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

Action Items 49—66

Action Item #49: Evaluate the Nature and Magnitude of the Impact of Using Various Antimicrobial Drugs as Growth Promotants in Different Species, Using Current Animal Husbandry Practices. Use This Information To Assist in Risk-Benefit Assessments of Such Use.

Project Title: Potential public health and food safety impacts associated with use of antibiotic growth promoters

• Agency: USDA
• Description: The objective of this proposal is to use molecular epidemiologic approaches to determine whether eliminating the use of antibiotic growth promoters has adverse affects on public health, reduces the health of swine, and whether antibiotic growth promoters mediate their effects by alteration of the intestinal bacterial microflora.
• Results: Funded, CSREES, NRI in 07. Isaacson, University of MN

Action Item #50: Conduct Additional Research To Further Define the Effects Of Using Various Veterinary Drugs on the Emergence of Resistant Bacteria That Infect or Colonize Food Animals of Different Species, Using Various Animal Husbandry Practices. Identify Risk Factors and Preventive Measures to Humans.

Project Title: Dissemination of Cephalosporin resistance genes

• Agency: USDA
• Description: Experimentally determine the frequency with which blacmy-2 and adjacent plasmid genes are transferred to previously susceptible e coli strains, and perform observational studies in calves and cows to determine the effects of ceftifur therapy on the frequency, diversity, and persistence of cmy-2 resistance in commensal e.coli populations
• Results: Funded, CSREES, NRI in 07. Sischo, Washington State Univ

Action Item #51: Conduct Epidemiologic And Laboratory Studies To Assess the Risk of Development and Transfer of Resistance Related to The Use of Antimicrobial Drugs in Food and Non-Food Plants, and Identify Risk Factors and Potential Preventive Measures.

Project Title: Antibiotics used as pesticides in orchards

• Agency: CDC
• Description: In the United States, apple and pear orchards are treated with streptomycin or oxytetracline sprays to control Erwinia amylovora bacteria (fireblight). We evaluated design protocols and methods to determine: 1) if there is a correlation between antibiotic treatment and resistance in bacteria from fruit samples; 2) if antibiotic-resistant bacteria on fruit are related to bacteria of human health concern; and 3) if they carry genetic elements for antibiotic resistance that could be transferred to other bacteria. Thirty composite fruit washes from hanging and dropped apples and pears treated with oxytetracycline, streptomycin, gentamicin, oxolinic acid or water were collected from 2 commercial and 2 research orchards. Bacterial abundance, and proportion resistant to treatment antibiotic, were determined for gram-negative (eosin-methylene blue medium), gram-positive (bile esculin agar) and environmental bacteria (R2A).
• Results: Bacteria resistant to treatment antibiotics were prevalent in each orchard, but extreme variability in bacterial numbers, and varying management practices in commercial and research orchards, confounded any association between treatment and proportion resistant. We are presently conducting focused analyses from the blossom stage to the fruit stage for bacteria with developed antibiotic resistance. Sample collection and most analyses for this experiment have been completed. We are presently evaluating the results of work completed to date. A manuscript will be prepared once analysis is completed.

Action Item #52: Develop Rapid Tests For Inspecting Fresh Commodities Like Fruit For Evidence Of Contamination With Bacteria That Are Resistant To Antibiotics.

Project Title: Rapid methods development

• Agency: FDA
• Description: Validated culture methods for foodborne pathogens in animal feeds.
• Results: Completed development and instillation of cultural methods to be used in screening feeds and feed commodities for the presence of the Bacillus cereus group. CVM continues to screen feeds and feed commodities for the presence of antimicrobial resistant Enterococcus and E. coli. CVM continues to collaborate with USDA-Agricultural Marketing Service to determine DNA fingerprint patterns and antimicrobial susceptibilities among Salmonella and E. coli isolates recovered from produce obtained from the microbiological data program plan.

Action Item #53: Evaluate the Effect of Current Food Processing and Distribution Methods on the Emergence and Spread of Drug-Resistant Organisms.

Project Title: NARMS retail food

• Agency: FDA
• Description: Monitor prevalence of antimicrobial resistant zoonotic pathogens and commensal organisms among foods of animal origin.
• Results: NARMS retail was initiated in 2002, as of 2008, 9 FoodNet sites plus Pennsylvania are participating. The 2005 NARMS retail meat annual report was recently published and can be found at http://www.fda.gov/AnimalVeterinary/SafetyHealth/AntimicrobialResistance/NationalAntimicrobialResistanceMonitoringSystem/ucm062595.htm. FDA is currently involved in publishing the 2006 annual report.

Action Item #54: Identify and Evaluate New Food Pasteurization Strategies.
Action Item #55: Assess the Risk of AR Emergence and Spread due to Environmental Contamination by Antimicrobial Drugs or by Resistant Bacteria in Animal and Human Waste. Collect Information on Whether Environmental Contamination by Antimicrobial Drugs Can Lead to the Development of Resistance in Bacteria That Live in Soil or Water.

Project Title: Animal production studies

• Agency: FDA
• Description: Determine dynamics of resistance development in naïve animal populations exposed to antimicrobial agents.
• Results: Completed animal studies focusing on the development and persistence of bacteria resistance after exposure to specific antimicrobials. Two studies have been completed in poultry: the first focused on fluoroquinolone resistance development in Campylobacter after exposure to veterinary approved fluoroquinolones, while the second concentrated on the emergence and carriage of streptogramin resistance in enterococci exposed to the veterinary streptogramin, virginamycin. Also, partnered with academic investigators at the University of Minnesota and Iowa State University in characterizing potential links between antimicrobial resistant E. coli recovered from foods and human extraintestinal pathogenic E. coli infections (e.g. UTIs, septicemia).

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

• Agency: USDA
• Description: Early studies show prevalence of Salmonella spp in oysters and bays in US. A majority of isolates are MDR Salmonella newport which match pulsenet. Hypothesis is the presence of this genotype in oysters suggests the role of dairy sheds. Information will help with intervention strategies
• Results: Funded by NRI, CSREES. Joens, University 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.

Action Item #57: Work with Veterinary and Agricultural Communities To Help Educate Users of Veterinary and Agriculture Antimicrobials About AR Issues, and Promote the Implementation and Evaluation of Guidelines That Address These Issues.

Project Title: Fund and develop state-based educational programs to promote appropriate antimicrobial drug use

• Agency: CDC
• Description: Several states are developing state based education programs in collaboration with agricultural industry groups to educate veterinarians and animal producers on appropriate antimicrobial drug use. Funding for these projects is provided by the Get Smart: Know When Antibiotics Work on the Farm program.
• Results: Continuing development of educational materials with partners at Tacoma-Pierce County Health Department in Tacoma Washington. A KAP survey of dairy producers was completed and educational materials were distributed to all of the state's dairy producers. The project is now evaluating six dairy farms for antibiotic use best practices. All other state programs were discontinued due to lack of funds.

** TOP PRIORITY **

Action Item #58: In Consultation with Stakeholders, Refine and Implement the Proposed FDA Framework for Approving New Antimicrobial Drugs for Use in Food-Animal Production and, When Appropriate, for Re-Evaluating Currently Approved Veterinary Antimicrobial Drugs.

Project Title: Risk assessment

• Agency: FDA
• Description: Risk assessment: Conduct an analysis of the relationship between emergence of streptogramin-resistant Enterococcus faecium (Synercid) in humans and use of streptogramins (virginiamycin) in food-producing animals.
• Results: Draft risk assessment published November 23, 2004; public comment period through February 25, 2005. The Center for Veterinary Medicine (CVM) conducted a thorough review and analysis of all the comments submitted to the Docket. Considerable attention was given to the potential impacts of suggested changes on risk estimates, particularly in light of new information in the scientific literature. However, there was insufficient basis to warrant revision of the original risk assessment. CVM will continue to monitor the scientific literature, the results of surveillance studies, the usage patterns of Synercid (and other future streptogramin drugs) in hospital and health care settings, and other relevant data that may affect the findings of the risk assessment and will revisit the risk assessment at a time dictated by the availability of new data and scientific developments in streptogramin resistance.

Action Item #59: Strongly Encourage Involvement of Veterinarians in Decisions Regarding the Use of Systemic Antimicrobial Drugs in Animals, Regardless of the Distribution System Through Which the Drug Is Obtained (e.g., Regardless of Whether a Prescription Is Required To Obtain the Drug).

Project Title: Educational materials

• Agency: FDA
• Description: Develop outreach materials on judicious use targeted to food animal producers.
• Results: CVM has developed a series of booklets that explain antimicrobial prudent use principles in depth for beef, dairy, swine, poultry, and more recently aquatic veterinarians. CVM has also produced a nine-minute animation explaining how antimicrobial resistance both emerges and proliferates among bacteria and can be found on the CVM web site http://www.fda.gov/AnimalVeterinary/SafetyHealth/AntimicrobialResistance/ucm134359.htm.

Project Title: AR use by veterinarians

• Agency: FDA
• Description: Develop a Web-based decision support system for use by veterinarians to select and use antimicrobial agents appropriately.
• Results: Provided funding for development of Veterinary Antimicrobial Decision Support System; five year contract awarded late 2001. The Veterinary Antimicrobial Decision System continues to be revised and improved. Feedback from users on the data used as well as modeling and interpretation methods are currently being solicited.

Action Item #62: Establish an Ongoing Mechanism To Obtain Periodic Input from External Experts on AR Issues. This Process Will Include Ensuring Input from Stakeholders and Partners (e.g., State and Local Health Agencies, the Private Sector, and the Public) in Developing and Reviewing Federal Efforts To Address Antimicrobial Resistance.

Project Title: Antibiotic resistance task force

• Agency: ARHQ, CDC, CMS, DoD, HRSA, USAID, VA, EPA, FDA, NIH, USDA
• Description: Annual Progress Report and Public Meeting.
• Results: 2001 - 2007, annual progress reports issued consisting of inventory of projects that address Action Plan items. Held eighth annual public meeting June 25, 2008, Bethesda, MD. December 2007, convened consultants meeting to discuss issues relating to revising the Action Plan.

Project Title: Antibiotic Resistance Task Force Action Plan Update

• Agency: ARHQ, CDC, CMS, DoD, HRSA, USAID, VA, EPA, FDA, NIH, USDA
• Description: The Task Force is currently working on Revising and Updating The Action Plan to Combat antimicrobial Resistance.
• Results: On December 12 and 13, 2007, the Interagency Task Force on Antimicrobial Resistance, held a consultants meeting in Atlanta, Georgia to obtain input and recommendations for revising and updating “A Public Health Action Plan to Combat Antimicrobial Resistance.”In addition to over fifty consultants from the United States, nine international consultants from Canada, Denmark, France, Germany, The Netherlands, and United Kingdom participated in the meeting. The consultants included experts from human and veterinary medicine, the pharmaceutical and diagnostics industries, animal husbandry industry, clinical microbiology, epidemiology, infectious disease and infection control specialists, and state and local public health departments. The consultants reviewed the 2001 Action Plan in detail and made a series of recommendations for the Interagency Task Force to consider. A revised Action Plan should be available for public comment in the Fall of 2008.

** TOP PRIORITY **

Action Item #63: Support Demonstration Projects To Evaluate Comprehensive Strategies That Use Multiple Interventions To Promote Appropriate Drug Use and Reduce Infection Rates.

Project Title: Prevention of Infection caused by Methicillin or Oxacillin resistant Staphylococcus aureus (PRIMO): Recurrent CA-MRSA prevention trial

• Agency: CDC
• Description: Primary Objectives are as follows:1. Test the efficacy and safety of a body decolonization regimen at preventing recurrent CA-MRSA infections among persons with recurrent CA-MRSA infection, 2.Test the efficacy of an environmental decolonization regimen at preventing recurrent CA-MRSA infections in persons with recurrent CA-MRSA infections
• Results: Protocol approved, enrollment initiated in June 2007 and is ongoing.

Project Title: Comprehensive demonstration project: building regional coalitions to prevent methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

• Agency: CDC
• Description: This project supports the development and implementation of comprehensive programs to reduce the incidence of  MRSA infections in states and/or large regional networks acute phase and nonacute phase healthcare facilities.  The Pittsburgh Regional Healthcare Initiative (PRHI) was recruited as a collaborating partner for this project.  PRHI is a coalition of regional healthcare facilities and civic, corporate, and healthcare leaders in the Pittsburgh area dedicated to improving the quality of healthcare delivery in southwestern Pennsylvania. 
• Results: 2007 milestones include: 1) National Veteran's Health Affairs MRSA Prevention Initiative-building on the work at VA Pittsburgh, a national pilot program was initiated in August 2006 to determine if results could be replicated in 17 other VA hospitals. In January 2007 plans were announced to initiate MRSA prevention programs in all VA hospitals. CDC continues to actively participate in that national task force. 2) Plexus Institute Initiative (funded by Robert Woods Johnson Foundation)-another expansion of Pittsburgh VA work, this project examines use of a social/cultural change improvement model (“positive deviance') applied to MRSA prevention at 6 funded sites. CDC is providing in-kind support and assistance. 3) Maryland Patient Safety Center Initiative has initiated a regional voluntary MRSA prevention program of 16 Maryland Hospitals that will implement MRSA prevention initiatives using the “positive deviance” change model. CDC is providing in-kind support and assistance in using NHSN as the outcome measurement tool.

Project Title: AHRQ 1 UC1 HS014237 Toward a Safety Culture: Reducing Nosocomial Infections C.

• Agency: VA
• Description: VA personnel are leading a regional research study sponsored by AHRQ designed to look at rapid-cycle implementation strategies of evidence-based practices that are known to reduce health care associated infections
• Results: Primary study accrual has completed and review and reporting of results is ongoing. This regional cooperative project received the 2005 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Ernest Amory Codman award and demonstrated findings of: i) reduced central line infections by 50 percent. ii) increased adherence to evidence-based practices to 95 percent from 30 percent. iii) created a new model for facilitating improvement as a community, with an increased chance of success, sharing of successful strategies, reducing rework across the sites, and speeding the implementation process.

Project Title: Toyota Production System (TPS) process to reduce infection

• Agency: VA
• Description: Through a demonstration project sponsored by CDC, VA facilities in Pittsburgh along with other health care institutions in the region participated in evaluation of a methodology (Toyota Production System process) for implementing change in infection control practices
• Results: Has demonstrated decrease with sustained success in resistant Staphylococcus aureus within facility Abstract presented at the Society for Healthcare Epidemiology of America Annual Scientific Conference April 2006, Chicago, IL authors R Muder, E McCray, C Cunningham, P Perreiah, C Squier, R Sinkowith-Cochran, J Jernigan. Ongoing and has led to both a further in depth evaluation process of 17 VHA medical centers nationwide and to nationwide implementation of a VHA MRSA Prevention Initiative.

Project Title: Positive Deviance

• Agency: VA
• Description: Use of Positive Deviance model to assist with national MRSA Prevention Initiative
• Results: Abstracts demonstrating use of positive deviance for cultural change at the Pittsburgh VA as part of its' successful MRSA reduction efforts presented at the Society for Healthcare Epidemiology of America Annual Scientific Conference April 2007, Baltimore, MD authors R. Muder, C Cunningham, C Squier, E McCray, R Jain, R Sinkowitz-Cocharn, J Lloyd, J Jernigan on the first abstract and J Jacob, R Muder, C Cunighham, E McCray, C Squier, C Mehta, R Jain, R Sinkowitz-Cochran, J Lloyd and J Jernigan on the second abstract Ongoing

Project Title: Inpatient Evaluation Center (IPEC)

• Agency: VA
• Description: The IPEC is a national program to improve outcomes (risk adjusted mortality and length of stay) in VA ICUs and eventually in inpatient care through feedback of outcomes and implementation of evidenced-based practices. Currently two of the initiatives deal with issues related to infection prevention--catheter-related bloodstream infections and ventilator-associated pneumonias--both of which may involve resistant organisms These data are reported back immediately to the local facilities who can track their rates over time and compliance with performance, as well as see the national mid-range statistical analysis results. 
• Results: IPEC program initiated nationwide during FY 2006 with initial data demonstrating a decrease in ventilator-associated pneumonias and central catheter related bloodstream infections nationwide within the past year.

Project Title: Methicillin-Resistant Staphylococcus aureus Prevention Initiative

• Agency: VA
• Description: Establishment of a national MRSA Prevention Initiative for all VA Medical Centers. In January 2007 VHA administration took strong directive action in plan to address infection with MRSA nationwide as a prototype agent for multidrug resistance issues; this national plan employs a bundle approach which includes hand hygiene, contact precautions, active surveillance culturing and cultural change. Seventeen VA medical centers ("beta-sites") across the country are also participating in a cooperative evaluation of this process with the Centers for Diseases Control and Prevention (CDC).
• Results: Implemented January 2007. By December 31, 2007 all inpatient acute care units nationwide in VHA had begun the initiative. Ongoing with evaluation for expansion into additional settings such as the long-term care/nursing home/community living center area. National data collection has begun for areas of prevalence of MRSA infection/colonization on admission, healthcare-associated infection with MRSA and MRSA transmission.

Action Item #64: Utilize Federal Health Care Systems (e.g., DoD, VA) as Models for AR Surveillance and Prevention and Control Activities Involving Appropriate Drug Use, Optimized Diagnostic Testing, Infection Control, and Vaccination Practice.

Project Title: Six SigmaTM process to promote hand hygiene in VA medical facilities.

• Agency: VA
• Description: National VA effort to use the Six SigmaTM process in the hand hygiene promotion effort. Pilot project at 3 VA medical facilities, with products from the testing to be distributed nationwide to all VA medical facilities.
• Results: National VA effort to use the Six SigmaTM process in the hand hygiene promotion effort. Pilot project at 3 VA medical facilities, with products from the testing to be distributed nationwide to all VA medical facilities.

Project Title: AHRQ 1 UC1 HS014237 Toward a Safety Culture: Reducing Nosocomial Infections

• Agency: VA
• Description: VA personnel are leading a regional research study sponsored by AHRQ designed to look at rapid-cycle implementation strategies of evidence-based practices that are known to reduce health care associated infections
• Results: Primary study accrual has completed and review and reporting of results is ongoing. This regional cooperative project received the 2005 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Ernest Amory Codman award and demonstrated findings of: i) reduced central line infections by 50 percent. ii) increased adherence to evidence-based practices to 95 percent from 30 percent. iii) created a new model for facilitating improvement as a community, with an increased chance of success, sharing of successful strategies, reducing rework across the sites, and speeding the implementation process.

Project Title: Influenza and Pneumococcal Vaccinations as Performance Measures

• Agency: VA
• Description: VHA has included the delivery of both influenza vaccination and pneumococcal vaccination to at-risk populations as a key performance measure for patient care.
• Results: Ongoing FY For Federal Fiscal Year 2006, VHA has introduced timing of antibiotics for community-acquired pneumonia for inpatients and is pursing measures for appropriate antibiotic choices.

Project Title: Inpatient Evaluation Center (IPEC)

• Agency: VA
• Description: The IPEC is a national program to improve outcomes (risk adjusted mortality and length of stay) in VA ICUs and eventually in inpatient care through feedback of outcomes and implementation of evidenced-based practices. Currently two of the initiatives deal with issues related to infection prevention--catheter-related bloodstream infections and ventilator-associated pneumonias--both of which may involve resistant organisms These data are reported back immediately to the local facilities who can track their rates over time and compliance with performance, as well as see the national mid-range statistical analysis results.
• Results: IPEC program initiated nationwide during FY 2006 with initial data demonstrating a decrease in ventilator-associated pneumonias and central catheter related bloodstream infections nationwide within the past year.

Project Title: National MRSA Prevention Initiative

• Agency: VA
• Description: Nationally directed MRSA Prevention Initiative incorporating a bundle approach consisting of hand hygiene, contact isolation, active surveillance culturing and cultural change/transformation.
• Results: Directive signed Jan 12, 2007 by Under Secretary for Health and all inpatient acute care units have established the MRSA Prevention Initiative nationwide in VHA. Ongoing.

Action Item #65: For All Healthcare Systems for Which Federal Funds Are Provided, Identify and Promote Strategies To Establish AR Prevention and Control Activities as Part of Quality Monitoring Programs.

Project Title: Quality assurance programs

• Agency: VA
• Description: The Office of Quality and Performance's Performance Measurement Program, which supports the VHA Strategic Plan, serves as a vehicle for effecting change in a balanced fashion. The Performance Plan operationalizes the premise that better quality, access, and satisfaction are often more efficient. Example, improved rates of inexpensive pneumococcal vaccinations may result in decreased antibiotic use. Immunization rates are assessed through a contract chart review system and are part of managers' perf. standards, and, therefore, used as part of the VHA quality-monitoring program. Excellent immunization rates in VHA have resulted from this program.
• Results: The VA Under Secretary for Health's hand hygiene memorandum was issued to VA medical facilities nationwide on 12/15/03. The study "Toward a Safety Culture" is in process.

Project Title: National MRSA Prevention Initiative

• Agency: VA
• Description: For the National MRSA Prevention Initiative (noted above in #64), the Office of Quality and Performance has sponsored support of 17 beta-testing sites for this initiative to determine if quality measures related any or all components of the bundle approach may be amenable to further analysis by quality monitors.
• Results: In progress with evaluation beginning with initiation of beta-test sites in Summer 2006. Ongoing collaboration with the Centers for Diseases Control and Prevention (CDC).

<— Previous Section: Action Items 27–48        Next Section: Action Item 67—>

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