Health Department Dear Colleague SURVEILLANCE OF ANTIMICROBIAL RESISTANCE A REPORT OF A SUBGROUP OF THE ADVISORY GROUP ON INFECTION Summary This letter alerts you to the second report of the subgroup of the Health Department s Advisory Group on Infection. The report contains recommendations for the development of co-ordinated surveillance of antimicrobial resistance patterns in Scotland. The Executive Summary of the Report and its key recommendations are attached and the full report is available on the SHOW website www.show.scot.nhs.uk/sehd. Its preparation was trailed in NHS HDL(2001) 57 which accompanied the publication of the subgroup s first report, A Framework of National Surveillance for Hospital Acquired Infection in Scotland. Having reviewed the systems currently in place, or being developed in Scotland, the subgroup concluded that in the fields of human (medical and dental) or veterinary practice, Scotland is not currently equipped with a national surveillance system that meets its requirements. It also concluded that the ideal, totally comprehensive system may not be achievable in the foreseeable future in human or veterinary practice. It therefore recommended the implementation of a number of co-ordinated, integrated surveillance initiatives that, together, will contribute to the building up of a comprehensive account of the impact and trends in antibiotic resistance in Scotland. Action 17 December 2002 Addresses For action Chief Executives, NHS Trusts Director, Scottish Centre for Infection and Environmental Health Chief Executive, Common Services Agency Food Standards Agency For information General Managers/Chief Executives, NHS Boards NHS Special Boards Chief Executive, Health Education Board for Scotland Enquiries to: Medical Dr P Christie 2N.07 St Andrew s House EDINBURGH EH1 3DG Fax 0131-244-2030 E mail Susan.Roberts@scotland.gsi.gov.uk Other Wendy McKendrick 3E(South) Address as above. Fax 0131-244-2157 E mail wendy.mckendrick@scotland.gsi.gov.uk NHS Trusts, the National Services Division (NSD) of the Common Services Agency, the Food Standards Agency (FSA) and the Scottish Centre for Infection and Environmental Health (SCIEH) are asked to facilitate the implementation of the report s recommendations as abcde abc a
they apply to them. The contents of this letter should be drawn to the attention of the Directors of Trust Microbiology and Virology Services, and other relevant bodies. All trusts are requested to facilitate the participation of their microbiology and/or virology departments in the surveillance activities outlined in the Report. National Services Division (NSD) of the Common Services Agency NSD should consider and address the recommendations made in the report as these relate to Reference Laboratories. It should review the contribution which Reference Laboratories make to monitoring antimicrobial resistance and put in place formal mechanisms for these data to be routinely reported in Scotland, where this is not already done. This issue should be addressed in all future contracts between NSD and the Reference Laboratories as well as between NSD and PHLS. Additional Information The Government gave a commitment to develop and take forward a comprehensive UK Antimicrobial Resistance Strategy in response to the House of Lords Select Committee on Science and Technology s Report Resistance to Antibiotics and Other Antimicrobial Agents. Following a widespread consultation exercise, the Scottish Executive published, on 25 June 2002, the Antimicrobial Resistance Strategy, together with an Action Plan for Scotland. The plan outlines the wide range of action proposed to address the three key inter-related elements of the Strategy to control antimicrobial resistance, i.e. surveillance, prudent antimicrobial use and infection control. Our National Plan, A Plan for Action, A Plan for Change gives a commitment to taking steps to strengthen and monitor infection control in hospitals and to take measures to ensure the prudent use of antibiotics, thus maximising their effectiveness for patients who require them. A key element to achieving both of these objectives is the implementation of appropriate surveillance systems. Resistance surveillance is needed to assess the extent of the problem and is well established as an essential cornerstone of any attempts to understand and control resistance and underpin the prudent prescribing of antimicrobial agents. Additional Funding This second report from the subgroup contains recommendations for the development of coordinated surveillance of antimicrobial resistance patterns in Scotland. The group makes a number of detailed recommendations with respect to the component parts of the complementary surveillance approaches they propose in human (medical and dental) practice, as well as in veterinary practice and food production in Scotland. Co-ordination of the integrated elements of the national surveillance programme will be undertaken by SCIEH which will set up an appropriate multi-disciplinary group to oversee this exercise. This group might be the HAI Surveillance Implementation Steering Group, established in line with the recommendation in the earlier Report on surveillance of HAI, with suitable enhancement of its membership, as required. In addition, the Executive is to provide some 40,000 to set up pilot studies in 2-4 laboratories across the country (to gauge their ability to link surveillance data and transfer it to the Scottish Centre for Infection and Environmental Health (SCIEH)) and ongoing costs of around 20,000 to set up and support a Scottish Microbiology Forum to debate fully and agree the most suitable methods for generating comparable data, taking account of local practice and preferences, the degree of bias within the data which is tolerable and the resource implications. 2
A pilot study of surveillance of HAI in intensive care units (ICUs) in Scotland was recommended in the first report of the subgroup. This second report recommends that surveillance of antibiotic resistance and prescribing in ICUs should also be included within this pilot surveillance scheme, in order to provide standardised, quantitative microbiology data, as well as prescribing data for ICUs. SEHD have made funding available for SCIEH, in association with the Scottish Intensive Care Association, to develop and implement a pilot surveillance scheme (modelled on the ICARE system which is in use in Northern Ireland) in 4 ICUs in Scotland. With respect to the other recommendations within the Report, the Department expects Trusts to facilitate the implementation of these recommendations within the increased allocations made available through NHS boards this year, and within indicative allocations for future years. Yours sincerely Trevor Jones Chief Executive, NHSScotland 3
EXECUTIVE SUMMARY 1. The Government gave a commitment to develop and take forward a comprehensive UK antimicrobial resistance strategy in response to the House of Lords Select Committee on Science and Technologies Report 'Resistance to Antibiotics and other Antimicrobial Agents'. The three key, interrelated elements of the strategy to control antimicrobial resistance are: surveillance prudent antimicrobial use infection control 2. Our National Health, A Plan for Action, a Plan for Change gives a commitment to taking steps to strengthen and monitor infection control in hospitals and to take measures to ensure the prudent use of antibiotics, thus maximising their effectiveness for patients who require them. 3. A key element to achieving both of these objectives is the implementation of appropriate surveillance systems. Resistance surveillance is needed to assess the extent of the problem and is well established as an essential cornerstone of any attempts to understand and control resistance and to underpin the prudent prescribing of antimicrobial agents. 4. This Report contains the recommendations of a Subgroup of the Advisory Group on Infection for the Development of Co-ordinated Surveillance of Antimicrobial Resistance Patterns in Scotland. 5. Objectives for surveillance in veterinary practice are very similar to those for human practice. Surveillance aims not only to provide information that is relevant to veterinary practice and the agricultural industries, but also to meet the important objective of containing the human public health impact of antimicrobial resistance. 6. Having reviewed the systems currently in place, or being developed in Scotland, the Subgroup concluded that at present Scotland is not equipped in the fields of human (medical) or veterinary practice with a national surveillance system that meets its requirements. Also, that the ideal, totally comprehensive system may not be achievable in the foreseeable future in human or veterinary practice. What is likely to be feasible is the implementation of a number of co-ordinated, integrated surveillance initiatives that together contribute to the building up of a comprehensive account of the impact and trends in antibiotic resistance. 7. In order to inform their deliberations the Subgroup heard presentations about the experience and practice in other parts of the UK (England, Wales and Northern Ireland) as well as in Denmark; about the potential benefits of collaborating with a private sector organisation FOCUS; and studied in depth the systems currently in place, or being developed, in both human (medical) and veterinary practice in Scotland. 8. The Subgroup have made a number of detailed recommendations with respect to the component parts of the complementary surveillance approaches they propose in human (medical and dental) practice in Scotland including specific recommendations with respect to data generation, data collection and analysis and data reporting. They also make recommendations with respect to surveillance in veterinary practice and food production in Scotland. These detailed recommendations are summarised in Annex 1 to the report (and detailed at the end of this summary for your information). 4
9. In addition to the specific recommendations detailed in Annex 1, a number of more general recommendations were made: i. There is a need to review the contribution which reference laboratories make to monitoring antimicrobial resistance and to put in place formal mechanisms for these data to be routinely reported in Scotland where that is not already done. This issue should also be addressed in contracts between NSD and PHLS. ii. The absence of routinely available data on antimicrobial resistance in dental practice, in the presence of inappropriate prescribing and the possibility of genetic transfer of resistance genes from resistant streptococci and other oral bacteria to other organisms in the mouth and gut is a cause for concern. Once the current CSO-funded pilot study of antimicrobial resistance in isolates recovered from dental abscesses in five UK dental schools has reported, consideration should be given to the logistics of long-term surveillance for acute dental infections. iii. Organisation and control of food animal production has a UK-wide base and containment of antimicrobial resistance in veterinary practice, therefore, has a UK wide perspective and is being addressed through the UK Action Plan prepared by MAFF (now DEFRA). Thus, the Subgroup recommend that the needs of Scotland should be considered in the knowledge that there is an overarching UK activity and that the Scottish Executive should identify special requirements that arise because of differences in the structure of its agricultural industry or organisation. In particular there should be increased reporting to veterinary and medical practitioners of collated antimicrobial resistance results generated from routine and active surveillance studies. iv. In medical practice, budgetary considerations determine that little extra work should be imposed on participating laboratories. Therefore, the Subgroup considered that the National Surveillance System should use routine data, downloaded regularly to the central database by electronic means. This will allow for timely, cost-effective and comprehensive surveillance. v. Standardisation of data capture from NHS laboratories is hampered by a lack of standardisation of specimen collection, testing methodologies, interpretative criteria and laboratory computer systems. There is agreement within the profession in Scotland that there is a need for standardisation in order to allow the development of a national surveillance system. Given resource and manpower constraints on laboratories at the present time, the implications of standardisation for clinical laboratories in Scotland need to be considered in depth and will require time for discussion and debate. vi. The Subgroup recommends that in order to fulfil the above objective for standardisation, a Scottish Microbiology Forum should be established to debate fully and agree the most suitable method(s) for generating comparable data taking into account local practice and preferences, the degree of bias within the data which is tolerable and the resource implications. vii. The main agent for co-ordinating nation-wide surveillance programmes in most European countries is the National Public Health Institute. In light of this, the Subgroup recommend that co-ordination of the integrated elements of national surveillance of antimicrobial resistance in Scotland should be undertaken by SCIEH. Further, that a group including representatives of infectious diseases, veterinary medicine, microbiology, 5
epidemiology, public health and information technology should be set up to monitor the implementation of surveillance of antimicrobial susceptibility. This group might be the HAI Surveillance Implementation Steering Group established in line with the recommendation in the earlier report on surveillance of HAI, with suitable enhancement of the membership as required. viii. The Subgroup were aware of the considerable, potential benefits in terms of data collection and analysis that could be offered by the commercial group FOCUS as well as the cost savings that would be made as a result of FOCUS equipping any contributing laboratories in Scotland. However, the Group were aware that not all Scottish laboratories would be involved in the scheme and the potential for an 'alert' system would be limited by this approach. Moreover, the implications of undertaking national surveillance through a commercial company would need to be more fully debated and detailed negotiations undertaken. FOCUS does not currently undertake national surveillance under contract in any other part of the UK or in any other country. The Group therefore recommend that whilst further debate takes place, FOCUS should be encouraged to identify and enter into discussion with those additional laboratories that it would wish to recruit within Scotland and that SCIEH and FOCUS should discuss the potential for a shared role as the central source. ix. The first report of the AGI Subgroup, recommended regular quarterly reporting of MRSA bacteraemias. The Group now recommend, in addition, that enhanced surveillance of MRSA should be undertaken either as a one-off exercise or as ongoing surveillance. This should be taken forward by the SCIEH-Ied HAI Surveillance Implementation Group, x. Intensive care units are often referred to as the genesis units for selection, maintenance and spread of antimicrobial resistance in the hospital. The highest incidence of antibiotic resistance is found in ICUS. A pilot study of surveillance of HAI in ICUs in Scotland was recommended in the first Report of the Subgroup. Surveillance of antibiotic resistance and prescribing in ICUs should also be included within this scheme. The Group therefore recommend that a pilot surveillance scheme in ICUs involving four hospitals able to provide standardised, quantitative microbiology data, as well as prescribing data for their intensive care units should be developed by SCIEH in association with the Scottish Intensive Care Association modelled on the ICARE system which is in use in Northern Ireland. xi. The Group were aware that the FSA is currently consulting on research needs in the area of food in relation to human health. FSA UK requested research proposals to Model current and past patterns and predict future trends in antibiotic resistance of food borne pathogens in humans and food animals. This work, which was advertised in April 2002, will focus on Salmonella, Campylobacter, Escherichia coli and Enterococus spp. The commissioned work will provide baseline information on antibiotic resistance within the food chain in humans and food animals. In addition to this, the Group recommends that, in the absence of any comprehensive surveillance programme examining antimicrobial resistance throughout the food chain a pilot study be established to provide baseline measurements at different points (including primary farm production and abattoir level) and that this be coordinated with sampling of the food chain. The pilot study should study zoonotic and indicator bacteria including E.coli, Campylobacter, Salmonella and Enterococci spp. The Group further recommends that consideration should be given to the design and implementation of appropriate surveillance within the expanding aquaculture industry. 6
Summary of key recommendations Data generation A Scottish Microbiology Forum should be established to debate fully and agree the most suitable method(s) for generating comparable data taking into account local practice and preferences, a careful consideration of the amount of bias in the data which is tolerable and the resource implications SARS should continue until a national surveillance system involving all Scottish laboratories is developed Standardization of speciation should be encouraged. The aim should be to speciate all isolates from patients in ICUs and those with cystic fibrosis. Recommendations on speciation of all hospital isolates should follow because of the importance of identification in interpretation of susceptibility tests and mechanisms of resistance Regarding speciation of urine isolates from general practices, laboratories not using routine automated identification and susceptability systems and those using direct susceptibility testing, could be asked to undertake speciation of batches of consecutive isolates at periodic intervals Quality control of the national system should be by existing internal and external systems, and also (for those using disc testing) introduction of statistical analysis of zone sizes as used routinely in Sweden The long-term aim should be to devise a system that would involve all Scottish laboratories in data generation. Testing and reporting would use standard methods either by NCCLS criteria in common with the rest of the world, or by the BSAC method in common with England and Wales. There will be cost implications for laboratories for the purchase of zone readers and/or multi-point identification systems for speciation Facilities for collection of data from a sentinel group of general practices and typing of isolates to detect clonal spread and investigation of new mechanisms of resistance should be considered. Data collection, analysis and reporting Those laboratories currently forwarding their local data for analysis to SCIEH should continue to do so A further specification/remit for ECOSS to include antimicrobial resistance data should be considered SCIEH should continue to be involved as the central source of data analysis with those laboratories that are willing to participate FOCUS should be encouraged to identify those additional laboratories that it would wish to recruit SCIEH and FOCUS should discuss the potential for a shared role as the central source/resource A minimum data set for surveillance, to be collected from all laboratories, should be specified Data and computer programmes should be checked by central data validation, harmonisation and analysis Reports produced should provide data which are comparable to those from existing systems in the UK and Europe SEHD should consider funding a pilot study involving 2-4 laboratories, equipped with zone readers and LIMS interphase and assess their performance and the ability of ECOSS (or RGSD) to transfer data to SCIEH. Should this approach prove to be effective then the experience from the pilot can be used as the basis on which the funding required to establish such a system can be estimated so that a bid can be made for the necessary resources. 7
Using the data Hospital and Community Infection Control Teams should regularly receive data on alert organisms, as well as analyses of their own and national trends. The facility to interrogate their own and Scottish databases should be available A system of international, national and local alert bacterial/antibiotic combinations needs to be agreed and established, along with clear instructions on the level of action required to contain these alerts as and when they arise The sub-group was particularly impressed by the In-Control computer package for local data collection which has been made available to all ICN teams in Wales and recommends that the opportunities for the use of this package in Scotland be investigated further General recommendations. The participation of Scottish laboratories in existing European surveillance, such as the EARSS scheme, should be encouraged and facilitated The requirements of the Data Protection Act and the Caldicott Guidance must be met Research should be undertaken into the mechanisms and typing of bacteria as they relate to the containment of antimicrobial resistance. Surveillance through SARS Alert and target organisms surveillance Alert organism surveillance and target organism surveillance should continue and be expanded as feasible until they can be replaced with electronic mechanisms for data collection and reporting. Surveillance using data routinely available from reference laboratories Reference laboratories should be encouraged to conform in the way that susceptibility testing is performed and a common methodology agreed to inform routine laboratory users Arrangements should be in place in the Reference Laboratories for routine and timely reporting of the results of tests, including trends in susceptibility, and these should be included in their Annual Reports Standard guidelines for sending specimens should be drawn up and should form part of the contract between the Reference Laboratory and NSD. Surveillance of methicillin resistant Staphylococcus aureus (MRSA) Enhanced surveillance of MRSA should be undertaken either as a one-off pilot study or as ongoing surveillance A clear national strategy is required to provide enhanced surveillance of MRSA. 8
Surveillance of antibiotic resistance in intensive care units A pilot surveillance scheme in ITUs involving four hospitals able to provide standardized, quantitative microbiology data, as well as prescribing data for their intensive care units should be developed in association with the Scottish Intensive Care Association. Coordination of National Surveillance Activity Coordination of national surveillance of antimicrobial resistance should be undertaken by SCIEH in collaboration with the Scottish Microbiology Forum when established A group including representatives of infectious diseases, veterinary medicine, microbiology, epidemiology, public health and information technology should be set up to monitor the implementation of surveillance of antimicrobial susceptibility. This group might be the HAI Surveillance Implementation Steering Group recommended in the earlier report on Surveillance of HAI (19), with suitable enhancement of the membership as required. Surveillance in Dental Practice The report on the study by Glasgow Dental school, and its recommendations for long-term surveillance, should be considered in the light of developments in national surveillance and the data included within the national data set Data should be used to provide general dental practitioners with advice on prescribing Proposals for Surveillance of Antibiotic Resistance in Veterinary Practice Surveillance based on routinely generated data produced by SAC should continue. The move to UK standardization will enhance data comparability in the veterinary field The introduction of a quality assurance system for antimicrobial sensitivity testing is recommended to further enhance data quality. The resource implications of this will require to be addressed The comparability of data generated and reported in veterinary practice, and those reported in medical practice, should to be addressed. SEHD, SEERAD and FSA should be consulted on the funding of a study to investigate this A minimum data set should be defined for alert organisms in veterinary practice, and data collection and timely reporting, implemented through a collaboration between SCIEH and SAC Consideration should be given as to whether the sampling base of ongoing surveillance schemes should be expanded to provide statistically robust information about certain zoonotic and indicator bacteria, or whether one-off, or intermittent surveys should be undertaken for this purpose The results of active surveillance being undertaken in the surveys summarised in Table 1, when available, and their implications for practice, should be made widely available to medical and veterinary practitioners 9
SEERAD and SAC should continue to develop a national strategy for surveillance of prescribing, and promotion of prudent usage, and public awareness, through the co-ordination activities of the DARC group SAC should be funded by SEERAD to publish nationally collated information on antimicrobial resistance data and to include prescribing advice There should be close collaboration between FSA, SEERAD and the SEHD in the development of research and to ensure that antimicrobial resistance surveillance in veterinary practice provides and regularly publishes information which is relevant to containing the human public health impact of antimicrobial resistance. Proposals for monitoring antibiotic resistance in food and in the aquaculture industry In the absence of any comprehensive surveillance programme examining antimicrobial resistance throughout the food chain, it is suggested that a pilot study be established to provide baseline measurements at different points, including primary farm production and abattoir level, and to co-ordinate this with sampling of the food chain. The pilot study should target zoonotic and indicator bacteria including E. coli, campylobacter, salmonella and enterococci Consideration should be given to the design and implementation of appropriate surveillance within the expanding aquaculture industry. 10