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Global Antibiotic Resistance Partnership-South Africa Inaugural Meeting 8-9 February, Stellenbosch, South Africa The Global Antibiotic Resistance Partnership-South Africa (GARP-SA) came into being at the Spier Estate in Stellenbosch on February 8-9, 2010. Professor Adriano Duse, of the Department of Clinical Microbiology of the Witwatersrand, led a gathering of 40 experts from the clinical, research, pharmaceutical, veterinary, and policy worlds, all with an interest in preserving the effectiveness of antibiotics for the greater good. Professor Duse has taken on the challenge of leading GARP-SA as chair of its National Working Group.

GARP was introduced by its principal investigator, Ramanan Laxminarayan, of Resources for the Future. Professor Keith Klugman of Emory University and chair of the GARP International Advisory Group, outlined the scope of the problem of antibiotic resistance globally and in subSaharan Africa.

The broad outlines of surveillance for antibiotic resistance in South African hospitals, and recent studies focusing on the levels of resistance seen in particular sites, was the focus of the following sessions. Strong initiatives exist in both the public and private sectors, for a variety of bacterial pathogens and clinical conditions. Dr. Anne Von Gottberg talked about surveillance for meningitis and respiratory pathogens, Dr. Karen Keddy on enteric pathogens, and Drs. Anwar Hoosen and David Lewis antibiotic resistance in sexually-transmitted infections. A national surveillance system—whose fate is not yet known—has been proposed, described by Dr. Olga Perovic. Rounding out the session, Dr. Sabiha Essack described work she had done, documenting increasing levels of antibiotic resistance from district to regional to tertiary hospitals in KwaZuluNatal.

Professionals in infectious diseases are also strongly representated in South Africa. The six major proefessional societies also come together under the umbrella of the Federation of Infection Diseases Societies of South Africa (FIDSSA). While each society retains its own focus, FIDSSA provides a forum for addressing overarching issues, one of which is antibiotic resistance.

How important antibiotic use in animals is to the development and spread of antibiotic resistance in humans is a perennial topic for debate. Using antibiotics to promote quick growth in chickens, pigs and cattle (getting them to market faster), and to prevent and treat bacterial disease in animals crowded together breeds resistant bacteria. Dr. James Oguttu reported relatively high

levels of resistance to a range of antibiotics (including quinolones not used in poultry) in E. coli from the gastrointestinal tracts of slaughtered broilers raised in factory farm conditions that included antibiotic use. Dr. Maryke Henton expanded on antibiotic use in other farm animals (and provided the evidence to dismiss aquaculture use as a problem). Dr. Jackie Picard ended the veterinary session with a look at two years of recent surveillance data—showing high levels of resistance to a variety of antibiotics of human significance—and reminded the assembled that no routine surveillance of animals is taking place.

A window into the antibiotic market was opened by Mr. Deon Benjamin from Sanofi-Aventis, the largest seller of these products in South Africa by sales value. Sales appear to be increasing, for both patented and some generic antibiotics, with more detail promised to separate out effects of price and volume. Mr. Andy Zoepke, from the South African medical device company Smith and Nephew, took the meeting in a different direction, exploring the role of topical antibiotic preparations for wound care and burns. Use of these products substitutes for systemic antibiotics, reducing exposure of commensals and thus the unnecessary spread of resistance elements.

Dr. Iruka Okeke brought a whole range of antibiotic sparing ideas to the fore—reminding the gathering that progress against infectious diseases occurred in the past and could again without recourse to antibiotics. And when antibiotics are used, there are ways of reducing drug pressure without jeopardizing effectiveness: e.g., cycling of antibiotics, combinations, multiple first-line drug use. Vaccines that prevent infectious diseases clearly save antibiotics, and the status of vaccines deployed, on the shelf and in development was reviewed by Dr. Anwar Hoosen.

Best Care…Always! is a national campaign recently begun by Discovery Health and open to all hospitals in South Africa. Dr. Gary Kantor spoke about infection control practices (e.g., checklists for preventing surgical and central line infections) and the emphasis on “antibiotic stewardship” by hospital physicians as elements that the program has started with. Completely voluntary, 137 hospitals have signed on for at least one intervention. With success, BCA can provide a platform for extending work on reducing antibiotic resistance.

Progress in GARP-Kenya, which began work in August 2009, was recounted by Dr. Sam Kariuki, chair of the National Working in Kenya. Dr. Laxminarayan updated the group on the work of GARP-India and GARP-Vietnam, both of which also started in late 2009. The countries share some characteristics but differ in what’s known about and is being done about antibiotic resistance. In most respects, South Africa has a head start, at least in information.

In Ghana and Uganda, where antibiotic resistance has been looked for, levels have been high.

But surveillance is not sustained in either country (similar to many countries) so overall levels and trends are not known. No national programs to address antibiotic resistance exist.

Disabusing participants of the notion that everything is well documented in wealthy countries, Mr. Mike Eber unveiled results of the first study using a large sample of nationwide data on costs associated with hospital-acquired infections and deaths from these infections in the United States. Bottom line: about 48,000 deaths per year and a cost of more than $8 billion.

The World Health Organization (WHO) has highlighted antibiotic resistance as a global issue at several times in the past and currently. WHO provides some support, but more active are the major international groups, including the Alliance for the Prudent Use of Antibiotics (APUA), represented at the meeting by Dr. Anibal Sosa and ReAct, represented by Dr. Otto Cars. APUA chapters in a dozen African countries (South Africa and Kenya included) and on every continent (except Antarctica) are focal points for local action, while the organization is headquarterted in Boston. Antimicrobial Resistance in Developing Countries, co-edited by Dr. Sosa and several meeting participants, is a recent book pulling together many of the lessons learned by APUA. ReAct grew out of the successful Swedish national experience in reducing antibiotic resistance through better infection control and improved stewardship of antibiotics by medical personnel. A number of countries in Africa are now working with ReAct to explore data gathering and other scene setting work.

Where does GARP-SA go from here? The first order of business will be consolidating what of importance is and is not known about antibiotic use and resistance. A core group already takes seriously the threat of antibiotic resistance and recognizes that actions taken can improve the situation. As in every country, the difficulty is in persuading an ever-widening circle to take responsibility for the problem and to take part in solutions.