A program to monitor antimicrobial
resistance in humans and animals
Antimicrobial resistance in foodborne
pathogens is an important health issue. Levels of resistance
are increasing and there is much we do not know about this problem.
We need more information to help us understand this problem
and the very real threat it presents to public health. There
is a program in place to monitor changes in resistance of bacteria
to the antimicrobial drugs used to treat animals and humans.
That program is the National Antimicrobial Resistance Monitoring
System (NARMS).
What is an antimicrobial?
Antibiotics and other antimicrobial drugs enable doctors to
treat bacterial illnesses such as ear infections and strep throat
in humans. Antimicrobial drugs are also used to treat or prevent
illness caused by bacteria in humans or animals. They work by
killing or inhibiting the growth of bacteria.
What are antimicrobial-resistant bacteria?
The use of antibiotics may eliminate susceptible bacteria,
leaving resistant bacteria behind. If those resistant bacteria
spread, they can cause an infection that may not respond to
the usual antibiotics, or may require an increased dose or a
longer treatment time. As a result, people or animals infected
with resistant bacteria may be sick for a longer time than if
they had an infection caused by bacteria that were easily treatable
with antibiotics.
How does resistance develop?
The increase in bacterial resistance to antimicrobial drugs
is a natural phenomenon -- an outcome of evolution. Any population
of organisms, including bacteria, naturally includes variants
with unusual traits. In this case, some bacteria have the ability
to fend off the action of an antimicrobial. The use of antimicrobial
drugs in humans and animals over the past 50 years has inadvertently
accelerated the development of resistance because resistant
bacteria are more likely to survive treatment with antimicrobial
drugs. Once it has been introduced into an environment, resistance
may be spread to other microbes.
Food animals can carry organisms that can make people sick,
but may not necessarily make the animals sick. For example,
Salmonella, Campylobacter, and E. coli
O157 are common bacteria found in the intestines of various
food animals. These bacteria might not cause disease in the
animal, but, all three bacteria can cause foodborne illness
in humans. These bacteria might develop resistance when exposed
to antibiotics given to the animal. These resistant bacteria
can contaminate meat at slaughter and then infect humans who
eat the meat, particularly if it is undercooked or cross-contaminated
after cooking.
Evidence of increasing resistance to antimicrobial drug treatment
in bacteria that infect humans has raised questions about the
role that antimicrobial drug use in food animals plays in the
emergence of antimicrobial drug resistant bacteria. The link
between antimicrobial resistance in foodborne bacteria that
cause disease (which are considered human pathogenic bacteria)
and use of antimicrobials in food animals has been reported
in a number of studies. For foodborne pathogens, particularly
Salmonella that are rarely transferred from person
to person in the United States, food (such as meat or eggs)
from animals is considered the most likely source of human exposure
to resistant bacteria.
How we monitor
We need to carefully watch for evidence of changes in levels
of resistance to antibiotics because increases in resistance
can make it more difficult to treat diseases caused by these
bacteria. The NARMS program allows the Food and Drug Administration
(FDA) to monitor resistance to antimicrobial drugs used in humans
and food animals. NARMS combines the activities of FDA, the
Centers for Disease Control and Prevention (CDC), and the U.S.
Department of Agriculture (USDA) to create a nationwide monitoring
system. As a part of NARMS, isolates of foodborne bacteria including
E. coli, Salmonella, Enterococci, and Campylobacter
from humans, animals, and retail meats are collected and tested
to determine changes in susceptibility to antimicrobial drugs.
Each year, samples are taken and tested to determine if there
have been changes over time in the resistance of certain enteric
(gut) bacteria to selected antimicrobial drugs. The antimicrobial
drugs tested are selected based on their importance in human
and animal medicine. The human samples are collected from sick
people. The animal samples are gathered from healthy farm animals,
animal clinical specimens, carcasses of food animals at slaughter,
ground products at processing plants. The retail meat samples
are collected from grocery stores and shops that sell meat to
the public.
Where are the samples tested?
The human-origin isolates are sent to the CDC in Atlanta, GA,
by state and local health departments in all 50 states.
Animal-origin isolates are collected from sites across the
U.S. and sent to the Antimicrobial Resistance Research Unit
(ARRU) of USDA in Athens, GA, for susceptibility testing. Animal
isolates come from federally inspected slaughter and processing
facilities, USDA’s animal health monitoring studies on
farms, and veterinary diagnostic laboratories.
The NARMS program also includes a retail program (the Iowa
Retail Meat Pilot Survey) that conducts susceptibility testing
of enteric bacteria isolated from retail meat samples collected
from grocery stores in states participating in the CDC FoodNet
program (a program that shares information electronically with
researchers and public health officials across the country)
on resistant bacteria isolated from people who got sick from
the food they ate). The FDA Center for Veterinary Medicine (CVM)
Office of Research Laboratory in Laurel, MD, conducts the susceptibility
testing of these samples.
CDC, USDA, and FDA test Salmonella, E. coli,
Campylobacter, Entercocci, and other bacteria for susceptibility
to the same group of antimicrobial drugs. The results of these
tests are compared with results from previous years to look
for changes in resistance patterns of the bacteria to these
drugs. NARMS reports are published annually. NARMS
data can be accessed through links on the CVM home page.
Human data is located
on the CDC web site. Animal
data is on the USDA web site.
Public health officials, animal producers, drug manufacturers,
physicians, and veterinarians can use the information from NARMS
to control and prevent harm from the use of antimicrobial drugs
in food animals.
NARMS Methods
Human data: State public health laboratories
systematically select every 20th non-Typhi Salmonella
isolate, Shigella, and E. coli O157:H7 submitted to their laboratory
and send the isolates to CDC. All Salmonella Typhi,
Listeria monocytogenes, and non-cholerae Vibrio
isolates are forwarded to CDC.
Additionally, health departments that participate in the FoodNet
Program submit one Campylobacter isolate each week
to the CDC Foodborne and Diarrheal Diseases Laboratory for susceptibility
testing. The number of states that participate in this program
continues to increase as more health departments join the FoodNet
Program. The FoodNet Web
Site contains a listing of current participants.
The antimicrobial susceptibility testing results are sent from
the CDC laboratory to NARMS epidemiologists at CDC, where data
are analyzed.
Animal data: The USDA ARRU laboratory receives
Salmonella, Campylobacter, E. coli
and Enterococci isolates from animals for antimicrobial susceptibility
testing. The Athens laboratory receives isolates from the sources
described in “How We Monitor.”
Samples of water used to rinse poultry carcasses at slaughter
plants are sent to ARRU from the Food Safety Inspection Service
laboratories for culture, isolation, and susceptibility testing
of Campylobacter, E. coli, and Enterococci
organisms. Salmonella isolates are received from USDA
programs and veterinary diagnostic laboratories. E. coli
and Enterococci also come from samples collected on farms.
Retail data: The Iowa Retail Meat
Pilot Survey included collection and antimicrobial
susceptibility testing of bacterial isolates from retail meats
purchased from Iowa retail grocery stores. This study was conducted
to figure out the best way to collect and test samples from
retail stores. Samples of ground beef, ground turkey, pork chops,
and chicken breasts were tested for Salmonella, Campylobacter,
E. coli, and Enterococci. The bacteria were then tested
for resistance to antimicrobials. The FoodNet Retail
Meat Surveillance was set up using the Iowa study as
a model. Samples of ground beef, ground turkey, pork chops and
chicken breasts are being collected from grocery stores in participating
FoodNet States. Enteric bacterial isolates from these samples
are being sent from the FoodNet laboratories to CVM Office of
Research for antimicrobial drug susceptibility testing of Salmonella,
Campylobacter, E. coli, and Enterococci.
The NARMS program is designed so that the same testing methods
are used in the human, animal, and retail programs. For all
isolates, testing bacteria for susceptibility to antimicrobials
currently involves the determination of the minimum inhibitory
concentration (MIC) for a panel of selected antimicrobial agents.
The MIC is the lowest concentration of a drug that will slow
or stop the growth of the bacteria being tested. The higher
the MIC number, the greater resistance the bacteria have. These
antimicrobial drugs are evaluated each year by FDA, CDC, and
USDA for their continued importance in human and animal medicine.
Based on these evaluations, some drugs may be removed and others
added in their place. Standardized national guidelines for conducting
laboratory studies are followed, when possible, throughout the
testing procedure.
What Can NARMS Tell Us?
Data collected by NARMS can provide useful information about
patterns of emerging resistance, which in turn can help guide
treatment decisions in human and veterinary medicine. NARMS
data are an asset to outbreak investigations. Antimicrobial
resistance patterns are useful in identifying the source and
magnitude of resistance. Antimicrobial resistance data from
humans and animals are important for the development of public
health recommendations for the use of drugs in humans and food
animals.
What Else is Being Done?
FDA's goal is to protect the public health by ensuring that
significant human antimicrobial therapies are not lost due to
use of antimicrobial drugs in food-producing animals, while
providing for the safe use of antimicrobial drugs in food-producing
animals.
FDA's Center for Veterinary Medicine is working to develop
a comprehensive approach to combat the complex problem of antimicrobial
resistance. Draft Guidance for Industry #152, titled "Evaluating
the Safety of Antimicrobial New Animal Drugs with Regard to
Their Microbiological Effects on Bacteria of Human Health Concern,"
represents the Agency's current thinking and discusses a suggested
approach for assessing the safety of antimicrobial new animal
drugs with regard to their microbiological effects on bacteria
of human health concern. (See www.fda.gov/cvm/guidance/published.htm#published_3)
This guidance document is an evolution of several previous
documents including the concept paper titled "Proposed
Framework for Evaluating and Assuring the Human Safety of the
Microbial Effects of Antimicrobial New Animal Drugs Intended
for Use in Food-Producing Animals" (Framework Document).
The Framework Document was published by the Agency in January
1999 and discussed possible strategies for managing the potential
risks associated with the use of antimicrobial drugs in food-producing
animals. Please refer to the FDA CVM
web site for the latest information on publications to implement
the Framework Document.
In addition to the work being done by CVM, the American Veterinary
Medical Association (AVMA), veterinary practitioner groups,
and producer groups have developed prudent and judicious antimicrobial
drug use programs to help veterinarians and producers make safe
and sound decisions about the use of these products in animal
production. Brochures and videotapes on the appropriate use
of antimicrobial drugs were developed by CVM in collaboration
with the AVMA and other groups. They are posted on the CVM website
and copies are available from CVM upon request. The CDC, in
collaboration with the American Medical Association (AMA) and
medical specialty groups, has developed prudent use guidelines
for physicians. Medical and veterinary school curricula are
also the focus of educational efforts to promote the appropriate
use of antimicrobial drugs. NARMS isolates are also used in
research on the molecular determinants of resistance.
Using NARMS as a template, CVM and Mexico are working together
on a cooperative project known as “ResistVet”
to conduct monitoring for trends in antimicrobial resistance
in humans, animals, and retail foods at four sites in Mexico.
To further support antimicrobial resistance monitoring in Mexico,
CVM collaborated with the World Health Organization to conduct
a training course in 2001 on the surveillance of Salmonella
and antimicrobial resistance in foodborne pathogens. The training
took place at a participating ResistVet
site in Mexico.
For additional information on the NARMS program, contact Dr.
Marcia Headrick, FDA CVM NARMS Coordinator, at mheadric@cvm.fda.gov
or (706)546-3689.
Revised and Updated May 2003
Web page updated by swd,October
10, 2003, 5:30 PM ET
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