May 21, 2016
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Table of Contents
  1. ARC members and civil society groups take part in WHO-NGO Dialogue on AMR in preparation for 69th World Health Assembly
  2. UK Review on AMR releases final report
  3. ReAct publishes Development Dialogue paper on AMR and Sustainable Development Goals
  4. Analysis of public funding in JPIAMR countries and EU shows most funds spent on developing new therapeutics
  5. #TurnYourNoseUp campaign targets UK pig factory farms, while UK pork industry launches antibiotic stewardship program
  6. US FDA finalizes species specific data collection rule, USDA announces $6 million in available AMR research funds
  7. Thirty percent of antibiotic prescriptions in US outpatient visits found to be inappropriate
  8. UK launches new antibiotic stewardship quality standards
  9. Rwanda Medical Association, GSK, and Lancet Laboratories host workshop on AMR
  10. Whole-Genome Sequencing and web-based data visualization to monitor MRSA

1. ARC members and civil society groups take part in WHO-NGO Dialogue on AMR in preparation for 69th World Health Assembly

At the invitation of the World Health Organization (WHO) Antimicrobial Resistance (AMR) Secretariat, over twenty civil society organizations including many within the Antibiotic Resistance Coalition (ARC) and others joined the second WHO-­NGO Dialogue with Assistant Director-­General Dr. Keiji Fukuda and AMR Coordinator Dr. Marc Sprenger. The aim of this discussion was for the WHO to hear the views of non­‐governmental/civil society organizations regarding two parallel processes - first, the efforts towards a United Nations (UN) High-­Level Meeting on AMR during the upcoming General Assembly in September 2016 and second, the efforts towards implementation of the Global Action Plan on AMR, adopted by the World Health Assembly in May 2015. According to Dr. Fukuda, the WHO views the meeting as not only useful for their efforts on AMR, but also important for building trust with the NGO community. At the 69th World Health Assembly this week, Member States will be discussing AMR under agenda item 14.4. They will be review the WHO AMR Secretariat's update on implementation of the Global Action Plan on AMR as well as a supporting report on "options for establishing a global development and stewardship framework to support the development, control, distribution and appropriate use of new antimicrobial medicines, diagnostic tools, vaccines and other interventions."

Click here to read the full summary of the WHO-NGO Dialogue.

2. UK Review on AMR releases final report 

Review on AMRThe UK Review on AMR has published its final report and recommendations on combating AMR. The Review on AMR called for global action, including by the G20 and UN, to carry out interventions to reduce the demand for antimicrobials and increase the supply of effective antimicrobials. The Review has estimated that these actions would cost 40 billion USD over a 10 year period, which would amount to 0.05 percent of what the G20 countries spend on healthcare. Since the recommended market incentives act to pull, or reward success, they do not require upfront public investments into projects that may not deliver improvements. The Review suggests that funds for AMR could be allocated from existing health and development budgets, or collected through an antibiotic tax. One funding option highlighted by the report is a "pay or play" antibiotic investment charge, in which companies either invest in AMR R&D themselves or pay a charge that would fund AMR R&D. This mechanism would incentivize companies to invest by lining up short-term financial incentives with the benefits to an industry that depends on antibiotics to enable complex medical procedures such as cancer care and surgery. Though the report has been welcomed as an important call to action, it has also been criticized by Médecins Sans Frontières (MSF) for not proposing ways to lower the prices of medicines rather than subsidizing their high prices. The Sustainable Food Trust has also noted the difficult position of farmers around the world, where the low prices of animal products is forcing farmers out of business and encouraging the remaining ones to intensify their operations and use more antibiotics. Therefore, a tax on antibiotics would only be a useful solution if the funds raised are recycled to cover the transition costs for farmers. Several commissioned studies were released alongside the Review's final report. One of these was a report by the ReAct Strategic Policy Program and the Johns Hopkins Center for a Livable Future proposing a framework for estimating the costs of lowering antimicrobial use in food animal production.

The proposed interventions are as follows:
1. A massive global public awareness campaign. Raising awareness is needed to reduce unnecessary demand among patients and farmers, to promote rational prescribing by clinicians and veterinarians, and to accelerate action by policymakers. The estimated cost of such a campaign is between 40 and 100 million USD per year in the form of existing public health programs in high-income countries and support for programs in low and middle-income countries, with corporate sponsorship for major events.

2. Improvement of hygiene and prevention of the spread of infection. Improvements are needed from expanding access to clean water and sanitation to reducing infection in healthcare settings. Proper handwashing is a simple but universal way to control the spread of infections.

3. Reduction of unnecessary agricultural use of antimicrobials and their spread into the environment. The Review recommends setting 10-year targets to reduce unnecessary antibiotic use in agriculture to be introduced in 2018 with progress milestones proportional with the economic development level of countries. The Review calls for restrictions of critically important antibiotics. In addition, the report emphasizes the importance of transparency from producers on their antibiotic use practices to enable consumers to make informed purchasing choices. Antibiotic residues and resistant pathogens spreading through sewage (such as from hospitals) and runoff from farms. The manufacture of antibiotics also releases residues into water systems, which indicates the need for minimum standards for waste treatment and release.

4. Improvement of global surveillance of drug resistance and antimicrobial consumption in humans and animals. The report highlights the need for sustained financing and country level development with WHO oversight of surveillance that monitors antimicrobial consumption, resistance levels, and biological determinants of resistance. Gathering "big data" on AMR can feed into diagnostic tools that may be used in LMIC.

5. Promotion of new rapid diagnostics. The Review calls for high-income countries to champion the use of diagnostics by requiring that by 2020, antibiotic prescriptions must be informed by data and testing technology. In addition to early-stage R&D funding, the report suggests stimulating the diagnostic market with "top-up" payments made to diagnostic producers when the diagnostics are purchased. This tool would incentivize sales in LMIC where access and affordability are the main barriers to diagnostic use. Such a model is similar to that used by Gavi, the Vaccine Alliance to procure vaccines.

6. Promotion of development and use of vaccines and alternatives to antimicrobials. Increasing the use of vaccines and alternative treatments in humans and animals is key to preventing infections. The report argues that R&D for vaccines and alternative treatments should be eligible for the same incentives recommended for antibiotic development.

7. Increasing the number, pay, and recognition of people working on infectious disease. The Review found that infectious disease doctors are the lowest paid of 25 medical fields in the US. Similarly, nurses, pharmacists, microbiologists, and laboratory scientists are rewarded less in terms of pay and in prestige. To alleviate this, the report advises that funding be aimed at improving the career paths and rewards in fields for those who work on AMR and infectious disease.

8. Creation of a Global Innovation Fund for early-stage and non-commercial research. The Review has proposed a Global Innovation Fund endowed with up to 2 billion USD over five years. This fund would seek to link up and increase the size of existing R&D funding initiatives like the UK-China Innovation Fund, the US Biomedical Advanced Research and Development Authority (BARDA), the European Innovative Medicines Initiative, and programs within the Joint Programming Initiative for AMR (JPIAMR). Importantly, these funds should go towards early-stage "blue sky" research, and to research whose outputs may not be "cutting edge" and lack commercial imperative.

9. Incentives to promote investment for new drugs and improving existing drugs. The Review stressed the need to reward innovation while reducing the link between profit and volume of sales to ensure access and stewardship. The centerpiece mechanism proposed by the Review is market entry rewards of about 1 billion USD per drug for effective treatments against areas of most urgent need (including tuberculosis, gonorrhea, Gram-negative pathogens, and certain fungal diseases) regardless of whether they are based on new or old drugs. These market entry rewards would come with stipulations about commitments to continued development, responsible sale and marketing, and affordable access facilitated or directly or through a licensing arrangement such as the Medicines Patent Pool. The report suggests that developers could also be required to support education about AMR and monitoring of use and resistance. The report argues that leaving control of a drug in the hands of the developer is superior to a "buyout" model, suggesting that commercial operators can manage pharmaceutical supply chains better than "bureaucratic entities."

To further promote R&D, the Review proposes ways to accelerate new drug development. The report suggests that harmonizing regulatory pathways, such as the expensive and slow process of registering a drug in each individual country, would reduce costs and improve access. The Review calls for simplifying clinical trials and provides a rationale for "non-inferiority trials", where new drugs are shown to be no worse than old drugs in broad populations and developers conduct additional research in animals or smaller groups of patients. The report argues that it is difficult to establish the superiority of a new drug in patients with antibiotic-susceptible infections. Patients with resistant infections are more difficult to find and enroll, and it is unethical to give first-line treatments that are known not to work. The Review also recommends the creation of a clinical trial network that reduces the startup costs for initiating new clinical trials through mechanisms such as sharing control groups between trials.

3. ReAct publishes Development Dialogue paper on AMR and Sustainable Development Goals

ReActReAct has written a paper discussing how AMR threatens not only health, but also global development due to its effects on the environmental, social, and economic targets within the United Nations Sustainable Development Goals (SDGs). The paper, published in the Dag Hammarskjöld Foundation Development Dialogue, recommends international multi-stakeholder partnerships to address AMR. The paper highlights comparable global initiatives worth emulating. One example is the response to the AIDS crisis where the UN General Assembly adopted the Declaration of Commitment on HIV/AIDS. In another case of global action, the UN hosted a High-Level Meeting on the Prevention and Control of Non-Communicable Diseases, thereby setting an international agenda on non-communicable diseases. The paper also notes that the global response to climate change shows the multisectoral collaboration needed to fight AMR. The paper also calls for commitments to share knowledge and build capacity in countries of all income levels, with action from stakeholders including government entities and UN agencies with strong national presence. Monitoring and accountability mechanisms on antibiotic access, use, and resistance would be enabled by financing national action plans, particularly in low- and middle-income countries.

According to the paper, AMR especially affects SDG 3, "Ensure healthy lives and promote well-being for all at all ages." AMR jeopardizes maternal and child health, to the extent that the UN Every Woman Every Child initiative included antibiotics in a list of 13 life-saving commodities that contributed to achievement of the Millennium Development Goals on maternal and child health. AMR not only  exacerbates the burden of communicable disease, but also complicates the safety and effectiveness of surgeries and cancer treatment. In addition to SDG 3, AMR has significant economic costs that affect progress towards SDG 1, "End poverty in all its forms everywhere," and SDG 8, to "promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all."

To meet SDG 2, "End hunger, achieve food security and improved nutrition and promote sustainable agriculture," countries need to resolve the conflict between the need to increase agricultural productivity and the growth of intensive animal protein production systems reliant on the use of antibiotics. This points to the value of improving animal husbandry and disease prevention, in combination with a strong regulatory framework surrounding the use of antibiotics in animals. AMR is also relevant to SDG 6, "Ensure availability and sustainable management of water and sanitation for all." Currently, drug manufacturing facilities and animal production sites pollute water systems with antibiotic residues and resistant pathogens. In addition, the lack of access to clean water and sanitation leads to the spread of bacterial disease. Antibiotics are a limited and possibly non-renewable resource, which makes them fit under SDG 12, "Ensure sustainable consumption and production patterns." Addressing AMR as a sustainability issue necessitates policy coherence on all levels, as recommended by SDG 17, "Strengthen the means of implementation and revitalise the Global Partnership for Sustainable Development."

4. Analysis of public funding in JPIAMR countries and EU shows most funds spent on developing new therapeutics

Kelly et al.The first systematic analysis of publicly-funded AMR studies in the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) countries and European Union has been published in the Lancet. Studies were categorized according to the six priority areas of the JPIAMR Strategic Research Agenda, which are therapeutics (e.g. new antibiotics or improvements or existing antibiotics), diagnostics, surveillance in both human and agricultural settings, transmission, environment, and interventions to prevent and control AMR in human and veterinary health. JPIAMR national-level funding accounted for 49.5% or €646.6 million of the total investments covered in the study. The review captured 1243 AMR projects from 2007 to 2013 funded by €1.3 billion from 19 countries and the European Union. The vast majority of studies covered in the review fell under the category of therapeutics, with 66% of national-level funds going towards 763 out of 1208 projects funded at the national level. This stands in contrast to the funding percentages of 14% for diagnostics, 9% for transmission, 5% for interventions, 4% for surveillance, and 2% for environment. At the EU level, there is a similar trend for the €647 million in funds, with 63% of funding going towards therapeutics (71 out of 133 projects). JPIAMR has developed a publicly available online database documenting the AMR projects that are included in the review. The database reports the country, funding organization, principal investigator, host institution, grant title, summary of research project, funding amount, and the study category.

There was large variation between countries in terms of the number of projects, investments, and areas of focus. Denmark, Estonia, Finland, the Netherlands, Sweden, and the UK had the highest number of
The amount of investment in AMR research is very small compared to total research funding in the JPIAMR countries. For example, AMR spending accounted for 1% of total research spending in the UK, the largest of the JPIAMR investors. Given the high representation of therapeutics research found by this study, the authors of this study have called for increased research on affordable, reliable, and rapid point of care diagnostics. The report also recommended increased national and international collaboration, research harmonization, and resource pooling. The review was led by the UK medical Research Council and funded by JPIAMR.Kelly et al.

5. #TurnYourNoseUp campaign targets UK pig factory farms, while UK pork industry launches antibiotic stewardship program

Celebrities turn their noses up at pig factories - #TurnYourNoseUp
Watch celebrities turn their noses up at pig farms in this campaign video →
The UK nonprofit organization Farms Not Factories launched the #TurnYourNoseUp campaign this month targeting factory farming of pigs and promoting sustainably produced pork. Farms Not Factories produced a video featuring prominent celebrities including Vivienne Westwood, Jeremy Irons, Kit Harington (Jon Snow on Game of Thrones). The campaign emphasizes the public health threat caused by antibiotic overuse in animals, noting how 25% of antibiotics in the UK are used in animals, and 9% of retail pork samples in the UK have contained MRSA. Overall, about 75% of UK pork is produced in factory farms. The campaign includes a scorecard of UK meat labels to educate consumers and encourage them to choose sustainably produced pork. The scorecard favorably rates pork labeled as organic, free-range, outdoor bred, and RSPCA Assured (Royal Society for the Prevention of Cruelty to Animals). Under the standards of these labels, antibiotic use is permitted only to treat illness with the exception of "outdoor bred" pigs, where piglets are typically given antibiotics after weaning.

Farms Not Factories has also created a guide to shifting to more sustainable meat consumption without spending more money. The guide recommends cutting meat consumption and choosing cheaper cuts of meat. For instance, two conventionally produced sausages in the UK cost the same as 1.5 sustainably produced sausages when comparing prices by weight. Members of the public are invited to take selfies with the hashtag #TurnYourNoseUp to be featured on the Farms Not Factories homepage. Thus far, the campaign's total social media reach is estimated to be over 75 million people. Farms Not Factories previously made a documentary about factory pig farming entitled Pig Business, and the nonprofit is engaged in an effort to stop the passage of the Transatlantic Trade and Investment Partnership (TTIP).

This May, the UK National Pork Association launched an antibiotic stewardship program to reduce the use of antibiotics. The program will include collection of antibiotic use data that is then anonymized and used to compare farms of similar types and sizes. The stewardship program will include education on disease control strategies. The program will also promote veterinary prescribing guidelines to limit the use of antibiotic of critical importance to human health. The NPA will appoint "Stewardship Commissars" who will review the industry's use of antimicrobials and lead further initiatives. This work will take place through a partnership among the Pig Veterinary Society, ADHB Pork (a UK pork business group), and the UK government Veterinary Medicines Directorate. Prior to initiating this work, the Pig Veterinary Society re-categorized colistin as a last-resort drug to be used only when no other options are available and its use is supported  by antibiotic sensitivity testing. Amoxycillin/clavulanic acid was also moved to this category, which already included fourth generation cephalosporins and fluoroquinolones, which are critically important antibiotics. The pork industry also notes that since no livestock medicines containing 3rd or 4th generation cephalosporins available for in-feed or in-water formulations, they are only administered to individual animals. NPA chief executive Dr. Zoe Davies stated, "We acknowledge the risk, albeit small, of antibiotic resistance developing in bacteria in pigs and this resistance spreading to humans."

6. US FDA finalizes species specific data collection rule, USDA announces $6 million in available AMR research funds

The US Food and Drug Administration has issued a final rule that will require antimicrobial drug sponsors to report estimates of sales broken down by animal species as part of the FDA's summary reports on antimicrobial sales for animal use. The species categories are cattle, swine, chicken, and turkey. Previously, data collected under the Animal Drug User Fee Amendments (ADUFA) were not broken down by species. The FDA intends to combine this enhanced sales data with proposed on-farm data collection on antibiotic use and resistance. The rule will also help the FDA assess the rate at which drug sponsors are removing growth promotion and feed efficiency uses from product labels in accordance with FDA Guidance for Industry 213. Under GFI 213, pharmaceutical companies are expected to bring medically important antibiotics under veterinary oversight for disease prevention, control, or treatment by December 2016. The rule also includes a provision requiring that the FDA publish the ADUFA Summary by December 31 of the following year, which aims to increase the timeliness of data reporting. The report for 2014 antimicrobial sales, which showed a continuing trend of increasing sales since 2009, was published in December 2015. The FDA has estimated that the financial burden on industry will be a one-time cost of $134,600 and an annual $57,300. The rule allows drug sponsors to report production units rather than calculating the amount of active ingredients, leading to an estimated annual benefit to industry of $122,300.

The US Department of Agriculture has announced the availability of $6 million in AMR research funding as part of Combating Antimicrobial Resistant Bacteria (CARB) activities, with a grant application deadline of August 3. Research proposals should address any of the following areas:
  • Novel systems approaches to investigate the ecology of microbial resistance microbes and gene reservoirs in the environment, animals, crops, food products, or aquaculture
  • Development and evaluation of sustainable resources and strategies to reduce the emergence, spread or persistence of resistant pathogens within the agricultural ecosystem, animals, crops, and food
  • Identification of critical control points for mitigating AMR in the pre- and post-harvest food production environment
  • Innovative training, education, and outreach resources that can be used across the food chain by policymakers, producers, processors, retailers, and consumers
  • Evaluation of the impact of proposed research, education, and extension and outreach interventions on AMR along the food chain

7. Thirty percent of antibiotic prescriptions in US outpatient visits found to be inappropriate 

A study by the CDC and the Pew Charitable Trusts has found that an estimated 30 percent of antibiotic prescriptions were inappropriate based on an analysis of data from 2010-2011 in the National Ambulatory Medical Care Survey. Out of a sample of 184,032 doctor's office visits, 12.6 percent were associated with antibiotic prescriptions. Using those visits, the researchers calculated the mean annual number of visits with a prescription per 1000 population. The NHAMCS lacks data that would directly validate the appropriateness of a prescription, in terms of whether an infection is bacterial or if the dose prescribed is appropriate. Therefore, the Pew Charitable Trusts convened a group of experts to devise a method of estimating appropriateness. Their method relied on comparing clinical diagnosis information in NHAMCS against national diagnosis guidelines for upper respiratory infections, pneumonia, otitis media (ear infection), urinary tract infections, and miscellaneous bacterial infections (such as pertussis and syphilis). They found that overall, there were 506 antibiotic prescriptions per 1000 people, with 353 prescriptions or 70 percent determined to be appropriate.

Accounting for 221 antibiotic prescriptions per 1000 population, acute respiratory conditions were the most common diagnoses associated with antibiotic prescriptions. However, only 111 prescriptions out of 1000 population or 50 percent of these prescriptions were appropriate. The US National Action Plan sets a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, and this study is the first to quantify rational use in outpatient settings in the US. Given these high rates of inappropriate antibiotic prescribing, the paper recommends interventions such as clinician and patient education, audit-and-feedback, academic detailing, communication training, rapid diagnostics, clinical decision support, and delayed prescription.

8. UK launches new antibiotic stewardship quality standards

UK National Institute for Health and Care ExcellenceThe UK National Institute for Health and Care Excellence (NICE) issued a new antibiotic stewardship quality standard which covers the effective use of antimicrobials in all human healthcare settings. The new standard seeks to address the continued trend of rising rates of antibiotic resistant infections and total antibiotic prescribing from 2010 to 2014. In the UK, 74% of antibiotics are prescribed in general practice, and 11% in hospitals. Through implementation of this quality standard, NICE aims to reduce inappropriate prescribing and stem the spread of AMR. The standards will be evaluated according to the number of patients treated in accordance with the standards, and the rate of antibiotic prescriptions is the common outcome measure among 6 quality statements.
  1. "People with a self-limiting condition, as assessed by a primary care prescriber, receive advice about self-management and adverse consequences of overusing antimicrobials." This standard seeks to move healthcare professionals to reduce antibiotic prescriptions and provide education for people whose conditions are likely to resolve without antibiotics.
  2. "Prescribers in primary care can use back-up (delayed) antimicrobial prescribing when there is clinical uncertainty about whether a condition is self-limiting or is likely to deteriorate." Delayed prescribing ensures access without necessitating an additional appointment, but also reduces unnecessary use.
  3. "People prescribed an antimicrobial have the clinical indication, dose and duration of treatment documented in their clinical record." This standard, evaluated by the number of patients for which this information is documented, will facilitate better follow-up care and the evaluation of appropriateness of prescribing.
  4. "People in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available." This standard aims to connect prescribing decisions with microbiological testing in order to reduce overall prescribing rates, and to enable clinicians to adjust treatments when initial ones are not effective.
  5. "Individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level." Data collection and feedback will take place to check adherence to local formularies, and provide feedback to ensure rational prescribing of antibiotics.
  6. "Prescribers in secondary and dental care use electronic prescribing systems that link indication with the antimicrobial prescription."
Meanwhile, researchers at the Imperial College London are initiating a project to understand whether reducing antibiotic use may lead to unintended consequences, such as a greater number of patients being admitted to hospitals with serious infections. The team will collect data from hospital admissions and general practice appointments, as well as mortality data. Using this information, the team will assess the effect of decreasing antibiotic prescriptions on serious infections and deaths. Professor Allison Holmes of Imperial College claims that this study is the first to ask this question. The project was commissioned and funded by the UK Department of Health Policy Research Programme.

9. Rwanda Medical Association, GSK, and Lancet Laboratories host workshop on AMR

Medical experts discussed the challenges of AMR in human health at a workshop in Kigali, Rwanda. Dr. Kayitesi Kayitenkore, the Rwanda Medical Association chairperson, described how poor or limited diagnostics lead to inappropriate prescribing and the continued rise of AMR. She emphasized that continuous culture tests are needed to assess drug resistance. Dr. Kizito Kayumba, a GSK epidemiologist, focused on how poor sanitary and cultural practices in communities expose people to resistant pathogens, which in turn increases the burden of importing costly drugs. Dr. Ben Prinsloo, a pathologist from Lancet Laboratories in South Africa, attributed increasing AMR to the use of antibiotics in agriculture. He also warned against unnecessary post-surgery prescription of antibiotics, which increases resistance and limits patients and doctors to using more costly drugs instead. Dr. Ahmed Kalebi, a pathologist from Kenya, argued that the largest bottleneck in addressing AMR in Africa is poor coordination between doctors and laboratory technicians, leading to incorrect diagnoses. An editorial by the New Times, a Rwandan newspaper, called for raising awareness among pharmacists and the public about how self-medication with over-the-counter antibiotics is a significant driver of AMR. The workshop was co-hosted by the Rwanda Medical Association, pharmaceutical company GlaxoSmithKline, and the private laboratory service provider Lancet Laboratories. Founded in South Africa, Lancet Laboratories is the largest laboratory service provider in East Africa and opened a facility in Rwanda in December 2015.

10. Whole-Genome Sequencing and web-based data visualization to monitor MRSA

Aanensen et al.Researchers at the Imperial College London Center for Genomic Pathogen Surveillance and the Wellcome Trust Sanger Institute has demonstrated the potential of monitoring antibiotic-resistant infections by visualizing whole-genome sequencing data using Microreact, a web-based interactive mapping tool. These techniques can be applied to epidemiological surveillance, and outbreak prevention and response. The interactive MRSA mapping is available on the Microreact website, and their study is published in mBio. To generate the mapping, the researchers worked with a network of 450 hospitals in 26 countries to collect nearly 3000 MRSA clinical isolates over a 6 month period. They conducted whole-genome sequencing on a sample of 308 isolates of staphylococcus aureus, 40% of which were methicillin-resistant. These data were then matched against European epidemiological and resistance data. Their analysis demonstrated that "high-risk clones" (bacterial lineages that pose a serious public health risk) can be identified using population-level properties such as clonal relatedness, abundance, and spatial structuring. Inferring virulence and resistance properties based on the genetic resistance elements contributed to the identification process. In fact, web-based prediction of antibiotic resistance profiles was at least as reliable as conventional susceptibility testing carried out in laboratories. There was agreement between the predictions and conventional testing in 98.6% or 5213 out of 5288 predictions made (from the 308 isolates as tested against 16 antibiotics).

The paper discusses the insights attainable from Microreact. In one example, their analyses suggest that the border between Germany and the Czech Republic may be a barrier to healthcare referral practices, thereby facilitating the spread of MRSA of the clonal complex designated as CC5 (a group of bacterial strains with a recent common ancestor). In another example, the researchers analyzed clonal complex CC22, which contains MRSA-15, the most abundant and fastest growing healthcare-associated MRSA clone in Europe. Their analysis found that 14 of the 31 MRSA-15 isolates originated in the UK, 11 from Germany, and 7 from Portugal. The Microreact platform suggests that UK was the likely origin for MRSA-15, with subsequent introductions into Germany and Portugal. This corroborates a previous characterization of the strain.

The authors suggest that whole-genome sequencing will be "inevitably" widely implemented given the decreasing cost of sequencing entire bacterial genomes and the rise of powerful bioinformatic tools. Through this project, the researchers have presented potential techniques to identify and communicate resistance hotspots to guide clinical decisionmaking and public health responses to outbreaks. This project provides a potential framework for integrating whole-genome sequencing data into routine pathogen surveillance. Large-scale routine surveys can provide the population context, and open-access bioinformatic tools can provide an infrastructure for combining and comparing independently generated data with publicly available datasets.

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The ARC Newsletter captures key meetings and developments, as well as news and resources, on antibiotic resistance for Coalition members and partners. This newsletter is prepared and published through ReAct North America/Strategic Policy Program at Johns Hopkins Bloomberg School of Public Health. The ARC Declaration on Antibiotic Resistance can be found here. Please share items for consideration for inclusion in future newsletters by writing to Reshma Ramachandran at rramach9@jhu.edu.