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Antimicrobial Resistance Interagency Task Force
2007 Annual Report (Released June 2008)

Action Items 8—20

Action Item #8: Ensure That Clinical Laboratories That Provide Data for AR Surveillance Purposes Have Access to and Routinely Participate in Pertinent Training and Proficiency Testing Programs with Good Performance and Indicate AR Testing Methodologies in Their Surveillance Reports (e.g., Specific Automated Methods or Manual Techniques).

Project Title: Quality HIV Drug Resistance genotyping Services to PEPFAR countries (International laboratory Branch, Division of Global AIDS, NCHHSTP).

• Agency: CDC
• Description: Purpose of this ongoing project is to provide the best possible quality data and services to PEPFAR countries on HIV drug resistance surveillance and monitoring.
• Results: Ongoing. Our laboratory is the only laboratory within CDC which has been accredited by College of American Pathologists (CAP). Any data we provided to the PEPFAR countries have been generated by certified technologists or scientists and the assays we used have been validated in our lab based on CAP standards. We routinely participated CAP, WHO and AccuTest PT programs for our assays. For the past two years, we have provide genotyping and analytic services for the surveillance of transmitted HIV DR in recently-HIV-infected populations for Tanzania, Malawi, Kenya, China and Botswana. The surveillance results indicate that transmitted HIV DR in recently-infected population are low, less than 5%. Two of the survey results from the Tanzania and Malawi have been published in peer-reviewed scientific journal--Antiviral Therapy, 2008.

Project Title: Pertinent training

• Agency: FDA
• Description: Continue to ensure validity of antimicrobial susceptibility information derived from NARMS.
• Results: Developed both an antimicrobial susceptibility testing quality control and quality assurance program for the three arms of NARMS, human, slaughter plants, and retail meat. NARMS also participates in the WHO-Global Salm-Surv External Quality Assurance System (EQAS). The EQAS supports the assessment of the quality of serotyping and antimicrobial susceptibility testing of Salmonella in all participating laboratories. The NARMS program has also developed two secondary antimicrobial testing plates for Salmonella and E. coli; a fluoroquinolone panel and extended-spectrum cephalosporin panel.

Action Item #10: Working with Partners, Including National Committee for Clinical Laboratory Standards (NCCLS), Further Develop, Refine, and Promote Standardized Clinical, Epidemiologic, and Laboratory Methods for Documenting and Assessing the Significance of Drug Resistance Among Yeasts and Moulds, Parasites, and Viruses.

Project Title: Adaptation and implementation of WHO methodologies on HIV drug resistance in PEPFAR countries (International laboratory Branch, Division of Global AIDS, NCHHSTP).

• Agency: CDC
• Description: Aim of the project is to harmonize the CDC-supported HIV drug resistance surveillance in PEPFAR countries is in line with the WHO recommended methodologies. To ensure the data generated can be compared and analyzed.
• Results: By adopting the WHO methodologies for transmitted HIV drug resistance survey, termed Threshold Survey (TS). We have shared data generated from 3 countries with WHO and make data analysis from different countries a reality. With the close collaboration on protocol developments and harmonization with WHO ResNet, data generated from CDC from PEPFAR countries have become part of the HIV drug resistance database at WHO. We have submitted data from Tanzania, Malawi and Kenya. For the first time in HIV DR surveillance history, all the data generated from PEPFAR and WHO-supported countries can be analyzed and compared which make a global HIV DR surveillance database a reality.

Project Title: Population-based, national/regional survey for TB drug resistance

• Agency: CDC
• Description: In 2008, the fourth report of ongoing population-based, national/regional survey for TB drug resistance sponsored by the WHO and the International Union Against TB and Lung Disease (IUATLD) will be issued, representing up to 85 countries and >50,000 patients. The Division of TB Elimination, via both the Mycobacteriology Laboratory Branch and the International Research and Programs Branch, has contributed substantially to this massive, sustained surveillance effort by: 1) providing scientific and technical leadership, quality assurance, and training to national and regional TB labs; 2) conducting surveys and surveillance programs in several countries which contribute data to the WHO/IUATLD program; and 3) leading in the development of international standard case and outcome definitions and surveillance procedures for MDR TB.
• Results: Ongoing, data on new cases were available for 72 countries and 2 special administrative regions (SARs) of China. DST results were available for 62, 746 patients. The proportion of resistance to at least one antituberculosis drug (any resistance) ranged from 0% in two Western European countries to 56.3% in Baku, Azerbaijan. The proportion of MDR ranged from 0% in eight countries to 22.3% in Baku, Azerbaijan and 19.4% in the Republic of Moldova. Data on previously treated cases were available for 66 countries and 2 SARs of China. In total, DST results were available for 12, 977 patients. Resistance to at least one anti-tuberculosis drug (any resistance) ranged from 0% in three European countries to 85.9%, in Tashkent, Uzbekistan. The highest proportions of MDR were reported in Tashkent, Uzbekistan (60.0%), and Baku, Azerbaijan (55.8%). Thirty five countries and two SARs were able to report data on XDR-TB either through routine surveillance data or through drug resistance surveys. In total, data were reported on 4, 012 MDR-TB cases, and among those 301 or 7.0% XDR-TB cases were detected.

Project Title: Multinational, prospective cohort study of MDR TB treatment to determine the added benefit of the programmatic approaches in preventing acquired resistance to 2nd-line drugs.

• Agency: CDC
• Description: Prospective cohort study of MDR TB treatment to determine the added benefit of the programmatic approaches in preventing acquired resistance to 2nd-line drugs.
• Results: Enrollment has now grown to 20 sites in 10 countries, ending in June 2008 with follow-up ending June 2010. This study demonstrated that large, multinational clinical and epidemiological studies of MDR TB with long-term follow-up are indeed possible and affordable and provided the first substantial data on the baseline prevalence and distribution of 2nd-line drug resistance and genotypes among MDR TB cases in several countries. The Division of TB Elimination has also implemented programmatic and clinical research projects to address principal issues during several international outbreaks of MDR TB.

Project Title: Development of a novel, rapid viability based assay for yeast antifungal susceptibility testing.

• Agency: CDC
• Description: The goals of this project: (1) Development of a yeast antifungal susceptibility testing method (AFST) using the viability dye FUN1in a flow cytometry based assay to generate objective results in under 6 hours. Results of conventional AFST methods are available in 24 hours and are often subjective. (2) To adapt the flow cytometry based system to a fluorescent plate reader format for AFST. This will allow routine clinical microbiology including state health laboratories to use this methodology in a cost-efficient, objective and user-friendly fashion. (3) To perform a multi-center study to evaluate the inter-laboratory reproducibility of this novel AFST assay
• Results: Ongoing. Assay parameters including dye concentrations, appropriate incubation temperature/ time, interpretation and analyses of results for representative Candida and Cryptococcus isolates have been established. Several domestic and international laboratories identified to participate in the multi-center study. Antifungal susceptibilities of 20 C. albicans and 10 C. neoformans isolates to amphotericin B and fluconazole have been generated using the new flow cytometry based assay. Results were comparable with the established CLSI AFST method.

Project Title: In-vitro antimicrobial susceptibility testing

• Agency: FDA
• Description: Develop quality control standards for the in-vitro antimicrobial susceptibility testing of bacterial pathogens isolated from aquatic animals and aquaculture foods.
• Results: Completed development of standardized in vitro susceptibility testing methods for bacteria isolated from aquatic animals. These methods were incorporated into the Clinical and Laboratory Standards Institute (CLSI) M42-A guideline “Methods for Broth Dilution Susceptibility Testing of Bacteria Isolated from Aquatic Animals”, and M49-A guideline “Methods for Antimicrobial Disk Susceptibility Testing of Bacteria Isolated from Aquatic Animals”.

Project Title: Devices containing antimicrobials guidance

• Agency: FDA
• Description: Draft guidance document for industry: how the Center for Devices and Radiologic Health (CDRH) intends to regulate devices containing antimicrobial agents, and what information regarding efficacy and resistance CDRH wants to see in premarket applications (interim until rulemaking is completed).
• Results: Draft guidance published in October 2007. Comments received and reviewed with final guidance to issue soon.

Action Item #15: Provide an Accessible, Centralized Source of AR Data from Major Surveillance Systems Involving Animal and Human Populations. In Consultation with Stakeholders, Determine How To Report AR Data in a Way That Is Valid and Useful to Interested Parties (e.g., Clinicians, Public Health Officials, Veterinarians, and Researchers). Include Sufficient Detail in Surveillance Reports To Permit Local Analysis and Comparison with Trends in Drug Use and Medical and Agricultural Practices.

Project Title: Surveillance for Streptococcus pyogenes among military trainees

• Agency: DoD
• Description: Increasing resistance of S. pyogenes to macrolide antibiotics is a concern. Furthermore, during military-recruit training exercises, penicillin-allergic patients are often given erythromycin when mass prophylaxis is recommended. If resistant organisms are present or develop in this population, S. pyogenes infections (latent or overt) may not be treated effectively. Recruits could be reservoirs of resistant pathogens for military populations. This project conducts antimicrobial susceptibility and gene typing on S. pyogenes isolates collected from recruits at 9 military training centers and monitors for S. pyogenes resistance rates.
• Results: Ongoing. Reports of susceptibility test results and summary statements are being provided to primary care facilities, are accessible to DoD staff at www.geis.fhp.osd.mil. Generated data show moderate antibiotic resistance through 2007. National DoD surveillance data for antibiotic resistance and emm gene type of group A streptococcal isolates from eight basic-training military sites was published in the Journal of Clinical Microbiology, Vol 48, October 2003. All isolates remain susceptible to penicillin, and macrolide resistance remained steady at approximately 10%. NHRC assisted in S. pyogenes outbreak investigations at 3 recruit training centers in 2006-07. Data from this surveillance was presented to the Defense Health Board (formerly the Armed Forces Epidemiology Board) in December 2006 and September 2007. Additional publication: Crum NF, Russell KL, Kaplan EL, Wallace MR, Wu J, Ashtari P, Morris DJ, Hale BR. Pneumonia outbreak associated with group a Streptococcus species at a military training facility. Clin Infect Dis. 2005 Feb 15;40(4):511-8.

Project Title: Multilocus sequence analysis of Streptococcus pneumoniae isolates

• Agency: DoD
• Description: DoD data from 1981 to 1991 suggest that S. pneumoniae may cause about 12% of military pneumonia hospitalizations. Multilocus sequence typing characterizes isolates of bacterial species using the sequences of internal fragments of 7 house-keeping genes. This highly discriminatory molecular typing method is used to track the global spread of virulence, to provide a direct comparison of isolates of multidrug-resistant S. pneumoniae, to define serotypes of isolates, estimate recombinational parameters, and identify discrete clonal complexes.
• Results: A pneumococcal isolate from a fatal case of meningitis was investigated using this technique, allowing the discovery of a non-vaccine serotype not commonly found among meningitis cases. During 2003 a conjunctivitis outbreak of S. pneumoniae was identified and analyzed. This work enabled the identification of a novel strain responsible for the outbreak and provided epidemiologic information on the causative isolate's resistance pattern. Further analyses of pneumococcal strains from Egypt is in process in hopes of providing valuable epidemiologic data for prevention and treatment options. Publications: Wasfy MO, et. al.. Antimicrobial susceptibility and serotype distribution of Streptococcus pneumoniae causing meningitis in Egypt, 1998-2003. J Antimicrob Chemother. 2005 Jun;55(6):958-64. Crum NF, Barrozo CP, Chapman FA, Ryan MA, Russell KL. An outbreak of conjunctivitis due to a novel unencapsulated Streptococcus pneumoniae among military trainees.

Project Title: Investigations of methicillin-resistant Staphylococcus aureus (MRSA) outbreaks occurring on military bases.

• Agency: DoD
• Description: Hospital acquired MRSA outbreaks are well known, but recent reports have caused concern about community acquired MRSA infections. Investigations into this recent trend have been conducted at several military bases. Laboratory work has involved culture identification followed by antibiotic resistance testing. The presence of the panton valentine leukocidin gene which is a known virulence factor has been shown in many of these investigations. The multilocus sequence typing method has also been used to identify global virulent clones by characterizing the isolates with the sequencing of 7 house-keeping genes. Further molecular analyses have been utilized to discover the specific SCCmec type of these MRSAs, which is the mobile genetic element that mediates the methicillin resistance.
• Results: BAMC investigators have conducted a randomized trial to look at mupirocin intranasal treatment and reduced MRSA carriage. Unfortunately, there was no reduction in carriage within the treated group. BAMC has also been collecting and characterizing MRSA isolates from across the MHS.NHRC has been testing MRSA isolates for over 15 years within military populations in the San Diego area. Molecular characterization has shown the emergence of distinct community-acquired MRSA strains that were genetically unrelated to nosocomial MRSA isolates from the same community.

Project Title: Investigation of multi-drug resistant Acinetobacter baumannii in US service members

• Agency: DoD
• Description: Acinetobacter baumannii is an opportunist, with pathogenicity usually associated with high infectious doses or contamination of deep or necrotic wounds. Its importance as an nosocomial agent is due to its high rate of multi-antibiotic resistance. A review of A. baumannii infection in wounded US service persons is underway to determine 1) the number and location of patients involved, 2) what risk factors are common to the patients (eg, military unit or geographic proximity before injury, type and site of wound causing hospitalization, specimen source, type and location of all medical and surgical treatment, exposure to other patients with A. baumannii infection), 3) the phenotypic strain(s) of A. baumannii involved, 4) genotyping of strains currently involved in hospitals at NNMC and WRAMC, and 5) sequencing isolates to conduct molecular epidemiology study with Tim Read at Naval Medical Research Center
• Results: DoD GEIS has established a strategic initiative to monitor changes in Acinetobacter isolates recovered from large medical centers. The medical centers that are participating are WRAMC, BAMC, LRMC and NNMC. WRAIR is coordinating the effort and serving as a focal point for sharing data. An epidemiologist is reviewing the data and providing monthly reports to critical MHS responsible officials to help raise awareness and augment infection control. This system will expand to other MDROs in the future. GEIS is also funding an in theater study at a combat support hospital to try to identify the common source of Acinetobacter infections.

Project Title: Electronic data capture of clinical microbiological and AR data in existing military treatment facility medical records, using HL7 message data, for surveillance of antimicrobial resistance (new effort)

• Agency: DoD
• Description: Surveillance of antimicrobial resistance and monitoring trends in emerging AR are important to military and public health. Empirical treatment guided by validated sensitivity and resistance data can lead to improved patient outcomes and a reduction in the emergence of resistance. However, it is difficult to establish this capability effectively across a spectrum of military medical facilities located in the US and in many foreign countries. A prior approach to developing such a system has been tried through a partnership with TSN (described in another part of this report); this was successful but has not expanded beyond four medical centers.
• Results: The Navy and Marine Corps Public Health Center, Portsmouth, VA, is testing a newer approach using Health Level 7 (HL7) data generated from the military health system. HL7 microbiology data were restructured for analysis using WHONET© to produce detailed reports characterizing antibiotic resistance in beneficiaries served by four military treatment facility (MTF) laboratories. A total of 32,264 isolates were identified from clinical specimens collected from July 2005 to October 2007. The efficiency and scope of DoD-level electronic surveillance, using this approach, will augment existing institutional-level surveillance techniques. This method can be expanded to include many more military centers and clinics - it is the first methodology to provide the possibility of timely AR surveillance and analysis of clinical microbiology laboratory data in the military population; this approach can lead to improvements in health outcomes, reduced healthcare costs and earlier recognition of adverse trends in antibiotic sensitivity.

Action Item #16: Provide Healthcare System Administrators and Other Decision Makers with Data on the Impact of Drug-Resistant Organisms (e.g., Outcome, Treatment Costs) and on Effective Prevention and Control Measures.

Project Title: Research Demonstration (U18): Centers for Education and Research on Therapeutics (CERTs) program: a national initiative to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research.

• Agency: AHRQ
• Description: The Harvard Pilgrim Healthcare CERT supports nine collaborating systems within an HMO Research Network to study antibiotic use in children and resistance and cost-effectiveness.
• Results: Enhanced surveillance of invasive pneumococcal disease (NPD) in Massachusetts began in October 2001 and remains ongoing. Nonvaccine serotypes caused 72%-91% of invasive pneumococcal disease annually in children less than 5 years of age between 2002 and 2005. Serotype 19A has emerged as the most frequent cause of IPD in Massachusetts. A multidrug-resistant clone (ceftriaxone, amoxicillin, azithromycin and trimethoprim-sulfamethoxazole) (MLST 320) was first identified in Massachusetts in 2005. Three years after the introduction of pneumococcal conjugate vaccine for universal administration to children less than 2 in Massachusetts, a significant increase in invasive disease due to serotype 19A was observed. Although MLST 199 remains the most frequent sequence type among invasive isolates (of 19A), a multidrug-resistant sequence type, not previously identified in Massachusetts, has become an important cause of invasive disease (Pelton SI et al. Pediatr Infect Dis J. 2007; 26:468-72.).

Action Item #17: Expand and Enhance Coordination of Surveillance for Drug-Resistance in Enteric Bacteria In Sick and Healthy Humans and in Sick and Healthy Animals on Farms, at Slaughter, and at Retail.

Project Title: FDA Science Board Review of the NARMS program 

• Agency: CDC, FDA, USDA
• Description: A scientific review designed to help the program identify how it can enhance the coordination among the three arms to provide a more comprehensive look at drug resistance in enteric bacteria was initiated.
• Results: In 2007, the NARMS program underwent an extensive review by the FDA Science Board, focusing on 4 major areas: sampling strategies, data reporting and harmonization, coordinated research, and international surveillance activities. FDA responded to the Board's recommendations, and is prioritizing recommendations for improving the program. A strategic planning meeting was held at CDC, September 17-18, 2007 focusing on how best to implement the Science Board recommendations where appropriate.

Project Title: Integrated  (human, animal, retail)   National Antibiotic Resistance Monitoring System for Enteric Bacteria (NARMS)  report

• Agency: CDC, FDA, USDA
• Description: An integrated summary of human, animal, and retail meat NARMS data for annual publication
• Results: CVM released the FY 2003 executive report, which summarizes data on Salmonella and Campylobacter isolates from all three components of the program in an integrated format, on CVM's website on February 5, 2007. The joint FDA, CDC and USDA FY 2004 Executive Summary of NARMS data will become available Summer 2007. The fourth annual NARMS retail meat report provides 2005 data on the prevalence of antimicrobial resistant foodborne pathogens and commensal bacteria among retail meat and poultry samples, comprising results from nearly 4,800 samples, was released in December, 2007.

Project Title: Antimicrobial resistant bacteria in feed ingredients

• Agency: FDA
• Description: Assess the prevalence of antimicrobial resistant bacteria in feed ingredients, primarily rendered product. This work will be done in conjunction with FDA field personnel. Results will be coordinated with NARMS. Expand NARMS into retail foods of animal origin.
• Results: Initial surveys of rendered products and plant based proteins completed. CVM continues to screen feeds and feed commodities for the presence of antimicrobial resistant Enterococcus and E. coli.

Action Item #18: Evaluate the Usefulness of Monitoring Sentinel Human Populations (e.g., Farm, Abattoir, Fruit and Vegetable, and Food Processing Plant Workers) and Persons in the General Community for Infection or Colonization with Resistant Enteric Bacteria.

Project Title: NARMS Enterococci and E coli surveillance study

• Agency: CDC
• Description: Determine the susceptibility patterns for isolates of Enterococci and E coli isolated from stool samples of healthy persons or outpatients from the community. Determine the risk factors associated with resistant and susceptible bacteria.
• Results: Four states are sending isolates of enterococci and two states for E. coli to NARMS CDC lab collected from stool of healthy volunteers or outpatients who report no hospitalization. Interviews are being conducted to determine specific environmental, medical, and food exposures previous to the culture. In 2007 susceptibility data were published in NARMS 2004 human isolate report.

Project Title: Antimicrobial resistant bacteria in sentinel human populations

• Agency: FDA
• Description: Evaluate abattoir workers for carriage of antimicrobial resistant bacterial pathogens.
• Results: CVM funded a cooperative research agreement to academic investigators at the University of Maryland to characterize antimicrobial resistance and genetic relatedness among enterococcal isolates from retail poultry, and healthy and ill humans. The study is complete and data analysis is in progress. CVM scientists also partnered with scientists in the Mexican Resist-Vet surveillance program to determine the prevalence of Salmonella species and quinolone-resistant non-type specific E .coli from human clinical cases, asymptomatic children, and raw retail meats.

Action Item #19: Conduct Pilot Studies To Assess the Extent of Environmental Contamination by Antimicrobial Drug Residues and Drug-Resistant Organisms That Enter the Soil or Water From Human and Animal Waste. If Contamination is Detected, Conduct Appropriate Surveillance in Waste, Surface and Ground Water, and Soil from Agricultural Areas in Which Waste Is Used for Fertilizer, and Conduct Studies To Determine Potential Impact on Human and Animal Health.

Project Title: Investigating Environmental Sinks of Macrolide Antibiotics, and Illicit Drugs, with Analytical Chemistry

• Agency: EPA
• Description: Research to determine what, if any, environmental sinks the macrolide antibiotics and illicit drugs (e.g., methamphetamine, MDMA) apportion to. This will include: source waters, wastewaters, biosolids, wetland plants, sediments, and possibly fish tissue. Antibiotics being analyzed include azithromycin, roxithromicin, and clarithromycin.
• Results: Ongoing. Preliminary data suggests that there are reservoirs of the macrolides other than wastewater and biosolids (i.e., wetland plant/roots and sediments). Some correlation between prescribed use of macrolides and environmental findings, but presence of Roxithromycin, which is not used in the U.S., suggests other means are used for obtaining antibiotics.

Project Title: Occurrence, Transport, and Fate of Pharmaceuticals and Other Emerging Contaminants Present in Wastewater

• Agency: EPA
• Description: At ten locations, samples were collected upstream and at two sites downstream from the wastewater treatment plant discharge, as well as from the effluent pipe. Of the 110 compounds investigated in effluents and surrounding surface waters, 78 were detected at least once. Different chemicals exhibited diverse environmental persistence.
• Results: This project supplied information on the occurrence and fate of pharmaceuticals and other wastewater derived compounds. This information is being applied in other projects that are (1) evaluating the compounds for use as indicators of human fecal contamination; and (2) ascertaining which chemicals are present in finished drinking water.

Project Title: Persistence of Contaminants from Wastewater Discharges During Drinking Water Treatment: Identification of Compounds and Degradation/Disinfection Byproducts, Evaluation of Removal, and Potential Exposure

• Agency: EPA
• Description: Compounds in wastewater, including antibiotics, discharged from a treatment plant or septic system have the potential to end up in surface or groundwater that may ultimately be used as a source of drinking water. Two different sampling plans will be implemented to determine the presence of these chemicals in drinking water. In Phase 1, the source and finished waters of 9 - 15 drinking water treatment plants, known to be impacted by wastewater, will be sampled. The samples will be analyzed using existing USGS methods for pharmaceuticals and wastewater compounds, as well as by two new methods currently under development at the USGS. The first new method will consist of pharmaceuticals not currently included in the existing methods; the second will focus on chlorination and degradation byproducts of wastewater contaminants. Phase 2 will be a more intensive investigation of two to four drinking water treatment facilities.
• Results: Ongoing. This work will assist the USEPA's Office of Water in determining which compounds should be included in future Unregulated Contaminant Monitoring Regulation (UCMR) sampling plans. Knowledge of the occurrence and persistence of these compounds will become increasingly important in the future as the demands on potable water sources increase and communities turn to approaches such as water reuse to supplement their drinking water supply.

Project Title: Defining the role of Salmonella newport in contaminated oysters

• Agency: USDA
• Description: Research to test the ability of Salmonella to survive in oysters and to track the source of Salmonella in surface waters
• Results: Overall prevalence of 7.4% of Salmonella in oysters with up to 78% in some bays. Majority is one genotype of S. newport. Funded by CSREES, NRI program (Univ of AZ)

Project Title: Enhance overall understanding of pathogens that pose a food-safety risk particularly from the environment.

• Agency: USDA
• Description: Pilot study to determine the contribution waterways play in movement of bacteria originating from animal production facilities in particular.
• Results: A mobile microbiology trailer has been designed and equipped. In the summer of 2005, collection will start in the southeastern US with the intent to visit all 50 states within the next 5 years. Bacterial Epidemiology and Antimicrobial Resistance Research Unit, ARS, Athens, GA.

Project Title: Enhance overall understanding of pathogens that pose a food-safety risk and to routinely monitor critical diseases in food-animal production, and develop a model for future surveillance efforts on a national level.

• Agency: USDA
• Description: CAHFSE will enable USDA to identify and implement mitigation strategies for animal health and food safety issues in a timely manner thereby averting adverse economic, animal well-being, and public health consequences. Further, it will provide comprehensive science based answers regarding animal health and public health, it will serve as a model for future surveillance efforts on a national level, and it will complement information obtained from both the National Antimicrobial Resistance Monitoring System (NARMS) and USDA VetNet programs. These data are being used by the swine industry to develop management recommendations for producers.
• Results: This program is being expanded to all commodities and has been endorsed by the Animal Ag Coalition and other commodity groups. Bacterial Epidemiology and Antimicrobial Resistance Research Unit, ARS, Athens, GA.

Action Item #20: Gather Information on the Relationship Between Antimicrobial Pesticide and Herbicide Use and the Emergence of Drug-Resistance by Monitoring.

<— Previous Section: Action Items 3–7        Next Section: Action Items 21—26 —>

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