Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis

Abstract

Background: Infections due to antibiotic-resistant bacteria are threatening modern health care. However, estimating their incidence, complications, and attributable mortality is challenging. We aimed to estimate the burden of infections caused by antibiotic-resistant bacteria of public health concern in countries of the EU and European Economic Area (EEA) in 2015, measured in number of cases, attributable deaths, and disability-adjusted life-years (DALYs).

Methods: We estimated the incidence of infections with 16 antibiotic resistance-bacterium combinations from European Antimicrobial Resistance Surveillance Network (EARS-Net) 2015 data that was country-corrected for population coverage. We multiplied the number of bloodstream infections (BSIs) by a conversion factor derived from the European Centre for Disease Prevention and Control point prevalence survey of health-care-associated infections in European acute care hospitals in 2011-12 to estimate the number of non-BSIs. We developed disease outcome models for five types of infection on the basis of systematic reviews of the literature.

Findings: From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 (95% uncertainty interval [UI] 583 148-763 966) infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. These infections accounted for an estimated 33 110 (28 480-38 430) attributable deaths and 874 541 (768 837-989 068) DALYs. The burden for the EU and EEA was highest in infants (aged <1 year) and people aged 65 years or older, had increased since 2007, and was highest in Italy and Greece.

Interpretation: Our results present the health burden of five types of infection with antibiotic-resistant bacteria expressed, for the first time, in DALYs. The estimated burden of infections with antibiotic-resistant bacteria in the EU and EEA is substantial compared with that of other infectious diseases, and has increased since 2007. Our burden estimates provide useful information for public health decision-makers prioritising interventions for infectious diseases.

Funding: European Centre for Disease Prevention and Control.

Figure 1

Infections with antibiotic-resistant bacteria, EU and European Economic Area, 2015 Diameter of bubbles represents the number of disability-adjusted life-years. ColRACI=colistin-resistant Acinetobacter spp. CRACI=carbapenem-resistant Acinetobacter spp. MDRACI=multidrug-resistant Acinetobacter spp. VRE=vancomycin-resistant Enterococcus faecalis and Enterococcus faecium. ColREC=colistin-resistant Escherichia coli. CREC=carbapenem-resistant E coli. 3GCREC=third-generation cephalosporin-resistant E coli. ColRKP=colistin-resistant Klebsiella pneumoniae. CRKP=carbapenem-resistant K pneumoniae. 3GCRKP=third-generation cephalosporin-resistant K pneumoniae. ColRPA=colistin-resistant Pseudomonas aeruginosa. CRPA=carbapenem-resistant P aeruginosa. MDRPA=multidrug-resistant P aeruginosa. MRSA=meticillin-resistant Staphylococcus aureus. PRSP=penicillin-resistant Streptococcus pneumoniae. PMRSP=penicillin-resistant and macrolide-resistant S pneumoniae.

Figure 2

Model estimates of the burden of infections with antibiotic-resistant bacteria of public health importance in DALYs, by age group, EU and European Economic Area, 2015 Error bars are 95% uncertainty intervals. DALYs=disability-adjusted life-years. *Excludes those resistant to carbapenem or colistin. †In 2015, most of the third-generation cephalosporin-resistant E coli (88·6%) and K pneumoniae (85·3%) isolates reported to the European Antimicrobial Resistance Surveillance Network produced an extended-spectrum β-lactamase.

Figure 3

Burden of infections with antibiotic-resistant bacteria in DALYs, EU and European Economic Area, 2015 Error bars are 95% uncertainty intervals. Greece did not report data on S pneumoniae isolates to the European Antimicrobial Resistance Surveillance Network in 2015. DALY rates are age-standardised to limit the effect of demographic differences across countries; numbers of cases and deaths are not age-standardised. DALYs=disability-adjusted life-years. *Excludes those resistant to carbapenem or colistin. †In 2015, most of the third-generation cephalosporin-resistant E coli (88·6%) and K pneumoniae (85·3%) isolates reported to the European Antimicrobial Resistance Surveillance Network produced an extended-spectrum β-lactamase.

Figure 4

Model estimates of the burden of infections with selected antibiotic-resistant bacteria of public health importance in DALYs per 100 000 population, EU and European Economic Area, 2015 Greece did not report data on S pneumoniae isolates to the European Antimicrobial Resistance Surveillance Network in 2015. DALYs=disability-adjusted life-years.