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This paper investigates which countries are seen as leaders in combatting AMR in Europe, and why they are seen as leaders. We do this by testing the explanatory capacity of three models specifying features of leaders attractive to followers. They are (1) performance, (2) power and (3) common interests. We use data from a survey among experts in the AMR field in 29 European countries, along with empirical indicators, to measure the three models. Our findings show that only eight of the 29 European countries are seen as leaders and that Denmark, Sweden and the Netherlands are considered the three top AMR leaders in Europe. Denmark is the top leader in the animal sector and Sweden in the human sector. We also find demand for several possible types of leadership and followership in the AMR problem. Performance explains the leading role of the top three countries, as they all score low on indicators of the severity of AMR. Power and influence explain why France, Germany and the UK are seen as AMR leaders. We also find support for the role of common interests. This factor may explain why neighbouring countries are often seen as leaders in AMR. [ABSTRACT FROM AUTHOR]

Based on 117 responses to a web survey in 29 European countries and interviews with bureaucrats in managerial positions, this paper investigates how people working professionally with antimicrobial resistance (AMR) assess the impact of the COVID-19 pandemic on their future long-run cooperation in the struggle against AMR, both within their own country and among the European countries. We measure whether the severity level of the AMR problem, cumulative COVID-19 death rates, and the daily number of confirmed new COVID-19 cases in their own countries have affected bureaucrats' beliefs about long-run AMR collaboration. We find that around 40% of the bureaucrats believe that the cooperation will increase domestically and at the European level, indicating that global health crises such as the COVID-19 pandemic can shape future collaboration across the European countries when it comes to the equally global but more long-run health problem, AMR. However, there are considerable differences across regions: Eastern European bureaucrats are clearly the most pessimistic about future cooperation, while the Southern European and Nordic bureaucrats are the most optimistic. Neither the severity of the AMR problem nor the number of confirmed new COVID-19 cases in their own countries has a significant impact on bureaucrats' beliefs about future collaboration. Instead, it is the cumulative COVID-19 death rate that increases the perceived likelihood of future AMR collaboration, both domestically and among the European countries. Furthermore, our interviews highlight the longer-term impact of the pandemic on public health in the EU countries and the prospect of increased EU control to prevent future cross-border health hazards. The mixed methods approach details both the broader patterns of bureaucrats' perceptions of the impact of the pandemic on AMR-related work as well as the more long-term institutional changes that are likely to follow in the wake of the pandemic. [ABSTRACT FROM AUTHOR]

Background: Antibiotic usage, contact with high transmission healthcare settings as well as changes in immune system function all vary by a patient's age and sex. Yet, most analyses of antimicrobial resistance (AMR) ignore demographic indicators and provide only country-level resistance prevalence values. This study aimed to address this knowledge gap by quantifying how resistance prevalence and incidence of bloodstream infection (BSI) varied by age and sex across bacteria and antibiotics in Europe. Methods and findings: We used patient-level data collected as part of routine surveillance between 2015 and 2019 on BSIs in 29 European countries from the European Antimicrobial Resistance Surveillance Network (EARS-Net). A total of 6,862,577 susceptibility results from isolates with age, sex, and spatial information from 944,520 individuals were used to characterise resistance prevalence patterns for 38 different bacterial species and antibiotic combinations, and 47% of these susceptibility results were from females, with a similar age distribution in both sexes (mean of 66 years old). A total of 349,448 isolates from 2019 with age and sex metadata were used to calculate incidence. We fit Bayesian multilevel regression models by country, laboratory code, sex, age, and year of sample to quantify resistant prevalence and provide estimates of country-, bacteria-, and drug-family effect variation. We explore our results in greater depths for 2 of the most clinically important bacteria–antibiotic combinations (aminopenicillin resistance in Escherichia coli and methicillin resistance in Staphylococcus aureus) and present a simplifying indicative index of the difference in predicted resistance between old (aged 100) and young (aged 1). At the European level, we find distinct patterns in resistance prevalence by age. Trends often vary more within an antibiotic family, such as fluroquinolones, than within a bacterial species, such as Pseudomonas aeruginosa. Clear resistance increases by age for methicillin-resistant Staphylococcus aureus (MRSA) contrast with a peak in resistance to several antibiotics at approximately 30 years of age for P. aeruginosa. For most bacterial species, there was a u-shaped pattern of infection incidence with age, which was higher in males. An important exception was E. coli, for which there was an elevated incidence in females between the ages of 15 and 40. At the country-level, subnational differences account for a large amount of resistance variation (approximately 38%), and there are a range of functional forms for the associations between age and resistance prevalence. For MRSA, age trends were mostly positive, with 72% (n = 21) of countries seeing an increased resistance between males aged 1 and 100 years and a greater change in resistance in males. This compares to age trends for aminopenicillin resistance in E. coli which were mostly negative (males: 93% (n = 27) of countries see decreased resistance between those aged 1 and 100 years) with a smaller change in resistance in females. A change in resistance prevalence between those aged 1 and 100 years ranged up to 0.51 (median, 95% quantile of model simulated prevalence using posterior parameter ranges 0.48, 0.55 in males) for MRSA in one country but varied between 0.16 (95% quantile 0.12, 0.21 in females) to −0.27 (95% quantile −0.4, −0.15 in males) across individual countries for aminopenicillin resistance in E. coli. Limitations include potential bias due to the nature of routine surveillance and dependency of results on model structure. Conclusions: In this study, we found that the prevalence of resistance in BSIs in Europe varies substantially by bacteria and antibiotic over the age and sex of the patient shedding new light on gaps in our understanding of AMR epidemiology. Future work is needed to determine the drivers of these associations in order to more effectively target transmission and antibiotic stewardship interventions. Naomi R Waterlow and colleagues leverage data from 29 countries across Europe to determine how antimicrobial resistance varies by age and sex. Author summary: Why was this study done?: Antimicrobial resistance (AMR) is a major global public health threat, but little is known about how the prevalence of resistance varies with age and sex. What did the researchers do and find?: We explored patterns of resistance prevalence and incidence by age and sex in routinely collected data from bloodstream infections (BSIs) across Europe for 8 bacterial species. We fitted a Bayesian multilevel regression model to quantify the variation nationally and subnationally. Distinct patterns in resistance prevalence by age were observed across Europe for different bacteria. Sex was often only weakly associated with resistance, except across ages in Escherichia coli and Klebsiella pneumoniae, and at younger ages for Acinetobacter species, where it was higher in males. What do these findings mean?: These findings highlight important gaps in our knowledge of the epidemiology of AMR that are difficult to explain through known patterns of antibiotic exposure and healthcare contact. Differences in AMR burden by age and sex may be explained by cultural differences between countries as well as variation in pathways to infection between bacteria. Our findings suggest that there may be value in considering interventions to reduce AMR burden that take into account important variations in AMR prevalence with age and sex. This study is limited by the nature of routine surveillance, the lack of open availability of disaggregated data, and the model structures explored. [ABSTRACT FROM AUTHOR]

Political issues sometimes display an intriguing combination of high degrees of complexity, low political saliency, and high levels of administrative autonomy. This article investigates how this type of issues shapes the relationship between politicians and the public service. More specifically, we advance the notion of "administrative action space" to describe the emergence of collaborative governance when directives from the political level are intermittent or absent. Using an illustrative case on the administration of measures to address antimicrobial resistance (AMR), a transnational public health issue in Europe, we find that senior public servants nested in epistemic communities play a leading role in driving agency and facilitating governance of complex but low‐salient issues when administrative autonomy is extensive. [ABSTRACT FROM AUTHOR]

Introduction: Public health campaigns with a well-defined outcome behaviour have been shown to successfully alter behaviour. However, the complex nature of antimicrobial resistance (AMR) creates challenges when evaluating campaigns aimed at raising awareness and changing behaviour. Aims: To determine what campaigns have been conducted and which reported being effective at improving awareness of antimicrobial resistance and changing behaviour around antimicrobial use in members of the public. It also sought to determine the outcome measures studies have used to assess campaign effectiveness. Methods: A systematic search of Ovid MEDLINE and Embase, was conducted in October 2022 using a predefined search strategy. Studies which were published between 2010 and September 2022 that outlined a campaign or invention aimed at the public and focusing on AMR or antibiotic usage were eligible for inclusion and studies which solely targeted healthcare professionals (HCP) were excluded. Results: Literature searches retrieved 6961 results. De-duplication and screening removed 6925 articles, five articles from grey literature and reference screening were included, giving a total of 41 studies and 30 unique interventions. There was a distribution of campaigns globally with the majority run in Europe (n = 15) with most campaigns were conducted nationally (n = 14). Campaigns tended to focus on adult members of the public (n = 14) or targeted resources towards both the public and HCPs (n = 13) and predominately assessed changes in knowledge of and/or attitudes towards AMR (n = 16). Campaigns where an improvement was seen in their primary outcome measure tended to use mass media to disseminate information, targeted messaging towards a specific infection, and including the use of HCP-patient interactions. Discussion: This review provides some evidence that campaigns can significantly improve outcome measures relating to AMR and antibiotic usage. Despite a lack of homogeneity between studies some common themes emerged between campaigns reported as being effective. However, the frequent use of observational study designs makes it difficult to establish causation between the campaign and changes seen in the studies outcome measures. It is important that clear evaluation processes are embedded as part of the design process for future campaigns; a campaign evaluation framework for use by campaign developers may facilitate this. [ABSTRACT FROM AUTHOR]

Background There is a broad consensus in the European public health community that international collaboration and coordination are key in the fight against antimicrobial resistance (AMR). Yet, while experts typically testify the importance of cross-national learning and a coordinated effort to reduce the spread of multi-resistant bacteria, there are mixed views about how that is best realized in practice, particularly on the dichotomy between horizontal and vertical activities. Methods National action plans (NAP) from all EU member states were systematically overviewed by two independent researchers. We followed a fixed procedure for locating a broad and comparable content on the international dimensions, and letting these vary on scales. Results We find that countries adhere to four different strategies for international coordination, varying between 'high' and 'low' on values of vertical and horizontal activities. Most countries spend none or very little space to discuss international activities, while some countries use their NAPs to outline their aspiration for taking leading roles in the international struggle. Moreover, in line with previous research, we find that many countries directly mimic the Global Action Plan, but also that a large share of countries describe independent arrangements in their international strategies. Conclusions European countries recognize AMR and its inherent international governance challenge differently in their NAPs, which may have implications for coordinated action to address the issue. [ABSTRACT FROM AUTHOR]

Pneumococcal disease is a major cause of morbidity/mortality worldwide, and vaccination is an important measure in its prevention. Despite European children being vaccinated with pneumococcal conjugate vaccines (PCVs), pneumococcal infections are still a major cause of morbidity/mortality in adults with risk conditions and their vaccination might be an important prevention strategy. New PCVs have been approved, but information is lacking on their potential impact in European adults. In our review, we searched PubMed, MEDLINE, and Embase for studies on the additional PCV20 serotypes (concerning incidence, prevalence, disease severity, lethality, and antimicrobial resistance) in European adults, between January 2010 and April 2022, having included 118 articles and data from 33 countries. We found that these serotypes have become more prevalent in both invasive and non-invasive pneumococcal disease (IPD and NIPD), representing a significant proportion of cases (serotypes 8, 12F, 22F) and more serious disease and/or lethality (10A, 11A, 15B, 22F), showing antimicrobial resistance (11A, 15B, 33F), and/or affecting more vulnerable individuals such as the elderly, immunocompromised patients, and those with comorbidities (8, 10A, 11A, 15B, 22F). The relevance of pneumococcal adult carriers (11A, 15B, 22F, and 8) was also identified. Altogether, our data showed an increase in the additional PCV20 serotypes' prevalence, accounting for a proportion of approximately 60% of all pneumococcal isolates in IPD in European adults since 2018/2019. Data suggest that adults, as older and/or more vulnerable patients, would benefit from vaccination with higher-coverage PCVs, and that PCV20 may address an unmet medical need. [ABSTRACT FROM AUTHOR]

Background: Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions.Method: A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described.Results: Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception/behaviour, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labelling, work ethos, perception of practitioner) or practitioner-related (RTI management, initial training, antibiotic awareness, legal issues, practice context) or both (antibiotic awareness).Discussion and Conclusion: Cultural factors should be considered as exerting an ubiquitous influence on all the consecutive stages of the disease process and seem closely linked to education. Interactions between determinant categories, cultural dimensions and antibiotic use in primary care are multiple, complex and require further investigation within overlapping disciplines. The context of European projects seems particularly relevant. [ABSTRACT FROM AUTHOR]

This section offers public health news briefs in Europe, as of October 2023. Topics covered include how much the European Public Health Association is able to do with its small secretariat, the regional roadmap on antimicrobial resistance for 2023-2030 which member states of the World Health Organization European Region are invited to adopt and the 16th European Public Health Conference to be held in Dublin, Ireland on November 8-11, 2023.

P. aeruginosa is still one of the most threatening pathogens responsible for serious hospital-acquired infections. It is intrinsically resistant to many antimicrobial agents and additional acquired resistance further complicates the management of such infections. High rates of combined antimicrobial resistance persist in many countries, especially in the eastern and south-eastern parts of Europe. The aim of this narrative review is to provide a comprehensive assessment of the epidemiology, latest data, and clinical evidence on the current and new available drugs active against P. aeruginosa isolates with limited treatment options. The latest evidence and recommendations supporting the use of ceftolozane-tazobactam and ceftazidime-avibactam, characterized by targeted clinical activity against a significant proportion of P. aeruginosa strains with limited treatment options, are described based on a review of the latest microbiological and clinical studies. Cefiderocol, with excellent in vitro activity against P. aeruginosa isolates, good stability to all β-lactamases and against porin and efflux pumps mutations, is also examined. New carbapenem combinations are explored, reviewing the latest experimental and initial clinical evidence. One section is devoted to a review of new anti-pseudomonal antibiotics in the pipeline, such as cefepime-taniborbactam and cefepime-zidebactam. Finally, other "old" antimicrobials, mainly fosfomycin, that can be used as combination strategies, are described. [ABSTRACT FROM AUTHOR]

The European Food Safety Authority (EFSA) is an agency funded by the European Union that acts as a source of scientific advice and communication on risks associated with the food chain. EFSA is actively involved in many activities in the area of antimicrobial resistance (AMR). It provides scientific advice used to support the European legislator and Member States in making effective and timely risk management decisions in the fight against AMR for example, in reducing the need to use antimicrobials in food-producing animals or in managing emerging threats such as resistance of microorganisms to beta-lactams, carbapenems and colistin. EFSA provides advice on how to monitor AMR in food-producing animals and food, and gathers and analyzes data collected at the national level in Europe. Finally, it actively communicates the risks linked to antimicrobial resistance. This paper provides an overview of the activities of EFSA in the area of AMR. [ABSTRACT FROM AUTHOR]

Background: Pneumonia from SARS-CoV-2 is difficult to distinguish from other viral and bacterial etiologies. Broad-spectrum antimicrobials are frequently prescribed to patients hospitalized with COVID-19 which potentially acts as a catalyst for the development of antimicrobial resistance (AMR). Objectives: We conducted a systematic review and meta-analysis during the first 18 months of the pandemic to quantify the prevalence and types of resistant co-infecting organisms in patients with COVID-19 and explore differences across hospital and geographic settings. Methods: We searched MEDLINE, Embase, Web of Science (BioSIS), and Scopus from November 1, 2019 to May 28, 2021 to identify relevant articles pertaining to resistant co-infections in patients with laboratory confirmed SARS-CoV-2. Patient- and study-level analyses were conducted. We calculated pooled prevalence estimates of co-infection with resistant bacterial or fungal organisms using random effects models. Stratified meta-analysis by hospital and geographic setting was also performed to elucidate any differences. Results: Of 1331 articles identified, 38 met inclusion criteria. A total of 1959 unique isolates were identified with 29% (569) resistant organisms identified. Co-infection with resistant bacterial or fungal organisms ranged from 0.2 to 100% among included studies. Pooled prevalence of co-infection with resistant bacterial and fungal organisms was 24% (95% CI 8–40%; n = 25 studies: I2 = 99%) and 0.3% (95% CI 0.1–0.6%; n = 8 studies: I2 = 78%), respectively. Among multi-drug resistant organisms, methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and multi-drug resistant Candida auris were most commonly reported. Stratified analyses found higher proportions of AMR outside of Europe and in ICU settings, though these results were not statistically significant. Patient-level analysis demonstrated > 50% (n = 58) mortality, whereby all but 6 patients were infected with a resistant organism. Conclusions: During the first 18 months of the pandemic, AMR prevalence was high in COVID-19 patients and varied by hospital and geography although there was substantial heterogeneity. Given the variation in patient populations within these studies, clinical settings, practice patterns, and definitions of AMR, further research is warranted to quantify AMR in COVID-19 patients to improve surveillance programs, infection prevention and control practices and antimicrobial stewardship programs globally. [ABSTRACT FROM AUTHOR]

Introduction: The burden of MDRO in health systems is a global issue, and a growing problem. We conducted a European multicenter cohort study to assess the incidence, impact and risk factors for multidrug-resistant organisms in patients with major trauma. We conducted this study because the predictive factors and effects of MDRO in severely injured patients are not yet described. Our hypothesis is that positive detection of MDRO in severely injured patients is associated with a less favorable outcome. Methods: Retrospective study of four level-1 trauma centers including all patients after major trauma with an injury severity score (ISS) ≥ 9 admitted to an intensive care unit (ICU) between 2013 and 2017. Outcome was measured using the Glasgow outcome scale (GOS). Results: Of 4131 included patients, 95 (2.3%) had a positive screening for MDRO. Risk factors for MDRO were male gender (OR 1.73 [95% CI 1.04–2.89]), ISS (OR 1.01 [95% CI 1.00–1.03]), PRBC's given (OR 1.73 [95% CI 1.09–2.78]), ICU stay > 48 h (OR 4.01 [95% CI 2.06–7.81]) and mechanical ventilation (OR 1.85 [95% CI 1.01–3.38]). A positive MDRO infection correlates with worse outcome. MDRO positive cases GOS: good recovery = 0.6%, moderate disability = 2.1%, severe disability = 5.6%, vegetative state = 5.7% (p < 0.001). Conclusions: MDRO in severely injured patients are rare but associated with a worse outcome at hospital discharge. We identified potential risk factors for MDRO in severely injured patients. Based on our results, we recommend a standardized screening procedure for major trauma patients. [ABSTRACT FROM AUTHOR]

Objectives: Excessive use of antibiotics has increased antimicrobial resistance (AMR) worldwide, which is a major public concern among the countries. To control this threat proper monitoring of the antimicrobial usage with increasing rate of AMR is required. Moreover, alternatives for antibiotics are surveyed and are being researched for quick use in the future. Thus, multisector intervention is highly encouraged for better outcomes. In this research article, six different European countries are discussed in terms of antimicrobial usage and AMR in human and livestock sectors with the help of literature study and various reports published by different organizations. Methods: Data study has been conducted to collect data for comparison study. Data sources of AMR and antimicrobial usage are analyzed and both antimicrobial use and AMR are compared. Results: This article provides surveillance systems that are formed to keep a track on the upcoming situation of AMR and the consumption of antimicrobials by humans as well as animals. The article firmly allows the readers to get broad information about the AMR across six countries of Europe. These annual reports have hugely helped the government to decide for alternatives and have focused in many training activities to combat the AMR situation globally. Conclusion: As antibiotic resistance genes persist on an interface between environment and animal and animal health, an approach is required in all three areas that stress the concept of "One Approach to Health. [ABSTRACT FROM AUTHOR]

Severe intra-abdominal infection commonly requires intensive care. Mortality is high and is mainly determined by disease-specific characteristics, i.e. setting of infection onset, anatomical barrier disruption, and severity of disease expression. Recent observations revealed that antimicrobial resistance appears equally common in community-acquired and late-onset hospital-acquired infection. This challenges basic principles in anti-infective therapy guidelines, including the paradigm that pathogens involved in community-acquired infection are covered by standard empiric antimicrobial regimens, and second, the concept of nosocomial acquisition as the main driver for resistance involvement. In this study, we report on resistance profiles of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecium in distinct European geographic regions based on an observational cohort study on intra-abdominal infections in intensive care unit (ICU) patients. Resistance against aminopenicillins, fluoroquinolones, and third-generation cephalosporins in E. coli, K. pneumoniae and P. aeruginosa is problematic, as is carbapenem-resistance in the latter pathogen. For E. coli and K. pneumoniae, resistance is mainly an issue in Central Europe, Eastern and South-East Europe, and Southern Europe, while resistance in P. aeruginosa is additionally problematic in Western Europe. Vancomycin-resistance in E. faecalis is of lesser concern but requires vigilance in E. faecium in Central and Eastern and South-East Europe. In the subcohort of patients with secondary peritonitis presenting with either sepsis or septic shock, the appropriateness of empiric antimicrobial therapy was not associated with mortality. In contrast, failure of source control was strongly associated with mortality. The relevance of these new insights for future recommendations regarding empiric antimicrobial therapy in intra-abdominal infections is discussed. [ABSTRACT FROM AUTHOR]

Vancomycin-resistant Enterococcus faecium (VREF) and methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant health burden. We investigated linezolid and daptomycin resistance among VREF and MRSA in the EU/EEA between 2014 and 2018. Descriptive statistics and multivariable logistic regression were used to analyze 6,949 VREF and 35,131 MRSA blood isolates from patients with bloodstream infection. The population-weighted mean proportion of linezolid resistance in VREF and MRSA between 2014 and 2018 was 1.6% (95% CI 1.33–2.03%) and 0.28% (95% CI 0.32–0.38%), respectively. Daptomycin resistance in MRSA isolates was similarly low [1.1% (95% CI 0.75–1.6%)]. On the European level, there was no temporal change of daptomycin and linezolid resistance in MRSA and VREF. Multivariable regression analyses showed that there was a higher likelihood of linezolid and daptomycin resistance in MRSA (aOR: 2.74, p < 0.001; aOR: 2.25, p < 0.001) and linezolid in VREF (aOR: 1.99, p < 0.001) compared to their sensitive isolates. The low proportion of linezolid and daptomycin resistance in VREF and MRSA suggests that these last-resort antibiotics remain effective and will continue to play an important role in the clinical management of these infections in Europe. However, regional and national efforts to contain antimicrobial resistance should continue to monitor the trend through strengthened surveillance that includes genomic surveillance for early warning and action. [ABSTRACT FROM AUTHOR]

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use. [ABSTRACT FROM AUTHOR]

Background: Due to limited therapeutic options and their association with high mortality and morbidity, carbapenem-non-susceptible Acinetobacter spp. (CNA) are of significant public health importance. This study aimed to describe current epidemiological trends of CNA proportions in Europe and to identify factors that are associated with carbapenem non-susceptibility of isolates from patients with invasive Acinetobacter spp. infections. Methods: Data from routine carbapenem susceptibility testing of 18,412 invasive clinical Acinetobacter spp. isolates from 30 European countries in 2013–2017 were analysed using descriptive statistical analyses and uni- and multivariable regression analyses. These data were obtained from the European Antimicrobial Resistance Surveillance Network (EARS-Net). Results: The population-weighted mean proportion of carbapenem-non-susceptible Acinetobacter spp. in Europe is 35.6% (95% confidence interval [CI] 29.7–42.0%). With CNA proportions of 75.5% (95% CI 71.2–79.4%) and 71.5% (95% CI 66.7–75.9%) the burden of CNA is particularly high in Southern and Eastern European regions. In contrast, Northern and Western European regions recorded CNA proportions of 2.8% (95% CI 1.2–6.0%) and 6.3% (95% CI 4.5–8.9%), respectively. Population-weighted mean CNA proportions are especially high in Acinetobacter spp. isolates from intensive care units (54.0% [95% CI 47.6–60.3%]). Male gender, age above 20 years and ICU admission were identified as independent factors associated with an increased likelihood of CNA. Conclusion: The burden of carbapenem-non-susceptible Acinetobacter spp. is particularly high in Southern and Eastern Europe. There is a risk that resistance could spread to other parts of Europe. Therefore, increased efforts in infection control and antibiotic stewardship, particularly in Intensive Care Units, are necessary to combat the spread of CNA in Europe. [ABSTRACT FROM AUTHOR]

Objectives: International spread has contributed substantially to the high prevalence of antimicrobial resistant (AMR) Neisseria gonorrhoeae infections worldwide. We compared the prevalence of AMR gonococcal isolates among native persons to foreign-born (reporting country different from country of birth) persons, and describe the epidemiological and clinical characteristics of foreign-born patients and their associations to AMR.Methods: We analysed isolates and patient data reported to the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) 2010-2014 (n=9529).Results: Forty-three per cent of isolates had known country of birth and 17.2% of these were from persons born abroad. Almost 50% of foreign-born were from the WHO European Region (13.1% from non-European Union [EU] and the European Economic Area [EEA] countries). Compared with isolates from natives, isolates from foreign-born had a similar level (p>0.05) of azithromycin resistance (7.5% vs 7.2%), ciprofloxacin resistance (50.0% vs 46.3%) and of decreased susceptibility to ceftriaxone (1.9% vs 2.8%); a lower rate of cefixime resistance (5.7% vs 3.6%, p=0.02), and a higher proportion of isolates producing penicillinase (8.4% vs 11.7%, p=0.02). Among isolates from persons born outside EU/EEA, the level of decreased susceptibility to ceftriaxone was higher (1.8% vs 3.5%, p=0.02), particularly in those from the WHO Eastern Mediterranean Region and non-EU/EEA WHO European countries (1.9% vs 9.6% and 8.7%, respectively, p<0.01). In multivariable analysis, foreign-born patients with AMR isolates were more likely to be from non-EU/EEA WHO European countries (adjusted OR [aOR]: 3.2, 95% CI 1.8 to 5.8), WHO Eastern Mediterranean countries (aOR: 1.8, 95% CI 1.1 to 3.3) and heterosexual males (aOR: 1.8, 95% CI 1.2 to 2.7).Conclusions: Importation of AMR strains remains an important threat in the EU/EEA. Research to improve understanding of sexual networks within foreign born and sexual tourism populations could help to inform effective tailor-made interventions. The Euro-GASP demonstrates the public health value of quality-assured surveillance of gonococcal AMR and the need for strengthened AMR surveillance, particularly in the non-EU/EEA WHO European Region. [ABSTRACT FROM AUTHOR]

Background: SARS-CoV-2 is a RNA coronavirus responsible for the pandemic of the Severe Acute Respiratory Syndrome (COVID-19). RNA viruses are characterized by a high mutation rate, up to a million times higher than that of their hosts. Virus mutagenic capability depends upon several factors, including the fidelity of viral enzymes that replicate nucleic acids, as SARS-CoV-2 RNA dependent RNA polymerase (RdRp). Mutation rate drives viral evolution and genome variability, thereby enabling viruses to escape host immunity and to develop drug resistance.Methods: We analyzed 220 genomic sequences from the GISAID database derived from patients infected by SARS-CoV-2 worldwide from December 2019 to mid-March 2020. SARS-CoV-2 reference genome was obtained from the GenBank database. Genomes alignment was performed using Clustal Omega. Mann-Whitney and Fisher-Exact tests were used to assess statistical significance.Results: We characterized 8 novel recurrent mutations of SARS-CoV-2, located at positions 1397, 2891, 14408, 17746, 17857, 18060, 23403 and 28881. Mutations in 2891, 3036, 14408, 23403 and 28881 positions are predominantly observed in Europe, whereas those located at positions 17746, 17857 and 18060 are exclusively present in North America. We noticed for the first time a silent mutation in RdRp gene in England (UK) on February 9th, 2020 while a different mutation in RdRp changing its amino acid composition emerged on February 20th, 2020 in Italy (Lombardy). Viruses with RdRp mutation have a median of 3 point mutations [range: 2-5], otherwise they have a median of 1 mutation [range: 0-3] (p value < 0.001).Conclusions: These findings suggest that the virus is evolving and European, North American and Asian strains might coexist, each of them characterized by a different mutation pattern. The contribution of the mutated RdRp to this phenomenon needs to be investigated. To date, several drugs targeting RdRp enzymes are being employed for SARS-CoV-2 infection treatment. Some of them have a predicted binding moiety in a SARS-CoV-2 RdRp hydrophobic cleft, which is adjacent to the 14408 mutation we identified. Consequently, it is important to study and characterize SARS-CoV-2 RdRp mutation in order to assess possible drug-resistance viral phenotypes. It is also important to recognize whether the presence of some mutations might correlate with different SARS-CoV-2 mortality rates. [ABSTRACT FROM AUTHOR]

Background: The resurgence of tuberculosis (TB) in western countries has been attributed to the HIV epidemic, immigration, and drug resistance. Multidrug resistant tuberculosis (MDR-TB) is caused by the transmission of multidrug resistant Mycobacterium tuberculosis strains in new cases, or by the selection of single drug resistant strains induced by previous treatment. The aim of this report is to determine risk factors for MDR-TB in Europe. Methods: A systematic review was conducted of published reports of risk factors associated with MDR-TB in Europe. Meta-analysis, meta-regression, and sub-grouping were used to pool risk estimates of MDR-TB and to analyse associations with age, sex, immigrant status, HIV status, occurrence year, study design, and area of Europe. Results: Twenty nine papers were eligible for the review from 123 identified in the search. The pooled risk of MDR-TB was 10.23 times higher in previously treated than in never treated cases, with wide heterogeneity between studies. Study design and geographical area were associated with MDR-TB risk estimates in previously treated patients; the risk estimates were higher in cohort studies carried out in western Europe (RR 12.63; 95% CI 8.20 to 19.45) than in eastern Europe (RR 8.53; 95% CI 6.57 to 11.06). National estimates were possible for six countries. MDR-TB cases were more likely to be foreign born (odds ratio (OR) 2.46; 95% CI 1.86 to 3.24), younger than 65 years (OR 2.53; 95% CI 1.74 to 4.83), male (OR 1.38; 95% CI 1.16 to 1.65), and HIV positive (OR 3.52; 95% CI 2.48 to 5.01). Conclusions: Previous treatment was the strongest determinant of MDR-TB in Europe. Detailed study of the reasons for inadequate treatment could improve control strategies. The risk of MDR-TB in foreign born people needs to be re-evaluated, taking into account any previous treatment. [ABSTRACT FROM AUTHOR]

Background: Using case-vignettes, we assessed the perception of European infection control (IC) specialists regarding the individual and collective risk associated with antimicrobial resistance (AMR) among inpatients. Methods: In this study, sixteen case-vignettes were developed to simulate hospitalised patient scenarios in the field of AMR and IC. A total of 245 IC specialists working in different hospitals from 15 European countries were contacted, among which 149 agreed to participate in the study. Using an online database, each participant scored five randomly-assigned case-vignettes, regarding the perceived risk associated with six different multidrug resistant organisms (MDRO). The intra-class correlation coefficient (ICC), varying from 0 (poor) to 1 (perfect), was used to assess the agreement for the risk on a 7-point Likert scale. High risk and low/neutral risk scorers were compared regarding their national, organisational and individual characteristics. Results: Between January and May 2017, 149 participants scored 655 case-vignettes. The perceptions of the individual (clinical outcome) and collective (spread) risks were consistently lower than other MDRO for extended spectrum beta-lactamase producing Enterobacteriaceae cases and higher for carbapenemase producing Enterobacteriaceae (CPE) cases. Regarding CPE cases, answers were influenced more by the resistance pattern (93%) than for other MDRO. The risk associated with vancomycin resistant Enterococci cases was considered higher for the collective impact than for the individual outcome (63% vs 40%). The intra-country agreement regarding the individual risk was globally poor varying from 0.00 (ICC: 0–0.25) to 0.51 (0.18–0.85). The overall agreement across countries was poor at 0.20 (0.07–0.33). IC specialists working in hospitals preserved from MDROs perceived a higher individual (local, p = 0.01; national, p < 0.01) and collective risk (local and national p < 0.01) than those frequently exposed to bacteraemia. Conversely, IC specialists working in hospitals with a high MDRO clinical burden had a decreased risk perception. Conclusions: The perception of the risk associated with AMR varied greatly across IC specialists and countries, relying on contextual factors including the epidemiology. IC specialists working in high prevalence areas may underestimate both the individual and collective risks, and might further negatively promote the MDRO spread. These finding highlight the need to shape local and national control strategies according to risk perceptions and contextual factors. [ABSTRACT FROM AUTHOR]

Background: Resistance to antimicrobial agents has become a problem in modern society. Antibiotic resistant bacteria undermine the prevention and treatment of infections. Undergraduate dental students in Europe are required to receive information in aspects of microbiology relevant for dental practice, including oral microbial pathogens and resistance mechanisms against antimicrobial compounds. The objective of this study was to implement a research-based strategy to aid the understanding of the increase in antimicrobial resistance in undergraduate dental student training. The primary outcome of this project is the efficacious delivery of the learning objectives. Methods: Ten volunteer undergraduate student "ambassadors" were recruited to manage the project with assistance from lead academics. Student ambassadors were a source of peer learning for their colleagues. The project consisted of three phases: Pre-project preparation (in which the ambassadors received special instruction and training); Practical experience (in which the ambassadors worked with volunteer student colleagues to carry out the project); Public presentation of results (in which ambassadors presented study results at a scientific conference of their choosing). Results: A total of 1164 students volunteered for the project, corresponding to an average participation rate of 76.4% students per year of the course. Following final debriefing, student participants and ambassadors were strongly positive in their evaluation of the achievement of 8 key student learning objectives. The results demonstrate that most volunteers improved their knowledge related to antimicrobial resistance mechanisms in microbiology. Additional benefits of participation in this project included an improvement in dental knowledge and ethics in biomedical research for the student volunteers, whilst the student ambassadors reported improved knowledge about critical thinking and study design, as well as a deeper understanding about microbiological analysis methods. Conclusions: To the best of our knowledge, this the first instance of the application of project-based methodologies to the teaching of a traditionally non-laboratory component of a subject taught in the dentistry curriculum. Results from both students and ambassadors highlighted the increase in dental knowledge and an increased awareness of antimicrobial resistance as the key outcomes of this project. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial de-escalation (ADE) is a strategy of antimicrobial stewardship, aiming at preventing the emergence of antimicrobial resistance (AMR) by decreasing the exposure to broad-spectrum antimicrobials. There is no high-quality research on ADE and its effects on AMR. Its definition varies and there is little evidence-based guidance for clinicians to use ADE in the intensive care unit (ICU).Methods: A task force of 16 international experts was formed in November 2016 to provide with guidelines for clinical practice to develop questions targeted at defining ADE, its effects on the ICU population and to provide clinical guidance. Groups of 2 experts were assigned 1-2 questions each within their field of expertise to provide draft statements and rationale. A Delphi method, with 3 rounds and an agreement threshold of 70% was required to reach consensus.Results: We present a comprehensive document with 13 statements, reviewing the evidence on the definition of ADE, its effects in the ICU population and providing guidance for clinicians in subsets of clinical scenarios where ADE may be considered.Conclusion: ADE remains a topic of controversy due to the complexity of clinical scenarios where it may be applied and the absence of evidence to the effects it may have on antimicrobial resistance. [ABSTRACT FROM AUTHOR]

Background This study was conducted to assess the variation in prescription practices for systemic antimicrobial agents used for prophylaxis among pediatric patients hospitalized in 41 countries worldwide. Methods Using the standardized Antibiotic Resistance and Prescribing in European Children Point Prevalence Survey protocol, a cross-sectional point-prevalence survey was conducted at 226 pediatric hospitals in 41 countries from October 1 to November 30, 2012. Results Overall, 17693 pediatric patients were surveyed and 36.7% of them received antibiotics (n = 6499). Of 6818 inpatient children, 2242 (32.9%) received at least 1 antimicrobial for prophylactic use. Of 11899 prescriptions for antimicrobials, 3400 (28.6%) were provided for prophylactic use. Prophylaxis for medical diseases was the indication in 73.4% of cases (2495 of 3400), whereas 26.6% of prescriptions were for surgical diseases (905 of 3400). In approximately half the cases (48.7% [1656 of 3400]), a combination of 2 or more antimicrobials was prescribed. The use of broad-spectrum antibiotics (BSAs), which included tetracyclines, macrolides, lincosamides, and sulfonamides/trimethoprim, was high (51.8% [1761 of 3400]). Broad-spectrum antibiotic use for medical prophylaxis was more common in Asia (risk ratio [RR], 1.322; 95% confidence interval [CI], 1.202–1.653) and more restricted in Australia (RR, 0.619; 95% CI, 0.521–0.736). Prescription of BSA for surgical prophylaxis also varied according to United Nations region. Finally, a high percentage of surgical patients (79.7% [721 of 905]) received their prophylaxis for longer than 1 day. Conclusions A high proportion of hospitalized children received prophylactic BSAs. This represents a clear target for quality improvement. Collectively speaking, it is critical to reduce total prophylactic prescribing, BSA use, and prolonged prescription. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies in food-producing animals have shown associations between antimicrobial use (AMU) and resistance (AMR) in specifically isolated bacterial species. Multi-country data are scarce and only describe between-country differences. Here we investigate associations between the pig faecal mobile resistome and characteristics at the farm-level across Europe.Methods: A cross-sectional study was conducted among 176 conventional pig farms from nine European countries. Twenty-five faecal samples from fattening pigs were pooled per farm and acquired resistomes were determined using shotgun metagenomics and the Resfinder reference database, i.e. the full collection of horizontally acquired AMR genes (ARGs). Normalized fragments resistance genes per kilobase reference per million bacterial fragments (FPKM) were calculated. Specific farm-level data (AMU, biosecurity) were collected. Random-effects meta-analyses were performed by country, relating farm-level data to relative ARG abundances (FPKM).Results: Total AMU during fattening was positively associated with total ARG (total FPKM). Positive associations were particularly observed between widely used macrolides and tetracyclines, and ARGs corresponding to the respective antimicrobial classes. Significant AMU-ARG associations were not found for β-lactams and only few colistin ARGs were found, despite high use of these antimicrobial classes in younger pigs. Increased internal biosecurity was directly related to higher abundances of ARGs mainly encoding macrolide resistance. These effects of biosecurity were independent of AMU in mutually adjusted models.Conclusions: Using resistome data in association studies is unprecedented and adds accuracy and new insights to previously observed AMU-AMR associations. Major components of the pig resistome are positively and independently associated with on-farm AMU and biosecurity conditions. [ABSTRACT FROM AUTHOR]

Background: Surveillance of Neisseria gonorrhoeae antimicrobial susceptibility in Europe is performed through the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP), which additionally provides data to inform the European gonorrhoea treatment guideline; currently recommending ceftriaxone 500 mg plus azithromycin 2 g as first-line therapy. We present antimicrobial susceptibility data from 24 European countries in 2015, linked to epidemiological data of patients, and compare the results to Euro-GASP data from previous years.Methods: Antimicrobial susceptibility testing by MIC gradient strips or agar dilution methodology was performed on 2134 N. gonorrhoeae isolates and interpreted using EUCAST breakpoints. Patient variables associated with resistance were established using logistic regression to estimate odds ratios (ORs).Results: In 2015, 1.7% of isolates were cefixime resistant compared to 2.0% in 2014. Ceftriaxone resistance was detected in only one (0.05%) isolate in 2015, compared with five (0.2%) in 2014. Azithromycin resistance was detected in 7.1% of isolates in 2015 (7.9% in 2014), and five (0.2%) isolates displayed high-level azithromycin resistance (MIC ≥ 256 mg/L) compared with one (0.05%) in 2014. Ciprofloxacin resistance remained high (49.4%, vs. 50.7% in 2014). Cefixime resistance significantly increased among heterosexual males (4.1% vs. 1.7% in 2014), which was mainly attributable to data from two countries with high cefixime resistance (~11%), however rates among men-who-have-sex-with-men (MSM) and females continued to decline to 0.5% and 1%, respectively. Azithromycin resistance in MSM and heterosexual males was higher (both 8.1%) than in females (4.9% vs. 2.2% in 2014). The association between azithromycin resistance and previous gonorrhoea infection, observed in 2014, continued in 2015 (OR 2.1, CI 1.2-3.5, p < 0.01).Conclusions: The 2015 Euro-GASP sentinel system revealed high, but stable azithromycin resistance and low overall resistance to ceftriaxone and cefixime. The low cephalosporin resistance may be attributable to the effectiveness of the currently recommended first-line dual antimicrobial therapy; however the high azithromycin resistance threatens the effectiveness of this therapeutic regimen. Whether the global use of azithromycin in mono- or dual antimicrobial therapy of gonorrhoea is contributing to the global increases in azithromycin resistance remains to be elucidated. The increasing cefixime resistance in heterosexual males also needs close monitoring. [ABSTRACT FROM AUTHOR]

Introduction: Candida auris is a recently discovered, rapidly emerging fungal pathogen. Infections due to C. auris are hospital-acquired, multidrug resistant and associated with high mortality. Areas covered: This review highlights epidemiology, pathogenesis, microbiological characteristics, clinical presentation, diagnostic challenges and treatment options of C. auris infections. Infection prevention measures to prevent spread of C. auris and special measures during an outbreak situation have also been reviewed. Expert commentary: Rapid emergence of hospital onset C. auris is worrisome. Early diagnosis of C. auris is essential for better outcomes and the implementation of infection prevention measures. Lack of widespread awareness, absence of general availability of diagnostic testing methods, and limited options for treatment of C. auris infections make it a difficult-to-treat pathogen. Further studies are needed for better understanding of this emerging pathogen. [ABSTRACT FROM AUTHOR]

Purpose: Prevention and control of healthcare-associated infection (HCAI) are important within and beyond Europe. However, it is unclear which areas are considered important by HCAI prevention and control professionals. This study assesses the priorities in the prevention and control of HCAI as judged by experts in the field. Methods: A survey was conducted by the European Society of Clinical Microbiology and Infectious Diseases focussing on seven topics using SurveyMonkey. Through a newsletter distributed by email, about 5000 individuals were targeted throughout the world in February and March 2013. Participants were asked to rate the importance of particular topics from one (low importance) to ten (extraordinary importance), and there was no restriction on giving equal importance to more than one topic. Results: A total of 589 experts from 86 countries participated including 462 from Europe (response rate: 11.8 %). Physicians accounted for 60 % of participants, and 57 % had ten or more years' experience in this area. Microbial epidemiology/resistance achieved the highest priority scoring with 8.9, followed by surveillance 8.2, and decolonisation/disinfection/antiseptics with 7.9. Under epidemiology/resistance, highly resistant Gram-negative bacilli scored highest (9.0-9.2). The provision of computerised healthcare information systems for the early detection of outbreaks was accorded the top priority under surveillance. The prevention of surgical site and central line infections ranked highest under the category of specific HCAI and HCAI in certain settings. Differences between regions are described. Conclusion: These findings reflect the concerns of experts in HCAI prevention and control. The results from this survey should inform national and international agencies on future action and research priorities. [ABSTRACT FROM AUTHOR]

Antimicrobial ( AM) resistance is an increasing problem in human and veterinary medicine. To manage this problem, the usage of AM should be reduced in pig farming, as well as in other areas. It is important to investigate the factors that influence both pig farmers' and veterinarians' intentions to reduce AM usage, which is a prerequisite for developing intervention measures. We conducted a mail survey among pig farmers ( N = 1,294) and an online survey among veterinarians ( N = 334) in Belgium, Denmark, France, Germany, Sweden and Switzerland. The farmers' survey assessed the perceived risks and benefits of and need for AM usage; the intention to reduce AM usage; farmers' efficacy (i.e. perception of their ability to reduce AM usage); support from their veterinarian; and the future reduction potential of AM usage. Additionally, self-reported reduction behaviours, the perceived farmers' barriers to reduce AM usage and relationships with farmers were assessed in the veterinarians' survey. The results showed that farmers and veterinarians had similar perceptions of the risks and benefits of AM usage. Veterinarians appeared to be more optimistic than pig farmers about reducing AM usage in pig farming. Farmers believed that their efficacy over AM reduction was relatively high. Farmers' intention to reduce AM usage and veterinarians' self-reported reduction behaviours were mainly associated with factors concerning the feasibility of reducing AM usage. To promote prudent AM usage, pig farmers should learn and experience how to reduce usage by applying alternative measures, whereas veterinarians should strengthen their advisory role and competencies to support and educate farmers. [ABSTRACT FROM AUTHOR]

Objectives: Previously, web-based tools for cross-sectional antimicrobial point prevalence surveys (PPSs) have been used in adults to develop indicators of quality improvement. We aimed to determine the feasibility of developing similar quality indicators of improved antimicrobial prescribing focusing specifically on hospitalized neonates and children worldwide.Methods: A standardized antimicrobial PPS method was employed. Included were all inpatient children and neonates receiving an antimicrobial at 8:00 am on the day of the PPS. Denominators included the total number of inpatients. A web-based application was used for data entry, validation and reporting. We analysed 2012 data from 226 hospitals (H) in 41 countries (C) from Europe (174H; 24C), Africa (6H; 4C), Asia (25H; 8C), Australia (6H), Latin America (11H; 3C) and North America (4H).Results: Of 17,693 admissions, 6499 (36.7%) inpatients received at least one antimicrobial, but this varied considerably between wards and regions. Potential indicators included very high broad-spectrum antibiotic prescribing in children of mainly ceftriaxone (ranked first in Eastern Europe, 31.3%; Asia, 13.0%; Southern Europe, 9.8%), cefepime (ranked third in North America, 7.8%) and meropenem (ranked first in Latin America, 13.1%). The survey identified worryingly high use of critically important antibiotics for hospital-acquired infections in neonates (34.9%; range from 14.2% in Africa to 68.0% in Latin America) compared with children (28.3%; range from 14.5% in Africa to 48.9% in Latin America). Parenteral administration was very common among children in Asia (88%), Latin America (81%) and Europe (67%). Documentation of the reasons for antibiotic prescribing was lowest in Latin America (52%). Prolonged surgical prophylaxis rates ranged from 78% (Europe) to 84% (Latin America).Conclusions: Simple web-based PPS tools provide a feasible method to identify areas for improvement of antibiotic use, to set benchmarks and to monitor future interventions in hospitalized neonates and children. To our knowledge, this study has derived the first global quality indicators for antibiotic use in hospitalized neonates and children. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to systematically review quantitative and qualitative studies on the public's knowledge and beliefs about antibiotic resistance.Methods: We searched four databases to July 2014, with no language or study design restrictions. Two reviewers independently extracted data. We calculated the median (IQR) of the proportion of participants who agreed with each statement and synthesized qualitative data by identifying emergent themes.Results: Of 3537 articles screened, 54 studies (41 quantitative, 3 mixed methods and 10 qualitative) were included (55 225 participants). Most studied adults (50; 93% studies) and were conducted in Europe (23; 43%), Asia (14; 26%) or North America (12; 22%). Some participants [median 70% (IQR 50%-84%); n = 8 studies] had heard of antibiotic resistance, but most [median 88% (IQR 86%-89%); n = 2 studies] believed it referred to changes in the human body. Many believed excessive antibiotic use [median 70% (IQR 59%-77%); n = 11 studies] and not completing antibiotic courses [median 62% (IQR 47%-77%); n = 8 studies] caused resistance. Most participants nominated reducing antibiotic use [median 74% (IQR 72%-85%); n = 4 studies] and discussing antibiotic resistance with their clinician (84%, n = 1 study) as strategies to reduce resistance. Qualitative data supported these findings and additionally identified that: participants believed they were at low risk from antibiotic resistance participants; largely attributed its development to the actions of others; and strategies to minimize resistance should be primarily aimed at clinicians.Conclusions: The public have an incomplete understanding of antibiotic resistance and misperceptions about it and its causes and do not believe they contribute to its development. These data can be used to inform interventions to change the public's beliefs about how they can contribute to tackling this global issue. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to analyse antimicrobial susceptibility testing data generated by the Assessing Worldwide Antimicrobial Resistance Evaluation (AWARE) global surveillance programme for pathogens causing skin and soft tissue infections (SSTIs) in European countries in 2012.Methods: Confirmation of pathogen identity by MALDI-TOF and antimicrobial susceptibility testing following the CLSI broth microdilution method were performed by a central laboratory.Results: Using CLSI breakpoint criteria, ceftaroline was active against MSSA (n = 1116; MIC90, 0.25 mg/L; 99.8% susceptible), MRSA (n = 1467; MIC90, 1 mg/L; 92.2% susceptible) and Streptococcus pyogenes (n = 312; MIC90, 0.008 mg/L; 100% susceptible). By CLSI interpretative criteria, two S. aureus isolates (2/2583, 0.08%) were ceftaroline resistant (MIC, ≥4 mg/L) and 114 isolates (114/2583, 4.4%) were ceftaroline intermediate (2 mg/L). By EUCAST interpretative criteria (MIC, >1 mg/L), 4.5% (116/2583) of S. aureus isolates were ceftaroline resistant. Most ceftaroline-non-susceptible isolates (81.0%, 94/116) were from Russia, Turkey, Italy and Hungary. Ceftaroline susceptibility was equal to or exceeded 99% for S. aureus isolates submitted by 7 of 17 countries. Against Escherichia coli (n = 349), Klebsiella pneumoniae (n = 215), Klebsiella oxytoca (n = 74) and Proteus mirabilis (n = 121), ceftaroline activity was dependent upon ESBL production. For ESBL-negative E. coli, K. pneumoniae, K. oxytoca and P. mirabilis, 87.5% (MIC90, 1 mg/L), 92.3% (MIC90, 0.5 mg/L), 93.2% (MIC90, 0.5 mg/L) and 85.1% (MIC90, 2 mg/L) of isolates were susceptible to ceftaroline, respectively.Conclusions: Ceftaroline demonstrated potent in vitro activity against a contemporary collection of bacterial pathogens from patients with SSTIs in European countries, Russia and Turkey. Surveillance programmes such as AWARE are essential to global efforts to improve antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

Background: Multidrug-resistant organisms (MDRO) are a worldwide problem. International migration and travel facilitate the spread of MDRO. Therefore the goal of our study was to assess the risk of influx of MDRO from patients transferred to one of Central Europe's largest hospitals from abroad.Methods: A mono-centre study was conducted. All patients transferred from other countries were screened; additional data was collected on comorbidities, etc. Presence of carbapenemases of multidrug-resistant Gram-negatives was confirmed by PCR. The association between length of stay, being colonized and/or infected by a MDRO, country of origin, diagnosis and other factors was assessed by binomial regression analyses.Results: From 2012 to 2013, one fifth of all patients were colonized with MDRO (Methicillin-resistant Staphylococcus aureus [4.1 %], Vancomycin-resistant Enterococci [2.9 %], multidrug-resistant Gram-negatives [12.8 %] and extensively drug-resistant Gram-negatives [3.4 %]). The Gram-negatives carried a variety of carbapenemases including OXA, VIM, KPC and NDM. The length of stay was significantly prolonged by 77.2 % in patients colonized with a MDRO, compared to those not colonized (p<0.0001).Conclusions: Country-to-Country transfer of patients to European hospitals represents a high risk of introduction of MDRO and infection control specialists should endorse containment and screening measures. [ABSTRACT FROM AUTHOR]

Purpose: To examine patterns of outpatient and community antibiotic use among adults in five European countries. Methods: We used healthcare data of 28.8 million adults from six population-based ARITMO project databases to ascertain information on systemic antibiotic use in Denmark (2000-2008), the Netherlands (1999-2010), Italy (2000-2010), the UK (1996-2009), and Germany (2004-2008). We estimated overall, and age-group and sex specific antibiotic use as defined daily doses (DDD) per 1000 inhabitants per day. We computed annual age- and sex-standardized population prevalence of antibiotic use per 1000 persons-years (p-y) and the mean duration (in days) of antibiotic use. Results: The overall antibiotic use varied from 8.7 DDD per 1000 inhabitants per day in the UK to 18.1 DDD in Denmark, representing a 2.1-fold geographical variation. In all countries, prescribing was relatively high among individuals aged 15-19 years; lower in those aged 20-50 years; and then increased steadily reaching 41.8 DDD per 1000 inhabitants per day in individuals ≥85 years in Denmark. After age- and sex-standardization, prevalence of antibiotic use varied threefold from 160.2/1000 p-y in the UK to 421.1/1000 p-y in Italy. The ratio of broad- to narrow-spectrum penicillin, cephalosporin, and macrolide use varied from 0.6 in Denmark to 120.2 in Italy. Women used more antibiotics than men did in all countries. Across countries, the mean duration of antibiotic use varied 1.3 to 21.1-fold for different antibiotics. Conclusions: Antibiotic use is high in women and the elderly. Prescribing patterns vary substantially across European countries, both according to overall consumption, user prevalence, duration, and narrow- versus broad-spectrum antibiotics. [ABSTRACT FROM AUTHOR]

Background: Over 90% of antibiotics for human use in Europe are prescribed in primary care. We assessed the congruence between primary care treatment guidelines for skin infections and commensal Staphylococcus aureus (S. aureus) antimicrobial resistance levels in community-dwelling persons. Methods: The prevalence of antimicrobial resistance in S. aureus was analysed by taking nose swabs from healthy primary care patients in nine European countries (total N = 32,032). Primary care treatment guidelines for bacterial skin infections were interpreted with respect to these antimicrobial resistance patterns. First- and second-choice recommendations were assessed and considered congruent if resistance to the antibiotic did not exceed 20%. Results: We included primary care treatment guidelines for impetigo, cellulitis, folliculitis and furuncle. Treatment recommendations in all countries were consistent: most of the first-choice recommendations were beta-lactams, both for children and adults. Antimicrobial resistance levels were low, except for penicillin (on average 73% resistance). Considerable variation in antimicrobial resistance levels was found between countries, with Sweden displaying the lowest levels and Spain the highest. In some countries resistance to penicillin and azithromycin was significantly higher in children (4-17 years) compared with adults. Conclusions: Most of the first- and second-choice recommendations in the treatment guidelines for skin infections were congruent with commensal S. aureus antimicrobial resistance patterns in the community, except for two recommendations for penicillin. Given the variation in antimicrobial resistance levels between countries, age groups and health care settings, national data regarding antimicrobial resistance in the community should be taken into account when updating or developing primary care treatment guidelines. [ABSTRACT FROM AUTHOR]

Objective. Uncomplicated urinary tract infection (uUTI) is a common reason for antibiotic treatment in primary health care. Due to the increasing prevalence of antibiotic-resistant uropathogens it is crucial to use the most appropriate antibiotics for first-choice empiric treatment of uUTI. Particularly, it is important to avoid antibiotics associated with a high rate of antimicrobial resistance. This study compares national recommendations from six European countries, investigating recommendations for first-choice antibiotic therapy of uUTI. Setting. General practice in six European countries. Method. Searches were undertaken on PubMed, the Cochrane Library databases, Google, and Google Scholar. Recommendations from different geographical regions in Europe were investigated: Northern Europe (Denmark, Sweden), Western Europe (Scotland), Central Europe (Germany), Southern Europe (Spain), and Eastern Europe (Croatia). Results. The six countries recommended seven different antibiotics. Five countries recommended more than one antibiotic as first-choice treatment. Half of the countries recommended antibiotics associated with a high rate (> 10-20%) of resistant E. coli. All countries recommended at least one antibiotic associated with a low (< 5%) resistance rate. Discussion. The differences in first-choice treatment of uUTI could not be explained by differences in local bacterial aetiology or by different patterns of antimicrobial resistance. Despite resistance rates exceeding 10-20%, sulphamethizole, trimethoprim. or fluoroquinolones were recommended in half of the countries. Conclusion. Within the European countries there are considerable differences in recommendations for empiric first-choice antibiotic treatment of uUTI. In order to reduce the increasing antimicrobial resistance in Europe, it is important to agree on the most appropriate antibiotics for empiric treatment of uUTI. [ABSTRACT FROM AUTHOR]

Frequent contact with human waste and liquid manure from intensive livestock breeding, and the increased loads of antibiotic-resistant bacteria that result, are believed to be responsible for the high carriage rates of ESBL-producing E. coli found in birds of prey (raptors) in Central Europe. To test this hypothesis against the influence of avian migration, we initiated a comparative analysis of faecal samples from wild birds found in Saxony-Anhalt in Germany and the Gobi-Desert in Mongolia, regions of dissimilar human and livestock population characteristics and agricultural practices. We sampled a total of 281 wild birds, mostly raptors with primarily north-to-south migration routes. We determined antimicrobial resistance, focusing on ESBL production, and unravelled the phylogenetic and clonal relatedness of identified ESBL-producing E. coli isolates using multi-locus sequence typing (MLST) and macrorestriction analyses. Surprisingly, the overall carriage rates (approximately 5%) and the proportion of ESBL-producers among E. coli (Germany: 13.8%, Mongolia: 10.8%) were similar in both regions. Whereas blaCTX-M-1 predominated among German isolates (100%), blaCTX-M-9 was the most prevalent in Mongolian isolates (75%). We identified sequence types (STs) that are well known in human and veterinary clinical ESBL-producing E. coli (ST12, ST117, ST167, ST648) and observed clonal relatedness between a Mongolian avian ESBL-E. coli (ST167) and a clinical isolate of the same ST that originated in a hospitalised patient in Europe. Our data suggest the influence of avian migratory species in the transmission of ESBL-producing E. coli and challenge the prevailing assumption that reducing human influence alone invariably leads to lower rates of antimicrobial resistance. [ABSTRACT FROM AUTHOR]

We examined how different drivers of infectious disease could interact to threaten control efforts in Europe. We considered projected trends through 2020 for 3 broad groups of drivers: globalization and environmental change, social and demographic change, and health system capacity. Eight plausible infectious disease threats with the potential to be significantly more problematic than they are today were identified through an expert consultation: extensively drug- resistant bacteria, vector-borne diseases, sexually transmitted infections, food- borne infections, a resurgence of vaccine-preventable diseases, health care- associated infections, multidrug-resistant tuberculosis, and pandemic influenza. Preemptive measures to be taken by the public health community to counteract these threats were identified. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is becoming a major global public health threat and has begun to command attention from European and US policy makers. An initial focus on monitoring AMR and conserving existing treatments by cutting down on misuse has been complemented by moves towards addressing the paucity of new drugs in the R&D pipeline of the pharmaceutical industry. We identify five economic challenges: the utilisation externality; the lack of incentives for R&D arising from use restrictions, low prices, and scientific and regulatory challenges; the global joint sunk nature of R&D cost; the need for access to drugs in middle and low income countries; and failures in the market for point of care diagnostics. We analyse 'push,' 'pull' and hybrid incentives and conclude that higher prices linked to targeted use with diagnostic tests and/or an AMC-based 'prize' for registering (but not necessarily using) desired new drugs would be effective, and could be linked to push measures. US and European collaboration on incentives would be desirable but not if achieving agreement leads to delays. Action on conservation needs to be global and linked to use of new products. This will not be easy given TRIPS provisions and national sensitivities on this issue as seen in the 2010 reaction to evidence on the origins of NDM-1. [ABSTRACT FROM AUTHOR]

Eight novel chromogenic substrates were evaluated for their efficacy in detecting lipase activity in clinical isolates of Staphylococcus aureus from the United Kingdom and Malta. All isolates metabolized the chromogenic lipase substrates 5-(4-hydroxy-3,5-dimethoxyphenylmethylene)-2-thioxothia-zolidin-4-one-3-ethanoic acid (SRA)-propionate, SRA-butyrate, SRA-octanoate and 2-[2-(4-hydroxy-3,5-dimethoxyphenyl)-vinyl]-3-methy-benzothiazolium salt (SBZTM)-acetate. Over 90% of the isolates metabolized the lipase substrates SRA-decanoate and SRA-laurate. However, only 0.6% of UK isolates and 2% of Maltese isolates metabolized the lipase substrate SRA-myristate; none of the isolates tested metabolized SBZTM-butyrate. Traditional Tween 80 assays showed that over 73% of the UK methicillin-resistant Staphylococcus aureus (MRSA) isolates and 83% of the UK methicillin-sensitive Staphylococcus aureus (MSSA) isolates demonstrated lipolytic activity. In contrast, Maltese isolates showed lipase activity in 94% and 88% of the MRSA and MSSA strains, respectively. Lipases in MRSA and MSSA demonstrated substrate specificity whose activity appeared dependent upon hydrocarbon chain length of the chromogen. These novel chromogens can be used for lipase enzyme detection and have application for full characterization of numerous S. aureus lipases. [ABSTRACT FROM AUTHOR]

Molecular surveillance of multidrug-resistant tuberculosis (MDR TB) was implemented in Europe as case reporting in 2005. For all new MDR TB cases detected from January 2003 through June 2007, countries reported case-based epidemiologic data and DNA fingerprint patterns of MDR TB strains when available. International clusters were detected and analyzed. From 2003 through mid-2007 in Europe, 2,494 cases of MDR TB were reported from 24 European countries. Epidemiologic and molecular data were linked for 593 (39%) cases, and 672 insertion sequence 6110 DNA fingerprint patterns were reported from 19 countries. Of these patterns, 288 (43%) belonged to 18 European clusters; 7 clusters (242/288 cases, 84%) were characterized by strains of the Beijing genotype family, including the largest cluster (175/288 cases, 61%). Both clustering and the Beijing genotype were associated with strains originating in eastern European countries. Molecular cluster detection contributes to identification of transmission profile, risk factors, and control measures. [ABSTRACT FROM AUTHOR]

The article provides information on the medical problem of a 63-year-old man with gonococcal arthritis and without the typical skin lesions and urethral discharge in Europe. The authors stated that the patient have been diagnosed with Neisseria gonorrhoeae after having three specimens obtained for blood culture. In addition, gonococcal resistance to fluoroquinolones and other antibiotics is increasing, which may cause future problems in the treatment of the disease.

Background: The project "Antibiotic resistance in bacteria of animal origin -- II" (ARBAO-II) was funded by the European Union (FAIR5-QLK2-2002-01146) for the period 2003-05. The aim of this project was to establish a program for the continuous monitoring of antimicrobial susceptibility of pathogenic and indicator bacteria from food animals using validated and harmonised methodologies. In this report the first data on the occurrence of antimicrobial resistance among bacteria causing infections in pigs are reported. Methods: Susceptibility data from 17,642 isolates of pathogens and indicator bacteria including Actinobacillus pleuropneumoniae, Streptococcus suis and Escherichia coli isolated from pigs were collected from fifteen European countries in 2002-2004. Results: Data for A. pleuropneumoniae from infected pigs were submitted from five countries. Most of the isolates from Denmark were susceptible to all drugs tested with the exceptions of a low frequency of resistance to tetracycline and trimethoprim -- sulphonamide. Data for S. suis were obtained from six countries. In general, a high level of resistance to tetracycline (48.0 - 92.0%) and erythromycin (29.1 - 75.0%) was observed in all countries whereas the level of resistance to ciprofloxacin and penicillin differed between the reporting countries. Isolates from England (and Wales), France and The Netherlands were all susceptible to penicillin. In contrast the proportion of strains resistant to ciprofloxacin ranged from 12.6 to 79.0% (2004) and to penicillin from 8.1 - 13.0% (2004) in Poland and Portugal. Data for E. coli from infected and healthy pigs were obtained from eleven countries. The data reveal a high level of resistance to tetracyclines, streptomycin and ampicillin among infected pigs whereas in healthy pigs the frequency of resistance was lower. Conclusion: Bacterial resistance to some antimicrobials was frequent with different levels of resistance being observed to several antimicrobial agents in different countries. The occurrence of resistance varied distinctly between isolates from healthy and diseased pigs, with the isolates from healthy pigs generally showing a lower level of resistance than those from diseased pigs. The study suggests that the choice of antimicrobials used for the treatment of diseased animals should preferably be based on knowledge of the local pattern of resistance. [ABSTRACT FROM AUTHOR]

Aim: To prospectively assess the antibacterial resistance rate in Helicobacter pylori strains obtained from symptomatic children in Europe. Methods: During a 4-year period, 17 paediatric centres from 14 European countries reported prospectively on patients infected with H pylori, for whom antibiotic susceptibility was tested. Results: A total of 1233 patients were reported from Northern (3%), Western (70%), Eastern (9%) and Southern Europe (18%); 41% originated from outside Europe as indicated by mother's birth-country; 13% were <6 years of age, 43% 6-11 years of age and 44% >11 years of age. Testing was carried out before the first treatment (group A, n = 1037), and after treatment failure (group B, n = 196). Overall resistance to clarithromycin was detected in 24% (mean, A: 20%, B: 42%). The primary clarithromycin resistance rate was higher in boys (odds ratio (OR) 1.58; 1.12 to 2.24, p = 0.01), in children <6 years compared with >12 years (OR 1.82, 1.10 to 3.03, p = 0.020) and in patients living in Southern Europe compared with those living in Northern Europe (OR 2.25; 1.52 to 3.30, p<0.001). Overall resistance rate to metronidazole was 25% (A: 23%, B: 35%) and higher in children born outside Europe (A: adjusted. OR 2.42, 95% CI: 1.61 to 3.66, p<0.001). Resistance to both antibiotics occurred in 6.9% (A: 5.3%, B: 15.3%). Resistance to amoxicillin was exceptional (0.6%). Children with peptic ulcer disease (80/1180, 6.8%) were older than patients without ulcer (p=0.001). Conclusion: The primary resistance rate of H pylori strains obtained from unselected children in Europe is high. The use of antibiotics for other indications seems to be the major risk factor for development of primary resistance. [ABSTRACT FROM AUTHOR]

Unlabelled: Streptococcus pneumoniae- the pneumococcus- affects children and adults worldwide. Invasive pneumococcal disease, including pneumonia, meningitis and bacteraemia, has been linked annually to the deaths of millions of children. The pneumococcus is also a significant contributor to mucosal infections such as acute otitis media and sinusitis. Though pneumococcal infections can occur at any age, persons at greatest risk include children younger than 2 years of age and adults aged 65 years or more. Rates of pneumococcal disease and the prevalence of pneumococcal serotypes vary by geographic location and patient age. Accurate ascertainment and sound epidemiological data are essential for the rational development of effective programmes for prevention and treatment. Pneumococcal resistance to penicillin and other antibiotics has emerged rapidly in recent years, highlighting the importance of vaccine development. Newer pneumococcal vaccines, such as those conjugated to protein carriers, can now overcome the limitations of older polysaccharide vaccines. Such conjugated vaccines induce excellent immune responses even in infants and young children and they may also reduce asymptomatic nasopharyngeal carriage of pneumococci. Pneumococcal 7-valent conjugated vaccine PNCRM7 contains common prevalent serotypes coupled to a nontoxic diphtheria variant (CRM197). This vaccine has demonstrated high efficacy against invasive pneumococcal disease in clinical trials in infants and young children and is currently licensed for use in the United States and selected countries in Europe and Latin America.Conclusion: across Europe, pneumococcal infection is responsible for considerable morbidity and mortality, particularly in the very young and the elderly, groups whose members respond poorly to non-conjugated vaccines. The advent of new conjugated pneumococcal vaccines now offers an exciting opportunity in developed countries to reduce both the current burden of disease and the threat of rising antibiotic resistance. Rolling out the use of such vaccines across Europe must be accompanied by detailed ongoing surveillance in order to detect any changes that might occur in the pattern of pneumococcal serotypes. [ABSTRACT FROM AUTHOR]

Bactericides, fungicides, and other pesticides play an important role in the management of plant diseases. However, their use can result in residues on plants and in the environment, with potentially detrimental consequences. The use of streptomycin, oxytetracycline, copper-based products, and some fungicides is correlated with increased resistance among plant pathogens to these agents. Likewise, the recent rise in the incidence of environmental triazole fungicide-resistant Aspergillus fumigatus, the cause of aspergillosis in humans, has caused concern, particularly in Europe. Through horizontal gene transfer, genes can be exchanged among a variety of bacteria in the plant production environment, including phytopathogens, soil bacteria, and zoonotic bacteria that are occasionally present in that environment and in the food chain. Through mechanisms of horizontal gene transfer, co-resistance, cross-resistance, and gene up-regulation, resistance to one compound may confer resistance and multi-drug resistance to other similar, or even very dissimilar, compounds. Given the global rise in antimicrobial-resistant (AMR) organisms, and their effects on plant, animal, and human health, the prudent use of pesticides is required to maintain their effectiveness for food security and sustainable production, and to minimize the emergence and transmission of AMR organisms from horticultural sources. [ABSTRACT FROM AUTHOR]

Simple Summary: Antimicrobial resistance (AMR) is one of the global public health challenges nowadays. AMR threatens the effective prevention and treatment of an ever-increasing range of infections, being present in healthcare settings but also detected across the whole ecosystem, including wildlife. This work compiles the available information about an important resistance mechanism that gives bacteria the ability to inactivate cephalosporin antibiotics, the cephalosporinases (extended-spectrum beta-lactamase (ESBL) and AmpC beta-lactamase), in wildlife. Through a rigorous systematic literature review in the Web of Science database, the available publications on this topic in the wildlife sphere were analysed. The emergence and spread of cephalosporinases in wildlife has been reported in 46 countries from all continents (52% in Europe), with descriptions mainly in birds and mammals. The most widely disseminated cephalosporinases in human-related settings (e.g. CTX-M-1, CTX-M-14, CTX-M-15 and CMY-2) are also the most reported in wildlife, suggesting that anthropogenic pressure upon natural environments have a strong impact on antimicrobial resistance spread, including the dissemination of genes encoding these enzymes. Our work highlights the urgence and importance of public and ecosystem health policies, including improved surveillance and control strategies that breakdown AMR transmission chains across wildlife, as part of an integrated strategy of the One Health approach. In the last decade, detection of antibiotic resistant bacteria from wildlife has received increasing interest, due to the potential risk posed by those bacteria to wild animals, livestock or humans at the interface with wildlife, and due to the ensuing contamination of the environment. According to World Health Organization, cephalosporins are critically important antibiotics to human health. However, acquired resistance to β-lactams is widely distributed and is mainly mediated by extended-spectrum beta-lactamase and AmpC beta-lactamases, such as cephalosporinases. This work thus aimed to compile and analyse the information available on the emergence and dissemination of cephalosporinases in wildlife worldwide. Results suggest a serious scenario, with reporting of cephalosporinases in 46 countries from all continents (52% in Europe), across 188 host species, mainly birds and mammals, especially gulls and ungulates. The most widely reported cephalosporinases, CTX-M-1, CTX-M-14, CTX-M-15 and CMY-2, were also the most common in wild animals, in agreement with their ubiquity in human settings, including their association to high-risk clones of Escherichia coli (E. coli), such as the worldwide distributed CTX-M-15/ST131 E. coli. Altogether, our findings show that anthropogenic activities affect the whole ecosystem and that public policies promoting animal and environmental surveillance, as well as mitigation measures to avoid antimicrobial misuse and AMR spread, are urgently needed to be out in practise. [ABSTRACT FROM AUTHOR]

Education in antimicrobial stewardship (AMS) in veterinary medicine is essential to foster responsible antimicrobial use and control of antimicrobial resistance (AMR) in animals. AMS is listed by the EU and international organizations among the basic 'Day One Competences' required of veterinary students upon graduation. Our aim was to evaluate the quality of education of European veterinary students in AMS. We distributed a 27-item survey addressing the perceptions of preparedness and acquired skills on key topics related to AMS to final-year veterinary students in Europe. We collected 3423 complete answers from 89 veterinary schools in 30 countries. Selection of treatment strategies and awareness of emerging AMR problems were markedly different between countries. Overall, only one in four students was familiar with guidelines for antimicrobial use. The students perceived a medium-high impact of veterinary antimicrobial use on AMR in humans. Notably, 75% of the students felt the need for improved teaching on AMS, half of which also demanded more teaching on general antimicrobial therapy. Our results highlight several possible strategies to improve the quality of education, ranging from a better link between clinical rotations and the theory taught in pre-clinical modules, to a more effective introduction into best practices for antimicrobial use. [ABSTRACT FROM AUTHOR]

Methicillin-resistant Staphylococcus aureus (MRSA) is a rare cause of community acquired soft tissue infection in Europe. We report a case of severe soft tissue infection caused by a MRSA strain originating from a pig bite. [ABSTRACT FROM AUTHOR]