APPENDIX A
Inventory of Surveillance Systems

DOMESTIC ANTIMICROBIAL SURVEILLANCE ACTIVITIES

United States

Antimicrobial Drug Use Surveillance

The Centers for Disease Control and Prevention's (CDC's) National Ambulatory Care Survey collects information on a sample of outpatient visits from a nationwide probability sample of office-based physicians. The survey provides data on patient diagnosis and medications prescribed, including antimicrobial drugs. A similar survey, the National Hospital Ambulatory Medical Care Survey, collects this information from hospital outpatient and emergency departments. Contact: Cheryl Nelson, M.S.P.H., Division of Healthcare Statistics, National Center for Health Statistics, CDC, 6525 Belcrest Rd., Hyattsville, MD, 20782. Tel.: (301) 436-7132.

Emerging Pathogens Initiative: Department of Veterans Affairs

An initiative by the U.S. Department of Veterans Affairs (DVA) will collect information about patients found to have organisms or diagnoses related to 14 emerging pathogens. These data, collected at each VA medical center, will be transmitted to the Austin Automation Center in Texas for use nationally. The 14 pathogens or related diseases included are vancomycin-resistant enterococcus; hepatitis C; penicillin-resistant pneumococcus; Clostridium difficile; tuberculosis; Group A streptococcus; Legionella; Candida; Cryptosporidium; Escherichia coli 0157:H7; malaria; dengue; Creutzfeldt—Jakob disease; and leishmaniasis. Software will be created to collate information for inpatient stays and outpatient visits in which one of these pathogens is identified. These data contain demographic and clinical information. The program will gather and transmit information, and provide reports for both local and national use. Medical centers will then be able to perform epidemiological analyses of the occurrence of pathogens at their own facilities and within their own patient populations. The program office will perform similar analyses at the national level. Contact: Gary



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APPENDIX A Inventory of Surveillance Systems DOMESTIC ANTIMICROBIAL SURVEILLANCE ACTIVITIES United States Antimicrobial Drug Use Surveillance The Centers for Disease Control and Prevention's (CDC's) National Ambulatory Care Survey collects information on a sample of outpatient visits from a nationwide probability sample of office-based physicians. The survey provides data on patient diagnosis and medications prescribed, including antimicrobial drugs. A similar survey, the National Hospital Ambulatory Medical Care Survey, collects this information from hospital outpatient and emergency departments. Contact: Cheryl Nelson, M.S.P.H., Division of Healthcare Statistics, National Center for Health Statistics, CDC, 6525 Belcrest Rd., Hyattsville, MD, 20782. Tel.: (301) 436-7132. Emerging Pathogens Initiative: Department of Veterans Affairs An initiative by the U.S. Department of Veterans Affairs (DVA) will collect information about patients found to have organisms or diagnoses related to 14 emerging pathogens. These data, collected at each VA medical center, will be transmitted to the Austin Automation Center in Texas for use nationally. The 14 pathogens or related diseases included are vancomycin-resistant enterococcus; hepatitis C; penicillin-resistant pneumococcus; Clostridium difficile; tuberculosis; Group A streptococcus; Legionella; Candida; Cryptosporidium; Escherichia coli 0157:H7; malaria; dengue; Creutzfeldt—Jakob disease; and leishmaniasis. Software will be created to collate information for inpatient stays and outpatient visits in which one of these pathogens is identified. These data contain demographic and clinical information. The program will gather and transmit information, and provide reports for both local and national use. Medical centers will then be able to perform epidemiological analyses of the occurrence of pathogens at their own facilities and within their own patient populations. The program office will perform similar analyses at the national level. Contact: Gary

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Roselle, M.D., DVA Program Director for Infectious Diseases, 3200 Vine St., Cincinnati, OH 45220. Tel.: (513) 475-6398. Gonococcal Isolate Surveillance Project (GISP) http://www.cdc.gov/ncidod/dastlr/gcdir/Resist/gisp.html GISP, established in 1986, is a collaborative project to monitor antimicrobial resistance in Neisseria gonorrhoeae in the United States and to establish a rational basis for the selection of gonococcal therapies. Participants also pheno-typically characterize antimicrobial-resistant isolates as a means to describe the diversity of antimicrobial resistance to N. gonorrhoeae. Participants are the CDC (Division of STD Prevention, National Center for HIV, STD, and TB Prevention, and the Division of AIDS, STD, and TB Laboratory Research of the National Center for Infectious Diseases), five regional laboratories, and selected STD clinics). Data and isolates are collected from STD clinics in 26 cities. Data from this project have been used to revise the CDC's STD Treatment recommendations in 1989, 1993, and 1997. Contact: Joan Knapp, Ph.D., Division of AIDS, STD, and TB Laboratory Research, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-2840. Herpes Simplex Virus Surveillance Herpes simplex virus isolates are tested for acyclovir resistance from patients in 22 STD and HIV clinics in 12 U.S. cities. In December 1997, funding from a pharmaceutical sponsor of this project expired. Currently, new sources of funding are being explored. Contact: Michelle Teyes, Ph.D., Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-3921. Human Immunodeficiency Virus Surveillance During 1998, CDC will begin conducting antiretroviral drug susceptibility testing on HIV strains obtained from groups of patients believed to have recently acquired HIV infection and/or for whom recommendations for drug prophylaxis to prevent transmission have been made. These include adult seroconverters, adult patients beginning antiretroviral therapy, women and infants in perinatal transmission studies, and source patients involved in health care worker needle-stick exposures. Funds have been awarded and equipment purchased. The objective is to study specimens from approximately 1,000 patients per year. Contact: Walid Heneine, Ph.D., Division of AIDS, STD, and TB Laboratory Research, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-0218. INSPEAR In collaboration with several European investigators, the CDC has initiated an International Surveillance Program for Emerging Antimicrobial Resistance (INSPEAR) specifically focusing on nosocomial infections. This project in-

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cludes standardization of antimicrobial susceptibility testing and linkage of epidemiological and laboratory data to assess the efficacy of surveillance and interventions in preventing the development and spread of antimicrobial resistance in hospitals. Thirty hospitals in France, Germany, Poland, Slovenia, Switzerland, United Kingdom, and the United States have joined INSPEAR to date, and the others are being recruited. Contact: Herve Richet, M.D., Hospital Infections Program, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-6413. Malaria Surveillance In the United States, surveillance for drug-resistant malaria is passive (i.e., limited to reports of cases). In Africa, Peace Corps volunteers are followed prospectively to assess prophylaxis failure. In certain other countries, a sentinel system is in place to monitor treatment of ill patients to detect clinical failures that serve as a marker of resistance. Contact: Peter Bloland DVM, MPV, Division of Parasitic Diseases, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (770) 488-7787. National Antimicrobial Resistance Monitoring System (NARMS) NARMS was established in 1986 by the U.S. Food and Drug Administration (FDA), the CDC, and the U.S. Department of Agriculture (USDA) to monitor changes in antimicrobial susceptibilities of foodborne zoonotic pathogens in humans and animals. This system provides timely information with a goal of prolonging the life span of approved drugs by promoting the prudent use of antibiotics, identifying areas for more detailed investigation, and guiding research in the areas of antibiotic resistance. Susceptibilities to 15 antimicrobial agents are determined from randomly selected Salmonella, E. coli 0157:H7, and Campylobacter isolates from humans and animals. Human isolates are obtained from clinical specimens forwarded by clinical laboratories to the public health laboratories of 14 participating state and local health departments. Animal isolates are obtained from several sources including the Veterinary Diagnostic Laboratory, surveys of healthy animals, and isolates collected at slaughter. Contact: Fred Angulo, D.V.M., Ph.D., Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-2840. National Electronic Telecommunications System for Surveillance (NETSS) http://www.cdc.gov/epo/dphsi/netss.html NETSS was developed by the CDC and the Council for State and Territorial Epidemiologists for electronically collecting, transmitting, analyzing, and publishing weekly reports of notifiable diseases and injuries from the 50 states, New York City, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands. The operation of NETSS is based on agreements on reporting conditions, standard case definitions, and protocols for formatting and transmitting data. For more

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information, contact the Division of Public Health and Informatics/EPO, mailstop C-08, CDC, 1600 Clifton Road, NE, Atlanta, GA 30333. Tel.: (404) 6393761, Fax: (404) 639-1546. National Nosocomial Infections Surveillance System (NNIS) and Project ICARE http://www.cdc.gov/ncidod/diseases/hip/nnis.htm NNIS is conducted by the CDC Hospital Infections Program (HIP). This system reports antimicrobial susceptibility profiles for pathogens causing nosocomial infections detected through active surveillance in approximately 260 voluntarily participating hospitals. The database is used to describe the epidemiology of nosocomial infections in hospitals in the United States and to produce nosocomial infection rates that can be used for comparison purposes. In a subset of approximately 40 hospitals, additional data are collected from the microbiology laboratories and pharmacies in a special study, Project ICARE (Intensive Care Antimicrobial Resistance Epidemiology), which is being conducted in collaboration with Emory University School of Public Health. Objectives of this project include more detailed examination of the relationship between antimicrobial use and antimicrobial resistance and early detection of new resistance mechanisms by establishing a sentinel network of microbiology laboratories in NNIS hospitals that can identify and send specific antimicrobial-resistant isolates to the CDC. Both the NNIS system and Project ICARE provide hospitals with semiannual reports containing data and methodologies to facilitate interhospital comparison of nosocomial infection and antimicrobial usage patterns. This allows hospital personnel to respond quickly to excessive infection, resistance, or usage rates in efforts to reduce antimicrobial resistance. Contact: Scott Fridkin, M.D., Hospital Infections Program, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-6436. Pneumococcal Disease Surveillance The Division of Bacterial and Mycotic Diseases has conducted surveillance for invasive pneumococcal disease, including drug-resistant infections, since 1978. The first system was a voluntary sentinel surveillance system designed to assess serotype distribution and antimicrobial susceptibility. Over time, the system has involved 12—54 hospitals in 11—26 states. With this system, researchers at participating hospitals collect all pneumococcal isolates from sterile sites along with some demographic and clinical information. The isolates are sent to CDC for serotyping and susceptibility testing. In 1994, the division began active, population-based surveillance for invasive pneumococcal disease. This system currently includes sites in eight states (total population 16.5 million) and is administered, in part, through the Emerging Infections Programs. Surveillance personnel in each site have regular contact with all microbiology laboratory directors or hospital infection control practitioners in their areas to detect patients with Streptococcus pneumoniae isolated from blood or other sterile sites. Clini-

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cal isolates are collected and undergo antimicrobial susceptibility testing at reference laboratories. Surveillance personnel complete a standardized report form for each case-patient. In addition to surveillance, the system provides an infrastructure for epidemiological and microbiological studies. Contact: Cynthia Whitney, M.D., Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, Atlanta, GA 30333. Tel.: (404) 639-4727. The Public Health Laboratory Information System (PHLIS) PHLIS is a CDC electronic reporting system used by public health department laboratories in all states, New York City, the District of Columbia, and Guam to report laboratory isolate-based surveillance data to the CDC. The system was developed jointly by the National Center for Infectious Diseases at CDC and the Association of State and Territorial Public Health Laboratory Directors to maintain a fast, direct link between public health laboratories in the United States and the CDC. PHLIS is used to gather, analyze, and transmit data (e.g., laboratory testing results, epidemiological information, and findings from special studies and surveys) among multiple sources of public health laboratory information (e.g., hospitals, laboratories, and public health departments), and it provides an automated program in its longitudinal databases to detect outbreaks. Salmonella Antibiotic Resistance Surveillance Project The CDC, FDA, a sample of public health laboratories, and the USDA are implementing a national surveillance program for Salmonella isolates obtained from clinical specimens from humans and animals to monitor changes in antimicrobial susceptibilities. The surveillance program will facilitate the timely detection of changes in susceptibility patterns to flouroquinolones in Salmonella in humans, animals, or vegetables and will identify areas for educational programs and further studies. (Morbidity and Mortality Weekly Report 45(5):110-111, 1996.) Surveillance and Control of Pathogens of Epidemiologic Importance (SCOPE) The SCOPE program was established to measure the predominant pathogens and antimicrobial susceptibility patterns of nosocomial bloodstream isolates from approximately 50 medical centers throughout the United States. The project was coordinated at the Medical College of Virginia in collaboration with the University of Iowa. The program was designed to include approximately the same number of participants from each of the four geographic regions (Northeast, Southeast, Northwest, and Southwest). Participants identified the organism, the date it was isolated, and the antimicrobial susceptibility profile during an initial period between April 1995 and June 1996. Organisms were also sent to the University of Iowa for storage and further molecular characterization and reference susceptibility testing methods. Wyeth-Ayerst Lederle was a sponsor of this project. Contact: Ron N. Jones, University of Iowa Hospital. Tel.:

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(319) 356-2990. (Pfaller MA, et al. Inducible amp c ß-lactamase-producing gram-negative bacilli from blood stream infections: Frequency, antimicrobial susceptibility, and molecular epidemiology in a national surveillance program (SCOPE). Diagnostic Microbiology and Infectious Disease 28:211-219, 1997.) The Surveillance NetworkTM Database http://www.thetsn.com/ The Surveillance NetworkTM (TSN) Database is a surveillance initiative sponsored by MRL Pharmaceutical Services, a private firm in Virginia specializing in the diagnosis of infectious and immunological diseases. The network relies on the creation of objective, interactive databases that are continuously expanded by an on-line network of 150 selected contributing U.S. hospitals and independent laboratories. Data collected each day by MRL include certain patient information, microbial culture results, and qualitative and quantitative antimicrobial susceptibility test results. All data received by TSN are processed daily, encrypted, and inspected electronically for correctness and consistency. These data are then merged every five weeks and accessible via the Internet. The benefits of TSN are its ability to (1) assess and continuously improve antimicrobial susceptibility testing; (2) detect the occurrence of antimicrobial resistance in real time from a large network of laboratories; (3) analyze data at a strain-specific level-multivariate analyses; and (4) perform real-time trending. TSN plans to establish a global network in the future, expanding collaboration with national and international public health organizations and researchers. Plans also include expansion of the database to include antifungal, antimycobacterial, and antiviral agents, and establishment of systems to acquire and include clinical information and pharmacy data. Contact: Brenda Pillari, MS-MRL Pharmaceutical Services, 11921 Freedom Dr., Reston, VA 20190. Tel.: (888) 942-0792, ext. 7635. Tuberculosis Surveillance The antimicrobial susceptibility profile of the isolate from every culture positive case of tuberculosis diagnosed in the United States is reported, along with epidemiological and clinical data, to the state health departments, which in turn are responsible for reporting this information to the CDC. Contact: Eugene McCray, M.D., Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, CDC, Atlanta, GA 30333. Tel.: (404) 639-8117. United States Military Surveillance Air Force Global Surveillance The Air Force Global Surveillance Program is guided by Presidential Decision Directive (PDD-NSTC-7, June 20, 1996), which instructed the Department of Defense (DoD) to improve medical readiness and better protect our military

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personnel and their families by strengthening our ability to prevent, detect, and respond to infectious diseases wherever in the world U.S. forces are or may go. The program is conducted by the Epidemiology Services Branch at Brooks Air Force Base, Texas. Global Surveillance consists of several separate programs, including the Air Force Reportable Events Surveillance System (AFRESS), Deployment Surveillance, Project Gargle, Communicable Disease Laboratories, and Molecular Epidemiology. AFRESS is an automated data collection system designed to track various components, such as communicable diseases, occupational illnesses, vector-borne diseases, and suicides. Deployment Surveillance provides a rapidly deployable database system to track the health status of troops and to provide combat fitness indicators to line commanders through real-time disease and nonbattle injury (DNBI) analysis. Project Gargle, directed by the Air Force Surgeon General, is an influenza surveillance program that has been in existence since 1976. Each year, sentinel sites are selected by personnel in Epidemiology Services and the clinical virology laboratory. The criterion for selection is the mission or the location of the base. The goal of the program is to provide public health information for the base, track vaccine efficacy, and detect emerging strains of influenza. Selected isolates are shared with the CDC, and these have played a significant role in vaccine determination by the World Health Organization. Presently, the program has the capability to test for influenza A and B, adenovirus, parainfluenza 1—3, enterovirus, and herpes simplex virus. Communicable Disease Laboratories provides diagnostic confirmation in areas of microbiology, virology, immunology, and parasitology. Molecular Epidemiology provides DNA fingerprinting of organisms to chart their evolution and global dissemination, with its main objective being identification of pathogenic organisms and the deployment of a rapid disease detection system. Contact: MAJ Laura Trent, Det 1, HSC/AOES, 2601 West Gate Rd., Ste. 114, Brooks AFB, TX 78235-5241. Tel.: (210) 536-3471. The DoD Global Emerging Infections Surveillance and Response System (DoD—GEIS) http://www.ha.osd.mil/geis DoD—GEIS has two primary arms, one focused on surveillance at the six Department of Defence (DoD) tropical medical research units and one focused on coordination of emerging infection surveillance activities of the three services. The overseas medical research unit component of the program embodies four standardized surveillance modules that are being implemented in whole or in part at each laboratory. Two of these modules deal with drug resistance studies. Several DoD overseas laboratories have projects under way to track in vitro drug resistance patterns of Plasmodium falciparium, the causitive agent of human malaria. Another module being implemented at most of the overseas units involves standardized antibiotic resistance testing of enteric organisms with a focus on quinolone resistance.

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The arm of the program focused on health care beneficiaries of the three services has under development an electronic system to capture laboratory data on particular agents from 10 sentinel DoD medical treatment facilities. The initial surveillance sites are in strategic geographic locations to emphasize capture of information on health care beneficiaries located overseas or where there is considerable overseas traffic. The output of this surveillance activity is expected to include antibiotic resistance information on the selected organisms. Surveillance summaries generated by both arms of the system will be posted on the DoD—GEIS Web site. Contact: LTC(P) Patrick W. Kelley, M.D., Dr.P.H., Director, DoD—Global Emerging Infections Surveillance and Response System, Division of Preventive Medicine, Walter Reed Army Institute of Research, Washington, DC 20307-5100. Tel.: (202) 782-1353/1300, Fax: (202) 782-0613. United States: Regional Surveillance Bacterial Antibiotic Resistance (BAR) Initiative The BAR Initiative was formed in late 1993 as a response to the spread of antibiotic-resistant pathogens in New York City. The core idea of the BAR Initiative was to introduce molecular fingerprinting techniques for the characterization and epidemiological tracking of antibiotic-resistant gram-positive pathogens (Staphylococcus aureus, enterococci, and Streptococcus pneumoniae) in hospitals in New York City, in collaboration with a group of physicians, clinical microbiologists, and the TB Center of the Public Health Research Institute. Late in 1997, the BAR Initiative was reorganized to concentrate on more research- oriented prospective studies in the area of antibiotic resistance, keeping close ties with a group of collaborating hospitals and offering training to clinical microbiologists in the techniques of molecular fingerprinting. Permanent headquarters for the BAR Initiative, fully supplied with communications equipment, computers, and software for epidemiological and molecular fingerprint analysis, was created under the direction of Richard B. Roberts, M.D., in affiliation with the Laboratory of Microbiology at The Rockefeller University (headed by Dr. Alexander Tomasz). Several ongoing studies include (1) a cost analysis of the economic impact of vancomycin-resistant enterococci; (2) frequency of occurrence, clinical relevance, and molecular mechanisms of staphylococcal vancomycin resistance; (3) prevalence of antibiotic-resistant S. pneumoniae in New York City; and (4) the mechanism of epidemicity of geographically expanding methicillin-resistant S. aureus clones. Contact: Dr. Alexander Tomasz or Dr. Richard B. Roberts, The Rockefeller University, 1230 York Avenue, New York, NY 10021. Tel.: (212) 327-8277 or -7360, Fax (212) 327-8688.

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Infectious Diseases Web Site for Western New York http://www.smbs.buffalo.edu/id/ The State University of New York at Buffalo Division of Infectious Diseases developed this Web site, which provides surveillance data for large hospitals, small hospitals (<200 beds), and nursing homes in western New York State. These data include statistics on nosocomial infections and antibiotic resistance patterns. The Web site also includes a fairly extensive list of references related to infections and infection control in long-term-care facilities. Infection control personnel and hospital epidemiologists should find the surveillance data useful for comparative purposes. The surveillance data are updated periodically. Contact: Joseph M. Mylotte, M.D., CIC; Infectious Diseases, Erie County Medical Center, 462 Grinder Street, Buffalo, NY 14215. Tel.: (716) 898-3848, Fax: (716) 898-3707, e-mail: mylotte@acsu.buffalo.edu. New Jersey Hospital Laboratory Isolate-Based Active Surveillance System for Antibiotic-Resistant Organisms In 1991, the New Jersey Department of Health initiated a statewide hospital laboratory isolate-based surveillance system for reporting antimicrobial-resistant bacteria. The aims of this system are to provide a framework to detect and monitor infections due to antimicrobial-resistant bacteria and to determine risk factors associated with acquisition of infections, so that effective control strategies can be developed and evaluated. This system encompasses all 96 acute care hospitals licensed by the state of New Jersey. Organisms targeted for surveillance by this system include methicillin-resistant Staphylococcus aureus; gram-positive cocci resistant to vancomycin; gram-negative rods resistant to imipenem; gram-negative rods resistant to amikacin, gentamicin, and tobramycin; and pneumococcal or streptococcal isolates resistant to penicillin. (Paul SM, et al. A statewide surveillance system for antimicrobial-resistant bacteria: New Jersey. Infection Control and Hospital Epidemiology 16(5):385-390, 1995.) OTHER COUNTRIES Canada Canadian Bacterial Disease Network (CBDN) http://www.cbdn.ca/ CBDN is a Canada-wide consortium of 57 researchers and their laboratory personnel who work at 15 universities and 3 government laboratories. Funded by the Canadian federal government's Networks of Centers of Excellence Program, its research focuses on bacterial diseases in humans, animals, fish, plants, and the environment. CBDN links together some of the top Canadian scientific minds in a collaborative multidisciplinary effort aimed at understanding the basis of bacterial diseases and developing new and innovative approaches to prevention, diagnosis, and treatment. Several researchers within the consortium are active in

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antimicrobial resistance surveillance programs. CBDN scientists work in collaboration with industry partners to ensure that novel ideas are developed into products that can improve or save people's lives. The Canadian Hospital Epidemiology Committee (CHEC) http://www.ualberta.ca/~mmid/cids/ CHEC was initiated by the Canadian Infectious Disease Society and receives support from the Canadian counterpart to the U.S. Centers for Disease Control and Prevention—the Laboratory Center for Disease Control (LCDC), http://www.hc-sc.gc.ca/hpb/lcdc/—and from industry. It consists of 23 hospitals in 9 of Canada's 10 provinces and will shortly include all 10. Detailed clinical data and information on organisms are collected, and all isolates are tested at a single facility. The program has focused primarily on multidrug-resistant S. aureus infections, vancomycin-resistant enterococcus, and Clostridium difficile. The Laboratory Proficiency Testing Program (LPTP) http://www.lptp.on.ca/lptphome.html LPTP is responsible for examining and evaluating the proficiency of test performance in all clinical laboratories in Ontario, Canada. LPTP ensures that laboratories are aware of new and emerging multidrug-resistant pathogens, know how to most accurately detect them, and are able to carry out clinically relevant challenges with the use of test materials that mimic patient samples as closely as possible. They also conduct surveillance programs to monitor the emergence of such pathogens as vancomycin-resistant enterococcus and multidrug-resistant S. aureus within the province. Ontario Invasive Group A Streptococcal Infections Surveillance Network http://www.mtsinai.on.ca/ This program, which has been in place since 1992, monitors invasive group A streptococci in all 150 hospitals in the province of Ontario, Canada (population 11 million). Each patient with an invasive infection with group A streptococci has the isolate, clinical information, and blood and tissue specimens, when possible and appropriate, forwarded to Mt. Sinai Hospital as part of an ongoing study of the epidemiology and pathogenesis of the disease. Toronto Invasive Bacterial Diseases Network (TIBDN) http://www.mtsinai.on.ca/ This is a population-based prospective surveillance program that monitors rates of invasive cases of group A and B streptococci, Streptococcus pneumoniae, Neisseria meningitidis, and Listeria monocytogenes in Toronto, Ontario (population 3.5 million). This program allows for the epidemiological study of these pathogens in order to better design preventive and treatment strategies.

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Denmark The Danish Antimicrobial Resistance Monitoring and Research Program (DANMAP) http://www.ssi.dk/epi-nyt.uk/1997/uge8.html In June 1995, the Ministry of Health and the Ministry of Agriculture and Fisheries in Denmark initiated a program to conduct coordinated monitoring and research of bacterial antibiotic resistance in Denmark. The program aims to monitor antibiotic resistance in bacteria isolated from livestock, food, and humans in addition to monitoring the use of antibiotics in human and animal therapy and for growth promotion. The program also aims to demonstrate any connection between such use and the occurrence of resistance. The surveillance program was organized in collaboration with the Danish Veterinary Laboratory, the National Food Agency of Denmark, and the Statens Serum Institute. Contact: Thomas Lund Sorensen, Statens Serum Institute, Artillerivej 5, DK-2300, Copenhagen S, Denmark. E-mail: tls@ssi.dk. Finland FiRe FiRe is a network of more than 90 percent of the major clinical laboratories in Finland that collaborate in the collection of data and monitoring of antimicrobial resistance. Antimicrobial resistance monitoring is carried out through two mechanisms. In the first, collected clinical strains (e.g., group A. streptococci, gonococci, pneumococci, Haemophilus influenzae, and Moraxella catarrhalis) are evaluated for minimum inhibitory concentration by the National Public Health Institute. In the second, routine disk-diffusion test data are collected. Quality control is routinely performed in all FiRe laboratories. In outpatients, S. aureus and E. coli are monitored in addition to the pathogens mentioned above. In hospitals, about 20 major pathogens are monitored. In 1998, the MIKSTRA-project (Strategies for Antimicrobial Use in Finland) will supplement ongoing FiRe activities and begin a nationwide five-year endeavor to develop national recommendations on uniform diagnostic and antimicrobial treatment practices for outpatient infections. MIKSTRA will also concentrate on developing a cost- analysis report for outpatient infections. Contact: Pentti Huovinen, M.D., Ph.D., Antimicrobial Research Laboratory, National Public Health Institute, P.O. Box 57, 20521 Turku, Finland. Tel.: 358-2-2519-255, Fax: 358-2-2519-254, e-mail: pentti.huovinen@ktl.fi. Greece WHONET Greece http://www.mednet.gr/whonet/whatis.htm The Greek system for surveillance of antimicrobial resistance is based on the development of a network of hospital microbiological laboratories that rou-

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tinely enter their susceptibility data into a common data analysis program. These data are reported on a hospital and national level. WHONET software is being adopted to facilitate the Greek surveillance system. The Greek system for surveillance of antimicrobial resistance is coordinated by the Department of Microbiology and the Department of Hygiene and Epidemiology at the Athens University Medical School. Iceland The Icelandic Surveillance System The system of surveillance in Iceland was set up by Dr. Karl Kristinsson in 1989. The original goal was to collect and record all pneumococci with reduced susceptibility to penicillin. The goal has expanded to now include multidrug-resistant S. aureus, vancomycin-resistant enterococcus, and multiresistant Mycobacterium tuberculosis. The Department of Microbiology of the National University Hospital in Reykjavik sets the standards and methods (according to National Committee for Clinical Laboratory Standards protocols and criteria) and serves as a reference laboratory for all of Iceland, as well as being the sole laboratory in the country for training technologists and doctors in microbiology. Surveillance of resistance in Iceland is facilitated by the country's small population and relative isolation, which also make it an ideal place to study the epidemiology of certain resistance traits. All microbiology laboratories within the country maintain close contact and report all resistant strains, along with basic patient and infection information, to the central laboratory in Reykjavik. It is hoped that in the future, the merging of health care, hospital, laboratory, and pharmacy databases can be coordinated in order to obtain more detailed information about how antimicrobial use and resistance affect the outcome of the main infections. A pilot project to reach this goal is about to get under way. Contact: Karl G. Kristinsson, Department of Microbiology, National University Hospital, P.O. Box 1465, 121 Reykjavik, Iceland. Tel.: (354) 560-1900, Fax: (354) 560-1957. EUROPEAN-WIDE SYSTEMS Antibiotic Resistance and Emerging Susceptibility Patterns in Europe (ARTEMIS) http://www.eurotransmed.nl/programs/1996/19-11-96.htm The ARTEMIS surveillance system was set up in late 1995 to provide a global surveillance system of antibiotic resistance. The goal of ARTEMIS is to study both hospital and community-acquired infections in order to provide data that will be relevant to individual doctors designing treatment protocols. ARTEMIS is funded by Pfizer.

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Center for Molecular Epidemiology and Network for Epidemiological Tracking of Antibiotic-Resistant Pathogens (CEM/NET) CEM/NET is an international initiative in molecular epidemiology formed in 1994. Two basic science microbiology laboratories make up the core: one in Europe (Molecular Genetics Unit, Universidade Nova de Lisboa [ITQB], Portugal, headed by Prof. Herminia de Lencastre, Ph.D.) and another in the United States (Laboratory of Microbiology, The Rockefeller University, New York, headed by Prof. Alexander Tomasz, Ph.D.). This novel research-oriented initiative has been performing prospective surveillance studies (in collaboration with colleagues from a large number of countries) on the prevalence, clonal type, and molecular mechanisms of resistance of antibiotic-resistant nosocomial and community-acquired bacterial pathogens (particularly staphylococci, enterococci, and pneumococci) recovered in hospitals and day-care centers in 11 Southern and Eastern European countries, 6 South American countries, and the United States. A second major activity of CEM/NET involves teaching DNA fingerprinting techniques through working visits of clinical microbiologists to the two core laboratories. Thus far, 25 colleagues from 16 different countries have participated. A third major activity involves research to develop DNA sequence-based rapid detection techniques. Support for CEM/NET has come from grants from national research sources and private foundations in Portugal, the National Institutes of Health, and several pharmaceutical companies. Contact: Dr. Herminia de Lencastre or Dr. Alexander Tomasz, both at The Rockefeller University, 1230 York Avenue, New York, NY 10021. Tel.: (212) 327-8278, Fax: (212) 327-8688. Communicable Disease Surveillance Center (CDSC) http://www.open.gov.uk/cdsc/cdschom2.htm CDSC works closely with Public Health Laboratory Service (PHLS) laboratories throughout England and Wales and with the Central Public Health Laboratory. CDSC also collaborates with the Department of Health and the Welsh Office, the Department of Health Northern Ireland, the Office of National Statistics, the Scottish Center for Infection and Environmental Health, the Ministry of Agriculture Fisheries and Food, the Department of the Environment, the World Health Organization, the European Commission, and other national and international centers. CDSC works in partnership with microbiologists in the PHLS and National Health Service laboratories. European Network for Antimicrobial Resistance and Epidemiology (ENARE) http://www.accu.nl/ewi-enare/enare/ ENARE was developed with the goal of increasing the understanding, control, and prevention of the spread of multidrug-resistant microbes. The program is devoted solely to approaching these problems on a European level and developing strategies to fight this major threat to public health. Funding for the pro

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gram is provided by the European Union. The project will provide effective commentary on antibiotic usage guidelines that will help decrease the appearance and spread of antimicrobial-resistant bacteria. Furthermore, results obtained from ENARE's research projects will contribute greatly to the scientific community's understanding of the specific molecular mechanisms that underlie antibiotic resistance. ENARE has recently been combined with the SENTRY program and is based at the Eijkman-Winkler Institute for Medical Microbiology, University Hospital Utrecht, and the National Institute of Public Health and the Environment, Bilthoven, The Netherlands. Participating centers in Europe are located in Belgium, Germany, Greece, Italy, The Netherlands, Poland, Spain, and the United Kingdom. Participating centers outside Europe are in Egypt and Saudi Arabia. Eurosurveillance www.eurosurv.org Eurosurveillance is a European communicable diseases bulletin that publishes data from surveillance networks and results of outbreak investigations, compares national approaches to communicable disease prevention, and collates material of international interest from national bulletins. Eurosurveillance is the work of an editorial committee comprising editors of surveillance bulletins in member states of the European Union (EU), coordinated by a French and English team associated with the National Public Health Center (RNSP, Saint-Maurice, France), the Communicable Disease Surveillance Center (London), and the European Center for the Epidemiological Monitoring of AIDS (CESES, Saint-Maurice) and supported by the Commission of the European Communities. Eurosurveillance is one of several initiatives implementing the EU's policy of increasing the exchange of information in public health and epidemiology, including the development of surveillance networks for communicable diseases and a European training program for field epidemiology. Eurosurveillance is a monthly, bilingual bulletin (French-English) in its printed format, distributed to more than 12,000 people in Europe. In its electronic version, the bulletin is accessible in four languages (French, English, Portuguese, and Spanish). Eurosurveillance Weekly http://www.eurosurv.org/main.htm eurowkly@eurosurv.org Eurosurveillance Weekly is a weekly electronic European bulletin on communicable diseases currently undergoing a feasibility study supported by the Directorate General V of the European Commission. The project's objective is to produce a weekly electronic bulletin containing timely, authoritative scientific information on communicable disease developments of European significance for public health professionals. Eurosurveillance Weekly complements the monthly Eurosurveillance, distributed on paper as well as on the World Wide Web. The bulletin is disseminated electronically, mainly as a Web site, but also

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as a plain text file sent by e-mail to subscribers who do not have access to the Web. Where no e-mail is available, the text can be faxed to subscribers. Copy is gathered by e-mail or fax from a public health professional in each European Community country (a ''gatekeeper"), who has, in turn, collected newsworthy items from within his or her country and gained appropriate clearance. Public Health Laboratory Service (PHLS) http://www.phls.co.uk/ The PHLS, located in England and Wales, consists of 53 laboratories. Since 1974, diagnostic laboratories in the PHLS network and increasing numbers of National Health Service (NHS) and private laboratories have reported, on a voluntary basis, all bacterial isolations from blood or cerebrospinal fluid to the PHLS Communicable Disease Surveillance Center. Since 1989, they have been asked to include their antimicrobial susceptibility test results on all isolates. All laboratories do not test the same antimicrobial agents, but a nucleus set is tested by most laboratories for each species. Although the methods are not standardized, external quality assurance is provided by the UK National External Quality Assessment Scheme, to which almost all laboratories subscribe. In addition, many laboratories refer isolates that show particularly critical resistance traits to the PHLS Antibiotic Reference Unit (ARU) for determination of minimum inhibitory concentrations; these can often be matched against the submitted results. Occasional prevalence surveys in the PHLS network, with testing of isolates in the ARU, act as a further monitoring measure. The PHLS is currently collaborating with the British Society for Antimicrobial Chemotherapy to introduce a standardized methodology and establish a surveillance network in the United Kingdom. (Speller, DCE, et al. PHLS Surveillance of antibiotic resistance, England and Wales: Emerging resistance in Streptococcus pneumoniae. Emerging Infectious Diseases 2(1):57—58, 1996.) Salm-Net Salm-Net was established in 1994 to improve the prevention and control of human salmonellosis and other foodborne infections in countries of the European Union and the European Cooperation in Science and Technology. Salm-Net (now superseded by the Enter-Net network) is a laboratory-based surveillance system designed to include an on-line network database. The system includes the following countries: Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Ireland, Italy, The Netherlands, Norway, Portugal, Scotland, Spain, Sweden, and Switzerland. Participants have also been identified in Greece and Luxembourg and await confirmation. The goal of the Enter-/Salm-Net is to improve the prevention and control of human salmonellosis and provide an opportunity to detect international clusters that indicate a common source outbreak at an early stage. In addition, the network provides the ability to evaluate the effectiveness of prevention measures and monitor trends in disease.

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GLOBAL SURVEILLANCE SYSTEMS The Alexander Project The Alexander Project was established as an ongoing, international multi-center study to investigate the antimicrobial susceptibility of community acquired lower respiratory tract infection (LRTI) pathogens. The 1996 data report microbiological tests on nearly 7,000 isolates, collected from 20 well-respected microbiological centers in Europe, the United States, South Africa, Saudia Arabia, and Hong Kong. The isolates have been tested against 16 commonly prescribed antibiotics and assessed in terms of their in vitro bacteriological activity against the key LTRI pathogens. This type of surveillance has been invaluable to prescribing physicians. The 1996 data from the Alexander Project identified a considerable country-to-country variation in the degree of antibiotic resistance, as well as significant differences in antibacterial activity among the most commonly prescribed antibiotics. The majority of these antibiotics were found to be ineffective against more than 85 percent of the isolates of three key LRTI pathogens: S. pneumoniae, H. influenzae, and M. catarrhis. The project is supported by a grant from SmithKline Beecham and is chaired by Dr. Reuben Gruneberg. Alliance for the Prudent Use of Antibiotics (APUA) http://www.healthsci.tufts.edu/apua/apua.html The APUA is the only international organization dedicated exclusively to protecting one of the world's great natural resources, antibiotics. APUA was established in 1981, following a historic meeting in the Dominican Republic. Since then, the organization has grown to include 10 national chapters and a membership of concerned health professionals and officials in more than 80 countries. The organization serves as an international network for information exchange and provides support for country-based initiatives to track and curb antibiotic use and resistance at the local level. Moreover, APUA aims to improve global public health through the education of health care providers and consumers concerning more prudent use of antibiotics. Division of Emerging and Other Communicable Diseases Surveillance and Control, Antimicrobial Resistance Monitoring Program http://www.who.ch/emc/amr.html The World Health Organization (WHO) Antimicrobial Resistance Monitoring (ARM) Program aims to assist countries, particularly developing countries, to establish national resistance surveillance networks and to use the information derived from these networks to update prescribing guidelines and ensure the availability of appropriate antimicrobials. To this end, the ARM Program organizes national policy workshops (in collaboration with other divisions in WHO) and laboratory training courses to improve the detection of antimicrobial resistance through carefully standardized laboratory tests and data analysis. Use of these test results locally

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to guide appropriate choice of therapy, to aid in infection control, and to provide early warning on the emergence of new and multiple drug-resistant bacteria is encouraged through laboratory training activities. Laboratories participating in the ARM Program are assisted in establishing internal quality control, and they enroll in an external quality assurance scheme organized by the WHO Collaborating Center for International Monitoring of Antimicrobial Resistance based in the Nosocomial Pathogens Laboratory Branch of CDC, Atlanta, Georgia. Infectious Disease Early Warning System http://eostest2.gsfc.nasa.gov/IDP/ The Early Warning Model for Dengue Fever is the initial effort of INTREPID (Interagency Research Partnership for Infectious Diseases). The model incorporates in situ weather data and long-term disease data sets to see if infectious disease outbreaks can be predicted. The working group of investigators consists of U.S. federal agencies, including the National Aeronautics and Space Administration (Goddard Space Fight Center), the U.S. Army (Walter Reed Army Institute of Research), the U.S. Navy (Navy Medical Research Institute), the CDC, and the USDA (Center for Medical, Agricultural, and Veterinary Entomology) as well as the University of Michigan and John Hopkins University. Their goal is to make various kinds of data available electronically for purposes of analysis and prediction, in a timely and easy-to-access manner. Once the dengue fever prototype is developed, with the assistance of the epidemiological research community, the group plans to expand this system to other infectious diseases that may have a strong environmental component. Eventually, the system will evolve into an interactive site on the World Wide Web. Both system access and data access are expected to be provided at no charge. Once operational, it should be useful to anyone seeking climate, land cover, demographic, or disease data for purposes of research, policy development, and public health intervention. ProMED-mail promed@usa.healthnet.org ProMED-mail is a creation of the Program for Monitoring Emerging Diseases, a project of the Federation of American Scientists. ProMED-mail is a moderated, free e-mail list, started in 1994, with more than 15,000 direct subscribers in more than 150 countries—and thousands more via the Web—who report and discuss outbreaks of emerging infectious diseases of man, animals, and plants. Calls for assistance are also passed through the list moderators to appropriate responders. ProMED-mail's primary objective is to report outbreaks of emerging diseases as fast as possible. Thanks to input from its subscribers, ProMED-mail has been able to notify the world of outbreaks up to four weeks before WHO's global reporting system. Postings and archives are also available on the Web at: http://www.healthnet.org/programs/promed.html.

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SENTRY Antimicrobial Surveillance SENTRY Antimicrobial Surveillance was designed by researchers at the University of Iowa and the Eijkman-Winkler Institute for Microbiology Infection and Inflammation in The Netherlands. The program is being funded by a grant from Bristol-Myers Squibb Company. This longitudinal surveillance program offers physicians, researchers, and public health officials comprehensive and timely data on the most pervasive and devastating infectious diseases. SENTRY will monitor hospital (nosocomial) and community-acquired infections via a worldwide network of 72 medical centers and outpatient facilities. In addition to testing and characterization, a panel of 55 oral and parenteral antibiotics will be investigated against isolated strains to assess antimicrobial resistance patterns. During the first year, the sites will include North America, Latin America, Europe, and Asia. In 1998, the program will expand to include sites in Australia, Japan, Asia, the Middle East, and parts of Africa. Contact: Ron N. Jones, University of Iowa Hospital. Tel.: (319) 356-2990; Anke Leys, Utrecht, Tel.: 31 30 2507483 WHONET WHONET software was developed by Dr. T. O'Brien and colleagues in the WHO Collaborating Center for Antimicrobial Resistance Monitoring based at the Brigham and Women's Hospital, Boston, Massachusetts, and at WHO headquarters. The software is freely available as a tool for laboratories, and instruction in its use is incorporated in the laboratory training courses. User support is provided by WHO headquarters. The BACLINK software, designed by WHO, facilitates the importation of data from existing laboratory systems into WHONET or other standard software packages. Laboratories are encouraged to use a common software such as WHONET to analyze and share routine antimicrobial test results. It is anticipated that national networks—both those that exist and those being established—will be linked to the WHO ARM Program Network of Networks, which is currently under development at WHO headquarters. The long-term goals of these activities are to strengthen the capacities of WHO member states to improve the standardization of interpretation of antimicrobial resistance data and to contain the emergence and spread of multidrug-resistant bacteria throughout the world. WHO also coordinates other international efforts for antimicrobial resistance surveillance, particularly in the field of gonococcal infections (through the gonococcal antimicrobial susceptibility program [GASP]), respiratory diseases, tuberculosis, and malaria. Further information can be obtained from the Antimicrobial Resistance Monitoring Program, Division of Emerging and Other Communicable Diseases Surveillance and Control (EMC), World Health Organization, 1211 Geneva 27 Switzerland. Fax: 41 22 791 4878, Internet: through the WHO home page at: http://www.who.ch/.

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WHO Western Pacific Region Gonococcal Antimicrobial Program This regional program of continuing long-term surveillance of antibiotic susceptibility of N. gonorrhoeae to an agreed-on group of antibiotics between 1992 and 1994 enrolled laboratories in 17 countries in the WHO Western Pacific Region. The laboratories analyzed 20,000 gonococci isolates over a three-year period, concluding that patterns of gonococcal resistance to antibiotics continue to evolve, at times rapidly, and have the potential for wide and rapid dissemination. Data derived have been used in the development of appropriate treatment regimens in the region and have emphasized the need for the expansion of gonococcal resistance surveillance to a global level. (WHO, Surveillance of antibiotic susceptibility of neisseria gonorrhoeae in the WHO Western Pacific region, 1992-1994. Genitourinary Medicine 73(5):355-361, 1997.) World Health Organization WER: Weekly Epidemiological Record http://www.who.ch/wer/wer_home.htm The Weekly Epidemiological Record (WER) serves as an essential instrument for the rapid and accurate dissemination of epidemiological information on cases and outbreaks of diseases under the International Health Regulations; other communicable diseases of public health importance, including newly emerging or reemerging infections; noncommunicable diseases; and other health problems. WER is distributed every Friday in a bilingual English—French edition. The electronic edition is free of charge and can be obtained at the URL above. Worldwide Antimicrobial Resistance Network (WARN) http://www.warn.cas.cz/about.html WARN is a global information system designed to disseminate antibiotic resistance data via the Internet. The system, set up as a World Wide Web server, is hosted at Charles University, Prague, Czech Republic. This system was established as a means of disseminating information on a worldwide basis to microbiologists, epidemiologists, and clinicians regarding current worldwide antibiotic resistance trends. It focuses on specific problems of antibiotic resistance, selective data processing, determinations of initial susceptibility or resistance to new antimicrobials, and screening of ß-lactamases. Contact: Submissions can be made to the WWW server either electronically via e-mail (submissions@warn.cas.cz) or on a PC or Mac disk to: Prof. Jiri Schindler Department of Microbiology, 3rd Medical Faculty, Charles University, Ruska 87, Praha 10, 10000, Czech Republic.