News and Opinions  –  2020

4 key reflections on the recently launched WHO GLASS-report

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The WHO GLASS-report summarizing antimicrobial resistance data from 2018 was launched end of May this year. The report is built on data reported from 78 of the 82 countries that were enrolled in GLASS at the end of the data call - 31st of July 2019 - and includes information extracted from over two million infected patients. In this article, ReAct highlights important findings in the report, describes the progress of GLASS and points out pitfalls to be aware of when interpreting the data.

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In 2015, the World Health Organization (WHO) established the Global Antimicrobial Resistance Surveillance System (GLASS), to address the need for harmonized surveillance of antimicrobial resistance (AMR).

Availability of data on antibiotic resistance frequencies serves multiple purposes and is key for designing targeted interventions aimed at lowering the impact of resistance. Importantly, such data – if representative – can for example help physicians make informed decisions about which antibiotics that are suitable for empirical treatment of patients. In GLASS, enrolled countries are called to report antibiotic resistance data for eight priority human pathogens isolated from clinical specimens: Acinetobacter spp. (blood), Escherichia coli (blood, urine), Klebsiella pneumoniae (blood, urine), Neisseria gonorrhoeae (cervical and urethral specimens), Salmonella spp. (blood, stool), Shigella spp. (stool), Staphylococcus aureus (blood) and Streptococcus pneumoniae (blood).

Empirical treatment

Treatment based on insights about trends in the patient population instead of individual test results. Empirical treatment is common practice when a patient is seriously ill and one cannot await the results from bacterial species identification and antibiotic resistance testing before initiating antibiotic therapy, or when access to laboratory diagnosis is limited.

1. Enrollment in GLASS is increasing

The number of countries, territories and areas (for simplicity referred to as “countries” in this article) enrolled in GLASS has steadily increased since its inception, and was in April 2020 adding up to 92. The newly published GLASS report includes AMR data from 66 countries, whereas 12 additional countries solely provided updates about the status of their AMR surveillance systems. Increased enrollment has occurred regardless of countries’ economic development status, which is particularly encouraging given the huge lack of AMR burden data from low- and middle-income countries (LMICs). Now, over 50% of countries that reported both AMR data and status of their surveillance programs were LMICs.

Data were submitted from nearly 65.000 surveillance sites in the 2019 data call, which is well over ten times more sites reporting data than in 2018. When looking at bit closer at these numbers, it does however become clear that the marked increase to a very large extent is attributed the reporting of two single countries – the USA and Germany. These countries submitted data from more than 44.000  and 16.000 surveillance sites, respectively. The number of surveillance sites on the African and South-East Asian regions was 93 and 110, respectively, which – despite being low – is about twice the number of sites reporting data in 2018.

2. Limitations in data quality call for cautious interpretations

Although the increased enrollment and reporting to GLASS is encouraging, it is important to remember that enrollment in itself does not ensure submission of quality or representative data. Countries may join GLASS regardless of whether a AMR surveillance system is in place or not, but by doing so, they commit to building or strengthening such a system. Although these open enrollment criteria are rightly facilitating long-term and sustainable investments by countries, one draw-back is that the quality of the reported data will differ substantially. Having a surveillance system in place is however not a guarantee for submission of complete data of high quality. This is exemplified by many high-income countries –  including for example Canada, Germany, Italy, the Netherlands and the United States  – which only reported data from a subset of the eight priority pathogens in the last data call, excluding information on common and easily isolated bacteria like E. coli from urine.

There are also huge differences in the number of patients that pathogens were isolated from. More precisely, it ranges from 19 to over 800.000 patients per country, which of course heavily impacts the quality and relevance of the national antibiotic resistance frequencies. Hence, it is impossible to compare resistance levels between countries. Also national resistance levels might be non-representative and must therefore be interpreted cautiously. Annex 1 of the GLASS report includes a readers’ guide as well as a more detailed and complete description of relevant data limitations.

3. Global data summaries show high resistance levels to important antibiotics

Despite these caveats, the global summaries of antibiotic resistance frequencies help sounding the alarm over the global health crisis that antibiotic resistance really is. Below, we describe some key findings in the report:

  • High levels of resistance to third-generation cephalosporins were found in E. coli and K. pneumoniae isolated from blood, with a median resistance frequency of about 35 % and 60 %, respectively. Disturbingly, 12 countries reported 80-100% resistance to these broad-spectrum antibiotics in K. pneumoniae isolates.
  • The median frequency of carbapenem-resistance was over 15 % for blood isolates of K. pneumoniae, which is alarming. Moreover, about 10 countries reported 30-60% resistance.
  • The median carbapenem-resistance frequency in Acinetobacter spp. isolated from blood was over 60% and a number of countries reported resistance frequencies well above 80%.

Carbapenems, which are last-line drugs, are effective also against pathogens that are resistant to third generation cephalosporins. They are often used empirically when there is an urgent need to quickly initiate effective antibiotic therapy to increase the chances of survival – for example in patients with bloodstream infections. High levels of resistance to these important antibiotics is thus extremely worrying.

4.  GLASS is one important piece in the AMR puzzle

Despite there is a long and winding way to go before the world has access to harmonized and comparable surveillance data on antibiotic resistance, the continuous expansion of GLASS is reassuring. There are no short-cuts to data generation, which is why GLASS can be viewed as a long-term engagement that increases our chances for data-driven action on antibiotic resistance in the future. In the meantime, however, we cannot afford inaction. As phrased in a 2019 report from the World Bank, “Knowledge gaps exist, but they are overshadowed by a ‘doing’ gap”. Now is the time to close the latter one.

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