Antimicrobial resistance poses a growing threat to public health in the Americas and the rest of the world. Drug-resistant strains of certain infectious agents are having a devastating impact on the control of diseases such as tuberculosis, malaria, cholera, diarrhea, and pneumonia, which together are responsible for more than 10 million deaths annually worldwide-this, at a time when the pharmaceutical industry is manufacturing very few new drugs to replace those that have lost their effectiveness.
It should be underscored that many of these antibiotics have become ineffective against two of the leading causes of death in children under 5: acute respiratory infections (especially pneumonia) and diarrhea. Antibiotic resistance in the Region’s hospitals is also a growing concern and threatens to leave physicians and public health professionals virtually impotent in the struggle against many infections.
Antimicrobial resistance implies that people with infections remain sick longer and run a greater risk of dying and, moreover, that epidemics of these diseases last longer. Furthermore, with the increasing frequency and speed of international travel, people infected with resistant pathogens can introduce them into other countries and thus contribute to the spread of resistance.
To combat drug resistance, a better understanding of all aspects related to its control is needed. No regional surveillance system for antimicrobial resistance is currently in place, nor is there a system for compiling standardized information in this regard. It is well known that one of the principal factors contributing to antibiotic resistance is the uncontrolled and improper use of these drugs, a phenomenon encouraged by health workers who prescribe them indiscriminately and the general population, which purchases them without prescription.
Motivated by the threat to public health posed by growing antimicrobial resistance, PAHO and the Pan American Association for Infectious Diseases, under the auspices of the Ministry of Health and Social Welfare of Venezuela, organized the Pan American Conference on Antimicrobial Resistance, held from 2 to 4 November 1998 in Caraballeda, Venezuela.
Experts in microbiology, infectious diseases, public health, and other disciplines attended the Conference, discussing the magnitude of antimicrobial resistance; the improper use of drugs in the community and hospital environments; the monitoring of antimicrobial resistance; and the use of the information generated for therapeutic, regulatory, and political decision-making.
The following is a summary of some of the problems discussed, together with participants’ recommendations regarding the topics addressed.
The participants proposed improvements in the basic education of medical students with regard to the use of antimicrobials, antimicrobial resistance, the spectrum, costs, and other aspects, as well as periodic updating of the medical and teaching staff who offer this instruction. They recommended persuading the pharmaceutical industry to adopt responsible advertising of antimicrobials and working together to achieve ethical business practices. Other recommendations were: to establish programs for continuing medical education and hospital committees to develop standards and issue recommendations for managing infections in the community; to design and carry out educational campaigns targeting mothers and children to curb self-medication with antibiotics; to create multidisciplinary medical committees on antimicrobial use; to disseminate the data on bacterial resistance to antibiotics and to secure the commitment of PAHO to support these objectives as part of its technical cooperation, with the object of promoting enforcement of legislation requiring the sale of antibiotics under medical prescription and the mobilization of resources to employ standardized research protocols and disseminate the results of these studies.
The participants determined that it is indeed possible to establish a Latin American network for monitoring antimicrobial resistance, considering such elements as the strengthening of existing networks and the creation of new networks where none are present. Other areas that should be tackled are promoting the analysis and proper use of information, establishing a regional registry to support studies of new resistant phenotypes, and creating a specific section in the PAHO website for communication among the participants and information on network activities.
The participating institutions of the surveillance network should be urged to make the network a permanent fixture with institutional or official backing. The network should have adequate internal and external quality control programs and the support of a local or regional reference laboratory.
Coordination among microbiologists, infectious disease specialists, and epidemiologists should be encouraged through training activities and joint data analysis. Profiles of unusual bacterial resistance should be identified and local recommendations issued. These and other activities could be part of the functions of professional organizations. A national information center should also be established and channels of communication should be opened between the various centers of each country. PAHO is the most suitable agency for coordinating the intercountry and regional mechanisms, as well as financing, and for evaluating the information and issuing the necessary recommendations.
To date, there is no guarantee of consistent and comparable results for laboratory tests of antimicrobial resistance. Among the factors contributing to the deficiencies in some of the data are the lack of standardized laboratory procedures owing to the lack of standards, methods, techniques, and manuals, as well as quality control. There is no integration, coordination, common standards, or external quality control programs for all laboratories participating in the network of each country; the economic resources for obtaining adequate reagents and materials are lacking; there is little access to up-to-date information and difficulties in disseminating what information there is; and there is no entity in charge of receiving and disseminating this information. There are no clear objectives for the monitoring of antimicrobial resistance, and there is a lack of training in laboratory methods and the use of computer software to process the data generated by such monitoring.
In light of these problems, the participants proposed the following: designation of a center to coordinate activities or reference on antimicrobial sensitivity in each country in order to train human resources; definition of the functions of each component of the system; integration of the information and its dissemination; establishment of an external quality control program for network laboratories and assumption of the responsibility for guaranteeing its continuity and sustainability.
The participants also recommended establishing similar national standards in all the countries to obtain comparable data; promoting cooperation among countries to take advantage of the progress that some of them have made; establishing an External Advisory Committee for Latin America through PAHO; collaborating with the pharmaceutical industry and professional organizations to implement the standards and promote teamwork among epidemiologists, infectious disease specialists, and public health professionals with the object of establishing clear objectives and applying the results of surveillance.
The participants analyzed the factors behind the inappropriate use and abuse of antibiotics, with a view to controlling their mass use in hospitals and the community. They recommended that every hospital undertake an assessment of local bacterial resistance to antibiotics in order to develop standards based on clinical and microbiological information. An infection committee in each hospital would be responsible for epidemiological surveillance of antimicrobial resistance, the selection of guidelines and policies for antibiotic use, and ongoing staff training in the correct use of antibiotics.
The participants determined that antibiotic use must be restricted in order to combat resistance and avoid other consequences. In this regard, the microbiology laboratory report should be a tool used by hospitals to guide therapeutic decision-making; the prescription of antibiotics in hospitals should be systematized and include the basic information needed; a list of antibiotics for restricted use should be available that takes cost, the potential for inducing resistance, toxicity, and sensitivity patterns into consideration. Hospitals should have a system in place to control the length of prophylactic and therapeutic treatment (for example, standards for automatic suspension and for the supervision of prescriptions by the antibiotics committee). The activities of the system should include periodic evaluation through prevalence studies and the analysis of databases, if available, using validated, reproducible instruments to assess the impact of the measures.
In order to prevent antimicrobial resistance from advancing in the community, the participants recommended a review of the current legislation in the different countries governing the registry, prescription, supply, and consumption of antibiotics, and promoting the formulation, application, and enforcement of these policies. The registration of antibiotics combined with other drugs, such as anti-inflammatories and mucolytics, should be avoided. It is essential to promote the sale of antibiotics exclusively by prescription. The public should be educated about the proper and improper use of antimicrobials and be informed about the risks of self-medication through television and radio campaigns, signs and posters, and pamphlets.
The participants suggested a number of specific research topics related to antibiotic use, such as the indication-prescription of antibiotics in upper respiratory infections; the incidence of self-medication in pharmacies; the prescription-indication of antibiotics in emergency rooms and outpatient clinics; and the use of antibiotics in animal husbandry and agriculture.
After the Caraballeda Conference in January 1999, PAHO brought together a group of experts in Asunción, Paraguay, to draw up a strategic plan for the monitoring of resistance to antibiotics. The result of this meeting was a three-year plan of action emphasizing technical cooperation among countries to strengthen the monitoring of antimicrobial resistance through internal and external quality control programs in laboratories and participating laboratory networks. The experts also proposed a concrete plan to review standards and policies in the countries of the Region.
The full version of this article was originally published as: Conferencia Panamericana de Resistencia Antimicrobiana en las Américas. Salvatierra-González R, Guzmán-Blanco M. Revista Panamericana de Infectología, published by the Asociación Panamericana de Infectología, May 1999, Vol. 3, Supplement No. 1, ISSN 0123-7039, Bogotá, Colombia.
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