The role of an AMR reference laboratorycarpha.org/Portals/0/docs/MEETINGS/AMR Workshop/3... · What...

The role of an AMR reference laboratory

Professor Neil Woodford

Antimicrobial Resistance & Healthcare Associated Infections (AMRHAI) Reference Unit

© Crown copyright

Primary purpose: regional AMR threats to healthcare

Colonized residents

or visitors

Non-human

reservoirs: animals

and environment

Victims from

conflict zones

Hospital treatment or

travel overseas

• Multiple risks to be assessed to minimize damage

• Requires the detail to be understood

• Continuous education of NHS staff at all levels

Inter-hospital

transfers

Non-human

reservoirs: foodstuffs

(domestic or imported)

2 CARPHA Workshop, 9th December 2014 © Crown Copyright

What tests should an AMR reference laboratory offer ?

• What the customer wants (…are you sure about this ?)

• Expert advice about their needs / how this may differ from their wishes

• What do resources allow ?

• Regular review of its services


Needs

Demands


• What the customer wants (…are you sure about this ?)

• Expert advice about their needs / how this may differ from their wishes

• What do resources allow ?

• Regular review of its services

* Reference Laboratory must be objective, not defensive


Customers don’t

need / want

Customers

need / want

Ref Lab doesn’t offer ✖ Negotiate / Review*

Ref Lab offers Satisfies wider need* ✔


• Susceptibility testing for confirmation of exceptional resistances

• Infer resistance mechanisms from antibiograms

• Investigation of priority resistance mechanisms

• Strain typing to aid outbreak investigation

• Treatment advice; infection prevention & control advice

• +/- Research

• +/- Evaluations of new drugs / diagnostics


My Unit’s goals

• Setting England’s (the UK’s) Resistance and HCAI Problems into

National and Global Context

• Better understanding of (resistant) bacterial clones

• distribution (global, national , regional)

• contribution resistance plays to success

• Coordinated surveillance of mechanisms

• global, regional and national

• Identify geographic ‘hot spots’ and ‘high risk’ patients

• early, targeted IPC interventions


AMRHAI’s Research Agenda

Setting England’s (the UK’s) Resistance and HCAI Problems into

National and Global Context

• Outbreak strains

• Resistance elements

• Population biology, ecology and biogeography

• Transmission pathways

• Reasons for success

• Better diagnostics, therapies and rational interventions


Our commonest AMR-related questions

• Can you confirm resistance to drug ‘X’ ?

• We got different AST results with two methods. Which is right ?

• Why is this isolate resistant to drug ‘X’ ?

• Are these isolates the same / different - is there evidence for

transmission?

• What can I treat the patient with ?

• …increasingly, does resistance in these different strains / species /

genera represent plasmid spread ?



International Consensus:

AMR is a critical public health threat

The resistance ratchet keeps turning

Pathogen Established problems Emerging threats

E. faecium VRE, HLGR, Amp-R Lin-R, Dap-R, Tig-R

S. aureus MRSA (ha/ca) Van-R, Lin-R, Dap-R

Klebsiella ESBLs Carbapenemases, Col-R

Acinetobacter MDR, Carbapenemases Tig-R, Col-R

Pseudomonas MDR, except Col Carbapenemases, Col-R

Enterobacter AmpC, ESBLs Carba-R, Carbapenemases

E. coli Cip-R, ESBLs Carbapenemases

• 5 of 7 ESKAPEEs are Gram-negative

• Increasing reliance on carbapenems

• The resistance issue for the next 5-10 years


Raising awareness of resistance: the

AMRHAI Newsletter

• Twice a year

• Short, chatty pieces

(coffee break reading)

• Service updates

• Wider science

• Sent electronically to our entire

customer database

• Links to PubMed entries for all of our

publications in previous 6 months


Reference labs must work with surveillance scientists

Pathogen % carbapenem resistance

2008 2009 2010 2011 2012 2013

E. coli 0.08 0.09 0.11 0.18 0.25 0.22

K. pneumoniae 0.7 0.4 0.6 1.2 1.1 1.6

12 CARPHA Workshop, 9th December 2014 © Crown Copyright Courtesy, Prof Alan Johnson

• Should provide specialist microbiology that seeks to explain trends

• Should be at the centre of a national / regional laboratory network

• Should benefit from a ‘spider’s web effect’

• Should monitor new and emerging AMR issues, long before they

register in surveillance programmes

CPE in the UK, 2000-2013

Klebsiella spp. 79%; E. coli 12%, Enterobacter spp., 7%; others 2%

0

200

400

600

800

1000

1200

Fre

qu

en

cy

IMP VIM KPC OXA-48 NDM IMI KPC + VIM NDM + OXA-48

13 CARPHA Workshop, 9th December 2014 © Crown Copyright AMRHAI, Unpublished data

Early cases often imported

Imported & ‘home grown’

Raising awareness of resistance:

Resistance Alerts

• Dec ’05 - Carbapenem-

resistant Enterobacteriaceae

• Jan ’09 - Carbapenemase-

producing

Enterobacteriaceae in the

UK: multi-faceted emergence

• Jul ’09 - NDM (New Delhi

Metallo-) -lactamase:

repeated importation from

Indian subcontinent


National & international capacity building

• Without lab testing we’re blind to (the extent of) AMR problems

• Improve lab access; aim for a reference lab in every country / region

• Each serving as the hub of a national network

• Each acting as a spoke in an international network

• Performing essential techniques, proficient to international standards

• Sharing data / experience

15 Tokyo, 10th November 2014 © Crown Copyright

Goals for the future

• Better capture of patient-level meta-

data, linked with lab data

• Routine deployment of WGS for

typing and resistance analysis

• evaluate accuracy of resistance

/ susceptibility prediction

• discover novel mechanisms

• Robust (sensitive and specific)

rapid diagnostics

• New treatment options


Effective IPC

Outbreaks

contained

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