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Antimicrobial resistance
Dr Charles Beck, Consultant Epidemiologist, Field Epidemiology Service,
National Infection Service
Dr Chaamala Klinger, Consultant in Communicable Disease Control, PHE
South West
Objectives
•
To describe information sources and aspects of how to interpret AMR data
•
To provide an overview of planned developments on AMR surveillance
locally within PHE
•
To share resources and tools available to support local public health action
on AMR e.g. Antibiotic Guardian, eBug, NICE, Start Smart Then Focus,
TARGET,
•
To describe AMR plans and discuss their development with workshop
participants
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Health Protection Update Day, October 2016
Context
•
Antimicrobial resistance is an international concern
•
Threat to health security
•
UK five year AMR strategy 2013-18 and action plan published September
2013; PHE responsible for leading on human health aspects
•
Few new antibiotic classes in last 30 years especially against gram negative
organisms
•
Focus on mandatory HCAI organisms, but ESBLs and CPE are an
international concern
•
Field Epidemiology Service (FES) has key role in surveillance of infectious
diseases and management of incidents and outbreaks
•
FES has a national role in enhancing surveillance of AMR
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Annual reports to mandatory and voluntary
MRSA bacteraemia surveillance
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ESPAUR report (2015) - antibiotic resistance in key infections, England, 2010−2014
*The arrows mean the
following: ↑statistically
significant increase;↓statistically
significant decrease;↔ no
statistically significant change.
^Due to differences in testing
methodology, results cannot be
compared. Antibiotic
susceptibility test results
reported as “intermediate” or
“resistant” were combined and
presented as “non-susceptible”,
as either result would usually
preclude treatment of the
bacteria with standard doses of
the antibiotic.
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ESPAUR report (2015) - summary of antibiotic consumption in general practice and
NHS trusts, presented as DDD per 1000 inhabitants per day (with changes
compared to 2010*), England, 2010−2014
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Incidence of bloodstream infections,
England, 2010-2014
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Proportions of non-susceptible bloodstream
isolates of E. coli, England, 2010-14
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Number and proportion of TB cases with
drug resistance, England, 2005−2014
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Numbers of isolates confirmed as carbapenemaseproducing Enterobacteriaceae by AMRHAI*
* = Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit
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Case example: Klebsiella pneumoniae
•
K. pneumoniae is an Enterobacteriaceae which causes healthcare
associated infections
•
Colonises the skin, GI tract and respiratory tract in hospitalised patients
•
May cause pneumonia, septicaemia, wound or surgical site infections,
meningitis, urinary tract infections in catheterised patients, clinical sepsis,
bacteraemia and death
•
Most frequently isolated species of Klebsiella in healthcare settings
•
Person-to-person transmission following close contact
•
Healthy individuals at low risk of symptomatic infections
•
Outbreaks previously reported
•
Naturally resistant to numerous antibiotics and can readily acquire
resistance
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Multidrug-resistant Klebsiella pneumoniae isolates in participating
countries in 2009 (resistant to third-generation cephalosporins,
fluoroquinolones and aminoglycosides)
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Multidrug-resistant Klebsiella pneumoniae isolates in participating
countries in 2011 (resistant to third-generation cephalosporins,
fluoroquinolones and aminoglycosides)
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Multidrug-resistant Klebsiella pneumoniae isolates in participating
countries in 2013 (resistant to third-generation cephalosporins,
fluoroquinolones and aminoglycosides)
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Multidrug-resistant Klebsiella pneumoniae isolates in participating
countries in 2014 (resistant to third-generation cephalosporins,
fluoroquinolones and aminoglycosides)
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Proportion of carbapenems resistant (R+I) Klebsiella
pneumoniae isolates in participating countries in 2009
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Proportion of carbapenems resistant (R+I) Klebsiella
pneumoniae isolates in participating countries in 2011
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Proportion of carbapenems resistant (R+I) Klebsiella
pneumoniae isolates in participating countries in 2013
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Proportion of carbapenems resistant (R+I) Klebsiella
pneumoniae isolates in participating countries in 2014
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Surveillance in England
• Cornerstone to epidemiology of AMR and intervention effectiveness
• SGSS - receives isolate data from NHS laboratories and some
private labs; previous systems:
• CoSurv – notifiable and ‘significant’ infections (CDR data feed)
• AmSurv – all positive isolates (AMR data feed)
• Web-enabled interface including analytical tools
• Automation of laboratory data submission to SGSS
• Laboratory coverage in AmSurv was initially poor; 95% of NHS
microbiology laboratories submitting AMR data to PHE in 2014
• Selected drug/bug combinations reported quarterly by FES –
separate workbooks for acute trusts and community
• Enhanced CPE surveillance system launched recently
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SGSS
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Limitations
• Case definitions
• Diagnostic variation
• Antimicrobial panel variation
• Speciation variation
• Standard microbial investigations
• No linkage to clinical or prescribing data
• Voluntary reporting (some organisms)
• Epidemiological biases e.g. ascertainment bias
• No data from negative samples to inform testing denominators
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Future actions and potential research
• Continued development of surveillance arrangements for AMR
• Improvement of quality and standardisation of routine antibiotic
testing and interpretation
• Publication of locally relevant data; automated reporting
• Improving epidemiological understanding of risk factors
• Impact of improved resistance data informing antimicrobial
stewardship and prescribing practice, for example:
• Change in prescribing rates
• Alterations in drug use
• Effect on resistance patterns
• Change in outcomes
• Whole genome sequencing – surveillance, outbreak investigation
and infection control
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Phylogenetic reconstruction
of S. aureus clonal complex
5 (CC5). Branch colour
indicates MSSA (green) or
MRSA (red). Clusters are
shaded grey. Symbols at the
tips indicate the geographic
origins of these isolates
Source: Aanensen et al. Whole-Genome Sequencing for Routine Pathogen Surveillance in Public Health: a Population
Snapshot of Invasive Staphylococcus aureus in Europe. mBio 7(3):e00444-16. doi:10.1128/mBio.00444-16.
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Phylogenetic reconstruction of S. aureus CC22.
Branch colour indicates MSSA (green) or MRSA
(red). The epidemic MRSA-15 cluster is shaded grey.
Symbols at the tips of the branches indicate the
geographic origins of these isolates. A cluster
consisting of isolates from Berlin indicating the
possible point of epidemic MRSA-15 introduction into
Germany from the UK is shaded a darker grey. The
position of an isolate from Lisbon is shown indicating
the possible location of its entry into Portugal.
Source: Aanensen et al. Whole-Genome Sequencing for Routine Pathogen Surveillance in Public Health: a Population
Snapshot of Invasive Staphylococcus aureus in Europe. mBio 7(3):e00444-16. doi:10.1128/mBio.00444-16.
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Source: Stucki et al. Standard Genotyping Overestimates Transmission of Mycobacterium tuberculosis among Immigrants in
a Low-Incidence Country. J Clin Microbiol 2016; 54(7): 1862-70.
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Resources for practice
• Browse to www.gov.uk
and search “antimicrobial
resistance resource
handbook”
• http://fingertips.phe.org.uk
/profile/amr-localindicators
• http://ecdc.europa.eu/en/
healthtopics/antimicrobial
-resistance-andconsumption/antimicrobia
l_resistance/EARSNet/Pages/EARSNet.aspx
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Fingertips
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Fingertips
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Thank you for your attention
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The Five Year UK AMR strategy
1. Improving infection prevention and control practices
2. Optimising prescribing practices (stewardship)
3. Improving professional education, training and public
engagement
4. Developing new drugs, treatments and diagnostics
5. Better access to and use of surveillance data
6. Better identification of research needs
7. Strengthened international collaboration
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Loss of antibiotics and future impact
Key document
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Loss of antibiotics and future impact
Some key resources
Public Engagement
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Loss of antibiotics and future impact
Some resources
Stewardship- primary care
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Loss of antibiotics and future impact
Some resources
Stewardship- secondary care
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Loss of antibiotics and future impact
NICE Guideline [NG15]
Antimicrobial stewardship:
systems and
processes for effective
antimicrobial medicine use
August 2015
AMR in your locality
What are your assets?
What are your challenges?
Who are your key partners?
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Loss of antibiotics and future impact
AMR – possible partners for action
NHS
JSNA process
England
and HWB
Local
Pharmacy
Network
Council
Health trainers
Child health
AMR
Action
Council
Group
Primary
care
Communicationschools,
Community
librabries,
health and
community
social care
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Loss of antibiotics and future impact
Acute
Trusts
Adult services
CCG