Antibiotic Use Decreased, Resistance Stable in Germany

New figures on antibiotic resistance in Germany and Europe give a clear picture. Favorable developments in the use of antibiotics and the number of antibiotic-resistant pathogens have occurred. Nevertheless, more than 35,000 people still die every year in the European Union (plus Iceland and Norway) from antibiotic-resistant infections.

"A long-lasting effort is necessary to keep the [antibiotic-resistance] situation at a good level," said Tim Eckmanns, MD, head of the Department for Nosocomial Infections, Surveillance of Antibiotic Resistance and Usage at the Robert Koch Institute (RKI) in Berlin, Germany. "We have a high-performance medicine in which we have to use antibiotics over and over again, and so resistance will carry on developing."

Two Resistant Pathogens

Eckmanns's department at the RKI has published the recent data on antibiotic resistance surveillance (ARS) in Germany up until 2021. The figures indicate that Germany is in a relatively favorable position. "Aside from the vancomycin-resistant Enterococcus faecum and the carbapenem-resistant Pseudomonas aeruginosa, nothing is on the rise," said Eckmanns.

While the prevalence of the carbapenem-resistant pseudomonads has risen in the last few years to 15%, the ARS reports that the vancomycin-resistant enterococci have reached a level as high as 20%-25%. "We have a problem with this pathogen in Germany; it has grown over the last few years, and the resistance has remained stable for the last 2-3 years, but at a very high level. It is also the only resistance for which Germany ranks over the average of the other EU countries," said Eckmanns.

Declining Resistance

The antibiotic-resistant proportions of the other relevant pathogens of nosocomial infections monitored by the ARS are significantly lower. Carbapenem-resistant Klebsiella pneumoniae makes up under 1%, and E coli with a combined resistance against third-generation cephalosporins, fluoroquinolones, and aminoglycosides is around 3%, following a decline in the last 3-4 years.

Acinetobacter species with a combined resistance against fluoroquinolones, aminoglycosides, and carbapenems make up 4% of the total in Germany. "And for methicillin-resistant Staphylococcus aureus (MRSA), 10 years ago we said we had 20%-25% resistance, but today it is significantly below 10%," said Eckmanns.

Infections and Deaths

The recent data from the RKI also contributes to a new evaluation of the resistance situation in the European Union (plus Iceland and Norway), which was recently published by the European Centre for Disease Prevention and Control (ECDC). The ECDC data show that from 2016 to 2020, the number of infections and deaths due to almost all antibiotic resistances had increased.

"In 2021, the number of reported cases of Acinetobacter species [infections], which are resistant to various classes of antibiotics, was almost twice as high (plus 121%) as the average from 2018 to 2019," reported the ECDC. Another example is the proportion of K pneumoniae, which are resistant to carbapenems. They rose by 31% in 2020 and then again by 20% in 2021.

International Differences

However, "the proportion of antibiotic resistance varies greatly between countries. In general, the lowest figures were reported in northern European countries, and the highest in southern and eastern European countries," reported the ECDC.

"If you take the K pneumoniae resistance to carbapenems, for example, which is under 1% in Germany, then this is actually comparable in almost every country in northwest Europe," said Eckmanns. "But we then have countries in EU-Europe that have over 50% resistance, such as Greece. Some Commonwealth of Independent States (CIS) countries have over 50%, and many countries have between 25% and 50%. And Italy belongs in this group, for example," said Eckmanns.

Constant Attention Necessary

"We are currently observing increases in certain resistances in eastern Europe, which also commonly have a fatal outcome," he added. These could also be registered in Germany at any time and then be spread in this country as well.

"The problem can develop quite quickly," said Eckmanns. There is thus no point in shifting the blame abroad. Therefore, a large amount of attention is necessary, as well as "truly united attempts on the clinical side, hygienic side, epidemiological side, and microbiological side."

Antibiotic Usage Declines

The most important measure to avoid antibiotic resistance is to use antibiotics as sparingly as possible. In this respect, the ECDC has positive news. According to them, the overall use of antibiotics in human medicine fell by 23% in the inpatient and outpatient sectors from 2012 to 2021.

As the ECDC reports, this is a success, but in contrast, the proportion of broad-spectrum antibiotics has increased, especially in hospitals. From 2012 to 2021, the use of broad-spectrum antibiotics increased in hospitals by 15%, the use of carbapenems by 34%, and the proportion of reserve antibiotics doubled in this period.

Inappropriate Antibiotic Use

The fact that further informational measures are needed among the European population to avoid antibiotic resistance is evident in a survey by Eurobarometer. The survey showed that the use of antibiotics had reached a record low. Only 23% of Europeans indicated having taken antibiotics in the last year, which is the lowest number since 2009. But this result varies greatly between countries. The figure in Malta was 42%, but only 15% in Germany and Sweden.

However, the proportion of Europeans who take antibiotics without a suitable indication, for example with viral infections, is still high. It showed a "worrying lack of awareness of the appropriate use of antibiotics," wrote the ECDC. Only around a half of those surveyed knew that antibiotics are not effective against viruses, and only three out of 10 Europeans knew that the unnecessary use of antibiotics contributes to them becoming less effective.

A Persistent Problem

There is still a lot of work in progress, including the development of new medications. According to Eckmanns, this is a priority, but is not a silver bullet, since "pathogens will eventually become resistant to new antibiotics, too."

He emphasized, "We will never get rid of the problem of antibiotic resistance. There will never be a time when it will be said that there is no more antibiotic resistance. It is something that will be with us permanently."

This article was translated from the Medscape German edition.

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