The reality of AMR in Greece

This week I attend the general assembly of COMBACTE, this year in Athens. COMBACTE stands for COMBatting AntibiotiC resistance in Europe (www.combacte.com) and is part of the New Drugs for Bad Bugs (ND4BB) program of the Innovative Medicines Initiative. Our local host is professor George Daikos, who opened the meeting with an overview of the epidemiology of antibiotic resistance in his country.

George Daikos presented mostly unpublished and very recent surveillance data. In 2016/17 a survey  in 8 Greek hospitals with 2,866 patients at risk yielded that 55.5% of these patients received antibiotics and 11.8% developed Healthcare-Associated Infections (HAI). These figures were more or less similar to results from 2012. Yet, the percentages are twice as high as in the reference of EU data coming from ECDC (274 hospitals, 60,288 patients, 29.7% getting antibiotics and 5.4% developing HAI).

These HAI mainly occurred in ICUs, but there also was a remarkable increase (compared to 2012) reported in paediatric wards (from about 2% to about 8%). The 3 most prevalent pathogens were Klebsiella spp., Pseudomonas aeruginosa and Acinetobacter spp., responsible for a little more than 50% of all HAI. Enterococcus spp. and E. coli were both found in about 8% of HAI. Quite astonishing was the data on resistance in these pathogens; MRSA 50% of S. aureus HAI, VRE 25% of enterococcal HAI, 25% of E. coli from HAI being resistant to 3rd-generation cephalosporins (was 50% in 2012), and carbapenem resistance (CR) was observed in 60% of Klebsiella spp, 40% in P. aeruginosa and 80% in Acinetobacter spp..

Of course we have heard such numbers before. Yet, to me, the most informative information was on the slide showing the incidence and prevalence of MDR blood isolates in 2017, with data from WHONET Greece. The incidence of BSI (in cases/10,000 patientdays) for CR Acinetobacter was 3.3 and 3.1 for CR Klebsiella spp., which was thrice as high as for P. aeruginosa (1.1) and MRSA (1.1). For CR Acinetobacter it didn’t matter where you were in the hospital as the prevalence of CR was 94% and 97.8% in BSI in wards and ICUs, respectively. For Klebsiella spp. and P. aeruginosa CR prevalence in wards was lower (45% and 31.5%, respectively) than in ICUs (being 76% and 46%, respectively).

Also insightful was the following: At this time, 5% of the patients admitted in a tertiary care hospital in Athens are colonized by CPE (80% KPC, 10% VIM, 8% NDM, 2% OXA-48). All carriage was considered to be healthcare associated, and 10-20% of these patients develop CPE infection. Molecular studies demonstrated different – dominant – clones for different resistance mechanisms.

Reasons for the problem seem very obvious:

  • breaches in infection control, with low compliance to of hand hygiene and contact precautions
  • lack of personnel with expertise in infection control in many hospitals;
  • underestimation of the problem, with lack of implementation strategies and of strong political will to implement infection control measures
  • a large reservoir of CPE carriers that is not detected on admission

There was also more positive news: implementation of an infection control bundle (screening for CPE carriage on admission, isolation of carriers and improving hand hygiene) in a haematology ward completely prevented the occurrence of new episodes of CPE BSI for more than a year now.

Contrary to the beautiful venue of the meeting and the weather, the overall picture doesn’t look good and major efforts will be needed to turn this situation into a more favourable direction. The economic crisis doesn’t help (and I think is even causally linked), so creative pragmatism is needed. Ironically the ancient Greeks already invented the 2 words to describe this situation: polyclonal endemicity.

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