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Table of Contents
                            SWEDRES/SVARM 2013
Preface
Contributors and participants
Content
Sammanfattning/Summary
Guidance for readers
Use of antimicrobials
	Total sales of antibiotics in humans
	Antibiotics in outpatient care
		Gender differences
		Antibiotics commonly used to treat RTI, UTI and SSTI
		In focus Diagnose linked prescribing data from primary care
		Antibiotic consumption in children
		County data
		In focus Respiratory tract infections – repeated courses in outpatient antibiotic use
		Antibiotics in dentistry
	Antibiotics in hospital care
		In focus IT-tool for automatic registration of healthcare-associatedand antibiotic use in hospital care
	Adverse reactionsrelated to antibiotic use
	Use of antifungals
		Hospital care
		In outpatient care
	Use of antimicrobials for animals
	Comparison of antimicrobial use inhuman and veterinary medicine
Antimicrobial resistance
	Notifiable diseases
		ESBL-producing Enterobacteriaceae
		In focus Gram-negative ESBL-producing bacteria in perspective - humans and animals
		Methicillin resistant Staphylococcus aureus (MRSA)
		Methicillin resistantStaphylococcus pseudintermedius (MRSP)
		Vancomycin resistant Enterococcusfaecalis and Enterococcus faecium (VRE)
		Streptococcus pneumoniaewith reduced susceptibility to penicillin (PNSP)
		In focus Outbreaks of resistant bacteria in health care
	Zoonotic pathogens
		Salmonella
		Campylobacter
		In focus Penicillin resistance in Bacillus anthracis
	Clinical isolates from humans
		Isolates from blood cultures reported to ECDC/EARS-Net
		Resistance in otherbacterial species from blood cultures
		The annual resistance surveillanceand quality control programme (ResNet)
		Clostridium difficile
		In focus Svebar - Swedish surveillance of antimicrobial resistance
		Neisseria gonorrhoeae
		Neisseria meningitidis
		Mycobacterium tuberculosis
	Clinical isolates from animals
		Pigs
		Cattle
		Farmed fish
		In focus SVARMpat
		Horses
		Dogs
		Cats
		In focus Dichelobacter nodosus
	Indicator bacteria from animals
		Escherichia coli
		Enterococcus
Background data, material, metods and references
	Demographics and denominator data
	Materials and methods, use of antimicrobials
	Materials and methods, resistance in bacteria from humans
	Materials and methods, resistance in bacteria from animals
	SVARM 2000-2013
	References
                        
Document Text Contents
Page 1

SWEDRES|SVARM
Use of antimicrobials and occurrence

of antimicrobial resistance in Sweden

2013

Page 2

SWEDRES |SVARM 20132

A report on Swedish Antibiotic Utilisation and Resistance
in Human Medicine (SWEDRES) and Swedish Veterinary
Antimicrobial Resistance Monitoring (SVARM)

Published by:
Public Health Agency of Sweden and National Veterinary
Institute

Editors:
Jenny Hellman and Olov Aspevall,
Public Health Agency of Sweden
Björn Bengtsson and Christina Greko,
National Veterinary Institute

Addresses:
The Public Health Agency of Sweden
SE-171 82 Solna, Sweden
Phone: +46 (0) 10 205 20 00
Fax: +46 (0) 8 32 83 30
E-mail: [email protected]
www.folkhalsomyndigheten.se

National Veterinary Institute
SE-751 89 Uppsala, Sweden
Phone: +46 (0) 18 67 40 00
Fax: +46 (0) 18 30 91 62
E-mail: [email protected]
www.sva.se

ISSN 1650-6332

This title and previous SWEDRES and SVARM reports are
available for downloading at
www.folkhalsomyndigheten.se/publicerat-material/
or www.sva.se

This title can be ordered from:
Folkhalsomyndighetens beställningsservice c/o Strömberg,
120 88 Stockholm
Fax: +46 (0) 8 779 96 67
E-mail: [email protected]

Department of Animal Health and Antimicrobial Strategies,
National Veterinary Institute,
SE-751 89 Uppsala, Sweden
Phone: +46 (0) 18 67 40 00
Fax: +46 (0) 18 30 91 62 E-mail: [email protected]

Text and tables may be cited and reprinted only with refer-
ence to this report. Images, photographs and illustrations are
protected by copyright.

Suggested citation:
SWEDRES-SVARM 2013. Use of antimicrobials and
occurrence of antimicrobial resistance in Sweden. Solna/
Uppsala ISSN 1650-6332

Print & Layout: Edita Västra Aros AB

Omslag: Ingvar Westerdahl/Thomas Isaksson

Page 57

SWEDRES |SVARM 2013 57

MRSA CC398

Internationally, the livestock-associated MRSA CC398 dom-
inates in farm animals and can be of importance for the over-
all human MRSA burden in countries with low prevalence
of MRSA in humans (EFSA, 2009). In countries with high
prevalence of MRSA CC398 in pigs, the pig population con-
stitutes a reservoir of MRSA with continuous transmission
to people in close contact with pigs. In the latest screening
study MRSA was not detected in Swedish pigs, indicating a
favourable situation. However, continuous monitoring is of
importance as the situation can change rapidly, for example
through import of live animals. MRSA CC398 also occurs
among horses and spa-type t011, belonging to CC398, is by
far the most common type among Swedish horses.

Four PVL-negative MRSA CC398-associated spa-types
(t034, t011, t571 and t108) were seen among 49 human cases
in 2006-2013. The two dominating spa-types were t034
(n=25) and t011 (n=19). Nine of the 49 cases were from 2013,
five with spa-type t034 and four with t011. The epidemio-
logical information on these cases is however scarce.

MRSA with mecC

Isolates of MRSA with mecC were first reported internation-
ally from dairy cows and humans in 2011 (García-Álvarez et
al., 2011, Shore et al., 2011, Ito et al., 2012). Such MRSA iso-
lates were detected in milk from Swedish dairy cows sampled
in 2010, 2011 and 2013 and were of spa-types t524, t9111 and
t843. Two of these spa-types, t9111 and t843, have also been
found in human cases. MRSA with mecC have been found in
51 human cases 2011-2013. The two most common spa-types
seen among the human isolates were t843 (13 cases) and t373
(11 cases).

MRSA in dairy cattle

Staphylococcus aureus is a common cause of mastitis in dairy
cows and the udder may constitute a reservoir. For example
during milking, close contact between farmer and dairy cows
may give good opportunities for transmission from human to
cow, or vice versa.

Suspected transmission between human and cattle was
detected on a dairy farm in 2012. Initiated by the detection
of PVL-positive MRSA of spa-type t002 in a dairy farmer, all
cattle on the farm were sampled. Milk samples from lactating
cows and body samples from nostrils and groin from other
cattle were taken initially. MRSA of the same spa-type as in
the farmer was detected in milk samples from several cows
and one nasal swab. Since MRSA of this spa-type is common
among humans in Sweden, it is likely that transmission has
occurred from the farmer to cows.

Hygienic measures were implemented on the farm in
order to reduce the risk of transmission and several of the
MRSA-positive cows were culled. This reduced the number
of colonized or infected animals, but MRSA was still detected
in milk from dairy cows, in the nostrils of five heifers and peri-
neum of one bull at a second sampling about ten months later.

MRSA in companion animals

MRSA isolated from dogs and cats often belong to spa-types
seen in MRSA from humans. This supports the view that
humans often constitute the source of MRSA in companion
animals (EFSA 2009, CVMP, 2009). The most common spa-
type among Swedish dogs and cats has been t032. This type
was one of the ten most common spa-types among human
MRSA isolates in Sweden up to 2011. In 2013 it was only
found in 18 isolates.

Conclusion

The prevalence of MRSA in Sweden is still low both in
humans and in animals. If the favourable situation in animals
is preserved, a reservoir of MRSA in animals with risk of
spread from animals to humans can be prevented. Infection
control and caution in trade of live animals are important
strategies for preventing introduction and spread of MRSA
in animal populations. Cautions to prevent transmission from
humans to animals are also of importance, since human types
of MRSA may be established also in animal populations.

Methicillin resistant
Staphylococcus pseudintermedius (MRSP)

MRSP in animals
Methicillin-resistant Staphylococcus pseudintermedius (MRSP)
was first isolated in Sweden from a healthy dog in a screening
for MRSA in 2006. In 2008, methicillin-resistant coagulase
positive staphylococci (including MRSP) isolated from ani-
mals in Sweden became notifiable.

From 2006 a large increase in the numbers of MRSP cases
was observed, the numbers peaked in 2009 with 130 cases
(Figure 2.10). However, since 2010 the number of cases has
dropped yearly with only 33 cases notified in 2013. Whether
this reflects a true reduction in the number of animals
infected with MRSP is uncertain. The drop appears primar-
ily be due to a decreasing occurrence of the European clone
ST71-J-t02-II-III.

One explanation for the observed decrease could be the
insight among veterinary practitioners in recent years on the
importance of preventing spread of MRSP and on the pru-
dent use of antimicrobials. For instance, in many animal clin-
ics and hospitals, infection control programmes have been
implemented with focus on strict hand hygiene routines.
In addition, veterinarians with special interest in dermatol-
ogy have agreed on an antimicrobial policy for treatment of
dogs with dermatological disorders. Over the years MRSP
has mostly been isolated from dogs, but also from a few cats
and horses. In 2013 all cases, except one involving a cat, were
from dogs.

In 2013, 27 of the 33 notified MRSP isolates were avail-
able at SVA for further epidemiological typing and extended
antimicrobial susceptibility testing. In 58% of the cases the
origin of isolates was unknown, but 19% were from wounds,

Page 58

SWEDRES |SVARM 201358

19% from skin including ears and the remaining isolates from
miscellaneous sampling sites. The majority of MRSP isolates
(52%) belonged to the spa-type t02 carrying SCCmec II/III.
Of the remaining isolates 11% belonged to t06-SCCmec II/
III, 4% to t06-SCCmec V, 7% to t10 with a non-typeable
(NT) SCCmec, and 22% were NT with spa-typing carrying
either a SCCmec IV or II/III.

Based on PFGE and spa-typing of all isolates and on
MLST on a subset, 63% of the isolates belonged to the
European clone ST71-J-t02-II-III described by Perreten et
al. (2010). Remarkable was that 3 of these isolates were non-
typeable using spa-typing, but all belonged to ST71. In addi-
tion, 4 isolates being t02-SCCmec II/III did not show close
relatedness to the ST71-J-t02-II-III clone based on PFGE
and one of these isolates was typed to as a new ST not related
to ST71.

All isolates were defined as multiresistant, but 89% were
susceptible to fusidic acid, 78% to tetracycline, and 70% to
chloramphenicol. The isolates belonging to the ST71-J-t02-
II-III clone were all susceptible to tetracycline and fusidic
acid, 65% were susceptible to chloramphenicol, and 35%
to kanamycin. The remaining isolates showed variable anti-
microbial susceptibility patterns. The isolates carrying the
SCCmec II/III were described to have a MIC >16 mg/L
for oxacillin, both when tested with or without NaCl, and a
MIC ≥8 mg/L for cephalothin. However, the isolates carry-
ing other SCCmec types had a wide range of MICs, 0.5-16
mg/L, of oxacillin and generally low MICs, below cut-off,
0.25-4 mg/L of cephalothin. Cefoxitin MICs varied from 0.5
to 16 mg/L.

Zoonotic aspects on MRSP
Staphylococcus pseudintermedius is generally not considered
to be a human pathogen, but there are several reports of
MRSP infections in humans with a varying degree of sever-
ity. Furthermore, in 2011 an outbreak of MRSP belonging to

0

20

40

60

80

100

120

140

2006 2007 2008 2009 2010 2011 2012 2013

N
u
m

b
e
r

o
f

ca
se

s
o
f

M
R

S
P



FIGURE 2.10. The number of cases with methicillin resistant Staphylo-
coccus pseudintermedius in Sweden notified to the Swedish Board
of Agriculture 2008-2013. In 2006-2007 the numbers represent the
isolates that were sent to SVA and confirmed as mecA-positive.

the ST71-J-t02-II-III clone was described among patients at
Uppsala University hospital without any established animal-
human contact (Starlander et al., 2011). The highest risk of
getting an infection with MRSP is most likely through dog
bites, but MRSP carriage is unusual among healthy dogs in
Sweden (SWEDRES-SVARM 2012).

Vancomycin resistant Enterococcus
faecalis and Enterococcus faecium (VRE)

VRE in humans
Background

Vancomycin resistant enterococci (VRE) are important
causes of nosocomial infections in many parts of the world,
usually involving high-risk populations such as immunocom-
promised and intensive care patients. Like MRSA, VRE were
made notifiable according to the Swedish Communicable
Disease Act in the year 2000 and since 2004 contact tracing is
mandatory. The following presentation is based on data col-
lected in the national web-based notification system SmiNet.
During the last seven years an active effort has been made to
improve the quality of data and to collect missing data. The
notifications have been reviewed and complemented with
available relevant epidemiologic information from investiga-
tions around each case in collaboration with the CMOs.

Notifications of VRE according to the Communicable Disease Act

From 2000 to 2006 only low numbers (18-35 per year) of
VRE-cases were reported in Sweden. In 2007, reports came
from Stockholm County about an increase in the num-
ber of VRE-cases, and the total yearly count was 53 cases
(Table 2.9, Figure 2.11). This was the beginning of an out-
break that would last until 2011, when it was finally declared
to have come to an end in the affected counties. The out-
break has been described in SWEDRES 2011 and else-
where (Söderblom et al., 2010). The total number of cases
with a strain of Enterococcus faecium with vanB belonging to
this outbreak was 872. The next large outbreak occurred in
Västernorrland County and lasted 2010-2011 with an esti-
mated number of 100 cases. It was caused by another strain
of E. faecium still with a vanB gene. In 2012 at least two out-
breaks caused by two different strains of E. faecium with vanA
genes contributed to the increase in this type of VRE. These
outbreaks occurred in Jönköping and Halland counties,
respectively, and led to extensive infection control measures
to limit and eradicate the outbreak strains (SMI Newsletter
2013).

During 2013 a total of 227 cases were reported, an
in crease by 49% compared to 2012 (Table 2.9). This largely
due to one major hospital outbreak in Gävleborg. VRE cases
were reported from 15 of the 21 Swedish counties. The aver-
age national incidence of VRE was 2.4 with higher than aver-
age incidence figures in Gävleborg (33.1), Kronoberg (3.7)
and Västra Götaland (2.6) counties. Of all cases, 165 (73%)

Page 114

SWEDRES |SVARM 2013114

SVARM. Swedish Veterinary Antimicrobial Resistance
Monitor ing. Uppsala, Sweden. ISSN 1650-6332. www.sva.se

SWEDRES. Report on Swedish antimicrobial utilisation
and resistance in human medicine. Solna, Sweden. ISBN
987-91-86723-09-5. www.smittskyddsinstitutet.se./publika-
tioner

Söderblom T, Aspevall O, et al. 2010, Alarming spread of
vancomycin resistant enterococci in Sweden since 2007. Euro
Surveill, 15.

Tham J. Extended-spectrum beta-lactamase-producing
Enterobacteriaceae: Epidemiology, risk factors, and duration
of carriage. Doctoral thesis. Lund University, Sweden, 2012.

Tängdén T. Multidrug-resistant Escherichia coli and Klebsiella
pneumoniae: treatment, selection and international spread.
Doctoral thesis. Uppsala University, Sweden, 2012.

Unnerstad HE, Bengtsson B, et al. 2013, Methicillin-
resistant Staphylococcus aureus containing mecC in Swedish
dairy cows. Acta Vet Scand, 55:6.

WHO. Anthrax in humans and animals – 4th ed. I.World
Health Organization. II .Food and Agriculture Organization
of the United Nations. III. World Organisation for Animal
Health. WHO Press. Geneva, Switzerland, 2008.

Vogler AJ, Busch JD, et al. 2002, Molecular analysis of
rifampin resistance in Bacillus anthracis and Bacillus cereus.
Antimicrob Agents Chemother, 46:511-3.

Woodford N, Fagan EJ, et al. 2006, Multiplex PCR for
rapid detection of genes encoding CTX-M extended-spec-
trum (beta)-lactamases. J Antimicrob Chemother, 57:154-5.

Växa Sverige. Animal Health 2012/2013: Annual report
from the animal health section Stockholm, Sweden. In
Swedish. 2013. www.vxa.se

Ågren J, Finn M, et al. 2014, Microevolution during an
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cillin resistance. PLoS One, 9:e89112.

Page 115

SWEDRES|SVARM 2013

The 2013 Swedish report from the monitoring of antimicrobial resistance and antimicrobial usage in
human and veterinary medicine, SWEDRES-SVARM, is an integrated report from the Public Health
Agency of Sweden and the National Veterinary Institute, with data from humans, animals and food.

From an international perspective the situation in Sweden is still favorable regarding antimicrobial
resistance in bacteria in the human and veterinary sectors. The strategy to promote rational antibiotic
use and to contain the spread of resistant bacteria has been effective, but this year’s report also shows
unfavorable trends.

The report covers:
• Use of antimicrobials in humans and animals
• Occurrence of resistance in
– Notifiable diseases
– Zoonotic pathogens
– Clinical isolates from humans and animals
– Indicator bacteria from animals

The report also focuses on:
• Diagnos linked prescribing data from primary and hospital care
• Repeated courses for respiratory tract infections
• Outbreaks caused by resistent bacteria in Swedish healtcare
• Surveillance by Svebar
• All about ESBL-producing bacteria
• Penicillin resistance in Bacillus anthracis
• SVARMpat
• Dichelobacter nodosus

The Public Health Agency of Sweden has a national responsibility for public health issues and also
a mission to monitor the epidemiology of communicable diseases among Swedish citizens and promote
control and prevention of these diseases. The Public Health Agency of Sweden is responsible for national
surveillance of anti biotic use and antibiotic resistance, and aims at providing expert analyses and advice
to laboratories, infection control officers, Strama-groups and county medical officers.

The National Veterinary Institute (SVA) is a Government expert authority that strives for good
animal and human health, a good environment and sustainable food production. SVA has expertise within
the fields of risk assessment, prevention, diagnostics and the control of contagious and other serious
infectious diseases including zoonotic agents and antimicrobial resistance. SVA is mandated to monitor
antimicrobial resistance in animals and food and to promote rational use of antimicrobials in animals.

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