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AMR-Times Newsletter #20
November 2017
In this issue
  • FLASH. AMR Control 2017 edition is available with contributions from MoH of Algeria, China, France, Germany, and Senegal, with USAID and BARDA initiatives from the USA or the World Bank: Web=link : www.amrcontrol.info
  • Editoral
  • Global Framework for Dev. and Stewardship to Combat AMR  - Human and animal health. At WHO, Member States elaborate a Framework on R&D and Stewardship, addressing objectives 4-5 of the GAPAMR. Hot debates in the WHO meeting Nov 9.
    • Debate over the WHO Guidelines on use of AB in animals
    • Public and private investments in R&D 
    • MRSA in Livestock, from the US and Portugal as well
  • IPC AGAINST AMR: WHO Initiates website on IPC against AMR
    • Strengthening prevention of HAI in India with Dr Soumya Swaminathan
    • Dirty injection practices in the USA even! A CDC study
    • A forgotten idea in AMR: hospital architecture can limit AMR spread
  • Clinical care
    • Launch of ANTARTICA, Coalition on AMR in Critical Care / Intensive care
    • Use of AB in Surgery, Coalition Statement

If you would like to subscribe to the newsletter please click here.You can also view the previous issue(s) of this newsletter by clicking hereYou can view WAAAR’s (World Alliance Against Antibiotic Resistance) /ACdeBMR yearly publication on AMR here: AMR Control 2015 /AMR Control 2016.

AMR Control 2017

AMR Control 2017 book of the WAAAR alliance is out, on line and in print (132 pages). It includes articles of reference in antibiotics in meat-producing animals notably with A. Aidara Kane, head of AGISAR WHO and OIE scientific leader E. E. Vindel, as well as "One Health"  presentation by former US CDC AMR director.

Covering a world of governance and expert views on AMR, the MoH of Algeria, China, Germany (leader of the G20 this year), Lebanon, and Senegal published their approach along with the USA's BARDA Initiatives and the USAID work in countries, globally as well as in Uganda (antibiotic stewardship) and the Palestine territories (first work on HAI), including a cost-benefit economic analysis of antibiotics in human health.

AMR Control covers a succinct resume of the World Bank report with E Baris and Tim Evans.

It opens the door to alternatives to antibiotics with US famous ethnobotaniste Pr Cassandra Quave, and Algerian researcher Nora Mahfouf.
 


Editorial: An Ambitious Framework

The WHO convened a meeting Nov 9-10 to discuss with Member States the drafting of a Global Framework for Development and Stewardship to Combat AMR, a "One Health" approach since the document is co-authored WHO-OIE-FAO. We participated as CSO. 

The Framework will only address two objectives of the GAPAMR: 4 & 5, meaning R&D for the production of new antibiotics (vaccines and diagnostics included)and stewardship in human and animal health use of antibiotics (generally referred to as 'antimicrobials', we abbreviated to AM).

Mexico alone attempted to transform the Framework proposal by objecting that resolution WHA68.7 did not limit the Framework to these 2 objectives. They were the only country to submit a lengthy comment in the meeting and on line. However they were not followed.

The Framework will not address objectives 1-3, and notably not objective one, Information, nor 2) to strengthen knowledge and evidence though surveillance, nor objective three, 'reducing the incidence of infection through..sanitation , hygiene and IPC measures, all said to be in various phase of implementation... A very optimistic comment, as regards IPC!

Germany pushed its R&D Hub proposal. 

The Global Framework thus focuses on two objectives: 'optimize the use of antimicrobial meds (basically antibiotics) in human and animal sectors, and increase investments in new medicines, diagnostics tools, vaccines and other interventions. Overall it is a clinical care approach: getting new products, generating research having decided what we want, organizing the means for a better management of products, notably antibiotics, divided into three classes: Access, Watch and Reserve. To succeed, political will is called for. 

It is both extremely ambitious and somewhat narrow, since so many elements are left out or ruled out. If we take but one element: diagnostics: there is an enormous need for investments in laboratory capacities in LMIC, in-vitro diagnostics at PoC are fine but insufficient without this buildup, and were IVD at PoC all available, it is the entire drug procurement systems which needs to be buildup in most LMIC. Then, at a time of austerity in the OECD, it is the means of reimbursement, the legislation and funding for our public health systems which needs to take in the need for systematic diagnostic use and susceptibility testing. 

If we look at the R&D, 15 years of inter-governmental discussion on that topic and the highly competent CEWG have not led to a concrete outcome, while public funding of public R&D is not discussed for ideological reasons in all fora where the subject is brought up (all schemes to attract private funding are laid out, and no one seems to make a reality check: the USA is among the largest public funder of public R&D in comparison to GDP). 

It is also fitting to remember that the London School of Economics study, commissioned by Jim O'Neill's AMR Review (chapter 6), estimated that investments in clean Water and Sanitation in just four countries: Brazil, India, Indonesia and Nigeria, would reduce antibiotic consumption in the four countries by 60% !


The Animal Farm war

At the Framework meeting, representative of the AGISAR/WHO Zoonosis department, Dr Awa Aidara Kane presented the "WHO Guidelines on the Use of Medically Important Antimicrobials in Food-Producing Animals" just released Nov 7th, FAO and OIE's Science Head, Dr Elisabeth Erlacher-Vindel) presented their respective agencies' work as well. 

The US Department of Agriculture (yes, agriculture) had already reacted on Nov 7th, with a very strong press release stating that the WHO Guidelines "are not in alignment with U.S. policy and are not supported by sound science. The recommendations erroneously conflate disease prevention with growth promotion in animals." 

As could be expected, the debate was very tense. WHO AMR Secretariat and WHO Director for the Dept of Food Safety and Zoonoses, Dr Kazuaki Miyagishima, explained that the Guidelines took two full years to elaborate so as to strengthen the scientific evidence. The Netherlands representative expressed full support stating that the NL, "second largest world meat exporter in the world", had banned antibiotics (along the lines of the Guidelines) nearly before anyone else, and has maintained its dominant world position in meat production. The WHO Coordinator cited the United Kingdom which had reduced antibiotics use in meat production by 70% and yet increased output by 11% in recent years. 

The UK (which is in the throes of Brexit) initially supported the WHO Guidelines, yet in later intervention, after the US and others, such as Brazil, questioned the timing of the release of the Guidelines. The UK was one of the funders of the WHO Guidelines on Food-producing Animals.

There was a decision for a later follow up meeting on the Guidelines with all three organizations (WHO, OIE and FAO). 

Several speakers asked why pesticides, for example, were not covered? Pr Otto Cars asked about alternatives to antibiotics research? Others asked about waste in the environment?
 


The R&D debate

In the Framework meeting, on the side of South Centre and the NGOs, the interventions focused on the issue of mechanisms to support R&D and the call for a convention on R&D was once again put to the forefront, while the IUATLD representative spoke of the terrible situation with ten million tuberculosis cases annually and the lack of medicines for drug resistant TB which is in real augmentation.

In AMR Control we have had then WHO ADG Marie-Paule Kieny (now Chair of IMI) in 2015, on "Creating an Inter-Governmental Consortium for New Antibiotics: a New Economic Model as well as Jens Plahte and John Arne Røttingen (head of the Norwegian "Antibiotic Innovation, some lessons from the WHO processes on public health, innovation and IPR", and in 2016: the Indian ICMR director (now DDG WHO) Dr Soumya Swaminathan with Dr Kāmini Walia, ICMRin India “ Strengthening Research and Innovation to Address AMR”, and "The global definition of responsible antibiotic use: The DRIVE-AB project" with Dr Stephen Harbarth for Drive AB, and, this year, Joe Larsen and Christopher Houchens from the US BARDA initiative.
 


There is a new leadership at the WHO!

There is a need to beef up the role of the WHO in its necessary technical and scientific role as leader in health, with special responsibility for the health of the poor, away from politics. In this regard, without prejudice to all the other new faces, we are especially glad to see Dr Soumya Swaminathan as Deputy Director General, considering her role and expertise in insisting on infection control in India (see further down in this issue) and her long involvement in tuberculosis, which she has made a priority in India – a few days before the Moscow Summit on TB. Her engagement for the Right to Health of the Poor, is exactly what the WHO needs at this juncture.

Lastly, we note the Public Services International congress in Geneva, just ended, with a clear slogan ("Pourquoi nous avons besoin de dépenses publiques"), “Why we need public expenditures", an in depth research report, which was backed by PHM representative speaker Amit Sengupta.

Indeed, amidst all the talk about attracting private funds to R & D for AMR, it is important to remember that we need to talk about public funding for public research against AMR at all levels. 

Without strong public health systems, we will not contain AMR infections spread, that is an impossibility. And, to add a teaser, none other than IFPMA director Harvey Bale had insisted in the late nineties, that strong health care systems were needed for ARV to be rolled out... With ARV resistance on the rise, this remains a real need. With AMR, the people living with HIV will be the first affected by weak, dirty, collapsed health care systems in poor communities.

Web=links:
AMR Control 2015, 2016, 2017 http://www.globalhealthdynamics.co.uk/wp-content/uploads/2015/06/AMR2015-June-3.pdf
http://resistancecontrol.info/rd-innovation/strengthening-research-and-innovation-to-address-the-challenge-of-antimicrobial-resistance/
www.amrcontrol.info
Public Services International TU and Health: No 50 Shades of Grey!
https://blogs.mediapart.fr/onu-un-news/blog/071117/public-services-international-tu-and-health-no-50-shades-grey

Nov 9 WHO consultation on the "Global Framework for Development and Stewardship", Draft Roadmap

The meeting opening was presided by one of the ADGs in the new team, the Brazilian Dr. Mariângela Batista Galvão Simão, Assistant Director General for Drug Access, Vaccines and Pharmaceuticals. The moderator was the director in the same department Dr Suzanne Hill.

Marc Sprenger, Director AMR Secretariat noted that controlling AMR is needed to achieve the SDGs worlwide, an opinion supported by REACT and ICGAR (Interagency Coordination Group on AMR) representative in attendance Pr Otto Cars. 

At present 92 national AMR programs exist today and 60 countries are preparing one.
All Member States should do their own campaign.
A program on Behavior modification is being elaborated by the WHO in collaboration with the Wellcome Trust.
The surveillance and monitoring program GLASS is progressing in countries, notably French speaking Africa lately. 

There are very wide differences in antibiotic use in food-producing animals, and on Nov 7th the WHO released the "Guidelines on Use of Medically Important Antimicrobials in Food-Producing Animals". Dr Awa Aidara Kane, chair of AGISAR, said Sprenger, spend two years working with experts (including representation from the OIE and FAO), and a thorough review of evidence to develop these Guidelines.

Marc Sprenger went on to say that WHO can only make recommendations, it is in governments' hands whether to implement or not. 

He recalled WHO work on infection prevention and control (IPC), with the release of the guidelines on CRE and CP, and the elaboration of the target listing of bacteria.

He went on to stress the importance of civil society participation, mentioning the EPN, Ecumenical Pharmaceutical Network as important collaborators.

The Netherlands representative congratulated the WHO on the Guidelines, adding that they were "very pleased because NL secong largest exporter of meat, and we encourage people to read the guidelines".

The UK thanked the WHO for these Guidelines, saying "we met our targets two years early" Sprenger noted that the UK reduced antbiotic animal consumption by 70% while increasing production by 11%
Brazil expressed reservations and said they were surprised by guidelines on animals.

 Dr Kazuaki Miyagishima, Director of the WHO's Department of Food Safety and Zoonoses, strongly backed up the Guidelines.

Several Member States asked why and how the WHO had set a target of 10% reduction in Sepsis death due to AMR? 

Mexico:
The Sub-secretariat for Multilateral Affairs and Human Rights General Directorate for Global Issues wrote, and the head of health at the Mexico Mission to the UN intervened to state that: “Mexico recognizes the multifactorial causes of AMR, which implies the need for inter-institutional response from the fields of health, food and livestock, the pharmaceutical and chemical industry, medical training and timely information to the population in general, as well as the integral management of drug residues in particular of antibiotics.” (...)

In line with the World Plan of Action adopted within the World Health Organization through resolution WHA68.7, Mexico considers that the global response should include:
a) Education, training and dissemination; b) Health regulation and surveillance; c) Prevention and control; d) Research and e) Financing.”

Mexico objected to the Framework being limited to objectives 4 & 5.

The Framework in details
Dr Peter Beyer, Senior Advisor, Department of Essential Medicines & Health Products, presented in details the Framework on Stewardship proposed, from the discussion on a "global R&D funding mechanism", to Priority pathogens for R&D: He stressed that there are "Insufficient innovative products in the pipeline : 10 products in phase one, only 1 or 2 will make it in seven years. So a big crisis coming."

There was also the need to prioritize vaccines both in animal health (a topic recently underlined by the PACCARB meeting). And the much needed R&D for in vitro diagnostics for AMR.

Beyer spoke of the importance of the GARDP initiative, Jean-Pierre Paccaud, GARDP Incubation Business Development & Strategy Director, DNDi was in the room.
Another discussion was on Access, where it was emphasized that there are shortages in production of basic generic older antibiotics, a situation which needs to be remedied. There are basically three groups of antibiotics: the basic ones where generics predominate 'Access', those of the 'Watch list' and those in the 'Reserve group' (antibiotics of last resort). What is put forth as the AWARe model: Access, Watch and Reserve.


There are also regulatory issues, including work on the regulation of pharmaceutical marketing, and the issue of transparency in costs and prices. "The Framework should cover the whole value chain." said Peter Beyer.


In R&D the Framework ambitions to be setting priorities. 

1-"Prioritization of human pathogens to guide R&D of new antibiotics."
The WHO report on prioritization of pathogens for R&D has identified 12 classes of priority pathogens (critical, high and medium priority", along with M. tb.
The WHO published an analysis of the pipeline in Sept 2017 which shows it's rather empty. More importantly, it is supporting a PoC (Rapid Point of Care) Diagnostics R&D effort.

2- Priority list of animal disease for vaccine development.

With the OIE (2015) priorities were set for chicken, pigs and fish. 

AMR-Times notes that The PACCARB proposal, very recently to create an Innovation Institute for Animal Health, notably to better understand immunity across species, might be useful for better basic scientific understanding.

Several speakers noted the absence of mention of needed research in the microbiome, in human or animal species.

3-Measures to reduce antibiotics as growth promoters. Banned in 2006 in the EU, they are still not banned in the US (only the FDA put out voluntary guidelines) and much of the emerging countries, and the US opposition to the new WHO Guidelines for Food-producing Animals may not help.

The Framework mentions good husbandry and housing practices, biosecurity, rigorous disease control measures...but will not apparently seek to elaborate on these.

4- Diagnostics and AMR Surveillance, refers to OIE and FAO manuals.

5- GARDP: an R&D initiative for global public health needs. GARDP is a DNDI-WHO intiative, 56.5 million US Dollars in pledges from Germany, Luxemburg, the Netherlands, the UK and the Wellcome Trust.

GARDP will co-develop Zoliflodacin for drug-resistant gonorrhoea and is working on neonatal Sepsis, said J-P Paccaud.

Mention was made of the German G20 launch of the Global AMR R&D Hub.

Link to UN group:
Interagency Coordination Group on Antimicrobial Resistance
https://www.un.org/sg/en/content/sg/personnel-appointments/2017-03-17/interagency-coordination-group-antimicrobial-resistance


WHO Guidelines on the use of Medically Important Antimicrobials in Food-Producing Animals

The Guidelines, put together under the leadership of WHO's AGISAR (Advisory Group of Integrated Surveillance for AMR), Chaired by Pr Awa Aidara Kane, worked over a two year period for this publication, and brought together a wide array of experts, including representation from the OIE (Elisabeth Erlanger-Vindel) and FAO (Henk Jan Ormel), while being a distinct WHO publication. 

The Guidelines recall the UN commitment to work on a 'One Health' approach and the fact that many antimicrobials used in food-producing animals – as well as in plant production, including orchards - are identical or closely related to AM used in humans. AM are used to treat sick animals, but are also used as growth-promoters (whenever they have not been banned – the EU forbade them in 2006 in the EU, the FDA recommended to phase them out, but did not yet forbade their use), or used in prophylaxis for prevention These usages can lead to "selection and dissemination of AMR bacteria in food-producing animals, which can then be transmitted to humans via food and other transmission routes." (water and soil, notably – AMR-Times).

The Guidelines uses the CIA (Critically Important Antimicrobials) list, which CIA guidelines last came out recently, as the basis for its recommendations. At the Framework meeting, Pr Kane said no more CIA list will be issued from the WHO in the future, because of the changes in the guidelines system.

The Guidelines on the use of medically important AM in food-producing animals took two full years to assemble because of the need to gather as much scientific evidence as could be identified on this interaction.

The Guidelines recommend:

  • An overall reduction in use of all classes of medically important AM in food-producing Animals
  • Complete restriction of use of all classes of medically important AM in food-producing animals for growth promotion
  • Complete restriction of use of all classes of medically important AM in food-producing animals for prevention of infectious diseases that have not yet been clinically diagnosed

In case of the presence of disease, the Guidelines recommend:

-  AM classified as critically important for human medicine should not be used for control of the dissemination of a clinically diagnosed infectious disease identified within a group of food-producing animals.

- Suggest that AM classified as highest priority critically important for human medicine should not be used for treatment of food-producing animals with a clinically diagnosed infectious disease.

They include a remark that however this can be overruled depending on the best judgment of a veterinarian, when bacterial culture and sensitivity results show that the selected drug is the only treatment option. 

Basically, the approach is from the 'precautionary principle' (more in use in Europe than in the USA as a principle). The Guidelines document says the recommendations should be 'conditionals' because of the low quality of evidence, so far. 

However, implementing these restrictions carries no undesirable consequence or hardly, and 'several countries have successfully accomplished such a restriction, demonstrating its feasibility."

Best  practice statements:

1- Any new class of AM or new AM combination developed for use in humans will be considered critically important for human medicine unless categorized otherwise by WHO

2- Medically important AM that are not currently used in food production should not be used in the future in food production (animals or plants)

The rationale is that a number of medically important AM not currently used in food production are AM "of last resort" for humans... carbapenems, oxazolidinones (e.g.linezolid), and lpopeptides (e.g. daptomycin). Preserving these for human use is best practice.

Development and marketing of new classes of AM for humans is likely. (...)

They note further that these best practices are consistent with the OIE statement that "AM classes/sub-classes used only in human medicine are not on the OIE list of Antimicrobials of Veterinary Importance (OIE list).

(we used AM for antimicrobials and other abbreviations consistent with the need to compress the length of an email newsletter- AMR-Times)

In the beginning, with Recommendations

The Guidelines notably justify writing that : Extensive research into mechanisms of AMR, including the important role of horizontal gene transfer of AMR determinants, supports the conclusion that using AM in food-producing animals select for AMR in bacteria isolated (in these) animals, which then spread among them, into their environment, and to humans.  Furthermore systematic reviews concluded that broad restrictions covering all AM classes appear to be more effective.. compared to narrow restrictions,  even though there are examples of marked reductions in AMR following restriction of a single AM. Finally this is in agreement with the GAPAMR.

The Guideline document does not mention ways and means to decrease the need for AM by improving the living quarters of the animals or its hygiene.

AMR-Times: Overall the Recommendations of the Guidelines appear medically sound in view of the danger posed to human health of AMR spread, which have been amply documented by the AMR Review and other expert bodies reviewing scientific evidence. Considering that the greater share of antibiotics use is in agriculture, and notably in food producing animal,  the PRECAUTIONARY principle is understandable. Now, since PPP have arisen and a global effort has been mounted to help industry being new products to market, while sales would be limited for human medicines ("Reserve" class to use the Framework term), one may hypothesis that the anger at the Guidelines would come from economic interest. If implemented by all countries, these Guidelines would decrease sales now and freeze income expectations on sales of new products if these antibiotics were restricted in human health but not in agriculture.

Since AMR infections are obviously on the rise among food-producing animals, the temptation will increase to use latest state of the art products whose sale price could be quite high, and the decoupling would apply to volumes but not prices.

Now why is the agricultural sector reluctant to cut costs in purchases of antibiotics?

Other unrelated source materials on this issue:

Center for Science in the Public Interest : Antibiotic Resistance in Food-borne Pathogens.

This report details antibiotic‐resistant food-borne outbreaks from 1973 to 2011. In total, 55 outbreaks were identified (sickened 20,601 individuals, of whom 3,166 required hospitalization and 27 died ). Food items most likely associated with antibiotic resistant pathogens included dairy products, ground beef, and poultry. These three food categories were implicated in more than half of reported outbreaks (31 of 55). Salmonella spp. was the most common cause of antibiotic‐resistant outbreaks identified (48 of 55). Pathogens exhibiting multi-drug resistance to five or more antibiotics were identified in more than half of the outbreaks (31 of 55, 56%) 

Web=links: https://cspinet.org/sites/default/files/attachment/outbreaks_antibiotic_resistance_in_foodborne_pathogens_2013.pdf
Meat producers against WHO guidelines, Web=links: http://www.tipperarystar.ie/news/home/280602/tipperary-farming-factual-evidence-must-support-decisions-on-antibiotic-use-in-animals-says-ifa.html
Restricting the use of antibiotics in food-producing animals and its associations with antibiotic resistance in food-producing animals and human beings: a systematic review and meta-analysis, Web=links:
http://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(17)30141-9/fulltext?elsca1=tlxpr
Costs and Benefits of Antimicrobial Use in Livestock, Aude Teillant, Web=links: http://www.globalhealthdynamics.co.uk/wp-content/uploads/2015/05/19_Aude-Teillant.pdf


Survey details spread of livestock-associated MRSA in Europe

"Results from a survey published yesterday in Eurosurveillance indicate more frequent detection and greater geographical dispersion of livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) in Europe.

The survey and questionnaire from the European Centre for Disease Prevention and Control (ECDC) collected data on LA-MRSA subtypes identified among MRSA isolates by national or regional reference laboratories in European Union/European Economic Area (EU/EEA) countries in 2013. The samples included both clinical and screening isolates. Overall, 28 reference labs (26 national and 2 regional) from 27 of 30 EU/EEA countries responded.

The respondents reported receiving MRSA isolates from 14,291 patients in 2013, of which 13,756 (96.3%) were molecularly typed. LA-MRSA was identified by 17 of 19 countries (89%) with MRSA typing data. The Netherlands, Denmark, and Spain reported the most LA-MRSA isolates (164, 157, and 52, respectively). The overall percentage of typed MRSA isolates that were LA-MRSA was 3.9% (535 of 13,756).

Almost all LA-MRSA isolates belonged clonal complex (CC) 398, which is commonly associated with swine and is the most widespread MRSA lineage in Europe. The only non-CC398 subtype considered to be LA-MRSA came from Italy.

This was the first survey conducted on LA-MRSA in the EU/EEA since 2007, when only eight countries reported LA-MRSA isolates from human; in that survey, the proportion of MRSA that were LA-MRSA was above 2% in four countries and one region of Germany. The authors of the current study say the 2013 survey results, along with more recent data suggesting that LA-MRSA is spreading in the Nordic countries, the Netherlands, Germany, and the UK, indicate an apparent upward trend and more widespread dispersion of LA-MRSA across Europe. They're also concerned that labs in seven of the responding countries did not report any MRSA typing.

The ECDC is recommending that EU/EEA countries repeat the survey periodically to monitor for changes and map potential reservoirs and transmission pathways.
Nov 2 Eurosurveillance report
Nov 3 ECDC news release

Livestock-associated meticillin-resistant Staphylococcus aureus (LA-MRSA) among MRSA from humans across the EU/EEA, 2013: ECDC survey

Web=link: https://ecdc.europa.eu/en/news-events/livestock-associated-meticillin-resistant-staphylococcus-aureus-la-mrsa-among-mrsa


WHO initiated a mobilization on IPC on the occasion of the antibiotic awareness week

As presented by Director AMR at WHO, Dr Marc Sprenger

  • New infographic on the role of IPC in preventing antibiotic resistance in health care (http://www.who.int/infection-prevention/en/)
  • Online publication of a Lancet Global Health Commentary on 10 November on national and global priorities for IPC, authored by WHO, US CDC, and informed by the WHO’s Global Infection Prevention and Control Network (GIPCN)
  • Launch of the new WHO Guidelines for Carbapenem-resistant Enterobacteriaceae (CRE), Carbapenemase-producing (CP) Pseudomonas aeruginosa and Acinetobacter baumannii during WAAW
  • Presentation on these new guidelines by Professor Lindsay Grayson (Austin Health and University of Melbourne, Australia) on 13 November 2017 through Webber Training

Strengthening IPC and systematic surveillance of HAIs in India

Analysis Antimicrobial Resistance in South East Asia 

"Establishing and expanding government led networks to strengthen infection prevention and control and healthcare associated infection surveillance are essential to effectively tackle antimicrobial resistance. Soumya Swaminathan and colleagues discuss the progress in India"

Dr Soumya Swaminathan (the director of the Indian MRC, now DDG WHO). Systems, policies, and procedures to measure and prevent healthcare associated infections are essential for a comprehensive response to antimicrobial resistance, write the authors who propose  surveillance of HAI as to 'drive the implementation of evidence-based IPC'.

The wording is very important, because too often, even in the WHO programs, 'surveillance' is put in a different box, in a different implementation stream than IPC. And this can lead to just 'northern' experts traveling in LIC to take samples from patients and reporting back on bacterial resistance, even reporting on the national authorities. Here we are obviously talking about outbreak investigations and enlisting the health carers as a team to understand what went wrong and to implement better infection control measures. 

Soumya and colleagues write that "The quality and consistency of surveillance data on healthcare associated infections are limited in India"

"Ministry of Health agencies in India, with support from the CDC, are implementing healthcare associated infection surveillance that is tied to strengthening IPC practices and characterizing AMRpatterns."

"In India, and elsewhere in South East Asia, government led initiatives can be used to advocate for and prioritize commitment and funding to sustain healthcare associated infection surveillance and infection prevention and control programs.

"The models developed and lessons learned in implementation and expansion of HAI surveillance and IPC capacity building in India apply to other countries in South East Asia that also have a mix of public and private sector facilities, higher capacity referral centers in urban areas, and a large number of resource constrained healthcare facilities in both urban and rural areas. (This)...will improve the detection and prevention of AMR in India and other countries in the region. "

Web=lien: BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3768


Hospital architecture's role in prevention of AMR infection spread

Hospitals should design premises and adapt their infection control routines to a society that no longer has effective antibiotics, and that is vulnerable to fast spreading global pandemics. This is argued in a new dissertation from Lund University in Sweden, and was used to build a hospital accordingly in Sweden.
"Many hospitals in Sweden and the world are becoming old and worn out. ... (we had) the chance to build properly from an infection control point of view", says Torsten Holmdahl, doctoral student at Lund University and medical consultant at the infection clinic at Skåne University Hospital. 


High level of Syringe reuse in US Hospitals

A study conducted by the US Centers for Disease Control, CDC, found that "12% of physicians and 3% of nurses indicated syringe reuse occurs in their workplace”, and that in general “Unsafe injection practices were reported by both surveyed physicians and nurses.”

They conclude that action is needed to remedy this situation!!

American Journal of Infection Control Vol 45 issue 9 pages 2018-1023One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety, by Rachel Kossover-Smith et col.
Web=lien:
http://www.sciencedirect.com/science/article/pii/S0196655317306806


Other news roundup:
Dame Sally Davies in the Guardian

"We need some real work on the ground to make a difference or we risk the end of modern medicine.”

She added: “Not to be able to effectively treat infections means that cesarean sections, hip replacements, modern surgery, is risky. Modern cancer treatment is risky and transplant medicine becomes a thing of the past.”

Davies said that if the global community did not act then the progress that had been made in Britain may be undermined.

She estimated that about one in three or one in four prescriptions in UK primary care were probably not needed. “But other countries use vastly more antibiotics in the community and they need to start doing as we are, which is reducing usage,” she said. “Our latest data shows that we have reduced human consumption by 4.3% in 2014-15 from the year before.”

Web=lien:https://www.theguardian.com/society/2017/oct/13/antibiotic-resistance-could-spell-end-of-modern-medicine-says-chief-medic


Facing the challenges of and providing solutions for antimicrobial resistance (AMR) in the intensive care unit. A call for action from the ANTARCTICA (ANTimicrobiAl Resistance CriTIcal CAre) – coalition.

Brussels, 15 November 2017. Today, intensive care and infectious disease specialists from the European Society of Intensive Care Medicine (ESICM), European Society of Microbiology and Infectious Diseases (ESCMID) and World Alliance Against Antimicrobial Resistance (WAAAR), united in the ANTARCTICA (ANTimicrobiAl Resistance CriTIcal CAre) – coalition, call for increased awareness and action among intensive care and infectious diseases health care professionals to reduce AMR development in critically ill patients, to improve treatment of AMR infections and to coordinate scientific research in this high-risk patient population.

AMR is a clear and present danger to patients in any intensive care unit (ICU) around the world. It is associated with increased mortality, prolonged length of stay, increased costs and paradoxically, increased antibiotic use. Studies indicate that at least 25.000 patients die each year of AMR in the hospital, many of them in the ICU. The number of patients affected by and dying from AMR infections in Europe is expected to increase significantly in the next years; by 2050 an estimated 390.000 patients will die from AMR in European countries.

Whereas AMR may affect any patient in the hospital, patients in the ICU are particularly at risk of acquiring AMR infections due to the intensity of the treatment, use of invasive devices, increased risk of transmission and exposure to antibiotics. AMR is present in every ICU, although prevalence is geographically different and AMR pathogens encountered are variable. In Southern and Eastern Europe, the Middle East, and many countries in Asia, AMR is a daily challenge, with often limited options for antibiotic therapy. 

Despite this threat, we are confident that we can turn the tide on AMR in our ICUs because of a number of reasons: 

  • Knowledge about the mechanisms involved in the development and spread of AMR is increasing. 
  • Technologies to rapidly diagnose infections and document the involvement of AMR pathogens are becoming available.
  • New antibiotics particularly aimed at AMR pathogens are becoming available and many are under investigation. In parallel, non-antibiotic strategies to treat severe infections are under development.
  • The importance of infection control in hospitals is now recognized and infection control programs are increasingly effective in controlling the spread of AMR infections.

In order to consolidate this knowledge, the Coalition against antimicrobial resistance in critical care has identified priorities in four domains to improve AMR infection management in the ICU (figure 1) and urges healthcare professionals, scientific societies and industry to take action.

This will require concerted, multifaceted and continued action from healthcare professionals as well as all stake holders involved including patient organisations, scientific societies, pharmaceutical industry, health care policy makers and politicians. We are aware that the same threat applies to low income countries where unfortunately some of the high-technological options may not be available. Nevertheless, we are confident that the other low-cost components also apply and may help to reduce the burden of MDR in these countries. In the ICU, tackling AMR remains a responsibility shared by all healthcare workers, from physicians to maintenance personnel, from nurses to physiotherapists, from consultants to medical students. Together, we can reduce AMR in the ICU, and continue to treat our patients effectively. 

References: AMR Control 2017


A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway

A declaration by the Global Alliance on Infections in Surgery

Abstract

This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by AMR and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. Tofacilitate its dissemination, the declaration was translated in different languages.

Web=link: http://online.liebertpub.com/doi/pdfplus/10.1089/sur.2017.219
www.liebertpub.com/sur. (for other languages)
In AMR Control 2017,
Dr Massimo Sartelli, Global Alliance on Infections in Surgery
http://resistancecontrol.info/2017/infections-in-surgery-a-key-battleground-to-combat-antimicrobial-resistance/

Upcoming AMR-related events

2018

Jan. 26-28, 2018, France
Congrès de Pneumologie de Langue Française (CPLF), Lyon Centre de Congrès

Web=link: http://www.congres-pneumologie.fr/

Jan 29 – Feb 3, 2018 Thailand
Prince Mahidol Award Conference Secretariat Institute for Population and Social Research
Mahidol University 999 Phuttamonthon 4 Road, Salaya, Nakhon Pathom 73170, Thailand
Tel: (66) 2441-0203 to 4 ext 627 or 628
E-mail: pmaconference@mahidol.ac.th
www.pmaconference.mahidol.ac.th

 
February 15 -16, 2018, Dublin, Republic of Ireland
23rd International Symposium On Infections In The Critically Ill Patients; The aim of this two-day symposium is to review current concepts, technology and present advances in infections in critically ill patients. Sepsis, Pulmonary Infections, Basic Research, Pulmonary Infections Treatment and Prophylaxis Therapy of severe infections will be the topics of the main sessions presented by experts who will review and update the new advances on infections in the critically ill patient. At the end of each session a Clinical Controversy, Panel Discussion or Case Report Discussion will be organized.

Organized by: 
  • Antonio Artigas, MD Critical Care Center, Sabadell Hospital, University Institute Parc Taulí, Autonomous University of Barcelona, Ciberes, Spain
  • Jean Carlet, MD Consultant, President of the World Alliance Against Antibiotic Resistance (WAAAR)
  • I. Martin-Loeches, MD, St James's Hospital. Trinity Centre for Health Sciences. HRB-Welcome Trust St James's Hospital, Dublin, Ireland
  • Antoni Torres, MD, Pulmonology Department, Clinic Hospital of Barcelona, Ciberes, Spain
  • Michael Niederman, MD, Division of Pulmonary and Critical Care Medicine, New York Presbyterian Hospital, Weill Cornell Medical College, USA
Web=link: https://www.srlf.org/en/agenda/evenement/23rd-international-symposium-on-infections-in-the-critically-ill-patient-2

May. 2-4, 2018, Amsterdam, The Netherlands
The International Forum on Quality and Safety in Healthcare (BMJ) , taking place in Amsterdam on 2-4 May 2018

Weblink: http://internationalforum.bmj.com/
AMR-TIMES
This newsletter is published by the not-for-profit NGOs ACdeBMR/WAAAR and SOI.
Disclaimer: The named authors alone are responsible for the views expressed in this publication. The content does not commit the WAAAR or SOI associations.
The Editorial Board: 
-Garance Fannie Upham, Editor in Chief (garance@waaar.ch; editor@amr-times.info)
-Mostafa El Yamany (Egypt and the Netherlands), pharmacist and Ph.D. Candidate on AMR, Editor (editor@amr-times.info)
-Caterina Floriani Mussolini (Italy and the Graduate Institute, Switzerland), Editor and Associate Researcher (editor@amr-times.info)
-Hervé Jaqueson, computer scientist, co-editor, French edition (editor@amr-times.info)
-Christy Mulhall (USA), Associate Researcher & Reporter, "Global Health Security" 
-Amr El-Ateek (Egypt), Pharm.D., researcher, translator (Arabic), and collaborator
-Nora Mahfouf, (Algeria) Ph.D. student on AMR, journalist, and translator (Arabic)
-Jean-Jacques Monot, (France) Computer Engineer, database, and edition
-Aletha Wallace (Belgium/Liberia) Biotechnologist, MSc Health Sc. Management, contributor
-Chi XU (China and the Graduate Institute, Switzerland), Associate Researcher & Reporter

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