# Presentation: 208106

## The National Antimicrobial Resistance Monitoring System (NARMS) 

- Dr. David G. White
- Center for Veterinary Medicine
- U.S. FDA
- Food Safety Summit on Attributing Illness to Food
- April 5th, 2007

## The National Antimicrobial Resistance Monitoring System (NARMS) is a national collaborative network between the FDA, CDC and USDA as well as public health laboratories in all 50 states and local health departments in three major cities 

NARMS was developed to monitor changes in susceptibility/resistance of select zoonotic bacterial pathogens and commensal organisms recovered from animals, retail meats and humans to antimicrobial agents of human and veterinary importance  

NARMS monitors susceptibility/resistance phenotypes using three testing sites including:
FDA/CVM (retail meat and poultry) 
CDC (humans) 
USDA (animal/slaughter)

**NARMS was developed to monitor changes in susceptibility/resistance of select zoonotic bacterial pathogens and commensal organisms recovered from animals, retail meats and humans to antimicrobial agents of human and veterinary importance  **
**NARMS monitors susceptibility/resistance phenotypes using three testing sites including:**
**FDA/CVM (retail meat and poultry) **
**CDC (humans) **
**USDA (animal/slaughter)**

**NARMS**

## NARMS/Retail Meats Sampling

**10 FoodNet sites **
**Similar sampling scheme**
**Random sampling of stores**
**Each site purchases ****10**** packages each of chicken breasts, pork chops, ground turkey, and ground beef**
**All ten sites culture meat and poultry rinsates for *****Salmonella***** and *****Campylobacter***
**In addition, four sites (GA, MD, OR and TN) culture rinsates for *****E. coli***** and *****Enterococcus***
**Isolates are sent to FDA-OR for confirmation of identification and antimicrobial susceptibility testing**

**Notes:**
Current sites: CT, GA, MD, MN, TN; GA, MD, TN  E. coli & Ecocci
*expanding to 9 sites in Jan 2003
Oregon began data collection August 2002; California, New York, and Colorado will begin January 2003.
Sampling scheme: 
The current sampling scheme is a convenience sample whereby sites go to at least one different grocery store per month and purchase as many different brands as possible of each commodity.
10 samples each of ground turkey, ground beef, chicken breasts, and pork chops per month.
If you sample more than once per month, it is important that you purchase all of one commodity during each grocery store visit.
All sites isolate Salmonella and Campylobacter; additionally, GA, MD, OR, and TN isolate E. coli and enterococci.
Log sheets: 
Standard numbering scheme
Complete – enter n/a if information is not available
Fax/e-mail to Jennifer w/ hard copy to David White
Retain copies of package labels
Susceptibility testing:
Salmonella, E. coli: Tested by broth microdilution (Sensititre, Trek Diagnostics) – for susceptibility to 16 antimicrobial agents:  amikacin, amox/clav, ampicillin, cefoxitin, ceftiofur, ceftriaxone, cephalothin, chloramphenicol, ciprofloxacin, gentamicin, kanamycin, nalidixic acid, streptomycin, sulfamethoxazole, tetracycline, and trimethoprim/sulfamethoxazole
Campylobacter: Tested by E-test for susceptibility to 8 antimicrobial agents: azithromycin, chloramphenicol, ciprofloxacin, clindamycin, erythromycin, gentamicin, nalidixic acid, and tetracycline.  Additionally, Campylobacter isolates are tested by agar dilution for susceptibility to: ciprofloxacin, doxycycline, erythromycin, and gentamicin
Enterococci: Tested by broth microdilution for susceptibility to 

## NARMS Retail meats sampled 

**2002, 6 states; 2003, 8 states; 2004, 2005 and 2006, 10 states**

- 				_2002__	__2003__	__2004__	__2005__	__2006_
- Chicken breast			616	897	1172	1194	1068
- Ground turkey			642	857	1165	1195	1056
- Ground beef			642	880	1186	1196	1070
- Pork chop			613	899	1176	1196	1062
- Total				2513	3533	4699	4781	4256*

***Salmonella *****and***** Campylobacter***

*******Preliminary data for 2006**

## NARMS/Retail food preliminary data Salmonella 2002 - 2006 

**2002,   6 FoodNet sites, n = 153**
**2003,   8 FoodNet sites, n = 212**
**2004, 10 FoodNet sites, n = 324**
**2005, 10 FoodNet sites, n = 353**
**2006, 10 FoodNet sites, n = 290*******

- Preliminary data

**Notes:**
I would like to thank all of you for attending this important training course.  We feel that this study is groundbreaking in that it will provide baseline data on the prevalence of antimicrobial resistance in the retail food supply.  We appreciate your participation.  Thank you.

**Total Number of *****Salmonella***** and  Serotypes Isolated in 2004**

|  | # Poultry Samples | # Salmonella Isolates | # Salmonella Serotypes  |
| --- | --- | --- | --- |
| Human | NA | 1798 | >100 |
| Chicken Breast | 1,172 | 157 (13.4%) | 15 |
| Ground Turkey | 1,165 | 142 (12.2%) | 21 |

- NA = not applicable

## Top 5 Serotypes among Human and Retail Poultry Isolates, 2004

| Rank | Human
(N=1798) |  | Chicken Breast
(N=157) |  | Ground Turkey
(N=142) |  |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Typhimurium* | 386 (21.5%) | Typhimurium* | 49 (31.2%) | Heidelberg | 37 (26.1%) |
| 2 | Enteritidis | 272 (15.1%) | Kentucky | 42 (26.8%) | Saintpaul | 24 (16.9%) |
| 3 | Newport | 189 (10.5%) | Heidelberg |  31 (19.7%) | Reading | 16 (11.3%) |
| 4 | Javiana | 106 (5.9%) | Hadar | 8 (5.1%) | Schwarzengrund | 16 (11.3%) |
| 5 | Heidelberg | 94 (5.2%)          | Schwarzengrund | 5 (3.2%) | Hadar | 11 (7.7%) |

**Top 5 Serotypes among Human and Retail Poultry Isolates, 2004**

**S*. Typhimurium includes Typhimurium var. 5-

**Other top 10 serotypes that are common among human and retail poultry isolates:**

- _Human and Chicken Breast_
*S*. Enteritidis
*S*. Montevideo

- _Human and Ground Turkey_
*S*. Saintpaul

## NARMS Slaughter Salmonella Data

**NARMS Slaughter *****Salmonella***** Data**

|   | Top serotypes by Source for Salmonella slaughter isolates (All years) |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
|   | SOURCE |  |  |  |  |  |  |  |
| Rank | Cattle
n=6815 |  | Chicken
n=10,605 |  | Swine
n=3,839 |  | Turkey
n=3,147 |  |
|   | Serotype | Pct | Serotype | Pct | Serotype | Pct | Serotype | Pct |
| 1 | Montevideo | 13.4  | Kentucky | 35.5  | Derby | 25.8  | Heidelberg | 20.7  |
| 2 | Anatum | 8.9  | Heidelberg | 20.3  | Typhimurium var 5-a | 11.2  | Hadar | 16.6  |
| 3 | Newport | 7.6  | Typhimurium var 5-a | 6.1  | Infantis | 6.5  | Senftenberg | 8.2  |
| 4 | Muenster | 7.1  | Typhimurium | 4.9  | Johannesburg | 6.3  | Reading | 7.3  |
| 5 | Typhimurium | 5.6  | Enteritidis | 4.3  | Anatum | 6.1  | Saintpaul | 6.5  |
| 6 | Typhimurium var 5-a | 5.5  | Hadar | 4.0  | Heidelberg | 3.9  | Agona | 5.0  |
| 7 | Kentucky | 5.1  | Monophasic | 3.1  | Reading | 3.9  | Schwarzengrund | 4.4  |
| 8 | Cerro | 4.0  | Thompson | 2.3  | Saint Paul | 3.0  | Muenster | 3.8  |
| 9 | Mbandaka | 3.9  | Schwarzengrund | 2.2  | Typhimurium | 2.8  | Arizona | 2.7  |
| 10 | Agona | 3.8  | Montevideo | 2.2  | Agona | 2.7  | Typhimurium | 2.6  |

## Antimicrobial Resistance Phenotypes among Salmonella Isolates: NARMS, 2004

- *No CLSI breakpoint

- All isolates were susceptible to amikacin

- *

**N = 2097 isolates; Human, n = 1798; Chicken breast, n = 157; Ground turkey, n = 142**

## Gentamicin and Ceftiofur Resistance among Salmonella by Source, NARMS 2004

**GEN****R**** = 57 isolates; TIO****R**** = 106 isolates**

**N = 2097 isolates; Human, n = 1798; Chicken breast, n = 157; Ground turkey, n = 142**

## Gentamicin and Ceftiofur Resistance among Salmonella Typhimurium by Source, NARMS 2004

**GEN****R**** = 9 isolates; TIO****R**** = 41 isolates**

**N = 437 isolates; Human, n = 386; Chicken breast, n = 49; Ground turkey, n = 2**

- 2.1%

- 2%

- 4.4%

- 49%

## Gentamicin and Ceftiofur Resistance among Salmonella Heidelberg by Source, NARMS 2004

**GEN****R**** = 20 isolates; TIO****R**** = 14 isolates**

**N = 162 isolates; Human, n = 94; Chicken breast, n = 31; Ground turkey, n = 37**

## NARMS/PulseNet

***Salmonella***** and *****Campylobacter***** isolates undergo further molecular characterization **
**PFGE analysis**
**Follow CDC guidelines for PFGE analysis**
**Data is shared with PulseNet**
**CVM PulseNet database has more than 7,000 data entries, including**** **
**4,015 *****Salmonella***** **
**432 *****E. coli***** **
**2,646 *****Campylobacter***
**69 *****Vibrio***
**Isolates can be used for future research projects **
**biosource tracking experiments**
**Virulence studies**
**Antimicrobial resistance studies **

**Notes:**
Current sites: CT, GA, MD, MN, TN; GA, MD, TN  E. coli & Ecocci
*expanding to 9 sites in Jan 2003
Oregon began data collection August 2002; California, New York, and Colorado will begin January 2003.
Sampling scheme: 
The current sampling scheme is a convenience sample whereby sites go to at least one different grocery store per month and purchase as many different brands as possible of each commodity.
10 samples each of ground turkey, ground beef, chicken breasts, and pork chops per month.
If you sample more than once per month, it is important that you purchase all of one commodity during each grocery store visit.
All sites isolate Salmonella and Campylobacter; additionally, GA, MD, OR, and TN isolate E. coli and enterococci.
Log sheets: 
Standard numbering scheme
Complete – enter n/a if information is not available
Fax/e-mail to Jennifer w/ hard copy to David White
Retain copies of package labels
Susceptibility testing:
Salmonella, E. coli: Tested by broth microdilution (Sensititre, Trek Diagnostics) – for susceptibility to 16 antimicrobial agents:  amikacin, amox/clav, ampicillin, cefoxitin, ceftiofur, ceftriaxone, cephalothin, chloramphenicol, ciprofloxacin, gentamicin, kanamycin, nalidixic acid, streptomycin, sulfamethoxazole, tetracycline, and trimethoprim/sulfamethoxazole
Campylobacter: Tested by E-test for susceptibility to 8 antimicrobial agents: azithromycin, chloramphenicol, ciprofloxacin, clindamycin, erythromycin, gentamicin, nalidixic acid, and tetracycline.  Additionally, Campylobacter isolates are tested by agar dilution for susceptibility to: ciprofloxacin, doxycycline, erythromycin, and gentamicin
Enterococci: Tested by broth microdilution for susceptibility to 

## NARMS Executive Reports

- First Executive NARMS report released
- summarizes 2003 data from FDA, USDA, CDC in single report
- Link on CVM’s Web site
- _[www.fda.gov/cvm](http://www.fda.gov/cvm)_
- Working on 2004 report

## Evaluating the Safety of Antimicrobial New Animal Drugs with Regard to Their Microbiological Effects on Bacteria of Human Health Concern, GFI #152

- Part of human food safety evaluation on antimicrobial use impacts on resistant pathogenic, zoonotic bacteria  (e.g. *Salmonella*, *E. coli*, *Campylobacter*, etc.).
- October 23, 2003
- Human exposure through ingestion of animal-derived food
- Approach applies to therapeutic and non-therapeutic antimicrobial drugs intended for food-producing animals
- Qualitative risk assessment approach
- Based on OIE Ad Hoc Group on Antimicrobial Resistance process

- Possible risk management steps range from denying the drug approval application to approving the application under various use conditions that assure the safe use of the product

## Acknowledgements

**FDA**
**Dr. Beth Karp**
**Dr. Elvira Hall-Robinson**
**Dr. Heather Harbottle**
**Dr. Patrick McDermott**
**Dr. Terry Proescholdt**
**Dr. Robert Walker**
**Dr. Antoinette Walker**
**Dr. Marleen Wekell**
**CDC**
**Lauren Stancik-Rosenthal**
**Felicita Medalla**
**Dr. Tom Chiller**
**Dr. Fred Angulo**
**Dr. Ezra Barzilay**
**Dr. Jean Whichard**

**FDA**
**Jason Abbott**
**Sherry Ayers**
**Karen Blickenstaff**
**Sonya Bodeis-Jones**
**Peggy Carter**
**Patti Cullen**
**Linda English**
**Sharon Friedman**
**Althea Glenn**
**Susannah Hubert**
**Stuart Gaines**
**Shawn McDermott**
**Sadaf Qaiyumi**
**Amanda Stearns**
**FoodNet EIP funded sites**
**CDC PulseNet**
**USDA**
**-****	****Dr. Paula Fedorka-Cray**

**Acknowledgements**

## Thank You

**Go to the CVM Website for the most current information **_[www.fda.gov/cvm](http://www.fda.gov/cvm)_

**For the invitation to this valuable meeting**
**Appreciate this chance to participate**