This section is a new initiative by CFID to develop a “one-stop shopping” website to highlight Canadian infectious disease information and expertise. Available data on incidence, prevalence, burden of disease, diagnosis, treatment, outcome, prognosis, antimicrobial resistance rates, emerging viral respiratory infections, etc. will be collected and updated periodically. Much of this information currently exists but are sometimes buried and often difficult and time-consuming to access. Bringing together Canada-wide and province-specific information on topics of interest, relevance and importance at a single site will hopefully enhance public awareness and promote meaningful interaction among healthcare professionals within our national as well as provincial jurisdictions.
The objectives are two-fold: a) to enhance awareness and introduce topical areas of importance to the public; and b) to serve as a valuable resource to healthcare professionals by providing links to existing websites and publications that emphasize Canadian or province-specific data or information. We welcome your feedback and comments, and most importantly, your suggestions on topics that should be included in future editions of this section.
Surveillance of Antimicrobial Resistance and Antimicrobial Utilization in Canada
Prepared for the National Collaborating Centre for Infectious Diseases by the Association of Medical Microbiology and Infectious Disease (AMMI) Canada – June 2014 read more …
Antimicrobial Resistance – the Canadian Experience
We have chosen to highlight antimicrobial resistance in Canada for this inaugural edition of the “Gateway”. Available data concerning antimicrobial resistance among various common pathogens within Canada are tabulated (see Tables below). The source of surveillance programs reporting on these microorganisms, their associated websites, as well as relevant publications are also listed.
Infections with resistant bacteria were first reported in the early part of the last century when optochin was used to treat pneumococcal pneumonia. Early on, the problem was often overlooked because if one antibiotic did not treat the infection another was usually available. Since then, infections with resistant bacteria have become more common in both healthcare and community settings, and many bacteria have become resistant to more than one type or class of antibiotics. Consequently, healthcare workers are faced with treating infections where antibiotic options become very limited, and in some cases, no effective antibiotics exist. Additional consequences of antimicrobial resistance include: need to use antibiotics that are more expensive or more toxic; risk of increased morbidity and mortality due to failure of effective treatment; persistence and spread of resistant microorganisms to others; and huge economic burden on the healthcare system. We are currently witnessing a number of newly emerging threats that will challenge how we care for our patients, including multi-drug resistant pathogens in both the hospital (MRSA, NDM-1 E. coli and Klebsiella spp.), the community (gonorrhoea, MRSA, pneumococci), and in agriculture (multidrug-resistant DT 104 Salmonella typhimurium). The importance of developing effective strategies to mitigate against antimicrobial resistance is highlighted in both the 2013 Chief Public Health Officer’s Report from the Public Health Agency of Canada, and the recent CDC report “Antibiotic Resistance Threats in the United States, 2013“.
For the Public
Through print and social media, the public has become more aware of the threat posed by bacterial resistance to antibiotics. The importance of this topic cannot be overstressed, and may help many people understand the “double edged sword” that antibiotics offer. When appropriately used, they can be lifesaving; but overuse may ultimately pose a threat. If misinformed of the facts, members of the public may develop an exaggerated fear of drug resistance. Two exceptionally well produced educational videos are posted below to provide a more balanced perspective on this important subject matter. Public understanding of the facts and support for corrective measures will be critical for any strategy to effectively address this threat.
- “Unstoppable Superbugs: Closer Than We Think?” produced and published by the Robert Wood Johnson Foundation, April 29, 2013. While we cannot stop antibiotic resistance, we can slow it down. Learn what we can all do to prevent the overuse of antibiotics and ensure they remain effective for our future generations. Watch Video
- “Drug-Resistant Gonorrhea: Is The Antibiotic Era Coming To An End?” produced and published by Huffpost Science, October 10, 2012. Huffpost Senior Science Correspondent Cara Santa Maria speaks with Maryn McKenna about antibiotic-resistant gonorrhea. Watch Video
For Health Professionals
Topic Selection. A list of infectious disease-related topics of public and professional interest was formulated by the working committee and prioritized by the CFID Board of Directors based on: a) topical interest within the medical literature; b) relevance to the Canadian public; c) high or increasing national prevalence; d) recent changes in epidemiology or intervention.
Data Ascertainment. Canadian and province-specific data on each topic were identified through: a) searches of various websites of national and provincial laboratories including Public Health Agency of Canada (PHAC), Association of Medical Microbiology and Infectious Disease Canada (AMMI-Canada), Community and Hospital Infection Control Association Canada (CHICA-Canada), Canadian Nosocomial Infection Surveillance Program (CNISP) and Canadian Antimicrobial Resistance Alliance (CARA) as well as other stakeholders referenced on these sites; b) literature search; and c) direct inquiry at the reference laboratories. In the case of the latter, contact was made via email with microbiologists at these laboratories only when searches of websites and published literature yielded no data.
Literature Search. The OVID search engine was used to access the Medline (1996-2013) database. The medical subject headings (MeSH) included a) resistance-related terms: drug resistance bacterial, antibacterial drug resistance, antibiotic resistance, drug resistance microbial, antifungal drug resistance, antibiotic resistance bacterial, fungal; b) country or province specifics: Canada (and specific provinces were added if the search employing Canada as a MeSH term yielded no results); c) the specific organism: Streptococcus pneumoniae, salmonella, Staphylococcus aureus, etc.); d) specific drug class or drug (e.g., beta-lactams, methicillin, macrolides or erythromycin, fluroquinolones, etc.) and e) drug resistance or the mechanism (e.g., methicillin-resistance, vancomycin-resistance, etc.). Other non-MeSH terms searched included extended-spectrum-beta-lactams, beta-lactamases, and susceptibility. The detailed search strategy for each subtopic is provided in the Appendix . Additionally, journal publications and abstracts listed on stakeholder websites (e.g., CNISP publications) were reviewed and cross-checked with OVID searches.
Selection Criteria. Published articles and web-based data were selected for inclusion and referenced if:
- the publication date was between 2007-2013 or the resistance data reported on the website were at least within a year of this time range;
- The study was a multicenter study. Exception was made for single center reports addressing newly emerging patterns of resistance such as NDM-1 carbapenemase-producing gram negative bacilli;
- national, regional or city-wide data were reported. Studies reporting national or regional data were given preference over those reporting from centers within a single city.
Potential for Bias. There are potential biases intrinsic to surveillance of antimicrobial resistance. These include inadequate or inappropriate use of: 1) denominator data; 2) case definitions and ascertainment; 3) sampling bias; 4) failure to deal with multiple occurrences; and 5) laboratory practice or procedures. The following reviews specifically address these concerns which should be considered in the interpretation of antimicrobial resistance surveillance data.
- Rempel OR, Laupland KB. 2009. Surveillance for antimicrobial resistant organisms: potential sources and magnitude of bias. Epidemio. Infect. 137:1665-1673. Read PDF
- Steven C, Parmley J, Dawson-Coates J, et al. 2007. Obstacles to developing a multinational report card on antimicrobial resistance for Canada: an evidence-based review. Microbial. Drug Resistance 13:251-259. Read PDF
Antimicrobial Resistance Programs in Canada (1995-2010)
In Canada, systematic efforts for controlling antibiotic resistance began in 1997 following a national Consensus Conference held in Montreal entitled “Controlling Antimicrobial Resistance: An Integrated Action Plan for Canadians”. Three core areas were emphasized: antimicrobial stewardship, surveillance to monitor resistance trends, and infection prevention and control. A number of national and provincial antimicrobial resistance programs were created, including: Canadian Committee of Antimicrobial Resistance (CCAR), Do Bugs Need Drugs (DBND), National Information Program on Antibiotics (NIPA), and the National Collaborating Centre for Infectious Diseases (NCCID). A critical evaluation of these programs was published in 2012 that included data since 1995 (Conly JM. Antimicrobial resistance programs in Canada 1995-2010: a critical evaluation. Antimicrob. Resist. Infect. Control 2012;1:10-14). Read PDF Six national antimicrobial resistance surveillance programs were highlighted (Canadian Integrated Program for Antimicrobial Surveillance (CIPARS), Canadian Nosocomial Infection Surveillance Program (CNISP), Canadian National Centre for Streptococcus, Canadian Tuberculosis Laboratory Surveillance System, Canadian Bacterial Surveillance Network (CBSN), and Canadian Antibiotic Resistance Alliance (CARA). Unfortunately, all the surveillance programs have limitations and none were population-based.
Nevertheless, coincident with these national efforts, a 25% decrease in total oral antimicrobial prescriptions was observed between 1995-2010 (see Figure below). Although this may be a spurious association, the consistent and sustained observations over 15 years suggests that these AMR programs have had an impact. The decreases were mainly for beta-lactams, sulphonamides and tetracycles. A more recent cross-Canada retrospective study by CIPARS utilizing data from IMS Health Canada (www.imshealth.com) has confirmed these findings. Overall reductions in outpatient antimicrobial use were seen according to population-adjusted prescription rates, defined daily doses, as well as inflation-adjusted spending during 1995-2010.
Antimicrobial Resistance Trends in Canada
Table 1. Gram-Positive Organisms
|Pathogens associated with Drug-resistance||Data available||Source||Source Link|
|Enterococci||Rates for Vancomycin-resistant Enterococci (VRE) infections in CNISP hospitals nationally and by region (1999-2011)||CNISP (via AMMI)||www.ammi.ca Download PDF|
|Molecular characteristics and relative distribution of VRE blood stream infections (1999-2010)||CNISP (via AMMI)||www.ammi.ca Download PDF|
|Prevalence of VRE in Canadian ICUs (2005-2006) (slide 21)||CARA||www.can-r.com View Powerpoint slides|
|New cases per month in Quebec 2006-2007 vs. 2007-2008 ( statistics across 16 laboratories) . Archived data (2000-2006) also available||Laboratoire de santé publique du Québec||www.inspq.qc.ca Download PDF|
|S. pneumoniae||Relative percent resistant pneumococci by antibiotic type, site of infection and by region (2009)||CBSN||www.microbiology.mtsinai.on.c View Powerpoint slides|
|Penicillin non-susceptible pneumococci among respiratory isolates by year (1988-2009)||CBSN||www.microbiology.mtsinai.on.ca View Powerpoint slides|
|Macrolide-resistant Pneumococci (1993-2009)||CBSN||www.microbiology.mtsinai.on.ca View Powerpoint slides|
|Fluoroquinolone-resistant pneumococci (1997-2009) (ppt)||CBSN||www.microbiology.mtsinai.on.ca View Powerpoint slides|
|Serotype distribution of pneumococci by year (1994-2009)||CBSN||www.microbiology.mtsinai.on.ca View Powerpoint slides|
|Rates for MRSA infection and colonization nationally (1995-2010) and by region (2008-2010||Laboratoire de santé publique du Québec||www.inspq.qc.ca Download PDF|
|S. aureus||Relative Distribution of Healthcare-associated and Community-associated MRSA infections among CNISP hospitals (1995-2010)||CNISP (via AMMI)||www.ammi.ca Download PDF|
|Changing epidemiology of MRSA in Canada (2007-2011)||CARA||Nichol KA et al. JAC 2013; 68 (supp 1):47-55|
|Population-based study of increasing CA-MRSA, skin and soft tissue infections, and associated antimicrobial use in British Columbia||OVID||Marra F, et al. AAC 2012;56:6243-49|
|National surveillance of MRSA among pediatric patients in acute care facilities (1995-2007)||CNISP||Matlow A et al. Pediatr Infect Dis J 2012;31: 814-82|
|Quebec-specific data on nosocomial MRSA: rates of bacteremia by age, infection site and by hospital 2006-2007 ( Data also available for 2001-2005)||Laboratoire de santé publique du Québec||www.inspq.qc.ca Download PDF|
|S. pyogenes||National prevalence of macrolide-resistant GAS among Canadian hospital isolates (2007-2011)||CANWARD||Zhanel GG et al. JAC 2013; 68(suppl 1):7-22|
|S. agalactiae||Prevalence of clindamycin-resistant Group B Streptococcus from a single hospital centre in Toronto (2008)||OVID||Shore EM, Yudin MH. J Obstet Gynecol Can 2012;3:230-5|
Abbreviations: CNISP, Canadian Nosocomial Infection Surveillance Program; AMMI-Canada, Canadian Association of Medical Microbiology and Infectious Disease; CARA, Canadian Antibotic Resistance Allicance; CBSN, Canadian Bacterial Surveillance Network
Table 2. Gram-Negative Organisms
|Pathogens associated with Drug-resistance||Data available||Source||Source Link|
|N. gonorrhoeae||Antimicrobial resistance trends in Canada (2000-2010)||NML||www.antibioticawareness.ca Download PDF|
|National trends: decreased susceptibility to cefixime and ceftriaxone (2001-2010)||NML||Martin I, et al. Sex Transm Dis 2012; 39:316-23 Download PDF|
|Decreased susceptibility to cefixime and ceftriaxone in Quebec (2000-2011)||Laboratoire de santé Publique du Québec||www.inspq.qc.ca Download PDF|
|Antimicrobial susceptibility trends in Quebec (2000-2011)||Laboratoire de santé Publique du Québec||www.inspq.qc.ca Download reports|
|E. coli||Prevalence of ESBL-producing E. coli in Canadian ICUs (2005-2006)||CARA||www.can-r.com View Powerpoint slides|
|Molecular epidemiology of ESBL, AmpC and carbapenemase-producing E. coli among Canadian hospital isolates (2007-2011)||CANWARD||Denisuik et al. JAC 2013;68 (suppl 1):57-65; View Powerpoint slides|
|K. pneumoniae||Prevalence of ESBL-producing K. pneumoniae in Canadian ICUs (2005-2006)||CARA||www.can-r.com View Powerpoint slides|
|Molecular epidemiology of ESBL, AmpC and carbapenemase-producing K. pneumoniae among Canadian hospital isolates (2007-2011)||CANWARD||Denisuik et al. JAC 2013; 68 (suppl 1):57-65; View Powerpoint slides|
|Salmonella||Temporal trends of antibiotic resistance by province (human isolates, 2002-2009; reports for 2010-2011 by special request from CIPARS)||CIPARS||www.phac-aspc.qc.ca View report|
|Pseudomonas and other GNB||Antimicrobial susceptibility of Pseudomonas isolates in Canadian ICUs (2005-2006)||CARA||www.can-r.com View Powerpoint slides|
|Meropenem–resistant Pseudomonas in Canada (2007-2009)||CANWARD||McCracken M et al. Diag Microbiol Infect Dis 2011; 69:335-41|
|First report of locally acquired infections with NDM1 carbapenemase- producing GNBs (Morganella and Proteus) in Ontario (2010-2011)||OVID||Kus JV et al. CMAJ 2011;183:1257-61|
|Emergence of Carbapenemase resistance among Enterobacteriaceae in Canada (2010-2011; listing of cases and outbreaks)||CNISP (via AMMI-Canada)||www.ammi.ca Download PDF|
Abbreviations: NML, National Microbiology Laboratory, Public Health Agency of Canada; CARA, Canadian Antibotic Resistance Allicance; CANWARD, Canadian Hospital Ward Antibiotic Resistance Surveillance, CNISP, Canadian Nosocomial Infection Surveillance Program; AMMI-Canada, Canadian Association of Medical Microbiology and Infectious Disease; CIPARS, Canadian Integrated Program for Antimicrobial Resistance Surveillance
Table 3. M. tuberculosis and Candida spp.
|Pathogens associated with Drug-resistance||Data Available||Source||Source Link/ References|
|M. tuberculosis||National data of resistance type by country of birth and by disease category (2003-2007)||PHAC||www.phac-aspc.gc.ca|
|National rate of mono-resistant, multi-drug resistant (MDR) and extensively drug-resistant (XDR) TB by age and sex (1997-2008)||PHAC||Minion J et al. PlosOne 2013;8:1-8|
|Drug-resistant TB in Quebec: new cases by year 2002-2011||Laboratoire de santé publique du Québec||www.inspq.qc.ca Download PDF|
|Candida spp||Population-based surveillance of susceptibility patterns from blood stream isolates across Quebec (2003-2005)||OVID||St Germain G et al. Can J Infect Dis Med Microbiol. 2008;19:55-62|
|Susceptibility patterns by species in blood stream isolates from single Centre in Quebec (1996-2006)||OVID||Labbe AC et al. Can J Infect Dis Med Microbiol 2009;20:45-50|
Abbreviations: PHAC, Public Health Agency of Canada
Table 4. Heathcare-Associated vs. Community-Acquired Pathogens
|Pathogens associated with Drug-resistance||Data Available||Source||Source Link/ References|
|Community-acquired||BC antimicrobial resistance trends (2002-2012)||BCCDC||www.bccdc.ca Download PDF|
|Healthcare-associated||National trends in antimicrobial susceptibility among hospital pathogens (2007-2011)||CANWARD||Zhanel GG et al. JAC 2013; 68(suppl 1):7-22|
|National trends in antibiotic resistance among hospital pathogens over time (2007-2011)||CANWARD||Lagace-Wiens PRS et al. JAC 2013; 68(suppl 1):23-29|
This inaugural edition of the “Gateway” was compiled by Dr. Michelle Barton-Forbes from the Division of Pediatric Infectious Diseases, University of Western Ontario, London, ON. The public awareness and educational component was put together by Dr. Robert Bortolussi, Dalhousie University, Halifax, NS. The “Gateway” initiative is supported by an unrestricted grant from Pfizer Canada.