**3. European data. ECDC**

Data on infections associated with healthcare acquired in ICU are assessed by the ECDC. Recent data (2015) [1, 2] show that 8.3% of patients who remain in the ICU for more than

in ICUs. It describes nosocomial infections (NI) acquired in ICUs associated with invasive instrumentation. The data are collected mainly during the second quarter of the year (few units carry out the project throughout the year). The more frequent NI in the ICU are urinary infections associated with urinary catheter (31.87%), followed by ventilation-associated pneumonia (29.97%) and bacteremia (catheter-associated bacteriemia in 11.31%). In recent years, there has been a relative increase in the former ones and a decrease in the latter. The most frequently isolated germs in ICU infections (excluding bacteremia from other foci) are: *E. coli* (14.1%), *P. aeruginosa* (12.9%), *K. pneumoniae* (9.8%), *S. epidermidis* (8.2%), *S. aureus* (4.9%), *C. albicans* (4.8%), *E. cloacae* (3.5%), *S. marcescens* (2.7%), and so on. The type of reported patients is variable: medical (44%), 19.5% of surgeries scheduled, 10.3% of urgent surgeries and 19.8% of coronary patients. The extrinsic risk factors for nosocomial infections are: antibiotics before admission (21.1%), antibiotic treatment in ICU (64%), surgery in 30 days before (32.8%), urgent surgery during their stay in ICU (10.2%), central venous catheter (63.9%), mechanical

Current Status of Colonization and Infection by Multiresistant Bacteria in the Spanish Intensive…

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ventilation (42.4%), bladder catheter (76.4%), parenteral nutrition (8.3%), and so on.

evolution of the different indicators collected in the project is reviewed.

**Figure 3.** Temporal variation of the rate of MRB colonization/infection in ICU.

The implementation of the RZ project is more complex than the previous programs. It involves the collaboration of more staff and services, so the number of participating ICUs has been lower (of>190 in the first two projects, compared to 103 in RZ). In the following graphs, the

The evolution by quarters of the frequency of colonization/infection of patients with MRB, per 100 patients admitted, throughout the development of the RZ project is observed in **Figure 3**, with an ascending tendency with peaks coinciding with the collection periods of data from the ENVIN project (second quarter of each year). The average value throughout the project is 6.23 patients per 100 admissions. The colonization/infection plot for 1000 stays is similar.

Throughout the RZ project, there is an increase in the isolation of germs at the admission (acquisition prior to admission to the ICU) versus isolation during their stay (discrete decrease),

**Figure 2.** North-south and west-east gradient of % resistance of *K. pneumoniae* to third generation cephalosporins.

48 h develop at least one infection (pneumonia, bacteremia or urinary tract infection). The most frequent causal germs are *P. aeruginosa* (pneumonia), *Staphylococcus* spp. coagulasenegative (bacteremia) and *Escherichia coli* (urinary tract infections). On average, 23.1% of *S. aureus* are MRSA; 3.4% of Enterococci are VRE. Resistance to third generation penicillin is described in variable percentages in E coli (20%), Klebsiella (43%) and Enterobacter (42%); resistance to carbapenems is also noticeable in Klebsiella (11%), *Pseudomonas aeruginosa* (24%) and *Acinetobacter baumannii* (69% of averages). In a report of the European Antimicrobial Resistance Surveillance Network (EARS-Net) of 2016 [2], the main surveillance system in the European Union on bacteria that can cause serious infections, broad variations are described in relation to bacterial species, antimicrobial group and geographical region. For many combinations of bacterial species (*E. coli*, *K. pneumoniae*, *P. aeruginosa*, *Acinetobacter*, *S. aureus*, *Enterococcus*)—resistance to antimicrobial groups, there is a growing gradient from north to south, and from west to east, perhaps in relation to variations in the use of antimicrobials, infection prevention and control practices, and differences in diagnosis and healthcare utilization patterns between countries [18]. Overall, there seems to be a slowly increasing resistance over time (in the 2013–2016 interval) of E coli resistant to one of the three key antimicrobial groups (fluoroquinolones, third generation cephalosporins and aminoglycosides), with a tendency to stabilize the percentage of *K. pneumoniae* resistances (**Figure 2**).
