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Staphylococcus aureus bacteremia, Europe.

To the Editor: In their article, Collignon et al. (1) present a table comparing absolute numbers and incidence rates of Staphylococcus aureus bacteremia (SAB) in Australia to those of 5 other countries, and state that "some data are available from other countries for comparison" and "only 2 countries, Denmark and England, appeared to have comprehensive collection systems."

We would like to add data from the European Antimicrobial Resistance Surveillance System (EARSS) to their table. EARSS is a multinational surveillance system that links national networks by collecting comparable and validated data on the prevalence of antimicrobial resistance of 5 microorganisms, including S. aureus (2). A total of 30 countries participate in EARSS. To ensure representativeness of the data it publishes, EARSS has set criteria, which can be found elsewhere (3).

In 2003, through a questionnaire, we collected background information on all hospitals served by laboratories participating in EARSS, including the estimated hospitals' catchment populations. Proportion of the country population covered by EARSS was then calculated by dividing the sum of catchment populations by the total population of the country (4). Catchment populations of hospitals providing single specialty or supraregional type of care were not counted to avoid overlap with other hospitals within the same country. Only the countries that provided denominator data for at least 60% of the isolates were included to ensure that the sample of hospitals was still representative of the country as a whole.

The number of SAB and the incidence of SAB per 100,000 inhabitants in 2003 were calculated from EARSS data, adjusted for population coverage, and are presented in the Table. These are crude estimates of the true number of SAB and should, thus, be interpreted with caution. For example, we assumed that the isolates for which hospital background information was not available did not differ from isolates for which we had this information, and that hospitals that participated in EARSS in 2003 were a representative sample of the countries' hospitals. Additionally, the incidence of SAB was positively correlated with the blood culturing rate (Spearman r = 0.74, p = 0.002), which means that the incidence of SAB is likely to have been underestimated in countries that reported few blood cultures. Although some countries did not report their blood culturing rate, the incidences of SAB in these countries were among the highest and are unlikely to be underestimated. For example, the EARSS data for Denmark and Ireland nicely fitted those presented in Table 4 of the article by Collignon et al. (1). Finally, reporting to the EARSS system greatly improved over the years, which is why this study was performed on the last available year, 2003. Nevertheless, one cannot exclude underreporting of SAB by EARSS participating hospitals since EARSS is a voluntary reporting system. For example, England reported 18,403 SAB cases or an incidence of 37 SAB per 100,000 inhabitants from April 2002 to March 2003 through its mandatory surveillance scheme (5), whereas an estimate for the United Kingdom from the EARSS database would only give 7,800 SAB cases for 2003. However, it is impossible to determine whether this discrepancy was due to poor voluntary reporting of SAB cases, a lower blood culturing rate in EARSS participating hospitals, or a poorly representative sample of the country's hospitals. Data from the United Kingdom were excluded from the present study on the basis of the latter possibility; denominator information for <60% of the isolates was available.

In conclusion, EARSS is the first comprehensive surveillance system on antimicrobial resistance in Europe. Within certain limitations, EARSS can also provide valuable information on blood-culturing practices and the incidence of SAB in Europe. The system is continuously being improved, and additional information on the representativeness of EARSS data is being collected. This will allow us to improve the quality and accuracy of the reported incidence rates. In the future, the system should allow reporting of similar data for an even larger number of European countries and for additional microorganisms, such as Escherichia coli.

Edine W. Tiemersma, * Dominique L. Monnet, ([dagger]) Nienke Bruinsma, * Robert Skov, ([dagger]) Jos C.M. Monen, * Hajo Grundmann, * and European Antimicrobial Resistance Surveillance System Participants

* National Institute for Public Health and the Environment, Bilthoven, the Netherlands; and ([dagger]) Statens Serum Institut, Copenhagen, Denmark


(1.) Collignon P, Nimmo GR, Gottlieb T, Gosbell IB, Australian Group on Antimicrobial Resistance. Staphylococcus aureus bacteremia, Australia. Emerg Infect Dis. 2005;11:554-61.

(2.) Tiemersma EW, Bronzwaer SL, Lyytikainen O, Degener JE, Schrijnemakers P, Bruinsma N, et al. Methicillin-resistant Staphylococcus aureus in Europe, 1999-2002. Emerg Infect Dis. 2004;10: 1627-34.

(3.) European Antimicrobial Resistance Surveillance System. EARSS manual 2004 [cited 2005 July 25]. Available from

(4.) Central Intelligence Agency. The world fact book 2003 [cited 2005 July 26]. Available from 2003.htm

(5.) Health Protection Agency. The second year of the Department of Health's mandatory MRSA bacteraemia surveillance scheme in acute trusts in England: April 2002-March 2003. CDR Weekly. 2003;13:1-9. [cited 2005 July 26]. Available from http://www.h

Address for correspondence: Edine W. Tiemersma, National Institute for Public Health and the Environment, Center for Infectious Diseases Epidemiology, PO Box 1, 3720 BA Bilthoven, the Netherlands; fax: 31-30-274-4409; email:
Table. Absolute numbers, rates of Staphylococcus aureus bacteremia
(SAB), and percentage of methicillin-resistant Staphylococcus aureus
(MRSA), European Antimicrobial Resistance Surveillance System (EARSS),
2003 *

 % population blood culture
 Population covered by sets/1,000
Country ([dagger]) (4) EARSS ([dagger]) inhabitants

Austria 8,188,207 42.7 NA
Bulgaria 7,537,929 100 2
Croatia 4,422,248 81.3 7
Czech Republic 10,249,216 92.3 11
Denmark 5,384,384 46.2 NA
Estonia 1,408,556 100 <1
Finland 5,190,785 94.3 27
Hungary 10,045,407 100 1
Iceland 280,798 100 28
Ireland 3,924,140 89.2 NA
Israel 6,116,533 39.7 42
Malta 400,420 100 4
Poland 38,622,660 24.3 3
Romania 22,271,839 59 <1
Slovenia 1,935,677 100 17
Spain 40,217,413 24.3 21
Sweden 8,878,085 100 28

 No. SAB No. SAB for SAB/100,000
 reported to country inhabitants
Country EARSS ([section]) ([section])

Austria 871 2,038 25
Bulgaria 157 149 2 ([paragraph])
Croatia 360 443 10
Czech Republic 1,387 1,503 15
Denmark 671 1,451 27
Estonia 98 98 7 ([paragraph])
Finland 727 771 15
Hungary 859 859 9 ([paragraph])
Iceland 64 64 23
Ireland 1,108 1,243 32
Israel 368 926 15
Malta 122 122 31
Poland 166 684 2 ([paragraph])
Romania 85 144 <1 ([paragraph])
Slovenia 299 296 15
Spain 1,391 5,731 14
Sweden 1,855 1,760 20

Country % MRSA

Austria 15
Bulgaria 31
Croatia 37
Czech Republic 7
Denmark <1
Estonia 5
Finland <1
Hungary 14
Iceland 0
Ireland 42
Israel 43
Malta 43
Poland 19
Romania 46
Slovenia 13
Spain 25
Sweden <1

* Only countries that provided hospital background information for at
least 60% of the isolates were included; NA, not available.

([dagger]) Source: (4).

([double dagger]) Population coverage rate as calculated from EARSS
hospitals that provided background information was adjusted for
nonresponding hospitals as follows: population coverage as calculated
divided by proportion of isolates with hospital background information.

([section]) The total number of SAB per country was calculated as
follows: number of S. aureus isolates in EARSS divided by adjusted
proportion of population covered.

([paragraph]) These rates are grossly underestimated because of the
very low blood culturing rate.
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Title Annotation:LETTERS
Author:Grundmann, Hajo
Publication:Emerging Infectious Diseases
Geographic Code:4E
Date:Nov 1, 2005
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