|Year : 2016 | Volume
| Issue : 4 | Page : 413-415
Strengthening surveillance key to addressing antimicrobial resistance
K Walia, VC Ohri
Division of Epidemiology and Communicable Diseases, n Council of Medical Research, New Delhi, India
|Date of Submission||19-Sep-2016|
|Date of Acceptance||13-Oct-2016|
|Date of Web Publication||8-Dec-2016|
Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Walia K, Ohri V C. Strengthening surveillance key to addressing antimicrobial resistance. Indian J Med Microbiol 2016;34:413-5
|How to cite this URL:|
Walia K, Ohri V C. Strengthening surveillance key to addressing antimicrobial resistance. Indian J Med Microbiol [serial online] 2016 [cited 2017 Feb 26];34:413-5. Available from: http://www.ijmm.org/text.asp?2016/34/4/413/195378
India has a large burden of infectious diseases, and the treatment of infections in India is often mishandled owing to many factors which include lack of appropriate diagnostic support in terms of quality and availability, absence of outbreak reports by any national agency for wider dissemination and the tendency of doctors to continue age-old prescription practices and various socio-economic factors. As a result, the management of many bacterial infections remains empirical. In India and many other low- and middle-income countries, weak antibiotic policies coupled with poor antibiotic resistance surveillance lead to build-up of antibiotic resistance contributing to global pool of difficult-to-treat infections.
To effectively counter the threat that antimicrobial resistance (AMR) poses, there is a need to strengthen surveillance that should provide data and monitor changes over a period and thus help in controlling resistance. The need to have a correct estimate of the drug-resistant infections, for which effective and responsive surveillance systems are needed at national and regional levels, is of paramount importance. A large number of AMR reports are published, from India, every year, but these reports cannot be utilised for monitoring AMR pan-country because of the methodological limitations. The absence of a common nationally accepted Standard Operating Guidelines for AMR renders the AMR data being generated impossible to collate and analyse. The methodological diversity has been recognised as a challenge globally across the networks and is well documented. However, surveillance systems continue to be set up with scant regard for well-known sources of inaccuracy like that drugs tested in the surveillance systems and organisms being samples and the choices are largely influenced by the funding organisations. Nevertheless, the countries who have put together an efficient surveillance system were able to make a case for good Antimicrobial Stewardship Programme (AMSP) enabling judicious utilisation of what we have and reduce infections in hospitals such that there are fewer situations warranting antibiotic use. WHO has recently launched the Global Antimicrobial Resistance Surveillance System (GLASS) to support a standardised approach to the collection, analysis and sharing of data on AMR at a global level, in order to inform decision-making, drive local, national and regional action and provide the evidence base for action and advocacy. GLASS aims to combine clinical, laboratory and epidemiological data on pathogens that pose the greatest threats to health globally.
India did not have a national surveillance system to monitor AMR and this gap was evident when NDM story was published in 2010. To streamline data collection and have nation-wide picture, the Indian Council of Medical Research (ICMR) in 2013 set up an AMR surveillance network which is currently networking the tertiary care hospitals in the country. At the moment, data are being collected from four tertiary care hospitals across the country though its six nodal centres on six pathogenic groups: (i) diarrhoeagenic bacterial organisms: CMC, Vellore, (ii) enteric fever pathogens: AIIMS, New Delhi, (iii) Enterobacteriaceae causing sepsis: PGIMER, Chandigarh, (iv) Gram-negative non-fermenters: CMC, Vellore, (v) Gram positives including MRSA: JIPMER, Puducherry, (vi) fungal infections: PGIMER, Chandigarh. The list of the pathogens covered under ICMR network covers 90% of the WHO priority pathogens. The aim of establishing this network is (i) to collect a nationally representative data on drug resistance and monitor trends across the country, (ii) to generate evidence on mechanisms of resistance in different pathogenic groups, (iii) to guide antimicrobial policies for both treatment and prophylaxis, (iv) to direct hospital infection control efforts that facilitate prevention of the spread of resistant organisms.
For surveillance data to be reliable, it is important that all participating sites follow the same methodology on antimicrobial susceptibility testing and external quality assurance. Recognising that methodological limitations are a major challenge, the ICMR published standard operating procedures for bacteriology and mycology to create uniformity and harmonisation of the clinical microbiology processes and procedures with respect to AMST across all participating sites. The guidelines are available to be used by any laboratory doing AMR-related work.
This issue carries the data emanating from first 2 years of network. From the data obtained so far, more than 70% Enterobacteriaceae is resistant to 3rd-generation cephalosporins. Among the Enterobacteriaceae species, Klebsiella and Escherichia coli have been found to be resistant to 3rd-generation cephalosporins (80%). A bulk of hospital-acquired infections is caused by Acinetobacter baumannii and Pseudomonas aeruginosa showing 50% resistance to carbapenems. Salmonella Typhi multidrug resistance (MDR) to ampicillin, chloramphenicol and trimethoprim – sulfamethoxazole is showing a downward trend and resistance to fluoroquinolones is increasing whereas resistance to cephalosporins is being reported. This finding is very promising as this provides evidence to start using the first-generation simple cheap drugs (ICMR data).
The biggest challenge of this network is that the data collected through this network are from tertiary care hospitals and do not reflect the AMR patterns in the community. The concerns are legitimate as most of the hospitals which are part of the network receive patients who have had multiple exposures to antibiotics before reaching out to a tertiary care hospital. Segregating data in intensive care unit, ward and outpatient department has not helped in getting community data as seen in other countries' hospital settings. The issue of differing resistance patterns in the community versus hospital is a well-established and much-discussed phenomenon. Many studies have supported recommendations for empirical antimicrobial prescribing based on an assessment of whether the infection is community or healthcare acquired highlighting a crucial element relating to surveillance capacity which have not been addressed adequately in AMR surveillance data. The clinical and epidemiological context of data is crucial for accurate interpretation, and without this context, the issue of resistance is magnified disproportionately because of blurring of data. Most AMR surveillance data give indication of overall increase or decrease in resistance levels but do not provide sufficient information to guide practice at a local level. ICMR's AMR surveillance network data which comes from tertiary care hospitals therefore need to be supported by the community data it be relevant to guide treatment in community and hospital settings. Since the microbiology data form basis of the antimicrobial stewardship activities, aggregated data without context can also be detrimental to antimicrobial stewardship initiatives, as the perceived threat of resistance may translate into prescription of for the 'big-gun' antibiotics. Community surveillance studies are very resource and time intensive and waiting to start these may cause further delay in our ability to launch a coherent response. One option is to strengthen AMR data collection and analysis in hospitals by building necessary capacities for contextualising the data being collected by microbiology labs. This will enable utilisation of data to develop epidemiologically relevant guidelines. This requires building AMSP capabilities in hospitals and at the same time building IT-enabled infrastructure. ICMR will be launching AMSP training component soon. The AMSP initiative of ICMR proposes to build AMSP capacities in tertiary care hospitals where the hospital AMR surveillance has already been initiated. The overarching aim will be to strengthen microbiology data analysis so that laboratories provide good quality, clinically relevant stratified data which can guide empirical treatment with only a marginal error.
Many surveillance networks in the past were collecting susceptibility data without investigating the mechanisms of resistance that are leading to resistance. Since understanding of mechanisms of resistance is key to determining intervention strategies, hence inclusion of this element has been strongly recommended. The uniqueness of ICMR network lies in creating a comprehensive data including the mechanisms of resistance and research studies which will enable understanding of transmission dynamics, clonality and forecasting AMR trends and patterns over the period through molecular studies. The six laboratories currently engaged in surveillance activities have capacities to do cutting edge science.
AMR is no longer seen as a problem limited to health-care institutions. The use of antibiotics in poultry and livestock and dumping of antibiotics in environment is being increasingly recognised as important contributors leading to transfer of drug-resistant pathogens through food chain and persistence of drug-resistant strains in environment. However, scientific evidence to establish these linkages is still lacking. ICMR proposes to expand the mandate of this surveillance system to also include surveillance in veterinary and environmental settings.
It is envisaged that having a robust AMR surveillance data will highlight the need for rationalising empirical therapy guidelines and regulating antibiotics use in the country. Besides, the insight into the burden of AMR as reflected through surveillance reports will be helpful in building a strong case for and institutionalising infection to reduce the spread of drug-resistant pathogens in hospital settings and vaccine introduction in community settings. Both of these interventions are resource incentive and require sustainable financial commitments which are hard to come by immediately. Nevertheless, continued quality data generation on AMR will provide compelling evidence which will be hard to ignore for policymakers, thus making investments in this area in future inevitable.
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