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Pan American Conference on Antimicrobial Resistance in the
Americas
I. Introduction
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.
II. The Conference
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.
III. Recommendations
The following is a summary of some of the problems discussed,
together with participants’ recommendations regarding the topics addressed.
- Educating Health Professionals
about the Proper Use of Antibiotics
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.
- Development of a Pan American
Network for Monitoring Resistance to Antibiotics
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.
- Quality Control and Ways
of Achieving Consistent and Comparable Laboratory Results
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.
- Clinical Use and Abuse
of Antibiotics
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.
IV. Follow-up
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.
Return to the Index,
Epidemiological Bulletin , Vol.
20 No. 2, June 1999
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