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Surveillance of antimicrobial resistance

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Transient nasal carriage (MRSA) Data validity. Specificity ... Carriage. Disease. Antibiotic. treatment. Treatment failure. Data validity ... – PowerPoint PPT presentation

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Title: Surveillance of antimicrobial resistance


1
Surveillance of antimicrobial resistance
  • Liselotte Högberg
  • Swedish Institute for Infectious Disease Control
  • E-mail liselotte.hogberg_at_smi.ki.se

2
OVERVIEW Basic principles Why, what, how and
who? Antimicrobial surveillance in
Sweden Different types of surveillance Validity
of surveillance data Sensitivity, specificity
3
Basic principles
WHY?
- Defining/updating treatment guidelines -
Identifying needs for infection control
measures - Monitoring the impact of interventions
to improve antimicrobial use and control spread
of infection
4
Basic principles
WHAT?
  • Should be focused on pathogens of greatest
    public health importance
  • Should include pathogens that are readily
    transmissible
  • Should provide information for action at local
    and national levels

5
Basic principles
HOW ?
  • Comprehensive surveillance
  • Sentinel surveillance
  • Point-prevalence studies

6
Basic principles
Comprehensive surveillance
  • Includes the whole population at risk
  • Aiming to capture all cases
  • Involves large number of clinicians and
    laboratories only limited set of data

7
Basic principles
Sentinel surveillance
  • Indicator data for rest of population
  • Suitable when prolonged and detailed data is
    required
  • Target approach (instead of representative
    sample) might be suitable

8
Basic principles
Point prevalence studies
  • Useful for validation of representativity of
    surveillance data
  • Evaluation of interventions

9
Basic principles
WHO ?
  • General population vs. hospital in-patients
  • Clinical reports
  • Laboratory reports

10
Basic principles
DATA SOURCE
Laboratory data
Clinical data
  • timely information on clinical disease
  • possibility to get detailed patient information
  • dependent on accuracy and consistency in
    diagnosis and timely and complete reporting
  • objective confirmation of the diagnosis
  • opportunity for detailed characterisation of
    the causative organism
  • less timely
  • often few clinical details

11
Numerators for surveillance
Basic principles
  • Data should relate to a single episode of illness
    in a patient
  • Microbiological data only the first positive
    culture from the patient from each disease
    episode should be reported
  • Microbiological data qualitative or quantitative

12
Basic principles
Examples of antimicrobial surveillance projects
ANNUAL REPORTS DANMAP Denmark FIRE
Finland NORM Norway SWEDRES Sweden EARSS
(www.earss.rivm.nl) RESEARCH/INDUSTRY
INITATIVES Alexander project Sentry
13
Basic principles
Examples of antimicrobial surveillance systems
ANNUAL REPORTS DANMAP Denmark FIRE
Finland NORM Norway SWEDRES Sweden EARSS
(www.earss.rivm.nl) RESEARCH/INDUSTRY
INTITATIVES Alexander project Sentry
14
AMR surveillance in Sweden
Antimicrobial resistance surveillance in Sweden
1. Mandatory case notification 2.
Annual resistance surveillance and quality
control programme (RSQC) 3. Sentinel surveillance
4. EARSS
15
AMR surveillance in Sweden
Antimicrobial resistance surveillance in Sweden
Mandatory case notification Comprehensive
surveillance of all cases of MRSA, VRE and
penicillin-resistant pneumococci (PRP) to the
Swedish Institute for Infectious Disease
Control Mandatory for both the clinician having
seen the patient and the laboratory diagnosing
the pathogen Basic patient data age, sex, place
of residence Data presented as incidence figures
(population denominator)
16
AMR surveillance in Sweden
Antimicrobial resistance surveillance in Sweden
Annual resistance surveillance and quality
control programme (RSQC) Each laboratory report
resistance data for at least 100 consecutive
bacteria per year Includes S. pneumoniae, S.
aureus, E. coli, S. pyogenes, H. pylori, E.
faecalis/faecium No patient data
avilable Detailed resistance data Data presented
as proportion ( resistant isolates/ all isolates)
17
AMR surveillance in Sweden
Antimicrobial resistance surveillance in Sweden
Sentinel surveillance Data mainly derived from
special investigations by devoted laboratories At
present includes salmonella, shigella,
campylobacter, N. gonorrhoeae, N.
meningitidis Quality of data varies
18
AMR surveillance in Sweden
Antimicrobial resistance surveillance in Sweden
EARSS Funded by DG SANCO of the European
Commission Surveillance of antmicrobial
susceptibility of invasive infections of S.
aureus, S. pneumoniea, E. coli, E.
faecalis/faecium 27 countries participates www.ear
ss.rivm.nl
19
EARSS Proportion PRP isolates in year
2000
20
AMR surveillance in Sweden
INFORMATION FEEDBACK
ResNet (www.srga.org/resnet_sok.ht
m) Electronic database containing data from RSQC,
EARSS and sentinel surveillance SwedRes
(www.smittskyddsinstitutet.se) Annual report on
Swedish antibiotic utilisation and resistance in
human and veterinary medicine
21
Data validity
PRP (penicillin-resistant pneumococci)
Streptococcus pneumoniae MIC PcG gt 0,5
mg/L Notifiable in Sweden since 1996 Increasing
resistance problem internationally Surveillance
data available from mandatory data, RSQC and EARSS
22
Data validity

Incidence/ 100 000 inh (PRP MIC PcG gt 0,5 mg/L)
23
Data validity

Incidence/ 100 000 inh (PRP MIC PcG gt 0,5
mg/L) RSQC rate (PRP MIC gt 0,12 mg/L)
24
Data validity

Incidence/ 100 000 inh (PRP MIC PcG gt 0,5
mg/L) RSQC rate (PRP MIC gt 0,12 mg/L) EARSS rate
(Invasive PRP gt 0,12 mg/L)
25
Data validity

Incidence/ 100 000 inh (PRP MIC PcG gt 0,5
mg/L) RSQC rate (PRP MIC gt 0,12 mg/L) EARSS rate
(Invasive PRP gt 0,12 mg/L) PRP rate (PRP MIC PcG
gt 0,5 mg/L)
26
Data validity
Nasopharyngeal cultures/1000 inhabitants in
Sweden 1998-2003
27
Changes in culturing propensity
Data validity
28
Ideal surveillance data
Data validity
  • Maximum specificity
  • Limit false positives
  • Maximum sensitivity
  • Captures all true positives
  • Determination of break-points at laboratories
  • Transient nasal carriage (MRSA)

29
Specificity
Data validity
  • Methodological problems at the laboratory
  • Reporting bias from laboratories

30
Determinants for sensitivity
Data validity
  • Contact with health care services
  • 2. The pathogen is isolated
  • 3. The case is reported
  • There is a risk for bias in each step!

31
Contact with health care services
Data validity
  • Accessibility
  • Better access to physicians in large cities
  • Costs
  • Free health care for children, cost recovery
    systems
  • Socio - economy, tradition
  • Screening/contact tracing initiatives

32
Routines for contact tracing for PRP
MIC PcG gt 0,5 mg/L
Multi-resistance or high MIC-values
Individual
33
Isolation of the pathogen
Data validity
  • Cultures from all cases/only on therapeutic
    failures?
  • Tradition in culturing propensity
  • Economical obstacles
  • Fear of time-consuming contact tracing

34
Data validity
Nasopharyngeal culturing propensity in Sweden
1998-2002 (Number of nasopharyngeal cultures/1000
inhabitants)
35
Who is sampled?
Data validity
Treatment failure
Disease
Carriage
Antibiotic treatment
36
Data validity
PRP incidence/1000 inhabitants
(all cases) in area G and M
37
Data validity
PRP incidence (only index cases)
in area G and M
38
Summary Basic principles
Summary
  • Obtaining appropriate specimens from the
    infected individual
  • Successful isolation of the causative organisms
  • Accurate determination of antimicrobial
    resistance
  • Data collection, collation and analysis
  • Dissemination of appropriate information for
    action
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