August 1, 2000 - Draft Public Health Action Plan to Combat Antimicrobial Resistance

The American Society for Microbiology (ASM) is pleased to comment on the Draft Public Health Action Plan to Combat Antimicrobial Resistance (Action Plan) which provides a blueprint for comprehensive and coordinated efforts by federal agencies in addressing the emergence of antimicrobial resistance. Representing over 42,000 members, the ASM is concerned about the complex issue of antimicrobial resistance and brings a broad spectrum of expertise to bear on this multi-faceted public health challenge.

General Comments

ASM finds the draft Action Plan to be comprehensive in scope and a laudable effort to deal with a topic of steadily increasing clinical and public health importance. The Action Plan is particularly welcome for bringing so many different component programs within the federal government into a systematic and coherent framework. In this regard, however, ASM urges federal officials to identify priorities within the overall Action Plan on which to focus during the early stages of its implementation, rather than to begin with a diffuse effort that would likely prove difficult to sustain and thus might unfairly risk sacrificing important elements within the overall undertaking.

ASM looks forward to the continuation of these efforts at the next and equally important essential stage involving cooperation and coordination of such programs at the international level. ASM believes that the complex problems associated with antimicrobial resistance simply cannot be fully addressed without a strong international component. It will be critical to engage fully both public and private sector international organizations in this next phase, including the World Health Organization; the United Nations Educational, Scientific, and Cultural Organization; the Pan American Health Organization; and private-sector organizations and relevant agricultural and human health industries representing professionals with special expertise for dealing with these problems.

Even as the Action Plan process needs to move toward the next international stage, however, ASM is concerned that federal-level coordination efforts are still not being optimized and are lacking in transparency. Although the Action Plan states that certain of its recommended components already are being implemented, so far it is proving difficult for members of the scientific community and the greater public to determine the actual status of those initiatives. Thus, further steps are needed to ensure transparency to the full-range and status of multi-agency federal activities and programs that are part of the overall Action Plan.

As specific components of the Action Plan are being implemented, it also will be critical to sustain several of its broader crosscutting features. They include: I) educating clinicians, allied health professionals, and health maintenance organization (HMOs) as well as the general public on these issues; II) recognizing that antimicrobial resistance involves complex interactions among plant, animal, and human pathogens as well as other non-pathogenic microbial species, all of which contribute to these problems within agriculture and in other complex ecological systems; and III) striving for a fully integrated approach to addressing these problems, including industry in this effort.

A great deal of the requisite educational effort needs to be directed at physicians and their patients, who should be urged to move toward diagnoses that are ever more precise and to uses of antimicrobials that are appropriate for the infection. We recognize that before this can be accomplished successfully, new rapid, reliable diagnostic tests for identifying specific infectious causes of illness must be developed and funding issues related to the development and use of these tests must be addressed. HMOs and other health insurance entities represent a critically important target of educational efforts, because their policies, when focused on short-term cost-cutting measures that emphasize symptom-based treatments, can undermine progress toward pathogen-specific diagnosis and treatment. At a more basic level, individual clinicians and HMOs should be encouraged to develop programs whereby patients taking antibiotics routinely receive reminders to complete their course of such drugs and to follow other measures to discourage the development of antibiotic resistance.

Comments on Surveillance

Monitoring and surveillance programs certainly deserve a prominent place in the Action Plan. However, ASM is concerned that the plan may place undue emphasis on development of elaborate, potentially costly new efforts, with new methodologies. A great deal of data already has been collected to document the development of antibiotic resistance.

Hence, the focus of the monitoring efforts called for in the Action Plan should be sharpened, with special attention paid to those types of resistance having the most important clinical impacts. Moreover, resources should be directed to monitoring those situations where the relationship between antibiotic usage and the development of resistance at the population level can be most clearly delineated.

Attention and resources may also be better directed to evaluating, integrating, and using those data that already are available, and to developing monitoring procedures and prudent-use guidelines to apply to new antimicrobials as they become available. In this regard, care should be taken to make better use of data available from relatively under-utilized national resources, including information being compiled in Department of Veterans Affairs databases. In addition, routine environmental surveillance should go beyond the clinical environment to include monitoring levels of antibiotics and their residues in a variety of non-clinical environments, including within foods; monitoring not only of agricultural activities involving both plants and animals but also of antibiotic usage patterns for treating companion animals; assessing the influence of non-pathogens found in natural ecological settings; and investigating through monitoring other potential reservoirs for antibiotic resistant microorganisms. We recognize that these activities would necessitate a major undertaking, but recommend that they receive attention.

Comments on Prevention and Control

ASM believes that resources need to be made available to hospitals for them to maintain infection control programs in the face of policies that now make it increasingly difficulty to obtain reimbursement for such services. Efforts also are needed to develop programs for controlling antibiotic resistant organisms in environmental reservoirs as well as for controlling the transmission of antibiotic resistance determinants among environmentally distributed microorganisms.

In addition, the Action Plan should not restrict its recommendations and scope to chemotherapeutic agents, but should also promote the prudent use of germicides, and studies about the effects of promiscuous use on the development of antibiotic resistance. The prudent use of environmentally safe germicides is also an important component of another important control and prevention measure, namely the public-educational campaign to encourage hand washing.

Comments on Research and Development

ASM strongly recommends that the Action Plan explicitly delineate steps for increasing and strengthening research programs and scientific expertise in this area. The ASM Task Force Report on Antibiotic Resistance and other federal advisory panels have emphasized the critical need for increasing basic, clinical and epidemiological research in the area of drug resistance. Although the draft Action Plan outlines many of the research topics, including microbial physiology, genetics, ecology and mechanisms of resistance, that properly fall within this subject area, it says little about appropriate support levels or plans for funding and expanding the scientific research infrastructure. ASM believes that this lapse needs to be directly addressed and, if it is not, recommends an external review of federal research agency efforts in this research area. Identifying and prioritizing needs and opportunities in the field of antibiotic research, allocating new resources and establishing a government-wide external program of review should receive high priority.

Important components of the broader effort to curb antibiotic resistance include research to develop better, faster diagnostic methods for infectious diseases and also research to develop-followed by public health campaigns to foster the appropriate use of-vaccines for preventing a range of infectious diseases, whose treatment might otherwise require wider use of antibiotics.

Attention should be paid to encouraging the development of particularly novel and innovative classes of antimicrobial products. Novel therapeutic products should have prudent usage guidelines and be monitored for development of resistance.

The ASM is concerned about new funding resources to implement the Action Plan and urges the interagency task force to develop the specific funding increases that will be needed for full implementation and areas of funding priority. The ASM offers its assistance to the interagency task force as the Action Plan is further developed and implemented.