Antimicrobial resistance

General information

Since the second half of the 20th century, the development and use of antibiotics has revolutionized the approach to treating and preventing infective diseases and infections, thus allowing the evolution of modern medicine. The emergence of resistance to antibiotics, however, risks undermining these achievements.

Over the last few years, antimicrobial resistance (AMR) has increased significantly, requiring specific public health impact assessments for each pathogen, antibiotic and geographical area. Diseases caused by each microorganism may indeed vary in terms of severity and incidence, and the same microorganism may be effectively targeted with few or several antibiotics, as well as other primary prevention measures such as vaccination.

Antimicrobial resistance is a complex problem in that it has multiple causes: the increased use (including inappropriate use) of antibiotics both in human and veterinary medicine; the use of antibiotics in animal husbandry and agriculture; the spread of hospital-acquired infections caused by antibiotic-resistant microorganisms (and the limited control of these infections); the growing spread of resistant strains due to an increase in international travel and migratory flows.

The constant use of antibiotics leads to higher selective pressure, contributing to the emergence, multiplication and spread of resistant strains. Moreover, the emergence of pathogens resistant to multiple antibiotics (multidrug resistance) further reduces options for effective treatment. It is important to stress that this phenomenon is often related to healthcare-associated infections, which develop and spread in hospitals and other healthcare facilities.

AMR is one of the greatest global public health threats of our times, with significant clinical implications (increased morbidity and lethality, longer illnesses, possible development of complications, possible epidemics) and a notable economic impact as more expensive medicines and procedures, longer hospital stays and possible disabilities result in extra costs.

Over the last decades, international organisations such as the World Health Organization (WHO), the European Union (EU) and the European Centre for Disease Prevention and Control (ECDC), have issued recommendations and proposed strategies and coordinated actions aimed at containing this phenomenon, identifying AMR as a priority in healthcare settings.

At the 2015 World Health Assembly, the WHO adopted the Global Action Plan (GAP) on antimicrobial resistance, which outlines five strategic objectives:

• To improve awareness through effective communication and education targeted at healthcare workers and the general population
• To strengthen surveillance activities
• To improve prevention and control of infections
• To optimize the use of antimicrobial medicines in human and animal health
• To support research and innovation.

The European Union has been committed to fighting antimicrobial resistance for several years, and in 2017 developed a new action plan against antimicrobial resistance based on a “One Health” integrated approach encompassing humans, animals and the environment.

In line with these recommendations, and following an agreement between the central Government and the Regions, in 2017 Italy adopted its “National Action Plan on Antimicrobial Resistance (Piano Nazionale di Contrasto dell’Antimicrobico-Resistenza - PNCAR) 2017-2020”. The plan outlines strategies to tackle this phenomenon at local, regional and national level, which are consistent with both the objectives set out in the WHO and EU action plans and the One Health approach. Surveillance of antimicrobial resistance is one of the activities identified in the PNCAR and a key point for assessing the impact of the adopted strategies as well as the achievement of some of the plan’s indicators.

AMR surveillance systems

The importance and global spread of AMR have prompted the implementation of several surveillance systems based on the collection of laboratory data at local and national level. To ensure that the data collected through these systems are comparable and interpretable, and to facilitate comparisons between countries, a European surveillance network was established in 2000. In 2010, this network acquired institutional capacity and became the European Antimicrobial Resistance Surveillance Network (EARS-Net), which is coordinated by ECDC. EARS-Net is a network of national networks collecting antimicrobial resistance data from 30 European countries.

In 2015, the WHO launched the Global Antimicrobial Resistance Surveillance System (GLASS) in support of the Global Action Plan to strengthen the evidence base on AMR worldwide. As of December 2018, 71 countries were enrolled in GLASS.

Since 2001, the Istituto Superiore di Sanità (ISS) has been coordinating Italy’s national antimicrobial resistance surveillance system (AR-ISS). The project started as a sentinel surveillance system based on a network of hospital microbiology laboratories recruited throughout the country on a voluntary basis. Its primary objective is describing frequency and trends in antimicrobial resistance in a selected group of bacteria isolated from infections of definite clinical relevance (bacteraemia or meningitis), including community-acquired infections (Streptococcus pneumoniae) and healthcare-associated infections (Staphylococcus aureus, Enterococcus faecium and E. faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, Acinetobacter baumannii group).

For each microorganism, the focus is on some antimicrobials or antimicrobial groups that are particularly important for treatment or monitoring trends in antimicrobial resistance, while taking into account the information needs of the EARS-Net system.

In January 2019, the AR-ISS protocol was updated via a circular issued by the Ministry of Health with the aim of improving its performance, in line with the requirements of the PNCAR, by actively involving the Regions also through existing and developing regional surveillance networks. This has led to a significant increase in regional and national representation. Laboratories participating in the AR-ISS surveillance system are now based in all Italian Regions and Autonomous Provinces, and their number has risen dramatically, from about 50 in previous years to 98 in 2018.

Through the AR-ISS, Italy participates in EARS-Net. Italy’s data are processed, analyzed and compared with those of the other European countries, and published each year during the European Antibiotic Awareness Day (18 November). Data can be found online, in the “Surveillance Atlas of Infectious Diseases” section of the ECDC website and in an annual report available on the same website. Since 2018, the AR-ISS has also contributed data on bacteraemia to GLASS.

In addition to the AR-ISS, in 2013 the Ministry of Health established a national surveillance system dedicated to bacteraemia caused by carbapenemase-producing enterobacteriaceae (CPE), and specifically by carbapenem-resistant and/or carbapenemase-producing Klebsiella pneumoniae and Escherichia coli. The protocol for this surveillance is currently being updated.