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09

0

Year

Non-EU member states: Norway and Iceland included, but not BosniaHerzegovina, Croatia, Israel, Switzerland and Turkey B Olsson-Liljequist, SMI, Sweden

Surveillance of AMR among invasive bacterial isolates (from blood cultures) Ps.aeruginosa (2005) Kl.pneumoniae (2005) Enterococcus faecium (2001) Enterococcus faecalis (2001) Escherichia coli (2001) Streptococcus pneumoniae (1998) Staphylococcus aureus (1998) B Olsson-Liljequist, SMI, Sweden

EARSS-data presented in maps

B Olsson-Liljequist, SMI, Sweden

New version by ECDC – EARS-Net

B Olsson-Liljequist, SMI, Sweden

From ECDC Surveillance report: Antimicrobial resistance surveillance in Europe 2009 (1)

BSI of E.coli increase more than S.aureus

B Olsson-Liljequist, SMI, Sweden

From ECDC Surveillance report: Antimicrobial resistance surveillance in Europe 2009 (2)

E.coli with ESBL increasing, MRSA decreasing

B Olsson-Liljequist, SMI, Sweden

In conclusion … • EUCAST has succeeded in harmonising MIC- and zone breakpoints in Europe • Now it is the task of each individual country to implement these, by help from NACs • EARSS was successfully transferred into EARS-Net • By using EUCAST guidelines for EARS-Net we will get sound AMR data for comparisons, trend analyses and ACTION! B Olsson-Liljequist, SMI, Sweden

Thank you!

B Olsson-Liljequist, SMI, Sweden