Surveillance of antibiotic resistance in priority bacteria from humans, food animals, and environmental sources is an essential component of a national action plan on antibiotic resistance.
The Global Action Plan on Antimicrobial Resistance calls for increasing the evidence base on resistance through surveillance and research. Standardized, comparable and validated data should be collected, analyzed, and shared between countries in order to inform decision-making and provide the evidence base to drive local, national and regional action and advocacy.
Gathering data on a small scale
As public and animal health infrastructure differs between countries, full-scale surveillance may not be possible in all settings initially. If resources and capacity are not yet available, data can still be collected on a smaller scale. Point prevalence studies or surveys can be a good way to get started and are useful tools to gather resistance data to quickly assess the current situation. Over time, efforts can be scaled up and eventually act as inputs to national surveillance. See MEASURE: Antibiotic Resistance for more information on how to collect data on antibiotic resistance from both humans and animals.
Regional surveillance of antibiotic resistance
A number of regional surveillance programs have been tracking antibiotic resistance, but still many gaps exist that prohibit comprehensive monitoring and analysis of the prevalence and trends of resistance worldwide to appropriately guide interventions. Challenges include a lack of capacity to use microbiology to guide treatment and perform laboratory tests according to recognized standards, as well as a lack of data-sharing and coordination at local, national, regional and global levels. Lack of harmonization between countries and between medical, veterinary, agricultural and environmental sectors make data comparison difficult.
Integrated surveillance between sectors
It is recommended that countries develop integrated surveillance programs with antibiotic resistance data from humans, food-producing animals, and retail meats to provide the data needed for public health decision-making and proper allocation of resources. Standards have been developed by the World Organization for Animal Health (WOAH). In addition, the WHO Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR) has a guidance document on the issue. One of the recommendations is to establish a working group to support national surveillance that includes professionals from different disciplines such as veterinarians, practicing clinicians, microbiologists, epidemiologists, pharmacists, as well as representatives from government agencies responsible for risk assessment and management. Important criteria for sustainable integrated surveillance include the ability for routine collection of samples for microbiological cultures and susceptibility testing, established laboratory facilities and trained personnel, and the capacity to analyze and report data.
Integrated surveillance of antibiotic resistance between sectors is the optimal long-term goal, however, many challenges exist for implementation, particularly in resource-limited settings.
Global Antimicrobial Resistance and Use Surveillance System (GLASS)
To aid implementation of routine surveillance on a national and global level, WHO initiated the Global Antimicrobial Resistance and Use Surveillance System (GLASS). GLASS initially focuses on priority bacterial infections in humans, but allows for a progressive integration of other data from surveillance systems such as those analyzing foodborne illness, monitoring antibiotic use or health care-associated infections.
GLASS seeks to combine patient, laboratory and epidemiological surveillance data on resistance across the globe. GLASS focuses on resistance in bacteria causing common infections of global public health importance, particularly those resistant to several antibiotics and with limited treatment options. Based on the resources and priorities in each country, GLASS surveillance standards can be gradually implemented.
Establish a national coordinating center
Participating countries should assign a national coordinating center to oversee the resistance surveillance system and identify a focal point for communication with WHO. The center should be placed under a suitable institution, have access to both laboratory and epidemiological expertise and have a defined structure for surveillance coordination and data management. Often a public health institute is an appropriate choice. The national coordination center is responsible for enrolment of surveillance sites. These sites should have the capacity to provide basic demographic, clinical, epidemiological and microbiological information from tested clinical specimens, and also have the capacity for a sustained commitment to participate. Ideally, the national coordinating center should also be linked with resistance surveillance in animals so they can eventually be integrated together.
Establish a national reference laboratory
A national reference laboratory should also be established to provide technical support to participating surveillance sites and to confirm findings of unexpected resistance. A public health or academic laboratory with experience in supporting implementation of quality assurance and also with expertise in methods for characterizing resistant pathogens should be nominated for this role. If such capacity does not yet exist in a country, a collaboration can be temporarily set up with a neighboring country. The reference laboratory should work together with the national coordinating center to implement quality assurance programs and to standardize and verify microbiological results.
Collection, management, analysis and reporting of data
Samples should be collected and sent to the laboratory serving the surveillance site for culture and susceptibility testing together with accompanying patient information. Laboratories then enter data into data management software such as the freely available WHONET. Data from surveillance sites is forwarded to the national coordinating center where it is aggregated and submitted electronically to WHO. Member States regularly report to WHO on progress in implementing national surveillance as well as resistance levels and unusual findings. This data provide input to reports on global resistance surveillance.
Surveillance methods
Priority pathogens, specimen types to be collected and a selection of antibiotics against which resistance can be monitored are outlined in the GLASS documents. Susceptibility results should be combined with basic demographic and epidemiological data collected on the patient and population covered. Countries can submit data even if they are only able to provide information on one of the pathogen-antibiotic combinations. Coverage can be increased incrementally depending on resources and needs. For more information on how to measure antibiotic resistance, see MEASURE: Antibiotic resistance.
Selected Resources
| Resource | Description |
|---|---|
| Global Antimicrobial Resistance and Use Surveillance System (GLASS) | Informational portal. GLASS provides a standardized approach to the collection, analysis, interpretation and sharing of antibiotic resistance and use data by countries. It promotes a shift from surveillance approaches based solely on laboratory data to a system that includes epidemiological, clinical, and population-level data. See also the GLASS resource Centre for guidelines and tools for enrolment and data management, and the reports. You can also access GLASS data and IT tools from this page. |
| Regional surveillance systems | Information portals of regional surveillance systems in partnership with GLASS.
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| GLASS method for estimating attributable mortality of antimicrobial resistant bloodstream infections | Protocol. Master template protocol from WHO GLASS for estimating in-hospital mortality attributable to resistant blood stream infections. Focuses on ESBL E. coli and MRSA infections of both community and hospital-origin. Can be expanded to other bacteria as well. Can also support tracking of progress towards the sustainable development goals and specifically the AMR indicator. |
| Protocol for Enhanced Isolate-Level Antimicrobial Resistance Surveillance in the Americas. Primary Phase: Bloodstream Infections | Protocol from PAHO that includes practical guidance and technical support for countries to participate in the early implementation of enhanced isolate-level data collection focused on blood isolates. The Spanish version can be found here. |
| Molecular methods for antimicrobial resistance (AMR) diagnostics to enhance the Global Antimicrobial Resistance Surveillance System | Guidance. Overview of benefits, costs, limitations and challenges of molecular antimicrobial resistance diagnostics that could be used for surveillance in non-reference laboratories and clinical settings. Intended to support decisions of for example study site managers on what molecular AMR diagnostics to choose and how to use them clinically and for surveillance, based on prior experience in antimicrobial susceptibility testing (AST). |
| WHONET Software | Software. WHONET is a database software for the management and analysis of antibiotic resistance data. The software is free to download and use and is developed and maintained by WHO. |
| GLASS One Health module | Information portal and protocol. A WHO integrated multi-sectoral surveillance for low-resource settings, based on the extended-spectrum beta-lactamase (ESBL)-Escherichia coli (Tricycle) project. See also the protocol: WHO integrated global surveillance on ESBL-producing E. coli using a “One Health” approach. Includes standard methodologies in the human, food chain and environmental sectors, to facilitate the establishment of the integrated multisectoral surveillance. |
| Integrated surveillance of antimicrobial resistance in foodborne bacteria: Application of a One Health approach | Guidelines developed by WHO AGISAR, that provides information for countries in the process of establishing integrated surveillance of antimicrobial resistance. Includes a step-by-step guide for designing an integrated surveillance program using standardized and validated antimicrobial susceptibility testing methods and harmonized interpretative criteria. |
| Health Policy and Systems Research on Antimicrobial Resistance (HPSR-AMR) Network Thailand | Country example. The HPSR-AMR network in Thailand aims to be a trust-based multi-disciplinary and multisectoral collaboration using the One Health approach for evidence-informed AMR policy. Through the Thailand One Health Dashboard on Antimicrobial Resistance data on antimicrobial consumption and resistance in both humans and food-producing animals is openly shared. It also collects data on knowledge and awareness. |
| Multisector Surveillance of Antibiotic Sales and Resistance in Sweden | Country example. Sweden was one of the first countries to implement long-term monitoring of antibiotic resistance. Strama started by conducting point prevalence studies and today, all counties are involved in an extensive surveillance program, involving nearly all microbiological laboratories in collecting data (see journal article for more details). The laboratories report data into a database and in return they receive training, feedback and discussion forums. Resistance data is similarly collected by the Swedish National Veterinary institute, and data from both systems are collected into One Health annual reports, Swedes-Svarm. |
| WOAH Terrestrial Animal Health Code | Guidelines. Chapter 6.8, Harmonisation of National Antimicrobial Resistance Surveillance and Monitoring Programmes, provides criteria for development and harmonization of national resistance surveillance and monitoring programs in food-producing animals and in products of animal origin intended for human consumption. |
| WOAH Aquatic Animal Health Code | Guidelines. WOAH guide to development and harmonisation of national antimicrobial resistance surveillance and monitoring programmes for aquatic animals. See for example Chapter 6.4, Development and Harmonisation of National Antimicrobial Resistance Surveillance and Monitoring Programmes for Aquatic Animals. |