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. 2020 Nov 12;25(45):2001735. doi: 10.2807/1560-7917.ES.2020.25.45.2001735

Epidemiological situation, laboratory capacity and preparedness for carbapenem-resistant Acinetobacter baumannii in Europe, 2019

Felix Lötsch 1, Barbara Albiger 1, Dominique L Monnet 1, Marc J Struelens 1, Harald Seifert 2,3, Anke Kohlenberg 1; European Antimicrobial Resistance Genes Surveillance Network (EURGen-Net) carbapenem-resistant Acinetobacter baumannii capacity survey group4; EURGen-Net carbapenem-resistant Acinetobacter baumannii capacity survey group; EURGen-Net carbapenem-resistant Acinetobacter baumannii capacity survey group, Petra Apfalter, Rainer Hartl, Te-Din Daniel Huang, Olivier Denis, Stefana Sabtcheva, Ivan N Ivanov, Arjana Tambić Andrašević, Irina Pristaš, Panagiota Maikanti, Despo Pieridou, Jaroslav Hrabak, Helena Žemličková, Anette M Hammerum, Louise Roer, Marika Jürna-Ellam, Jari Jalava, Kati Räisänen, Anaïs Potron, Patrick Plésiat, Niels Pfennigwerth, Spyros Pournaras, Alkiviadis Vatopoulos, Ákos Tóth, Andrea Kurcz, Kristján Orri Helgason, Karen Burns, Monica Monaco, Giulia Errico, Oksana Savicka, Aistė Mierauskaitė, Monique Perrin, Alexandre Mzabi, Elizabeth Anne Scicluna, Nina Nestorova, Leo M Schouls, Ørjan Samuelsen, Oliver Kacelnik, Dorota Żabicka, Manuela Caniça, Vera Manageiro, Irina Codita, Gabriel Popescu, Eva Schréterová, Andrea Žáková, Mateja Pirš, Jesús Oteo-Iglesias, Belén Aracil, Karin Sjöström, Petra Edquist, Katie L Hopkins, Jane Turton, Christopher Nugent, Alistair Leanord, Mandy Wootton, Mari Morgan, Andi Koraqi, Artan Bego, Maja Travar, Arsim Kurti, Lul Raka, Vineta Vuksanović, Milena Lopičić, Ana Kaftandjieva, Ivana Ćirković, Deana Medic, Serap Süzük Yildiz, Hüsniye Şimşek
PMCID: PMC7667627  PMID: 33183407

Abstract

To update information on the epidemiological situation and national capacity for detection, surveillance and containment of carbapenem-resistant Acinetobacter baumannii (CRAb) in Europe, we performed a survey in 37 countries. Nine countries reported regional or inter-regional spread and seven an endemic situation. Laboratories with a reference function, surveillance systems, and a national containment plan for CRAb existed in 30, 23 and eight countries, respectively. A pan-European molecular survey would provide in-depth understanding of the CRAb epidemiology.

Keywords: Acinetobacter baumannii, carbapenem resistance, Whole Genome Sequencing, laboratory capacity, Surveillance, Europe

To better understand the current epidemiological situation of carbapenem-resistant Acinetobacter baumannii (CRAb) in Europe and the surveillance and control activities in invididual countries, we conducted a survey in 37 countries. The main aims were (i) to update the information about the epidemiological stages of spread of CRAb in Europe, and (ii) to assess the current national capacity for laboratory detection, identification and characterisation, surveillance and containment of CRAb.

Terminology

Most nosocomial outbreaks are caused by A. baumannii sensu stricto (s.s.), which is characterised by its ability to survive long periods of time on dry surfaces [1], while outbreaks of other closely related species are rare. In this report and unless specified otherwise, ‘A. baumannii’, or ‘Ab’ as in CRAb, refer to A. baumannii s.s. as a species (and not the A. calcoaceticus-A. baumannii complex or the A. baumannii group).

Epidemiological situation

A questionnaire using the EUSurvey online tool was sent to the EURGen-Net national coordinators from 37 countries in December 2019. The questions in this survey about the situation in 2019 were adapted from two previous assessments of CRAb in Europe, one in 2013 for that same year [2] and one in 2015 covering 2014 and the beginning of 2015. To assess the epidemiological stage of CRAb dissemination across each country, a previously used seven-stage scale (0, 1, 2a, 2b, 3, 4 and 5) was applied [3]. All contacted coordinators completed the survey, with individual answers received from the United Kingdom (UK) for England, Northern Ireland, Scotland and Wales. While the data for these four countries in the UK are shown separately in some of the tables of the current report, all analyses count the United Kingdom as a single country.

With regards to the epidemiological stage of spread in 2019, 10 countries reported sporadic, unrelated cases (stage 1), two reported single hospital outbreaks (stage 2a), eight reported sporadic hospital outbreaks (stage 2b), five reported regional spread (stage 3), four reported inter-regional spread (stage 4), and seven reported an endemic situation (stage 5). For one country the stage was uncertain. The epidemiological stages by country are shown in the Figure and a comparison with the results from previous similar surveys is provided in  Table 1. Compared to the result of the 2015 survey, there was a decrease of the epidemiological stage in 13 countries, an identical stage in 16 countries, and an increase in five countries. No comparison could be made for three countries as no epidemiological stage was available from the 2015 study ( Table 1).

Figure.

Epidemiological situation of carbapenem-resistant Acinetobacter baumannii, assessment by national experts in European countries, 2019 (n = 37)

Administrative boundaries: EuroGeographics, UN-FAO.

Figure

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Table 1. Comparison of epidemiological stages of carbapenem-resistant Acinetobacter baumannii in European countries, 2013–2019 (n = 37).

Country Epidemiological stage of spread of CRAb Change between 2014–15 and 2019
2013 [2] 2014–15
(previously unpublished)		 2019
Albania Stage 1 Stage 1 Stage 1 →
Austria Stage 1 Stage 1 Stage 2b ↑
Belgium Stage 3 Stage 2b Stage 2b →
Bosnia and Herzegovinaa Stage 1 Stage 3 Stage 3 →
Bulgaria Stage 2b Stage 2a Stage 2b →
Croatia Stage 5 Stage 5 Stage 5 →
Cyprus Stage 3 Stage 4 Stage 2a ↓
Czechia Stage 4 Stage 2b Stage 2b →
Denmark Stage 2b Stage 1 Stage 1 →
Estonia Stage 2a Uncertain Stage 2a NA
Finland Stage 1 Stage 2a Stage 1 ↓
France Stage 3 Stage 2b Stage 3 ↑
Germany Stage 4 Stage 3 Stage 2b ↓
Greece Stage 5 Stage 5 Stage 5 →
Hungary Stage 4 Stage 4 Stage 4 →
Iceland Stage 0 Stage 1 Stage 1 →
Ireland Stage 2a Stage 1 Stage 1 →
Italy Stage 5 Stage 5 Stage 5 →
Kosovob Stage 3 Stage 5 Stage 2b ↓
Latvia Stage 5 Stage 2b Stage 4 ↑
Lithuania Stage 5 Uncertain Stage 5 NA
Luxembourg Stage 1 Stage 0 Stage 1 ↑
Malta Stage 1 Stage 2a Stage 1 ↓
Montenegro Stage 0 Uncertain Uncertainc NA
Netherlands Stage 1 Stage 2a Stage 1 ↓
North Macedonia Stage 1 Stage 1 Stage 2b ↑
Norway Stage 1 Stage 2a Stage 1 ↓
Poland Stage 2b Stage 4 Stage 3 ↓
Portugal Stage 4 Stage 5 Stage 5 →
Romania Stage 2b Stage 5 Stage 5 →
Serbia Stage 2b Stage 5 Stage 4 ↓
Slovakia Stage 4 Stage 4 Stage 4 →
Slovenia Stage 2a Stage 4 Stage 3 ↓
Spain Stage 3 Stage 4 Stage 3 ↓
Sweden Stage 2a Stage 2a Stage 1 ↓
Turkey Stage 2b Stage 5 Stage 5 →
United Kingdomd Stage 4 Stage 4 Stage 2b ↓
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CRAb: carbapenem-resistant Acinetobacter baumannii. NA: not applicable.

The epidemiological stages of carbapenem-resistant Acinetobacter baumannii are defined as follow: stage 0: no cases reported; stage 1: sporadic occurrence (epidemiologically-unrelated single cases); stage 2a: single hospital outbreak (two or more epidemiologically-associated cases with indistinguishable geno- or phenotype in a single institution); stage 2b: sporadic hospital outbreaks (unrelated hospital outbreaks with epidemiologically unrelated introduction or different strains, no autochthonous inter-institutional transmission reported); stage 3: regional spread (more than one epidemiologically-related hospital outbreak confined to hospitals that are part of the same region or health district, indicating regional autochthonous inter-institutional transmission); stage 4: inter-regional spread (multiple epidemiologically-related outbreaks occurring in different health districts, indicating inter-regional autochthonous inter-institutional transmission); stage 5: endemic situation (most hospitals in a country are repeatedly seeing cases admitted from autochthonous sources).

a The results reported for Bosnia and Herzegovina only apply to the Republic of Srpska.

b This designation is without prejudice to positions on status, and is in line with United Nations Security Council resolution 1244/99 and the International Court of Justice Opinion on the Kosovo declaration of independence.

c Acinetobacter spp. and Pseudomonas spp. are becoming a major problem in Montenegro as they are frequently isolated and are increasingly resistant to carbapenems. However, a National Reference Laboratory for these bacteria does not exist and all answers in the manuscript are connected with that fact. Therefore, it was judged that a realistic picture of the situation cannot be presented.

d The reported results are for the United Kingdom overall. The epidemiological stages vary among countries within the United Kingdom.

National surveillance and notification of cases as well as control guidelines

A national system for surveillance of CRAb, either mandatory or voluntary, was in place in only 23 of the 37 countries (Table 2) with establishment of surveillance systems in only four additional countries since the previous survey, indicating that surveillance has not been further expanded and that attention and resources might have shifted away from CRAb, possibly with a focus on the spread of carbapenem-resistant Enterobacterales in many European countries [3]. Notification of cases was mandatory or recommended in 14 countries compared to nine in the period 2014 to 2015.

Table 2. National capacity for surveillance and containment of carbapenem-resistant Acinetobacter baumannii, European countries, 2019 (n = 37).

Country NRL Routine referral of suspected CRAb isolates to NRL National system for surveillance National recommendation or obligation for notification National guideline on phenotypic carbapenem susceptibility testing National guideline on molecular characterisation of carbapenem resistance National recommendation or guideline on infection control measures for CRAb National plan for containment of CRAb National policy or guideline on screening
Albania Yes No No No No No No No No
Austria Yes Subset of isolates Voluntary No No No No No Selective screening
Belgium Yes Subset of isolates Mandatory Yes Yes No For single cases and outbreaks Yes Selective screening
Bosnia and Herzegovinaa No NA No No No No No No No
Bulgaria Yes Subset of isolates Voluntary No Yes No For single cases and outbreaks In preparation No
Croatia No NA Mandatory No No No In preparation for single cases No Selective screening
Cyprus No NA Voluntary No No No No No No
Czechia Expert laboratoryb Subset of isolates No No No No No No No
Denmark Yes All isolates Mandatory No Yes No For single cases and outbreaks Yes Selective screening
Estonia No NA No In preparation No No No No No
Finland Expert laboratoryb Subset of isolates Mandatory Yes No Yes For single cases and outbreaks Yes Selective screening
France Yes All isolates Voluntary No Yes No No No No
Germany Yes Subset of isolates Mandatory Yes No No For single cases No No
Greece No NA Voluntary Yes, for bacteraemias No No For single cases and outbreaks Yes No
Hungary Yes Subset of isolates Mandatory Yes Yes No For single cases and outbreaks In preparation Selective screening
Iceland Expert laboratoryb All isolates Mandatory Yes Yes Yes For single cases and outbreaks Yes Selective screening
Ireland Yes Subset of isolates Mandatory Yes Yes Yes For single cases No No
Italy Expert laboratoryb No Voluntary No No No Yesc No No
Kosovod Expert laboratoryb All isolates No No No No No No No
Latvia Expert laboratoryb No Yes Yes No No No answer No answer No
Lithuania Expert laboratoryb Subset of isolates Mandatory No No No No No No
Luxembourg Expert laboratoryb All isolates No No No No No No No
Malta Expert laboratoryb All isolates Voluntary Othere No No Yese No No
Montenegro No NA No No No No No No No
The Netherlands Expert laboratoryb No No No No No Yes No No
North Macedonia Expert laboratoryb No Yesf No No No Nog No No
Norway Yes All isolates Mandatory Yes Yes No For single cases and outbreaks Yes Selective screening
Poland Expert laboratoryb Subset of isolates No Yes Yes No No No No
Portugal Yes Subset of isolates Mandatory Yes Yes No In preparation In preparation No
Romania Expert laboratoryb Subset of isolates Voluntary No No No In preparation No No
Serbia Yes Subset of isolates In preparation No No No No No No
Slovakia No NA No Yes No No No No No
Slovenia Expert laboratoryb No No No Yes No Noh No No
Spain Expert laboratoryb Subset of isolates In preparation In preparation Yes No In preparation Yes No
Sweden Yes All isolates Voluntary Yes Yes No Yes Yes Selective screening
Turkey Yes No Voluntary Yes Yes No For outbreaks No Selective screening
UK England Yes Subset of isolates Voluntary In preparation Yes No For outbreaks No Yes
Northern Ireland Yes Subset of isolates No No Yes Do not know Otherh No No
Scotland Yes All isolates Voluntary Yes Yes No For single cases and outbreaks Yes No
Wales Yes All isolates In preparation No Yes No Otheri No Selective screening
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CRAb: carbapenem-resistant Acinetobacter baumannii; NA: not applicable; NRL: national reference laboratory; UK: United Kingdom.

a Results reported for Bosnia and Herzegovina only apply to Republic of Srpska.

b An expert laboratory fulfils the role of a NRL.

c Regional or local recommendations/guidelines apply.

d This designation is without prejudice to positions on status, and is in line with United Nations Security Council resolution 1244/99 and the International Court of Justice Opinion on the Kosovo declaration of independence.

e All organisms are isolated in one laboratory, which is interfaced with the surveillance unit.

f There is a national system for surveillance of multidrug-resistant microorganisms, but not specifically for CRAb. It is an obligation to report these microorganisms through the Centers of Public Health to the National Institute of Public health.

g There is no national recommendation or guideline on infection control measures for CRAb, but World Health Organization guidelines are followed.

h Guidelines available at institutional level.

i Part of the general policy on multidrug-resistant organisms.

Progress was made in developing national recommendations or guidelines on infection control measures for CRAb, with 15 countries having guidelines in 2019 compared to 12 countries in the 2014 to 2015 period. A national plan for containment of CRAb existed in eight countries; however, six of the seven CRAb endemic countries did not have such a plan. National guidelines on phenotypic carbapenem susceptibility testing were present in 15 countries, whereas a national guideline on molecular characterisation of carbapenem resistance was available in only three countries. Ten countries had a national screening policy or guideline. For admission screening of patients to acute care hospitals, all of these guidelines recommended selective screening in high-risk situations (outbreaks) or of high-risk groups, for example after hospitalisation abroad. The survey did not include any questions regarding the laboratory capacity and microbiological methods used for screening.

National laboratory capacity

Collection of data on isolates analysed by standardised microbiological methods is crucial for a reliable assessment of the spread of CRAb. However, laboratories with a reference function for CRAb existed in only 30 of the 37 countries. Differentiation between A. baumannii s.s. and other closely related species, such as A. pittii, A. nosocomialis, A. dijkshoorniae or A. seifertii, has been considered difficult in the past, but has improved with the widespread availability of matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF/MS) method for species discrimination [4]. Widespread use of this technology in clinical laboratories is reflected in the answers indicating that, in 11 countries, all or nearly all clinical laboratories routinely use MALDI-TOF/MS for species identification; however, on the other end of the scale, experts from 13 countries reported that no or very few clinical laboratories in their country have access to MALDI-TOF/MS. In the national reference or expert laboratories, the most common method for species identification was MALDI-TOF/MS (n = 22) followed by PCR / gene-sequencing (n = 15).

The most frequently used methods for determination of phenotypic carbapenem susceptibility were disk diffusion (n = 23), gradient tests (n = 19) and commercial broth microdilution (n = 17). European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints for susceptibility testing were used in all countries with a laboratory with reference function. Most national reference or expert laboratories (25 of 30 laboratories) reported that they perform genotypic characterisation of carbapenem resistance. The most commonly used methods were PCR (n = 18) and whole genome sequencing (n = 16).

Colistin susceptibility testing of A. baumannii isolates was performed in 25 of the 30 reference or expert laboratories with broth microdilution according to EUCAST recommendations (four laboratories did not use broth microdilution and the information was missing for one laboratory). Of the 25 laboratories using broth microdilution for colistin testing, nine tested all referred A. baumannii isolates for colistin susceptibility and the remaining 16 only tested a subset of isolates. The survey did not include questions regarding internal and external quality assessment in the laboratories. Detailed information on the laboratory capacity is provided in Table 3.

Table 3. Methods used by national reference or expert laboratories for species identification, phenotypic carbapenem susceptibility testing and genotypic characterisation of carbapenem-resistant Acinetobacter baumannii (CRAb), European countries, 2019 (n = 37).

Country Method for
species determination		 Method for phenotypic
carbapenem susceptibility testing		 Method for genotypic characterisation
of carbapenem resistance
Biochemical MALDI-TOF PCR/gene sequencing WGS Automated system Disc diffusion Gradient test Commercial broth microdilution Agar dilution In-house broth microdilution PCR Real-time PCR Single-gene sequencing WGS Other
Albania Yes No No No Yes Yes Yes No No No Not performed
Austria Yes Yes Yes No No Yes Yes Yes No No Yes No No No Yesa
Belgium No Yes Yes Yes No Yes No Yes No No Yes No Yes Yes No
Bosnia and Herzegovinab No NRL or expert laboratory
Bulgaria Yes No Yes No No Yes No Yes No No Yes No No No No
Croatia No NRL or expert laboratory
Cyprus No NRL or expert laboratory
Czechia Yes Yes No No No Yes Yes Yes No No Yes No Yes Yes No
Denmark No Yes Yes Yes No Yes Yes Yes Yes No No No No Yes No
Estonia No NRL or expert laboratory
Finland No No No Yes Yes Yes Yes No No No No No No Yes No
France No Yes Yes No No Yes Yes Yes No Yes Yes No Yes Yes No
Germany No Yes Yes No No Yes Yes Yes No No Yes No Yes Yes No
Greece No NRL or expert laboratory
Hungary No Yes Yes No No Yes Yes No No Yes Yes No No Yes No
Iceland No Yes Yes No No Yes Yes Yes No No Yes Yes No Yes Yesc
Ireland No Yes No No No No Yes No No No No Yes No No No
Italyd Yes No Yes Yes No Yes Yes Yes No No Yes No Yes Yes No
Kosovoe Yes No No No Yes Yes Yes Yes No No Not performed
Latvia Yes Yes No No Yes No Yes No No No No Yes No No No
Lithuania No Yes No No No Yes No Yes No No Not performed
Luxembourg No Yes No No No Yes No Yes No No No Yes No Yes No
Malta No Yes No No Yes No No No No No Not performed
Montenegro No NRL or expert laboratory
The Netherlands No Yes No No Yes No No No No No Yes No No Yes No
North Macedonia Yes N No No Yes Yes Yes No No No No Yes No No No
Norway No Yes Yes Yes No No No Yes No No Yes No No Yes No
Poland Yes No No No No Yes Yes No No Yes Yes No No No No
Portugal No Yes Yes No No Yes No No No Yes Yes No Yes Yes No
Romania Yes Yes Yes No No Yes No No No No Yes No Yes No No
Serbia No Yes No No No Yes Yes Yes No No Yes No No No No
Slovakia No NRL or expert laboratory
Slovenia No Yes Yes No No Yes Yes Yes No No Yes Yes No Yes No
Spain Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes No
Sweden No Yes No Yes No No No Yes No No No No No Yes No
Turkey No Yes Yes No No Yes Yes No Yes Yes Yes No No No No
UK England No Yes Yes No No No Yes Yes No No Yes Yes No No No
Northern Ireland See UK – England
Scotland Yes No No No No No No Yes No No Not performed
Wales No Yes No Yes No Yes Yes No No Yes Yes Yes No Yes No
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MALDI-TOF: matrix-assisted laser desorption/ionization-time of flight mass spectrometry; NRL: national reference laboratory; PCR: polymerase chain reaction; UK: United Kingdom; WGS: whole genome sequencing.

a Commercial multiplex nucleic acid amplification methods.

b Results reported for Bosnia and Herzegovina only apply to Republic of Srpska.

c Commercial loop-mediated isothermal amplification.

d Species determination, phenotypic and genotypic characterisation are not routinely performed but only upon request.

e This designation is without prejudice to positions on status, and is in line with United Nations Security Council resolution 1244/99 and the International Court of Justice Opinion on the Kosovo declaration of independence.

Ethical statement

This study did not involve personal data and ethical approval was thus not required. The release of the included national data was approved by the authors.

Discussion

CRAb poses a significant threat to patients and healthcare systems in countries of the European Union (EU)/European Economic Area (EEA) [5] with an estimated 2,363 annual attributable deaths in 2015 [6]. According to 2018 data from the European Antimicrobial Resistance Surveillance Network (EARS-Net), nearly a third of invasive Acinetobacter spp. isolates in the EU/EEA are already resistant to carbapenems, limiting the availability of adequate treatment [7]. Several reports on outbreaks of CRAb in European countries have recently been published, possibly indicating increasing spread [8-12]. These outbreaks frequently affect intensive care units, and morbidity and mortality are high. In the current study however, our results show that perception of the epidemiological situation of CRAb has not changed substantially since the last survey conducted in 2015. The extent of spread of CRAb appeared to be decreasing in some countries while it was increasing in other countries. The underlying reasons for these developments are not clear. On the one hand, decreasing epidemiological stages may reflect successful local or national control efforts. Control programmes were shown to be effective both in settings of high endemicity [13] and outbreaks [14,15]. On the other hand, the decrease in the epidemiological stage was not always confirmed by the carbapenem resistance rates in invasive isolates reported by EARS-Net or the Central Asian and European Surveillance of Antimicrobial Resistance network (CAESAR) [7,16]. Some countries reported a low epidemiological stage of spread of CRAb whereas EARS-Net showed that, in 2018, a high or very high proportion of Acinetobacter spp. invasive isolates in the same country were resistant to carbapenems [7]. One possible explanation for such discrepancies could be that local outbreaks of CRAb are driving the national resistance proportions in Acinetobacter spp. invasive isolates as reported to EARS-Net. In addition, two countries also mentioned increasing numbers of carbapenem-resistant isolates in Acinetobacter species other than A. baumannii s.s., e.g. A. pittii or A. lwoffii that were not included in this assessment of epidemiological stages but are included in the EARS-Net collection of data on Acinetobacter species. Finally, the epidemiological stages were determined by a self-assessment of the national representatives and might have been affected by unavailability of national surveillance data or reference laboratories in some countries, especially as differentiation between stages might be difficult without molecular typing results. The three surveys over time were also not always answered by the same national expert and it cannot be excluded that changes resulted from differences in subjective judgement.

An interest to participate in a European structured survey including the collection of CRAb isolates or whole genome sequencing data thereof as well as related epidemiological information was expressed by 32 countries. Such a survey would help identify successful clones and predominant lineages and the extent of their spread, provide a better understanding of predominant resistance mechanisms to carbapenems and other antimicrobials and allow conclusions on potential cross-border spread of CRAb.

EURGen-Net carbapenem-resistant Acinetobacter baumannii capacity survey group

Austria: Petra Apfalter and Rainer Hartl; Belgium: Te-Din Daniel Huang and Olivier Denis; Bulgaria: Stefana Sabtcheva and Ivan N. Ivanov; Croatia: Arjana Tambić Andrašević and Irina Pristaš; Cyprus: Panagiota Maikanti and Despo Pieridou; Czechia: Jaroslav Hrabak and Helena Žemličková; Denmark: Anette M. Hammerum and Louise Roer; Estonia: Marika Jürna-Ellam; Finland: Jari Jalava and Kati Räisänen; France: Anaïs Potron and Patrick Plésiat; Germany: Niels Pfennigwerth; Greece: Spyros Pournaras and Alkiviadis Vatopoulos, Hungary: Ákos Tóth and Andrea Kurcz; Iceland: Kristján Orri Helgason; Ireland: Karen Burns; Italy: Monica Monaco and Giulia Errico; Latvia: Oksana Savicka; Lithuania: Aistė Mierauskaitė; Luxembourg: Monique Perrin and Alexandre Mzabi; Malta: Elizabeth Anne Scicluna and Nina Nestorova; Netherlands: Leo M. Schouls; Norway: Ørjan Samuelsen and Oliver Kacelnik; Poland: Dorota Żabicka; Portugal: Manuela Caniça and Vera Manageiro; Romania: Irina Codita and Gabriel Popescu; Slovakia: Eva Schréterová and Andrea Žáková; Slovenia: Mateja Pirš; Spain: Jesús Oteo-Iglesias and Belén Aracil; Sweden: Karin Sjöström and Petra Edquist; United Kingdom (UK)-England: Katie L. Hopkins and Jane Turton, UK- Northern Ireland: Christopher Nugent; UK – Scotland: Alistair Leanord; UK-Wales: Mandy Wootton and Mari Morgan; Albania: Andi Koraqi and Artan Bego; Bosnia and Herzegovina: Maja Travar; Kosovoa: Arsim Kurti and Lul Raka; Montenegro: Vineta Vuksanović and Milena Lopičić ; North Macedonia: Ana Kaftandjieva; Serbia: Ivana Ćirković and Deana Medic; Turkey: Serap Süzük Yildiz and Hüsniye Şimşek.

a This designation is without prejudice to positions on status, and is in line with United Nations Security Council Resolution 1244/99 and the International Court of Justice Opinion on the Kosovo declaration of independence.

Conflict of interest: KLH and JT are members of PHE’s Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, which has received financial support for conference attendance, lectures, research projects, or contracted evaluations from numerous sources, including Accelerate Diagnostics, Achaogen Inc, Allecra Therapeutics, Amplex, AstraZeneca UK Ltd, AusDiagnostics, Basilea Pharmaceutica, Becton Dickinson Diagnostics, bioMérieux, Bio-Rad Laboratories, British Society for Antimicrobial Chemotherapy, Cepheid, Check-Points B.V., Cubist Pharmaceuticals, Department of Health, Enigma Diagnostics, the European Centre for Disease Prevention and Control, Food Standards Agency, GenePOC, GlaxoSmithKline Services Ltd, Helperby Therapeutics, Henry Stewart Talks, International Health Management Associates Ltd, Innovate UK, Kalidex Pharmaceuticals, Melinta Therapeutics, Merck Sharpe and Dohme, Meiji Seika Pharma Co Ltd, Mobidiag, Momentum Biosciences Ltd, Neem Biotech, NIHR, Nordic Pharma Ltd, Norgine Pharmaceuticals, Paratek, Rabiotics Rx, Rempex Pharmaceuticals Ltd, Roche, Rokitan Ltd, Smith and Nephew UK Ltd, Shionogi and Co Ltd, Tetraphase Pharmaceuticals, Trius Therapeutics, VenatoRx Pharmaceuticals, Wockhardt Ltd, and the World Health Organization.

Authors’ contributions: F. Lötsch, B. Albiger, D.L. Monnet, M. Struelens, A. Kohlenberg: design and implementation of the survey, compilation of information received from individual countries and preparation of European overview, drafting and reviewing the manuscript;

H. Seifert: design of the survey and review of the manuscript;

EURGen-Net carbapenem-resistant Acinetobacter baumannii capacity survey group: compilation and analysis of national data from laboratories and surveillance databases, validation of national data included in the manuscript and review of the manuscript.

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