Antimicrobial resistance surveillance in Ireland

1. 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)

2. 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

3. 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)

4. 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/A-Z/MicrobiologyAntimicrobialResistance/EuropeanAntimicrobialResistanceSurveillanceSystemEARSS/

5. Antibiotic codes and abbreviations: CTX, Ciprofloxacin CRO, Ceftriaxone ERY, Erythromycin NOR, Norfloxacin OXA, Oxacillin PEN, Penicillin TCY, Tetracycline 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)

6. 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***

7. Numbers and proportions of S. pneumoniae/ PNSP from invasive infection with 95% confidence Intervals (CI), 1999-2009* * Data for 2009 provisional up to the end of Q4; ** Excludes 2 isolates with no susceptibility results

8. PNSPtrends among invasive isolates of S. pneumoniae, 1999-2009* * Data for 2009 provisional up to the end of Q4; Number of laboratories participating by year-end and quarter are indicated above the bars

9. PNSPtrends among invasive isolates of S. pneumoniae, 1999-2009* * Data for 2009 provisional up to the end of Q4; Number of laboratories participating by year-end and quarter are indicated above the bars

10. 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 non-meningitis 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

11. Penicillin MIC distribution:Latest CLSI non-meningitis breakpoints 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)

12. Penicillin MIC distribution:Latest CLSI meningitis breakpoints 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)

13. Penicillin MIC distribution:Latest CLSI oral (=old) breakpoints 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)

14. Erythromycin resistance trends among invasive isolates of S. pneumoniae, 1999-2009* * Data for 2009 provisional up to the end of Q4; Number of laboratories participating by year-end and quarter are indicated above the bars

15. Susceptibility data for invasive S. pneumoniae isolates reported in 2009Q1-4 (n=356) * No MIC available to determine level of penicillin susceptibility

16. Resistance profiles of S. pneumoniae isolates, 2009Q1-4 • 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 non-susceptible to both (2008, 10.3%)

17. Age and sex of invasive S. pneumoniae isolates, 2009Q1-4

18. Pneumococcal serotype data (n=300 of 356 isolates; 84%), 2009Q1-4 * 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

19. Pneumococcal serotype data by age group, 2009Q1-4 * Serotypes included in PPV23; serotypes in PCV7; ND, Not determined (not referred for serotyping); NT, Non-Typable

20. Pneumococcal serotype data and coverage among patient age groups by vaccines, 2009Q1-4: All isolates (PSSP & PNSP) 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

21. Pneumococcal serotype data and coverage among patient age groups by vaccines, 2009Q1-3: PNSP isolates only 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

22. PNSP isolates, 2009Q1-4: data by serotype and age * Serotypes covered by both PCV7 and PPV23; ** Serotypes covered by PPV23 only; Serotypes 6A and 35B are not covered by either vaccine

23. Rates of invasive S. pneumoniae infection (or invasive pneumococcal disease, IPD), 1999-2009

24. Age distribution of patients with invasive PNSP and PSP infection in 2008

25. Age-specific incidence rates of invasive PNSP and PSP infection in 2008 ASIR, Age-Specific Incidence Rate (per 100,000 population)

26. Age and sex distribution of patients with invasive PNSP infection in 2008

27. Age and sex-specific incidence rates of invasive PNSP infection in 2008 ASIR, Age-Specific Incidence Rate (per 100,000 population)

28. Age and sex distribution of patients with invasive PSP bacteraemia in 2008

29. Age and sex-specific incidence rates of invasive PSP bacteraemia in 2008 ASIR, Age-Specific Incidence Rate (per 100,000 population)

30. Age-specific incidence rates* of IPD in 2008 * Using age groups from UK study by Gungabissoon et al (2005) ASIR, Age-Specific Incidence Rate (per 100,000 population)

31. Mean, median, mode and range of ages of patients with invasive S. pneumoniae (PNSP and PSP) infection in 2008

32. Sex distribution of patients with invasive S. pneumoniae (PNSP and PSP) infection in 2008 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)

33. Distribution of PNSP in EARSS countries in 2008 Map downloaded from http://www.rivm.nl/earss/database/ on 24/08/2009

34. Distribution of PNSP in EARSS countries in 2007 Map downloaded from http://www.rivm.nl/earss/database/ on 26/08/2008

35. 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

36. 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

37. Distribution of erythromycin resistance in EARSS countries in 2008 Map downloaded from http://www.rivm.nl/earss/database/ on 24/08/2009

38. Distribution of erythromycin resistance in EARSS countries in 2007 Map downloaded from http://www.rivm.nl/earss/database/ on 26/08/2008

39. 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

40. 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