What Argentina is doing about AMR? and How this will relate to collaborating with CARPHA to combat AMR?

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1 What Argentina is doing about AMR? and How this will relate to collaborating with CARPHA to combat AMR? ALEJANDRA CORSO Antimicrobial Resistance Service National Institute of Infectious Diseases ANLIS Dr. Carlos Malbrán National/ Regional Reference Laboratory in Antimicrobial Resistance- Ministry of Health PAHO

2 Instituto Nacional de Enfermedades Infecciosas (inei) National Institute of Infectious Diseases (inei)

3 VISION National Reference Institution - To promote public health through prevention, surveillance and control of infectious diseases. MISSION - To promote the knowledge about etiologic agents that cause human pathologies. - Transmission - Referential diagnosis Active role as National Reference Laboratory

4 Natio a I stitute of I fectious Diseases (i ei) - Professionals - 5 Administratives Department of Bacteriolog y Department of Virology Department of Parasitolog y Department of Mycology - 46 Professionals - 43 Professionals - 19 Professionals - 11 Professional - 31 Technicians - Technicians - 10 Technicians - 10 Technicians - 6 Administratives- 5 Administratives- 4 Administratives - Administrative 9 Divisions 7 Divisions 3 Divisions 3 Divisions

5 Organize and Coordinate the Laboratorial Surveillance of 16 Networks

6 Participation in International Programs Pan American Health Organization World Health Organization Ø Tuberculosis Ø Hemolytic Uremic Syndrome Ø Brucelosis Ø Antimicrobial Resistance Ø Diarrheas Ø Food borne Diseases Ø Poliovirus Ø Influenza Ø HPV - Surveillance - Training - Technical assistance - Quality Assurance Programs Ø Invasive fungi infections and susceptibility to antifungals

7 Antimicrobial Resistance Service INEI Regional Reference Laboratory in Antimicrobial Resistance (LRR) Coordinator Latin American Quality Assurance Program on Bacteriology and Antimicrobial Resistance (000) Laboratory of Sexual Transmition Diseases- INEI Regional Laboratory of Reference for N. gonorrhoeae (01) Focal point for the WHO Gonococcal ATB Surveillance Program Coordinator LA Quality Assurance Program on N. gonorrhoeae (01)

8 Antimicrobial Resistance Service INEI

9 MAIN ACTIVITIES 1) Referencial Diagnosis in ATM )Surveillance of ATM in human pathogens 3)External Quality Assurance Programs 4)Human Resources Training 5)Research Antimicrobial Resistance Service INEI

10 ENZIMATIC ASSAYS metholologies? IEF PROTEINS Phenotypic and Molecular Characterization of AMR strains PFGE

11 Newsletters CLSI News EFERENCIAL DIAGNOSIS NTIMICROBIAL RESISTANCE Procedure Manuals Epidemiological Alerts

12 Work Protocols Publications in Internationa EFERENCIAL DIAGNOSIS NTIMICROBIAL RESISTANCE Publications in Congress

13 REFERENCIAL DIAGNOSI IN ANTIMICROBIAL RESISTA

14 REFERENCIAL DIAGNOSIS IN ANTIMICROBIAL RESISTAN

15 REFERENCIAL DIAGNOSIS ANTIMICROBIAL RESISTANCE

16 MOLECULAR EPIDE ANTIMICROBIAL RESISTANCE RAINING COURSES

17 SIREVA- ARGENTINA WHONET- ARGENTINA RELAVRA- PAHO SURVEILLANCE OF ANTIMICROBIAL RESISTAN

18 NATIONAL SURVEILLANCE NETWORK 3 0 IN ANTIMICROBIAL RESISTANCE 014: 96 htals WHONET- ARGENTINA Antimicrobial Resistance Service INEI ARGENTINA

19 NATIONAL SURVEILLANCE NETWORK IN ANTIMICROBIAL RESISTANCE. WHONET- ARGENTINA Orientation of empiric therapy O B J E T I V E S Early detection of new mechanism of AMR and control of its spread Participation in prevention, detection and control of health care associated infections Colaboration in the implementation of local, regional and national strategies for the proper use of antimicrobial agents and the control of AMR Strengthening of Provincial Centers and Regional Reference labs. in the surveillance of AMR

20 Evolution of WHONET-Network Argentina labs N aisl. per year (thousands) N hospitals años 014: 96 htals Antimicrobial Resistance Service INEI

21 National External Quality Assurance Program in Bacteriology - Biochemical Identification - Susceptibility Testing - Two panels per year: 3 strains each/one Antimicrobial Resistance Service INEI

22 013/ National External Quality Assurance Program in Bacteriology N o Public Labs (Nro.) n=47 Private Labs (Nro.) n=179 Evolution of the Quality Assurance Program In the Number of Labs. Participants Total = 46 Año

23 LATIN AMERICAN QUALITY ASSURANCE PROGRAM ON BACTERIOLOGY AND ANTIBIOTIC RESISTANCE One panel per year: 10 strains + 5 ATCC strains Antimicrobial Resistance Service INEI

24 LATIN AMERICAN QUALITY ASSURANCE PROGRAM ON BACTERIOLOGY AND ANTIBIOTIC RESISTANCE BOLIVIA ECUADOR PERÚ EL SALVADOR NICARAGUA GUATEMALA PARAGUAY COSTA RICA HONDURAS PANAMÁ REPÚBLICA DOMINICANA VENEZUELA URUGUAY CHILE Coordination OPS Regional Reference Labotatory ARGENTINA MEXICO COLOMBIA

25 LATIN AMERICAN QUALITY ASSURANCE PROGRAM ON BACTERIOLOGY AND ANTIBIOTIC RESISTANCE MAIN OBJETIVES 1) To contribute in the improvement of the Bacterial Diagnosis, ensuring maximum efficiency in Bacterial Identification and Antimicrobial Susceptibility Testing ) To promote the participation in Quality Assurance Programs 3) To establish a system of continuing education, trying to find common error sources and assistance to resolve them. 4) To distribute pheno and genotypically characterized strains, reference strains for internal QC, updated guidelines and procedures manuals for detection of new or emergent mechanisms of resistance. INEI-PAHO

26 LATIN AMERICAN QUALITY ASSURANCE PROGRAM ON BACTERIOLOGY AND ANTIBIOTIC RESISTANCE PARAMETERS EVALUATED 1) BACTERIAL IDENTIFICATION ) INTERPRETATION OF SUSCEPTIBILITY TEST 3) CONCORDANCE WITH THE RANGES OF INHIBITION ZONES OR MICs 4) SUGGESTED MECHANISM OF RESISTANCE 5) TIME of DELAY IN RESPONSE

27 BACTERIAL SPECIES DELIVERED GRAM NEG.: 38 spp E. coli K. pneumoniae K. oxytoca P. aeruginosa P. putida P. stutzeri Complejo C. freundii Complejo B. cepacia C. koseri S. marcescens S. odorifera M. morganii P. rettgeri E. cloacae E. aerogenes P. mirabilis P. vulgaris S. Enteritidis S. Infantis S.Typhimurium E. tarda S. sonnei S. flexneri S. maltophilia A. baumannii A. lwoffii E. meningoseptica A. xylosoxidans C. gleum/indologenes V. cholerae no O1 Complejo A.hydrophila Complejo A. caviae P. shigelloides H. influenzae H. parainfluenzae H. aphrophilus M. catarrhalis P. multocida GRAM POS.:9 spp S. aureus S. epidermidis S. saprophyticus S. haemolyticus S. lugdunensis E. faecalis E. faecium E. gallinarum E. raffinosus E. casseliflavus S. pneumoniae S. pyogenes S. agalactiae S.dysgalactiae S. grupo bovis S. grupo C S. grupo anginosus S. grupo sanguinis S. grupo mutans R. equi C. urealyticum C. striatum Complejo N. asteroides B. cereus A. haemolyticum E. rhusiopathiae L. monocytogenes A. urinae Complejo Mycobacterium fortuitum

28 EASY DETECTION/ INTERPRETATION Tetraciclina Cloranfenicol Trimetoprima/ sulfametoxazol Aminoglucósidos Rifampicina Quinolonas Nitrofuranos MECHANISM of RESISTANCE DIFFICULT DETECTION/ INTERPRETATION and/or EMERGENT BLEE en Enterobacteriaceae (CTX-M, PER-, SHV-, SHV-5, SHV-18) BLEE en P. aeruginosa (GES) MBL en P. aeruginosa (VIM, IMP) Carbapenemasa KPC (P. aeruginosa) MBL en Enterobacterias (IMP) Carbapenemasa SME (S. marcescens) Carbapenemasa KPC (K. pneumoniae) Hiperproducción de AMP-C AMP-C plasmídico Hiperproducción de ADC (A. baumannii) Resistencia a imipenem por déficit OprD (P. aeruginosa) Sensibilidad disminuida a fluorquinolonas Mecanismos plasmídicos de resistencia a fluorquinolonas (PMQRs: qnrs, oqx AB) Resistencia a fluorquinolonas en S. agalactiae Meticilino resistencia MLSb constitutivo e inducible Eflujo de macrólidos Resistencia intermedia a Vancomicina (VISA) Resistencia a vancomicina: fenotipo VanA, VanB y VanC Resistencia de alto nivel a aminoglucósidos Sensibilidad disminuida a penicilina β- lactamasas en H. influenzae, E. faecalis y M. catarrhalis

29 CONCORDANCE (%) IN IDENTIFICATION: Panels % 80% a 89% 70% a 79% <70% E. coli S. aureus K. pneumoniae P. aeruginosa P. putida E. faecalis S. pneumoniae S. agalactiae S. saprophyticus Complejo C. freundii Complejo B. cepacia P. rettgeri P. vulgaris E. tarda S. flexneri S. pyogenes P. shigelloides P. mirabilis K. oxytoca S. marcescens H. influenzae E. faecium S. grupo bovis M. morganii H. aphrophilus S. haemolyticus P. multocida S. lugdunensis E. cloacae S. epidermidis A. lwoffii Complejo A. hydrophila E. aerogenes S. sonnei C. gleum/indologenes S. Enteritidis Complejo A. caviae V. cholerae no O1 E. raffinosus E. casseliflavus E. gallinarum S. grupo anginosus R. equi S. Infantis S. Typhimurium P. stutzeri E. meningoseptica M. catarrhalis A. xilosoxydans S. grupo C S. grupo sanguinis S. grupo mutans C. urealyticum Complejo N.asteroides B. cereus A.haemolyticum C. striatum A. urinae Complejo M. fortuitum

30 CONCORDANCE (%) IN DETECTION OF RESISTANCE MECHANISM : PANELS 18/19 90% 80% a 89% 70% a 79% <70% MBL IMP (P. aeruginosa) β- lactamasa (H. influenzae) BLEE- CTX-M (S. flexneri) BLEE- SHV-18 (K. pneumoniae) Sensibilidad disminuida a FQ (S. Enteritidis) KPC (P. aeruginosa OPS-181) MBL VIM (P. aeruginosa) VanC + VanA (E. gallinarum) VanC (E. casseliflavus) VanB (E. faecalis) KPC (P. aeruginosa OPS-17) AMP-C plasmídico (K. pneumoniae OPS-173) AMP-C plasmídico (P. mirabilis OPS-18) Sensibilidad disminuida a FQ (H. influenzae) PMQRs (S. flexneri) PMQRs (K. pneumoniae)

31 CONCORDANCE (%) IN THE DETECTION OF BLEE: Panel BLEE Tipo CTX-M 77 % 54% 38 % 40% 18% 9 % 85 % 9 % 100 % S. flexnerii OPS-187: 100% Concordance in BLEE detection K. pneumoniae OPS-190 (ATCC ): 100% Concordance in BLEE detection BLEE Tipo SHV (SHV-, SHV-5, SHV-18) 9% 77% 71% 43 % 100 %

32 DETECTION of EMERGENT MECHANISM DETECTION of Reduced Susceptibility to Fluorquinolones OPS- 180 Salmonella Enteritidis OPS-180 QRDR gyra: Asp 87 Tyr NAL: 6 mm (R) CIP: 4 mm (SR) CIM NAL: 3 µg/ml (R) CIM CIP: 0.5 µg/ml (SR) Sensibilidad Reducida a Fluorquinolonas 8% 50 % 1 18 N Encuesta

33 How INEI has contributed to the improvement of the Diagnosis of ATM in LA-countries? Through different activities the capacities of the LA-countries were have been strengthen in: Diagnosis and early detection of emergent mechanisms of ATM, Surveillance of ATM in pathogens of public health relevance, Received technical training at RRL of professionals of National Laboratories of Public Health (3 months to 1 year), Participated in training courses and workshops on phenotypic and molecular diagnosis of resistance mechanisms, Received updates of procedure manuals, work protocols, epidemiological alerts, algorithms to search for resistance mechanisms of clinical impact, standard strains to control the quality of susceptibility testing and strains of reference of all resistance mechanisms, Continual technical assistance in public health emergences related with the spread of organisms or mechanism of ATB R, etc.

34 Name of the initiative: Strengthening of CARPHA and national capacities of the countries of the Region for Diagnosis and Surveillance of Antimicrobial Resistance

35 General Objective/s of the Project To improve AMR diagnosis and To establish National and Regional networks for Surveillance of AMR in Caribbean countries. This project will focus on: a. Supporting the countries to create/improve their AMR detection and surveillance programs. b. Establishing a formal Regional network for AMR. c. Develop programs on sustainable quality guarantee on clinical bacteriological diagnosis and AMR.

36 Specific Objectives of the Project Strengthen the laboratories of Reference on AMR in the Caribbean. Improve the capacity for AMR diagnosis in clinical labs. of the countries. Develop a Surveillance Networks for AMR in the countries involved. Implement an External Quality Assurance Program for the Reference Laboratory/ies for the Caribbean countries. Implement a External National Quality Assurance Program on bacteriological diagnosis and AMR for the in Caribbean countries. Develop a Regional Laboratory System to Prevent and Control the AMR in the Caribbean countries.

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