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Nosocomial infections and antimicrobial resistance are two special health issues listed in Annex 1 of Commission Decision 2000/96/EC of 22 December 1999 on the communicable diseases to be progressively covered by the Community network under Decision No 2119/98/EC of the European Parliament and of the Council.
Nosocomial infections correspond to infections acquired in hospitals. The term “Healthcare-associated infections” is now preferred because it includes not only infections acquired in hospitals, but also in other settings where healthcare is provided, e.g. long-term care facilities, nursing homes, home care, etc.
Microorganisms – also called microbes – include bacteria, viruses, fungi and parasites.
Antimicrobials are medicinal products that kill or stop the growth of living microorganisms and include among others:
Antimicrobial resistance, i.e. being resistant to one or several antimicrobials used for therapy or prophylaxis, is not a disease but a characteristic that may apply, as a matter of principle, to each of the microorganisms responsible for the communicable diseases listed in Commission Decision 2000/96/EC and for nosocomial and other healthcare-associated infections.
Antimicrobial-resistant microorganisms, including multidrug-resistant types, are often responsible for healthcare-associated infections, but they are also responsible for infections in patients outside hospitals and can be found as part of the normal bacterial flora of healthy individuals, in pet animals and in the environment. They are also responsible for infections and isolated from food-producing animals and sometimes isolated from foods.
Conversely, many healthcare-associated infections are caused by microorganisms that are not resistant to antimicrobials. The two concepts are thus really quite separate, but for historical and professional reasons they are often dealt with together.
Antimicrobial resistance is the ability of a microorganism (e.g., a bacterium, a virus, or a parasite, such as the malaria parasite) to resist the action of an antimicrobial agent.
For bacteria, antibiotic resistance is the ability of bacteria to resist to the action of an antibiotic.
Multidrug resistance corresponds to resistance of a microorganism to multiple antimicrobials.
Examples of common multidrug-resistant bacteria are:
The two major drivers for antimicrobial resistance are:
The two major areas for management, control and prevention of antimicrobial resistance therefore are:
Part of the burden of antimicrobial resistance in the EU is due to antimicrobials used in food-producing animals.
However, the major cause of antimicrobial resistance in microorganisms from humans remains the use of antimicrobials in human medicine, in the community and in hospitals and other healthcare settings.
At individual/patient level:
At population level:
Based on Directive 2001/83/EC and national legislations in Member States, antimicrobials to be used systemically (i.e. not locally) should only be dispensed at pharmacies upon presentation of a prescription, usually from a medical doctor. Despite this, dispensation of antimicrobials without a prescription still occurs at pharmacies in several Member States.
Since October 2008, it is possible for patients in the UK who are asymptomatic but who have a diagnosed genital infection with Chlamydia to obtain from pharmacists (without a prescription) a single dose of the antibiotic azithromycin, representing a complete treatment course. This is the only exception where systemic antibiotics can be dispensed without a prescription.
In a few countries, decreasing trends are being observed for antibiotic use in outpatients and for antibiotic resistance in bacteria commonly responsible for infections in outpatients.
In a few countries, decreasing trends in resistance are also being observed for one microorganism responsible for healthcare-associated infections, namely MRSA.
The EARSS Annual Report 2007 indicated that seven Member States now report significantly decreasing percentages of MRSA among Staphylococcus aureus from bloodstream infections.
This is likely due to increased efforts on infection control, hand hygiene and antibiotic policy in hospitals in these countries as demonstrated by national data from, e.g. Slovenia, France and UK.
Despite these encouraging experiences, antimicrobial resistance still is high or increasing in a majority of Member States, in particular for common bacteria such as Staphylococcus aureus (MRSA), Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa.
Additionally, cases of infections due to bacteria totally or almost totally resistant to antibiotics are currently emerging in the EU. Examples of such bacteria are carbapenemase (KPC)-producing Enterobacteriaceae (often Klebsiella pneumoniae), andmultidrug-resistant Acinetobacter. There is no rational choice of antibiotic therapy for treating such patients and treatment often relies on old and toxic antibiotics such as colistin.
This new trend is worrying since there are very few compounds in the research and development pipeline that would potentially have an activity against these bacteria and could be marketed within the next 5-10 years.
Modern medicine relies on availability of effective antibiotics in the case an infectious complication occurs or for prophylaxis of infection. Without effective antibiotics, intensive care, organ transplants, cancer chemotherapy, care of preterm babies, or even common surgical procedures, such as hip or knee replacement, would not be possible.
Because antimicrobial-resistant microorganisms fail to respond to therapy, infections due to these microorganisms result in greater risk of death, prolonged illness and stay in hospitals and greater risk of death. The total burden of antimicrobial resistance across all the communicable diseases listed in Commission Decision 2000/96/EC (including nosocomial infections) is currently unknown. Preliminary estimates of the number of deaths directly attributable to hospital-acquired infections due to the most common major multidrug-resistant bacteria are 1/3 to 1/2 of that for hospital-acquired infections overall (see below) (ECDC, preliminary data).
Antimicrobial resistance is a worldwide problem.
Travellers that require hospital care while visiting a country with high prevalence of antimicrobial resistance, within or outside of the EU, and who are subsequently repatriated to their home country, may return being colonised or even infected by multidrug-resistant bacteria. Even without having been in contact with healthcare, people who travel in a country with high prevalence of antimicrobial resistance may return being colonised by multidrug-resistant bacteria.