Transcript AAAS_Kessel_AMR_2015_feb_4

“Back in Time”: Surveillance for Public
Health Action
American Association for the Advancement of Science (AAAS)
‘Bugs Without Borders’ session
Annual Conference, San Jose, 13 February 2015
Professor Anthony Kessel
Director of International Public Health
Public Health England
Outline of talk
• Historical backdrop
• Global picture of antimicrobial resistance
(AMR)
• Surveillance of AMR in England
– Public Health Actions
• Philosophical challenges for One Health
approach to AMR
• Conclusions
Timeline I: Discovery of microbes and the first
systematic infection control policies in hospitals
Anton van Leeuwenhoek
1676
Florence Nightingale
antiseptic hand wash
discovery of bacteria
1840s
proposition of germ theory
hygiene in field
hospitals
Ignaz Semmelweiss
Theory of Miasma
1847
Joseph Lister
1864
1870
causal link between bacteria and
disease
introduction of antiseptic
Louis Pasteur
surgery
1890
Robert Koch
Germ Theory
Timeline II: From germ theory to
antimicrobial therapy
William S. Halstead
1890
Alexander Fleming
Introduction of
surgical masks
introduction of surgical
1897
gloves
1928
discovery of
penicillin
Johannes Mikulicz-Radecki
Pre-antibiotic age
Selman Waksman
1943 “The time has come to close the
discovery of
sulfonamides
book on infectious diseases”
Streptomycin
is discovered
1932
Gerhard Domagk
Antibiotic age
1967
Surgeon Gen. William Stewart
Timeline III: From antimicrobial therapy to
antimicrobial resistance
Penicillin resistance
1948
Treatment for plant
diseases
Resistance observed
in Staphylococci 1952
1955
Methicillin resistance
in S. aureus
S. Dysaentriae
outbreak in Japan
Streptomycin first used in agriculture
Antibiotic age
*http://www.bbc.co.uk/news/health-16592199
TB & MDR-TB ‘global health emergency
’
First MDR case
1961
1993 First confirmed case of completely
drug-resistant TB in Mumbai*
WHO declaration
First case of MRSA
2011
Complete drug resistance
Post-antibiotic age?
Review on AMR (O’Neill)
Review on AMR (O’Neill)
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Global Picture: AMR Surveillance
World Health Organization 2014 surveillance
report:
“…very
high rates of resistance have been
observed in all WHO regions in common
bacteria…”
There are significant gaps in
global surveillance
Many countries are
reporting AMR data
on less than 5/9 WHO
microbes of
international concern.
Some of best data
on AMR is from
disease-specific
programmes (e.g.
TB).
Global antimicrobial resistance picture: XDR-TB
 Since the
introduction of antiTB drugs in 1940s
cases of drug
resistant TB have
been observed with
increasing
frequency.
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AMR in the United States
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AMR in Europe
ECDC surveillance report 2012
A majority of the E. Coli and K. pneumoniae
isolates reported to EARS-Net in 2012 was
resistant to at least one of the antimicrobials
under surveillance…
The percentage of carbapenem resistance among K. pneumoniae
isolates increased during 2012…
….most commonly reported from southern Europe.
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Proportion of resistant E. Coli isolates in 2012
Data source: ECDC (EARS-Net)
Aminoglycosides Resistant
3rd gen. cephalosporins Resistant
Fluoroquinolones
Resistant
Antibiotic (mis)use drives resistance
Global: 36%
increase in
consumption
of antibiotic
drugs
(2000-2010)
- increased
consumption of
carbapenems
(45%)
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Global consumption of antibiotics
2000-2010
•In 2010, the high-income
Asian countries and regions
(Hong Kong, Malaysia,
Singapore, and South Korea)
all ranked within the top eight
consumers of antibiotics per
person.
•From 2000-2010, antibiotic
consumption increased
substantially in developing
countries, with the highest
rates shown in BRICS
countries (Brazil, Russia, India,
China, and South Africa) and
French West Africa.
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Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2010: an analysis of national
pharmaceutical sales data; Lancet Infect Dis 2014; 14: 742–50
Surveillance of AMR in England
English Surveillance Programme for Antimicrobial Utilisation and Resistance
(ESPAUR)
First ESAPUR report to be published in October 2014
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Summary of 2014 ESPAUR Report
Antibiotic resistance is a key threat to everyone’s health and modern
medical care.
In England
• The number of patients with bloodstream infections has increased each
year, 2010 to 2013 (e.g. 12% for E.coli)
• Increased numbers of these bloodstream infections are caused by
resistant bacteria, 2010 to 2013
• Antibiotic prescribing to patients has increased by 6% between 2010 to
2013 (GP 4% rise; Hospital 12% rise)
• Almost 80% of antibiotics are prescribed by General Practices
• Significant variability of resistance and antibiotics prescribing
• Concerning data for resistance and prescribing in England
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ESPAUR data – ESPAUR Report 2014
Antimicrobial resistance
Pathogen
Escherichia
coli
Klebsiella
pneumoniae
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Rate 2013
per
100,000
(compare
d to 2010)
52.6 (↑)
8.8 (↑)
Pseudomonas
spp.
6.3 (↓)
Streptococcus
pneumoniae
6.1 (↓)
Antibiotic or
antibiotic class
Ciprofloxacin
Third-generation
cephalosporins
Gentamicin
Imipenem/meropenem
Ciprofloxacin
Third-generation
cephalosporins
Gentamicin
Imipenem/meropenem
Ciprofloxacin
Ceftazidime
Gentamicin
Imipenem/meropenem
Penicillin
Macrolides
Tetracycline
ESPAUR data – ESPAUR Report 2014
%
resistant
2013
(compared
to 2010)
18.2 (↔)
10.9 (↔)
Change in
number of
resistant
bacteria
2010 to 2013
↑
↑
%
resistant
Europe
2012
9.7 (↔)
0.1 (↔)
11.1 (↔)
11.4 (↔)
↑
↑
↑
↑
10.3
<0.1
25.3
25.7
8.5 (↑)
1.0 (↑)
10.4 (↔)
6.7 (↔)
3.6 (↓)
9.5 (↔)
3.1 (↔)
8.1 (↑)
6.1(↑)
↑
↑
↑
↓
↓
↓
↓
↑
↑
22.2
6.2
21.0
13.5
18.4
17.1
4.6
8.5
-
22.3
11.8
Resistance in Escherichia coli
Proportion resistance stable
Increased rate of bacteraemias & antibiotic resistant bacteraemias
Regional variation across the country
Counts of E. coli isolates non-susceptible to
ciprofloxacin, third-generation cephalosporins and
gentamicin, based on voluntary reporting to LabBase2,
England 2010-2013
Proportions of E. coli bloodstream infection isolates
non-susceptible to indicated antibiotics at the level of
NHS Area Team in 2013.
Grey areas represent ATs where <70% of isolates had susceptibility data
available
Antimicrobial Prescribing
Antibiotic group
Penicillins
Other β-lactam antibacterials
Tetracyclines
Sulfonamides and trimethoprim
Macrolides & similar
Quinolones
Other
Total
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ESPAUR data – ESPAUR Report 2014
England 2013
England 2013
(DDD per 1000
compared to
inhabitants per
England 2010
day)
13.7
0.6
4.9
1.9
4.1
0.6
1.7
27.4
Europe 2011
(Median DDD per
1000 inhabitants
per day)
↑
10.4
↓
2
↑
2.2
↑
0.5
↑
3
↓
1.5
↑
1.7
↑
21.3
Significant regional variation
General Practice
•
•
Durham, Darlington and Tees, which was over 40% higher than London
26.5 compared to 18.9 DDD per 1000 Inhabitants per Day (DID)
Hospital
•
•
London twice Leicestershire and Lincolnshire
6.0 DID compared to 2.9 DID
Total
• Merseyside, highest (similar to Southern Europe) over 30% higher Thames Valley
• 30.4 DID compared to 22.8 DID
General Practice consumption
by ATs,
England, 2013
Hospital consumption, by ATs,
England, 2013
Total consumption, by ATs,
England, 2013
Global action on AMR
• WHA 2014 resolution
• WHO Global AMR Action Plan 2015 – framework for
action
• Global Health Security Agenda: AMR action package
- mechanism and collaboration to accelerate
implementation
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UK 5-year AMR Strategy 2013 -18
‘One Health’
CMO Annual
Report 2011*
Strategic aims
1. Improve the
knowledge and
understanding of AMR
2. Conserve and steward
the effectiveness of
existing treatments
*published: March 2013
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3. Stimulate the
development of new
antibiotics, diagnostics
and novel therapies
UK 5-year AMR Strategy 2013-18:
Seven key areas for action
DH – High Level Steering Group
1.
2.
3.
4.
PHE
Defra
Human health
Animal health
Optimising prescribing practice
Improving infection prevention and
control
Improving professional education,
training and public engagement
Better access to and use of
surveillance data
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DH
• Improving the evidence
base through research
• Developing new drugs,
vaccines and other
diagnostics and
treatments
• Strengthening UK and
international
collaboration
National actions
1. Optimising prescribing practice
•
Implementation of national antibiotic prescribing competencies
•
Antimicrobial Prescribing Quality Measures (APQM)
2. Improving infection prevention and control
•
Developing a national strategy for Infection Prevention and Control across the health and care system in
2015
3. Improving professional education, training and public engagement
•
Implementation of national antibiotic prescribing competencies
•
NICE Guideline ‘Antimicrobial stewardship: systems and processes for effective antimicrobial medicines
use’ (May 2015)
•
NICE Public Health Guideline: Antimicrobial resistance: changing risk-related behaviours (March 2016)
4. Better access to and use of surveillance data
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•
Infections in Critical Care Quality Improvement Programme (ICCQIP)
•
The English Surveillance Programme for AMR usage and resistance (ESPAUR)
National actions
Longitude prize challenge….
create a cost-effective, accurate
rapid and easy-to-use test for
bacterial infections
Research coordination…
UK AMR Funders Forum….
Joint Programming Initiative on
AMR (Europe)…
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Prime minister’s Commission
on Antibiotic Resistance...
encouraging the development
of new antibiotics…
Public Engagement: e-Bug
E-Bug for school
children
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Become an antibiotic guardian today
http://antibioticguardian.com/
René Descartes (31 March 1596 –11 February 1650)
Immanuel Kant (22April 1724 –12 February 1804)
John Stuart Mill (20 May 1806 –8 May 1873)
Environmental philosophy
INSTRUMENTAL VALUE
(MORAL WORTH)
VS
INTRINSIC / INHERENT VALUE
(MORAL WORTH)
Conclusions
• Tackling AMR requires collaborative cross-sectoral
approach, nationally and internationally
• Surveillance a foundational tool for public health
action
• Thinking about antibiotics as an invaluable societal
resource
• Harmonisation of One Health approach
SCIENTISTS CAN PLAY THEIR PART!
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