Fighting antibiotic resistance all over Europe

Abstract

On 10–13 April 2010, the 20th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) took place in Vienna, Austria. The scientific program touched a wide range of issues, some controversial, in the fields of clinical microbiology and infectious diseases. Particular attention was dedicated to modern aspects in research methodology, the European Committee on Antimicrobial Susceptibility Testing breakpoints and methods, infection control programs, antibiotic stewardship and new therapeutic challenges for antibiotic-resistant bacteria. This year ECCMID attracted more than 7000 delegates from 98 countries all over Europe and beyond. The participation of a such significant number of scientists presented a unique opportunity for discussion on several clinical and research topics.

Keywords::

• congress
• ECCMID
• ESCMID
• infectious diseases
• microbiology

On 10–13 April 2010, the 20th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) took place in Vienna, Austria [101]. ECCMID is the official yearly congress organized by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and it is recognized as the largest European congress in the fields of clinical microbiology and infectious diseases. Since the first congress took place in 1983, the ECCMID has grown in size and stature, and this year has attracted 7635 delegates from 98 countries all over Europe and beyond. This year, the scientific program touched wide and controversial issues in the fields of clinical microbiology and infectious diseases. The participation of a such significant number of scientists provided a unique opportunity for discussion of several clinical and research topics.

The ESCMID has been largely involved in improving research methodology in clinical microbiology and infectious diseases. In fact, methodological limitations in the literature currently represent an issue, hence they are largely debated in the scientific community worldwide and several sessions of the ECCMID were dedicated to define major limitations and future perspectives in research methodology in infectious diseases and clinical microbiology. We particularly enjoyed an expert session and an official symposia, chaired by J Rodríguez-Baño (Hospital Universitario Virgen Macarena, Seville, Spain) and A MacGowan (University of Bristol and North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, UK), and by M Falagas (Alfa Institute of Biomedical Sciences, Athens, Greece) and S Gorbach (Tufts University School of Medicine, Boston, USA), respectively. The major message from experts was to limit publication of low-quality research, and to strongly encourage authors and reviewers to focus on high-quality study design. Where possible, and according to the ethical aspects of the investigation, randomized trials should be preferred to observational studies. This point was tackled by Sibel Ascioglu (Hacettepe University Medical School, Ankara, Turkey) in the presentation entitled ‘Randomised trials versus observational studies: cases from infectious diseases’. L Leibovici (Rabin Medical Center, Petah Tikva, Israel) also addressed the importance of systematic review of the literature and meta-analysis as unique methodologies to critically evaluate published literature and to make rational decisions for the treatment of infectious diseases. He also interestingly underlined the importance of ethical issues in reviewing scientific literature, particularly when including unpublished data. Another important point frequently addressed in different symposia was how to handle data deriving from case–control studies, which represent the major source of information on the epidemiology of infections due to antibiotic-resistant bacteria. Speakers reviewed in detail the bias arising from the wrong selection of control subjects and lack of adjustment for confounders. A proposal to overcome the significant heterogeneity detected among such studies has been presented by our study group. We proved that significant heterogeneity was present among 88 studies evaluating risk factors for methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Acinetobacter baumannii acquisition [1]. Our analysis revealed that heterogeneity was linked to study design, selection of the control group and the sampling frame used for inclusion (MA Cataldo, Catholic University of the Sacred Heart, Rome, Italy). We therefore discussed the need to produce new guidelines for reviewing and reporting studies focused on risk factors for the acquisition of antibiotic-resistant bacteria with other experts.

A second major topic covered in the ECCMID 2010 was discussed in the workshop that took place on Saturday 10 April. The workshop, entitled ‘Antimicrobial susceptibility testing – practical implementation of the EUCAST breakpoints and methods’, was arranged with the European Committee on Antimicrobial Susceptibility Testing (EUCAST). EUCAST is a standing committee organized by the ESCMID, European CDC and the European national breakpoint committees. One of the leading objectives of EUCAST is harmonizing antimicrobial breakpoints in Europe, since seven different sets of antimicrobial MIC breakpoints are currently used in Europe, and in the absence of a national system, several European countries subscribe to breakpoints published by the American Clinical and Laboratory Standards Institute with a significant heterogeneity in interpretation. To achieve harmonization, the EUCAST disc diffusion test was launched in 2009. The method is derived from the Kirby–Bauer method, variants of which are currently widely used in Europe, but is calibrated to EUCAST MIC breakpoints. The workshop, coordinated by G Kahlmeter (Central Hospital, Vaxjo, Sweden) and D Brown (Addenbrooke’s Hospital, Peterborough, UK), stressed the need of national strategies and joint decisions on antibiotic susceptibility tests at a national and international level. Kahlmeter updated the audience on national antimicrobial committees that improved strategy at national level through implementation of breakpoints and methods, education, liaison and consultation with EUCAST as well as with groups involved in antibiotic resistance surveillance, such as the ECDC and European Antimicrobial Resistance Surveillance System (EARSS). EUCAST breakpoints have been approved in several European countries, such as Sweden, Denmark, Norway, Belgium, The Netherlands, Austria, Estonia, Ireland, Finland, Scotland, Wales, Switzerland and have recently been discussed in Spain, Greece, Italy, Turkey and Israel.

As expected, a large percentage of symposia, oral and poster sessions was focused on infections due to antibiotic-resistant bacteria in hospitalized patients, as well as outpatients or residents in long-term care facilities. Updates on antibiotic stewardship (ABS) and in-favor and not-in-favor experiences were widely analyzed in detail. An interesting study was performed in a 21-bed neurosurgery ward of an 850-bed Italian tertiary hospital, to assess the impact of an ABS program on antimicrobial usage and consumption on patients’ outcome. L Pagani (Bolzano Central Hospital, Bolzano, Italy) showed that respect to the pre-intervention period, the introduction of antimicrobial recommendation prescription on a regular and on-call basis, formulary restrictions and encouraging appropriate prophylaxis or targeted therapy, resulted in the improvement of appropriate antimicrobial prescription, decreasing the total antimicrobial expenditure from €88,787,94 to 60,584,34 [2]. An interrupted time series, using data from the intensive care unit of the same Italian hospital, showed that a restrictive antibiotic policy significantly reduced the use of ampicillin–sulbactam and vancomycin, as well as the MRSA incidence (N Vernaz, Hopitaux Universitaires de Geneva, Geneva, Switzerland) [3]. Two different outbreak control teams from the UK and Ireland showed the effect of a complete ban on the prescription of fluoroquinolones and cephalosporins in the first hospital, and fluoroquinolones alone in the second hospital, as one component of the multifactorial outbreak management program launched to fight a Clostridium difficile outbreak. In the first hospital, a 400-bed district general hospital, the average monthly consumption of ceftriaxone and ciprofloxacin over the post-intervention period dropped by 95 and 76%, respectively. There were corresponding increases in the consumption of amoxicillin and gentamicin, no change in the consumption of piperacillin–tazobactam and a small decrease in consumption of carbapenems. The restrictive antibiotic policy had a significant effect on the number of cases of hospital-acquired C. difficile but little effect on extended-spectrum β-lactamase-producing Gram-negative bacteria and MRSA (S Dancer, Southern General Hospital, Glasgow, UK) [4]. The results of the second study performed in an Irish hospital showed a significant decrease in C. difficile infections, quinolone usage (59%) and the rate of fluoroquinolone resistance in Escherichia coli isolates. However, an impressive increase in meropenem use was described (K Burns, Beaumont Hospital, Dublin, Ireland) [5]. The authors concluded that, while it is important to reduce antibiotic consumption, additional infection control interventions are required for hospital-acquired infection. Unfortunately, many reports, in particular from Southern Europe, showed that the majority of hospitals still do not have an ABS program or an antibiotic policy. For example, a Spanish group showed the results of a 2-month online survey involving 110 working groups from 76 Spanish hospitals. Only 41% of the surveyed hospitals in Spain were found to have an ongoing ABS program with large geographical variations (JR Paño-Pardo, Hospital Universitario La Paz, Madrid, Spain) [6].

A challenging official symposia entitled ‘Success stories about control of nosocomial antimicrobial resistance – yes, we can!’ was chaired by G French (St Thomas Hospital, London, UK). MJ Schwaber (National Center for Infection Control, Tel Aviv, Israel), presented the results of a nationwide infection control intervention to fight an outbreak of carbapenem-resistant Klebsiella pneumonia. Intervention included a professional task force outbreak control, physical separation of hospitalized carriers and dedicated staff. After 14 months, the number of new monthly cases of carbapenem-resistant Enterobacteriaceae was reduced from 180 to 46 cases. Following the introduction of active surveillance guidelines, monthly incidence reached 24 cases. A Pearson (Health Protection Agency, London, UK) and B Coignard (Institut de Veille Sanitaire, Paris, France) reported similar successful experiences in controlling hospital-acquired MRSA and vancomycin-resistant enterococci (VRE).

Concerning new anti-infective therapy for Gram-positive bacteria, special attention was put on the lipoglycopeptide telavancin. According to J Garau (Hospital Universitari Mútua de Terrassa, Barcelona, Spain), the speaker of the symposium supported by Astellas ‘Serious Gram-positive infections: the need for new treatment options’, telavancin is a promising drug for serious multidrug-resistant Gram-positive bacterial infections. For multidrug-resistant Gram-negative bacteria, such as carbapenem-resistant A. baumannii and Pseudomonas aeruginosa, the role of old antibiotics (polymyxin B) has re-emerged as the last resort therapy. As outlined by N Petrosillo (National Institute for Infectious Diseases L. Spallanzani, Rome, Italy), doripenem is a new carbapenem which seems to have a lower potential for resistance selection and a more favorable pharmacokinetic profile. Conversely, according to Rodrìguez-Baño (Seville, Spain), the wide use of carbapenems should be discouraged due to the increasing levels of carbapenem-resistance worldwide.

Over recent years the ECCMID has become a favored occasion for project groups to meet and interact. Participants met at the ‘European Network Corner’ where ESCMID Study Groups, networks and project teams and ESCMID Collaborative Centers all over Europe were presenting their work, hospitals and research. This year 15 centers from 12 countries in Europe presented a descriptive poster on a designated area of the European Network Corner.

All the abstracts presented at the 20th ECCMID have been published on the ESCMID website [102]. The 21st ECCMID will take place in Milan, Italy, in May 2011, and will be jointly held with the 27th International Congress of Chemotherapy (ICC).

Financial & competing interests disclosure

Evelina Tacconelli is the ESCMID Professional Affairs Officer for Infectious Diseases. Giulia De Angelis is the vice-president of the Trainee Association of ESCMID. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.