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Antimicrobial resistance in Romania--current status and risk reduction interventions.

Antimicrobial resistance (AMR) represents a major threat to health and to healthcare. With worrisome rates of AMR, the World Health Organization has warned about the threat of returning to the pre-antibiotic era unless risk reduction interventions are taken urgently. (1)

While the epidemiology of multidrug-resistant (MDR) germs is different in different parts of the world, each country, each region and each hospital need a good understanding of their own resistance rates to the most commonly used antimicrobials for the pathogens that are most often involved in clinically-significant infections.

Surveillance of AMR uses multiple different techniques and multiple data collection sources, which at times might lead to heterogenous results and non-comparable patient populations, making it hard to generalize the data for a specific region or for a specific pathogen.

Much effort is being put nowadays into the standardization of data collection for AMR assessment, in order to better align data coming from different countries and also from different settings in the same country.

In Romania, AMR needs to be approached from the perspective of two major classes of pathogens, i.e., Gram-positive cocci and Gram-negative bacilli. For example, methicillin-resistant Staphylococcus aureus (MRSA) has been reported to be the causative agent of many clinical infections, from limited skin and soft tissue infections, to more invasive, deep-seated infections, to life-threatening bloodstream infections or chronic biofilm-driven infections (2) such as osteomyelitis or osteodiscitis.

In the Transylvania region of Romania, 26.8% of S. aureus strains have been reported as MRSA, (3) while rates of resistance to methicillin as high as 58.12% were reported for S. aureus from 2010 to 2015 in samples obtained from a tertiary care pulmonology hospital in Bucharest, (4) and 53.53% in samples collected from 2012 to 2013 in an intensive care unit from Timi'oara. (5) Furthermore, an analysis of clinical isolates from an infectious disease and dermatovenerology hospital from South-Eastern Romania reported that from 2016 to 2020 the rate of MRSA among all S. aureus isolates varied from 30.9% to as high as 46.2%, with an upward trend during the last three years of the study. (6) What is even more worrisome is that MRSA was detected as nasal or pharyngeal colonizer in 18.46% of patients routinely screened while attending a clinical emergency hospital in Craiova in 2016. (7) Under normal circumstances, nasopharyngeal colonization with S. aureus should pose no concern at all in otherwise healthy patients, even when talking about MRSA. However, if the patients have particular risk factors for developing infections, it is quite likely that the infection they will go on to develop will be generated by germs that were initially only present as bystander colonizers, but which revert to virulence in the presence of particular host conditions such as immune suppression, foreign body placement, including through orthopedic surgery, or other specific risk factors.

If S. aureus was the most frequently encountered Gram-positive coccus, other pathogens such as Streptococcus pneumoniae or Enterococcus spp. should not be neglected either, since they can also generate clinically-relevant infections and they can display, under certain circumstances, particular resistance profiles.

For Gram-negative bacilli, ESKAPE pathogens such as resistant Klebsiella pneumoniae, Acinetobacter baumannii, or Pseudomonas aeruginosa pose a major burden on healthcare. In South-Eastern Romania from 2016 to 2020, MDR was reported in 36.8% of Acinetobacter baumannii strains, 29.1% of P. aeruginosa strains and 24.4% of K. pneumoniae strains. (6) Furthermore, in intensive care in Timi'oara the following even higher resistance rates were reported in isolates dating back to 2012-2013: 55.91% extended spectrum beta-lactamase (ESBL) Klebsiella pneumoniae, 54.47% MDR Acinetobacter baumannii, 37.96% MDR Pseudomonas aeruginosa, and worrisome rates of resistance were also reported for other Gramnegative pathogens such as 47.79% ESBL Proteus mirabilis and 16.67% ESBL Escherichia coli. (5)

In the context of these important resistance rates reported from Romania, which are somewhat aligned with rates from comparable countries with a similar epidemiological profile, it becomes apparent that it is extremely important to develop on the one hand targeted interventions for high-prevalence AMR settings such as intensive care for example, and on the other hand wider action plans that can be applied nationwide, to provide accurate and comparable estimates of AMR from different settings and to design risk reduction interventions.

Important steps have already been taken, such as the development of antimicrobial stewardship programs and the designation of one infectious disease or microbiology specialist responsible for rational antimicrobial use practices in each hospital, and improvements have been seen to a certain extent. However, much work still remains to be done, not only in Romania but globally, for fighting AMR.

Funding: SEE 2014/2021, Norway grants. Project PDP-8.


(1.) World Health Organization. 2015. Urgent action needed to prevent a return to pre-antibiotic era: WHO. Accessed on: 14 April 2021. Available at:

(2.) Sandulescu O, Bleotu C, Matei L, et al. Comparative evaluation of aggressiveness traits in staphylococcal strains from severe infections versus nasopharyngeal carriage. Microb Pathog. 2017;102:45-53.

(3.) Jakab E, Colcieru M, Jakab RI, et al. Screening of mecI gene in Staphylococcus strains isolated in Transylvania region of Romania. Microb Drug Resist. 2019;25:639-43.

(4.) Penes NO, Muntean AA, Moisoiu A, et al. An overview of resistance profiles ESKAPE pathogens from 2010-2015 in a tertiary respiratory center in Romania. Rom J Morphol Embryol. 2017;58:909-22.

(5.) Axente C, Licker M, Moldovan R, et al. Antimicrobial consumption, costs and resistance patterns: a two year prospective study in a Romanian intensive care unit. BMC Infect Dis. 2017;17:358.

(6.) Arbune M, Gurau G, Niculet E, et al. Prevalence of antibiotic resistance of ESKAPE pathogens over five years in an infectious diseases hospital from South-East of Romania. Infect Drug Resist. 2021;in press.

(7.) Ungureanu A, Zlatian O, Mitroi G, et al. Staphylococcus aureus colonisation in patients from a primary regional hospital. Mol Med Rep. 2017;16:8771-80.

doi: 10.18683/jccp.2021.1065.

Adrian Streinu-Cercel (*)

(*) MD, PhD, Carol Davila University of Medicine and Pharmacy, National Institute for Infectious Diseases "Prof. Dr. Matei Bal'", No. 1 Dr. Calistrat Grozovici street, Bucharest 021105, Romania.

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Published May 2021

ISSN 2457 - 7200

ISSN - L = 2457 - 7200
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Title Annotation:Editorial
Author:Streinu-Cercel, Adrian
Publication:Journal of Contemporary Clinical Practice
Geographic Code:4EXRO
Date:May 1, 2021
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