Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Aug 31;64(4):272-283.
doi: 10.3325/cmj.2023.64.272.

The burden of bacterial antimicrobial resistance in Croatia in 2019: a country-level systematic analysis

Tomislav Meštrović  1 , Kevin Shunji Ikuta, Lucien Swetschinski, Authia Gray, Gisela Robles Aguilar, Chieh Han, Eve Wool, Anna Gershberg Hayoon, Christopher Jl Murray, Mohsen Naghavi
Affiliations

The burden of bacterial antimicrobial resistance in Croatia in 2019: a country-level systematic analysis

Tomislav Meštrović et al. Croat Med J. .

Abstract

Aim: To deliver the most wide-ranging set of antimicrobial resistance (AMR) burden estimates for Croatia to date.

Methods: A complex modeling approach with five broad modeling components was used to estimate the disease burden for 12 main infectious syndromes and one residual group, 23 pathogenic bacteria, and 88 bug-drug combinations. This was represented by two relevant counterfactual scenarios: deaths/disability-adjusted life years (DALYs) that are attributable to AMR considering a situation where drug-resistant infections are substituted with sensitive ones, and deaths/DALYs associated with AMR considering a scenario where people with drug-resistant infections would instead present without any infection. The 95% uncertainty intervals (UI) were based on 1000 posterior draws in each modeling step, reported at the 2.5% and 97.5% of the draws' distribution, while out-of-sample predictive validation was pursued for all the models.

Results: The total burden associated with AMR in Croatia was 2546 (95% UI 1558-3803) deaths and 46958 (28,033-71,628) DALYs, while the attributable burden was 614 (365-943) deaths and 11321 (6,544-17,809) DALYs. The highest number of deaths was established for bloodstream infections, followed by peritoneal and intra-abdominal infections and infections of the urinary tract. Five leading pathogenic bacterial agents were responsible for 1808 deaths associated with resistance: Escherichia coli, Staphylococcus aureus, Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa (ordered by the number of deaths). Trimethoprim/sulfamethoxazole-resistant E coli and methicillin-resistant S. aureus were dominant pathogen-drug combinations in regard to mortality associated with and attributable to AMR, respectively.

Conclusion: We showed that AMR represented a substantial public health concern in Croatia, which reflects global trends; hence, our detailed country-level findings may fast-track the implementation of multipronged strategies tailored in accordance with leading pathogens and pathogen-drug combinations.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Death counts attributable to antimicrobial resistance (AMR) by pathogen-drug combination in Croatia in 2019. Abbreviations: 3GC - third-generation cephalosporins. 4GC - fourth-generation cephalosporins. Anti-pseudomonal - anti-pseudomonal penicillin or beta-lactamase inhibitors. BL-BLI - beta-lactam or beta-lactamase inhibitors. MDR - multidrug resistance. mono INH - isoniazid mono-resistance. mono RIF - rifampicin mono-resistance. NA - not applicable. Resistance to 1+ - resistance to one or more drug. TMP-SMX - trimethoprim-sulfamethoxazole. XDR - extensive drug resistance; AG - aminoglycosides; CP – carbapenems; FQ – fluoroquinolones; PCN – penicillin; TB – tuberculosis.
Figure 2
Figure 2
Death counts associated with antimicrobial resistance (AMR) by pathogen–drug combination in Croatia in 2019. Abbreviations: 3GC - third-generation cephalosporins. 4GC - fourth-generation cephalosporins. Anti-pseudomonal - anti-pseudomonal penicillin or beta-lactamase inhibitors. BL-BLI - beta-lactam or beta-lactamase inhibitors. MDR - multidrug resistance. mono INH - isoniazid mono-resistance. mono RIF - rifampicin mono-resistance. NA - not applicable. Resistance to 1+ - resistance to one or more drug. TMP-SMX - trimethoprim-sulfamethoxazole. XDR - extensive drug resistance; AG - aminoglycosides; CP – carbapenems; FQ – fluoroquinolones; PCN – penicillin; TB – tuberculosis.
Figure 3
Figure 3
Disability-adjusted life year (DALY) counts attributable to antimicrobial resistance (AMR) by pathogen-drug combination in Croatia in 2019. Abbreviations: 3GC - third-generation cephalosporins. 4GC - fourth-generation cephalosporins. Anti-pseudomonal - anti-pseudomonal penicillin or beta-lactamase inhibitors. BL-BLI - beta-lactam or beta-lactamase inhibitors. MDR - multidrug resistance. mono INH - isoniazid mono-resistance. mono RIF - rifampicin mono-resistance. NA - not applicable. Resistance to 1+ - resistance to one or more drug. TMP-SMX - trimethoprim-sulfamethoxazole. XDR - extensive drug resistance; AG - aminoglycosides; CP – carbapenems; FQ – fluoroquinolones; PCN – penicillin; TB – tuberculosis.
Figure 4
Figure 4
Disability-adjusted life year (DALY) counts associated with antimicrobial resistance (AMR) by pathogen-drug combination in Croatia in 2019. Abbreviations: 3GC - third-generation cephalosporins. 4GC - fourth-generation cephalosporins. Anti-pseudomonal - anti-pseudomonal penicillin or beta-lactamase inhibitors. BL-BLI - beta-lactam or beta-lactamase inhibitors. MDR - multidrug resistance. mono INH - isoniazid mono-resistance. mono RIF - rifampicin mono-resistance. NA - not applicable. Resistance to 1+ - resistance to one or more drug. TMP-SMX - trimethoprim-sulfamethoxazole. XDR - extensive drug resistance; AG - aminoglycosides; CP – carbapenems; FQ – fluoroquinolones; PCN – penicillin; TB – tuberculosis.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. Pulingam T, Parumasivam T, Gazzali AM, Sulaiman AM, Chee JY, Lakshmanan M, et al. Antimicrobial resistance: Prevalence, economic burden, mechanisms of resistance and strategies to overcome. Eur J Pharm Sci. 2022;170:106103. doi: 10.1016/j.ejps.2021.106103. - DOI - PubMed
    1. Murray CJI, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399:629–55. doi: 10.1016/S0140-6736(21)02724-0. - DOI - PMC - PubMed
    1. Hofer U. The cost of antimicrobial resistance. Nat Rev Microbiol. 2019;17:3. doi: 10.1038/s41579-018-0125-x. - DOI - PubMed
    1. Tambić-Adrašević A. Antibiotic resistance control in Croatia. Croatian Journal of Infection. 2009;29:145–50. [in Croatian]
    1. Tambić-Andrašević A, Lucić S, Tambić T. Antibiotic resistance in Croatia. Med Flum. 2018;54:312–21. doi: 10.21860/medflum2018_203562. [in Croatian] - DOI

Substances