Action Plan — The Focus Areas:
I. Surveillance (Issues B-C)

B.	Issue: Implementation of the national plan for AR surveillance will require:
		Reliable drug susceptibility data;
		Adequate capacity and resources at state and local health and agricultural agencies; and
		An accessible, centralized source of AR data.
	1.	Goal: Promote the consistent and appropriate use of reliable laboratory tests for antimicrobial drug susceptibility.
		a.	Action Items
			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). Coordinator: CDC; Collaborator: HCFA Timeline: Initiated
			9.	Evaluate the performance of licensed, automated AR testing devices in the context of changing resistance patterns and update their labeling where appropriate (e.g., changes in quantitative resistance that may make a test result invalid). Coordinators: FDA, CDC Timeline: Initiated
			10.	Working with partners (b), including the 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 Coordinators: CDC, NIH, FDA, USDA, HCFA Timeline: Initiated
			11.	Identify ways to overcome economic, legal, and other barriers to appropriate AR testing and to the reporting of results (e.g., sufficient human resources, cost considerations, empiric treatment recommendations, managed-care practices, etc.). (Related Action Item: Prevention and Control #34) Coordinators: HCFA, HRSA, CDC, AHRQ Timeline: Begin within one to two years
			12.	Pursue legal mechanisms for manufacturers to provide otherwise unavailable drugs to government reference laboratories for the sole purpose of antimicrobial drug susceptibility testing (as part of surveillance) with the understanding that these drugs will not be used for drug discovery purposes. Coordinator: CDC Timeline: Begin within one to two years
	2.	Goal: Ensure that state and local health and agricultural agencies have the capacity to conduct surveillance of drug-resistant organisms of public health importance.
		a.	Action Items
			13.	With state health and agriculture departments and other stakeholders, define needed core capacity (the minimum needed in human, laboratory, and electronic resources) at the state and local level to ensure that basic AR surveillance is conducted in these jurisdictions. As part of this effort, ensure that state public health and veterinary diagnostic laboratories maintain the capacity to test the drug-susceptibility patterns of resistant organisms of public health importance, especially for drug-microorganism combinations for which testing methods are not routinely available at hospital and commercial laboratories. Coordinators: CDC, USDA, FDA Timeline: Begin within one to two years
			14.	Provide resources to assist in meeting state and local core capacity needs for AR surveillance. Strive to provide consistent funding from year to year to state and local public health and veterinary diagnostic laboratories that meet quality assurance standards. Coordinators: CDC, USDA Timeline: Initiated
	3.	Goal: Disseminate surveillance data in a timely manner to public health officials, clinicians, and others who may make decisions based on an analysis of the data.
		a.	Action Items
			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. Coordinators: CDC, USDA, FDA, HCFA Timeline: Begin within one to two years
			16.	Provide health care 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. Coordinators: CDC, AHRQ Timeline: Begin within one to two years
C.	Issue: Monitoring AR in agricultural settings is essential to ensure animal and plant health and a safe food supply.
	1.	Goal: Monitor AR in animal and plant pathogens and in bacteria that can be transmitted to humans through the food supply.
		a.	Action Items
			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. This effort includes:
					Expanding the National Antimicrobial Resistance Monitoring System: Enteric Bacteria (NARMS:EB);
					Comparing AR data on pathogenic and nonpathogenic organisms detected on farms (in sick and healthy animals), at slaughter, and in commercial food products; and
					Utilizing these data to monitor the transmission of resistant infections and assess the effectiveness of prevention measures Coordinators: CDC, FDA, USDA Timeline: Initiated
			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. Coordinators: CDC, USDA, FDA Timeline: Begin within three to five years
			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. (Related Action Item: Prevention and Control #55) Coordinators: EPA, CDC, USDA Timeline: Initiated
			20.	Gather information on the relationship between antimicrobial pesticide and herbicide use and the emergence of drug-resistance by monitoring:
					The prevalence and incidence of drug-resistant organisms in agricultural areas where antimicrobial pesticides are used and areas where they are not used, and
					The prevalence of colonization or infection with resistant bacteria in human or animal populations who live or work near orchards or who consume fruit products sprayed (or treated) with antimicrobial pesticides. (Related Action Item: Prevention and Control #62) Coordinators: EPA, CDC, USDA Timeline: Begin within three to five years
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