One-Health approach of Antimicrobial Resistance

May 17, Brussels, SsID seminar

Dik Mevius

Tales of the unexpected in resistance epidemiology: convenient and inconvenient truths

Roald Dahl (writer, not microbiologist)

Antibiotic use in animals and humans

The “obvious” pathway of antibiotic resistance Antibiotic use in

animals

Antibiotic resistance in animals

Antibiotic resistance in healthy humans

Infections

Livestock-Associated MRSA ESBL CRE/CPE

What would make LA-MRSA a public health threat?

High acquisition rate after animal contact High transmission rate through the food chain High transmission rate among humans (in community and/or

health care settings ● High transmission and short duration of carriage ● Low transmission but long duration of carriage

High virulence Few (if any) treatment options

LA-MRSA: after 10 years of research:

High acquisition rate after animal contact Van Cleef et al. JCM 2011; 49: 1030-3 No evidence of transmission through the food chain EFSA nov. 2009 Low transmission rate among humans (in community and/or

health care settings

● Low transmission and short duration of carriage Van Cleef et al. PLoS One 2010; e9385; Van Cleef et al. JCM 2011; 49: 1030-3 Graveland et al. PLoS One 2011; e16830 ;

Wassenberg et al. CMI 2011; 17: 316-9; Hetem et al. EID 2013; 19: 1797-1802

Virulence, not different from other S. aureus Multiple treatment options remaining 0 of the last 40 reported healthcare-associated MRSA-outbreaks in

the Netherlands were caused by LA-MRSA

New variants emerging?

LA-MRSA CC9/CC398 displaying spa type t899 ● Backbone CC398 ● CC9 region with spa-

gene

Infections not associated to livestock Poultry products?

Enzymes that are able to hydrolyze the β-lactam ring

• Narrow-spectrum β-lactamases (TEM-1, SHV-1)

Hydrolyse: amoxicillin, 1st generation cephalosporins

• Extended-spectrum β-lactamases (= ESBLs: predominantly CTX-M)

Hydrolyse: amoxicillin, cephalosporins and aztreonam

• Carbapenemases (= CPs: KPC, OXA-48, NDM, VIM)

Hydrolyse: amoxicillin, cephalosporins and carbapenems

β-lactamases

Plasmids? • Extrachromosomal DNA

– Toolboxes for bacteria to rapidly adapt to environmental circumstances, such as:

• Antibiotics • Disinfectants • Heavy metals

• Horizontal transfer from E. coli -> E. coli, but also from E. coli -> Salmonella or Klebsiella

• No limitations in the possibilities to spread (compared to e.g. MRSA)

– Contact, environment, food

• ESBL > Food safety problem!!

27 Replicon (plasmid) types in Enterobacteriaceae (?? Additional small untypeable plasmids)

CTX-M-15

CTX-M-1

CMY-2

SafefoodERA-project: The Role of Commensal Microflora in the transmission of ESBLs CVI: Dik Mevius; Alieda van Essen, Cindy Dierikx HPA: John Wain, Neil Woodford, Michaela Williams AHVLA: Martin Woodard, Nick Coldham, Guanghui Wu BfR: Beatriz Guerra, Irene Rodriguez, Janine Beutlich, Reiner Helmuth FLI: Stefan Schwarz, Kristina Kadlec, Anne-Kathrin Schink

Figure 1. Minimum Spanning trees of MLST STs of 294 isolates in which ESBL/AmpC genes and plasmids were identified . A. ESBL. Green: CTX-M-1, red: CTX-M-15 B: replicon-type. Green: incI1, red: multi-F, yellow: incK, blue: incN

CTX-M-15: clonally distributed CTX-M-1: distribution is plasmid mediated

A B

Use of 3rd and 4th gen cephalosporins in animals until 2011 in the Netherlands

• Ceftiofur: – As spray and sc/in ovo injection in hatcheries – Preventive use of Naxcel on day 1 (and 8) to young

piglets – Treatment of (endo)metritis in dairy cows and

administration for eg mastitis because of 0 withdrawal period for milk

• Use of cefquinome for dry cow treatment • Use of Convenia (cefovecin) for infections in cats

ESBL-producing E. coli (MARAN-reports)

Cefotaxime R% in E. coli

0

5

10

15

20

25

1998 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

R%

Dairy cattleVeal calvesPigsBroiler chickens

kip

AmoxicillinCefotaximImipenemGentamicinNeomycinTetracyclineSulphamethoxazoleTrimethoprimCiprofloxacinNalidixic acidChloramphenicolFlorfenicolN

1998 (303)199838.92.605.655.436.043.643.95.00.7303

1999 (318)199935.50.603.564.244.036.039.66.30.3318

2001 (318)200151.61.603.59.158.851.941.241.210.70.0318.0

2002 (164)200251.87.303.011.659.158.545.145.116.51.8164.0

2003 (165)200349.73.00.03.013.960.046.135.837.015.80.0165.0

2004 (300)200464.39.705.313.366.772.762.745.246.323.02.0300.0

2005 (304)200563.514.10.03.911.260.971.663.250.852.018.11.0304.0

2006 (153)200665.615.67.816.252.670.861.750.050.018.80.6153.0

2007 (43)200760.520.92.355.862.848.848.848.816.32.343.0

440200865.515.014.514.558.270.960.060.961.825.24.860.021.60.0

200917.917.5

varken

AmoxicillinCefotaximImipenemGentamicinNeomycinTetracyclineSulphamethoxazoleTrimethoprimCiprofloxacinNalidixic acidChloramphenicolFlorfenicol

1998 (302)19981710048330180

1999 (318)199914002534022120

2001 (318)200119000347331150

2002 (149)200226103140441190

2003 (155)200328102469450081

2004 (296)200426101264534332121

2005 (299)20053010146251410090

2006 (79)20063400347053471183

2007 (169)200736.71.25.34.572.855.050.93.02.412.40.651.94.90

296200835112685749121015670

200944

0123456789

199851%25%19%3%2%0%0%0%0%0%

199947%29%15%8%2%0%0%0%0%0%

200153%22%17%8%1%0%0%0%0%0%

200238%23%22%14%3%0%1%0%0%0%

200326%26%21%23%3%1%0%0%0%0%

200426%19%15%15%17%6%1%0%0%0%

200528%17%14%17%18%5%0%0%0%0%

200628%17%14%17%18%5%0%0%0%0%

kalf

AmoxicillinCefotaximCeftazidimeGentamicinNeomycinTetracyclineSulphamethoxazoleTrimethorpimCiprofloxacinNalidixic acidChloramphenicolFlorfenicol

1996 (166)33.74.84.81.252.453.616.318.130.71.2

1998 (38)199831.60.00.00.068.463.215.810.526.30.0

2005 (165)1999

2006 (152)2001

2007 (175)2002

2003

2004

200548.53.00.612.727.382.454.544.225.526.133.318.2

200648.02.02.611.225.072.454.644.118.418.421.715.8

200746.94.62.96.922.069.751.441.712.616.028.09.7

200840.52.02.012.467.345.142.520.320.319.012.4

20091.82.3

Grafiekamp

1998199819981998

1999199919991999

2001200120012001

2002200220022002

2003200320032003

2004200420042004

2005200520052005

2006200620062006

2007200720072007

Dairy

Veal

Pig

Broiler

R%

Ampicillin R% in commensal E. coli

31.5789473684

16.5562913907

38.9438943894

13.8364779874

35.534591195

18.8679245283

51.572327044

25.5033557047

51.8292682927

27.7419354839

49.696969697

26.0135135135

64.3333333333

0

48.4848484848

30.4347826087

63.4868421053

2.3622047244

48.0263157895

34.1772151899

65.5844155844

5.2631578947

46.8571428571

36.6863905325

60.4651162791

koe

AmoxicillinCefotaximeCeftazidimeGentamicinNeomycinTetracyclineSulphamethoxazoleTrimethorpimCiprofloxacinNalidixic acidChloramphenicolFlorfenicol

2005 (139)1998

2006 (127)1999

2007 (152)2001

2002

2003

2004

20050.00.00.00.70.00.70.70.70.00.00.00.0

20062.40.80.80.00.83.13.93.10.00.80.80.8

20075.30.00.00.71.26.65.95.30.00.71.31.3

14820089.51.41.43.413.510.16.14.75.44.12.710.16.80.0

20091.51.5

20052006

099%94%

11%2%

20%2%

31%0%

40%2%

50%0%

60%0%

70%0%

80%0%

90%0%

Grafiek1 fot

1998199819981998

1999199919991999

2001200120012001

2002200220022002

2003200320032003

2004200420042004

2005200520052005

2006200620062006

2007200720072007

2008200820082008

2009200920092009

Dairy cattle

Veal calves

Pigs

Broiler chickens

R%

Cefotaxime R% in E. coli

0

0.6622516556

2.6402640264

0.3154574132

0.6289308176

0.3144654088

1.572327044

1.3422818792

7.3170731707

0.6451612903

3.0303030303

0.6756756757

9.6666666667

0

3.0303030303

0.6688963211

14.1447368421

0.7874015748

1.9736842105

0

15.5844155844

0

4.5714285714

1.1834319527

20.9302325581

1.3513513514

1.9607843137

1.0135135135

15

1.5

1.8

4

17.9

Prevalence of ESBLs in broilers

0 10 20 30 40 50 60 70 80 90 100

ABCDEFGHI

JKL

MNOPQRSTUVWXYZ

Percentage ESBL positive isolates per farm (n=26)

• All farms ESBL-positive

ESBL-genes and plasmids in Broiler isolates (Dierikx et al. 2010)

0

2

4

6

8

10

12

14

16

18

CTXM-1 TEM-52 CMY-2 TEM-20 CTXM-2 ACC-1 SHV-2

S. enterica (n=21)

E. coli (n=23)

IncI1 IncHI2/P IncK IncI1 Nt IncK IncI1

+ nt

Predominant in humans:

CTX-M-15, 14, 9, 3, SHV-12

Which types of ESBLs in humans in NL?

Voets GM, Platteel TN, Fluit AC, Scharringa J, Schapendonk CM, et al. (2012) Population Distribution of Beta-Lactamase Conferring Resistance to Third-Generation Cephalosporins in Human Clinical Enterobacteriaceae in The Netherlands. PLoS ONE 7(12): e52102. doi:10.1371/journal.pone.0052102 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0052102

“Poultry Associated

genes”:

25.5%

Voets et al. 2013:

4.6%

CMY-2 pos E. coli

“Human associated

genes”:

45.5%

http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0052102

Association with humans

CMI, 2011

Conclusion: ● Yes an animal attribution is apparent ● Poultry meat was considered to be the most likely source

84 – 100% of poultry meat positive for ESBLs Pork/beef incidentally positive

Prevalences in the Netherlands

> 50% in (herds) animals Broilers Layers Veal calves Fattening pigs Turkeys Dogs Cattle 41%

Environment Soil Surface water

Knapp, Dolfing et al. 2009

13% birds (waders)

ESBLpositive

Is poultry the source or part of the problem??

ESBL-attribution analysis (ESBLAT) 2013 - 2018

Veilig voedsel produceren

Determine the contribution of all ESBL-reservoirs to carriership and infections in humans

Determine the transmissieroutes from these reservoirs to humans.

Contact Food Water Air

Major output

Humans

Water

Meat

Animals

Prev

alen

ces

Humans

Water

Meat

Animals

Genetic associations

Humans

Water

Meat

Animals

Quantified as Proportional Similarity index (PSI)

Humans

Water

Meat

Animals

PCA

27

QMRA analysis

For consumers (RIVM) (Evers et al, PLoS One. 2017 Feb 24;12)

Environment: ● Swimmers

(IRAS/RIVM) ● Residents (IRAS:

resistance genes in farm dust (PM10))

Consumption of meat and swimming will lead to exposure to ESBLs People living close to

farms are permanently exposed to ESBLs

Independent of the prevalence the quantitative exposure of humans is low (except for farmers) and it does `not` contribute to carriership

Conclusion

ESBLs epidemiology has a real One-Health character ● ESBLs found in all reservoirs and exchange between

reservoirs

Everything is everywhere

Dorado-Garca et al, 2018)

Sources for and routes to man

● Humans are the most important source for humans

● 4.5% prevalence in community comparable to Sweden (S. Ny et al, JAC 2017)

● Meat (large population consumers) and water (limited population recreational swimmers) provide limited exposure of humans

● Farmers at risk to be carrier (via dust and direct contact)

● Residents are relatively low exposed, but no enhanced risk to be carrier (via dust in air, or environment)

From: Fecal Colonization With Extended-spectrum Beta-lactamase–Producing Enterobacteriaceae and Risk Factors Among Healthy Individuals: A Systematic Review and Metaanalysis Clin Infect Dis. 2016;63(3):310-318. doi:10.1093/cid/ciw283 Clin Infect Dis | © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com .

Current models do not adequately describe the complex

epidemiology of ESBLs and need adjustment

Humans are host and source

Carbapenemases in Animals

Dec 2016!!

Current questions in NL

Are we prepared for the next generation of transferable AMR-genes of Public Health concern?

Is current reduction of antibiotic use sufficient?? What type of surveillance is required for early warning? What are the intervention options and which are

effective?

Or...... do we let it get out of control as occurred for LA-MRSA and the ESBLs??

Effect of reductions in AMU in NL (Source MARAN, SDa 2016)

Stop use of ceftiofur at hatcheries

AB-Use Germany/Belgium/Netherlands

ESVAC, 2017

Veilig voedsel produceren

Met dank aan ESBLAT http://www.1health4food.nl/esblat

WBVR: Kees Veldman, Alieda van Essen, Arie Kant, Apostolos Liakopoulos, Yvon Geurts

RIVM: Engeline van Duijkeren, Wilfrid van Pelt, Lapo Mughini Gras, Heike Schmitt, Cindy Dierikx, Angela van Hoek, Eric Evers, Annemaria de Roda Husman, Hetty Blaak, Jaap van Dissel

IRAS: Joost Smid, Wietske Dohmen, Alejandro Dorado-Garcia, Heike Schmitt, Arie Havelaar, Dick Heederik

I&I:, Joost Hordijk, Jaap Wagenaar

UMCU: Ad Fluit, Gerrita van den Bunt, Marc Bonten

GD: Annet Velthuis, Annet Heuvelink, Rianne Buter, Maaike Gonggrijp, Inge Santman-Berends, Theo Lam

VionFood Group: Bert Urlings, Lourens Heres, Martijn Bouwknecht

Van Drie Group: Jacques de Groot, Meindert Nieland

Acknowledgements

SafefoodERA (WBVR, PH-England, APHA, FLI, BfR) Marc Bonten

One-Health approach of Antimicrobial ResistanceTales of the unexpected in resistance epidemiology: convenient and inconvenient truths�Antibiotic use in animals and humansThe “obvious” pathway of antibiotic resistanceSlide Number 5What would make LA-MRSA a public health threat?LA-MRSA: after 10 years of research:New variants emerging?Slide Number 9Plasmids?27 Replicon (plasmid) types in Enterobacteriaceae�(?? Additional small untypeable plasmids)Slide Number 12Use of 3rd and 4th gen cephalosporins in animals until 2011 in the NetherlandsESBL-producing E. coli (MARAN-reports)Prevalence of ESBLs in broilersESBL-genes and plasmids in Broiler isolates (Dierikx et al. 2010)Which types of ESBLs in humans in NL?Association with humansSlide Number 19Prevalences in the NetherlandsSlide Number 21Major outputSlide Number 23Slide Number 24Genetic associationsQuantified as Proportional Similarity index (PSI)PCAQMRA analysisConclusionSources for and routes to manSlide Number 31Current models do not adequately describe the complex epidemiology of ESBLs and need adjustmentCarbapenemases in AnimalsCurrent questions in NLEffect of reductions in AMU in NL (Source MARAN, SDa 2016)AB-Use Germany/Belgium/NetherlandsSlide Number 37Acknowledgements