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Time to strengthen international collaboration against antimicrobial resistance
Date: 2008-08-27  Read: 6714

Jae-Hoon Song, MD, PhD

Chairman, Asian-Pacific Research Foundation for Infectious Diseases (ARFID)
Organizer, Asian Network for Surveillance of Resistant Pathogens (ANSORP)
Professor of Medicine, Samsung Medical Center,
Sungkyunkwan University School of Medicine
Seoul, Korea

Major infectious diseases including acute respiratory infections, AIDS, diarrheal disease, malaria, and tuberculosis that account for more than 85% of the mortality from infectious diseases worldwide have increasing problems in the treatment due to widespread emergence of antimicrobial resistance.  The emergence and spread of multidrug-resistant microorganisms are among the most important global health threats.  Community pathogens have acquired antimicrobial resistance including penicillin- or macrolide-resistant Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus, and multidrug-resistant enteric pathogens.  Not only these community-acquired infections but also nosocomial pathogens such as methicillin- or glycopeptide-resistant S. aureus, glycopeptide-resistant enterococci, extended-spectrum beta-lactamase (ESBL)-producing enterobacteriaceae, and multidrug-resistant non-fermenters are also being recognized with increasing frequency around the world. 

Public health surveillance can be defined as ongoing and systematic collection, analysis, and interpretation of outcome-specific data essential to the planning, implementation, and evaluation of public health practice, closely integrated with timely dissemination of these data to those who need to know; the final link of the surveillance chain being the application of these data to the control and prevention of human diseases and injury.  The objectives of antimicrobial resistance surveillance are to provide the information necessary to secure an approach to the management of communicable diseases that minimizes morbidity and mortality.  The principal uses of the information from surveillance are to optimize the use of antimicrobial agents and assist in the prevention, control, and containment of antimicrobial resistance at the local, regional, and national levels.  To better understand the situation and to provide an early warning of new resistant strains, surveillance of antimicrobial resistance is critical.

Surveillance activities can be performed at different levels with different goals.  Local information can be used in clinical management and to update treatment guidelines, educate physicians and guide infection control policies in a certain region or hospitals.  National surveillance data are used to guide policies, update national formularies or lists of essential drugs and standard treatment guidelines and evaluate the cost-effectiveness of interventions.  International surveillance data are used to share information on the emergence of resistance in key pathogens, analysis of the impact of resistance and of policies for control, stimulating dialogue and engaging policy makers, developing advocacy and educational programs and stimulating research.

Although regional situation of antimicrobial resistance varies by countries or areas, it is evident that most major human pathogens have been increasingly resistant to almost all antimicrobial agents used in the clinical practice.  It is also clearly anticipated that antimicrobial resistance will become more prevalent in most parts of the world due to regional situation such as antibiotic abuse or misuse as well as spread of resistance between regions and countries.  International travel and globalization of trade and food supply could make the international spread of resistance more rapidly and effectively.  There are many examples of international spread of resistant clones between countries.  International spread of antibiotic-resistant pathogens suggests that antimicrobial resistance should be regarded as a global problem requiring a common strategy.  Today’s problem of antimicrobial resistance in certain pathogens in one country could be a serious disaster in other countries tomorrow. 

Given the global nature of antimicrobial resistance, it is critical to collect data representing as wide and diversified a geographic and population base as possible.  Moreover, it is especially important to collect data from developing countries where antibiotic abuse or misuse is more common.  International surveillance of antimicrobial resistance is aimed to identify emerging resistance problems and recommend alternative solutions, monitor changing trends in resistance from a local through to an international level, track the spread of significant resistance patterns on an international scale, and generate information for design and implementation of early intervention to halt the spread of resistance.  Based on these epidemiologic information, international surveillance of resistance should contribute to improve the quality of empirical antibiotic treatment in both the community and hospital, to guide the construction of antimicrobial policies and usage, to educate all those involved in the use of antimicrobial agents, to monitor prospectively the activity and usefulness of antimicrobial agents, to guide pharmaceutical industry in the development of new compounds, and to direct hospital infection control efforts.  International surveillance should also be utilized to raise awareness of the problems posed by antimicrobial resistance, to promote the sharing of information about resistance, to provide strategic and technical guidance on interventions to contain resistance, to assist member countries to implement these interventions, and to stimulate research to address the knowledge gaps and improve understanding of antimicrobial resistance.

There are many local, regional, or international surveillance systems of antimicrobial resistance currently working for different goals and programs.  The Asian Network for Surveillance of Resistant Pathogens (ANSORP) is one of the most representative international networks for research on antimicrobial resistance and infectious diseases.  ANSORP was first organized by Asian investigators in 1996 including 14 centers in 11 Asian countries.  Since the first international collaboration for the surveillance of pneumococcal resistance in Asian countries in 1996, ANSORP has been successfully performing many international studies on antimicrobial resistance in the region.  As of 2008, ANSORP has 135 centers in 65 cities in 14 countries in Asia and the Middle East.  Not only ANSORP but many other networks have been working on the international collaboration on antimicrobial resistance such as SENTRY, Alexander Project, MYSTIC project, or EARSS. 

International surveillance system should maintain simple and efficient structure to utilize data from the surveillance more conveniently.  International surveillance systems should include qualified centers in each country or region and should provide current data to all participating centers through effective communication system. More importantly, coordination and exchange of information between various international systems is critical to achieve basic objectives of many systems.  Given the serious nature of antimicrobial resistance worldwide, more effective and well-organized international systems should perform continuous and relevant surveillance studies on resistance and should prepare future strategies to control and prevent the emergence of resistance. 

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