A NARMS Update - APHL...A NARMS Update Tom Chiller MD MPH Enteric Diseases Epidemiology Branch...
Transcript of A NARMS Update - APHL...A NARMS Update Tom Chiller MD MPH Enteric Diseases Epidemiology Branch...
Another 10th Year Anniversary:A NARMS Update
Tom Chiller MD MPHEnteric Diseases Epidemiology Branch
Division of Foodborne, Bacterial and Mycotic DiseasesCenters for Disease Control and Prevention
Atlanta GA
National Antimicrobial Resistance Monitoring System (NARMS)
• Established in 1996 (10 years old)• Three components
– CDC: Human surveillance (1996)– USDA: Animal surveillance (1996)– FDA-CVM: Retail meat surveillance (2002)
• Microbiologists and Epidemiologists• Human, Veterinary, and Food Disciplines
1944
Antibiotic Resistance• Global problem
– Emergence – Dissemination
• Antibiotics are widely used in humans and animals– Overuse and misuse in humans and animals
• Empirical therapy • Non-therapeutic uses
• Complex: interaction of antimicrobials, resistance mechanisms, and pathogenicity of bacteria
There are > 100 antibacterial agents currently approved for
use in clinical medicine.
However, resistance has followed the development of
each new antibiotic.
Antimicrobial Resistance and the role of the Food Supply
• Antibiotics are commonly used in food animals– Selects for antimicrobial resistant bacteria
• Food animals constitute an important reservoir of– Resistant bacteria– Resistance genes - transferable
• Resistant bacteria can be transmitted to humans through the food supply– Most evident with pathogens (Salmonella and
Campylobacter)– Also occurs with commensal bacteria (Enterococci)
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Human use Animal use(AHI)
Animal use(UCS)
Use inmillions ofpounds
Estimates of Antibiotic Use
Dissemination of StreptothricinResistance in E. coli
Origin 1982 1983 1984 1985 1986 1987
Pigs - + + + + +Farm Personnel - - + + + +Farm Families - - + + + +Community - - - + + +Community UTI’s - - - + + +S. sonnei - - - - - +
From: Witte, W. 1997. Antibiotic resistance, Ciba Foundation SymFrom: Witte, W. 1997. Antibiotic resistance, Ciba Foundation Symposium 207posium 207
Nourseothricin introduced in animal feed in 1983 in former East Germany
Bacteria Tested in NARMSHuman, Food, Animal• Non-Typhi Salmonella• Campylobacter• Enterococci
Food, Animal• Generic E. coli
Human & Animal• E. coli 0157:H7• Listeria
Human only• S. Typhi• Shigella• Listeria - sometimes
1996: 14 sites 1999: 17 sitesHuman NARMS 1996-2006
2002: 28 sites 2003: 54 sites
NARMS Sites
Human Isolate Sampling • Bacteria are isolated and identified at the
state health departments• Passive Surveillance
– Isolates Submitted to CDC/NARMS• Nationwide
– Every 20th non-Typhi Salmonella, Shigella, and E. coli O157
– All Salmonella Typhi, Listeria, and Vibrio– Representative sample of Campylobacter from 10
states sites
Unique Characteristics
• Only surveillance system where all 50 states send bacteria routinely to CDC
• High level of ivolvement– Quarterly conference calls with over 45
states joining– Nationwide IRB for special studies
Accomplishments and Goals
• 2005 PulseNet Goals– Pulse all NARMS isolates– Common state ID for NARMS/PulseNet
• Provide summary data and integrate• Link data • Increase outbreak isolate testing• Web access to data
Percentage of Campylobacter isolates resistant to ciprofloxacin (MIC≥4), by year,1997-2004*
12.9 13.918.3
14.819.5 20.1
17.7 18.3
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1997(N=217)
1998(N=310)
1999(N=317)
2000(N=324)
2001(N=384)
2002(N=354)
2003(N=328)
2004(N=415)
Year
Perc
ent
Preliminary 2004
*
2002 vs 1997: OR=1.7 (95% CI 1.1, 2.7)
Fluoroquinolone use and percent resistance in Campylobacter, 1987-2004
13 14
1815
19 2018 18
86 90 94 97 02 05Year
Approved for use in humans
Approved for use in poultry
2004 Preliminary Data
FDA withdrewapproval
County surveys
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Regulatory Action: Flouroquinolones and Poultry
• FDA proposes withdrawal of flouroquinolones use for poultry in 2003
• Industry appeals decision • NARMS data used at hearings to
support FDA’s withdrawal• Judge rules to withdraw FQ• FDA commissioner officially withdraws
FQ in 2005
Avian Influenza and Antiviral Use in Poultry
• Evidence for use of anti-virals (amantadine) in poultry in China and SE Asia
• Joint FAO/OIE/WHO statement: ‘‘Use of Antiviral Drugs in Poultry, a Threat to Their Effectiveness for The Treatment of Human AvianInfluenza,’’ November 11, 2005
March 2006• The Food and Drug Administration (FDA) is issuing an order
prohibiting the extralabel use of anti-influenza adamantane and neuraminidase inhibitor drugs in chickens, turkeys, and ducks. We are issuing this order based on evidence that extralabel use of these antiinfluenza drugs in chickens, 21 CFR Part 530 [Docket No. 2006N–0106]
Order of Prohibition: New Animal DrugsEffective date June 1 2006
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1980 1983 1986 1989 1992 1995 1998 2001 2004
Perc
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Percent of Salmonella Typhimurium isolates with multidrug ACSSuT
resistance pattern (1980 – 2004)
NARMS launchedCounty surveys
Percentage of S. Typhimurium resistant to at least ACSSuT, by year, 1996-2004*
34 35 32 28 28 3021 26 23
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Year
Perc
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* 2004 preliminary data
34% in 1996 to 23% in 2004 OR=0.6 [95% CI 0.4, 0.8]
PositiveCulture
PulseNet
Case ReportForms
PHLIS/FoodNet
eFORS
NARMS
Routine NARMSIsolates(34,816)
PulseNet Isolates(170,927)
Salmonellaisolates(17,617)
SalmonellaSchwarzengrund
isolates(71)
Linked isolates with PFGE and susceptibility results
(40)
Salmonellaisolates(118,179)
SalmonellaSchwarzengrund
isolates(582)
US SalmonellaSchwarzengrund
Isolates
19 18
2723
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Pat
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s BothACSSuTACSSuT Susceptible
Number of Unique XbaI Patterns Among Linked SalmonellaTyphimurium with ACSSuT Resistance
Number of Isolates N=36 N=34 N=68 N=53
JPXX01.0003
Clinical Relevance of Nalidixic Acid Resistance in Non-Typhi Salmonella
• Nalidixic acid is the prototype quinolone• Nalidixic acid resistance correlates with
decreased susceptibility to ciprofloxacin (MIC ≥ 0.12 µg/mL)
• Fluoroquinolone-susceptible strains of Salmonella that test resistant to nalidixic acid may be associated with clinical failure/delayed response in fluoroquinolone-treated patients with salmonellosis
Percentage of S. Enteritidis resistant to nalidixic acid, by year, 1996-2004*
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1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Resistant to nalidixic acid
* 2004 preliminary data
1% in 1996 to 6% in 2004 OR=8.9 [95% CI 2.3, 50.3]
117 9
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Num
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XbaI
Pat
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Resistant to Nalidixic Acid
Nalidixic Acid Susceptible
Number of Unique XbaI Patterns Among Linked Salmonella Enteritidis with Nalidixic Acid Resistance
Number of Isolates N=38 N=43 N=66 N=99
JEGX01.0002
JEGX01.0002
JEGX01.0002JEGX01.0002
S. Paratyphi A:Emergence of Quinolone Resistance
• Ciprofloxacin, a fluoroquinolone, is the first line agent• Increasing resistance to nalidixic acid (18 - 100%) • Correlates with decreased susceptibility to
ciprofloxacin (DSC)• DSC causes poor clinical response or treatment failure• Full ciprofloxacin resistance also reported • Resistance to other drugs has already occurred, and
so could become impossible to treat in endemic areas
Salmonella Paratyphi A and TyphiUnited States, 1968-2003
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1968 1973 1978 1983 1988 1993 1998 2003Year
Rat
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r 100
,000
per
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National Salmonella Surveillance System, CDC
S. Typhi
S. Paratyphi A
Methods
• One year study beginning April 1, 2005
• For all paratyphoid fever patients, all state health departments agreed to:
– Perform standard interview, asking about clinical and travel history
– Send clinical isolates to CDC for antimicrobial susceptibility testing
• Interview and laboratory data compared at CDC
ResultsApril 1, 2005 to January 31, 2006
• 93 S. Paratyphi A cases identified– 62 interviews completed– 59 isolates tested– 40 with both interview and test results
• 224 S. Typhi cases in 2003
Results are preliminary
Foreign travel
• 95% (58/61) traveled outside United States within 30 days before illness onset
• 85% (45/53) travelers visited friends or family
• 70% (40/57) born outside the United States
Countries visited (N=58)• South Asia 53 91%
– India 40 69%
– Bangladesh 9 16%
– Pakistan 5 9%
• Southeast Asia 5 9%– Indonesia 2 3%
– Cambodia 2 3%
• Latin America 1 2%– Brazil 1 2%
Antimicrobial susceptibility (N=59)
• Nalidixic acid resistant 47 80%
– DSC * 46 78%
– Ciprofloxacin sensitive 1 2%
* MIC between 0.12 and 1 mcg/ml
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Nalidixic AcidResistant
Nalidixic AcidSensitive
Trav
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sia
p < 0.01, Fisher’s exact test
94%
44%
n=31
n=9
Quinolone resistance and travel to South Asia
International ActivitiesWHO Global Salm-Surv
Argentina
Mexico
Poland
ThailandTrinidad
Cameroon
Egypt
Russia, St. Petersburg
China
Regional CentreTraining SiteProposed Training Site
Kazakhstan
Kenya
Brazil
Western/Southern Europe
South Africa
Russia, Moscow
India
International Network of Integrated Antimicrobial Resistance Surveillance in
Enteric Bacteria(INISAR)
• Emerging bacteria – C. diff
• Testing methods– Support– Harmonize
• Reporting– Res vs Non-Sus– Define MDR (class or drug)– Statistical issues
CDC’s Programs To Reduce the Spread of
Antimicrobial Resistance
Environment
HospitalCommunity
Cycle of Foodborne Disease Control and Prevention
Surveillance
EpidemiologicInvestigation
AppliedResearch
PreventionMeasures
LINKING
Thank You