Current activities in human sector including public awareness

Human AMR surveillance programs in Japan （NESID and JANIS）

Satowa SuzukiAntimicrobial Resistance Research CenterNational Institute of Infectious Diseases,

Japan

Antimicrobial resistance surveillance in Japan

• National Epidemiological Surveillance of Infectious Diseases (NESID)– patient reporting– pathogen surveillance

• Japan Nosocomial Infections Surveillance (JANIS)

• Antimicrobial Stewardship in Japan

– Based on Infectious Diseases Control Act (Mandatory reporting) for infectious diseases in community (>100 infectious diseases)

– patient reporting – AMR: Symptomatic cases of 7 AMR pathogens– pathogen surveillance for AMR (Carbapenem resistant Enterobacteriaceae) 

has been started from 2017

National Epidemiological Surveillance of Infectious Diseases (NESID)

• Carbapenem‐resistant Enterobacteriaceae

(CRE)• Vancomycin‐resistant 

Enterococcus sp.(VRE)• Multidrug‐resistant 

Acinetobacter sp.(MDRA)• Vancomycin‐resistant 

Staphylococcus aureus (VRSA, never been reported)

(VRSA)

• Methicillin‐resistant Staphylococcus aureus (MRSA)• Multidrug‐resistant Pseudomonas aeruginosa (MDRP)• Penicillin‐resistant Streptococcus pneumoniae (PRSP)

Pathogen surveillance 

CREMDRA and 

VRE

National dataShowing trend and geographical difference of AMR prevalence 

Antibiogram for selected bacteria species and antimicrobial agent

Hospital A Hospital B Hospital C

Aggregated data by Hospital⇒ Feedback report

WardA

WardB

WardC

Patient‐Isolate Tracing tool

JANIS Clinical Laboratory Division Hospital B Hospital C

Clinical microbiological 

data

JANIS Analysis Program

Hospital A

Boxplot forinter‐hospitalcomparison

E. coli

https://janis.mhlw.go.jp/english/index.asp

Automated system for bacterial identification and drug susceptibility test

Laboratory Information System (LIS) of hospital

Data submission and Feedback,  JANIS Clinical Laboratory Division

JANIS Data format

Surveillance Site, Hospital Diagnostic labs

Upload to JANIS website

Feedback data

https://janis.mhlw.go.jp/index.asp

Comparison of 47 prefectures

Antimicrobial susceptibility pattern

Evidence for appropriate antimicrobial prescription

0

10

20

30

40

50

60

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

2007 53.15

JANIS and NESID‐AMR in HumanMRSA: Methicillin‐resistant Staphylococcus aureus

NESID Number of Reported cases of MRSA infection per sentinel site

69%66% 65% 67% 66% 67%

63% 62% 60% 59% 58%55% 53% 51% 49% 49% 48%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Proportion of MRSA among S. aureus   JANIS CL division 

Goal of MRSA control in National Action Plan (by 2020)

00.20.40.60.81

1.21.41.61.8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Multidrug‐resistant Pseudomonas aeruginosa（MDRP)

Imipenem

Meropenem

Levofloxacin

Gentamicin

Amikacin

JANIS and NESID‐AMR in Human

NESID Number of Reported cases of MDRP infection per sentinel site

JANIS CL division, resistance rate(%) of P. aeruginosa to antimicrobials 

MDRP: resistant to carbapenems(e.g. imipenem), amikacin and fluoroquinolones(e.g. levofloxacin)

Vancomycin‐Resistant Enterococci (VRE)JANIS CL division, Resistance rate(%) of Enterococci to vancomycin(VCM) and teicoplanin 

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

2008 2009 2010 2011 2012 2013 2014 2015 2016

E. faecalisVCMTEIC

0%

1%

1%

2%

2%

3%

2008 2009 2010 2011 2012 2013 2014 2015 2016

E. faecium

VCMTEIC

0

50

100

150

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

NESID   Number of Reported case of VRE 

infection

JANIS and NESID‐AMR in Human

Nosocomial AMR pathogen Comparison between EU countries and Japan 

Establishment of hospital infection control in Japan

0

200

400

600

800

Number of Infection Control

Microbiological Technologist

Morikane, K. J Epidemiol 2012

Number of certified Infection Control Nurse

Year

JANIS

Tsutsui et al.  BMC Health service research  in press

Prevalence of MRSA by prefecture

What can we know from AMR surveillance?Consider “local factor” in AMR epidemiology

Number of hospital per 100,000 capita

More MRSA in western part of Japan

More small hospitals in western part of Japan

0

2

4

6

8

10

12

14

16

18

20

Okina

wa

Kago

shim

aMiyazaki

Ohita

Kumam

oto

Nagasaki

Fuku

oka

Saga

Kochi

Ehim

eKa

gawa

Tokushim

aYamaguchi

Hiro

shim

aOkayama

Shim

ane

Tottori

Wakayam

aNara

Hyo

goOsaka

Kyoto

Shiga

Mie

Aichi

Shizuo

kaGifu

Nagan

oYaman

ashi

Fuku

iIshikawa

Toyama

Niigata

Kana

gawa

Tokyo

Chiba

Saita

ma

Gun

ma

Tochigi

Ibaragi

Fuku

shim

aYamagata

Akita

Miyagi

Iwate

Aomori

Hok

kaido

Hospitals<200 beds per 100,000 capita

Hospitals≧200 beds per 100,000 capita 

West East

JANIS‐JVARM integrationJVARM Japanese Veterinary Antimicrobial Resistance Monitoring System

JANIS analysis program

JVARM analysisprogram

Copy+ minor modification

HumanE. coli

CattleE. coli

Annual report in same format

International use of JANIS system

JANIS analysis program

JANIS system for other countries

Copy+ minor modification

JVARM data

WHONET output

Hospital dataNational  dataRegional dataHospital data

0%

5%

10%

15%

20%

25%

30%

2003 2005 2007 2009 2011 2013

採卵鶏 豚 ⾁⽤⽜ ⾁⽤鶏 JANIS

Proportion of cefazoline resistance in E. coli

Layer chicken

Broiler chicken

Pig Cattle

0%

5%

10%

15%

20%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013採卵鶏 豚 ⾁⽤⽜ ⾁⽤鶏 JANIS（CTX)Layer chicken

Broiler chicken

Pig Cattle

Proportion of ceftiofur(JVARM) /cefotaxime(JANIS) resistance in E. coli

Hiki M et al. Foodborne Pathog Dis. 2015 Jul;12(7):639-43.Emerg Infect Dis. 2010 Jan;16(1):48‐54. 

JapanCanada

The voluntarily withdrawal of ceftiofur at hatcheries dramatically decreased cephalosporin resistance in E. coli from broiler chicken 

NESID‐Pathogen surveillance • Started from 2017 for carbapenem‐resistant Enterobacteriaceae

• In 2017, 1660 CRE cases were reported and 865 isolates from those cases were tested for carbapenemase genes at public health laboratories in prefectures.

• AMR training course for public health laboratories.– Antimicrobial susceptibility testing, differentiation of ‐

lactamases by phenotype and genotype…– Standardized methods – In 2018, 78 participants (4 courses)– Providing training materials and control (DNA and strains)

Antimicrobial Steward Ship

90% of the prescription was for outpatients

Public awareness activities by AMR Clinical Reference Center

Education tools

Commendation for excellent AMR public awareness activities

Famous TV stars are appointed to “AMR containment ambassador”

Antimicrobial Stewardship andMedical Reimbursement

For InpatientsOrganizing Antimicrobial Stewardship Team

For Out patients (pediatric )

1000 JPY/ admission

800 JPY/ First visit of patient

To inform the reason of not to prescribe antimicrobial drug