textbox-2015-producing-5.html
DANMAP 2015 3D
6 / 144
danmap
2015
6 1. 1. editorial welcome to danmap 2015, a 20-year anniversary edition of the danish surveillance
programme of antimicrobial resistance
and consumption in humans and animals. the report includes the annual surveillance and a jubilee chapter presenting the main milestones and experiences from the last 20 years. the jubilee chapter also outlines suggestions on monitoring of antimicrobial resistance (amr) in the future. the layout of the report has changed slightly compared to previous years: each chapter commences with a short introduction to most important findings and highlights of 2015. most chapters also include the most significant findings in their area from the last 20 years. this has made the main summary obsolete. danmap was developed making the most of a collaborative spirit between stakeholders and with a common understand- ing of amr as a serious health threat requiring a one health approach to counter - because humans, foods and animals constitute overlapping reservoirs of antimicrobial resistance. the driver for danmap was the concern that use of the an- timicrobial growth promoter avoparcin posed a risk for occur- rence of vancomycin resistant enterococci (vre) in hospitals. these concerns led to intensive research and the danish ban on avoparcin in 1995, eventually followed by termination of the use of all antimicrobial agents for growth promotion in the entire eu from 2006. you can read more about the collabora- tion and itsī impacts on the danish and international animal and human welfare in the jubilee chapter on page 9. a circle closes, a new one begins. vre has re-appeared on the health agenda, since 2013 in the form of hospital outbreaks in the capital region of denmark and in the region of zealand. this report describes whole-genome sequencing of vres, which points towards a niche in the hospital environment, where certain subtypes of these bacteria thrive (textbox 8.3). the biggest emerging threat we are facing is the occurrence of carbapenemase-producing enterobacteriacea (cpe) and other carbapenemase-producing organisms (cpo) in danish hospitals (textbox 8.2). spread is not only restricted to specific species but also includes their resistance genes, which move between the different bacterial species with ease. as for the vre there is no known or suspected animal or food reservoir of the cpe and cpo in denmark. although only sporadic cases and outbreaks have been reported, the numbers are increasing at a frightening speed, and spread not only within departments but between hospitals has been observed. this demands an inten- sification of all efforts, if we are to control the situation. while some departments have begun screening, others have not yet encountered cpe in their patients. thus a new surveillance programme for these resistance genes is needed, if we want to stop the spread in time. the questions are: how do we both extend and restrict the screening to cover all relevant patients and departments in a timely national surveillance programme? and should screening procedures, for the first time, include hospital staff at exposed departments? ? a decision to carry out such screening would be in conflict with the protection of the individual worker and will demand ethical discussions as well. once again, we need to draw on our experience and knowl- edge from 20 years of collaboration and research. here we benefit from our experience with methicillin-resistant s taphy- lococcus aureus (mrsa). during the last eight years, livestock- associated mrsa (la-mrsa) has been danmaps biggest one health encounter. the knowledge gained from an extensive surveillance and research programme on mrsa has enabled definition and control of some of the health problems that arise from transmissible resistant bacteria. it also supports development of targeted efforts for protection of the vulner- able population at hospitals. an example is the newest version of ?the national guidelines on prevention of transmission of mrsa? published by the danish health authority. characterization of possible zoonotic transmission links of escherichia coli and their many resistance mechanisms has proven more difficult and challenging than for mrsa. in denmark, no specific direct transmission route from food to humans has been identified and we suspect a complex link to exist between animals and humans. this link might only consist of transmission of the resistance genes and not neces- sarily the bacterial strains. several attempts have been made to establish these possible transmission routes and the latest attempt is described in textbox 7.3. it is important to remember that most surveillance pro- grammes have gaps and primarily find what they are designed to look for. the task is to discover new or unknown resistances in a timely manner, which requires special surveillance designs. one of the newest examples is the discovery of the mcr-1 gene conferring resistance to colistin. historically, danmap has not had focus on colistin consumption and resistance in animals as the drug was rarely used in humans, though it had been reintroduced due to the occurrence of cpe. the finding of the mcr-1 genes in chinese meat and humans in august 2015, with a possible high rate of transfer even between different species, was alarming (liu et al, 2015). using the existing esbl-surveillance data from danmap, denmark was the first country outside of china to identify mcr-1 among sequences from human blood and animal indicator e.coli isolates in no- vember 2015 [hasman et al, 2015]. since then, it has been described by most european countries in human and animal isolates, some of which date back as early as the 1980s. in the last 20 years, technology, methodology and interpreta- tion of antimicrobial resistance identification have developed
2015-need-antimicrobial-7.html
