Antimicrobial Resistance (AMR) Systems Map · Antimicrobial Resistance (AMR) Systems Map. Overview of the factors influencing the . development of AMR and the interactions between

Antimicrobial Resistance (AMR) Systems MapOverview of the factors influencing the development of AMR and the interactions between them

Departmentfor EnvironmentFood & Rural Affairs

Departmentof Health

Public HealthEngland

VeterinaryMedicinesDirectorate

December 2014

2 Antimicrobial Resistance (AMR) Systems Map

Description

Purpose

The aim of producing an antimicrobial resistance (AMR) systems map is to provide a broad overview of the factors influencing the development of antimicrobial resistance and the interactions between them rather than detailed consideration of individual factors or infectious agents. We hope this will increase awareness of the diverse factors that influence AMR, aid research groups in identifying issues for investigation and aid in policy development.

We recognise that the map would benefit from further development. By publishing our first iteration of this map we hope that others can suggest improvements and/or develop particular aspects in more detail, either independently or in collaboration with us.

Description

The systems map provides a visual representation of the various influences on the development of AMR and the interaction between them. The aim is to provide a qualitative insight into the issues around antimicrobial resistance from a United Kingdom perspective. This includes both understanding the pathways that spread infection and resistance that could cause increased mortality and morbidity and identifying interventions (e.g. antibiotic stewardship programmes, behaviour change, infection control measures, etc.) that may impact on these pathways. This has been done by identifying reservoirs of infection and the pathways that link these reservoirs. By reservoirs of infection we mean any person, animal, plant, soil, substance or place in which an infectious agent normally lives and multiplies. The reservoir may harbour the infectious agent without injury to itself and serves as a source from which other individuals can be infected.

Please note that the map adopts a generic approach; it does not represent pathways for a particular infectious agent. The particular pathways which are applicable will depend on the infectious agent. There is no attempt, at this stage, to identify the relative importance of different pathways or prioritise the interventions. Interventions will require investigation of their impact, associated risk:benefit, and cost effectiveness. The size of boxes in the map does not reflect scale or significance.

Structure of the map and sub maps

A top level map shows the high level pathways that infections may take between animals, the environment and humans. High level interventions and influences act on these pathways to have four key outcomes:

1. Reduce burden of disease2. Conserve and steward the effectiveness of existing outcomes3. Slow down the emergence and spread of AMR4. Stimulate the development of new antimicrobials, diagnostics and novel therapies

These in turn drive the ultimate desired outcome of minimising mortality and morbidity due to AMR which sits at the centre of the map.

Antimicrobial Resistance (AMR) Systems Map

AMR Systems Map – Influences on the development of AMR 3

From the top level map more detailed sub maps are layered. These more detailed sub maps cover:

1. Animals & Environment2. Hospital3. G.P. Care & the Community4. Pharmaceuticals, diagnostics and vaccinations

These seek to show the interventions and actions within each of these areas which can influence the key outcomes (these are the same as those shown in the Top Level map). Relevant links are also made between the different areas (e.g. the influence of transmission of infections between humans and animals) through the rectangular boxes on the side of each sub map. The elements within each of maps are:

1. Reservoirs for microbes/infection2. Influences on risk of infection3. Influences on development of resistance4. Interventions (that either impact the reservoirs or the influences)5. Outcomes.

Across all the maps, mentions are made of the potential international interactions that may influence the development of AMR.

Methodology

The systems mapping approach itself is described below. The map and sub maps were developed in a series of facilitated workshops through a process of first identifying the reservoirs, then the pathways linking them and finally the interventions. The maps were then constructed on Visio. Some individual contributions were received after the workshops and have been incorporated.

The Top Level map and the Animals & Environment sub map were developed in joint workshops involving participants from DEFRA, DH and Public Health England. The Hospital and the G.P. Care & the Community sub-maps were developed in a workshop of invited experts. A list of participants is at the end of this document.

Systems Mapping

Systems mapping is the process of conceptually representing a system (a set of elements and the relationships between them) and illustrating how events in one part of it affect other parts. Whole systems generally exhibit properties or behaviours that cannot be predicted from the properties of the individual parts.

A key purpose in building systems maps is to gain insight in the underlying structure of a messy, complex situation. A systems map shows how the elements interrelate and where there are opportunities to intervene in the modelled system to influence its behaviour. The essential contribution of systems maps is to summarise and communicate current trends, relationships and constraints that may influence the future behaviour of a system.

Systems mapping is a precursor to more detailed modelling. The map can be used to identify feedback effects, as a structure for the evidence base and in the longer term provide a basis for quantitative systems modelling.

Further Development

We intend to establish a panel to review and update the map on an (at least) annual basis. If you wish the panel to consider any additions or changes to the map please submit your suggestions to [email protected].

mailto:[email protected]

Departmentof Health

AMR Systems Map – Influences on the development of AMR Top Level

Departmentof Health

Pathway for microbes

KEY

Interventions

Influence on risk of infection

Influence on development of resistance

Reservoirs for microbes/resistance

Intended effects

FOOD PRODUCING ANIMALS

INTER-NATIONAL

INTER-ACTIONS

WILDLIFE

ANIMAL FOOD

COMPANION ANIMALS

HUMANS

HUMAN FOODPASTURE & CROPS

THE ENVIRONMENT(Water, soil, vegetation)

ABATTOIR & CARCASS

PROCESSING

MEAT & OTHER FOOD PROCESSING

SLURRY PIT

Animals importedfrom abroad

Food importedfrom abroad

Excludesmeat in the UK

Animal waste

Animal waste to wider environment

SlurryDirect to land

Direct contact(inc. children playing,

water sports,leisure activies)

Direct contactFood waste

Septic tank outflows + Sewage

Wastes(solid + liquid)

Appropriate cleaning, cooking, contamination

controls and chilling (FSA’s 4 C’s)

Metals

Internal transfer of resistance (inc. from

commensals)

Probiotics/Feed additives

Cleaning

Disease treatment, metaphylaxis and

prophylaxis

Resistance genes from genetically modified crops

Biocides & pesticides

Poor husbandry

Industry structure (breeding pyramid)

Production system

Vaccination

Terminal hygiene

Industrial effluent (inc.pharmaceutical)Heavy metals

Metals

Natural processes

Crosscontamination

Crosscontamination

Processing (e.g. pasteurisation for dairy products,

irradiation)Cleaning

Cleaning and hygiene

Crossinfection

Crossinfection

Crossinfection

Inter-farm transport

Veterinary Care Acquried

Infections

Appropriate control measures for animal

keepers

Legislative contol, guidance

& education

Optimised prescribing practice

G.P. CARE & THE

COMMUNITY

Surveillance

Antimicrobial stewardship programmes

Improve professional education, training

and public engagement

Improve knowledge and understanding

of AMR

Crossinfection

Improved guidance and best practice in

husbandry

Internal transfer of resistance (inc. from

commensals)

Transfer of resistance in reservoir

Countries with poor quality control and hygiene standards

during food preparation

UK import controls

Countries with poor animal husbandry,

biosecurity and production standards

Poor control on use of antimicrobials

International consensus and

action on controls for antimicrobial

use

International consensus and action on animal

husbandry

International consensus and action on quality control and

hygiene standards

Best practice in food controls in other countries

EU controls on food

production

Best practice in prescribing

in EU and other countries

Best practice controls on animal husbandry in EU and

other countries

Stockmanship

Infection Prevention and Controls

Biosecurity measures

Better Nutrition/Water Quality

Housing

Stimulate anti-microbial diagnostics and novel therapies

Sewage treaments and controls

Animal by-product treatment

Direct contact (inc. vectors)

AMR Systems Map – Influences on the development of AMR Animals and the Environment

Departmentof Health


KEY

Interventions




Intended effects

People, who have recently been abroad in areas where multi drug resistant bacteria are circulating,

entering hospitals

PATIENTS

HOSPITAL ENVIRONMENT

FOOD

G.P. CARE & THE

COMMUNITYVISITORSANIMALS

ENVIRON-MENT

Imported food and imported animals (please see the Animal & Environment map)

Food Source

Crossinfection

Transfer of resistance in

reservoir



Cross contamination controls (e.g. bed

management)

Stratified medicine

Diagnostics at pace

Screening of patients/ infections for AMR

New diagnostic tests (including Whole

Genome Sequencing)Consistent surveillance

Hospital antimicrobial use

Appropriate prophylactic use


Improve professional education, training, and professional and public

engagement

Patient treatment completion

Levels of cleanliness

Surgery, other invasive

procedures, catheterisation, injections etc

Best practice in facility design

Improve knowledge and understanding of AMR

Crossinfection

Crossinfection


reservoir


reservoir

Standard precautions e.g. hand hygiene

INTER-NATIONAL

INTER-ACTIONS

Transfer of patients from abroad(repatriation following emergency or mitigation of unsuccessful surgery)

Inter-hospitaltransfers

Poor facility design features e.g. inadequate

ventilation system

Low staffing levels

Reduced skills and competence through

staff turnover

Increased training

Culture and Leadership

PEOPLE WORKING IN HOSPITALS

Crossinfection

Clinical Ownership

Information and Communication

Uncontrolled source

Assurance of appropriate premises

management

Gaps in the medical knowledge base for what

drives infections

Inadequate single room facilities &

inconsistent procedures

Asepsis e.g. improved

management of catheter use

Bed management and patient

flows

Start Safe Then Focus

Alternatives to antibiotics

Lab centralisation

Stimulate the development of new antimicrobials, diagnostics and novel

therapies

Improve prescribing practice

Improved electronic prescribing

Assurance of appropriate waste

management

Patients admitted and discharged from hospitals

Internal transfer of resistance

(inc. from commensals)

Understand other drivers of infections

Hydration

Patient management

Preventable chest infections

Medical equipment

that is difficult to clean

Facility difficult to clean due to its design

Increased risk factorse.g. Hospital attendance frequency, Age

Military personnel, treated for wounds suffered in countries Where multi drug resistant strains are circulating, returning

to the UK for follow up treatment

Conserve and steward the effectiveness of existing

treatments


action on controls for antimicrobial use

AMR Systems Map – Influences on the development of AMR Hospital

Departmentof Health


KEY

Interventions




Intended effects

OTHER PEOPLE IN THE COMMUNITY

FOOD

ANIMALS

ENVIRON-MENT

Food Source

Food Source



Increased risk

factors e.g. Age

HOSPITALS

PLACES PEOPLE WORK

AND LIVE

Inappropriate use of industrial and household

antimicrobial cleaners

Effluent discharged intothe environment

Waste discharged intothe environment

levels of cleanliness/

hygiene

Transfer of resistance in reservoir

Assurance of appropriate cleaning (where appropriate)

Controls on manufacture/use of cleaning materials

Effluent discharge controls

Manufacturing and use of

antimicrobials

Infection prevention and control

Invasive procedures in primary care

INTER-NATIONAL

INTER-ACTIONS

Lighter controls on antibioticprescription/usage abroad

Direct contact + waste discharged into the environment

Direct contact

Education e.g.Not flushing incomplete antibiotic

courses down the toilet

Internal transfer of resistance (inc. from commensals)

Risk factors from community interaction e.g.Poor hand washing/general hygiene

Antibiotics available

on the internet

CARE HOMES

HARD TO REACH

GROUPS

Appropriate patient management e.g.

hydration

Insufficient antibitotic resistance training

More training and awareness

Uncompleted antibiotic courses

Gaps in the medical knowledge base for what

drives infections

OTHER PUBLIC SPACES

(e.g. public transport, gyms)

COMMUNITY HOSPITALS

Nurse prescribers Education

Understand other factors driving

Understand other drivers of infections

DAY CENTRES FOR THE ELDERLY

Sexually transmitted infections

Ineffective decontamination of dental equipment

Antibiotic prescribers

Dentists

Overprescribing antibiotics

GPs

Antibiotic prescribers

Overprescribing antibiotics

Resistant STI strains

Patients and visitorsentering & leaving hospitalsSCHOOLS/

NURSERIES/CRECHES


action on controls for antimicrobial use

People entering the UK from abroad

Poor infection prevention and

control

Best practice in prescribing in EU and other countries

Surveillance

Best practice on infection prevention and control in EU

and other countries

Imported food and imported animals (please see the Animal& Environment map)

Improve professional education, training and

public engagement

Direct Contact

Antimicrobial Use

Screening of patients/ infections for AMR

Development of new vaccines

Vaccinationcross-over between classes of

veterinary and medical antimicrobials

Conserve and steward the effectiveness of existing

treatments

Stimulate the development of new

antimicrobials, diagnostics and novel

therapies



Patient treatment completion

Surveillance

Improve prescribing practice

Manage patient expectations

Appropriate prophylactic use

Follow up care

Stratified medicine

Diagnostics at pace

New diagnostic tests (including Whole

Genome Sequencing)

Faster access to patient’s medical history

AMR Systems Map – Influences on the development of AMR G.P. Care and the Community

Departmentof Health

AMR Systems Map – Influences on the development of AMR Pharmaceuticals Diagnostics and Vaccination


KEY

Interventions




Intended effects

Use of existing antimicrobials selects for

resistance

Use of new antimicrobials selects for resistance

Gen

eric

infe

ctio

n pa

thw

ay

Stimulate the development of new antimicrobials,

diagnostics and novel therapies

Diagnostics

Access to surveillance data

Identification and prioritisation of research and

development

Appropriate research and development

Funding

Industry confidence in demand for new products

Government influence

Take into account costs of AMR when evaluating

value for money

Address concerns over cost and complexity of regulatory

approval process

Address uncertainty about the regulatory environment

for new antimicrobials

Pharmaceutical industry develops new products

Joined up approach to antimicrobial prescribing/use

between animals and humans

Guidance/legislation on appropriate use of existing

and new antimicrobials

Use of new antimicrobials

Use of existing antimicrobials

Conserve and steward the effectiveness of new

treatments

INTER-NATIONAL

INTER-ACTIONS

International consensusand action

Sharing of data internationally

EU regulation

MHRA and VMD

Rapid diagnostics

Drug/Bug combinations

Improved surveillance data


Whole genome sequencing

Point of care testing

Acknowledgements 9

AcknowledgementsAMR Systems Map Design

Stephen Dobra & Peter Johnston – Department of Health

Further developed by:

Matthew Baugh, Christina Barfoot, Peter Bennett, Stephen Dobra – Department of Health Suzanne Eckford – DEFRA

Created on Microsoft Visio 2010 by Peter Johnston, Matthew Baugh & George Chappelle

Thank you to the following for participation in workshops developing the initial map and the Animals & the Environment Map sub map:

From DEFRA:

Suzanne Eckford Head of Antimicrobial Resistance Team, Veterinary Medicines Directorate (VMD)

Helen Jukes Head of General Assessment and Research Team, VMDKen Stapleton Human and Environmental Safety Assessor, VMDChris Teale Head of AMR, Animal Health and Veterinary Laboratories Agency

(AHVLA)Emma Snary Head of Risk Analysis, AHVLA

From DH:

Dr Peter Bennett Head of Analysis, Health Protection, Public and International Health Directorate (PIHD)

Stephen Dobra Analytical Programme Manager, PIHDMichael Fleming Analytical Programme Manager, PIHDPeter Johnston Operational Research Analyst, PIHDRoss Leach Economic Advisor: Medicine, Pharmacy and IndustrySally Wellsteed Antimicrobial Resistance and HCAI Team Leader, PIHD

From Public Health England:

Dr Andre Charlett Head of Statistics, Modelling and Economics Department

Professor Alan Johnson Head, Department of Healthcare Associated Infection and Antimicrobial Resistance

Dr Julie Robotham Mathematical Modeller/Health Economist

Facilitated by: Dr Peter Bennett, Stephen Dobra & Peter Johnston – DH

10 Antimicrobial Resistance (AMR) Systems Map

© Crown copyright 2014 2902838 Produced by Williams Lea for the Department of Health

Departmentof Health

Thank you to the following for participation in a workshop that developed the G.P. Care & the Community and Hospital sub maps:

Isabel Boyer – Lay Member, Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)

Dr Ceire Costelloe – Lecturer in Medical Statistics, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London

Dr Nicholas Brown – Consultant Medical Microbiologist at Addenbrooke’s Hospital in Cambridge and Clinical Services Director. President of the British Society for Antimicrobial Chemotherapy (BSAC)

Dr Kumara Dharmasena – Consultant Microbiologist, Walsall Hospitals NHS Trust

Rosie Dixon – Senior Nurse, Infection Prevention and Control at Sheffield Health and Social Care NHS FT

Michael Fleming – Analytical Programme Manager, Department of Health

Dr Nick Francis – Senior Clinical Research Fellow, Cardiff University

Martin Kiernan – Nurse Consultant – Southport & Ormskirk NHS Trust & member of ARHAI

Dr Chris Settle – Consultant Microbiologist, City Hospitals Sunderland

Facilitated by Peter Bennett, Stephen Dobra & Carole Fry – DH

Reporting by Christina Barfoot & Matthew Baugh

Thank you to Dr Elizabeth Jones – Head of Patient Environment, Department of Health for contributing on Estates issues.

Thank you to:

Richard Carter – DH Life Sciences, Office for Life SciencesRoss Leach for reviewing the Pharmaceutical sub map

Documents

Antimicrobial Resistance (AMR) Systems Map · Antimicrobial Resistance (AMR) Systems Map. Overview of the factors influencing the . development of AMR and the interactions between