Surveillance Of Antimicrobial Use Research Articles

P15 UK Antimicrobial Registry Study: progress to date

Abstract Background Effective antimicrobial stewardship is key in the fight against antimicrobial resistance, a key element of which is the surveillance of antimicrobial use and antimicrobial resistance. In addition to quantitative analysis of antibiotic use trends it is also important to understand qualitative aspects of how antimicrobials are used in routine clinical settings. Objectives The UK Antimicrobial Registry (UKAR) Study, a 5 year collaboration between BSAC and the University of Aberdeen, aims to determine how recently licensed antimicrobial agents are being used, their effectiveness and safety. The study is included in the NIHR portfolio in England with similar arrangements in Scotland and Wales. Here, we present brief information on the first few months of participant recruitment. Methods The study commenced recruiting patients prescribed selected antibiotics in May 2023. The intention was to commence with a small number of pilot hospital sites then to expand to a larger number of hospitals. Adult patients are potentially eligible if they have been prescribed any drug on the eligible drug list within their current stay in hospital unless the drug is actively withdrawn after less than 24 h. Data are collected from the medical records of participants who have given informed consent. Clinical data, including infection, microbiology susceptibility testing, eligible drug and dosing regimens are collected as well as prior and concurrent antibiotic therapy. Results As of November 2023, the study is open to recruitment in nine sites across the UK. There are a further 22 sites across the UK in study set-up and a further 15 sites who have submitted an expression of interest to join the registry. Fifty-two patients have been recruited as of November 2023. Five of the 11 study drugs were prescribed; the majority of the participants (N=29) were prescribed dalbavancin, the remainder received various Gram-negative agents (Table 1). Study drugs were used to treat bone and joint infections (33%) and lower respiratory tract infections (33%), with other disease areas including skin and subcutaneous tissue infections and urinary tract infections. Conclusions A key objective for UKAR pilot sites was to verify that the data collection process was feasible and address any issues around clarity of responses. Very few issues were identified, and all were resolved quickly. Early data show that participants are most likely to be female with a median age above 60 years. There is also, currently, a preponderance of patients commencing dalbavancin, although the study is still in its infancy. As more sites recruit participants to the UKAR Study, more detailed analyses can be performed on the clinical usage and outcomes being achieved. Also, follow-up data including clinical outcomes and adverse events will be collected 56 days after commencing therapy, and 28 days after last administration of an eligible study drug. In addition, clinical outcomes and relapse of the initial infection will be recorded at 6 and 12 months.

A comprehensive point prevalence survey of the quality and quantity of antimicrobial use in Chinese general hospitals and clinical specialties

Antimicrobial resistance (AMR) is a serious, worldwide public health crisis. Surveillance of antimicrobial use forms part of an essential strategy to contain AMR. We aimed to conduct a national point prevalence survey (PPS) on antimicrobial use, and to compare this data with similar international surveillance programs to provide a reference for future AMR strategy development in China. Twenty general hospitals encompassing 10,881 beds and 10,209 inpatients around the country participated the survey using a standardized protocol, at 8am of someday from October 10th to November 31st, 2019. Of the patients, 37.00% (3777/10209) received antimicrobial agents, 31.30% (1630/5208) had surgical operations, and 76.63% (1249/1630) received prophylactic antibiotic. The prevalence of antimicrobial use in medical, surgical, and intensive care units (ICU) patients was 38.84% (1712/4408), 32.07% (1670/5208), and 66.61% (395/593), respectively. Of prescriptions, 5.79% (356/6151) were made in the absence of indication. The intensity of antimicrobial use was 61.25 DDDs/100 patient days, while the intensity of use in internal medicine, surgery, and ICU were 67.79, 45.81, 124.45 DDDs/100 patient days, respectively. Only 11.62% (715/6151) of prescriptions had a reason described in the patient record. Furthermore, 8.44% (210/2487), 14.19% (424/2989), and 12% (81/675) of the prescriptions in internal medicine, surgery, and ICU had a recorded indication, respectively. The review and stop date recorded for antimicrobial therapy was 43.73% (1976/4518). Of the patients, 38.07% (1438/3777) received combination therapy. The classes of antimicrobials prescribed were limited, and the proportion of prescriptions encompassed by the top 20 antimicrobial agents was 75.06% (4617/6151). The prevalence of antimicrobial use in China is close to that of Sweden, the UK, and Canada, but lower than that in India, and higher than that in Switzerland. The data described in this report indicate that the quality of antimicrobial prescriptions requires improvement in China. Further, hospitals should implement professional interventions to improve the rational use of antimicrobials.

Quantifying antimicrobial use on Canadian dairy farms using garbage can audits.

Antimicrobial resistance in pathogenic bacteria is one of the preeminent concerns for the future of global health. There is a dose-dependent relationship between antimicrobial use (AMU) and the prevalence of antimicrobial-resistant pathogens. As most AMU in Canada is related to animal agriculture, there is a need to reduce overall AMU, which could be accomplished through surveillance of AMU in animal agriculture, including the dairy industry. The objective of this study was to quantify AMU on dairy farms across Canada. This study had two parts: a description of data collected in 2019-2020, and a meta-analysis comparing this data to previous estimates of AMU in the Canadian dairy industry. The first included a garbage can audit (GCA) on 107 farms in four Canadian provinces (British Columbia, Alberta, Ontario, and Nova Scotia) in 2020; AMU data were converted to the dose-based metrics of defined course doses (DCD) and defined daily doses (DDD). Mixed-effect linear models were fit to determine the relationship between province and use of different classes of antimicrobials. On average, for every 100 animals on the farm, 117 DCD of antimicrobials were administered per year (IQR: 55, 158). These treatments amounted to 623 DDD / 100 animal-yr (IQR: 302, 677 DDD/100 animal-years). Penicillins were the most used class of antimicrobials, followed by first-and third-generation cephalosporins. Farms in Ontario used more third-generation cephalosporins than other provinces. The second part of this study compared AMU in 2020 to previously reported Canadian studies through a meta-analysis. A GCA was conducted in 2007-2008 in Alberta, Ontario, Québec, and the Maritime provinces (Prince Edward Island, New Brunswick and Nova Scotia); another GCA was conducted in Québec in 2018. Overall, AMU was lower in 2018-2020 than in 2007-2008, with the exception of third-generation cephalosporin use, which increased.

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018

BackgroundAntimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals.MethodsAcute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd).ResultsNine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409–554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd).ConclusionsThis study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.

Determination of antimicrobial use in commercial poultry farms in Plateau and Oyo States, Nigeria

BackgroundIndiscriminate use of antimicrobials for the prevention and treatment of bacterial infection in animals is a common practice in Nigeria as in other developing countries. These antimicrobials are purchased over the counter without restrictions and often administered in form of medicated feedstuffs. In Nigeria, like most developing countries, antimicrobial prescription data are not routinely collected or reported at the farm level, instead import data are used in reporting antimicrobial consumption. Farmers can be useful sources of data on the use of antimicrobial agents by class, animal species, production type and age. The objective of the study was to determine the knowledge, attitude and practices of poultry farmers on antimicrobial resistance and to generate data on antimicrobial use (AMU) in poultry farms in Plateau and Oyo states in accordance with the guidelines of the World Organization for Animal Health (WOAH).MethodsA questionnaire used by the Food and Agriculture Organization (FAO) of the United Nations in Ghana was adopted and modified to collect data on the knowledge, attitude and practices of farmers on AMR and AMU and to collect AMU data from selected poultry farms. A focus group discussion (FGD) was conducted in Plateau state with poultry farmers and representatives from the state veterinary services, using a checklist. The aim of the FGD was to have an idea on antimicrobial use among poultry farmers and to generate additional questions that might be added to the questionnaire. Stratified random sampling technique was used to select 50 farms from Plateau and Oyo states, using the list of registered poultry farms in the two states as sampling frame.ResultsNinety eight percent (98%) of farmers gave antibiotics as prophylactic treatment to day old chicks. There were 47 different products used in the two states within the study period. We observed that five classes of antibiotics (Tetracyclines, Penicillins, Aminoglycosides, Polypeptides and Fluoroquinolone) were used in the two states. A total of 351 kg of active ingredients from seven different classes, namely: tetracyclines, penicillins, aminoglycosides, polypeptide, fluoroquinolones, amphenicol and macrolides were recorded from the two states. Some products contained cocktail of antibiotics, having up to six different classes with very high concentration of active ingredients which are not in the list of registered antimicrobials reported to WOAH.ConclusionThe concept used for this survey proved that the approach can be applied for AMU surveillance in the animal health sector. It also provided insight on farmers’ knowledge and practices with regards to the use of antimicrobials which is missing in the national import data. The need for “stronger” antibiotics was identified as one of the drivers of antibiotic resistance.

Capturing systematically users' experience of evaluation tools for integrated AMU and AMR surveillance.

Tackling antimicrobial resistance (AMR) is a goal for many countries. Integrated surveillance of antimicrobial use (AMU) and resistance is a prerequisite for effective risk mitigation. Regular evaluation of any surveillance is needed to ensure its effectiveness and efficiency. The question is how to evaluate specifically integrated surveillance for AMU and AMR. In an international network called CoEvalAMR, we have developed guidelines for selection of the most appropriate tools for such an evaluation. Moreover, we have assessed different evaluation tools as examples using a country case format and a methodology with a focus on the user's experience. This paper describes the updated methodology, which consists of a brief introduction to the case and to the tool separately. Moreover, there are 12 functional aspects and nine content themes which should be scored using a 4-tiered scale. Additionally, four Strengths, Weaknesses, Opportunities, Threats (SWOT) questions should be addressed. Results are illustrated using radar diagrams. An example of application of the updated methodology is given using the ECoSur evaluation tool. No tool can cover all evaluation aspects comprehensively in a user-friendly manner, so the choice of tool must be based upon the specific evaluation purpose. Moreover, adequate resources, time and training are needed to obtain useful outputs from the evaluation. Our updated methodology can be used by tool users to share their experience with available tools, and hereby assist other users in identifying the most suited tool for their evaluation purpose. Additionally, tool developers can get valuable information for further improvements of their tool.

One Health Surveillance of Antimicrobial Use and Resistance: Challenges and Successes of Implementing Surveillance Programs in Sri Lanka.

Sri Lanka is a low-income country, as defined by the World Bank. The country suffered further economic downturn during the COVID-19 pandemic. This situation adversely affected the prioritization of policies and programs around healthcare and public health. In particular, inflation, fuel prices, and shortage of food supplies increased struggles to implement antimicrobial resistance (AMR) programs. However, in the long run, it is crucial to gather data and evidence to plan AMR policies and track interventions. (1) Aim: To establish and reiterate the importance of prioritizing AMR programs in the One Health framework, the Fleming Fellows collected and studied antimicrobial use/consumption (AMU/AMC) and resistance (AMR) in humans, food-producing animals, and the environment. (2) Methods: A systematic and cross-sectional study was conducted between 2019 and 2021. By way of coordinating an AMU/AMC and AMR prevalence study across six agencies from human health and food-producing animal sectors, the authors established a field epidemiology study, laboratory testing, and data processing at their institutions. AMU/AMC patterns were surveyed using questionnaires and interviews, while AMR samples were collected for antibiotic susceptibility tests and genomic tests. Samples were tested for phenotypic and genotypic resistance. (3) Results: In human samples, resistance was highest to beta-lactam antibiotics. In non-human samples, resistance was highest to erythromycin, a highest-priority, critically important antibiotic defined by the World Health Organization. From government records, tylosin was sold the most in the food-producing animal sector. (4) Conclusions: Sri Lanka AMU and AMR trends in human and non-human sectors can be ascertained by a One Health framework. Further coordinated, consistent, and sustainable planning is feasible, and can help implement an AMU/AMR surveillance system in Sri Lanka.

Identifying and addressing challenges to antimicrobial use surveillance in the human health sector in low- and middle-income countries: experiences and lessons learned from Tanzania and Uganda

BackgroundAntimicrobial resistance (AMR) is a global health security threat and is associated with increased morbidity and mortality. One of the key drivers of AMR is the inappropriate use of antibiotics. A key component of improving antibiotic use is conducting antimicrobial use (AMU) surveillance.MethodsUSAID Medicines Technologies and Pharmaceutical Services Program has supported the implementation of antimicrobial stewardship activities, including setting up systems for AMU surveillance in Tanzania and Uganda. Results from both countries have been previously published. However, additional implementation experience and lessons learned from addressing challenges to AMU surveillance have not been previously published and are the subject of this narrative article.ResultsThe team identified challenges including poor quality data, low digitalization of tools, and inadequate resources including both financial and human resources. To address these gaps, the Program has supported the use of continuous quality improvement approaches addressing gaps in skills, providing tools, and developing guidelines to fill policy gaps in AMU surveillance. Recommendations to fill these gaps, based on the Potter and Brough systematic capacity building model have been proposed.ConclusionsStrengthening AMU surveillance through using a capacity-building approach will fill gaps and strengthen efforts for AMR control in both countries.

Antimicrobial use in animals: a journey towards integrated surveillance.

In 2015, the World Organisation for Animal Health (WOAH, founded as OIE) initiated the annual collection of data on antimicrobials intended for use in animals using a Microsoft Excel questionnaire. In 2022, WOAH initiated the migration to a customised interactive online system: ANIMUSE Global Database. This system enables national Veterinary Services not only to monitor and report data more easily and more accurately, but also to visualise, analyse and use data for surveillance purposes to their own benefit in the implementation of national action plans on antimicrobial resistance. This journey started seven years ago, with progressive improvements in the way data are collected, analysed and reported and continuous adaptations to overcome various challenges encountered (e.g. data confidentiality, training of civil servants, calculation of active ingredients, standardisation to enable fair comparisons and trend analyses, and data interoperability). Technical developments have been key in the success of this endeavour. However, it is important not to underestimate the importance of the human element: to listen to WOAH Members and their needs, and to exchange to solve issues, adapt tools, and gain and maintain trust. The journey is not over yet, and more developments are foreseen, such as to complement current data sources with data collected directly at the farm level; strengthen interoperability and integrated analysis with cross-sectoral databases; and facilitate institutionalisation of data collection and systematic use in monitoring, evaluation, lesson learning, reporting and, eventually, surveillance of antimicrobial use and antimicrobial resistance when implementing and updating national action plans. This paper describes how all these challenges were overcome and how future challenges will be addressed.

Antimicrobial Resistance in the Food Chain: Trends, Mechanisms, Pathways, and Possible Regulation Strategies.

Antimicrobial resistance (AMR) remains of major interest for different types of food stakeholders since it can negatively impact human health on a global scale. Antimicrobial-resistant bacteria and/or antimicrobial resistance genes (transfer in pathogenic bacteria) may contaminate food at any stage, from the field to retail. Research demonstrates that antimicrobial-resistant bacterial infection(s) occur more frequently in low- and middle-income countries (LMICs) than in developed countries. Worldwide, foodborne pathogens are a primary cause of morbidity and mortality. The spread of pathogenic bacteria from food to consumers may occur by direct or indirect routes. Therefore, an array of approaches both at the national and international level to control the spread of foodborne pathogens and promote food safety and security are essential. Zoonotic microbes can spread through the environment, animals, humans, and the food chain. Antimicrobial drugs are used globally to treat infections in humans and animals and prophylactically in production agriculture. Research highlights that foods may become contaminated with AMR bacteria (AMRB) during the continuum from the farm to processing to retail to the consumer. To mitigate the risk of AMRB in humans, it is crucial to control antibiotic use throughout food production, both for animal and crop agriculture. The main inferences of this review are (1) routes by which AMRB enters the food chain during crop and animal production and other modes, (2) prevention and control steps for AMRB, and (3) impact on human health if AMR is not addressed globally. A thorough perspective is presented on the gaps in current systems for surveillance of antimicrobial use in food production and/ or AMR in the food chain.

Impact of expired stock on antimicrobial surveillance in rural hospitals: Implications and challenges for stewardship.

BackgroundQuantitative surveillance of antimicrobial use is a valuable tool used to support antimicrobial stewardship, identify overprescribing, monitor unexpected changes in usage, and assess the impact of interventions to improve prescribing. Smaller, more remote hospitals face many challenges in conducting effective antimicrobial surveillance.AimTo investigate the impact of expired stock on reported antimicrobial usage rates in smaller, more remote hospitals.MethodAntimicrobial usage rates (defined daily doses [DDDs] per 1000 occupied bed days [OBDs]) were calculated using monthly dispensing data and hospital activity data from 12 rural South Australian facilities for the period January 2018 to December 2020. Usage rates were re‐calculated, excluding expired stock, to estimate the impact expired stock had on reported usage rates and to quantify stock wastage.ResultsBetween 2018 and 2020, the average monthly aggregate usage rate for all 12 hospitals was 650 DDD/1000 OBDs, with the exclusion of expired stock resulting in an average monthly reduction of 37 DDD/1000 OBDs (5.7%). Analysis by the Australian Institute of Health and Welfare peer group demonstrated that the exclusion of expired stock reduced average monthly usage rates by 6.0% for Public Acute Group C sites and 10.6% for Public Acute Group D and Very Small Hospitals.ConclusionReplacement of expired stock may account for a substantial proportion of perceived antimicrobial usage in rural and remote hospitals, particularly for agents infrequently prescribed. Pharmacy distribution data is a surrogate measure for actual patient consumption; utilisation reports for smaller rural facilities should be interpreted with acknowledgment of the challenges of stock management in remote locations.

Guidance for evaluating integrated surveillance of antimicrobial use and resistance

Abstract Antimicrobial resistance (AMR) resulting from antimicrobial use (AMU) is an emerging threat to global health. One of the key elements for a better understanding and management of AMU and AMR is to develop effective and efficient integrated surveillance systems that consider the complex epidemiology of these issues and the impacts of resistance on humans, animals and the environment. Consequently, for this project, an international consortium of experts from multiple fields called CoEvalAMR was formed with the objectives to study user needs, characterise and compare existing tools for the evaluation of integrated AMU and AMR surveillance, apply them to case studies, and elaborate guidance on the purpose-fit selection and the use of the tools. For the comparison of evaluation tools, questions were extracted from existing tools and attributed to themes, to assess the user needs, interviews were conducted with national key stakeholders, and we applied a series of different evaluation tools to understand and document their strengths and weaknesses. The guidance was refined iteratively. From 12 evaluation tools, 1117 questions/indicators were extracted and attributed to seven emerging themes. Twenty-three experts were interviewed, who suggested to increase the ease-of-use, grant open access, provide web-based interfaces and allow results to be automatically generated. Respondents also wished for tools providing the flexibility to conduct a rapid review, or an in-depth analysis of the surveillance system, depending on the evaluation objectives. The case studies emphasised that proper evaluations require adequate resources, typically requiring the involvement of several assessors and/or stakeholders, and can take weeks or months to complete. The resulting web-based guidance comprises six main sections: 1. Introduction to surveillance evaluation, 2. Evaluation of surveillance for AMU and AMR, 3. Evaluation tools, 4. Support for selecting an evaluation tool, 5. Case studies and 6. Directory of existing tools. The audience for the guidance is personnel working in public, private, and non-governmental organisations, from public health, animal health, plant health and environmental health, at local, national and international levels. We conclude that the field is challenged by opposing user needs for reduction and simplicity versus system approaches allowing the synthesis of that knowledge to sufficiently reflect the complexity of AMU and AMR ecology for real-world decisions. The CoEvalAMR web platform allows a better understanding of the different evaluation tools and assists users in the selection of an approach that corresponds to their evaluation needs. The CoEvalAMR consortium continues to address remaining gaps and consolidate evaluation tools and approaches in the future. One Health Impact Statement Antimicrobial resistance (AMR) resulting from antimicrobial use is a threat to human and animal health and may have unknown impacts on the environment. To understand how governance and human behaviour relate to AMR, it is important to implement integrated surveillance across the human, animal and environmental sectors. In this work, we describe the development of guidance on how to evaluate such surveillance, what the available tools cover and what gaps remain. The integration of surveillance is essential to address the interrelated pathways across the system. Consequently, the work with the reporting interdisciplinary consortium revealed that the broad diversity of users and their needs imply that a sustained exchange is needed to address the evolving challenge. This will be important to develop meaningful measures of impact and to avoid fixing one sector’s problems at the expense of another.

Antimicrobial use in lactating sows, piglets, nursery, and grower-finisher pigs on swine farms in Ontario, Canada during 2017 and 2018

BackgroundData on antimicrobial use (AMU) in pig production are needed for the development of good antimicrobial stewardship practices to reduce the risk of antimicrobial resistance in bacteria that can cause illness in animals and humans. In Canada, there is a lack of quantitative data on AMU in the farrowing and nursery stages of pig production. This study aimed to determine which antimicrobial active ingredients are currently used in farrowing, nursery, and grower-finisher herds in the province of Ontario, Canada, and to quantify AMU using various metrics. We collected data on herd demographics, biosecurity, health status, and AMU during one production cycle from 25 farrowing and 25 nursery herds in Ontario, between May 2017 and April 2018, and obtained data from 23 Ontario grower-finisher herds during the same time frame from the Public Health Agency’s Canadian Integrated Program for Antimicrobial Resistance Surveillance. We applied frequency measures, and weight-, and dose-based metrics to the data.ResultsIn all pigs, the highest quantity of AMU was administered in-feed. By all routes of administration and compared to other production stages, nursery pigs used more antimicrobials in mg/kg biomass and the number of Canadian defined daily doses per 1000 pig-days (doseCA rate), while grower-finisher pigs used more antimicrobials in total kilograms and the number of Canadian defined daily doses per pig. In suckling pigs in some herds, there was routine disease prevention use of ceftiofur, an antimicrobial active ingredient categorized as very highly important in human medicine by Health Canada. The top antimicrobial used in each stage of pig production often varied by the metric used. There was producer-reported growth promotion use of antimicrobials in suckling and grower-finisher feed.ConclusionsThe results of this study provide a current picture of AMU in pigs in Ontario and can be used as a basis for further research on AMU in farrowing and nursery herds in Canada. Our findings confirm that it would be useful to include farrowing and nursery herds in routine AMU surveillance in Canada. A future analysis using data from this project will examine factors that affect the quantity of AMU.

Veterinary drug residues in animal-derived foods: occurrence, veterinary legislation and perceived risk factors in Cameroon

The presence of veterinary drug residues in animal-derived foods (ADF) remains a public health concern in low-income countries such as Cameroon. This paper provides an overview of the current status of antimicrobial (AM) residues in ADF, veterinary legislation on the use of AM and perception of risk factors with emphasis on the need for sustainable management in Cameroon from a one health perspective. Results show that a wide range of antimicrobials is used in the country with little or no attention to good veterinary practices. Residues of commonly used AM agents including those banned for use in food animal production in high-income countries were reported. The current legislation on the use of veterinary drugs is weak and does not make provision for key concepts such as Maximum Residue Limit. Veterinarians argue that the lack of disease diagnostic facilities and excessive use of AM has led to the presence of residues in ADFs. The government and relevant agencies need to enforce regulations for the use of veterinary drugs. Further, awareness creation through educational campaigns for users and consumers as well as the implementation of measures to restrict prescription and dispensation of AM agents to recognised veterinarians are necessary. More studies on AM residues in ADFs are needed to support veterinary drug surveillance policies. This paper strongly suggests collaboration between food safety experts, animal and human health professionals as well as policymakers to help implement good surveillance of antimicrobial use and to safeguard potent AM suitable for disease control for forthcoming generations.

Canadian Collaboration to Identify a Minimum Dataset for Antimicrobial Use Surveillance for Policy and Intervention Development across Food Animal Sectors.

Surveillance of antimicrobial use (AMU) and antimicrobial resistance (AMR) is a core component of the 2017 Pan-Canadian Framework for Action. There are existing AMU and AMR surveillance systems in Canada, but some stakeholders are interested in developing their own AMU monitoring/surveillance systems. It was recognized that the establishment of core (minimum) AMU data elements, as is necessary for policy or intervention development, would inform the development of practical and sustainable AMU surveillance capacity across food animal sectors in Canada. The Canadian Animal Health Surveillance System (CAHSS) AMU Network was established as a multisectoral working group to explore the possibility of harmonizing data inputs and outputs. There was a consensus that a minimum AMU dataset for AMU surveillance (MDS-AMU-surv) should be developed to guide interested parties in initiating AMU data collection. This multisectoral collaboration is an example of how consultative consensus building across relevant sectors can contribute to the development of harmonized approaches to AMU data collection and reporting and ultimately improve AMU stewardship. The MDS-AMU-surv could be used as a starting point for the progressive development or strengthening of AMU surveillance programs, and the collaborative work could serve as a model for addressing AMR and other shared threats at the human–animal–environment interface.

Antimicrobial Usage Surveillance Through Sales at Veterinary Drug Shops Intended for Livestock in Vietnam

There is a pressing need to establish surveillance systems for antimicrobial use (AMU) intended for animal production particularly in many low- and middle-income countries. This is an extremely challenging task, notably due to the wide range of animal species, production types and antimicrobials available in the market. In Vietnam, farmers commonly buy antimicrobials from veterinary drug shops. Therefore, veterinary drug shops are a potential target for data collection on AMU. We collected antimicrobial sales data at veterinary drug shops and estimated the amount of AMU in different animal species by antimicrobial active ingredient (AAI) class using different measurement metrics. We compiled information on all antimicrobials licensed in Vietnam and used this information to develop a mobile application to capture sales of antimicrobials intended for use in poultry, pig, and ruminant. We provided tablets with this application to 60 veterinary drug shops in two provinces of the country (Bac Giang in the north, Dong Thap in the south; three districts and 30 shops per province) for data collection over 3 weeks. Total sales of antimicrobials were extrapolated to 1 year, and these amounts were related to three different denominator estimates in each province including standing animal body weight, animal biomass, and Population Correction Unit (PCU). A total of 3,960 transactions [2,577 (median 75.5 per shop) in Bac Giang; 1,383 (median 28.5 per shop) in Dong Thap] of 831 different antimicrobial-containing products were recorded in the 3-week period. Sales of 57 AAIs belonging to 17 classes were recorded. In the three Bac Giang districts, we estimated that 242.0 kg of AAI were hypothetically sold over 1 year. Of those, 202.2 kg (83.6%) were intended for poultry, 19.8 kg (8.1%) for pigs, and 20.0 kg (8.3%) for ruminants. In Dong Thap, an estimated 48.4 kg of antimicrobials were sold, including 28.9 kg (59.7%) for poultry, 16.0 kg (33.1%) for pigs, and 3.5 kg (7.2%) for ruminants. After standardized by different animal population denominators, AMU in Bac Giang amounted to 1129.2 mg/kg standing animal body weight, 480.2 mg/kg biomass, and 636.1 mg/kg PCU. In Dong Thap, AMU figures were 1211.0 mg/kg standing animal body weight, 595.8 mg/kg biomass and 818.5 mg/kg PCU. We discuss the observed differences between species, location and metrics, as well as the potential advantages and limitations (including potential sources of bias) of this methodology and its applicability at country level. Retail level data collection can effectively be integrated into AMU surveillance systems that help identify priority AMU management areas (species, regions, and antimicrobial classes), establish national benchmarks and reduction targets.

Informing Stewardship Measures in Canadian Food Animal Species through Integrated Reporting of Antimicrobial Use and Antimicrobial Resistance Surveillance Data-Part II, Application.

Using the methodology developed for integrated analysis and reporting of antimicrobial use (AMU) and antimicrobial resistance (AMR) data, farm-level surveillance data were synthesized and integrated to assess trends and explore potential AMU and AMR associations. Data from broiler chicken flocks (n = 656), grower–finisher pig herds (n = 462) and turkey flocks (n = 339) surveyed by the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) at the farm-level (2015–2019) were used. The analyses showed a reduction in mean flock/herd level number of defined daily doses using Canadian standards (nDDDvetCA) adjusted for kg animal biomass that coincided with the decline in % resistance in the three species. This was noted in most AMU-AMR pairs studied except for ciprofloxacin resistant Campylobacter where resistance continued to be detected (moderate to high levels) despite limited fluoroquinolone use. Noteworthy was the significantly negative association between the nDDDvetCA/kg animal biomass and susceptible Escherichia coli (multispecies data), an early indication that AMU stewardship actions are having an impact. However, an increase in the reporting of diseases in recent years was observed. This study highlighted the value of collecting high-resolution AMU surveillance data with animal health context at the farm-level to understand AMR trends, enable data integration and measure the impact of AMU stewardship actions.

G20 Declaration on Health

Health ministers met to discuss global recovery and the G20 Declaration on Health was subsequently published. It sets forth the G20's intentions for achieving global health goals, including tackling the COVID-19 pandemic and fulfilling priorities surrounding healthy and sustainable recovery, One Health resilience, coordinated and collaborative responses and the accessibility of vaccines, therapeutics and diagnostics. A key focus is on collaboration and people-centred preparedness, a need for which was highlighted by the pandemic, as well as strengthening healthcare systems through continuous investment. The Declaration underlines the need to, 'strengthen our collective preparedness to prevent, detect, report, and respond to health emergencies and notably promoting resilience of health systems and communities; to create trust by exchanging reliable information, data and scientific knowledge in a timely manner to develop science- and evidence-informed policies, measures and tools; and to sustain financial support and economic recovery in order to achieve full implementation of the 2019 Political Declaration on Universal Health Coverage (UHC).' A primary commitment for the G20 health ministers is providing 'timely, equitable and global access to safe, affordable and effective COVID-19 vaccines, therapeutics and diagnostics (VTDs).' This includes promoting confidence in vaccines by providing reliable information. Further important elements of the Declaration are whole-society cooperation and cross-border collaboration, as well as the importance of a One Health approach. Concerns that emerged from the meeting were antimicrobial resistance (AMR), food systems and environmental health. Solutions will involve improved surveillance of antimicrobial use and the rise of resistance to new and existing therapeutics.

Knowledge Gaps in the Understanding of Antimicrobial Resistance in Canada.

Current limitations in the understanding and control of antimicrobial resistance (AMR) in Canada are described through a comprehensive review focusing on: (1) treatment optimization; (2) surveillance of antimicrobial use and AMR; and (3) prevention of transmission of AMR. Without addressing gaps in identified areas, sustained progress in AMR mitigation is unlikely. Expert opinions and perspectives contributed to prioritizing identified gaps. Using Canada as an example, this review emphasizes the importance and necessity of a One Health approach for understanding and mitigating AMR. Specifically, antimicrobial use in human, animal, crop, and environmental sectors cannot be regarded as independent; therefore, a One Health approach is needed in AMR research and understanding, current surveillance efforts, and policy. Discussions regarding addressing described knowledge gaps are separated into four categories: (1) further research; (2) increased capacity/resources; (3) increased prescriber/end-user knowledge; and (4) policy development/enforcement. This review highlights the research and increased capacity and resources to generate new knowledge and implement recommendations needed to address all identified gaps, including economic, social, and environmental considerations. More prescriber/end-user knowledge and policy development/enforcement are needed, but must be informed by realistic recommendations, with input from all relevant stakeholders. For most knowledge gaps, important next steps are uncertain. In conclusion, identified knowledge gaps underlined the need for AMR policy decisions to be considered in a One Health framework, while highlighting critical needs to achieve realistic and meaningful progress.

National Antibiotics Utilization Trends for Human Use in Tanzania from 2010 to 2016 Inferred from Tanzania Medicines and Medical Devices Authority Importation Data.

Antimicrobial use (AMU) is one of the major drivers of emerging antimicrobial resistance (AMR). The surveillance of AMU, which is a pillar of AMR stewardship (AMS), helps devise strategies to mitigate AMR. This descriptive, longitudinal retrospective study quantified the trends in human antibiotics utilization between 2010 and 2016 using data on all antibiotics imported for systemic human use into Tanzania’s mainland. Regression and time series analyses were used to establish trends in antibiotics use. A total of 12,073 records for antibiotics were retrieved, totaling 154.51 Defined Daily Doses per 1000 inhabitants per day (DID), with a mean (±standard deviation) of 22.07 (±48.85) DID. The private sector contributed 93.76% of utilized antibiotics. The top-ranking antibiotics were amoxicillin, metronidazole, tetracycline, ciprofloxacin, and cefalexin. The DIDs and percentage contribution of these antibiotics were 53.78 (34.81%), 23.86 (15.44), 20.53 (13.29), 9.27 (6.0) and 6.94 (4.49), respectively. The time series model predicted a significant increase in utilization (p-value = 0.002). The model forecasted that by 2022, the total antibiotics consumed would be 89.6 DIDs, which is a 13-fold increase compared to 2010. Government intervention to curb inappropriate antibiotics utilization and mitigate the rising threat of antibiotic resistance should focus on implementing AMS programs in pharmacies and hospitals in Tanzania.