ii iii WORLD HEALTH ORGANIZATION Integrated Surveillance of Antimicrobial Resistance Guidance from a WHO Advisory Group World Health Organization, Geneva iv WHO Library Cataloguing-in-Publication Data Integrated surveillance of antimicrobial resistance: guidance from a WHO Advisory Group. 1.Anti-infective agents. 2.Drug resistance, microbial. 3.Risk management. 4.Humans. 5.National health programs. I.World Health Organization. ISBN 978 92 4 150631 1 (NLM classification: QV 250) © World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switerland. v Contents Preamble ....................................................................................................................................................... 1 Declaration of interest .................................................................................................................................. 2 Acknowledgements ....................................................................................................................................... 3 Acronyms and abbreviations used in this document ................................................................................... 4 Executive summary ....................................................................................................................................... 6 1. Integrated surveillance of antimicrobial resistance in foodborne bacteria .......................................... 8 1.1 Scope ............................................................................................................................................. 8 1.2 Purpose of antimicrobial resistance monitoring .......................................................................... 8 1.3 Minimum requirements for surveillance ...................................................................................... 9 1.4 Elements of an integrated antimicrobial resistance surveillance system................................... 11 1.5 Sample sources ........................................................................................................................... 11 1.6 Target organisms ......................................................................................................................... 13 1.7 Sampling design .......................................................................................................................... 13 1.8 Laboratory testing ....................................................................................................................... 17 1.9 Data analysis and reporting ........................................................................................................ 19 1.10 Refining the monitoring system .................................................................................................. 22 1.11 References .................................................................................................................................. 23 2. Surveillance of the consumption of antimicrobial agents in humans and animals ............................ 24 2.1 Background ................................................................................................................................. 24 2.2 Terms of reference ...................................................................................................................... 26 2.3 General considerations ............................................................................................................... 26 2.4 Collection and reporting of data on consumption of antimicrobial agents in humans .............. 27 2.5 Collection of data on antimicrobial usage in animals ................................................................. 28 2.6 References .................................................................................................................................. 29 3. Collection of data on usage of antimicrobial agents in humans ......................................................... 32 3.1 General considerations ............................................................................................................... 32 3.2 Collection of point prevalence data on antimicrobial use in hospitals ....................................... 33 3.3 Longitudinal surveys of antimicrobial use in hospitals and the community .............................. 37 3.4 Continuous surveillance programmes ........................................................................................ 40 3.5 References .................................................................................................................................. 43 4. Collection of point prevalence data on consumption of antimicrobial agents in animals at the farm level ............................................................................................................................................................. 44 4.1 Confidentiality ............................................................................................................................. 44 vi 4.2 Identification of animal species of concern ................................................................................ 44 4.3 Farm-level data collection: general considerations .................................................................... 45 4.4 Recruitment of farmers ............................................................................................................... 45 4.5 Data to be collected .................................................................................................................... 46 4.6 Methods of data collection ......................................................................................................... 47 4.7 Farm-level (end-user) point prevalence data collection ............................................................. 48 4.8 References .................................................................................................................................. 48 5. Data management to support integrated surveillance of antimicrobial resistance ........................... 50 5.1 General principles ....................................................................................................................... 50 5.2 Minimal data elements ............................................................................................................... 50 5.3 Examples of data analysis ........................................................................................................... 52 5.4 Software tools ............................................................................................................................. 62 5.5 Reference .................................................................................................................................... 63 6. Data management to support integrated surveillance of antimicrobial consumption ...................... 64 6.1 General principles ....................................................................................................................... 64 6.2 Examples of data analysis ........................................................................................................... 66 6.3 Software tools ............................................................................................................................. 70 6.4 References .................................................................................................................................. 72 7. Effective risk communication in promotion of integrated surveillance for antimicrobial resistance .................................................................................................................................................... 74 7.1. Background and