Antimicrobial Resistance Surveillance Data Requirements for Priority Organisms

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The Communicable and Infectious Disease Steering Committee Antimicrobial Resistance Surveillance Task Group

Final Report to the Public Health Network Council
April 2016

Table of Contents

Report to CIDSC: the Antimicrobial Resistance Surveillance Data Requirements for Priority Organisms

CIDSC Antimicrobial Resistance Surveillance Task Group

  • Kanchana Amaratunga, Public Health Agency of Canada
  • Chris Archibald (Chair), Public Health Agency of Canada
  • Jacqueline Arthur (Secretariat), Public Health Agency of Canada
  • John Conly, Foothills Medical Centre
  • Christine Cryan (Secretariat), Public Health Agency of Canada
  • Rita Finley, Public Health Agency of Canada
  • Charles Frenette, McGill University
  • Greg German, Health PEI
  • Rebecca Irwin, Public Health Agency of Canada
  • Jennie Johnstone, Public Health Ontario
  • Paul N. Levett, Saskatchewan Disease Control Laboratory
  • Warren McIsaac, University of Toronto (until March 2015)
  • Jessica Minion, Regina General Hospital
  • Michael Mulvey, Public Health Agency of Canada
  • Lindsay E. Nicolle, University of Manitoba
  • David Patrick, British Columbia Centre for Disease Control
  • Virginia Roth, The Ottawa Hospital (until April 2015)
  • Nadine Sicard, Direction de la protection de la santé publique Ministère de la Santé et des Services sociaux
  • Kimberley Simmonds, Alberta Health
  • Jill Tarasuk (Secretariat), Public Health Agency of Canada

1. Introduction

1.1 Report Objective

The purpose of this report is to fulfill the mandate to the Pan-Canadian Public Health Network’s Communicable and Infectious Disease Steering Committee (CIDSC) by identifying the priority antimicrobial resistance surveillance data metric requirements needed for each of the priority organisms previously identified by the first CIDSC AMR Surveillance Task Group in December 2014. This exercise, in turn, will help to support a robust  Pan-Canadian antimicrobial resistance (AMR) surveillance system. This report provides general recommendations regarding national AMR surveillance priorities which may encompass all jurisdictions: provincial, territorial, as well as federal levels. The recommendations for priority data metrics in this report reflect the AMR surveillance needs from a national perspective and they do not supersede any ongoing or future surveillance initiatives at the provincial or territorial levels. In addition, the outlined recommendations may impact several national surveillance programs; however, the purpose of this report is to provide high level guidance and not to provide prescriptive program changes. This report is the result of expert opinion and it should be also noted that surveillance needs are dynamic and can change as priorities change and as new pathogens emerge. Hence, it should be emphasized that the following recommendations are based on current surveillance needs and should be subject to regular review.

This report is focussed on pathogenic bacteria relevant to human clinical disease. Integrated surveillance of AMR through the food chain relies on capturing data on indicator bacteria which can also transmit AMR to human pathogens and though they remain an important priority for surveillance of AMR as recommended by the World Health Organization, these organisms are not discussed for the purposes of this report  (WHO, AGISAR 2013 Integrated Surveillance of Antimicrobial Resistance, Guidance from a WHO Advisory Group).

1.2 Background

Antimicrobials are essential for the prevention, control and treatment of infectious disease in both humans and animals. Antimicrobial resistance (AMR) and antimicrobial use (AMU) remain complex multi-sectorial issues with cross-jurisdictional implications for human health care, public health, food safety, food production, animal health care and environmental protection sectors. 

AMR is an important health issue and appropriate surveillance systems are necessary to provide the information needed to develop effective AMR prevention and control programs and policies. It is recognized that there may be gaps, redundancies and changes required to surveillance programs to improve on the data metrics necessary to make better evidence-informed program and policy decisions.

1.3 Mandate of the CIDSC Antimicrobial Resistance Surveillance Task Group

The Pan-Canadian Public Health Network’s Communicable and Infectious Disease Steering Committee (CIDSC) has identified AMR as a priority.  In February, 2014, CIDSC established an expert-based task group to develop recommendations to address common health-care acquired infections (HAI) and operational issues related to surveillance of AMR.  Specifically, the task group was asked to identify key elements of a pan-Canadian AMR-AMU approach to surveillance (focusing initially on the human health aspects of the surveillance) as well as identify the priority list of organisms for AMR surveillance. The task group presented its findings to the CIDSC in December 2014 in its report entitled CIDSC AMR Surveillance Task Group:  Report of the Key Elements of a Pan-Canadian AMR-AMU Surveillance System.

Following the presentation of this report, CIDSC agreed to revise the membership and mandate of the CIDSC Antimicrobial Resistance Surveillance Task Group to develop advice and recommendations on the priority data metrics needed to support a robust AMR surveillance system for each of the top priority organisms (with a focus on human health) previously identified by the task group (Table 1). 

Table 1: Priority organisms considered for AMR SurveillanceTable 1 - Footnote *
1st priority 2nd priority 3rd priority

Table 1 Footnotes

Table 1 - Footnote *

As developed and accepted by the CIDSC AMR Surveillance Task Group, December 2014.

Return to Table 1 - Footnote * referrer

Table 1 - Footnote †

Extended-spectrum β-lactamase (ESBL)-producing organisms: Enterobacteriaceae spp. (Klebsiella, E. coli), Pseudomonas, Others to consider: Providencia stuartii, Citrobacter, Serratia, Proteus, Enterobacter.

Return to Table 1 - Footnote referrer

Table 1 - Footnote ‡

Carbapenem-resistant organisms (CROs): Enterobacteriaceae spp (Klebsiella, E. coli), Pseudomonas, Acinetobacter.

Return to Table 1 - Footnote referrer

Clostridium difficile Aspergillus spp. Aeromonas spp.
Table 1 - Footnote ESBL-producing organisms Bacteroides spp. Chlamydia pneumoniae
Table 1 - Footnote Carbapenem-resistant organisms (Acinetobacter + Enterobacteriaceae spp.) Candida albicans Cryptococcus neoformans
Enterococcus spp. Chlamydia trachomatis Haemophilus influenza
Neisseria gonorrhoeae Helicobacter pylori Non-tuberculosis mycobacteria (pulmonary)
Streptococcus pyogenes & pneumoniae Pseudomonas aeruginosa N/A
Salmonella spp. Group B Streptococcus N/A
Staphylococcus aureus Shigella spp. N/A
Mycobacterium tuberculosis N/A N/A
Campylobacter spp. N/A N/A

2. Methods and approach to examining Data Requirements for Priority Organisms

2.1 Task Group Discussions

The CIDSC Antimicrobial Resistance Surveillance Task Group reviewed the data requirements for each of the identified 1st priority organisms (Table 1). A template (Appendix B) was developed to guide the discussions where for each of the priority organisms the following aspects were reviewed:

  • Site of infection
  • Data source
  • Variable of interest (as measured by a priority data metric)
  • Priority / Relevance
  • Feasibility
  • Rationale for measure (as required)
  • AntibioticsFootnote 1 to consider for testing (as required)
  • Other considerations (as required)
  • Summary / Recommendation

2.2 Summary of Discussions

Subsequently, for each organism a summary of the discussions was prepared for this report including a description of the existing surveillance system(s) and respective system limitations. This summary includes a subjective ranking of priorities according to expert opinion of members. This was followed by a Summary of the Priority Data Metrics and Recommendations which included a Synopsis Table which presents (see Table 2 for more details):

  • the setting (healthcare or community) and the required data metric (infection rate, colonization rate, susceptibility of infection isolate, susceptibility of colonization isolate);
  • a rating of the priority of the data metric (high, medium, low);
  • an assessment of whether the current surveillance system is meeting the identified need (meets needs, partially meets needs, does not meet needs or a brief description if the data metric is considered low priority);
  • the feasibility to implement the proposed new action to fill the identified gap; and
  • what, if any, action is required to fill identified gaps.
Table 2. Components of the Synopsis Table for each organism and definitions
  Legend Description
Setting Healthcare setting Includes acute care hospitals and acute rehabilitation hospitals
Community setting Includes locations where primary healthcare is provided outside of the acute care hospital setting (i.e., community health centres, physician offices, primary healthcare clinics, long-term care facilities etc.).
Data Metric Infection rate (incidence and/or prevalence) For example:
  • Per 1,000 admissions or per 10,000 patient days per year (healthcare setting)
  • Per 1,000 population per year (community setting)
Colonization rate
(incidence and/or prevalence)
For example:
  • Per 1,000 admissions or per 10,000 patient days per year (healthcare setting)
  • Per 1,000 population per year (community setting)
Susceptibility of  the infection isolate Susceptible, intermediate, resistant data (i.e., % of isolates resistant). The resistance will be determined by susceptible/intermediate/resistant (SIR) data rather than minimum inhibitory concentration (MIC) data as SIR is likely more feasible to obtain than MIC.
Susceptibility of the colonization  isolate Susceptible, intermediate, resistant data (i.e., % of isolates resistant). The resistance will be determined by susceptible/intermediate/resistant (SIR) data rather than minimum inhibitory concentration (MIC) data as SIR is likely more feasible to obtain than MIC.
Priority of Data Metric
This is an assessment of the importance of the data metric for national AMR surveillance as deemed by the Task Group.
High Data metric is of high importance
Medium Data metric is of medium importance
Low Data metric is of low importance
Current Surveillance System Status
This is an assessment of the status of the corresponding surveillance system in place and whether the system currently collects and/or reports on the priority data metric identified.
Meets needs The current surveillance system collects and reports on the priority data metrics discussed.
Partially meets needs The current surveillance system partially collects and reports on the priority data metrics discussed.
Does not meet needs The current surveillance system does not collect or report on the priority data metrics discussed.
Feasibility
This is a subjective assessment of the feasibility to implement the proposed new action to fill the identified gap. This is determined by the amount person-time effort and financial resources that will be needed to accomplish the new action.
No It is not feasible to address the identified action required.
Low There is low feasibility to address the identified action required.
Medium There is medium feasibility to address the identified action required.
High It is highly feasible to address the identified action required and/or to continue this action if the current surveillance systems meets needs.
Not assessed The feasibility is not considered because the data metric is considered a low priority.

3. Summary and Recommendations

The following summarizes the expert opinions of the CIDSC TG members including the recommendations on priority data metrics for each of the identified priority organisms (in order of review by the CIDSC TG).

3.1 Clostridium difficile (Diarrheal illness)

Existing surveillance system(s):

Clostridium difficile infection (CDI) is a national notifiable disease since 2009. PHAC works closely with provincial and territorial partners to monitor CDI across Canada however, current data holdings are incomplete across some provinces and territories (P/Ts). In addition, PHAC collects data on healthcare associated-CDI (HA-CDI) through CNISP surveillance since 2005. Starting in 2015, CNISP is collecting data on CA-CDI (ER, outpatients and inpatients) and recurrent CDI as a pilot study and this may partially represent community level data.

Limitations:

CNISP collects data from acute care hospitals and does not capture the overall burden of CDIin the community. In addition, CNISP mainly represents more tertiary care, large urban acute care centres and hence, the data may not be representative of smaller, remote or more rural healthcare settings in Canada. As the CDI data provided to CNDSS is not always complete, a fully comprehensive picture of the burden of CDI in Canada is not available at this time.

Summary of Priority Data Metrics and Recommendations: Clostridium difficile (Diarrheal illness)

Summary of Priority Data Metrics:
  1. Monitoring CDI rates in the healthcare setting is a high priority. This is currently collected by CNISP.
  2. Monitoring CDI rates in the community setting is a high priority. Currently there is no national surveillance system in place to monitor this.
Recommendations:
A. Health care setting:

Currently CNISP collects data on HA-CDI in acute care hospitals and the TG recommended continuing with this activity. Community-associated CDI (CA-CDI) cases may be captured in the hospital setting based on timing of infection. It may be feasible to capture some CA-CDI  data via CNISP surveillance and at present CNISP is undertaking a pilot study to explore this, as mentioned above.

The TG determined that capturing Clostridium difficile colonization data as part of a national surveillance program is of low priority.

The TG also determined that monitoring the susceptibility of Clostridium difficile infection isolates as part of a national surveillance system is a medium priority. Currently, the NML conducts susceptibility testing on all received toxigenic CDI strain isolates submitted by CNISP hospitals. Though there are reports of decreased response rates to metronidazole, this has not been linked directly to resistance. It may be of importance to monitor susceptibility patterns, however, this would not be the main  focus for routine national surveillance.

B. Community setting:

In order to capture overall CDI burden in the community setting, it was determined that it may be more feasible to capture this data in the form of point-prevalence studies.

Similar to the healthcare setting, the TG determined that capturing Clostridium difficile colonization data in the community setting is a low priority and collecting susceptibility data of infection isolates is a medium priority.

Synopsis Table: Clostridium difficile (Diarrheal illness)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 3 - Footnote *

Table 3 Footnotes

Table 3 - Footnote *

Action Required to Fill Gap:
In the healthcare setting, no new action is required. In the community setting, point prevalence studies should be conducted to capture the burden of CDI. Capturing susceptibility data in the community would likely be unfeasible given it is difficult to conduct routine susceptibility on this organism and the limited availability of testing across community private labs.

Return to Table 3 - Footnote * referrer

Table 3 - Footnote †

May be partially addressed by the CNISP pilot study previously mentioned in Section 3.1.

Return to Table 3 - Footnote referrer

Healthcare setting
Infection Rate High Meets needs High
Susceptibility of infection isolate Medium Meets needs High
Colonization Rate
& Susceptibility of colonization isolate
Low Current surveillance system does not collect and/or report. Feasibility not assessed.
Community setting
Infection Rate High Does not meetTable 3 - Footnote Medium
Susceptibility of infection isolate Medium Does not meet Low
Colonization Rate
& Susceptibility of colonization isolate
Low Current surveillance system does not collect and/or report. Feasibility not assessed.

3.2 Enterobacteriaceae spp. - E. coli and Klebsiella (Bloodstream infections)

Existing surveillance system(s):

PHAC does not currently monitor resistance in generic or pathogenic E. coli or Klebsiella in humans.  The Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) monitors E. coli isolated from retail food and animals. CNISP does collect data on both infections (including blood stream infections [BSI]) and colonizations among hospitalized patients with carbapenem-resistant gram negatives (CRGN). This can include carbapenem resistant E. coli or Klebsiella in the form of carbapenemase-producing organisms (CPO) and/or carbapenem-resistant Enterobacteriaceae (CRE). In addition, CNISP surveillance of central venous catheter BSI (CVC-BSI) can pick up some E. coli or Klebsiella BSI in hospitalized intensive care unit (ICU) patients with CVCs in place.

Limitations:

Currently no national human surveillance system monitors E. coli or Klebsiella BSI specifically. The existing surveillance system data (i.e., CNISP) is limited to either carbapenem resistant organisms (both infections including BSI and colonizations) and limited data from CVC-BSI in ICU patients only. CNISP does not collect data on primary or secondary BSI. In addition, resistance monitored for E. coli by CIPARS involves retail food and animals and does not include human surveillance.

Summary of Priority Data Metrics and Recommendations: Enterobacteriaceae spp. E. coli and Klebsiella (Bloodstream infections)

Summary of Priority Data Metrics:
  1. Monitoring infection rates for E. coli and Klebsiella BSI in the healthcare setting is a high priority. To add, monitoring rates of resistant E. coli and Klebsiella BSI in the healthcare setting is of particular importance. This is partially collected by CNISP.
  2. Monitoring susceptibility patterns of these organisms causing infection in the healthcare setting is a high priority.
Recommendations:

Currently CNISP captures data on carbapenem resistance in both these organisms (for both infections and colonizations); however, the TG was interested in monitoring infection rates (particularly BSI) across a broader spectrum of resistance. After considering antibiotics of interest for these two organisms as per the WHO as well as antibiotics most commonly used for treating these infections, the TG discussed seven classes of antibiotics of interest with respect to susceptibility patterns: ureidopenicillins, 3rd generation cephalosporins, fluoroquinolones, carbapenems, aminoglycosides, trimethoprim-sulphamethazole, and polymyxins (i.e. colistin). Concerns were raised whether all labs would test for all antibiotics of interest and whether there is consistency across labs. It was decided that raw lab data should be obtained wherever possible (versus reported lab data) allowing further sub-categorization of the resistance pattern for these organism. Once resistant patterns are known, these can be further classified into multi-drug resistant organism (MDRO) and/or extensively drug-resistant organism (XDRO) groupings (which are currently being defined by the Canadian Public Health Laboratory Network [CPHLN]) and if needed, ESBL and carbapenem resistant organisms. However, the TG did determine that the focus on ESBL organisms is a low priority given their widespread prevalence.

As the majority of BSI in the community will be admitted to hospital, community-associated infections may be captured in the hospital setting. The TG members indicated that differentiating healthcare- versus community-associated data would be desirable, however this would require substantial person-power and hence the feasibility of this task is medium.

Synopsis Table: Enterobacteriaceae spp. E. coli and Klebsiella (Bloodstream infections)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 4 - Footnote *
Healthcare settingTable 4 - Footnote

Table 4 Footnotes

Table 4 - Footnote *

Action Required to Fill Gap:
In the healthcare setting, monitoring rates of resistant E. coli and Klebsiella BSI is of particular importance. Several classes of antibiotics of interest were discussed as above.

Return to Table 4 - Footnote * referrer

Table 4 - Footnote †

National surveillance for E. coli and Klebsiella BSIis represented by healthcare level data and data in the community setting for this organism is likely captured in the healthcare setting as most patients are admitted to hospital for BSI.

Return to Table 4 - Footnote referrer

Table 4 - Footnote ‡

The feasibility is assessed as medium providing all jurisdictions have adequate infrastructure to accomplish this.

Return to Table 4 - Footnote referrer

Infection Rate High Partially meets MediumTable 4 - Footnote
Susceptibility of infection isolate High Partially meets Medium
Synopsis Table: Enterobacteriaceae spp. E. coli and Klebsiella (Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 5 - Footnote *
Healthcare setting

Table 5 Footnotes

Table 5 - Footnote *

Action Required to Fill Gap:
Collection of selective hospital antibiogram data for colonization isolates for antibiotics discussed in Section 3.2.

Return to Table 5 - Footnote * referrer

Colonization Rate Low Current surveillance system partially collects and/or reports. Feasibility not assessed.
Susceptibility of colonization isolate Medium Partially meets Medium

3.3 Enterobacteriaceae spp. - E. coli and Klebsiella (Genito-urinary tract infections)

Existing surveillance system(s):

As mentioned above, PHAC does not currently monitor resistance in generic or pathogenic E. coli or Klebsiella in humans.  The Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) monitors E. coli isolated from retail food and animals. CNISP does collect data on both infections (including genito-urinary) and colonizations among hospitalized patients with carbapenem-resistant gram negatives (CRGN). This can include carbapenem-resistant E. coli or Klebsiella in the form of carbapenemase producing organisms (CPO) and/or carbapenem resistant Enterobacteriaceae (CRE). In addition, CNISP surveillance of central venous catheter BSI (CVC-BSI) can pick up some E. coli or Klebsiella BSIin hospitalized ICU patients but this may not reflect genito-urinary tract infections.

Limitations:

Currently no national human surveillance system monitors E. coli or Klebsiella in genito-urinary tract infections specifically. The existing surveillance system data (i.e., CNISP) is limited to either carbapenem resistant organisms (both infections and colonizations) or limited data from CVC-BSIs in hospitalized ICU patients. In addition, resistance monitored for E. coli by CIPARS involves retail food and animals and does not include human surveillance.

Summary of Priority Data Metrics and Recommendations: Enterobacteriaceae spp. E. coli and Klebsiella (Genito-urinary tract infections)

Summary of Priority Data Metrics:
  1. Monitoring susceptibility patterns of E. coli and Klebsiella genito-urinary tract infections in the community setting is a high priority.
  2. Monitoring infection rates for resistant E. coli and Klebsiella genito-urinary tract infections in the community is a medium priority.
Recommendations:

In order to capture susceptibility patterns of these two organisms in the community setting, the TG discussed using community level antibiogram data on an annual basis (i.e., BC Antibiogram Pilot). In addition, the TG recommended conducting a point-prevalence community-based study (i.e., every 5 years) provided that funding is available which would allow for a verification of the antibiogram data findings.

It was discussed that between the two organisms, E. coli may be a higher priority than Klebsiella in genito-urinary tract infections surveillance, mainly as it is a more common urinary pathogen. Furthermore the TG suggested stratifying analyses by age, sex, and if possible identify if the isolate is from a long-term care facility (though this may be difficult to determine).The TG also recommended that raw lab data (i.e., all available susceptibility testing done by the lab) should be obtained wherever possible versus lab data that is just reported back to the healthcare provider as this would provide for a broader profile of susceptibility testing conducted. To add, susceptible/intermediate/resistant (SIR) data is likely more feasible to obtain than minimum inhibitory concentration (MIC) data.

After considering the antibiotics of interest for these two organisms as per the WHO as well as antibiotics most commonly used for treating genito-urinary tract infections, the TG discussed several classes of antibiotics of interest (6 are similar to the BSI discussion): amino/ureidopenicillins, 3rd generation cephalosporins, fluoroquinolones, carbapenems, aminoglycosides, trimethoprim-sulphamethazole, and nitrofurantoin. Concerns were raised whether all labs would test for all antibiotics of interest and whether there is consistency across labs. Once resistant patterns are known, these can be further classified into MDRO and/or XDRO groupings (which are currently being defined by the CPHLN) and if needed, ESBL and carbapenem resistant organisms. However, the TG did determine that the focus on ESBL organisms is a low priority given their widespread prevalence.

A few caveats to consider:

  1. Urine isolates in the community may not be representative of all genito-urinary tract infections as not every case in the community will have a urine sample sent to the lab as some infections are diagnosed clinically without lab confirmation.  Hence, there may be an inherent bias in the samples collected (i.e., sample sent may be from patients with recurrent disease or those failing to respond to treatment, etc.).
  2. In addition, not every urine isolate identified may represent an infection. Some may represent asymptomatic bacteriuria or colonization which requires caution in interpretation of the data.

The TG noted that capturing genito-urinary tract infections alone in the healthcare setting is a low priority as the majority of BSI (for which the TG recommended collecting surveillance data as discussed in Section 3.2) are usually secondary to genito-urinary tract infections. Hence, the susceptibility pattern for these two organisms will be captured by the BSI surveillance in the healthcare setting.

Synopsis Table: Enterobacteriaceae spp. E. coli and Klebsiella (Genito-urinary tract infections)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 6 - Footnote *
Community setting

Table 6 Footnotes

Table 6 - Footnote *

Action Required to Fill Gap:
For AMR data, consider use of community level antibiogram data on an annual basis (i.e., BC Antibiogram Pilot). For infection rate data, a periodic point-prevalence community-based study can be conducted, provided funding is available.

Return to Table 6 - Footnote * referrer

Infection Rate Medium Does not meet Low
Susceptibility of infection isolate High Does not meet Medium
Colonization Rate & Susceptibility of colonization isolate Low Current surveillance system does not collect and/or report. Feasibility not assessed.

3.4 Enterococcus (Bloodstream infections)

Existing surveillance system(s):

PHAC has been monitoring incidence rates of vancomycin resistant Enterococcus (VRE) in acute care hospitals through CNISP since 1999. In addition to infection rates (which includes BSI), CNISP also collects data on screening and colonization. However, due to the differences and variations in screening practices across facilities, the analysis of the data is challenging.

Limitations:

CNISP only collects data on vancomycin resistance in this organism from acute care hospitals and does not capture the overall susceptibility spectrum for Enterococcus.

Summary of Priority Data Metrics and Recommendations: Enterococcus (Bloodstream infections)

Summary of Priority Data Metrics:
  1. Monitoring infection rates of resistant Enterococcus BSI in the healthcare setting as part of a national surveillance system is a high priority. VRE rates are currently collected by CNISP.
  2. Monitoring susceptibility patterns of this organism in the healthcare setting is a high priority, with specific focus on VRE.
Recommendations:

The TG determined that the recommended monitoring of infection rates of resistant Enterococcus BSI in the healthcare setting is already captured by CNISP via VRE surveillance.  It was acknowledged that VRE was the priority resistant pattern to consider for this organism. Though CNISP currently collects VRE rates for all sites of infection, it was recommended that BSI, given its higher morbidity and mortality, remains a priority. It was proposed that CNISP continue to collect data on BSI and if data and resources are available, other infection sites can continue to be monitored. The data captured by blood samples may be easier to collect; however it was advised that the definition of BSI should be clearly defined so as not to include contaminants. CNISP already uses clear standardized definitions for capturing BSI data.  In addition, if there are further resources, it would be useful to: 1) combine VRE BSI infection rates with mortality data as an outcome measure and 2) capture all Enterococcus BSI and then determine what proportion are VRE in addition to monitoring other susceptibility patterns for this organism.

The TG determined that capturing VRE colonization data as part of a national surveillance program is of low priority as there are differences and variations in screening practices across facilities. Several hospitals have stopped screening for VRE colonization and there is debate whether all hospitals in Canada should continue, which results in VRE colonization data being limited in routine national surveillance practice.

The TG commented that even though Enterococcus BSI rates in the community may not be a priority as most cases are picked up in the hospital setting, if antibiogram data is already available, it would be of interest to look at the susceptibility patterns of Enterococcal isolates in the community. It should be noted that VRE specifically is not considered a community organism.

Synopsis Table: Enterococcus (Bloodstream infections)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 7 - Footnote *
Healthcare setting

Table 7 Footnotes

Table 7 - Footnote *

Action Required to Fill Gap:
Capture all Enterococcus BSI and then determine what proportion are VRE in addition to monitoring other susceptibility patterns for this organism.

Return to Table 7 - Footnote * referrer

Table 7 - Footnote †

This is in regards to VRE BSI infection rates however, the current surveillance system does not capture all Enterococcus BSI infection rates.

Return to Table 7 - Footnote referrer

Infection Rate for VRE High Meets needsTable 7 - Footnote High
Susceptibility of infection isolate High Partially meets High
Synopsis Table: Enterococcus (Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 8 - Footnote *
Healthcare setting

Table 8 Footnotes

Table 8 - Footnote *

Action Required to Fill Gap:
No new action is required.

Return to Table 8 - Footnote * referrer

Table 8 - Footnote †

This was not assessed as capturing colonization (VRE) information has been phased out in many healthcare settings.

Return to Table 8 - Footnote referrer

Colonization Rate for VRE Low Current surveillance system does collect and/or report. Feasibility not assessed.Table 8 - Footnote
Susceptibility of colonization isolate (all Enterococcus including VRE) Low Current surveillance system partially collects and/or reports. Feasibility not assessed.

3.5 Enterococcus (Genito-urinary tract infections)

Existing surveillance system(s):

As mentioned above, PHAC has been monitoring incidence rates of vancomycin resistant Enterococcus (VRE) in acute care hospitals through CNISP since 1999. In addition to infection rates (which includes genito-urinary tract infections), CNISP also collects data on screening and colonization; however, due to the differences and variations in screening practices across facilities, the analysis of this data is challenging. Historically CIPARS monitored Enterococcus in the food chain due to the role the food chain played in VRE in Europe; however, no VRE was found in Canada.

Limitations:

CNISP only collects data on vancomycin resistance in this organism from acute care hospitals and does not capture the overall susceptibility spectrum for Enterococcus.

Summary of Priority Data Metrics and Recommendations: Enterococcus (Genito-urinary tract infections)

Summary of Priority Data Metrics:
  1. Monitoring rates and susceptibility of Enterococcus genito-urinary tract infections as part of a national surveillance system is a low priority.
Recommendations:

The TG provided the above recommendation based on several factors: 1) low prevalence (i.e., less than 10% of genito-urinary tract infections are EnterococcalFootnote 2); 2) the amount of resources required to capture the required data outweighs the usefulness of the information obtained; and 3) the difficulty to differentiate between infection and colonization with regards to this particular organism in genito-urinary tract infections. However, the TG discussed that if antibiogram data is already available in the community (i.e., BC Antibiogram Pilot), it would be of interest to look at the susceptibility patterns of Enterococcal isolates in the community (with the caveat of knowing that it may not be possible to differentiate between infection and colonization).

The TG determined that capturing VRE colonization data as part of a national surveillance program is of low priority as there are differences and variations in screening practices across facilities.

Synopsis Table: Enterococcus (Genito-urinary tract infections)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 9 - Footnote *
Healthcare and Community setting

Table 9 Footnotes

Table 9 - Footnote *

Action Required to Fill Gap:
No action required.

Return to Table 9 - Footnote * referrer

Infection Rate & Susceptibility of infection isolate Low Current surveillance system partially collects and/or reports. Feasibility not assessed.
Colonization Rate & Susceptibility of colonization isolate Low Current surveillance system partially collects and/or reports. Feasibility not assessed.

3.6 Pseudomonas spp. and Acinetobacter spp. (Bloodstream infections)

Existing surveillance system(s):

Currently there is no national surveillance system in place which strictly monitors the infection rate and susceptibility of Pseudomonas spp. and Acinetobacter spp. CNISP, however, currently does indirectly capture some data on Pseudomonas spp. and Acinetobacter spp. bloodstream infections in the healthcare setting via two surveillance projects: Carbapenem-Resistant Gram Negative (CRGN) surveillance (which only captures Acinetobacter spp. data) and Central Venous Catheter-Bloodstream Infections (CVC-BSI) surveillance (which captures both Pseudomonas spp. and Acinetobacter spp. data).

The CRGN surveillance project mainly focuses on carbapenem resistant organisms such as carbapenemase producing organisms (CPOs), carbapenem resistance Enterobacteriaceae (CRE)  and carbapenem-resistant Acinetobacter (CRA) and hence captures one of these two organisms from a specific resistance pattern perspective. This data includes both infections (including BSI) and colonization.

The CVC-BSI surveillance project mainly focuses on BSI induced by central venous catheters in ICU patients only and this does not represent primary or secondary BSI; and these two organisms are captured in some of these cases. Currently CNISP reports on the incidence of CVC-BSI overall and also provides a breakdown of the specific organisms involved which can include Pseudomonas spp. and Acinetobacter spp..  Overall these two organisms represent a fairly small proportion of CVC-BSI (i.e., <5%). In 2015, CNISP started collecting antibiogram data for the organisms captured from CVC-BSI.

Limitations:

With respect to Pseudomonas spp. and Acinetobacter spp., the CRGN surveillance project through CNISP only focuses on carbapenem resistance among Acinetobacter spp. and does not capture carbapenem resistance data for Pseudomonas spp.. CNISP also does not monitor the  full resistance spectrum for Acinetobacter spp. for other antibiotics. The CVC-BSI surveillance project only focuses on CVC-associated BSI in only ICU patients, which does not constitute all BSI. In addition AMR data from the CVC-BSI surveillance project has not been available in the past, but will be available for the 2015 data and onwards.

Summary of Priority Data Metrics and Recommendations: Pseudomonas spp. and Acinetobacter spp. (BSI)

Summary of Priority Data Metrics:
  1. Monitoring the susceptibility of Pseudomonas spp. and Acinetobacter spp. BSI in the healthcare setting is a medium priority. As highly resistance cases emerge in other countries, there will be a need to re-evaluate the priority level of these 2 organisms.
  2. Monitoring the infection rate of these 2 organisms is a low priority as part of a national surveillance program as most of these infections are seen in specialized sub-populations (i.e., hemodialysis patients, bone marrow transplant patients).
Recommendations:

If antibiogram data is already available (i.e., CVC-BSI data), the TG determined that it would be of interest to look at the susceptibility patterns of these isolates in the healthcare setting. With additional resources, point prevalence studies may be a mechanism to monitor for emerging resistance. It may be necessary to collect samples beyond just blood (i.e., respiratory, etc.) in order to have a larger sample size for antibiogram data. In addition, once resistant patterns for these two organisms are captured by antibiogram data, these can be further classified into MDRO and/or XDRO groupings (which are currently being defined by CPHLN) and if needed, ESBL and carbapenem resistant organisms. However, the TG did determine that the focus on ESBL organisms is a low priority given their widespread prevalence.

One caveat to note is that it may prove difficult to differentiate between infection versus colonization for these isolates found in different high-risk sub-populations who will likely also have different susceptibility patterns based on different exposures to different antibiotic regimens.

Synopsis Table: Pseudomonas spp. and Acinetobacter spp. (Bloodstream infections)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 10 - Footnote *
Healthcare settingTable 10 - Footnote

Table 10 Footnotes

Table 10 - Footnote *

Action Required to Fill Gap:
If antibiogram data is already available (i.e., CVC-BSI data), it would be of interest to look at the susceptibility patterns in the healthcare setting. If additional resources are available, point prevalence studies may be another mechanism to monitor for emerging resistance. It may be necessary to collect samples beyond just blood in order to have a larger sample size.

Return to Table 10 - Footnote * referrer

Table 10 - Footnote †

Pseudomonas spp. and Acinetobacter spp. (BSI) is represented by healthcare level data as these 2 organisms are usually considered healthcare-associated.

Return to Table 10 - Footnote referrer

Table 10 - Footnote ‡

If MDRO or XDRO patterns are detected, the priority of this data metric should be considered as high.

Return to Table 10 - Footnote referrer

Infection Rate Low Current surveillance system partially collects and/or reports. Feasibility not assessed.
Susceptibility of infection isolateTable 10 - Footnote Medium Partially meets Medium
Synopsis Table: Pseudomonas spp. and Acinetobacter spp. (Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 11 - Footnote *
Healthcare settingTable 11 - Footnote

Table 11 Footnotes

Table 11 - Footnote *

Action Required to Fill Gap:
Collection of selective hospital antibiogram data for colonization isolates and assess patterns that would determine MDRO and/or XDRO.

Return to Table 11 - Footnote * referrer

Table 11 - Footnote †

Pseudomonas spp. and Acinetobacter spp. (BSI) is represented by healthcare level data as these 2 organisms are usually considered healthcare-associated. 

Return to Table 11 - Footnote referrer

Colonization Rate Low Current surveillance system partially collects and/or reports. Feasibility not assessed.
Susceptibility of colonization isolate Medium Partially meets Medium

3.7 Staphylococcus aureus (Bloodstream infections and Other Infection Sites)

Existing surveillance system(s):

PHAC undertakes limited surveillance of Staphylococcus aureus (S. aureus), specifically only the surveillance of methicillin-resistant staphylococcus aureus (MRSA), under CNISP. CNISP collects both epidemiological and laboratory data for MRSA infections (clinical [non-blood] and bloodstream) and epidemiological data for screening and colonizations. Surveillance for MRSA has been ongoing since 1995.

Limitations:

The TG was interested in looking at all S. aureus BSI rates; however, CNISP only collects data on MRSA and does not capture all S. aureus infections. This limits the ability to calculate measures such as the proportion of MRSA BSI out of all S. aureus BSI. Secondly, CNISP only collects data from acute care hospitals and does not capture the overall burden of S. aureus infection in the community. While some community-associated infections are captured by CNISP (i.e., patients admitted to hospital where the MRSA was acquired in the community), these do not represent the overall burden of community MRSA.

Summary of Priority Data Metrics and Recommendations: Staphylococcus aureus

Summary of Priority Data Metrics:
  1. Monitoring S. aureus bloodstream infection rates in the healthcare setting is a high priority. Currently CNISP collects MRSA bloodstream infection rates.
  2. Monitoring susceptibility patterns of this organism in the healthcare setting is a high priority, with specific focus on MRSA.
  3. Monitoring overall MRSA burden in the community setting is a high priority. Currently there is no national surveillance system in place to monitor this.
Recommendations:
A. Healthcare setting:

Currently CNISP looks at both blood and other sites of infection with MRSA; however, the TG agreed that BSI was the top priority site of infection for surveillance given the associated high morbidity and mortality. It was proposed that CNISP continue to collect data on MRSA BSI and if data and resources are available, other infection sites can continue to be monitored. Given funding and resources, the TG recommended examining all S. aureus BSI rates in the healthcare setting and the associated resistance patterns. In addition, the TG recommended that the proportion by type of antibiotic resistance provided by antibiogram data (i.e., proportion MRSA BSI out of all S. aureus BSI) should be considered, citing MRSA as the most important antimicrobial resistance pattern to monitor for S. aureus BSI.

The TG also discussed examining strain types to help differentiate between healthcare-associated versus community-associated MRSA (either by phenotype or genotype); however, one caveat to consider is that genotyping may not be universally available. It should be noted that at present, CNISP (via NML) does conduct strain typing for MRSA (both blood and non-blood isolates) over specified months of the year. If collected, the denominator data can be presented, for example, as community acquired-MRSA as “per 1,000 admissions/year” and HA-MRSA as “per 10,000 patient days/year”.

The TG determined that capturing MRSA screening and colonization data as part of a national surveillance program is of low priority as there are differences and variations in screening practices across facilities.

B. Community setting:

In order to capture overall MRSA burden in the community setting, it was determined that antibiogram data from the community would be the best method to capture this information as it would be more difficult and less feasible to collect the required data to measure MRSA infection rates in the community beyond laboratory antibiogram data.

The TG recommended looking at all available S. aureus lab isolates (i.e., BSI as well as other infection sites) in order to capture the proportion of MRSA out of all the S. aureus isolates collected in the community. The TG also recommended determining the proportion of MRSA infection sites (i.e., out of all MRSA infections captured, what is the proportion that are BSI, Skin and soft tissue infections, etc.).

The TG also discussed strain typing (either by phenotyping or genotyping) in the community setting; however, this would likely be unfeasible given the varied practices and limited availability of testing across community private labs.

Synopsis Table: S. aureus (Bloodstream infections)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 12 - Footnote *
Healthcare settingTable 12 - Footnote

Table 12 Footnotes

Table 12 - Footnote *

Action Required to Fill Gap:
Capture all S. aureus BSI rates in the healthcare setting and the associated resistance patterns. The proportion by type of antibiotic resistance provided by antibiogram data (i.e., proportion MRSA BSI out of all S. aureus BSI, etc.) should be monitored with MRSA as the most important antimicrobial resistance pattern to monitor.  This may need to be reviewed if vancomycin-intermediate and vancomycin-resistant S. aureus (VISA and VRSA, respectively)  were to emerge in Canada.

Return to Table 12 - Footnote * referrer

Table 12 - Footnote †

It was determined that S. aureus BSI was a priority in the healthcare setting.

Return to Table 12 - Footnote referrer

Table 12 - Footnote ¥

CNISP only captures MRSA data in the healthcare setting (which was determined to be the most important antimicrobial resistance pattern to monitor for S. aureus at present),  though it would be ideal to monitor all S. aureus BSI rates in the healthcare setting and the associated resistance patterns.

Return to first Table 12 - Footnote ¥ referrer

Infection Rate High Partially meetsTable 12 - Footnote ¥ Medium
Susceptibility of infection isolate High Partially meetsTable 12 - Footnote ¥ Medium
Synopsis Table: S. aureus (Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 13 - Footnote *
Healthcare setting

Table 13 Footnotes

Table 13 - Footnote *

Action Required to Fill Gap:
No new action is required. This may need to be reviewed if VISA and VRSA were to emerge in Canada.

Return to Table 13 - Footnote * referrer

Table 13 - Footnote †

This was not assessed as MRSA colonization data is difficult to interpret given there are differences and variations in screening practices across facilities.

Return to Table 13 - Footnote referrer

Colonization Rate for MRSA Low Current surveillance system does collect and/or report. Feasibility not assessed.Table 13 - Footnote
Susceptibility of colonization isolate (all S. aureus  including MRSA) Low Current surveillance system partially collects and/or reports. Feasibility not assessed.
Synopsis Table: S. aureus (Other infection sites [including BSI] and Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 14 - Footnote *
Community setting

Table 14 Footnotes

Table 14 - Footnote *

Action Required to Fill Gap:
Use antibiogram data from the community; monitor all available S. aureus lab isolates (i.e. BSI as well as other infection sites) in order to capture the proportion of MRSA out of all the S. aureus isolates collected in the community. Capturing infection rate data would require specific point prevalence studies.

Return to Table 14 - Footnote * referrer

Table 14 - Footnote ‡

It was determined that MRSA was the specific organism of interest for the community setting. Most BSI will be captured in the healthcare setting.

Return to Table 14 - Footnote referrer

Table 14 - Footnote ¥

While some community-associated infections (CA-MRSA) are captured by CNISP (i.e. patients admitted to hospital where the MRSA was acquired in the community), these do not represent the overall burden of CA-MRSA.

Return to first Table 14 - Footnote ¥ referrer

Infection Rate Medium Partially meetsTable 14 - Footnote ¥ Low
Susceptibility of infection isolateTable 14 - Footnote High Partially meetsTable 14 - Footnote ¥ Medium
Colonization Rate for MRSA Low Current surveillance system does not collect and/or report. Feasibility not assessed.
Susceptibility of colonization isolate (all S. aureus including MRSA) Low Current surveillance system does not collect and/or report. Feasibility not assessed.

3.8 Streptococcus pneumoniae (Invasive disease)

Existing surveillance system(s):

Invasive disease caused by Streptococcus pneumoniae is a nationally notifiable disease. The Agency undertakes surveillance to monitor epidemiological trends of invasive pneumococcal disease (IPD) through a number of systems:

The Canadian Notifiable Disease Surveillance System (CNDSS) is a passive surveillance system that captures basic demographic information of IPD cases reported nationally.

The NML (Streptococcus and Sexually Transmitted Infections [STI] Unit) receives invasive isolates submitted by the provincial and regional laboratories and conducts serotyping and susceptibility testing on these samples. The results are released through the National Laboratory Surveillance of Invasive Streptococcal Disease in Canada Annual Summary and has also been included in the CARSS Report 2015. The susceptibility testing referred to above is outsourced by NML to the Canadian Antimicrobial Resistance Alliance (CARA) which is affiliated with the University of Manitoba.

In addition, the Immunization Monitoring Program, ACTive (IMPACT) and International Circumpolar Surveillance (ICS) are two enhanced surveillance systems targeting special populations. IMPACT is a pediatric hospital-based active surveillance network administered by the Canadian Paediatrics Society with funding from the Agency. ICS is a population-based surveillance network of circumpolar countries. Within Canada, ICS targets populations of the three territories, as well as Labrador and northern Quebec. Both IMPACT and ICS capture epidemiologic-laboratory linked data on IPD (e.g. demographic information, serotype, susceptibility results).

Finally, the Enhanced Invasive Pneumococcal Disease Surveillance System (eIPDSS) pilot, launched in 2011, is an enhanced case-based surveillance system. The system is currently being piloted in New Brunswick to assess the feasibility of conducting a timely, epidemiologic-laboratory linked national IPD surveillance through a web-based application. It is jointly managed by the Agency’s Centre for Immunization and Respiratory Infectious Diseases (CIRID) and the NML. As an expansion of eIPDSS pilot, the Agency is currently working to develop an integrated enhanced epidemiologic-laboratory linked surveillance system for five nationally notifiable invasive bacterial diseases, including IPD. Through this expanded surveillance, all sterile-site isolates from confirmed IPD cases will be submitted for serotyping and susceptibility testing. The system will foster a better understanding of IPD trends, especially changes in serotype distribution and antimicrobial resistance (AMR) at the national level.

Limitations:

At the present time CNDSS surveillance of the incidence of IPD is adequate provided there is full reporting by P/Ts.  However, the existing surveillance systems do not fully support the interpretation of disease trends and susceptibility pattern at the national level.

Although only about 50% of all national invasive cases are sent to NML through provincial and regional labs for serotyping, provinces that do their own serotyping submit serotyping data to be included in the National Laboratory Surveillance of Invasive Streptococcal Disease in Canada Annual Summary. Approximately 80% of all isolates from IPD are serotyped and are included in this report. Of those that are serotyped, only one-third receive antibiogram susceptibility testing which may not be representative of the susceptibility pattern of all IPD cases in Canada. Also, given that susceptibility testing is outsourced, ongoing funding will be required and without secured funding, the feasibility for susceptibility testing would become an issue.

Because IMPACT and ICS target special populations, IPD trends and susceptibility pattern interpreted by data from these two systems may only represent pediatric populations and Northern Canadians, respectively.

In addition, the epidemiologic and laboratory data from CNDSS and the NML reference testing mentioned above are not linked, limiting the ability to interpret IPD trends in Canada. The goal of the eIPDSS as a pilot study was to establish a national surveillance system combining both epidemiologic and laboratory data to better represent IPD trends across the country with greater confidence into regional variation in serotype distribution and antimicrobial susceptibility.

Summary of Priority Data Metrics and Recommendations: Streptococcus pneumoniae (Invasive disease)

Summary of Priority Data Metrics:
  1. Monitoring the infection rate of Streptococcus pneumoniae invasive disease (or IPD) is a high priority and is currently collected and reported (CNDSS).
  2. The TG determined that capturing Streptococcus pneumoniae susceptibility data in the form of antibiogram data for patients with invasive disease is a high priority. Furthermore, it was recommended that serotyping is also of importance.
Recommendations:

The TG recommended that NML should continue to arrange for (i.e., CARA) or provide reference susceptibility testing. A recommended first step would be to determine whether NML reference testing is nationally representative and whether this has long-term feasibility. National representativeness can be assessed by having a more detailed look at case details of the IPD isolates sent to the NML. This can include determining which samples are sent to the lab, the case-based criteria used, as well as the antibiogram and serotype data produced.

The eIPDSS pilot, is unique in providing epidemiological and clinical aspects of the antimicrobial resistant IPD cases. Therefore, it is important to make sure all isolates of the cases captured by the eIPDSS pilot study are submitted for susceptibility testing and serotyping. The eIPDSS pilot study has undergone an evaluation and the release of the evaluation report regarding the ongoing feasibility of this enhanced surveillance system is pending.

The TG also recommended examining the current BC Antibiogram Pilot data to determine what information if any is available for Streptococcus pneumoniae and whether this is another feasible modality for capturing antibiogram data for this organism. One caveat to consider would be that the isolates from this pilot could represent invasive disease, non-invasive disease, as well as normal flora. Hence it would be difficult to determine if certain isolates represent  colonization versus disease.

Synopsis Table: Streptococcus pneumoniae (Invasive disease)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 15 - Footnote *
Healthcare and Community settingTable 15 - Footnote

Table 15 Footnotes

Table 15 - Footnote *

Action Required to Fill Gap:
Determine whether NML reference susceptibility testing is nationally representative and whether this has long-term feasibility. In addition, the eIPDSS pilot study for IPD should be evaluated and it should be assessed whether it has additional benefit beyond the baseline reference services provided by the NML. A final action would be an examination of the current BC Antibiogram Pilot data to determine what information if any is available for Streptococcus pneumoniae in the community and determine whether this is another feasible modality for capturing antibiogram data for this organism.

Return to Table 15 - Footnote * referrer

Table 15 - Footnote †

Examination of invasive isolates would represent both healthcare and community cases given that most of the invasive cases will be hospitalized.

Return to Table 15 - Footnote referrer

Infection Rate High Meets needs High
Susceptibility of infection isolate High Partially meets Medium
Synopsis Table: Streptococcus pneumoniae (Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 16 - Footnote *
Healthcare and Community settingTable 16 - Footnote

Table 16 Footnotes

Table 16 - Footnote *

Action Required to Fill Gap:
No new action is required.

Return to Table 16 - Footnote * referrer

Table 16 - Footnote †

Examination of invasive isolates would represent both healthcare and community cases given that most of the invasive cases will be hospitalized.

Return to Table 16 - Footnote referrer

Colonization Rate & Susceptibility of colonization isolate Low Current surveillance system does not collect and/or report. Feasibility not assessed.

3.9 Streptococcus pyogenes (Invasive disease)

Existing surveillance system(s):

Invasive disease caused by Streptococcus pyogenes (Group A Streptococcus or GAS) is a nationally notifiable disease. The Agency undertakes surveillance to monitor epidemiological trends of invasive GAS disease via the Canadian Notifiable Disease Surveillance System (CNDSS).

The National Microbiology Laboratory’s (NML) Streptococcus and STI Unit also receive all invasive GAS isolates and conducts limited susceptibility testing on these samples and the results are released through the National Laboratory Surveillance of Invasive Streptococcal Disease in Canada Annual Summary and has also been included in the CARSS Report 2015.

In addition, the International Circumpolar Surveillance (ICS) captures epidemiologic-laboratory linked data on invasive GAS disease (i.e., including incidence and susceptibility rates). ICS is a population-based surveillance network of circumpolar countries. Within Canada, ICS targets populations of the three territories, in addition to Labrador and northern Quebec.

Limitations:

At the present time, surveillance of invasive GAS disease (infection rate) is adequate provided there is full reporting by P/Ts. However, the existing surveillance systems do not fully support the interpretation of disease trends and susceptibility pattern at the national level.

Approximately 80% of all national invasive cases are sent to NML through provincial and regional labs for sequence typing. Of those that are sequence typed, all receive antibiogram susceptibility testing but this may not be representative of the susceptibility pattern of all invasive GAS cases in Canada. Antimicrobial susceptibility testing on GAS is performed using disk diffusion, which only results in interpretations and not minimum inhibitory concentrations (MICs). 

Because ICS target special populations in Canada, invasive GAS disease trends and susceptibility pattern interpreted by ICS data may only represent Northern Canadians.

Summary of Priority Data Metrics and Recommendations: Streptococcus pyogenes (Invasive disease)

Summary of Priority Data Metrics:
  1. Monitoring the infection rate of Streptococcus pyogenes (or GAS)invasive disease is a high priority and is currently collected and reported (CNDSS).
  2. The TG determined that capturing Streptococcus pyogenes (or GAS) susceptibility data as part of a national surveillance program is of low priority. Given resistance is not an overall concern for this organism at the present time; consider removing GASfrom the Top Priority Group of Organisms for AMR surveillance and placing it in the Second Priority Group of Organisms.
Recommendations:

NML should continue to provide reference susceptibility testing. Examination of invasive isolates would represent both healthcare and community cases given that most of the invasive cases will be hospitalized. The TG recommended that it would be of interest to consider the proportion of all invasive isolates that are resistant to macrolides and this can be accomplished by the NML on a periodic basis.

Synopsis Table: Streptococcus pyogenes (Invasive disease)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 17 - Footnote *
Healthcare and Community setting
Table 17 - Footnote *

Action Required to Fill Gap:
No new action is required.

Return to Table 17 - Footnote * referrer

Infection Rate High Meets needs High
Susceptibility of infection isolate Low Current surveillance system partially  collects and/or reports. Feasibility not assessed.
Synopsis Table: Streptococcus pyogenes (Colonization sites)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 18 - Footnote *
Healthcare and Community setting
Table 18 - Footnote *

Action Required to Fill Gap:
No new action is required.

Return to Table 18 - Footnote * referrer

Colonization Rate & Susceptibility of colonization isolate Low Current surveillance system does not collect and/or report. Feasibility not assessed.

3.10 Neisseria gonorrhoeae

Existing surveillance system(s):

Neisseria gonorrhoeae is a notifiable disease and the Agency undertakes surveillance to monitor epidemiological trends of Neisseria gonorrhoeae via the Canadian Notifiable Disease Surveillance System (CNDSS).

The collection and reporting on Neisseria gonorrhoeae antimicrobial resistance in Canada is only limited to a laboratory-based system. Approximately one-third of Neisseria gonorrhoeae cases are cultured by P/Ts and tested for AMR.  Resistant isolates as well as all isolates from jurisdictions that do not do AMR testing are sent to the NML. These select samples sent to NML represent approximately 10% of all nationally reported gonorrhea cases, the remaining cases are diagnosed by nucleic acid amplification testing (NAAT) and it is not possible to determine antimicrobial resistance associated with those cases. Using the submitted cultures to determine resistance has inherent biases and may not be representative because the criteria to determine which isolates are submitted may not be consistent; often these were known resistant cases. Hence, the full spectrum of susceptibility of the organism within Canada is not captured (for example, in a given year of all the samples tested by the NML, only about 8% of isolates were susceptibleFootnote 3). Limited epidemiological information (i.e., only age and gender) is provided with these select samples sent to the NML. Results are released through the National Surveillance of Antimicrobial Susceptibilities of Neisseria gonorrhoeae Annual Summary and were also included in the CARSS Report 2015. 

In 2014, the Public Health Agency of Canada also started a pilot project called the Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea (ESAG), which during its pilot phase is collecting data on resistance information and epidemiological data at sentinel sites in select provinces (Alberta, Manitoba, and Nova Scotia).  Provincial public health authorities and laboratories across Canada were invited to participate as sentinel sites to collect additional epidemiologic data (such as risk factors, demographics, treatments, and treatment failures) on all or a subset of clients and to increase the number of cultures obtained from clients.

Limitations:

Currently there is no robust surveillance system in place that monitors Neisseria gonorrhoeae AMR. Given the increased use of NAAT (i.e., the majority of gonorrhea cases in Canada are diagnosed using NAAT), the availability of antibiogram data has become limited. 

A pilot project has been started as mentioned above; however, several limitations and barriers need to be considered. To start, sentinel sites may not be representative of the general population in the province (i.e., over/underrepresented sub-populations may be an issue). There is difficulty obtaining valid denominators to estimate representativeness and complete risk factor data. In addition, logistics of culture collection, refusals to have cultures done and the need to follow clinical guidelines may also be barriers. Varied processes are used by different sites to collect epidemiological data which affect the completion of risk factor data.

In addition to these limitations, the challenges that need consideration are the time and resources required to fully adopt and implement an ESAG-like sentinel site surveillance system as well as securing the funding required to implement such a surveillance system nationally.

Summary of Priority Data Metrics and Recommendations: Neisseria gonorrhoeae

Summary of Priority Data Metrics:
  1. Monitoring the infection rate of Neisseria gonorrhoeae is a high priority and is currently collected and reported (CNDSS).
  2. Susceptibility of the organism (i.e., monitoring for Neisseria gonorrhoeae drug resistance in Canada) is a high priority given the increasing prevalence of resistance worldwide.  Currently there is no robust surveillance system in place that monitors Neisseria gonorrhoeae AMR.
Recommendations:

Continue with the selected susceptibility testing that NML already provides and also consider looking at sentinel sites across Canada either in the form of periodic testing or as point prevalence studies. This would help to increase the number of isolates collected for culture and susceptibility testing in order to enhance available resistance data on Neisseria gonorrhoeae.

ESAG is a current pilot project that collects information on resistance and epidemiological data from sentinel sites. This project would need to be assessed along with considerations of its long term feasibility and need for ongoing funding.

Synopsis Table: Neisseria gonorrhoeaeTable 19 - Footnote
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 19 - Footnote *
Community settingTable 19 - Footnote

Table 19 Footnotes

Table 19 - Footnote *

Action Required to Fill Gap:
Given the select samples tested by NML is limited with regards to susceptibility data, consider looking at sentinel sites across Canada either in the form of periodic testing or as point prevalence studies.
The ESAG project as a national surveillance system for gonorrhea AMR could be possible, but would need to be validated along with considerations of its long term feasibility and need for ongoing funding.

Return to Table 19 - Footnote * referrer

Table 19 - Footnote †

Colonization is not applicable for this organism.

Return to Table 19 - Footnote referrer

Table 19 - Footnote ‡

National surveillance for Neisseria gonorrhoeae is represented by community level data. Data in the healthcare setting for this organism is not relevant for national surveillance.

Return to Table 19 - Footnote referrer

Infection Rate High Meets needs High
Susceptibility of infection isolate High Partially meets Low

3.11 Mycobacterium tuberculosis (Active disease)

Existing surveillance system(s):

Mycobacterium tuberculosis is a notifiable disease and the Agency undertakes surveillance to monitor epidemiological trends of active tuberculosis (TB) disease and TB drug resistance via two surveillance systems: the Canadian Tuberculosis Reporting System (CTBRS) and the Canadian Tuberculosis Laboratory Surveillance System (CTBLSS).

The CTBRS is a case-based surveillance system that collects selected non-nominal data on people diagnosed with active TB disease. Provincial and territorial public health authorities voluntarily submit data on TB cases that meet the case definition for national-level surveillanceFootnote 4. Data captured include information on demographics, diagnostics, drug-susceptibility testing results (including first- and second-line drugs), clinical risk factors and treatment outcomes for all active cases diagnosed in Canada.  A limited number of data elements collected by the CTBRS are provided to the Canadian Notifiable Disease Surveillance System (CNDSS), none of which are related to antimicrobial resistance.

The CTBLSS monitors drug resistance patterns in Mycobacterium tuberculosis. The Agency collaborates with the Canadian Tuberculosis Laboratory Technical Network and participating laboratories (representing all provinces and territories) to monitor TB resistance in Canada. This is a laboratory-based surveillance system which captures all the drug-susceptibility results from isolates tested within a year. Limited demographic detail is provided with the test result (i.e., sex, age and/or date of birth). These data are usually available for publication earlier in the calendar year than the case-based data system mentioned above (CTBRS) and provides data on trends in drug resistance over time.

Limitations:

One limitation for consideration is that the CTBRS and CTBLSS are unlinked systems and hence the ability to examine case-based data against the laboratory-based data is currently not feasible.

Summary of Priority Data Metrics and Recommendations: Mycobacterium tuberculosis (Active disease)

Summary of Priority Data Metrics:
  1. Monitoring the rate of active TB disease is a high priority and is currently adequately collected and reported (i.e., CTBRS data is released in annual TB surveillance reports; annual updates are provided to CNDSS for reporting purposes).
  2. Susceptibility of the organism (i.e., monitoring for TB drug resistance in Canada) is a high priority given the increasing resistance worldwide. Two national surveillance systems (CTBRS and CTBLSS) collect this information; however, these systems are not linked.
Recommendations:

Given that the rate of TB drug resistance in Canada is fairly low, the amount of work and resources needed to try and attempt a linkage between the two data systems above may be greater than the benefit. However, it may be worthwhile assessing the feasibility of linking the two systems and this would require provincial and territorial Ministry of Health agreements and would require exploration of the logistics required. This recommendation only refers to TB active disease. Latent tuberculosis infection (LTBI) was not discussed.

Synopsis Table: Mycobacterium tuberculosis (Active disease)
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 20 - Footnote *
Healthcare & Community settingsTable 20 - Footnote

Table 20 Footnotes

Table 20 - Footnote *

Action Required to Fill Gap:
Assess the feasibility of linking the case-based and lab-based surveillance systems.

Return to Table 20 - Footnote * referrer

Table 20 - Footnote †

All active TB cases captured by these above systems represent both the healthcare and community settings.

Return to Table 20 - Footnote referrer

Infection Rate High Meets needs Medium
Susceptibility of infection isolate High Meets needs Medium

3.12 Salmonella spp.

Existing surveillance system(s):

Salmonella spp. is a notifiable disease and the Agency undertakes surveillance to monitor epidemiological trends of Salmonella via the Canadian Notifiable Disease Surveillance System (CNDSS). CNDSS provides total annual case numbers and some demographic information is collected.

In addition, the National Enteric Surveillance Program (NESP) collects weekly data on all samples of enteric organisms (including Salmonella spp.) and mainly serves as an outbreak identification system. NESP is accurate and timely as it provides total counted cases per week and is cross validated with provinces, although under-reporting does occur. NESP does not provide demographic information (e.g., age, sex, etc.).

CIPARS reports on the incidence of human Salmonella spp. infections using NESP data, and on the occurrence of antimicrobial resistance in Salmonella isolates from those  infections using CIPARS susceptibility test results. Although listed separately from the ESBL-producing and carbapenem-resistant organisms, because the primary concern about Salmonella is as an enteric pathogen, Salmonella is an Enterobacteriaceae related to E. coli and Klebsiella, and isolates can be ESBL-producing and/or carbapenem-resistant and can cause invasive disease (e.g., bloodstream infections, pneumonia, etc.). CIPARS monitors trends in antimicrobial use in animals and antimicrobial resistance in enteric bacteria from human, animal, and food sources across Canada. This information supports the creation of evidence-based policies and mitigation strategies to contain the emergence and spread of resistant bacteria between animals, food, and people in Canada. Salmonella is one of the bacterial species under surveillance in CIPARS, and the only one represented in all components. Human Salmonella isolates are forwarded to the NML by the provincial public health laboratories. This is an enhanced passive surveillance; a letter of agreement was signed in 2002 by the provincial public health reference laboratories and PHAC (then Health Canada) wherein the provinces agreed to forward all or a subset of their Salmonella spp. isolates to NML for the purposes of AMR surveillance. This agreement officially launched the human component of CIPARS. The large population provinces (British Columbia, Alberta, Ontario, and Québec) submit isolates from cases for the first 15 days of the month, while the other provinces (Saskatchewan, Manitoba, New Brunswick, Prince Edward Island, Nova Scotia and Newfoundland and Labrador) submit all isolates received. All human Salmonella Newport and Salmonella Typhi isolates are forwarded because of multidrug resistance concerns and their clinical importance, respectively. The human isolates represent cases from both the community and healthcare settings, and are not differentiated. Current Clinical and Laboratory Standards Institute (CLSI) standards are used to determine whether the isolates are susceptible or resistant. Susceptibility testing is routinely performed on the following serotypes: S. Enteritidis, S. Heidelberg, S. Newport, S.Typhimurium, S. 4,[5],12:i:- , S. Typhi, and S. Paratyphi A & B. This sub-set represents approximately 70%-80% of isolates submitted to the NML. Isolates from other serotypes are stored and tested on an ad hoc/issues basis as issues and questions arise.

CIPARS also collects samples from animal and food sectors for isolation of Salmonella and antimicrobial susceptibility testing. Active surveillance of AMR in Salmonella is conducted on sentinel farms (broiler chickens and pig), abattoirs/slaughter houses (chickens and pigs),  and  retail meats (chicken, pork, beef, and turkey).  Salmonella isolates from veterinary diagnostic laboratories and from animal feed samples collected by the Canadian Food Inspection Agency are also submitted to CIPARS for susceptibility testing (passive surveillance).

In addition, FoodNet Canada conducts active surveillance of Salmonella isolated from humans, food and farm animals across three sentinel sites (in Ontario, British Columbia, and Alberta). The human data generated include both community and hospital cases, and the farm data are a subset of the CIPARS data. For each human Salmonella case, information on demographics, clinical spectrum and risk factors are collected. Although antimicrobial susceptibility testing is not conducted for FoodNet Canada, a subset of FoodNet Canada human, animal, food and water isolates are tested for susceptibility by CIPARS.

Limitations:

At the present time, surveillance of Salmonella is adequate via CNDSS and NESP although these surveillance systems serve different needs. Specific limitations include: under-reporting of the number of Salmonella spp. cases by P/Ts to CNDSS and, although NESP data are considered more timely and accurate, the system does not collect any demographic data. CIPARS monitoring of Salmonella spp. human isolates for AMR is adequate and there are currently no major limitations for reporting on the metrics chosen in this assessment; however, only 7 serotypes, representing 70-80% of isolates, are tested on an ongoing basis.

Summary of Priority Data Metrics and Recommendations: Salmonella spp.

Summary of Priority Data Metrics:
  1. Monitoring the infection rate of Salmonella spp. is a high priority and data are currently collected and reported (CNDSS and NESP).
  2. Monitoring the susceptibility of Salmonella spp. is a high priority given the increasing resistance (CIPARS).
Recommendations:

The current surveillance systems in place (i.e., CNDSS, NESP, and CIPARS) for the purpose of monitoring incidence rates of disease as well as AMR are working well to capture the priority data needed. Currently the WHO is working towards adopting a surveillance system model that monitors human, food and animal samples for AMR. Given that CIPARS collects AMR data about Salmonella spp. in food, animals as well as humans, Canada meets this WHO approach for Salmonella and for the three major food animal commodities (chickens, pigs, cattle) under surveillance.

Synopsis Table: Salmonella spp.
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 21 - Footnote *
Healthcare and Community setting

Table 21 Footnotes

Table 21 - Footnote *

Action Required to Fill Gap:
No new action is required.

Return to Table 21 - Footnote * referrer

Infection Rate High Meets needs High
Susceptibility of infection isolate High Meets needs High
Colonization Rate & Susceptibility of colonization isolate Low Current surveillance system does not collect and/or report. Feasibility not assessed.

3.13 Campylobacter spp.

Existing surveillance system(s):

Campylobacter spp. is a notifiable disease and the Agency undertakes surveillance to monitor epidemiological trends of this organism via the Canadian Notifiable Disease Surveillance System (CNDSS). CNDSS provides total annual case numbers and some demographic information is collected.

In addition, the National Enteric Surveillance Program (NESP) collects weekly data on all samples of enteric organisms (including Campylobacter spp.) and mainly serves as an outbreak identification system. NESP is accurate and timely as it provides total counted cases per week and is cross validated with provinces, although under-reporting does occur. NESP does not provide demographic information (e.g., age, sex, etc.).

CIPARS actively monitors AMR for this organism in animal and food sectors only . Active surveillance for Campylobacter is conducted on sentinel farms (broiler chicken), abattoirs/slaughter houses (chicken, pig and cattle), and select retail meats (chicken and turkey).

FoodNet Canada conducts surveillance of Campylobacter isolated from humans, food and farm animals across three sentinel sites (in Ontario, British Columbia, and Alberta). The human cases include both community and hospital samples. For each human Campylobacter case, information on demographics, clinical spectrum and risk factors are collected. Although antimicrobial susceptibility testing is not part of the FoodNet Canada, a retrospective pilot project is currently being carried out to test all FoodNet Canada(Ontario site) human isolates. As is the case for Salmonella, depending on the surveillance component (farm, retail, water), some FoodNet Canada isolates are tested for antimicrobial susceptibility by CIPARS. Discussions are being held on the feasibility of conducting AMR testing on human Campylobacter isolates moving forward.

Limitations:

At the present time, surveillance of Campylobacter is adequate via CNDSS and NESP for incidence rate information, although these surveillance systems serve different needs. Specific limitations include: under-reporting of the number of Campylobacter spp. cases by P/Ts to CNDSS and although NESP data is considered more timely and accurate, the system does not collect any demographic data.

CIPARS is the only surveillance program that routinely monitors AMR in Campylobacter spp.; however, this is only regularly done for animal and food sectors.  FoodNet Canada does collect some information on human isolates from sentinel sites; while there is no routine antimicrobial susceptibility testing done, both retrospective and prospective (on a trial basis) testing of human isolates from FoodNet Canada is being conducted by CIPARS.

Summary of Priority Data Metrics and Recommendations: Campylobacter spp.

Summary of Priority Data Metrics:
  1. Monitoring the infection rate of Campylobacter spp. is a high priority and is currently collected and reported (CNDSS and NESP).
  2. The TG determined that capturing Campylobacter spp. susceptibility data as part of a national surveillance program is of medium priority overall. However, in relation to all the priority organisms discussed by the TG and the actions needed to enhance surveillance for the listed top priority organisms, surveillance of susceptibility for Campylobacter spp. was ranked as the lowest priority in terms of current urgency and need pending further assessment as described below. Under the WHO Global Action Plan on AMR, information on Campylobacter spp. is not currently required or requested.
Recommendations:

It was noted by the TG members that not enough is known about the burden of AMR Campylobacter spp. in humans within Canada. Campylobacter is the leading foodborne bacterial pathogen. There are reports of increasing resistance (e.g., to fluoroquinolones) outside of Canada,  and some increases in fluoroquinolone resistance in Campylobacter from poultry meat (chicken, turkey) have been observed in Canada by CIPARS.  There may be more information available with regards to AMR for Campylobacter spp. in Canada in the foreseeable future through two Agency led efforts: 1) CIPARS is currently conducting retrospective and some prospective susceptibility testing on FoodNet Canada human isolates; and 2) the BC Antibiogram Pilot data analysis is underway which includes human Campylobacter spp. isolates.

Synopsis Table: Campylobacter spp.
Setting and Required Data Metric Priority of Data Metric Current Surveillance System FeasibilityTable 22 - Footnote *
Healthcare and Community setting

Table 22 Footnotes

Table 22 - Footnote *

Action Required to Fill Gap:
Examine the outcomes of the CIPARS retrospective susceptibility testing and the BC Antibiogram Pilot study analysis for Campylobacter spp. and determine whether AMR surveillance in humans for this organism should become a higher priority within Canada.

Return to Table 22 - Footnote * referrer

Infection Rate High Meets needs High
Susceptibility of infection isolate Medium Partially meets needs Medium
Colonization Rate & Susceptibility of colonization isolate Low Current surveillance system does not collect and/or report. Feasibility not assessed.

4. Conclusions

The CIDSC AMR Surveillance Task Group reviewed the data metric requirements for each of the identified 1st priority organisms and provided specific recommendations for each organism. The TG recommended focusing on the high and medium priority data metrics where the current surveillance systems partially met or did not completely meet the data requirements and where there is medium to high feasibility to address the data gaps identified. It was also recommended that a review of the national AMR surveillance data metric priorities should occur on an ongoing basis and as new issues emerge. The next sections summarize the data metric priorities.

4.1 High priority data metrics

Among the 1st priority organisms, the TG identified 19 high priority data metrics. For over half of these data metrics (10/19), the existing surveillance system(s) meet the required needs.

For 7 data metrics identified, the current surveillance systems are partially meeting required needs. Specifically, it was identified that the respective current surveillance system partially monitors:

  1. Susceptibility of infection isolates for Enterococcus (Bloodstream infections) in the healthcare setting, with VRE being the most important organism to monitor
  2. Infection rate and susceptibility of infection isolates for Enterobacteriaceae spp.  E. coli and Klebsiella (Bloodstream infections) in the healthcare setting
  3. Infection rate of S. aureus (Bloodstream infections) in the healthcare setting
  4. Susceptibility of infection isolates for S. aureus (Bloodstream infections) in the healthcare setting, with MRSA being the most important organism to monitor
  5. Susceptibility of infection isolates for S. aureus (Other infection sites including BSI) in the community setting, with MRSA being the most important organism to monitor
  6. Susceptibility of infection isolates for Streptococcus pneumoniae (Invasive disease) in the healthcare and community settings
  7. Susceptibility of infection isolates for Neisseria gonorrhoeae in the community setting

Finally, for 2 of the high priority data metrics, the current surveillance systems do not meet the data metric requirements and the feasibility to address the actions was assessed as medium. Specifically:

  1. It was identified that there is no surveillance system that monitors Clostridium difficile infection rates in the community.
  2. There is no system in place which monitors susceptibility data for Enterobacteriaceae spp.(E. coli and Klebsiella) causing genito-urinary tract infections.

For further details see Table 3 in Section 4.4.

4.2 Medium priority data metrics

Among the 1st priority organisms, the TG then identified 8 medium priority data metrics. Among these, the existing surveillance systems meet the required needs for one of the identified data metrics.

For 5 data metrics identified, the current surveillance systems are partially meeting required needs. Specifically:

  1. Susceptibility of colonization isolates for Enterobacteriaceae spp. E. coli and Klebsiella (Colonization sites) in the healthcare setting
  2. Susceptibility of infection isolates for Pseudomonas spp. and Acinetobacter spp. (Bloodstream infections) in the healthcare setting
  3. Susceptibility of colonization isolates for Pseudomonas spp. and Acinetobacter spp. (Colonization sites) in the healthcare setting
  4. Infection rate for S. aureus (Other infection sites including BSI) in the community setting
  5. Susceptibility of infection isolates for Campylobacter spp. in the healthcare and the community settings

Finally, for 2 of the medium priority data metrics, the current surveillance systems do not meet the data metric requirements however the feasibility to address the actions was assessed as low. Specifically:

  1. Susceptibility of infection isolates for Clostridium difficile (Diarrheal disease) in the community setting
  2. Infection rate for Enterobacteriaceae spp.  E. coli and Klebsiella (Genito-urinary tract infections) in the community setting

For further details see Table 3 in Section 4.4.

4.3 Low priority data metrics

Among the 1st priority organisms, the TG identified 14 low priority data metrics. Currently some surveillance systems collect or partially collect these identified low priority data metrics and it was acknowledged that surveillance programs may need to review whether these data metrics are ongoing priorities.

4.4 Order of actions required to fill data metric gaps for priority organisms

In order to provide a means of examining the most important data metrics and the respective most feasible next steps, an ordered table is presented.  Table 3 summarizes the identified data metrics by a ranking of the order of action required to fill the data metric gaps. Table 3 is ranked by priority of data metric, status of current surveillance system and feasibility to address the identified action required.

The following steps were taken to establish Table 3:

  • Step 1: Stratified list of data metrics by priority of data metric (high, medium, low)
  • Step 2: Within the stratification of Step 1, further stratified the list of data metrics by status of current surveillance system (does not meet needs, partially meets needs, meets needs)
  • Step 3: Within the stratification of Step 2, further stratified the list of data metrics by feasibility to address the identified action required (see legend below)

Legend for Feasibility:

No
It is not feasible to address the identified action required.
Low
There is low feasibility to address the identified action required.
Medium
There is medium feasibility to address the identified action required.
High
It is highly feasible to address the identified action required or to continue this action if the current surveillance systems meets needs.
Not assessed
The feasibility is not considered because the data metric is considered a low priority.
Table 3. Order of actions required to fill data metric gaps for priority organisms
High Priority Data Metric  
Organism Setting Priority Data Metric Current Surveillance System Feasibility Action required to fill gap
Clostridium difficile (Diarrheal disease) Community Infection Rate Does not meet needs Medium In the community setting, point prevalence studies should be conducted to capture the burden of CDI.
Enterobacteriaceae spp. 
E. coli and Klebsiella (Genito-urinary tract infections)
Community Susceptibility of infection isolate Does not meet needs Medium For AMR data, consider use of community level antibiogram data on an annual basis (i.e., BC Antibiogram Pilot).
Enterococcus: (Bloodstream infections) Healthcare Susceptibility of infection isolate Partially meets needs High Capture all Enterococcus BSI and then determine what proportion are VRE in addition to monitoring other susceptibility patterns for this organism.
Enterobacteriaceae spp. 
E. coli and Klebsiella (Bloodstream infections)
Healthcare Infection Rate & Susceptibility of infection isolate Partially meets needs Medium In the healthcare setting, monitoring rates of resistant E. coli and Klebsiella BSI is of particular importance.
Several classes of antibiotics of interest were discussed.
S. aureus (Bloodstream infections) Healthcare Infection Rate Partially meets needs Medium Capture all S. aureus BSI rates in the healthcare setting and the associated resistance patterns. The proportion by type of antibiotic resistance provided by antibiogram data (i.e., proportion MRSA BSI out of all S. aureus BSI, etc.) should be monitored with MRSA as the most important antimicrobial resistance pattern to monitor.  This may need to be reviewed if vancomycin-intermediate and vancomycin-resistant S. aureus (VISA and VRSA, respectively)  were to emerge in Canada.
S. aureus (Bloodstream infections) Healthcare Susceptibility of infection isolate Partially meets needs Medium Capture all S. aureus BSI rates in the healthcare setting and the associated resistance patterns. The proportion by type of antibiotic resistance provided by antibiogram data (i.e., proportion MRSA BSI out of all S. aureus BSI, etc.) should be monitored with MRSA as the most important antimicrobial resistance pattern to monitor.  This may need to be reviewed if vancomycin-intermediate and vancomycin-resistant S. aureus (VISA and VRSA, respectively)  were to emerge in Canada.
S. aureus (Other infection sites [including BSI] and Colonization sites) Community Susceptibility of infection isolate Partially meets needs Medium Use antibiogram data from the community; monitor all available S. aureus lab isolates (i.e., BSI as well as other sites of infection) in order to capture the proportion of MRSA out of all the S. aureus isolates collected in the community.
Streptococcus pneumoniae (Invasive disease) Healthcare & Community Susceptibility of infection isolate Partially meets needs Medium Determine whether NML reference susceptibility testing is nationally representative and whether this has long-term feasibility. In addition, the eIPDSS pilot study for IPD should be evaluated and it should be assessed whether it has additional benefit beyond the baseline reference services provided by the NML. A final action would be an examination of the current BC Antibiogram Pilot data to determine what information, if any, is available for Streptococcus pneumoniae in the community and determine whether this is another feasible modality for capturing antibiogram data for this organism.
Neisseria gonorrhoeae Community Susceptibility of infection isolate Partially meets needs Low Given the select samples tested by NML is limited with regards to susceptibility data, consider looking at sentinel sites across Canada either in the form of periodic testing or as point prevalence studies.
The ESAG project as a national surveillance system for gonorrhea AMR could be possible but would need to be validated along with considerations of its long term feasibility and need for ongoing funding.
Clostridium difficile (Diarrheal disease) Healthcare Infection Rate Meets needs High No new action is required.
Enterococcus: (Bloodstream infections) Healthcare Infection Rate for VRE Meets needs High No new action is required.
Streptococcus pneumoniae (Invasive disease) Healthcare & Community Infection Rate Meets needs High No new action is required.
Streptococcus pyogenes (Invasive disease) Healthcare & Community Infection Rate Meets needs High No new action is required.
Neisseria gonorrhoeae Community Infection Rate Meets needs High No new action is required.
Salmonella spp. Healthcare & Community Infection Rate Meets needs High No new action is required.
Salmonella spp. Healthcare & Community Susceptibility of infection isolate Meets needs High No new action is required.
Campylobacter spp. Healthcare & Community Infection Rate Meets needs High No new action is required.
Mycobacterium tuberculosis (Active disease) Healthcare & Community Infection Rate Meets needs Medium Assess the feasibility of linking the case-based and lab-based surveillance systems.
Mycobacterium tuberculosis (Active disease) Healthcare & Community Susceptibility of infection isolate Meets needs Medium Assess the feasibility of linking the case-based and lab-based surveillance systems.
Table 3. Order of actions required to fill data metric gaps for priority organisms (continued)
Medium Priority Data Metric  
Organism Setting Priority Data Metric Current Surveillance System Feasibility Action required to fill gap
Clostridium difficile (Diarrheal disease) Community Susceptibility of infection isolate Does not meet needs Low In the community setting, point prevalence studies should be conducted to capture the burden of CDI. Capturing susceptibility data in the community would likely be unfeasible given it is difficult to conduct routine susceptibility on this organism and the limited availability of testing across community private labs.
Enterobacteriaceae spp. 
E. coli and Klebsiella (Genito-urinary tract infections)
Community Infection Rate Does not meet needs Low For infection rate data, a periodic point-prevalence community-based study can be conducted, provided funding is available.
Enterobacteriaceae spp. 
E. coli and Klebsiella (Colonization sites)
Healthcare Susceptibility of colonization isolate Partially meets
needs
Medium Collection of selective hospital antibiogram data for colonization isolates for antibiotics discussed in Section 3.2.
Pseudomonas spp. and Acinetobacter spp. (Bloodstream infections) Healthcare Susceptibility of infection isolate Partially meets needs Medium If antibiogram data is already available (i.e., CVC-BSI data), it would be of interest to look at the susceptibility patterns in the healthcare setting. If additional resources are available, point prevalence studies may be another mechanism to monitor for emerging resistance. It may be necessary to collect samples beyond just blood in order to have a larger sample size.
If MDRO or XDRO patterns are detected, the priority of this data metric should be considered as high.
Pseudomonas spp. and Acinetobacter spp. (Colonization sites) Healthcare Susceptibility of colonization isolate Partially meets needs Medium Collection of selective hospital antibiogram data for colonization isolates and assess patterns that would determine MDRO and/or XDRO.
Campylobacter spp. Healthcare & Community Susceptibility of infection isolate Partially meets needs Medium Examine the outcomes of the CIPARS retrospective susceptibility testing and the BC Antibiogram Pilot study analysis for Campylobacter spp. and determine whether AMR surveillance in humans for this organism should become a higher priority within Canada.
S. aureus (Other infection sites [including BSI] and Colonization sites) Community Infection Rate Partially meets needs Low Capturing infection rate data would require specific point prevalence studies.
Clostridium difficile (Diarrheal disease) Healthcare Susceptibility of infection isolate Meets needs High No new action is required.
Table 3. Order of actions required to fill data metric gaps for priority organisms (continued)
Low Priority Data Metric  
Organism Setting Priority Data Metric Current Surveillance System Feasibility Action required to fill gap
Clostridium difficile (Diarrheal disease) Healthcare & Community Colonization Rate & Susceptibility of colonization isolate Current surveillance system does not collect and/or report. Feasibility not assessed.
Enterobacteriaceae spp. 
E. coli and Klebsiella (Colonization sites)
Healthcare Colonization
Rate
Current surveillance system partially collects and/or reports. Feasibility not assessed.
Enterobacteriaceae spp. 
E. coli and Klebsiella (Genito-urinary tract infections)
Community Colonization Rate & Susceptibility of colonization isolate Current surveillance system does not collect and/or report. Feasibility not assessed.
Enterococcus: (Colonization sites) Healthcare Colonization Rate for VRE & Susceptibility of colonization isolate (all Enterococcus, including VRE) Current surveillance system partially collects and/or reports. Feasibility not assessed.
Enterococcus: (Genito-urinary tract infections) Healthcare & Community Infection Rate & Susceptibility of infection isolate Current surveillance system partially collects and/or reports. Feasibility not assessed.
Enterococcus: (Genito-urinary tract infections) Healthcare & Community Colonization Rate & Susceptibility of colonization isolate Current surveillance system partially collects and/or reports. Feasibility not assessed.
Pseudomonas spp. and Acinetobacter spp. (Bloodstream infections) Healthcare Infection Rate and Colonization rate Current surveillance system partially collects and/or reports. Feasibility not assessed.
S. aureus (Colonization sites) Healthcare Colonization Rate for MRSA & Susceptibility of colonization isolate (all S. aureus  including MRSA) Current surveillance system partially collects and/or reports. Feasibility not assessed. This may need to be reviewed if VISA and VRSA were to emerge in Canada.
S. aureus (Other infection sites [including BSI] and Colonization sites) Community Colonization Rate for MRSA & Susceptibility of colonization isolate (all S. aureus including MRSA) Current surveillance system does not collect and/or report. Feasibility not assessed.
Streptococcus pneumoniae (Colonization sites) Healthcare & Community Colonization Rate &
Susceptibility of colonization isolate
Current surveillance system does not collect and/or report. Feasibility not assessed.
Streptococcus pyogenes (Invasive disease) Healthcare & Community Susceptibility of infection isolate Current surveillance system partially  collects and/or reports. Feasibility not assessed.
Streptococcus pyogenes (Colonization sites) Healthcare & Community Colonization Rate & Susceptibility of colonization isolate Current surveillance system does not collect and/or report. Feasibility not assessed.
Campylobacter spp. Healthcare & Community Colonization Rate & Susceptibility of colonization isolate Current surveillance system does not collect and/or report. Feasibility not assessed.
Salmonella spp. Healthcare & Community Colonization Rate & Susceptibility of colonization isolate Current surveillance system does not collect and/or report. Feasibility not assessed.

Appendix A: Glossary

AMR
Antimicrobial resistance
BSI
Bloodstream infection
CA-CDI
Community-associated Clostridium difficile infection
CA-MRSA
Community-associated Methicillin-resistant Staphylococcus aureus
CANWARD
Canadian Ward Surveillance Study
CARA
Canadian Antimicrobial Resistance Alliance
CARSS
Canadian Antimicrobial Resistance Surveillance System
CDI
Clostridium difficile infection
CIPARS
Canadian Integrated Program for Antimicrobial Resistance Surveillance
CLSI
The Clinical and Laboratory Standards Institute
CNDSS
Canadian Notifiable Disease Surveillance System
CNISP
Canadian Nosocomial Infection Surveillance Program
CPHLN
Canadian Public Health Laboratory Network
CPO
Carbapenamase-producing organism
CRA
Carbapenem-resistant Acinetobacter
CRE
Carbapenem-resistant Enterobacteriaceae
CRGN
Carbapenem-resistant gram negatives
CRO
Carbapenem-resistant organism
CTBLSS
Canadian Tuberculosis Laboratory Surveillance System
CTRS
Canadian Tuberculosis Reporting System
CVC-BSI
Central Venous Catheter-Bloodstream Infections
ESAG
Enhanced Surveillance of Antimicrobial-resistant Gonorrhea
ESBL
Extended-spectrum β-lactamase
GAS
Group A Streptococcus
HA-CDI
Healthcare-associated Clostridium difficile infection
HA-MRSA
Healthcare-associated Methicillin-resistant Staphylococcus aureus
ICU
Intensive Care Unit
IPD
Invasive pneumococcal disease
LFZ
Laboratory for Foodborne Zoonoses
LTBI
Latent tuberculosis infection
MDRO
Multidrug-resistant organism
MIC
Minimum inhibitory concentration
MRSA
Methicillin resistant Staphylococcus aureus
NESP
National Enteric Surveillance Program
NML
National Microbiology Laboratories
SIR
Susceptible, intermediate, resistant
TB
Tuberculosis
VISA
Vancomycin Intermediate Staphylococcus aureus
VRE
Vancomycin-resistant Enterococci
VRSA
Vancomycin Resistant Staphylococcus aureus
XDRO
Extensively drug-resistant organism

Appendix B: Data Metrics Template

Types of AMR data for Organism X (Site of Infection)
Setting All Settings
(data collection usually passive)
Healthcare settings Community setting
Variable Infection (Notifiable diseases) Infection Colonization Susceptibility of organism (antibiogram) Infection Colonization (special studies) Susceptibility of organism (antibiogram)
Measure Per 1,000 population/yr Per 1,000 admissions/yr Per 1,000 admissions/yr % of isolates resistant Per 1,000 population/yr Per 1,000 population/yr % of isolates resistant
Summary / Recommendation
Top Pick #1:
Top Pick #2:
Priority / Relevance - - - - - - -
Feasibility - - - - - - -
Rationale re: Measure  - - - - - - -
Antibiotics to consider for testing - - - - - - -
Other Considerations - - - - - - -

LEGEND

Site of infection: This was considered based on CIDSC Task Group (CIDSC TG) and WHO “syndrome” categories as follows:

  • Genito-urinary tract infections (WHO)
  • Bloodstream infections (WHO)
  • Diarrheal illness (WHO)
  • Gonorrhea (WHO)
  • Respiratory tract infections (CIDSC TG)
  • Surgical site infections (CIDSC TG)
  • Soft skin and tissues infections (CIDSC TG)
  • Other

Setting: Canadian Notifiable Disease Surveillance, National Microbiology Reference Testing (early warning system), Healthcare setting, Community setting, Other (as mentioned in “Other Considerations”)

Variable/Measure: Variable of interest (as measured by a priority data metric):

  1. Infection rate (i.e., number of cases per 1,000 admissions/year, number of cases per 1,000 population/year)
  2. Colonization rate  (i.e., number of cases per 1,000 admissions/year, number of cases per 1,000 population/year)
  3. Susceptibility of organism (i.e., susceptible, intermediate, resistant [SIR])

Priority / Relevance: Refers to the importance of this measure for each organism and whether this is the most suitable measure (i.e., Is it important to collect the respective data for this measure?)

Scale:

  • 3 = High
  • 2 = Medium
  • 1 = Low
  • 0 = Not applicable

Feasibility: Refers to whether it is possible to collect the data required for the recommended data metric (i.e., Based on current resources, is it possible to collect data for this measure?)

Scale:

  • n/a = Not applicable
  • 1 = No, not feasible with current resources or would require major adjustments
  • 2 = Yes, possibly feasible with some resource adjustments
  • 3 = Yes, feasible with current or minor resource adjustments
  • Rationale for measure (as required)
  • Antibiotics to consider for testing (as required)
  • Other Considerations (as required)
  • Summary/Recommendation

Footnotes

Footnote 1

For the purposes of this report the term antibiotics is defined as a subset of antimicrobials which are directed to bacterial organisms.

Return to footnote 1 referrer

Footnote 2

BEHZADI, Payam et al. "A Survey on Urinary Tract Infections Associated with the Three Most Common Uropathogenic Bacteria." Mædica 5.2 (2010): 111–115

Return to footnote 2 referrer

Footnote 3

National Microbiology Laboratory. 2015. National Surveillance of Antimicrobial Susceptibilities of Neisseria gonorrhoeae Annual Summary 2013. Public Health Agency of Canada, Winnipeg, MB. http://healthycanadians.gc.ca/publications/drugs-products-medicaments-produits/2013-neisseria/index-eng.php

Return to footnote 3 referrer

Footnote 4

Source: http://www.phac-aspc.gc.ca/tbpc-latb/pubs/tbcan13pre/assets/pdf/tbcan13pre-eng.pdf

Return to footnote 4 referrer