Building a public national system
for antimicrobial resistance
surveillance in Argentina
“THE MICROBIAL
CHALLENGE – AN EMERGING THREAT TO
HUMAN / ANIMAL HEALTH”
Marcelo Galas
Buenos Aires
Argentina
República Argentina
Towards a Global Research Agenda for AMR
OBJECTIVES 3 April 2014 |Brussels|Belgium
Systemic new antibiotics aproved by fda between 1983-2012
Boucher H. Clinical Infectious Diseases 2013;56(12):1685–94
Increasing of CIP Non Susceptibility in
NG between 1995 and 2008
0,02,04,06,08,010,012,014,016,018,020,022,024,0
Iso
late
, %
Resistance Intermediate
In 1993, CIP was reccomended as first line drug to treat gonorrhoea by the
Ministry of Health of Argetnina and begun the resistance monitoring
Between 1993 and 1995, the isolates were highly susceptibles to this drug
In 1996 was detected the first strain with reduced susceptibility in Buenos Aires
National Network for Surveillance of STI. Dr P. Galarza
Antimicrobial resistance In ACI for commonly
used antibiotics between 2000 and 2011
Nosocomial acquired isolates. 89 hospitals. N=1411
Dissemination of carbapenemases (oxas) responsible for XDR
“To obtain reliable, appropriate and reproducible microbiological data, to
be used for the improvement of patient care and the strengthening of the surveillance program through the
implementation of sustainable quality guaranty programs”
Mission of Argentinian Network for Antimicrobial Resistance Surveillance
O
B
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Surveillance of Antimicrobial Resistance.
WHONET – Argentina Network
Orientation of empirical therapy
Collaboration in prevention, detection and control of
Health care asociated infections
Local, Regional and National strategies for
antimicrobial agents use
Early detection of new resistance mechanisms and
dissemination control
Design and evaluation of strategies for the antimicrobial
resistance control
Strengthening of Provincial and Regional Reference
Centers for AR surveillance and QC for peripherals Hosp
20
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Laboratories Members 1/3 HOSPITAL FOCAL POINT
HOSPITAL HIGA PRESIDENTE PERON MARIA ADELAIDA ROSSETTI
HOSPITAL ZONAL MATERNO INFANTIL ARGENTINA DIEGO ANA MOLA
HOSPITAL HIGA "DR JOSE PENNA" MARIA LUZ BENVENUTTI - MABEL RIZZO
HOSPITAL LEONIDAS LUCERO DINA PEDERSEN
HIGA VICENTE LOPEZ Y PLANES HEBE GULLO
HOSPITAL NACIONAL PROF.DR. ALEJANDRO POSADAS ADRIANA DI BELLA y ADRIANA FERNANDEZ LAUSI
HOSPITAL GOBERNADOR MERCANTE SANDRA KARINA BOGNANI
HIGA "DR. A. PIÑEYRO" - JUNIN MONICA MACHAIN
HOSPITAL DE AGUDOS SOR MARIA LUDOVICA CECILIA VESCINA - MARISA BETTIOL
HOSPITAL SAN JUAN DE DIOS ANDREA SILVIA PACHA - RICARDO CABRERA
HOSPITAL INTERZONAL GENERAL DE AGUDOS “EVITA” ANA TOGNERI
HOSPITAL DR. CARLOS BOCALANDRO NORY CERDA - CAROLINA VACCINO
HOSPITAL PRIVADO DE LA COMUNIDAD VALLEJO MONICA ALICIA
INSTITUTO NACIONAL DE EPIDEMIOLOGÍA JUAN JARA SILVINA LAVAYEN
HOSPITAL AUSTRAL VIVIANA VILCHES
HOSPITAL INTERZONAL DE AGUDOS EVA PERON MARISA ALMUZARA - ALICIA TUDURI
HOSPITAL SANTAMARINA MONICA SPARO
HOSPITAL MUNICIPAL "DR. PEDRO T. ORELLANA" MARIA CECILIA BARRACCHIA
HOSPITAL ANTONIO A. CETRANGOLO ANA SANGOY - LAURA BIGLIERI
HOSPITAL ZONAL DE AGUDOS VIRGEN DEL CARMEN ADRIANA MELO
BUENOS AIRES
HOSPITAL FOCAL POINT
FLENI NORA ORELLANA
HOSPITAL DE CLINICAS "JOSE DE SAN MARTIN" ANGELA FAMIGLIETTI - CARLOS VAY
HOSPITAL DE INFECCIOSAS FRANCISCO JAVIER MUÑIZ MIRIAM MORTARINI - RAQUEL ROLLET
HOSPITAL DE PEDIATRIA S.A.M.I.C. PROF.DR. JUAN GARRAHANCLAUDIA HERNANDEZ
HOSPITAL DONACION F. SANTOJANNI CLAUDIA ALFONSO - CECILIA ORMAZABAL
HOSPITAL ELIZALDE ROXANA PEREDA
HOSPITAL FERNANDEZ LAURA ERRECALDE - SARA KAUFMAN
HOSPITAL GRAL. DE AGUDOS PARMENIO PIÑERO CELESTE LUCERO - FLAVIA AMALFA
HOSPITAL GRAL.DE AGUDOS DR.COSME ARGERICH NORA ALEJANDRA GOMEZ
HOSPITAL NIÑOS DR.RICARDO GUTIERREZ MIRIAM VAZQUEZ - ESTEFANIA BIONDI
HOSPITAL UNIVERSITARIO FUNDACIÓN FAVALORO PATRICIA ANDRES - ANALIA FERNANDEZ
CAPITAL FEDERAL
HOSPITAL FOCAL POINT
HOSPITAL DE NIÑOS DE CATAMARCA SILVIA MARIELA FARFAN
HOSPITAL INTERZONAL SAN JUAN BAUTISTA VIVIANA DEL VALLE DAVID
CATAMARCA
HOSPITAL FOCAL POINT
HOSPITAL 4 DE JUNIO - DR. RAMON CARRILLO NORMA ESTHER CECH
HOSPITAL "DR JULIO PERRANDO" ISABEL ANA MARQUES
HOSPITAL PEDIATRICO "AVELINO LORENZO CASTELLAN" ANA MARIA ZALOFF DAKOF
CHACO
HOSPITAL FOCAL POINT
HOSPITAL REG "DR. SANGUINETTI" COMODORO RIVADAVIA MARCIA BERNALDO DE QUIROS - SUSANA ORTIZ
HOSPITAL ZONAL ESQUEL OMAR DAHER
CHUBUT
20
11
2 3
2
8
2
3
2
2
2
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3
4
2
2
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Laboratories Members 2/3 HOSPITAL FOCAL POINT
CLINICA PRIVADA "REINA FABIOLA" MARINA BOTTIGLIERI
CLINICA PRIVADA VELEZ SARSFIELD LIDIA WOLFF DE JAKOB
HOSPITAL DE NIÑOS DE LA SANTISIMA TRINIDAD DE CORDOBAPATRICIA MONTANARO - PAREDES MARISA
HOSPITAL DOMINGO FUNES LILIA CAMISASSA
HOSPITAL GUILLERMO RAWSON ANA MARIA LITTVIK - TERESA NILDA LOPEZ
HOSPITAL INFANTIL MUNICIPAL DE CORDOBA LILIANA LORENA GONZALEZ
HOSPITAL PEDIATRICO DEL NIÑO JESUS PAULO CORTES - PATRICIA GONZALEZ
HOSPITAL PASTEUR CLAUDIA AIMARETTO DE COSTABELLA
CORDOBA
HOSPITAL FOCAL POINT
HOSPITAL ANGELA I. LLANO ANA MARIA PATO
HOSPITAL JUAN PABLO II SANDRA MARISA PIERLORENZI
CORRIENTES
HOSPITAL FOCAL POINT
HOSPITAL MASVERNAT NORMA YOYA - MARIA OFELIA MOULINS
HOSPITAL MATERNO INFANTIL SAN ROQUE MARIA SILVIA DIAZ - LORENA SOLEDAD DEL BARCO
HOSPITAL SAN MARTIN FRANCISCO SALAMONE
ENTRE RIOS
HOSPITAL FOCAL POINT
HOSPITAL CENTRAL DE FORMOSA NANCY PEREYRA
HOSPITAL DE LA MADRE Y EL NIÑO MARIA SILVANA VIVALDO
FORMOSA
HOSPITAL FOCAL POINT
HOSPITAL DE NIÑOS DR. HECTOR QUINTANA MARCELO TOFFOLI
HOSPITAL PABLO SORIA MARIA SILVIA WEIBEL, SILVIA GROSSO
JUJUY
HOSPITAL FOCAL POINT
ESTABLECIMIENTO ASISTENCIAL GOBERNADOR CENTENO ADRIANA PEREYRA
HOSPITAL LUCIO MOLAS GLADYS MARGARITA ALMADA
LA PAMPA
HOSPITAL FOCAL POINT
HOSPITAL DE LA MADRE Y EL NIÑO KARINA CONTRERAS
HOSPITAL REGIONAL "DR ENRIQUE VERA BARROS" SONIA FLORES DE GALIMBERTI
LA RIOJA
HOSPITAL FOCAL POINT
HOSPITAL CENTRAL DE MENDOZA LORENA CONTRERAS - MIGUEL ANGEL DISTEFANO
HOSPITAL NOTTI BEATRIZ CRISTINA GARCIA
HOSPITAL TEODORO SCHESTAKOW ADRIANA ACOSTA - ADA ZANUSO
MENDOZA
HOSPITAL FOCAL POINT
HOSPITAL SAMIC ELDORADO MISIONES ANA MARÍA MIRANDA
HOSPITAL DE NIVEL III OBERÁ CRISTINA ALICIA GONZALEZ - ERICA GERLACH
HOSPITAL DR. RAMON MADARIAGA VIVIANA CLAUDIA VILLALBA - GLADYS BELLO VELAZQUEZ
HOSPITAL PROVINCIAL DE PEDIATRIA "Dr. Fernando Barreyro". MARTHA HELENA VON SPECHT
MISIONES
HOSPITAL FOCAL POINT
HTAL DE JUNÍN DE LOS ANDES ABEL ZURSCHMITTEN
HOSPITAL HELLER HERMAN FRANCISCO SAUER
HOSPITAL PROVINCIAL NEUQUEN "DR. CASTRO RENDON" MARIA ROSA NUNEZ - MARIA MARTA SCHINCHIRIMINI
NEUQUEN
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3
4
2
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7
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Laboratories Members 3/3 HOSPITAL FOCAL POINT
HOSPITAL ZONAL BARILOCHE NESTOR BLAZQUEZ, SABRINA DE BUNDER
HOSPITAL AREA CIPOLLETTI MARIELA RONCALLO -CRISTINA CARRANZA
HOSPITAL GENERAL ROCA DANIELA ALEJANDRA DURANY - GONZALO CROMBAS
HOSPITAL ARTEMIDES ZATTI GRACIELA STAFFORINI
RIO NEGRO
HOSPITAL FOCAL POINT
HOSPITAL SAN VICENTE DE PAUL SILVIA GRACIELA AMADOR
HOSPITAL PUBLICO MATERNO INFANTIL ANA BEREJNOI - NORMA SPONTON
SALTA
HOSPITAL FOCAL POINT
HOSPITAL MARCIAL QUIROGA HUGO CASTRO - NANCY RUTH VEGA
HOSPITAL GUILLERMO RAWSON ROBERTO NAVARRO
SAN JUAN
HOSPITAL FOCAL POINT
POLICLINICO CENTRAL DE SAN LUIS HUGO ARMANDO RIGO
POLICLINICO REGIONAL DE VILLA MERCEDES CARINA CHIRINO
SAN LUIS
HOSPITAL FOCAL POINT
HOSPITAL ZONAL CALETA OLIVIA "PADRE TARDIVO" GUILLERMO RAMÓN GARCÍA - JOSEFINA VILLEGAS
HOSPITAL REGIONAL RIO GALLEGOS WILMA KRAUSE - ALEJANDRA VIVIANA VARGAS
SANTA CRUZ
HOSPITAL FOCAL POINT
ABC HOSPITAL ESPAÑOL DE ROSARIO NOEMI BORDA - RODOLFO NOTARIO
CEMAR MONICA BORGO - STELLA MURA
FACULTAD BIOQUIMICA ROSARIO, HTAL CENTENARIO PATRICIA MARCHIARO - EMA SUTICH
HOSPITAL DE NIÑOS V. J. VILELA ADRIANA ERNST -ANDREA BADANO
HOSPITAL ROQUE SAENZ PENA GRACIELA ARCIERO - ADRIANA DI COSCO
HOSPITAL DE NIÑOS "DR. O. ALLASIA" MARIA ROSA BARONI
HOSPITAL DR. JOSE MARIA CULLEN EMILCE MENDEZ - ANALIA MOLLERACH
SANTA FE
HOSPITAL FOCAL POINT
HOSPITAL DE NIÑOS EVA PERON MARIA ELISA PAVON
HTAL. REGIONAL "DR. RAMON CARRILLO" ANA MARIA NANNI - MARIANA CRAGNOLINO
SANTIAGO DEL ESTERO
HOSPITAL FOCAL POINT
HOSPITAL REGIONAL RIO GRANDE MARCELA FABIANA VARGAS
HOSPITAL REGIONAL DE USHUAIA MANUEL FABIAN BOUTUREIRA
TIERRA DEL FUEGO
HOSPITAL FOCAL POINT
CENTRO DE MICROBIOLOGIA MEDICA MARIA ANGELA JURE
HOSPITAL DEL NIÑO JESUS ANA CRISTINA VILLAGRA - JOSE DANIEL ASSA
HOSPITAL PADILLA AMALIA DEL VALLE AMILAGA
HOSPITAL AVELLANEDA NORMA MERCEDES CUDMANI
TUCUMAN
0
50
100
150
200
250
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Isolates by year (thousands)
años
Evolution of WHONET – Argentina Network
1992 – 2013
0
10
20
30
40
50
60
70
80
90
100N Hosp
17% have VITEK or PHOENIX and account for the 40 % of isolates collected
Representative and stable network
Agreed common protocol
WHONET Argentina
Network
characteristics
and mode of
operation
Salmonella sp, Shigella spp
Antibiograma de mínima sólo para diarreas (una placa)
1. Ampicilina
2. Trimetoprima /sulfametoxazol
3. Ciprofloxacina1
4. Cefpodoxima2,3
5. Ac. Nalidíxico4
6. Fosfomicina 7. Cloranfenicol (sólo para Salmonella) 7’. Nitrofurantoína (sólo para Shigella)
Representative and stable network
Standardized methodology (CLSI)
Internal and external Quality Control
WHONET Argentina
Network
characteristics
and mode of
operation
Agreed common protocol
INTERNAL QUALITY CONTROL
Susceptibility Test
Standards ATCC:
E. coli ATCC ® 25922
E. coli ATCC ® 35218
P. aeruginosa ATCC ® 27853
S. aureus ATCC ® 25923
E. faecalis ATCC ® 29212
IDEAL WEEKLY
ACEPTABLE EACH TWO WEEK
Standards ATCC
K. pneumoniae ATCC ® 700603
S. aureus ATCC ® 43300
E. faecalis ATCC ® 51299
H. influenzae ATCC ® 49247
H. influenzae ATCC ® 49766
S. pneumoniae ATCC ® 49619
EACH TIME THE TEST IS PERFORMED
Standards ATCC K. pneumoniae ATCC ® 700603
H. Influenzae ATCC ® 10211
EACH TIME A NEW BACH OF DISKS IS MADE
(C3G+CLAV) OR LOT OF HTM IS PREPARED
Representative and stable network
Standardized methodology (CLSI)
Data dissemination
Alerts Systems
Internal and external Quality Control
Building capacities and Research projects
Focus on Improving Clinical Diagnostic
WHONET Argentina
Network
characteristics
and mode of
operation
Agreed common protocol
Training strategies Building capacities
•Courses
•Workshops
•On web
•Bulletins
•Training in LNR
•Technical visits
- MIDAS Project – Early Outbreak detection. Modeling Infectious Diseases Agent
Study
- Characterization study of mechanisms of resistance to quinolones in ETB
- Molecular characterization of serotype 19A of Streptococcus pneumoniae
causing invasive infections in children from Arg between the 1994-2013 period
- Epidemiological and molecular characterization of carbapenemase producing
clinical isolates. This project collect isolates through the country
- Molecular characterization and virulence factors in methicillin resistant
Staphylococcus aureus isolates recovered in hospitals and in the community of
Argentina
- Characterization of Enterococci and Staphylococci clinical isolates recovered
from national hospitals
- Characterization of ESBLs in Enterobacteriaceae of Argentine
- Characterization of MLS resistance in Staphylococcus and β-haemolitic
Streptococcus
- Phenotipic and Molecular Characterization of resistance to ß-lactamic antibiotics
in clinical isolates of Enterobacteriaceae and no fermenters gram - bacilli in Arg
- Characterization of all the strains that the labs send us
Representative and stable network
Standardized methodology (CLSI)
Data dissemination
Alerts Systems
Internal and external Quality Control
Agreed common protocol
Building capacities and Research projects
Referential Diagnostic - Provincial Networks
Focus on Improving Clinical Diagnostic
Data collected monthly
WHONET Argentina
Network
characteristics
and mode of
operation
WHONET Argentina
Network
characteristics
and mode of
operation
Representative and stable network
Standardized methodology (CLSI)
Data dissemination
Alerts Systems
Internal and external Quality Control
Building capacities and Research projects
Referential Diagnostic - Provincial Networks
Focus on Improving Clinical Diagnostic
Data collected monthly
Software WHONET
Agreed common protocol
Structure of the Argentinian Laboratory Networks
System
Ministry of Health
Secretariat of Policies, Regulations and
Institutes
National Administration of Laboratories and
Health Institutes
National Institute of Infectious
Diseases
National Centre of Laboratory
Networks
Other Health
Institutes
Thematics Laboratory
Networks
(Reference Labs)
Provincial
Laboratory
Networks
Thematics
network member
(Hospitals)
Jurisdictional
Coordinators (Prov.
Ministry of Health)
Structure of the Argentinian Laboratory Networks
System
Jurisdictional
Coordinators (Prov.
Ministry of Health)
1 by Province
Coordinate all the public
Provincial Laboratories
Officials of the
Provincial Min of
Health
Administrative
functions
Articulate with national
Thematic Networks at
INEI and Centre of
Laboratory Networks
Structure of the Argentinian Laboratory Networks
System
Thematics
network member
(Hospitals)
More than 20 Thematic Networks
In charge of surveillance
of specific infectious
diseases
Clinical Microbiologist Technical
features
Articulate with national
Thematic Networks at INEI
and Jurisdictional
coordinators
WHONET-Argentina
Network is one of the
Surveillance Networks
Referential
functions
Operational Strategy of WHONET-Argentina
Network
Ministry of Health
Secretariat of Policies, Regulations and
Institutes
National Administration of Laboratories and
Health Institutes
National Institute of Infectious
Diseases
National Centre of Laboratory
Networks
Other Health
Institutes
Thematics Laboratory
Networks
(Reference Labs)
Provincial
Laboratory
Networks
Thematics
network member
(Hospitals)
Jurisdictional
Coordinators (Prov.
Ministry of Health)
ANTIMICROBIAL RESISTANCE SURVEILLANCE SYSTEM AND QUALITY
GUARANTY ACROSS THE COUNTRY
FLUX OF TRAINING, INFORMATION AND ADVICE
SECURE AND FAST
Flux of training, information and advice
secure and fast
i
i
i i
i
i i
LNR
Guaranty of Information
Reliable
Standardized
Homogeneous
= EQUITY
Clinical experience
Detection of Emergencies
Lab data
Failure Hypothesis
Characterization of resistance mechanism
Clinical correlation
Prevalence evaluation
Strategies of detection and report
Depth knowledge of circulating mechanisms
Identification of emergency of new profiles
WHONET-Argentina Network
National Reference Lab
funding
ANLIS/Min of Health
-100% Ref diagnostic -100% Standards supply -80% EQAS -50% of Research
-20% EQAS
-50% of Research
Private labs
Min Science and Techn
Clinical Labs -100% Clinical diagn Prov Min
of Health
-100% Activities
Jurisdictional Coordinators
Prov Min of Health
Canada
Surveillnace
American Antimicrobial Resistance Surveillance Network
Mexico
El Salvador
Guatemala
Nicaragua
Costa Rica
Cuba
Panama
Colombia
Venezuela
Ecuador
Perú
Bolivia
Chile
Paraguay
Brasil
Argentina
Canada Argentina
Reference Centers
For Quality Assurance
Coordinator
PAHO
Uruguay
Honduras
Rep. Dominicana
United States
2004
American networks for antimicrobial resistance surveillance by paho
•RELAVRA •SIREVA •GFN
•PULSENET Each one with its own EQAS