Antimicrobial Resistance Surveillance from sentinel public ... · Antimicrobial Resistance Surveillance from sentinel public hospitals, ... 2015 Authors: Olga Perovic1,2 and Verushka

August 2016_v1

Antimicrobial Resistance Surveillance from sentinel public hospitals, South Africa, 2015

Authors: Olga Perovic1,2 and Verushka Chetty1 1 National Institute for Communicable Diseases at National Health Laboratory Service 2Department of Clinical Microbiology and Infectious Diseases at University of

Witwatersrand

Introduction

Antimicrobial resistance (AMR) is a significant public health concern that threatens effective

treatment of severe infections, both locally and globally. Surveillance is conducted to

determine the extent and pattern of resistance amongst the most common pathogens causing

infections in humans.1 Integrated data on bacterial resistance is obtained from an electronic

database of bacterial antimicrobial susceptibility results generated by public health

laboratories in South Africa. This report is designed to provide information on antimicrobial

resistance trends in bacteria causing healthcare-associated infections and is prepared by the

National Institute for Communicable Diseases (NICD) and Corporate Data Warehouse

(CDW) at the National Health Laboratory Service (NHLS).

Objectives

1. To determine the number of cases reported from selected hospitals by month for the

following organisms isolated from blood cultures: Acinetobacter baumannii complex,

Enterobacter cloacae complex, Escherichia coli, Enterococcus faecalis, Enterococcus

faecium, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphylococcus

aureus.

2. To describe the antimicrobial susceptibility to the most important agents by individual

pathogen and by hospital.

Methods

The data for this report were sourced from the NHLS CDW. CDW is a national repository for

all public health hospitals in South Africa which contains archived data from the laboratory

information system (LIS), TrakCare.2

Bloodstream isolates data over a one-year period (January –December 2015) were extracted

for the following ESKAPE pathogens: Enterococcus faecalis, Enterococcus faecium,

Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii complex,

Pseudomonas aeruginosa, Enterobacter cloacae complex, and Escherichia coli. Routine

electronic data were collected from sentinel sites, mostly tertiary academic hospitals (Table

1).

Antimicrobial susceptibility test (AST) reporting was based on CLSI standards.3 Table 2

describes the different AST methods used in laboratories based at the sentinel sites.

Due to site-specific differences in testing methodologies and data capture on the LIS,

extensive cleaning and recoding of data were necessary; this was done within the CDW. The

CDW linking algorithm was used to create unique patient identifiers, which enabled the

generation of patient-level data and de-duplication within a 21 day patient episode initiated

from the first occurrence of resistance to a given antibiotic for a given pathogen.

August 2016_v1

Limitations 1. Data may be incomplete due to missing cases not captured on the LIS or non-standardised

coding of pathogens and antibiotics. Testing methods and microbiological practice vary

between sites and this could account for the results presented in this report.

2. Confirmatory AST methods were not performed for any of these organisms and results

presented here are reported as captured on LIS. Thus, while some results may suggest the

occurrence of an outbreak, it is not possible to confirm this.

3. For certain sites, not all organisms are represented; this may be due to organisms not being

identified at a particular site for 2015.

4. Vancomycin resistance is not reported for Staphylococcus aureus due to the lack of

confirmatory test methods (pending agreement with SASCM).

5. Data were omitted for those sites that tested less than 30 organisms for a particular

antibiotic.

Table 1. Characteristics of hospital sites involved in antimicrobial surveillance

Hospital Site Province Academic

Hospital

No of

beds

Frere Hospital Eastern Cape No 916

Livingstone Hospital Eastern Cape Yes 616

Nelson Mandela Academic Hospital/Mthatha

Tertiary (NMAH)

Eastern Cape Yes 520

Universitas Hospital (UH) Free State Yes 650

Charlotte Maxeke Johannesburg Academic

Hospital (CMJAH)

Gauteng Yes 1088

Chris Hani Baragwanath Hospital (CHBH) Gauteng Yes 3200

Dr George Mukhari Hospital (DGMH) Gauteng Yes 1200

Steve Biko Academic Hospital (SBAH) Gauteng Yes 832

Helen Joseph Hospital (HJH) Gauteng Yes 700

Grey’s Hospital (GH) KwaZulu-Natal Yes 530

Inkosi Albert Luthuli Central Hospital

(IALCH)

KwaZulu-Natal Yes 846

King Edward VIII Hospital (KEH) KwaZulu-Natal Yes 922

Mahatma Gandhi Hospital (MGH) KwaZulu-Natal No 350

RK Khan Hospital (RKKH) KwaZulu-Natal No 543

Tygerberg Hospital (TH) Western Cape Yes 1310

Groote Schuur Hospital (GSH) Western Cape Yes 893

August 2016_v1

Table 2. Antimicrobial susceptibility testing methods

NHLS Laboratories at Public

Hospitals

MicroScan Vitek 2 Disk diffusion

method

Charlotte Maxeke Johannesburg

Academic Hospital

√ √ √

Chris Hani Baragwanath Hospital √ √

Dr George Mukhari Hospital √

Grey’s Hospital/Northdale Laboratory √

Groote Schuur Hospital √

Helen Joseph Hospital √ √

Inkosi Albert Luthuli Central Hospital √

King Edward VIII Hospital √

Mahatma Gandhi Hospital √

Nelson Mandela Academic

Hospital/Mthatha Tertiary

√

Steve Biko Academic Hospital

(SBAH)

√

Frere Hospital √

Livingstone Hospital √

Universitas Hospital (UH) √

RK Khan Hospital (RKKH) √

Tygerberg Hospital (TH) √

Based on NHLS SOPs confirmation MIC for carbapenems resistance is recommended

by Etest at the routine laboratory level.

Results

Antimicrobial susceptibility results are shown as follows:

- Acinetobacter baumannii complex (Figures 1 & 2; Table 3),

- Enterobacter cloacae complex (Figures 3 & 4; table 4),

- Enterococcus faecalis (Figures 5 & 6; table 5),

- Enterococcus faecium (Figure 7 & 8; table 6)

- Escherichia coli (Figure 9 & 10, table 7)

- Klebsiella pneumoniae (Figures 11 & 12; table 8),

- Pseudomonas aeruginosa, (Figures 13 & 14; table 9 ) and

- Staphylococcus aureus (Figure 15 & 16; table 10).

For each organism, the total number of cases, susceptibility to selected antimicrobial agents

with numbers and ratios (susceptible: non-susceptible), and percentages of antimicrobial

susceptibility per site were analysed (Figures 1-16). Data in tables is not shown for sites

where less than 30 isolates were identified.

August 2016_v1

Acinetobacter baumannii complex

Figure 1. Number of isolates per month and susceptibility profile of Acinetobacter

baumannii complex from blood culture at public-sector sentinel sites, 2015, N=1 529

126 131122 122

138

117

136 139 136 139

98

125

0

20

40

60

80

100

120

140

160

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

mb

er

of

Cas

es

Months

583

453

390

186

319

271

262

264

447

1

799

595

976

542

1 168

1 107

1 144

1 160

1 159

954

3

20

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin

Tobramycin

Piperacillin-tazobactam

Ceftazidime

Cefepime

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin

Colistin

Susceptible Non-Susceptible

August 2016_v1

*PY-2014; CY-2015

Figure 2. Comparison of Acinetobacter baumannii complex susceptibility profile at

public-sector sentinel sites, 2014 vs. 2015

57% (651)

33% (382)

46% (384)

16% (152)

26% (304)

20% (225)

23% (257)

22% (258)

32% (380)

62% (16)

95% (605)

49% (583)

32% (453)

42% (390)

14% (186)

22% (319)

19% (271)

18% (262)

19% (264)

32% (447)

25% (1)

98% (799)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin

Tobramycin

Piperacillin-…

Ceftazidime

Cefepime

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin

Colistin

Percentage susceptible (number susceptible)

Susceptability Ratio PY Susceptibility Ratio CY

August 2016_v1

Table 3. Antimicrobial susceptibility and total number of Acinetobacter baumannii

isolates by hospital, 2015

A. baumannii is resistant to a majority of antimicrobial agents, due to its ability to encode and

upregulate various mechanisms of resistance such as the loss of outer membrane porins and

permeability, efflux systems, Amp C beta-lactamases and others. Resistance was high to

imipenem, cefepime and ceftazidime 82%, 81%, 78%, respectively; whereas it was 68% to

ciprofloxacin, 50% to amikacin and 61% to tobramycin. Percentages of resistance to the most

agents have changed in comparison to the previous year; there was a significant decrease in

resistance to imipenem (23% (2014) vs. 18% (2015) p value < 0.001) resistance to

carbapenems, cephalosporins 3rd and 4th generations and aminoglycosides have shown

increase except for the resistance to colistin. Colistin resistance was 2%. From referral

isolates sent to Antimicrobial Resistance Laboratory (AMRL) at NICD no colistin resistance

conferred by the mcr1 gene was confirmed. Except for these few isolates no confirmation of

colistin resistance is performed at reference laboratory.

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497 88 65 91

40% 35% 85% 66%

497 92 67 109

15% 13% 28% 37%

495 92 70 109

27% 18% 24% 37%

471 92 70 109

28% 46% 31% 39%

92 68 95

97% 96% 96%

498 92 69 109

24% 53% 43% 50%

499 92 68 109

7% 14% 29% 37%

496 92 70 109

6% 14% 33% 37%

500 92 69 108

6% 11% 25% 32%

499 90 95

29% 72% 92%

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AMIKACIN 76 41 44 44 39 93

68% 46% 66% 25% 69% 34%

CEFEPIME 94 77 42 44 47 53 114 94

23% 13% 17% 25% 4% 38% 12% 9%

CEFTAZIDIME 94 79 41 44 47 60 114 94

21% 10% 15% 18% 6% 28% 11% 12%

CIPROFLOXACIN 93 79 42 44 47 60 113 94

45% 28% 26% 30% 13% 38% 35% 11%

COLISTIN 94 78 37 44 45 60 114

99% 100% 100% 95% 98% 100% 97%

GENTAMICIN 95 80 41 44 47 61 114 92

37% 19% 32% 41% 19% 48% 26% 10%

IMIPENEM 95 80 42 43 46 59 114 93

26% 18% 31% 26% 7% 39% 13% 10%

LEVOFLOXACIN

MEROPENEM 94 79 41 43 47 59 114 94

27% 16% 32% 26% 9% 39% 13% 10%

PIPERACILLIN/TA

ZOBACTAM95 56 37 45 60 95 94

19% 9% 8% 9% 32% 9% 9%

TOBRAMYCIN 41 39 37 83

63% 59% 32% 13%

August 2016_v1

Enterobacter cloacae complex

Figure 3. Number of isolates per month and susceptibility profile of Enterobacter

cloacae complex from blood culture at public-sector sentinel sites, 2015 N= 624

55

40

64

5256

46 47

60

46

66

40

52

0

10

20

30

40

50

60

70

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

mb

er

of

Cas

es

Months

487

381

376

9

331

337

350

464

522

527

445

3

52

152

160

516

201

199

161

42

15

12

89

1

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin


Cefoxitin

Cefotaxime/ceftriaxone

Ceftazidime

Cefepime

Ertapenem

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin


August 2016_v1

*PY-2014; CY-2015

Figure 4. Comparison of Enterobacter cloacae complex susceptibility profile, public-

sector sentinel sites, 2014 vs. 2015

93% (495)

66% (354)

71% (387)

4% (21)

55% (275)

56% (293)

63% (312)

89% (403)

98% (497)

98% (515)

80% (425)

89% (32)

90% (487)

71% (381)

70% (376)

2% (9)

62% (331)

63% (337)

68% (350)

92% (464)

97% (522)

98% (527)

83% (445)

75% (3)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin


Cefoxitin


Ceftazidime

Cefepime

Ertapenem

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin



August 2016_v1

Table 4. Antimicrobial susceptibility and total number of Enterobacter cloacae isolates

by hospital, 2015

The prevalence of presumptive (no molecular confirmation) resistance of Enterobacter

cloacae complex to ertapenem (8%) has decreased in comparison to 2014 resistance of 11%,

though resistance to imipenem and meropenem has remained stable (2%). Resistance to

ceftazidime has decreased (p value =0.02) but increased to piperacillin-tazobactam in 2015

(not statistically significant. Resistance to cefepime (31%) is suggestive of AmpC hyper-

production due to de-repressed AmpC mutants which confers resistance to all cephalosporins.

It may also indicate co-carriage of an extended-spectrum ß-lactamase (ESBL).

Enterococcus faecalis

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97 40 34 41

92% 88% 94% 93%

98 40 41

65% 75% 73%

96 41 34 41

60% 66% 74% 71%

99 40 35 31

5% 0% 0% 0%

96 41 35 41

60% 68% 71% 71%

92 40 36 41

84% 85% 89% 80%

97 40 41

91% 88% 93%

98 40 31 41

67% 80% 74% 76%

98 40 34 41

96% 100% 94% 100%

98 40 36 41

96% 100% 94% 100%

97 41 35 40

80% 78% 77% 78%

DrugC

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AMIKACIN 75 43 71

93% 81% 93%

CEFEPIME 75 41 71

77% 59% 66%

CEFOTAXIME/CEF

TRIAXONE74 41 71

70% 37% 65%

CEFOXITIN 75 43 71

0% 0% 0%

CEFTAZIDIME 76 42 70

74% 33% 64%

CIPROFLOXACIN 73 42 70

88% 79% 83%

ERTAPENEM 74 43 71

92% 86% 92%

GENTAMICIN 73 41 70

81% 63% 79%

IMIPENEM 74 43 71

96% 98% 96%

LEVOFLOXACIN

MEROPENEM 74 43 71

99% 98% 100%

PIPERACILLIN/TA

ZOBACTAM75 42 71

69% 43% 68%

6956

7264

73 69 71 70 71 73

54

81

0

20

40

60

80

100

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

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of

Cas

es

Months

August 2016_v1

Figure 5. Number of isolates per month and susceptibility profile of Enterococcus

faecalis from blood culture at public-sector sentinel sites, 2015, N= 823

Figure 6. Comparison of Enterococcus faecalis isolates numbers and susceptibility

profile, public-sector sentinel sites, 2014 vs. 2015

3

2

270

0

344

762

610

4

8

41

3

1

7

24

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin

Penicillin/ampicillin

Quinupristin-dalfopristin

Teicoplanin

Vancomycin

Linezolid


100% (1)

50% (2)

85% (333)

4% (4)

100% (260)

98% (688)

97% (540)

43% (3)

20% (2)

87% (270)

0%

100% (344)

99% (762)

96% (610)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin



Teicoplanin

Vancomycin

Linezolid



August 2016_v1

Table 5. Antimicrobial susceptibility and total number of Enterococcus faecalis by

hospital, 2015

The 14% of Enterococcus faecalis isolates exhibited resistance to penicillins and 1% (non-

confirmed) displayed resistance to vancomycin, in comparison to the previous year, With the

exception of decreased resistance to penicillins, there are no other changes that have been

noted.

Enterococcus faecium

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161 32 48

100% 100% 100%

34

100%

34 31

100% 100%

167 34 39 68

100% 100% 100% 99%

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AMIKACIN

GENTAMICIN

LINEZOLID 71 47 43 82 36

99% 91% 93% 88% 94%

PENICILLIN/AMPI

CILLIN57 31 80

88% 58% 98%

QUINUPRISTIN-

DALFOPRISTIN

TEICOPLANIN 57 35 80

100% 100% 100%

VANCOMYCIN 74 49 43 85 63

100% 100% 98% 100% 94%

68

51

67 64 67

93

69

89

64

88

64 65

0

20

40

60

80

100

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

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Months

August 2016_v1

Figure 7. Number of isolates per month and susceptibility profile of Enterococcus

faecium from blood culture at public-sector sentinel sites, 2015, N= 849

Figure 8. Comparison of Enterococcus faecium isolate numbers and susceptibility


2

0

34

7

1

373

769

720

1

4

770

345

0

10

43

12

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin

Ampicillin/amoxycillin



Teicoplanin

Vancomycin

Linezolid


0% (0)

0%

5% (33)

4% (4)

97% (110)

97% (292)

95% (709)

98% (664)

67% (2)

0%

4% (34)

2% (7)

100% (1)

97% (373)

95% (769)

98% (720)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin




Teicoplanin

Vancomycin

Linezolid



August 2016_v1

Table 6. Antimicrobial susceptibility of Enterococcus faecium by hospital, 2015

Enterococcus faecium is naturally resistant to penicillin agents. In 2015 resistance prevalence

to vancomycin of 5% was the same as in 2014.

Escherichia coli

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224 40 37

5% 0% 3%

223 37 36

100% 100% 97%

40

0%

38

92%

224 42 37

96% 93% 100%

Drug

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AMIKACIN

AMPICILLIN/AMO

XICILLIN90 65 40 49 34 30 60 63

4% 2% 0% 10% 0% 0% 2% 8%

GENTAMICIN

LINEZOLID 90 61 38 48 58 47

98% 98% 82% 98% 100% 100%

PENICILLIN/AMPI

CILLIN81 44 36 32 57

2% 2% 0% 0% 2%

QUINUPRISTIN-

DALFOPRISTIN

TEICOPLANIN 82 49 36 32 58

99% 100% 100% 97% 91%

VANCOMYCIN 92 64 40 49 35 32 60 62

99% 100% 100% 98% 97% 100% 92% 63%

147 135

207

141 149164

149 140 149174 164 163

0

50

100

150

200

250

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

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August 2016_v1

Figure 9. Number of isolates per month and susceptibility profile of Escherichia coli

from blood culture at public-sector sentinel sites, 2015, N= 1 882

Figure 10. Comparison of Escherichia coli isolates numbers and susceptibility profile,

public-sector sentinel sites, 2014 vs. 2015

1 6151 419

2451 419

01 486

1 3171 3381 307

1 6371 6841 723

1 2378

87

111311

1 480254

0151

402384367

189

12465

2178

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin


Cefazolin/cephalexin


Cefepime

Imipenem

Ciprofloxacin

Trimethoprim-sulfamethoxazole


95% (1 431)

78% (1 174)

12% (186)

85% (1 244)

60% (127)

91% (1 331)

75% (1 077)

76% (1 119)

76% (1 079)

99% (1 327)

100% (1 434)

100% (1 454)

74% (1 120)

67% (56)

32% (130)

94% (1 615)

82% (1 419)

14% (245)

85% (1 419)

91% (1 486)

77% (1 317)

78% (1 338)

78% (1 307)

99% (1 637)

99% (1 684)

99% (1 723)

73% (1 237)

80% (8)

33% (87%)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin



Cefazolin/cephalexin

Cefoxitin


Ceftazidime

Cefepime

Ertapenem

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin




August 2016_v1

Table 7. Antimicrobial susceptibility of Escherichia coli by hospital, 2015

E. coli showed a no change in resistance to piperacillin-tazobactam and ciprofloxacin but no

significant increase to the β-lactam group over a two-year period. Resistance to 3rd generation

cephalosporins, indicates the presence of extended spectrum beta-lactamases (ESBLs) and

was recorded in 22% of all isolates and increase in 2015 was not significant.

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397 218 71 55 167

95% 93% 89% 93% 97%

396 217 70 55 170

4% 24% 10% 16% 22%

400 216 58 55 170

74% 83% 59% 84% 87%

393 216 70 55 171

73% 83% 53% 84% 87%

400 216 69 49 89

92% 93% 74% 96% 89%

399 216 70 55 170

74% 83% 53% 84% 87%

373 217 71 55 170

75% 70% 46% 78% 79%

167 97

34% 32%

392 217 56 54 169

96% 100% 100% 100% 100%

402 217 66 55 171

79% 82% 64% 80% 86%

398 216 63 55 171

98% 100% 100% 100% 100%

401 216 71 55 171

98% 100% 100% 100% 100%

401 215 70 54 170

86% 87% 86% 93% 91%

Drug

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AMIKACIN 170 74 56 46 123 70 48 45 105 54

92% 89% 89% 98% 100% 84% 100% 98% 86% 93%

AMPICILLIN/AMO

XICILLIN168 75 56 46 124 70 48 45 105 53

13% 20% 18% 7% 15% 16% 13% 16% 20% 13%

CEFAZOLIN/CEPH

ALEXIN

CEFEPIME 170 73 56 46 124 58 39 105 52

81% 79% 63% 67% 90% 71% 85% 84% 69%

CEFOTAXIME/CEF

TRIAXONE169 73 56 46 124 70 49 44 104 54

78% 79% 63% 67% 83% 66% 76% 86% 84% 70%

CEFOXITIN 170 76 53 46 123 68 49 45 105 53

90% 92% 89% 85% 93% 81% 94% 93% 97% 94%

CEFTAZIDIME 170 73 56 46 123 69 49 45 105 50

83% 79% 63% 67% 85% 67% 78% 87% 84% 74%

CIPROFLOXACIN 168 73 56 46 123 70 49 45 105 54

71% 78% 75% 59% 80% 60% 69% 78% 78% 70%

COTRIMOXAZOLE

ERTAPENEM 170 73 50 45 124 56 38 105 53

98% 100% 100% 100% 100% 100% 100% 100% 100%

GENTAMICIN 168 73 56 46 124 70 49 47 105 54

82% 88% 82% 78% 88% 74% 84% 94% 86% 85%

IMIPENEM 171 76 56 46 124 69 38 105 52

99% 100% 100% 100% 100% 97% 100% 100% 100%

LEVOFLOXACIN

MEROPENEM 171 76 56 46 124 69 49 45 105 53

99% 100% 100% 100% 100% 99% 98% 100% 100% 100%

PIPERACILLIN/TA

ZOBACTAM171 76 45 124 69 49 45 105 53

82% 88% 71% 85% 71% 98% 89% 74% 77%

August 2016_v1

Klebsiella pneumoniae

Figure 11. Number of isolates per month and susceptibility profile of Klebsiella

pneumoniae from blood culture at public-sector sentinel sites, 2015, N= 2 921

267

218

258

208230

259235

207 214236

284305

0

50

100

150

200

250

300

350

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

mb

er

of

Cas

es

Months

2 089

987

1 248

2 089

772

783

792

2 276

2 320

2 341

1 638

3

382

1 499

1 217

323

1 700

1 686

1 666

97

159

155

820

8

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin


Cefoxitin


Ceftazidime

Cefepime

Ertapenem

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin


August 2016_v1

Figure 12. Comparison of Klebsiella pneumoniae isolate numbers and susceptibility


89% (1 767)

35% (691)

52% (1 005)

88% (1 717)

26% (495)

28% (522)

27% (510)

96% (1730)

97% (1 872)

97% (1 904)

61% (1 205)

67% (101)

85% ( 2 089)

40% (987)

51% ( 1 248)

87% ( 2 089)

31% (772)

32% (783)

32% (792)

97% (2 276

94% (2 320)

94% (2 341)

67% (67%)

27% (273)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin

Piperacillin-…

Cefoxitin

Cefotaxime/ce…

Ceftazidime

Cefepime

Ertapenem

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin



August 2016_v1

Table 8. Antimicrobial susceptibility of Klebsiella pneumoniae by hospital, 2015

Klebsiella pneumoniae was resistant to multiple antimicrobials including third-generation

cephalosporins (69%) indicating ESBL-production, ciprofloxacin (33%) and piperacillin-

tazobactam (50%). Ertapenem resistance was unchanged over the two-year period (4%);

although the resistance rate to imipenem (6%) and meropenem (6%) showed significant

increase (.p<0.001). Although resistance to carbapenems was generally low, the rapid

emergence of strains producing carbapenemases threatens this vital therapeutic option. Thus,

knowledge of local hospital epidemiology and monitoring of carbapenem resistance is

essential.

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482 114 183 60 53 144

93% 87% 73% 70% 57% 94%

487 114 168 62 54 147

29% 49% 23% 24% 4% 46%

476 114 183 61 51 147

27% 49% 22% 25% 4% 46%

490 114 182 62 54 81

87% 97% 75% 89% 94% 95%

484 114 182 60 54 147

28% 49% 23% 23% 4% 46%

462 114 183 61 54 146

61% 74% 60% 59% 80% 66%

480 114 145 56 54 147

92% 100% 99% 100% 96% 99%

485 114 180 61 54 146

32% 55% 30% 41% 9% 52%

488 114 173 60 54 147

94% 99% 84% 100% 98% 100%

489 114 183 60 53 147

95% 99% 84% 100% 96% 100%

488 114 183 62 47 145

49% 75% 51% 63% 32% 75%

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AMIKACIN 299 312 79 122 64 128 44 33 240 114

90% 92% 73% 93% 92% 65% 70% 76% 70% 95%

CEFEPIME 299 318 79 122 67 120 39 30 239 113

29% 56% 11% 22% 30% 22% 28% 50% 27% 32%

CEFOTAXIME/CEF

TRIAXONE298 317 79 122 67 128 44 31 240 114

27% 55% 11% 22% 24% 20% 34% 48% 27% 30%

CEFOXITIN 300 320 75 122 65 126 44 31 237 109

82% 97% 95% 91% 82% 73% 82% 84% 83% 85%

CEFTAZIDIME 298 314 79 122 66 127 44 31 239 108

28% 56% 11% 22% 26% 23% 34% 48% 26% 29%

CIPROFLOXACIN 297 320 79 122 66 127 44 32 238 113

72% 79% 66% 82% 45% 51% 55% 69% 68% 60%

ERTAPENEM 294 321 75 122 67 92 32 233 114

91% 100% 100% 98% 96% 97% 97% 94% 97%

GENTAMICIN 299 321 79 122 67 128 44 33 240 113

35% 62% 25% 33% 52% 30% 43% 58% 37% 42%

IMIPENEM 300 326 79 122 67 127 39 31 239 113

90% 100% 100% 98% 97% 72% 79% 87% 94% 97%

LEVOFLOXACIN

MEROPENEM 300 326 79 122 67 128 44 32 240 112

90% 100% 100% 98% 99% 73% 82% 88% 94% 98%

PIPERACILLIN/TA

ZOBACTAM300 325 54 122 67 129 44 33 239 113

43% 69% 59% 42% 39% 42% 55% 64% 22% 50%

August 2016_v1

Pseudomonas aeruginosa

Figure 13. Number of isolates per month and susceptibility profile of Pseudomonas

aeruginosa from blood culture at public-sector sentinel sites, 2015, N= 670

49

7065

61 5954

59

34

5461

44

60

0

10

20

30

40

50

60

70

80

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

mb

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of

Cas

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Months

474

436

391

447

421

407

423

441

2

411

122

159

171

143

157

180

169

146

1

5

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin


Ceftazidime

Cefepime

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin

Colistin


August 2016_v1

Figure 14. Comparison of Pseudomonas aeruginosa isolate numbers and susceptibility


Table 9. Antimicrobial susceptibility of Pseudomonas aeruginosa by hospital, 2015

80% (384)

73% (345)

69% (317)

74% (354)

73% (337)

71% (328)

73% (338)

77% (365)

77% (24)

98% (275)

80% (474)

73% (436)

70% (391)

76% (447)

73% (421)

69% (407)

71% (423)

75% (441)

67% (2)

99% (411)

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin


Ceftazidime

Cefepime

Imipenem

Meropenem

Ciprofloxacin

Levofloxacin

Colistin



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136 43 42 52

75% 77% 86% 71%

135 43 36 52

64% 72% 64% 56%

132 43 41 52

73% 79% 73% 54%

127 43 42 52

74% 60% 71% 58%

30 43 36 33

100% 100% 97% 97%

136 43 41 52

68% 70% 73% 54%

135 43 36 52

65% 60% 72% 56%

135 42 41 52

62% 71% 76% 56%

135 34 42 50

62% 76% 57% 62%

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AMIKACIN 63 82

87% 78%

CEFEPIME 63 82

84% 77%

CEFTAZIDIME 63 81

75% 78%

CIPROFLOXACIN 62 82

84% 74%

COLISTIN 63 81

100% 100%

GENTAMICIN 63 82

86% 79%

IMIPENEM 63 82

79% 68%

LEVOFLOXACIN

MEROPENEM 63 82

78% 73%

PIPERACILLIN/TA

ZOBACTAM59 77

83% 71%

August 2016_v1

Thirty percent of Pseudomonas aeruginosa isolates were resistant to piperacillin-tazobactam

and 27% resistant to cefepime. Colistin resistance was low (1%); however this was not

confirmed by reference or molecular methods.

Staphylococcus aureus

Figure 15. Number of isolates per month and susceptibility profile of Staphylococcus

aureus from blood culture at public-sector sentinel sites, 2015, N= 2 507

254

177

215239 241

202 191 185 184

221199 199

0

50

100

150

200

250

300

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

Nu

mb

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of

Cas

es

Months

2

1 346

158

1 453

25

1 487

1 783

0

1 235

215

1 498

1 191

2 220

1 981

1

733

2 086

794

6

775

484

0

667

61

654

5

5

4

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Amikacin

Gentamicin


Oxacillin

Cefoxitin

Erythromycin/Azithromycin

Clindamycin


Ciprofloxacin


Rifampicin

Teicoplanin

Vancomycin

Linezolid


August 2016_v1

Figure 16. Comparison of Staphylococcus aureus isolates numbers and susceptibility


100% (1)

62% (1019)

8% (132)

66% (`1 209)

58% (155)

64% ( 1 1 54)

79% (1 412)

95% (308)

67% (1 066)

62% (265)

65% (1 090)_

99%

99%

99%

67% (2)

65% (1346)

7% (158)

65% (1 453)

81% (25)

66% (1 487)

79% (1 783)

65% (1 235)

78% (215)

70% (1 498)

100%

100%

100%

0% 20% 40% 60% 80% 100% 120%

Amikacin

Gentamicin


Oxacillin

Cefoxitin

Erythromycin/Azithromycin

Clindamycin


Ciprofloxacin


Rifampicin

Teicoplanin

Vancomycin

Linezolid



August 2016_v1

Table 10. Antimicrobial susceptibility of Staphylococcus aureus by hospital, 2015

No S. aureus isolates were reported to be vancomycin resistant in 2015. Resistance to

methicillin/oxacillin and all other beta-lactams showed a minor increase compared to 2014.

Cefoxitin resistance was indicative of methicillin-resistance (MRSA). Resistance rates to

erythromycin and clindamycin remained unchanged.

Carbapenemases Producing Enterobacteriaceae

The Antimicrobial Resistance Laboratory at NICD confirmed the presence of carbapenemase

genes on Enterobacteriaceae isolates that were referred from public laboratories following

phenotypic confirmation of carbapenem-resistance Table 11. Few organisms presented with

more than one CPE genes.

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481 112 108 69 56 76

49% 72% 77% 74% 66% 50%

525 192 110 71 56 206

95% 82% 82% 79% 80% 76%

523 192 114 72 206

50% 73% 73% 79% 69%

156 120

72% 85%

521 192 110 71 55 206

50% 81% 75% 79% 75% 76%

520 192 109 68 55 205

47% 76% 74% 82% 73% 78%

519 190 109 69 81

100% 100% 100% 100% 99%

524 191 109 72 47 203

3% 9% 8% 4% 4% 6%

523 192 109 69 48 206

88% 84% 1% 80% 54% 93%

109 109 69

100% 99% 100%

522 190 111 67 206

100% 100% 99% 100% 100%

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AMIKACIN

CEFOXITIN

CIPROFLOXACIN 236 124 84 106 70 109 56 77 138

49% 67% 81% 69% 86% 74% 84% 88% 81%

CLINDAMYCIN 240 126 89 105 72 115 57 86 141 76

54% 64% 70% 64% 89% 77% 89% 83% 79% 68%

CLOXACILLIN 236 130 89 106 71 116 59 87 141 76

51% 62% 66% 58% 87% 70% 81% 78% 81% 70%

COTRIMOXAZOLE

ERYTHROMYCIN/A

ZITHROMYCIN238 128 89 106 71 115 57 85 141 77

46% 63% 67% 64% 82% 70% 88% 80% 79% 60%

GENTAMICIN 235 127 106 71 112 56 77 141

52% 59% 56% 85% 68% 88% 81% 81%

LINEZOLID 239 125 106 71 110 57 76 141 74

100% 100% 100% 100% 100% 100% 100% 100% 97%

PENICILLIN/AMPI

CILLIN228 129 89 106 69 115 59 86 140 77

8% 6% 0% 2% 12% 9% 7% 14% 18% 13%

QUINUPRISTIN-

DALFOPRISTIN

RIFAMPICIN 240 129 106 68 108 58 76 141 76

94% 93% 0% 91% 0% 2% 0% 93% 84%

TEICOPLANIN 171 125 84 106 107 59 75 141

99% 100% 100% 100% 99% 100% 100% 100%

VANCOMYCIN 241 131 89 106 66 113 59 86 140 75

100% 100% 100% 100% 100% 99% 98% 100% 100% 100%

August 2016_v1

Table 11. Total number of confirmed Carbapenemases producing Enterobactericeae C

arb

ap

enem

ase

s P

rod

uci

ng E

nte

robact

eria

ceae

Carbapenemases producing

Enterobacteriaceae

n = Total of isolates submitted to reference

laboratory 880

Species

Citrobacter freundii 19

Enterobacter aerogenes 8

Enterobacter asburiae 3

Enterobacter cloacae 114

Enterobacter kobei 2

Enterobacter spp. 2

Escherichia coli 64

Klebsiella oxytoca 20

Klebsiella pneumoniae 552

Klebsiella spp. 3

Morganella morganii 10

Proteus mirabilis 2

Proteus spp. 1

Providencia rettgeri 23

Providencia vermicola 1

Raoutella Ornithinolytica 1

Serratia marcescens 55

Genotype

OXA-48like 234

VIM 55

NDM 438

GES 12

KPC 11

IMP 8

Conclusion and final remarks

The data presented in this report highlighted the importance of surveillance for antimicrobial

resistance patterns. Surveillance for CPE’s is currently being conducted at 14 national sites.

Due to limitations listed in this report there is a continuous need for improvement in quality

of data obtained by electronic surveillance.

August 2016_v1

Disclaimer

Data are reported as received through the CDW. No demographic, epidemiological, clinical

or molecular data were available to distinguish between hospital-associated and community

acquired infections.

Acknowledgements

We wish to thank the following:

- NHLS CDW Sue Candy and her team for cleaning the data and preparing the tables

and figures.

- PhD scientist: Ashika Singh-Moodley for CPE genes identification

- SASCM editorial committee for comments and suggestions.

References

1. Langmuir AD. The surveillance of communicable diseases of national importance. N

Engl J Med, 1963; 268: 182-92.

2. Garner JS, et al. CDC definitons for nosocomial infections. Am J Infect Control, 1988;

16: 128-140.

3. Performance Standards for Antimicrobial Susceptibility Testing. Clinical and Laboratory

Standards Institute (CLSI), 2016; M 100-S26

Documents

Antimicrobial Resistance Surveillance from sentinel public ... · Antimicrobial Resistance Surveillance from sentinel public hospitals, ... 2015 Authors: Olga Perovic1,2 and Verushka