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Antimicrobial resistance One world – One Health

Antimicrobial resistance One world – One Health. Ernst Kristian Rødland, MD PhD e.k.rodland@medisin.uio.no. Topics. What is antimicrobial resistance (AMR) AMR in Norway AMR globally Future perspectives. One Health.

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Antimicrobial resistance One world – One Health

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  1. Antimicrobial resistanceOne world – One Health Ernst Kristian Rødland, MD PhD e.k.rodland@medisin.uio.no

  2. Topics • What is antimicrobial resistance (AMR) • AMR in Norway • AMR globally • Futureperspectives

  3. One Health • Initiative to forgecollaborationbetweenphysicians, veterinarians and otherscientific, health and environmentallyrelateddisciplines • One Health recognizesthatthehealthofpeople is connected to thehealthofanimals and theenvironment

  4. Microbial biosphere • Bacteria • Environmental • Pathogen • Natural antibiotics • Reservoirofantibioticresistance genes Resistome

  5. How do bacteriabecomeresistant? • Vertical • Spontaneousmutations • Transferred to thebacteria`sprogeny • Horizontal • Exchange ofgenetic elements/plasmids • Packagesofresistance genes

  6. Historyofsomeantibiotics • Penicillin – 1928, regularuse in human medicine from the 1940s • Chlortetracyclin (Aureomycin) – 1945, used as a growth promotor in meatproduction • Fluoroquinolones (Nalidixic acid) – 1962

  7. Exposureroutesofantibiotics to theenvironment • Discharge from manufacturing • Urine and feces from usersofantibiotics • Antibiotics used in agriculture and aquaculture • Discardedmedicines – lackoftake-back programs

  8. Usageofantibiotics • 65% increase in human consumption (2000-2015) globally(1) • Approximately 80% ofa.b. consumption is in the animal sector(2) • Globally: 80000 (??) tonnes in agriculture (1) Klein et al. PNAS 2018 (2) WHO, 2017

  9. Antibioticselectionpressure Significantimpactontheresistome in the microbial biosphere

  10. AMR is omnipresent • E.coli from arcticbirds • Siberia, Alaska, Greenland • AMR detected in 8/97 isolates • 17 antimicrobials weretested, resistance to 14 weredetected Sjølund-Karlsson et. al. EmergingInfectiousDiseases www.cdc.gov/eid • Vol. 14, No. 1, January 2008

  11. Antibiotics in agricultureAMR transmission • «Drugresistance in Salmonella typhimurium and itsimplications»(1) • «Changes in intestinal flora of farm personnelafterintroductionof a tetracycline-supplementedfeedon a farm»(2) (1) ES Anderson, Br Med J., 1968 (2) Levy et al. N Eng J Med. 1976

  12. Ny Powerpoint mal 2011

  13. AMR, a global challenge • AMR is a global challenge(1) • Compromisestreatmentofcommoninfections • Undermines advances in modernmedicine and health • Estimation by 2050(2) • 10 million deaths/yr globally • Costs: 100 trillion USD/yr (1) WHO, 2015 (2) Jim O`Neill et.al 2016

  14. Whatcan be done?

  15. WHO Global action plan Strenghtenknowledgethroughsurveillanceand research

  16. AMR in Norway

  17. Microbiological Laboratories • Norway • 22 clinicallaboratories in total • 11 referancelaboratories • Different (several, 5-7) platforms to register microbiological data

  18. NORM/NORM-VET • Established in 1999/2000 • Surveillance program for AMR in humans, animals, food and feed • Publish data on the usage of antimicrobial agents in humans and animals • Annual reports

  19. Human clinicalisolates • All positive bloodcultures • A patientwith a given bacterialisolate is excluded from registrationwith a newisolateofthe same species within a month from the first entry • Bacteriawhichcommonlyinfecttheskinareexcluded • Other samples for selectedbacteria • Urine (E.coli, Klebsiella, Proteus) • Respiratorytractspecimen (HaemophilusInfl., S. Pneumonia) • CSF (N. Meningitidis) • Wounds (Staph. Aureus)

  20. Notifiablediseases in the Norwegian Surveillance System for CommunicableDiseases (MSIS) MRSA, VRE, ESBL-carba

  21. Challenges, computational • «Old» technology • Different laboratoriesoftenuse different laboratoryinformation systems • Investment in one system -> costly to change • Oslo University Hospital (OUS):

  22. Challenges, registrationof data • Manual work • Not possible to send data directly to NORM • Strictprivacypolicies • Avoid double registration in the system • Qualitycheck • Demanding and work intense for laboratory staff

  23. Useofantibiotics in Norway NORM NORM-VET 2016

  24. ESBL – NorwayExtended-spectrum beta-lactamases

  25. MRSA – NorwayMethicillin-resistantstaphylococcusaureus

  26. AMR Globally

  27. Global antibioticconsumption Klein et al. PNAS, 2018

  28. Results • AMR data from 22 surveillance systems • 67 countries • HICs 57%, 38 countries • UMICs 24%, 16 countries • LMICs 16%, 11 countries • LICs 3%, 2 countries

  29. AMRDevelopement and spread • Improperuseof antimicrobials • Lackofmicrobiologicaldiagnostic services • Poorsanitation and shortageofclean water • Crowding– interpersonal spread • Migration Resource limitedcountries (RLCs)

  30. AMR in the WHO African region • High prevalenceof AMR in clinical relevant bacteria • 2011: WHO publishes a policy package to combat AMR • Top priority: strenghtensurveillance and laboratorycapacity • No reliable data available from 42,6% ofAfricancountries(1) (2) (1) Tadesse, B.T., et al., BMC Infect Dis, 2017 (2) Essack, S.Y., et al.J Public Health (Oxf), 2017

  31. Availablereference labs in Africa Barbe`et. al, ClinicalMicrobiology and Infection, 2017

  32. China • Antibioticconsumptionincreased from 2,3 to 4,2 (79%) billion DDDs from 2000-2015 • 92700 tonnesofa.b. was used in China in 2013(1) • 48 % was used in human medicine • 46% wasreleasedintotheenvironment • Antibioticsaccount for approx. half thedrugs used in hospitals(1) (1) M Qiao et al., Environment International, 2018

  33. China • Colistin. «Last resort» antibiotic • 2015 – Plasmid mediatedcolistinresistance (mcr-1) wasdiscovered in pigs and humans in China Wang et al. Nature 2018

  34. India • Antibioticconsumptionincreased from 3,2 to 6,5 (103%) billion DDDs from 2000-2015

  35. AMR migration • Approx. 2 billion peoplemoveacrosslargedistances/year and 1 billion cross international borders • 20–60% ofasylumseekersarecolonizedwithresistantmicrobes(1,2) • 50-90% oftouristsvisitingthetropicsgetcolonizedwith MDR enterobacteriacea New Dehli Metallo-beta-lactamase-1 (NDM-1) (1) de Smalen, A.W., et al., Travel Med Infect Dis, 2017 (2) Heudorf, U., et al.,GMSHygInfect Control, 2016

  36. ”....If walls have proveninsufficient to stop migratingpeople, it willcertainly be so for multi-resistantmicrobes and theirconsequences.....”

  37. Future perspectives

  38. InterpretationReductionofantibioticconsumptionwill not be sufficient to control antimicrobial resistancebecausecontagion—thespreadofresistantstrains and resistance genes—seems to be the dominant contributingfactor. Improvingsanitation, increasingaccess to clean water, and ensuringgoodgovernance, as well as increasingpublic health-careexpenditure and betterregulatingthe private healthsectorare all necessary to reduce global antimicrobial resistance. My answer has to be fighting poverty

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