Biregional Workshop on Antimicrobial Resistance Surveillance and Containment in Asia and the Pacific, Manila, Philippines, 7-9 June 2005 : report

(WP) ICP/CSRlI.1I00 I English only Report series number: RS/2005/GE/13(PHL) REPORT BIREGIONAL WORKSHOP ON ANTIMICROBIAL RESISTANCE SURVEILLANCE AND CONTAINMENT IN ASIA AND IN THE PACIFIC Convened by: WORLD HEALTH ORGANIZA nON Manila, Philippines 7-9 June 2005 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines September 2005 \VHO/Wl'RO LIDRARY :tL\\~I..\, ;':::T )?PINES NOTE The views expressed in this report are those ofthe participants, consultant and temporary advisers in the Biregional Workshop on Antimicrobial Resistance Surveillance and Containment in Asia and the Pacific and do not necessarily reflect the policies of the World Health Organization. This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants in the Biregional Workshop on Antimicrobial Resistance Surveillance and Containment in Asia and the Pacific, which was held in Manila, the Philippines, from 7 to 9 June 2005. TABLE OF CONTENTS SUMMARY 1. INTRODUCTION ............................................................................................................ 1 1.1 Objectives .................................................................................................................. 1 1.2 Opening remarks ........................................................................................................ 1 1.3 Appointment of Chairperson, Vice-Chairperson and Rapporteur .............................. 2 1.4 Organization of the workshop .................................................................................... 2 2. PROCEEDINGS ............................................................................................................... 2 2.1 Presentations ................................................................................................................. 2 2.2 Working group discussioru ........................................................................................... 2 2.3 Information from questionnaires ................................................................................... 3 2.4 Round table plenary discussion ..................................................................................... 4 3. CONCLUSIONS .................................................................................................................. 4 ANNEXES ANNEX I Agenda ......................................................................................................... 9 ANNEX 2 List of Participants ..................................................................................... 12 ANNEX 3 List of Facilitators ...................................................................................... 18 ANNEX 4 Organisms and Antimicrobials Recommended for Surveillance at the Regional Level ............................................................ 19 Keywords: Antimicrobial resistance - Surveillance, Epidemiology / Laboratory personnel / Guidelines SUMMARY The Biregional Workshop on Antimicrobial Resistance Surveillance and Containment in Asia and the Pacific was held at the WHO Western Pacific Regional Office in Manila, the Philippines from 7 to 9 June 2005. The workshop was attended by 28 participants from Member States of the WHO South-East Asia and Western Pacific regions, as well as 14 facilitators from WHO, WHO antimicrobial resistance collaborating centres and other international centres. The objectives of the workshop were: (l) to review the current situation of antimicrobial resistance and identify the strengths and weaknesses of current national and regional antimicrobial resistance surveillance programmes, including quality assurance programmes; (2) to finalize the biregional guideline strategies, which will facilitate the development of national surveillance strategies; (3) to develop recommendations on the use of surveillance data in the development and implementation of national strategies for resistance containment; (4) to propose modifications to the current regional antimicrobial resistance surveillance programme to enhance the reliability of surveillance data and to strengthen regional collaboration; and (5) to come up with proposals for containment of antimicrobial resistance. Participants were asked to complete a survey questionnaire on the status of antimicrobial resistance (AMR) surveillance activities in their countries. These were collated and analysed by WHO staff. The workshop consisted of technical presentations by participants and facilitators, working group discussions and a round table plenary session. A minimum capacity for AMR surveillance should be developed in each country as a key element in the national resistance containment strategy. Workshop participants worked to finalize practical WHO guidelines on the organization and conduct of national surveillance programmes appropriate to different levels of resources and capability. To support regional surveillance objectives, a core list of pathogens of public health importance and key antimicrobials was elaborated. Participants concluded that WHO should establish a scientific advisory group to assist the ongoing formulation and implementation of WHO activities and guidelines in this area, including support for the compilation and interpretation of collected data and assistance in evaluating the strengths and weaknesses of surveillance efforts in Member States of the regions. WHO should proceed with the planning of a follow-up biregional workshop on antimicrobial resistance containment strategies, and continue to build on the collegial biregional collaboration between the Western Pacific and South-East Asia regional offices. - I - INTRODUCTION The WHO Global Strategy for Containment of Antimicrobial Resistance, released in September 2001 (www.who.intJdrugresistancefWHO_Global_Strategy _English. pdt), identifies, as one of two fundamental priorities, the need to "designate or develop reference microbiology laboratory facilities to coordinate epidemiologically sound surveillance of antimicrobial resistance". However, most countries in the Western Pacific Region have not yet established programmes for surveillance of antimicrobial resistance that collect nationwide data in a systematic manner, and data which are available are often unreliable or underutilized. In 1991, the WHO Western Pacific Regional Office established a multicountry surveillance programme to monitor antimicrobial resistance in the Western Pacific Region, following trends in resistance in several bacterial species of public health and clinical importance. This regional surveillance programme has been a valuable initiative within the framework of the Global Strategy. In 2000 to 2001, consultants reviewed the results of the Western Pacific antimicrobial resistance (AMR) surveillance programme, and a number of recommendations were made to improve the regional surveillance programme and additionally to strengthen national surveillance and resistance containment efforts. Expansion and revision of the system are recommended to monitor resistance in the Region more effectively. 1.1 Objectives The objectives of the workshop were: (I) to review the current situation of antimicrobial resistance and identify the strengths and weaknesses of current national and regional antimicrobial resistance surveillance programmes, including quality aSsurance programmes; (2) to finalize the biregional guideline strategies, which will facilitate the development of national surveillance strategies; (3) to develop recommendations on the use of surveillance data in the development and implementation of national strategies for resistance containment; (4) to propose modifications to the current regional antimicrobial resistance surveillance programme to enhance the reliability of surveillance data and to strengthen regional collaboration; and (5) to come up with proposals for containment of antimicrobial resistance. 1.2 Opening remarks Dr Richard Nesbit, Director, Programme Management, WHO Western Pacific Region, delivered the opening remarks on behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific. In his opening address, Dr Nesbit noted the importance of the workshop, being the first biregional workshop on the health threat posed by antimicrobial-resistant infections. He also noted that the WHO Global Strategy for Containment of Antimicrobial Resistance highlights two fundamental priorities. The first is to "make the containment of antimicrobial resistance a national priority", including the establishment of a national intersectoral task force and the allocation of adequate funds to implement containment strategies. The second is to "designate or develop reference microbiology laboratory facilities to coordinate effective, epidemiologically s(und surveillance of antimicrobial resistance". He further noted that the conclusions of the -2- workshop would serve as a practical and significant contribution to advancing resistance containment efforts in the WHO South-East Asia and the Western Pacific regions. Dr Nesbit gave special thanks to Dr Rajesh Bhatia of the Regional Office for South-East Asia for arranging the participation of India, Sri Lanka and Thailand. 1.3 Appointment of Chairperson, Vice-Chairperson and Rapporteur Professor Victor K.E. Lim of Malaysia was appointed Chairperson, Dr Eka Buadromo of Fiji as Vice-Chairperson and Dr Helen Mary Heffernan as Rapporteur for the workshop. 1.4 Organization of the workshop Twenty-eight senior scientists, clinicians and coordinators of national antimicrobial resistance surveillance programmes attended the workshop, representing Brunei Darussalam, Cambodia, China, Hong Kong (China), Macao (China), Fiji, India, the Lao People's Democratic Republic, Malaysia, Mongolia, New Zealand, Papua New Guinea, the Philippines, Republic of Korea, Singapore, Sri Lanka, Thailand, Tonga and Viet Nam. The list of participants is provided in Annex 2. A number of international experts, staff from the WHO Western Pacific Region, and a consultant from the WHO Collaborating Centre for Surveillance of Antimicrobial Resistance facilitated the workshop, as provided in Annex 3. The workshop consisted of technical presentations by participants and facilitators, working group discussions and a round table plenary session. The workshop was organized and sponsored by WHO. The agenda is provided in Annex 1. 2. PROCEEDINGS 2.1 Presentations Several participants and other inviIed speakers from WHO, WHO collaborating centres, and other experts in the Western Pacific and South-East Asia regions gave presentations on topics related to antimicrobiall'esistancc ,urveillance, antimicrobial consumption, and resistance containment imervemions. See agenda in Annex 1 for titles of presentations and corresponding speakers. 2.2 Working group d:~':llssici . .ci Participants were divided into three working groups covering the following topics: (1) guidelines for national surveillance of antimicrobial resistance and quality assurance in antimicrobial susceptibility testing; (2) a protocol for regional surveillance of antimicrobial resistance in the WHO Western Pacific and South-East Asia regions; and (3) translating surveillance into action - recommendations to surveillance programme coordinators to support local and national resistam.e-containment strategies. The working group discussions established the basis of the tinal conclusions of the workshop. - 3 - 2.3 Information from questionnaires Prior to the workshop, participants were given survey forms to elicit information on the current status of the AMR activities in their countries. These forms were submitted prior to the workshop and the data were collated and analysed by staff from the WHO Western Pacific Regional Office. Responses were returned from 19 participants. A summary of results is given below. Responses reflect only the activities of workshop participants, and may not necessarily reflect the status of other active surveillance efforts in the Member States. • Multilaboratory networks exist in China, India, New Zealand, the Philippines, the Republic of Korea, Malaysia, Sri Lanka, Thailand and Viet Nam. AMR surveillance based on laboratory testing in a single institution is conducted in Brunei Darussalam, Fiji, Hong Kong (China), Papua New Guinea and Tonga. No ongoing AMR surveillance activities were reported in Cambodia, the Lao People's Democratic Republic, Macao (China) or Mongolia. In Singapore, AMR surveillance is conducted by individual hospitals in the country but without centralized data collection, with the exception of a surveillance programme for methicillin-resistant Staphylococcus aureus. • All programmes include surveillance of human clinical isolates. In addition, the Chinese National Institute for the Control of Pharmaceutical and Biological Products also studies animal isolates, while the Korean National Antimicrobial Resistance Management Programme studies human, animal, food and environmental isolates. • Most programmes collect data on all routinely available clinical specimens and all available bacterial species. In others, surveillance is targeted to specific bacterial pathogens and/or specimen types, for example, in Papua New Guinea and Sri Lanka, only isolates of N. gonorrhoeae from genital samples are studied as part of the regional Gonococcal Antimicrobial Surveillance Programme (GASP) initiative. • Most countries rely principally on routinely generated antimicrobial susceptibility test results. With only a few exceptions, disk diffusion testing using NCCLS/CLSI performance and interpretation standards is used as the primary susceptibility test method. Agar dilution, broth microdilution, Etest®, and beta-Iactamase testing are also used by several countries. • Over half of the laboratories use the following quality control strains routinely for internal testing: ATCC 25922 E. coli (13115), ATCC 25923 or ATCC 29213 S. aureus (12/15), ATCC 27853 P. aeruginosa (11115), ATCC 49619 S. pneumoniae (9115) and ATCC 29212 E. faecalis (8/15). Testing is performed weekly in eight out of 15 laboratories and monthly in three out of 15. • Over half ofthe network coordinators recommend the following quality control strains for use by laboratories in their network: ATCC 25922 E. coli (8/9), ATCC 25923 or ATCC 29213 S. aureus (7/9), ATCC 27853 P. aeruginosa (7/9), ATCC 49619 S. pneumoniae (6/9), ATCC 700603 K. pneumoniae (5/9) and ATCC 49247 H. injluenzae (5/9). Weekly testing is recommended in four out of eight laboratories and biweekly in one out of eight. In one out of eight, a minimum of monthly testing is required, but weekly testing is recommended. • Twelve of the 15 coordinating laboratories participate in one of more external quality assurance programmes. The most common are the WHO/CDC External Quality Assurance Scheme in Antimicrobial Susceptibility Testing (4115), the Royal College of - 4 - Pathologists of Australia (4/15), the Gonococcal Antimicrobial Susceptibility Programme (4/15), and the Global SalmSurv (3/15). • Obstacles to the conduct and sustainability of the surveillance programmes included limited funding for reagents, training and network activities; lack of a national reference laboratory with specialized expertise in antimicrobial resistance testing and epidemiology; a limited number of clinical samples; poor standards in reagent quality or test performance, with poor knowledge by laboratory staff, difficulties with data management and lack of materials in a national language. A full report of the survey is available on request from the WHO Western Pacific Regional Office. 2.4 Round table plenary discussion Most of the final day of the workshop was dedicated to presentation of the conclusions of the working groups for discussion by all participants. A summary of the main conclusions follows. 3. CONCLUSIONS 3.1 National surveillance of antimicrobial resistance (1) In each Member State, an intersectorial committee should be set up to steer the national antimicrobial resistance surveillance programme and its functions, as described in the Global Strategy for Containment of Antimicrobial Resistance. (2) Each Member State should establish a quality national antimicrobial resistance surveillance system to guide resistance containment efforts. The surveillance programme should have the following qualities: • It should be epidemiologically sound. • It should be microbiologically sound. • It should be active, with iutegrated AMR data analysis and reporting. • Action must be initiated 0n the basis of data collected. (3) Recognizillg the different capacities for AMR surveillance in Member States of the Westem Pacific and South-East Asia regions, countries should consider adapting a core list of organisms or antibiotics to comply with the reporting requirements of the regional surveillance programme. (4) The WHO Western Pacific and South-East Asia regional offices should ensure the quality of national data collected. .. Established or <emerging reference centres, nominated by Member States, should submit themselves to external assessment drawing on the existing expertise nominated by WHO. . - 5 - • For countries without a reference laboratory, WHO should assist in capacity building to establish such a centre to serve as a coordinating and reference centre. • Reference centres in each Member State, with WHO support, should implement activities, such as establishment of a recognized external quality assessment scheme, to ensure the quality of data collected within the Member State. (5) Network coordinators of Member States should have the responsibility of ensuring the availability of resource documents appropriate to AMR surveillance. (6) Participants should ensure alignment oftheir performance with standards operating in the national network. (7) The participants agree to adopt the general thrust of the draft document Guidelines for national surveillance of antimicrobial resistance and quality assurance of antimicrobial susceptibility testing, produced by the WHO Western Pacific Regional Office, subject to revisions according to the following suggestions made by the working group: • The definition of each key data element and purpose of the type of surveillance should be clearly stated in the document. • Key recommendations in each chapter should be highlighted in the document. (8) Some of the key recommendations from this draft document include the following: • Where feasible, Member States should strengthen or initiate enhanced surveillance of antimicrobial resistance utilizing routine clinical and public health samples. • At a minimum, all Member States should establish an alert surveillance programme in which individual isolates with important or unusual resistance findings of public health significance are sent to a central laboratory for confirmation and, if confirmed, communicated to microbiologists, clinicians and national authorities when appropriate. • Where feasible, national surveillance should be based on isolate-level databases utilizing quantitative susceptibility test measurements, such as disk diffusion zones of inhibition or minimal inhibitory concentration determinations. • If routine data do not exist or are unreliable, there should be targeted surveillance of important public health problems, if possible, to assess the value of the routine approach and to collect complementary clinical or epidemiological information not available in the course of routine testing. • Analysis and timely feedback to participating laboratories is crucial in the areas of potential quality assurance problems, compliance with surveillance protocols, important resistance findings, and use of the data to guide local practices. • The draft document makes recommendations for minimal standards for both internal and external quality assurance practices. The details of these recommendations will be further discussed by workshop participants and other partners following the conclusion ofthe workshop. - 6- (9) An adequate data management system to support national surveillance efforts should be seen as a minimum requirement. (10) Each country should establish a list of resistant organisms that are considered unusual or of great public health importance. Important findings should be confirmed by a public health laboratory. (11) In countries with several, distinct surveillance efforts, collaboration and integration between programmes should be explored, particularly in the areas of training, capacity-building, quality assurance, reagent acquisition and guiding of antimicrobial policy. 3.2 Regional surveillance of antimicrobial resistance in the WHO Western Pacific and South East Asia regions. (I) The Western Pacific Regional Office should reinitiate its data collection efforts, and the South-East Asia Regional Office should begin a regional surveillance programme. (2) The group should continue its biregional collegial working relationship and should explore ways of maintaining that relationship. (3) National surveillance coordinators should collectively form an advisory group to support the analysis of the regional data, the continuing development and improvement of the networks; and the exploration of collaboration with other networks, such as the initiative for the Americas, led by the Pan American Health Organization, and the European Antimicrobial Resistance Surveillance Programme (EARSS). (4) Participants would find it useful to have an electronic discussion group for ongoing collegial discussion of their findings and problems. (5) As the basis of the regional surveillance programme: • If feasible, national AMR surveillance coordinators should submit annually to the WHO Western Pacific Regional Office or South-East Asia Regional Office isolate- level data utilizing quantitative susceptibility test measurements (disk diffusion zones of inhibition and/or minimal inhibitory concentration determinations). o If the submission of isolate-level databases is not feasible, national surveillance coordinators should submit annually summary data, which could include averages of national resistance and susceptibility rates, as well as ranges of rates within the national network. • National surveillance coordinators should send interpretive commentaries and any related publications and reports with their submission of data to the Western Pacific Regional Office or South-East Asia Regional Office. • National centres should aim to collect the resistance data proposed in the draft document Regional surveillance of antimicrobial resistance in the WHO Western Pacific Region. However, many of the suggested modifications will need to be optional, as many laboratories do not have the necessary data. " A revised format and protocol for data submission needs to be developed. - 7 - • National AMR surveillance coordinators should submit antimicrobial resistance data annually to the Western Pacific Regional Office or South-East Asia Regional Office ori the organisms and antimicrobials recommended in Annex 4. 3.3 Translating surveillance into action The objective of Working Group 3 was to provide suggestions to coordinators of antimicrobial resiStance surveillance programmes on (1): bow to more effectively promote the use of existing surveillance findings to guide resistance containment efforts; and (2) modifications that could realistically be introduced into surveillance programmes that would enhance the value or application of results for clinical or public health purposes. (1) Reports on antimicrobial resistance need to be accurate, submitted on a regular basis and in a timely manner, and provide information using understandable terminology, targeting political decision-makers as well as other stakeholders. • In order to make antimicrobial resistance data useful for political decision-makers for guideline development or for the formulation of containment strategies at national, community.andhospitallevels, surveillance data should be reported in a useful and appropriate fashion. • . Reports on antimicrobial resistance also need to give conclusive information for a wide range of different stakeholders at various levels, often meaning that reports should use non-scientific terminology to reach specific target groups. (2) Data on antimicrobial resistance need to be coupled with data on its impact on health and economic outcomes. • Political· decision-makers and other stakeholders need information about the . impact of resistance development on different health outcome panlmeters, such as infection rates in the community and health care facilities, the societal and economic impact, and other implications, whenever data are available and meaningful in guiding the political process. • Data are needed which demonstrate the efficacy and cost-effectiveness of surveillance and various containment strategies. WHO can assist in cost- effectiveness analyses of interventions. (3) A high level national committee is needed to coordinate activities and the response to fmdings. • It is important to also involve a wider range of stakeholders (other than the political level) in surveillance and containment programmes and to share information on resistance and containment strategies with those stakeholders. • In order to successfully coordinate surveillance and containment activities, political commitment and a high-level national coordinating committee is needed. The committee should be established above ministerial level and involve all national stakeholders to ensure infonnation-sharing and involvement of all levels. (4) Training is needed for surveillance programmes, as well as for the selection of appropriate containment strategies and the successful implementation of containment programmes. WHO already offers training courses for containment programmes, but - 8- recent interest has been too low to sustain the courses. Member States need to sustain demand for these courses by sending participants. (5) The World Health Assembly resolution on antimicrobial resistance, passed in May 2005, defines AMR as a health priority. To sustain WHO support for resistance surveillance and containment, this resolution should be usedto lobby within Member States,with the Government or.the Ministry of Health, to enhance resistance surveillance and containment activities .. 3.4 Action points for WHO within the next six months (l) WHO should finalize and disseminate the Guidelines for national surveillance of antimicrobial resistance. (2) WHO should finalize and disseminate the new protocol for regional AMR surveillance. • In addition to the list of organisms and antimicrobials, the protocol should address the desired information about network laboratories, test methods, format of submitted data (for example national averages vs. ranges of susceptibility rates vs. reporting of institution-level statistics), the time-frame for data submission, and the development of any tools which would facilitate the reporting of information to WHO . • A time-frame should be established for restarting of data collection efforts. (3) WHO should establish a scientific advisory group to assist with the ongoing formulation and implementation of WHO activities and guidelines in the area of AMR surveillance, including support for the compilation and interpretation of collected data.. (4) WHO should establish a strategy for assessing the strengths and weakness of current surveillance programmes. Priority areas include data quality and test performance; network activities, such as training courses, site visits, and feedback to laboratories; and use of data to guide resistance containment strategies aUhe local and national levels. The process should begin with a review of the queStionnaire results and available network reports and publications, followed by feedback to laboratories on the basis of the initial review. (5) The WHO South-East Asia Regional Office should discuss the feasibility, value and steps required for initiation of a regional surveillance programme in the South-East Asia Region. (6) WHO should proceed with planning a follow-up biregional workshop on antimicrobial resistance containment strategies. -9- AGENDA Day 1 - Tuesday, 7 June 08:00 - 08:30 Registration 08:30-09:15 Openmgceremony Opening remarks Dr Richard Nesbit, Director, Programme Management Administrative announcements Dr Hitoshi Oshitani, Responsible Officer 09: 15 - 09:30 Objectives ofthe workshop Dr Hitoshi Oshitani ANNEX 1 09:30 - 10:00 Antimicrobial resistance in the Western Pacific Region (WPRO) Dr Thomas O'Brien 10:00-10:15 Coffee break 10: 15 - 10:45 Antimicrobial resistance in the South-East Asia Region (SEARO) Professor Lalitha M Kesavan 10:45 - 11: 15 WHO Global strategy for containment of antimicrobial resistance MrJun Yoshida 11: 15 - 11 :45 Overview on surveillance and quality assurance programmes in WPRO andSEARO, Dr John Stelling 11:45 - 12:45 Lunch break 12:45 - 13:00 Group photo 13:00 - 13:30 Laboratory capacity-building and quality assurance Dr Surang Dejsiri/ert 13:30 - 14:00 Antimicrobial resistance surveillance needs at national level Dr Celia Carlos 14:00 - 14:30 Changing antimicrobial practices at local level Dr Christopher Lee - 10 - Annex 1 14:30 - 15:00 Resistance containment strategies at national level Dr Gun-Jo Woo 15:00 - 15:30 Working Group 15 :30 - 15 :45 Coffee break 15:45 - 17:00 Working Group I: Surveillance and quality assurance at national level Working Group II: Surveillance of antimicrobial resistance at regional level 17:00-17:15 18:30 Working Group Ill: Translating surveillance into action- recommendations for containment strategies Wrap up Reception WHO Conference Lounge Day 2 - Wednesday, 8 June 2005 09:00 - 09:30 WHONET - Software for antimicrobial resistance (AMR) surveillance and infection control Dr John Stelling 09:30 - 10:30 Multi-level analyses of multi-centre, multi-national surveillance data Dr Thomas F. O'Brien 10:30 -10:45 Coffee break 10:45 - 11: 15 Targeted AMR surveillance for public health action Dr John Tapsal/ 11: 15 - 11 :45 Surveillance in the lowest-resource countries Dr Traykhouane Phouthavane 11 :45 - 12: 15 Impact of healthcare associated infections and antimicrobial resistance on health and economic outcome Dr Gerald Dziekan 12:15 - 13:30 Lunch break 13:30 - 15:15 Working Groups I, II, III (continued) 15:15 - 15:30 Coffee break 15:30 - 17:00 Working Groups I, II, III (continued) - 11 - Annex 1 Day 3 - Thursday, 9 June 09:00 - 09:30 Really making effective antimicrobial stewardship work - successful integration with infection control and the microbiology laboratory Dr Wing Hong Seta 09:30 - 10:00 Antimicrobial use and resistance in food animals Dr Jin Shao-hong 10:00 - 10:30 SurveiUance of antimicrobial use and practices Dr Kathleen Holloway 10:30 - 10:45 Coffee break 10:45 - 11: 15 Improving antimicrobial use Dr Kathleen Holloway II: 15 - 12: 15 Report of Working Group II: Surveillance of antimicrobial resistance at the regional level 12:15 - 13:30 Lunch break 13 :30 - 15 :00 Report of Working Group I: Surveillance and quality assurance at national level 15:00-15:15 Coffee break 15:15 -16:45 Report of Working Group III: Translating surveilIance into action - recommendations for containment strategies 16:45 - 17:00 Conclusions 17 :00 Closing ceremony - 12 - ANNEX 2 LIST OF P ARTICIP ANTS REGIONAL OFFICE FOR THE WESTERN PACIFIC (WPRO) BRUNEI DARUSSALAM CAMBODIA CHINA HONG KONG (CHINA) MACAO (CHINA) Dr Haji Mohamad Haji Kassim, Acting Director Department of Laboratory Services, R.LP.A.S. Hospital Ministry of Health, Bandar Seri Begawan BA1710 Tel. no.: (6732) 242 424 ext 510. Fax no.: (6732) 220869 E-mail: mhkassim@yahoo.com Mr Kong Meng, Chief of Microbiological Section National Laboratory for Drug Quality Control Ministry of Health, #151-153 Kampuchea Krom Avenue Phnom Penh._Tel. no.: (855) 1161 3115/23882965 Fax no.: (855) 2321 6211. E-mail: ndgclab@forum.org.kh Dr Wang Dayou, Direct Pharmacist, Hua Shan Hospital (Teaching Hospital of Fudan University), Room 1601,2/333 Ruijin Nan Road, 12 WUlumogi Zhong Road, Shanghai 200040 Tel. no.: (8621) 6248 9999 - 6633. Fax no.: (8621) 6248 6927 E-mail: wangdayou@hotmail.com Dr Xian Ming, Deputy Director, Division of Medical Administration, Public Health Bureau of Si Chuan Province, Wen miao Xijie 80, Chengdu. Tel. no. : (8628) 8613 8686 Fax no. : (8628) 8611 3239. E-mail: xianming@hotmail.com Professor XIAO Yonghong, MD, Ph.D., Deputy Director Institute of Clinical Pharmacology, Peking University, 38 Xueyuan Road, Haidian District 100083, Beijing. Tel. no.: (8610) 82802546. Fax no.: (8610) 6207 2817. E-mail: xiaoyonghong@bjmu.edu.cn Dr Raymond W.H. Yung, Head, Infection Control Branch, Centre for Health Protection, Department of Health, G/F, 147C Argyle Street, Kowloon. Tel. no.: (852) 3523 0162. Fax no.: (852) 25159657. E-mail : rwhyung@ha.org.hk Dr Kin Veng Koon, Head, Department of Clinical Pathology, Chairman ofInfection Control Committee in Hospital, Servigo de Patologia Clinica, Centro Hospitalar Conde de S. Januario, Macao._ Tel. no.: (853) 662 7675. Fax no.: (853) 710 430. E-mail: vkoon@ssm.gov.mo Annex 2 FIJI LAO PEOPLE'S DEMOCRA TIC= REPUBLIC MALAYSIA MONGOLIA NEW ZEALAND PAPUA NEW GUINEA PHILIPPINES - 13 - Dr Eka Buadromo, Consultant Pathologist, Pathology Department, Colonial War Memorial Hospital, (CWMH) Government Buildings, P.O. Box 115, Suva. Tel. no.: (679) 321 5226. Fax no.: (679) 330 5810. E-mail: ebuadromo@health.gov.fj Dr Traykhouane Phouthavane, Deputy Chief Laboratory Service Centre for Laboratory and Epidemiology, Ministry of Health, Km3 Thadeua Road, Vientiane. Tel. no.: (856) 21312351. Fax no.: (856) 2131 5347. E-mail: raykhouane@yahoo.com Dr Christopher Lee, Consultant Physician, Department of Medicine, Hospital Kuala Lumpur, la1an Pahang, 50586 Kuala Lumpur. Tel. no.: (603) 2615 5699/2615 5690. Fax no.: (603) 2692 302112692 5021126924810. E-mail: chrislee@hkl.gov.my Dr Rohani Md. Yasin, Head, Bacteriology Unit and Specialized Diagnostic Centre, Institute for Medical Research lalan Pahang, 50588 Kuala Lumpur. Tel. no.: (603) 4040 2361/26986033. Fax no.: (603) 29620675/26924949. E-mail: rohani@imr.gov.my Dr Buyankhishig Burneebaatar, Chief National Reference Laboratory, Tuberculosis Department, National Centre for Communicable Disease, Bayanzurkh District, Ulaanbaatar 48. Tel. no.: (976) 1145 1169/450492. Fax no.: (976) 1145 0492 E-mail: ntpml@mongol.net Dr Helen Mary Heffernan, Senior Scientist, Antibiotic Reference Laboratory and Nosocomial Infections Laboratory, Communicable Disease Group, ESR, 34 Kenepuru Drive, P.O. Box 50 348, Porirua. Tel. no.: (6404) 914 0781. Fax no.: (6404) 914 0770. E-mail: helen.heffernan@esr.crLnz Mr Darrell Cecil, Senior Medical Laboratory Technician Pathology Laboratories, Port Moresby General Hospital, Free Mail Bag, Boroko, NCD. Tel. no.: (675) 324 8492. Fax no.: (675) 325 6342. Dr Abelardo laca Alera, Medical Specialist II, Department of Laboratory, San Lazaro Hospital, Quiricada Street, Sta. Cruz, Manila. Tel. no.: (632) 732 3125. Fax no.: (632) 711 6979. E-mail: beil56@yahoo.com Annex 2 REPUBLIC OF KOREA SINGAPORE TONGA VIETNAM - 14- Dr Celia C. Carlos, Medical Specialist IV, Chairperson, Committee on Antimicrobial Resistance Surveillance, Research Institute for Tropical Medicine, Department of Health, Filinvest Corporate City, Alabang, Muntinlupa, Metro Manila .. TeVfax. no.: (632) 809 9763. E-mail: ccarlos@ritm.gov.ph Dr Hyo Shun Kwak, Senior Scientist Officer, Food Microbiology Division, Center for Food Safety Evaluation, Korea Food and Drug Administration, #5 Nokbun-dong Eunpyung-gu, Seoul 122-704. Tel. no.: (822) 380 1682. Fax no.: (822) 3801615. E-mail: kwakhyos@kfda.go.kr Ms Mi-Gyeong KIM, Scientific Officer, Center for Food Safety Evaluation, Korea Food and Drug Administration, #5 Nokbun-dong Eunpyung-gu, Seoul 122-704. Tel. no.: (822) 3801682. Fax no.: (822) 3801615 E-mail: ange1mg@kfda.go.kr Dr Kyungwon Lee, Director, Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Severance Hospital, Yonsei University College of Medicine, 134 Shinchon-dong Seodaemun-ku, Seoul. Tel. no.: (822) 361 5866. Fax no.: (822) 313 0908. E-mail: leekcp@yumc.yonsei.ac.kr Gun-Jo Woo, Ph. D., Director, Centre for Food Safety Evaluation, Korea Food and Drug Administration, 5 Nokbun-dong, Eunpyong-gu. Seoul 122-704. Tel. no.: (822) 3801681. Fax no.: (822) 3801615. Email: visionkorea@empal.com;gjwoo@kfda.go.kr Mrs Genedine Lim, Assistant Director (Clinical Performance), Clinical Quality Branch, Health Regulations Division, Ministry of Health, College of Medicine Building, 16 College Road, Singapore 169854. Tel. no.: (65) 6314 5807/63145804. Fax no.: (65) 62241677. E-mail: GenedineLIM@moh.gov.sg Ms Mary Fakahau, Senior Medical Scientist, Public Health Laboratory, Ministry of Health, P.O. Box 59, Nuku'alofa. Tel. no.: (676) 23 200 ext 376. Fax no.: (676) 24 291. E-mail: mfakahau@health.gov.to Dr Do Khang Chien, Vice Director, Department of Therapy Ministry of Health, 138A Giang Yo Street, Ha Noi. Tel. no.: (844) 846 4416 ext 463. Fax no: (844) 846 0966 E-mail: hoidieuduong@fpt.vn Annex 2 Annex 2 - 15- Dr Vo Thi Chi Mai, Head, Department of Microbiology, Cho Ray Hospital, 201B Nguyen Chi Thanh Street District 5, Ho Chi Minh City. Tel no.: (848) 855 4137 ext 158. Fax no: (848) 8557267. E-mail: chimai@hcm.vnn.vn Mrs Nguyen Thi Vinh, Assistant Professor, Department of Microbiology, Ha Noi Medical University, 1 Ton That Tung Street, Ha Noi. Tel. no.: (844) 852 3798 ext 226. Fax no.: (844) 852 5115. E-mail: nguyentvinb2001@yahoo.com REGIONAL OFFICE FOR SOUTH-EAST ASIA (SEARO) INDIA Professor Lalitba M. Kesavan, Head ICMR National Centre for Antimicrobial Resistance, Department of Microbiology, Christian Medical College and Hospitals, Vellore. Tel. no: (0416) 2232623 ext 2588. Fax no.: (0416) 2232103/2232035. E-mail: mkl_micro@yahoo.com SRI LANKA Dr Sujatha Mananwatte, Consultant Microbiologist STDIAIDS Control Programme, P.O. Box 567, De Saram Place Colombo 10. Tel. no.: (9411) 2856549. Fax no.: (9411) 5336873. E-mail: sarathbm@sltnet.lk THAILAND Dr Surang Dejsirilert, Head, Thai Antimicrobial Resistance Surveillance Centre, Department of Miscellaneous Bacteriology, National Institute of Healtb, Nontbaburi. Tel. no.: (662) 951 000 ext 99415. Fax no.: (662) 589 9867 E-mail: surang@dmsc.healtb.go.th;sudejsi@healtb.moph.go.th 2. SHORT-TERM CONSULTANT Dr John Stelling, Co-Director, WHO Collaborating Centre for Surveillance and Antimicrobial Resistance, Scientist, Microbiology Laboratory, Brigham and Women's Hospital, 75 Francis Street, Boston, Massacbusetts 02115, United States of America. Tel. no.: (1-617) 732 6803. Fax no.: (1-617) 277 1762. E-mail: jstelling@rics.bwh.harvard.edu - 16- 3. TEMPORARY ADVISERS Dr Thomas F. O'Brien, Co-Director, WHO Collaborating Centre for, Surveillance and Antimicrobial Resistance, Medical Director, Microbiology Laboratory, Brigham and Annex 2 Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115,United States of America. Tel. no: (1-617) 732 6803. Fax no: (1-617) 277 1762. E-mail: tobrien@rics.bwh.harvard.edu Professor Victor K.E. Lim, Dean and Professor of Pathology, Faculty of Medicine, International Medicine University, Sesame Centre, Plaza Komanwel, Bukit Jalil, 57000 Kuala Lumpur, Malaysia. Tel. no: (603) 8656 8832. Fax no: (603) 8656 7239. E-mail: victor@imu.edu.my Dr Wing Hong Seto, Focal Point for Western Pacific Regional Office, Chief of Service, Queen Mary Hospital, Department of Microbiology, Pathology Building, K Block LB 110, 102 Pokfulam Road, Hong Kong, SAR. Tel. no.: (852) 2855 3206. Fax no.: (852) 28551241. E-mail: whseto@ha.org.hk. Dr Jin Shao-Hong, Deputy Director-General, National Institute for the Control of Pharmaceutical and Biological Products (NICPBP), 2 Tiantan Xiii, Beijing, People's Republic of China. Tel. no.: (8610) 6701 7755 ext 258/6701 8094. Fax no.: (8610) 6701 3755. E-mail: jinshh@nicpbp.org.cn Dr John Tapsall, Microbiology Laboratory, Prince of Wales Hospital, High Street, Randwick N'3W 2031, Sydney, Australia. Tel. no.: (612) 9382 9079. Fax no.: (612) 9398 4275. E-mail: Ltapsall@unsw.edu.au 4. SECRETARIAT Dr Bernard Fabre-Teste, Acting Director, Combating Communicable Diseases and Regional Adviser in Sexually Transmitted Infections including HIV / AIDs, WHO Regional Office for the Western Pacific, Manila, Philippines. Tel. no.: (632) 528 9714. Fax no.: (632) 521 1036. E-mail: fabretesteb@wpro.who.int Dr Hitoshi Oshitani (Responsible Officer), Regional Adviser, Communicable Disease Surveillance and Response, WHO Regional Office for the Western Pacific, Manila, Philippines. Tel. no.: (632) 528 9730. Fax no.: (632) 528 9075. E-mail: oshitanih@wpro.who.int Dr Dong II Ahn, Regional Adviser in Stop TB and Leprosy Elimination, WHO Regional Office for the Western Pacific, Manila, Philippines. Tel. no.: (632) 528 9704. Fax no.: (632) 521 1036. E-mail: ahnd@wpro.who.int - 17- Annex 2 Dr Eva-Maria Christophel, Medical Officer, Malaria, Vectorborne and other, Parasitic Diseases, WHO Regional Office for the Western Pacific, Manila, Philippines Tel. no.: (632) 528 9723. Fax no.: (632) 521 1036. E-mail: ChristopheIE@wpro.who.int Mrs Kathleen Fritsch, Regional Adviser in Nursing, WHO Regional Office for the Western Pacific, P.O. Box 2932, Manila, Philippines. Tel. no.: (632) 528 9804. Fax no.: (632) 521 1036. E-mail: fritschk@wpro.who.int Mr lun Yoshida, Technical Officer, Pharmaceuticals, WHO Regional Office for the Western Pacific, Box 2932, Manila, Philippines. Tel. no.: (632) 528 9849. Fax no: (632) 521 1036. E-mail: yoshidaj@wpro.who.int Dr lunping Yu, Blood Safety Specialist, Health Technology, WHO Regional Office for the Western Pacific, Manila, Philippines. Tel. no.: (632) 528 9848. Fax no: (632) 521 1036 E-mail: yuj@wpro.who.int Dr Gerald Dziekan, Infection Control Specialist, ADB Consultant, WHO Regional Office for the Western Pacific, P.O. Box 2932, Manila, Philippines. Tel. no.: (632) 528 9920. Fax no.: (632) 528 9075. E-mail: dziekang@wpro.who.int Dr Kathleen Holloway, Medical Officer, Policy, Access and Rational Use, Department of Medicines, Policy and Standards, World Health Organization, Geneva, Switzerland. Tel. no.: (4122) 7912336. Fax no.: (4122) 7914167. E-mail: Hollowayk@who.int - 18 - LIST OF FACILITATORS Temporary Advisors 1. Dr Thomas O'BRIEN, Brigham and Women's Hospital, Boston, USA 2. Professor Victor K.E. LIM, International Medicine University, Kuala Lumpur, Malaysia 3. Dr Wing Hong SETO, Queen Mary Hospital, Hong Kong (China) ANNEX 3 4. Dr Jin SHAO HONG, National Institute for the Control of Pharmaceutical and Biological Products, Beijing, People's People's Republic of China 5. Dr John TAPSALL, Prince of Wales Hospital, Sydney, Australia WHOlWestern Pacific Regional Office I. Dr Hitoshi OSHIT ANI, Regional Adviser 2. Dr Bernard FABRE-TESTE 3. Dr Dong II Ahn 4. Mrs Kathleen FRITSCH 5. Mr Jun YOSHIDA 6. Dr Junping YU 7. Dr Gerald DZIEKAN 8. Dr Kathleen HOLLOW A Y 9. Dr John STELLING, WHO Consultant - 19 - ORGANISMS AND ANTIMICROBIALS RECOMMENDED FOR SURVEILLANCE AT THE REGIONAL LEVEL ANNEX 4 The list of organisms which have been under surveillance by the Western Pacific Regional Office was reviewed by workshop participants. It was decided that the following species could be removed from the list for purposes of regional surveillance: Citrobacter freundii, Enterobacter sp., Morganella (Branhamella) morganii, Proteus vulgaris, Providencia sp., and Staphylococcus saprophyticus. It was also proposed the Neisseria meningitidis be included for surveillance in those countries with adequate capacity for this organism, and that institutions which do not currently participate in the regional GASP surveillance programme could include Neisseria gonorrhoeae in their reports to the regional surveillance programme. This thus leaves the following organisms as those recommended for surveillance at the regional level: Gram-positive organisms Enterococcus sp. Staphylococcus aureus Staphylococcus, coagulase-negative Streptococcus pneumoniae - blood, cerebrospinal fluid isolates Streptococcus pneumoniae - respiratory isolates Enterobacteriaceae - non-enteric pathogens Escherichia coli - non-urine isolates Escherichia coli - urine isolates Klebsiella sp. Proteus mirabilis -Serratia sp. Enterobacteriaceae - enteric pathogens Salmonella Paratyphi A Salmonella Typhi Salmonella non-Typhi, non-Paratyphi A Shigella boydii Shigella dysenteriae Shigella jlexneri Shigella sonnei Vibrio cholerae 01 Non-fermenting Gram-negative bacilli Acinetobacter sp Pseudomonas aeruginosa - 20- Other Gram-negative organisms Haemophilus injluenzae - blood, cerebrospinal fluid isolates Haemophilus injluenzae - respiratory isolates Neisseria gonorrhoeae - for institutions not participating in GASP Neisseria meningitidis The following modifications to the antimicrobials recommended for testing were suggested: • Enterobacteriaceae o Imipenemlmeropenem should be added. Annex 4 o Cefoxitin, piperacillinltazobactam and ticarcillinlclavulanic acid could be added. o Cefamandol, chloramphenicol, tetracycline, and nalidixic acid should be removed. • Non-fermenting Gram-negative bacilli o Imipenemlmeropenem should be added. o Ampicilinlsulbactam should be added for Acinetobacter. • Streptococcus pneumoniae o Fluoroquinolone should be added. • Staphylcoccus aureus o Trimethoprim and methicillin should be removed. o Vancomycin should be added. o A cefoxitin disk may be used as a surrogate for oxacillin susceptibility. The complete list of antimicrobials recommended for testing and reporting is provided below in Tables 1 to Table J. For comparison, comparable lists from the PAHO regional surveillance programme and the European Antimicrobial Resistance Surveillance System (EARSS) are also provided. ~ .... £_~. ---------------- ----------- --~ --- --------- ~ ---bial ded fi E b Surveillance Enterobacteriaceae E. coli (urine) Salmonella sp. Shigella sp. V. cholerae program Amikacin WPRO Amoxicillinlclavulanic acid Same + Ampicillin Ampicillin Chloramphenicol Ampicillin Cefotaxime or ceftriaxone Chloramphenicol Ciprofloxacin or other Cefotaxime or ceftriaxone Nitrofurantoin Chloramphenicol Ciprofloxacin or other fluoroquinolone Cefuroxime Trimethoprim Ciprofloxacin or other fluoroquinolone Tetracycline Cephalothin or cefazolin f1uoroquinolone Nalidixic acid Trimethoprimlsulfamethox. Ciprofloxacin or other except chloramphenicol Trimethoprimlsulfamethox. Tetracycline f1uoroquinolone Trimethoprim Gentamicin Trimethoprimlsulfamethox. Imipenem or meropenem Netilmicin Tobramycin Trimethoprimlsulfamethox. Optional: cefoxitin, pip/tazo, ticarcillinlclavulanic acid Minimal Minimal Minimal Minimal Minimal PAHO Amikacin Ampicillin Ampicillin Ampicillin Ampicillin Ampicillin Ampicillinlsulbactam Amoxicillinlclavulanic acid Trimethoprimlsulfamethox. Chloramphenicol Piperacillinltazobactam Cephalothin Trimethoprirn/sulfamethox. Cefotaxime Ciprofloxacin Cephalothin Gentamicin 3n1 generation cephalosporin Chloramphenicol Doxycycline 3,d generation cephalosporin Ciprofloxacin Chloramphenicol Ciprofloxacin Erythromycin Ciprofloxacin Nitrofurantoin Ciprofloxacin Fosfomycin Nitrofurantoin Gentamicin Trimethoprimlsulfamethox. Nitrofurantoin Gentamicin (optional) Trimethoprimlsulfamethox. Imipenem Gentamicin (optional) Nalidixic acid Trimethoprimlsulfamethox. Nitrofurantoin Maximal Maximal Maximal Maximal Maximal Same + Ampicillin Same + Same as Salmonella Same Amoxicillinlclavulanic acid Amoxicillinlclavulanic acid Cefotaxime Cefotaxime Cephalothin Cefoxitin Cefoxitin Cefuroxime Ceftazidime Ceftazidime Ciprofloxacin Nalidixic acid Colistin Nitrofurantoin Tetracycline Nalidixic acid Trimethoprimlsulfamethox. Amoxicillin or ampicillin EARSS Gentamicin, netilmicin, or Not covered by surveillance Not covered by surveillance Not covered by surveillance Not covered by surveillance tobramycin Ciprofloxacin, ofloxacin, or levofloxacin Cefotaxime, ceftriaxone, or ceftazidime ESBL confirmation Optional: imipenem, meropenem, piperacillin, piperacillinltazobactam, amikacin, tetracycline '----- - trimethoprimlsulfa - bial ded f( OtherG , ram-negauve orgamsms Surveillance Pseudomonas sp. ACinetobacter sp. Haemophilus sp. Neisseria gonorrhoea Neisseria meningitidis program WPRO Amikacin Same as Pseudomonas + Ampicillin Not covered by surveillance Not covered by surveillance Ceftazidime Ampicillinlsulbactam Beta-lactamase Fluoroquinolone Trimethoprimlsulfamethox. Chloramphenicol Gentamicin Trimethoprimlsulfamethox. Imipenem or meropenem Tetracycline Netilmicin Piperacillin Ticarcillin Tobramycin P AHO Minimal Minimal Minimal Minimal Minimal- all by MIC Amikacin Amikacin Ampicillin Beta-lactamase Cefotaxime or ceftriaxone Aztreonam AmpicillinJsulbactam Ampicillinlsnlbactam Cefotaxime or ceftriaxone Chloramphenicol Cefepime Cefepime Azithromycin Ciprofloxacin Ciprofloxacin Cefoperazone Ceftazidime Cefaclor Penicillin Penicillin Ceftazidime Ciprofloxacin Cefotaxime Tetracycline Rifampicin Ciprofloxacin Gentamicin Cefuroxime Gentamicin Imipenem Chloramphenicol Imipenem Meropenem Levofloxacin Meropenem Piperacillin Trimethoprimlsulfamethox. Piperacillin Piperacillinltazobactam Piperacillinltazobactam Trimethoprimlsulfamethox. Maximal Maximal Maximal Maximal Maximal- all by MIC Same + Same + Same Same Ofloxacin Colistin Colistin Tetracycline Doxycycline Trimethoprimlsulfamethox. Tetracycline EARSS Piperacillin or Not covered by surveillance Not covered by surveillance Not covered by surveillance Not covered by surveillance piperacillinltazobactam Ceftazidime lmipenem or meropenem Ciprofloxacin or levofloxacin Gentamicin, tobramcyin, or amikacin - .. - - - - oS Table 3. Antimicrobials recommended for testing, Gram-=positiveJ)fgamsms Surveillance I program WPRO PAHO EARSS Staphylococcus sp. Amikacin Chloramphenicol Clindamycin Erythromycin Fluoroquinolone Gentamicin Oxacillin or cefoxitin Netilmicin Penicillin Tetracycline Trimethoprimlsulfamethox. Vancomycin Minimal Chloramphenicol Ciprofloxacin Clindamycin Erythromycin Gentamicin Minocycline Oxacillin or cefoxitin Penicillin Rifampicin Tetracycline Trimethoprimlsulfamethox. Maximal Same + Teicoplanin Doxycycline Novobiocin Cefoxitin or oxacillin Oxacillin MIC, PCR, or PB2a (for MRSA) Vancomycin Linezolid Rifampin Optional: ciprofloxacin, erythromycin, gentamicin, streptomycin, tetracycline, fusidic acid Streptococcus pneumoniae Chloramphenicol Erythromycin Fluoroquinolone Penicillin Tetracycline Trimethoprimlsulfamethox. Minimal Cefotaxime MIC Chloramphenicol Erythromycin Ofloxacin Oxacillin Disk Penicillin MIC Rifampicin Tetracycline TrimethoprimAsulfamethox. Vancomycin Maximal Imipenem MIC Cefuroxime MIC Levofloxacin Oxacillin Disk Erythromycin Norfloxacin or ciprofloxacin Penicillin MIC Cefotaxime or ceftriaxone MIC Ciprofloxacin MIC Optional: clindamycin, rifampin, tetracycline, vancomycin, levofloxacin, moxifloxacin Enterococcus sp. Ampicillin Nitrofurantoin Tetracycline Vancomycin Minimal Ampicillin Beta-lactamase (sterile sites) Gentamicin (high potency) Streptomycin (high potency) Vancomycin Maximal Ampicillin/sulbactam (only for comparison with ampicillin disk result) Teicoplanin Ampicillin or amoxicillin Gentamicin Vancomycin Optional: streptomycin, erythromycin, teicoplanin, trimethoprimlsulfamethox., tetracycline, linezolid, quinupristinldalfopristin