antimicrobial resistance: a continuing canadian...

Can J Infect Dis Vol 13 No 6 November/December 2002350

In 1997, Health Canada and the Canadian InfectiousDiseases Society coordinated the Canadian ConsensusConference on Antimicrobial Resistance. The Action Plandeveloped at this meeting was a series of recommendationsfor a Canadian initiative to address the serious and expand-ing problem of resistance (1). Other national and interna-tional documents have since repeated this theme, andnational strategies have been developed for other countries,including Britain (2) and the United States (3). The WorldHealth Organization proposed a Global Strategy foraddressing antimicrobial resistance in 2001 (4). Since 1997,flouroquinolone-resistant Streptococcus pneumoniae, flouroquinolone-resistant Salmonella typhi, trimethoprim/sulfamethoxazole-resistant community Escherichia coli,flouroquinolone-resistant community E coli, extended spec-trum beta-lactamase-producing E coli, vancomycin-intermediate Staphylococcus aureus, and now vancomycin-resistant S aureus have become issues of clinical and publichealth concern. In Canadian hospitals, methicillin-resistant S aureus (MRSA) continues to increase (5) andClostridium difficile with high-level resistance to clin-damycin and flouroquinolones is widespread. AlthoughCanada was among the first countries to propose a nationalagenda to contain antimicrobial resistance, five years laterthe antimicrobial resistance initiative appears to have lan-guished. Antimicrobial resistance evolves – is Canadastanding still?

One recommendation of the 1997 conference was theformation of a coordinating committee to provide leader-ship and to take responsibility for forwarding the CanadianAction Plan. The Canadian Committee on AntimicrobialResistance (CCAR) was formed within a year, and hasspearheaded the antimicrobial resistance containmentagenda through an advocacy and promotion role. A CCAR

summary of Canadian activities relevant to resistance is pub-lished in The Canadian Journal of Infectious Diseases twiceyearly. CCAR has been restricted, however, in its pursuit ofthe resistance agenda by limited resources, with support pri-marily through short term funding from the federal govern-ment. In early October, 2002, CCAR organized a NationalCanadian Policy Conference on Antimicrobial Resistance.The goal of this conference was to review the current statusof antimicrobial resistance in Canada in the context of theglobal experience, and to revitalize and refocus the nationalaction plan to limit antimicrobial resistance.

One theme of the conference was frustration. Frustrationat the apparent failure of the antimicrobial resistance issueto capture government attention or the public policy agen-da. Frustration at the lack of progress for infrastructuredevelopment for data collection systems to measure andmonitor antimicrobial use and resistance. Frustration at therising rates of MRSA and other key organisms in healthcare institutions despite intensive infection control meas-ures. Frustration at the failure to secure dedicated resourcesfor effective antimicrobial containment programs, includinga lack of consistent funding for CCAR. And, certainly, frus-tration at the high talk-to-action ratio for this topic.

There was also a shining light – the draft report, “Uses ofantimicrobials in food animals in Canada: impact on resist-ance in human health” by the Advisory Committee onAnimal Uses of Antimicrobials and Impact on Resistanceand Human Health (7). The report, prepared for theVeterinary Drugs Directorate, summarized the controver-sial, polarized and complex issues of antimicrobial use foragriculture in Canada. The recommendations of the report,including greater controls on prescribing, limitations ofantimicrobial use for growth promotion, and developmentof a national surveillance system for antimicrobial resist-

Antimicrobial resistance: A continuing Canadian tale

LE Nicolle MD FRCPC, Editor-in-Chief

EDITORIAL

Health Sciences Centre, Department of Internal Medicine, Winnipeg, ManitobaCorrespondence: Dr LE Nicolle, Health Sciences Centre, Department of Internal Medicine, CG443-820 Sherbrook Street, Winnipeg,

Manitoba R3A 1R9. Telephone 204-787-7029, fax 204-787-4826, e-mail [email protected]

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ance in food animal production are essential to addressingantimicrobial resistance nationally. The full implementa-tion of all recommendations is pending, but progress towarda national surveillance program is apparent, with resourcescommitted by the federal government to support develop-ment. The initial impetus for this funding was not concernfor health or resistance, but rather that current Canadianpractices in the use of antimicrobials in food animals jeop-ardize potential international trade opportunities.

The conference goal was to identify a limited numberof key areas where efforts should be focused to most effec-tively move the National Action Plan forward. After twodays of intense discussion, the five issues proposed weremonitoring antibiotic use, developing a multidisciplinarynational education program for the appropriate use ofantibiotics, ensuring effective infection control and pre-vention methods in all sectors, developing an integratedsurveillance plan with external quality assurance forhuman and animal antimicrobial resistance, and imple-menting the animal recommendations contained in theVeterinary Drugs Directorate Health Canada Report.These are the same themes recurring in all strategies toaddress resistance – surveillance, education, infection pre-vention and animal husbandry. Apart from the animalhusbandry initiative, are we likely to have more success inimplementing the other agenda priorities now than we didin 1997?

Monitoring antimicrobial use seems to be the moststraightforward objective. Provinces currently collect out-patient antimicrobial prescribing information within phar-macare programs, and some already have a relevantanalytical framework. Surveillance and reporting back toprescribers, by themselves, may influence use. Standardizeddescriptors such as defined daily doses need to be applied,and the relative use of antimicrobials should be comparedamong physician groups within a province, and usageshould be compared across provinces. Some programs arealready in existence in New Brunswick and Saskatchewan.The example of Denmark was before us throughout themeeting. Canada is larger, with a more diverse populationand a more complex health care delivery system thanDenmark, but opportunities for rapid implementationalready exist in some provinces in Canada. While antimi-crobial resistance may not be a priority for the provincialgovernment, antimicrobial use analysis will benefit provin-cial drug plans beyond resistance considerations. It is gener-ally accepted that a critical and appropriate program for theevaluation of antimicrobial use is likely to lead to decreaseduse, given consistent evidence of substantial antimicrobialoveruse throughout the health care system.

There are also several small-scale, Canadian, regionaleducation programs to modify antimicrobial use in whichoutcomes of decreased use have been reported (8). Whethersuch programs are applicable at a larger scale, or will havesustained results, are open questions. However, the limita-tion of antimicrobial use for selected outpatient infections

is a message that the public appears willing to hear. Butthere are pitfalls here, too. Decreased outpatient prescribingin the United States has been paralleled by a trend to lessuse of older, first-line agents, and greater use of more recent-ly introduced broad-spectrum antimicrobials. This rein-forces the need for critical monitoring and analysis ofantimicrobial use trends.

The implementation of effective infection preventionmethods is also controversial. Vaccine programs are ever-expanding and, at least for childhood illnesses, maydecrease overall antimicrobial use as well as infection withantimicrobial-resistant organisms such as Haemophilusinfluenzae and S pneumoniae. Hygiene messages are alsowidespread, but have, in part, been perverted to the wide-spread promotion of household disinfectant use, which mayactually promote resistance. Within acute care facilities,infection control programs have often been hampered bythe antimicrobial resistance agenda. Limited institutionalresources in infection control are applied to colonizationprevention rather than to infection prevention, and pro-gram components of proven benefit in infection reductionmay languish. Achieving appropriate resources for bothinfection control and antimicrobial resistance containmentis essential.

Developing a surveillance program for antimicrobial-resistant organisms is complex, at least partially because thegoals for such a program have not been clearly articulated.How do we select organisms of interest? How does surveil-lance evolve to remain timely and relevant as antimicrobialresistance and use evolves? How can surveillance bridge thespectrum of health care delivery from community to criticalcare? Should both colonization and infection be measured?How are morbidity and potential mortality assessed? A lim-ited, focused surveillance for selected organisms of highinterest is likely the most effective way to start. Thisapproach has proved to be successful with the CanadianNosocomial Infection Surveillance Program, which hasmeasured trends and impacts of MRSA (5) and van-comycin-resistant enterococci (9) in Canada. The develop-ment of an effective surveillance program to serve publichealth policy remains a great challenge.

Antimicrobial-resistant organisms will be an integralpart of our environment as long as antimicrobial agents areused. We need to live effectively with all of the outcomes ofantimicrobial use, both good and bad. The recent CCARconference reminds us that the principle themes of antimi-crobial resistance containment do not change. In Canada,despite a relatively early start, limited progress has beenmade in addressing this problem. The status quo in antimi-crobial use has a clear future – ever increasing antimicrobialuse, antimicrobial resistance and costs. An alternate path isclear and has been repeatedly articulated, including at therecent CCAR conference. Antimicrobial resistance con-tainment is a clinical, public health and economic impera-tive. This country needs to move aggressively beyond theAction Plan, to the action.

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REFERENCES1. Health Canada. Controlling antimicrobial resistance. An integrated

action plan for Canadians. Can Comm Dis Rep 1997;23(Suppl7):1-32.

2. Standing Medical Advisory Committee, Sub-group on AntimicrobialResistance: Main Report. The path of least resistance. London:Department of Health, 1998. <http://www.doh.gov.uk/arbstrat.htm>.

3. CDC, FDA, NIH: A Public Health Action Plan to CombatAntimicrobial Resistance. <www.cdc.gov/drugresistance/actionplan/index.htm>. Version current November 22, 2002.

4. WHO Global Strategy for Containment of Antimicrobial ResistanceWHO/CDS/CSR/DRS 2001-2. <http://www.who.int/emc-documents/antimicrobial_resistance/docs/EGlobal_Strat.pdf>Version current November 22, 2002.

5. Simor AE, Ofner-Agostini M, Bryce E, et al, for Canadian Nosocomial Infection Surveillance Program, Health Canada. The

evolution of methicillin-resistant Staphylococcus aureus in Canadianhospitals: 5 years of national surveillance. CMAJ 2001;165:21-32.

6. Conly J, Canadian Committee on Antibiotic Resistance.Antimicrobial resistance in Canada: Update on activities of theCanadian Committee on Antibiotic Resistance. Can J Infect Dis2002;13:236-8.

7. Health Canada, Health Products and Food Branch. Uses ofantimicrobials in food animals in Canada: Impact on resistance andhuman health. <http://www.hc-sc.gc.ca/vetdrugs-medsvet>. Versioncurrent at November 27, 2002.

8. Conly J. Antimicrobial resistance in Canada. CMAJ 2002;167:885-91.9. Ofner-Agostini ME, Conly J, Paton S, et al. Vancomycin-resistant

enterococci in Canada – results of the Canadian NosocomialInfection Surveillance Program 1996: VRE point prevalencesurveillance project. Can J Infect Dis 1997;8:73-8.

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