The role of PHE’s AMRHAI Reference Unit

Professor Neil Woodford Antimicrobial Resistance & Healthcare Associated Infections (AMRHAI) Reference Unit

© Crown copyright

What does AMRHAI offer ?

•  Susceptibility testing •  for confirmation of exceptional resistances

•  Infer resistance mechanisms from antibiograms

•  Investigation of priority resistance mechanisms

•  Strain typing to aid outbreak investigation

•  Treatment advice; infection prevention & control advice

•  + Research (externally-funded)

•  + Evaluations of new drugs and diagnostics (externally-funded)

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My Unit’s goals

•  Setting England’s (the UK’s) Resistance and HCAI Problems into National and Global Context

•  Better understanding of (resistant) bacterial clones

•  distribution (global, national , regional)

•  contribution resistance plays to success

•  Coordinated surveillance of mechanisms

•  global, regional and national

•  Identify geographic ‘hot spots’ and ‘high risk’ patients

•  early, targeted IPC interventions

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Feed into the UK’s integrated surveillance of AMR risks

Colonized residents or visitors

Non-human reservoirs: animals and environment

Victims from conflict zones

Hospital treatment or travel overseas

•  Multiple risks to be assessed to minimize damage •  We need better intelligence

Inter-hospital transfers (UK)

Non-human reservoirs: foodstuffs (domestic or imported)

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AMRHAI works with PHE’s surveillance scientists

Pathogen % carbapenem resistance 2008 2009 2010 2011 2012 2013

E. coli 0.08 0.09 0.11 0.18 0.25 0.22 K. pneumoniae 0.7 0.4 0.6 1.2 1.1 1.6

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•  Provides specialist microbiology that seeks to explain trends •  Is at the centre of a national / regional laboratory network •  Benefits from a ‘spider’s web effect’ •  Monitors new and emerging AMR issues, long before they register in surveillance programmes

CPE in the UK, 2000-2014

Klebsiella spp. 79%; E. coli 12%, Enterobacter spp., 7%; others 2%

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Early cases often imported

Imported & ‘home grown’

Towards WGS for reference services

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ID Define lineage & surveillance

Assess virulence

+

Predict resistance

Outbreak investigations

WGS

Biomarkers

Phase 2

WGS-based genotypic antibiograms •  could ‘soon’ replace much AST for surveillance purposes

•  low impact of the low error rate

•  could ‘soon’ reduce need for AST in reference laboratories unless •  to guide treatment •  for agents with poorest genotypic/phenotypic concordance •  comparative in-vitro activity of new agents

•  EUCAST Subcommittee on the role of whole genome sequencing (WGS) in antimicrobial susceptibility testing of bacteria •  Chair: Neil Woodford, London UK; will report in mid-2016

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Working with academia

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•  Health Protection Research Units in HCAI and AMR •  Imperial College and PHE (Alison Holmes and Alan Johnson) •  University of Oxford and PHE (Derrick Crook and Neil Woodford)

•  National research units involving a network of relevant, world class expertise that can comprehensively address the challenges of AMR and HCAI, with the resilience and capacity to respond to emerging issues and public health priorities

•  Creating integrated programmes of research to develop new, cost-effective approaches for detection, surveillance, investigation and reduction of HCAI and AMR in the NHS

Working with industry

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•  extensive collections of MDR clinical isolates

•  independent evaluations

of: •  diagnostics •  AST platforms •  developmental

antibiotics

0

2

4

6

8

10

12

14

16

18

20

Approved Phase 3 Phase 2 Phase 1

Possible

No

Active vs. >90% UK CPE

AMRHAI is a WHO Collaborating Centre •  Participate in missions and training courses

•  AMR and/or IPC

•  Promote reference microbiology for AMR •  Reference testing and characterisation of isolates received •  Supply ‘control ‘ isolates

•  Promote research/development in reference laboratories •  Host overseas visitors on short or long-term placements •  Support applications for funding

•  Seek funding for WHO CC activities •  Lobbying •  Groundwork for bids to The Fleming Fund in 2016

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Improving interaction with other AMR CCs

CAESAR Network

•  one-year FTC post (lab-based) secured from PHE’s AMR Priority Programme Delivery Board, 2016-17 to support projects

•  Seek close working with CCs at RIVM and in Smolensk

•  bid to Gates Foundation (Karolinska / PHE / RIVM)

WHO-Net

•  close working with CC in Boston; named collaborators on bid to NIH

•  develop the software to increase capacity for handling molecular and WGS-derived data

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National & international capacity building •  Without lab testing we’re blind to (the extent of) AMR problems •  Improve lab access; aim for a reference lab in every country / region

•  Each serving as the hub of a national network •  Each acting as a spoke in an international network •  Performing essential techniques, proficient to international standards •  Sharing data / experience

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