A survey carried out within Member States of the European Union and Norway shows that in all but two countries national surveillance of microorganisms resistant to antibiotics existed in December 2000. In Italy, Ireland and Scotland, the systems were set up very recently (respectively in 1998, 1999 and 1999). Moreover, excepting of Ireland and Scotland, all countries have a national system for data collection on the consumption of antibiotics, namely since 2000 in Austria, Italy and Luxembourg. Several of these systems were set up after 1998 when the recommendations of the European conference ‘The Microbial Threat’ held in Copenhague were published. In addition, a certain number of other measures have been undertaken since then: education campaigns to the population in England and Wales, in Ireland or in France, creation of committees specifically in charge of consumption surveillance in Italy or of the prevention of resistance in Belgium or in Ireland, publications of recommendations on the good use of antibiotics in Austria and in Finland, etc.

The first introduction of antibiotics in clinical practice dates back to the 1940s, and the possibility for microorganisms to develop resistance to antibiotics was quickly recognised with the emergence of methicillin resistant Staphylococcus aureus (MRSA) strains. Some 50 years later, antimicrobial resistance had become a major concern and a worldwide problem (1). Despite the data published each year, either at national level or through multinational studies involving several countries, the extent of the problem is still unknown. In the past two decades this problem has been raised at numerous scientific and political meetings. At the latest European Union (EU) conference, "The Microbial Threat", held in Copenhagen in September 1998, all EU member states unanimously agreed that antimicrobial resistance was no longer a national problem, but a major international issue requiring a common strategy at European level (2). Recommendations released following this meeting expressed four important issues: the need for surveillance of microorganisms resistant to antimicrobial agents, for collecting data on the supply and consumption of antimicrobial agents, for encouraging good practice on the use of antimicrobial agents, and to carry out research to fight the problem of antimicrobial resistance.

Eurosurveillance has undertaken, on the one hand, an overview of the current surveillance policies on antibiotic resistance in EU countries, and, on the other hand, an assessment of how the Copenhagen recommendations have been followed.

A questionnaire was sent in March 2000 to representatives of public health authorities (members of the editorial board of Eurosurveillance) in 17 European countries (Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Norway, Portugal, Scotland, Spain, Sweden, the Netherlands). Data requested included whether the following were undertaken: monitoring of antibiotic consumption, surveillance of antibiotic resistant microorganisms, recommendations issued for good practice on the use of antimicrobial agents, types of actions undertaken since the Copenhagen recommendations were issued. Recipients either completed the questionnaires themselves or asked a national expert on antibiotic resistance to do so. Responses to the questionnaire have been updated in December 2000.

All 17 countries responded to the questionnaire. National policies of surveillance and control of antimicrobial resistance vary between European countries.

Out of 17 European countries, 15 conducted surveillance of microorganisms resistant to antibiotics at a national level; the years of implementation vary from 1960 to 1999 (table 1). In 13 out of 15, the national public health institute is the main agent in charge of this surveillance. Concerning surveillance of resistance in nosocomial infection, some countries have a specific national (for example Belgium, Germany, Netherlands) or regional (England and Wales, France) system for surveillance of nosocomial infection and, in this context, monitor antibiotic resistance, whereas in some others (Austria, Denmark, Finland, Sweden) the nosocomial surveillance of specific resistant microorganisms is part of the surveillance system. Other countries such as Italy, Greece, Portugal and Spain, have infection control committees at hospital level, which are in charge of this surveillance at local level.

Table 1. Surveillance of microorganisms resistant to antimicrobial agents in human medicine in European countries

Country

Level (year of startt)

Institute in charge of surveillance

Austria

National (1994)

FM for Social Security and Generations

Belgium

National (1984)

Institut de Santé Publique and GDEPIH*

Denmark

National (1960 for S. aureus)

Statens Serum Institute

England and Wales

National (1989)

Public Health Laboratory Service

Finland

Regional and national (1991 and 1995)

Finnish Study Group for Antimicrobial Resistance (FiRe) and Kansanterveyslaitos Folkhälsoinstitutet (KTL)

France

Regional and national (1993)

CCLIN, CNR, ONERBA and  InVS **

Germany

National (1975)

Paul-Ehrlich- Society for Chemotherapy (PEG)

Greece

National (1995)

Ministry of Health and Department of Hygiene Medical School (Athens University)

Ireland

National (1999)

National Disease Surveillance Centre

Italy

National (sentinel network) (1999)

Istituto Superiore di Sanità

Luxembourg

Local

One major hospital only 

Norway

National (1995)

National Institute of Public Health

Portugal

National (1989)

National Institute of Health / Microbiology Laboratory (Universidade de Lisboa)

Scotland

National (1998)

SCIEH et SMA ***

Spain

Regional

Many hospitals 

Sweden

National (1980s)

Swedish Institute for Infectious Disease Control and SRGA and SRGA-M****

Netherlands

National (1990)

Rijksinstituut voor Volksgezondheit en milieu

Most other countries set up surveillance systems in the 1980s and 1990s. In Finland, the first multilaboratory resistance report concerning isolates from blood cultures was published in 1984, and then in 1986 with a surveillance report of S. aureus and Escherichia coli. In 1991 the Finnish Study Group for Antimicrobial Resistance (FINRES) was founded and put in charge of collecting data on resistance (3). In 1997 a national programme of surveillance of resistance in nosocomial infections, SIRO (the Finnish hospital infection programme) (www.ktl.fi/siro) was set up. In Sweden, notification of Streptococcus pneumoniae with reduced susceptibility to penicillin has been mandatory notifiable since 1996, and MRSA and vancomycin resistant enterococci (VRE) since 2000. The latter two have been voluntarily notified by the laboratories since 1995 and 1997, respectively. A national sentinel system for a number of specific combinations of microorganisms and antibiotics is under development.

In the Netherlands, in addition to the national surveillance system managed by the Rijksinstituut voor Volksgezondheit en Milieu (RIVM, the national institute for public health and the environment), a large scale national surveillance programme, PREZIES (PREventie van Ziekenhuisinfecties door Surveillance), for the prevention of hospital infections has been launched in 1996.

In France, the surveillance of nosocomial infections, including monitoring of resistance, has been achieved since 1992 at interregional level through five coordinating centres (CCLIN, Centre de Coordination Inter-régionale de la Lutte contre les Infections Nosocomiales). A project is underway for the constitution of a national network (RAISIN, Réseau d’Alerte, d’Investigation et de Surveillance des Infections Nosocomiales) gathering these CCLINs, in cooperation with the InVS (Institut de Veille Sanitaire). In addition, the surveillance of antibiotic resistance is achieved by the CNR (Centres Nationaux de Référence) since the beginning of 1990s, and by a private organisation, ONERBA (Observatoire National de l'Epidémiologie de la Résistance Bactérienne aux Antibiotiques) since 1999. Recently, the system has been consolidated by a partnership between these three organisations and the InVS. It will be reinforced by the definition of needs and priorities at the national level.

In Germany, surveillance of antimicrobial resistance at national level has been conducted since 1975 through regular studies and reports by the Paul Ehrlich Society for Chemotherapy (4). Moreover, a continuous local but nationwide surveillance of (a) defined nosocomial infections and (b) the most prominent antimicrobial resistant bacteria in hospitals has started in January 2001 on the basis of the Communicable Diseases Law Reform Act. A list of the nosocomial infections and bacteria to be documented was published by the Robert Koch-Institute (5). Device associated and postsurgical nosocomial infections have been reported since 1997 by about 200 hospitals, currently on a voluntary basis (KISS, Krankenhaus-Infektions-Surveillance-System). Data are collected and published as reference data in a collaboration between the national reference laboratory for hospital hygiene and the Robert Koch-Institute (http://www.medizin.fu-berlin.de/hygiene/nrz/main.html).

In Belgium, surveillance has been progressively introduced, starting in 1984 with S. pneumoniae, in 1990 for MRSA, by the public health institute (Brussels). Furthermore, a non-profit professional association, the GDEPIH-GOSPIZ (Groupe pour le Dépistage , l’Etude et la Prévention des Infections Hospitalières) is in charge specifically of monitoring resistance in hospitals.

In England and Wales, blood stream isolates have been monitored by the Public Health Laboratory Service (PHLS) since 1989, (6) and many ad hoc surveys supported by public funds or by the pharmaceutical industry are carried out. Furthermore, a surveillance system of nosocomial infection is being developed through a number of regional pilots (although there is a national system that offers modules for participation along the lines of the USA NNIS (National Nosocomial Infection Surveillance) system. In Austria, a national surveillance system was implemented in 1994, which includes surveillance of MRSA. In Portugal, the surveillance of antibiotic resistance is organised by the Antibiotic Resistance Unit, which is part of the National Institute of Health since 1989 and the Laboratory of Microbiology of the University of Lisbon since 1993.

In Greece, surveillance of microorganisms resistant to antibiotics has existed since 1995 in most hospitals coordinated by the Ministry of Health and Athens University. Besides this, Hospital Infection Control Committees are in charge of the surveillance of nosocomial infection, including monitoring of resistance.

Ireland, Italy, and Scotland implemented national surveillance of microorganisms resistant to antibiotics in the past two years. Scotland set up a voluntary surveillance system for 15 microorganisms in 1998, with the Scottish Medical Association (SMA) in cooperation with the Scottish Centre for Infection and Environmental Health (SCIEH) (7). In Italy, while data on antimicrobial resistance on Neisseria meningitidis strains from cases with invasive disease have been available since the early 1990s, a national system through a sentinel network was set up in 1999.

Reporting of specific resistant microorganisms is mandatory in only four countries – Finland, Germany, Norway, and Sweden. This was introduced very recently in Germany where, until the end of 2000, it was mandatory for resistant strains to be reported only in case of outbreaks. Furthermore, in France, mandatory notification of resistant nosocomial infections is in the process of being agreed.

Resistant microorganisms monitored through these surveillance systems vary between countries (table 2). In all countries, they include major resistant bacteria such as multiresistant Mycobacterium tuberculosis and MRSA. In Ireland, M. tuberculosis is specifically monitored through an enhanced surveillance system with public health practitioners. Other microorganisms such as glycopeptide-intermediate S. aureus (GISA) and VRE are reported by more than half of the considered countries. In France, although GISA are not reported, a national survey is currently under way.

Table 2.  Resistant microorganisms monitored in European countries

Austria

MDR M. tuberculosis, MRSA, VRE, resistance in  N. meningitidis, E coli, Salmonella spp, Campylobacter, Shigella, S. pyogenes, others

Belgium

MDR M. tuberculosis, GISA, VRE, MRSA, resistance in  E. aerogenes, S. pneumoniae, N. meningitidis, S. pyogenes

Denmark

MDR M. tuberculosis, GISA, MRSA, resistance in S. pyogenes, S. pneumoniae, E. coli, Salmonella spp, Campylobacter

England and Wales

MDR M. tuberculosis, GISA, VRE, MRSA, resistance in  S. pyogenes (macrolides)

Finland

MDR M. tuberculosis, VRE, MRSA, PRP/PIP and resistance in 15 other clinically most important bacteria (S.pneumoniae, H.influenzae, M.catarrhalis, S.pyogenes, N.gonorrhoeae, S.aureus, E.coli , Salmonella spp., Campylobacter spp., Klebsiella spp., Pseudomonas aeruginosa , Enterococcus faecalis, Enterococcus faecium)

France

MDR M. tuberculosis, MRSA, resistance in S. pneumoniae, Salmonella, Haemophilus influenza, Neisseria meningitidis, Helicobacter pylori, autres

Germany

MDR M. tuberculosis, GISA, VRE, MRSA and resistance in predominant hospital pathogens  (N. meningitidis, S. pyogenes)

Greece

MDR M. tuberculosis, VRE, MRSA (and all organisms detected through routine results from hospitals)

Ireland

MDR M. tuberculosis, GISA, MRSA, invasive S. pneumoniae 

Italy

MDR M. tuberculosis, GISA, MRSA, S. pneumoniae, N. meningitidis (invasive), Salmonella spp, Campylobacter

Luxembourg

MDR M. tuberculosis, GISA, VRE, MRSA, S. pneumoniae, Enterobacter sp, Stenotrophomonas maltophilia, Aspergillus sp, Pseudomonas aeruginosa

Norway

MDR M. tuberculosis, VRE, MRSA, S. pneumoniae

Portugal

MDR M. tuberculosis, GISA, VRE, MRSA, bêta-lactamases producing enterobacteriaceae, S. pneumoniae, H. influenzae, Moraxella catarrhalis, N. meningitidis, multiresistant Acinetobacter spp, multiresistant P. aeruginosa

Scotland

MDR M. tuberculosis, GISA, VRE, MRSA, others

Spain

MDR M. tuberculosis

Sweden

MDR M. tuberculosis, VRE, MRSA, penicillin resistant S. pneumoniae 

The Netherlands

MDR M tuberculosis, VRE, MRSA, macrolide resistant Streptococcus, others

National surveillance of antibiotic consumption in human medicine is performed in all countries (except Ireland and Scotland) and in most (12 out of 15), both the hospital and the community sector are considered (table 3). Spain and the Netherlands monitor consumption of antibiotics only in the community whereas Austria monitors only hospital consumption (but the non-hospital sector should be monitored in the future). In Scotland, although there is no formal national surveillance, data are available on the community sector.

 Table 3. Surveillance of antibiotic consumption in European countries

Country

Level

Institute

Sector (unit)

Austria

National (project in progress – start 2000)

FM for Social Security and Generations

H (C, DDD, P)

Belgium

National (1991)

INAMI/RIZIV ¹

H and NH (C, P, DDD)

Denmark

National (1970)

Danish Medicines Agency

H and NH (C, DD, P, DDD)

England and Wales

National

IMS-Health Prescription Pricing Authority

H and NH (AWPV)

Finland

National (1978)

National Agency for Medicines - National Insurance Institution - MIKSTRA ²

H and NH (C, DDD, P)

France

National (1989)

ONCP ³

H and NH (C, selling units)

Germany

National

pharmaceutical industry - Robert Koch-Institute (local studies)

H and HN (C, DD, packing units)

Greece

National (1987)

EOF ⁴

H and NH (C, DD, DDD, packing units)

Ireland

No

Italy

National (2000)

MoH (National Observatory for Drugs)

H and  NH (mean DD per  1000 local population)

Luxembourg

National (2000)

GNGPIN ⁵

H and NH (DD)

Norway

National (1974)

Nork Medisinaldepot

H and NH (C, DDD)

Portugal

National (1995)

INFARMED ⁶

H and NH (W,C,DDD)

Scotland

No

Spain

National (1985)

Ministry of Public Health

NH (W, DD, P)

Sweden

National (1980)

Swedish Corporation of Pharmacies

H and NH (C, DDD, P)

Netherlands

National (1990)

GIP and SFK ⁷

NH (C, DDD, P)

H: Hospital 
NH: community 
W : weight
C : cost 
DD : daily dose  
DDD: defined DD  
P : prescription
AWPV : age weighted prescription unit. 

The four Nordic countries have set up national consumption surveillance systems since 1980. Moreover in Finland, besides the medical statistics published annually since 1978 by the National Agency for Medicines and the National Insurance Institution, prescription based data in community settings have been produced by the Programme for Antimicrobial Treatment Statregies (MIKSTRA) since 1998.

In the 11 other countries, national consumption monitoring systems were introduced between 1980 and 1999, and even more recently (in 2000 and 2001) in Austria, Italy, and Luxembourg.

The organisation in charge of this monitoring varies from one country to another: health institute, insurance organisation, the pharmaceutical industry, national physicians’ organisations, health ministries and specific government committees such as the newly created national observatory for drug consumption in Italy, which depends on the Ministry of Health may be the responsible bodies. This observatory collects data on antibiotics sold from pharmacies and provided within hospitals. 

In some countries, such as Germany, there are various systems for collecting data involving both central institutes and producers. In France, this surveillance is the role of the ONPCM (Observatoire National des Prescriptions et des Consommations des Médicaments) for the public agency AFSSAPS (Agence Française de Sécurité Sanitaire des Produits de Santé). A board table of the consumption of different antimicrobial agents is published every 10 years. Data can be also provided by a nationwide 10 yearly surveys conducted by the Institut National des Statistiques et des Etudes Economiques (INSEE) on health and medical care. Moreover, a survey was launched in November 1999 in all French hospitals to have an overview of the modes of antimicrobial delivery.

The units used for the collected data vary widely between countries (table 3). There is generally no national evaluation of the data. In France, analysis tools are under development to assess, the number of treatment days and patients treated on the basis of data from antimicrobial drugs sales. In Portugal hospital data cover about 90% of public hospitals, and community data cover all the antimicrobials dispensed under the national health service, which is currently about 65% of the consumption

Except Luxembourg and Portugal, all other European countries that participated have national guidelines or recommendations for good practice in prescribing antimicrobial agents. These recommendations apply to both the hospital and the non-hospital sectors in Belgium, Denmark, France, Germany, Greece, Netherlands, Scotland, Spain, and Sweden. In Finland, England and Wales, and Norway only the non-hospital sector is included, whereas only hospitals are included in Austria. For example, in Finland, evidence based current care treatment guidelines for six most common outpatient infections (otitis media, sinusitis, acute bronchitis, pharyngitis, skin infections, and urinary tract infections) were published in 1999-2000. Each hospital is responsible for its own antibiotic policy.

These recommendations are generally issued by governmental and/or private organisations. In Belgium, several groups (independent non-profit professional associations as well as the High Council for Health of the Ministry of Social Affairs, Public Health and Environment) have issued recommendations, the health ministry in Spain (8,9), the Paul Ehrlich Society for Chemotherapy in Germany (10,11), the Dutch College of General Practitioners and two working groups (WIP, Working Group on Infection Prevention, and SWAB, Working Group on Antibiotic Policy) in the Netherlands, the Danish Medical Association in Denmark, the PHLS in England and Wales, and the National Board of Health in Norway. In France, several organisations have issued recommendations including the national health insurance organisation (CNAM, Caisse Nationale d’Assurance Maladie), the Agence Nationale pour le Développement de l’Evaluation Médicale (ANDEM). Furthermore the AFSSAPS (Agence Française de Sécurité Sanitaire des Produits de Santé) is currently undertaking actions meant for prescriptors (thematic recommendations, medico-economical help forms for prescription) (12).

In Sweden, there is a programme for the early detection and prevention of dissemination of multiresistant bacteria in Swedish healthcare institutions. Ireland has specific recommendations concerning MRSA and multiresistant M. tuberculosis (13,14), and others are being developed (15).

In Italy, guidelines are in progress in the context of the National Health Plan 1998-2000. They include the careful use of antibiotics, particularly for surgical prophylaxis. In Austria, guidelines have been formulated in the ABS (Antibiotic Strategy Project) (16), launched in 1998 by the health ministry and performed by the Federal Ministry for Social Security and Generations

National guidelines specifically devoted to prevention of nosocomial infections have been issued in Finland (for MRSA and VRE), Germany (5, 17), Italy, Scotland, Sweden (National Board of Health and Welfare), Denmark (National Centre for Hospital Hygiene, Statens Serum Institut), England and Wales (Standards and Performance indicators, DOH/PHLS guidelines), the Netherlands (WIP, Working Group on Infection Prevention), Greece, Portugal (Hospital Infection Control Commission), Austria, Belgium (GDIPEH-GOSPIZ, Groupe de Dépistage d’Etude et de Prévention des Infections Hospitalières, a non-profit independent professional association), and Ireland.

For example, national guidance for the prevention and control of MRSA in both hospital and community settings are available in Ireland. Austria’s ABS project includes guidelines for the development of an ‘antibiotic culture’ (including a more rationed use of antibiotics) in hospitals; and Belgium’s recommendations include antibiotic prophylaxis in surgery and acute sore throat in both hospital and non-hospital settings (other guidelines are currently at a development stage).

In France, a committee in charge of technical issues related to nosocomial infections, the CTIN (Comité Technique des Infections Nosocomiales) has published several recommendations for the prevention of hospital acquired infections since 1992 (18).

In Greece, hospital committees for the prevention, surveillance, and control of hospital infection and for the control of antimicrobial resistance were set up in 1986 in the context of the National Greek Nosocomial Infection Control Committee established within the health ministry. In this context, recommendations concerning hospital staff working in laboratories, operating theatres, etc, have been issued. The situation is similar in Luxembourg, where a national group in charge of the prevention of nosocomial infections (GNPIN, Groupe National de Guidance: Prévention des infections nosocomiales), under the auspices of the DGS (Directeur Général de la Santé), was created in 1997. Since 1998, each hospital must have its CLIN (Comité de Prévention de l’Infection nosocomiale) and a UPI (unité de prévention des infections).

Spain does not have real national guidelines, but each hospital has its own specific guidelines.

As part of the recommendations on good prescribing practice, issued after the Copenhagen conference, appeared education and training of health professionals, development of diagnostic tests, and prescription and advertising of antibiotics.

Only Italy and Spain have not taken any initiatives in the fields of education and professional training. Three countries (Belgium, Luxembourg, and Portugal) started to implement education and training for health professionals after the Copenhagen conference. The 12 remaining countries implemented education programmes and training for health professionals before the conference, and most of them (Denmark, England and Wales, Finland, France, Ireland, Netherlands, and Scotland) continued after. For example, England and Wales ran a public advertising and promotion campaign in 1999, and France and Ireland launched a national educational campaign. Since 1997, the National Institute of Public Health in Norway has published a monthly newsletter for health professionals, which focuses on antibiotic resistance (www.folkehelsa.no/nyhetsbrev/resistens).

Regulatory measures concerning marketing, prescription, or reimbursement of antibiotics were adopted by a few countries in the past five years. In Greece, a restrictive reimbursement antibiotic policy has been implemented in the community in 1996, and restrictions for the prescription of newer antibiotics have been adopted. France has adopted measures concerning advertising and promoting (including the insertion of an information notice in all antimicrobial packages from 2000). Moreover, generic drugs have been promoted since 1996. In Belgium, for example, the royal decree concerning the reimbursement of antibiotic prophylaxis in hospital has been revised in 1998 (19).

Five countries (Denmark, France, Germany, Scotland, and Sweden) have initiatives related to the development of new diagnostic tests. In France, an experiment is under way for using a rapid diagnosis test for group A streptococci in acute pharyngotonsillitis, with the aim to reduce the abuse of prescribed antimicrobials in these specific infections.

Three countries (Denmark, Finland and Sweden) implemented programmes specifically in charge of the antimicrobial issue before the Copenhagen conference. In Denmark, an official action plan, DANMAP (Danish Integrated Antimicrobial Resistance Monitoring and Research Programme) was implemented in 1995 (20, 21). In Finland, this issue was first raised in 1987, with the launch of a special programme against bacterial resistance in the ‘Health for All Year 2000.’ This led to the creation of the Antimicrobial Research Laboratory in the National Public Health Institute in 1990. The principles to fight against bacterial resistance were stated during a consensus meeting entitled ‘Antibiotic resistance: can we maintain the power of antibiotics?,’ held in November 1997. In 1999 a working group for antibiotic resistance control and development of antibiotic policy was created, the official working group for the Ministry of Social Affairs and Health. In Sweden, a first organisational change occurred in 1994 with the implementation of the Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance Resistance (STRAMA).

In several countries, organisational changes occurred in the late 1990s. In Belgium the Commission for the Coordination of the Antibiotic Policy located at the Ministry of Public Health has been operational since October 1998 (although its official creation was in 1999 (22)). In Finland, a national committee involving both the Ministry of Health and the Ministry of Agriculture was nominated in March 1999 to enhance development of a national policy. In France, important organisational changes during the 1990s included the creation of national agencies partly dealing with the antibiotic resistance issues (12). A decree is currently in preparation for the notification of hospital acquired infections; Ireland has set up in 1999 a subcommittee of the Scientific Advisory Committee of the National Disease Surveillance Centre to devise strategy on prevention of antimicrobial resistance. In the same year, Portugal has set up a multidisciplinary working group to deal with all aspects of antimicrobial resistance.

Six countries (Belgium, Denmark, England and Wales, Finland, Greece, and Norway) have an official action plan for the prevention of antibiotic resistance concerning both hospitals and the community, introduced in 1999, 1995, 1998 (23), 1999, 1993, and 2000, respectively (24).

Four countries (France, Ireland, the Netherlands, and Sweden) have taken a first step towards a national policy. In France, a proposal for a national action plan to control antimicrobial resistance has been presented to the French health ministry in January 1999 by working groups coordinated by the InVS (12). One of the recommendations issued in this proposal, the organisation of the prevention of nosocomial infections, is currently being implemented, as mentioned above. In Sweden, a proposal has been issued for a national action plan on antibiotic resistance in May 2000 (25). In Ireland, a similar proposal, Antimicrobial Resistance in Ireland – a strategy for prevention, was published in April 2000 (15). In the Netherlands, after a meeting by the Ministry of Health , Welfare, and Sports in April 2000, it has been decided that the SWAB, together with RIVM and the National Veterinary Institute, is going to work out an integrated plan on how to monitor antimicrobial resistance and use in the different sectors. This plan is expected in the beginning of 2001.

The results show that the 17 European countries included in our study are progressively taking initiatives to prevent antimicrobial resistance, by, for example, training health professionals, providing information to the population, implementating national surveillance systems for resistant microorganisms and antibiotic consumption, creating new agencies, groups, or committees, issuing national recommendations, etc.

Monitoring of resistant microorganisms and collection of data on the consumption of antibiotics are now widely implemented. Only two countries (Luxembourg and Spain) do not have a system to monitor resistant organisms at the national level. Among the 15 other countries included in our study – except for the Nordic countries, where such surveillance systems have been set up since the early 1980s – this surveillance has been implemented after the mid 1990s. In the specific field of nosocomial infections, several countries have specific committees in charge of this surveillance, some of them since 1998, whereas other countries have issued national recommendations for their prevention. In comparison with the data from the European project HELICS (Hospital in Europe Link for Infection Control through Surveillance) (26), a growing number of countries monitor or collect data on resistant microorganisms from nosocomial infection.

Although the notification of strains resistant to antibiotics was mandatory in only two countries before 1998, two one additional countries (Germany and Sweden) has adopted mandatory notification since then, and France is in the process of doing so for nosocomial infections.

Important variations are observed between countries with respect to resistant strains subject to surveillance, but these data should be interpreted very carefully. The fact that a given strain is ‘under surveillance’ is not related to the fact that resistance has been identified in a corresponding strain. Some countries, such as England and Wales or Portugal, monitor GISA, although up to now none has been detected in either country.

Among the 15 countries who monitor the consumption of antibiotics, generally in communities and hospitals, three have set up such a system after 1998. Most countries reported several measurement units for antibiotic consumption such as cost, defined daily dose (DDD), weight, etc, but one unit of the DDD is shared by most of them. This unit has been recommended by the World Health Organization (27), which means that it could become the proper unit used for international comparison.

The growing number of countries where national plans for preventing antimicrobial resistance have been adopted or are currently proposed, the numerous national organisational changes in the past years and the multiple recommendations on good practice on the use of antimicrobial agents recently issued show how the situation has evolved since the Copenhagen recommendations were issued.

Apart from these national changes or initiatives, the participation in European networks or projects dealing with antimicrobial resistance is important. The participation of EU countries in European projects such as the European Antimicrobial Resistance Surveillance Scheme (EARSS) (28), Enter-net (29), or EuroTB (30) dealing with surveillance of antibiotic resistance among specific pathogens, or in projects such as HELICS (26) provides guidelines for collecting comparable data. Moreover, many other European collaborations (31) are sources of data on antimicrobial resistance in Europe or pharmaceutical cosponsored surveys such as SENTRY antimicrobial surveillance programme (32) or the Alexander project (33).

In the past decade, policies concerning antimicrobial resistance have hardly changed, and in some European countries major changes occurred since 1998, the year in which the Copenhagen recommendations were published.

I wish to thank Hélène Aubry-Damon from the InVS and Dominique Monnet from the SSI for their valuable help in writing this article.

* Based on data provided by:

Drs Maria Woschitz-Merkac and Reinhild Strauss, Federal Ministry for Social Security and Generations, Austria
Dr Koen de Schrijver, Ministerie van de Vlaamse Gemeenschap, Belgium
Prof H Goossens, Drs H Imberechts, L Laurier, and I Bauraind, Ministry of Social Affairs, Public Health and Environment, and Dr O Ronveaux, Institute of Public Health, Belgium
Dr Niels Frimodt-Møller, Statens Serum Institut, Denmark
Dr Tove Rønne, Statens Serum Institut, Denmark
Drs D Livermore and B Cookson, Public Health Laboratory Service, England and Wales 
Drs Pentti Huovinen and Outi Lyytikäinen, National Public Health Institute, Finland
Dr Hélène Aubry-Damon, Institut de Veille Sanitaire, France
Béatrice Tran, Direction Générale de la Santé (DGS), France
Prs M Mielke and W Witte, Dr Kiehl, Dr. G. Krause (Robert Koch Institut), H Lode (Paul-Ehrlich Society), Pr A Rodloff (Universität Leipzig), Germany
Dr A Karaitianou-Velonaki, Ministry of Health, Greece
Dr Darina O’Flanagan, National Disease Surveillance Centre, Ireland
Dr M L Moro, Istituto Superiore di Sanità, and Dr A Caprioli, Veterinary Laboratory, Istituto Superiore di Sanità, Italy
Dr Stefania Salmaso, Istituto Superiore di Sanità, Italy
Dr Robert Hemmer, Centre hospitalier de Luxembourg, Luxembourg
Dr Wim Goettsch, Rijksinstituut voor de Volksgezondheit en Milieu, the Netherlands
Dr Preben Aavitsland, Statens Institutt for Folkehelsea, Norway
Dr José Melo-Cristino, University of Lisbon, Portugal
Dr Manuela Caniça, National Institute of Health Dr Ricardo Jorge, Portugal.
Dr Graça Lima, Direcção Geral da Saúde, Portugal
Dr Luis Caldeira, Observatório do Medicamento, INFARMED, Lisbon, Portugal
Dr Ahilya Noone, Scottish Centre for Infection and Environmental Health, Scotland
Dr Salvador de Mateo, Instituto de Salud Carlos III, Spain
Dr Karl Ekdahl, Swedish Institute for Infectious Disease, Sweden
Prof Julius Weinberg, City University, London, United Kingdom

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