| ______________________ CONFERENCES ______________________ ANTIMICROBIAL RESISTANCE IN VETERINARY PRACTICE AND ITS IMPACT ON HUMAN MEDICINE K. Ben Jebara Head, Animal Health Information Department.Wolrd Organisation for Animal Health (OIE).Paris. France Antimicrobial agents are essential drugs for human and animal health and welfare. Their use in animals can induce the development of antimicrobial resistant strains of pathogenic micro-organisms. This can result in the loss of therapeutic efficacy of one or more antimicrobial drugs and may lead to the emergence of multiresistant micro-organisms in both humans and animals. While there is certainly an impact of the use antimicrobial agents in veterinary medicine and in food-produ-cing animals, only few studies have provided qualitative evidence that antibiotics fed to animals have led to resistant bacteria and that these bacteria or their resistant genes are passed on to humans, mainly through the food chain. The OIE is recognised by the World Trade Organization as the reference organisation for the development of international standards on animal health and zoonoses relevant for trade of animals and their products. Antimicrobial resistance, as it relates to zoonotic bacteria which may be transferred between animals and from animals to humans and measures to control them, fall within its responsibility. The OIE has developed guidelines for the responsible and prudent use of antimicrobial agents in veterinary medicine, aimed at protecting animal and human health (http://www.oie.int/eng/normes /mcode/en_chapitre_3.9.3.htm). Their objectives include the prevention or reduction of the selection of antimicrobial resistant bacteria in animals and the prevention or reduction of the transfer of resistant micro-orga-nisms from animals to humans. The responsibilities of each contributor to antibiotics in the animal sector namely regulatory authorities, veterinary pharmaceutical industry, wholesale and retail distributors, veterinarians and food-animal producers are described. Advice is given on how to choose antimicrobial agents and how to use them in an appropriate manner. Other guidelines address the establishment and harmonisation of antimicrobial resistance surveillance and monitoring plans for animals and their products intended for human consumption (http://www.oie.int/eng/normes/mcode/en_chapitre_3.9.1.htm). The veterinary sector should work toward decreasing the antimicrobial resistance risk for both human and animal populations by applying the relevant international standards. While the respect and proper implementation of the OIE’s guidelines would assist in limiting the risk of antimicrobial resistance in animals and its transfer to humans, the better use of antibiotics in animals alone would not resolve the problem of antimicrobial resistance in humans, since much of it originates from the misuse or overuse of antimicrobial agents in human medicine.
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RELATIONSHIP BETWEEN THE ANTIMICROBIAL RESISTANCE IN HUMAN AND THE ENVIRONMENT Prof. Dr. Asem A. Shehabi Faculty of Medicine, University of Jordan, Amman, Jordan The selection and development of antimicrobial-resistant organisms is currently one of the greatest concerns of the WHO and the medical and scientific organizations worldwide. Resistance to antimicrobial agents constitutes a major threat to public health and should be considered as such more widely and serious than many other infectious diseases. The increased prevalence of antimicrobial resistance in most ecosystems is due mainly to the selective pressure imposed by the use of antibiotics in human and animals, and recently by introducing genetically modified organisms in agriculture. Most studies on antimicrobial resistance are done in hospitals and less related to community or environment. The relationship between the usage and occurrence of antimicrobial resistant organisms in humans, animals and the environment should be investigated within the same scope. Generally, very little is known about the development of bacterial resistance in the environment and its significance, particularly in the Arab countries. In case antimicrobial-resistant organisms and agents are not eliminated during sewage treatment or within the environment, they will reach surface water and ground water sources, and potentially drinking water. Three studies carried recently in Jordan, have demonstrated the prevalence of certain common epidemiological characteristics, including antimicrobial resistance patterns, R-plasmids and R-integrons among P. aeruginosa and E.coli isolates from patients stools, clinical specimens, healthy human controls and drinking water sources in Jordan. These results indicated that water can be an important potential reservoir to preserve and increase the incidence of antimicrobial- resistant among human pathogens.
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THREAT OF ANTIMICROBIAL RESIDENCE IN HUMAN MEDICINE EASTERN MEDITERRANEAN REGION (EMRO) N. E. Metwalli Regional Advisor, Blood Safety, laboratory and Imaging. WHO/ EMRO. Cairo. Egypt 1. Introduction All available evidence points to a marked increase in drug resistance among microorganisms that has paralleled an increase in the use of antimicrobial drugs. Particularly difficult clinical management problems are now posed by certain bacterial species which have shown the ability to acquire resistance to the majority of antimicrobial agents currently available. New and re-emerging infections are expected to pose a growing global health threat over the next 20 years. As many as a third of the estimated 54 million global deaths which occurred in 1998 were related to infectious disease, and this number is increasing. Researchers predict that the burden of morbidity and mortality due to communicable disease will increase over the next 10 years, with only limited improvement in the situation thereafter. The subject of resistance to antimicrobial agents is considered a top priority in WHO in light of the growing problem of emerging and re-emerging diseases caused by drug-resistant pathogens. Although most countries of the Eastern Mediterranean Region have focal points for surveillance of resistance against antimicrobial agents, many countries still have unreliable treatment protocols that do not conform to WHO treatment guidelines, and irrational prescribing of antibiotics is still practised. In many countries antibiotics continue to be available from pharmacies without prescription. This lack of awareness and standardization in the use of antibiotics has led not only to emergence and reemergence of drug-resistant disease, but also to higher treatment costs as a result of failing primary and sometimes secondary lines of treatment. These factors, along with the lag in development of new antibiotics, the rise of megacities with associated severe health care deficiencies and environmental degradation, and the growing ease and frequency of movements of people, livestock and produce across borders, have greatly facilitated the spread of infectious disease. In 2002, the Forty-ninth Session of the Regional Committee for the Eastern Mediterranean discussed this pressing problem and adopted a resolution (EM/RC49/R.10) on antimicrobial resistance and rational use of antimicrobial agents, aimed at reducing the overall use of antimicrobials in a balanced way in both human and veterinary medicine. Necessary actions should involve improved disease preventive measures, elimination of unnecessary and improper use of antimicrobials and improving the effective use of antimicrobials currently available, based on more precise diagnosis of infectious agents and on monitoring of antimicrobial resistance and control of antimicrobial usage. Although WHO can provide Member States with drugs at low cost through bulk procurement, countries should also be actively involved in price negotiations based on various trade agreements such as the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement and the General Agreement on Trade in Services (GATS), in order to ensure affordable prices for antibiotics on the essential drug list. 2. Progress since 2002 A consultation on antimicrobial resistance surveillance was held in Geneva in November 2002 to enhance collaboration between essential drugs, communicable disease surveillance, laboratory and maternal and child health programmes in the area of antimicrobial resistance surveillance. The Eastern Mediterranean Region was selected as a pilot region for antimicrobial resistance surveillance and containment. A survey was sent to all countries of the Region to evaluate their technical and financial capacity to conduct antimicrobial resistance surveillance, and a regional publication on antimicrobial resistance surveillance and containment in developing countries is currently in process. A training course on WHONET laboratory database software was held in the Regional Office in 2002 to develop expertise on data entry and analysis for antimicrobial resistance monitoring. The results of monitoring will enable identification of first-line, second-line and third-line antimicrobials, which will eventually result in considerable financial savings at national level. A regional consultation on antimicrobial resistance surveillance was held in May 2003 in which focal points for three areas, laboratory, drug regulatory authority and communicable disease surveillance, were invited from each country of the Region for discussions and deliberations. Technical staff from WHO and other international institutions supported the consultation. Several microorganisms were discussed, including Staphylococcus aureus, streptococci and Escherichia coli, as well as more aggressive pathogens such as those causing HIV, hepatitis B and C, tuberculosis and malaria. Hospital infections were given special attention. The Regional Office provided technical and financial support to the Third Arab Symposium on Antimicrobial Agents, held in Cairo in March 2004, which was organized by the Alliance for the Prudent Use of Antimicrobials. Copies of the WHO Global Strategy for Containment of Antimicrobial Resistance were distributed to participants. The consultation produced a plan of action for implementation of an antimicrobial resistance surveillance and containment programme for Arab countries. 3. Future directions A number of areas for action have been identified based on the WHO Global Strategy for Containment of Antimicrobial Resistance and the discussions of the Biennial Intercountry Meeting for Directors of Public Health Laboratories in the Eastern Mediterranean Region in May 2004. By the end of 2005, all countries should have in place a national intersectoral committee on containment of antimicrobial resistance. Membership should include health care professionals, veterinarians, agriculturalists, pharmaceutical manufacturers, government, media representatives, consumers and other concerned parties from different sectors. The committee should be supported by the national legislative and regulatory authorities to ensure appropriate use of antimicrobials. National strategy documents and master plans on containment of antimicrobial resistance need to be formulated and should include laboratory surveillance and data analysis, regular national updates based on available information and an emphasis on research in this area. The Regional Office could provide support by including antimicrobial resistance research in the Small Grants Scheme and by publication encouraging submission of relevant research findings to the Eastern Mediterranean health journal. Advocacy needs to be strengthened and should be directed not only to decision makers, political leaders and professionals but also to patients and the general public. The subject of antimicrobial resistance should be included in school health education programmes and in the curriculum of medical and paramedical education. Of particular importance is the establishment of hospital therapeutic committees and infection control programmes. Standard treatment guidelines should be implemented and national lists of essential antimicrobial drugs should be classified according to level of use, e.g. general practitioner, consultant and hospital use. Training courses for physicians, nurses and paramedics should be implemented if necessary. National monitoring and auditing systems should be introduced and feedback provided to both users and prescribers. At the regional level, regional reference laboratories and epidemiology programmes should report to the Regional Office through entry and analysis of data on the WHONET program. Regional reference laboratories should also support quality assurance and external quality assurance (EQA) schemes in the Region. Such schemes should include antimicrobial use in the veterinary, agricultural and aquacultural sectors and should include monitoring the use of antimicrobials as growth promoters. The Regional Office should consider reviving the taskforce established by the Regional Director in 2000 and posting antimicrobial resistance surveillance data from the Region on the EMRO website. The currently available data, produced from questionnaires sent to Member States, are being analysed and will pave the way for future planning of further activities. Countries of the Region will continue to be updated regularly with progress in this area.
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