Bad Gram Negatives Are “Big” in Greece

By Iosifina Giannakikou, MD

Dr. Giannakikou is an anesthesiologist and critical care physician who divides her time between Johns Hopkins Hospital, Baltimore, and Hygeia Hospital and Mitera Hospital, both in Athens, Greece.

Greece is a small country with some big problems—and one of them is the incidence of multidrug-resistant pathogens. Although there is a worldwide increase in the infections caused by multi-resistant gram negative pathogens, the pathogens’ high incidence and upstream rise from previous studies in Greece are particularly concerning.

The Greek System for the Surveillance of Antimicrobial Resistance (GSSAR) provides alarming data about these pathogens. Extended-spectrum β-lactamase Enterobacteriaceae are becoming an epidemic in the country. The prevalence of ceftriaxone resistance in bloodstream infections in Greek ICUs is 96.7% for Klebsiella pneumonia, 46.7% for Enterobacter, and 42.4% for Proteus mirabilis. K pneumonia isolates are 69.8% resistant to imipenem. Carbapenem-resistant Enterobacteriaceae also are increasing. Resistant strains of A baumannii are becoming more prevalent, with resistance to ciprofloxacin (90%), carbapenem (90%), and amikacin (80%). Pseudomonas aeruginosa resistance to carbapenem (55%) also is becoming a health issue.

Although multi-resistant, gram-positive microorganisms are on the decline in Greece, they still pose a public health threat, with an unacceptable high incidence. Rates of methicillin resistance in Streptococcus aureus are among the highest in Europe. Fifty percent of MRSA infections are community acquired and resistant to fusidic acid, tetracycline, and ciprofloxacin. MRSA in the Greek ICUs has an incidence of 48%, which is a decrease from previous years. The incidence of Enterococcus faecium that is resistant to vancomycin is 26.9%—the third highest incidence in Europe. Finally, the country’s rate of Streptococcus pneumonia resistant to penicillin strains is 48.3%.

ICU physicians practicing in the US should be aware of these facts. As population mobility (through travel and immigration) is increasing, it is easier for pathogens to spread between countries. Appropriate and timely antibiotics are crucial in the management of sepsis. When it comes to deciding on empiric antibiotic therapies for patients with recent hospitalizations in Greece or giving second opinions to Greek patients through telemedicine, keeping Greece’s big problem in mind may be crucial.